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



The same observer examined with great care 23 cases and found that in nearly 

 all of them the folds of the tube were hypertrophiecl and grown together at many 

 points, forming in transverse sections a network in the tube lumen. At other 

 points there were outgrowths of the epithelial tube, forming glandlike structures in 

 the muscular wall. All these changes he believed to be due to some earlier inflam- 

 matory process which had brought about the production of numerous pockets 

 which could easily have arrested the ovum. He also found that in the majority 

 of cases there had been sterility before tubal pregnancy had taken place. Many 

 of the instances were in women who had borne several children, and then after a 

 lapse of years had had a tubal pregnancy. In multiparae tubal pregnancy seldom 

 followed immediately after marriage. These observations, taken in connection with 

 the clinical signs of pelvic inflammation, would indicate that a slow inflammatory 

 process had taken place before pregnancy occurred in the tube. In general, our own 

 specimens confirm Williams's view that the chief cause of tubal pregnancy is due to 

 a condition improperly called " follicular salpingitis." These "follicles " are in reality 

 partitions formed by adherent folds which with the lower power of the microscope give 

 the appearance of follicles. This condition, however, is not always present and 

 certain investigators even deny its occurrence, but whenever I have examined with 

 care a portion of the tube between the pregnancy and the uterus, I have nearly 

 always found marked changes in the form of the lumen of the tube wall, either with 

 follicular formation or numerous outpouchings of the epithelial lining. In some 

 instances I found multiple lumina; in one there were as many as 20. 



In more recent anatomical studies by Wallgren reference is frequently made to 

 inflammatory conditions accompanying tubal pregnancy, but it is not clearly stated 

 whether these conditions should be viewed as the cause or the effect of the mis- 

 placement of the ovum. Wallgren gives a very detailed description of four cases 

 which he had studied in complete serial sections, thereby enabling him to give a 

 comprehensive view of the condition of the tube wall. It is clear that such a method 

 is more satisfactory than when occasional sections cut from different portions of a 

 greatly enlarged tube are examined, yet I do not believe that as much is to be gained 

 through the very laborious work of complete sets of serial sections as Wallgren would 

 lead us to believe. Any marked alteration in the tube wall would probably cover 

 a large area and therefore could be found in individual sections, as I have myself 

 found and as is indicated by the studies of Opitz. 



The various earlier beliefs regarding the implantation of the ovum in the 

 uterus namely, that it must be clasped by a decidua made it extremely difficult 

 to understand how the ovum could become attached to the tube where no decidua 

 or only a poorly developed one appears. This difficulty, however, has now been 

 fully overcome, since it has been shown by von Spee and by Peters that the normal 

 ovum burrows through the mucous membrane and implants itself against the 

 muscular wall of the uterus, the decidua forming later. A similar condition could 

 easily take place in the tube, and an abundant experience shows us that, in case the 

 ovum is not detached, it rapidly burrows through the thin tubal wall and causes 

 an early rupture. 8uch an active process must necessarily be accompanied by a 



