Book - Uterine and tubal gestation (1903) 2-1
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Bandler SW. Uterine and tubal gestation. (1903) William Wood & Company, New York.
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Part II. The Essentials of Tubal Gestation
Chapter 1. Processes Antedating Tubal Gestation
Etiology. — In former years our views concerning the origin of ectopic gestation depended mainly on the discovery of pathological conditions macroscopically evident. Cases were reported with fibroma of the isthmus tubEe or with polyps at the uterine end of the tube. The growth of the ovum in a tubal diverticulum or in an accessory tube was considered to furnish a satisfactory etiology. In some cases the pressure of ovarian or abdominal tumors was supposed to obstruct the onward movement of the ovum. Abel and Freund found in a twisting of the tube and in a failure of development a satisfactory theory for the frequent occurrence of ectopic gestation. Since, in a majority of such cases, peritoneal adhesions are present, these were, and even yet are, considered to so alter the course of the tube's lumen as to prevent the entrance of the ovum into the uterus. Therefore visible inflammations were considered to be the important etiological element.
During my labors a colleague gave me a specimen of extrauterine gestation combined with a multilocular serous ovarian cyst, with the request that I should find, if possible, a Graafian follicle in the ovary, though he believed none to be present. I considered that this specimen would furnish a proof of external migration of the ovum, and that this migration might stand in an etiological relation to the ectopic gestation. Examination of the ovarian cyst showed no Graafian follicle. Therefore the ovum had come by external migration from the other ovary. In Case 3 the same absence of a Graafian follicle was noted.
The experiments of Leopold have shown that the ovum given off by one ovary may enter the tube of the other side. The cases are not so rare in which the tube of one side was closed or absent, and although the corpus luteum verum was found in the ovary of the same side, yet the ovum was found in the uterus. Schroder, Koblanck, and others have found a pregnancy in a rudimentary horn between which and the uterus no epithelial connection existed. Manierre has collected 39 cases of pregnancy in rudimentary horns. The same is true of those cases in which the corpus luteum verum is on one side and the ovum has developed in the horn of a uterus unicornis of the opposite side. Kustner removed a right-sided extrauterine gestation sac "and a left-sided ovarian cyst. Shortly after a uterine pregnancy "took place.
External migration occurs frequently in tubal gestation. 'Although Kustner took note of the frequency of this event in only the la'st 25 of a series of 100 cases, he found it to have taken place in seven. Prochownik found that external migration had taken place in one case of eight which he had examined closely. Martin found the corpus luteum on the same side as the tubal gestation in thirty-seven cases, on the opposite side in four, and uncertain in thirty-six.
External migration of the ovum has been viewed by Sippel and others as the etiological factor. They believe that the ovum in its migration becomes too large to permit of its passage through the tube lumen. The examinations of Peters, however, show conclusively that no chorionic villi are present until the ovum has been nourished for a considerable time by the decidua in which it is embedded. In addition the Graafian follicle is in the majority of instances found in the ovary of the affected side, so that such an etiology would explain only the smaller number of cases.
This migration, however, calls our attention to the presence of a pathological condition in the mucous membrane of the opposite tube. While it calls our attention to the fact that the other tube is affected, it only proves that it is more affected than the tube in which the ovum is finally embedded, for some cilia must be present in the latter to influence the external migration of the ovum. Various experiments make it seem probable that in the perfectly normal tube no ovum can develop.
Kustner, in his experiments on rabbits, extirpated one ovary and extirpated or tied off the uterine horn of the other side. In these attempts no extrauterine gestation resulted. However, since such a pathological point of development of the ovum does occur in animals, a satisfactory explanation of the failure of these attempts could not be found until the experiments of Mandl and Schmit were published. In their work upon animals they found the following to be the case : After coitus, and after the lapse of time sufficient to permit union between the ovum and the spermatozoa at the abdominal end of the tube, they tied off the tube at the uterine end. ' Their results were negative. No tubal gestation resulted. When, however, the uterine horn was tied off a pregnancy in this horn resulted, showing that the ligation was not the disturbing factor and that in all probability ova do not develop on a normal tubal mucosa.
In considering the history of those cases which have been closely noted, it is found that ectopic gestation occurs most frequently in multipara? and that a sterile period of varying length precedes this pathological development. Martin found that 65 multipara? were affected as compared with 20 nullipara?. In a series of 100 cases of Kiistner's, only 10 ectopic gestations occurred in nullipara?. The other 87 had borne children and 3 had aborted. In 24 cases it occurred five or more years after the last labor ; in 55 cases, from one to five years after ; and in 8, in less than twelve months. Veit found that in 52 cases of repeated ectopic gestation a sterile period of two to eleven years preceded the occurrence of this process. Between the two events was a period of six weeks to six years. This sterile period represents the time in which inflammatory changes in the mucosa may occur, either gonorrheal, puerperal, or tubercular. These changes naturally involve the uterine end of the tube more than the abdominal, and in the subsequent course of events, when healing does result, the uterine end improves slowly. What are, then, the pathological changes in the tubal mucosa which stand in an etiological relation to ectopic gestation?
