Book - Uterine and tubal gestation (1903) 2-3
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Bandler SW. Uterine and tubal gestation. (1903) William Wood & Company, New York.
|zygote, morula, and blastocyst stages with implantation occurring in week 2.|
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Part II. The Essentials of Tubal Gestation
Chapter III. Embedding of the Ovum and Development of Extra-Embryonal Structures
Of the cases examined in series sections, these three are taken as types representing the important forms and stages.
I. The Columnar Type of Tubal Gestation
The following specimen (Fig. 47) presents an oval body, measuring one-third of a centimetre in its greatest diameter, situated on the mucous folds of a tube removed because of the diagnosis of ectopic gestation (on operation the abdomen contained clotted blood). The tube was stained in toto, embedded in celloidin, and cut in series sections. Fifty slides from the middle area of the tube contain sections of this oval-shaped structure (Fig. 47a). A section through its greatest diameter shows it to be composed of two unequal halves : a smaller half consisting of a blood coagulum, and a larger half composed of closely grouped cells, of protoplasmatic cells and masses containing one or more nuclei, and of villi. Villi are also found, but sparsely, about the coagulum (Fig. 48).
Fig. 47. — Very young ovum situated on the tip of the folds of the tubal mucosa in a case of ectopic gestation accompanied by an old intraperitoneal hemorrhage.
Sections through the smaller diameters show the coagulum diminishing in size and extent, with an actual and relative increase in the extent and area composed of closely grouped cells and villi, furnishing, then, a centre composed of cells and a periphery in which are villi (Fig. 49).
Fig. 47a. — Ovum of Fig. 47, showing division into two halves and an intimate connection with the tubal mucosa on the right. (Section through the greatest diameter.)
The more external sections are continually smaller (Fig. 50), and the central cell area diminishes in size, so that the small and most external sections present only villi (Fig. 51). In all the sections the villi are in the periphery of the centrally situated closely grouped cells.
By reconstruction, then, we obtain a solid, oval-shaped body possessing a covering composed of protoplasmatic cells and villi. Within this covering are closely grouped cells, and in the interior, although eccentrically situated, is the coagulum. We are dealing with an ovum (?) in which the amnion, umbilical vesicle, and the central cavity are obliterated by blood, while the trophoblast and villi are preserved. This ovum, as we may view it, is adherent on one side to folds of mucosa which evidence a proliferation of their epithelial covering. On the epithelial covering, and between the folds, are rows of round, structureless bodies densely grouped, and the same are found at numerous points covering the ovum, except at the end opposite to the coagulum. In other words, on and between the mucosa folds in contact with the ovum is seen a plasmatic substance distinctly excreted by the epithelium, and in it are also red blood cells and leucocyte nuclei.
Fig. 48. — Another section through ovum of Fig. 47, showing in one half trophoblast cells, villi, and very dark syncytial masses.
Fig. 49. — A more peripheral section, showing trophoblast cells and villi and very little of the blood coagulum.
The tube wall facing the other end of the ovum presents mucosa folds, whose epithelium is interrupted at various points, while at other points are proliferations of epithelium and round cells. The stroma of many of the folds is absent, while others possess dilated capillaries and vessels, and still others are filled with blood extravasations. The tube wall itself is covered with epithelium, and in the wall are extravasations of blood, and dilated arteries and veins. At no point in the tube wall or in the mucosa is there any decidual change or any condition representing an entrance of trophoblast cells or of villi. The ovum is surrounded by a plasmatic substance which I have observed on uterine and cervical polyps covered with epithelium and in active growth. It is not a deposit from the blood, as such, but one actively secreted or produced. This same element is found on the mucosa folds in immediate contact with the ovum. The adhesion of the ovum at these points is a firm one. It is well preserved and therefore in active contact with some nutritionproducing tissue. The shape and character of the oval body, together with its other characteristics, prove it beyond doubt to be an ovum. If not entirely surrounded by the tips ofx the mucosa folds, it was probably situated among them near the tube wall, but not on or in the wall.
