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 THE PATHOLOGY 
 
 INTRA-UTERINE DEATH 
 
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THE PATHOLOGY 
 
 INTRA-UTERINE DEATH 
 
 ^be Xumleian 1lccturc6 
 
 DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANS 
 OF LONDON, MARCH 1887 
 
 BY 
 
 WILLIAM O. PRIESTLEY 
 
 M.D., F.R.C.P., LL.D. 
 
 CONSULTING PHYSICIAN TO KINg's COLLEGE HOSPITAL ; AND LATE PROFESSOR OF 
 OBSTETRIC MEDICINE, KINO's COLLEGE 
 
 [Reprinted for the Author front the British Medical Journal 
 March 26, April 2, 9, and 16, 1887] 
 
 LONDON 
 J. & A. CHURCHILL 
 
 11 NEW BURLINGTON STREET 
 1SS7 
 
K^,^r^L 
 
TO 
 
 SIR WILLIAM JENNER, BART. 
 
 K.C.B., M.D., &c. 
 
 PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS 
 
 IN RECOGNITION OF 
 
 THOSE SCIENTIFIC ATTAINMENTS AND PERSONAL MERITS 
 
 WHICH HAVE PLACED HIM 
 
 AT THE HEAD OF HIS PROFESSION 
 
PROGRESS OF INVESTIGATION. 3 
 
 Charpentier's, Bustamente's, Verdier's, and Whit- 
 taker's ; and, besides, we have the well known 
 contributions, illustrating special diseases of the 
 placenta, from the pens of E-obin, Virchow, Hyrtl, 
 Hegar, Kokitansky, Ercolani, and others. 
 
 It is obvious that a general treatise on Obstetric 
 Medicine can scarcely find room for a full discussion 
 of all that has been done in this branch of pathology ; 
 and, in reference to the special treatises or mono- 
 graphs on placental disease, it may be said that some 
 of them, at least, are out of date. Like all other 
 branches of morbid anatomy, the investigation of 
 diseases in the placenta has made in recent years con- 
 siderable progress, and opinions and views formerly 
 held in reference to the nature of some of the 
 alterations observed, are now regarded as untenable. 
 
 Besides examining many fresh specimens, I have 
 gone carefully over the preparations bearing on the 
 causes of intra-uterine death in all the London 
 museums and some of those on the Continent, and it 
 has been an interesting study, in inspecting these 
 preparations, to compare them with the various 
 pathological views which have been expressed by 
 authorities, both in this country and abroad. 
 
 I may state at the outset that the complex and 
 intricate anatomical structure and the alterations 
 associated w^ith the rapid development of the con- 
 tents of the gravid uterus even in the normal state, 
 render all investigation very difficult. When preg- 
 nancy goes its natural course, and development 
 follows its normal progress, the changes wliich take 
 place are incessant and varying. From the time at 
 which the decidua is first formed in the interior of 
 
 B 2 
 
4 THE TATHOLOCiY OF INTRA-UTERINE DEATH. 
 
 the litems to become the outermost of the foetal 
 membranes, to the formation of the fully grown 
 placenta, tliere is no ])ause or cessation in the active 
 changes which characterise the progress of gi'owth. 
 The cells and fibres which build up the tissues day 
 by day undergo progressive change, and the vessels 
 equally undergo modification in size, form, character, 
 and in theii' relation to surrounding parts. The 
 vegetative process is, indeed, so active that if 
 any derangement occurs, either from accident or 
 disease, the morbid change thus initiated is, or may 
 be, impressed with the same activity, and rapid 
 degeneration takes place, or abnormal growths are 
 produced with surprising cjuickness. 
 
 It can scarcely be a matter of surprise, therefore, 
 that pathological researches into these unstable and 
 ever-chano'ino; structures should be beset with diffi- 
 culties, and that equally conscientious and accurate 
 observers hold different views concerning the nature 
 of some of the pathological results hereafter to be 
 described. The earlier the period of gestation, the 
 greater apparently is the difficulty of pursuing inves- 
 tio-ations. Then all the tissues are so frao-ile and 
 delicate that if specimens are procurable their 
 efficient injection is well-nigh impossible, and they 
 are likely to be so contused and broken that their 
 true condition is not easily determined. Notwith- 
 standing: all the difficulties, researches have been 
 attempted by very competent observers at ever}^ 
 period of pregnancy, and the accumulated results so 
 recorded may to a certain extent be formulated, and 
 some at least of the pathological conditions be 
 thoroughly understood. 
 
" HABIT OF ABORTING. 5 
 
 Many of the causes wliicli either remotely or 
 •directly bring about intra-uterine death are very 
 difficult to trace, and some are so subtle in their 
 influence as to be impossible to detect. Thus the 
 child dies in utero with some women in successive 
 23regnancies, and without any clearly assignable cause. 
 The " habit of aborting " has been spoken of, as 
 though it were independent of disease. It is not 
 infrequent to hear of women apparently healthy 
 aborting or losing their children in the later months 
 •of gestation ten, twelve, or thirteen successive times. 
 Oharpentier mentions the case of a woman who had 
 no living child until the eighteenth pregnancy, and 
 this was born at eight months. Both parents were 
 apparently healthy. 
 
 Some women are so prone to miscarriage at any 
 period of gestation, that the slightest imprudence 
 «eems to be enough to endanger the existence of 
 pregnancy, and lead to a detachment of the ovum. 
 
 This is in marked contrast to other and aj^parently 
 not healthier women, who will bear an extraordinary 
 amount of violence or injury without disturbance to 
 pregnancy. Mauriceau"'" relates tlie case of a woman 
 in the seventh month of pregnancy, who fell from the 
 window of a house, and broke her arm, dislocated 
 her wrist, and, besides, received extensive bruises in 
 various parts of her body, without bringing on labour. 
 Dr. Henry Davies saw a pregnant woman, who, in 
 throwing water out of a ^dndow, lost her balance, 
 .and fell into the street, breaking both tliighs, but she 
 recovered without aborting. Dupuytren has put on 
 record the case of a woman who had severe trau- 
 
 * See Tyler Smith, " Manual of Obstetrics," 1S58. 
 
6 THE PATHOLOGY OF INTllA -UTERINE DEATJl. 
 
 inatic tetanus during pregnancy, and who neverthe- 
 less went to her full time. M. Brillaud Laujardiere 
 relates the case of a peasant who took his wife, while 
 pregnant, behind him on horseback, and started off 
 at full gallop, with the object of bringing on abortion. 
 After shaking her thoroughly in this way, he dropped 
 her suddenly on the ground without stopping. This 
 treatment he repeated twice without success.* I 
 have on more than one occasion failed to bring on 
 abortion when extreme peril to a woman called for 
 this interference, by passing the sound deep into the 
 uterine cavity, and stirring up its contents ; and one 
 case is on record in which an intra-uterine pessary 
 Avas unwittingly introduced into the womb of a 
 jDregnant woman, and was worn for some time with- 
 out provoking abortion. 
 
 The frequency of embroynic death in the earlier 
 stages of gestation is approximately shown by the 
 tables of Whitehead.! These were taken from the 
 records of the Manchester Lying-in Hospital, and 
 give an estimate so far as it relates to women of the 
 poorer classes. Whitehead interrogated 2000 preg- 
 nant women, whose average age "\^'as a fraction below 
 thirty years, and he found the sum of their preg- 
 nancies had been 8681, or 4.34 for each; of which 
 about one in seven had terminated abortively. Seven 
 hundred and forty-seven women had aborted once at 
 least, some oftener ; their average age was 32.08 
 years ; the number of their pregnancies was 4775 ; 
 that of their abortions 1222 or 1.63 for each person. 
 
 * Sec T. Gallard, " De I'avortemeut, &,c., au poiut de but meJ.- 
 legal." 
 
 f "Abortion and Sterility,'' 1847. 
 
STATISTICS OF ABORTION. 7 
 
 These figures, however, do not accurately represent 
 the frequency of abortion throughout the whole child- 
 bearing period, and a considerable proportion of the 
 women were pregnant for the first time. In any 
 case, they only afford a calculation of the average 
 number of abortions in the first half of the repro- 
 ductive period ; and inasmuch as abortion is alleged 
 to be more frequent in the latter half of the child- 
 bearing period, it is probably much below the 
 average of the whole. This is rendered the more 
 probable by some further statistics of Dr. Whitehead, 
 which he nevertheless admits are too limited to 
 warrant a general conclusion. Of sixty-four women 
 who were livino; in wedlock until after the final 
 menstrual crisis, only eight had escaped having an 
 unsuccessful pregnancy, the percentage of those who 
 had aborted being eighty-seven. 
 
 Hegar* reckons that there is about one abortion to 
 every eight or ten full-time deliveries. 
 
 Quite recently I attempted to draw up some tables 
 on the basis of looo cases concerning which I 
 possessed notes of private patients. It seemed to me 
 that as Whitehead's figures were taken exclusively 
 from the poorer classes in a manufacturing town 
 where, according to his account, they were exposed 
 to many privations, and to causes which deteriorate 
 general health, there might be some difference as to 
 the proclivity to abortion in the well-to-do classes. 
 Unfortunately I found that, so far as many of the 
 cases were concerned, the accounts of miscarriage 
 were so untrustworthy or so indistinct as to be value- 
 less. A large number of women had expressed 
 
 * " Monat. fiir Geburt." Band sxi. Sup. 
 
S THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 themselves as Laving had " many " or " several " 
 abortions, and some had persuaded themseves that 
 miscarriage had occurred when there was no satis- 
 factory evidence that pregnancy had occurred at all. 
 I took, therefore, the figures representing 400 
 jDatients, in -whom the evidence was distinct and 
 unequivocal. All the women had reached at least 
 then- 40th year, and hence the history included for 
 most of them the whole of the child-bearmg period 
 of life. 
 
 The results were as follows : 400 women had been 
 pregnant 2325 times. Of these, pregnancy had 
 resulted in living children 1783 times, and there had 
 been 542 abortions. The proportion of abortions to 
 children was, therefore, 30.40 per cent, or about 
 I in 3, Avhile the proportion of abortions to preg- 
 nancies was 23,32, or about i in 4. The number of 
 women who had borne children but had never 
 suffered abortion was 152 in the 400, or 3S per 
 cent., while the number of Avomen who had borne no 
 living child and only had abortions was 27, or 6.75 
 per cent. The sum of the pregnancies in 400 women 
 being, therefore, 2325, or 5.81 for each, and the sum 
 of the abortions being 524, it was 1.35 for each. 
 
 It will be seen that the proportion of abortions to 
 full-time pregnancies is considerably higher than 
 Hegar's computation. The proportion approximates 
 more closely to Dr. Whitehead's figures ; but there 
 is a larger average of abortions, as the calcula- 
 tion embraces a longer portion of the reproductive 
 period ; and there is another notable difierence, 
 which may perhaps be put down to easier circum- 
 stances and exemption from bodily toil — namely, 
 
STATISTICS OF ABORTION. 
 
 TABLE I. 
 Analysis op Number op Women who kab and had not ABoaTED. 
 
 Women who had not 
 
 aborted . 
 Women wlio had 
 
 aborted . 
 
 Total number of women 
 under observation . 
 
 Women who only 
 aborted — that is, 
 who had borne no 
 living child 
 
 Women below 30 years 
 of age (Whitehead). 
 
 Number. 
 
 Perccntago 
 of whole. 
 
 1253 
 
 747 
 
 62.65 
 37-35 
 
 2000 
 
 100.00 
 
 Women over 40 years of 
 age (Prietjtley). 
 
 Number. 
 152 
 248 
 
 Percentage, 
 of whole. 
 
 38.00 
 6 2. CO 
 
 400 
 
 6.75 
 
 Table I. illustrates the point tliat whereas among the younger women the pro- 
 portion who aborted was about i in 3— that is, i aborted to 2 who did not— 
 among the older women the proportion was almost exactly reversed, and 2 
 aborted to i who did not. 
 
 TABLE IL 
 
 Analysis of Phegnancies in Eepekence to Aboktions 
 and to Fecundity. 
 
 Children . 
 Abortions . 
 
 Tot. pregnancies 
 
 2000 Women below 30 years 
 of age (Whitehead). 
 
 400 Women over 40 j^ears j 
 of age (Priestley). ' 
 
 S 
 g 
 
 'A 
 
 Percent- 
 age of 
 whole. 
 
 Number 
 
 per 
 Woman. 
 
 
 
 Percent- ' Number 
 age of per 
 whole. Woman. 
 
 7459 
 ! 1222 
 
 85.92 
 14.08 
 
 3-73 
 0.61 
 
 1783 
 
 542 
 
 76.68 
 23-32 
 
 4.46 
 1-35 
 
 8681 
 
 100.00 
 
 4-34 2325 
 
 100.00 5.81 
 
 TABLE HI. 
 Eatios op Abortions to Pregnancies and Children. 
 
 Eatio of abortions to preg- 
 nancies .... 
 1 Eatio of abortions to children 
 
 Whitehead. | Priestley. 
 
 Per- 
 centage. 
 
 Being Per- Being 
 about 1 in centage. about i in 
 
 14.08 
 16.39 
 
 7 23.32 
 6 3040 
 
 4i 
 3i 
 
 Table II. shows that the older period is more pi-oductive of pregnancies than 
 the younger in the proportion of 5.81 to 4.34 or (4 to 3) ; but that the percentage 
 •■;)f them terminating in abortions is also much greater in the older period than m 
 the younger (23.32 against 14.08). Table ill. illustrates the last point iu auotlier 
 luauuer. 
 
lO TUE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 that if a comparison is made with Dr. Whitehead's 
 limited data, concerning those women who had 
 passed the menstrual epoch, it will be remarked that 
 while among the poor of the manufacturing town as 
 many as 87 per cent, had incurred abortion, only 
 62 per cent, of the women in better circumstances 
 had suffered in tliis way. 
 
 Granville, in his work on " Abortion," states that 
 of 400 women 128 of them had miscarried, and 
 among them there had been 305 abortions. Bland'' 
 computed that, out of 515 mothers, 147 of them bad 
 miscarried. Dr. Tyler Smith, writing on this sub- 
 ject in 1 85 8, remarks that, as according to the last 
 census, the married female population in England 
 and Wales between the ages of fifteen and fifty-five 
 amounted to 2,553,894, the loss of foetal life based 
 on Dr. Whitehead's or any other calculation must be 
 enormous. 
 
 As to the particular pregnancies in which abortion 
 most frequently takes place, considerable difference 
 of ojDinion exists. Dr. Tyler Smith regarded the 
 danger as greater in first pregnancies, particularly 
 among the upper classes, and in those later preg- 
 nancies which occur before the cessation of the 
 menses. Whitehead believed that the third and 
 fourth and subsequent pregnancies, and in one or 
 two of the last near the termination of the fruitful 
 period, are most commonly unsuccessful. Schroederf 
 says that there are twenty-three multiparce Vv'ho 
 abort to three primiparse. I am l^ound to say that I 
 do not think these computations at all satisfactory 
 or conclusive, inasmuch as various elements are not 
 
 * "Calculations, &c.," 1781. f " Lehrbucli der Geburt." 
 
IN LATER PERIODS OF GESTATION. I I 
 
 considered which become important factors in making- 
 the calculation. Age has a marked influence on the 
 continuance of pregnancy, be it the first or latest 
 gestation, and the social circumstances in which the 
 w^oman finds her place in life, are not without effect 
 on her successful child-bearing. Thus, women of 
 the better classes incur much more risk of aborting 
 in their first pregnancies than their poorer sisters, 
 from the prevailing fashion of taking long journeys 
 immediately after marriage. If conception begins 
 then, it is very likely to break down as the result of 
 the shakino' and fatio^ue incurred, combined with the 
 UTitation often set up in the reproductive organs, 
 as the result of the new conditions of life. 
 
 The preceding remarks refer more particularly to 
 abortion in the earlier periods of pregnancy. 
 
 Concerning the amount and frequency of foetal 
 mortality in utero in the later periods of gestation, 
 no very large amount of information is accessible. 
 There are abundant statistics by Collins, MacClin- 
 tock, Sir James Simpson, and others, concerning the 
 number of still-born children resulting from tedious,, 
 difficult, and complicated delivery, and with these 
 are included a certain number of children who died 
 antecedent to the supervention of labour. But 
 taking these two together it is obvious that the sum 
 of both, forms only a small proportion of the abso- 
 lute mortality which occurs in the later periods of 
 gestation. Of 16,654 children born in the Dublin 
 Lying-in Hospital, and recorded by Collins,* 1 1 2 1 
 were still-born. Of these still-born children, Soi 
 were either premature, or if at the full time, were 
 
 " Practical Treatise on ]\Iidwifery," 1S3J. 
 
12 THE PATHOLOGY OF INTRA-UTERIXE DEATH. 
 
 putrid, and their deatlis were therefore not due to 
 injuries during delivery, or what may be called 
 traumatic causes. 
 
 Tlie relative period of utero- gestation in which 
 intra-uterine death most frequently takes place, has 
 been variously stated, and for certain reasons cannot 
 be very precisely determined. It is probably very 
 frequent in the form of abortion during the early 
 weeks of pregnancy, and then it may produce so 
 little disturbance in a woman's Jiealth as to be 
 scarcely noticed. Among the poor this is certainly 
 the case, and consequently an estimate of its 
 frequency among them is practically impossible. 
 Madame la Chapelle '•" regarded it as most frequent 
 in the sixth month of utero-gestation. Cazeau f 
 believes abortion to be most frec^uent in the two or 
 three first months, and Depaul | states its greatest 
 frequency to be between two and a half and three 
 and a half months. Jacquemier,§ on the otlier 
 hand, declares abortion is not less fi'equent in the 
 .sixth month than in the first half of pregnancy. 
 Whitehead's fio;ures show that of 602 cases of abor- 
 tion, 275 occuiTed between two and a half and 
 three and a half months, and 147 between three 
 and a half to four and a half months. {See Table IV. ) 
 
 The stage at which development has arrived, 
 about three to three and a half months, points to a 
 jjeriod when, pro tan to, abortion may be supposed 
 the more readily to be brought about, and so coin- 
 cides with Whitehead's statistics, just quoted. 
 
 * " Pratique des Accouch."' t " Traite des Accouch." 
 
 * '• Lcoons de Clinique Obstet." 
 
 § Art. Avortement : " Diet. Encycl." 
 
PERIOD OF ABORTION. 
 
 TABLE IV. 
 
 Showing thi!: Period op Piiegnaxcy at which Abohtiox occurred 
 IN 602 Cases, the Relative Number op Still-borx and Living 
 Children, and the Number living at the end oi' a Month 
 
 AFTER BiRTU ( WHITEHEAD j. 
 
 Period of Preg- 
 ' naucy at which 
 
 Abortion 
 occurred. 
 
 1 
 
 Number of 
 
 Births at each 
 
 Period. 
 
 Number 
 still-boru. 
 
 j Number living 
 Number living; at the end of a 
 at Birth. month after 
 Birth. 
 
 j 2 months 
 
 i 3 M 
 
 |4 V 
 
 5 " 
 
 . 6 „ 
 
 7 
 
 8 „ 
 
 35 
 
 27s 
 
 147 
 30 
 32 
 55 
 28 
 
 24 
 38 
 23 
 
 8 — 
 
 17 : 3 
 
 5 I I 
 
 Total . 1 602 1 85 30 1 4 
 
 Then the villi of the chorion have become more con- 
 centrated on the decidua serotina, and the young- 
 placenta is in progress of formation. There is great 
 increased vascular activity in all the tissues, and yet 
 a certain instability, for the vascular loops projected 
 from the maternal circulation are beoimiino- to sur- 
 round the foetal villi in a delicate sort of network, 
 and the spaces which intervene between the mem- 
 bra,nes, so obvious in the earliest weeks, are not yet 
 obliterated. Besides, the union between the mem- 
 branes and the uterine walls is less stable than later 
 on, and so separation more readily occurs. Hence a 
 greater liability to blood extravasations, not only 
 into the layers of the decidua, but also between the 
 several membranes, and more especially between the 
 decidua reflexa and the chorion. From the twelfth 
 to the sixteenth week the phenomenon of " quicken- 
 ing" occurs, and if anything hinders or prevents the 
 ascent of the uterus into the abdomen, abortion is 
 
14 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 2)recipitated. Morgagni and Desormeaux * are of 
 opinion that abortion is more frequent with female 
 than with male embryos, but give no statistics ; 
 and Cazeau's reasons for thinking this may be true 
 is scarcely a sound one — namely, because at term 
 there are sixteen boys born to every fifteen girls. 
 
 Some of the indirect causes which lead to intra- 
 uterine death may be regarded as general rather 
 than specific in their effect. In the case of domestic 
 animals we find abortion, which is not infrequent 
 among them, attributed to a series of indefinite 
 causes, as bad and wet seasons, insufficient and 
 unsuital^le food, &c. ; and in women, apart from 
 injuries and specific diseases, abortion and death of 
 the foetus during pregnancy are, by most authors, 
 regarded as brought about by influences which 
 impair the general health and lower vitality, as well 
 as by mental and emotional causes, Avhich are 
 necessarily more potent in the human subject than 
 in the lower animals. 
 
 An inquiry into all the circumstances which 
 conduce to, or more directly produce, intra-uterine 
 death, extends therefore over a wide range of sub- 
 jects, and embraces a variety of pathological con- 
 siderations. Not only does it involve a minute 
 inquiry into the several morbid constitutional states 
 in the woman which may tend to destroy the oif- 
 spring, but involves also an inquiry into various 
 deviations of health which may produce a like result 
 on the side of the male parent. It includes various 
 morbid changes which take place in the uterus and 
 its appendages, in the foetal membranes and placenta, 
 * Vide Charpentier. 
 
CLASSIFICATION OF CAUSES. I 5 
 
 and, lastly, in the embryo itself. Various classifica- 
 tions of the causes of intra-uterine death have been 
 made by Spiegelberg, Leopold, Barnes, and others. 
 
 I do not propose to follow closely any of these 
 classifications, but shall take first the causes acting 
 through the male parent ; then those which act 
 through the intervention of the mother ; and, lastly, 
 those which more particularly belong to the fcetus 
 itself, although possibly remotely related to both 
 parents. 
 
 I. Causes of Intra-uterine Death referahle to the 
 Father. — Authorities concur in stating that the death 
 of the embryo, after conception, is due, in some cases 
 at least, to defects in the male parent. The fault is, 
 as it were, ah initio. Conception takes place, but it 
 is vitiated from the beginning by some alteration in 
 the fecundating fluid. The male parent may be too 
 young or too old to impart the necessary potency to 
 the spermatic fluid, and so the product of conception 
 breaks down and drops like untimely fruit, because 
 it does not possess the necessary amount of vitality 
 to prolong its development. The same thing is seen 
 in plants as in animals. The pollen-cells are some- 
 imperfectly developed, as the result of an unhealthy 
 state of the plant ; or the pollen may be injured or 
 spoilt, before or during the time it is applied to the 
 pistil, and the result is an imperfectly formed seed or 
 fruit, which never reaches maturity. This is par- 
 ticularly noticeable in dioecious plants, and in these 
 experiments can readily be verified. In birds' eggs, 
 again, it is often observed that they cannot be 
 hatched, although no imperfection can be discovered 
 in them. The fault here is prol^ably to be sought in 
 
I 6 THE TATHOLOGY OF INTRA-UTERINE DEATH. 
 
 the imperfect impregnation by the male. It seems 
 probable also that some of the forms of monstrosity 
 are due to faulty conditions in the male parent, and 
 these, in a large proportion of cases, lead to abortion 
 or premature foetal death. Debauchery, various 
 diseases and injuries from which men suffer, may so 
 deteriorate the constitution as to impair the procreat- 
 ing power, and so cause abortion in the woman. 
 
 Devilliers* points out that procreating power is 
 essentially distinct from that of development ; and 
 hence, that a man may possess the power to fertilise, 
 but his whole strength may be expended in this act, 
 and. may not extend beyond, so that there is no 
 further development. He further states that the 
 faculty of development is relative. Thus a weak 
 man may impregnate a robust woman, and, by so 
 much as she has strength to impart, the vitality of 
 the germ may be carried on entirely under the in- 
 fluence of the woman. Instances are recorded of 
 women who have aborted in every pregnancy by a 
 first husband, and by a second have gone to the full 
 time. I know of one case where a man, the subject 
 of slight albuminuria, married a young woman 
 apparently in perfect health. They had one child, 
 delicate and fragile, within a year, and the wife 
 aborted successively in three subsequent preg- 
 nancies — the husband growing weaker year by year, 
 and eventually dying of uraemia. Since then, I have 
 inquired of several authorities on renal affections, 
 whether they had remarked a special proclivity to 
 abortion in the wives of men who were the subjects 
 of albuminuria, or saccharine diabetes. I have not 
 
 * " Diet. Med. et Cliir. Pract., &c." : Jaccoud, art. Avort. 
 
SATURNINE INTOXICATION. 1/ 
 
 been able to procure any precise information on tlie 
 point, but the general outcome of opinion is that, 
 during the progress of these maladies, the vital 
 powers become so exhausted, that sexual power and 
 desire fall into abeyance ; and that it is only during 
 the slighter forms of disease that they are likely to 
 continue. My friend, Dr. Frank, of Cannes, has 
 related to me the case of a diabetic man married to 
 a healthy young woman. Their first child was born 
 alive, the diabetic tendency being slight. After this 
 the wife had a series of abortions, generally in the 
 fourth or fifth month, the diabetic condition in the 
 husband having become more confirmed. Singularly 
 enough, the wife herself eventually died after her 
 husband of albuminuria. 
 
 In the "Arch. Generales de Med.," 1 860, is a curious 
 paper by Constantin Paul, in which he shows that 
 lead-poisoning, or saturnine intoxication as it is 
 called, not only injuriously affects the child in utero 
 when the mother is the subject of it, but indkectly 
 also when the father is affected. In this way it 
 may lead to the death of the foetus i}i utero, and pro- 
 duce abortion or premature expulsion. In many 
 cases, also, where the child is born alive, the poison 
 may so lower its vitality that it does not long survive 
 its birth. Thus, of seven women whose husbands 
 suffered from lead-poisoning, there were thirty-nine 
 pregnancies. Out of these there were eleven 
 abortions and one dead-born child, and of twenty- 
 seven children born alive, eighteen died in early 
 infancy, while only nine survived. 
 
 Syphilis. — Perhaps the most potent of all poisons 
 in producing intra-uterine death, at all stages of 
 
 c 
 
I 8 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 pregnancy, is tlie poison of syphilis, and this wliether 
 the disease exists in the male or in the female 
 parent. I shall have to speak more fully afterwards 
 of its effects when the woman is the subject of 
 syphilis. Here I propose to say a few words only on 
 its influence on conception in the male. It is readily 
 understood that if a man be affected with syphilis he 
 may communicate the disease directly to a woman in 
 coitu, and the usual result will be a local affection, 
 followed by constitutional symptoms, and a general 
 poisoning of all the fountains of life — so much so, 
 indeed, that the fecundated germ as part of the 
 maternal system is blighted from the first. But it 
 is, perhaps, not so readily understood that when a 
 woman has shown no indication of syphilis in her 
 own person she may become impregnated by a 
 spermatic fluid, which carries with it so potent a 
 syphilitic virus that, in its development, it sooner or 
 later kills the product of conception, and this, in its 
 turn, so poisons the maternal blood that the woman 
 eventually becomes tainted with constitutional 
 syphilis. Charpentier, in his " Traite des Accouche- 
 ments," gives a good illustration of this indirect 
 influence of syphilis in the male on conception, and it 
 is but typical of facts accumulated by other obsers^ers. 
 A student of medicine contracted an indurated 
 chancre, followed by syphilitic roseola. This was 
 carefully and immediately treated, and he had no 
 other sie^n either then or afterwards. Two vears 
 after the primitive affection, this young man married. 
 Although he had shown no indication of syphilis in 
 the meantime, he was so anxious on the subject, that 
 he submitted himself to a fresh anti-syphilitic course 
 
SYPHILIS IN THE MALE. 1 9 
 
 for three months before his mariiaGfe. His wife's 
 first pregnancy occurred some months after the 
 marriage. She went to her full time, and her child 
 when born had syphilitic pemphigus. It was care- 
 fully treated, and apparently recovered, inasmuch as 
 up to four years of age it seemed healthy and 
 vigorous. At this time it took whooping cough, 
 followed by double pneumonia, and a blister was 
 applied to the back of its chest. In forty -eight 
 hours the whole blistered surface was covered with 
 "plaques muqueuses," and it died in forty-eight 
 hours later, in the opinion of those attending it, not 
 of the pneumonia, but of visceral syphilis. Two other 
 consecutive pregnancies of this wife ended in abor- 
 tion between three and four months. The fourth 
 pregnancy went to the full time, but the child died 
 twenty-four hours after birth of convulsions. The 
 fifth pregnancy again ended in abortion between 
 three and four months. Notwithstanding this his- 
 tory, the mother continued in good health, and 
 showed no signs of syphilis. At her own instance, 
 nevertheless, she submitted to a course of anti- 
 syphilitic treatment, and her husband again adopted 
 the same plan. Nearly seven years elapsed without 
 pregnancy, when a sixth supervened. This followed 
 its regular course, and the w^oman was in due time 
 delivered of a healthy vigorous child. This, nine 
 months after its birth, when last reported on, had 
 shown no indication of syphilis. 
 
 The idea that syphilis could be transmitted 
 directly from the father to the foetus without visibly 
 affecting the mother, was long doubted and com- 
 bated, but it has been sustained in later days by 
 
 c 2 
 
20 THE PATHOLOGY OF INTKA-LTTERINE DEATH. 
 
 Trousseau, Depaul, Vidal, Ricord, and hy Diday, 
 whose treatise on Syphilis has been translated for 
 the Sydenham Society. In our own country, Pro- 
 fessor Harvey* and Mr. Jonathan Hutchinson also 
 have adduced very cogent evidence in proof that the 
 mother may be infected by syphilis through the 
 medium of the foetus, and there is every reason to 
 believe that., in many instances where sypliilis is, so 
 to speak, latent in the husband, it is not communi- 
 cated to the wife unless she becomes pregnant by 
 him ; in other words, that coitus without conception 
 does not impart the venereal taint to the woman. 
 
 It has occurred to me on more than one occasion 
 to treat cases of pregnancy in which there was a 
 strong presumption that the male parent not only 
 begot a syphilitic child, but that the child in its 
 turn infected the mother. For instance, a young 
 man having suffered from both primary and secondary 
 syphilis two years before, and being apparently cured 
 — as all external sio-ns of venereal disease had dis- 
 appeared — married a healthy wife about his own age. 
 The wife soon became pregnant, and seemed to go on 
 ■well until the fourtli month of gestation, when, about 
 the time of quickening, she began to have great 
 irritation of the vulva, and mucous tubercles made 
 their appearance all over the vulva and round the 
 anus. The throat became affected about the same 
 time, and syphilitic psoriasis made its appearance on 
 the face and chest. Pregnancy w^ent on to the end 
 of the seventh month, when the woman was delivered 
 of a dead child, putrid, and of a placenta infiltrated 
 with nodules of whitish deposit. The mother dis- 
 
 * Vide "On the Footus in Utero," by Alex. Harvey, M.D., iS86. 
 
SYPHILIS IN THE MALE. 21 
 
 tinctly stated that she had no sore in the earlier part 
 of her pregnancy, and there was no indication of her 
 being the subject of syphiUs until nearly halfway in 
 her gestation. 
 
 As remarked by Lancereaux,* the difficulty in this 
 class of cases is to determine Avhen the contamina- 
 tion took place. The father may have had some sore 
 hidden in the urethra and not detected, and the 
 mother may have had some primary lesion which had 
 passed unperceived. In further proof, however, of 
 what has been stated, and of the persistence of 
 syphilis when apparently cured, Yidalf refers to 
 three physicians who, believing themselves cured of 
 syphilitic affections, married. The children, the issue 
 of these marriages, presented, a few days after birth, 
 evident traces of syphilitic affection, their mothers 
 never having manifested any suspicious lesion. Lan- 
 cereaux remarks that this "collection of facts furnished 
 by men well informed and placed in conditions of 
 observation often very different from each other, can- 
 not leave any doubt as to the exclusive action of the 
 father in the inheritance of syphilis." 
 
 Baerensprung, the latest authoritative writer on 
 this subject, in his work " Die Hereditaire Syphilis," 
 cites forty cases occurring in his own experience of 
 hereditary transmission by the father, and although 
 infection in all his cases did not lead to the death of 
 the foetus in uiero, yet they afford evidence of the 
 point under discussion, namely, the infection of the 
 ovum directly by the male parent. Diday quotes 
 several instances where syphilis was thus transmitted 
 
 * " On Syphilis," trans, for Sydenham Society, 1868. 
 t "Traite des Maladies Yeneriennes." 
 
2 2 THE PATHOLOGY OF IXTRA-UTP:RIN"E DEATH. 
 
 by fathers ; and Baerensprung gives fourteen cases 
 in which the father was exempt from any manifesta- 
 tion of syphiUs — it was, so to speak, latent — and yet 
 both the mother and child were infected by him. 
 Baerensprung furtlier concludes, from numerous 
 observations made by him, that syphilis in the father 
 is transmissible during the primary and secondary 
 periods only, not in the tertiary period, or, if so, in 
 a much slighter degree. 
 
 2. On the part of the Mother. — Before speaking of the 
 specific diseases and local pathological causes which 
 may produce intra-uterine death on the part of the 
 mother, it may be well to glance at the general con- 
 ditions which conduce to this end. The same general 
 causes which influence sterility, and which have been 
 indicated by Dr. Matthews Duncan,* are concerned 
 in a greater or less degree in the production of 
 abortion and premature death of the foetus. Thus 
 constitutional conditions, external agencies whicli 
 depress the general health, unhealthy habits and 
 occupations, extremes of heat and cold, climate, 
 locality, under-feedmg and over-feeding, prematurity 
 or old age ; in fact, anything in the mother which 
 tends to deteriorate strength and vigour, must be 
 counted as productive of embryonic death. Some of 
 these influences, as we have seen, are indefinite in 
 their effects, equally in the human subject as in the 
 lower animals. Others are more specific and better 
 defined. Thus, as wild animals in confinement are 
 apt to bring forth abortions, so deviations from normal 
 modes of living, in an insidious way, mar the repro- 
 ductive faculty in women. Unnatural ways of 
 
 * " Lectures on Sterility," 18S4. 
 
GENERAL TATHOLOGICAL CONDITIONS. 
 
 -:> 
 
 dressing, particularly tight-lacing and the like, late 
 hours, absence of healthy exercise in the open air, 
 confinement in close rooms, all tell in the long run 
 in producing deterioration of the individual, and just 
 as the unhealthy tree will j^i'oduce monstrous leaves 
 or flowers, or shrivelled or seedless fruit, so we have 
 the analogues in abortions, dead foetuses, sickly 
 children, and monstrous products of women. The 
 change from a temperate to a hot, relaxing climate, 
 I have noticed, predisposes women not only to over- 
 profuse and frequent menstruation, but also to 
 abortion. English women going to reside in India 
 are prone to abort. This may in part be due to the 
 luxurious habits of life and the relinquishing of 
 healthy exercise so often superadded to the hot 
 climate. These especially produce sluggishness in 
 the portal circulation and congestion of all the pelvic 
 blood-vessels. 
 
 So far as I know, we have no data by way of 
 enabling us to determine the relative effect of over- 
 or under-feeding on intra-uterine life. That both 
 have an effect is undoubted. We have the analogy 
 shown in the vegetable kingdom, where starved trees 
 and plants produce abortive fruit and seeds. On the 
 other hand, over-manuring or over-nourishment of 
 plants leads to a great growth of tissue, but it con- 
 duces to sterility or imperfectly developed fruits. In 
 the poorer class of patients, reported upon by Dr. 
 Whitehead, as we have seen, 87 per cent, had 
 suffered abortion, but in the more affluent class 
 from which I have taken my figures, 62 per cent, 
 only had aborted. But these figures do not throw 
 much light on the eftects of over- or under-feeding. 
 
2 4 THE PATHOLOGY OF IXTRA-UTERINE DEATH. 
 
 as happily it by no means follows that the majority 
 of women who can afford it feed to repletion ; nor, 
 on the other hand, are women who become hospital 
 patients, as a rule, so imperfectly fed as seriously to 
 interfere with the processes of nutrition and repro- 
 duction, I hold a strong conviction, nevertheless, 
 that over-feeding is more peruicious in its effects on 
 the product of conception than under-feeding. The 
 indulgence in larger quantities of food and stimulating 
 drinks certainly tends to produce sterihty, and in like 
 manner it imperils the safet}^ of the germ, when once 
 fertihsation has been effected. Besides overloading 
 all the tissues with more material than they can 
 assimilate, and in this way disturbing every function, 
 it more especially disturbs the portal circulation, 
 leads to a congested condition of all the pelvic 
 viscera, and thus favours blood extravasations into 
 the foetal envelopes, or provokes abnormal uterine 
 conditions. Among authors who have noticed this 
 kind of influence I may mention that Stolz* has 
 observed that fat women are often sterile, and if 
 they conceive they are apt to abort. He believes 
 this depends on nutrition taking an abnormal direc- 
 tion, and the nutritive fluids destined for the nutri- 
 tion of the embryo are thus insufficient for its 
 development. 
 
 I have notes of the effects of anaemia, of high 
 altitudes, of inter-breedirig, of plural births, of too 
 frequent or too rapidly succeeding pregnancies, of 
 prematurity and advanced age, and of tempera- 
 ment, as influencing pregnancy adversely ; but I 
 must not dwell upon each of these in great detail. 
 
 * " Des Accouchements." 
 
ANEMIA. 2 5 
 
 Ancemia in the mother is a well-recognised cause 
 of foetal death, and large and sudden losses of blood 
 from the maternal circulation may also cause death 
 of the child in ufero. Convulsions are said to have 
 been produced in the child before its death, when 
 the mother has suffered from much depletion, and 
 syncope in the pregnant woman, long continued, will 
 so suspend the utero-placental circulation as to kill 
 the unborn child. Anaemia going beyond the normal 
 limits so impoverishes the blood, that it affords but 
 feeble nutriment to the growing embryo, and so it may 
 perish from sheer inanition. Anaemia does not neces- 
 sarily prevent pregnancy, and when conception occurs 
 in a woman already anremic, this condition is apt to 
 increase. As one authority says : " Anaemic women 
 are prone to abort habitually, for in them the genital 
 function is imperfectly performed — menstruation being 
 irregular, scanty, and painful. It may be from a 
 lack of activity and tone, for these women are usually 
 pale, of feeble constitution, and subject to leucor- 
 rhoea." Jacquemier* remarks of them, that from 
 the commencement of pregnancy the uterine neck is 
 soft, partly open, very low, and acts in an indirect 
 manner in favouring abortion. The state, he adds, 
 " is allied to a state of congestion or irritabihty of 
 the uterus." 
 
 Anaemia in the mother is recognized as a cause of 
 foetal death by Leopold,! Spiegelberg,± and other 
 writers. In normal pregnancy, Cazeaux§ says there 
 
 * " Diet. Encycl." : art. Avortement. 
 
 + " Lehrbucli der Geburt." 
 
 t lUcl. 
 
 § " Traite, &c., de I'Art des Accouch." 
 
