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



tion. If it contains a pathological embryo, the changes in the tube wall are usually 

 marked, and when the ovum is well disintegrated the changes are still more pro- 

 nounced. Read in the otherway this would mean that if the inflammatory condition 

 is nearly healed, the ovum implants itself in the tube and grows normally, but if 

 the results of infection are still pronounced, the ovum rapidly disintegrates. Such an 

 inflammatory process is signalized not only by an inflammatory reaction in the tube 

 wall, but also by very pronounced changes within the tube lumen, the most common 

 of these being a condition known as follicular salpingitis (Opitz). The tubal folds 

 h} r pertrophy, their tips becoming adherent, and, when sections are made, small 

 cavities are seen between the folds; hence the term "follicular." Often this process 

 is so marked that a section of the tube shows the folds as an extensive and delicate 

 reticulum permeating the entire tube lumen. In such cases the individual meshes 

 of the folds have projecting into them numerous fingerlike processes, reminding one 

 very much of a section of the intestine. While this process is at its height, it is 

 clear that an ovum can not pass through the tube and much less can the spermato- 

 zoon pass outward to reach the ovum. It is only after this process has abated 

 somewhat that it is possible to have conditions suitable for the production of a 

 tubal pregnancy. 



Another type of change differs markedly from follicular salpingitis, but in a 

 way seems to go hand and hand with it. This condition I have constantly spoken 

 of as outpocketing of the epithelial lining. No doubt this is the variety first 

 described by Werth. Here the muscular wall is thick and fibrous and numerous 

 small diverticula reach out into the muscular coat. Sometimes these are markedly 

 distended at their blind ends. In other species they seem to run in parallel lines, 

 indicating that, instead of a single tube, we have numerous small tubes side by side. 

 Either of these conditions would account for the arrest of the ovum. The ovum is 

 taken up by the mucous membrane of the outer end of the tube and, owing to the 

 impairment of the ciliated cells, is delayed in its progress. On account of this 

 delay it grows too large to be carried through the narrow portion of the tube into 

 the uterus. This condition would be aggravated when the tube lumen is greatly 

 reduced at the uterine end, so we can easily postulate two kinds of changes to account 

 for the two kinds of implantation so frequent!}' encountered. When the ovum 

 lodges at the outer end of the tube, we should expect the outer end of the tube to be 

 lined with fairly normal mucous membrane, but if the ovum is delayed in its progress 

 and becomes too large to pass later through the uterine end of the tube, we should 

 expect to find the tube lumen reduced in size in this situation. 



A third type of implantation usually takes place in the middle of the tube, 

 and is the most common variety. In this type we most frequently encounter tubal 

 inflammation and follicular salpingitis. It seems as though the ciliated cells can 

 carry the ovum to the middle of the tube, but no further. The ovum then implants 

 itself within the folds of the tube, and, soon becoming too large for the space it 

 started to occupy, through secondary rupture is cast into the tube lumen. This 

 process is always accompanied by considerable hemorrhage with marked distent-ion 

 of the outer end of the tube. In case the ovum is not aborted into the peritoneal 



