Clinical Records from Private and Hospital Practice.

I.-Case of Tubo-Interstitial Pregnancy; Destruction of the Life of the Fœtus by the Galvanic Current; Recovery. By CHARLES MCBURNEY, M. D., New York.

EARLY in December, 1877, I took charge of Mrs. C., a young married lady, who supposed herself to be pregnant for the first time, and obtained from her the following history:

Up to October 1, 1877, Mrs. C. had always menstruated regularly, with one exception, when, several years ago, her period was delayed for two weeks, owing to a severe cold. Up to the same date she had never had any uterine disease or other malady affecting the pelvic organs. Her last menstruation began on October 1st, and terminated on October 5, 1877. From this date, up to November 22d, no menstrual discharge appeared. On November 22d, and again on the 23d, a slight flow occurred on the afternoon only of each day. This flow was not accompanied by pain. On November 24th there was no flow. On the afternoon of November 25th the discharge of blood was "quite abundant." From this date to December 1st there was an entire cessation of flow, but in the evening of December 1st it reappeared. There was now another intermission till December 9th, when, on that day, and on the two succeeding ones, there occurred a slight discharge of blood, which was not continuous.

The gastric and mammary signs of pregnancy were wellmarked, nausea having been troublesome since the middle of October. On December 16th there was a slight discharge of blood from the vagina, and again, on the 20th, it recurred for a few hours in the morning. On none of these occasions had there been pain, or other symptom of abnormal pregnancy. On December 25th I made a thorough examination.

In examining the abdomen, I could not feel the fundus of the uterus; but on the left side, overhanging the edge of the true pelvis, and extending beyond about two inches, I could distinctly feel a smooth tumor, apparently about the size of a large egg. Slight pressure over this tumor gave decided pain.

Pressure at any point, in the lower half of the abdomen, gave pain in the region of this tumor.

On making a vaginal examination, I found the uterus displaced decidedly to the right of the median line. The uterus was certainly very slightly, if at all, enlarged; and the cervix, which I examined with the speculum, appeared to be the cervix of a non-impregnated uterus. To the left of the cervix could be very distinctly felt a fluctuating tumor, with a very thin wall. Pressure against this caused decided pain. Pressure applied over the tumor, felt through the abdominal wall, did not perceptibly disturb the position of the cervix, but did very decidedly force down the roof and left wall of the vagina.

The history of the case, and the results of my examination, led me to make the diagnosis of extra-uterine pregnancy-probably tubal; but I did not use the sound, as I wished to have others examine the case, and I did not think it well to have the sound used more than once.

December 30th.-I made a second examination, with precisely the same result as that obtained before.

January 2d.-At my request, Dr. T. G. Thomas examined Mrs. C., and coincided entirely in the diagnosis. Dr. Thomas was able, by bi-manual examination, to feel the fundus of the uterus quite to the right of the median line, and little, if at all, enlarged.

I then asked Dr. T. Addis Emmet to examine the case, which he did without being informed of its nature. He pronounced the case to be certainly one of extra-uterine pregnancy, and also stated that, in his examination by the rectum, he thought he could feel a sort of vermicular motion in the tumor, such as might be caused by a small foetus.

To avoid a possible mistake, we again met on January 3d, and the uterine sound was passed by Dr. Thomas, Dr. Emmet, and myself. The fundus was reached at a depth of exactly 3 inches. Not a drop of blood followed this examination. In discussing the treatment of the case, we were unanimously of the opinion that delay was not to be thought of. Three methods of treatment were spoken of: 1. Gastrotomy. 2. Delivery through the vagina, after Thomas's method, using

the galvano cautery-knife. 3. Destruction of the life of the fœtus by the galvanic current. This last method was strongly urged by Dr. Thomas, and was agreed upon as offering the best chance of success. (See Ohio Medical and Surgical Journal for October, 1877; "Transactions of the Obstetrical Society of London, 1866," vol. vii., p. 96; "American Journal of Obstetrics, May, 1872," p. 161.)

What we expected as a result of the death of the foetus was one of two things: either the foetal mass would become encysted and remain inert, or an abscess would eventually form, and discharge through one of the usual channels.

