Columbia Wim\)Mit^ 
 in tf)e Citp of ^cbj |?orfe 
 
 College of ^tP^ictans: anb burgeons; 
 
 ^tttvmtt l^itirarp 
 
ft! \.' 
 
 r 
 
EXTRA-UTERINE PREGNANCY 
 
 A DISCUSSION. 
 
 REPRINTED FROM THE TRANSACTIONS OF THE 
 AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, 
 
 VOLUME I., 1888. 
 
 WITH AN APPENDIX REVIEWING MR. LAWSON TAIT'S 
 ECTOPIC GESTATION AND PELVIC HEMATOCELE 
 
 PHILADELPHIA: 
 
 WILLIAM J. DORNAN, PRINTER. 
 
 188 0. 
 

CONTENTS. 
 
 PAGE. 
 
 I. Its Pathology. By Franklin Townsend, MD j 
 
 Report of Dr. Parkhdrst's Case of E?:tra- uterine Conception . 13 
 
 II. Its Diagnosis. By Joseph Price, M.D 15 
 
 III. Its Treatment. By E. E. Mont(JOMERY, M.D 21 
 
 IV. Observations — Clinical, Pathological, and Surgical. By W. H. 
 
 Wathen, M.D 27 
 
 v. A Critique of its Management. By J. M. Baldy. M.D. . . 35 
 
 VI. The Technique of the Operation. By John B. Deaver, M.D. . 39 
 VII. Its Management when the Fetus Survives Tubal Rupture and goes 
 
 on to the Period of Viability. By L. S. McMurtry, M.D. . 43 
 
 VIII. Its Treatment (cont??<c?erf). By A. Vander Veer, M.D. . . 47 
 
 APPENDIX. 
 
 Ectopic Gestation and Pelvic Hematocele. Considered in the light of 
 Mr. Tait's views — being principally a discussion of these as 
 enunciated in his lectures on the subject. An editorial review. 
 From the Buffalo Medical and Surgical Journal, March, 1889. . 55 
 
 - 3000. » " 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/extrauterinepregOOtown 
 
EXTRA- UTERINE ' PREGfliK C Y. 
 
 A DISCUSSION. 
 
 I. ITS PATHOLOGY. 
 By franklin TOWNSEND, M.D., 
 
 ALBANY, N. Y. 
 
 Mr, President and Fellows : In beginning the discussion 
 upon so important a subject as that of extra-uterine pregnancy, 
 I am not unmindful of the necessarily limited time each one has at 
 his disposal, and, therefore, have attempted to condense, so far as 
 possible, that portion of the subject — its pathology — which I have 
 been invited to present. Indeed, much of interest has been already 
 published, both of a theoretical as well as of a practical nature, but 
 it is to be regretted that in all this wealth of literature reference to 
 results from broad studies in comparative anatomy is but scanty. 
 • What a field would this topic place at the disposal of him who 
 might care to unravel these hidden mysteries, in seeking out tiie 
 analogy between man and the lower animals! 
 
 In tracing out pathological conditions we should of necessity 
 refer to histology and physiology, for without these scientific aids to 
 our study we lose sight of the finer shades of beginning morbid 
 processes as differentiated from absolutely normal ones. 
 
 From deductions like these then, we should begin our study of 
 the pathology of ectopic gestation, by comprehending the physio- 
 logical functions of the organs most intimately involved. We 
 should, therefore, know primarily the functions of the Fallopian 
 tubes and ovaries ; and, lastly, we are to deduce from such knowledge 
 the physiological processes by which the ovum becomes fecundated, 
 as well as the site of its fecundation. The pathological processes 
 following may then, I think, be more distinctly and definitely 
 traced. 
 
2 '" 'feXT*RA- UTERINE PREGNANCY. 
 
 Function; (T-f; $ui{KS*tnr.:-Mic)st authorities are agreed that the 
 functions of. tlie ,tubes,are :. First, to transmit the ovum from the 
 ovary to thtj t!i:<Jru6'-;';a'pd.,; ^Second, to permit the passage of the 
 spermatozoa from the uterus in the direction of the ovary. There 
 are a few, and the best of authorities too, who differ from this view, 
 as will be presently shown. 
 
 Physiology of Impregnation of the Ovum. — The seat of 
 contact between ovum and spermatozoon has not as yet been deter- 
 mined with absolute certainty. " But in all probability it occurs 
 generally in the ovary itself, or in the vicinity of the Fallopian 
 tubes, seeing that in mammalia after intercourse has taken place 
 the surface of the ovaries is generally covered with spermatozoids." 
 (Bischoflt:) 
 
 Hermann ascribes to the peculiar movements of the tubes (per- 
 istaltic) in the direction of the ovaries, as have been observed to 
 occur in the lower animals, the passage of the spermatozoa through 
 the tubes to the ovaries. {Human Physiology, Hermann, 1878.) 
 
 " The spermatozoa find their way into the Fallopian tubes, and 
 here (probably in its upper part) come in contact with the ovaries. 
 In the c^se of some animals impregnation may take place at the 
 ovary itself." This author accounts for the passage of the sperma- 
 tozoa toward the ovary by : First, their inherent vibratile activity ; 
 and, second, by a retrograde peristaltic movement travelling from 
 the uterus along the Fallopian tubes, as has been observed in some 
 animals. {Text-book of Physiology, M. Foster, 1885.) 
 
 Impregnation of the ovum normally takes place in the tubes, as 
 Gray considers Dr. Allen Thomson has clearly shown. {Anatomy, 
 Gray, 1883.) 
 
 The place where fertilization of the ovum occurs is either the 
 (yoary or Fallojyian tube. Thus the spermatozoa must be able to 
 pass through the tubes to the ovaries, which is probably brought 
 about chiefly by the movements proper to the spermatozoa them- 
 selves. "When once the ovum has passed unfertilized into the 
 uterus it is not fertilized in the uterus." {A Text-book of Human 
 Physiology, Landois and Sterling, 1886.) 
 
 " The usual place for the ovum to meet the spermatozoa, and to be 
 impregnated, is the Fallopian tubes," etc. (Yeo's Manual of Physi- 
 ology, 1888.) 
 
 In Prof. John C. Dalton's latest edition of Human Physiology 
 
PATHOLOGY. 3 
 
 the following statements are found : " The egg, when discharged 
 from the ovary enters the fimbriated extremity of the Fallopian 
 tube and commences its passage toward the uterus." Dalton regards 
 the mechanism as due to the movement of the cilia of the epithelium 
 lining the tube "producing a kind of vortex." He recognizes, also, 
 that the ovum becomes impregnated in the tube. (Dalton's Human 
 Physiology, 1882.) 
 
 Austin Flint says : " It is probable that the ovum is fecundated 
 either as it enters the Fallopian tube or in the dilated portion near 
 the ovary. (Flint's Physiology of Man, 1875.) 
 
 " That the spermatozoa make their way toward the ovarium and 
 fecundate the ovum, either before it entirely quits the ovisac or very 
 shortly afterward, appears to be the general rule in regard to the 
 mammalia, and the question naturally arises, ' By what means do 
 they arrive there? ' " This author's view in regard to this last ques- 
 tion is, that it is due to the inherent power of movement in the 
 spermatozoa. [Principles of Human Physiology, Wm. B. Carpen- 
 ter, 1853.) 
 
 Fecundation " usually takes place in the Fallopian tube just 
 outside of the womb." [A Compend. of Human Physiology, by 
 Albert P. Brubaker, M.D., 1883.) 
 
 " In all instances the spermatozoa make their way by virtue of 
 their vibratile movements," through the whole length of the uterus 
 and " Fallopian tube to the ovary." " It is probable, however, that 
 impregnation generally takes place in the upper part of the Fallo- 
 pian tube," etc. (Human Physiology, Henry Power, 1884.) 
 
 Fertilization of the ovum must occur in the Fallopian tube. 
 Chapman speaks of the changes " by which the egg is transformed 
 into the blastodermic vesicle " as appearing " during the passage 
 of the egg through the tube." (Treatise on Human Physiology, 
 Henry C. Chapman, 1887.) 
 
 It is generally supposed that it (the ovum) becomes impregnated 
 by the " sperm cells before it reaches the uterine cavity." " Where 
 this takes place exactly cannot for certainty be determined ; it proba- 
 bly varies, and is possible at any point, as the teachings of extra- 
 uterine pregnancy or gestation show." (A Manual of Midwifery, 
 Alfred Meadows, 1876.) 
 
 Cazeaux, in his Theory and Practice of Obstetrics (Cazeaux and 
 Tarnier, 1886), puts the question as to this point wliere the ovum 
 
4 EXTRA-UTERINE PREGNANCY. 
 
 meets the spermatozoou, and says : "Already had the preexisteiiee 
 of the ovule iu the ovary, the occasional occurrence of ovarian and 
 abdominal pregnancies, and the experiments of Niick and Haighton, 
 which had rendered fecundation impossible, by ligating the Fallo- . 
 pian tubes, tended toward the conclusion that it occurred in the 
 ovary. Still this fact was not actually demonstrated, and it needed 
 the definite proof of finding the spermatozoa on the ovary itself." 
 
 "At present there cannot be a further doubt on this point, for Bis- 
 choif has been fortunate enough to see them there^'' etc. Since that 
 period Wagner and Barry have made similar observations. " Now 
 such results evidently prove that fecundation sometimes takes place 
 in the ovary. But may it not take place also iu the tubes? or even 
 in the uterine cavity ?" 
 
 "After coitus the spermatozoa make their way through the Fal- 
 lopian tubes to the pelvic cavity. It is possible, therefore, for the 
 ovum to become fecundated iu any portion of the route from the 
 ovary to the uterus." In exceptional cases it may, after being 
 impregnated, develop after being arrested in its course of travel, 
 entirely extra-uterine. Such terms as " abdominal pregnancy," 
 " ovarian" and "tubal gestation," simply express the site of attach- 
 ment of the developing ovum, which naturally is ectopic. (Lusk's 
 Science and Art of Midwifery, 1882.) 
 
 Of this Leishman says : " The ovum is, as has been shown, 
 developed within the ovary in the Graafian vesicle, and what has 
 been observed in the lower animals leads us to conclude, that while 
 yet it occupies that situation, and even before rupture of the 
 vesicle has occurred, impregnation may occur." On rupture of 
 the vesicle the fecundated ovum passes into the infuudibulum of 
 the Fallopian tube, thence by the tube into the uterine cavity, where 
 its further development continues or progresses to maturity. (Leish- 
 man's Sj/sfem of Mid wife nj, 1873.) 
 
 As additional evidence that the spermatozoon reaches even so far 
 as the ovary itself, and fertilizes the ovum, I may only quote from 
 Parry's great work on extra-uterine pregnancy. Parry does not 
 regard it difficult to conceive that the Graafian follicle might rup- 
 ture and the ovum yet remain ; this act at the same time allows of a 
 better opportunity for the spermatozoa to fecundate the egg in its 
 very shell. " When we remember the processes by which the ovum 
 escapes from the Fallopian tube it may occasion no surprise that it 
 
PATHOLOGY. 5 
 
 sliould be sometimes retained, even after ruptnre of the vesicle of 
 DeGraaf has occurred." 
 
 The following is the course of the fertilized ovum in its passage 
 through the uterus: First, Graafian follicle; second, fimbriated end 
 of tube ; third, canal of F. tube ; fourth, interstitial (tube within 
 uterine wall) portion of F. tube, or horn of uterus. It may be 
 arrested at any point in this course and continue its development 
 (fetal), just as it does in the uterine cavity. (Hart and Barbour 
 Ilanual of Gynecology, Wood's Library, 1883.) 
 
 Barnes ascribes two functions to the Fallopian tube : First, to 
 convey liquids and the ovum by tlie movements of the cilia cover- 
 ing the epithelial cells of the mucous membrane to the cavity of the 
 uterus. Second, to receive and transmit toward the ovary the sper- 
 matozoa of the male. The uterus is regarded by this author as 
 being a thick, hollow, muscular organ, "destined to receive the 
 fecundated ovaim," etc. 
 
 Coste's observations seem to prove that fecundation is almost 
 always effected either upon the ovary or in the part of the tube 
 nearest the fimbriated extremity, inasmuch as he maintains that the 
 ovule spoils very quickly when it enters the tube without previous 
 fecundation. His views regarding the course of the spermatozoa 
 reaching the ovum are : First, owing to the movements of the uterus 
 and tube, following the direction from the vagina toward the ovary; 
 and, second, to the inherent power of the spermatozoa themselves. 
 
 "The statement that impregnation takes place before the ovum 
 has reached the true uterus, seems to me to be an assumption based 
 upon insufficient evidence; indeed, upon no evidence at all. A pri- 
 ori, we may safely say that, if it is the rule. Fallopian pregnancies 
 and the disasters which follow them ought to be much more com- 
 mon than they are, and I believe it to be more than likely that the 
 real cause of this accident is the coincidence of a set of circumstances, 
 ijie most important of which is the destruction or insufficiency of 
 the ciliary movement." [Diseases of Women, Talt, Wood's Library, 
 1879.) 
 
 That the uterus is tiie " meeting-place of the ovum and sperma- 
 tozoa" is a theory held by Dr. Wyder, and is certainly opposed to 
 the views as just quoted by the most eminent of German, Eng- 
 lish, and American physiologists, gynecologists, and obstetricians. 
 Wyder regards the appearance of the cilia on the uterine mucosa at 
 
6 EXTRA-UTERINE PREGNANCY. 
 
 puberty, and their action from without inward as indicating- that 
 they are intended to assist the progress of the spermatozoa, while 
 they prevent the too rapid descent of the ovum toward the cervix. 
 The cilia covering the mucous membrane of the tubes, which are 
 present from birth, move in a direction directly opposite ; and this 
 movement, taken in conjunction with the peristaltic motion of the 
 tubes themselves, also in the direction of the uterus, as well as the 
 sinuosity of their passages, tends seriously to retard the advance- 
 ment of the spermatozoa, notwithstanding their inherent power of 
 motion. {The 3Icdical News, Vol. 49, Phila., 1886.) 
 
 Regarding the function of the tubes and ovaries, Mr. Tait has 
 proven conclusively to ray mind that ovulation can and does take 
 place before, during, and even after menstruation ceases (menopause) ; 
 also, that the changes in the ovary at puberty are simply vascular, 
 and that those in the tubes at this period are vascular, muscular, and 
 epithelial, and that the change of greatest importance is in the func- 
 tional movement of these accessory organs — that is, the "grasping," 
 so to speak, of the ovary by the fimbriated extremity of the tube 
 at only stated times, viz., during the menstrual epoch. Ovulation 
 and menstruation, then, are not necessarily coincident, for, as Tait, 
 Jackson, and myself have shown, it is not always that the passage 
 of an ovum takes place through the tube, though its fimbriated 
 extremity is grasping the ovary, since it frequently happens at such 
 time that there is no ripe ovisac present. 
 
 If, then, as has been shown, ovulation continues intermenstrually, 
 when the tubes are quiescent, the question naturally arises. What 
 becomes of the ovum when the ovisac ruptures ? There is only one 
 place it can go, and that is into the peritoneal cavity, where it 
 perishes and is absorbed. Mr. Tait, in speaking on this subject in 
 his work on Diseases of the Ovaries, says : " I believe that the ovum 
 falls into and perishes in the peritoneal cavity in by far the greater 
 number of cases, and that the passage of it into the uterus occubs 
 in only a small minority of the ova produced." 
 
 Accepting, then, the views of the majority of the authorities, that 
 fecundation usually takes place either in the tubes or on the surface 
 of the ovary, or even in the Graafian follicle, or possibly, as has 
 been intimated by Parry, in the peritoneal cavity, and granting the 
 admirable stand taken by Tait, as just dilated upon, it would seem 
 to me that : 
 
PATHOLOGY. 7 
 
 1st. Fecundation of the ovum takes place more frecjueutly than 
 is supposed. 
 
 2d. That this being a fact, many sterile women — that is, objec- 
 tively sterile — who never complain of pain or ache, who ovulate 
 and menstruate with the greatest nicety and regularity, and whose 
 general health is perfect — and such, no doubt, all of us present have 
 met with — such women, I say, may frequently have fecundated ova 
 which, like the non-fecundated ova, may drop into the peritoneal 
 cavity and perish, because the soil there is unpropitious for their 
 development. 
 
