ON THE FATE OF THE HUMAN EMBRYO IN TUBAL PREGNANCY. 



folds, which are hyperemic and more or less matted to- 

 gether. The cavity is lined with degenerating villi. 

 The two other sections are through the ehorion and its 

 wall. At no point is there any ovarian tissue around this 

 cavity. In one section the tube communicates with the 

 cavity containing the ovum. It is clear that we are here 

 dealing with a tubal pregnancy, which has ruptured into 

 this broad ligament, and not with an ovarian pregnancy. 

 The embryo is normal in form, but the ehorion is mark- 

 edly changed in appearance. The chorionic membrane is 

 quite normal in appearance, but the villi are fibrous and 

 degenerating. Many of them are necrotic and covered 

 with masses of necrotic syneytiuni. Some of them contain 

 blood-vessels from the embryo, showing that an embryonic 

 circulation could still take place. What is especially 

 remarkable is the great activity of the trophoblast, which 

 is invading everything necrotic syncytium masses, 

 mesoderm, blood clot, and the adjacent maternal tissue. 

 In some places the scattered trophoblast cells in the 

 maternal tissue give the exact appearance of cancer. In 

 fact, the cells have invaded the venous sinuses and in some 

 instances a whole villus may be seen in them. There is 

 much inflammatory reaction all through the specimen. 

 In some instances, the leucocytes are invading the necrotic 

 villi. A small degenerated ovary lies upon the specimen, 

 as shown in the figure. Sections through it contain no 

 follicle, but numerous corpora fibrosa. As the cavity under 

 this small ovary communicates freely with the tube, the 

 interpretation of the specimen, namely, that a tubal preg- 

 nancy has ruptured into the broad ligament, is the only 

 tenable one. 



No. 794. 



(Dr. T. Cullen, Baltimore.) 



Unruptured tube, 60X20X20 mm. 



Patient, white, aged 29, admitted to the Johns Hopkins 

 Hospital November 6, 1913. Operation: Right salpin- 

 gostomy; appendectomy; D. & C. on November 8, 1913. 

 Diagnosis: Extra-uterine pregnancy and chronic pelvi- 

 appendicitis. Complaint: pain in abdomen and bleeding. 

 Catamenia began at 15; regular from onset every 28 days, 

 duration about a week. Flow not excessive. Has never 

 had any leucorrhea. Last menstruation 7 weeks ago. Pre- 

 ceding one 11 weeks ago. Married 7 years. Two children, 

 aged 5 and 6 years respectively; no miscarriages. 



Present illness: Missed last regular period 3 weeks ago. 

 Following this she had considerable pain in the abdomen, 

 gradually becoming more and more severe. Ten days 

 ago she had nausea and vomiting, with acute attacks of 

 cramps in the lower abdomen, more severe on the right 

 side. For a few days preceding this pain she had a faint 

 trace of bloody discharge from the vagina. The pain 10 

 days ago was so severe that morphine was required. 

 This pain was of a labor-like character. Two days after 

 this acute attack she began to pass large clots of blood and 

 thick mucus and continued to pass these clots of blood 

 for 2 or 3 days. She had very little pain at this time, but 

 very marked "soreness" in lower abdomen. She has con- 

 tinued to have a constant flow since that time, which has 

 resembled in every way a regular period. For the past 

 week she has had no sharp pain, but extreme tenderness. 

 She is a fairly well nourished woman. 



Note on admission: Considerable tenderness over lower 

 abdomen; no muscle spasm and no mass felt; outlet not 

 relaxed; some bloody discharge; cervix small and somewhat 

 softened; uterus small and in anteposition; some induration 

 in both fornices; considerable tenderness. No mass is felt. 

 Convalescence was prolonged by a phlebitis in the right leg. 



The specimen was sent to the laboratory fresh, being the 

 right tube from a woman 29 years old. It was fixed in 

 formalin. Tube evenly distended in outer half and, upon 

 section, is found filled with blood, a portion of which 

 reaches almost to the fimbriie. This is well illustrated in 

 the figures. Sections show that the clot is not adherent 

 to the tube wall. It distends the tube lumen near the 

 uterus. Here the mucous membrane is thrown into single 

 folds. Near the fimbria the tube also shows normal folding 

 of the mucous membrane, but the clot is streaked with 

 fibrin bands. At, no part is it adherent to the tube wall. 

 The central end of the distention, like the uterine end of 

 the tube, contains blood. 



The clot was cut into small blocks and in its middle was 

 found a small white nodule, about 5 mm. in diameter, 

 composed of an old clot much infiltrated with leucocytes; 

 also many thick fibrin bands; no villi. This old clot is 

 surrounded with blood in circular layers marked by semi- 

 circles of fibrin strands. Occasionally there are small 

 groups of cells which may represent syncytium; otherwise 

 there is no sign of the ehorion. The clot was carefully 

 cut in small blocks and each examined under a lens, but no 

 suspicious places could be found. However, since in a 

 specimen like this only a villus or two are sometimes found, 

 this is probably one in which the ovum has been entirely 

 destroyed. 



FIG. 17. Sketch of distended tube, showing a kink between 

 the pregnancy and the uterus (No. 794). Xj. 



No. 804. 



(Dr. Thomas S. Cullen, Baltimore.) 



Pathological, embryonic mass. Unruptured tube with 

 fimbriated end attached, measuring 50X40X40 mm., 

 came from an unmarried negress, 20 years of age. There 

 had been one previous pregnancy, 3 years before, but no 

 miscarriages. The last menstrual period had begun 

 November 25; the previous one November 4; the opera! ion 

 was performed December 6. Except for severe pain in 

 the iliac fossa for one month before operation, there hail 

 been no symptom of tubal pregnancy. The patient had 

 had a puerperal infection and pelvic peritonitis after the 

 birth of her child, 3 years before. At the time of the 

 operation the ovaries and tubes showed dense adhesions. 

 Gonorrhea probable. 



The specimen consists of an organized blood clot, appar- 

 ently in the middle of the tube, with a fimbriated extremity 

 attached. The clot is organized in the middle with 

 numerous fresh hemorrhages nearly 1 cm. in diameter 

 on the periphery. There is an irregular cavity, 8 mm. in 

 diameter, lined with a smooth membrane, filled with a 

 granular mass and blood (chorionic cavity). Sections 

 were taken from the central end of the enlargement, through 

 the middle of the enlargement, and through the distal end 

 of the tube. The section through the central end shows an 

 organized clot without any tube wall surrounding it. 

 Evidently it was stripped off in the operation. The 



