Book - Ectopic Pregnancy 1895

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Webster GJ. Ectopic Pregnancy - Its Etiology, Classification, Embryology, Diagnosis , and Treatment (1895)

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Most of the cases described in this historic 1895 book would today be detected by ultrasound during the first trimester scan.



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Ectopic Pregnancy

Ectopic Pregnancy - Its Etiology, Classification, Embryology, Diagnosis , and Treatment.

By

J. Clarence Webster, B.A., M.D., F.R.C.P.Ed.,


Assistant To The Professor Of Midwifery And Diseases Of Women And Children In The University Of Edinburgh.


With Eighty Illustrations Of Naked Eye And Microscopic Appearances.


Edinburgh And London: Young J. Pentland.


1895.


Edinburgh I Printed For Young J. Pentland, Ii Teviot Place,

And 38 West Smith Field, London., E.C., By Scott And Ferguson And Burness And Company.

Dedication

To My Friends


A. H. Freeland Barbour And D. Berry Hart.


Introduction

The subject of [[Ectopic Pregnancy has received a great deal of attention during the last few years both in Europe and America. Though the importance of the subject might be considered a sufficient justification for the publication of a work which is an embodiment of the recent advances made in our knowledge of the nature and treatment of the condition, the author urges a stronger plea, viz., that he is able to bring forward for consideration a large body of original matter, based upon several years clinical and laboratory work.


He desires especially to call the attention of the embryologist, and of the scientific teacher of Obstetrics, to the chapters on Development. The detailed observations therein presented are the outcome of a careful examination of a large amount of material taken from the operation room and post mortem theatre during the last six years. The investigations have been carried on in the Laboratory of the Loyal College of Physicians, Edinburgh.


The author is also able, from an examination of the voluminous literature which he has collected, to bring to the light some interesting records of workers during the past three centuries, which have for a long time been overlooked.


Throughout the book, the word - Ectopic -  is used in preference to - Extra-Uterine. -  The former term was first used by Robert Barnes in 1873. It includes all gestations developing outside the uterine cavity, being therefore more comprehensive than the term - extra-uterine, which, in strictness, cannot be held to include interstitial pregnancy.


Though Cornual pregnancy is considered in this work, it is not included in the classification of ectopic gestations, because, of course, this form of pregnancy is developed in relation to the cavity of the uterus, though the latter is mal-developed. It is necessary, however, to describe the condition in connection with ectopic pregnancy, because of the many resemblances between them.


The author is deeply indebted to Professor Simpson, Drs. Halliday Groom, Berry Hart, Freeland Barbour, and several other friends for the material which he has obtained from them; and also to Mr. Cathcart, Curator of the Museum of the Royal College of Surgeons, Edinburgh, for permission to investigate the specimens of ectopic pregnancy in his care.


Several illustrations are taken from the publications of Berry Hart, Orthmann, Bland Sutton, Sir Wm. Turner, and the author. The great majority of the plates, however, are from original water-colour drawings made by the author, and hitherto unpublished.


My thanks are due to Mr. James Y. Simpson, M.A., for his kind assistance in the revision of the proofs.


JOHN CLARENCE WEBSTER.

