PRENATAL ANOMALIES. 1 page

Extrauterine Pregnancy.--In the consideration of prenatal anomalies,

the first to be discussed will be those of extrauterine pregnancy. This

abnormalism has been known almost as long as there has been any real

knowledge of obstetrics. In the writings of Albucasis, during the

eleventh century, extrauterine pregnancy is discussed, and later the

works of N. Polinus and Cordseus, about the sixteenth century, speak of

it; in the case of Cordseus the fetus was converted into a lithopedion

and carried in the abdomen twenty-eight years. Horstius in the

sixteenth century relates the history of a woman who conceived for the

third time in March, 1547, and in 1563 the remains of the fetus were

still in the abdomen.

Israel Spach, in an extensive gynecologic work published in 1557,

figures a lithopedion drawn in situ in the case of a woman with her

belly laid open. He dedicated to this calcified fetus, which he

regarded as a reversion, the following curious epigram, in allusion to

the classical myth that after the flood the world was repopulated by

the two survivors, Deucalion and Pyrrha, who walked over the earth and

cast stones behind them, which, on striking the ground, became people.

Roughly translated from the Latin, this epigram read as follows:

"Deucalion cast stones behind him and thus fashioned our tender race

from the hard marble. How comes it that nowadays, by a reversal of

things, the tender body of a little babe has limbs nearer akin to

stone?" Many of the older writers mention this form of fetation as a

curiosity, but offer no explanation as to its cause. Mauriceau and de

Graaf discuss in full extrauterine pregnancy, and Salmuth, Hannseus,

and Bartholinus describe it. From the beginning of the eighteenth

century this subject always demanded the attention and interest of

medical observers. In more modern times, Campbell and

Geoffroy-Saint-Hilaire, who named it "Grossesse Pathologique," have

carefully defined and classified the forms, and to-day every text-book

on obstetrics gives a scientific discussion and classification of the

different forms of extrauterine pregnancy.

The site of the conception is generally the wall of the uterus, the

Fallopian tube, or the ovary, although there are instances of pregnancy

in the vagina, as for example when there is scirrhus of the uterus; and

again, cases supposed to be only extrauterine have been instances

simply of double uterus, with single or concurrent pregnancy. Ross

speaks of a woman of thirty-three who had been married fourteen years,

had borne six children, and who on July 16, 1870, miscarried with twins

of about five months' development. After a week she declared that she

was still pregnant with another child, but as the physician had placed

his hand in the uterine cavity after the abortion, he knew the fetus

must be elsewhere or that no pregnancy existed. We can readily see how

this condition might lead to a diagnosis of extrauterine pregnancy, but

as the patient insisted on a thorough examination, the doctor found by

the stethoscope the presence of a beating fetal heart, and by vaginal

examination a double uterus. On introducing a sound into the new

aperture he discovered that it opened into another cavity; but as the

woman was pregnant in this, he proceeded no further. On October 31st

she was delivered of a female child of full growth. She had menstruated

from this bipartite uterus three times during the period between the

miscarriage of the twins and the birth of the child. Both the mother

and child did well.

In most cases there is rupture of the fetal sac into the abdominal

cavity or the uterus, and the fetus is ejected into this location, from

thence to be removed or carried therein many years; but there are

instances in which the conception has been found in situ, as depicted

in Figure 2. A sturdy woman of thirty was executed on January 16, 1735,

for the murder of her child. It was ascertained that she had passed her

catamenia about the first of the month, and thereafter had sexual

intercourse with one of her fellow-prisoners. On dissection both

Fallopian tubes were found distended, and the left ovary, which bore

signs of conception, was twice as large as the right. Campbell quotes

another such case in a woman of thirty-eight who for twenty years had

practised her vocation as a Cyprian, and who unexpectedly conceived. At

the third month of pregnancy a hard extrauterine tumor was found, which

was gradually increasing in size and extending to the left side of the

hypogastrium, the associate symptoms of pregnancy, sense of pressure,

pain, tormina, and dysuria, being unusually severe. There was

subsequently at attack of inflammatory fever, followed by tumefaction

of the abdomen, convulsions, and death on the ninth day. The fetus had

been contained in the peritoneal coat of the ovary until the fourth

month, when one of the feet passed through the cyst and caused the

fatal result. Signs of acute peritonitis were seen postmortem, the

abdominal cavity was full of blood, and the ovary much lacerated.

The termination of extrauterine pregnancy varies; in some cases the

fetus is extracted by operation after rupture; in others the fetus has

been delivered alive by abdominal section; it may be partially

absorbed, or carried many years in the abdomen; or it may ulcerate

through the confining walls, enter the bowels or bladder, and the

remnants of the fetal body be discharged.

