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Ovarian Pregnancy

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Ovarian Pregnancy Obstetrical and GynTcological Section 137 months afterwards. Dr. Roberts was interested to hear Dr. Whitehouse's remarks on draining the bladder in such cases. Dr. Roberts thought that a vaginal cystotomy would be perhaps preferable to suprapubic drainage. Dr. TATE referred to the difficulty that sometimes occurred in diagnosing some cases of prolapse of the urethra from malignant disease. He had seen two cases in which the prolapse had the appearance of a circular protruding growth, indurated on the surface and having a purplish colour very suggestive of malignancy. In the former of the two cases the swelling was removed freely, but when examined microscopically it proved to be non-malignant. Dr. BECKWITH WHITEHOUSE, in reply, thanked the Section for the kind way in which his communication had been received. He was interested to hear of the cases mentioned by Dr. Hubert Roberts, Dr. Cuthbert Lockyer and Dr. Walter Tate, and thought that if all cases were published it would be found that carcinoma in this situation was not such a very rare condition. In all, about 150 cases had been described, but for reasons already given he had felt compelled to reduce this list considerably. He was glad to hear that Dr. Victor Bonney agreed with the theory of chronic inflammation pre-existing the incidence of carcinoma. The common situation of the growth in this position certainly appeared to afford some evidence in confirmation of the theory. With regard to the second case described by Dr. Cuthbert Lockyer, from the description Dr. Whitehouse would include it under the first group of vulvo-urethral neoplasms-viz., the "papillomatous growths which may be mistaken for a simple polypus or caruncular condition of the urethral orifice." He was interested in Dr. Tate's experience, and appreciated the difficulty that might arise in the diagnosis of malignant disease from chronic urethral prolapse. A Case of Ovarian Pregnancy. By EARDLEY HOLLAND, M.D. THIS case has a double interest: firstly, the interest associated with the occurrence of pregnancy within the ovary; secondly, a still greater interest associated with a peculiar structure found within the blood-clot from a recently ruptured follicle in the opposite ovary. It may be stated at once that the specimen has no more than an anatomical value, as being one of ovarian pregnancy: it throws no light on the mode of embedding of the ovum within the ovary or on its subsequent develop- ment. Further, the authenticity of the specimen rests on the fact that the gestation sac is completely encapsulated by ovarian tissue; additional criteria, such as the condition of the corresponding tube and the relation 138 Holland: Case of Ovarian Pregnancy of the ovarian ligament, are obviously unnecessary. The period of the pregnancy is, as far as can be estimated, about four weeks. I most gratefully acknowledge my indebtedness to Dr. John Phillips, under whose care the patient was, for permitting me to publish these notes. CLINICAL HISTORY. The patient, aged 40, had been married for twelve years; she had never borne children, but had miscarried once, nine years before the present pregnancy. She was admitted to King's College Hospital in March, 1909. In October, 1908, after a period of six weeks' amenorrhcea, she was suddenly seized with severe abdominal pain, accompanied by uterine haemorrhage. She went to bed and in fourteen days was sufficiently well to get up; after three days she had another attack which compelled her to return to bed for a few days. Throughout the following December, January and February she men- struated regularly and, except for a constant slight, blood-stained dis- charge, was quite well. On March 6 she had a third attack, and her doctor sent her into hospital with the diagnosis of extra-uterine gestation. On March 20 Dr. John Phillips opened her abdomen: some recent blood-clot was found in Douglas's pouch and the right ovary, considerably enlarged and adherent to the posterior surface of the right broad ligament and floor of the pelvis, was removed without much difficulty, though when the ovary was pulled from its bed there was brisk haemorrhage which ceased immediately the broad ligainent on either side of the enlarged ovary was clamped. The left ovary, which was not enlarged, had on its posterior surface a small rent from which blood was oozing and through which a clot was projecting. This was evidently a recently ruptured Graafian follicle. The clot was expressed and the oozing controlled by two sutures. The patient made a straightforward recovery. DESCRIPTION OF THE SPECIMEN. The specimen consists of the enlarged right ovary, to which is attached part of the mesosalpinx and Fallopian tube. The ovary forms an ovoid swelling and measures 6'3 cm. in its greatest and 4'5 cm. in its smallest diameter. Its external surface, except for an irregular opening on the anterior aspect, is smooth and of a bluish-grey colour, very similar to the colour of a simple cystadenoma. On the anterior surface, Obstetrical and Gynecological Section 139 FIG. 1. Anterior surface of the right ovary. Part of the tube and mesosalpinx are attached to the superior border; immediately beneath the two cut edges of the anterior and