Lectures on ectopic pregnancy and pelvic haematocele

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LECTURES

ON

ECTOPIC PREGNANCY

AHD

PELVIC HJ5MAT0CELE.

BT

LAWSON TAIT, F.R.C.S., Edin. & Eng., LL.D.,

Fro/eiior of Gynaecrihtn

Himorurj CoiuulHiff BtiTgcm to He Brooklyn BoipUat for B'oims, (o Uie NaUinghan

Samarttari Hospital fiir WoJiun, to fAfi Wolmrhainpton Dispe^^aary /nT iroprren,

unit to Iht Wat Bn^iviidv DiiMct HotpUal, ilo.;

PraiiUiU q/ BifTninijAnm uiiJ ISUtawl C:

BIEMIKGHAM :

TUE "JOURNAL" PRlHflNCJ WORKS, NEW STKEKT.

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LECTUEES ON ECTOPIC TREGNANCY
AND PELVIC HEMATOCELE.

Atizz much consideration I liave adopted tho phrase ectopic
pregnancy, designed originally by Dr. Eobett Baniei!, as by far the
beat which can be applied to the curious aud most interesting
displacement which we liave first to consider, for it gives a
convenient and very complete definition without expressing any
theoretical explanation of the condition. The cavity of the uterus
is the proper place for any gestation, but a gestation may be
Eetopic without being exlra-iileHne as in what has been called
the interstitial or tubo-uteriue variety. I believe we might call
all ectopic gestations "tubular pregnancies," but that would be
hardly fair to those who still cling to the belief in the occurrence
of the ovarian kind. " Ectopic " includes them all and therefore
I adopt it

The literature of this subject is very extensive and the
confusion wliich exists in it is almost as great, but there we two
works which stand prominent for different reasons, and to these
I propose to make some extended allusions, for I am greatly
indebted to both of them for valuable information. The first is
that of Dr. William Campbell, a teacher of midwifery in
Edinburgh, who published in 1842 a work in which its induBtrioua
author has collected in all probabihty all the material up to his
time, thus forming a mine from which many a quotation has been
made by subsequent writers without any kind of acknowledgement.
Campbell seems to have had no great critical acumen, however,
and his material is confusing alike in ita abundance and its utter
want of arrangement His notions of pathology were of the
vaguest kind and his capacity for believing all that was told him
must have been extensive. His work, however, stands as a
landmark in the literature of the subject as the first real effort to
place into its appropriate position of importance a subject which,
up to that time, seems to have been regarded more as a curiosity
than aa oue of the most dreadful calamities to which women can
be subjected. He also exhaustively investigated the literary
history of the subject, and his book is of great interest in showing
how often discoveries have been made and how easily they are
forgotten.

A l»ok of a very different order is that of Dr. John S. Parry,
of Philadelphia, published in 18V6. It is at once remarkable for

4 ECTOPIC PREGNAls'CT.

its scholarly research (imi fine critical sagacity. Most unfortunately
tMa promiain" autlior died in the same year, and I never look at
the finely cut handsome young face which looks out upon me from
the book as its frontispiece, faced by a pathetic letter from liis
■mourning widow, but I become persuaded that in Pany's death
one of the greatest lights in gynaecology of my time was lost
to us. Had he lived to give ua a second edition of his book,
its few incompletenesses -would have been filled up and its few
errors rectified. "Where he hfta got astray liaa chiefly been
by the delusive use of statistics, a point which I shall deal with
by-and-hye.

I have already discussed at length my view upon the
physiological process of impregnation and the machinery concerned
in it, 80 that I need not do more here than repeat that the uterus
alone is the seat of normal conception, that as soon as the ovum ia
affected by the spermatozoa it adheres to the mucous surface of
the uterus ; that the function of the ciliated lining of the
Fallopian tubes is to prevent spermatozoa entering them and to
facilitate the progress of the ovum into the proper nest ; furtlier,
that the plications and crj-pts of the uterine mucous membrane
lodge and retain the oviim either till it is impregnated or till it
dies or ia discharged.

With such views it is easy to understand the cause of tubal
pregnancy, for we have only to turn to the papers of Arthur
Johnstone and Bland Sutton, to see that desquamative salpingitis
could at once put the mucous lining of the tube into a condition
exactly similar to that of the uterua, and in that condition access
of spermatozoa would be possible, retardation of the ovum in the
tube would be inevitable, and its immediate adhesion to the tube-
wall after impregnation would be as easy and as likely as its
occurrence in the uterus. The cause, therefore, of ectopic gestation
or tubal pregnancy will be any process or accident which has
reduced the Fallopian tube, so far as concerns its internal lining
surface, to the same condition aa the uterua.

Virchow long ago drew attention to the fact, that at post-
mortem examination of cases of ectopic gestation ending fatally at
the period of primary nipture, traces of previous pelvic peritonitis
were often found and nothing is more common than to find a
record of such attacks in the history of cases that come under
clinical investigation. Indeed there is one fact about these c
which is very notable in the relation, that a very large proportion
of them have a history of prolonged sterility and menstrual
suffering, showing that their procreative machinery was out of
gear, Thus we often have the history common to tubal mischief
that after a fii'st labour there was an illness with marked
symptoms of pelvic trouble, then a long period of sterility, then
the ectopic gestation ending in rupture. In my clinical records of

I

PHYSIOLOGY OF IMPEEGNATION. 5

such cases I have laid special stress on this feature of their history
OS a guide to diagnosis. Parry impresses this by saying that
" women who have become pregnant with a child outside the
uterine cavity frequently sliow a previous inaptitude for. conception.
TJie interval between marriage and the iirst impregnation is
frequently long, IE the woman has borne children a period of
sterility frequently preceda the extra-uterine pregnancy," and he
gives a long list of authorities from whom he elicits confirtnatory
statements. This is eminently suggestive of the view I have
advanced that ectopic gestation is caused by destruction of the
proper ciliated epithehuni of tbe tubes, and there are many other
points to be successively discussed, which all pohit iu the same
dii'eetion. Indeed there ia no ai^ument against this save the
belief that impregnation takes place usually in the tube. For this
belief there is no foundation in fact, nothing at all except the
misinterpreted facts obtained by experiment in the lower mammals,
In these, spermatozoa have been found liigh up in tiie cornua of
the bipartite uteri and these cornua have been erroneously supposed
to be Fallopian tubes, whilst they ai'e nothing of the kind. The
Fallopian tubes do not really exist save in the higher order of
animals who have assumed the upright position. If we accept this
view the physiology of the process of reproduction is immensely
simplified and tlie pathology of ectopic gestation becomes
intelligible. I cannot see that any other views than these are
consistent with the recent discovery of Arthur Johnstone and
Uland Sutton, nor indcLd cau any others be leconciled with the
facta of ectopic gestation as unravtlled ty modLrn surgery.

] I t 1 ( n r Dl d SnttonV

We have now to deal with the larieties of ectopic gestation
and I propose at once to dismiss all previous classifications as
inconsistent with tlie facts as they ba\B occurred in my own
experience and incompatible alike with the view of the explanation
of the cause of ectopic gestation winch I havi, offered and with the
physiology of impregnation Iht, uterus being regarded as tlie

TWO KINIlS OF TUBAL PEEGNAKCT.

only site possible for normal pregnancy and the tract through
which the ovum passes and in which it may be impregnated in the
abnormal process, it follows as a matter of course that all ectopic
gestations must, in their origin, be tubal. A possible exception to
this may he the impregnation of an ovum in its vesicle before it
leaves the ovary — a matter I shall discuss immediately.

A clinical distinction of two kinds of tubal pregnancy must be
made, though pathologically they must be regarded aa quite
similar. This division occurs between the cases in which the
fertUiaed ovum becomes attached to the inner wall of the tube
wliere it is free from uterine tissue, and those cases where the
ovum cavity is formed by tbe distension of the tube at that part
imbedded in the structure of the uterine wall. These cases have
been called " interstitial " and I propose to retain this term.

Tbe process of development of an ovum in the tube at any
part of it, inevitably results in rupture of the tube. In the
" interatitial " cases, the rupture, so far as is known, always takes
place into the peritoneal cavity, and I cannot imagine any other
way in which it might go, though we have assertions that a diagnosis
has been made of tubal pregnancy which has ended by the ovum
being discharged through tlie uterus. Such cases are easUy dismissed
from serious discussion, for I have never seen a preparation of
intei-stitial pregnancy which could, by any posaibiEty, liave been
diagnoisod from normal pregnancy before the period of rupture.
It is easier to believe, therefore, that such cases as I speak of
have been errors of diagnosis than that tbe uterine tissue has
been ruptured and the pregnancy has become intra-nterine. And
here let me state that about this subject, aa indeed about nearly
everything else in this book, I do not give as a fact anytliing which
has not been verified, either by post-mortem or ante-mortem
examination. Any man who gives an opinion that he diagnosed a
tubal pregnancy, or any other lesion, and that its course was this,
that, or the other, merely upon the unaided discrimination of
symptoms or the dim light of a pelvic examination, I regard with
so much suspicion that I do not accept his evidence for argument
save under exceptional circumstances. Post-mortem records,
museum specimens, and the facts observed at operations yield
evidence which is usually incontrovertible, and such as these only
do I care to use. The interstitial ectopic gestation ruptures
uniformly as I have said, and so far as we know, into the peritoneal
cavity. The period of its rupture seems to be variable from three
to twenty weeks, a fact which I derive from post-mortem record
and museum specimens solely, for I have had no operative
experience of this disaster and have had only one case within my
own associations.

Ectopic gestation in the free portion of the tube infallibly
involves rupture at some part of its progress befoie the fourteenth

PRIMAET AND BEOONDARY EUFTOHE. 7

week, in fact I think I might say the twelfth week, for out of an
enormous numher of specimona I have examined I have entirely
failed to satisfy myself that rupture had been delayed later than
the twelfth week, and I have seen it as early as the fourth week of
gestation, This rapture I propose to term " iirimary rupture," and
it constitutes in one direction, the most diaastroua accident known
amongst women.

This tubal rupture takes two directions (a) into the peritouenui
wliich is the fatal form; and (h) into the cavity of the broad
ligament, a form whicli yields the variety of ectopic gestation
which I propose to call extra-peritoneal which was called the
" aou8-peritoneo-pelvienne " variety by Dezeimeris, and which alone
yields all the cases which go on to the period of viability, all tlie
lithopoedia all the snppuratni^ cysts discharging into bladder,
rectum &c and also the case'^ which by secmtdari/ rupture of the
ovum cyst get called abdommal pregnancy."

llgsuirul ffltli (H) foJd

This is the view of ectopic gestations I first propounded in
1873, and Parry commended it with the expression that it at least
had the merit of simplicity. I have, during the fifteen yeai's which
have elapsed, missed no possible opportunity of examining
preparations of ectopic gestations, and nearly a hundred cases have
passed under my own oliservation, directly or indirectly, for
post-moi-tem investigation or surgical interference, and I have not
found a single fact inconsiBtent with the views just briefly
announced and now to be discussed at length. On the contrary.

8 aCUEM£ OF ECTOPIC GESTATIONS.

tlieae views of ectopic gestation bring harmony where formerly all
was discord, make orderly what lias hitherto been nothing but
confusion. We may, therefore, construct a genealogical table of
Ectopic Gestation, which gives tlie iiistory at a glance as follows ; —

Scheme of Ectopic Gestations (in tubo-ovarian tract),
I. — Ovarian, possible but not yet proved.

II. — Tubal, in free part of tube, is (a) contained in tube up to
fourteentli week, at or before which time primary rupture
occurs, and then progress of the gestation is directed into

(b] AMominal or intra-ptritonea! gentation unitormir fcUl Cc/ Braui ligiiniei

{DuleM rumoveii l>y iMomlnil gectiDU), piinwril; by hemoiTliage, or viCm- peritonei
sutODdulIy 'by supjmrstioD o! tlic uc inil peritoniUi ; guaUtion :

(■JJ imijf ilBvelop (■•; iiiijr die und ,'// maydiB auil Uio fa) mtj te- (\i las] beeomo

in bnud ilgament bo sbaoibod oa snppuratlDH ovum tDaln qniciceat abdomtntl or intra-

to rail time and ba eitrii-iieritimejil miy be diidurged u litiioptcdioa ; peritoneai gutttion

remaTfld at rimblB hamatoceie ; at or near ninbiliciu, by dacondary mp-

poriod aa Uving or tbnmgb bladder, Xate.

cbild I vagina, or iateatlnal
tract;

III. — ^Tubo-uterine or interstitial is contained in part of tube
embraced by uterine tissue, and, so far as is known, is
uniformly fatal by primary intra-peritoneal rupture (as V)
before fifth month.

A few cases of pregnancy in hernial sacs have been unearthed
by Campbell and Parry, but these, so far as can be judged by the
somewhat meagre details and unsatisfactory accounts of most of
them, can hardly be regai-ded as instances of ectopic gestations.
They are rather instances of a hernial uterus in which impregnation

The first division of our subject in natural oi-der is the much
discussed " ovarian " gestation. Concerning this I may well quote
a sentence from Pany, for though it is not dkectly applied to this
point it most truly may be : " Special treatises on obstetrics, as
well as periodical medical Uterature, teem with statements which
are utterly unreliable, and which are calculated to mislead
investigators of this subject."

Tlie beliefs prevalent on the subject of impregnation naturally
enough have always influenced the theories of writers on ectopic
gestations, it is so now in my own instance, and therefore we find
writers of the time of Haller beUeviug that ovulation was excited
by coitus, expressing many strange notions about abnormal
pregnancies. The belief that the spermatozoa reached the ovum

OVARIAN PREGNANCY. 9

in the ovary and that impregnation was afi'ected there, brought
about the notion at the end of last century and the lieginning of
this, that most ectopic pregnancies were ovarian, Hausman made
a series of observations which were regarded as final and therefore
the belief not only became universal but it infects our text hooka
to this day, for authors of text-books copy one another with
scrupulous fidelity and unblushing absence of acknowledgment
But if Hausmau's observations on animals are carefully perused,
and of course no writer of a text book woidd ever think of going
to the original authority for infonnation, it will be found that the
observations on different animals give results so inconsistent with
one another that it becomes absolute simplicity of intellect to
attempt to a]iply them to the human being. Finally, Sir Everard
Home published a paper in the Transactions of the Eayal Society
(Ijefore his audacious inventions were made manifest), and the
belief in ovarian pregnancy became a creed, and it remained so
till Velpeau raised the cry of unbelief. Even Campbell (1842)
says that he believes cases of ovarian pregnancy are not so rare
as his predecessors had asserted. Yet he quotes Velpeau as having
examined four such cases, aidetl by two competent assessors, and
as having easily determined that the ovary was not involved in
three of them -. " but in the fourth they experienced not a little
difficulty in determining the product of conception, which did not
exceed in size thai of a flea, to be placed, not in the substance, but
in the cyst between the peritoneal and proper tunic of the ovary."
At another place (p. 29) he describes the occluded and distended
tubes of a prostitute from one of which a white oval body the
the size of a garden pea with some white viscid matter (doubtless
an old pyosalpinx) was forced out by pressure, as an ovarian
pregnancy. Again he quotes the dissection of a cliild i^ed thirteen,
a coufinned masturbator, in whom was a dermoid cyst of tlie left
ovary, as confirmation of his view. So credulous is Campbell that
on a point like this his book is absolutely foolish. Ho has, however,
discovered a number of descriptions which might be accepted aa
authentic but from their extreme antiquity (1682, 1697. 1735, and
1767). Unfortunately the preparations of none of these cases can
be traced, even the instance said to be visible in the museum at
Wurzbuig seems to liave disappeared, and certainly in modem
times there has not been exiiibitetl any preparation which can bear
the test of critical investigation.

Of course it is impossible to admit any case as one of ovarian
pregnancy in which no post-mortem examination had been made,
indeed even when such an examination is made it would have to
be at the hands of a competent observer only that an assertion of
an ovarian pregnancy could be accepted. The uterus and both
tubes would have to be recoixled as intact and we should have
one ovary present and the other not to bo accounted for save by

10

OVARIAN PEEGNANCY.

its existence on the cyst of the ovum ; and in the cyat wall of such
a ease microscopic evidence of the presence of the ovarian tissues
would he reijuired.

In severed cases of tuhal pregnancy wliich I have dissected it
was a matter of the utmost difficulty to find the corresponding
ovary, even when it was perfectly clear that the seat of the
pregnancy was one of tlie Fallopian tuhes. In one of my
dissections I could not find the ovary, and yet that case was,
with perfect certainty, one of tuhal pregnancy. In Spiegelberg's .
paper there is only one case cited to which these tests apply with
any degree of satisfaction, and therefore I give the details in full

An abdominal section was perfoi-med under circumstances of
gi'cat difficulty, and after peritonitis had been some time in
existence, the sac had become closely adherent to the great
intestine and to the right wall of the pelvis. On both sides tbe
tuhes were normally distributed, but the left one, after a course
of 7 ctm,, disappeared ou the walla of its broad ligament. The
right tube extended 10 ctm. along the upper edge of the thickened
broad ligament toward a sac which was united by the ligameiUwni
ovarii to the ala vespertilionis of the utema ; it had a diameter of
10 ctm. and was in a collapsed condition. After the tube liad
reached tbe sac it could be traced along its surface for a distance
of 22 ctm. and was permeable for a distance of 12 ctm,, and in
the remaining 10 ctm. of its length it disappeared as a narrow,
smooth band on the outer surface of the sac. There was in this
neighbourhood a small dennoid cyst in the wall of the sac without
any distinct boundary. The sac itself had two layers, the outer
of which was thick and firm, and the inner one fino and dehcate,
these two being capable of separation. The inner layer was clearly
the chorion, for over its greater part it had the structure of
placenta, which was thickest at the bottom of the sac and thin
at the upper part.

Spiegelberg therefore concludes that the right ovary was the
bag containing the child. He could find uo ovary ou the right
side, but lie found distinct ovarian elements in the outer wall of
the sac. It must be pointed out that, in the first place, the
post-mortem examination is admitted to have been Jiot very
efficiently performed, and the description given of the tube makes
it, I think, quite as likely that it was a case of pregnancy in the
hroad ligament which resulted from the rupture of the tube on its
lower aspect — that being the most common variety of tlie tubal
preguauciea whicli are not fatal in iheir early rupture — as tlmt it
was a case of ovarian pregnancy. The fact that there was present
an ovarian tumour is proved by the existence of a dermoid cyst
This would account for the somewliat wide distribution of ovarian
elements in the wall of the sac, and as Spiegelberg does not claim
to have found ovarian elements all over the wall of the sac, I think

OVARIAN PBEGNANCY, H

we may "be quite justified in being somewhat sceptical even about
tliis case ; thougli I frankly admit that the eminence of the
obsei'ver and the manifuat care with which all Ms tecorda are given
make it quite possible that his conclusioua are correct.

In a paper published by M, Puech upon this subject he
describes a caae in which the left Fallopian tube, like the right,
was fixed behind the ovary by adhesion, but had remained perme-
able, Ita pavilion wn3 closed in a great measure, but not
completely, and admitted a probe. The left ovary measured 46 mms.
long, 26 mms. broad, and 18 mma. thick. It contained Graafian
follicles of various degi-eea of developmentj the largest being 8 mms.
in diameter. On ita outer extremity was a rounded body about
the size of a large cheiTy, its largest diameter being 20 mms.,
while its smallest was 12 mms. Its envelope was transparent and
furnished with weU-mai-ked reticulated vessels. Atone spot a deep
violet colouration was seen over a apace about the size of a lentil,
and arountl this the envelope was thickened. Over most
of the rest of the surface a yellowish substance could be seen
through the translucent envelope. On opening the cyst with
scissors a prominence with a villous surface was found attached at
the area of colouration, while over the rest of the surface a layer
^ mm. thick could be easily separated from the cyst wall. The
villous prominence was furnished with lai^e vessels, and formed a
semi-ellipsoid measuring 11 mms. by 10' mms. On incising this
with cataract scissors it was found to contain a cavity distended by
a clear fluid, and in the fluid floated an embryo in the form of a
vermiform body 1 mm, long, curved in the middle and swollen at one
extremity. It was enveloped in an excessively delicate membrane
by wliich it was fixed to the presumed chorion.

Of course the whole conclusion in this case depends upon the
assumption that this vermiform body, only 1 mm. long, was an
embryo. It may have been one, but certainly there is no proof
advanced in favour of this view ; and although I am by no
means prepared to deny ita accuracy, I am certainly very doubtful
about it. If it was an embryo it could only have been one of a
few liours' existence, and one could hardly expect to find the
machinery of tlie whole process ao defective that the pavilion of the
tube — the most important part of the whole machinery — was so
damaged as to be, according to M. Puech's description, almost
closed and fixed behind the ovary by adhesion. One would have
at least expected this adhesion to have been over the seat of the
rupture, and yet it is distinctly stated not to have been so, I have
seen so many queer looking things in ovarian cysts and follicles
that I am not inclined to admit that this vei'miform body has been
shown conclusively to have been an embryo.

A very important paper was publiahed in 1859 by Professor
Arthur Willigh (Vierteljahrbuch. fur Pract. Heilkunde) in which

12 OVARIAN rREGNA-SCY.

the author suggests that critical inveatigation by means of the
microscope ia necessary to determine tlie reality of the so-called
ovarian gestation. By this test he dismisses absolutely the evidence
of a number of preparations which had been labelled in various
museuma aa ovarian pregnancy, even one to which there was
attached tlie great authority of the name of Kiwiscb.

Such a teat is wanted, for instance, in the case narrated by
Dr. Walter, of Dorpat (Monatscbr. fiir Geburtsh, Ap. 1862).
Tliere the account is given merely to the effect that the right ovary
had become developed into a long tumour, its long axis being in
the same direction as the body of the full-grown child, and that no
other trace of the right ovary could be discovered ; but some
evidence is needed more than is given that this tumour possessed
ovarian structure. We know perfectly well that an ovary can be
enlarged by cystic growth indefinitely, but we can always identify
by microscopic inveatigation the origin of the growth.

Walter's specimen is still in the Dorpat Museum, and I would
suggeat a careful investigation of it.

A large number of cases have been published in modem
times with the title of ovarian pregnancy and placed before us in the
most reckless faahion. No less an authority than Hildebrandt, of
Berlin, published a case as one of ovarian pregnancy in 1864, where
a lot of old fcetal debris was discharged by the rectum and the
patient recovered, not a scrap of evidence being given, or being
suggested as to where the pregnancy was, though the very tact that
it was discharged by the rectum ia conclusive that it rested in the
broad ligament and originated as a pregnancy in the free part of
the tube, and that it ruptured and passed into the extra-peritoneal
variety. Another case to which the same criticism applies haa
much stress laid upon it by Dr. Parry on account of a post-mortem
record which is perfectly satisfactory, except that there is no proof
that a substance the " size of a honey bee which was found to escape
on making the incision into the ovary, which was enlarged to the
size of a very small hen's e^," was in reality a foetus of the sixth
or seventh week, as Dr. Parry believed. In fact, it is an endless
task to go over the numerously recorded cases of this kind. Not
one of them has been subjected to the necessary condition of
criticism, a satisfactory compliance with which alone can establish
the occurrence of ovarian pregnancy.

Parry (p. 38) says, "whatever doubts liad previously existed,
they were settled by Granville's description of an example of this
fonn of aberrant gestation," But when the original description
and figure are turned up it is found that Granville figures only
a small cystic ovary wiUi a gelatinous lining to the cyst, a very
frequent object. There is no fcetua, not the faintest resemblance
of one, but Sir Charles Clarke assured him that at one time there
was an embryo hanging pendulous fram the yet visible rudiment

VAUIETIES OF ECTOPIC PREGNAKCY.

13

of ftn umbilical cord. In fact, Granville's case is of no more
value than any of the othera.

Parry sums up the sulfject by saying that tlie weight of
authority is in favour of the po.9sihility of ovarian pregnancy. Its
posaibility I admit, because I can easily imagine a Fallopian
tube glued on to the ovary and depiived of its lining epithelium,
permitting the coutact of tlie spermatozoa with a follicle burst
within the area (of the ovary) of adliesion. Then the
apei-matozoa might infect the ovum before it escaped from tlio
follicle, the ovum might adhere to the follicular wall aud then
develope. But tliere are so many contiugenciea in such a case
that the doctrine of cliances make it so remote that its occurrence
may be regarded as likely as the birth of a Idue lion or a swau
with two necks, like a heraldic nmntrosity — a mere pathological
curiosity. Finally it would have no kind of clinical interest or
importance not idready decided u]Xin in tlie cjise of pregnancies
in the free part of the tube, so that we may avoid any further
discussion of ovarian pregnancy as futile. If it does occur it
must be rare and will bo curious. If it never occurs so much
the better.

