Extrauterine Pregnancy Treated by Cystectomy, or Cystotomy without Ex section. WITH SPECIAL REFERENCE TO CASES IN WHICH THE FCETUS IS LIVING AND VIABLE. BY ROBERT P. HARRIS, A. M., M. D., OF PHILADELPHIA. FROM THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, September, 1888. Extracted from the American Journal of the Medical Sciences for September, 1888. EXTRAUTERINE PREGNANCY TREATED BY CYSTECTOMY, OR CYSTOTOMY WITHOUT EXSECTION, WITH SPECIAL REFERENCE TO CASES IN WHICH THE FCETUS IS LIVING AND VIABLE. By Robert P. Harris, A.M., M.D., OF PHILADELPHIA. Recent important changes in the treatment of extrauterine preg- nancy, at all periods of development, and the diminished mortality under exsection in cases in which the object is to save two lives, have led me to take a more hopeful view of the whole subject than I felt warranted in taking a year ago, in a paper entitled " Primary Laparotomy in Cases of Extrauterine Pregnancy." The term primary has been so differ- ently applied of late years, that it has ceased to convey to the mind any definite meaning, such as it had until quite recently. Laparotomy has become of such general use in many countries as a legitimate term, that I can see no valid objection to its continuance; but the nomenclature has become deranged by the introduction of exsective operations at every stage of embryonic and foetal growth, from three weeks to full maturity. Thus we have exsection : 1, before rupture, while the embryo is presumed to be alive; 2, before the same accident, when the foetus is already dead; 3, after rupture, when the object is to save the woman from bleeding to death ; 4, at a later period, when the foetus is alive, and is being developed either subperitoneally, or within the abdominal cavity; 5, at or near foetal maturity, in the hope of saving both child and mother; and 6, when the foetus has been some time dead, to save the woman from the fatal effects of septic infection, hectic, peritonitis, perforation of hollow viscera, etc. These various operations bear an age in the reverse order of their enumeration. The oldest exsective operation was simply the enlargement of a foetal fistula of the abdominal wall, and the removal of a dead and putrid foetus in fragments or entire. The next step in progress was to disregard the fistula and make an incision into the cyst directly over some pre- senting part of the foetus. This was first done, on August 20, 1595, by Jacob Noierus,1 in the case of Giralda Tiaca, of Grandiniano, upon 1 Jacobus Primerosii " De Mulierum Morbis," 1655, p. 138. 2 HARRIS, EXTRAUTERINE PREGNANCY. whom he had, on a former occasion, performed the first mentioned section, she having had two ectopic impregnations within a few years. At a much later period, when surgeons became more venturesome, the dead foetus was delivered by abdominal section while still unchanged by putrefaction, there being no fistula : and, finally, a decidedly more daring step was taken, in the exsection of a living and mature foetus, in the year 1813. This latter operation became designated in time, by way of distinction, as the primary operation, and the older form, in which the foetus is already dead, as the secondary one. When Mr. Tait began to exsect Fallopian foetal cysts after their rupture, he claimed that his opera- tion was better entitled to the term primary; and now we have another claimant in Dr. John S. Hawley, of New York,1 who, with several others, has exsected a foetal cyst prior to rupture, and calls his a primary laparotomy. We have also the same title given by Dr. Francis H. Champneys,2 of London, to abdominal section in the latter half of preg- nancy, the child being alive. So, as the term has in a measure lost its original signification and now belongs to nothing definite, I must drop it for the present, until the nomenclature is settled. In importance, the operation designed to save mother and child