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already alluded to my own examinations of human nervesin a state of degeneration, and shall now describe theappearances I have met with in cases in which regenerationof the peripheral end had occurred after section, indepen-dently of union with the upper portion.

The first case was that of a lad, aged eighteen, in whoman operation for reunion of a divided ulnar nerve was under-taken seven months after injury. An examination of the

portion of the peripheral end, which was removed prepara-tory to suture, showed that, scattered throughout a trans-verse section, were several small, imperfectly developednerve fibres such as are met with (and have already beendescribed) in the bulbous proximal end. These new fibreswere not collected into definite bundles; they were muchsmaller than natural, and their myeline sheath was scarcelyperceptible. The total number of these new fibres was butsmall, and I was unable to trace their development in asatisfactory manner.The second case was that of a woman, aged fifty-three,

who had divided the median nerve just above the wrist-joint. An operation for suture was undertaken nine monthslater, and the condition of the resected portion of the peri-pheral end was found to be as follows. The circular spacesin the neurilemma, which, in a state of degeneration, 1 hadpreviously found in other cases and have already describedas partly filled with nucleated connective tissue, I nowfound to be occupied by nerve fibres, in varying stages ofregeneration. The steps in the formation of these fibrescould, moreover, be most clearly traced. Their first appear-ance was in the form of oval and spindle-shaped nuclei,which seemed to be identical in structure with the nuclei ofthe sheath. These nuclei were arranged in bundles, withtheir long axes parallel to that of the nerve trunk. Thenext step was the elongation of the nuclei and their gradualtransformation into fibres, around which subsequently amyeline sheath was formed. In some parts of the section,bundles of newly formed nerve fibrils could be seen occupy-ing the spaces in the neurilemma which had evidently beenpreviously occupied by the healthy nerve bundles, beforethe time when the injury was inflicted. The new fibres insome bundles were in a much more advanced stage of de-velopment than those in others, the regeneration appearingto progress simultaneously throughout all the tubules in each Ibundle irrespective of the condition of the fibres in others.

I have also had the opportunity of examining the nerveends in a case in which the ulnar had been divided nearlytwo years before I saw the patient. The nerve had beencompletely cut across, and no union had taken place, theupper and lower ends being separated by about half an inchor more of firm cicatricial tissue. A microscopical examina-tion of the peripheral end showed that many of the fibreshad been regenerated. A large number of the bundles con-tained numerous nerve fibres in various stages of develop-ment. In some the axis cylinder alone was formed. In

many others the myeline sheath surrounded the young axiscylinders, whilst in some the "nodes of Ranvier" were wellmarked.There is, indeed, a tolerable consensus of opinion as to

the part played by the nuclei of the sheath, from which, ac-.cording to most authors, the new axis cylinders are formed.The strongest objection to Ranvier’s theory, that the unde-generate fibres of the central end grow into the empty sheathof the periphery, lies in the fact that, as I have alreadydescribed, the peripheral end will regenerate even whenununited to the central healthy fibres; and if further proofof this be necessary, it may be found in the investigations ofPhillippeaux and Vulpian, who not only saw regenerationof the peripheral fibres without union with the proximalend, but found the same take place in a piece of nerveresected and transplanted into the surrounding tissues. If,then, the peripheral end has become regenerated, and isplaced in sufficiently close proximity to the central portion,union will result by the continued formation of nerve fibresbetween the divided extremities. But, on the other hand,should union fail, it appears probable that the nerve againdegenerates, perhaps never to recover. I have found nomention of this by other authors, but am, nevertheless, in-.clined to feel certain that such changes must occur, forotherwise we should have some difficulty in explainingthose cases in which many years after injury the nerveshave been found completely atrophied. As examples of suchI append the following two cases. Israel 10 records the case

9 Gaz. des Hôp., 1861. 10 Virchow’s Archiv, vol. lxxxv.

of a man who had been shot through the median and ulnarnerves thirty-two years previously. The peripheral endswere found to have only the thickness of a knitting-needle,and to consist chiefly of connective tissue. In vol. xxiv. ofthe Pathological Society’s Transactions, Mr. Butlin describesa case in which the ulnar nerve had been divided fourteenyears before death. No union had taken place, and thelower end was found to consist nearly entirely of connectivetissue, a microscopic section showing that the healthy nervefibres had entirely disappeared, while the presence of anyaxis cylinders was very doubtful. No doubt many suchcases can be found, and all bear but one of two explana-

i tions. Either the divided nerve never became regeneratedL at all, or else it subsequently again degenerated. The latter.

appears to me the most likely, but before the matter can be; considered settled more investigation is necessary.