 3d. That occasionally, but rarely I will admit, this same perito- 
 neal soil, if I may be permitted to use such a term, does present a 
 favorable site for the development of the fecundated ovum, and 
 what is called " primary abdominal pregnancy " results. 
 
 4th. This propitious site may be due to old peritoneal inflamma- 
 tory troubles, which may be so slight, indeed, as to have never 
 given rise to suspicion of their existence; such nesting spots in the 
 peritoneum for the development of the young fecundated ovum, 
 though occurring not so frequently as those inflammatory changes 
 in the tubes causing desquamation of the ciliated epithelium, and 
 thereby tubal pregnancy, as Mr. Tait so ably advocates, are, never- 
 theless, to my mind, a factor of causation of the so-called '^primary 
 abdominal pregnancy." 
 
 From the physiological proofs, as already cited, I am convinced 
 that extra-uterine fetation can and does occur either in the Fallopian 
 tubes (by far the most frequent form), in the ovary, or upon it, and 
 even in the peritoneal cavity; and I must truthfully say, that in 
 the study of any given case of misplaced conception, one of the 
 most perplexing questions to decide is, as to which class it properly 
 belongs : whether tubal, ovarian, or abdominal. This is assuredly 
 true, not only while the patient is living but after her death, and I 
 can heartily endorse the views of Parry, when he says, " that not- 
 withstanding these common and insuperable difficulties which the 
 pathological anatomist may encounter, even under the most favora- 
 ble circumstances, a large number of physicians do not hesitate to 
 classify their cases, even when their patients have been carrying the 
 products of a misplaced gestation for years. These remarks apply 
 not only to the statements of physicians who have observed only 
 one case, but to those accoucheurs who have seen many. The result 
 
8 EXTRA-UTERINE PREGNANCY. 
 
 is that special treatises, as well as periodical literature, teem with 
 statenieuts which are decidedly uurelial-jle and calculated to mislead 
 those who attempt investigatiug this subject." 
 
 Tubal Ectopic Gestation. — By far the most frequent form 
 is tubal ectopic gestation, ascribed usually to a number of causes, as 
 catarrh of the mucous membrane, causing possibly a loss of the cili- 
 ated epithelium, allowing thereby the fecundated ovum to rest and 
 develop in the denuded spot ; flexions of the tubes; and dilatations 
 with hernial pouches, produced by the protrusion of the mucous 
 membrane through separate bundles of the muscular fibers (Lusk). 
 Constrictions from inflammatory changes causing adhesions, obstruc- 
 tive catarrh, physiological aberrations, or even paralysis, etc., have 
 all been assigned as factors. 
 
 Naturally the pathological changes taking place will vary accord- 
 ing to the duration and behavior of the pregnancy. As the growth 
 of the ovum continues, the mucous membrane of the tube thickens, 
 the tubes themselves gradually distend, the villi enter into the 
 mucous membrane, and, according to Bandl, " the two poles of the 
 decidua-like covering are closed, though sometimes the uterine end 
 remains open and in continuity with the mucous membrane of the 
 tube and the decidua of the uterine cavity," Hennig remarks that 
 a decidua reflexa is rare. 
 
 The villi continue in their growth, penetrating the mucous mem- 
 brane to the muscular layer, but, according to Leopold, never 
 breaking through the walls of the maternal vessels ; nor are any 
 evidences of blood to be found, as is presumed to exist in intra- 
 uterine development, between the villi. The vascularity of the 
 vessels of the tubes and those of the broad ligament in which they 
 lie is greatly increased, the muscular fibres of the tubes, enlarging 
 at first, subsequently become markedly thin by stretching from the 
 continued and increasing pressure due to the growth of the ovum, 
 which finally ruptures the tube, usually between the second and 
 third months. According to Mr. Tait, the most common seat of 
 rupture is through the surface of the tube into the cavity of the 
 peritoneum, because, as he says, " the proportion of the circumfer- 
 ence of the tube which is covered by peritoneum is very much 
 greater than the proportion of the circumference of the tube which 
 is related to what is called the cavity of the broad ligament." As 
 a result of such tubal ruptures the placenta is frequently lacerated 
 
PATHOLOGY. 9 
 
 and the hemorrhage excessive which pours into the peritoneal cavity, 
 death being frequently due to shock, hemorrhage, or, if not from 
 either of these, purulent peritonitis is apt to develop. 
 
 Associated with the rupture in the wall of the tube may be that 
 of the ovum, with the escape of the fetus into the peritoneal cavity, 
 or, it may be that the ovum remains ichole, and in such condition 
 falls into the abdominal cavity. Should the ovum, though, remain 
 in the tubes, which is rare indeed and most favorable, the extent 
 of the hemorrhage may be lessened. Spiegel berg mentions three 
 instances where this form of extra-uterine pregnancy advanced to 
 full term, and Hofmeier still another. In all three cases the enor- 
 mous muscular development in the tubal_ walls was characteristic. 
 Fatal as this form of ectopic gestation usually is, recovery may occur 
 in case of premature death of the fetus before the tube gives way ; 
 and even after rupture lias taken place recovery is possible, owing 
 to the formation of inflammatory false membrane around the embfyo 
 of the entire ovum. Should the tube rupture at any point not 
 involved by the peritoneum, the folds of the broad ligament become 
 separated by the effused blood, forming a cavity, into which the 
 ovum may fall, and either become destroyed or continue developing 
 up to the fourth, fifth or sixth month, when it usually dies. Then 
 we have, according to Tait, " a group of cases in which, after 
 suppuration has taken place, the bones of the fetus are discharged 
 through the rectum, through the bladder, or through Douglas's cul- 
 de-sac into the vagina, or sometimes a lithopedion results. The 
 minority proceed to the full time and are removed either as living 
 or as dead children " from an extra-peritoneal cavity. 
 
 OvAPJAN Pregnancy. — So long ago as the latter part of the 
 seventeenth century, St. Maurice demonstrated a case of ovarian 
 pregnancy. Since that day a number of cases of this very rare con- 
 dition have been recorded, as those of Granville, Porter, Kammerer, 
 and Bandl, supported by the thorough investigations of Marimus of 
 three preparations found in the Pathological Museum of Wurzburg, 
 which prove unquestionably the presence of gravid ovaries. In 
 Porter's case the woman died from rupture at between the sixth and 
 seventh week of gestation in her fourth pregnancy. The autopsy 
 revealed the left ovary greatly enlarged, conkunimj the </rarid sac, 
 while the Fallopian tube on the same side was found " foatinr/ fire 
 and hnprrrioKs.'' Fu ovarian fetation, as is usual, the cyst is void 
 
10 EXTRA-UTERINE PREGNANCY. 
 
 of a peritoneal iDvestiiieut, the walls of the Graafian follicle and the 
 stroma of the ovary forming the envelope about the developing 
 ovum. The chorion is in intimate relation with the interior of the 
 sac. Subsequent to fecundation the Graafian follicle may close and 
 the ovum continue extra-peritoneal, or the ovum may gradually 
 make its way through the opening occasioned by the escape of the 
 Graafian fluid, and thus come to lie eventually for the most part 
 within the peritoneal cavity. In either case rupture of the sac 
 takes place early, though, when the sac walls are reinforced by 
 inflammatory adhesions to the peritoneal coverings of the adjacent 
 viscera, gestation at full term may be reached. 
 
 Abdominal Pregnancy. — Primary, Secondary. As was shown 
 in an earlier part of this paper, ova frequently becoming fecundated, 
 drop into the abdominal cavity and perish, the soil being unpro- 
 pitious for their further development ; occasionally it happens, 
 though, as has been demonstrated, their death is not so immi- 
 nent, and their growth may continue for an indefinite period. 
 Now, the pathological changes occurring in this form of "primary 
 abdominal pregnancy " must be distinguished from those that take 
 place in that form which is termed " secondary." In the one 
 instance we have so minute, soft, fragile, and delicate a corpuscle 
 deposited in the peritoneal cavity that one could not well imagine 
 any grave inflammatory results accruing from its immediate pres- 
 ence. This being the case then, the contiguous abdominal organs 
 will not be injured by its ulterior development, because, as Cazeaux 
 remarks, they gradually become habituated to it, and the ovule 
 having obtained a right of possession, " lives, grows, and presents 
 to the smooth, polished surfaces which touch it, a surface equally 
 smooth, polished, and moistened at their expense, and not having 
 occasion for any other protecting envelope, no cyst is formed," the 
 ovum being simply surrounded by the chorion and amnion. 
 
 On the other hand, in the secondary form of intra-peritoneal 
 pregnancy, we have a voluminous product of conception suddenly 
 thrust upon the peritoneum, accompanied by large quantities of 
 blood, wounding possibly, irritating certainly, this membrane so 
 unaccustomed to such harsh intrusion. Here the ovum acts the 
 part of a foreign body, soon determining an acute inflammatory 
 process about it, that possibly may form a cyst wall made up 
 almost wholly of plastic lymph, which completely isolates it from 
 
PATHOLOGY. 11 
 
 the rest of the peritoneal cavity. If the fetal cyst ruptures and the 
 contents escape from the amniotic cavity into the midst of the intes- 
 tinal mass, a renewal of the inflammation occurs and the cyst just 
 described forms around it. As a rule, the fetus perishes at, or soon 
 after, the time of rupture ; still, there are cases recorded, notably 
 by Bandl, where it continued developing even within a sac formed 
 of proliferating connective tissue. With the death of the child it 
 may be converted into a lithopedion, or, through the blood-supply of 
 the connective tissue, it may be preserved for years in its soft integrity. 
 
 In all cases numerous and greatly exaggerated vessels form in 
 the cyst walls, the rupturing of which frequently causes almost 
 instant death from hemorrhage. Sometimes, especially when the 
 pregnancy is prolonged, these walls may become destroyed by per- 
 forating fistulous canals, running in various directions, frequently 
 communicating with the intestines, vagina, uterus, bladder, or even 
 with the abdominal parietes, and thus directly into the external 
 world. Through these fistulous channels the skeleton portions of a 
 putrescent fetus frequently find their exit. This change is undoubt- 
 edly more frequent than that the fetus should be transformed into 
 osseous or cretaceous substance, or even adipocere. Beside these 
 varieties of extra-uterine fetation, Bandl, as already mentioned, 
 records histories of the coexistence of extra- and intra-uterine preg- 
 nancies, " the latter occurring at the same menstrual period as the 
 former, or possibly after the death of the extra-uterine fetus." 
 
 Placenta. — In all forms of ectopic gestation the connection 
 between the ovum and the abnormal surface upon which it is 
 engrafted, is established by a vital adhesion between the chorionic 
 villi and the tissues with which they come in contact, plastic mate- 
 rial helping to cement them as it were. This has been demonstrated 
 thoroughly by Braxton Hicks and Engelmann. As there is here 
 absence of the decidua, the process differs from that found in the 
 uterus, where the sub-ovula portion (the serotina) performs an im- 
 portant and active part in connecting the ovula and maternal tissues 
 by proliferating cell activity. 
 
 The Uterus in Ectopic Gestation. — From researches made 
 by Clark, Oldham, Virchow, Ramsbotham, Cazeaux, Kiwish, 
 Hodge, Hennig, and others, it would seem fair to conclude that 
 the uterus is enlarged even in the early stages of ectopic gestation ; 
 that it undergoes changes which are the normal preparatory trans- 
 
12 EXTRA-UTERINE PREGNANCY. 
 
 formations for the reception of the ovum. A deoidiia forms in its 
 cavity, which is seldom retained until the completion of gestation. 
 On the contrary, it is usually expelled during the early stages of 
 gestation en masse, with pain and symptoms of abortion, or it may 
 be discharged in shreds and pieces without symptoms. 
 
 And now, gentlemen, I take pleasure in exhibiting to you a most 
 perfect specimen of a " lithopedion," beside that of the cyst walls 
 which incased it, as well as the uterus and adnexa, all carefully 
 removed (post-mortem) from the abdominal and pelvic cavities of 
 a woman almost thirty-seven years ago. The specimens are the 
 property of the Albany Medical College Museum, Albany, N. Y., 
 and are most interesting and useful in clearly demonstrating the 
 views as already stated in my discussion relative to " Primary Ab- 
 dominal Pregnancy." 
 
 With the specimens I likewise submit a report of the case, a& 
 compiled by the late Prof. J. H. Armsby, of Albany, N. Y. 
 
 Bibliography. 
 
 References. Phjsiolofjical and Anatomical. — Dalton, Flint, Herman, Foster, Yeo, 
 Power, Landois and Sterling, Chapman, Gray, Carpenter, Brubaker. 
 
 Special. From Text-books and Journals. — Parry, Spiegelberg, Bandl, Hofmeier. 
 Leopold, Hennig, Braxton Hicks, Engelmann, Meadows, Cazeaux and Tarnier, Lusk, 
 Leishman, Hart and Barbour, Greig Smith, Barnes, Tait, Wyder, Jackson, Townsend. 
 
PATHOLOGY. 13 
 
 Report of Dr. Parkhurst's case of extra-uterine conception, 
 by the late Dr. Armsby, of Albany, N. Y. 
 
 "The specimens from which the following illustrations were taken were 
 obtained at a post-mortem examination held by Dr. Parkhurst, in the pres- 
 ence of about twenty persons, upon the body of Mrs. Amos Eddy, aged 
 seventy-seven, of Frankfort, Herkimer County, N. Y. Mrs. Eddy's maiden 
 name was Rebecca Smith. She was born in Frederickstown, Columbia 
 County, N. Y. , in 1775, of English parents. Her mother, Sarah Smith, gave 
 birth to twenty-four children, of whom four pairs were twins, Rebecca being 
 the twelfth child. Mrs. Eddy was married in New Lebanon, Columbia 
 County, N. Y., in 1795, at the age of twenty, and removed with her hus- 
 band, Amos Eddy, to Frankfort, Herkimer County, N. Y., where they both 
 lived and died, he at the age of seventy and she at seventy-seven. She 
 became pregnant in 1802, seven years after her marriage, and died in 1852, 
 carrying this fetus fifty years. 
 
 " No unusual symptoms attended her pregnancy; the catamenia ceased; 
 quickening was felt at the usual time, and the motions of the child increased 
 with its growth. 
 
 " At the expiration of eight and a half months she had severe labor pains 
 following a sudden fright from the falling of a vessel into the fire, while she 
 was engaged in cooking. Her physician, Dr. Farewell, of Litchfield, was 
 called; the labor pains continued for several hours with regularity and 
 force, but at length subsided and she remained comfortable for two or three 
 weeks. Her health then began to decline, and the full period of pregnancy 
 having passed by, her friends became extremely anxious and availed them- 
 selves of the advice of Drs. Guiteau, Hull, Coventry, White, and others. 
 For a considerable time she was confined to her bed, and, after a year and 
 a half of extreme suffering, her health began to improve and was finally 
 restored. During the remainder of her life she enjoyed good general health, 
 but suffered occasionally from severe attacks of pain in the abdomen which 
 resembled labor pains. After her health was restored her catamenia 
 returned and continued until the age of forty-five. She travelled much about 
 the country and consulted various medical men, among others the late Prof. 
 Willoughby, of Fairfield Medical College. Her health continued remarka- 
 bly good up to the time of her death, and at the age of seventy-six she was 
 accustomed to walk five miles from her residence to the village and back 
 again. 
 
 " The specimen with its covering cyst (see illustrations) weighed eight 
 pounds at the time of its removal. The external surface of the envelope 
 was smooth and white, composed of concentric layers of fibro-cartilage, 
 varying at different points from a line or two to three-fourths of an inch in 
 thickness. It had no connections with the abdominal viscera or walls but 
 was slightly attached to the Fallopian tubes and omentum. The external 
 surface of the fetus was encrusted with an earthy substance of sufiicient 
 thickness to preserve its form when dried. The interior seems to be a soft 
 substance resembling adipocere." 
 
14 EXTRA-UTEEINE PREGNANCY. 
 
 EXPLANATION OF PLATES. 
 
 Plate I. — To the left is the lithopedion — side view. 
 
 To the right is an anterior view of the external surface of the walls which 
 encased the fetus, made up wholly of inflammatory products. 
 