The curious cases mentioned by older writers, and called abortion by

the mouth, etc., are doubtless, in many instances, remnants of

extrauterine pregnancies or dermoid cysts. Maroldus speaks in full of

such cases; Bartholinus, Salmuth, and a Reyes speak of women vomiting

remnants of fetuses. In Germany, in the seventeenth century, there

lived a woman who on three different occasions is said to have vomited

a fetus. The last miscarriage in this manner was of eight months'

growth and was accompanied by its placenta. The older observers thought

this woman must have had two orifices to her womb, one of which had

some connection with the stomach, as they had records of the dissection

of a female in whom was found a conformation similar to this.

Discharge of the fetal bones or even the whole of an extrauterine fetus

by the rectum is not uncommon. There are two early cases mentioned in

which the bones of a fetus were discharged at stool, causing intense

pain. Armstrong describes an anomalous case of pregnancy in a

syphilitic patient who discharged fetal bones by the rectum. Bubendorf

reports the spontaneous elimination of a fetal skeleton by the rectum

after five years of retention, with recovery of the patient. Butcher

speaks of delivery through the rectum at the fourth month, with

recovery. Depaul mentions a similar expulsion after a pregnancy of

about two months and a half. Jackson reports the dissection of an

extrauterine sac which communicated freely with the large intestine.

Peck has an example of spontaneous delivery of an extrauterine fetus by

the rectum, with recovery of the mother. Skippon, in the early part of

the last century, reports the discharge of the bones of a fetus through

an "imposthume" in the groin. Other cases of anal discharge of the

product of extrauterine conception are recorded by Winthrop, Woodbury,

Tuttle, Atkinson, Browne, Weinlechner, Gibson, Littre, Magruder,

Gilland, and many others. De Brun du Bois-Noir speaks of the expulsion

of extrauterine remains by the anus after seven years, and Heyerdahl

after thirteen years. Benham mentions the discharge of a fetus by the

rectum; there was a stricture of the rectum associated with syphilitic

patches, necessitating the performance of colotomy.

Bartholinus and Rosseus speak of fetal bones being discharged from the

urinary passages. Ebersbach, in the Ephemerides of 1717, describes a

necropsy in which a human fetus was found contained in the bladder. In

1878 White reported an instance of the discharge of fetal remains

through the bladder.

Discharge of the Fetus through the Abdominal Walls.--Margaret Parry of

Berkshire in 1668 voided the bones of a fetus through the flesh above

the os pubis, and in 1684 she was alive and well, having had healthy

children afterward. Brodie reports the history of a case in a negress

who voided a fetus from an abscess at the navel about the seventeenth

month of conception. Modern instances of the discharge of the

extrauterine fetus from the walls of the abdomen are frequently

reported. Algora speaks of an abdominal pregnancy in which there was

spontaneous perforation of the anterior abdominal parietes, followed by

death. Bouzal cites an extraordinary case of ectopic gestation in which

there was natural expulsion of the fetus through abdominal walls, with

subsequent intestinal strangulation. An artificial anus was established

and the mother recovered. Brodie, Dunglison, Erich, Rodbard, Fox, and

Wilson are among others reporting the expulsion of remnants of ectopic

pregnancies through the abdominal parietes. Campbell quotes the case of

a Polish woman, aged thirty-five, the mother of nine children, most of

whom were stillborn, who conceived for the tenth time, the gestation

being normal up to the lying-in period. She had pains followed by

extraordinary effusion and some blood into the vagina. After various

protracted complaints the abdominal tumor became painful and inflamed

in the umbilical region. A breach in the walls soon formed, giving exit

to purulent matter and all the bones of a fetus. During this process

the patient received no medical treatment, and frequently no assistance

in dressing the opening. She recovered, but had an artificial anus all

her life. Sarah McKinna was married at sixteen and menstruated for the

first time a month thereafter. Ten months after marriage she showed

signs of pregnancy and was delivered at full term of a living child;

the second child was born ten months after the first, and the second

month after the second birth she again showed signs of pregnancy. At

the close of nine months these symptoms, with the exception of the

suppression of menses, subsided, and in this state she continued for

six years. During the first four years she felt discomfort in the

region of the umbilicus. About the seventh year she suffered

tumefaction of the abdomen and thought she had conceived again. The

abscess burst and an elbow of the fetus protruded from the wound. A

butcher enlarged the wound and, fixing his finger under the jaw of the

fetus, extracted the head. On looking into the abdomen he perceived a

black object, whereupon he introduced his hand and extracted piecemeal

an entire fetal skeleton and some decomposed animal-matter. The abdomen

was bound up, and in six weeks the woman was enabled to superintend her

domestic affairs; excepting a ventral hernia she had no bad

after-results. Kimura, quoted by Whitney, speaks of a case of

extrauterine pregnancy in a Japanese woman of forty-one similar to the

foregoing, in which an arm protruded through the abdominal wall above

the umbilicus and the remains of a fetus were removed through the

aperture. The accompanying illustration shows the appearance of the arm

in situ before extraction of the fetus and the location of the wound.