20 Charlotte Square, February 1895 .


Contents

  • Chapter I. Etiology.
    • Place of fertilisation of ovum - Part played by epithelium of mucosa - Nature of menstruation - Changes in the non-pregnant tube - Decidual reaction - Improbability of ovarian pregnancy
  • Chapter II. Classification.
    • Early described cases - Old classification - Opinions of old writers - Present views - Author’s arrangement
  • Chapter III. Varieties Studied In Detail.
    • Ampullar tubal pregnancy - Extra-peritoneal pregnancy - Sub-peritoneoabdominal pregnancy - Rupture into peritoneal cavity - Haematoma formation - Intestinal escape of fcetus - Tubo-peritoneal pregnancy - Cases of doubtful nature - Haemorrhage into peritoneal cavity - Sequelae of haematocele - Effect of blood on peritoneum - Tubal abortion - Haemato-salpinx
  • Chapter IV. Varieties Studied In Detail Continued.
    • Interstitial tubal pregnancy - Changes in interstitial pregnancy - Infundibular pregnancy - Cornual pregnancy - Wandering of ovum - Adipoeere formation - Lithopaedion formation - Placenta after foetal
  • Chapter V. General Considerations.
    • Age - Side of the gestation - Repeated ectopic gestation - Plural ectopic gestation - Intercurrent uterine gestation - Hernia of ectopic gestation
  • Chapter VI. Developmental Changes.
    • Changes in the tube wall - Peritoneum - Muscular part of the wall - Decidua vera - Decidua serotina - Changes in decidua - Decidua reflexa - Relations between ovum and decidua - Fcetal epiblast - The chorion - Placental chorion - Villi and decidua - Non-placental chorion - The amnion
  • Chapter VII. Symptoms And Signs.
    • Symptoms resulting from the pregnancy per se - Periodic colicky pains - Discharge of uterine decidua - Stirrage - -Abdominal enlargement - Ecetal movements - Changes in the uterus - Phenomena occurring at full term - Spurious labour - Bimanual examination- - Symptoms resulting from complications - Pressure effects - Pain - Haemorrhage - Suppuration - Death of foetus
  • Chapter Viii. Diagnosis.
    • Uterine pregnancy - Retroversion of the gravid uterus - Ovarian tumours - Haematocele and haematoma - Inflammatory exudations - Malignant disease - Spurious pregnancy
  • Chapter IX. Treatment.
    • Injection of drugs - Compression of the gestation sac - Electricity - Elytrotomy - Modern treatment - Tubal pregnancy - Interstitial pregnancy - Rupture into peritoneal cavity - Rupture into broad ligament - Extra-peritoneal development - Secondary rupture - After spurious labour - Suppuration

Figures

Fig 1

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Sagittal lateral section (right) of pelvis, it sub-peritoneo-pelvic gestation in right broad ligament. (Hart)

Fig 2

Webster1895 fig02.jpg

Fig 3

Webster1895 fig03.jpg

Sagittal medial section of abdomen and pelvis, with advanced sub-peritonea-abdominal gestation. (Hart)

Fig 4

Webster1895 fig04.jpg

Sagittal lateral section of abdomen and pelvis, with advanced sub-peritonea-abdominal gestation. (Hart)

Fig 5

Webster1895 fig05.jpg

Another sagittal lateral section of the same ([[:File:Webster1895 fig04.jpg|Fig. 4) sub-peritonea-abdominal gestation. (Hart)

Plates

Plate 1

Webster1895 plate01.jpg

Plate 2

Webster1895 plate02.jpg

Plate 3

Webster1895 plate03.jpg

Chapter I. Etiology

Until recently the occurrence of Ectopic Gestation has been attributed to the following conditions : -

  1. Those meclianicctlly interfering with the passage of the ovum to the uterus, e.g . : - Peritonitic bands constricting the Fallopian tube ; Polypi in the tube lumen ; Tumours of its wall ; Tumours of surrounding parts pressing upon it ; Abnormal foldings of its wall ; Diverticula from the lumen in the wall ; Displacements and hernia of the appendages.
  2. Those interfering with the peristaltic action of the tube, e.g . : - Adhesions between the tube and neighbouring parts ; Thickening of its walls by inflammation.
  3. Those destroying the ciliary action of the epithelial cells lining the tubal mucosa, e.g . : - Endosalpingitis.


I think it is unnecessary to mention various' mental and moral conditions, e.g., fright, strong passion, etc., at time of coitus, cited by Astruc , 1 Eamsbotham , 2 Eaudelocque , 3 and others, as causes of ectopic gestation.


A careful analysis of these various conditions, hitherto described as the causes of tubal pregnancy, leads to the conclusion that the views current in regard to the subject are hazy and indefinite, their acceptance involving numerous contradictions as well as certain assumptions which are based entirely upon speculation, and, in some instances, not in accordance with facts. One of these assumptions is to the effect that in normal pregnancy the ovum becomes fertilised in the Fallopian tube ; another, that this always takes place in the uterus. A very widely held view is that a fertilised ovum will grow in a tube with a healthy normal mucosa if it merely be prevented by some mechanical obstruction from reaching the uterine cavity; another assumption of more recent origin is that this cannot take place, but that development will only occur when the epithelium of the mucosa has been destroyed by inflammation.


That the above tabulated conditions have been founded upon observations is undoubtedly true. To associate them in some way with the occurrence of the tubal pregnancy is natural; but to establish them as the ultimate or essential factors in its causation is anything but logical.


It is my endeavour in this chapter to analyse carefully the relationship which these conditions bear to ectopic gestation, and to endeavour to allot to them their true proportional values as factors in its causation. In addition, I desire to bring forward some new observations in the hope of removing many of the difficulties connected with the subject, and of establishing a more scientific basis for its future investigation.


1 - Traits des Maladies des Femmes, -  Paris, 1675, tome iv., p. 69.


