The Operative Treatment of Extra-Uterine 
Pregnancy at or Near Term, with 
Report of a Case. 
CHRISTIAN FENGER, M.D., 
RV 
OF CHICAGO, ILL. 
Read before the Illinois State fledical Society, May 20, 1891. 
Reprinted from “ The Jourmvi of the AmCTTCan Medical., 
Association,” June 2|,.iB<A. 
cHidrcrrr 
Printed at the Office of the Associatin', 
iB9 [. THE OPERATIVE TREATMENT OF 
EXTRA-UTERINE PREGNANCY 
AT OR NEAR TERM, WITH 
REPORT OF A CASE. 
It is not my intention in this paper to give an 
exhaustive expose of all the details and the 
questions that arise in late extra-uterine preg- 
nancy, but merely in connection with a case of 
this kind, which terminated fatally, to describe 
the thoughts and reflections that presented them- 
selves to me in connection with the case. 
I shall, then, first describe the case, the differ- 
ent methods of operation and their prognoses, 
and later, review the more important points in 
the management of such cases from m 3' own ex- 
perience and from the literature as far as I havß 
been able to obtain it. 
Case.—-Mrs. C., 34 years of age, married thir- 
teen years. Healthy as a child ; first menstru- 
ated at the age of 14 ; always regular ; three 
days’ duration ; for the past ten years two days 
only; never very abundant. A slight leucorrhoea 
for a few days following menstruation. Married 
at 21 ; a year later, after a normal pregnancy, 
was delivered of a female child who lived only 
ten days. Labor was difficult, but forceps were 
not used. Slight laceration of perineum. She 
was in labor from midnight until half-past ten 
the next morning. She had puerperal fever and 2 
pelvic cellulitis which confined her to bed for 
tliree months. She had a slow convalescence, 
not being well until three months later. Menstru- 
ation returned five months after the birth of the 
child, and since that time, about ten years ago, 
has been always regular. She has occasionally 
had slight leucorrhoea, but otherwise has had no 
symptoms of disease of the genital organs ex- 
cepting sterility. 
March 20, 1890, she had her last normal 
menstruation. Two or three weeks later, in 
April, she felt sick, wanted to eat, but after eat- 
ing would often feel nauseated. May 15, 
she suddenly felt a severe pain through the an- 
terior part of the abdomen and the rectum, 
followed by vomiting. These symptoms lasted 
for ten days, during which time she was obliged 
to stay in bed. No fever, no symptoms of haem- 
orrhage. The symptoms then disappeared and 
after three weeks she resumed her work of teach- 
ing school. She was well until July when a sud- 
den attack of pain which came on at night while 
she was in bed, necessitated her keeping quiet 
for a few days. After this time pain would often 
qprae on during the night, extending from the 
abdomen down to the knee, more severe in the 
right leg. August 5, she had a sudden, severe 
attack of pain and vomiting which kept her in 
bed for two weeks and necessitated her stay at 
home for two weeks longer. During this time 
her temperature was normal. 
Between the fifth and tenth of August, while 
in bed with this apparent attack of peritonitis, 
she first felt foetal movements, faint at first, later 
stronger. These continued to be felt until De- 
cember 29. Uterine haemorrhage with passage 
of a decidual membrane was never observed. 
During September, October and November, she 3 
was able to be up and about attending to her 
work in school, but almost every evening she 
would have pain in the abdomen, which would 
be aggravated on change of position, and would 
prevent her from sleeping in the early part of the 
night. In the second wreek of December the ab- 
dominal pain increased and also came on during 
the day, so that for fear the.pain would come on, 
she did not dare go out of the house. 
December 31, spurious labor set in with severe 
pain in the left side of the abdomen increasing 
toward night, which lasted for two days. At 
this time foetal movements ceased. She remained 
in bed three weeks, during wrhich time the ab- 
domen commenced to decrease in size. Febru- 
ary 10, 1891, §ix weeks after the death of the 
child, there was a sudden recurrence of the ab- 
dominal pain with vomiting and rise of pulse and 
temperature. 
February ir, I made an examination. The 
patient was in bed, somewhat pale, pulse 100, 
temperature 100.0 She had been suffering from 
pain and vomiting for two days, but at this time 
the vomiting had ceased. The mammary glands 
were large, areolae, pigmented and abundance 
of milk coming from the nipples on pressure. 
