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ECTOPIC PREGNANCY INSIDE THE UTERINE WALL IN A FIBROMATOUS UTERUS
63 in bed for a few days at home. On April 18 she seemed well but had a positive swab on that day and on May 2. About May 9 she developed pain and swelling in the left knee, and was admitted to hospital on May 17 with a slight relapse. She had further positive swabs on May 21 and June 7. It would clearly have been desirable to attempt a comparison between the incidence of sore throats in the penicillin and lactose groups, but in an investigation of outpatients it is impossible to define a sore throat with sufficient precision to give useful comparisons. None of the children reported any ill effects from the penicillin, and none of the streptococci of group A isolated were resistant to penicillin. was
DISCUSSION
This that a
confirms
investigation previous work in showing of dose daily penicillin by mouth will very considerably reduce the number of throat swabs positive for group-A haemolytio streptococci in rheumatic children. It leaves unanswered two questions which are more important from the practical point of view: (1) does oral penicillin prevent relapses ? and (2) does it prevent
’
acute infectionsP It is difficult to see how the first could be in a reasonable time with answered question numbers of children of the order available in this investigation. The second question is difficult to answer by an experiment on outpatients. It seems certain, however, that oral penicillin is not a sure preventive of mild throat infections, because at least 2 of the penicillin group (nos. 8 and 11) had them. SUMMARY
A group of 73 rheumatic children was observed at intervals in an outpatient department from October, 1950, to May, 1951. 41 children were given a daily dose of 200,000 units of penicillin with 10% glucose before breakfast, and 32 were given lactose and glucose. The number of throat swabs positive for group-A heemolytic streptococci obtained from the penicillin group was very much less than the number obtained from the lactose group. No conclusive evidence was obtained about the effect of the penicillin in preventing either rheumatic relapses
fortnightly
acute streptococcal throat infections. Only 2 children, both in the lactose group, had rheumatic relapses. or
NOTE ON RESULTS OF TYPING
In the lactose group there were 17 children who had In 9 of those children the more than one positive swab. of the same in every positive swab, was type organism in 2 there was a definite change of type, and in the remaining 6 there was some doubt because some swabs produced several types. In the penicillin group there were 6 children who had more than one positive swab. In 5 of them the organism was of the same type in every positive swab, and in 1 (no. 5) there was a definite change of type. The child who had a definite change of type was irregular in attendance. We are indebted to Mr. L. J. Waller for much technical
ECTOPIC PREGNANCY INSIDE THE UTERINE WALL IN A FIBROMATOUS UTERUS L. ACHMATOWICZ M.D. Warsaw SURGEON,
THE
following
LAUTOKA
case
HOSPITAL,
is worth
FIJI ISLANDS
recording
because of its
rarity. CASE-RECORD
On Oct. 15, 1951, a European woman, aged 41, was admitted to hospital with what appeared to be a ruptured ectopic pregnancy. That day, while having lunch, she had suddenly felt an extremely sharp pain in the umbilical region and left " shoulder, and had felt as if a sharp knife had been pushed into her vagina " ; she fell down on the floor, but did not lose consciousness. She had vomited at home twice, and four times on the 75-mile ambulance journey to hospital. - Micturition and defaecation were normal. She had menstruated in August, when her period began on Aug. 3, lasted only three days, and was very scanty. In September and October she had menstruated at normal intervals, but only one day on each occasion, and very little. Past History She began to menstruate at 12, the menstrual cycle being 8/28 days, and bleeding heavy. At the age of 16 she underwent appendicectomy. At 28 she married, and she conceived soon afterwards. At the time of the first suppressed period she had extremely severe lower abdominal pain and laparotomy was done under spinal anaesthesia. When the abdomen was opened, she heard the surgeon say " she is pregnant," and the abdomen was closed. She subsequently miscarried a 51/2 month foetus. After this, her periods became heavier, and each time she lost much blood. Fibromatosis of the uterus was diagnosed, and in 1939 a myomectomy was done, several fibroids being removed. In spite of this operation abdominal pain and distension persisted, and though she became pregnant in 1940 she aborted at 3 months. In 1941, however, she was delivered of a healthy girl. During her pregnancy she had severe haematuria every 28 days, lasting 8 days, which coincided with her suppressed menstrual period. Her urine had the same odour and consistence as the menstrual flow, and she " felt very weak." Immediately after the birth of the baby the periodical haematuria disappeared. After 31/4 years, in 1944, she again became pregnant, and again had periodical haematuria. At cystoscopy the bladder appeared to be normal. The hsematuria was attributed to an anterior low attachment of the placenta and adhesions between the uterus and the bladder. A girl was born at term, and the haematuria disappeared immediately after. The next pregnancy, in 1945, terminated in abortion at 3 months. During this pregnancy, the patient again had periodic haematuria, which ceased after abortion.
