Of course we are not justified in making a diagnosis of extra-uterine pregnancy simply from the fact that we can appreciate fcetal parts covered only by walls, and see their motions. This occurs not infrequently in ordinary pregnancies in badly-uourished women with thin uterine and abdominal walls. The mistake has, however, been made, and we must beware of being deceived. If under such circumstances we are in any doubt, we must prove either that the product of conception is surrounded by the uterine walls, or that the womb is empty. If external abdominal palpation is carefully made, especially with a cold hand, we may feel and see the thin uterine walls contract under the stimulus. An absence of this reaction, however, affords no basis for a conclusion. We must then endeavor to prove that the uterus is empty by a most careful bi-manual examination, if necessary, under chloroform. In advanced extra-uterine pregnancy the foetal sac is often so intimately united to the womb by multiple adhesions that both masses seem to form one tumor, and the determination whether the gravidity is extra or intra-uterine is very diffi cult. In a doubtful case of this kind, when the extra-uterine fcrtus had reached term, we succeeded after repeated examinations in passing the forefinger into the open cervix uteri and bringing out shreds of decidua, thus proving that the foetus was not in the uterine cavity.
When we cannot arrive at certainty by means of bi-manual examina tion, we must rely upon the uterine sound, being mindful of the cautions before given. If a foetus should be in the womb. we may be so unlucky as to produce abortion. Nor must we lose sight of the possibility of there being an extra- and intra-uterine pregnancy at one and the same time.
Another diagnostic point worthy of mention is the passage of portions of decidua, especially in advanced extra-uterine pregnancy, either.with or without bearing-down pains. Of less value are certain other signs, such as the development of the arteries at the fundus vaginae, the form of the foetal sac, etc.
If we find great difficulty in the diagnosis of extra-uterine pregnancy while the product of conception is alive and growing, how much greater must it be when the foetus is dead and the placenta alone develops for some time, or when one or other of the terminations above mentioned is in process? The certain signs of pregnancy are absent, and the contours of the foetus are obscured by shrinkage, by neighboring exudations and pseudo-membranous masses. And if we recollect that various tumors, fibroids, mad cystoid tumors may be of such shape as to simulate a head and limbs, we will understand in how many cases it is simply a guess to make a diagnosis of terminated extra-uterine pregnancy. An abdominal
tumor in a woman can only be certainly pronounced an extrauterine pregnancy which has terminated when we have ourselves watched the development of the living ovum, or when it has been seen by trustworthy medical witnesses. Women often make statements which would lead one to suppose that the case had been one of abdominal pregnancy when giv ing the history of their tumors; they say that the lump has become harder and smaller, that swelling of the breasts and other symptoms of preg nancy have diminished; and yet the tumors turn out to be of quite another kind.
We have ourselves seen a cystoid removed by Billroth by ovariotomy, in a woman where the formation of a lithopxdion had been diagnosticated with great probability.
Thus the greatest caution is necessary in the diagnosis of a terminated extra-uterine pregnancy.
and appreciate the dangers from this affection from what has already been said. Out of Biwisch's 100 cases, eighty-two, out of Hennig's 150 cases, 133, and out of Hecker's 132 cases, fifty-six died. But the last figure is far too favorable.
It also follows from the above statistics that more cases have been cured by unaided nature than by operative procedure. This is not sur prising when we remember that most of these cases belong to a time when we were yet very much afraid of opening the abdominal cavity; and operative aid was only sought in isolated cases. It by no means follows that we must avoid attempts to cure the affection by operation. On the contrary, nowadays, when ovariotomy, when the removal by laparotomy of the largest uterine tumors, when Porro's ablation of the body of the uterus after Caesarean section, when Freund and Czerny's total extirpa tion of the carcinomatous uterus, have given us cures bordering upon the marvellous, we must bend all our efforts to the operative cure of the affec tion we are considering. Already, I think, the percentage of cures after operation is greater than it was; probably largely on account of our im mensely increased experience in abdominal operations.
Since the different phases of extra-uterine pregnancy require quite different treatments, it will be useful for us to divide the therapy into that of a, early pregnancy, b, advanced pregnancy, and c, terminated pregnancy.
a. Treatment of Early Extra-Uterine Pregnancy.
Hennig's collection of cases shows us very conclusively that the greatest danger to the life of the mother is, especially in interstitial and tubal pregnancy, during the first weeks and months, when rupture of the sac and fatal internal hemorrhage is so liable to occur.