Second-Sudden, severe cramps in the pelvis, and Ordinarily the patient considers herself pregnant, has the usual subjective symptoms and may suffer from slight pains in the ovarian region (Williams). The menses were suppressed in 43% of the cases of Martin and others. In many cases the first manifestation of an abnormal pregnancy is the sudden occurrence of intense pain in one or other ovarian region, followed by faintings and collapse. This signifies tubal abortion or rupture. In cases of tubal abortion the patient usually soon rallies, but if rupture has occurred, the symptoms are more severe-collapse, pallor, and pain in the lower abdomen and sub-normal temperature being present. In cases that become infected, later, with pyogenic bacteria, the temperature may be from 100° F. to 102 F., but this is not an early symptom. An examination of the blood shows diminution of the red blood corpuscles and of the hemoglobin. Bi-manual, vaginal and rectal examinations frequently reveal the presence of a large fluctuating mass which fills more or less of the pelvic cavity. In case of doubt a vaginal section into the cul-de-sac of Douglas will often reveal the presence of blood. A secondary abdominal pregnancy may result if the patient survives the rupture of a tubal pregnancy, provided the placenta has not been detached too extensively. In these cases the usual symptoms of pregnancy persist, but the patient feels more pain, due principally to the pulling apart of the adhesions which have formed between the sac and the adjoining abominal organs. If a secondary abdominal pregnancy or an uninterrupted tubal gestation goes on to full term, false labor sets in associated with distinct pains similar to those in the early stage of normal labor. False labor may last from a few hours to several days and is soon followed by the death of the child. After the death of the foetus the circulation in the placenta gradually ceases, the amniotic fluid is absorbed and the sac of the foetus retracts and occupies a smaller space than formerly. Then the mass may remain stationary in size for a number of years. The foetus may undergo any of the changes previously mentioned. Combined and Multiple Pregnancy: Twenty-two out of 500 cases of tubal pregnancy collected by Parry were complicated by a co-existing intra-uterine pregnancy. Twin and triplet tubal gestations have been reported. Repeated Tubal Pregnancy: The case I wish to report belongs to this class. Primrose in 1594 (according to Parry) was the first person to describe such a condition. With the increased employment of abdominal surgery, the abnormality has been noticed more frequently. Pestalozza collected 111 cases. The time intervening between the pregnancy varies from a few months to several years. In my case the interval between the two tubal pregnancies was about 19 months. Diagnosis: An unilateral tubal tumor, found in a patient giving the usual subjective and some of the objective symptoms of pregnancy would indicate an ectopic gestation, especially if the patient has been sterile for a number of years. The tubal tumor is soft and doughy and corresponds roughly in size to the supposed duration of pregnancy. The unruptured pregnant tube may be mistaken for a retroflexed pregnant uterus. A careful, bi-manual, vaginal and rectal examination of the uterus and tubes will usually enable one to differentiate this condition from uterine abortions. The discharge of uterine decidua associated with tubal enlargement gives strong presumptive evidence of tubal pregnancy, but occasionally the uterine decidua has been cast off at an early period and been replaced by normal endometrium by the time the patient is examined. Tubal rupture or abortion may be suspected if the patient complains of pain in the lower abdomen, and faintness and shows symptoms of more or less collapse, especially if one can elicit a history pointing to a pregnancy. If rapid recovery from collapse occurs the probabiliities are that a tubal abortion has taken place. The patient may be seen some time after she has recovered. from the primary shock, due to abortion or rupture. In such cases vaginal and bi-manual examination will show a mass on one side of the uterus which is usually mistaken for pelvic inflammation. A fluctuating tumor is sometimes felt posterior and lateral to the uterus. Vaginal exploratory incision may be resorted to in case of doubt. This will reveal the presence of a dark, bloody fluid. After ectopic gestation has reached full term the diagnosis is comparatively easy and is based upon a history of pregnancy followed by false labor pains and a gradual decrease in the size of the abdomen. The uterus is displaced by a large tumor in which the outlines of the child can occasonally be distinguished. Treatment: As soon as an unruptured tubal pregnancy is diagnosed, a laparatomy for its removal is indicated to avoid the danger to the patient from rupture of the tube and hemorrhage. In 1883 Tait performed the first laparotomy for the purpose of checking hemorrhage from a ruptured tubal pregnancy. Schauta found, after a careful study of literature on the subject, that 123 cases operated upon showed a mortality of 5.7%, while 121 cases treated wit hout surgical intervention presented a mortality of 88.9% For the majority of cases an abdominal incision is preferable to operating through the vagina, because of the free exposure of the field of operation. The tubal mass is clamped on either side by long forceps. The hemorrhage being