EXTRA-UTERINE PREGNANCY: OPERATION AT 266TH DAY:

RECOVERY.*

BY D. C. BOWEN, M. D.

It is not the purpose of the essayist to introduce to this Society today any novelty in the treatment of ectopic gestation, but simply to recall the great importance of early diagnosis and to emphasize the already well-known facts, in the hope that it may lead to an early recognition, or at least to a more prompt action toward the institution of the best means that are in any way promising to the mother and ofttimes the only means of saving the child. The success of the operative intervention so often depends on its early performance that the question of diagnosis becomes second only in importance to that of treatment. Lawson Tait says that all extra-uterine pregnancies are to be considered primarily tubal, and that the other varieties are developed after rupture. We will assume that this is correct, and leave the subclassification to men of like eminence and experience.

It is said that extra-uterine fetation may be produced by any condition which prevents or renders difficult the passage of the ovule to the uterus, while it does not prevent the spermatozöa reaching the ovule. This is brought about by various morbid conditions, such as adhesions from peritonitis, inflammation of the mucous coats of fallopian tubes, polypoid growths, pressure of uterine or other tumors, and that of chronic salpingitis. Tait thinks this to be the most common cause. Playfair says that a curiously large proportion of cases occur in women who have been previously sterile, or in whom a long interval of time had elapsed since last pregnancy. He also says that the progress and termination of tubal pregnancy in the majority of cases is death; produced by laceration, giving rise either to internal hemorrhage or to subsequent intense peritonitis or to septicemia. Rupture usually occurs at an early period of gestation, and, according to the best authorities, at from the fourth to twelfth week. The diagnosis of tubal pregnancy, prior to rupture, is unfortunately difficult, and no doubt that many cases end in death without any suspicion of the nature of the case, the practitioner attributing death to colic, hematoma, etc. If we are called to a case of supposed colic with symptoms of early pregnancy, in which there are irregular losses of blood, with possible discharge of membranous shreds, and abdominal pain, a careful and painstaking

* Read before the Muldraugh Hill Medical Society, December 12, 1901.

examination should be made, bearing in mind the difficult differential diagnosis, which is sometimes impossible; if the true nature of the case be made out, we are at once better able to give intelligent advice.

The treatment by laparotomy is the only one to be recommended. If there is the slightest suspicion of the existence of tubal pregnancy, based on rational and physical signs, we should on no account wait until symptoms of impending rupture have made their appearance, or until that accident has occurred, but at once procure competent assistance and remove the ovisac and contents by laparotomy. The writer hopes to further elicit discussion on this important subject by reporting the following case: J. C., colored, age thirty-four, married.. I delivered her of a living child, with forceps, May 2, 1900, and an uneventful recovery followed. The family history excellent. Having treated her husband for gonorrhea previous to their marriage, I felt quite sure that she had become infected, and, upon investigation, found that she gave a history of salpingitis, following marked symptoms of gonorrhea; otherwise history was good. On December 26, 1900, I was called and found her suffering from agonizing pelvic pains; cold extremities, face bathed with cold sweat, rapid and feeble pulse, nausea and occasional vomiting, and in a state of collapse.

Digital examination per vaginam revealed slight discharge of serum, patulous os uteri, with slight enlargement of womb; also gave a history of morning sickness and missing one menstrual period. I gave a hypodermatic injection of morphia gr., atropia o gr., applied cold pack to abdomen, hot applications to extremities, and during the two hours that I remained with her gave hypodermatic injections of strychnia and nitro-glycerine, and at the expiration of this time she had reacted sufficiently for me to leave. I left gr. of morphia to be given every three or four hours per oris as necessary to relieve the pain, also ordered cold pack continued, and to remain in the recumbent posture. Called next day and found her doing very nicely. No temperature, pulse 96, some periodic pelvic pains, and complaining of weakness. Treatment continued; patient ordered to keep perfectly quiet in bed for two or three weeks, and if symptoms returned to let me know.

This was the last that I saw of case till July 14, 1901. I heard occasionally from her through her husband, who came for medicine, saying that she was still threatened with a miscarriage. My diagnosis at the time of visit in December was rupture of the tube from tubal pregnancy, with resulting hemorrhage. After a time the case was

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thought of as a mistaken diagnosis, then passed entirely out of mind until I was called again the 14th of July, finding the intermittent pains in back and abdomen. I made a careful. examination, introducing my index and middle fingers into the vagina; came in contact with a bulging cul-de-sac. With my right hand to press uterus down into pelvis, I inserted the index finger of left hand into uterus; at the same time was able to outline the fundus as being separate from the main tumor, which lay above and to the left. No history of having passed the decidua, but said she had felt the movements of child frequently.

