In already stated, they are by no means uniformly vesicular in shape, but pyriform, clavate, fusiform bodies, the narrow part connecting them, like a stalk, with the end or side of the villus; or sometimes the extremity of a villus appears enlarged, and divided into a number of lobes, no contraction of a part resembling a stalk being observed. perhaps the earliest ovum we have had an opportunity of examining in the fresh stateone probably not four weeks old-the termination of every villus exhibited a simple or compound lobular appearance, or distinct projections; some villi had similar processes from their sides. At a later stage of growth, instead of the clavate or fusiform processes, there are seen cylinders of greater or less length, but still bearing a resemblance to the I primitive shape in their somewhat dilated extremities: these are young villi. upon these, again, secondary processes or buds may be observed. Inasmuch as the rapid growth of the foetus, towards the term of gestation, is ever calling for an increased expansion of placenta, it may be presumed that fresh villi are constantly growing. These buds are accordingly seen on the villi of placentas approaching maturity: but they are far less frequent in early ova. Now, it appears that under the influence of a perverted developmental force, these buds, instead of growing into villi, may dilate into true vesicles, or hydatidiform cysts. Such a perversion of growth necessarily involves the destruction of the placenta as a respiratory organ, and the consequent death of the embryo. Those who have examined a great number of ova of different epochs, and who have registered what they have seen, will have become familiar with various appearances which can neither be distinctly referred to healthy villi, nor to hydatidiform degeneration. They will have observed bodies attached to villi which, although evidently of the same origin as the ordinary budding villi, were yet so different in some of their characters as clearly to have failed as villi, and which, nevertheless, were not recognised as hydatidiform cysts. The following case is an example of this kind:-A woman, who thought herself ten weeks pregnant, aborted suddenly. The decidua and chorion were undoubtedly of an earlier date than ten weeks; it was judged from the appearance of these structures that the embryo had perished four or five weeks before the expulsion of the ovum; the decidua had retained some connexion with the uterus to the last. Viewed with the naked eye, the villi of the chorion were dull yellowish white; they did not float out freely; they presented numerous nodular enlargements on the sides and extremities. With an inch glass the enlargements were seen more clearly they were then seen to be pear-shaped bodies, springing from the sides and ends of the villi by very narrow pedicles, altogether resem bling hydatids which have shrunk from being kept a day or two. With a quarter-inch these enlargements were found to contain granular fat, they were opaque, some quite dark. No embryo was discovered. These bodies did not possess the characters of healthy villi, and the great disproportion between their slender stalks and the diameter of the bodies themselves, as well as of the villi to which they were attached, precluded the idea that they could ever assume the function of villi. We will not, however, do more than express a conjecture that these bodies were in course of degeneration into hydatidiform cysts. In addition to the peculiar appearance of these bodies, the villi generally were affected with fatty degeneration. This change may possibly have been the first morbid process, and the cause of the destruction of the embryo, and of the abortion. It is one of those numerous cases which mark the imperfection of our knowledge of the pathology of the ovum. The appearances observed may, however, justify a suspicion that, if these hydatid-like bodies were not really budding villi in the incipient stage of cystic degeneration, they were examples of some other hitherto unrecognised form of degeneration. But, quitting this doubtfully intermediate state, let us pass on to the clearer forms of cystic degeneration of the chorion. A very clear account of this affection has been given by Mettenheimer. This very careful observer objects to the comparison made by Cruveilhier of hydatid placenta to a bunch of grapes. He thus draws the distinction: "Whilst in the grape-bunch there is a central trunk and branches, the latter giving off twigs, each of which bears its berries, in the hydatid chorion the central trunk is wanting, the * Müller's Archiv, 1850. centre of the whole vegetation being a bladder (the chorion) on whose walls a new generation of cysts is formed, each one of which has in like manner the property of developing one or many daughter-cysts. Berry grows out of berry, and the stalks do not unite berries with principal stems, but berries with berries, and lastly with a central mother-cyst." We may here observe, that Madame Boivin* gives a very correct drawing of the com-. mon aspect of the hydatid placenta, exhibiting the manner in which the cysts are connected with each other. In this drawing it is seen that the cysts are not attached individually by stalks to a central stem, but that, in many instances, series of cysts are connected