TWO CASES OF EXTRA-UTERINE PREGNANCY (FROM EXAMINATION OF THE SPECIMENS)*

THE exact anatomic diagnosis or minute classification of an extrauterine pregnancy is easy enough in the early stages of the disease, but it becomes more and more difficult in the latter half and toward the termination of the pregnancy.

In the earliest months of the pregnancy it is only by accident that a pathologic specimen is found. Here the exact diagnosis is easy enough. From the third to the sixth month specimens are secured by operation or after death, as the result of hemorrhage from rupture, and here the diagnosis is still comparatively easy.

In the latter half of pregnancy, from the sixth to the tenth month, the diagnosis, viz., exact location of the fecundated ovum, becomes often exceedingly difficult-next to impossible-on account of secondary changes and often partial destruction of Fallopian tubes and ovaries, and still more difficult if a fatal peritonitis has contributed to mask the normal anatomic features of the organs in question.

The two specimens sent to me for examination belong to the class of late and consequently difficult cases, and in one of them the specimen was very much decomposed. Nevertheless, I think that a close examination of the specimens permits of a comparatively exact classification of the two cases- at least, of one of them.

Before describing and demonstrating the specimens, permit me to recall to your memories the different forms of extra-uterine pregnancy: Extra-uterine Pregnancy.-The ovum is arrested somewhere in its normal passage from the Graafian follicle down to the cavum uteri, or drops out of the passage, without or after rupture of the latter, into adjoining cavities or spaces.

1. Ovarian Pregnancy. The ovum remains in the ovary. In epiovarian pregnancy the ovum develops on the ovary, having left the Graafian follicle.

2. Abdominal or Peritoneal Pregnancy. The ovum falls down into the peritoneal cavity and does not enter the Fallopian tube at all.

3. Tubal Pregnancy.—(1) Tubo-abdominal or tubo-ovarian pregnancy. (2) Tubal pregnancy. (3) Tubo-uterine, interstitial, or mural

pregnancy.

4. Extraperitoneal pregnancy in the broad ligament after rupture of the Fallopian tube.

* Read before the Chicago Gynecological Society, February 20, 1885. Chic. Med. Jour. and Examiner, 1885, vol. xxx, p. 211.

5. Pregnancy in one side of a uterus bicornis.

6. Secondary Abdominal or Peritoneal Pregnancy. Ovary, tube, or even uterus (bicornis or normal) is ruptured, and the fetus slips into the peritoneal cavity, but remains in connection with the primary sac.

I shall first describe and demonstrate Professor Byford's Case No. 2:

Fig. 41.-Case 2. Anterior view of sac and pelvic organs, left Fallopian tube laid open except in its uterine portion: 1, Uterus; 2, vagina; 3, bladder; 4, inside of fetal sac; 5, 5, 5, 5, Fallopian tube dilating and opening into the fetal sac.

PROFESSOR BYFORD'S CASE 2.-The uterus is large, 41⁄2 inches long, 3 inches broad at the fundus; the cavity is also considerably enlarged. In the left side of uterus and vagina I find an incision opening, 31⁄2 inches long, closed with silk sutures, leading from

Fig. 42.-Case 2. Sac and pelvic organs seen from the left, to show situation of sac; 1, The sac; 2, dilated end of Fallopian tube opening into or continuous with the wall of the sac, which partially covers the following organs: 3, bladder; 4, 4, uterus; 5, rectum.

the uterus and vagina into the sac, or, as some members of the Society called it, the adventitious uterus. The sac can be seen only in fragments. Its wall is 1 to 2 lines thick, the outside partly covered with peritoneum, and partly adherent to the surrounding organs,

viz., bladder, uterus, omentum. The rectum I do not find. pian tube are missing.

The right ovary and Fallo

The left Fallopian tube shows the following conditions: the uterine portion is of normal size, passable only for a thin probe, 1⁄2 mm. in diameter; at the distance of 1⁄2 inch from the fundus it is wider, 1 inch in diameter, and so it continues for 4 inches; then it suddenly dilates to 1 inch in diameter, continues so for 1 inch, and thereafter opens into the fetal sac, the wall of the latter going continuously over into the wall of the tube.

