ON THE FATE OF THE HUMAN EMBRYO IN TUBAL PREGNANCY. 17 



during the 5 years following those 16, with an increase of gynecological patients in 

 Marburg, there was a marked increase of cases of tubal pregnancy. To what 

 extent venereal diseases play a causal role in tubal pregnancy remains an open ques- 

 tion, but this much seems to be certain: gonorrhea is at least one of the causes of 

 the inflammatory changes which obstruct the tube-lumen and thereby favor the 

 arrest of the ovum in its passage through the tube. 



In all his wide experience Tait states that he never saw a case of unruptured 

 tubal pregnancy (Lectures on Ectopic Pregnancy, Birmingham, 1888), and in fact 

 he doubted very much whether a diagnosis could be made before rupture, although 

 as early as 1710 Petit had maintained to the contrary. At the time Tait wrote 

 tubal pregnancy was believed to be a rare disease and the peasant women around 

 Marburg may not have gone to Ahlfeld's clinic for a minor complaint. Hence the 

 condition may not have been recognized. Now that unruptured tubes are fre- 

 quently removed and found to contain only a few villi, we must conclude that with- 

 out operative interference many of the patients would get well. Again, sometimes 

 tubal abortion occurs, and the ovum may degenerate, together with its encircling 

 clot. Even with rupture, therefore, the disease may not prove fatal. All these 

 possibilities must be taken into account in the further discussion and investigation 

 of the causal relation of gonorrhea and tubal pregnancy. 



In discussing the frequency of diverticula in the tube a difficulty arises from the 

 fact that we possess no suitable standard to follow. Whenever the diverticulum 

 is very pronounced as, for instance, when it can be found with a probe, where there 

 is a double ostium, or when the uterine end of the tube is obliterated we could 

 readily account for the arrest of the ovum in its passage to the uterus. However, 

 in most cases of tubal pregnancy anomalies of this kind are not found, but instead 

 we have inflammatory changes which have produced adhesions between the folds 

 in the tube. As a result, there are produced numerous small pockets, any of which 

 might be able to catch up the ovum. Unfortunately, so far we have never 

 examined a specimen from a very early case of tubal pregnancy, and in the somewhat 

 advanced cases the ovum is found not in the folds of the tube, but well implanted 

 within the muscular wall. Hence it would seem that if the ovum is caught up in 

 the small pocket it immediately proceeds to burrow into the tube wall, and later 

 there is a secondary rupture into the tube lumen. This is the condition seen in our 

 youngest specimen, No. 808. 



The form of the tube lumen has been carefully studied by Kroemer in a single 

 case. He cut serial sections of a tube which appeared to be normal. The specimen 

 came from a multipara, 48 years old. To the naked eye the tube, which was 9 cm. 

 long, seemed perfectly normal. It was hardened immediately in formalin and cut 

 into serial sections 15/z thick. Reconstructions were made from three portions of 

 the tube, from the interstitial portion, from the middle of the isthmus, and from 

 the middle of the ampulla. Kroemer found that throughout its length the tube 

 showed definite folds, beginning within the uterus and becoming more and more 

 pronounced as the fimbriated end was approached; he also found a number of 



