A Case of Twin Extra-Uterine Pregnancy. Abortion per Vias Maturates at the Fourteenth Week. A. L. ROBINSON, M. I)., BY SEATTLE, WASH. REPRINTED PROM THE ■Neto Yorft fHeOical journal for June 18, 1898. Reprinted from, the Nero York Medical Journal for June 18, 1892. A CASE OF TWIN EXTRA-UTERINE PREGNANCY. ABORTION PER VIAS NATURALES AT THE FOURTEENTH WEEK.* A. L. ROBINSON, M. D., SEATTLE, WASH. Mrs. F. K., aged twenty-seven, multipara, came under my care about the middle of January, 1892, while suffering with la grippe. After the acute symptoms had passed, but while still weak, morning sickness came on. She informed me that her last menstrual period had commenced on November 4,1891. The vomiting soon became almost constant, and was but slightly modified by any of the numerous remedies employed, which in- cluded rectal feeding. Extreme prostration, insomnia, and in- cipient nephritis made abortion advisable, and the patient, her husband, and other members of the household were so informed. While this procedure was being discussed, the patient told me that for several days small blood-clots had been passing, but that free haemorrhage had not occurred. On the following day, February 6, 1892, Dr. Montgomery Russell, of this city, was called in consultation, and the previous treatment and proposed operation were approved by him. Ether was administered, and, anaesthesia being obtained, the cervix was exposed and a pro- truding muco-blood-clot removed. An intense violet color of * Read before the Seattle Medical Society and Library Association, March 16, 1892. ... --- Copyright, 1893, by D. Appleton and Company. 2 TWIN EXTRA-UTERINE PREGNANCY. the vagina was observed. After dilating the cervical canal a careful examination of the uterine cavity was made. It meas- ured five inches and a quarter from external os to fundus, and its contents were a few small blood-clots only. These were re- moved. A roughness was noticed at or near the right Fallop- pian uterine ostium. Dr. Russell’s examination confirmed the results of mine. We concluded that the product of conception had died in utero, undergone maceration and partial absorption, and the remainder passed with the discharges previously men- tioned, which had probably been greater in amount than the patient supposed. The uterine cavity was then syringed out with two quarts of a warm bichloride-of-mercury solution (1 to 3,000), and faradaic electricity applied for fifteen minutes. That evening it occurred to me that the condition was pos- sibly extra-uterine pregnancy. At my next visit the patient was closely questioned, and it was ascertained that for several weeks dull pains had been emanating from the right iliac fossa and extending downward on the thigh. An extremely offensive discharge from the vagina, which she supposed was leucorrhoea, had continued during this period. At first it was thick and viscid, but recently had become watery and mixed with small blood-clots. Since the cessation of menstruation her subjective symptoms had differed greatly from those of her two former pregnancies, but in what manner she could not clearly state. An attempt was then made to make a bimanual examina- tion of the pelvic viscera, hut fear of pain caused so much pro- testation that it was not persisted in, for she was so weak and nervous that convulsions were feared. The employment of an anaesthetic was considered unsafe at that time. External palpa- tion gave no positive results, as pressure was not tolerated. The family was informed of my conjectures, and the various forms of extra-uterine pregnancy with their possible termina- tions were explained. The day following the operation the attacks of vomiting de- creased in frequency. Nausea and occasional vomiting persisted, consequently but little nourishment could be taken at one time. Rectal feeding, gastric and nerve sedatives, tonics and stimu- lants were employed, but the general condition was not greatly TWIN EXTRA-UTERINE PREGNANCY. 8 improved. Pains emanating from the right iliac fossa con- tinued ; also a slight discharge of blood from the uterus. The cavity of the latter was several times explored, the blood-clots found therein removed, and warm bichloride injections made. On the evening of February 17, 1892, eleven days after first examining the uterus, 1 was sent for in haste. Considerable pains had been experienced all that afternoon, commencing in the right iliac fossa, but later extending to the sacrum and assum- ing the characteristics of labor pains. Previous to my arrival she had been delivered of an embryo with considerable ligemorrhage. The patient was too much prostrated to permit cleansing the uterus at that time, the pulse being 120 and weak, temperature 100° F. Haemorrhage was checked by ergotin hypodermically, and brandy and digitalis were ordered. During my visit the following morning a second embryo was passed without pain. Haemorrhage was inconsiderable. The uterus was at once cu- retted and a large blood-clot and sbreds of membrane removed, as well as small pieces of placenta, which were scraped with