A Case of Tubal Pregnancy. By Henry Hun, M.D., Lecturer on Nervous Diseases in the Albany Medical College. Reprinted from THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. July, 1884. A CASE OF TUBAL PREGNANCY. By Henry Hun, M.D., Lecturer on Nervous Diseases in the Albany Medical College. Mrs. T., a Scotch woman, 36 years old, married, had always been re- markably healthy; she had had one miscarriage, and had given birth to seven children, the youngest of whom was thirteen months old and was still nursing at the time of her mother's death. Since the birth of her baby the patient had menstruated once. This menstruation commenced seven days before her death, lasted three days, and was, as far as could be ascertained, entirely normal. On September 7, 1882, three days after her menstruation had ceased, she was suddenly seized at about half past seven in the evening with great pain in the right inguinal region. She did not suspect that she was pregnant, and attri- buted the pain to colic. Soon after the pain commenced she had an operation of the bowels, and after taking a mixture of whiskey and mustard which her husband prepared for her, she vomited a little. On the same evening Dr. W. H. Fowler was called in and prescribed stimulants, and a little morphine. On the afternoon of the next day Dr. Purple saw the patient for the first time. She was then in a condition of collapse, with cold extremities, pale face, and a pulse so small and rapid that it could not be counted. Patient complained of some pain in lower part of abdomen, but espe- cially of great weakness. Dr. Purple ordered stimulants, but about half an hour later the patient had a convulsion and died. 2 At the autopsy, which was held twenty hours after death, a quart or more of blood, partly fluid, partly in the form of a black clot, was found in the pelvis and in the lower part of the abdominal cavity. The abdominal organs, especially the uterus and kidneys, were very anaemic. There was no injection of the vessels of the peritoneum, and no traces of either recent or old peritonitis. The right Fallopian tube at its middle was enlarged and formed an ovoid swelling of dark red colour, about two inches in its long and one inch in its short diameter. On the posterior surface of this swelling was a small rent, about one-fifth of an inch long, through which the blood had passed out into the peritoneal cavity, and from which at the time of the autopsy protruded a small cyst filled with a clear fluid. In the centre of the cyst was floating a small embryo. There was a considerable quantity of am- niotic fluid, so that the embryo could float about freely, and a short umbilical cord could be plainly seen connecting the embryo with the wall of the cyst. No umbilical vesicle could be seen, which does not prove that none was present; for at this stage of the autopsy, which was per- formed by the light of one lamp, the cyst and the umbilical cord both ac- cidentally ruptured, and when the embryo was put into alcohol for future examination no umbilical vesicle was connected with it. On the outer side of the chorion were a great number of villi, and these were especially numerous at a point just opposite to the point of rupture. Between the ovum and the walls of the Fallopian tube was a blood clot, firmer, of colour, and apparently of slightly older date than the blood clot found in the peritoneal cavity. Nothing like a decidua could be dis- covered macroscopically or microscopically. The walls of the tumour were composed of the Fallopian tube, which was more vascular than usual, and in which there was a slight amount of round cell infiltration. The effusion of blood had taken place in this wall, and had broken through the mucous coat and worked its way between the ovum and the walls of the Fallopian tube which surrounded it. No large vessel could be found from which the hemorrhage had proceeded. A probe introduced into the abdominal opening of the Fallopian tube penetrated until near the ovoid swelling where it was arrested by the adherence of the walls of the tube. From the ovoid swelling to the uterus, the Fallopian tube was occluded by an adherence of its walls. The left Fallopian tube was normal. The left ovary presented on its surface several linear scars, but its form and colour were normal. On sec- tion of the ovary underneath a linear scar a corpus luteum was found one- half by three-fourths of an inch in diameter, of oval form, and limited by a well-marked white capsule. At that point of the corpus luteum which was nearest the surface of the ovary was a small cavity divided by a delicate partition into two equal parts, the greatest diameter of the cavity being 3 one-eighth of an inch. The rest of the mass of the corpus luteum was made up of yellow tissue. Numerous sections were made through the right ovary, but nothing like a corpus luteum of pregnancy was found. One corpus luteum was found in which all the yellow matter had been absorbed, and where the white lining walls were almost in apposition, leaving a small linear cavity with somewhat irregular margins. The uterus was pale and not appreciably enlarged; the distance from the external os to the fundus being two inches. Its walls were one-half inch thick, its inner surface was slightly rough. Over the greater part of the body no trace of a decidua could be seen either by the naked eye or by the aid of the microscope, but near the internal os there was a small fragment of what appeared to be a decidua. The embryo found at this autopsy is worthy of notice. It is coiled up, forming an arch. Its length in its coiled-up position is a little less than three-eighths of an inch, and if straightened out it would probably measure one-half an inch. Judging from the length of the embryo and the devel- opment of its organs it is between twenty-five and twenty-eight days old. The accompanying plate is an accurate drawing made with the camera lucida of the embryo after it had been rendered transparent by oil of cloves. Projecting from the ventral surface is the umbilical cord, which is just above a small, square fragment of the amnion. The umbilical cord, which is very nearly the middle point of a child at term, is in this case very near the lower end of the embryo. The legs and arms are represented by little buds springing out on each side of the body. The vertebrae, with their centres of ossification, are very distinct, and are the only traces of bone that can be seen. The nervous system is developed out of all proportion to the other organs, and in point of size is nearly equal to all the rest of the embryo. The delicate nature of the nervous tissue is also seen in that, although it was preserved as carefully as possible, being put immediately into weak alcohol, the strength of which was gradually and rapidly increased, yet the nervous tissue does not have its original form, but its outlines are wavy and it has the appearance of a semi-fluid body which has coagulated. The angle which the medulla oblongata makes with the spinal cord, and the still greater angle which the hemispheres make with the ganglia at the base of the brain, are plainly seen. The ventral surface of the embryo has almost entirely closed along the median line. The branchial arches are well formed; the upper one is divided into the upper and lower jaws, leaving the cavity of the mouth between them. The nasal cavity is also widely open. At the base of the second branchial arch the ear can be seen, but its structure cannot be made out. The eye, however, is well formed, and shows the lens lying- free and surrounded by the retina. The heart and aorta are very distinct. 