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notwithstanding its wider range of application, can not be compared with those attending the operation of laparotomy. Each principle, however, has its sphere of usefulness, and the seasonable application of electricity, as indicated by the conclusions of careful diagnosis, can not fail in the future to yield the most encouraging clinical results.
It should unquestionably be the rule, in all cases of extrauterine gestation seen in the earlier months, to destroy the life of the fœtus, and, even in cases where this condition is suspected but the diagnosis is open to doubt, to apply electricity, which, for safety and certainty, is emphatically the remedy. With this principle more widely recognized, there will be fewer instances demanding a resort to the graver procedure of laparotomy, and it is to be hoped that the matter of diagnosis and the employment of this mode of treatment may eventually become so accurate and effectual that there will be no occasion for the latter operation.
A word may now be added with regard to the etiology and mechanical philosophy of extra-uterine pregnancy, points which I need scarcely say are difficult of explanation. The belief has become generally accepted that women with long-enforced sterility after fruitfulness are more prone to ectopic gestation than those passing through the fruitful period of their lives in the regular exercise of their procreative functions; but exactly why a certain number of widows should be more liable to it than an equal number of married women, no satisfactory reason has as yet been assigned and probably never will be. I think, myself, that the explanation is to be found in backward displacements of the uterus.
I maintain that, in retroversion, and especially in retrolateroversions of the organ, one ovary is often dragged down and fixed, with a corresponding displacement of the Fallopian tube, at a lower plane in the pelvis than that of the same structures on the opposite side, and that, as a result of such malposition, there is necessarily more or less rolling or turning of the uterus to the affected side. By this form of displacement, not only is the axis of the uterus placed on a line horizontal with
that of the vagina, but the entrance into the uterus of the Fallopian tube on the same side is depressed to a lower level than the opposite one. This change of relationships in the parts and in their aptitudes, as regards the cervical canal, the plane of the cavity of the uterus, and the utero-tubal orifice, is highly favorable to the entrance of the spermatozoa and their migration in a continuous line. In the reversed order of relationships of the same structures, and from the same anatomical considerations, the aptitude of the affected Fallopian tube, in its lower or fimbriated extremity, to receive and to convey the ova from the corresponding ovary, is in a like degree diminished. From the movements, then, of the spermatozoa out of the vagina, which are almost unopposed by physical obstructions and the operation of gravity, and of the ova coming from the corresponding prolapsed and fixed ovary almost completely opposed by the law of gravity, it is easy to see that the chances, mechanically considered, are altogether in favor of the former reaching the depressed utero-tubal orifice instead of the elevated one, and of falling into the Fallopian tube itself, as into a deep well, to meet, at some point in their descent (perhaps in the fimbriated extremity of the tube or upon the surface of the corresponding ovary), an ascending or stationary ovum or ova ready in some one of these localities for the impress of fructification, or conception, and gestation. To these pathologico-physiological conditions of the uterus and its annexa, with the physical phenomena of abnormity regarding the performance of their functions pointed out, may we not reasonably ascribe the occurrence of ectopic gestation, rather than to the length of time of widowhood after fruitfulness, the latter itself presupposing the sequelae of retro-lateroversion, the first link in the chain of morbid results?
What the force is, inherent in the two essential elements to conception, to insure their movements independently of natural laws and to impart the spark of life when their contact is effected in situations other than the uterine cavity, I do not pretend to know. This remains for the physiologist to explain. But, as proof of the possibility of the spermatozoa, in their migrations in the vagina and uterus, surmounting seemingly the
gravest obstacles in reaching their usual destination in the latter organ, it is only necessary to refer to the well-attested instances on record of impregnation taking place without rupture of the hymen, among which are the notable examples recently cited by Professor Karl Braun. I have myself seen extraordinary instances of their power to accomplish their work of impregnation in the face of the greatest obstacles. In one case in my practice, which I now recall, there was a continuous flow of urine from the os uteri, arising from a vesico-utero-cervical fistula situated high up. Here they stemmed the opposing current of urine, so to speak, and reached their destination in the cavity of the uterus, with the result of conception, gestation, and safe delivery of a child. In another case which I saw with Sir Spencer Wells in Heidelberg, in the autumn of 1874, in the practice of the late Professor Gustav Simon, a vesico-vaginal fistula, complicated with stenosis of the vagina, had been operated upon by this eminent surgeon for incontinence of urine, a year or two before, by shutting up the mouth of the vagina (kolpokleisis) about half an inch behind the meatus urinarius. The operation was successful, except that an orifice of the size of a cambric needle was left, and, strange as it may seem, the spermatozoa entered through this minute fistulous tract, traversed the vagina, though stenosed and acting as the receptacle of the urine from the bladder, and finally made their entrance through the os uteri into the cavity of the organ. The result was conception and gestation; but a sad termination, as might well be imagined, attended the labor. In both of these cases, there was marked retroversion of the uterus. This digression may be thought irrelevant, but the facts presented are interesting, I think, in connection with my subject, as showing some of the possibilities of normal pregnancy under circumstances seemingly but little less difficult of explanation than those overhanging the causation of extra-uterine gestation.
