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1
\ -
ECTOPIC gestation;
is of interest to the nedkal prof eenon and of value to the
^tgr. 'ha i^yaaian ia aaiiwi Wvmim a dkinoaia aai tha lay
mmmmmuAmu'lmtiiW^ Ajiwl iwl >■■ Uf mivm
of late on tiie aubjeet and tiMM in anQK ^MitiaM ttat raqaiN
forther oooaideration.
X Mia ft aanM aMrnh thioa^ wmar at tha avigiMt vmm-
grapln <m the anbjeet aome yeara ago, aad- yt ag gat a d -ir^ pa^f v |
b^(g8^<he^-AB>wQfl»i»-Aaaoaia*io« of 0bB(atnai<taa aikU6yii»aela! /
giats>ip,lMa-io>ath«^3!^<^-a, j^ art-ei«ftJb w . — i I m n9«(
able ht^tre a further reptttt of my ezjseiieaeer^iiS- app»d~t» \
thia4)aper^t«balat«d atatentent ot tha.eaflea upQg^^ahieL-it-in
haCBck —
All writers on the subject are familiar with the work of Dr.
William Campbell, who was a teacher of midwifery in £din>
bnri^ who published his monograph about 18^. Ha gave a
large amoont of material with but little attempt at good arrange^
ment, aMq^.5!«ii, His work, however, is a landmark in the litera-
tnre of the sobject
On tibia aide ci the Atlantic, Parry, of Philadelphia, published
a very remarioditle work on the subject in 1876. Again, later,
the subject chosen for the Jenks Prize Essay of the C( Mege of
Phyaidaiia and SurgMoa, Philadelphia, about the year 1889, waa
^ aSa^fioAi tM Mi^BMDt of e i Lta r witeri ne pregnaney, and the
prize wa awarded to Joim Strahan, of Bdfaat.
<saa« iMiDs* tfcaAiit mni a tHa eTBilMt mmmfmm^'
s
Tait, in 1888, wrote on eetopi« pregnaney and pelvie teMli^
Ml*, nw woric ii b«Md on an vqmkBoe of lortgr OMM.
SiiiM tte tiM tvta <iim wrilia«i m ghMB to ikt
•everal pointa have been noticed: First, the leaa frequent mp-
tnre of Mto^ pregqancgr into the br^ Ugameat thac wm np-
poMd bgr VMt to Miart mmd, Ikt mm uttk iMA tfct taail.
tion may be diagnosed before mptnre; third, the freqnenejr witli
wkadk the diaaue oeenxi a aeoond time in the aame patknt It
i>at» my ri»tohy» t» toi ">«» ^»«'»^"*»P"*'*»^*»
<£' leetnre.
I have a record of 45 eaaea (inelnding one caae of ruptured
eramial imgnuMj) opmtod npeo. they include 3 eaaea opow
ated on before rapture, 41 eaaea operated <m after mptare,
1 caae operated <m after full time (raptored comaal pregnaiugr),
5 eaaea after aoppnrati«m, 1 caae of doable ectopic geatation, 8
eaaea in whidi eetopie gestation oectirred twice in the aame
patioit, 1 case of interatitial pregnaney in ita very eariicst atage.
I will andaavor to gW« ym tiM o nt e ot of thia experionee, not
embelliahed in flowery langnage, but aa a simide atatement of
f aeta. It will be wdl, however, to . . the anbjeet up ajatemati-
eafiy.
OusamcATioN.— The daatfeatitm that I adopted in 1892 re-
^ofaea no change. £et(^ gtatotion may be met with in any
part of Ae tnbe, fewa Ha intrantwrine opuiag to iti abdwteal
end. When the pregnancy is developed in the tube aa it paaaes
1]troa|^ the wall of the aterna, we call it interrtitial or tobo-
ittertoa; if dtfnlopect in the middle pcvtion af Aa taba, tabti;
if developed at Htm oiwaton «ai at thatttb^ l abo »i WMri la g m tofca^
abdominaL
A pregnancy originating aa an abdmninal iwegnaneifAa not
been proved to exist. Tait says that he cannot believ#^hat a
fertilized ovam nuqr drop in'-o the cavity of tite peritaiieam and
haeoBM davdoped there, beeanae the powoa of digestion of die
poitsaenm are so extraordinary that an ovum, evra if furtilized,
coald have no chanee of development. If it ia poaaiUa for the
peritoneam to digeat live atructur e a ao rapidly, wkf do w find
intraperitoneal worms, and how can spermatozoa exist in this
r»>giont I have seen intraperitoneal worms free in the cavity
of the perit<«aain in fiih, and I yraamaa ftat ilia tlw aiiatawuM
of ttfi ^ trarm tint pravwte -AIb digeatm. Ttp ataaaaaii
* MWi SOMNO OTRASMI.
wall k only digeitod pott mortem. I feel, mjnelf, that tltiMOfli
■Momlnil pregnanoy fxr m hai not been dMMUtnted, thwt is
■9 nawi wbj it oumot oeear.
A pregnuMj oirigiiiatiiig m an ovarian pregnancy haa not yet
bean proifed to esiat Parry eayi "that if an ovarian pi-egnan^y
doaa oeenr it moat be rare and win be eorioMit it never oeeora,
•0 xaatk the better." Biaehoff and Barry are eaid to have dia-
eorared ^ermatona on the rarfaee of the vntim (tf biteh«
thortly after ooitua. If it is poariUe for the n i rmaln i u a to
penetrate the wall of the ovary and prodoee an ovarian preg-
nancy, then, aa a eooBMiiwiMa of MMkoffli and Barry'a obaerva-
Ikma, avarian pregnancy dMBld be frequently met with.
Thtie are two etmditiona that moat not be eonf oondod in tiie
e l — tff jatt on of aetofrfe geitatioagu The lint of ttaaa ia preg>
nancy in a bilid or bieomuate ntema, and the seomd ia a pregr
aano} ogeorring in a mdimoitary ntarioe horn. llMaa eon^
•Mna Biiia% nowever, m aoMMefW u «t aiserautsai '"*gri I'Tti
of an ectopic geitation.
Pathoiomcai. Amatoxt.— After the impregnated ovnm haa
beeome atw a lad in the tobe, a daddm avotiBa, if net a deeidna
vera, ia formed; the chorionic villi develop. Thia devel pment
ia beantifoll; diown in an early imj^regtrnted ntema of the rab-
Irit I have a dide prepared from mnA a vtnna vdiite a ati^eBt
in Zurich. The tubal wall, into wld< h the ehorioofe villi jmah
titemeelvea, beroi ia thinned, and thia ia wdl diown in ma
of my Bpedmoia oi nnmptnred tnbal pregnancy. The speeimen
had not ruptured, but was in the ^int of rupturing.
Still fnrfter diangea raw take place. Blood veaaels beoomo
fBH Waaa d in aiae aad ia manben, the parte heeooM very mndi
ooogeated, and the awelling of the tube, aa eeen nn aevend of tiieae
ap ae im e n i , doady reaemblea a small myraia in in interior. A
deddna ia fmased in die intnior of the nteriiM eavi^; this de-
cidua forms early, but is not likely to be shed nntil aftnr the
death of the ovnm takes place or the tube haa ruptured. I show
here a qpeeimen taken from a wcsiian who died at our Un'on
Station a few months ago. She died from intraperitoneal henKN^
rhage that was produced by mptare of a tube containing an
ectopic gestati(m. Even though the pregnancy was of short
-duration, ^ deddual lining can be distinctly seen.
A tdml i^^BaaoT^ ia ficefoaufly inisredbir
4
mm TiMtlij Uood ii ihm ponnd oat •round the ovtua into tho
teHtioroCtbotiibc Tho pNftM of tho oonditlMi mv dipMdi
teply upon the aite occupied by the imprognatod ovum. Hm
ipol in whieh ewlMrt rupture take* pUoe k oMur to, or in, tiM
rtlgfaw wmU whMC t>» tabo p i wm tfct himwIw ■twwtewi of
tth organ. The middle portimi of the tube allowi of mneh
giwitr dirtwHti'Wj and, m • eontoqawMii, tho pregnancy in thk
jHuiUih. win muMwl fti l fc w >m i M il n ptifi VkwtlMonuB
k lilMliA tMMid liM abdeiriMl of Ikt tab% abi^
Vm. li—A, niptwtd tnlwl prafsaaqr ; B, deetdiui in (Mm.
tioB is Uriilo to OMBr throBgh the fimbriated end. mda kdc SHgr
only be small, or, in other words, a tubal "drip."
Bupture of the sac may occur at any of the sites liable to be
occulted by the impregnated orum, and the result may or bmj
not be i$M to Htm notlitf nd nasf at majr not bo &td to Hit
fetua.
Tlw oiram amnrtres the mptore in only a very few eoaea. Tha
site of rupture in the interstitial variety may be so small as al-
most to escape detection, as is shown in the specimen here ex-
hibited (Ilg. 2) and rqwrted in tbe taMo aa Ko. M.
Tait says that rupture may occur as early as the fourth week.
I think I have aeen it oeeor eaiiier. , In Thb Amwocam Joubkal
worn I MTono owrAiMM.
i
or OBSTmiicB, October, 18f >. one of my eun w recorded that
nip.tiped at • vciy rrly st , ge— I tlioai^t aboat two> or thm>
wcaks i M t a tk M. ▲ iiistr m Hmm fffwi^ Amhi fecai — tm,
but tbc plate does not exactly repreamt tbe aixe of tha tuba at
tba ntarine end. It waa nnaUar tbao it ia tbm npn aatai vaA
aoffwq wu ded more mtaif arMi tta cMidMea of Urn taMNil tto
distal lidu of the rapture.
Tha bleeding fr<Hn an ectopic geataticm nay ba either kitr»>
portaMri or oitnNparilaaeol. ht w y o rit aaeri hwwrrhmaaMy
occnr in two wajrts fint, by direct mptnre of the tube into the
paritoneal asvtty; atoand, by the tubal drip or a leakage drop
Fia 2.— Intmtlttal prcgaaaey, tot mOg t«tw* (Can SM. A. (Mt at
^ieb ntcrint w«ii was to 9m!tm^mmmK»mi ^ *mmm 'miiii» •*
bgr drop, of blood throogh tiie fhribrteted 00** of the tite. Vthm
extraperitoneal it becomes so as a couaequence of rapture
through the mesoulpinx into the l^ren of the looad ligaiMnt.
A great deal of streai haa been laid upon this lattor font <rf rup-
ture, but in my experience I have not met with it
In the table it may be noted that I found diatenaioB of tha
bMMid Ugament on a certain nda after opening the abdoiueB, hot
that the sac waa peeled out aa the operation proceeded. Had the
rapture been into the layera of tiie broad ligament it woi<diJ|Mf« .
bten impoasiUa to have peeled out the MC in this way.
On superficial examination many of these <i8es will simulate
% mm in tiM tooad UgaBMfit, aa Oflse t^ftta do that iMM
fMmsrIy reeordfld, and llMt m perhaps itm nemrded, by tbe in-
qrati. The qnta referred to
are now known to be un-
der tiw broad lifanmt—
anbliCHBentoiiB and not
irtraHiaiiMfntoaa Thqr
«aabei«iiilrJBttiBgaiah-
ed owing to the f aet that
the tube will be found
per Btirfaee. On closer
inq>eeti(Hi thegr will be
foBBd dodbM vadar ^
ligament, but intimatdsr
aaaoeiated with it I do
not for on* OKment deny
that hmorrhage into the
broad ligament does not
oeetir, bat I nrait idtfit
that very few of theaer
cases are brought to the
operating table.
