Prize Essay on the Corpus Luteum (1851) 2
Part 2 Corpus Luteum of Pregnancy
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Dalton JC. Prize essay on the corpus luteum of menstruation and pregnancy. (1851) Philadelphia: T.K. and P.G. Collins.
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| Corpus Luteum 1851: Part 1 - Corpus Luteum of Menstruation | Part 2 - Corpus Luteum of Pregnancy | Part 3 - Observations on Animals | Plates |
Observation XII
Corpus luteum of pregnancy about the end of the second month.
R. D. L., a married woman, twenty-nine years of age, died in Boston on the 28th of April, 1851, under the following circumstances. She sat down to the tea-table with her family, in perfect health, on the evening of Friday the 25th. While they were at tea, a notorious quack, a Thompsonian, who had already been at the house in the early part of the afternoon, returned ; and Mrs. L. left the table, and went up stairs to her chamber in company With him. She was known to have previously resorted to this man for the purpose of procuring abortion.
After remaining for some time in the chamber with Mrs. L., the Thompsonian left the house, but Mrs. L. kept her bed, and, in fact, never left it from that time till her death, which took place on the Monday following. On Saturday she was quite ill, and on Sunday so much worse that her friends insisted on discharging the Thompsonian and calling in other advice. Dr. M. S. Perry was accordingly sent for. On arriving, he found Mrs. L. exceedingly collapsed, and presenting marked signs of peritonitis. There was so much disturbance of the intellectual faculties that the patient was unable to give any account of herself ; but her appearance and symptoms were so characteristic that Dr. P. at once concluded that abortion had been produced. He sent for Dr. C. E. Buckingham, who in the evening visited the patient with him, and concurred entirely in his diagnosis. There was no reaction of the system at any time after Dr. P. was first called, and the patient died on Monday about 11 A. M.
The friends of the woman were convinced that abortion had been produced; and there were various other suspicious circumstances, besides those above related, which were testified to at the inquest. Owing to the absence of her husband, there were reasons why Mrs. L. should wish to have the fact of her pregnancy concealed. The verdict of the coroner's jury was that she came to her death in consequence of an abortion produced by the above-mentioned Thompsonian.
At the autopsy, which was performed on the day succeeding death, the body generally presented an appearance of perfect development and full health. There were no marks of disease except such as were quite recent. These consisted in a moderate peritoneal effusion, and in some inflammation of the mucous membrane of the stomach, oesophagus, and larynx, rendering it probable that the patient had swallowed some irritating drug, a portion of which had found its way into the air-passages.
The uterus was much enlarged. It measured four and a half inches in length, two and three-quarters in width, and one and threequarters in its antero-posterior diameter. Its increased thickness was caused by the bulging of its posterior face, which had a nearly globular form, while the anterior face was hardly more rounded than in the natural condition. There was some bright vascularity about the posterior face and fundus of the uterus, but not of an inflammatory appearance. The Fallopian tubes were also very vascular.
On cutting into the uterus from behind, its cavity was found to be entirely occupied by the reddened and hypertrophied mucous membrane, and a fibrinous-looking granular substance entangled with it. The walls of the uterus were of their natural colour and consistency, so far as regarded their muscular substance, but the mucous membrane was exceedingly hypertrophied and reddened, presenting all the appearances met with in the ordinary formation of decidua, in connection with menstruation, but in an infinitely greater degree. The decidua was continuous with the muscular substance, and could not be very readily separated from it ; though the line of division between the two was very well marked, owing to their difi"erence in colour; the latter being pale, the former dark red. The decidua was composed of a multitude of fine softish fibres, easily seen by the naked eye, which lay in a parallel position, and projected into the cavity of the uterus ; hanging from its internal surface like the hair from a bear skin. On the posterior wall and a little to the right side, the decidua was much thicker than elsewhere, and was here continued into a moderately firm, stringy, fibrinous-looking mass, which enclosed a multitude of minute granules. This mass hung down freely into tlie cavity of the cervix, and before opening the uterus, miglit be made to protrude from the os externum by compressing the uterus in the hand. Its lower extremity "was soft, sloughy, and grayish ; but its upper part still firm, red, and freshlooking.
Fig. 9. Villi of the chorion.
Examined by the microscope, it was evidently composed of the villi of the chorion, a part of which had remained, after the expulsion of the ovum, still entangled with the mucous membrane of the uterus. The villi presented somewhat the appearance of membranous tubes, of various sizes, terminating by a single or double cul-de-sac, and some- . times having lateral dilatations or processes. With high powers, an appearance was seen as if the villi contained minute cells, or as if the tubes were lined with a delicate epithelium.
There was no blood in the uterine cavity, except at one spot on its posterior aspect, near the fundus, where there was a roundish cavity about the size of a pea, in the substance of the chorion and decidua, which was filled with very dark, but fresh-looking blood.
There was nowhere in the uterus any appearance of a defined placental attachment.
The right ovary, an inch and a quarter in length, was yellowish white externally, with several slender, old adhesions to its surface. It contained no corpora lutea, with the exception of a single yellow 'point, too small to show any definite structure. There were a number of Graafian vesicles beneath the albugineous tunic, varying in size from one-eighth of an inch diameter downward; but none projecting on the surface of the ovary, or at all visible from the outside.
The left ovary, considerably thicker than the right, showed on its posterior surface a slightly depressed spot, over which was attached a long, slender, organized, bridle-shaped adhesion, and in the neighbourhood of which a yellow colour showed through from beneath the fibrous coat. On makinjr a lonffitudinal section through the depressed spot, a corpus luteum was exposed, measuring seven- eighths of an inch in length by one-half an inch in depth. It consisted of a light-yellow, thin, convoluted external layer, and an enclosed, colourless, firm, fibrinous mass, with a central cavity containing a few drops of limpid fluid. The relations of the central coagulum, the yellow wall, and the investing membrane were the same as in all the corpora lutea previously observed. (See Plate II. Fig. 2.)
This ovary contained another corpus luteum, situated directly beneath the albugineous tunic, three-eighths of an inch long, but very narrow, and much compressed, the yellow matter very thin and friable, and incapable of being separated whole from the ovarian tissue. The walls of this corpus luteum were nearly in contact, and its contents colourless.