2 Loud. Med. Gaz., 1849, N. S., vol. viii., p. 651.


3 - Diet. d. sc. m6d., -  tome xix - ž p. 399.



Place of Fertilisation of Ovum

It is necessary, in the first place, to consider one question which has an important bearing on the subject, viz., where the spermatozoa fertilise the ovum. It is generally believed that their meeting place is normally, the Fallopian tube. Lawson Tait, Wyder, and a few others, believe that it is the uterine cavity ; they hold that the ciliary action of the epithelium of the tubal mucosa prevents normally the spermatazoa from passing into the tubes.


Mr. Tait’s words [1] are : - - The uterus alone is the seat of normal conception ; as soon as the ovum is affected by the spermatozoa it adheres to the mucous surface of the uteius, the function of the ciliated lining of the Fallopian tubes is to prevent spermatozoa entering them, and to facilitate the progress of the ovum into the proper nest ; . . . the plications and crypts of the uterine mucous membrane lodge and retain the ovum either till it is impregnated or till it dies or is discharged. - Without referring to the lower mammals, regarding which but scanty observations have been made, facts derived from the study of ectopic human pregnancy furnish evidence in favour of the view that spermatozoa can make their way from the uterine cavity into the tube lumen, whose lining epithelium may be healthy. It is not uncommon to find an early tubal pregnancy in the outer end of a tube whose inner end is perfectly normal. Such cases have been examined by Bland Sutton , [2] Martin , [3] Veit , [4] myself, and others. This being so, it is difficult to know why fertilisation may not take place in the tube in any number of cases where the parts are entirely healthy.


That it may also take place within the uterine cavity cannot, of course, be denied. The truth is probably that the spermatozoa care capable of working their way into both uterus and tubes, fertilising the ovum wherever they chance to meet it.



Another important question to he considered is the following ; - is there any ground for supposing that a fertilised ovum can develop in the normal mucosa of the Fallopian tube –  That such a thing is possible has long been believed, especially by those who have insisted on the importance of mechanical obstruction as a cause of tubal gestation.


If the genital tract be studied phylogenetically, it is found that in the lowest animals there is no marked distinction between oviduct and uterus ; that, in higher forms, each lateral tube becomes differentiated into an upper oviduct portion and a lower uterine portion ; and that, in the very highest forms, the lowest portions blend into a single uterus. In these highest mammals only the uterus is able normally to furnish the place of development for the ovum; the upper ends of the original lateral tubes, i.e., the oviducts or Fallopian tubes, though remaining in continuity with the uterus, retain only the power of carrying the ovum from the ovary to the uterus. The tubal mucosa and that of the uterus ( corpus uteri) behave differently in the reproductive process - the former is passive, the latter active ; the one undergoes no important changes, the other reacts markedly to the genetic influence, becoming transformed into the decidual tissue, which is, it must be believed, essential to the attachment and development of the young ovum.


The differentiation is as well marked as that between the lining membranes of the oesophagus and stomach. There is no more authority for supposing that the normal tube can perform the function of the uterus than for believing that the oesophagus can perform that of the stomach. In each of these cases the evolution of structural differences has been accompanied by marked functional differentiation.



PART PLAYED BY EPITHELIUM OF MUCOSA. 5 No doubt the resemblance between the epithelial cells of the uterine and tubal mucous membranes and their direct continuity have helped to establish the assumption that the ovum can develop in relation to one set as well as in relation to the other. Such an assumption is, of course, entirely unwarranted, because structural similarities do not necessarily imply physiological harmonies or identical reaction tendencies.


Moreover, all recent work, c.g., that of Minot , 1 Hart and Gulland , 2 myself , 3 and others, goes to show that the lining epithelium of the mucosa, both in tubal and uterine gestation, plays an entirely negative part as regards the development of the ovum.


Next, what is to be said regarding the statements that the ovum can develop in the tube only when the lining epithelium has been destroyed by inflammation ?


It might be sufficient, in refutation of this belief, only to mention those cases of tubal pregnancy in which no inflammatory or other diseased condition is found in the mucosa. Moreover, in some of the cases in which inflammation is found, there can be no doubt that it follows upon the disturbances in the tube attendant upon the development of the gestation. This has been strongly urged of late by Martin , 4 whose recent observations have led him to give up his older views 5 regarding the part played by endosalpingitis in causing tubal pregnancy.


