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Studies on Abortuses: A Survey of Pathologic Ova in the Carnegie Embryological Collection

By Franklin Paine Mall and Abthxtb William Meter.

With twenty-four plates, five text-figures, and one chart.

Links: Carnegie Institution of Washington - Contributions to Embryology

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Pages where the terms "Historic" (textbooks, papers, people, recommendations) appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms, interpretations and recommendations may not reflect our current scientific understanding. (More? Embryology History \| Historic Embryology Papers)

CONTRIBUTIONS TO EMBRYOLOGY

VOLUME XII, No. 56

PUBLISHED BY THE CARNEGIE INSTITUTION OF WASHINGTON WASHINGTON, 1921

CARNEGIE INSTITUTION OF WASHINGTON PUBLICATION No. 275

PRESS OF A. B. GRAHAM CO. WASHINGTON

CONTRIBUTIONS TO EMBRYOLOGY, No. 56.

STUDIES ON ABORTUSES: A SURVEY OF PATHOLOGIC OYA IN THE CARNEGIE EMBRYOLOGICAL COLLECTION.

BY FRANKLIN PAINE MALL AND ARTHUR WILLIAM MEYER.

With twenty-four plates, five text-figures, and one chart.

Preface

The following survey comprises a review and an analysis of conceptuses which are classed as pathologic in the first 1,000 accessions to the collection of the Department of Embryology of the Carnegie Institution of Washington. The majority of these accessions were included in the Johns Hopkins Medical School collection. They had been collected with untiring effort by Professor Mall, with the generous cooperation of numerous physicians, both at home and abroad, during the course of two decades. The accompanying studies on special topics are not, however, so limited, nor are they confined to pathologic conceptuses only. Although closely related, they aim neither at completeness nor even at unity, except as individual contributions. Since, with the exception of the tables, the survey proper is limited to the first 1,200 accessions, with only such references to the remainder of the collection as time permitted, it is very probable that some of the results and conclusions drawn from them will not be fully supported by an extension of this study to the material in the entire collection. This is due not only to the fact that the abortuses received more recently are better preserved and that the later histories are fuller, but also to the increasingly closer cooperation with clinicians which often brings us very helpful clinical sidelights. Indeed, it is this cooperation which alone can enable us satisfactorily to develop certain aspects of the new field of antenatal pathology, and help to bring a final answer to some of the many unsettled questions. Without the information which the practitioner alone can furnish one often feels helpless; for although many of the specimens are eloquent with facts, others remain entirely mute as to their story because they appear wholly normal.

The much larger series of abortuses composing the entire collection also includes unique specimens which are the product of some rare experiment on the part of nature. One is much less likely to find such specimens in a smaller and hence less representative collection. What is lacking, however, in connection with many of the specimens, otherwise so valuable, is the decidua. In the absence of the latter it is often impossible to reach even a tentative conclusion regarding the genesis of the abnormalities found in a particular specimen. In many instances this defect could be easily remedied by an appeal to our many coworkers and benefactors engaged in the practice of medicine. I am certain that they will gladly save the decidua whenever possible, merely as a matter of cooperation, although it need not be forgotten that the assistance we can give to donors when reporting our findings is very largely contingent upon its preservation. It is true that in the course of time, and even now to some extent, we shall be able to give a report suggestive of the possible intrauterine conditions from an examination of the conceptus alone, and just in proportion as our knowledge of the condition of the decidua increases this opinion will become more reliable, and hence also of more practical value.

NOTE In view of the suggestions made in Science (A. W. Meyer, 1919: A suggestion from Plato, with others, vol. 49, p. 530) some of which have been incorporated in the following pages, the title of this volume demands a word of explanation. I have retained the word ova because the title had in part been decided upon. Moreover, the word is still used in this sense in current medical literature, but we are not considering ova but conceptuses. Besides, a considerable percentage of these undoubtedly are not pathologic or diseased, for surely post-mortem changes in structure, however profound, can not strictly be regarded as pathologic; and since derangement of function is made impossible by death, no matter how deformed or how infiltrated the tissues of an abortus may be with the cells of maternal origin, it can not therefore be said to be diseased. A. W. M.

The chief reason why the decidua, or the membranes, or the placenta are not preserved oftener is that physicians have not fully realized that they are needed and wanted. A mere reference to the protocols and summaries will illustrate in how large a percentage of the cases it is not included at present. Although I fully realize that often it is impossible for the physician to secure it, and that in other cases it is of little value even when secured, I am certain that the percentage of cases in which it is missing can be greatly reduced in the future with consequent mutual benefit. The closest cooperation with clinicians is necessary, not only in order to secure the necessary material, but also to obtain further information through supplementary observations upon the living patient. Only in this way can the great gap left in human obstetrics and embryology, by the impossibility of performing experiments, be partly filled. In the case of animals, experimentation no doubt will eventually determine for us the relationship of teratology to pathology, but in the case of man this relationship must be determined very largely by observation alone, for although every instance of human gestation under abnormal conditions answers to an experiment, such experiments must always remain uncontrolled, and the exact conditions which usually obtain must remain unascertainable. Nevertheless, the practitioner, with the patient's help, frequently can bear witness as to the conditions under which nature's experiment was performed and as to the sequence of crucial events, and it is on the unselfish efforts of physicians that we must depend for assistance in this matter.

Mall did a very great service in calling attention to the fact that abnormalities of the fetus are frequently associated with, even if not always or necessarily produced by, uterine diseases. The relationship between the two is revealed still further, especially in Chapter IV, and further investigation of this subject ought to bring to light facts not only of further scientific interest, but pregnant with great humanitarian service. It is startling indeed to observe what a monstrous fetus may accompany an apparently moderately diseased chorion, and it is equally startling to observe that a chorionic vesicle apparently normal may be wholly devoid of an embryo. But here we meet one of the obstacles in the way of present progress, for we do not yet know exactly what a normal ovum or villus looks like in all stages of development. Both must yet be standardized, and for this standardization a knowledge of the condition of the decidua and of the probable cause of the abortion will be extremely helpful. If all early conceptuses were undoubtedly normal, the problem would be a simple one; but very many are abnormal or atypical at least.

As our knowledge of the normal becomes more complete, we find that more and more young embryos which formerly were regarded as normal are not really so. The literature of human embryology contains many such instances, and it was impossible, and it remains impossible even at the present time, to determine in all cases whether we are dealing with a normal or an abnormal specimen, even after it has been mounted in serial sections. Hence it happens that abnormal human embryos and fetuses still are represented as normal in contemporary embryologies. It has often seemed to me that there is one source of material which could bring much help in this connection. If the many tragedies with which our coroners come in contact could always be utilized scientifically, as they rarely have been in the past, much desired information would soon be in our possession. It seems that a very promising opportunity for progress lies here. In an intelligent community public opinion will, I believe, gladly support any one in such utilization of these chance cases as soon as a broadly humanitarian, even if not a keenly scientific, attitude can be cultivated on the part of our coroners.

What can be accomplished through cooperation between public officials and laboratory workers was illustrated by the fine assistance given Professor Mall and the Department of Embryology of the Carnegie Institution of Washington by the department of health of the city of Baltimore. Indeed, one can not recall this service without feeling the deepest regret that similar cooperation, especially with coroners, has not yet been realized in more American municipalities. Such cooperation, supplemented by that of the practitioner, especially in obstetrics and gynecology, can accomplish much in the course of years. But cooperation between laboratory workers also is necessary. Even the chemist, not only the pathologist, is indispensable. Without him the anatomist often is helpless. Here, for example, is an unopened, fairly normal looking abortus composed of a clean conceptus. The periamniotic fluid, to all appearances, is absolutely normal. The interior of the chorionic vesicle also appears normal. The amniotic vesicle, although much smaller than one would expect, is normal in all other respects and distended moderately with perfectly clear and absolutely normal-looking fluid; yet such a conceptus may contain not even a trace of an embryo, even if the yolk-sac still looks normal. Such specimens are rare, but they occur, and one of the things wholly inexplicable to the anatomist is not so much the absence of the embryo as the fact that its disintegration has not resulted in the least turbidity of or deposit in the amniotic fluid or the dissolution of the amnion. Even a microscopic examination of the fluid may fail to reveal any cellular content. The anatomist desires to know not merely in what respects the composition of the intra-amniotic and periamniotic fluids has been changed, but what the enzymes are that have caused the complete lysis of the embryo, from what these arise, and how they become active. These and many other questions the chemist only can answer. For this answer fresh material is indispensable, but this the neighboring practitioners or a closely associated clinic can supply. I am aware of the fact that chemists and physiologists have not neglected these questions, but at present our knowledge regarding these matters seems quite insufficient to enable one to formulate satisfactory hypotheses regarding many of the phenomena encountered in abortuses. To enable us to do this a much better localization and identification of the enzymes concerned would seem to be necessary.

