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Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exoosure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les cartes, planches, tableaux, etc., peuvent dtre filmds d des taux de reduction diffdrents. Lorsque le document est trop grand pour etre reproduit en un seul clich6, il est filmS ck partir de Tangle sup6rieur gauche, de gauche d droite, et de haut en has, en prenant le nombre d'images n^cessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 6/il TUBO-PERITONEAL ECTOPIC GESTATION y> vmmma TUBO-PERITONEAL ECTOPIC GESTATION \. nv J. CLARENCE WEBSTER, B.A., M.D., M.R.C.P.En., ASSrSTANT Tl» TItE [•MUl'ESHOK OF MIUW[KEKV AND DISEASES OK WOMEN AND CHILUKEN IN THE UNIVHRSITV OP EUINHURUK. EDINBURGH AND LONDON : YOUNG J. PENTLAND I 892 EiiiNiii-K(,ii : i'uni.isni;i) hok tiu: hiwai. coLiWii'. oy nivsitiANs iiv vounc; j. h:mi.anti, II TEHOT I'l.AtK ; AND 38 WKST SMI rilKIP.M), l.llNDON, t.C. TO PROFESSOR A. R. SIMPSON, PKESIDENT, AND TllIC FELLOWS OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, IN RECOGNITION OP THKIR RFFORTS TO mOMOTK SCIKNTIFIC RESKARCII IN MEDICINE, AND IN ACKNOWLEDGMENT OP THE flENKROUS ENCOURAGEMENT WHICH THE AUTHOR HAS RECErVED FROM THEM, THIS WORK IS DEDICATED. ' i $ i PREFACE Tills inonogrnpli pivcs a dctuiled account of ati orifrinal research into the nature of a mixed variety of Ectopic (Jestation, partly within the left Fallopian tul)e (Extra-pcritonc;d) and partly within the peritoneal cavity (Intra-peritoncal). Such a variety has never yet been described, and to it I propose to give the name " Tubo-Peritoneal." Tlie work of investigation has been carried out at tlic Laboratory of the Royal College of Physicians during the past two years. I desire to express my deepest thanks to the Laboratory officials for the generous manner in which they have supplied my many needs during the prosecution of the research, and to acknowledge especially the kindness of Di'. J. Batty Tukc, Curator, Dr. Noel Paton, Superintendent, and Dr. G. Sims Woodhead, former Super- intendent of the Laboratory. J. CLARENCE AVEBSTER. Edinduiwh, (Jclulier 1892. f * •« TABLE OF CONTENTS ritAr. I. Classification . . I!. Cr.ixit'Ai. IIiHTOuy . III. MUTIIOP OP I'^VEHTICIATION . IV. Nakkd Eyk Skctionai, Kxamin'ation V. Nakkd Kye Disskctional Kxamination VI. MlCUOHCOi'IC E.VAMINATION . VII. UiisuMiS .... ninuoouAPnY Inpi'.x .... PAOK 1 4 12 20 d2 38 01 53 I ILLUSTRATIONS ri.\TK 1 . Vertical Mesial Section 2. First Transverse do. 3. Second do. do. 4. Third do. do. T). Fourth do. do. (i. Fil'tli do. do. 7. Sixth do. do. 8. Microscopic Sections 9. Do. do. 10. Do. do. 11. Do. do. foriiuj patje 12 ji 16 »» 18 j> 22 »» 24 n 26 )) 28 » 32 »» 34 »» 36 )i 36 3B "1 TUBO-PEKITONEAL ECTOPIC GESTATION SJjjBjgp 'V TUBO-PEUITONEAL ECTOPIC GESTATION CHAPTER I Classification Theue is at present a coiisiclorablc dilieroiice of opinion among writers regarding the varieties of Ectopic Gestation, ' Until the year 1837 four varieties were recognised,' viz. — 1. Tul)al. 3. Abdominal. 2. Ovarian. 4. Interstitial. In that year Dezeimeris' published a new classification embracing several previously undescribcd forms. It was as follows : 1. Tubal. 2. Ovarian. 3. Abdominal. 4. Interstitial-tubo-uterine. 5. Utero-interstitial. G. Utero-tubal. 7. Utero-tubo-abdominal 8. Tubo-ovariuu. t). Tubo-abdominal. 10, Sub-peritoneo-pelvic. A few words in explanation of these terms are necessary. The first, second, and third, in this list require no explanation. lutei'stUial-ttiho-utcriiH- was the term given to a gestation in the uterine portion of the tube. Utero-interstitial was used to designate a gestation taking place in the substance of the uteriiie wall proper (owing probably to the escape of the ovum through a rupture in the uterine part of the tube). ' I do not liert' iiicliulo (,'oniual iiivt,'niuii'icH - Parry : Kjim-Ukrivc I'rcij., 1870. uuiler Ectopic CicBtalioii. •' JournahksConnuimmccs Mid.Chir., .hdn. 1837. r TUDO-PEmTOVj^AL ECTOPIC GESTATION Utvro-tubal was the naino givoii liy Do/oimoris to a goatatioii ucciUTiiig partly in the utv riiie portion of the tube and partly in the cavity of the uterus. Utcro-ttiho-ahlominal was the variety in which the fcetus was in the aljilominal cavity, while the umbilical cord passed through the Fallopian trJ)e to the placenta, which was in tlic interior of the uterus. Tuho-ovaria7i gestation was one which developed in the pavilion of the tube, the fimbriated end forming adhesions with the ovary. The Tuho-ahdominal gestation developed in the same place, the end of the tube contracting adhesions with the side wall of the pelvis or viscm-a in the neighbourhood. Suh-jici-itoneo-jK'Ivic was the name given by Dczeimcris to a gestation developing within the layers of the broad ligament. This classification has, with slight variations, been used in the text- books of all countries, until the present time. Recently, however, Lawsou Tait and Berry Hart have called into question its accuracy, and have stated that several of the varieties so long described have never at all l)een demonstrated. The former describes ' only the following forms : 1. Interstitial or tuho-uterine, in which the gestation is within tlie uterine portion of the tulje. This, so far as is known, is uniformly fatal Itefure the fifth month by rupture into the peritoneal cavity. 2. Tuhul, in which the gestation occurs in the free part of the tube. iVt or before the fourteenth week of ju'egnancy rupture always occurs — {<() Into the peritoui'al cavity. This is always a fatal event unless recourse is had to abdominal section. (h) Into the broad ligament. In this case there may result either of the following conditions, viz. : (1) Development of the gestation in the extra-peritoneal tissue up to full time (sub-peritoneo-pelvic and sub-peritonco-abdomijial). (2) Death of the fa'tus ;ind absorption of the mass as a hmnatonm. (3) Death of the fcetus and discharge by suppuration through the abdominal wall, bladder, vagina, or intestines. ' IHs. iij Women iiiitl /!/«/. Smy., vol i. ji. 4-1 15. i CI ASSIFICATION (4) Forniatinii of a lithopocdioii. (5) Rui)tiU(' may aftoiwaidH take place into the peritoneal cavity. As to Ovarian gestation, he says that it is not yet proved, though it is possihlc. Neither does he l)elieve in the occurrence of the Al)d()niiMal variety. I'crry Ifart,' in his recent article, says that oidy the following forms have liccn demonstrated, viz. — "Tuhal" (inchiding the interstitial), " Tuho- Ovarian, Sul)-pcrit(meo-pelvic, .Sul^peritoneo-abdominal." lie says that an Abdominal variety, purely intra-peritoneal, has yet to Ix; demonstrated, as is idso the case with the Ovarian, lie also says that an Abdimiinal variety, partly intra-peritoneal and partly (!Xtra-peritoneal, is ordy probable. Since these authorities have published their views wc have been shown undoubted evidence of the occurrence of Ovarian pregnancy. Two specimens f>f this condition were demonstrated l)y Leopold - at the recent International Medical Congress at Berlin. Bland Sutton,^ however, is still of tiie opinion that " ovarian fjcstatioii has no existence." He thiidis that the few cases described as such were in reality gestation occurring in a complete ovarian sac, an abortion having taken jdacc from the tube, in which the pregnancy started, through the fimbriated end which opened into the sac. I am now able, in this thesis, to describe a variety of Ectopic Gestation never before demonstrated. ' It is a mixed variety, partly extra- and partly intra-peritonefil. As the extra-peritoneal portion is entirely tubal, and the remaining part within the peritoneal cavity, I propose to give to this variety the name of Tuho-Pcvitoncal. The cadaver, the study of which has enabled me to establish this new form, I owe to the kindness of Dr. Ilalliday Croom, in whose practice the case occurred. To him, also, I am indebted for the following history of the patient. It has been compiled from Dr. Groom's private notes, as well as from the account of the Clinical Clerk of Ward 28 of the Royal Infirmary •riven in the Ward Journal, vol. 7, p. 85. 1 Lnh. Eqwfs E.C.P.K., vol. i. j). 34. ' Since tlio completion of my invcstif,'ations 2 Trans, of Inter. Mai. Congress, licrlin, IH'dO. a somewhat similar case lias been recently ro- ^ Hurijirnl Diseases of the Omriis anil Fal- ported Ijy Lawson Tait. lopian lubes, 18i)l, p. 'V'i. CTIAPTER II i (.'LrMcAi, Ifisnii'v Mils, K.. I -piuii, aged 33, wiis adniittiMl t.. W.-ml 28 on Fob. lltli, 1890, couiiiliiiiiiiig of |iiiiii ill tlic loCt (lank niul lower pait of llif ahdoincii, as woll as of oroat .swelling of the abdomen. The iswelling was fir.'t iiotieed in July 1889, in the lower part of the a-lidomcn to the left of the middle line. Ever since, it had continuepc;ired and the foetus was found lying dead, in an attitude of flexion, its head lying in the right iliac fossa, with the occiput to the back, the l)r(>,ech being in the left hypochondrium. It was adherent to the sac wall in .several places, especially ovur tlie scalp. The separation of these adhesions caused .some bleeding. The cord wa.s cut close to the child, after being tied, and the foetus removed through the incision, which had to l)c enlarged for that purpose. The sac was then examined. The wall which had been cut seemed to consist of an inner fleshy-looking and an outer yellowish-looking part. It was impossible to determine its nature or relation— whether it was extra-uterine or the distended horn of a bicornuate uterus. The placenta lay in the left half of the pelvis. It appeared as a thick t'LINK'AL IIISTOltV tli.sfuki iiiiiwH, wliiuli reiiclicd iiruiiiul in (runt aiinu.st to (lie luiildle line. It wiiH nut interlureil with, liiit left uncli.stiubcd. The Huc iuul pcritoneiil cavity wcro next wa "ie believed that the ovum, after leaving the ovary, did not enter the Fallopian tube, but passed l)etween the folds of the broad ligament and there grew. In my own case, 1 cannot but believe that a disscctional study might have led to erroneous conclusions regarding its