The abdomen was enlarged to about the size of 
pregnancy at term, but more prominent on the 
left side, with an area of dull percussion up to 
the body of the ninth rib, while on the right side 
it did not extend to within two inches of the 
lower border of the ribs. Tympanitic percussion 
in the epigastric and both lumbar regions ; dull 
percussion over the umbilical, hypogastric and 
inguinal regions. 
Through the abdominal wall could be felt a 
harder, round portion of the tumor to the right 
of and above the umbilicus—the foetal head. 4 
Over the remainder of the tumor no distinct 
foetal parts could be felt. In the territory below 
a line extending from the border of the right 
ribs downward and inward, to midway between 
the umbilicus and symphisis pubis, and from 
here to the outer third of the left Poupart’s liga- 
ment, a distinct placental souffle could be heard, 
most pronounced in tjie right hypogastrium. 
On vaginal examination, the vaginal portion 
of the uterus was shown to be somewhat flaccid, 
standing high up and directed forward against 
the symphysis pubis. The posterior lacuna was 
pushed downward into the vagina by a doughy, 
immovable tumor, probably the placenta, as no 
foetal parts could be felt. The patient com- 
plained of frequent micturation, that she was 
obliged to pass water every hour except when 
asleep. The urine was normal in quantity and 
color and contained neither pus, sugar nor 
albumin. 
I resolved to wait for the cessation of the pla- 
cental circulation, as might be indicated by the 
placental souffle, keeping the patient in bed and 
under symptomatic treatment. 
February 10. Area of placental souffle di- 
minished about one-half. 
February 22. No placental souffle could be 
heard. The patient was removed to the Emer- 
gency Hospital for operation, which was fixed 
for a week after her arrival there. 
February 25. Diarrhoea set in with slightly 
bloody stools, the passages soon becoming 
chocolate-colored. On microscopic examination 
no pus cells were found, but fecal matter, fine 
granular matter and blood corpuscles. Pulse and 
temperature increasing. 
February 28. Pulse no; temperature 103°. 
She had several passages of a dark, reddish- 5 
brown color. Concluding from this that perfor- 
ation of the sac into the bowel had taken place, 
and consequently that sepsis had commenced to 
appear in the sac, operation at once became neces- 
sary. 
March i. Operation. In the presence of the 
doctors from the Policlinic, Dr. Bellinger, of 
Council Bluffs, lowa ; assisted by Drs. Bernauer, 
Hall and Brohm. Chloroform given by Dr. Rosa 
Rngert. Percussion at this time over the entire 
tumor was tympanitic where it had formerly been 
dull, showing the presence of air in the fcetal sac 
from perforation of the intestines. 
An incision was made in the linea alba, seven 
inches long, from a point midway between the 
symphysis pubis and umbilicus, to three inches 
above the umbilicus. The parietal peritoneum 
was loosely adherent to the wall of the sac down- 
ward ; above was the free peritoneal cavity. The 
sac was here covered with omentum containing 
a large number of dilated vessels, some of the 
veins two or three lines in diameter, while most 
of the adipose tissue of the omentum had dis- 
appeared. The parietal peritoneum was united 
by sutures to the skin. As the adhesions be- 
tween the parietal peritoneum and the omentum 
were incomplete, I separated the remaining ad- 
hesions with the hand, and packed large sponges 
into the peritoneal cavity all around the incision, 
or rather around the territory where the opening 
of the sac was to be made. 
On account of the numerous and large ves- 
sels, double ligature of which would have taken 
too long, I opened the sac with a Paquelin cautery 
knife. This was used only at red heat. There 
was considerable haemorrhage from the omentum, 
necessitating numerous ligatures. On opening 
into the sac there was an escape of fetid air, and 6 
later on a discharge of a thin, grayish, fetid fluid 
of fecal odor. During this time the patient was 
turned on the side and the wound flushed with 
warm sterilized water. 
The incision was now prolonged six inches. 
The child presented with the back and left 
shoulder in the wound. The left arm was first 
drawn out, but as it was found impossible to de- 
liver the head, the arm was replaced and the left 
leg drawn out, then the right leg, and thus the 
child was delivered. After incising the tympan- 
itic abdomen, which collapsed after the escape of 
the gases, extraction was now easy without vio- 
lence to the wall of the sac. The umbilical cord 
was tied two inches from the placenta, at the 
lower border of the wound. The foetal cavity 
contained fetid, chocolate-colored fluid and 
smegma. The patient was now turned on the 
side and warm sterilized water poured in from a 
pitcher to flush the cavitj' until it became reasona- 
bly clean, the water being mopped off with large 
sponges. The large placenta entirely filled the 
small pelvis and the right iliac fossa up over the 
surface of the transverse colon. The uterus 
could not be seen, as it was covered by placenta. 