That the dissolution of these early embryos, and undoubtedly also of the chorionic vesicles, is not due primarily or even very materially to phagocytic activity, is very evident, even upon cursory examination. In the presence of the intact chorionic and amniotic vesicles such a process is wholly excluded. Besides, one never sees any evidence of phagocytosis of the preserved fetal by the maternal tissues in human conceptuses, although evidences of the contrary processes are not wanting.

In considering some of the many problems of human antenatal pathology, it seems very probable that much light can be thrown upon them by comparative experimental pathology and studies in comparative gestation. A reliable knowledge of the comparative incidence of abnormalities in man and higher vertebrates alone would be of great value. The same thing would be true of a knowledge of the comparative incidence of uterine and ovarian or testicular disease and abnormalities of the uterine mucosa. Indeed, until these and other similar and related questions have received at least a partial answer, it will always remain rather venturesome to draw final conclusions regarding many things in human antenatal pathology, for the first question that always must be answered in connection with a particular specimen is that of its normality or pathogenicity.

His, Giacomini, and Mall took up this problem with especial devotion and have done much to lay the basis for the accomplishment of the task set for pathologic embryology by MUller (1847). Miiller stated that it was the task of the pathological anatomy of prenatal life to show the progressive steps leading from the slightest deviation from the normal to the most pronounced deformity. This task is only begun and progress naturally will be slow, especially in connection with early forms, until we can discriminate better between the normal and the abnormal and the pathologic.

A comparison of the clinical data relating to infection, with the microscopic findings, will show that the correspondence is extremely slight. This is not surprising, for physicians themselves often emphasize that the history probably is quite untrustworthy. Moreover, the clinical diagnosis of infection is usually based upon the presence of fever, a putrid discharge, or certain symptoms usually regarded as indicative of fever. If the clinical reports regarding infection were based upon bacteriologic or even upon histologic examination, they would undoubtedly agree better with our findings. These showed the presence of infection, as indicated by infiltration of the decidua or by abscess formation, in a large percentage of the cases in which the decidua was present, in the specimens falling into the first five groups.

The unavoidable confusion resulting from the use of the word ovum to designate the unfertilized female sex-cell, this cell when fertilized, the chorionic and amniotic vesicles with or without the embryo, and even the later product of conception in any and all stages of development, even up to birth, has prompted me to resort to additional terms. It certainly would seem best to restrict the term ovum to its comparative embryological significance and thus avoid confusion. But this restriction leaves us without a word to designate the whole product of conception. For this the word conceptus seemed available. At present the word embryo is frequently used loosely to designate conceptuses of any age. It is used still more frequently to designate merely the body of the future individual during the early stages of its development, in contradistinction to the word fetus, which usually is restricted to the later months. Hence we have need for still another term to be used in common for the embryonic disk, the embryo, or the fetus. Dr. Schultz has kindly suggested kyema, which Professor Foster suggests is preferably spelled cyema, adding that it is excellent Greek and was used in the proposed sense by Plato himself. It also has the advantage of being available for comparative embryology and of being easily adapted to meet such needs as are represented by the terms cyemetric and cyemology. Change may not imply improvement or progress, but the absence of it certainly never does. I realize fully that the use of unnecessary terms is to be avoided, but this is equally true of awkward circumlocution and misunderstanding. When one writes or says at present that no embryonic remnants were seen, it is impossible to know what is meant. Although the word embryo could by common consent be used in the proposed sense of cyema, long usage probably would make such an attempt futile for this reason alone. The use of this term and of others, presently to be suggested, does not change old meanings or old usage. It abrogates nothing save confusion.

Although the word abortion is available to designate the individual or the material aborted, it has not been the custom to use it in this inclusive sense. The word abortion, as now used, is usually restricted to the act itself. To use it in a double sense would lead to some confusion. Since blood-clot, pus, decidua, and mucosa usually are not only included with but frequently also surround the entire conceptus, I have used the word abortus to designate all the material expelled during an abortion. Only in this way can one avoid the use of such words as ovum, mole, chorion, and such expressions as the entire mass, embryonic mass, abortion mass, or (quite inaccurately) the chorionic vesicle, even when the latter is surrounded by a certain amount of decidua and blood-clot.

Since the term fetus compressus, as customarily used, refers to a twin fetus which died and was later subjected to pressure from the surviving, growing fetus during an extended period of time while it was undergoing mummification, the use of this term in Chapters III and IV requires definition. Practically all the specimens so designated in this survey are single, not twin. Besides, they have but rarely been subjected to pressure, and not a single specimen is dehydrated to the extent of being papyraceous. Rarely, when fetuses so termed have been subjected to pressure, this was the pressure of the contracted uterus subsequent to the absorption of the amniotic fluid. In many instances, however, these specimens were contained in a quantity of amniotic fluid sufficient to be protected from direct pressure of the uterus transmitted through the fetal membranes. Moreover, since all these, as well as the specimens of group 7, are macerated, and since all manner of gradations are found between the macerated swollen and the macerated wrinkled (fetus compressus) specimen, it may be preferable to restrict this term to its original usage. Much would also seem to be gained by an abandonment of such terms as decidua vera and serotina, which, although historical, convey false suggestions. The occurrence of a psuedo decidua does not seem to be at all established, and the sense in which the term vera was first used necessarily has been lost in the progress of modern embryology. The same thing applies to the term serotina. Hence, as suggested by others, it would seem preferable to speak of a parietal, a basal, and a capsular decidua, and finally relinquish the older terms.

In order to avoid possible confusion through the introduction of new terms, I have added the following diagram, which presents their relationship at a glance:

--Insert Diagram here--

In spite of the fact that some great names have long been associated with the rising subject of the pathology of human development, a routine examination of abortuses seems quite worthless to many investigators. This is natural, for, aside from the poor preservation of many of these abortuses, the conditions under which nature performs her experiments on man necessarily are uncontrolled and often also unknown. But there would seem to be no reason for rejecting any testimony which such experiments may offer, though the search be a long and a disappointing one and the conditions not standard. To regard all attempts at a study of these specimens as futile is very largely to abandon man to a cruel fate. He never can be made the subject of accurately controlled experiment or a wholly satisfying study. The rigid requirements of scientific investigation must, in the nature of things, almost always remain unfulfilled. Comparative anatomy, medicine, and pathology, as well as experiments upon animals, undoubtedly offer greater returns merely because the subject of experiment can be bred, nurtured, and sacrificed at the will and by the hand of man. But if it be conceded that in the last analysis the aim of all human effort must be directed toward the amelioration of the lot of mankind, then it would be folly to reject even the chance stalk that may spring from the grain of wheat which lay hidden in a bushel of chaff.

The conception, as well as the general plan, of this volume is that of Professor Mall himself. It was my happy experience to be invited to share in both. An unkind fate made it impossible for Professor Mall to complete his own work; for his part everyone will feel deeply grateful; for the part that might have been his, others than myself will feel an immeasurable regret.

Although the table of contents had not been prepared, the possible scope of the volume and the order of the topics had often been considered. It was the intention not only to read each other's chapters, but to discuss and revise them together. With characteristic generosity, Professor Mall suggested that, except for one chapter not contributed by either one of us (Chapter VI), we share equally in that part of the undertaking not included in the special studies. Partly in accordance with this desire, he wrote the introductory chapters in the first person plural, much against my earnest remonstrance, for my share in them is quite negligible. However, since they had been considered together they stand as he wrote them, except for a few footnotes. Unfortunately, only one of my studies was in final form before his death, but he was familiar with it, although we had not considered the paper together. Since all the remainder of my part was written subsequently, it did not seem justifiable to me to charge him with responsibility for conclusions of my own or for personal opinions which might not have commended themselves to him.

It is with the greatest satisfaction that I record in this connection his decision to mutually consider all points of difference and, if common ground could not be found, to state frankly our individual views. It was characteristic of him never to use the weight of his authority in the discussion of controverted questions or to influence anyone's conclusions. He was ever willing to leave the truth to the future. It was this attitude that made the completion of this unfinished work a very satisfying effort, even if lonely and in some respects unsatisfactory. Chapters I, II, and VIII, and all the protocols at the end of Chapter IV, below No. 1,000, fortunately had been written by him. However, in accordance with his intentions, protocols were revised and a number of them entirely rewritten. Since he himself had requested this in the case of several which we considered together, I feel that I have merely followed his desire in this matter. In the exercise of this privilege and duty of revision I have used the greatest care to preserve his descriptions as far as possible. Indeed, in the completion of this volume, it has been my constant purpose to follow his plan, to preserve his views, and to realize his intentions. Although I feel the deepest scientific interest in this work, it has also been a labor of love and devotion, and it was a great satisfaction that its continuation was made possible by the Carnegie Institution of Washington, and that its realization was furthered in every way by my friend and former colleague, Dr. George L. Streeter.

