THE SOUTHERN

PRACTITIONER

AN INDEPENDENT MONTHLY JOURNAL

DEVOTED TO MEDICINE AND SURGERY

CLINICAL LECTURE AT THE WOMAN'S HOSPITAL OF THE STATE OF TENNESSEE

BY M. C. M'GANNON, M.D., F.A.C.S.,

Professor of Surgery at Vanderbilt Hospital and Surgeon at the Woman's Hospital of the State of Tennessee.

CASE I. ECTOPIC GESTATION.

The patient whom we have here under observation has. been brought in a distance of fifty miles by train and gives the following history: She is twenty-four years old, has always enjoyed good health. During her childhood she has had measles, whooping-cough and scarlet fever, from each of which she recovered promptly and with no complications. At seventeen years of age she was in bed for five weeks with typhoid fever; her recovery was uneventful and her health from that time has been perfect.

Menstrual Life: She began to menstruate at fourteen years of age. It has always been regular, the flow continuing four and five days, normal in quantity and without clots

or pain. She complains of some leucorrheal discharge. Her last menstruation appeared two weeks ago. It continued four days and was normal in quantity. The period preceding this occurred one month before, at the right time and also continued four days and was normal in quantity.

Present Symptoms: Twenty-four hours ago this patient had a sudedn attack of pain. The suffering was severe and was referred to the center of the abdomen. This was accompanied by nausea and vomiting and she states that during the night she vomited four times. The pain was soon referred to the lower part of the abdomen with the greatest severity on the right side. The doctor, who was called to attend her, stated that there was a marked tenderness in the right lower quadrant of the abdomen, and that pressure on the left side from the colon caused the patient to complain of pain on the right side. This attack of pain was accompanied by increased pulse rate, but there was no elevation of temperature and no shock. A diagnosis of appendicitis was made and the patient was advised to come to the Woman's Hospital. This she decided to do and so she was at once brought here.

Upon her arrival at the hospital an examination demonstrated the fact that the temperature was normal, the pulse rate 110 and the urine negative. The examination of the blood showed a hemaglobin percentage of seventy and a leukocyte count of seven thousand. There was no distention of the abdomen, but the abdominal walls were tense and did not expand on deep inspiration. There was marked tenderness over the whole of the lower abdomen with maximum intensity on the right side. This is the condition which we now find to be present.

We will now examine the pelvic structures through the vagina. This is a procedure which should be employed in every case in which a woman comes with a history of this kind, and it should be especially observed where the pain is referred all over the hypogastric region.

In this case we find a mass to be distinctly felt on the right side of the uterus. It is somewhat doughy to the touch, and the patient complains of tenderness upon the attempt to make a satisfactory bimanual examination.

Now comes the question of diagnosis. With what have we to deal? Is this a case of appendicitis? The suddenness of the onset, the marked pain referred to the center of the belly, accompanied by nausea and vomiting, and especially when we get, as we do in this case, a history of several attacks somewhat similar which have occurred in the last two or three years, makes the diagnosis of appendicitis, to say the least of it, very likely to be the correct one. But when we consider the fact that the temperature is normal, that there is no leukocytosis (the white blood count being only seven thousand), that the pain is all across the lower abdomen, and that there is a mass to be distinctly felt in the right pelvic region, the question of the diagnosis of appendicitis is practically eliminated. The question arises, "With what have we to deal?" Is this a case of salpingitis? The inflammation of the Fallopian tubes undoubtedly might produce the pain which the patient has complained of. It might be responsible for the pain elicited across the lower part of the abdomen. It could be the main factor in the production of the rigidity of the abdominal walls and might be the cause of the mass that is to be felt in the pelvic region. However, the acuteness of the onset is not indicative of an inflammatory process in this situation. The leukocytosis, too, tends to put to one side the thought of an inflammatory process, so that we may safely conclude that this patient is not suffering with an acute salpingitis.

The next diseased condition that comes to one's mind is the possibility that this patient's suffering is due to an ectopic gastation.

The classical symptoms of this disease are, an interference with the menstruation, either a complete suppression,

that is, a period is missed altogether, or a flow sometimes only amounting to a stain and then in two or three weeks. a more or less sudden pain referred to one or the other inguinal regions, accompanied by nausea and vomiting.

Upon examination of such a case we will ascertain that there is some rigidity of the abdominal muscles across the lower abdomen, tenderness upon pressure and the vaginal examination of the pelvic contents will demonstrate a mass more or less firm and pyriform in shape, lying to one or the other side of the uterus, provided, however, that rupture has not taken place. If, however, the rupture has taken place, then the pelvis will be filled with a more or less. doughy mass which will represent a quantity of blood which has clotted in this region. The blood picture, in such a case, will depend somewhat upon the amount of blood that has escaped. If the amount be large, there will be a reduced hemaglobin per cent, while the leukocyte count will be practically. normal.

Now let us apply these classical symptoms to the case under observation. This patient gave a history of normal menstruation. That is quite different from the classical sign of an inteference with the menstrual flow, but there are many exceptions to this classical sign. We have had a number of cases in the hospital in which there was no interference with the menstrual flow and yet upon operation, extra-uterine pregnancy was found. So that to be menstruating normally is no proof that she is not suffering with an extra-uterine gestation.

This patient had a sudden onset of pain, more or less central in the abdomen. This is the usual symptom in extrauterine pregnancy where rupture, either partial or complete,

occurs.

Nausea and vomiting were symptoms in this case. Nausea and vomiting are symptoms of any condition inside the peritoneal cavity in which the peritoneum is put upon the stretch or injured.

This patient, soon after her attack of pain, had a rapid pulse, and upon examination it was found that her hemaglobin per cent was seventy. This is just the condition we would expect to find where a rupture of a blood vessel and a hidden hemorrhage had taken place. This reduced hemaglobin per cent is an essential anemia due to the loss of blood, and her increased pulse rate is just what we might expect to find in such a condition. Upon examination the tenderness over the lower abdomen, with the tension of the muscles of the abdominal walls, are both conditions to be expected when the peritoneum is irritated by a foreign body or by any inflammatory process.

Then the mass that is felt in the pelvis, doughy in type, is just what we would expect where there has been an escape of blood with clotting of the mass in the pelvic region. The picture, while not classical and by no means perfect, is quite sufficient to warrant the diagnosis of extra-uterine pregnancy with rupture. So this patient will be prepared for operation and immediately subjected to an abdominal section.

There are many causes of gestation occurring in the Fallopian tubes. These causes may be congenital or acquired. Usually, however, they are acquired. They may be external to the tube or internal to that structure. They are more commonly internal. Of the external causes bands of adhesions, narrowing the channel of the Fallopian tube or twisting the tube out of shape may be mentioned. The most common cause is infection of the mucous membrane lining the tube. This infection follows either an abortion or a delivery, or what is more commonly the case, is due to gonorrheal contagion.

In the early stages of this inflammatory process the mucous membrane is not capable of lodging the fecundated ovum. The cells that line the Fallopian tube are columnar in type and ciliated with its wave-like motion toward the