The cord was attached down near the symphysis 
pubis, was of a whitish-gray color and macerated 
on the surface, showing no signs of circulation. 
The foetal surface of the placenta was smooth 
and bluish-gray, looking as if the circulation had 
ceased. 
An attempt to cleanse the inside of the sac by 
means of soft sponges on long artery forceps, the 
borders of the sac being held apart by the hand, 
was immediately followed by a sudden gush of 
bright red arterial blood from the borders of the 
placenta, which necessitated immediate packing 
of the cavity with large pieces of gauze. The 7 
deepest part of the sac was in the left iliac fossa 
where, to the left of the placenta, the distinct 
contour of loops of large intestine, probably the 
descending colon and sigmoid flexure, were dis- 
tinctly seen. They were felt to be covered with 
a layer of tissue so thin as to indicate that no 
sac wall existed. No perforation into the bowel 
could be seen at any point and no escape of 
gases from the bowel into the sac was noticed, 
but the contents of the sac had a distinctly fecal 
odor. A thorough search for the opening into 
the intestine was not made, as even the slightest 
manipulation caused copious haemorrhage from 
the borders of the placenta. 
The large sponges were now removed from the 
peritoneal cavity, which was then cleansed by 
means of smaller sponges on long forceps, and 
the borders of the sac united to the skin by 
sutures. Strips of iodoform gauze, for capillary 
drainage, were introduced between the sutures at 
six different places to a depth of about two inches 
between the sac and the abdominal wall. One 
strip at the right upper border of the wound was 
introduced four inches, up under the liver. A 
handful of a mixture of equal parts of salicylic 
and tannic acids was strewn over the inner wall 
of the sac and the whole cavity packed loosely 
with sterilized gause impregnated with the same 
powder, of which four ounces in all was used. 
The wound of incision into the sac was left open 
and over the packing an antiseptic dressing was 
applied. 
The child was a normally developed male at 
full term, in a state of commencing maceration, 
The epidermis was covered with smegma, and in 
many places was loosened from thecorium, which 
presented a brownish-red, discolored surface. 
At the end of the operation, which lasted an 8 
hour and a half, the pulse was 150, and reasona- 
bly strong ; color natural. Half an hour after 
the operation, pulse 120. Seven p.m. : temperature 
ioo°; pulse 120; no vomiting; the patient has 
some pain in the sac and the wound; skin moist, 
expression natural. She has slept for a short 
time and does not complain much. 
March 2. No vomiting; has slept a little and 
taken some boiled milk ; pulse 120 ; temperature 
ioi°. The outer-dressing, which contained a 
great amount of thin, grayish fluid of fecal odor, 
was changed. 
March 3. A verj- little discharge in the dress- 
ings. Pulse no; temperature ioi°. She takes 
liquid nourishment and has a moderate amount 
of pain, which can be controlled by morphine. 
March 5. Two stools of a chocolate-colored 
fluid containing many small clots of blood. 
Very little secretion from the dressings. 
March 6. Three copious evacuations of a 
bloody fluid containing several clots as large as 
a hen’s egg. 
March 7. Last night and this morning several 
large coagula and liquid blood passed through 
the rectum. The patient is pale, extremely 
anaemic, conjunctiva pale, exsanguinated, pulse 
130, weak ; temperature 99.50. The patient is 
fully conscious, and complains of extreme weak- 
ness. Skin c f extremities and face coM. In- 
fundation of sixteen ounces of slightly alkaline, 
saccharated saline solution into the cephalic vein. 
In the evening pulse 120, stronger, and the ex- 
tremities warm after the application of hot water 
bottles. 
March 8. During the night there was another 
haemorrhage from the bowel, after which the pa- 
tient became semi conscious, dozing most of the 
time and complaining but little. Extremities 9 
and face cold. Pulse 150, weak; temperature 
98°. Died at midnight. 
March 9. Autopsy, ten hours after death. 
No blood in the dressings or in the cavity of the 
sac. The packing of the cavity is almost dry. 
The cavity of the sac has diminished to one- 
quarter of the size at time of operation, partly 
by retraction of the walls, partly by filling in. 
After removal of the gauze, the placenta was 
found in place on the posterior wall of the sac. 
