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



consultation a number of prominent physicians. Five years after the mechanical 

 abortion she was operated upon for appendicitis, at which time it was found that 

 the tube and ovaries were adherent. These were separated by the surgeon, who 

 hoped thereby to bring about a condition to favor pregnancy, as the woman was 

 anxious to have a child. A year later she was operated upon for tubal pregnancy. 

 The other tube was found well matted together and would have been removed, 

 had it not been for the woman's desire to have a child. The following year preg- 

 nancy took place in this tube, which contained the pathological ovum mentioned 

 above. Examination of the specimen showed that the folds of the tube had become 

 adherent, forming a follicular salpingitis. This seems to be a clear case in which 

 the trouble may have arisen from the abortion which was performed 7 years before 

 the second tubal pregnancy. 



IMPLANTATION IN TUBAL PREGNANCY. 



We have examined with care all the tube walls and as yet have never found 

 any tissue that could be considered as the decidua, nor have we found any speci- 

 mens of early implantation. Whenever we have encountered an ovum which was 

 very small, it was invariably found separated from the tube wall by a definite layer 

 of blood. It would appear that in these cases some time had elapsed since the 

 implantation, which could hardly be accomplished without attachment of the ovum 

 to the tube wall. For the present we must admit that the trophoblast often fastens 

 itself to one of the folds of the tube and gets its nourishment from the adjacent 

 venous sinuses, for which it seems to have a great affinity. In older specimens 

 the trophoblast has eaten its way into the muscle wall and tapped blood-vessels, 

 from which marked hemorrhages have taken place. In the uterus the formation 

 of the decidua seems to aid in checking the hemorrhage by forming, as it were, a dam 

 between the tips of the villi and eroded uterus upon which the trophoblast feeds, only 

 a little of the blood passing this dam to enter the spaces between the villi. Nor do the 

 trophoblast and syncytium at once become active as a result of the increased amount 

 of nourishment. In general the trophoblast between the villi becomes necrotic and 

 contracts into small yellow spherical masses about 1 mm. in diameter, which in 

 turn are often eaten up by other syncytial cells. It appears therefore that in a 

 normal condition of the chorion and uterus the trophoblast keeps the blood from 

 entering the spaces between the villi. In the tube, however, there being no decidua, 

 implantation must be effected by the trophoblast alone. The tube wall does not 

 respond as actively as does the uterine wall. In the latter case implantation is 

 aided by the production of the decidua. In the tube we must necessarily have more 

 hemorrhage, and in studying the chorion one finds numerous hemorrhages between 

 the villi, forming old blood coagula. The fibrinous substance is formed and the 

 trophoblast makes every effort to implant itself in these clots. So we have a double 

 process. The trophoblast has eaten into the tube wall, and at the same time is 

 attaching itself to the clots of blood which have escaped into the lumen. We 

 have every indication in specimens under 2 cm. in diameter of repeated hemorrhages 