 Lying directly in front of this inflammatory sac is to be seen the uterus 
 with its anterior surface up, the os externum prominent, and, running oft" 
 from either side, are to be noticed the Fallopian tubes and ovaries; besides, 
 inflammatory bands are adherent to the surface of the sac. 
 
 INFLAM BANDS. jj// T\ .. ^ . „ 
 
 --./Lj/ r\ .- tNFCAM SANDS 
 
 ^/ V'\\ ^, LEFT TUBE. 
 
 (/ YV )T^ _ ,,.-LEFr 0VA8V. 
 
 SIGHT TUBE.- . - - . --/-'^^>___^ .j^ir^-<r 
 
 RtGHT OVAftV,' / "^^ 
 
 * BODY Of UTERUS. 
 
 Plate IL — To the left is the lithopedion — front view. 
 
 To the right is a posterior and inferior view of the inflammatory sac which 
 contained the fetus, its walls being broken open when reiuoving it from the 
 abdominal cavity ; the thickness of which is to be noted, also the view pf 
 the interior of the sac. The shaggy portion shows the large amount of old 
 adhesions from inflammatory deposit. 
 
 The uterus — posterior surface, with tubes and ovaries — is plainly to be 
 seen. 
 
PLATE I. 
 
 I'', .'. :>B> ; 
 
 A. Lithopedioii. Side view. 
 
 B. Inflammatory r^ac ^>t' lymph, (niijinally cniitaiuiuii- Lithopediou. Exterior view. 
 
 C. Uterus. Atrophied. 
 
 D D'. Fallopian Tubes. Uni'uptured. 
 
 E E'. Ovaries. 
 
 F F'. Adhesions of inflammatory lymph. 
 
 PLATE II. 
 
 A. Lithopediou. Anterior view. 
 
 B. Inflammatory lymph sac, originally containing Litiiopedion. Interior view, 
 f. Uterus. Atrophied. 
 
 D D'. Fallopian Tuhes. L'nrujitnrod. 
 E E'. Ovaries. 
 F F'. Adhesions. 
 
II. ITS DIAGNOSIS.. 
 
 By JOSEPH PRICE, M.D. 
 
 PHILADELPHIA, PA. 
 
 In inaugurating the discussion of the diagnosis of extra-uterine 
 pregnancy I desire to be as brief and jjointed as possible, and for 
 this reason I have generah'zed the subject and omitted all allusions 
 to the literature. The literature of extra-uterine pregnancy is scat- 
 tered through a vast number of periodicals, and consists, for the 
 most part, of descriptions of cases occurring in the practice of the 
 writers. The discussions of Mr. Lawson Tait and the classical 
 work of Dr. John S. Parry have proved of the most value to me. 
 
 Accepting, as I do, the proposition of Mr. Tait, that all extra- 
 uterine pregnancies are primarily tubal and that all the so-called 
 varieties depend upon the location of the ovum in the tube and the 
 location of the point of rupture of the tube, I have divided the 
 subject for the sake of the discussion of the diagnosis into three 
 classes : First, extra-uterine pregnancy before the rupture of the 
 tube ; second, at the time of rupture of the tube ; and third, after 
 the rupture of the tube. 
 
 Rupture of the tube is not synonymous witli rupture of the fetal 
 sac, for, though rupture of the tube and sac generally occurs at the 
 same time, it sometimes happens that the tube ruptures and the sac 
 remains intact ; and this may in part explain the fact that cases 
 sometimes occur in which the tube ruptures without causing 
 exhaustive hemorrhage. 
 
 The diagnosis of extra-uterine pregnancy before rupture of tlie 
 tube is rarely made, and when it is made, is of necessity not positive, 
 because tlie same set of symptoms may arise from a number of 
 pathological conditions ; for example, a retroflexed gravid uterus, 
 an ovarian cyst, a uterine fibroid, and hematosalpinx, have all been 
 mistaken for tubal pregnancy, differential points of diagnosis not 
 being clearly presented. Moreover, the physician rarely sees such 
 cases until rupture has taken place. When such cases are seen 
 
16 EXTRA-UTERINE PREGNANCY. 
 
 they arevi>:r!ueial,'y fi? patieuus exceedingly anxious to conceive, who, 
 after a long-continued sterility, have reason to suspect themselves 
 pregnant; or by patients who, having missed one or more menstrual 
 periods, are anxious to know their condition. 
 
 The syrnptonift the} jiresent are as follows : First, partial or com- 
 plete cessation of menstruation for one or more periods, generally 
 accompanied by other rational symptoms of pregnancy, though 
 occasionally these are all wanting ; second, pain which is peculiar, 
 being generally severe, paroxysmal, and long continued — a sicken- 
 ing pelvic pain, which is neither cramp-like nor colicky, though it 
 is often described by these terms^these pains, probably caused by 
 the distention of the tube, are apt to subside for a time only to recur ; 
 third, the appearance of uterine hemorrhage, which is again peculiar 
 in that it is usually irregular, both as to time and quantity, gener- 
 ally lighter in color than the normal discharge and containing shreds 
 of tissue which are portions of the decidua vera. 
 
 The occurrence of these symptoms justifies a physical examina- 
 tion, when the general condition of the vagina and cervix may or 
 may not be found to correspond to normal pregnancy. The uterus 
 is o-enerally enlarged and pushed out of place by a tender or exceed- 
 ino-ly painful cystic mass, occupying the position of one or the other 
 of the tubes. This cystic mass at this period is freely movable. 
 A differential diagnosis is extremely uncertain, and care must be 
 taken not to exclude pregnancy hastily because of the apparent 
 return of catamenia, nor to conclude that miscarriage has taken 
 place on account of the appearance of tmue in the discharge, nor to 
 pronounce the trouble some other pelvic tumor while rational symp- 
 toms of pregnancy exist in fact. Some of the tumors liable to be 
 mistaken for extra-uterine pregnancy have been mentioned, and 
 when, as sometimes occurs, the fetus and placenta die before the 
 rupture of the tube, the difficulty of differential diagnosis is prac- 
 iically ins iirmountable. 
 
 These symptoms continue as the i)regnancy advances. The tumor, 
 as it increases in size, causes additional symptoms by pressure on 
 the bladder and rectum until rupture occurs. Rupture takes place 
 almost always between the eighth and fourteenth weeks of preg- 
 nancy — in a majority of cases before the twelfth week. Now, the 
 symptoms vary somewhat, according to the point of rupture in the 
 tube — whether into the peritoneal cavity or below it. 
 
DIAGNOSIS. 17 
 
 If it takes place into the peritoneal cavity — as on account of the 
 anatomical relations of the tube it is prone to do in a large majority 
 of cases — the symptoms suddenly become most alarming. The 
 patient is seized with agonizing pelvic pain, shows all the symptoms 
 of internal hemorrhage and shock, goes into syncope, collapse and 
 death. That this end is more frequent than is generally supposed 
 is shown by a statement made to me by a well-known pathologist, 
 Dr. Forraad, Coroner's physician of Philadelphia, that within a 
 very short period he had found in his post-mortem work eighteen 
 deaths due to ruptured tubal pregnancy — a class of cases which for 
 many years had been grouped as death due to accidental hemor- 
 rhage. These deaths all occurred before .the twelfth week of 
 pregnancy. 
 
 Where death does not immediately supervene the recovery from 
 shock is gradual, the attacks of syncope often recurring. The 
 patient presents an exsanguinated appearance ; uterine hemorrhage 
 generally occurs ; symptoms of peritonitis, localized or general, 
 make their appearance, and the patient slowly recovers only to un- 
 dergo another attack of the same kind. A physical examination 
 now may or may not disclose characteristic lesions ; when it does 
 the uterus is found enlarged, displaced and fixed, and a tumor will be 
 foiind occupying the position of the pregnancy. This examination, 
 however, is often unsatisfactory, for the tube may discharge its con- 
 tents beyond the reach of the examining finger ; or the adhesions 
 may so fix the whole vault of the vagina that nothing can be made 
 out. The diagnosis must be made from the history of the case and 
 the condition of the patient. The liability of multiparous women 
 to extra-uterine fetation must be borne in mind, and the occurrence 
 of the above catalogue of symptoms in such a patient must be given 
 immediate and serious consideration. 
 
 As has been said, these attacks may be recurrent, and it has been 
 demonstrated by operative disclosures that hemorrhage may cease 
 entirely for a time only to recur with renewed violence, or may con- 
 tinue in small quantity as long as the patient has any blood to lost. 
 If the patient survive thus far, the symptoms of purulent peritonitis 
 or of a more or less severe septicemia set in, Avhen finally death 
 relieves the suffering woman. 
 
 When rupture occurs below the peritoneum these symptoms are 
 rarely so severe, and may, indeed, be scarcely noticed by the patient, 
 
 2 
 
18 EXTRA-UTERINE PREGNANCY. 
 
 the pain of rupture seeraiug to be only a transitory pang of colic. 
 The hemorrhage is rarely or never fatal at the time of rupture — 
 easily accounted for by the anatomical relations. The syncope, if 
 occurring, is evanescent. The discomfort of bearing-down sensa- 
 tions is frequently complained of, difficulty of micturition and defe- 
 cation is increased, but the patient recovers power very readily. 
 Here, again, recurrent attacks mark the progress of the case and the 
 ultimate outcome depends on whether the fetal sac is ruptured or 
 not. Examination at this point will reveal a sensation of bogginess 
 and distention in the pelvis — precisely that of a pelvic hematocele 
 and often the body or extremities of the fetus. The symptoms of 
 peritonitis are wanting generally, and if examination be not imme- 
 diate the distention may in a large measure disappear, not necessarily 
 by reabsorption but by extension through the connective tissue 
 spaces of the pelvis. If the fetal sac has ruptured the fetus dies, and 
 if the condition is not recognized and relieved by operative measures 
 the patient goes into a state of chronic invalidism — the victim of 
 obscure pelvic troubles — until nature relieves her as much as possi- 
 ble by disposing of the misplaced products of the accident. Some- 
 times the patients recover fair health and comfort. 
 
 In a small minority of cases the fetal sac is not ruptured, and 
 now the progress of gestation is similar to the normal until full 
 terra, providing a secondary rupture into the peritoneal cavity does 
 not occur. This may oocur, and when it does it kills immediately, 
 the symptoms being those of the primary rupture greatly magnified. 
 
 After quickening, the doubts of pregnancy are settled and the 
 question is the location of the fetus, whether within or without the 
 the uterus. The metrorrhagic discharge may have ceased by this 
 time, especially so if the entire decidua has been thrown off. The 
 severe paroxysmal pelvic pains may be very infrequent or have ceased 
 altogether. The mammary changes are as in normal pregnancy, 
 but the fetal movements generally cau.se more discomfort, and are 
 spoken of as being entirely on one side. The fetal heart sounds and 
 the placental bruit are usually intensified, and as the fetal sac en- 
 larges it produces unusually distressing pressure-symptoms on rec- 
 tum, bladder, and bloodves.sels. Physical examination is the only 
 mode of determining the diagnosis. Examination of the abdomen 
 will generally show the fetal tumor decidedly on one side or the 
 other. Occasionally the fetal extremities may be felt very distinctly 
 
DIAGNOSIS. 19 
 
 and even appear as projections on the abdominal wall. This, how- 
 ever, is of no use unless in conjunction with other more distinctive 
 signs. The fetal sac is generally less movable than the gravid 
 uterus. The fundus uteri can frequently be felt as a distinct mass 
 on the fetal tumor. Vaginal examination shows the uterus enlarged, 
 hut not in proportion to the duration of pregnancy ; generally dis- 
 placed to one side, in front, or beneath the tumor. The cervix is 
 enlarged and soft as in normal pregnancy, but not in proportion to 
 the duration of pregnancy . The cervix is also greatly displaced. 
 The pelvis is filled with the fetal sac, which gives the sensation of 
 fluctuation or of semi-fluctuation, and frequently a part of the fetus 
 may present. The fetus sometimes is so plainly felt as to leave the 
 impression of a presenting part covered only by membrane. This, 
 however, is not peculiar to extra-uterine pregnancy. If the patient 
 carries the extra- uterine gestation to term, spurious labor will take 
 place. It is accompanied by metrorrhagia and sometimes followed 
 by a vaginal discharge resembling the lochia. After this spurious 
 labor the fetus dies and is disposed of in a variety of ways by 
 nature. A discussion of these ways lies outside the province of this 
 paper. I have also purposely omitted any discussion of such grave 
 occurrences as extra-uterine pregnancy occurring in a hernial sac, 
 twin extra-uterine pregnancies, or extra- and intra-uterine preg- 
 nancies combined, for the reason that I have desired to make my 
 remarks so general as to leave the way open for a very full and 
 free discussion. 
 
III. ITS TREXTMlENf. 
 
 By E. E. MONTGOMERY, M.D., 
 
 PHILADELPHIA, PA. 
 
 When asked to take part in this discussiou I choose the surgical 
 treatment. While my subsequent study of the subject has not in- 
 duced me to depreciate the value of surgery, it has caused me to 
 have a higher appreciation than I before held of the possibilities of 
 treatment by electricity. The method and urgency of treatment 
 must, of necessity, depend upon the form of extra-uterine pregnancy 
 we have under consideration. 
 
 It is recognized that the ovum may become impregnated and 
 arrested at any point in its progress from the ovary to the uterus ; 
 indeed, it may develop in the Graafian follicle, forming a true 
 ovarian pregnancy. The forms recognized are tubal, tubo-uterine or 
 interstitial, tubo-ovarian, ovarian, and abdominal. It will be readily 
 comprehended that these various forms are only distinguishable as 
 such during the early periods of pregnancy. As the ovum grows, 
 and the surrounding tissues become involved, it is difficult to deter- 
 mine in what organ it had its first implantation. 
 
 The course of the gestation varies, however, according to the 
 original site. Thus, the tubal variety, owing to the limit to the 
 growth and dilatability of the tube, ruptures from the sixth to the 
 twentieth week, while the ovarian or peritoneal varieties may go 
 to the completion of pregnancy without untoward circumstances. 
 
 These forms must, of necessity, present symptoms of a different 
 character. Hence the purely tubal early presents marked and typical 
 symptoms. The first experiences do not differ from those of ordinary 
 j)regnancy, such as missed menstruation, nausea, feelings of depres- 
 sion, sleeplessness, swelling of the breasts, etc.; later, we have them 
 complicated by characteristic symptoms, such as pain in the abdomen, 
 in one or other inguinal region, sensation of pressure, attacks of 
 fainting, severe pain occurring in paroxysms, often so acute and 
 
22 EXTRA-UTERINE PREGNANCY. 
 
 lancinating as to cause the patient: to fall, and even render lier uncon- 
 scious. The fiTst attack may be accompanied by symptoms of col- 
 lapse and internal hen'orrha:ye so marked as to demand immediate 
 laparatomy, or tlicoe may occai as frequent attacks during a period 
 of some months. The atta(!k may be accompanied by uterine dis- 
 charge of a bloody oIiAracter, lending the patient to believe that it is 
 a return of the ordinary menstruation. An examination of the fluid 
 will usually disclose the presence of a decidual membrane, thrown 
 off either as a cast or in shreds. The presence of this symptom in a 
 woman who has not before suffered from dysmenorrhea is almost a 
 pathognomonic indication of extra-uterine pregnancy. In the other 
 forms the patient may suffer so little distress that she does not mis- 
 trust the grave form of the pregnancy. She reaches what she sup- 
 poses the completion of the pregnancy, when, after a futile attempt at 
 labor, the fetus dies and may undergo one of various forms of retro- 
 gression. It may become macerated and disintegrated, causing the 
 formation of an abscess which opens through the abdominal walls, 
 the vagina, the bladder, or the intestinal canal. 
 
 Dr. Brown (Virginia Medical Monthly, 1884) relates the his- 
 tory of a colored woman who had been married sixteen years without 
 having reason to believe herself pregnant, in whom, after consider- 
 able disturbance of the bowels, there was found a bone projecting 
 from the anus. An examination revealed the greater portion of a 
 nearly mature fetal skeleton in the rectum, which, after some diffi- 
 culty, was removed. 
 