Bland Sutton 6 is of the opinion that the so-called causal relation between desquamative salpingitis and tubal gestation is mere speculation which contains an element of truth, but does not hold in all cases. He points out that where the inflammation is so severe as to destroy the tubal epithelium, stricture and occlusion of the outer end of the tube usually occur as well ; it is very rare to find tubes denuded of their mucosal epithelium and with a patent fimbriated end.


1 - Uterus and Embyro, -  Journ. Morphol., Boston, April, 1889.


Rep. Lab. Roy. Coll. Phys ., Edin., vol. iv. 3 See Chapter on Development.


4 Op. cit., vide supra.


Ztschr. f. Oeburtsh. u. Gyndk ., Stuttgart, bd. xiii., p. 298.



11 Op. cit., p. 309.



One might also justly state that, whereas inflammation in the endometrium is not favourable to the development of uterine gestation, so inflammation in the tubal mucosa is unfavourable, to the development of a tubal pregnancy.


I wish, however, to consider this statement as part of a more comprehensive idea which has been strongly urged of late, more particularly by Lawson Tait, 1 and also by Berry Hart, 2 viz., that the human ovum can graft itself only on a connective tissue from which the covering epithelium has been removed. Mr. Tait holds especially that in normal uterine pregnancy this supposed necessary raw surface is prepared by menstruation, as was first suggested by Pfluger, and in tubal pregnancy by endosalpingitis. In referring to the uterus he used the words - a healthy mucous surface freshly denuded ; -  and in reference to the tube he says that - a desquamative salpingitis could put the mucous lining of the tube into a condition exactly similar to that of the uterus. -  This statement is open to the criticism that, while a resemblance might possibly be pointed out between an endometrium partially denuded and an early acutely inflamed mucosa, there is not a very close resemblance in the case of chronic inflammatory surface.


That these authors are right in insisting upon the passive and unimportant part played by the epithelium of the mucosa, both in the case of tubal and uterine pregnancy, cannot be too strongly urged. All the latest embryological investigations give support to the view that the attachment and early development of the ovum takes place entirely in relation to the subepithelial connective tissue of the mucosa. I take except tion, however, to the explanation of the early establishment of this relationship in normal pregnancy, on account of the great difficulties in the way of believing that menstruation is the process essential to the removal of the epithelium and the consequent laying bare of the connective tissue. These difficulties are as follows : -

  1. Pregnancy may occur in a girl before the onset of menstruation, at a time, therefore, when the mucosa cannot be denuded by that process.
  2. It may occur late during the period of lactation when there is no menstruation and after the mucosa has been completely renewed.
  3. It may take place at the menopause during a period of amenorrhoea.
  4. Pregnancy may occur in the rudimentary horn of a malformed uterus, menstruation never having taken place in that horn {vide p. 92).
  5. It may occur in periods of amenorrhoea associated with diseased conditions, e.g., anaemia, phthisis.
  6. Clinical experience of cases of pregnancy following a single coitus shows that the ovum may begin to develop at any time - not necessarily immediately after menstruation. {Evidence in regard to this point, lioivevcr, is of doubtful significance, otoing to the uncertainty in our knowledge as to hoio long the spermatozoa may remain in the genital tract, and how long the ovum may take in some cases to reach the uterus.)
  7. In the great majority of the mammals menstruation does not take place, and in many of them we know that the early ovum develops in relation to the connective tissue of the mucosa, the superjacent epithelium being removed by the ovum itself.



Op. cit., p. 439. 8 - Selected Papers, -  1S93, p. 61.


Indeed, it is not at all necessary to look to menstruation as the process by which the epithelium is removed. The absorptive power of the trophoblast or outer layers of the foetal epiblast is an important factor in bringing about its disappearance. My recent studies in early tubal pregnancy lead me to believe that this is also accomplished partly by another agency, viz., the rapid changes in the connective tissue of the mucosa leading to the formation of the decidua vcrct, causing the covering epithelium to be stretched and broken up.


Regarding the exact nature and significance of menstruation we are still ignorant. The opinion of Hirsch , 1 Slavianski , 2 Reeves Jackson , 3 Lawson Tait , 4 and others, that ovulation and menstruation are entirely independent of one another, can scarcely be disputed. The recent work of Heape 5 is confirmatory of this belief ; he examined the genitals of Semnopithccus cntcllus in forty-two cases of menstruation, and found that only in two was there any evidence of a discharge of ova from the ovaries. It seems certain that ovulation does not necessarily take place during menstruation, and that menstruation is not due to ovulation.


