EXTRA-UTERINE PREGNANCY.

Tubarian, ovarian, and ventral pregnancy.—Pregnancy in the substance of the uterus.

The ovum when impregnated does not always quit the ovary and pass along the Fallopian tube into the uterus. It may remain in the ovary and become here developed; it may pass into the Fallopian tube and remain there; or from some defect in the action of the fimbriated extremity of this canal, it may escape into the cavity of the abdomen, and become attached to some of the viscera. Hence, extra-uterine pregnancy has been divided into three species, viz. graviditas tuberia, ovaria, and ventralis, according to the situation which the ovum takes. A fourth has been also described by M. Breschet, which he has called graviditas in substantia uteri, a modification probably of tubarian pregnancy.

a The uterus, its cavity laid open. b Its parietes thickened, as in natural pregnancy. c A portion of decidua separated from its inner surface. d Bristles to show the direction of the Fallopian tubes. e Right Fallopian tube distended into a sac which has burst, containing the extra-uterine ovum. f The foetus. g The chorion. h The ovaries; in the right one is a well marked corpus luteum. i The round ligament.

This singular deviation from the usual course of conception is fortunately of rare occurrence, for few cases terminate favourably. If it be in the Fallopian tube or ovary, these become immensely distended into a species of sac or cyst, to the sides of which the placenta adheres: as the ovum increases, this at length gives way from excessive distension, and the patient usually dies from internal hÆmorrhage. In ventral pregnancy, the sac is attached to the abdominal viscera, and is usually imbedded among the convolutions of the intestines: hence the duration of extra-uterine pregnancy will depend upon its situation; thus, if it be in the Fallopian tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will continue for five or six months; on the other hand, in ventral pregnancy the foetus will not only be carried to the full term, but far beyond that period, amounting to several years.[50]

Although the uterus does not receive the ovum into its cavity as it does in natural conception, it nevertheless undergoes many of those changes which are known to take place in regular pregnancy. The layer of coagulable lymph, which is effused upon its internal surface, and which forms the membrana decidua of Hunter, is present, and the uterus undergoes a slight increase of volume. As the ovum increases, excruciating pains are felt in the lower part of the abdomen, coming on at irregular intervals, and of irregular duration; in some cases lasting for a short time, in others continuing for twenty-four hours. These attacks of pain are generally accompanied with very painful forcing and tenesmus, and not unfrequently with a discharge of bloody mucus from the vagina. In tubarian pregnancy, however, the case generally follows a much shorter course: the patient is suddenly seized with an acute pain in the lower part of the abdomen, followed by nausea and vomiting; she becomes faint and weak; the abdomen evidently increases in size (from effusion of blood into the cavity;) the debility becomes more alarming, and death quickly follows.

In ovarian pregnancy the fatal termination is merely postponed till a later period, during which the patient has to undergo attacks of most terrible suffering: at length, after a paroxysm more than usually severe, and frequently attended with the sensation of something giving way in the abdomen, faintings come on, speedily followed by death. During the attacks there is obstinate constipation, which is attended with painful and fruitless efforts to evacuate the bladder and rectum; the face is pale, and expressive not only of the most acute suffering, but of great anxiety and mental depression; nevertheless, in the intervals of the attacks she feels easy, and appears well and cheerful.

The termination of a ventral pregnancy is very different; after a time the foetus dies, and may either remain enclosed in the cyst for life, or it may be discharged in portions by means of an abscess, either through the intestines, uterus, vagina, or abdominal parietes. Cases have occurred where it has come away by the bladder; in the former case, where it is retained, it diminishes more or less in size, becomes hard and closely packed together, and, in some instances, encrusted with a layer of calcareous matter.

It is to our venerable friend, the late Dr. Heim, of Berlin, that we are indebted for much curious and interesting knowledge respecting extra-uterine pregnancy. Although the symptoms in the very early stages are so obscure as to render it nearly impossible to detect its presence, he has nevertheless observed some facts connected with it, which are peculiar, and deserve to be noticed. No morning sickness has been observed in cases of extra-uterine pregnancy, a circumstance which can easily be accounted for, if we bear in mind the causes of morning sickness in natural pregnancy: the patient could only lie on the affected side, and the abdomen was observed to swell irregularly, not in the same manner as in regular pregnancy.