difficulty from the location of the right Falloppian uterine os- tium. Its cavity was then syringed out with a warm bichloride solution and ergot prescribed. Examination of the embryos showed them to be of about fourteen weeks’ development. They were more than five inches in length, and had evidently been considerably compressed and elongated. The heads were shapeless masses. Membranous nails were forming on fingers and toes. The sexes were not dis- tinguishable. Haemorrhage continued daily, at times requiring electricity, astringent and styptic injections, and the administration of ergot, but these measures failed to satisfactorily control it. Examina- tions of the uterine cavity were several times made, and its only contents, blood-clots, removed. The patient continued weak, with continual nausea and fre- quent vomiting. Temperature varied from normal to 99*5° F., and pulse from 95 to 105 and weak. Pain was constantly com- plained of, mainly on right side of the uterus. Morphine, phen- acetin, salol, and gelsemium were frequently administered to modify it. 4 TWIN EXTRA-UTERINE PREGNANCY. Laparotomy for the removal of the placentas and membranes was considered, but neither at that time nor at any other was the patient strong enough to justify such an operation. On February 23d she had a slight chill followed by rise of temperature to 102,5° F. The following morning the tempera- ture was 102° F., pulse 130, respiration 30. The abdomen was considerably distended and tympanitic, severe pain was com- plained of, and vomiting was more frequent. Dr. Russell was again called in consultation, and he con- curred in my diagnosis of general peritonitis. Turpentine stupes were applied to the abdomen and the “ Alonzo Clark opium treatment ” was agreed upon and commenced, the patient being closely watched until her tolerance for the drug was ascertained. Respiration increased to 88 that day. The duration of this treatment was ninety hours; one hundred and forty-one grains and a half of pulverized opium were administered, and three gx-ains and three eighths of sulphate of morphine given hypo- dermically to lessen vomiting. The acute symptoms gradually subsided, and on the evening of February 28th vomiting had not occurred for six hours, abdominal pain and tympanites had disappeared, temperature was normal, pulse 105, respiration 14. Opium was given that night at increasing intervals and then discontinued. On the morning of Febi-uary 29th I found the patient with temperature of 100° F., pulse 125, respiration 20. The uterine cavity was explored, an entire placenta removed, and it was then syi'inged out with a warm bichloride solution.* An enema of warm water and soap brought away considei*able hardened clay-colored faeces. Fifteen gi-ains of sulphate of qui- nine and cardiac stimulants were given. A tablespoonful of a satui’ated solution of sulphate of magnesium was ordered every four hours. During the afteimoon the temperatni’e fell to 99° F., but the pulse increased in rapidity and feebleness. I remained by the patient’s bedside all that night. At 4 a. m., March 1st, the pulse was 150. At 5.20 a. m., shortly after waking from an hour’s sleep, death resulted from asthenia. * A large piece of placenta had been removed from the uterus four days previously. TWIN EXTRA-UTERINE PREGNANCY. 5 For some years palpitation of the heart and uneasiness in the cardiac region had at times been complained of. Much prostra- tion had been caused by la grippe, and the vomiting of pregnancy following this disease so closely prevented the retention of the tonics and stimulants ordered. But for debility caused by la grippe it is believed the patient would have recovered. Minor details of treatment, etc., have been omitted. It was undoubtedly an interstitial pregnancy on the right side, the growth of the embryos enlarging the Falloppian uterine ostium and permitting their entrance into the uterus. The shape of the uterine cavity, as disclosed by the several examinations, negatives the probability that this was a case of pregnancy in one portion of a uterus bicornis. A post-mortem examination was not obtained. Cases of extra-uterine pregnancy with delivery per vias naturales are extremely rare. Dr. Charles McBurney re- ported one in the New York Medical March num- ber, 1878, page 273, and Dr. Cornelius Williams another in the same journal, December number, 1878, page 595, but an examination of the literature at my disposal fails to dis- close a case of multiple extra-uterine pregnancy with that termination; indeed, I find no cases of multiple extra-uter- ine pregnancy of any variety, though possibly some are of record. 2506 Jackson Street, March 8, 1892. REASONS WHY Physicians shonli Sntiscriiie -FOR- The New York Medical Journal, Edited by FRANK P. FOSTER, M.D., Published by D. APPLETON & CO., 1, 3, & 5 Eond St. 1. BECAUSE : It is the LEADING J0 URNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought, 3. BECAUSE : Its contributors are among the most learned medi- cal men of this country, 4. 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