OVAKIAN PREGNANCY. 



265 



CLINICAL HISTORIES. 



No. 550. 



The patient, who was 24 years old, came to the 

 Johns Hopkins Hospital June 1 with a diagnosis 

 of appendicitis, which later was changed to 

 ovarian pregnancy. The diagnosis was made 

 unusually difficult by the patient's misleading 

 statements. 



When admitted to the ward the patient was 

 not complaining of acute pain, but only of 

 general soreness in the abdomen. There were 

 paroxysms of pain, general throughout the 

 abdomen, with intermissions in which she was 

 somewhat more comfortable. With difficulty 

 the pain was localized in both left and right 

 sides of the abdomen. 



When examined, general soreness of abdomen 

 was found, the pain being more acute along the 

 left side, shooting up to the right shoulder. 

 The pain had not changed in character or 

 intensity. There were sharp attacks of pain, 

 especially in the left side, when the patient tried 

 to move. There was also difficulty in breathing. 



During the afternoon the condition of the 

 patient was very uncomfortable, with repetition 

 of the symptoms just given. The pains became 

 more acute after taking ice. A renewed onset 

 occurred at 11 p. m., and this continued with 

 some nausea and occasional vomiting. 



The pain had been sharp (not crampy), and 

 had apparently gone up under the right C. M. 

 in the morning. There had been pain also under 

 the shoulder. The patient said she had never 

 had any similar attacks, and was not constipated 

 previous to this one. 



On June 3 patient said she had a similar attack 

 of abdominal pain three years before. This was 

 general at first and finally became more pro- 

 nounced on the right side, accompanied by 

 nausea and vomiting. From this attack she 

 did not recover entirely for 10 days. She had 

 a similar but milder attack several months later. 

 Dr. Finney writes: 



"When I saw the patient I did not think it 

 was appendicitis, but the history of similar 

 attacks, which I had reason to believe afterwards 

 were fictitious, and the patient's misstatements 

 as to the subjective signs, together with the fact 

 that the patient was unmarried, misled us as to 

 the true diagnosis. Upon opening the abdomen, 

 however, it was found to be filled with blood. 

 At once the diagnosis was clear. I looked for the 

 tubes, but found both intact. The right ovary 

 was the point of bleeding; it was swollen and 

 appeared as you found it in the specimen. The 

 whole process was so definitely confined to the 

 ovary that it seemed, clinically, to be a definite 

 case of ovarian pregnancy." 



No. 1552. 



The patient, an Italian woman of 37 years, 

 was admitted to the Gynecological Service of 

 the Johns Hopkins Hospital July 12, 1916, com- 

 plaining of a pain in the lower abdomen, nausea, 

 and vomiting. 



Family history. Negative. 



Past history. General health good. She has 

 never had any serious illness. For the past 5 

 years following a labor she has had recurring 

 mild attacks of pain in the abdomen without 

 nausea or vomiting. 



Menstrual history. Always regular every 

 month, except when pregnant or lactating. 

 Duration 4 to 5 days; painless, moderate flow. 

 Last period June 25, 1916. Last preceding 

 period, March 16, 1916. No intermenstrual 

 bleeding before present illness. 



Marital Married 18 years; seven children, 

 oldest 16, youngest born \y% years ago (died, 

 1915). Has had three miscarriages. History of 

 labors and puerperia vague. 



Present illness. Began 5 days ago (July 7, 

 1916) with sudden pain in lower abdomen, 

 nausea, and vomiting. She has had marked 

 dysuria and painful defecation. For 12 hours 

 after onset there was rather profuse bleeding 

 from the vagina and there has been a bloody 

 vaginal discharge since. 



(The patient does not understand English and 

 her husband acted as interpreter.) 



Physical examination. T. 101.6 degrees F. 

 P. 96. W. B. C. 8400. Hbg. 46 per cent. 



The patient lies in bed grunting with pain. 

 The skin is pale. The lips and mucous mem- 

 branes are quite pale. There is a systolic blow 

 heard at the apex and increasing toward the 

 base, being loudest over the pulmonic area. 



A drop of clear fluid was expressed from the 

 right breast. 



The abdominal respiratory movements are 

 limited, although she does not complain of pain 

 on deep inspiration. The flanks bulge some- 

 what. There is no demonstrable movable dul- 

 ness. There is tenderness all over the abdomen, 

 most marked over the lower left quadrant. 

 There is increased resistance over the lower 

 abdomen, but no muscle spasm. No masses can 

 be made out. 



There is a profuse bloody vaginal discharge. 

 The cervix is pushed up behind the symphysis 

 by a soft, exquisitely tender mass, filling the 

 cul-de-sac. No crepitus is made out. Rectal 

 examination confirms the vaginal. The fundus 

 of the uterus is not felt. 



July 13, 1916. Ether examination. 



There is a dark, bloody discharge from the 

 vagina. There is no vaginal cyanosis. The 

 cervix is lacerated, firm, and normal in size. 



