A Case of Unruptured Tubal Pregnancy Continuing to Full Term.*

A CASE OF UNRUPTURED TUBAL PREGNANCY CONTINUING TO FULL TERM.*

By HUGH MILLER, M.B., F.R.C.S.Ed. Honorary Surgeon, Royal Northern Infirmary, Inverness.

It is well known that the lodgement and growth of a fertilised ovum in a uterine tube is a not uncommon occurrence. The cause of this is far from obvious in most cases, but it is held that possible predisposing factors may be (i) some mechanical condition?inflammatory or otherwise?interfering with the passage of the ovum along the tube and into the uterus ; and (2) some anomaly in the fertilised ovum, such as early dis- appearance of the corona radiata, favouring its immediate embedding in the uterine tube. The commonest site in which the ovum may become implanted is the ampulla, the widest part of the tube ; and this is accompanied by a form of decidual reaction in the tubal mucosa similar to the decidual formation in uterine pregnancy, but a corresponding hyper- trophy of the muscle wall of the tube does not take place. It has been found that an ovum which has taken up a situation in a tube seldom lives there for more than a few weeks. The ovum either dies in the tube, becomes extruded through the abdominal ostium?a tubal abortion?or, tubal rupture takes place, due to the eroding action of the chorion and the distension by the growing ovum of the thinned-out wall of the tube. Should the pregnancy continue after either of the latter two happenings, it does so within the peritoneal cavity (the amniotic sac becoming covered by adhesions to pelvic and abdominal structures and the placenta gaining attachment to similar tissues), that is, a Secondary Abdominal Pregnancy. The ability of the uterine tube to continue to accommodate the growing ovum is by no means certain ; as a matter of fact, it only does so in extremely rare instances (Eden and Lockyer1). Williams2 and Blacker3 admit the possibility of such occurring, and the latter illustrates and describes briefly a specimen removed at operation and in addition gives references to other cases. I have come across three cases diagnosed as examples of advanced unruptured tubal pregnancy recently reported * Read at a Meeting of the Edinburgh Obstetrical Society, 12th January 1938. OBST. 29 Hugh Miller

4 in the literature. In Fink's case, the pregnant tube was removed two years after the expected date of confinement. 5 Schumann diagnosed his case before operation as one of concealed accidental haemorrhage, but on opening the abdomen the true state of affairs revealed itself, and there was no evidence of placental separation. The child was born dead although the foetal heart had been heard a short time previously. This author suggests that if the seat of placentation is in the lower wall of the gestation sac near the mesosalpinx it favours non- rupture of the tube, as elasticity of the broad ligament permits of greater hypertrophy of the tube wall, and less chance of 6 perforation by the chorionic villi. Tottenham includes a macroscopical and microscopical report on the specimen he removed at operation. Pathological Differential Diagnosis.?In considering such cases, the pathological differentiation lies between :? Primary Abdominal Pregnancy. Secondary Abdominal Pregnancy. Ovarian Pregnancy. Pregnancy in a Rudimentary Uterine Horn.

7 Sarker describes the case of a Primary Abdominal Pregnancy which he removed at operation thirteen months after the commencement of pregnancy and six months after " the patient had experienced a false labour." Both tubal fimbria in this case were free from adhesions, loops of gut were attached to the placenta, and the sac could not be removed posteriorly. An interesting and valuable contribution is made in this paper by Sarkar regarding the pre-operative diagnosis of these rare cases. He made use of hystero-salpingography and demonstrated the relation of both tubes to the gestation sac. The lipiodol passed easily through both tubes and the shadow showed no distortion. Forty-eight hours later, oil was shown to be lying in the Pouch of Douglas between coils of bowel, while it had drained completely away from the tubes and uterine cavity. Before confirming a diagnosis of primary abdominal pregnancy both tubes should be examined in detail microscopically to exclude evidence of a previous rupture. The tube heals rapidly after such complete extrusion of an ovum, and will show no evidence of rupture to the naked eye. It is further essential that neither tubes nor ovaries take any part in the formation of the gestation sac. 3o A Case of Unruptured Tubal Pregnancy

