REVIEW XIV.

1. De cognoscendis et curandis Placenta Morbis. WILDE-Berol., 1833.

2. Handbuch der Speciellen Pathologischen Anatomie. Von CARL ROKITANSKY.— Wien, 1842.

3. Lectures on the Theory and Practice of Midwifery. By ROBERT LEE, M. D.

1844.

4. Ueber die Krankheiten des Eies und der Placenta. GIERSE und H. MECKEL. (Verhandl. der Ges. für Geburtsk.')—Berlin, 1847.

5. Abhandlungen über den Bau der Molen. Von H. MULLER.-Würzburg, 1847. 6. Ueber den Bau der Molen. METTENHEIMER. (MULLER'S Archiv,' 1850.)

7. Note sur les Altérations du Placenta. Par CHARLES ROBIN. (Archives Gen. de Méd.,' Juin, 1854.)*

(Continued from No. 27, p. 36.)

In the writings of the older obstetric authors there occur isolated reports of cases in which morbid conditions of the placenta were observed. Many of these cases are of great interest, as illustrations of the general fact of a close connexion between morbid alterations of the placenta and abortion or death of the foetus. But very few, if we except the instances of that remarkable and unmistakable condition known as the vesicular mole, are of any value as illustrations of the morbid anatomy of the organ. We have already stated our opinion, that it is owing to the want of that minute microscopical analysis of the altered structures, without which an accurate knowledge of structural alterations cannot be obtained, that the greater part of the cases recorded by the older authors must be rejected as useless in any attempt to delineate the history of the diseases of the placenta. What would it avail to discuss the pathological import of morbid appearances, the real nature of which is uncertain? They defy all attempts at interpretation. In thus excluding all those cases which are defective from imperfect investigation, or obscured by erroneous interpretation, we are not insensible to the attending advantage of greatly simplifying our task by narrowing the field of our inquiry. In passing under review the facts recorded by recent observers, we shall tread upon firmer ground; and the soundness of the conclusions we may arrive at will be more easily tested by others.

From time to time various authors have sought to collect the scattered records of individual diseases into a systematic compendium of placental pathology. Some of these evince considerable research; few bring any original additions to extend or to correct what was previously known. Besides these necessarily imperfect attempts at forming systems of placental pathology, there exist innumerable records of cases and many monographs treating of particular diseases. It is not our purpose to give a bibliography of the subject, or to enter upon a minute critical analysis of the more important contributions. But the plan we have proposed to ourselves would not be complete without passing in rapid review the names of the principal authors who have laboured to illustrate the subject before us.

One of the earliest systematic attempts was that of Schacher and Seiler, who published a treatise, entitled ' De Placenta Morbis,' in Haller's Disputations,' (vol. iv.) in 1709. This essay contains a summary of the old opinions, but not much that deserves to arrest attention at the present day. In the edition of the works of Vallisnieri published at Padua, in 1710, there is an excellent commentary upon a case of hydatidinous placenta, entitled 'Storia del Parto Vesicolare.' In the 48th epistle of Morgagni, 'On Moles and Abortions,' are several interesting cases. Stein and D'Outrepont have each contributed important cases and observations.

But the first author whose views we think it useful to notice is Murat. This writer, in a special article on the diseases of the placenta, drawn up for the 'Dictionnaire des Sciences Médicales,' gave a systematic summary of the scattered observations of previous authors. He observed that the placenta might be altered in its colour, dimensions, structure, or consistence; that it might be scirrhous, cartilaginous, or osseous; that its

*The titles of other works will be found at the head of the first part of this article.

adhesions might be too dense or too slender; that different concretions, hydatids, might be found; that its protracted retention in the womb might occasion different modes of alteration; and lastly, that rupture of the parenchymatous tissue had been observed. He especially observes, that the colour and substance of the placenta are often changed in women affected with syphilis; and that these affections seem to favour detachment. He says, further, that osseous or calcareous concretions have been found; sometimes true steatomatous concretions; and, occasionally, sanguineous concretions. Of all the diseases of the placenta, he says, that in which this organ is transformed into a vesicular mass is the most frequent. It cannot be said that the article of Murat possesses any greater merit than that of being the first attempt to epitomise the observations of other authors.

The contributions of M. Dance are of a more original character, and of greater interest that that of Murat. In his first paper* M. Dance relates two cases: the first is in an example of inflammation of the decidua; the second, of congestion of the placenta. In another papert M. Dance relates an example of inflammation of the chlorion and amnion. These cases are all valuable, as elucidating the pathology of the ovum: they will again engage our attention.

