Paper - A study of the causes underlying the origin of human monsters 12
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Mall FP. A study of the causes underlying the origin of human monsters. (1908) Jour, of Morphol., 19:
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A Study Of The Causes Underlying The Origin Of Human Monsters
Ova in which the Embryo and Amnion have been Destroyed, including certain Moles
Under the previous heading those specimens were discussed in which most or all of the embryo and amnion had been destroyed, leaving only the umbilical vesicle. Various stages of destruction of the umbilical vesicle were also considered. Altogether there were 19 specimens which came under this heading. Now we have a second group of 29 specimens in which the whole embryo, amnion, belly stalk and yolk sac are missing, leaving only the main wall of the chorion and its villi.
In the first group a number of the specimens showed ﬁbrous changes in the mesoderm of the chorion with more or less destruction of the villi with other changes, such as leucocytic inﬁltration or mechanical injury, indicating that the primary cause for these changes is located in the environment of the ovum rather than within it.
In the second group, where the change in the embryo mass is more radical, greater changes should be found in the chorion, and, in fact, this is the case, as a glance at Table III will show. The ﬁrst eight specimens of the group, from Nos. 298 to 204, inclusive, may be considered together, for in many respects they are alike. They belong to the first weeks of pregnancy.
TABLE III. PATHOLOGICAL OVA AND Moms wrrn N21-man Eumnvo NOR Amman Pnnsrm-r.
190 29 I95 243 358 55
Chorionic Mass. I Ctelom. ‘menstnmll
1ox9x5 _ I0 1ox7x5 12 14xr2x8 16x12x1o r7x1ox7
25x22x12 3o 3ox3ox3o 30 3oxI6XIo 35x20): 14
4ox25xI5 4ox18x5 4ox25x25 45x3ox28 5ox2ox2o goxrsxro 7ox45x4o
Absent 1ox5x5 5
6 wks. 54
77 6 wks.
3 wks. 4 01' 5 weeks.
4I 3 wks. 6 wks.
Numbers in brackets are estimated. None.
Some. Reticular. Reticular.
Granular . Granular. Reticular.
Granular. Reticular. None. None. None.
Normal. Somewhat changed.
Normal. Normal. Normal. (Edematous. Fibrous. Gidematous.
Invaded by leucocytes.
Invaded by leucocytes.
Invaded by leucocytes.
Invaded by leucocytes
Hypertrophic. Hypertrophic .
Fibrous and invaded
by leucocytes. Normal. Somewhat changed
Gidematous. CEdematous. Normal.
Fibrous. (Fdematous. Hyaline.
Normal. Atrophic. Normal . Atrophic. Fibrous. N ecrotic.
INIorma1. h_ ypertrop 1c.
Invaded by leucocy teS
Atrophic. Netrotic. Normal. Normal. Irregular.
Irregular, invades chorlon. Normal.
Leucocytes in syncytium
Norm. Leucocytes ? Necrotic. Normal.
Increased. Necrotic. Increased. Normal.
Invaded by leucocy- Irregular.
tes . Atrophic. H ypertrophic.
Increased. I Ne_CIOt1C.
No. 298 is from a tubal pregnancy regarding which there was much doubt until the remains of the ovum were found in serial sections. The remnants of a very small ovum were found at the edge of the rupture of the tube. They are composed of ﬁbrous villi partly invaded by leucocytes and surrounded by an irregular mass of syncytium, decidua and blood, I am inclined to believe that the case might have cured itself if it had not been treated by the surgeon.
The second specimen (No. 278) is of the greatest signiﬁcance in this discussion, for we have in it the whole ovum with its surrounding decidua, which appear normal, and changes within, which show that the embryo has been destroyed. The specimen was removed by a curette from a woman suffering with endometritis. Although no inﬂammatory changes were seen in the decidua and chorion, the condition of the uterus may have caused the destruction of the embryo. The coelom is found ﬁlled with reticular magma, and this is permeated by a coarse network of mesodermal cells, which are continuous with and no doubt derived from those of the chorion. In one of the sections, lying free in the middle of the coelom, there is a small clump of epithelial cells, about I00 in number, which may have been derived from the embryo. The chorion contains no blood-vessels and in general reminds one much of Peters’ ovum.
No. 71 has a history similar to No. 278, it being, however, a natural abortion from a woman suffering from endometritis. The exterior of the specimen is normal in appearance, and in sections the structure of the chorion and villi also appears to be so. Within the coelom there is some reticular magma and a small mass, which would not stain, and appears like a mass of dried blood corpuscles. With this there is another specimen (No. 204), without any history. Its chorion is again normal, both macroscopically and microscopically, is ﬁlled with a mass of granular magma, but contains no remnant of an embryo nor amnion.