Since these studies were completed very largely during 1918 and the spring of 1919, no references are made to the recent literature in a large portion of the volume.

A. W. MEYER.

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Contents

Studies on Abortuses: A Survey of Pathologic Ova in the Carnegie Embryological Collection

Contents

Preface

Glossary Links

@@ Line 14: / Line 14: @@
-Preface. By A. W. Meter 5-11
+CONTRIBUTIONS TO EMBRYOLOGY
-Chapter I. Origin of the collection. By F. P. Mall 13-24
-II. Care and utilization of the collection. By F. P. Mall 25-40
-III. Classification. By A. W. Meyer 41-49
+VOLUME XII, No. 56
-IV. Analysis of abortuses classed as pathologic. By A. W. Meter. (Plates 1-6.) 51-170
-Group 1 : Specimens composed of villi only 51-69
-Group 2: Chorion without amnion or cyema 60-69
+PUBLISHED BY THE CARNEGIE INSTITUTION OF WASHINGTON WASHINGTON, 1921
-Group 3: Chorion with amnion 69-74
-Group 4: Chorionic vesicles with nodular cyemata 74-81
+CARNEGIE INSTITUTION OF WASHINGTON PUBLICATION No. 275
-Group 5: Cylindrical cyemata 81-85
-Group 6: Stunted cyemata 85-92
+PRESS OF A. B. GRAHAM CO. WASHINGTON
-Group 7: Fetus compressus 92-102
-Summary 102-107
+CONTRIBUTIONS TO EMBRYOLOGY, No. 56.
-Protocols 107-170
+STUDIES ON ABORTUSES: A SURVEY OF PATHOLOGIC OYA IN THE CARNEGIE EMBRYOLOGICAL COLLECTION.
-V. Relation of cyemic to chorionic size. By A. W. Meter 171-176
-VI. Sex incidence in abortions. By A. H. Schultz 177-191
-VII. Occurrence of locahzedanomalies in human embryos and fetuses. ByF. P. Mall. (Plate 7.) 193-202
+BY FRANKLIN PAINE MALL AND ARTHUR WILLIAM MEYER.
-VIII. Hydatiform degeneration in uterine pregnancy. By A. W. Meyer. (Plates 8-12.). , . . 203-231
-IX. Hydatiform degeneration in tubal pregnancy. By A. W. Meyer (Plate 13.) 233-242
-X. The alleged occurrence of superfetation. By A. W. Meyer. (Plate'l4.) 243-250
+With twenty-four plates, five text-figures, and one chart.
-XI. Ovarian pregnancy. By F. P. Mall and A. W. Meyer. (Plates 15 and 16.) 251-266
-XII. Lysis and resorption of conceptuses. By A. W. Meyer 267-279
+==Contents==
-XIII. Post-mortem intrauterine changes. By A. W. Meyer. (Plates 17-19.) 281-300
+CONTENTS.
-XIV. Hofbauer cells in normal and pathologic conceptuses. By A. W. Meyer. (Plate 20.) 301-314
+PAGE
-XV. The vim in abortuses. By A. W. Meyer. (Plates 21-23.) 315-326
+PREFACE. By A. W. MEYER 5-11
-XVI. Villous nodules. By A. W. Meyer. (Plate 24.) 327-331
+CHAPTER I. Origin of the collection. By F. P. MALL 13-24
-XVII. Changes suggestive of lues. By A. W. Meyer 333-338
+II. Care and utilization of the collection. By F. P. MALL 25-40
-XVIII. Some aspects of abortion. By A. W. Meyer 339-356
+III. Classification. By A. W. MEYER 41-49
-Bibliography 357-364
+IV. Analysis of abortuses classed as pathologic. By A. W. MEYER. (Plates 1-6.) 51-170
+Group 1 : Specimens composed of villi only 51-59
-==Preface==
+Group 2: Chorion without amnion or cyema 60-69
-The following survey comprises a review and an analysis of conceptuses which
+Group 3: Chorion with amnion 69-74
-are classed as pathologic in the first 1,000 accessions to the collection of the
-Department of Embryology of the Carnegie Institution of Washington. The
-majority of these accessions were included in the Johns Hopkins Medical School
-collection. They had been collected with untiring effort by Professor Mall, with
-the generous cooperation of numerous physicians, both at home and abroad,
-during the course of two decades. The accompanying studies on special topics
-are not, however, so limited, nor are they confined to pathologic conceptuses only.
-Although closely related, they aim neither at completeness nor even at unity,
-except as individual contributions. Since, with the exception of the tables, the
-survey proper is limited to the first 1,200 accessions, with only such references to
-the remainder of the collection as time permitted, it is very probable that some of
-the results and conclusions drawn from them will not be fully supported by an
-extension of this study to the material in the entire collection. This is due not
-only to the fact that the abortuses received more recently are better preserved
-and that the later histories are fuller, but also to the increasingly closer cooperation
-with cUnicians which often brings us very helpful clinical sidelights. Indeed, it
-is this cooperation which alone can enable us satisfactorily to develop certain
-aspects of the new field of antenatal pathology, and help to bring a final answer
-to some of the many unsettled questions. Without the information which the
-practitioner alone can furnish one often feels helpless; for although many of the
-specimens are eloquent with facts, others remain entirely mute as to their story
-because they appear wholly normal.
+Group 4: Chorionic vesicles with nodular cyemata 74-81
-The much larger series of abortuses composing the entire collection also
+Group 5: Cylindrical cyemata 81-85
-includes unique specimens which are the product of some rare experiment on the
-part of nature. One is much less likely to find such specimens in a smaller and
-hence less representative collection. What is lacking, however, in connection
-with many of the specimens, otherwise so valuable, is the decidua. In the absence
-of the latter it is often impossible to reach even a tentative conclusion regarding
-the genesis of the abnormalities found in a particular specimen. In many instances
-this defect could be easUy remedied by an appeal to our many coworkers and
-benefactors engaged in the practice of medicine. I am certain that they will gladly
-save the decidua whenever possible, merely as a matter of cooperation, although it need not be forgotten that the assistance we can give to donors when reporting
-our findings is very largely contingent upon its preservation. It is true that in the
-course of time, and even now to some extent, we shall be able to give a report
-suggestive of the possible intrauterine conditions from an examination of the
-conceptus alone, and just in proportion as our knowledge of the condition of
-the decidua increases this opinion will become more reliable, and hence also of
-more practical value.
+Group 6: Stunted cyemata 85-92
-The chief reason why the decidua, or the membranes, or the placenta are
+Group 7: Fetus compressus 92-102
-not preserved oftener is that physicians have not fully realized that they are
-needed and wanted. A mere reference to the protocols and summaries will illustrate in how large a percentage of the cases it is not included at present. Although
-I fully reahze that often it is impossible for the physician to secure it, and that in
-other cases it is of little value even when secured, I am certain that the percentage
-of cases in which it is missing can be greatly reduced in the future with consequent
-mutual benefit. The closest cooperation with clinicians is necessary, not only
-in order to secure the necessary material, but also to obtain further information
-through supplementary observations upon the living patient. Only in this way
-can the great gap left in human obstetrics and embryology, by the impossibility
-of performing experiments, be partly filled. In the case of animals, experimentation
-no doubt will eventually determine for us the relationship of teratology to pathology, but in the case of man this relationship must be determined very largely
-by observation alone, for although every instance of human gestation under
-abnormal conditions answers to an experiment, such experiments must always
-remain uncontrolled, and the exact conditions which usually obtain must remain
-unascertainable. Nevertheless, the practitioner, with the patient's help, frequently
-can bear witness as to the conditions under which nature's experiment was performed and as to the sequence of crucial events, and it is on the unselfish efforts
-of physicians that we must depend for assistance in this matter.
+Summary '. 102-107
-Mall did a very great service in calling attention to the fact that abnormalities
+Protocols 107-170
-of the fetus are frequently associated with, even if not always or necessarily produced by, uterine diseases. The relationship between the two is revealed still
-further, especially in Chapter IV, and further investigation of this subject ought
-to bring to light facts not only of further scientific interest, but pregnant with
-great humanitarian service. It is startling indeed to observe what a monstrous
-fetus may accompany an apparently moderately diseased chorion, and it is equally
-startling to observe that a chorionic vesicle apparently normal may be wholly devoid
-of an embryo. But here we meet one of the obstacles in the way of present
-progress, for we do not yet know exactly what a normal ovum or villus looks like
-in all stages of development. Both must yet be standardized, and for this standardization a knowledge of the condition of the decidua and of the probable cause of the
-abortion will be extremely helpful. If all early conceptuses were undoubtedly
-normal, the problem would be a simple one; but very many are abnormal or
-atypical at least.
+V. Relation of cyemic to chorionic size. By A. W. MEYER 171-176
-As our knowledge of the normal becomes more complete, we find that more
+VI. Sex incidence in abortions. By A. H. SCHULTZ 177-191
-and more young embryos which formerly were regarded as normal are not really so.
-The literature of human embryology contains many such instances, and it was
-impossible, and it remains impossible even at the present time, to determine in all
-cases whether we are deahng with a normal or an abnormal specimen, even after
-it has been mounted in serial sections. Hence it happens that abnormal human
-embryos and fetuses still are represented as normal in contemporary embryologies.
-It has often seemed to me that there is one source of material which could bring
-much help in this connection. If the many tragedies with which our coroners
-come in contact could always be utiHzed scientifically, as they rarely have been
-in the past, much desired information would soon be in our possession. It seems
-that a very promising opportunity for progress lies here. In an inteUigent community public opinion will, I believe, gladly support any one in such utilization of
-these chance cases as soon as a broadly humanitarian, even if not a keenly scientific, attitude can be cultivated on the part of our coroners.
+VII. Occurrence of localized anomalies in human embryos and fetuses. ByF.P.MALL. (Plate7.) 193-202
-What can be accomplished through cooperation between public oflScials and
+VIII. Hydatiform degeneration in uterine pregnancy. By A. W. METER. (Plates 8-12.) .... 203-231
-laboratory workers was illustrated by the fine assistance given Professor Mall
-and the Department of Embryology of the Carnegie Institution of Washington by
-the department of health of the city of Baltimore. Indeed, one can not recall this
