course of the case cannot be given. From the rapid clearing up of the urine, however, recovery is a safe assumption, provided there is no further development of the parasites in the blood.

I take pleasure in expressing my thanks to Dr. W. E. Fischel for his interest and kind assistance in the care of this case.

REFERENCES.

1 The Malarial Fevers, 1897.

2 Die Bright'sche Krankheit, 1851.

3 Krankheiten des Harnapparates, Ziemssen's Handbuch, 1875.

4 Archiv. de Phys. Norm. et Path., 1882.

5 Am. Med. Assn., 1880.

6 Am. Jour. Med. Sci., 1884.

7 Med. Rec., 1887.

s Pathol. u. Ther. d. Nieren-Krankheiten, 1886.

9 Die Erkrankungen der Nieren, 1902.

10 Das Wechselfieber im Kindersalter. Jahrb. f. Kinderheilkunde N. F. 6.

THE DIAGNOSIS OF TUBAL PREGNANCY BEFORE RUPTURE.*

BY GEORGE GELLHORN, M.D.

I take pleasure in demonstrating to you a few specimens which are of general interest from a diagnostic point of view.

The vast majority of cases of extra-uterine pregnancy are not discovered until the sudden onset of internal hemorrhage places the patient in immediate danger of death and only too often frustrates even our speediest efforts toward operation. It is, therefore, of the utmost importance that a correct diagnosis be made before the catastrophe occurs, and I believe that, if the general practitioner would but bear in mind the possibility of ectopic gestation, this anomaly would be detected at an earlier date and more often than has been done heretofore. The very history of

extra-uterine pregnancy will bear me out.

Fifteen years ago, this condition was considered to be extremely rare. but since such authorities as Werth, Veit, Webster and others have persistently and impressively called the attention of the profession to it, the number of cases of extra-uterine pregnancy continued to increase, and to-day we are not far from the truth if we assume that about four per cent of all gynecologic patients belong to this class.

There is a large group of cases in which the abnormal insertion of the ovum in the Fallopian tube produces no clinical symptoms of any kind. Such patients not even suspecting that they are pregnant, do not consult any physician. In other instances, the

*Read before the Alumni Association of the Medical Department of Washington University, Feb. 12, 1906.

symptoms point toward a miscarriage. The menstruation has been missed once, and at about the time of the next period, a more or less prolonged flow of blood from the vagina occurs with or without premonitory pain in the abdomen. If, in addition, membranes are expelled from the uterus, both patient and physician suspect a miscarriage. The usual internal medicines are administered, yet the hemorrhage only increases in intensity.

It was in this stage that Case I. was referred to me. The patient, 39 years of age, has had three confinements and three miscarriages, the last of these four years ago. Since then she was in excellent health. Menstruation appeared first when she was thirteen years old, was always regular and occurred last, Dec. 24, 1903. The January menstruation was delayed, yet there were no subjective signs of pregnancy. February 6, 1904, she was suddenly taken ill, on the street, with severe abdominal pain. Similar attacks, lasting one-half hour, occurred several times during the ensuing days and were associated twice with fainting spells. The family physician was called in, three days after the first attack, and treated the case at first as one of appendicitis. When, however, in the course of a few days, a uterine hemorrhage with expulsion of membranes set in, he diagnosed a miscarriage and turned the case over to me. Naturally, my first thought was of extra-uterine pregnancy, but although I examined the patient, a rather stout woman, several times every day, I was unable to palpate any tubal tumor which would justify my suspicion. I, therefore, accepted the diagnosis: abortus, complicated, perhaps, by appendicitis, and, as the flow did not abate under the usual treatment, I inserted iodoform gauze into the uterus in order to bring about the spontaneous expulsion of any remnants of the ovum that may have kept up the bleeding. However, upon removal of the gauze, the uterine cavity was found to be empty, but on the evening of the same day, I found, for the first time, an oval tumor in the place of the right tube. Dr. Mudd and Dr. Ehrenfest whom I called in

consultation agreed with me on the diagnosis: ectopic pregnancy, and on Feb. 28, 1904, operation was performed from which the patient speedily recovered perfect health.

The pregnant tube itself was embedded in celloidin for microscopic purposes, but I show you here an accurate drawing. You will see the tube greatly distended, but without any external rupture. Hemorrhages have occurred inside the ovum, distending the latter until its capsule broke. The blood clots filled the entire lumen and protruded from the widely gaping fimbriated end. For the sake of clearness, this blood clot is not presented in the drawing. There was a small cyst, separated from the lumen of the tube, with an embryo-like body the exact nature of which has not yet been determined. (See Figure 4.)

A popular method of diagnosing extra-uterine pregnancy is the introduction of a sound or curette in order to demonstrate the absence of an ovum inside the uterine cavity. This is a very dangerous practice as the irritation by these instruments may cause uterine and tubal contractions and frequently produce immediate rupture. It should never be done, unless everything is prepared for operation. Such a case formed the subject of my inaugural dissertation in 1894. Prof. Hofmeier of Wurzburg had a case of unruptured tubal pregnancy upon the table, ready for laparotomy. In order to secure some of the uterine decidua, he very cautiously curetted the uterus, performed laparotomy a few minutes later and found the pelvic cavity filled with fresh blood. The short interval had sufficed for a rupture with abundant hemorrhage.

Moreover, examination with a sound is quite uncertain, as an ovum may well be in the uterus without being detected. I am, also, far from recommending for general use the packing of the uterus with gauze, as practiced in my case, although the result happened not to be disastrous.

The history of Case II. presented certain features which pointed toward the correct diagnosis. The young woman, 26 years of

The

age, had been operated upon for appendicitis, six years ago. convalescence, at that time, had apparently not been undisturbed, at any rate, a second operation had to be performed on account of the formation of a wound abscess. The patient has been in ill-health ever since. One year prior to this operation, she had acquired a displacement of the uterus, due to a fall from horseback. She began menstruating at the age of 15, the menstruation was always regular and occurred last, May 20, 1905. Early in June, 1905, she was married and when I first saw her, exactly six weeks later, the period had not yet reappeared. Ten days after the wedding, nausea commenced, and a little later, the breasts began to swell. About three weeks previous to my examination, she commenced having severe attacks of colicky pains, very much like, but more intense, than the cramps she had experienced ever since the operation for appendicitis. These pains were located in the right iliac and inguinal regions and did not yield to any treatment. It seemed advisable to make an examination under general anesthesia as the patient was excessively nervous, and the general appearance of the case was of such gravity that an immediate decision seemed imperative. The uterus was found slightly enlarged and softened, and lying in mobile retroversion. To the right of the uterus, there was a tumor of the size of a man's thumb, corresponding in location to the right tube. This tumor was bent and totally immovable, it extended rather high up towards the appendiceal region as if it were fixed in its position by adhesions. The connection between tumor and uterus could not clearly be mapped out. The ovary was not palpable on this side. The left tube and ovary were normal. The cervix and vagina showed no discoloration.

For reasons of which I shall speak later, I made the diagnosis of ectopic pregnancy. I at once transferred the patient to the hospital and after allowing sufficient time for recovery from the first narcosis, I performed laparotomy on July 26, 1905. Upon opening the peritoneal cavity, the omentum was found markedly