is certainly primary, and it was this which gave the distinctive title originally; the primitive operation is that described by Dr. Hawley as the first in the order of time. The tabular record to date shows that the prognostic status of the operation has been decidedly improved of late years; as is evinced by the fact that four women have been saved under the last ten opera- tions. By correspondence, either directly or indirectly with twenty of the operators, I am enabled to fill up many points in the tabular matter that would otherwise have appeared in blank, as well as to give an esti- mate of the conditions of the women when subjected to the use of the knife, and to state the causes of their death and of that of the children who survived beyond a few hours or days. When an extracted ectopic child is well formed, and has lived beyond the first month, there is no reason why it should not have the same prospect of continuing to live that a normally delivered foetus has, but for the fact that it is too frequently motherless, and is often much neglected or injudiciously cared for. A fair proportion of ectopic foetuses will be found perfect in form, and about one in three extracted at full term will present all the signs of physical vigor. Of the thirty children in my table, two boys, aged respectively six and eight years, are now alive and well; a third boy had an intemperate father, and, although hale and strong, was fed into cholera infantum at eighteen months ; a fourth child, a female, whose mother survived, died of croup 1 New York Medical Journal, June 16, 1888, p. 648. 2 Transactions Obstetrical Society of London for 1887, p. 456. HARRIS, EXTRAUTERINE PREGNANCY. 3 at eleven months; a fifth fell a victim to diarrhoea at seven months; a sixth was alive and well when lost sight of at six months; and a seventh died of broncho-pneumonia at the same age. The placenta always has been, and is still a subject for anxiety in the exsection of a living or dead foetus. What to do with it was for years a question in cases in which the child delivered was already dead ; until, after many discouragements, it was discovered nearly a hundred years ago that it should be left intact, to separate spontaneously if the woman is to escape death by hemorrhage; and for the last twenty-five years it has been firmly established that in this class of cases the cyst and abdomen are to be stitched up together; the cord brought out at the lower angle of the wound; a drainage tube is to be used, and the ab- dominal cavity to be kept clean by occasional irrigation with warm water. When the exsective operation for saving the living ectopic foetus, as well as the mother, was introduced seventy-five years ago, it was soon realized that not only was any attempt at peeling off the placenta fatal, but the non-interference plan, so successful after foetal death, was attended almost universally with the same result. After nineteen women out of twenty had died, in the half of whose operations the placenta had remained intact, Prof. August Martin, of Berlin (Case XXI.), made a new departure, by which he saved his patient; and he is now an advocate of ligating the placental vessels and removing this viscus when- ever feasible. Unfortunately, the placental location and attachments are such in many cases that this new plan is not practicable, and the placenta must be left to exfoliate, with its accompaniments of danger, under which risk, however, Cases X. and XXV. were saved. An ectopic placenta may be very much larger and thicker, or much smaller, than one developed in utero. In general, it is thinner and less developed and is sometimes divided into lobes, or is only a membranous and vascular cake. The death of the fetus'does not necessarily cause entire placental death, but the placenta undergoes important vascular changes after its functional activity ceases with the death of the fetus. A