The left ovary cannot be found. Large shreds of the membranes of the ovum, viz., amnion and chorion, adhere to the sac here and there. The inside of the sac is dark, brown spotted, the color of decomposed blood. This condition is most pronounced in the part of the sac that covers the posterior wall of the bladder and the anterior and posterior walls of the uterus. On the uterus the sac is thinner and more adherent (no subserous connective tissue) than on the bladder, where the wall of the sac is about 2 mm. in thickness, firm and movable against the bladder.

Fig. 43. Case 1. Anterior view of uterus, its appendices, and the extra-uterine sac: 1, Uterus laid open; fine silver wires passed through the uterine portion of both Fallopian tubes; 2, right Fallopian tube; 3, right round ligament; 4, right ovary; 5, 5, left round ligament, enlarged but in normal position, viz., commencing at upper corner of uterus; 6, 6, 6, ridge on the upper free border of the pocket (10) containing the left Fallopian tube, through which silver wires (dotted lines) are passed. It is seen that the Fallopian tube passes through only the first two-thirds of the ridge, and then branches off, backward and downward (dotted line), to penetrate into the wall of the sac; 7, terminal end of the ridge probably the left ligamentum ovarii; 8, 8, 8, 8, 8, the sac; 9, place of the placenta; 10, pocket on upper posterior wall of sac.

From the condition in which we find the left Fallopian tube I think it safe to conclude that the ovum has developed in its outer half, near the abdominal end of the tube. The funnel-shaped dilatation of the tube in this place, and the thickening of its wall, which continues uninterruptedly as the wall of the fetal sac, prove the connection between the two cavities, and this case of extra-uterine pregnancy would thus be of the tubo-abdominal variety. I believe that the ovum has commenced its development in the tube, and then, with or without rupture of the latter, has formed its sac on the surface of the pelvic and surrounding the abdominal organs. In this respect it might be classified as a secondary abdominal or peritoneal pregnancy originating in the abdominal end of the left tube.

PROFESSOR BYFORD'S CASE NO. 1.—This case has a greater interest, partly because the specimen is in a good state of preservation and partly because some of its features seemingly point to one, others to another, of the varieties of abdominal pregnancy.

In this case, as will be remembered, laparotomy was performed, and part of the cyst,

the placenta, and the upper two-thirds of the uterus removed. I shall not undertake, here, to describe the child, as it is irrelevant to the matter in question.

We find the uterine appendages of the right side, viz., broad ligament, round ligament, Fallopian tube, and ovary, normal (Fig. 43).

Fig. 44. Case 1. Inside of the extra-uterine sac seen from below: 1, Uterus-transverse section of the neck, where the uterus was amputated, shows the open cavity of the neck; 2, 2, the right Fallopian tube; 3, right round ligament; 4, right ovary; 5, 5, 5, 5, the wall of the sac; 6, 6, 6, inside of the sac, with, 7, place of the placenta right behind the neck of the uterus; 8, 8, 8, 8, 8, 8, 8, accessory placenta places; 9, 9, 9, large vessels on and in the inside of the sac; 10, 10, place where the outer layer of the wall of the sac is separated from the inner layer because the wall has been cut obliquely here at the operation; 11, probe in the left Fallopian tube; 12, oval opening on the inside of the outer layer of the sac, viz., termination of the Fallopian tube or cross-cut of the Fallopian tube just before it (probably) opened into the cavity of the extra-uterine sac.

