UC SOUTHERN REGIONAL LIBRARY FACILITY G 000 005 406 4 !! " 1 Li ''■i^?130NY-S01^ ■S^[yN!VtR% f7l]aNVS01^ ,^v\[-UNIVERi.v >r :^> perhaps more satisfaction than almost any other class of my work. I have said nothing about the differential diagnosis of broad ligament abscesses I JESSOP'S CASE. 59 originating in the deaths of ectopic ova, because I hardly think it possible till bones are found in the discharges, and then of course it is easy enough. Before this has happened I have had no experience of them, as I have said, when I do have I shall certainly not trouble about the differential diagnosis, and the want of it will certainly not delay my interference for an hour, ftjr my rule is to get pus out of the pelvis as soon as I am satisfied it is there. The death of the fcetus may occur, as I have said, up to any time of foetal life, and if suppuration of the foetal cavity occurs there can be but little variation in the processes, or in the proceedings required for their relief. Of course the larger the foetus the greater the trouble, the more urgent need for interference; and the larger the foetus the greater the possibility of the sac bursting at the umbilicus, an accident to be afterwards discussed. Now we come to the later stage, and the last division of my subject, the minority of the minority of cases, where the ovum survives and grows towards the full time. During this process of growth the secondary rupture of the broad ligament sac may take place, and prove fatal, as in the case recorded by Nonat, Bernutz and Mathews Duncan. Such an accident would give rise to alarming symptoms, similar to those ob'^.erved in primary rupture, and so far as we know from a few recorded cases, the accident would be quite as fatal. One case of such a rupture has been recorded which was not fatal, and in which the child was removed, and it forms an instance perfectly unique in the history of ectopic pregnancy, for the child was absolutely free in the peritoneal cavity, not encapsulated by cyst. INIr. T. E. Jessop, who records the case, puts it among what he calls, quoting the text books, the ''abdominal variety." If he had said intra-peritoneal variety his language would have been more accurate, but as a matter of fact it stands by itself, and may therefore be known as the case of intra-peritoneal ectopic gestation. Fortunately no post-mortem was necessary, but it is perfectly clear from the history, that about the tenth week she had a " rupture " and that this was tubal is, in my belief, quite certain. If the pregnancy had ruptured its way into the peritoneum it would have been at once digested ; for I am certain, from what I know of the digesting powers of the abdomen, no gelatinous foetus of the tenth week could resist them. I interpret this case then to be one where a broad ligament pregnancy on the right side went on till the seventh or eighth month, and that then a secondary rupture of the broad ligament cyst took place, the child escaped into the peritoneal cavity, and continued its life amongst the intestines, its tissues having arrived at a period of development by that time which enabled them to resist the efforts of digestion which doubtless would be directed towards them. The ruptured cyst 60 JESSOP'S CASE. would contract and disappear towards its edges, and the placenta was found where it is found in the great bulk of broad ligament cysts, plastered over the pelvic contents. The following is an abstract of the case : — " M. C, nged 26, has enjoyed fair average health up to the commencement of the illness. In March, 1869, she gave birth to an only child, after a labour in all respects natural, and, having weaned the child, she menstruated with moderate regularity up to 1874. From the beginning of January, 1875, her menstruation ceased, and she believed herself to be in the family way, early in March she was about two months pregnant, v/hilst wasliing she was suddenly seized with violent pain in tlie right side of the belly, which caused her to faint, she was taken to bed, and her ordinary medical attendant was sent for, she was suffering from violent pain in the abdomen, with swelling, vomiting, retention of urine, and high pulse, and for two months she was confined to bed, suffering from abdominal pain, sickness, and loss of appetite. Towards tlie middle of May she began to feel the movements of a child, and at the same time noticed a hard swelling in the loM'cr part of the abdomen, towards the right side. On the 13th August Mr. Samuel Hey and Mr. Clayton in consultation determined the existence of an extra-uterine living foetus, and she was taken to the Leeds Infirmary, under Mr. Jessop, the same day. The abdomen was throughout distended. At the umbilicus and below was a large rounded prominence, which gradually sloped off towards the ensiform cartilage, and terminated inferiorly somewhat abruptly in a hollow, which was bounded again by a lesser prominence immediately above the pubes. On a closer examination the umbilical prominence presented the characters of a child's breech ; the cleft and the two buttocks were distinctly traceable through the thin abdominal walls, and extending upwards in a straight line towards the sternum the little prominences of the vertebral spinal processes were plainly perceptible. Above the pubes two feet could be made out, and above the umbilicus, immediately lielow the ribs, it was not difficult to map out the outlines of the two scapuke. The rapid beating of the fcctal heart could be most distinctly heard towards the right side above the umbilicus. The breasts were enlarged and the areola? were fairly developed." " On examination, per vaginam, the uterus felt somewhat enlarged, and on measurement by Simpson's sound its cavity was found to be 2| inches in length. The uterus remained motionless, whilst the abdominal contents Avere swayed from side to side. On several occasions the movements of the child were plainly visible, and indicated considerable vigour. After repeated careful search we were unable to satisfy ourselves of the presence of a placental souffle. The diagnosis of extra-uterine gestation seemed complete. The woman's condition was becoming extremely critical. Under JESSOP'S CASE. 61 these circumstances it was decided to remove the child by abdominal section. With the full concurrence of my colleagues, I accordingly proceeded to perform the operation at 12.30, on the morning of the 14tli of August." The patient having been placed under the influence of ether, and the bladder emptied of urine, an incision six inches long was made through the linea alba, with the umbilicus at its centre. The abdominal wall was unusually thin, but more vascular than common ; and the peritoneal lining, though natural on its free surface, appeared thick and velvety on section. Immediately upon the completion of the incision the breech and back of the child, thickly coated with vernix cascosa, came directly into view. At the upper part of the wound the omentum was seen lying like a cape upon the child's shoulders, and inferiorly the funis, of natural appearance, passed transversely across the wound, and was traced round the external aspect of the left thigh of the fu'tus to its attachment at the umbilicus. The child was in a kneeling position, its breech presenting towards the mother's navel; its head, folded upon its chest, buried beneath ' the omentum and transverse colon ; the soles of its feet pointing towards the pubes, and its knees resting upon the posterior brim of the pelvis Its removal was readily effected. The funis was tied and separated in the usual manner, and the child was handed over to the custody of two gentlemen previously appointed to look after its well-being It was now seen that the gestation had been of the " abdominal " variety ; no trace of cyst or of membrane could be found. The child had lodged in the midst of the bowels, free in the cavity of the abdomen. A few bands of unorganized lymph of a very friable nature lying upon, but not adherent to, intestines, were readily removed by sponging, and about an ounce of a clear serum was found in the peritoneal cavity. On tracing the umbilical cord, the placenta, having a larger superficial area than natural, was seen covering the inlet of the pelvis, like the lid of a pot, and extending some distance posteriorly above the brim, where it apparently had an- attachment to the large bowel and posterior abdominal wall. Near its centre was a round prominence, which seemed to correspond with the swollen fundus of the uterus beneath. Great and especial care was taken not to cause the smallest disturbance to its connections. The placenta was indeed left untouched. On the 29th of October the wound is reported as quite healed ; and three weeks later she returned to her home. Trom that time to the present she has kept in good health. Menstruation commenced about a month after she left the infirmary, and has recurred at regular periods ever since. The child was as liealthy, vigorous, and large as an average child born in the natural wix^f ; and it continued to thrive well 62 DIAGNOSIS AT VIABLE PERIOD. until July, 1876, wlieii, after a week's illness, it died of croup and inflammation of the lungs at the age of eleven months." I have placed this case by itself, because it is the only one of its kind, and the only one which, after critical investigation, will admit of being termed " abdominal," or intra-peritoneal pregnancy. Certainly those quoted by Parry will not do so, and I have met with no others. Another somewhat similar case is published in the Die Krankheiten der Tuhen, by L. Bandl and is to be found in Tarnier and Budin's book, and is as follows : — " In the case reported by this last author in a multipara examined several times, he diagnosed extra-uterine pregnancy. The child was living and arrived at full time. The patient refused gastrotomy ; phenomena of false labour, and expulsion of the decidua occurred, and some symptoms of peritonitis having supervened, she succundjed. He immediately performed laparotomy ; the child, wlio weighed 3,800 grammes, was extracted alive, but it only breathed three times and died. The following day, at the autopsy on the mother, they found in the abdominal cavity about 2,500 grammes of thick fluid, but nowhere could they discover the foetal membranes. There existed, however, a pocket which enclosed the foetus on all sides, but the walls of this pocket were formed by false membranes about four or five milimetres thick, and which hid the anterior, posterior, and lateral abdominal walls, the small intestines, the ascending colon, the descending colon, etc. On the internal surface of the pouch were a certain number of threads, some thick and some thin, which extended from one wall to the other. A mass which comprised the placenta in its thickness lay in part on the internal iliac fossa, and penetrated into the little basin on the right side. Some very dilated vessels, being the size of a raven's quill, were very close to this placenta. The umbilical cord, part of the foetus, formed a handle round the uterus., and penetrated by a circular orifice, which was a centimeter and a half in diameter, into a cavity of which the walls were smooth ; the foetal surface of the placenta limited this cavity, into whicli the finger could easily penetrate. Outside the opening round the cord were prominences of wrinkled ovular membranes of a yellow-brown colour, and dating from the first months of the pregnancy. Here the evidence of the remains of the broad ligament cyst clearly point to the occurrence of secondary rupture." Under the circumstances of Jessop's case nothing could have been easier than the diagnosis, though there is one source of error which I have met with several times, and no authority, Parry excepted, makes any allusion to it, so far as I know. At page 103 he says : — " I have met with an example of thinning of the abdominal walls a few years since, which was exceedingly puzzling. I was asked by Dr. E. W. Watson to see a young woman, to decide ABNORMAL THINNESS OF UTERINE "WALLS. 63 the nature of an abdominal tumour, -whicli was the size of a seven and a half or eight months' gravid uterus. Upon making pressure upon the enlarged abdomen a foetus was felt receding from Ijeneath the finger, against which it immediately rebounded. It was so superficial in its situation that it appeared impossible to believe that there was anything more than the skin of the abdominal wall interposed between the fingers and the child." It is clear that in such a condition we must have not only a " thinning of the abdominal walls," but a want of development of the uterine tissue ; and a few cases in which this arrest of development was so remarkable that the walls were no thicker than a single fold of a towel, forms a part of the curiosities of my experience. In one case in the practice of Mr. Langley ]5rowne, of West Bromwich, we found a very thin uterus extremely retroverted. In the others the conditions were those of extremely thin walls, with some kind of displacement, as latero-flexion or retrotlection, and in these patience always solved the doubts. If I met with a case where any urgent symptoms existed, I would not hesitate to use the sound or use my dilators if necessary ; for the worst that could happen, in the event of mistake, would be a premature labour. This condition of extreme thinness of the uterine walls, in a pregnancy perfectly normal in every other respect, is a point wliich has not yet received the notice it deserves. It is, however, of sufficiently common occurrence to be a source of difficulty and danger, and therefore I propose to say here what I have noticed about it, in the hope that it may draw the attention of someone engaged in obstetric practice who may be able to investigate it more fully. I can now recall eight cases in which I have been consulted concerning a supposed extra-uterine pregnancy, yet in which there was only an extreme thinness of the uterine walls. I have no record of three of the cases, but of the others I have more accurate data than mere recollection. The features of all of them had much in common, and the known histories of four quite establish this. The ordinary symptoms of pregnancy were present in all of them, and in only one was there any doubt as to its existence. The question generally was, Is the child in the abdominal cavity ? and sometimes I had great difficulty in persuading the gentlemen who brought the patients to me that the position of the child was normal. Save in one case — that seen by me with Dr. Whitwell, at Shrewsbury — there was a marked absence of the liquor anniii, so that the movements of the child could be seen and felt in a most striking manner. In the pelvis the finger came upon the presenting part of the foetus, as if it lay immediately under the mucous membrane ; and it was only on very careful investigation that the attenuated cervix uteri could be made out, spread over the body of the child. 64 PREGNANCY IN BiriD UTERUS. These cases were, with one exception, all under the seventh month. In the eighth and ninth months the walls of the uterus thickened, the quantity of liquor aninii increased, and the cases terminated in perfectly natural labours. The exceptional case I have seen within the last few days, and the pregnancy had advanced well into the eighth month. Vaginal examination makes it quite clear that the pregnancy was iutra-uterine, whilst from the appearance of the abdomen alone the conclusion would have been inevitable that the child lay amongst the intestines. These facts were given to me in connection with ]\Ir. Langley Browne's case, also with a case which was watched by Dr. Hill Norris, and attended by him in her confinement. In Dr. Whitwell's case there was a large, thin-walled cyst, through wliicli the child could he felt with the most astonishing distinctness, and it floated about as if it were perfectly free in the abdomen. He wrote to me afterwards that " the i)atient went on very well, that some time before the expiry of gestation the foetus became mucli more a fixed body, which undoubtedly showed an increased thickening of the walls of the uterus, as well as enlargement of the fcetus, and that her labour was quick and without any subsequent haiuiorrhage." The other conditions with which extra-uterine pregnancy may be confused, before the death of the child, are (a) displacement of the normally pregnant uterus during the early months of pregnancy, complicated with fibro-myoma or cystic disease of the uterus ; and, more rarely, (h) pregnancy of one-half of a double uterus. In a case which I saw with the late Mr. Eoss, of Wake- field, I diagnosed either extra-uterine gestation or a double uterus with pregnancy of one side, and it turned out to be the latter. Frequently we have considerable lateral displacements of the normally pregnant uterus, especially in unmarried women, sent to the specialist as something very different to what they really are. But it is in cases seen after the death of the child, or at least when the time of the expected confinement has passed so long that if there is a child it is sure to be dead, that our most serious difficulties in diagnosis are met with. The first point to consider is the history given by the patient of her supposed pregnancy, and the events which occurred at and after the time of her expected delivery. It is somewhat remarkable, and I think it is in favour of the views of the pathology of tubal pregnancy which I have advanced, that the majority of the instances of this abnormality occur in women who have not borne children previously, or in those who have had no children for many years. This point in the history of the patient is therefore always noteworthy. The other matters requiring careful considera- tion are tlie sudden arrest of the menses, the gradual increase in size, the occurrence of symptoms of labour at or about the end of HISTORY OF CASE LEADING TO ERROR. 