I take it that the bleed-
ing tnm an extrauterine
pregnnqr auqr be either
slow or n^id. When
slow the blood coagulates;
when rapid it does not
eoagnlate to nieh an «s-
tent When tiw blood
eoagtdates it produces a
noMs; when it does not
eoagnlate no todi bum fa
produced. When the
hemorrhage ia slow and
■9A Mlift ll flOAffDlSltfiB flu*
h Matm are rapidly form-
ed ■MBBd the site of tiw
kmorfhaga, ntd in ft
short time just as mueh
tenaioD will be prodneed in this way aa ean be tmtad by the fatoia
layers of the broad ligament. Aftw a tfane tito ■aaooat of btood
BOM: ECTOPIC OIBTATIOH.
T
irill bt iacnaaad bgr lr«i^ ktBurriugt and tha tdhcnoM will no
lBBgtrb»«M>tetetifatfc»aMMi,»nd,M»B a B Mq«wi i wi, fa<»W>dl
wiU be poared into the peritoneal cavity, and, if in any large
qoaatilgr, will ba found aahii^ op aatibe liver and Hileen. Wkm
flw Weed I ow a ibw Iy tiwp aUeM l iliiw tttodaafiynaape and <>f
pain, and if the hemorrhage ceaaes for a time they resume ap-
pamt good haaUh. The maaa otmtinQea to inereaae in tba pd-
▼ia as bof aa Hm keauntega a — tinm i into n ri ttaM tt y.
In support of his argument in favor of broad-ligameBt np*
tax*, Tait aaya that peritmiitia nuraly ocenra in eaaea of t w d
HgnMRt mptam aad that the talk aboat eoUaetkna of Mood
becoming encysted is tiie veriest nonsense. I beg to assert that
the blood doea baoome encysted and that I have removed such «n-
flTitad Uood maiqr tu<Ma. It is not difBenlt to ondMatrnd hafw
we nuiy have the organization of this blood dot without an ap-
predable amount of inflammation. Such organization of the
UOfld is BSl ft Ssaolt of inflammation. Campbell recognized this
feature years ago, and said in his book that the connection with
the original mass— meaning the poured-out blood— through time,
with the adjacent parta baeowea ao intimate that, when super-
ficially considered, the ovum majr aoem to be invd^Tid bgr the
layers of the broad ligament.
Tait considers that, in many cases after other operationa upon
the tubea, tha maaa Oat oeeaaioaally forma ia an intialiganait-
ous hoauttooela. There baa been no proof adduced that Hmm
BMMM ai« intraligamentous hematoceles. Sec(mdary hemor-
rittfa fa a wall^recognized occurrenea after tba ligi^ora ol tha
blood ▼eaaeli in other parta of the body, «Dd amang Hum ttkMi,
dense, and edematous structures in the pelvis there is no reason
why secondary hemorrhage should not also occur. When these
bamriliagea do oeear it ia difknlt to nMbmtaBd wlqr ttey AevM
select the layers of the broad ligament instead of the pelvic cavity
itself. I am satisfied that oozing may take place from the atump-
of an amputated ovary and tabe faito Hte gamnd paxitonaal
cavity among the intestines, and that this oozing may cease and
the blood clot may be absorbed or require vaginal section tot ita
raaoival (m ia a mm of Dr. E. O'Baffly, of BntftoB).
Tait says in his "Lectures," on page 37: "Thua I tied the
pidide of one ovarian tumor with catgut and the patioit died
m tiN Um&L day after opwatioa. I UmaA a Ihv» la/smfmA-
tfnil hematocele, due to the gestation and loosening of the liga-
tara." He atatea that these hematooelea produced by ruptore
8
B08B: ICTOPIO OEBTATION.
into the broad ligament pradoM itrietiire ot the netani; and in
leoording nidi a eaae, tiie taty eridenee tiiat be bringa to bear
to prove that the effusion of blood was in the left broad ligament
is the faet that the floor and the posterior wall of the ab se e s s
wwe fbond to eo ws tot 9t tki lawiiiiated Uood dot. £d Ui seal
to establish the new theory he goes so far as to state that effusion
of blood into the broad ligament may be prodneed by a sadden
arrest of menstmaticHi, aac^ farther, tilwt uuiBlwa df eaaea in
which this effosion occurs do not think it worth while to ask for
medieal assistanee and get quite well without it "And, atiU
forfter," Tait aiya, fai dl a eu wi a g a eaa^ that wa a ■awx *'^ t»
one of ovarian pregnancy, reported by Hildebrand, "the very
fact that it was discharged by the rectum is conclusive evidenoe
that it rested in tlM bXNid UgUMSl."
Such is the argument he uses to prove his case. Do not ab-
scess of the ovary and abscess of the tube burst into the rectum
without going throo^ the diverse channel of the broad liga-
ment f I have reported one case, in the Transactions of the
Michigan State Medical Society, 1892, of secondary suppuration
of an ectopic gestation that ruptured directly into the abdominal
cavity itself, and I feel satisfied that these intraperitoneal hemor-
rhages, producing organized masses, may rupture either into the
rectum, bladder, or abdominal cavity at will, and tiiat they are
not inflneneed in any way by the preaaeew ahamea of the broad
ligammt.
If the fetus dies and the placental structures become inactive,
recovery may occur whether the hemorrhage has hem into the
layers of the broad ligament or into the poritonad eavity, as a
consequence of absorption of the masses. If the placenta re-
mains active, a further hemorrhage either into the broad lig»>
ment or into tite pelvic cavity may occur and serious and dan-
gerous symptoms may supervene. Or, further, suppuratioa may
take place with the formation of a pelvic abscess.
If fBtea lives H »^ develop in tiie abdomteal otvity, in
the layers of the broad ligament, and— but very rarely— in the
tube itaelf . When it develops in the abdominal cavity the fetus
is really surrounded by amaitm, tho&g^ it mtj be difflenh to
make it out. In one case on which I operated the fetus hi^
escaped from a bicomuate uterus that had ruptured. The preg^
nancy readied full time and a secondary rapture of ^e sac oe-
curred at the end of the ninth month. Primary rupture did not
ntlce place into the brutd ligament The »ic surrounding the
MM; BCTOnO OBRATICnf.
f
ftHm wof^ eisily have been BiiMaken for broad ligament at the
tinw ot eptatioB. Hm plaiecBte after rapton aMgr ranain
tnthin the omui geetation sac, or it may be partially extruded
and, with the eontimanee of it» growth, may epread out over the
B^l^hAori]^ viaetia.
When tnbal abortion oeenta Oe pk w wt a is of conree extruded
into the'abdominal cavity', and under mdt oircumstanees it seema
h$mBf pvolNiila that it ean have any power of taking oa new
adhesions to continue its life. If the placenta remains entire
within the gestation sac after the extrusion of the fetus, there
will then be two laes, one containing the fetoa and tha othw tlw
placenta, and the cord will pav through M epeoing eommini-
cating from the one to the other.
Saa OF THE Rabeb CoNDinoNa.— /utrnMioI pregnancy is
tat nurdy met with. Ihavemet withitiBOoeeaa^of whidithe
following is a report: Mrs. S. (No. 3i in table). Patfaotofl^.
'fyftaoM, of Toronto. She had missed one period; had sli|^t
hemonhafe from the uterus. Bef on the doctor saw her ah^
had fainted three or four tisMa. Had been t^t ill at boob
on .the previous day with sudden, severe pain in the abdomen.
She vraa sent into the hospital under my eare, and the case was,
nnfortnnatdy, not eorrectly diagnoaed by tiia luoie largeQa;, M
he thought the patient was threatened with a miscarriage. In
the morning, when I saw her, she waa almost moribund. Oper-
ated, hsmtnr, and tomA the abdiuaiiBal eavity fnll <si Ueod.
It waa very difficult to make out the point from wfakii the hemor-
ibage waa e(»ning. Drew up one tube, found it he a lth y; drew
up the ot^ tube, f<»iiKl it healthy, anl waa lor a BHnent at a
loss to know what to do. On raising the uterus I found a small
spot on its anterior wall behind the junction of the round liga-
meirt iritt Ibo ttterisa faadna. On sp<mging this off I eod&
make out distinctly a small cavity about the size of a small pea,
with dark edges, and from which blood oozed. It was evidently
a nqptnre of an interstitial preipaaflgr of but very short duration.
The patient died the same afteniooB and I have hare *hA J)§§!§p
men to show you (see Fig. 2).
Intaia^ial or tubo-uterine pregnancy may, however, contima
to grow for several weeks, up to ^e end of the fourth month, or
even longer. Buptore may take place either downward into the
cavity of the uterus or upward into the abdomen. We have no
positive evidence that a downward JlBlWO has ever taken place
without eoineident ruptnre into tht^lliilMB, bat nqttnre into
10
mom: tct<ma gibtatiok.
the abdomen slone has been met wttii. Yergr nvm ^maanha^
is one t9ie nuun features of tins fom of e&tiaiitariiM ptt^
imiqr. Tiqrior met iri^ but one ease in his secies of 4Z, Law-
son Tait met witii bnt one ease in Ma asnai «f lit, «ad I «Nt irMl
bnt one ease in a series of 45.
Intra- and Extrauterine Pregnancy.— Tf^f friend Dr. Stn^,
of our ettgr, has net wifli mA a easa. He has kiadly tuoMmA
me with the follcnring notes: The pwtf«it% Hi al <M M rnmlmm
after an ordinary labor of a few honrs. Another ehild wm then
felttobeintiwaibdocidbdMmty. It eoold be eaaily aadia ««t
and the fMal hMi^ aonnda <BewM bo Iwttd. IRs aMtoHMi WMi
not opened until the following day, when the ohJd was reMWai
without trouble. The placenta was foond sttariad iiMUlllll|
Over "thfe psoas nnisele vsA ina oot Wms^^afl. fiMsMtriH^t
gan at the time of the operation and could notba e fllitwllt i, Mli
the patient died four oe five hours after.
ail oWorwirta eflfipkwfasa ^tte ftot Aat ft is •rtwiHafy
dangerous to operate during the life of the fetus.
Doutle Extrauterine Pregnancy.— I have met with oat «aae
ttf dtiUMa mntuteriM preguauey, of wtMi fha fdknniig w ii
report: Mrs. E. (No. 42 in table). Patient of Dr. Andrew
Eadie. Wn taken ill one .<igfat with sudden, severe fainting
i^dli whib ^g in bed. Wub not seen by Dr. Bii^ tailB flw
morning, when, on examination, he found a large mass in the
pelvis behind and to the eft of the uterus. I saw her at <mee
and from her appearance judged that the case was one of rup-
tured ectopic gestation. She had the peeulir r' o(doring of the
skin so frequently noticed and a e<^psed appearance. On
fnrfiier inquiry it was found that in Av^gvmt she had men-
struated. In September she had seen very, vwy little; m
Oetober again but little was seen. Some pieoea of deeidaa had
come away from the uterus, but ttey were not pt ea er ved. The
br«»ts indicated pregnucy. On auauaatkn, lettaA Uood elot,
breakii^ down under the finger. Was Mtfafied4iMrt1iM«Hfti»aB
one of ruptured extrauterine pregnancy.
On November 1, 1901, in the Toronto €l«T>eral Hoqtital Ftttvfl-
ion, aaaisted by Dr. Eadie, I opened the cbdoBMB Ib Om awAan
line and found the abdcnmnal cavity full of blood, ^passing
the fingers down to the right side, found a smidl raaii; Mi dr«w-
fa^C itiB vp, fistnid ft "to %0 ouautom with ha wtopio'garia^ "
iMteder its folds, running up to the surrounded Fallopian tube.