nature, and would not have furnished the large number of vaUud)le facts which I am aljle to bring forward regarding this very interesting pathological condition. In view of these results it is evident that a great many of the statistics reo-ardiu" many of the described forms of ectopic gestation are entirely untrustworthy. Conclusions have been arrived at, in many cases from ordinary post-mortem examination, which would u'ldoubtedly have proved wrono' had more minute and careful methods of investigation been adopted. It is not going too far to say that by the ordinary post-mortem method of study it is impossible to acquire an accurate knowledge of the anatomy and pathology of many forms of ectoi)ic gestation. Frozen sections supple- mented by disscctional and microscopic examination arc necessary. Ante- mortem examination before or at the time of operation is, in advanced pregnancy, utterly untrustworthy. In Hart's cases the body was undisturbed, the foetus, a most valuable landmark, being in situ. In my case certain complications were introduced as a result of the operative i.rocednrc carried out. These were as follows : 1 OjK cit. METHOD OF INVESTIGATION 11 I {a) The opening of tlie abdomen as well us the sac containing tlio fotus ; (/>) The separation of some of the adhesions between the sac and the anterior aljdominal wall ; (o) Post-operation changes in the placenta and the wall to which it was attached. These complications have not been very important, and have not seriously interfered with the complete investigation of the case save as rco'ards certain points in the structure of the placenta. As a result of my investigation I am able to describe the exact nature of the gestation, its probalde anatomical and pathological histoiy during pregnancy, and also the post-operation changes whicli have taken place. Techniquk. The whole al)domen and pelvis were removed from the cadaver and frozen for three days in a niixtun* of e(pial parts of salt and ice. At the end of this time a vertical mesial section was made with a thin Ijroad- bladed saw. The specimen was thus divided into two equal parts with very little loss of substance and no disturbance of parts. The sawn surfaces were perfectly flat ; that of the left half was then .sketched (PI. I.) An exact outline of the various structures seen was first traced upon a transparent gelatine sheet and then transferred to paper, the details l)eing filled in and coloured ad naturam. The two parts were then carefully placed together and six transverse .sections (PI. II.-VII.) made at different levels, drawings being made, in each case, of the cut surface of the lower part. The description of each section, and its measurements, were made in the frozen condition. While one part was being sketched and described the rest of the specimen was kept in the freezing mixture. In this way the body has been rendered practically transparent, the abdominal and pelvic; contents Ijcing preserved in situ, their form and relation undisturbed hy 2>ost-mortem manipulations. The various slal)S were next carefully hardened in methylated spirits and examined in detail, small pieces being removed from various parts for microscopic investigation. ■IHi jez CHAPTER IV Naked Eye Sectional Examination Vertical Mesial Section (Plate 1.) This section is made in the vertical mesial plane of the body, in line with the sagittal suture. The loft half of the pelvis and lower part of th abdomen is here shown. The Ijoncs scon in the section arc the symphysis pubis in front and the lumbar, sacral, and coccygeal vertebra; behind. Bony Pelvis. —The sacrum and coccyx ^i.m one well-marked curve from above downwards. The sacrum measures 4| in. in length and the coccyx I5 in. The symphysis pubis measures lA in. vertically and -J in. in its widest transverse diameter. Conjugate of brim (anatomical) measures 4]f; in. „ „ (obstetrical) ,, 4j-',., in. „ cavity ,, 5 in. outlet (sacral) „ (coccygeal) 'T6 m. 3§ in. The symphysis pubis is not parallel to the upper part of the sacrum, but diverges slightly from above downwards. Uterus. — The Uterus lies opposite the 3rd, 4th, and 5th sacral vcrtebra3. The body only is cut through near to its right side. The section is somewhat oval, has a pale grey pink appearance, and is of a very firm consistence. No blood-vessels can be seen in its substance. Its highest point is ljj5 in. below the brim or just below the middle of the second sacral vertebra. Its greatest antero-posterior measurement is \{% in. The posterior surface is more rounded than the anterior. Three- eighths of an inch below the upper border Is seen the right Fallopian tube PLATE I. Vkutical Mksial Section. (Reduced by J.) a. i'yl(jric end of stomach. h. Tniiisvcrso colon. c. Secondary or amniotic sac in which foetus lay. (/. Umbilical cord. (!. Peritoneal cavity behind anterior abdominal wall. /. Great omentum altered in character, being dense and fibrous in its inner part, and entering into the formation of the secondary sac. ;/. Wall of primary or ttibal sac containing the placenta. h. Adhesion lietwecn anterior abdominal wall and great omentum. i. Blood and torn up placenta forming the mass in the primary sac. j. Symphysis pubis. /,-. Bladder. /. Urethra. III. Vagina. n. First lumbar vertebra. (I. Small intestines. p. Fold of anuiiotic cavity dipping down into top of primary sac caused by e.xtcnsion upwards of anterior part of .sac by hiemorrhago into it. (/. Promontory. i: Adhesions between posterior wall of primary sac and parieUvl peritoneum. .<. Pale firm mass, remains of old blood extravasation into placental. t. Space containing fluid in wall of primary sac. «. Right Fallopian tube in wall of uterus. V. Rectum. w. Adhesions between primary .sac wall and bottom of utero- vesical pouch. ,c. Pouch of Douglas. , ij. Tip of coccyx. II PLATE I. 4. >-'-.■ f-".V:JrV--,„-M'r^ NAKED FA'F. SKCTIONAl, EXAMINATION 13 in the substance of the muscle. It contains dark fluid; the tissue immediately around it is darker than the rest of the uterus. Below the body, the section passes through the junction of the right broad ligament with the supra-vaginal portion of the cervix. This broad ligament tissue is of a light purple colour and of softer textuie than the uterus. It passes downwards to become continuous with the vaginal walls and the posterior part of the bladder. It measures antero-posteviorly f in. Jii'latluns.—hfi anterior surfaci' is in contact with the peritoneum covering the posterior surface of the placental sac. Several small adhesions exist near the upper border. The posterior surface ia entirely in relation to the rectum. Vagina.— The vagina is a sigmoid slit 2}:il in. in length. The upper end is nearly the highest part of the right fornix and lies 3^ in. below the brim, in a line joining the lower edge of the symphysis with the lower end of the sacrum. The rvu^r are well marked, and the walls are deeply congested. The 2^»• l''''"» ''"' «.Vi»i»liysis ; IVom tlio middle nf each ramus it, is ,\;j in. 'I'lie rij^lit posterior extremity is 1^ in. from tiie sacrum, its left '2\ in. The left edge is nearer t lie left side of the pelvis than I lie right is to the right side. The greatest thickness of llie whole organ, from hefore hiickwards, is I,";., in. The cavity is a .•nrveil transverse sul, I {, in. in length. The walls are of a pale grey pink colour; extending backwards on each side is the paravesical tissue continuous with Mi;it lining the pelvic wall, as well as with the parametric tissue. The tis.sue between the bladder and pelvic wall is closely compressed, lieing due to the pressure of the placental and blood mass iu front of the uterus. The bladd'.'r is, as a whole, not exactly mesially situated, but some- what rotated so that its left edge has moved a little forwards and to the left. //,,,./„,;(, _Thc rectum lies comju'cssed beliiml the uterus and right broad ligament, against the sacrum. It extends almost across the latter, being mouhled by the posterior surface of the uterus. A little more than half lies to the right of the middle line. The cavity is ipiite empty. /Vr/V(u/(/'/;(.— The utero-vesical pouch is almost entirely occ ipied by the lowermost part of the placental sac, to which it is attached by delicate adhesions which scarcely prevent the dark red mass from being lifted up from its bed. The width of the pouch is !■; in., of which only ',. in. lies l„ th.' right of the middle line. (The greatest depth below the surface of the section '■■ \ in- to the left of the middle line, where it is ,■;., in.) The ])ouch of Douglas lies nearly altogether to the lel't of the middle of the sacrum. It is a curved slit U in. wide. The leir extremity lies in the great sacro-sciatic notch, nearly A in. being to the left of the sa 'um. Uijamentu, Connective TUsnes, <7c.