The views of Leopold and Mironoff , 6 who have lately worked at this subject, are as follows : -

-  Ovulation usually accompanies menstruation, though not always. Menstruation depends upon the presence of the ovaries and a well-formed uterine mucosa. Ovulation usually coincides with menstruation ; it rarely occurs in normal conditions between the menstrual periods.

There is considerable evidence in favour of the view that the menstrual function is connected with a special nervous mechanism. Christopher Martin , 7 in his recent paper on this subject, thinks that there is reason to believe : -


1 Schmidt - ™s Jalirb., Leipzig, 1850. 2 Arch, dc physiol, norm, ct path., Paris. 1S74.


3 Am. Journ. Obst., N.Y.. Oct. 1876. 4 Op. cit., p. 300 ct scq.


6 Proc. Roy. Soc. London, vol. liv., p. 169.


8 Arch. f. Gynack., Berlin, bd. xlv., lift. 3.


7 - The Nerve Theory of Menstruation, -  Med. Press and Circ., Loudon. 1893, vol. lvi., p. 420.

References

  1. Diseases of Women and Abdominal Surgery, -  18S9, vol. i., p. 439.
  2. Surgical Diseases of the Ovaries and Fallopian Tubes, -  1891, p. 310.
  3. Ueber ektop. Schwang.. -  Berl. Min. IVchnschr., 1893, Nr. 22.
  4. 7Aio.hr. f. Geburtsli. u. Gyndk., Stuttgart, bd. xxiv., p. 2.

Nature of Menstruation

  1. That menstruation is a process directly controlled by a special nerve centre.
  2. That this centre is situated in the lumbar part of the cord.
  3. That the changes in the uterine mucosa during the period are brought about by katabolic nerves, and during the interval by anabolic nerves.
  4. That the menstrual impulses reach the uterus either through the pelvic splanchnics or the ovarian plexus, possibly through both.
  5. That removal of the uterine appendages arrests menstruation by severing the menstrual nerves.

There can be little doubt that menstruation is not necessary to conception. The view of Hirsch, Lawson Tait, and others is that menstruation in the human female and rut in lower animals are different processes.


Regarding the extent to which menstruation occurs in the primates we are as yet ignorant, nor are we aware of the changes brought about by the change from the wild state to captivity. We are also in want of evidence in regard to menstruation among the lowest races of man, and also in regard to the variations which result when these races are civilised.


There is much difference of opinion regarding the anatomical changes in the uterine mucosa during menstruation. The latest evidence points clearly to the view that there is but a slight denudation, irregular in distribution in the superficial layers of the mucosa.


Having thus considered these important questions, I wish now to bring forward certain facts which seem to me of sufficient importance to suggest a sound basis for an explanation of the occurrence of ectopic gestation.


I have referred to the gradual evolution of the Fallopian tube and uterus, and to the marked differences in function which exist between them in the human female.


Hitherto it has been believed that in every case of uterine gestation the decidual changes in the mucosa which are apparently essential to the early ovum, and which result from some sympathetic reaction following its fertilisation, take place only in the body of the uterus, the tubal mucosa remaining unchanged. This view is based upon the microscopic examination of the tubes in normal pregnancy. It is also held that in cases of single tubal pregnancy, while the uterine mucosa undergoes marked decidual change, the non-pregnant tube of the other side remains practically unaltered. Recent observations which I have made prove that the latter statement is not accurate, and throw some doubt upon the value of observations made upon the tubes in pregnancy. To study these points thoroughly it is necessary to examine serial sections of every part of the tube, not of one part only, as is usually done.


The observations to which I refer will be found on pp. 120, 121. They may shortly be recapitulated here. In examining a large number of tubal gestations, I have found marked differences in the extent to which a decidua vera is formed. In some cases only a small part of the mucosa undergoes this change, in others a large part. In no case is there an absence of decidual formation. In those instances in which I obtained the non-pregnant tube (only in post-mortem cases), I always examined a small part of it. In one case, however, in which the tube was enlarged in its ampullary portion, I made a thorough examination of every part of it, and found to my great surprise that an irregular ring-like portion of the ampullary mucosa, in its entii - ™e circumference, differed markedly from the rest of the mucosa, as well as from the mucosa of every tube that I had examined. The differences consisted, in the first place, in a simpler arrangment of the folds than is found in the normal ampulla; they were much fewer in number, shorter, and only slightly branched. In the normal ampulla the delicate branching mucous hinges, as seen on transverse section, practically fill the tube lumen. In this case they formed thick projections, club-shaped, fingeishaped, wart-shaped, etc., extending inwards only for a slioit distance. In the second place, this part of the ampullary mucosa showed marked decidual formation, the large cells resembling exactly those found in the uterus in normal pregnancy.


