Mr. Edgar?Cases simulating Extra-uterine Pregnancy. 417

NOTES ON CASES SIMULATING EXTRA-UTERINE

PREGNANCY.1

By JOHN EDGAR, M.A., B.Sc., M.B., C.M., F.F.P.S.G.,

Professor of Midwifery and Diseases of Women, Anderson's College Medical School; Surgeon, Glasgow Samaritan Hospital for Women.

In a case of ordinary pregnancy it is about the eighteenth week before the condition can be diagnosed with absolute

certainty. Prior to this, if, with a history of amenorrhoea, morning sickness and mammary symptoms, one can make out by bimanual examination that the body of the uterus is

enlarged, globular, and elastic, and that Hegar's sign is

present, the diagnosis may be made with reasonable con-

fidence, but cannot be absolutely affirmed, because other conditions may simulate pregnancy at this stage in every particular. The same remarks hold good in respect to extra-uterine

pregnancy. As the great majority of such cases terminate in tubal rupture, or, more frequently, tubal abortion in the course of the second month, so in most cases the diagnosis can only be provisional until the presence of a foetus or of chorionic villi is demonstrated after operation. Just as in ordinary pregnancy, however, if the history be fairly typical, and a bimanual examination corroborates one's suspicions, one may be reasonably confident of the diagnosis.

Extra-uterine pregnancy is now generally recognised as

being a comparatively frequent disease. In the Glasgow Samaritan Hospital for Women, since my appointment as

surgeon three and a half years ago, out of 470 cases which have been under my care, 26 have been cases of ectopic gestation. In addition, I have had in my private practice during the same time five other cases. In all, therefore, I have treated thirty-one cases of extra-uterine pregnancy in three and a half years, an average of nine per year. An

affection which occurs so commonly as this cannot be regarded as rare. For this reason, and also owing to the danger which

may be incurred by a failure to diagnose the condition, it is

important to be on the watch. A fairly typical case would have the following history:?

After a period of five, eight, or twelve weeks amenorrhoea,

1 Read at a meeting of the Glasgow Obstetrical and Gynaecological Society held on 14th March, 1900.

1 T TTT No. 6. 21) vol. Li 11.

418 Mr. Edgar?Notes on Cases

with or without morning sickness and breast symptoms, the patient is seized with one or more sudden attacks of cramp- like abdominal pains, with, as a rule, on each occasion semi- or complete collapse, vomiting, cold sweats, and abdominal distension. Generally with the first attack, or within a few days afterwards, uterine haemorrhage makes its appearance, and continues more or less constantly for some weeks, or even months; this may or may not be accompanied by the expulsion of a uterine decidual cast or of membranous shreds, which, under the microscope, show the characteristic decidual cells of pregnancy. On examination, tenderness is elicited at one or other iliac region, and either a boggy, distended Fallopian tube, or a hematocele, is felt to one side of and behind the

uterus; the latter may fill the pelvis, and may even reach to the umbilicus. In the lateral vaginal fornix corresponding to the tube affected pulsation is, as a rule, more pronounced than in the other. The temperature .does not rise unless sepsis supervenes.

In such a case one may be reasonably certain of the

diagnosis. As an example, let me describe a case which I have not previously published, and which, moreover, contains one or two points of interest.

Mrs. G., set. 34, iv-para, was admitted into the Samaritan Hospital on 17th February, 1898. Menstruation regular till 25th December, 1897; thereafter amenorrhoea and morning sickness until the day before admission. Slight shooting pains in the breasts, but no mammary secretion. Otherwise

patient felt well till 14th February, when she suddenly turned sick and faint and had severe cramp-like pains, like labour pains, in the sacral and hypogastric regions. There was also a good deal of retching, and she was unable to pass urine from 7 a.m. till 11 P.M. During the following two days the patient felt weak, micturition was difficult, and the cramp- like pains recurred at intervals. On the 16th, uterine

haemorrhage appeared, but there were no clots nor mem-

brane. Condition on admission.?Weak and anaemic. Uterus

dextroposed and enlarged. Behind it, a lobulated, boggy mass was felt adherent to the pelvic walls and to the uterus, and extending especially to the left side. Pulsation was more marked in the left fornix than in the right. Sound passed 3f inches.