^ removing tiiiis sac the FBllopi;< '. tube was torn off; ovary tad
ti** Ml tiiit ode were lifted with silk. As worn m fwta-
Ite Mi distvrbtd a gr«at deal of fresh blood wm pound
•■1 n»ifliM>tiK»llien pMMd dowB t tlM otbar side at a
matter of routine, and to my surprise I found aaoOier g« at a t iff»
•M eoBMOtsd witii tke left tnbo. This waa rapidly ranovad
htm Urn adhaMM, and on its ranoval it btust and tha lienor
amnii escaped, together with a three-and-ona-bali^MMitfaa fotaa.
The two gcoUtimi saoa were, tharef««, of dilEnrsnt agea, and
the right <Mie, thoii<(h analler, was eertainly actiTe as well as the
left. Tha padiilA waa than tiad off oatiMlaftsida, a portion of
Vts. *.—Cam 42. SoaH* mn pNgMwe/. A, flfM m», aisM mmn a,
the ovaiy bang left to continue meustruation. Abdominal
cavity was washed out rapidly and the patient alzuost sank on
tha tabla. Snbentaneoos inje«tiia» of sidisfla were 'ven under
the breasts, the arms and legs bandaged, a drainage t '.be was
plaoed, and the wound dosed with ailkwonn gat The pa-
tient devstoped plauriqr with *Mmim. into the 1^ ehc^ l»Ha
which I ranoved twenty-eight ounces; inH, aotn^MwiihBg this
f net, she made an excellent recovery.
Tlia fast that both sidia wars active proved to ne that it ia
quite po ible to have pregnancy occur in one tube and then, at a
subsequ«ut date, occur in the opposita tube while the £Lrat is still
12
KMB: XCTOPIO eCSTATION.
developintr. The pngmney in one tube, in this eaM, wm evi-
dently of three and one-half nonlhs' dnntion, while tt* preg-
nancy on oter iiia^ we jviiBd, was of *byat two noBfti'
doratioii^
Ket^pie Bntation Oetmrrk tg Twie« im Ifte 8mm Mjenl.— Ify
experience with caaea oeeoning t^riee in the aoM pstiflBt ii m
foUowa (three eaaea):
Cjm i.—1tn. H., «t 21 (Ho, 8 is tiMe). Operatod ob Jidjr
6, 1891. Had no children, but ttm^lht ted wiacarried. Had
paaaed three weeks over her xomiti^fPoM^ aad had beoome on-
mil and reBidiied so for seren wedn. The ftowing then eeased
aad eonunenced again two or three weeks after. Severe pains,
like labor pains, appeared ; she became eoUapsed. The collapse
disqipeared and on Jane 90 she walked to tite hosf^tal. On ex-
aminatitni a mass was found in front and to the right side of the
utorns. Betnming, two days later, to the hospital, I operated
aod iMrad the abdomoi f&ed with old datk liqnid, and not
clotted, blood. The woman had evidently been going around
with this blood in her abdominal cavity. Removed ectopic gesta-
tion from the "ight side.
(Table, No. 9.) On October 10, 1895, I saw her again with
Dr. Noble. Found her collapsed, pale, with all the appearance
9t ia^bumi. iKmorrhage; precordial uneasiness. Patient locked
andoos and very ill. She had gone two weeks past her period.
A siriden pain eame on shortly after she wakened in the morn-
ing. No elevation of temperature. A mass was felt in the cul-
d ee ae of Doui^ and broke down under the examining finger.
Removed an extrauterine pregntmcy frran tin lett side. Pati^
recovered. This case was reported in Thb AniOiir iovwHJJj.
or Obstetbicb, Febmary, 1896.
Cjub n.— Mm. h., et. S6 (table, No. 14). Referred by Dr.
IfcMahon. Was nursing child 17 months old. Did not miss a
mcmthly period. Was quite regular until she began, after one
poriod, to 1km eoBtinoonsly. I^is eontfmied for fonr weeks.
Patient was sent to my office, and I found the left tube and ovary
normal, right ovary normal, right tube enlarged at its outer end
and lyhig in £nmt of the uterus. Two di^s after (August 14,
1896) I removed an extrauterine pregnancy, unruptured, from
right tube. Though the tube was unruptured, the abdomen
contained <M Uood, nd hfood eoold be seen to ooae from the
fimbriated end of the tube when it was dnom ^tap hjr dse^
coming very slowly (tubal drip).
On Ctptmber 88, 1898 (teble, Ma 27) law tlM patknt again
wHhi. .iBadfo; Had bImmI a oMBfUjr p«M and goM a f^f
dsys over. Irr<sgalar hemorrhage from the utenu and cramp-like
paina in tba lower part U the abdomen and ebiefly <»: the left
■Mt. 91w««vfl9rf«i8m wkfrfeaiaiMier
again and found a man to the left side and behind the utenu. I
ezamiiied her and found the ovarjr to oe <doae to the uterui and
Mnnat In dm. Nest day TtmamA aa Mrtnraterine pregnaney
from the left inbe. The ovary formed a cysi that had evidently
been taken for the geatation sac, and the gebtation sac had been
lakni fwthaovaiy, being hard and firm and unruptured. The
ehorionic villi were pcTictTiiting the tube wall, and the wall mi|^t
have ruptured any moment. There wan no blood present in the
abdominal eavity. There was no etv'denee of ligature or stump
of tube on the opposite side, removed two years bef<Hre. The wall
of the uterus was smooth from the fundus downward. Paliest
recovered. This was reported in Ths American Joubnal of
OMTimucs, volume zxxviii, No. 6, with the names of the attend-
ing physicians.
Case in.— Mrs. R. (table, No. 20). This case has not been
previously reported. Her physidan was Dr. Fletcher, of Enelid
avenue, Toronto. She had not missed a period, but uterine hem-
orrhage came on and etmtinned for tfat ^e weeks. She then had a
sudden attaek of f aintaeas uA beeaioe bathed in por^iratioo.
Had paina of irregular eharaeter in the htwwr abdomoi. On ez-
amination a mass was found beh< id the uterus.
On January 14, 1898, dielle . -at an eeb^ie-geptatioo soe with
tiMdotsfoundrabaequatttoiaptore. Left tube and ovaiywm
incorporated in the mass and were removed. Patient recovered.
(TaUe, No. 88.) In June, 1901, saw the patient agun with
Br. Refedwr. Sla bad tedeinite pelvic paina and bad wm hmA
on account of these, as we had advised her. On careful exami-
natifm the doctor found a little nodule, he thought, on the right
tabe. I examined and taanA tiw «me. ^e patient had a
iHl^t flow of blood from the uterus. We sint her to her home in
the country and advised her to return in two weeks. She did so,
and we examined her again and found the maas had ineMcaed to
double its size, and concluded um mm m» 9t tat/bna^Mkm
pregnancy on the other side.
On JmM 21, 1901, 1 opened fbe abdomen and fuund a bema>>
taam of the right ovary; drew up the right tube and found an
mlbagie gestation the sixe of the aid of the little flng». It was
14
MM: BUTOPIC snTATicnr.
the MtfUMt imniptiired eetoj^o gartatte I ksvt mr imb. B*>
moved tobe and omy on tiut aide.
When making njr flnt report of Caae 1, in which ectopiv geata'
tioD eeeamd twiee ia the mhb* pati«it> I hwhed m> the litara-
tnre of the eiAJeet cod fevttd hot five itetkur lapofflatiHrt entbfeljr
satiBfled me as to the correctness of the diagneaia in each ease.
It cannot be poeaible, however, that I have had an ese^pli«mal
eap eriea ee in HHk rmptek Ttgior aaja that vpwaid of fif^ aodi
cases have been re^rded. In his own case I find, however, that
the fiiat ectopic ge^tion waa not demonatrated by aorgieal apW'
aticB or perta aer f gai tiwlnatio n, tad, in view of idttk I h«rt to
relate later regarding conditions that simnlate mptared eztra-
vtnine pregnancy, I am not pr^red to accept rqwrta without
aadi aar gi ea l w peatei'Tfliai verifleatioai. b sgr eaaaa Ike fseih
nan^ oeeorred fltat <« the <«e nde and than ea tiM ether.
ViQ. 5.— V«i7 •Ml; aaraptortd tvtisl pNgaaacy at A (Cm 88).
Coe has reported a case in which a lithopedion was found on
the same side as that on which the ectopic gestation 'vaa situated
at^timeof operatioB. TluadanoartratedtbefaettSurteet^pie
gestation can occur twice on the same side.
Ectopic Geatation FoUowed by Conditions Simulating Ectopie
Oe$t9tion and Requiring Operation. Cabs I.— In the table t -'is
case is reported as No. 1. Was operated on for extrautenae
pregnant^ December 24, 1886. She had good health and bore
ene ehild. Betianed «gain and was epncatad on Peaamber 10«
ISSdf and a hematosalpinx, the blood of which was uncoogulated,
was removed from the other side. There was no evidence to indi-
01^ ttat^ftia waa the wanh of impregnation. The uTurtrwi on
the second occasion were a contii>ucd Sow fres ^ stKOS to-
gether with a mass on the left side.
MM: KTono OMiAnair.
1ft
Cam XL— This caw k recorded in Um table m No. 32. Oper*
turned on April 24, 1902, and was operated on April 26, when a
tiib<H>varian cyat on the left side was removed. She eomphuned,
on the second occaaion, of pains in the lAdomm, ehkflj OB tht
left side. Had missed one week, but had no nterina IrniMlffrlnail
The mass conld be felt on physical examination.
Casi UL— CaM Mo. 13 in the table was operated on for eztra-
oterina ymspanqr Seeember 24, 1895. She returned again and
«M opwatad en Oetebar 19, 1^, for a hydrosalpinx on the left
aide.
Gam IY.— This ease is reported in the table as No. 17. Oper-
ated oa ior extrauterine pregnancy on July 13, 1897, when the
right tube and ovary were reiioved, U^tether with gestation sM
on that aide. Left tube and o^tay looked beaUby. She re-
turned again <m Mareh 25. 1898, and at the operatkm I lemoved
a hcmatoealpinx un the left side.
Cases of Previous Operation for Othtr Conditions, F oU ow td
by Eetopie Otstatum. Csn Mia. MeC. (No. 22 in tabte).
In o ily, 1897, 1 removed a small cyst of the ri|^t ovary. Patient
made an uninterrupted recovery. In Febm&iy, 1898, removed
eetopk gertatum after rupture <rf the see or tin left rida.
CaSb II.— Mrs. B. (No. 44 in table). W perated on May 4,
1890, for large ovarian tumor. Seeondary hemorrhafe ooeocrod
«Bd the paiiMt was reqmied A» aam dajr. B a eorer e d iiiA
some inflammatory symptoms. On January 28, 1902, operated
&^ain and removed an extrauterine pregnaney a£ter mptuxa of
^ aa^ f^ the <^posite side.
The experience with these cases gm to i^e that ectopic
gestation follows the woman who has once hst* it pelvic inflammj-
tion. The report shows how diffioilt it ia ta> be ewtam that a
condition givifl^ enrtamigni^taiM ia mdoidrtatBir mlm^ tf^
tion.
I operated on the wife of one of our leading pnetitioBWB for a
ruptured ectopic gestation. She subsequently became pregnant
and bore a living chi](l, but in the interval, before pregnaney oc-
curred, she was suddenly seized with all the apaptana-flf a^mp>
tured ectopic gestation. No surgical operation was performed
and she made a good recover^'. Can I state, in such a case, that
the patient undoubtedly suffered from extrauterine pregnane
on two diJiterent oc^sionfi? I have refrained from including
thia eaae in my table of ectopic gestation occurring twice in the
If
ROM: CCTOnC GOTATlOir.
same patkot, owing to the anetrtmiatj that tzkted, but I flad
that there bave been maiqr liBiikr eaaaa raended wMMmt ngr
greater amount of prodl.