Examples of Secondary Abdominal Pregnancy advancing to a late stage of gestation have been described within recent 8 years. Hoskings' case was dealt with at the 254th day of gestation. Here the cord passed from the large gestation sac containing the foetus, through a rent in the ampulla of the tube, and became attached to the placenta which was embedded in the lateral end of the tube. Steel 9 brings out another point which is helpful in the diagnosis of this variety of abdominal pregnancy. When he reviewed in retrospect the history of his case, a diagnosis of tubal rupture in the early weeks of pregnancy was suggested, and he feels this might have been made at that time. If the primary rupture of the tube results in the ovum becoming intraligamentous and it survives, the placenta is found to lie above the foetus, whereas if the rupture is intra-abdominal, the placenta develops inferiorly. Two cases of Ovarian Pregnancy advancing to term have 10 been accepted as genuine. One was described by Gottshalk and the other by Ludwig.11 Spiegelberg's 12 four conditions should be fulfilled before a diagnosis of such is made. These are:?1. The absence of the ovary in question. 2. The presence of well-marked ovarian structures in the gestation sac wall. 3. The connection of the latter with the uterus by means of the ovarian ligament. 4. The tube plays no part in the formation of the sac, and its anatomical relations to the sac are the same as in a case of ovarian cyst. The specimen to be described fulfils none of these essential data. Specimens of advanced Pregnancy in a Rudimentary Uterine Horn have been described within recent years to this Society by Fahmy 13 and Sturrock.14 These specimens showed that healthy uterine appendages were present on the side involved and were attached to the lateral aspect of the gravid horn, the insertions of the tube, ligament of the ovary and the round ligament being in close opposition to each other. Further, there were no adhesions of the sac to adjacent viscera. A review of these varieties of ectopic pregnancy advancing to a late stage of gestation is of help when examining and attempting to classify the following case. I have recently had a patient under my care who had a tubal pregnancy of forty weeks' duration, and an account of this case is given, in the belief that the details of a condition of such rarity may be of value. 3i Hugh Miller

History of a Case of Unruptured Tubal Pregnancy.