 Such an elimination of the fetus may continue over a period of 
 years and the patient subsequently regain good health. In other cases, 
 the influence of the absorption of septic material furnished by the 
 decomposing and macerated fetus may lead to a fatal termination. The 
 fetus may become encysted, or form a lithopedion, which has been 
 carried in rare cases as long as fifty years without producing any 
 unfavorable symptoms. In the peritoneal or abdominal form, the 
 envelope of the fetus is partially composed by the gluing together 
 of the intestinal loops and the viscera of the abdomen in proximity 
 to it. In such cases the symptoms will depend largely upon the 
 site of the placenta. If, in its growth, it becomes attached to the 
 intestines, it generates such a congestion of the intestinal structures 
 as to lead to violent catarrhal symptoms, such as vomiting and 
 
TREATMENT. 23 
 
 purging, frequently recurring, severe intestinal pains. The only 
 relief is in the arrest of the vitality of the ovum. 
 
 In the tubal varieties early rupture is the most frequent result. 
 This may occur suddenly with the first attack of pain experienced, 
 or there may be a number of attacks to warn patient and physician 
 of the impending danger. In the interstitial form the rupture may 
 occur either into the uterine canal or the abdominal cavity. In- 
 deed, cases have occurred in which the rupture has taken place into 
 both simultaneously, as in the case described by Maschka, in which 
 the autopsy upon the body of a servant girl disclosed the head of 
 the child and the placenta in the abdomen, while the body was found 
 secreted in the room. The rupture of the tube is usually accom- 
 panied by profound shock, symptoms of collapse, and internal hem- 
 orrhage. A number of cases are upon record in which the shock of 
 rupture was so great as to render the patient unconscious, and to lead 
 to an immediately fatal termination. In other cases, where death 
 is not immediate, the hemorrhage is not arrested and results fatally. 
 
 As the various forms of the disease present such a variety of 
 symptoms, we can readily understand that our treatment must 
 depend somewhat upon the form with which we are confronted. 
 
 As we have seen, from an investigation of the literature, that the 
 more or less matured fetus may become encysted or form a litho- 
 jiedion, producing little or no disturbance during a long period of 
 years, we are justified in hoping that a plan of procedure may be 
 advanced by which the vitality of the ovum may be arrested in its 
 earlier stages, when its products are of such a character as will 
 admit of being readily absorbed and eliminated. To accomplish 
 this end various procedures, such as puncturing the cyst and the in- 
 jection of morphia, have been practised. These methods are either 
 uncertain or attended with more or less danger. Electricity, how- 
 ever, aiFords an agent for the destruction of fetal life, which experi- 
 ence discloses can be relied upon for the arrest of development and 
 the speedy and safe cure of our jiatients. I am aware that in enter- 
 ing upon the discussion of this procedure I am advancing upon a 
 field that has been fiercely debated ; but, in the decision of the value 
 of this agent, we cannot accept tlie dicta of men who are ignorant of 
 the manner in which it is used, or of those who condemn it without 
 a trial. An agent which is capable of arresting the life of mice and 
 insa^ts by passing a charge through a vessel of water in which they 
 
24 EXTRA-UTERINE PREGNANCY. 
 
 have been placed, as shown by the experiments of Laudis, should 
 be effective in destroying fetal life when brought in close contact 
 with the fetal envelope. Its method of action is not electrolytic — 
 the proper method of use is not by puncture. The ovum is brought 
 within the circuit of a faradic current by placing one pole over the 
 abdomen and the other against the sac, either in the vagina or rec- 
 tum as may be most convenient, and a current employed as strong as 
 can be comfortably borne for ten or fifteen minutes. This should 
 be repeated once or twice daily for several days. Usually from 
 two to five applications are sufficient to accomplish the arrest of 
 development. 
 
 Naturally, among those who would discredit the efficacy of this 
 agent the correctness of the diagnosis is questioned. It is possible 
 that, in some of the reported cases of cure by electricity, the operators 
 may have been at fault as to the condition. But it is not probable 
 that in a large series of cases, many of them seen by several men of 
 unexcelled prominence and experience in the diagnosis and treatment 
 of abdominal and pelvic troubles, an error should have been made 
 in every case. If it would prove successful in one case, there is no 
 reason why it should not in many. The abdominal surgeon meets us 
 with a number of objections — as, the uncertainty in our diagnosis ; 
 the possibility of the continuation of the growth of the placenta 
 even after the death of the fetus; and, finally, that the presence of 
 this foreign growth is a standing menace to the health of the 
 patient — all of which he claims are obviated by laparatomy. 
 
 But an agent that will enable us to dispel an abnormal condition 
 which presents all the symptoms of extra-uterine pregnancy, such 
 as the subjective signs reinforced by the presence of a tumor in the 
 pelvis — a tumor that was growing as we would expect an ectopic 
 gestation, which was accompanied by the discharge of a decidual 
 membrane — such an agent, I say, should not be hastily cast aside. 
 The growth of the placenta is, at least, entitled to the Scotch ver- 
 dict of " not proven." Should the expected dangers result from the 
 presence of the residuum of the ovum laparatomy may be performed. 
 
 Electricity has the advantage that it does not require a special 
 amount of skill for its administration, hence can be practised where 
 life would be sacrificed had we to depend upon the abdominal sur- 
 geon. Then, too, we that practise abdominal surgery are aware 
 that cases will come to us that we are uuable to impress sufficiently 
 
TREATMENT. 25 
 
 with the gravity of their position, to induce them to undergo wliat 
 they regard as a difficult and dangerous operation. 
 
 In those oases in which there has been a gradual rupture of the 
 tube, and development of the embryo has taken place between the 
 folds of the broad ligament, electricity seems to us the easiest way 
 out of the difficulty. The agent is, however, of limited application. 
 It is better fitted for the treatment of ectopic gestation of the first 
 four months. After this period the danger to the individual would 
 be enhanced by the indefinite retention of the dead embryo. Even 
 after this period, however, in view of the frequently dangerous 
 hemorrhage from the placental vessels, it seems to us that it would 
 be good treatment to destroy life by electricity and await the coagu- 
 lation of blood in the vessels, before proceeding to laparatomy. 
 
 Tubal pregnancy is regarded as presenting the gravest prognosis. 
 This form rarely goes beyond the fourth or fifth month without rup- 
 ture. Such an occurrence, aside from the effects of shock produced 
 by the escape of the contents of the sac into the peritoneal cavity, 
 is a source of danger through free and uncontrollable hemorrhage. 
 In rupture the better plan of procedure is abdominal section, 
 although Freund opposes operation, directing rather to wait and 
 treat anemia and peritonitis. He quotes a large series of successful 
 cases as justification of such advice. An analysis of his cases, how- 
 ever, shows that convalescence is of long duration. Laparatomy 
 has been earnestly and ably advocated by Tait. This operation 
 enables us to ligate the bleeding vessels and diminish the danger of 
 peritonitis and septic conditions, by the removal of the blood and 
 sac contents from the peritoneal cavity. 
 
 Tait and his school of abdominal surgeons advocate abdominal 
 section when the existence of ectopic gestation is strongly suspected ; 
 but we would prefer, at any time before the fourth month, the 
 application of the faradic current. After the fourth month we 
 would still recommend the destruction of life by the electric current, 
 and that abdominal section be postponed for some weeks, until oblit- 
 eration of the placental vessels has had an opportunity to take place. 
 By such a course we increase the probability of successful removal 
 of the placenta and lessen the danger of hemorrhage. Where the 
 fetus is living and viable, laparatomy should be done to save the lives 
 of both individuals. The operation under such circumstances should 
 
26 EXTRA-UTEEINE PREGNANCY. 
 
 be done with the greatest care, so as to avoid separation of the 
 placenta and the resnlting hemorrhage. 
 
 This operation is denominated by Harris and other obstetrical 
 writers, the primary operation. The results, according to the care- 
 ful and painstaking researches of Harris, are exceedingly unfavora- 
 ble. Of twenty-five cases operated upon in seventy-four years, but 
 twenty-three recovered. He says this mortality can be lessened 
 only in one of two ways : 
 
 1. By ligation of the vessels supplying the placenta and its 
 removal with the cyst. 
 
 2. Treating the placenta autiseptically to prevent its decompo- 
 sition. 
 
 Probably the best method of treating such cases is that of Martin, 
 who makes a puncture from the most dependent portion of the sac 
 into the vagina, through which the cord is passed and a drainage- 
 tube inserted ; the sac above is sewn up to close its cavity to the 
 peritoneum. 
 
 To resume, we would recommend the following plan of procedure : 
 
 1. In every form of ectopic gestation prior to the fourth mouth, 
 the destruction of the embryo by electricity (faradic current). 
 
 2. Between the fourth and sixth mouths, destruction of life by 
 electricity and some weeks later laparatomy. 
 
 3. In rupture, immediate laparatomy with removal of sac, con- 
 tents, and effused blood. 
 
 4. In cases that have passed the sixth month, wait until viability 
 is well established and perform laparatomy; observe every precau- 
 tion that separation of the placenta does not occur, close the sac 
 above, and drain through the vagina. 
 
 5. In case of the death of the fetus it should be removed by 
 laparatomy a few weeks later. 
 
 6. Where the fetus has become macerated and abscess has formed, 
 its sinus should be enlarged and the fetal residuum remov^ed. 
 
IV. OBSERVATIONS— CLINICAL, PATHOLOGICAL, 
 AND SUEGICAL. 
 
 By W. H. WATHEN, M.D., 
 
 LOUISVILLE, KT. 
 
 It was not my purpose to say anything upon the learned papers 
 just read by Drs. Townseud, Price, and Montgomery, for they will 
 be discussed by other men of experience, but I beg you to bear with 
 me a few minutes while I offer some suggestions — clinical, patho- 
 logical, and surgical — on this interesting topic. 
 
 Mr. Lawson Tait has done more than anyone else to correct the 
 false, but generally accepted, theories about the etiology and the 
 pathology of ectopic pregnancy, and, with a few exceptions, I fully 
 concur in his views. All ectopic pregnancies must begin in the 
 Fallopian tubes, with the possible exception of ovarian pregnancy, 
 and this cannot occur unless the ovule is held in the Graafian follicle 
 after its rupture, and becomes impregnated there ; but I do not 
 believe that ovarian pregnancy has been positively demonstrated. 
 An impregnated ovule cannot form villous and placental attach- 
 ments unless it is held by the maternal structures nearly immovable 
 in one place, hence the impossibility of fixation in the abdominal 
 cavity, where the peritoneum and other structures are in nearly con- 
 stant motion ; and, were the ovule to fail to enter the tube, it would 
 become dead matter and be absorbed by the peritoneum before 
 fixation could occur. All abdominal pregnancies become such by 
 secondary rupture, the cyst having primarily ruptured into the folds 
 of the broad ligament before the end of the twelfth week of gesta- 
 tion. If the primary rupture is into the abdominal cavity, death is 
 the usual result, unless the sac is removed by abdominal section; and 
 if the woman does not die, the blood and the contents of the sac are 
 absorbed by the peritoneum. In secondary ruptures, the conception 
 cannot continue to develop in the peritoneal cavity if the villous or 
 the placental attachments are entirely separated. But, if these attach- 
 
28 EXTRA-UTERINE PREGNANCY. 
 
 ments to the tube, or to the folds of the broad ligament, are not 
 separated, the conception may continue, and the placenta may extend 
 its attachments to any structures which it is possible for it to reach 
 — the uterus, intestines, omentum, bladder, etc. This briefly 
 expresses the whole truth, and so simplifies matters that it is not 
 logical to draw any other conclusion. I do not remember to have 
 seen that any one has before called attention to the fact that fixation 
 of an impregnated ovule cannot occur unless it be held in one place 
 long enough for such attachments to form. An additional proof of 
 this fact is observed in placenta previa, when the uterine walls fail 
 to hold the impregnated ovule near the fundus of the uterus ; it is 
 finally caught and held in the mucous folds at or near the internal 
 OS uteri, and becomes fixed at the lower segment of the uterus. 
 
 I am in perfect accord with Mr. Tait in his views of the relation 
 ectopic pregnancy sustains to extra-peritoneal or to intra-peritoneal 
 hematocele. But I do not believe he is correct in saying that 
 interstitial pregnancy always ruptures into the peritoneal cavity. 
 " Maschka ( Wien. mcd. Woehenschrij't, 1885) has proved by a post- 
 mortem examination that the cyst in interstitial pregnancy may 
 rupture into the uterus. A woman, twenty-nine years old, died 
 suddenly, and criminal abortion being suspected, a judicial autopsy 
 was made and an interstitial pregnancy with rupture into the uterus 
 was found. The body of the fetus had passed into the uterus and 
 had been removed, but the head was torn from the body and re- 
 mained in the sac." 
 
 In the American Journal of Obstetrics, 1887, page 536, Dr. 
 Parkes, of Chicago, reports a case of ectopic pregnancy that he 
 believed was interstitial, which was discharged from the sac into the 
 uterus. I will briefly report a case that came under my immediate 
 observation in the fall and winter of 1873, in which I feel sure an 
 interstitial pregnancy ruptured into the uterus, and the woman 
 recovered. Mr. Tait may object to the introduction of this case 
 because the woman got well and no post-mortem could be held' to 
 verify the correctness of the diagnosis ; but an assumption that no 
 case of ectopic pregnancy in which we are unable to avail ourselves 
 of the objective facts as seen in an autopsy, or in an abdominal 
 section, can be relied upon, is not logical, for in careful physical 
 examinations we may learn facts of great value in solving problems 
 otherwise not understood. 
 
CLIJSriCAL AXD PATHOLOGICAL OBSERVATIONS. 29 
 
 I was called in the late fall of 1873 to see Mrs. C, an Irish 
 woman, aged twenty-seven ; she had not menstruated for three 
 months, and had all the subjective symptoms of pregnancy. With 
 the exception of some sharp pains in the right inguinal region low 
 down, and pains in the lower part of the back, she had no untoward 
 symptoms until the day before I saw her. She then began to 
 suffer severe pains in the right iliac region and had considerable 
 uterine hemorrhage. She became partly unconscious for a while ; 
 as pain and bleeding continued, I suspected that she was threatened 
 with abortion, and kept her in bed under the influence of an opiate. 
 She continued to bleed and suffered enough pain to require the 
 occasional use of the opiate. In a careful -physical examination I 
 found the uterus enlarged, but a greater enlargement was observed 
 toward the right ovarian region, connected with the uterus. She 
 had but little fever, but continued to suffer and lose blood. As 
 she did not improve, and had no one to care for her properly 
 at home, I sent her to St. Joseph's Infirmary, where I saw her 
 frequently during her illness. The enlargement in the right 
 ovarian region did not appear to increase, but at the end of the 
 fourth month the uterus began to enlarge rapidly, and in another 
 month it was as large as the gravid uterus at term. About this time 
 she again suffered severe pains, when more than a quart of clotted 
 blood was expelled, which caused a marked decrease in the size of 
 the uterus and a^bdomen. In a few days the enlargement returned, 
 and another hemorrhage was followed by a corresponding decrease 
 in size of the uterus and abdomen. This occurred nearly every 
 week for several weeks. Finally, I was called in haste and found 
 her suffering severe uterine contractions with a large mass protrud- 
 ing from the uterus into the vagina. In a little while, more than a 
 gallon of hydatiform growths was expelled and the uterus con- 
 tracted to less than its usual size after labor, but there remained an 
 enlargement connected with its right cornua in the site of the origi- 
 nal tumor. The next day local peritonitis developed in this region 
 and increased the size of the tumor until it was as large as a goose's 
 egg. Her pulse grew rapid and her temperature was 103° to 104° 
 for a week. She then began to improve and was able to leave 
 the Infirmary in two months, but the tumor did not entirely dis- 
 appear for many months afterward. 
 
 The late Professor John E. Crowe was associated with me in the 
 
30 EXTRA-UTERINE PREGNANCY. 
 
 case, and we fully concurred in the diagnosis, but neither of us came 
 to any positive conclusion until after the expulsion of the hydatiforni 
 growths. She narrowly escaped with her life from the peritonitis, 
 and we did not think for several days that she would recover. She 
 became pregnant two years afterward and gave birth to twins, and 
 three years later gave birth to another child. I examined her care- 
 fully a few days ago and could detect nothing abnormal in the pelvis 
 except a completely retroverted uterus, and decided tenderness when 
 I pressed in the region of the right ovary and tube. 
 
