[To be Continued.]

REPORT OF A CASE OF EXTRA-UTERINE PREGNANCY.

BY H. J. LEE, M. D., CLEVELAND, OHIO.

The following case came under my care during my term of service in the wards of Charity Hospital in this city. Mrs. D., age thirty-five, married, one child two years of age, was admitted to the hospital July 14, 1885, with the following history: She had always enjoyed good health, and there was no history of uterine disease. She menstruated about the first of April, 1885, did not menstruate in May, and supposed herself pregnant, as she had always been regular before, and during the latter part of May she had considerable nausea and other symptoms of pregnancy. About the first of June, while in church, she was taken with a severe hemorrhage. She was taken home and a physician called, who examined her and decided from the symptoms and history that she had had a miscarriage. There was very little hemorrhage after she arrived home, in fact very little at any subsequent time, but she did not recover well, had some pains in the abdomen, and she said had some fever all the time. Not getting on well, as she and her friends thought, it was decided to change physicians, which was done. The second physician concurred in the diagnosis of the first, and treated her evidently on the expectant plan, as any one would be compelled to do, owing to the difficulty of making a correct diagnosis at such an early stage. After a time, there being no improvement, she decided to go to the hospital. On admission she was quite emaciated and had an anaemic appearance; her temperature was about 99° to 100° in the morning and 100° to 102° in the evening. There was considerable tenderness in the right iliac region, extending into the hypogastric region. Uterus was not felt to be at all enlarged, but the os was patulous. There was an enlargement to the right of the uterus. This could be felt both externally and through the vagina; was of an irregular outline, and quite tense and tender upon pressure. A sound was introduced into the uterus and passed in about three inches and was deflected to the left quite perceptibly. It did not appear quite certain that there was nothing in the uterus, and in view of the history of the case it seemed justifiable to explore the cavity. Accordingly a good sized sponge tent was introduced and allowed to remain twenty-four hours, when it was removed and the uterine cavity explored with purely negative results. The patient had now been under observation over a week, and attempts made to improve her general condition with tonics and nutritious diet, but without success. Her temperature continued about 101° most of the time. A positive diagnosis had not been made, though it seemed that about everything could be excluded except extra-uterine pregnancy. At this juncture Dr. W. J. Scott was asked to see the patient. He did so and made a very careful examination, and gave it as his opinion the case was one of extra-uterine pregnancy. The next day Dr. Dudley P. Allen was called in consultation with Dr. Scott and myself. Dr. Allen's examination was careful and exhaustive, and at its close he gave it as his opinion that while there were some obscure points, the most probable conclusion was that the case was one of extra-uterine fœtation.

Having all arrived at this conclusion, independently of each other, it was agreed that as there was some obscurity in the case, and also that in the event of there being a fœtus outside of the uterus it had now advanced to about the fourth month of gestation; consequently the most favorable time for the employment of the electric current had passed. In view of these facts, and also of the fact that exploratory incisions are attended with comparatively little danger, it was decided to make an exploratory incision and determine what was the condition of things. If a fœtus was found remove it if possible. If the trouble was something that could not be removed, the incision could be closed and the patient probably in no wise injured. Dr. Allen was asked to operate, and on the sixth of August the operation was performed. There were present, Dr. Allen, Dr. Scott, Dr. Millikin and the house staff. The anæsthetic was administered, and before commencing the operation an aspirator needle of good size was introduced into the tumor through the vagina. Upon exhausting the air no fluid was obtained, but upon partially withdrawing the needle about a drachm of clear serum was obtained, which was thought to be peritoneal fluid. It was then decided to proceed with the operation. An incision was made about an inch above and parallel to Poupart's ligament, commencing at the anterior superior spinous process of the ilium, and terminating at the outer margin of the rectus muscle.

On opening the abdomen an adherent mass was found closely attached to the coecum. Strong bands also passed from the mass toward the symphysis pubis. In order to reach the mass more fully, and also the annexes of the uterus, the adhesions to the pubis were divided between ligatures. This having been done, it was still found to be impossible to detach the intestines which were closely adherent to the coecum, and nothing abnormal could be found in connection with the uterus. Failing to discover the cause of the adhesions about the coecum from the abdominal cavity, it was thought this might be accomplished by separating the peritoneum from the iliac fossa, and reaching the coecum from the outer and posterior side. This separation was continued until it could be carried no further without great danger of wounding the external iliac vessels, which were exposed for several inches. Although nothing further than a closely adherent mass of intestines had been found, an attempt to separate which had been carried to the limit of safety, and the cause of the malady had not been demonstrated with entire satisfaction, it was deemed best to close the abdominal incision, which was accordingly done.

The subsequent history of the cure was as favorable as could be desired. The wound united very readily. The temperature never rose above 103°, and was only at that point for a few hours; most of the time was 100° to 101.5°. Two weeks after the operation temperature was normal, a point it had not reached since her admission, and probably not for some time previous.

Patient was examined September 8; the tumor was found to be considerably diminished in size, and tenderness almost entirely disappeared. She had apparently gained in weight, and expressed herself as feeling well. She was discharged from the hospital September 9. On the tenth of October she again presented herself, according to agreement, and was examined by Dr. Scott, Dr. Allen and myself. The tumor had entirely disappeared, only a slight thickening of the tissues remaining, the uterus had resumed its normal position, and the patient, to all appearances, was as well as ever.

I have reported this case as one of extra-uterine pregnancy, and yet it will be seen by the report that the existence of that condition was not demonstrated at the operation, but it seems to me that the history of the case, both prior and subsequent to the operation, demonstrates pretty conclusively that it could be nothing else. Both the gentlemen who saw the case before operation were of the opinion that everything could be excluded except a collection of fluid, disease of the coecum and extra-uterine pregnancy, and to my mind (and the gentlemen who were called in consultation have expressed themselves in the same manner) the operation and the result of it excludes everything except the last mentioned condition. It may be said that in the treatment of the case less severe measures should first have been tried; that the electric current should have been employed before resorting to an operation. This subject was fully discussed, and the decision against the employment of electricity was unanimous, from the fact that the most favorable time for its employment had passed and the time had arrived when any further delay was dangerous. Then the danger from an exploratory incision is so small that it seemed to be more than counterbalanced by the knowledge that would be obtained by it. If an exploratory incision was made we would then be better able to tell what we had to deal with, and would also be in a position to deal with whatever was found in the most effectual manner, and it was thought that the most certain means of cure should be employed first and the patient not be subjected to the danger of delay in order that less certain methods might first be tried; also the high temperature seemed to render any delay more dangerous. The incision described was employed because it seemed that the tumor could be more easily reached and removed by means of it than by means of the central one. When, however, the mass was reached it was found to be so firmly attached to the cœcum by strong adhesions that it was absolutely immoveable. Under these circumstances it was decided that it would be unwise to attempt its removal, consequently the wound was closed and the operation desisted from. The subsequent history was all that could be desired, or could, under any circumstances, have been expected.

I think the most probable explanation of the disappearance of the tumor is this: The case was one of extra-uterine pregnancy of the abdominal variety, the ovum became attached to the peritoneum and a connective tissue proliferation was set up which surrounded it with a vascular sack, the walls of which kept pace with the growth of the ovum, and as they extended into the abdominal cavity formed adhesions to the cœcum, intestines, and other parts in the vicinity. During the operation these adhesions were ligated and divided, and in consequence the nutrition of the ovum was entirely cut off, and death and absorption was the result.