IMAGE EVALUATION TEST TARGET (MT-S) fe // 4is <, ^ CC: 1/ Ua 1.0 I.I ■- Ilia |M II 2.2 12.0 1.8 1.25 1.4 1.6 •• 6" ► Photographic Sciences Corporation ^ ft« --ar. ; ij e^gjfv ,. ' -- - - -5r': wr »"J» j^''a:^-'*-: - - , - i -m^ , - . ^ PART PLA YED B Y EPITHELIUM OF MUCOSA. 5 No doubt the resemblance between the epithelial cells of the uterine and tubal mucous membranes and their direct continuity have helped to establish the assumption that the ovum can develop in relation to one set as well as in relation to the other. Such an assumption is, of course, entirely un- warranted, because structural similarities do not necessarily imply physiological harmonies or identical reaction tendencies. Moreover, all recent work, e.g., that of Minot,^ Hart and Gulland,2 myself,^ and others, goes to show that the lining epithelium of the mucosa, both in tubal and uterine gestation, plays an entirely negative part as regards the development of the ovum. ... Next, what is to be said regarding the statements that the ovum can develop in the tube only when the lining epithelium has been destroyed by inflammation ? It might be sufficient, in refutation of this belief, only to mention those cases of tubal pregnancy in which no inflamma- tory or other diseased condition is found in the mucosa. More- over, in some of the cases in which inflammation is found, there can be no doubt that it follows upon the disturbances in the tube attendant upon the development of the gestation. This has been strongly urged of late by Martin,* whose recent observations have led him to give up his older views ^ regarding the part played by endosalpingitis in causing tubal pregnancy. Bland Sutton" is of 1iie f opinion that the so-called causal relation between desquamative salpingitis and tubal gestation is mere speculation which contains an element of truth, but does not hold in all cases. He points out that where the inflammation is so severe as to destroy the tubal epithelium, * '-Uterus and Embyro," Joum. Morphol., Boston, April, 1889. ■^ Rep. Lab. Roy. Coll. Phys., Edin., vol. iv. ^ See Chapter on Development. * Op. cit., vide supra. ' Ztachr.f. Oehurtah. u. Gyndk.. Stuttgart, bd. xiii., p. 298. " Op. cit., p. 309. ! i( 6 ETIOLOGY. stricture and occlusion of the outer end of the tube usually occur as well ; ic is very rare to find tubes denuded of their mucosal epithelium and with a patent fimbriated end. One might also justly state that, whereas inflammation in the endometrium is not favourable to the development of uterine gestation, so inflammation in the tubal mucosa is u.i- favourahle to the development of a tvhal pi'egnancy. 1 wish, however, to consider this statement as part of a more comprehensive idea which has been strongly urged of late, more particularly by Lawson Tait,^ and also by Berry Hart,'^ viz., that the human ovum can graft itself only on a connective tissue from which the covering epithelium has been removed. Mr. Tait holds especially that in normal uterine pregnancy this supposed necessary raw surface is prepared by menstruation, as was first suggefited by Pfliiger, and in tubal pregnancy by endosalpingitis. In referring to the uterus he used the words " a healthy mucous surf Me freshly demided ; " and in reference to the tube he says that " a desquamative salpingitis could put the mucous lining of the tube intv"> a condition exactly similar to that of the uterus." This statement is open to the criticism that, while a resemblance might possibly be pointed out between an endometrium partially denuded and an early acutely inflamed mucosa, there is not a very close resemblance in the case of chronic inflammatory surface. ^ i That these authors are right in insisting upon the passive and unimportant part played by the epithelium of the mucosa, botii ia the case of tubal and uterine pregnancy, cannot be too strongly urged. All the latest embryological investigations give support to the view that the attachment and early de- velopment of the ovum takes place entirely in relation to the subepithelial connective tissue of the mucosa. I take excep- * Op. cit., p. 439. 2 " Selected Papers," 1893, p. 61. PART PLA YED B V EPITHELIUM OF MUCOSA. 7 tion, however, to the explanation of the early establishment of tliis relationship in normal pregnancy, on accoimt of the great difficulties in the way of believing that menstruation is the process esuential to the removal of the ej^thelium and the consequent laying bare of the connective tissue. These diffi- culties are as follows : — 1. Pregnancy may occur in a girl before the onset of men- struation, vj a time, therefore, when the mucosa cannot be denuded b> L. at process. 2. It may occur late during the period of lactation when there is no menstruation and after the mucosa has been com- pletely renewed. 3. It may take place at the menopause during a period of amenorrhoea. 4. Pregnancy may occur in the rudimentary horn of a mal- formed uterus, menstruation never having taken place in that horn {mile p. 92), 5. It may occur in periods of amenorrhoea associated with diseased conditions, e.g., ancemia, phthisis. 6. Clinical experience of cases of pregnancy following a single coitus shows that the ovum may begin to develop at any time — not necessarily immediately after menstruation. {Evidence in regard to this point, hoivever, is of doubtful significance, owing to the uncertainty in otir knowledge as to liow long the spermatozoa may remain in the genital tract, and Jww long the ovum may take in some cases to reach the tUerus.) 7. In the great majority of the mammals menstruation does not take place, and in many of them we know that the early ovum develops in relation to the connective tissue of the mucosa, the superjacent epithelium being removed by the ovum itself. Indeed, it is not at all necessary to look to menstruation as the process by which the epithelium is removed. The absorptive I 8 ETIOLOGY. '"K. I power of the trophoblast or outer layers of the foetal epiblast is an important factor in bringing about its disappearance. My recent studies in early tubal pregnancy lead me to believe that this is also accomplished partly by another agency, viz., the rapid changes in the connective tissue of the mucosa leading to the formation of the decidua vera, causing the covering epithelium to be stretched and broken up. » Regarding the exact nature and significance of menstruation we are still ignorant. The opinion of Hirsch,^ Slavianski,^ Eeeves Jackson,^ Lawson Tait,* and others, that ovulation and menstruation are entirely independent of one another, can scarcely be disputed. The recent work of Heape^ is confirmatory of this belief ; he examined the genitals of Semnopithecus entellus in forty-two cases of menstruation, and found that only in two was there any evidence of a discharge of ova from the ovaries. It seems certain that ovulation does not necessarily take place during menstruation, and that menstruation is not due to ovulation. The views of Leopold and Mironoff,^ who have lately worked at this subject, are as follows : — "Ovulation usually accompanies menstruation, though not always. Menstruation depends upon the presence of the ovaiies and a well-formed uterine mucosa. Ovulation usually coincides with menstruation ; it rarely occurs in normal condi- tions between the menstrual periods." t' There is considerable evidence in favour of the view that the menstrual function is connected with a special nervous mechanism. Christopher Martin,^ in his recent paper on this subject, thinks that there is reason to believe : — ' Schmidt's Jahrb., Leipzig, 1850. * Arch, dephysiol. norm, et path., Paris, 1874. 3 Am. Journ. Obst., N. Y., Oct. 1876. * Op. cit., p. 300 ct seq. ' Proc. Roy. Soc. Ziondon, vol. liv., p. 169. * Arch.f. Oynaek., Berlin, bd. xlv., hft. 3. ^ "The Nerve Theory of Menstruation," Med, Pn^ and Oirc, London, 1893, vol. Ivi., p. 420. NATURE OF MENSTRUATION, 9 (1.) That menstruation is a process directly controlled by a special nerve centre. (2.) That this centre is situated in the lumbar part of the cord. (3.) That the changes in the uterine mucosa during the period are brought about by katabolic nerves, and during the interval by anabolic nerves. (4.) That the menstrual impulses reach the uterus either through the pelvic splanchnics or the ovarian plexus, possibly through both. (5.) That removal of the uterine appendages arrests menstrua- tion by severing the menstrual nerves. There can be little doubt that menstruation is not necessary to conception. The view of Hirsch, Lawson Tait, and others is that menstruation in the human female and rut in lower animals are different processes. Regarding the extent to which menstruation occurs in the primates we are as yet ignorant, nor are we aware of the changes brought about by the change from the wild state to captivity. We are also in want of evidence in regard to menstruation among the lowest races of man, and also in regard to the variations which result when these races are civilised. There is much difference of opinion regarding the anatomical changes in the uterine mucosa during menstruation. The latest evidence points clearly to the view that there is but a alight denudation, irregular in distribution in the superficial layers of the mucosa. Having thus considered these important questions, I wish now to bring forward certain facts which seem to me of sufficient importance to suggest a sound basis ^or an explanation of the occurrence of ectopic gestation. I have referred to the gradual evolution of the Fallopian tube i I i 10 ETIOLOGY. and uterus, and to the marked differences in function which exist between them in the human female. • Hitherto it has been believed that in every case of utertne gestation the decidual changes in the mucosa which are apparently essential to the early ovum, and which result from some sympathetic reaction following its fertilisation, take place only in the body of the uterus, the tubal mucosa remaining unchanged. This view is based upon the microscopic examina- tion of the tubes in normal pregnancy. It is also held that in cases of single tubal pregnancy, while the uterine mucosa under- goes marked decidual change, the non-pregnant tube of the other side remains practically unaltered. Recent observations which I have made prove that the latter statement is not accurate, and throw some doubt upon the value of observations , made upon the tubes in pregnancy. To study these points thoroughly it is necessary to examine serial sections of every 'part of the tube, not of one part only, as is usually done. The observations to which I refer will be found on pp. 120, 121. They may shortly be recapitulated here. In examining a large number of tubal gestations, / have foiincl marked differences in the extent to which a deeidua vera is formed.. In some cases only a small part of the mucosa undergoes this change, in others a large part. In no case is there an absence of decidual formation. In those instances in which I obtained the non-pregnant tube (only in post-mortem cases), I always examined a small part of it. In one case, however, in which the tube was enlarged in its ampullary portion, I made a thorough examination of every part of it, and found to my great surprise that an irregular ring-like portion of the ampullary mucosa, in its entire circum- ference, differed markedly from the rest of the mucosa, as well as from the mucosa of every tube that I had examined. The differences consisted, in the first place, in a simpler arrange- i CHANGES IN THE NON-PREGNANT TUBE. 11 ment of the folds than is found in the normal ampulla ; they were much fewer in number, shorter, and only slightly branched. In the normal ampulla the delicate branching mucous fringes, as seen on transverse section, practically fill the tube lumen. In this case they formed thick projections, club-shaped, finger- shaped, wart-shaped, etc., extending inwards only for a short distance. In the second place, this part of the ampullary mucosa shotoed marked decidual formation, the large cells resembling exactly those found in the uterus in normal pregnane^ . • -. .. The tube ^i the opposite side (the left one) was about two months pregnant, and the uterine mucosa showed marked decidual changes ; the left ovary contained a corpus luteuvi, the right one (that on the non-pregnant side) containing none. This ease is most instructive. It emphasises most strongly that decidual formation is due to the influence of the fertilised ovum in the genital tract ; that this influence can act at a distance, direct contact of the ovum not being necessary ; that while in tubal pregnancy the uterine mucosa always undergoes this change, the tube of the other side muy also sometimes he similarly affected. In another case of an early tube pregnancy which I have recently examined, a large part of the non-pregnant tube pos- sessed a mucosa entirely different from the normal tubal mucosa. Instead of consisting of a series of folds, it presented more of the appearance of the uterine mucosa, being of more or less uniform thickness, and filled with gland spaces lined with columnar epithelium. Only here and there did a partially formed fold exist. In the connective tissue stroma of the mucosa decidual cell formation was found in different places. The uterus was well formed and normal. All these facts, it seems to me, taken along with those relat- 12 ETIOLOGY. I I ing to the evolution of the uterus and Fallopian tubes, suggest a hypothesis which lends itself to a satisfactory explanation of all the well recognised forms of ectopic gestation. Among those animals (some non-mammalians) possessing a genital tract, the least specialised condition is that in which there is no distinction between oviduct and uterus, in which the tract is bilateral, and in which the ova may develop practically along its whole extent. In higher forms — certain mammalians — differentiation has occurred in the MUllerian ducts, as I have already described. In many of these, e.g., cat, with bicornuate uterus, several ova develop in the whole extent of each horn, the mucosa undergoing the necessary decidual changes. In cases of human bicornuate uterus, usually only one ovum develops in one horn ; in other cases, one may develop in both horns ; in rare instances, two may develop in one and one in the other. In other forms with bicornuate uterus, e.g., cow, only one ovum, as a rule, develops in one of the horns, hid the mucosa of both Iwrns undergoes, as a result of the genetic influence, marked decidual changes ; the same thing may be found in pregnancy in the uterus hicornis in the human female ; these changes are, in the case of the non-pregnant horn, as far as we know, entirely unnecessary to the development of the ovum in the other horn. It is well known that pregnancy may go on perfectly well in cases where one horn is absent. When we come now to the human female, in which the single uterus exists, we find that the decidual changes induced by pregnancy in the great majority of cases take place only in the uterine mucosa where the ovum normally grows. However, in some cases, as I have shown, the tubal mucosa can, in great or small extent, respond to the genetic influence, as well as that of the uterus. This is probably because of some developmental fault whereby there is reversion either of structure I ^B^^HEff^^ DECIDUAL REACTION. 13 or reaction tendency in the tubal mucosa to an earlier type in mammalian evolution — I mean that in which a larger portion of the Miillerian ducts showed decidual reaction. Because of these occasional changes in the Fallopian tube, conditions are brought about capable of establishing with a fertilised ovum that relationship which is essential to its development. If, then, the deduction be established that it is possible for a fertilised ovum to grow only in relation to that part of the genital tract, whether tube or uterus, in which the genetic reaction occurs, the explanation is evident, why in the human female a pregnancy may occur sometimes in a part of the genital tract outside the uterine cavity. When the above mentioned conditiouB exist, in any case, several factors determine whether a fertilised ovum shall develop in the tube or uterus. The place of fertilisation of the ovum is important. Ectopic gestation probably only occurs when this takes place in the tube above the part of the mucosa showing the decidual reaction. When it occurs in the uterus, the gestation will only take place there. Fertilisation may occur in that tube which does not show the decidual reaction ; or it may occur in the tube show- ing the reaction, but at a point lower down. It is possible, however, that it may occur above the reacting part, and yet be carried down past it to the uterine cavity, if no conditions exist which can prevent this taking place. And, in this connection, we are able to understand the part played by such conditions as inflammation, displacements, tumours, &c., in the tube or outside it, which lead to some interference with the free continuity of the tube lumen. Given the fertilisation of the ovum his^h in the tube, the obstruction to its free passage to the uterus after this takes place, along with the occurrence of the necessary decidual I 14 ETIOLOGY. reaction in the mvwsa with which the ovum comes in contact, and we have a satisfactory explanation of the pregnancy which '^velops. , • le adoption of these views, which imply that the ovum can only begin its development on a tissue capable of a special genetic reaction, and therefore only in some portion of the passage derived from the original MtiUerian ducts, makes it difficult to believe in the possibility of the occurrence of a pnmary abdominal pregnancy. .■ ; ' ' Though of late, owing to the writings of Bland Sutton, Lawson Tait, and Berry Hart, belief in the existence of such a gestation has been widely discredited, no well-founded reason has been raised to show why it should not take place. Indeed, considering the factor which the two latter authors had believed to be of chief importance in the development of tubal pregnancy, viz., inflammation destroying the mucosal epithelium, it does not appear, according to that view, why a fertilised ovum might not attach itself and grow on a part of the wall of the abdominal cavity which had lost its superficial covering of cells through the same pathological piocess. According, how- ever, to the view which I have advanced, the primary intra- peritoneal development is improbable, because the peritoneal tissues cannot, as far as is known, undergo the changes required for the establishment of the necessary relationship with the young ovum. , / As regards the ovary there is more difficulty. We have no reason to believe that the Graafian follicles can respond to the genetic influence, and there is no proof that a pregnancy has ever started in them. Supposed cases of ovarian pregnancy require to be studied carefully, and in every instance must be distinguished from the following conditions which may be mistaken for it, viz., preg- IMPROBABILITY OF O VARIAN PREGNANC Y. 1 5 nancy in the outer end of the tube which has become inti- mately connected with the ovary; pregnancy in an accessory tube end which has become attached to it ; pregnancy in the ovarian fimbria, which may be hollow sometimes, representing the extreme outer end of the tube; pregnancy in the tube which has extended into the ovarian sac of peritoneum, which occasionally occurs in women. (Also vide p. 45.) Primary development of the ovum in the ovarian sac is as improbable as its development in any part of the peritoneal cavity. \'> V ■r CHAPTER 11. CLASSIFICATION. In studying the literature of Ectopic Gestation two names, viz., those of Dezeimeris and Lawson Tait stand out in such pro- minence that they serve to indicate its division into three distinct periods, which may be stated as follows : — 1. The period before Dezeimeris; 2. The period between Dezeimeris and Lawson Tait ; 8. The present period. ' 1. The 'period hefore Dezeimeris. — Before the 16th century, while references are found in medical literature which prove that the occurrence of ectopic gestation was known, there are no detailed records of cases, nor any attempt whatever at classifica- tion. The first case of which we have any clear account is one described in the 11th century by Albucasis,^ an Arabian physician living in Spain, in which he observed parts of a foetus escaping through the abdominal wall by suppuration. During the 16th century several cases were described, but so vaguely that their exact nature cannot be determined; among these may be specially mentioned the cases of Polinus,^ Horstius,'* Platerus,* and Primerose.^ 1 " De Chirurgia," cura J. Channing, Oxon., 1778. •■: " Miscell. Nat. Curios," 1670. Ohs. 110. * "Opera Medica," Norimb., 1660. ■• " De partium corporis humani structura et usu," Basil, 1597. s " De mulierum morbis et symptomatis," lib. iv., Rotterodami, 1655. EARLY DESCRIBED CASES. 17 During the 17th century, however, more exact descriptions were published, and distinct varieties mentioned. In 1604 Riolanus ^ examined a case of tubal pregnancy, described by him in his " Anthropographia," the first accurately recorded case of the kind. In 1614 Mercerus'^ examined the body of a woman who had died of a ruptured two months' ectopic pregnancy — described by him as right ovarian, but which was probably either a tubal or a tubo-ovarian, since he mentions the tube as much enlarged and ruptured. As to who first described abdominal gestation I can find no record. Some of the 16 th century writers, to whom I have referred, mention cases in which the foetus was said to have been found in the abdomen, but no special name was used by them to indicate this variety. In 1682 St. Maurice^ described a case which has always been regarded as the earliest noted case of ovarian pregnancy, that detailed by Mercerus sixty-eight years previously having been overlooked by most authors. During the 17th century a clear distinction was recognised between primary and secondary abdominal gestations : one of the earliest cases of the former variety being mentioned by the Abbe de la Eoque* in 1663 ; others are noted by De Monconys^ and Courtial.^ During the 18th century, cases are noted by Martin Qejils)^ Duverney,** Turnbull,^ and others. ^ "Anthropographia et Osteologia," Parisiis, 1626. * Jo. Riolanus, op. cit, p. 283. ' J. J. Mangetus "Theatrum Anatomicum," Geneva, 1717, tome ii., p. 140. * " Ephemeri des med. Gallica," Paris, 1663. '^ " Itiner. Italic," tome ii. " " Nouvelles observations," &c., Leide. 7 " Hist, de I'Acad. des Sciences," Paris, 1716. * " GEuvres Anatomique," Paris, 1761. * The New London Med, Joum. " vol. i., 1792. 2 ! i ' II 18 CLASSIFICA TION. Secondary abdominal pregnancies are described by many during these three centuries, one of the earliest accounts being that of Berengarius Carpus.^ It is interesting to note, however, that the most common cause supposed to give rise to this con- dition was rupture of the gravid uterus, the ovum escaping into the peritoneal cavity. The most complete account of abdominal pregnancies before the present century was that of W. Josephi,'* whose Dissertation in Latin was published in 1784. The occasional occurrence of uterine along with extra-uterine pregnancy was long ago noted. The case of Albucasis ^ already noted would appear to have been an example of this, though the description is not clear. Primerose,* Thomas Bartholin,* Buchner,^ von Haller,^ and several others described cases during the 17th and 18th centuries. In 1779, Noel, a French physician of Lorraine, described a ^ case ^ which he had attended in 1765 as one of Vaginal Preg- nancy. Though this case, along with one or two others described during the present century, has been noticed by several writers, they have never been regarded as of any value, save as showing how far astray men can be led by imperfect observation. In the same category must be placed the case observed by Ebersbach^ in 1714, and named Bladder Pregnancy. He made a post-mortem examination of a woman who died after severe labour pains, and describes the bladder as being pregnant, the placenta being attached to its inner wall. 1 " Isagogae breves in anatomiam humani corporis," Venet., 1536. * •' De conoeptione abdominali," Gottingse, 1784. '^ « Vide, p. 1. •» Op. cit. e " EpistolsB mad.," 1740, p. 134. « " Miscellan. physico-med.," Erf., 1730, iv., art. 2. ' " Disput. ad morb. historiam," Lausannse, 1757-60, tome iv., p. 793. * Journ. de mM. de Paris, 1779, tome i., p. 51. ' " Ephemer. Nat. Cur.," cent. v. obe., xx. f EARL Y DESCRIBED CASES. 19 The first clear description of Interstitial Tubal Pregnancy in which the pregnancy developed in the uterine portion of the tube, was given by Dionis of France,^ in 1718, though it appears that Mauriceau had previously recognised the condition. In the beginning of the present century similar cases were noted by Schmitt,2 in 1801, by Albers of Bremen,^ in 1811, and by others. During the same period another variety was first described, Utero Interstitial, in which the ovum was supposed in some way to pass from the tube into the very substance of the uterus, and there develop. There is some doubt as to who is responsible for this description. Albers had in his possession a specimen so named which he had bought, and which he described in an unpublished paper, but which first was noticed by Carus* in 1822. Meyer ^ mentions having seen in Lobstein's Museum in Strassburg a specimen of 2^ months' pregnancy in the poste ior uterine wall. Similar cases were described by Dance, Hedrich, and others, all of which were considered by Breschet " in his memoir of 1824. The first clearly described case of the extra - peritoneal development of the ovum between the layers of the broad ligament was that of Madame Lefort, published by Bergeret,'^ near the end of last century. Loschge^ of Erlangen, in 1818, and Lobstein^ of Strassburg, in 1824, described other cases, It was Dezeimeris,^" however, who first gave the name Suh- ^ " Trait^ gdnerale des Accouchements," Paris, 1718. ^ " Beobachtungen d. k. k. med. chir. Josephs akad. zu Wien," 1801, bd, iv., p. 1. * Dezeimeris, Journ. d. conn. mid. -chir., Paris, 1836, p. 243. ■* " Zur Lehre von d. Schwangerschaft u, Geburt," &c., Leipzig, 1822, 1st Abt. " " Besohreibung einer Gravid. Interstit. Uteri.," Bonn, 1825, p. 5. * Jtheinisch- Westphal. Jahrb. d. Med. u. Chir., Hamm., 1824, bd. viii., p. 54. ^ Baudeiocque, "L'art des Accouchements," Paris, 6th ed., tome ii., p. 460. 8 Arch.f. die Erfahrtmg, &c., von Horn, Nasse u. Henke, 1818. " Compt. rend, a la FaculU de MM. de Strasabicrg, &c., 1824, p. 48. ^^ "Grossesses extra-ut^rines," Journ. d. conn. irUd.-chir., Paris, Dec, 1836, p. 257. 20 CLASSIFICA TION. \\ peritoneo-pelvic to this variety, pointing out its importance, and showing that certain cases previously published, but never understood, had probably bee" of this nature. » The term Tubo-ovarian was first employed by Dezeimeris,^ who was led to use it from having studied several published descriptions of post-mortem examinations of ectopic pregnancies, e.ff., Giff'ard's ^ and Jackson's." As I have already pointed out, the case observed by Mercerus in 1614 was probably a tubo- ovarian. Similarly, he introduced the term Tuho-abdominal from the study of imperfect descriptions by several older observers, e.g., Bianchi,"* Buchner,** Rust,*" and others. * Utero-tiibal was the name given by him to those cases in which the ovum was supposed to develop partly in the tube and partly in the uterine cavity. The first case recorded is that of Guillemot,^ in 1832. '^ Utero-tuho-ahdominal was the term he used for certain cases which had been described by Patuna,* William Hunter and Hey," and Hofmeister.i" In these the foetus was described as being found in the abdomen, the placenta in the uterus, while the cord passed through the tube. Before Dezeimeris' time the two chief systematic classifica- tions of ectopic gestations were those of Bianchi^^ (1741) and W. Josephii2(1803). 1 Op. cit., p. 258. 2 "Cases in Midwifry," &o., London, 1734. * Dublin Journ, Med. Sc, 18.S3, tome ii. * " De natural! in humano corpore, vitiosa morbosaque Generations historia," Geneva, 1741, p. 177. " "Annonceslitt^rairea," Gott. 1786. « Med.-chir. Ztg., 1824, bd. iii., p. 440. ' "Memoire sur la grossesse extra-uterine," Arch. gin. de mid., Paris, 1832, tome xxviii., p. 298. 8 "Epist. phys.-med.," &c., Vienna, 1765. 9 "Med. Obs. Soc. Phys. London," vol. iii. pp. 341-355. 10 "Mag. f. d. ges. Heilk.," Berlin, 1823, bd. xv., p. 126. " Op. cit., pp. 158-174. 12 "Ueber die Schwangerschaft ausserhalb d. Gebarmutter," &o., Rostock, 1803. OLD CLASSIFICATION. 21 Bianchi divided them (extra-uterine gestation was called by him gestatio vitiosa) into — External; Internal; Intermediate. By extcimal he meant abdominal or ventral. His definition of the other two is not clear — they embrace the tubal and ovarian varieties, the intermediate probably being those furthest from the uterus, and the internal those nearest it. Josephi's classification was as follows : — Tubal ; Ovarian ; Abdominal ; Primary ; Secondary or False ; Vaginal ; Bladder ; Extra-uterine combined with uterine. During this period the possibility of the existence of certai~\ of these forms was denied or considered doubtful by several writers. Thus, Duges^ was one of the first to dispute the occurrence of a. primary Vaginal Pvtgnanoy. Josephi - was one of the earliest to deny the possibility of a primary Bladder Pregnancy. Hinze ^ was the first to call into question the occurrence of primary Abdominal Pregnancy. Velpeau,* a few years before, first denied the existence of Ovarian Pregnancy. 1 "Diction, de med. et chir.," Paris, 1833, tome ix., p. 317. - Op. cit., p. 117. ^ "Versuch eines systemat. Grundrisses d. theoret. u. pract. Geburtshiilfe," Stendal, 1791, tome i., p. 38. •• •' Traits complet de I'art dea accouchements," Paris, 1835, tome i., p. 214. \/ 22 CLASSIFICA TION. \ 1 'I I - 2. The Period between Dezdmeris and Lawson Tait. — Dezeimeris' ^ (1837) well - known classification was as follows :- \ / Ovarian; ' " Sub-peritoneo-pelvic ; Tubo-ovarian ; ■ •': Tubo-abdominal ; Interstitial tubo-uterine ; ^ Interstitial uterine ; Utero-tubal ; Utero-tubo-abdominal ; Abdominal. During this period several attempts were made to simplify the minute description of Dezeimeris, but, though many individual cases of ectopic gestation were recorded, no thorough investigation was undertaken for the purpose of establishing a scientific basis of classification. Campbell 2 of Edinburgh, in 1840, van Cauwenberghe 3 of Gand, in 1867, and Hennig* of Leipzig, in 1876, in their important works were much more simple in their classification than Dezeimeris. Parry, in his well-known work,^ mentioned almost all the varieties in the Frenchman's list, but arranged them differently. During this period there was as well a good deal of criticism in regard to some of the varieties recognised by Dezeimeris. Thus, in regard to the Ovarian variety, several able writers in support of Velpeau declared not only that it had never been 1 Op. cU., p. 254. * "Memoir on Extra-Uterine Gestation," 'FIdin.. 1840, p. 17. ' "Des Grosaesaes extra-ut^rines," Bruxelles. 1867, p. 17. * " Die Krankheiten d. Eileiter und d. Tubenschwangerschaft," &c., Stuttgart, 1876, pp. 109-121. ' "Extra-Uterine Pregnancy," &c., Philadelphia, 1876. OPINIONS OF OLD WRITERS. 23 ;c.. Stuttgart, proven, but even that its occurrence was improbable or impos- sible. One of the strongest of these was Mayer,^ who gives among various reasons the following,, viz., that the formation of a decidua which is indispensable to the young ovum cannot take place in the ovary. This will be read with interest in relation to the views which I have advanced in regard to the etiology of Ectopic Gestation. ' Among the others may be mentioned the name of Allen Thomson,2 — who held that the ovum was not likely to be developed in the ovary, because after bursting of the Graafian follicle it would either pass into the tube or get into the peritoneal cavity, and also those of St. Hilaire, Pouchet,^ and of Thomas.4 Primary Abdominal Pregnancy was also doubted or denied by many writers during this period. Merriman^ was one of the earliest ; he believed that the movements of the intestines offered a mechanical obstacle to the attachment of the ovum. Campbell,^ Eokitausky,^ and Barnes,*^ also held that this form was not probable. The extra-peritoneal development of the ovum, due to ex- tension of a tubal pregnancy between the layers of the broad ligament, and named by Dezeimeris Sub-peritoneo-pelvic, was scarcely noticed by some of the ablest writers during this period. Campbell," in his work, does not consider this variety, ^ "Kritik d. Extra-Uterinal-Schwang. vom Standpunkte d. Phyaiologie u. Entwicklungsgeschichte," Giessen, 1845. - " Cycl. of Anat. and Phys.," vol. ii., p. 456. * " Thdorie positive de I'ovulation spontanee," Paris, 1847, p. 421. * Nmv York Med. Journ., 1875. ' " A Dissertation on Retroversion of the Womb," Philadelphia, 1817, p. 67. « Op. cit., p. 136. 