Role of the Uterus in the Production of Manometric Fluctuations During Uterotubal Insufflation (Rubin Test)

ROLE OP THE UTERUS IN THE PRODUCTION OF MANOMETRIC FijUCTUATIONS DURING UTEROTUBAL INSUFFijATION (RUBIN TEST)* SEYMOUR WIMPFHEillmR, M.D., AND MoRRis FERES'rEN, M.D.,

NEw YoRK, N. Y. (From the Gynecological Service and the Laboratory of Mt. Sinai Hospital)

INCE Kehrer 's classic experiments with isolated strips of excised S tube, numerous animal experiments have demonstrated the presence of tubal contractions and peristalsis. In May, 1925, Rubin began the 1

2

study of human tubal peristalsis by recording on a revolving drum the variations in pressure coincident with the passage of gas through the uterus and tubes. Gnthman 3 was the first to express the opinion that manometric fluctuations were due to tubal peristalsis. He based this conclusion on the wellknown fact that when the tubes are closed, fluctuations are not observed on the manometer. Much experimental work was done to substantiate this contention. However, further evidence is necessary to determine whether or not the uterus participates in the production of manometric fluctuations during uterotubal insufflation, and if so, to what extent. To clarify this subject, these experiments have been earried out on the uterus and tubes of living rabbits, and on excised specimens. MATERIAL AND METHOD

Experimental observations were made on the intact uteri and tubl~s of 60 mature rabbits, weighing from 2 to 4 kilograms. They were anesthetized by the intravenous injection of nembutal, 1 gr. to 2.2 kilograms. Further studies were made on the excised specimens suspendetJ in oxygenated Locke solution. Changes in manometric fluctuations during gas insufflation of the uterus and tubes were recorded o,n the kymograph of the Rubin apparatuf,4 Ctnbon dioxide gas under 15 pounds of pressure was employed at a eonstant rate of flow, one second being required for the passage of 1 c.c. For the routine uterotubal insufflation, a bulb tipped medicine dropper or KeyeeUltzman cannula was passed into the uterus through a small incision 2 em. from the uterotubal junction, and tied tightly. For retrograde tubouterine insufflation, a needle cannula was tied in the fimbriated end of the tube. For uterine insufflation alone, the cannula was tied into a segment of utems, the wall of which was punctured to allow the gas to escape through it and thus preventing it from passing through the uterotubal junction and tubes. For tubal insufflation alone, a needle cannula was passed through the uterotubal junction into the tube, and tied tightly. In order to demonstrate focal contractions of the uterine and tubal muscle a small needle hook was passed through the entire thickness of muscle, down to the mucosa, and the contractions were recorded on a smoked drum. TUBAL PATENCY NECESSARY FOR MAKOMETRIC FLUCTUATIONS

During uterotubal insufflation, pressures of 50 to 200 mm. Hg were necessary in different rabbits to force the gas from the much wider uterine cavity through •we are indebted to Dr. I. C. Rubin for the suggestion and supervision of these

experiments.

405

thP nanpw utNotnl>nl ;jull<'l ion. Chi<'<' lit<' .~a~ J>Ho:urP and m~Hwm..tri<· tltwtunt i"n" \\'en· n···nnl•·d "" Jon~ as the ga:< was allow<'l'iiit·lt ga:< fai],•d to [>a:nl juH•·tiou at precR\ll'h of ::!llo to 2:!!1 Illllt. Hg, thPn' WNI' no prPK"Ul'l' tluduntion:<. ln thrH' ••xpNiniPntH the tul>t•:< IH'l'P patPnt to tl>I' ga:< nud t•xhil>it!'d f'l'l.'Kolll'<' liKI'.illat.ill!lK :1:< tlte gaK iiOII'I'·lnmpl'll off tl11• flnduntiollK t'PaSl'd. vVhen th-e vressure wa;: relPa:<<'1'1' produi·Pd. HoW!'\'I'r, wlH~n the damps W0ff' renlm'e:uerl with viHihle p1'1'iB1ah tuht•s. 'I'IJP prPB~\ll'e pnttPms wt>rf' s
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ThPse PXperiment;; indieatP that tubal patency mmt bf) prE'sent for thP •lemon· stration of nnmOJnPtric flHduntionR durin~ utProtubal im
In the undi;;turbents. How\'wr, during ut.erot.nbal insufflation, the uterus