The patient is aged 23 years, of good physical development, and unmarried. Menstruation commenced when she was 13, and she had regular periods every twenty-eight days and lasting five days. Six years ago she had a normal pregnancy which ended after a labour lasting three days in the delivery of a healthy female child weighing ten pounds, and there is no history of her having pelvic inflammation or venereal disease then or at any other time. She was working in London in 1936 and became pregnant, the date of the first day of the last menstrual period being 14th September. At the end of November she went to someone to have abortion procured, and an " " " operation was done on two occasions, but these were not " " successful." She was then taken to a doctor who carried out a similar procedure, and following this she had some vaginal bleeding each day for three weeks. About this time she started to have pain in her abdomen, especially on the right side, and sometimes going to the right shoulder. This pain persisted throughout the greater part of the subsequent nine months. She also had vomiting and suffered from dysuria and increased frequency of micturition. She never felt well, had fainting attacks, and spent most of the time in bed. Swelling of the abdomen was noticed in January 1937, and this continued to " " enlarge uniformly. She began to feel movements of the child in March, and these were more marked on the left side of her abdomen. An X-ray examination was made on 6th May, and this showed the presence of the foetus in the longitudinal lie, the breech presenting and the back to the left; the X-ray film did not suggest any abnormality. The foetal heart sounds were heard on 8th May. According to the date of her last menstruation, labour was expected about 21st June, and on that very day she commenced to have pain in the back and across the abdomen, which came on at regular intervals of about half-an-hour and lasted about three minutes ; this continued for four days, after which a brownish vaginal discharge was seen for a week. She " had noticed, however, that for a week before this false labour," the foetal movements had stopped. The patient was admitted to hospital on the 24th June, and as the expected emptying of the uterus did not occur spontaneously, attempts to induce this by the use of quinine and pituitary extract were made on two occasions but with no effect. An X-ray examination made on 27th July showed the foetus fully developed, in the same position, breech presenting. No shadow of the uterus was visible, and the foetal bones showed up 32 Full-Term Tubal Pregnancy. The right tube forms the gestation sac, which has been incised to show the foetus. The body of the uterus, divided through the cervix, is firmly adherent to the front of the sac. A Case of Unruptured Tubal Pregnancy particularly clearly, which might have suggested that the pregnancy was extra-uterine. I saw the patient for the first time on the 16th August, at which time she was feeling perfectly well, and said that her " " abdomen had gone down a little. On examination there was a firm symmetrical swelling like a full-term uterus within the abdomen, the fundus lying at a hand's breadth below the xiphisternum ; the breech of the foetus was entering the pelvis, but other foetal parts could not be identified. On vaginal examination the breech of the foetus could be easily felt through the vaginal vault; the cervix was situated far upwards and forwards behind the symphysis pubis, and the external os was sufficiently dilated to admit one finger. By making further exploration with the finger, the patient being under a general anaesthetic, it was found that the uterine cavity was only slightly enlarged and was quite empty; the foetus was felt lying entirely behind the uterus, and the condition was recognised to be an extra-uterine pregnancy. On the 17th August 1937 abdominal section was performed, the incision stretching from the pubes to about three inches above the umbilicus. The structure revealed within the abdomen was most unusual. The right uterine tube was a hugely distended sac and its wall in the upper part was so thin and transparent that parts of a foetus could be seen inside it. This sac filled up the lower part of the abdomen, and the pelvis, the back of it being adherent to the pelvic colon and wall of the pelvis, and also to great omentum and coils of small intestine. The uterus, about twice its non-pregnant size, was closely adherent to the front of the sac, and as it was lying within the abdomen the cervix was very much elongated. The procedure adopted was to free the adhesions from the back and sides of the sac until the back of the cervix could be exposed. The adhesions actually were not very difficult to separate and gave by sweeping a hand round the gestation sac. Only a few had to be ligated. The ligaments and attachments to the uterus were then divided and the cervix cut across, so that the body of the uterus with the adherent tubes including the pregnancy were removed.

Description of the Specimen. After removal and hardening of the specimen a closer inspection could be made. The uterus, measuring 11*5 cm. from divided cervix to fundus, was in front of the lower part of the specimen. From the right cornu the uterine tube could be seen passing back- wards and to the left for 3 ins., where it expanded into a large sac firmly fixed to the posterior wall of the uterus and extending beyond obst. 33 c 2 Hugh Miller its lateral margins and well below the point where the cervix had been cut across. The abdominal end of the tube was not recognisable, but the ostium seemed completely closed. The left tube, ovary and broad ligament were adherent to the anterior surface of the gestation " " sac. An incision was made down the posterior wall of the sac so that its contents could be examined. The wall of the sac was very thin, in no place being more than o* 5 c.cm., and at others reduced to the thinness of paper. Within the sac the amnion and chorion could be separated from the wall, and the liquor amnii was very small in amount. The foetus, a female, was lying with the breech in the lowest position, and its head was well flexed and pushed into the narrow isthmic part of the tube, causing a marked caput deformity of the skull at the vertex. The back was towards the left?a left sacro-posterior position, and the legs were flexed. There was talipes equino-varus of the right foot. Apart from this, and the vertex deformity, the foetus showed no other abnormality ; and full maturity was evident, the skull bones being firm and the nails projecting beyond the pulp of the digits. The weight of the foetus was 4? lb. and its length 21^ ins. The umbilical cord, which measured 17^ ins., entered the membranes some distance from the placenta, i.e. a velamentous insertion, and the placenta was a small structure, about 3 ins. in diameter, and attached to the middle of the posterior wall of the sac. At this site the wall was as thin as elsewhere, but dense adhesions were evident over its external surface. Microscopical examination of certain portions of the specimen were made at the Midwifery Department of Edinburgh University by Dr John Sturrock, and these yield further information. (1) The wall of the sac : this was composed of fibro-muscular tissue; the fibrous tissue predominated, but sections stained by van Giesen's method showed areas of muscle. This fact, along with the very obvious direct continuity of the gestation sac with recognisable uterine tube, indicate that the condition was an unruptured tubal pregnancy rather than a secondary abdominal one. (2) The tubes : the mucosa of both tubes showed chronic infection with plical adhesions and formation of pseudo-follicles ; this strongly suggests a possible cause of the arrest of the ovum in the tube. There was evidence of decidual reaction in the mucosa of both tubes, but especially the right. (3) The uterus : in this case only the deeper layers of the endometrium were present; their glands showed some dilatation, but there was no decidual reaction. (4) The placenta : a section showed this organ to have become completely degenerated and functionless, the microscopical features being those of an old- standing placental infarct; these changes were doubtless associated with the time which had elapsed between death of the foetus and the operation. (5) An adhesion to the wall of the sac at the placental site : in a section of this, well-formed, thick-walled blood vessels 34 A Case of Unruptured Tubal Pregnancy