Bodinier and Lusk report instances of the delivery of an extrauterine

fetus by the vagina; and Mathieson relates the history of the delivery

of a living ectopic child by the vagina, with recovery of the mother.

Gordon speaks of a curious case in a negress, six months pregnant, in

which an extrauterine fetus passed down from the posterior culdesac and

occluded the uterus. It was removed through the vagina, and two days

later labor-pains set in, and in two hours she was delivered of a

uterine child. The placenta was left behind and drainage established

through the vagina, and the woman made complete recovery.

Combined Intrauterine and Extrauterine Gestation.--Many

well-authenticated cases of combined pregnancy, in which one of the

products of conception was intrauterine and the other of extrauterine

gestation, have been recorded. Clark and Ramsbotham report instances of

double conception, one fetus being born alive in the ordinary manner

and the other located extrauterine. Chasser speaks of a case in which

there was concurrent pregnancy in both the uterus and the Fallopian

tube. Smith cites an instance of a woman of twenty-three who became

pregnant in August, 1870. In the following December she passed fetal

bones from the rectum, and a month later gave birth to an intrauterine

fetus of six months' growth. McGee mentions the case of a woman of

twenty-eight who became pregnant in July, 1872, and on October 20th and

21st passed several fetal bones by the rectum, and about four months

later expelled some from the uterus. From this time she rapidly

recovered her strength and health. Devergie quotes an instance of a

woman of thirty who had several children, but who died suddenly, and

being pregnant was opened. In the right iliac fossa was found a male

child weighing 5 pounds and 5 ounces, 8 1/2 inches long, and of about

five months' growth. The uterus also contained a male fetus of about

three months' gestation. Figure 4 shows combined intrauterine and

extrauterine gestation. Hodgen speaks of a woman of twenty-seven, who

was regular until November, 1872; early in January, 1873, she had an

attack of pain with peritonitis, shortly after which what was

apparently an extrauterine pregnancy gradually diminished. On August

17, 1873, after a labor of eight hours, she gave birth to a healthy

fetus. The hand in the uterus detected a tumor to the left, which wag

reduced to about one-fourth the former size. In April, 1874, the woman

still suffered pain and tenderness in the tumor. Hodgen believed this

to have been originally a tubal pregnancy, which burst, causing much

hemorrhage and the death of the fetus, together with a limited

peritonitis. Beach has seen a twin compound pregnancy in which after

connection there was a miscarriage in six weeks, and four years after

delivery of an extrauterine fetus through the abdominal walls. Cooke

cites an example of intrauterine and extrauterine pregnancy progressing

simultaneously to full period of gestation, with resultant death.

Rosset reports the case of a woman of twenty-seven, who menstruated

last in November, 1878, and on August 5, 1879, was delivered of a

well-developed dead female child weighing seven pounds. The uterine

contractions were feeble, and the attached placenta was removed only

with difficulty; there was considerable hemorrhage. The hemorrhage

continued to occur at intervals of two weeks, and an extrauterine tumor

remained. Two weeks later septicemia supervened and life was despaired

of. On the 15th of October a portion of a fetus of five months' growth

in an advanced stage of decomposition protruded from the vulva. After

the escape of this putrid mass her health returned, and in four months

she was again robust and healthy. Whinery speaks of a young woman who

at the time of her second child-birth observed a tumor in the abdomen

on her right side and felt motion in it. In about a month she was with

severe pain which continued a week and then ceased. Health soon

improved, and the woman afterward gave birth to a third child;

subsequently she noticed that the tumor had enlarged since the first

birth, and she had a recurrence of pain and a slight hemorrhage every

three weeks, and distinctly felt motion in the tumor. This continued

for eighteen months, when, after a most violent attack of pain, all

movement ceased, and, as she expressed it, she knew the moment the

child died. The tumor lost its natural consistence and felt flabby and

dead. An incision was made through the linea alba, and the knife came

in contact with a hard, gritty substance, three or four lines thick.