Fig. 50. — A still more peripheral section, showing only villi.
The other end, with the numerous trophoblast cells, plasmodial elements, and villi, was probably surrounded, too, by mucosa folds, and here, too, an intervillous space, containing blood coming from the capillaries of the mucosa, was probably present. Although we shall see that this end was infiltrated by maternal blood, I cannot forbear, in this connection, to mention the possibility that the ovum obtained nutrition from the epithelium of the mucosa at the point of adhesion, which represents to me the reflexa or capsularis composed of tubal folds.
(In the placenta of many animals it is found that the blood extravasated from the uterine vessels is made use of by the fetus, in that the degenerating products of the extravasated blood cells are taken up and absorbed by the ectoderm cells. According to Strahl, in Galago, a Madagascar lemuride, numerous extravasations are found in the uterine mucous membrane, and their products lie in the connective tissue in the form of larger and smaller yellow granules. The epithelia of the glands near this extravasated blood are more or less filled with granules resembling these. He considers them to be rests of the blood cells which are taken up by the gland epithelium and made use of by the latter in furnishing an iron-containing secretion. The gland epithelia here perform a function which in other placenta? is performed by the fetal ectoderm. In Galago fetal villi are always in contact with the uterine epithelium and obtain nourishment from it. Between the uterine epithelium and the epithelium of the villi are seen strands which represent the uterine milk taken up by the villi. Thus the fetus gains the greatest portion of its nourishment through the chorionic epithelium.)
Fig. 51. — Most peripheral section, showing a villus only.
The main cell body is composed of cells, without distinct cell boundaries, containing nuclei of varying form and staining darkly. At various points are found paler cells with a distinct nuclear membrane which unite in groups of three or more. More external, in the region of the villi, the cells are more distinct and the nuclear membrane is more clear and nucleoli can be distinctly seen (Fig. 52). The more external these cells are found the larger and the more swollen and the paler do they become, and a homogeneous intercellular substance is present. In the centre of those sections where the cells are so densely grouped (Fig. 49) are minute, darkly-staining granules whose identity at first was not distinct. In the more peripheral areas, however, their character is evident ; for they are only found where red blood cells are present and they are therefore leucocyte nuclei. The nearer we approach the circumference the more do we find blood in the interstices between the cells, at first as isolated cells or groups, and later in larger spaces containing red blood cells. Wherever blood in small amount is present, the cell nuclei become dark and change their form, becoming long spindle-shaped, arranged in single strands or in longer parallel groups. "Where, however, blood in larger amounts is present, protoplasmatic masses containing numerous round or spindle nuclei may be observed. Near the circumference the number and extent of the round protoplasmatic groups and the number of the darker or longer spindleshaped nuclei increase, and the latter seem to invade the sections described from the exterior toward the interior. In the exterior of the sections are villi covered with a double layer of thin syncytium with flat nuclei. The centre is composed of embryonal connective tissue staining blue and containing branching cells (Fig. 52). Other villi, some of which are quite long, have a centre composed of round nuclei with nucleoli which are very closely grouped, and transitions from these cells to syncytium may be distinctly observed, as in Fig. 52. These villi, as well as the others, are found only in the external area or near the coagulum. Knobs of syncytium and so-called syncytial giant cells are present about these villi, connected by a pedicle or lying apart. In the central areas no connective tissue can be observed. In the external layers, however, as said before, it is, evident in the form of a structureless substance between the cells, giving these areas a pale appearance (Fig. 52). It is not present in the younger villi and is only evident in the fully formed ones.
Fig. 52. — An area from Fig. 48, showing trophoblast cells, their transition to the chorionic epithelium in the upper part, and to syncytial groups in the lower part.
Fig. 53. — Section of tube, showing normal mucosa in the lower and left area, while above and to the right is the area of attachment of the ovum, giving a typical picture of the tube after tubal abortion.