were seen, which was evidence that the placenta had obtained at least some of its blood supply by this route.

Summary. The significant features which issue from the study of this case are :?(i) Pregnancy occurred in the right uterine tube, and gestation continued within the tube for about forty weeks. (2) The course of the pregnancy was attended by pain in the lower abdomen and right iliac fossa, increased frequency of micturition, fainting attacks, and general ill-health. (3) The other signs, namely, amenorrhcea, enlargement of the abdomen, recognition of foetal life, and the X-ray appearances were similar to those of a normal pregnancy. (4) Death of the " " foetus took place, and was followed by a false labour at about the fortieth week. (5) An operation was performed eight weeks later, wrhen the gestation sac was removed un- ruptured along with the body of the uterus. (6) The foetus was below average weight ; there was distortion of the skull, apparently due to its position, and a right talipes equino-varus probably due to the same cause, but otherwise its development and maturity was normal. (7) Chronic infection, with adhesions wuthin the tubes, suggests that this was the cause of the fertilised ovum failing to pass into the uterus. (8) The nature of the pregnancy was unrecognised, but it might have been diagnosed earlier had more reliance been placed on the history of attempts to procure abortion being followed by continuance of the pregnancy ; on the painful symptoms accompanying the course of the pregnancy ; and possibly if X-ray examination by means of hystero-salpingography had been employed.

Subsequent History.

The patient was making a very satisfactory recovery, but three weeks after the operation an unfortunate sequel became evident. Urine was escaping at the vulva, and inspection of the vagina revealed that there was an intermittent flow of urine through the external os of the stump of the cervix. A firm mass of inflammatory exudate could be felt in the pelvis continuous with cervix and vaginal vault. The bladder was examined with a cystoscope, and had no abnormal appearances ; a ureteric catheter was passed up the left ureter to the pelvis 35 Hugh Miller

of the left kidney, and a secretion of urine was obtained through it, but a ureteric catheter could only be passed through the right ureteric orifice for 5 cms., and no urine was secreted from this catheter. X-ray films which were taken showed that the left pyelogram was normal, but that on the light side the tip of the ureteric catheter was arrested a few cms. above the bladder, and sodium iodide injected through this catheter merely flowed back alongside it into the bladder. This led me to believe that the urinary fistula was coming from the right ureter near its lower end, and further, that there was no communication between the fistula and that portion of the ureter distal to it. This had resulted from some damage to the right ureter in the floor of the pelvis during the course of the operation. An examination by intravenous pyelography was next carried out, and it was seen from the X-ray films that there was a good secretion of the dye by the left kidney, giving a normal shadow of the calyces, renal pelvis and ureter. On the right side, however, the absence of any shadow in the renal pelvis or ureter indicated a very poorly functioning right kidney. The lines of treatment considered were, an operation to free the lower end of the right ureter from its fibrous adhesions and transplant it into the bladder, or to remove the right kidney. It was anticipated that the first operation would be a difficult one and with doubtful chances of success ; and in view of the fact that the right kidney was apparently of little functional value, the second option was adopted, and on the 8th December a right nephrectomy was carried out. At this operation the renal pelvis and ureter were seen to be very much dilated and hypertrophied. Histological examination of the kidney showed :?The glomeruli were lobulated and hypertrophied and in some places replaced by hyaline connective tissue; the convoluted tubules showed degenerative changes, and there was patchy increase of inter- stitial tissue becoming more diffuse in the medulla; these appearances were presumed to be due to a hydronephrotic condition. This patient is now in very good health, and a blood urea estimation made on the 23rd December was 30*0 mgms. per cent., which would indicate that the remaining left kidney is performing the renal function of the body quite efficiently. 36 A Case of Unruptured Tubal Pregnancy

