Paper - On the fate of the human embryo in tubal pregnancy (1915)
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Mall FP. On the fate of the human embryo in tubal pregnancy. (1915) Contrib. Embryol., Carnegie Inst. Wash. Publ. 221, 1: 1-104.
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On The Fate Of The Human Embryo In Tubal Pregnancy
By Franklin P. Mall Director of Department of Embryology, Carnegie Institution of Washington
Contributions To Embryology Volume 1, No. 1, Published By The Carnegie Institution of Washington 1915, Carnegie Institution Of Washington Publication No. 221.
- Cause of tubal pregnancy
- Tubal pregnancy with normal embryos
- Tubal pregnancy with pathological embryos
- Tubal pregnancy with pathological ova
- Fertility and sterility
- Implantation in tubal pregnancy
- Normal implantation in uterus
- Normal embryos in the tube
- The trophoblast
- Normal embryos from 6 to 9 mm in length
- Normal embryos over 9 mm long
- Conclusions regarding normal implantation
- Pathological embryos in tubal pregnancy
- Pathological ova in tubal pregnancy
- Degeneration of villi and chorion
- Description of the individual specimens
- Bibliography of papers cited
- Explanation Plates 1, 2, and 3
The following study on tubal pregnancy is to be regarded somewhat as a byproduct from our embryological collection. Originally we were of the opinion that the very earliest stages of human development would be found in a recent tubal pregnancy removed by the surgeon. Before 1897 physicians were under the impression that an embryological collection should consist only of normal specimens, and the first tubal pregnancy added to the collection (No. 109) was sent to us by Dr. Cushing because it contained a normal embryo. We soon found that we would not obtain very early specimens by this method from the fact that the diagnosis of tubal pregnancy is made much too late. The smallest normal specimen we have received (No. 808) contained an embryo 6 weeks old. The very small tubes which have been sent invariably contained pathological embryos or small ova without embryos. According to our records 59 per cent of tubal pregnancies fall in the latter class. In 46 carefully selected cases from Dr. Kelly's clinic this percentage is raised to 84.8; if we could collect all cases of tubal pregnancy, the probabilities are that it would be still higher.
The normal specimens accumulated slowly among the numbers of our collection below 500. In this group 21 out of 27 specimens, which had been examined by physicians before they were sent to the laboratory, contained normal embryos. Among the specimens that had not been previously examined, only 4 out of 19 were normal. (See table 1.)
Table 1. List of specimens reviewed in this publication
(total number 117)
(Table to be formatted)
|Table 1 - Carnegie Embryos in Publication|
|Normal embryos (No.)||Pathological embryos (No.)||Pathological ova (No.)|
|Examined before received||Not examined before received||Examined before received||Not examined before received||Examined before received||Not examined before received|
|109 Template:CE456||Nos. 183 Nos. 389
|Nos. 307 Nos. 314||Nos. 196 Nos. 324
|Nos. 685 Nos. 697||Nos. 369||378
|Nos. 154 Nos. 540 Nos. 772
298 553 773
|361 561 775
418 659 794
430 673 8096
488 686 809c
513 720 825
514 726 835
515 734 874
517 741 889
I have been able to collect three sets of statistics regarding the frequency of normal and pathological embryos and pathological ova in tubal pregnancy. The first includes specimens examined by physicians who sent them to us; to the second belong those not previously examined, which means that in these there was no selection; the third is made up of unruptured specimens examined in the gynecological laboratory of the Johns Hopkins Hospital before 1908. These data are given in table 2.
Table 2. Number and percentage of normal embryos, pathological embryos, and pathological ova obtained
(Table to be formatted)Per cent. Number. Per cent. Number. Per cent. Specimens sent to me after they had been examined 30 13 2 81 10 4.3 o 20 5 5.5 25 10.9 47 39 13.5 59 84.8
Specimens sent to me without any previous
46 unruptured specimens examined in Dr. Kelly's laboratory
Table No. 2 gives number and percentage of normal embryos, pathological embryos, and pathological ova obtained (1) from specimens that had been previously examined; (2) from those which had not been previously examined, i. e., unselected; (3) from 46 unruptured specimens from Dr. Kelly's laboratory.
It is of interest to consider together the pathological ova obtained from tubal pregnancies, for it is through a study of these that light may be thrown upon the question whether their condition is inherited or is due to faulty environment. In the former case, the percentage of pathological embryos should be the same as among those obtained from the uterus; in the latter, the percentage should be increased.
