EARLY PREGNANCY, 
SIMULATING ACUTE UTERINE 
AND 
fflfflili lliliATIi 
GEO. J. ENGELMANN. M. D. 
Reprint from the St. Louis Medical and Surgical Journal. 
1877. 
W. P. KBEMER, PRINTER, 8!6 NORTH EIGHTH STREET. 
ST. LOUIS, MO. EARLY PREGNANCY 
SIMULATING ACUTE UTERINE AND CIRCUMUTERINE * 
INFLAMMATION. 
li V Cr EGO. J. ENGELMANN, M U, 
I have recently observed a class of deceptive, but for- 
tunately rare, cases which are exceedingly liable to mis- 
lead, and in which an error in diagnosis will at least 
greatly protract the temporary suffering of the patient, 
if it does not result in serious and lasting injury. 
These cases generally occur at a period of gestation, 
in the first and second months, when it is often impossi- 
ble to determine even normal pregnancy with certainty, 
and as in them pregnancy is accompanied by all the sym- 
toms of acute inflammation of the uterus and its appen- 
dages, the difficulty of diagnosis is greatly increased. 
Since not only the general practitioner,but skilled special- 
ists have been perplexed by the deceptive symptoms of 
these strange cases I will briefly outline one of the 
more characteristic ones. 
On the seventh of February last I was called to see Mrs. 
M., whose friends seemed exceedingly anxious as to her 
*1 have used the term circumuterine in place of ihe hybrid periuterine which is 
philologically incorrect and technically confusing. 
In the first place the combination ot "Latin and Greek, when wholly unnecessary, 
should not be tolerated. Secondly, as to the technical application, periuterine in- 
flammation or cellulitis Is generally used synonymous with parametritis; yet -verbatim 
periuterine inflammation means perimetritis under which term We comprehend a 
different disease. 
I trust that periuterine will be discarded for the more correct and appropriate circum- 
ut erine. 2 
condition. I found the patient a slender, nervous bru- 
nette of more than medium height with pale, anxious 
facies, and quite weak, as she had been unable to retain 
anything on her stomach for several days, and the ex- 
cessive pain had prevented sleep. She complained of 
nausea persistent vomiting, of intense back-ache, a 
burning feeling and pain in the hypogastric region 
which at times became excessive, apparently paroxysmal, 
dysuria, constipation and vaginal discharge; her menses, 
previously regular,she had last had from the fourth to 
the twelfth of of December, 1876. 
I found the skin moist, the temperature somewhat 
above the normal, pulse feeble and rapid, the hypogastric 
region sensitive to the touch, especially so the left, which 
showed some tumefaction, and, on percussion, exquisite 
tenderness, and slight dulness. 
The uterus was somewhat enlarged,as it is often found in 
acute or in chronic metritis,not very resistant, 
moveable and sensitive to pressure in bimanual examin- 
ation. The vaginal portion was somewhat tumefied, the 
mucosa relaxed,but its color scarcely deepened and almost 
normal like that of the vagina, the discoloration in both 
being no more than was to be expected from the copious 
vaginal and cervical discharge, and the apparent inflam- 
matory condition. 
The external os appeared as a circular depression and 
was surrounded by ugly looking erosions. The breasts 
were neither enlarged nor painful. 
The history of the patient developed some important 
facts: 
An actress by profession; thirty-eight years of age; she 
had been married twenty years; had been delivered of 
seven children at term, and suffered two abortions; was al- 
ways sick with nausea and vomiting during pregnancy, 
and each menstrual period was also preceded by nausea 
and vomiting with distension and tenderness of the epi- gastric region; tire condition which was described 
by me at the September meeting of the Amer- 
ican Gynaecological Society as one of the more remark- 
able of the menstrual hystero-neuroses. 
Her courses ceased in November, 1873, while Mrs. 
M was living in Cincinnati; in the beginning of 
December, her suffering began with uterine colic, nausea 
and vomiting; and toward the end of the month, menor- 
rhagia and severe hypogastric pain set in. Patient 
then sought medical advice, and was treated with 
narcotics, blisters, poultices, etc., notwithstanding which 
the pain, especially hypogastric, and epigastric increased, 
menorrhagia and nausea continued so that for three 
weeks she vomited all nourishment, and even sedatives 
that were given her until on the th of February a 
small, macerated embryo was expelled; thennausea and 
vomiting at once ceased, but the manipulation necessary 
for the removal of the membranes was followed by pelvic 
cellulitis from which she finally recovered; menstruation 
returned, attended by the same hystero-neurosis of the 
stomach. Early in December, 1876, the menstrual flow 
again ceased. January 1, 1877, she was seized with 
a severe attack of vomiting, which lasted throughout the 
day, then gradually became less annoying, though the pa- 
tient was continually nauseated until towards the end of 
the month, when her suffering increased and she was able 
to retain but very little on her stomach; since the early 
part of January she also suffered more or less with 
pains in the side and back, and hypogastric pains, 
which at times were paroxysmal, becoming very 
severe. 
The history suggested pregnancy; the symptoms as 
well as the examination indicated parametritis con- 
fined more especially to the left broad ligament, ovary 
and side of the uterus, complicated as it often, I may say 
generally, is with pelvic peritonitis, parenchymatous 
metritis, endo-metritis, and uterine displacement. 4 
The diagnosis was doubtful. Fearing pregnancy as a 
complication, I did not introduce the uterine sound, nor 
was I willing to make any local application to the ap- 
parently inflamed membrane of the cervix, as I dreaded 
cellulitis. 
