them mechanically to effect the displacement of the caput cœcum. At the same time, however, we derive some probability of their formation at that early period, not only from considering that their necessary agency would have been such as to have produced the result in question, but from our having in other analogous cases decisive evidence that morbid peritonitic adhesions formed during intra-uterine life have, in the indirect mode that we have indicated, occasionally given rise to marked displacement of portions of the intestinal canal. In fact, the particular instances of congenital and foetal hernia which we have considered under the previous section, may in reality be looked upon as so many examples of true malformation by displacement, resulting from such a cause. We make this remark in reference to the various examples of displacement of the intestines that we have cited from Bartholin, Reisig, Cloquet, &c., under the heads of umbilical and diaphragmatic hernia; and it perhaps applies in a still more direct manner to the cases that we have quoted from Sandifort, Jobert, and others, in which the inflammatory adhesions resulting from previous foetal peritonitis produced various displacements of the cœcum, omentum, &c., by the testicle to which they were morbidly united, dragging them more or less along with it during its descent from the abdominal cavity. But, in addition to these, we may here also recall to our recollection that other analogous facts seem to show, that the occasional retention of the testicle within the abdomen for some years after birth, or, as sometimes happens, during the whole of life, may depend upon a similar cause, viz., on inflammatory adhesions formed between the testicle with the more fixed abdominal organs which it meets with during its descent. Thus Cloquet' mentions an instance in which he found, in an aged adult, the left testis natural in size, but retained within the abdomen, one inch above the upper opening of the inguinal canal, by a strong, short, rounded, fibrous cord or false membrane, which bound the epididymis to the sigmoid flexure of the colon. And we know further, from the researches of M. Serres,2 that in cases, such as this, the cœcum will not in general occupy its own natural position within the abdominal cavity, since it has been shown that there exists a fixed relation between the position of that bowel and the position of the testicle in the male, and the ovary in the female. The following instance of morbid adhesion of one of the testicles within the abdominal cavity, and of partial displacement of the intestines in connection with the same cause, furnishes an apposite illustration of some of the preceding remarks. 1 Recherches sur les Causes et Anat. des Hernies Abdominales, p. 24, pl. v. fig. 2. CASE XXX.-On dissecting, with Mr. F. Angus, 1st November, 1838, the body of an anencephalic fœtus, I found, on opening the abdomen, particles of coagulable lymph on several points of the abdominal peritoneum, and upon the upper surface of the right lobe of the liver. The contiguous folds of the small intestine were in various places agglutinated by coagulable lymph. The small intestine was in several points, also, adherent to the large, as, for instance, very extensively along the transverse and descending colon, by the medium of a strong web of coagulable lymph. The caput cœcum was displaced. It lay fully an inch above its natural situation, and was bound down to the peritoneum covering the right kidney, by a quantity of false membrane. The surface of the large intestine was very adherent to the abdominal peritoneum at the top of the descending colon. At its sigmoid flexure this bowel was twisted forward; it formed one fold in the left iliac region, and then stretched upwards and across for more than an inch, till it reached the right lumbar region and touched the appendix vermiformis, when it again turned round at a very acute angle, and ran downwards behind the urinary bladder. The pelvic viscera were matted together by coagulable lymph; and the posterior surface of the bladder was intimately united by false membrane to the first mentioned fold of the sigmoid flexure, and to that part of it situated immediately above the rectum. A fold of small intestine lay in the angle of the second fold of the sigmoid flexure, and was morbidly adherent to the mesocolon. Two other folds of the small intestine were firmly bound down by morbid adhesions into the right iliac fossa, and thus occupied the natural situation of the caput cœcum. The right testicle lay nearly contiguous to them, and was there imbedded in a quantity of coagulable lymph, which in a similar manner strongly attached it to the peritoneal surface of the iliac fossa. The left testicle was not morbidly adherent. The lower surface of the right lobe of the liver was studded with numerous small masses, which, on section, had all the usual physical appearances of semicretaceous tubercle. A few such bodies were also seen on the lower surface of the left lobe, and some of them were imbedded two or three lines deep in the substance of the organ.' The spleen was 1 Bonetus, in his Sepulchretum Anatomicum (tom. iii. p. 104), mentions a case exhibiting an analogous morbid appearance in the fœtal liver. "In jecore fœtus abortivi sex mensium, ad lobum infimum detectus est tumor inequalis, asper tophorum particulis tanquam confractis cerasorum nucleis, absque pure, tamen plenus visu tactuque durus." Wrisberg (Sandifort's Thesaurus Dissertationum, tom. iií. p. 214), gives a case in which several biliary calculi were detected in the gall-bladder of a woman who died during parturition. The child died seven weeks after birth, and from the dissection it appeared that a tendency to the formation of similar morbid concretions in the same organ had been transmitted from the mother to her offspring, for, on the examination of its body, " vera concrementa calculosa, small and healthy. The thoracic organs were sound. The lungs were solid, the child never having breathed. CASE XXXI.-On the body of a dead male fœtus, sent to me by Mr. David Angus of Glasgow, I found numerous adhesions from coagulable lymph in different parts of the abdominal cavity. The spleen was covered on its convex surface with a web of false membrane. A fold of the sigmoid flexure of the colon crossed completely over to the right side of the vertebral column, and was firmly retained by the morbid adhesions to the peritoneum in that anormal situation. The caput cœcum and its vermiform process were placed in the right lumbar region.' As one additional illustration, from among many others that might be quoted, of the strong effects of morbid contractions and adhesions in producing malformations by displacement in the manner alluded to, I may here refer to a remarkable case of congenital hernia of the ovary, represented by Billard' in the atlas attached to his work on the diseases of infants. The sketch which is given of the case shows that, in consequence of the great and apparently morbid shortening of the left broad ligament of the uterus, the ovary, which is naturally very intimately attached