I shall now present the histories in detail of my two cases of extra-uterine pregnancy, with their treatment and results.
CASE I-Right Tubal Pregnancy, end of the Twelfth Week; Rupture of Cyst; Profuse Hamorrhage; Laparotomy on the
Thirteenth Day; Death.-This case I first saw, August 16, 1884, in consultation with Dr. R. Burns, of Honesdale, Pennsylvania, from whose very full report I am permitted to present the following points regarding the history and treatment :
Mrs. G., of Honesdale, aged thirty, says that she first menstruated at the age of thirteen, married at nineteen, miscarried at twenty-four, and was delivered of a full-term child at twentyseven. The labor was difficult and instruments were used, but her health was afterward good. She married the second time, at twenty-nine, in October, 1883.
On May 9, 1884, menstruation, which had been regular and normal during her married life, except when she was pregnant, appeared for the last time, and continued four or five days as usual. On June 6th it appeared for one day only, and on July 4th it failed entirely. She now had slight nausea, and after a week or two she began to have colicky pains in the right iliac region, with a slight sanguinolent discharge. On July 23d, her pains being more extended over the lower part of the abdomen than usual, she discharged from the vagina a membranous substance about one third the size of the hand. A digital examination by Dr. Burns showed the uterus to be enlarged and tender, with a patulous os, and, by conjoined manipulation, considerable pain was caused in the right iliac region. On August 3d, the patient walked to church and back, about a mile altogether, and afterward suffered from severe pain in the back and right side. A hypodermic injection of morphine was necessary to afford relief. After this, colicky pains, attended by more or less nausea and vomiting, recurred every few days until Saturday night, August 9th, when they became so violent as to require several successive hypodermic injections of morphine before they could be relieved. Next morning the patient was much prostrated. She looked pale and suffered from nausea and vomiting, with a feeble pulse and vesical tenesmus. A digital examination then made showed the uterus to be crowded forward and upward behind the pubes, and Douglas's pouch filled with a soft, doughy mass protruding into the vagina, extending upward into the right iliac region, and pressing the uterus to the left side. The uterus was enlarged, being about four inches long, while its fundus could be easily felt two or three inches above the brim of the pelvis. When pressure was applied,
great pain was complained of across the entire lower part of the abdomen and in the vagina. There was a constant bloody discharge from the latter. The diagnosis naturally was that of pelvic hæmatocele arising from bleeding vessels probably situated in the right broad ligament.
The patient was kept quiet with opiate enemata and was given liquid food when the stomach would tolerate it. Progress was satisfactory for two days, there being no apparent increase in the size of the pelvic mass. On the third day, August 12th, the patient was seized with the same violent pains as at first, for which a hypodermic injection of morphine, and afterward chloroform by inhalation, were used before relief was obtained. After this attack, there was a perceptible increase in the size of the supposed hæmatocele, as well as an augmentation of the prostration, nausea, and vomiting, with a more feeble pulse, although there was little or no elevation of temperature. Retention of urine now occurred, requiring the use of the catheter. On August 14th, there was a similar attack, with an aggravation of all the symptoms, and the same treatment was repeated.
On August 16th, two days later, in response to a telegram, I first met Dr. Burns in consultation in the case. At my examination, I found the ordinary signs of pregnancy present, including the cessation of regular menstruation for nearly twelve weeks, deepened areolæ, and increased prominence of the surrounding papillæ. These, associated with the foregoing history, all pointed, as I believed, to tubal pregnancy and to rupture of the tube-cyst, the hemorrhage having produced the doughy mass in Douglas's pouch. I stated my views to Dr. Burns, and said that, had I seen the patient soon after the rupture of the cyst, I should have recommended immediate laparotomy in order to clear the pelvic and abdominal cavities of blood and secure the bleeding vessels, as sanctioned by the highest authorities; but that, as seven days had elapsed, and as the favorable condition of the patient, shown by an improving pulse of 90 without elevation of temperature, warranted the hope of an ultimate recovery without an operation, I should advise waiting for further developments. The doctor coincided with me fully in the latter view, and with this understanding I returned home.
On Tuesday evening, August 19th, Dr. Burns apprised me by