— The right parametric tissue appears [o be of greater transver.sc width than on the hd't sid(>, but has a very much smaller aritero-posterior measurement; it is looser in texture, its vessels gape to a greater extent, and are not so close together. These 18 TUBO-PEKITONEAL ECTOPIC GESTATION diirereuccs are due to tlir stretching of the riyht panimetriuii; and the coni])re.ssion of the left l)y the uterus puslied over to the left side of the pelvis. A considerable dilicrence is also seen between he paravesical tissue of the right and left sides. Tliat on the right side is widei, of looser texture, and contains a good deal of serum in the meshes of its tissue. The right broad ligament is well marked, but appears thicker than normal, en account of its having been cut somewhat obli(jueIy. On the left side a broad ligament can scarcely be distinguished. The distance between the utero-vcsical pouch and the pouch of Douglas is much greater than on the left side. This is due to two causes, viz. the closure of the left side of the utero-vesical pouch by several adhesions, and also the stretching of the right ligament, due to the distui banco of the uterus. riacinital and Blood Mass. — This section passes through the great mass seen in the vertical mesial section, near its lower end. Roughly speaking, its form is triangular, tln' angles Ijeing rounded. It lies in the utero-vesical pouch, more than half being to the right of the middle line. Its greatest antero-posterior thickness is 1^ in., and its transverse 2-g^ in. It Indges for a considerable extent into the posterior wall of the Idadder. The wall of the sac on the left side is ^^■, to ^ iu. tjuck ; it has a fleshy appearance, and contains two large venous sinuses ; as it passes to the right it becomes thin and more fibrous-looking. The mass is of a dark red colour, with paler areas towards the front and several small fdn'ous-looking patches. The maso can easily Ijc lifted up from the peritoneal pouch in which it lies and to which it is partly attached by fine soft adhesions. SccoikI Transrcrsc Section (I'late III.) This pa.sses, in bout, tlu'ougli the nu cavity to the wall of tin; sac which is here attache. i. Wall of primary sac. ;. Pale firm mass resulting from change in old hicmorrhago into placenta. k. Left ovary attached to wall of primary sac. /. Kcctum. ■^-^ PLATE IV. '. ■S^-Ws V i 1^ NAKED EYE SECTIONAL EXAMINATION 23 The left broad ligament cannot be distinctly made out. It is in front of the ovary and matted to the side wall of the pelvi.s as well as to the surface of the }ilacental sac by dense adhesion. The left round ligament is seen cut across olp]i(|uely in the extra- peritoneal conuective tissue. It is continuous behind with the broad ligament and mass of adhesions in front of the ovary. The i'Xtra-2)eritoncal connective tissue is more compressed on the left than on the right side, and is therefore more compact. In front, to the right of the middle line, a quantity of greenish serum lies in spaces of considerable size, immediately external to the peritoneum. Placental and BJood Mdxfi. — It occupies the great part of the pelvic cavity. All other pelvic structures are pressed by it against the bony wall, especially on the left side. Its greatest antero-posterior measurement is h in. to the left of the middle line, where it is Al^^ in.; in the middle line it is 4 in. An inch to the right of this it is 3j>, in. The "-reatest transverse measurement is 4}i in. and is in line with the trans- verse diameter of the pelvic cavity. In its right half . .s of a dark red colour witli paler ari'as scattered through it; towards the J'ront the tissue i.s of a lighter red fleshy coloui'. In the left lialf is ycen a larae solid yellowish-white fibrous mass lying internal to the sac wall. From the inner end of tliis mass sevei'al small fibrous bands ])ass inwards; one of these, \ in. tiiick, passi's ibrwards into the placental ti.ssiie. In front of it is seen red-brown |>lacental (issue cdntinuous with that fonn- iug the anterior part of the right half of the mass. In (Vuut of this is seen a mass of greenish lluid ,", in. in diameter, lying internal to the sac wall. The wall of the .sac varies in appearance in dilierent [larts of the secttion. Immediately in front of the ovary it is, fur a distance of half-an- inch, so uniteil with the wall of the pelvis by adhesions that its thickness cannot be accurately defined. In front of this it is a distinct fleshv-loukin.r band ,•;., i... thick. As it passes forward it gets thinner, and a little to the left of the middle line it is only a strong fibrous mend)rane. This can be traced tu-ound as far as the middle line posteriorly, when it becomes thicker and passes in front of the i>vary. I 2i TUUO-PEi.lTONEAL ECTOriC GESTATION Fourth 'rraiisimsc Seel ion (Plate V.) Tlii.s passes through tlie promontory beliiiul, and in front goes immeiliatcly above the syni2)hysis. On each side the wings of the ilium are cut through. Rectum. — The rectum extends \'i in. from the middle line to the right. It is closed and firmly compressed against the sacrum by tlie placental and blood mass. Ritjht Omnj wid R'ajht Broad Lif/anient. — Lyin,) 0]>posite the right anterior corner for 2,^ in.; (o) Opposite the left posterior corner extending from the left border of the rectum around to the left for 4 in. ; to tlio left of the sacrum the adhesions are denser than elsewhere. Plaeeiital and Blood Mass. — Its greatest transverse measure is 5^^,. in. Its greatest autero-posterior 4,'\( in. Its wall is well marked. From the l)Osterior angle it extends forwards as a pale grey pink l)and ^-f^. in. in width ; it gets thinner towards the middle line, and becomes a thin fibrous mem- In-aue on the right and posterior surfaces of the mass. In the thick portion are seen several closed sinuses, the most anterior of which are of consider- able size. Internal to this capsule two areas of difiereut colour are seen : ('«) Pale Area. — This is irregularly crescentic in shape and lies imme- diately under the capsule on the left and posterior walls. It extends from an inch behind the posterior wall backwards as far as the posterior end of the right lateral wall. The outer surface is smooth and lines the capsule ; the inner is irregular and sends PLATE V. Fourth Transverse Section. (Keduccd by ^.) a. Placenta and blood mass. h. Peritoneal cavity. c. Rectum. d. Promontory. e. Wing of ilium. /. Adhesions between primary sac and peritoneum. ;/. Wall of primary sac showing closed sinuses. h. Space containing fluid partly in and partly within primary sac wall. i. Space containing fluid in extra-peritoneal tissues. j. Pale firm mass resulting from old hajraorrhage into placenta. ' r PLATE V. (1 NAKED EYE SECTIONAL EXAMINATION 26 Huveral prolongations into the dark arou. It is a solid yellowish fibrous-looking mass slightly blood-stained in its posterior half. Immediately to the left of the vertebra its structure is interrupted somewhat by a mass of scrum across which these memlmmous bands extend so as to form a large number of loculi. {h) Dark Area. — Two parts can be distinguished in this. One, con- tinuous in front with the pale area, is brownish red and is mostly placental tissue. At the left extremity it is 1.1, in. thick. As it passes to the left it gets thinner. Its inner surface is considerably broken up by blood. The rest of the mass is of a dark red colour with paler areas scattered through it, and consists chiefly of poured out bluod with debris of placental and fibrinous masses. Fifth Transverse Section (Plate VI.) This passes through the lower part of the iuterverlebrul disc between the last two lumbar vertebne behind and the anterior abdominal wall in front, 4f in. al)ove the pubes. The abdominal cavity in its central part is occupied by the placental and blood mass, the intestines being pushed to each side. Placental and Blood Mass. — The capsule in front is a fleshy band i\j in. thick. It extends from the pale triangular area on the left of the great mass around the front, becoming thinner until it is half-way around the right side of the mass. From this point it passes backwards for a distance of two inches, and is split up into a number of blood- vessels (probably vessels of cord running in the wall and cut obliquely). Beyond this it is much thinner over the left half of the posterior surface, and opposite the left posterior corner of the mass it cannot be traced because of its incorporation with the fibrous tissue internal to it, as well as with the parietal peritoneum by firm adhesions. The great mass which fills the capsule consists of two parts : 1, An anterior kidney -shaped part separated from the posterior by a fine slit (seen as a black line in the section), which is formed by a dipping downwards of the capsule and amnion from the uppermost end of I i: 26 TUUO PEUITONEAL ECTOPIC GESTATION the mass. It forms the grciitcr portion of the mass. At its left extremity is a triangular yellowish -grey area, partly solid ami partly spongy in appearance. This is continuous with a fibrous-looking pink-stained band \ in, thick which passes to the right and joins an oval area with a pink- stained circumference and yellow centre (in which is a mass of dark blood clot, which resembles considerably a laminated blood clot). From the anterior surface of this pale mass prolongations extend into the dark tissue lying immediately in front of it. The dark area is striated trans- versely in its anterior half (laminated blood clot), while the posterior half looks more solid, having several pale areas .scattered through it. 2. A posterior part lying immediately in front of the spine especially on the left side. It is pear-shaped, the large end being to the loft side ; it lies moulded upon the spine. It is pale grey brown, with several blood-stained patches scattered through it. Towards the left it is more solid than on the right side, where it has a somewhat spongy appearance. Immediately external to the large end is seen a band of some thickness which consists partly of capsule and partly of adhesions. In it several vessels are divided belonging to the capsule. Behind each end of the posterior surface of th«. great mass is seen a naass of dark green Huid with numerous bands running through it. They arc probably serous collections in the peritoneal cavity formed in connection with the adhesive processes taking place. I'he A^nniotic Sac. — This is really peritoneal cavity behind the altered great omentum. Its cavity is a closed slit which can be traced from opposite the middle of the section of the left ilium forwards in front of the great mass and around nearly to the posterior wall ; here, however, adhesions occur on the right side and partly close it. In front of the pear-shaped mass is a curved slit running transversely. It is also amniotic cavity dipping into the mass from the upper end. Ijchind the pcar-,sliaped body, for a space of three inches to the left of the middle line, is free peritoneal cavity. There is no amnion lining this part. Beyond this, for a considerable distance on each side, adhesions have taken place between the sac wall and peritoneum. In front of these PLATE VI. FlCTH TllANSVERSE SECTION. (Reduced by J.) (I. Altered great omentum forming anterior wall of secondary sac in which fix'tus hiy. b. Peritoneal cavity. c. Great omentum more normal in appearance. d. Pale fibrous mass resulting from changes in old placental hcemor- rhage. c. Large vessels of umbilical cord cut obliquely, as they run from above downwards and to the loft to enter the placentfi, being at the level in close union with the wall of the primary sac. /. Litestines closely packed in lateral regions of abdomen and matted together by adhesions. [/. Junction of fourth and fifth lumbar vertebra). /(. Placenta and l)lood mass. i. Secondary or amniotic .sac cavity which contained the fivtus. j. Fluid in spaces among adhesions matting intestines together. k: Wall of primary sac greatly thickened by adhesions. 