2 6 THE rATIIOLOGY OF INTHA-UTEIUNE DEATH. 
 
 is a sort of relative chlorosis or anaemia. Long ago 
 the changes in the blood produced by pregnancy 
 were investigated by Andral and Gavarret, and 
 their views have been more recently confirmed by 
 Nasse ("Archiv fur Gyn.," 1876). The whole 
 blood mass, according to these authors, is notably 
 increased, and particularly in the latter half of preg- 
 nancy. There is increase of water and a diminution 
 of the red corpuscles. The white corj)uscles in some 
 cases increase to such an extent as to ' produce what 
 Kegnault calls a "normal leucocytosis." Fibrin 
 diminishes until about the sixth month. In the last 
 three it is increased above the usual standard, and 
 the blood cups when drawn off. All the vessels are 
 more distended, more especially the pelvic ones, and 
 there is everywhere increased arterial tension, with 
 more rapid pulse. This physiological anaemia of 
 pregnancy may be so pushed beyond normal limits 
 that it not only imperils the condition of the child 
 but exhausts the mother. 
 
 Gusserow* relates five cases of j)regnancy in which 
 nothino- bat excessive anaemia could be detected, and 
 they all ended fatally. 
 
 It is to be noted, however, that pernicious or 
 excessive anaemia in the pregnant woman does not 
 necessarily lead to abortion. It may end fatally to 
 the mother without being preceded by abortion. 
 When present, however, in moderate degree, it clearly 
 has an influence in destroying the product of con- 
 ception, sometimes by starving it in ufero, at other 
 times, it may be, by leading to disease in the mem- 
 branes or placenta. 
 
 * "Arch, fill- Gyn.'' 1S71. 
 
PREMATUKITY AND ADVANCED AGE. 2/ 
 
 Higli Altitudes have iDeen stated to be incompatiljle 
 with successful pregnancy. Lancerotte and Jour- 
 danet* state that in certain mountainous regions, the 
 women habitually descend into the valleys when 
 pregnant to avoid miscarriage. The way in which 
 the elevation so acts is not explained. 
 
 Of Inter-hree.ding. — It may be said that this in 
 plants as well as animals produces weakness and 
 malformation in the progeny, and a tendency to pre- 
 mature death. The abortions of plants so produced 
 is typical of that observed in animals. Tliere is a 
 tendency to the formation of double flowers, of seeds 
 which do not ripen, and, if apparently perfect, they 
 do not germinate. 
 
 Plural births also conduce to bring about intra- 
 uterine death. Shorthouse has pointed out that 
 " twinning," as it is called, is apt to favour abortion 
 in horses, and like observations have been made in 
 the human subject. Braun, Chiari, and Spaethf 
 have produced some evidence to prove that abortions 
 are comj)aratively more frequent in plural than in 
 single pregnancies. More dead children are born, 
 and monstrosities are also common, with multiple 
 bnths, while children born alive are more difficult to 
 rear. 
 
 Neither ■prematurity nor advanced age in the 
 parent is favourable to the continuance of preg- 
 nancy. Immature plants do not ripen fruit, and 
 young animals, or girls who become pregnant before 
 maturity is reached, are apt to abort, or, if the full 
 time of gestation is reached for once, the reproductive 
 power may be so exhausted as to lead either to 
 
 * Vide Charpentier. f "Clin, der GeLurt." 1S55. 
 
2 8 THE PATHOLOGY OF INTRA-UTERIXE DEATH. 
 
 absolute sterility in the future, or to subsequent 
 abortion. Charpentier states that he has seen 
 fjirls of thirteen or thirteen-and-a-half and fourteen 
 years go to the full term, but these are exceptional 
 cases. 
 
 Again, an old bitch, as Dr. Duncan has told us, often 
 ends her career by producing a dead or premature 
 jDuppy, and it is a prevalent opinion that the last 
 born of women may either be an abortion or an idiot. 
 It is certainly a fact that the children born of the 
 later pregnancies in women are often not so well 
 developed physically nor mentally, nor so well en- 
 dowed, as the earlier children ; and this disparity is 
 the more marked if in the meantime the mother's 
 health has deteriorated, from disease or vicious 
 habits, such as drinking, &c. It is a noticeable 
 feature in the cases occurring in my own practice 
 which I have analysed, that abortion frequently ends 
 the reproductive faculty in wives ; but whether this 
 fact means that the function of the generative 
 apparatus is exhausted per se, or that the general 
 powers of the constitution have been so expended on 
 previous child-bearing, or from some other cause, as 
 to preclude the growth and nourishment of further 
 offspring, is not clear. Jacquemier asserts that it is 
 not uncommon to see women abort with the greater 
 facility the nearer they approach to the age when 
 aptitude for fecundation ceases. Depaul* does not 
 admit this, but Dr. Duncan's remark on the influence 
 of age on sterility has a direct bearing on this point. 
 Dr. Duncan says : " I know of no cause of sterility 
 or its allies — excessive production, pluriparity, abor- 
 
 * " Lemons de Clinique Obstet." 
 
EPIDEMICS OF ABORTIOiSr. 29 
 
 tion, &c. — that can be compared witli age in extent 
 and power." 
 
 Broadly, then, general causes, contradistinguished 
 from the specific, resolve themselves into any adverse 
 influences which enfeeble and depress the general 
 health of the individual parents, and so impair the 
 procreative power. There seems to be a rule, to 
 which, however, there may be exceptions, that a 
 certain measure of vitality meted out to the indi- 
 vidual may be suflScient to maintain and prolong 
 individual life indefinitely, but there mnst be a 
 superfluity of this vitality to ensure the successful 
 procreation of healthy offspring. In many cases, 
 wdiere the death of the embryo arises from obscure 
 or apparently inscrutable causes, there is no doubt 
 that some inherent weakness exists in the body of 
 the parents, which, while it f)^^iiii'fcs conception, 
 affords so small an amount of initial vitality to the 
 germ, that it dies down, out of mere feebleness, and 
 the death of the embryo thus only antedates, as it 
 were, the death of the feeble children in infancy 
 who have just survived long enough to be exjDelled 
 livino' from the interior of the womb. 
 
 Some writers, as Madame Boivin * and Madame 
 La C]mpelle,t have spoken of epidemics of abortion ; 
 but these, when inquired into, have been found 
 to be associated with famines, sieges, and the like. 
 Nagele and Hoffman j have made some observations 
 on the subject, and during the siege of Paris in 
 1870-71, abortion was noticed as particularly fre- 
 
 * " De I'Art des Accoiichements." 
 t " Pratique des Accoucliements." 
 X Vide Charpentier, " Traite Pratique des Accouchements." 
 
30 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 quent. " The children born at that time are said to be 
 one and all of a very weak constitution, and are still 
 called ' cnfants du sic'cje.'' "* Here emotional causes, 
 and constant dread of " the Prussians," were no 
 doubt important factors in bringing about the re- 
 sults mentioned ; but the utter weakness and want 
 of food suffered by large classes of people must also 
 have told in a marked degree. When epidemics of 
 abortion have been studied in domestic animals, 
 they have probably been due to some epidemic 
 disease or plague making havoc among them, of 
 Avhich abortion was the secondary effect ; or to the 
 presence of ergot either in the grain or on the 
 grasses upon which they had been fed. 
 
 Professor Nocard, of the Veterinary School of 
 Alfort, speaks of an epidemic of abortion among 
 cows which is essentially propagated by infection. 
 He says: " L'avortement epizootique semble bien 
 etre une maladie microbienne du foetus et de ses 
 envelopes, maladie a laquelle la mere reste absolu- 
 ment etrangere," f 
 
 Principal Veterinary Surgeon Fleming points out 
 that Franck, of Munich, originally demonstrated that 
 epidemics of abortion in cows depended on the 
 presence of microbes, and he shows that there 
 is abundant evidence of this fact published by 
 observers boi-h in France and Germany. | 
 
 Some recent authorities seem to doubt whether 
 ergot in grasses is so frequently a cause of abortion 
 in cows as was supposed. Mr. Harker,§ of the 
 
 * "Pall Mall Gazette," April 3rd. 1884. 
 t See "Times," October 13th, 18S6. 
 + Vide Fleming, " Veterinary Obstetrics." 
 § See "Times," October, 1886. 
 
SPECIFIC CAUSES IN TILE MOTHER. 3 I 
 
 Agricultural College, Cirencester, is among these ; 
 and the experiments of Dr. Wright, referred to by 
 Christison, seemed to indicate that ergot had no 
 power of inducing abortion in the lower animals. 
 Nevertheless, there is some curious evidence in 
 favour of ergot in grasses producing abortion in 
 cows, in Land and Water for 1884 ; and it is else- 
 where stated that abortion among cattle in New 
 Zealand was comparatively rare until the intro- 
 duction of rye-grass, and its becoming affected with 
 ergot, when it caused great losses to the farmers 
 (Fleming). 
 
 I have now to speak of the 
 
 Direct and Specific Causes in the Mother. — Some 
 acute diseases of a specific kind in the mother have 
 a very marked and direct influence in destroying 
 foetal life. This is especially observed in reference 
 to forms of illness which are attended with pyrexia 
 and increase of temperature, and the danger to the 
 child in utero bears a strict relation to the height of 
 the temperature and the amount of systemic disturb- 
 ance. It may indeed be asserted that, ceteris paribus, 
 in proportion to the gravity of the maternal affection 
 so is the danger to her progeny. It is well known 
 how serious is the complication of some febrile affec- 
 tions with the puerperal state, and it seems almost 
 to be the rule that if a pregnant woman is attacked 
 by any of the exanthemata, or in fact by any dis- 
 ease which is attended by pyrexia, and the attack 
 assumes a severe form, death of the foetus is brought 
 about, and is followed by its ultimate expulsion. 
 
 Take, for example. Small-pox. Serres, quoted by 
 Charpentier, states that in twenty-seven cases 
 
32 THE PATHOLOGY" OF INTRA- UTERINE DEATH. 
 
 which he records, there were twenty-three abortions 
 with twenty-two maternal deaths. This is a sufti- 
 cient indication of the serious complication small- 
 pox is, when combined with pregnancy. Cazeaux"^ 
 asserts that there is a great difference in reference 
 to the effects of small-pox both on the pregnancy 
 and on the life of the mother, according as the affec- 
 tion is discrete or " confluent" in its character. When 
 "confluent" smail-pox attacks a pregnant woman, 
 it acquires by the fact of pregnancy existing a par- 
 ticular gravity, and abortion is the rule, followed by 
 the death of the mother. Abortion is stated to be 
 most frequent at the suppurating stage, but it may 
 be at any period in the progress of the affection, and 
 in the later periods of pregnancy the child is some- 
 times expelled living and sometimes dead. Dr. 
 Barnes, Avho published some cases of pregnancy 
 complicated with small-pox in i868,f lays down the 
 proposition that Nature hardly tolerates the con- 
 current progress of an active disease with i^reg- 
 nancy, and that abortion in these cases may in 
 some sort be regarded as a conservative process. 
 In the three cases he records the children were born 
 alive, and he concludes that the morbid poison of a 
 zymotic disease, aggravated by further blood-poison- 
 ing resulting from arrested or disordered secretory 
 function, sets up uterine contraction, and so expels 
 the foetus without interfering with its vitality. 
 When the child dies, a variety of causes have been 
 assiofned for its death — the state of the maternal 
 blood, the infection of the child by the mother, and 
 
 * " Traite des Accouchements." 
 t " Obstet. Trans." 
 
SMALL-POX. 3 3 
 
 the Increase of the maternal temperature acting 
 injuriously on her cliild. The foetus once dead, 
 it becomes ipso facto a foreign body, and must be 
 expelled. 
 
 It has been observed that uterine hcemorrhage is 
 frequent at all stages of pregnancy during the pro- 
 gress of small-pox. This hremorrhage, according to 
 Spiegelberg and Hervieux/' is due to hasmorrhagic 
 endometritis, which separates the membranes from 
 the uterus, and in the earher months leads to abor- 
 tion, or later to premature labour. 
 
 When the child dies in the later months as the 
 result of small-pox, Brouardelf regards the death 
 as due to alterations in the maternal blood, which 
 becomes charged with an increased quantity of 
 carbonic acid, and both asphyxiates the child and 
 brings on premature uterine contraction. Spiegel- 
 berg and Charpentier regard the death of the child 
 as due to the increase of maternal temperature 
 incident to the disease, and consider that haemor- 
 rhage, when present, although it may favour uterine 
 expulsion, yet plays only a secondary part in 
 producing foetal death. It seems established that 
 during the suppurating stage of small-pox the 
 temperature is the highest, and then expulsion from 
 the uterus most frequently takes place. Children 
 thus expelled, if born alive, have been observed to 
 die soon after from convulsions. Whether this is 
 due to the disease having been conveyed by the 
 mother to the child can only be surmised. Be this as 
 it may, the mother can no doubt communicate the 
 disease to the infant in utero, for children have been 
 
 * •• Gaz. des Hopit." 1S64. t Vide Charpentier, Tr, 
 
34 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 born covered with small-pox pustules, generally less 
 advanced than those of the mother. In some cases, 
 however, the mother and child have taken the dis- 
 ease simultaneously, and the pustules have shown 
 the same stage of development in each. 
 
 Scarlatina, measles, erysipelas, diphtheria, typhoid 
 fever, and its congeners, come within the same cate- 
 gory as small-pox ; each and all are inimical to 
 pregnancy. 
 
 Scarlatina. — From the scanty records, it may be 
 inferred either that scarlatina is not frequent during 
 pregnancy, or else that its relation to the puerperal 
 state after delivery has absorbed the attention of 
 authors to the exclusion of the earlier period. The 
 disease is well known to be an especially perilous 
 complication in the puerperal patient, but Cazeau 
 expresses his belief that pregnant women are not apt 
 to contract the disease, and Montgomery thought the 
 poison when absorbed during pregnancy might remain 
 latent until delivery, when its characteristic effects 
 would be produced. Nevertheless, Bourgeois* men- 
 tions an epidemic observed in Vienna, in 1801, 
 where the disease assumed a very grave form, and 
 all pregnant women miscarried, most of them dying. 
 
 Measles, like scarlatina, has a tendency to provoke 
 premature emptying of the gravid uterus and to 
 destroy embryonic life, but its effect is less virulent 
 in this respect than small-pox and scarlatina. Levret 
 notices it in these relations, and regarded it as par- 
 taking of the gravity of other eruptive fevers during 
 pregnancy, and nearly always provoking abortion. 
 Bourgeois, in the " Memoires de 1' Academic de 
 
 * "Memoires de I'Acad. de M6l1." 1861. 
 
FEVERS. 3 5 
 
 Mcdecine," states that of fifteen cases of measles 
 during pregnancy there were eight abortions or 
 deUveries before term. The signs of abortion gene- 
 rally showed themselves towards the end of the 
 disease, and the disease itself was usually less viru- 
 lent if attacking the patient in early pregnancy than 
 at a later period. When a woman was near the full 
 term, and was seized with measles, the signs of 
 labour began in the midst of the fever, and grave 
 symptoms were generally developed. The child was 
 usually born dead or died soon after birth. 
 
 De Tourcoing, mentioned by Playfair, states tliat 
 out of fifteen cases the mother aborted in seven, these 
 being all severe attacks. Some cases are recorded in 
 which the child was born with the rubeolous eruption 
 upon it. 
 
 Erysipelas also, if attacking a pregnant woman, 
 may, like other affections attended by pyrexifi, lead to 
 abortion or premature labour. If the elevation of tem- 
 perature be great, the life of the foetus may be compro- 
 mised. According to the opinion of authorities, it is 
 less grave in its effects than small-pox or scarlatina, 
 and about on a level in f-his respect with measles. 
 
 Typhoid Fever and its congeners have received a 
 considerable amount of attention in their relation to 
 pregnancy. At one time Kokitansky and Niemeyer 
 were quoted as believing that pregnancy gEive a sort 
 ■of immunity from typhoid, but the later opinions of 
 Jenner and Murchison do not bear out this statement. 
 Murchison and others have shown that not only many 
 pregnant women contract the disease, but they may be 
 the subjects of some other varieties of fever, as typhus 
 and relapsing fever. Murchison says, if a woman far 
 
 D 2 
 
36 THE PATHOLOGY OF INTRA-UTERIXE DEATH. 
 
 advanced in pregnancy is attacked with typhoid or 
 enteric fever, the case is almost certain to be fatal ; 
 death being usually preceded by abortion. He further 
 says that abortion during the progress of typhus is 
 the exception, and if labour is induced by the disease 
 near the full time, the child lives. In relapsing 
 fever, on the contrary, pregnant females, no matter 
 at what stage of pregnancy they are attacked, almost 
 invariably miscarry. Of thirty-six pregnant women 
 who took the fever, luider Smith and Jackson, all 
 miscarried but one. If pregnancy is far advanced, the- 
 child is always stillborn, or only survives a few hours. 
 
 According to some observations published by 
 Weber in 1870 (in the Berlin "Klin. Wochensch."),. 
 of sixty- three cases of typhoid in pregnant Avomen, 
 there were twenty-three abortions, forty going to the- 
 full time. Of 322 cases collected by Charpentier, 
 abortion and premature delivery occurred 182 times ;. 
 in 140 cases pregnancy was not interfered with. 
 When the child was born prematurely, it was often 
 dead or died soon after birth. Charpentier states- 
 that typhoid has been observed more frequently in 
 the early than in the later months of joregnancy, and 
 if uterine action is broug-ht on in the earlier stag-es, 
 it more certainly leads to the death of the embryo.. 
 Spiegelberg alleges that the danger is not so much 
 influenced by the form which the fever assumes, as- 
 by the period of pregnancy at which the attack 
 begins. The danger is greatest in the earlier months,, 
 because it is apt to lead to more serious uterine 
 haemorrhage than in the later months, when it may 
 only induce premature labour. 
 
 Pneumonia. — Of the non-specific forms of disease 
 
PNEUMONIA. 37 
 
 -attended by fevev, I may instance pneumonia, which 
 has always a special gravity when, complicated by 
 pregnancy. If severe, it almost invariably leads to 
 ■emptying of the uterus, and then it depends, to some 
 -extent at least, upon the date of the pregnancy and 
 the rapidity of its expulsion as to whether the child 
 is born alive. I have on more than one occasion seen 
 abortion produced in the earlier months as the result 
 of a sharp attack of pneumonia or pleiiro-pneuraonia, 
 .and I particularly recollect one case I attended with 
 n"!y friend Dr. Henri Gueneau de Mussy where, during 
 an attack of pneumonia, a foetus was expelled at the 
 fourth month, of a deep red colour, and the placenta 
 was retained. The complication thus arising was a 
 very serious one, as with the activity of change 
 going on in the body of the patient the retained 
 placenta showed signs of very rapid decomposition, 
 and consequent contamination of the maternal blood. 
 The placenta was at length removed, but with great 
 difficulty, on account of the rigid contraction of the 
 uterus, and from that moment there was an ameliora- 
 tion of all the symptoms, and the patient eventually 
 recovered. 
 
 The causes of the expulsion and death of the foetus 
 during pneumonia are said by Churchill," Cazeaux, 
 and others, to be the violence of the cough and other 
 attendant symptoms. Grisollef considers that the 
 importance of the organs affected, the suddenness of 
 the attack, the intensity of the fever, and the number 
 of sympathetic phenomena, disturb all the bodily 
 functions, and are sufficient to account for the inter- 
 ruption to pregnancy. 
 
 * " I\ridwifery." f " Traite Je Pathol. lutcrn." 
 
38 TUE PATHOLOGY OF INTRA-L'TERIXE DEATH. 
 
 Ricau* and Chatelainf state that the hindrance 
 to respiration accumulates carbonic acid in the bloody 
 which thus becomes inimical to foetal life, and induces 
 uterine contraction. Eicau, wlio wrote an interesting 
 thesis on this subject in 1874, collected forty-three 
 cases of pregnancy complicated with pneumonia, and 
 in these the foetus was expelled prematurely in 
 twenty-one cases, or nearly half, eleven of the children 
 being: not viable. 
 
 Pleurisy may also^ if severe, imperil pregnancy in 
 the same way. 
 
 The feverish state which follows surgical opera- 
 tions frequently leads to abortion and premature 
 labour, if the constitutional state of the mother 
 is seriously disturbed, and this apparently apart 
 from the reflex effect of such minor operations 
 as, for instance, tooth-extraction, which has been 
 followed by abortion. I have repeatedly noticed, 
 after surgical operations on pregnant women, that as 
 soon as there were distinct evidences of the patient 
 going wrong from septic poisoning, uterine disturb- 
 ance has set in, and if the symptoms increase haemor- 
 rhage begins, which is followed by the expulsion of 
 the embryo. In other cases the emptying of the 
 uterus has been almost the last act of vitality before 
 the death of the patient. Thus, in the case of a 
 woman who, being five months pregnant, had sub- 
 mitted to colotomy for obstruction of the bowels, 
 irritative fever set in after the operation, and she 
 eventually died of blood-poisoning. A few hours 
 before death, the uterus was emptied by a sudden 
 
 * " These," 18S4. f Vide Charpentier. 
 
EFFECTS OF HIGH TEMPERATURE. 39 
 
 expulsive effort, the child being extruded enveloped 
 in the membranes and placenta entire. There was 
 scarcely any flooding, and the uterus contracted firmly 
 afterwards. It seemed, so to speak, that Nature, 
 finding life was surely departing from the mother, 
 made an effort to save her ojBTspring, the last and final 
 act of her being. Since the child was too premature 
 to be viable, the effort was unavailing-. 
 
 The study of the way in which acute diseases, 
 attended with elevated temperature, bring about 
 intra-uterine death and expulsion of the embryo is 
 very interesting. 
 
 In 1833, HohP found that the temperature of the 
 mother not only influenced the child, but he found 
 also that it increased the pulse of the foetus, and a 
 diminution of heat made the foetal pulse slower. 
 Hut erf made similar observations in 1861. In six 
 cases he noted a marked increase of the foetal pul- 
 sations corresponding to increased frequency of the 
 maternal jDulse. Fiedler, | in 1 8 6 2 , watched two cases 
 of typhus with pregnancy, and he found the pulse of 
 the foetus was increased in frequency like the mother's 
 pulse, and it showed similar morning remissions and 
 evening exacerbations. In the charts he made, he 
 found the fever-curve of the mother's pulse parallel 
 with the frequency of the foetal heart. Kaminsky,§ 
 during an epidemic of typhus and recurring fever in 
 Kussia, in 1866, saw eighty-seven cases with preg- 
 nancy ; fifty-five were in the first half of gestation, 
 thirty -two in the second half As soon as the 
 
 * "Die Geburtshiilf Explor." 18S3. 
 t "Monatss. filr Gebnrt.s." 1861. 
 i "Archiv der Heilkunde," 1862. 
 § "Moskauer Med. Zeit." 1866. 
 
40 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 temperature of a ]^regnant woman reached 40° C. 
 (104° F.), lie observed the child to become disturbed, 
 (i) There was increased activity of its heart, parallel 
 with the increased temperature of the mother. (2) 
 Increased restless movements of the child, the higher 
 the maternal temperature. These signs were marked 
 until the temperature reached 42.5"^ C. (108° F.), 
 when the movements ceased, and he inferred the 
 child was dead. Danger began at 40° C, and in- 
 creased with each advance of temperature. The 
 more intense the feverish state of the mother, the 
 surer was the death of the child. The child so 
 killed was not necessarily thrown off immediately, 
 but might be retained for some time. In only two 
 cases in the latter half of pregnancy was uterine 
 haemorrhage observed, while it was much more 
 frequent in the first half Similar observations were 
 made by Winckel,"^ in 1869, and Lohlein, in a grave 
 case of erysipelas, counted the child's heart-beats at 
 200 in the minute. 
 
 These observations suggested to Runge the idea 
 of making some experiments on the effects of high 
 temperature on the gestation of lower animals, and 
 in the " Archivfiir Gynecol." for 1877 his results are 
 published. He placed a series of pregnant rabbits 
 in a well-ventilated box, and raised its temperature 
 in ten minutes to 50° C. (122° F.). The temperature 
 of the animal increased 1° in each five minutes, and 
 the animal died in forty minutes from " heat-stroke " 
 — analogous, I presume, to sun-stroke — if not re- 
 moved from the box. But the remarkable thing was 
 that the foetuses in utero died when a certain temper- 
 
 * "Pathol, der GeLurt." 1S69. 
 
EFFECTS OF HIGH TEMPERATURE. 4 1 
 
 atiire wns reached wliicli M^as not sufficient to kill the 
 mother. liunge took the maternal temperature 
 every ten minutes, and killed the animals, with 
 certain precautions, when it reached an elevation 
 varying from 39° to 42° C. On the uterus being- 
 opened, the foetuses were found sometimes dead, 
 sometimes living, and their temperature was con- 
 stantly found some tenths of a degree higher than 
 that of the mother. They were dead every time the 
 temperature rose to 41.5° C. (106.7'^ F.), and were 
 always alive when the maternal temperature was not 
 higher than 40.5° C, or a little over 104° P. At 
 intermediate temperatures they were sometimes 
 dead, sometimes living. The chief lesions were 
 dilatation of the right ventricle of the heart, which 
 was distended with blood, and retraction of the left 
 ventricle, which was hardened by contraction. 
 From these experiments Runge concludes that : 
 
 1. The temperature of the foetus is habitually 
 higher than that of the mother, and keeps higher 
 when the mother's heat becomes abnormal, 
 
 2. That the foetus dies solely from the heat l^efore 
 it becomes fatal to the mother. 
 
 3. That the temperature of the mother if only 
 raised for a short period to 41.5° C. is fatal to the 
 foetus. 
 
 In reference to this last deduction, it has been re- 
 marked that the danger probably does not at once 
 cease with the reduction of the mother's temperature 
 to normal, for Claude Bernard has seen animals sub- 
 mitted to experiment die several days after being 
 removed safe from a heated stove. 
 
 These experiments of Kunge's are extremely in- 
 
42 THE TATHOLOGY OF INTRA-UTERINE DEATH. 
 
 teresting, and I thought it might be easy to ascertain 
 Avhether the inference he draws from them is correct, 
 that the animal heat is proportionately higher in the 
 foetus than in the mother, even when no abnormal 
 condition is present. In order to elucidate this 
 point, Mr. Tyrell Brooks, of the Physiological 
 Laboratory in King's College, kindly undertook to 
 make some experiments under my direction. It 
 seemed at first an investigation of no great difficulty, 
 and yet it was less easy than might be supposed. 
 It was necessary, in order to avoid the infliction 
 of pain, to put the animals under chloroform, and 
 rabbits were found so sensitive to the anojsthetic, 
 that their ordinary temperature was speedily altered, 
 and it sank progressively with the depth of the 
 anaesthesia. Nevertheless, by careful management, 
 and by wrapping the body up in warm flannels, the 
 heat was fairly kept up during the continuance of 
 the experiment. Dr. Sclater, of the Zoological 
 Society, was good enough to lend me the very 
 sensitive thermometer which had been used for 
 taking the temperature of the python during in- 
 cubation at the Zoological Gardens, and in this 
 instrument the column of mercury would run up 
 the entire length of its fine tube in from three to 
 six seconds. This we used in one experiment, but 
 it was found that good sensitive chnical thermometers 
 answered practically very well, and it was necessary 
 to use three at the same moment, so as to make the 
 temperature in the several localities relative. Thus, 
 one was placed in the vagina, the temperature being 
 taken there ; afterwards an incision was made into 
 
EFPECTS OF HIGH TEMPERATURE. 43 
 
 the abdomen and uterus — a thermometer was placed 
 in the cavity of the womb, and another in some part 
 of the body of a foetus, the vaginal thermometer still 
 being retained, and its variations carefully watched. 
 Ilie result showed that in all the experiments where 
 vitality was not so suddenly lowered by the chloro- 
 form as seriously to disturb the animal temperature, 
 there was a marked difference between the vaginal, 
 the uterine, and the foetal temperature. Thus, in a 
 large pregnant white rabbit marked with black, the 
 vaginal temperature was ioo°F., the uterine temper- 
 ature 101.4°. Both temperatures w^ere taken simul- 
 taneously. A foetus being found, a thermometer was 
 introduced into its mouth, and another into the 
 uterine cavity. The uterine temperature was then 
 100°, the foetal 100.6°. Ten minutes later a second 
 observation was made on another foetus, three ther- 
 mometers being used. The uterine temperature was 
 then 99.1°, the foetal (taken in the mouth) 99.3°, the 
 vaginal 98°. In another ten minutes the other cornu 
 of the uterus was opened, and a third observation taken. 
 The uterine temperature was then 99°, the foetal 99. s"? 
 and the vaginal 98.5°. The foetal temperature in this 
 case was taken in the cavity of the peritoneum, which 
 probably accounts for the higher relative temperature. 
 After another ten minutes' interval a fourth foetus was 
 exposed, and the temperatures were — uterine 97.9°, 
 foetal (taken in the mouth) 98.8°, vaginal 97.7°. The 
 natural temperature of the rabbit is about two 
 degrees higher than in the human subject, but it will 
 be observed that the animal heat gradually sank 
 during the experiments, apparently as the result of 
 
44 'i'lIE PATHOLOGY OF INTRA-UTERIXE DEATH. 
 
 tlie anaesthesia. The relative height of the temper- 
 atures nevertlisless remained the same, the f(jetal 
 being invariably the liighest. 
 
 The temperature of the cat is nearly that of the 
 human subject, and in one of these animals near the 
 full period of pregnancy, deeply chloroformed, the 
 vaginal and uterine temperatures being taken simul- 
 taneously, the former was found to be 99°, the uterine 
 100°. Some time was here lost on account of 
 hasmorrhage occurring from divided uterme veins. 
 A foetus at length being secured, the temperature 
 was taken and found to be: vaginal, 98°; uterine, 
 99.6°; foetal, 99.5°. There^was probably some error 
 here, due to the placenta of the foetus being sepa- 
 rated from the uterus several minutes before the 
 temperature was taken, for in two other observations 
 on foetuses in the same uterus the temperature was 
 as follows : 
 
 Yaginal, 98.2° Vaginal, 96.5° 
 
 Uterine, 98.4° Uterine, 99° 
 
 Fostal, 99° Foetal, 99.3°. 
 
 These experiments were repeated on other animals, 
 but these details are a fair sample of the whole. In 
 all the uterine temperature was relatively higher 
 than that of other parts of the pregnant animal, and 
 in all, except in one instance, where a shock was 
 given to the vitality of the foetus, the foetal tempera- 
 ture was higher, sometimes considerably higher than 
 the general temperature of the body of the mother. 
 Further, the temperature of the ftetus, although not 
 sinking so fif-t as the maternal temperature, was 
 manifestly influenced by it, declining at a somewhat 
 
EFFECTS OF HIGH TEMPERATURE. 45 
 
 loss rapid rate, but still keeping a sort of relation to 
 tlie heat of the mother's body. 
 
 All the facts collectively are very instructive. It 
 follows that if the temperature of the mother is raised 
 either as the result of experiment, or from diseased 
 action, the temperature of the foetus will rise with it, 
 and inasmuch as this is higher from the first, the 
 foetus will arrive at the heat indicatino- dano-er before 
 the mother does. Winckel indeed remarks that it 
 is probable the foetal warmth rises in quicker pro- 
 portion in the foetus, because the liqour amnii, part 
 of whose function it is to conduct heat from the 
 foetal body, becomes itself over-heated, and so ceases 
 to control the foetal temperature. I may mention 
 that I have taken the temperature of the foetus while 
 in utero in a case of breech presentation. In this 
 case I put a clinical thermometer into the foetal anus, 
 and the temperature then was five-tenths of a degree 
 higher than in the maternal vagina. Gusserow has 
 shown that the temperature of the foetus immediately 
 after birth is constantly from 0.1° to 0.3° above that 
 of the maternal uterus and vaoina. 
 
 It seems to be well known to physiologists that 
 wherever great activity of function is going on in 
 animal bodies there will be an increase of temperature. 
 Professor Gerald Yeo informs me that there is in- 
 crease of heat in the liver, beyond what is observed 
 in other parts of the body, and this is most notable 
 after a meal. The observations of M. Valencienne 
 and Dr. Sclater have demonstrated that a consider- 
 able increase of heat is generated in the body of the 
 female python during incubation, but the remarkable 
 thing, and one perhaps which has not been sufficiently 
 
46 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 appreciated, is that regions of the body in mararai- 
 ferous animals, where rapid nutrition or change are 
 going on, may have a considerably higher temperature 
 than the rest of the body, and it is just possible that 
 some suggestions for treatment by way of controlling 
 local temperature may arise out of this. 
 
 The next point of inquiry or conjecture is, how 
 does increase of heat destroy the foetus in utero / In 
 other words, what is the modus oiierandi- Is it 
 from " heat-stroke," somewhat analogous to " sun- 
 stroke," which, according to Runge, killed the adult 
 rabbits when long exposed to high temperature ^. 
 Houlier"* has stated his belief that death is owing to 
 degeneration of the myocardium. The heart at tirst 
 becomes excited, then paralysed, and there is coagu- 
 lation of the myosin. The same author states that 
 in a child born of an eclamptic mother with a tem- 
 perature of 40° C. at the moment of birth, he found 
 granular degeneration of the cardiac vessels. I am, 
 however, informed that it Avould require a tem- 
 perature of 60° C. to coagulate myosin, so that some 
 other explanation must be sought for. From the 
 highly congested appearance of the foetus expelled 
 during the continuance of high fever tem23erature in 
 the mother, it is obvious, that as the result of the 
 heat, all the capillary blood-vessels become over- 
 charged, and a state of hyperemia is engendered, 
 which is quite incompatible A^ith foetal life. Not 
 only is the cutaneous surface of a deep livid colour 
 from distension of the capillaries, but every tissue in 
 the interior of the foetal bodv is ejor2:ed Avith blood, 
 as in a state of active inflammation. These changes 
 
 * Sec Charpentier, " Trait(5," &.c. 
 
EFFECTS OF HIGH TEMPERATURE. 47 
 
 of themselves one may imagine would be sufficient 
 to account for the movements of the foetus first 
 becoming restless, then convulsive, and at last 
 ceasing altogether. On microscopic examination of 
 the congested tissues, I found the capillaries dis- 
 tended with blood, and the globules heaped up in 
 confused masses, with here and there indications of 
 rui^ture, and more or less of extra- vascular exudation. 
 
 It will be observed that, while the heat-theory 
 affords a tolerably clear explanation of the cause of 
 death in utero during the progress of diseases in 
 which the maternal temperature is raised largely 
 above the normal standard, it yet furnishes no 
 adequate explanation of those cases in w^hich the 
 foetus is frequently and rapidly expelled from the 
 uterus, alive or dead, during the progress of some of 
 these affections. It is true that the child may die 
 from increased internal temperature, and be long- 
 retained after its death. It is also true that, in a 
 large number of instances, the fostus is expelled 
 alive ; and if sufficiently developed it may continue 
 to live, although it is prone to succumb after birth, 
 even if near the full time. 
 
 The explanation of this tendency to forcible uterine 
 contraction is, I take it, to be found in some obser- 
 vations of Brown-Sequard^ in 1S51. This dis- 
 tinguished physiologist showed that the circulation of 
 dark venous blood — that is, blood imperfectly aerated, 
 or from any cause rendered impure and charged with 
 carbonic acid — had a remarkable effect in stimu- 
 lating the nervous centres and contractile tissues. 
 He made the deduction that oxygen gave and 
 
 * See " Journal de Physiol.'' 
 
48 THE PATHOLOGY OF INTRA- UTERINE DEATH. 
 
 created contractile force ; carbonic acid Ijroucrlit 
 contraction into play. These elements properly 
 correlated and balanced, are in consonance with the 
 continuance of pregnancy. If blood accumulates in 
 the uterine sinuses, not only does distension act in 
 promoting rliythmical contraction, l^ut the carbonic 
 acid of the blood is still more potent in Ijringing 
 the uterine muscles into play, and so stagnation is 
 prevented. Anything, therefore, which disturbs the 
 systemic circulation, and more especially anything 
 which prevents or retards the proper aeration of the 
 maternal blood, acts as a direct incentive to uterine 
 action ; and if this passes beyond the normal physio- 
 logical limits, abortion or premature labour is the 
 result. 
 
 In pneumonia, in the eruptive fevers, and in other 
 diseases or injuries attended with febrile excitement, 
 we have this pathological state directly induced, and 
 hence the liability to emptying of the uterus. The 
 same explanation would apply to asphyxia in the 
 mother. It is recorded* that, during a razzia in 
 Algeria, conducted by the Due de Malakoff, hundreds 
 of Arab women were suffocated in the caverns of 
 Dahra, and it was found that many of those pregnant 
 had aborted. The same thing occurred in a similar 
 exploit under the celebrated Chevalier Bayard. In 
 some forms of heart-disease, and in some of the other 
 acute or chronic lesions of the circulation, similar 
 pathological conditions may be produced, and so 
 lead to premature uterine action. 
 
 There is still another complication occurring in 
 connection with pregnancy, and said to be attended 
 
 * Tvler Smith. "Manual of Obstetrics." 
 
PUERPERAL ECLAMPSIA. 49 
 
 "vvitli remarkable increase of heat, wliicli can scarcely 
 be passed over without notice. 
 
 In Eclampsia, or puerperal convulsions, it is well 
 known that great peril attends the child. If labour 
 and rapid delivery follo^v the supervention of con- 
 vulsions towards the end of pregnancy, the child 
 may survive, but convulsions are almost uniformly 
 fatal to it if labour does not come on. The child is 
 then expelled later, marked by such changes as are 
 peculiar to the longer or shorter time it is retained 
 in utero. The nearer the attack of convulsions comes 
 on to the completion of pregnancy, the greater the 
 chance of its preservation, and the chance is the 
 greater if convulsion comes on for the first time 
 during labour, and the case admits of speedy delivery. 
 The cause of foetal death in eclampsia has been 
 attributed to the convulsions interfering with the 
 h^emastosis of the blood — that is, producing asphyxia. 
 
 Braun,* of Vienna, believes uraemia to be the 
 cause of death. The foetus is impressed by the first 
 or second access, and almost always dies after a 
 certain number of attacks. If the mother dies, and 
 the child is removed by the CsBsarean section, it is 
 always dead. It is asserted that if the child is 
 perchance born alive, much urea is found coming 
 from the cord ; if dead, much carbonate of ammonia 
 is found in the blood. It is further asserted that 
 uraemia may kill the child without eclampsia having 
 come on, and that the children of eclamptic patients 
 are often albuminuric. 
 
 In seeking for the explanation of foetal death in 
 puerperal convulsions, Winckelf claims that he first 
 
 * " Lehrbuch der Gesammt Gyn." f " Berichte und Studien." 
 
 E 
 
50 THE PATHOLOGY OF INTllA-UTERINE DEATH. 
 
 pointed out a remarkable rise of temperature in the 
 mother during the paroxysms. The French dispute 
 his priority, and Charpentier, in controverting his 
 claim, makes an attack upon him which shows that 
 the anti-German feeling has permeated even the 
 realm of science. He endeavours to show that Kien, 
 a pupil of Hirtz, made the first serious researches 
 with the thermometer in eclampsia, and after him 
 Bourne ville,* a pupil of Charcot's, who, in 1871 and 
 1875, made observations on thirteen patients, to 
 which he adds four of Budin. Bourneville concludes 
 that the temperature increases from the beginning 
 of the attacks to the end ; it ninj run up to 43° C. or 
 i09'4°F. In the intervals, a high temperature is 
 maintained, and this is slightly increased with each 
 paroxysm. If the case terminates fatally to the 
 mother, the temperature goes on increasing until 
 death, but, if better symptoms supervene, the 
 temperature declines. 
 