7 " Handbuch d. pathol. Anat.," Wien, 1855. - "Diseases of Women," London, 1873. » Op. cit., p. 20. 24 CLASSIFICA TION. i !ii not having understood how it was possible for an ovum to get between the folds of the broad ligament. Hennig/ while recognising its importance, gives but slight attention to it. Parry 2 does not give it in his classification. Though Dezeimeris described this variety, he was not clear as to how it originated. He believed that it was quite distinct from tubal or any other described variety, but how the ovum got between the layers of the broad ligament he did not attempt to state. The follow- ing paragraph from his article ^ is of interest : — " Ces faits me paraissent suffisants pour l^gitimer I'admission d'une grossesse sous-periton^o-pelvienne ; d'une grossesse qui n'est ni ovarique, ni tubaire, et qui, si Ton pent s'exprimer ainsi, est moins abdominale qu'aucune autre, puisque, plac^e, au premier temps de son existence, en dehors du pdritoine, les progres de son developpemeut ne paraissent point devoir I'y faire p^ndtr* r, mais au contraire le ligament large, en 86 developpant k mesure que le produit de la conception grossit dans la cavitd pelvienne, doit former une sorte de plancher qui I'y retient et qui lui ferme I'entr^e dans la cavit^ abdominale." , I have already referred to the observation of Madame Lefort,* who showed that this form resulted from the extension of a tiihal gestation into the broad ligaments (or ovaria7i as well). She described, for the first time, a case in tohich the peritoneum became gradually stripped from the uterus as the gestation sac extended uptvards and toivards the opposite side. Lobstein's case^ also seems clear as being the extension of a tubal pregnancy into the broad ligament. Jacquemier,*' Decori and Pelvet," and others, made similar observations. 1 Op. cit., p. 115. 2 Op. eit., p. 49. « Op. cit., p. 257. •» Vide, p. 5. » Op. cit., p. 48. " " Manuel des Accouchements," Paris, 1846, tome i., p. 374 7 Gaz. mid. de Paris, 1864, p. 748. PRESENT VIEWS. 25 Eosshirt^ was the first to describe the development of this variety from the extension upwards of an interstitial pregnaincy; in this case he noticed the placenta partly attached to the colon, evidently displaced upwards, and partly to the wall of the uterine gestation sac. : - • According to Hennig,^ Bianchi was the first to describe the bursting of a tubal gestation into the broad ligament through thinning and rupture of the lower part of the tube wall. 3. The Present Period. — During the last twenty years the previously held views have been subjected to the most searching criticism, while, at the same time, most valuable information has been acquired from various carefully conducted researches in cases of ectopic gestation, and, as a result, we have departed from the other methods of classification. The writer to whom belongs the honour of having first thoroughly dissected traditional beliefs, pointing out their untrustworthiness or inaccuracy, was Lawson Tait. His able consideration of the subject^ from the year 1873, when he first brought it forward, until the year 1889, when he published in his well-known text-book* a complete account of his work, has been of the greatest value, and has been the means of stimulating other workers who have helped to add to our knowledge of the subject. Mr. Tait criticised severely the classification of ectopic gestation as given by Dezeimeris and others, and pointed out how utterly unreliable was much of the evidence on which the older writers had based their views. He demonstrated the overwhelming importance of tubal gestation, and the conditions 1 Gaz. mid. ie Paris, 1844, p. 298. - Op. cit, p. 115. ^ Trans. Obst. Soc. London, vol. xv., p. 156. •• " Diseases of Women and Abdominal Surgery," 1889, vol. i. 26 CLASSIFICA TION. I I \ li 'i ! U which might develop from it, especially the extra-peritoneal development of the ovum after rupture of the tube into the broad ligaments. . ' ' He very strongly insisted that the long described Primary abdominal variety had never been established, his own belief being that it is an impossible form. He also held that Ovarian gestation was not proved, though it was possible to have it. / In a recent paper ^ his conclusion in regard to this form is that it is not very likely to occur. ''' His well-known classification is as follows : — - '; I. Ovarian, possible but not yet proved. ' '^ 11. Tubal, in free part of tube, is — a. Contained in tube up to fourteenth week, at or before which time primary rupture occurs, and then progress of the gestation is directed into — &. Abdominal or intra-peritoneal gestation, uniformly fatal (unless removed by abdominal secti n), primary by I haemorrhage, secondarily by suppuration of the sac and peritonitis. c. Broad ligament or extra-peritoneal gestation. d. May develop in broad ligament to full time and be re- moved at viable period as living child. e. May die, and suppurating ovum may be discharged at or near umbilicus or through bladder, vagina, or intestinal tract. /. May remain quiescent as lithopsedion. g. May become abdominal or intra-peritoneal gestation by secondary rupture. «. III. Tubo-uterine or interstitial in part of tube embraced by 1 "Note on the alleged occurrence of Ovarian Pregnancy," Med.-Chir, Trans., London, vol. Ixxv. / ! 1 PRESENT VIEWS. 27 uterine tissue, and so far as it is known, is uniformly fatal by primary intra-peritoneal rupture before fifth month. These views were based chiefly on Mr. Tait's extensive clinical and operative experience. They have to a large extent been corroborated by post-viortem investigation by other workers. Thus, Berry Hart^ clearly described the extra-peritoneal de- velopment of the ovum in two cases, one of which represented an advanced degree of pregnancy in which the peritoneum had been pushed upwards out of the lower part of the abdomen to a marked extent, and named by him sub-peritoneo-abdominal, i.e., a far advanced sub-peritoneo-pelvic.^ I have also been able clearly to estabUsh a form in which the gestation is partly extra- and partly m^ra-peritoneal, to which I have given the name tubo-peritoneal — described by Mr. Tait 1889 as unproven. Bland Sutton's writings ^ also have gone to support several of Mr. Tait's views, especially disbelief in an ovarian or a primary abdominal pregnancy. and be re- Atithor's Claasijication. We may gain information regarding the varieties of ectopic gestation by the study of cases during life, i.e., before and at the time of operation, and by ordinary post-mortem examination. The accumulated information acquired by these methods during the last two centuries is, as far as classification is concerned, to a large extent utterly untrustworthy, because the older observers were not aware of the fallacies associated with their employment. The difficulties in the way of accurately esti- mating the anatomy and pathology of several of the varieties ^ Rep. Lab. Roy. CM. Phys., Edin., vol. i. 2 "Tubo-Peritoneal Ectopic Gestation," Edin., 1892. ^ "Surgical Diseases of the Ovaries and Fallopian Tubes," London, 1891. 28 CLASSIFICA TION. of ectopic gestation have only recently been shown by Berry Hart 1 and myself.^ We have demonstrated the great value of the sectional method of examination in determining topo- graphical relationships which are essential to the clear re- cognition of specimens, especially those in which gestation is advanced. In advanced ectopic pregnancy the displace- ments of organs, along with peritoneal adhesions, render it practically impossible in many cases to determine the nature of the gestation sac, either by examination at the time of an operation or by ordinary dissectional study. It is necessary first of all to study the body with the parts undisturbed by means of frozen sections; in this way we get a correct idea of the arrangement of the peritoneum. Auxiliary to this method are dissection and microscopic examination of parts. . It was by following this plan that we demonstrated the true nature of cases which had always been described as primary intra -peritoneal, viz.. Hart's siih-'peritoneo-ahdominal and my tubo-peritoneal ; in both of these cases the peritoneal relations had become so altered by inflammation that it was believed, until careful examination had been carried out, that they were primary abdominal. The nature of our investiga- tions has made evident the unreliability of all published accounts of primary abdominal pregnancy. Two special cases have often been quoted as instances of abdominal pregnancy, viz., those of Lecluyse^ and Koeberle.* When examined carefully, however, it is found that this assumption is entirely unwarranted. Lecluyse's case was one in which a woman became pregnant for the second time, her first pregnancy having ended in the 1 Reji. Lai). Roy. Coll. Phy»., Edin., vol. i. ■i " Tubo-Peritoneal Ectopic Gestation," Edin., 1892. * Bull. Acad. roy. dc mid. de Belg., Bruxelles, 1869. •• Keller, "Dea Grossesaea extra-ut^rines," &c., Paris, 1872, p. 23. ■ i! PRESENT VIEWS. ' •. ' 90 performance of Csesarean section. The second pregnancy was ectopic, and after the death of the foetus at the eighth month abdominal section was performed for its removal. The woman died, and on post-viortem examination the uterine scar of the old Caesarean operation was partly unclosed, and it was supposed that the ovum had escaped into the peritoneal cavity and there developed. Nothing is said about the nature of the gestation sac or the appendages, and it is most likely that the gestation was tubal or tubo-ligamentous, the opening in the uterus having nothing to do with it. Moreover, all the evidence that we possess in reference to the fate of an early ovum placed in the peritoneal cavity points to the conclusion that death and absorption always follow. Koeberle's case was that in which a full time pregnancy occurred in a woman in whom part of the uterus had been removed along with a fibroid tumour by abdominal hysterec- tomy, the appendages having been left. We are not sure as to how much of the uterus was taken away. KoeberM says that only part of the cervix was removed. As we know that the uterus is elongated with big fibroids, more of it may have been left than was believed. Enough may have been left to be in communication with a tube, or the tube may have become adherent to the uterine stump after operation, their cavities communicating, so that the gestation may have started in the uterus. It is also possible that the ovum may have been fertilised in the tube, the gestation being thus tubal. It is an unwarranted assumption to suppose that it had passed into the peritoneal cavity. As I have stated in the chapter on Etiology, it is extremely probable that no gestation can begin its development except in some part of the genital tract derived from the Miillerian ducts which forms the uterus and tubes. so CLASSIFICA TION. Regarding Ovarian 'pregnancy there has been m\ich discussion during this century, and at the present time it must be admitted that there is no proof that a gestation can start in a Graafian follicle. In the chapter on Etiology T give the ground for this statement. Bland Sutton's and Lawson Tait's views on this point have already been alluded to. In the present state of our knowledge a classification of Ectopic Gestation must necessarily be incomplete. As more exact methods of examination are employed, and doubtful ones abolished, it will be more and more perfected and extended. The following table indicates the range within which we should limit our attention. Beyond this is uncertainty and speculation. It is evident, then, that the study of ectopijc gestation is but the study of pregnancies of tubal origin : — ^ Ectopic Gestation. ! . SI Primary Tubal in all cases as far as is known. ' I. Ampullar, in which the gestation begins in the ampulla of the tube. This is by far the most common origin. 1. Persistent. In rare instances the tubal gestation may go on to full time. 2. Rupture may take place early into the broad ligament — subperitoneo- pelvic, tubo- ligamentous, extra-peri- toneal, broad ligament gestation. (a). The gestation may continue to develop. Sub- .•! . peritoneo-abdominal. (b). A secondary rupture of the sub-peritoneo-pelvic gestation may take place into the peritoneal cavity. AUTHORS ARRANGEMENT. ,'b views on 31 (c). The gestation comes to an end : — (a). By the formation of a ha?matoma. (P). By suppuration, (y). By mummification, adipocere or litho- psedion formation. 3. Eupture may take place into the peritoneal cavity. (a). Tubo-peritoneal gestation in which escape of the foetus in the membranes occurs into the peritoneal cavity, the placenta remaining in the tube, its development contin-iing. (b). The gestation terminates in various ways : — By the formation of a hsematocele, the patient dying from the shock and loss of blood, or from peritonitis. In some cases, absorption of the mass may occur. In others, mummification, adipocere or litho- ptedion formation, may take place in the foetus. Or suppuration may result. 4. The gestation may be destroyed : — (a). By the formation of a tubal abortion, and its passage through the fimbriated end of the tube into the peritoneal cavity. (b). By the formation of a hgemato-salpinx. (c). By the formation of a mole. (d). By suppuration resulting in a pyo-salpinx. (e). By absorption after early death, by mummifi- cation, adipocere or lithopsedion formation. II. Intekstitial. The gestation may develop in the inter- stitial portion of the tube : — 1. The gestation may go on to full time. II / 82 CLASSIFICATION. . 2. Rupture of the gestation into the peritoneal cavity may occur. 3. Eupture into the uterine cavity may occur. ' ' 4. Rupture both into the uterine and peritoneal cavities may occur. 5. Rupture may occur between the layers of the broad / ligament. 6. After the death of the foetus it may remain in its sac, and (possibly may undergo the same changes as in the other forms), e.g., mummification, adipocere or lithopsedion formation. III. Infundibular. The gestation begins in the outer end of the tube, or in an accessory tube ending. Under this heading are to be included the forms described as Tubo-Ovarian and Tubo- Abdominal, names which appear to me to be unnecessary since the gestation is a tubal one in origin, the end of the gestation sac merely becoming adherent to the abdominal wall, the ovary, or other of the viscera. (CoRNUAL Pregnancy will be considered, though it is not, strictly speaking, ectopic in nature.) 1 1 */ CHAPTER III. VARIETIES STUDIED IN DETAIL. Ampullar. 1. Petjsistent, ', Though the development of the tubal gestation to full time, without rupture taking place either into the broad ligaments or peritoneal cavity, is extremely rare, there can be no doubt that it does sometimes occur. Recorded cases are few. Some of these, e.g., Lamm's,^ Sobelschtsihoffs, and one in Guy's Hospital Museum (No. 2517 ^'') are doubtful. One case recorded both by Spiegelberg ^ and Galezowski ^ seems beyond dispute. This case was that of a post-mistress, aged thirty-two, four- para, who was first seen in Spiegelberg's clinic, 14th April 1869, complaining of abdominal pains. She had menstruated last in August 1868. She had not suffered previously save from weak- ness, sickness, and occasional frequency of micturition during the preceding four months. The pains complained of were labour-like. Shortly after she had a seizure of an eclamptic nature. On examination the uterus was found enlarged (12 cm.), pushed down in the pelvis, the cervix being in the left fornix. After a series of fits she died on 17th April. On examination after death by Waldeyer, there was found a large ^ Monatschr. f. Oeburtakunde, Berlin, 1855, bd. v., p. 145. 2 Arch. f. GynaeL, Berlin, 1870, p. 406. ^ " Eine ausgetragene Tubenschwang.," Breslau, 1869. !• 34 VARIETIES STUDIED IN DETAIL. t/hin walled sac containing a dead full time foetus. It was adherent in parts to surrounding structures ; the enlarged uterus was close to it and under it, on the left side. The upper part had a small tear from which hremorrhage had taken place into the peritoneal cavity. A considerable amount of blood was also in the sac, the placenta being found partially sepavated. On close examination the sac was found to be the right tube enormously distended ; the right broad ligament was unaffected. Another very probable case is described by Saxtorph,i also one by Martin.^ Werth 3 has collected thirteen other cases, in which the preg- nancy had lasted for six months or more. Four of these were full time cases, and have been described by Litzman,* Hennig- sen,^ Litzmann and Werth," and Cooke.^ As regards the relationships of the gestation sac in tubal gestation, the following facts are to be noted : — The swelling is more or less pedunculated, and is consequently movable unless prevented by adhesions or incarceration in the pelvis. Mobility is especially noticeable in the early months. The position of the sac varies. It may be found in its own side of the pelvis in the normal position of the tube ; it may fall in front or behind the broad ligament ; it may be turned inwards and lie in the pouch of Douglas ; or forwards and lie in the utero-vesical pouch. As the sac increases in size, it tends to grow mainly upwards out of the p ivis, though it grows also to a varying extent in the pelvis aes to a considerable extent. It may sometimes iiova regice Soc. med. Ilavniensis, 1818, vol. i. jH. klin. Wchnschr., 1881, Nrs. 51, 52. ^ " Beitr. z. Anat. und z. operativen Behandlung d. Extra-uterinschwang.," Stuttgart, 1887, p. 34. ■* Arch. f. Gynaeh., Berlin, bd. xvi., p. 96, and bd. xix., p. 343. ' ^ Arch.f. Oynaek., Berlin, bd. i., p. 335. * Arch.f, Gynaeh., Berlin, 'od. xviii., pp. 1 and 14. ^ Trans. Obstet. Soc. LorAon, vol. v. AMPULLAR TUBAL PREGNANCY. » develop into the pouch of Douglas, giving rise to a condition very like retroversion of the gravid uterus. In the abdomen the sac is usually on the side from which it arose, but some- times it may be on the other side fixed by adhesions. The long axis usually lies more or less obliquely, sometimes vertically. The uterus takes up various positions. In some cases it lies retroverted ; sometimes it lies very deeply in the pelvis ; some- times it is pushed towards the side opposite to that in which the pregnancy began ; rarely is the fundus directed towards the gestation side; sometimes it may be considerably rotated. When the gestation develops in the pouch of Douglas, the uterus is pushed to the front, and may be considerably elevated. It is important to note that in the absence of adhesions, the uterus is usually in this form more or less distinct from the gestation sac. When adhesions occur, it may be closely united to the sac, and so its position may be greatly changed ; thus, it may be markedly elevated or drawn towards the gestation side. The ovary in the affected side is usually easily recognisable. It is not markedly displaced as a rule, and corresponds in its alterations pretty much to the uterus. It may often be found distinct from the gestation sac, though it may be close to or in contact with it. Sometimes, as a result of adhesions, it may become intimately connected with the sac. It is possible that full time tubal pregnancy occurs somewhat more frequently than is believed. When marked adhesions take place between the gestation sac and surrounding structures, especially in the pelvis, it is practically impossible to say by ordinary examination whether the case was purely tubal or tubo-ligamentous. Frozen sections will doubtless help to clear up the nature of difficult specimens. i<; 36 VARIETIES STUDIED IN DETAIL. 2. Cases which rupture into the Broad Ligament. Sub-peritoneo-pelvic. Tubo-ligamentous. Extra-peritoneal. Broad ligament gestation. (rt.) Persistent. Sub-peritoneo-abdominal. / Amnion Rectum Chorion Levator ani Obturator intemus. Levator ani. Paraproctal tissue. Fio. 1. — Sagittal lateral section (right) of pelvis, with sub-peritoneo- pelvic gestation in right broad ligament. (Hart.) A large number of ampullar pregnancies rupture into the broad ligament and continue to develop. Several names have been applied to this variety — viz., "Extra-peritoneal," "Tubo- ligamentous," " Sub-peritoneo-pelvic," and " Sub-peritoneo- EXTRA-PERITONEAL PREGNANCY. 37 abdominal." The term " Extra- peritoneal " really includes the purely tubal as well as this form, since in both the gestation goes on outside the peritoneum. " Tubo-ligamentous," " Broad ligament gestation," and " Sub- peritoneo-pelvic " should be limited to early cases where the gestation sac is within the pelvis. " Sub-peritoneo -abdominal " to the later stages of development when it has extended higher up than the pelvis. The rupture, which occurs usually from the eighth to the fourteenth week or earlier, may take place suddenly or very gradually. It probably results from a gradual' thinning and stretching of the lower part of the tube wall on account of the^ absence of a peritoneal covering. A large hole may be formed quickly, but probably most commonly only a small one, through which the ovum gradually works its way. In some cases the process causes no disturbance of any kind to indicate that it is taking place. The ovum, as it grows, occupies more and more of the liga- ment, which thus early helps to form, along with the tube, the walls of the gestation sac. The laminae of the ligament become condensed in parts, owing to the compression of their loose con- nective tissue. They may also become thickened, as a result of the irritation of the growing ovum, and may form adhesions with surrounding structures. The ovum may gradually extend down to the pelvic tioor and out to the side wall resting on the bladder, obturator internus, and other structures. Occasionally, however, it may not extend down through the whole ligauient, part of which may then remain unaltered below the sac. The gestation tends to increase in all directions, and, as a result, dis- placements of the uterus, bladder, and rectum may take place, along with stripping ^f the peritoneum from them and the pelvic wall. Displacement is chiefly noticed in the uterus. It II I 38 VARIETIES STUDIED IN DETAIL. tends to be pushed more or less over to the side opposite to that in which the pregnancy has taken place. It may also be ele- vated and pushed against the anterior wall of the pelvis and lower abdominal regions, or it may be pushed behind and below the gestation sac remaining low down in the pelvis. The posi- tion of the uterus depends mainly on whether the gestation develops in the first place mainly under the peritoneum be- Peritoueuni Uterus Pouch of Douglas Vagina- Rectum4" Peritoneum. . — Placenta. Venous sinuses. Syra: pubis. BUdder. Fig. 2. — Sagittal mesial section of pelvis, with sub-peritoneo- pelvic gestation. The placenta is seen to be extra-peritoneal, and to be partly above the pelvic brim. The tetus, in this case, had ruptured into the peritoneal cavity. (Hart.) hind or in front of the uterus. These different relationships between gestation sao and uterus may be well seen in Figs. 2 and 3. In the majority of cases the gestation develops posterior to the uterus. As the gestation extends upwards into the abdomen, it re- mains always extra-peritoneal, the peritoneum being gradually % EXTRA-PERITOimAL PREGNANCY. 39 us sinuses. stripped from the abdominal parietes and viscera. Berry Hart conclusively showed this by means of the frozen sections he made in the case o1 a woman who died while still pregnant. Figs. 3, 4, 5, 6, which give the appearances seen in various sagittal sections, show at a glance the altered relationships of parts. The diaphragm, in this case, in which the gestation began in the right side, was higher than in normal pregnancy, owing to the greater relative vertical growtTi. The stomach was dis- placed, and also the intestines, which were pushed over to the left. The ureters had evidently been pressed on, the kidneys and ureters being increased in size, the left one being irregularly dilated. The uterus lay mainly above the brim, against the anterior abdominal wall, and mostly to the left of the middle line. The most marked alterations had taken place in the arrangement of the peritoneum. It was raised upwards out of the pelvis, entirely from the bladder, from the posterior surface and from the upper part of the anterior surface of the uterus. On the right side it was stripped from the anterior abdominal wall for a distance of seven and three- eighth inches above the brim. Behind, its lowest dip lay at the le\el of the junction of the fourth and fifth sacral vertebrjB. The gestation sac was thus composed of a variety of structures, viz., pelvic iloor, bladder, uterus, expanded tube, abdominal wall, connective tissue, surface of the elevated peritoneum, &c. The peritoneal cavity was obliterated in different parts by inflam- mation, and several adhesions between the bowels and peritoneal surface of the sac had occurred. Of great importance in regard to the development of the sub- peritoneo-abdominal gestation, as Berry Hart has pointed out, is the position of the placenta. When the placenta lies below 40 VARIETIES STUDIED IN DETAIL. I I I j the foetus in the tube and rupture takes place into the ligament, without death of the foetus occurring, it {i.e., the placenta) in its further growth descends and spreads in the extra-peritoneal tissues, becoming attached, it may be, to bladder, uterus, fascial, ' J, Liver f/ Diaphragm Pyloric end - Pancreas Small intestine Blood Decomposition gases Peritoneum closed here Para-uterine tissue-''' Foetus Utero-vesical pouch Cervical canal Bladder Aorta. 12th dorsal vertebra. Ist lumbar vertebra. 'Duodenum. Site of rupture of gestation sac. Placenta. 5th lumbar vertebra. Ist sacral vertebra. Pouch of Douglas. -Rectum. ■:, 6|j ^ Cervix uteri. ,w Vaginal portion of cer- Rectuni. l • ix. Vagina. Fig. 3. — Sagittal mesial section of abdomen and pelvis, with ^ advanced sub-peritoneo-abdominal gestation. (Hart.) and other structures in pelvic floor, and on the side wall. At full time one edge may extend to several inches above the brim, where it is somewhat laterally situated. SUB-PERITONEO-ABDOMINAL PREGNANCY. 41 As the gestation sac enlarges in such a case, the placenta does not tend to become displaced. When the placenta lies uppermost in the tube, a different state of matters results. The upward growth of the gestation Diaphragm Liver — "' Colon - Blood clot- Decomposition gases - Site of rupture Adhesions Peritoneal dip Placenta Extra-peritoneal veins -' Gallbladder. Ascending colon — Adhesions. — Kidney. -Small intestine. -Adhesions. -Ovarian vein. — Psoas. - External iliac artery. - Vein. -Internal iliac artery. Vein. '--Rectum. Bladder Fig. 4. — Sagittal lateral section of abdomen and pelvis, with advanced sub-peritoneo-abdominal gestation. (Hart.) sac causes the gradual elevation of the placenta, which is attached to its upper wall. In Hart's full time case (Figs. 3, 4, o) the placenta was displaced upwards for ten inches, being 42 VARIETIES STUDIED IN DETAIL. attached to the anterior abdominal wall outside the stripped off peritoneum, and also to the latter. This displacement is accom- panied by gradual destruction of placental tissue owing to blood extravasation, so that the nutrition of the foetus is Left lung Diaphragm Spleen Tail of pancreas Kidney Dilated pelvis and ureter Heart. Liver. Colon. Ilium Sacrum Bowel Vessels Placenta. Lowest dip of peritoneum. Fig. 5. — Another sagittal lateral section of the same sub-peritoneo- abdominal case. (Hart.) impaired. Such cases, therefore, are not so favourable to the full time development of the gestation as those in which the placenta is lowermost from the beginning. As regards the extension of the gestation into the broad SUB-PERITONEO-ABDOMINAL PREGNANCY. 43 ligament, Werth^ says that it most cominonly spreads downwards in the outer part of the ligament, gradually advancing inwards towards the uterus. In two cases of about 4 to 4J months' duration, the uterus was still separated from the gestation sac Fig. 6. — Another sagittal lateral section from the same case. (Hart.) by a small piece of broad ligament, though in the outer part of the ligament the sac had reached the floor. The part of the tube internal to the pregnant portion comes to lie on the 1 Op. cit., p. 27. 44 VARIETIES STUDIED IN DETAIL. gestation sac and to form part of it. It may be gradually opened up, remain as a ridge, or be flattened out so as to be unrecognisable. It may sometimes become stretched and hyper- trophied with the development of the gestation. Its lumen may remain pervious or become obliterated. After the early months the fimbriated end can rarely be recognised; it gets flattened out and incorporated with the gestation sac, or hidden by inflammatory deposit. The thinnest part of the gestation sac appears to be, in the early months at least, the posterior upper portion ; the wall seems to stretch and bulge most in this part. According to Werth.^ as the ligament is split up by the ovum, more of the subserous tissue goes with the anterior lamella. The relations of the uterus are similar to those found in the case of other intra-ligamentous tumours. As the ligament gets more and more distended the uterus is pushed towards the opposite side. By the middle of pregnancy it is usually part of the wall of the sac. It usually also is found well to the front and elevated ; the fundus may reach as high as the umbilicus, and it may become plastered over with adhesions. The large size to which the uterus may attain in this form of pregnancy is due partly to sympathetic increase, but also to its being stretched through its attachment to the gestation sac ; the latter explains especially the increased length often found. The ovary is found in various conditions. Sometimes it is found attached to the sac by the hilum, as in the normal state. Usually it becomes incorporated with the sac wall, and may be considerably increased in size and sometimes greatly flattened out. This increase may be due in some cases to inflam- mation, but in others to its better nourishment, from the increased vascular supply of the parts, or to being irritated by the stretching of the growing sac. The flattening and blending 1 Op. ct«., p. 28. RUPTURE INTO PERITONEAL CAVITY. 