The next author is Brachet, who describes several cases of inflammation of the placenta and membranes. He sums up his observations with the general remark, that the placenta is subject to the same affections as the other organs, and that these are produced in it by the same causes. Inflammation, he says, is the most frequent. The facts he relates constitute an important accession to the subject.

Cruveilhier, appreciating fully the great importance of the subject, added largely to our knowledge by numerous valuable cases, and by many admirable reflections. He observes, that "by the placenta, morbid causes are transmitted directly to the foetus, the complex organization of which is susceptible of all the diseases observed in the adult; but the placenta itself may be subjected to the influence of some of these causes, and in some degree may arrest them; the channels for the transmission and revivification of the nutritive materials being interrupted wholly or in part, the child is born dead, or greatly enfeebled. It may be said that the diseases proper to the foetus influence its nutrition only in a moderate degree, and that the diseases of the mother exercise over this nutrition a much smaller influence than do the diseases of the placenta itself." We shall adduce evidence hereafter to show that this eminent pathologist has, in this summary, somewhat underrated the influence of the diseases of the mother upon the fœtus. He thus classifies the diseases of the placenta:

1. Hypertrophy.-This consists sometimes in a serous infiltration, analogous to that so often observed in the umbilical cord. In one case related, this condition coincided with a pseudo-membranous infiltration.

2. Atrophy, which may be either general or partial, invading particular cotyledons only. 3. Inflammation.-M. Cruveilhier cites the observations of Brachet in proof of this affection.

4. Ossification. This almost always takes place on the uterine surface. Two kinds may be distinguished: in one, there is an osseous, or rather a stony shell, one or two lines in thickness, covering uniformly, or in patches, the uterine surface, without penetrating its substance; in the other, a kind of osseous needles penetrate the placenta, and traverse it in every direction. This kind of petrification always proceeds from the uterine towards the foetal surface. The seat of the first appears to be in the fibrous membrane which invests each cotyledon (decidua); the seat of the needle-like concretions, or of the small masses forming grit, is very obviously in the arterial vessels.

5. Hydatidiform Cysts.-This is the most frequent of the alterations of the placenta. Cruveilhier has the merit of demonstrating that these cysts are not hydatids.

6. Apoplexy. This name is given to a condition in which collections of blood are found in the torn substance of the placenta.

We shall have occasion to recur to the facts and views adduced in the writings of Cruveilhier.

*Répert. Gen. de Méd., tom. iii., 1827.

† Arch. Gén. de Méd., 1829.

*

Wilde, who next attempted a methodical arrangement of the diseases of the placenta, has been frequently, but without much reason, referred to as an authority upon the subject. He divides all diseases of the placenta into three genera: dynamical, organic, and mechanical. Dynamical diseases are those which affect the vital forces of the placenta. Organic diseases are those which attack and impair the structure of the organ. Mechanical comprise injuries and solutions of the relations of the organ with adjacent parts. Under the head of dynamical diseases he ranges inflammation, suppuration, hepatization and induration, and gangrene. Under organic diseases he places hypertrophy and atrophy, designating these, diseases of evolution; as diseases of intimate cohesion, hardness and ossification, and mollities or malacia; as diseases of the proper texture, scirrhus, and the "placenta obesa;" as diseases of heterologous formation, tumours. The mechanical diseases are, faults of adhesion-viz., firm and lax; faults of position, as placenta prævia and antica; wounds; faults of original conformation, as defective, double, and membranaceous placenta. Hardly any original information, either in the way of fact or deduction, is contributed in this thesis. It may be characterized as an imperfect digest of the then current ideas about placental pathology. That Wilde's own notions concerning the diseases of the placenta could not be very accurate may be inferred from the following statement concerning the physiology of the organ:- Multi placentam distinxerunt in fetalem et uterinam, quæ tamen differentia non existit." Poverty of material is concealed under the imposing garb of the Latin tongue. As a digest of the subject, it is inferior to the article of Murat.

M. Ollivier (d'Angers) relates an interesting case of inflammation of the membranes of the ovum. In 1835, Troll published an inaugural dissertation, 'De Placenta Morbis.' It is a mere compilation.

