Vol. 60, 1909 - University of North Carolina at Chapel Hill

376 THE CHARLOTTK MEDIOAL JOURNAL
nearly always impossible to distinguish one moment's notice and it is highly importani i
variety from another. In making a diag- that the patient be in easy reach of compe- }
iiosis we have what we can elicit from, the tent surgical skill at all times,
story of the patient in her own words, her It is nearly always best to approach these''
replies to minute questionings, and aphysi- pregnancies by a median laparotomy. Com-ii
cal examination. After the escape of the plete removal of fetus, membranes and pla- i
fetus from the tube and the beginning of the centa is highly desirable. By reason oi'
secondary abdominal type, the acute symp- dense adhesions great danger of hemorrhage'!
toms may subside, but there are apt to be or dangerous condition of the patient the I
recurrent attacks of pain. An apparently above procedure will at times be impossible I
normal condition necessarily tends to throw under such circumstances the edges of the i
the physician and patient off their guard, opening in the sac should be sutured to theH
The diagnosis is naturally difficult because parietal peritoneum and the sac carefully;'^
of the irregularity of the symptoms, the fre- drained. The placenta in such cases willij
'
i
quency with which it is stimulated by other come away gradually by fragments, and in
conditions, and the ease with which the two or three weeks its exfoliation will have
bleeding with or without expulsion of the
decidua may be taken for an ordinary aborbeen
complete. Surgical intervention',
should take place as early as possible aftett:'
tion.
more
Probably there are few conditions the death of the fetus. If the cyst in suchji
plain to the careful observer than a case is in the Cul de Sac—vaginal section i.t'j
typical case of exfetation but comparatively appropriate: after the extraction of fetus andi!|
few cases are typical. The diagnosis of placenta the cavity had best be packed withi|i
abdominal pregnancy is rather rarely made a five per cent, iodoform gauze. I wish toi
prior to false labor, for the reason that the urgently emphasize the absolute necessityl'i
physician's attention is seldom called to the for removal as early as a diagnosis can be]
ca.e- We should regard sudden collapse made and the stringent indications for im-;;
associated with pallor and other symptoms mediate operation when we see a pregnantji
of intra abdominal hemorrhage in any woman showing symptoms of intra- abdom-iji
woman having a possibility of pregnancy inal hemorrhage. «
as prima facie evidence of ruptured etopic Report of Case.—In connection with the J
pregnancy. A period of amenorrhoea usually above I will report the followihg case. The*
precedes the bloody discharge which does patient, S. J., a young married woman 28i
not correspond in nature nor necessarily in years old, was referred to me by Dr. C. W.'i
in point of time with the natural monthly Lemon of Claremont, W. Va. Shehadnot^
bleeding. Important points relative to the been under the immediate notice of the atbleeding
are the color, the persistence and tending physician much of the time. He
presence the of membrane of pieces of mem- had been called on occasionally to prescribe
brane. Among the most chaiacteristic for abdominal pains of a rather vague and
symptoms are the variable period of amen- indefinite character. The patient was of a
orrhoea, irregular uterine hemorrhage, pel- comparativefy ignorant and unobservanti
vie pain and discomfort, and the shedding type. The true nature of the trouble had
of the uterine decidua. so far gone undetected. The woman con-
Prognosis.—Abdominal pregnancy means sidered herself pregnant about six weeks
death to the fetus in nearly all cases and to when she entered the hospital March 28,
the mother in one half the cases. Clubfoot 1906. She, according to her statement, had
and other deformities are apt to be present been suffering a good deal from indigestion
in the child owing to the deficiency of am- associated with nausea, her monthly periods
niotic fluid and 'the pressure on the sac had been irregular and painful for some
walls. The outcome in untreated cases not months, and that the lasl month had been
ending fatally, is chronic invalidism. especially painful.
Treatment.—The first reported, definitely On surgical examination I found a large
planned operation after a specific diagnosis mass posterior to the uterus which apparwas
performed in 1SS5 by \'eit of Berlin, ently extended up well into the pelvis, a
Immediate operation is advisable if a diag- uterus which in enlargement appeared to
nosis can be made during the first period or reseml^le closely that usually found about
even if there is a suspicion of exfetation, the fourth month of pregnancy. This organ
which is backed by good circumstantial was low in the pelvis and fixed in its posievidence.
After the fifth month has elapsed tion. There was considerable pelvic tenand
the fetus is still living if its preserva- derness, fetal heart sounds could be heard
tion is deemed desirable the woman should and the case was diagnosed as one of afe'
be kept very quiet in order to minimize the dominal pregnancy. The heart, lungs atfd
chances of rupture and to give her an op- kidneys were normal so far as could be as^
portunity to go to term. This pregnancy is certained at the time. Several times there
like a mine—ready to explode without a was an evening rise of temperature but oin