II. The Intercolumnar Type of Tubal Gestation
A further stage of development of a tubal ovum is well represented in Fig. 53. The examination, in series sections, of this specimen, known clinically as tubal abortion, divulges numerous interesting features. One half of the circumference of the tube lumen is of a normal character; the other half is in a torn, infiltrated condition which involves not only the mucosa folds but also the submucosa up to the muscularis. Close examination evidences the fact that the ovum was situated on the tube wall, compressing and destroying the mucosa folds at the situation known as the serotina. On either side of this point the mucosa folds were evidently united about the ovum, forming a pseudoreflexa. The capillaries and large vessels at the serotinal point are filled with blood (Fig. 53), and many evidence larger or smaller injuries and invasions of the wall. At the serotinal portion and for some distance on either side is observed in the submucosa a tissue resembling at first sight decidua.
Fig. 54. — Portion of serotinal area of Pig. 53, showing pale trophoblast cells and cell groups and the darker syncytial cells.
Fig. 54a. — Typical area in Pig. 54, commonly mistaken for decidua, showing pale trophoblast cells and dark syncytial cells.
On close examination we find oval, very closely grouped cells, consisting mainly of nuclei and possessing each a nucleolus (Fig. 54). They are extremely closely grouped and between them are found no capillaries or spaces. This tissue rests not only on the free surface of the tube wall, but invades it at many points to a considerable depth (Fig. 55). The invasion of the tube wall is not an even one, for at some points it forms a continuous deep layer like the decidua, at other points it enters the submucous tissue in irregular branches and projections, and at other points, through lateral infiltration, is separated from the free surface of the tube wall by a considerable space of normal submucous tissue.
Dense group of trophoblast veils, representing a "cell group." as found at the tip of the villi
Fig. 55. — Section through tube wall at serotinal area, showing the paler character of the advanced trophoblast cells and the darker character of the densely grouped trophoblast cells near the ovum. Typical field formerly mistaken for decidua, but differentiated by the dark spindle-shaped syncytial cells. This drawing shows that in tubal abortion the "rests" are of the same nature as in uterine abortion.
These cells are found about the smaller and the larger vessels, invading and infiltrating their muscular walls up to and into the lumen of the vessel.
The character, arrangement, and structure of these cell masses leave no doubt that they are trophoblast cells. In addition they may be identified by the fact that at almost all points, especially those points near the inner surface of the tube, they are accompanied by isolated, long, spindle-shaped protoplasmatic cells, by groups of polynuclear protoplasmatic masses, and by long, often parallel bands of the same character (Figs. 54a and 55a). These are the syncytial cells, absolutely identical with the same elements observed in all the previous specimens, especially those seen in the first tubal ovum.
These cells may be further identified as trophoblast cells by the fact that they are found, at the tip of some adherent villi, extending directly into the tube wall. These trophoblast cells enter into the submucosa and museularis, forming the tissue which so many investigators have called decidua. These complexes of trophoblast and syncytial cells, especially the groups found at the tips of the villi, are not yet filled out with mesoderm, but are to form future villi.
Fig. 55a. — Another area from Pig. 55, showing the "advance guard" of infiltrating trophoblast and syncytial cells.
At no point do the connective-tissue cells of the tubal folds or of the submucosa evidence any change resembling, in the slightest degree, those changes occurring in the uterine mucosa which result in the formation of decidua cells.
At no point do the epithelial cells of the mucosa evidence any change of a so-called syncytial character.
III. The Centrifugal Type of Tubal Gestation
Figure 56 represents a tubal gestation, containing a fetus, in the sixth or seventh week. The tube wall is preserved in its entire circumference, with the exception of two minute areas where the chorionic villi have actively perforated it. Projecting into the dilated lumen of the tube, and almost touching the mucous lining, is the outer covering of the fetal sac, the capsularis. One half of the circumference of the tube is invaded, infiltrated, and stretched by the other half of the fetal sac wall, that is, the placenta. On both sides, at the junction between the infiltrated tube wall and the preserved but decidedly stretched tube wall which surrounds that half of the fetal sac which projects into the tube lumen, the mucosa of the latter passes over upon the fetal sae and can be followed upon it as a covering of the latter for a certain distance. The summit of the sac is covered by a tissue composed of fibrin, trophoblast cells, leucocytes, etc. The ovum possesses, then, a capsularis composed in part of fetal folds and submucosa. This capsularis is, strictly speaking, no reflexa. It must be called a pseudo-reflexa or capsularis.