65 the ninth month, and the suhsequent diminution in size. Of all those points, the last is the only one having the importance of a sign ; but it must always be born in mind that no history, however complete, is of sufficient weight to establish a diagnosis unless there be some distinct physical signs in support of it. This I lay down as a rule based upon a remarkable experience, which I published in detail in the "Transactions of the Obstetrical Society of London " for 1874. In this case I had diagnosed double ovarian tumour, but was completely misled by a subsequent history which the patient volunteered. This was to the effect that just three years before she had believed herself pregnant, because her menstruation had ceased for eight months, her abdomen had slowly enlarged, and so had also her breasts. She was also quite sure that she had often felt movements, and, indeed, had all the feelings that she had experienced in each of her seven pregnancies. One day, when walking in the street, she was seized with pains, exactly like lal)Our pains, and these lasted for four hours. At these pains she felt no surprise, fully believing that she was in labour. She felt as if a child was about to pass from her, and was aware of the " swelling pressing downward." She afterward felt this " pass back into the belly," the pains ceased, and her size remained unaltered. At this false labour there was no discharge. Up to the time when I first saw her she is quite certain no diminution of her size had ever occurred, and that there had been very little increase, if any. The physical signs of the case were those of multilocular disease of both ovaries, and on them I need not dwell. I found it vs^as so M'hen I operated, and the operation was successful. The lesson of the case is that we should place very little confidence in the statements of patients, if they are not in harmony with physical signs. I must plead in extenuation, that I never saw a woman farther removed from any taint of hysteria, and, being an illiterate woman, there could have been no cramming up of symptoms from books. The strongest points in her story were the arrest of menstruation for eight months, and the very complete narration of the phenomena of labour, and on these points I had corrobora- tion of her statement. This singular imitation of the process of labour is a striking feature in most of the cases in which an ectopic gestation is carried beyond the normal period, and seems thus to indicate the conclusion that the initial mechanism of labour is not in the uterus, as generally supposed. It was first noticed in 1652 (Phil. Trans., Vol. V.) l3y Vassal and has been constantly alluded to hj writers recording such cases, one case being given in the Memoirs of the Medical Society of London in 1789, when the spurious labour went on eight days, and then abdominal section was performed. The child was dead, and, as the placenta was 9 66 HISTORY OF CASE LEADING TO ERROR. unfortunately removed at the same time, the patient died in four hours. Campbell gives a great deal of curious information on this point * as on others, and he especially emphasises the records of cases where there has been a " show " and separation of secundines. It is also worthy of note that he gives a long list of records where it is especially noted that up to the occurrence of the false labour no trouble of any kind was encountered by which the patient was led to suspect that there was anything wrong. The gestation in the case which I am now discussing, which led me astray as much as anything, was the suppres- sion of menstruation, and the digest of the records made by Campbell on this point is worth quoting at length to show how little trust can be placed in histories. " In many instances of the different varieties of misplaced gestation, tlie catamenia are suspended ; frequently, however, they appear regularly in each of the early months ; in some cases they How at uncertain periods ; and in other examples they are either profuse, or limited in quantity. In many cases, at an uncertain period of gestation, we have hemorrhage, uterine effusions, the extrusion of coagula, of bodies which resemble moles, or portions of the placenta. These appearances have occasionally led to the belief that the patient has actually aborted, so that the ovum was originally not extra- but intra-uterine, and had escaped through a rent in the uterus into the peritoneal cavity, the extruded body in either case being viewed as the placenta. Cases attended witli much uterine excitement, whether arising from unusual exertion, or some external injury, are the most likely to be accompanied by these latter phenomena." (p. 104.) The weak points in the story of my case were those I did not attach sufficient weight to, and they were those alone on which we ought to place any reliance whatever. They are that she had no " show " during the false labour, and that her size did not diminish after it. Having now almost exhausted, I believe, the literature of the subject, I am satisfied that these two circumstances are invariable in extra-uterine gestation which has gone past the period. The first is due to the general excitement and congestion of the organs involved, specially to the enlargement of the uterus, which is always present to some extent ; and the second, to the absorption of the liquor amnii after the death of the child. The complete arrest of menstruation during the period corresponding to normal pregnancy is far from l^eing a constant condition. But even though it were like its accompanying signs, such as * For once (p. 120) Campbell Indulges in a piece of criticism based on a wliolesome sceiiticisni concerning the utterance of "a veteran practitioner," who I suspect was Hamilton, "He says :— "Those of the profession who have been led to bestow some share of attention on the subject under consideration, will excuse me from entering my dissent against tlie dictum of a late veteran practitioner, who imagined that there was something so characteristic in the mere moans of the patient, that it would be sufficient for the medical attendant to hear them once, to enable him to pronounee any future case to be one of a certain variety of extra-uterine gestation." I RELATIONS OF UTERUS TO GESTATION SAC. 67 enlargement of the breasts, darkening of the areolae, increase of ]\Iontgomery's tubercles, malaise, vomiting, etc., it Avould help iis to do little more than suspect a pregnancy. Sometimes there is metrorrhagia, due to the large size and empty condition of the uterus, a symptom which would incline us to the diagnosis of uterine myoma. Parry has fully investigated this point in the numerous records he has collected, and tells us that " the uterus, except in some rare instances, undergoes striking alterations, both in its structure and volume. Its developement has been found to vary from twice the size of an unimpregnated organ to the volume which it is known to attain when gestation is four months advanced." After the death of the child, auscultatory signs cannot, of course, be made available ; though in one of my cases, where the child was clearly dead, the placental sound was heard at my first visit, but had disappeared entirely at my second, ten hours afterward — a set of signs which tended to confirm my diagnosis. The invariable condition of the uterus in extra-uterine pregnancy, whether before or after the death of the child, is that it is intimately associated with the tumour, generally in front of it, moveable to a limited extent, always enlarged Ijefore the death of the child, and remaining so afterward if the placenta be attached, as it generally is, to the posterior surface of the fundus. The most important point is that the cervix is always quite open — in my cases almost admitting the finger. Under such circumstances, if a fetal heart is audible, the case is clear. If not, then the character of the tumour must be taken carefully into account. If the case is seen soon after the death of the child, the tumour will be soft, more or less obscure ballottement will be felt in it, and possibly a part of the child may be made out by rectal, vaginal, or supra-pelvic examination. It is at this stage the great difticulties in diagnosis are met with, and Parry has so well summed this up that I cannot do better than reproduce what he has said on the subject : — " If the patient is not seen until after the death of the child, the diagnosis of an extra-uterine pregnancy may be very difficult. Many years may have intervened before the woman comes under notice. Of course, if the cyst has opened into the bladder, bowels, or vagina, or a fistula has formed through the abdominal walls, there will be little or no trouble in arriving at a correct conclusion. Difficulty will arise only when the cyst has not ruptured, or, having opened into the bladder or into the rectum out of reach, it has not discharged any of its solid contents. Under these circumstances, a correct conclusion can be reached by carefully sifting the clinical history. No point is too minute for examination. As a rule, it will be found that all such women have a firm conviction that they were pregnant when the abdominal tumour 68 DANGER OF TAPPING. made its appearance. Though more than a score of years may have passed, they will not have abandoned the idea that they still carry a child somewhere in the abdominal cavity. Such Avonien will nearly always give the history of labour at or near term, attended with uterine haemorrhage, and followed by the secretion of milk ; after which they will assert that the abdomen diminished in size, and that this diminution steadily continued until the tumour reached the dimensions presented when the patient comes under observation. This association of phenomena is very characteristic, and when they are all present, erratic gestation should always be suspected. The diminution in the size of the abdomen after labour is a most important symptom." After the absorption of the liquor amnii, the character of the tumour in extra-uterine pregnancy alters very much. The uterus may become smaller and more mobile, and parts of the child may be felt, especially in the rectum, such a sign at once pointing out the nature of the case. These prominences, and likewise the " bosselures," or knobs of the hands and feet, which are often felt above the pelvis, may be closely imitated by the small nut-like cysts of small ovarian tumours, and especially by the hard irregularities of dermoid cysts. These resemljlances existed in the case I have narrated above to a considerable extent, but to a very much more marked degree in another patient, where I removed both ovaries — one dermoid — Ijut where the re- semblances, fortunately, did not lead me astray. If the cyst be packed down in the pelvis, the deception may be great, and notliing but an exploratory incision will clear up the case. I would strongly recommend that, in such cases, the aspirator should not be used. In a joint, or in the pleura, where the conditions between which diagnosis has to be macle are limited in number, this instrument is doubtless of great use, as it is for treatment as well. But in the abdomen and pelvis it is very different. The aspirator may tell you a tumor contains serum, blood, or pus, but that lielps you but little as to the seat of the disease, and nothing at all as to its treatment. Besides, the risk of the aspirator is great, quite as great as the risk of an abdominal section. The use of the aspirator in my special line of practice is therefore diminishing, has almost disappeared, and in all cases of abdominal tumor where there seems a reasonable prospect of doing good to the patient, I open the abdomen and make out the condition. I have never had to regret this practice, and I very often have had reason to be pleased with its results. Parry's evidence on this point is so strong and important that I quote it at length to strengthen my position : — " In cases of doubt, the foetus being dead, the trocar has been used to draw off some liquor amnii in order to confirm the diagnosis. Unless it has been decided to operate immediately for DANGER OF TAPPING. 69 the removal of the foetus, the use of the trocar is utterly unjustifi- able. A few, but very few women have long survived its use. Mr. Jonathan Hutchinson, in a clinical lecture upon tliis subject, says that this practice " is in itself attended by great danger, nor shall I deal honestly with you or myself if I do not candidly admit that, with due care and patience, 1 do not think that jjaracentesis ought to be necessary in a case of foetal tumor simulating ovarian dropsy." Mv. Hutchinson reached this con- clusion after having been so unfortunate as to see fatal peritonitis follow the use of the trocar in his hands. Dr. Cardeza's patient was tapped after consultation with Dr. W. L. Atlee, of Philadelphia, on November 19th, and the latter gentleman performed gastrotomy five days later. As soon as the cyst was opened, " there was a rush of offensive gas." Jordan used the aspirator for diagnostic purposes, the woman, there is every reason to believe, having no bad symptom at the time. She was given chloroform, the puncture made, and two hours after " complete collapse came on." Speaking of the use of the aspirator under these circumstances. Dr. Jordan remarks : " The doubts cast on my diagnosis, and the variety of opposing views in regard to the nature of the case, which unfortunately resulted in the use of the aspirator, were nearly the cause of tlie patient's death." Slow-growing cancer of an ovary, or in the neighbourhood of the uterus, especially behind it, might be difficult to diagnose b}'- physical signs from extra-uterine pregnancy of long standing, but the history would here greatly help us. The increase would probably be steady, and if a rapid accession to the growth took place, a temperature chart ^\'ould settle the difficulty ; for the only condition whicli could induce rapid increase of the cyst of an extra-uterine pregnancy is suppuration, and this would tell its story on the chart in lines that could not be mistaken. The history of the case would probably help, but it might just as easily lead one astray, as in the case I have detailed. I once saw a very eminent obstetric physician attack an abdominal tumour wliich, from the history mainly, he had assured himself was an instance of ectopic gestation gone beyond the full time. He asked me to examine the case and give an opinion, but as the physical signs were in no way distinctive from those of a large uterine tumour, certainly not myomatous, I said I should depend more upon the exploratory incision than upon the history. The event proved that the history was entirely fallacious, for the tumour was a mass of cancer of the omentum, adherent to and involving everytliing. After the liquor amnii has been absorbed, and the contents of the ovum cyst consolidated, the relations of the mass to the uterus and the other pelvic viscera are made so close by the placental connections, that the physical signs never can be very clear, and therefore, alternative diagnosis of fibrocystic tumour of 70 TREATMENT OF ECTOPIC GESTATION the uterus must be the refuge of uncertainty.