 In view of the researches of Runge, therefore, it 
 may be that foetal death in eclampsia is due to such 
 elevation of temperature in the mother's body as is 
 incompatible with the safety of the child. When 
 the temperature does not reach so high a standard, 
 the death must be attributed to uterine contraction 
 producing imperfect aeration of the blood, or vitiation 
 of the blood from urpemic poison. 
 
 It is stated that there is a very marked contrast 
 in the temperature of the patients suffering from 
 puerperal eclampsia and those stricken with con- 
 vulsions the result of general urpemia, and it is 
 asserted that the therm(3meter indicates a positive 
 diagnosis between the two ; for while in eclampsia 
 
 * "Archives de Tocol." 1875. 
 
PHTHISIS. 5 1 
 
 the temperature always rises, and may run up, 
 indeed, to 43° C, in uroemic convulsions and coma — 
 and equally in men and women — the temperature 
 invariably falls progressively, and sometimes falls to 
 30° C With some exceptions, it falls until death. 
 The authors mentioned, therefore, conclude that 
 eclampsia is not from uraemia, because the tem- 
 perature is different in the two cases. 
 
 Hoffmeier"'" states " that in thirty-three cases of 
 simple nephritis twenty children died, thirteen only 
 lived. In 104 cases of nephritis with eclampsia 
 sixty-two children died and forty-six lived — that is, 
 on a total of 1 3 7 births eighty-two infants died and 
 sixty-one only lived. Kayer, Fordyce Barker, and 
 Hubert, of Louvain, admit the frequency of abortion 
 and premature labour in women who have albuminous 
 urine, and Braun estimated the foetal mortality in 
 such cases at eighty per cent." t 
 
 There are some diseases of women, attended by 
 abnormal increase of temperature, in which the 
 tendency to abortion and premature labour is greater 
 than in healthy women, and yet in which the higher 
 temperature probably plays but an unimportant part 
 in contributing to foetal death. 
 
 In Phthisis there is an admitted fertility among 
 women which is almost abnormal, and the tendency 
 to abortion and premature delivery, although not very 
 striking, is yet greater than among iiealthy women. 
 We are indebted for much precise information on this 
 subject to theses published in France by M. Ortega 
 and M. Gaulard, quoted by Charpentier. 
 
 * Vide Charpentier. 
 
 f " At the recent meeting of Gei-man scientists and medical men. 
 at Strasburg, Dr. Fehling, of Stuttgart, read a memoir on habitual 
 death of the embryo in kidney disease. In the first case under his 
 
5 2 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 Mr. J. Scott Battams, in the " Lancet " of 1 8 8 3 , gives 
 some statistics relative to this subject — as well as on 
 the influence of syphilis. Seventeen mothers bring- 
 ing phthisical, rickety, or atrophic children for advice 
 had collectively been pregnant ninety times — twenty- 
 four of these pregnancies had terminated in abortion 
 — and there had been thirty-seven infantile deaths. 
 Mr. Battams remarks that these figures illustrate 
 the well-known fertility of phthisical women. Lebert 
 (Archiv fiir Gyn. 1877) says that " advanced 
 phthisis prevents pregnancy. In early stages it does 
 not do so, and pregnancy as a rule will go the full 
 time. Pregnancy, abortion and delivery determine 
 the development of phthisis in those predisposed to it. 
 Children born of phthisical parents are ordinarily 
 feeble ; often they are first scrofulous and then tuber- 
 observation, premature expulsion of a dead foetus occurred six times 
 and there was no evidence of syphilis. At every pregnancy, anasarca, 
 albuminuria, and death of the foetus, with severe cramp of the abdo- 
 minal muscles, occurred between the fifth and six months ; the dead 
 foetus was exj^elled from three to ten weeks later. In the second case, 
 similar symptoms appeared in a young unipara; the foetus died, and 
 thereupon the albuminuria abated. In the third case, the patient had 
 borne two healthy children. During her third pregnancy, albuminuria 
 and characteristic changes in the retina occurred; and during the 
 fourth she was seized with hemiplegia ; in both a decomposed foetus 
 was expelled at the fifth month, with subsequent decrease of the albu- 
 minuria. In the fourth case, the patient in her first pregnancy aborted 
 at the fifth month ; then she gave birth at term to a recently dead 
 child. In the third pregnancy great oedema and albuminuria super- 
 vened, the child was still-born, and. the mother died of ura3mia. Dr. 
 Fehling believed that in all these cases kidney disease existed before 
 pregnancy, which aggravated the renal symptoms. Winter had 
 described two cases of premature detachment of the placenta, normally 
 situated, where albuminuria existed. Dr. Fehling found atrophy of 
 the villi of the chorion, with wedge-shaped or spherical infarcts in 
 the placenta, in his cases, similar to renal infarcts. The infiltration 
 of the chorionic villi and vessels of the umbiHcal cord with small cells, 
 as suen in syphilis, was absent, nor did any of the embryos exhibit 
 a trace of congenital syphilis." — British Medical Juunial. 
 
DIABETES. 5 3 
 
 culous." The well marked anasmia which is so 
 constantly a concomitant of phthisis is no doubt 
 largely concerned not only in leading to intra-uteririe 
 death, but in the production of feeble progeny when 
 the children are born alive. 
 
 The measure of vitality in children either intra- or 
 extra- uterine, bears a sort of relation to the strength 
 or exhaustion of the mother at the moment of con- 
 ception, and during pregnancy. In the early stages 
 of phthisis the disease seems to be arrested by the 
 occurrence of pregnancy. An impulse is given to 
 nutrition generally, — but later when the growing 
 foetus makes more demand on the resources of the 
 mother, the disease advances more rapidly. It has 
 been remarked also that when phthisis comes on 
 during gestation or is developed in those predisposed 
 to it as the result of exhaustion by child-bearing — a 
 renewed pregnancy rarely goes to the full term. 
 
 Diabetes. — Saccharine diabetes deserves a moment's 
 notice in relation to its influence on foetal life. The 
 presence of sugar is common as an ingredient of the 
 urine in the course of pregnancy, and no harm may 
 result from it, but when diabetes w^ith its usual 
 attendant symptoms is fully developed, the results 
 to intra-uterine life are very adverse. In a paper 
 published by Dr. M. Duncan on Puerperal Diabetes, 
 in 1 88 2,* it is stated that in seven of nineteen 
 pregnancies in fourteen mothers, the child died during 
 pregnancy, having in all these reached a viable age. 
 In two more the child was feeble, and died a few 
 hours after birth, making an unsuccessful result in 
 nine out of nineteen pregnancies. The dead child 
 was sometimes described as enormous, or its weight 
 
 * "Obstet. Trans." 
 
54 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 extraordinary. Tliis was probably in part at least 
 from dropsical infiltration. Hydramnios was frequent, 
 and sugar was found in the liquor amnii. 
 
 Jaundice, in some of its forms, has a decidedly 
 adverse effect on foetal life, Cazeaux, Hervieux and 
 Bardinet speak of an " abortive jaundice." Epidemic 
 forms of jaundice indeed have been observed affecting 
 alike pregnant and non-pregnant women, and in those 
 pregnant, the affection always assumed an exceptional 
 severity. In the simpler or more benign forms 
 associated sometimes with the gravid condition, the 
 jaundice may be only due to functional derangement 
 or to physical pressure. These forms are not 
 generally serious unless attended with much pyrexia, 
 when the element of high temperature comes into 
 play. In the more malignant types, the intensity of 
 the blood-poisoning, as observed by Woillez, was so 
 great, that some of the patients died before abortion 
 or delivery could take place, and in those a shade 
 less severe collected from the writings of dijfferent 
 observers, there were forty- two abortions or pre- 
 mature deliveries in sixty- eight cases, with thirty 
 maternal deaths. The abortion generally took place 
 from three to five days from the beginning of the 
 jaundice, and it was generally after the abortion that 
 the gravest symptoms set in. The rise of temperature 
 in these instances could not be the cause of abortion 
 or of foetal death, for the temperature of the body 
 nearly always fell, and Traube has proved that the 
 elements of bile in the blood have not only the effect 
 of lowering the general temperature, but of paralysing 
 the heart's action. It is probable, therefore, that the 
 poison contained in the blood played a similar rule to 
 
MALIGNANT CHOLERA. 5 5 
 
 that of carbonic acid — preventing the proper aeration 
 of the blood in the placenta, and exciting uterine 
 action. Davidson, in the "Monat. fiir Geburt." 1867, 
 and after him Dr. Barnes, speak of acute atrophy 
 of the liver in the mother during pregnancy as 
 inimical to the child. In almost all cases observed, 
 abortion set in, and thus the product of conception 
 was destroyed. 
 
 Heart Disease, according to Dr. Angus McDonald,* 
 has a tendency to shorten gestation, while pregnancy 
 ao-ojravates heart disease in the mother. The effects do 
 not usually appear until midway in gestation, and then 
 the distress may become so extreme as to threaten the 
 life of both mother and child. It can be readily under- 
 stood how the congestion of the pelvic circulation, and 
 the imperfect aeration of the maternal blood, may so 
 alter the condition of the uterine circulation as to 
 produce foetal death even if the mother survives. 
 
 Chorea also may endanger pregnancy. Dr, Earnest 
 has pointed out that it may lead to abortion as well 
 as be a dangerous complication for the mother. 
 
 Malignant Cholera. — I have it on the authority of 
 medical officers who have observed epidemics of 
 cholera in India, and more recently in Egypt, that 
 pregnant women when stricken with the disease 
 nearly always abort, or if further advanced in 
 pregnancy are seized with the symptoms of labour as 
 soon as the symptoms assume a grave form. The 
 effects of the disease in connection with the o-ravid 
 state have been studied more particularly by 
 Bouchut, Henning, Drasche and others. Bouchut| 
 
 * "Heart Disease during Pregnancy, Parturition, and Childbed." 
 t " Obstetrical Trans.," vol. x. + " Gazette Medicale," 1849. 
 
56 THE PATliOLOUY OF INTRA- UTERINE DEATH. 
 
 has put Oil record twenty-five abortions in 
 lifty-two pregnant women seized witli cholera, 
 and remarks that the number of abortions would pro- 
 bably have been greater had not some of the women 
 died so raj^idly from collapse that there was not time 
 for abortion. Henning in one epidemic noted twenty- 
 seven abortions or premature labours in thirty-nine 
 cases of cholera. Of these there were twenty-two 
 foetal deaths and nine of the mothers died. Besides 
 he collected eighty-five cases from various sources, 
 and of these there were fifty dead infants and thirty- 
 five Hving. Bouchut attributes the child's death to 
 mechanical conditions, uterine contractions coming 
 on with the cramps or convulsions of the voluntary 
 muscles, and these would either expel the foetus, or 
 stop its nutrition and the aeration of its blood. 
 Cazeaux looks upon asphyxia as the cause of fcetal 
 death. The coao-ulation of the blood and its staffua- 
 tion in the vessels suspends the utero-placental 
 circulation and so leads to death. Slavjansky dwells 
 upon the tendency to uterine ha3morrhage in these 
 cases, and considers it due to a special endometritis 
 of the decidua, characterised by thickening and 
 softening; of the membrane. In some cases he 
 examined, small collections of blood were found all 
 through the meshes of the tissue and down even to 
 the muscular coat itself. These effects, however, 
 may have been in a large measure due to the intense 
 congestion produced by the muscular contractions, 
 and to look upon foetal death in these rapid cases as 
 produced by endometritis would seem to be looking 
 too far away from the obvious and immediate cause 
 pointed out by other authors — viz., the sudden 
 
MORBID POISONS. 57 
 
 perturbation of the placental circulation, and its 
 eventual suspension. 
 
 The morbid conditions I have specified, with then- 
 allies, if they stop short of producing expulsive efforts, 
 may yet produce congestion and possible extravasation 
 of blood in the placenta. They may thus so injure 
 the nutritive and depurative functions of that organ 
 as to compromise the life of the foetus. These con- 
 gestions and extravasations in moderate degree may 
 interrupt the utero-placental circulation, and destroy 
 the child without leading to its immediate expulsion ; 
 but if more intense and rapid so as to produce at once 
 irritation of the uterine walls as well as disturbance 
 in the placenta, they excite the uterus suddenly to 
 contract, and delivery speedily follows. 
 
 I have spoken of certain morbid poisons acting 
 upon the product of conception through the paternal 
 organism. There are some specific poisons, both in- 
 organic and organic, which, getting an entrance into 
 the maternal blood, act more directly on the contents 
 of the gravid uterus, and either kill the child or lead 
 to its premature expulsion before it is capable of 
 maintaining a separate existence. 
 
 I have no time to go into the proofs, which are now 
 ample enough, that poisons can be transmitted 
 through the maternal organism and destroy the pro- 
 duct of conception, sometimes, indeed, without much 
 perceptible effect on the mother, so far as the specific 
 poison is concerned. Thus lead-poisoning acts deleteri- 
 ously on pregnancy in the female as well as on the male. 
 Other poisons have been named, both organic and 
 inorganic — arsenic, mercury, savin, and the like. 
 
5 8 THE PATHOLOGY OF INTRA -UTERINE DEATH. 
 
 The morbid organic poison, wliicli is probably the 
 most pernicious, and has the most extended adverse 
 influence on fa3tal hfe, is syphilis. I have spoken of 
 the effects when transmitted by the father. Its 
 power in destroying fcrtal and infantile life, when the 
 mother is the subject of venereal disease, is now 
 almost universally admitted by authors, both in this 
 country and abroad. 
 
 Syphilis was mentioned in this relation as long ago 
 as Astruc. And yet it is curious to note, consider- 
 ing the unanimity of opinion about it at the present 
 time, how comparatively recent is the recognition of 
 its lethal power in this resj)ect. Dr. Whitehead was 
 one of the earliest and 1)est writers on abortion in 
 this country, and on turning to his book published in 
 1847 I find the following: "The complaint in ques- 
 tion was not suspected of being so frequent a cause 
 of abortion as it has since appeared to be, noi" did it 
 until very recently engage a particular share of 
 attention. I remember it was the opinion of my 
 la^mented and eminent friend, Mr. Fawdington, that 
 abortion in a great proportion of cases was occasioned 
 by a condition induced by the venereal taint." And 
 he goes on to express his entire confidence in the 
 accuracy of his friend's observation. Since then the 
 evidence has so accumulated concerning the influence 
 of syphilis in destroying children in vtcrn, both early 
 and late in gestation, as to be overwhelming. For 
 example, in some comparatively limited statistics of 
 Mr. Scott Battams, given in the " Lancet" for 1883, 
 ten syphilitic mothers produced forty children, of whom 
 twelve had died, and they had suffered among them 
 twenty abortions, or half as many as they had borne 
 
SYPHILIS IN THE MOTHER. 59 
 
 children. Of fifty-tliree syphilitic women observed by 
 Fournier,* twenty-eight only went to the full time, 
 and there were twenty-five abortions or premature 
 deliveries. Of 390 pregnancies with syphilis recorded 
 by Lepileur, 249 went to term, and there were 141 
 abortions or premature births. In the larger tables 
 collected by Gharpentierf from the data of Fournier, 
 Lepileur, Weber, and others, it appears that of 657 
 pregnancies in syphilitic women there were 426 
 deliveries at term, many of the children, however, 
 being still-born, and there were 231 abortions, or 28*4 
 per cent, of the whole. Evidence, indeed, might be 
 multiplied almost indefinitely, and, viewed in this 
 respect alone, the ravages of syphilis appear most 
 deplorable. | 
 
 The non-professional public can, of course, know 
 little of the insidious and noxious influence of syphilis 
 so manifested, and of the way in which it afl"ects 
 large numbers of women and children, innocent of 
 any trace of immorality. Did they fully realise the 
 disastrous consequences of permitting a diffusion of 
 this loathsome disease without let or hindrance, they 
 would bestir themselves to adopt preventive measures 
 against its propagation, and until such a time as it 
 could be absolutely prevented, would be glad to aid 
 partial projects for its diminution, even when such 
 projects seem in some degree to clash with the 
 
 * " Syphilis." t Loc. cit. 
 
 X It is besides abundantly proved that syphilitic disease may not 
 only destroy the embryo at all stages of its development in uicro, 
 but also that if the child is born at full term it may show evident 
 traces of venereal taint at its birth, or if apparently healthy when 
 born of syphilitic parents, it will develop infantile syphilis before 
 many weeks or months of its life have elapsed, and either die or 
 remain a miserable object afterwards. 
 
6o TUE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 generally understood idea of the liberty of the 
 subject, or run counter to cherished notions on 
 ^^■hat has been termed the " State regulation of 
 vice." 
 
 In women who are the subjects of syphilis, abor- 
 tions often succeed each other in frequent repetition, 
 and with a persistency belonging to no other cause. 
 It has, moreover, been often remarked that when 
 there are no external indications of maternal syphilis, 
 the succession of abortions, or of dead children in 
 more advanced pregnancy, is traceable to a latent 
 form of the disease which manifests itself in this 
 fashion. Fournier especially dwells on this point, and 
 holds that women who are most deeply and viscerally 
 affected are most liable to abortion, although it may 
 happen to those affected in all degrees, even the most 
 lightly. Confirmatory evidence of Fournier's position 
 is educed by the effect of ant i- syphilitic treatment, 
 which very frequently succeeds in stopping the 
 tendency to abortion. Some cases of abortion with- 
 out apparently syphilitic symptoms in tlie mother, 
 are no doubt due to the transmission of venereal 
 taint from the father. 
 
 The effect of syphilis has been now so carefully 
 studied that some general laws have been formulated 
 concerning^ its effects on human orestation. Thus it has 
 been proved { i ) that if a woman has syphilis before 
 conception she is much more predisposed to abortion 
 than a M'oman taking the disease after conce^Dtion ; 
 (2) if conception and syphilis commence together, 
 abortion or premature labour Avith a dead child are 
 the rule, but treatment is more potent in preventing 
 them ; (3) syphilis acquired after the mid-period of 
 
SYPHILIS IN THE MOTHER. 6 1 
 
 pregnancy has less influence on the child, and it may 
 escape altogether. 
 
 Perhaps the worst feature in the relation between 
 syphilis and pregnancy is its persistent and extended 
 influence. It is impossible to say when the eflect of 
 the poison will be expended, and long after all out- 
 ward signs of the disease have vanished in the bodies 
 of both parents, the tendency to abortion may remain, 
 or there may still be the production of dead children, 
 or of feeble emaciated children if born alive, showing 
 external evidences of venereal taint ; or, lastly, in the 
 absence of these, so small an amount of vitality that 
 the children are reared with difficulty. 
 
 One of the ways in which syphilis brings about 
 intra-uterine death, as will be seen later, is by pro- 
 ducing disease in the foetal appendages. There can 
 be no doubt that the venereal poison is transmitted 
 to the embryo through the maternal blood, and thus 
 it may affect all the tissues in the gravid womb, 
 sometimes manifesting itself in one locality, some- 
 times in another. Thus it may attack the body of 
 the foetus or its placenta and membranes. We have 
 both the direct evidence of such transmission, and 
 also the collateral evidence derived from the trans- 
 mission of other agents, through the maternal circu- 
 lation. 
 
 Belonging to this section of the subject as recog- 
 nised causes, under certain conditions, of mtra-uterine 
 death, are 
 
 The local affections of the generative organs in women. 
 
 Uterine congestion no doubt plays an active 
 part in inducing abortion. Jacquemier enlarges 
 
 * Loc. cif. 
 
62 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 on tliis cause of intra-uteiine death, and Charpentier 
 remarks that he treats the subject in a way 
 quite magisterial. Jacquemier says the conges- 
 tion may be active or passive, and he believes it the 
 commonest cause of abortion. It excites abnormal 
 contractions, determines frequent extravasations 
 between the uterus and membranes or placenta, and 
 causes apoplexy by rupture of the utero-placental 
 blood-vessels. All women are not equally predisposed, 
 but those chiefly who are liable to uterine congestion 
 before pregnancy begins — who menstruate too pro- 
 fusely, and have other symptoms of uterine or general 
 congestion. To these pregnancy brings new features 
 into play. The whole circulation becomes more active 
 and more easily disturbed, and there is greater local 
 relaxation. As the catamenial periods are normally 
 periods of congestion, so in women predisposed at all 
 times to hypertemia of the pelvic organs, the monthly 
 times become a source of peril during pregnancy. 
 
 The various inflammatory affections of the uterus 
 and its appendages act injuriously on the child 
 in utero during the course of pregnancy. Acute in- 
 flammations are fortunately rare apart from external 
 injuries. The chronic forms of inflammation affecting 
 the walls and cavity of the uterus, as I shall show 
 subsequently, very commonly lead to abortion by pro- 
 ducing: disease in the foetal membranes. The chronic 
 forms affecting the cervix, such as induration and 
 ulceration, have a less marked effect, inasmuch as 
 they are external to the womb cavity, and unless 
 they penetrate there do not necessarily interfere with 
 the coui'se of pregnancy. Hyperplasia of the neck as 
 well as of the body may j)erchance interfere with the 
 
INFLAMMATION OF THE UTERUS. C^ 
 
 proper expansion of the uterine walls during develop- 
 ment, and so lead to a state of irritability which 
 terminates in expulsion, but just as in malignant dis- 
 ease of the cervix, there may be much induration of 
 tissue there, and yet pregnancy will go to the full 
 time. Erosions and ulcerations of the os are common 
 enough during pregnancy as the result of congestion 
 incident to that state, and if they remain superficial 
 and are not over-treated, they do no great harm. 
 Cazeaux says that even when they penetrate into the 
 cervical canal and have a tendency to become fungous 
 or vegetative during the course of pregnancy, they do 
 not imperil its continuance. He believes, however, 
 and Kichet agrees with him, that these conditions 
 existing before conception, are more likely to lead to 
 abortion. Dr. Henry Bennet^ distinguishes between 
 the simple forais of ulceration, which, he says have 
 little influence on pregnancy, and others of a more 
 profound character. These he regards as frequently 
 leading to premature delivery, and when penetrating 
 into the canal of the cervix and characterized by 
 destruction of tissue, as rendering abortion almost 
 certain. 
 
 Whitehead endeavoured to show that the presence 
 of vaginal leucorrhoea, which may or may not be 
 associated with inflammatory conditions of the uterus, 
 had a marked influence in predisposing to abortion. 
 Thus of 2,000 pregnant women, i , 1 1 6 had leucorrhoea 
 when the inquiry was made. 936, or eighty-three 
 per cent., had purulent or sanious discharge ; of these 
 5 44, or fifty-eight per cent. , had previously miscarried 
 — the discharge in the remaining 180 cases being 
 
 * " Inflam. of the Uterus." 
 
64 THE PATHOLOGY OF INTllA-UTERINE DEATH. 
 
 absent or trivial in amount. There is nothing very 
 conclusive as to cause and effect in these figures, and 
 they may simply mean tliat delicate women were 
 equally liable to abortion as to vaginal discharges. 
 
 The various displacements of the uterus, if extreme 
 in character, — retroflexion or version, ante-flexion, 
 prolapsus, tumours in the uterine walls, in the ovaries 
 or elsewhere in the pelvis, — malignant disease of the 
 uterus, — pelvic haematocele or cellulitis, may each 
 and all lead to abortion or premature labour, and on 
 the other hand experience teaches that mechanical 
 displacements or organic diseases may in some cases 
 be present in a very marked degree, Avithout interfer- 
 ing Avith the course of pregnancy. 
 
 There is a drawing of a placenta in Guy's Hospital, 
 which, otherwise healthy, is entirely altered in its 
 shape by the compression of fibroid tumours in the 
 uterine walls. The unevenness of the interior of the 
 uterus has turned up the edge of the placenta in all 
 its circumference and made the foetal membranes so 
 considerably overlap the uterine surface, that fully 
 one-half of it must have been separated from its con- 
 nection with the uterus. 
 
 Pelvic Adhesions. — Madame Boivin* noticed tliat 
 in Avomen liable to frequent abortion, the womb was 
 often bound down by pelvic adhesions, probably due 
 to previous pelvic peritonitis. This has been noted 
 by other authors, and there can be no doubt that 
 when such adhesions do exist, if they are at all firm 
 or extensive, they must prevent the proper expansion 
 of the gravid uterus during its development, and 
 eventually lead to abortion. 
 
 * " Eechcrches sur une des Causes de rAvortement," 1828. 
 
REFLEX CAUSES. 6$ 
 
 Direct irritation of the uterus and vagina, and in- 
 juries produced designedly or by accident, may of 
 course lead to premature expulsion of the ovum and 
 its consequent death. Under this head may be 
 classed, too frequent or violent coitus ; falls or blows 
 on the pelvis, jolting on horseback or in carriages, and 
 plugging the vagina for any purpose. All these may 
 lead to separation of the membranes, or irritation and 
 dilatation of the os uteri, with consequent haemorrhage 
 and abortion, I need not say that various gyneco- 
 logical proceedings, such as passing the sound, 
 injudicious insertion of pessaries, and treatment with 
 the speculum, as well as all operations about the 
 uterus during pregnancy ; oxytocic medicines, 
 whether given for criminal purposes or otherwise — • 
 all are apt to be followed by voiding of the uterine 
 contents, especially in sensitive women. 
 
 Beflex Causes. — The late Dr. Tyler Smith* drew 
 attention to the frequency of reflex or excito-motor 
 causes of abortion, and particularly to the effect of 
 irritation of the mammary nerves. He averred that 
 he had seen abortion produced during lactation from 
 the irritation of constant suckling. He inferred that 
 it was not mere weakness or exhaustion producing 
 the effect, because the mammary secretion may cease 
 on the occurrence of impregnation, but a plentiful 
 supply of milk returns after the occurrence of abor- 
 tion. It is well known that the uterus may be made 
 to contract after delivery by putting the child to the 
 breast ; and Professor Scanzoni, in view of these facts, 
 has proposed irritation of the mammce as one of the 
 methods of inducing premature labour. The results 
 
 * Loc. cit. 
 
 F 
 
66 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 of tlie method have proved too uncertahi for general 
 adoption. But reflex motor actions originating in 
 other organs besides the mamma? are acknowledged 
 to have the effect of inducing abortion in some cases. 
 Thus irritation of the trifacial nerve durinor the cuttinor 
 
 o o 
 
 of a wisdom-tooth, or from toothache, are said to have 
 this effect. I have seen abortion brought on by the 
 extraction of a tooth, but I do not think this peculiar 
 to dental operations, as I have seen it follow other 
 minor surgical proceedings, apparently from the 
 nerve-disturbance they produced, as there was no 
 marked increase of temperature. 
 
 Quite recently I was confronted, not for the first 
 time, with the question, " Is it desirable to remove 
 the breast by surgical operation during pregnancy. 
 The patient was about thirty years of age, six months 
 pregnant, and she had a tumour, believed to be 
 malignant, in the right breast. It had somewhat 
 rapidly developed, and the axillary glands were 
 enlarged. The whole aspect of the patient was un- 
 healthy, if not cachectic, and it was deemed advisable 
 to remove the breast as speedy as practicable. The 
 eminent suro-eons consulted in the case hesitated to 
 operate during the continuance of pregnancy, as one 
 of them at least had recollection of similar cases end- 
 ing disastrously, abortion coming on after the opera- 
 tion, and the patient dying as the result of the double 
 injury. From my own experience, I was able to say 
 that abortion seemed chiefly to have been provoked 
 under such circumstances when the breast wound 
 was going wrong, and there were evidences of con- 
 stitutional irritative fever. In fact, that although 
 there is such well-known and intimate sympathy 
 
EFFECT OF SURGICAL OPERATIONS. 6/ 
 
 between the nerves of the breast and the uterus, the 
 .abortion was less due to reflex action than to elevation 
 of maternal temperature associated with septicaemia. 
 In tliese days of antiseptic surgery, where healing 
 by the first intention is the rule, removal of the breast 
 and other similar operations may certainly be under- 
 taken with less risk of abortion than formerly. In 
 view, nevertheless, of the fact that abortion some- 
 times comes on from the reflex eflect of all operations, 
 however trivial in character, it is well to abstain from 
 surgical proceedings during pregnancy, unless 
 urgently required. In the case I have referred to, it 
 was at one time proposed to bring on. premature 
 labour, and to operate on the breast as soon as the 
 puerperal period was passed. The proposal was 
 eventually abandoned, because some time must elapse 
 before the child would be viable, and the disease in 
 the breast was extending. Consequently the opera- 
 tion was performed at once, and the patient made a 
 good recovery without aborting."^ 
 
 In undertaking any operation upon a pregnant 
 woman it is important to recollect that the uterus is 
 more irritable at times which correspond to the 
 catamenial periods. It is well, therefore, to avoid 
 these periods. 
 
 Intense and persistent gastric irritation has also 
 been known to bring on abortion, and this notwith- 
 standing the fact that a pregnant woman is some- 
 times brought almost to death's door, by continued 
 
 * AccDi'dlug CO Massot (Sclimidt's " Jalirbucli ") and Colinstein 
 (Volkmanu, " Saml. Klin. Vorte," 1875) operations on the genito- 
 urinary organs are most likely to be followed by abortion, and Spiegel- 
 berg says that no operation on pregnant women should be performed at 
 the time of the menstrual epoch, as al)ortion is more likely to occur then. 
 
 F 2 
 
68 THE PATHOLOGY OF INTRA-UTERTXE DEATH. 
 
 nausea and vomiting, witliout provoking any sign 
 of uterine contraction. Vesical, renal, and rectal 
 irritation may act in like manner. Lastly, ovarian 
 irritation undoubtedly favours the occurrence of abor- 
 tion, and consequently there has been observed a 
 marked tendency to abortion at times corresjjonding 
 to the catamenial periods, more especially in women 
 who have been the subjects of ovarian dysmenorrhoea. 
 Nearly akin to excito-motor causes are the effects 
 of mental emotion on pregnant women. There is no 
 doubt greatly increased nervous tension in all preg- 
 nant women. Fright, anxiety, a sudden impression 
 made upon the mind or body, may not only initiate 
 uterine contraction at any period of pregnancy, but 
 there is reason to believe that a sudden mental shock 
 may at once kill the early embryo or more mature 
 child, even if it be retained some time afterwards. 
 Kepeatedly it has occurred to me, as to others in 
 practice, to have patients dating the exact time of 
 their child's death in utero to some alarm or shocking 
 occurrence which has profoundly affected the whole 
 nervous system. The immediate effect described 
 was first violent perturbation and undue active 
 movement of the child for a brief interval, followed 
 by cessation of foetal movement, and absolute 
 quiescence in the future. In a few rare instances 
 the woman has been mistaken in supposing her child 
 to be dead after a shock or fright she has experienced, 
 but in a large number of cases the relation between 
 the cause and the effect has been too clear to be 
 accounted for by mere coincidence, and the child has 
 sooner or later been expelled dead, possibly both 
 dead and putrid. 
 
MENTAL INFLUENCES. 69 
 
 It is no nncommon thing for a woman in early- 
 pregnancy, on the receipt of bad news, wliich much 
 perturbs her, to he seized with uterine htemor- 
 rhao-e, endinp- in abortion. Condemned women 
 jmor to execution have been known to abort 
 beforehand, and, under the influence of terror and 
 pain, martyred women in former days are said to 
 have aborted at the stake. So potent is mental 
 influence on the stabiHty of pregnancy, that I have 
 had reason to beUeve the mere dread of miscarriage 
 has in some women been an important faccor in 
 bringing it about, and I have known pregnant women 
 who had previously miscarried get into such violent 
 mental agitation as the time approached when they 
 had aborted before, that the event they feared was 
 precipitated, and pregnancy was brought to a 
 premature conclusion. 
 
LECTURE II. 
 
 DISEASES OF ECETAL APPENDAGES. 
 
 I PROCEED now to speak of the causes of intra- 
 uterine death Avhich are associated with faulty 
 conditions of the foetal envelopes and foetal append- 
 ages, and I shall take those first which properly 
 belong to the earlier part of pregnancy. 
 
 In the earlier stages of its development, the ovum 
 is in shape like an egg, and consists of the central 
 embryo, with its surrounding envelopes. The outer 
 one, or clecidua, which lies next to the uterine wall, 
 is the earliest in its formation, for it appears in the 
 uterine cavity before the descent of the fecundated 
 ovule from the FallojDian tube. It is now well 
 known to be the product of the uterus itself, and to 
 consist of the mucous membrane linino- the interior 
 of the womb, thickened and modified in such a way 
 as to fulfil the necessary requirements of a foetal 
 envelope. A membrane in all res])ects like this, 
 both in external appearance and minute structure, is^ 
 sometimes exj)elled from the unimpregnated uterus 
 at the catamenial periods in cases of dysmenorrhoea. 
 It is then produced by an over-activity of formative 
 elements, which occurs as the result of some reflex 
 
DYSMENORRHCEAL MEMBRANES. 
 
 71 
 
 irritation, probably in the ovary, and which simu- 
 lates the commencement of pregnancy. The expul- 
 
 Fia. I. 
 
 A dysmenorrhEeal membrane expelled from the uterus of 
 an immarried woman, showing the follicular apertures on 
 the internal surface, and the openings corresponding to 
 the Fallopian tubes. (After Coste.) 
 
 sion of such membranes, therefore, does not always 
 mean that an abortion has taken place, for they may 
 be formed and extruded without impregnation ; but, 
 in a considerable number of cases in which these 
 membranes are thrown off by married women, they 
 are the result of conception. This is inferred from 
 theh^ frequent recurrence so long as sexual relations 
 are continued, and their cessation when coitus is 
 intermitted. Besides, the catamenial period is often 
 missed once, at least, before expulsion, in women 
 who at other times are perfectly regular. When 
 entire, these membranes generally appear as 
 membranous sacs, of triangular form, corresponduig 
 to the shape of the uterine cavity, and the walls of 
 the sac are thick or thin according to the amount of 
 
72 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 organised material of which they are composed. The 
 outer surface is commonly rough, and, if the prepara- 
 tion is placed in water, shreds or flocculi float out in 
 the fluid. When laid open, it is a common thing to 
 find the cavity quite empty. The inner surface is 
 smooth, and marked everywhere with the apertures 
 of hypertrophic glandular follicles, but there is no 
 embryo. The ovule has either missed getting into 
 the decidual cavity, or it has been endowed with so 
 small an amount of vitality that it has undergone 
 solution before it could plant itself in the decidual 
 tissue. The reflex stimulus which has come from 
 the ovary or tube, in wliichever locality fecundation 
 took place, has been enough to evoke the formation 
 of the decidua in the womb ; but the ovule being 
 wanting, development is arrested, no decidua reflexa 
 is formed, and the useless decidua vera is eventually 
 thrown off as a foreign body. Here the fault in 
 procreating power, as distinguished from generative 
 power, may be either with the male or female ; and, 
 if the A^^oman is otherwise healthy, it is quite as 
 likely to be some defect in the fertilising fluid as 
 faulty ovulation on the part of the female. These 
 decidua of early pregnancy are in many cases found 
 covered with coagulated l^lood, and the cavity may 
 be filled with clot, soft or semi-fluid, if recently 
 deposited there — firm and partially decolorised, if 
 some time has elapsed since its extravasation. But 
 these membranes are not always expelled in their 
 entirety. More frequently they are thrown oft' in 
 detached portions or shreds at variable intervals, and 
 mixed with the fluid or coagulated blood which 
 escapes at the same time. It is no uncommon 
 
DEFECTS IN FORMATION OF THE DECIDUA. JZ 
 
 occurrence for a patient, or even the medical man, to 
 infer that the supposition of pregnancy has been 
 erroneous, because no substantial mass has been 
 expelled — ^the discharges being taken for an over- 
 profuse and perhaps deferred period. Eigenbrodt 
 and Hegar,* in a memoir " On Apoplectic Destruc- 
 tion of the Decidua," assert that in some cases the 
 presence of the elements of the decidua could only be 
 ascertained by the aid of the microscope. This 
 accords with my own observation. 
 
 Akin to this is another defect of development 
 which has been described by Matthews Duncanf 
 and copied into the various textbooks. This con- 
 sists, according to the author named, in a defective 
 develo23ment of the decidua round the ovum. The 
 Q^g then comes in contact only with a limited surface 
 of the mucous membrane which corresponds to the 
 serotina, and as it is not supported, as usual, by 
 growth of the decidua around it, it becomes, as it 
 were, pediculated, and is easily detached from its 
 limited adhesion. This is probably one of many 
 faults of development occurring in early gestation. 
 In one specimen I examined which had been expelled 
 as an abortion, the ovule had evidently failed to get 
 inside the decidual cavity, and began its develop- 
 ment on its outer rough surface, attaching itself, 
 as it does in extra-uterine pregnancy, to the sur- 
 rounding structures. The surrounding structures 
 were partly the outer surface of the decidua, and 
 partly the wall of the uterus, and for three-fourths 
 of the circumference of the ovum the clear trans- 
 
 * " Monat. fiir Geburt." Bd. xx. 1863. 
 t " Eesearches in Obstetrics." 
 
74 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 parent chorion was quite uncovered, its villi there 
 being either atrophied or never developed. The 
 decidua seems in some instances to be detached from 
 the uterine wall, and to lie so loosely in the uterine 
 cavity, more especially if atrophied or imperfectly 
 developed, that one can imagine the ovule as it 
 enters the uterus from the Fallopian tube dropping 
 between the decidua and uterine wall. 
 
 We get some sort of idea, now that our knowledge 
 is more precise concerning the formation of the 
 decidua, and of the behaviour of the ovule Avhen it 
 enters the uterine cavity, of the w^ay in which 
 placenta prsevia and other variations in tlie site of 
 the placenta are produced. Ordinarily the thickened 
 decidua fills pretty fully the cavity of the uterus, 
 and the ovule is received into the cushion so formed, 
 to be sustained in the upper part of the uterus. 
 When, however, the decidua is less luxuriant in 
 growth, its cavity will be larger, and the fertilised 
 ovule may then drop down to the lowest part of its 
 cavity, and become implanted there. Dr. Robert 
 Lee'^ has recorded the appearances of a very early 
 placenta praevia, which bears out this idea, and 
 such an anatomical fault ftivours the occurrence 
 of abortion, although we know by experience 
 that these cases may go on to the later periods of 
 pregnancy. 
 
 The varieties of insertion of the ovum into the 
 decidua, and the several forms of hyj^ertrophy and 
 atrophy, with other anomalies of the same membrane, 
 have been elaborately studied by Kussmaulf, Hegar J, 
 
 * "Theory and Practice of Midwifery." 
 
 t " Vou dem jMangel, &c., der Gebamutter." 1859. 
 
 t " Monatssch. fiir Geburts." Bd. xxi. Supplement Heft. 
 
EXTRAVASATIONS IN THE DECIDUA. 75 
 
 and Dohrn* in special and excellent memoirs, which 
 are well worth perusal. It seems obvious that a too 
 scanty formation of the decidua may lead to the 
 growth of a placenta too small for the needs of the 
 embryo. Charpentier believes that an arrest of 
 development in the decidua reflexa, or its premature 
 destruction, are frequent causes of death in the 
 embryo. The egg then is covered in a large part of 
 its extent only by the chorion, and may be sus- 
 pended by a sort of pedicle from the decidua serotina. 
 It has thus a very limited attachment to the decidua, 
 and is easily disturbed. Probably, indeed, preg- 
 nancy cannot go on with so slight an attachment, 
 and it is a variety of a similar kind which Bokitansky t 
 has called " Cervical Pregnancy." 
 