 The hydatiform growths prove that this woman was pregnant ; 
 and if it were in the uterus then, Why the primary and secondary 
 enlargement to the right of the uterus and the localized peritonitis ? 
 How can we explain all the symptoms ? Her uterus is now 
 normal in shape internally and externally. 
 
 I must adhere to the generally accepted belief that the sperma- 
 tozoa come in contact with the ovule in the outer part of the tube, 
 or probably before it enters the tube, and that the fructified ovule 
 passes slowly through the tube to the uterine cavity. All the facts 
 that we know in relation to generation favor this view, and I 
 know of no logical argument against it. Mr. Tait's belief that the 
 spermatozoa cannot pass out through the Fallopian tubes unless 
 disease has destroyed the ciliated epithelium, is based upon no tangi- 
 ble evidence, and is contrary to all that is known upon this subject. 
 It is positively known that the spermatozoa pass out through the 
 tubes upon the ovaries and into the abdominal cavity in the lower 
 animals. While these tubes are not identical in shape, etc., with 
 the Fallopian tubes of the woman, they serve the same purpose and 
 are lined with ciliated epithelium, which sustains the same relations 
 to the movements of the spermatozoa that exist in the Fallopian 
 tubes of the woman. It is doubtless true that desquamative salpin- 
 gitis is a frequent cause of ectopic pregnancy, but it is because of the 
 obstruction offered to the passage of the impregnated ovule. This 
 character of tubal disease would not facilitate but would obstruct 
 the passage of the spermatozoa, just as it does the impregnated 
 ovule. 
 
 It is a well-known fact that the spermatozoa move by an inherent 
 force at a rate variously estimated. Henle concludes that they 
 move one inch in seven and a half minutes, and Sims that they 
 move their length in one second. Nor are their ^lovements easily 
 
CLINICAL AND PATHOLOGICAL OBSERVATIONS. 31 
 
 interfered with, for Robin has observed that they push out of their 
 way epithelial cells or crystals ten times their size ; so why should 
 they not overcome any possible obstruction caused by the cilia of the 
 tubes ? The impregnated ovule passes slowly through the tubes — 
 in the bitch it does not reach the uterus for eight or nine days, and 
 in the guinea-pig for three or four days. Play fair and other dis- 
 tinguished authorities claim that in the human female the ovum 
 has never been found in the uterine cavity before the tenth day 
 after impregnation. The uterine mucous membrane becomes suc- 
 culent and thickened during the passage of the fecundated ovule 
 through the tube, so as to prepare a proper nidus upon which it 
 may rest and from which it may be nourished. If this did not 
 occur in woman, the ovule would often fail to become attached at 
 the upper segment of the uterus and would pass down to the 
 internal os, or out of the uterine cavity. The inherent power of 
 the spermatozoa to reach the ovule is made manifest in those cases 
 where women have become pregnant with an almost imperforate 
 hymen, or with atresia vaginae so nearly complete that there was 
 only a very small fistulous tract leading to the uterus ; or in that 
 very remarkable instance where the spermatozoa reached the uterus 
 through the bladder, having to pass through the urine. 
 
 Koeberle reports a case " where the uterus had been amputated 
 two years before for fibroid tumor, but a fistula was present in the 
 cicatrix of the cervix through which spermatozoa passed into the 
 abdominal cavity, and pregnancy resulted." The tube may be 
 entirely closed and the ovule may become impregnated by sperma- 
 tozoa from the other tube. " Leopold tied the right Fallopian tube 
 in rabbits in two places and exsected a portion of the tube between 
 the ligatures ; the left ovary was carefully removed and the abdomi- 
 nal wound was closed. After recovery the rabbits were put to the 
 male. In two such cases pregnancy followed." (Arch.f. Gyna.k., 
 vol. xvi. page 24.) 
 
 The ovule is short-lived, and if not vivified in the tube by con- 
 tact with the male element degenerative changes will destroy its 
 vitality before it reaches the uterus. Charpeutier and other recog- 
 nized observers claim that after it passes the outer tiiird of the tube, 
 it is covered by a layer of albumen which the spermatozoa cannot 
 pierce. Many other facts could be given to prove that impregna- 
 tion does not occur in the uterus. 
 
32 EXTRA-UTERINE PREGNANCY. 
 
 I wish to iuveigh earnestly against electricity, or any other means 
 used to destroy the life of an ectopic gestation, for I believe such 
 treatment harmful, if we have made a correct diagnosis, which is 
 nearly impossible until after the rupture of the sac. I put little 
 confidence in the reported successes by the use of electricity, for 
 I am convinced that in nearly every instance there was an error in 
 diagnosis, and that the women were not pregnant. 
 
 Abdominal section and the removal of the fetus and sac is the 
 correct treatment, and the experience of Mr. Tait has proven that 
 it is the most successful method of treatment. 
 
 In conclusion, I wish to impress upon the Fellows the fact that 
 it has not been my purpose to criticise Mr. Tait; his work in 
 ectopic gestation, if he had done nothing else, would entitle him 
 to the lasting praise of not only the members of the medical pro- 
 fession, but of every enlightened man and woman. His kind heart 
 has probably caused him sometimes to do things that he after- 
 ward had cause to regret, and to accept conclusions of some one 
 in whose judgment and powers of observation he had too much 
 confidence. I will mention two instances. He accepts as a demon- 
 strative truth that "desquamative salpingitis could at once put 
 the mucous lining of the tube into a condition exactly similar 
 to that of the uterus." This is a physical impossibility, for these 
 membranes are so dissimilar anatomically and histologically that 
 they can no more be made identical in structure, than can the 
 skin and the mucous membrane of the stomach. This I assert 
 without fear of contradiction, and the investigations of men learned 
 in anatomy, histology, pathology, and microscopy will positively 
 demonstrate its truth. It must be remembered that there are but 
 few observers whose statements upon such subjects as this can be 
 accepted without reservation. The similarity coidd go but little, if 
 any, further than in the total destruction of the ciliated epithelium 
 lining the tube and the endometrium. He again accepts as a fact 
 the discovery by one of his assistants, "Of a large nerve-trunk 
 entering or leaving the coruua of the uterus at the angle between 
 the round ligament and the tube." The gentleman who claims to 
 have made this discovery was doubtless honest in his belief, but his 
 powers of observation were defective, and he probably mistook some- 
 thing else for a large nerve. It is no longer a disputed fact that 
 the uterus in all its parts is well supplied with nerves, and that the 
 
CLINICAL AND PATHOLOGICAL OBSERVATIONS. 33 
 
 tubes, ovaries, and upper part of the uterus are in part supplied 
 from the spermatic plexus, which is probably derived from the 
 renal plexus and the upper aortic plexus ; but there is no nerve of 
 any magnitude that has not previously been discovered, by someone 
 of the many well-trained and learned observers who have so 
 patiently and carefully worked in this field. If we will examine 
 the illustration of Frankenhaeuser, 1867, showing the ganglionic 
 and nerv^e supply and distribution to the uterus, we will see how 
 neatly he traces a 7ierve-trunk formed by the uterine and ovarian 
 nerves, to the cornua of the uterus at the angle between the round 
 ligament and the tube. The nerves of the uterus and ovaries are 
 also made conspicuous in the illustration of De Graaf, 1678. 
 
V. A CRITIQUE OF ITS MANAGEMENT. 
 
 By J. M. BALDY, M.D. 
 
 PHILADELPHIA, PA. 
 
 I AM glad to take the floor and discuss this exceedingly interest- 
 ing and important subject of extra-uterine pregnancy, because it will 
 enable me to express views that I have not heard advocated here 
 as yet. My remarks will be confined to that variety of the disease 
 which is known as tubal pregnancy, and in this connection I shall 
 only dwell on two points, viz., diagnosis and treatment. As to the 
 pathology of this disease, some of what has been said I can accept, 
 but nmch of it I cannot endorse. I accept almost in toto the teach- 
 ings of Mr. Tait on this subject. 
 
 The diagnosis I consider beyond the reach of man, and never 
 expect to see the time when it can be made with certainty and 
 accuracy. One may see a patient suffering with all the symptoms 
 that have been put down as diagnostic of the disease, and yet it 
 may turn out to be something else. Such a case has passed under 
 my own observation. The woman had missed her menses for one 
 or two periods ; her breasts were swollen, contained milk, and pre- 
 sented the other characteristic symptoms ; her abdomen was slightly 
 swollen, and she had vomited a number of times ; she had vesical 
 irritation and constipation ; characteristic colicky pains were present 
 and she had passed " something " from the vagina, which, from her 
 description, was considered decidual membrane. Vaginal examina- 
 tion revealed a mass about the size of a small orange to the right 
 of the cervix uteri. An operation two days later disclosed an 
 ovarian cyst. 
 
 It may be contended that such a mistake is not likely to occnr 
 in careful hands. Surely no one would pretend that Dr. Mann, of 
 Buffalo, could not make the diagnosis, if it could be made at all ; 
 and yet Dr. Mann did diagnosticate a case as one of extra-uterine 
 pregnancy and suppositively destroyed the fetus by electricity. 
 That same case, a short while afterward, fell into the hands of Dr. 
 
36 EXTRA-UTERINE PREGNANCY. 
 
 Wylie, of New York, who operated and found a large purulent sac, 
 containing a pint or more of fluid, but nowhere any trace of an 
 extra-uterine pregnancy ever having been present. I think the 
 advocates of the electrical treatment are not exactly honest in not 
 reporting such cases, and I have no doubt that there are plenty 
 like this one. Certainly there have been and will be plenty like 
 mine. 
 
 There are only two methods of treatment worthy of any consid- 
 eration, viz., that by electricity, and that by abdominal section. 
 After rupture has taken place all are agreed that abdominal section 
 is the only thing to be done. 
 
 Before rupture has taken place most of our American surgeons, 
 I am sorry to say, advocate the treatment by electricity. Electricity 
 will, beyond doubt, kill the fetus and thus save the patient from 
 all the worry and excitement of a surgical operation. However, 
 after the fetus is dead a diseased mass is left behind. Lusk has 
 reported two cases in which the mass was still present for four and 
 six years afterward, and there are others on record. Now this mass 
 is just as likely to take on active inflammatory action as any other 
 pelvic mass, and a woman with such a disease remaining is very 
 liable to have later trouble, and eventually come to the knife. I 
 consider it the height of folly to operate on inflammatory disease of 
 the appendages and leave such a condition as this. These sacs have 
 been known to ulcerate their way out, and quite a number of such 
 cases are on record. Again, after the operation a vessel has been 
 known to burst and the patient thereby lost. Mann says these 
 accidents have happened so seldom that they need not be taken into 
 consideration. But what sane man would not take accidents into 
 consideration when they have occurred in two or three per cent, of all 
 the cases reported? This matter is too serious to be thrown aside in 
 that manner. Electricity leaves the woman in as much a mutilated 
 condition as if the tube had been removed. This is not all the 
 objection to this treatment, for we have some immediate dangers 
 we must contend with. Dr. Janvrin lost a case, a few hours after 
 having killed the fetus, from a rupture of a vessel in the cyst wall. 
 I have seen electricity passed through a cyst not extra-uterine and 
 the patient became worse after each application. 
 
 With all these objections arrayed against electricity we find nothing 
 against the knife, excepting that it is a surgical operation. No case 
 
CRITIQUE OF ITS MANAGEMENT. 37 
 
 of death has ever been reported as due to the knife. If a mistake 
 in diagnosis has been made no harm has been done, as the disease, 
 whatever it is, will require the knife at any rate. The operation 
 is no harder than the removal of pus-tubes or inflamed tubes, and 
 the statement which has been made that we have no Martins or 
 Taits in this country is a gross insult to American surgeons ; there 
 are probably twenty men here present who are competent to deal 
 surgically with an extra- uterine pregnancy. 
 
 I can only end by stating, as I have before done, that I consider 
 that while playing with electricity in this disease, we are running 
 much the same risk that the proverbial child did when it played 
 with fire. 
 
VI. THE TECHNIQUE OF THE OPERATION. 
 
 By JOHN B. DEAVER, M.D. 
 
 PHILADELPHIA. 
 
 Before a body of distinguished gynecologists a general surgeon 
 might feel out of place in discussing a subject which has been here- 
 tofore considered foreign to his mission ; but as extra-uterine preg- 
 nancy calls for the treatment of a foreign body within the abdomen, 
 and, especially when the sac has ruptured, for the treatment ot 
 hemorrhage within the abdominal cavity, I feel that every surgeon 
 should be alive to his sense of responsibility, and to the demands 
 made on him by his patients who may require his services for the 
 treatment of this unfortunate condition ; or, perhaps, by his fellow 
 j)ractitioner who may call on him for assistance. Therefore, he 
 should be prepared to do the necessary operation with dispatch, and 
 meet with the many complications that so often arise in abdominal 
 and pelvic surgery. 
 
 In considering the technique of the operation let me speak, first, 
 of the length of the incision that should be made and the size of the 
 same. The linea alba offers the best point through which to make 
 our incision, it giving us like command of either side of the interior 
 of the pelvis. Here the abdominal walls are thinnest and fewer 
 bloodvessels call for division, than if we selected a point elsewhere 
 than through either semilunar line. The length of the incision 
 should not be greater than is necessary for the introduction of the 
 index and middle fingers of the more educated of the two hands, 
 and for the easy manipulation of them when inserted into the pelvis. 
 Through an incision of this size, in the event that we are dealing 
 with hemorrhage, we are able to remove the blood-clots and find 
 our way to the uterine appendage, the seat of the trouble, and deter- 
 mine the further manipulation necessary to inspect it. By such au 
 incision there is less exposure of the contents of the abdomen and 
 less likelihood of the escape of the intestines and great omentum — a 
 
40 EXTRA-UTERINE PREGNANCY. 
 
 very iniportaut precaution, I consider, to be observed. Through 
 an incision of this size we are able to bring the diseased tube to the 
 bottom of the wound and, if necessary, to inspect it. Again, it 
 gives us ample room through which to irrigate, an equally impor- 
 tant point to be observed in nearly all abdominal and pelvic opera- 
 tions. If we are dealing with an extra-uterine pregnancy of some 
 months' standing, and the original incision is too small, it is a very 
 simple matter to enlarge it and thereby give us as much room as 
 had the incision been originally a long one. 
 
 Second, having reached the interior of the pelvis and found our 
 way to the site of the trouble, in the event that it is a ruptured 
 sac with which we have to deal, it is important to deliver it and tie 
 it off as soon as possible, thereby lessening the amount of shock 
 which would result from prolonged manipulation. When there are 
 few, if any, adhesions, it is a simple procedure, the difficulties of the 
 operation, therefore, being increased in proportion to the number, 
 the position, and the strength of the adhesions met with. In dealing 
 with an adherent mass, we should first survey the interior of the 
 pelvis at the point where the enucleation is to be made, bearing 
 in mind the position the small intestine and the sigmoid flexure 
 of the colon hold to it, also the ureters and the bloodvessels of the 
 pelvis. 
 
 To gain access to the cavity of the pelvis, after the abdominal 
 walls have been divided, it may be necessary either to dissect up 
 the great omentum, which is sometimes found adherent to the 
 fundus of the uterus, or to break through it; in which event, after 
 the enucleation is completed, the abdominal cavity thoroughly 
 irrigated and the drainage-tube introduced, any remaining rent in 
 the great omentum should be brought and maintained in apposition 
 by a continuous catgut suture, the object being to prevent any like- 
 lihood of an acute strangulation of the small intestine, from a nuckle 
 of the same becoming engaged therein. Having reached the fundus 
 of the uterus the fingers are to be passed down to the floor of the 
 pelvis behind the mass, their dorsal surfaces looking into the hollow 
 of the sacrum. In performing the enucleation the points of the 
 fingers are to be kept close to the mass, when its connections with the 
 surrounding parts are to be severed in the direction of from below 
 upward, and at the farthest point from the important surrounding 
 structures. The small vessels supplying these adhesions will bleed 
 
TECHNIQUE OF THE OPERATION. 41 
 
 but little owing to the character of the manipulatiou by which they 
 have been separated. By dealing with the mass first from below, 
 and severing its connections there, we are able to lift it up, bring- 
 ing it to the bottom of the womb, it resting upon the palmar sur- 
 face of the fingers, and in the event of there being strong intestinal 
 adhesions we are additionally guided in their separation by being 
 able to see them by their having been made more accessible, when, 
 if necessary, they can be surrounded by two ligatures and severed. 
 