I wish to express my thanks to Dr John Sturrock for his valuable help with regard to references to previously reported similar cases, and for his examination and comments on microscopical preparations of the specimen ; also to Professor Johnstone of the Midwifery Department, University of Edinburgh, in which department this examination was carried out.

REFERENCES.

1 Eden and Lockyer, Gyticzcology, 1927, p. 176. 2 Williams' Obstetrics, 1936, p. 896. 3 Eden and Lockyer, New System of Gynecology, 1917, i., 456. 4 Fink, Amer. Journ. Obstet. and Gyn., 1934, xxviii., 454. 5 Schumann, Amer. Journ. Surg., 1936, xxxiii., 570. 6 Tottenham, Journ. Obstet. and Gyn. of Brit. Emp., 1934, xli., 56. 7 Sarkar, Journ. Obstet. and Gyn. of Brit. Emp., 1935, xlii., 1122. 8 Hoskings, Brit. Med. Journ., 1934, ii., ill. 9 Steel, Brit. Med. Journ., ii., 62. 10 Gottshalk, Zeitschr. f. Geb. und Gyn., 1902, xlvii., 488. 11 Ludwig, Wiener Klin. Wochenschr., 1896, ix., 600. 12 Eden and Lockyer, New System of Gyn., 1917, i., 447. 13 Fahmy, Trans. Edinburgh Obstet. Society, 1932-33, liii., 92. 14 Sturrock, Trans. Edinburgh Obstet. Society, 1933-34, liv., 150.