The work of Dr. Granville supplies many valuable materials towards the pathological history of the placenta. The descriptions of this author are indeed somewhat obscured by his erroneous ideas concerning the nature of the several membranes of the ovum. Ile insists that the covering found external to the chorion in early ova, that is the decidua reflexa, is a proper tunic of the ovum, and calls it the "cortex ovi." The effect of adopting this error would be to render futile any attempt to connect the morbid conditions of this structure with the morbid states of the uterus and the mother. Fortunately, however, the morbid ova described are also depicted in the most accurate and truly beautiful drawings. We are thus enabled to judge of the exact nature of the structures affected, and of the changes they have undergone, with almost as much certainty as if the fresh specimens were placed before us. These plates exhibit various morbid appearances of the decidua, chorion, and amnion in the early ovum; sanguineous infiltration of the decidua; hydatidiform chorion; thickening and discoloration (inflammation) of the chorion and amnion. The conditions so frequently observed in ova aborted at an early period are well illustrated; but no light is thrown upon the alterations the placenta is liable to at the more advanced periods of its development.

The elaborate essay of Professor Simpson contains a most able analysis of much that was hitherto known, and its value is greatly increased by the addition of many important original observations. The scheme of the Professor was evidently intended to embrace the entire range of the morbid alterations of the placenta, but the portion published includes only congestion and inflammation. He states that these two are

"The most frequent and important diseased states to which the placenta is liable. . . The placentary parenchyma, and the membranes investing the organs, are, however, liable to other morbid states-to hypertrophy and atrophy, to softening and induration, to cartilaginous and calcareous degeneration, and the secretion or formation of other morbid products and tissues, to an anormal cystoid or hydatiform structure, and to various forms of malformation and displacement; but in a practical point of view most of these lesions are comparatively less important than congestion and inflammation, and the effects which these conditions produce."

We shall have frequent occasion to recur to this essay for illustrations of the various morbid alterations of the placenta. In the clinical lecture of Dr. Simpson, the title of

*De cognoscendis et curandis Placenta Morbis. Berol., 1833.

which is given at the head of this article, he again refers to inflammatory induration and degeneration of the placenta, and to hypertrophy.

The account that Rokitansky* gives of the pathology of the placenta is so summary as to display most clearly the obscurity of the subject. After observing that the placenta may vary as to size, shape, and position, he observes that placental hæmorrhages may occur from violence causing separation from the uterus, or lesion of the placental structure. He says that the blood may be either infiltrated in the parenchyma, or collected into foci. The placenta may be also affected with plethora and congestion. Inflammation, which he says is the most frequent of placental diseases, he describes more fully. We shall revert to this part of the Professor's description hereafter. He barely alludes to the hydatid mole; refers to bony and calcareous depositions in a few words; denies the existence of tuberculosis of the placenta; exposes the misapplication of the term scirrhosis; and says that adhesions of the placenta to the foetus have been observed. For minuteness and definition, the account given of the morbid alterations of the placenta, by this great pathologist, is in striking contrast with the luminous precision with which he has discussed the morbid alterations of other organs.

Dr. Leef has, from the stores of that ample experience which has illustrated so many difficult obstetric problems, contributed many facts of interest in placental pathology. He questions the frequency of inflammation. He says that hypertrophy or atrophy, and apoplexy, are amongst the most frequent diseases. He relates in detail the histories of thirteen cases in which the placenta was found diseased. These cases are mostly striking examples of the relation frequently existing between disease of the placenta and abortion. In some instances, although no microscopic characters are given, the general description of the morbid appearances is perhaps sufficiently clear to indicate the pathological nature of the change. But upon the hazardous ground of conjectural interpretation, we have already declared our resolution not to tread.

The subject-matter of the contributions of Gierse and Meckel, H. Müller, Mettenheimer, Schroeder van der Kolk, Virchow, of those of the reviewer, and the consequent researches of Dr. Handfield Jones, Dr. Druitt, M. Ch. Robin, and Dr. Cowan, will be more conveniently discussed hereafter.

Having thus rapidly surveyed the principal writings which contain the most authentic and systematic information on the subject, we will now apply ourselves to the task of including in a methodical survey all that may be considered available and trustworthy in the construction of a comprehensive placental nosology, such as may serve to define the boundaries of our actual knowledge, and be suggestive of further advances. We have already pointed out the leading principle in such an investigation, which appears to us the most promising in useful results. 1. There are morbid conditions of the placenta which may originate in its own structure. 2. There are morbid conditions of the placenta resulting from the state of the blood of the mother brought into it, or from contact with diseased uterine structures. 3. There are morbid conditions secondary to disease, or defective developmental force in the embryo. In adopting this plan, we will not disguise the difficulties that must attend the attempt to adhere to it rigidly. It will often be difficult, if not impossible, to determine whether a particular lesion owes its origin to one or more of the sources referred to. But difficulties, perhaps not less grave, would attend any other plan. Some classification is essential; and we are sure we shall meet with indulgence, if we select that which seems to us to present the greatest facilities for developing our views upon so extensive and intricate a subject. We shall not hesitate to diverge, as occasion may require, from a scheme which is adopted only on account of its general convenience.