In tubarian and ovarian pregnancy, the pain was in the pelvis, but in ventral pregnancy it occupied more or less the whole abdomen, the parietes of which were very tender upon pressure. In cases where the foetus died at an early period, the symptoms gradually disappeared after a time, especially when followed by the bursting of an abscess through the rectum or any other part. One of the most remarkable facts which Dr. Heim observed, was a peculiar whining tone of voice, with which the patient expressed her sufferings during a paroxysm of pain; so peculiar, that when once heard, the sound can never be mistaken. On several occasions Dr. Heim was enabled by means of this symptom alone to decide confidently as to the nature of the case the moment he entered the room, a fact which would appear scarcely credible had not the results of the cases proved the correctness of his assertion. A most interesting case of this sort occurred, which he pronounced to be ventral pregnancy, and when it had gone the full term gastrotomy was performed, a living child was extracted but the unfortunate mother perished: she could not be induced to submit to the operation until inflammation had come on, and she died in two days after.

It must always remain a matter of great obscurity as to the immediate causes of extra-uterine pregnancy, more especially of the ovarian and ventral species; and the more so as we are still ignorant of the mechanism by which the fimbriated extremity of the Fallopian tube grasps the ovary immediately over the impregnated vesicle of de Graaf at the moment of conception. In many cases we are inclined to think that this function of the Fallopian tube is destroyed by adhesions between it and the ovary, a circumstance of not uncommon occurrence; but from the alteration in the shape and size of these parts, as also from the extensive adhesions which are usually found after death, in such cases it will ever be difficult, and perhaps impossible, to prove it.

The treatment of extra-uterine pregnancy must be chiefly guided by the prevailing symptoms: where any portion of the abdomen is very tender to the touch, leeches and warm fomentations will be required; the pain during the attacks can only be alleviated by frequently repeated opiates; and constipation must be carefully guarded against by laxatives and enemata between the paroxysms. Where an effort is made by nature to discharge the foetus by means of an abcess, the case will require all our care to sustain the powers of the system through a long protracted struggle. Portions of the foetus come away from time to time, and if the exit afforded them be by way of the intestine, the suffering produced is very great, particularly when any of the larger bones are passing. The presence of such a mass of semi-decomposed animal matter in the abdomen is of itself sufficient to injure the general health materially: hence it is that patients, during the process of expulsion, suffer greatly from severe attacks of fever, which recur from time to time. Where the abscess opens through the abdominal parietes, the whole is completed with much greater ease and safety to the patient: in some instances the tumour has been opened, and a foetus with a large quantity of putrid pus has been removed. (Medical Obs. and Inquiries, vol. ii. p. 369.)

A case of ventral pregnancy has recently come under our care, a short account of which will enable the reader to understand the subject better than a mere enumeration of symptoms; the more so as we believe it to have been the first case of extra-uterine pregnancy in which the stethoscope has been used.

The patient, Æt. 32, and the mother of four children, was admitted, May 26, 1837, into St. Bartholomew’s Hospital, under Dr. Latham, who kindly consigned her to our charge. She considers herself to be six months advanced in pregnancy; is continually suffering from attacks of acute pain in the lower part of the abdomen, both at the sides and front, causing her to moan from its great severity; this is accompanied with a constant dragging pain on the right side, and in the loins: the attacks of abdominal pain go off at intervals, leaving her comparatively easy. She is pale, with an anxious expression of face. Pulse 120, and firm. Tongue moist. Bowels very constipated.

The abdomen is as large as in common pregnancy at the sixth month, but does not present the same uniform distension, being irregularly shaped. At the left hypogastrium is a soft tympanitic prominence of considerable extent, and appears, from its feel and also from auscultation, to consist of a large portion of the intestines pushed over to that side: at the inner edge of this tumour a solid mass, as large as the head of a six months’ foetus, can be felt. Between this and the median line of the abdomen, and half way between the pubes and umbilicus, a small hard knob-like and moveable prominence is felt immediately beneath the abdominal parietes, and intensely painful to the touch. From this point, quite to the right side, the abdomen has a solid irregular feel; below this to the symphysis pubis, a very loud souffle is heard, synchronous with the mother’s pulse, having all the characters of the uterine souffle in common pregnancy except its extraordinary loudness. Its limits, superiorly, are remarkably defined; below a transverse line, drawn half way between the umbilicus and pubes, it is heard in full strength, whereas, immediately above it the sound ceases: it is also heard some way to the right side. At the upper part of the right iliac region two ridge-like prominences, like the extremities of a child, may be felt close beneath the abdominal parietes. No trace of foetal pulsation can be heard over any part of the abdomen, although it has been carefully ausculted round to the loins: it was however distinctly heard the day before we saw her, by two gentlemen who are proficients in the use of the stethoscope, and whom we consider fully capable of judging in such a case.