Discussion. Professor Johnstone said that Mr Miller had, he thought, had the good fortune to describe the first case of this sort before the Society. Mr Miller had been characteristically modest in his description of his diagnosis and treatment, but they would agree that it would scarcely have been possible to have made a definite diagnosis before operation. Hysterography might certainly have indicated the state of affairs, but with the history which the patient gave, hysterography was contraindicated. Mr Miller was fortunate that he was not asked to operate until two months after term, because earlier operation would probably have been much more serious as fewer of the placental blood spaces would have been thrombosed. Mr Miller had opened up the question of differential diagnosis. The only two cases of ovarian pregnancy that he (Professor Johnstone) had seen came into his ward in the course of one month; and ten days after Mr Miller had sent this specimen to the Laboratory of his Department in the University for investigation he had received from Dr Jeffares of Loughborough another specimen which was a full-term pregnancy in an unruptured rudimentary uterine horn. Briefly the history of this case was that the mother, aged 32, had had two normal pregnancies before, the last five years previously. Her last menstrual period began on 20th April 1936. Dr Jeffares was asked to see her by the district nurse on the 20th February 1937, 37 Hugh Miller by which time she was about three weeks past the expected date " of her delivery. For the last three months she was completely unable to get out of bed or to turn over in bed and was very sore and tender in the right iliac fossa." The patient showed the appearance of a full-time pregnancy, but there was a very marked divarication of the recti muscles and the pregnancy appeared to be carried very low. The foetal head was palpated in the right iliac fossa but could be pushed down into the pelvis, although this move- ment caused considerable pain. The foetal limbs were very easily palpated, lying well to the front. No foetal heart could be heard, but the mother stated that she had felt life that day and there was a very loud placental souffle. X-ray examination showed a single foetus with the head lying in the right iliac fossa. No vaginal examination was made, but Dr Jeffares concluded that the patient had made a mistake in her dates and that the labour was due to start at any time. He proposed to rectify the presentation of the child as soon as labour started properly. Apparently he did not see the patient again until twelve days later when the patient was complaining of more abdominal pain and discomfort and thought she was starting labour. There was no show and no recognisable contractions. The patient said that she felt life that day. Two days later, when he saw her again, he made a vaginal examination and found the os high up admitting the tip of one finger. He stated that there was no evidence of any obstruction but that the head could be felt high up through the posterior fornix. Three days later, as there was no material change, she was admitted to the hospital, and forty-eight hours later an abdominal operation was performed because there was no advance in labour and the temperature had risen to 99-4 and the pulse to 116. The abdomen was very tender all over the tumour and the patient's general condition was deteriorating. The operation notes state that the tumour was found to be a left-sided tubal gestation occupying the centre of that tube, freely mobile. The left tube and ovary were removed and the vessels ligated with silk. It was noted that the uterus was enlarged to the size of a three months' pregnancy. The specimen was incised and found to contain a male child of 7 lb. 3 oz. The patient made an uninterrupted recovery and was discharged from hospital on the 3rd April. Slight vaginal discharge of blood for five weeks. Dr Jeffares' specimen had evidently been preserved in very strong formalin with the result that investigation of it was rendered very difficult. But so far as can be made out it consists of a uterine horn containing a full-time pregnancy. The tube and ovary are attached to the horn, the tube being long and tortuous. At the lower pole of the horn is a raw area where it has been separated from the other horn. Adherent to the back is a portion of omentum. The foetus is a male, and, to judge by its size and the fact that the finger nails are 33 A Case of Unruptured Tubal Pregnancy fully developed, appears to be at term. It shows evidence of pressure in the form of a talipes and a torticollis, but it was impossible to say whether these are the result of cramped quarters antenatally or of the very strong fixative. Dr Fahmy congratulated Mr Miller on his presentation of a most interesting and rare case. Advanced extra-uterine pregnancy was admittedly difficult to diagnose, and even with the aid of X-ray photography the true state of affairs may not be revealed until operation has been undertaken. The causation of the adhesions round the pregnant tube was uncertain. They might be the result of some infection consequent upon the attempts to procure abortion early in pregnancy. The most advanced case of extra-uterine gestation which Dr Fahmy had personally dealt with was one of 6J- months' duration, but there the pregnancy was in a rudimentary horn of a uterus. Dr Haultain said that he had recently been called into consultation on a case of a seven months' pregnancy in a multipara where the doctor in charge suspected an advanced extra-uterine gestation because of the ease with which the foetal parts could be recognised through the abdominal wall. The foetus presented as a breech, and on vaginal examination in the first instance Dr Haultain could feel a body posteriorly which he thought might be an empty uterus. As the patient was being anaesthetised for re-examination, the diagnosis was cleared up because a uterine contraction developed as the patient reached the second stage of anaesthesia. The uterine wall could be felt contracting over the foetus, and this demonstrated conclusively that the pregnancy was intra-uterine. On vaginal examination the mass in the posterior fornix turned out to be one of the lower limbs of the foetus. Dr Sturrock agreed with Mr Miller's opinion that the specimen was an example of an advanced unruptured tubal pregnancy. The pathological diagnosis rested on several positive findings. There was the continuation of obvious tube lumen into the gestation sac. Certainly no closed fimbrial end had been demonstrated, but the surface adhesions made that impossible. Finding muscle tissue in the wall of the sac far removed from recognisable tube and the fact that it was possible to remove the sac entire, were also supporting evidence. The absence of features diagnostic of the other varieties of advanced extra-uterine pregnancy which Mr Miller had referred to in the preliminary part of his paper might be taken as negative findings. The late development of the urinary fistula meant ureteric necrosis from interference with its blood supply rather than direct injury. The degree of hydroureter and hydronephrosis found at the second operation were almost certainly due to the pressure exerted by the growing gestation sac. Bruce Low and McCurrich,. 39 Hugh Miller in their description of a case of secondary abdominal pregnancy in the British Medical Journal, 1934, i., 657, stated that when separating the placenta from the depths of the cavity they realised the close relation of the right ureter but did not see it. Subsequent cystoscopic examination revealed complete occlusion of that ureter. This raised the question of the advisability of simply opening such a gestation sac, delivering the foetus and leaving the placenta in situ. Thereby there was no risk of damaging the ureter or its blood supply and no risk of hsemorrhage from the placental area. St George Wilson recently reported a case of secondary abdominal pregnancy in which he had used sequestration of the placenta. He ligated and cut off the cord close to the placenta, and closed the abdomen. The patient's progress was satisfactory. The President congratulated Mr Miller on a most interesting communication. Mall estimated that only about 1 per cent, of ectopic pregnancies went to full term, but clinical experience suggested that even that estimate was high. The only case of this type which Professor Hendry had met with in the past ten years was operated on when the British Congress of Obstetrics and Gynaecology was in session at Glasgow in April 1931. The patient was an elderly multipara, who had been in the antenatal wards for almost a month under treatment for albuminuria and high blood pressure. She had had considerable pain and her urine had been examined bacteriologically to exclude a urinary infection, and X-rayed to exclude a calculus. The film showed a normal foetus, lying apparently in normal position and certainly revealed nothing to suggest an ectopic pregnancy. As the albuminuria was not responding to treatment and the patient was very near term, it was decided that labour should be induced. When an attempt was made to introduce " " a pig's bladder through the cervical canal (a method of induction at that time being tried out in the Unit), it was found that the uterine cavity only measured 2\ ins., and that the body of the uterus could, with a little difficulty, be identified as separate from the gestation sac. It was impossible at that examination to decide whether the foetus was lying in an ectopic sac or in the rudimentary horn of a double uterus. The abdomen was opened and a well-developed, almost mature living foetus was extracted. The baby did very well. A little difficulty was experienced in removing the placenta, as it was still very vascular. The vessels were under-stitched and eventually the abdomen was closed. There were some points of similarity between this case and Mr Miller's case. In both the X-ray examination failed to help in reaching an exact preoperative diagnosis. Mr Miller was perhaps more fortunate in that consideration of operation did not arise in his case until almost two months after the spurious labour. 40 A Case of Unruptured Tubal Pregnancy

