% Jptirror of Hospital fjractuc.

EXTRA-UTERINE (TUBO-ABDOMINAL) GESTATION, THE FALLOPIAN TUBE

SHOWING AN ACCESSORY OSTIUM AND

DIVERTICULUM.

By R. F. STANDAGB,

CAPTAIN, I.M.S.,

Residency Surgeon, Bangalore.

Mrs. S., Eurasian, age 25, was admitted into the Lady Curzon Hospital on 1st Februar}' 1904, complaining of metrorrhagia and abdominal

pain. She was married in 1900, and had one child three years ago, since which she had not been pregnant. Menstruation commenced at

fourteen years of age, and since her confinement in 1901 was quite regular and normal, lasting seven days, till the period which should have occurred between 27th October and 3rd November 1903. This period was suppressed, and patient "feared she had become pregnant again." On 29th November, five days later than her November

period was due, bleeding began again,, and was continuous till her admission into hospital. The

discharge of blood was occasionally very slight, but was noticeably increased about the time when she would expect her menstrual period. The blood was dark in colour, and once, a few days before admission, was passed in the form of small clots. It contained no shreds, and had no odour.

288 THE INDIAN MEDICAL GAZETTE. [Aug. 1904.

The patient complained of tenderness all over the lower part of the abdomen. She stated that she had never had any sudden, severe

attack of abdominal pain, but suffered from more or less severe "grinding" pain on the

right side ever since the bleeding began. She was well nourished, but looked pale and ill. Examination per vaginam was exceedingly

painful, so it was conducted under chloroform. The uterus was normal in size and position, but the os and vaginal mucous membrane were con- gested. Blood escaped freely from the os, which was not patulous. The mobilitj' of the uterus was distinctly diminished. A sound passed the normal distance. A rounded fixed tumour, about the size of a

hen's egg, giving a sense of elasticity on bi- manual examination, was felt posteriorly and to the right of the uterus, and the whole right posterior quarter gave an abnormal sense of fulness and resistance. The tube or ovary could not be palpated on the right side, but the left

ovary was felt fixed low down with considerable

surrounding thickening. The breasts were

flaccid, but a drop of milk could be expressed from each. Pure carbolic acid was applied to the interior of the uterus and the patient was sent back to bed.

After the examination the patient complained of severe pain in the lower abdomen and the

bleeding continued, but had a tendency to

decrease in quantity, until, on February 14th only the slightest stain was noticeable on the diapers. The swelling to the right of the uterus, however, increased very decidedly in size, and was very tender. The grinding pain continued, but was less severe. The milk in the breasts did not increase in quantity. Between the 14th, February and the 17th the pelvic tumour enlarged much more rapidly, and extended to

the back of the uterus, filling Douglas' pouch. The patient at this time made a statement that her confinement in 1901 was a very bad one and that she had a dread of becoming pregnant. She therefore "took medicine" in November when her course did not come on, and this she

thought, caused the discharge of blood which continued ever since. The patient was evidently not getting better,

she was decidedly paler and weaker than on ad- mission, and her friends were very anxious. It was decided that she was suffering from intra-ab- dominal haemorrhage, the result of an abnormal gestation, either tubal or tubo-ahdominal. An

operation was advised and agreed to and was

performed on 17th February. Under chloroform a median incision about

inches long was made below the umbilicus, and the pelvis was explored. The right tube was enclosed in a mass of recent adhesions. On freeing these a quantity of loose blood clot was turned out from Douglas' pouch and from around the outer end of the right tube. This blood clot was most abundant round what appeared to

be a rupture of the superior wall of the tube. The clot was enclosed in a sac of loose

adhesions, which separated it from the general peritoneal cavity. The tube itself was thickened and was adherent to the posterior wall of the broad ligament, and some time was spent in

freeing it. It was eventually brought outside the abdomen, ligatured close to the uterus, and

amputated. The right ovary was separately ligatured and removed. The left ovary and tube were freed from some loose adhesions and examined. The fimbria of the tube were thicken-

ed, and the ovary showed one small follicular

cyst. Both were returned into the pelvis. Great care was taken to clear the pelvis of all

clots, and the cavity was irrigated with warm,

weak boric solution. The wound was closed

by interrupted sutures of silkworm gut, embrac- ing all the abdominal parietes, but not piercing the peritoneum. Miss Ada Niebel, M.D., the

lady doctor of the hospital, assisted me most ably throughout the operation. Chloroform was

given by the Assistant-Surgeon Miss M. de Lemos. The blood clots removed from the abdominal

cavity were carefully examined, but no foetus was found. Several fleshy pieces were found, like placental tissue, and a white smooth mem- brane, the remains of the sac, which showed villi on being floated in water. The discharge of blood stopped entirely the

day after the operation and never recurred. The patient suffered much from constipation during convalescence, and she needed repeated doses of mag. sulpli. or sulphur confection. A

small stitch abscess occurred, but healed rapidly. With these exceptions the patient made an

Fig. 1.

Fhe anterior surfacc of the right Fallopian tube. This shows the small cyst-like prominence at the uterine end of the tube, which, when laid open, was found to bo a diverticulum lined with tubal mucous membrane. The shaggy site of the rupture of the sac, which point is also the opening of the accessory ostium is well shown.

Fig. 1.

The anterior surfacc of the right Fallopian tube. This shows, the small eyst-like prominence at the uterine end of the tube, which, when laid open, was found to bo a diverticulum lined with tubal mucous membrane. The shaggy site of the rupture of the sac, which point is also the opening of the accessory ostium is well shown.