* But an exploratory incision will clear up all doubt as to the diagnosis, and at the same time it will put the operator on the road to the proper method of treatment. After the diagnosis of a case of extra-uterine pregnancy lias been satisfactorily determined, tlie question arises. What is to be done with it ? If the child is still alive and near the full term, I believe it to be our duty to operate. If the child is dead, the propriety of operating seems to me quite evident, though it has been disputed by so eminent an authority as Mr. Jonathan Hutch- inson. Of course no strict rule can be laid down, and each case must be decided on its own merits ; but the records of surgery are so full of instances of the risks which such cases have to run when suppuration of the sac occurs, as it almost always does some time or other, that I think we are in most instances justified in operating. Moreover, the surgical principles on which tlie operation is to be conducted are now so well established, and its results are so good, that the opponents of the operation seem to me to be in a very illogical position if they still continue to advocate certain other surgical proceedings, of which the results are notoriously bad. Of late years much discussion has turned on various forms of treatment designed to obviate the necessity for surgical operations, and in the arguments used to support them, an altogether new and I venture to think, a very immoral element has been introduced. It is to the effect that if the child is alive the proper thing is to kill it in the belief that the infant's sacrifice is the mother's safety. I am no theologian and this is hardly the place for a discussion on morals, but I am bound to say that this seems a most mysterious kind of belief, and it would put legitimate practitioners of medicine quite on a level with abortion-mongers and reckless craniotomists. Certainly I will have none of it, the more that the men who urge it happen, commonly enough, to be notoriously unfortunate in all their surgical efforts, belonging generally to the hybrid class of obstetric physicians. If the death of the child did bring the mother safety, something might be said for the proceeding, but nature kills the child in the vast majority of instances of ectopic gestation, as we have seen, and safety is thereby brought to a mere fraction of the cases, as Parry * Writers of "library papers" and otlier inexperienced persons talk so lightly of diagnosis in pelvic and abdominal troubles, and so assuredly of the accuraey of tlieir diagnosis, tliat I am disposed to ask those who are passing through those stages of their jirofessioual existence to read the following extracts on the subject of the diagnosis of ectopic gestation: — "Although from the careful perusal of numerous histories of cases ot this nature, some degree of facility of distinguishing their presence may be acquired after a certain period of their duration, and of deciding even, in occasional instances, on the particular variety of such pregnancies, yet assuredly every practitioner who has attentively studied the subject, must admit the distinction to be a task of no ordinary difficulty.— Parry. "Telle est I'obscurite du diagnostic, apres I'exploration du col uterin, que les Baudelocque, les Osiander, les Dubois, ete, n'ont jamais ose, au milieu des incertitudes qu'il laisse, entre- piendre, au terme de neuf mois, Tuxtraction de Teufant. Archives Geiier. Vol. xxvii., p. 211." — Lesouef. AT OR NEAR FULL TIME. 71 has proved. Puncturing the ovum sac with needles, medicated or galvanic, is therefore an immoral and dangerous proceeding, which ought to have professional condemnation. Parry is of opinion that all measures that necessitate wounding the cyst without removing the child are not without danger to the woman, and that the question to determine is whether the risks of such a therapeutic measure, though they may be grave, may not be less than those which follow when the accident is abandoned to nature. This is a fair way of stating the case, certainly at the time Parry wrote (1874) it was a very advanced kind of statement, but now we can speak with far greater certainty. He himself says in this very passage that future experience must settle the question. I venture to think that my own experience settles the question in favour of surgical interference in ectopic gestation at the time of primary rupture. I think there is no appeal against the decision to cut down and tie the bleeding point. No acupuncture, simple or medicated, and no electrolytic charlatanry will save a Avoman who has a vessel bleeding into the peritoneal cavity. If the child survives that rupture it has a legal and a moral right to its life, and ought not to be deliberately killed as has been done by Dr. Braxton Hicks and Dr. Aveling. Parry says of this case, narrated by the former authority : — " The observation of Dr. Hicks is more important, since it involves less speculation. This case has already been alluded to. The patient died, when four months pregnant, of internal hemorr- hage, the result of an attempt to destroy the foetus by puncturing it with a trocar. About a fortnight before her death she had some symptoms of rupture, but these were not distinctive. At the post- mortem the cyst, which had originally contained the ovum, was found ruptured ; and outside of it, having formed new connections, was the perfect ovum with its placental attachments, on the side opposite the opening into the cyst and to the posterior surface of the uterus." In Dr. Aveling's case both mother and child had survived the primary rupture, and the ovum was going on developing in the broad ligament. Beyond the fact that an ectopic gestation was diagnosed by Dr. Aveling, and was even made clear by him to My. Spencer "Wells, there was no reason apparent for interfering. If the case had been carefully tended up to the viable period a livinfT child midit have been removed. Instead of this the child was killed by galvanism, and that seems to me a wrong thing — a far more immoral thing even than " spaying." One of the most recent cases in which electricity has been used for the purpose of dealing with an ectopic gestation is that reported by Dr. Buckmaster, of Brooklyn, in the Medical Ncius, July 21st, 1888, and this case is so characteristic that it may serve as a type against which criticism can be easily and justly directed. 72 ELECTRICITY. Dr. Buckmaster asks three questions in connection with his case, of which the first is : " Was the diagnosis of extra-uterine pregnancy warrantable?" and in reply there can be no doubt at all, for the description that he gives of the accident which occurred to the patient about the ninth week of pregnancy is essentially characteristic of tubal rupture — " She suddenly felt a violent pain in the ' pit of the slomach,' heard a ringing noise in tlie ears, and fainted. She lay on the floor groaning, and did not have strength enough to call loudly for assistance. She was found in this condition by her husband and removed to her bed. It is said that her face was very pale, and she fainted at each attempt to sit up. She was very thirsty, and ' thought the doctor cruel ' in that he did not permit her to drink all the water she desired." The second question is : " Was the child living when the electricity was first applied ? " and then Dr. Buckmaster gives a categorical reply in the affirmative, when really it is a matter open to the greatest suspicion. I think in all probability from the details of the case given that the patient was suffering from a hematocele of the broad ligament, due to the rupture of the tubal pregnancy, to such an extent that the ovum had been destroyed, and that if she had been left alone the absorption of blood would have taken place without the violent influence of the electric current, just as generally follows when the electric current is not applied. Further, he describes the tumour as not only decreasing in size but changing in character, losing its elastic feeling on account of the absorption of the fluid contents. But supposing the child had not died, his third ({uestion comes up for discussion : " Is the uninterrupted current the best means for destroying the foetus ? " and to this I reply. What right had Dr. Buckmaster to destroy the child at all ? There can be no doubt from the very clear description given that the pregnancy w^as in the broad ligament. " An ill-defined mass, elastic to the touch, was distinctly traceable on the right side. Vaginal examination showed that the uterus was crowded forward toward the pubes, and that it was somewhat enlarged and softened. The sac of Douglas was occupied by an elastic mass in which fluctuation could be detected, and which felt not unlike a small ovarian cyst, and seemed to be part of the tumour felt in the right iliac region, from which the uterus appeared free." After carefully considering the different methods for destroy- ing the foetus, none of which seemed altogether satisfactory. Dr. Buckmaster continued to use the galvanic current unin- terruptedly, but he gives no justification whatever fur his determination to destroy the child. All the severe symptoms had disappeared, the patient was suffering from nothing but slight discomfort and the unfortunate fact that Dr. Buckmaster had diagnosed an ectopic gestation. If the case had been left ELECTRICITY. 73 alone a living child might have been the result, for there can be no doubt whatever that it was an extra-peritoneal pregnancy, which, if there really was a living child, would have gone on precisely in the way to be described hereafter. Then, finally. Dr. Buckmaster tells us that three months after the electric treatment the patient still had left a hard mass, which could be felt on making a vaginal examination, and that there was a slight tenderness about it, in fact the physical condition of the patient was precisely that in which lie found her, except that the mass had diminished in size, it still remained there, a source of danger, and in all probability will some day suppurate. Certainly three months is far too short a period on which to base any conclusions for the safety of the treatment, even supposing that he achieved the result which he says he desired in killing the child. My own belief is that he did not do so, for the method which he employed is one Mdiich could not by any means be applied Avith safety to the child, and the strength of the current was not such as is likely to be fatal to anything at all. In Dr. Buckmaster's papers there are two other points upon whicli some criticism might be directed. In the first place he credits Dr. T. G. Thomas Avith the belief that the electrolytic treatment has these great advantages, if any error of diagnosis has been made, it will do no harm, and if the diagnosis be correct, experience proves it to be sufficient. My answer to such statements is this, that it is by no means clear from experience which we have had in this method that the electric current is without harm, whether the diagnosis be correct or not, and it is equally without proof that it is sufficient to produce the effect desired. Further, Dr. Buckmaster says on his own account, that cases will undoubtedly appear, as the literature of the subject expands, in which, after cutting into the abdomen, it will be found impossible to complete the operation. I say from my own experience that this is absolutely inaccurate, it may be impossible for the immediate operator in certain cases to complete the operation, but the rule ought to be that all such operations should be completed, and any man who has such want of pluck and skill as to stop in the middle of one of them ought not to attempt them. They can all be completed. The second point is that Dr. Buckmaster says that " it has been claimed recently that the placenta continues to grow after the death of the foetus, but as we have seen no corroborative evidence, it is not worth consideration at present." As I am responsible for having first made a statement that I had seen the placenta growing after the foetus had clearly been dead for some time let me here draw the attention of Dr. Buckmaster and others to the evidence upon which the statement is based. In case number six the rupture had occurred apparently in the 10 74 GROWTH OF PLACENTA tenth or eleventh week of gestation, and the placenta was lying in the midst of a quantity of clots, as a round mass the size of a cricket ball, for the most part in the wall of the tube, for when the tumour was removed the placenta was still adherent to part of its inner surface, and the pelvic mass was intact. On slitting it open, the ovum cavity was found to contain about a desert- spoonful of liquor amnii, but there was no trace of foetus at all. As we have very frequent experience of this kind of incident — the growth of a large placenta, embracing a small ovum cavity without any, or with only very slight trace of a foetus, in the so-called uterine " moles " — we have no reason to do other than expect that they will occasionally occur in tubal pregnancy. As a matter of fact such was the state of matters in this case. In case 19, when the foetus was found it was only about 2| inches long, and had evidently been dead for some considerable time, for it was partly digested. Whereas the placenta had grown to be quite as large as that of an intra-uterine fcetation of four months, and it had been forming adhesions to intestine and omentum, giving rise to recurrent hajmorrhages, for which the operation had ultimately to be performed. Similar appearances occurred also in cases 24, 30, 32, and 37. At the meeting of the Obstetrical Society, at which Dr. Champne5\g read his case, ]\Ir. Thornton gave testimony to the same conclusion, and in the first edition of the "Manual of Gynaecology," by Hart and Barbour, published in 1882, there is the following evidence on this important question : — ■ " Case of extra-uterine gestation, with deatli of the foetus, but continued growth of the placenta, which led to fatal haemorrhage. A. B., pet. 24, had passed two periods without menstruating, and thought herself pregnant; three months ago she began to have irregular haemorrhages three times a month, and in considerable quantity. The tumour was found in the pelvis, the vagina being compressed against the pubis, the cervix reaching about tlie brim, and the bladder displaced into the abdomen. The tumour was as large as a uterine pregnancy of 4| months. After a puncture of the cyst with an aspirator needle the patient died with symptoms of internal haemorrhage, and on a post-mortem examina- tion, by freezing the pelvis and cutting sections, the uterus was found to be 5f inches long, tlie fundus being 5 inches above the symphysis, and the cervix so drawn up that the fornices are obliterated. The gestation sac lay in the pouch of Douglas, and was chiefly occupied by the placenta. The cavity of the amnion contained but little fluid, and the fcetus was about the size of a three months' pregnancy. The continued growth of the placenta after the foetus had died had led to fatal liaimorrhage. In looking over the records of cases which have gone beyond the full period of gestation, I find numerous illustrations which AFTER DEATH OF FCETUS. 75 cannot be other than the growth of the placenta after the death of the child. No emphasis in any case is laid upon this fact, but the descriptions completely establish it. In a case mentioned by the first Mr. Samuel Hey, of Leeds, the patient went over the nine months with a false labour, and the child died. Three months afterwards the mother succumbed from the sufferings involved in the carriage of the ectopic gestation. The child was found to be fully formed, and showed no marks of decomposition. As the child had attained a size so unusual as to weigh nearly two pounds and a half, the cyst was supposed to be the right Fallopian tube, but the description makes it perfectly clear that it was the right broad ligament, together with the tube. The placenta in this case must have grown greatly after the death of the child. Some of the facts which have been recently recorded in the application of electricity for the treatment of ectopic gestation are positively ghastly, as illustrated in the paper by Dr. Matthews Duncan in the Bartholomew's Hospital Eeports for 1883. Electricity was first tried in the form of an induced current as strong as the faradic coil in a Croxeter's combined battery could give. A carbon disc electrode in connection with the positive pole was placed over the tumour on the left side, and a gum-elastic electrode, with a nickel-plated end, was passed into the vagina towards the left side and connected with the negative pole. A current was alternately passed and withheld during periods of two seconds for about a minute and a half. A continuous current of forty modified Leclanche elements was then passed for a space of six minutes, producing slight vesication of the skin, and a rough dried surface in the vagina. The foetal heart was heard beating the same evening. On the following day two grains of morphia were injected into the amniotic cavity. An hour afterwards the mother began to feel drowsy and her pupils became slightly contracted. It was thought advisable to draw off the liquor amnii, which was done through the abdominal wall by aspiration, eight ounces being removed. The foetal heart still continuing to beat. Dr. Duncan, five days later, injected I gr. of morphia into the hodi/ of the fcdiis, to the depth of two inches, at the spot where the foetal heart was heard plainest. The opera- tion was twice repeated at intervals of two days, but without the desired result. It was decided now to try and destroy the foetus by galvano - puncture. Two insulated electrolysis needles were passed into the tumour for an inch and a half and connected with the negative pole of a battery composed of modified Leclanche elements, a carbon disc-shaped electrode connected with tho positive pole being applied over the tumour externally. A current from forty cells of the battery was passed for six minutes with occasional interruptions. After the operation the foetal heart could still be heard beating, but more slowly. Four days later 76 ABDOMINAL SECTION. Dr. Duncan, having heard the foetal pulsation, drew off the liquor amnii, with the aspirator, and then injected m. xiij. of equal parts of water and liq. morph. liypod. into the foetus just over where the heart was heard. After this the fa^tal heart could not be heard. The patient died two days subsequently. At the autopsy, twenty-six hours after death, the contents of the cyst were found very foetid, and the soft parts of the foetus itself were for the most part as if comi^letely macerated, the bones being exposed. Almost all the internal organs were diffused in the surrounding fluid, or were diffluent. The heart was scarcely recognisable. Such a record is positively discreditable to the art we practice, a series of ineffectual experiments were tried upon this poor mother and child, one after another involving fearful suffering and finally double death, when probably both lives might have been saved by following the ordinary rules of surgical proceedings. If the ovum perishes between the period of primary rupture and the viable period and becomes a source of danger it ought to be removed, but if it can be nursed through the time till the end of gestation it ought to be saved by abdominal section. If the patient discovers herself only after the child is beyond the gestation period and dead, it ought to be removed for it is a source of perpetual risk. Quiescent lithopedia are far too rare and suppurating ovum sacs far too common and far too fatal for us to recommend such a risk to our patient. Parry sums up the Cjuestion very well in the following passage : — " After the death of the foetus, and the restoration of the normal condition of the system, the retention of an extra-uterine foetus is not incompatible with a long and useful life, but a woman is never free from danger while she is carrying an encysted child. Violent exercise, injuries, blows, strainings, and similar mechanical irritations may be the exciting cause of inflammation of the sac at any time. Hence, violent pain, with fever and evidences of inflammation following these, always demand a cautious prognosis. " Depressing diseases, as any of the continued fevers, or local affections which introduce a profoundly typhoid condition, endanger the woman by impairing the nutrition of the cyst, and leading to destructive inflammation," The earliest case of abdominal section for ectopic gestation which has been found upon record, is that of Primerose, who operated in October, 1594. The history of this patient has become classical. She was twice pregnant with extra-uterine children — first in 1591, and again some time before 1594. The cyst of the first child opened spontaneously through the abdominal wall. The fistula was enlarged, and the child extracted by Jacob .Noierus, a surgeon. This operation proving successful, Primerose removed the second child by abdominal section two months later. It is easy to imagine how he was led to perform the second and more ABDOMINAL SECTION. 