There was also another yellow spot, much smaller than the last, and very indistinct in structure, but which, apparently, was also an old corpus luteum of menstruation.
The left ovary contained but few Graafian vesicles which were visible, and those of very small size.
Both oviducts contained an abundance of thick, opake, yellowish fluid, consisting mostly of ciliated columnar epithelium.
The period of pregnancy in this case was estimated, first, from the size of the uterus; and, secondly, from the fact that the placenta had as yet assumed no regular shape, while, at the same time, its future situation was sufficiently well marked by an unusual development of the villi of the chorion at one spot, and their adhesion to the uterine surface. It will at once be observed, on comparing the corpus luteum in this case, with that of Obs. X (Pi. I. Fig. 5), how great is the diff"erence between them. The latter, of only four weeks' date, is already considerably advanced in the process of atrophy; while the former, nearly or quite twice as old, has still retained all its activity, and is, indeed, increasing in size, notwithstanding that sufficient time has elapsed for the colouring matter of the coagulum to be completely absorbed. The difi"erence will be still more striking if we compare it with PI. II. Fig. 1, in which the corpus luteum is of nearly the same date with the present.
Observation XIII
Corpus luteum of pregnancy about the termination of the fourth month.
E. S., a fine, healthy-looking girl, twenty-one years of age, died at the house of Mr. A., in Boston, on Wednesday the 7th May, 1851. She had been employed in Mr. A.'s family as a seamstress since the previous winter, living in the house during the week, but going away on Saturdays to her cousin's in Pleasant Street, and returning to Mr. A.'s on Monday morning. She had been for some months receiving the attentions of a young man who was reputed to be engaged to her. None of her friends suspected anything to be wrong "with her until Monday evening, May 5th, when her cousin, with whom she had been spending Sunday as usual, perceived the odour of tansy in the room which she had occupied; whereupon it occurred to her that the girl might have become pregnant, and used the drug for the purpose of producing abortion.
On Tuesday she was in good spirits, and engaged in her ordinary employment throughout the day. She took leave of the family as usual, and went up stairs to her room about half past nine o'clock, P. M. Soon afterward, the family were alarmed by a scream, and on going up stairs, found the girl stretched on the floor by the side of her bed, insensible, and in violent convulsions. Dr. Samuel Morrill was immediately called, and I also saw her soon after. There Avas a strong odour of tansy in her breath, and, on searching the room, a two ounce phial was found in the pocket of one of the girl's dresses, still containing 5v of the oil of tansy. The mug from which she had drunk the oil was also found, with several drops remaining on the bottom. It was subsequently ascertained that she had purchased the phial full of oil of tansy a few days previously. She remained totally insensible, with violent convulsions at short intervals, till a quarter past 2, A.M., when she died.
At the autopsy, made May 7th, ten hours after death, there were found some marks of congestion of the brain. The stomach and upper part of the small intestine contained an abundance of oil of tansy. On first opening the body, the odour of tansy was powerfully exhaled from the cavity of the peritoneum, from the interior of the heart, and from the cut surface of the pectoral muscles.
The uterus was enlarged so that its upper edge was two inches and three-quarters above the level of the symphysis pubis. It was also slightly inclined to tlie left, and lay in a somewhat diagonal position, so that its left edge was considerably nearer the abdominal parietes than the right. Its external surface was generally yellowish-gray, mottled, in some situations, with large bundles of red vessels, but without any inflammatory appearance. The vascularity of the oviducts was also quite moderate.
The uterus, unopened, weighed one pound. Its length, including the neck, was six inches and a quarter. Length of neck, measured internally, was one inch and three-eighths. Breadth of uterus, four inches and one-eighth. The amnion and chorion were in contact. The placenta was perfectly formed, circular in shape, three inches in diameter. The cord was five inches long, very slightly twisted from left to right. It was well covered with gelatinous matter.
The umbilical vesicle still existed as a delicate, flattened, pellucid sac, three-sixteenths of an inch in diameter, situated beneath the amnion, on the internal surface of the placenta, at a distance of three-quarters of an inch from the insertion of the cord. In its centre there was a yellowish, granular, opake spot. A single fine red vessel ran from the insertion of the cord to the vesicle, and then branched over it in minute ramifications.
The foetus, a female, was nearly six inches in length. Its surface was smooth, without sebaceous covering or hair. Skin transparent, and everywhere marked by an elegant vascular network. It showed also very distinctly the numerous hair follicles as minute, opake, white specks. The muscles were contracted, and the limbs rigid. Umbilicus situated a little above pubis. Middle point of body situated nearly midway between umbilicus and lower end of sternum. Head voluminous. Mouth widely open. Tongue well formed. Eyelids in contact ; not to be separated without forcibly tearing epidermis. Pupils widely dilated. Nostrils open. Pupillary membrane complete. Fingers and toes completely formed, and nails distinctly visible.
External genital organs distinct. Clitoris projecting far beyond nymphte.
The liver came down nearly as low as pubis. The kidneys and STipra-renal capsules were equal in size : kidneys pale and lobulatcd ; capsules dark red.
The large intestine was destitute of either transverse or longitudinal bands.
Ossification of the ribs was sufficiently well advanced. Considerable ossification of ilium; none of ischium or pubis; none of calcaneum ; none of ossicula auditus.
The foetus was, therefore, estimated to be about four months old.
The left ovary, which hung doAvn a little lower than the right, had, on its outer extremity, a small conical prominence, where the fibrous coat was wanting, and its place supplied by peritoneum alone. There was a slight appearance here of a cicatrix, visible only on close inspection. No unusual vascularity here or at any other part of the ovary. Beneath this prominence, the corpus luteum could be felt through the ovarian tissue tolerably firm and well defined, and having the form of a sphere, compressed laterally, much like that of the crystalline lens. On dividing the ovary longitudinally through the prominence, the corpus luteum presented a nearly circular section, seven-eighths of an inch in its long, and three-fourths of an inch in its short, diameter. (Plate II. Fig. 3.) The convoluted wall was of a dull yellow, considerably less brilliant than in the preceding case, and decidedly thicker, as it measured, at its deepest part, a little over three-sixteenths of an inch in thickness. The space enclosed by the yellow wall was occupied by a fibrinous, colourless, reticulated coagulum, which possessed a few minute vessels. This central coagulum was much compressed laterally ; for, though it presented a cut surface of about half an inch in diameter, it had hardly more than one line in thickness. There was no cavity nor fluid anywhere.