I do not propose to discuss fnrtlier the varieties of ectopic
gestation whicli liave been proposed by previous writers, for in
doing so I should merely introduce elements of conl'usion whicli
I am anxious to avoid. I shall merely any therefore that my
second variety, the tubal pregnancy, arises from the attachment
of tlie fertilised ovum to any part of the lining membrane of
the tube, from the pavilion onwards. There can be no doubt
that the pavilion may itself become the seat of the gestation and
I am free to accej)t a sub-vnriety of the ovario-tubal as a
possibility. It would occur amongst tlieae numerous cases when
the pavilion has become agglutinated to the surface of tl e var}
and lias communicated by the bursting of a folli le u de t
with the substance of the ovary itself. Tubo-ovarian jst f n
in this way, and I liave seen a lai;ge number of tl en I ha e
never seen anything like a pregnancy of this kind, 1 e a 1

therefore whilst 1 admit the possibility of its occu en e I can
say nothing about it. It must be clearly understood tl at su 1
a variety, if accepted, would be different from tlie all d o a
form, for in this the condition would be that tl e o a

developed in the ovary with the tube free and not attached to
the ovary. That a fertilised ovnm may drop into the cavity of
the peritoneum and become developed there, ia a coiitmgency I
cannot accept for a moment, for tlie powers of digestion of the
peritoneum are so extraordinaiy that an ovum, even if fertilised,
could have no chance of development. What liave been called
abdominal pregnancies are clearly exceptional cases where primary
tubal rupture at the end of the thiid month, has not proved

14

PROCESS OF BUFIUEE.

fatal, where the extnided placenta has made for itself visceral
attachment3 wherever it lias touched, or where secondary rupture
of a liroad ligament cyst has converted an extra-peritoneal
ectopic gestation into one within the peritoneal cavity. Thai,
the first of these processes is hy far the most common condition
lias heen proved to me beyond doubt in my operations, for I
Live seen the ruptured tube within a few days of the catastrophe
contammg the great bulk of tlie placenta whilst thi, \ilh of the
extruded portion has been engaged m making epiphytic inioada
on intestine bltddei tl e back of the uterus and the folds of the
omentum I have pulled these \illi out of the livmg crjpts they
liave mode much as one pulls n baiiiacle out of its bed leaving
Heeding holes behind them But Beny Hart has proved this
beyond dispute for he has been abit, to inject the plicenta which
Ind come out of its ruptured tubi, and acjuuei these strange
and unusual assoLiitiona and I heie ^i\e a drawing of one of
the jrei uaticns showing the yiocLSS

a

Irom the relation? of the outer extremity of the tube I should
suppose thit a tnho o-vinan pregnancy or one in the pavilion
must of necessity alwajs end ly lupture mto the peritoneal
eivity and I tlimk it would do so within the period which
limits the existence of the juieiy tubal ectopic ^estatious that
H thuteen oi fouitLen weel s Chnically therefoie tl ere would
le no ahintage m multipljing by further subdivisions the
varieties of tubd gestations Whatever diflcicnce of opinion on
these matters there may be there can be but a umform concensus

STATISTICS. 15

of belief to this effect, that by far tlie greater number of cases
of ectoijic gestations are tubal. I believe that they are really
all tubal, anil iii this consists the novelty of my views on the
subject. I do not see any difiiculty in believing oven that a
pregnancy originally tubal may be completely extruded from the
tube, that the tube may contract and lieal, and that a secondaiy
and wholly intra-peritoneal gestation may thus be formed
(Dezeimeris) as in the remarkable case recorded by Maticki
(Monats. fUr GeinirtshvZfe, Mai, 1860) where the uterus and its
appendages could all be traced, and where the attaclmieut of the
placenta had become almost wholly omental. Having seen all
stages of sucli a process as this would require, I am sure that
this is possible, and the very rarity of the observation, unique
so far as I know, proves how exceptional the completion of such
a process must be, as we would naturally expect it would bo.
There is indeed notliing more remarkable about it than the well
estabbsbed fact that by axial rotation an ovarian tumour may
be twisted off its pedicle and grow entirely from the omentum
or, as I have seen, from the ascending colour. Similarly I have
seen this strange transplantation in all its phases and in all
stages of tbe process. That such a hypothesis is tenable, is shown
by the actual fact recorded by Lecluyse (Bulletin d V Acadcniie
de Belgigue, 1S69) that an intra-uterine gestation became ventral
by the ovum escaping througli an apeiture left in the uterus tiy
the defective healing of the wound of a previous Cieaareau
section. The placenta became attached cliiefly to tbe small
intestines, and the liiatory does not give any clue to a sudden
rupture. I think it far more consistent with the facts given, that
the fistulous opening was gradually dilated during the early weeks
of pregnancy, before the differentiation of the placenta as a cake,
and that tbe ovum was gradually passed through tlie opening,
the placenta making epiphytic inroads on whatever it came in
contact with.

Concerning the statistics of ectopic gestation, I'arry very well
says that with our present facilities for arriving at the truth in
regard to the location of the ovum, it is believed that " we are
not warranted, excepting in rare instances, in asserting that tbe
ovum is developed in any particular portion of the genital canal,
unless we have tbe opjiortunity of making a post-mortem
examination." With this I entirely agree, and can only qualify
his remarks by adding that we can accurately state the position
of the ectopic gestation, when we remove the parts by abdominal
section to evert the need of post-mortem examination. I have
now been concerned directly and indirectly in the post-mortem
examinations of twenty-six women, who have died from ha*morrhage
into the peritoneum (inti^a-peritoneal hiematocele) from ruptured
ectopic gestation, I have Imd to operate forty times for tbe same

u

FATALITY 01' Et'PTUllE.

cttuse, and I ImvG witnessed about Um einiUar opcratiouB liy other
anrgeoiia, making in all tlio unique exiwriencu of aeventy-six coses.
In every ona at tlieau tlje seat oi' the prugnancy was ascertained to
he without doubt the Fiilto])iaii tube, and in only one was the seat of
pi'i.'guancy lu that part of the tube embraced by the uterine
tissue. Interstitial ectopic pregnancy must therefore be very
mi'e, and that form which occupies the free part of the tube must
have nn over-whuhniug preponderance, and tlie other alleged
forma 1 liave yet to see. All the cases which have occurred in
my experieuco in wliich tlie gustation has gone beyond the period
of primory rupture Ijhvo been in tlie cavity of the broad ligament,
where they wero lodged by that rupture. These facts are so
inconsistent with the hiburiously (and 1 think uselessly) collected
statistics of Pan-y that further rcseiircli must be made before any
conclusions are accepted. I do not sec how Parry's statistics con
be of any value for any puriioao whatever, collected as they are for
the must pnvt from imporfoet records made by men who were
untikiUt;d in patholngioal resoaivli.

Parry says, " It ia very rarely indeed that an opportunity ia
obtained to examine an unruptured cyst in the early stages of its
development." I doubt very much if such a case has ever
occurred, Certainly the instances he quotes will not bear the
crtticiil investigation. Indeed, the best of the lot (Stanley's case)
ia oloarly not accepted by Pwry. for he emphasisea tlie fact that
nc enthrj/Q icrH foumt I iim of opinion that no authentic descrip-
tion exists of an unruptured tube-pregnancy. Of tlie frequency
of niptutvd tubal gestations we reiiuire no more proof than the
current literature of our profession, nhioli abounds with instances,
and there are few men of experience in general practice who
cannot eall to mind one or more examjilea of this ghastly
ontastTophtv. IHirry says, that " The almost universal opinion of
the profession is that this accident is uniformly fatal, and if not so,
that we have no reliable means of combating its dangers." Much
diaoussion has taken place of late years as to the possibility of
diagnosing tubal pntguauoy before the period of rupture, and
many stmugely dogmatio assertious hnw l>eeu made to the effect
that such cases ha\'e bt«n diagnoses! aud succt^sfnlly treated. I
am bound to say that 1 am excoediugly sceptical conc«niing the
eorrectliess of these statements, aud oue tact alone would justify
my attitude. It is this, that of alt the cases that I have operated
oo, and in luauy where I have seen the ixwt-mortem examiuatioo
and have kuown the history, the j^tieuts have mat.le no complaints
till ttw alarming symptwits of raptuw have srt in. I hai-e waly
S"?eu ouo case bef\>rv tlie \<vtm\ of ntpturw, aud tlwrv^i I diognu^txl
tttbal ticclttwon ami dtsteusiou eastlj' enough ; tmt the question of
the woman being pr^oaut uewr eutned t&^ uiiuU of any ooe who
mv Iter, and for reasons which wiU be plaiu wfaMU the sfa«y is

SYMPTOMS.

17

read. See " The Briiish Ghjnmcologicai Jownal," Part XIII. p. 38,
from wliicli the following is an extract ; —

" The woman cnmo to me a few weeks ago in the ordinary
course of out-patient practice, with symptoms of obscure
pelvic pain of sevei-al montJis slandtTig — in short with the usual
symptoms ol tubal disease. She was examined and I came
to the conclusion that it was a case of gonorrhceal salpingitis,
and so clear were the symptoms that I used the case to
demonstrate to my pupil, Dr. Iticketts, tlie nature of the symptoms
in that disease. That was on a Monday. On the Tliursday she
turned up again with the most acute symptoms — she was bent
double and could haixlly walk. Finding that the whole floor of
of the pelvis was fixed in one mass she was at once admitted,
The next moi-ning I opened the abdomen and found a ruptured
tubal pregnancy, than wliich nothing was less suspected. I
defy anybody to have diagnosed such a case before hand, for
the woman had not even missed a period."

The fact is that the notions of Antoine Petit of 1710 still
permeate the professional mind, and in spite of all that can be
said they are handed down from text hook to text book with
unfailing regularity and uniform inaccuracy. Of these misleading
statements Pwry said, " Could they be verified the detection of
extra-uterine gestation would he an easy task ; but unfortunately
for the comfort of the obstetric surgeon scarcely one of them
contains a grain of truth ; yet strange to say the opinions of Petit
influenced and impeded the progress of onr knowledge on this
subject for more than iialf a century." Parry might have said for
a century and three-q^uarters.

The curious thing is that the great bulk of my patients had
no suspicion that they were pregnant at all, and therefore the first
factor in a correct di^mosis was absent. Even when this leading
point is present there is generally nothing unusual about the
sensations of the patient till tlie period of danger. As Parry
well says, " The patient in the first instance supposes heraelf to
he pregnant, and during the first four or five or eight weeks
nothing particular occurs to warn her of her anomalous condition.
The usual signs of this early period of gestation appear successively;
or, indeed, she may enjoy better health than she did during the
same period of previous pregnancies, when suddenly and without
any warning the unfortmiate victim of this terrible accident is
seized with very characteristic symptoms."

But the very fact to which I have drawn attention, that a very
large proportion of these victims, a large majority in my own
experience, are women who either Iiave never been motlieia or
who have not been pregnant for mitny yciirs, shows how misleading
the whole history may be. The last thing these women would
admit would be pregnancy.

I must point out here tliat Petit is right on one point to a very
large extent, thougli by no means uniformly, wlieii lie says tliat
" the menses, contrary to what is seen in normal gestation, continue
to appear, but in smaller quantities tbrouglioiit the pregnancy."
Menstruation is aometimea Buapended absolutely, as in uoriiial
pregnancy, but more usually it occurs irregularly and profusely,
80 that here again we are misled. lu fact, the history of these
cases is more usually a souixie of danger than a help to the
diagnosis, and unless some exceptional incident occurs, or unless
the patient is a good deal more anxious about the state of her
pelvis and a good deal less reluctant to have it examined into
than Englishwomen are as a rule, no diagnosis is possible before
the period of rupture, for the patients make no demand upon us.
Amongst the women of other countries it may be different. I
cannot improve on the words of Parry in continuing tliia vexed
question of early diagnosis of tubal pregnancy, and therefore I
quote further : " An extra-uterine gestation is frequently ushered
in quietly enough, aud during the first four or six weeks all may
go well, but after this time symptoms supervene winch in their
violence are as unlike the signs of uterine pregnancy as the
tbe surface of a stormy sea is unlike that of a deoid calm. The
one moves on with some sort of regularity, tbe discomforts of tlie
coudition appearing in a certain order, but the other follows no
plan and sets all order at defiance. This is tbe period of rupture
which is (in my own experience) limited between the fourth and
the twelfth week of pregnancy." I possess, and have frequently
exhibited, a preparation of a ruptured tubal pregnancy which
proved fatal in a woman aged thirty-one after an Ulness of only
seven and half hours. She was under the care of Dr. Guthrie Rankin,
of "Warwick, and Dr. Thursfield, of Leamington, and the following
is the history of the case :— " On November 2nd, 1887, at 1.30 p.m.,

Mrs. was seized with pain in tbe abdomen, followed by

vomiting and faiutness. Dr. Gutbrie Eankin was called in, the
pain was relieved by an opiate ; but collapse followed, aud death
ensued at 9 o'clock the same evening. She was seen in consultation
by Dr. Tliursfield just before death. She was tbe mother of three
children, suckling the youngest aged seven montlia, of good
constitution, with no histoiy of previous illness. At the post-
mortem examination the abdomen was found full of clots, estimated
at from seventy to eighty ounces. The left Fallopian tube
presented an ovoid-swelling which had raptured, and was full of
blood clot; on exaniiiiatiow tliis swelling proved to be a tubal
pregnancy.

One curious point about tlie preparation is that the ruptured
ovum in the tube, as it is seen in the preparation bottle, looks
exactly like the ovary aud every one who sees it at once says —
" Case of ruptured ovai-ian pregnancy." But a little more careful

PERIOD OF RUPTURE,

19

examination displays the ovary uninjured, and the further fact
that what is taken nt first to be the ovary really ia an ovum in
the Pallopian tiibe of certainly not more than five weeks. The
rupture which caused death was not larger tlian a pea, I mention
these facts to sliow how carefully records of these cases
must be made,

Ou the other hand I have seen no case of ruptured tubal
pregnancy (primary rupture) either in my own practice or in
museums in which there was evidence to show that it was over
the twelfth week. Of course I am not talking of cases where the
pregnancy had gone on in the broad ligament after primary
rupture into that cavity, but purely of those of fatal primary
rupture req^uiring operation for the arrest of hiemorrhago.

The cause of the primaiy rupture of the tube is chiefly in its
thinning at the site of the placenta. When distended either by
pregnancy or otherwise, the walls of the tube never thicken
materially. Ceitainly in tubal pr^nancy there ia no imitation
of the thickening of the muscular coats of the uterus. The villi
of the placenta penneate the walls, seem even completely to
penetrate them, and the blood-vessels increase enormously in size,
especially tlie veins. Some slight exertion occurs, such as stooping
at some household work, a violent attack of pain comes on, the
patient becomes faint, collapsed, cold, pulseless, and anemic, and
dies almost uniformly if unaided. This is the story of a great
number of these cases, for q^uite a number of cases in which I have
seen post-mortem examinations, the women have been found dead
or dying, and suspicions of foul play have not unfreqneutly been
aroused. Sometimes the symptoms abate, the patient recovera for
a few days and even gets about, then a recurrence of the peritoneal
hjemorrhage occasions a revival of the serious symptoms, and this
may be repeated at intervals several tunes beiore the fatal issue
ia arrived at. A most notable example it was of this which drove
me to attempt to save these cases by prompt sui^ical interference,
it was indeed an epoch-making case for it has revolutionised our
practice in. these cases.

In the summer of 1881, I was asked by Mr. Hallwright to see
with him in consultation a patient who had amved by train from
London in a condition of serious illness, that illness having been
diagnosed by Mr, Hallwright as probably ha^morrh^e into the
peritoneal cavity from a ruptured tubal pregnancy. The patient
was blanched and eoUapaed, the uterus was fixed by a doughy mass
ill the pelvis, and there was clearly a consideral>le amount of
effusion in the peritoneum but no distinct tumour could be felt
above, and I agreed with Mr. Hallwright as to the nature of the
lesion. This gentleman made the bold suggestion that I should
open the abdomen and remove the ruptured tube. The .suggestion
staggered me, and I am ashamed to have to say I did not receive

20 ILLUSTRAIIVE CASES.

it favourably. I saw the patient again in conaultation witli
Mr. Hallwriglit and Dr. James Johnaon and again I declined to
act upon Mr. Hallwright'a request, and a further hinnorrbago
killed the patient. A post-mortem examination revealed the
perfect accuracy of the diagnosis. I carefully injected the
specimen which was removed, and I found that if I had tied
the broad ligament and removed the ruptured tul>e I should have
completely arrested the hEemorrhage, and I now believe that had
I done this the patient's life would Imve been saved. The
appearances in this case are precisely given in the annexed
illustrations from Duguet: —

Fatal C>aE or FALLoriAN TREOtijiKCV at EiaEmi Wehk (apieu Duqcet).

w;

Fio. S.—A, ntanu Ilia Dnn on tho Ulterior . .

to tlm right aterlDs cornu : C, decidiu, noiU'ly fnlltn, eiiwllml Iwfi

part cit llie ileciMiin still wlliere
■ ' - Itath ; D, right tube ai

iliying" VvorUio" mbnl cuvurlna of en

Fio. e.—A, Vluv of the paiterior aaztace ot the ntenu : B, B

ronta in tuhnl ooterins of cjat. cortu •"— '- -"- -' ~' ■

snd hiEinorchage dune j D, otst]' a
B, right tube.

A most striking contrast to this terrible incident will be found
in tho following case, wlien, thanks to tlie ability and firmnesa of
Dr. Dolan of HaKfax, I was able to save a valuable life : —

Late on the evening of February 16th I received a tel^ram

ILLUSTRATIVE CASES. 21

from Dr. Dolan, of Halifax, to proceed at once to that town to
operate upon a case wbicli he lielieved to be one of ruptured tubal
pregnancy. The followiu}^ is the account which Dr. Dolan has
(jiven me: — "P. W., aged twenty-nine, mamed, four children
living, youngest two years old, had a miscarriage nine months ago,
has always been regular but missed the last period. Felt uneasy
for the last few weeks ; felt, she said, as if there was a weight and
as if the womb were coming down the passage, enjoyed good health
np to this time. About 9.30 a.m., February 11th, I was called to
see her and found her in a state of collapse. She revived and then
complained of pain in her abdomen. Symptoms like those of colic,
vomiting, abdomen distended, great deal of flatus. This continued
for some hours ; was relieved by ether and champagne. She had
several attacks during the day, and I saw her altc^ethcr seven
times. At 10 p.m. same night she beggctl for something to give
her sleep, and I gave her a dose of chloral, bromide of potash, and
camphor water. She slept the whole night. A nurse had been
obtained immediately after the first attack. On the morning of
February 12th she was, to all appearances, perfectly well, was free
from pain, and, as she said, she felt as if there was nothing the
matter with her. There was, however, a good deal of flatus, and
the abdomen was distendal. She told me she had gone to beil on
the Tuesday night perfectly well, but on rising in the morning
about 7 a,ra, she felt a audden pain about tlie umbilicus. When
she got up she tried to work it off. I told her husband I feared
there was some internal hreTuoiThcige caused by nipture of tube,
but as she was so much better I would wait and see whether I was
right She was kept in bed in charge of tlie nurse and not
allowed to move. This treatment was continued until the
following Tliursday. There was no return of pain or collapse, and
she said she did not know why she was kept in bed. At midnight
I was Imrriedly summoned to see her. Slie had been out of bed
for a short time and almost the same symptoms came on— sickness,
tendency to faint, cold sweata, with a sense of fulness in the
abdomen. Her appearance was changed, face was blanched, the
abdomen was distended, but there was no localised swelling. By
resting she again revived. I told her husband that I was now certain
OS to what she was suffering from and an operation would be
required. He gave me permission to call in Mr. Lawson Tait,
whom I telegraphed for as soon as I could." On my arrival I
completely agreed with Dr. Dolau's diagnosis, and I opened the
abdomen without further delay and removed an enormous quantity
of clots and bloody senim and debris. The tubal pregoancy was
on the left side. I tied the broad ligament, removed the pregnancy,
washed her out thorouglily, and put in a drainage-tube. Dr. Dolan
stayed wilh her all night feeding from time to time with diluted
champagne. She gradually rallied, there was but a slight discharge

from the tube, very little pain, the pulse came down day by day,
and on Februaiy 25th she was regarded as convalescent and is now
in a condition of perfect health.

What a contrast hes iu aucli a pair of cases ! And to make the
lesson still more emphatic let me make a long quotation again
from Parry's book (p. 211—13). " In speaking of the result of this
pitiless termination of extra-uterine gestation, it was stated that bo
few recovered from it, that all hope of such a happy result is to he
dismissed iu considering the treatment. No douht, notwithstanding
the statement of Rogers to the contrary, a few women have
recovered, though the number is very small — so small that when
one is called to a case of the kind, it is hia duty to look upon liia
unhappy patient as inevitably doomed to die, uuleas he can by
some active measures wrest her from the grave already yawning
before her."

" A bleeding vessel through which the red stream of life is
rushing away, can he h'gatured. A gangrenous limb wldch is
destroying the possessor by sending its poisonous emanations to
the remotest regions of the body can be amputated, A cancerous
breast, which is sapping the vitality of its victim Iiour by hour,
can be removed wJtli the prospect of temporary relief. An
aneurism tliat places life in constant jeopardy, can often be cured
by proximal or distal ligation. The tumultuous action of the
heart oi^anically diseased may he quieted till nature restores the
balance after whicli the person may enjoy a long and even a useful
life. Even phthisis now counts its many cures ; but here is an
accident which may happen to any wife in the most useful period
of her existence, which good authorities have said Js never cured ;
and for which even in this age, when science and art boast of such
high attainments, no remedy, either medical or sui'gical, has been
tried with a single success. From the middle of the eleventh
century when Albucasis described the first known case of extra-
uterine pregnancy, men have doubtless watched the life ebb
rapidly from tlie pale victim of this accident as the torrent of
blood is poured into the abdominal cavity, hut have never raised a
liand to help her. Surely this is an anomaly, and it has no
parallel in the whole history of human injuries. The fact seems
incredible, for if one life is saved by active interference it may he
triumphantly pointed to as the first and only instance of the kind
on record. In the wliolc domain of snrgeiy — for we cannot look
to other than surgical measures under the circumstances — there is
now left no field like this. In this accident, if in any, there is
certain death. How often do we see persons recover from injuries
which their surgeons tell them will be mortal, if they do not
submit to a grave and terrible operation, and which with a do^ed
determination they refuse to have performed, preferring to perish
rather than to suffer such grave bodily multilation ; or else, with

PEINCaPLE or SaCPLOEATOBY ISOIBION. 23

a keener instinct they foresee a happier result and get well
notwithstanding tlie evil prognostications of the aurgeon and in
defiance of all the laws which, as man with his fallible knowledge
supjioses, govern human injuries. But in rupture of an exti-a-
uterine fcetal sac, in the early stages of pregnancy, a whole lifetime
— a whole century — is not enough to enable one pei-son to make
two errors in regard to the prognosis of this accident."

" The only remedy that can be proposed to rescue a woman
under these unfortunate circumstances is gaatrotoniy — to open the
abdomen, tie the bleeding vessels or to remove the sac entire.
The first suggestion of performing gastrotomy to save a woman
dying from early rupture of the cyst eaine, so far as we know,
from our countryman Dr. Haibert, while to Rogers belongs the
credit of formulating tlie arguments in favour of this practice and
bringing them prominently before tlie profession. Since he wrote
the same plan of treatment has been advocated by Meadows,
Hewitt, ami Greenlialgh in a discussion before the Obstetrical
Society of Loudon. Koeberle, Bebier, Scbroeder, and Atlee
countenance the proceeding, but no person baa yet performed
gastrotomy for the relief of this accident. The great impediment
to tlie adoption of this treatment is the vncertainiy of diagnosis."

Mark the importance of the last sentence, which I have
italicised, for this sentence it is, reiterated by almost every writer
on abdominal sui^ery up to 1878, and continued as a tendency by
a great many still, which has stood in the way of our success.
I iiave long since thrown it to the winds, and when I find my
patient " in danger of death from conditions within the abdomen
which do not seem to be clearly of a malignant nature, but a
correct diagnosis of which is impossible, I open the abdomen and
at once make the diagnosis certain and a successful treatment

This is the rule I laid down in 1878, adding to it, for other
pui^poses, that I did the same thing when " the conditions were
such that the patient's life was miserable by reason of suflermg
which could not be relieved, or at least had not been — by all other
measures." The result has been an enormous adva'ice in abdominal
surgery, obtained only after a severe struggle with the authority of
the elders, who asserted that the abdomen was a region into which
the writs of ordinary sui^ical laws sboiJd not run.

This principle of exploration is nothing new, in fact the way it
is sometimes used or rather abused is almost horrible. I once saw
a surgeon, who is now a baronet and has a Court appuiutuient,
remove a breast with a tumour in it. After he liad the whole
thing away in his hands, be drew his knife across the tumour and
out spurted a lot of pus, "laudable pus." Ho had made hia
exploration after the treatment was complete. If he had explored
first his diagnosis would have been completed, hia blunder saved

24 DUGN08IB BEFORE HUPTURE.

and the radical and exa^erated treatment rendered wholly
unneceasaiy. I bave similiirly seen a limb amputated for a
sequestrum opening into the knee joint, whicli a preliminary
exploration would Lave shown to be capable of removal without
amputation and the limb would liave been saved. Crowds of
illustrations of this kind of theory could be given ; shewing iu the
first place, that complete accuracy of diagnosis is no more possible
in the breaat than it is iu the abdomen, that exploration is a sound
prinuiple when there is doubt, and that many ghastly blunders
would be saved if the practice were extended into general surgery.
Absolute accuracy of diagnosis in the abdomen is very far from
being possible ; only the ignorant assert that it is, and only fools
wait for it.

After the terrible lesson j^iven to me by Mr, Hallwright's case,
I did not see another example of ruptured tubal pregnancy, or one
which I suspected to be of that nature till I was called to
Wolverhampton by Mr. Spackmaii, on June 17tli, 18S3. There
could be no doubt as to the nature of the case and Mr. Spackman
was fully aware of it before I was summoned. The patient was
clearly dying of hemorrhage, and I at once advised abdominal
section. The fo;tu3, about the twelfth week was lying amongst
masses of clot and coils of intestine and to these latter the partially
extruded placenta liad obtained new attachments. These I
cautiously separated and occasioned fast aud copious bleeding
at every point. I wasted much time in trying to atop this
hiemorrhage so that by the time the operation was finished my
patient was practically dead. We got her to bed alive, and that is
all that can be said. I thought much about tiiis case, for it was a
bitter disappointmeut, I thought I should achieve a triumph and 1
had only a failure. But my conclusion was speedily arrived at
that I had blundered, that the tme method of operating in such a
case was to separate adhesions rapidly, regardless of bleeding and
make at once for the source of the biemoiTlii^e, the broad
ligament, tie it at its base, and then remove the ovum debris and
clots at leisure. This I have done now in thirty-niue cases with
one death, and I think I may fairly say that I have really achieved
a surgical triumph. My example has been widely followed, and
the success is almost nniforra.

The diagnosis of tubal pregnancy before rupture of the tube
is not easy, as I have said, because the patients do not claim onr
attention. What symptoms there are, as in the solitary case where
I had a chance of making a diagnosis, are merely those of tubal
occlusion and distension — mattei-s very easy to diagnose and to
treat. If 1 ever should make a diagnosis of tubal pregnancy before
rupture I should advise its immediate removal by abdominal section
as being more ceilain and far more safe tlian the fancy methods of
puncturing the cyst and injecting poisonous fluids or ;

HEMATOCELE.