45 of the ovary with the sac wall may be so marked that all trace of i*j as a distinct body is lost. In such a condition it is easy to see how the pregnancy might wrongly be described as "ovarian." Occasionally it may be found lying on the top or anterior wall of the sac, owing to the marked bulging of the posterior wall of the broad ligament below the ovary. The intimate relation of the ovary to the sac in broad ligament gestation has no doubt led to the description of several cases as having been in the beginning ovarian pregnancies. The disposition of the ovary is very similar to what is found in various broad ligament cysts. (&.) Rupture of the sub-peritoneo-pelvic form into the peritoneal cavity. After the rupture of a tubal gestation into the broad liga- ment there may be an almost immediate rupture of th sac into the peritoneal cavity. Owing to the extensive laceration of vessels, this occurrence is almost sure to end fatally unless the patient be operated upon. If rupture does not take place thus early, it may take place at any period during the continued development of the gesta- tion, even shortly before or at full time. This is probably most apt to occur in cases where the placenta is uppermost, because of the following reasons: — First, the haemorrhage that tends to occur as a result of the upward displacement of tht- placenta is apt to burst the sac wall. Secondly, the wall to which the placenta is attached is sometimes greatly thinned, and being very vascular may easily rupture from some sudden change in intra-abdominal pressure or from a placental hsemorrhage of only a small size. It is possible, also, that in these cases the non-placental part of the wall may tend to give way more than 46 VARIETIES STUDIED IN DETAIL. where the placenta is lowermost in the pelvis. In the latter form the greater part of the sac is uniformly stretched as growth proceeds. In the former variety the resistance of the wall varies to a greater extent; and possibly that part not situated in the pelvis and supported by the surrounding walls and floor, nor attached to the placenta which may help to steady and support it, may tend to burst more easily. On carefully examining a series of cases, I find no special frequency of rupture through the placental part of the wall. According to Werthi the place of rupture is most frequently the postero-superior portion of the sac wall. As to the extent and results of rupture I shall speak later on when discussing rupture of pure tubal gestations into the peritoneal cavity. As regards both the ovum and the peri- toneum, both tubal and sub-peritoneo-pelvic varieties may be considered together. II;; . ! II (c.) Disappearance in various ways. (a) By the formation of a hcematoma. — The rupture of the tube into the broad ligament may be accompanied with such destruc- tion of placental tissue and pouring out of blood between the layers of the ligament that the gestation ceases to develop farther. This is most apt to occur when the placenta is situated on the lower aspect of the tube. When situated uppermost it may escape tearing altogether, though even in such a case con- siderable blood may accompany the rupture; when placed laterally, the edge only may be torn through. The placenta in some cases, therefore, may only be partially destroyed, but in others it may be completely torn up by the blood. In these cases the amniotic cavity may be ruptured, or it may be greatly compressed along with the fretus, by the pressure of -the blood 1 Op. cit., p. 28. HEMATOMA FORMATION. 47 outside it. If much of the phicenta be destroyed, whether there be much blood effusion or not, the foetus must nearly always die. If only a smaJ' part be destroyed, it will very probably die if the blood mass be of any size. If the placenta be only slightly affected, death may also be caused by some injury to the cord or foetus. We thus see how the ovum may get embedded in a mass of blood, known as a hsematoma or extra-peritoneal hiema- tocele. This varies greatly in size in different cases, e.g., from a small orange to the size of a new-born child's head, or even larger. Usually the mass is localised on one side, rarely rising above the brim. If a large amount of blood is poured out it tends to spread in various directions. Thus, sometimes it may burrow in the connective tissue around the pouch of Douglas, enveloping the rectum, giving rise to a swelling known as a peri-rectal or retro-uterine hsematoma (Fig. 15). Sometimes the blood burrows deeply into the broad ligament by the side of the vagina and bladder ; it may pass out in some cases to the side of the pelvis, and tend to follow the psoas-iliacus, or it may even spread through the round ligament. The displacements of the uterus vary according to the size and distribution of the htematoma. In a well-marked case it is always pushed to the opposite side, the upper surface of the blood mass being irregu- larly convex, the lower irregularly concave. The blood, at first fluid, very soon clots and becomes a solid though elastic mass, which gradually gets smaller, as it is absorbed along with the torn up parts of the foetus. Complete disappearance may take place, nothing being left after a few months save a slight thickening in the broad liga- ment. As to the age limit for the absorption of a foetus we know nothing. It is certain that three or three and a half months' gestations may entirely disappear after rupture. (/3) By suppuration. — In a few cases very shortly after i It 48 VARIETIES STUDIED IN DETAIL. rupture into the broad ligament, suppuration may occur in the blood mass, and an abscess be formed which runs the usual course of parametric collections of pus. This early sup- puration occurs, however, but rarely. More commonly this termination is found after the gestation has progressed to mid term or beyond. This is to be associated with the closer relation of the gestation sac to the bowel in the late months as a result of the stripping upwards of the peritoneum which takes place. After pus formation, the patient may die before the matter escapes, or, if not, the abscess may discharge itself in various ways, viz., through the bowel, bladder, vagina, abdominal wall, perineum, buttock, or groin. There is some difference of opinion as to the most frequent manner in which the abscess contents escape. Taking all kinds of ectopic gestation together, we have the following statistics : — 1. In 29 cases published by Lusk^ : — 16 discharged by the rectum. 6 „ „ abdominal wall. 4 ■ „ „ vagina. 3 not clearly described. 2. In 85 cases published by van Cauwenberghe^ : — 48 discharged by the intestinal canal. 24 „ „ abdominal wall. 10 „ „ bladder. 3 „ „ vagina. 3. In a series of cases published by Mattei^ : — 38 per cent, discharged by the abdominal wall. 30 „ „ „ intestinal canal. 8 „ „ „ bladder. 7 „ „ „ vagina. 1 Brvt. Med. Joum., London, 188fi, vol. ii., p. 1086. 2 Op. cit., p. 250. ^ Oaz. d. h6p., Paris, 1860, No. 110. INTESTINAL ESCAPE OF FCETUS. 49 4. In a series of cases published by I'arry^ : — 2G'20 per cent, discharged into the intestinal canal. 16"12 „ „ through the abdominal wall. 4-88 „ „ - „ vagina. 362 „ „ „ bladder. 5. In 137 cases published l)y Puech^ : — 69 c" charged through the intestinal canal. 28 „ „ abdominal wall. 23 „ „ vagina. 17 „ „ bladder. Intestinal Escape. — With the exception of Mattel, authorities agree that the escape of a suppurating ectopic gestation ^dkes place in most cases through the large intestine, chiefly through the rectum or sigmoid flexure. The gestation sac and bowel may communicate by one or several openings. The fcetus has been expelled entire through the bowel in a short time, but in most cases the process is a very long one, and may go on for months or years. In one instance the discharge is reported to have lasted for twenty years. A patient has been known to fall pregnant in the uterus while passing the remains of an old ectopic gestation. Dezeimeris and others have con- sidered the intestinal escape most favourable for the mother, but statistics show that it is the most unfavourable. Thus, in 48 cases collected by van Cauwenberghe, death occurred in 30. In 30 cases mentioned by Mattel, 19 deaths took place. Petit,'* Moreai7 * and Chailly-Honore,^ state that rarely the sac may open into the stomach and the contents be vomited. Darby •* has 1 Op. cit, p. 164. 2 Courty, " Traits pratique des maladies de I'uterus," Paris, 1866, p. 996. 3 " Traits des Maladies des Femmes," Paris, tome i., p. 90. ■» "Traite des Accouchements," Paris, 1841, tome ii., p. 366. 5 "Traits pratique de I'art des Accouchements," Paris, 1867, p. 13{j. « Trans. South Car. M. Ass., 1872, p. 97. 4 Ilil.l P! i 50 VARIETIES STUDIED IN DETAIL. described an interesting case in which the contents were discharged through the abdominal wall, and in which there was also a communication between the gestation sac and the stomach. Abdominal Wall Escape. — The opening is formed in the great majority of cases at or below the level of the umbilicus, and near the middL line. This method is very favourable for the mother. Out of 53 cases collected by van Cauwenberghe only 8 deaths took place, and in 21 described by Mattel only 1 death occurred. Vaginal Escape. — This occurs so rarely that little can be said regarding it. The maternal mortality is high. Out of 12 cases collected by Parry 5 were fatal, and out of 7 men- tioned by Mattel 2 deaths took place. Bladder Escape. — This is a very infrequent occurrence. The maternal mortality is likewise high. Out of 10 cases collected by van Cauwenberghe 3 died. Out of 9 cases collected by Parry 5 died. Puech mentions, however, 17 cases in which only 3 died. The ureter also may be opened into. The bladder may secondarily open into the vagina. Uterine Escape. — Gervis^ has recorded a case in which the pus burst into the uterus and escaped through the cervix. Perineal Escape, &c. — Escape through the perineum is ex- tremely rare. Yard ley ^ describes a case. As far as is known, the child is always dead before communi- cation is established between the gestation sac and the part into which it opens. This may take place before the full term of pregnancy or afterwards. If after, the opening is established in most cases within the first six months. In several it may not take place 1 Med.-Chir. Trans., London, vol. Ixx., p. 35. ■ Am. Journ. Med. So., Phila., 1846, p. 348. \ rl -.'. EXTRA-PERITONEAL PREGNANCY. 51 until a year or two have elapsed ; in a few cases not until three, four, five, or six have passed ; and, in a very few cases, many years, e.g., thirty-two, may supervene. Full statistics in regard to this are given by Parry. ^ In a few cases the gestation sac may open in more than one way. Thus it may communicate with rectum and vagina, with rectum and bladder, with uterus and intestine, with abdominal wall and intestine, and even with bowel, ladder, and abdominal wall. Several writers have given statistics as to the relative fre- quency of the different channels of pus-discharge in the various forms of ectopic gestation described according to the old classi- fications. These are, of course, entirely unreliable, seeing that the classifications are themselves in error. As regards the sub - peritoneo - pelvic variety, Dezeimeris pointed out the great frequency of the discharge "per rectum in it. Mattei,'^ in 1860, suggested that the stripping upwards of the peritoneum, and the close relation of the gestation sac to bowel in these cases, facilitated the entrance of poisonous matters from the bowel. Recently Berry Hart^ has insisted upon the very great importance of this form in relation to suppuration. He thinks that two factors are essential to the termination of an ectopic gestation by suppuration, viz. (1) extra-peritoneal development after rupture of the tube into the broad ligament ; (2) uppermost position of the placenta and its consequent displacement as the gestation advances. The ovum lying extra-peritoneally comes into close relation with bowel, especially with the rectum, and, in left-sided cases, from an early stage. The displacement of the placenta leads to its 1 Op. cit., p. 168. 2 "Des divers modes de terminaison des grossesses extra-uterinesanciennes," &c., Paris, 1860. 3 '• Selected Papers," Edin., 1893, 1. I t ii N -■ ; ^ ! 52 VARIETIES STUDIED IN DETAIL. \ % m gradual and sometimes to its rapid destruction by blood extravasation, so that the nutrition of the foetus is interfered with ; death of the foetus may therefore be brought about, and suppuration may then be set up by the entrance of noxious matter from the bowel. I am strongly of the opinion that Hart is right in insisting upon the importance of these factors in the causation of abscess formation. The occurrence of suppuration in any variety other than the extra-peritoneal will most probably be shown to be extremely rare. In the purely tubal form the placenta does not undergo such alterations, nor are the peritoneal relations so disturbed. The foetus tends therefore to be healthier, and there is greater protection from the bowel. Hart is of the opinion that the extra-peritoneal form in which the placenta lies above the foetus is the one that always suppurates. There is no reason why in certain cases in which it lies below suppuration should not occur; I mean those in which, at the time of rupture, a considerable amount of the placenta was destroyed. In such a case the damage may be so great that the foetus may die and suppuration follow. In cases in which the placenta has not been much injured at the time of rupture, and in which ' '■ lies lowermost, the progress of the gestation is not, so far as we know, accompanied with destructive placental changes of any extent, and the ^oetus is therefore not so apt to die as in cases where the placenta lies above, and is displaced. » Hart believes that death of the foetus occurs first. This may be so, but it is not necessary to suppuration in every case. This process may begin in blood clot. We know, of course, that suppuration may occur in a htematoma not associated with gestation, or in the sac wall, probably more especially if the latter be at all inflamed. Death of the foetus may thus be fl TUBO-PERITONEAL PREGNANCY. 68 sometimes secondary. It is possible that the septic germs may sometimes pass first of all from the maternal tissues into the placenta, thus reaching the foetus and causing its death — (y> By mummification {vide p. 92). (8) By conversion to adipocere {vide p. 93). (e) By conversion to lithopsedion {vide p. 94). » (■ 3. Cases which rttpture into the Pemtoneal Cavity. (a.) Tuho-peritoneal gestation, in which escape of the foetus in the membranes takes place into the peritoneal cavity, the placenta remaining in the tube, and development continuing. The first undoubted case of such a form of ectopic gestation was described by me in a monograph^ published in 1892. Several of the older writers, and also recent ones, e.g., Kustner,^ Werth,^ and Berry Hart* thought this form possible, while others denied its possibility, believing that rupture of the tube into the peritoneal cavity meant death to the mother, unless she were operated upon. This case,^ which occurred in the practice of Halliday Groom, was seen first in February 1890. The patient complained of great swelling in the abdomen and pain in the left iliac region. The history pointed to ectopic gestation, or to pregnancy in the horn of a bi-cornuate uterus. Laparotomy was performed on 15 th February. A large, well-formed, recently dead foetus was removed from a sac which extended nearly up to the liver, and which had in the lower part of the abdomen a thick anterior wall. There was an excessive amount of amniotic fluid. The 1 "Tubo-Peritoneal Ectopic Gestation," Edin., 1892. 2 Op. cit, p. 514. ^ Op. cit, p. 57. * Rep. Lab. Roy, Coll. Phys., Edin,, vol. i., p. 34. * First communicated by me to the Pathological Club, Edinburgh, May 28, 1890. ■« ill Mj I I 54 VARIETIES STUDIED IN DETAIL. uterus was enlarged, elevated, and drawn towards the right side. The placenta was in a separate sac in the left side of Fig. 7. — Vertical mesial section of body with tubo-peritoneal gestation. ((. Pyloric end of stoinacli. I. Urethra. 6. Traiisverso colon. m Vagina. c. Secondary or amniotic sac, in n. First lumbar vertebra. which la'tns lay. 0. Small intestines. \ <\. Umbilical cord. P- Fold of amniotic cavity. e. Peritoneal cavity behind anterior '1- Promontory. abdominal wall. /'. Adhesions between posterior wall of /• Great omentum altered in charac- primary sac and parietal peri- ter, beinf,' deii.se and Itbrous in toneum. its inner part, and entering into s. Pale (inn mass remains of old the formation of the secondary blood extravasation into pla- sac. centa. P- Wall of primary or tubal sac t. Space containing fluid in wall of containin;< the placenta. primary sac. /(. Adhesion between anterior ab- u. Right Fallopian tube in wall of dominal wall and great omen- uterus. tum. V. Rectum. x. Blood and toiii up placenta form- w Adhesions between primary sac ing the mnss in primary .sac. wall and utero-vesical pouch. i- Symphysis pubis. X. Pouch of Douglas. k. Bladder. y- Tip of coccyx. TUBO-PERITONEAL PREGNANCY. 55 Ai the pelvis — a < 'ck viscoid mass extending two inches above the brim. It was left m situ. The sac which contained the foetus was washed out and drained. The patient died thirty- eight hours after operation, with symptoms pointing to uraemia. The cadaver was studied by me by means of the sectional, dissectional, and microscopical methods. The gestation was found to be of mixed nature, partly within and partly without the peritoneal cavity. Fig. 8. — Transverse section of pelvis in tubo-peritoneal gestation, through fourth sacral vertebra and subpubic ligament. o. Paravesical connective tissue con- tainin;; fluid in its spaces. 6. Utero-vesical poucli partly closed by adhesions. c. Riglit broad ligament. d. Rectum. e. Fourth sacral vertebra. /. Pouch of Douglas. gr. Left side of uterus bulging into great saorosciatie notch. h. Placenta and blood in primary sac which is lying in the utero- vesical pouch. i'. Ischium. j. Descending ramus of pubes. k. Bladder. I. Left broad ligament pushed against pelvic wall by uterus. Nature. — The gestation sac was double, one containing the foetus, the other the placenta. The former was that part of the peritoneal cavity behind the stomach, transverse colon, and great omentum ; the latter consisted of the enormously dilated left Fallopian tube lying in front of the uterus and extending vertically from the utero-vesical pouch to the fourth lumbar vertebra. Though quite distinct from one another, they were connected by means of the umbilical cord and amnion; this lii'l 66 VARIETIES STUDIED IN DETAIL. membrane lined the secondary (peritoneal) sac, and passed into the substance of the primary (tubal) sac. The left ovary was found blended with the posterior wall of the primary sac. The broad ligaments were about the same size. The left one was adherent in several places to the primary sac. The uterus was well-formed and enlarged. The right tube and ovary were found somewhat bound together by adhesions. Development. — The ovum in this case began to grow in the Fig. 9. — A higher transverse section in the same tubo-peritoneal case, made through the junction of the first and second sacral verte- brae and the upper part of symphysis. ff. Symphysis pubis. 6. Peritoneal cavity. c. Adhesions between sac wall anil parietal peritoneum. d. Right acetabulum. e. Placenta and blood mass. /. Outer end of right Fallopian tube. !if. Right ovary. U. Cartilage between first and second sacral vertebne. t. Wall of primary .sac. j. Pale firm mass resulting from old hii'inorrhage into placenta. /.•. Left ovary attached to wall of primary sac. I. Rectum. left tube, which very early fell forwards in front of the broad ligament, where it continued to increase in size. Then, at sometime during the early months, in a manner unknown, escape of the foetus in the amnion took place into the peritoneal cavity. This must have occurred very gradually, there being nothing in the clinical history to make either the patient or her physician aware of it. It may have been brought TUBO-PERITONEAL PREGNANCY. 57 about in one of two ways. The tube wall in its upper and posterior part may have been greatly thinned, so that the amnion and foetus gradually protruded as a hernia-like mass. Veit ^ and others have noticed such a method of escape of the ovum. Or the escape may have occurred by the fimbriated end of the tube, gradually dilated by the increase in the siiic of the ovum. This has bee -bserved by Kustner,^ Orthmann,^ and others. It is impossible to say whether or not any chorionic 'II ^ Fig. 10. — Another transverse section through abdomen in same tubo-peritoneal case, made at level of junction of third and fourth lumbar vertebrse. a. Folding of altered great omentum. h. Peritoneal cavity. c. Intestines. il. Great omentum. e. Junction of third and fourth lum- bar vertebra;. /. Amniotic cavity. tissue escaped along with the amnion. The sub-amniotic layer in the wall of the secondary sac was well-formed fibrous tissue, in some parts very dense ; in others, of loose nature and allow- ing of the folding of the amnion exactly similar to that which occurs ill uterine pregnancy. However much of the membranes escaped, they were unbroken and became attached to the peritoneum, its epithelial lining becoming destroyed and its 1 Schroeder's " Lehrbuch d. Geburtshiilfe," lOte Aafl. 1888, p. 423. - Op. cit.. p. 503. '^ Op cit., chap. v. I ': 08 VARIETIES STUDIED IN DETAIL. subepithelial layer becoming dense and fibrous, forming a second, ry sac wall for the foetus. The amniotic fluid continued to be St jreted, and to such an extent that in the later ntonths hydrami ios resulted. The intestines also became somewhat matted together, especially in each lumbar region, while the great ommtum, which entered into the formation of the anterior \\ all of the secondary sac, became changed into thick fibrous tiss le, especially in its inner layers. Strong adhesions developed Istween the primary sac wall and the left side of the pelvis. That part of the wall not in contact with the pelvic wall a.id floor became covered with the escaped amnion, thus forming . \ portion of the secondary sac wall. Fost-operaticn changes. — Haemorrhage took place inside the primary sac, causing it to be greatly distended. The uterus wao pushed baci:wards and to the left to such an extent that it bulged into tl e great sacro-sciatic foramen. The uterus and appendages, the i actum, bladder, ligaments, and extra-peritoneal structures were greatly compressed, the vessels being almost completely closed. The placenta wai greatly torn up by the haemorrhage, which resulted probably fr im the bursting of some of the thin walled sinuses in the inner part of the tube wall. A case similar to this has recently been described by Mr. Lawson Tait. As to the frequency of its occurrence, it is impossible to say anytl'ing. No doubt, in the past, it has been put down as an abdominal pregnancy (primary). It is one of the case;5 difficult to make out except by most careful examination. At the time of operation in the case I have described, the true nature of the gestation could not be made out. It is believed by some that, at the time of rupture of the primary sac, only the foetus may escape into the peritoneal CASES OF DOUBTFUL NATURE. 09 cavity, and that, in certain cases, the gestation may progress until full time. Several cases of this nature have been described. ' Charpentier ^ mentions the case of Walther, in which, after the rupture of a pregnancy, said to be " ovarian," the foetus developed 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." Bandl - records a case in which, after rupture of the primary sac at the fourth month, the foetus grew till full time in the abdominal cavity, and was extracted alive by laparotomy, the mother being in articulo mortis. At the post-mortem the child was said to be lying in the abdominal cavity together with a quantity of dirty fluid, no membranes, however, being found. Jessop's'^ case was one in which the fcEtus was described as escaping alone into the peritoneal cavity, where it continued to grow until full time, when it was extracted alive. 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 unorganised lymph of very friable nature were found lying upon, but not adherent to, the intestines. As the mother recovered from the operation, the condition of the appendages, the true nature of the gestation sac, and the relations of the placenta and membranes, were not ascertained. Champneys 1 also describes a case in which a seven month foetus was removed from the abdomen. It lay among the intestines, "covered only by a dull white membrane." The mother died on the thirty-second day after the operation. At the post-mortem it was impossible to make out the relations of 1 "Traite des Accouchements," Paris, vol. ii., p. 10.30. 2 " Cycl. of Obstet. and Gyn.," vol. xii., p. 690. ^ Trans. Obst. Soe. London, vol. xviii., p. 261. Trans. Obst. Soc. London, vol. xxix., p. 456. 60 VARIETIES STUDIED IN DETAIL. parts in the pelvis, though the placenta was found ahwe the pules lying loose in a sac. From the descriptions given in these cases we cannot be certain as to their nature, and we are not justified in consider- ing them instances of escape of the foetus alone, and of its after-development in the peritoneal cavity. These cases and others of similar description may be either tubo-peritoneal in which the membranes escaped along with the foetus, surround- ing it and afterwards becoming attached to the peritoneum, or sub-peritoneo-abdominal cases in which rupture into the peri- toneal cavity had never occurred at all. As I have already pointed out (p. 27) the operation examination or the oxAinaxy post-mortem examination is insufficient to determine the true nature. Careful sectional and microscopic study are also necessary, especially to determine the true relations of the peritoneum. We are, therefore, yet without proof that a foetus can escape into the peritoneum free of membranes and there continue to develop to full time. It is, moreover, exceedingly unlikely that such an occurrence can take place. The long held belief, viz., that an early complete ovum may escape into the cavity of the abdomen and develop on the peritoneum is a pure supposition, unsupported by any evidence whatever. On the other hand, all our knowledge tends to show the exceedingly great improbability of this view. Leopold's experiments in regard to the absorptive power of the peritoneum on young foetuses placed in the abdominal cavity will shortly be quoted (p. 66). All recent embryo- logical investigations go to show that the relation of the ovum to the mother is so specialised and intimate, that complete disassociation of the two, especially at the period most common in tubal rupture, would result in rapid death of the ovum and its absorption by the peritoneum. HEMORRHAGE INTO PERITONEAL CAVITY. 61 We know that the villous connection between ovum and decidua develops very early, the maternal blood very soon furnishing nutriment and oxygen to the ovum through the medium of the villi. It is inconceivable that a villus covered ovum could attach itself to a peritoneal surface and wait for the development of an intervillous blood circulation. This is still more improbable when the chorion frondosum is more consolidated into a placenta. No, this old belief is quite untenable. The result of a meeting between a delicate embryonic tissue cut off" suddenly from its normal source of nutriment, and therefore presumably in a weakened condition, and the strong resistant peritoneum, which possesses such marked absorptive powers, can only be the destruction of the former by the latter. (i.) Gestation terminates. By the escape of blood into the peritoneal cavity endangering the mother's life, through rupture of the tube wall. Eupture of the tubal gestation into the peritoneal cavity, in the great majority of cases, is accompanied with such escape of blood that the mother's life is in peril unless saved by laparotomy. The rupture is due to the thinning and bursting of the tube wall by the expanding ovum, but sometimes it is directly caused by injury, such as a sudden fall or lift. The rupture may be large or small, the rent in the tube being rounded, elongated, or irregular. In some cases that part of the wall to which the placenta is attached may burst, or in others the non-placental portion. The whole ovum may escape into the peritoneum or only part of it. According to Orthmann's statistics complete expulsion takes place in a majority of cases. The hole in the tube may become plugged by the foetus partly passed through it. It is thus easy to see 62 VARIETIES STUDIED IN DETAIL. \ that many vuriutionH tiro to be fiiuiul in the nature and extent of the rupture, the amount of blood lost and the danger to the mother. There can be no doubt that, in the majority of cases of rupture, death will occur within 24 hours unless an operation be performed. Thus, Parry ^ found that, out of 113 cases, 39 died within ten hours, 81 within twenty-four hours, and 98 witiiiu forty-eight hours. The explanation of this is the large loss of blood which usually accompanies rupture. In other cases only a small loss may take place, and this may be followed at successive intervals by more hemorrhage. The temporary cessations may be due to contractions of the tube wall or vessel wall, or to plugging of the rent by the foetal structures. A succession of small losses may prove fatal to the mother after a short time. In some cases blood may accumu- late first in the tube, e.g., between the wall and placenta, and afterwards burst into the peritoneal cavity. In another class of cases where the tube is surrounded with adhesions, the blood may only slowly work its way through bhem. The earlier in the pregnancy the rupture occurs, the less will be the immediate danger to the mother, because the vessels torn are not much enlarged, and will be more apt to be closed by the contraction of the muscular part of the tube wall. Also, an escaped early ovum along with the blood will probably more easily be absorbed in the early than in the late months. The mother will therefore run a somewhat less risk from rupture during the first and second months than during the succeeding months. In the majority of cases rupture occurs during the first four months of pregnancy, but may also take place during the succeeding months. During the first month it is rare, but has been reported^ as taking place in the second and third weeks. 1 Op., cit. p. 152. ^ Parry, op, cit., p. lf>2. HAEMORRHAGE INTO PERITONEAL CAVITY. Hennig ' jjives the following table : — Rupture during the 1st month occurred in 5 cases. » . 2nd 22 1) .. 3rd 18 )i 4th 23 »i » „ 5th 8 » » „ 6th 1 » 7th 1 )) „ 8th -- 6 »> ,, 9th 1 i» „ 10th 9 » Beyond „ 1 J) In Von Schrenck's 141 collected cases ^ of rupture '. — In the 1st month in 13 cases. 2nd 67 „ 3rd 28 „ 4th 12 „ In Schauta's 87 cases ^ : — In the 1st month in 15 cases. 2nd 29 „ „ 3rd 23 ., 4th 10 „ In Mackenrodt's 38 cases * : — In the Ist month in 6 cases. 2nd 23 „ 3rd 5 „ 4th 4 , 1 Op. cit, p. 143. * " Ueber ektopische Graviditiit." Inaug. Diss. Jurjeio, Dorpat, 1893. ^ " Beitrage zur Casuistik, Prognose und Therapie d. Extra-uterinschwanger- schaft," Prague, 1891. * " Vier praparate v. Extrauterinsch," Ztschr. f. Qehurtsh, u. Oyndk,, Stuttgart, 1893, bd. xxvii. V i 64 VARIETIES STUDIED IN DETAIL. A large number of cases ruptured, it thus appears, during the second month. When death of the mother occurs immediately after rupture or within a few hours, the blood poured forth may not have coagulated, but may be found lying free in the peritoneal cavity with or without part of the whole of the ovum. In other cases a hsematocele is formed. The effused blood gathers in the pelvis, and may extend high into the abdomen, forming a soft mass at first and afterwards a solid elastic structure. The small intestines usually lie on the iipper surface and help to form a covering for it along with membranes formed by the peritonitis which often follows rupture. The relation of the uterus to the htematocele mass is interesting. It may lie retro- verted or retro-placed below the blood, or may be pushed in front of it against the anterior abdominal wall, or may be upright, completely surrounded by the ha3matocele. A good deal has been written in recent years as to the rela- tion of ruptured ectopic pregnancy to intra-peritoneal ha^ma- tocele. Lawson Tait i is of the opinion that the great majority of cases can be attributed to this cause. Veit ^ gives the follow- ing statistics : — In 66 cases of his own 16 were due to ruptured tubal gestation. „ 20 „ Jousset 9 „ „ „ 17 „ Dubousquet 5 „ „ „ 36 „ Voison 9 „ „ „ 7 „ Engelhardt 1 „ » „ 146 „ in all 40 or 28 .)er cent. 1 Of. cit, p. 472. ^ "Die Eileiterschwangerschaft," Stuttgart; 1884, p. 14. 11 SEQUELS OF HAiMATOCELE. %% There can be no doubt, as Veit indeed thinks, that this figure is far too small. Many cases of early ectopic pregnancy un- doubtedly are never recognised because of the great difficulties which many present, and in some instances because of careless- ness in examine uion. Very many cases of haematocele are reported without the question of ectopic pregnancy being taken into consideration. Sequelce of hccmatocele. — These need not be fully discussed here, as they are scarcely within the scope of this work. Wh3n once the hssmatocele is formed, it may progress as follows : — 1. Tlie patient may die from the result of the shock and exhaustion, even after some days. 2. Peritonitis may occur of such a severe nature or so protracted as to kill the patient. The relation of hsematocele to peritonitis has been a subject considerably discussec, Bernutz and GoupiU were of the opinion that the peritoneal changes resulting from escape of blood into the abdominal cavity were not so great as had been supposed. Eogers^ said that peritonitis never occurred. Parry's^ opinion " is that it is so rare . . . that the possibility of its supervention need scarcely be taken into consideration." Some other writers have held that it is a very common occurrence. There can be no doubt that the majority of cases of hifimatocele run a course with neither the signs nor symptoms of peritonitis, and it may be at once conceded that acute peritonitis very rarely 'upervenes in a hferaatocele. As to the occurrence of chronic peritonitis, careful observations require to be made, and post-mortem evidence is alone to be depended upon for information, because we kaow that often in the abdom ' 1 " Diseases of Women," Neiu Syd. Soc. Trans., vol. i., p. 269. - " Extra-Uterine Fuitation and Gestation," Pliila., 1867, p. .'