 When the ovule has been successfully implanted 
 in the decidua, and the normal development of the 
 decidua reflexa and other structures are going on in 
 progressive series, there is great tendency in some 
 women to go wrong, apparently from mere weakness 
 of the outer structures which form the ovum. The 
 decidua is commonly composed of so lax a tissue, and 
 is so abundantly supplied with blood-vessels under- 
 going various modifications of size and distribution, 
 that during early pregnancy it is prone to suffer from 
 extravasations of blood into its parenchymatous sub- 
 stance, more especially in delicate women. It is true 
 that the uterus is so suspended in the maternal pelvis 
 as to be affected in the least possible degree by 
 ordinary locomotion and by accidental concussions ; 
 yet, in some women, the union between the pregnant 
 uterus and the decidua is so unstable, that a fall or 
 
 * "Monatsscli fiir Geburts." 1863. f " Lehrbuch der Path. Anat." 
 
"J 6 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 stumble, or a shaking of any kind, may be quite 
 sufficient to detach a portion of the latter, inipture 
 the intervening vessels, and cause extravasation of 
 blood. Small and circumscribed clots produced in 
 this way are frequently found between the uterus 
 and decidua ; at other times they are in the meshes 
 of the decidua itself, or both may be conjoined. If 
 limited, these extravasations need not interrupt the 
 continuance of pregnancy. If more extensive, and 
 separating a larger portion of the decidua, they 
 necessarily interfere with the nutrition of the ovum, 
 produce death of the embryo, and precipitate abor- 
 tion. When the escape of blood from the vessels is 
 confined to a limited space at the upper part of the 
 uterus, it may cause uneasiness, but no external 
 haemorrhage will be noticed. If it takes place near 
 the cervix, the blood more readily finds exit from the 
 uterus, and is discharged by the vagina, thus becom- 
 ing a manifest symptom of threatened abortion. Blood- 
 clots in every stage of transition, and every variety 
 of firmness and colour, may be observed in some 
 aborted ova. The latest are deep red or purple, and 
 those older pass through the several tints of chocolate 
 brown to yellow, like apoplectic clots elsewhere. 
 
 The same results may ensue from contractions of 
 the uterus, either provoked by local irritation directly 
 applied, or from reflex causes, as, for example, suck- 
 ling a child after a fresh pregnancy has commenced. 
 It is well known that abortion is frequent if a new 
 pregnancy begins during the time that a mother is 
 suckling her child. 
 
 Occasionally, during the very early stages of gesta- 
 tion, blood flows directly into the decidual cavity. 
 
EXTRAVASATIONS IN THE DECIDUA. 7/ 
 
 and fills it with coagula. The result is, either that 
 all trace of the embryo and its immediate surround- 
 ing structures are obliterated, or the embryo is 
 compressed and destroyed by the invading flood, 
 rudimentary portions only of it being discovered. 
 More than once under these conditions I have found 
 the embryo, wrapped in its small and budding chorion, 
 detached from the decidua and floatino- in the semi- 
 fluid blood contained in the decidual cavity. The 
 decidua reflexa had not yet been sufficiently developed 
 around it to give it a stable attachment. The small 
 aborted ova of this early period are frequently thrown 
 off entire in triangular or ovoid form, the outer layer 
 being the decidua, which encloses, first, firm layers 
 of fibrin, and, as one proceeds to the centre, soft clot. 
 In the second to the third months, the decidua 
 reflexa or ovuli is fully formed, and the villi of the 
 chorion are everywhere imbedded in its substance. 
 Then another form of haemorrhage may occur. In 
 this, the blood is not alone extravasated between the 
 decidua vera and the uterine wall, or into the meshes 
 of the decidua itself, but between the decidua reflexa 
 and serotina, and the chorion or outermost of the 
 true foetal membranes. In the process of develop- 
 ment the villi of the chorion are pushed into the 
 decidual tissue, and are soon surrounded by the 
 blood-vessels which are to form the maternal placenta. 
 The decidua is then a highly vascular membrane, 
 especially at the site of the future placenta, and the 
 maternal vessels which everywhere ramify through it 
 undergo a development which in the human body is 
 unique. Appearing first as capillaries, they rapidly 
 enlarge, and eventually become sinuses, which are 
 
78 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 filled with maternal blood, and in which the foetal 
 villi are eventually suspended. 
 
 It can scarcely excite surprise that these delicate 
 and rapidly dilating maternal vessels should be very 
 liable to rupture. Haemorrhage taking place in this 
 locality, floods the loose tissue of which the decidua 
 reflexa is composed, and destroys or compresses the 
 chorion villi implanted there. It may be so exten- 
 sive as entirely to surround the embryo. At the 
 earlier periods, when there is a considerable space 
 between the decidua uteri and reflexa, it may be 
 Hmited to the circumference of the latter membrane, 
 which, when cut into, is found to contain clot with 
 or without traces of the chorion and embryo. Later, 
 when the decidua reflexa is in apposition with the 
 decidua uteri throughout its whole extent, and the 
 amnion is formed, the cavity, if exposed from within, 
 exhibits eminences or projections from the walls, 
 which may seem like projecting cysts if the blood is 
 imperfectly coagulated ; but they represent hard and 
 firm bosses or nodules, when the blood has been long 
 enough deposited to become solid. The force of the 
 extravasation has in fact pushed forward both the 
 chorion and the amnion, and diminished the size of 
 the cavity. There are all possible gradations in the 
 amount of blood so extravasated, and the morbid 
 appearances vary from slight thickening or consolida- 
 tion to the extreme forms seen in the drawings and 
 preparations on the table. The nutrition of the 
 embryo is necessarily arrested if the extravasation be 
 extensive enough to interrupt the normal circulation 
 through the imperfectly formed placenta, and the 
 embryo may be found stunted and shrivelled, sus- 
 
APOPLEXY OF THE OVUM. 79 
 
 IDended by its umbilical cord from some part of tlie 
 amniotic cavity. If the ovum has been long retained 
 after these morbid changes have taken place, the 
 embryo will appear small in proportion to the size of 
 its containing cavity, for there can be no doubt that 
 when the central embyro has perished, the mem- 
 branous envelopes may go on growing until they are 
 expelled by uterine action. In some specimens again, 
 the embyro deprived of its nourishment breaks down 
 and dissolves, leaving only the remains of a slender 
 or rudimentary umbilical cord, and not uncommonly 
 also a distinct umbilical vesicle, imbedded between 
 the chorion and amnion. 
 
 These extravasations of blood between the chorion 
 and the decidua constitute the typical " apoplexy of 
 the ovum " described by many authors. It is found 
 in a multiplicity of forms and modifications, and is, 
 no doubt, produced by a variety of causes. Thus it 
 may be produced by faults in early development, or 
 by any cause which produces detachment of the well- 
 formed decidua from the uterine walls, or from 
 rupture of its blood-vessels. Gendrin said he saw- 
 one case where blood tore its way through both 
 chorion and amnion, and overwhelmed the embryo, 
 and Hegar gives another. A drawing in my posses- 
 sion, by Westmacott, shows the cavity of the decidua 
 reflexa entirely occupied by a blood-clot, no trace of 
 embyro or its special envelopes being found. 
 
 Wagner, in his " Traite de Physiologie," states 
 that in the majority of cases an extravasation of 
 blood at the time of the formation of the decidua 
 reflexa is the first cause of the death of the foetus. 
 In some cases, notwithstanding this, the egg may 
 
So THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 grow, but the embiyo is tlien not properly nourished, 
 and so a disproportion of different parts of the egg 
 occurs. The extravasation of blood may therefore be 
 the cause of disease in the decidua and of malforma- 
 tion in the foetus. 
 
 Hegar says, and Verdier* agrees "with him, that 
 anomalies in the insertion of the placenta, and 
 abnormal insertions of the allantoid and umbilical 
 vessels, predispose to apoplexy, as well as hyper- 
 trophy and atrophy of the various parts of the 
 decidua. 
 
 In examining ova which have been extruded as 
 the result of abortion during the earlier period, one 
 is often struck with the amount of compound granular 
 cells, as they are called, and of distinct fat or oil- 
 particles, not only mixed up with the parenchyma of 
 the decidua, but contained even in the interior of the 
 decidual cells and fibro-cells, thus constituting a 
 true fatty degeneration. Sometimes the decidual 
 blood-vessels, namely, those which permeate every- 
 where the decidual tissue, and ramify among the 
 villi at the site of the future placenta, have undergone 
 fatty change, and this is more marked near the seat 
 of the haemorrhages. At one tmie I thought this was 
 due merely to the after-changes in the extravasations 
 of blood produced by traumatic and other causes, but 
 I subsequently found this fatty change in portions 
 of the membranes distant from the clots, and occa- 
 sionally I have found the whole decidual structures 
 affected by this form of granular degeneration. 
 
 I have elsewhere pointed outf that in the parietal 
 decidua which does not take part in the formation 
 
 * " These." 1868. t " I>evel. of Gravid Uterus." 
 
DEGENERATION IN THE DECIDUA. 8 I 
 
 of the placenta, a granular or fatty degeneration sets 
 In as soon as its function is superseded by the organi- 
 sation of the placenta. The drawing there shows the 
 glandular follicles in the third month, filled with fat- 
 granules prior to their final disappearance, and similar 
 fatty molecules are scattered over the parenchyma 
 generally. In the normal condition this fatty degene- 
 ration does not extend beyond the border of the 
 placenta, but it can readily be understood that in 
 such close proximity, it may invade the placental 
 decidua also, when impaired nutrition or other cause 
 predisposes it to decay. 
 
 On becoming acquainted with the remarkable 
 researches of Ercolani,* I found he believed that the 
 true cause of extravasation and of the formation of 
 clots between the decidua and chorion in early preg- 
 nancy, to be this fatty degeneration of the cells of 
 the decidua serotina, which ought to be forming the 
 young placenta. These cells so transformed out of 
 the .decidua, when in a state of fatty degeneration, 
 imperfectly support the pressure of blood in the 
 sinuses, and hence, as he says, there is a breakdown 
 and veritable interstitial hsemorrhage. The rupture 
 of the layers of serotina permits the blood to pass 
 from one cotyledon to another, and necessarily pro- 
 duces a slackening of the maternal blood in the 
 imperfectly formed sinuses. Thus a true thrombosis 
 is produced, but preceded by morbid change of 
 structure, not arisino- out of a normal state as 
 supposed by Bustamente,t whose views I shall 
 notice presently. Sirelius,| of Helsingfors, also 
 
 * " Delle Malattie della PL," Mem. 1S71. 
 t "Theselnaug.," 186S. X FicZe Ercolani. 
 
 G 
 
82 THE PATHOLOGY OF INTRA- UTERINE DEATH. 
 
 attributed htemorrliage in the early formed placenta 
 to the breaking down or rupture of the decidual 
 structures forraino- the boundaries of the lacunce, 
 thus producing coalescence and arrest of circulation, 
 with extravasation. 
 
 That the presence of a pathological fatty degene- 
 ration in the structures of the decidua will, in many 
 cases, account for the occurrence of hremorrhasfe both 
 in the parietal decidua and in the serotina, is no 
 doubt true, but there are many cases where no such 
 explanation can apply, otherwise there would be 
 very little chance of checking a threatened abortion 
 when once indications of haemorrhage have set in. 
 The frequent recovery of patients from the symptoms 
 of abortion with the successful continuance of preg- 
 nancy to the full time, is sufficient proof either that 
 haemorrhage is due to other causes than fatty 
 degeneration, or that, in particular cases, the degene- 
 ration was at least so partial that only a very limited 
 area of the structures is affected. Thickening and 
 fatty degeneration to a marked extent in the- 
 decidual structures is noticeable in many instances 
 of recurring early abortion ; and, as we shall see 
 presently, this may be associated with an inflam- 
 matory process. In other cases, separation of the 
 ovum is clearly traceable to some violence or 
 traumatic cause ; then the structures show no indi- 
 cation of morbid transformation, and the extruded 
 ovum frequently tears away with it from the interior 
 of the uterus shreds of the uterine muscular fibre 
 which are found attached to its outer surface. 
 
 Apoplexy of the ovum deserves careful study, 
 because it is a very common cause of embryonic 
 
APOPLECTIC OVA. St, 
 
 death, and, if one may judge from the large number 
 of spechnens jDreserved in the various museums, 
 compared with others, it is by far the most frequent 
 of all the pathological changes affecting the early 
 ovum. In almost every museum in London are 
 examples of the ajDoplectic ovum in its various 
 phases, even where there is an absolute poverty of 
 other specimens illustrating diseases of the ovum, 
 and it may be inferred, therefore, that it is probably 
 the most frequent of the immediate causes pro- 
 ducing intra-uterine death in the early months 
 of gestation. The specimens are often wrongly 
 described in the museum catalogues as " tubercular 
 ova," or " cystic ova," and other misnomers are 
 applied to them. 
 
 The largest number of the preparations of this 
 kind in our museums are of ova so advanced that the 
 two decidua are united in close apposition. This 
 corresponds to about the third month of gestation. 
 The chorion has imbedded its tufts everywhere in 
 the decidua, and the amniotic cavity is distinctly 
 formed. On account of the size of the aborted ova, 
 the morbid changes are so marked that they are 
 obvious to the most casual inspection, and hence they 
 come to be preserved. 
 
 We have no accurate means of knowing the com- 
 parative frequency of apoplexy and resulting abortion 
 in ova at an earlier stage than this, because in the 
 first weeks aborted ova have less marked character- 
 istics — they are often passed unobserved, or, if 
 noticed, they are, from their fragility, likely to be 
 torn and injured during expulsion. For both these 
 reasons preserved specimens of this kind are much 
 
 C- 2 
 
84 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 rarer in the several museums than otherwise they 
 might be. 
 
 One of the moH^id conditions of the decidua, the 
 presence of which is inferred rather than demon- 
 strated, is congestion.* The inference is drawn from 
 the fact that in some ova expelled during abortion 
 the decidual vessels are found gorged with blood, 
 not only on the outer or uterine surface, but in the 
 deeper layers, and no evidence of other pathological 
 change is observable. The women chiefly predis- 
 posed to it are the plethoric, those suffering repeatedly 
 or habitually from disorders of the portal circulation, 
 from heart-disease, and also those who, from any 
 other cause, are the subjects of pelvic congestion 
 generally. Hegar noticed the uterus proportion- 
 ately larger in those prone to congestion and 
 apoplexy of the ovum. 
 
 It is believed that congestion of the decidua is a 
 sufficient and adequate cause, irrespective of any 
 other, to produce rupture of its blood-vessels and 
 extravasation into its substance. It depends, of 
 course, upon the amount and extent of the congestion 
 and its consequent results, as to whether abortion is 
 provoked and pregnancy comes to an end. If blood 
 is extravasated as the result of congestion, it goes 
 through the same changes and phases as M'hen extra- 
 vasated from other causes. But there is reason to 
 suppose, also, that hyperremia, arising from what- 
 ever cause it may, apart from extravasation, can have 
 the effect, by the distension and irritation it pro- 
 duces, of bringing on uterine action and thus 
 precipitating abortion. This is the more probable 
 
 * See Devilliers, " Eeview Med.," 1842. 
 
INFLAMMATION OF THE DECIDUA. 85 
 
 as the whole uterus must partake of the congestion, 
 and be proportionately irritable. 
 
 Inflammation of the decidua, taking various forms, 
 litis been described by Virchow, Hegar, Schroeder, 
 and Spiegelberg. Slavjansky has described an acute 
 form associated with cholera in pregnant women, 
 and leading to hsemorrhage with the death of the 
 foetus.* These inflammations are, however, generally 
 chronic, and are continuations or extensions of 
 previously existing inflammation in the unim- 
 pregnated mucous membrane of the uterus. Three 
 forms have been described as producing difl'erent 
 alterations in the decidua. 
 
 I. The first, " chronic difluse endometritis " of 
 authors, produces a thickening or hyperplasia of the 
 uterine mucous membrane, which, when conception 
 occurs, renders it unfit for the reception and growth 
 of the fecundated germ. According to Spiegelberg^ 
 the hypertrophy consists in a development of con- 
 junctive tissue, which not only thickens, but 
 indurates the membrane, and extends down to the 
 muscular fibres themselves. The arrangement of the 
 hypertrophied tissues is such as often to give rise to 
 the appearance of cysts, which, however, are pro- 
 bably only the "cups" of Montgomery enlarged. 
 Schroeder regards it as a chronic and difluse jDro- 
 life ration of the mucous cells, both parietal and 
 reflected. The thickened membrane presents, he 
 says, the large cells of the decidua united en masse. 
 By their proliferation, particularly in the deeper 
 layers, they may produce a cavernous structure, and 
 even form cysts. This alteration, he says, produces 
 
 * " Arcliiv filr Gynakol.,'' 18S2. 
 
86 THE PATHOLOGY OF IXTRA-UTERINE DEATH. 
 
 death of the embryo and abortion, by the irritation 
 which the inflammation produces on the uterine 
 nerves. 
 
 Other cases have been described in whicli inflam- 
 mation Avas still more chronic, and wliere the 
 nutrition of the germ was not interfered with. 
 Madame Kaschewarowa,* a Kussian woman doctor, 
 whose researches are sufiiciently accredited to find 
 a place in Virchow's " Archives," alleges that she has 
 found the membranes thickened of a fcetus at term, 
 not only by proliferation of conjunctival tissue and 
 decidual cells, but even by smooth muscular fibres 
 of new formation. Hofef has described other altera- 
 tions of form, and SchroederJ and Spiegelberg§ both 
 state that there may be proh'feration of decidual cells, 
 which is secondary to the death of the foetus, although, 
 if it begins before, it is apt to deprive it of vitality. 
 
 In examining early deciduse thrown ofl" as the result 
 of early abortion I have repeatedly observed a morbid 
 condition, which diflfers in its histology from the 
 description just given by Spiegelberg, Schroeder, and 
 others, and which does not seem to have been sufli- 
 ciently noticed. In this the membrane is distinctly 
 thickened and hypertrophied, and its structure is 
 firmer than normal, while its outer surface exhibits 
 none of those floating filaments seen in comparatively 
 healthy deciduse, but is more or less nodular, and 
 shows indications of being slowly separated from the 
 uterine walls. Microscopic examination shows that 
 there may be an attempt to increase the cell element 
 peculiar to the decidual structure, and tha.t the cells 
 
 * A^irchow's " Avcliiv," 1868. t '■ Arcbiv fih- Gj^niikol.," 1869. 
 
 J "Lehrb. der Geb." § rbid. 
 
HYPERTROPHY OF THE DECIDUA. 8/ 
 
 themselves are more frequently split up than usual, 
 and otherwise deformed ; but in addition to the cell 
 element, there is besides a copious exudation, which 
 is at first simply amorphous or granular, but soon 
 degenerates into fat. The granular deposit is in much 
 larger proportion than the increase of the cell element 
 or of connective tissue, and it may be free from fat in 
 some portions of the membrane, but is elsewhere per- 
 vaded with compound granular cells and oil globules. 
 A condition somewhat similar to this has been briefly 
 noticed by Hegar. It is, I believe, the result of 
 a low form of inflammation, and as it degenerates, 
 which it readily does if at all abundant, it involves 
 the decidual cells, fibro-cells, and blood-vessels in the 
 same morbid change. The inflammatory action is 
 probably due to an unhealthy condition of the uterine 
 mucous membrane prior to conception, or to impaired 
 nutrition afterwards, from faults in the maternal 
 blood. Had the exudation been less abundant or 
 endowed with greater vitality, it w^ould probably have 
 been converted into connective tissue as described 
 by the authors named. 
 
 The engraving of a hypertrophied decidua given by 
 Duncan at p. 292 of his " Besearches in Obstetrics," is 
 probably an example of one of the forms of hyperplasia 
 produced by endometritis, syphilitic or otherAvise. 
 The membrane is described as much increased in 
 thickness, its walls thrown into prominent folds or 
 rugfe, and the cavity was very large in comparison 
 with the small size of the embryo attached to the 
 fundal portion. The embryo had evidently ceased to 
 grow soon after conception, while the decidua had 
 c;one on veofetatinsf. 
 
88 THE PATHOLOGY OF INTRA- UTERINE DEATH. 
 
 Dr. Duncan remarks that fatty degeneration was 
 present in tins as in other specimens of hypertrophied 
 decidua which he examined, and I may observe that 
 fatty change is noticeable in all preparations of this 
 kind which have been retained after the death of the 
 embryo. It is often difficult to say whether the fatty 
 degeneration was a primary change arising from faulty 
 conditions of the maternal blood, and which caused 
 the death of the embryo ; or whether it was secondary 
 to foetal death from some other cause. In either 
 case the fatty change, by the friability it produces, 
 loosens the attachments of the decidua to the uterus, 
 and so precipitates abortion. 
 
 A variety of this chronic diffuse endometritis con- 
 stitutes the ''adhesive endometritis" of Braun.* It 
 takes place in the later months, and it then attacks 
 the utero-placental mucous membrane, setting up 
 such irritation that it imperils the life of the foetus 
 and precipitates premature labour. Strictly speaking, 
 the affection may be regarded as a disease affecting 
 the placenta. One of its results is to produce 
 adhesions between the placenta and uterus, and so 
 complicate delivery. Its presence is characterised by 
 the foetal movements giving pain, and often besides 
 this, acute j)ain and tenderness are experienced in 
 the walls of the womb which some have described as 
 " uterine rheumatism." It may be produced by 
 chills, overwork, &c. ; and according to Kaschewarowa, 
 it is one of the results of syphilis, or of a pre-existing 
 endometritis. 
 
 II. A second form of inflammation affectiusf the 
 
 o 
 
 * " Gesammt Gyn.," iSSi. 
 
POLYPOID ENDOMETEITIS. 
 
 89 
 
 decidua has been described by Virchow* under the 
 name of "polypoid endoraetiitis." It would seem to 
 
 Fig. 2. 
 
 Polypoid Endometritis (Vircliow). a, fine apertures of tlie glands ; 
 h, larger apertures of glands ; c, protuberances, or jDolypi. 
 
 be only a more advanced degree of the inflammatory 
 condition just described, but the mucous membrane 
 is thickened to twice or thrice its ordinary depth, 
 and prominences and projections like polypi protrude 
 from the free internal surface. Where the eminences 
 exist, the uterine gland apertures are obliterated, 
 while they are apparent on other parts of the surface. 
 According to Virchow, the microscopic element, which 
 grows here in excess, is the interstitial mucous tissue, 
 which increases and proliferates in such Avise as to 
 cause the hypertrophy. Spiegelberg, Schroeder, 
 
 * Virchow's " Arcliiv," i86r and 1865. 
 
90 THE PATHOLOGY OF IXTRA-UTERINE DEATH. 
 
 Dohrn, and Gusserow*, have all verified Yirchow's 
 observations with some modifications as to detail in 
 structure. Virchow's case was attributed to syphilis, 
 but there was no proof of this in others. This change 
 is only seen in very young ova, and it always pro- 
 duces an alteration in the chorial villi, which may be 
 in contact with it, disturbing and altering their form ; 
 • and in some cases, as pointed out b}^ Dohrn and 
 Muller,t causing them to show conomencing myxoma. 
 Tlie emljryo in nearly all the recorded cases had 
 disappeared. 
 
 III. A form of inflammation affecting the decidua 
 has been named "catarrhal endometritis." It is 
 characterised by a persistent discharge from the 
 gravid uterus, which constitutes the " hyclrorrhcea " 
 of pregnant women. A woman generally about the 
 sixth month of pregnancy loses suddenly and at 
 intervals a quantity of transparent colourless iluid, 
 analogous to ascitic fluid. This is succeeded by a 
 dribbling more or less prolonged and without pain. 
 The pregnancy may go on to term : and the 
 membranes, as a rule, are found intact. The affec- 
 tion has given rise to much discussion, and there is 
 an extended literature on the subject. Naegele has 
 seen it persist for sixteen weeks Avithout interrupting 
 jDregnancy. 
 
 According to Spiegelberg, Schroeder, Braun, and 
 HegarJ, the fluid comes from the cavity of the 
 decidua, which is a secreting membrane even during 
 pregnancy, and hydrorrhoea is only a hyper-secretion 
 
 * "Mon. fiir Geburt.," iS66. 
 
 f '• liau der !Molen," 1867. 
 
 X Hegar, " ^loiiat. fiir Gubiivt.," 1863. 
 
HYDRORRIKEA. 
 
 91 
 
 of this membrane depending on chronic inflammation 
 of the decidual glands. A great diversity of opinion 
 has, however, been expressed as to the source of this 
 fluid. Tarnier and Buclin, besides the decidual form, 
 speak of an amniotic hydrorrhoea, v^hich occurs as the 
 result of perforations of the amniotic sac far up in 
 the uterine cavity, and, on account of the position of 
 the aperture, do not necessarily precipitate labour. 
 A drawing of a portion of the amnion, with such 
 perforation, is given in their conjoint work on Mid- 
 icifery. 
 
 Fifi 
 
 Aperture in the bag of membranes found in the upper part of 
 the sac, distant from the usual seat of rupture. (Tarnier 
 and Budin.) 
 
 Hydrorrhoea is a somewhat rare condition, only 
 seventy cases having been collected in the most recent 
 essay on the subject. It is only under exceptional 
 circumstances that simple hydrorrhoea compromises 
 the course of pregnancy ; most w^omen aflected by it 
 go to the full period. I need not, therefore, dwell 
 further on the subject. Those interested may be 
 referred to the Thesis of M. Stapper,* and to the 
 
 * Vide Charpentier, "Tr. des. Ace." 
 
92 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 " Traite des Accouchements," by Tarnier and Budin, 
 which contains the last and most able exposition on 
 this topic. 
 
 A form of catarrhal endometritis I have sometimes 
 met with in early pregnancy, and attended with sero- 
 sanguineous or dark grumous discharges, is more 
 formidable so far as pregnancy is concerned. Its 
 persistence generally indicates chronic disease going 
 on in the foetal envelopes — of the decidua more 
 especially — and it commonly ends in abortion. There 
 is usually, in such cases, some antecedent history 
 either of injury or of endometritis existing before the 
 advent of pregnancy. 
 
 Some of the so-called ''moles" consist of the 
 decidua altered and distorted by one of the morbid 
 processes I have just described. A " carneous mole " 
 is so termed because it looks like a fleshy mass 
 expelled from the uterus, and it usually consists of 
 the morbidly thickened decidua which forms the 
 outer covering, and the contents are either lamin£e 
 of blood-clot arranged like the layers of an aneurysm, 
 or such remains of the disorganised embryo and its 
 special membranes as have escaped entire destruction. 
 Most frequently, in the case of carneous moles, no 
 trace of the embryo can be discovered. 
 
 Morbid Changes in the Chorion. — The pathological 
 change affecting the outermost true foetal envelope 
 or chorion, which has received most attention, is 
 what is commonly called " cystic or vesicular or 
 hydatid degeneration." In this affection small or 
 large quantities of cyst-like bodies are expelled at 
 intervals from the uterus of the pregnant woman, 
 theu' expulsion being attended with haemorrhage, and 
 
gYSTic ciiomox. 93 
 
 commonly with the dischrarge of a large quantity of 
 serous fluid of pinkLsh colour, which has been com- 
 pared to red-currant juice. Madame Boivin* stated 
 that she found this disease occurring only twice in 
 20,375 pregnancies, but I suspect this account does 
 not represent the true frequency of the affection, for 
 most accoucheurs in large practice have met with it, 
 and specimens of cystic chorion, in its various stages, 
 are to be found in almost all our museums. In its 
 earlier phases it is not uncommon, but then may be 
 readily overlooked. When fully developed the appear- 
 ance of the growth is very remarkable, and must at 
 once arrest the attention of the medical attendant. 
 Although commonly thrown ofP at first in detached 
 portions, a time comes when uterine action fully sets 
 in, and then a large quantity of cysts may be expelled 
 in one mass, which, in some instances, is sufficient to 
 fill a large basin. The vesicles or cysts of which the 
 mass is composed vary from the size of a millet-seed 
 to that of a grape, and these are intimately united 
 together at various points by thin stems or pedicles. 
 They have been compared to bunches of grapes, but 
 the cysts do not necessarily terminate the stem on 
 which they are suspended, like grapes, but are united 
 in a plexiform arrangement one with another in a 
 sort of network. 
 
 In Pares "Surgery" it is recounted "that the 
 Countess Margaret, daughter of Florent IV., Earl of 
 Holland, and spouse to Count Herman of Heneberg, 
 on Good Friday, in the year of our Lord 1276, and 
 of her age forty- two, brought forth at one birth 365 
 infants, Avhereof 182 are said to have been males, as 
 
 * " Mem. de I'Art dcs Accouch." 
 
94 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 many females, and the odd one an hermaphrodite, 
 who were all baptized, those by the name of John, 
 
 Fi»i. 4. 
 
 A portion of cystic chorion as seen with the naked ere. Tlie 
 arrangement of the vesicles is seen anrl also their attach- 
 ments to the chorion membrane. (Ercolani.) 
 
 these by the name of Elizabeth, in two brazen dishes, 
 by Don William, Suffragan Bishop of Treves." It is 
 added : " The basins are still to be seen in the village of 
 Losdiin, where all strangers go (on purpose) from the 
 
CYSTIC ClIORIOX. 95 
 
 Hague, being reckoned among the great curiosities 
 of Holland." This account is not regarded by modern 
 authorities as a pure invention. Ambrose Pare was 
 eminently lionest, and these 365 children are now 
 regarded as having been merely vesicles of a cystic 
 chorion, magnified into infants by some one whose 
 interest it was to promulgate the illusion. 
 
 The published literature on this single disease of 
 the chorion is more extensive than of any affection of 
 the foetal membranes, and both detached observations 
 and separate monographs exist in several different 
 languages. Cloquet,* Percy,! and Boivin regarded 
 the vesicles of the chorion as true acephalocysts ; but 
 it has been abundantly ]3rovecl that they are not so, 
 being furnished neither with booklets nor other 
 minute structures characteristic of true hydatids. 
 Bidlos and Soemmering believed cystic chorion to be 
 a disease of the lymphatic vessels ; and Bartolin, 
 MtlUer, and CruveilhierJ a disease of the blood- 
 vessels. Ptuysch§ attributed the formation of the 
 cysts to accumulation of fluid in the cellular tissue 
 which unites the vascular tunics of the foetal 
 membranes. 
 
 Nearly all modern authorities agree in regarding 
 them as the results of pathological changes of one 
 kind or other in the villi of the chorion. The single 
 exception, I think, is Ancelet, who in 1868 published 
 a paper in the "Gazette des Hopitaux," and he there 
 reverts to an old idea that the hydatid mole is a 
 disease of the decidua. 
 
 * " No. I de la Faune des Med." 
 
 t " Ancien Journ. de Med.," 1793. 
 
 J Vide Chavpentier, " Maladies du Placeuta." 
 
 § " Obser. Anat. Clin.," 1691. 
 
g6 THE PATHOLOGY OF INTRxV-UTERINE DEATH. 
 
 Velpean* seems to have been the first to indicate 
 that the cysts were not true or indejjendent vesicles. 
 He regarded them as swollen chorionic villi, the 
 terminal extremities being enlarged by the accumu- 
 lation of fluid, as a sponge is distended by water. 
 H. Mickelt and Giersej said there was hypertrophy 
 of the natural structures, with oedema of the villi, 
 which they considered secondary. An excellent 
 description of the different stages of this transforma- 
 tion and its mode of growth, after Mettenheimer, is to 
 be found in Sir James Paget's " Surgical Pathology ;" 
 and Dr. Barnes, § Dr. Graily Hewitt, |I and Dr. Braxton 
 Hicks,^ in this country, have further illustrated the 
 various stages of its development in separate papers. 
 In France, C. Pvobin's observations have attracted 
 much attention, and his views are adopted by M. 
 Cayla, who wrote a well-known thesis on the subject. 
 Probably the most lucid and notable contribution to 
 the pathology of this subject is from the pen of the 
 celebrated Virchow.** He points out that the many 
 discrepancies in the ideas promulgated concerning the 
 true nature of cystic chorion are due to incomplete 
 knowledge of the villous structure in normal conditions. 
 According to him, the villi consist of a prolongation 
 of the same mucous tissue wliicli forms the gelatin 
 of "Wharton in the cord. The villi have two essen- 
 tial portions — an epithelial covering (exochorion) and 
 
 * " De I'Art des Accoucbemeuts." 
 
 t " Handbuch dea j\[ensch. Anat.," 1S20. 
 
 X "Verhandl. der Gcselb. fiir Geburt.,'' 1847. 
 
 § "Biitisb and Foreign Medical Review," 1855. 
 
 II " Obstet. Trans.," vol. i. 
 
 V " (iiiiy's Hospital Reports," 1864. 
 
 ** " Die Kranlc. d. Geschw.," t. i. 
 
VIRCHOWS VIEWS. 97 
 
 a substratum or body of mucous tissue (endocliorlon) 
 which, iion-vascuhir when the villi first appear as 
 buds on the outer surface of the chorion, later contain 
 blood-vessels. The proliferation of the epithelium 
 which Heinrich Mtiller* regarded as the point dc 
 depart for the production of cysts, Virchow regards as 
 the expression of regular and normal development. 
 The buds or cysts are formed in the same way as in 
 normal growth, and it is the interior of the villus — 
 not in its epithelium — that the particular and morbid 
 transformation takes place. In effect, Virchow^ 
 regards the cystic chorion as a typical form of 
 myxoma, and he avers that he has found the same 
 productions in other parts of the envelopes. Both 
 Ruysch and Yirchow have found these cyst-like bodies 
 in the umbilical cord. Virchow noticed certain buds 
 of the external epithelial covering of the villi which 
 contained transparent cavities ; these he called " phy- 
 salides." Single large dilated cells containing a 
 hyaline liquid he called " physalifores." Wedl had 
 previously described them in his " Histological 
 Pathology ; " and Virchow, while confirming Wedl's 
 observation, regarded them as accidental products. 
 Ercolani inter]:)reted their presence after another 
 fashion, and as affording evidence of a different theory 
 of cyst development. 
 
 Virchow further states that the mucous meta- 
 morphosis of cells seen in the villi of the chorion may 
 disappear in fatty transformation, or the cells may 
 be changed into fibrous elements, thus constituting a 
 " myxoma fibrosum." This change I shall describe 
 later. 
 
 * "Der Bau der Molen," 1847. 
 
 H 
 
98 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 As long ago as 1858,* before I knew anything 
 of the researches of Virchow, I had pointed out that 
 the cysts of the chorion were not mere dropsical 
 dilatations of the terminal villi, l^ut that the fluid 
 distending them, in the earlier stages at least, was 
 formed or secreted in the interior of beautiful thin- 
 
 FlG. 
 
 A a, Extremity of a villus in early stage of cystic degeneration ; a. 
 shows the first stage of enlargement in the cells of the villus 
 trunk ; h, a somevphat more advanced stage, showing hyaline 
 cells escaping from the ruptured capsule of a young cyst. 
 (Priestley.) 
 
 B Terminal villus of cystic chorion ; a, stellate connective tissue ; 
 &, c, inner and outer layers of wall ; d, early stage of h. 
 (Braxton Hicks.) 
 
 walled cells, which had their origin in the centre of 
 the villus. The microscopic examination I described 
 in my lectures on the gravid uterus as follows : — 
 " Placing a terminal branch under the microscope, 
 which seemed to the naked eye nearest to the normal 
 condition, it was seen to be enveloped by a granular 
 covering, probably derived from the altered decidua ; 
 the club-shaped extremities were observed to be dis- 
 tended with large nucleated cells, and bearing little 
 resemblance to the small and more uniform cellules 
 
 * " Lectures on Development of Gravid Utertis. 
 
MINUTE STRTICTURE OF CYSTIC CIIORK^N. 99 
 
 composing a terminal villus in a healthy state. By 
 com])ression the envelope bounding the villus could 
 be ruptured, and gave egress to tlie cells. The 
 fully developed cysts had two coats, like a normal 
 villus, the external epithelial, the internal delicately 
 fibrous, but firm and dense. An incision being made 
 through these (if the preparation was fresh) what 
 appeared to be a viscous or gelatinous fluid escaped 
 from the aperture, and this was found to be con- 
 tained in large transparent cells, with walls of extreme 
 tenuity, assuming the polyhedral form from the pres- 
 sure to which they had been subject. The entire con- 
 tents had much the appearance of the vitreous humour 
 of the eye, which has transparent partitions running 
 across, separating the fluid into compartments ; the 
 presence of a nucleus, however, in each compartment 
 clearly proved it to consist of largely developed thin- 
 walled cells. In the largest cysts, the pellucid 
 cells were not readily discernible, having probably 
 undergone solution. Scattered over the vesicles and 
 their connecting peduncles were little nodular pro- 
 jections, consisting of cellular buds for new branches, 
 such as exist in healthy villi. The narrow stems 
 uniting the cysts were fibrous, with a cellular cover- 
 ing, and sometimes enclosed a small vessel full of 
 blood. Fat granules vv^ere copiously deposited in the 
 texture of both stems and vesicles." 
 
 There is no discrepancy between this account from 
 actual observation and the view taken by Yirchow, 
 that the morbid change is a true myxoma. The 
 only difference is that Yirchow seems to look upon 
 the distension of the villi as due to the accumulation 
 of mucus in the inter-cellular tissue, while I found 
 
 TT 2 
 
lOO THE PATHOLOGY OF INTRA-UTERTXK DEATH. 
 
 the distension produced during early de\ielopment 
 at least in the rapid production of thin-walled, 
 nucleated cells. Possibly both may be right. It 
 seems highly probable that, in the smaller cysts, large 
 cells with fluid contents constitute the first stage of 
 the disease, and, later, these cells form themselves 
 into spaces traversed by trabeculse of connective 
 tissue, and containin^f the fluid. This is identical 
 with the process by which the gelatin of Wharton is 
 produced in the cord. The exuded fluid in both cases 
 has all the chemical reactions of mucine. It is by no 
 means uncommon to find in the extremity of a com- 
 paratively healthy villus one or more large transparent 
 hyaline cells. These represent the beginnings of the 
 cvstic chano'e, or the first transformation from the 
 more uniform cell-structures which compose the 
 parenchyma in a normal state. 
 
 Ercolani'^ (who wrote in 1876) differs in toto fi'om 
 Virchow and other authors in his view of the pro- 
 duction of cystic chorion, and, disbelieving in its 
 myxomatous origin, he regards Virchow's appellation 
 for it as misleading. He, like Yirchow and Robin, 
 describes a villus as composed of two parts : one 
 internal or parenchymatous (tissue chorial of Robin, 
 mucous tissue of Virchow) which is in direct com- 
 munication, and in fact continuous, with the chorion. 
 Besides, this is an external portion, which constitutes 
 an outer envelope or casing to the villus (the exo- 
 chorion of Robin). Before the villus pe'netrates the 
 decidua, this outer envelope is constituted of an 
 epithelium which belongs to the fcetal structures, but 
 directly the villus is embedded in the decidua to 
 
 * hoc. cif. 
 
ERCOLANI S VI]:\VS. 
 
 lOI 
 
 form the placenta this ei^itheUal envelope disappears, 
 and its place is taken by a layer of cells derived from 
 the decidua, which he calls the " glandular organ," 
 because in this glandular organ, he conceives, is carried 
 on the process of elaboration by which materials are 
 provided from the mother's blood for the nutrition 
 of the foetus. Now it is from this outer enve- 
 lope — the epithelial covering in the primitive chorial 
 
 Fig. 6. 
 
