A CONTRIBUTION TO THE STUDY OF ABDOMINAL PREGNANCY. BY HENRY C. COE/M.D., M.R.C.S., OF NEW YORK. FROM THE MEDICAL NEWS, December io, 1892. [Reprinted from The Medical News, December io, 1892.] 4 CONTRIBUTION TO THE STUDY OF ABDOMINAL PREGNANCY.1 BY HENRY C. COE, M.D., M.R.C.S., OF NEW YORK. In spite of the amount of recent literature bearing on the subject of ectopic gestation, our knowledge of this interesting abnormality has been widened almost entirely in the direction of early tubal pregnancy; unfortunately, the same atten- tion has not been bestowed upon its later stages, especially upon that described as secondary ab- dominal pregnancy, because the opportunities for studying it at the operating-table and post-mortem are limited. The consensus of opinion is now against the existence of primary abdominal gestation, and we may assume that (excluding a few doubtful cases of the ovarian variety) every ectopic pregnancy is originally tubal. The fact that even the second- ary form of abdominal gestation is still denied by competent observers, and that many of the pub- lished cases have been described so inaccurately as to make them comparatively valueless, renders it important that every authentic one should be de- scribed as fully as possible. In the following case 1 Read by title at the Fifth Annual Meeting of the Southern Surgical and Gynecological Association. 2 the history was so unusual as to render it quite in- teresting, while the opportunities for studying the anatomy of the condition were as favorable as could be secured outside of the deadhouse. Mrs. A., thirty-eight years old, is the mother of three living children, her labors having been normal. She had never had any previous pelvic trouble. She menstruated in April, 1891, skipped the fol- lowing period, and on June 26th began to have what she described as labor-pains, accompanied by profuse metrorrhagia, which continued for twelve days. The patient passed several large clots, and supposed that she had aborted. She recovered, and there was no more flow until September 22d, when she was first examined by Dr. S. Marx, a skilled obstetrician, who found that the uterus presented the ordinary condition of the pregnant organ at the beginning of the fourth month, as to size, elasticity, softening of the cervix, and the pres- ence of Hegar's sign. The patient had morn- ing sickness, with enlargement and tenderness of the breasts, and a few days later she affirmed that she felt quickening. There seemed to be no reason to doubt the existence of normal pregnancy. On November 5th she was seized with severe pains in the right inguinal region, and had the same pro- fuse flow as before, without any assignable cause. The hemorrhage continued for several days, but without the uterine contractions that had been present on the former occasion. There was no col- lapse or other evidence of internal bleeding. A mild attack of peritonitis, localized to the right side, followed and lasted for two weeks, the tem- perature seldom exceeding ioo° F. The patient made such a good recovery that she was soon able to resume her household duties, being 3 entirely free from pain. In the meantime the sup- posed uterine tumor continued to enlarge regu- larly and symmetrically, corresponding to the normal increase in size of the pregnant organ, and the patient insisted that she could feel fetal movements, though her physician was never able (after repeated attempts) either to feel these or to hear the heart-beat. By external palpation he could detect fetal parts, though internal ballottement could not be obtained. I saw the patient in consultation April 19th. She was in good general condition and had no pain. She still insisted that she felt life. The breasts were flabby, with retracted nipples. The abdomen was symmetrically enlarged, presenting the appear- ance ordinarily observed at the end of pregnancy. On making external palpation I felt a median, thin- walled sac, filled with fluid, by tapping upon which the characteristic sensation given by the small parts of a fetus was clearly appreciable. There were no intermittent contractions in the sac and auscultation was entirely negative. On making a vaginal ex- amination I noted the fact that the cervix was hard, but thought that this might be explained by the pres- ence of an old laceration with extensive induration. The cervix was continuous with the abdominal tumor and moved with it. It was impossible to separate the body of the uterus from the enlarge- ment. There seemed to be no reason for passing a sound. The sac bulged posteriorly into Douglas's pouch, but the sensation was rather boggy than fluctuating. Internal ballottement could not be ob- tained. Nothing abnormal could be detected in either ovarian region. The examination was un- accompanied by pain or discomfort. In spite of the somewhat peculiar history, and the impossibility of determining when conception oc- 4 curred, the case seemed to be one of intra-uterine pregnancy at term. I made a probable diagnosis of hydramnios, with death of the fetus, and saw no reason for immediate interference. I did not hear from the patient again until the middle of May, a month later, when her physician informed me that she was still in statu quo. As she had long passed the normal period of pregnancy, and her abdomen had continued to enlarge from the increased accumulation of fluid, he began to think that the condition must be either ovarian cyst or abdominal pregnancy. She was admitted to the hospital, and it was evident that a marked change had taken place, both locally and gen- erally. She had become much emaciated, pre- senting the appearance of a patient with malignant disease. The abdomen was much distended, with general fluctuation, and the superficial veins were prominent, as in ascites accompanying malig- nant disease. A thorough examination was made under anesthesia. External ballottement was ob- tained as before, but less distinctly. Fluctuation was general, but there was still to be felt a thin- walled median sac, filling the entire abdominal cavity, displacing the stomach and liver upward, and bulging downward into Douglas's pouch, where distinct