Page images
PDF
EPUB

I do not know that the case just reported is one of especial value, only so far as the symptoms given might aid in the diagnosis of a future similar case. As far as treatment was concerned, I at that time knew of no operation that could have been justified under existing circumstances, nor did I know the "indicated remedy." Now, if called upon to treat a similar case, I should feel more equal to the emergency, and should depend, with all confidence, upon the application of electricity, used with sufficient intensity to destroy the life of the precocious wanderer, any good faradic battery being abundantly sufficient for that purpose.

If, however, the time should come when an accurate, differential diagnosis is possible between a strictly tubal or abdominal pregnancy, like the one just cited, and a tubo-uterine or possibly interstitial pregnancy, an illustration of which will be given under case II, the indication for treatment will be plain beyond question; namely: to kill or destroy the product of conception proven to be tubal, by the electric current; and use every legitimate means at your disposal, to facilitate the removal of the fœtus from its adjoining cavity to the womb proper, there to fulfill its mission.

CASE II. Mrs. L., a lady of lax muscular fiber, æt. 32 years, married thirteen years; the mother of four children, the youngest being three years old, consulted me September 22, 1884, at which time she complained as follows:

As

Pain in right ovarian region, extending to the hip of same side, and a general feeling of discomfort through the entire pelvic viscera. On examination, I found the uterus enlarged, tender to the touch and considerably retroflexed. The corvix was inflamed and the os, as large in diameter as an ordinary lead pencil, was full of tenacious mucus. she had missed one menstrual period, I examined her with great care, and after partially correcting the mal-position and applying a tampon of cotton, wet with a solution of quercus, alba and glycerine, dismissed her, with instructions to report in three days. At the second examination, made September 26, I thoroughly and easily explored the uterus, and found it empty; the sound entered the cervix, with the greatest ease and could be manipulated in every direction without resistance, and the examination, notwithstanding its thoroughness, was not, except in a slight degree, painful. The inflamed and sensitive condition of four days previous, having, to a great extent, disappeared, I advised hot water injections, and prescribed Actea rac., a dose every four hours, and requested her to report her condition later.

The following week gastric disturbances, similar to those noticed in

the first month of pregnancy, became somewhat annoying, but under the use of indicated remedies, and such local measures as seemed necessary, were much modified, and gradually disappeared.

About the third month, however, a suspicious swelling made itself known, more prominent to the right of the median line, and not sufficiently well defined to locate absolutely, and erratic as well, inasmuch as it would be noticeable one day and wanting the next. The breasts also began to increase in size, and, in fact, everything began to indicate, to a greater or lesser degree, the pregnant condition.

Notwithstanding all this, repeated and careful explorations of the womb failed to discover the presence of an intruder, and the symptoms above enumerated continuing, I now came to the conclusion that a tumor of some description had located to the right of the uterus, possibly attached to it, and by an enlargement and pressure had set up an irritation sufficient to elicit the existing symptoms which ordinarily would very strongly indicate the pregnant state.

This enlargement, however, varied in size so much, from one examination to another, as to make a positive diagnosis extremely difficult. So, acquainting my patient's husband with all necessary facts, I requested and obtained his consent to a consultation, and in November, we took her to Philadelphia to see Dr. C. M. Thomas. Finding the Doctor disabled by a dissecting wound of finger, and consequently unable to make the necessary examination, we called in Drs. A. R. Thomas and J. N. Mitchell, the former not excelled as a general diagnostician, and the latter a gynælogical specialist of acknowledged ability. Both made careful examinations, and both pronounced the uterus to be empty. The enlargement noted before was provokingly less noticeable than usual, and as neither of the consulting physicians felt warranted in committing themselves to a positive diagnosis, we returned home, not greatly wiser than when we came. Dr. Mitchell, intimating, however, that the location of the trouble appeared to be in the right Fallopian tube, near its junction with the womb. After returning to her home, the tumor became more prominent, and gradually it was more evident that it was becoming part of the uterine body. It was also not infrequently the seat of sharp pains. About the middle of December the patient became cognizant of a fluttering sensation similar to that first noticed about the fourth month of gestation. She became very much depressed, and suffered greatly at times from an aggravation of the old gastric troubles. I now, for the first time, began to be reasonably positive that I had a case of interstitial or extra-uterine pregnancy to deal with, and recognizing the gravity of

the case, felt that I was justified in adopting active measures for relief. Local treatment was accordingly resumed.

The womb thoroughly

[graphic][subsumed][subsumed][subsumed]

A, 08 Uleri. B, Uterine Cavity. C, Fatus in Fallopian Tube.

dilated, large tampons were placed therein; applications of caustic potash and glycerine freely made on right uterine wall, which could, before long, be noticed to encroach decidedly on the true uterine cavity, as sloughs were formed by its action. The pain caused by this treatment was considerable at times, but was never beyond the strength and courage of the patient to endure.

