CASE OF EXTRA UTERINE BY DONALD DALRYMPLE, SURGEON, NORWICH. COMMUNICATED BY JOHN DALRYMPLE, Esq. Received March 30th-Read April 11th, 1848. THE numerous cases on record of extra uterine fœtation may be classed for the most part under three heads: tubular, interstitial or parietal, and ovarian. Such are the cases reported by Dr. Oldham, in the Guy's Hospital Reports, and by Mr. Cobbold, in the Provincial Medical and Surgical Journal. The case I now present differs entirely from the classes mentioned, and is remarkable in many points. On the 26th of June 1847, I was called to see Mrs. A a patient of the Norwich Lying-in Charity: being from home, my colleague, Mr. Master, attended for me, and found a woman with the uterus hanging out of the os externum. The uterus was of considerable size (as large as the full grown fœtal head), of a red purplish hue, with a large ulcerated patch on its anterior surface. The woman stated that it had descended frequently before, but not to so great an extent, and that she was in the sixth month of her pregnancy: she also complained much of the movements of the child very high up in the abdomen. The uterus was with some difficulty replaced, the recumbent position strictly enjoined, and an astringent injection prescribed. I saw the patient on the following day. The uterus had descended to, but not through, the os externum. On examining her with the speculum I found a large irregular patch of superficial ulceration on the anterior aspect of the womb, with a profuse yellow discharge. The cervix uteri was scarcely shortened; the os was patent to the admission of the forefinger, and presented none of the conditions of that part at the sixth month of pregnancy. On examining the abdomen I found an enlargement commensurate with her calculation, but reaching much higher and not so full over the pubes as usual: the swelling was hard and elastic, and I distinctly felt movements under my hand. The umbilicus was protruding, the areola of the nipples were dark and extended. Mrs. A—— stated she was 32 years of age; that she had borne five children; had enjoyed very good health; and, though small-sized, was capable of great muscular exertion. She said she believed she became pregnant in the early part of January, as she had menstruated in the last week of the previous month. She believed she quickened at the early part of April; but that shortly after, or about that period, she lifted, with one hand, a full pail of water from a tub, after which her feelings became different from those on former occasions. Her husband stated, after his wife's decease, that during coition at the latter end of April, or thereabouts, during a violent movement, she suddenly felt something give way within her, and that immediately afterwards both of them perceived, on placing the hand on the umbilicus, a strange fluttering sort of movement, from which time she always referred the movements of the foetus to a position higher than before. The woman, from motives of delicacy, had never mentioned this circumstance to me. Shortly after this she first perceived the descent of the uterus, and was attended by a medical man (who told her she was pregnant) for four or five weeks, when, being unable longer to afford to pay for advice, she sought the aid of the parish surgeon. Upon the uterus descending nearly through the os externum, he also told her she was pregnant, and ordered a pessary; but this occasioned so much pain that she could not wear it. The womb continued to descend sometimes, but was always returnable by her own efforts, till the time of her becoming my patient. I saw her repeatedly; and, after a few days, the foetal circulation was heard by Mr. Master and myself; it was most unequivocally made out, though in an unusual position, namely, high up, midway between the umbilicus and the right hypochondriac region; but we could nowhere find the placental bruit. We decided that she was pregnant, and recommended her to wait the accomplishment of her time in a recumbent position, believing that, as pregnancy advanced, the disposition to prolapsus would subside. This, however, only partially took place; for, though the uterus did not escape through the external aperture, the cervix still lay on the perinæum. On the 30th of September she sent for me, being in labour, and as I was again absent, Mr. Master kindly visited her. He found her suffering irregular pains, but there was no dilatation of the os uteri: the cervix was in the same state as in June, and there were no evidences of labour. I saw her at night; her pains had ceased, and with them all movements of the child. She said also that the pains had differed from labour pains, though unable to define the difference. After a few days she diminished in size, her health improved, and she began to get about again. At the expiration of a month, believing she might have made an error of a month in her reckoning, I again visited her. Her abdomen was smaller, and had lost much of its elastic feel; her general aspect was improved; she was able to get about better; she had lost all feeling of movement in the abdomen, and no sensation was conveyed to the hand. She had a slight sanious discharge, free from fœtor; her bowels acted regularly; she passed her water freely, but no change had taken place in the state of the os and cervix uteri, and occasional protrusion took place. Mr. Master again saw our patient with me, and we in vain sought for the foetal circulation we had heard in June and July. We placed her on her knees and elbows, but there was no displacement or falling forwards as of a mass or tumour. There was a circumscribed swelling, about the size of an infant's head, extending from the pubes to the right iliac fossa; and this was rather tender to the touch. A week or two passed by without any change, and I proposed her going into the Norfolk and Norwich Hospital, for the benefit of further advice and treatment. This she did on the 12th of November, and I met her medical attendants there. The conclusions arrived at were very indecisive. She remained in the hospital seventeen days, undergoing no treatment, but improving in health for the first twelve days, so that she was enabled to assist in the lesser labours of the ward. During the last three or four days of her sojourn she complained of pain and tenderness of the body; but, as her husband was ill, she left the house. From this time she got rapidly worse, complaining much of the enlargement of the abdomen, which had assumed a very different shape, of great pain, shortness of breath, and cough. I did not see her; but the medical men, under whose care she now fell, treated with ridicule the idea of her previous or present condition being that of pregnancy. She died on the morning of the 23rd of December; and in the afternoon of the same day I examined the body. Unfortunately I was unable to procure the assistance of Mr. Master, and was obliged to perform the inspection alone. I carefully dissected back the integuments and muscles of the abdomen; but, after dividing the peritoneum, I did not enter the abdominal cavity, for there was a thick layer of soft yellow lymph, lining the whole surface of the peritoneum, and easily pulled off. On dividing this, out rushed a large quantity of thick sanious pus (seven or eight pints were saved and measured), which was not offensive nor putrid. Immediately across the abdomen, above the umbilicus, lay what at first sight I took to be a large purplish liver, with patches of lymph upon it; but which, on further uncovering, I found to be the back and shoulders of a large full-grown fœtus, with patches of smegma. The child was lying in a cavity, formed and bounded above by the intestines and the omentum adhering to the parietes of the abdomen, and below by the pelvis: this cavity was lined with a thick layer of soft yellow lymph, highly vascular in places; and in the iliac fossæ and over the psoæ muscles, thoroughly organized. The child lay with the head occupying the usual position. of the spleen, the vertex touching the five last ribs of the left side, with the scalp adherent to the insertions of the diaphragm; the feet were lying in, and adherent to, the right iliac fossa; and from both of these points it was requisite to dissect the attachments, in order to extricate the child. I traced the umbilical cord, which wound round the loins of the child, obliquely down to a large mass occupying the region of the pubes, extending to the right iliac fossa, and touching the heels of the child. I was quite unable to extricate this mass, which, on section, presented the appearance of a deep maroon-coloured spongy texture, more like the lungs of aquatic birds than anything else I can compare it to. I could not make out the uterus, so irregular and confused was this mass; and being unaided, and surrounded by a number of prying women, in a dark December afternoon, I was unable to bring away the mass to dissect it thoroughly. I, however, passed my finger into the vagina, and found the cervix uteri lying low down, unaltered in length or character from what it was six months before; and, on pushing it upwards, I found that I moved the whole of the before-mentioned spongy mass, which prevented my passing the cervix uteri up to its normal position. The bowels were all driven upwards, and matted together by abundance of lymph: the liver, which was very large, but not structurally diseased, was driven up into the chest, so that its convex surface reached to the fourth rib, and ex |