Operation on 19th February.?Abdominal incision. On

removing some black clot, which lay at the pelvic brim,

siDniilating Extra-uterine Pregnancy. 419

alarming arterial hemorrhage immediately occurred. I at once passed my left hand down to the fundus uteri, slipped it along the left appendages, which, according to the bimanual examination, were presumably the site of the pregnancy, and seized the left infundibulo-pelvic ligament. Using this hand as a guide, I inserted a pair of long pressure-forceps into the abdominal cavity and clamped the ligament. To my surprise, however, the bleeding continued. I immediately explored the state of the other tube, found it distended, and clamped the ligament on that side. To my relief, the haemorrhage at once ceased. After clearing the blood out of the pelvis, I discovered that the left tube was healthy, and that the right tube was distended and retort-shaped. The latter was therefore removed. On examination subsequently, it was found to be unruptured, and to contain a tubal mole with chorionic villi. The haemorrhage had occurred through the ostium abdominale. O o

The case was, therefore, one of tubal abortion, with the formation of a pelvic haematocele. The patient made a good recovery, and has remained well. She passed a complete decidual cast on the third day after the operation.

The special points of interest in this case are:? 1. The absence of mammary secretion. 2. The increased pulsation in the left fornix, and the

presence of the mass on the left side of the pelvis in spite of the fact that it was the right tube which was gravid. The

main portion of the mass was, of course, extravasated blood. 3. The free arterial haemorrhage which occurred on dis-

lodging the clot which blocked the ostium abdominale of the tube. The possibility of this occurrence should be remembered when examining cases of extra-uterine pregnancy.

4. The immediate arrest of haemorrhage on clamping the infundibulo-pelvic ligament, through which runs the ovarian artery. Had I attempted to sponge away the blood, separate

, adhesions, and bring up and ligature the tube, before clamping the ligament, time would have been lost, and the patient would, in all probability, have died from haemorrhage. I can

never forget a case in which this occurred in the hands of a brother surgeon.

So far as the symptoms and signs are concerned, the fore-

going is a fairly typical case. In considering the subject of differential diagnosis, one must

bear in mind that many of the usual symptoms may be

absent, and, on the other hand, that what one would regard as a typical case may turn out after operation to be something

420 Mr. Edgar?Notes on Cases ?

totally different. The most common mistake, so far as I have seen in my consulting practice, is to diagnose extra-uterine pregnancy as ordinary abortion. Amenorrhcea, morning sick- ness, and breast symptoms followed by an attack of labour-like pains, more or less continuous haemorrhage, and the expulsion of a decidua are met with in both conditions, and in many cases of extra-uterine pregnancy the collapse following tubal abortion is slight, so that a mistake is very easily made. In one or two of my cases of tubal abortion the patient was able to go about, and even do a little housework.

In such cases, however, a physical examination will generally settle the diagnosis. It is only when a sactosalpinx is present in addition to the uterine pregnancy that one would be still in doubt, and in such a case abdominal section is usually indicated at anyrate. Of course, the demonstration of chorionic villi, or of a foetus, among the contents of the

vaginal discharge would at once settle the diagnosis of uterine abortion, though even in such cases it must not be forgotten that the two conditions may, on rare occasions, be associated. The cases which occasion the greatest difficulty in diagnosis

are: (1) those of pelvic haematocele due to other causes, and (2) those of pyosalpinx or suppurating pelvic tumour, accom- panied by exudative pelvic peritonitis, in which no clear

history of elevated temperature at the onset can be obtained. I shall first describe a case of pelvic hematocele, due to

rupture of an ovarian haematoma, which simulated ectopic gestation very closely.

Case of rpelvic hematocele due to ruptured hcematoma of ovary.

Mrs. S.,%aet. 35, vi-pava, was admitted into the Samaritan Hospital on 20th January, 1900, complaining of pain in the left iliac region, and of uterine haemorrhage of eight weeks* duration.