The autopsy revealed an opening at the upper 
insertion of the placenta, between the sac and 
the transverse colon. This opening was so cov- 
ered by the border of the placenta as to make the 
blood pass down into the bowels, and not out 
into the sac. The sac was of very different 
thickness in its different portions. On the an- 
terior surface it was about one-quarter of an 
inch thick, corresponding to the surface where 
the foetus was covered with omentum, and con- 
sisted in fact, of the thickened omentum. The 
remainder of the foetal cavity was entirely sur- 
rounded by loops of intestines, small intestine 
and colon, and here the sac wall was extremely 
thin, in some places cobweb-like, in other places 
slightly thicker, and everywhere more or less in- 
timately adherent to the wall of the intestine. 
These adhesions were the result of a plastic 
peritonitis commencing at the time of the pri- 
mary rupture into the peritoneal cavity, and ex- 
tending as the foetus increased in size. 
The placenta extended from the posterior sur- 
face of the uterus, entirely filling Douglas’ fossa, 
more than six inches upward to the transverse 
colon. The placental area of the sac was very 
thin in some places ; so much so that it tore into 
shreds on even so slight a manipulation as that required for the removal of the intestines en 
masse during the autopsy. 
Summary of History.—We find, in a patient 
34 years old, who had had one child, child-bed 
being followed by pelvic cellulitis, and who was 
then sterile for eleven years, an extra-uterine 
pregnancy characterized by the following course: 
In the eighth week after last menstruation, 
probable rupture of a tubal pregnancy, indicated 
by sudden pain and vomiting ; that is, symptoms 
of peritonitis, lasting for ten days. In the six- 
teenth week a similar attack, less severe. In 
the nineteenth week another severe attack of 
peritonitic symptoms keeping the patient in bed 
for one month. In the fifth month she felt life. 
In the second week of the ninth month a moder- 
ate attack of peritonitis. At the end of the 
ninth month spurious labor and death of the 
child, indicated by cessation of fcetal movements. 
In the fifth week after the death of the child, the 
placental souffle began to diminish, and two 
weeks later it had ceased entirely. Six weeks 
after the death of the child another severe attack 
attended with peritonitic symptoms, In the 
eighth week perforation of the sac into transverse 
colon. At beginning of ninth week, operation; 
death six days later from haemorrhage through 
the bowel. 
Remarks.-—This case undoubtedly belongs to 
a class of cases consisting of an original tubal 
pregnancy which secondarily becomes an ab- 
dominal pregnancy with the placenta and foetus 
located in the abdominal cavity. In the great 
majority of cases where a tubal pregnancy rup- 
tures at the end of the second or in the third 
month, the foetus dies and disappears, and if the 
patient survives the haemorrhage, both foetus and 
placenta are removed by absorption. In a small 11 
proportion of cases after this rupture the develop- 
ment of the foetus is continued, and the placenta, 
still partially connected with the old site in the 
tube, keeps on growing and implants itself on 
the walls of the peritoneal cavity, from the small 
pelvis upward on the anterior, posterior or lateral 
abdominal wall. When the rupture has given 
rise to no symptoms of haemorrhage a plastic 
peritonitis takes place which quickly forms a 
barrier between the territory occupied by the 
foetus and placenta, and the remainder of the 
peritoneal cavity. The product of this plastic 
peritonitis is probably first a fibrinous exudate, 
later on organized into connective tissue which 
forms the so-called sac. This probably does not 
differ in any respect from the connective tissue 
laj'er found in the wall of any other localized or, 
as it is called, encapsulated peritoneal exudate. 
As the growth of the foetus and placenta con- 
tinues, more and more space is required, rupture 
of the sac occurs into a new territory of peri- 
toneal cavity up to this time intact, and this 
territory is again limited by a plastic peritonitis 
resulting in an enlargement of the sac sufficient 
for the needs of its contents for some time. This 
procedure gives rise to symptoms of peritonitis, 
acute in its onset, but which gradually subside. 
In certain forms of purulent peritonitis we find a 
similar method of intermittent extension giving 
rise to successive attacks of peritonitis with free 
intervals between the attacks. 
This mode of development makes it natural 
that the sac should vary in thickness and re- 
sistance in different parts. Thus we would ex- 
pect to find it thicker in the space between two 
intestinal loops or between a loop of intestine 
and one of the viscera, than on the convexity of 
the of these organs. The greatest thick- 12 
ness of the sac will be found, as in this case, 
where the omentum has participated in its forma- 
tion. This would naturally occur on the an- 
terior surface of the foetal sac. The thinnest 
portion of the sac wall will be found on the con- 
vexity of the loops of intestine, and this is the 
place where rupture into the intestine takes 
place, either spontaneously or during attempts at 
extirpation of the sac. 