Various writers have stated that in tubal pregnancies embryos are rarely found, but that remnants of the chorion are common. Nevertheless the proviso is made that when the tube has been found ruptured and much blood has escaped into the peritoneal cavity, the embryo may have been present, but may not have been found on account of the great quantity of blood. On the other hand, Professor Brodel informed me in 1907 that among 11 cases of tubal pregnancies recorded in his catalogue of human embryos 9 normal specimens were found. At that time 7 tubal pregnancies out of 19 in our collection contained normal embryos. It must be remembered that at that time the rule of surgeons was to withhold the pathological specimens and to send us only the normal embryos. Taking into consideration, then, only the tubes that were sent to us unopened, and excluding those obtained from Dr. Kelly's gynecological laboratory, I found in 7 specimens 2 ova without embryos, 4 with pathological embryos, and only 1 with a normal embryo. The other 6 normal embryos spoken of above were all recognized by the surgeons as "normal and valuable specimens" before they came into our hands.
Following the hint obtained by considering all the specimens coming to us unopened, I collected all of the histories of similar specimens from Dr. Kelly's laboratory. These covered a period of about 10 years and were taken from the laboratory records of over 10,000 miscellaneous cases. I found 128 cases of tubal pregnancy which were carefully described from numerous microscopic sections. I have excluded the reports of 82 of these specimens in which the lubes had ruptured before the operation. Of the 46 that remain the histories state that they were unruptured and varied from 1 to 6 cm. in diameter; 2 of the 46 contained normal embryos of the second month and in 5 of them pathological embryos were present . The rest, 39 in number, contained entire ova without embryos or simply villi of the chorion in various stages of degeneration. Usually the dilated tube was found filled with blood, through which were found scattered villi, the chorion rarely being intact, that is, it was not encircling a coelom. The chorion had collapsed, leaving scattered villi, which were variously described in different cases as "degenerated," "poorly formed," or "necrotic." Usually it is stated in the records, "Scattered villi were present in the clot; no embryo was found."
The normal embryos need not be discussed more than to mention that the amnion was very small, as is usually the case in these specimens. The pathological specimens, however, show a similar nature and degree of degeneration as in specimens obtained from the uterus. A number of small specimens which were cut into serial sections contained no embryos at all; they are included among the 39 mentioned above. From my experience in searching for embryos in pathological ova I am of the opinion that a few more pathological embryos would have been found had the specimens been examined with greater care. It is unlikely, however, that more normal embryos would have been discovered, inasmuch as they always lie in a crelom or in an amnion filled with clear fluid. I have never found a normal embryo in an ovum which did not contain a cavity showing a definite sharp wall and filled with transparent fluid. Hence, I believe that those who made the sections for microscopical examination could hardly have overlooked any normal embryos.
These data, which were obtained 7 years ago, form the basis of the present study. By reference to table 2 a comparison can readily be made between the number of specimens which came to me after preliminary examination, between those which were not examined and the 46 unruptured cases from Dr. Kelly's laboratory. The difference between the first and second lines of the table is easy to explain. In the specimens represented in the first line a selection was made by the surgeon, whereas those of the second line were unselected. The difference between the second and third lines is more difficult to explain. In all probability Dr. Kelly's statistics include more small specimens than mine, for frequently the surgeon sends apologies with a small specimen containing no embryo. I am inclined to believe that many small specimens were discarded by the surgeons as worthless for our purposes. Again, the question of early diagnosis must not be overlooked. It is probable that in well-regulated clinics tubal pregnancy is recognized more readily than in outside practice. In fact, most of the very small specimens in our collection came from the Johns Hopkins Hospital. That the number of pathological embryos found in our statistics is larger than in Dr. Kelly's is easy to explain. My examinations were probably more thorough. At the preliminary examination we also found only 10 per cent of pathological embryos, whereas more careful search brought this percentage up to 25. Had serial sections been made of all of these specimens it would no doubt have been higher.
The larger percentage of normal specimens in the first line of the table is also easily explained. There was a tendency to send us "beautiful specimens," and these often contained normal embryos, for example, No. 657. We must assume that, in the routine of a laboratory, practically all normal specimens will be discovered by the pathologist, and with this assumption we may conclude that the first set of statistics (line 1, table 2) represents 455 cases, and the second set (line 2), 520 cases, provided the diagnoses were as accurate and as early as at the Johns Hopkins Hospital.