^9. ^ Op. . :'(.,p.l33. 5 ii -_ i 1 I 66 VARIETIES STUDIED IN DETAIL. cavity extensive adhesions may be slowly formed, e.g., over an ovarian tumour, without the accompaniment of sufficient clinical signs to mtke evident the progress of the pathological process. As far as we know at present from post-mortem evidence, the upper surface of a ha^matocele gets roofed ove: by the bowels and omentum matted together by slowly formed peritonitic adhesions. 3. The blood may become entirely absorbed, so that the patient recovers. The progress of every case depends upon the fate of the ovum. If the pregnancy be early, the ovum may probably be easily absorbed if it escape along with the blood into the peritoneal cavity. After the early months, when the placenta is a well-marked structure, partial or total escape of it along with the foetus probably always is fatal to the mother. When the foetus alone escapes, we cannot definitely speak as to its fate in all cases. If young, it may be removed gradually by the peritoneum, whuse absorptive power is so great. Older foetuses may be partly absorbed, or may, with or without absorption, become encapsuled by peritonitis, and, as a result, the patient may die ; or the fcetus may become shrivelled, turned into adipocere, into a lithoptedion, or it may become softened and form an abscess. Interesting in this connection are Leopold's i experiments, in which he placed canine foetuses in tlie peritoneal cavity of other animals. Breaking up and absorption of tlie foetuses occurred with great rapidity. In one dog in which was placed a foetus 2\ cm. in length, as well as anotlier which had gone beyond the mid term of pregnancy, no trace was found after two days. In another case in which two fcetuses 2A cm. in length were placed, three days afterwards, when the abdomen was ' " Experimentelle Untersuchungen ueber d. Schicksal implantirter Freten," Arch. f. Gynneh, Berlin, bd. xviii., hft. i. V EFFECT OF BLOOD ON PERITONEUM. 67 opened, two yellowish white round masses were found, which looked like embryonic tissue, and which were hound to the intestine and anterior abdominal wall with peritonitic ad- hesions ; they were very soft to the touch, and easily broke up. Small cartilaginous bits were still found in them. In another case two fa3tuse8 were implanted, and the abdo- luen opened on the fifteenth day. Nothing was found save two small bodies, each the size of half a lentil, and fastened to the intestines by adhesions. Similar results were got with older foetuses. When septic peritonitis followed the implantation, it was found that the breaking up of the foetus took place more quickly than when no septic complication occurred. In the septic cases complete breaking up and absorption took place, save in the most resisting tissues — cs]., bone. It is interesting to quote, in conclusion, the results i of Willian Hunter's recent experiments on the fate of blood poured into the peritoneal cavity of animals. " The results of the foregoing experiments may be regarded as definitely proving that, in the case of the peritoneal cavity at least, the fate of extravasated blood is not so entirely a merely local one as has hitherto lieen generally supposed. On the contrary, a very considerable, sometimes even a large, pro- portion of the red corpuscles may escape a local fate altogether, becoming absorbed mainly through the lymphatics of the dia- phragm into the circulation, where they continue, for a certain time at least, to perform their functions as before. "The rapidity with which this absorption takes place is always both relatively and absolutely greatest during the earlier hours after the effusion, especially in the case of entire blood, ' "Intraperitoneal Blood Transfusion," &c., Journ. Anat. and Physiol^liondon, 1887. I . C8 VARIETIES STUDIED IN DETAIL. i ffli the absorption extending, however, over a period of twenty-four hours or even longer, according to the amount of the effusion. " The maximum increase is attained on the third or fourth day after the injection, the time depending partly on the quan- tity of blood transfused, partly on its fluidity. . . . " The actual absorption of corpuscles \\ hich takes place dur- ing the earlier hours after the transfusion can, however, never be accurately determined, even by enumeration of the corpuscles in the circulating l^lood, still less by estimation of the hajmo- globin. For, owing to the serious effusion which almost always occurs into the abdomen as the immediate result of the injec- tion, the number of corpuscles in the circulating blood, as deter- mined by enumeration, is always apparently much increased; and it is not until this infused serum, along with the injected serum, has become re-absorbed, and the injected serum has become removed from the circulating blood, that the actual amount of absorption of corpuscles which has taken place becomes apparent. " A diglit inflammatory reaction always occurs for a few hours after the injection, resulting in an effusion of serum containing leucocytes, more or less marked according to the amount of irritation. This effusion is, however, of short duration, ceasing generally in the course of the first few hours, after which the effused serum, along with that of the injected blood, becomes re-absorbed into the circulation. The irritation produced by the presence of clots is probably of more consequence, as it cer- tainly is longer lasting. The resulting inflammation, however, is generally localised. In no instance, at least in these experi- ments, was it such as in any way to endanger life. . . . " It is in the neighbourhood of the female generative organs, and in connection with pathological conditions of these organs, that such extravasations most frequently occur. A few con- siderations only need be presented here. EFFECT OF BLOOD ON PERITONEUM. 69 " If the extravasation take place extra-peri toneally, e.g., be- tween the layers of the broad ligament, . . . it is clear that most of the conditions will be present, especially as regards the more or less definite boundaries of the extravasated blood, to ensure the early coagulation of the blood, and that, too, en masse. As any absorption of corpuscles which may then occur can only take place through the ordinary lymphatic channels of the pelvis, through which the absorption of the corpuscles as such is but slight, by far the greater portion of the corpuscles will thus be doomed to a local fate. " If, on the other hand, the effusion of blood occur not only extra-peritoneally, but also in part into the peritoneal cavity itself, as is probably not unfrequently the case, the ultimate fate of the Vlood may l)e different. Its coagulation may then be more or less delayed, and its absorption greatly facilitated by the special action of the diaphragm in promoting absorption. " The distribution of the blood in such cases will naturally be, in the first instance at least, in the npighbourhood of the pelvic organs, although the peristaltic action of the intestines will tend to distribute it more or less amidst the coils of intestine. However clear may be the part played by the diapliragm in absorption in the case of animals in whom the (piantity of blood injected, relative to the size of the abdomen, is so great, the case is otherwise in the human subject, where the quantity of blood relative to the size of the abdomen may be very small, and the blood itself is generally situated at that part of the abdomen most distant from the diaphragm. " It became of interest, therefore, to determine what part the diaphragm played in the absorption of small quantities of fluid. " In two experiments on rabbits, in which death took place within a period of 24 to 26 hours after the injection, the infiam- matiou was observed to be most intense over the under surface S 1 , j o i '■ 70 VARIETIES STUDIED IN DETAIL. of the diaphragm and upper surface of the liver, these surfaces beiug covered with a thickish layer of fibrinous lymph, with at parts larger nodules of fibrine and leucocytes. It seeiued as if the septic poison introduced had acted most virulently at the seat of its absorption. " It has already been seen that it was in this neighbourhood that fluid blood was always found most abundant, if examina- tion were made shortly after its injection." 4. Suppuration may follow. — Suppuration may take place in the early or late stages of a htematocele, or may, after the blood mass has been entirely absorbed, start in connection with the remains of the fretus. The pus tends to work its way to the outside, bursting through bowel, vagina, or bladder. 4. Gestation may be destroyed. («.) By the formation of the so-called "tubal abortion." By this is meant the separation, partial or complete, of the ovum from the tube wall, accompanied with haemorrhage into the tube lumen and the escape of the blood, along with part or whole of the ovum into the peritoneal cavity through the fimbriated extremity of the tube. The condition was first fully described by Werth,i tliough cases had been noticed by other observers, c.g., Westermark ^ and Veit.3 Recently Keller,^ Bland Sutton,^ and Orthmann ^ have written at some length regarding it. The abortion is most apt to occur during the first months before the ostium abdominale has become closed, though it is likely that it may also take place if the ostium be only closed with weak adhesions. In thirty-two cases " collected by Mackenrodt — » 02\ cit., \). 105. - "Hygiea," Stockholm, 1885, Nr. 6. ^ Ztschr.f. Gchurtsh. u. Gyniik., Stutigart, hd. xii., lift. ii. * Ztschr. f. Oehurtsh. u. Gywik., Stuttgart, 1890, pp. 21, 22. » Op. cit. 8 Op. cit. '^ Ztschr. f. Gchurtsh. u. Gi/nak:, Stuttgart, 1893. TUBAL ABORTION. 71 il It occurred during the 1st month in 8 cases. 2nd „ „ 19 „ i> )) orci ,, ,, 4 ,, )) j> 'xXiU. „ „ i „ In twenty-nine cases occurring in Martin's Hospital — It occurred during the 1st month in 13 cases. 2nd „ „ 10 „ » » OlQ. ,, ,, 4 „ Aih 9 » » '±tii ,, „ ^ „ The expulsion probably takes place as a result of the contrac- tions of the muscular part of the tube wall, the tubal contents abortion nuiss. tube lUIIII'll ovaiy, EiG. ll.^Left tubal priignaney, 1-2 months, longitudinal section. The tubal abortion is gradually passing through outer end of tube (Orthmanx.) moving in the direction of least resistance. It can most easily take place when the ovum is primarily situated in the outer part of the tube, but, it must be remembered, the ovum, may be moved some distance along the tube.- ^ Orthmann : " Beitrag zur friihzeitigen Untorlirechung der Tubenschwanger- schaft," Ztschr.f. Gchurtsh. it. "ijndk:, Stuttgart, 1394, bd. xxix. - According to Lawson Tait {Brit. Gynwc. Jotini., London, May 1892, p. 99) this so-called " tubal abortion " is extremely rare, and he objects to She use of the term, because its clinical and pathological features are the same as in the case cf ru])ture of the tube. Moreover, he believes that the introduction of this term may lead practitioners to consider it as, on the whole, of no more seriousness than an ordiucii> " uterine abortion." 72 VARIETIES STUDIED IN DETAIL. In iTK.at cases, according to Orthniann, the ovum is completely expelled. The results to the mother arc practically the same as when rup- titre of the tube wall occurs, and all that has been said under this heading will apply here. A hiematoeele is formed in the peri- toneum ; death may be immediate or delayed ; peritonitis, suppuration, &c., may follow ; or, sometimes, recovery may ensue. In some cases where the patient does not at once die, a hfemato-salpinx may be formed along with the luematocele ; and according to Werth, the outer end of the tube may become closed after the escape of blood, so that the hrematocele and htemato-salpinx become distinct from one another. Orthmann, however, states that in quite a nnmber of abor- tions (ten out of twenty-nine operated upon in Martin's Hospital) the ovum may be found in the peritoneal cavity with- out any blood, the latter having been absorbed quickly by the peritoneum. In such cases, however, more or lens blood clot is found in the tube. He points out that this condition never occurs in cases of tubal rupture where blood is always found in the peritoneal cavity. This difference is probably explained by the fact that, with a considerable number of tubal abortions, very little blood may escape from the tube, so that rapid absorption of it can take place. According to Bland Sutton, tubal abortion is the real condi- tion in those cases of hematocele that have been wrongly attributed to reflux of menstrual blood from the uterus as well as to haemorrhage from the tube. The supposed menstruation is really, according to him, the separation of uterine decidua with blood escape in cases of tubal pregnancy, the internal hemorrhage being due to the absorption of the ovum into the peritoneum. As there is only a slight H^MA TO-SALPINX. 73 es'^.ape from the uterus in sucli cases, it is easily understood how the belief has been more readily adopted that the blood had regurgitated through the Fallopian tubes. In cases where the htematocelc forms without any external bleeding, and therefore, presumably not associated with men- struation, the opinion has usually been that the bleeding occurred in some way from the tubal mucosa. All such supposed cases must be examined with the greatest care, clinically, to ascertain the existence of ectopic gestation, and, at the time of operation or post-mortem, to make out the real nature of the haemorrhage ; above all, to examine the clot carefully for bits of the foetus, and the tube for remains of the ovum. The importance of accuracy is great from the practical point of view, since, now-a-days, it is considered safest to perform a laparotomy and remove the tube, if the bleeding be associated with a tubal gestation. In many of these cases, besides the free blood which is poured into the tube, there are also found extravasations in the substance of the fatal membranes of small or large amount. There can be no doubt that the latter haemorrhages may, by destroying the ovum and forming the so-called " mole," lead to tho abortion and the consequent tearing of maternal vessels, which is accompanied with tlie loss of a large quantity of blood. I have pointed out in my desqription of the membranes (p. 132) the almost constant tendency to haemorrhage, especially in the dccidua reflexa. (h.) By the formation of a liccmato-salpiiix. The ovum may be entirely broken up and diffused through the blood, or it may be partly or entirely detached and become incorporated as a mole with the blood mass. In these cases 'A I ll i-'i; -fMI h n VARIETIES STUDIED IN DETAIL. there is often a tendency for the mass to increase, owing to fresh hti'morrhages succeeding the primary loss. (c.) By the formation of a mole. In a number of cases the ovum may die, as a result of haemorrhage in its membranes, but without very marked out- pouring of the blood around it. There is thus formed what is known in uterine pregnancy as "blighted ovum," "fleshy or carneous mole," or "apoplectic ovum." The amount of blood extravasation varies. It may be limited to the decidua and chorion, and may be so great as to compress and so almost close the amniotic cavity, or it may burst into the amniotic cavity. The foetus may be partly or entirely destroyed. Immediately after these changes the ovum looks like a fresh blood clot, and, unless the specimen be studied with care, the gestation elements, e.g., amnion, chorionic villi, and decidua may not be recognised. Later on the mass is paler and firmer, undergoing the ordinary organisation changes of blood clot. They gradually tend to shrink in size, but may remain as small hard musses for long periods. The importance of the fresh mole in relation to abortion into the peritoneum has already been considered. {(l.) By the formation of a pyu-salinnx, owing to decomposition of the ovum and blood clot. The septic process may be very rapid, and the pus may burst into the peritoneal cavity, uterus, l)ladder, bowel, or vagina. (c.) In cases %vhcre the ovum may have advanced beyond the second month, absorption of the fcetus may take place, but the bones may remain for years unabsorbed. Mummification, transformation to adipocere or lithopsedion, also sometimes takes place. / ' CHAPTER IV. VARIETIES STUDIED IN DETAIL— Qmtinued. Interstitial Tubal rREGNANCY. An ovum may develop in that part of the lallopian tube which is situated in the uterine wall. This form of gestation is extremely rare. Most of the statistics regarding its fre- quency are not to be trusted, because some of the cases on which they are based have not been interstitial, but prol)ably either cornual pregnancies or ampullar gestations which have ruptured into the bro.i ' ligament. Parry ^ describes thrrty-one of his collected 500 cases as of this variety. Hennig^ makes the remarkable statement that out of 150 cases forty-two were interstitial. Baart de la Faille,'^ in 1807, could gather only sixteen cases. Sassmann,* in 1880, was able to collect only four additional undoubted cases in literature published after 1867. The development of this form of gestation is so characteristic that it should not, in the great majority of cases, be mistaken on post-mortem examination. The gestation sac, being embedded in one wall of the uterus, is not distinct from this organ, but is an intimate part of it. Viewed from the outside the whole uterus appears to be enlarged, but in i»n irregular manner. The gestation grows 1 Op. cit„ p. 51. 2 Qp gif_^ p 109. " Schmidt's Jahrb., Leipzig, bd. 138, p. 190. •» "Ein Fall von interstitieller Schwangerschaft," 1880, p. 3. :l ti m M i . ;i IMAGE EVALUATION TEST TARGET (MT-3) V // :/. & ^ 1.0 I.I ■ 50 ™'^= I— 2.2 ImUu 1.8 1.25 1.4 1.6 ^ 6" ~ ► V <^ /; Hiotographic Sciences Corporation <^ ^ 8 >> 4th J) 4 >> 5th >> 4 V 6th n 2 ') 8th >) 1 )) 9th J> 5 )) 10th 5> 7 after the 10th )> 2 1 •' Cycl. of Obstet. and Gyn.," vol. xii., p. 49. - Kiistner, Op. ciV., p. 508. •* Of), cit. * Op. cit., p. 143. m r / i 80 VARIETIES STUDIED IN DETAIL. Parry's list is as follows — Eupture took place in the 6th week in 1 case. )> 11 )> otn ,, i „ u 10th J) 2 )» II 3rd month in 10 cases. II 4th 1 „ II 5th 2 „ II 5i 1 „ II 6th 1 » ,, >> 8th 1 „ According to Lawsou Tait,^ rupture occurs always befor^o the fifth month. On comparing these statistics with those relating to tubal rupture, it appears that, while both varieties occur mainly before the fifth month, a very much larger number of tubal ruptures take place in the early weeks. This difference might be expected. The interstitial gestation being surrounded by a thicker and stronger muscular wall tends to remain for a longer period less liable to rupture. The accident is a very fatal one, on account of the hiemorrhage which accompanies it. In the 26 cases collected by Hecker,^ death of the mother occurred in every one from this cause. The maternal mortality is therefore greater than in the case of tubal rupture. The explanation is that the rupture does not usually take place in the early weeks, but later, when the vessels of the wall have reached a considerable sii.f , so that there cannot fail to be profuse haemorrhage. If the placental area be torn through, the loss will be more rapidly fatal. It is also likely that, when rupture takes place, the foetus or liquor amnii escaping into the peritoneal cavity, the muscular wall of the gestation sac contracts, causing the placenta to be partly or 1 Op. ct<., p. 443. - " Beitrage z. Lehre von d. schwangerschaft auBScmuIb I'.br Gebarmutterhohle," Monatschr. f. Geburtskunde, Berlin, 1859, Bd. xiii. ' CHANGES IN INTERSTITIAL PREGNANCY. 81 wholly detached. As a result of this, especially if the placenta be situated oa the torn wall, there will be great loss of blood. Complete expulsion of the ovum from the sac, followed by thorough contraction of the latter, would tend to diminish the bleeding, though probably not to check it entirely, because in the thin torn wall the muscular elements are so scanty as to be powerless to close the bleeding vessels. It is certain that death may not occur immediately after rupture. Hennig mentions a few cases where the mother lived from ten to forty hours afterwards. . In some instances the whole ovum escapes into the abdomen ; in others only the foitus; while in others the placenta may escape and the foetus remain behind. 3. EUPTURE OF THE GESTATION SaC INTO THE UTERINE CAVITY. I have already pointed out that this may occur in the early months partly or wholly. If partly, the ovum may continue to develop ; if wholly, it probably always dies, and is expelled from the uterus. A? to how old a gestation may rupture in this way nothing is known. As will be found in the next section, it has occurred as late as the eighteenth week. The rupture may take place through the dilated inner end of the tube, or the muscular septum between the gestation sac and uterine cavity may burst. Hennigi believes that when the latter form occurs, the placenta is attached to the septum, and that the latter is weakened by the enormous development of vessels in it in relation to the placental supply. 4. Rupture may occur both into the Uterine and Peritoneal Cavities. Earely this double rupture may occur, and, as has been described by Leopold,^ besides the internal haemorrhage which 1 Op. cit., p. 111. - " Cycl. of Obstet. and Gyn.," vol. xii., p. 51. G iv ■ 11 82 VARIETIES STUDIED IN DETAIL. (■J i occurs, blood may also work its way to the exterior through the uterine cavity. When this takes place . le foetus may escape into the \ abdomen, and the placenta into the uterus, or the order may be reversed. BandP mentions a preparation in Eudolf's Hospital, Vienna, in which the former of these conditions exists, pregnancy having advanced for four months. He also refers to a case of IMaachka in which rupture occurred at the 18th week, the placenta, head, and part of the neck of the child having escaped into the abdomen, while the child's body was born into the iiterine cavity and thence through the vagina. 5. Rupture may occur between the Layers of the Broad Ligament. This is denied by Bland Sutton and others. I have already mentioned the cases of Martin and Leopold {vide p. 76), in which a growing interstitial pregnancy gradually extended into the ligament. Actual rupture must be extremely rare. I can find only one oase in which the description clearly points to its having taken place. It is recorded by Eosshirt.- The woman went to full time and died after a false laljour. The rupture had apparently occurred early. The placenta was found mainly attached to the uterus, but partly also to the adjacent extra-peritoneal broad ligament tissue, into which the rupture had taken place. A case described by Hey ,3 and known to William Hunter, may have been one of this nature, though from the account it is impossible to be certain. The woman died three months after she had gone to full time. On post-mortem examination a large ' sac was found in the abdomen containing the foetus, and com- ^ " Cycl. of Obstet. and Gyn.," vol. xii., p. 51. - Oaz. mid. de Paris, 1841, p. 289. * " Med. Obs. Soc. Phys. Lond3n," vol. viii., p. 341. INFUNDIBULAR PREGNANCY. 88 municating with a cavity in the uterus which contained the placenta. In the same category may be placed the case of Hofmeister.^ 6. The Fcktus may reach full time, die, and remain in its sac. Klob 2 and Eokitansky ^ ha /e each described a case in which the dead foetus was removec. from an interstitial gestation sac seven months after full time had been reached. Eathgeb * says that a lithoptedion may be formed, but there is no definite information in regard to this point. Infundibular Pregnancy. A gestation may start in the outer end of the Fallopian tube, though this is not of frequent occurrence. Cases of this have been described by many authors under the name of " Tubo-Ovarian " and " Tubo- Abdominal," e.g., by Bussiere,'' Dezeimeris,*' Beaucamp,^ Bandl,^ &c. We are not in possession of sufficiently well authenticated facts to give a special description A this variety. But any extended reference to it would appear to be unnecessary, because all that has been said in reference to ampullar gestation might apply to the infundibular. One or two special points must be noted, however : — The outer end of the tube is the most movable, and, therefore, unless fixed by adhesions, is liable to be found in various positions. Adhesions are very apt to form between it and surrounding parts, e.g., ovary, abdominal 1 Mag.f. d. rjcs. Heilk., . eriin, voL xv., p. 126. - " Cycl. of Obstet. and Gyn.," vol. xii.. •^. 49. 3 " Handbuch d. pathoL Anat," Wien, 1855, vol. iii., p. 542. ■• " Ein Fad. v. Graviditas interstitialis," Miinchen, 1884, p. 21. " Phil. Trans., London, vol. iii., p. 605. '' Op. cit., p. 258. ' " Ueber Tubo-ovarialschwang.," Stuttgart, 1884. ** Op, cit., p. 51. h:i™i 5 1 t 84 VARIETIES STUDIED IN DETAIL. wall, colon, omentum, rectum, bladder, &c. Rupture may more easily occur through the fimbriated end. This may take place into the peritoneal cavity, into a sac formed by peritonitic adhesio.is around the end of the tube, or into a tubo-ovarian cyst caused by the persistence of an ovarian sac of peritoneum, sometimes found in woman. Tliis ovarian sac has been especially noticed by Arthur Robinson ^ and Bland Sutton.''' In mammals, the sac is found in various stages of completeness. Thus, in the hyrena, rat, and mouse, it quite surrounds the ovary, the end of the tube opening into it ; in the baboon and porcupine it is partly formed. In the human subject it is usually only found as a recess in the mesosalpinx ; this varies in depth in different women. In some it is deep enough to hold the whole ovary. Bland Sutton points out that in the virgin the ampulla of the tube falls over the opening of the recess and hides the ovary, this relationship being disturbed after the first pregnancy. That oases may proceed to full time is proved by the experience of Bandl and others. In some cases the outer end of the tube may be from the first in close relation to the ovary, either from a developmental peculiarity or from peritonitis.'' It is also probable that pregnancy may sometimes occur in an accessory tube end or in a hollow ovarian fimbria, which is thought by many to be the real end of the Fallopian tube. In most of the forms of infundibular gestation it is easy to understand how intimate may be the relation of the ovary 1 " On the Peritoneal Relations of the Mammalian Ovary," Journ. Anat, and Physiol., London, vol. xxi., p. 169. - Op. cit., p. 114. ^ Hasse, Arch. f. Oynael:, Berlin, bd. viii. p. 402. Burnier, Ztschr. f. Geburtsh. u. Gyniik., Stuttgart, bd. v. p. 357. Spencer Wells, " Diseases of the Ovaries," London, 1872. CORNUAL PREGNANCY. 8ft to the gestation sac. In many cases it becomes ttattened out and stretched, so completely blending with the other tissues of the wall that it may be lost sight of altogether as a distinct structure. Martin ^ reports five cases of tubo-ovarian pregnancy in which the tube communicated with a small ovarian cyst. The ovum had ruptured into the cyst, and then had passed into the tube. CoRNU/.L Pregnancy, Pregnancy in certain forms of developmentally defective uterus presents so many resemblances to ectopic gestation that the two subjects cannot be disassociated. It is necessary to bear in mind the mode of origin of the normal uterus. At first, in the embryo, two well-marked rods of tissue appear on the posterior wall of the abdomen and pelvis. These become hollow, and are known as the Miillerian ducts. After the eighth week of foetal life these gradually blend in their lower and middle portions, the septum between them disappearing, giving rise to the vp^ina and uterus. It is not here necessary to name all the malformations which may arise from the varl >us interferences with this normal develop- ment. Only certain ones need be indicated. First, both parts may develop equally, but blending may not be complete, and a uterus hicornis tmicollis may be formed. Either horn may become pregnant aud the ovum may develop to full time and be delivered in the normal manner. Again, only one horn may have developed from the first, giving rise to a uterus unicorvis, all remains of the other horn being absent. This horn behaves like the well-formed normal uterus. It may ^ Berl. ilin. Wchnschr., Nr. xxii., 1892. 86 VARIETIES STUDIED IN DETAIL. II il become pregnant, and the fojtus may be delivered at full time through the vagina, but, owing to the oblique position of the uterus, rupture may occur as a result of the labour pains. This was illustrated in Moldenhauer's case, quoted by P. Miiller.' In another set of cases one horn is well-developed and the other only partially, being attached to it. This condition is known as litems unicornis cum Cornxi rudimentario. It is this form only to which special attention need now be directed. The rudimentary horn is found in various conditions. It may be throughout its length a thin solid band ; it may be a very small tube which communicates with its own Fallopian tube and with the other horn ; it may be solid at both ends and hollow in the middle ; or it may be solid next the other horn and pervious in the outer part communicating with its Fallopian tube. That pregnancy may occur in the rudimentary horn is a well- established fact. Not many cases have been recorded, but this is probably due to the fact that they have often been described as tubal. Kussmaul,^ in 1859, was the first to collect all the undoubted cases, twelve in number, which had been published, and according to him, Dionis, in 1681, was the earliest to describe the condition. In 1883, Sanger ^ could only find records of fifteen additional cases, and in 1888 Himmelfarb* gathered only seven others, making a total of thirty-four. Out of these thirty-four cases the foetus died in twenty-six before the mid term of pregnancy, and in two after this time. In six cases only did the ovum grow in the horn to full time. In twenty-four cases rupture of the horn occurred and was 1 Op. cit., p. 205. - "Von dem Mangel d, Verkritmnmng und Verdopplung der Gebiirmutter," Wurzhurg, 1859, pp. 124-163. ^ CentralW. f. Gyndk., Leipzig, 1893, Nr. xx., p. 324. * "Ueber Nebenhornschwangerschaft," Milnchen. vied. Wchnschr., 1888, Nrs. xvii,, xviii. \ CORNUAL PREGNANCY. 87 fatal to the mother. In three cases Hthopiedion formation occurred ; one of these was a four month, another a five montli, and the third a full time case. In two cases laparatomy for the removal of the pregnant horn was done at the seventh month, and in five at the full time. It is evident, therefore, that the tendency to fatal rupture is, as is the case with tubal pregnancy, preat. The rupture, however, tends to occur at a later period. In none of the cases to which I have just referud did it take place before the third month. No particular accounts of the nature of the rupture have been given, so that it is impossible to say how often it may have taken place into the broad liga- mert as well as into the peritoneal cavity, and no comparison can, therefore, be made in this relation with tubal pregnancy. The duration and termination of a horn pregnancy are doubt- less related to the degree to which the horn was developed. If the wall is very thin and contains but little muscle, the tend- ency to sliort duration and to termination by rupture will be more marked than where the wall is thicker. In eases in which the pregnancy goes on to full time, accord- ing to Hinimelfarb, the onset of an attempt at labour is either attended with no contraction pains, or with but a very few in the wall of the pregnant horn, owi^/j to its thinness and the small amount of muscular tissue in it. Cornual pregnancy may, in the living woman, be mistaken for ectopic gestation. On post-mortem examination the follow- ing anatomical relationships serve to distinguish the one from the other : — 1. In infundibular and ampullar pregnancies the round liga- ment is found attached to the normal uterus on the uterine side of the gestation sac. The normal appearance of the pregnant Fallopian tube is greatly altered. 