ON THE FATE OF THE HUMAN EMBRYO IN TUBAL PREGNANCY. 



75 



On January 17 she noticed that the period was not like 

 her normal flow, and on January 18 there was only a 

 little brownish discharge. I saw the patient January 19, 

 and she complained that the breasts had remained sore 

 and swollen. Pelvic examination showed the left ovary 



. . 



Fia. 8. Clot containing the ovum which was removed 

 from the tube lumen (No. 4S8). X 2J. 



adherent to the left broad ligament, and tender. No mass 

 could be felt in the tube region. The patient was kept 

 under close observation and continued to have more or 

 less spotting until January 25, the day of operation. 

 The tube was found non-adherent and contained the speci- 

 men sent you. The corpus luteum of pregnancy in the 

 left ovary had unfortunately ruptured during the pre- 

 operative examination. 



FIG. 9. Outline of the ovum, which is covered with straggling 

 villi (No. 488). X 8. (Sketches by Professor Evans.) 



On February 28, 1911, Dr. Hunner wrote: "The history 

 of the patient whose ectopic specimen you got on January 



25 is as follows: I saw her first May 18, 1908. She was 



26 years of age and had been married five years and had 

 had an abortion performed at four months, one year after 

 marriage. Apparently this had produced an infection. 

 A few months after the abortion she had two separate 

 attacks, about 6 months apart, of agonizing pain in the 

 lower abdomen accompanied by fever. Drs. Osier and 

 Russell saw her in these attacks and considered them due 

 to the appendix. Two years after the last attack she 

 consulted me concerning a constant heavy weight in the 

 lower abdomen and because of a desire to become preg- 

 nant. I found the pelvic organs bound back on the floor 

 of the pelvis by adhesions. 



"Menstrual history: Periods occur on time or 7 to 10 

 days late, 4 to 5 days flow, moderate at times has to go to 

 bed for a few hours, because of pain in epigastrium and 

 over entire abdomen. In April 1909, while visiting in 

 Boston, she had another attack, considered to be appendi- 

 citis. On May 12, 1909, I operated, removing an appendix 

 which was undergoing fibrous degeneration; I freed the 

 uterus, tubes, and ovaries from adhesions and brought 

 them into position by bringing the round ligaments through 



the recti muscles (Gilliam method). The tubes and ovaries 

 were so fastened to the pelvic floor as to make a complete 

 covering for the fimbriated ends of the tubes. By brushing 

 off these adhesions in the act of freeing the structures the 

 fimbriated ends were found to be open. The tubes were 

 somewhat thickened and I made a note at the time that 

 conditions were favorable for ectopic pregnancy. 



"Operation July 28, 1910. Unruptured ectopic preg- 

 nancy right tube. On July 18, the patient began to have 

 an abnormal spotting of dark, thick material which per- 

 sisted off and on every day for the intervening 10 days. 

 Her period was one week late, but this was not unusual for 

 her. She always had tender, swollen breasts for some days 

 before the period and normally this disappeared after the 

 first day or two of flow. On this occasion the swelling and 

 tenderness had persisted for the 10 days of spotting. She 

 had had a queer feeling in the right side of the pelvis. A 

 small, soft, tense mass was felt in the region of the right tube. 

 Operation revealed near the outer end of the right tube a 

 small swelling about 1 cm. in diameter and 2 cm. long, evi- 

 dently a tubal pregnancy. The tube was removed. At 

 this operation the left tube was found considerably kinked 

 by adhesions and would have been removed had the patient 

 not been so anxious to become pregnant. So far as possible 

 the adhesions were gently freed." 



The tube, considerably swollen in its middle portion, 

 came to us fresh from the operating room. It was opened 

 over the area of enlargement in warm salt solution under 

 the binocular microscope, the coats being carefully dis- 

 sected apart until the tube lumen was reached. Nothing 

 suggesting a placenta was found, but a large blood clot 

 lay practically free in the lumen. By careful manipu- 

 lation of the tube from the exterior the blood mass was com- 

 pletely evaginated and freed from the tube, the interior 

 of which was not touched. The lumen was then carefully 

 laid open from the area in question through to the fim- 

 briated extremity. The whole was fixed in Zenker's 

 solution, in which the acetic acid was substituted by 10 

 per cent formalin (4 per cent formaldehyde) for 24 hours, 

 after which the blood mass was explored and the ovum 

 found and opened, the fixative continuing to act for 8 hours. 



Alcohol: 35, 40, 45, 50, 55, 60, 62, 64, 66, 68, 70, 72, 74, 

 76, 78, 80, etc., to absolute alcohol (4 hours in each). 



The specimen, which had been carefully fixed, was cut 

 into blocks, as shown in the figure, and sections were 

 taken from each part. From block No. 6 serial sections 

 were taken. The lumen of the tube is nearly obliterated 

 at its uterine extremity, and towards its fimbriated end the 

 folds become more and more marked. In region 6, these 

 folds cut the tube into many compartments and where the 

 ovum is located the folds are very large and have large 

 blood-vessels in them. In this region there are peculiar 

 cells possibly decidual in the connective tissue. The 

 blood mass is cylindrical in shape and measures 31X12 

 mm. Near its center the ovum is lodged. This was 

 carefully cleared of blood and found to contain long, irregu- 

 lar villi, some of which measure 3.5 mm. The ovum was 

 opened by Dr. Evans, who noted that it was filled with an 

 amorphous mass. Nothing resembling an embryonic 

 rudiment or an embryo was seen. This mass was subse- 

 quently cut into serial sections. 



The mesoderm at points seems to be necrotic. No 

 blood-vessels are encountered. The interior of the ovum is 

 filled with granular magma. But little trophoblast is 

 present. Within the ccelom curious hyaline bands are seen 

 intermingled with maternal blood corpuscles. The meso- 

 derm of the villi is partly fibrous and partly granular. In 

 the latter case there are only a few nuclei present. 