Fig. 56. — Tubal gestation with fetus attached by umbilical cord, showing perforation by the growing villi closed by a thrombus.
The area of the tube circumference entirely filled by villi is the true placental site, and here is found a real intervillous space bounded on all sides by the point of union of the tube wall with the base of the capsularis. The remainder of the circumference of the fetal sac evidences villi, but the space between the capsularis and the inner lining of the sac is mainly filled with blood and blood crystals. At the real placental site almost no remnants of the tube wall can be found. At this half of the tube wall there are nothing but villi, trophoblast cells, syncytial cells, and a sea of maternal blood (Fig. 56a-).
Fig. 56a. — Tubal ovum with perfectly developed capsularis. Tubal wall passes on both sides over into the capsularis. Major portion of placenta is at the lower border, where tubal tissue is eroded and perforated by the villi. This area is the intervillous space. Between the tube lumen and the central cavity of the ovum is the capsularis filled with blood and blood crystals.
The process involved in this invasion of the tube wall and the process involved in the formation of the villi can, in each section, be extremely well judged on either side at the point of junction of the capsularis with the tube wall (Fig. 57). Here, on either side, there extend into the gradually thinning tissue of the tube villi, cell groups, and syncytial cells which invade the muscularis in what may be called a concentric path. We observe, at the tips of fully formed villi, the typical trophoblast cell groups. We see them extending into and between the muscular fibres, changing into and accompanied by syncytial cells and masses of every kind and form yet described (Fig. 58). At no point is there the slightest evidence of any decidua or of any decidual reaction. The trophoblast cells invade the vessels of the tube wall, and the villi themselves enter the tube wall and, with the trophoblast groups at their tips, enter the vessel lumina.
At the main placental site are found trophoblast cells with the clearest and most distinct change into various forms of independent syncytial groups and into the syncytial covering of the villi (Fig. 58). They are likewise seen to pass over gradually into the layer of Langhans, which at all points resembles, the syncytial layer to such an extent that it might be said that the covering of the villi consists of a double layer of syncytial cells (Fig. 59). The villi have actively perforated the tube wall individually and in groups, so that the intervillous space communicated with the abdominal cavity at these points.
Fig. 57. — Area XX of Fig. 56a magnified, showing the reflexa or capsularis and the infiltration and invasion of the tube wall by the trophoblast and villi.
This stage is the exact macroscopic and microscopic counterpart of the stage seen in Fig. 39. If no interruption take place, the capsularis unites with the mucosa of the enveloping tube wall in the same way that this processes exemplified in the uterus.
The various steps in the succeeding months of development of a tubal gestation may, so far as the development of the placenta, the fetal sac, and the fetus is concerned, be considered as identical with the same processes in the uterus; for over ninety cases of full-term ectopic gestation with viable fetus are recorded.
Fig. 58. — Area of advancing trophoblast cells of Fig. 57, showing transition of trophoblast cells to syncytial groups and to the syncytial covering of the villi.
The various steps in the development of the tubal placenta, depending as they do mainly on the cells of the ovum itself, the trophoblast cells, are the same as in the uterus. The difference is mainly in the different character of the base or trophospongia. We may draw the following conclusions :
(1) In tubal gestation no decidua or trophospongia develops. The mucous lining of the uterus is really a lymph tissue; the submucosa of the tube is not.
(2) Fetal cells, in tubal gestation, may at any time enter the maternal circulation.
(3) As regards the troplioblast, the syncytium, the villi, the formation of blood by the trophoblast cells, and all other particulars, the processes depending on and originating in the ovum are the same in both uterus and tube.