The treatment consisted of warm applications to the 
abdomen and powders of bismuth, soda, and opium, al- 
ternating with calomel and rhubarb. 
At my next visit, February the eighth, I found the con- 
dition unchanged; although the calomel had acted freely 
and the applications were faithfully continued as long 
as they could be borne by the exquisitely sensitive ab- 
domen, the hypogastric pain remained equally severe. 
Beef-tea, brandy, and even ice and the bismuth powders 
were rejected by the stomach. 
Local applications to the hypogastrium and sedatives 
effecting no improvement, I was inclined to suspect 
the symptoms as merely reflex, and to seek the excit* 
ing cause in the uterus. 
A second careful examination merely confirmed the 
points already established; pelvic cellulitis seemed un- 
questionably present, yet I still suspected pregnancy, 
with nothing but the suppression of the menses to justify 
the belief. 
Determined to satisfy myself as to this point, and to 
remove the offending contents of the uterus if present, I 
introduced the sound. A medium sized probe (Martin’s) 
entered easily to the depth of almost three inches, caus- 
ing some pain as it passed the internal os. I rotated the 
sound somewhat, and followed it with the dilator. A 
drop or two of blood, but no amniotic fluid escaped, 
and I concluded by touching the erosions with iodine. 
On the following day, February ninth, some beef-tea 
and brandy was retained by the stomach, and being still 
in doubt as to a conception I intended to introduce a 
sponge tent, but was obliged to cease all treatment, as 
the patient—an actress—notwithstanding my protesta- 5 
tions, feeble as she was, was obliged to go to a neighbor- 
ing city, fifteen miles by rail, to perform before the pleas- 
ure seeking community! While on the stage on the 
evening of the eleventh she suffered intense pain, and pro- 
fuse haemorrhage set in. On the twelfth, the pain not 
being diminished, still vomiting and bleeding, she 
returned to St. Louis, at times overcome by fainting 
spells, and early on the morning of the thirteenth an 
embryo* one and a half inches in length, the product of a 
seven week’s conception, was passed, followed after sev- 
eral hours by a piece of the decidua probably from the 
anterior wall of the uterus. 
Nausea and vomiting ceased at once, the pain, sacral 
and hypograstric, grew rapidly less; in short, all the 
threatening symptoms before observed soon disappeared, 
food was relished and digested, urine was freely passed, 
some little tenderness remained above the uterus but the 
hypogastrium was free from pain, and even the left iliac 
region showed no sensitiveness on deep pressure. 
The recovery was a rapid one considering the debilita- 
ted condition of the patient,due to incessant vomiting and 
the profuse hemorrhage when forced to leave her bed. 
This case, as it appeared to me on my first examina- 
tion of the patient on the seventh of February, presented 
all the subjective and objective symptoms of the first 
stage of parametritis (pelvic cellulitis), with the usual 
complications of endometritis and perimetritis (pelvic 
peritonitis), nausea and vomiting, back-ache, hypogas- 
tric pain more marked in the one apparently tumefied 
side, a sensitive, somewhat enlarged uterus discharging 
the endo-metritic fluid, the fever, however, but slight; on 
the other hand, characteristic signs of pregnancy were 
wanting with the exception of the cessation of the men- 
strual flow. This entire group of symptoms, as proved 
by the termination of the case, was due to conception, 
♦The embryo could not have been dead but a very short time. Jt was tresh, well 
preserved, and seven, almost eight weeks old, with lingers and toes developed. 6 
the development of the ovum in a hypermsthetic uterus- 
mere pelvic and gastric hystero-neurosis of pregnancy. 
Two equally deceptive cases are mentioned by that 
eminent obstetrician Fleetwood Churchill among a 
number cited in his recent paper on retention of the ovum 
after the death of the foetus. {Dublin Journal, Ixi; pp. 
455. May, 1876.) 
In one case, finding a somewhat enlarged uterus, and 
an eroded os, he treated the patient for endometritis, and 
after the lapse of three weeks was surprised to observe 
profuse menorrhagia, followed by expulsion of a macer- 
ated fostus. 
In another the enlarged uterus with the absence of any 
signs of pregnancy whatever, led him to suppose the 
tumor due to an interstitial or polypoid fibroma until 
the introduction of the sound induced labor pain and 
again the expulsion of a macerated foetus, as in the 
other case. 
A careful analysis is necessary in such cases on ac- 
count of the difficulty of diagnosis. I have already al- 
luded to the questionable certainty of determining even 
normal pregnancy in the second month, and here we find 
it complicated with perplexing nervous symptoms close- 
ly simulating inflammation. 
In my case I was assisted in the diagnosis by the his- 
tory given me of the previous similar but very much pro- 
longed sickness followed by expulsion of a foetus which 
had been dead for some time and by my study of the 
hystero-neuroses, as I have called those nervous condi- 
tions dependent upon uterine disorders. 
The diagnosis once established the treatment is simple 
and naturally follows. In milder cases hydrate of chloral 
should be given per rectum to allay the nervous symp- 
toms, but if this does not succeed, we must resort to those 
more energetic measures which I would recommend at 7 
once in all more severe and threatening cases, the probe 
or the tent to hasten the expulsion of the ovum, after 
which speedy recovery may he expected. 
3003 Locu :T Street, S*. Louis. x