-service without feeling the deepest regret that similar cooperation, especially with
-coroners, has not yet been realized in more American municipalities. Such cooperation, supplemented by that of the practitioner, especially in obstetrics and
-gynecology, can accomplish much in the course of years. But cooperation between
-laboratory workers also is necessary. Even the chemist, not only the pathologist,
-is indispensable. Without him the anatomist often is helpless. Here, for example,
-is an unopened, fairly normal looking abortus composed of a clean conceptus.
-The periamniotic fluid, to all appearances, is absolutely normal. The interior
-of the chorionic vesicle also appears normal. The amniotic vesicle, although
-much smaller than one would expect, is normal in all other respects and distended
-moderately with perfectly clear and absolutely normal-looking fluid; yet such a
-conceptus may contain not even a trace of an embryo, even if the yolk-sac still
-looks normal. Such specimens are rare, but they occur, and one of the things
-wholly inexpUcable to the anatomist is not so much the absence of the embryo as
-the fact that its disintegration has not resulted in the least turbidity of or deposit
-in the amniotic fluid or the dissolution of the amnion. Even a microscopic examination of the fluid may fail to reveal any cellular content. The anatomist desires regarding these matters seems quite insufficient to enable one to formulate satisfactory hyiiotheses regarding many of the phenomena encountered in abortuses.
-To enable us to do this a much better localization and identification of the
-enzymes concerned would seem to be necessary to know not merely in what respects the composition of the intra-amniotic and
-periamniotic fluids has been changed, but what the enzymes are that have caused
-the complete lysis of the embryo, from what these arise, and how they become
-active. These and many other questions the chemist only can answer. For this
-answer fresh material is indispensable, but this the neighboring practitioners or a
-closely associated clinic can supply. I am aware of the fact that chemists and
-physiologists have not neglected these questions, but at present our knowledge regarding these matters seems quite insufficient to enable one to formulate satis-
-factory hyiiotheses regarding many of the phenomena encountered in abortuses.
-To enable us to do this a much better localization and identification of the
-enzymes concerned would seem to be necessary.
+IX. Hydatiform degeneration in tubal pregnancy. By A. W. METER (Plate 13.) 233-242
-That the dissolution of these early embryos, and undoubtedly also of the
+X. The alleged occurrence of superfetation. By A. W. METER. (Plate 14.) 243-250
-chorionic vesicles, is not due primarily or even very materially to phagocytic
-activity, is very evident, even upon cursory examination. In the presence of the
-intact chorionic and amniotic vesicles such a process is wholly excluded. Besides,
-one never sees any evidence of phagocytosis of the preserved fetal by the maternal
-tissues in human conceptuses, although evidences of the contrary processes are
-not wanting.
-In considering some of the many problems of human antenatal pathology,
+XI. Ovarian pregnancy. By F. P. MALL and A. W. METER. (Plates 15 and 16.) 251-266
-it seems very probable that much hght can be thrown upon them by comparative
-experimental pathology and studies in comparative gestation. A reliable knowledge
-of the comparative incidence of abnormalities in man and higher vertebrates
-alone would be of great value. The same thing would be true of a knowledge of the
-comparative incidence of uterine and ovarian or testicular disease and abnormalities of the uterine mucosa. Indeed, until these and other similar and related
-questions have received at least a partial answer, it will always remain rather
-venturesome to draw final conclusions regarding many things in human antenatal
-pathologj', for the first question that always must be answered in connection with
-a particular specimen is that of its normality or pathogenicity.
+XII. Lysis and resorption of conceptuses. By A. W. METER 267-279
-His, Giacomini, and Mall took up this problem with especial devotion and have done much to lay the basis for the accomplishment of the task set for pathologic embryology by Muller (1847). Miiller stated that it was the task of the
+XIII. Postmortem intrauterine changes. By A. W. METER. (Plates 17-19.) 281-300
-pathological anatomy of prenatal life to show the progressive steps leading from
-the slightest deviation from the normal to the most pronounced deformity. This
-task is only begun and progress naturally will be slow, especially in connection
-with early forms, until we can discriminate better between the normal and the
-abnormal and the pathologic.
+XIV. Hofbauer cells in normal and pathologic conceptuses. By A. W. METER. (Plate 20.) 301-314 XV. The villi in abortuses. By A. W. METER. (Plates 21-23.) 315-326
-A comparison of the clinical data relating to infection, wdth the microscopic
+XVI. Villous nodules. By A. W. METER. (Plate 24.) 327-331
-findings, will show that the correspondence is extremely shght. This is not surprising, for physicians themselves often emphasize that the history probably is
-quite untrustworthy. Moreover, the chnical diagnosis of infection is usually
-based upon the presence of fever, a putrid discharge, or certain symptoms usually
-regarded as indicative of fever. If the clinical reports regarding infection were
-based upon bacteriologic or even upon histologic examination, they would undoubtedly agree better with our findings. These showed the presence of infection,
-as indicated by infiltration of the decidua or by abscess formation, in a large
-percentage of the cases in which the decidua was present, in the specimens falling
-into the first five groups.
+XVII. Changes suggestive of lues. By A. W. METER 333-338
-The unavoidable confusion resulting from the use of the word ovum to designate the unfertilized female sex-cell, this cell when fertihzed, the chorionic and
+XVIII. Some aspects of abortion. By A. W. METER 339-356
-amniotic vesicles with or without the embryo, and even the later product of conception in any and all stages of development, even up to birth, has prompted me
-to resort to additional terms. It certainly would seem best to restrict the term
-ovum to its comparative embryological significance and thus avoid confusion.
-But this restriction leaves us without a word to designate the whole product of
-conception. For this the word conceptus seemed available. At present the word
-embryo is frequently used loosely to designate conceptuses of any age. It is used
-still more frequently to designate merely the body of the future individual during
-the early stages of its development, in contradistinction to the word fetus, which
-usually is restricted to the later months. Hence we have need for still another
-term to be used in common for the embryonic disk, the embryo, or the fetus.
-Dr. Schultz has kindly suggested kyema, which Professor Foster suggests is preferably spelled cyema, adding that it is excellent Greek and was used in the proposed
-sense by Plato himself. It also has the advantage of being available for comparative embrj^ology and of being easily adapted to meet such needs as are represented
-by the terms cyemetric and cyemology. Change may not imply improvement or
-progress, but the absence of it certainly never does. I realize fuUj^ that the use
-of unnecessary terms is to be avoided, but this is equally true of awkward circumlocution and misunderstanding. When one WTites or says at present that no
-embryonic remnants were seen, it is impossible to know what is meant. Although
-the word embryo could by common consent be used in the proposed sense of cyema,
-long usage probably would make such an attempt futile for this reason alone. The
-use of this term and of others, presently to be suggested, does not change old meanings or old usage. It abrogates nothing save confusion.
+BIBLIOGRAPHT . 357-364
-Although the word abortion is available to designate the individual or the
-material aborted, it has not been the custom to use it in this inclusive sense. The
-word abortion, as now used, is usually restricted to the act itself. To use it in a
-double sense would lead to some confusion. Since blood-clot, pus, decidua, and
-mucosa usually are not only included with but frequently also surround the entire
-conceptus, I have used the word abortus to designate all the material expelled
-during an abortion. Only in this way can one avoid the use of such words as ovum,
-mole, chorion, and such expressions as the entire mass, embryonic mass, abortion mass,
-or (quite inaccurateljO the chorionic vesicle, even when the latter is surrounded by a
-certain amount of decidua and blood-clot.
-Since the term fetus compressus, as customarily used, refers to a twin fetus
+STUDIES ON ABORTUSES: A SURVEY OF PATHOLOGIC OVA IN THE CARNEGIE EMBRYOLOGICAL COLLECTION.
-which died and was later subjected to pressure from the surviving, growing fetus
-during an extended period of time while it was undergoing mummification, the
-use of this term in Chapters III and IV requires definition. Practically all the
-specimens so designated in this survey are single, not twin. Besides, they have
-but rarely been subjected to pressure, and not a single specimen is dehydrated
-to the extent of being papyraceous. Rarely, when fetuses so termed have been
-subjected to pressure, this was the pressure of the contracted uterus subsequent to
-the absorption of the amniotic fluid. In many instances, however, these specimens were contained in a quantity of amniotic fluid sufficient to be protected from
-direct pressure of the uterus transmitted through the fetal membranes. Moreover, since all these, as well as the specimens of group 7, are macerated, and since
-all manner of gradations are found between the macerated swollen and the macerated wrinkled (fetus compressus) specimen, it may be preferable to restrict this
-term to its original usage. Much would also seem to be gained by an abandonment
-of such terms as dccidua vera and serotina, which, although historical, convey false
-suggestions. The occurrence of a psuedo decidua does not seem to be at all established, and the sense in which the term vera was first used necessarily has been lost
-in the progress of modern embryology. The same thing applies to the term serotina. Hence, as suggested by others, it would seem preferable to speak of a parietal,
-a basal, and a capsular decidua, and finally relinquish the older terms.
+==Preface==
-In spite of the fact that some great names have long been associated with the