The escape of several quarts of dark brown fluid followed the incision,

and the operation had to be discontinued on account of the ensuing

syncope. About six weeks afterward a bone presented at the orifice,

which the woman extracted, and this was soon followed by a mass of

bones, hair, and putrid matter. The discharge was small, and gradually

grew less in quantity and offensiveness, soon ceasing altogether, and

the wound closed. By December health was good and the menses had

returned.

Ahlfeld, Ambrosioni, Galabin, Packard, Thiernesse, Maxson, de

Belamizaran, Dibot, and Chabert are among others recording the

phenomenon of coexisting extrauterine and intrauterine pregnancy.

Argles mentions simultaneous extrauterine fetation and superfetation.

Sanger mentions a triple ectopic gestation, in which there was twin

pregnancy in the wall of the uterus and a third ovum at the fimbriated

end of the right tube. Careful examination showed this to be a case of

intramural twin pregnancy at the point of entrance of the tube and the

uterus, while at the abdominal end of the same tube there was another

ovum,--the whole being an example of triple unilateral ectopic

gestation.

The instances of delivery of an extrauterine fetus, with viability of

the child, from the abdomen of the mother would attract attention from

their rarity alone, but when coupled with associations of additional

interest they surely deserve a place in a work of this nature. Osiander

speaks of an abdominal fetus being taken out alive, and there is a

similar case on record in the early part of this century. The London

Medical and Physical Journal, in one of its early numbers, contained an

account of an abdominal fetus penetrating the walls of the bladder and

being extracted from the walls of the hypogastrium; but Sennertus gives

a case which far eclipses this, both mother and fetus surviving. He

says that in this case the woman, while pregnant, received a blow on

the lower part of her body, in consequence of which a small tumor

appeared shortly after the accident. It so happened in this case that

the peritoneum was extremely dilatable, and the uterus, with the child

inside, made its way into the peritoneal sac. In his presence an

incision was made and the fetus taken out alive. Jessop gives an

example of extrauterine gestation in a woman of twenty-six, who had

previously had normal delivery. In this case an incision was made and a

fetus of about eight months' growth was found lying loose in the

abdominal cavity in the midst of the intestines. Both the mother and

child were saved. This is a very rare result. Campbell, in his

celebrated monograph, in a total of 51 operations had only seen

recorded the accounts of two children saved, and one of these was too

marvelous to believe. Lawson Tait reports a case in which he saved the

child, but lost the mother on the fourth day. Parvin describes a case

in which death occurred on the third day. Browne quotes Parry as saying

that there is one twin pregnancy in 23 extrauterine conceptions. He

gives 24 cases of twin conception, one of which was uterine, the other

extrauterine, and says that of 7 in the third month, with no operation,

the mother died in 5. Of 6 cases of from four and a half to seven

months' duration, 2 lived, and in 1 case at the fifth month there was

an intrauterine fetus delivered which lived. Of 11 such cases at nine

months, 6 mothers lived and 6 intrauterine fetuses lived. In 6 of these

cases no operation was performed. In one case the mother died, but both

the uterine and the extrauterine conceptions lived. In another the

mother and intrauterine fetus died, and the extrauterine fetus lived.

Wilson a gives an instance of a woman delivered of a healthy female

child at eight months which lived. The after-birth came away without

assistance, but the woman still presented every appearance of having

another child within her, although examination by the vagina revealed

none. Wilson called Chatard in consultation, and from the fetal

heart-sounds and other symptoms they decided that there was another

pregnancy wholly extrauterine. They allowed the case to go twenty-three

days, until pains similar to those of labor occurred, and then decided

on celiotomy. The operation was almost bloodless, and a living child

weighing eight pounds was extracted. Unfortunately, the mother

succumbed after ninety hours, and in a month the intrauterine child

died from inanition, but the child of extrauterine gestation thrived.

Sales gives the case of a negress of twenty-two, who said that she had

been "tricked by a negro," and had a large snake in the abdomen, and

could distinctly feel its movements. She stoutly denied any

intercourse. It was decided to open the abdominal cyst; the incision

was followed by a gush of blood and a placenta came into view, which

was extracted with a living child. To the astonishment of the operators

the uterus was distended, and it was decided to open it, when another

living child was seen and extracted. The cyst and the uterus were

cleansed of all clots and the wound closed. The mother died of

septicemia, but the children both lived and were doing well six weeks

after the operation. A curious case was seen in 1814 of a woman who at

her fifth gestation suffered abdominal uneasiness at the third month,

and this became intolerable at the ninth month. The head of the fetus

could be felt through the abdomen; an incision was made through the

parietes; a fully developed female child was delivered, but,

unfortunately, the mother died of septic infection.