BnouMT.— Bekqpk i w tetk n aeeBia to be intimatdy a Mo d at a d
win iBiHBBMnMMi Ok hh mWM> h boo Don waieo not no ip>
flammation haa bam loBoiiad bf desquamation of the epithelium
lining the nneono wuibnBtf, md that^ owing to tbia fiMt» tbe
AMiher cause of the disease is undoubtedly mechanical ob-
■ti'uatiou to the progieaa of the ovum throo|^ Um ovidnat This
muehanieal dhrtip e ti o B aMjr ba ea— d bgr pt—iu a ftmn wHh-
out or within the tube, by growth, or as a consequenee of dis-
tortion of the tnbe prodoeed by adheaiaia. It haa been atated
that atroiAy of the tnbo is a eaoaa of extraularino pregnanqr,
bol I have not noticed such atrophy in any of my cases. Tbe
tubes have always appeared to be healthy and normal on the
oppoaite side. It is evident that they were not haaltiqr or tiwy
would not have required subsequent operative interference.
My experience does not coincide with that of Taylor, who
atatea that he does not believe that ectopic gestatioL is produced
by a result of previous inflammatim of the tubes. I have al-
most always been able to elieit tiie hiatory of a previona attaek of
oiflammation from these patients, and this inflanmwtiQB big fre-
quently been followed by a period of sterility.
I have met with ectopic gestation in a young unmarried wo-
man, and once in a bride of aeveit weaba who wa% I btfiovob •
virgin when married.
SnfFTom.— The symptoms of ectopic geataticn mnt be eon-
sidered: first, before rupture ; seeood, «t the time ol nftaK;
third, after rapture.
SpmptOHU htfwif Jh^ytsfW.— History ot > prefvioiia attaidf of
inflammation and sterility; a missed period, more or less subse-
quent, more or leas continuous diaduu^ of blood from the
ulevus; pdv^e dia c oHifo rt; bcarfak|f<towB pidu, paroxyamal in
character, but not severe ; soreness or enlargement of the breasts.
Physiedl Signs.— On examination, with or without an anes-
thetie, a small bmsb to bo made out in fte tube on mm aicto of tiie
uterus, firm in consistence, rounded, regular, and not pitted like
the ovary, and at the same time the ovary can be made out as
aeparate and diatinet from it
Symptoms at the Time of Rupture —The symptoms present
before rupture will have added to them the following: suddtm,
ROM: KCTOnO mTATION.
imn paSsui eoUapM with ooM ptnpinitLii; pnoordud oneMi'
nm;pti»tmdmakm Dm*; rqiM, tftta pnlN tad dttatod pnpUtf
■hifting dulncM m the intraperitoneal bkwd shifts with th«
dMBfs of positkm of the pstitBts Tisiblji increased vwakidar
MtioB tt tta tBt astliiea ; gftst vMttMiBcss } sn^pnHlM a( whw
or great diminution in the quantity of wrimn • liwhn tt diftwta
withont the aUUty to do so.
fwfmesf JwyiM.— UB memMHMH imn «• mr ntna to . '
felt. It will be difflenU to make out any small mass in the t.ube.
ExaminatioD under thsM eireoBBtaneeo may give do doe aa to
dM aalvre ^ tiw traMt.
Symptoms after Rupture.— In addition to the symptoms given
before and at the time of mptore, we have the foUowing: sal-
lowid^ f aded-toitf OBkr of tfaa site frma absorptioa of Mood pif.
OMUt and loss of Mood; alig^ pulBng of the abdomen, withont
■meh tenderness and witlMmt rigidity of the abdominal mosdaa;
reeorrenee ot severe yaptwa inm time to tiow; rilght tOen^
tioa of temperature, irregular v ariX fa w ni poise { fanitiAi^ «(
the bladder may be present.
Ph^.-'cal Signs.— Vclvie examinatkn diadoses a nasa oa one
side of, or behind or in front of the uterus. The blood clot may
be felt to break down under the finger. There is a boggy feeling
«t the parts. The uterus is found dli^Mljr CBfaurged. ▲ dtirMna
Bsay be discharged entire or in pieces.
I have not found the presence of the deeidua of value in diag-
nosis. It is generally extruded too late and only after serious
symptonu have set in. When it is extruded the case very eloadly
sinnlates one of miscarriage and may be mistaken for it.
Tait says that he saw only one case of unruptured extra-
uterine pregnancy, and Pany saya that it it v«y rarely that an
opportnnity n obtaiiMd to oxainiiir wi *nred cyst I have
brought three or four such speeime Jiibit here to-day.
When the symptoms before rupture a. ^re oarefully studied
and more earofidfy tan^t, unruptured eztoanterine pregnancy
will be more frequently met with. The unruptured easea wit*
which I have met have oeeorred in the praetim of those who hu.e-
disenssed the subject very earefaUy and wlio have been thor-^
oughly familiar with the very earliest symptoms and physical
signs. The diagnosis has, therefore, been made hy them and
Mily sobsequently confirmed me.
These are no "society utterances or library paper ssprcsBOOS^'*
as Tait dubs them, but a atatement of faets.
H WOmi ECTOPIC OKTATIOM.
cele on the one hand and eetopie teatatkm mi the other. We
now know that hematocele is. in most cases, due to ectopic getta*
tion and that, therefore, the symptomB of hematocele a re prae-
tidily the i^Tnptoma <rf eetqfne geatation aobntpiiBt to rkiptur*
wkidnfe.
was iMliMBt.
IHwebentulDiagkosb. Bcfdw Rt^»«.— A diagaoA must
be Bade from the following conditions: first, abortion; second,
mroma, aarajma, carcinoma of the tube; third, hematosalpinx;
fourtb, hydroMlpinx ; flfth, pyoMlpinxi uzth, eyit, fibn^ or
htmatooMi of the ovsrj.
In abortion there will be no nun* felt in the tube. The aterm
will, in all probability, be larger than in eetopie gestation. In
growths of the tube there will be no qrmptoma of pregnanes ; no
period will have been miaied. In hematoaalpinz and hjrdro-
•alpinz, as well as in hematoma of the ovary, the sjrmptmna will
closely simulate those of eetopk giMtimi. i mn the Mses re-
corded it will be sera that it is inpoMiUe to oMdn a diffemtial
diagnosfa nntil after the abdomen has uem o^^ncd. In oasss of
pyosalpinx there will generally be a history of inflammation
with an deration of temperature and an abantee of the qrmptooN
of pregnancy. A mail «yst of the chrary wQI fireqrtintly produea
utenne hemorrhage, coming on after a miased period, but with-
out any of the other aymptooa of pregnaney. The < t can gen-
erauy na laacniy BhMM oih} n m voo aerae bmi ro oiici e o aiHi
fluctuating to be a tubal pngpUUMy- The ovMriaa ligament as-
sista us in emning to a cmidaiitMi as to whether dH enlargamrat
ia tubal or ovarkiB, md, fiulhaiii iaw, Iht orary on that skia wffl
be found wanting.
In two of my eases I was enabled to diagnose unruptured
ealDiria fsttetiea ow^ to Uttk vaix laat The enlargMaeBt of
the ovary led to the dtagnos's of extrauterine pregnaney; the
mass in the tube was mistaken fur the normal ovary. Fortu-
nately, b eaeh eaae the abdomra waa <qieBed, and, ttoi^ tiw en-
larged ovary had been mistaken for the gestation sac and the
gestation sao had been mistaken for the normal ovary, the pa-
ints were readily relieved from what could have been makm
danger.
A fibroid of the ovary may be made out by feeling the ovarian
ligament, and the irregular and hard outline of the growth itself
is its chief characteristie. It ia not Wmfy to be acoompanied hy
uterine hemorrhage.
At the Time of £upt«re.— Differential diagnosis at iMt tine
must be made, first, from acute poisoning ; second, from rupture
of the bladder ; third, from rupture of the stomach or intestines ;
fourth, from intraperitoneal bottorrhage from womi otte bboM,
mMb as ruptured uterus in a case of normal pregnancy, rupture
ot a pregnant bicomuate uterus, or rupture of a pregnant ill-
developed uterine horn; fifth, a«rte goeflndwal endemetrM i;
and, sixth, attempted abortion.
Ia aeute poiaaiiing tiiere may not be the symptoms of preg-
'7
10
»«y er h«>ar>te|« fto™ the utjnM. Rupture of the bbuWer
JVw me oeeomnee and gweraUy a«oriated with trau-
Itii^nymptonm of preg«iw4iia »ot be pre«mt and there
^l^t h^Ln uterine hemorrhage. Perforation of stomach or
"Ss^ea. not dn. to tn»nmati«n, may closely B,m«late ectop«
gestation at the toe of wptnre. Symptom, of P;ep«J«y^
Serine hemontoge will be absent and there wiU. m aU^
abiUty. have be«i symptom, of pre^iating inflammatory or
Ser^di-H^e. B«.pt i« «— <rf P«<«~t7 of a gaMric lU^,
the patient is not, in my experience, greatly eoUap^d. Intra-
peritoneal hemorrhage from some other «.nwe ewmot ^
Sitdy diagnosed from a ropt«red ectopic gestation. Acute .on-
orrheal endometritis will vfery closely shniUaf ^^^^^
nterine pregnancy. It is accompanied by feT«r sad
by a disdiarge of blood fewn the vagina in which pus is found,
aJd a discharge of either pus or blood
ping the same with the finger. There » <rfte»
5»e «rt«mal genital.. Oollap« is not marked , great abdomind
tenderness is present. There wiU be no symptoms
and the patient will not have misaed a monthly period. Vonnt-
iBg often p«*ent, as weU a. rigidity of the abdominal waUs^
In cases of attempted abortion there will be found some good
wwn why the patient does not wiA to have a diHd. 8y«f«»
STregnaney will be pre«nt; temperature very high; piUse of
inflammatory type, collapse not marked; rigidity of the abdom-
inal walls. Patient gives evasive answers, though she may ae-
knowledge having pawed an instrument.
In the address on "Midwifery" read at the twenty-ninA an-
nual meeting of the Canadian Medical A»ociation, held at Mont-
real, I presented the taWi on page 21, that may be of interest.
Intraperitoneal hemorrhage may occur in a smaU amountand
,tiU give rise to severe symptoms. One of the patients «m whom
I operated for extranteriBe plUgBMCy became pregnant subse-
ouently. After she had missed two periods she was taken sud-
denly with severe pain in the side, in the lower abdomen, and Wt
„ if something had given way. She had a large hernia from the
PMking that had been used at the time of the previous operation
tToheck the terrible hemorrhage. I opened the abdomen, fear-
ing that a loop of intestine xMgA »«ve become caught or that
M Had. had been torn, and feeling that I could, at the same
tiiae, apair the large hernia and place her in a better oonditioB.
tl
Km: tCTOnC GESTATION.
It WM only after she was ancsActued tliat I wu »l>le to out
intrauterine pregnancy. ,
After the abdomen was opened I found a imaJl quantity of
blood and a large adhesion binding Qteroi to tfwpdTie rtrue-
tures, that ha'd been torn through. fiBie ABwed IrtW flo,
in the fifth month, in the early morning, and I saw her at 3 in
the afternoon. I never had wash diffienlty in cenoving a pUr
centa ; it was univeraally adherent. She reeofwed.
I met with one other case of severe vomiting of pregnancy
and ecdlapse that simulated a ease of ectopic gestaticm with rup-
ture. The patfwit was threatfflwd with a iBiM«rrii«e and there-
fore had uterine hemorrhage after having missed a period. The
pregnancy had been allowed to go on until the ccmdition from ez-
eesmveTomitingWM extreme. Su^tei pain Md faintneas ae* in.