+The following survey comprises a review and an analysis of conceptuses which are classed as pathologic in the first 1,000 accessions to the collection of the Department of Embryology of the Carnegie Institution of Washington. The majority of these accessions were included in the Johns Hopkins Medical School collection. They had been collected with untiring effort by Professor Mall, with the generous cooperation of numerous physicians, both at home and abroad, during the course of two decades. The accompanying studies on special topics are not, however, so limited, nor are they confined to pathologic conceptuses only. Although closely related, they aim neither at completeness nor even at unity, except as individual contributions. Since, with the exception of the tables, the survey proper is limited to the first 1,200 accessions, with only such references to the remainder of the collection as time permitted, it is very probable that some of the results and conclusions drawn from them will not be fully supported by an extension of this study to the material in the entire collection. This is due not only to the fact that the abortuses received more recently are better preserved and that the later histories are fuller, but also to the increasingly closer cooperation with clinicians which often brings us very helpful clinical sidelights. Indeed, it is this cooperation which alone can enable us satisfactorily to develop certain aspects of the new field of antenatal pathology, and help to bring a final answer to some of the many unsettled questions. Without the information which the practitioner alone can furnish one often feels helpless; for although many of the specimens are eloquent with facts, others remain entirely mute as to their story because they appear wholly normal.
-rising subject of the pathology of human development, a routine examination of
-abortuses seems quite worthless to many investigators. This is natural, for, aside
-from the poor preservation of many of these abortuses, the conditions under which
-nature performs her experiments on man necessarily are uncontrolled and often
-also unknown. But there would seem to be no reason for rejecting any testimony
-which such experiments may offer, though the search be a long and a disappointing
-one and the conditions not standard. To regard all attempts at a study of these
-specimens as futile is very largely to abandon man to a cruel fate. He never can
-be made the subject of accurately controlled experiment or a wholly satisfying
-study. The rigid requirements of scientific investigation must, in the nature of
-things, almost always remain unfulfilled. Comparative anatomy, medicine, and
-pathology, as well as experiments upon animals, undoubtedly offer greater returns
-merely because the subject of experiment can be bred, nurtured, and sacrificed at
-the will and by the hand of man. But if it be conceded that in the last analysis
-the aim of all human effort must be duected toward the amelioration of the lot of
-mankind, then it would be folly to reject even the chance stalk that may spring
-from the grain of wheat which lay hidden in a bushel of chaff.
-The conception, as well as the general plan, of this volume is that of Professor
-Mall himself. It was my happy experience to be invited to share in both. An
-unkind fate made it impossible for Professor Mall to complete his own work; for
-his part everyone will feel deeply grateful; for the part that might have been his,
-others than myself will feel an immeasurable regriet.
-Although the table of contents had not been prepared, the possible scope of
-the volume and the order of the topics had often been considered. It was the
-intention not only to read each other's chapters, but to discuss and revise them
-together. With characteristic generosity. Professor Mall suggested that, except
-for one chapter not contributed by either one of us (Chapter VI), we share equally
-in that part of the undertaking not included in the special studies. Partly in
-accordance with this desire, he wrote the introductory chapters in the first person
-plural, much against my earnest remonstrance, for my share in them is quite
-negligible. However, since they had been considered together they stand as he
-wrote them, except for a few footnotes. Unfortunately, only one of my studies
-was in final form before his death, but he was familiar with it, although we had
-not considered the paper together. Since all the remainder of my part was written
-subsequently, it did not seem justifiable to me to charge him with responsibiHty
-for conclusions of my own or for personal opinions which might not have commended themselves to him.
-It is with the greatest satisfaction that I record in this connection his decision
-to mutually consider all points of diflference and, if common ground could not be
-found, to state frankly our individual views. It was characteristic of him never
-to use the weight of his authority in the discussion of controverted questions — or
-to influence anyone's conclusions. He was ever willing to leave the truth to
-the future. It was this attitude that made the completion of this unfinished
-work a very satisfying effort, even if lonely and in some respects unsatisfactory.
-Chapters I, II, and VIII, and all the protocols at the end of Chapter IV, below
-No. 1,000, fortunately had been written by him. However, in accordance with his
-intentions, protocols were revised and a number of them entirely rewritten. Since
-he himself had requested this in the case of several which we considered together,
-I feel that I have merely followed his desire in this matter. In the exercise of this
-privilege and duty of revision I have used the greatest care to preserve his descriptions as far as possible. Indeed, in the completion of this volume, it has been my
-constant purpose to follow his plan, to preserve his views, and to reahze his intentions. Although I feel the deepest scientific interest in this work, it has also
-been a labor of love and devotion, and it was a great satisfaction that its continuation was made possible by the Carnegie Institution of Washington, and that its
-reaUzation was furthered in every way by my friend and former colleague, Dr.
-George L. Streeter.
-Since these studies were completed very largely during 1918 and the spring
-of 1919, no references are made to the recent literature in a large portion of the
-volume.
-A. W. Meyer.
-==Chapter 1 - Origin of the Collection==
-The collection of human embryos belonging to the Carnegie Institution of
+The much larger series of abortuses composing the entire collection also includes unique specimens which are the product of some rare experiment on the part of nature. One is much less likely to find such specimens in a smaller and hence less representative collection. What is lacking, however, in connection with many of the specimens, otherwise so valuable, is the decidua. In the absence of the latter it is often impossible to reach even a tentative conclusion regarding the genesis of the abnormalities found in a particular specimen. In many instances this defect could be easily remedied by an appeal to our many coworkers and benefactors engaged in the practice of medicine. I am certain that they will gladly save the decidua whenever possible, merely as a matter of cooperation, although it need not be forgotten that the assistance we can give to donors when reporting our findings is very largely contingent upon its preservation. It is true that in the course of time, and even now to some extent, we shall be able to give a report suggestive of the possible intrauterine conditions from an examination of the conceptus alone, and just in proportion as our knowledge of the condition of the decidua increases this opinion will become more reliable, and hence also of more practical value.
-Washington owes its origin to thirty years of untiring effort on the part of one of
-the authors (Mall) . The first specimen was obtained while he was a student under
-Professor Welch in the Pathological Department of the Johns Hopkins University ;
-very soon another, in excellent state of preservation, was added. After his (Mall's)
-transfer to Clark University in 1899, embryo No. 2 was studied and modeled in
-wax. This was the first reconstruction of a human embryo ever made in America
-and at that time the most elaborate one in existence. In 1890 this specimen was
-offered to Professor His, who refused to accept the gift, and returned it, together
-with several from his own collection, expressing the hope that this small number
-of specimens might serve as a nucleus for a much larger collection. With the
-subsequent foundation of the Universitj^ of Chicago, the collection was transferred
-there, and during the following year a few additions were made. Now somewhat
-augmented, it was returned to Baltimore in 1893, at the opening of the Johns
-Hopkins Medical School, and here it grew for a number of j^ears, at first slowly,
-then more rapidly, until it was finally taken over by the Carnegie Institution of
-Washington in 1915.
+NOTE In view of the suggestions made in Science (A. W. Meyer, 1919: A suggestion from Plato, with others, vol. 49, p. 530) some of which have been incorporated in the following pages, the title of this volume demands a word of explanation. I have retained the word ova because the title had in part been decided upon. Moreover, the word is still used in this sense in current medical literature, but we are not considering ova but conceptuses. Besides, a considerable percentage of these undoubtedly are not pathologic or diseased, for surely post-mortem changes in structure, however profound, can not strictly be regarded as pathologic; and since derangement of function is made impossible by death, no matter how deformed or how infiltrated the tissues of an abortus may be with the cells of maternal origin, it can not therefore be said to be diseased. A. W. M.
-In the beginning each specimen was labeled with the name of the physician
-who donated it, but it was soon found that this method was not accurate. Bottles
-were easUy misplaced and notes lest from the files were not missed unless marked
-with consecutive numbers. Therefore, after the collection had grown to about 100
-specimens, a sj'stem of numbering, somewhat in the order of accession, was
-adopted. However, a review of the catalogue later disclosed the fact that some of
-the specimens collected at Worcester followed in numerical order those collected at
-Chicago, so that for the first 100 specimens the sequence of accession can not be
-viewed as chronologically reUable. From an examination of table 1, in which the
-specimens are arranged in hundreds (or centuries), it will be observed that the
-fijst century includes catalogue numbers 1 to 98, the second century, 99 to 205,
-etc. These numerical discrepancies are due to the fact that quite frequently the
-same number is given to two or more specimens, as illustrated in the first
-century; or, as illustrated in the second centurj^, a number once used may be