The tube of the opposite side (the left one) was about two months pregnant, and the uterine mucosa showed marked decidual changes ; the left ovary contained a corpus hit earn, the right one (that on the non-pregnant side) containing none.


This case is most instructive. It emphasises most strongly that decidual formation is due to the influence of the fertilised ovum in the genital tract ; that this influence can act at a distance, direct contact of the ovum not being necessary ; that while in tubal pregnancy the uterine mucosa always undergoes this change, the tube of the other side may also sometimes be similarly affected.


In another case of an early tube pregnancy which I have recently examined, a large part of the non-pregnant tube possessed a mucosa entirely different from the normal tubal mucosa. Instead of consisting of a series of folds, it presented more of the appearance of the uterine mucosa, being of more or less uniform thickness, and filled with gland spaces lined with columnar epithelium. Only here and there did a partially formed fold exist. In the connective tissue stroma of the mucosa decidual cell formation was found in different places.


The uterus was well formed and normal.


All these facts, it seems to me, taken along with those relating to the evolution of the uterus and Fallopian tubes, suggest a hypothesis which lends itself to a satisfactory explanation of all the well recognised forms of ectopic gestation.


Among those animals (some non-mammalians) possessing a genital tract, the least specialised condition is that in which there is no distinction between oviduct and uterus, in which the tract is bilateral, and in which the ova may develop practically along its whole extent. In higher forms - certain mammalians - differentiation has occurred in the Mullerian ducts, as I have already described. In many .of these, e.g., cat, with bicornuate uterus, several ova develop in the whole extent of each horn, the mucosa undergoing the necessary decidual changes. In cases of human bicornuate uterus, usually only one ovum develops in one horn ; in other cases, one may develop in both horns ; in rare instances, two may develop in one and one in the other.


In other forms with bicornuate uterus, e.g., cow, only one ovum, as a rule, develops in one of the horns, but the mucosa of both horns undergoes, as a result of the genetic influence, marked decidual changes ; the same thing may be found in pregnancy in the uterus bicornis in the human female ; these changes are, in the case of the non-pregnant horn, as far as we know, entirely unnecessary to the development of the ovum in the other horn. It is well known that pregnancy may go on perfectly well in cases where one horn is absent. When we come now to the human female, in which the single uterus exists, we find that the decidual changes induced by pregnancy in the great majority of cases take place only in the uterine mucosa where the ovum normally grows.


However, in some cases, as I have shown, the tubal mucosa can, in great or small extent, respond to the genetic influence, as well as that of the uterus. This is probably because of some developmental fault whereby there is reversion either of structure or reaction tendency in the tubal mucosa to an earlier type in mammalian evolution - I mean that in which a larger poi lion of the Mullerian ducts showed decidual reaction.


Because of these occasional changes in the Fallopian tube, conditions are brought about capable of establishing with a fertilised ovum that relationship which is essential to its development.


If, then, the deduction be established that it is possible for a fertilised ovum to grow only in relation to that part of the genital tract, whether tube or uterus, in which the genetic reaction occurs, the explanation is evident, why in the human female a pregnancy may occur sometimes in a part of the genital tract outside the uterine cavity.


When the above mentioned conditions exist, in any case, several factors determine whether a fertilised ovum shall develop in the tube or uterus.


The place of fertilisation of the ovum is important. Ectopic gestation probably only occurs when this takes place in the tube above the part of the mucosa showing the decidual reaction. When it occurs in the uterus, the gestation will only take place there. Fertilisation may occur in that tube which does not show the decidual reaction ; or it may occur in the tube showing the reaction, but at a point lower down. It is possible, however, that it may occur above the reacting part, and yet be carried down past it to the uterine cavity, if no conditions exist which can prevent this taking place. And, in this connection, we are able to understand the part played by such conditions as inflammation, displacements, tumours, &c., in the tube or outside it, which lead to some interference with the free continuity of the tube lumen. Given the fertilisation of the ovum high in the tube, the obstruction to its free passage to the uterus after this takes place, along with the occurrence of the necessary decidual reaction in the mucosa with which the ovum comes in contact, and we have a satisfactory explanation of the pregnancy which develops.


The adoption of these views, which imply that the ovum can only begin its development on a tissue capable of a special genetic reaction, and therefore only in some portion of the passage derived from the original Mullerian ducts, makes it difficult to believe in the possibility of the occurrence of a primary abdominal - ¢pregnancy.