25

through it some kind of galvaniG current. There can be, there
clearly is from the statements of those who have tried these plans,
neither certainty nor safety about them ; and they will commend
themselves only to snch as, by lack of com-age and skill to obtain
good reaidts, have only had records to show in abdominal section.

The diagnosis of tubal pregnancy at the time of rupture may
be made witli certainty seven times out of eight, and may be
guessed at in the eighth instance. They are too serious to be
lightly regarded at any time, and are practically coincident with
those of pelvic hjematocele. If the rupture takes place into the
broad hgameut they are the symptoms of extra-peritoneal
hrematocele. If the rapture takes place into the peritoneal cavity
they are the characteristic and most serious group which belong to
intra-peritoneal hiematocelo.

No more appropriate place than this occurs to me to discuss
this much confused c[ueation, if for no other reason than that I
have never seen an intra-peritoneal hiematocele that was not
due to a ruptured tubal pregnancy ; and very many cases
of extra-peritoneal hematocele (effusions of blood into the
broad hgament) have undoubtedly been tubal pregnancies which
have ruptui-ed between the peritoneal folds of that important
structure. The difference between them is all unportant in every
way, for the intra-peritoneal ruptures seem to be almost uniformly
fatal, whilst the exti-a-peritoneal hematoceles, whether arising from
tubal pregnancies or not, should certainly be left to take their own
coui'se unless they give signs that they are suppurating.

A most especial interest was given to this c[uestion by a trial
which took place at Liverpool some two years ago, which raised
the whole q^uestion, and displayed tlie extraordinary confusion
which existed then in the professional mind upon it.

The first important contribution to the literature of pelvic or
abdominal hematocele was the work of Eernutz and Goupil,
translated by Dr. Alfred Meadows, and published by tiie New
Syndenham Society in its English form in 1866. It appears to
me a matter of great regret that the writers of our text books on
gyutecologj- have so neglected this admirable work, most of them
seem never to have read it at all, and in those where it is quoted
it is clear that nearly every one of the writers has faded to
understand the meaning of the Trencli author. An instance, by
no means remarkable as an exception, may he found in one of the
most recent text hooks on gynecology— that by Dr. Emmett, of
New Tork, and we see that t&oughout his chapter on this subject
this confusion is remarkably prevalent. The chapter begins vrith
the definition that licematocele is an " accidental collection of blood
in the pelvis, eitlier in the peritoneal cavity, or outside the
peritoneum, or within the connective tissue of the pelvis." This
definition is faulty to begin with, because the second and third

26 HEMATOCELE.

varieties must o£ course be classed togetlier, and to cliiss uuder tlic
same name — the common name of hfematocele — two conditions
which must be so absolutely apart aa hjemorrhage within the
peritoneal cavity and hjemorrhage outside it, is the very fountain
and origin of all the confusion which has arisen. Dr. Emmet
quotes N^laton as having given the first accurate description of the
pathology of the lesion ; hut in reality N^laton's views, from the
very words he coined to express tiiem, are very largely answerable
for the confusion. M. Nelaton regarded the origin of hematocele
as being from the rupture of a Graafian follicle, tlic bleeding
naturally gravitating from tlie surface of the ovary to the bottom
of Douglas's cul-de-sac, the most dependent point, and for this
the term he invented was " retro-uterine hematocele." On page
228, Dr. Emmet gives a dif^am labelled a " retro-uterine
hffimatocele " in which the section of the blood-clot is clearly
enough placed behind the uterus, but a glance at it will show that
such clot never could possibly arise from an ovary, so that cither
Dr. Emmet is wrong in his notions of the pathology, or he has
altogether misunderstood M. Kelaton. On page 231 he gives a
diagram which is really the diagram intended by Niilaton, but in
which the blood-clot is peri-uteiine, and therefore the case in the
second instance comes under the definition and title which we
owe to Simpson.

Between the appearance of the first real essay on the subject
by Berautz in 1848, and the translation of his larger work in
1866, a great many contributions to the Hterature of this subject
were made, each of which advanced some peculiar theory on the
subject, and to aU of these there may be urged the objection that
they were too exclusive, and they did not in any instance, as it
appears to me, grasp the whole pith of the case. The word
" hasmatocele " is a convenient though not very accurate term,
and so long aa it is limited to the idea of an effusion of blood it
may be taken a^ the basis of our consideration. The moment,
however, sucli terms as liiie hajmatocele and falsf. hn^uiatocele
were introduced confusion reigned supreme. Bernutz held that
true hffimatocele consisted of an effiision of blood within the
peritoneal cavity, whilst Simpson argued that it could never be
an intra-peritoneal effiision. \Vhat I am inclined to advise, and
for reasons that will be given immediately, is that the phrase
" pelvic hjematocele " ought to be retained t-o cover all effusions
of blood which have their origin in the pelvis. Tliis I advise
because it would cover the vast majority of cases of effusion of
Mood into the peritonei cavity ; for if we exclude the results of
traumatic lesion, there are very few effusions of blood into the
peritoneal cavity which have not a pelvic origin — a fact which is
at once indicated by the extreme rarity of tlie occurrence in men.
With this simplification we can look over the great bulk of the

H,ffiMATOCELB.

27

literature on this subject with a certainty of aniving at more
logical conclusions than it' wo did not accept the limitation. Berautz
and all other writers agree in recognising the fact that any effusion
of blood must he regarded rather as a symptom than a disease of
itself, and tliia is true enougli if we are discussing merely the
etiology of the condition ; hut if we regard the condition in itself
as an entity we certainly cannot accept this as a limitation^ for
whatever the origin of the effusion may be the moment the
effusion is in existence it becomes in itself a disease, and some-
times an extremely severe one. But in the two great classes into
which I am about to divide hEematocele this is far more true about
the first class than it is about the second, and this is the first indica-
tion that we get of the differeucea which are found to exist between
the two classes. This difference is created «6 initio by differences
in the anatomical relations o£ the effusion.

In the pelvis — indeed we may take the whole abdomen and
say in the abdomen — an effusion of blood must be either within
the peritoneum or outside it. And let lis just speak for a moment
on what the primary, what the initial result is in any effusion of
blood under these two different circumstances. Let us take an
imaginary case of rupture of a blood vessel in the neighbourhood
of the kidney by reason of a blow or other injury. Effusion of
blood in that neighbourhood must of necessity be extra-peritoneal ;
it would travel through the cellular tissue, and by reason of the very
fact it had so to travel, provided there was no rupture of a vessel
into the pelvis of the kidney, the effusion would be limited, the
interstices of the cellular tissue would form the very best of all
known hfemostatics, and I find it difficult to imagine that an effusion
of blood — let ua c^l it a renal haematocele — in the neighbourhood
of the kidney could be so extensive as to be fatal, always supposing
it was not a main trunk which had been wounded. But on the
other hand, if we imagine from some cause or other a blood vessel
of the kidney bursting into the cavity of the perit^Dneum, there
would be no natural haamostatic to assist it in the an'est of the
luemorrhage ; the bleeding would go On indefinitely, and unless
some means could be secured to assist nature in arresting it, the
patient would almost with certainty die.

Let us now take another illustration. Suppose that a small
vein on the posterior peritoneal surface of the uterus were to
rupture and to bleed into the peritoneal cavity. There the blood
would of course naturally tend to coagulate, but not in the same
way as when extravasated into the connective tissue, All of ua
who have experience in abdominal surgery know that when blood
flows in quantity into the peritoneal cavity, probably by reason of
its dilution by the lymph always present there, and easily excited
into excessive flow by any abnormal condition, it does not show
much tendency to coagulate, save in a veryjfitful and fragmentary

28 -HEMATOCELE.

way. One of the most remarkable proofs of this is the influence
of the drainage-tube in aixesting hsemorrhage. If the cftvity is
kept dry by frequent withdrawal of blood and serum oozing from
torn pelvic adhesions, the bleeding will soon stop ; but if drainage
is not kept up the bleeding will probably prove fatal.

Supposing, on the other hand, Uiat a small vein should rupture
in the tissue and between the folds of the broad ligament, we siionld
again have exactly the same condition as I have imagined to occur
about the kidney ; in fact it would be still more marked, for in the
first place the cellular tissue through whicli the bleeding could
permeate is much more limited in quantity than it is in the
neighbourhood of the kidney. Again, we have a space between
the folds of the broad ligament wliich is not capable of rapid
distension to an indefinite extent. The broad ligament when
distended forma a limited cavity, and we shall then have two
processes by which the tendency to excessive hninorrhage is
arrested ; the first is the natural tendency on the part of the
interstices of the broad ligament to limit the bleeding; and
again the pressure of the broad ligament itself, as a membrane
distended and resisting further distension, exercises pressure upon
the bleeding point and becomes a powerful natural hiemostatio.

Those anatomical considerations alone, were tliey supported
by no other facts at all, would be enougli to persuade us into an
acceptance ot the diviaion, wliicli has often been described hut
never precisely laid down by writers of tliis subject, of pelvic
htematocele into the two classes of fxtra-peritmual and intra-
periionetxl, tlic former corrected and chocked by two powerful
agencies which are absent in the latter, whilst the liivmorrhnge
in intra-peritoneal hifniatocele is actually favoui-ed by the dilution
of the blood as it passes out of the bleeding ve,ssels. The confusion
which has arisen from a want of the recognition ot the two classes
of cases of intra- and extra-peiitoneal, may be seen by taking up
any text books on the subject, and turning to the allusions which
are made as to the frequency of the occurrence of ha'matocele or
to its differential diagnosis and still more to the treatment.
Thus, Dr. Emmet says : " If we limit the acceptation of the term
' hfematocele ' to an accumulation of blood passing into the
peritoneal cavity, the accident is comparatively a rare one ; but
if it is held to embrace all blood accumulations in the pelvis, the
occurrence is certainly a far more common one than the profession
at large have any conception." If wc accept the first sentence of
this passage as alluding to intra-peritoneal hfcmatocelo the
statement is relatively correct ; and if we accept the second sentence
as referring to extra-peritoneal hiematocele the statement is
absohitely exact ; but if we go a few more pages further on in
Dr. Emmet's book we find him attempting to make a differential
diagnosis between luematocele — of which he has given no precise

I

HEMATOCELE. 29

definition either for extra- or intra-peritoneal effuBion — and tubal
pregnancy, antl tlie confusion becomes positively amazing ; for it
will lie seen aa we proceed tliat for iiitra-peritoiieal ]ia;matocele
by far the most common cause is the tubal pregnancy for which
Dr. Emmet desires to find a differential diagnosis. This is what
lie says upon treatment : " Surgical interference has been advocated
by many in its practice, and been urged as the necesaiiry procedure
at an early sta^je. Unquestionably cases must occur when the
sui^eon would be wanting in sense of duty if he did not assume
the responsibility and puncture the mass. But with a large
majority of cases such interference would be criminal, as it
needlessly places the life of the patient in jeopardy." Here, again,
what Dr. Emmet says is absoultely true about extra-peritoneal
hiematocele, and it is absolutely untrue about intra-peritoneal
effusion. I only desire to say that I have taken up Dr. Emmet
as an example of this eonfusiou in EugHsh writings, not because
he is worse than others, but merely because his work liappeued
to be the first text book on gynaecology which caught my eye as
I started to write this leetm^e. If we accept the anatomical and
pliysical facts before alluded to as a basis, we shall find tliat it
is not a difficult matter to reconcile a very large number of
discordant facts and many discrepancies in the views of various
authorities ; in fact, the whole story of liasmatocele may be reduced
from confusion into order. We shall find also tliat the two
varieties of haematocele are diflercnt in their relative frequency,
in their causation, in their history, and of course particularly in
their relative fatality, difl'erent in their symptoms and the signs
by whicli they may be diagnosed, and, finally, in tlieir demand
for surgical interference.

Dr. Bernutz has expressed an opinion to whicli I have already
alluded " that the bloody tumour which is left aa the remains of a
hemorrhage has no riglit to be regarded as a specific disease apart
from what has caused it." This is true, I hold, of intra-peritoneal
hfematocele, but not of the extra-peritoneal variety. When
htemorrhage into the broad ligament occurs the an^est of the
hasmoiThage lias already been brought about, in the vast majority
of cases, by Nature's own methods, probably even before the
accident has tieen diagnosed, and therefore all we have to do with
is the thrombus, and in the great bulk of cases that may be and
generally is let alone. But cases do arise, as I shall tell you by-
and-bye, when it becomes a serious disease, for if the sac of the
broad ligament bursts into the peritoneal cavity the hiemostatic
pressure is relieved and bleeding goes on, the two forms of the
lesion co-exist and the patient bleeds to death. That such an
ending may occur and has actually occurred is known by a case I
shall quote as a result of this secondary rupture of the broad
ligament pregnancy cyst, the primary rupture having taken place

so H£MATOCELS.

at the ordinary period and the direction of rapture being into the
cavity of the broad ligament The secondary rupture takes place
into the cavity of the peritoneum and proves fatal. I have seen
no such case, but more than one is faithfully recoixled by Beniutz,
and such a case is reconled by Goupil, and is a perfect example of
wliat I can fully believe to be iwasible, though I have not seen it,
therefore I quote it at length.

S. , aged thirty-two, from a delay in menstruation thought

lierself pi-egnant and regardeil a metrorrhagia wliich occmreO, as an
abortion, though she liad seen no trace of an ovum. On admission,
tlie abdomen was distended, and veiy tender on pressure, and it
wa.9 resonant on percussion, The cervix was open and the uterus
was pushed somewhat to the left and forwards by an enormous
swelluig which was behind it. The posterior cul-de-aac was
occupied by a fluctuating tumour which was felt filling np the
pelvis entirely and the fluctuation was very distinct. The
diagnosis was (and I regard it as one of the most brilliant on
record) intra- and extra-peritoueal blood tumour, probably
accompanied by extra-uterine gestation. She gradually grew
worse and died ou the third day after admission. She died,
because in 1855 M. Konat, under whose care she waa, had not
been infected by the " restless spirit of snidery let loose " since
1878, which lias done so much to save cases such as this.

The post-mortem record of tliJs case, however, is a perfectly
peculiar record of facts. In tlie peritoneal cavity about twenty-
five ounces of black fluid blood and clot were found, constituting
the intra-peritoueal ha:matocele, the cause of the patient's death.
When tliat was removed an ovoid tumour was observed covered by
the peritoneum of the broad ligament. It seemed to be formed by
a mass of blood. This was the extra-peritoneal liiematocele. At
the bottom of the left recto-uterine cul-de-sac the peritoneum
forming tlie posterior layer of the bi-oad ligament presented a
perforation with a communication between the recto-vaginal
cul-de-sac and the cellular tissue separating the peritoneal layers
of the left broad ligament. Ou making an iuciaiou into the ovoid
tumour a small fcetus was discovered.

The importance oE this record cannot be over estimated, for it
proves, as I shall show afterwards how some cases of broad
ligament liiematocele arise. It shows tliat broad ligament
lufmatocele may occasionally be fatal by becoming intra-peritoneal
hteniatocele, and it shows us (this case has shown me) how tliirty-
eight out of forty of such cases may be saved from death.
Furtlier.it proves what is perhaps not very pertinent to the present
discussion, that tlie views I have advanced about the tubal origin
of all extra-nteriue pregnancies are correct. The only other case of
this kind familiar to me is one very imperfectly nan-ated by
Uuvemey, as having occurred in 1712. These two caaea are all the

HjEMATOCELE.

31

records I liave foiuul of the coincidence of intra- and exfcra-jieritoneal
li:cniatoceIe and the comhinatioa was due in both instances to
rupture of a broad ligament pregnancy with hiemori'hage into the
peritoneum. Both cases ended fatally by reason of the hiemoiThiige
into the peritoneum. I have seen dozens of cases of broad
ligament hannatocele and have never met with a fatal one. I have
seen nearly eighty cases of intra-peritoneal hiiematocele all
resulting in death save those (with two exceptions) in which
ahdominal section was performed ibr the purpose of obviating
death, so that we find a very wide difl'erenee in the results of the
two classes of cases in my experience. It will also be found that
when the real difference between the varieties is understood, it will
explain all the discrepancies in the views held hy various authors
and all the confusion will cease.

I propose to deal first of all with the extra-peritoneal
hrematocele and to give first in detail two cases which prove in every
way its character and relations, and which illustrate also two of
the exceptionnl instances in which it requires to be interfered with.

C. T., aged twenty-six was placed under my care in December
1883, by Dr. Faussett, of Tamworth on account of a large par-
ovarian tumour. I operated on January 3rd, 1884, and removed a
cystoma of the left ovaiy weighing fourteen pounds. There were
no adhesious, the pedicle was long and thin, and the operation was
aa easy as possible. A metrostaxis appeared about twenty-four
hours after the operation, as is usual after such operations, the
only peculiarity in this instance being that the loss was very
abundant. It suddenly ceased after being present for about
twelve hours and immediately the patient was in great pain. From
having seen the same accident under similar circumstances very
frequently, I knew at once what had happened. I examined and
found, as I suspected, a large htematocele of the left broad ligament.
The hiematocele increased slowly in size until a tumour could be
felt above the brim of the pelvis, and the patient suffered greatly,
I also found that the rectum was completely blocked as I had seen
it often before hy a stricture caused by the effused blood dissecting
round the rectiun outside the peritoneum. This is one of the signs
of broad ligament h.-ematocele which has not yet been noted hy
any writer with whose work I am acquainted, and it is of great
importance. It does not — indeed it cannot — occur in an intra-
peritoneal effusion. In the case of C, T., I tapped the hematocele
from the vagina and drew off a lai^e quantity of taiTy blood, hut
in fourteen or fifteen hours the sac had filled again, and the patient
had become exsanguine. I therefore re-opened the abdomen,
opened the distended cavity of the broad ligament, emptied out the
blood fluid and clots, sponged it out with vinegar and water,
fastened the edges in the aperture, to the edges of the parietal
wound, and placed in a drainage-tube. The patient then made a

32 H.EMA.TOCELE.

rapid recovery. I only wish to empliasise the fact that this secoad
operation made it absolutely certain tliat the eQ'usioa was in the
cavity of tlie broad ligament, and not iu the peritoneal cavity, for
the peritoneal covering of the blooti mass was perfectly free from
adtiesions, and ita entire relation could be made oat with the
greatest ease, quite as easy as if it had been a post-mortem instead
of an ante-mortem examination.

The second case was one in which a tubal pregnancy had
ruptured into the broad ligament, and the subsequent eS'usioa of
blood was so great that it caused complete obstniction of the
rectum by annular constriction. The dif^osis of broad ligament
iiEematocele was ea^y enough, but I did not diagnose its cause, for
the patient had never missed a period. She had been married
four years and had never been pregnant. Suddenly she experienced
violent pelvic pain whilst engaged in some social amusement and
the symptoms so rapidly advanced tliat tn about four hours she
was collapsed. I was called to her and found a laige ovoid well-
de&ued and quite firm tumour alwve the brim of tlie pelvis, the
roof quite fixed by an effusion which followed the arclungs of the
pelvic fascia and completely blocked the rectiun. It was so firm
that I decided not to tap it but to open the abdomeu, and it was
well I did so. Ne.\t morning I carried out my proijosal and
removed from the cavity of tlie broad ligament about two pounds
of blood-clot and a fcetus and placenta of about the ninth week.
I sponged out the cavity with vin^r and water, stitched the
opening in the broad ligament to the opening in the abdominal
wall, as in the operation for pelvic abscess, and the patient made
a rapid recovery.

This case proves that tubal pregnancies rupturing into the
broad ligament (c, in the scheme) may occasionally reqiure
interference at the time of primary rupture.

Speaking of a series of cases by Nonat, M. Beruutz saya very
quaintly that there should have been at least one neci-oiisy in
order to demonstrate the legitimacy of the different diagnoses —
that is, between what he calls true (intra-i>eritoueal) and spurious
(extra-jwritoneal) hEematocele. But these five cases recorded by
M. Nonat are precisely in point in the pi-esent discussion, for four
of them were diagnosed by that eminent gj'naecologist as being the
subjects of extra-periton^ effusion, and they all recovered, whilst
the patient in whom he diagnosed intra-peritoneal liieniatocele
died, and M. Bemutz was gratified by an accurate post-mortem
record. Nothing could prove more satisfactorily than this, what I
contend for, that it is tlie anatomical relations of the two kinds
of hajmorrhage which make all their difl'ereuces, and now we
examine them carefully before death, and by that very uxamination
prevent death by curing them, we get the tirat corroboration of all
that M. BernuU has said.

HEMATOCELE.

33

Of extra-peritoneal hfcmatocele there are only two causes
known to me, one very common, and one relatively rare, Tlia
first in amiden arrust of metrostaxis which may either be normal
menstruation or the pseudo menstruation which occurs so constantly
after abdominal operations. The first case I have just detailed is a
typical example of what occurs veiy often after any opei-ation on
the broad Ugameut, and to the inexperienced surgeon is a fertile
source o£ worry, The accident is always indicated by the sudden
access of pain, and often an alarming feeling of faintuess. The
pulse always rises and sometimes the temperature does so too. On
examination the uterus will he found to be fixed on one side,
sometimes on both, and tliis occurs with a suddenness that puts
inflammatory effusion out of the question altogether, In the
majority of cases the effusion is not extensive enough to be felt
above the brim of the pelvis, but in severe cases it is, and then it
forms a rounded and distinctly Hniited tumour, with a feeling of
distinct fluctuation. Tliis upward limitation of the tumour and
a distinct vaulting of the upper surface, the effusion of blood round
the rectum, and a i)ecuhar concave vaulting of tiie lower surface
of the mass, form the characteristic signs of extra-peritoneal
effusion of blood. The mass is, in fact, like an u-regularly shaped
jelly-fish, rounded above, concave below, and this shape is
uniformly regulated by the relations of the peritoneum and pelvic
fascia. The edges of the mass are felt to fade off downwards on
the walls of tlie pelvis, just as the groins of a Norman crj-pt fade
off on the brackets or capitals which support them. The effusion
of the intra-peritoneal hiematocele, contained in the rounded cavity
of the retro-uterine cul-de-sac, bulges into the vagina like a dilated
bag. I cannot form any exact estimate of how many cases of
these operative hranatoceles I have seen, but it certamly is not
less than fifty, and is more likely to be seventy or eighty, and I
have been induced to meddle only witli the one I have narrated.
In every case in which I have diagnosed the condition the patient
has recovered, and in the necropsies which Imvo been made upon
cases operated upon by me no record of the incident occurs, so
that I conclude it is an accident very nearly, if not quite, devoid
of mortality. Its only drawbrack is that it delays convalesence
for ten or fourteen days, and otherwise I believe it to be of no
account at all.

Extra-peritoneal effusion of blood is also very common apart
from cases of operation, but by reason of the same sudden arrest
of a metrostaxis. Its symptoms in such cases are very nmch what
I have described — sudden pain, a feeling of faintness in severe
cases, with a rise of pulse, and even of temperature. On
examination the utems is felt fixed and generally pushed forwards
with a boggy swelling behind or on one side of the uterus, and if
the effusion he large the muss is (elt distinctly limited by the

u

CAUSES OF HEMATOCELE,

disteuded broad ligament above the brim of the pelvis, this latter
conditioa being the essential dia^ostic difference Imtweeu the
two varieties of hematocele. An intra-peritoneal hiemorrhage
unlimited in quantity or by membrane has never yet been felt
by me as a defined tumour above the brim, and I have now had
a large experience of such cases in which the diagnosis was
confirmed by operation or post-mortem examination.

Cases of effusion of blood into the broad ligament by sudden
arrest, or at least associated with sudden arrest of menstruation,
are, as I have said, very common, and I am sure that large
numbers of these occur without the patieute tliinking it worth
while to ask for medical assistance, and they get quite well
without it, It is, as I have said, a condition probably almost free
from primary mortality, and has only a remote secondary mortality
when one thrambua breaks down and suppurates, and brings about
the tedious condition of pelvic abscess.

Effusion of blood into the broad ligament also occurs from
another cause, much more rare and probably much more fatal,
certainly much more serious — I mean rupture of a tubal pregnancy
about the twelfth week of its existence into the cavity of the
broad ligament. It is now pretty well admitted that the scheme
of the pathology of extra-uterine pregnancy which I have just given
in detail covers and explains all the facts of that curious condition,
and now it is capable of being used to help us to understand
pelvic luematocele. Briefly, to recapitulate what I have said at
length elsewhere, this view is that impregnation under normal
conditions can and does occur only in the uterus. So loi^ as the
ciliated epithehum is in action in the tubes, spermatozoa cannot
enter them, and the ovules cannot adhere to their walls. But the
moment an ovule reaches the cleansed and fresh endometrium
infiltrated with spermatozoa, its adhesion occurs. Destruction of
the ciliated epithelium of the tubes by desquamative salpingitis, or
otherwise, reduces the internal tubal surface to the condition of
that of the endometrium, and then entrance of the spermatozoa,
impregnation and adliesion of tlie ovum are possible, and we have
the occurrence of tubal pregnancy. Tlie tube is lUstended by the
growing ovum, and as it is not capable of indefinite disteusioiis it
ruptures, and the seat of rupture seems to be determined by the
site of the placenta where the sinuses have so cliannelled the walls
as to weaken them greatly. A glance at a section of a Fallopian
tube win show (see p. 5) that tliere are two areas in that section
which will severally give very different results, as one or other of
them is the site of the rupture. One is much the smaller of the
two, and is situated between the layers of the broad ligament,
forming, as it were, an ideal raof to the cavity of that space.
Rupture here of course means that hasmorrhage occurs into the
cavity of the broad ligament, and that an extra-peritoneal

EXTBA-PERITONEAL HEMATOCELE,

35

IiajDjatocele results. Such a case may, as I have already proved
from Bernutz, become fatal in its later course by a further
aud second rupture of the broad ligament cyst and htemorrhage
into the peritoneal cavity. But I feel sure that the great majority
of these cases end then aud there by the natural cure as mere
extra-peritoneal hffimatoceles ; the ovum dies and everything is
absorbed (e in my tabulated scheme). I am quite sure that I
have watched several cases of this kind. In the minority of cases
the ovum is not tilled but developes into a broad ligament
pregnancy (d in my tabulated scheme), formerly known as the
"sous-peritoueo-pelvienne" variety of Dezeimeria. I have had
seven cases of tliis kind which I have operated upon, saving five
of the mothers and three of the children. Everyone of the cases
of extra-uterine pr^naney operated upon at or after the full time
with which I am familiar, comes easily within this explanation,
aud it makes quite simple what is an otherwise wholly unin-
telligible jumble iu physiology as well as pathology. These cases may
die at any point of their subsequent progress up to the full time,
and then either remain quiescent as lithopedia (i; in the scheme),
or may suppurate and be discharged in various directions (k in
scheme). The conclusions therefore are that, save under three seta
of circumstances, extra-peritoneal hematocele is an accident per-
fectly free from danger. These are fa) when a secondary rupture of
the cyst occurs with continued bleeding into the peritoneum ;
(b) when it is merely a stage in the growth of extra-uterine
pregnancy ; (c) when it goes on to suppuration, a condition I
shall refer to in its proper place.