'M s PLATE VI. -t r * NAKED EYE SECTIONAL EXAMINATION 27 ndlicsions tho .amniotic sac wiill is chiefly formed Ity the nltcrcd great omentum. On the riglit side the intestines iiro packed in tlie riglit lumhiir region, somewliat matted together. The anterior hirgc coil is on the right side of the transverse coh)n. From its anterior surface is seen extending a wide hand of tissue, soHd in its inner third and of loose texture in its outer part. This is great omentum cut obliquely. Its outer part has more of the normal structure, while the inner part is largely changed into fibrous tissue fijrming the wall of the sac in which the child lay. Several vessels are seen in the wall. Immediately to the right of the middle line the wall presents a double appearance, one i)art ^ying as a tongue-like process within the main part of the widl. This is caused by a fold of the wall having been cut across. To the left of the middle line the wall becomes thinner, ^^ in., being cut more transversely, it is nearly all filn-ous, the outer fatty appearance being seen only for a short distance to the loft of the middle line. As it passes around the left side it becomes attached to the side wall so that the peritoneal cavity outside it is obliterated at this part. It is almost connected by adhesions with the left posterior corner of the placental and blcod mass. Peritoneal Cavity. — It can be traced among the intestines, lying iu the right lumbar region, but is in places obliterated by adhesions. Thence it passes forwards, internal to the abdominal wall and external to the great omentum, as far as a point 4 in. to the left of the middle line. Beyond this it is entirely closed, the great omentum (amniotic sac wall) entering into close union with it. To the right of the vertelma the peritoneum can be traced partly around the coil of intestine lying against it. It can also bo traced for a distance on the left side of the spine, but imhicdiately in front of the vertebra it is closed by adhesions. Sixth Transverse Section (Plate VII.) This passes through tho intervertebral cartilage between the 3rd and 4th lumbar vertebra) behind, and in front through the anterior abdominal wall just below the level of tho transverse colon. The intestines are lying in each lumbar region chiefly in the right. I * 28 TUlJOrEUrrONEAL ECTOPIC GESTATION They are somewhat nuittcd together, so that the peritoneal eavity cannot easily be traced among them. The wide extent of the amniotic sac is seen. It is bounded on each side by intestines; behind, by intestines to the right of the spine, and by the posterior abdominal wall on tlic left ; in front by the great omentum which is, in great part, solid and pinkish grey in colour. Opposite the vertebra several pieces of the wall arc seen. The wall was considerably folded at ihis point, and so has been divided in several places. I hf' I i PLATE VII. Sixth Tuansverse Section. (Rotluccd by .^.) ((. Folding of the ultcrcil great oiiietitiiin. b. Peritoneal cavity. c. Intestines. (I. Great omentum more normal in apprar.ince. i: Juncl'on of third and four*' lumbar viTtel)ra'. /. Amniotic cavity. w^r T PLATE VII. I'' CIIAPTEll V Naked Eye Djsskctional Examination Uterus.— T\iG uterus is retro-placed, slightly anteflexed, and almost entirely in the left half of the pelvis. Its long axis has a slight inclina- tion from below upwards and to the right. The highest part of the uterus is the fundus, which lies 1| in. below the brim, or # in. hioher than the highest part seen in the vertical mesial section; the lowest part is the anterior lip of the cervix, which is on a level with a line joining the tip of the coccyx and the inferior margin of the symphysis ; its entire length is 3| in. The organ is quite fixed in position, there being numerous adhesions between the anterior surface and the placental sac, and between the posterior surface and the pelvic wall. The adhesions are most numerous around the uterine end of the left Fallopian tube. The cervix is soft and flattened from l)efore backwards, the anterior lip being lower than the posterior by f in. The body is of much firmer consistence. The os externum is patulous, easily admitting the end of the index finger. The anterior fornix is very shallow, being only j. in. in depth; the posterior is nearly 1 in. in depth. The highest part of the latter fornix is on a level with a line joining the cartilage between the 4th and 5th sacral vertebra) with the inferior margin of the symphysis. The left lateral fornix is much narrower than the right, the vaginal portion of the cervix lying almost against the left side of the vagina. Vagina.—TiliG vagina in its upper part is not symmetrically placed. More than half lies to the left of the middle line. Its walls are in apposition, and show the rugous condition in their whole extent. They are of considerable thickness and deeply blood-stained. T 30 TUBO rERITONEAL ECTOl'IC GESTATION The perineal body is well formed and is deeply congested. Riyht FaUopkiti Tube. — The right tube starts from the left border of the uterus, close behind the round ligament, about 2^ in. below the level of the brim and opposite the junction of the 2nd and 3rd sacral vertebi'a). It runs outward for 1^ in. and then curves upwards and inwards for about 2;j; in., ending immediately external to the rectum, the fimbriated end lying upon the uterine end of the tube. It is, for a considerable extent, adherent to the posterior wall of the placental and blood sac and the right ovary, but the adhesions are not very firm. It is somewhat larger than the tube in the non - pregnant woman. In the vertical mesial section it is seen cut across in the wall of the uterus. Ifnjht Orwy. — This body lies behind the folded right Fallopian tube and against the posterior pelvic wall external to the rectum. Its length is about If in., its width f in., and its average thickness ;j; in. Its highest point is immediately l)elow the level of the brim nearly opposite the right sacro-sciatic joint ; from this point it slopes downwards and inwards. Its free border looks inwards, its surfiices are anterior and posterior. Left Fnllopian Tube. — The left tube starts from the left side of the uterus opposite the junction of the 2ud and ;3rd sacral vertcbno. It is larger than the uterine end of the right tube and thickens greatly as it passes upwai'ds and forwards for half- an -inch immediately above the left round ligament. It can be traced no further as a tube, but opens out to form the wall of the sac which contains the placental and blood mass. The sac wall is thickest where this opening-out takes place, and it is connected to the surrounding structures — viz. uterus, ovary, rectum, and pelvic wall — by numerous adhesions. No trace of the fimbriated end of the tube can be found. It is probably lost among adhesions. Left Ovary. — This body lies upon the outer part of the fundus behind the placental and blood mass and internal to the origin of the tube. Its T NAKED EYE DISSECTIONAL EXAMINATION 31 I free l)orcler and outer surface are partly attacliccl by adhesions to tlie posterior pelvic wall ; its inner surface, which looks downwards, inwards, and forwards, is joined by bands to the outer part of the left half of the fundus. Its anterior and upper part is in close contact with the wall of the placental sac. Round Lir/aments.— Both can be traced in almost their whole extent. The left is a little higher than the right. Umbilical Cord.—TliQ outer end lies free in the amniotic sac, above the level of the placental mass. It passes to the right and then disappears in the wall of the sac at the level of the sixth transverse section, where some of its vessels are seen cut obliquely and transversely. These vessels pass inwards in relation to the posterior part of the placental mass in the region of the most fibrous portion in the mass. Amniotic Sac. — Its vertical extent has already been noticed. Its capacity has been greatly altered by post-operation changes, the chief of these being the distension of the placental sac upwards into the lower part of the abdomen by blood extravasation into the placental tissue. Its ui)2)er end, when the walls are separated, is dome shaped. It lies behind the pyloric end of the stomach, a little more than one half beincr in the left half of the abdomen. Below the stomach the anterior wall consists of transverse colon and great omentum. The posterioi' wall and sides are formed by parietal peritoneum, intestines, and their mesentery considerably matted together in several places, most of all on the right side. t CHAPTEK VJ Microscopic Examination (Plates VIII.-Xl.) From each of the .slabs into wliieli tlic body was divided sniuj] portions were removed, carefully hardened in alcohol, and then prepared for microscopic study by means of the paraffin method. 1 have devoted my attention mostly to the wall of the placental sac, the placenta, and the secondary or abdominal sac, twenty diderent portions of these struc- tures being examined. Besides, I have also examined the condition of the ovaries, the uterus, and the Fallopian tubes. Placental &«o.