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so well was she at this time that she did not wish any further notice taken of her case, although the enlargement of the lower part of the abdomen still continued.
In the autumn and early winter of 1883, nearly three years after this pregnancy, her general health, in the intervals between her neuralgic attacks which had continued up to this time, was better than ever before. The enlargement of the abdomen seemed to her by this time to be greatly reduced, and its situation was much lower.
In the last week of January, 1884, her menstruation appeared as usual, lasting four days; but it did not return in February, March, or April. At this time, the facial neuralgia became more frequent and severe, and the pain soon extended to the teeth, and thence to the whole side of the body as far down as the toes. A dentist was consulted, who extracted several teeth, including some that were sound, but with the result of producing little abatement of the suffering. Owing to the unpleasant effects of morphine upon the patient, Dr. Burke put her on the use of Duquesnel's aconitine, the ninetieth of a grain three times a day, which was followed very soon by marked diminution in the severity of the pain.
In this way matters went on a few months longer, when the patient's attention was directed for the first time to an increase in her abdominal enlargement; but, feeling a repugnance to having an examination made as to the cause of the change, she decided not to ask medical advice.
It was not until September, more than seven months after the last appearance of the catamenia, that Dr. Burke was consulted. He, of course, insisted upon an examination, and the result was that he found in the abdomen a somewhat solid and rolling body, with an unusually marked degree of prominence anteriorly. Having three years before closely watched the case for months as one of abdominal pregnancy, he naturally concluded that the present enlargement of the abdomen might be attributed to the products of that conception.
On September 18, 1884, several days after his examination, he requested me to see the case in consultation. The former abdominal pregnancy being now overshadowed by the actual existence of a new growth, my attention was directed specially to this.
From the general good health of the patient and the presence of most of the rational and physical signs of pregnancy, as well as from the evidence afforded by palpation, I was at once led to eliminate the existence of uterine and ovarian disease and to decide that the enlargement was probably due to the presence of a fœtus in utero. I even thought I heard the pulsations of the fœtal heart; but in this I was mistaken, as the result proved. Further examination per vaginam, however, disclosed the fact that the patient was actually in labor.
Two peculiarities in the presentation of the child attracted my attention: 1. The prominence of the head felt through the expanded anterior segment of the cervix uteri. 2. The difficulty in reaching the os uteri with the finger. Only the anterior margin of this could be touched, and this condition of affairs I attributed to the forward inclination of the body of the uterus, in consequence of the presence of the remains of the abdominal fœtus.
After this, Dr. Burke, with his friend, Dr. McSweeny, conducted the labor and delivered the child with forceps after eight or ten hours. The child proved to be of about seven and a half months' growth and had evidently been dead for several days. Immediately after the completion of labor, an uneven and projecting mass presented in Douglas's pouch, which was recognized through the vaginal wall as the remains of a fœtus encysted in this locality. Dr. McSweeny, with the sanction and approval of Dr. Burke, made a longitudinal incision just below the cervix uteri into the cyst, and with a pair of forceps removed the several portions of it. The patient recovered without an untoward symptom, and when I saw her with Dr. Burke, some three weeks ago, she was the picture of health, having even lost her facial neuralgia. An examination showed the uterus to be but slightly enlarged and anteverted. Only the line of cicatrization in the posterior cul-de-sac remained to indicate where the incision had been made for the removal of the abdominal fœtus.
Dr. Burke's reasons for removing the encysted fœtus, as was done, was that it had presented at the most favorable point possible for an operation, and that he feared the future health, and probably the life, of the patient might be jeopardized by a longer continuance of its remains in the abdomen.
I present here the products of the abdominal pregnancy, preserved by Dr. Burke; and I have also in alcohol the intrauterine product, a well-formed child of seven and a half or eight months' growth, which possesses no point of interest other than the fact of its conception, development, and delivery during the presence of the former fœtus in the abdomen.
The first specimen, consisting of wet and dry preparations, is interesting in at least three particulars: 1. In having sojourned encysted in the abdomen from July, 1881 (when death took place at six months), to September 18, 1884, about three years and two months, and in having been removed, through an incision made into the cyst through the posterior wall of the vagina, a few minutes after the extraction of the normal fœtus with forceps. 2. From the fact that the soft parts had been almost entirely removed by absorption, there remaining scarcely anything save the bones, tendons, dura mater, and some portions of the skin. 3. In having caused the mother, prior to and during her subsequent pregnancy, so little trouble and inconvenience, the general health remaining good during the time indicated, with the exception of the paroxysms of neuralgia mentioned. The fingers and toes and the features of the face are easily distinguishable in the wet preparation.