88 VARIETIES STUDIED IN DETAIL |: 2. In cormial pregnancy the round ligament is situated external to the gestation sac. The unimpregnated horn differs markedly in shape from the normal uterus. The Fallopian tube is found attached to the pregnant horn and is not neces- sarily altered. The preguunt rudimentary horn is attached to the opposite well-developed horn at the upper end of the cervix. 3. An interstitial pregnancy may be more difficult to distin- guish from a cornual. The round ligament is situated external to the gestation sac in this case, though, if the pregnancy be partly interstitial and partly ampullar, it may be attached to the anterior aspect of the sac. The close incorporation of the Fig. 13. — Pregnancy in a rudimentary horn. (Turner.) B. Bladder. V. Vagina. //. Round ligaments. 0. Ovaries. F. Fallopian tubes. S. Pregnancy in oornu. P. Inner part of lelt comu ; it is not pervious but quite solid. sac with the rest of the uterus and the absence of a separate horn serve, however, to distintruish this form from the cornual pregnancy. In several cases in which the diagnosis of tubal gestation liad been made, the application of these rules served to establish the incorrectness of the diagnosis (vide Turner's article, Udin. Med. Journal, May 1866). As regards the nature of the attachment of the rudimentary horn to the well-developed one, Himmelfarb found that, out of CORNUAL PREGNANCY. ' 89 27 cases, the bit of horn internal to the gestation sac was canalised, and opened into the cavity of the other horn in 6 cases. In 2 cases the connecting portion was patent, ')ut only in its middle part, its outer and inner ends being solid. In 19 cases it was not canalised but solid from the gestation sac to the junction with the well-developed horn. The occurrence of gestation in a rudimentary horn whose cavity is not in communication with the rest of the uterus has led to interesting speculations regarding the manner in which such a pregnancy can be brought about. The following suppositions are possible : — 1. The so-called solid portion of the horn may have Ijeen hollow before the pregnancy oegan — i.e., after the sper- i-iatozoa had passed up and fertilised the ovum. Its f closure may have resulted from swelling of the mucosa from decidual changes in it and obliteration of the small lumen in whole or in part. That this takes place can neither be proved nor disproved from the facts at our disposal. It is more difificult to disprove it, since in any given case while we have the condition after pregnancy has begun, we have no record of the state of matters in the non-pregnant condition. If closure took place in this way, however, careful examination of the solid stalk, especially in early preg- nancy cases, should reveal changes in the central portion sufficient to indicate their nature. No such alterations have as yet been pointed out. 2. We know that, in the non-pregnant state, rudimentary horns are found with a perfectly solid band connecting them to the opposite horn, and it has not unnaturally been concluded by many that, when the same condition 90 VARIETIES STUDIED IN DETAIL. r is found along with pregnancy of the rudimentary horn, the spermatozoa must have reached an ovum from one or other ovary, having travelled up through the well- , developed horn, and that then the ovum passed into the lumen of the outer part of the rudimentary horn through its Fallopian tube. In other words, there is either a wandering of the fertilised ovum outside the uterus from the ovary on the side of the well-developed horn to the ' opposite rudimentary horn, or the spermatozoa pass _/om the tube of tlu sound horn across the pelvis to the opposite side, fertilising an ovum from the ovary belong- ing to the horn which becomes pregnant. In favour of the first view are the cases in which the corpus hcteitm is found on the side of the non-pregnant horn. In favour of the other view are the cases in which it is found on the side of the pregnant horn ; also, in cases in which the bodies of female animals have been examined after coitus, spermatozoa have been found in various parts of the pelvis. As to the frequency with which these methods of fertilisation occur, Himmelfarb found that, out of the cases collected by him, only in six could the external wandering of the fertilised ovum from the other side be supposed to have taken place. This subject has been much discussed, but as yet definite conclusions have not been arrived at. The first to describe this so-called external wandering was Eschricht of Copenhagen, in 1834. He based his theory on the facts observed in Brejer's case, in which there was no communication between the preg- nant horn and the other save by r ^olid band, and in which the corpus lutcum was in the ovary of the opposite side. In 1859, Kussmaul, from a careful study of Bischoffs experiments in ^ Kussmaul, op. cit. i^^^^Mii^^li^ WANDERING OF OVUM. 91 1842 on animals with a double-horned uterus, in which the latter had demonstrated an internal wandering of the ovum — i.e., its passage inside tho uterus from one horn to the other, and from his own studies, came to the conclusion that in the human female an internal wandering might occur, but never an external. In 1862, however, from new observations published, he^ altered his opinion, and believed that the latter might occa- sionallv occur. " * In 1879 Leopold 2 and Parsenow^ performed experiments on animals, removing the ovary on one side and tying the tube on the other, before impregnation. Kiistner'* and others have made similar experiments. While Parsenow and Kiistner got negative results, Leopold, Kireieff, and Bruzzi satisfied them- selves that, in the dog, external wandering of the ovum could take place. Recently, Lode,^ in experimenting on rabbits, has found that charcoal particles, and also the ova of ascaris hi7nbricoides suis, if injected into the peritoneal cavity, were carried into the Fal- lopian tubes. He concludes that it is not necessary that the tube end should be in contact with the ovary in order to receive the ovum after the bursting of the Graafian follicle, but that the ovum is carried by currents to the tube, external wandering being thus possible. Of interest in relation to cornual pregnancy is the question of menstruation. It is now well known that there is not always, in cases of the malformation of the uterus which we are now considering, accumulation of menstrual blood in the rudimentary ' Monatschr. f, Gcburtskunde, Berlin, 1862, bd. xx., p. 225. - '* Experiment. Beitrage z. Ueberwand. d. Eies," Rostock. =' Arch.f. GynaeL, Berlin, bd. xvi. 1880, p. 24. •» Ibid., bd. XV., p. 259. ' Arch.f. Oynaek., Berlin, bd. xlv. 92 VARIETIES STUDIED IN DETAIL. horn. There seems to be, in some cases, no discharge of blood at all from the mucosa of this horn.^ Were menstruation con- stant, leading to the accumulation of the retained blood, there , can be very little doubt that pregnancy in the rudimentary horn would be unknown. Development of a fertilised ovum will probably occur only in those cases in which no menstrual discharge has occurred in the horn. Changes in the Ovum after its death, where it is not ABSORBED NOR DISCHARGED AS AN AbSCESS, BUT RETAINED in SITU. Mummification. — This is a change which appears to be asso- ciated with an absorption of water from the tissues of the foetus, and in most cases of the membranes and placenta as well, followed by a shrinkage of parts which produces a mummified appearance. Chiari^ lias described an interesting case which he dissected in 1876. A woman died at the age of eighty-two, and in her was foum *he remains of an ectopic pregnancy which had been carried for fifty years. On opening the gesta- tion sac a full time shrunken fcstus was found attached by a shrivelled cord to a shrivelled placenta. The latter along with the membranes formed a fibrous capsule which closely enveloped the foetus, and was adherent to it in parts. The cartilage and bone of the foetus appeared normal. The soft tissues were hard and darkened. The vessels and cavities contained whitish detritus. The organs were shrunken but retained their form ; the brain, however, was changed into a shapeless red thick mass. On microscopical examination, the structure of the various parts could still be made out. The most marked alterations are found in the tissues and Muller, op. cit, p. 209. ^ Wien. ined. / resse, bd. xvii., p. 1092. ADIPOCERE FORMATION. $a hd organs containing much fat. The fat is changed into margarin and cholesterin. The braia becomes a red-brown pulp contain- ing margarin and cholesterin crystals and remains of the ganglion cells. The liver cells retain their characteristic shape. In the kidney the distinction between the cortical and pyra- midal substance may be retained, and even the tubules may be found lined with epithelium. The heart and blood vessels contain debris in which margarin crystals may be found, and also red blood corpuscles. The striped muscle looks like dried tlesh, but under the microscope appears very like fresh muscle. According to van Cauwenberghe ^ mummification is usually associated with some salt deposition in the membranes, in the fa3tus or in both. In Chiari's case calcareous concretions were found in the shrivelled placenta and membranes, and crystals of unknown composition were found scattered through the foetus. Adipocere formaiion. — In some cases the soft tissues of the foetus are converted into a soap-like mass — adipocere — in which are found the bones of the foetus, either arranged somewhat in their normal relations to one another or irregularly disposed throughout the mass. In other cases the bones may be partly or wholly changed, so that all degrees of transformation may be found. The mass is usually coloured more or less uniformly with a golden-yellow tinge — probably due to alteration in the blood pigment. Along with this change may be found deposi- tion of lime salts in various parts. Bland Sutton ^ has pointed out the tendency of adipocere foetuses to adhere to the wall of the sac in which they lie. Interesting cases are recorded by Wagner;^ Bossi,"* and Keiser,^ 1 Op. cit., p. 145. =* L. Tai*- op. cit., p. 537. » L. Tai >p. cit.. p. 536. - Op. cit., p. 374. •» L. Tail, op. cit., p. 537. s 94 VARIETIES STUDIED IN DETAIL. With the exact nature and conditions of adipocere formation we are not perfectly acquainted. It is made by the union of a fatty acid with ammonia, and is structureless like soap. Fat appears necessary to its formation, but the other tissues of the body can undergo the change after it has begun. Moisture is an essential factor. Calcification. — Lime salts may be deposited in different parts of the ovum in different cases. In most instances, as Kiichen- meister^ has shown, the body of the foetus is not infiltrated. The membranes and placenta, and also the wall of the gestation sac, may be studded with calcareous nodules or plates, the foetus being in a state of mummification or adipocere, but without any salt deposits in it ; for this condition Kiichenmeister has sug- gested the name of Litholcclyplios {Kkkvo DECIDUA REFLEX A, 131 cavity. It, no doubt, varies in different cases. In some the lumen may be so small that from the first it may be in very close relation to the ovum, and, as the mucosa thickens to form the decidua, it may soon get in contact with the ovum on all sides, so that the formation of a distinct reflexa is impossible. In other cases the lumen may be larger, the ovum attaching itself to one side of the tube, the decidua vera thickening and attempting to form a reflexa ; this may never reach completion, however, because the free surface of the growing ovum meets the mucosa opposite it, not allowing the edges of the reflexa to meet. In a few cases, where the tube lumen is exceptionally large, a complete reflexa may be undoubtedly formed. A well- preserved specimen of this is to be seen in the museum of the Eoyal College of Surgeons, Edinburgh. Structure.-^— T\i% reflexa has much the same structure as the superficial portion of the serotina. In it, however, the degen- erative changes, which appear to be also of the nature of coagulation necrosis, progress more rapidly, and it has a large proportion of intercellular substance and fewer decidual cells than the serotina of the same age. In different cases it shows great vascularity, especially near the attachment to the serotina. Eugen FraenkeP says that small arteries and veins may be sometimes found near the base, but that at the pole only capillary spaces are found. Blood is often found escaping from the sinuses into the surrounding decidual tissue, or it may burst through the reflexa either on its inner side coming into relation with fcetal structures, or on its outer side forming ! clot in the tube outside the gestation sac. Eupture of reflexal vessels is probably the main source of blood found in that part c . the tube outside the gestation. Very slight endo- thelial proliferation appears to take place in the reflexal 1 Op cit., p. 161. '■>v 181 DEVELOPMENTAL CHANGES. V sinuses. On the outer surface may be found in places remains of the original epithelium lining the tubal mucosa, cubical, flattened, or broken down. Over the greater extent, however, it has completely degenerated. On its inner surface a greater or less area along with the serotina forms part of the site of attachment for the permanent placenta, the rest of it being related to the temporary chorion Icevc. This fact, along with the already described hsenxorrhagic tendency in the reflexa, helps to explain the almost constant occurrence of blood effusions in the placenta or membranes of tubal pregnancy. They often reach a considerable size, and may lead to the destruction of the foetus and the formation of a haemato-salpinx. Where the reflexa is not destroyed completely by blood effusion, it becomes stretched and thinned, and pressed, by the growing ovum against the surrounding portion of the decidua vera, to which it becomes blended at a much earlier period than in uterine pregnancy. I have no specimen in which it has come into contact with a portion of the mucosa unaltered by decidual formation, and cannot, therefore, say what takes place in such a case. The Tubal 3fucosa outside the attachment of the Ovum. This part of the mucosa varies in different cases. Sometimes a part or the whole of it may undergo decidual changes, though, as pregnancy advances, the decidual cells gradually disappear. In some cases no changes are found in the mucosa in the early weeks, the epithelium being apparently normal; in other cases inflammatory changes, slight or marked, have been observed, though not always with disappearance of the epithelium; such changes may have existed before the FCETAL EPIBLAST. 133 pregnancy, or may have followed it. When blood is effused into the lumen the folds of the mucosa are pressed against the wall and massed in irregular heaps. As the gestation advances, the membranes take up more and more of the lumen of the tube, which also undergoes enlarge- ment ; the mucosa outside the ovum is gradually stretched, thinned and broken up, the original folds becoming separated and the epithelium flattened and cast off. The whole tube thus gradually tends to become part of the gestation sac which is lined by the placenta and membranes. At full time, however, small portions of tube may still remain little altered between the gestation sac and uterus. Olshausen ^ has described an interesting eight months' tubal gestation in which the part of the tube between gestation sac and uterus remaining pervious, and communicating with the amniotic cavity, allowed of the escape of liquor amnii in small quantities from time to time. Eelations between Ovum and Decidua. Early Importance of Fcetal Epiblast. Neither in uterine nor in extra-uterine pregnancy have the earliest relations between the ovum and decidua been demonstrated. Published descriptions have been either largely speculative or based upon the conditions found in lower animals, especially in the rabbit, ape, bat, &c. Though in the large amount of material which I have exam- ined there are wanting some of the very earliest stages, it seems to me that the remnants of these stages found in speci- mens of four weeks and upwards throw some light upon the 1 "Ueber Extrauterinschwang," DexUsche med. Wchnschr., Leipzig, 1890, p. 24. !• 134 DEVELOPMENTAL CHANGES. early relations of the ovum to the decidua, and the nature of their attachment to one another. I have also carefully studied early uterine abortions of the third and fourth weeks, and find that they correspond exactly to the tubal speci- mens in regard to the relationship of epiblast and decidua. These points cannot be definitely settled until the uterus with the ovum in situ has been examined in the early days. All that can be done at present is to indicate their probable nature from a study of the facts as yet at our disposal. The writer, conscious of the difficulties in the points at issue, desires to advance the following suggestions as to the early relationship of the epiblast and decidua, not as definitely proven, but only as highly probable : — In all my early specimens (viz., three and four weeks' uterine, four, five, six, and eight weeks' ectopic pregnancies) the surface of the decidua, both serotina and reflexa, ^'° more or less uniformly covered with a nucleated layer of protoplasm in which only occasionally can cell outlines be recognised. The layer might in fact almost be termed plasmodial. This protoplasm stains very deeply with eosine, the nuclei, which are large and oval or rounded, staining darkly with htematoxylin. In great part the layer shows on section only a single row of nuclei, as if com- posed of a single layer of fused cells ; in many places it is two or three times as thick, several rows of nuclei being seen on section. Here and there large nucleated masses, rounded, ovoid, or irregular, are seen either broken off from the general layer or formiag part of it, and partly embedded in the decidua. Sometimes detached masses are found entirely embedded in the decidua, and having no apparent connection with the surface layer ; these are probably sections across portions of the general layer which have extended into the decidua obliquely. A f \ tt FCETAL EPIBLAST. 135 From the surface are found projecting inwards stalks of this material of various shapes and sizes, some of which we shall afterwards see are in direct continuity with a similar proto- plasmic structure covering the early v'^U. SHll more striking are vacuolated plasrmdial masses,^ causing a reticulated appearance, found in some places continuous with the layer covering the decidua, in others, lying free near the surface ; the interstices of this network vary in size and often contain blood ; the trabeculte resemble eocactly the surface layer, being only, as a rule, thicker and showing mo"e numerous nuclei. Among the villi of the early placentte (two, three, and four months), similar bits of this reticulated protoplasm of various sizes may be often found, as well as broken off trabecule and large multinucleated plasmodial masses similar to those lying on the decidua, and of different shapes and sizes. When I describe the nature of the epithelium of the early chorion, it will be found that it is in its superficial portion of the same nature as this structure, having the same appearance and staining reactions. That they are identical is clear, and this is established beyond doubt by the many evidences of their direct continuity. In uterine placentation, Kastschenko^ has already called attention to the plasmodial nature of the outer epiblastic layer covi ing the early villi. Minot^ has also referred to the embryonic remains found covering the villi, especially in the early human placenta, and Ed. van Beneden* has noticed in the young ovum the same 1 It is extremely interesting to me to find that Kossmann {Ztschr. f. Oehurtsh. u. Oyndk., Stuttgart, bd. xxvii., chap, i.) has described in an early uterine and an early ectopic pregnancy precisely similar appearances. Only, he makes the error of regarding the plasmodium. or syncytium as derived from the uterine epithelium. ^ "Das menschliche Chorionepithel, &c." Arch. f. Anat. u. Entwcklngs- gesch., Leipzig, ISS.^. * "Uterus and Embryo," Journ. Morphol., Boston, April 1889. * Compt. rend. Soo. de bid., Paris, ser. viii., tome v., p. 731. 136 DEVELOPMENTAL CHANGES. \ appearances in the outer portion of the epiblast. How are these appearances to be explained ? • . It is well to consider for a moment the early stages of the hedgehog's development. Hubrecht has shown that here the epiblastic layer of the blastocyst increases rapidly, forming a protoplasmic coat of several thicknesses of cells, a plasmodia- like mass, in fact. This becomes applied to the decidua, and then rapid vacuolation takes place in it, whereby a reticulated structure is formed connecting the ovum and decidua; the outermost layer of the epiblast, that attached to the decidua, being called by him the troplioblast. So, too, it is probable that in the human ovum — whether from the whole blastocyst or parts of it is not certain, although from the early ova described, possibly only part may undergo the change — the outer epiblastic layer, on entering into relation- ship with the decidua, gets to consist of a thick nucleated protoplasmic mass which attaches itself to the decidua, to the serotina, and also to the reflexa, if there be one. As growth goes on vacuolation appears in this mass, so that the ovum becomes connected to the decidua by a reticulated nucleated protoplasmic structure. The cause of the vactiolation is not evident ; it may be due to its not growing at an eqial rate in all its parts along with the rapidly enlarging ovum. The outermost portion, which first came into contact with the decidua, forms a layer, which remains, however far the vacuo- lation is carried on ; it corresponds to the outermost portion of the epiblast in the case of the hedgehog, and like it may be called the trophohlast layer, being however a much thinner one. Whether the plasmodial character of the protoplasm in my sections is the same in its first formed condition, or whether it represents some degree of change, such as is found in the outermost layer of the epithelia, generally, cannot be absolutely FCETAL EFJBLAST. 137 */ settled, though the probability is that it represents a degeneiated condition of the cellular mass. As to the functions to be associated with the marked epiblastic development, there is room for considerable specu- lation. The following suggestions may be offered : — 1. There is no doubt that one important purpose which it performs is the firm fixation of the ovum to the decidua. 2. The trabecule of the reticulum may serve, as has been suggested by Hubrecht, as pathfinders for the future permanent villi. 3. It serves, probably, for the absorption of nutriment from the decidua. It must be remembered that the yolk supply in the human ovum is exceedingly small, and that it requires to be supplemented at an early period for the supply of the rapidly growing blastocyst. In all probability this nutriment is mainly derived by absorption through the trophoblast of the serous fluid of the swollen succulent decidua, as well as from any of this fluid which has transuded through the upper layers of the decidua into the lumen of the tube. It is possible, also, that there is actual absorption of the solids of the decidua by the trophoblastic tissue, but there is no evidence that this occurs to any marked extent. That the trophoblast possesses phagocytic properties has been now well established, not only in the case of the hedgehog, but in other of the insectivora, in several of the carnivora, the rodentia, and the primates, as has been shown by Hubrecht,^ Ed. van Beneden,^ Heinricius,^ Duval,'* Hart and Gulland,^ and others, though in these animals the function appears to vary considerably, both as regards the degree of its development and the extent to which it is employed. I I ^ Op. cit. * Op, cit. ^ Arch. f. Mikr. Anat., Bonn, bd. xxxiii. * "Le placenta des Rongeurs," Paris, 1893. ' Op. cit. 188 DEVELOPMENTAL CHANGES. In the case of man it is extremely probable that this action is not exercised mainly for the nutritive requirements of the early blastocyst, but is of chief importance in relation to the following requirements, viz, : — (a.) The embedding of the early foetal epiblast in parts, so as to produce a firm union between it and the decidua. This is seen also at a later stage in the fixation of the permanent villi. (6.) The establishment of a communication between the maternal blood sinuses and the lacunje of the early epiblastic reticulum connecting the blastocyst and decidua.^ It may be that, phy logon etically considered, these functions in the case of the human ovum bear a different relation to the other functions of the trophoblast from what is found in the lower mammals. In some of these an important purpose of the phagocytic action may be the destruction of the epithelium lining the uterus ; in providing nutriment it is said also to play a considerable part. As regards these latter functions in tubal gestation, I have already shown that the degeneration and partial disappearance of the mucosa epithelium takes place along with decidual formation — not prior to it by the action of foetal epiblast. The remains of these cells may, of course, be removed by the phagocytic action of the trophoblast. The absorption of nutriment from the decidua through the epiblast is merely a temporary stage, preliminary to absorption from the maternal blood direct, though at what early period the change takes place cannot yet be decided. In the hedgehog, Hubrecht has shown that the blood spaces in the decidua gradually communicate with the lacunw in the trophoblast, before mesodermic tissue has extended outwards * KoBsmann is also of the opinion, based upon his study of the specimens to which I have referred {vide p. 135), that the vacuolation of the early plasmodial connection between ovum and decidua is the method of origin of the intervillous space, maternal blood early finding its way into the vacuoles. \\^USi^ii>Ur\, FCETAL EPIBLAST. 139 into the epiblastic strands. The same thing has been shown by- Ed. van Beneden^ as taking place in the bat, Vespcrtilio murinus, and by Duval,^ Selenka,^ and Masius,* in rodents. The method by which this communication is brought about has not been, however, satisfactorily explained in the case of any animal. In man it is as yet entirely problematical. One supposition is that the gradually distending maternal sinuses near the surface of the decidua may burst, and thus allow blood to escape into the epiblastic lacunte. One can scarcely believe that such a haphazard process is the method, because it would probably frequently be attended by such a sudden outpouring of blood that great damage might be done to the ovum. A more gradual process would be best suited to the delicacy of the epiblast reticulum. This seems to be brought about, as my sections indicate by the phagocytic action of the troplioUast, the decidual tissue between the surface and the nearest sinuses being eaten through, the blood thereby being allowed to escape slowly into the spaces between the early villi. This process may be clearly studied in various stages in my sections. The trophoblast seems to advance by throwing out processes of different shapes and sizes which absorb the tissue in front of them. After the sinuses are opened these processes may spread along their walls and may even penetrate them, burrowing into the surrounding decidua. Parts of them may also be broken off in the lumen of the vessel, and be i ried away by the blood stream. In Plate XVIIL, Fig. 1, a vessel is seen in the muscular layer of the tube almost filled by a plasmodial mass. It is this appearance of festal epiblast extending from the surface of the decidua down along the sides of the maternal ' Op. cit., p. 730. ■■' Compt. rend. Soc. de hwL, Paris, 1887, p. 149. ■* " Keimbliitter und Primitivorgane der Maus," 1883. * Arch, de bioL, Gand, vol. ix. f ii; ,;, 140 DEVELOPMENTAL CHANGES. sinuses that has so long been misinterpreted, having been described as the outward extension of the sinus endothelium. The study of early sections makes clear the true nature of the process. In the later stages of pregnancy this foetal lining becomes flattened out and more or less disappears, some of it being carried away by the blood and absorbed. Direct rupture of the maternal sinuses may take place here and there normally, though it cannot be clearly estal)- lished. One does certainly find in early pregnancy sinuses without any trophoblastic masses lining their walls, but in these there may never have been any downward extension after communication had been opened up, or this might have taken place to a slight extent and the masses then been washed away. It may be, indeed, that spontaneous rupture is to be con- sidered pathological, and this is strongly supported by the conditions found in the reflexa, where it is so apt to be followed by extensive tearing up of the reflexa, haemorrhage into the surrounding tube lumen or among the foetal villi causing much damage. When once the maternal blood is thus established in the lacunae of the foetal epiblastic reticulum, the structure might be described as the primitive or temporary placenta. Its structure is probably simple, being entirely composed of foetal epiblast bathed in maternal blood, nutriment being absorbed directly from the latter. This, however, is probably only a very short stage on the way to the formation of the per- manent placenta, in which the foetal parts consist, not only of epiblast, but of mesoblast containing blood vessels. The epiblastic reticulum in part is broken up, probably because it does not keep pace thoughout with the rapidly growing ovum. These broken off masses, as my sections show, become \ II CHORION. U\ gradually reduced to smaller portions, which are, by degrees, uisintegrated and absorbed. Some bits of considerable size lose their nuclei and appear to degenerate, having a somewhat hyaline staining reaction. Part of the reticulum however remains, the trabeculse serving as pathfinders for the foetal (chorionic) mesoblast, which penetrates them as a delicate structure of branching cells, and thus forms a core in them gradually extending out towards the decidua. Thus are established some of the per- manent villous stems which connect foetal and maternal parts in the permanent placenta. Probably only a small number of the full time villi take their origin in this way. The majority develop afterwards from the chorion, but it will be necessary to consider this structure before taking up their formation. That part of the original epiblast which is left on the surface of the decidua does not appear to follow the increase in area of the latter as pregnancy advances, and so gets broken up. At the end of pregnancy it is found only at irregular intervals, and it differs from its early condition in appearing somewhat shrunken, and with smaller and less brightly stained nuclei. 'n\ The Chorion. It is necessary clearly to understand what is meant when this term is used since it is one which has been employed in different senses by embryologists. Thus, it used to be applied to the zona pellucida, though now this is generally referred to as the " primitive chorion." It has also been given to the epiblastic covering of the blastodermic vesicle, and more recently to the external ■ amniotic fold or false amnion. According to our knowledge up to the present time, the best definition of the U2 DEVELOPMENTAL CHANGES. permanent cliorion has been either that used by Schiifer,^ viz., " that external membrane of the ovum, from which the villi spring," or the one given by Minot,'^ viz., " the whole of that portion of the extra-embryonic sonuitopleure, which is not concerned in the formation of the amnion." In view, however, of the probable changes in the early foetal epiblast, viz., the formation of a trophoblast and protoplasmic reticulum, it would be necessary to modify somewhat the latter phraseology, in order not to include these structures in the definiti(m. It would be well to use Minot's definition with the additional words, "and which remains after the disappearance of the temporary epiblastic reticulum which at first connects the ovum with the decidua." Having first fixed this limitation, we are in a position to take up the description of the chorion at a point where comparisons may be instituted with existing descriptions. 