to Dr. R. E. 0. Williams and his co-workers at Colindale for the typing; and to Prof. R. H. Parry, medical officer of health for Bristol. The trial was made possible by a grant from the Royal College of Physicians (Miss H. A. M. Thomnson beauest).
assistance ;
REFERENCES
Brick, M., McKinley, H., Gourley, M., Roy, T. M. (1950) Canad. med. Ass. J. 63, 255. Burke, P. J. (1947) Lancet, i, 255. Goerner, J. R., Massell, B. F., Jones, T. D. (1947) New Engl. J. Med. 237, 576. Kohn, K. H., Milzer, A., MacLean, H. (1950) J. Amer. med. Ass. 142, 20.
Maliner,
M. M. (1950) J. Pediat. 37, 858. Amsterdam, S. D. (1947) Ibid, 31, 658. Arreche, C. C. (1949) Ibid, 35, 145. Massell, B. F., Dow, J. W., Jones, T. D. (1948) J. Amer. med. Ass. 138, 1030. Maxted, W. R. (1948) Lancet, ii, 255. Pitt Evans, J. A. (1950) Proc. R. Soc. Med. 43, 206. -
—
—
fcetus ; b, chorionic villi ;c, pin in left fallopian tube ; d, fibroma ; e, opening into gestation cavity ; f, pin in right fallopian tube.
Posterior view of uterus : a,
64 On Examination The patient was pale, with temperature 97-8°F, and pulserate 84. Her abdomen was slightly distended, very rigid, and extremely tender, especially in the right groin and in the A large oval smooth soft mass area of McBurney’s point. could be felt in the right iliac fossa. Vaginal examination revealed no bleeding. The uterus was enlarged to the size of a grape-fruit, soft, and tender, and there was tenderness in both lateral fornices.
Treatment and Progress As the patient’s condition was still satisfactory after her long trip in an ambulance on a rough rubble road, it seemed probable that, if she had a ruptured ectopic pregnancy, the bleeding had stopped. Anti-shock treatment was applied, and the patient observed throughout the night. Next morning her general condition was satisfactory, and she had slept well, but was nauseated and had vomited small amounts several times. Her temperature was 98’4°F, her pulse-rate 90, and a blood-count showed red cells 2,200,000 per c.mm., Hb 32%, white cells 9500 per c.mm. At 11 A.M. her pulse-rate was 100. A ruptured ectopic pregnancy, probably in the right
muscle 3-5 cm. thick, and the right tube by intact uterine wall 1-5 cm. thick. (3) The third possibility is that the ovum, on its external migration after fertilisation, became implanted on the posterior surface of the uterus, possibly where the epithelium had been damaged by fibromatosis or by dense adhesions. In the further course of its development the ovum burrowed into the uterine wall and, after nearly three months growth, ruptured into the abdominal
cavity.
.
This last mechanism appears the most
Cruickshank, Director of Medical Services, Fiji, for permission to publish, and Dr. P. E. C. Manson-Bahr, acting pathologist, for the histological examination.
AN OUTBREAK DUE TO
SALMONELLA BRANCASTER E. HINDEN
JOAN TAYLOR
M.D. Camb., M.R.C.P.
M.B. Lond., D.P.H.
-
tube,
was
diagnosed.
