Houston S. Everett

Cyclical and other variations in the tubal epithelium

Abstract While the tubal mucosa does not participate in the bleeding of the menstrual process, its epithelium exhibits a definite cyclical change comparable with that of the endometrium. It is, however, not nearly so conspicuous as the latter, being concerned more with microscopic changes in the cells rather than with the grosser changes in pattern seen in the endometrium. The present study, based upon the careful examination of the tubes, from 136 cases, in almost all of which the endometrium was also available for study, has demonstrated the following chief facts: 1. 1. The tubal epithelium consists of two chief types of cells, the ciliated and the nonciliated. The latter are often spoken of as “secretory” cells. A third type, the “peg” cells (“Stiftchenzellen,” “Schaltzellen”) are also described, but it is probable that these represent only a phase of the nonciliated cells. 2. 2. In the interval phase, the epithelium is uniformly tall, the ciliated cells being broad, with rounded nuclei near the free margin, while the nonciliated cells are rather narrower, the nuclei being more deeply placed and taking a deeper stain. 3. 3. In the premenstrual phase the ciliated cells become lower, so that the “secretory” cells project beyond them, giving the epithelial margin a ragged, uneven appearance. The “secretory” cells show a bulbous herniation into the lumen of the tube, often carrying the nucleus with it. This extrusion of nuclei is similar to that seen in many lower animals, but its significance is not known. In spite of the great loss of cells, mitoses are rarely seen in the tubal epithelium. 4. 4. During the stage of menstruation, the premenstrual changes are carried further, the epithelium becoming quite low. The ciliated cells, especially, remain broad and low, but the secretory cells also, having been emptied of their cytoplasm, are much lessened in height, the nuclei often being quite bare of cytoplasm. “Peg” cells are numerous, their appearance and distribution suggesting that they are merely emptied “secretory” cells. 5. 5. The postmenstrual phase is characterized first by a low epithelium, which quite rapidly, however, increases in height, so that by the third or fourth day after menstruation it is often almost as tall as during the interval phase. The cells are narrow, closely placed, and, after the first day or so, of uniform height. 6. 6. During pregnancy, the epithelium becomes even lower than in the menstrual stage, and in the later stages it may become almost flat in many places. Secretory changes are not seen at this time. 7. 7. Cilia can be demonstrated in all stages, especially through the examination of fresh tissues, by the technic described in the paper. They are also found in the tubal epithelium of young children and in women many years beyond the menopause. This suggests that they must have some other function than that of assisting in the propulsion of the ovum. Perhaps, as has been suggested by Hartman. their chief role may be that of keeping the tubal lumen cleansed of foreign particles of any kind. 8. 8. Efforts at differential staining of the secretion have thus far been unsuccessful. Neither glycogen nor mucin can be demonstrated, unlike the findings in the secreting endometrium. The various views as to the significance of this tubal secretion are discussed in the paper, although there is as yet no positive knowledge as to this point. 9. 9. The prepuberal tubal epithelium is rather low, but shows both chief types of cells. Cilia, however, are very sparse, and are usually not seen at all in fetal or very early postnatal life. 10. 10. The epithelium of the postmenopausal tube may remain quite high for a surprisingly long time, perhaps a number of years after the cessation of menstruation. Cilia, likewise, may persist for many years. Sooner or later, however, the tubal folds become rounded, of fibrous appearance, the epithelium becomes low or even quite flat, and cilia, of course, disappear. 11. 11. The tubal epithelium of tubes removed from patients suffering with hyperplasia of the endometrium was studied because the latter condition is unquestionably associated with a functional disturbance of the ovaries. Characteristically the epithelium was found to be high, uniform, compact, with narrow cells, most of which were ciliated. There was no evidence of secretory change. This bears out the view, for which there is other evidence, that the functional disturbance consists of an excess or persistence of the follicle stimulus, with an absence of the corpus luteum influence. 12. 12. The comparison of the tubal cycle in women with that of the lower animals, like the comparative study of the uterine and ovarian cycles, emphasizes the important differences, chronologic and histologic, which exist. For example, the estrus tube of the rodent resembles, not the menstrual or premenstrual tube of the human, but the interval phase. Since estrus in the lower type is undoubtedly due to the follicle hormone, it seems clear that in the human the maximum of follicle influence is reached during the interval phase, and that the later changes are due to the corpus luteum influence. To bear this out, the picture in the animal tube which resembles the human premenstrual tube is that seen in the metoestrum, during which stage the corpus luteum apparently plays the dominating role.

Primary malignant Bartholin gland tumors.

PRIMARY MALIGNANT BARTHOLIN GLAND TUMORS LAWRENCE WHARTON;HOUSTON EVERETT; Obstetrical & Gynecological Survey

Probable tubal origin of endometriosis

Abstract It has been pointed out that an adenomatous formation composed of either tubal epithelium or endometrium, or in a few cases of both simultaneously, occurs rather frequently in the region of the uterine cornu and tubal isthmus. A previous operative trauma of this region is not essential for the production of such an adenomatous formation, nor is it necessarily associated with any previous inflammatory process. It may be considered then as a truly neoplastic formation or primary adenomyoma. From the types of epithelium described in these adenomyomas it is evident that they may arise from tubal epithelium as well as endometrium. The presence in a few cases of spaces lined by tubal epithelium as well as islands of true endometrium in the same specimen suggests the possibility of a metaplasia of one of these types of mucosa into the other. The finding of gland-like spaces lined by tubal epithelium but surrounded by endometrial stroma is even more suggestive of this possibility. The finding of ten cases in which the interstitial or isthmic portion of the tube is lined by endometrium rather than tubal mucosa is further evidence of the histologic variability of this region, and suggests again the possibility of a metaplasia of one of these types of mucosa into the other. Evidence gathered from the literature, particularly from the work of Sampson, tends to show that a number of cases reported as endometriosis are really cases of aberrant tubal epithelium. It is noted, however, that Sampson has called attention to this fact from time to time, and in a more recent work on “Endometriosis Following Salpingectomy” has stressed the probability of a metaplasia of tubal mucosa into endometrium. In a review of 24 cases diagnosed as endometriosis in our own laboratory it has been found that in a third of them the epithelial elements were definitely tubal in type. In some of them there was in addition to the tubal epithelium an endometrial-like stroma. In a few instances cysts lined by tubal epithelium and others with real endometrium occurred in the same case. In one very striking case the same hemorrhagic cyst of an ovary was lined in part by tubal epithelium, while another area of the cyst wall showed real endometrium with stroma and glands. Such cases lend additional evidence to the hypothesis that tubal epithelium may, by metaplasia, be transformed into endometrium.

Arrhenoblastoma of the ovary, with a report of two cases

Abstract Two cases of arrhenoblastoma of the ovary have been reported. Both occurred in relatively young women and in the right ovary. One was associated with rather marked virulism and microscopically was of the intermediate cell type. The other tumor, which was associated with only slight masculinization, was microscopically highly differentiated and resembled a tubular adenoma of Pick. The 17-ketosteroid exeretion was studied in one case and proved to be elevated preoperatively, falling to normal within twelve days postoperatively. Noopregnanediol was present in the urine in this case. A simple salpingo-oophorectomy was performed in one case, and the patient is well one year postoperatively with some regression of masculinization and regular menses. The other patient had a bilateral salpingo-oophorectomy and hysterectomy, and is well six months postoperatively.