History of illness.?Eight weeks prior to admission, after a period of seven weeks' amenorrhcea without morning sickness or breast symptoms, but with, during the last two weeks, a

feeling of weight in the pelvis, patient, while undressing at night, was suddenly seized with such severe pain in the right iliac region that she lost consciousness, and remained in this condition for five minutes. She felt sick, but did not vomit. Next morning free uterine haemorrhage began, and continued until admission. There were no clots, nor any portions of membrane. The pain continued, and there were three sub- sequent attacks accompanied by syncope.

simulating Extra-uterine Pregnancy. 421

On admission, patient complained of the pain and hemor- rhage, and of frequent micturition. The urine contained a large quantity of albumen, with a faint trace of blood. There was no mammary secretion. On bimanual examination, the uterus was found to be

pushed forwards, and fixed by a large mass, which filled the pelvis and extended up to within 2 inches of the umbilicus. There was no tenderness, and the mass was distinctly fluctuant. On 25th January the abdomen was opened, and, after free-

ing several coils of adherent bowel, about a pint and a half of dark fluid blood was removed from the pelvis. The small intestine was found to be adherent to the bottom of the pouch of Douglas, in such a position, therefore, that, had posterior colpotomy been performed, it might have been injured. On

bringing the right appendages into view, the tube was found to be normal, but the ovary was distended with dark fluid blood to the size of a hen's egg. A small laceration of this hematoma of the ovary was evidently the source of the intra- peritoneal haemorrhage. The tube and ovary were ligatured and removed, and showed under the microscope no traces of any ovular structure. The other appendages, being apparently normal, were not removed. The patient made an uninterrupted recovery, and was

dismissed on 23rd February.

In this case morning sickness and mammary symptoms, including mammary secretion, were absent, but such symptoms are by no means invariably present in pregnancy. Otherwise

the history, and the condition ascertained by a pelvic examina- tion, were in every respect typical of tubal abortion.

In the next two cases the symptoms and signs were due to

suppuration in a Fallopian tube, and in the last to a sup-

purating ovarian cyst. In such cases, in addition to the

distended tube or the pelvic mass met with on bimanual examination, there may be sudden attacks of abdominal

cramp-like pains, collapse, abdominal distension, vomiting, and also occasionally a history of amenorrhoea and mammary symptoms. If the swelling be very tender or very firm, it is not likely to be extra-uterine pregnancy; but occasionally one fails to make out tenderness, and the consistence may be

boggy, even when no extravasation of blood is present. Marked vaginal pulsation in one lateral fornix may be

obtained, and there may be no clear history of elevated

temperature.

422 Mr. Edgar?Notes on Cases

This last point is a very important one, because pyrexia at the onset is never observed in tubal rupture or abortion, whereas it is the rule in pelvic inflammation. Professor Martin1 reports five cases of pyosalpinx with chronic exudative peritonitis which, before operation, had been diagnosed as cases of ectopic gestation, both from the symptoms?delayed menstruation, labour-like pains, external uterine haemorrhage, and apyrexial course ; and from signs?a non-gravid uterus, and a distended tube. The following two cases are of similar interest:?

Case of purulent salpingitis. Mrs. F., aet. 33, ii-para, was admitted into the Samaritan

Hospital on 1st June, 1899. The recovery from each of her

confinements, which were normal, was good. Menstruation had always been normal. No period had been missed, the last occurring on 11th to 13th May (rather shorter than usual), but patient stated that during both her pregnancies menstrua- tion had continued regularly up till term. On 14th May patient had ar sudden attack of sickness and

vomiting, followed in a few hours by severe labour-like pains. She did not faint, nor feel cold, but was covered with

perspiration. There was no rigor. The vomiting ceased on the second day, but the pains continued with short inter- missions for about a week. Thenceforth there was a constant

bearing-down pain in the pelvic region. Four days before admission there was a second severe attack of labour-like

pains, with semi-collapse and with distension of the abdomen, but no vomiting.

During both attacks the pain was so severe that morphia had to be administered. At no time was there any discharge of membrane. Micturition was at times difficult, but otherwise normal. On admission, a serous secretion could be expressed from

the vnammce. The uterus was retro verted, and fixed by a large firm mass filling up the left half of the pelvis.