 Extremity of a chorion villus, hypertrophied, and beginning cystic 
 degeneration. The celhdar structure, seen at li, is the epithe- 
 lial covering of the villus. Neoplasms are springing from the 
 surface of the villus (ee), and large dilated cells (physalifores) 
 are seen at rj. (From Ercolani.) 
 
 villus, or, if the disease begins later, from the glan- 
 dular organ in the villi of the placenta — that, 
 according to Ercolani, the proliferations take place 
 which form the cystic disease of the chorion, and not 
 from the mucous tissue or parenchyma, as stated by 
 
102 THE PATHOLOGY OF INTRA-UTERTNE DEATH. 
 
 Yircliow. Heinrich Miiller had in 1843 declared that 
 these morhid changes commence with an enlargement 
 of the external envelope of the villi, and that later 
 these buds or enlargements give place to internal 
 cavities which become vesicles. Virchow so far 
 agreed with Miiller that the epithelium is the point 
 of departure for the formation of cysts, but he con- 
 tends that, in the production of vesicles, the paren- 
 chymatous or basic substance of the villi must 
 })enetrate the new epithelial product, thus carrying 
 with it the mucous cells continuous with the chorionic 
 structure, and which are necessary to the production 
 of the true myxoma. From this view Ercolani 
 emphatically dissents, and he gives various details 
 of investigation to sustain his position. Thus, Ijesides 
 his asseveration, that the buds take their origin in 
 the epithelial or glandular layer surrounding the 
 villi, he points out what had before been indicated by 
 Ancelet, that the vesicles in their development do 
 not necessarily spring fi'om the parent villus trunk, 
 but take their orig-in in other vesicles, and that some 
 vesicles not only proliferate from large vesicles, l^ut 
 also that the largest often spring from those which 
 are much smaller. This he holds is quite incom- 
 patible with the idea of the mucous tissue from the 
 chorion penetrating or sending prolongations into all 
 the vesicles. 
 
 /// limine Ercolani holds that there may be a forma- 
 tion of cyst-like bodies beginning in the epithelial 
 envelope of a villus, when disease attacks the 
 chorionic villi at a very early period. But when the 
 chorion has united with the serotina to form the 
 young placenta, the typical form of cystic degenera- 
 
RELATION OF CYSTS TO DECIDUA. 103 
 
 tioii begins in morbid proliferations of the decidual or 
 glandular organ, and so the disease apparently belongs 
 more to the mother than her offspring. It is worth 
 while to appreciate this point, if it be true, as it may 
 afford some clue to subsequent treatment, which 
 must necessarily be on the maternal side. Ercolani s 
 researches and speculations on this subject are 
 marked by great painstaking and ingenuity, but I 
 confess I am not convinced of the truth of his view 
 as opposed to Virchow's. Ercolani has certainly con- 
 tributed to produce some confusion in the pathology 
 of the condition by describing myxoma of the chorion 
 and myxoma of the placenta as different affections, 
 and giving to each a separate chapter, while there 
 can be no doubt that both are essentially the same 
 disease with but slight modifications. 
 
 The general relation of the cystic chorion to the 
 decidua is sometimes very distinctly seen in the 
 incipient stages of the morbid change. Many years 
 ago the late Dr. McClintock showed me in Dublin a 
 preparation which is mentioned by Dr. Montgomery 
 in his " Signs of Pregnancy," in which a mass of 
 cysts is enclosed between two layers of decidua — the 
 decidua vera and the decidua reflexa. Dr. Graily 
 Hewitt,*' has also figured a specimen in which both 
 deciduse are well shown, and the relation of the cyst- 
 like structures to the serotina is delineated. When 
 cystic disease is further advanced, the relations of the 
 various membranes become so confused that the 
 vesicles are inextricably mixed up with the hyper- 
 trophied decidual structures, and separation of the 
 two is impossible. 
 
 * " Obstet. Trans." 
 
1 04 THE PATHOLOCJY OF INTRA-UTERTNE DEATH. 
 
 There are all possible varieties in the degree and 
 stage of the disease to be met with, and the different 
 appearance of the mass which is expelled from the 
 uterus has given rise to a classification of these 
 "moles," as they are called. Thus we have the 
 " vesicular mole/' in which the chief part of the sub- 
 stance passed consists of the pellucid cysts just 
 described, varying in size from a pin's head to the 
 size of a grape. With the cysts, however, is always 
 mixed up a certain amount of a denser envelope — 
 the altered decidua — which either adheres to the 
 cysts or is loosened from them and expelled sepa- 
 rately. If the thickness of the outer envelope of the 
 mass greatly preponderates over the cystic stiTictures 
 within, we liave another modification of the so-called 
 "carneous mole," which may with propriety be 
 named " carneo-cystic," to distinguish it from the 
 other carneous mole I have described as a mere 
 thickened decidua. In this the mass is made up of 
 a more or less fleshy substance, granular in appear- 
 ance, and blood-stained, with a small proportion of 
 vesicles. Some time ago I carefully examined a 
 specimen of this kind, which had been expelled from 
 the uterus with all the symptoms of miscarriage. 
 The mass was half the size of a cocoa-nut, and, when 
 cut into, was seen to be composed of a granular, dark 
 red substance, interspersed here and there, at distant 
 intervals, with vesicular bodies. In this case the 
 chorionic villi had degenerated, as in the more marked 
 form of vesicular mole ; but the decidua had become 
 proportionately much more morbidly developed than 
 the chorionic villi, and hence the different appearance 
 of the mass. In this and in other instances I have 
 
MOLES. 105 
 
 repeatedly examined tlie microscopic structure of the 
 granular matrix in which the cysts were sparingly or 
 more amply imbedded, and I have rarely failed to 
 find distinct evidences of a definite arrangement of 
 glandular structure, such as exists in the normal 
 decidua. All the elements were, however, enor- 
 mously hypertrophied ; while the glandular particles 
 were infiltrated with fat-granules and the d^hrh of 
 blood-corpuscles and crystals. The blood-vessels 
 themselves were surrounded with fat-granules and 
 molecules, and crumbling in degeneration. This fatty 
 degeneration must cause a tendency to separation 
 from the walls of the uterus. The mass then becomes 
 a foreign body, which at length excites uterine con- 
 traction, and ends in its exjjulsion. 
 
 When cystic disease of the chorion is far advanced, 
 the embryo either entirely disappears, or, if Ibund, it 
 is commonly shrivelled and wrapped in its amnion in 
 the centre of the mass. In some rare cases, even 
 when the embryo is found, no trace of the amnion is 
 present. It has either not been developed, or, once 
 formed, it has disappeared, and the shrivelled and 
 distorted embryo remains attached directly to the 
 inner surface of the chorion. 
 
 Chorionic villi which have undergone cystic degene- 
 ration have a remarkable way of forcing themselves 
 not only through the deciclua, but into the very sub- 
 stance of the uterine walls. This is strikingly 
 illustrated in a preparation in St. Thomas's Hospital, 
 which is recorded in the " Obstetrical Transactions " 
 by Dr. Cory. The woman from whom it was taken 
 was forty years of age and had had eight children. 
 When more tlian four months pregnant, she passed a 
 
I06 THE PATHOLOGY OF INTRA- I'TERINE DEATH. 
 
 u 
 
 large hydatid mole. Bleeding, with serous discharge, 
 continuing, the uterus was eventually injected with 
 perchloride of iron. The patient 
 died very suddenly after, and it was 
 ^ found that the iron had penetrated 
 I to the peritoneal cavity. Tlie 
 
 I uterus shows a portion of cystic 
 ? chorion still attached to the in- 
 = terior of its cavity, and the C3'stic 
 ^ villi have forced themselves along 
 ^ ^ the uterine sinuses so far doM'n 
 0| into the deep structures of the 
 |.; w^omb that they are close to the 
 
 I I peritoneal surface. There was con- 
 i ^ sequently very little tissue left be- 
 f^ . tween the cavity of the uterus and 
 I I the peritoneal cavity. Somewhat 
 't^B similar cases have been recorded 
 ^ =^ by Waldeyer"^ and Jarotzky, Spie- 
 tr, gelberg,t and Volkmann.J 
 ■? Cystic degeneration of the chorion 
 'Z is essentially a disease of the mem- 
 i branes in early pregnancy. It has 
 ^ been supposed to begin before the 
 
 \ \ I allantois reaches the chorion, and, 
 
 \ \ ^ therefore, before the villi are sup- 
 
 ])lied with vascular loops. That this 
 
 cannot be always the case is proved by the fact that 
 
 foetal blood-vessels are sometimes seen in the stems 
 
 of the diseased villi and in the vesicles, and also by 
 
 * Virchow's " Arch.," Bd. xliv. 
 t " Lehrb. der Geburt." 
 
 X \'irchow's •• Arcb.," Bd. xli. 
 
PARTIAL MYXOMAS. 10/ 
 
 the cases of partial myxonui Avliicli have been re- 
 corded. 
 
 In early gestation, the whole outer surface of the 
 chorion is furnished pretty equally with villi. Those 
 which are to form the placenta, and which are 
 imbedded in the decidua serotiria, soon beconie more 
 developed, and the rest, under ordinary circumstances, 
 remain for a while stationary or retrograde. If cystic 
 disease begins, it is generally at the crisis of develop- 
 ment, when the placenta is aliout to take a definite 
 shape, and the villi are concentrating themselves on 
 the placental spot. Then the villi over the whole 
 sphere of the ovum have about an equal growth, 
 although they may be somewhat more luxuriant at 
 the placental spot ; and all may be like affected by 
 the myxomatous change. Not only do the villi 
 destined to form the placenta dilate, but the chorial 
 villi, which should become atrophied, increase in 
 volume and hypertrophy. This accounts for the 
 general appearance of the cystic mass when it is 
 expelled from the uterus, the vesicles being pretty 
 equally distributed everywhere through it. There are 
 some few exceptions in which the placenta is attacked 
 by cystic change after the placenta is already local- 
 ised ; but the disease then rarely shows itself in an 
 advanced form, the dilatations of the villi being com- 
 paratively small. Instances, however, have occasion- 
 ally been recorded in which living foetuses have been 
 born with the placenta in a state of partial cystic 
 degeneration, and some of these seem sufficiently 
 authenticated by modern observers to be admitted. 
 
 Partial myxomas have been described in which 
 one or more branches of villi alone have been affected. 
 
loS THE PATHOLOGY ()!• INTRA-UTERINE DEATH. 
 
 the rest remainino- healthy and the child well 
 developed. These cases are, however, rare. When 
 the disease does occur, as l)efbre stated, it generally 
 attacks all the villi alike. Still rarer are instances 
 which have been recorded where a twin embryo has 
 perished in early pregnancy, and has eventually been 
 expelled with cystic degeneration of its membranes, 
 at the same time as a living child with its placenta 
 healthy. Siebold gives an example of this, and Dr. 
 Hall Davis has recorded another in the " Obstetrical 
 Transactions ' ' for 1862. 
 
 The crucial question, and one which has been much 
 discussed, is, whetiier the disease of the chorion pre- 
 cedes the death of the embryo, and so causes its 
 death, or whether the embryo dies first, and the 
 cystic degeneration takes place subsequently, and is 
 in some sense the consequence. Most modern 
 authors regard the disease of the chorion as first in 
 the order of events ; but Mikschik,* Gierse, and Dr. 
 Graily Hewitt have endeavoured to show that the 
 disease is consequent on the death of the embryo. 
 The reasons advanced for this view are, that, in many 
 cases, the embryo has either been arrested in growth 
 or has disappeared altogether ; and, further, that in 
 some twin conceptions one chorion has degenerated, 
 the other remaining healthy until term. This view 
 is vitiated, in the first place, by the recorded instances 
 of living foetuses where the ])lacenta was cystic, 
 notably by Martin of Berlin, t Villers,! and Krieger;§ 
 
 * " Zeit. der Wien. Aer/.te," 1845. t " iMouat. f. Geburt." Bd. xxix. 
 1 Schmidt's "Jahrb." Bd.xxxix. 
 
 § Ibid. 1864. Dr. Allan Sym, in the '"Edia. Med. Jour."' for Aug. 
 1887, has recorded another instance of this kind. 
 
THE F<KTUS I\ CYSTIC CHORION. I09 
 
 and, further, by tlie fact that we may have partial 
 inyxoma of the chorion with continued growth of the 
 embryo. Graily Hewitt gives, as one of his reasons 
 for regarding the death of the embryo as first in the 
 order of events, its small size in all cases where the 
 chorion has become cystic ; the largest he had been 
 able to find was Dr. Granville's example, in which the 
 embryo was only one inch and three quarters in length. 
 
 In St. Thomas's Hospital, however, is a foetus of 
 from three to four months' growth, with cystic chorion 
 fully developed. The foetus is not shrivelled, as 
 commonly happens in such cases, but seems as 
 though, up to a certain time, it must have been fairly 
 nourished, notwithstanding a very marked twisting 
 of the umbilical cord. The largest portion of the 
 placental mass had in this specimen undergone 
 advanced cystic degeneration, but enough of the villi 
 had, up to a certain time, remained capable of supply- 
 ing nourishment to the f(jetus. A time came at 
 length when the distension of tbe uterus, from the 
 rapidly growing chorion, brought on uterine contrac- 
 tion and eventual expulsion of the contents. The 
 placenta in this preparation is seen to be as large as 
 that organ commonly is at the full time. 
 
 I take it, therefore, that both the direct and in- 
 direct evidence is clearly in favour of cystic disease 
 of the chorion preceding the death, and in most cases 
 being the cause of death in the foetus. There may be 
 exceptional instances where cystic degeneration takes 
 place after the death of the embryo. This may be 
 the case where one placenta of twins only is affected 
 by disease ; but this does not invalidate the main 
 position ; it only indicates tluit cystic change in the 
 
1 10 THE PATIJOLOGY OF INTRA- UTERINE DEATH. 
 
 villi may take place l)otli before and after the death 
 of the embryo. 
 
 As to the cause of the disease, Virchow believes 
 that the original fault is in the decidua, which, 
 becoming inflamed and thickened before impregna- 
 tion, is incapable of receiving and supporting tlie 
 chorionic villi which try to take root in it. It is con- 
 verted, so to speak, into a soil incapable of affording 
 nourishment for normal gTOwth, and the result is the 
 2)roduction of a monstrosity, which acquires all the 
 characters of a parasite, and kills the embryo by 
 appropriating all the nutrient materials to its own 
 vegetation. It may not be regarded as fanciful to 
 remark that the various forms of mole seem not only 
 to bear analogy, as previously remarked, to monstrous 
 flowers and fruits, but also that the structural parts of 
 these monstrosities find their counterparts in these 
 abortive masses from the human subject. Thus, the 
 carneous mole, with its overgrown decidua, may 
 represent the deformed calyx, and the vesicular mole 
 the distorted and over-developed corolla, being 
 developed at the expense of the central embryonic 
 portion. 
 
 Virchow's theory — that the cause of cystic disease 
 in the chorion is to he found in a faulty condition of 
 the uterine mucous membrane — is supported by the 
 fact that the same woman will often produce several 
 vesicular moles in succession, and Virchow asserts 
 that in these women the decidua bears traces of in- 
 flammatory thickening, sometimes with polypoid 
 excrescences on its free surface. Depaul* mentions 
 a woman who l^ad the affection three times. There 
 
 * " Lcipns de Clin. Obstet.," 1S72. 
 
CAUSE OF CYSTIC CHORION. Ill 
 
 is, nevertheless, abundant evidence to show that a 
 woman may have living children at some later period, 
 after being the subject of cystic disease of the chorion. 
 The only objection to Virchow's view which strikes 
 me, is the fact, previously mentioned, that twin ova 
 have been expelled in abortion, one of which had 
 cystic chorion and the other not. It is difficult to 
 understand, if disease of the decidua was the cause of 
 cystic degeneration, how one embryo should be 
 affected and the other escape.* 
 
 The last point in connection with this subject is 
 the question : Can cystic or vesicular chorion ever 
 occur in women without conception ? This question 
 came before a Court of Inquiry in India some years 
 ago, and involved both the character of an unmarried 
 woman and the reputation of a medical man whose 
 opinion had impugned her chastity. The medical 
 man collected the opinions of all the leading 
 obstetricians in this country, and, although the 
 balance of opinion greatly preponderated in favour of 
 vesicular chorion being always the result of impreg- 
 nation, there was at least one notable dissentient, 
 who believed that the vesicles miofht be formed in 
 the virgin uterus. We now know so accurately the 
 way in which these vegetations are produced that 
 doubt should no longer exist on the matter. With 
 our present knowledge it would be just as reasonable 
 to suppose that a child might be expelled from an 
 imimpregnated uterus as a true vesicular chorion. 
 
 A portion of cystic chorion may be long retained in 
 
 * Underbill asserts that cystic diorion, in the majority of cases, is 
 associated with a cancerous or syiiliilitic dyscrasia. — (" Obstet. Gaz.," 
 1879.) 
 
I 12 THE PATHOLOGY OF INTRA-UTKRIXK DEATH. 
 
 utero without giving rise to active symptoms, and 
 thus unfounded suspicion may arise concerning the 
 chastity of women when this is expelled. The late 
 Dr. McClintock* specially called attention to this, 
 and said, "Hydatids may be retained in utero for 
 many months or years, or a portion only may be 
 expelled, and the residue may throw out a fresh crop 
 of vesicles, to be discharged on a future occasion." 
 
 There can be no doubt also of the fact, which is 
 well illustrated in Dr. Cory's preparation, previously 
 described, that after a cystic mole has been expelled, 
 a portion of the cyst growth may remain behind and 
 proliferate in the uterine walls, thus keeping up 
 exhausting discharges, and imperilling the safety of 
 the patient. In these cases, therefore, the prognosis 
 should be a guarded one. I need not say that cystic 
 chorion must not be mistaken for true hydatids or 
 acephalocysts, which on very rare occasions have 
 been expelled from the unimpregnated uterus. 
 
 Morbid Changes in the Amnion. — The amnion, or 
 innermost foetal envelope, bears a very close resem- 
 blance to a serous membrane. In its earliest develop- 
 ment it may be seen raised like a blister over the 
 whole dorstd surface of the embryo, and as it gradually 
 grows away from the foetus and forms a more distinct 
 cavity to surround it, it increases in firmness and 
 density, and at length coalesces with the inner surface 
 of the chorion to form the future bag of membranes. 
 
 In the early stages of pregnancy the amnion 
 does not always escape the eft'ects of extrava- 
 sation beginning in the decidual structures. The 
 force of the blood extravasation may be such as to 
 
 * "Clin. Mem.," 1S63. 
 
INFLAMMATION OF THE AMNION. I I 3 
 
 break down the resistance both of the chorion and 
 amnion, and if the cavity of the amnion is invaded, 
 the invariable result is the destruction of the embryo, 
 with abortion sooner or later. The eai-lier in preg- 
 nancy this extravasation takes place, the greater 
 the likelihood of the inner envelope giving way, for it 
 is then most fragile and most easily ruptured. There 
 is great variation in the amount of resistance offered 
 by the amnion in different cases. This is notable 
 even to the end of pregnancy, for we sometimes find 
 the bag of membranes of which the amnion forms an 
 integral part so thin that the first uterine contractions 
 produce escape of the waters, while in other cases the 
 membranes are so tough as to impede the progress 
 of labour and require puncture for its acceleration. 
 Dubois'* says the feeble resistance of membranes may 
 be due to natural structure, I suppose, as some -women 
 may have thinner skins than others, or it may be due 
 to alterations consequent on inflammation. However 
 produced, it may, by facilitating rupture and escape 
 of the liquor amnii in early pregnancy, and before the 
 child is viable, lead to intra-uterine death, for it is 
 well known that pregnancy cannot continue long- 
 after the entire evacuation of the amniotic fluid. 
 
 The question as to whether there is a true inflam- 
 mation of the amnion has been discussed, and various 
 supposed pathological results have been pointed out. 
 Jacquemier details three cases which he regards as 
 clearly indicating the occurrence of inflammation on 
 its free surface. One of the patients had peritonitis, 
 and al^orted five days later ; another had been kicked 
 in the abdomen at the third month, and although she 
 
 * " Diet." iu 30 vols., Art. Hydrometrite. 
 
I 1 4 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 went to the fall time, there was a rapid development 
 in size of the abdomen as the result of the injury, 
 and a large quantity of liquor amnii was formed in 
 the uterus. In all the cases the membranes were 
 thickened and traversed by abundant vessels, and in 
 one the containing fluid was cloudy and whitish in 
 colour, with flakes like curd of milk floating in it, 
 which were portions of false membrane detached from 
 the free surface of the amnion. 
 
 The adhesions sometimes noticed between the 
 amnion and the umbiHcal cord, or between the amnion 
 and the foetus, are almost invariably associated with 
 some malformation or monstrosity of the child, and 
 have been attributed to inflammatory action. The 
 diflSculty in accepting this theory is the general 
 absence of other inflammatory signs in such cases, 
 besides the mere adhesion and its associated mon- 
 strosity.* The natural history of such malformations 
 further points to some entanglements of embryonic 
 structures in the process of development — these 
 resulting in distortion and displacement of normal 
 parts. 
 
 The condition which has received most attention in 
 connection with the pathology of the amnion is what 
 has been termed " Hydramnios," or superabundance 
 of liquor amnii. The presence of a certain amount 
 of fluid in the cavity of the amnion is necessary to 
 the development of the foetus, but in some cases it 
 is so abnormally large as to endanger the life of the 
 child, and if it does not necessarily bring peril to the 
 
 * Courtsey says when the phenomena are produced early, it is by 
 the liqiior amnii being absorbed, and the membranes then acquire 
 adhesions to the integument of the foetus. In others, inflammation 
 is the cause, and there are false membranes formed from the amnion. 
 
HYDRAMNIOS. I I 5 
 
 mother, it may place her in very grave discomfort. 
 Dr. Kidd, who wrote on the subject in the 
 " Proceedings of the DubUn Obstetrical Society " for 
 1S78, limits the term "hydramnios" to those cases 
 in which more than two quarts of amniotic fluid are 
 present. The quantity of fluid is sometimes very 
 large. Baudelocque gives one case where thirty 
 pints escaped from the uterus ; other authors 
 give thirty or forty pints. Coming on suddenly in 
 some instances, more slowly in others, the fluid so 
 distends the uterus that it acquires a volume entirely 
 disproportioned to the stage of pregnancy. The result 
 to the mother is that she may sufier greatly from the 
 distension. Respiration is impeded, and the patient 
 may not be able to lie down night or day. The 
 digestion is deranged from physical pressure, and 
 the heart's action is disordered, while other secondary 
 symptoms, such as oedema of the lower limbs and 
 blueness of the countenance, may be superadded. 
 
 The effect on the child is to impede its develop- 
 ment, and, if born alive, it is commonly too feeble to 
 survive its birth. Frequently the child is affected 
 with dropsy, hydrocephalus, or other complication. 
 Of thirty-three cases mentioned by McClintock, 
 nineteen children only were born alive ; ten of these 
 died a few hours after birth, and nine survived. 
 Often the foetus dies in utero, and may then be 
 retained a considerable time after its death, thus pro- 
 longing the discomfort of the mother. The condition 
 has a tendency to repeat itself in the same woman. 
 I saw a patient some years ago in her tenth preg- 
 nancy, who was sent to me by Dr. Matthews Duncan, 
 and who had suffered from hydramnios in nine out 
 
 I 2 
 
I 1 6 THE TATHOLOGY OF INTRA-UTERINE DEATH. 
 
 of the ten gestations, losing most of her children, the 
 first pregnancy being the only healthy one. 
 
 There is an extensive literature on the subject, but 
 little is known as to the cause or causes. Mercier 
 noted traces of inflammation in the amnion, but 
 Dubois and Desormeaux cite cases where there was 
 no appreciable lesion of the membranes, and there 
 are no constant appearances in the placenta associ- 
 ated with the condition. Churchill attributed it to 
 excessive secretory activity in the amnion, and 
 various other explanations have been given, but they 
 do not add much to the precision of our knowledge 
 of its causation. 
 
 In the case I have alluded to as occurring in my 
 own experience, there was nothing to account for the 
 phenomena beyond a short residence in India, which 
 had impaired the general health, and I found no 
 albumen in the urine. 
 
 It has been said to be rare before the fifth month, 
 but in going through the museums, I find many 
 examples of it in the earlier periods of pregnancy ; 
 and both from this and my own experience, I infer 
 that it is far from infrequent in the first half of ges- 
 tation. In St. Mary's Hospital there is a specimen 
 in which the amniotic cavity is from three to four 
 inches long, and the embryo is not larger than a 
 horse-bean. In St. Bartholomew's again there is a 
 large amniotic cavity with no embryo at all. 
 
 Merriman,* Robert Lee,t and others, attribute 
 liydramnios to a morbid state of the mother, and 
 particularly to the effects of syphilis, That the 
 
 * " Synopsis," &c., 1838. 
 
 t " Theory and Practice of Midwifery." 
 
HYDRAMNIOS. I I 7 
 
 liquor amnii may be affected by the state of the 
 mother is evident from many facts. Dr. Duncan,* 
 in a paper on Puerperal Diabetes, states that 
 hydramnios is frequent in association with this con- 
 dition, and sugar has been found in the liquor amnii. 
 Two or tliree tacts have been distinctly made out in 
 relation to its pathology. 
 
 1. Scarpat noticed a coincidence between this 
 form of dropsy and the presence of twins. This has 
 been fully confirmed by the observations of Winckel,| 
 McClintock,§ and others. 
 
 2. In pregnancies complicated with hydramnios 
 the child often presents some vice of conformation. 
 Monsters are, in fact, common with this affection. 
 
 3. The children born with a superabundance of 
 liquor amnii often present evidences of syphilis, and 
 this whether they are born dead or alive. 
 
 4. Hydramnios is comparatively rare in first 
 pregnancies as compared with others. 
 
 5. It is more frequent with female children than 
 males. Of thirty-three cases collected by McClintock, 
 only eight were males. 
 
 The impression derived from a careful study of all 
 the circumstances is, that hydramnios is not a pro- 
 duct of inflammation of the amnion, as some have 
 supposed, but that it arises sometimes from constitu- 
 tional conditions affecting the mother, sometimes 
 from local causes. The idea of local origin, in some 
 cases at least, is strengthened by the fact that it may 
 occur with twins, one only being affected ; and Char- 
 pentier mentions a case where the abdomen increased 
 
 * " Obstet. Trans.," 18S2. f " Opuscula di Cbir.," 1S25-32. 
 :J: " Path, der Geburt," § " Diseases of Women." 
 
1 I 8 THE PATHOLOGY OF INTKA-UTERINE DEATH. 
 
 rapidly after local injury from a fall at the fifth 
 month, and the woman was delivered of a dead child 
 at seven months, with seven to eight litres of liquor 
 amnii. In this instance, the placenta was found to 
 be diseased to a third of its extent. It would thus 
 seem to be due to some fault in development, as 
 cystic chorion is a fault of this kind. 
 
LECTURE III. 
 
 DISEASES AND ANOMALIES OF THE PLACENTA. 
 
 One of the chief difficulties in studying the literature 
 of these diseases as they have been described by 
 various observers arises from the tendency on the 
 part of authors to regard the particular morbid 
 change which they have had the opportunity of 
 investigating as the chief or only disease with which 
 the organ is affected. All other morbid appearances 
 are for them but consequences or complications of a 
 specific and cardinal lesion upon which the rest 
 depend. To give an example, Charpentier avers that 
 the placenta is attacked by only one morbid change. 
 He accepts the investigations of Robin as illustrating 
 the whole range of placental pathology, and believes 
 that when disease has invaded the placenta, it com- 
 mences always in fibro-fatty change, and consequent 
 on this, blood extravasations, and successive trans- 
 formations of effused blood, account for all the various 
 pathological appearances associated with the death 
 or enfeebling of the foetus. 
 
 Verdier and Bustamente take entirely another 
 view of these chano^es. It seems to me that one can- 
 not long investigate the diseases of the placenta 
 
I 2 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 without discovering that they are most complex in 
 their nature, and that they proceed from a variety of 
 causes inextricably intermixed — sometimes one patho- 
 logical condition having the precedence, sometimes 
 another. The placenta is, in truth, as liable to be 
 affected by a variety of diseases as the liver or the 
 lung, and some of its diseases bear not only a striking 
 resemblance to diseases occurring in those organs, 
 but have affinities with them, and may depend on 
 the same causes. Again, confusion has arisen from 
 investiq-ators describino- the same morbid condition 
 under a different name, probably because it was 
 observed only in one stage of progress or with some 
 variations, and some have fallen into the error of 
 ranging affections which are intrinsically different 
 under the same appellations. 
 
 After the third month of utero-gestation, the 
 various membranes surrounding the embryo have 
 come into apposition ; there is no distinct interspace 
 between them, and the foetus lies suspended in its 
 liquor amnii in the centre of the ovum. By this time 
 the placenta has assumed a definite form, and the 
 embryo is now chiefly dependent upon it for the 
 supply of those materials wdiich are necessary for its 
 gro^vth. It is as yet, however, in a rudimentary 
 form, and instead of having those sinuses, or cavities, 
 everyw^here permeating its substance which are 
 peculiar to its structure at a later period, it consists 
 of villi of the chorion, round which loops of maternal 
 vessels have been thrown, in such fashion as to form 
 a complex, but very distinct, network throughout 
 the placental mass. I have repeatedly seen these 
 maternal loojos naturally injected in young placenta, 
 
DISEASE IX TflE EARLY PLACENTA. 121 
 
 diseased, as well as normal, for in some forms of in- 
 durated young placenta they are almost as distinctly 
 seen as wlien the organ is healthy, and microscopic 
 sections are more easily made. Their prototypes are 
 seen in the placenta of some mammalia, which have 
 been described more especially by Professor Turner, 
 and I have thrown out the suggestion that by dilata- 
 tion and further development, these maternal vessels, 
 appearing at first in the young placenta as capillary 
 loops, become eventually the sinuses of the maternal 
 portion of the placenta, into which the foetal villi are 
 suspended, as the gills of a fish are suspended in 
 water. There they are bathed by the maternal blood 
 current, and both absorb materials for the growth of 
 the embryo, and also effect the aeration of the foetal 
 blood, which is so necessary for its well-being. It is 
 obvious, therefore, that a healthy sta,te of the placenta 
 is necessary for the safety of the foetus, both in the 
 earlier and later months. Until the placenta is fully 
 organised, the nutrition of the embryo is carried on 
 by the chorion villi more or less over the whole 
 sphere of the ovum. But when the placenta is 
 formed, the whole nutritive and respiratory function 
 is concentrated upon it, and the chorion villi degene- 
 rate and atrophy over the rest of the chorion mem- 
 brane. 
 
 Extravasations of blood into the young j^lacenta 
 are very common, and they occur as the result of 
 rupture of some of those vascular maternal loops 
 which I have just described. If the extravasations 
 be limited in extent, the life of the embryo may not 
 be compromised ; but a more extended apoplexy at 
 once stops its nutrition, and the root-like processes 
 
I 2 2 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 of the young villi l)ecome so compressed, that the cir- 
 culation can no longer be carried on through the 
 minute foetal blood-vessels which they contain. It is 
 common enough to see clots in varying stages of 
 change in accordance with tlie date of their forma- 
 tion in young placenta which have been expelled as 
 the result of aboition, and if the ovum has been long 
 retained, and extravasation has been of such extent as 
 to kill the embryo, the whole placenta is generally 
 found to have become indurated and in a measure con- 
 tracted. The clots have been consolidated, decolor- 
 ised, and contracted, while the villi in other parts 
 of the organ, not in the immediate vicinity of the 
 altered blood-clots, have become atrophied, and so 
 firmly fused together, that it is almost impossible to 
 separate them for microscopic purposes. 
 
 Apoplexy takes place into the substance and on 
 the uterine surface of the full-grown placenta also 
 very frequently. There is, however, this marked 
 difference from the earlier period, that now the 
 placenta is larger and thicker, and isolated clots may 
 be deeply imbedded in its substance, only to be 
 exposed by incision. Others may have been fonned 
 between the uterine walls and the maternal surface 
 of the j^lacenta, making a deep depression into the 
 centre of a placental cotyledon, and compressing the 
 placental structures. It is further to be remarked, 
 as a difierence in the results of blood extravasations 
 in the young and more mature placenta, that in the 
 latter several successive effusions of blood may take 
 place, forming ajDoplexies of varying sizes and dates, 
 without so seriously jeopardising the life of the foetus 
 as it would do at an earlier period of gestation. The 
 
APOPLEXY IN TIIK PLACENTA. 1 23 
 
 larger size of tlie placenta and its more extended 
 surface afford a better chance of so much of the 
 potential part of it retaining its healthy relations, 
 and so carrying on the placento-foetal circulation 
 that embryonic life is sustained. This may be, not- 
 withstanding that the whole amount of intended 
 pabulum is not furnished, for the simple reason that 
 a considerable portion of what may be called absorb- 
 ing radicles have been destroyed, or their function 
 impaired by the local lesion. 
 
 Apoplexy, and the various morbid changes asso- 
 ciated with it, is, perhaps, of all others, the most 
 frequent pathological condition easily recognisable 
 with the naked eye in the placenta. This being so, 
 it can scarcely be a matter of surprise that some 
 authors have regarded it as the chief of placental 
 diseases, being the prime factor, indeed, in all placental 
 disease, and the forerunner of all other pathological 
 appearances. To it has been attributed the occur- 
 rence of the so-called tubercle, and also the formation 
 of scirrhus in the placenta. 
 
 Sir James Simpson,* in his " Memoir on Conges- 
 tion and Inflammation of the Placenta," which is 
 remarkable for its literary research, describes placen- 
 tal congestion as the forerunner of apoplexy. The 
 congestion, according to him, consists of an extra- 
 ordinary accumulation of blood in the spongy tissue 
 of the placenta. This only requires to be pushed a 
 degree further to lead to rupture of the vascular 
 coats, and escape of blood into the parenchyma or on 
 the maternal surface of the organ. He then goes on 
 to describe the changes which take place in the 
 
 * Vide " Obstet. Works," p. 397. 
 
124 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 extravasated blood, and the effect on the placental 
 structure. 
 
 In 1839, M. Jacquemier wrote a communication on 
 Extravasations of Blood in the Placenta which is still 
 regarded as classical in France, and he gives an 
 excellent description of the pathological appearances 
 observed. He points out that the eifects of extra- 
 vasation vary with the stage at which gestation has 
 arrived. According to him, at an early period the 
 villi of the chorion are so loosely imbedded in the 
 decidua serotina, that there may be said to be space 
 between the two membranes. If, therefore, a rupture 
 takes place in a utero-placental blood-vessel, the 
 extravasation is the more general, and wide spread, 
 because of the laxity of tissue, and thus pregnancy 
 is the more likely to be interrupted. In the later 
 period, the placenta is more developed and compact 
 — the chorion and decidua have become fused 
 together, and if extravasation occurs into the substance 
 of the placenta it is more limited in extent — gener- 
 ally, indeed, confined to the lobe in which the 
 apoplexy has occurred, although more than one lobe 
 may be affected. Jacquemier describes three 
 varieties of placental apoplexy in the later months 
 which I need not give in detail here. 
 
 Yerdier, who wrote a thesis in 1868, entitled 
 " Researches on Apoplexies and Hrematoses of the 
 Placenta," goes so far as to say that iiljrous changes — 
 scirrhus hardness, fibro-fatty, and those which appear 
 due to inflammation — are due only to extravasated 
 blood and the changes taking place in it. 
 
 In 1848, Bustamente publislied a memoir on 
 Placental Disease, which attracted much attention in 
 
TimoMBOsrs ix tuk placenta. 125 
 
 France and elsewhere. Admitting the accuracy of 
 previous observers as to the frequent presence of so- 
 called apoplexies in the placental tissue, and their 
 influence in producing death of the foetus, he contends 
 that the masses of blood so found are not due to 
 vascular rupture and extravasation, but are produced 
 by thrombosis in the maternal sinuses of the placenta. 
 He points out that deposits are very frequent in the 
 deeper structures of the placenta, and even near its 
 foetal surface. The mechanism of their production he 
 believes to be somewhat as follows : The whole of the 
 villi constituting the foetal portion of the placenta, 
 and found equally distributed throughout its entire 
 mass, are bathed with the maternal blood in the 
 lacunse in which they are immersed. The maternal 
 circulation through these lacunas is necessarily slow, 
 because it is poured into the placenta by maternal 
 arteries, and, before passing back into the maternal 
 veins, it must pass through the dilatations which con- 
 stitute the placental sinuses or lacunae. Anything, 
 therefore, which disturbs the utero-placental circula- 
 tion, favours stasis in the placental lacunae, and more 
 especially in those portions of the placenta which are 
 most distant from the maternal suj)ply. The increase 
 of fibrin observed in the blood of pregnant women, 
 various general pathological conditions which render 
 the blood more readily coagulable, syncope by slowing 
 or arresting the circulation, even for a limited period, 
 — all favour stasis of the utero-placental circulation 
 and resulting thrombosis. The villi, once imbedded 
 in the blood of a thrombosis, although at the moment 
 healthy, speedily degenerate. The loops of foetal 
 capillaries become granular, and eventually disappear. 
 
2 6 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 The epithelial covering of the villus and the proper 
 fibroid structure of the stem becoroe fatty and dis- 
 organized, and the whole tissue eventually shrivels. 
 But this is not the only change which takes place, 
 according to Bustamente., when placental thrombosis 
 has occurred. The blood-clot itself becomes 
 organized. He quotes 0. Weber, in Billroth's 
 " Surgery," as an authority on the organisation of 
 extravasated blood, and avers that he has himself 
 seen leucocytes in the centre of placental clots, not 
 near living tissue. These leucocytes develop, and 
 form a connective tissue, with nuclei readily seen by 
 the addition of acetic acid, and firmly unite the villi 
 to each other, thus producing a dense and resisting 
 tissue, the component elements of which it is difficult 
 to separate. 
 
 Other and later authors have expressed the opinion 
 that no apoplexy takes place into the substance of 
 the placenta, either in the early or later periods of 
 gestation, without some previous degeneration of 
 structure. Charpentier quotes from a contribu- 
 tion of M. Bailly, who endeavours to prove that some 
 morbid change invariably takes place prior to blood 
 extravasation, and in this way the morbid condition 
 bears analogy to apoplexies in the brain and else- 
 where. Charpentier himself, in his elaborate essay on 
 " Diseases of the Placenta," says it is a law that clots 
 are only found in cotyledons of the placenta previously 
 altered by disease. There is a very general consensus 
 of opinion that when effiision of blood takes place 
 into the placenta, it is always, or almost always, from 
 the maternal system ; and there are some curious 
 coincidences occasionally noticeable between blood 
 
DEGENERATION OF VESSELS IN PLACENTA. 12/ 
 
 extravasations in the placenta and apoplexies in other 
 parts of the body of the same patient, indicating a 
 feeble resistance in the blood-vessels in more than 
 one organ at the same time. Latour (" Rev, Med." 
 1843) has put on record the case of a woman who 
 died of cerebral apoplexy after spontaneous abortion 
 at twenty-eight years. A painful case occurred in 
 my own practice some years ago illustrating the 
 point. A lady, most anxious to have children, lost 
 three successively in the latter half of gestation. In 
 each pregnancy uterine haemorrhage came on, 
 apparently without cause, and ended in the expulsion 
 of the child before it was viable. No disease of the 
 child or placenta could be detected, beyond the fact 
 that the twisting or spiral arteries in the centre of 
 each maternal lobule were found to be in a state of 
 partial fatty degeneration. In the fourt.h pregnancy, 
 as the result of great care and absolute rest, gestation 
 was carried on to the eighth month, when uterine 
 haemorrhage set in as before. The labour being speedy 
 the child was born alive, but within an hour of what 
 seemed a comparatively happy delivery, a sort of con- 
 vulsive seizure supervened, followed by deep coma, 
 and in two hours later the patient died with all the 
 signs of apoplexy of the base of the brain. 
 