January 3d.-2 P. M.: Present, Dr. A. D. Rockwell, Dr. Thomas, Dr. Emmet, and myself. Dr. Rockwell brought with him his own battery, and took charge of its management during the application of the current. I am indebted to him for an accurate account of the quantity of electricity used, which I give in full, as it may be of use to others. The galvanic current was used, generated by zinc-carbon elements immersed in the following solution:

Each zinc-carbon element was 5 inches long and 14 inches wide. The negative electrode consisted of a long, insulated stem, surmounted by a metal ball -inch diameter, and covered with wet sponge. This was passed through the anus about 4 inches, and applied to the rectal aspect of the tumor. The positive electrode consisted of a broad, flat, wet sponge, and was applied to the abdominal surface of the tumor. The circuit of 17 cells was now closed, and a series of current interruptions-about 120 to the minute-passed. Excluding several short intervals of rest, the patient was under the influence of electricity during three minutes.

Very marked contractions of the muscles of the abdomen and limbs accompanied the shocks, and decided pain was caused, but the patient was perfectly comfortable as soon as the current was stopped. The patient passed a comfortable day and night, without pain or disturbance of any kind.

January 4th.-9 A. M.: Battery again used in .the same way. The application was begun with 18 cells, which number was gradually increased to 23, with which the last series of shocks was given. Violent muscular contractions were caused, and the patient complained of intense pain. Two minutes were consumed in actual treatment, and during the application the current was twice reversed. The pain caused was very severe, and did not entirely cease after the cessation of the current.

During the afternoon and evening the patient complained of occasional severe pains, always referred to the left iliac fossa. 11. A. M.: Pulse, 88; temperature, 99.3°. 12.45 P. M.: Pain severe. Gave one-quarter grain morphine subcutaneously. Nausea became constant, and before night the patient vomited after taking anything, even water, into the stomach. 2 P. M.: Pulse, 96; temperature, 99.5°. 3.30 P. M.: Gave suppository, containing extract opium, one-half grain; extract belladonna, one-quarter grain. About 9 P. M., a slight discharge of blood from the vagina was noticed. During the night, nausea, vomiting, and severe pain continued. Pain was partly controlled by morphine, given hypodermically. A slight flow of blood continued through the night.

January 5th.-9 A. M.: Consultation: present, Drs. Thomas, Emmet, and myself. Temperature, 100.5°. Abdomen very tender at all points; tumor very hard, prominent, and painful; patient's expression worn; pulse rapid and feeble. Everything pointed to an early rupture of the sac. This opinion was entertained by all those present. 10.30 A. M.: The flow suddenly became much more abundant; and, on examining the abdomen, I found that the tumor in the left fossa had disappeared, with the exception of a small mass on the brim of the pelvis. In the median line, reaching to within about two inches of the umbilicus, I could distinctly feel a smooth, symmetrical tumor, precisely like a uterus containing a foetus of three or four months. My first impression was that the uterus had filled with blood, but, on making a vaginal examination, I felt a tense and very strong bag of membranes protruding from a fully-dilated cervix. On rupturing the membranes, there was a large discharge of pure liquor amnii,

and with it a dead foetus of about three months. The placenta followed in about 20 minutes, and the uterus contracted naturally and remained firm. The patient at once felt an intense relief.

During the day there were a few ordinary after-pains, and the abdomen continued to be somewhat sensitive to pressure. It was easy, at several examinations made during the day, to feel the fundus of the contracted uterus, and, at the same time, a thickening of the tissues where the former tumor had been.

January 6th.-10 A. M.: Patient passed a pretty comfortable night. The flow was rather abundant. Pulse, 104; temperature, 100°. 8 P. M.: Pulse, 110; temperature, 101°. General soreness of muscles all over the body.

January 8th.-Pulse, 88; temperature, 99.5°.

Mrs. C. made as rapid a recovery as is usual after an abortion.

In concluding my report of this case, I wish to state distinctly the position which I believe the foetus to have occupied. That it was not in the uterus, the repeated and careful examinations made have, I think, demonstrated. That it was not far from the uterus, the result has rendered more than probable. The foetus was, no doubt, situated in the left Fallopian tube, and probably so close to its point of entrance into the uterine cavity that, by dilatation of the mouth of the tube, with, very probably, some rupture of its margin, the foetal mass was enabled to escape into the uterus. The drawing given on the next page is intended to represent (of course in a purely diagrammatic manner) the probable position of the foetus.

The escape of the foetal mass from its abnormal position into the uterine cavity and the rapid dilatation of the latter to receive it were certainly remarkable. Might not the unusual strength of the membranes have contributed largely to the attainment of this fortunate result? In a similar case, I should attempt, by another means, to render the diagnosis of the position of the fœtus still more certain. There could be no serious objection to thoroughly dilating the cervix uteri, and introducing the finger to the fundus, as by that means one could, perhaps, ascertain the possibility of delivery through the uterus.