The points brought out in the preceding pages justify, I think, the following conclusions:
1. That retroversion and retro-lateroversions of the uterus, and the consequent changes in the relationship of its appendages, contribute largely toward explaining the causation of extrauterine pregnancy.
2. That extra-uterine pregnancy probably has its seat originally in one or the other of the Fallopian tubes, and that the abdominal varieties of it occur afterward, either from rupture of the tube (Tait) or partial or complete escape of the impregnated ovum from its fimbriated extremity.
3. That, after completing the diagnosis of tubal pregnancy between the seventh and fourteenth weeks, it is of urgent importance in all cases to destroy the life of the fœtus, without delay, by electricity, which is the surest and safest method at
our command, in order to guard against the immediate dangers of rupture of the cyst, now liable to take place at any moment.
4. That the practitioner, if he do not himself feel competent to meet the threatened danger of rupture of the cyst by prompt surgical interference, should at once summon to his aid a surgeon prepared to carry out his wishes at a moment's notice.
5. That the surgeon, when rupture of the cyst occurs, as indicated by the usual symptoms of shock and loss of blood, should open the abdomen and secure the bleeding vessels without delay, success in all cases depending on the promptness and thoroughness of this procedure.
6. That the differentiation of the particular variety of ectopic gestation existing is of no consequence at this early stage, the treatment before and after the rupture of the cyst being the same in all cases.
7. That, when abdominal pregnancy is diagnosticated at a later period of gestation, whether seated partially in the fimbriated extremity of a Fallopian tube or entirely within the peritoneal cavity, electricity should still be promptly employed, on the assumption that the earlier the life of the fœtus is destroyed, the less grave will be the remote dangers arising from disintegration, absorption, suppuration, ulceration, and the use of the knife.
8. That, in all cases of abdominal pregnancy, the foetus becomes encysted more or less completely, and that, whether its life be destroyed artificially or it die before or at the full term of gestation, it is liable to complicate a subsequent normal pregnancy, by obscuring its diagnosis and seriously interfering with natural labor.
9. That, when normal labor occurs with pre-existing abdominal pregnancy, it should be allowed to progress to its natural termination, the practitioner, of course, assisting the delivery with instruments when demanded; but that, in the event of the dead foetus presenting in Douglas's pouch, either as an impediment to the normal labor or as a prominent projection from the pouch into the vagina, immediately after the completion of labor, the cyst should be opened and emptied of its contents,
the delivery of both foetuses thus being completed at the same operation.
I shall now briefly refer to a third case of extra-uterine pregnancy, which I saw in consultation with Dr. J. F. Chauveau, of New York, November 10, 1884, for the purpose simply of showing how the treatment with electricity was carried out, it being too soon after the occurrence to report the case in full. It occurred in a young woman, aged twenty-five, in the twelfth week of her second pregnancy, and was found to be of the tubal variety, on the left side, the uterus being retroflexed. The diagnosis was clearly made out, the patient being put in the recumbent and knee-face positions, even to the extent of proving with the finger the vacuity of the uterus. As the result of the consultation, it was decided to destroy the life of the fœtus with as little delay as possible. Dr. A. D. Rockwell was called in to apply the electricity, November 13, the form preferred by him being the interrupted galvanic current. The negative electrode was applied per vaginam to the pelvic mass to the left of the uterus, and the positive, over the enlargement in the left iliac region, at its most painful point, the current being thus established through the structures. A series of twelve cells, gradually increased to fifteen, was employed, and the interruptions were about one hundred per minute. The séance lasted five minutes, with momentary intervals of rest. The patient bore the treatment well, and there was little or no pain. Four applications were made, from November 13 to 17, the first three on successive days, and the fourth, after an interval of one day.
Dr. Rockwell's opinion was that one application, as above described, was sufficient to destroy the life of the fœtus; but, as there was no way of determining this fact positively, he thought, in order to be sure, the patient should be subjected to at least four séances.
Note, December 9, 1884.-With this the treatment was concluded, and the patient was believed to be protected against the dangers of rupture of the cyst; but, about sixty hours after the last séance, she was seized with another violent paroxysm of pain in the same region as before, which soon extended to the