— This comi)letely surrounds the placenta and the recently poured out mass of blood. Though to the nakerl eye it is so intimately connected with the fibrous masses internal to it, and with adhesions outside, that it cannot in certain places (cy. Trans. Sec. VI., left side) be distinguished, microscopically it can be traced all over the outer part uf the mass. Vertically it extends from the bottom of the utero- vesical pouch as high as the lower margin of the 4th lumbar vertebra. It varies in thickness ; in general it may be said that the left half of the wall is thicker than the right half In the former part the thickness is greater, and in the latter part less than that of the normal Fallopian tube wall. At the level of Trans. Sect. II., on the left side, the sac wall consists of thick bundles of connective tissue with cells, for the most part spindle- shaped, but also oval, lying in spaces between them. In the inner part of the wall, the fibres are considerably larger than those of ordinary connective tissue. - PLATE Vlll. Fio. 1. Section through right side of primary sac wall and canaiisud filirin internal to it. L. P. a. Dense fibrous tissue of wall. h. Fibrin deeply stained. c. Fibrin faintly stained. d. Muscle in wall. Fig. 2. Section through left side of primary sac wall where it consists of an outer thin dense layer connected to a middle thick layer anil an inner looso layer. The outer and middle portions are connected by loose connoctivo tissue. II. P. a. IMuscles cut in various directions. h. Dense fibrous tissue. c. Loose connective tissue, Fig. 3. Section through anterior wall of primary sac on the left of the middle line, and through condensed canalised fibrin internal to it. II. P. a. Amniotic layer. h. Condensed fibrin deeply stained. c. Looso connective tissue of wall. d. Vessels of wall obli(juely cut, e. Fibrin faintly stained. PLATE VIII. :->:'«i: -'^•:^ ' 'filT^^ ./*' Fin 3, MICUOSCOI'IC KXAMINATION 33 Hon; ami tliero, especially towards the iniior ])ait, are seen groiip.s of iniisclo fihroH, sonio cut traiiHVcr.sfly, otlicrH loiijritudiiially, and otIiorB nbli(juely. Iiitcnial to tlie nuiHclc tlic filiroiiH tisnuc is, in partH, very compact, and contains small elastic fd)res. In the deeper layers of the wall arc seen several sinus-like spaces containinjj; Itlood as well as several small arteries. Extendiuta. — The exact size and shape of this structure before it PLATE IX. Fig. 1. Section through great omentum where it forms anterior wall of secondary sac. L. P. ". Posterior or amniotic surface. b. Posterior part consisting of greatly condensed fibrous tissue, c Anterior part consisting of loose coiniective tissue with abundant masses of fat. (/. Outer surface in relation to anterior abdominal wall. Fig. 2. Section through posterior wall of stomach as it enters into the formation of anterior wall of secondary sac. L. P. ((. Posterior or amniotic surface. b. Dense fibrous tissue closely connected to subjacent muscular wall. c. Loose fibrous tissue and fat. il. Muscularis mucosse. c. Eemains of glandular lining of stomach. Fio. 3. Section through wall of primary .sac and trabecular extending from it into a mass of fibrin. L. P. a. Amniotic surface. b. Outer part of wall. c. Deeper and denser part of wall with a few nuiscular fibres. (' Trabocula; from wall broken across liy old hemorrhage. e. Faintly stained filjrin. /. Villi surrounded by partly altered blood. Fiq. I. PLATE ;X. Fig, 2. — a b a - F.q, 3. ^r MICROSCOPIC EXAMINATION 35 became altered by the extravasation of blood throughout its substance we are unable to state. At the operation it was seen in its sac as a discoid mass on the left side of the pelvis reaching above the brim, occupying, also, partly the posterior and partly the anterior wall left of the middle line. In the cadaver, however, we have to do with placental tissue so torn up l)y blood extravasation that it is no longer a discoid mass, but an irregularly rounded mass which completely fills up the pelvis. Nowhere can we find a piece of placental tissue which allows us to make a section from the foetal to the maternal surface. We are unable accurately to give the extent of the tube wall to which placenta was attached. Roughly speaking, the placenta occupied the left two-thirds of the dilated tube. The detailed examiuatiuu of tlie mass is as follows : At the level of Trans. Sect. II., in the left half, is a large amcunt of fibrin in tho form of a network surrounding many villus stems, villi, and trabecuhe of various sizes. The latter consist for the most part of masses of dense connective tissue, the cells, oval or spindle-shape, lying singly or in rows between the closely packed bundles. Several vessels are seen, sonic of which appear as little more than channels lined by a single epithelial layer, others, however, having a distinct muscular wall, outside which are numerous connective tissue cells, while inside scarcely any intima is visible ; no elastic fibres are visible. A few trabecuhe pass inwards from the tube wall for a distance and are then torn across. Farther to thi' right the fibrin is very granular in nature, evidently breaking down. Trabecular are pushed against the wall. Farther over are masses of more normal placental tissue, consisting of villi, villus stems, and a ^ew trabecuho. Surrounding them is breaking- down blood, in which very many leucocytes are seen. Tile villi have much the appearance of those in a normal placenta. There is an external single layer of cubical epithelium, internal to which is loose connective tissue containing capilhiry spaces. At the level of Trans. Sect. III., on the left side, there is a large mass of canalised fibrin, with crystals of blood pigment, and containing villi and villus stems of denser fibrous tissue than is found in the more nOi'mal ones. 36 TUBO-PEKITONEAL ECTOPIC GESTATION On the right side is more recently poured out blood surrounding villi and traboculre as before. Under the capsule and around the large trabeculas and villus stems where large blood masses occur, there is a great exudation of leucocytes (or great proliferation of connective tissue cells) into the latter. Altered blood pigment is also seen in several places. At the level of Trans. Sect. IV. much the same conditions arc found. At the level of Trans. Sect. V. there is a much greater amount of solid canalised fibrin on the posterior wall — that part lying behind the amniotic layer ; in its substance are seen many altered villi and villus stems. The vessels of the latter are almost closed by the increase in dense fibrous tissue which has taken place. In fact it seems as if in this part the placenta was destroyed in its entire thickness. From the inner part of the wall covered with amnion, viz. the antf^rior, trabeculte of various sizes extend inwards. This is the only place where we can get a section completely through the placenta, but the structure is altogether altered by the old blood extra'^ asations. Summing up the most important facts regarding the placenta, we find: (a) That sections of the unaltered placenta tissues resemble closely those of normal tissue, consisting of villi and villus stems surrounded with blood. The relations and origin of these blood spaces cannot be made out. (h) Many villi are seen next to the capsule. (c) Trabecular pass from the deepest layer of tlu; capsule into the sub- stance of the placenta. {d) A considerable part of the placenta on the left side as well as in its upper part is greatly altered by old htemorrhages ; the compressed villi having become very fibrous, many blood crystals mark the line of the vessels of the villi. {(') Recent haemorrhages (post-operation) have completely torn up the remaining portion. Secondwy Sac. — A section made through the anterior wall consisting PLATE X. Fig. 1. Section through a bit of isomowhat normal-looking placental tissue. L. P. a. A villus stem. h. Blood surrounding villi and villus steia. c. Villus. Fig. 2. Section through villi and villus stems compressed together and surrounded by fibrin resulting from old hieinorrhage. II. P. a. Part of right wall of primary sac. b. Villus st'jm. f. Faintly stained fibrin, d. Villus. Fig. 3. Section through normai-lookiug placental tissue. H. P. a. V'illus stem co>-ered with a single laj-er of culncnl epithelium. h. Villus covered with a single layer of cubinal epithelium. c. Blood surrounding villi. d. Lencocvtes. Fig. I. n. : mm0 '^>: PLATE X. Fie Fin. 3). jkJ^ •_•-* i^^Ktl* 11*0 • PLATE XI. Fui. 1. Section through a palo fibrous -looking area in placenta and blood mass. L. P. ((. Fibrin of old extravasated blood. h. Space in the fibrin. e. Villus surrounded by fibrin and greatly altered, being fibrous, without any covering epithelium, and with abundant Ijlood pigment. Fig. 2. Part of the above, highly magnified, showing altered villus stems with blood-pigment surrounded by fibrin in which are numerous blood crystals. a. Blood crystals causing pigmentati'in in villus stem. b. Blood-pigmont in fibrin. Fi(i. 3. Section showing decidual tissue from wall of uterine cavity. H. P. rt. Decidual cells. 'iu ^^y. S- IMAGE EVALUATION TEST TARGET (MT-3) do <<. {/ '/^ 1.0 |S»- I.I !M IIIIIM :!f 1^ 1^ 12.2 2.0 1.8 1.25 1.4 1.6 ^ 6' - ► VQ ^ /a "> 7 > > o 7 /A Sciences Corporation s. % 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^>C^. ^r<^. Wr^ ^ ^ itaB k \ Fiq. I. \ u PLATE XI. Fig 2. f Fig. 3 r* * , 7 ■> ^-i» »*> --ate '-V 'S**: "*ai- MlCliOSCOPIC EXAMINATION 37 of altered great omentum has the following structure. Next the cavity is the cubical celk I layer of the amnion; externa) to this is a thick dense mass of fibrous tissue; outside this are loose connective tissue and masses of fat cells, external to this is a thinner layer of connective tissue lying under the peritoneum. Many vessels are seen in the wall. A section through the posterior wall of the stomach which enters into the formation of the upper part of the anterior wall of the sac has the following appearance : Externally is the mucous membrane of the stomach; inside this is the musctilaris mucosce, then a layer of fat and loose connec- tive tissue, then the muscular coat, outside which is dense connective tissue covered with amnion. The transverse colon is similarly altered in its posterior wall. Mnnhranes.