I do not think that suppuration of a broad ligament hiematocele
is very common, and yet I have met with quite a lai^ number of
cases. Of course by the ordinary methods of proceeding, and those
which certainly ought to be adopted in the milder cases, it would
be very difficult indeed if not impossible to make anything like an
exact differential diagnosis between a suppurating hffimatoeele of
the broad ligament and several other conditions which I need not
specifically allude to, and therefore any assertions concerning them,
after dealing with them as they used to be, and as I say they ought
to be dealt with in the majority of instances, by tapping from the
vagina may easily be met by the criticism adopted by M. Bernutz
against M. Konat, that at least one necropsy ought to be in
existence to prove the assertions. I have, however, already pointed
out that an abdominal section performed before death is, for such a
purpose as this, quite as satisfactory as a post-mortem examination,
Iu the sixty-third volume of the "Transactions of the Royal
Medical and Chirui^ical Society " I published a series of six cases
in which I had adopted, for reasons of extreme seriousness, an
abdominal section for deahng with pelvic abscesses which otherwise
would have opened out in the usual disastrous ways. I say there

36

STJPPUBATIKG H.BMATOCELE.

that " these six cases have all been, ao far as I can discover, cases
of suppuration occuiTing in pelvic hiematocelos," and I may at
once dismiss this question bj saying briefly that this depended
upon the fact that in clearing out the cavity of the abscesses I ,
removed a considerable quantity of laminated, broken down, old
clot. All these cases were uudoubtedly extra-peritoneal
hEematoceles. i

Of these cases I select only one as a characteristic example, to
illustrate alike their pathology and treatment ; and the history of
the case is eminenty suggestive that it had its origin in a broad
ligament pregnancy.

The patient was sent to me by Dr. Flynn, of Eirchills, now of
Kingstown, Dublin. She was forty-five years of age, and had
never been pregnant save one doubtful miscarriage soon after
marriage nineteen years before. Symptoms resembling those of
hiematocele had occun'ed eight mouths before (after an aiTest of
menstruation for three months) 1 saw her and since that time she
bad been loaiug flesh, had lost lier appetite, was troubled by
constant tliirst and night sweats, and had a rising night
temperature. The uterus was fixed iu a mass of effusion occupying
the left broad ligament and partly the right one also, and the mass
on the left side encircled the rectum forming a pronounced
stricture of the rectum as hicmatocelea of the left broad ligament
frequently cause. No point of fluctuation could be felt in tlie
pelvis but the symptoms pointed clearly to the presence of pus.
I therefore determined to open the abdomen and readily obtained
the consent of ray colleague to this proceeding. A large abscess
was opened just behind the base of tlie bladder, between which
and the uterus it principally lay, but stretcliing round beliind the
rectum. The floor and posterior wall of the abscess were found to
consist of old laminated blooil clot, so that its origin had been in a
blood effusion into the broad hgament. A glass drainage-tube was
inserted and this was changed for one of Chassaignac's wire tubes
on the eleventh day after operation. She sat up on the twenty-flrst
day and the tube was fiually removed on the twenty-sixth. She
went home on the thirtietJi day perfectly well and has remained so
ever since, now nearly eight years.

About thirty of such cases have been operated on by me and
have all recovered. I say about thirty because I could not be sure
that all those cases of pelvic abscess originated in sujipurating
hfematocele, and I can form no estimate of how mauy of these
were originally cases of tnbal pregnancies bursting into the broad
ligament and then suppurating, but I suspect that more than half
of them were.

Therefore, I conclude that extra-peritoneal hematocele arising
from tubal pregnancy though rarely fatal, has serious consequences
in a fairly large proportion of cases. How diflerent it is with intra-

fNTKA-PERlTONEAL H.*:MATOCELB. 37

peritoneal hfematocele from the same cause, I have already
sufflciuntly indicated. My first experience of this condition waa
one of the saddest things I have ever known, a young married lady
one of the most charming and brilliant of women, the daughter of
an author known wherever the English language is spoken, the
wife of one of tlie most brilliant of surgeons, died after a short
illness, and after a post-mortem examination, a ruptured tubal
pregnancy was found to bo the cause of an enormous intra-
peritoneal liicmatocele. Another case of immense importance in
my own experience, and I venture to think of atill greater
impoiiance in the history of surgery, I have already giveu because
from that point we have beeu able to fulfil tlie indications so
urgently presented by the quotations I have made from
Jolin I'arry.

During the twenty yciu^ which elapsed between the case I am
speaking of, and the flrat of my sui'gical ante-mortem experiences
of these dreadful accidents, I had seen at least twenty-three
cases of a similar kind, and therefore I can entirely confirm
what M. Goupil says of these cases to this effect — " So frequent
is tho oceun'ence of intra-pelvic" (by this he means the
true or intra-pei'itoneal) "hematocele that I have made an
analysis of forty-two of my cases, which are iiTefutablo as
to their diagnosis." Ke gives us the causes of these
eases. 1. Hsemorrhage caused by the mpture of dilated utero-
ovarian veins. 2. HajmoiThage from rupture of the ovary,

3. Hffimorrliage caused by rupture of the Fallopian tube.

4. Hiemorrhage from the fcetal cyst itself having ruptured ; and
he says, "The largest number of cases fall under the last head" —

5. HtemoiThage within the fcetal cyst. Probably, now, M. Goupil
would group the last three causes under oue head — at least I
certainly should. At anotlier place he says that ruptured tubal
pregnancies are very common; for according to Nonat, Baudelocque
saw live examples in three months, and I know that anyone who
makes a research in our serial literature will find them iu
abundance. Tlie final argument as to their not being so rare, as
our text books seem to assert, is the fact that between Jauuaiy,
1883, and July, 1888, I operated upon thirty-nine cases, and
succeeded in saving thirty-seven of them — a very striking contrast
to tlie old plan of letting them alone to die. I have never seen
a case of suspected rupture, or one iu which we susoected
intra-peritoneal effusion of blood, recover if left alone.

As to the causes of intra-pevitoneal hiemorrhage, I have been
able to speak only of two from personal experience — the first, and
by far the most common, being ruptured tubal pregnancy. The
second is hiemorrhage from some torn adliesions or badly-tied vessel
ater an abdominal section. Thus, I tietl the pedicle of oue ovarian
tiunour with catgut, and the patient died on the fourth day after the

38

INTRA-PERITONEAL HEMATOCELE.

operation. I found a lai^o iutrn-peritoneal hiEmatocele due to
the digestion and loosening of the hgatiire. In searching the
literatui'e of tins question I have found one case due to the
rupture of an aneurism of the coeliac axia, and a large
nuniher of cases having a traumatic origin chiefly fi-om rupture of
the liver. Beruutz and Goutul have collected a few instances
due to rupture of dilated uterine and ovarian veins not connected
with pregnancy ; also two cases of rupture of the ovary iu
pi'eguaucy. But everywhere the evidence is overwhelming that
tlie most fertile source of tliis most fatal accident is rupture of a
Fallopian tuhe dilated hy a fertilised ovum. In very niaTiy of
these eases a feature of great interest is tlie fact tliat the first
attack of hromorrhago is generally not fatal, and that the records
yield incontestihle evidence that it may require the repeated
occurrence of bleeding to bring about the fatal issue. In some of
these attacks liremorrhage seems to have been separated by long
intervals. Thus, one case recorded aa having occurred in the
Maison d' Accouchement in 1816, where the liistory makes it
evident that tlie tubal rupture occurred at the usual time, in the
third month ; tlie fatal liKuiorrhago did not occur till the sixth
month of extra-uterine gestation. In this case the f(Ptus was
found, so that there could be no doubt aa to the nature of
the case.

But in some of the instances recorded by Bernutz and Goupil
themselves — and I prefer their facts to all othei-s, being as they
are so carefully sifted and so free from any effort to theorise — it
seems to me that the history was that of tubal rupture, repeated
hajmorrhage, absorption of the gelatinous fiiitus, and final death
from hiemorrhage ; so that when the post-mortem was made, tlie
absence of a fietus, which the authors note, blinded them to the
real nature of the case. That the fcetus may disappear by
absorption is made certain by my own experience. I have removed
it only twelve times in my forty cases, though I have found
the placenta in every one. Thus, case thirty-two in the work
of Bernutz and Goupil is an instance of fatal intra-peritoneal
haamatocele due to a ruptured Fallopian tube wMcli was distended
by a tumour to the size of a pigeon's egg. I have no doubt that
a microscopic examination of the tumour would have shown it to
have been a placenta. I think that this explanation applied to
many of the carefully recorded cases of tliese distinguished French
authors, in which the details given would incline us to characterise
them as being indentical with that which was the subject of the
recent lamentable trial at Liverpool. There are half-a-dozen cases
in Bernutz's book which are identical with that case, except that
they wore all fatal, whereas the Liverpool case was successful, the
patient having been saved from death by surgical plnck and skill.
That woman's peritoneum was occupied by a quantity of blood-clot

INTRA-PERITONEAL H.5^rATO0KLE. 39

and blood serum so great that it could be recognised by palpation
before the operation. One of the Fallopian tubea was the source
of haimorrhage because it had a t[uautity of blood and blood-clot
in it when removed. Here is a case almost identical taken from
the Laiicet of 1848. " A woman aged twenty-eight was suffering
from rheumatism when she was suddenly eeized with nausea,
vomiting, and pain in the right side of the abdomen ; her face
became anxious and pallid, the pulse imperceptible, tlie extremities
cold, and the respiration oppressed, in short, collapse was complete
and she died in twenty-four hours, evidently from internal
liHjmoiThage. On opening the abdomen a quantity of blood was
seen but no rupture of any of the viscera could be detected. In
the pelvis a clot was found in the left Fallopian tube, On
sepai-ating the uterus, its cavity was filled with muco sanguineous
fluid and lined with a decidual membrane. The left tube contained
a clot of blood the size of an almond. About an inch from the
uterus at the upper part of this tumour was a rent, and witldn was
a small sac so compressed and deformed by the clot that it was
impossible to say whether or not it was an ovima. The left ovary
waa the size of an apple, filled with blood and ruptured."

Another case on the authority of Dr. Tilt is given by Eernutz
at page 196, "A multipara, aged thirty-seven, was seized with
lumbar pain, the menses were four days late, the left byjxigastric
region became tender, and some tympanites and vomiting followed.
She succumbed in ten days. On post-mortem examination there
was general peritonitis, a large clot of blood iilled the left iliac
fossa and pelvic cavity, the uterus was normal in size, and the
appendages on the right side healthy ; the left half of the uterus
and its appendages were lai^er and more distended than the right ;
the Fallopian tube midway the size of a nut ; a probe introduced
at the fimbriated extremity passed into a cavity ui the centre of the
clot, which dilated that portion of the tube." Another on page 197
is to the same effect—" On post-mortem examination all the
abdominal organs were observed to be quite healthy, but very
bloodless. In the pelvis a large quantity of blood waa discovered,
clotty and fluid. After careful examination of the principal blood-
vessels, arterial and venous, without discovering anything abnormal
the uterus was examuied, together with its appendages and the
source of the hiemorrbj^je waa soon apparent, a small rupture of
the right Fallopian tube being discovered at about half an inch
from its distal extremity; blood was oozing from it, and it waa
evident that this waa the seat of the bleeding. The tube itself was
also a good deal enlarged."

Dr, Goodall also gives a fatal case where death occuiTed from
about eight pounds of blood being lost from the Fallopian tube,
though there was no evidence of a tubal pregnancy.

Case 2 given by Beruutz (page 208) is extremely instructive.

40

e it is a fatal case of Iiiemorriiage from the Fallopian tube in
a youug woman, aged twenty-two, due apparently to lueaales.
" On ]iost-morteni examination liitmorrliajje was found to have
proceetled from the left Fallopian tube, which was distended to the
aize of the index finger, and contained about two ounces of blood,
partly fluid, partly coagulated, and through the abdominal orifice
as much as sixteen ounces of blood had escaped into the pelvis.
These samples of hiematocele occui-ring in rubeola, scarlatina and
variola, demonstrate that this accident may occur in any severe
fever."

Finally, I wish to refer to a case originally contributed to the
London and Edinhiirgli Monthly Journal tot 1841, because it
establishes beyond all doubt, that fatal bajmorrbage can occur
from the Fallopian tube into the peritoneum, under circumstances
where the occuiTcnce of rupture of the tube by an ovum is out
of the question. An illuatratiou of the tube is given. " A lame
quantity of blood was effused into the abdonieu and pelvis, mostly
coagulated but partly fluid. At first it was impossible to say
wheuee all this blood came, but on examining the pelvic viscera
solid coagula were observed protrading from the oi)en orifices of the
Fallopian tubes. The tubes themselves were filled with blood and
distended at a shoit distance from the uterus up to the distal
extremity. The condition of the parts is very well shown in the
Bccompanj'ing sketch, which represents the serious state of one of
the tubes and the appearance of the clot attached ; the latter has a
sort of lobulated appearance produced by the constrictions exerted
upon it in its passage along the tube. The other tube was the
same. The greater part of the blood found in the pelvis escaped
from the tubes no doubt in a fiuid state, but that which was
attached to the tubes was coagulated before it left the canal, as is
evident from its shape."

Concerning the prognosis of such cases Goupil says: "It is
but too true, I fear that we are authorised in saying, that all the
cases of intra-peritoneal heicmorrhage ai'ising from extra-uterine
pregnancy, end in death — in fact all the cases that I have quoted
have terminated in death ; generally it has taken place in a few
hours or days, and though death has been delayed for six months
(as in the case already quoted) it is wholly exceptional." This waa
absolutely true in my own experience till I was emboldened — shall
I say till I was shamed by Mr. Hallwrights case, into opening the
abdomeu and saving their lives.

We come to the following conclusions : That in the great
majority of cases of extra-peritoneal biumatocele, even when due to
ectopic pregnancy, the disease may generally be loft alone, being
rarely fatal, and that it is to be interfered with only when
suppuration or extreme haemon-hage has occurred. That, on
the contrary, intra-peritoneal hematocele is fatal with sucii

almost uniforni certainty that so soon as it is suspected
the abdomen must be opened and tlie hicmorrhiige an-ested.
In the overwhelming majority of cases the source of the
hiematocele will be found in the broad ligament, and then it can
be dealt with, and with every prospect o£ success. If any one
objects to this I appeal again to the canon of surgery which is of
uniform application : For surgical hEemorrhage cut down and tie the
bleeding point ; if a big branch of the femoral artery were bleeding
my colleagues who deed in such cases would cut down and tie it.
Why should Poupart's ligament be a line of demarcation within
which this surgical writ will not run ? Why should my friend
Mr. Bryant be allowed to do to the external iliac artery what I am
prohibited from doing to the internal iliac division ? Indeed, at
page 202 of Bemutz and Goupil's work they assert this principle :
" The indication in such a case is plain — we must stop the
hfemorrhage."

A very admirable contribution has recently appeared from the
pen of Professor Charles A, L, Read, of Cincinnati, which has so
completely corroborated what I had already published on tho
matter that I venture to make some abstractions from liis writings.

" It is stated by Mr. Lawson Tait ('), in the " Ingleby Lecture
for 1886, that Bemutz {"), in 1848, was the first to recognise the
causal relationship existing between tubal pregnancy aud
hEematocele, and to indicate the proper line of treatment, viz,,
laparotomy and ligature. I am disposed to accept this claim for
Bemutz, eo far as it relates to a suggestion of treatment ; but I
must insist that all the e^ential conditions of intra-abdominal
accumulations of blood fi'om ruptured tubal pregnancy were
recognised and described (^) by one of Mr. Tail's own countrymen.
Dr. John Burns, of Glasgow, as early as 1814. It is true, Bums
does not use the word "hematocele," which was coined by Nt;laton
a quarter of a century later, and is such a positive misnomer that
it had better never have been coined at aU.

" Burns, however, said that ' the sac might burst and the
patient die from hjemorrhage.' He clearly described the
subsequent changes when he said that ' irritation is produced,
inflammatory symptoms supervene, and hectic takes place.' He
still further indicated his insight into tlieae cases when he said of
them that ' the most frequent termination is that by inflammation
ending in abscess.' And I know no better way to round out a
description of what is now known as hiematocele than by
employing Bums' observation tliat tho suppurating contents of a
bu^ tubal pregnancy ' might be enclosed in a kind of cyst of

(') LitHCit. OctobiT SOtli, ISSrt.
(=) BomuU and Goiipil; "iJiaciuoii of Wore
ocislr, ISSS.
<>) "Filaa[plMatlliairLfbrT,"l;Jabsl]uiua, edited b;

I, Vol I., s. Its, riilUdeljjlOik,

42

OPERAXrVE INTERFEKENCE.

lymph." Elundell ('), writing in 1S30, recognised tlie same
condition, and said that he did not doubt that ' many women die
in tliia way, bnt, being buried without examination, the real cause
of their death is never ascertained.' He even went so far as to
mention the expediency of abdomiual incision for the control of
the haimorrhage, but doubtless under the pressure of the inediajval
conservatism of Guy's Hospital — a conservatism which still exists
in that institution — he abandoned the idea, lenving it to be again
suggested by Eemutz thirty years later, and finally to be realised
by Mr, Lawson Tait after the lopse of a half-dozeu decades.
Between Blundell and Tait, numerous writers touched upon both
topics, but relatively few of them recognised that tubal pregnancy
caused intra-peritoueal hnBmatocele. As soon as Nelaton, and,
subsequently, Eernutz and Goupil, began to write upon
lifBmatocele, the profession appeared to drift away from the definite
etiology and pathology so clearly outlined by John Burns, until
latter-day authors attribute the condition tu almost every otlter
than what I believe to be the one most fmitful cause."

" It is fortunate, however, tliat the other side of this important
pathological question has not been entirely neglected. From the
time Blundell, in 1830, and Bernutz, in 1848, guessed at the
nature of these cases and suggested the expediency of abdominal
section for the control of the progressive hiemorrhage, there was no
one to put the suggestion into practice until Mr. Lawson Tait (^),
in 1883, did the operation. It was the beginning of a new era in
the inteUigent understanding and management of these hitherto
intractable coses. Prior to that time the mortality was almost
one hundred per cent.; since that time I have heard of no one
losing a case subjected to Mr. Tait's line of treatment, except in
one instance, and that was a case in Mr. Tait's own hands. The
pathology upon wliicli the treatment was based, and which has
been confirmed by the revelations of the treatment itself, has,
however, been more generally accepted tlian has the practice.
Schroeder ('), J. Veit ('), and Kliwisch (°) are among the leading
Germans who agreed with Fritsch ("), that 'tlie most frequent
source of the hsemon-hage is the ruptured ovisacs of a tubal or
other extra-uterine pregnancy.' Among gynaec 1 t T t
Imlach, Berry Hart, Thomas, and Emmet are am tl m t
conspicuous who concur in the doctrine, while an n tl
obstetricians, Lusk, I'arvin, Barnes, Galabin, and PI yf m y le
mentioned; indeed, it appears that among those 1 tl

closest students of this question there is practical u n m ty tl at

p. m. Wasiilngbill, 1S34
ifunn nf OvarTiui.'' n tlAA.

"DiB. of Womou."

OPERATIVE INTEKFEREHCB.

43

tubal pregnancy is tbe most common cause of intrft-peritoneal
liiematocele, but, as I have inlmated, there ia less imammity on
the subject of treatment. Why there should be vai'iance on this
qaestion, when there ia practical agreement on the more primary
and fundamental one, is not apparent, unless we shall find that
different constructions are placed upon those pathological changes
which take place subsequent to extravasation. To my mmd
those changes were described witli great fidelity to truth, if not to
details, by John Burns, already quoted.

" With tliis pathology as the guide, the duty of the surgeon
with r^ard to treatment ia, to my mind, obvious. It is merely
an application of that general law of surgery which, aa formulated
by Tait and applied to these cases, is aa ibllows : ' For surgical
hfemoiThage, cut down aud tie the bleeding-point ; if a big branch
of the femoral artery were bleeding, my colleagues who deal with
such cases would cut down and tie it. Why should Poupart'a
ligament be a line of demarcation within which this writ will not
run ? ' Bernutz and Goupil (') say : ' The indication in such cases
is plain — we must stop the hiemorrhage.' No peraon, I fancy, who
properly realises the situation in the cases will deny the propriety
of the proposition ; but it occurs to me that there are other
indications than hiemorrhage for surgical interference — the
damnged tube, the fcetal atructurea, and the placenta tissue demand
attention. Of the latter two it may be said tliat, even though
they Leconie incapsulated and partially absorbed and the residue
remain inocuous, they cannot be considered in a surgical sense
otlier than as foreign bodies, and, as such, constant menaces to the
health and life of tbe patient. The tube of necessity becomes
destroyed as an oviduct, and, if left intact, it will only be to figure
at a later period as a hEemato-salpinx or a pyo-salpinx, and
consequently to demand extirpation."

Dr. Bead concludes this paper with the following summary :
(1) Intra-peritoneal hfematocele is an intra-peritoneal accumulation
of blood. (2) Kuptured tubal pregnancy, the moat common form
of extra-uterine fcctation, gives rise to an accumulation of blood
within the peritoneum. (3) In consequence of the fluid condition
of the extravaaated blood and of the yielding character of the
adjacent tisanes, the hsemorrhage has a tendency to continue.
(4) In consequence of the death of the fcetus, there is a developed
a marked tendency to suppuration. (5) In consequence of
becoming a foreign body, the product of conception, even though
it become encysted, ia a constant source of danger. (6) The
damaged tube, if left in situ, can aei-ve no other than a pathological
pui-pose. (7) Abdominal section is therefore called for (a) to
control progressive hfiemorrhage, (J>) to remove dangerous dJbris,

44 OREBATIYE INTEKFEBENCE.

(c) to extirpate wortliless appendages, and (d) to overcome septic
conditions.

I have now to conclude this important branch of my subject
by submitting a list of the cases, properly authenticated, as the
custom now is, in which I have performed this operation up to
time of writing. The number is thirty-nine,* and I need hardly
say that this number includes every case of the kind I have done.
There have been only two deaths. The first was due to my want
of appreciation of the proper principle of the operation, and the
second was due to the fact that the patient was practically in
articfido mortis when I operated, interference having been too
long delayed. The results on this list show a very different
possibility of prognosis in this dreadful disaster when promptly
treated on sound surgical principles, from that so hopelessly
pronounced by Dr. Parry when they are left alone : " From a
careful examination of this subject it must be acknowledged that
a happy termination of the rupture of the cyst is exceedingly
rare." " Of 149 cases in which the ovum was located in that
portion of the tube which does not traverse tlie tissues of the
uterus, 145 died."

* The ftill number is forty, including the extra-peritoneal case given on p. 82.

COMPLETE LIST OF CASES.

Ho.

Resilience.

M«Ii«a Attendant

A&.

Date.

«.

».

1

Wolverhampton
Sohhull

Dr. Spackraan

Dr Piige

41
40
37
27
34
28
31
30
35
41
30
37
25
34
42
31
26
28
42
37
24
35
32
34
44
31
29
29
30
44
29
37
37
37
41
30
38
27
27
26
27
35

17, 1, 1883
3, III., 1883

10, IV., 18B4
21, v., IB84

6, VL, 1884
23, VII., 1884

29, X., 1884
23, XL, 1884

9, XII., 1884
9, II., 1885
2, IV., 1885
B, v., 1885

11, v., 1885
2, VII., 1885

11, VIL, 1885
2, IX., 1885
6, IX., 1885
19, IX., 1885
23, X., 1885
31, X., 1885

2, IL, 1886

3, TIL, 1886

16, VIL, 1886
27, IX., 1886

26, L, 1887

18, II., 1887

17, IL, 1887

27, IV., 1887

6, v., 1887

19, IX., 1887

20, IX., 1887

30, IX., 1887
16, XL, 1887
16, Xn., 1887

7, L, 1888
IC, IL, 1888

11, v., 1888

12, VL, 1888
9, Vn., 1888

28,VIIL, 1888
29,VIIL, 1888
25, IX., 1688

a

R.

B.
R.

n.

R.
R.

B.
R.
H.
B.

R.
R.
R.

E.
B.
R.
B.
B.
B.
B.
B.

B.
R.
».
B.

B.

R.
R.
H.

D.

3
4
5

r.

Birmingham

Birniiugbam

Birmingham

Walsall

Di-- Taylor

Dr. Wilson

Dr. Leech

Dr. G. Sharpe....

7

Smethwick

Birmingham

Birminj;httm....
Wolverhampton

Birmingham

Birmingham

Birmingham

Birmingham

Birmingham

Wolverhampton

Manchester

Birmingham

Birmingham ....

8

Mr. Farncomhe ...

u
1"

Dr. A. E. Clarke
L T. .

13
14
IB

Dr. Whitcombe...

Dr. AVhitley

L. T

17
1f^

Dr. Walter

K T

Dr. Davidson.,..

■19

Oldbury

Dr. Ciiniiingham
Dr. Wilson

23

Birmingham

2S

Birmingham

Birmingham

Halifax

Dr. A. K Clarke

Dr. Dolan

Dr. ProBser

Dr. Gordon

Dr. Lafarelle

Dr. Wilson

Dr. WiUiams

30
31
32

Birmingham....

Birmingham

Wrexham

Nottingham ....