posterior layers of the broad ligament which unite as they pass outwards to form the infundibulo-pelvic fold, is the site of rupture; below this is the terminal portion of the ovarian fimbria. FIG. 2. Cut surface seen on bisection of the ovary. A capsule of stretched ovarian tissue encloses blood-clot, in the centre of which lies the gestation sac. The clot is mostly pale and laminated, but there are also dark areas of recent clot. 140. Holland: Case of Ovarian Pregnancy just beneath the hilum of the ovary, is a large opening through which projects old blood-clot: this is where the ovary was adherent to the pelvic peritoneum and is the site of rupture of the gestation sac. On the outer pole of the ovary is the ovarian fimbria. These appearances are seen in fig. 1. After having been hardened in formalin, the ovary was bisected and the cut surface seen in fig. 2 was revealed. A capsule, consisting of tunica albuginea and of stretched ovarian tissue, encloses blood-clot in the midst of which lies the gestation sac. A complete section, parallel to the cut surface and I in. in thickness, was removed for embedding in paraffin and was cut in serial sections. Fig. 3 is a photomicrograph of one such section. (a) The Capsule. - The capsule, which completely surrounds the specimen except at the hilum and at the point of rupture, is composed of the stretched ovary. The thickness of the capsule varies in different parts. It is thickest at the pole remote from the hilum, and here several follicles, primordial ova and corpora albicantia are met with. At other parts the capsule consists merely of the tunica albuginea and a few underlying connective tissue fibres. This complete capsule of ovarian tissue is the absolute evidence upon which the authenticity of the speci- men rests. Where the ovarian tissue and blood-clot are in contact no special structure -denoting lutein or decidual cells is apparent. In fact, a disappointing feature of the specimen is the lack of fine histological details (except in the ovarian tissue) owing to autolytic changes. It is only natural that such changes should have occurred when it is recol- lected that the specimen was not removed until five months after the patient's first attack of pain and hmmorrhage, at which time it may be assumed that the connexions between the ovum and its site of implanta- tion were originally disturbed. (b) The Blood-clot.-This is mostly pale in colour and laminated, and is evidently the result of recurrent small hamorrhages. There are some dark red areas of recent heemorrhage situated, for the most part, near the point of rupture. Scattered throughout the clot are a few degenerated villi, greatest in number near the thick part of the capsule. (c) The Gestation Sac.-This is shrunken and collapsed and consists of a well-marked chorionic membrane with remnants of trophoblast; within this and joined to it by an amnio-chorionic pedicle, is part of another membrane which is evidently the amnion. No embryo was found and the only trace of it was a little amorphous material within the gestation sac. Obstetrical and Gynwcological|| Section 141 ~~~~~~~~~~~~~~~~~~~~~~~~~~2-B....Ws ..................................... -' o _se*_*ss|,|_1__iOBB~~~~~~~~~~~~~~~~~~~~~~~~~~~-2L-_._,~~~~~~~~~~~~~~~~~~~~~~~~~~~~eoti | | | ! tI - l i | _e=>.o~~~~~~~~~~~~~~~~~~~~~~~' ffi~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~C *-4 n11_;~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~e_S_SiS_~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~a -_ 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~b ECao __||~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~n|~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-4x\g=~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-4_B__Be_q;CeOSo~~~~~~~~~~~~~~~~~POV JL ' _ W _m___~~~~~~~~~~~~~~~~~~~~~~~~~~cs v g~~~~~~~~~~~~~~~~~~~~~~~~,(D5.2 -_- . r;> _t °; -t c3~~~~~~~~~ 0; _1 = s ~ _ o za~~~~~~~~~~~~~~~~~~~~P :E£.f~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~P.'-B ~~~~~~~~~~~~~~~~~'co-z.,NJ * <: d Q H°~~~~~~~~~')Q X _rY~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-0*~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~_,8{~ . l e e .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~cY V41,. * ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~U CB _ _ _~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~b 0;,_0 7s~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-OO -- 11~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~cIg_ ~~~~~~~~~~~~~~~~~~~~~~~~EnI -__~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~- CjEe$ CQ U2 142 Holland: Case of Ovarian Pregnancy The Clot from the Left Ovary.-This clot was expressed from what appeared to be a recently ruptured follicle. As it seemed likely that it might contain remnants of the shed membrana granulosa, and even, perhaps, the ovum itself, it was, merely out of curiosity, embedded in paraffin and cut into serial sections. I was rewarded by finding a very remarkable structure running through eleven sections. It is composed of multinucleated protoplasm and, obviously, once had a definitely arranged form, but it must have been mutilated during the expression of the clot from the follicle. The drawings (fig. 4) demonstrate this structure better than a written description.
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