[Reprinted from The Medical News, Oct. 17, 1896.]

REPORT OF A CASE OF TYPHOID FEVERCOMPLICATED BY EXTRAUTERINE

PREGNANCY.

JAMES B. HERRICK, M.D.,OF CHICAGO, ILL.

I desire to place on record the followingcase, becauseof the rare, if not unique, combination of typhoid feverand extrauterine pregnancy.

A woman, about thirty-eight years of age, entered theCook County Hospital, January 25, 1896, with many ofthe initial symptoms of typhoid fever—headaches, chilli-ness, anorexia, malaise, fever for several days, etc. Nosplenic tumor or rose-spots could, however, be made outat this time, and a diagnosis of typhoid was, therefore,reserved. This reservation was also made, because ofthe suspicion of a puerperal or post-partum septicemia.The patient told us that a few weeks before, being, asshe then supposed, three months pregnant, she had takenmedicine to bring on an abortion and had, as she be-lieved, accomplished the object. For there had been adischarge of blood with some other material, that she de-scribed very indefinitely, but which she thought was thefetus. This continued for nearly three weeks, and thenshe suffered from the loss of appetite, the headache, thechilliness, etc., that finally induced her to come to thehospital. A fact that she reported, and which, in thelight of later revelations was very significant, but to whichnot enough importance was attached in the making of thediagnosis, was that about this time, i.e. , the time of thesupposed miscarriage, she had suffered severe abdominal

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pain, nausea, and had an attack of fainting, with someform of convulsion.

The examination gave the ordinary findings in a feverpatient. In addition, there was plainly made out whatwas believed to be an enlarged uterus, presumably fourmonths advanced in pregnancy. The question of its con-taining a live or dead fetus, secundines, or a fibroid, wasdiscussed as well as the possibility of its being the sourceof infection. The absence of odor, discharge, or evidenceof local uterine or peritoneal inflammation, with the manyindications of typhoid, led to an expectant and non-inter-fering policy. This was rewarded in a few days by theappearance of rose-spots, and by such enlargement of thespleen as to make this organ plainly palpable. The diag-nosis was further confirmed by an intestinal hemorrhagethat proved fatal. The urine had shown on all examina-tions an abundance of albumin with numerous casts.

The autopsy (Drs. Hektoen and Tice) revealed healedapical tuberculosis, old pleuritis, pericarditis, endarteritis,chronic nephritis, and a ureteral anomaly. The find-ings, to which I call attention, were:

I. Typhoid fever. —Typical typhoid ulcers in ileum andcolon; enlarged mesenteric glands; splenic tumor; typhoidbacilli in spleen, kidney, and heart’s blood.

2. Extrauterine pregnancy. —The uterus was slightlyincreased in size and pushed to the left. Back of theuterus, occupying the middle of the pelvis and risingabove its brim, was a globular mass containing a mummi-fied fetus, placental tissue, and an old blood-clot. Thismass was bound to the surrounding intestines by firmadhesions. The right tube could be traced for but halfthe length of the left. Apparently there had been primaryright tubal pregnancy, with rupture at the time of thepain and syncope.

I have been unable to find other records of this unusualaccidental complication of typhoid fever, and report the

3case, therefore, because of its rarity. It also teaches thelesson that it is not always wise to resort to operations—-even exploratory operations—until the diagnosis is reason-ably clear. It is often good practice to wait for hours ordays before deciding as to the nature of an illness or themethod of treatment proper to be employed. Had opera-tive interference been resorted to, in this case, for the re-moval of a possible uterine source of infection, deathwould probably have resulted earlier than it did, and fromthe effects of the operation. The patient with typhoidand chronic nephritis would have been a poor subject forthe surgeon. Had we been more skillful in recognizingthe extrauterine pregnancy, the temptation would havebeen very strong to have looked upon the case as one ofinfected gestational sac, and clearly suitable for imme-diate operation. Fortunately, we temporized, and thedeath cannot be attributed to too zealous or unskilledtreatment, but solely to acute anemia following intestinalhemorrhage.