Though of late, owing to the writings of Bland Sutton, Lawson Tait, and Berry Hart, belief in the existence of such a gestation has been widely discredited, no well-founded reason has been raised to show why it should not .take place. Indeed, considering the factor which the two latter authors had believed to be of chief importance in the development of tubal pregnancy, viz., inflammation destroying the mucosal epithelium, it does not appear, according to that view, why a fertilised ovum might not attach itself and grow on a part of the wall of the abdominal cavity which had lost its superficial covering of cells through the same pathological process. According, however, to the view which I have advanced, the primary intraperitoneal development is improbable, because the peritoneal tissues cannot, as far as is known, undergo the changes required for the establishment of the necessary relationship with the young ovum.


As regards the ovary there is more difficulty. We have no reason to believe that the Graafian follicles can respond to the genetic influence, and there is no proof that a pregnancy has ever started in them.


Supposed cases of ovarian pregnancy require to be studied carefully, and in every instance must be distinguished from the following conditions which may be mistaken for it, viz., pregnancy in the outer end of the tube which has become intimately connected with the ovary ; pregnancy in an accessory tube end which has become attached to it ; pregnancy in the ovarian fimbria, which may be hollow sometimes, representing the extreme outer end of the tube; pregnancy in the tube which has extended into the ovarian sac of peritoneum, which occasionally occurs in women. (Also vide, p. 45.) Primary development of the ovum in the ovarian sac is as improbable as its development in any part of the peritoneal cavity.

Chapter II. Classification

In studying the literature of Ectopic Gestation two names, viz., those of Dezeimeris and Lawson Tait stand out in such prominence that they serve to indicate its division into three distinct periods, which may be stated as follows : - 1. The period before Dezeimeris; 2. The period between Dezeimeris and Lawson Tait ; 3. The present period.


1. The period before Dezeimeris. - Before the 16th century, while references are found in medical literature which prove that the occurrence of ectopic gestation was known, there are no detailed records of cases, nor any attempt whatever at classification.


The first case of which we have any clear account is onedescribed in the 11th century by Albucasis, 1 an Arabian physician living in Spain, in which he observed parts of a foetus escaping through the abdominal wall by suppuration. During the 16th century several cases were described, but so vaguely that their exact nature cannot be determined; among these may be specially mentioned the cases of Polinus, 2 Horstius, 3 Platerus, 4 and Primerose. 6 1 - De Chirurgia, -  cura J. Channing, Oxon., 1778.


2 - Miscell. Nat. Curios, -  1670. Obs. 110.


3 - Opera Medica, -  Norimb., 1660.


4 - De partium corporis humani structura et usu, -  Basil, 1597.


«  - De mulierum morbis et symptomatis, -  lib. iv., Rotterodami, 1655.



Early Described Cases

During the 17th century, however, more exact descriptions were published, and distinct varieties mentioned.


In 1604 Eiolanus 1 examined a case of tubal pregnancy, described by him in his - Anthropographia, - the first accurately recorded case of the kind.


In 1614 Mercerus 2 examined the body of a woman who had died of a ruptured two months - ectopic pregnancy - described by him as right ovarian, but which was probably either a tubal or a tubo-ovarian, since he mentions the tube as much enlarged and ruptured.


As to who first described abdominal gestation I can find no record. Some of the 16 th century writers, to whom I have referred, mention cases in which the foetus was said to have been found in the abdomen, but no special name was used by them to indicate this variety.


In 1682 St. Maurice 3 described a case which has always been regarded as the earliest noted case of ovarian pregnancy, that detailed by Mercerus sixty-eight years previously having been overlooked by most authors.


During the 17th century a clear distinction was recognised between primary and secondary abdominal gestations : one of the earliest cases of the former variety being mentioned by the Abbe de la Roque 4 in 1663 ; others are noted by De Monconys 5 and Courtial. 6 During the 18th century, cases are noted by Martin (le fils), 7 Duverney, s Turnbull, 9 and others.


1 - Anthropographia et Osteologia, -  Parisiis, 1626.


2 Jo. Riolanus, op. cit., p. 283.


3 J. J. Mangetus - Theatrum Anatomicum, -  Geneva, 1717, tome ii., p. 140.


4 - Ephemeri des med. Gallics, -  Paris, 1663.


5 - Itiner. Italic., -  tome ii.


6 - NouveUes observations, -  &c., Leide.


7 - Hist, de l - ™Acad. des Sciences, -  Paris, 1716.