Both ovaries were carefully divided in every direction, but only one other body was found bearing any resemblance to a corpus luteum, and that was so small and imperfect as to be hardly recognizable. There were many Graafian vesicles in the interior of each ovary, varying in diameter from three-sixteenths of an inch downward, but none at all prominent on the surface. Both ovaries were quite healthy.
On comparing this case with that detailed in Obs. XII., it will be seen that the corpus luteum has increased in development. The convoluted wall has become thicker, and has begun to lose its brilliant tinge; the fibrinous coagulum has become more compressed and absorbed, and the central cavity, if any had existed, is completely obliterated. At the same time, it is interesting to observe that the old corpora lutea of menstruation, of which three existed in the preceding case, have now been reduced to one. They have, in fact, successively disappeared, while the corpus luteum last formed has continued its development under the influence of pregnancy.
Observation XIV
Death at the termination of the seventh month of pregnancy — One ovary destroyed by disease, the other containing tvro corpora lutea — A blighted ovum in the corresponding oviduct, and a seven months' foetus in the uterus.
M. M., a married woman, thirty-two years of age, stout and fullblooded, died suddenly at Lowell, on Tuesday, December 17th, 1850. She was the mother of four children, the youngest of whom was two years and a half old. At the time of her death, she considered herself to be seven months advanced in pregnancy, expecting to be confined in the middle of February, 1851.
Her husband, who performed duty as a night-watchman, left his wife on Monday, the 16th, at 11 P. M., apparently in perfect health. She had then retired to bed, but talked to him, just before he left, in her ordinary cheerful manner. He passed his watch, and returned home next morning at 5 A. M., and, on going up to his wife's chamber, found her lying on the floor, warm but quite dead. There were no appearances of any disturbance in the room. The husband immediately gave the alarm, and a physician was called; but there were no signs of life.
At the autopsy, next day, there were no marks of violence to be seen, with the exception of some slight bruises on the right knee, and the right side of the head and face, which slie might easily have received in falling. All the internal organs were in a state of marked congestion, and the blood was everywhere fluid. No other lesion, however, was discoverable anywhere, With the exception of a change in one of the ovaries, and one or two serous cysts in the liver, which could not, in any way, account for death.
The uterus, of a natural grayish-yellow, and dull-red colour, was in the median line. Its upper edge was half an inch above the level of the umbilicus (subject lying on the back). It was covered for the upper third of its anterior surface by the transverse colon and great omentum. It measured eleven and one-fourth inches in its long diameter, and eight and one-eighth inches in its transverse. It weighed, unopened, a little less than seven pounds. The thickness of the uterine parietes, at its fundus, was three-eighths of an inch. The cervix uteri, two inches in length, was plugged by a mass of colourless, tenacious secretion. Its lower extremity was lax and soft, admitting the little finger with ease; but its upper part was contracted and impassable. The os uteri and upper portion of the vagina •svere of a purplish colour; the rest of the vagina being of a light rosy hue.
The chorion and amnion were in contact ; and the amniotic fluid something over one pint in amount. The placenta was situated at the lower and anterior part of the uterus, a short distance from the uterine orifice of the cervix. The cord measured nineteen inches in length. The foetus, perfectly formed, weighed, together with one inch of the cord, three pounds. It had no cadaveric rigidity. Its skin was of a reddish colour, and had a thin covering of sebaceous matter. There was rather an abundance of dark hair on the scalp. The nails projected, in many instances, quite to the ends of the fingers; in others, not so far. They were all very soft. The eyelids were in contact, but not adherent. There was some opacity of each cornea. Both testicles had descended into the scrotum, but could be pushed back nearly into the cavity of the abdomen.
There was no mark of violence or disease about either the uterus or foetus.
The right ovary, situated immediately beneath the liver, was almost entirely converted into an encysted tumour, nearly globular in shape, with thin, tough, membranous walls, and about the size of the foetal head. It weighed, unopened, a little less than one pound. It contained a mass of yellowish-white fatty matter, resembling lard in appearance and consistency. There were also a few drachms of thickish, dingy-yellow, oily fluid, with a fetid odour. Intermixed with the lardaceous matter, was a large quantity of long and short, dark-coloured hair; most of it, like the fatty matter, entirely unconnected with the internal surface of the cyst. This surface was, for the most part, smooth and glistening, like a serous surface; but at one spot it assumed the appearance of skin, becoming whitish-opake, and provided with follicles, from which short hairs projected into the cavity of the cyst. At one spot underneath this scalp-likc surface, was a considerable mass, like adipose tissue, and beneath that an irregularly-shaped piece of bone, hard, white, and surrounded by periosteum. There were two other, much smaller cysts, filled with transparent, gelatinous fluid, and a little of what appeared to be the remains of genuine ovarian stroma ; but there were no normal Graafian vesicles, nor any other appearance natural to the organ.
There were no appearances of old or recent inflammatory action anywhere about the ovary, but all the surfaces externally were smooth and normal ; only the oviduct and its fimbriated extremity were of a lively red colour.
The left ovary, one inch and a half in length, was pale, and of natural appearance externally. On one of its lateral surfaces there was a small oval-shaped spot, where the albugineous tunic was Avanting, and which showed a faint yellowish coloration. (Plate II. Fig. 4.) The centre of this spot showed a faint linear cicatrix, very slightly depressed, from which radiated a few red and purple vessels. The corpus luteum, situated immediately underneath, caused a slight prominence externally, and could be readily felt as a roundish, welldefined tumour, not hard, but still having considerable resistance. Its section, of an oval form, showed the body to be somewhat compressed from within outward. It was half an inch in length, and a quarter of an inch in depth. It consisted of a central, whitish, radiated cicatrix, surrounded by a thick, softish, elastic, and strongly convoluted wall. The relative proportion of these parts is exhibited in the drawing. (Plate 11. Fig. 5.) No distinct communication of the central cicatrix with the exterior could be detected; probably owing to the abundant growth of the convolutions, which had reduced this communication to a linear cicatrix, easily missed in making a section of the ovary. The thickness of the wall was considerably less on its superficial than on its deep aspect. Its colour was a faint yellowish-white, not much unlike recent lymph, and very diff"erent from the bright yellow hue of the corpus luteum of menstruation, at an advanced period. It showed an abundance of fine red vessels converging from the exterior, which had at first the appearance of being situated in the substance of the wall, but which, on close inspection, seemed only to penetrate the interstices of the convolutions. Externally, the corpus luteum was invested by an exceedingly thin, transparent, vascular membrane, to which it was intimately attached, and with which it could be readily separated from the rest of the ovary; but, in performing the separation, several irregular strips of cellular tissue were raised with it.