Aug. 1904.] TUBAL PREGNANCY. 289

excellent recover}' and left hospital quite well on 2Gth March 19(H. The chief interest of this case is in the diseased Fallopian tube which [ removed from the right side of the uterus. In the photographs, which illustrate this article, it

tfote. The openings in the mucous membrane are

much larger in this photograph than in the fresh speci- men. The tube was some weeks in spirit solution before

bein"- photographed, which caused shrinking of the

mucous membrane.

will be seen that tlie tube was considerably thickened, and, in Fig. 2, which shows the tube

laid open from above, the thickness of the tubnl

walls, and the obliteration of the fimbriated

opening will be noticed. The lumen of the tube

is patent in its entire length, so the gestation did not take place there. I feel sure that this

is a case which goes far towards proving the

latest theories of German gynaecologists, which

has been advocated lately in England by Dr. H. Russell Andrews, viz., that

"

tubal" pregnancies seldom or never occur in the lumen of the tube, but in the muscular tissue of the tube wall.

About one inch from the obliterated fimbriated

extremity of the tube, on the upper surface of

the ampulla, will be seen in both figures a shaggy fleshy mass. This corresponds to the point of attachment to the tube of the mass of clot

which I removed. A minute opening in this

situation, through which, in Fig. 2, a bristle has been passed, connected the lumen of the tube with the peritoneal cavity. An inch and a half

nearer the uterine end of the tube will be seen

(Fig. 2) a second opening in the tubal mucosa.

Tliis corresponds with a small cyst-like swell-

ing on the anterior outer wall ot the tube. On

cutting into this it was found to be lined with

mucous membrane, continuous through the

small hole with that of the tube, and its walls

were muscular and serous like those of the tube.

It was, in fact, a true diverticulum. This diver-

ticulum is shown in Fig. I, a bristle having been

passed into it from within and the small cavity laid open. The views of the German authorities, who

have worked upon this subject, are that the

minute embryo burrows through the epithelial linino- of the tube into the subjacent muscles and there? develops. I put forward this ease with

the su<?restion that diverticula, such as that

shown Tit the uterine end of this Fallopian tube, may quite frequently form resting places for belated impregnated ova, and nests for their

further development. At any rate, after rup- ture, it would be difficult to say whether the

sac had developed in a diverticulum, or in the muscular coat of an otherwise normal tube wall.

[ was at first inclined to think that in this

specimen we had a case in point, and that here

was a tube showing on its mucous surface the

openings of two diverticula, in one of which

gestation had taken place. On further consi-

deration however, I found it difficult to account

for the presence of a fertilized ovum in a di-

verticulum from a tube whose fimbriated ex-

tremity was entirely closed. I could find no

trace of an opening at the ovarian extremity of the tube, though it is, of course, quite possible that the fimbriated opening was patent when the fertilization occurred in October 1903, and

became obliterated during the inflammatory changes following the rupture of the sac. I am

inclined to think, however, that the opening in

the ampullar portion of the tube is an accessory

ostium, and that gestation took place at the site of'its entrance into the tubal lumen. This

would explain the absence of a clinical history of rupture of the sac, distinctly marked by sudden pain and faintness.

No sudden giving way of a resisting tube wall occurred, but,

I have

no doubt, the foetus was discharged from the narrow opening of the ostium, and perished, at an early stage of the pregnancy, probably when

bleeding first took place on November 29th. The

subsequent loss of blood was from the site of the placental attachment, probably

the shaggy, torn

prominence shown in the photogiaphs. Kelly (Op. Gynaecology, Vol. II, pp. 431-432)

quotes Landau, Rheinstein and J. W. Williams

as having drawn attention to tubal diverticula, and Kossmann (zeit. fur Geb. and Gyn. Bd.

xxvii, p. 266) as regards the possibility of ac-

cessory ostia being factors in the arrest of the

passage of fertilized ova to the

_

uterua, This

case, "presenting as it does both forms of abnor- mality, is, I think, worthy of record. It also very

well illustrates the clinical fact that the text-

book series of events, a missed period or two

and a sudden attack of agonising pain, are not

to be expected in every case. In a large num- ber of cases menorrhagia, or irregular bleedings dating from a period which

" was not quite all

right," are all the symptoms, and on these, with

Fig. 2.

I Showing the right Fallopian tube laid open by an incision along its upper surface. The tipper bristle is merely for suspending 1 the specimen. The middle one is passed through an opening in the mucous membrane into the diverticulum described in (he text. The lower bristle goes through a hole in the mucosa marking the site of an accessory ostium.

Fig. 2.

Showing the right Fallopian tube laid open by an incision along

lis upper surface. The upper bristle is merely for suspending the specimen. The middle one is passed through an opening in the mucous membrane into

the diverticulum described in

fhe text. The lower bristle goes through a hole in the mucosa

marking the site of an accessory ostium.

290 THE INDIAN MEDICAL GAZETTE. [Aug. 1904.

the objective sign of a thickened tube or a

lump in Douglas' pouch, a decision must be made as to treatment.

it is a much discussed subject, and one whose argument is quite beyond the limits of this

paper, but I would say shortly, that, with proper precautions, no harm can follow early operation in cases presenting the above signs, more espe- cially the sign of an enlarging lump in the

pelvis. On the other hand, I have seen the most disastrous results follow the "expectant"

method.