A CASE OF EXTRA-UTERINE GESTATION; OPERATION DURING THE SIXTH MONTH OF PREGNANCY

HerbertJ. Paterson
1908 The Lancet  
entirely to cover the area round the depressed portion where the dura mater had been torn away. The whole surface was irrigated with normal saline solution. One small drainage-tube was passed through an incision in the scalp opposite the wounded artery, another through the original wound, and one at each end of the long operation wound which was sutured with silkworm gut. The patient's condition on being put back to bed was better ; the pulse was 100 and small, the respirations were 24, the
more » ... ns were 24, the colour was fair, and the skin was cold. At night his temperature was 102°, the pulse was 110, and the respirations were 16. On Dec. 14th the patient's temperature was 99' 80, the pulse was 90, and the respirations were 18. He was very restless, irritable, and unconscious and struggled violently when a catheter was passed. On the 15th the temperature was 99' 80, the pulse was 96, and the respirations were 16. No squint was present; there was some loss of power in the right arm but there was no paralysis of the face. He was able to take nourishment. He passed urine into a urinal when placed for him and also passed it in bed. The kneejerks were increased. The plantar reflexes were present. On the 16th the temperature was 99 -40, the pulse was 76, and the respirations were 16. He recognised his friend this morning. On the 17th the temperature was normal and the pulse was 60. The wound was dressed ; it looked clean and there was some serous discharge. All the tubes were removed. The patient asked for a urinal. He was fairly sensible. From this time his progress was uneventful. He had constant but not very severe headache for two months but no paralysis or loss of sense or memorv. On March 1st, 1907, under ether, a scale of dead bone was removed from the site of the original wound and the bone and tissues were scraped. This wound healed rapidly. A mould was taken of the skull and a silver plate fitted into a cap tightly fitted to the head. The patient left the hospital well on May 3rd. He came to see me a short time ago, 14 months after the operation. He had worked during the hot summer months without any headache or inconvenience. He is as strong as ever and wants more work. He has never had any fits. There is a large amount of fibrous thickening of the tissues of the scalp filling in the cavity in the vertex, but the pulsation of the brain can still be felt on deep pressure. The size of this cavity is roughly 4 inches by 2 inches. The chief points of interest in this case are : 1. The extent of the injury to the brain substance without subsequent paralysis or fits and without any hernia cerebri. 2. The immediate improvement in the respiration on removing the depressed bone. 3. The rapid response to the intravenous injection of saline solution when the patient was collapsed from the haemorrhage. The accompanying reproduction of a photograph of the patient after recovery shows the deformity left in the skull. Reproduction of a photograph of the patient after recovery. THREE years ago I reported to the Obstetrical Society a case of Operation during the Sixth Month of Extra-uterine Pregnancy.2 2 In that case the placenta was removed and the hasmorrhage controlled by the ligation with silk of many vessels and by packing the sac with gauze. The points of interest in that case were : First, that the gestation persisted in spite of two severe and three slight attacks of internal haemorrhage. Secondly, the difficulty in determining whether the fcetus was alive or dead. Thirdly, the severity of the symptoms caused by intestinal toxaemia due to intestinal paresis, the result, as I then thought, mainly of injury of the peritoneal coat of the bowel produced by the separation of adhesions, but which I am now of opinion was due almost entirely to the gauze packing. The paresis was successfully treated by repeated doses of calomel. Fourthly, the prolonged convalescence of the patient, due to the persistence of a sinus for 18 months, from which ligatures were discharged from time to time. For several months the patient suffered from abscesses in her neck, probably the result of septic absorption from the persistent sinus. Eventually, however, the patient made a complete recovery, and is at the present time, six and a half years after the operation, enjoying robust health. A few months back I had under mv care a somewhat similar case, of which the following are brief details :-The patient, aged 29 years, suffering from abdominal pain, was admitted into the London Temperance Hospital on March 9th last, under the care of my colleague Dr. J. Porter Parkinson. She had had ten children, of whom five were premature and stillborn. The catamenia had been perfectly regular, the last period having ceased on the day of admission. On admission the patient was extremely anaemic, but well nourished. The temperature was 100° F. and the pulse was 116. In the right iliac region reaching inwards beyond the middle line, and to the level of the umbilicus was a. smooth, firm, rounded, fixed, tender swelling. Per vaginam there was some fulness in the vaginal roof, the cervix lay to the left, the texture was firm, and the canal was closed. Bimanually the uterus was somewhat large; the abdominal swelling could not be felt in the pelvis but tendernessprevented a satisfactory examination. I thought that thepatient had an ovarian cystoma with a twisted pedicle. The question of an extra-uterine gestation was discussed, but the very definite statement by the patient as to theabsolute regularity of the catamenia seemed against this. hypothesis. On March 14th the patient was markedly jaundiced, but by the 16th the jaundice had almost dis-appeared. On March 18th I opened the abdomen in the middle linebelow the umbilicus. The intestines in the lower part of the abdomen were much matted together. On separating the adhesions much recent blood welled up and and a dark purple cyst-like swelling was exposed, which was recognised as an extra-uterine gestation sac. On incising the sac there was copious bleeding. The foetus was rapidly extracted and the bleeding was checked by the pressure of the hand inside the sac. Further examination showed that the sac was incomplete, the roof of the cavitv being formed of matted intestine. The placenta was attached to the posterior wall of the uterus and to the intestine. It was very friable and readily separated hut the bleeding was profuse. The placental site was compressed by the hand, while the cavity was tightly packed with gauze. The Fcetation had apparently occurred in the right Fallopian tube which was ruptured close to the uterus. The pouch of Douglas was filled with recent unelotted blood. There was some free recent blood in the flanks. After 1 A communication read at
doi:10.1016/s0140-6736(01)63884-4 fatcat:rdvpnkprwjhbtf2kuci6wbbixa