Birmingham

Birmingham....

Birmingham

Kidderminster..
Derby

35

Dr. Harraar

Dr. Yokes

37

in

Dr. JotLam

Dr. Carter Wigg
Dr. Slade King...

39

to*

nfracombe

Birmingham..,.

Biirainghara

Birmingham....

i}*

42*

Dr. Hallwright...

The patienlfi were all married women,

* Cisiig wblch hnvu Dccarred since Uiuu Lectures i

46

EURTUItED TUBAL PEEGNANCV.

Two of these cases require further details for special reasons,
the first (number 13), as strangely enough she fell a victim to a
second calamity of the same kind, and the whole of her history is
as follows : —

On May 10th, 1885, Mrs. E. li,, aged 25, -was sent to me by
Mr. W. P. Whitcombe, Victoria lioad, Aston, suffering from ui^geiit
abdominal symptoms. The history was to the effect that she had
been ailing from a short time before Christmas, She thought it
was pregnancy. Menstruation had been suspended for three
months. In April she had a period, and again early in May, and
ftt the latter time she complained of violent pains in the lower
abdomen, and on the 9th she had an attack of fainting with
vomiting, the pain being refeiTed to the lower abdomen. AVhen I
saw her she looked extremely ill aud antemic. A lai^e ill-defined
mass existed on tlie right side of the uterus intimately associated
with tlie organ, and tlie roof of tlie pelvis was fixed. There was
no dilflculty in diagnosing the case to be one of ruptured tulwil
pregnancy. I opened the abdomen on the 11th, and found the
belly full of blood-clots and bloody serum. I removed the right
Fallopian tube, which was occupied by a pregnancy of about the
third month, and in its walls a large rent had occurred, through
which the fcetua and placenta were partly protruding. Some points
of bleeding from the intestine required touching with pereUoride
of iron, I inserted a drain^e-tube, and the patient made an easy
and I'apid I'ecovery. The case is puhHshed in a short paper on
Euptm'ed Tubal Pregnancy, in the British Medical Journal of
December 19th, 1885.

About eighteen months after this operation, she was confined of
a child, at the full tenn, being attended by a midwife, and there
was nothing remarkable about the labour.

About fifteen months after this confinement she again became
pregnant, and her husband states that during the period of this
pregnancy (which she thought had turned four months), she had
no symptoms of note, but only complained at intei'vals of shght
pain in the abdomen, but not sufficiently severe to induce her to
call in medical assistance. The only point on wliich he lays any
stress was that she stated that she felt the child very plainly, more
ao it seemed to her, tliaa at the same period in any previous
pr^nancy.

Mr. Whitcombe was sent for to see her in the forenoon of March
9th, but he being from home, the patient was seen by his assistant
sliortly before 1 o'clock on that day. Slie was lying fully dressed
on the bed, her knees drawn up, and was complaining of great
pain in the hypogastrium. She was extremely pale and almost
pulseless, and had had some vomiting. Mr. Hall was informed
that only half an hour before she had been cleaning her fireplace,
and, in the act of stooping, was seized with acute pain and a

INTERSTITIAL PEEGtfAKCY.

47

I

feeling of faiiitness. Stinuilauts were at once ndministered, and
every effort made to restore her without avail, and the patient died
shortly after 5 o'clock, clearly from internal hfemoiThage.

Mr. Whitcomhe made a j'ost-inerievi examination, and has heen
kind enough to give me the following particulars : He found tlie
abdomen full of hlood-clota and fluid blood ; a lai^e clot was
adherent to a portion of the placenta which protruded from the
uterine wall, and when this clot was separated it had a quantity
of villous placental tissue adhei-ent to it. AU the organs were
very auiemic, and there could he no doubt that the licemorrhage
was the cause of death. Mr. Whitcombe was good enough to
bring me the preparation, and aided by my assistant, Mr.
Teicbelmann, I am enabled to give the following report and
drawing of the appeai^ances presented.

There can be no doubt that the specimeu represents an
interstitial tubal pregnancy of the left side. The cavity in which
the foetus is situated' is separated from tlie true uterine cavity by a
sti-ong septum of uterine tisane springing from each aide of the
uterine walls. The under surface of the septum and the rest of
the uterine cavity is lined by hypertrophied mucous membrane
(decidua) (b). The stump of the right Tallopian tube (c) is
attached to what appears to he the lower angle of the uterus,
hut which is i-eally the much displaced upper angle. This
displacement, liowever, is only apparent, and aiisea from enormous
development of the left cornu of the uterus. A fine probe may be
passed from the true uterine cavity into this stump. The left

48

INTEESTITUL TUBAL PREGNANCY.

Fallopian tube, (A) on tlie contrary, communicates with the
cavity in which the fcetiis and placenta lie, and the rupture has
taken place in the upper and back part of the left uterine cornu.
In this case we have the almost incredibly strange instance of a
woman suffering from tubal pregnancy twice, with the still stranger
fact of her having a normal pregnancy between the two occurences.

Fio 8.— DlAeTiminallc lepnaeDlAtlaD ol inUTStilkl tuhnl pirgnanc; at time of i

From the first of her disastera she was saved by prompt surgical
inteference, and she might even have been saved the second time,
but there can be no doubt that the poor woman's doom was sealed
before medical assistance reached her, and there was no time then
to effect the interference which was necessary. All the appearances
of the preparation point to the fact that the woman's esthnate of
the period of her pregnancy was correct, and we have therefore an
indication that the interstitial form of pregnancy does, as we might
have expected it would, take a longer time to arrive at the period
of piimary rupture than do those cases in which the pregnancy
occupies tlie free part of the tube. In these latter we have no
evidence as yet of any instance going beyond the twelfth or
thu-teenth week before primary nipture. It may be noticed here
I am introducing a new phrase in using " primary rapture." I do
so because I am becoming convinced that unless we make such a
distinction as I have indicated we shall still continue some of
the elements of confusion which exist about this interesting
displacement.

It is perfectly clear that in all cases of tubal pregnancy, when
the ovum is growing, the tube must burst, and that it bursts in

PKIMARY AND SKCOSDARY RUITUKE. 49

two directious, either into the peritoneal cavity or into the cavity
of tlte hroad ligament. In the free part of the tube this rupture
takes place, aa I have said, about the twelfth or thirteenth week.
In the interstitial form, the case before ua shows that the rupture
may be deferred to a later date. The primary rupture into the
peritoneal cavity seems to he almost necessarily fatal alike to
mother and child ; hut when the rupture occurs into the cavity of
the broad ligament, it may he followed by a continuance of the
development of the child, and these only are the cases in which
the child is permitted to reach a viable period.

In a recent number of the N'ew York Medical Record, a case is
reported by Dr. Taft as being one of which no rupture had
taken place. But the description given makes it perfectly certain
that this was a case where the primary rupture had taken place
into tile cavity of the broad ligament. In this group of cases a
secondary i-uptnre at any period is possible, and therefore it is that
the adoption of the terms, used strictly to indicate relative dates,
■wUl become very useful. This secondarj- rupture was most clearly
demonstrated in Nonat's celebrated case as given by Bemutz, a
case wliich, on account of the occurrence of this secondary rupture,
is full of the greatest interest (see p. 32). This secondary rupture
explauis such an occurrence as that in Jessop's celebrated case.

Connected with the case I am now discussing there are many
important points worth alluding to, some of which are new, and
others, though quite familiar, are worth noticing on account of the
confusion which still seems to exist in the mind of most recent
writers on this subject, some illustrations which I have already
given.

The patient was rather an intelligent woman for her class, who,
having undergone the terrible experience involving lier first
operation, had obtained a fairly full knowledge of the nature of the
accident, and what had been the condition as a consequence.
Yet, with this dreadful experience, and the knowledge of it when
the same condition recuiTetl, so little did she suffer that, up to the
moment of rupture, knowing she was pregnant, she never thought
of asking for medical assistance ; and tiiis was the case also in her
first tubal pregnancy. There were no symptoms whatever to draw
attention to her state until the rupture occurred ; indeed, there
were no symptoms even calling for examination.

The strangest thing of all to me is that, in the enormous
experience I have now had of tubal pregnancy, I have never but
once been called npon to make an examination until the rupture
had occurred, and in that case thure was neither history nor
symptoms which enabled me to do more than determine that there
was tubal occlusion ; not, indeed, until the rupture occurred and the
abdomen was opened was a diagnosis possible. Under these
circumstances I think I may be excused for maintaining a

50

PAUCITY OF SYMPfOMS I'REVIOUS TO RUPTUBE.

somewhat sceptical attitude concerning the correctness of the
diagnoses of those gentlemen who speak so confidently of making .
certain diagnosis in cases of tuhal pregnancy before the period of
rupture, and who epeak with equal confidence of curing the cases
hy a puncture either simple, medicated, or electrolytic.

The great hulk of the utterances in these directions may stand,
very well in " society discussions," or in " library papers," but they
will not stand the test o£ bedside experience. Upon these points I
have been much misrepresented, and am glad to have an
opportunity of clearly stating my views ; hut I wish to state tliat
after the period of rupture a diagnosis can be, and has in my own
experience been, made correctly in the majority of instances.

Another point in connection with this interesting case is the
fact, made abundantly clear by the preparation, that, no matter
what the symptoms had been previous to rupture, physical
examiuatton could not liave permitted any diagnosis other than
that of noiTual pregnancy of about four months and a half.

This is my solitary experience of interstitial tubal pregnancy,
but it BO cloB^y resembles a number which I have seen in museums
that I take it to be q^uitc typical of its class. I am, therefore
disposed to believe that from physical examination interstitial
tubal prej,nancy could not he diagnosed, and I can imagine no
symptoms which would help as to recognise it before rupture.

The whole of the museum specimens of this class do not appear
to amount to more than five or six, there is one in the Edinburgh
College of Suigeons, one in the museum at Guy's Hospital, one in
the museum at "University College Hospital, and another in the
museum of the College of Sui^ons, described by Mr. Alban Doran.
That authority has also mentioned two i]i the museum of the
London Hospital, which clearly, however, do not belong to tliis
class at all, but are broad Hgament pregnancies. Dr. John Parry,
speaks of 31 cases of interstitial pregnancy in his table of 500 of
all kinds, but that he is mistaken in the great bulk of this group of
31 there can be no doubt whatever. TJiis is indeed one of the
illustrations of the want of critical acumen on the part of Dr.
Parry in making his statistical collections. There can be no doubt
that this interstitial form is much more rare than he believed.

IE we were to assume that in such a case as this a diagnosis
could be made, much ingenious speculation might be indulged in
as to what could have been best to do for the patient. If a correct
estimate of the relation of parts could have been made, clearly
what ought to have been done was to dilate the cervix, divide the
septum freely, and empty the comual cavity. To have attempted
to destroy the child would not have benefitted the patient one bit.
The placenta would have gone on growing ; and even if it had not
putrescible material would have been left, which must have burst
into the peritonefd cavity. At the time of rupture, if surgical

I

INTRA-PEBITONEAL DIGESTION OF FCETUS.

51

asaiatance could have readied the woman with sufficient
promptitude, slie might have been saved by a hysterectomy ; and
from the appearancea at the post-mortem examination, there is no
doubt that this could have been easily accomplished.

The last case on my list is also worthy of recital in detail,
because it proves what we might have expected would occur
occasionally, though it has never before been clearly proved, that
iutra-peritonial rupture of a tubal pregnancy may not liave an
immediate fatal ending from hfemorrhage. In such a case wa
might expect that intra-peritonial di{»eation of the ovum would
prove a satisfactory solution of the difficulty ; but here it did not.
A suppuration process interfered, the patient had repeated attacks
of peritonitis from which she nearly died, and had I not relieved
her from the presence of the decomposed remains of the ovum in
ft lai^e suppurating cavity, there is uo doubt but that one or two
more such illnesses as it had already caused would have seen the
end of the case.

The patient in cLuestion was twenty-seven years of age, had
been married six years, and had never been, as far as she knew,
pregnant, this being not unfrec[uently a leading feature of these
cases. She had menstruated with perfect regularity until
Clu-istmas, then she had missed till March, and during the whole
of that time she had been confined to bed with what was called
inflammation of the womb, and was attended during that Illness by
a well-known practitioner in Liverpool. At the beginning of
March she had ao far recovered as to be able to get up for a short
time, hut on the second day of her getting out of bed, she was
suddenly seized with acute violent pain, and was kept in bed again
for three weeks with what was said to be, and what clearly waa
from her description, an attack of acute peritonitis. Early in April
she returned home to Ilfracombc, and was then seen by Dr. Slade
King, who recognized the fact that there was a tumour on the left
side of the uterus. In April she had an attack which she described
as being very like a recurrence of the peritonitis that she had in
the previous month, and there had been two or three attacks since
then, more or less severe. She had menstruated twice for a
fortnight each time, the loss being very profuse, and the pain
extremely severe. When I saw her on July 4th, she was emaciated,
in constant pain, quite unable to get about, and evidently suffering
from the presence of pus in the pelvis. Examination revealed a
tumour, f[uite as large as a fostal head, on the left aide of the
pelvis, fixed and extremely tender to touch. Such a history gave
no clue whatever to what proved to be the real nature of the case,
for even the suspension of the menstrual flow from January till
March waa what precisely might have occurred in a case of
hiematocele of the broad ligament, or in several other conditions,
which might liave been referred as an explanation of this case.

52

ILLUSTRATIVE CASE.

Certainly, in the minds of those who gave the history, the suspicion
of pregnQncy had never heen entertained, and my own diagnosis
did not include a differential suggestion in the direction of tubal
pregnancy, but wa.? given as that of suppuration of the left
Tallopian tuhe. That diaguosia proved to he perfectly correct so
far as it went, but to he complete it ought to have been extended
to include suppuration aa the result of ruptured tubal pregnancy,
but such an extension cUd not occur to me. The state of the
patient was such as to demand immediate interference, and
therefore I opened the abdomen, and found a state of matters,
the details of which were easily ascertained, and were as
follows T —

Tlie omentum was glued over the contents of tlie pelvis, and I
had a little difficulty in detaching its fringe fi-oni the base of the
bladder. After I had done so, I found several coils of intestine
adherent below it, and on removing these, I at once opened up a
cavity from which escaped a quantity of extremely fcetid purulent
fluid.

This cavity was as large as a Jaffa orauge, and the first thing I
came in contact with was a large mass of easily detached substance
recognised at once by my fingers as a piece of placenta. I removed
it, and the nalced eye appearances confii-med wliat I had uttered
about it before I removed it. I then easily recognised that the
cavity from which I had taken it was formed of the dilated and
distended Fallopian tube, formiug the anterior, posterior, and lower
walls of the cavity, whilst the upper pait was composed of the coils
of intestine and omentum, wliich I had partly detached. All round
the cavity I could feel a number of sharp hard points, and these I
easily recognised as fcetal bones embedded in the walls of tlie cyst.
I removed aa many of them as I could, and found that they were
what I had believed them to he, for included in what I removed
where a number of fostal libs and flat bones. I then proceeded
carefully to detach that part of the cyst formed by the Fallopian
tube, and when I had done so, I tied the pedicle, and removed
what you now see before you. The presence of fimhriffi proved
conclusively the accuracy of my supposition. We have here, then,
a case of the greatest possible interest, for it proves what certainly
lias not been completely established up to the present time, that
nipture of a tubal pregnancy into tlie peritoneal cavity may not he
fatal at the time of nipture by reason of recun-ent hasmoiThage.
There is one case quoted by Campbell, and originally narrated by
the late Mr. Samuel Hey, of Leeds, in which I think it is possible
to accept this conclusion as very nearly proved, but the difficulties
of ft certain diagnosis of ruptured tubal pregnancy are so great that
without the complete proof which can be obtained only from a
post-mortem examination or an abdominal section, it is very easy
to throw doubt upon any such record.

HUPTUHE IHTO OAVITT OF BROAD UGAMENT.

53

Here, however, we have absolute proof of the occurrence of
tubal mpture into the peritoneal cavity, not only without a fatal
issue at the time, but apparently without the occiurreuce of much
bEemorrhiige, It is, however, very likely that such cases are
very rare.

In the absence of this fatal incident of lijeniorrhage, it is not
difficult to believe that the whole contents of the tube may be
absorbed by the peritoneum, as the fcetus was in process of being
alMorbed in this instance; and but for the occuixence of suppuration,
it probably would have been so completely absorbed in a few niontlis
that no trace of its existence could have be recognised. The facts,
liowever, that in nature's own pi-ocess of cure an iuterraption by
suppuration occurred, leading to such extreme peril that the patient
escaped uari-owly at least three times from peritonitis, and that if
she had been left alone long her death from tlie recurrence of tlda
trouble would have been absolutely certain, shows completely that
it is never safe to leave these cases to a natural termination, and
that their treatment by electrolysis is mere nonsense.

It is impossible to imagine that tlie Fallopian tube could ever
have resumed its functions, after being submitted to snch an
accident as this, and it is not difficult to believe tliat for months
after, if not for years, it would have continued liable at any
moment to the suppurative process, wMeh you see here had
taken place.

The patient has made an easy recovery, and under these
circumstances, and with a growing experience of the small fatahty
resulting from tliis operation, I nnhesitatingly recommend the
removal of tlie Fallopian tube, together with the remains of the
pregnancy in every instance, and as soon as possible.

It nnist now lie clear that the progress of an ectopic gestation
is the subject of a great cataclysm, the primary rupture of tlie tube
duct which may, and in the great majority of instances most
certainly does, arrest its progress by destroying at one blow both
mother and cliild, unless the sut^eon boldly steps in to save the
former.

We have now to consider the minority of cases in which the
ovum survives the process of rupture, and this it can do ouly when
the rupture talcea place into the cavity of the broad ligament.

When the rupture takes tliis direction there is a great
probabihty that the pi-ocess is accompanied by basmorrhage into
the cellular tissue, and that we have a lifomatocele residting. The
actual proof of this I place on record at page 32, and I have no
doubt, as I have already said, that many of the suppurating
hrematoceles upon which I have operated, have been originally
tubal pregnancies, in which the rupture has tjken place into the
broad h'gament and has caused ha^matocele. And I am quite as
certain that many of the cxtra-peritoucal ha^matoceles which we

54 EXTRA-l'ERITONEAL H.EMATOCELE.

see, and with wliicli we never interfere, are also proiluced in this
way. It ia easy to uuderstaud now how I'arry could say that
"Extra-uterine gestation may bo occaaioually confounded with
pelvio hiematocele. It may sometimes be impossible to distinguish
between tiiem." This nuiat be clearly the case when the
hiematocele is a mere stage or a i-esult of the processes of the
extm-uteiine pregnancy. The confusion into which Parry gets at
this point is very interesting, for it leads him to a series of
quotations, and a series of inconsistent conclusions which go a
very great way negatively to show the value ol the scheme of
ectopic pregnancy for which I am now arguing. Thus he soys,
" It has been stated, however, that peritonitis, by which means
alone intra-peritoneal effusions can become encysted, rarely follows
the rupture of an ectopic gestation," and in this lie is perfectly
conBct" Peritonitis rarely occurs in these cases, and the talk there
about the collections of blood becoming encysted by intlammatory
pitwess is the merest nonsense. The encystment is brought about
by the distension of the broad ligament, by the efl'usion of blood
into its cavity, and of coui-se exists from the first. Parry quotes
a case from Matthews Duncan, in which the latter authority gives
his facts so clearly as to admit of no doubt as to what liad
happened, but without in the least understanding them. Duncan
says that the Woman had all the symptoms of intra-peritoneal
hismorrbage, about a month before her death, whereas it Was
extra-peritonenl hicraorrhage into the broad ligament, which he
describes. He goes on to say that the process of encystment
was going on with every prospect of recovery, when the tumour
(a broad ligament hffimatocele) burst into the cavity of the
peritoneum (by a secondary rupture) causing fatal peritonitis.
It would be difficult to find a clinical record so clearly given as
this, with the evident concliisions so maladroitly overlooked and
erroneous inferences put on record. The strangest thing, however,
is that this broad ligament htematocele of Duncan is correctly
interpreted by Parry in another part of his book, but still the
true conclusion escaped him. In another passage Party strongly
ui^es the arguent against the encystment theory by peretonitis, as
follows, and I entirely agree with hiiu : — " There are lew thin^ in
regard to extra-uterine pregnancy which exite more surprise than
the rarity with which peritonitis is noted upon examination after
death from rupture of the fcetal cyst. The practical conclusions
that may be drawn from a carefid investigation of this subject
are : — That peritonitis ia a rare sequel of rupture of the cyst,
aud even wiien pain, tenderness, and other symptoms of this
affection supervene after tlie escape of the ovum, they do not
necessarily indicate the existence of inflammation."

" Peritonitis so rarely follows rupture of an extra-uterine gravid
cyst, tliat the possibility of its occurence need not be taken into

SECONDARY ItUPTURE,

55

consideration in tbe decision of any (xiieations relating either to
prognosia or to treatment."

Here the views of the process following the primary tuhal
rupture which I have advocated explain all the difficulties of
the situation. Dezeiuieria was the first to discover the fact that
there was such a thing as a pregnancy under the pelvic peritoneum,
though lie neither recognised its frequency nor discovered the
]"procesa by which it was brought about. Rut there was no
disputing Dezeimeris' facts, for almost as soon as they were
published they were conflrmod. As late as 1842 Campbell
disputed them, and brought forward the familiar " encystraent
theory " as an alternative explanation. " In the soiis-^ritioneo
pelviemie, or second variety oE Dezeimeris," Campbell says, " it is
difficult to comprehend how the ovulum can insinuate itself under
the peritoneum which is reflected over the organs situated in the
brim of the pelvis. Through time, certainly, the connexions of
the original cyst with the adjacent part^s become so numerous that
when superficially considered the ovum may seem to be enveloped
by the layers of the broad ligament ; but how it can pass under
this appendage it is impossible to conceive." But the explanation
is now before us, and Dezeimeris' facts have been confirmed by
every unprejudiced observer.

As we have from this point to deal exchiaively with cases in
wliicli the direction of rupture has been into the cavity of the broad
ligament, I must ask to be excused further re-iteration of the fact,
and it must at the same time be taken for granted that when I
apeak of effusion of blood in connection with these cases, I mean
eETusion into the broad ligament only — extra-peritoneal hematocele.
The only exception to tliis will be when I speak of secondary
rupture, by which I mean rupture of the broad ligament, distended
as the result of the primary rupture and its resulting hiemorrhage,
as in Nonat's case (p. 32), or in the case just alluded to, as so
raiaunderstood by Matthews Duncan. This secondary rupture
must, if it cause hiemorrhage at all, pour the blood into the
peritoneal cavity, and thus produce intra-peritoneal htematocele.
If, when the rupture takes place into the broad ligament, the
blood effusion should be considerable, it is not difficult to
understand that the ovum will frequently be killed at once, and
be absorbed in time as the blood itself is. The whole tiling will
disappear, and the patient will get well, and I have no doubt that
tins is the origin of many of the inexplicable htematoceles of the
broad ligament which we meet with. I have ah-eady given a case
of the kind proved by abdominal section. I have as little doubt
that in this way very many cases of ectopic gestation have a
fortunate ending.

But they do not all die in this way, and many of them go on
developing iu their new position, and their development may go

56

DEVELOrsiEST OF OVUM IN BKOAD LIGAMENT.

to the full time. On tlie other haiul, tlie death of the oviim may
(iccur at any time up to tlie full period, and then a change, wbicii
1 believe to be perfectly miiform, goes on slowly. The first part
of this process is tliat the liquor amnii is absorbed, and then tbesoft
parts of the foetus and tlie bones are also as far as they can be. At
the end we have a small cyst in the broad ligament contaiuinf; fcctal
bones and debris of foBtal tissue. From the record of numberless
cases in the literature of this subject it is certain that ultimately
most of tliese cysts begin to suppurate, aud cause much sufferiug.
Some of them ve know reinaiu quiescent, aud are found as
lithopedia, Uttle and big, on tlie post-mortem table. Farry knew
this, and expresses the fact well, when he aaya that " If the woman
does not perish from rupture of the cyst during the first four or
four and a lialf months of gestation, it is not likely that an
opportunity will offer to inspect the body until at, or near, or even
some time after, the close of pregnancy." But as he did not
recognise the process of rupture into the broad ligament, he failed
to understand the position, and his clinical accuracy suffers
accordingly, whilst his subsequent pathological speculations are
full of error, Thus, he continues his guesses about " eucystmeut,"
though he has himself given the most conclusive argument against
it, that the encysting process of inflammation is extremely rare —
personally, I doubt if it occurs at all. He says, " Though the
presence of an eneygted fajtua is not incompatible with life, and
even with comfort and usefulness, the woman wlio beara such a
burden within her is in constant danger of the cyst taking ou
inflammatory action, which will greatly endanger and may even
destroy her."

When the bone-contaiuing cyst suppurates, the matter seeks
au exit, and that is found uniformly in one of four directions:
through the rectum, by far the most common ; through tlie
posterior vaginal cul-de-sac, the next in frequency ; through the
bladder ; and most rarely through the abdominal wall at the
timbilicus. " During the discbarge of the decomposed child," says
I'arry, " the mother is subjected to all the dangers which result
from the absorption of purulent and putrid matter," and he gives
a table which, though it has no absolute value, is immensely
su^estive of the terrible mortality of this process. He has
tiibulated 330 cases, and of these 105 died, and we may feel
quite sure tliat, as in all such reckonings, this is an under-
statement of the true death-mte, as we never hear so much of
uusucceasfnl cases as of those that have a satisfactory ending.
The cures involve a great amount of suffering, for they go on for
years, and therefore deserve the sui'gical interference for which I
shall afterwards advance arguments.