half-developed fetus in some situations may be attached to a placenta which is out of all proportion to the fetal size and age; hence has risen the idea that the placenta may grow after foetal death ; of which no absolute proof has as yet been produced, and it does not comport with the usual teachings of embryology. If the fetus and placenta are mu- tually dependent upon each other; if the child makes and circulates its own blood; and if the placenta is in loco pulmonis until the child can inhale air and use its lungs instead ; then we cannot see why the placenta should, in any case, become exceptional and grow larger after its functional life is no longer called upon. It may be found a great deal larger than it should be some time after the death of the fetus, but what proof is 4 HARRIS, EXTRAUTERINE PREGNANCY. Abdominal Exsection of the Living £ Condition of woman at 'A Date. Operator. Locality. - G Gestation. time of operation. Result to woman 1 Aug. 29, Dr. Brukert Berlin, 32 3d 9 months Sac ruptured; legs of fcetus Died in 40 hours ; peri- 1813 protruding; peritonitis. tonitis. 2 Dec. 7, Dr. Domenico Novara Porto Mau- 38 5th 9 " Pseudo-labor - pains ; fever ; Died in 33 days from 1814 rizio, Italy, cough, emaciation, abdomi- nal dropsy and oedema of the slow septic poisoning. extremities. 3 1827 ? Dr. Matfeld Tubingen, 24 3d 9th m'th In pseudo-labor 8 days before Died in 20 days from 4 Mar. 1, Dr. Hauff Germany, 7 1st 35 weeks the ectopic gestation was re- cognized Violent labor ; lame ; rapid pulse; much prostrated. In extremis; special danger subacute peritonitis. Died in 24 hours of in- 5 1841 1852 Prof. Pietro Lazzati Milan, ? ? 9 months ternal hemorrhage. Died in 29 hours; shock not stated. and exhaustion. 6 Mar. 27, 1863 Prof. Eugen Koeberle Strasbourg, 39 3d 9 " Peritonitis; fecal vomiting from intestinal obstruction; Died soon after opera- tion ; peritonitis and in extremis. hemorrhage. 7 April 21, Dr. Rob. Greenhalgh London, 40 2d 8 " In extremis; emaciated ; jaun- Died in 32 hours from 1864 diced ; oedema of lower ex- collapse. tremities; almost constant vomiting; violent colicky 8 Mar. 3, Dr. E. Paul Sale Aberdeen, Mississippi, London, 22 1st 9 " pains. Pulse 135, small and weak; temperature 97%°; rupture of cyst threatened. Pulse 135; temp. 104.2°; pain; Died in 4 days of septi- 9 1870 Oct. 5, Dr. John Scott 23 1st 29 or 30 csemia. Died in 5 hours of heart- 10 1872 Aug. 14, Mr. T. R. Jessop Leeds, Eng. 26 2d weeks 33 or 34 vomiting; prostration. Prostrated by pain and re- clot. Recovered. 11 1875 Mar. 5, 1877 Prof. Otto Spiegelberg Breslau, 36 2d weeks 40 weeks peated attacks of vomiting ; pulse feeble and rapid. Sac ruptured ; peritonitis ; pulse 148 ; fecal vomiting from intestinal obstruction. Died in a few hours; collapse from hemor- rhage. 12 May 25, Dr. Heywood Smith London, 32 4th 9 months Pulse 100 ; temp. 98.2°; urine Died in 22 hours; 13 14 1877 Nov. 5, 1877 Aug. 19, Dr. Henry Gervis Dr. Ernst Frankel London, Breslau, 39 34 9th 3d 36% w^8- highly albuminous. Vomiting and pain; strength failing. Pseudo-labor-pains; fever ; hemorrhage Died in 56 hours; peri- tonitis and hemor'ge Died soon after opera- 15 1878 May 29, Prof. Carl Schroder Berlin, 33 7th 34% " emesis; rupture of sac threatened. General health fair. tion: hemorrhage from separating placenta. Died in 36 hours ; fever, 1879 vomiting, meteorism, exhaustion. 16 Dec. 19, Dr. B. Chris. Vedeler Christiana, 40 4th 35 Sac ruptured ; peritonitis ; Died the next after- 1879 affected with gonorrhoeal endometritis. noon; peritonitis. 17 Jan. 10, Prof C. C. Th. Litz- Kiel, 29 2d 39% » In a hectic condition ; opera- Died in 16 days; septi- 18 1880 Jan. 31, 1880 mann Mr. Lawson Tait Birmingham, 33 7th 9 months tion of election(?). Exhausted from severe pains and loss of rest. ctemia and hemor- rhage. Died on the 4th day; "prolonged shock." 