1 Placental portion of Chorion. Structure. — The membrane is at first composed of an outer epiblastic layer and an inner mesoblastic layer. As to the outer layer, it is now evident that it is at first but the remnant left on the somatopleure of the early proliferated epiblast, which afterwards became reticulated and gradually disappeared. I have already referred to the plasmodia-like appearance of these structures, the outlines being indistinguish- able. The early chorionic epiblast has in its outer portion the very same appearance. It consists of several layers, Minot says that the greatest thickness reached by it is only a two-layered stage. In the earliest condition it is very rarely as thin as this, being usually three or four layers in thickness. It varies con- 1 Quain's *' Anatomy,' vol. i., pt. i., p. 43. ^ Op. cit., p. 390. ..,i(.!';iSI-i:ii PLACENTAL CHORION. 143 siderably in different parts. With the advance of pregnancy it probably does not increase in size, save at points in connection with tlie development of new villi, but gradually thins, though slowly, in the early months. From the surface at intervals are found plasmodial projections differing in size and shape. Some of these appear to be broken off trabecule of the original reticulum, others are buds of newly forming villi. Everywhere throughout the chorion the cells next the mesoblast are different from the superficial ones just described. They are more or less differentiated from one another, the cell substance taking on a lighter stain than the superficial ones ; the nuclei are larger and show a well marked intranuclear network. This layer varies in thickness ; it may be a single layer with the cells close together or somewhat separated (Plate XIX., Fig. 3), or it may be thickened in parts (Plate XVI 1 1., Fig. 2). With the advance of pregnancy, the superficial cells get thinned, their nuclei more or less flattened parallel to the surface, degenerating more or less and often becoming split up. The diminution in the number of the active deep cells is very marked. At full time these cannot be specially recognised in many parts, the whole thickness of the epithelium being a homogeneous nucleated mass, degenerating and splitting into layers. Below the epithelial layer, after the earliest periods, there can often be traced a layer of cells which appears to form a kind of basement membrane — it is probably of connective tissue origin. It can be more easily traced in some parts than in others. Eegarding the mesoblastic portion of the chorion little need be said. In the earliest specimens, it consists of variously branching cells in a homogeneous matrix. In sections from the third and fourth months, the cells are =^ 144 DEVELOPMENTAL CHANGES. 'V less branched, and they appear gradually to become arranged in great part more or less parallel to the epithelial surface. Their cell substance stains more deeply than the surrounding matrix; they may lie in spaces in the latter, or may be apparently continuous with it. Around the vessels in the mesoblast the tissue appears to be more condensed, the ceils often being concentrically arranged. Fibrillation becomes also more marked in the matrix, which becomes of denser consistence as pregnancy advances, these changes commencing usually nearest the epithelial layer. The cells become relatively fewer. In the early stages the chorion is connected with the amnion by delicate strands of matrix in which an occasional cell may be seen. Later these turn somewhat denser, and at full time may have altogether disappeared in places, the amniotic and chorionic mesoblast having become closely united. Formation of the villi. — I have already described how the earliest of the permanent villi are probably formed — viz., by the extension outwards into the epiblastic trabeculse of the reticulum oi chorionic mesoblast. In the very early human ovum described by Coste, it is highly probable that the villus- like projections described by him were really the remains of the epiblast reticulum ; some of them had a hollow core, into which the mesoblast was probably just beginning to push its way. It is possible that the chorion Iceve represents the early villous condition alone, there being, as a rule, in it but little after new formation such as I am about to describe. The chief source of the villi is undoubtedly the new chorionic outgrowths after the early stage just referred to. This has been established by many investigations. These probably develop */ PLACENTAL CHORION. 145 during a great part of pregnancy, though in diminishing num- bers as the later months are reached. They commence as surface projections of the epiblast, varying in thickness and length, into which the mesoblast makes its way. Sometimes there is no marked epiblastic bud formation, the mesoblast projecting with but a thin covering around it. These outgrowths give of econdary branches, which again r ay ramify until the characteristic villous form is reached. These vary greatly in their degree of branching, some few remaining, indeed, single. Some of the largest trunks may even reach the decidua, though most of them only become attached through their branches, Very few run at right angles to the surface ; most have an oblique direction. In the early months a section of the placenta shows the villi to be relatively less numerous than at the end of pregnancy, and the numbers of large villi greatly to exceed the small ones ; they are also thicker and shorter, and not so near one another. At full time a few large stems are seen, but small villi are by far the most abundant in the placenta, and they are more closely packed together than in the aarly months. In structure the villi vary according to their age. In the early stages, on section, they consist of an outer covering of chorionic epiblast, inside which is a core of very embryonic connective tissue, consisting of branching cells and a few oval or round ones, and a delicate homogeneous undifferentiated matrix, into which, very soon, capillary loops make their way from the vessels in the chorionic mesoblast. The epiblast pre- sents much the same appearance as that described in connection with the original chorion. It consists of an outer portion of nucleated protoplasm of the thickness of two, three, or four layers of eel)" *^he cell outlines being indistinguishable, and an inner portion composed of cells like the deep ones already 10 , '^ 'i''^i .li'V/y-' -^-jVii.:tL','.''/.i'. ' 146 DEVELOPMENTAL CHANGES. described in the early chorion ; these latter may be very scanty and separated, or may form a continuous layer. Often these appear to lie upon flattened cells, perhaps a kind of basement membrane. Here and there the outer epiblast may be heaped up into thickened masses, or may extend out as long processes. Some of these indicate the place of origin of new branch villi ; the long processes are probably remains of broken trabeculae from the primitive reticulum. • * At the end of pregnancy similar appearances may be seen in a few villi — i.e., in those which are young and recently formed ; in these, however, the connective tissue is more advanced than in the villi just described. As pregnancy advances the following changes occur: — The epithelial covering thins. About the third month the outer nuclei are often flattened somewhat parallel to the surface. For the most part it gets to consist only of a single layer of deeply stained cubical or flattened cells, whose outlines can usually be distinguished ; sometimes two or three layers may be left, thickened irregularly at different spots. Often the outer- most layer may, at full time, show degeneration, being fissured parallel or oblique to the surface. In some villi the cells may have so degenerated th c only a thin membrane is left, in which no nuclei can be seen ; in others even this nay be absent, and the connective tissue exposed. The connective tissue also changes as pregnancy advances. It gets denser and more fibrillated, the corpuscles being smaller and, usually, being more oval or spindle shaped, branching being rarely made out. In the larger stems it may become some- what fibrous, consolidation being especially marked around the vessels. Mode of attachment of the villi to the serotina. — Some of the earliest villi, consisting only of epiblast, have of course become il VILLI AND DECIDUA, 14T' attached to the decidua before the mesoblast has penetrated them to any extent. It is easy to recognise these in early specimens by the stalk of plasmodial epiblast, which may be short or long, single or multiple, and is attached to the surface of the decidua, where it is continuous with the trophoblastic layer. As pregnancy advances the stalk becomes gradually altered in appearance, so as to resemble that found in the later formed villi. At full time it is impossible to distinguish these villi; most of those which are outgrowths from the chorion become attached to the decidua in the following manner, which is the same for both villous stems and villi. As they near the decidua, there takes place a marked proliferation of the deep layer of epithelial cells at the end of the villus, varying in extent in different cases. Owing to this change the end of the villus becomes swollen, and the superficial epithelial cells, i.e., the deeply stained plasmodial layer seen in the sections, becomes thinned, stretched, and broken up somewhat, being cast oflf in pieces of different sizes. The villous end then comes into con- tact with the trophoblast remains on the decidua, penetrates it, apparently absorbing parts of it, and becomes firmly attaclied to the decidua proper. Usually the end sinks for a slight dis- tance, probably owing to this abeorption. The bits of superficial epithelium broken off from the villus and unabsbrbed portions of the trophoblast layer may be pushed ahead of the villus, and remain unabsorbed for some time. After the villus is well fixed, its superficial layer of epithelium appears to fuse more or less with the trophoblast on the decidua adjacent to the villus, and to become continuous with it. Occasionally not the end but the side of a villus becomes attached to the decidua, either continuously or only at intervals ; in tlie latter case, between the points of attachment a thin space I 148 DEVELOPMENTAL CHANGES. >li may be seen between the villous epithelium and the trophoblast remains on the decidua. There seems to be no reaction in the decidua, as the result of the fixation of the villi ; the attach- ment takes place, also, equally well whether there are few or many decidual cells. In a few instances, \/here the tropho- spongia cells, proliferated endothelium from maternal sinuses, have worked their way to the surface of "^he decidua, the villi may become directly attached to them. They become fixed indiscriminately to elevations or depres- sions in the decidua. Sometimes they ma- get to lie in pits between the remains of the original mucous fringes, and becoming attached to their sides may appear to be deeply embedded in decidual tissue. Apart from this appearance it is extremely rare that a villus is seen burrowing for any distance into the serotina. In the embedded villi, as pregnancy advances, the covering epithelium becomes early degenerated or absorbed, and largely disappeari., °o that the line of distinction between them and the surrounding decidual tissue becomes less clearly marked. Occasionally the end of one may dip into the opening of a maternal sinus, and may become attached to its wall, though this is rarely found. In some of the villi the capillary loops do not reach their outer ends ; this is especially seen in those which are most deeply embedded in the decidua. Hart and Gulland^ have recently suggested that the villi perform an important part in thinning the serotina by absorbing the degenerating decidua. While agreeing with them that the epiblastic covering is trophoblastic, and that it can absorb the decidua, I do not tliink that this is the main factor in the thinning of the decidua. I have already (p. 124) stated that. 1 Rcj). Lab. Boy. Coll. Phys., Edin., vol. iv., p. 17. London, 1893. Joum. AtMt. and Physiol., NON-PLACENTAL CHORION. 149 after the decidua reaches its highest state of development in the early months, its growth must be very slow ; it is marked by degeneration, and it must be much affected by the pressure of the growing ovum. The proliferation of epiblast at the ends of the villi is, I believe, to be associated mainly with their fixation. There can be no nutritive stimulus to absorption of decidua after the placental circulation is established, because the blood in the intervillous spaces is the great source of nourishment to the foetus. It is also to be noted that, as pregnancy advances, the pro- liferated epiblastic cells become fewer and smaller, and, in some cases, disappear entirely. The villi, also, are least vascular near their ends, the embedded portion rarely containing any of the capillary loops. These facts are not in favour of the idea of axitim absorptive action on the part of the attached ends of the villi. Non- Placental Portion of Chorion. Whether the villi of the chorion Iccve are entirely formed from the trabeculte of the original epiblast reticulum, or partly also by a few new outgrowths from the permanent chorion, is not quite certain, though, probably, they are chiefly derived from the former source. Though they may be mainly epiblast, some contain mesoblast. They never reach a high development, nor ramify to any extent. Their relations to the decidua are the same as in the case of the early chorion frondosum. Very often they appear only slightly vascularised, or not at all. As the ovum grows they become flattened against the decidua, into which they may be forced for a distance. They cease to grow, their covering epithelium degenerates, and they become more <^r less continuous with the aurrounding decidua. Here and there in early specimens, under the villi may be seen the trophoblast •'if 150 DEVELOPMENTAL CHANGES. remains on the surface of the decidua, distinct from the epithelium of the villus, though of the same nature. The chorionic membrane, which presses these villi outwards on the decidua, comes directly into contact with the decidual tropho- blast between the villi — to the reflexa, or where this is not developed to the vera alone ; or when partly developed both to vera and reflexa. Its structure is the same as that already described in the case of the frondose portion. Its epithelium blends with the trophoblast, and afterwards with the decidua as pregnancy advances, the epithelial layer gradually degenerating and thinning. ! Intervillous Circulation. The probable nature of the early establishment of the inter- villous circulation I have already described. In its first formed condition, the blood which has come from the maternal sinuses flows in the lacunar spaces of the primitive epiblastic reticulum, and later among the more numerous permanent villi. As to the nature of the lining of this great blood space, there can be no doubt that it is mainly of fatal epiblast — in the early stages entirely ; but in the late stages of pregnancy, when the trophoblastic layer on the decidual surface becomes broken up, the layer may in places be in direct contact with the blood stream. I have not been able to discover any maternal arteries opening directly into the intervillous space — only the large sinuses in the manner already described. There is no extension of endothelium from the maternal vessels forming a layer covering the villi. On the other hand, I have shown (p. 139) that the original trophoblast may extend into some of the maternal sinuses and line their walls, a con- // AMNION. 151 dition which has hitherto been overlooked. It has undoubtedly been recognised, but always described as a maternal layer of endothelium which has extended outwards. The error of this opinion is now clearly established, especially since the part played by the foetal epiblast has been recognised, as a result of the examination of many sections by the most careful stain- ing methods. T have not noticed a well marked circular sinus, though Zedel claims that it is formed in tubal pregnancy. An appearance somewhat resembling it is often seen. The intervillous circulation may be studied in Plates IX., XL, XII., XIII., XVII. I have already referred to the great frequency with which clots are found in the placenta, associated with the occurrence of ha?morrhages from the decidua, especially from the reflexal portion. The Amnion. Little need be said regarding this membrane. It resembles exactly the amnion of uterine gestation. With Minot's description I am in entire accord. It consists of epiblast and mesoblast, the former being a single layer (occasionally double) of cells, which are mostly cubical, though in some cases columnar; sometimes they are considerably flattened. These variations depend probably upon differences in cells according to the pressure upon them. The free surface of the cells may be flat, rounded, or irregular. The nuclei are very distinct and stain deeply. The mesoblast consists of a layer of more or less undifferen- tiated tissue containing cells, which lie in spaces, arranged mostly parallel to the surface. The intercellular substance is denser near the epiblast, and fibrillated deeper down. ii^ 152 DEVELOPMENTAL CHANGES. The connective tissue cells are mainly in the deeper portions, there being left under the epithelium a non-cellular part which varies in thickness — the mesoblastic non-vascular. It is con- nected with the chorionic mesoblast by delicate fibrils, which get denser as pregnancy advances. In parts they may not be seen in the late months, the amnion and chorion having become firmly united. ' ■ ■~dominal swellings in the different ectopic varieties tend to resemble one another ; and at full time the eye of the physician will not generally be able to distinguish the condition from that caused by an advanced uterine pregnancy. Occasionally, also, the changes in shape of the abdomen during the last five or six months will correspond closely to those found . in normal cases. In the majority of cases, however, the enlargement of the abdomen, especially in the first five or six months, is mainly one-sided. At an early period this peculiarity may be detected. Van Cauwenberghe ^ mentions that an early ectopic gestation has been first noted as a swelling the size of a walnut, egg, or orange, in the groin. In the tubo-peritoneal case described by me ^ the woman noticed a swelling in the iliac region during the third month. This is an important point to bear in mind. In normal pregnancy no change can be detected by the eye in tlie abdominal wall until after the fourth month has begun. In tubal gestation, owing to the higher position of the tube, the pregnancy may cause a bulging of the abdominal wall at a period when, in normal cases, it would not do so, from being still below the pelvic brim. This appearance will be found only in certain ectopic cases. It cannot be expected in tubal gestation, where the tube early falls into the pouch of Douglas; interstitial cases, also, will probably i.ot cause any early lateral swelling, and they may be supposed to cause an abdominal projection at about the same time as in normal pregnancy. As the one-sided ectopic swelling increases, it has not the regular outline of a normal pregnancy. Instead of the longest » Op. eit., p. 104. 2 Op. "U., p. 45. FCETAL MOVEMENTS. 161 diameter being vertical, it is generally oblique or transverse ; sometimes the various diameters of the sac are about equal Changes occur in the umbilicus similar to those found in normal cases. Fcetal movements. — Movements of the foetus in ectopic gesta- tion sacs, which early lie close to the anterior abdominal wall, can be detected by the stethoscope before the mother feels them, and they may be recognised with greater ease than in cases of uterine pregnancy. After the mid term, the movements may often be recog- nised with great facility on inspection of the abdomen, and, sometimes, distinct irregularities may be seen, caused by the moulding of the abdomen and gestation sac on the foetus. On palpation, the foetal parts may be made out more readily than in normal cases ; and in thin-walled women they may, to- wards the end of pregnancy, be very distinctly felt. Fcetal heart sounds. — These may be heard with the stetho- scope, as in uterine pregnancy. In some cases they may be heard with ijreat distinctness, l)ut many variations occur in the ease with which they may be distinguished, depending upon the health of the foetus, its position, the relation of the sac to the abdominal wall, and the thickness of the latter. Maternal soujjle. — A souttle may generally be heard after the first two or three months, though there are numerous variations, both in regard to the time of its commencement and also in regard to its intensity. Sometimes it may be heard very faintly, or not at all; at other times it may be heard very loudly. It is most marked on the side corresponding to the gestation. In many cases it cannot be detected on the opposite side. 11 162 SYMPTOMS AND SIGNS. Changes in the vagina. — Changes occur in the vagina similar to those found in normal pregnancy, varying in degree in dif- ferent cases. Its walls become softer, more relaxed, and acquire a dusky hue. The,5e characteristics are most marked in the last half of gestation. Changes in the nterus. — It has long been known that, in ectopic pregnancy, the uterus undergoes certain changes, viz., enlargement, and decidual transformation of the mucosa of the body. These were first pointed out by Boehmei\i About twenty-one years later, William Hunter ^ corroborated this discovery, and has, as a result, been attributed by many with having first noted it. The enlargement occurs in all cases of ectopic gestation, but with considerable variations. Thus, in the following full time cases, the following measurements were found: — in Spiegelberg's,3 4|^ in.; in Martin's,^ 1\ in.; in Friinkel's,^ 4 J in.; in Hart's,*' 4 in. These were all of the subperitoneo-abdominal variety. In a pure tubal pregnancy,'^ at the sixth month, the uterus measured 5| in. in length ; in another,^ advanced to full time, 4y\ in. ; in the full time tubo-peritoneal case,'' described by me, 4| in. According to Bandl,^^ Kiistner," Hecker.i^ and others, the enlargement is greatest in interstitial pregnancies. While this is probably true, it must be remembered that, in the other varieties, exceptional length may be found as in 1 "Observat. Anatom.," 17.^2. - Med. Comment., London, 1773. ^ Arch.f. Gynaek., Berlin, bd. i., p. 406. ■* Trans. Obst. Soc. London, vol. vi., p. 57. ^ Arch.f. Gynaek., Berlin, bd. xvi., pp. 5, 299. " "Sect. Anat. of advanced Extra-uterine Gest.," Rep. Lab. Roy. Coll. Phys., Edin., vol. i., p. 26. '' Litzmann, Arch.f. Gynaek., Berlin, bd. xvi., p. 336. * Depaul, Arch, de tocol., Paris, tome ii., obs. 9. 9 " Tubo-Peritoneal Ectopic Gestation," EJin. 1892. i» " Cycl. of Obst. and Gyn.," vol. xii., p. 59. 11 Op. cit., p. 499. '- Op. cit. \ CHANGES IN UTERUS. les Litzmann's case, quoted above, and in an 8 month tubal case of Frankel's,^ where it was over 7 in.) Bandl has stated as a law that the nearer to the uterus the ovum is developed, the greater will be the enlargement. On comparing the measurements from a large number of cases, however, I find it impossible to cor- roborate this statement, except in regard to interstitial preg- nancies, where the average length of the uterus is greater than in other cases. Frankel ^ notes that the increase in size is especially marked in the long diameter, less in the transverse, and least in the antero-posterior. At any rate, the uterus doe& not cliatuje in shape so as to resemble the corulition fouiul %vhen the organ is itself pregnant. It retains more or less the shape found in the non- pregnant state. As the iiterus increases, it becomes softer, but the softness is not that of a pregnant uterus ; it is more that of a uterus in the second or thi'xl week of the puerperium. The peculiar rounding and indistinctness in outline, which is so characteristic of early uterine pregnancy, is entirely wanting in ectopic cases. Another difference important to note is absence of the thinning of the xiterine wall immediately above the cervix, so as to form an easily distinguishable lower segment, which is an important characteristic of normal pregnancy from an early period, and recognised on rectal examination. The cervix softens some- what, varying considerably in different cases, rarely being found as soft as at the end of normal gestation. It very often tends to become patulous in its lower part, so that it may even admit a finger. Sometimes it may not become opened at all, or only ti> a small extent. Often a tenacious plug of mucus is found filling the cervical canal. 1 Arch. f. Gynaek., Berlin, bd. xiv., chap. ii. '•* "Ueber die Diag. u. Behand. d. Extrauterinschwang. in d. ersten Monaten." 1 164 SYMPTOMS AND SIGNS. Shortening of the cervix has been described by some authors,^ but there is no proof that this occurs. As I have shown elsewhere,^ this statement is not true in normal pregnancy, in the sense understood by the older authors, who believed that it was gradually taken up into the uterus, and so shortened as pregnancy advanced. Sectional anatomy has shown that the cervix is as big at the end of pregnancy as at the beginning, that it may even be larger, and that the apparent diminution in its length, usually only slight, is mechanically produced as a result of the uterine body with its contents pressing on the softened cervix from above. In ectopic gestation the cervix is not usually so softened, and the pressure factors are wanting to bring about the mechanical shortening. The frozen sections made by Hart and myself are sufficient evidence in regard to this point. When the uterus is drawn up and displaced, the fornices may be partly or wholly obliterated,^ thus causing an apparent shortening of the vaginal portion of the cervix. The decidual changes in the uterus in ectopic pregnaiicy were tirst carefully investigated by Ercolani.* They have also been studied by Conrad and Langhans,^ Abel and others. One of the most exhaiistive accounts is that of Abel.^ The changes begin very early in the gestation. An early specimen has been described by the latter author. On opening the uterus, the mucosa is found to be arranged in a series of eleva- tions bounded by furrows, varying in complexity on the » Strahan " Extra-Uterine Pregnancy," Phila.. 1889. ^ "Researches in Female Pelvic Anatomy," Edin., 1892, p. 120. '■^ Barbour, Edin. Med. Journ., Sept. 1882. * "Delia struttura anat. d. caduca uterina nei casi di Gravidanza extrauterina," Bologna, 1874. " " Tubenschwangerschaft," &c.. Arch. f. Gynack., Berlin, bd. ix. ^ Arch. f. Oynaek., Berlin, bd. xxxix, p. 393. CHANGES IN UTERUS. 165 anterior and posterior walls. The elevations vary consider- ably in size, and the furrows may be deep or shallow. In specimens from later periods of pregnancy the same changes are found, but there are relatively fewer furrows, and the areas of elevation are larger.^ It has been suggested by Langhans that t'lese swellings are to be associated with the distribution of the vessels in the mucosa, the increase in size taking place chiefly around vascular trunks. This view has not been corroborated. On close inspection, the openings of the glands may be seen Fig. 14. — Ruptured tubal pregnancy at end of second month. (Bandl.) iJ. Seat of rupture in right tube. Td. Site of gestation in riglit tAibe. 0(1. Right ovary. ilr. Deciduii lining uterus, a quarter of an incl> in thickness. over the surface, mainly in the furrows. They become, to a large extent, obliterated on tho elevated areas. Microscopically, the following conditions are found : — In an early specimen the connective tissue cells show transforma- tion into decidual cells, especially in the uppermost layers of the mucosa. This interglandular increase leads to some com- pression and obliteration of superficial portions of the glands, ^ Conrad and Langhans, o/j. cit. Virchow, Oesammeltc Abhand. zur Wmen,' achfift. Med., Frankfurt a/M., 1856. \ •■"'■^'>S^'' Cycl. of Obst. and Gyn.," vol. viii., p. 88. Oji. cit., p. 44. If It: 182 SYMPTOMS AND SIGNS. marked symptoms, though in some cases this method of escape may be marked with pain and loss of blood. Symptoms and signs associated with hcemon^ha^e in connection with ectopic gestation. — When hfemorrhage occurs inside the tube, destroying ihe ovum, and giving rise to a hsemato-salpinx, without any secondary escape into the peritoneal cavity, the symptoms may be so slight as to escape notice. Localised pain may be felt in some cases, but there are usually no marked symptoms due to the pouring out of blood, the amount not being great — in the early months at least. The hjemato-salpinx may increase by successive haemorrhages at intervals, and more pain may be felt on these occasions. When perisalpingitis occurs, as it often does in these cases, pain may be felt in the affected region. i On bimanual examination, after the formation of the hremato- salpinx, the distended tube is felt, and, if the patient had been examined previous to the blood escape, it is recognised as being less cystic, firmer, and larger. The mass is usually painful, though it may be so only to a slight extent. At later periods, after some consolidation has taken place in the blood clot, the mass gets harder, and, in some cases, gradually sinks in size. When rupture of the gestation sac occurs, the symptoms vary according to the seat of rupture, its suddenness and the amount of blood 1 st. First, rupture may occur into the broad ligament only, giving rise oo a hamiatoma. I have already pointed out (p. 46) that the amount of blood poured out depends, probably, mainly on the amount of placenta torn through. The symptoms of this occurrence vary, accordingly, in intensity. In a well marked case pain is felt in the pelvis, especially on one side ; the patient becomes somewhat an?emic, the pulse is quickened, and there may bo some degree of shock. HEMORRHAGE. 183 The patient may sometimes feel faint. Retention of urine, difficulty of micturition, and defrecation may follow. The worst cases are those in which much blood escapes and Peritoneum Utenis Decidua Bladdei- Hseniatoma. Pouch of Douglas. Cervical canal. Vagina. Rectum Fig. 15, — Sagittal mesial section of pelvis, with sub-peritoneo- pelvic gestation on right side. The uterine cavity is exposed, show- ing the decidua. A hismatoma is seen posterior to the pouch of Douglas. (Hart.) burrows around the rectum, or out to the side of the pelvis following the psoas iliacus. ; I* ¥ .' i u ! Ill 4 1,1 ' 184 SYMPTOMS AND SIGNS. On examination, the conditions found vary according to the amount of blood poured out. When in the broad ligament alone, the mass is felt as a tense swelling, obliterating the lateral fornix, it may be, or extending down the side of the vagina for a distance. If the blood has spread outwards, it may be felt in the region of the psoas iliacus or round ligament. The uterus is displaced towards the opposite side of the polvis. If the blood has spread around the pouch of Douglas, a mass is felt behind the uterus, pressing it forward? along with the .pper part of the 'agina, the rectum being compressed. The iipper surface of the hDeraatoma is irregularly convex, the lower more or less concave. Just after its formation the mass feels tense; after consolidation and organisation has begun, it has a firmer elastic feeling, and gradually becoiaes harder. When the ovum is not destroyed, but remains intact above the hrematoma, it may still be felt as a cystic swelling, though probably more tense than before the haemorrhage took place. When rupture of the gestation sac takes place into the peritoneal cavity, either by escape of blood through the wall or through the fimbriated end of the tube, giving rise to a haematocele, the symptoms vary in different cases, but are in general of a much more severe type than in the case of a heematoma. In the majority of cases a large quantity of blood escapes, accompanied with sudden pain, anaemia, faintness, quickened and smaller pulse, collapse, vomiting. Sometimes there are convulsions and delirium. On palpation of the abdomen, dulness may be made out in its lower regions in extremp cases. On bimanual examination, soon after the loss of blood, the fluid may only be felt as an indefinite fulness, in the midst of which the gestation sac may be made out. If the patient does not die, and consolidation \ HEMORRHAGE. 