But, first of all, let me say that the four directions in which
the debris is evacuated preve clearly that its seat Lt the cavity of

I

I

SUPPURATION OF DEAD OVDM. 67

the broad ligament. If the seat of the trouble were the left broad
ligament, and the effusion had dissected the peritoneum up from
the rectum in forming tlio annular stricture of which I have
spoken, it is into the rectum that the abscess would most likely
lead. I have seen a number of these cases, and have removed
foetal debris through a, hole in the rectum, opening straight into
the cavity of the broad ligament ; and, with my finger in the
apertui"e, and a sound in the uterus I have proved the site, The
bladder and posterior fiexure of the vagina would naturally
expect to be the next most available seats of evacuation, and in
the case of the latter opening I have again proved, as in the case
of a rectal aperture, that the cavity of the broad ligament was
the seat of the debris cavity. Finally, in the case of lady who
came to me from South America, and who for years had been
passing phosphatio calculi from the bladder, the nuclei of which
were foetal vertebrae (the bodies of them), I opened the abscesa
cavity from above, without opening the peritoneum, cleared out
a quantity of pus, fcetal hair, phosphatic deposit, and foetal bones,
and promptly cured her, I could pass my finger into tho
bladder by a hole in its right wall, and as the uterus was quite
fixed in situ, there wae no doubt but that the abscess was the
result of the death of an ovum which had been extruded into the
right broad ligament.

The exit of the products of the foetal decomposition at the
umbilicus was not intelligible to me till I saw the marveUoua
frozen sections, made by Berry Hart, of a cadaver in which he
found a well-advanced broad ligament pr^nancy. Then this and
the many other riddles were cleared up ; but these had all better
wait till I speak of the relations of the peritoneum as altered by
the growth of a broad ligament pregnancy.

Let me speak of the abscesses opening by rectum, vagina, and
bladder more in detail.

In all of these the histoiy helps but little, for the atory is
seldom more than that of obscure pelvic trouble ending in an
abscess bursting and continuously discharging into the rectum, and
it is not till the arrest of some shai-p spicula of fcetal bone in
the anus declares the true solution that the nature of the case ia
discovered. Moat of these women suffer severely till the absoees
bursts, and then they are able to get about at times, tliongh on
the whole they lead invalid lives. The mortality is doubtless
quite what it is asserted by Parry, though I never saw a fatal
case. All that have come under my own care have been easily
cured by the complete emptying of the sac.

The cases where the abscess has burst through the vagina
have histories very much as in the fonner case, and they certainly
suffer less, and the cure is easier still. Quite lately a woman
came to my out-patient department with the remains of a fcetal

58 DISCHARGE OP VCETKL DEBBIB.

lumar BUekiiiy uut of ii hole jiiat IjcliinJ the cervix, and to the
left. I eulaiged the opening, took out two or three teaspooufula
of dehris, and she was cured withiu a uiontli. Pany tella ua that
under exceptional circumstances the contents of extta-iiterme
foital cavities may make their way to the surface hy a fistula
through the perineum, and he quoted Dr. Yardloy, of Philadelphia,
as having recorded an observation of this kind. Such an
occurrence would clearly form only au extension of their
method of extrusion hy the vagina, the widls of the vagina
and bladder being separated by the advancing abscess, and the
opening taking place as low down as it could in the periueuui.

In the cases when the dischai'ge is into the bladder the stoiy
is very different. Parry says it is much more fatal than
dischai-ge in other directions ; and I think tliis ia very likely, for
in addition to the pelvic abscess we have the very serious
complication of cystitis, leading to pyelitis and abscess of the
kidney, a complication I ceitainly have not seen, hut one which
is, on a priori ground, very probable. But the mere sufferings
of the patient, greatly enhanced by the formation of phosphatic
concretions, would alone be enough to increase the mortality.

Curiously enough I have never yet seen one of these cases
in its early stage, tliough I have for long expected to come acroaa
them, because it has been my habit for years to deal with all
pelvic suppuration by abdominal section, By this method I get
i-esults far more rapid, complete, and permanent than in any
other way, and doubtless some day I shall have the experience
of opening a suppurating fcetal cyst before it has made its
external opening. As I have said, 1 have opened one from above
after it had already made its own way into the bladder, and with a
biTlliant result, for the patient was cured at once after years of
suffering. But the case does not reckon as one of abdominal
section, aa I did not open the peritoneum, and by the definition I
have adopted ; and have Llluatrated and defended elsewhere, this is
necessary to constitute an abdominal section.

I feel q_uite confident that if these cases were dealt witli
by opening from above in their earlier stages, much of their
mortaUty wmdd disappear, and the patients would be spared years
of suffering. I would treat them as I do pelvic absceaaes, and if
the peritoneum were opened I should close it in my usual fashion,
by stitching the opening in the walls of the cavity of the broad
ligament to the opening in tlie parietal peritoneum (see pelvic
abscess), after emptying the decomjiosiiig debris and cleaning out the
cavity. I have now done over fifty ojierations of this nature, and
not only has there been no mortality, but the cures have been so
rapid, complete, and permanent as to give mo perhaps more
satisfaction than almost any other class of my work. I have said
notliing about the differential diagnosis of broad ligament a

JESSOPS CASE.

59

originating in the deaths of ectopic ova, because I hardly think it
possible tiU bonea are found in the discharges, and then of course
it is easy enougli. Before this has happened I have had no
experience of them, as I have aaid, 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, for my
rule is to get pus out of the pelvia as soon ae I am satisfied it
is there.

The death of the foetus may occur, as I liave said, up to any
time of fffital Ufe, and if suppuration of the foital cavity occurs
there can be but little variation in the processes, or in the
proceedings required for their relief. Of course the larger the
fcetus the greater the trouble, the more indent need for interference;
and the larger the fcetus the greater the possibility of the sao
bursting at the umbilicus, an accident to be afterwaixls 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 sao 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
observed 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 ruptui^e has been recoi-ded 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.
Mr. T. E. Jeasop, who records the case, puts it among what he calls,
quoting the text books, the " abdominal variety." If he had said
intra-peritoneal variety hia language would have been more
accurate, but as a matter of fact it stands by itfielf, 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, ia my belief, quite certain. If the
pregnancy had ruptured its way into the peritoneiun it would have
been at once digested ; for I am certain, from what I know of the
digesting powers of the abdomen, no gelatinous fcetus of the tenth
week coidd resist tliem. 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 eacaped into the
peritoneal cavity, and continued its life amongst the intestinea, 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

JESSOPS CASK.

would contract and disappear towards its edgas, aud 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, aged 26, liaa
enjoyed fair average health up to the commeDcement of the illness.
In March, 1869, she gave birth to an only child, after a labour in
all reapects natural, and, having weaned the child, she menstruated
with moderate regularity up to 1874. From the beginning ot
January, 1875, her menstruation ceased, and she believed lietself
to be in the family way, early in March she was about two months
pregnant, whilst washing 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 fop,
ehe was suffering from violent pain in the abdomen, with awelliug,
vomiting, retention of urine, and high pulse, and for two months
she was confined to bed, sufi'ering from abdominal pain, sickness,
and loss of appetite. Towards the middle of May she Ijegan to feel
the movements of a child, and at the same time notiml a hard
swelling in the lower 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
fffitus, and she was taken to tlie Leeds Infirmary, under Mr. Jessop,
the same day. The abdomen was throughout distended. At Uie
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 puhes.
On a closer examination the umbilical prominence presented
the characters of a child's breech ; the cleft and the two
buttocks were distinctly tmceable through the thin abdominal
walls, ond 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 umljilicus, immediately below
the riba, it was not difficult to map out the outlines of the two
seapulre. The rapid beating of the fcctd heart could be most
distinctly heard towards the right side above the umbilicus. The
breasts were enlarged and the areoliu were fairly developed."

" On examination, per vaginam, the uterus felt somewhat
enlarged, and on measurement by Simpson's sound its cavity was
foimd to be 2J inches in length. The uterus remained motioidess,
whilst the abdominal contents were 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
soufHe. The diagnosis of extra-uterine gestation seemed complete.
The woman's condition was becomiug extremely ctiticaL Under

JESSOP'S CASE. 61

these circnmstanceB it was decided to remove the child by
abdominal section. With tlie full concun-eiice of my colleagues,
I accoi-diiigly proceeded to perform the operation at 12.30, on the
morning of the 14th of August"

Tlie patient having been placed under the influence of ether,
and tlie hladder emptied of urine, an incision sis inches long was
made through the linea alba, witli the umhilicua at its centre.
The abdominal wall was unnsually 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 hreeeh and hack
of the child, thickly coated with ve^-nix caseosa, came directly
into view. At tlie upper part of the wound the omeutum was seen
lying like & cape upon the child's shoulders, and inferiorly the
funis, of natural appearance, passed transversely across the wonnd,
and was tracal round tlie external aspect of the left thigh of the
fietns to its attachment at the umbilicus. The child was in a
kneeling position, its breech presenting towards the mother's navel;
its Iiead, 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 hrim of the
pehis. .... Its removal was readily efi'ected. I'lie funis
was tied and separated in tlie usual mamier, 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 adhei-eut 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 abdombal
wall. Near its centre was a round iiromineuce, 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 :i9th of October the wound is reported as
quite healed ; and three weeks later she returned to her home.
From that time to the present slie has kept in good health,

Menstruation commenced about a month after she left the
infirmary, and has recuixed at regular periotls ever since. The
cliild was as healthy, vigorous, and large as an average child
bom in the natural way ; and it continued to thrive well

S2 DIAGNOSIS AT VUBLE PERIOD.

until July, 1876, when, after a ■week's illneas, it died of cionp
and inflammation of the lungs at tlio 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 cntical investigation, will
admit of beiTig tenned " abdominal," or intra-peritoneal pregnancy.
Certainly those quoted by I'arry will not do bo, and I have met
with no others.

Another somewhat similar case is published in the Die
Krankheiten der Taben, by L. Bandl and is to be found in Tarnier
and Eudin's book, and is as follows ; — " la the cose reported by
this last author in a multipara examined several times, he
dii^osed extra-uterine pregnancy, The cliild was living and
arrived at full time. The patient refused gastrotoniy ; phenomena
of false labour, and expulsion of the decidua occnried, and some
symptoms of peritonitis having supervened, she succumbed. He
immediately performed laparotomy ; the child, who 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 fcetus on all sides,
but the walls of this pocket wei-e formed by false membranes about
four or five mil i metres thick, and which liid tlie anterior, posterior,
and lateral abdominal walls, the small intestines, the ascending
colon, the descending colon, etc. On the interual 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 fcetus, formed a handle round the uterus, and
penetrated by a circular orifice, wliich 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 which the
finger could easily penetrate. Outside the opening round the cord
were prominences of wrinkled ovular membi-anes of a yeUow-brown
colour, and dating from the first montlis of tlie 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 autliority, Tarry
excepted, makes any allusion to it, so far as I know. At page 103
he says: — "I have met with an example of tliinniug of the
abdominal walls a few years siuce, which was exceedingly puzzling,
I was asked by Dr, K W. Watson to see a young woman, to decide

ABNOKMAL THIKHESS OF UTBKIKE WALLS.

63

tlie nature of an ahJoiinnal tniuour, whicli was the size of a anveu
and a half or eiglit months' gi'avid uterus. Upon making pressure
upon the enlai^etl alidomeu a fcetua was felt recediiig fram beneath
the finger, against which it immediately rebounded. It was so
superficial in its situation that it appeared inipoasible 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 tew 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 cuiiosities of my
experience. In one case in the practice of Mr. Langley Jirowne,
of West Eromwich, we found a very thin uterus extremely
retroverted, In the others the conditions were those of extremely
thin walla, with some kind of displacement, as latero-flexion or
retroflection, 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 which
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 featui'es 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 tjuestion 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 cliild was noimal. Save in one case — that seen by
me with' Dr, Whitwell, at Shrewsbury— there was a marked
absence of the liquor amini, 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 PHrGSANCT IN BIPID UTERUS. ^^^^H

These cases were, with ouo exception, nil under the seventlH
month. In the eighth and ninth months the waUa of the uterufl
thickened, the quantity of liquor aninii increased, and the casEn
tenninated in perrectly natural labours. The exceptional case fl
have seen within the last few days, and the jiregnancy hafl
advanced well into the eighth mouth. Vaginal examination makeS
it quite clear that the pregnancy was intra-iiterine, whilst from th«
appearance of the abdomen alone the conclusion wonld have beenfl
inevitable that the child lay amongst the intestines. 'm

These facts were given to me in connection with Mr. Langleyfl
Browne's case, also with a case which was watched by Dr. HilH
Norris, and attended by hira in her confinement. In Dr,fl
Whitwell's case there was a lai^e, thin-waUed cyst, through whicbfl
the child could be felt with the moat astonishing distinctness, andfl
it floated about as if it were perfectly free in the abdomen. H^l
wrote to me afterwards that " the patient went on very well, that^
some time before the expiry of gestation the fretiis became much
more a fixed body, which undoubtedly showed an increased
thickening of the walls of the uterus, as well as eidargement of the
ftetus, and that her labour was quick and without any subsequent
hemorrhage." J

The other conditions with which extra-uterine pregnancy mayl
be confused, before the death of the child, are (a) displacement of 1
the normally pregnant uterus during the early months of
pregnancy, complicated with fibro-myoma or cystic disease of the
uterus ; and, more rarely, (6) pregnancy of one-half of a double
uterus. In a case which I saw with the late Mr. Ross, of Wake- _
field, I diagnosed either extra-uterine gestation or a double uterus J
with pregnancy of one side, and it turned out to be the latter. I
Frequently we have considerable lateral displacements of the -I
normally pregnant uterus, especially in unmarried women, sent to M
the specialist as something very different to wliat they really are. I

But it is in cases seen after the death of the child, or at leaab M
when the time of the expected confiuemeut has passed so long ■
that if there is a child it is sure to be dead, that our most serious I
difficulties in diagnosis are met with. I

The first point to consider ia tlie history given by the patient I
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 I
pregnancy which I have advanced, that the majority of the I
instances of this abnormality occur in women who have not borne I
children previously, or in those who have had no children for I
many years. This point in the history of the patient is therefore I
always noteworthy. The other matters requiring cai-eful considera- 1
I tion are the sudden arrest of the menses, the grathml increase in I
i size, the occurrence of symptoms of laboui' at or about the end of I

nrSTOKY OF CASE LEADIKG TO EREOB. 65

the ninth month, and the mbseqiient diminution in size. Of all
those points, the last ia tlie only one having the importance of a
sign ; but it must always be born in mind that no history,
however complete, ia 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 yeai-s before she had believed herself pr^uant, because her
menstruation had ceased for eight months, her abdomen had slowly
enlai^ed, and so had also her breasts. She was also quite sure that
she Imd often felt movements, and, indeed, had all the feelings that
she had experienced in each of her seven preguancies. One day,
when walking in the street, she was seized with pains, exactly like
labour imins, and these lasted for four hours. At these pains she
felt no surprise, fully beheviug 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." Slie afterward felt this " pass back
into the belly," the imins 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 occun'ed, 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
was so when I operated, and the operation was successful. The
lesson of the case is that we should place very Uttle 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
womau, 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 coiTobora-
tion of her statement.

This singular imitation of the process of labour is a striking
feature iu most of the cases in wliich an ectopic gestation is can-ied
beyond the normal period, and seems thus to indicate the
conclusion that the initial mechanism ot labour is not in the uterus,
as generally supposed. It was first noticed in 1652 (Phil Trans.,
Vol. V.) by Vassal and lias been constantly alluded to by
Avriters 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. Tlie duld was dead, and, as the placenta was

66

EISTOEY OF CASE LEADING TO ERROR.

unfortunately removed at the eame time, tlie patieut died in four I
hours. Campbell gives a great deal of curious information on this
point* as on othei-s, and he especially emphasises the recoi-ds 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 tliat 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 anytliing
wrong. The gestation in the case which I am now discussing,
which led me astray aa much as anything, was the suppres-
sion of menstruation, and the digest of the records made
by Campbell on this point is worth c[uoting at length to
show how little trust can be placed in histories. " In many
instances of the different varieties of misplaced gestation,
the catamenia are suspended ; frequently, however, they appear '
regularly in each of the early months ; in some cases they
flow 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
behef 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 with
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 beUeve, 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 gome extent ; and the second, to the
absorption of the liquor anmii after the death of the child. The
complete arrest of menstruation during the period corresponding
to normal pregnancy is far from being a constant condition.
But even though it were like its accompanying signs, such aa

•x [p, 130; CampboU Indnlgsa

lotitSiiRr," wUi

RELATIONS OF DTEHUS TO GESTATION BAG.

67

enlargement of the breasts, darkening oE the areolEe, increase of
Mon^omery's tubercles, malaise, vomiting, etc., it -would help us
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 dii^nosia of
uterine myoma. Parry has fidly investigated this point in the
numerous records he has collected, and tells us that " the utenia,
except in some rare instances, undergoes striking alterationa, 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 souud was heard at
my first visit, but had disappeared entu'ely at my second, ten
lioura 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 tlie tumour, generally in front of it,
moveable to a limited extent, always enlarged before 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 tlie cervix is always q^nite open — in my
cases almost admitting tlie finger. Under such circumstances, if a
fetal heart is audible, the ca.se is clear. If not, then the character
of the tumour must be taken carefully into account, IE the case is
seen soon after the death of the child, the tumour will be soft, more
or less obscure baUottemeut 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 difficulties 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 di^nosis of an extra-uterine pregnancy may be veiy diflicult.
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.
Difficidty 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 coiTcct conclusion can be reached by carefully
sifting the clinical liistory. No point is too minute for examination.
As a rule, it wiU be found that all such women have a firm
conviction that they were pregnant when the abdominal tumour

68

DANGER OF TAPPING.

nmdo its appGnrance. Though more than a score of years may have
passed, they will not have abniidoned the idea that they still carry
a child somewhere in the abdominal cavity. Such women will
nearly always give the history of labour at or near term, attended
with uterine hitraorrhage, 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 chai-acteristic,
and when they are all present, en-atic gestation should always be
suspected, nie diminution in the size of the abdomen after labour
is a most important symptom."

After the absorption of the lifjuor amuii, the character of the
tumour in extra-nteriue pregnancy alt&rs very mnch. The uterus
may become smaller and more nioliile, and parts of the cliild may
bo felt, especially in the rectum, such a sign at once pointing out
the nature of the case. These prominences, and likewise the
" bossehires," 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 tumonrs, and especially by the Iiard
irregulai'itiea of dermoid cysts. These resemblances 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 — but 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 nothing 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 made are limited
in number, this instrument is doubtless of gi^eat use, as it is for
treatment as well, Ihit in the abdomen and pelvis it is very
different. The aspirator may tell you a tumor contains serum,
blood, or pus, but that helps 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 grmt, quite as great as the risk of an abdominal
section. The use of the aspirator in my special line of practice is
therefore dirainisliing, has almost disappeared, and in all cases of
abdominal tumor where tliere 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 tliis practice, and I very
often have had reason to be pleased with its results. I'arry's
evidence on this iKiint is so strong and important that I quote it
at length to strengthen my position : —

" In cases of doubt, the fcetus being dead, the trocar has been
used to draw off some liquor amnii in order to conflnn the
diagnosis. Unless it has been decided to opemtc immediately for

DANGER OF TAPPIMQ.

69

tlie removal of the fcetua, the use of the trocar is utterly unjustifi-
able. A few, but very few women have long survived its use,
Mr. Jonatliau Hutchinson, in a clinical lecture upon this subject,
says that this practice " is iii itself attended by jji'eat 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 tbat
paracentesis ought to bo necessary in a case of ffctal tumor
simulating ovarian dropsy." Mr. Hutchinson reached this con-
clusion after having been so unfortunate aa 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 Pliiladelpliia,
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 tlie aspirator for diagnostic
purposes, the woman, there is every reason to believe, having no
bad symptom at the time. Slie was given chloroform, the pimcture
made, and two liours 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 the patient's death."

Slow-growing cancer of an ovary, or in the neighbourhood of
tlie uterus, especially behind it, might he difficult to diagnose by
physical sigus from extra-uterine pregnancy of long standing, hut
the history would here greatly help us. The inci-ease would
probably be steady, and if a rapid accession to the growth took
place, a temperature chart would settle the difBculty ; for tlie
only conditiou which 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 tliat could not be mistaken. The
history of the case would probably lielp, but it might just aa easily
lead one astray, as in the case I have detailed. I once saw a very
eminent obstetric physician attack an abdominal tumour which,
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 aigna
were in no way distinctive from those of a lai^e 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 tlie tumour was a mass of
cancer of tlte omentum, adherent to and involving everything.

After the liquor amnii has becu absorbed, and the contents
of the ovum cyst consolidated, the relations of the mass to the
uterus and the otlier pelvic viscera are made so close by the
placental connections, that the physical signs never can be very
clear, and therefore, alternative dii^noais of fibrocystic tumour of

i

70 TEEATMEKT OF ECTOPIC GESTATION

the uterus must be the refuge of uncertainty .• But au 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 treatmeut.

After the diagnosis of ft case of extra-uterine pregnancy has
been satisfactorily determined, the question arises. What is to
be done with it ? If the child ia still alive and near the ftdl 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 emiueut an authority aa Mr. Jonatliau Hutch-
inson. Of eourae no strict rule can he laid down, and each case
must be decided on its own merits ; but the records of sui^ery are
80 full of instances of the risks which such cases have to run when
suppm'atiou of the sac occura, as it almost always does some time
or other, that I think we are in uiost instances justified in operating.
Moreover, the surgical principles on which the 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
illc^ical 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 forma of
treatment designed to obviate the necessity for surgical operations,
and in the argumeuts used to support them, an altc^ther new and
I venture to think, ft 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.
Uertainiy 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 effoi-ta, 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 killa 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 I'arry

* Wrilin of "llbnrir pipen" uid otbcr fiieipericiicea iwnons Ulk so lightly oT dIggnoBis
in piilr[o and abdotnlnil (rouul«, nod lo lusurcdlT of (li« bccuui'j of tlisir diignosls, tbnc I am
diapoied to tak ttioax wlio art paBainM tliroimh tfiosB atago of tlielr iirofosaloiial eiJBUjnce lo
read the foUoiving Hliactg on ilin Bubjoot of Uie iliagnuaia of ectopic geitatlDn:-

"Altbousb tioiu tlie careful inrusal of nuioeroui hlBlorles o! aaei ol Ibin Ditum, bodio
iBgne of fadllty of diBtldguiBlilnti their presenoa may bo acqulre.1 ailar a certain period of Oieit
duration, and of dtjoldlug evdo. In occuionol inetancca, on the particular variety of Butib
prpEnancioB, yi^t aasurmlly eTi:ry practitioner wbo bOB attentively Btudled the subject, must
admit tlio dlBtincUon to bo a laali of no onUnary dlffinolty.— J'arrif,

"Telle est robaoutil* du diagnoiOc, aprfi I'oiploration dii ool ntorin, qua lea Baudelooqne,
lea OBiandir, lea Duboli, el£, n'ont Junaia osd, an milieu dcB inoerlitiulai qu'll lalaia, eatre-
piendn], lu tetme de Deal tnoli, I'extnetlou de I'enEMiL AnAivit Qihit, Vol iXTiL, f. 111."—

AT OR NEAH FDLL TIME,

71

lias proved. Punoturiug the ovum sac with needles, medicated or
gfvlviiuic, is tlierefore an immoral and dangerous proceeding, which
ought to have professional condeniuatiou. Parry is of opinion that
all measures that necessitate wounding the cyst without removing
the chilli 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. Tliis 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. lie himself says iu this very
passage that future experience must settle the question. I venture
to think tliat 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 tlie bleeding point. No acupuncture, simple or
medicated, and no electrolytic charlatanry will siive a woman who
lias 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,
uan-ated by the former authority : —

"The observation of Dr. Hicks is more important, since it
involves less speculation. This case liaa already been alluded to.
The patient died, when four months pregnant, of internal hemorr-
hage, tlie result of an attempt to destroy the foBtiis by punctming it
with a trocar. About a fortnight before her deatli 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 fonued new connections,
was the perfect ovum witJi 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 cliild had survived the
primary ruptiu"e, and the ovum was going on developing in the
broad ligament Beyond the fact that an ectopic gestation was
diagnosetl by Dr. Aveling, and was even made clear by Iiim to
Mr. Spencer Wells, there was no reason apparent for interfering.
If the case had been carefully tended up to tlie viable period a
living child might liave been removed. Insteatl of tliis the child
was killed by galvanism, and that seems to me a wrong thing —
a far more immoral thing even than " sjiaying."

One of the most recent cases iu 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 ^ews, 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, i

72 ELECTRIcmr.

Dr. Buckmaster asks three questions in connection with hia case,
of wiiicli tlie first is : " Was the diagnosis of extra-utei-iuo
pregnancy warrantable?" and in Mply there can be no doubt at all,
for the description that he gives of the accident which occurred
to the patient about tlie ninth week of pregnancy is essentially
characteristic of tubal rupture — " She suddenly felt a violent
jiain in the ' pit of the atomacb,' heard a ringing noise iu the 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."

Tlie second question is ; " Was the child living when tlie
electricity was first applied ? " aud then Dr. Buckmaster gives
a categorical reply in the aifirmativG, when really it is a matter
open to the greatest suspicion. I tiiiuk in all probability from the
details o£ 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 aa generally follows when the electric cun'ent 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 thii-d question comes up for discussion :
" Is the uninterrupted current the best means for destroying the
fcetus ? " aud to this I reply, Wliat right had Dr. Buckmast«r
to destroy the child at all ? There can be no doubt from the very
clear description given that the pregnancy was 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 tlie 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 foBtus, none of which seemed altogetlier satisfactory,
Dr. Buckmaster continued to use the galvanic current unin-
terruptedly, bnt he gives no justification M'hatcver for his
determination to destroy the child. All the severe symptoms
had disappeared, the patient was suffering from nothing but
slight discomfort aud the unfortunate fact that Dr. Buckmaster
had diagnosed an ectopic gestation. If the case had been left

ELECTRICITT.