-discarded subsequently because the specimen is found to contain no remnants of
-an ovum. The latter specimens are finally marked on the catalogue card "No
-pregnancy." In this way we have been able to retain in the catalogues of the
-collection ovaries and uteri from non-pregnant women. The second column of the
-table shows the time required to collect each 100 specimens. It took 10 years
-for the first, 4 for the second, and 2 for the third 100; but after the collection had
-been transferred to the Carnegie Institution, about 400 specimens were collected
-in one year. It will be observed also that approximately 60 physicians contributed to the collection of each 100 specimens, of which number 8 (or about 13 per cent)
-resided in hospitals. The last column of the table shows the territorial source
-of each century, representing an average of 18 States from which material has been
-drawn. Upon comparing columns 2 and 3, it becomes apparent that by far the
-largest portion of the collection has come from physicians in private practice. Yet
-nearly all of our perfect specimens were obtained from hospitals. This is easily
-understood when one considers that only when the operator is near can perfectly
-fresh embryos be secured. In several instances these have been brought to the
-laboratory still hving.
-Table 2 gives a list of the contributing hospitals, with the number of specimens
+The chief reason why the decidua, or the membranes, or the placenta are not preserved oftener is that physicians have not fully realized that they are needed and wanted. A mere reference to the protocols and summaries will illustrate in how large a percentage of the cases it is not included at present. Although I fully realize that often it is impossible for the physician to secure it, and that in other cases it is of little value even when secured, I am certain that the percentage of cases in which it is missing can be greatly reduced in the future with consequent mutual benefit. The closest cooperation with clinicians is necessary, not only in order to secure the necessary material, but also to obtain further information through supplementary observations upon the living patient. Only in this way can the great gap left in human obstetrics and embryology, by the impossibility of performing experiments, be partly filled. In the case of animals, experimentation no doubt will eventually determine for us the relationship of teratology to pathology, but in the case of man this relationship must be determined very largely by observation alone, for although every instance of human gestation under abnormal conditions answers to an experiment, such experiments must always remain uncontrolled, and the exact conditions which usually obtain must remain unascertainable. Nevertheless, the practitioner, with the patient's help, frequently can bear witness as to the conditions under which nature's experiment was performed and as to the sequence of crucial events, and it is on the unselfish efforts of physicians that we must depend for assistance in this matter.
-from each. As would be expected, the majority of the specimens came from
-hospitals located in Baltimore; second in order is New York, and third Manila,
-Philippine Islands. Naturally, the Johns Hopkins Hospital contributes the largest
-number, for its work is intimately related to our own and the members of its staff
-frequently are interested in embryological studies, both in this laboratory and in
-the clinical laboratories of the hospital. Hence we receive all of the embryological
-specimens found at operation.
-Attention is called to the large number of specimens emanating from a single
+Mall did a very great service in calling attention to the fact that abnormalities of the fetus are frequently associated with, even if not always or necessarily produced by, uterine diseases. The relationship between the two is revealed still further, especially in Chapter IV, and further investigation of this subject ought to bring to light facts not only of further scientific interest, but pregnant with great humanitarian service. It is startling indeed to observe what a monstrous fetus may accompany an apparently moderately diseased chorion, and it is equally startling to observe that a chorionic vesicle apparently normal may be wholly devoid of an embryo. But here we meet one of the obstacles in the way of present progress, for we do not yet know exactly what a normal ovum or villus looks like in all stages of development. Both must yet be standardized, and for this standardization a knowledge of the condition of the decidua and of the probable cause of the abortion will be extremely helpful. If all early conceptuses were undoubtedly normal, the problem would be a simple one; but very many are abnormal or atypical at least.
-hospital in Manila. This is due to the fact that this hospital numbers among
-its staff several graduates from the Johns Hopkins Medical School, and these
-have responded loyally to our request for Filipino embryos for a study of racial
-embryology.
-Table 2.— List of hospitals and laboratories contributing embryological material.
+As our knowledge of the normal becomes more complete, we find that more and more young embryos which formerly were regarded as normal are not really so. The literature of human embryology contains many such instances, and it was impossible, and it remains impossible even at the present time, to determine in all cases whether we are dealing with a normal or an abnormal specimen, even after it has been mounted in serial sections. Hence it happens that abnormal human embryos and fetuses still are represented as normal in contemporary embryologies. It has often seemed to me that there is one source of material which could bring much help in this connection. If the many tragedies with which our coroners come in contact could always be utilized scientifically, as they rarely have been in the past, much desired information would soon be in our possession. It seems that a very promising opportunity for progress lies here. In an intelligent community public opinion will, I believe, gladly support any one in such utilization of these chance cases as soon as a broadly humanitarian, even if not a keenly scientific, attitude can be cultivated on the part of our coroners.
-In order to obtain good specimens from hospitals, it is necessary that surgeons
-and pathologists connected therewith be sufficiently interested in embryology to
-preserve and transmit to this department any valuable specimens obtained at
-operations. Only in this way can we secure human embryos in as good preservation
-as those from the lower animals. It is very gratifying that in several instances
-authorities of hospitals have passed resolutions requesting the members of their
-respective staffs to send all of their embryological material to this department.
-Upon the receipt of a specimen it is described, the records filed, and a copy
-sent to the hospital. These records have in a number of instances enabled us to
-give expert information, especially in operations upon the uterine tubes in cases
-of doubtful pregnancy
+What can be accomplished through cooperation between public officials and laboratory workers was illustrated by the fine assistance given Professor Mall and the Department of Embryology of the Carnegie Institution of Washington by the department of health of the city of Baltimore. Indeed, one can not recall this service without feeling the deepest regret that similar cooperation, especially with coroners, has not yet been realized in more American municipalities. Such cooperation, supplemented by that of the practitioner, especially in obstetrics and gynecology, can accomplish much in the course of years. But cooperation between laboratory workers also is necessary. Even the chemist, not only the pathologist, is indispensable. Without him the anatomist often is helpless. Here, for example, is an unopened, fairly normal looking abortus composed of a clean conceptus. The periamniotic fluid, to all appearances, is absolutely normal. The interior of the chorionic vesicle also appears normal. The amniotic vesicle, although much smaller than one would expect, is normal in all other respects and distended moderately with perfectly clear and absolutely normal-looking fluid; yet such a conceptus may contain not even a trace of an embryo, even if the yolk-sac still looks normal. Such specimens are rare, but they occur, and one of the things wholly inexplicable to the anatomist is not so much the absence of the embryo as the fact that its disintegration has not resulted in the least turbidity of or deposit in the amniotic fluid or the dissolution of the amnion. Even a microscopic examination of the fluid may fail to reveal any cellular content. The anatomist desires to know not merely in what respects the composition of the intra-amniotic and periamniotic fluids has been changed, but what the enzymes are that have caused the complete lysis of the embryo, from what these arise, and how they become active. These and many other questions the chemist only can answer. For this answer fresh material is indispensable, but this the neighboring practitioners or a closely associated clinic can supply. I am aware of the fact that chemists and physiologists have not neglected these questions, but at present our knowledge regarding these matters seems quite insufficient to enable one to formulate satisfactory hypotheses regarding many of the phenomena encountered in abortuses. To enable us to do this a much better localization and identification of the enzymes concerned would seem to be necessary.
-Table 3 is interesting as showing the difficulties encountered by embryologists
+That the dissolution of these early embryos, and undoubtedly also of the chorionic vesicles, is not due primarily or even very materially to phagocytic activity, is very evident, even upon cursory examination. In the presence of the intact chorionic and amniotic vesicles such a process is wholly excluded. Besides, one never sees any evidence of phagocytosis of the preserved fetal by the maternal tissues in human conceptuses, although evidences of the contrary processes are not wanting.
-in collecting material. In our own experience we found at first that, although
-physicians seemed to be entirely wiUing to send specimens, we rarely received them;
-or, at best, only those which had been standing upon the shelves for years. These
-were badly preserved and of little scientific value, not only because the tissues were
-unfit for microscopic examination, but because histories were entirely lacking.
-Nevertheless, we always thankfully receive such specimens, and in return gladly
-send fixing fluids, write letters, and also send reprints of embryological studies to
-donors. In this way we have learned that a physician who will take the trouble to