185 of the blood takes place, the mass is felt as a solid structure bulging down into the pelvis and reaching up into the abdomen, often higher on one side than on the other, and to a varying height. This mass has a resistant elastic feeling. The uterus may be felt pushed to the front, close behind the symphysis ; it may be felt lying retroverted ; or it may not be felt between the hands, on account of its being surrounded on all sides by the blood which then bulges down the fornices, the 'ponM vagince being sc ely distinguishable. It is also often felt laterally displaced. The intestines are made out on percussion to be pushed above the blood mass. The bladder and bowel disturbances in these cases may be very marked. Escape of blood from the uterine mucosa into the vagina may some- times accompany the internal loss of blood. In a certain number of cases these symptoms may be much less marked, i.e., where the blood escapes but slowly or in small quantities at successive periods. The causes of these variations I have already given (p. 62). Sometimes, indeed, the symp- toms may be very slight indeed. If the patient does not die immediately from the loss of blood, the symptoms and signs which follow vary according to the course taken by the hiematocele. Its absorption may take place in process of time, the patient suffering mainly from weak- ness and some bladder and bowel disturbances. Only rarely does acute peritonitis follow, and it is generally septic. Sometimes the patient may suffer from chronic peritonitis. In some cases repeated haemorrhages may follow, causing death. Suppuration of the hit matocele may sometimes occur. Signs and symptoms associated with suppuration. — I have already {vide p. 47) discussed the conditions under which the various forms of ectopic gestation may undergo septic changes. The result of these changes is the formation of pus, 186 SYMPTOMS AND SIGNS. either intra-peritoneal, extra-peritoneal, or both intra- and extra- peritoneal. The symptoms and signs vary considerably in different cases, though there are certain well-marked charac- teristics common to all. Occasionally the septic process is of the nature of acute septiccemia, the patient rapidly succumbing after symptoms of rigors, exhaustion, high temperature, quick feeble pulse, and, it may be, delirium and coma. In the majority of instances the affection is a more chronic one, the pus working its way to the exterior by the bowel, vagina, skin, &c., as has already been described. The dis- charge varies greatly in different cases, and may be prolonged for years. The main element affecting its continuance is the condition of the foetus. The older the fojtus, the more diflficult the escape of its bones and the longer the condition of pytemia. The symptoms in these cases are well known. The patient loses strengtl ' and weight, becomes hectic ; night sweats and diarrhoea may rcur, and the temperature is elevated and irregular. Pain is a very variable feature. It may be severe before the abscess bursts, afterwards disappearing more or less. Later there may be returns, especially marked where large bits of bone are working their way to the outside. When the bladder is opened into, symptoms of cystitis supervene, causing much discomfort ; if a further opening through its base develops, the symptoms of vesico-vaginal fistula are added. Sometimes without the latter condition being pro- duced, calculi may form in the bladder, the nuclei being usually bits of foetal bones. "When the bladder is affected the septic process may spread to the kidney, giving rise to a pyo-nephritis, a most serious condition. If the gestation sac commuj icates with some other part as SUPPURATION. 187 I n well as with the bladder, the urine may be partly discharged by the other opening. When the bowel is opened into, its mucosa becomes irritated and inflamed, and diarrhoea often results, which may some- times be bloody. Diarrhoea in long standing cases may also be caused by waxy disease. Difficulty in the passage of bones through the rectum may cause pain, a feeling of weight and heat and tenesmus in the region of the anus; sloughing may take place, giving rise to a fistulous opening into the rectum or on the surface. When the gestation sac opens into the bowel, and communi- cat(!S at the same time with the surface by skin, vagina, &c., ffEces may pass by the latter opening. In the rare cases where the bowel is opened into high up, the digestive process may be greatly interfered with, the partly digested food passing into the abscess cavity and thence to the surface by another opening when one exists. If the stomach be opened into, distressing vomiting occurs. Sometimes symptoms of strangulation of the gut may develop when it becomes constricted or twisted by peritoneal adhesion to the gestation sac. In many cases where discharge of the contents of the gestation sac is taking place, the odour is extremely foetid and offensive. The conditions felt on examination are much the same as in ordinary septic peritonitis and cellulitis. Fluctuation may be obtained, and pain is usually caused on palpation. Before the abscess opens it may be recognised as pointing in the abdominal wall, perineum, buttocks, vagina, &c. After bursting has occurred, the foetal structures may be seen issuing from the abscess cavity, or the exploring finger may readily detect them. i 188 SYMPTOMS AND SIGNS. I, In some cases where the gestation sac communicates with the bowel, the percussion note over the former, which was at first dull, becomes resonant from the passage of gas into it. In cases where an abscess has formed around a lithopttdion which has remained quiescent for a number of years, there may- be no escape to the surface of the foetal parts, or only a very gradual escape, the lithoptedion tending to remain in the abscess cavity as a solid hard mass. Rupture of the gestation sac at the time of sp.rious labour. — Various forms of rupture of the gestation sac at the time of the spurious labour are described. The rarest is rupture into the peritoneal cavity. In Parry's analysis^ of five hundred cases of ectopic gestation, not a single example occurred. It is doubtful if it has been observed. In a few cases,^ under the influence of the pains, the burst has occurred into the vagina and the child expelled. These have probably been examples of the subperitoneo- abdominal varieties, in which the ovum had grown extra- peritoneally, after having burst from the tube into the broad ligament, and had spread over the tissues of the pelvic floor. Eupture has occurred into the large intestine where the spurious labour has been premature, the foetus being born through the anus. This has happened at the sixth,^ seventh,^ and eighth^ months of pregnancy. I do not know that it has been witnessed at full term. Such cases are probably also subperitoneo-abdominal where the gestation sac enters into close relation with the lower part of the large intestine, especially with the rectum. J Op. cU., p. 118. ^ Emmons, Bost. Med, and S. Joum,, July 1883. Hugier, Lancet, Nov. 20, 1852. 3 Giffard " Cases in Midwifry," London, 1794. * Clark, Phila. M. Museum, 1806, vol. ii., p. 292. " Adelon, Arch, de nUd,, 1826, tome xii. DEATH OF FCETUS. 189 % 111 interstitial pregnancies occasionally the foetus bursts through the septum which shuts it off from the true uterine cavity, afterwards being delivered through the vagina, though generally by artificial means. This happened at full time in the cases of Langier ^ and Fielitz.^ Braxton Hicks '^ described an instance of rupture during the fifth month of gestation. Changes folloiving the death of the foettis. — The maternal souffle gradually disappears, though at varying periods in different cases ; in one instance it was not heard after the fourteenth day. I have already (pp. 158, 169) alluded to the change in the milk secretion, as well as to the labour-like pains which may return from time to time. Menstruati» »t Pelvic In- Ectopic Gestation, . 106 flamma- Chorion, 141 tory Exu- „ Non-Placental Portion of. 149 dations, 202 „ Placental Portion of, 142 ,, »» ,1 Pregnancy in Classification, .... 16 Bi-Cornuate „ Author's, 27 Uterus, 204 „ Bianchi's, 21 »* „ ,» „ in a Rudi- „ Dezeimeris', . 22 mentary Josephi's, 21 Horn, 203 Tait's, . 26 »* jt »» Retroversion Combined Intra- and Extra- Uterine of Gravid Gestation, 18 Uterus, 195 Concurrent Ectopic and Uterine ,, 11 »t Spurious Gestation, .... 110 Pregnancy, 204 Hi (; 238 INDEX. Diagnosis, differential from Uterine Pregnancy, . . . . 191 Discharge of Uterine Deoidua, . 157 Electricity, use of, to destroy Ovum, 209 Elytrotoray 210 Enlargement of Abdomen, . . 159 Etiology, 1 External wandering of Ovum, . 90 Extra-Peritoneal Growth of Ovum, 19, 24 ,, Hsemorrhage, . 46 ,, Rupture of Tube, 36 Fsecal Fistula, .... 49 Fertilisation of Ovum, . 3 Foetal Heart 161 ,, Movements, 161 FcEtus in Ectopic Gestation, . 112 ,, death of, at term. 172 ,, destruction of, in Peritoneal Cavity, . . . . 66 , , development of, . 112 ,, discharge of, through Abdo- minal Wall, 50 ,, ,, ,, Bladder, 50 „ ,, „ Bowel, 49 ,, ,, ,, Perineum, 50 „ Uterus, 50 » . Vagina, 50 Full Time Ectopic Gestation, changes at 169 Genetic reaction in Miillerian Tract, after fertilisation of Ovum, . 11 Growth of Placenta, supposed, after death of Fcetus, . . . 101 Haematocele, Sequelae of, . . 65 Heemato-salpinx, .... 73 Hsemorrhage from Uterus during Pregnancy, . . 154 „ into Broad Ligament, accompanying Rup- ture of Tube, . 46,182 „ „ Peritoneal Cavity, 61, 184 Hernia of Ectopic Gestation, . Ill Hunter's Experiments on the fate of Blood poured into the Peri- toneal Cavity, .... 67 Injection of Poisons into Gestation Sac, 208 Intercurrent Uterine Gestation, . 110 Interstitial Pregnancy, ... 75 ,, „ first described, 19 Intervillous Circulation, . 139, 150 Intestines, relation of, to Ectopic Sac 37, 47, 49, 51, 179 Intestinal Escape of Fcstus, . . 49, 187 Labour, Spurious, at Full Time, . 169 PAOB Labour, Spurious, duration of, . 169 ,, „ influence of, on Foetus, . . 172 „ „ premature, . 169 „ „ repeated, . . 169 Ligament, Broad, Gestation, . 36 Liquor Aranii, . . . . 173 Lithopaedion. .... 94 Mammee, Changes in, , . . 158 Menstruation, Normal, Nature of, 8 „ Relation of, to Preg- nancy, _ . . 7 „ History of, in Ecto- pic Pregnancy, . 154 Micturition Troubles, . . . 178 Mole, Tubal, .... 74 Multiparity in Relation to Ectopic Gestation, 105 Mummification, .... 92 Muscular Part of Tube Wall, Changes in 115 Nerves, Results of Pressure on, . 179 Ovarian Pregnancy, so-called, . 14, 44 „ „ first described Case of, . 17 Pain in Ectopic Pregnancy, . . 180 Peritoneum, Changes in, . . 41, 113 Perineal Discharge of Foetus, . 50 Periodic Colicky Pains, . . 155 Peritonitis, . . . .28, 115, 180 P rifaetion, so-called, ... 95 Phylogeny of Genital Tract, . . 4 „ „ Placenta, . . . 128 Placenta, 142 ,, Displacement of, . . 43 „ Supposed growth of, after Death of Foetus, . 101 Plural Ectopic Gestation, . . 109 Pressure Symptoms, . . . 179 Primary Abdominal Pregnancy, so- called, 28 „ „ „ KoeberM's sup- posed Case of, 29 „ ,, „ Lecluyse's sup- posed Case of, 28 Post-mortem Examination, Fallacies "1. 28 Primiparity in relation to Ectopic Pregnancy, .... Proportion of Ectopic to Normal Gestations, .... 105 106 Puncture of Gestation Sac, . 207 Pyo-salpinx, 74 Rectum, Delivery by, . „ Examination by, 49 190 INDEX. 239 PAGE Rectum, Pressure on, . . . 179 Repeated Ectopic GeHtation, 107, 169 Retention of Foetus, . , 92,99,111 Rudimentary Uterine Cornu, Preg- nancy in 86 Rupture of Gestation Sac, . 66, 61, 181 „ „ ,, at time of spurious Labour, 188 Side of Gestation 106 Signs and Symptoms of Ectopic Pregnancy, . . . 153 Site of Gestation in Tube, . . 106 Souflfle 161 Sound, use of, in Diagnosis. . , 194 Spurious Labour, . . . . 169 Stirrage, 159 Sub-peritoneo-Pelvic Pregnancy, . 36 „ ,, „ first described, 19 ,, Abdominal Pregnancy, 37 Suppuration, 47, 51 185 153 153 159 173 158 162 162 154 157 161 161 161 154 155 169 159 178 178 179 189 180 184 182 182 182 179 180 178 179 188 185 Symptoms of, . Symptoms and Signs of Ectopic Pregnancy, Those resulting from the Preg- nancy per se, . Abdominal Examination, Bimanual Examination, Changes in Breasts, . „ ,, Uterus, „ Vagina, . Constitutional and Sjonpa- thetic Changes, Discharge of Uterine Decidua, Foetal Movements, „ Heart-sounds, . Maternal Souffle, Menstruation History, Periodic Colicky Pains, Phenomena at Full Time, Stirrage, Those resulting from Compli- cations, . Bladder, Circulation, Death of Foetus, . Inflammation, . Internal Heematocele, „ Hsematoma, . „ Heemato-salpinx, „ Hffitnorrhage, Nerves, Pain, .... Pressure Efifects, Rectum, Rupture of Gestation Sac at Spurious Labour, . Suppuration, Treatment, Elytrotomy Old methods of destroying Ovum through influences brought to bear on Mother, Compression of Gestation Sac, Injection of Drugs into Sac, . Puncture of Sac, . Use of Electricity, . The best Methods to Adopt, Where combined Ectopic and Uterine Gestation oxist, „ the Kctopic Gesl tion is of o i stand - 207 201 207 '!08 208 207 209 213 232 232 ing, . „ „ is actively growing, 232 „ ,, ,, has passed Full Time, the Foetus having died, 229 „ ., „ hiis reached Full Time, 228 „ „ „ is entirely Tubal . 215 „ „ „ Ampullar and Infun- dibular, 215 „ „ „ Interstitial, 217 „ Mummification, &c., have followed Death of the Foetus, „ Pregnancy exists in a Rudimentary Horn, . „ Rupture into Broad Liga- ment has occurred, . „ at time of Rupture, . „ after Rupture, develop- ment of Ovum has continued, „ when a Secondary Rup- ture into Peritoneal Cavity occurs, . ,, Rupiure into Peritoneal Cavity occurs, . ,. with marked Loss of Blood, Shook, &c., „ „ Slight Sjrmptoms, „ „ no Symptoms, „ Suppuration has occurred in old or recent Ectopic Gestations, „ before the Pus has worked its way to the Exterior, . ,, alter jt * • ■ Tubal Abortion, .... ,, Gestation, Developmental Changes in, . . 113 230 233 223 223 224 218 218 218 220 220 230 230 231 70 ^:i ii m 240 Tubal Gestation, Mucous Membrane, ,, „ Decidua Reflexa, ,, ,, „ Serotina, ,, ., Progressive Changes in Blood INDEX. PAOE 117 129 123 Vessels, 127, 129 Connective Tissue, . Epithelium, 124 124 117 115 113 » » „ „ Vera, „ Muscular Wall. „ Peritoneum, „ Relations between Ovum and Decidua, . . 133 „ Early Importance of Foetal Epiblast, . . . 133 Amnion, . . . 151 Chorion 141 Non-Placental Portion, 149 Placental Portion, . 142 Attachment of Villi to Decidua Serotina. 146 ,, „ Intervillous Circulation, 139, 150 ,, „ Formation of Villi, . . 144 ,, Mucosa outside Ovum, . 132 Tubo- Abdominal Gestation, so-called. 20 „ -Ovarian „ ,, 20 „ -Peritoneal Gestation, . . 53 Twin Pregnancy, . . . . Ill Uterine Escape of Foetus, . . 50 Uterus in Ectopic Gestation, . 162 Utero-Interstitial Gestation, so-called, 19 ,. -Tubal ., „ 20 ,, -Tubo-Abdominal ,, „ 20 Vaginal Changes, , . . . 162 „ Discharge of Ovum, . 50 „ Pregnancy, so-called, . 18 „ Section, . . . . 210 Varieties of Ectopic Gestation studied ind. 1, . . 33 „ Ampulk Tubal, . 33 „ Gestation Destroyed, 70 „ Hsemato-salpinx, . 73 PAGE Varieties of Ectopic Gestation studied in detail — „ Mole Formation, . 74 „ Mummification, &c,, 74 „ Pyo-salpinx, . . 74 „ Tubal Abortion, . 70 „ Persistent, . . . 33 „ Ruptures into broad ligament, . . 36 „ Sub-Peritoneo-Pelvic Gestation, . . 36 „ May Grow to Full Time, 39 „ Rupture into Peritoneal Cavity, , . 45 „ Terminate by Adipocere Formation, 53 ., ,, Hsematoma, 46 „ ,, Lithopsedion, 153 „ ,, Mummifica- tion, . 153 „ „ Suppuration, 47 „ Ruptures into Peritoneal Cavity. ... 53 „ May Grow to Full Time, Tubo-Peritoneal, . 53 „ May Terminate, . 61 „ Sequelajof Hsematocele, 63 Infundibular Tubal, . 83 „ Tubo-Ovarian and Tubo- Abdominal, so-called, 32, 83 ,, Interstitial Tubal, . 7r> ,. Ovum may die and be retained under- going various Changes, 83 „ Persistent, . . 179 „ Rupture may occur into Broad Ligament, 82 ,, Peritoneal Cavity, 79 ,, Uterine „ 81 „ ,, Peritoneal and Uterine Cavities, 81 Vesical Fistula, . , .50, 186, 231 Villi Attachment to Serotina, . 1 46 ,, Changes in, . . . . 146 ,, i'^'ormation of. . . 141, 144 74 74 74 70 33 36 ', ; {' / Vl f.>- 83 PLATE I. Fig. 1. Wall of gestation sac (tubal) at full time. The membranes are not shown. (a) Connective tissue. (6) Muscular bundles. X 175. Fig. 2. Transverse section through ampullary part of Fallopian tube (referred to on pp. 11, 119) showing simple arrangement of folds of mucosa, and also decidual changes in them. The tube of the opposite side was occupied by a two months' pregnancy. (a) Folds of mucosa showing decidual changes. (6) Muscular part of wall. X 10. Fig. 3. Another portion of the same. X 10. ties, 81 186, 231 146 146 141,144 y V. Plate I. / / ^. Fty "--mimmw^. - iitL'iifejtii^iSISStArJiyaA^'^li'ii^i?^^ / V t PLATE III. Fio. 1. Decidual formation in tubal mucosa. Specimen referred to in Plate I., iigs. 2 and 3. (o) Flattened and partly separated mucosal epithelium (originally columnar). (6) Decidual cells in various stages of formation, (c) Muscular bundles. X 230. Fig. 2. Section across one of the fringes of mucosa in a normal tube. (a) Columnar ciliated epithelium. (h) Delicate connective tissue core. X 435. ' ^ Fio. 3. Section across one of the fringes of mucosa in tube showing decidual changes, (a) Flattened epithelium. {b) Broken and degenerating epithelium. (c) Decidual changes in connective tissue core. X 230. Fig. 4. Decidual tissue torn up by blood extravasation. (a) Branching decidual cells. (6) Blood corpuscles. X 435. 1 J Plate hi. a ::r:^_-A Fiy 1 II a f'ly 2 lii i Flj J iig 4 V ■x^.'../- PLATE IV. Fig. 1. A portion of wall showing decidual changes in the mucosa. a Marked formation of decidual cells in superficial compact layer Spaces in the deep or spongy layer, c) Muscle. X 52. Fio 2. Another portion showing the same conditions. (a) Marked decidual formation in two of the simple fringes of mucosa (6) Spaces of spongy layer ; in them lies cast-oflf epithelium, (c) Muscle. X 52. I i all- ! Plate IV i > i miii*it;k«mm^>'*^-C'^ ,^ jm^^ ', > PLATE V. Fig, 1. Another part of the tube showii;cr ch,, same conditions. (a) Decidual changes in mucosa fringes, ('i) Spaces of spongy or deep layer, (c) Muscle. Fig. 2. X 52, This section shows a bit of the spongy layer highly magnified. In the upper part of the section are seen a few decidual cells belonging to the compact layer of the mucosa. The decidual changes have not extended far into the spongy layer. (a) Decidual cells jf compact layer. (h) Spaces of spongy layer containing cast-off and degenerating epithelium. (c) Muscle. (d) Ordinary connective tissue cells of the mucosa. X 435. \ ii Plate v Fig 1 Fis 2 I I PLATE VI. Fig. 1. Another section showing short projecting folds of mucosa in which decidual changes are progressing. («) Fringes of mucosa. (b) Muscular part of tube wall, X 52. Fig. 2. Another section showing a very short broad fringe with decidual changes. (a) Fringe of mucosa. (b) Muscle of tube wall. X 52. Fig. 3. A portion of the compact layer of decidua, with gland-like spaces. They are either gland-like spaces which have been prenent from the first, or are artificially formed by the blending of the outer portions of adjacent mucosal fringes, in the process of decidual transformation. («) Connective tissue with some decidual cells. (b) Gland-like spaces. 2 mos. X 175. Fig. 4. Villus attached to decidua serotina not by its end, but by its side. There is very little proliferation of the epithelial (chorionic epiblast) cells covering it. (a) Delicate mucoid tissue of villus. (6) Epithelial covering somewhat proliferated in its deep layer. (c) Mass of fcetal epithelium, remains of original epiblastic proliferation- trophoblast layer, lying on decidual surface. (d) Capillary space in decidua. (c) Gland-like space in decidua. 2 mos. X 97. V Plate vi h F:j I m .ft-!- -— /(. * » * < Fit/ 4 BMAGE EVALUATION TEST TARGET (MT-3) ^ WO V w^.. /- / ^< & y. ^ 1.0 I.I 1.25 ■- ilM ■ 50 "'"^^ If ua IlM IM 1.8 U 11.6 V] <^ /] / Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 'Q.- KP.r e V •^ ,/,'. I i ' V n w PLATE VII. Fig, 1. Section through compact layer of decidua aerotina. (a) Fillua partly embedded in serotina. (6) Row of cubical cells, probably remains of epithelium which lined a gland- like space. (c) Decidual cells. (d) Another embedded villus. (c) Foetal epiblast lying on decidua. 3mcc. X 62. Fig. 2. Compact layer of decidua. (a) Superficial mass of degeneration, probably coagulation-necrosis. (6) Muscular bundles of tube wall. Note also scattered decidual cells, and rows of cells which have probably belonged to gland-like spaces. 2 mos. X 175. Fio. 3. Compact layer of decidua. (a) Degenerated layer in upper part. (b) Decidual cells. (c) Layer of homogeneous nucleated protoplasm, remains of original foetal epiblast. 2 mos. X 175. "'y /^ V i\ \- ^ ^r^b:^***^ " Plate VII. Fy 1 -(I Fig j-iemrn -0, Fig V / ''i PLATE VIM. Fro. 1. . Another of the same. (a) Decidual cells. (6) Superficial layer of original trophoblastic layer. (c) Mass of nucleated protoplasm of same nature as that on the surface of the decidua ; this is probably a section through a projection from the surface layer which has extended inwards obliquely. 2 mos. X 175. ■ ' Fig. 2. ' ' Section across wall of gestation sac (tubal) wall at full time. (a) Villi attached to serotina. (6) Remains of foetal epiblast on surface. * ■ (c) Thickness of decidua ; there are few cells seen. (d) Thickness of sac wall ; it is made up almost entirely of connective tissue. __ 9 mos. X 97. Fig. 3. Another of the same. (a) Villus. (6) Remains of foetal epiblast layer, (c) Thickness of sac wall. Note that the decidual layer has almost entirely disappeared. 9 mos. X 97. I Plate viii. J i :!=>/' ^^y ^ />_-. ili(i Fr^ Ftff 3 / V. W f \ ! I I / // w PLATE IX. Fig. 1. Section through part of placenta und tube wall. (a) Amnion. (6) Chorion. (c) Large villuB-stem. (d) Villi. (e) Villus attached to decidua. {/) Blood sinus in decidua. ((/) Decidual tissue. {h) Muscular part of wall. 2 mos. X 10. Fio. 2. Section through reflexa, amnion and chorion. (o) Decidual tissue of reflexa ; there are few large decidual cells and many leucocytes. (5) Large blood spaces. (c) Remains of a villus of chorion Iceve embedded ir surface. (d) Another villus embedded ; it is quite degent^- j.ced having lost its covering epithelium. (e) Remains of fcetal epiblast on surface of rcaexa. 2imo8. X 38. Pi! i! IN! / Plate tx *-. 9— h^. Fiq 1 Fig^. l<}\ PLATE X. Fig. 1. Decidua serotina at third month. (a) Numerous large decidual cells. (6) Fibrin and blood lying on surface of decidua. (c) Fcetal epiblastic remains on surface. (d) Degenerated superficial decidual tissue. (c) Fibrin from blood extravasation in deep layers of serotina. 3 mos. X 175. Fig. 2. Decidua serotina and part of ...iiscular wall of tube. {a) Prijecting fringe of mucosa showing marked decidual changes in its connective tissue. (6) Decidual cells in another part of mucosa. (c) Blood sinus. (d) Marked endothelial proliferation — trophospongia formation ; it extends out somewhat into surrounding tissue. 5 to 6 weeks x 97. Fig. 3. Section through part of decidua serotina. (a) Decidual tissue. (6) Large blood sinus. (c) Trophospongia. (d) Extension outwards of trophospongia towards surface. (e) Villus attached to surface ; the proliferated cells of its epithelium join the trophospongia. (/) Remains of foetal epiblast on surface of decidua. 3 mos. X 97. V. Plate x ,.* Fiy i n c .. F!:/ V, PLATE XI. Fig. 1. Part of decidua serotina. (o) Decidual tissue. (6) Part of large sinus in decidua opening outwards into intervillous space. (a) Blood in sinus. (d) Masses of fcetal epiblast ; they have apparently led to the absorption of decidual tissue so as to open into blood sinus, (c) Villus. 2 mos. X 175. Fig. 2. Part of decidua serotina with villus attached by its side. (a) Villus. (6) Decidua. (c) Large sinus in decidua. (d) Proliferated endothelium — trophospongia. (e) B«mains of foetal epiblast on surface of decidua. 3 mos. X 175. Fig. 3. Artery at junction of muscular and decidual part of tube. {a) Artery with blood and cast-otf endothelium in its lumen. (6) Decidua. (c) Muscle. (d) Proliferated endothelium. 5 to 6 weeks x 38. V d J, .1' ™ . f rt.V /'///. -^'7 -^^ h Plate XI _/>- ,/ ..-.(' ny il 1 is 1 r 1 i ' ; ! :.' J i' il d r> PLATE XII. Section through decidua and placenta. (a) Amnion. (h) Chorion. (c) Villi. (d) Villus attached to surface, (c) Decidua. (/) Large blood sinus opening into intervillous spaces, ((/) Remains of villi between membranes and decidua outside sero* i. 3 mos. X 10. Platf XII l'> n\ I ' PLATE XIII. Section through decidua reflexa and part of tube wall outside it. («) Decidual tissue of reflexa. (6) Blood Hiiiice in reflexa. (c) Blood space which has burst through foetal surface, tearing apart villi. (d) Villus attached to surface, (c) Amnion. (/) Chorion. (a) Villi. '' 2imo8. X 10. !;( Plate nil '; . ; v. \ PLATE XIV. Fig. 1. Section through one wall of a blood space in decidua, (a) Decidual tissue. (b) Endothelial proliferation — trophospongia, extending outwards absorbing decidua. 3 mos. X 435. Fig. 2. Section across a blood sinus. {a) Lumen of vessel. (6) Endotheliiim unchanged on one side. (c) Marked endothelial proliferation — trophosjxjngia. 4 mos. X 435. Fig. 3. Section through membranes, blended reflexa and vera, and part of muscular wall of tube. (a.) Amnion. (6) Chorion. (c) Villi attached to surface of reflexa ; they are fibrous and have, to a great extent, lost their covering epithelium. (d) Blended reflexa and vera, (c) Muscular part of wall. (/) Blood sinus. (y) Remains of fcetal epiblast on surface of reflexa. Fig. 4. Another of the same. (a) Amnion. (6) Chorion. (c) Reflexa and vera. (d) Muscular part of wall. 4 mos. X 38. 3 mos. X 38. Plate xiv. a. _/6 Fig J Fiif 2 C 9- f- *_^t*-'**'itf-'— —-J-."*-" <5t /■/^ i^ 1 I ; r m :!ifll m ^Ullfe: ll ^1 \ y> PLATE XV. Fig. 1. Another of the same, (a) Amnion. (6) Chorion, (c) Villi are embedded in the decidua, they have undergone fibrous change, and have lost their epithelium, (rf) Decidua. (e) Muscular bundles of tube wall. 2^ mos. X 38. Fig. 2. Villus attached to a decidual hillock ; the latter is probably the remains of a muc jal fold. (a) Villus. (b) Decidual tissue, (c) Remains of fcetal epiblast on surface of decidua. 2 mos. X 97. Fig. 3. ' Decidua virith villi attached and embedded in various ways. (a) Projecting mass of decidual tissue, (6) Villi. (c) Remains of fcetal epiblast. 3 mos. X 38. Fig. 4. Villus attached to decidua serotina. (a) Connective tissue of villus. (b) Surface layer of epithelium ; note its resemblance to the fcetal epiblast found on surface of decidua. (c) Proliferated mass of deep layers of epithelial cells on end of villus. (d) Remains of fcetal epiblast on surface of decidua. (c) Decidua serotina. 2 mos. X 175. m Plate xv i'V^ i Fly 2 .iV«: -••'/•^ "•^, •f^^. Flif ,/ ■"v -?;•- /{^/ #, I:' ; - .' •v. I K'^ H PLATE XVI. Fio. 1. Serotina and villi. («) Proliferating cells of deep layer of the epithelium covering the villi, before adhesion to the decidua, (b) Superficial layer of cells being stretched, broken and caat off. (c) Remains of fretal epiblast on surface of decidua. (d) Decidua. 2 mos. X 175. Fio. 2. Attachment of villus to serotina by a plasmodium-like stalk of foetal epiblast. (a) Villus. (b) Stalk of epiblast continuous with superficial layer of villus and with that on decidual surface. (c) Decidua. 2 mos. X 230. Fig. 3. Another of the same, (a) Villus. (6) Stalks of foetal epiblast. (c) Remains of fcetal epiblast on surface of decidua. (d) Decidua. 2 mos. X 230. Fig. 4. Masses of foetal epiblast and early villus. (a) Multinucleated plasmodium-like mass. (6) Early villus ; the epiblast ring has a core of young connective tissue. (c) Strands of epiblast, (d) Pale hyaline strand with nuclei broken into granules — degenerating. 3 mos. X 500. ^ I I V / Plate xvi a ^ It h d Fij 1 c Fiss. Fig 4 M PLATE XVII. Fig. 1. Reticulated mass of plasmodium-like foetal epiblast, probably the remains of early epiblastic connection between ovum and decidua. In one part it is continuous with the layer Ijang on the decidua. (a) Decidua. (b) Reticulated epiblast. (c) Epiblastic layer on surface of decidua. (d) Maternal blood corpuscles. 5 to 6 weeks x 435. Fig. 2. Large blood sinus in decidua opening into intervillous space. {a) Sinus. (6) Decidua. (c) Masses of fretal epiblast which have spread along walls of sinus. (d) Maternal blood. 2 mos. X 38. V h Plate xvil / , ^rW Fip 7 ("^ ^<^ A^ i v.. f \ PLATE XVIII. Fig. 1. Sinus in decidua with masses of foetal epiblast attached to its side and lying in its lumen. (a) Sinus. (b) Foetal epiblast. • • " (c) Decidual tissue. (d) Muscular bundles of tube wall. ^ (e) A mass of foetal epiblast occupying part of the lumen of a small vessel. 2 mos. X 38. Fig. 2. Section through amnion and chorion, (a) Amnion. (b) Chorion. (c) Vessel in chorion containing fcetal blood. (d) Part of a villus-stem. I 3 mos. X 97. Fig. 3. Another section of amnion and chorion highly magnified. (a) Superficial layer of low cubical epithelial cells of amnion. (b) Connective tissue layer of amnion. (c) Superficial darkly stained epithelial layer of chorion — note a thickening at one part ; this layer is the same in nature as that seen on the surface of the decidua and villi, (rf) Deep layer of epithelial covering of chorion : it ia here several layers in thickness. • (e) Connective tissue of chorion, 3 mos. X 400. i V / \ ( \ Plate xviii «.«•«•««»» Fig 3 V -' ; n^ \') PLATE XIX. Fia. 1. Another of the same. | / (a) Amnion. (6) Chorion. The chorionic connective tissue is thicker, and the deep layer of epithelial cells thinner than in Fig. 3. o mos. X 400. ,; Fig. 2. Another section of amnion and chorion. (a) Amnion. (6) Chorion, (c) Villus-stem. Note variations in thickness of chorionic epithelial layer ; at one point it is splitting in its superficial part. 9 mos. X 97. Fig. 3, Another section of amnion and chorion, highly magnified. (a) Amnion ; note the small amount of the connective tissue layer. (6) Chorion ; note the thinness of its epithelial covering. 3 mos. X 400. Fig. 4. Another section showing amnion and chorion completely blended. (a) Amniotic epithelium. (h) Chorionic epithelium ; note how this layer varies in thickness and tends to split into layers. 9 mos. X 97. Plate xix o ^i^?-'*;,: '*uSliB'^' /•«y i Fly 2 -TtT'--^'-. ,. -«t _^ * /-zy # rf ^ PLATE XX. Fig. 1. Early villiw formation. {a) ■^piblastic covering. (6) Mesoblastio core. 6 weeks x 540, Fio, 2. Early villus formation. (a) Epiblastio covering. (h) Mesoblastio core. (c) Large villus-stem from which villus is arising. 6 weeks X 540. Fig. 3. Another of the same. (a) Villus bud. (6) Main villus-stem. 2 mos. X 540. Pig. 4. Transverse section of early villus. {a) Superficial layer of epiblastic covering. (h) Deep layer of cells of epiblast. (c) Branching cells of mesoblastic core. (d) Capillary of villus. 3 mos. X 540. Fig. 5. Another section of an early villus. (a) Outer layer of epiblastic covering ; note the small number of cells belonging to the deep layer. (6) Deep cells of epiblast. (c) Connective tisdue core of villus. [d) A bud of the superficial epiblastic layer. 2 mos. X 405. Fig. 6. Another of the same, (a) Epiblastic covering. (b) Connective tissue. (c) Strand of epiblast attached to villus. 2 mos. X 405. V(t . / t\ a_ Fl(f 1. r LATE XX 'ri ^l^S Fig 2. Fiy 4 ^ II \ Fig 6. \\ ■^. wm PLATE XXI. Fig. 1. Villi from full time placenta. Note the condensed fibrous nature of the connective tissue. The epithelial covering is very thin in some parts, split up in others, and in others almost entirely removed. 9 mos. X 52. Fig. 2. Section through a part of the decidua serotina and placenta at full time. (a) Decidua ; it is thicker in this section than in any others which I have made in cases of full time ectopic gestation. (b) Villi. (c) Remains of fcEtal epiblast on surface of decidua ; very little of this is found at full time. (d) Intervillous space in which maternal blood circulates. (e) Blood sinus in decidua. (/) Well formed decidual cells. (gr) Degenerated layer in decidua. 9 mos. X 97. y\ vc n Plate XXT ■f.N .v.. If 4. »' 4< ' 1 Fty ' I • It // , / YOUNG J. PENTLAND'S PUBLICATIONS. EDINBURGH : 1 1 TEVIOT PLACE. LONDON: 38 WEST SMITHFIELD, E.G. 1895. ssssa^- l _r-: ^tumixsise^. ikliHiiiiitfH nantamniMt. >Ttt^lliiilii ; / YOUNG J. PENTLAND'S PUBLICATIONS. 