Upon careful examination, however, a correct conclusion wa»
eome to and a miscarriage induced, and even then we feared that
tte pcttettt would meeimib. A lew dajn ago I saw the patiei^
ag«tw in a similar condition and was struck with the eloae re-
■enUoiee to a case of ruptured ectopic gestation.
Afiw Mvphm.—JJ^leta^ diagnorii matt be made from,
first, inflammatory disease; second, from tumor of the ovary >
third, from pelvic abscess ; fourth, from myoma uteri ; fifth, f rwB
flnrnual pregnant; sixth, frwn pregnancy in tm ffl-daydop«d
horn ; seventh, from malignant disease.
The mass discovered in the inflammatory diMase is usually
ntuated on both sides of the uterus. It is harder and more sen-
sitive to touch. Great elevation of temperature is noted. Tumor
of the ovary is not accompanied by symptoms of previo» rup-
tured eetopifi gettation unless it has been twisted on its pedicle.
An ovarian tumor, pelvic in situation, that has been accompanied
by uterine hemorrhage, and whidi has become fixed and inflamed
as a Mmaequenee of a twist of its pedicle, will be difilcult to diag-
ttofe from a nma left in the pelvis from ruptured ectopic gest*-
tion.
Pelvic abscess often results from ruptured ectopic gestation and
breaking-down of the clot. Perhaps ectopic gestation is one of
the most frequent causes of pelvic abscess. If of inllunmattny
origin, the history will assist in making a differential diagnosis.
Mymna uteri is usually more solid in consistence and rounder
in outline, and the voisaim on its snrfaee a gnat miktaam
in making a diagnoms. "awfe will hw* bam no snddMi onset <rf
severe symptoms.
HOSS: XCTOFIC ODrTAtlOy.
It is difBenlt to ^ttagnow eonnoal pregtuun^, bat the wrflM
symptoms of rupture wfll, in all prokitbility, hitO IW e fc lfl iM lt
The same may be said. of pregnancy in &u ill-developed horn. If
el Jier of these have ruptured it will be imposrible t? SMagtMi
ftms ed topi e gestation after fttptuw. ftitwiWjjliwiit jHWMilfcliiie
will not have been any sudden onset of severe symptoms. The
doeaae is aeeompaiiied more pain and is of longer duratiim.
I ted • eariiR» gipetfaBwe wHh • eaw tevtHg «ik lB-d»Mi^M
uterine horn. The patient was 41 years of age, mother of four
children. Had pain in the abdomoi off and <m for araie time.
It began in tin left iUae region and passed in Tafioa difeetiotti.
In September, 1891, had what she called typhoid fever and
peritonitis; pain continued after this and came on diiefly at the
menstrual period. When the patient was only 21 yettt of age
she had had a Inmp, that appeared the size of a goose egg, to the
left of the linea alba, in the lower pelvic region. A ponltice was
applied to it and it finally opened externally two o: t' ree inches
below the umbilicus. The abscess remained as a chronic ab-
scess for two years and then healed up. Owing to her indefinite
symptoms when I saw her some years later, I ^eided to open
the abdomen, and on April 9, 1892, this was carried out at t>><^
Toronto Oeneral Hospltd. I found a bicomuate uterus ; the mass
to be felt to the left was one horn apparently only slightly at-
tadwd to the eorvix. Tins was determined by the situation of
tliO round ligament joining its outer angle and the abeenee of
broad ligament between the two uterine masses.
A year or two later I was called to see the patMnt with I!Kr«
nown. Ox loromo, ana xonna ner suiieruig ifubi severe par-
oxysmal pains and obstinate constipation. She had been suffer-
ing from these pains for some wedos. The rectum was obstracted
tcoA a large mass irai to be IMt in the pelvia md ooOld be Ciit
above the pubes. I knew dwt the patient had a rudimentary
uterine horn and decided that tiik mass must be retained men-
gtntA fttM. She wis not living wifli hm hnlMi^ XJpen.
puncture through the vagina a large quantity of black, tarry
blood, resembling retained menses in cases of imperforate hymoi.
esMped. Bftd I Mt knowii the eztet nttare of the mm I itwM
have taken it to be oae of pelvic hematocele caused by a rupture
of an ectopic gestati(m into the broad ligament, bat would hare
oeen puzztcu oy me carry appeanraee (htm dioocl
€6t%ml Pregnancy.— In comnal pregnancy the round Kga^
BiBat wffl be found to nm to the outer aide of the mass, wherea»
ROSS: tcranc amaAnoK.
in tribal pngnancy tbe roond liguMnt nuw to the inner aide of
the BUM toward the nedian line.
D^trential Diagnosis at FvU Time before Death of Child.—
Thb il^g"""" moat be made at thia time between eetopic gesta-
tknand^s; a aornial iatrantniac pngaaa^ with a very thin
wall; (h) isplacement of the pregnant uterua by a fibrocystic
or nyematouB tumor; (c) bifid uterua with pregnancy in one
dtamber. I have met with several ea!"^ of thin utniiM wall with
intrauterine pregnancy that felt as if le pregnancy must be out-
aide of the uterua, but on more careful examination I was able
to aatiafy BQrself that the condition was a normal one. In caaes
of displacement of the pregnant uterus by a myomatous tumor
I have never had any diflSculty in making a diagnosis.
I have met with one case of bifid uterus with pregnancy in one
ehamber, and the report is as follows: MIm E., »t 23. Had
menstruated and had a discharge cx blood from the uteras.
Ifenstruation then ceased and she had seen nothing for two
aonths. There had been no abdominal pain and there was no
hwtory of collapse. Patient looked in good healtii. I was so
uncertain as to the diagnosis of the case that I decided to use the
uterine aoond. This passed in toward the right a distance of
atxrat three inehes. A tumor eonld b6 dafthMtly made oot, to tin
left side of the uterus, as large as a pregnancy at about three and
one-half months. I felt satisfied that the patient was pregnant
and dedded that, as the ntems was onpty, the i^wgnanqr mait
be an extrauterine one. There was milk in the breasts. Oper-
ation was advised and the abdomen opened on November 22, 1900.
I foond a tomor that lo<dced red and exaetly Hke a pregnant
ntema. The sound was passed again and it went in, as before,
towaid the right the same distance. On careful inspection the
«ne was found to be one of a pregnancy in one horn of a utenis
bicomis unicoUis. Abdomen wr alosed and the patient went on
to full time and was attended by my friend Dr. Mcllwraith, of
oor eity, i^ found the septum present at the time of delivery.
JfiffmnmtilA Diagnosis at Full Time after Death of Child.—
The dionnntitm in size of the abdomen, the false labor, and the
diow that occurs are characteristic of this oonc^on. The cer-
vix is oftentimes found to be open, and in my own case (No. 45 in
table) the finger could be readily passed up into the uterine
eavity and the bicornuate condition of the uterus could be readily
made out. The diagnosis iiiust be made at this time between
(aj slow-growing cancer, (b) fibroeystie tumor of the uterus.
aOW: ECTOPIC OCSTATION.
25
•ad (c) tubereular ptritonitw. In dow-growing cancer the in-
er e io is rttady, ud if tiwn » my gnat iaereaw in the growth
the temperature chart will show evidence of suppuration, tmA
this suppuration will be moat likely to accompany an eztrauterlM
pttgaauey. A dktgaom betwem extrauterine pvegnanqr at tids
time and a fibrocyst of the uterus must be a difficult one.
I know of a eaae of tubercular peritmiitis with the nodules
floating about in the e n c y s t e d fluid, siiBnlrting fetal parts, ids-
taken by an able surgeon for a case of extrauterine pregnancy
after the death of the fetus. It was only after an exploratory
o p sratiim had been performed that the diagnows was settled.
Treatment. Operation.— Tail's first operation wps per-
formed in 1883. Operation is now the accepted method of pro-
cedure. It is called for to eontnd the heaHRkafi, to ramove
debris that may be dangerous to life, and to OTweome the s^tie
conditions that may present themselves.
Some have stated that the great impediment to the adopticHt d
this treatment is the uncertainty of diagnosis. Tait laid down
the dictum, however, that when the patient is found in danger
of death from coi^HioBS within the abdomen which do not seem
to be dearly of a lualignant nature, but a correct diagnosis of
whi^ is impossible, the abdtnnen should be opened and the
diagnods mads eertain and thus sacifftil treatment made pos-
siUe.
He concluJed "that in the great majority of eases of extra-
peritoneal hematocele, wen when due to ectopic gestation, the
disease may generally be let al<Hie, being rardy fatal, and that it
is to lie interfered with only when sni^niratitm or extrane temor-
rhage has occurred. That, oii the contrary, intraperitoneal hem-
atocele is fatal, with almost uniform certainty, that so soon as it
is sujqpeeted the abdomen mtist be opened and the hemorriiage
arrest'
1 1> ke exception this opinion. I am satisfied that the
eases < . ■ raporitoneal h<.!ii«toede ure not uniformly fatal, and
I have operated jn cases that I feel satisfied might have recovered
H^thout operative interference, and have left unoperated on
«am^Mae% ^ hm reeorand, ^ had hsoi ooQqised m& al-
most moribund at a considerable distance of time before I saw
them. The fact that the patients had presented all the symp-
toiBS of intrapnhoinal h a motilu iy showed that soefa mm «Mt
mover without operation and that they need not uaemmiify %•
Mses of hemorrhage into the broF.d ligament.
ROBS: tCtOPK onTATION.
Bat it mum to sw Uiit waOk fine dktiiietimw eumot aerve any
gooa pttrpoM. H > mgaoria mi ht mat hOof r upU u » -u iA
that it can frequently be made is now beymid diapnte— the ab-
domen ahoold be opoied, nther tiiroogh the abdominal wall in
tioat oe fbmtigb Ubi t^ihte %«tow, mi the mmiptand tube
should be removed. It is not necessary to remove the ovary if it
is healthy. This will be a Very simple prooedure and the mor-
ttBty, in di^liaD^a>>oaUI1watnaak«a. men mptnre has
occurred operation should be Undertaken without delay. I have
in one iiwtance taken the patient in my carriage at once to the
ho^tal it 1 A.M. in order to save cMay. I have never regretted
rapid action in these cases, but in two oases I have regretted de-
lay. We should not attempt to quiet our fears by endeavoring to
dedde between tobd ^Mp or mufim, and tubal raptore into the
peritoneal cavity or the broad ligament. If your experience tal-
lies with mine you will not often find the rupture into the broad
If you Avill do me the honor of earefuUy reviewing my taUe,
you will see that the lowest mortality accompanies the eariy
operation. When puzzled over these cases one should send im-
mediately for further advice. We should not wait until the not
day. If one consultant cannot be obtaiite^ viOg to tiw latenen
of the hour, another should be procured. Waiting means in-
OMMMd risk to the patient and inereaaed diffieultiea for the C|[W>
itof. An operation Is tte oi^ form of tfeaitmeiit in MlMii mm.
The terrible contingencies that sometimes arise when the con-
dition is allowed to prooeed ue particularly exen4>Ufied in Case
^<tf the table (Mrs. J.). Sa'^ean, after opmilig^abdmMii
I found the uterus pushed forward ; it looked like a uterus con-
ta^"»T*g a six-weeks pregnancy. Adhesions of the omentum were
br^N» down and ikmt Med very freely. An oraeleatkm a flie
mass was then started. After a time the finger burst into it and
fluid escaped. Then portion of old clot came out With the
finger throo^ the opening a fetw eoold be diatiBetly Mi aad
this was extracted. The placental adhesion was now reached and
blood gushed out immediately. It eame sd-fast that, in a moment
tepenittaB, I ^sqied the right ttterke artery and flm
clamped the left one, and decided that il; would be necessary to
perform hysterectomy in order to get at the hemorrhage. Hem-
onrIui§e fMHi tinae aAeriMis ^rae Mpril^. Tfee putieiit lAlMrt
died on the table during the operation. Gauze wasJ^t^Kd into
the pelvis after the surface, from whidi the plaeento iiii IteMi re-
mm: woKsto QanAngp.