Near the other extremity, and on the opposite surface of the ovary, was another spot similar to that already described; i. e., a space where the fibrous tunic was wanting, and in which there existed a faint yellowish coloration, and a noticeable concentration of vessels. Immediately beneath, was a second corpus luteum, absolutely similar to the first except in being a little smaller as the section was made, i. e., seven-sixteenths of an inch long, by a quarter of an inch deep. The central cicatrix here had a verv distinct communication With the exterior. The whole appearance of this corpus luteum indicated the same stage of development with the former.
Fig. 10. Left ovary of M. M. — Second corpus luteum.
The left oviduct Tvas quite free and pervious throughout. On cutting it open, there Avas found, at a distance of three inches from its fimbriated extremity, a soft, greenish-yellow mass, about the size of a hazelnut. Externally, it Avas quite smooth and soft, and without any appearance of organization ; but toward its centre it had considerable firmness and a more ruddy colour, and showed some fine red vessels, ramifying in its substance. Altogether, it had much the appearance of a slough of cellular tissue, which had not yet become quite disorganized and difiluent. At one spot it had distinct vascular connections with the internal surface of the oviduct; but could easily be separated, leaving some shreds of the slough-like material adhering to the spot. There was no particular vascularity or other alteration of the mucous membrane of the oviduct in its immediate neighbourhood, but only some unevenness of surface at the point where the tumour had adhered.
There were absolutely no Graafian vesicles on the surface of the ovary, but several were situated beneath the albugineous tunic, along the free edge of the organ, varying in size from an eighth of an inch in diameter, downward. The ovary was carefully divided in every direction, but nothing else like a corpus luteum was anywhere to be met with.
It will immediately be seen how much this corpus luteum differs in appearance and description from those heretofore delineated, as existing in company with an unimpregnated uterus. This case is particularly interesting from the fact that two ova had evidently been discharged from the left ovary at about the same time, and had both been fecundated. One, however, contracted adhesions to the oviduct and became blighted after a very short period of development ; while the other proceeded to the uterus, and underwent the ordinary changes of uterine growth. This woman had evidently a constitutional tendency to arrest the progress of the ova through the tubes, since very much the same thing had previously happened on the right side. For we must certainly regard these encysted tumours of the ovary, containing bones, fat, and hair, as the result of degenerate ova, which have become arrested at the ovary, either before or after their impregnation.
This case also makes it evident that it is not any particular change in the ovum itself, which gives a peculiar character to the corpus luteum of pregnancy, but the condition of the uterine organs generally ; for we have here two perfect corpora lutea, though only one of the ova had become developed. If it were otherwise, as the ovum became blighted, its corresponding corpus luteum would have been atrophied simultaneously with it.
Observation XV
Corpus luteum of pregnancy in the eighth month.
C. H., a woman, thirty years of age, evidently advanced in pregnancy, died at the Cholera Hospital in Boston, August 8th, 1849, after an illness of fifteen and a half hours.
The uterus came up nearly to the level of the umbilicus. It was pear-shaped, and inclined to the right side, so that full two-thirds of the organ lay to the right of the median line. It had a dull reddish vascularity on its external surface. The fluctuation of the liquor amnii could be readily felt through the uterine walls, as well as the head and limbs of the foetus. The uterus measured nine and a half inches in its longitudinal diameter, and six and a half in its transverse. The thickness of its walls, divided through the middle of its anterior surface, was three-eighths of an inch. The os uteri had a rounded, tumefied appearance, and a dark purplish colour. The cavity of the cervix was filled With tenacious secretion. The attachment of the placenta was at nearly the middle part of the anterior uterine wall, but a little to the left of the median line. It was nearly circular in shape, and five-eighths of an inch in thickness. The chorion and amnion were in contact, and the amniotic fluid about fourteen ounces in amount. The cord was twenty-two inches in length.
The right ovary, one inch and three-quarters long, contained a corpus luteum, situated at one extremity of the organ. This body was irregularly ovoid in shape, measuring nine-sixteenths of an inch in lenp^th, and half an inch in depth. It consisted of a firm, yellowish-'wlntc, -well-organized looking substance, -which showed fine red vessels converging towards the centre. It had no cavity, but its centre was occupied by an irregularly elongated, firm, opaline coagulum, closely connected with the rest of the body. Externally, there Avere the same layers of cellular tissue previously described.
The colour of this body was a much less decided yellow than is often seen in "false" corpora lutea. It differed from them also in several other respects, as follows : —
- I. Its globular form, and firm, resisting feel.
- II. Its organized appearance internally.
- III. There was, on the surface of the ovary, at a spot corresponding to the corpus luteum, a well-defined, strongly-depressed cicatrix.
The ovary also contained a firm, opake, whitish body, in the situation indicated in the drawing, much smaller than the corpus luteum, and not exhibiting any of its peculiar structure; apparently a morbid growth.
The left ovary was two inches in length, but very slender and much atrophied. It contained a small, globular, whitish, opake body, like that mentioned as occurring in the right ovary (morbid). There was nothins; else remarkable about the uterus or appendages.
The foetus, a female, measured fourteen inches in length, and weighed, with one inch of the cord attached, three pounds five and a-half ounces. There was no cadaveric rigidity. The skin was of a rosy hue, rather thick and tough, and covered, over a great part of its surface, with fine,
white, short hairs. The scalp was covered with fine dark hair, a quarter of an inch long. The nails reached nearly, but not quite, to the ends of the fingers. The umbilicus was situated an inch above the pubis, and three-quarters of an inch below the middle point of the body. The eyelids were in contact, but easily separated. There was slight opacity of each cornea. There was no pupillary membrane.