The conclusions which may be drawn from the mostrecent investigations are: 1. That the nuclei of the sheath

, of Schwann (which are developed from epiblast) form the. new axis cylinder. 2. That the myeline is subsequently! formed around the new cylinder. 3. That the peripheral. end may become in part regenerated without forming any3 union with the proximal extremity, but that it probablyL again tends to degenerate if union fails.L

(To be concluded.)r

ABSTRACT OF

Lumleian LecturesON THE PATHOLOGY OF INTRA-UTERINE

DEATH.Delivered at the Royal College of Physicians of London,

March, 1887,

BY W. O. PRIESTLEY, M.D., F.R.C.P., LL,D.,CONSULTING PHYSICIAN TO KING’S COLLEGE HOSPITAL, AND LATE

PROFESSOR OF OBSTETRIC MEDICINE, KING’S COLLEGE.

LECTURE Ill.

Dit. PRIESTLEY in this lecture discussed the diseases andanomalies of the placenta, one of the chief difficulties in thestudy of which arose, he observed, from the tendency onthe part of authors to regard the particular morbid changewhich they have had the opportunity of investigating asthe chief or only disease with which the organ is affected.All other morbid appearances are for them but consequencesor complications of a specific and cardinal lesion upon whichthe rest depend. Thus Charpentier accepts the investiga-tions of Robin as illustrating the whole range of placentalpathology, and believes that when disease has invaded theplacenta it commences always in fibro-fatty change; andconsequent on this, blood extravasations and successivetransformations of effused blood account for all the variouspathological appearances associated with the death or

enfeebling of the foetus. Verdier and Bustamente, on theother hand, take entirely another view of these changes. Tothe lecturer it appeared that one cannot long investigatethe diseases of the placenta without discovering that theyare most complex in their nature, and that they proceedfrom a variety of causes inextricably intermixed-some-times one pathological condition having the precedence,sometimes another. The placenta is, in truth, as liable to beaffected by a variety of diseases as the liver or the lung, andsome of its diseases bear not only a striking resemblance todiseases occurring in those organs, but have affinities withthem and may depend on the same causes. Confusion hasalso arisen from investigators describing the same morbidcondition under a different name, probably because it wasobserved only in one stage of progress or with somevariations ;and some have fallen into the error of ranging affectionswhich are intrinsically different under the same appellations.Extravasations of blood into the young placenta are verycommon, and they occur as the result of rupture of some ofthe vascular maternal loops which ramify throughout theplacental mass and surround the villi of the chorion. Thesevascular maternal loops eventually become the sinuses or

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cavities which permeate the placental tissue at a later period. 1 ]If the extravasations be limited in extent, the life of the i

embryo may not be compromised, but a more extended ]apoplexy at once stops its nutrition, and the root-like pro- i

cesses of the young villi become so compressed that the icirculation can no longer be carried on through the minute i

foetal bloodvessels which they contain. Apoplexy takes i

place into the substance and on the uterine surface of the surface

full-grown placenta also very frequently. There is, however,this marked difference from the earlier Deriod-that now Ithe placenta is larger and thicker, and isolated clots may bedeeply embedded in its substance, only to be exposed byincision. Others may have been formed between theuterine walls and the maternal surface of the placenta,making a deep depression into the centre of a placentalcotyledon and compressing the placental structures. As afurther difference in the results of blood extravasations inthe young and more mature placenta, Dr. Priestley pointedout that in the latter several successive effusions of bloodmay take place, forming apoplexies of varying sizes anddates, without so seriously jeopardising the life of the foetusas it would do at an earlier period of gestation. The largersize of the placenta and its more extended surface afford abetter chance of so much of the potential part of it retainingits healthy relations, and so carrying on the placento-foetalcirculation that embryonic life is sustained. Among thewriters on this disease are Sir James Simpson, M. Jacquemier,Verdier, Bustamente, and Robin. The last named differsin toto from other workers in the same field as to theorder of pathological events in the placenta. He insists thatno blood extravasations take place in the placenta withoutprevious disease in the tissue, and that the morbid changeryhich is the most common forerunner of apoplexy is notmere vascular change, but an alteration of the whole struc-ture of the villus. The interference with the life of the..child or with the course of gestation depends upon theamount of extravasation, and the excitability or quiescenceof the uterine walls under the provocation to contraction.