The small tubes which have been received are, in many respects, the most interesting, and I regret very much that we have been deprived of the privilege of examining more of them. In this material the very small ova were found, as well as tubes without ova, showing also most interesting pathological changes. In such specimens the younger normal embryos will ultimately be found. The question that interests us most, namely, the cause of tubal pregnancy, will be answered satisfactorily only from the study of very .early specimens.
This paper is to be viewed as our fourth contribution to the pathology of the human embryo. The first was published in the Welch Festschrift in 1900, the second in the Vaughan Festschrift in 1903, and the third in the Journal of Morphology in 1908. In the third study a group of tubal pregnancies was considered, inasmuch as it gave us an opportunity of comparing pathological embryos found in the tube with those obtained from the uterus.
The first tubal specimen was obtained in 1897 from Dr. Harvey Gushing. It contained a normal embryo, 10.5 mm. long, which was studied with great care and has been found useful and referred to in some forty publications. Not long after pathological tubal specimens began to be added to the collection, and a small group of these was first considered in my paper on monsters mentioned above. Since 1908 I have made an especial effort to collect tubal pregnancies, and of late these have accumulated so rapidly that I am enabled to include 117 in this report. 1
The 117 specimens of tubal pregnancy have been received from the following sources: From the Johns Hopkins Hospital, 26; from the Hebrew Hospital, 5; from the Church Home and Infirmary, 5; from the Franklin Square Hospital, 3; from the Union Protestant Infirmary, St. Joseph's, St. Agnes', the University and Woman's Hospitals, Baltimore, 1 each; from the Brooklyn Hospital, 2; from Bellevue Hospital, 5; from the Bender Hygiene Laboratory, 3; from St. Peter's Hospital, 1; from the Ontario County (New York) Laboratory, 1; from the Bridgeport (Conn.) General Hospital, 1; from Christ Hospital, New Jersey, 1; from the Marine Eye and Ear Hospital, Maine, 1; from Sibley Hospital, Washington, D. C., 1; from the Frederick City (Maryland) Hospital, 1; from the New England Hospital, Massachusetts, 1 ; from physicians and hospitals undesignated, 54.
The physicians sending me the specimens have been credited in the protocols. To them, as well as to the hospital authorities, I am deeply indebted for the opportunity which has made this study possible.
- the "Addendum" includes 29 new specimens, making 140 in all.
I wish to express my thanks especially to Dr. Herbert M. Evans, Research Associate in the Carnegie Institution of Washington, for his successful efforts in collecting specimens and for his aid in working up embryological material.
During the past two years it has been possible to expedite the work through generous aid from the Carnegie Institution of Washington. Much better histories are now obtained than formerly, thanks to the efficiency of a private secretary; microscopic examinations have been greatly facilitated by competent technical assistants, and the illustrations have been markedly improved through the skill of a talented artist. A study of the protocols will show that those of recent date are more complete than the earlier ones.
The specimens here described, together with the rest of my human embryos, have been presented to the Carnegie Institution of Washington to form the nucleus of the collection of its newly established Department of Embryology.
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|Embryology History | Historic Embryology Papers)|
|Fate of the Human Embryo in Tubal Pregnancy: Introduction | Acknowledgments | Tubal pregnancy with normal embryos | Tubal pregnancy with pathological embryos | Tubal pregnancy with pathological ova | Fertility and sterility | Implantation in tubal pregnancy | Normal implantation in uterus | Normal embryos in the tube | The trophoblast | Normal embryos from 6 to 9 mm in length | Normal embryos over 9 mm long | Conclusions regarding normal implantation | Pathological embryos in tubal pregnancy | Pathological ova in tubal pregnancy | Degeneration of villi and chorion | Summary | Cause | Normal implantation | Tubal pregnancy containing pathological embryos | Pathological ova | Addendum | Description of the individual specimens | Bibliography of papers cited | Explanation Plates 1, 2, and 3|
Cite this page: Hill, M.A. (2021, June 19) Embryology Paper - On the fate of the human embryo in tubal pregnancy (1915). Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Paper_-_On_the_fate_of_the_human_embryo_in_tubal_pregnancy_(1915)
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