97
moved, had beoi toodMd wiHh penolplMto of iron. Tiw Uood
■eeiiMd to aooM frgpv lnndi«di
Prmore wu applied exfeBmiyay, reetom pid^nd with gaiue,
vagina pa«ked with gauM^ and a finn bandage placed t» litu,
M tttwmm a mifnt ^ fact that the ntenia, tobea, and ovariaa had
been removed with the map, the bleeding emtinned from the anr-
faoe of the enl-de-aae of Donglaa and the aorrounding pitrta, ao
tiiat gauze had to be vmA in fb» nfovonentifHied aumner. Tim
patient Uved for three days.
Sneh an experience should be sufficient to warn us to ntit, in
such cases, until after the death of the child or ontil full time.
It is very easy to lay down this role, bat itia ao eaiQr tor as to
observe it. The life or death of the fetna is difltenlt to determine,
end many operators find timnaelves faoe to face with a live fetoa
and an active placenta, owing to thia very diiBenl^. 1%ey
would like to draw baek, bnt are forced to go <».
When the pregnancy is advanced vaipnal section should give
way to abdcnainal seetiim. Tait belieiM that vaginal section is
an muatkfactory method for the purpose of saving the ddld.
There are man> cases recorded in which great difficulties were
met iinth in getting th« child out, and only two eases w^ known
to Mn tst whidl the eiM had been extracted aUve. His ex-
perience is similar to mine and was sufficient to deter him from
making another attempt to deliver the fetna in this way. He
wrate limt fee w«M nemr, nnder any dtvowtaMM, atttdk a
subperitoneal pregnancy from the vagina. He considered that
the child could not be dragged out without tearing tisanes in
i^dA terge sinosB ha;v« ben atmovnaBy devalued, and throQi^
Straetures i^jrielding as they are this can only be drnc with
mneh fnree and with the likelihood of losing ita life. If large
vessdi be ttmi it is simply iuposstt^ to fiad flMBiand seevt tli«
Ueeding points.
In one case, that of Mrs. J. (No. 19 in the table), I operated
in this way. The fotlo'tving is the history of the case: The
patient had been ill five weeks. Had missed a month and then
had gone five weeks after that and then went six weeks. Sudden,
severe pain in the abdomen came on, and when I saw her, after
she had been ill for five weeks, she was profoundly septio. Uterus
was pushed forward by a maps as large as an adult's head, and I
was satisfied the case waa ather one of suppurating hematocele
from ectopic gestation or retained BKUiteQal fluid in an unde-
veloped ntonne horn.
28
■088: ccropio enfri.TKnr.
Vn. A.
•ho.
I.
Nn.W.
IMn. U
HJ. F. W.
BMI.
II
1-
IMn. UM
id.
)Mn.ll.
76
I Mr*. O.
a.G.
Sowe.
BoaptUI
wrrln
LiUMn.
Ko.
tyn.
tjn
yn.
C. B.'
Cutb-
bert-
• OD.
Only mar-
ried 7
moothi.
t w ai n
10 daya
OTW.
Wentr
week a.
Sdaya.,
I weeka.
ScMBliar'^SirLS?
•d UU Juaarrt.
■atiilar to DaMa-
btr.ilBoatlmpro-
tmi. Imm I*
wa pah
«<Nka aftar.
to Ua down. DIa-
ctaara* oopiooa.
UBabIa to act up
Vary »(*k
March to. IWI, na
w«ll; wcBt mm
•eeka, and anala
UBwall JuM t.
Taken with palna
like labor patau and
llowlnc. Tbousht
had a mlaoarriace.
OoHaptr. Hot
olotha and went to
bed. BleedlBKCon
tinned.
Doctor thoucbt the
had a mUcairlaRC
and curetted. Jut
'^
then
ahow.
None....k..
After mlialnir three
weeka had dla-
ot bkwd
cbarga <
for tin*
I • ••MM ••■• MAM* •••
Mo rigna of prat-
nanqr. Oua tent
aa oM of probable
haawtocMa or pel-
wio abaoaaa. My
dlaaaoala waa el-
tber raptor* of
eetop'e lato broad
Unaent «r -
rtB«
and HI
Nona
ThoaRht ahe waa
pregnant. After
the curetting tem-
perature went to
lot*, pulae lit.
TWnperatiire roae
auddaaly. Tlolaat
No other lymptoma
otprenanoy. No
BiBUar attack be-
foraoMrrlaNa. Be-
morad lohoapital
to be taon cl- iely
walebad. While
tbara audden ae-
Tcre attaoka of
peritonttia a» < <>'
termlned to apa>
rateatcmoa.
Had a mlacarrtage
three yeara before.
Temperature and
pulae normal until
llTe daya after Brat
atteefc, wh<apvlae
waatM. ttanata.
ROSS: ECTOPIG OMfATKnr.
29
PslMoa UrttaR.oowth'
After wmliiitlon per
vantBua, I Mt lb«
honw. BaMllraalM
back. fatlMt ool
DoM oa neoad or third iter
ter mptiu*. fooad rnptiirad
tubal Dragaaaer. TSoacbt
probaMa bmnatoaaipnz.
aot lit
M
IB'
After Maine BUcht
mtm, taken lllwlth
firiB In right groin
aad acroaa abdomen,
not verj Mvere
Pain In head and
limb*. Put to bed
Pain increased.
Waat out week after I
weal to doctor*!
bouw. Paiaraenrred
m three dajra, ee-
vna; la bad; ap-
Marad
Wtoin,thaan>aBd
aowa* rvNunoad.
nillllli il labor
jp^a. Doetar toM
I DtcathaafteraMr' BteaO
nta
riage Mii>«d with and-
dea pain, right fide,
low down In abdo-
awn. Went to bed,
aeat for doctor. Cold
Bwaat. In bed one
aad a half days. Up
Abdominal pain, un-
comfortabM but not
aerere, luted two
weeks. Was striiln-
ing at stool when
sudden serere pain
seised, low down in
rlcbt side losrer ab-
•lomen, Crawled to
bad. aot op • (s«
h a m after, patara-
to 'Va?fe
Larfce mass eztendinc
neatly to the lerel
of umMllcns, dull
on percussion and
fluctuating. Utems
three and a hall
Inches In length,
empty and In centm
of perns, pressed by
the mass back
aaalnst sacrum.
Diagnosed suppurat-
ing hematocele, but
801 sore whether
dna to ectopic gesta
^ felt OB
ri|^ aide of abdo-
men, low dowa, IB
froBt of ntaros aad
appareaUy betwi
utema aad bkMlder,
not morabla or flae-
toatiag. Otagaaste
PeWla AIM with a
mass. DIainiosrd
ruptured ectopic
Restetion, com-
Bumeing snppura-
ttaohnateblMddot.
Operated abotM
week. Ar '
•tettartaath
Tumor Mtbi right la- Doaa about thirteenth or four^
H!5i"'»i}«lV«»F traathwsek. Masa fouud ap-
**^:. yirt teHay pareatly la broad Uguaeal
Osrvtz aad aot reaiofabla. Boiopti
gtatatloa. Opeaed and wash
~7 T-z- adoataaeaaddrataed. Bern
i5S=z =j=i»Jj2- on*agaatlBter»alaforao»r
pSSKiS^TJm?^ U.-k-arthsfrom
Jnaa n walked
hoivttal. Izaai
tioa found Bteas. TO
ratWB In two da^
Uader chloroforra a
inorable masa (ait
drOBB|M[ iBlO
Doae aftt flre weeks of sup-
purattoa Patleat profonadly
septle. Washsd oqt chrts
from abdomea aad ramored
fetel sao of about twelfth
week (rem amoaa tataattaea
-and uneoBBcoted with tube,
niote iB abdomen had become
aatonr ad-
!a aad had
ersd,
Be-
COT-
COT.
ercd.
Operated i
Toroato
Hospital
Died.
encysted by
baakMaof -
Fouad secoBdary rupture of a
aupporatlBg seBrf-orgaalsed
old ceto»te gtiteUsu dot
Re-
COT-
ered.
Eighth to tenth week. Abdo-
men llllpd with blood, gru-
Sa-
OOT-
arcd
3
Mn.II.
MBoWM
a Mn. P.
3jf
• Mn.H.
3#
lOMim. B
Doetor.
T.8.
wan.
n
I a.
Ubon.
Me.
1 yim.
H BMpttal
lar.
J.T.
Fother-
inftSuun
t wmkt
tokiM
blood
OUmt
Mr*
Ir •IVWM& Mkni
with fMntnm*.
Dootor found her
IB MBil^laptrd
coadiikw; colii
pKrapiraUoB and
ward oonplalDol
of Irritaunir of
rectom; 4uMu-
■too. Improved
aodwHup Taken
111, aad dootor
thiragbt hjraWri'
oal. A«alB Im-
prorcd, and then
Motbrr attack
wiMB I MW bar.
,|Tamiaroa p regwe.
aiSTtMittoltMS!!
bookadllL
Ro vmptOBa of
pmoaae). Out
walklBKWiwn nd-
denly ntaed with
pain in abdomen.
fWt faint and
ttUTM
IttOT^B
fana(MM«ela(,Moi
lijr Iwdftili iMiwtu
At OBO* oooetaiM H
wH raptnrpd utim-i
•lOtlBMlvta.
oidcd to wait ooviito
of (■»■ to pnimf
■mt. but luddenlT
took wom, aiid <to-
ckM to opento im-
mcdiaMr. Con-
0odar MM«tbatlc felt
blood clot brpsk
down under my fln-
gerini«(ina. Outer
•Dd ct tube felt
OMMd ud Mwr-
— ntVoT tiloodlBcta-
•lc«M0( OoailM. PmMoM
cc td Bifl t tni R M me otaktmt
third Soptuw
tbromk tolitiM miSat
tube. Tab* end damped with
forcepa to itop baaorrhace
retue not fooad. PIseeoUl
tlmie. Enlanted tube, slae of
■mall oraan. data waahed
out aad drafaafa tab* luert-
ad. TttbetMwttheOk.
Oold haade, denrewd
polee, pale Opi, aU
appaaraaoe of latrs-
abdominal hemor-
rhage. Found blood
clot la abdomaa on
Operated Ineide of an hour after BC'
lint leelnic her. On opanloK cot-
abdomen blood cnahed out. ered,
Enormooi quaatltir uncMted
blood free In peritoneal car-
\*Z- Left tuba aad OW7 tied
"Hghthagjmaniiiuua-
iTr
fcnai tubal a ealatlua ruptured
Into btvad Umunent on left
Me, and remomd. Alao eju
of onrj and dilated tube on
rUAt aftla; pealed oit ~
aa juu i y i aad Ugt**
O^TMBpia Qb my '
full of Mood,
■ctopic aeetatloB In rlRfat Ma.
Placenta eztrudinc tbrounA
rupture In tuba. Tied off ped-
icle. Petue about one bch
lone Axeoonaa peritoneum
cut ttaioutrh, blood ipurted
out. Inormoua clot! and iuld
blood lemoTod^ Waahed out
Died
Operation
Toronto
General
Eoapttal
NoTembar
It, IMS.
rant pia-
truded.
IMui aa
eapad into
Mdomaa.
peeSSr
QStS
niln.w.