Operation Laparotomy
was performed under general ansesthesia A blood-transfusion of 1/z pints was given. On opening the abdomen through a midline incision, clotted, and fluid blood was found, especially in the right half of the pelvic cavity. Old dense adhesions covered both appendages and the uterus, and multiple adhesions connected the omentum intestines, and uterus. These were cut and tied off to free the reproductive organs. The uterus, which was as big as two fists, occupied the middle part of the pelvic cavity. No ectopic pregnancy was found in the appendages, but on the posterior wall of the uterus, near the base of the fundus, among dense adhesions, which had at first limited the bleeding from the tear, an opening, 0-5-1-0 c.m. across, was found into which chorionic villi and a shining ovum were protruding. When this aperture was palpated it suddenly became larger, and first the ovum, and then the placenta, prolapsed. As soon as this happened, profuse haemorrhage took place, which was controlled. In view of the extremely long history of the case, and the present rupture of the uterus, a supracervical hysterectomy was done. The postoperative course
PÆDIATRICIAN TO
at 2.30 P.M.
was
uneventful.
Pathology The uterus contained several small subperitoneal and intramural fibromata. Old dense adhesions covered its posterior and anterior surfaces, especially at the fundus. Just off centre in the right side of the posterior surface of the fundus, among adhesions, there was a tear in the wall of the uterus about 2-5 cm. in diameter. The left flap of the torn wall was everted medially, and a fibroid as big as a pea was embedded in it. The torn opening in the wall of the uterus led to a cavity 4-5 cm. deep and 2-5 em. wide containing a fcetus and chorionic villi ; it was not lined with decidua. Only a few decidual cells were attached in a corner to the chorionic villi (verified microscopically), and this cavity was separated from the uterine cavity by an intact muscular wall 4 mm. thick. No connection of any kind could be found between these two cavities. The intra-uterine parts of both tubes were separated from the gestation cavity by an intact muscular wall 1-5 cm. thick on the right side and 3-5 cm. thick on the left. The tubes were apparently healthy. The uterine cavity was lined with decidua vera. DISCUSSION
In discussing the mechanism of this ectopic gestation several possibilities must be considered. (1) The ovum may have been fertilised and implanted in a mucous crypt inside the uterine wall, or in a diverticulum from the uterine cavity. This is improbable, since the gestation cavity was not lined with decidua, and only a few decidual cells were found in a corner attached to the chorionic villi. In addition, the wall which separated the gestation cavity from the uterine cavity was 4 mm. thick, and there was no connection between them. (2) The possibility of implantation of the ovum in the intra-uterine portion of the right or left tube, with further expansion into the uterine wall, and subsequent rupture, must be discarded because the interstitial portion of the left tube was separated by intact uterine
probable.
I wish to thank Dr. J. M.
SALMONELLA
WHIPPS CROSS HOSPITAL, LONDON
REFERENCE
LABORATORY, COLINDALE, LONDON
W. W. WALTHER M.B. Lond. AREA
PATHOLOGIST,
WHIPPS CROSS
HOSPITAL, LONDON
was first described by Macdonald it had been discovered in mussels. (1948) ; Subsequently a second strain was isolated from the liver of a dead turkey poult. Although this organism has been found in the stools of a healthy person (Ministry of Health 1951) it has not hitherto been described as a cause of disease in man. An outbreak caused by S. brancaster in a children’s ward is therefore considered worthy of record. The organism was isolated, almost simultaneously, from two widely separated sources in the hospital. The first was an infant (case 1 in the accompanying table), " an unidentified salmonella " being grown from a stool passed on Jan. 17, 1951. The second source was an old lady who died on Jan. 19 from " senile myocardial degeneration " ; a culture taken from her spleen because it was unaccountably enlarged and soft grew a salmonella. Both cultures were sent to the Salmonella Reference Laboratory and identified as S. brancaster. The ward where the outbreak occurred was used mainly for bottle-fed babies ; most of them were aged less than 12 months, but babies were accepted up to the age of 18 months. The ward consisted of a long corridor along one wall, with cubicles and the kitchen opening to it from the other side ; on the wall side opened the sluices, bathroom, and sterilising-room. There were 12 cubicles, arranged 6 on each side of the kitchen, which was fitted out as a milk-kitchen also. One of the 12 cubicles was used as the sister’s office ; the others each held two cots, but often one of a pair could not be used because an infectious patient was in the other. This gave a theoretical capacity of 22, but in practice at least 3 or 4 cubicles were used for infectious diseases, giving a practical maximum of 18 or 19 infants. January was not very busy, but February and March made very heavy demands on our accommodation, and there were often 18 babies in the ward. The outbreak occurred in two clearly defined periods. The first report of S. brancaster in an infant’s stool was returned on Jan. 19 ; positives were often found from then till Feb. 6. This we call " the first positive period." Thereafter the organism could not be found at all in the ward for a fortnight-" the negative period." It was isolated again on Feb. 18, and thereafter was constantly found till the ward was evacuated on April 17 -" the second positive period."