19 May 11, Dr. H. P. C Wilson Baltimore, 24 4th 9 " Pulse 104; temp. 100°, rose to Died in 90 hours; col- 1880 130, and 103.6° in 8 hours lapse. 20 July 26, Dr. W. Netzel Stockholm, 28 3d 9 " after operation. Died in 45 hours, ex- 18S0 hausted by hemor'ge. 21 July 9, Prof. Aug. Martin Berlin, 39 3d 7 " Emaciated; sleep prevented Recovered. 1881 by constant pain. 22 July 13, Dr. Giuseppe Beisone Buriasco,near Pinerolo, It., Konigsberg, Kbnigsberg, London, 40 1st 9 " No grave symptoms yet de- Died on the 6th day; 23 24 25 1881 Feb. 15, 1882 Oct. 3, 1882 June 6, Dr. Hildebrandt Dr. Hildebrandt Prof. John Williams 26 28 30 2d 7th 2d 9 " 34% wks. 35'th wk veloped; pseudo-labor-pains. Almost moribund from peri- tonitis. In extremis. Thin and antemic ; subject to septicaemia. Died on the 10th day; slow peritonitis. Died in 17% hours; collapse. Recovered 1885 attacks of vomiting and pain with symptoms of peritonitis. 26 Nov. 4, 1885 Prof. J. Lazarewitch Kharkof, Russsia, 27 2d 9 months Suffering from violent abdom- inal pains; had had perito- nitis and jaundice. Recovered. 27 28 Jan. 29, 1886 Oct 19, Prof. A Stadfeldt Dr. F. H. Ohampneys Copenhagen, London, 29 42 1st 4th 9 " 7 th " Pulse 110 ; temp, normal. Sleep disturbed by abdominal Died in 38 hours ; prob- ably hemorrhage. Died in 11% weeks; 29 1886 Mar. 30, 1887 Dr. Joseph Price, Philadelphia. Camden, New Jersey, 37 5th 7%" pain. Sac ruptured ; peritonitis ; greatly emaciated septic intoxication. Died in 15 days; hemor- rhages. 30 Oct. 29, Prof. Aug. Breisky Vienna, 39 9 " Recovered. 3| , 1887 JvlUl. <0 sA & " 5 73 Tl/jLOveJlLtL , HARRIS, EXTRAUTERINE PREGNANCY. 5 and Viable Extra uterine Foetus. No. Result to child. Remarks. References.. 1 2 Lived, male, strong, healthy at 3 weeks ; not mentioned in operator's account of case on July 24, 1817, in Rust's Magazin. Lived, cried at once, was a large and well-formed fe- male. Operation by long incision ; intestines could not be replaced until evening of second day ; in- cision 9 inches. Placenta left in situ ; cord ligated and left hang- ing out of lower end of abdominal wound. Magazin fiir die gasammte Heilkunde, von Johann N. Rust, 1818, Bd. iii. S. 1. Journ. Univer. des Sciences Med;,1816, t. iii.pp.119-124. 3 4 5 6 7 Lived. Died in 50 hours; lower ex- tremities deformed. Alive, but did not breathe. Died on the second morning ; born asphyxiated ; 17U( in. long. Died in a few minutes. Placenta left intact in the iliac fossa, and the ab- dominal wound closed; exfoliation began on 6th day. About two-thirds of placenta separated by fingers and scissors and removed; part left bled largely. Patient, the wife of an intimate friend of the ope- rator, was operated upon as a possible, last hope. Placenta torn in the delivery of the foetus; not removed; hemorrhage arrested by sponge pres- sure. Dr. Greenhalgh was an ardent advocate of Ceesar- ean section, and probably regarded this case 7 as one of little encouragement; but to be ope- rated on as a duty. Neue Zeitschrift fiir Geburt, 1834, Bd. i. S. 134 Medicinische Anualen (Heid- elberg), 1842, Bd. vii. S. 439. Manuele del parto Meccanico od Instrumentale del Lo- vati, Milano, 1854. p. 194. Gazette Medicale de Stras- bourg, 1863, t. x. p. 160. Medical Mirror, Nov. 1864, p. 689. 8 9 10 Lived 6 months; died of bron- cho-pneumonia (Black) Died on the second day. Lived; female; died at 11 months of croup. Placenta removed; an intrauterine foetus de- livered by Ceesarean operation ; died in a year of measles. Placenta removed ; much blood lost; hemorrhage ceased from the woman fainting. Placenta intact; no cyst; foetus free in abdominal cavity ; head under stomach New Orleans Med. and Surg. Journ., 1870, vol xxiii. p. 727. Trans. Obstet Soc. London, 1873, vol. xv. p. 309. Trans. Obstet. Soc. London, 1876, vol. xvii. p. 261. 11 Lived 3 months ; hand-fed ; died of inanition. Placenta incised ; violent hemorrhage ; ligated and partially removed. Archiv fiir Gynakol., 1S79, Bd xiii. S. 74. 