4 Ear. Na.sa.1 Cavity. Mouth, - al Arcfc± Zd Branchial Arch. ---3d Branchial Arch. Per'CO.Ydiurn - Liver. Cord. " The sharp and distinct lines of the drawing, although entirely accurate, are in marked con- trast to the delicate outlines of the embryo. The heavy line which arches backwards from the eye to the base of the first branchial cleft, appears under the microscope as a depression upon the surface of the embryo; while the outlines of the alimentary canal are so indistinct that they can only here and there be made out." The arch of the aorta can be seen indistinctly bending downwards behind the second and third branchial arches. The aorta appears to spring from the auricle, but with proper focusing it is seen to pass behind the auricle to the ventricle. The heart is surrounded by the pericardium, and the ventricle is made up of a sort of spongy tissue, which is not very well shown in the drawing. The trabeculae of this spongy tissue, in the further development of the embryo, are gradually forced more and more to the 5 periphery and form the columns carneae. Below the heart is the large body of the liver. In this case the ovum was in the right Fallopian tube and its corpus luteum was in the left ovary. Such a condition of things is found not in- frequently in tubal pregnancies, and there are several ways in which it can be accounted for. It is possible that the ovum may pass from the ovary through the tube of the same side into the uterus and then pass out of the uterus into the other tube and there go on in its development. This is, doubtless, a very rare occurrence, and its possibility has been denied by many authors. A case reported by Schultze,1 however, in which the abdominal end of the pregnant tube was closed by old adhesions due to a previous peritonitis, leaves no doubt that this may occur; the abdominal end of the tube being closed the ovum could have entered the tube only from the uterus. In the great majority of these cases, however, it is probable that the ovum passes from the ovary into the abdominal end of the tube of the opposite side, and in many of these cases this wander- ing of the ovum is proved by the occlusion by old adhesions of the tube on the same side as the corpus luteum. In order to accomplish this wandering of the ovum the tube may swing across to the opposite side of the pelvis and grasp the opposite ovary, as is shown in a preparation in the anatomical museum in Cambridge,2 in which both tubes are grasping the same ovary, to which they are attached by adhesions, or, what is probably more common, the ovum passes into the peritoneal cavity, and crossing over to the other side of the pelvis is sucked into the Fallopian tube by the current produced by the vibration of its ciliated epithelium. In whatever way it is produced, it is certain that in a considerable number of cases of tubal pregnancy the corpus luteum is found in the ovary of the other side, and it is very possible that this unusual origin of the ovum may be the cause of the tubal pregnancy, for if the tube bends over and reaches the opposite ovary it will be apt to be so bent and twisted that the ovum will meet with great difficulty in passing through it, or if an impregnated ovum passes across the pelvis and enters the tube of the other side so much time will be consumed in its journey that it may de- velop to such a size before it gets to the uterus that it cannot pass through the tube, and will continue its development in this organ. This is the only cause which we can assume in our case, for there was no occlusion of the tube by tumours, bands of adhesions, or displacements of the uterus, as are sometimes found in these cases; neither was there any great fright or emotion experienced at or near the time of sexual intercourse, which in a number of such cases has appeared to cause the extra-uterine pregnancy. (i) Hassfurther von der Ueberwanderung des menschlichen Eies, Dissert. Inaug. Jena, 1868. (a) Parry on Extra-uterine Pregnancy, page 75, Philadelphia, 1876. 6 The adhesion of the walls of the Fallopian tube on each side of the tumour in this case is what is usually found. It must have occurred after the ovum reached its place of development in the tube, because the occlusion was on both sides of the ovum, although, as is usual in such cases, the occlusion was much more extensive between the ovum and the uterus than between the ovum and the fimbriated extremity of the tube. Probably in all cases of tubal pregnancy there is a decidua formed in the uterus which may be cast off at any time during the pregnancy, but in many cases is not cast off till the end of eight or nine months, when regu- lar labour-pains come on. In our case the decidua was probably cast off at the menstruation or the metrorrhagia, for it can well be doubted whether this was a true menstruation, which ceased four days before death; only a small fragment near the cervix remaining. It seems likely that the in- creased congestion of the internal genital organs attendant upon this menstruation or metrorrhagia led to a slight hemorrhage between the ovum and the surrounding walls of the tube. The increased pressure in the tumour due to this extravasation of blood finally led to its rupture and the escape of blood into the peritoneal cavity, which caused the pain, the collapse, and the death of the patient. In support of this is the fact that the blood found in the tube was firmer, more organized, and apparently of older date than the blood in the peritoneal cavity. It has been noticed in cases of extra-uterine pregnancy that menstruation or metrorrhagia very often immediately precedes rupture of the cyst. In this case the rupture of the cyst took place a month or two earlier than is usual in cases of tubal pregnancy. In the first six weeks of tubal pregnancy rupture of the cyst is either very rare or else it does not cause the death of the patient.