A CASE OF EXTRAUTERINE PREGNANCY. DISCHARGE OF FETUS THROUGH THE POSTERIOR VAGINAL

WALL. RECOVERY.

BY

WILLIAM T. LUSK, M.D.

A. M. æt. 32, Bohemian, was admitted to ward 21 of the Bellevue Hospital, on the 25th of May, 1885. She had had three children, the last of which was born three years ago. At her third confinement she had no physician, and received no proper care. Since that time she had suffered constantly from pelvic pains. After the birth of her child she was removed to the Mt. Sinai Hospital, where she remained for a year, during which period an operation for laceration of the cervex was performed. Soon after leaving the hospital her pelvic pains returned, though she continued to work until six months previous to admission to Bellevue. From that time to the present, the pains at intervals were so severe that work became impossible. After the birth of her last child, menstruation recurred at two to three weeks' intervals, and lasted two to three days. During the month previous to her admission, a bloody discharge occurred two to three days in each week. On the day of admission, the hemorrhage was quite profuse. The patient was then seized with severe pains attended with partial collapse.

The first examination revealed a tense fluctuating tumor occupying the cul-de-sac of Douglas, which pressed the uterus upwards and forward. I saw the patient on the following day (May 26th), and pronounced the case one of fresh hematocele with the blood still in a fluid condition. On the 30th of May I examined the tumor again. It had increased in size; it still fluctuated, and extended beyond the median line toward the left side. This condition led me to suspect extrauterine pregnancy, but on puncturing the tumor with Mundé's aspirating syringe, I withdrew a quantity of nearly pure blood, so that the original diagnosis was seemingly confirmed. The tumor, however, continued to increase in size. On the 15th of June, the cervix uteri was flattened against the symphysis, and the fundus was elevated upward toward the navel. The extension of the tumor to the left side was pronounced. On introducing the sound, the uterine cavity was found to measure three inches, and the uterus was freely movable. The distinct pulsations of the vessels in the vaginal walls, together with the previous history, now convinced me that I had to deal with an extrauterine pregnancy. A small quantity of fluid was again withdrawn with a hypodermic syringe. This time the fluid was perfectly clear, and, according to Dr. Biggs'

report, contained no fibrin, a very small amount of albumin, a few leucocytes, and a considerable number of flat epithelial cells. From the negative appearances the fluid was regarded in all probability as amniotic. The faradic current was ordered on the 17th of June, to be employed twice daily, for five minutes each time, the positive pole being applied to the left side, and the negative pole to the surface of the tumor alternately through the vagina and the rectum. At this time I departed for Europe, and left the case in the care of Dr. Reginald Sayre. On June 19th, the temperature rose to 102°, and the faradic current was discontinued. On the 20th, the patient had a chill; temperature 1023°. Symptoms of mild inflammatory trouble continued until July 2d, when the axillary temperature sank to 953°, and the rectal temperature ranged between 963 and 98°. With this fall the patient expressed herself as almost free from pain, and as feeling very comfortable. The pulse ranged from 90 to 120, but was very thin and compressible. A slight diarrhea developed. The next day the temperature rose to 100°, and the diarrhea became almost continuous. On the 8th of July, the diarrhea had ceased, but the temperature rose to 1033°. On the 9th, the patient vomited and the high temperature continued. On the 10th, the temperature reached 104°. Owing to the feebleness of the pulse, stimulants were freely administered. From the 10th to the 15th inst., the temperature ranged between 100° and 1024°. On the 15th, the nurse observed a swelling projecting from the posterior vaginal wall. Dr. Sayre was summoned, and discovered an opening through which protruded a fetal head. After enlarging the opening with his finger, he removed a fetus measuring seven and one-eighth inches in length, with about eight inches of cord attached. The fetus was partially decomposed and the odor from the sac was extremely fetid. Dr. Sayre then inserted the half-hand into the sac and removed the placenta piecemeal. The sac-walls were thick and were everywhere smooth except at the placental attachment. No bleeding ensued upon the removal of the placenta. After the manipulations mentioned, the patient was extremely feeble. The pulse was 144 and the respirations were 58. Six hypodermic injections of whiskey were employed, together with a hypodermic containing Magendie's sol. morph. Miij.; ext. dig. fl., gtt. ij., and atropia, 1 gr. Owing to the feebleness of the patient no disinfectants were employed for several hours.

From this time onward, Dr. Sayre combated the weakness of the heart with stimulants and digitalis. Many times the patient became so feeble that recovery seemed impossible, but with judicious care and watching, the asthenic symptoms gradually disappeared, so that by the middle of September she was able to sit up, and by the 1st of October returned home cured.

In considering the foregoing history, we find, as is not uncommon in cases of extrauterine pregnancy, a prolonged precedent pelvic inflammation. At the first examination, hematocele,

due probably to partial rupture of the sac, existed as a complication. At the time of the application of the faradic current I believe the fetus was still living. The continued rapid growth of the tumor, and the marked pulsation of the vaginal vessels exclude the theory that the fetus had perished. The introduction of the needle into the amniotic sac was probably the cause of the subsequent putridity of the fetus and the sac-contents. The final recovery of the patient was doubtless due to the good judgment of Dr. Sayre in the after-treatment. Disinfectant injections were employed daily, but were never pushed from theoretical grounds, when contra-indicated by the patient's condition. At times the patient was so feeble that stimulants had to be administered by a dropper, deglutition of any quantity of fluid at one time being impossible.