-send one specimen is always wiUing to preserve carefully the next that falls into
-his hands, and, in the course of time, he naturally becomes a regular contributor.
-A number of physicians have been contributors for 30 years, and their unselfish
-efforts have been a great encouragement to us.
+In considering some of the many problems of human antenatal pathology, it seems very probable that much light can be thrown upon them by comparative experimental pathology and studies in comparative gestation. A reliable knowledge of the comparative incidence of abnormalities in man and higher vertebrates alone would be of great value. The same thing would be true of a knowledge of the comparative incidence of uterine and ovarian or testicular disease and abnormalities of the uterine mucosa. Indeed, until these and other similar and related questions have received at least a partial answer, it will always remain rather venturesome to draw final conclusions regarding many things in human antenatal pathology, for the first question that always must be answered in connection with a particular specimen is that of its normality or pathogenicity.
-A glance at table 3 will suffice to show that over half of the specimens came from
+His, Giacomini, and Mall took up this problem with especial devotion and have done much to lay the basis for the accomplishment of the task set for pathologic embryology by MUller (1847). Miiller stated that it was the task of the pathological anatomy of prenatal life to show the progressive steps leading from the slightest deviation from the normal to the most pronounced deformity. This task is only begun and progress naturally will be slow, especially in connection with early forms, until we can discriminate better between the normal and the abnormal and the pathologic.
-Maryland, and most of these necessarily from Baltimore; next in order is New York,
-and the third, Pennsylvania. The remainder cover widely scattered points, the
-first century being drawn from 21 States, the second from 29 States, the sources
-gradually expanding to include practically every State and Territory of the Union.
-From the beginning, a few have come regularly from abroad, so that now we have
+A comparison of the clinical data relating to infection, with the microscopic findings, will show that the correspondence is extremely slight. This is not surprising, for physicians themselves often emphasize that the history probably is quite untrustworthy. Moreover, the clinical diagnosis of infection is usually based upon the presence of fever, a putrid discharge, or certain symptoms usually regarded as indicative of fever. If the clinical reports regarding infection were based upon bacteriologic or even upon histologic examination, they would undoubtedly agree better with our findings. These showed the presence of infection, as indicated by infiltration of the decidua or by abscess formation, in a large percentage of the cases in which the decidua was present, in the specimens falling into the first five groups.
-Table 3. — Sources of emhryologieal material by states, cities, and countries.
-specimens from widely different countries. This wide distribution is due to the
+The unavoidable confusion resulting from the use of the word ovum to designate the unfertilized female sex-cell, this cell when fertilized, the chorionic and amniotic vesicles with or without the embryo, and even the later product of conception in any and all stages of development, even up to birth, has prompted me to resort to additional terms. It certainly would seem best to restrict the term ovum to its comparative embryological significance and thus avoid confusion. But this restriction leaves us without a word to designate the whole product of conception. For this the word conceptus seemed available. At present the word embryo is frequently used loosely to designate conceptuses of any age. It is used still more frequently to designate merely the body of the future individual during the early stages of its development, in contradistinction to the word fetus, which usually is restricted to the later months. Hence we have need for still another term to be used in common for the embryonic disk, the embryo, or the fetus. Dr. Schultz has kindly suggested kyema, which Professor Foster suggests is preferably spelled cyema, adding that it is excellent Greek and was used in the proposed sense by Plato himself. It also has the advantage of being available for comparative embryology and of being easily adapted to meet such needs as are represented by the terms cyemetric and cyemology. Change may not imply improvement or progress, but the absence of it certainly never does. I realize fully that the use of unnecessary terms is to be avoided, but this is equally true of awkward circumlocution and misunderstanding. When one writes or says at present that no embryonic remnants were seen, it is impossible to know what is meant. Although the word embryo could by common consent be used in the proposed sense of cyema, long usage probably would make such an attempt futile for this reason alone. The use of this term and of others, presently to be suggested, does not change old meanings or old usage. It abrogates nothing save confusion.
-systematic circularization of the medical profession. We began by pubUshing
-letters of appeal in scientific journals, such as the American Naturalist; but as
-this was rarely seen by physicians it proved a waste of effort. Then, at the suggestion of Professor Minot, a number of articles were published in Wood's Reference
-Handbook in the belief that these would come under the eyes of physicians whom
-we hoped to reach; this plan likewise proved of httle value. Finally, a circular
-was drawn up, widely distributed, and reprinted in most of the medical journals of
-the country. For a number of years our esteemed colleague, Dr. Howard A. Kelly,
-inclosed a copy of this circular with every one of his reprints.
-This circularization, we beheve, accounts for the responses we first received
+Although the word abortion is available to designate the individual or the material aborted, it has not been the custom to use it in this inclusive sense. The word abortion, as now used, is usually restricted to the act itself. To use it in a double sense would lead to some confusion. Since blood-clot, pus, decidua, and mucosa usually are not only included with but frequently also surround the entire conceptus, I have used the word abortus to designate all the material expelled during an abortion. Only in this way can one avoid the use of such words as ovum, mole, chorion, and such expressions as the entire mass, embryonic mass, abortion mass, or (quite inaccurately) the chorionic vesicle, even when the latter is surrounded by a certain amount of decidua and blood-clot.
-from distant and varied points. Furthermore, if the effort is worth while, as a
-collection grows a Hterature develops from it, and papers from studies of our own
-collection began to appear in rapid succession. Reprints of these were sent to all
-our contributors. This doubtless served to stimulate their interest and encour-
-age others to send specimens, for in numerous instances physicians have written to
-us, at the suggestion of one of our donors, asking for information and instructions
-concerning the preservation and shipment of specimens. Thus, for a number of
-years our efforts were directed toward stimulating an increasingly large group of
-contributors, and we found that a succession of specimens from a physician gradually improved in quahty as his knowledge and interest increased. In the course of
-time certain contributors, who were especially interested in the work, developed
-contributing centers, so that in a few instances our collection has been augmented
-by a number of specimens received at one time from one or another of these centers.
-Aside from those in our own country, such a center was established at Manila,
-another at Shanghai, and quite recently one in Korea. The contributors at the
-last two points have carried their efforts to the extent of writing letters to the
-various Asiatic journals, requesting the preservation of embryos for this collection;
-and although unforeseen difficulties are to be overcome in Asia, we hope in the
-course of time to acquire at least a representative number of specimens from each
-of the important races.
-It may prove helpful to others who are making embryological collections to
+Since the term fetus compressus, as customarily used, refers to a twin fetus which died and was later subjected to pressure from the surviving, growing fetus during an extended period of time while it was undergoing mummification, the use of this term in Chapters III and IV requires definition. Practically all the specimens so designated in this survey are single, not twin. Besides, they have but rarely been subjected to pressure, and not a single specimen is dehydrated to the extent of being papyraceous. Rarely, when fetuses so termed have been subjected to pressure, this was the pressure of the contracted uterus subsequent to the absorption of the amniotic fluid. In many instances, however, these specimens were contained in a quantity of amniotic fluid sufficient to be protected from direct pressure of the uterus transmitted through the fetal membranes. Moreover, since all these, as well as the specimens of group 7, are macerated, and since all manner of gradations are found between the macerated swollen and the macerated wrinkled (fetus compressus) specimen, it may be preferable to restrict this term to its original usage. Much would also seem to be gained by an abandonment of such terms as decidua vera and serotina, which, although historical, convey false suggestions. The occurrence of a psuedo decidua does not seem to be at all established, and the sense in which the term vera was first used necessarily has been lost in the progress of modern embryology. The same thing applies to the term serotina. Hence, as suggested by others, it would seem preferable to speak of a parietal, a basal, and a capsular decidua, and finally relinquish the older terms.
-state that the task will probably be simplified if they will focus most of their
-efforts upon the immediate territory. In this way a collector can doubtless secure
-aU the specimens he can use and, in a way, pay his debt to the local profession by
-running a gratuitous pathological laboratory. The collection will thus be made
-a central point of interest for the physicians of the community who are scientifically
-incUned. Our many accessions from Maryland are due largely to personal
-influence through which the cooperation of the practising physicians of the Johns
-Hopkins Hospital was secured. We have also found that most of the physicians
-of Baltimore were not only wiUing but anxious to send specimens, especially from