In Mr Miller's case the attempt to terminate pregnancy in the early months was interesting. Mr Miller had referred to the possibility of making an exact diagnosis at this stage by the use of lipiodol, but if the pregnancy had been intra-uterine, such a procedure would almost certainly have produced abortion. Even if the right-sided pain, which was present in both cases, had been thoroughly investigated, pyelography would probably have suggested that unusually severe kinking of the ureter was responsible for the pain. The evidence of decidual reaction in Mr Miller's case was interesting. The left tube appeared to have just as marked a decidual reaction as the right. Sections of the tube showed the very great importance of endosalpingitis as a factor in the occurrence of ectopic pregnancy. Mr Miller referred in his case to the thinning out of the Fallopian tube to form the wall of the gestation sac. Pinard records a case in which the wall of the tube continued to hypertrophy so that at operation he mistook the wall of the overstretched tube for uterine wall: it was muscular and contractile. The later history of Mr Miller's case was particularly interesting. The late appearance of the urinary fistula suggested that it resulted from necrosis probably due either to long-continued pressure or some operative trauma. There were certainly adhesions in the area. The interference with the ureter in this case might have been the cause of the pain of which the patient had complained from time to time. He congratulated Mr Miller on his very successful handling of this case and on the frankness and modesty with which he had described each step of a singularly difficult clinical problem. Mr Miller, in replying to Dr Fahmy's question as to the reason why there were adhesions present, said that this raised a big subject. There was probably more than one cause, but he imagined that in this case they were produced by the enlarging sac displacing other pelvic organs and producing irritation by friction between their peritoneal surfaces, and that they need not necessarily have been caused by inflammation or haemorrhage. In addition, the formation of vascular adhesions appeared to be an attempt on Nature's part to provide a blood supply to the placental site of the sac. He agreed that he was lucky in having to operate at a later stage than might have happened.

41