—kmixion. The presence of this membrane lining the secondary sac has already been noticed. It consists of a layer of cubical epithelial cells, resting on a thin layer of connective tissue. In some places it is wrinkled and in others quite flat. Within the primary .sac I have noticed no trace of it in any of the sections after most careful searching. It is most probable that the epithelium was destroyed as a result of the clninges which took place after the escape of the foetus from the tube. Chorion.— OixG sees traces of the chorionic surface of the placenta, consisting of rather dense fibrous tissue with villus stems attached. It is impossible, however, to determine with accuracy how much of the chorion has followed the amnion in its escape from the tube. In some place,, the amnion is connected to underlying structures, through the medium of a layer of connective tissue, which might have been chorionic originally, which now appears in no wise different from the connective tissue of the sac wall. CHAPTER VII RliSUMlS With the facts obtained from this detaik'd examination of the specimen, we are now in a position to form our conclusions in regard to the followin-'- points : ° a. The nature, growth, and progress of the gestation. b. Relation to clinical facts c. Post-o})eration changes. The Nature, Growth, and Prorjrcss of the Gestation. The case is one of mixed nature, being partly tubal (extra-peritoneal) and partly abdominal (intra-peritoneal). Clinically, it was impossible to make this diagnosis. After the most thorough ante-mortem examination it was impossible to say which one of the varieties of extra-uterine gestation might exist. Even the careful inspection of the abdominal cavity at the time ofq^eration failed to give much information. It is, indeed, only at the end of a complete sectional and microscopic examination that we can be absolutely certain of the nature of the case. The chief facts which make evident the conclusion arrived at by us are the followiuir : a. Two sacs exist, one of which contained the foetus, the other the placenta. The former was f ,rmed by the peritoneal cavity behind the stomach, transverse colon, and great omentum ; the latter by the enor- mously dilated left Fallopian tube lying in front of the uterus and extending vertically from the utero-vesical pouch to the 4th lumbar ' RESUME gg vcrtclnu Though ,uitc distinct from one another, fhey were eonnected by means of the umbilical cortal extremity lay free in the secon that in the former the ute'rus is usu-dly I earned forwards and upwards in front of the lower part of the tumour M (this was so ni Hart's sub-peritoneo-pelvic case) ; -> in the latter it is pushed to the opposite side, or retroverted. In the former the ovary of the affected side may often with difticulty be found, whereas, in the latter case, it is usually speedily found. In the next place, what was the probable history of its ..rowth and development ? That the ovum began to grow in the left tube there is no doubt; very early the pregnant tube fell forwards in front of the left broad ligament, where it continued to increase both in an upward and downward direction. Then at some time during the early months, 1 Handbuch der GeburtsMlfe herausgegehen von P. Miillcr, Band IT 2 tT.,iff c,. ,. 1889, p. 565. 2 0^,. „., ;,,^j^ J ' ^'•"'t'-'' St"«g«rt, 40 TUBO PKRITONKAL ECTOl'IC CiKSTATION entirely imknowii to us, the wall of the sac (possihly at its U2)pcr and posterior part) became so greatly thiiniod that it burst and allowed the fcxitus to oscjipc, carrying with it the unbroken amnion. It is impossible to say whether any chorionic tissue was carried into the peritoneal cavity along with the amnion. The sub -amniotic hiyer in the wall of the secondaiy sac is well formed fibrous tissue, in some parts very dense, in other parts of loose nature, allowing of the folding of the amnion exactly similar to the folding which occurs in that membrane during ordinary uterine lal)our. ^^'it ' and others have noticed the partial hernia- like protrusion of the contents of the tube in tul)al pregnancy through a part of the Widl whose tissues have become stretched and separated. It may l)e, however, that rupture did not occur in this way, but that the fimbriated end became gradually opened up, allowing the foetus to escape. Kiistner - has observed the fimbriated end of the affected tube disposed in three different ways. It may either be attached to the side wall of the pelvis by peritonitis, remain free as a projection on the surface of the gestation sac, or become cVdcited hy the outimrd jn'cssn e of the ovitm; he has seen an ovum lying in the dilated fimbriated end, after having gradually worked its way from an inner portion. At any rate, however escape may take place, it is well authenticated that the membranes may escape unbroken with the foetus where the primary gestation sac ruptures into the peritoneal cavity. In a very fully described case published by Professor Sir William Turner,^ where rupture of a three months pregnant horn of a bi-cornuate uterus occurred, resulting in the patient's death, it was found that the foetus, covered with membranes unbroken, lay in the peritoneal cavity, having been protruded together with a part ef a placental-like mass through the rupture in the horn. As the foetus grew the amnion became attached to the peritoneal lining of that part of the abdomen into which it was cast, and as a result the sub-endothelial layer of the peritoneum became thickened and 1 Sclirocdor'g Lehrbuch tra- Ulcrine Pregmnaj, p. 49 ; T.usk, Midwifmj, p. 329. ^ licit riige zur Anatomie mid xur Oiierativcn Behandlmuj der E.dra - iderinschwaiijemhaft, StuUgiU't, 1887, p. 57. •' Op. cit. p. 34. ^ Diseases ofJFoiiiin and Ahdomimd Surgery, vol. i. p. 443, '' Kdra- Uterine Pregnancy, I'liilailflpliia, 188IJ, p. 3. ■1'2 TUBO-l'KKlTONKAI. ECTOl'IU ( i KSTATIUN ■mil tliat tlicn tlic lu-ogress of gesttitiun i.s diroctcd citli v into ;t broml ligjimcnt (oxtra-poritoiiciil) gestation or into an abcloniiiiiil (iutra-poritoneal) gestation, " loiifornili/ fatal {itnh'ns removed by ahdouiinnl section), [)riniarily hy luumorrliage, secondarily by siipiniration of the sac and j)eritoniti.s." Again ^ he says tliat it is only the form which has burst from the tube into the broad liga'icnt which afterwards may give rise to those cases called abdominal pregnancy through secondary rupture of the ovum sac; and, in another place,^ he says that the ovum can only survive the process of rupture in those cases where the rupture of the tube takes place into the cavity of the broad ligament. Strahan merely emphasises Tait's opinion. On the other hand, llnndP records a case in which, after rupture of the primary sac at the fourth month, the foetus grew to full time in the abdominal cavity and was extracted alive by laparotomy, the mother being {)i articido mortis. At the j()oA'^?uor<('JH the abdominal cavity in whicl the chik' had been lying contained a large quantity of dirty serous fluid, but no membranes could be found. There was matting together of the intestines, the peritoneal lining of the sac being covered with a pseudo-membranous etiusiou. Jessop'' describes a case in which the foetus alone escaped into the abdominal cavity after rupture of the primary sac ; it lived, and was extracted alive at full time. At the operation the peritoneum was more vascular than normal, and appeared " thick and velvety on section. No trace of cyst or of membranes could be found. A few bands of un- organised lymph of very fi'ialjlc nature were found lying upon, but not adherent to, the intestines." As the mother recovered from the oi^era- tion, the condition of the appendages, the nature of the gestation sac, and the relations of the placenta and membranes, was not ascertained. Champneys'* also describes a case in which a seventh-month foetus was removed from the abdomen. It lay among the intestines, covered only by "a dull white mcmljrane." The mother died on the thirty - second 1 Op. cit. y. 442. 2 Op. cit. II. 488. '■' Uyc. of Ohst. and Gyn., vul. xii. i>. GUO. ^ Trails. Ohstet. .S'or., Loiuloii, vt 1>. 2(i]. '' Ibid. vul. .xxix. J). 4.')0, R£SUMfi 43 day lifter the opciiitiiiii. At the post-mo rinn it wiis iinpossihle to make out the relation of parts in the pelvitf, though the phaecntu was t'ound ahotr the pubcs lying loose in u sac. From the facts given we cannot be at all sure us to the nature of these cases, 'i'hcy nuiy have been ruptured tubal, tul)o-ovarian, or sub- peritoneo - pelvic gestations, or po.ssibly, even, in Bandl's case at least, of the sub-peritoneo-abdominal variety in which rupture into the peritoneal cavity had never occurred at all, Veit' says that after rupture of a tubal gestation the ovum may go on developing in the aljdominal cavity whether the membranes luirrouTiding the fcetus be broken or not, but most Jreqnenthj iit, thf latter case. Charpentier,- though believing that in most cases the fcetus dies after ru[)ture, says that it also may live. The last two authors give no ground for their statements whatever, save an extremely questionable case of one Walther mentioned by Charpentier, in which, after the rupture of an " ovarian " pregnancy, the foetus de- veloped for four months amidst the abdominal viscera, and " was found at the end of gestation as free and without cyst as at the time of its escape from the ovary." Relation to Clinical Facts. f{ow, now, does the history of the development of the gestation in our case, based upon the facts derived from anatomical study, correspond to the clinical phenomena observed during the course of pregnancy ? As regards the si/mjitoins, they were, during the greater part of preg- nancy, practically the same as those experienced normally by women, e.g.— It was for the first seven months almost a painless gestation — a most remarkable fact. There neither occurred the symptoms of a rupture into the broad liga- ment, nor those accompanying rupture into the peritoneal cavity. The only symptom that might indicate the escape of the fujtus from 1 Schroeder's Lchrhich d. Gehiirtshulfe, Zehnte Auflage, ji. 430. - Traile des Accomhemcnts, vol. ii. p. 1030. 