-cases of repeated abortions. Usually a physician will bring his specimen directly
-to the laboratory, thus affording us an opportunity to show him what is done with
-it and thereby increase his interest. We do not receive all the embryological
-material available in the State of Maryland or in the city of Baltimore, but we
-do get a large amount from physicians practising among the poorer classes, as well
-as^fromfgynecologists and obstetricians practising among the wealthier. Most
-of the specimens from the poorer people belong in the third to sixth month of
-pregnancy and usually appear normal; while those from the upper classes are, as
-a rule, younger specimens and most of them are pathological.
+In order to avoid possible confusion through the introduction of new terms, I have added the following diagram, which presents their relationship at a glance:
-After our collection was well established we came somewhat in conflict with
+--Insert Diagram here--
-the department of health of the city of Baltimore, owing to the passage of a law requiring physicians to register all miscarriages and still-births. For a time it
-seemed as though this would place a ban upon collecting material in the city, but
-what appeared at first to be a hindrance later proved to be of great advantage
-and help; for the departments of health, both in city and State, have since been
-doing everything in their power to facihtate our work. This is well attested by
-the following excerpt from the Report of the Commissioner of Health to the mayor
-and city council of Baltimore, published in October 1913, and sent to every practising physician:
-:"We have through this monthly pubHcation called attention of physicians to the
+In spite of the fact that some great names have long been associated with the rising subject of the pathology of human development, a routine examination of abortuses seems quite worthless to many investigators. This is natural, for, aside from the poor preservation of many of these abortuses, the conditions under which nature performs her experiments on man necessarily are uncontrolled and often also unknown. But there would seem to be no reason for rejecting any testimony which such experiments may offer, though the search be a long and a disappointing one and the conditions not standard. To regard all attempts at a study of these specimens as futile is very largely to abandon man to a cruel fate. He never can be made the subject of accurately controlled experiment or a wholly satisfying study. The rigid requirements of scientific investigation must, in the nature of things, almost always remain unfulfilled. Comparative anatomy, medicine, and pathology, as well as experiments upon animals, undoubtedly offer greater returns merely because the subject of experiment can be bred, nurtured, and sacrificed at the will and by the hand of man. But if it be conceded that in the last analysis the aim of all human effort must be directed toward the amelioration of the lot of mankind, then it would be folly to reject even the chance stalk that may spring from the grain of wheat which lay hidden in a bushel of chaff.
-requirements of the law concerning the proper registration of all abortions or still-births.
-We have told you that every abortion or still-birth requires a birth certificate and a
-death certificate. As in the application of many new laws, we have found that the
-practical working out of this one has produced occasionally some hardships, particularly
-on the poorer people, which if they had been anticipated could have been avoided by
-appUcation for instructions to this department. So I take advantage of this month's
-publication to inform the physicians that it is not necessary to place their patrons to
-the expense of having a fetus, born during the period of gestation of less than five months,
-buried by an undertaker. Of course the body must not be disposed of in an irregular
-way, such as throwing it down a privy sink or burying it in the yard or cellar, as has
-been more or less common in the past, but if the fetal body is properly wrapped up and
-placed in a small box and sent to this department, along with the birth certificate and
-death certificate, we will see that the body is properly disposed of. I feel quite sure
-that this arrangement will meet, or certainly ought to meet, all the reasonable objections
-that can be brought against the enforcement of the new law.
+The conception, as well as the general plan, of this volume is that of Professor Mall himself. It was my happy experience to be invited to share in both. An unkind fate made it impossible for Professor Mall to complete his own work; for his part everyone will feel deeply grateful; for the part that might have been his, others than myself will feel an immeasurable regret.
-:"One word concerning the specimens desired by Dr. Mall of the Johns Hopkins
-Medical School. We want in every way to assist Dr. Mall in obtaining the specimens
-that he so much desires, and this regulftion of the department does not in any way
-interfere with it, but probably may be just as easy and certainly safer in supplying the
-specimen. Whenever a physician has a specimen to transmit to Dr. Mall, it will not
-add much to the physician's trouble to stop at the Health Department, which is open
-at all times, to leave a birth and death certificate and get permission to leave the specimen
-with Dr. Mall."
-However, this note delayed unduly the sending of young specimens and doubt-
+Although the table of contents had not been prepared, the possible scope of the volume and the order of the topics had often been considered. It was the intention not only to read each other's chapters, but to discuss and revise them together. With characteristic generosity, Professor Mall suggested that, except for one chapter not contributed by either one of us (Chapter VI), we share equally in that part of the undertaking not included in the special studies. Partly in accordance with this desire, he wrote the introductory chapters in the first person plural, much against my earnest remonstrance, for my share in them is quite negligible. However, since they had been considered together they stand as he wrote them, except for a few footnotes. Unfortunately, only one of my studies was in final form before his death, but he was familiar with it, although we had not considered the paper together. Since all the remainder of my part was written subsequently, it did not seem justifiable to me to charge him with responsibility for conclusions of my own or for personal opinions which might not have commended themselves to him.
-ful ones from operations, such as uterine scrappings and tubal pregnancies, and
-did not, it appears, encourage the reporting of abortions. Later the Department
-of Health of the State of Maryland permitted the fiUng of birth and death certifi-
-cates after the specimen had been sent to this laboratory. Many more abortions
-are now reported than before, but in order to make the records more complete
-the following letter was sent out by the Department of Health in November 1916,
-to all practising physicians in Maryland:
+It is with the greatest satisfaction that I record in this connection his decision to mutually consider all points of difference and, if common ground could not be found, to state frankly our individual views. It was characteristic of him never to use the weight of his authority in the discussion of controverted questions or to influence anyone's conclusions. He was ever willing to leave the truth to the future. It was this attitude that made the completion of this unfinished work a very satisfying effort, even if lonely and in some respects unsatisfactory. Chapters I, II, and VIII, and all the protocols at the end of Chapter IV, below No. 1,000, fortunately had been written by him. However, in accordance with his intentions, protocols were revised and a number of them entirely rewritten. Since he himself had requested this in the case of several which we considered together, I feel that I have merely followed his desire in this matter. In the exercise of this privilege and duty of revision I have used the greatest care to preserve his descriptions as far as possible. Indeed, in the completion of this volume, it has been my constant purpose to follow his plan, to preserve his views, and to realize his intentions. Although I feel the deepest scientific interest in this work, it has also been a labor of love and devotion, and it was a great satisfaction that its continuation was made possible by the Carnegie Institution of Washington, and that its realization was furthered in every way by my friend and former colleague, Dr. George L. Streeter.
-:"From information this Department has received, we are convinced that we are
+Since these studies were completed very largely during 1918 and the spring of 1919, no references are made to the recent literature in a large portion of the volume.
-not receiving full reports of still-births. It appears that most physicians do not com-
-prehend what is embodied in the term 'still-birth,' as used in the Registration Law of
-this State. For the purpose of learning the extent to which we should expect reports
-of still-births under this law, I have requested from the Honorable Edgar Allan Poe,
-Attorney General of the State of Maryland (1912-1916), a legal definition of the term,
-which I am enclosing herewith. You will note that it is required of you to make a report of all products of conception no matter how early. Every still-birth should, according
-to the law, be treated as a birtli and a death; that is, there should be fded with the
-registrar of vital statistics for each still-birth, no matter how early, a certificate of birth
-and a certificate of death.
+A. W. MEYER.
-"The Department has learned that Dr. Franklin P. Mall has been endeavoring to
-collect embryological material for scientific purposes, and is particularly anxious to receive
-fresh specimens. This, or a similar procedure, is a permissible disposition of the materials
-in question, and physicians may forward that which comes into their possession to Dr.
-Mall, corner Monument and Wolfe Streets, Baltimore, provided that as soon as they
-have done so, they file a certificate of birth and death, in Baltimore City with Dr. John
-D. Blake, and in the rural districts with the local registrar of the district in which the
-birth occurred. The local registrar will issue a burial permit in receipt thereof, which
-permit should be forwarded to Dr. Mall immediately. When material is preserved in
-formalin or other hardening fluid before forwarding, or in instances when it is disposed
-of locally, a certificate of birth and death should be filed and a burial permit received
-thereon before it is disposed of. In any instance where a certificate of birth and death
-is not filed for a still-birth it will be treated as a violation of the Registration Act."