73

alone a living child might have heen the reault, for there can
be no doubt whatever that it was an extra-peritoneal pregnancy,
wliich, 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, wliich could he
felt on making a vaginal examination, and that there was a alight
tenderness about it, in fact the physical condition of the patient
was precisely that in which he 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 wliich he says he desired in killing the child. My own
belief is that he did not do so, for the method which he employed
la one which could not by any means be applied with 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
which some criticism might be directed. In the first place he
credits Dr. T, G. Tliomaa with the belief that the electrolytic
treatment has these great advant^es, if any error of diagnosis
baa 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 tliis 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 eiiect desired. Further, Dr, Buckmaster says on his
own account, that cases will undoubtedly appeal-, 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 he that all such
operations should he 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
jjoint is that Dr. Buckmaster says that " it has been claimed
recently that the placenta continues to grow after the death of
the fcetus, 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 fcctua 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 ca.se number six the rupture hud occurred iippai-ently in the

10

74 GROWTH OF TLACENTA

tenth or eleventh week of gestation, and the placenta was lying
in the tuidst of a quantity of clots, as a roand maaa the size of a
cricket ball, for the most part iu the wall of the tube, for when
the tumour was removed the placenta waa 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 deserts
spoonful of liquor amnii, but there was no trace of fcetus 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 fcetus, in the
so-called uterine " moles "—we have no reason to do other than
expect that they will occasionally occur iu tubal pregnancy. As
a matter of fact such was the state of matters in tlm case.

In case 19, when the fcetus was found it was only about
2J inchea long, and had evidently l>een 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 hfemorrhagea, 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. Champneys read his case, Mr. Thornton gave
testimony to the same conclusion, and in the first edition of the
"Manual of Gynscology," by Hart and Barbour, published in
1882, there is the following evidence on this important question: — ■
" Case of extra-uterine gestation, with death of the fcetus, but
continued growth of the placenta, which led to fatal haemorrhage.
A. B., a3t. 24, had passed two periods without menstruating, and
thought herself pregnant; three months ago she b^an to have
irregular hfemorrhages 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 the brim,
and the bladder displaced into the abdomen. The tumour was as
lai^e as a uterine pregnancy of 4J mouths. After a puncture
of the cyst with an aspirator ueedle the patient died with
symptoms of internal hiemorrhage, and on a post-mortem examina-
tion, by freezing the pelvis and cutting sections, the uterus was
found to be 5J inches long, the 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 fatus was about the size of a
three months' pregnancy.

The continned growth of the placenta after the fcetus had died
had led to fatal hemorrhage.

In looking over the records of cases which have gone beyond
the i'uU period of gestation, I find numeroiis illustrations which

ATTBR DEATH OF FCETUS.

75

caunot be other than the growth of the placenta after the death
of the chCd, 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 weut over the
nine months with a false labour, and the child died. Three mouths
afterwards the mother auccumbed from the sufferings involved iu
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 Pallopian 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 iUnstrated in the paper by Dr. Matthews
Duuoan in the Bartholomew's Hospital Repoita 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 turnout ou 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 Leclanch(5 elements was then passed for a space
of six minutes, producing slight vesication o£ the skin, and a rough
dried surface in the vagina. The fcetal heart was heard beating
the same evening. On the followii^ 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
amniij which was done through the abdominal wall by aspiration,
eight ounces being removed. The fcetal heart still continuing
to beat, Dr. Duncan, five days later, injected ^ gr. of morphia
into the body of the fmtm, to the depth of two inches, at the
spot where the fcetal 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
th^ positive pole being applied over the tumoiu' externally. A
current from forty cells of the battery was passed for six minutes
with occasional interruptions. After the operati:)n the fcetal heai't
could atill be heard heating, but more slowly. Four days later

76 ABllOMINAL SECTION.

Dr. Duncan, Imving heard tlic fcetal pulsation, drew off the liquor
nmnii, ■with the nspimtor, and then injectetl in. xiij. of equal parts
of wftter and liq, moriih. Iiypod. into the fa>tua just over where the
heart was hearfl. After this the fcetal heart could not be heard.

The patient died two days subaequently. At the autopsy,
twenty-six hours after death, the contents of the cyat were found
very fcetid, and the soft parts of the fcEtua itself were for the most
part as if completely macerated, the bonea being exposed. Almost
all the internal organs were diffused in the surrounding Huid, 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 suifering and finally
double death, when probably both lives might liavo been saved by
following the ordinary rules of surgical proceedings.

If the ovum perisliea 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 lierself only after the cluld ia beyond the gestation
period aud dead, it ought to be removed for it is a source of
perpetual risk, Quiescent lithopedia are far too rare and
suppurating ovum saca far too common and far too fatal for us
to recommend such a risk to our patient. Voxry sums up the
question very well in the following passage :—

" After the death of the fcetns, 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 ia never
free from danger while ahe ia carrying an encysted child. Violent
exercise, injuries, blows, strainings, aud similar mechanical
irritations may be the exciting cause of inflammation of the aac
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 wliich 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 tliat of Primerose, who
operated in October, 1594. Tlio history of this patient has become
classical. Slie was twice pregnant witli extra-uterine cliildren —
firat in 1591, and again some time before 1594. The cy.st of the
first child opened spontaneously through tlie abdominal wall.
The fistula was enlarged, and the child extracted by Jacob Noiems,
a Hui'geon. This operation proving successful, Primeroso 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

,VBDOMINAL SECTION. 77

liazardoua operation. Felix Platerus reported another successful
case only three years later. After this wb have found no indication
that the operation was performed for more than a century. In
1714 C'alvo reported a case in France, and in 1764 Bard another
in AmeTica.—(Fairt/.)

Mr. John Bard was a surgeon in New York, and no one is
known to have operated in that countiy before him. The patient
was the wife of a moaon, and the operation was performed several
years before it was published, for Mr. Bard communicated an
account of it to l)r. Fothergill, in a letter, which waa 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,
tho wife of a Virginia planter. The operation which Wiis done
by Dr. William Baynham, a country physician, was entirely
successful. Tlie same gentleman operated with the same happy
result upon a negro slave on February 6th, 1790. This was the
fourth American abdominal section for the removal of an extm-
uteriue fcetus. The third one was performed by Mr. Knight, and
communicated to the celebrated Dr. Lettsom, by Dr. Mease, of
Philadelphia, and published in 1795. Dr. liaynham's eases are
well worth attentive study. They illustrate the intrepidity and

Lgood judgment so often displayed by the countiy surgeon, who,
separated by long distances from his fellows, often has to act in
the greatest emergencies without the counsel which 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 ^ain perfoimed by Dr. Wishart, likewise
a country practitioner. The sixtli American operation was
performed on February 6th, 1846, by Dr. A. H. Stevens, of
New York, a man who had all the advaiitngos of a metropolitan
experience. — (FatTy. )
Sprengel, in his History of Medicine, vol. VII. p. 290, et seq.
refers to the following authorities for cases of tliis nature, viz.,
Comax, a professor at Vienna, said to be the first who operated
successfully for gastrotoniy ; Hector and Gassarus, both of
Augabourg; 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 which
fcctuses were extracttsd ; Rnnge a surgeon of Bremen, who operated
on a woman in whose abdomen a foitus 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
fcotus of thirteen yeai-s i-etention; Breyerof Loipsie, and Weinhardt,
both of whom operated successfully by gastrotomy ; Professor
Colomb of Lyons, and Professor Josophus of Rostock ; both were
unsucceaaful. — (Campbell.)

\

78 ABDOMIKAI, SECTION.

Parry gives a number of tables wliieh are intended to show the
mortality of extra-uterine pregnancy reaching to and going beyond
term, and submitted on the one liaud to abdominal section, or left
to uatui-e, 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 snidery
was revolutionized by 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 wliere the details are
given, the great bulk of them have been operated upon when the
patients were too far gone iu illness, the result of accidental
complicationa or suppuration of the sac, to give the collection any
value whatever. The following are his conclusions. Of thirty cases
in which gastrotoniy was performed, or the breach dilated, twenty-
eight 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, however,
during the existence of ftetal life, or soon after its extiuction, the
whole died.

If these couditious had to be accepted there would be au end
of the discussion concerning the saving of tlie child. I, for one,
would say no more about it, and willingly woidd adopt some means
of destroying tlie foetus ; or I would watch till it died, and tlien, after
waiting awhile, I should remove it, I'arry seems to have been greatly
impressed with the belief that the fatality attending the removal
of living 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 believe that it is only true that
they are specially susceptible to the influences of bad surgeiy 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 G-esai-ian operation and in the modern
methods of amputating a pregnant uterus convinces me that this ia
so. I never succeeded in getting a woman through a CieaariaQ
section, and I concluded that it was tlie 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 useil to do tlie Ciesarian
section merely to save the child, now I amputate the prtignant
uterus to save both mother and child, and therefore I begin to look
upon a man who does craniotomy as a person worthy of suspicioQ.

ABDOMINAL SECTIOK.

79

If thia revolution lias been effected about one puerperal
opertition, wby may not the basis of scepticism be applied to
Dr, Parry's tables and tlieir conclusioiis ? Further objections may
be urged against them. First of all, the figures are too small for
auy just oonclusioii. Then the conditions of individual cases, when
unearthed, are so dissimilar that they cannot with any justice be
slumped together in tabular fonn. The great majority of the
" primary " cases weie operated upon " in extremis," wliilst 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 ids 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 5P61 per cent. It
ia doubtful, however, if this can be accepted as the true mortality
after gastrotomy. Tiiis result is to be compared with that of the
tliii-d table, which shows appi-oximatively the mortality of extra-
uterine pregnancy left to nature, or, to speak more coiTectly,
allowed to progress without operative iuterfereuce until nature had
pointed out the way in which she intended to effect eliminatiou by
forming openings either through the abdominal walls, bowels,
vagina, or bladder. Of these women, 52'G5 per cent, perished, a
mortality of only 1 per cent, in favour of gastrotomy. Tliia is
certainly a very poor showing for sui^cal interference in this
unhappy accident."

The great, and a very important qualification of tins last
statistical statement is entirely overlooked by Dr. Parry, and yet
it ia rendered perfectly clear throughout the whole of his writings
on the subject, that these cases are only the renmants, the mere
survivals of a vast number who died during the processes of
suppuration, whereas a table of gastrotomies for living cldldren, or
children recently dead, represents no such residuum. To tho
mortality of the cases left to themselves there must of course be
added a large number of those who died wlien 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 tlie terms " primary "
and " secondary " in connection with these operations, for which
Dr. I'any ia responsible and in wliich I tlunk he has committed a
grave error. He regards as primary operations those in which the
life of the cliild was considered in determining tlio time for
interference or in which the operation was performed shortly after
its death, or near term ; and as " secondary " operations he has
placed all operations performed some time after the deatli of the
child, and when the system of the mother had recovered to a great

80 PKIMAHY AND 9EC0NCARK OPERATIONS,

extent from the " puerperal condition." It seems to me that those
terms are moat inappropriate and ill-used, and ore certain to be
most misleading.

In general sui^ery we have the words ^'imary and Kcondmij
operations, more particularly in relation to tlie amputation of the
limhs, used in difi'erent senses altogether, and so engrafted in
professional parlance as to have become an almost necessary part of
our conversation, certainly tliey are a great convenience. Used,
liowever, as Dr. Pany has proposed they should be, they would
be without meaning and would necessarily cause a great deal
of confusion. I would greatly prefer tliat if we were to
speak of a primary operation for e.xtra - uterine gestations,
we should speak of the operation for arrest of the haemorr-
hage at ttie period of primari/ rupture. My reasons for this
ai'e that according to the ordinary meaning of the English
language, abdominal section would then he certainly primaiy iu
point of date and also primary in the sense of being of greater
impoi-tance, that is to say of far more fref|uent 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 when tlie patient is
collapsed from shock, pain and liffimorrhagc, then the patient who
is suffering from collapse as the result of the violent pain and
hfemorrhage 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 anytliing
else we can conceive. Most of my patients have been so,
as much as if they had been cases of smaslied knee-joint,
and if left alone these cases must surely die. On the
contmry, 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 ngainst the introduction of these tenns
in the relation proposed by Dr, I'arry, is that they would practically
be determined only by saving the life of tlie 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, " No th withstanding the possibility of realizing this
Iiappy result, and even of saving both mother and child, as has
been done a few times, the primary oixiration cannot be too
emphatically condemned."

I cannot admit such a conclusion for a moment, for the

VAGINAL SECTION.

81

material upon whicli he has based it is made up of sucli discordant
elements, every one of whidi recjutres special ijualificatiou, that it
is quite impossible to submit it to a satisfactory investigation.
But even if we admitted his premiaaes, Lis argument after all is
based on a nine jier cent, difference only against an operation
which lias aaved child as well as mother ; and this even is to be
qualified, as I have said, by the mortality having Iweu influenced
by unintelligent delay and a vast amouJit of unscieutifie
iustrnmentatiou. One of his cases was operated upon (tiiisnceess-
fully of course) after having been in false labour tor over a week ;
and another (equally, of coursu, uusuccesaful) after moat 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 haa
survived the catastrophe of the primary rupture of the tube by
being extruded into the broad ligament. If its existence is
recogniaed during its life, the mother ought to bo carefully guarded
and watched till the false labour seta in, just as we watch a cose
for puerijeral hysterectomy and seize tlie onset of labour or its
early stage, as the most favourable time for both mother and child,

From this point of view, therefore, neither the time selected
for the operation nor the details of the proceeding will be
influenced save by two consideratioiis, not to operate before the
cliild 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 tliis down for the pnrpose, amongst others, of
excluding all operations for the removal of the cliild by vaginal
flection.

Dr. Herman has collected a series of twenty-three coaes of
vaginal aection 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 ia evident that there are so many points of
discrepancy, that it ia the merest nonsense to argue from such a
collection to any general, atill 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 difliculties
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 forma 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 hromorrhago, which was nearly
always the ascertained cause of deatli. My own experience of one
case ia quite suIBcient, and I shall never, under any circumstancea
whatever, attack a sub-peritoneal pregnancy from the vagina.

82 VAGINAL SECTION.

I give that case in detail as published ia the Medical Times and
Gazette for 1873.

"On July 16th, 1872, I was asked by Dr. Call Weddell, of
Bloomsbuiy, to see in cousultation with him Mrs. T., aged 32, who
had been suffering for some time from anomalous and periilexing
symptoms. She had had oue child, nine years previous to the
above date, and for some months had been under the impression
that she was again pi-egnant. For some days before I saw her sho
had been sufl'ering from feverish symptoms, and her condition had
evidently become very critical. A ci-esceutiforni tumour occupied
the pelvis and iliac fossa, giviag no special indication of its nature
from above, save that at oue spot less than half an inch in
diameter, and situated about an inch l)e]ow the umbilicus, there
was a distinct bridt, whicli waa much intensified when the pressure
of the stethoscope was increased. Vaginal examination revealed
a tumour beliind the utems, occupying the whole available space,
immovable, and with a peculiar boggy feeling to the touch, The
uterus waa open, four inches in internal meaauremeut, and
presenting very much the characters as if a miscarriage at the
third or fourth month had recently occurred. It was movable over
tlie front of the ttimour to a liinited 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 fm'ther 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, whidi
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 fcetns. I enlarged the incision, and
delivered a fcetus of about the eighth month, which had
evidently been dead for some time. As soon as the cluld waa
born I passed my hand through the aperture and searched for the
placenta, wliich I found situated in front. I also found that the
cyst had been ruptured above, and that some intestine was e.xtruded
into the sac. There was no difficulty in removing the placenta,
and no hremorrhage seemed to i-esult 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 Di-a. 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 utems waa enlarged and displaced,
being carried so much to the left that its right margin corresponded
to the middle line, and so much forwaixl that its fundus projected

VAGINAL SECTION. 83

over the symphysis piibia. The cyst was large enough to contain
two clenched flsta, 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 baa
come to the term or after it is dead ; second, v^nal section should
invariably give place to abdominal section, the latter being more
acicutilic and less risky ; and third, that the placenta should not be
interfered with, but 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
lingers 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. Rut 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 largo 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 ftetus ; then, if there bo 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 cliild under
such circunistauces 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 fetus 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
tlie cyst to extract the fcetus, which, however, could not be effected,
though the abdomen was compressed by an assistant ; but extrac-
tion was ultimately accomplished by forceps, and Eilthough the
child, when bom, was asphyxiated, it was nevertheless resuscitated.
The operation was attended with little hasmorrhage, and scarcely
any pain ; and in two weeks the woman was going about, and no
traces of the incision could be discovered per vnginam, — (An
American case. Medical and Surgical Itevieiv, 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

3

84 VAGTKAL 3ECT10N.

has no advaiit^e whatever over the suprapubic method, it poseeases
many disavantagijs. Dr. Herniau has very well summed up a
series of conclusions on this subject, wliich 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 objectiona to the vaginal operation, for after the death of the
foetus and the majority of cases will present themselves after this has
liappened, it is absolutely impossible to tell where 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 ftetal sac.
I am also of opinion that the most expert accoucheurs could not
accurately ascertain the presentation of an ectopic ftetus 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) TJie 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, ia 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 hfemorrhage, 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 some as those in hiematocele from any
other cause.

(4) At, or soon after, full term, before suppuration has taken

place, thera may be conditions which indicate delivery by
the vi^ina as preferable to abdominal section. These
are —

(5) When the tcetus 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 fi'om the vt^nal canal,
that the placenta is not implanted on this side of the sac,
and it is not certain that tiie 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 coUeeted a number of cases from which he draws
the conclusion that about seventy-five per cent, of the cases which
00 towards full term (that is, according to my views, of the cases

ABDOMIKAL SECTION.

85

which survive primary rupture, and are developed extra*
piiritoneally), arrive at that term, and die at or shortly after it,
(if not destroyed by sui^ical interference), the minority dying at
various periods in the progress. I have not tested tlie evidence on
which lie bases his conchisiona, for I do not think iliey are of
. much niomeut. I am inclined to think that most of tlie 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 tlie steps of the operation will l>e 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 — tliat the opening should not be made in the
middle line, so as to avoid opening the peritoneum. In fact, the
ojioration should not be an abdominal section at all, in the strict
sense of the defiuition I have adopted. This fact has been the
cjiuae 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 oi-dinary
incision in dealing with a case of ectopic pregnancy we must reveit
to the explanations already given of the process at the time of
rupture, and to the views I have advanced, tliat all the full term
ectopic pregnancies are those which have grown in the broad
ligament — extra-peritoneally. As they grow they separate tlie
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 ixjund as a point
corresponding to the coruu of the uterus on each side, The result
of this is that tlie posterior and lateral levels oE the reflections of
the peritoneum are raised very materially, whilst tlie 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 an-angement in them
is less systematic, and the explanation of both is simple. The
peritoneum la very easily lifted off any of the organs round which
it is wrapped, if the process is slowly carried on. The gi-owth of
the ovum, therefore, easily lifts the peritoneum everywhere if the
pull is direct ; but when the pull comes to be indirect, as it must
be the moment the top of the fundus is reached, the lifting of the
peritoneum ceases, and the long tubular process is formed. As the
growth of tlie ovum is not quite symmetrical, this tube is some-
times on one or other aide, and sometimea in the middle, and

86 HART AND CARTER'S HESEAKCHES.

therefore it la that some of my operationa 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 hut well to one side.

Tliis curious lifting of the peritoneum may of couriie be
interrupted by a secondary rupture of the sac into the peritoneum,
and we may find — probably sliall — that many of the minor varia-
tions which are quite well established, such as invasions of tlie
intestines by the placenta, are due to the same cause. We may
also find, what I have already indicated aa a probability, that
direct primary rupture into the peritoneum of a tubal pregnancy
of the twelfth week, may end neither in the death of the mother
nor in that of the cliild, 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 fretal sac always lias witli the posterior wall
of the uterus.

What was, on my part, originally a pure speculation concerning
the methods of origin of tlie relations of the peritoneum and their
details, lias 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
described 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 Edinhurgh Medical Journal for permission to reproduce an
admirable illustration wliich will assist my readers gi-eatly 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 Eoyal Infirmary, and found her with a
tumour the size of a eocoanut in the site of the right broad
ligament, and reaching from tlie 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.
l''rom the history of five months' amenorrhtca, 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 ligameut. 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 l>e done. Blood
poured out whenever the peritoneum was opened, and on passing
the fingers in, rupture deep down through the posterior lamina of

HAET AND CARTEKS BESEAHCHES.

87

the broad ligament waa found, a condition which did not admit o£
removal of the sac, inasmuch as it had developed down between
the rectum and the vagina. The incision waa therefore closed, and
the patient sank in about ton hours.

At tho post-mortem, which was performed by Dr. Bruce, the
bony pelvis and contents were removed and frozen, and in tliis
way tlie relations wei-e preserved — an impossibility if the parts are
scooped out from the pelvis in the usual way.

The pelvis when frozen waa sawu in tlie mesial, right saggital
lateral, and left saggital lateral planes, bo aa to cut sac and uterus.

The following points are noteworthy : —

In the mesial line the fcetus and placenta are contained in a
sjmce bounded above by the laminte 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, tlie 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 hajmatoma between the peritoneum and the
rectum. Tho 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 iutra-peritoneal rupture, entirely
extra-peritoneal (v. Plate I., Figs. 1 and 2},"

The description here given by the authors couclusively
establishes the process of primary rupture into the cavity of the
broad ligament, for which I liave already advanced very many
arguments, aa the explanation of the occuiTence of the sous-
peritoneo-pelvienne variety of Uezeimeris. The rupture, which
was the immediate cause of death, was the secondary rupture
into the peritoneal cavity which I have already described aa having
occurred in Nonat's case, and I tJiink 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 fasliion that I have described
(p. 32), a more satisfactory ending of the case would have been
arrived at. But the unfortunate tei-mination is, at least to some
extent, compensated for by tho brilliant contribution to the
elucidation of tiie pathology of ectopic gestations, of which it has
been the itamediate cause.

The second specimen " was the unopened body of a female,
aged 33, small and veiy emaciated, who was supposed to have
goue a little beyond the term of normal preguaucy ; but little

88 IIAET AKD CARTEKS ]{ESEAi;cllES.

information of any kind could be obtained, as she was destitute,
with no friends. Tlie usual appearance of a multiparous pregnancy
were present, witliout any varicosity of tiie venous system."

" On delivery into the dissecting room the extremities were cut
off; and the head and trunk, after a process of freezing by means
of ice and salt, were cut into a scries of sE^^ital, mesial and lateral
slabs, six in all, of about IJ inches in thickness. These slabs may
be for convenience mentioned as IE, 2R, 3B, 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 fii-st great point to settle is the
relations of the peritoneum to tlie 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 fcetua 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 ia 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 fimdus 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 peritoneiun has been entirely stripped away
from its posterior and the upper part of its anterior surfaces, and
from tlie fundus bauds of tissue connect it with the upper and
inner surface of the fiEtal aac. On the left side of the fundus a
small fold of peritoneum enclosed the left Fallopion tube and left
ovary."

" Tlie left Fallopian tube passed obliquely dowuwai\ls from the
left side of the fundus to the left iliac fossa, ita limibriated end
being attached to the tumour."

" nie 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. C.) It measured
1" X 1} X I 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 tnhc ami ovary
cannoi he identified, being takC7t vp with tlie sac. Owing
to the surfaces of the peritoneum being more or less adherent.

HART AND CARTER'S RESEAECHES.

89

it required great care to trace its general relation, In tlie mesial
section it will be seen to be reflected from the inner surface of tbe
anterior abdominal wall on the front of the uterus at the upper
level of the piibes ; 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 tbe peritoneimi is there
reflected on the fcetal 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 lietiind the
membrane is reflected on to the rectum at about the level of the
fourth sacral vertebra. On tbe left side the peritoneum passes
from the left iliac fossa and covers a small portion of the upper
part of the body of the uteinis, and from this is reflected on to the
capsule, forming a fold iu which the left Fallopian tube and ovary
are enclosed. The relations of the peritoneum to tbe other organs
do not require any special remark. On the right side the peritoneum
is lifted up. The foetus has thus developed beneatli the peritoneum,
elevating the folds of the broad ligament after distending them, and
iu 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 He at the level of the fourth and fifth sacral vertebraEe.
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 iu the sections.
Microscopical examination of its walls were made at various points,
viz., at its uppermost portion, and also at tbe anterior abdominal
wall below the peritoneal reflection (Plate II., Fig. 4)."

" In the former part there was peritoneum and un,9triped muscle,
showing the Fallopian tube origin ; in the latter, connective tissue.
The capsule was thus foraied by connective tissue, bounded outside
by the special structures displayed, viz., either by muscular
abdominal wall or by peritoneum. On the right side of tbe body a
deep dissection was made from the skin, and the ccecum and
peritoneum found displaced up."

" The Uterus. — The cervix contained a plug of mucus, and in
tbe flattened cavity of the uterus was found a small amount of
disintegrated tissue. The fcetus is situated below the placenta and
between the uterus in front and the abdominal wall beliind.
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 tlie abdominal cavity and extra-peritoneally, and
lying above tbe 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 veitebra to a little below the upper border of
the first sacral vertebra. It is attached to tbe posterior aspect of

90

HABT AND CABTEK'S RE8EAECHE8.

the anterior abdominal wall and outer surface of peritoneum.
Wliere attached to the anterior abdominal wall, the voiua thei-e are
enlarged."

" The diameter of its long axia is 13'5 cm., and its average antero-
posterior measurement ia V'5 cm. Arouud it ia a thiu iuvestuient
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 between the
capsule and the placenta, wluch was filled with a maas of grumoua
blood, and gases of decomposition, the poaitionof which corresponds
to a well-defined darkening of the skin of the anterior abdominal
wall, as if the patient had suffered from a sevei"e blow or fall.
The foitus weighed 2 lbs. 4 oz. without the umbilical cord. It was
fairly well nourished, hU decomposition had coiinitcnccd. especially
at tiie lower part of the abdomen."

"The consideration of these two sections shows, therefore, a
special phase in the development of e.>;tra-uterine gestation. Tliey
demonstrate that a Fallopian tube pregnancy may develop between
the layers of the broad hgament, and may continue this extra-
peritoneal mode of growth, stripping off the peritoneum from tfie
utenis, bladder, and pelvic floor until it becomes in great part
surrounded by a peritoneal capsule derived fix>m these organs. All
this is done without any actual intra-peritoneal invasion. The
placenta in the advanced gestation case is attached in front to tba
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 gi-ew extra-peritoneally,
lifting up the peritoneum on the right side of the middle line, both
anteriorly and posteriorly, and also stripping the posterior uterine
wall and upper part of the anterior uterine wall. The extra-
peritoneal tissue, with its blood-vessels, ia therefore not only
capable of forming anastomoses in abdominal anemism, 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 the
placenta. At first it lay in the Fallopian tube, but the growing
ovum has slowly pushed it up (a procesa attended with blood
extravasation) from pelvis to abdominal cavity, mitil at last its
upper edge is about ten inches from its original site. Part of this
is duo 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 cxti-a-uterine
gestation. Much has been written, and little reidly demonatratad
on this point. Tlie Tubal variety ia 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

[

HART AND CAETEIl'S REBEAHCnEB,

91

DoKeJmeris, Tait, and Werth, is demonstrated in the second speci-
men, whicli also shows the ovary thinned out on the posterior
lamina of the broad ligament. Tlie presence of 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 ia Sub-peritoneo-pelvic."