 When we meet with an adherent vermiform appendix, unless 
 the patient's condition is very bad and contraindicates undue 
 or prolonged manipulation, I think it well to tie off and cut 
 away the appendix, it being, as we know, a useless organ and 
 one capable of serious trouble. Were we so unfortunate as to 
 tear either iliac vein it should be tied both above and below the 
 opening made in it, this being much safer than to attempt to ligate 
 it laterally. Should we have a portion of gangrenous bowel to 
 deal with, resection or the formation of a temporary artificial anus, 
 which can subsequently be closed, would be the treatment. In the 
 event of tearing the ureter and having discovered it, the proximal 
 end of the ureter could be stitched in the abdominal wound, makinof 
 a urinary fistula ; but a safer procedure would be to do a median 
 nephrectomy. If the condition of a portion of the great omentum 
 is questionable, I unhesitatingly state that, in ray experience, it is 
 far better to ligate it and remove the doubtful portion than to 
 return it with the hope that it may recover itself; this I have 
 had demonstrated in operations for strangulated hernia. 
 
 TIdrd, irrigation. In all cases of abdominal section for intra- 
 al)dominal hemorrhage, where there has been escape of the con- 
 tents of a cyst into the abdomen and where adhesions have been 
 separated, the abdomen should always be most thoroughly washed 
 out. In fact, in all cases of section where the indications do 
 not seem to call for irrigation, yet if there is any doubt in the 
 mind of the operator as to whether or not he should wash out the 
 cavity, I should say that it was safer to err upon the side of safety 
 and irrigate. This, irrespective of the removal of all foreign 
 matter and leaving the parts in a perfectly aseptic condition, in 
 depressed conditions acts as a stimulant by exciting the sympa- 
 thetic nerves, with which it is brought into close contact, by being 
 introduced into the abdominal cavity, where the greatest number of 
 
42 EXTRA-UTERINE PREGNANCY. 
 
 branches of this system of nerves are distributed ; while in cases 
 where there has been much leakage from the skin, an evidence of 
 profound shock, it acts in a two-fold manner by filling up the 
 depleted bloodvessels and by stimulation. 
 
 The rationale of the use of hot distilled water in the abdominal 
 cavity to my mind is so logical, that I use it extensively in other 
 than abdominal sections, particularly after the operation for the 
 relief of a strangulated hernia, where there is always much depres- 
 sion ; here I always open the sac, thereby giving me access to the 
 cavity. In cases where I have had to make a large incision in the 
 abdominal walls, I flush the cavity by pouring the water into it 
 directly from the basin ; this I have done after the operation of 
 ovariotomy complicating a six months pregnancy, without provok- 
 ing abortion, where I had to deal with a multilocular cyst filled 
 with colloid matter, and where the adhesions were universal and the 
 wall of the cyst so friable as to prevent its giving away. 
 
 Fourth, drainage. In all cases of section for hemorrhage or 
 where much bleeding has occurred while doing the section, where 
 there has been escape of pus or other septic matter into the peri- 
 toneal cavity, there should be no hesitation about the case being a 
 proper one for drainage. In fact, my experience has been that 
 cases where a drainage-tube has been inserted have proved less com- 
 plicated after the operation, than in cases where it has not been 
 used. 
 
YII. ITS MANAGEMENT WHEN THE FETUS SUR- 
 VIVES TUBAL RUPTURE AND GOES ON 
 TO THE PERIOD OF VIABILITY. 
 
 By L. S. McMURTRY, M.D., 
 
 DANVILLE, KT. 
 
 The subject of ectopic gestation deserves very careful discussion 
 on account of its interest and importance, and from the fact that 
 recent advances in pelvic surgery have recast the pathology of this 
 condition and remodelled its treatment. I accept unequivocally the 
 teachings of Lawson Tait upon this subject, since they throw light 
 where all was darkness, and bring order out of confusion and con- 
 jecture. The essential points in the pathology have been concisely 
 stated by Dr. J. Price, and are confirmed by the rapidly accumulating 
 data of pathologists and operating surgeons. 
 
 The important points are these : First All cases of ectopic preg- 
 nancy are in the beginning tubal. Second. "When rupture occurs, 
 the ovum may pass into the intra-ligameutous cellular space or into 
 the peritoneal cavity — the intra-peritoneal being a deadly accident, 
 and the intra-ligamentous favoring the growth and development 
 of the fetus. As to diagnosis, I believe it altogether impracticable 
 before the period of rupture. I am sceptical in regard to all claims 
 of diagnosis previous to that time. Indeed, if I were to witness 
 the confirmation of such a so-called diagnosis I would consider it 
 only a happy guess. This insurmountable difficulty in diagnosis — 
 a difficulty enhanced by the fact that the patient rarely requires or 
 seeks aid from the physician previous to rupture of the tube — must 
 necessarily impair confidence in the results claimed for treatment by 
 electricity in the early weeks of ectopic pregnancy. When the 
 diagnosis is made, which will, as a rule, be at the time of rupture, 
 abdominal section, removal of fetal tissues, and cleansing away 
 extravasated blood, constitute the only treatment worthy of confi- 
 dence. This procedure is thoroughly surgical, and if done promptly 
 and skilfully the result is satisfactory in every respect. 
 
44 extra-uterijste pregnancy. 
 
 But, Mr. President, I desire to address my remarks iu this dis- 
 cussion, more particularly, to the management of extra-uterine 
 pregnancy when the fetus survives tubal rupture and goes on to the 
 period of viability. Six months ago I operated in a case in which 
 the child had perished after the period of false labor. This occurred 
 one month before I saw the patient. The operation was necessitated 
 by the appearance of septic symptoms. On opening the abdomen I 
 found the child loose, without a trace of the sac. The liquor amnii 
 had been absorbed and the child was undergoing decomposition. 
 The placenta formed a large mass attached to the uterus, bowel, and 
 floor of the pelvis. The cord was shrivelled, and in examining the 
 placenta I started a hemorrhage which compelled me quickly to 
 remove that mass. By sponge-packing and forceps-pressure I 
 arrested the hemorrhage, put in a drainage-tube, and closed the ab- 
 domen. My patient never fully reacted and died the following 
 day. The cord was shrivelled and the placenta gave no evidence 
 of active circulation. 
 
 Just how to deal with the placenta is the great problem in 
 these cases. The popular plan seems to be to stitch the sac to the 
 edges of the incision, to leave the placenta untouched, and to place 
 a drainage-tube at the site of the placenta with the cord hanging 
 from the lower angle of the wound. During the long process of 
 suppuration and discharge of placental debris the patient is exposed 
 to the perils of sepsis. In such a case, in the hands of one of our 
 Fellows, death occurred from hemorrhage during separation of the 
 placenta two weeks after the operation. Thornton has reported a 
 successful case in which he removed the entire gestation sac. Mar- 
 tin had a successful case at full term with living child, in which he 
 removed the placenta. Some operators have endeavored to quilt 
 around the placenta with the cobbler's stitch and thereby arrest 
 hemorrhage ; others have tried to tie the vessels feeding the placenta. 
 Unfortunately, there is no way to ascertain beforehand that the 
 placental circulation has ceased. Schroeder found in one case obliter- 
 ation of the vessels three weeks after death of the fetus, while Depaul 
 lost his patient from placental hemorrhage four mouths after the 
 death of the fetus. The truth is, that no hard and fast rules can be 
 laid down for deciding the management of these cases, since no two 
 cases are alike. After my own experience I would prefer to leave 
 the placenta untouched, unless its arrangement is such that it can 
 
MANAGEMENT WHEN FETUS IS VIABLE. 45 
 
 be securely claraped or tied away. Mr. Tait suggests that the sac 
 be thoroughly cleansed after removing the fetus, and, while filled 
 with water, to stitch the incision in the sac so as to close it tightly 
 as the water is removed, thereby closing it hermetically ; then to 
 close the abdomen and leave the sac and placenta to atrophy and 
 absorption. 
 
 One other point of great importance presses for consideration. 
 When a case of ectopic gestation has advanced near or quite to full 
 term shall we await the death of the child and the approach of sepsis 
 before operating ; or shall we, at the advent of spurious labor, open 
 the abdomen and attempt to save both motlier and child ? Harris 
 has collected thirty cases operated upon after the period of viability, 
 with the result of only five women and twenty-two children saved, a 
 number of the children dying within short periods after birth. It 
 must be remembered that nearly all of these cases occurred before 
 the days of modern abdominal surgery, and hence cannot properly 
 be either a guide or a hindrance to future action. Mr. Tait has 
 performed three operations at this period, with the splendid result 
 of " one death of a mother and no deaths of the children." Several 
 successful operations have likewise been done in our own country, 
 and it is quite safe to predict that they will become more numerous. 
 
VIII. ITS TREATMENT (concluded). 
 
 By a, VANDER VEER, M.D., 
 
 ALBANY, N. Y. 
 
 Many eminent writers and operators in, the field of abdominal 
 surgery have paid especial tribute to the worth of Sir Spencer Wells's 
 monograph on abdominal tumors, published in 1865. The particu- 
 lar excellence of this work lies in the full, clear history of cases, 
 the concise yet minute description of the surgical devices employed 
 in overcoming obstacles and bringing his cases to a successful 
 termination. 
 
 Much of the literature upon ectopic gestation, especially that 
 which deals with the subject before rupture and hemorrhage, as to 
 histories, points of diagnosis, and the details of treatment, is very 
 vague. The busy writer is often prone to pass rapidly over the 
 history, symptoms, and general manner of treatment, to enter some 
 special pleading for this or that form of treatment. 
 
 The abdominal surgeon will often be called in consultation by 
 the general practitioner when a suspicion of ectopic gestation may 
 arise. It will be necessary for him to have in mind the various 
 ])oints of diagnosis, especially of early diagnosis — that is, some 
 time prior to the sixteenth week. 
 
 I believe there are, on the one hand, a class of cases in which a 
 diagnosis can be made before rupture and by the tenth week. On the 
 other hand, there are cases which do not give rise to any symptoms 
 other than those of a normal pregnancy before the rupture takes 
 place ; witness the thirty-five cases of Tait, the eighteen cases found 
 po.st-mortem within a very short period by Dr. H. F. Formad, of 
 Philadelphia, and numerous other cases in literature, as well as many, 
 I dare say, buried without a diagnosis having been made. In For- 
 mad's cases no examinations had been made ; the pain and collapse 
 had been attributed to colic or cramps. The deaths all occurred in 
 laboring women and before the twelfth week. 
 
48 EXTRA-UTERINE PREGNANCY. 
 
 The first class of cases are such patients as have been under the 
 eye of the gynecologist perhaps for years, and have been treated for 
 some form or other of pelvic disease. He will therefore be convers- 
 ant with the pelvic conditions and relations, the presence or absence 
 of new growths, the condition of the periuterine connective tissue, the 
 broad ligaments, the tubes and ovaries, as well as the position of the 
 uterus. In such cases there will be the onset of menstrual disorders 
 altogether new or diiferent from those heretofore experienced ; severe 
 and recurrent attacks of pelvic pain ; mammary and gastric disturb- 
 ances ; perhaps the expulsion of shreds of membrane with the clots ; 
 dysuria — any or all of these symptoms may bring the patient to him. 
 When to these symptoms, upon examination, the vaginal hue (the 
 so-called wine cast), which I believe to be valuable in a goodly per 
 cent, of cases as early as the second month (Chadwick), is present, 
 the uterus displaced either laterally or forward, the cervix softer, the 
 OS more patulous, the uterus enlarged, and finally a new growth, 
 behind or to the side of the uterus, globular, semi-fluctuant to the 
 touch — a strong presumption of ectopic gestation exists. If, after 
 another examination, the pelvic conditions are aggravated by the 
 rapid increase of the tumor, or, as in many cases, fresh decidual 
 shreds are expelled, it seems to me that we are quite as sure of our 
 diagnosis as when we have decided an abdominal tumor to be 
 ovarian. 
 
 The literature of ectopic gestation is not without a goodly number 
 of histories with symptoms subjective and objective as clearly defined 
 as already mentioned. We have made our diagnosis. How and 
 when shall we treat our cases ? 
 
 For convenience' sake the treatment may be relatively divided 
 into three classes : Firsts cases diagnosticated before the fourth 
 month ; second, cases between the fourth month and term ; thirds 
 cases after term and spurious labor. 
 
 Among obstetrical and gynecological writers there is no great 
 diiference of opinion relative to the maimer of treatment of the 
 second and third classes, and even some of the first class of cases. 
 As I understand it, the general consensus of opinion of those who 
 advocate the use of electricity is that it is not applicable after the 
 fourth month, or after rupture and hemorrhage whenever they occur. 
 Aside from abdominal section and electricity, no method of treat- 
 ment has any considerable number of advocates. 
 
TREATMENT. 49 
 
 The use of electricity as a feticidal agent is largely an American 
 method of treatment. Aveling claims the first successful case in 
 England, in the British Gynecological Journal for May, 1888. It 
 has gained no considerable foothold in England and has no advo- 
 cates on the continent. In America there have been reported forty 
 cases with one death, and that from hemorrhage following an appli- 
 cation. In nearly all of the cases, from reading the histories, there 
 can be little doubt of the diagnosis. The treatment was instituted 
 at periods varying from the end of the second month to the end of 
 the fifth. One case in which the fetus was afterward discharged by 
 ulceration into the vagina (Chadwick's) was approximately at the 
 one hundred and fifty-third day of gestation. The advocates of 
 electricity are very generally agreed that treatment by electricity 
 should not be instituted after the fourth month. The galvanic and 
 faradic currents have both been used with equally good results. 
 However, the majority, I think, prefer the faradic current. Apos- 
 toli, one year ago, recommended the use of galvano-puncture. In 
 reply to a question asked, he said that he had no personal experience 
 with it. Galvano-puncture of the sac has been an unusually fatal 
 procedure. I know of but one successful case. 
 
 Objections have been urged against electricity as a feticidal agent 
 — that it is an immediately dangerous operation, that the diagnosis 
 has not always been established beyond reasonable doubt, that the 
 placenta continues to grow after the death of the fetus, that the 
 method often fails, and that the after-histories of many of the cases 
 have been serious ones. It seems to me that there are not enough 
 data yet collected either to refute or confirm these objections. How- 
 ever, it seems to have been followed by no immediately serious 
 results save in one case. The objection that the diagnosis has not 
 always been clear doubtless has considerable weight in a few of the 
 cases, yet the question may be seriously asked, With the present 
 mortality following exploratory incisions in America, are we justi- 
 fied in doing laparatomy in similar cases? In none of the cases yet 
 treated by electricity has the placenta been shown to have grown 
 after the death of the fetus. I think the placenta of an ectopic ges- 
 tation does not resemble in size, weight, or outline that of a normal 
 one — Thomas's case, for example. That the method fails has been 
 demonstrated by Price and others. The objection that untoward 
 results follow the operation seems to have a better ground than 
 
 4 
 
50 EXTRA-UTERINE PREGISTANCY. 
 
 many others. Surely many of the cases treated by electricity have 
 not been followed by absorption of the ovulum or product. One 
 case already cited was followed by septicemia with the discharge 
 of the contents of the sac through the vagina. (Chadwick's case, 
 afterward treated by Dr. Murphy, of Washington.) The conva- 
 lescence in this case was tedious. There are several cases in which, 
 after months, considerable thickening of the broad ligaments re- 
 mained, and in a few the fetal sac did not materially decrease in size 
 (e, g., Reeve's case). Manifestly, an uuabsorbed product of ectopic 
 gestation is not a desirable mass to have located in the pelvis, by its 
 presence producing uterine displacements with all of their attending 
 symptoms, or being a seat of chronic irritation ready at any moment, 
 under favoring circumstances, to be lighted up into an active inflam- 
 mation. Again, a tube once the seat of an ectopic gestation can 
 never afterward be of any functional use. 
 