 Charles Robin"^ is one of the chief and explicit 
 exponents of the doctrine that morbid change goes 
 on in the placental tissue preliminary to blood extra- 
 vasation. He differs in toto from Jacquemier, Yerdier, 
 Bustamente, and others, as to the order of patho- 
 logical events in the placenta. He insists that no 
 blood extravasations take place in the placenta with- 
 
 Societe de Biologic. See " Gazette Medicale," 1S54. 
 
128 THE PATHOLOGY OF INTRA-UTERENE DEATH. 
 
 out previous disease in the tissue, and the morbid 
 change which is the most common forerunner of 
 apoplexy is not mere vascular change, but an altera- 
 tion of the whole structure of the villus. 
 
 As Eobin's researches on this subject are regarded 
 in France as the most important contribution of late 
 years, I venture to speak of them in some detail. 
 M. Kobin points out that in the early formation of 
 the chorion a certain proportion of the villi do not 
 contain vascular loops, but the centre becomes fibro- 
 cellular, and the nuclei are seen, by the addition of 
 acetic acid, to be of an elongated form. This centre 
 is easily distinguished from the elastic sheath, which 
 retracts and corrugates when lacerated. In some of 
 these non- vascular villi are fine granules and distinct 
 
 o 
 
 drops of oil or fat, highly refracting the light, and 
 attacked by potash, but not by acetic acid. The 
 fibro-fatty degeneration of villi is, therefore, according 
 to E,obin, a normal process, by which useless and 
 non-vascular villi undergo atrophy, but this fibro- 
 fatty change may become a morbid process, and, by 
 extending to other and active villi, may first compress 
 and then obliterate the contained foetal blood-vessels, 
 thus producing a solid villus which is composed of 
 dense fibro-cellular structures admixed with fat, and 
 whose function is entirely abrogated by the change. 
 This morbid transformation may occur in the mature 
 placenta as well as in the earlier stages of its forma- 
 tion, and the ultimate effect is to produce a firmness 
 and density of tissue, in which it is most difficult to 
 separate the component elements. The amount of 
 fatty deposit and its proportion to fibroid change 
 varies in different cases, and the larger the amount 
 
PLACENTAL HAEMORRHAGE. I 29 
 
 of fatty granules and molecules, the less distinct are 
 the nuclei of the fibroid structures. 
 
 According to Eobin, extravasations of blood are 
 always consecutive to placental disease of this or a 
 kindred form, and he contends that this prior change 
 is fibrous obliteration of the villi with fatty degenera- 
 tion of tissue. 
 
 I have mentioned the views of M. Robin here 
 because they have a direct bearing on the production 
 of placental apoplexy, and are associated by him, and 
 those who think with him, as cause and efPect — the 
 fibro-fatty d egeneration being the invariable precursor 
 of haemorrhage into the placental substance. 
 
 Supposing it to be admitted that some pathological 
 change not unfrequently precedes blood-extravasation 
 into the deeper structures of the placenta, there can 
 be no doubt that effusion of blood takes place with 
 comparative frequency on the maternal or decidual 
 surface of the placenta from other causes. The most 
 common of these causes is an accident of some kind ; 
 or uterine contraction, which tears the utero-placental 
 vessels across, and causes the formation of apoplectic 
 clots between the placenta and uterine walls. Such 
 haemorrhage may go on to separate the membranes 
 from the uterus down to the os uteri, and then it 
 appears as flooding from the genital passages. If, on 
 the other hand, the results remain at the point of 
 extravasation, the amount of clot may be so con- 
 siderable that it bulges forward the uterine wall, and 
 can be felt as a projection by abdominal examination, 
 constituting the so-called " concealed haemorrhage." 
 When the clot is small, it remains in the locality of 
 its formation, and, if pregnancy is not further dis- 
 
 K 
 
I30 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 turbed, it undergoes all the changes peculiar to 
 retained clot elsewhere. Large or small, the clots 
 before disapjoearing go through various phases. 
 According to Ercolani, the fibrin assumes a lar- 
 daceous, yellowish aspect, the appearance of fibrillae 
 gives place to two kinds of granulations, the one of 
 proteic nature, soluble in alkalies and acetic acid ; 
 the other of a fatty nature, resisting these reactive 
 agents. If a clot is to become organised through 
 the process originally described by O. Weber, and 
 afterwards confirmed by Virchow, it may eventually 
 form a distinct neoplasm in the placenta. These 
 neoplasms are rare, but cases have been put on 
 record by Yirchow and also by Danyau. 
 
 The interference with the life of the child or with 
 the course of gestation depends upon the amount of 
 extravasation, and the excitabihty or quiescence of 
 the uterine walls under the provocation to contrac- 
 tion. 
 
 Inflammation of the Placenta, or Placentitis, has 
 been described by Brachet, Dance,* Simpson, Cru- 
 veilliier,t and other authors. Simpson described it 
 as consistino^ of three stag^es, the first heino- one of 
 congestion, in which the tissue is engorged by an 
 unusual accumulation of blood in the vessels ; the 
 second characterised by the exudations of co- 
 agidable lymph, producing a greater density of tissue 
 and eventual induration ; the third stage being that 
 in which purulent matter is formed. 
 
 Brachet, m the " Revue Medicale " for 1828, gave a 
 very full and precise description of four cases in 
 which the placenta bore a resemblance to the red 
 
 * " Keport Gen. d'Anat.," torn. iii. f " Anat. Pathol." 
 
PLACENTITIS. I 3 I 
 
 liepatlsation of the lungs — was friable, engorged with 
 blood, and dense in tissue. In some sections the 
 structure was yellowish, and strewn with fatty 
 degeneration analogous to fatty liver. He further 
 states that he has seen circumscribed abscesses in 
 the placenta, such as occur in inflammation of other 
 parenchymatous organs. Dance and Brachet both 
 aver that they have seen a deposit of pus covering 
 the entire surface of the placenta, while Jacquemier 
 and Cruveilhier each report the presence of purulent 
 matter as the result of inflammation in the placenta 
 and adjacent uterine veins. Jacquemier teaches, that 
 especially when a portion of the placenta has been sepa- 
 rated, inflammation may be set up and pus formed. 
 
 In later days a good deal of scepticism has been 
 expressed about the existence of placentitis ; at least, 
 so far as its parenchyma or foetal portion is concerned. 
 Bustamente disbelieves in its existence altogether, 
 and says the evidence rests on the supposed presence 
 of pus, which has been shown to be fallacious ; the 
 supposed purulent matter, according to Bobin and 
 other observers, being merely pseudo-pus, produced 
 by broken-down fibrin. 
 
 It has been further argued that, according to 
 modern theories, inflammation of the placenta is 
 impossible, since there are no capillaries in the 
 maternal portion, and there are no nerves to regulate 
 the contractility of vascular walls in the entire struc- 
 ture. This seems to me not conclusive reasoninof. 
 There are foetal capillary loops in all the active villi, 
 and there are also minute capillaries of maternal 
 origin in processes or dissepiments of the decidua 
 which circumscribe the fcetal villi. 
 
 K 2 
 
132 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 It is true, nevertheless, that the presence of 
 purulent matter in the placenta in most of the 
 reported cases is supported by imperfect evidence. 
 There are only some ten cases of abscess in the 
 jDlacenta recorded, and as no account is given of the 
 microscopic examination of the supposed pus, the 
 evidence is plainly unsatisfactory. Purulent matter 
 has, however, been found and duly authenticated on 
 the surface of the placenta, and in the uterine sinuses 
 at or near the placental site. 
 
 That some morbid chano-e analoo^ous to inflamma- 
 tion does take place in the placenta or its neighbour- 
 hood, is apparently indicated by the firm adhesions 
 which are occasionally formed between the placenta 
 and the uterine walls,* and from the traces of an 
 exudation which agglutinates and compresses the 
 villi of the placenta. The progress of such inflam- 
 matory action is, moreover, often marked by the 
 presence of tenderness over the gravid uterus, with 
 general mdications of pyrexia. Braun, Schroeder, 
 and Spiegelberg regard this placental inflammation 
 as not a form of true placentitis, but of chronic 
 endometritis affecting the mucous membrane of the 
 ■uterus primarily, and only extending to the foetal 
 structures incidentally. Hegar and Maierf describe 
 it as a form of interstitial endometritis, in which the 
 villi are agglutinated and compressed by the hyper- 
 
 * Desormeaux and Dixbois say tliat inflammation not only makes 
 tlie placenta adhere to the uterus, but also to the foetus, and so pro- 
 duces monstrosities. On the other hand, Robin holds that adhesions 
 between the placenta and uterus are not due to inflammation, but 
 result from the persistence of the firm condition of the uterine mucous 
 membrane found in the unirapregnated uterus, instead of softening as 
 usual in pregnancy. 
 
 f Virchow'a "Archiv," 1871. 
 
PLACENTITIS. I 3 3 
 
 tropliied elements of the serotina, and the develop- 
 ment of a new connective tissue. 
 
 According to Spiegelberg, it is only through the 
 work of Hegar and Maier that we have got precise 
 knowledge concerning the so-called inflammation of 
 the placenta. Their memoir is certainly an example 
 of careful work, and is well worth perusal. I regret 
 that I must pass it with so brief a notice. This 
 inflammation begins, according to them, in the forma- 
 tion of soft granular exudation, and ends in the pro- 
 duction of induration and disorganisation. The 
 decidual tissue normally consists of elongated cells 
 imbedded in a small quantity of amorphous inter- 
 cellular substance. When inflammation begins there 
 is an enormous development of fusiform cells with an 
 
 Fig. 8. 
 
 
 '■'^X^-^^ 
 
 /f^ 
 
 Placental tissue showiDg graniilar or slightly striated 
 matrix, with elongated decidual cells, constituting 
 the first stage of interstitial jDlacentitis. (Hegar and 
 Maier.) 
 
 increase of intercellular granular material. Then the 
 cells become deformed, distended with fine fat 
 granules, and eventually the whole structure is con- 
 verted into fibroid tissue. It is apt to repeat itself 
 
134 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 in the same Individual, and the chronic morbid con- 
 dition of the mucous membrane, upon which it 
 depends, may lead to earlier abortion in other 
 pregnancies. The recognition of the true cause of 
 this placentitis, as Splegelberg points out, affords a 
 clue for treatment, and also a hope that its recurrence 
 may be prevented on future occasions. 
 
 Fig. 9. 
 
 a. Strong development of connective tissue taking the place of the 
 earlier cellular formation seen in the normal placental structure. 
 b. Indication of vessels obliterated by the growth of connective 
 tissue, c. Extremities of villi atrophied and in fatty degeneration. 
 (Hegar and Milier.) 
 
 Under the influence of this morbid change, the 
 utero-placental vessels and the villi undergo varied 
 modifications, of which the constant result Is atrophy 
 and degeneration by compression, in such sort that, 
 passing through various intermediate stages, they 
 become hard, whitish nodules or cords, like old 
 cicatrices, imbedded m the spongy substance of the 
 
SCLEROSIS OF THE PLACENTA. 135 
 
 placenta. This chronic and progressive production 
 of connective tissue, on the surface and in the sub- 
 stance of the placenta, constitutes a work of indura- 
 tion, the net result of which is the obliteration of the 
 double system of foetal and maternal vessels, and 
 secondary disturbances in the circulation, which are 
 evidenced in thrombosis or in apoplexy more or less 
 extended. The whole morbid process, say these 
 authors, bears the closest resemblance to cirrhosis of 
 the liver. 
 
 Neumann * has described a condition which he also 
 regards as produced by inflammation, and which he 
 terms " sclerosis " of the placenta. In this form of 
 disease the villi develop in such luxuriance as to 
 encroach ujDon the maternal sinuses, and eventually 
 to obliterate them. It may therefore be regarded 
 essentially as an aflection of the foetal part of the 
 placenta. Neumann recognises the fact that this 
 sclerosis of the placenta, in some cases at least, may 
 be the result of an inflammatory process in the 
 decidua, and result in a hyperplasia of its connective 
 tissue. 
 
 Meyer,f of Freyburg, while he says that he has 
 never found the condition which Neumann calls 
 " sclerosis of the placenta," describes a morbid pro- 
 cess which he has carefully investigated, and which 
 consists of hypertrophic proliferation of the connective 
 tissue in the placenta, with consecutive induration. 
 The more this connective tissue grows, the more the 
 proper parenchyma of the placenta dwindles by 
 pressure and v/asting of the vessels ; the whole organ 
 
 * " Kocigsb. Med. Jahrb/' 
 t " Monat, fiir Geburt.," iS6S. 
 
I 36 TUE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 shrivels, and the diminution in the size of the organ 
 results as much from the loss of normal, as the con- 
 traction of newly formed tissue. In the normal 
 placenta there is, he says, only a small amount of 
 connective tissue, but there is a large amount in these 
 abnormal cases. This author does not agree with 
 Simpson, Eokitansky, Scanzoni, and others, who 
 suppose inflammation followed by exudation to be 
 the cause of the formation of connective tissue. 
 
 There is a sort of general resemblance between the 
 descriptions given by Hegar and Maier of placentitis 
 originating in the decidual part of the placenta and 
 Meyer's " hypertrophic proliferation of the connective 
 tissue in the placenta." The differences are as to the 
 nature of the process and in the details of microscopic 
 change. Henning has further made an important 
 contribution on the subject of placentitis, and 
 explained how it produces adhesions between the 
 uterus and placenta and membranes. 
 
 Placental Phthisis. — At different times, extending 
 over years, I have seen specimens of a disease of the 
 placenta Avhich does not correspond accurately with 
 any of these descriptions. In some of its stages, it 
 bears a close resemblance to morbid changes which 
 have already been described by the authorities I 
 have quoted, and I have endeavoured to trace its 
 connection with these morbid processes. It may, 
 indeed, combine more than cne of them in the 
 progress of its development. It differs, nevertheless, 
 in some important particulars of its pathological 
 history, which I shall endeavour to indicate. It has 
 so many analogies to phthisis in the lung, that it 
 may with propriety be named "phthisis of the 
 
PLACENTAL PHTHISLS. 137 
 
 placenta." Sir James Simpson has previously used 
 the term "placental phthisis;" but he comprehended 
 under this appellation various forms of disease in the 
 placenta which interfere with intra-uterine respiration 
 and nutrition. 
 
 In its earlier stages, repeated investigations have 
 convinced me that it is not, primarily at least, a mere 
 increase of the cell structure, nor of the fibroid 
 element in the placenta, as described by Hegar and 
 Miiier, or by Meyer ; but that, in its first stage, it 
 consists of an exudation or deposit, thrown out among 
 the villi, and that it is probably due to some modi- 
 fication of a low inflammatory process. 
 
 The disease is not really tubercular in its character, 
 and so far as I can make out it is not associated with 
 any form of bacteria as phthisis is. It seems to me 
 rather the result of an inflammatory process which 
 throws out an exudation or deposit into the paren- 
 chyma of the placenta. This deposit may be in 
 masses, or in a more diffused form, and if it be of low 
 organisation, it is prone to crumble in the centre of 
 the masses, thus producing blood extravasation and 
 resulting apoplexies. If the deposit be more sparing 
 in quantity, and endowed with a higher organising 
 power, it becomes gradually converted into fibroid 
 connective tissue, which binds the placental villi firmly 
 together. In either case it seriously cripples the 
 functions of the placenta. The initial deposit sepa- 
 rates and compresses the placental viUi and prevents 
 their being bathed by the maternal blood. If the 
 deposit breaks down, and apoplectic clots are formed, 
 a considerable portion of the placental structure may 
 be destroyed ; and, lastly, if the fibroid transforma- 
 
13S THE PATHOLOGY OF INTllA-UTERINE DEATH. 
 
 tion takes place, tliis so binds and contracts the villi, 
 that all circulation through them is impossible, the 
 cavernous structure is obliterated, and the placenta, 
 in its entirety, or in part, is converted into a dense 
 and inert mass. It depends, of course, on the amount 
 of placenta involved in these morbid changes, as to 
 whether the child lives or dies, and there is an inter- 
 mediate stage in which the child is born alive, but 
 shows ev^idence of imperfect nutrition. I have seen 
 a number of instances of this form of placental disease, 
 no two perhaps being exactly alike, and some seem- 
 ing so dissimilar that they might be taken for different 
 affections. In some placentae, however, all the various 
 stages may be observed in progess together, thus 
 indicating that they are only different phases of the 
 same pathological condition. 
 
 I may state that, as a rule, it is not possible effi- 
 ciently to inject placentae of this description, so far at 
 least as the morbid parts are concerned. The finest 
 size injected with considerable jiressure will penetrate 
 the vessels of any villi which are comparatively 
 healthy, but none of the injection appears in those 
 Avhich are firmly matted together, proving that the 
 capillaries are occluded or obUterated. 
 
 In making microscopic reseai'ches, therefore, one 
 has to be content with making thin sections and 
 staining them. 
 
 The best example I have met with as illustrating 
 the earlier j^hases of the disease, is in a placenta 
 preserved in the Middlesex Hospital Museum. 
 
 The child was born at the eighth month of gesta- 
 tion, and it was alive, notwithstanding evidence of 
 extensive disease in the placenta, but it seemed to 
 
PLACENTAL PHTHISIS. 139 
 
 have been imperfectly nourished. The placenta was 
 about the usual size. Several lobules on tlie uterine 
 surface had lost the usual healthy appearance, and 
 were paler and more prominent than under normal 
 conditions, while to the touch they were firm and 
 resisting. Throughout the whole placenta one could 
 feel indurated portions imbedded in the healthy 
 structure, and some of these extended to the foetal 
 surface and could be seen as white patches through 
 the membranes there. 
 
 On section, the tissue of these firmer portions was 
 found to have lost its normal character, and to have 
 become, so to speak, " hepatized " {see Plate I.). These 
 hepatizations were generally situated in the centre oi 
 a lobule, with comparatively healthy tissue around, 
 but there were exceptions to this rule, as some masses 
 were irregularly placed. They were in various stages 
 of morbid progress, some of them consisting of mere 
 thickening or induration of tissue from solid infiltra- 
 tion, with no trace of blood globules or blood crystals 
 anywhere ; other masses were undergoing a process 
 of crumbling or disintegration in their centre, after 
 the fashion of tubercular masses in the lungs ; and in 
 a third form, the disintegration of the centre had 
 attacked both the villi and the blood-vessels ; blood 
 was extravasated, and apoplectic clots, limited by 
 layers of fibrin, were undergoing all the usual changes 
 in accordance with the date of their extravasation. 
 In the parts where the changes were more recent, 
 and more or less round the outer borders of all the 
 masses, the villi were found either simply glued 
 together, or they were imbedded in an amorphous or 
 finely granular material somewhat striated, which 
 
I40 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 was not fat, but consisted of proteic elements not 
 soluble in the chemical agents which dissolve fat. 
 Unlike fat granules, the corpuscles of the deposit 
 were thoroughly coloured by the material used for 
 staining the microscopic sections. Here the villi 
 were as yet but little altered in form, their walls 
 being only slightly granular or darker in colour, and 
 blood-vessels w^ere still seen in their interior. In 
 portions further advanced, the villi were firmly 
 adherent to each other, and were becoming dis- 
 organized. Their external membrane was wrinkled 
 or broken, and their vessels either absent or their 
 course marked by clusters of minute granules, appear- 
 ing like exudation from their coats (fig. lo). Still 
 further diseased portions, especially where the tissue 
 was crumbling, showed the villi very much as Dr. 
 Barnes described and figured them when affected by 
 fatty degeneration. The villi were broken up, con- 
 tained no indications of blood-vessels, and the cellular 
 structure seemed to have disappeared ; its place now 
 being taken by amorphous granules, and by spherules 
 of oil or fat, soluble in ether. 
 
 In places, again, where exudation had been poured 
 out in moderate degree, — and was not undergoing 
 this retrograde metamorphosis, — the primary round 
 corpuscles were assuming, or had assumed, an elon- 
 gated foiTu, as seen in commencing fibroid structure, 
 and the deposit was being converted into a new con- 
 nective tissue, firmly binding the villi into one solid 
 mass, and as it became more organized, completely 
 interrupting their functions, and rendering those 
 portions of the placenta dense and inert structures. 
 
 Mr. Thurston, lately cui'ator of the museum in 
 
PLACENTAL PHTHISIS. 
 
 141 
 
 King's College, and now director of the Natural 
 History Museum in Madras, kindly made sections 
 and drawings for me {see Plate II. fig. I.), 
 
 It will be seen that the amount of deposit in some 
 microscopic sections, taken from parts of the placenta 
 where the exudation seemed most recent, is so con- 
 siderable, that it pushes aside altogether the normal 
 villi. Here and there it crowds them into groups 
 closely packed together. In one section the field of 
 the microscope is occupied to a large extent by the 
 adventitious deposit, instead of sections of villi at 
 regular intervals. Sometimes the exudation assumes 
 a somewhat capsular form. The deposit itself is 
 irregularly striated, and studded with round inter- 
 spersed corj^uscles. There is yet no trace of fatty 
 change. This is observable only in a later stage, 
 when disorganisation begins. 
 
 Other sections show the effect of softening in pro- 
 ducing degeneration of the villi. In the earlier phases 
 of this degeneration the villi have not yet lost their 
 
 Fig. 10. 
 
 Fig. II. 
 
 Showing fat granules and 
 molecules following course 
 of tortuous capillaries in 
 
 vim. 
 
 Villi in which all trace of ca]3illary 
 loop has disappeared, in progress 
 of disintegration. 
 
142 THE PATHOLOGY OF IXTRA-UTERINE DEATH. 
 
 cellular structure, but fat granules are seen scattered 
 over their surface, more especially following the 
 course of the tortuous capillaries ramifying in their 
 extremities (figs. lo and 1 1). A further stage of this 
 degeneration is indicated in the appearance of villi 
 which have lost all trace of capillaiy loops, — their 
 outer sheath often broken and retracted, and the 
 cellular structure well-nigh gone, its place being 
 taken by fat granules and oil globules, both on the 
 surface and in their interior. 
 
 A notable feature in all the sections where dis- 
 organization is not too far advanced, is the gi^eat 
 hypertrophy of the contractile coat of the foetal blood- 
 vessels. This is observable in the laro;er branches, but 
 is most marked in those of intermediate size, before 
 they divide into capillaries. The sections are seen 
 in most microscopic specimens {see Plate III. fig. II. ), 
 imbedded in the placental substance, and the con- 
 tractile coat of the arteiy is observed to be at least 
 twice its ordinary thickness, and marked by the 
 usual minute nuclei arranged in a circular manner 
 round the calibre of the vessel. A similar hyper- 
 trophy of the vascular tunics was observed by Frankel 
 in a placenta which he has described as syphilitic, 
 and also by Lawson Tait in his description of a form 
 of placental disease published in the " Transactions 
 of the Obstetrical Society." Lawson Tait regards it 
 as the result of a compensating eflfort on the part 
 of the arteries to overcome the obstruction found 
 at the extremities of the villi, which eventually 
 ends in their contraction and closure, and looks upon 
 it as analogous to the hypertrophy of the vessels 
 observed in renal disease, and described by Dr. 
 
PLACENTAL PHTHISIS. 1 43 
 
 George Jolmson. Hegar and Maier had previously 
 spoken of this compensating action as likely to lead 
 to extravasation and apoplexy in sounder portions 
 of the placenta. 
 
 Thei'e is a marked difference between this affection 
 and primary flitty degeneration of tlie placenta, which 
 is comparable for example with flitty degeneration of 
 muscle. Here there is an adhesive exudation or 
 mfiltration distinctly seen to be thrown in among the 
 villi as the first step in the morbid process. In some 
 examples of recent deposit it bears a resemblance to 
 the exudation found in the tissue of the lung in pneu- 
 monia as figured for example in Woodhead's " Prac- 
 tical Pathology." The deposit, whatever its exact 
 nature, stops the circulation both foetal and maternal, 
 and the effort to overcome this obstruction probably 
 accounts for the vascular hypertrophy. If the deposit 
 degenerates because of its foreign origin — which it 
 may do as one of the results of the pathological pro- 
 cess — it produces also degeneration of the villi, which 
 gradually break up and soften. Thus cavities are 
 formed which become full of blood. In places again 
 where no softening takes place, the exudation 
 becomes organized, and produces a density of tissue, 
 quite unlike that found in the normal placenta. 
 
 Some time ago a placenta was kindly sent to me 
 by Dr. Hunt, of Dalston. The patient, after giving 
 birth to two healthy children, had a series of mis- 
 carriages at six and a half months, without any 
 known cause. The child usually died about a fort- 
 night before its birth. There was no syphilitic 
 history. 
 
 In this case the placenta was smaller than at the 
 
144 THE PATHOLOGY OF INTHA-UTERINE DEATH. 
 
 full time ; denser throughout than in the normal 
 state, and was of a paler colour than usual, having a 
 waxy or fatty appearance. Some portions were 
 much firmer than others, and between these firmer 
 portions were parts of comparatively sponj^y tissue. 
 Here and there were small apoplectic cavities, but 
 none of large size, and they were for the most part 
 old, the blood being changed in colour, and having 
 the appearance of cysts with thickened walls. Some 
 of these cavities were contracted to very small 
 dimensions, and interspersed here and there were 
 cicatrices or patches of indurated tissue, which, from 
 their surroundings, give the impression of blood cysts 
 which had become obliterated by contraction. 
 
 The microscopic sections showed pretty uniformly 
 throughout the placenta, except where disease had 
 produced further disorganisation, an exudation thrown 
 in among the villi — in one place separating them 
 widely from each other — in other places crowding 
 them together, so that over the field of the microscope 
 they were most irregularly distributed. The exuda- 
 tion or deposit was in some sections finely granular 
 or molecular, with indications of strice ; in other sec- 
 tions it had a more distinct fibrous appearance, being 
 constituted of very fine wavy fibrillse, dotted at 
 intervals with small rounded corpuscles. In portions 
 of the placenta where the exudation M-as obviously 
 older and the structure more consolidated, the villi 
 were seen to be fused together, by a firm fibroid 
 tissue, having all the characters of connective tissue 
 elsewhere. Here the villi themselves had lost all 
 trace of their ordinary cellular structure, and con- 
 tained no vessels in their interior. Thev were 
 
PHTHISIS OF THE PLACENTA. 1 45 
 
 shrunken and atrophied, the stems fibroid in 
 structure, with interspersed fat granules. The 
 extremities were misshapen and shrivelled, and had 
 dark masses of amorphous granules occupying their 
 interior. The villi were, in fact, disorganized and 
 imbedded in a fibroid matrix. (See fig. 12.) 
 
 Fig. 12. 
 
 Distorted and atrophied villi imbedded in 
 fibrous stroma. 
 
 Jn this specimen, as in the preceding one, the coats 
 of the blood vessels were much hypertrophied. This 
 hypertrophy is well shown in the drawing by Mr. 
 Thurston in Plate III. fig. II. 
 
 There is a specimen preserved in the Hunterian 
 Museum, which I was permitted to examine. The 
 catalogue shows that " the foetus w^as at the eighth 
 month of utero-gestation, and was born dead, with 
 a small diseased placenta. The whole organ had a 
 yellowish, bloodless aspect, and in various parts were 
 flattened circular nodules of amber yellow colour, 
 and thicker than the rest of the placenta. They 
 were not unlike syphilitic gummata. Under the 
 microscope they appeared to have been due to an 
 inflammatory process, altered or followed by fatty 
 degeneration." 
 
 " The woman had borne four children previous to 
 
 L 
 
I4<-> THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 her last pregnancy, and two were of weak intellect. 
 No distinct history of syphilis could be obtained." 
 
 The above is the account of the preparation taken 
 from the museum catalogue. 
 
 The placenta was small and contracted in its 
 entire dimensions. It was of a whitish grey colour, 
 and its tissue was firm and condensed throughout. 
 The component structures would not separate, being 
 hard and brittle, and indissohibly united together. 
 It was well-nigh impossible to tease out a portion for 
 the microscope, but a small broken fragment or a thin 
 section showed the remains of the villi stunted and 
 shrunken. They had lost all cellular structure, and 
 all indication of vascular supply in their extremities, 
 but a section of their trunks still showed the 
 apertures indicating the position of the now contracted 
 arteries and veins in their interior. The villi were 
 now represented by fibroid structures with or with- 
 out fat granules, and the uniting medium which 
 bound them so firmly together was fibrous connective 
 tissue, either in the form of long fusiform cells, or 
 fully grown fibrous tissue with interspersed nuclei. 
 Plate III. fig. II. is from a drawing by Mr. Thurston 
 of a microscopic section of this placenta. 
 
 I might give details of other cases, but I have 
 selected these as illustrating what I am disposed to 
 regard as variations of the same pathological process, 
 originating in a low form of placentitis. The later 
 stages correspond very closely in the results produced, 
 with certain pathological conditions which have 
 been described by eminent authorities I have 
 mentioned under different names, and not necessarily 
 associated with an inflammatoiy process. 
 
PHTHISIS OF THE PLACENTA. 1 47 
 
 None of the authors seem to have noticed the 
 crumbhncr in masses of feeble oro^anization in the 
 midst of the placental structure, and the formation of 
 apoplexies in this way. Hegar and Maier indeed com- 
 pare the induration of the placenta constituting the 
 later stage of placentitis as they have observed it, to 
 cirrhosis of the liver, and the limited hsemorrhages 
 connected with it to collateral fluxions of blood. The 
 irregular distribution throws increased pressure upon 
 parts of the placenta already weakened by softening, 
 but where the circulation has not yet been obliterated, 
 — and so apoplexy occurs. 
 
 It seems to me not difficult to trace the links which 
 unite these various pathological changes occurring 
 in the placenta. They are probably all the result of 
 an inflammatory process assuming different forms. 
 It may be a refinement in pathological precision to 
 insist with Hegar and Maier that the origin of the 
 inflammation is always in the maternal portion of the 
 placenta, which corresponds to the uterine mucous 
 membrane ; and more especially when exudation or 
 deposit is poured out equally into the various 
 structures which form the parenchyma of the placenta, 
 but it would be of some importance if the origin of 
 the pathological processes could be so localized, 
 because, as remarked by Spiegelberg, we should thus 
 have a cue to treatment on the side of the mother, 
 in her subsequent pregnancies. Spiegelberg says 
 inflammation of the placenta is apt to repeat itself in 
 the same individual, and the chronic morbid condition 
 of the mucous membrane upon which it depends may 
 lead to earlier abortion in other pregnancies. 
 
 It should be further remarked that not only may 
 
 L 2 
 
148 THE PATHOLOGY OF INTRA-UTERTNE DEATH. 
 
 inflammatory changes in the placenta, such as those 
 described, destroy the child or impair its nutrition, 
 but they may favour placental retention at the time 
 of delivery. This may be either by producing 
 adhesions to the uterine walls, or as maintained by 
 Hegar and Maier in the monograph previously 
 mentioned, by lessening the cohesion of parts of the 
 placenta, — in such wise that even with the ordinary 
 uterine contractions, or as the result of even moderate 
 traction on the umbilical cord to promote the expul- 
 sion of the placenta, some solution of continuity may 
 take place, and thus portions of the placenta may be 
 left adherent in the uterine cavity. 
 
 So far as I have observed this affection of the 
 placenta, it is most frequently chronic in its course 
 and gradually impairs the function of the organ, 
 until it eventually destroys the child. In some 
 exceptional cases, nevertheless, it seems to run a more 
 rapid course. I have occasionally seen dead children 
 born plump and well nourished, with a placenta so 
 largely affected with the first stage of infiltration 
 that intra-uterine respiration could no longer be 
 maintained, and the history in these cases has been 
 that the foetal movements after being unduly restless 
 for a short period, ceased altogether a few days before 
 labour came on. The well-nourished condition of the 
 child seemed to indicate that the disease was of 
 recent origin, and killed the child more speedily than 
 by slowly starving it, as in the more chronic form 
 usually observed. 
 
 As to the cause or causes of these morbid changes 
 in the placenta, they may be approximately stated 
 to be those which produce impairment of the general 
 
PHTHISIS OF THE PLACENTA. 1 49 
 
 health and deterioration in the maternal blood. The 
 patient in the first case I have narrated was not at 
 the time the subject of j^hthisis, but her family were 
 strumous, and she had lost other children from disease 
 of the placenta. I have seen other cases associated 
 with anaemia, and also with syphilis. In ansemia, it 
 is well known there is a deficiency of red globules in 
 the blood, with a larger proportion of fibrin. This, 
 as well as syphilis and other conditions, may pre- 
 dispose to a low form of inflammation in the placenta, 
 as in other organs of the body, and to such patho- 
 logical changes as those described. 
 
 To recapitulate, therefore, in the order of successive 
 changes observable in this form of placental disease, 
 we have first hepatization or solidification of tissue 
 from exudation. Then softening may take place in 
 the centre of masses of exudation, if the exudation is 
 sufficiently abundant and of low organization, — and 
 as the result of this softening, cavities are formed as 
 in phthisis of the lung, which become full of blood, and 
 constitute one of the forms of so-called apoplexy of the 
 placenta. When the exudation or deposit, which pro- 
 duces hepatization, is endowed with higher vitality — 
 and this may be when it is more sparing in quantity 
 and thus remains in closer proximity to active struc- 
 tures — it does not break down or crumble, as in the 
 preceding case, but becomes organized into fibroid 
 tissue, going through the processes which have been 
 described by other authors. The placenta is thus 
 rendered firm and dense, and its function, as an 
 organ for intra-uterine respiration and nutrition, is 
 completely abrogated. This stage bears an analogy 
 to the chancre in the lung; which is termed *' fibroid 
 
I50 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 phthisis," or as Hegar and Maier have put it, to 
 cirrhosis of the liver. 
 
 Fatty Degeneration of the placenta, as first 
 described by Dr. Barnes * in this country, is, accord- 
 ing to the author named, analogous to fatty change 
 attacking other organs, as the heart and arteries, for 
 example. In its simplest form it is seen in cases 
 where the death of the child has arisen from some 
 other cause than disesase in the placenta. In the 
 case of a child which died near the full time from 
 intra-uterine small-pox, and was retained some time 
 after, all the villi, as well as the maternal portion of 
 the placenta which I examined, were crowded with 
 oil-globules and compound granular fat particles. 
 The villi were swollen and oedematous, and their 
 external covering was readily separated. The entire 
 placenta was paler and softer than usual, and con- 
 tained an abundance of serous fluid in all its meshes. 
 Dr. Barnes is careful to draw a distinction between 
 this sort of passive fatty change following the death 
 of the foetus, which he calls "fatty transformation," 
 as distinguished from " fatty degeneration," which, 
 according to him, commences previously in tlie 
 placenta, and, if extensive enough, kills the child. 
 This he calls " true fatty degeneration," and com- 
 pares it to the fatty degeneration of the brain, liver, 
 and muscles occurring in the adult. It is charac- 
 terised by the morbid changes being jmrtial, invading 
 one or more cotyledons, and the diseased masses are 
 often imbedded in the midst of healthy tissue. The 
 child may be living if only limited portions of the 
 placenta are diseased. If the disease in extensive, 
 
 * " Medico-Chir. Trans.," 1851, <fec. 
 
FATTY DEGENERATION IN THE PLACENTA. 1 5 I 
 
 it kills the cliilcl, and there is an intermediate stage 
 in which the child lives, but its nutrition is 
 interfered with, and it becomes puny and starved. 
 Dr. Barnes figures both the decidual cells forming 
 the maternal part of the placenta, and also the foetal 
 villi studded everywhere with fat globules. The 
 villi are brittle and firmer than natural. Under the 
 microscope they are seen to be thickly covered with 
 oil-globules ; the jDroper structures are disorganized ; 
 and the blood-vessels, which are empty, have their 
 courses marked out by the clusters of oil -molecules 
 which follow their tortuous course. 
 
 Fig. 13. 
 
 Fatty degeneration of placental villus. (Barnes.) 
 
 Kilian* had, prior to Barnes, written on "A New 
 Disease of the Placenta," which partly anticipated 
 Dr. Barnes's observations on " fatty placenta ;" and, 
 soon after Barnes, C. Bobin published his monograph, 
 to which I have previously alluded. Bobm, as we 
 have seen, does not believe in a purely fatty degene- 
 ration, and regards the fibrous transformation of the 
 
 * " Neue Zeitschr. fiir Geburt.," 1850. 
 
152 THE PATHOLOGY OF INTRA- UTERINE DEATH. 
 
 villi in so-called fatty placenta as the chief lesion, 
 the fatty deposit being associated with it only as a 
 complication in the obliteration of the villi. 
 
 The description of Barnes is certainly accurate so 
 far as some phases of placental change are concerned. 
 The question is whether fatty degeneration of the 
 placenta during the life of the child really occurs as 
 a primary pathological change, or is invariably pre- 
 ceded by some exudation or other morbid process 
 which initiates the fatty metamorphosis. Adventitious 
 deposits are more liable to fatty degeneration than 
 normal tissues ; and it is to be noted that, in the 
 majority of examples where fatty degeneration has 
 attacked the placenta, the portions affected are not 
 softer, but firmer and denser, than usual, the villi 
 being almost inseparably united together. It is 
 conceivable, nevertheless, that some depraved and 
 impoverished conditions of the maternal blood may 
 lead to such deterioration of vitality in the placenta, 
 that it begins to degenerate and die, and thus kills 
 the foetus. 
 
 The deposit of minute fatty molecules and of larger 
 oil-globules is associated Avith most forms of morbid 
 change in the placenta — in some stages, at least. In 
 consonance with the general law that effete and 
 useless parts of the organism undergo degeneration 
 into fat, and so are more amenable to absorption, the 
 placental structures, when altered by disease so far 
 us to be unfit for the exercise of their normal 
 function, begin to undergo fatty change, and this 
 results in atrophy of the part affected. 
 
 Fatty degeneration, whether it occurs as a primary 
 change or is the secondary effect of some other 
 
FATTY DEGENERATION IN THE PLACENTA. 1 53 
 
 pathological condition which precedes it, may produce 
 softening and disorganization of the placental tissue, 
 and so favour extravasation of blood or apoplexy. 
 In other placentae it leads to atrophy. All the 
 structures shrivel and condense, so that the organ 
 seems like a mass of dense fibroid tissue ; it under- 
 goes, in fact, the fibrous transformation which I 
 have previously described. The tendency of modern 
 investigators is evidently to regard fatty degenera- 
 tion not as a primitive change, but a phase or stage of 
 some other morbid condition which precedes it or is 
 associated with it. 
 
 Dr. Druitt * regarded fatty degeneration of the 
 placenta as a normal condition towards the end of 
 pregnancy, and as preparatory to detachment at the 
 time of delivery. For him, therefore, fatty degenera- 
 tion was only the extension to a morbid degree of a 
 condition which exists normally to a certain extent 
 towards the end of pregnancy in all placentse. There 
 is, it is true, some amount of fatty change towards the 
 end of pregnancy in certain portions of the after-birth 
 which have now no active purpose to serve. This is 
 notable round the margins and in the membranes. 
 The nuclei in the epithelial cells of the amnion are 
 surrounded with a ring of fat particles in nearly all 
 placentae at the full term ; but normally there is no 
 fatty degeneration in the potential villi as pregnancy 
 advances, and it is obvious that the nutritive and 
 respiratory functions have to be carried on for the 
 well-being of the child just as actively up to the 
 termination of pregnancy as at any previous period. 
 
 ♦ "Lancet,"' 1853. 
 
I 5 4 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 Hiffelsein and Laboulbcne,* Cliarpentier, Simp- 
 son,t Goodell,:|: Whitaker,§ Cowan, || and others, 
 have all made contributions to the subject, and all 
 regard it, however it may arise, as intimately asso- 
 ciated with the ]Drocesses which produce destruction 
 of foetal life. 
 