12 13 14 Alive; heart beat 30 to 40 minutes. Died in 6 hours. Died in 24 hours. Placenta torn in operation ; torn portion ligated and removed. Placenta intact; became decomposed ; cyst wall likewise; pint of blood in abdomen. Placenta separated in operation, and almost en- tirely removed; violent bleeding resulted. Trans. Obstet. Soc. London, 1878, vol. xx. p. 5. British Med. Journ., 1877,vol. ii. p. 884. Archiv. fiir Gynakol, 1879, Bd. xiv S. 197. 15 16 Lived; alive and well at 6 months, then lost sight of. Died the day after the opera- tion. Placenta intact; cyst plugged with salicylated wool; considerable blood-loss in operation. Placenta intact. Zeitschrift fiir Geburtshiilfe und Gynakol , 1880, Bd v. S. 115. Norsk Magazin for Laegevi- denskaben, Juni, 1880, Tiende, Binde, 6te Hefte, S. 86. Archiv fur Gynakol., 1880, Bd xvi S. 362. Obstet Journ. Great Brit and Ireland, Oct 1880. vol. ii. p. 577. Trans. Amer. Gynecol. Soc., 1882, vol. vi. p. 461. Hygeia (Stockholm), 1881, vol. xliii. p. 169. Berlin, klin. Woch., Dec 26, 1881, Bd. xviii. S. 753-775. Gazetta Medica di Torino, 1881,vol. xxxii. pp. 553-557. Berlin klin. Woch., July 20, No. xxix. S. 465. Opus citatus, S. 465, 1885. Brit. Med. Journ , Dec. 3, 1887, p. 1213; Trans. Obstet. Soc. London, 1887, vol xxix. p. 482. Vrach. St. Petersburg, 1886, vii. 66,115; Repertoire Uni- verselie de Nouvelles Archives d'Obstet. et de Gynec., 25 Juil, 1886, p. 277. Hospitals Tidende, Sep. 22, 1886, p 889. Trans. Obstet. Soc. London, 1887, vol. xxix. p. 456. Communicated by the opera- tor, April 19, 1887. Wiener med. Woch., 1887, 48, 49, 50. 17 18 Died in 15 minutes. Lived, male ; active and well at last report. Placenta intact; no bleeding until the 13th day ; all placenta came away by the 16th day; sepsis began on 12th day. Placenta intact; foetus developed between the laminae of the right broad ligamant (see case 30) 19 20 21 22 23 24 25 26 27 28 29 30 if. Lived 18 months ; male; died of cholera infantum. Died in 48 hours. Alive ; cord pulsated ; did not breathe; had a large en- cephalocele. Lived ; male ; alive'and well in May, 1888. Lived. Alive; asphyxiated beyond resuscitation. Died in a few minutes; heart- beat 108 before operation ; head and neck were oede- matous. Lived 26 days ; wet nursed ; had two eclamptic seizures; died of inanition. Lived 7 months ; died of diar- rhoea. Died soon after operation ; fe- male, 15 in long, 21bs 10oz. Died in 4 hours; female ; ac- tive at delivery. Lived 19 days; died of an abscess of abdominal wall near the umbilicus. . MufL k (m1L cd?. S' uunjtci Placenta intact; it was found firmly adherent at the autopsy; an intrauterine twin had been born 36 days before. Placenta divided in operation, with severe hem- orrhage. Placenta removed after ligation at three points. Placenta intact; located mainly in right iliac fossa ; small and malformed. Placenta undisturbed ; located deeply down in the lower pelvis Placenta left in place; it was over the fundus uteri and extended into the Douglas space. Placenta not removed; located anteriorly be- tween umbilicus and right ant. sup. spinous process ; placenta came away between July 3d and 14th ; woman well and fat Aug. 14th. Placenta and cyst drawn out, pursed up in the abdominal wound; ligated ; and a large part removed. Placenta intact; cord allowed to bleed ; no cyst, as in Case 10 ; foetus with head downward. Placenta intact ; adherent to uterus, left ovary, broad ligament, right side of pelvis, ilium and colon. Placenta and cyst exsected from fold of broad ligament after ligating vessels; placenta lo- cated at superior part of cyst, and subperi- toneal. OuA. Cut , 6 HARRIS, EXTRA UTERINE PREGNANCY. there that it was not of this size at the time the foetus died, and that the hypertrophic condition did not in a measure cause the death of the latter? Prof. T. G. Thomas1 found in one case that the placenta covered the