AN OBSCURE CASE OF ABDOMINAL GESTATION, WITH REMARKS BEARING PARTICULARLY ON TIMELY DIAGNOSIS AND TREATMENT.

BY

EGBERT H. GRANDIN, M.D.

Obstetric Surgeon to Maternity Hospital; Instructor in Gynecology, New York Polyclinic.

CASES of abdominal gestation are rarities, and correct and timely diagnosis of this condition is exceptional. Bandl' tells us that out of sixty thousand obstetrical and gynecological cases admitted to Karl Braun's Clinic, in the Vienna General Hospital, only five were cases of extrauterine gestation; but this statement, whilst true of this particular clinic, makes the condition rarer than in reality it is, and requires modification in the light of more recent researches. Garrigues, in preparing a paper on the subject of extrauterine pregnancy, carefully consulted the literature, and reached the conclusion that, while the impression is general, and the statement is made in our textbooks that extrauterine pregnancy is rare, it is not by any

1 Hart and Barbour, "Manual of Gynecology," p. 548.

2 Trans. Am. Gyn. Society, vol. 7.

means an uncommon abnormality when compared with many other abnormalties of gestation. He found, for instance, nearly two hundred cases recorded within less than four years. These data concern all varieties of extrauterine gestation, however, and so a single variety is still deserving of the name-rarity, and we possess in this fact one reason why correct diagnosis is exceptional. Further, when we consider the means at our command for diagnosis, as stated in our text-books, and when we remember the factors which almost infallibly tend to lead the physician towards error, this becomes pardonable and ceases to be a reproach, although the incentive towards formulating further means towards correct and timely diagnosis becomes all the stronger. I cannot more forcibly instance the obscurity surrounding diagnosis than by citing, as typical of what ordinarily happens, the following case,' in the words of the reporter, Goodell of Philadelphia: "The second case was one of ventral fetation, which occurred in the practice of Dr. S. Perkins, of West Philadelphia, and which I saw in consultation in the second month. It was also seen later by Dr. Parry, and it led him to write his most excellent book on the subject. Several eminent men of Philadelphia saw the patient. Two of them diagnosticated pelvic cellulitis. At the time of my visit I believed it to be a case of pelvic peritonitis. Some months later, Dr. Parry was called in; the same day he came into my office and said it was a case of normal pregnancy, and laughed greatly at my blunder. But I said in reply, I am sure there is something abnormal there. As the child died and labor did not come on, I was again called in, and made up my mind that it was a case of pregnancy in a retroflexed womb. But on the next day it suddenly flashed across my mind that it was a case of extrauterine fetation." In other words, here was a case watched from its inception by careful and eminent men, with the result that cellulitis, peritonitis, normal pregnancy, pregnancy in a retroflexed uterus were the changes rung on diagnosis before the correct note was struck.

"Almost

Such an eminent authority as Robert Barnes says:" all the cases in which this form of gestation was suspected, which have come under our observation, turned out to be ovarian cysts." Playfair says: "The diagnosis of abdominal ges1 Trans. Am. Gyn. Society, vol. 7, p. 239.

2.44

3

System of Obstetric Medicine and Surgery." 1885. 3 "System of Midwifery" (Harris), 1885.

2

tation is by no means as easy as might be thought, and the most experienced practitioners have been mistaken with regard to it.” Cazeaux says: "Finally, when by the usual signs we have become assured of the existence of pregnancy, and we suspect that it is extrauterine, the diagnosis will be reduced to a certainty if we can determine the capital point, which is that the uterus is empty." Schroeder says: " or if there be an abdominal pregnancy, it is generally easy in the first months to make sure of an extrauterine tumor, whilst the diagnosis of pregnancy is frequently involved in difficulties. At a later period the reverse is the case. .. Pregnancy can easily be diagnosed, but to show that the fetus is outside the uterus may be very difficult." Thomas says: "The keynote to successful treatment in this formidable class of cases is diagnosis, and diagnosis not late, but early, not approximate in its character, but to a great degree certain. . . . Even after fetal movements, the fetal heart, and the precious results of abdominal palpation put themselves at our disposal, accurate diagnosis is often far from easy; for a uterus bicorporeus, or double uterus, may exist one being empty and the other full; a very thin-walled uterus may, while containing the child, give to the palpating hands the impression that nothing but the abdominal walls can possibly intervene between them and the fetal body; or both normal and extrauterine pregnancy may have advanced simultaneously to full term, the extrauterine fetus, as in the well-known case of Dr. Pollak, being much the more generously nourished of the two."

The above extracts from authoritative sources sufficiently prove, in the first place, the assertion that diagnosis is difficult, and, in the second place, that diagnosis is believed only to be possible by differentiating the body of the uterus from the abdominal gestation sac, or, this failing, by proving the uterus empty by means of the sound. Indeed, the difficulty in diagnosis hinges on the double fact that we are first called upon to prove the existence of pregnancy, and then to prove that the embryo is developing outside of the uterus. Now, the classical rational signs of pregnancy are, as a rule, so obscured in the presence of an ectopic gestation, and the physical signs are so modified, that, even though careful inquiry and examination may lead us to "Theoretical and Practical Midwifery," 1878.

2" Manual of Midwifery," 1873.

3 T. Gaillard Thomas: "Extrauterine Pregnancy." ("Trans. Am. Gyn. Society," vol. 9.)