Salmonella brancaster
et
al.
DISCUSSION
This that a
confirms
investigation previous work in showing of dose daily penicillin by mouth will very considerably reduce the number of throat swabs positive for group-A haemolytio streptococci in rheumatic children. It leaves unanswered two questions which are more important from the practical point of view: (1) does oral penicillin prevent relapses ? and (2) does it prevent
’
acute infectionsP It is difficult to see how the first could be in a reasonable time with answered question numbers of children of the order available in this investigation. The second question is difficult to answer by an experiment on outpatients. It seems certain, however, that oral penicillin is not a sure preventive of mild throat infections, because at least 2 of the penicillin group (nos. 8 and 11) had them. SUMMARY
A group of 73 rheumatic children was observed at intervals in an outpatient department from October, 1950, to May, 1951. 41 children were given a daily dose of 200,000 units of penicillin with 10% glucose before breakfast, and 32 were given lactose and glucose. The number of throat swabs positive for group-A heemolytic streptococci obtained from the penicillin group was very much less than the number obtained from the lactose group. No conclusive evidence was obtained about the effect of the penicillin in preventing either rheumatic relapses
fortnightly
acute streptococcal throat infections. Only 2 children, both in the lactose group, had rheumatic relapses. or
NOTE ON RESULTS OF TYPING
In the lactose group there were 17 children who had In 9 of those children the more than one positive swab. of the same in every positive swab, was type organism in 2 there was a definite change of type, and in the remaining 6 there was some doubt because some swabs produced several types. In the penicillin group there were 6 children who had more than one positive swab. In 5 of them the organism was of the same type in every positive swab, and in 1 (no. 5) there was a definite change of type. The child who had a definite change of type was irregular in attendance. We are indebted to Mr. L. J. Waller for much technical
ECTOPIC PREGNANCY INSIDE THE UTERINE WALL IN A FIBROMATOUS UTERUS L. ACHMATOWICZ M.D. Warsaw SURGEON,
THE
following
LAUTOKA
case
HOSPITAL,
is worth
FIJI ISLANDS
recording
because of its
rarity. CASE-RECORD
On Oct. 15, 1951, a European woman, aged 41, was admitted to hospital with what appeared to be a ruptured ectopic pregnancy. That day, while having lunch, she had suddenly felt an extremely sharp pain in the umbilical region and left " shoulder, and had felt as if a sharp knife had been pushed into her vagina " ; she fell down on the floor, but did not lose consciousness. She had vomited at home twice, and four times on the 75-mile ambulance journey to hospital. - Micturition and defaecation were normal. She had menstruated in August, when her period began on Aug. 3, lasted only three days, and was very scanty. In September and October she had menstruated at normal intervals, but only one day on each occasion, and very little. Past History She began to menstruate at 12, the menstrual cycle being 8/28 days, and bleeding heavy. At the age of 16 she underwent appendicectomy. At 28 she married, and she conceived soon afterwards. At the time of the first suppressed period she had extremely severe lower abdominal pain and laparotomy was done under spinal anaesthesia. When the abdomen was opened, she heard the surgeon say " she is pregnant," and the abdomen was closed. She subsequently miscarried a 51/2 month foetus. After this, her periods became heavier, and each time she lost much blood. Fibromatosis of the uterus was diagnosed, and in 1939 a myomectomy was done, several fibroids being removed. In spite of this operation abdominal pain and distension persisted, and though she became pregnant in 1940 she aborted at 3 months. In 1941, however, she was delivered of a healthy girl. During her pregnancy she had severe haematuria every 28 days, lasting 8 days, which coincided with her suppressed menstrual period. Her urine had the same odour and consistence as the menstrual flow, and she " felt very weak." Immediately after the birth of the baby the periodical haematuria disappeared. After 31/4 years, in 1944, she again became pregnant, and again had periodical haematuria. At cystoscopy the bladder appeared to be normal. The hsematuria was attributed to an anterior low attachment of the placenta and adhesions between the uterus and the bladder. A girl was born at term, and the haematuria disappeared immediately after. The next pregnancy, in 1945, terminated in abortion at 3 months. During this pregnancy, the patient again had periodic haematuria, which ceased after abortion.