The lesions that may with the least doubt be ranged under the first division of strictly local affections are, mechanical injuries, such as rupture of the placental tissues, congestion, extravasation of blood (by some authors called apoplexy and aneurism), inflammation, hydatidiform degeneration of the chorion. Fatty degeneration is sometimes primary in the placenta, but perhaps more frequently of secondary origin. To what extent hypertrophy or atrophy are primary is doubtful. Calcareous and osseous deposits

Handbuch der Speciellen Pathol. Anatom., 1842.

† Lectures on the Theory and Practice of Midwifery, 1844.

are most frequently connected with constitutional conditions of the mother, and their seat is commonly in the maternal structures.

Under the second or maternal division may be included all those conditions which may be clearly traced to abnormal states of the mother's blood. Inflammation probably arises from some such condition. We shall adduce evidence to show that one form of hypertrophy, at least, arises from disease of the mother's blood. Atrophy we believe to be more commonly dependent upon foetal conditions. One form of fatty degeneration, that commencing in the decidual element, belongs especially to this division. That form of this affection which begins in the foetal element, the chorion, may also, sometimes at least, be traced to a maternal cause. Calcareous and osseous deposits are almost invariably so associated. The source of fibrinous deposits may be either the maternal or the foetal blood. The same may be said of serous or dropsical effusions.

The third or foetal division will comprise atrophy; many cases of fatty degeneration of the chorion; some deposits of fibrinous masses; serous effusions; some forms of sanguineous congestion, and of extravasation.

I. We put aside all consideration of the mechanical lesions of the placenta, such as laceration of its structure, as scarcely coming within the definition of disease. The first morbid condition we propose to consider is that which presents the leaat divergence from the healthy state, namely, congestion. Inasmuch as there are portions of two distinct circulating systems in the placenta, there must also be two distinct forms of placental congestion. The maternal placenta may be congested. The foetal placenta may be congested. Strictly speaking, in the great majority of instances, each of these forms is connected with some abnormal condition of the circulatory apparatus, or of the blood, of the mother or of the foetus. But either form, in a mixed form in which both the maternal and foetal placentas are congested, may, under some circumstances, depend upon simply local causes. In the case of a placenta of an advanced period, it must often be difficult to determine whether the maternal or foetal congestion predominate. In early ova, in which the apposition of the two portions of the placenta is incomplete, the vascular condition of each admits of being more easily distinguished. We believe it may be generally stated that maternal congestion is more frequent in early ova; and that foetal congestion, or the mixed form, is more frequent in older ova. Foetal congestion, in its simplest form, may be observed in cases of delivery at the full term, in which the child is born alive, the cord having been tied on the placental as well as on the foetal side of the point of division by the scissors. In such a case, the vessels of the cords are seen to be greatly distended, presenting the appearance of varicose enlargements. Tracing the vessels back, a similar appearance is seen on the foetal surface of the placenta. The whole mass of the organ is firm, rounded, of a dark purple colour, and gorged with blood. The vessels in the villi, if examined under the microscope, are seen to be crammed with blood-corpuscles, and enlarged in their dimensions from distension.

The illustration given by Professor Simpson marks a second and more advanced degree of congestion. He refers to the condition of the placenta in cases in which the heart of the child has happened to be long impacted in the passages of the pelvis.

"The appearance which the placenta exhibits on its being expelled after such cases, the more particularly if the impaction has been so great as to prove fatal to the child, are well known to every practical accoucheur. The external surface of the organ is of a more or less deep violet, and sometimes almost livid colour; its internal structure, when torn or divided by the scalpel, presents a deep purple hue; its vessels are everywhere distended with darkcoloured blood; the organ appears enlarged, and its substance feels heavier and more solid than natural."

Rokitansky gives a precisely similar description of the appearance of congestion of the placenta. We witness the counterpart of congestion of the placenta in the intensely livid hue and swelling of the face of the child, arising from stagnation of the blood from long-continued pressure. The cases cited are examples of fatal or chorial congestion. If we bring to our aid the physiological homology of the placenta, and the air-breathing lung, we shall have no difficulty in understanding how the placenta may be exposed to congestion, inflammation, and effusions from analogous causes to those which induce

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