together, as it were, by one string, one cyst supporting a second, and this in its turn a third, and so on. Mr. Paget, also basing his views upon the observations of Mettenheimer, regards the hydatidiform placenta as an example of cystic development. He says: "A part, or even the whole of the chorion is covered with pellucid vesicles, with limpid contents, borne on long, slender, and often, branching pedicles. The cysts are usually oval or pyriform; their walls are clear, or have minute opaque dots; they may be either simple, or may bear others projecting from their walls. . . . . Dr. Mettenheimer has found that the minute dots besetting these cysts are 'villous processes,' exactly resembling those of the natural chorion, and growing from the walls of the cysts, either outwardly or into their cavities. In these villi he traced the development of cysts. In their natural state, they may be described as filiform or clavate projections, and composed of dimly-granular substance, in which are embedded minute nucleated cells. In this cystic disease, vesicular bodies may be seen scattered among the cells in the villi, which bodies are distinguished from the cells by their pellucidity, their larger size, and double contours; but from the cells to these every gradation may be traced, so as to leave scarcely a doubt that the vesicles are derived from cells deviating from their normal characters. . . . The whole process may, therefore, be probably thus described: Certain of the cells in the proper villi of the chorion, deviating from their cellform, and increasing disproportionately in size, form cysts which remain connected by the gradually elongated and hypertrophied tissue of the villi. On the outer surface of the newformed cysts, each of which would, as it were, repeat the chorion, and surpass its powers, a new vegetation of villi sprouts out of the same structure as the proper villi of the chorion. In these begins again a similar development of cysts; and so on, ad infinitum. Each cyst, as it enlarges, seems to lead to the wasting of the cells around it; and then, moving away from the villus in which it was formed, it draws out the base of the villus, which strengthens itself, and forms the pedicle on which the cyst remains suspended." To this account we think it interesting to add Mettenheimer's appeal to the admirable researches of Dr. Hodgkin, for the purpose of drawing more especial attention to the relation subsisting between the cystic disease of chorion and abnormal cystic development in other structures of the body: "Hodgkin distinguishes two kinds of cystoid formation: in the first, the young cysts stand out upon the walls of the old ones, without any tendency to grow inwards or to become stalked; in the second, the secondary cysts grow inwards, as pear-shaped stalked growths, from the inner wall of the mother cyst, developing again new progeny; and so forth. In the bladder-moles, it appears, from my researches, that there is a third kind, which exhibits the reverse of the second of Hodgkin. In this kind, the secondary cysts grow in villus-form, from the outer surface of the cysts." It is not consistent with the plan of this article to dwell much upon the bearings of the diseased conditions of the placenta upon obstetric practice; but the following observations will not be out of place: Dr. F. H. Ramsbotham, in considering the subject of adherent placenta after delivery, says, "At other times again, but very rarely, the remaining portions of placenta (after removing part by hand, etc.) become the nucleus for hydatinous formations, and more rarely still, I believe, they are actually absorbed." The question thus raised is one of great interest. But we are not aware that any unequivocal case exists, upon which the inference that a portion of placenta left in the uterus, the portion extracted at the time of labour being free from cystic degeneration, has subsequently become the seat of * Nouvelles Recherches sur la Mole Vésiculaire. cystic disease, can be firmly based. It does not seem very probable that this disease ever begins at a late period of gestation. It seems essentially an affection of the young chorion. Beginning thus early, one of the first and surest effects is to destroy the embryo while this is still very small in size. It is consequently found, in the great majority of instances, that when this disease exists no trace of an embryo can be found, or if found, that it is exceedingly minute. Is there a case recorded in which the placenta was found affected with hydatidiform degeneration, even partial, at the normal term of gestation, and concurrently with the birth of a fully developed living child? We put our doubt in the interrogative form because, although we consider it at variance with the known course and history of the disease under consideration that such a case should occur, we are not willing to hazard an absolute denial. But assuming it to be in the highest degree improbable that the chorion of the placenta approaching maturity should become the seat of cystic degeneration, how much more improbable is it that a portion of mature placenta, remaining attached to the uterus after delivery, should then take on a new cystic life of this kind? What is the condition of a fragment of retained adherent placenta? The foetal vessels