to this ligament, has been dragged during intra-uterine life through the inguinal canal, and the uterus itself, by a similar mechanism, has been partially displaced towards the left side.3 The kidney also of the same side has, as is seen in his plate, been dragged downwards below the level of that of the opposite side by the contraction of the cellular tissue around it, and by a fold of membrane connecting it intimately with the abdominal orifice of the hernial sac. The renal artery and vein have yielded to the same cause of displacement, and are seen to have become elongated in consequence of it. In fact, after the ovary had once become displaced and fixed, it would seem that all those other more loose and movable viscera of the left side of the abdominal cavity, which were in any way intimately and organically connected with it, and the uterine ligaments, came themselves to be displaced in turn by being held in morbid approximation to the site of the protruded organ, and thus not allowed to follow those salbuli instar," were found in the gall-bladder. The liver of this infant was at the same time large and indurated, a condition, which we may look upon as indicating a chronic, and hence probably an intra-uterine, diseased state. 1 This and the preceding case were shown to the Anatomical Society; and I have preparations of them in my Museum. 2 Atlas, Tab. x. Traité des Maladies des Enfans, p. 492. 3 I have in my possession a preparation showing a well-marked instance of anteversion of the uterus in the fœtus, in consequence of either an original or a morbid shortening of both the round ligaments. gradual changes of relative distance and position that naturally occur under the general enlargement of the abdomen in the course of the development. In an essay on abortion as dependent on morbid organic conditions of the uterus, Madame Boivin has shown that the existence of old inflammatory adhesions between the uterus or uterine appendages, and any of the more fixed organs in their neighborhood, may lead to an early expulsion of the embryo, by preventing, during pregnancy, the uterine tumor becoming developed beyond a fixed and limited point. The same author has further suggested that the peritoneal inflammation producing such adhesions may occasionally occur during intra-uterine life, when the uterus is strictly an abdominal and not a pelvic organ.' In my former communication, I have detailed one instance (Case VII.), in which I found some patches of coagulable lymph adhering to the right Fallopian tube of a fœtus that had died in utero about the seventh month of pregnancy. Unless, however, this lymph was thrown out in large quantities, and formed very strong false membranes, it is doubtful whether it could have persisted for such a long period after birth as Madame Boivin supposes. At least we know, that, after the lapse of a considerable time, old suffused lymph or false membrane is often more or less entirely absorbed, as attested by numerous experiments and observations on adhesive inflammation of the peritoneum in the adult by Ribes, Beclard, Dupuytren, and others-by the ulterior stethoscopic history of some cases of pneumonia that had reached the stage of hepatization-and by what we have constant opportunities of seeing in cases of iritis, in the transparent portion of the eye-an organ which affords us a beautiful microcosm for the accurate and direct observation of this and other similar pathological phenomena. The consideration of the above pathological point suggests it as an interesting question, whether in some of those cases of partial transposition of the viscera that we have described, the absence of all appearance of peritonitic adhesions or false membranes in the adult may not depend upon the absorption, during the intervening period, of those adhesive bands that led to this visceral displacement in the early fœtus? The facts adduced by the pathologists I have just named, give to such a supposition a degree at least of great probability, if not of inductive certainty; and hence a much greater number of visceral displacements may possibly have such an inflammatory origin as we have described, than can be proved by any anatomical examination of them in the adult subject. We have already stated, that, in instances of malformation by 'Recherches sur l'une des Causes de l'Avortement, p. 57. displacement among the abdominal viscera, arising from peritoneal inflammation in the early foetus, the intestines were, in some cases, retained by their morbid adhesions in those positions which they were intended to occupy for a transitory period only during intrauterine life, and so far we may look upon these adhesions as liable also at the same time to produce malformation by arrestment of development. This last effect, however, of abdominal inflammation in the embryo may be even more marked when the inflammatory action extends from the peritoneal surface to the structure of some of the more solid organs which the membrane envelopes. Thus, for an example of this inflammatory origin of some cases of malformations by deficient development, let us return for an instant to the testicles. I have already alluded to the effect produced by fœtal peritonitis in causing malformation by displacement of the organs. If the same organs, from any general abdominal inflammation, had, on both sides, their substance as well as their surface attacked by inflammatory or other morbid action, so as to produce such lesions of them as would impede or destroy their full development, their own organization would not only be prevented from arriving at perfection, but the power which their development appears to exercise upon the development of the other sexual organs and of the system in general, would be more or less completely suspended. In old age, the natural atrophy, and during adult age, the destruction of these organs by disease or by operation, produces a very marked effect upon the stability of those anatomical and physiological changes which constitute the secondary sexual characters; -if they are disorganized or removed at or before puberty, then these secondary characters are only very imperfectly evolved, or remain altogether undeveloped; and if their disorganization were effected in an early stage of embryonic life, there are various facts, we conceive, which go far to show that the different subordinate sexual organs themselves would be arrested in their further development, and present to us at birth in the reproductive apparatus, under a permanent form, one or other of those various but naturally temporary types of foetal sexual structure, the persistence of which constitutes a large class of hermaphroditic malformations by deficiency which we occasionally meet with in the higher animals. INFLAMMATORY ORIGIN OF SOME MALFORMATIONS IN OTHER There appears to us to be every reason to believe that inflammatory action in the other serous cavities of the embryo may lead to occasional malformations among the visceral contents of these cavi I See my article on Hermaphroditism, in Todd's Cyclopædia of Anatomy, vol. ii. pp. 733-34, &c., given in a future page. |