While the way in which the involved organ tolerated this heroic treatment was truly wonderful and commanded my admiration, it could not but daily excite my fears.

This treatment was continued, with slight variations, until February 1, when, so far as could be determined, the enlargement seemed to be a well-defined portion of the right uterine wall, and the general condition of the patient much improved.

On February 15 I was sent for shortly after midnight, and on my arrival found my patient suffering with well-marked labor pains. On examination, I discovered, well up in the uterine cavity, what proved later to be a fœtal head, for in comparatively a short time I succeeded in delivering her of a foetus weighing 4 pounds, the placental membranes following nicely soon after. An examination made at this time determined the existence of a compartment or foetal sac, which

had doubtless developed in the uterine end of the right Fallopian tube, presumably half an inch or less distant from the womb proper, but later, by development, had become an annex, so to speak, of the uterus itself, so that by gradual absorption of intervening tissue, what was at first extra-uterine became ultimately, by rupture of the dividing septum, intra-uterine pregnancy, followed naturally by labor and expulsion in a natural manner.

The hemorrhage was not greater than in many ordinary deliveries, nor was the patient's recovery marked by any especial outward symptoms. Solutions of permanganate of potash were used twice daily for ten days. A greater sense of pain and soreness was noticeable for some time through the entire abdominal viscera. By the expiration of the third month the menses reappeared, and the patient has been in her usual health from that time to this writing.

This case I diagnose as one of tubal pregnancy changed to uterine by combined natural and artificial means, with the result of saving a life which, had it been left to the unaided efforts of Nature, might, certainly, have reached a fatal termination. A case surely of unusual interest, inasmuch as it was seen to a successful issue, and that it goes to establish what is usually admitted, namely, that, under such circumstances, the womb will tolerate a more agressive treatment than the generality of practitioners have supposed, and that, too, without any undue resentment or danger.

CASE III.-On May 10, 1885, Mrs. W., a comely looking widow, æt. 40 years, of Caucasian parentage, but living in concubinage with a coal black negro, came to my office to consult me in reference to a gastric trouble, and incidentally mentioned, in the course of questioning, that she had long been a sufferer from diseases peculiar to her sex. As she was somewhat deaf and inclined to be reticent, I did not, at this time, elicit any especial symptom bearing on her female weaknesses, save that she had not menstruated for five months. She did not report the result of my prescription, and I did not see her again until the following November, six months after the visit mentioned. I was then called to the house to prescribe for a hæmorrhage, which she had wrestled with but had been unable to control, and which had prostrated her greatly. On examining her abdomen, at her request, I discovered an enlargement in the right of the hypogastrium, which was irregularly globular in form, as large as a small child's head, and hard and unyielding on pressure. The impression conveyed to my mind at the time was that it was a uterine fibroid.

The hæmorrhage for which I had been called had grown noticeably

less after sending for me, and was soon under control and the patient reassured, so that when I called the following day it had entirely ceased, and she was sufficiently comfortable to give me the following history:

In January, 1886, she had ceased to menstruate, but owing to previous irregularities this occasioned no alarm until, not long after, she began having slight pains through the womb, which continued in a bearable degree until April, when they increased to the extent of frightening her into consulting a physician, who pronounced her disease gall-stone colic, and prescribed morphia. After this she continued to take morphia ad libitum, whenever the pain was severe.

In May, she first noticed an enlargement or swelling in the abdomen, which being more pronounced over the seat of pain, excited her apprehension, and she again consulted her physician, who, after examination, pronounced her suffering from fibroid tumor of the womb, and advised her to place herself in the hospital, preparatory to having it cut out. This she fortunately refused to do, having a great dread of hospitals. Shortly after this she began to feel a throbbing through the tumor, which created an impression in her mind that possibly she might be in the family way after all. So, having lost all confidence in her last medical adviser, she sought another, who, after examination, scouted the baby idea as not tenable, and assured her positively that the trouble was undoubtedly a tumor, and the knife was the only remedy. He afterward brought counsel, and both urged the hospital and an operation, but to no avail. She was willing to undergo the operation, but refused to enter the hospital, while the physicians very wisely concluded not to operate at her home. The pains in the meanwhile having grown more and more unbearable, the morphia became more and more necessary, and was taken freely and frequently, until one day about the middle of July, her distress becoming intolerable, she took a much larger dose than ever before, and from that date to the finish she had no further throbbing or sense of pulsation in the abdominal tumor.

As near as I could ascertain, it was a month or six weeks after the cessation of motion that she was taken with a violent chill, followed by lancinating pains through the bowels, vomiting, great abdominal distension, difficulty in breathing, in fact, a reasonably good picture of a severe attack of inflammation of the peritoneum, and from such data it was obtainable from those with her at this time she was presumably a very sick woman for several weeks, but finally succceeded in regaining strength sufficient to crawl out of bed in a state of almost hopeless invalidism, a picture of emaciation, pain, feebleness, and great bodily

VOL. XXII.-3.

« PreviousContinue »