with the villi of the chorion are torn across, and the foetal portion of the placenta-that portion which is the seat of cystic disease-may fairly be said to be organically destroyed. The only portion of the placenta which preserves life is the maternal portion, the decidual or uterine element; and this is not susceptible of cystic degeneration. Whether the difficulties we have raised be valid or not, it must at any rate be admitted that the doctrine enunciated by Dr. Ramsbotham requires to be substantiated by facts rigorously analysed. The interest of the question at issue will appear from this: If it be true that a portion of retained mature placenta may, subsequently to delivery, undergo hydatidiform growth, then one conception will account both for the product of the delivery in the usual course at which a child was born, and a portion of placenta brought away, and for a subsequent delivery at a remote period from the first, at which a hydatid mole was expelled. If it be not true that a portion of placenta so retained can undergo this change, then it follows that, in any case in which a hydatid mole may be expelled after an interval more or less remote from an ordinary labour, a fresh conception has occurred. The medico-legal bearings of the case are then of the greatest importance. er. One other observation we take the opportunity of adding. It is clear from the account we have given of the histology of the cystic disease of the placenta, that Mettenheimer and others regard it as a disease of the chorion, originating in an abnormal development of the cells observed in the villi. This is equally clear from the figures given by MettenheimBut these cells are regarded by Goodsir, and those who follow him, as decidual or maternal. It would thence follow, that the cystic disease of the placenta is not an affection of the foetal element, but in reality one of maternal origin. We are not aware that any pathologist has advocated this view. It therefore appears to us that we possess, in the history of the cystic disease of the placenta, a conformation of that view which regards the cells of the chorion as an integral part of the foetal portion of the pla centa. Although it is in the highest degree probable that fatty degeneration of villi of the chorion may take place as a primitive condition, we defer the minute consideration of this affection until we take up the diseases of the placenta that may be traced to the mother or embryo. We will simply observe in this place that, according to our observations, a considerable amount of fatty degeneration of the chorion is commonly found concur rently with the hydatiginous degeneration. Case X., recorded in the reviewer's second paper in the Medico-Chirurgical Transactions,' is an instructive example of this kind. In most cases it is probably secondary upon the physiological destruction of the villi produced by the hydatiginous change. But independently of any hydatiginous affection, and independently of any morbid influence transmitted from the mother, or of failure of the developmental force in the foetus, it seems not an unreasonable conjecture, that in like manner as by an abnormal excess of cystic developmental force the villi may pass into hydatiginous degeneration, so by an opposite defective developmental power the cellular chorion may pass into atrophy, and fatty degeneration may follow. PART SECOND. Bibliographical Record. ART. I.-1. A System of Instruction in Quantitative Chemical Analysis. By Dr. C. R. FRESENIUS. Second Edition. Edited by J. LLOYD BULLOCK, F.C.S.-London, 1854. 2. A Course of Practical Chemistry, arranged for the Use of Medical Students. By WILLIAM ODLING, M.B., F.C.S., Professor of Practical Chemistry and of Natural History at Guy's Hospital.-London, 1854. 3. Anleitung zur Qualitativen und Quantitativen Zoochemischen Analyse. Von E. VON GORUP-BESANEZ. Zweite Auflage.-Nurnberg, 1854. Guide to Qualitative and Quantitative Zoo-chemical Analysis. 4. Anleitung zur Qualitativen und Quantitativen Analyse des Harns. NEUBAUER.-Wiesbaden, 1854. Guide to the Qualitative and Quantitative Analysis of the Urine. VON CARL THESE four works on chemistry are adapted to special ends, and are therefore very different in scope and execution. The masterly work of Fresenius, it is scarcely necessary to say, treats of the whole subject of quantitative chemistry in the broadest way. It is not necessary to do more than announce the appearance of the second edition, which has evidently been most carefully proposed by Mr. Bullock. The little work by Dr. Odling is one of more modest pretensions, though in its way of not less use. The preface informs us that it contains an outline of the course of practical chemistry as annually carried out in Guy's Hospital. Inorganic, toxicological, and animal chemistry are discussed in as many sections. We are rather surprised to find under the last head no notice taken of the new modes of analysing urine, by using known quantities of test solutions; and although Dr. Odling may consider that this did not enter into his plan, it would have been a useful addition. Gorup-Besanez has attempted to do for medical what Fresenius has done for general chemistry. He has given a comprehensive account of the modes of determining the presence and the quantity of the various constituents of the body, and has had especial reference to the wants of the physician. He has also given a very excellent short account of the various animal principles. The author of the last work, Dr. Neubauer, is assistant to Fresenius, and, under the direction of that able chemist, has compiled a very perfect code of instructions for determining, according to the most approved and recent methods, the amount of the urinary constituents. We do not observe anything novel in the work. The method of Liebig is employed for urea, although all other accurate plans are also given. Liebig's plan for chloride of sodium, Breed's for phosphoric acid, &c., are all carefully detailed. Three plates of urinary sediments are added, from Funke's Atlas. By CHARLES WEST, ART. II.