8 - CEuvres Anatomique, -  Paris, 1761.


9 The New London Med. Journ. " vol. i., 1792.


Secondary abdominal pregnancies are described by many during these three centuries, one of the earliest accounts being that of Berengarius Carpus. 1 It is interesting to note, however, that the most common cause supposed to give rise to this condition was rupture of the gravid uterus, the ovum escaping into the peritoneal cavity. The most complete account of abdominal pregnancies before the present century was that of W. Josephi, 2 whose Dissertation in Latin was published in 1784.


The occasional occurrence of uterine along with extra-uterine pregnancy was long ago noted. The case of Albucasis 3 already noted would appear to have been an example of this, though the description is not clear. Primerose, 4 Thomas Bartholin, 5 Buchner, 6 von Haller, 7 and several others described cases during the 17th and 18th centuries.


In 1779, Noel, a French physician of Lorraine, described a case 8 which he had attended in 1765 as one of Vaginal Pregnancy. Though this case, along with one or two others described during the present century, has been noticed by several writers, they have never been regarded as of any value, save as showing how far astray men can be led by imperfect observation.


In the same category must be placed the case observed by Ebersbach 9 in 1714, and named Bladder Pregnancy. He made a post-mortem examination of a woman who died after severe labour pains, and describes the bladder as being pregnant, the placenta being attached to its inner wall.


1 - Isagog® breves in anatomiam humani corporis, -  Venet., 1535.


2 - De conceptione abdominali, -  Gottingas, 1784.


2 Vide, p. 1. 4 Op. cit.


6 - Epistolse med., -  1740, p. 134.


8 - Miscellan. physico-med., -  Erf., 1730. iv., art. 2.


7 - Disput. ad morb. historiam, -  Lausannre, 1757-60, tome iv., p. 793.


8 Journ. de mid. de Paris, 1779, tome i., p. 51.


9 - Ephemer. Nat. Cur., -  cent. v. obs., xx.



The first clear description of Interstitial Tubal Pregnancy in which the pregnancy developed in the uterine portion of the tube, was given by Dionis of France, 1 in 1718, though it appears that Mauriceau had previously recognised the condition. In the beginning of the present century similar cases were noted by Schmitt, 2 in 1801, by Albers of Bremen, 3 in 1811, .and by others. During the same period another variety was first described, Utcro Interstitial, in which the ovum was supposed in some way to pass from the tube into the very substance of the uterus, and there develop. There is some doubt as to who is responsible for this description. Albers had in his possession a specimen so named which he had bought, and which he described in an unpublished paper, but which first was noticed by Carus 4 in 1822. Meyer 5 mentions having seen in Lobstein - ™s Museum in Strassburg a specimen of 21 months - ™ pregnancy in the posterior uterine wall. Similar cases were described by Dance, Hedrich, and others, all of which were considered by Breschet 6 in his memoir of 1824.


The first clearly described case of the extra - peritoneal development of the ovum between the layers of the broad ligament was that of Madame Lefort, published by Bergeret, 7 near the end of last century. Loschge 8 of Erlangen, in 1818, and Lobstein 9 of Strassburg, in 1824, described other cases, It was Dezeimeris, 10 however, who first gave the name Sub


1 - Traite generate des Accouchements, -  Paris, 1718.


2 - Beobaohtiingen d. k. k. med. chir. Josephs akad. zu Wien, -  1801, bd. iv., p. 1.


3 Dezeimeris, Journ. d. conn. mid. -chir., Paris, 1836, p. 243.


4 - Zur Lehre von d. Schwangerschaft u. Geburt, -  &c., Leipzig, 1822, 1st Abt.


6 - Beschreibung einer Gravid. Interstit. Uteri., -  Bonn, 1826, p. 5.


6 Rlieinisch- Westphal. Jalirh. d. Med. u. Chir., Hamm., 1824, bd. viii., p. 54.


7 Baudelocque, - L - ™art des Accouchements, -  Paris, 6th ed., tome ii. , p. 460.


8 Arch. f. die Erfahrung, &c., von Horn, Nasse u. Henke, 1818.


8 Compt. rend, a la Faculti de Mid. de Strassburg, &c., 1824, p. 48.


10 - Grossesses extra-uterines, -  Journ. d. conn. mid. -chir., Paris, Dec., 1836, p. 257.



Cite this page: Hill, M.A. (2019, July 21) Embryology Book - Ectopic Pregnancy 1895. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Ectopic_Pregnancy_1895

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