16 ON THE FATE OF THE HUMAN EMBRYO IN TUBAL PREGNANCY. 



the second there is an outgrowth of the epithelial lining into the muscular coat. 

 In both conditions pockets are formed in which the ovum lodges in its passage 

 through the tube. Of course this does not exclude other mechanical factors, such 

 as kinking, as the cause of tubal pregnancy. 



In the older specimens examined, as, for instance, in No. 741, we see the later 

 stage of this abnormal process, namely, the ovum eating its way through the walls 

 of the pockets into the tube lumen. In practically all cases there is a very free 

 hemorrhage in the tube lumen, and this helps to destroy the ovum. Finally, the 

 ovum and clot may become completely separated from the tube wall, and if the mass 

 is lodged within the fimbriated end it may be easily extruded into the abdominal 

 cavity. On the other hand, if it has lodged in the uterine end this part of the tube 

 does not appear to dilate so easily. The ovum eats into the muscular wall and 

 usually produces perforation. In typical cases the ovum lies in the middle of the 

 tube, and while it does not destroy the muscular wall, it becomes encircled with a 

 mass of blood and ceases to grow. The clot organizes, and if it is not removed by 

 the surgeon it gradually contracts and healing occurs. In many of these cases only 

 a few degenerated villi are found in a highly organized clot. 



FERTILITY AND STERILITY 



It has been repeatedly observed that the larger number of tubal pregnancies 

 are found in women who are mothers, but who have not been pregnant for a number 

 of .years, or in women who have been married for a relatively long time but who 

 have never been pregnant. It is also well known that tubal pregnancy frequently 

 occurs in women who have been treated for salpingitis. In fact, Engstrom oper- 

 ated four times for tubal pregnancy on women who had been treated for salpingitis 

 on the same side on which the pregnancy was found. These data point very decid- 

 edly toward a causal relation between an acquired inflammatory process and tubal 

 pregnancy. 



According to Ahlfeld (Lehrbuch der Geburtshulfe, Leipzig, 1903) tubal preg- 

 nancy is due to obstructions in the tube lumen which arrest the ovum in its passage 

 to the uterus. These abnormalities in the tube frequently follow inflammation of 

 the perimetrium, which explains the greater frequency of tubal pregnancy in women 

 who have already borne children. The adhesions around the uterus produce a 

 kinking of the tube and a catarrhal inflammation of its lining membrane. 



Ahlfeld states further that tubal pregnancy is relatively more frequent in large 

 cities. This may be due partly to the fact that the patients have freer access to 

 good surgeons, but also to the higher percentage of gonorrhea is these communities. 

 Thus, during a period of 16 years, Ahlfeld observed only two cases of tubal pregnancy 

 in his clinics in Giessen and Marburg, and that this was not due to faulty diagnosis 

 is proved by the fact that gynecological patients often remained in his clinics for 

 long periods of time and he frequently opened the abdominal cavity for other rea- 

 sons; furthermore, no case of tubal pregnancy came to autopsy. Most of his patients 

 came from country districts, and Ahlfeld states that gonorrhea is of much rarer 

 occurrence among the country people of Hesse than in large cities. Nevertheless, 