Inflammation of the placenta, or placentitis, has beendiscussed by several authors, amongst whom Simpsondescribed it as consisting of three stages: the first being oneof congestion, in which the tissue is engorged by an unusualaccumulation of blood in the vessels; the second charac-terised by the exudation of coagulable lymph, producing agreater density of tissue and eventual induration; the thirdstage being that in which purulent matter is formed. Inlater days a good deal of scepticism has been expressed about,the existence of placentitis-at least, so far as its parenchymaor foetal portion is concerned. Bustamente disbelieves inits existence altogether, and says the evidence rests on thesupposed presence of pus, which has been shown to befallacious; the supposed purulent matter, according toRobin and other observers, being merely pseudo-pus, pro-duced by broken-down fibrin. It has been further arguedthat, according to modern theories, inflammation of theplacenta is impossible, since there are no capillaries in thematernal portion, and there are no nerves to regulate thecontractility of vascular walls in the entire structure. Thisreasoning does not, however, seem conclusive to Dr.Priestley. There are foetal capillary loops in all the activevilli, and there are also minute capillaries of maternal originin processes or dissepiments of the decidua which circum-scribe the fcetal villi. It is true, nevertheless, that the

Ipresence of purulent matter in the placenta in most of thereported cases is supported by imperfect evidence. Thereare only some ten cases of abscess in the placenta recorded,and as no account is given of the microscopic examinationof the supposed pus, the evidence is plainly unsatisfactory.Purulent matter has, however, been found and dulyauthenticated on the surface of the placenta and in theuterine sinuses at or near the placental site. That somemorbid change analogous to inflammation does take placein the placenta or its neighbourhood is apparently indicatedby the firm adhesions which are occasionally formed betweenthe placenta and the uterine walls, and from the traces ofan exudation which agglutinates and compresses the villiof the placenta.

Dr. Priestley then spoke of a remarkable affection whichhe designated as placental phthisis, a disease which repeatedinvestigations have convinced him is not, primarily at least,a mere increase of the cell structure or of the fibroidelement in the placenta, but in its first stage consists of anexudation or deposit thrown out among the villi, and isprobably due to some modification of a low inflammatory

process. The disease is not really tubercular in its character;nor have bacilli been found in its substance; neither is itprimarily or essentially a fatty degeneration, for the depositis not affected by the reagents which show the presence offat. Its corpuscles, unlike fat-granules, are thoroughlycoloured by the material used for staining the microscopicsections. It is not due to changed blood clot, for there areneither altered blood-corpuscles nor crystals in its substance.Its general appearance, both before and after section in theearlier phases, is rather that which has been described asfibrinous or other analogous deposit, and it has the chemicalcharacters of protein compounds. Dr. Priestley announcedhis intention of going into the minute pathological anatomyof this so-called placental phthisis in a paper which hepurposes offering to the Obstetrical Society. In the orderof successive changes the disease runs in somewhat parallellines with phthisis in the lungs. First comes solidification,then softening, with breaking up of tissue and resultinghaemorrhage. A notable feature in many of the microscopicsections was the great hypertrophy of the contractile coatof the foetal bloodvessels. It is not an uncommon form ofdisease, and there is some reason to believe that althoughcommonly it runs a chronic course, yet occasionally itsprogress is very rapid. With regard to fatty degenerationof the placenta, the lecturer remarked that the questionis whether this disease during the life of the child reallyoccurs as a primary pathological change, or is invariablypreceded by some exudation or other morbid change whichinitiates the fatty metamorphosis. Fatty degeneration,whether it occurs as a primary change or is the secondaryeffect of some other pathological condition which precedesit, may produce softening and disorganisation of the placentaltissue, and so favour extravasation of blood or apoplexy. Inother placentae it leads to atrophy. Virchow has describeda very curious morbid transformation of the villi of theplacenta, which he terms" myxoma fibrosum: It consistsof such enlargement of the stems and villi by fibroid hyper-trophy that they form in some cases distinct tumours in theplacental structure. Cases of this disease are somewhat rare;but Dr. Priestley has seen two excellent examples in Copen-hagen, which have been described in Virchow’s Archiv, in1878, by Storch. Virchow regards the disease as a trans-formation of the mucous element pertaining to the villusstructure into fibroid tissue, instead of the soft myxomawhich is seen in cystic chorion. The fibroid change is, how-ever, unlike the cystic chorion, more frequently connectedwith the later period of pregnancy, although indications ofit are sometimes seen in the earlier months.