Certain investigators have described ova embedded in the tube wall, where a capsularis, was present containing muscle fibres passing out from the tube wall into the base of the capsularis. The ovum was found entirely under the entire thickness of the tube wall, lying on the vessels of the ligamentum latum— the socalled pseudo-intraligamentous form.
In the tube, the embedding of the ovum and the development of the placenta, then, is found to follow three fairly distinct forms: (1) the columnar, (2) the inter columnar, (3) the centrifugal.
Fig. 59. — Drawing from serotinal area of Fig. 56a, showing trophoblast cells going over into isolated syncytial cells and into syncytial masses.
1. In the columnar type of development (Fig. 47) the ovum is surrounded by mucosa folds only. Here an invasion of the capillaries of the tubal mucosa occurs. Such a columnar situation makes abortion easy and of little danger. Very soon after the entrance of the ovum tubal bleeding may result; the ovum dies and further hemorrhage expels it. The tube may return to a normal state without any evidence of the previous condition, or else a hematosalpinx may be formed if the abdominal end of the tube is closed. The ovum may, theoretically, develop to a much further degree and press the folds against the tubal wall. If development continues the villi may extend into it, and the connection of the ovum and the villi with the surrounding tissue is a loose one, as in the case of Abel and of Wyder and in the specimen Fig. 47.
2. In the intercolumnar form (Fig. 53) the ovum may rest on the wall of the tube. Any tubal fold beneath it will be compressed, but epithelium may be present in a depression. Other folds may form a capsularis, which consists then of mucosa alone ; if such a capsularis be firm an intervillous space may develop. The villi at the placental site enter into the wall ; here a hemorrhage may result through this invasion of the wall and of the vessels and through an invasion of the capsularis by fetal cells ; or, since the capsularis does not undergo decidual change and is therefore less yielding, the capsularis may rupture. If it be torn, or if it be not closely adherent, the intervillous space is opened. Abortion, complete or incomplete — usually incomplete —is the general rule, but rupture might occur. If the abdominal end be closed a hematosalpinx or a tubal mole may represent the final outcome.
3. In the centrifugal form (Fig. 56a) the ovum sinks into the wall of the tube and an invasion of the wall and vessels by the villi may take place even up to the serosa. The capsularis is formed by muscularis and mucosa. It may rupture at its summit. The invasion of the vessels entering the intervillous space may cause hemorrhage. The villi which extend up to the serosa may cause bleeding, though their penetration is so gradual that these points are usually covered with thrombi. Finally a rupture may take place at the placental site through multiple perforations producing an arrosion. The ovum practically eats up the wall. Even though the tubal diameter be large enough to give sufficient room, this occurs. It is not the result of pressure, as may be seen in gestation at the fimbrian end, where rupture also can result. Villi which perforate the serosa may cause a very decided hemorrhage into the peritoneal cavity. "When no rupture has occurred and the abdominal end of the tube is closed, only the microscope may divulge the source of such an intraperitoneal bleeding. Such minute perforations, may cause collapse through hemorrhage, even though the opening be no larger than the head of a pin. Even after the death of the ovum the villi can grow, and an active tubal mole is found with continued bleeding. If they do not grow, hemorrhage continues, since no contraction can take place, as is the case in the uterus. The centrifugal form furnishes the majority of tubal ruptures. But the vast majority of these so-called tubal ruptures are either erosions or due to erosion by the perforating villi.
Chapter IV. The Usual Course of Ectopic Gestation
The theory that the tube ruptures because the ovum is too big is, as a rule, wrong for cases in the first three months. The various interruptions of ectopic gestation are all the result of hemorrhages primarily minute. The usual ending, clinically, of the gestation begins with bleeding in the tube. The invasion of the vessels of the mucosa and the tube wall and the invasion of the serosa furnish the causes for hemorrhage. The death of the fetus, as in the case of the uterus, brings about changes which result in bleeding. The primary cause is a lack of decidua. In a mucosa previously affected, when many large vessels are changed by the fetal cells and invaded by villi, an increase in tension through contraction of the tube walls furnishes an easy explanation of this hemorrhage. In the uterus the vessels are firmly embedded in the thick decidua and take a twisted course ; in the tube the vessels are straight and embedded in loose connective or fetal tissue. Bleeding on the part of the capsule is possible and of frequent occurrence, since it does not undergo decidual change and may be invaded by fetal cells. The contraction of the muscle fibres on either side of the capsularis renders the rupture of this pseudo-reflexa easy because of the absence of decidual changes, and the point of rupture is usually at the summit of the capsularis. If the capsularis be composed of tubal folds the intervillous space is easily involved. If the capsularis be composed of muscularis and mucosa a decided bleeding may result if only the summit of the capsularis be torn.