The foramen of Dotal was a quarter of an inch in diameter, but could be completely covered, from the left side, by its valve. The arterial duct appeared like the continuation of the pulmonary trunk, while the right and left pulmonary arteries seemed to be only small branches.
Corpus luteum of pregnancy in the middle of the eighth month.
There were no valvule conniventes in the small intestine, and the large intestine was quite round and smooth, unmarked by either transverse or longitudinal bands. It was distended with dark greenish meconium from the ilco-coecal valve to within an inch of the anus. The kidneys were lobulated externally, and rather more bulky than the supra-renal capsules; but the length of the two bodies was the same, viz., one and one-eighth inch.
There Avere three points of ossification in the sternum. The calcaneum had one point of ossification, well advanced ; and the astragalus also one point, just commenced. The axis had one point of ossification in its body, and another in the odontoid process.
The foetus was therefore, in all probability, seven months and a-half old.
Observation XVI
Corpus luteum at the termination of pregnancy.
E. S., a healthy woman, about twenty-seven years of age, a patient of Dr. Samuel Cabot, was taken with labour pains on Wednesday, February 19th, 1851; only five days before her full time, according to the patient's reckoning. After labour had continued eight hours, rupture of the uterus took place, and the woman died five days afterward.
The uterus and ovaries were given to me by Dr. Cabot.
The body of the uterus was five inches and a half long, and its anterior wall a little over one inch in thickness. The cervix uteri was two and one-eighth inches in length, and thoroughly dihated. The OS internum was distinctly marked by a slightly projecting ridge, viewed internally, at the lower extremity of the uterine body. The rupture was transverse, three and a half inches long, and situated just at the junction of the body of the uterus with the cervix. The edges of the rupture were everted, and retained in the everted position by a deposit of recent lymph ; which was also abundant all over the peritoneal surface of the uterus. The right ovary was plentifully covered With lymph, but, on stripping off This deposit, the cicatrix of the corpus luteum could be readily distinguished on the free edge of the organ. Immediately beneath, the body itself was indistinctly perceptible to the touch.
On cutting it open, the corpus luteum was seen to be of an indefinite, light-yellowish hue, but little contrasted with the remainder of the organ. The central coagulum was very scanty, having been reduced to a thin white cicatrix.
In the above drawing, the walls of the yellow body are shown very much folded in, at one spot. This is in consequence of the first section, from which the drawing was taken, not having been made directly through the centre; but another section, more successfully performed, showed its whole surface occupied by yellow matter, thrown into minute folds.
There was no other appearance of corpora lutea in either ovary, nor any prominent Graafian vesicles.
Corpus luteum at the termination of pregnancy.
Observation XVII
Corpus lueum of pregnancy nine weeks after delivery.
A. G., a married woman, twenty-six years of age, died in Boston, Sept. 20th, 1850, of irritant poisoning. In early life she had shown some symptoms of insanity, but of late years her health had been good. A fortnight previous to her death, she had lost an infant child, seven weeks old, and since that time had been much depressed in spirits, and had not had her usual appetite, but had not been otherwise indisposed. She left her home soon after breakfast on the mornin"; of the 20th, and in the afternoon was found in the station house of the "Western Railroad, evidently very sick, and unable to give any account of herself. She was immediately removed to the Massachusetts General Hospital, where she arrived at half past four P. M. She was then much nauseated, with lividity and coolness of the skin, swelling of the lips, and a very rapid and feeble pulse. She could neither speak nor swallow. She rapidly became more and more collapsed and insensible, and died in a little less than two hours after her entrance.
At the autopsy, next day, the stomach was found excessively inflamed. It was somewhat contracted and collapsed, and contained six ounces of a dark red, bloody-looking fluid, which was thickened by holding in suspension a large amount of light reddish flakes, like those seen in the discharges of dysentery. The parietes of the stomach generally were exceedingly thickened, so that its anterior wall, near the pyloric extremity, measured three-eighths of an inch in thickness, and about the cardiac extremity nearly a quarter of an inch. This abnormal thickness was entirely owing to infiltration of the submucous cellular tissue, of a slight reddish tinge, nearly uniform throughout the organ. The mucous and muscular coats were unchanged in thickness.
The internal surface of the stomach was of an intense purple red throughout the middle third of the organ, where the mucous membrane was thrown into numerous transverse and longitudinal folds. In the great pouch the mucous membrane was of a dark slate colour, and had, at the same time, a finely granulated appearance, owing to its surface having been strongly corrugated and thrown into minute folds, of an opake gray colour. There Avas also, at this part, much dark purple and black ecchymosis, situated in the substance of the mucous membrane, as well as beneath it. There was, besides, some redness of the small intestine, and much submucous infiltration and ecchymosis about the larynx and upper part of the trachea; as if some of the poison had accidentally found its way into the air-passages. There were no other morbid appearances of importance. The woman was known to have had corrosive sublimate in her possession previous to leaving home.
The vagina was smeared, at its upper part, with a little leucorrhoeal secretion. The uterus, much reduced in size, was only a little larger than in the ordinary, unimpregnated state. The os uteri was transverse, purple, and much fissured. The internal uterine surface showed considerable dark-coloured redness, but was otherwise unaltered.
Both ovaries showed many Graafian vesicles in process of development, but no sign of any recent rupture. One of them had also a very small and ancient-looking body, situated immediately beneath a depressed cicatrix, which was the only thing like a corpus luteum to be found in the ovary. The colour of this body was very similar to that of the ovarian tissue. Its section was slightly oval, about a quarter of an inch in diameter, and presented an opake, whitish, central mass, external to which traces of a convoluted structure were visible on close examination. The whole aspect of the body, however, was obsolete and inactive, and its markings quite indistinct.
Observation XVIII
Corpus luteum of pregnancy nine months and a half after delivery.
C. L., a married woman, twenty-six years of age, a patient of Dr. G. N. Thompson, died in Boston, June 24th, 1850. She was the mother of three children, the youngest of whom, a healthy boy, was nine months and a half old. The patient had not menstruated since the birth of this last child.