"The chief interest centres on the anatomic^ nature of abdominal
gestation. The second case shows that this can be cxtra-peiitoneal,
a fact never hitherto demonstrated, altliough strongly contended
for by Tait. We do not deny that we may have either a partial
Bxtrii-peritoueal and iutra-peritoneal variety, or an entirely intra-
peritoneal variety, but wo ask for actual proof of such. If it be
urged tliat a purely intra-peritoneal form must exist because
placenta has been found attached to the uterus and intestine, wo
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
viscera, but yet carrying a layer of peritoneum before it, he still
extra-peritoneal. We, therefore, hold that the following varieties
have been demonstrated, viz. : — Tubal, tubo-ovarian, sub-peritoneo-
pelvic, sub-poritoneo- abdominal. An abdominal variety, partly
intra-poritoncal and partly extra -peritoneal, is probable ; a purely
intra-peritoneal variety has yet to be demonstrated, and the same
liolda good aa 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 recoi'd,
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, aa 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 tlie rupture thi-ongb which the
ovum escapes into the broad ligament takes place at that part of
the tube wliich lies at the junction of the two laminae. The second
point worthy of note are that even in this case decomposition had
commenced, and that, therefere, had the woman been received in
the clinical ward instead of the diesccting 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 ILLUSTKATIVE CASES.

that what is termed clinically retro-uterine litemato-
cele may be htematoma.

Part II.
Fig. 3. — St^gital mesial section of cadaver, with advanced extra-
uterine gestation — subperitoneo-abdominal (IE).
Fig. i.^Saggital lateral section of same (2R).

Plate III.
Fig. 5. — Sa^ital lateral (2L) of same.
Fig. 6. — Saggital lateral (3L) of same.

Dr. James Eraithwaite, of Leeds, recoi-ds two cases in wliich he
operated auccesafully, and lie has given such interesting details
(BHtish Medical Jownal, Jan. 3, 1885), all of which du'eetly
support the views I have advanced in the preceding pages, that
I need offer no apology for quoting them at length.

The first ease had symptoms of primary rupture at the thii-d
month of gestation, aud was opei'ated upon about a fortnight after
a spurious labour at the full time, the opemtion taking place 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 hy its feet, hut it proved so lai^e that it was
necessary to extend the incision upwards another inch. This
unfortunately detached the cyst from the abdominal wall, aud a
coil of bowel protruded into view at the upper part of the wound.
The cyst was carefully stitched to tlie 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 eyst was of considerable thickness, already black
from decomposition and lined with a smooth sliining 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: aud I
recognised the catgut wliich 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 cai-e was used hEcmorrhage occurred. When the
whole of tlie 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.

ILLUSTRATIVE CASES.

93

" Case 2. — Mrs. W , of Holbeck, a patient of Dr. Dodson'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
occciin-ed. Menstruation all her life quite tegular and natural ;
the last period was about October 15tli, 1883. On December 3rd,
having missed exactly seven weeka, she was sliglitly unwell, and
had at the same time, to use her own woi-ds, " a very violent paiti "
in tlie body. The symptoms were such as would be produced by
rupture of an eai-ly tubal gestation — viz., pain and collapse. She
recovered from this, but the body went on increasing in size just
aa in normal pregnancy. At the end of August a aanguinolent
discharge occurred, and this therefore may be taken aa the time
when labour would have taken place liad gestation been uterine.
Tlie movements of the child, however, ceased to be felt aboiit the
end of the first week in August. By examination of the abdomen
the outlines of the child were not pereeptible as in the last case,
but some thick substance intervened, which subsequently turned
out to be the plocouta. This much inci-eased our difBculty 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 frctal or placental sounds audible. Tlie uterus raeasuretl
only two inches and three-quarters and the cervix was w&M open,
80 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 tliat, 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 seporation
of the placenta in this direction did not produce hfeniorrhage, An
incision at right angles to the firat 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 afterwanls, this was the case. There were no veins in
the abdominal walls at the seat of the placental attachment except
just at tlie 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, tlie funis being left out,
and a drainage tube inserted, both at the extreme right of the
lateral incision. An attempt to separate the placenta with the
finger and traction in about two weeks set up htemorrhage, and it
was not attempted again until the discharge became very decidedly
purulent at the end of six weeks. The whole of the placenta

94 1LLCSTBA.TITZ CASES.

wliinli luul not been romoved, for (tome small portions Imd been,
Wiu> at tli't v.iu\ lit Rix weckfl neftamted by the finger aud removed
witliniii iiiii'Ji dilliiiulLy. It wci^'hcd thirteon ounces. The patient
i>i nI ill in thii him|iilul, but 'm iiunrly wull. In intrcMlucing the finger
fi;r iviiii.viil uf thd jiluci-iita I felt tho cyst walla, which appeared to
|ir> |>rir|ly firm uinl thick.

" '1 111' llrHt thiuK worth remarking in tlie hiatrtry of these cases
JH t,hc oiidiirrouou of siiverc iMitu early in gestation, attended with
Nririjd dMgniu of collnpHe, This indicated rupture of the Fallopian
tiiltii, ill wliich, lip to that period, t)io fa'tus had resided, and ita
(iNiiii|ii' in ihi^ Ili'Ht ciLHe into tin; interior of the broad ligament, and
In llin Moniinl into tho peritoneal cavity. I assume that the
ii%|iliUiiiti'Mi 1)1' tlicHo ciiRca given by Mr, Lawson Tait is the correct
dill', iinil I Iidlitwo it to be ao — namely, that all cases are originally
lilbid. that riiiituiti Fdwuyn occurs, but tliat tliia raptuTO may be in
ilUI'uniiit pnrta of tho tulm ; and if on tho lower surface of the tube
tliii I'li'tiiH is lot down boLwoen tho folda of the broad ligament, and
th«n dtiV(ilo]iH, tlio plucenltL retaining its original hold upon the
iiitorior of tliii tubal cyst ; if the tube ruptures on its upper surface
the firtUB eacii]iea into tlie puritouoal cavity; and if the mother
HurvivdH it develnpiis there just as it would have done in tlie
utiTim. It atHMus pit'tty clow that in my second case the placenta
wuB dt^taohod fitnu H» original {xisition and took root again in a
frwili one, uiid tlmt tlio interior of tho abdominal walls. This
aituntiou of the placenta is rare, and I tliink it may witliout much
ililllutllly bo dingnoaed by the thickness of the structures inter-
viuiiug U'tweon tho fa'tus and the examining hand."

Or. \l 11. Miinry. of Monipbis, has recently published the
di'tjtib iif the iH«t-morU'iH oxaniinatiou of a case which completely
ciuilirnis ihe c^uu-lusiona of Hurt and C'urter ; and now that the
favljn )\ro known, doubtloss, itiforuatiou will be abuudaut, and the
idd wnl'Uaion will a|»(wiUly will.

" Tho i»elvio oi)iuus wwe carefully remo^-eU. and it was then
jBlOU U.>yin>d all iHwsibility of doulit Uial the fuftal sac was entirely
vxtm-in'riUuit^al. lliat tlw jpfslatiou had originated in the right
K»Ui>|>i!tu tuU*. aud hitd dewlot^t U'tweeu the folds of the broul
liSWiU'nU dowiiwai\l lo (he (>elvio flix>r, ktendly to the pelvic wall,
Htid UV^^'^^I >»t** ^*> aUhtiuoii.

" Th(> ovum iu its davuloinuent had lifted (he peritOBcnm off
(iTAut tlw l4*tMor tUMl tlte aut«ncr suifitoe of the atans, vUle tic
niklMtts o( dw )vmtoiM<uiu to the pcstcnor ataiae vail umI to
l>Mig^'!S potttji wwe wA altco^xL

" Ttw ac «cl«Mk«l >iait« to the pdvtc nA ■'*-*r*^-' vail on
Uw 1^ ^di^ b«t dht not go lM>y«i>d Uw 1^ «on« «r the stens

I.

yiriMMNi^ «iA Ais VM ch«^ abvni

' MUMVM to w cwtnd ^v
after telk.

DETAILS OF OPERATIOK.

95

" The gestation was therefore entirely extra-peritoneal, and
belonged to tlie variety, iutra-ligamentous of Werth, or sub-
peritoneo-pelvic of Dezeimeris.

" No trace of the ovary was discoverable iu the structures
belonging to the sac, hut ou the left side the ovary was found
much shriveled and otherwise changed in appearance,

" This autopsy conxjboi-ates the view taught by Mr, Lawson Tail,
that in extra-nterine pregnancy, no matter where tlie ftEtus may he
found, its development begins in the Fallopian tube, ' and that it
may become intra-peritoneal or extra-peritonenl, just as the tube
happens to burst.'" — Memphis Medical Monthly, March, 1888.

We come now to consider the further details of the operation
of removing a foetus developed in the broad ligament at or near
or past the full time of gestation ; and no variation ou this point
will make any (.Uffereuce 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 liistory together with the
physical signs will probably enable us to decide on which side of
the middle hue 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 ii-om the middle line
and towai"ds that side in which the pregnancy lias been developed
— if this point can be detennined. 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 lianded 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 he hermetically closed.

By means of my syphon trocar the sac should ^in 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
bo reversed and the sac emptied of water as much as possible and
the trocar removed — in so doing care should he taken that no air
enters, and that the wound is hermetically closed,

I reconunend this proceeding from the splendid results I have
obtained by it, in dealing with congenital cysts (Traus. Gyniecological
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 tlio same means being tried
for success in the other. Tlie crux of the discussion is, of course,
the removal of the placenta, and 1 have tried all ways with it, and
I am disposed to think that leaving it will he tlie best. I have
ah'eady detailed a disastrous case where I removed it by vaginal

96

TREATMENT OF PLACENTA.

section. 1 have twice removed it, aiTesting easily wliat hreinorrliage
there was by the application of percliloride of iron. Both cliildreD
were alive and still live, and both mothers survived, hut in both
cases I was able to tie a big pedicle — the reiniiins of the tulie aud
broad ligament— whicli doubtless eontaiiied the bulk of the blood
supply to the placenta. This proceeding I certainly should
recommend in all cases where it ia practicable, and from nij own
experience alone it seems certain that it will he 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 whicli it would have been
removed only with great difficulty aud much hajinorrliage. I
confess under such circumstances I should hesitate before com-
mencing its removal, hut 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. Braitbwaite's first case) all save an aperture through
which I brought the umbilical cord and a drainage tube. TIjese
three women all survived, but they survived a process of offensive
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 ceitainly, therefore, am not in love with this method of
dealing with the placenta — for it deliberately induces the process
of necrosis, which I do not in the least believe is necessary.

We must bear in mind that when the placenta has acquired
adhesions outside the uterus it is in a condition altogether
diffei-ent from that in whicli it ia placed when in contact with the
endometrium. In both cases it is of course essentially a foetal
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 replaced,
which are not present when its columnar villi invade intestines,
muscles, and other matornal stmctiires. Again, when the process
of labour is going on in the utei-us, every contraction of the organ
tends to disturb the comiectiona between the ftetal and maternal
tissues, so that when finally the complete contraction of the uterus
is effected on the expulsion of the child, the placental relatious are
completely diaconuected by the mere pressure of uterine coutrac-

TREATMENT OF PLACENTA.

97

tiwii. Ko such disconnection occurs to an ectopic placenta. Tlie
histories of all the cases where an extra-uterine pregnancy lias
gone on for an indefinite period after the tei-m of gestation without
disturbance, show conclusively that all the tissues except the bones
are capable of being digested and absorbed, and even the bones to
a large extent yield to Uiis powerful influence. The placenta, as a
rule, is the first of the tissues to disappear, even despite the
somewhat numerous instances to wliich I have alreaily alluded,
where the placenta at first seeins inclined to grow For the majority
of cases sucli 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 fcetus, we should have the advantage at
least of having gained time in the treatment of the case ; for
nothing lias so strongly impressetl itself upon me in my experience
of abdominal surgery, that we may deal safely by secondary steps
with conditions which, had tliey 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 fcetus
ouly, 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
whicli 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,
whicli could not fail to be produced by groping for it among the
abdominal viscera, or the hfemorrhage 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 fcstus, 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 ease of great iuterest in the consideration of this point
is narrated in the " Obstetrical Transactions " of 1887, by
Dr. (Jhampneys, in which the proceeding whicli I now recommend
was more nearly carried out than in any other I have seen. Tlie
placenta was emptied of blood, but unfortunately the cord was not

13

98 TBEATMEHT OF PLACENTA.

cut short, but was allowed to haug out of the wound, depeiidance
haviDg been most unfoitunately placed upou the so-called
autiseptic ayatem to prevent decomposition.

The operation was performed on the 19th 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," Subseq^uent events made
it perfectly clear, however, that the patient was suffering from
placental decomposition and reaulting 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
poat-mortem examination the placenta was seen to be lying in the
aac like a round ball, as large as a fcetal head, and of a dark
maroon colour. On passing t!ie fingers round it a few bands and
one or two adheaious were found between the placenta and the
sac, but otherwise the placenta was detached. The blunder, of
course, in this case was that the fcetal aac waa not opened a second
time, and the placenta removed immediately at the outset of
serious symptoms — that is to say, within five weeks of the original
operation. It is perfectly astonishing 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, tliat
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 leas 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 upou me
not only by my experience in ectopic gestations, but by my
experience in a large mmiber 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 hut confusion when paraded in the form of statistical
evidence.

Campbell gives a very interesting list, and withal a veiy ghastly
one, of instances which he has unearthed where there have been
multiple extra-uterine gestations, and of instances also where they
have lieen 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 FCETDS.

99

individuals all tlie decomposed stnicturGS were evacuated through
tlie abdominal parietes, and each recovered. Nine -women
conceived onco during the retention of the extra-uterine fcetus ;
two, twice ; one, three times ; one, four times ; one, six times ;
and one aeven 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 mouths 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 yeara 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 yeara in one, thirty-two years in one,
thirty-tliree 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. lu 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 vagiuam, and three of the patients died."

True lithopiedion — 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 hfetime 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 Edinhurgh Medical
Journal for 1862 : —

. was bom

.. 1778

was married

.. 1795,

at the ag

BOf 17

first child

.. 1796

_j

, 18

second child

.. 1801

^^

, 23

pregnant

., 1804

, 26

third child

.. 1808

, 30

fourth child

.. 1815

, 37

died

.. 1858

„

, 80

100

TBtJE UTHOPjSDION.

No history of the third pregnancy. The autopsy was performed
September, 1858. The tnmour 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 fcetua, head uppermost, looking to the
left and downwards. The spine and back were in apposition with
the right aide of the cavity ; the head was decidedly compressed ;
the cord couM 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 alow recovery
ensued, attended by a hard tumour in her side, which caused her
no iiiconvenience 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
fcetus, 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 ot 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 ; fcetal
movements appeared at the usual time. Premature labour was
begun at eight-and-half months, as the elfect of a fright. 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 iiTegular
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 fcetus 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 eighty-

TB0E tlTHOP^DION, 101

two, of pneumonia. At tlie autopny tlie tunrnur was fonnd to be
attached to the walls of the utenis. It wna about the size of a man's
head, ami here and there, over its surface pointa of calcification
could bo detected. The uterus, right tube, and ovary were normal ;
the left ovaiy was wanting. The fcrtus was enveloped in a
capsule, and was in a remarkably well-preserved state ; the face,
internal organs, and even the atriic of the mnsclea being
recognisable. The placenta was found, but its position is not
stated.

" Case 5 ia reported by Ur, Ualli, in La Spcrimenlalc, xxxix., 2,
p. 135 :—

In this case, two children having Ijeen born, pregnancy,
occurred, for the third time, at the age of thirty. FcDtal move-
ments ceased after the eighth 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 cairied for
thiity-seven years. In her sixty-seventh year she fell, and
probably disturbed the lithopiediou, as a violent peritonitis
intervened, from which she died. The autopsy revealed a well-
formed lithopffidiou ; but nothing further is stated.

" Case 6 is reported by Di'. Plexa, Moiiatschr f. Geburtsh, xxix.,
4, p. 242 ;—

In this case symptoms were manifest whicli caused the diagnosis
of extra-nterine pregnancy to be made. There were repeated
attacks of abdominal pain, accompanied by fever. TJiese gradually
subsided, and strong hopes were entertained that this case would
eventuate in a Lithopredion. After one and a quarter years,
however, a peritonitis ensued, from compression of the intestines
between the tumour and the abdominal walls, whicli caused the
patient's death at the age of forty. At the autopsy it was found
that the fcetiis had entered the abdominal cavity by the bursting of
the left Fallopian-tube. The right ovary and tube were normal.
The colour of the fcetus was daik-brown and calcification had
begun.

" Cask 7 is reported by Professor J. Van Grau and Dr. Schrant
in Oeaees. en Hciihfnde te Avisterdam, ii., 1, pp. 17 — 9G : —

The patient was married at twenty years of ago. Had seven
children, and three miscarriages. Twelve years before lier death
she noticed a gradually increasing swelling of the abdomen, The
tumour was distinctly movcablo, and appeared to be adherent at
the umbilicus. A diagnosis of lithopfedion was made ; and, at her
death, at the age of forty-two, in the Amsterdam Hospital, this

102

TETTE LITHOP^riON.

was confirmed. The tumour was free, except at the front, where
it was attached to the ahdominal walls. Tlie fcetua was developed
in a calcified membrane ; its head was situated at the iimhilicua,
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 brownish substance, attached to the tube. After the
covering was stripped off the fcetus was seen with the head, legs,
and arms drawn towaixls each other. The interna! organs, muscles
and other structures were easily i

" Case 8 is reported by Dr. Wagner, Arck. der Heilk, vi., No. 2,
p. 174 :—

The patient was a widow, sixty-eight years old. At the age of
twenty-four she liad given birth to five children, In her thirty-
seveuth year she again became pregnant, but was never delivered ot
the child. Labour-pains were not present. For a long period the
abdominal enlargement remained constant in size, and Cieaareaa
section was advised, Finally, the tumour began to grow smaller ;
lier 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 fmm 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
sknll was markedly compressed, the bones iaverlappiug ; calcification
was present, but not uniformly. The various organs and muscles
were not distinguishable, being changed to a fatty mass, which
contained htematoidin ciystala.

" Case 9 is reported by Dr. Hossi, Siizmeister d. Vereiiis d. Aei'tze
in Steirmark, xi., p. 37 : —

In this case a lithopEedion 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 fcetus 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
noi-mal. Eight ovary atrophied, left one adherent to tumour.

TKUE LITHOPjEDION.

103

" Case 10.-—' Tubingen [naiigural-Abliitndluug,' von Willielm
Keiser,

The ]itliopa;dion waa found in a woman ninety years of age, in
1720, lu 1674 slio had all the symptoms of pregnancy, fcetal
iiiovenientB lieing very noticeable. At the expiration of nine
months labour-pains started up ; the membiuiies ruptured. Pains
continued for two weeks, and then gradually disappeared ; tlie
ftutua having appoi'ently 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
with 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 foetus 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, whicii was pulvenilent 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.

" Oase 1 1 is reported by Smellie in his ' Collection of Cases and
Observations in Midwifery,' vol. ii,, p. 65 :—

The 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
yeara and two months from lier 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. Slie died November 7th, 1747. The autopsy showed the
obdominal contents to be neai'ly in their natural state. In tlie
right pelvis wua a cliild, attached to the ilium and neighbouring
membranes by the peritoneum, in which the tube and fimbrae
were apparently lost. The fcetal integument had become partially
calcified,

" Case 12. — In giving the Iiistory of this case I hoped to quote
fr<.iiti the record books of the physician in attendance at tlie time
of the accident, who, as I understand, took extensive notes, but
I am unable to do so owiug to his death a few years ago, and the
subsequent destruction of his records. I am fortunate, though,
inasmuch as such infoimation as I have of the case cornea from
u twin sister, who is still a remarkably vigorous woman, both

^

KM

TKUE LITIiOP^DION,

moiitnlly niitl pliyHically, iiiid whose Btatc-meiits, aa far as timy go,

are undoubtedly correct. Mrs. A was martied September 24th,

1844. Sbe never hpid any miacarriages. She was delivered of a
perfectly Iinnlthy cliild, January 29th, 1848. Early in Jauuaiy,
185ti, she bocanio, na events proved, pregnant again, though her
condition at the time was merely surmised, aa menstruotion
continued to be present, and, in fact, existed, with more or less
mgularity, throughout her entire jiregnancy. It waa not until the
middle of May that the attending physician made a positive
diacHoBis of pregnancy, basing his opinion on foetal movements,
which became manifest at that time. Early in March, while
visiting friends, she fainted, vomited, and complained of epigrastric

Sain. There waa no (lowing at this time. The following
ay alio rode home, a distance of four miles. I^irectly after
this slio 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 pubea, which opened, but did not di^diat^
mucli, if any. Counting from the middle of May, when f<£tal
movements began, October 1 would be the probable date of
coufiuomeat About that time the physician was summoned, not
on account of labour pains, as she never had them, but on account
of excessive and paiuful movements of the child. These were
always wry marked, and caused her tiie 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 " somelliiug was rubbed on the abdomen," after whidi
tha movements gi«\v less and less, and finally ceased. For the
foUowiug ten years she n'as an in^idid, though nothing veiy
explicit could be obtained as to her condition. She was geneially
luiseiaUe:. and had a number of attacks of abdominal pain at
irregttlar intervals, sometimes accompanied by icterus. Onring
this period the tumour very gradually decreased in ^ze, finally
reuuuning stationary, and causing no trouble other than a feelii^
of weight wht'u standing or walking too long. Her healdt was
Eur until 1$$S, when a malignant grv>wth attacked her huynx,
which etvutUAted iu her death IVcembcr 24. lS^t>. The antopsy
w*s perforeied I>eceuiber 2^, ISSiO. Drs. Bill and Metcalf *«i«ring
The body Ytas \-ert' much emaciated. The tumour was appanotlj-
sttuAted in the me^Uau line, with its most piominent punt »t tlie
)uuliiUcus> hut i>u (idliiatiitu it was fuuud Iu extend downwards aad
h> the left. On lunkiug the iucistuu it was fi>und tu be adbwcBl
to the abdiHBLiiwl wsUs, aud it s««aie<l ta tbou^ it vooU kki«
soon BMida ite «n^ tkpM^ eitbw Eroiu pmssnie or "**°t-*'*". a»
tUued tad tbo stradune beoMM at tlM» i»uit of its adWoocnk
The poeitMii vf the tuwMr may he beet di«eehbe«l by bo m w ia g

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 probably 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, the hands being placed well up beside
the head. The tumour weighed 2f lbs., was 8J inches long, and
12 J inches in circumference. The cross section showed it to
consist of a fa'tus and its envelopes, the process of calcification
being especially marked in the membranes. The 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 G7."

We are quite justified in concluding from such records that
Campbell and Parry are correct in their belief that a " quiescent
lithopaedion " 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

INDEX.

Abdominal Gestatiojt SB

Section for eolopio genUtion ... 77

daring pnerperal period ... 79

Primsry and Secondary

rnplure 80

Blaiidbr, discharge of Buppnntiiig aac

Into 67

Caksn of ectopic gcstition operated

upon 45

CoQceptioD, normal ieat of 4

Ectopic GraTATiod, cauae of 4

Clinical history of 6

Electrolysia in tubal gestation CIS

Exploratory iocision, principle of 23

Fallopian Tubk B

F»EtuB, ttbiorption of 88

Gehtatjon, AWominal fiB

T. R, Jeasop'a case flft

Ectopic, scheme of 8

Illuatrative casei 23

rrimary and Secondaiy

rupture 49

HOTOial 8

Interstitial 6

Casp of 47

Rupture of 6

Oirarian B

Spiegel berg's case 10

fipanville's case 12

Dr. Walter's Hi«eimen 12

M. Puech's case 11

' its jKiHsibility 12

Sous pfriloneo-ptlvienne variety 55

Tubal, iliiRnosin of. fl

Pathology of 6

multiple 98

Mr. Hallwriglil's case 20

liaptnrc of 18

nnrupturiid, symiitoms of,. 18

Retention of frilus 99

Dr. DoUn's case 21

Suppuration in niplured esc 67

Tubo-ovarian 13

Pag*
Hart and Cajitke — Researches on

ectopir pitgnnnry 86—82

Hicmatoccii', ^lelioition of 27

Exlra-pcritoiieal 31

Csuses of 83

Suppuration of 36

iDtra-periCotieal 36

Causes of. 37

Exanthemntic 40

Prognosis 40

Treatment 41

ol broad Ligament 64

Pelvic 26

Herman's conclusions in re vsgiual

section 84

luPHEOKATiOH, I'hyMology of G

Theories of 8

LiTHOi'AJixos, Cases ot 99—105

Quiescent 105

PmiTTONiTiH after ruptured tubal

pregnancy 64

Placenta, extrusion of in ruptured

tube 14

Growth after death of fcBlns ... 74

Secondary attachments to viscera IS

Treatment of after operation ... 96

Pregnancy, bifid uterus 84

Rkctuh. discharge of tuppurating sac

through 57

Relation of uteris to gestation sac ... 67

SiTPi'uiiATrNQ FiETAL Cybt, abdominal
B«.:tion in 68

Tappcso. dangers of 08

Treatment uf ectopic gestation TO

by electricity 72

Umuimi^ith, discharge of soppuraling

aac through 67

Uterine Walls, abnormal thinness of 83

Vaiitna, dlschaise of suppurating

contents through 67

Vaginal section for ectopic pregnancy 82

(

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T13 Eotoplo pregnancy and

1888 pelvio haematooele.