Rupture of the tube almost always takes place at the placental site, which is the seat of old and new hemorrhages. The hemorrhage and loosening of the ovum which represent the clinical ending of these cases is not the first bleeding, for older ones are usually present. The various processes depend upon the ovum, the condition of the tube before pregnancy, the character of the union of the ovum with the tube, the place of union, and trauma. The reaction of the tube is limited to the area of the ovum ; and in this we find the main difference between tubal and uterine gestation. The uterus undergoes early independent growth, the tube does not. With the development of the ovum the uterus grows hand in hand, while in the tube the ovum makes room for itself and obtains its nourishment by the invasion of the tube walls. It may stretch the circumference of the tube so that its wall, as in the case of Abel, may be reduced to a layer of connective tissue so thin that rupture may result at any point.
Ampullar cases usually end -in abortion, generally with hematocele. There is no obstruction, unless decided adhesions are present, and the blood is generally poured out quickly into the pelvic peritoneum or into the sac of Douglas. Such an abortion may be complete or incomplete. Rupture in this situation occurs, but very rarely. The majority of tubal gestations are situated in the isthmus tuba? nearer the uterine end. In those cases we have (1) abortion without rupture, complete or incomplete, with bleeding from the abdominal end of the tube. Generally a hematocele is found at the abdominal end. The tubes are often so curved that it is difficult for the blood to make its way to the fimbriae, and the oozing is of a slow character. The blood extends rarely more than a very short distance toward the uterine end, because of the numerous short curves present here. ( 2 ) We may have single or multiple microscopic perforations of the tube wall by villi, causing even decided hemorrhage without apparent cause. (3) We may have macroscopic perforations or "erosions" of the tube wall, covered or not covered by thrombi, and causing great hemorrhage. (4) We may have abortion with rupture either into the free abdominal cavity with no hematocele at the abdominal end of the tube, or with partial encapsulation, in which event there may be hematocele at the abdominal end if the tube is open. (5) We may have an intraligamentous tear with hematocele at the abdominal end. In these latter cases the placental site is always on the inferior surface of the tube and the ovum has descended centrifugally to the vessels of the ligamentum latum. These are by far the most difficult cases surgically, and may require hysterectomy to remove the mass in toto.
Case I. (Fig. 47). — Twenty-eight years of age, married thirteen years. One labor eleven years ago. Divorced ten years ago, and operated vaginally at Mt. Sinai for pelvic abscess, since which time periodical attacks of pain on the right side every three months. Married again twenty months ago. One year ago, pain, fainting spells. Three months before admission, pain. Two months before, only stains instead of menstruation. One week before, severe cramps, fainting spells, following a metrorrhagia of several weeks. Operation showed plenty of old blood in the pelvic cavity. Tube distended, clot at fimbrian end. Other tube normal. Microscope, columnar type, with evidences of a previous old ectopic gestation.
Case II. (Fig. 53). — Twenty-seven years old; four children, last nine months ago. Nursing. Four weeks of abdominal cramps and uterine hemorrhage. Well for one week and then symptoms returned up to admission, on which day she fainted three times on account of pain.
Operation.— Much blood; right tube distended and clot at fimbrian end. Ovarian cyst. Incomplete tubal abortion. Intercolumnar type, villi and cells of Langhans and syncytium in the wall. Keflexa consisted probably of folds involving one half the circumference of the tube. The other half of the lumen normal.