She was confined on the eighth of September, 1849, without any unusual occurrence. Two or three weeks after delivery, she was attacked, from some unknown cause, with salivation, followed by great irritability of the bowels, so that she had ten or twelve discharges daily; often bloody and mucous in character. These symptoms were at first controlled by remedies ; but not long afterward the irritability of the bowels again returned, her strength and flesh failed, and the skin became excessively pallid. She improved again under tonic treatment, but afterward failed a third time; anaemia, emaciation, weakness, and irritability of the bowels being the most prominent symptoms. She had also a moderate cough, not frequent or troublesome. During the latter part of her life, the discharges from the bowels were not bloody nor mucous, but fluid and greenish. The intelligence was not affected.
At the autopsy, there was some sub-acute pneumonia of the posterior surface of both lower pulmonary lobes. There was also considerable ulceration of the lower part of the small intestine, and the mucous membrane of the larfjre intestine was finelv (rranulated and roughened throughout its extent.
There were no other remarkable appearances.
The body of the uterus was pale, and natural in size and consistency; but there were some morbid appearances about the os and the upper part of the vagina. The cervix and os uteri were considerably swollen, with an oedematous aspect, and a dark red and purple colour internally. The external parts of the os and upper portion of the vagina were equally dark coloured, and covered with large patches of a whitish, semi-opake exudation. The internal surface of the body of the uterus was lighter coloured. It was finely reticulated over the greater part of its extent, but there was a spot on its posterior wall which was smooth, and of a cicatrix-like appearance. The internal surface of the uterus was natural in consistency.
Fig. 13. Left ovary of C. L.
Fig. 14. Corpus luteum of pregnancy- nine months and a half after delivery.
Both ovaries were rather large. They were pale, like the other organs, and entirely destitute of vascularity. Both presented externally several very shallow, bluish-looking cicatrices, but the left had, in addition, on its anterior surface, two puckered, strongly depressed cicatrices. (Fig. 13.) On making a longitudinal section, there was found, immediately beneath the deepest of these, and evidently connected with it, a solid body, having a nearly circular section. (Fig. 14.) This body was little or not at all distinguishable in colour from the rest of the ovarian tissue, and might easily have been overlooked in a hasty examination. On close inspection, however, it was seen to be imbedded in the substance of the ovary, from which it was separated by a sufficiently distinct line of demarkation. It contained in its centre a body rather whiter and more opake than the external parts, while the latter, on minute examination, presented indications of being traversed by radiating lines. The whole body was similar in consistency to the rest of the ovary, and could not be felt at all from the outside. It had no yellow nor red coloration in any part.
Both ovaries contained many Graafian vesicles in an inactive condition, but no other body than that described having any resemblance to a corpus luteum.
Both oviducts were natural in appearance and free from adhesions.
There can be no doubt that, in the first periods^ the corpus luteum follows the same course of development, whether the discharged ovum becomes impregnated or not. Together with the rupture of the vesicle, the same effusion of blood takes place in either case, followed by a gradual absorption of the colouring matter of the clot, and hypertrophy and folding up of the membrane of the vesicle. When, however, the ovum becomes impregnated, and continues its growth in the uterus, the corpus luteum, instead of reaching its maximum of development at the end of three weeks, and afterward undergoing a rapid process of atrophy, continues to develop itself for a considerable period, and does not, in fact, become very decidedly retrograde until after the termination of pregnancy. At the same time the ordinary periodical processes of the ovary are suspended. No new vesicles protrude themselves from its surface, and even those which, at the time of conception, happened to be more or less prominent, appear again to recede and become concealed beneath the albugineous coat.
The difference in the progress of the corpus luteum, however, relates not only to its size, but also to its general characters and aspect. The external wall becomes much thicker in proportion to the central coagulum, and at the same time acquires a firmer and more highly organized structure. Moreover, the colour, both of the convoluted wall and of the central coagulum, constitutes an important means of distinction. It has been shown that the corpus luteum of menstruation retains the bright yellow colour of its walls till the whole body has become much reduced in size ; and that the coagulum in its interior also remains more or less stained with red till a late period. In other words, the substance of the corpus luteum diminishes more rapidly than its colour fades. On the other hand, if pregnancy occurs, the circumstances are reversed. The colour both of the wall and the coagulum fades rapidly after the first tAVO months, while the substance of the yellow body continues to increase ; consequently, during the greater part of gestation, the corpus luteum of pregnancy will be distinguished from that of menstruation by the dull hue of its convoluted wall, and by the absence of colour in the central coagulum.
The occasional existence of a central cavity in the coagulum, containing clear fluid, is a circumstance which has been noticed by several different authors. It does not seem to be an essential or even an ordinary appearance ; since, among the eighteen observations on the human female which have been detailed in the preceding pages, we have met with it but once (Obs. XII). It is probably occasioned by an early closure of the rupture in the Graafian vesicle, by which the serum of the effused blood is retained in its interior, instead of being expelled through the aperture by the contraction of the coagulum.
It is difiicult to ascertain with certainty the exact period of pregnancy at which the corpus luteum attains its maximum of development. It certainly constitutes a very perceptible tumour so late as the middle of the eighth month, and most of the older writers agree that it is to be found a short time after delivery. Dr. Robert Knox has drawn up a table of measurements of the corpus luteum at different periods of pregnancy, collated from various reliable authorities, which was published in the London Medical Grazette.
The table is as follows: —
It appears probable from this table that the period of the greatest thickness of the convoluted wall, the structure which constitutes the most characteristic portion of the corpus luteum, continues from the beginning of the third to the end of the sixth month, and that the entire bulk of the corpus luteum is also the greatest between nearly the same periods. After delivery, the corpus luteum rapidly diminishes ; though its characteristic structure is still to be distinguished for many months by close inspection.
The corpus luteum of pregnancy, then, differs from that which is merely the result of menstruation in several important particulars.
I. It arrives more slowly at its maximum of development, and afterward remains for a long time as a very noticeable tumour, instead of undergoing a process of rapid atrophy.
II. It retains a globular, or only slightly flattened form, and gives to the touch a sense of considerable resistance and solidity.