On examining per vaginam, the os uteri is found high up and backwards, barely within reach. Its edges are thick, soft, and closed; the cervix is short, and seems less than half an inch. The anterior portion of the inferior segment of the uterus feels somewhat firm and full, as if there was something in the uterus. We were confirmed in this respect by our friend, Dr. Nebel, jun., of Heidelberg, who was on a visit to this country at the time, and who examined the case with us. He was at first induced to suppose that it was the head. We considered that it was the uterus more or less anteverted, the fundus being pressed forwards and downwards, and the os uteri backwards, by the extra-uterine cyst above; farther examinations tended to confirm this view.

She states that the catamenia appeared last in November, during the middle of which month she was attacked with inflammation of the bowels, for which she was treated, and soon afterwards began to have the violent attacks of pain of which she now complains. She felt the child move at the usual time; it evidently formed the mass which occupies the lower part of the abdomen, and its movements appeared unusually close to the surface. During the last few days they have ceased altogether. The above-mentioned attacks of pain have continued to recur ever since at short intervals and with increasing severity.

As leeches had been applied without relief, and as the pulse was quick and hard, she was ordered to be bled to eight ounces, and to take half a grain of morphia immediately.

June 2.—Has been in constant suffering, in spite of leeches and morphia; bowels obstinately constipated, but moved at length by repeated injections and doses of house medicine. Has not felt the motions of the child since the intestines have become tympanitic: still, however, the mass can be felt lying across the abdomen, half-way between the pubes and umbilicus, commencing from about three inches to the left of the median line, and extending to about four inches on the opposite side. On the left side it feels firm and rounded, and so superficial, that it can almost be grasped through the abdominal integuments. Face very pale and anxious. Pulse 120.

June 10.—Was easy and free from pain when we first saw her: the souffle is heard over a smaller extent; in the centre of the space where it is heard it is as remarkably loud as ever, but it gradually becomes indistinct towards the circumference. As she was able to rise we examined her standing: the os uteri is exceedingly high up to the left sacro-iliac symphysis, so that it can scarcely be reached; the cervix is short, the lips somewhat larger than usual, and the whole very firm and immoveable. The anterior portion of the uterus, to be felt through the vaginal parietes, is somewhat firmer and larger than usual: on pressing the tumour in the left hypogastrium, this appeared to lie altogether anterior to the uterus. Little motion is communicated to the os uteri when this is moved.

June 20.—Has been in much suffering since last report; much emaciated; complains of a fetid taste in the mouth; bowels inclined to be purged; stools of a whitish purulent appearance; tongue clean; pulse tolerably natural; has continued to pass portions of fibrinous matter from the vagina, mixed with bloody mucus, since last report. The hard globular swelling at the left side of the abdomen is more distinct at times: the hand can almost pass round it: it has the precise feeling of the head; the mass which lies across the abdomen is also more distinct: the souffle is heard over a much smaller space and is diminished in strength.

June 27.—Much the same, except that, after severe bearing down and tenesmus, she has passed a considerable quantity of blood from the rectum and vagina. The little prominences on the right side, presumed to be the extremities, are remarkably distinct, like two heels or knees.

July 18.—No material change has taken place since last report; she has suffered from irregular attacks of pain, and has had repeated discharges of blood from the vagina, which always give relief; is weaker than usual, and feels exhausted from the continued character of the pain; abdomen less swollen; the globular mass on the left side is lower and much nearer to the median line; the little prominences on the right are also lower, and nearer the median line; the whole mass appears much more compressed together and nearer to the pubes; it is extremely painful on the left side, and at the most painful spot the skin is red and inflamed; the bowels, appetite, &c. are natural; pulse feeble, but regular; scarcely any trace of souffle to be heard.

Shortly after this she left the hospital, and for some time continued to enjoy tolerable health, occasionally suffering from severe paroxysms of abdominal pain; the abdomen diminished considerably in size, and the various prominences became indistinct.

In May, 1839, she was again admitted in a state of great exhaustion from constant severe pain. The abdomen had diminished still more, and a portion of the mass had descended between the uterus and rectum; the constipated bowels were moved with great difficulty, but with much relief. The symptoms gradually diminished, and she was discharged in the first week of the following August.