'vj iSmo, Cloth limp, pp. xii., 120, Price 3s. SYNOPSIS OF THERAPEUTICS ARRANGED FOR THE USE OF PRESCRIBER3 : WITH POSOI.OGICAI, TABLE AND AN ARRANGEMENT OF THE POISONS. By R. S. AITCHISON, M.B., Edin. (1886.) 8vo. Cloth, pp. X., 220, with 9 illustrations, Price 7s. 6d. THE TREATMENT OF EPILEPSY, By WILLIAM ALEXANDER, M.D., F.R.C.S., HONORARY SURGEON, ROYAL SOUTHERN HOSPITAL, LIVERPOOL; VISITING SURGEON, LIVERPOOL WORKHOUSE HOSPITAL ; ACTING HONORARY CONSULTING SURGEON, EPILEPTIC INSTITUTION, MANOR HOUSE, MAGHULU (1889.) For Sale by Subscription only. In Three handsome volumes. Royal Svo, containing about 1000 pages each, with fully 1700 elaborate Illustrations, Price ^OS. per volume nett. THE AMERICAN SYSTEM OF DENTISTRY, IN TREATISES BY VARIOUS AUTHORS. Edited by WILBUR F. LITCH, M.D., D.D.S., PROFESSOR OF PROSTHETIC DENTISTRY, THERAPEUTICS, AND MATERIA MEDICA, IN THE PENNSYLVANIA COLLEGE OF DENTAL SURGERY, PHILADELPHIA. ■: MEDICAL PUBLICATIONS ISSUED BY For Sale by Subscription only. Re-issue in Monthly Volumes To be re-issued in 8 very handsome volumes. Royal 8vo, Cloth, of about 400 pages each, fully illustrated with Engravings and Coloured Plates, Price I2S. 6d. each, nett. SYSTEM OF \ GYNECOLOGY & OBSTETRICS, B Y AMERICAN A UTHORS. Edited by MATTHEW D. MANN, A.M., M.D., PROFESSOR OF OBSTETRICS AND GVNBCOLOGV IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF BUFFALO, N.Y. AND BARTON COOKE HIRST, M.D., ASSOCIATE PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA \ OBSTETRICIAN TO THB PHILADELPHIA MATERNITY HOSPITALS J GYNECOLOGIST TO THE ORTHOP-BDIC HOSPITAL. %vo, Cloth, pp. viii., 374, with 408 Illustrations, finely engraved on Wood, and 4 analytical tables, new and Cheaper Edition, Price 55. 1 TEXT-BOOK OF GENERAL BOTANY By Dr. W. J. BEHR^NS. TRANSLATION FROM THE SECOND GERMAN EDITION. Revised by PATRICK GEDDES, F.R.S.E. PROFESSOR OF BOTANY IN THE UNIVERSITY OF DUNDEE. (1893) Crown Zvo, CU>th^ pp. 154, with 5 Illustrations, Price 4s. 6d. DISEASES AND INJURIES OF THE EAR ; THEIR PREVENTION AND CURE. By CHARLES HENRY BURNETT, A.M., M.D., AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL ; ONE OP THE CONSULTING AUR18TS TO THB PENNSYLVANIA INSTITUTION FOB THB DEAF AND DUMB; LECTURER ON OTOLOGY, women's MEDICAL COLLEGE OF PENNSYLVANIA, IH PHILADELPHIA. (1889.) YOUNG J. PENTLAND. Second Edition, ?)V0, pp. xvi., 730, thoroughly revised atid illustrated with many additional Coloured Plates from original drawings, Price 25s. DISEASES OF THE EYE. A PRACTICAL TREATISE FOR STUDENTS OF OPHTHALMOLOGY. By GEORGE A. BERRY, M.B., F.R.CS.Ed., OPHTHALMIC SUROEON, EDINBURGH ROYAL INFIRMAUV ; SENIOR SUROEON, EDINBURGH EYE DISPENSARY : ■ ."TTURER ON d'HTHALMOLOGY, ROYAL COLLEGE OF OEONS, EDINBURGH. (PeuUand's Medical Series. Volume S'icond.) (1893-) Crown Zvo, Cloth, pp. xii., 83, Price 3s. 6d. . . THE ELEMENTS OF OPHTHALMOSCOPIC DIAGNOSIS. FOR THE USE OF STUDENTS ATTENDING OPHTHALMIC PRACTICE. By GEORGE A. BERRY, M.B., F.R.C.S.Ed.. OPHTHALMIC SURGEON, EDINBURGH ROYAL INFIRMARY; LECTURER ON OPHTHALMOLOGY, ROYAL COLLliGB OF SURGEONS, EDINBURGH. (189I.) Royal 4to, illustrated with a series 0/2"] Coloured Plates from Original Draivings, and numerous Figures throughout the text. Price 5OS. nett. ILLUSTRATIONS OF THE NERVE TRACTS IN THE MID AND HIND BRAIN AND THE CRANIAL NERVES ARISING THEREFROM. By ALEXANDER BRUCE, M.D., F.R.C.REd., LECTURER ON PATHOLOGY IN THE SCHOOL OF MEDICINE, EDINBURGH; ASSISTANT PHYSICIAN (FORMERLY PATHOLOGIST), EDINBURGH ROYAL INFIRMARY; PATHOLOGIS"- ~ ' THB ROYAL HOSPITAL FOR SICK CHILDREN. (1893.) 6 MEDIGAL PUBLICATIONS ISSUED BY handsome Imperial 8vo volumes, containing about 1600 pages, Price 50s. nett. ^ In two very THE NATIONAL MEDICAL DICTIONARY Including: Engflish, French, German, Italian, and Latin Technical Terms used in Medicine and the Collateral Sciences, and a Series of Tables of useful data. By JOHN S. BILLINGS, A.M., M.D., LL.D., Harv. and Edin., D.C.L., OxoN., MBMBBR OF THE NATIONAL ACADEMY OF SCIENCES, SURGEON, U.S.A., ETC. W. O. Atwater, M.D. Frank Baker, M.D. C. S. MiNOT, M.D. WITH THE COLLABORATrON OF James M. Flint, M.D. S. M. Burnett, M.D. H. C. Yarrow, M.D. R. LoRiNi, M.D. J. H. Kidder, M.D. William Lee, M.D. Washington Matthews, M.D. W. T. Councilman, M.D. (1890.) Large 8vo, Cloth, pp. xvi., 783, Price 25s. Illustrated with 226 Wood Engravings, and dZ pages of Lithograph Plates, exhibiting 91 Figures — 317 Illustrations in all. DISEASES OF THE HEART AND THORACIC AORTA. By BYROM BRAMWELL, M.D., F.R.C.P.Ed,, LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE, AND ON PRACTICAL MEDICINE AND MEDICAL DIAGNOSIS, IN "'»"'. EXTRA-ACADEMICAL SCHOOL OF MEDICINE, EDINBURGH ; ASSISTANT P.. 1IAN, EDINBURGH B07AL INFIRMARY. (1884.) %vo, Cloth, pp. xiv., 270, with 116 Illustrations, Price 14s. INTRACRANIAL TUMOURS. By BYROM BRAMWELL, M.D., F.RC.P.Ed, LECTURER ON THE PRINCIPLES AND PRACTICF OK MEDICINE IN THE EXTRA-ACADEMICAL SCHOOL OF MEDICINE, EDINBURQU ; ASSISTANT PHYSICIAN TO THE EDUIBUBOH ROYAL INFIRMARY. (1888.) •».«i-iiirT9<«p'* YOUNG J. PENT LAND. J To be issued in Fasciculi at intervals of Two Months. Fasciculi I. to VIII. now ready, price 21 S. each, sold only by subscription. ATLAS OF THE DISEASES OF THE SKIN. JN A SERIES OF ILLUSTRATIONS FROM ORIGINAL DRA WINGS WITH DESCRIPTIVE LETTERPRESS. By H. RADCLIFFE CROCKER, M.D., F.R.C.P., PHYSICIAN TO THE DEPARTMENT FOR DISEASES OF THt, SKIN, I'NIVERSITY COLLEGE HOSPIT/L; PHYSICIAN TO THE EAST LONDON HOSPITAL /OR CHILDREN; EXAMINER IN MEDICINE AT APOTHECARIES' HALL, LONDON. •** Subscribers' Names can now be received. In 2 Vols., Crown 8vo, cloth, fully illustrated ivith Wood Engravings. Vol. I. — Upper Limb, Loiver Limb, Abdomen ; Vol. II. — Thorax, Head and Neck. Price per volume, I2S. 6d. MANUAL OF PRACTICAL ANATOMY. By D. J. CUNNINGHAM, M.D. F.R.S., PROFESSOR OF ANATOMY AND CHIRURGEKV, TRINITY COLLEGE, DUBLIN. (Pentland's Students' Manuals.) (1894.) In 8 Vols. Royal Svo, of about 500 pages each, Illustrated ivith Wood Engravings in the Text, and numerous full-page Plates. Price I2S. 6d. per Volume nett. Carriage Free. CYCLOPEDIA OP THE DISEASES OF CHILDREN, MEDICAL AND SURGICAL. THE ARTICLES WRITTEN ESPECIALLY FOR THE WORK BY AMERICAN, BRITISH AND CANADIAN AUTHORS. ■\'\ Edited by JOHN M. KEATING, M.D. *,* Detailed Prospectus on application. MEDICAL PUBLICATIONS ISSUED BY (( THE COMPEND" SERIES. A Series of Handbooks to assist Students preparing for Examinations. Compend of Human Anatomy, Including the Anatomy of the Viscera. By Samuel 0. L. Potter, M.D., M.RC.P. (Lond.), Cooper Medical College, San Francisco. Fifth Edition, revised and enlarged, Crown 8vo, cloth, pp. 289, with 117 engravings, and 16 full page plates. Price 5s. . . , Compend of the Practice of Medicine. By Daniel E. Hughes, M.D., late Demonstratoi of Clinical Medicine in the Jefferson Medical College of Philadelphia. Fourth Edition, re' ised and enlarged, Crown Svo, cloth, pp. 328. Price 7s. 6d. Compend of Obstetrics. By Henky G. Landis, A.M., M.D., late Professor of Obstetrics and Diseases of Women in Starling Medical College. Third Edition, thoroughly revised, enla. ged, and improved. Crown Svo, cloth, pp. 118, with 17 illustrations. Price 4s. 6d. Compend of Surgery. By Orville Horwitz, B.S., M.D., Chief of the Outdoor Surgical Dei)artment, Jefferson Medical College Hospital. Fourth Edition, revised. Crown Svo, cloth, pp. 272, with 136 illustra- tions. Price 5s. Compend of the Diseases of the Eye, Including Eefraction and Surgical Operations. By L. Webster Fox, M.D., Ophthalmic Surgeon to the Germanto\vn Hospital, and George M. Gould, M.D. Second Edition, thoroughly revised, CroAvn Svo, cloth, pp. 164, with 71 illus- trations. Price 4s. 6d. Compend of Gynaecology. By Henry Morris, M.D., late Demon- strator of Obstetrics and Diseases of Women and Children, Jeflferson Medical College, Philadelphia. Crowm Svo, cloth, pp. 178, with 45 illustrations. Price 4s. 6d. Compend of Diseases of Children. By Marcus P. Hatfield, A.M., M.D., Professor of Diseases of Children, Chicago Medical College. Crown Svo, cloth, pp. 186, with coloured plate. Price 4s. 6d. Compend of Pathology and Morbid Anatomy. By H. Newbery Hall, Ph.G., M.D., Professor of Pathology and Medical Chemistry, Post-Graduate Medical School : Surgeon to the Emergency Hospital, &c., Chicago. Crown Svo, cioth, pp. 204, with 91 Ulustrationt. Price 4s. 6d. Compend of Dental Pathology and Dental Medicine. By Geo. W. Wauren, D.D.S., Clinical Chief, Pennsylvania College of Dental Surgery. Cruwn Svo, cloth, pp. 109, illustrations. Price 4s. 6d. YOUNG J. PENTLAND. In one Handsome Volume, Crown 4^0, Cloth, bevelled boards, pp. xii., 344, illustrated with numerous Wood Engravings and full-page Lithograph Plates, some Coloured, Price I2S. 6d. nett. 1 < Studies IN Clinical Medicine. By BYROM BRAMWELL, M.D., F.R.C.P.Ed., ASSISTANT PHYSICIAN TO THE EDINBUROII ROYAL INFIRMARY ; LECTURER ON THE PRIMClFLEa AND PRACTICE OF MEDICINE IN THE BXTRA-ACADEIIIOAL SCHOOL or MEDIC'INE, EDINBURGH. (189a) In Press, 8vo, Illustrated with ntimerous Wood Engravings throughout the text. DISEASES OF THE JOINTS. By W. WATSON CHEYNE, F.R.S., F.R.C.S., PROFESSOR OF SURGERY, KlNO's COLLEGE ; SURGEON TO KING'S COLLEGE HOSPiTAI. AND PADDINOTON GREEN CHILDREN'S HOSPITAL, LONDON. Crown %vo, pp. viii., 198, Price 3s. 6d. THE TREATMENT OF WOUNDS, ABSCESSES, AND ULCERS. By W. WATSON CHEYNE, F.R.S., F.R.C.S., PROFESSOR OF SURGERY IN KING'S COLLEGE ; SURGEON TO KING'S COLLEGE HOSPITAL, AND PADDINGTON GRKEN CHILDREN'S HOSPITAL, LONDON. (1894.) %vo. Cloth, pp. xii., 102, with 4 Illustrations, Price 5s. SUPPURATION AND SEPTIC DISEASES. THREE LECTURES DELIVERED AT THE ROYAL COLLEGE OF SURGEONS OF ENGLAND. By W. WATSON CHEYNE, F.R.S., F.R.C.S., PROFESSOR OF SURGERY IN KING'S COLLEGE ; SURGEON TO KINO's COLLEGE HOSPITAL, AND PADDINOTON OREEN CHILDREN'S HOSPITAL, LONDON. ti3l'9.) im II* 10 MEDICAL PUBLICATIONS ISSUED BY In 2 vols., large Svo, pp. xvi., 1008, illustrated with Maps and Charts, Price 3IS. 6d. GEOGRAPHICAL PATHOLOGY. An Inquiry into the Geographical Distribution of Infective and Climatic Diseases. By ANDREW DAVIDSON, M.D., F.R.C.P.Ed., LATE VISITING AND SUl'KRINTENDING SURGEON, CIVIL HOSPITAL; riiOFESSOR OF CHEMISTRY, ROVAL COLLEGE, MAURITIUS. (1892.) One Volume, Royal Zvo, Cloth, pp. xx., 1014, illustrated with Engravings and full-page Plates. Price 31s. 6d. THE HYGIENE AND DISEASES OF WARM CLIMATES, IN A SERIES OF ARTICLES BY EMINENT AUTHORITIES. , Edited by ANDREW DAVIDSON, M.D., F.R.C.P.Ed., LATE VISITING AND SUPR1{INTENDIN(; SURGEON, CIVIL HOSPITAI. ; PROFESSOR OF CHEMISTRV, ROVAL COLLEGE, MAURITIUS; AUTHOR OF "GEOGRAPHICAL PATHOLOGY." ,% The Articles are contributed by SiR Joseph Fayrer ; Drs. Macnamara; Patrick Manson ; Lane Notter ; "E. A. Birch ; R. W. Coppinger ; David Bruce; G. M. Sternberg; Montagu Lubbock; Hy. Cayley ; Sonsino; The Editor; &c. &c. (1893) Crown 8vo, Cloth, pp. xvi., 520, illustrated with Charts, Price lOS. 6d. DISEASE IN CHILDREN: A Manual for Students and Practitioners. By JAMES CARMICHAEL, M.D., F.R.C.P.Ed., I'HYSICIAK, ROYAL HOSPITAL FOR SICK CHILDREN ; UNIVERSITY LECTURER ON DISEASE IN CHILDREN, EDINBURGH. (Pentland's Students' Manuals.) (1892.) YOUNG J. PEN TL AND. 11 EXAMINATION QUESTIONS Set for the Professional Examinations in Edinburgh University during the past ten years, selected from the Calendars. By W. RAMSAY SMITH, M.B., B.Sc, DEMONSTRATOR OF ANATOMY, EDINBURGH SCHOOL OF MEDICINE, MINTO HOUSE; LATB SENIOR ASSISTANT TO THE PROFESSOR OF NATURAL HISTORY, UNIVERSITY OP EDINBURGH. NATURAL HISTORY, arranged and annotated, price 1%. BOTANY, arranged and annotated, price Is. 6d. CHEMISTRY, answered and annotated, price 2s. ANATOMY, answered and annotated, price 2s. MATERIA MEDIOA AND THERAPEUTICS, answered and annotated, price 2s. PHYSIOLOGY, answered and annotated, price 2s. MIDWIFERY AND GYNAECOLOGY, answered and annotated, price Is. 6d. PRACTICE OP PHYSIC, ansivered and annotated, price 2s. SURGERY, answered and annotated, price 2s. \* Other Volumes to Follow. Large %vo, pp. xvi., 498, with 30 Illustrations. Price i6s. DISEASES OF THE STOMACH. By Dr. C. A. EWALD, EXTRAORDINARY PROFESSOR OF MEDICINE AT THE UNIVERSITY OF BERLIN i DIRECrOR OF THE AUGUSTA HOSPITAL. AUTHORISED TRANSLATION, WITH SPECIAL ADDITIONS BY THE AUTHOR, By morris manges, A.M., M.D., ATTENDING PHYSICIAN, MOUNT SINAI HOSPITAL, NEW YORK CITY. (X892.) %vo. Cloth, pp. 54, illustrated with 16 Coloured Maps. Price 5s. GEOGRAPHICAL DISTRIBUTION OF SOME TROPICAL DISEASES AND THEIR RELATION TO PHYSICAL PHENOMENA. By R, W. FELKIN, M.D., F.R.S.E., F.R.G.S., LECTURER ON DISEASES OF THE TROPICS AND CLIMATOLOGY, SCHOOL OP MEDICINE, EDINBURGH. r/)' (i88q.) 12 MEDICAL PUBLICATIONS ISSUED BY In Press, to be issued in a handsome 4(0 volume. Illustrated by a series of about 150 Coloured Plates from Original Drawings from Nature and numerous Engravings in the Text. ATLAS OF OPHTHALMOSCOPY. A Treatise on the Fundus Oculi. By W. ADAMS FROST, F.R.C.S., OPHTFIALMIC SURGEON AND LECTURER ON OPHTHALMIC SURCIKRY, ST. aEOIlOE'S HOSPITAL SURQEON, ROYAL WESTMINSTER OPHTHALMIC HOSPITAL, LONDON. %vo, Cloth, pp. 362, illustrated with 60 Photographic Reproductions, Price I2S. 6d. PRACTICAL PATHOLOGY AND MORBID HISTOLOGY. By HENEAGE GIBBES, M.D., rBOFESSOE OF PATHOLOGY IN THE UNIVERSITY OF MICHIGAN ; FORMERLY LECTURER ON HISTOLOGY IN THE MEDICAL SCHOOL, WESTMINSTER HOSPITAL. (1891.) Second Edition, Crown 8vo, Cloth, pp. xvi., 376, tvith 109 Illustrations, some coloured. Price lOS. 6d. PHYSICAL DIAGNOSIS, A Guide to Methods of Clinical Investigation. By G. a. GIBSON, M.D., D.Sc, F.R.C.P.Ed., LECTURER ON THE PRINCIPLES AND PRACTICE OP MEDICINE IN TUB EDINBURGH MEDICAL SCHOOL ; ASSISTANT PHYSICIAN, EDINBURGH ROYAL INFIRMARY. AND WILLIAM RUSSELL, M.D., F.R.C.P.Ed., ASSISTANT PHYSICIAN EDINBURGH ROYAL INFIRMARY", LECTURER ON PATHOLOGY AND MORBID ANATOMY IN THE EDINBURGH MEDICAL SCHOOL. (Pentland's Students' Manuals.) (1893.) Zvo, pp. xvi., 204, with ^4 full-page Coloured Plates, Price l6s. HYDATID DISEASE IN ITS CLINICAL ASPECTS. , By JAMES GRAHAM, M.A., M.D., LATE DEMONSTRATOR OF ANATOMY, SYDNEY UNIVERSITY; MEDICAL SUPERINTENDENT, PRINCE ALFRED HOSPITAL, SYDNEY. (189I. TOUNQ J. PENTLAND. 13 Fourth Edition, Revised, Svo, Cloth, pp. 172, with 16 Wood Engraviii^Sy Price 7s. 6d. A PRACTICAL TREATISE ON IMPOTENCE, STERILITY, AND ALLIED DISEASES OF THE MALE SEXUAL ORGANS. By SAMUEL W. GROSS,, A.M., M.D., LL.D. FROFESSOn OF THE PRINOIPLES OF BURQERY AND CLINICAL BUROERT IN THE JEFFERSON MEDICAL COLLEOE OF PHILADELFHIA. Fourth Edition Revised by F. R. STURGIS, M.D. (1891.) Large 8vo, doth, pp. 624. Price i6s. A TEXT-BOOK OF PRACTICAL THERAPEUTICS, WITH ESPECIAL BEFitBENOE TO THE APPLICATION OF REMEDIAL MEASURES TO DISEASE AND THEIR EMPLOYMENT UPON A RATIONAL BASIS. By HOBART AMORY HARE, M.D., B.Sc, CLINICAL PROFESSOR OF THE DISEASES OF CHILDREN AND DEMONSTRATOR OF THERAPEUTICB IN THE UNIVERSITY OF PENNSYLVANIA ; PHYSICIAN TO ST. AGNES's HOSl'ITAL AND TO THE MEDICAL DISPENSARY OF THE CHILDREN'S HOSPITAL. (1890.) In handsome folio, contaitiing about 230 pages of text, Illustrated with Engravings and t,') full-page Photographic Plates from Nature. In four fasciculi, price 25s. each, carriage free. HUMAN MONSTROSITIES. By barton COOKE HIRST, M.D., PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA: AND GEORGE A. PIERSOL, M.D., PROFESSOR OF EMBRYOLOGY AND HISTOLOGY IN THE UNIVERSITY OF PENNSYLVANIA *,* The Edition is limited, and is for sale oniy by Subscription. u MEDICAL PUBLICATIONS ISSUED BY In 3 Volumes, Royal Svo, of about looo pages each. Uniform with tlie " Cyclopadia of Children's Diseases " and " Systems of Gynecology and Obstetrics" Price per Volume 22s. 6d., carriage free. ^ A SYSTEM OF •^ t PRACTICAL THERAPEUTICS. ! BY VARIOUS AUTHORS. EDITED BY HOBART AMORY HARE. M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN, AND DEMONSTRATOR OF THERAPEUTICS IN THE UNIVERSITY OP PENNSYLVANIA ; PHYSICIAN TO ST. AGNES HOSPITAL, PHILADELPHIA. To be issued annually, Svo, pp. xvi., 650 or thereby, handsomely printed, illustrated with full-page Plates and Engravings. Price per Volume, I2S. 6d. nett. Carriage free. Volumes I. and II. now Ready EDINBURGH 'mc>. Cloth, pp. 303, Price 43. STUDENTS' POCKET MEDICAL LEXICON, Giving tiie oorreot Pronunciation and Definition of all Words and Terms in general use in Medicine and the Collateral Sciences. By ELIAS LONGLEY. . (1891. Second Edition, Revised and Enlarged, Svo, Cloth, pp. xvi., 682, with Coloured Illustrations from Original Drawings, Price 25s. DISEASES OF THE THROAT, NOSE, & EAR, By p. McBRIDE, M.D., F.RC.P.Ed., LBCTUBER ON THE DISEASES OF THE EAR AND THROAT, EDINBUBOH SCHOOL OF MEDIOINK ; AURAL SUROEON >\D LARVNQOLOOIST, ROYAL INFIBMABY, EDINBUBOH; BUROF- A, BDIKBUROH BAR AND THROAT DISPENSARY. (Pentla:id's Medical Series, Volume Third.) (1894) VOLUME SECOND JUST READY. In 2 handsome Volumes, large 4to of over 3So/a^ej each, illustated with 100 full-page Fascimile Chromo-Lithographic Plates, reproduced from Photo- graphs taken by the Author of his own Dissections, expressly designed and prepared for this Work, and coloured by him after Nature. Price per Volume, 42s. nett. Carriage paid. REGIONAL ANATOMY IN ITS RELATION TO IVIEDICINE AND SURGERY. By CEORGE McCLELLAN, M.D., LBCrURBR ON DESCRIPTIVE AND REGIONAL ANATOMY AT THE PENNSYLVANIA SCHOOL OF .anatomy; PROFESSOR OF ANATOMY AT THE PENNSYLVANIA -VCADEMV OF TUB FINE arts; member OF THE ACADFMY OF NATURAL SCIENCES, COI LEGE OF PHYSICIANS, ETC., OF PHILADRLPIIIA. ^ \ ^ ii\ YOUNG J. PENTLAND. 19 lOO ^oto- \and per In \o fasciculi, price 6s. each ; or complete in one Handsome Royal 4to Volume, Extra Cloth, Price 63s. tiett. Atlas of Venereal Diseases. A Series of illustrations from Original Paintings with \ Descriptions of the Varied Lesions, their differential Diagnosis and Treatment. By p. H. M'LAREN, M.D., F.R.C.S.E., SURGEON, EDINBURGH ROYAL INFIRMARY ; FORMERLY SURGEON IN CHARGE OF THE LOCK WARDS, EDINBURGH ROYAL INFIRMARY; EXAMINER IN THE ROYAL COLLEGE OF SURGEONS, EDINBURGH. In Six Divisional Volumes, Royal Svo, cloth extra, gilt tops, of about 550 pages each. Illustrated with Coloured Plates and Engravings throughout the Text. Price per Volume, 14s. nett. SYSTEM OF GENITO-URINARY DISEASES, SYPHILOLOGY, AND DERMATOLOGY. Edited by PRINCE A. MORROW, M.D., CLINICAL PROFESSOR OF GENITO-URINARY DISEASES', FORMERLY LECTURER ON DERMATOLOGY IN THE UNIVERSITY OF THE CW , OF NEW YORK ', SURGEON TO CHARITY HOSPITAL, NEW YORK. Third Edition, Revised and Enlarged, iSmo, pp. xx., 336, in Flexible Leather Binding for the Pocket, Price 6s. 6d. PRESCRIBING & TREATMENT IN THE DISEASES OF INFANTS AND CHILDREN By PHILIP E. MUSKETT, L.R.C.R & S. Ed., LATE SUKGEON TO THE SYDNEY HOSPITAL; FORMERLY SENIOR RESIDENT MEDICAL OFFICER, SYDNEY HOSPITAL. (1894.) Royal Svo, Cloth, pp. viii., 882. Illustrated with 162 Engravings and 2 Coloured Plates. Price 24s. rRACTICAL TREATISE ON MEDICAL DIAGNOSIS. FOR STUDENTS AND PHYSIC J '^. By JOHN H. MUSSER, M.U, ASSISTANT PROFESSOR OF CLINICAL MEDICINE IN THE NIVEP.SITY OF PENNSYLVANIA : PHYSICIAN TO THE PfllLADELPLU AND TUB PUF.SBYTEIIIAN HOSPITALS, &0. ■r i\ i (1894.) •JO MEDICAL PUBLICATIONS ISSUED BY 8v0, pp. xvi., 212, with 3 Illustrations. Price 8s. 6d. ' MALIGNANT DISEASE OF THE THROAT AND NOSE. Bv DAVID NEWMAN, M.D., LARYNGOLOOIST TO THE OLASOOW ROYAL INFIRMARY ; ASSISTANT SUROEOV TO T IE WESTERN INFIf lARY ; EXAMINER IN PATHOLOUY IN THE UNIVERSITY OF OLASOOW. (1892.) Zvo, pp. xii., 122, with 32 Illustrations^ mostly in Colours, Price lOS. 6d LEAD POISONING, IN ITS ACUTE AND CHRONIC FORMS. By THOMAS OLIVER, M.D., F.R.C.P., PHYSICIAN, ROYAL INFIRMARY, NEWCASTLE-ON-TYNE ; PROFESSOR OF PHYSIOLOGY, UNIVERSITY OF DURHAM ; HONORARY PHYSICIAN, NEWCASTLE-ON-TYNB DISPENSARY AND INDUSTRIAI^ SCHOOLS. (189I.) Large 8vo, pp. xvi., 1080, w h Charts anti Illustrations, Price 24s. THE PRINCIPLES & PRACTICE OF MEDICINE, By WILLIAM OSLER. M.D., F.R.C.P., PROFESSOR OF MEDICINE IN THE JOHNS HOPKINS UNIVERSITY, AND PHYSICIAN-IN-CHIEF TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE. (1894.) The work is an eminently practical one, deals with diseases from the most modern scientific standpoint, and is in every way thoroughly up to the times. In it the etiology, symptoms, diagnosis, prognosis, treatment, and pathology of diseases are fully set forth, making it one of the most thorough and scientific text-books on the subject ever presented to the profession. Dr. Osler's reputation as a writer, clinician, and teacher, insures to the reader of this work a fund of information so arranged and classified as to make it easily available. Second Edition, thoroughly revised, large 8vo, Cloth, pp. 701, with 214 Wood Engravings, and a Coloured Plate, Price l8s. THE SCIENCE AND ART OF OBSTETRICS, Bv THEOPHILUS PARVIN, M.D., LL.D., PROFESSOR OK OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN JEFFERSON MEDICAL COI .,EGK, PHILADELPHIA, AND ONE OF THIi OBSTETRICIANS TO THE PHILADELPHIA HOSPITAL. (1891.) k YOUNG J. PENTLAND. 21 PRACTICAL LESSONS IN NURSING: A NEW SERIES OF HANDBOOKS. Now ready, Crown 2>vo, Cloth, each t^s. 6d. THE NURSING AND CARE OF THE NERVOUS AND THE INSANE. By CHARLES K. MILLS, M.D., PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IN THE PHILADELPHIA POLYCLINIC AND COLLEGE FOR GRADUATES IN MEDICINE ; LECTURER ON MENTAL DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. MATERNITY, INFANCY, CHILDHOOD, Hygiene of Pregnancy; Nursing and Weaning of Infants; Tiie Care of Children in Health and Disease. Adapted especially to the use of Mothers or those intrusted with the dringitig up of Infants and Children, and Training Schools for Nurses, as an aid to the teaching of the Nursing of Women and Children. By JOHN M. KEATING, M.D., LBCTURER ON THE DISEASES OF WOMEN AND CHILDREN, PHILADELPHIA HOSPITAL OUTLINES FOR THE MANAGEMENT OF DIET: Or, The Regulation of Food to the Requirements of Health and the Treatment of Disease. By E. T. BRUEN, M.D., ASSISTANT PROFESSOR OF PHYSICAL DIAGNOSIS, UNIVERSITY OF PENNSYLVANIA; ONE OF THE PHYSICIANS TO THE PHILADELPHIA AND UNIVERSITY HOSPITALS. 22 MEDICAL PUBLICATIONS ISSUED BY • Hoya/ Svo, Cloth, pp. viii., 622, Illustrated with 5 Coloured Plates ^^^ 357 Woodcuts, Price 25s. TEXT-BOOK OF OPHTHALMOLOGY, By W. F. NORRIS, A.M., M.D.. AND - C. A. OLIVER, A.M., M.D. (1894.) 8w, Cloth, pp. xiv., 160, with Coloured Illustrations from Original .Drawings, Price lOS. 6(1. nett. B E R I-B E R I: Researches Concerning its Nature and Cause and the Means of its Arrest. By C. a. PEKELHARING, PROFBSSOR IN THE FACULTY OP MEDICINE, UNIVERSITY OF UTKECHT ; AND C. WINKLER, \ ' LECTUREU IN THE UNIVERSITY OF UTRECHT. Translated by JAMES CANTLIE, M.A., M.B., F.R.C.S. (1393.) 8w, Cloth, pp. xvi., 271, with Coloured Plates and ^^ Engravings, Price lOS. 6d. THE CAUSES AND TREATMENT OF ABORTION, By ROBERT R. RENTOUL, M.D., M.R.C.S., FELLOW OF THE OBSTETRICAL MCIETV, LONDON. WITH AN INTRODUCTION BY LAWSON TAIT, F.R.C.S. (1889.) II YOUNG J. PENTLAND. 23 REPORTS FROM THE LABORATORY OF THE ROYAL COLLEGE OF PHYSICIANS, EDINBURGH. EDITED BY J. BATTY TUKE, M.D.. G. SIMS WOODHEAD, M.D., AND D. NOEL PATON, M.D. Volume First, %vo, Cloth, pp. 212, with 23 full-page Plates^ and 19 Engravings. Price 7s. 6d. nett. Volume Second, 8w, Cloth, pp. xiv., 280, with 43 full-page Plates, con- sisting of Lithographs, Chromo-Lithographs, and Micro-Photographs. Price lOS. 6d. nett. Volume Third, Zvo, Cloth, pp. xii., 304, with 11 Plates and Folding Charts. Price 9s. nett. Volume Fourth, Zvo, Cloth, pp. xii., 254, with 25 Plates and Folding Charts. Price, lOS. 6d. nett. (; %vo, Cloth, pp. xii., 302, with 5 Wood Engravings, Price Qs. DISEASES OF THE MOUTH, THROAT, AND NOSE, INCLUDING RHINOSCOPY AND METHODS OF LOCAL TREATMENT. By PHILIP SCHECH, M.D., LECTURER IN THE UNIVERSITY OF MUNICH. TRANSLATED BY R. H. BLAIKIE, M.D., F.R.S.E., rORUERLV CunvlEON, EDINBURGH EAR AND THROAT DISPENRARY ', LATE CLINICAL A8SIBTAVT. EAR AND THROAT DEPARTMENT, ROTAL INFIRMARY, EDINBURUB. (1886.) 24 MEDICAL PUBLICATIONS ISSUED BY Svo, Cloth, pp. xii., 223, with 7 Illustrations, Price QS. ELEMENTS OF PHARMACOLOGY. By Dr. OSWALD SCHMIEDEBERG, PROFKaSOR OF PHARMACOLOOY, AND DIRECTOR OF THE PnARMACOI.OOICAL IN8TITDTE, ONIVERSITY OF 8TRA8B0RO. TRANSLATED UNDER THE AUTHOR'S SUPERVISION, By THOMAS DIXSON, M.B., LECTURER ON MATERIA MF.DICA IN THE UNIVER8ITT OF 8TDNBT, N S.W. (1887.) Crown Svo, Clot/,, pp. xii., 173, with 60 Illustrations, Price 5s. MANUAL OF CLINICAL DIAGNOSIS. By Dr. OTTO SEIFERT, PRIVAT DOCEMT IN WUBZBURO. AND Dr. FRIEDRICH MULLER, ABSI8TENT DEB II. MED. KLINIK IN BERLIN. THIRD EDITION, REVISED AND CORRECTED. TRANSLATED WITH THE PERMISSION OF THE AUTHORS, By WILLIAM B. CANFIELD, A.M., M.D., CHIEF OF CLINIC FOB THROAT AND CHE8T, UNIVERSITY OF MABYLAND. (1887.) '•• ^liMjtv- 70UNG J. PENTLAND. 25 Second Edition, Crown Svo, extra Cloth, pp. xvi., 287, Price 3s. 6(1. THE LIFE AND RECOLLECTIONS OF DOCTOR DUGUID OP KILWINNING. WRITTEN BY HIMSELF, AND NOW FIRST PRINTED FROM THE RECOVERED MANUSCRIPT. By JOHN SERVICE, L.R.C.S. & P., Ed., Sydney. (1890.) Crown 8vo, Cloth, pp. xvi., 222, Price 3s. 6d. THIR NOTANDUMS, Being the Literary Recreations of Laird Canticari of IVIongrynen (of kittle memory), TO WHICH IS APPENDED A BIOGRAPHICAL SKETCH OF JAMES DUNLOP, Esq.. F.R.S.S, Lond. & Ed., Astronomer Royal at the Observatory of Parptnatta, New South Wales, 1831-47. By JOHN SERVICE, L.R.C.S. & R. Ed. (1890.) Crown 2>vo, Cloth, pp. xii., 226, Priu 6s. SURGICAL ANATOMY: A MANUAL FOR STUDENTS. By a. MARMADUKE SHEILD, M.B. (Cantab.), F.R.C.S.. SENIOR ASSISTANT 8URQE0N, AURAI, SURGEON AND TEACUEB OF OPEBATIVR SURGERY, CHARINO CROSS HOSPITAL. (Pentland's Studeots' Manuals.) '1801.I :// •mm*'''^ MEDICAL PUBLICATIONS ISSUED BY Crown 4^0, extra Cloih, gilt top, with 70 Plates exhibiting over 400 Figures, Price I2S. 6d. ILLUSTRATIONS OF ZOOLOGY, INVERTEBRATES AND VERTEBRATES. By WILLIAM RAMSAY SMITH, B.Sc, KORMERLY DEMONSTRATOR OF ANATOMY, EDINBURGH SCHOOL OF MEDICINE, MINTO HOUSE; LATB SENIOR ASSISTANT TO THE PROFESSOR OF NATURAL HISTORY, UNIVERSITY OP BOINBURCH. AND J. STEWART NORWELL, B.Sc. (1889.) Second Edition, post 8w, Cloth, pp. 396, with Illustrations, Price los. DISEASES OF THE DIGESTIVE ORGANS IN INFANTS AND CHILDREN. WITH CHAPTERS ON THE INVESTIGATION OF DISEASE AND ON THE GENERAL MANAGEMENT OF CHILDREN. By LOUIS STARR, M.D., LATB CI.IMICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE CNIVERSITY OF PENNSYLVANIA ; PHYSICIAN TO TH« children's hospital, PHILADELPHIA. {I89I.) In press. Second Edition, Revised and Enlarged, Crown ^vo, with numerous Illustrations. Outlines of Zoology. By J. ARTHUR THOMSON, M.A., LECTURER ON ZOOLOGY, SCHOOL OF MEDICINE, EDINBURGH. (Pentland's Students' Manuals.) ' '' "' "' < ' ■|^ ' ' '(?, Cloth, pp. viii., 239, Price 6s. APPENDICITIS AND PERITYPHLITIS, BY CH. TALAMON, PHYSICIAN TO THE TENON HOSPITAL, PARIS. TRANSLATED FROM THE FRENCH BV RICHARD J. A. BERRY, M.B., CM., LATE PRESIDENT OF THE ROYAL MEDICAL SOCIETY, EDINBURGH. (^893>) Large 2,vo, pp. xvi., 700, with 178 Fine Engravings, many in Colour, Price l8s. CLINICAL TEXT-BOOK OF M EDiCAL Diagnosis, FOR PHYSICIANS AND STUDENTS. BASED ON THE MOST RECENT METHODS OF EXAMINATION. By OSWALD VIERORDT, M.D., PROFESSOU OF MEDICINE AT THE UNIVERSITY OF HEIDELBERO. TRANSLATED, WITH ADDITIONS FROM THE SECOND ENLARGED GERMAN EDITION, WITH THE AUTHOR'S PERMISSION. By FRANCIS H. STUART, M.D., MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS, NEW YORK. (1892.) " In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. // is distinctly a clinical work by a master teacher, characterised by thoroughness, fulness, and accuracy ; /'/ is a mine of information upon the points that are so often passed over without explanation." Third enlarged and thoroughly revised Edition, 8vo, pp. xxiv., 652, with 195 Coloured Illustrations, mostly from Original Drawings, Price 2$S. PRACTICAL PATHOLOGY: A Manual for Students and Practitioners. By G. SIMS WOODHEAD, M.D., F.R.CP.Ed., DIRECTOR OF THE LABORATORIES O" THE KOYAL COLLEGES OF PHYSICIANS (LONDON) ANP SJRGEONS (ENGLAND). (1892.) 28 MEDICAL PUBLICATIONS ISSUED BY Subscription One Guinea per annum (in advance), post free, THE JOURNAL OF PATHOLOGY AND BACTERIOLOGY EDITED, WITH THE COLLABORA TION OF DISTINGUISHED BRITISH AND FOREIGN PATHOLOGISTS, By GERMAN SIMS WOODHEAD, M.D., DIRECTOR OP THE LABORATORIES OF THE ROYAL COLLEGES OP PHYSICIANS (LONDON) AND SURGEONS (ENGLAND). ASSISTED IN SPECIAL DEPARTMENTS BY SIDNEY MARTIN, M.D. (Lond.) (Pathological Chemistry): M. ARMAND RUFFER. M.D. (Oxon.) (Morbid Anatomy and Histology); S. G. SIIATTOCK, F.R.C.S. (Morbid Anatomy): G. E. CARTWRIGHT WOOD, M.D. (Edin.) (Bacteriology); 0. S. SHERRINGTON, M.D. (Cantab.) (Experimental Pathology). IT has been felt for some time tliat the want in this country of a Journal dealing specially with General and Experimental Pathology has militated most seriously against the free interchange of ideas, not only between English-speaking pathologists, but also between British and Foreign workers. Although the Transactions of the Pathological Society deal with communications which are brought before its members, there is no medium in which longer articles, and especially those from workers throughout the United Kingdom and abroad, can be brought before a less limited circle of readers. It has been thought desirable, there- fore, to found a Journal specially devoted to the publication of original contributions on General Pathology, Pathological Anatomy, and Experimental Pathology, including Bacteriology. These articles will, of course, be mainly from British Laboratories and Hospitals ; but the co-operation of many distinguished Continental, American, and Colonial Pathologists has been obtained, and papers written or edited by them will be placed before our readers. In order to increase the interest and extend the usefulness of the YCUNG J. PENTLAND. M Journal, it is intended that, in addition to original articles, critical summaries of work done in special departments of Pathology and Bacteriology shall from time to time be published. All articles appearing in the Journal will be signed. The Journal will appear at least four times a year, but it will be issued more frequently if necessary, in order to ensure publication of all papers as early as possible after they are received. The numbers issued throughout the year will form a volume, royal 8vo, of about 500 pages. It will be printed on good paper, and will be freely illustrated with Woodcuts and Chromolithographs. Amongst those who have already promised to collaborate are the following : — Sir Henry Acland, Bart., Oxford. S. Arloing, Lyons. B. Bang, Copenhagen. Alex. Barron, Liverpool. W. H. Barrett, Belfast. J. Rose Bradford, London. Ch. Bouchard, Paris. H. BucHNER, Munich. Angelo Cel' ■, Rome. Sir Charle ''ameron, Dublin. A. B. Charrin, Paris. A. Chantemesse, Paris. A. Chauveau, Paris. W. Watson Chevne, London. H. Chiari, Prague. Joseph Coats, Glasgow. W. T. Councilman, Boston. D. Drummond, Newcastle. S. Del^pine, Manchester. J. Dreschfeld, Manchester. Von Esmarch, Koenigsberg. R. H. FiTZ, Boston. P. Grawitz, Greifswald. W. S. Greenfield, Edinburgh. H. Heiberg, Christiania. Victor Horslev, London. F. Hueppe, Prague. J. W. HuLKE, London. O. Israel, Berlin. E. H. Jacob, Leeds. E. Klebs, Zurich. Alfred Lingard, Poonah. Sir Joseph Lister, Bart., London. 0. Lubarsch, Rostock. P. Marie, Paris. E. Metchnikoff, Paris. F. W. MoTT, London. E. Nocard, Alfort. T. Oliver, Newcastle. J. Orth, Gottingen. William Osler, Baltimore. T. Mitchell Prudden, New York. J. F. Payne, London. J. M. Purser, Dublin. C. S. RoY, Cambridge. J. C. Salomonsen, Copenhagen. A. M. Stalker, Dundee. J. Burdon Sanderson, Oxford. J. Lindsay Steven, Glasgow. H. Stilling, Lausanne. 1. Straus, Paris. T. P. Anderson Stuart, Sydney. R. Thoma, Dorpat. J. Batty Tuke, Edinburgh. L. Vaillard, Paris. Rud. Virchow, Berlin. H. Marshall Ward, Cooper's Hill C. Weigert, Frankfort a/M. A. Weichselbaum, Vienna. W. H. Welch, Baltimore. Samuel Wilks, London. A. E. Wright, London. Von Zenker, Erlangen. R. Ziegler, Freiburg. ^t \ IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 2.5 *- lilM •^ IM {{|||2.2 Ir lis III 2.0 u ^ — ^^— 1.8 1.25 1.4 1.6 -< 6" - ► Photographic Sciences Corporation 23 WEST VAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 1 30 MEDICAL PUBLICATIONS ISSUED BY Post ?ivo, pp. 496, with 403 Engravtfigs, Price I2S. 6d. >i^>,,; i'e, li MINOR SURGERY AND BANDAGING, Including the Treatment of Fractures and Dislocations, dc. &q. By HENRY R. WHARTON, M.D, ; t BEMONSTBATOH OF SURGERY AND LECTURBB ON THE SURGICAL DISEASES OF CHILDREN, UNIVERSITY OF PENNSYLVANIA. (188I.) ' 8»