Fig. 1.-A, l'terotubal g:a,; in,;ufflation. sho" ing nunwroc~s nvmomdric fluctuations. B, Insufflation of solitary uterine seg:m••nt, .'
became uistendeu anR. 'l'his <1 tlte ntProtnhal june.t ion at a low prPi'slll'f.' withont t'ausing marlwd distention of the utnns, nnmployP<, toward or away from the vagina, had little cff<:>c't on the findingH. In the plra~c of r•rmtra('.tiou the utPrn:> or lithe beeamr• shorter and thicker. During insufflation, tlw eontraeti(ln,; appeared sinmlt.nneous with tlw upwanl ri~e of the mereury pressure and the: upward strokt> on the d in large, rapidly surceeding bubble~.

WIMPFHEIMER AND FERES'I'EN :

407

UTEROTUBAL INSUFFLA'riON

In 30 experiments the contractions obtained by insufflating a solitary segment of uterus were entirely different from those of uterotubal insufflation (Fig. 1). The uterotubal junction acted as a barl'ier to the gas to a pressure far in excess to that which was neeessary when the gas passed through the uterine opening. Thus, ga~ passed through the artificial uterine opening at pressures of 10 to 50 mm. Hg. The pressures required to force gas through the uterotubal junction to record tubal contr·actions varied from 50 to 200 mm. Hg, and correspondingly higher pressure levels were maintained as long as the gaR was allowed to flow. 'When the uterus alone was insufflateu, the rate of contraction~ was much le~s than when the tube was included.

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Fig. 2.-A, Uterotubal gas insufflation. B. Insufflation after ex<'IS!On of half of ampulla. C, Insufflation after excision of entire ampulla. D. Insufflation after excision of half of isthmus, showing an occasional shallow contraction. E, Insufflation after excision of entire isthmus. Note absence of manometric fluctuatione.

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Fig, 3.-A, Tubouterine gas insufflation. B. Insufflation after excision of uterus. Insufflation after excision of tubouterine junction. D. Insufflation after excision of half of isthmus. E, Insufflation after excision of entire isthmus. Contractions have disappeared, C.

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Uterotubal gas insutllation. B, Insufflation of tube (uterus excluded). Note similarity of manometric fluctuations recorded.

In 12 tests there were less than 4 contractions per minute; during uterotubal insufflation there were always more than 4 contractions per minute. In 14 experiments uterotubal insufflation registered 10 to Hi contractions per minute; when the uterus alone was insufflated there were never more than 9 contractions per minute. The uterine contractions usually had a larger amplitude than those which were obtained at uterotubal insufflation. \Yhen the uterus alone was insufflated, there were

408

Al'\fERICAX JOURXAL OF OH~TE'l'RICS AXP OY:--.!ECOLO(;y

only 9 tests with contraetion~ of an amplitudt> les~ than 15 nun. Hg, the others having a range of J5 to 50 mm. Hg·. During ujprotubal in:lufllation tlwre were 24 tests in which the contractions luvi an amplitude les5 than J::i nnn. Hg;. awl only I) with a depth of 15 to 30 mm. Hg. EFFlWT OJ<' EXC!;-)1::\G SEGJIIEST" OF TUm

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CTERO'l'UBAL .J !l.:'\CTIOS

During nine utprotuhal in,ufllations succeHsive Begnwnts of tube from the fimbria toward the uterus were ex(·ised, eventually cutting off the uterotubal junetion. Usually, a momentary rise in prPssure resulted from the ex<·ision. However, aft('r a minute or less the contractions regained their u~ual pattern.

Fig. 5.-Sketch showing uterine and tubal muscle lever preparation with cannula for gas insufflation leading to the Rubin apparatus.

Excision of the outer third of the tube did not affect ihe character of the con· tractions. Excision of the entire ampulla, leaving the isthmus, did not affect the depth .of contractions, but in one-third of the tests the eontractions were slightly less frequent and were maintained at a lower pressure level. When only half of the isthmus remained, the contractions were rare and at a much lower pressure level.