Case III. (Fig. 56). — Old blood clots in the abdominal cavity showed the cause of the increasing attacks of pain with intervals of relief to be due to bleedings from perforations of the tube wall which were closed at times by the formation of thrombi.
Case IV.— Patient 32 years old; two children, last three years ago. Skipped two menstrual periods. Two weeks later examined because of abdominal pain. Examination showed leftsided tumor, elastic, with pulsating vessels on the left side of the vagina. Uterus enlarged. Next day signs of hemorrhage, pale, pulse 120.
Operation showed much blood, dark clots, and bleeding from the tubal end. Incomplete tubal abortion, placental mole, slight involvement of the wall. No Graafian follicle in the ovary.
Case V. — Twenty-five years old; three children, last fifteen months ago. Three months ago first menstruation (probably nursing). Two months ago skipped menstrual period. For four weeks metrorrhagia and cramps lasting fifteen to twenty minutes and recurring as often as three to four times a day.
Operation.— Vaginal celiotomy. Little free blood. Microscope. Ovum, disintegrated by blood and surrounded by villi and tubal folds, found in the tube. Folds also present in the wall at many points. Organized clot adherent at one point. Intercolumnar and partly centrifugal, for muscularis and mucosa extend on either side partly over the mole. Organized tubal mole. No fresh bleeding.
Case VI. — Thirty-seven years old; married eighteen years; six children, last three years ago. Last menstruation four months ago. Operated because of abdominal pains. No blood in the peritoneum. Tube and ovary free. Continued bleeding into the tube, which was full of fresh blood. Probably would have broken through the closed abdominal end. Incomplete tubal abortion of the type of hematosalpinx. Placental mole. Decided involvement of tubal wall. Large vessel in the periphery going over gradually into the intervillous space.
These cases, point to the decided danger from continued bleedings involved in tubal abortion. The general view is that tubal rupture gives much more pronounced symptoms and a much more decided hemorrhage than tubal abortion. When we consider that incomplete abortion means that villi are left in the tubal wall and that so-called complete tubal abortion means the retention of trophoblast cells, we may readily understand that bleeding may continue for an indefinitely long period. It is a fact, however, that even complete abortion may cause decided symptoms. Mandl reports two cases from the clinic of Schauta, accompanied by pronounced collapse and decided hemorrhage. In the first case no villi were found in the tube wall (see Fig. 53). In the second case, although villi were found in the blood clot in the tube, none were found in the tube wall. Like cases of tubal abortion, with symptoms as severe as are frequently the rule with tubal rupture, have been reported by Klein, Zedel, Piering, and others. It seems to me these histological and clinical evidences are of sufficient weight to destroy the view, prevailing in many minds, that tubal rupture should be treated by extirpation of the tube and that tubal abortion demands only conservative treatment. The proportion of tubal abortion to tubal rupture is probably 8 or 10 to 1. In this connection it is quite sufficient to mention the dangers arising from hematocele. The injury to the peritoneum, the adhesions which take place, and above all the by no means infrequent occurrence of subsequent purulent degeneration of such an accumulation of blood, are only some of the injurious results avoided by prompt removal.
The possibilities are represented by the processes of abortion, microscopic perforation, macroscopic perforation, rupture, hematosalpinx, and tubal mole. In 99 cases of interrupted tubal gestation in the clinic of Schauta, a hematocele was found 60 times — 55 after abortion, 5 times after rupture. If the bleedingbe very slow, the blood forms a capsule (due to peritoneal adhesions) into which the subsequent hemorrhages enter, the so called secondary hematocele. If adhesions are present at the abdominal end of the tube they may form a portion of the capsule. The resulting hematocele after rapid bleeding furnishes the primary or diffuse form. The secondary hematocele occurs much more frequently than the primary. In the 60 hematoceles found among 99 cases in the clinic of Schauta, only 4 were diffuse. Of the abortions found in the same clinic, 75 were incomplete and 6 were complete.
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Reference: Bandler SW. Uterine and tubal gestation. (1903) William Wood & Company, New York.
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