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Processes of Tubal Pregnancy
124
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
as she could not speak English, but the husband told showed a mast94 presenting in the cervix which was hand and felt like a projecting placenta. The1 cervix the head was above the brim and I did a rapid version I got the baby out I found that what I had supposed was a rupture which extended out through the lower
AND
GYNECOLOGY
us of it later. Examination soft, about as long as the seemed to be fully and breech extraction. was a fully dilated uterine segment into
dilated, After cervix the ab-
dominal cavity and the intestine was hanging down into the same. The mass which I thought was a placenta was a fibroid in the lower uterine segment which was sticking down into the ruptured cervix. I have no doubt from the history of the case and the denial from the doctor in attendance that he had done anything, that this woman had a spontaneous rupture of a fibroid uterus. It is possible and probable that some of these cases of spontaneous rupture of the uterus may be due to this cause.
DR. E~CE MCDONALD read a paper entitled Processes of Tubal nancy. (For orginal article see page 72.)
Preg-
DISCUSSION DR. EDWARD A. SCHUMANN.-Except in a few instances, I am entirely in accord with this presentation, but I do hold it to be a little bit confused as to just why SO much stress was laid upon the first accident of extravasation into the tubal wall. If my recollect.ion is correct, I think Veit called attention to this in 1897. I was so taught as an undergraduate and indeed I can hardly recall any careful pathologic study of the subject that has not discussed intramural extravasation. It has usually been termed “hemorrhage, with death of ovum. ” In Williams’ Textbook there ia a passage in which Dr. McDonald’s words are almost paraphrased. In regard to the scar, I do not believe Dr. McDonald will often find it. If you will remember the process of embedding of the ovum in the uterus where you have decidua, the ovum after it enters the uterus begins to seek for a blood supply and the endometrium is literally eaten away, the great folds of endometrium COVPrecisely the same thing holds true in ering up the cavity and there is no sear. the tube, the ovum embedded, begins to digest its way into the structures of the tube. Dr. McDonald also said this type of so-called tubal abortion was neither tubal pregnancy nor abortion. It is tubal pregnancy because it is bounded by the serous surface of the tubes and anything within the seroua surface is tubal. As to separation of muscle fibers and final escape of the ovum by fimbrial rupture, that is an accident which does take place occasionally. It is much simpler for a tubal ovum by protoplastic activity or mere pressure to get back into the already partially eroded mucosa than to dissect out of all these muscle bundlesI. I believe, however, that in a large number of tubal abortions, the entire ovum surrounded by blood clot, may be found in the lumen of the tube and I have two specimens in which the ovum is partly extruded from the tube and in which careful serial sections demonstrated that the fbnbriae were not injured at all. DR. EDWARD P. proteolytic ferment in that one of the causes acter of the pain as I recall a ease which disclosed a minimum be traced to successive
DAVIS.-Two clinical points: does not the abssorption of the tuba.1 and rupturing pregnancy predispose to shock? Is not of shock out of proportion to hemorrhage? Second, the charthe muscular layers of tube rupture, is important clinically. went to a fatal termination through shock, where operation hemorrhage and where two distinct accessions of pain could rupture of muscular layers of the tube. I do not think that
NEW
YORK
ACADEMY
125
OF’ MEDICINE
we should get the idea that rupure of tubal pregnancy comes with great suddenness, as a tour de force. The gradual pain, with increasing shock, seems to me to be the essential clinical picture. DR. MCDONALD (closing).-There is no rupture is not a sudden process, as a rule. ferment, I do not know the amount of the In eebpic pregnancy the degree of shock
doubt, as Dr. Davis says, that ectopic As regards the shock fr.om proteolytie ferment, but it is probably very small. is sometimes rather diverse from the
amount of blaod lost. The question of hemorrhage between the coats has not been described except by Bonney, although hemorrhage into sinuses of the gestation itself has been long recognized, but the fact of intramural extravasation of blood between the coats has never been referred to, except by Bonney. Hemorrhage from the nourishing blood lake itself has been recognized but not dissecting hemorrhage between the coats. At least I am unfamiliar with it. I have never seen the gestation begin in the lumen of the tube itself. As described by Dr. Schumann, this covering up by the mucosa occurs in the uterus, but never has beon described by any one as occurring in the tube. I have seen one sear and it is very difficult to find even in tube where the ovum has passed. I have suggested an alteration of the nomenclature, not with a view of upsetting any old nomenclature, but with the idea of correlating symptoms and pathology more exactly. The first accident of tubal pregnancy, intramural extravasation of blood between the muscular coats of the tube wall, should have some expression in the terminology. The old terms of tubal abortion and tubal rupture are inexact and misleading as to the pathology. Fimbrial rupture, is a better term than tubal abortion, because that implies that rupture comes from the mucosal canal. No doubt in many cases it does not. Transperitoneal rupture is what Bonney calls extratubal rupture under the old terminology, tubal rupture which is not truly tubal as it only bursts through the outer coat of the tube.
