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Intosh, J. A.: J. A. M. A. 87: 996, 1926. (25) BlatMJ,, P. B.: Urol. !lJld Cutan. Rev. 31: 293, 1927. (26) Pollidori, A.: Arch. ital. di chir. 24: 202, 1929. (27) Frei, W.: Klin. Wchnschr. 8: 2038, 1929. (28) Eoegholt, M. N.: Klin. Wchnschr. 8: 1085, 1929. (29) Wilson, L. A.: J. A. M. A. 95: 1093, 1930. (30) Harupt, W.: Ztschr. f. Geburtsh. u. Gynak. 99: 95, 1930. (31) MoCarthy, L.: Histopathology of Skin Disease, p. 334, St. Louis, 1931, The C. V. Mosby Co. (32) Sears, N. P.: AM. J. OBST. &:J GYNEC. 25: 906, 1933. (33) Duramd, M., Nicolas, F., ®d Favre, M.: Province med. Par. 24: 55, 1913. (34) Frei, W,: Klin. Wchnschr. 4: 2148, 1925; Klin. Wchnschr. 11: 512, 1932; and Dermat. Wchnschr. 95: 1575, 1932. (35) Symposium, Lymphogranuloma Inguinale at the Strasbourg Clinic, Bull. Soc. :fran~. de dermat. et syph. 38: 524, 1931. (36) Barthels, C., ®d Bibersteiln, H.: Beitr. z. klin. Chir. 152: 161, 1931. (37) De Wolf, H. F., ®iJ v® Cleve, J. V.: J. A. M. A. 99: 1065, 1932. (38) Sulzberger, M. B., Olltd Wise, F.: J. A. M. A. 99: 1407, 1932. (39) Lohe; H., aM Rosenfeld, H.: Med. Klin, 28: 1486, 1932. (40) Cole, H. N.: J. A. M. A. 101: 1069, 1933. 511

}"fEDICAL ARTS BUILDING -----------

PREGNANCY IN AN ATRETIC UTERINE HORN JoHN

M.

NoKEs,

M.D.,

UNIVERSITY, VA.

(From the Dez;:artment of Obstetrics amd Gyneoology, Umversity of Virgilnia) case is reported because of its interest from a diagnostic viewTHE following associated as it was with an attempted induction of abortion. It is also

. point undoubtedly an instance of transmigration of the fertilized ovum or sperm. Mrs. W. H. G.-The patient, a nineteen-year-old married woman, was admitted to the hospital December 26, 1932, complaining of ''death of fetus'' and wishing it to be removed inst!lJltly. She was married in April, 1932, and the last menstrual period occurred on June 15, 1932. Present Ilmess.-She considered herself normally pregnant until October 22, when she was seized by lower abdominal cramps associated with vaginal bleeding and passage of clots. Fetal movements were felt about the middle of October, but ce:tsed on October 22. Bleeding continued from October 22 to the time of admission on December 26, although somewhat diminished in amount. The pains throughout the lower abdomen have been fairly constant since October but seem to have increased in severity during the two weeks prior to admission and at times were so severe that the weight of the bedclothes could scarcely be tolerated on the abdomen. Breast cha.nges and morning sickness were said to have been present during August and September but had disappeared entirely since then. Seventy-two hours prior to admission nausea and vomiting recurred, associated with severe abdominal cramps. At the time of admission the patient emphatically denied any attempts to interrupt pregnancy, but several days later she :finally admitted having been to a professional abortionist October 22 and again November 24. On these occasions a dilator was inserted into the cervix causing considerable pain, as no anesthetic was used. Each time the dilator was used there was an increase in the amount of

vaginal bleeding. Pa.rl History.-Except for an attack of cystitis when she was eleven years old, there h.ad been no serious illnesses. Menses were regular prior to the present illness. There had been no previous operations. Ph&sical Ea;CIIIIIi4uJtif>n..-At the time of admission to the hospital the temperature The patient seemed acutely ill, having W\lS 99• F.; pulse, 100; respirations, 30. a haggard expression and some pallor. The general physical examination with the exception of the abdomen and pelvis was essentially normal. Abdominal examination revealed some distention of the upper abdomen with definite tenderness, spasm, and

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slight rigidity. The liver, spleen and kidneys could not be palpated. There was a firm, tender, irregular mass arising above the symphysis and extending to two fingerbreadths above the umbilicus. No fetal small parts could be outlined and no fetal heart was heard. Vaginal examination showed normal external genitals with marital introitus. The cervix was large, boggy, and lacerated showing definite evidence of recent trauma. Posterior to the main abdominal mass described above there was a soft, symmetrical mass about one and one-half times the normal-sized uterus, which seemed to be connected with the cervix. Only one cervical opening could be seen. Exquisite tenderness prevented an accurate determination of the relationship of the pelvi·' masses. On bimanual examination it was impossible to outline the course of the round ligaments. L
Fig. !.-Rudimenta ry horn sectioned.