Operation (7th June).?After opening the abdomen, the sigmoid flexure had to be separated from the utero-vesical pouch, to which it was so firmly adherent that the peritoneal covering of the bowel was torn, and the resulting raw surface had to be stitched. The uterus was then freed from its adhesions posteriorly, and brought forward. While this was

being done, some foetid fluid escaped from among the adhesions. Finally, the appendages were isolated with difficulty, ligatured,

1 Martin, Die Kran/cheiten der Eileiter, p. 365.

simulating Extra-uterine Pregnancy. 423

and removed, and the fundus uteri was sutured to the anterior abdominal wall.

Right appendages.?The tube was thickened, but contained nothing; the ostium abdominale was patent. The ovary was cystic, and of the size of a plum.

Left appendages.?The tube was distinctly enlarged, and pus was seen exuding through the ostium abdominale. The ovary was little larger than normal.

Patient made a good recovery, and was dismissed on 8th August.

Tubercular uterus and pyosalpinx. Mrs. E., aet. 31, iii-para, was admitted into the Samaritan

Hospital on 26th September, 1899, complaining of uterine

haemorrhage of two months' duration. Her labours and

puerperia were normal. Menstruation was normal, except for slight dysmenorrhoea, until after the birth of her second child, eight years ago, when for a year or two it appeared at intervals of a fortnight. Thereafter it was regular. It ceased in April, 1899, but neither morning sickness nor any mammary symptoms made their appearance. On 7th July patient had a sudden attack of severe cramp-

like pains all over the abdomen, accompanied by sickness and faintness. For a week she perspired freely every night, but stated that she did not think she was feverish. She remained in bed for three days, and then, the pain becoming less severe, she got up, but felt unable to work. A week afterwards she had to return to bed, owing to a sudden attack of profuse uterine haemorrhage and a recurrence of the cramp-like pains. The bleeding continued till admission into hospital, but at

no time did she notice any lumps nor membranous shreds in the discharge. Though the colicky pains did not recur, there was a continuous dragging and aching feeling in the lower part of the abdomen. At no time had she any rigors, nor,, with the exception of one day, a week before admission, did she think she was feverish.

Micturition had from July, 1899, been frequent and painful,, and during this period there were night sweats and loss of flesh. Lungs and heart normal. Colostrum could be expressed from the mammae. On bimanual examination, the uterus was found to be

pushed over to the left, and fixed by a lobulated, circumscribed, and firm mass of the size of a man s fist. Pulsation in

both fornices was marked, but more so in the right than in the left.

424 Mr. Edgar?Notes on Cases

Operation (30th September, 1899).?On opening the abdomen a loop of small intestine was found very firmly adherent to the right cornu uteri, which was enlarged to the size of a cherry. After carefully separating the bowel, the right tube was freed from its adhesions in the pouch of Douglas, and was found to be distended and retort-shaped. It was ligatured and removed along with the swollen cornu of the uterus.

While making the wedge-shaped incision necessary to remove the cornu, the uterine wall was ascertained to be infiltrated with caseous deposits. It was thought advisable, therefore, to remove the whole corpus uteri by a supra-vaginal amputation. The left appendages, which were matted, were removed along with it.

After removal, the uterus was found to be enlarged and dense. Like the right cornu, the left cornu was rounded and enlarged, though to a minor degree. The right tube was

retort-shaped. The inner cylindrical portion measured 1 \ inch in length and one eighth of an inch in thickness. The outer

portion of the tube was yellowish in colour, and was distended with pus into an ovoid mass measuring 2b inches by 1J inch by If inch. The ovary, also distended with pus and measuring 2 inches by 1| inch by If inch, was likewise yellowish, and lay between the outer distended portion of the tube and the uterus. It was closely adherent to both.

The case was, therefore, one of tuberculosis of the uterus and the right appendages, with salpingitis isthmica nodosa. The patient made an uninterrupted recovery, and was dismissed on 28th October, 1899.

Both these cases resembled extra-uterine pregnancy, as

regards not only their history, but also the condition on

physical examination. The only thing which made me hesitate to diagnose them definitely as such was the statement made by both patients that they had perspired at the onset of the attack. This pointed to the possibility of pelvic inflamma- tion ; but the assertion that there had been no pyrexia, together with the fact that there was certainly no rise in

temperature while the cases were under observation in the hospital, caused me to doubt whether after all the perspiration was not merely the cold sweat which so commonly accompanies the shock of internal haemorrhage. Otherwise the history, and the facts ascertained on examination, pointed very strongly to a diagnosis of extra-uterine pregnancy.