77 liazardous operation. Felix Platerus reported another successful case only three years later. After this we have found no indication that the operation was performed for more than a century. In 1714 Calvo reported a case in France, and in 17G4 Bard another in America. — (Parry.) Mr. John Bard was a surgeon in New York, and no one is known to have operated in that country before him. The patient was the wife of a mason, and the operation was performed several years before it was published, for Mr. Bard communicated an account of it to Dr. Fothergill, in a letter, which was dated on the 25th of December, 1759. On January 14th, 1791, this operation was performed in America for the second time, the subject of it being a Mrs. Cocke, the wife of a Virginia planter. The operation which was done by Dr. William Baynham, a country physician, was entirely successful. The same gentleman operated with the same happy result upon a negro slave on February 6th, 1799. This was the fourth American abdominal section for the removal of an extra- uterine foetus. The third one was performed by Mr. Knio]it, and communicated to the celebrated Dr. Lettsom, by Dr. Mease, of Philadelphia, and published in 1795. Dr. Baynham's cases are well worth attentive study. They illustrate the intrepidity and good judgment so often displayed by the country surgeon, who, separated by long distances from his fellows, often has to act in the greatest emergencies without the counsel wliich he may earnestly desire. Almost a (quarter of a century passed before the operation was repeated in America. On the sixth day of October, 1823, it was again performed by Dr. Wishart, likewise a country practitioner. The sixth American operation was performed on February 6th, 1846, by Dr. A. H. Stevens, of New York, a man who liad all the advantages of a metropolitan experience. — (Parry.) Sprengel, in his History of Medicine, vol. VII. p. 290, et seq. refers to the following authorities for cases of this nature, viz.. Com ax, a professor at Vienna, said to be the first who operated successfully for gastrotomy ; Hector and Gassarus, both of Augsbourg ; Soligen, who is said to have practised the operation repeatedly ; C. Denys, a French Physician, who relates several cases of extra-uterine conception, followed by abscesses, from wliich fcetuses were extracted ; Pamge a surgeon of Bremen, who operated on a woman in whose abdomen a fatus had been retained eleven years ; Spaering a Swedish physician, who, with a lancet, opened an abscess, and from the lower part of the abdomen extracted a foetus of thirteen years retention; Breyer of Leipsic, and AVeinhardt, both of whom operated successfully by gastrotomy ; Professor Colomb of Lyons, and Professor Josephus of Rostock ; both were unsuccessful. — ( Camphell.) 78 ABDOMINAL SECTION. Parry gives a number of tal3les which are intended to show the mortality of extra-uterine pregnancy reaching to and going beyond term, and submitted on the one hand to abdominal section, or left to nature, on the other. But it is perfectly clear that no tables of abdominal operations of any kind are of the slightest value anteced- ent to the year 1878, when the whole practice of abdominal surgery was revolutionized Ijy the final discontinuance of the clamp in ovariotomy ; and further, it is quite clear that the heterogeneous collection of cases of which rarely more than two are contributed to the list by the same operator, can have little or no value. In turning back over the records of the cases where the details are given, the great bulk of them have been operated upon when the patients were too far gone in illness, the result of accidental complications or suppuration of the sac, to give the collection any value whatever. The following are his conclusions. Of thirty cases in which gastrotomy was performed, or the breach dilated, twent}'-- ei^ht patients recovered. In twelve cases of gastrotomy performed after the suppurative process was well advanced, ten of the operations were successful. Of nine women operated on, liowever, durinfT the existence of fcetal life, or soon after its extinction, the whole died. If these conditions had to be accepted there would be an end of the discussion concerning the saving of the child. I, for one, would say no more al)Out it, and willingly would adopt some means of destroying the fa?tus ; or I would watch till it died, and then, after waiting awhile, I should remove it. Parry seems to have been greatly impressed with the lielief that the fatality attending tlie removal of liviug children was due to the " puerperal state," and therefore he advised waiting till the child had been dead some time. In fact, he divided the operations into " primary " and " secondary " on this principle — a most mistaken one. That puerperal women are especially susceptible to surgical influences is true enough ; but our recent experiences make me Ijelieve that it is only true that they are specially susceptible to the influences of bad surgery and unskilful operators. If, therefore, we have a proceeding based on sound principles and a skilful operator, I believe the puerperal woman has no more to fear from an operation than any others. My own experience in the CVesarian operation and in the modern methods of amputating a pregnant uterus convinces me that tliis is so. I never succeeded in getting a woman througli a Cfiesarian section, and I concluded that it was the puerperal influence. But I know now that this conclusion was nonsense. As soon as I began to amputate the uterus all my patients recovered, and recovered easily, just as ovariotomies recover. I used to do the Ciesarian section merely to save the child, now I amputate the pregnant uterus to save both mother and child, and therefore I begin to look upon a man who does craniotomy as a person worthy of suspicion. ABDOMINAL SECTION. 79 If this revolution has been effected about one puerperal operation, why may not the basis of scepticism be applied to Dr. Parry's tables and their conclusions ? Further objections may be urged against them. First of all, the figures are too small for any just conclusion. Then the conditions of individual cases, when unearthed, are so dissimilar that they cannot with any justice be slumped together in tabular form. The great majority of the "primary" cases were operated upon "in extremis," whilst the secondary cases had been going on in chronic form, and were operated on by specially experienced men. Generally speaking, the cases of " primary " operations are only surgical curiosities of a somewhat horrible kind, and of no value whatever. Indeed, Dr. Parry practically admits all this about his tables, for he says (page 223), of the 62 cases tabulated in what he calls " primary operations " were performed for the removal of extra-uterine children, " 30 lived and 32 died, a mortality of 51'61 per cent. It is doubtful, however, if this can be accepted as the true mortality after gastrotomy. This result is to be compared with that of the third table, which shows approximatively the mortality of extra- uterine pregnancy left to nature, or, to speak more correctly, allowed to progress without operative interference until nature had pointed out the way in which she intended to effect elimination by forming openings either through the abdominal walls, bowels, vagina, or bladder. Of these women, 52 '65 per cent, perished, a mortality of only 1 per cent, in favour of gastrotomy. This is certainly a very poor showing for surgical interference in this unhappy accident." The great, and a very important qualification of this last statistical statement is entirely overlooked by Dr. Parry, and yet it is rendered perfectly clear throughout the whole of his writings on the subject, that these cases are only the remnants, the mere survivals of a vast number who died during the processes of suppuration, whereas a table of gastrotomies for living children, or children recently dead, represents no such residuum. To the mortality of the cases left to themselves there must of course be added a large number of those who died when their condition as recognised was beyond remedy, and this number I fancy vastly out-runs the number of the residuum. Here I may speak of the application of the terms " primary " and " secondary " in connection with these operations, for which Dr. Parry is responsible and in which I think he has committed a grave error. He regards as primary operations those in which the life of the child was considered in determining the time for interference or in which the operation was performed shortly after its deatli, or near term ; and as " secondary " operations he has placed all operations performed some time after the death of the child, and when the system of the mother had recovered to a great 80 PRIMARY AND SECONDARR OPERATIONS. extent from the " puerperal condition." It seems to me thcat these terms are most inappropriate and ill-used, and are certain to be most misleading. In general surgery we liave the words primary and secondary operations, more particularly in relation to the amputation of the limbs, used in different senses altogether, and so engrafted in professional parlance as to have become an almost necessary part of our conversation, certainly they are a great convenience. Used, however, as Dr. Parry has proposed they should be, they would be without meaning and would necessarily cause a great deal of confusion. I would greatly prefer that if we were to speak of a iirimary operation for extra - uterine gestations, we should speak of the operation for arrest of the hemorr- hage at the period of ^;?T;)ior_y rupture. My reasons for this are that according to the ordinary meaning of the English language, abdominal section would then be certainly primary in point of date and also primary in the sense of being of greater importance, that is to say of far more frerpient necessity. Abdominal section for a viable child is secondary so far as date is concerned, and it is but of very little importance in the matter of frequency. If we take the technical meaning of " primary," as in amputations, to mean operation at the time of accident Mdien the patient is collapsed from shock, pain and ha:^morr]iage, then the patient who is suffering from collapse as the result of the violent pain and hasmorrhage which occurs at the primary rupture is surely in a condition much more resembling the state of the patient who has to submit to a primary amputation than anything else we can conceive. Most of my patients have been so, as much as if they had been cases of smashed knee-joint, and if left alone these cases must surely die. On the contrary, the women from whom I have removed viable children, or children dead by reason of having passed the ordinary geriod of gestation, have far more resembled cases of amputation for disease, and surely they are secondary operations in the technical sense. A further argument against the introduction of these terms in the relation proposed by Dr. Parry, is that they would practically be determined only by saving the life of the child, and though this must be, as strongly argued by Dr. Meadows, the vital element in the further consideration of such an operation, it cannot be the chief element. Finally by the adoption of these terms and .by the argument he urges for their use. Dr. Parry would practically close the door against further advance in the possibility of saving the child : he says, " Nothwithstanding the possibility of realizing this happy result, and even of saving both mother and child, as has been done a few times, the primary operation cannot be too emphatically condemned." I cannot admit such a conclusion for a moment, for the VAGINAL SECTION. 81 material upon which he has based it is made up of such discordant elements, every one of which requires special qualification, that it is quite impossible to submit it to a satisfactory investigation. But even if we admitted his premisses, his argument after all is based on a nine per cent, difference only against an operation which has saved child as well as mother ; and this even is to be qualified, as I have said, by the mortality having been influenced by unintelligent delay and a vast amount of unscientific instrumentation. One of his cases was operated upon (unsuccess- fully of course) after having been in false labour for over a week ; and another (equally, of course, unsuccessful) after most strenuous efforts had been made for a whole day to deliver the woman by the forceps. I therefore advocate the principle of saving a child who has survived the catastrophe of the primary rupture of the tube by being extruded into the broad ligament. If its existence is recognised during its life, the mother ought to be carefully guarded and watched till the false labour sets in, just as we watch a case for puerperal hysterectomy and seize the onset of labour or its early stage, as the most favourable time for both mother and child. Prom this point of view, therefore, neither the time selected for the operation nor the details of the proceeding will be influenced save by two considerations, not to operate before the child is likely to be viable, provided the delay necessary does not prejudice the mother, and not to delay at all after the death of the child. I specially lay this down for the purpose, amongst others, of excluding all operations for the removal of the child by vaginal section. Dr. Herman has collected a series of twenty-three cases of vaginal section with fourteen maternal recoveries and only one child saved. I have unearthed a few more, but this kind of research is really of little value, for when the details of the case come to be perused it is evident that there are so many points of discrepancy, that it is the merest nonsense to argue from such a collection to any general, still more to any particular conclusion. That vaginal section is an unsatisfactory method for the purpose of saving the child is certain from the constantly recorded difficulties in getting the child out, and only two cases are known where the child has been extracted living, only two cases where it ultimately survived. The mortality of the collection is over 60 per cent., but this forms an argument not half so strong as the records of the tearing of the parts which was revealed at the post-mortem examinations, and the concealed hremorrluige, which was nearly always the ascertained cause of death. My own experience of one case is quite sufficient, and I shall never, under any circumstances whatever, attack a sub-peritoneal pregnancy from the vagina. 