to Dr. R. E. 0. Williams and his co-workers at Colindale for the typing; and to Prof. R. H. Parry, medical officer of health for Bristol. The trial was made possible by a grant from the Royal College of Physicians (Miss H. A. M. Thomnson beauest).
assistance ;
REFERENCES
Brick, M., McKinley, H., Gourley, M., Roy, T. M. (1950) Canad. med. Ass. J. 63, 255. Burke, P. J. (1947) Lancet, i, 255. Goerner, J. R., Massell, B. F., Jones, T. D. (1947) New Engl. J. Med. 237, 576. Kohn, K. H., Milzer, A., MacLean, H. (1950) J. Amer. med. Ass. 142, 20.
Maliner,
M. M. (1950) J. Pediat. 37, 858. Amsterdam, S. D. (1947) Ibid, 31, 658. Arreche, C. C. (1949) Ibid, 35, 145. Massell, B. F., Dow, J. W., Jones, T. D. (1948) J. Amer. med. Ass. 138, 1030. Maxted, W. R. (1948) Lancet, ii, 255. Pitt Evans, J. A. (1950) Proc. R. Soc. Med. 43, 206. -
—
—
fcetus ; b, chorionic villi ;c, pin in left fallopian tube ; d, fibroma ; e, opening into gestation cavity ; f, pin in right fallopian tube.
Posterior view of uterus : a,
64 On Examination The patient was pale, with temperature 97-8°F, and pulserate 84. Her abdomen was slightly distended, very rigid, and extremely tender, especially in the right groin and in the A large oval smooth soft mass area of McBurney’s point. could be felt in the right iliac fossa. Vaginal examination revealed no bleeding. The uterus was enlarged to the size of a grape-fruit, soft, and tender, and there was tenderness in both lateral fornices.
Treatment and Progress As the patient’s condition was still satisfactory after her long trip in an ambulance on a rough rubble road, it seemed probable that, if she had a ruptured ectopic pregnancy, the bleeding had stopped. Anti-shock treatment was applied, and the patient observed throughout the night. Next morning her general condition was satisfactory, and she had slept well, but was nauseated and had vomited small amounts several times. Her temperature was 98’4°F, her pulse-rate 90, and a blood-count showed red cells 2,200,000 per c.mm., Hb 32%, white cells 9500 per c.mm. At 11 A.M. her pulse-rate was 100. A ruptured ectopic pregnancy, probably in the right
muscle 3-5 cm. thick, and the right tube by intact uterine wall 1-5 cm. thick. (3) The third possibility is that the ovum, on its external migration after fertilisation, became implanted on the posterior surface of the uterus, possibly where the epithelium had been damaged by fibromatosis or by dense adhesions. In the further course of its development the ovum burrowed into the uterine wall and, after nearly three months growth, ruptured into the abdominal
cavity.
.
This last mechanism appears the most
Cruickshank, Director of Medical Services, Fiji, for permission to publish, and Dr. P. E. C. Manson-Bahr, acting pathologist, for the histological examination.
AN OUTBREAK DUE TO
SALMONELLA BRANCASTER E. HINDEN
JOAN TAYLOR
M.D. Camb., M.R.C.P.
M.B. Lond., D.P.H.
-
tube,
was
diagnosed.
Operation Laparotomy
was performed under general ansesthesia A blood-transfusion of 1/z pints was given. On opening the abdomen through a midline incision, clotted, and fluid blood was found, especially in the right half of the pelvic cavity. Old dense adhesions covered both appendages and the uterus, and multiple adhesions connected the omentum intestines, and uterus. These were cut and tied off to free the reproductive organs. The uterus, which was as big as two fists, occupied the middle part of the pelvic cavity. No ectopic pregnancy was found in the appendages, but on the posterior wall of the uterus, near the base of the fundus, among dense adhesions, which had at first limited the bleeding from the tear, an opening, 0-5-1-0 c.m. across, was found into which chorionic villi and a shining ovum were protruding. When this aperture was palpated it suddenly became larger, and first the ovum, and then the placenta, prolapsed. As soon as this happened, profuse haemorrhage took place, which was controlled. In view of the extremely long history of the case, and the present rupture of the uterus, a supracervical hysterectomy was done. The postoperative course
PÆDIATRICIAN TO
at 2.30 P.M.
was
uneventful.