In extra-uterine pregnancy where a uniformly 
thick sac wall is found, it is natural to suppose 
that rupture of the tube has not taken place, but 
rather a uniform dilatation. These are probably 
the cases in which one layer of the wall of the 
sac is composed of organic muscular fibres, and 
in such cases, total extirpation of the sac is 
possible. 
Entire absence of the sac, the foetus lying in 
the free peritoneal cavity between intestines 
which are not matted together with adhesions, is 
a rare occurrence. Such cases have, however, 
been described by King, Eawson Tait and 
Goetsch. In the case of Eawson Tait, the in- 
testines protruded immediately after the extrac- 
tion of the foetus through an opening made in 
the posterior cul de-sac of the vagina. In the 
case of Goetsch, at the time of laparotomy, a 
full grown child was found free amongst the in- 
testines, but yet, strange as it may seem, fresh 
and not decomposed, although laparotomy was 
not performed until two years and a half after the 
spurious labor. 
Symptoms.—I shall not enter into a considera- 
tion of all the symptoms of extra-uterine preg- 
nancy, because these are to be found in the text- 
books. There are, however, two symptoms in 
this case to which I wish to call attention, mainly 
on account of their prognostic significance ; first, 13 
the repeated attacks of peritoneal irritation, and 
second, the final symptom of perforation into the 
bowels—the bloody diarrhoea. 
We notice in this case repeated, severe attacks 
of symptoms of peritonitis, so severe as to keep 
the patient in bed sometimes for a month at a 
time, and characterized by intense abdominal 
pain, vomiting and occasionally tympanitis. 
These attacks necessarily caused progressive loss 
of strength and emaciation, and thus the patient’s 
condition became gradually less and less favora- 
ble for operation. In this class of cases early op- 
eration, irrespective of the condition of the child 
or of the placenta, would be likely to give a bet- 
ter prognosis for the mother. 
The final catastrophe, perforation of the sac 
into the intestines, bladder or vagina, is charac- 
terized by a discharge of the liquid contents of 
the foetal sac, liquor aranii or pus; usually mixed 
with blood. Perforation into the intestinal tract 
is by far the most common, as the intestinal wall 
furnishes only slight resistance, and as a large 
area of the foetal sac must necessarily be formed 
of loops of intestine. Diarrhoea, usually bloody , 
is the first symptom, rapidty followed by symp- 
toms of sepsis due to microbic invasion of the 
sac. Rapid pulse and high temperature com- 
mence within twenty-four hours of the rupture. 
An especially characteristic symptom and one 
well marked in this case and caused the en- 
trance of gases from the intestinal tract into the 
sac, is tympanitic percussion over the area where 
formerly dull percussion was found. This symp- 
tom is of course absolutely pathognomonic of 
rupture into the bowel. 
Rupture into the bowel is a common occur- 
rence, as out of one hundred and thirty-two cases 
collected by Hecker, cited by Bandl, the foetus 14 
was eliminated through the rectum in twenty- 
eight instances with recovery of the mother. It 
is not too much to assume that this condition was 
present in at least a corresponding proportion of 
the forty-four cases in which the mother died 
without an operation having been performed, as 
sepsis must invariably follow the perforation. 
Prognosis.—The prognosis is always grave, 
varying in the older statistics between a mortali- 
ty of forty-two and eighty-eight per cent. Heck- 
er forty-two percent., Kiwisch eighty-two per 
cent., Henning eighty-eight per cent. 
Operative treatment.- Asepsis in operating has 
recently given a mighty impulse toward the 
amelioration of the prognosis of this grave con- 
dition, and the successful results as regards sav- 
ing the lives of the mothers has made the opera- 
tions for extra-uterine pregnancy to be counted 
by hundreds during the last four- or five years, 
while formerly they were only sporadic occur- 
rences. 
The greatest success is accompl1 shed by the 
operation in the early months of pregnancy, but 
it must be acknowledged that operations at or 
near term are at present not nearly so dangerous 
as they were in former years. A strict line of 
distinction must be drawn between the operations 
in the beginning, and those toward the end of 
extra-uterine The two conditions, 
although only different stages of the same ano- 
maly, present such vitally different anatomical 
conditions, chiefly on account of the difference in 
the size of the territory and the difficulty of the 
operation,that comparison is impossible. The early 
operation is technically no more difficult than the 
extirpation of the normal non-adherent uterine 
appendages; the operation toward the end of 
pregnancy, however, by which we mean the to- 15 
tal removal of ovum and its contents, is always 
formidable and often technically an absolute im- 
possibility. 