 The operation for the removal of the product of an ectopic gesta- 
 tion by abdominal section before rupture has taken place, or before 
 the expiration of the fourth month, ought not to be more serious 
 than the removal of the tubes and ovaries. Veit records seven 
 successful cases with no failures. If the operation can be done 
 without increased danger to the mother, it should be done, and that, 
 too, at the earliest possible date after the diagnosis has been made. 
 It is to the surgeon an ideal method. There remains no foreign 
 body to be disposed of and no serious after-effects to be feared. 
 This method, I am sure, is receiving no little attention in this 
 country, and is the recognized procedure in Germany. Dr. A. 
 Martin, after commenting on the after-histories of cases treated by 
 electricity "as running on a slow course," said we have agreed 
 (Proc. Brit. Gynee. Soc, 1886) to operate at once in our tubal cases. 
 Waiting in any case for rupture is dangerous. Tweuty-five per 
 cent, of the cases after rupture die before an operation can be done. 
 It is to be hoped that sufficient experience will soon be collected to 
 show the relative value of electricity and abdominal section, in the 
 treatment of early ectopic gestation. 
 
 When in a case there arise the symptoms of shock, and internal 
 hemorrhage occui'riug, as shown in the case reported by Dr. Henry 
 Hun, in the Amer. Journ. of the Med. Sciences, July, 1884 (and a few 
 reprints I here present, as the paper is a very complete one in many 
 respects), then it will be seen the achievements of Mr. Tait clearly 
 
TREATMENT. 51 
 
 point out to US our duty. He has done more than all others to give 
 to the world a great life-saving operation. There can be no doubt 
 that an immediate abdominal section is the only proper thing to do ; 
 ligating the broad ligaments, removing the tube with the product 
 of conception, and cleansing the abdominal cavity. If a case of 
 ectopic gestation goes safely beyond the fourth mouth the dangers 
 of rupture become very small. The general tendency of operators 
 is to leave the cases alone until the onset of spurious labor, if the 
 fetus be living. Then comes the question of whether we shall try 
 to remove a living child, or wait until after the child is dead and 
 the placental circulation has ceased. The first method has been 
 most disastrous in the past as regards the safety of the mother. Har- 
 ris collected twenty-five cases, with twenty-three deaths. However, 
 the same author has examined ten cases occurring since 1881, in 
 which the operation was done after the fetus became viable. There 
 were four recoveries and six deaths. Five children lived, or their 
 deaths were attributable to natural causes. Mr. Tait reports seven 
 cases with six recoveries. The tendency of operators is growing 
 more and more toward primary laparatomy even at the increased 
 risk of mothers. 
 
 After spurious labor and the death of the fetus, the onset of sup- 
 puration makes abdominal section imperative. If the fetus is 
 quiescent, operation, although advisable, is not urgent (Greig Smith). 
 It is better to wait until absorption of the amnion indicates that the 
 placental circulation has ceased. 
 
 The following cases coming under my observation I report 
 briefly : 
 
 Mrs. v., the wife of one of our most prominent physicians, 
 became pregnant a few years after marriage. In time it-was recog- 
 nized as a tubal pregnancy. She suffered nearly twenty years 
 previous to her death with constantly recurring pelvic abscesses, 
 discharging through vagina and rectum, and accompanied with por- 
 tions of the fetus. No operation attempted. 
 
 Mrs. B., young, happily married, and with the brightest prospects 
 in life. She became pregnant; suffered much. I am not sure 
 whether a diagnosis of extra-uterine pregnancy was made, but after 
 spurious labor and when septic symptoms presented, I was consulted ; 
 but another surgeon was called to perform abdominal section for 
 reasons I cannot now explain. The sac was found, a suppurating 
 
52 EXTRA-UTEEINE PREGNANCY. 
 
 fetus removed, the cavity washed and drained, but tlie patient lived 
 only a few hours. 
 
 Mrs. B. married in 1871 and became pregnant in 1874. At the 
 time of each monthly period afterward she had a thin, pinkish dis- 
 charge from the vagina. In November, 1874, she had severe abdom- 
 inal pains and a watery discharge from the uterus. A physician was 
 called who declared her to be in the seventh month of pregnancy. 
 She was ill for some time after this and confined to her bed for five 
 or six months. Slowly regained her usual health and the natural 
 monthly flow returned, but she did not change much if any in her 
 size or form. In 1877 she became pregnant, and at the seventh 
 month was delivered of a dead child. In July, 1879, after severe 
 efiPort, she felt something give way in her abdomen which was fol- 
 lowed by a slimy discharge from the rectum for three days, and then 
 by profuse yellow pus. Periodic discharges of this nature continued 
 up to February, 1881. Dr. Newcombe states that he made an 
 examination, and then discovered fetal bones protruding into the 
 rectum about three inches above the external sphincter. Several 
 attempts were made by him during a period of two weeks, when he 
 finally succeeded in reaching the mouth of the sac, enlarged its 
 opening and, with the aid of forceps, removed the fetal bones, which 
 are here presented. The smaller bones were scooped out. Some 
 two or three pieces were embedded in the wall of the sac, but were 
 dislodged by scraping. On the sixth day afterward the sac filled, but 
 opened on the 13th of March, when, by careful washing, the patient 
 was kept in good condition and finally went on to recovery. 
 
 When we consider these cases as a class carefully, and think of 
 their intense sufferings, anxiety of friends, and their small hope 
 of ultimate recovery, it seems to me we are justified in urging, when 
 the diagnosis is clear, primary laparatoray, especially in view of 
 our improved technique in doing the operation. 
 
 Finally, allow me to record my belief that in primary laparatoray 
 the placenta ought to be removed either by ligation or by exsection, 
 as in Prof. Aug. Breisky's case. In the four recent successful cases 
 collated by Harris the placenta was removed in three. Tait, who 
 has been so signally successful, removed the placenta. 
 
APPENDIX. 
 
 Note. — Since the foregoing discussion was held Mr. Tait's lec- 
 tures on this subject have appeared. For the purpose of making 
 this brochure embrace the latest thought on the question ; and, 
 further, to enable those who may not have Mr. Tait's book at hand 
 to form a judgment as to its inestimable value, the following pages 
 are here introduced. 
 
ECTOPIC GESTATION AND PELVIC HEMATOCELE 
 
 Considered in the Light of Mr. Tait's Views — being 
 
 PRINCIPALLY A DISCUSSION OF ThESE AS ENUNCIATED 
 
 IN His Lectures on this Subject.^ 
 
 AN editorial review. 
 
 [From the Buffalo Medical and Surgical Journal, March, 1889.] 
 
 In the light of his achievements in the surgery of ectopic gestation, 
 no future consideration of this subject can be approached without 
 due acknowledgmentof thevakieof Mr. Tait's contributions toward 
 the clearing up of doubtful questions of this hitherto niuch discussed, 
 though little understood, bUe noir of abdominal surgery. 
 
 The lectures that are taken as the text of these remarks — chiefly 
 in the nature of a review — are the most important addition to the 
 literature of the subject since the appearance of Beruutz and GoupiPs 
 Memoirs. This book, as Mr. Tait most justly remarks, has received 
 by far too little notice, containing, as it does, a basis scientifically 
 correct for the pathological study of aberrant gestation ; while, on 
 the other hand, from the point of treatment, it is absolutely of no 
 value whatever, barely suggesting, as it will be found, the possibility 
 of the success of surgical interference. In this connection, it is 
 interesting to note that the passage of the electric current through 
 the fetal sac is suggested by these authors as a vague possibility of 
 benefit. The use of this agent in extra-uterine pregnancy will be 
 referred to further on. Mr. Tait's views as to tiie pathological 
 changes in the tubes, the retention of the ova thus being made 
 possible when impregnated, though not capable of exact demonstra- 
 
 1 Lectures on Ectopic Pregnancy and Pelvic Hematocele. By Lawson Tait, 
 F. R. C. S. Edin. and Eng., LL.D., Professor of Gynecology in Queen's College, Birming- 
 ham, etc. 
 
66 
 
 EXTRA-UTERINE PREGNANCY. 
 
 tion, is at once so plausible aud natural that it impresses the careful 
 thinker as perhaps the best possible hypothesis of the first step of 
 this most dread surgical affection in women. 
 
 Mr. Tait regards all ectopic pregnancies as primarily tubal, ad- 
 mitting, however, the possibility of an ovarian pregnancy. The 
 time of rupture is placed before the fourteenth week. Bernutz and 
 Goupil extended the period to four months. Mr. Tait's opinion on 
 this point is more likely to be correct. His view of the history of 
 the rupture is as follows : 
 
 " It takes two directions (a) into the peritoneum, which is the 
 fatal form; and (b) into the cavity of the broad ligament, a form 
 which yields the variety of ectopic gestation, which I propose to 
 call the extra-peritoneal, which was called the sous-peritoneo- 
 pelvienne variety by Dezeimeri.s, and which alone yields all the 
 cases which go on to the period of viability, all the lithopedia, all 
 the suppurating cysts discharging into bladder, rectum, etc., and 
 also the cases which by secondary rupture of the ovum cyst get called 
 ' abdominal pregnancy.' " 
 
 Mr. Tait first proposed this view of the varieties of ectopic gesta- 
 tion in 1873. Its simplicity, and the logical defence of his position 
 in expounding his theory, render it probable that it will ultimately 
 be accepted by all. Mr. Tait's " genealogical table " of ectopic 
 gestation is as follows : 
 
 I. — Ovarian, possible but not yet proved. 
 
 II. — Tubal, in free part of tube, is (a) contained in tube up to 
 fourteenth week, at or before which time primary rupture 
 occurs, and then the progress of gestation is directed into 
 
 (b) Abdominal or intra-peritoneal gestation uniformly (c) Broad ligament 
 fatal (unless removed by abdominal section), primarily or extra- peritoneal 
 by hemorrhage, secondarily by suppuration of the sac 
 and peritonitis. 
 
 (d) may de- 
 velop in broad 
 ligament to full 
 time and be re- 
 moved at viable 
 period as living 
 child; 
 
 (e) may 
 die and be 
 absorbed as 
 extra- peri- 
 toneal he- 
 matocele ; 
 
 (/) may die and 
 the suppurating ovum 
 may be discharged at 
 or near umbilicus, or 
 through bladder, va- 
 gina, or intestinal 
 tract ; 
 
 (g) may 
 remain qui- 
 escent as 
 lithopedion; 
 
 ( h ) may be- 
 come abdominal 
 or intra-perito- 
 neal gestation by 
 secondary rup- 
 ture. 
 
APPENDIX. 57 
 
 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 6) 
 before fifth month. 
 
 As has already been stated, Mr. Tait does not deny the possibility 
 of ovarian pregnancy, but doubts its probability. All the cases of 
 this variety of pregnancy, save Spiegelberg's, he regards as ques- 
 tionable, or entirely fallacious. 
 
 As to the diagnosis of ectopic gestation previous to the period of 
 rupture, Mr. Tait plainly states that nothing positive can be insisted 
 upon. That is to say, that while it may be held and proven by 
 operation that ectopic gestation has existed, still in other cases, 
 where the diagnosis is just as positive with just as strong presump- 
 tive evidence, an error in diagnosis will be found to have been made 
 and no ectopic pregnancy exists. This view comes with peculiar 
 force in view of the author's vast experience. He cites one case in 
 which the lesion occured a second time in the same woman, who, in 
 spite of her own previous experience, did not recognize or suspect 
 her condition, and died of hemorrhage from rupture. Than this 
 nothing can be stronger proof that symptoms may count for naught, 
 and that while it is possible to categorize upon the presence of this 
 symptom and that, as a proof of extra-uterine gestation, one or 
 many or all of these symptoms may be absent, and the only presage 
 of the condition will be the rupture. In this connection it is fitting 
 to refer to two sets of cases, almost unique in their persistent claim 
 for record as remarkable diagnoses. As will be seen, the claims of 
 the one treated by electricity are presumptive, proving nothing. 
 Those of the other are presumptuous and pertinacious. The cases 
 referred to are those of Dr. J. G. Allen, of Philadelphia, American 
 Journal of Obstetrics, vol. v. p. 161, 1872, and Dr. H. A. Kelly, 
 reported in the the American Journal of Obstetrics, Aug. 1886. 
 
 The cases of Dr. Allen are frequently referred to, especially in 
 reference to the treatment of this condition by the electric current. 
 It is not our purpose to discuss treatment at this point, but simply 
 to consider diagnosis. In the first of Dr. Allen's cases, something 
 resembling a decidua was passed at about the second month of preg- 
 nancy. Later, ballottement gave assurance of the presence of a 
 fetus. The current being passed, the tumor ceased growing and 
 
68 EXTRA-UTERINE PREGNANCY. 
 
 gradually diminished to the size of a large fist. In Dr. Allen's 
 second case the history is defective. No symptoms were discovera- 
 ble, and all that is asserted as proven is that the tumor decreased in 
 size after the application of the current. In his third case, which 
 the after-history shows indisputably, by the discharge of the fetal 
 bones, to have been extra-uterine pregnancy, the condition was not 
 even suspected. Nothing abnormal was noticed till after the sixth 
 month. The woman had supposed herself pregnant and engaged 
 Dr. Allen to attend her. "A special examination," by which a 
 tumor could be detected, led him to think it a fibroid growth. 
 Here, then, are three cases considered extra-uterine. One has 
 proven, by its termination, its right to be so maintained. In it, the 
 condition was not even suspected. The other two are, if not sup- 
 posititious, at least suppositional ; and this statement is true of all 
 cases claimed to be extra-uterine fetation on no better evidence 
 than some or many of the symptoms of pregnancy, the subsequent 
 passage of the electric current, and the after-shrinkage of the tumor. 
 Such a history cannot be claimed to be distinctly peculiar to this 
 condition. At best, it is the expression only of a probability. It 
 is not even presumptive evidence. Then, again, shrinkage of the 
 cyst, as a pathognomonic symptom of extra-uterine fetation, would 
 have no value, where diagnosis for operation by the abdominal sec- 
 tion might be considered ; shrinkage could only occur after the death 
 of the fetus, and as advocates of the electric current desire only to 
 kill it, operation from their standpoint would be a useless procedure. 
 We will refer to this point further on. The case of Dr. Kelly is 
 only worthy of attention as showing how a diagnosis may grow 
 after operation, and points become developed by time as vital, that 
 have no place in the original communication. 
 
 The special point since claimed in this case is the shrinkage of 
 the cyst. This step in the diagnosis is absolutely wanting in the 
 original report of the case, and, therefore, is an after-thought, 
 making its addition to a consideration of the subject simply super- 
 fluous, and therefore valueless. Nay, more ; it is misleading and 
 fallacious, in that it seeks to put up for a positive sign what pre- 
 viously had not been considered, but also loses sight of the fact that 
 as a diagnostic sign, where operation is held under advisal previous 
 to rupture, it is positively of no value whatever. Further, the 
 
APPENDIX. 59 
 
 remarks of Dr. E,. P. Harris, after the presentation of the case, 
 distinctly say : 
 
 " The case reported by Dr. Kelly had as clear a history as we ever 
 find in the very early history of ectopic gestation, when it cannot be 
 claimed that a j}ositive diagnosis can be made." 
 
 Here is an admission by Harris himself, which we have taken the 
 liberty to italicise, that a claimed positive diagnosis was only a guess, 
 and that on mere presumptive evidence. Further, the passage of a 
 piece of flesh, which the doctor did not see, is taken as a step in the 
 diagnosis. This is in all cases questionable. First, because even 
 in cases of undisputed ectopic gestation, the decidua is frequently, 
 if not always, passed as shreds or debris, and attracts no attention 
 whatever. If the membrane, then, is an important point in diag- 
 nosis, it must in these cases be wanting, and a decision reached 
 without it. Further, in closing his discussion. Dr. Kelly reported 
 having another " case of extra-uterine fetation on hand now, and is 
 waiting for the death of the fetus, when he will operate." Where 
 is the report of this case ? There is certainly none on record. 
 
 One other case remains to be noticed, especially in reference to the 
 use of the electric current, after a supposedly correct diagnosis. Dr. 
 Wylie, American Journal of Obstetrics, vol. xix. p. 75, reports a 
 " case of hydrosalpinx, diagnosticated as extra-uterine pregnancy." 
 