In January, 1840, she returned to the hospital, all her former sufferings being greatly aggravated. The abdomen had subsided still farther; early in February she passed a quantity of putrid purulent matter from the rectum, after which the abdomen diminished considerably. The pain appeared to be chiefly situated in the upper part of the rectum, accompanied with severe bearing down, and on examining per vaginam the mass was felt deep at the posterior part of the pelvic brim: the debility and emaciation increased, and she died early in February. Our notes of the post mortem examination were as follows:—

Much emaciated, abdomen concave, but on pressing it the tumour can be felt at the brim of the pelvis. On opening the abdominal cavity, the mass was found adhering firmly to the neighbouring intestines, and on the right side to the soft linings of the pelvis: it was of an irregular form, with spots of livid vascularity in different parts: on the upper and left side of it, fetid purulent matter was seen exuding from a small orifice. The uterus was below, its fundus pushed over to the left side. On separating its adhesions, and attempting to raise the sac from the pelvis, the half-softened parietes gave way, and the decomposed putty-like mass of the foetus became visible; the cranial bones were at the left side; the feet were still distinct on the right side; the whole was immersed in a quantity of thick fetid pus, and there were no traces either of umbilical cord or placenta.

Cases of ventral pregnancy have been recorded where the child has remained in the mother’s abdomen without producing any dangerous symptoms, and where she has again become pregnant in the natural way. The earliest instance of this sort was recorded so long ago as by Albucasis. A very interesting case of this nature is described by Dr. Bard of New York. (Med. Obs. and Inquiries, vol. ii. p. 369.) It was the patient’s second pregnancy; at the end of nine months she had pains, which after a time went off; the tumour gradually diminished somewhat, and in about five months after she conceived again, and in due time was delivered, after an easy labour, of a healthy child. “Five days after delivery she was seized with a violent fever, a purging, suppression, pain in the tumour, and profuse fetid sweats:” an abscess formed in the abdomen, which was opened, and a vast quantity of extremely fetid matter was discharged; the opening was enlarged, and a foetus of the full size was extracted. Dr. Bard “imagined the placenta and funis umbilicalis were dissolved in the pus, of which there was a great quantity.”

It becomes a question of deep interest whether it be really possible to save the patient and the child in cases of ventral pregnancy, by performing gastrotomy. The separation of the placenta from the walls of the cyst can only be effected with much difficulty and hazard; indeed, we are at a loss to conceive how it can be removed with any degree of safety, where the child has been found alive. The attachment in these cases was more than usually firm, and it has been left to undergo that process of solution which has been described in Dr. Bard’s case. In all the cases where gastrotomy has been performed some time after the child’s death, little or no trace of the placenta has been found, but in its place a quantity of ill-conditioned purulent matter, which was excessively fetid.

The fourth species of extra-uterine pregnancy, which M. Breschet has described as taking place in the substance of the uterus, is of very rare occurrence, four cases only having been recorded by him. (Med. Chir. Trans. vol. xiii.) M. Breschet has attempted a variety of explanations of this singular anomaly, but without success; and from the circumstance of the cyst having always been found situated in the fundus to one side, the Fallopian tube of which was closed at its uterine extremity, we think that there can be little doubt of its having been a modification of tubarian pregnancy, where the ovum had been obstructed at that portion of the Fallopian tube where it passes obliquely through the wall of the uterus: in one case the tube appears to have given way at this part, and the ovum to have insinuated itself between the uterus and peritoneum. In these cases the sac ruptured at about the same period as in tubarian pregnancy, except in one instance, where she went five months. A rather inexplicable case of extra-uterine pregnancy has been recorded by Mr. Hay, of Leeds (Med. Obs. and Inquiries, vol. iii.,) where a full grown foetus was found enclosed in a large sac, which filled the abdominal cavity, and which communicated inferiorly with the uterus. On tracing the umbilical cord, “we were led,” says Mr. Hay, “to a large aperture in the right side of the inferior globular sac already mentioned, from which that which contained the foetus seemed to have its origin. This inferior sac we now found to be the uterus, containing a very thick placenta, which adhered very firmly to about three-fourths of its internal surface, having the navel string attached to its centre, and this centre corresponded nearly with the centre of the fundus uteri. The placenta filled up the greatest part of the aperture of communication between the uterus and sac. The Fallopian tube on the left side was very small; the place of that on the right was occupied by the beginning or orifice of the sac.” (Op. cit.)

This would seem to have been a case of pregnancy in the substance of the uterus, and where a portion of the ovum had burst its way into the cavity of the uterus lined with decidua, to which it adhered; the other portion, containing the embryo, distended the uterine parietes in a contrary direction, and thus formed the large sac which communicated with the cavity of the uterus.