NEW
YORK
SECTION
ON
STATED
DR. DR.
LYNN
Bladder
LYLE
WILLIAM FULKEESON
ACADEMY OBSTETRICS
ZEETING,
E.
OF MEDICINE AND
GYNECOLOGY
FEBRUARY CALDWELL
presented
37, 1983. IN
a
THE
CHAIR
New Cystoscope for Female
and Urethra.
This instrument is a direct vision oystoscope designed to permit examination of the female bladder and urethra by either air or water distention. It consists of four tubes of sizes 24, 27, 30, and 33 F any one of which may be adjusted to a universal light-carrier. (Fig. 1.) The tubes are 10 cm. in length and each is furnished with an obturator. ‘The light-carrier is provided with a lock-screw for holding the tube in place, with a tube and cut-off for regulating the filling of the bladder and urethra with water, with a small opening for air escapement, and with a lightcarrier base which sets into a slit-tube at the end of a nickel cord terminal. (Fig. 2.) The cord terminal serves as a handle and is provided with a switch for oontrolling the light. Four eyepieces are furnished, one of which is without a lens, being left open for use when operating. The other three eyepieces are closed by lenses. They are l.ocked on the light-carrier before filling is begun. When the eyepieces are partly locked a hole is left open for air escapement; when completely locked
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
as she could not speak English, but the husband told showed a mast94 presenting in the cervix which was hand and felt like a projecting placenta. The1 cervix the head was above the brim and I did a rapid version I got the baby out I found that what I had supposed was a rupture which extended out through the lower
AND
GYNECOLOGY
us of it later. Examination soft, about as long as the seemed to be fully and breech extraction. was a fully dilated uterine segment into
dilated, After cervix the ab-
dominal cavity and the intestine was hanging down into the same. The mass which I thought was a placenta was a fibroid in the lower uterine segment which was sticking down into the ruptured cervix. I have no doubt from the history of the case and the denial from the doctor in attendance that he had done anything, that this woman had a spontaneous rupture of a fibroid uterus. It is possible and probable that some of these cases of spontaneous rupture of the uterus may be due to this cause.
DR. E~CE MCDONALD read a paper entitled Processes of Tubal nancy. (For orginal article see page 72.)