The remaining specimens of this group are all from tubal pregnancies and show no remarkable reactions. They are valuable because they show the early changes in the chorion when its implantation is faulty. The structure of the main wall of the chorion and its villi is also more or less changed, as the table and histories of the specimens show. It is natural to read into these specimens the following history: The embryonic mass grew for some time, but was soon arrested because the chorion could not supply the proper nutrition. Soon the embryonic mass began to degenerate, and this process was only hastened by the secondary changes which were beginning in the villi. Soon the whole ovum was disorganized, as we see by the study of the specimens.
This group of specimens throws much light upon the primary cause in the destruction of very young embryos. In ﬁve it is mechanical and in two it is clearly due to endometritis, although no secondary changes are found in the chorion. I have every reason to think that this kind of abortion is much more common than is believed to be, for physicians often have told me that they “found but lost, or threw away, suspicious specimens,” or that they “sought but failed to ﬁnd small foetuses in suspected abortions.” No doubt curing the endometritis in such cases would favor future pregnancies, as is generally believed by gynecologists. At any rate, for our purpose, these specimens show that impaired nutrition due to faulty implantation causes destruction of the embryo without making any marked impression upon the chorion.
The ﬁrst group of this series is no doubt composed of specimens of the second and third week of pregnancy, in which the whole embryo was destroyed and the ovum aborted before any change took place in the chorion. The next group includes ova of the third and fourth week, judging by their size, and by the presence of blood—vessels in the chorion of some of them.
The smaller specimens of the second group also show no macroscopic changes in the chorion, but microscopic examination tells a different story. In specimen No. 299 there is a dense magma reticulé, and the mesoderm of the chorion and the villi appear to be oedematous. Nos. 395 and 181 tell the same story. In 310 the villi are of irregular length, their structure is hyaline with vacuoles, and they contain remnants of blood-vessels of the embryo. They are imbedded in a mass of ﬁbrin and pus.
In No. 20 the only change found is a considerable amount of granular matter between the villi, and in No. 190 there are no changes whatever; however, the villi contain bloodvessels. In specimen No. 255 it is again observed macroscopically that the villi are atrophic, and sections show that the mesoderm is ﬁbrous. In between the syncytial masses there are many leucocytes, which have invaded the villi and the mesoderm of the main wall of the chorion.
Up to this time the coelom contains reticular magma in most cases, but as the specimens grow larger and presumably older first granular magma is found mixed with the reticular and ﬁnally displaces it altogether. The last four ova of the group under consideration (Nos. 29, I95, 243 and 358) are each 30 mm. in diameter, may be fully four weeks old, and are beginning to take on secondary changes. No 29 is ﬁlled with granular magma, the mesoderm of the chorion and its villi are ﬁbrous and being invaded by the syncytial cells. The whole is encapsulated in a layer of mucus, in which there are numerous leucocytes. No. 195 shows no changes in the chorion, which, however, contains blood-vessels. Extreme changes have taken place in No. 243. It is an irregular, collapsed, pear—shaped chorion, showing the beginning of 3 solid mole. Sections of No. 3 58 show that the villi are matted together, much blood and syncytium being between them, and they are encircled by a ﬁbrous syncytium rich in leucocytes.
Up to this time the changes in the chorion are quite equally distributed over its walls, and a change found on one part of it is also found on the other. However, the impaired nutrition may inﬂuence villi which stand side by side, some becoming smaller and disappearing while others are becoming hyper— trophic. In fact, one of the best signs of the abnormality of an ovum before it is opened is this inequality of its villi. However, when an ovum is collapsed the story is entirely different. In so doing it makes more room for itself, the various structures from magma reticulé to decidua become intermixed, and if there is any further growth it is irregular, as is shown by numerous specimens. In specimens of this sort, that is those in which the amnion is destroyed in an early ovum, the diameter of the coelom does not exceed 24 mm. in any of my specimens, while if the amnion is retained and reaches the chorion, obliterating the coelom, the amniotic cavity is then often over 75 mm. in diameter. In a measure this is repeating what takes place in normal development, for here the coelom reaches its largest diameter (25 mm.) at the beginning of the ﬁfth week. So in pathological ova, in which the amnion is absent, the ovum goes on developing, as in the normal, until the coelom has reached its maximum size; beyond this it cannot continue to grow, for under normal conditions its further growth is due to the presence of bloodvessels in the chorion, which carry ﬂuid to the embryo from which the liquor amnii is secreted.