In the second case the night sweats indicated the possibility

simulating Extra-uterine Pregnancy. 425

of tuberculosis or of suppuration. There was, however, no evidence of the former in the lungs. This case is interesting as an example of the rare affection salpingitis isthmica nodosa. We owe the name of this condition to Chiari1 and Schauta,2

who considered that it was always due to gonorrhoea. Alterthum,3 011 the other hand, after a careful examination of several cases, has come to the conclusion that the cause in most, if not all, cases is tuberculosis. He gives the credit of this view regarding the etiology to Hegar,4 who described the affection in 1886 (two years prior to the publication of Schauta's paper), without, however, designating it under any distinctive name. The opinion that the condition is due to tuberculosis is supported by the case which I have just described, as also by another on which I operated by vaginal coeliotomy three years ago.

In conclusion, I shall report one other case of pelvic suppura- tion simulating ectopic gestation.

Case of suppurating intraligamentous ovarian cyst. Mrs. P., vet. 30, iv-para, was admitted into the Samaritan

Hospital 011 16th December, 1899. The last confinement, six months prior to admission, was very difficult, but was non- instrumental. The midwife stated that there was some

obstruction in the right side of the pelvis. The three previous labours were easy, and all the puerperia were normal. Menstrua-

tion was regular. '

On 25th November, after six weeks' amenorrhoea, during which there was neither morning sickness nor any mammary symptom, patient, while lifting a bed, suddenly felt some-

thing give way in the right iliac region, and was seized with severe cramp-like pains at that place, which made her cry out. Four days afterwards she had a second attack, accompanied by vomiting, a rigor, and perspiration. From that time till

admission there were constant pelvic pain and dysuria. On

1 Cliia i, " Zur pathologischen Anatomie des Eileiterkatarrhs," Zeitschr.

fiir Heilkunde, Bd. viii, 1887. 2 Schauta, "Ueber die Diagnose derFriihstadien chronischer Salpingitis,"

Arch, fiir GynBd. 33, 1888. 3 Alterthum, "Tuberkulose der Tuben und des Beckenbauchfells,"

Hegar's Beitrdge fiir Geb. und Gyn., Bd. i, Heft. 1, 1898. 4 Hegar, Die Entstehung, Diagnose und chirurgische Behandlung der

Genitaltuberculose des Weibes, 1886.

426 Mr. Edgar?Cases simulating Extra-uterine Pregnancy.

the day succeeding the second attack she had a flooding, which continued four days, and was accompanied by clots, but no membranous shreds. She stated that she thought she was feverish for a few days after the second attack of pain, but there were no more rigors nor sweats. On examination, the os was found patent enough to admit

the index-finger as far as to the first joint. The right fornix was obliterated, and pulsation here was stronger than in the left fornix. The uterus was pushed over to the left side by a somewhat boggy, lobulated mass, of the size of a man's fist,, situated on the right side of the pelvis. This mass was closely adherent both to the uterus and to the right pelvic wall. It was very slightly sensitive on pressure. On 2.'3rd December, the mass was removed by abdominal

section. It was found to be an ovarian cyst filled with

purulent material, and growing between the layers of the

right broad ligament. The other ovary, which was also found to be cystic and enlarged to the size of a plum, was likewise removed. The patient made an uneventful recovery, was dismissed on 26th January, and has remained well.

The diagnosis of this case, like that of the two last described* was rendered doubtful by the history of sweating. This, with the patient's statement that she had had a rigor and had been* she thought, feverish for a few days subsequently, led to the supposition that there was possibly some pelvic inflammation. However, the facts that these symptoms did not begin until the time of the second attack, four days after the first, and that, while in the hospital, the temperature remained normal* and very little tenderness could be elicited by pressure on the mass, together with the condition determined by bimanual examination and the history of amenorrhea, the flooding, and the two sudden attacks of cramp-like pains, led to the

provisional diagnosis of extra-uterine pregnancy, with* possibly, superadded pelvic inflammation.