 Ercolani has describd as synonymous with fatty 
 degeneration of the placenta what he calls " cellular 
 hyperplasia and hypertrophy of the parenchyma of 
 the placental villi." He agrees with the general 
 accuracy of Bobin's observations in regarding the 
 presence of fat-granules with fibroid degeneration of 
 the villi as an accidental and not essential complica- 
 tion. The firm and dense placentae, which have been 
 written upon by Bustamente and Neumann as 
 " sclerosis of the placenta," he considers as essentially 
 due to a hyperplasia not of the connective tissue, but 
 to a cellular hypertrophy of the parenchyma of the 
 villi, either simple or complicated w-itli obliteration 
 of the contained vessels, and also in some cases with 
 lesion of the glandular organ or decidual covering. 
 
 It is obvious from the description that the disease 
 described by Ercolani is different from fatty degene- 
 ration as described by Barnes, and I have not seen 
 any specimen having the exact characters as those 
 described by Ercolani. 
 
 Myxoma Fibrosum. — Yirchow has described a very 
 curious morbid transformation of the villi of the 
 placenta, which he terms "myxoma fibrosum." It is 
 quite different from the cellular or fibrous degenera- 
 
 * " Soc. de Biolog.," 1S65. f " Obstet. Works." 
 
 X "American Journal of Obstet.," vol. ii. 
 
 § Ihld. 1870. II "Ediu. Med. Journ.," 1854. 
 
MYXOMA FIBROSUM. 
 
 155 
 
 tLDii of the villi described by Ercolani and E-obin. It 
 consists of such enlargement of the stems and villi by- 
 fibroid hypertrophy that they form in some cases 
 
 Fig. 14. 
 
 Myxoma fibrosum of the placenta. Virchow (after Storch.) 
 
 distinct tumours in the placental structure. The 
 cases are somewhat rare, but I saw two excellent 
 
 Fig. 15. 
 
 Section of a tnmour showing fibroid structure. 
 
 examples in Copenhagen which have been described 
 in Virchow's "Archiv" in 1878, by Storch. 
 
15(3 THE TATHOLOGY OF INTRA-UTERINE DEATH. 
 
 In one, the tumours were as large as hazel-nuts, 
 attached by pedicles to the deeper seated trunks of 
 the placental villi, and, when an incision was made 
 into the substance of the placenta, they projected 
 through the opening like so many adherent hard 
 nodules, or perhaps I may say digitated radishes. 
 Microscopic examination showed that they were 
 composed entirely of fibroid elements formed by a 
 cellular hyperplasia of the central part of the villi, 
 and that they were enlargements or excrescences on 
 the villus trunks, with an external arrangement 
 somewhat analogous in appearance to cystic chorion. 
 Virchow regards the disease as a transformation of 
 the mucous element pertaining to the villus structure 
 into fibroid tissue, instead of the soft myxoma which 
 is seen in cystic chorion. The fibroid change is, 
 however, unlike the cystic chorion, more frequently 
 connected with the later period of pregnancy, 
 although indications of it are sometimes seen in the 
 earlier months, and, therefore, it is described as a 
 disease of the fully developed placenta. Hildebrandt 
 has also described a good example in the " Mon. fiir 
 Geburt." Bd. xxxi. ; and Dr. Sinclair, of Boston, 
 United States,* another. It is probable that the 
 case of sarcoma in the placenta given by Hyrtl is one 
 of the same kind. In Storch's first case the child 
 was born alive, but feeble, and died an hour after 
 birth. If the placenta is only partially afiected, the 
 child, though emaciated, may live ; if the disease is 
 more universal, the child dies. 
 
 (Edema, or Dropsy of the Placenta, is characterized 
 by serous infiltration of the villi, by increased soft- 
 
 * "Journal of the Obstetrical Society of Boston," 1871. 
 
CEDEMA OF THE PLACENTA. I 57 
 
 ness and succulence of texture, by paler colour, and 
 by marked friability. There is not necessarily fatty 
 degeneration, but the outer covering of the villi is 
 more easily broken and detached than usual. 
 Generally the placenta looks larger and heavier in 
 all its dimensions, and its weight before it is drained 
 is greater. The child with such a placenta is often 
 still-born prematurely, and it may be even dead. 
 When born alive it has been found poorly nourished, 
 and sometimes dropsical. The effect on the foetus of 
 course varies with the extent of the mischief, but 
 if very extensive the serous effusion is supposed to 
 compress the foetal blood-vessels, and obstruct the 
 double circulation of the placenta. Some authors 
 have regarded it as a post-mortem change, but this 
 is not so in all cases, for children have been born 
 alive with marked oedema of the placenta. Lange* 
 found it associated with hydramnios, a.nd generally 
 with chlorois in the mother. 
 
 Barnes has observed it in association with 
 hydrsemia of the mother, with anasarca and dropsy 
 connected with kidney or other visceral disease, and 
 also with dropsy and peritonitis in the foetus. On 
 this last point it may be remarked that Charpentier 
 in three cases was unable to find any morbid lesion 
 in the foetus. Joulint suggests that it is due to 
 some obstruction in the circulation of the umbilical 
 cord, or in the circulatory organs of the foetus, dis- 
 tending the villi a,nd producing hypertrophy with 
 serous effusion. Simpson found oedema of the 
 jDlacenta associated with obstruction in the cord, but 
 tliis is evidently only one of the causes or complica- 
 * " Geburtshiilfe." f See Whittaker. 
 
158 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 tions. Scanzoni* regards it as analogous to cystic 
 dilatation of the chorion villi, but arising in later 
 pregnancy, and the dropsy exists more especially 
 between the villi, instead of in their interior. Klobf 
 avers that oedema predisposes to apoplexy. In this 
 affection the child may not only lose its life from 
 interruption in its circulation, but it may be from 
 its premature birth, as the oedematous placenta, 
 besides being large in itself, is commonly associated 
 with superabundance of liquor amnii, and these 
 together may so distend the uterus beyond what 
 it will bear, that premature uterine action may 
 come on. 
 
 Melanosis of the placenta has heexi described by 
 Ercolani, Henning,+ and other authors. It does not 
 seem to be in itself a specific disease, but rather an 
 incident and effect of other morbid conditions, and it 
 deserves a passing notice as occasionally associated 
 with disease and death of the foetus. The tissue of 
 the placenta is stained black or deep purple in 
 detached portions or larger masses ; and the colour 
 has commonly been attributed to blood extravasa- 
 tion. Latterly, however, it has been shown to be 
 due to the deposit of granules of haematoidin from the 
 colouring matter of the blood. It is situated in the 
 villi or their pedicles, and is free — not contained in 
 cells. Henning believes it due to heart disease 
 or changes in the blood of the foetus, and Wedl§ 
 noticed it in connection with oedema of the cellular 
 tissue in a child. Heschl thought that deposits of 
 
 * " Letrbuch der Gerburt." 
 
 t " Patb. Anat. d Weibl. Sexualorgan." 
 
 X " Studien iiber den Bau der Menscb. PI.," 1872. 
 
 § " Allgem, Pathol.," Uble and Wagner. 
 
CALCAREOUS PLACENTA. 159 
 
 pigment only took place when the lia3matin abandons 
 the globules of the blood and becomes attached to 
 the vascular walls, and Ercolani, in quoting Heschl, 
 in connection with his own observations on the 
 subject, considers it especially interesting as indicating 
 the way in which materials pass from the mother to 
 the foetus through the placenta. He believes he has 
 proved that the hsematoidin contained in solution is 
 absorbed by the serotinal cells, where it leaves traces, 
 and is then transmitted or secreted into the substance 
 of the villi, where it chiefly accumulates. The pig- 
 ment granules are formed about the utero-placental 
 or maternal vessels, or infiltrated into the cells which 
 limit the lacunae, and they reappear in equal if not 
 larger number in the interior of the foetal villi. 
 
 Calcareous or osseous concretions in the placenta 
 have received a considerable amount of attention, as 
 it was supposed they were indications of a degenera- 
 tion which might influence the life of the child, and 
 besides had some relation to diathesis or conditions 
 of health in the mother which it might be desirable 
 to counteract for successful pregnancy. Practically 
 it has been found that calcareous depositions in 
 certain portions of the placenta, and even in com- 
 parative abundance, may be present without com- 
 promising the existence of pregnancy or the child's 
 life. The commonest form is shown on the uterine 
 surface, where stellated or irregular patches, hard and 
 gritty, are often seen studded over the decidual 
 membrane. They are not distinctly crystalline, but 
 amorphous, and under the microscope resemble frag- 
 ments of chalk aggregated together as they might 
 appear to the naked eye if larger. Acetic acid does 
 
1 Go THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 not affect tliem, but they are dissolved by nitric acid 
 with efiervescence. Robin states that they are 
 formed in the cells of the decidua and are composed 
 of carbonates and phosphates of lime and magnesia. 
 It is sometimes easy to dissect off the decidual layer 
 of tlie placenta, and with this carry off the chief part 
 of the chalky spicules, which may be well seen in the 
 dried preparation. They follow the decidua, how- 
 ever, into the inter-cotyledonary spaces when the 
 decidua dips inwards to form boundaries to the 
 maternal lacunae. 
 
 Besides being in the decidua, they have been found 
 to exist in the extremities of the villi and in their 
 pedicles. Lobstein, Meckel, and Cruveilhier con- 
 sidered them as ossifications of the capillary walls of 
 the vessels, and Spath, according to Whittaker,* 
 regarded them as superfluous lime salts in the blood 
 of the foetus, which are deposited in the extreme 
 capillaries. Decker and Milletf found a placenta 
 with more than 200 calculi adherent to the vascular 
 ramifications, the largest of the size of a nut. They 
 are frequently associated with adherent placenta, and 
 Garin mentions an instance where the deposit was 
 three lines in thickness. Another case is mentioned 
 by Carestria, where fully half the placenta was 
 involved, and where the chalky substance formed 
 plates on the foetal surface. They seem particularly 
 prone to develop themselves in any adventitious 
 deposit, and as placental adhesions are no doubt due 
 in some cases at least to inflammatory action in the 
 decidua during pregnancy, this probably accounts for 
 
 * " American Journ. of Obstet.," vol. iii. 
 t See Ercolani. 
 
CALCAREOUS PLACENTA. l6l 
 
 their frequent presence in cases of adherent placenta. 
 They are found at all periods of pregnancy, but more 
 especially at the full period of gestation, and hence 
 Heschl* thought that they were but indications 
 of the ripeness or maturity of the after-birth — 
 all placentae at full term showing some signs 
 both of fatty and calcareous change. In an observa- 
 tion in a case of calcareous placenta made by 
 Ercolani, all the villi were affected by fibrous 
 transformation ; and this author believes that the 
 calcareous productions are but a metamorphosis of 
 adipose substance in degenerating decidual cells. 
 Lobstein thought they were indicative of protracted 
 gestation, but, according to Spath, of nineteen cases 
 in which calcareous concretions were present, there 
 was only one in which there was a probability of 
 over-maturity of the foetus. Of the nineteen cases, 
 however, there was one of congenital rachitis, one of 
 spina bifida with hydrocephalus, and one of slight 
 hydrocephalus. (Whittaker.) The presence of cal- 
 careous deposits in the placenta, therefore, seems 
 associated with some pathological conditions un- 
 favourable to the welfare of the child, although the 
 adverse influence does not proceed far enough in most 
 cases to extinguish life. Madame Boivin remarked 
 that it was reproduced several times in the same 
 woman, and Carus affirms that it occurs oftener in 
 some countries than in others. Dr. Barnes alleges 
 that calcareous deposits are frequently associated 
 with scrofula, tuberculosis, and poor living, and he 
 draws a parallel between such deposits occasionally 
 found in the brain in tubercular subjects, but more 
 
 * See Whittaker. 
 
 M 
 
l62 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 especially between such deposits found in the tuber- 
 cular lung — the lung in the air-breathing subject 
 being the homologue of the placenta in utero. It must 
 be admitted, nevertheless, that calcareous concre- 
 tions of the placenta are very frequent in seem- 
 ingly healthy mothers, who produce well-developed 
 children. I have found them in placentae of women 
 unusually robust, and have imagined they were some- 
 times at least the product of a gouty diathesis, more 
 especially as this diathesis was distinctly tracealile 
 in the family history. 
 
 As may be inferred from these observations, 
 calcareous deposition in the placenta takes place as 
 the result of various causes. It may occur as one of 
 the pathological results of degeneration of tissue, and 
 it may occur from constitutional conditions present 
 in the mother or child influencing the composition of 
 the blood. 
 
 Cysts of the Placenta have been described by several 
 authors. These are not to be confounded with cystic 
 chorion, being situated commonly on the foetal surface 
 between the chorion and amnion, or in the substance 
 of the fully developed placenta. They occur singly 
 or there may be several. Those which lie between 
 the chorion and amnion sometimes attain a consider- 
 able size, and project towards the amniotic cavity. 
 They are commonly like vesicles more or less trans- 
 lucent, with slightly turbid contents, the turbidity 
 being due to fat granules with disintegrating fibrin 
 and perhaps the debris of blood corpuscles. They 
 have been supposed by Millet* to be filled with fluid 
 identical with the gelatin of Wharton in the cord, 
 
 * Vide Ercolani. 
 
CYSTS OF THE PLACENTA. iG^ 
 
 and to be offslioots indeed from this ; and it is possible 
 such an explanation may account for some of the 
 varieties, but for others a different origin must be 
 sought. 
 
 Bustamente believed some of the cysts at least to 
 be the result of previous blood extravasation or 
 htematocele, and this explanation is probably the 
 true one, for many of those which are imbedded in 
 the substance of the placenta. As Ercolani suggests, 
 the term cyst in these cases is obviously incorrect. 
 In some apparent cyst -like cavities projecting for- 
 ward beneath the membranes on the foetal surface, 
 the cavity is filled with coagulated fibrin, and the 
 remains of disintegrated blood, while the walls are 
 formed of laminse of fibrin and degenerated and com- 
 pressed placental villi. In one of Ercolani's cases a 
 large number of small calcareous concretions were 
 found mixed up with the fibrous laminae forming the 
 so-called cyst wall. 
 
 A good specimen of a serous cyst developed on the 
 foetal surface of the placenta, and having two cover- 
 ings, showing it to be both beneath the chorion and 
 the amnion, is to be found in St. Thomas's Museum. 
 
 Tumours of various kinds have been described as 
 occurring in the placenta. Klob mentions a case 
 which occurred in the Rokitansky Institute, where 
 a fibroid tumour of nearly the size of a child's head 
 was found loosely adherent between the amnion and 
 the inner surface of the placenta near the cord. 
 Tumours of less size have been put on record by 
 Danyau''^ — one of them eleven centimetres in length 
 and eight in breadth. It was on the foetal surface 
 
 * "Memrir sur deux cas de Tumeurs volum, <tc." 
 
 M 2 
 
I 64 THE PATHOLOGY OF INTRA- UTERINE DEATH. 
 
 of the placenta, covered by the membranes, and near 
 the circumference. It was shghtly lobulated and 
 enclosed in a sort of capsule. It was dense like 
 scirrhus, and was hard and resistant on section, like 
 a fibroid. Blood-vessels were found on its surface 
 and penetrating to its interior. Wliittaker mentions 
 a remarkable specimen in the Hyrtl collection, which 
 like the last was attached to the foetal surface. It 
 had a vascular connection with the placental mass, 
 and was like a placentula or supplementary placenta. 
 In structure, however, it was found to be sarco- 
 matous. 
 
 Other so-called tumours are no doubt the result of 
 blood extravasations, the bulk of the mass being made 
 up of clot and disintegrating villi in various grades 
 of transformation. Barnes mentions one of this 
 character in St. George's Hospital, and others are to 
 be found in the museums. When of this kind they 
 are of all sizes, and may appear like tubercles or pro- 
 jections on the foetal surface of the placenta, covered 
 by the amnion, or they may be so large as to project 
 as a mass towards the amniotic cavity. If it be true 
 that blood clots may become organized, as taught by 
 Weber, Yirchow, and others, some of the apparent 
 neoplasms may originally have been blood clots ; but 
 it is certain that others are simply hyperplasias or 
 hypertrophies in previously existing structures. 
 
 Syphilitic Placentcd. — It is important, if possible, 
 to answer the question. Is there a syphilitic placenta? 
 — that is, a form of disease in the placenta associated 
 with syphilis which may be recognized by examina- 
 tion. Much diversity of opinion has been expressed 
 concernmg this matter, and various descriptions have 
 
SYPHILITIC PLACENTA. 165 
 
 been given of the syphilitic placenta which do not 
 agree. 
 
 That syphilis is a potent cause of placental disease 
 and abortion has been recognized by some of the 
 oldest authors. Astruc mentioned it as far back as 
 1796, but Murat (according to Deschamp*) was the 
 first to describe certain appearances as belonging to 
 the syphilitic placenta. To illustrate the diversity 
 of opinions in recent times, I may mention that 
 Verdier reo-ards a thickenins; of the arterial walls 
 joroduced by a form of arteritis in the foetal part of 
 the placenta as characteristic of syphilis. After 
 thickening, the vascular walls degenerate, and the 
 vessels become obstructed. Eokitanskyt associated 
 some of the fibrinous deposits found in the placenta 
 with the syphilitic taint. These had a syphilitic 
 aspect on section, whatever that may mean. Lebert,t 
 before him, had observed yellow granulations which 
 had the same structure as tubercles, but he did not 
 regard them as of special importance. 
 
 Gusserow and Klebs§ observed a morbid hyper- 
 plasia of the decidual cells in a case where the father 
 was syphilitic, but Straussman|| and Madame 
 Kaschewarowa have since shown the same changes 
 in the placenta where there was no suspicion of 
 syphilis. Yirchow,^ who always brings a certain 
 originality into his work, has made some observations 
 on syphilitic placentae. Virchow points out that in 
 
 * "These," 1880. 
 t " Leiirbncli der Path. Anat." 
 X " Comptes reudus," 1853. 
 § Virchow, " Archiv," Bd. xxvii. s. 
 II " Verhandl. d. Berlin Geburts.," 1863. 
 'W " Path, der Geschw.," Bd. ii. 
 
1 66 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 studying this subject we must remember the envelopes 
 consist of two portions, the fcjetal and the maternal. 
 He then proceeds to point out that syphilis may pro- 
 duce two forms of endometritis during pregnancy, 
 the one attacking that part of the decidua which 
 enters into the formation of the placenta, the other 
 the parietal decidua, or vera, which is away from the 
 placental spot. The first form produces thickening 
 and fibrous induration which may cause atrophy of 
 the villi. In the second form the most marked effects 
 were shown upon the decidua vera. It was thickened 
 and covered on its uterine side with growths almost 
 polypoid, composed of very vascular proliferating 
 mucous tissue, with no trace of fatty degeneration. 
 Virchow considers this chano-e is analos^ous to mucous 
 papulce, or flat condylomata, observed elsewhere on 
 mucous membranes in connection with syphilis. 
 
 Straussman ,has thrown some doubt on the supposed 
 specific character of this lesion by finding it in the 
 case of a mother who had not the least symptom of 
 venereal disease. Henning regards these prohferations 
 as simple angiomas. Virchow's observations on this 
 subject seem to me to refer rather to the effects of 
 syphilis on the ovular membranes in early pregnancy 
 than to the full-grown placenta. Friinkel* is the 
 author whose researches in later days have received 
 most attention in Germany and France, and they bear 
 the Impress of great care. Friinkel's conclusions, which 
 he says are founded on the examination of over one 
 hundred placentaD, point distinctly in favour of there 
 being a syphilitic placenta, which may be recognized 
 by certain definite characteristics. The placentae 
 
 '" " Arch, fill- Gyniikol.," 1873. 
 
SYPHILITIC PLACENTA.. I 6/ 
 
 mostly belonged to syphilitic, mature, or immature 
 children, and he took the indications pointed out by 
 Wagner, of Berlin,* as peculiar to syphilitic foetuses, 
 to be unfailing evidence that syphilis was present. 
 Wagner has pointed out that in all syphilitic children 
 there is a peculiar band of tissue between the shaft 
 of the bone and the cartilage of the epiphysis, which 
 is in a state of inflammatory irritation. The micro- 
 scope, as well as the naked eye, shows that the 
 changes tlius produced are unlike any other changes, 
 and consequently are specific. Taking this test as a 
 basis, Friinkel states that the evidences of placental 
 syphilis vary according as to whether the syphilitic 
 virus is derived from the mother or the father. If 
 from the male parent, the villi constituting the foetal 
 2Dart of the placenta are chiefly or primarily aftected, 
 but the disease may extend thence to the maternal 
 ]Dart. The villi undergo a peculiar cellular hyper- 
 trophy, with thickening and proliferation of their 
 epithelial covering, which alters and distorts their 
 form in a remarkable manner. There is a particularly 
 marked hypertrophy in the coats of the vessels, with 
 consecutive obliteration of their canals. This morbid 
 change Frank el calls by the awkward name of " dis- 
 figuring granulation-cell disease." The placentae in 
 their entirety were in the early stage of the disease 
 unusually large, notwithstanding that in most cases 
 the foetuses were atrophied and shrivelled. After 
 the hypertrophy, came one of atrophy, in which the 
 vessels were completely obstructed, the epithelial 
 covering of the villi disintegrated, and fatty degener- 
 ation in full progress. Friinkel insists strongly on one 
 
 * Vircla. "Arch.," Bd. i. p. 305. 
 
1 68 THE PATHOLOGY OF INTRA-UTERINE DEATH. 
 
 point, namely, that although fatty degeneration of the 
 villi, blood extravasations, &c., may be present in 
 
 Villus of placenta, affected with " disfiguring granulation-cell disease." 
 (Frankel.) a. Portion of villus covered with gi-anulation ceUs ; h. normal 
 villus dei^rived of its epithelial covering bj maceration ; c. junction 
 between sound and diseased structure. 
 
 placental syphilis, they are secondary, the primary 
 disturbance beino; increase in the normal cells of 
 the villi, a revolutionary growth brought about by 
 diseased blood. 
 
 When the mother was the subject of syphilis the 
 pathological lesion was more complex, and the changes 
 were especially marked in the decidual or maternal 
 part of the placenta, but also might extend by con- 
 tiguity to the viUi or foetal portion. The changes in 
 the decidua took the form of disease described by 
 Virchow as placental endometritis, or by Sla^'jansky* 
 and Klem\^itchtert as " placentaris gummosa." 
 These consisted of increased growth of the connective 
 tissue, and enormous hypertrophy of the large 
 decidual cells, these so crowding and compressing 
 the vilh that their circulation was interrupted, and 
 the result was mterference with the nutrition and 
 
 * " Prager Vierteljahrs.," 1871. f Vixd.y Bd. cxiv. 
 
SYPHILITIC PLACENTA. 
 
 169 
 
 placental respiration of the fostus. I believe Henn- 
 ing was the first to call attention to the intimate 
 
 Fio. 17. 
 
 Section of villi affected with " disfiguring granulation cell disease." 
 AA. Luxuriant cell development in the interior ; VV. lumen 
 of blood-vessels with hypertrophied walls ; JB. villus in which 
 only a trace of blood-vessels can be seen at 86' ; C. villus with- 
 out trace of vascular canal ; Z>. epithelial covering. (Frankel.) 
 
 relation of the cell-growth to the vessels in syphilitic 
 placenta, and his observations are confirmed by 
 Frankel. If both father and mother were syphilitic, 
 the lesion was of course a mixed one, and in all there 
 were variations, consisting of changes of colour, dark 
 hyperaemic patches, alternating with paler structure, 
 and frequently smaller or larger blood extravasa- 
 tions. 
 
 The late Dr. Angus Macdonald,* of Edinburgh, 
 wrote a paper confirming these observations of 
 Friinkel, and asserted that although the syphilitic 
 placenta may be mistaken for a fatty placenta, and, 
 
 * " Obstetrical Journal," 1S75-6. 
 
I 70 TIIK PATHOLOGY OF FNTRA-UTERINE DEATH. 
 
 ill fact, had been so mistaken by Kilian and Robin, 
 this is easily rectified by miscroscopic examination. 
 In these cases the death of the foetus is the result 
 of progressively increasing defective blood-supply, 
 ovvino" to the chancres described. 
 
 I have on different occasions had the opportunity 
 of examining placentae in the early months of gesta- 
 tion with certain peculiarities of morbid change which 
 I considered were undoubtedly due to syphilis, and 
 which bore some resemblance to Fhinkel's descrip- 
 tions. For example, T examined the placentae in two 
 separate pregnancies of the same individual. She 
 had contracted syphilis immediately afterher marriage, 
 and at the same time became pregnant. During the 
 early part of her pregnancy the vulva became the 
 seat of specific sores, mucous tubercles, and warts. 
 Later her body was covered with patches of syphilitic 
 psoriasis. She miscarried in both the first and 
 second pregnancies in the fifth month. Both the 
 placentae exhibited changes very closely resembling- 
 each other. On the uterine side of the placenta the 
 decidua was much thickened, and there was great 
 increase of all the cellular and fibroid structures 
 which normally constitute that membrane. Pro- 
 lono-ations of this dense tissue were sent down into 
 the substance of the placenta, and seemed to termin- 
 ate about half-way through its thickness. The effect 
 of this dense layer was apparently to compress and 
 contract the sinuses or lacunte, to do away with the 
 spongy character of the organ, and so to prevent the 
 growth of the villi into the sinuses. The villi next 
 to this layer were stunted and atrophied. Those 
 near the fcetal surface were hypertrophied, and were 
 
SYPHILITIC PLACENTA. 171 
 
 beginning to undergo fibroid or fatty degeneration or 
 both. In all the microscopic sections, hypertrophy 
 of the arterial coats in the fetal blood-vessels was 
 noted, and those nearest the maternal surface were 
 absolutely obliterated. Here was a case in which 
 syphilis in the mother was clear and distinct, and 
 M'here the changes in the maternal portion of the 
 placenta were most marked, supporting the doctrine 
 that it is this portion which is most affected when 
 the mother is syphilitic in early pregnancy. 
 
 So far as my observation goes, I do not think we 
 are yet able to say with precision that any one 
 specific lesion of the placenta belongs alone to syphilis, 
 although some morbid appearances are more constant 
 than others in connection with syphilis, as, for 
 examj)le, the changes described by Frankel. In 
 addition to the hyjDertrophy of the villi delineated by 
 Frankel, and the morbid changes in the clecidua just 
 described, I have seen fibroid deposits, such as those 
 observed by Kokitansky, some unchanged, others 
 undergoing fatty transformation. Again, I have seen 
 the yellowish granulations of varying sizes looking 
 like tubercles as observed by Lebert, but I have also 
 seen most, if not all, of these pathological ap^Dearances 
 where no syphilitic history could be traced. The 
 nearest approach to precision in this respect is to say 
 that, as a general rule, when the decidual or maternal 
 portion of the placenta has become so far changed by 
 hyperplasia as to arrest the utero-placental circula- 
 tion and the full development of the placental villi, 
 that this is probably due to maternal syphilis. It 
 finds its analogy in the changes which take place in 
 the mucous membrane in the uterus and elsewhere 
 
I 72 THE TATHOLOGY OF INTRA-UTERINE DEATH. 
 
 wlien the blood is undoubtedly poisoned by syphilis, 
 and also in the thickening of the decidua during the 
 early pregnancy of syphilitic women, which has been 
 described by Virchow and Dohrn as " endometritis 
 papulosa et tuberosa." When fibrinous and pseudo- 
 tubercular deposits are found in the placenta in con- 
 nection with syphilis, they are probably only the 
 expression of a depraved or impoverished condition 
 of the blood, which may be equally associated with 
 an?emia or with some form of dyscrasia. When there 
 is marked hypertrophy and degeneration of the villi, 
 the maternal portion of the placenta being less 
 affected, the syphilitic taint more probably comes 
 from the male parent, and the mother may show no 
 signs of the disease. Both Depaul and Tarnier, 
 among modern observers, dispute the existence of 
 absolutely specific lesions in the pla,centa as the 
 result of syphilis. 
 
 De Sinety, one of the latest writers quoted by 
 Charpentier, did not find placental lesions in all 
 women affected with syphilis, but where lesions were 
 present he was able to demonstrate three important 
 points: (i) Hypertrophy of the placental villi; (2) 
 fibrous degeneration of them ; (3) islands of granula- 
 tion belonging to the caseous form of degeneration. 
 This coincidence of the fibrous and caseous forms of 
 degeneration is found in syphilitic gumma, notably 
 in gummata of the liver. De Sindty had not found 
 this combined degeneration except in syphilis. He 
 does not know if any other disease may produce the 
 combined changes, and does not decide the question 
 as to a specific placental lesion in connection with 
 syphilis. 
 
EFFECTS OF PLACENTAL DISEASE. I / 3 
 
 In reference to all diseases wliich affect tJie 
 placenta, it is to be noted that the eiiect on the life 
 of the child bears a direct relation to the amount of 
 damage done to its tissues, and impairing its double 
 function as an organ for respiration and absorption. 
 In cases of separation of the placenta a portion still 
 adherent to the uterine walls may be enough to sus- 
 tain the life of the child, for a time at least, and, in 
 like manner, when the placenta has become diseased, 
 if some portions of it only remain sound, vitality may 
 still be maintained in the body of the foetus. If the 
 morbid process be slow and chronic, there will pro- 
 bably be progressive emaciation, and if the child be 
 born alive it will have all the appearances of being 
 starved during its development. If the placental 
 disease is more acute and rapid, and affecting a large 
 area of tissue, the child's movements become at first 
 more restless than usual, and then become less marked 
 and distinct as they subside into absolute quiescence. 
 With the aid of the stethoscope the beats of the foetal 
 heart have repeatedly been noted in cases of sus- 
 pected placental disease to become slower and slower, 
 and thus to furnish important indications for the 
 induction of premature labour. 
 
 Among the further causes of foetal death in uteru 
 which I cannot here overtake are the pathological 
 conditions of the umbilical cord, ante-partum hsemor- 
 rhage, extra-uterine gestation, and allied conditions, 
 the malformations and diseases of the unborn child — 
 the most fertile cause of the latter probably being 
 syphilis. 
 
 Did time permit I might say something besides, 
 concerning the changes taking place in the body of 
 
I 74 TUE PATHOLOGY OF INTllA-UTERINE DEATH. 
 
 the fuetus wlieii it is long contained in the utenis 
 after its death ; of the inferences to be drawn as to 
 
 the cause of its death from the a})pearances it pre- 
 sents after long or shorter periods of retention, and 
 other kindred topics. 
 
 I must, however, hasten to say a few words on the 
 subject of preventive treatment. 
 
 Treat III cut. — And now, it may be asked, what are 
 the remedies suggested for these many and varying 
 causes of intra-uterine death ? The answer must, 
 I fear, in regard to a large number of them, be con- 
 sidered as eminently unsatisfactory. Notwithstand- 
 ing all that has been done, we are yet only on the 
 threshold of those investigations which must reveal 
 to us eventually the best methods of obviating death 
 in unborn children. In the meantime, so far as the 
 prevention of some of the forms of intra-uterine death 
 is concerned, we are absolutely in the dark, and the 
 therapeutics of the subject are still as a closed book. 
 
 Fortunately this need not be said of all. A careful 
 study of the several pathological conditions in the 
 parents, combined with the local expression of the 
 results of those conditions, enables us in some cases to 
 formulate methods of treatment and lay down rules 
 for guidance which in practice have been attended 
 with happy results. 
 
 Whenever, therefore, a woman has once or more 
 frequently lost the product of conception at an early 
 or later period, careful inquiry should be made into 
 the health of both parents, and any previous history 
 of illness should be accurately scrutinised. If the con- 
 stitution of either parent be found at fault, measures 
 must be taken to amend this. The question of 
 
TREATMENT. 1 75 
 
 syphilis is so important, and tlie venereal poison is so 
 persistent and all-pervading, that no pains must be 
 spared to ascertain whether this is the root of the 
 misadventures. If a patient has once had syphilis it 
 is impossible to say when the effects on the constitu- 
 tion have entirely passed away, and many men who 
 have believed themselves to be cured and free from 
 every taint of the disease, find the evidence still 
 remaining in their wives' frequent abortions, or in 
 the indications of syphilis in their living children. 
 When, therefore, either patient has suffered from 
 syphilis in the near or distant past, and the wife has 
 recurring abortion, or has her children die in utero at 
 a later period of gestation, the presumption is that 
 syphilis is the cause. Both parents ought at once to 
 be put mider anti-syphilitic treatment before a fresh 
 conception is permitted, and this ought to be suffi- 
 ciently prolonged to give it a fair chance of producing 
 satisfactory results. Diday recommends that the 
 physician should not be contented with submitting 
 both parents to anti-syphilitic treatment prior to the 
 occurrence of pregnancy, but that witli each succes- 
 sive pregnancy, as it occurs, the mother should at 
 once recommence a mercurial course, even if she has 
 no visible indications of the disease. I can testify 
 that I have repeatedly seen good effects from small 
 doses of bichloride of mercury, with bark, given 
 during the first three months of gestation, when 
 there has been no opportunity of commencing the 
 treatment before conception began ; and under this 
 method, with a careful diet and regime, women who 
 had repeatedly miscarried before went to the full 
 time. 
 
176 THE PATHOLCJGY OF INTRA-UTERINE DEATH. 
 
 Similar favourable results have been observed to 
 follow the administration of iodide of potassium. 
 M. Goshkevich, quoted in the " Brit. Med. Journal " 
 (July I, 1885), advises its use in habitual abortion, 
 even when no syphilitic symptoms have been re- 
 cognized, and testifies to its utility in saving foetal 
 life. It must be left for the medical man in chargfe of 
 a case to determine whether in any given case some 
 of the approved forms of mercurial treatment are 
 most appropriate, or a course of iodide of potassium. 
 Possibly both may be judiciously combined, or one 
 course succeed the other. Depaul has such confidence 
 in mercurial treatment that he uro-es it should be 
 adopted in all cases of recurring abortion, even when 
 no syphilitic history is traceable in either parent. 
 Charpentier, by way of enforcing this precept, records 
 a case in which a woman had four consecutive abor- 
 tions without known cause, and in which both 
 parents not only denied any knowledge of syphilis, 
 but no traces of the disease could be found upon 
 them. The two parents were then subjected to an 
 anti-syphilitic course, and two children were born 
 subsequently quite healthy, and with no trace of 
 disease upon them. 
 
 I may mention, for what it is w^orth, the case of a 
 patient who had aborted in five successive pregnancies. 
 In the sixth she was salivated by accident in the third 
 month. On this occasion she went her full time, and 
 was delivered of a living child. 
 
 In attempting to forma just estimate of the effects 
 of mercurial treatment in syphilitic cases, it is but 
 fair to say that the venereal poison has a natural 
 tendency to attenuate itself and wear out, in such 
 
MERCURIAL TREATMENT. 177 
 
 way, that, apart from treatment, pregnancy may at 
 length be continued to the normal term in women 
 who. have repeatedly miscarried from this cause 
 before. In these cases each successive pregnancy 
 may have longer duration, until eventually a living 
 child is born. The value of mercurial treatment is 
 nevertheless almost universally acknowledged. So 
 far as my reading goes, tliere is only one notable 
 dissentient to its utility. Despres, a French author, 
 looks upon mercury as the cause of all the evils which 
 it is expected to remedy, and to be itself a cause of 
 abortion. It is probable that some of the forms of 
 mercury (the bichloride, for example) in very small 
 doses over a continued period, and so regulated as not 
 to produce ptyalism, have a beneficial effect in other 
 than syphilitic cases, for more than one reason. The 
 treatment certainly has a good effect on some consti- 
 tutions. It restores the secretions, regula,tes the 
 bowels, and, if coml^ined with bark, improves the 
 appetite and aids nutrition. I have frequently seen 
 patients fatten while taking the bichloride. Further, 
 it is an acknowledged remedy for certain forms of 
 uterine hypertrophy, and iTiore especially acts on the 
 mucous membrane. In those instances, therefore, where 
 the uterine walls are thickened, and their elasticity 
 impaired — in those cases where chronic endometritis 
 so hinders the formative power of the uterine mucous 
 membrane that a faulty or diseased decidua is pro- 
 duced — an alterative mercurial course may best 
 fulfil the indication of treatment demanded, and 
 indirectly hinder the repetition of abortion. If 
 inquiry shows that the health of either parent is dis- 
 ordered or deranged from some other cause tl.'an 
 
 N 
 
178 THE PATHOLOGY OF INTRA-UTEEINE DEATH. 
 
 syphilis, care must be taken to trace out the nature 
 of the deviation in liealth, and so to define it that 
 treatment fulfils its j^urpose. It cannot be too much 
 insisted upon that not the mother only, but the 
 father also, must be put under supervision. If there 
 is any constitutional peculiarity or diathesis, it must 
 be met by appropriate means — the strumous diathesis 
 by tonics and cod-liver oil, with such improved 
 climatic conditions as may be feasible ; the gouty 
 rheumatic by limitations of diet, careful regimen, and 
 alkaline medicines. The gouty rheumatic constitu- 
 tion is often associated with congestion of the portal 
 circulation, and this may become so important a 
 factor in bringing on abortion that it deserves special 
 mention. The late Dr. Edward Rigby constantly 
 dwelt on the importance of keeping the bowels from 
 being constipated in women liable to abortion, and 
 he preferred saline ajDerients to aloes or other drastic 
 purgatives, as easier in action and less likely to be 
 injurious during pregnancy. The effect of carefully 
 regulating the bowels is to lessen the tendency to 
 congestion in the pelvic organs, and so aid in avert- 
 ing engorgement of the foetal membranes and placenta. 
 Care must be taken to choose such laxatives as are 
 not likely to stimulate undue action of the bowels or 
 straining, else the medicines may stir up the very 
 mischief they are given to avoid. Compounds of 
 sulphur, like the German compound liquorice powder, 
 the confection of senna, and saline aperients seem 
 best to fulfil the needful indications. Venesection 
 has been recommended in cases of general plethora, 
 and local depletion, where local congestion seemed to 
 threaten abortion from the pain and sense of en- 
 
TREATMENT OF ANEMIA. I 79 
 
 Cforo-ement which it entailed. General hloocllettino- 
 is now rarely employed in these instances. Its advan- 
 tages are doubtful, and its employment may lead to 
 harm instead of good. Where fainting is produced 
 in the mother, the embryo may be destroyed and 
 abortion follow. Local de]3letion by leeches is less 
 objectionable, and leeches applied round the anus, as 
 the best point for abstracting blood, will readily relieve 
 tension in the hsemorrhoidal vessels. They may 
 require repetition two or three times during the early 
 months of gestation, if indications of congestion recur ; 
 and as a rule they are of most use when applied just 
 before the time which corresponds to the catamenial 
 period. 
 
 The constitutional condition which, next to 
 sy23hilis, seems to hold the most prominent place 
 as predisposing to abortion, is ansemia, and for this 
 it is plain a plan of treatment is called for the very 
 opposite to a depleting one. Preparations of iron 
 must be administered in some form least likely to 
 disturb the digestive organs of the patient ; and 
 these should be given not only antecedent to the 
 occurrence of conception, but they should be con- 
 tinued with such modifications and in such combina- 
 tions as may be suitable during the progress of 
 pregnancy. It has been thought by some that iron 
 is counter-indicated when gestation has once com- 
 menced, as it might favour the occurrence of abortion 
 by inducing hsemorrhage. As a general rule there is 
 no ground for this supposition, and iron, if cautiously 
 given, may be taken by ansemic patients throughout 
 pregnancy without harm. There is often the greatest 
 tolerance of it where it is most urgently needed. 
 