UiMni r.
Mn. L.
HMn. 8.
I Mn. T
0^
r.r. Me-
J. w.
BOW>D.
IT
Mn. B.
6^0
)Mn.W
M. WrI-
W.J.
rietob-
He.
IT
»
lar.
T. Web-
■tar.
two
mat
H bMMi to taim;
aovlferaeMwA •
Uttto wkttf la Jas-
aaa.bMkMboM
■Ufciiii tofM to
-
M—iUU'
Ttoi oa
aad Umb
waat 5
P>Aa .
I
I montbst
: and then
I beKan to
, flow.
Se»er
recolar
Am* flnt
babr-
•4ari.
Menitniated in Jan-
naiT and rM>ni-
ary. MlMOd
March and April.
In May raipilar.
but (mall quantitjr
and Terr painfnl,
and faint spells
walUag or
Ob Majr ti obwoB
and eottouad aa-
tU Juaa IT. WeU
(oratawdaraaad
ttaDoama on^o-
Opmtad
sss^
Heart beat hM«ttr
with leMt excnlM
orezoitemaM.
SwellioK of limba
and pains from
knaas downward.
Appaltta poor.
Vtotoont daaira to
urtnata. aad pain
nttttcmt
fait iSoSm
tattal soma th inn.
aapaciallir wban
ridlnrbl
Faimtal
Some
oiot
Ro
On namiBMloi feoad
ricbi tub* mnall at
■to(
)lMtMlalB
J, MM teiat-
«4. Ootte wall pra-
TiOMfr. Tkte oe
coirMatlr.*.
l'»ln cune oo (addMi-
I7 and iHMd two
houn. VsiTMTm
PWd aonManaek
■eblng aeroH bow-
ela. OouM not baar
clotheato touob bar
after pain eeaaad.
Pain oommenoed
witb flow and In-
craaaad each day.
raintad. Ratchlog
dnrinf time of pain.
Oonttanad for two
weaka before opera-
ttOB.
Intenaa pain about
toar wena prertona
to operation. Three
week* preTiooa, ae-
Tere palm, and oon-
tinned for theee
thr«e weeks. Pain
Uka diaeoBif ort from
•sMrlatadSTS
— lotfT Hoa
man fall of 1, , _
MMood. Tabaaoti
bat bioad oooM ba
I out by
1 tad;
pncnaaer
hadautoi
brialad
dialaad.
P"gw» •« »i« »^S««>?^ «»»ltJ h«U o* blood.
> •. ii...t. waahad out eaonaaaa elou
from bahiad alam. fiba
eoatalalnit tea or t mSi *
^ Baada cold
raUJd, uxlout ap-
pearuee of face.
Polaeieta at wriat.
Prtoordial unaaai-
naaa lying on aide.
On tamloir on baek
dnfawea introat die-
apoeared, ihowlaR
oTIdenaa of flold ia
Wrttoaaal cavi^.
•Mac of tolaaaa b
round large maa* tying in left
broad Uinmaot. ned^oJt left
tube aikt orarj, aad remored
old eotoDks caatation. Sz-
trmnely lumcult enuoleatloa.
Rigbt lube and ovary louia-
what Bzed and durlas exami-
nation b<>gan to Uaed, tbere-
_ fore removad tbem alio.
BM»o»od^taaBd(OTaiy „
towMSMafSdRuum.*^""
I
«f Doug'
dot.
*Mwd MM ia troat
wTalanN «■ right
Under aaeatbetic
found maaa to toft
side, and ooaetaded
ntrauterlaa
naney.
Drew up ectopto
tared to a aH
under autfaee.
but DO blood ia
Re-
er«d.
Re-
UMn. J
n
Mra. p.
40
Hn.
MoT.
Mn. C
^^
run. L
▼mo>
J.
Dwyar.
». W.
• T.llc-
a Me-
KeaM
Ubon.
No.
Mot
1 BOMh
Tkanwant
6we«ki.
ter.
J. F. W.
Boa.
A. tadto.
MlMd.
««Bt6
Ohm 01
1 ■onth
before
mats
waeki
overtime.
Hived 1
BiMrtblr
on ud iMtod
ewne oa
■ad ooa-
tianed 8
week*.
MiSKdt
period.
•ttaek of
batMMlfinvMa-
tkm. T«tjr««ak.
jlaaelith-
t^Mt ovary
ata. In
eraeied peristaltir
■etton at boweln
noticed throuKh
■Un. XndeaToreil
to gat up, but
falBted three
Vomited,
of abdo-
I Bot in-
ereaned. Tempera
tnreeleTatcdto99°
« of
Pnlwi
When doctor mw
Seeoad ope rat ion for
cctoptegeettiioD.
While in
atora mddra
wltti palD
■Bd
Mptia Vtmxm
ymktt forward b*
■Mi tbm ot mtaiA
hmd. OMMd cBl-
d»«M. ftaaU nil-
(ol o( «loli la tin*
at '
Hum found behind ate'
roe, niliu aBl-de«ac
of Douglia, nad ez-
taading from (ight
tolittiid*.
1401
Omf .
Had toopea aMtaawto
InestnwlioaetfMji.
After dUBenit mwitpeUittoe of Ke-
ilngan la eaMe-aa* ct Done- ooi
tae. tateatlBiil •dbe«ionel ercd
bnAcB down and Mood elot
Urethra on „
tion rliowed
or
wowed ^Bjpne
BMMia. nohad aarHv of
mem tJSi.
i
■helled
■ete a le ■Htattoa at
■d«aSial\SbaoaMt
■ •■■Mh«(«M,air
Re-
OOT-
Two or three dajre af-
ter abdooMn ewoUca,
dnlneea on pereoe-
■ion on lide been ly-
iaton. rurtatfaam
could feel blood ekx
breakdown.
fOnad.
Drained,
■eloplo geitation at outer end
of tube on left aide, eighth or
ttath itaek; iwaoved. Tnbe
renoTod by chain oatgnt m-
tare, hot thleellpped, then tied
withellk. Peritoneum darken-
ed. Inteetlnee corared with
blood; pelTiB full of blood.
Oranr not remofad. atthmich
■mair flbroid aajKtla on
rarfaee. Clota "
No drainage.
geetatlea Mad
out eetovio
naidtr. Seooped out hand-
fob a Hood idat. btaaHan
dark-oolgtad. Waabcd oat
Orataad.
IMoBla ■ iila llL n on right ride
Tnbe and oraiy canorad.
tab paStM af Maad etol
eeooped «at of perttoneai cav-
~T. Waabadontaaddralaad
eetoptc^iMatloBaae eaal^
mt aai «Maaed
.jRemored eetopio gtetatiaB of
I right tube, * —
{ ovary behind.
: ovary adherent
and remored.
. iEctopicnitatlonof aboutelgMh
week fn left tube. Tube and
I oTarv remoTTd. Aleo oyet of
■ OTery.
third
ter.
Re-
Re-
cov-
ered.
Re-
cov-
ered.
Re-
cov-
ered
QMraliaa
Toronto
Ocnml
im.
OpnratloB
laa B09I-
Miitataak-
Unmi
'nmn-
lured.
36
BOH: acTono obbtation.
jBlIn.J
TV
Mmm.
Mn. L.
U5
aoMn. C.
as Hospital
lenlce.
as.
U
lIn.W,
US'-
Mrt.S.
Hn.
Hn. K.
■n. S.
Dootor.
O.
Parker.
G. Gor-
don.
A.Eadie
W.F.
Bryans.
Mo.
Menae*.
Kot
Mom.
1 week over
period.
Not
miM-
ed.
Kot
, DliM-
ed.
SooM attor bIhIbc Three MatiBC at
HemorrluRe about
two weeka pre-
vioualy. Dootor
thoufcbt a mlMsar-
aad caret
A tew daja
past peri-
od.
1 period.
Imgolar
OtkariVMVtoaia.
Itautmated ooo'
aadailkte
at
Itboaciil
NipiOes looked du'k.
Falntneia. Al-
most died from
tbia. Went from
one talBt to an
other. BeTatioD
of temperature to
israttarearrstte-
In
btanfcd brtaats.
■Ok la theai.
Doctor found her al
SUfhthaaNRhaKe.
with
cUed
amais ooi-
aMl fWat-
Doator de-
had
but
tkm oatfl my re
In two
tluee dajra. af-
ter rallying, taken
home.
Fainted three or four
times. Beads of
penpiratloD on
fawiaail PBlae
87
Cnunp-llke pains, pu-
osjinml.
luaa Middenl* with
MlB while iB ohureh.
Ckrried to • kooia
Tak» in at noon pre-
▼ioin day witli «ad-
daii;wm« pain in
OIMM paekod high
op, t uunwl i t <
larged. Pawd
muHl two and a half
tneliM. ITtenu
piwaed forward and
latinetlT felt on out-
UOM, OckMtru. ' oa ri«lst
I Wf» toaTteg towa
on table. Saline baneatb
breai t i. Draiaaice.
Aa Extrauterine pra«DaBer about
•bdoalBal oMr, M eiota
Two weeks after when
I WW her, found
maia nUIng pelTie,
■eal-OBCtaaat. Tern-
to
Utene puriied CsrwaML looked
like contataied liz waeta fetus.
Broke down adheetoaa of
omentum, bled f reelr. When
mass bunt Into, fluid and por-
tions of old clot escaped. Fe-
tus felt wltb flnger and with
placenta remoTed. Blood
gnabed out immediately
piaeeate touched. Uterine
arteries clamped preparatory
to hyiterectomy. Portion of
left ovary left behind. Hem-
orrhaite from adhesion ter
ribly profuse. AUnost died
on Ubie. Necessary to pack
with iraaae after toucnlng
surface with iron, rressuie
externally. Rectum paded
and Taglna partially packed,
■otopk! na£stion and hirge
mass ouuide of tuba. Hole in
side of tube quite Ism. Be-
mofedmaa. Bowel folded In
over site of oU clot.
8ao flmly adbstent to omen
torn and abdominal wall. On
f rii^tful hemor^ase.
■ ■ latoeacD
removed
H e mui i h a a e continued
jyrtBrigtoiiiiBal wall.
toba raoMvad. Ataoat died
Died
Re-
cov-
ered,
Re-
cov-
ered,
Re-
cov-
ered.
Removed ectopic geatatioa
from right broad tta iieBt
siae of cocoaaut. B^Eior-
rhage coasldenhia. Keoaa-
aarv to pack fai gause to con-
trol. Snbcntaneoos Injec-
tions under each breast.
Omentum adherent in fi-».t.
Pulled op and out fras.i'<l
quart or mora of Mood. Re-
moved Mt tuba aad ovary.
Oesutkn near vMlM aad aft
tube. Qaoaa pMiatf to eia
trolooslaK.
Abdominal cavity full of blo> d
fluid and dots. Point of het i
orrfaage difficult to find. Ri--
movsd tubO'Ovarian cyst on
one sMe. Blood ooaiog droi>
by drop from small spot when
tube eaters uterine wall. Con-;
gested appearaaee of vestelil
indfciated voy early ectoplci
>estalk», Interstitial and of a
few days' duration. Salines
injected, arms and leas ban-
daged, foot of *«ble elevated
everything to sustain life;
almost coDay ied aa tabla.
Ra-
Re-
cov-
ered.
Died
same
af-
ter'
noon
ation
St-Hi-
ehasll
98
Mmm.
Mn. L
n
lIn.P.n
5
n.a
■wtttt.
R> C
uninth.
aRMn-R
Mn.
J.L.
41
A. EmUc
[t*. B.
Mn. L.
Mn. E.
Mn. T.
Daator.
Lirimn
No.