11 82 VAGINAL SECTION. I give that case in detail as published in the Medical Times and Gazette for 1873. " On July 16th, 1872, I was asked by Dr. Call Weddell, of Bloomsbury, to see in consultation with him Mrs. T., aged 32, who had been suffering for some time from anomalous and perplexing symptoms. She had had one child, nine years previous to the above date, and for some months had been under the impression that she was again pregnant. For some days before I saw her she had been suffering from feverish symptoms, and her condition had evidently become very critical. A crescentiform tumour occupied the pelvis and iliac fossa, giving no special indication of its nature from above, save that at one spot less than half an inch in diameter, and situated about an inch below the umbilicus, there was a distinct bruit, which was much intensified when the pressure of the stethoscope was increased. Vaginal examination revealed a tumour behind the uterus, occupying the whole available space, immovable, and with a peculiar boggy feeling to the touch. The uterus was open, four inches in internal measurement, and presenting very much the characters as if a miscarriage at the tliird or fourth month had recently occurred. It was movable over the front of the tumour to a limited extent, the fundus being anteverted and readily felt over the pubis. On examination by the rectum I felt what I believed to be the knee of a child and the edge of the placenta. " On July 17th the condition of the patient was manifestly much worse, and admitted of no further delay. We therefore placed her under chloroform, and I passed the needle of an aspirator into the retro-uterine tumour and evacuated a few ounces of fluid, which was undoubtedly liquor amnii. The diagnosis being thus placed beyond doubt, I followed the needle with a knife, and came at once on the knee of a foetus. I enlarged the incision, and delivered a foetus of about the eighth month, which had evidently been dead for some time. As soon as the child was born I passed my hand through the aperture and searched for the placenta, which I found situated in front. I also found that the cyst had been ruptured above, and that some intestine was extruded into the sac. Tliere was no difiicvdty in removing the placenta, and no haemorrhage seemed to result from its separation. It weighed when put together nearly three pounds, and was very hard and fleshy. The patient rallied from the chloroform, but sank in a few hours." I am indebted to Drs. Sawyer and Weddell for notes of the post-mortem examination : — " There was a considerable amount of clotted blood among the coils of the intestines. The uterus was enlarged and displaced, being carried so much to the left that its right margin corresponded to the middle line, and so much forward that its fundus projected I VAGINAL SECTION. 83 over the symplij^sis pubis. The cyst was large enough to contain two clenched fists, and was situated between the uterus and vagina in front, and the rectum and sacrum behind, the greater portion of it being to the right of the middle line. The cyst was extensively ruptured inferiorly, and the small intestines freely protruded into its cavity." " The lessons derived from this case and its failure are three : — First, that we should not delay interference after the child has come to the term or after it is dead ; second, vaginal section should invariably give place to abdominal section, the latter lieing more scientific and less risky ; and third, that the placenta should not be interfered with, luit should be left to separate. I have profited by these lessons, and have since been able to operate on a case successfully." In this case the temptation to remove the child from the vagina was very great, for it felt just as if it were separated from the fingers by the vaginal mucous membrane, and indeed there was little else. It felt as if a mere notch in the mucous membrane, and the child would come, and it is clear from the records that most of the operators have yielded to the temptation in similar conditions. But to do so is wrong, if for two reasons only. In the first place, as the placental relations are always chiefly pelvic, generally wholly so, the child cannot be dragged out without tear- ing tissues in which large sinuses have been abnormally developed, and through structures, as they are unyielding, a child can be dragged only with much damage to the tissues, and likelihood of killing the foetus ; then, if there be torn vessels bleeding it is simply hopeless to expect to be able to find them and secure the bleeding points. A case illustrating the difficulty of delivering a child under such circmnstances is seen in one of the two cases known where the child lived. A woman who had been four days in labour, and exhausted by her efforts, but in whom no os uteri could be traced, though the head of a foetus was easily felt, was delivered by an incision five or six inches backwards and downwards through the posterior wall of the vagina. Liquor amnii escaped, and the hand was passed into the cyst to extract the foetus, which, however, could not be effected, though the abdomen was compressed by an assistant ; but extrac- tion was ultimately accomplished by forceps, and although the child, when born, was asphyxiated, it was nevertheless resuscitated. The operation was attended with little haemorrhage, and scarcely any pain ; and in two weeks the woman was going about, and no traces of the incision could be discovered per vaginam. — (An American case, Medical and Surgical Revieiv, vol. ii., p. 132.) Opening the peritoneal cavity from the vagina is a clumsy and risky method of proceeding under any circumstances, and whilst it 84 VAGINAL SECTION. has no advantage whatever over the suprapubic method, it possesses many disavautages. Dr. Herman has very well summed up a series of conclusions on this subject, which I here reproduce, pointing out, of course, that in the first four he gives indications of some amount of the usual confusion as to the periods of rupture, and what happens at them. In paragraphs 5, 6, 7 he lays down fatal objections to the vaginal operation, for after the death of the foetus and the majority of cases will present themselves after this has happened, it is absolutely impossible to tell wliere the placenta is, nor is it always certain even when the child is alive. I have twice failed to discover its seat, even with my hands in the foetal sac. I am also of opinion that the most expert accoucheurs could not accurately ascertain the presentation of an ectopic fcetus until the sac had been opened — at least I once saw a very experienced man utterly fail. Dr. Herman's conclusions are as follows : — (1) The operation of opening an extra-uterine gestation sac by the vagina early in pregnancy, before rupture has taken place, by the cautery knife or otherwise, is a dangerous and unscientific proceeding. Abdominal section ought always to be preferred to this. (2) Soon after rupture has taken place, when interference is called for to arrest haemorrhage, abdominal section is more likely to succeed than vaginal. (3) When rupture has taken place, and the effusion of blood is followed by pyrexia, the indications for incision of the vagina are the same as those in lifematocele from any other cause. (4) At, or soon after, full term, before suppuration has taken place, there may be conditions which indicate delivery by the vagina as preferable to abdominal section. These are — (5) When the foetus is presenting with the head, breech, or feet, so that it can be extracted without altering its condition, and (6) When it is quite certain, from the thinness of the structures separating the presenting part from the vaginal canal, that the placenta is not implanted on this side of the sac, and it is not certain that the placenta is not implanted on the anterior abdominal wall. (7) If the child cannot be delivered by the vagina without being turned, abdominal section should be performed. These conclusions may be taken as practically fatal to vaginal section. Parry has collected a number of cases from which he draws the conclusion that about seventy-five per cent, of the cases which go towards full term (that is, according to my views, of the cases ABDOMINAL SECTION. 85 which survive primary rupture, and are developed extra- peritoneally), arrive at that term, and die at or shortly after it, (if not destroyed by surgical interference), the minority dying at various periods in the progress. I have not tested the evidence on which he bases his conclusions, for I do not think they are of nuich moment. I am inclined to think that most of the women will not present themselves till they begin to believe that, having gone past their time and the child having ceased to move, some- thing has gone wrong. Then it will simply be a matter of relieving the mother of a risky burden. If the child is living, an effort ought, in my opinion, to be made to save it. But whether the child be living or dead the steps of the operation will be practically the same, and the early part of the proceedings will not vary very much from the ordinary processes of any abdominal section, save in one particular — that the opening should not be made in the middle line, so as to avoid opening the peritoneum. In fact, the operation should not be an abdominal section at all, in the strict sense of the definition I have adopted. This fact has been the cause of much confusion on the part of one perverse critic, whose diatribes require no further notice or explanation. To understand the motive of this avoidance of the ordinary incision in dealing with a case of ectopic pregnancy we must revert to the explanations already given of the process at the time of rupture, and to the views I have advanced, that all the full term ectopic pregnancies are those which have grown in the broad ligament — extra-peritoneally. As they grow they separate the folds of the broad ligament, and finally lift the peritoneum slowly out of Douglas' pouch, off the rectum, sides and brim of the pelvis, off the posterior surface of the uterus, and off the back and sides of the lower abdominal walls as far round as a point corresponding to the cornu of the uterus on each side. The result of this is that the posterior and lateral levels of the reflections of the peritoneum are raised very materially, whilst the utero-vesical pouch is uninterfered with, and it remains as a long process, like the finger of a huge glove running down in front of the gestation sac, to its normal ending on the base of the bladder. This curious re-arrangement of the peritoneum is similar to what we constantly find in cysts of the broad ligament, only the arrangement in them is less systematic, and the explanation of both is simple. The peritoneum is very easily lifted off any of the organs round which it is wrapped, if the process is slowly carried on. The growth of the ovum, therefore, easily lifts the peritoneum everywhere if the 2ndl is direct ; but when the pull conies to be indirect, as it nuist be the moment the top of the fundus is reached, the lifting of tlie peritoneum ceases, and the long tubular process is formed. As the growth of the ovum is not quite symmetrical, this tube is some- times on one or other side, and sometimes in the middle, and 86 HART AND CARTER'S RESEARCHES. therefore it is that some of my operations for ectopic gestation at the full time have been abdominal sections, and some have not been. Therefore it is also that the opening in this case should be made not central but well to one side. This curious lifting of the peritoneum may of course be interrupted by a secondary rupture of the sac into the peritoneum, and we may find — probably shall — that many of the minor varia- tions which are quite well established, such as invasions of the intestines by the placenta, are due to the same cause. We may also find, what I have already indicated as a probability, that direct primary rupture into the peritoneum of a tulml pregnancy of the twelfth week, may end neither in the death of the mother nor in that of the child, but that it may go on developing in the peritoneum. I regard this as very unlikely, and as yet wholly unproven. The' lifting of the peritoneum also explains the intimate association which the fcetal sac always has with the posterior wall of the uterus. What was, on my part, originally a pure speculation concerning the methods of origin of the relations of the peritoneum and their details, has been elevated into a series of indisputable facts by the fortunate experience by Dr. Berry Hart, of Edinburgh, of two bodies which contained ectopic pregnancies. The bodies were frozen and sections made, and these have been so carefully and elaboraely descriljed by Dr. Hart and Mr. Carter that I cannot do better than reproduce their original observations. I must acknowledge at the same time my indebtedness to these gentlemen, and to the proprietors of the Edinhurcjh Medical Journal for permission to reproduce an admirable illustration which will assist my readers greatly in understanding the description of the parts. " The first specimen had advanced to between the fourth and fifth month. Dr. Hart saw the patient for the first time in the Buchanan Ward of the Royal Infirmary, and found her with a tumour the size of a cocoanut in the site of the right broad ligament, and reaching from the right iliac margin to the region of the recto-vaginal space, which bulged down markedly. The uterus was displaced to the left side of a two months' pregnancy. From the history of five months' amenorrhoea, and the occasional attacks of fainting and pain during that time, there was no difficulty in coming to the conclusion that we had here to deal with an extra-uterine gestation developing between the layers of the broad ligament. Two days after, the patient collapsed markedly, evidently from rupture of the sac and loss of blood. Eight hours afterwards, when she had somewhat rallied, an exploratory abdom- inal incision was made to see if anything could be done. Blood poured out whenever the peritoneum was opened, and on passing the fingers in, rupture deep down through the posterior lamina of HART AND CARTER'S RESEARCHES. 87 the broad ligament was found, a condition which did not admit of removal of the sac, inasmuch as it had developed down between the rectum and the vagina. The incision was therefore closed, and the patient sank in about ten hours. At the post-mortem, which was performed by Dr. Bruce, the bony pelvis and contents were removed and frozen, and in this way the relations were preserved — an impossibility if the parts are scooped out from the pelvis in the usual way. The pelvis when frozen was sawn in the mesial, right saggital lateral, and left saggital lateral planes, so as to cut sac and uterus. The following points are noteworthy : — In the mesial line the fcetus and placenta are contained in a space bounded above by the laminae of the broad ligament, and below by the paraproctal tissue and that at the base of the broad ligament. The placenta is attached to the inner aspect of the tube and broad ligament, the fcetus lying below. The vertical measure- ment is 4'10 cm., the transverse 8"7 cm. A similar section to the left of the middle line shows the enlarged uterus, and hsematoma between the peritoneum and the rectum. The rupture had occurred through the posterior lamina, and low down. The uterus measures 10 cm. vertically, has a well-marked decidua, and the dip of the vesico-uterine pouch is only 5 cm. from the fundus. The left Fallopian tube and ovary are intact. This specimen, therefore, shows that the gestation, primarily Fallopian, had developed between the layers of the broad ligament and into the connective tissue between the peritoneum and the rectum. It was thus, prior to its intra-peritoneal rupture, entirely extra-peritoneal (v. Plate I., Figs. 1 and 2)." The description here given by the authors conclusively establishes the process of primary rupture into the cavity of the broad ligament, for which I have already advanced very many arguments, as the explanation of the occurrence of the sous- peritoneo-pelvienne variety of Dezeimeris. The rupture, M'hich was the immediate cause of death, was the secondary rupture into the peritoneal cavity which I have already described as having occurred in Nonat's case, and I think that if the operator had been bold enough to carry on his proceedings, had opened the sac, and sponged it out with a styptic in the fashion that I have described (p. 32), a more satisfactory ending of the case would have been arrived at. But the unfortunate termination is, at least to some extent, compensated for by the brilliant contribution to the elucidation of the pathology of ectopic gestations, of which it has been the immediate cause. The second specimen " was the unopened body of a female, aged 33, small and very emaciated, wdio was supposed to have gone a little beyond the term of normal pregnancy ; but little 88 HAET AND CARTER'S RESEARCHES. information of any kind could be obtained, as she was destitute, with no friends. The usual appearance of a muciparous pregnancy were present, without any varicosity of the venous system." " On delivery into the dissecting room the extremities were cut off ; and tlie head and trunk, after a process of freezing by means of ice and salt, were cut into a series of saggital, mesial and lateral slabs, six in all, of about 1^ inches in thickness. These slabs may be for convenience mentioned as IE, 2Pt, 3K, and IL, 2L, 3L, viz., the first slab on the right side, and so on." " In the saggital mesial section the saw passed almost exactly in the mesial plane of the body. There is nothing particular to remark about the brain and head and neck, the specimen presenting the usual appearances exhibited in sections made in this manner." " In describing the gestation sac and its contents we shall try to avoid too minute details. The first great point to settle is the relations of the peritoneum to the sac, and it will simplify matters if we state the one broad fact brought out in the sections, viz., that the gestation is entirely extra-peritoneal, and that foetus and placenta lie in extra-peritoneal connective tissue. The foetal capsule and its contents, which occupy a great portion of the abdominal cavity, rise up to the upper margin of the second lumbar vertebra and extend well into the right half of the sections, pushing the intestines up and to the left. In front the tumour is separated above from the abdominal wall by the great omentum, while below, its wall is formed by the uterus, behind, it is separated from the posterior abdominal wall by a double layer of peritoneum. The uterus is much enlarged, the upper surface of the fundus being on a level with the upper border of the first sacral vertebra. It was pushed over to the left side, none being found in the right outer lateral section. The peritoneum has been entirely stripped away from its posterior and the upper part of its anterior surfaces, and from the fundus bands of tissue connect it with the upper and inner surface of the fcetal sac. On the left side of the fundus a small fold of peritoneum enclosed the left Fallopion tube and left ovary." " The left Fallopian tube passed obliquely downwards from the left side of the fundus to the left iliac fossa, its fimibriated end being attached to the tumour." " The left ovary was found below the Fallopian tube and left under surface of the capsule, and is seen in the left lateral section 3 ' from the median line in the angle between the abdominal wall and the left iliac fossa, (v. Plate III., Fig. 6.) It measured 1" X li} X f in thickness, and was enclosed in the same fold of peritoneum with the Fallopian tube. The ovarian vessels were greatly increased in calibre. The right Fallopian tiibc and ovary cannot he identified, being taken up vnth the sac. Owing to the surfaces of the peritoneum being more or less adherent, HART AND CARTER'S RESEARCHES. 