The British Medical Journal quotes: "Pinard (Bull. de l'Acad. de Med.,

August 6, 1895) records the following, which he describes as an ideal

case. The patient was aged thirty-six, had had no illness, and had been

regular from the age of fourteen till July, 1894. During August of that

year she had nausea and vomiting; on the 22d and 23d she lost a fluid,

which was just pink. The symptoms continued during September, on the

22d and 23d of which month there was a similar loss. In October she was

kept in bed for two days by abdominal pain, which reappeared in

November, and was then associated with pain in micturition and

defecation. From that time till February 26, 1895, when she came under

Pinard's care, she was attended by several doctors, each of whom

adopted a different diagnosis and treatment. One of them, thinking she

had a fibroid, made her take in all about an ounce of savin powder,

which did not, however, produce any ill effect. When admitted she

looked ill and pinched. The left thigh and leg were painful and

edematous. The abdomen looked like that of the sixth month of

pregnancy. The abdominal wall was tense, smooth, and without lineae

albicantes. Palpation revealed a cystic immobile tumor, extending 2

inches above the umbilicus and apparently fixed by deep adhesions. The

fetal parts could only be made out with difficulty by deep palpation,

but the heart-sounds were easily heard to the right of and below the

umbilicus. By the right side of this tumor one could feel a small one,

the size of a Tangerine orange, which hardened and softened under

examination. When contracted the groove between it and the large tumor

became evident. Vaginal examination showed that the cervix, which was

slightly deflected forward and to the right and softened, as in uterine

gestation, was continuous with the smaller tumor. Cephalic

ballottement was obtained in the large tumor. No sound was passed into

the uterus for fear of setting up reflex action; the diagnosis of

extrauterine gestation at about six and a half months with a living

child was established without requiring to be clinched by proving the

uterus empty. The patient was kept absolutely at rest in bed and the

edema of the left leg cured by position. On April 30th the fundus of

the tumor was 35 cm. above the symphysis and the uterus 11 1/2 cm.; the

cervix was soft as that of a primipara at term. Operation, May 2d:

Uterus found empty, cavity 14 1/2 cm. long. Median incision in

abdominal wall; cyst walls exposed; seen to be very slight and filled

with enormous vessels, some greater than the little finger. On seizing

the wall one of these vessels burst, and the hemorrhage was only

rendered greater on attempting to secure it, so great was the

friability of the walls. The cyst was therefore rapidly opened and the

child extracted by the foot. Hemorrhage was restrained first by

pressure of the hands, then by pressure-forceps and ligatures. The

walls of the cyst were sewn to the margins of the abdominal wound, the

edge of the placenta being included in the suture. A wound was thus

formed 10 cm. in diameter, with the placenta for its base; it was

filled with iodoform and salicylic gauze. The operation lasted an hour,

and the child, a boy weighing 5 1/2 pounds, after a brief period of

respiratory difficulties, was perfectly vigorous. There was at first a

slight facial asymmetry and a depression on the left upper jaw caused

by the point of the left shoulder, against which it had been pressed in

the cyst; these soon disappeared, and on the nineteenth day the boy

weighed 12 pounds. The maternal wound was not dressed till May 13th,

when it was washed with biniodid, 1:4000. The placenta came away

piecemeal between May 25th and June 2d. The wound healed up, and the

patient got up on the forty-third day, having suckled her infant from

the first day after its birth."

Quite recently Werder has investigated the question of the ultimate

fate of ectopic children delivered alive. He has been able to obtain

the record of 40 cases. Of these, 18 died within a week after birth; 5

within a month; 1 died at six months of bronchopneumonia; 1 at seven

months of diarrhea; 2 at eleven months, 1 from croup; 1 at eighteen

months from cholera infantum--making a total of 26 deaths and leaving

14 children to be accounted for. Of these, 5 were reported as living

and well after operation, with no subsequent report; 1 was strong and

healthy after three weeks, but there has been no report since; 1 was

well at six months, then was lost sight of; 1 was well at the Last

report; 2 live and are well at one year; 2 are living and well at two

years; 1 (Beisone's case) is well at seven years; and 1 (Tait's case)

is well at fourteen and one-half years. The list given on pages 60 and

61 has been quoted by Hirst and Dorland. It contains data relative to

17 cases in which abdominal section has been successfully performed for

advanced ectopic gestation with living children.

Long Retention of Extrauterine Pregnancy.--The time of the retention of

an extrauterine gestation is sometimes remarkable, and it is no

uncommon occurrence for several pregnancies to successfully ensue

during such retention. The Ephemerides contains examples of

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