Early in pregnancy,' whether before or after 
rupture of the tube, which is almost always the 
primary seat of extra-uterine pregnancy, the op- 
eration presents no technical difficulties. The 
adhesions are slight or not present, for the tumor 
rarely exceeds the size of an orange or a large 
fist. Haemorrhage is easily controlled by liga- 
tion of the vessels of the broad ligament, which 
can always be found without difficulty. The 
prognosis of the operation is always good if the 
mother is in good condition; that is, is not ex- 
sanguinated by copious intra-abdominal haemor- 
,hhage from a previous rupture of the tube. 
The operation in the latter half or at the end 
of pregnancy is usually formidable. The extir- 
pation of a sac which often fills the greater part 
of the abdominal cavity, with adhesions to innu- 
merable loops of intestines, the walls of the sac 
varying in thickness and consistency from that 
of tissue paper to a quarter of an inch, together 
with the danger of haemorrhage from a full grown 
placenta which may be divided by the incision 
into the sac, or if not divided may even by slight 
detachment at its border cause a gush of blood 
which would fill the sac in a minute; such condi- 
tions put to a most severe test the presence of 
mind of even the most experienced operator. 
In considering the operation in the latter 
half of extra-uterine pregnancy we distinguish 
between laparotomy with living child, the so- 
called primary laparotomy, and laparotomy after 
the death of the child, the so called secondary 
laparotomy. This distinction has no technical, 
but only a prognostic value for the child and 
mother. From another point of view, we distinguish 
between the radical operation, removal of the 
whole of the foetal sac with its contents, child 
and placenta, and the non-radical operation or 
incision of the sac, a linear opening into the sac 
large enough for the delivery of the child, and 
the union of the borders of this incision with the 
opening in the abdominal wall. As regards this 
latter operation, we make a further distinction 
between the operations where the placenta is re- 
moved at the operation and those in which it is 
left to come away spontaneously later on, or as 
in very rare instances to remain in the peritoneal 
cavity, where it partially disappears by absorp- 
tion, or may be transformed into a mass of cica- 
tricial tissue, as has been observed by Goetsch. 
and Braithwaite, on the outer wall of the uterus. 
It is evident from what has been already stated 
that the radical operation is technically the most 
difficult one, for on account of the nature of the 
so called sac, its total removal is usually difficult, 
and very often impossible. Thus the choice be- 
tween incision and extirpation would require 
very serious consideration in the individual case, 
and the surgeon will often find himself in a very 
serious dilemma in this regard. 
Thus in a number of instances, extirpation of 
the sac has been commenced, but after the oper- 
ation has been partially performed the extirpa- 
tion had to be abandoned on account of the im- 
possibility of proceeding further. In such cases 
a part of the wall has been extirpated and part 
united with the abdominal wound; in other in- 
stances the connection of the sac with the uterus 
has made it necessary to amputate the latter, in 
order to accomplish the total removal of the sac. 
The advantage of the total removal of the sac, 
even if it involve so serious a complication as ab- dominal supra-vaginal amputation of the uterus, 
lies in the control of haemorrhage by ligation of 
the uterine arteries, and in the greater security 
against sepsis or intoxication from a non-removed 
sac and placenta. 
The prognosis of the operation as given by the 
statistics from the literature up to date shows a 
remarkable decrease in mortality in the last five 
years. Primary laparotomy was attended by a 
very great mortality up to the end of xBB6. Thus, 
Werth reports eight cases with seven deaths, a 
mortality of eighty-five per cent.; Uitzmann, ten 
cases with nine deaths, ninety per cent.; Harris, 
thirty cases with twenty-five deaths, eight}^-three 
per cent. From 1887 to 1890 inclusive we find 
reported by Leopold Meyer seventeen cases with 
five deaths, a mortality of thirty per cent. This 
may be fairly considered as the present mortality 
of primary laparotomy for this condition. 
Up to 1886 the mortality of secondary laparotomy 
was, as Uitzmann states, to a great extent depend- 
ent upon the presence or absence of. placental 
circulation. The operations before cessation of 
placental circulation had a high mortality. In ten 
cases in which the operation was done within the 
first five weeks after the death of the foetus there 
were eight deaths, a mortality of eighty per cent.; 
while later operations, from six weeks to a year 
after death of the foetus, had a much less mortal- 
ity; Uitzmann reports twenty-three cases with 
six deaths, a mortality of twenty-six per cent., 
and Werth, twenty-five cases with eight deaths, 
a mortality of thirty-two per cent. This great 
difference in the mortality led Uitzmann to ad- 
vise against operation immediately after the 
death of the foetus and to advocate delay until 
after cessation of the placental circulation. 