III. Internally, it has an appearance of advanced organization, which is wanting in the corpus luteum of menstruation.
IV. Its convoluted wall, particularly, attains a greater development, this portion measuring sometimes so much as three-sixteenths to onefourth of an inch in thickness, while in the corpus luteum of menstruation it never exceeds one-eighth, and is almost always less tlian that. This difference in the thickness of the convoluted wall is one of the most important points of distinction. It will be much more striking when viewed relatively to the size of the central coagulum.
V. The colour is not, by any means, so decided a yellow, but a more dusky and indefinite hue.
VI. If the period of pregnancy is at all advanced, it is not found, like the corpus luteum of menstruation, in company with unruptured vesicles in active process of development.
The preceding histories and observations will serve to show how very imperfect are some of the marks which various writers have heretofore laid down as distinguishing "true" from "false" corpora lutea. Dr. Montgomery* gives seven characteristics by which, he says, the "false" or "virgin" corpora lutea may be recognized.
" I. There is no prominence or enlargement of the ovary over them."
This is manifestly incorrect, for the corpora lutea of menstruation often cause a noticeable protuberance on the surface of the ovary, as may be seen in Observations II., IV., V., VL, and VII.
" II. The external cicatrix is almost always wanting." According to the present observations, an external cicatrix is always present in the corpus luteum of menstruation, and in fact must necessarily be so, since these bodies result from the rupture of a vesicle, in the same manner with the corpora lutea of pregnancy.
" III, There are often several of them found in both ovaries," &c. This is, no doubt, a very important distinction, since we never find more than one corpus luteum of pregnancy at a time, unless in cases of twins ; and then the two corpora lutea are evidently of the same date, and have the same aspect, while the co-existent corpora lutea of menstruation are usually in many difierent stages of retrogression.
"IV. They present no trace whatever of vessels in their substance, of which they are, in fact, entirely destitute, and of course cannot be injected."
According to the present observations, the distribution of vessels in the two difierent kinds of corpora lutea is the same. In both, the substance of the convoluted wall itself is non-vascular; and the vessels exist only in the interstices of the folds. This fact is very easily demonstrated in a corpus luteum of menstruation when completely developed, as the convolutions are here pretty easily separated from each other ; but in the corpus luteum of pregnancy the new growth from the internal surface of the vesicle has been so abundant, and the convolutions are consequently pressed so firmly together, that it is not always easy to decide whether a section has divided the substance of the wall, or only by accident passed between two convolutions; particularly as we have not so strong a contrast in colour, to assist us, between the yellow wall and red vessels, as exists in the corpus luteum of menstruation.
• Signs and Symptoms of Pregnancy, p. 245.
"V. Their texture is sometimes so infirm that it seems to be merely the remains of a coagulum," &c. This is frequently a good distinguishing mark.
"VI. In figure they are often triangular, or square, or of some figure bounded by straight lines." This has already been seen to be an appearance frequently presented by the corpus luteum of menstruation, at an advanced period of atrophy.
" VII. They never present either the central cavity, or the radiated or stelliform white line which results from its closure." This last distinction is so exceedingly incorrect that it is difiicult to understand how it could have been laid down by such an observer as Dr. Montgomery. The corpus luteum of menstruation always presents a central cavity, i. e., a space included by the convoluted wall, which space is filled by a coagulum ; and as the whole yellow body becomes atrophied, the coagulum is transformed into a radiated or stelliform cicatrix, more or less coloured with blood, according to the rapidity with which the absorption of the hsematin has proceeded.
There can be no doubt, therefore, of the existence of certain distinct and reliable marks by which the corpus luteum may be recognized as a sign of pregnancy, and distinguished from all other appearances, either morbid or physiological, to be met with in the ovary. The length of time which elapses before its disappearance is alone sufficient to show that it is a peculiar and distinctive phenomenon. It has been demonstrated, in the foregoing pages, that the corpus luteum of menstruation becomes atrophied in a very short space of time. Other observations, also, bear testimony to the same fact. N^grier,* who considers all corpora lutea as identical, says that the remains of the ruptured vesicle diminish successively with so much regularity that we " can appreciate the loss of voliime which takes place from one month to another." "It is in accordance with such facts that I have been able to calculate that five to six months are sufficient to reduce the most voluminous corpora lutea to the size of a grape-seed; and that after two years a bluish stain is often the only vestige that remains."
- Page 79.
Raciborski[1] states also that a period of four to six months is sufficient to reduce the corpus luteum to an insignificant remnant ; " a simple slate-coloured or yellowish trace."
Notwithstanding this, when the menstrual periods return with reo'ularity, new corpora lutea are so rapidly produced that we meet with many of them of different sizes in the same subject. Thus, in Obs. X. we have four of these bodies, in Obs. VI. six, and in Obs. IX. so many as eight, co-existing in the same ovaries. On the other hand, the corpus luteum of pregnancy, after a certain period has elapsed, is found alone. It has outlived all vestiges of the vesicles previously ruptured, and no new ones have come forward to form fresh corpora lutea. If, however, the yellow body of menstruation were entirely similar to that of pregnancy, produced every month, and yet remaining nearly undiminished for the greater part of a year, we should find, in almost every female dead between the ages of fifteen and forty-five, the ovaries crowded with prominent solid tumours which could not fail to be recognized on the most superficial inspection. Pouchet would then never have been obliged to account for the failure of older observers to discover corpora lutea in the ovaries of virgins. f " If certain physiologists (De Graaf, Morgagni, Haller), not having been favoured by circumstances, never discovered corpora lutea in the virgin females of mammalia, we cannot, nevertheless, at the present day deny their existence," &c. These observers could hardly have failed to discover them if the corpora lutea of menstruation continued permanent for any length of time. It is this very circumstance of their rapid atrophy and disappearance, joined to the fact that almost all grave diseases check the ovarian processes for some time previous to death, that prevents our meeting more frequently with specimens of these bodies at ordinary post-mortem examinations. Pouchet himself gives some observations which of themselves establish partially the distinction above alluded to. One of them he adduces while speaking of the proofs of the regular maturation and discharge of ova in virgins. " In the case of a young woman," he says, " twenty years of age, I had the good fortune to discover together Graafian vesicles and their contents in all stages of development and retrogression. This woman had never borne children, and presented all the marks of virginity. The ovaries presented on the surface of their fibrous tunic many very noticeable cicatrices, vestiges of obsolete Graafian vesicles wliicli had previously discharged their ovum. In the interior of the organs were to be seen many anfractuosities, which were probably merely Graafian vesicles which had been more recently ruptured. This appeared probable from the condition of their internal membrane, which was of a brownish colour, and appeared no longer to be in an active condition. Finally there existed, near the surface of the organs, eight vesicles, in different stages of development, and varying from one-half to onesixth of an inch in diameter. Their internal membrane was like a mucous surface, ruddy and very vascular," &c. &c.
