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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