In a series of 8 closely examined cases Prochownik found a gonorrheal history three times; in one of these cases there was an acute gonorrheal affection of the pregnant tube. Moskowicz found that of two cases tuberculosis was the etiological factor in one, and that in the other gonococci and staphylococci were present in the pyosalpinx of the non-pregnant tube. Median to the ovum Veit found microscopical changes which represent the results of pus inflammation. In two cases Diihrssen found cilia abdominal to the ovum, but none toward the uterine end. Kiistner observed very frequently a hemorrhagic tendency of the non-affected tube, showing that tube at least to have been abnormal. I found in three cases distinct changes in the mucosa median to the ovum.
Franz makes inflammatory changes in the tubes responsible for the occurrence of ectopic gestation. This is the more probable since inflammatory processes are so frequently found in the other tube. Franz found such changes in eighty per cent of these cases in which a sterile period of two to seventeen years was noted.. In cases where a sterile period of less than two years was observed tubal changes of the other side were present in only 53 per cent. He comes to the conclusion that we must seek the etiology in those affections of the tubes which have run their course, and which, having for a long time prevented the moving of the ovum, have permitted a gradual and partial restoration to normal conditions.
While in a certain number of cases no pathological microscopic changes are found in the tubal mucosa, it may be explained by the fact that so-called catarrhal conditions frequently show little microscopical change. Even during or after gonorrhea the tube may seem microscopically perfectly normal. Ahlfeld, in an experience of many years at the University of Marburg, met with so few cases of tubal gestation that he considers the relative freedom of his patients from gonorrhea, as compared with those in the larger cities, to be the only explanation.
Various inflammatory influences are etiological factors in that they destroy the cilia in whole or in part or diminish their functional activity. Besides, from the experiments made on animals we know that absence or early atrophy of the ovaries influences the muscular development and the functional activity of the uterine wall and the structure of the mucous membrane and the cilia. In cases of functional interference with the secretion of the ovary, or in the atrophy subsequent to labor or as the result of lactation or of constitutional disturbances or of failures of development, the activity of the cilia is diminished.
Naturally there must be activity to a certain extent on the part of the cilia, especially at the abdominal end of the tube, for extrauterine gestation occurs most frequently in the isthmus tubas. Prochownik found an ampullar location in only 3 cases out of 45. Mandl and Schmit found in 69 cases an ampullar situation in only 15. Diihrssen found an isthmic location in all of his 29 patients. In the 5 cases which I have examined closely the same is true. Although Mercier has collected 30 cases of interstitial gestation (with rupture), Leopold 10 cases of ovarian gestation ( ? ) , and although the growth of an ovum on the fimbriae, as well as tubo-ovarian pregnancies, occurs, yet the vast majority are found near the uterine end of the tube.
A further proof may be found in the fact that recurrences of tubal gestation take place but rarely in the same tube.
Patellani, in a tabulation of 36 cases, found that first one tube and then the other was the seat of development. Veit in 52 cases found that it recurred only three times in the same side. An additional point of importance is the occurrence of tubal gestation in either tube at the same time, of which Gebhardt mentions 9 cases. Further, Patellani has collected 37 instances of combined uterine and extrauterine gestation— a practical proof of an affection of one tube, and certainly excluding external migration.
I believe that in the so-called sterile period gonorrheal. puerperal, tubercular, and atrophic processes take place. The interval of years between the last labor and the ectopic gestation, the fact that the location is generally in the middle area of the tube, the fact that repeated gestations are observed and rarely in the same tube, the occurrence of an ectopic gestation on both sides at the same time, and the frequency of external migration together with a combination of extra- and intrauterine gestation, point certainly to an affection of one tube and probably, but to a lesser degree, of the other tube. The frequency with which, according to Kiistner, a hemorrhagic tendency of the nonaffected side occurs, as well as the microscopic discovery of catarrhal conditions, together with the history and the microscopical evidence of the presence of gonococci, point distinctly to a tubal affection. The observation of Duhrssen, who found cilia abdominal to the placental site and none median to it, and Veit's observation of the presence of inflammation median to the ovum, as well as the theory of congenital and acquired atrophy of the tube, especially subsequent to labor, lead us at the present day to seek in the microscopical changes of the tubal mucosa, the injury to the cilia, the etiological factor in tubal gestation.
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Reference: Bandler SW. Uterine and tubal gestation. (1903) William Wood & Company, New York.
Cite this page: Hill, M.A. (2020, July 14) Embryology Book - Uterine and tubal gestation (1903) 2-1. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Uterine_and_tubal_gestation_(1903)_2-1
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