44 TUI'.0 I'KIMTONHAI. KCTOIMC (iHSTATION uio tube was ii pain in tlic loft sitle wliidi ciimo mthor Hudflcnly during the third month, lasting for four or live days and then disappearing. Tliero, was uo fainting xor collapse, and the physician considered it as due to Iterimetritia or threatening of an abortion. There was no reason in his mind for suspecting anything of a more serious nature. In fact, there were no symptoms whatever to indicate that rupture had occurred. This can only bo accounted for by supposing that either the membranes and fa'tus were forced very slowly through the opened-up fimbriated end of the tube, or that the tube wall itself became so greatly thinned at one point that the l)undles of muscle and connective tissue became separated, so that a heruiai-like protrusion of the membranes occurred, followed by the foetus, the process being accomplished with little or no haemorrhage and with no special pain. Even more remarkable is the fact that the further growth of the anniion in the al)dominal cavity was unaccompanied by pain. We have seen that ilie amnion became attached over a large peritoneal area by changes which resulted in the formation of a considerable amount of fibrous tissue immediately beneath it, that the great omentum was largely changed into fibrous tissue, and that iii parts the intestines were matted together. Besides, other inflammatory adhesions occurred between the left side of the primary sac, the parietal peritoneum, the ovary, uterus, and rectum. It is generally supposed that such changes arc accompanied by pain. Veit' says that pain always accompanies the inflammatory changes which give rise to the matting of the intestines and the encapsuling of the foetus, Bandl," in de.scril)ing the clinical history of the case already referred to (p. 42), says that at the third month abdomiii'd pain began, and ihiit it continued, with loss of flesh and strength, during the rest of the pregnancy. We may account for this in one of two ways : either there did exist a certain amount of pain of which the patient, being a primipara, did not complain, considering these as necessary accompaniments of pregnancy ; or the adhesions really were formed without pain being caused, just as is the case sometimes with large ovarian tumours. This latter fact is now well established. 1 0)). cit. 2 Op. ril. I). GO. llRSUMK 45 LnwHOii Tiiit* says that " it is H\iri)riHiiif^ to what extent a tumour may 1)0 found to 1h' adherent, and yet throu^^hout its history no indieations of inflamnnitory attacks have been given." OlshauHcn '" says, " in the htiyc majonty of cases adhesive intlamma- tions which result in parietal adhesions run an apyrexinl and latent course, ])ut that in other cases they jirc attended with ]i;iins which may last for days or weeks." I)uring the last two months of her pregnancy the patient complained of sharp pains in the left hypochoi'driac and lumbar regions, intermittent in character and accompanied by dyspnoja. These may possibly have; been partly due to tlu^ inllammatory changes going on in these regions, but, if so, it is remarkable that similar symptoms were not pioduced by the same cause acting in the other parts of the abdomen, it is more probable that these attacks of pain and dysi)n(ra wen; due to the condition of hydramnios together with the derangement of the alimentary canal which existed. Charpentier,'' in his well-known article mi hydramnios, speaks of the characteristic pains in the late months, due to this condition, as occurring sometimes in the hypogastrium, sometimes in the lumbar, inguinal, or sacral region, and being intermittent or continuous in character. There was considerable gastric and intestinal di.sturbance throughout pregnancy. On admission to the hospital she was greatly troubled with flatulence, which escaped both by mouth and rectum, and she complained frequently of a pain at her heart, which passed through to the back. Durrng the last week she also had spasms of pain in the lower part of the abdomen. As to the signs in the early stage wc have very little history. The swelling caused uy the growing ovum was noticed in the third month of prec^nancy in the left half of the lower part of the abdomen. This is of course cjuite different from the condition met with in normal pregnancy, where at the same period of gestation the uterus is below the pelvic brim. Had the physician's attention been directed to this swelling it must, apart from its left-sideduess, have aroused his suspicions, and we see no reason to 1 Diseases of the Ovaries, 1883, p. 191. - Cyclopediu cf Obst. and Gyn., vol. viii. p. 88. •' Op. cil. p. 89f). 46 TUBO-PERITONEAL ECTOriC CKSTATION tloubt that, had a careful bi-muminl boon made with the aid of an •ina3S- thetic, the abnormal condition would have been diagnosed. The great majority of tubal gcstatioris are never diagnosed until rupture occurs, because until then no abnormal signs or symptoms make the pi.^-ient seek for advice. The menstrual history was similar to tha*" recorded in many cases of extra-utorinc pregnancy — a period of amenorrhooa at first, followed ])y small discharges of blood at intervals afterwards. In this case there was ameuorrhcea for the first two months, while a slight bloody discharge occurred from the uterus in the third, fourth, and eighth months. Tho breasts were flabby, not much enlarged, and containing very little colastrum. A well-marked scuttle was heard in the iliac regions. ( )n examination before operation the vagina was patulous and its walls very soft. The cervix was eidarged, softened, and not at all shortened, the posterior lip being 1 in. in length. (Strahan ' says that the cervix becomes shortened in extra-uterine pregnancy.) A finger could be passed for some distance into its canal. This patulous condition of the cervix in extra-uterine gestation has been noticed by several observers. Tait - says that it is a most important sign, being found in all cases. Strahan'' says that "the cervix is always open." Kiistner"' also notes this fact. The uterus was found at this time pushed to the rlcilit, upright and somewhat retro-posed. It was enlarged to the length of 4 inches. This growth of the uterus in extra-uterine gestation has long been known, but the variations in size found in diflerent cases of full-time pregnancy have not been satisfactorily explained. In Berry Hart's sub-peritoueo-abdominal case the length of the whole uterus was 4 in., about f in. shorter than in this case. In Bandl's mixed case (already referred to) it was 3 "2 in. Bandl '' says that the growth of the uterus depends upon the nature of the gestation, and that the nearer the ovum is developed to it " the more • Op. cil. \K 13. -' Oji. cil. p. 502. ^ Op. ril. p. 43. 4 0)1. nl. p. 488. '' Oji. cit. p. .'iO. til I liKSUMfi 47 iTguliirly will the utenis participate in developnicut " ; thus in inter.stitial cases the utenis is most of all enlarged, in tubal cases less, and in mixed cases still less. Kiistner^ ulso says that the greatest development is found in the inter- stitial variety. The uterine mucous membrane was greatly swollen, and on microH(a)pic examination presented the characteristic appearance of decidual tissue. It was well formed, containing many large decidual cells, and closely resembled the uterine decidua in Berry Hart's 4^ months sub -peritonco- pelvic gestation." According to most authorities a uterine decidui> is found in most cases of extra-uterine gestation, but C'harpentier is the only one, as far as 1 am able to find out, who says that its character changes with the progress of the pregnancy. Pie says that it is at first voluminous but that " it soon becomes the seat of true atrophy, of active absorption, so that at term scarcely any traces remain." Kiistner,^ on the contrary, says that at the end of pregnancy, especially after the child's death, a division of the decidua takes place through its middle layer and that this is usually expelled. In some cases, undoubtedly, no decidua is found, but this is, according to Campbell,-' because the examination is made just after it has Ijeen thrown oil", during the previous discharge of blood from the uterus. In this case the decidua was well formed and not undergoing perceptible atrophy or absorption. Decidual tissue could be traced from the uterine cavity into the inner end of the left tube. The extent and relations of this were not, however, well made out. Bandl-> says that in tubal pregnancy the uterine end of the pregnant tube is occasionally open, and its dei'idua extends to the nuicous membrane of the uterus. Shortly before operation, a "spurious l;d)our" took place, lasting for several hours. It consisted of frequent uterine contracti)ns (accompanied 1 Op. rit. p. 409. '^ Op. cit. vol. ii. jiliito xxi, fig. ■> Op. cit. p. 4S)0. ■• Memoir on Extra-Uterine Gestation, Eiliii- burgli, 1810. •'■' 0)). at. p. 47. 