Passing over oedema of the placenta, melanosis, calcareousor osseous concretions, cysts and tumours, Dr. Priestley thencame to the subject of syphilitic placenta, concerning whichmuch diversity of opinion exists. So far as his observationgoes, he does not think we are yet able to say with precisionthat any one specific lesion of the placenta belongs alone tosyphilis, although some morbid appearances are more constantthan others in connexion with syphilis-as, for example, thechanges described by Frankel. In addition to the hyper-trophy of the villi described by niinkel, and morbid changesin the decidua, he had seen fibroid deposits, such as thosedescribed by Rokitansky--some unchanged, others under-going fatty transformation. Again, he had seen the yellowishgranulations of varying sizes looking like tubercles, as ob-I served by Lebert; but he had also seen most, if not all, of

I these pathological appearances where no syphilitic historyI could be traced. The nearest approach to precision in this, respect is to say, as a general rule, whenthedecidualormater-L nal portion of the placenta has become so far changed by. hyperplasia as to arrest the utero-placental circulation and ther full development of the placental villi, that this is probably

due to maternal syphilis. It finds its analogy in the changeswhich take place in the mucous membrane in the uterus

3 and elsewhere when the blood is undoubtedly poisoned by1 syphilis, and also in the thickening of the decidua duringi the early pregnancy of syphilitic women, which hasf been described by Virchow and Dohrn as "endometritisi papulosa et tuberosa." When fibrinous and pseudo-tuber-

cular deposits are found in the placenta in connexion withti syphilis, they are probably only the expression of a de-d praved or impoverished condition of the blood, which mayj, be equally associated with anaemia or with some form ofd dyscrasia. When there is marked hypertrophy and de-n generation of the villi, the maternal portion of the placentalS being less affected, the syphilitic taint more probably comesy from the male parent, and the mother may show no signs of

867

the disease. Both Depaul and Tarnier, among modernobservers, dispute the existence of absolutely specific lesionsin the placenta as the result of syphilis. De Sinéty, one ofthe latest writers quoted by Caarpentier, did not llnd

placental lesions in all women affected with syphilis, butwhere lesions were present he was able to demonstrate threeimportant points: (1) hypertrophy of the placental villi;(2) fibrous degeneration of them; (3) ilands of granulationbelonging to the caseous forms ot degeneration. Tnis co-incidence of the fibrous and caseous forms of degeneration isfound in syphilitic gumma, notably in gummata of the liver.De Stnety had not tound this comoined degeneration exceptin syphilis. He does not know if any other disease may pro-duce the combined changes, and does not decide the questionas to a specific placental lesion in connexion with syphilis.In reference to all diseases which affect the placenta, it is tobe noted that the effect on the life of the child bears a directrelation to the amount of damage done to its tissues, andimpairing its double function as an organ for respirationand absorption. In cases of separation of the placenta, aportion still adherent to the uterine walls may be enough tosustain the life of the child, for a time at least ; and, in likemanner, when the placenta has become diseased, if some

portions of it only remain sound, vitality may still bemaintained in the body of the foetus. If the morbid processbe slow and chronic, there will probably be progressiveemaciation; and if the child be born alive, it will have allthe appearances of being starved during its development.If the placental disease is more acute and rapid, and affectinga large area of tissue, the child’s movements become at firstmore restless than usual, and then become less marked anddistinct as they subside into absolute quiescence. With theaid of the stethoscope the beats of the foetal heart haverepeatedly been noted in cases of suspected placentaldisease to become slower and slower, and thus to furnishimportant indications for the induction of premature labour.Among the further causes of foetal death in utero whichDr. Priestley said he could not in these lectures overtakeare the pathological conditions of the umbilical cord, ante-partum haemorrhage, extra-uterine gestation, and alliedconditions, the malformations and diseases of the unbornchild-the most fertile cause of the latter probably beingsyphilis. Time, also, did not permit him to speak of thechanges taking place in the body of the foetus when it islong retained in the uterus after its death; of the inferencesto be drawn as to the cause of death from the appearancesit presents after longer or shorter periods of retention ; andother kindred topics.With regard to the subject of preventive treatment, Dr.