89 it required great care to trace its general relation. In the mesial section it will be seen to be reflected from the inner surface of tlie anterior abdominal Avail on the front of the uterus at the upper level of the pubes ; the bladder lies below the lines of reflection, and is deficient of a serous covering. The front of the enlarged uterus is covered for a short distance, and the peritoneum is there reflected on the foetal capsule, this portion of its surface being rough and deficient of any serous investment. The foetal capsule is seen to be enveloped in front and above, and behind the membrane is reflected on to the rectum at about the level of the fourtli sacral vertebra. On the left side the peritoneum passes from the left iliac fossa and covers a small portion of the upper part of the body of the uterus, and from this is reflected on to the capsule, forming a fold in which the left Fallopian tube and ovary are enclosed. The relations of the peritoneum to the other organs do not require any special remark. On the right side the peritoneum is lifted up. The fcetus has thus developed beneath the peritoneum, elevating the folds of the broad ligament after distending them, and in its upward growth stripping the peritoneum up from the right side of the anterior abdominal wall for a distance of 7-| in., above the pelvic brim. Posteriorly the deepest portions of the pouch of Douglas lie at the level of the fourtli and fifth sacral vertebrae. The foital capsule and its contents are found to extend into the hypogastric, umbilical, lumbar, and right inguinal regions." '" The sac can be studied in all its relations in the sections. Microscopical examination of its walls were made at various points, viz., at its uppermost portion, and also at the anterior abdominal wall below the peritoneal reflection (Plate II., Fig. 4)." " In the former part there was peritoneum and unstriped muscle, showing the Fallopian tube origin ; in the latter, connective tissue. The capsule was thus formed by connective tissue, bounded outside by the special structures displayed, viz., either by muscular alDdominal wall or by peritoneum. On the right side of the body a deep dissection was made from the skin, and the coecum and peritoneum found displaced up." " Tlw Uterus. — The cervix contained a plug of mucus, and in the flattened cavity of the uterus was found a small amount of disintegrated tissue. The foetus is situated below the placenta and between the uterus in front and the abdominal wall behind. Together with the placenta it is seen to be enclosed in a distinct capsule." " The placenta consists of an oval-shaped and flattened mass of tissue situated in the abdominal cavity and extra-peritoneally, and lying above the fcetus. Its long axis is directed up and down, and in the mesial section is seen to extend from the upper margin of the second lumbar vertebra to a little below the upper border of the first sacral vertebra. It is attached to the posterior aspect of 12 90 HAET AND CAKTER'S RESEARCHES. the anterior abdominal wall and outer surface of peritoneum. Where attached to the anterior abdominal wall, the veins there are enlarged." " The diameter of its long axis is 13'5 cm., and its average antero- posterior measurement is 7"5 cm. Around it is a thin investment of connective tissue, and it is firmly attached at points, especially in front and above, to the surrounding capsule by bands of vascu- larized tissue. In the right sections a cavity is seen Ijetween the capsule and the placenta, which was filled with a mass of grumous blood, and gases of decomposition, the position of which corresponds to a well-defined darkening of the skin of the anterior abdominal wall, as if the patient had suffered from a severe blow or fall. The foetus weighed 2 lbs. 4 oz. without the umbilical cord. It was fairly well nourished, hut decomposition had commenced, cspecicdly at the lower part of the cdjdomen." " The consideration of these two sections shows, therefore, a special phase in the development of extra-uterine gestation. They demonstrate that a Fallopian tube pregnancy may develop between the layers of the broad ligament, and may continue this extra- peritoneal mode of growth, stripping off the peritoneum from the uterus, bladder, and pelvic floor until it becomes in great part surrounded by a peritoneal capsule derived from these organs. All this is done without any actual intra-peritoneal invasion. The placenta in the advanced gestation case is attached in front to the extra-peritoneal connective tissue, the veins there enlarging and acting like uterine veins. In this special cadaver, therefore, the gestation began probably in the right Fallopian tube, developed into the layers of the broad ligament, and grew extra-peritoneally, lifting up the peritoneum on the right side of the middle line, both anteriorly and posteriorly, and also strij)ping the posterior uterine wall and upper part of the anterior uterine Avail. The extra- peritoneal tissue, with its blood-vessels, is therefore not only capable of forming anastomoses in abdominal aneurism, as Turner and Chiene have shown, but may attempt to carry on the functions of the maternal portion of the placenta." "We have here what may be termed slow displacement of tlie placenta. At first it lay in the Fallopian tube, but the growing ovum has slowly pushed it up (a process attended with blood extravasation) from pelvis to abdominal cavity, until at last its upper edge is about ten inches from its original site. Part of this is due to growth of course. The uterus also has had its cervical portions elongated in the same way to three inches. These sections have an important bearing on the classification of extra-uterine gestation. Much has been written, and little really demonstrated on this point. The Tubal variety is undoubted ; the Tubo-ovarian has also been demonstrated ; but the Ovarian is a very doubtful form. The Sub-peritoneo-pelvic or intra-ligamentous variety of I \. . HART AND CARTER'S RESEARCHES. 91 Dezeimeris, Tait, and Werth, is demonstrated in the second speci- men, which also shows the ovary thinned out on the posterior lamina of the broad ligament. The presence o-f the ovarian structure in the cyst wall of an extra-uterine gestation has been brought forward as evidence of its being the Ovarian variety ; it more probably shows that it is Sub-peritoneo-pelvic." "The chief interest centres on the anatomical nature of abdominal gestation. The second case shows that this can be extra-peritoneal, a fact never hitherto demonstrated, although strongly contended for by Tait. We do not deny that we may have either a partial extra-peritoneal and intra-peritoneal variety, or an entirely intra- peritoneal variety, but we ask for actual proof of such. If it be urged that a purely intra-peritoneal form must exist because placenta has been found attached to the uterus and intestine, we answer that in the cadaver shown (Plate II.) the placenta has been attached to the portion of uterine wall where the peritoneum is stripped off ; or it might have been attached to the other abdominal Adscera, luit yet carrying a layer of peritoneum before it, be still extra-peritoneal. We, therefore, hold that the following varieties have been demonstrated, viz. : — Tubal, tubo-ovarian, sub-peritoneo- pelvic, sub-peritoneo-abdominal. An abdominal variety, partly intra-peritoneal and partly extra-peritoneal, is probable ; a purely intra-peritoneal variety has yet to be demonstrated, and the same holds good as to the ovarian variety. Hitherto we have always regarded the peritoneal cavity as the site specially chosen by extra- uterine gestation, for its development, but we must now more closely scrutinize such in the light of this and similar cases." I have placed in the italics two sentences in this record. The first to the effect that the right Fallopian tube and ovary could not be identified, having been taken up by the sac. This clearly shows that, as Dr. Berry Hart concludes, and as I have for years argued, that such a pregnancy as this is originally tubal ; and that the tube is carried up to form the upper part of the cyst is due to the fact that the rupture through which the ovum escapes into the broad ligament takes place at that part of the tube which lies at the junction of the two laminte. The second point worthy of note are that even in this case decomposition had commenced, and that, therefore, had the woman been received in the clinical ward instead of the dissecting room, a surgical operation would have been demanded. Description of Plates. Plate I. Fig. 1. — Saggital lateral section (right) of pelvis, with extra- uterine gestation in right broad ligament. Fig. 2. — Saggital mesial section of same pelvis, showing uterus with decidua. This section demonstrates, inter alia, 92 ILLUSTRATIVE CASES. that what is termed clinically retro-uterine litemato- cele may be haBmatoma. Part II. Fig. 3. — Saggital mesial section of cadaver, with advanced extra- uterine gestation — subperitoneo-abdominal (IR). rig. 4. — Saggital lateral section of same (2E). Plate III. Fig. 5. — Saggital lateral (2L) of same. Fig. 6. — Saggital lateral (3L) of same. Dr. James Braithwaite, of Leeds, records two cases in wliich ho operated successfully, and he has given such interesting details (Bntish Medical Journal, Jan. 3, 1885), all of which directly support the views I have advanced in the preceding pages, that I need offer no apology for (pioting them at length. The first case had symptoms of primary rupture at the third month of gestation, and was operated upon about a fortnight after a spurious labour at the full time, the operation taking })lacc on May 5, 1883. " The incision was central ; no peritoneum was met with, and the sac was closely adherent to the abdominal walls. The child was lifted out by its feet, 1)ut it proved so large that it was necessary to extend the incision upwards another inch. This unfortunately detached the cyst from the abdominal wall, and a coil of bowel protruded into view at the upper i)art of the wound. The cyst was carefully stitched to the lower surface of the wound with a continuous catgut suture. The placenta was deeply situated, but to what part it was attached was not positively ascertained. The cyst was of considerable thickness, already black from decomposition and lined with a smooth shining membrane (the amnion), which readily peeled off. After washing out the cavity with warm carbolic water the wound was closed with silver wire sutures, the cord being left hanging out at the lower end of wound. A large glass drainage tube was also inserted. During the next three weeks the whole of the placenta came away through the lower part of the wound. The cyst came with it: and I recognised the catgut which had been used at the upper margin of the abdominal wall incision. Much of the black and putrid mass was removed by daily traction upon the projecting parts, but unless great care was used haemorrhage occurred. When the whole of the placenta and cyst had come away the wound healed up rapidly, and the patient made a good though slow recovery, and she is at the present time as well as she was before her illness." The extension of the incision probably opened the " finger glove process " of the peritoneum, rather than separated the cyst wall. Perito'iuum closed here Loose tissve - beside uterus and peritonivm 1 Z _ Duodenum Siti- of recent rupture I Vesica vtenne dtp _ Cemcal canol — Bladder — Pouch of Douglcs Rectum I Cervix uteri Vaginal cervix Bectum i Vagina Fig 3 (1 R) W.ScA.K.JolmsMii.Idiiibtirsli •5 a ILLUSTRATIVE CASES. 93 " Case 2. — Mrs, W , of Holbeck, a patient of Dr. DoJson's, with whom I saw her in September last year, aged thirty-five, has been married ten years, but never pregnant until the present case oeccurred. Menstruation all her life quite regular and natural ; the last period was about October loth, 1883. On December 3rd, having missed exactly seven weeks, she was slightly unwell, and had at the same time, to use her own words, " a very violent pain " in the body. The symptoms were such as would be produced by rupture of an early tubal gestation — viz., pain and collapse. She recovered from this, but the body went on increasing in size just as in normal pregnancy. At the end of August a sanguinolent discharge occurred, and tliis therefore may be taken as the time when labour would have taken place had gestation ]jeen uterine. The movements of the child, however, ceased to be felt about the end of the first week in August. By examination of the abdomen tlie outlines of the child were not perceptible as in the last case, but some thick substance intervened, wliich subsequently turned out to be the placenta. This much increased our difficulty in the diagnosis. There was a projection outwards of the abdominal walls in the right inguinal region, which felt not unlike a foot. There were no foetal or placental sounds audible. The uterus measured only two inches and three-quarters and the cervix was well open, so that the finger could he passed up to, but not through, the os internum. The pulse was weak, and the condition of the patient such that, being quite certain it was a case of abdominal extra- uterine gestation, we decided to remove the child at once. This was done on September 11th, 1884, at the Women and Children's Hospital. The incision was central, and we came, as expected, directly upon the placenta, the edge of which, however, was found about two inches to the right of the incision. Careful separation of the placenta in this direction did not produce lucmorrliage. An incision at right angles to tlie first was now made, and the edge of the placenta being pushed back the feet of the child were seized, and it was removed without much difficulty, the placenta yielding without being torn or separated from its attachment to the abdominal walls. Whether the child was enclosed in a cyst or not we were not quite certain at the time of the operation ; but, as proved afterwards, this was the case. There were no veins in the abdominal walls at the seat of the placental attachment except just at the lowest angle of the central incision. These I was careful to avoid wounding ; they were, however, only of small size. The wound was closed with silver wire, the funis being left out, and a drainage tube inserted, both at the extreme right of the lateral incision. An attempt to separate the placenta Avith the finger and traction in about two weeks set up luemorrhage, and it v>'as not attempted again until the discharge became very decidedly purulent at the end of six weeks. The whole of the placenta 94 ILLUSTEATIVE CASES. which had not been removed, for some small portions had been, was at the end of six weeks separated by the finger and removed without much difficulty. It weighed thirteen ounces. The patient is still in the hospital, but is nearly well. In introducing the finger for removal of the placenta I felt the cyst walls, which appeared to be pretty firm and thick. " The first thing worth remarking in the history of these cases is the occurrence of severe pain early in gestation, attended with some degree of collapse. This indicated rupture of the Fallopian tube, in which, up to that period, the fcetus had resided, and its escape in the first case into the interior of the broad ligament, and in the second into the peritoneal cavity. I assume that the explanation of these cases given by Mr. Lawson Tait is the correct one, and I believe it to be so — namely, that all cases are originally tubal, that rupture always occurs, but tliat tliis rupture may be in difterent parts of the tube ; and if on the lower surface of the tube the foetus is let down between the folds of the broad ligament, and then develops, the placenta retaining its original hold upon the interior of the tubal cyst ; if the tube ruptures on its upper surface the foetus escapes into the peritoneal cavity ; and if the mother survives it developes there just as it would have done in the uterus. It seems pretty clear that in my second case the placenta was detached from its original position and took root again in a fresh one, and that the interior of the abdominal walls. This situation of the placenta is rare, and I think it may without much difficulty be diagnosed by the thickness of the structures inter- vening between the foetus and tlie examining hand." Dr. It. B. ]\Iaury, of Memphis, has recently published the details of the post-mortem examination of a case which completely confirms the conclusions of Hart and Carter ; and now that the facts are known, doubtless, information will be abundant, and the old confusion will speedily end. " The pelvic organs were carefully removed, and it was then seen beyond all possibility of doubt that the fijetal sac was entirely extra-peritoneal, that the gestation had originated in the right Fallopian tube, and had developed between the folds of the broad ligament, downward to the pelvic floor, laterally to the pelvic wall, and upward into the abdomen. " The ovum in its development had lifted the peritoneum off from the bladder and the anterior surface of the uterus, while the relations of the peritoneum to the posterior uterine wall and to Douglas's pouch were not altered. " The sac extended quite to the pelvic and abdominal wall on the right side, but did not go beyond the left cornu of the uterus on the left. " At the time of the operation it was observed to be covered by peritoneum, and this was clearly shown after death.. DETAILS OF OPERATION. 