-Lectures on the Diseases of Infancy and Childhood. 1854. years, it WHEN two editions of a medical book on a special subject are exhausted in six is a sure sign that that book has supplied a want, and has supplied it well. In the present edition of his well-known lectures, Dr. West has taken every pains to support the reputation they have already acquired. Many alterations are made in the text, and in foot-notes, and the bulk of the volume has been increased by sixty pages. A larger number of cases, too, has been brought to bear on every doubtful point, and the latest authors on every subject are carefully referred to. It is almost superfluous to say, that this work should be in the library of every one engaged in the treatment of the diseases of children. ART. III-A Practical Treatise on the Diseases of the Eye. By WILLIAM MACKENZIE, M.D. Fourth Edition.-London, 1854. THE fourth edition of this standard work will no doubt be as fully appreciated as the three former editions. It is unnecessary to say a word in its praise, for the verdict has already been passed upon it by the most competent judges, and Mackenzie on the Eye' has justly obtained a reputation, which it is no figure of speech to call world-wide. ART. IV.—On the Topical Medication of the Larynx in certain Diseases of the Respiratory and Vocal Organs. By EBEN. WATSON, M.D., Lecturer on the Institutes of Medicine in the Andersonian University, &c.—London, 1854. TOPICAL medication to the interior of the larynx, by means of a sponge, was used by Sir Charles Bell, and afterwards by Trousseau and Belloc, but was first brought prominently forward by Dr. Horace Green, and we may add also, by the author of the work before us, for he was one of the first in this country to put Dr. Green's statements to the test, and he has written several valuable papers on the subject. Much discussion has taken place as to whether Dr. Horace Green succeeded in really introducing the sponge into the larynx. Dr. Watson tries to prove that the entrance into the larynx can be readily accomplished, and he does most certainly show that bodies larger than the sponge have accidently passed into the trachea, that the dimensions of the larynx in the dead body are such as to admit the sponge, and that in the dead body the passage can be accomplished. But we do not see that he has been more fortunate than others in adducing absolute proof that the larynx has been entered during life; and, although we do not deny that this can be sometimes done, we are very certain that it is an operation of great difficulty, and that in the great majority of cases, the operator has simply passed the sponge down the pharynx and oesophagus. In his remarks on this point, Dr. Watson appears to us to have been really unwarrantably uncivil to Mr. Erichsen, who, in his late work on 'Surgery,' has expressed doubts of the possibility of the operation. Whether or not the sponge enters the larynx, the fact remains that the application of caustic to the upper part of the throat, to the epiglottis, and it may be to the interior of the larynx, is of the greatest service in many troublesome and serious diseases. Dr. Watson prefers the nitrate of silver, but he has used also the hyposulphite of soda and silver, and has found it sometimes useful. The strength of the nitrate of silver varies from ten to sixty grains in an ounce of water. In acute cases Dr. Watson's experience is thus summed up:— "In acute laryngitis in which there is no false membrane, the local application of solution of caustic, varying in strength inversely in proportion to the intensity of the inflammation, may be employed with more or less speedy benefit. "During the exudative stage of true croup, the stimulant application to the part affected is injurious, but when the disease begins to yield to antiphlogistic and other treatment, it may assist in the cure. "There is reason to believe that, in many cases of croup, there is an active inflammatory stage prior to exudation, in which the disease may be checked by topical and other means, appropriate to such cases. "Edema glottidis, whether occurring as a primary disease, or as a complication of other morbid states, is always speedily relieved, and in some cases effectually cured, by the application of strong solutions of the nitrate of silver to the œdematous organ." In chronic laryngitis and aphonia, the use of the caustic is illustrated by some very interesting cases, but the utility of the remedy is so thorougly admitted in similar cases, that it would be useless to delay on the point. |