I was thoroughly convinced that my first opinion was correct; that I had to deal with a case of ectopic gestation, and, on calculating the time, found that she was at or about her 226th day, and that I had a fair chance of saving both mother and child if I could prolong the time, hoping that nature would give the signal for action. I told them that all was not quite right, and that we would trust nature to carry her nearer term, and that they must call me on the slightest symptom. This was the last I heard from case till August 21st; found her with the symptoms of labor rapidly approaching. I resumed the morphine treatment, hoping to postpone till I could have her prepared for the operation. I now gave them my opinion of the true nature of the case for the first time, and advised operative measures, which was readily. consented to, as I had been preparing the way for some time. I gave explicit directions in detail how to prepare patient and room for the operation, telling them that I would be back next day to meet the doctors, and that we would then be governed according to our best judgment. I asked Drs. Aud, Nusz, and Brownfield to see the case with me, which they did on the 22d, concurring in diagnosis. We set the 24th to operate, and, after the strictest precautions in the minutest details of preparing patient, room, instruments, and dressings, I, assisted by Drs. Aud, Nusz, Ligon, Brownfield, Glascock, and English, did a celio-cystotomy. After removing fetus, which, to all appearances, had been dead for a week or ten days, and about two or three gallons of foul liquor amnii, we found placenta attached to the left broad ligament, which I peeled off with my fingers without any trouble.

There was but little hemorrhage, which was controlled with hotwater douche. After cleansing sac with sterilized water, we washed out the peritoneal cavity with normal salt solution, as there had been leakage into this cavity. The sac was closed by continuous sutures, which included parietal peritoneum, leaving space for gauze drainage

at lower portion of incision; brought the abdominal muscles and skin in apposition in the usual way by interrupted sutures; applied the usual dressings and a snugly-fitting binder.

I forgot to say that on the morning of operation patient told of having passed the decidua ten days previously, and that the uterus was pushed down to the left and over the pubic arch till it was perceptible and felt much like the placenta in situ after normal delivery of baby. The patient was in a state of septic infection; temperature 100° to 101.5° F.; pulse 120 to 130. The convalescence was uneventful; pulse began to fall, and by the third day had receded to 96. Temperature by this time had become normal, and remained so throughout. In twelve days wound had healed perfectly and patient sitting up, and was able to move about by the twenty-first day and was doing light work. And now she is well, and is, to all appearances, in perfect health. NOLIN, KY.

Reports of Societies.

THE KENTUCKY SCHOOL AND HOSPITAL MEDICAL SOCIETY.* Stated Meeting, December 19, 1901, the President, William A. Jenkins, M. D., in the Chair.

Epileptiform Seizures Following an Operation for Appendicitis. Dr. J. W. Irwin: A graduate of the Kentucky School of Medicine of about a year ago consulted me two weeks ago with reference to a singular condition of his new wife. He had been married a few months, and prior to his marriage the young woman had been operated upon six or seven months previously for appendicitis. She was confined in an infirmary or private hospital at Evansville, Ind., and the proprietor of the hospital did the work. He did the operation, and, so far as life is concerned, and so far as removal of the appendix is concerned, the results are satisfactory.

About six weeks ago this woman began to develop nervous paroxysms, coming on at irregular intervals of sometimes every second day, sometimes two or three times a week. Lately they have occurred as often as three times a day. She would go into a state of unconsciousness, and while she would not fall backward, nor would she foam at * Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

the mouth, nor would she have any premonition of the attack coming on, yet there was a certain amount of rhythm, showing certain indications of epilepsy. Various remedies have been administered without relief.

The case came under my observation two weeks ago, and in an examination I found that the right ovary had been drawn away from the body of the uterus to the extent of three inches, with a mass of hardened material just below and at the bottom of the cicatrix left after the operation for appendicitis. I believe the ovary is incarcerated in the cicatrix, and by reason of the irritation incidental to the cicatrix, and also to the displaced condition of the ovary that is incarcerated, that this is the focal point of irritation; and to prove that I was correct in this matter, I made a few applications locally of equal parts of the compound tincture of iodine and pure carbolic acid, and while vesication existed there was no return of these paroxysms, of these nervous attacks, but, after the wound healed, in three or four days she had another attack. Menstruation is now upon her, and during menstruation she has had three attacks in one day, showing that the engorgement incidental to that function is causing a greater amount of excitement, and that she is undoubtedly on the verge of permanent epilepsy from the local irritation.

This case bears out one view of the cause of epilepsy, and that is an adherent prepuce. You will find a great deal written about that, perhaps a great deal too much, but it is one of the causes that might be considered analogous, and I think I shall have to refer her to the abdominal surgeon to have this ovary removed or liberated from the mass, which will cure this patient so long as the habit has not become fixed upon her. It has existed now for two months only.

Discussion. Dr. W. H. Wathen: No one can discuss a case of this kind so well as the man who has examined the patient carefully and watched the condition, and has observed the pathological condition of the organs referred to.

While the experience of abdominal surgeons in operating for epilepsy by removal of the uterine appendages where there was no disease has been abandoned because of almost universally bad results or failure to benefit the patients, we have found that where there is a local disease in the generative organs that is the cause, as it sometimes is, of epilepsy or of any form of nervous disturbance, the removal of these