95 " The gestation was therefore entirely extra-peritoneal, and belonged to the variety, intra-ligamentous of AVerth, or sub- peritoneo-pelvic of Dezeimeris. " Xo trace of the ovary was discoverable in the structures belonging to the sac, but on the left side the ovary was found much shriveled and otherwise changed in appearance. " This autopsy corroborates the view taught by Mr. Lawson Tait, that in extra-nterine pregnancy, no matter where the foetus may be found, its development begins in the Fallopian tube, ' and that it may become intra-peritoneal or extra-peritoneal, just as tlie tube happens to burst.' " — Mem'phis Medical Monthly, March, 1888. We come now to consider the further details of the operation of removing a fcetus developed in the broad ligament at or near or past the full time of gestation ; and no variation on this point will make any difference in the essential details of the proceeding. The opening of the abdomen and sac should be, as I have said, to one side of the middle line, and the history together with the physical signs will probably enable us to decide on which side of the middle line the incision should be made. As the purpose is to avoid opening the uterine process of peritoneum, the incision should be made two or three inches away from the middle line and towards that side in which the pregnancy has been developed — if this point can be determined. When the sac is opened the fcetus is to be removed carefully, so as to avoid tearing as much as possible ; and if it is alive, it should be handed over to those specially detailed for this duty. The umbilical cord should be divided close to its placental origin, and the placenta should be emptied, as far as possible, of blood. The interior of the sac should then be carefully cleansed of all dirt and loose membrane, and then filled and washed thoroughly with clean water, and the stitches carefully placed in the wound so that when they are drawn tight the sac shall be hermetically closed. By means of my syphon trocar the sac should again be washed out with warm water, and then the stitches drawn tight with the trocar (small sized) still in the sac. The syphon action should then be reversed and the sac emptied of water as much as possible and the trocar removed — in so doing care should be taken that no air enters, and that the wound is hermetically closed. I recommend this proceeding from the splendid results I have obtained by it, in dealing with congenital cysts (Trans. Gynecological Society, 1887), strikingly different from those arrived at by drainage. It seems to me that the conditions of the two cases are very similar, and that the success in one may justify the same means being tried for success in the other. The crux of the discussion is, of course, the removal of the placenta, and I have tried all ways with it, and I am disposed to think that leaving it will be the best. I have already detailed a disastrous case where I removed it by vaginal 96 TREATMENT OF PLACENTA. section. I have twice removed it, arresting easily wliat hai'niorrhage there was by the application of perchloride of iron. Both children ■Nvere alive and still live, and both mothers survived, but in both cases I was able to tie a big pedicle — the remains of the tul)e and broad ligament — which doubtless contained the bulk of the blood supply to the placenta. This proceeding I certainly should recommend in all cases where it is practicable, and from my own experience alone it seems certain that it will be possible in a considerable number of cases. But there are others, and I have published these, where such a proceeding was not possible, where the placenta was plastered flat on various structures to which it was intimately adherent, and from which it would have been removed only with great difficulty and much hemorrhage. I confess under such circumstances I should hesitate before com- mencing its removal, but if I did begin it I should rush rapidly through with it and follow^ separation with a sponge soaked either in strong vinegar, or a solution of perchloride of iron. Such a process would be very risky, and I confess I should not like to face it, and for the further reason that I do not think it will prove to be necessary. The alternative proceeding which I have adopted in these cases — all three mothers surviving — was to close the sac (closing the peritoneum in one case, when it had been opened as in Dr. Braithwaite's first case) fill .save an aperture through which I brought the umbilical cord and a drainage tube. These three women all survived, but they survived a process of olfeiLsive suppuration lasting for months, and which nearly killed them all. One of them — as result of this profuse suppuration and of her own carelessness — has a ventral hernia, which contains most of her intestines. I certainly, therefore, am not in love with this method of dealing with the placenta — for it deliberately induces the process of necrosis, Avhich I do not in the least believe is necessary. We must bear in mind that Avhen the placenta has acquired adhesions outside the uterus it is in a condition altogether different from that in which it is placed when in contact with the endometrium. In both cases it is of course essentially a fcetal structure, but it is far less so when it has its relations in ectopic pregnancy. When intra-uterine it is separated by a maternal layer of cells easily destroyed, and being constantly rei^laced, which are not present when its columnar villi invade intestines, muscles, and other maternal structures. Again, when the process of labour is going on in the uterus, every contraction of the organ tends to disturlj the connections lietween the fcetal and maternal tissues, so that when finally the complete contraction of the uterus is effected on the expulsion of the child, the placental relations are completely disconnected by the mere pressure of uterine contrac- TREATMENT OF PLACENTA. 97 tiou. No such disconnection occurs to an ectopic placenta. The histories of all the cases where an extra-uterine pregnancy has gone on for an indefinite period after the term of gestation without disturbance, show conclusively that all the tissues except the bones are capaljle of being digested and absorbed, and even the bones to a large extent yield to this powerful influence. The placenta, as a rule, is the first of the tissues to disappear, even despite the somewhat numerous instances to which I have already alluded, where the placenta at first seems inclined to grow For the majority of cases such a tendency at this period might, for a time at least, be disregarded, but even if it became from subsequent observation evident in any particular instance ; that the placenta was growing after the removal of the foetus, we should have the advantage at least of having gained time in the treatment of the case ; for nothing has so strongly impressed itself upon me in my experience of abdominal surgery, that we may deal safely by secondary steps with conditions which, had they occurred to us in a primary stage would certainly have led to unfortunate issues. I am therefore disposed, for the present at least, and until I am corrected by future experience, to advise that in dealing with an ectopic gestation in the advanced stages, we should deal with the foetus only, should empty the placenta of blood and close the wound hermetically upon it. The only exception would be where it can be dealt with largely by tying the broad ligament only to a relatively small extent requiring separation from the tissues with which it is associated. Campbell has to some extent anticipated my argument on this point in the following passage : — " As the placenta, when long retained, is destroyed during the suppurative process, except in some rare instances, and removed from the abdominal cavity with the other decomposed structures, or cannot be discovered, this discloses to us the important fact that the retention of the mass may be permitted without any detriment to the parent ; while it can scarcely be doubted that the irritation, which could not fail to be produced by groping for it among the abdominal viscera, or the hsemorrhage arising from its detachment, might be succeeded by formidable effects. At one period it was supposed that the placenta could not be suffered to remain in the abdominal cavity with impunity ; but it may be asked, can the retention of the mass be more injurious to the patient than that of a full grown foetus, which, as we are now aware, may remain in the abdominal cavity for a long series of years without any injurious effect ? " (p. 152.) A case of great interest in the consideration of this point is narrated in the "Obstetrical Transactions" of 1887, by Dr. Champneys, in which the proceeding which I now recommend was more nearly carried out than in any other I have seen. The placenta was emptied of blood, but unfortunately the cord was not 13 98 TREATMENT OF PLACENTA. cut short, but was allowed to hang out of the wound, dependance having been most unfortunately placed upon the so-called antiseptic system to prevent decomposition. The operation was performed on the 19tli of October, and upon the 19th of November the progress of the case is noted to the effect that " the incision was completely healed, but the lower abdomen markedly distended, and a swelling which was supposed to be the placenta considerably smaller," Subsequent events made it perfectly clear, however, that the patient was suffering from placental decomposition and resulting peritonitis, and she went on from bad to worse, with a pulse of 114 and temperature 104, and as high even as 106, to the 7th of January when she died. On post-mortem examination the placenta was seen to be lying in the sac like a round ball, as large as a foetal head, and of a dark maroon colour. On passing tlie fingers round it a few bands and one or two adhesions were found between the placenta and the sac, but otherwise the placenta was detached. The blunder, of course, in this case was that the foetal sac was not opened a second time, and the placenta removed immediately at the outset of serious symptoms — that is to say, witliin five weeks of the original operation. It is perfectly astonisliing that the patient should have been allowed to go on for very nearly six weeks after this, in a condition of sub-acute blood-poisoning, without any effort being made to save her. The lesson of the case I feel strongly is, that we ought to make a preliminary effort, by leaving the placenta alone and closing the sac over it, to permit of its absorption. Should that not occur, we may then, by a secondary operation at such time after the first as may be indicated by the course of events, remove the placenta. This proceeding would then be rendered far less hazardous, at least in the matter of haemorrhage, by nature's own process of the inflammatory occlusion of the bloodvessels. Certainly this is the reasonable method, as it seems to me, of dealing with this important question, the only one yet awaiting its proper solution, and its solution is forced upon me not only by my experience in ectopic gestations, but by my experience in a large number of other operations in abdominal surgery. Certainly it is not a question which will be settled by the tabulation of a number of cases mostly dissimilar in the extremest degree from one another, and incapable of leading to anything but confusion when paraded in the form of statistical evidence. Campbell gives a very interesting list, and withal a very ghastly one, of instances which he has unearthed where tliere have been multiple extra-uterine gestations, and of instances also where they have been retained for very many years. As a mere matter of curiosity I reproduce it : — " Two patients had the product of three extra-uterine gestations in their abdomen at one time ; in both RETENTION OF FCETUS. 99 individuals all the decomposed structures were evacuated through the abdominal parietes, and each recovered. Nine women conceived once during the retention of the extra-uterine foetus ; two, twice ; one, three times ; one, four times ; one, six times ; and one seven times. There were two cases of contemporaneous intra- and extra-uterine gestation. In this variety two single women only are particularised. In seventy-five cases the foetus was retained for the following periods, viz. : — three months in two instances, four months in one, five months in one, nine months in two, fifteen months in three, sixteen months in two, two years in eight, three years in seven, four years in four, five years in one, six years in two, seven years in three, nine years in one, ten years in three, eleven years in two, thirteen years in one, fourteen years in two, sixteen years in one, twenty-one years in one, twenty-two years in one, twenty-six years in two, twenty- eight years in one, thirty-one years in one, thirty-two years in one, thirty-three years in one, thirty-five years in two, forty-eight years in one, fifty years in one, fifty-two years in one, fifty-five years in one, and fifty-six years in one. In twenty-six patients the decomposed structures were evacuated through the rectum, and of this number six died. The fcetal structures passed through the abdominal parietes in twenty-nine cases, and three of the number died. In eight instances the remains of the fcetus were discharged per vaginam, and three of the patients died." True lithopfedion — that is to say, where the fcetal sac has been encrusted, after more or less digestion and absorption, with a layer of the salts of lime, and has remained quiescent, is of remarkably rare occurrence. I have only once in my lifetime seen a case where it was suspected to have occurred. Dr. Fales, of Boston, has spent much labour in examining the literature on the subject, and he has found only eleven cases where the condition has been verified by post-mortem examination, and he adds a twelfth occurring in his own experience. As his paper is in a journal, the " Annals of Gynecology," not very easy of access, and as the subject certainly has a considerable amount of interest, I venture here to reproduce his record. " Case 1 is reported by Dr. Brandt, in the Edinburgh Medical Journal for 1862 : — Miss A. was born „ was married „ first child „ second child „ pregnant „ third child „ fourth child died 1778 1795, at the age of 17 1796 » 18 1801 „ 23 1804 „ 26 1808 „ 30 1815 „ 37 1858 „ 80 100 TRUE LITHOP^DION. No history of the third pregnancy. The autopsy was performed September, 1858. The tumour weighed 1.8 kilos, 20.32 cm. in length, 13.33 cm. in diameter, 40.64 cm. in circumference. It was a bony cyst containing a foetus, head uppermost, looking to the left and downwards. The spine and l)ack were in apposition with the right side of the cavity ; the head was decidedly compressed ; the cord could be distinguished passing round the neck ; the whole body was twisted in its long axis. " Case 2 is reported by Dr. Conant, in New York Medical Journal, May 10th, 1865, p. 140.: — So far as known, the pregnancy, which was the first, was • normal, labour-pains came on at the usual time, lasted a few days, and subsided. Subsequently she was afflicted with profuse and most offensive perspiration, which was almost unbearable to her attendants. After a time this disappeared, and slow recovery ensued, attended ])y a hard tumour in her side, which caused her no inconvenience other than a sense of weight. Subsequently she gave birth to three children. In June, 1863, thirty- five years after the accident, she died. The autopsy revealed a calcified foetus, extra-uterine, seemingly, not enveloped with or in, membranes ; another hard mass, said to have been the uterus, was found in the abdomen, this, however, contained the remains of the placenta, in the opinion of Dr. Conant. " Case 3 is reported by Dr. Parkhurst in Medical Times and Gazette, vol. I, 72, p. 655 :— She became pregnant in 1802 ; nothing unusual about the pregnancy was noticed ; the catamenia ceased entirely ; fcotal movements appeared at the usual time. Premature labour was begun at eight-and-half months, as the effect of a friglit. The pains gradually subsided, and for two or three weeks she was comfortable. Her health then began to decline, and for one-and- half years she was an invalid. After this period there was a gradual restoration to a condition of comparative health, though she was subject to attacks of severe abdominal pains at irregular intervals. She died in 1852, at the age of seventy-seven. The autopsy disclosed a tumour, the external surface of which was smooth and white, and composed of fibro-cartilage. Its weight was 3.6 kilos. There was no connection with the Fallopian-tubes or omentum. The external surface of the foetus was encrusted with an earthy substance. " Case 4 is reported by Dr. Hans Chiari, Vienna Med. Presse, vol. 17, No. 38, p. 1092:— In this case symptoms of pregnancy were observed in 1827 ; but no birth followed them ; the patient died at the age of eiglity- TRUE LITHOP^DION. 101 two, of pneumonia. At the autopsy the tumour was found to be attached to the walls of the uterus. It was about the size of a man's head, and here and there, over its surface points of calcification could be detected. The uterus, right tube, and ovary were normal ; the left ovary was wanting. The foetus was enveloped in a capsule, and was in a remarkably well-preserved state ; the face, internal organs, and even the stri;e of the muscles being recognisable. The placenta Avas found, but its position is not stated. " Case 5 is reported by Dr. Galli, in Lo Spcrimentale, xxxix. 