This girl's menstruation and ovulation had evidently, therefore, as Pouchet supposes, gone on in an uninterrupted manner till near the time of her death. Why, then, if the menstrual corpus luteum lasts as long as that of pregnancy, did he not find many yellow bodies in full development, instead of mere "anfractuosities" with a "brownish-coloured and inactive-looking internal membrane?" The same remark may be made with regard to other similar observations, as those by Bischoff already referred to (op. cit. p. 50), and those by Dr. Seymour, when he says, " I have examined ovaria in many instances; many had ova (Graafian vesicles) ready for impregnation large, projecting, vascular: yet no corpora lutea were visible." In these subjects, the development of the vesicles had evidently suffered only a very recent arrest, and yet the corpora lutea had become so much diminished as to escape observation.
On the other hand, it cannot be doubted that the corpus luteum of pregnancy does remain, throughout the period of gestation, too bulky and remarkable an object to be very readily overlooked. This is established by the testimony of many other observers, as well as by that of the foregoing cases. Raeiborski,[2] indeed, not recognizing any difference between the two classes of yellow bodies, goes so far as to deny positively that the corpus luteum is ever visible at the termination of pregnancy. "We are," he says, "at a loss to understand the grounds upon which most of the writers on midwifery and legal medicine have laid down the presence of a corpus luteum in the ovaries as the sign of a recent delivery. The process of ovulation having been suppressed during the period of pregnancy, the pretended corpora lutea, which are only different forms of the anatomical marks of preceding ovulations, have had more than sufficient time to become entirely effaced, and we never meet with anything more than feeble traces of them in women who die after delivery."
The direct testimony, however, of many reliable authors, such, for instance, as those quoted in Dr. Knox's table, is certainly not to be outweighed by a sweeping assertion like the foregoing; particularly, as many of the descriptions are accompanied with drawings. Montgomery gives quite a number of coloured plates of the corpus luteum at different periods of pregnancy; and states, with regard to the time of its disappearance,* that he has met with it "distinctly visible so late as the fifth month after delivery." Dr. Lee, in his "Lectures on Midwifery," already referred to, gives two wood-cuts of corpora lutea; one of them in the second month of pregnancy, half an inch in length, and the other in the fourth month, nearly seveneighths of an inch in length.
William Hunter, also, in his plates of the gravid human uterus, gives two representations of the corpus luteum. One, at the beginning of the fifth month, is three-quarters of an inch in length, and nine-sixteenths in depth ; the other, at term, is nearly circular in section and half an inch in diameter.
Fig. 15. William Hunter's plate of the human corpus luteum, at the lx;ginningof the lil'ih month.
Fig. 16. William Hunter's plate of the human corpus luteum at term.
• Op. cit. p. 227.
The foregoing account of the corpus luteum of menstruation and pregnancy must be considered as differing, to some extent, from all the observations hitherto published. Sulficient, however, has already been said in a previous part of the treatise to show the discrepancy which has existed among authors on the subject, and to demonstrate the justice of Raciborski's remark, that " science has so far possessed only vague ideas, or rather assertions altogether false on the nature of the alterations which merit the name" of corpora lutea. A memoir by Dr. Frank Renaud, however,[3] has already been mentioned as containing much the best account of these bodies heretofore published. That writer, nevertheless, does not acknowledge the regular and periodical discharge of ova and formation of corpora lutea ; consequently, those bodies which he designates as " false corpora lutea" he does not regard as necessarily connected with menstruation. "The theory," he says, " that would indicate each menstrual period to be co-existent with the secretion of a small yellow body in the ovaries requires facts much more imperative than any yet advanced." He therefore thinks it best to "receive with caution a theory that requires so much show of ingenuity for its establishment."
Dr. R. also lays down one or two points of distinction between "true and false" corpora lutea which it would be impossible to admit, according to the observations in the present paper. He states, for instance, that " the yellow secretion of the false corpus luteum is contained within the inner ovisac ;" but that " true corpora lutea are always to be found located between the proper tunics of the Graafian follicles, or, in other words, between the two ovisacs." In reality, the situation of the yellow matter in the two bodies is the same ; it varies only in amount, and in some peculiarities of intimate structure.
Another distinction of Dr. Renaud is that the true corpus luteum is vascular, while the false is destitute of vessels, and cannot be injected.
Reasons, however, have already been given for believing that the distribution of vessels is the same in both bodies, though they are certainly often more distinct to the eye in the " true corpus luteum," owing to the dull colour of the yellow matter and the greater depth of its anfractuosities.
Neither does Dr. Renaud, in his memoir, give any such regular and detailed comparison of true and false corpora lutea as could be called a demonstration of the difference between them. Indeed, it was only by a reference to previous observations of my own that I was enabled, on meeting with Dr. R.'s paper, to recognize its great superiority, in point of accuracy, to the numerous other accounts, whose conflicting statements have involved this subject in so much confusion. How otherwise, indeed, could one ever be enabled to discriminate in a case like this, where the facts are so obscure and the opinions of authors so various? It is only by arranging a detailed history of the corpus luteum, and by offering the proofs together with the assertions, that we can ever expect to settle the question in a manner satisfactory to the general reader.
References
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Dalton JC. Prize essay on the corpus luteum of menstruation and pregnancy. (1851) Philadelphia: T.K. and P.G. Collins.
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| Corpus Luteum 1851: Part 1 - Corpus Luteum of Menstruation | Part 2 - Corpus Luteum of Pregnancy | Part 3 - Observations on Animals | Plates |