 N 2 
 
1 So THE PATHOLOGY OF INT.RA-UTERINE DEATH. 
 
 Cazeaiix remarks that in ordinary ])regnancy a state 
 of chlorosis is produced — tliere is a relative anceraia, 
 for there is a diminution of red globules, with increase 
 of fibrin in the blood. A slight increase, therefore, 
 of this anaemia may have the effect of deranging the 
 progress of gestation by lessening the nutrition of 
 the foetus and by predisposing to fibrinous deposits 
 in the placenta or membranes. 
 
 It is probable that some of the forms of degenera- 
 tion found in the fa2tal membranes and placenta are 
 due to defects in the constitution of the blood in one 
 or both parents. Whether the fault lies with the male 
 or the female parent may not be easily determined. 
 If there is obvious anaemia or deterioration of health 
 in one or other, it may be enough to place the one 
 apparently deranged under treatment ; but this in- 
 dication not being forthcoming, it will be desirable to 
 put both parents on iron, combined, perhaps, with 
 quinine, arsenic, or other tonic remedies, as may seem 
 suitable in each particular case. 
 
 Where local conditions have been ascertained or 
 suspected to be the cause of repeated abolition, or of 
 later foetal death, the treatment must be directed in 
 accordance with the special requirements of the case. 
 Especial care should be taken to remove as far as 
 possible all indications of endometritis prior to the 
 commencement of pregnancy, as an unhealthy condi- 
 tion of the lininof membrane of the uterus is regarded 
 by most authorities as a potent cause of disease in 
 the foetal membranes and placenta. 
 
 In all instances where past experience has proved 
 the proneness to miscarriage, it is an essential part 
 of any plan of treatment that the patient should be 
 
TREATMENT BY EEST. l8l 
 
 habitually at rest in the recumbent position, so that 
 the uterus may be affected as little as possible by the 
 effects of gravitation. It is doubtful in most cases 
 whether the ^^i^^tient should be entirely precluded 
 from taking exercise and fresh air, lest the general 
 health should so suffer as to undo some of the advan- 
 tages of rest. This jDoint deserves especial considera- 
 tion, so far as anagmic and naturally bilious patients 
 are concerned, both suffering if deprived of fresh air 
 and exercise. A moderate amount of vs^alkins: out of 
 doors may, therefore, be permitted, with repose in 
 the recumbent posture at other times. All carriage 
 exercise and other forms of locomotion likely to jar 
 the body should be sedulously avoided, and a carrying 
 chair may be advantageously used to take the patient 
 up and down stairs. 
 
 While this latitude of movement is permitted 
 ordinarily, absolute rest on the sofa or in bed should 
 be enjoined at the times which correspond to the 
 days of the catamenial period. A greater tendency 
 to abort has been noted at those times than at others, 
 and, if abortion does not immediately take place 
 then, damage is done, which culminates in mis- 
 carriage later, and is traced back to the menstrual 
 epoch for its first symptoms. At those times, even 
 during pregnancy, there is a nisus often distinctly 
 observable in increased discomfort, or in some other 
 way. It appears like a periodical tidal wave, which, 
 in weakly women or those liable to go wrong, readily 
 overflows its barriers, and ends in a.bortion. The 
 influence of this menstrual wave is so fully acknow- 
 ledged at all times in women, that, by common consent, 
 operations are avoided during its continuance, in 
 
I o2 THE TATHOLOGY OF INTRA-UTERIXE DEATH. 
 
 order to avoid the period of local liypercX'mia with 
 which it is accompanied. Charpentier remarks that, 
 in certain women who abort frequently witliout 
 known cause, there seems to be a peculiar irritability 
 of the uterine fibre. The sphincter uteri seems 
 weakened, and, when pregnancy occurs, the smallest 
 effort promotes its dilatation. Irritability also deter- 
 mines premature contractions, and the sphincter 
 being weak it easily yields, and so abortion occurs. 
 It is obvious that in these cases, whatever else is 
 prescribed, absolute rest in the recumbent posture is 
 imperative so long as the irritability remains. . 
 
 To Sir James Simpson we owe the suggestion that, 
 in all cases where there is reason to believe the 
 placenta is partially disabled by disease, chlorate 
 of potash should be given^ with the object of keeping 
 the child alive during its further detention in utero. 
 Simpson's theory was that, because chlorate of potash 
 contained six atoms of oxygen to one of chlorine and 
 one of potassium, it would sensibly increase the 
 amount of oxygen in the mother's blood, and afford 
 a larger proportion of this element for the placental 
 respiration of the foetus. The maternal blood- current 
 being thus more abundantly charged with oxygen 
 than under ordinary circumstances, a smaller portion 
 of sound placenta could absorb more for the require- 
 ments of tlie foetus, and so supplement the function 
 of those Darts of the oro-an damap'ed or destroyed. 
 Whether this theory be true or not, it is certain 
 that many practitioners have testified to its utility 
 as well as to its harmlessness. Dr. Playfair suggests 
 that it may act, in virtue of its tonic properties, on 
 the constitution of the mother ; and I think it may 
 
INDUCTION OF LABOUR. I 83 
 
 act usefully as an alkaline salt in preventing the 
 formation of coa.gula and fibrinous deposits in the 
 placenta. It is given in ten or fifteen grain doses 
 three times a day, and may be administered at any 
 period of pregnancy, but it is believed to be most 
 useful in the latter half. 
 
 The induction of premature labour, also recom- 
 mended by Simpson as a m^eans of averting the death 
 of the child in, ntcro. is only available in those cases 
 where it dies in successive pregnancies after the 
 expira.tion of the seventh month. At any period 
 antecedent to this the child would not be viable, or 
 would be so feeble that nothing would be gained by 
 the proceeding. But in a limited number of instances 
 it has been observed that placental disease begins 
 apparently just before the seventh month, and 
 gradually and steadily advances until it kills the 
 child and its movements cease to be felt by the 
 mother. With such experience of past times to 
 guide the practitioner, the induction of labour is 
 perfectly justifiable if the movements of the child 
 continue to be felt after the seventh month is com- 
 pleted ; and the operation is the more imperative if 
 the movements grow slower and feebler, and the 
 stethoscope indicates a declension of strength in the 
 beating of the foetal heart. In this way children's 
 lives have been saved which would probably have 
 been sacrificed by further delay. 
 
 In patients where intra-uterine death is threatened 
 or feared as the result of some form of poison, in- 
 organic or organic, to which I have alluded, the 
 treatment must necessarily consist in removal of 
 the cause. Id those special instances where the pro- 
 
1^4 THE rATIIOLOGY OF INTRA-UTEUINE DEATH. 
 
 gress of zymotic disease or of inflammation in some 
 organ of the patient's body is attended with high 
 temperature, it is possible some attempt may be made 
 to avert the usual consequences so far as the preg- 
 nancy is concerned. As the experiments of Kunge 
 and others have shown that peril comes to the child 
 i)i utero directly the temperature of the mother rises 
 persistently up to 105°. while the infant's tempera- 
 ture rises still higher, it may be possible, in the 
 progress of therapeutics, not only to keep down the 
 general maternal hyperpyrexia, but I would throw out 
 the suggestion that, where it is feasible, an attempt 
 should be made to lower also the temperature of the 
 uterus and of the foetus, either by the apjjlication of 
 ice-bags to the maternal abdomen, or of those tubular 
 appliances so ingeniously invented for the application 
 of cold, and which may be modified to fit any part of 
 the body. 
 
 When all our most ingenious methods of diagnosis 
 and treatment are exhausted in attempting to obviate 
 intra-uterine death, there, will still be a large number 
 of cases in which no further clue can be found than 
 an obvious constitutional feebleness, permanent or 
 temporary, in one or both parents. In some of these 
 the organic weakness or degeneration in health may 
 be of such character that it is hopeless to expect a 
 remedy, and perhaps it is well for the race in general 
 that such constitutional faults or diseases should not 
 be perpetuated in progeny. But where the constitu- 
 tional weakness may be but temporary, attempts 
 should be made to resuscitate the health. Every- 
 thing that science and practice teaches to be useful 
 for the restoration of strength in single organs and 
 
CONTINENTAL WATERS. 185 
 
 in the entire system should be called into requi- 
 sition. 
 
 Boerhaave is said to have recommended horse- 
 riding as a remedy for abortion. In any case whei-e 
 this proved useful it would probably be by improving 
 the general health. Apropos of this I may mention 
 a case within ray own experience of a lady in India 
 who, after aborting several times under the most 
 careful system of rest — in some pregnancies amount- 
 ing to absolute repose for many months in the 
 recumbent posture — at length gave up the hope of 
 bearing children, and took to riding on horseback, 
 not only before a fresh gestation began, but after she 
 had reason to believe that she was again pregnant. 
 As the result she went for the first time to the full 
 period, and was delivered of a living child. 
 
 Some of the baths and waters on the Continent 
 have a high reputation for their tonic properties and 
 their favourable influence on pregnancy. Aix-les- 
 Bains is said to be useful in these cases. I have seen 
 courses at Schwalbach and Kissingen followed by 
 happy results. Schwalbach, perhaps, is more appro- 
 priate for patients who are more or less anaemic ; 
 Kissingen for those in whom the digestion and portal 
 system are at fault. One successful case is fresh in 
 my memory, where a mother who had previously borne 
 healthy children was stricken with severe pleuro- 
 pneumonia, and continued for some time after in 
 comparatively feeble health, although she resumed 
 her place in society again after an interval. Not 
 long afterwards she conceived, and at the end of six 
 months lost her child. A little later a fresh preg- 
 nancy occurred, and this terminated, apparently with- 
 
I 86 THE PATHOLOGY OF INTEA-UTEllINE DEATH. 
 
 out cause, at the end of four months. After this she 
 went to Kissingen, experienced a notable improve- 
 ment in health, and subsequently bore two healthy 
 children without misadventure. 
 
 My task is now ended, however imperfectly it may 
 have been completed. I have had a sense, in giving 
 these lectures, as of rushing rapidly through a 
 harvest field, — rich in pathological facts and illustra- 
 tions,- — and j)lucking a few ears by the way, while I 
 have left an abundant crop to be garnered by any 
 who may be able and willing to undertake the 
 Avork. 
 
i' iq I 
 
 n. 
 
 Fiq III 
 
PLATE I. 
 
 Fig. I.-^The larger half of a placenta, sliowiug in 
 
 section infiltration of low inflammatory deposit, and 
 
 apoplexies, formed by the breaking doAvn of tissue. 
 The child was born alive. 
 
 Fig. II. — 'A portion of the same placenta, showing- 
 masses of dense deposit, in contrast with the normal 
 spongy tissue in its neighbourhood. 
 
 Fig. III. — A portion of the same placenta in section, 
 showing deposit of low organization crumbling in the 
 centre. 
 
 Specimen in Middlesex Hosiriial. 
 
Plate II 
 
 Fiq 
 
 r-.v- • 
 
 4, <- < 
 • • •. 
 
 V»r- 
 
 <•• • 
 
 .:• ^ 
 
 * • • 
 
 • • •. * 
 
 • • • . • ^ - 
 
 • .•-.. '^ 
 
 • % 
 
 IP, 
 
 Fiq. n. 
 
 
 \ -V 
 
 £'Tliurston del. 
 
 K.Bvirgess ch.lil>i 
 
PLATE II. 
 
 Fig. I. — Inflammatory deposit between the placental 
 villi; pushing them aside and compressing them. The 
 mass of deposit in the centre is almost structureless, and 
 surrounded by a pseudo-capsule. 
 
 From Specimen in Middlesex Hospital. 
 
 Fig. II. — Microscopic section of a placenta, showing 
 sections of atrophied and deformed villi, their vessels 
 being obliterated. Tliey are embedded in a fibroid 
 stroma, which has contracted upon them. 
 
 Coll. of Surgeons Specimen. 
 
' v^r 
 
 Pla^e II 
 
 z-;^ 
 
 Fiq. I. 
 
 3- 
 
 » V 
 
 
 k 
 
 \. 
 
 -\ 
 
 7!^ 
 
 
 f . 
 
 « / 
 
 ■E.Tharston del 
 
 E.B'Jircrcss ri\.Ut>i 
 
PLATE III. 
 
 Fig. I. — Microscopic section of a placenta, showing the 
 commencing conversion into fibroid tissue of inflamma- 
 tory deposit between the villi. 
 
 King's Coll. Specvmen. 
 
 Fig. II. — Microscopic section of the same placenta, 
 showing great hypertrophy of vascular walls, and enlarged 
 calibre of vessels. 
 
 Kincfs Coll. S]pecimen. 
 
INDEX. 
 
 ABOETioy, frequent reiDetitiou of, 1-5 
 
 chlorate of potash in, 1S2 
 
 climate, predisposing to, 23 
 
 deterioration of health, a cause of, 22 
 
 difficulty of producing, in some cases, 5 
 
 early, often overlooked, 12 
 
 epidemics of, 29 
 
 ergot as a cause of, 30 
 
 frequency of, 6 
 
 from syphilis in male, 17 
 in female, 58 
 
 impaired vitality a cause of, 14 
 
 in animals, 14, 22, 27 
 
 in connection with albuminuria, 49 
 diabetes, 53 
 phthisis, 51 
 
 in trees and plants, 23, 27 
 
 iodide of potassium in, 176 
 
 iron in, 179 
 
 mercury in ti*eatment of, 175 
 
 more frequent in later life, 28 
 
 preventive treatment of, 174 
 
 produced by losses of blood, 25 
 
 ratio of, to pregnancies, 9 
 
 sieges and famines producing, 30 
 
 statistics of, 7, 8, 9 
 Acephalocysts ia uterus, 95-1 12 
 " Adhesive endometritis," 88 
 
 Acute diseases, as a cause of intra-uterine death, 3 1 
 Age, as cause of intra-uteiine death, 27 
 Altitude, as a cause of intra-uterine death, 27 
 Amnion, morbid changes in, 112 
 
 adhesions of, 1 1 4 
 
1 88 INDEX. 
 
 Aniuion, blood extravasations into, 113 
 
 development of, 112 
 
 dropsy of, 115 
 
 effects of rupture of, 113 
 
 fragile structure of, 113 
 
 infiammation of, 113 
 "Amniotic hydrorrhocu," 91 
 Anaemia, 25 
 
 treatment of, 179 
 Antiseptic surgery as a preventive of intra-uterine death, 67 
 Apoplexy of ovum, 79-83 
 
 Carbonic acid poisoning a cause of abortion, 48 
 Catamenial period, uterus irritable during, 67 
 " Catarrhal endometritis," 90 
 " Cervical pregnancy," 75 
 
 Chlorate of potash in cases of intra-uterine death, 1S2 
 Cholera a cause of abortion, 55 
 Chorion, morbid changes in, 92 
 partial disease of, 108 
 cystic or vesicular, 92 
 
 causes of, 110 
 
 condition of embryo in, 105, loS 
 
 different views concerning, 95 
 
 essentially a pi'oduct of pregnancy, 1 1 1 
 
 forced into walls of uterus, 105 
 
 its relation to death of embr3'o, 108 
 
 minute structure of, 98 
 
 period of its occurrence, 106 
 
 relation of the decidua3 to, 103 
 
 retention of, for long perioJs, ] 12 
 " Chronic diffuse endometritis," 85 
 Cod-liver oil in cases of intra-uterine death, 178 
 
 Decidtja, structure of, 70 
 apoplectic, 76 
 
 arrested development of, 72> 
 atrophy of, 73 
 congestion of, 84 
 diseases of, 76 
 fatty degeneration of, 81 
 hypertrophy of, 74-87 
 inflammation of, 85 
 its liability to extravasations, 76 
 reflexa, hsemorrhage into, 78 
 weakness of, 75 
 
JNDEX. 189 
 
 Dysmenorrliccal membraue.s, 71 
 
 Eclampsia, causing foetal death, 49 
 
 temperature in, 50 
 Endometritis, causing inflammation of placenta, 132 
 
 "interstitial," 132 
 Epidemics of abortion, 29 
 Ergot, as producing abortion, 30 
 
 Fertilising fluid, defects in, 15 
 
 Foetal appendages, diseases of, 70 
 
 Foetus, appearances of, after death from pyrexia, 46 
 
 Gastric irritation, producing abortion, d"] 
 
 Habit of aborting, 5 
 
 Heart disease as cause of intra-uterine death, 5 5 
 Horse-riding during pregnancy, 185 
 Hydramnios, 114 
 
 causes of, 116 
 
 diabetes in connection with, 117 
 
 effects and symptoms of, 115 
 
 pathology of, 1 1 7 
 
 period of its occurrence, 116 
 " HydroiTlioea," 90 
 Hyperpyrexia a cause of intra-uterine death, 39 
 
 treatment of, during pregnancy, 184 
 
 Induction of premature labour, 183 
 
 Inflammation of uterus as cause of intra-uterine death, 63 
 Injuries of uterus, &c., causing intra-uterine death, 65 
 Interbreeding as cause of intra-uterine death, 27 
 Intra-uterine death, causes referable to father, 1 5 
 
 causes referable to mother, 22 
 
 classification of causes, 14 
 
 direct and specific causes of, 31 
 
 in connection with diabetes, 53 
 with albuminuria, 51 
 
 over- and under-feeding causing, 23 
 
 preventive treatment of, 174 
 Iodide of potassium in aboi'tion, 176 
 Iron, influence of, on pregnancy, 179 
 Irritations, various, causing intra-uterine death, 65 
 
 Jaundice a cause of foetal death, 54 
 
1 90 INDEX. 
 
 LEAD-roisoNixG, 1 7, 57 
 
 Leucorrlioca, it3 relation to abortion, 63 
 
 Local conditions inducinfj abortion, 61 
 
 treatment of, when causing intra- uterine death, i8o 
 
 Male parent may be cause of intra-uterine death. 15 
 
 should be treated in some cases, 174 
 " Menstrual wave," importance of observing, 67, 181 
 Mental influences on pregnancy, 68 
 Mercurial treatment in syphilis, 175 
 Mineral waters and baths, 185 
 Moles, " cystic" and " carneous," 92, 104 
 Mortality, fcetal, in late periods of gestation, 1 1 
 Myxoma of chorion, 97 
 
 partial, 106 
 " Myxoma fibrosum," 154 
 
 Operations during pregnancy, 67 
 Ovum, shape of, 70 
 
 apoplexy of, 79 
 
 insertion of, 74 
 
 Pelvic adhesions as cause of abortion, 64 
 
 Phthisis in relation to foetal death, 5 1 
 
 Placenta, disease of, produced by general congestions, 57-61 
 
 abscesses in, 132 
 
 adhesions of, 132-136 
 
 apoplexy of, 123 
 
 its relation to other forms of apoplexy, 126 
 generally preceded by degeneration, 126 
 
 at third month, 120 
 
 calcareous concretions in, 159 
 
 " cellular hyperplasia," &c., of, 154 
 
 congestion of, 123 
 
 cysts and tumours of, 162-3 
 
 diseases of, 119 
 
 "disfiguring granulation-cell disease '" of, 167 
 
 early circulation in, 121 
 structure of, 120 
 
 extravasations in, 121 
 
 exudations in, 133-137 
 
 fatty degeneration of, 1 50 
 
 a normal process, 153 
 
 fibro-fatty degeneration in, 12S 
 
 haematosis of, 124 
 
 bepatisation of, 131-139 
 
INDEX. I 9 I 
 
 Placenta, " hypei'tropliy of connective tissue " in, 133, 135, 145 
 
 inflammation of, 130 
 
 melanosis of, 158 
 
 CDclcma of, 136 
 
 organization of clots in, 130 
 
 phthisis of, 136 
 
 prajvia, origin of, 74 
 
 " sclerosis " of, 135 
 
 syphilitic, 164 
 
 a potent cause of abortion, 165 
 opinions concerning, 165 
 summary of conclusions, 172 
 
 theories of disease in, 119 
 
 thrombosis of, 125 
 Placental phthisis, 136 
 
 syphilis, 164 
 
 treatment of, 175 
 
 villi, fibro-fatty degeneration of, 127 
 Placentitis, 130 
 
 pathology of. 131 
 Pleurisy in pregnancy, 38 
 Plural births, 27 
 Pneumonia in pregnancy, 36 
 Poisoned blood a cause of abortion, 47, 57 
 Poisons, organic and inorganic, in pregnancy, 57 
 "Polypoid endometritis," 89 
 Prematurity as cause of intra-uterine death, 27 
 Procreating power different from development, 16 
 Purgatives in habitual abortion, 178 
 Pyrexia in relation to intra-uterine death, 39 
 
 " Qtjickenikg," abortion at time of, 13 
 
 Reflex causes of abortion, 65 
 
 Eest, importance of, in preventing intra-uterine death, 181 
 
 Satuknine intoxication, abortion from, 17, 57 
 Sieges and famine producing abortion, 29 
 Small-pox a cause of intra-uterine death, 31 
 Syphilis in the male, abortion from, 17 
 
 in female, intra-uterine death fi-om, 58 
 
 causes disease in foetal appendages, 61 
 
 laws concerning its influence, 60 
 
 prevention of, 59 
 Syphilitic placenta, 164 
 
192 INDEX. 
 
 Temperature, high, a cause of fojtal death, 39 
 
 foetal, higher than maternal, 41 
 
 Runge's ex2:)eriments on, 40 
 Treatnnent, preventive, of intra-uterine death, 174 
 
 anti-syphilitic, 175 
 
 by baths and waters, 185 
 
 chlorate of potash, 182 
 
 iron, by cod-liver oil, &c., 178-9 
 
 importance of rest in, 181 
 
 of hyperpyrexia during pregnancy, 184 
 
 Uterine congestion, &c., as cause of abortion, 62 
 displacements, 64 
 haemorrhage, 129 
 
 " concealed," 129 
 inflammation and ulceration, 63 
 other diseases, 64 
 
 Venesection generally to be avoided during pregnancy, 179 
 
 Vesicular chorion, 92 
 
 Villi, placental, fibro-fatty degeneration of, 123 
 
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 Being Six Lectures on Temperament, 
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 Treatment of Wounds and Frac- 
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 Gamgee, F.R.S.E., Surgeon to the 
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 F.R.C.S., Surgeon to the Royal Ortho- 
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 By the same Author. 
 
 On Anchylosis, and the Treat- 
 ment for the Removal of De- 
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 Fourth Edition. Svo, with Engravings, 5s. 
 
 Also. 
 
 Curvatures and Diseases of the 
 
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 Diseases of Bones and Joints. 
 
 ]',Y Charles Macnamaka, F.R.C.S.^ 
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 Injuries of the Spine and Spinal 
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J. S,- A. CHURCHILL'S RECENT WORKS. 
 
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J. ^- A. CHURCHILL'S RECENT WORK'S. 
 
 13 
 
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34 
 
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INDEX. 
 
 Abercrombie's Medical Jurisprudence, 4 
 Adams (W.) on Clubfoot, 11 
 
 on Contraction of the Fingers, 11 
 
 on Curvature of the Spine, 11 
 
 Alexander's Displacements of the Uterus, 6 
 Allan on Fever Nursing, 7 
 
 Outlines of Infectious Diseases, 7 
 
 Allingham on Diseases of the Rectum, 14 
 Anatomical Remembrancer, 3 
 
 Balfour's Diseases of the Heart and Aorta, 9 
 Balkwill's Mechanical Dentistry, 12 
 Barnes (R.) on Obstetric Operations, 5 
 
 on Diseases of Women, 5 
 
 Basil's Commoner Diseases and Accidents, 10 
 Beale's Microscope in Medicine, 8 
 
 Slight Ailments, 8 
 
 Urinary and Renal Derangements, 14 
 
 Bellamy's Surgical Anatomy, 3 
 
 Bennet (J. H.) on the Mediterranean, 10 
 
 on Pulmonary Consumption, 10 
 
 Bentley and Trimen's Medicinal Plants, 7 
 Bentley's Manual of Botany, 7 
 
 Structural Botany, 7 
 
 Systematic Botany, 7 
 
 Bowlby's Surgical Pathology and Morbid Anatomy, 10 
 Braune's Topographical Anatomy, 3 
 Brodhurst's Anchj'losis, 11 
 
 Curvatures, &c., of the Spine, 11 
 
 Orthopaedic Surgery, 11 
 
 Bryant's Acute Intestinal Strangulation, 9 
 
 Practice of Surgery, it 
 
 Bucknill and Tuke's Psychological Medicine, 5 
 Buist's Vaccinia and Variola, 8 
 Bulkley's Acne, 13 
 
 Diseases of the Skin, 13 
 
 Burdett's Cottage Hospitals, 4 
 
 Pay Hospitals, 4 
 
 Burton's Midwifeiy for Midwives, 6 
 
 Butlin's Malignant Disease of the Larynx, 13 
 
 Operative Surgery of Malignant Disease, 13 
 
 Sarcoma and Carcinoma, 13 
 
 Buzzard's Diseases of the Nervous System 9 
 
 Peripheral Neuritis, 9 
 
 Carpenter's Human Physiology, 4 
 Cayley's Tj'phoid Fever, 8 
 
 Charteris on Health Resorts, 10 
 
 Practice of Medicine, 8 
 
 Chavers' Diseases of India, 8 
 Churchill's Face and Foot Deformities, 11 
 Clouston's Lectures on Mental Diseases, s 
 Cobbold on Parasites, 13 
 
 Coles' Dental Mechanics, iq 
 Cooper's Syphilis and Pseudo-Syphilis, 14 
 Coulson on Diseases of the Bladder, 14 
 Courty's Diseases of the Uterus, Ovaries, &c., 6 
 Cripps' Diseases of the Rectum and Anus, 14 
 CuUingworth's Manual of Nursing, 6 
 
 Short Manual for Monthly Nurses, 6 
 
 Curling's Diseases of the 'I'estis, 14 
 Dalby's Diseases and Injuries of the Ear, 12 
 Day on Diseases of Children, 6 
 
 on Headaches, 10 
 
 Dobell's Lectures on Winter Cough, 8 
 
 Loss of Weight, &c., 8 
 
 Mont Dor^ Cure, 8 
 
 Domville's Manual for Nurses, 6 
 Doran's Gynaecological Operations, 6 
 Down's Mental Affections of Childhood, 5 
 Draper's Text Book of Medical Physics, 4 
 Druitt's Surgeon's Vade-Mecum, 11 
 Duncan on Diseases of Women, 5 
 
 on Sterility in Woman, 5 
 
 Dunglison's Medical Dictionary, 14 
 East's Private I'reatment of the Insane, 5 
 Ebstein on Regimen in Gout, 9 
 
 Ellis's Diseases of Children, 6 
 Fagge's Principles and Practice of Medicine, 
 Fayrer's Climate and Fevers of India, 7 
 Fenwick's Chronic Atrophy of the Stomach, 8 
 
 Medical Diagnosis, 8 
 
 Outlines of Medical Treatment, 8 
 
 Flint's Principles and Practice of Medicine, 7 
 
 Flower's Diagrams of the Nerves, 3 
 
 Fox's (C. B.) Examinations of Water, Air, and Food, 5 
 
 Fox's (T.) Atlas of Skin Diseases, 13 
 
 Freyer's Litholopaxy, 14 
 
 Frey's Histology and Histo-Chemistry, 4 
 
 Galabin's Diseases of Women, 6 
 
 Manual of Midwifery, 5 
 
 Gamgee's Treatment of Wounds and Fractures, 11 
 
 Godlee's Atlas of Human Anatomy, 3 
 (ioodhart's Diseases of Children, 6 
 Gorgas' Dental Medicine, 13 
 Gowers' Diseases of the Brain, 9 
 
 Diseases of the Spinal Cord, 9 
 
 Manual of Diseases of Nervous System, 9 
 
 Medical Ophthalmoscopy, 9 
 
 -; — Pseudo- Hypertrophic Muscular Paralysis, 9 
 
 Granville on Gout, g 
 
 ; on Nerve Vibration and Excitation, 9 
 
 Guy's Hospital F'ormula;, 2 
 
 ■ • — Reports, 2 
 
 Habershon's Diseases of the Abdomen, 9 
 
 Liver, 9 
 
 Stomach, 9 
 
 Pneumogastric Nerve, 9 
 
 Hambleton's What is Consumotion? 8 
 Hardwicke's Medical Education, 14 
 Harley on Diseases of the Liver, g 
 
 Inflammations of the Liver, 9 
 
 Harris's Dentistry, 13 
 
 Harrison's Surgical Disorders of the Urinary Organs, 13 
 
 Hartridge's Refraction of the Eye, 12 
 
 Harvey's Manuscript Lectures, 3 
 
 Heath's Injuries and Diseases of the Jaws, 10 
 
 Minor Surgery and Bandaging, 10 
 
 Operative Surgery, 10 
 
 Practical Anatomy, 3 
 
 Surgical Diagnosis, 10 
 
 Helm on Short and Long Sight, &c., 11 
 Higgens' Ophthalmic Out-patient Practice, n 
 Hillis' Leprosy in British Guiana, 13 
 Holden's Dissections, 3 
 
 Human Osteology, 3 
 
 Landmarks, 3 
 
 Holmes' (G.) Vocal Physiology and Hygiene, 12 
 Hood's (D. C.) Diseases and their Commencement, 6 
 Hood (P.) on Gout, Rheumatism, &c., 9 
 Hooper's Physician's Vade-Mecum, 8 
 Hutchinson's Clinical Surgery, ii 
 
 — — — ■ Pedigree of Disease, 11 
 
 Rare Diseases of the S'lcin, 13 
 
 Hyde's Diseases of the Skin, 13 
 
 James (P.) on Sore Throat, 12 
 
 Jessett's Cancer of the Mouth, &c., 13 
 
 Johnson's Medical Lectures and Essays, 8 
 
 Jones (C. H.) and Sieveking's Pathological Anatomy, 4 
 
 Jones' (H. McN.) Diseases of the Ear and Pharj-nx, 12 
 
 Atlas of Diseases of iMembrana Tympani, 12 
 
 Spinal Curvatures. 11 
 
 Journal of British Dental Association, 2 
 
 Mental Science, 2 
 
 King's Manual of Obstetrics, 5 
 
 Lancereaux's Atlas of Pathological Anatomy, 4 
 
 Lewis (Bevan) on the Human Brain, 4 
 
 Liebreich's Atlas of Ophthalmoscopy, 12 
 
 Liveing's Megrim, Sick Headache, &c. , 9 
 
 London Hospital Reports, 2 
 
 Li'ickes' Hospital Sisters and their Duties, 7 
 
 Macdonald's (J. D.) Examination of Water and Air, 4 
 
 Mackenzie on Diphtheria, 12 
 
 on Diseases of the Throat and Nose, 12 
 
 McLeod's Operative Surgery, 10 
 MacMunn's Spectroscope in Medicine, 8 
 Macnamara's Diseases of the Eye, 1 1 
 
 Bones and Joints, 11 
 
 Marcet's Southern and Swiss Health-Resorts, 10 
 
 IMartin's Ambulance Lectures, 10 
 
 Mayne's Medical Vocabulaiy, 14 
 
 Middlesex Hospital Reports, 2 
 
 Mitchell's Diseases of the Nervous System, 9 
 
 Moore's Family Medicine for India, 7 
 
 Health-Resorts for Tropical Invalids, 7 
 
 Manual of the Diseases of India, 7 
 
 Morris' (H.) Anatomy of the Joints, 3 
 
 jNIorton's Spina Bifida, 10 
 
 Mouat and Snell on Hospitals, 4 
 
 Nettleship's Diseases of the Eye, 12 
 
 Nunn's Cancer of the Breast, 13 
 
 Ogston's Medical Jurisprudence, 4 
 
 Ophthalmic (Royal London) Hospital Reports, 2 
 
 Ophthalmological Society's Transactions, 2 
 
 Oppert's Hospitals, Infirmaries, Dispensaries, &c., 4 
 
 Osborn on Diseases of the Testis, 13 
 
 on Hydrocele, i,; 
 
 Owen's Materia Medica, 7 
 Page's Injuries of the Spine, 11 
 Parkes' Practical Hygiene, 5 
 Pavj' on Diabetes, 10 
 
 Pavy on Food and Dietetics, 10 
 
 [Co/iii/ii/Ci/ oti the next page. 
 
Pharmaceutical Journal, 2 
 Pharmacopcfia of the London Hospital, 7 
 Phillips' Materia Medica and Therapeutics, 7 
 Pollock's Histology of the liye and Eyelids, 12 
 Porritt's Intra-Thoracic Effusion, 8 
 Purcell on Cancer, 13 
 Quinhy's Notes on Dental Practice, 12 
 Raye's Ambulance Handbook, 10 
 Reynolds' (J. J.) Diseases of Women, 5 
 
 Notes on Midwifery, 5 
 
 Richardson's Mechanical Dentistry, 12 
 Roberts' (C.) Manual of Anthropometry, 5 
 
 Detection of Colour-Blindness, 5 
 
 Roberts' (D. Lloyd) Practice of Midwifery, 5 
 Robinson (Tom) on Eczema, 14 
 
 on Syphilis, 14 
 
 Robinson (W.) on Endemic Goitre or 'Ihyreocele, 12 
 
 Ross's Aphasia, 9 
 
 Diseases of the Nervous System, 9 
 
 Handbook of ditto, 9 
 
 Routh's Infant Feeding, 7 
 
 Royal College of Surgeons Museum Catalogues, 2 
 
 Royle and Harley's Materia Medica, 7 
 
 St. Bartholomew's Hospital Catalogue, 2 
 
 St. George's Hospital Reports, ? 
 
 St. Thomas's Hospital Reports, 2 
 
 Sansom's Valvular Disease of the Heart, 8 
 
 Savage on the Female Pelvic Organs, 6 
 
 Schweigger on Squint, 12 
 
 Sewill's Dental Anatomy, 12 
 
 Sharkey's Spasm in Chronic Nerve Disease, 9 
 
 Shore's Elementary Practical Biology, 4 
 
 Sieveking's Life Assurance, 14 
 
 Simon's Public Health Reports, 4 
 
 Smith's (E.) Clinical Studies, 6 
 
 Diseases in Children, 6 
 
 Wasting Diseasesof Infants and Children, 6 
 
 Smith's (J. Greig) Abdominal Surgerj-, 6 
 
 Smith's (HenrjO Surgerj- of the Rectum, 14 
 
 Smith's (Heywood) Dysmenorrhcea, 5 
 
 Smith (Priestley) on Glaucoma, 12 
 
 Snell's Electro-.Magnet in Ophthalmic Surgery, 12 
 
 Snow's Clinical Notes on Cancer, 13 
 
 Southam's Regional Surgery, 11 
 
 Squire's Companion to the Pharmacopoeia, 7 
 
 Pharmacopoeias of London Hospitals, 7 
 
 Steavenson's Electricity, 11 
 
 Stills and Maisch's National Dispensator>', 7 
 
 Stocken's Dental Materia Medica and Therapeutics, 13 
 
 Sutton's General Pathologj', 4 
 
 Swain's Surgical Emergencies, 10 
 
 Swayne's Obstetric Aphorisms, 6 
 
 Taylor's Medical Jurisprudence, 4 
 
 I N DEX — continiicti. 
 
 Taylor's Poisons in relation to Medical Juri<prudence, 4 
 
 Teale's Dangers to Health, 5 
 
 Thin's Cancerous Affections of the .Skin, 13 
 
 Pathology and Treatment of Ringworm, 
 
 Thomas's Diseases of Women, 6 
 Thomp.son's (Sir H.) Calculous Disease, 14 
 
 Diseases of the Prostate, 14 
 
 Diseasesof the Urinary Organs, 14 
 
 Lithotomy and Lithotrity, 14 
 
 Stricture of the Urethra, 14 
 
 Suprapubic Operation, 14 
 
 .Surgery of the Urinary Organs, 14 
 
 Tumours of the Bladder, 14 
 
 Thorowgood on Asthma, 8 
 
 ■ on Materia Medica and Therapeutics, i 
 
 Thudichum's Pathology of the Urine, 14 
 Tibbits' Medical and Surgical Electricity, 10 
 
 Map of Motor Points, 10 
 
 How to use a Galvanic Batterj', 10 
 
 Electrical and Anatomical Demonstrations, 10 
 
 Tilt's Change of Life, b 
 
 Uterine Therapeutics, 6 
 
 Tirard's Prescriber's Pharmacopoeia, 7 
 Tomes' (C. S.) Dental Anatomy, 12 
 Tomes' (J. and C. .S.) Dental .Surgerj', 12 
 Tuke's Influence of the Mind upon the Body, 5 
 
 Sleep-Walking and Hypnotism, 5 
 
 Vintras on the Mineral Waters, &c., of France, 10 
 Virchow's Post-mortem Examinations, 4 
 Walsham's Surgery : its Theory and Practice, 11 
 Waring's Indian Bazaar Medicines, 7 
 
 Practical Therapeutics, 7 
 
 Warlomont's Animal Vaccination, 13 
 Warner's Guide to Medical Case-Taking, 8 
 Waters' (A. T. H.) Diseases of the Chest, 8 
 Weaver's Pulmonary Consumption, 8 
 Wells' (Spencer) Abdominal 'I'umours, 6 
 
 Ovarian and Uterine Tumours, 6 
 
 West and Duncan's Diseases of Women, 6 
 West's (S.) How to Examine the Chest, 8 
 Whittaker's Primer on the Urine, 14 
 Wilks' Diseases of the Nervous System, 8 
 Williams' (Roger) Influence ot Sex, 4 
 Wilson's (Sir E.) Anatomists' Vade-Mecum, 3 
 Wilson's (G.) Handbook of Hygiene, 5 
 
 Healthy Life and Dwellings, 5 
 
 Wilson's (W. S.) Ocean as a Health-Resort, 10 
 Wolfe's Diseases and Injuries of the Eye, 11 
 Year Book of Pharmacy, 2 
 Yeo's (G. F.) Manual of Physiologj', 4 
 Yeo's (J. B.) Contagiousness of Pulmonary Consump- 
 tion, 8 
 
 The following Catalogues issued by J. & A. Churchill will be forwarded 
 post free on application : — 
 
 A. J. i^- A. Chi/rchilPs General List of about 650 ii<orks o?i Anatomy^ 
 Physiology, Hygiene, Midn'ifery, Materia Medica, Medicine, Sicrgejy, Chemistry^ 
 Botany, ^'c, ii)C., with a complete Index to their Subjects, for easy reference. 
 N.B. — This List includes B, C, & D. 
 
 B. Selection from J. 8r A. ChiirchilVs General List, compiising all recent 
 IVoris published by them on the Art and Science of Medicine. 
 
 C. J. S^- A. ChurchilPs Catalogue of Text Books specially arranged for Students. 
 
 D. A selected and descriptive List of J. 8; A. Churchill's Works on 
 Chemistry, Materia Medica, Pharmacy, Botany, Photography, Zoolog)', the 
 Microscope, and other bratiches of Science. 
 
 E. The Half-yearly List of New Works and New Editions published by 
 J. 4- A. Churchill during the pre-uious six months, together with particulars of 
 the Periodicals issued from their House. 
 
 [Sent in January and July of each year to every Medical Practitioner in the United 
 Kingdom whose name and address can be ascertained. A large number are 
 also sent to the United vStates of America, Continental Europe, India, and the 
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 America. — J. S^ A. Churchill being in constant communication luith 
 various publishing houses in Boston, Nexv York, and Philadelphia, are 
 able, notzi'ithstanding the absence of international copyright, to conduct 
 negotiations favourable to English Authors. 
 
 LONDON: II, NEW BURLINGTON STREET. 
 
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