For the last four years, the statistics of secon- dary laparotomy show a still better prognosis. 
Leopold Meyer reports seventy-two cases with 
twelve deaths, a mortality of only eighteen per 
cent. As far as can be observed, the secondary 
laparotomies during the last four years have not 
been performed with strict regard to the cessa- 
tion of placental circulation. It is likely, how- 
ever, that lyitzmann’s advice has caused many 
operators to postpone the operation as long as 
possible. 
The prognosis of extirpation as compared with 
incision, so far as the statistics of the last four 
years enable us to judge of this question, shows 
very little difference in the mortality of the two 
operations. Thirty-six cases of extirpation, or 
the radical operation, have been reported, with six 
deaths, a mortality of sixteen and seven-tenths 
per cent.; and cases of incision, or the 
non radical operation, with twelve deaths, a mor- 
tality of eighteen and seven-tenths per cent. 
Four cases were reported in 1890 of partial extir- 
pation; that is, cases in which extirpation was 
attempted but could not be completed on account 
of the impossibility of freeing the sac, with two 
deaths, a mortality of fifty per cent. It will thus 
be seen from the statistics that incision has been 
performed nearly twice as often as extirpation. 
In the non radical operation, incision, the 
question has been raised as to what should be 
done about the placenta, whether it should be re- 
moved or left in situ. The attempt to remove it 
had its justification in the desire to obviate the 
danger of sepsis or intoxication from the consid- 
erable amount of dead tissue of the decomposing 
placenta. The danger of removing the placenta 
at the time of operation is on account of the diffi- 
culty or impossibility of controlling the haemor- 
rhage from the site of the placenta. It has been 19 
proposed that those who perform the radical op- 
eration should control the haemorrhage in one of 
the following three ways: 
i. By previous ligature of the spermatic and 
uterine arteries before removal of the placenta. 
2. By ligature en masse of the bleeding parts 
of the placental territory of the sac after the re- 
moval of the placenta. 
3. By pressure from packing the sac full of 
sterilized gauze impregnated either with iodo- 
form or with a mixture of salicylic and tannic 
acids. 
Ligation of the spermatic and uterine arteries 
can be done only in cases where the broad liga- 
ments are accessible. This is probably of com- 
paratively rare occurrence, as in most cases in 
which the sacs are not well defined, the broad 
ligaments and uterus are hidden below the pla- 
centa. 
Ligature en masse of the placental territory of 
the sac is extremely difficult and often impossible, 
partly because of the enormous haemorrhage 
from this territory and partly because of the dan- 
ger of injury to the intestines if in close proxim- 
ity to the bleeding placental site. 
Pressure by packing the sac with gauze is un- 
reliable, as we have to deal with a cavity which 
has no firm wmlls against which to make pres- 
sure. 
The statistics for the last four years show 
twmlve cases in which the placenta wms removed, 
with four deaths, a mortality of thirty three per 
cent.; and twent}7-nine cases in which the pla- 
centa was left undisturbed, with five deaths, a 
mortalit}7 of seventeen per cent. Thus we may 
conclude that it is at the present time more safe 
to leave the placenta intact, as was done in the 
majority of cases, or at any rate, to limit the at- 20 
tempt to remove the placenta to those special- 
ly favorable cases where the afferent vessels can 
be found and secured before its removal. 
Final Remarks.—The most important points 
to consider in extra-uterine pregnancy advanced 
beyond four months are: 
i. When shall we operate? 
2. And what operation shall be done? 
The question of the time for operation cannot 
be solved merely by looking at the mortality 
from the statistics. The fate of the child I shall 
leave entirely out of consideration, as I believe 
that very few operators of to-day agree with Taw- 
son Tait in weighing the life of the child against 
that of the mother. 
The maternal mortality as seen in the statis- 
tics, shows as stated above, a great difference be- 
tween primary and secondary laparotom}l-, a dif- 
ference of twelve per cent, in favor of the latter. 
Notwithstanding this, a number of modern oper- 
ators are inclined to give up the secondary oper- 
ation and operate as early as the diagnosis is made 
irrespective of the child or of the placental circu- 
lation. 