red blood cells, 3,800,000; white blood cells, 11,600. Blood Wassermann was negative. Friedman test was strongly positive. Catheterized urine showed very slight trace of albumin, innumerable white blood cells with clumps, an occasional red blood cell, and no casts. An x-ray picture of the abdomen showed a small fetus, approxi· mately six months in development. After several days' observation with no change in the general condition of the patient, an examination under anesthesia was done. At this ·time the firm mass felt abdominally seemed to be definitely separated from the posterior mass in the culdesac. The latter was perhaps a little larger than the normal-sized uterus but was little if any softened. The main abdominal mass was exceedingly firm and felt more symmetrical than formerly and extended two fingerbreadths above the umbilicus. One was able to trace a band running from the anterior surface of the mass in the culdesac to the posterior wall of the firm, anterior mass. A probe passed into the cervix entered the posterior mass to the extent of its enlargement. The round ligaments could not be traced. ·

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A tentative diagnosis of extrauterine pregnancy or rudimentary horn pregnancy was made and laparotomy advised. Five hundred cubic centimeters of citrated blood were given preoperatively. Operation.-January 7, 1933, twelve days after admission to hospital. Midline incision was made extending from the symphysis to the left of and just above the umbilicus. When the peritoneal cavity was opened, moderate injection of the peritoneum was noted; and a large rounded mass somewhat eystic in nature, whose surface was covered by very tortuous hlootl vessels, was found arising from the left cornu of the normal-sized uterus. The left tube and ovary were normal and lateral to the main mass. The uterus itself was slightly larger than normal and was to the right and in the culdesac. The tulle and ovary on the right sid<· were normal. There was marked congestion around the base of the left broad ligament, while the left round ligament was laternl to the mass described above. The

Fig. 2.-Sectlon through the thinnest portion of the

w~ll

of the rudimentary horn.

broad and round ligaments on the left side were clamped, cut and tied, the left tube and ovary being removed with the rudimentary horn. The bladder reflection which was markedly distorted was dissected free from the main mass, which was attached to the left cornu of the uterus by a very small pedicle. The pedicle was clamped, cut and ligated. No cervical opening could be seen or probed. The pedicle seemed to be composed of large blood vessels and some fibrous tissue. The round and broad ligaments were sutured to the left cornu of the normal uterus and the bladder. reflection was used to cover over the raw surfaces. Tne uterus itseu was somewhat conical in shape. On the posterior surface of the uterus there was a weakened spot which was thought to be a partial perforation, perhaps the result of the attempted instrumentation, but while the muscle wall was weakened in one area, the peritoneal coat was intact. The upper abdomen showed evidence of recent generalized peritonitis. Only one cervix could be identified. In view of the wealtened spot in .the cornu of the uterus where the rudimentary horn was attached and in view of the general appearanee of the uterus it was thought best

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IN

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UTERINE HORN

253

that no further pregnancies be allowed in spite of the fac.t that the patient was without children and was only nineteen years of age. Accordingly the right tube was cut and doubly ligated with braided silk. The appendix was not investigated. The abdomen was closed in the usual manner without drainage. The patient bled for several days after operation, but at no time was there any decidual-like tissue passed. The postoperative course was uneventful and the patient was di 'charged on the fifteenth day. Subsequent follow-up examination did not reveal any menstrual irregularities. Partl•ology Report.-Gross specimen consisted of an ovoid, semicystic mass about 15 em. x 18 em. The surface was bluish gray and was covered by numerous dilated and to•·tuous veins. At the site of amputation there were numerous blood vessels, but no opening could be identified. The left tube and left ovary were intact and showed normal relationship. On 'ection of gross specimen ( l<'ig. 1) there was a laminated appearance to the wall ot' the horn. The placenta had a weblike appearance and covered the entire surfac•·· The wall was thickest at the fundus and thinnest near the site of amputation. ·rhe pedicle did not reveal any opening and seemed to consist of large blood vessels and fibrous tissue. The fetus was normal in development for a six months' fetus :1nd was not macerated. There was practically no amniotic fluid present. Microscopic examination (Fig. 2) through a portion of the wall of the rudimentary horn (magnification 20 times) showed the wall to consist chiefly of fibrous tissue rather loosely arranged. ·with van Gieson 's stain there was seen some muscle tissue with moderate hyalinization. The placenta was attached to the inner surface. DISCUSSION

Careful study of the left ovary, removed. with the rudimentary horn, failed to reveal any evidence of a corpus luteum of pregnancy. As there was no evidence of communication between the proximal end of the rudimentary horn and the uterine cavity. this was undoubtedly an instance of transmigration of the fertilized ovum or sp€'rm. Transmigration has been noted in many of the reported cases and occurred in 78 per cent of the 84 cas
Eden, T. W.:

Midwifery in the Home, Brit. M. J. 1: iW9, 1933.

Th••re has been a gradual cl1ange i.n the rclationshipR between genre will probably be a further change. New oppor· tunities are consequently arising fer the physician. Although a con~iderable amount of practice is being taken out of the physician's hands, he is becoming a consultant to the midwife. It is estimated that midwives attend from 60 to 70 per cent of all the births in England with the proportion increasing each year. Since the physidau acts in the role of consultant, more frequently his general obstfltrical efficien~.y must increase correspondingly. In comparing mortality statistics, it is found that the English mortality rate between 1926 and 1931 was 4.26 per 1,000 births, while the maternal death rate of the midwives of the Queen's Institute of Distriet Nursing during the same period was 0.42 per 1,000 births, with a total of 385,000 cases during this period. A physician was called in 26 per cent of these 385,000 eases. These cases were all delivered in the homes of the patients. FRED L. ADAIR AND L. E. ARNOLD.