In case the ovum does not collapse, e. g., No. 358, the walls of the chorion become gradually thicker, the villi longer, and the diameter of the coelom smaller. This is seen to be the case in regular order in specimens Nos. 55, 280, 70 and 223.
No. 55, an ordinary ﬂeshy mole, contains a sharply deﬁned cavity, which proves to be the coelom, for it is not lined by the amnion. From its lining membrane, the chorion, the villi rise and radiate through a mass of syncytium, decidua. blood, ﬁbrin and pus. The bulk of the syncytium is necrotic and the mesoderm of the chorion is invaded in part by leucocytes.
Another specimen (No. 185), as large as No. 55, is considered here, for it was not the outside, but the inside, of the chorion that was ﬁlled with pus. No doubt the ovum was punctured by mechanical means and ﬁlled with pus, as was the early stage (No. I 34) described above. In this the leucocytes invaded the chorion from the inside, but had not entered the villi. Some of the villi are atrophic and some are oedematous; the syncytium is normal.
Nos. 280 and 223 follow in regular order No. 55. In the ﬁrst the coelom is small, contains some reticular magma and the wall of the chorion is thin. The villi are not very large. are well developed, contain remnants of blood-vessels and are covered with a mass of necrotic syncytium. The whole specimen is surrounded with mucus, blood and pus. Leucocytes have entered the mesoderm of many of the villi. The second specimen is a solid mass with its base broken off. Radiating from its base of attachment there are long villi, which encircle mostly, and partly penetrate, the main mass of the tissues composed of blood and ﬁbrin. Between the villi there is an active syncytium more or less necrotic, which gives the picture of a cancer. The whole is covered with a capsule of pus.
The remaining specimens may be considered in two groups, solid moles and hydatiform moles. Belonging to the first group (No. I 53) is a pear-shaped body composed of an inverted chorion imbedded in an organized blood clot, intermixed with villi and syncytium. There are also numerous leucocytes, which have invaded the mesoderm from its coelom side. No. 290 is composed of decidua, mucous membrane of the uterus, blood, ﬁbrin, pus and villi which are being destroyed by leucocytes. No. 233 is composed of an irregular mixture of villi, syncytium, decidua, blood and pus. Fresh blood is in the middle of the tissues, which, like most moles of this kind, are nourished through their centers. Its exterior is covered with pus.
To what extent a collapsed ovum may grow is shown in specimen No. 82. A large solid mass the size of a duck’s egg was expelled nine months after the last menstrual period. On the end which lay in the os uteri there is an extensive ulceration of the mole; otherwise it is very compact. After it had been hardened, I cut it into two parts, which, to my astonishment, contained within a collapsed chorion, sending its folds in all directions throughout the mole. In the middle of the specimen there are large spaces along the collapsed chorion, ﬁlled ‘with fresh blood. The opposite walls of the chorion are in apposition throughout most of the specimen, and at points they have grown together. There is no amnion, and on this account I place the beginning of this mole back to the ﬁrst month of pregnancy. The extensive ramiﬁcation of the folds of the chorion shows that it must have continued to grow throughout the nine months of its existence, this being made possible by the nourishment brought to it by the fresh blood in its interior. Islands of syncytial cells are located upon the chorionic wall throughout the specimen. The syncytium shows active growth and its cells stain well at numerous points where they come in contact with fresh blood. All the syncytial masses, distant from the fresh blood. are necrotic, which is undoubtedly due to the lack of nutrition. Nests of leucocytes with fragmented nuclei are scattered throughout the specimen. The walls of the chorion are not invaded by the syncytium.
In a number of the specimens enumerated above it was noted that the villi are oedematous and hyaline, a condition which might easily end in hydatid degeneration of the villi, forming hydatiform mole. In a specimen which contains an embryo 17 mm. long (No. 357) many of the villi are quite large and have undergone hydatiform degeneration. Another specimen (No. 70) contains a small coelom which sends radiaating cavities into the walls of the hypertrophied villi. There is no amnion. In a second very large mole (No. 323) most of the villi are about 5 mm. in diameter, and some of them four times as long. They are very irregular in form, the larger ones containing cavities, some measuring I 5 x IO mm., giving all the characteristics of the coelom. Between the villi there are numerous masses of necrotic syncytium, some blood and Ieucocytes, which invade the mesoderm of some of them.