W. J.
Fletch-
er.
DO A. Eadle,
W,B.
Waltera.
T. Noble
A. Eadle.
O.H.
Oanetb.
MHn. R
■OD.
Only m
lied 7
ITOI.
4 year aco
ninad 4
Not
mlw-
ed.
Not
tnlw-
cd.
Begu-
lar.
Nota anw^ aaaaaal
InNovaflBber.
oo.i
«.••«•*••«•
OtiMri
CtaraMoo of, trai-
peratare after aec-
ond attack. 102°.
Pale Upa, quite pal-
lid whan 1 law nar
atBlgM.
Poor health for aome
tlaa. aaaaayaan
tiOB JoitlaK IB
r- - to honMal
brouffht on tamam-
maUon. Bore aod
dMndad. Etora-
tloB of tampeia-
BentowWtilde..
on and
laated Umr dayi
looKtr tbanaaoaL
No aymptoiDa of
praRnaocy. Bath-
ed la ooM pargta-
Tboo^t Bhe r waa
pregnant. Coo-
ilderablylB dia-
tended.
Hoi aymptoma; of
In Auguat awnatru
ated; In Septem
berbutTety, very
little; October
very aHghUy.
Soine ptecca of
deoMva bttd eosie
•way.
Takes B ^
Tfamrwttk
open
bed
1 period .. Some... .
i montha
aso mil*
M 10 day*.
Beiian to Uaad and
contiattad four
weeks. Seelor
aaya be saw pla
c-nta and that abe
hadanriaewrrtaira.
No bnaat aiatp-
tonu. Very weak
and ptoalrated.
Manand to dnw
hanaR sjprtain
•Bd Ue down.
Thraa mootha ago
bad atekneaa at
atooaob, paln.
Prarioaaly oparat-
adoBlnrdvaywn
hafwaCar omHm
TkiM ■Maoka of m-
iBdateitapaiM...
One tUcbt atUok of
MiD wban eraeuat-
in( bowels. Three
week! after, aerere
attack of paiD while
lying In bed.
Serar* pata la abdo-
8udd«i, tennv*'-' In
abdomn what walk-
lnKoaafaaat.^1^
iioca.
A mk before had
behind utama,
and latiiaed blood
dot poured uot br
mptwwd ectopic
fwmd
first
AdTiiad watUaf
weeks. Than found
enlargad
■Ue.
to
Large blood okXbaUad a ^—
Gaatatloa lao in tntaaaettlag
np to left oa top o( dot, about
twelfth V '<ek. Hemonhage
la tube boyond produoing
heraatoialplnz. This leaked
Into paritooeal miHtf ia
■mall quaatitiea, owing to ad-
hedoaa. BaoMiTed t^ and
ooatenta. Draiaad.
■mall nodule iBamoTed hematoma of right
oTaiT, alao ectopie gaatatloa
of right tube daa (3 end of
little linger, unruptured.
to
VMiUar eolottng of
aUn and collapaud
hwk. PaH bSod
---^
to Mt
vsd ga rtatl on aac, four to
atx wceka' duration, cnbo-
ab ihi aa hi a l . Large aaooat of
aHiaiaHovaa4
Fonad adhataal
olarai, laiga aaioaat of old
awparallag doc Kaptufsd
aetata g aa t a M aa about a yeai
ago aad aoppaiatad. Vary
th
Re-
COT-
eied.
asd of right
BamoTcd ectopie geatation of
b»rt inbe. tttbo«bdomlnal.
Alao large nnaa of Uood dot
Waabed out with aaltaolution.
Drainage tuba.
Small ectopic «estatk>n, fror^
tea dara' to two waaha'dBca.
tloo, in left tube,
with ovary. Abdoma*
blood, waahedout.
Abdominal caTlfrr full of Uood.
Ectopic geatation aac under
folda of omaotnm and run-
alov up to aumnnded ntllo-
ptantube. Removed thia and
« jile doing ao tore olT tube.
BMBoead tube and orair.
niaa Mood poured out. alao
■aatattaaae bMt aide about
nwaaaadahalfmontha Por-
UmtoiMtoaarrlaft Waahad
oat Md draiaad. aaltee In-
JaMad
~ thhkaaaa of Oagar,
^-iaalr. Miofbtood.
- — vie gaatatioa of foor or
tre wii ft IB rigkt tuba, ta-
moved with tube
behMTMMkI miiiiilu
■* '* rupture Into
ered
wRhBa-
Re-
Rc-
OOT-
Ra-
COT-
aiad.
Unim-
tured.
Ra-
eoT-
Re-
cov-
Re-
Ra-
OOT-
llamatliyi
OomUAI. FBHOIAirOT
nn.B.»
Doctor.
Dr. Mo-
No.
• 5rrf,
Monna,
Not
Om mlioatrlaitr.
MeoitruMed J air
1. ISM, beosnui ttl.
Mb Soptcmber M,
IM. La«t goao-
tlt7 of btoodoM
WMk< TbMC#MMl
ted of Btptviubor* a
■wollluf, riM of
iMTRComn, to be
frit Ic right iliac
TofcloD. Doctor In
ooMtant attond-
•occ (or bearlDE-
dowD paiu. In
bed two moBtba.
Larga witli ohUd
whan aba got up.
LegaawcUad. Felt
Ijagai
lite In left aide.
Bicaata luve and
bot. Felt life be-
fora Ob rlatmaa
Op«ied the porterior enl-d e me tiiroag^ tiie vftgiiui and re-
moved a small pailful of dots. These clots were in different
stages of dflcompoHition. It wm found to be impowibhi to cte-
Ihrer Am fetas, aad, as a oanacywea, I was faread to opea tito
abdomen. After the abdomen was opened I was able to remove
the fetus, about five and <»e-half months, and hastily ekiee the
«^)eaiBt aad padt fta aai^ af liw h e mato e de with gaaaa. The
polaa had now reached 140. Tba patient did not stand operation
well. Oave a very unfavoraUa progWHis and left for home.
She died within a week. There was not much hope of reoovaiy
in this case, owing to the profoundly septic condition of the pa-
tient, and she died from this prolonged sepsis and not as the re-
sult of operati<Hi.
I mention this case to show that even after <^ration has bt n
done throuf^ the vagina it may be impossible to deliver the fetus
safely in this way.
At FvU Ttme.— Tait thought it advisable not to operate before
the child is likely to be viable, provided the delay necessary does
not jeopardise tiie mother; and, further, that after the death of
the fetus <^>«ntk» should ba done without ddajr. I think that
this is v«7 sound advise.
Any attempt to destroy the fetus by medicines or the elartria
current is to be candeainad. Ifany instaneea in whieh tUa haa
been attempted have resulted fatally. After the death of tito
child growth of the placenta may c(mtinne. I had one such case
in which the woman bled throiq^ the drainaga toba for a period
<tf two months after q^mtka. Tb» fitaa ana zamoved, but it
1
AprttlS, lair. mow
MftMOMM OB. SSBt
tor dootor. Paint
emmi aad did not
rMan^t taMMd >
PrtTtoorty brM III
off aad oa tor two or
t^roo wMks. Dootor
n^Mtod drilTtry of
DIoohaixe of blood
from vairtM nsdw
enmlnatiaii. wtth
clots aad d«bri(Uk«
plawnta ordaddoa.
Ooaalaa* pala. Es-
taraal iialjMlaa
nm fotal nrtllb
round ateraaliMtk
all ualoolUa*
rmporltnaaal fat yww abuB'
daat. Opaaed parltooauai
aad atomod all Ueodtat
points, nrai adhaslons to-
ward pub«s In froat, blad
freoly. On prssatag abe*e,
Ihild gnahad out Bao waU
iMlBiad. Uqaor aauitt la
■MliilaalcaTlty. Petua fall
Mar* icmoTsd. Faalaasd taa
to abdominal wall. Cord
dmwa out. Dratead oavl^.
Flaoaata Tnitiiiiiilia<l
Ba-
OOT-
ai«d.
wu not eoniidavd adviiiU* to riaiove the piManta. Whrthw
tius bleeding occurs as a conaequence of growth of the placenta,
or of a single detachmoit of portions of the plaeenta^ it is diil|>
nfttoMgr. A piaee of idaoe^ nIdM wi tttwo ^eodsaei fra^
quently grave hemorrhage for two or three months after mis-
carriage, and yet the placenta does not increase in sise or grow,
aad when removed it looks organized, but not pitei^ aadi doaa
not give rise to the idea that it is active. I presume the same
iModitiaii may exist within the abdomen after what correspond
to a partial miscarriage is eiEaeied Jhgr means of operative intav
forenoe and the fetos has been removed. One thing is certain,
that surgical interference in the fourth and succeeding months
when the fetus is alive, is extremely dangerous, and surgical ift-
terfuaaee in the fourth, fifth, sixth, and seventh months is man
dangBfoas ttaa it ia towaxd the end of gestation; aad that toiv
gical interference at any time before the death of the child ii
muidt more dangwons than it is after the death of the ehild.
Fidt 2^ a/tsr D«ath of CkOd.— There is danger to say wo-
man who carries an encysted fetus. Abscess may form at any
tine and the fetal parts may be extruded tiirough the vagina,
titroiq^ Ite reetom, or thnmi^ the Uadto. But soeb a «^
dition need not be incompatible with « klig wmiA H£a^ pt^
vided that no abaoeaa forma.
I aaw a Ufltopediai removed by Prof. BUlrt^, when I was •
s Indent in Vienna, that had been carried in the abdominal cavity
forannmbnrof yeara. The patient died aa a resalt of the oper-
ation. fitetedBOtbecBgn^maaBT«^aBaedhyhtt«aHittkgi
■ad I him alwagm felt that it would have been better to have let
Treatment of Placenta.— In the caae on which I operated the
plaeenta was left in litu. The opening into the wall of the aae
wm ftMlmed to the abdomiinal opening and a Fergnaon'a apeeu-
Inm waa paaaed in to act as a drainage tube. SjrmptooM of aapiia
developed and irrigation of the sac waa carried out at frequaat
intervals. The plaeenta came away pieeemeaL The sae ftMiBj
doaed and the patient made » food XMOfveiT* tbon^ tt«
valescence was tedious.
Tait considered that the umbilical cord should be divided doae
to its placental origin, that the plaeenta should be emptied, as
far as possible, of blood, and that after waibfaiff and oleantng fte
- aac it should be hermetically sealed by closing tha opening into it
with atitdiea; and, further, that if aymptoma of aeptieemia ariae
the aae ahoold be reopened and drained. Ha bad, howevei,
treated three cases in a manner similar to that adopted by myself.
Thegr all aarvived, but only after g«Mng throogh a proeeas of of-
ftnaive aupp uratio u tliat hwted far Moatiw mH ft«t nearly kfflad
them all. Theoretically, the method of closing the ne ought to
give good reaulta, but in practice I am afraid anbsequent sup-
poratkn wBl b» foottd to e«Bttr.
And now, gentlemen, allow me to thank you for your patient
hearing. This evening's address has given you the result of part
of nqr^Bwoik. BMOrda hafv» bean earefolfy kept for tUa pmw
pose and I cannot, in my lifetime, reduplicate them. Lawsott
Tait, my brilliant and much-admired master, has already jMuaed
into great bqrond, but not before he had instilled into me,
and into others who had the benefit of his teaching, the habit of
keeping accurate records of cases requiring abdominal operationa.
To tibis habit you owe the preaentatim oi thaae eaaea and tbe ka-
aons to be drawn from them.
I feel that I have been greatly hmuaad by your AMoetaHo i i ud
will atways eury witt me a pleaaaat raoo&etkm <tf Ha aeatai to
1902.
in SBnaODBMK STBER.