 The case had been first seen by Dr. Mann, of this city, who 
 judged it extra-uterine pregnancy, passed the electric current at in- 
 tervals for ten days, and sent the patient home. Dr. Wylie oper- 
 ated, as stated above. The question now arises whether many of 
 the so-called early diagnoses, insisted upon by Dr. Thomas, are not 
 merely errors, that are buried by the disappearance of the patient, 
 who subsequently falls into the hands of a less confident diagnos- 
 tician, which latter more correctly finds her trouble by operation, 
 and removes it without trifling with it. Dr. Thomas says : 
 
 "Were I asked to what I attribute the good results obtained in 
 my cases, I should feel forced, in simple candor, to run the risk of 
 the charge of egotism and to reply, ' I attribute it to three influences : 
 first, early and positive diagnosis; second, the prompt resort to de- 
 struction of the life of the fetus during the early months (of twelve 
 thus treated all recovered) ; and third, to an equally prompt resort 
 to surgery in the later." 
 
 It is well to remark that what Mr. Tait places first — operation — 
 
60 EXTRA-UTERINE PREGNANCY. 
 
 Dr. Thomas places last. Mr. Tait insists upon the essential guess- 
 work of early diagnosis, while Dr. Thomas insists upon its certainty. 
 It would be interesting to know in what proportion of cases oper- 
 ated upon the diagnosis was verified, and in what proportion it 
 failed. It is significant that, after the above positive claim for 
 early diagnostic precision, Dr. Thomas should write : 
 
 "After all that has been said with regard to the diagnosis of ecto- 
 pic gestation, it must be added that a positive conclusion is very 
 generally difficult and often impossible." 
 
 Why not confess that the diagnosis is, after all, only a suspicion ? 
 If Dr. Thomas, with all his experience, writes the above, what must 
 be thought of the claims of those whose diagnostic experience is 
 based upon one or two cases, and who yet urgently, in season and 
 out, herald their unprecedented feat of early diagnosis in this condi- 
 tion? In fact, if not in expression. Dr. Thomas and Mr. Tait are 
 nearer together than, at first sight, would appear. 
 
 On the treatment after the rupture of the sac, Mr. Tait is un- 
 equivocally decided upon the propriety of operative interference. 
 Dr. Thomas recites one case " trusted to nature," with ultimate re- 
 covery. With Mr. Tait's wonderful record, the weight of authority 
 is on the side of early interference after rupture, or before if dis- 
 covered. On what Dr. Thomas has to say upon the treatment of 
 the sac before rupture, hinges its entire value as regards the ques- 
 tion of correct diagnosis. In view of the uncertainty of this, to 
 positive surgeons of the Tait type his dictum will have little weight. 
 With these we believe that in competent hands, in case of doubt, the 
 exploratory incision should be resorted to, and if the diagnosis is 
 verified, the sac should be dealt with surgically, as hereafter to be 
 noticed. The use of the electric current is all the less to be recom- 
 mended in the light of Mr. Tait's successes. At best it only at- 
 tempts the killing of the fetus, and can promise nothing more. It 
 remains for the reproach of this treatment, that the sac and its con- 
 tents still remain, and may at any subsequent period menace the life 
 and safety of the patient. Or, in the most favorable event of sup- 
 puration and discharge, the comfort of the patient is for an indefinite 
 period interfered with. The treatment appeals more to the electri- 
 cal experimentist than to the practical surgeon — more to the trier of 
 novelties than to him who is satisfied with nothing less than tangi- 
 ble results. 
 
APPENDIX. 61 
 
 Mr. Tail's view that, iu most instauces, the so-called hematocele 
 is a ruptured extra- uterine cyst, is fully substantiated, both by his 
 investigations and those of Bernutz, to whom he gives especial 
 credit. 
 
 Bernutz's classification of the possible varieties of intra-pelvic 
 hemorrhage is worthy at this time of great consideration, and is : 
 
 1. Hemorrhage caused by the rupture of dilated utero-ovarian 
 veins. (This kind of hematocele occurring sometimes in extra-uterine 
 pregnancy, may be said to represent one of the varieties of thrombus 
 in normal gestation.) 
 
 2. Hemorrhage caused by the rupture of the ovary. (This we 
 see happen in cases of pregnancy, whether the product of conception 
 occupies the uterus or not.) 
 
 3. Hemorrhage caused by the rupture of the Fallopian tube. 
 
 4. Hemorrhage from the fetal cyst itself having ruptured. (The 
 largest number of cases fall under this last head ; both it and the 
 next are of special interest, because they are peculiar to extra-uterine 
 pregnancy, while the three former belong also to intra-uterine preg- 
 nancy.) 
 
 5. Hemorrhage within the fetal cyst (which may end in death 
 without effusion of blood into the peritoneal cavity, and, therefore, 
 may not produce a real hematocele). 
 
 Had these views received the attention they deserve, there would 
 not now be so much conflict of statement concerning the affection, 
 or rather the symptoms they elucidate. Of hematocele due to sup- 
 pressed menstruation, Bernutz also makes distinct mention. Of this 
 variety Mr. Tait says : 
 
 '^ There are only two causes known to me, one very common and 
 one relatively rare. The first is sudden arrest of metrotaxis, which 
 may be either normal menstruation, or the pseudo-menstruation 
 which occurs so constantly after abdominal operations." . . . 
 
 He then goes on to elucidate this condition. The abdominal sur- 
 geon, who has not studied or considered it, will here find much infor- 
 mation, and with it much comfort concerning a matter which must 
 often have worried and perplexed him. The second cause of extra- 
 peritoneal hematocele is efi"usion of blood into the broad ligament 
 from ruptured tubal pregnancy of about the twelfth week. Of this 
 Mr. Tait says it is " much more rare and probably much more fatal, 
 certainly much more serious." 
 
62 EXTRA-UTERINE PREGNANCY. 
 
 The scheme Mr. Tait ha.? given of extra-uteriue pregnancy so well 
 speaks for itself, that there is no need of repeating his argument. It 
 is perfectly plain that, if the primary rupture takes place so as to 
 fall within the folds of the broad ligament, the hemorrhage must be 
 limited. It is also perfectly clear that a further secondary rupture 
 may occur into the peritoneal cavity, and will then be almost neces- 
 sarily fatal, unless by the merest chance. 
 
 Mr. Tait, in considering the question of rupture into the broad 
 ligament, clearly shows that no two cases necessarily have the same 
 history. Some terminate quickly by the death of the fetus and rapid 
 absorption, others go on in their development for varying lengths of 
 time, then to die and suppurate, or to remain quiescent as lithopedia. 
 Still others may go on until full development, necessitating surgical 
 interference; while others, as has been shown, rupture, and unless 
 promptly dealt with, in the vast majority of instances, terminate 
 fatally. 
 
 Of suppurating cysts, Mr. Tait, after calling attention to their 
 various paths of exit — umbilicus, rectum, vagina, and bladder — thus 
 sums up: 
 
 " In all of these the history helps but little, for the story is sel- 
 dom more than that of obscure pelvic trouble, ending in abscess, 
 bursting and continually discharging into the rectum, and it is not 
 till the arrest of some sharp spicula of fetal bone in the anus de- 
 clares the true solution, that the nature of the case is discovered. 
 The mortality is doubtless quite what 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." 
 
 Of the fatality of cases opening into the bladder, Mr. Tait agrees 
 with Parry, that they are much more fatal than those opening in the 
 other directions. Mr. Tait has never seen one of these cases in its 
 early stages, but expresses the belief that the correct method of deal- 
 ing with them is by abdominal section. He says : 
 
 " I feel quite confident that if these cases were dealt with by 
 opening from above in their earlier stages much of their mortality 
 would disappear, and the patients would be spared years of suffering. 
 I would treat them as I do pelvic abscesses, 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 the parietal peritoneum, after emptying the decomposing 
 
APPENDIX. 63 
 
 debi'is and cleaning out the cavity. I have now done over fifty op- 
 erations of this nature, and not only has there been no mortality, 
 but the cures have been so rapid, complete, and permanent as to 
 give me perhaps more satisfaction than almost any other class of my 
 work." 
 
 For a complete discussion of what Mr. Tait terms the minority 
 of the minority of cases, i. e., where the ovum survives and grows 
 toward full time, the reader must follow minutely the a"gument of 
 the author. To do it full justice almost a complete reproduction 
 would be necessary. Jessop's remarkable case is cited at length as 
 the only instance of the so-called " abdominal " pregnancy on record. 
 Mr. Tait, rightly we agree, refuses to accept those collected by Parry. 
 The difficulty of diagnosis, in broad-ligament cases approaching 
 maturity, is thoroughly discussed. Conditions conducing to error 
 are : extreme thinness of the uterine walls in normal pregnancy, dis- 
 placement of the normally pregnant uterus, during the early months 
 of pregnancy, complicated with fibro-myoma or cystic diseases of 
 the uterus, and more rarely pregnancy in one-half of a double uterus. 
 The greatest difficulties in diagnosis are met, according to Mr. Tait's 
 experience, after the death of the child, or, at least, when the time 
 of the expected confinement has passed so long that if there is a 
 child it is sure to be dead. " No history," says Mr. Tait, " however 
 complete, is of sufficient weight to establish a diagnosis, unless there 
 be some distinct physical signs in support of it." Quoting from 
 Campbell's curious work, referred to by Ramsbotham as a " publi- 
 cation full of most valuable facts and deep research," he cites the 
 following passage, showing how little trust can be placed in his- 
 tories : 
 
 " In many instances of the different varieties of misplaced gesta- 
 tion, the cataraenia 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 ges- 
 tation, we have hemorrhage, uterine effusions, the extrusion of coag- 
 ula, of bodies which resemble moles, or portions of placenta. These 
 appearances have occasionally led to the belief that the patient has 
 aborted, so that the ovum was originally not extra- but intra-uterine, 
 and had escaped through a rent in the uterus into the peritoneal cav- 
 ity, the extruded body in either case being viewed as the placenta. 
 
64 EXTRA-UTERINE PREGNANCY. 
 
 Cases attended with much uterine excitement, whether arising from 
 unusual exertion or some external injury, are most likely to be ac- 
 companied by these latter phenomena." 
 
 Two symptoms are regarded by Mr. Tait as invariable in extra- 
 uterine gestation which has gone past the period : a " show " during 
 false labor and a diminution of size after false labor. This opinion 
 is fortified by Parry's authority, which is regarded throughout as 
 especially weighty. 
 
 As to the treatment of these extra-uterine fetal cysts, Mr. Tait 
 leaves no doubt or question as to his position. Tapping is con- 
 demned as a diagnostic procedure. The author says : " I open the 
 abdomen and make out the condition." The use of the trocar in 
 diagnosis, as shown by Parry, is simply a record of mortality, and 
 cannot be too strongly condemned. The treatment by electricity, at 
 or near full time, in order to kill the child when viable, is con- 
 demned by Mr. Tait in the strongest terms, especially as its death 
 does not bring safety to the mother. His own experience has shown 
 that, by operation, both may be saved, and his argument cannot be 
 refuted. The treatment by electricity has been referred to before. 
 Mr. Tait has no place for it. Dr. Buckmaster's case is cited at 
 length. Mr. Tait here clearly has the best of the argument, and 
 sums up his belief as follows : 
 
 " It is by no means clear from experience which we have had in 
 this method that the current is without harm, whether the diagnosis 
 be correct or not, and it is equally without proof that it is sufficient 
 to produce the effect desired." 
 
 In reply to the assertion that it is sometimes impossible to com- 
 plete these operations, the following strong statement is made : " The 
 rule ought to be that all such operations should be completed, and 
 any man who has such want of skill and pluck as to stop in the 
 middle of one of them, ought not to attempt them. They can all 
 BE COMPLETED." It may be well to give the author's concluding 
 creed in reference to the operation to save both mother and child : 
 
 He says : " I therefore advocate the principle of saving a child 
 who has survived the catastrophe of the primary rupture of the tube 
 by being extruded into the broad ligament. If its existence is 
 recognized during life, the mother ought to be carefully watched till 
 the false labor sets in, just as w-e watch for a case of puerperal hys- 
 terectomy and seize the onset of labor or its early stage as t' e most 
 
APPENIiIX, 65 
 
 favorable time for both mother and child. From this point of view, 
 therefore, neither the time selected nor the details of the proceeding 
 will be influenced save by tw^o considerations : not to operate before 
 the child is likely to be viable, provided the delay necessary does 
 not prejudice the mother; and not to delay at all after the death of 
 the child. I specially lay [this down for the purpose, amongst others, 
 of excluding all operations for the removal of the child by vaginal 
 section." Mr. Tait then goes on to show the utter unjustifiableness 
 of the vaginal section as a surgical procedure, and concludes, " I 
 shall never, under any circumstances whatever, attack a sub-peri- 
 toneal pregnancy from the vagina." 
 
 Strong expression indeed, but a weaker would be inadequate con- 
 demnation of a procedure that has its origin in timidity and its end 
 in failure. 
 
 The last portion of the book is devoted to a consideration of the 
 pathological post-mortem researches of Hart and Carter. These 
 are worthy the most careful study. By their frozen sections the 
 peculiar arrangement of the peritoneum in extra-peritoneal ectopic 
 gestation is fully elucidated, showing why, as Mr. Tait holds, the 
 incision for operation should not be made in the middle line, so as 
 to avoid opening the peritoneum. "In fact," he says, "the opera- 
 tion should not be an abdominal section at all, in the strict sense of 
 the definition I have adopted." 
 
 As to the method of dealing with the placenta, Mr. Tait's conclu- 
 sions are : 
 
 " I am, therefore, disposed for the present, at least, and until I am 
 corrected by future experience, to advise in dealing with an ectopic 
 gestation in the advanced stages, that we should deal with the fetus 
 only, should empty the placenta of blood, and close the w^ound her- 
 metically upon it." 
 
 The lectures are closed by a reference and tables of the length of 
 time of retention of the fetus, and cases of lithopedion. More than 
 simple reference to these is impossible. 
 
 Mr. Tait's tribute to Parry in the beginning of his book, and his 
 continual citation throughout his discussion, is well deserved, gen- 
 erous, and graceful — a respect from the living teacher to the voice- 
 less but speaking dead. 
 
 No attempt has been made in this review to give the literature of 
 
 5 
 
66 EXTRA-UTERINE PREGNANCY. 
 
 the subject, ^yith Mr. Tait's treatment of extra-uterine gestation, 
 there is little need or use for ancient literature, save as it may be 
 necessary to show how little was really known concerning it patho- 
 logically ; j)radically nothing. 
 
 His treatment marks a new era in the handling of this condition, 
 and may be taken as tlie starting-point of its real surgery. 
 
[From Annals of Gynecoloyy, Boston, February, ]889. By pennisision.] 
 
 PLATE III. 
 
 
 /Imnton /l 
 
 7op o/ dutended broad 
 ligarnetit and tub'. 
 
 Rectum 
 
 Ckorion 
 
 Foetus 
 
 wi£'^'fA. Obturator internua 
 
 K'Ji'Jf/ ievatnr hmi 
 
 Paraproctal lissve 
 
 Sagittal lateral section (rijrht) ol' pelvis, with extra uterine gestation in right broad 
 
 ligament. — T.mt. 
 
[From Annals of Gynecology, Boston, February, 18S0. By pennlssion.] 
 
 PLATE IV. 
 
 
 — Pouch of I>ouglat 
 
 Cervical canal 
 
 Sagittal mesial section of same pelvis, showing utei-iis with ileciclu;i. This section 
 demonstrates, inter alia, tliat what is tcnncil cliniciilly retro-uterine lieiiia1<icele. may 
 be bematomata. — Tait. 
 
[From Annals of Gijnecologjf, Boston, Feljruaiy, 18S0. By peniiission.] 
 
 PLATE V. 
 
 Diaiph, agvi 
 
 Pyloric end. 
 
 Head of vancrea» 
 
 Site of recent rupture 
 
 ioose (issve 
 
 beside uterus 
 
 and perxtu tfum 
 
 .\,lyj Pouch of DoiLglos 
 
 VeiKO ixUnnt dip, 
 Ctrmcal canal 
 
 Bladder 
 
 Cervix uleH 
 Vaginal cervix 
 
 Rectum 
 Vagina 
 
 Sagittal iiK'r^ial si>ctioii oi' cailnvrr wilh advanciMl cxtra-utcriiie ■gestation- 
 sub] )eritoiiei)-alj<loiiiiiial. — Tait.