Priestley stated that, so far as obviating some of the formsof intra-uterine death is concerned, we are absolutely in thedark, and the therapeutics of the subject are still a closedbook. Still, a careful study of the several pathological con-ditions in the parents, combined with the local expressionof the results of these conditions, allows in some cases ofmethods of treatment being formulated and of rules forguidance being laid down which in practice have baenattended with happy results. Whenever, therefore, a womanhas once or more frequently lost the product of conceptionat an early or later period, careful inquiry should be madeinto the health of both parents, and any previous history ofillness should be accurately scrutinised. No pains must baspared to ascertain whether syphilis is at the root of the mis-adventures. When either parent has, in the near or distantpast, contracted this disease, both should at once be put underanti-syphilitic treatment before a fresh conception is per-mitted, and this ought to be sufficiently prolonged to give ita fair chance of producing satisfactory results. Dr. Priestleysaid that he had repeatedly seen good effects from small dosesof bichloride of mercury, with bark, given during the firstthree months of gestation, when there has bean no oppor-tunity of commencing the treatment before conceptionbegan. Similar favourable results have been observedto follow the administration of iodide of potassium. Ifinquiry shows that the health of either parent is disorderedor deranged from some other cause than syphilis, care mustbe taken to trace out the nature of the deviation fromhealth, and so to define it that treatment fulfils its purpose.Xot the mother only, but the father also, must be put undersupervision. Any constitutional peculiarity or diathesismust be met by appropriate means-the strumous, by tonicsand cod-liver oil, with such improved climatic conditionsas may be feasible; the gouty rheumatic by limitations ofdiet, careful regimen, and alkaline medicines. Keeping the

bowels of women who are liable to abortion unloaded byaperients is important. Such laxatives as are not likely tostimulate undue action of the bowels or straining must bechosen, else the medicines may stir up the very mischiefthey are given to prevent. Compounds of sulphur, theconfection of senna, and saline aperients seem best tofulfil the needful indications. The advantages of generalbloodletting are doubtful, and its employment may lead toharm instead of good; but local depletion by leechesis less objectionable. For anaemia, preparations of ironmust be administered in some form least likely todisturb the digestive organs of the patient, and these shouldbe given not only antecedent to the occurrence of conception,but continued with such modifications and in such com-binations as may be suitable during the progress ofpregnancy. Where local conditions have been ascertainedor suspected to be the cause of repeated abortion or of laterfoetal death, the treatment must be directed in accordancewith the special requirements of the case. Especial careshould be taken to remove as far as possible all indicationsof endometritis prior to the commencement of pregnancy,an unhealthy condition of the lining membrane of the uterusbeing regarded by most authorities as a potent cause ofdisease in the fcetal membranes and placenta. Rest in therecumbent position is important, especially at the times whichcorrespond to the days of the catamenial period, and all formsof locomotion likely to jar the body must be sedulouslyavoided. Chlorate of potash, Dr. Priestley thinks, may actusefully as an alkaline salt in preventing the formation ofcoagula and fibrinous deposits in the placenta. In instanceswhere the progress of zymotic disease or of inflammationin some organ of the patient’s body is attended with hightemperature, he suggested that an attempt should be made.to lower the temperature of the uterus and of the foetuseither by the application of ice-bags to the maternal abdo-men, or of those tubular appliances for the application ofcold which may be modified to fit any part of the body.Some of the baths and waters on the Continent have a highreputation for their tonic properties and their favourableinfluence on pregnancy. Aix-les-Bains is said to be useful inthese cases. Courses at Schwalbach and Kissingen havebeen followed by happy results. The former place is moreappropriate for patients who are more or less anaemic,.Kissingen for those in whom the digestion and portalsystem are at fault.

ON THE USE OF THE

THERMOPILE AND SECONDARY BATTERIESAS A CONVENIENT MEANS OF PRODUCINGELECTRICITY FOR MEDICAL AND SUR-GICAL BATTERIES.

BY ALEX. OGSTON, C M.,PROFESSOR OF SURGERY, UNIVERSITY OF ABERDEEN.

ELECTRICITY has never played so important a part in theroutine of daily practice and consulting-room work as itsundoubted usefulness would seem to indicate that it should.In comparing it, for instance, with the stethoscope andthermometer, we find that, while these are m the hands of-every physician and surgeon, electricity is hardly met withat work, save in the chambars of a few specialists and in afew well-equipped hospitals. Many common mechanicalinstruments for studying and treating disease-such as themeasuring line, the weighing machine, the concave reflect-ing mirror, and the cpeculum-are regularly employed bythe majority of practitioners; while electricity, despite itsvalue in the diagnosis and treatment of nervous disease, asan unsurpassed illuminating agent, as an electrolytic de-stroyer of diseased tissues, tumours, and nsevi, as the mostmanageable cauterising agent, and as supplying the electro-magnet for extracting fragments of iron from the eye-ball, is superseded for these purposes by less efficientmeans. The expense of electrical apparatus, and thewant of knowledge concerning it, are not the chiefreasons for this neglect. The explanation is to be foundin the extreme inconvenience attendant upon the methodsof generating electricity at present employed. Not tomention, then, the initial cost of procuring a good com-bined battary, capable of furnishing both continuous and