Pathology The uterus contained several small subperitoneal and intramural fibromata. Old dense adhesions covered its posterior and anterior surfaces, especially at the fundus. Just off centre in the right side of the posterior surface of the fundus, among adhesions, there was a tear in the wall of the uterus about 2-5 cm. in diameter. The left flap of the torn wall was everted medially, and a fibroid as big as a pea was embedded in it. The torn opening in the wall of the uterus led to a cavity 4-5 cm. deep and 2-5 em. wide containing a fcetus and chorionic villi ; it was not lined with decidua. Only a few decidual cells were attached in a corner to the chorionic villi (verified microscopically), and this cavity was separated from the uterine cavity by an intact muscular wall 4 mm. thick. No connection of any kind could be found between these two cavities. The intra-uterine parts of both tubes were separated from the gestation cavity by an intact muscular wall 1-5 cm. thick on the right side and 3-5 cm. thick on the left. The tubes were apparently healthy. The uterine cavity was lined with decidua vera. DISCUSSION
In discussing the mechanism of this ectopic gestation several possibilities must be considered. (1) The ovum may have been fertilised and implanted in a mucous crypt inside the uterine wall, or in a diverticulum from the uterine cavity. This is improbable, since the gestation cavity was not lined with decidua, and only a few decidual cells were found in a corner attached to the chorionic villi. In addition, the wall which separated the gestation cavity from the uterine cavity was 4 mm. thick, and there was no connection between them. (2) The possibility of implantation of the ovum in the intra-uterine portion of the right or left tube, with further expansion into the uterine wall, and subsequent rupture, must be discarded because the interstitial portion of the left tube was separated by intact uterine
probable.
I wish to thank Dr. J. M.
SALMONELLA
WHIPPS CROSS HOSPITAL, LONDON
REFERENCE
LABORATORY, COLINDALE, LONDON
W. W. WALTHER M.B. Lond. AREA
PATHOLOGIST,
WHIPPS CROSS
HOSPITAL, LONDON
was first described by Macdonald it had been discovered in mussels. (1948) ; Subsequently a second strain was isolated from the liver of a dead turkey poult. Although this organism has been found in the stools of a healthy person (Ministry of Health 1951) it has not hitherto been described as a cause of disease in man. An outbreak caused by S. brancaster in a children’s ward is therefore considered worthy of record. The organism was isolated, almost simultaneously, from two widely separated sources in the hospital. The first was an infant (case 1 in the accompanying table), " an unidentified salmonella " being grown from a stool passed on Jan. 17, 1951. The second source was an old lady who died on Jan. 19 from " senile myocardial degeneration " ; a culture taken from her spleen because it was unaccountably enlarged and soft grew a salmonella. Both cultures were sent to the Salmonella Reference Laboratory and identified as S. brancaster. The ward where the outbreak occurred was used mainly for bottle-fed babies ; most of them were aged less than 12 months, but babies were accepted up to the age of 18 months. The ward consisted of a long corridor along one wall, with cubicles and the kitchen opening to it from the other side ; on the wall side opened the sluices, bathroom, and sterilising-room. There were 12 cubicles, arranged 6 on each side of the kitchen, which was fitted out as a milk-kitchen also. One of the 12 cubicles was used as the sister’s office ; the others each held two cots, but often one of a pair could not be used because an infectious patient was in the other. This gave a theoretical capacity of 22, but in practice at least 3 or 4 cubicles were used for infectious diseases, giving a practical maximum of 18 or 19 infants. January was not very busy, but February and March made very heavy demands on our accommodation, and there were often 18 babies in the ward. The outbreak occurred in two clearly defined periods. The first report of S. brancaster in an infant’s stool was returned on Jan. 19 ; positives were often found from then till Feb. 6. This we call " the first positive period." Thereafter the organism could not be found at all in the ward for a fortnight-" the negative period." It was isolated again on Feb. 18, and thereafter was constantly found till the ward was evacuated on April 17 -" the second positive period."
Salmonella brancaster
et
al.