2 p. 135 :— In this case, two children having been born, pregnancy, occurred, for the third time, at the age of thirty. Foetal move- ments ceased after the eightli month. No birth followed. Subsequently, for a long period, she suffered from severe abdominal pain. Became pregnant again, and was delivered of a healthy male child. The product of the third pregnancy was carried for thirty-seven years. In her sixty-seventh year she fell, and probably disturbed the lithopredion, as a violent peritonitis intervened, from which she died. The autopsy revealed a well- formed lithopffidion ; but nothing further is stated. " Case 6 is reported by Dr. Plexa, Monatschr f. GebuHsh, xxix., 4, p. 242 :— In this case symptoms were manifest which caused the diagnosis of extra-uterine pregnancy to be made. There were repeated attacks of abdominal pain, accompanied by fever. These gradually subsided, and strong hopes were entertained that this case would eventuate in a Lithopa3dion. After one and a quarter years, however, a peritonitis ensued, from compression of the intestines between the tumour and the abdominal walls, which caused the patient's death at the age of forty. At the autopsy it was found that the fcetus had entered the abdominal cavity by the bursting of the left Fallopian-tube. The right ovary and tube were normal. The colour of the fa3tus was dark-brown and calcification had begun. " Case 7 is reported by Professor J. Van Grau and Dr. Scbrant in Genees. en Hcilkundc te Amsterdam, ii., 1, pp. 17 — 90 : — The patient was married at twenty years of age. Had seven children, and three miscarriages. Twelve years before her death she noticed a gradually increasing swelling of the abdomen. The tumour was distinctly moveable, and appeared to be adherent at the umbilicus. A diagnosis of lithopiedion was made ; and, at her death, at the age of forty-two, in the Amsterdam Hospital, this 102 TRUE LITHOP^DION. was confirmed. The tumour was free, except at the front, where it was attached to the abdominal walls. The foetus was developed in a calcified membrane ; its head was situated at the umbilicus, the back towards the left hypochondrium ; arms and legs drawn towards each other, and to the right. The uterus was in the lower pelvis, and was normal. The left ovary and tube were also normal. In the place of the right ovary there seemed to be a cyst, filled with a brownisli substance, attached to the tube. After the covering was stripped off the foetus was seen with the head, legs, and arms drawn towards each other. The internal organs, muscles, and other structures were easily recognised. " Case 8 is reported by Dr. Wagner, Arch, der Heilk., vi., No. 2, p. 174 :— The patient was a widow, sixty-eight years old. At the age of twenty-four she had given birth to five children. In her thirty- seventh year she again ])ecamc pregnant, but was never delivered of the child. Lal)our-pains were not present. For a long period the abdominal enlargement remained constant in size, and Csesarean section was advised. Finally, the tumour began to grow smaller ; her menses returned, and fair health was experienced, the only complaint being of a feeling of weight in the abdomen. At the autopsy the tumour was found to fill the lower pelvis, and to be attached to the bladder, rectum, and uterus. The tumour weighed three-quarters of a pound, and was about the size of a man's head. It was covered by a yellowish membrane. The left tube and ovary seemed to be growing from the tumour, the uterus being pushed from the right. The fcetus was of female sex ; the head was much drawn to the right, and bent upon the thorax. The skull was markedly compressed, the bones overlapping ; calcification was present, but not uniformly. The various organs and muscles were not distinguishable, being changed to a fatty mass, which contained ha3matoidin crystals. " Case 9 is reported by Dr. Bossi, Sitzmeister d. Vereins d. Aerfze in Steirmark, xi., p. 37 : — In this case a lithopsedion was diagnosed in 1868. During the years 1869 and 1870 abortion was induced several times. The operation was repeated in 1872, with a fatal result, peritonitis following. The autopsy revealed a pear-shaped tumour about the size of a man's head, covered with a capsule, which was very thick and hard (calcified). Portions of the foetus were in a natural condition, and portions were changed to adipocere, some of the bones being entirely denuded. The tumour communicated with the rectum by a small opening. The uterus and tubes were normal. Right ovary atrophied, left one adherent to tumour. TRUE LITHOP^DION. 103 " Case 10. — ' Tubingen Inaugural- Abhandluug,' von Willielm Keiser. The lithopwclion was found in a woman ninety years of age, in 1720. In 1674 she had all the symptoms of pregnancy, foetal movements being very noticeable. At the expiration of nine months labour-pains started up ; the membranes ruptured. Pains continued for two weeks, and then gradually disappeared ; the foetus having apparently escaped into the abdominal cavity, after rupture of the uterus. Two children were subsequently born. The autopsy revealed a large tumour, 13.5 cm. in diameter, covered M'ith a capsule so hard that a knife could not cut it. The stroma contained an exudation in lime-salts were deposited, The skin of the fatus was well preserved, covered by epidermis more or less calcified. The muscles could not be recognised, having been changed to a ' soft substance ' (adipocere). The brain was a blackish-brown mass, which was pulverulent and easily melted ; the membranes were of a leathery consistence. A citron colour was diffused throughout the entire structure. The reports con- cerning the position of the tumour are not trustworthy. " Case 11 is reported by Smellie in his ' Collection of Cases and Observations in Midwifery,' vol. ii., p. 65 : — Tlie patient was pregnant in 1731, with the usual signs. At the sixth month fcetal movements ceased, as the result of a fright. Under treatment she discharged a mass, which was thought to be a part of the placenta, as well as a small amount of fluid. There was no decrease in the size of the abdomen. In July, 1733, two years and two months from her first pregnancy, labour-pains returned, with an apparent rupture of membranes. At this time the child was found in the abdomen. In January, 1734, she became pregnant, and was delivered, October 28th. She was again delivered, October 22nd, 1735, also October 9th, 1738, and June 17th, 1741. She was admitted to Guy's Hospital October 14th, 1747. She died November 7th, 1747. The autopsy showed the abdominal contents to be nearly in their natural state. In the right pelvis was a child, attached to the ilium and neighbouring membranes by the peritoneum, in which the tube and fimbrae were apparently lost. The foetal integument had become partially calcified. " Case 12. — In giving the history of this case I hoped to quote from the record books of the physician in attendance at the time of the accident, who, as I understand, took extensive notes, but I am unable to do so owing to his death a few years ago, and the subsequent destruction of his records. I am fortunate, though, inasmuch as such information as I have of tlie case comes from a twin sister, who is still a remarkably vigorous woman, both 104 TRUE LITHOPiEDION. mentally and physically, and whose statements, as far as they go, are undoubtedly correct. Mrs. A was married September 24th, 1844. She never had any miscarriages. She was delivered of a perfectly healthy child, January 29th, 1848. Early in January, 1856, she became, as events proved, pregnant again, though her condition at the time was merely surmised, as menstruation continued to be present, and, in fact, existed, with more or less regularity, throughout her entire pregnancy. It was not until the middle of May that the attending physician made a positive diagnosis of pregnancy, basing his opinion on foetal movements, which became manifest at that time. Early in March, Avhile visiting friends, she fainted, vomited, and complained of epigrastric pain. There was no flowing at this time. The following day she rode home, a distance of four miles. Directly after this she had three " inflammatory fevers," characterised by abdominal Jpain, excessive tympanitis and uncontrollable nausea and vomiting. During one of these attacks an abscess formed just above the pubes, which opened, but did not discharge much, if any. Counting from the middle of May, when foetal movements began, October 1 would be the probable date of confinement. About that time the physician was summoned, not on account of labour pains, as she never had them, but on account of excessive and painful movements of the child. These were always very marked, and caused her the utmost inconvenience. As she expressed it, she felt more life with this child in two hours than during her entire previous pregnancy. October 13 the physician was again summoned for the same reason as before. At this time " something was rubbed on the abdomen," after which the movements grew less and less, and finally ceased. For the following ten years she was an invalid, though nothing very explicit could be obtained as to her condition. She was generally miserable, and had a number of attacks of abdominal pain at irregular intervals, sometimes accompanied by icterus. During this period the tumour very gradually decreased in size, finally remaining stationary, and causing no trouble other than a feeling of weight when standing or walking too long. Her health was fair until 1883, when a malignant growth attacked her larynx, which eventuated in her death December 24, 1886. The autopsy was performed December 26, 1886, Drs. Bill and Metcalf assisting. The body was very much emaciated. The tumour was apparently situated in the median line, with its most prominent point at the umbilicus, but on palpation it was found to extend downwards and to the left. On making the incision it was found to be adlierent to the abdominal walls, and it seemed as though it would have soon made its way through, either from pressure or ulceration, so thinned had the structures become at the point of its adherence. The position of the tumour may be best described by borrowing OPERATION JUSTIFIED. 105 the obstetric expression, sacrum, left anterior, though it was entirely out of the pelvic cavity, the base of the skull being on a level with the umbilicus. It was almost lying loose in the abdominal cavity, the only points of attachment being the one just referred to, to the abdominal wall ; what was ]3robably the umbilical cord, and some small adhesions to the intestines. These were ranged round the tumour, none in front of it, and were one mass of adhesions, forming, with the abdominal wall, a cavity, as it were, containing the tumour. The umbilical cord (?) passed directly downwards, enclosing the uterus, and then gradually fading out into the peritoneum. Nothing that would answer for a placenta, or the remains of one even, could be found. Eoughly speaking, the parts of the foetus were normally disposed, the thighs and arms being flexed on the abdomen and chest respectively. The left leg was rotated slightly outwards, as well as extended, and the forearms, instead of being crossed, were more or less parallel with the long axis of the body, tlie hands being placed well up beside the head. The tumour weighed 2| lbs., was 8i inches long, and 12|- inches in circumference. The cross section showed it to consist of a fcjetus and its envelopes, the process of calcification being especially marked in the membranes. Tlie uterus. Fallopian tubes, and ovaries were also removed, but furnished no points of importance. The autopsy suggested an extra-uterine pregnancy of the abdominal variety ; but the history points rather to one of the tubal variety, primarily. To epitomise the various dates : — Mrs. A was married in ... ... 1844 First child ... ... ... ... ... 4 years later. Second pregnancy ... ... ... ... 8 „ „ Probable rupture of cyst and peritonitis ... at the third month. Death of fcetus ... ... ... ... at the ninth „ Period of ill health ... ... ... 10 years. Period of health ... ... ... ... 27 Death from cancer of larynx invading the lung, at the age of 67." We are quite justiiied in concluding from such records that Campbell and Parry are correct in their belief that a " quiescent lithopwdinn " is a very rare occurrence, and that a woman with the remains of an ectopic gestation sac in her abdomen or pelvis had far better have them removed. 14 107 INDEX. Page Abdominal Gestation 59 Section for ectopic gestation ... 77 during puerperal pciiod ... 79 ■ Primary and Secondary lupture SO Bladder, discharge of suppurating .sac into 57 ^ Case.s of ectopic gestation operated upon 45 Conception, normal seat of 4 Ectopic Ge.station, cause of 4 Clinical history of 5 Electrolysis in tubal gestation 53 Exploratory incision, principle of 23 k Fallopian Tube 5 Fcetus, absorption of 38 Gestation, Abdominal 59 T. R. Je.'isop's case 60 Ectopic, scheme of 8 Illustrative cases 23 Primary and Secondary rupture 49 Hernial 8 ■ Interstitial 6 Case of 47 Rupture of 6 Ovarian 9 Spiegelberg's case 10 Granville's case 12 Dr. Walter's specimen 12 M. Puech's case 11 its possibility 12 Sous peritoneo-pelvienne variety 55 Tubal, diagnosis of 6 Pathology of 5 multiple 98 Mr. Hallwright's case 20 Rupture of 19 unruptured, symj)toms of.. 18 Retention of fietus 99 Dr. Dolan's case 21 Suppuration in ruptured sac 67 Tubo-ovarian 13 Page Hart and Carter — Researches on ectopic pregnancy 86 — 92 Hiematocele, definition of 27 Extra-peritoneal 31 Causes of 33 ■ Suppuration of 35 Intra-peritoneal 36 Causes of 37 Exantheniatic 40 — — Prognosis 40 Treatment 41 of broad Ligament 54 Pelvic 25 Herman's conclusions in re vaginal section 84 Impregnation, Phy.siology of 5 Theories of 8 LithoPjEDION, Cases of... 99 — 105 Quiescent 105 Peritonitis after ruptured tubal pregnancy r 54 Placenta, extrusion of in ruptured tube . 14 Growth after death of fatus ... 74 Secondary attachments to viscera 15 Treatment of after operation ... 96 Pregnancy, bifid uterus 64 Rectum, discharge of suppurating sac through 57 Relation of uterus to gestation sac ... 67 Suppup.ATiNo FarrAL Cyst, abdominal section in 58 Tapping, dangers of 68 Treatment of ectopic gestation 70 by electricity 72 Umbilicus, discharge of suppurating sac through 57 Uterine WalLs, abnormal thinness of 63 Yaoina, discharge of suppurating contents through 57 Vaginal .section for ectopic pregnancy 32 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. DCS 1 ^ "^"S MAY 1 REC'O 73 NOV 2 9 RK'5i BI6MED mih'i Form L9-10)rt-9,'54(7413s4)444 BIOMEDaB. MAR 19 1986 REca FAlteK, ■' I ! 1 l\ ; n linn "1 r-n ^SSII 1 E \1[-UN1\l.._ 1 ^^xT — n f/Or-1 i.-». i ^KSSH^H I^B!' ilHH^BS Zl_ i^^i ^'^VH^AINn]\^^- ''Or — n -.LUyA:NULLCJ^ \ S ^KaSBi ^HHHiii^B RARY a-^. mL?" -1 1 1 /— ' ™i)