thus controlled, the blood is swabbed out, ligatures applied and the mass removed. If the patient's condition justifies it, and the uterine appendages on the opposite side are diseased, they should be removed. The abdominal cavity may then be carefully flushed out with warm normal salt solution to remove all blood clots. Subcutaneous or intravenous injection of the same solution may be used in desperate cases to prevent shock. Kelly and others claim good results in the treatment of pelvic hematoma by making an incision through the vaginal fornix, evacuating the blood and diseased tissue and packing with sterile gauze. In the later months the treatment of ectopic gestation differs according as the foetus is alive or dead. In a secondary abnormal pregnancy the child usually lies in the peritoneal cavity inclosed in a sac made up of foetal membranes and surrounded by adhesions; the placenta being usually within the tube or broadly implanted on the pelvic floor. Prompt laparotomy in these cases to avoid the danger to the mother of sudden severe hemorrhage, is recommended by Williams. As a rule, in advanced cases, the complete removal of the gestation sac is difficult and can only be done by performing a hysterectomy. When it becomes evident that an attempt to completely remove the placenta would endanger the life of the patient, the sac should be incised, the placenta being avoided and the foetus removed. In a case of this kind which I assisted Fr. F. Henrotin operate (in the Chicago Policlinic in 1896) after removing the child, which was fully developed, but dead, he sutured the margins of the sac to the abdominal wound and put in a large Mikulicz drain. The patient made a good recovery, although she had to remain in the hospital for about six weeks. The use of modern aseptic methods of operating has reduced the mortality when the child is still alive from 93% to 31%. The death of the foetus renders the operation much less dangerous to the mother. Some authorities, therefore, recommend the injection of aboutgr. of morphine sulphate into the foetal sac which, it is stated, is sufficient to kill the foetus, but does not affect the mother. The operation should be delayed for six or eight weeks after the death of the foetus in order to allow the maternal blood spaces in the placenta to become obliterated, thus facilitating its removal without hemorrhage. In such cases, however, should the patient develop any dangerous symptoms, immediate operation is indicated. Case of Repeated Tubal Pregnancy: August 19, 1902, I was first called to see patient. The following is briefly the history of the case: Mrs. C., married, age 32, mother of one child, a boy 12 years of age. No normal pregnancy since. About one month previously was taken with severe pain in lower abdomen. She had been treated medically without any, except temporary, relief. The temperature was at times as high as 102°. A bi-manual pelvic examination showed a mass in the region of the right tube which was quite painful on pressure. I advised operation and patient was sent to the hospital and operated August 21, 1902, by Dr H. D. Niles and myself. The right tube was ruptured and incorporated in an inflammatory mass of exudate. Large blood clots were in the abdominal cavity. The right tube and ovary was removed, normal salt solution was given the patient sub-cutaneously while she was on the operating table. She made a very satisfactory recovery and left the hospital September 6th, two weeks after the operation. Her health was good for over a year and a half. March 22, 1904, I was again called to see her. She complained of pain in the lower part of the abdomen and there was a discharge of blood from the uterus, and she gave rather indefinite symptoms of pregnancy. The pain persisting, I made a pelvic examination March 28, 1904, and a mass was found in region of left tube. Temperature normal or slightly below. Ectopic tubal pregnancy being suspected, I again advised her to go to the hospital and on March 29, 1904, I, assisted by Dr. Jackson, did a second laparotomy on her. I removed the left Fallopian tube, but did not remove the left ovary. The left tube was ruptured about the middle and there was considerable black clotted blood in the peritoneal cavity, which was removed by thoroughly flushing with warm normal salt solution. The patient again made a satisfactory recovery and left the hospital in three weeks. In conclusion I wish to emphasize the following points: (2) Do not depend on the patient's statements entirely, but make a thorough pelvic examination. (3) Operate promptly. References: Will!ams' Obstetrics; M. Herzog, F, Henrotin, International Text Book of Surgery; Kelly's Operative Gynecology; Pryor's Gynecology. VOMITING IN TUBERCULOSIS. By DANIEL S. NEUMAN, M. D. Denver. For the proper rational therapeutics in vomiting of tubercu losis, one must carefully analyze the cause of its production. Vomiting in itself is only a symptom of some morbid process and should be treated according to the cause. Taking into consideration the fact that the already lessened vitality of the tubercular patient demands a proper amount of nourishment, which is impossible at the time vomiting occurs, it has to be controlled as soon as possible, as it has a demoralizing effect on a patient, and prevents a good many, from fear of its occurrence, from eating a proper amount of food. It is my intention carefully to separate the causes of its production and give its differential diagnosis and treatment. |