The uterus, amputated about the middle of the neck, is of normal size, viz., the cavity, 14 inches between the two uterine orifices of the Fallopian tubes. Farther down, 1 inch; still lower down, 1/2 inch, and in the neck, 14 inch, broad. The average thickness of the uterine wall is 1/2 to 3/4 inch. To the left and behind the uterus, and in uninterrupted

Fig. 45-Case 1. Sagittal section through the uterus and the sac, showing the pocket on the posterior wall of the sac: 1, Uterus; 2, cavum uteri; 3, space (dissected) between posterior wall of the uterus and anterior wall of the sac; 4, place of the placenta on inside of sac behind the uterus; 5, wall of the sac; 6, posterior wall of the pocket, that is, the tubular or Fallopian fold of the left broad ligament; 7, left Fallopian tube, cross-cut showing its lumen; 8, pocket between 5 and 6.

connection with its surface, is the sac or adventitious uterus. Fig. 43 shows the uterus and sac seen from the anterior side. From the anterior surface of the sac, 1/4 inch from the left corner of fundus, is the left round ligament; it is enlarged, 4 inch in diameter. On the upper surface of the sac, behind and to the left of the fundus uteri, is a pocket

covered with peritoneum, 21⁄2 inches broad, 3 to 31⁄2 inches deep (Fig. 45) (Case 1, Fig. 43, 10).

The upper free border of the pocket, or broad ligament, forms a somewhat thickened ridge, which runs in an arch, first to the left backward, then to the right, then divides into two branches—a lower one that runs downward and to the right, an upper one that runs forward to the left, pointing toward the left corner of the uterus. The ridge contains the left Fallopian tube (Figs. 43 and 45). The tube is 7 inches long-the same as the right tube. It runs to the left backward in an arch, and then bends to the right downward and backward; here it leaves the broad ligament, and the canal enters the wall of the sac. How it terminates—if on the inside of the posterior wall of the sac (Case 1, Fig. 44) or not-cannot be made out for certain, because the sac is cut off here, but as there are no fimbriæ, it does not open outside of the sac, and has undoubtedly opened into the fetal cavity.

The uterine portion of tube is of normal size, permitting the passage of only a very fine probe. The median portion of the tube is normal, perhaps slightly dilated, 3 to 5 lines wide.

The termination of the tube in the wall of the sac (Fig. 44, 12) is an oval opening, 4 inch in diameter, the borders of which are perfectly smooth, no fimbriæ being visible anywhere.

Of the left ovary no trace can be found. The sac is clad on the outside with the peritoneum and is smooth.

The wall of the sac is from 1 to 8 mm. thick, white, and firm. The thickest part of the sac is right behind the fundus uteri, 1⁄4 to 1⁄2 inch in thickness, and there the tissue, viz., fibers of the uterine tissue of the upper surface of the fundus, is continuous with the wall of the sac; however, on the posterior surface of neck and fundus the tissue of uterus is not continuous with the sac, but the latter is separated from the uterus by a short layer of connective tissue that permits of dissection and leaves the posterior surface of uterus and wall of sac with smooth surfaces. This is the place where the placenta was situated (Figs. 44, 7, and 45, 4). The inner surface of the sac has an uneven, ragged, or velvety appearance, most ragged over the site of the placenta, close to and behind the neck of the uterus. Outside of this region there are numerous islands of uneven, ragged, appearance, with more smooth spots between them. Several large vessels, 4 inch in diameter (Fig. 45, 9), are found, partly free, partly adherent to the inside of the sac. A microscopic examination of the wall of the sac shows the following: (a) In the site of the placenta:

1. An inner layer of free cotyledons or fimbriæ.

2. A layer of maternal tissue, with cross-cuts of the cotyledons, embedded in cavities (whether lymph-spaces or blood-vessels I am unable to decide, but they look to me like venous blood-vessels) tightly surrounding them.

3. A heavy layer of connective-tissue bundles, interspersed with some organic musclebundles.

4. Peritoneum.

(b) A thick spot in the wall, near the peripheral opening of the Fallopian tube into the sac, which I examined to find ovarian tissue, presents exactly the same appearance as (a).

(c) A thin place in the sac, some distance from placenta and tube, gives—

1. An inner layer of areolar connective tissue without cotyledons.

2. A median heavy layer of connective-tissue bundles and bundles of organic musclefibers.

3. Peritoneum.

(d) A third place in the sac presents the same layers as (a).

Nowhere in the wall of the sac is any trace of ovarian tissue to be found.