fluctuation was obtained, the wave being transmitted from the abdomen. The corpus uteri was fused with the sac, but a sound was introduced anteriorly to the depth of four inches, proving that the uterus was probably empty. Normal preg- nancy was thus excluded, and the diagnosis lay between abdominal pregnancy, ovarian cystoma, or possibly malignant disease of the peritoneum with encysted ascites. The possibility of intra-uterine gestation as a complication of an abnormal condi- tion (ovarian cyst or malignant disease) was also 5 borne in mind, as well as the existence of a former tubal gestation with rupture, as indicated by the history. The patient was examined by several of my colleagues, who inclined to the diagnosis of multilocular ovarian cystoma. Operation, May 25, 1892. The usual median incision was made. The peritoneum was found to be much thickened and fused with the wall of the sac, which was firmly adherent to the abdominal wall. At least a gallon of chocolate-colored fluid was evacuated. A fully developed fetus was found in the upper part of the sac, its head resting against the under surface of the liver. The fetus was removed and the cord ligated. The placenta was attached to the entire posterior surface of the uterus, filling the culde-sac. It was bloodless, and was readily detached without hemorrhage. The pelvic as well as the abdominal viscera were so com- pletely shut off from the sac that it was not deemed advisable to attempt any extensive detachment of the latter for the sake of studying its relations. The following points were, however, clearly deter- mined : The sac was symmetrical with respect to the uterus (which was moderately enlarged and lay in front of and below it), being firmly adherent to the entire posterior surface of the organ and to the posterior layers of both broad ligaments, and dipping down to the bottom of the cul-de-sac. So far as could be determined by palpation, the adnexa were not enlarged. The abdominal viscera were displaced upward, but whether extensive in- testinal adhesions were present or not it was im- possible to determine. The wall of the sac had a uniform thickness of an eighth of an inch, and was lined with a cheesy, disintegrated mass, evidently the result of degenerative changes. The sac was thoroughly irrigated and, on ac- 6 count of slight general oozing, was packed with iodoform-gauze, a drainage-tube being introduced to the bottom of Douglas's pouch. The edges of the sac were stitched into the abdominal wound, a large opening being left. An examination of the fetus (which weighed six and a quarter pounds) showed that it was fully de- veloped and only slightly macerated. The placenta corresponded with the full term of pregnancy, but was dry and bloodless. The patient did well at first, but in a few days became septic, as the pouch behind the uterus did not drain perfectly. To correct this a counter- opening was established in the cul-de-sac, the good effect of which was soon evident. After the con- tinuance of a high temperature and an unusually rapid pulse for a fortnight, with an exhausting sep- tic diarrhea, convalescence was finally established, and the patient was able to be up a month after the operation, the sac having contracted to the capacity of a couple of ounces. She was discharged at her own request July 6th, as there remained only a small sinus at the lower angle of the abdominal wound. Two weeks later she was readmitted, as her mental condition was such that she could not be kept at home. It was evident that she was in a condition of well-marked melancholia, with suicidal tenden- cies. Locally her condition was much improved; the remains of the sac were represented by an elongated induration as large as the thumb, behind the uterus, which was reduced in size and somewhat anteverted. There was no tenderness on pressure at any point. A probe passed into the fistula at the lower angle of the abdominal wound entered to the depth of three inches. It was impossible to keep the patient in the hos- pital more than a week, as she refused to take nour- 7 ishment and twice attempted suicide. At the end of that time she was transferred to an insane asylum, from which she was discharged three months later, mentally sound and with the sinus entirely closed. Several interesting questions suggest themselves in connection with this case, which may be con- sidered most conveniently under the heads of pathology, diagnosis, and treatment. Pathology. The condition found at the time of operation-the symmetrical disposition and perfect development of the sac, with the apparent normal condition of the uterus and adnexa-would to a superficial observer seem to prove that the case could fairly be regarded as one of primary abdom- inal pregnancy; but the history clearly points to an original tubal pregnancy, with intra-peritoneal rup- ture, and either immediate or gradual escape of the product of conception. That a careful post mortem examination may fail to reveal in which tube the impregnated ovum originally developed before it was expelled is shown in the two cases reported by Sutugin. My own opinion is that the patient had in the latter part of June, 1891, an early abortion, and became impregnated in the right tube very soon after. When examined three months later, the uterus was so much enlarged as to resemble the normally preg- nant organ. Two weeks later the tube ruptured (not into the broad ligament, but into the general cavity), as a tubal abortion after the second month has by Sutton been shown to be anatomically im- possible, on account of the closure of the fimbriated extremity of the tube. The placenta, on being 8 expelled into the peritoneal cavity, gravitated to the bottom of Douglas's pouch, and at once became attached to the posterior surface of the uterus and right broad ligament. The accompanying hemor- rhage was, fortunately, moderate, so that the patient did not show its effects. A localized peritonitis naturally followed, the resulting adhesions shutting off the fetus, placenta, and blood-clot from the general cavity. The clot later became liquefied. In consequence of the long-standing irritation of this foreign body (and doubtless also from a low grade of peritonitis) a regular sac was formed, which enlarged symmetrically with the growth of the fetus and the increased exudation. Being fused with the uterus, it was naturally inferred that this organ was gradually enlarging as pregnancy ad- vanced. The failure of the physician to detect either the fetal heart-beat or movements is not strange, considering the abnormal position and re- lations of the fetus. When I saw the patient in April (at which time her confinement was expected) the fetus was dead, and what the woman regarded as evidences of life were doubtless the peristaltic movements of the intestines around the sac. As no pulsation was felt behind the uterus, the placenta was probably already bloodless. An unusual feature in the subsequent course of the case was the rapid accumulation of fluid after the death of the fetus-a phenomenon directly con- trary to that usually observed. It is interesting to note how little the patient's health was disturbed by her abnormal condition, and that there was an absence of symptoms pointing to other than intra- 9 uterine gestation, from the time at which the tube ruptured until after the date of her expected con- finement. Diagnosis. This has been thoroughly discussed in a recent paper by Sutugin,1 who reports two fatal cases with histories similar to mine and refers to others. Contrary to the positive statement of Tar- nier and Budin, in the case in which he made a correct diagnosis Sutugin noted distinct intermittent con- tractions in the sac, which were afterward explained by the finding of muscular fibers in its wall. The absence of such contractions in my case was regarded simply as strong negative evidence against the exist- ence of intra-uterine pregnancy. These are, however, equally absent in cases of hydramnios with extreme flaccidity of the uterine wall. Considerable stress has been laid upon the fact that in abdominal gestation the fetal parts can be felt with unusual distinctness through the abdominal wall. This was by no means a prominent feature in my case. In fact, the fetus was felt with far more startling clearness in a case of hydramnios in which I was called to perform celiotomy, but deliv- ered per vias naturales. My experience with these puzzling cases has been similar to that of our dis- tinguished Fellow, Dr. Engelmann, whose paper on "Abnormal Thinness of the Uterine Wall" was read at the last meeting of the Association. Tar- nier and Budin attach no little importance to the absence of internal ballottement, associated with the presence of a soft, boggy mass behind the uterus, which may or may not pulsate. This was 1 Zeitschr. fiir Geb. u. Gyn., Bd. xxiv, Heft i. 10 not clearly marked in this case, but still it was pres- ent, and I would not mistake it on another occasion, though the characteristic sensation imparted to the examining finger is obscured by the surrounding fluid. If the body of the uterus can be identified, of course advanced intra-uterine gestation can be positively excluded. Examination per rectum may throw a good deal of light upon the position of the uterus. If there is even a reasonable doubt that its cavity may be empty, it should be thoroughly ex- plored with a sound, especially if the pregnancy has reached term and the fetus is alive. It may be briefly stated, then, that in the case of a woman who presents such disturbances early in pregnancy as to justify the inference that it might have been originally tubal, and goes on to develop a thin-walled gestation-sac in which fetal parts can be felt (whether the movements and heart-beat are detected or not), and when on vaginal examina- tion we find an elastic retro-uterine tumor we should begin to suspect that the pregnancy is not intra-uterine. As the abdominal tumor enlarges, the thinness of the sac and the irregular increase in the contained fluid, with certain pressure symp- toms of which the patient complains (pains in the back and abdomen, vesical and intestinal disturb- ances), will strengthen this suspicion and lead the attendant to insist upon a thorough examination under anesthesia. If the diagnosis has not been made before, it certainly will be after the expected date of confinement has long passed without visible results, though this is now too late for the diagnosis to be of any benefit to the fetus. 11 It is only fair to remark that the absence of nearly all of the symptoms detailed was what made the diagnosis so obscure in the case reported. Treatment. It seems hardly necessary to dwell upon this point, as our modern surgical training naturally inclines us to adopt the only rational method of procedure-abdominal section. We do not need to review the disastrous results of vaginal incision to know that this is an exceedingly danger- ous and unscientific method of emptying the sac. It is, as Sutugin observes, tempting to evacuate its contents in this way, but, as he found to his cost, there is imminent danger of fatal hemorrhage from laceration of the placenta; and the surgeon pro- ceeds blindly, not knowing the exact relations of the fetus or sac. In a case of doubtful diagnosis I would prefer to make an explorative incision and find a pregnant uterus than to expose the patient to the danger of vaginal incision. It is highly impor- tant that the relation of the sac and its contents should be carefully studied. If the child has been long dead and the placenta is bloodless, of course the latter should be peeled off at once. Nature usually indicates the best way of disposing of the sac, i. e., to stitch it to the edges of the abdominal wound and drain it. There is no object in trying to enucleate it if it is perfectly isolated. I believe that I made a mistake in not establishing a counter-opening in the vaginal fornix at the time of the operation. A certain amount of septic infection is to be ex- pected ; there is an unusually large cavity, contain- ing many pockets, and one cannot err in securing free drainage. 27 East Sixty-fourth Street. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820. A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, fr.jo PER ANNUM. LEA BROTHERS 5a CO. PHILADELPHIA.