48 TUBO-PEUITONEAT, ECTOPIC GESTATJON by ijtniiuing cfi'oits on tlic part of the patient) whereby Hiiiall bits of decidua and clot were expelled. It is now well established that this nsually occurs in cases of full-time ectopic gestation whether the fa>tus has died or not. According to Tait,' Vidal in the year 1G52 was the first to notice it. Kiistner ^ says that also contractions take place in the tube wall whereby separation of the placenta and luDniorrhage into its substance may take place, leading to the death of the fcetus. Whether or not this occurred in the present case one cannot say. Judging, however, from the small amount of muscular tissue in the wall of the plr -tal sac, in proportion to the great quantity of connective tissue, we believe that only slight contractions could occur. Certain it is that the htomorrhage into the placenta was a post-operation occurrence, because the examination of the patient after the " spurious labour " had occurred, just before the operation, showed that the uterus was still in the right side of the pelvis and its relations to surrounding parts the same as in the previous examinations. There is, indeed, no ground for believing that, in an extra-uterine gestation, where the tube forms part of the sac, contractions will be set up in the wall of the latter in the same way that they are set up in the uterus in a full-time normal pregnancy. Kiistncr's statement, though possibly true, cannot be at all su})ported by evidence. It is more probable that the tearing of the sac wall and placenta is due to the contractions of the abdominal muscles in the violent strain- ing efforts often made by the patient during the " spurious hd)our." Strahan ^ says that this may rupture the gestation sac to such an extent that the blood may ho poured outside it into the peritoneal cavity causing death. The condition of hydramnios is of special interest. I have found only one'' mention of its occurrence in extra-uterine pregnancy in the chief literature of the subject. Its cause is unknown to us. We may, however, associate with it the great amount of amniotic membrane lining the sac ' Op. i-ii. \>. mo. ■i Up. at. ]>. r.s.'j. •' Op. cil. p. 48. ■* Teiiird, Archil' f. G\i»., IkI. xvii. KfiSUME 49 which contained the foetus— an area nuicli laiger than the inner surface of the full-time prognax^^ uterus.' It is to l>c noted that the signs and symptoms were much the same as those seen in cases of extensi"e hydramnios in uterine pregnancy. Post-(yperation Changes. These have occurred chietly in connection with the primary gestation sac — that containing the placenta. The secondary sac, emptied of its contents, is now only a potential cavity, its walls being in apposition. The pelvic cavity is now occupied by a mass which was not present at the time of the operation. At that time the placental mass occupied the left side of the pelvis extending for about 3 in. above the brim, the uterus being pushed over to the rujht side of the pelvis. Now, the uterus is pushed backwards and against the left side while in front of it and to the right is a dark red black mass filling the pelvis, pressing on the bladder below, and reaching above the brim. This mass is not in the secondary sac, nor in the peritoneal cavity, but entirely within the primary sac ; it consists of placenta and recently poured out blood in the early stages of alteration. The greater portion of the placenta has been destroyed, more normal portions being on the left side under the wall. In most places these parts are greatly compressed. The distension of the sac has been upwards, and downwards, and to the right. The wall, as we have seen, is much thinner on the left than on the right side. To understand how the placental sac (tube wall) was capable of such great distension without rupture we must bear in mind the previous escape of the fcttus from the tube. When this took place there was left a considerable portion of the sac wall lying flaccid. It must have been pressed against the placenta and probably their opposed amniotic surfaces blended. We are now unable to find any trace of amnion inside the primary 1 We do not know exactly the averayo area of the inner surface of the full-time pregnant uterus. Barbour and Wel).ster ("Anatomy of Advanced Pregnancy and of Labour," etc. ; Liihor- afonj Bi-jiorts A'.C'.i'.Vi'., vol. ii.) found the inner wall of the eight-month i)regnant uteniM to measure 147 square inches, of which the placenta occupied 48 sciuare inches ; while that of a full-time uterus in the second stage of labour was 1C"'09 sijuare inches (including the cervix). I 50 TUBO-PElilTONEAL KCTOriC CJESTATIUN sue, nor can we tnicc the cord inside the sac, tlic latter probably entering the placenta close to the wall. It was most probably the existence of the Haccid portion of the wall which allowed such a great distension of the sac to take place. The luemorrhage in the sac, occurring chiclly in the right half of the pelvis, pressed the uterus backwards and to the left to such an extent that it bul"-ed into the srcat sacro-sciatic foramen. To such an extent did the distension take place thiit the sac fills the pelvis as if in a mould. The uterus and appendages, the rectum, bladder, ligaments and excra-pcritoneal tissues are greatly compressed, the vessels being nearly closed. It is easy moreover to see how the action of the ureters may have been greatly interfered with. The cause of this great hrcmorrliage was probably due to the change in pressure which followed the removal of such a large quantity of fluid as was contained in the secondary sac. As to the source of the haemorrhage we cannot speak with certainty. It may have been a general increase of the blood of the maternal portion of the placenta or it may ha^ e been due to the bursting of some of the thin walled sinuses in the inner part of the tube wall. As to the clinical signs accompanying these changes we know practically nothing ; the patient was kept under the influence of morphia for the first 24 hours after the operation, so that all subjective symptoms were masked during that period. Afterwards she felt no pain or sickness ; the pulse, however, was feeble and rapid. The symptoms which followed, and only ended with the patient's death, were those of urtmnic poisoning. The catheter was passed from time to time, but only very small quantities of urine were drawn away. The sections show that the liladder was so compressed by the mass lying above it that scarcely any dilatation of the cavity was possible, and this condition, together with the pressure upon the urethra and the ureters, is the explanation of the passage of such small quantities of urine, and probably also of the consequent symptoms of uraamic poisoning. \ BIBLIOGRAPHY Ban'dl, Extra-Uterine Pregnancy, Cyclopa'dia of Obst. iviul Oyn., eil, by Gramlin, vol. zii. Baubour, Diagnosis of Advanced Extra-Uterine Gestation, Obstet. Trans., Ediii., vol. vii., 1882. BARnouR and Wedster, Aniitomy of Advanced Pregnancy and of Labour, Lab. Reports R.C.P.E., v.d. ii., 1889. Campbell, A Memoir on Extra-Uterine Oe.sta- tion, E.lin., 1840. Champnevs, Trans. Obstet. Soc, Lond., vol. xxix. CiiARrEN'TiEn, Traito des Accouclienicnts, vol. ii., 1883. Dezeimeris, Jour, des Connaissances Med. Cliir., Jan. 1837. Hart (1), Sectional Anatomy of Advanced Extra- uterine Gestation, Lab. Rep. R.C.P.E. vol. i. (2) Anatomy of Placenta in Extra-Uterinr Gestation, Lab. Rep. R.G.P.E., vol. ii. jESsor, Trans. Obstet. Soc., Lond., vol. xviii. KChtner, llandlmeli der Geburtshiilfi^ berauage- gcben von P. Mitller, bd. ii., Stuttgart, 1880. Leopold, Trans, of Inter. Medical Congrfs."*, Berlin, 1890. LlKK, Tlie Science and Art of Midwifery, New- York, 1889. Olsiiausen, Diseases of the Ovaries, Cye. of Obst. and Gyn., edited by Grandin, vol. viii. Paruv, Extra - Uterine Pregnancy, Eng. ed., London, 1S7G. Stuahan, Extra - Uterine Pregnancy, Phila- delphia, 1 SriEnKLUKRCi, Text -Book of Miilwifcry, Eng. Trans. Sutton, Surgical Diseases of tlie Ovaries and Fallopian Tubes, Lond., 1891. Tait, (1) Diseases of Women and Abdominal Surgery, vol. i., Leicester, 1889. (2) Diseases of the Ovaries, ".883. Turner, Edin. Med. Jour., May 1860. Teuffel, Arcliiv f. Gj'n., bd. xvii. Veit, Scliroeder's Lel-.rbuch d. Geburtshiilfe, Zelmte Auflage, Bonn, 1888. Weuth, Britriige zur Anatoniie und zur Oper- ativi'U Behandlung der Extra - Utu.in- schwangerscliaft, Stuttgart, 1887. fe mi INDEX Amniotic Sac, 14, 2C, 31, 37, 10. liiiilionr's C'lisc, !>. IJlaiUlcr, 13, 17, 19, f.O. Cervix, '29, IG. Clinical Ilistoiy, -I. Corr(!s]ioii(lL'i)ce lietwt'on Patliology ami Clinical History, -13. First Transverse Section, IG, Fourth Tnvnsverso Suction, '21. Fifth Tran.sverse Sui'tion, 'J.'i. Ila'niorrhaj^e in I'riinary .Sue, TiO. History of (h?volo|iinent of Tnlio-lVritoncal Closta- tion, 3.S. Hydraninio.s, 48. .rcs-sop's Case, 4'2. I.ijjaniunts and Coniioctivo Tissues, 17, '20, '22, '24, 39. Menstrual ni.story, 4ti. Jlicro.scopic F.xaniiuMiion, 3'2 Ainniotii' Sac, ;W. Memlirancs, •'i7. I'lacontii, 31 Placental Sac, 3'2. Nature of Case, 3.S. IVritoncuni, 14, 17, 19, 22, 2 CiiImiiihI I'liitcs fniin (M'ij.'iii,il l)iii\viiij;s, I'licc '2ris, PRACTICAL PATHOLOO-Y. A Manual for Students and Practitioners. IJy lii-.li.MAN Sims WdOiiiiKAii, M.I)., l''.l;.C.IMM., Dircct.i ui' tho Lulwrnlories of Iho Kojiil v^'olli'gc » of I'liysiciitiiN (Ijdi.ilnii) iiiiil Smpiiii.H (Kii^liiinl). Thir.l Kilili.ni, Rovi.sc.l uii.l KMlai>;r,l, 8v(>, CInlli, Cilt T..]!, ; ,'. xx. lUl. 'Villi AVooilcut iiiil 'J Moiililf-imKi^ Coliiiircd llUistiiitioiiH. I'rici' lils. DISEASES OF THE SKIN: A Manual for Students and Practitioners. l!y W. Ai.r.AN .Iamikson, M.l)., K. R.C.I'. I'M., Kxini I'liy.siiun r„i' lii.w.ws of tli^ Sl.i.i, Kiliiilinj^li Koyal Inliniiiiiy ; CoiisiiUinj; I'liysicuvii, EiUuljurgli City Uoaliital , L. i hin-r on Discu.si's of tlw .''.kin, Stliool of Mwlicini', KcliiilniiKli. [I'mlhuiiVn ilrdieal .^mm—l jI. 1. In I'lcs.^, Stcunil K lition, 8vo. To l.o Illnstmtwl \yith many ail.litioniil ColoiiRd I'laU'S I'roin (li'iirjiiiil l)i'i\wiii^;s. DISEASES OP THE BYE : A Practical Treatise for Students of Ophthalmology. liy (Ir.oiKiK. A. lii'.iiuv, M.H., K.li.C.S.Kd., Uplitlialmic Sni'Ki'on, Kilinlmrnh Koyal Inlinniiiy; Scnioi- Sniw'oii, Kilinlini-Kli Kyr- Di.sin'n.siiry ; Loclnrii tm OiilitlialnioldKy, Royal Colliw ot Surj^cMjiis, Edinlinixh. [I'nit/itinr.t Mnlii-nl Sn-ies—iol. J J. 8vo, lip. xvi. 01(1. With Coluurud Illu.stiation.s from Oiininiil Dnnvin-js. I'rici; '2,'i.s. DISEASES OP THE THROAT, N03E, AND EAR. I!y P. M'15uinK., M.D., !•'. R.C.I '.Ed., [,,rtiiivi-on tlio Disrasi-s cif 111,' Eai iin.l Tlin.at, Kdiiil>\n;,'li Srliool of Mcdicini' ; Anial Siir.'n.m and l.aiyiiL'oloi'i.st, Royal Inlinuary, Edinlnirgli ; .Smwon, EdiiilmiKli Ear and lliniat Uispoii.sary. ■> *^ h . J l, r,, y,,,^„,„„c^ Mcdu-al Ha-ics-i\d. III. 2 vol.s. lar^c 8vo, Clotli, yy. xvi. 1008. lllustrati'd witli Maps and Charts. Trice 31.s. «d. GEOGRAPHICAL PATHOLOGY : An Inquiry into the Geographical Distribution (d' Inflictive and Climatic Di.^ciiscs. ily A.sni;i;\v Davih.min, M.H., K. II.C. I'. Ed., late Visitinf^ and Superintending,' Surtjuon, Civil Hospital, anil I'lufcxMur ot Chemistry, Royal College, Manntms. Larw 8vo, pp. xxviii. TTli. With 101 Illustrations. I'rice 31s. Od. „„^,. THE PARASITES OF MAN AND THE DISEASES WHICH PROCEED PROM TIIK.M. 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