WIMPFHEIMER AND FERESTEN :

UTEROTUBAL INSUFFLATION

40~

As long as any portion of the tube remained, manometric fluctuations were recorded on the kymograph. In four tests in which gas had passed the uterotubal junction at pressures below 50 mm. Hg, the uterus was not distended and muscle tone was retained. The result was an occasional weak manometric fluctuation from the uterus when the entire tube and uterotubal junction were excised. In fiv e testR which required high pressures so that the uterus was markedly distended during uterotubal insufflation, no contra ctions occurred when the tube and uterotubal junction were excised (Fig. 2). In ten experiments tubouterine insufflation was performed through a needle cannula, tied in the :fimbriated end of the tube. When the entire uterus was excised up to the uterotubal junction, no change was noted in the manometric fluctuations. Excision of the uterotubal junction merely resulteu in a slight lowering of the base line at which the manometric changes occurred. Excision of hal:E of the isthmus

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Fig. 6.-A, Contractions registered by hook in tubal muscle. B , Contractions registered by hook in uterine muscle. At, Contractions registered by hook in tubal muscle during uterotubal insufflation, showing no alteration in strength. Bt, Contractions registered by hook in uterine muscle during uterotubal insufflation, showing diminished muscle action. C, Contractions registered by uterotubal gas insufflation on the kymograph of the Rubin apparatus during the recording of At and Bo.

did not affect the depth of contractions. In three tests, there were 2 to 3 contractions more per minute. There was a drop of 10 to 30 mm. Hg in the pressure level at which the gas maintained itself. When all of the isthmus was excised, gas bubbled through the ampulla almost continuously at a level of 0 to 8 mm. Hg, with the production of an occasional weak manometric fluctuation (Fig. 3) .

•!10

AMERH'A.\i .JOl'H::-.IAL OF UB:-;TE'l'lll\':- AXD GY:\E('OLOGY

From the above Pxperinlt'nt,;, it appt>ars that tht: ui.(·.rus exhibit~ <.·ontraetions during uterotnhal in;;ufliati{!ll only when it is uot dist.e11dl'rl. Excision of sm·cessive segmc•ntH of tlw f>'allopitlll tube int!i<·at,., tl1nt the arnpu]h, has very littk poiH'r of •·nntradility, :1ud tbat t]ti;; prop<>rty is rPll•gated to th<.' more mus<·ula r isthmus. l'Ol\ll' .\!H:-;0:\ OF l."fERO'ITB.\L .\l\'ll 'l'l'B.\L ll\"S! ' F'l>'l..\'l'l
In six experiments, :m op1•ortunity \I'W' affonlP
Fig. 7.-A. , Contractions r egistcrc· 11ook in uterinp muscl e. B, Cterotubal !> "~ insufflation was performed, resulting in an absence uf uterine muscle function. ('. Ma nometric flu ctu a tions r ecord ed eon the li ymogra ph of the Rub in apparatus, conr·sponding to the r ecording of B .

The manometric fluctuations obtained during uterotubal and tubal insufflation were similar. There wa~ no noticeable
INSUFFLATIOK

The contraction strength of uterine and tubal musele during uterotubal insuf· flation was determined in five rn.bbits in vivo by placing a hook in the uterine

WllVIPFHEIMER AND FERESTEN:

t:TEROTUBAL INSUFFI,ATION

411

muscle and another in the tubal musde, and registering muscle action of both simultaneously on a smoked drum. Before insufflation, strong contractions of both the uterine and tubal muscle were seen. During uterotubal insufflation, the tubal muscle action was unaltered. The uterine musde contractions nearly disappeared in 3 experiments and were absent in 2 other~ (Figs. 5 and 6). In five other experimentH, a solitary needle hook was plai·ed through the uterine muscle and recordings made on a smokepeated on the exdsed uterus and tubes of seven rabbits, suspended in oxygenated Loeke 8olution. No effect was noted on tubal musele funetion during uterotubal insufflation. In the undisturbed state strong uterine muscle contraction~ were reeorded on the smoked drum. However, when the uterus became distended by the insufflated gas, mu~de eontractions were rare or entirely absent. In tlw above experimentF, the hook on the uterus did not ('ause nny ('hnnge in the manometric fluctuations recorded on the kymograph of the Rubin apparatus during uterotubal insufflation. Only when the hook in the tubal muscle prevented free movement of the tube, did the manometric fluctuation be<•ome weaker, irregular, or absent. Similar results were observed when the utPru;; and tuhe were alternately fixed to the abdominal wall by sutures. From the above ohservntions, it nppears that distention nf the uterus ns prodnr,ed by uterotnbal insufflation, results in a diminished or absent function of the uterine musele. The tube, on the other hand, shows no vi~ible distention and its muscle function remains unaltered. The diminished or absent musrle action of the uterus, when insufflated, would limit its participation in the production of manometric fluctuations during uterotubal gas insufflation. SUMMARY