Certain operators, such as Olshausen, Tawson 
Tait, Thornton, Werth, Tusk, Wilson, Doran, 
Hart* Martin, and others, advocate operating as 
early as possible. To explain this, notwith- 
standing the apparently greater safety of the late 
operation, there must be a fallacy in the conclu- 
sions drawn from the statistics. This fallacy is 
the following: A number of patients, especially 
those having recurrent attacks of peritonitis, will 
die either from peritonitis or from perforation and 
sepsis before the time for the late operation has 
arrived. If these cases of speedy death after rup- 
ture were included in the statistics of the mortal- 21 
ity of the secondary operation, its percentage 
would be materially increased. 
During extra-uterine pregnancy the mother is 
in danger all the time, from rupture with haem- 
orrhage and sepsis. It is impossible to know 
when this will occur and it has often been ob- 
served, as it was in my case, that rupture has 
taken place during the time of waiting, before 
the day set for the operation. 
Rupture is always followed by sepsis, and an 
operation of necessity in the case of a septic pa- 
tient has of course a bad prognosis. Sometimes 
even, death will come so suddenly that it would 
have been impossible to perform an operation, as 
in an instance mentioned by Harris in which the 
patient died half an hour after perforation had 
taken place. 
It remains true that a number of extra-uterine 
pregnancies go through to full term without rup- 
ture or even after term for months or years. It 
also remains true that the longer after the death of 
the foetus the operation is performed, the less is 
the mortality. But it is impossible to foresee in 
a given case whether or not the patient will 
escape rupture and sepsis. Hence the conclusion 
to operate as early as possible as a prophylactic 
measure. As early as possible means as early as 
the diagnosis is made, and this I consider to be 
the standpoint of to-day in this regard. 
If the future repeats the history of the past we 
may confidently expect that the prognosis of the 
early operation will be still better than hereto- 
fore. Future clinical observations should enable 
us to make a differential diagnosis between two 
distinct classes of cases : The one, those in 
which perforating peritonitis does not take place 
and the patient is in no danger at any period be- 
fore or after term ; the other, those in which the 22 
patient is exposed to the dangers of perforation 
and sepsis at any time. When this stage of pro- 
gress has been reached the late operation may 
again have a legitimate field. 
The question of the choice between extirpation 
and incision is much more difficult. The almost 
equal mortality from these operations, as shown 
above in the statistics, helps us very little in this 
respect, as it does not indicate by any means an 
equal choice between the two procedures. 
The radical operation, desirable as it is, as far 
as control of sepsis and haemorrhage is concerned, 
can be done only in a limited number of cases 
where the sac is so uniformly strong and the ad- 
hesions so favorably arranged as to make this 
operation possible. In a large number of cases 
incision would have to be done as a matter of 
dire necessity, in cases in which the condition of 
the sac and extensive, short adhesions, especially 
to the intestines, have made extirpation im- 
possible. 
The choice between the two operations is much 
more difficult after the sac has been opened and 
the child delivered, for it is often impossible 
to determine whether an attempted extirpation 
can be finished or not. The unfinished operation, 
the so-called partial extirpation, has a mortality 
of fifty per cent. 
A difficult radical operation will tax the skill 
of the most experienced operator to its utmost, 
and the attempt to loosen the sac from the in- 
testines has in several instances resulted in 
multiple intestinal wounds followed by death 
from shock and haemorrhage, and this result may 
follow too bold an attempt in this direction even 
during the operation. Slight manipulations of 
the sac have often caused such a formidable and 
sudden haemorrhage from the placenta that 23 
further operating has been rendered well nigh 
impossible. 
The future will have to decide whether rapid 
removal of the placenta, and haemostasis after its 
removal, can be advocated as a justifiable and 
safe procedure. 
The non-radical operation has the advantage 
of being easy of performance, of requiring only 
a slight amount of operating and of taking but 
little time. Thus it would seem natural that this 
operation should be preferred by less experienced 
operators in all cases. 
The placenta should not be removed in the op- 
eration of incision excepting in those very late 
cases where it has been already detached and lies 
loose in the sac. 
BIBLIOGRAPHY. 
Ernst Herman, Obstetrical Transactions, Vol. xxix, 
1887. Leopold Meyer, Copenhagen, Litteratur Over- 
sigt, Gynakologiske og Obstetristiske Meddelelser 
udgivne of Prof. F. Howitz. Band 7, Heft. 1, 2, 3. Ibid, 
Band 8, Heft. 1, 2. Bandl, Deutsche Chirurgie, lieferung 
59, 1886. Harris, American Journal of the Medical 
Sciences, 1888.