Preg-
DISCUSSION DR. EDWARD A. SCHUMANN.-Except in a few instances, I am entirely in accord with this presentation, but I do hold it to be a little bit confused as to just why SO much stress was laid upon the first accident of extravasation into the tubal wall. If my recollect.ion is correct, I think Veit called attention to this in 1897. I was so taught as an undergraduate and indeed I can hardly recall any careful pathologic study of the subject that has not discussed intramural extravasation. It has usually been termed “hemorrhage, with death of ovum. ” In Williams’ Textbook there ia a passage in which Dr. McDonald’s words are almost paraphrased. In regard to the scar, I do not believe Dr. McDonald will often find it. If you will remember the process of embedding of the ovum in the uterus where you have decidua, the ovum after it enters the uterus begins to seek for a blood supply and the endometrium is literally eaten away, the great folds of endometrium COVPrecisely the same thing holds true in ering up the cavity and there is no sear. the tube, the ovum embedded, begins to digest its way into the structures of the tube. Dr. McDonald also said this type of so-called tubal abortion was neither tubal pregnancy nor abortion. It is tubal pregnancy because it is bounded by the serous surface of the tubes and anything within the seroua surface is tubal. As to separation of muscle fibers and final escape of the ovum by fimbrial rupture, that is an accident which does take place occasionally. It is much simpler for a tubal ovum by protoplastic activity or mere pressure to get back into the already partially eroded mucosa than to dissect out of all these muscle bundlesI. I believe, however, that in a large number of tubal abortions, the entire ovum surrounded by blood clot, may be found in the lumen of the tube and I have two specimens in which the ovum is partly extruded from the tube and in which careful serial sections demonstrated that the fbnbriae were not injured at all. DR. EDWARD P. proteolytic ferment in that one of the causes acter of the pain as I recall a ease which disclosed a minimum be traced to successive
DAVIS.-Two clinical points: does not the abssorption of the tuba.1 and rupturing pregnancy predispose to shock? Is not of shock out of proportion to hemorrhage? Second, the charthe muscular layers of tube rupture, is important clinically. went to a fatal termination through shock, where operation hemorrhage and where two distinct accessions of pain could rupture of muscular layers of the tube. I do not think that
NEW
YORK
ACADEMY
125
OF’ MEDICINE
we should get the idea that rupure of tubal pregnancy comes with great suddenness, as a tour de force. The gradual pain, with increasing shock, seems to me to be the essential clinical picture. DR. MCDONALD (closing).-There is no rupture is not a sudden process, as a rule. ferment, I do not know the amount of the In eebpic pregnancy the degree of shock
doubt, as Dr. Davis says, that ectopic As regards the shock fr.om proteolytie ferment, but it is probably very small. is sometimes rather diverse from the
amount of blaod lost. The question of hemorrhage between the coats has not been described except by Bonney, although hemorrhage into sinuses of the gestation itself has been long recognized, but the fact of intramural extravasation of blood between the coats has never been referred to, except by Bonney. Hemorrhage from the nourishing blood lake itself has been recognized but not dissecting hemorrhage between the coats. At least I am unfamiliar with it. I have never seen the gestation begin in the lumen of the tube itself. As described by Dr. Schumann, this covering up by the mucosa occurs in the uterus, but never has beon described by any one as occurring in the tube. I have seen one sear and it is very difficult to find even in tube where the ovum has passed. I have suggested an alteration of the nomenclature, not with a view of upsetting any old nomenclature, but with the idea of correlating symptoms and pathology more exactly. The first accident of tubal pregnancy, intramural extravasation of blood between the muscular coats of the tube wall, should have some expression in the terminology. The old terms of tubal abortion and tubal rupture are inexact and misleading as to the pathology. Fimbrial rupture, is a better term than tubal abortion, because that implies that rupture comes from the mucosal canal. No doubt in many cases it does not. Transperitoneal rupture is what Bonney calls extratubal rupture under the old terminology, tubal rupture which is not truly tubal as it only bursts through the outer coat of the tube.
NEW
YORK
SECTION
ON
STATED
DR. DR.
LYNN
Bladder
LYLE
WILLIAM FULKEESON
ACADEMY OBSTETRICS
ZEETING,
E.
OF MEDICINE AND
GYNECOLOGY
FEBRUARY CALDWELL
presented
37, 1983. IN
a
THE
CHAIR
New Cystoscope for Female
and Urethra.
This instrument is a direct vision oystoscope designed to permit examination of the female bladder and urethra by either air or water distention. It consists of four tubes of sizes 24, 27, 30, and 33 F any one of which may be adjusted to a universal light-carrier. (Fig. 1.) The tubes are 10 cm. in length and each is furnished with an obturator. ‘The light-carrier is provided with a lock-screw for holding the tube in place, with a tube and cut-off for regulating the filling of the bladder and urethra with water, with a small opening for air escapement, and with a lightcarrier base which sets into a slit-tube at the end of a nickel cord terminal. (Fig. 2.) The cord terminal serves as a handle and is provided with a switch for oontrolling the light. Four eyepieces are furnished, one of which is without a lens, being left open for use when operating. The other three eyepieces are closed by lenses. They are l.ocked on the light-carrier before filling is begun. When the eyepieces are partly locked a hole is left open for air escapement; when completely locked