Experimental observations were made on the uteri and tubes of 60 living rabbits to determine whether or not the uterus participates in the production of manometric fluctuations, which are uniformly seen during uterotubal gas insufflation. Manometric fluctuations occurred during uterotubal insufflation only when tubal patency was present. The undisturbed uterus and tubes were seen to undergo rhythmic peristaltic movements. During uterotubal insufflation the uterus became distended and its motion was reduced or disappeared. The tube, on the other hand, showed no visible distention and its motion was unaltered. The character of the contractions obtained b~r insufflating a solitary uterus was entirely different from the pattern recorded during uterotubal insufflation. Excision of successive segments of the tube during uterotubal or tubouterine insuffiation showed that the ampulla has very little pO\ver of contrartility, and that this property is possessed by the more muscular isthmus. During tubouterine insufflation, excision of the uterus had no effect on the production of manometric fluctuations. 'Vhen the tube alone was insuffiated, there was no noticeable difference in the character of the contractions obtained with the uterus

412

A.MERICAK .JOl:R:"lAI, OF OBSTETRICS AC'\D GYNECOLOGY

<~xcluded, showing dt•finitdy that thl' latter did not have any iniluence in the production of tlw eontt·aetion \\'11\'CS as llPmons1raterl on the kymograph of the Rubin appnt·atu;.;. Recording uterine nnd In hal 111 w:wit' ftmf·tion during nterotubal illsnffiation hr means or d!'lif•ate hooks in the llll!sele attaf:hed to writiJlg levers on a smokell d h.\- any presRm·e levels during gas insuftlatirm. nwl its musc-le fmwt ion remains unimpaired. CONC!.l:HION

Experiments on l'ahbits indiPilt(' the limited degree to which the kymographic curves of pressure fluctuations (rhythmic contractions) observable during uterotubal insufflation are influenced by the uterine muscle, and that tlwrdore tlwse manometric fluetuations are due to the unimpeded ad ion of tnha lmuselc in freely patent tubes. REFERK:\!'Ji:l'

Arcl1. (, Gyniik. 81: J!lfl, 1!!01. (!!l Ruliin, l. ('.: AM. ,T, 0BST. & HYNEr. 14: fifli. ln2i. 1 :n authmw1, H.: Monat~ehr. f. Gebnrt~h. u. G}-nak. 69: • 10, 1922. (4) R·1/bin. J. ('.: .1. .\.:\f. \. 92: li'i\li, 1H2\l. (1) Kehrer, R.:

PHEGNANCY WITH IJEUCElVIIA* A

CAfSE HI~PORT AKD HEYIEW OF THE LITERATlJRE

R J\L GRIER, M.D., A?\D H. A. RrcHTER, :;n.D., BvANSTON. ILI,. (From the Depatlmtl!t nf Ob8tctri
A

Mrs. C. B. D., aged 29 years, was cared for by one of us in 1935 through her :first pregnancy which was uneventful. The Wassermann was negative and blood findings were normaL The baby is alive aud welL Her past history was entir<'ly normal except for the usual childhood diseases. Her tonsils had been removed. Menstruation had always been normal. A chronic car infection had persisted for year~. She came under observati(ln for this pregnancy on March 20, 1937. Her last menstrual period was Dec. 5, 1931i. Xo abnormal findings were noted. The hemoglobin was 81 per cent and the erythrocytes '1,120,000. There were no unusual com· plaints until Mny 12, lficll, when she developed headache, malaise, frequent stools, and a low grade fever. These symptoms diRappeared in a few days on rest in bed, a liquid diet, and a few doses of paregoric. However, on May 22, they returned and she noticed in addition, petechiae on the arms and legs, enlargement of the cervical glands and blt>eding from the gums. A blood examination was made at t.his time which revealed: hemoglobin 48 per cent, erythrocytes 2,250,000, leucocytes 295,000 with 97 per cent lymphoblasts. 'rhe platelet count was 93,000. Hospitaliza· tion was advised but refu;;ed. Rhe remained in bed until entering the hospital on May 30. *Presented at t11e meeting of the Chicago Gynecological Society, May 20, l9$8.