intra-abdominal centre, and was attached to the ascending, trans- verse and descending colon, forming an enormous, thick and heavy growth of several pounds in weight ; in fact, it was the largest placenta he had ever seen; the foetus had died at maturity, four months before. Is it probable that this placenta grew after its death ? Is it not much more likely that it was too large for the foetus to be of normal propor- tion at any stage of gestation ? If all ectopic placentte have originally been tubal, no matter where they may be found located in the abdominal cavity, as we are asked to believe, the migratory character of abdominal pregnancies would be less pronounced. To account for some of the remote localities of the placenta, we are also asked to credit the hypothesis, that a tubal ovum may be forced entirely from its attachments through a lacerated vent, and its placental surface after a migration form a new union for itself in a remote region of the abdominal cavity and develop to full maturity. Reasoning analogically, we cannot believe in this as a possibility ; and we find much less difficulty in accounting for such cases on the hypoth- esis that they are ab origine abdominal. We know that, for a time at least, a human ovum is possessed of a certain measure of inherent and independent life, which admits of its migrating from the ovary along the Fallopian tube to the uterine cavity and there becoming attached, after which its inherent life is changed into one of dependence. A bird's egg, a seed and the bud of a tree are all endowed with an inde- pendent vitality, lasting longest in the seed. Apply blood-heat to the egg and the incubative process soon commences; stop the process by cooling sufficiently and the embryo dies, because heat has become an essential of its new dependent existence. As the inherent life is lost, the egg cannot be made to hatch by renewing the heat; it now only hastens its decay. The incubative process must be continued uninter- ruptedly, or it will end in a failure. Moisture with heat will sprout a seed ; dry it a second time: Will it then produce a plant ? No, it will decay. If a human ovum has lost its independent vitality by becoming attached to the lining of the Fallopian tube or uterus, and is made de- pendent for existence upon a blood-supply, can it resume this lost inde- pendent life when it again migrates to form anew home for itself? Will not the simple separation of an ovum in utero cause it to die and be expelled ? Prof. Koeberle, of Strasburg,2 once removed a uterus for a fibroid tumor, leaving the cervix and the appendages; the woman re- 1 Transactions American Gynecological Society, 1884, p. 179 2 Des Grossesses Extrauterines : par Theodore Keller, 1872, p. 23. HARRIS, EXTRAUTERINE PREGNANCY. 7 covered, with a pervious cervical canal, through which she became impregnated, with a fatal result. Was this likely to have been a tubal pregnancy ? Why is it that within a few years so much doubt has been cast upon the existence of an original abdominal variety of pregnancy, to explain which away requires much more extravagant hypotheses than to credit it on the faith of many learned obstetrical writers ? One year ago, it appeared scarcely possible that an ectopic foetal growth at full maturity could be entirely removed, as by a form of enu- cleation, with complete success. But since the report of Case XXX., under Prof. Breisky, of Vienna, was issued, it has become a question whether his process of subperitoneal ligation and exsection cannot be made available in a fair proportion of intra-peritoneal cases. Prof. Breisky exsected the whole foetal growth-i. e., amniotic sac, placenta and child, in a case in which the development took place external to the peritoneal cavity, between the laminae of the broad ligament, the placenta being located at the top of the cyst. Prof. Martin, of Berlin, and Prof. Lazarewitch, of Kharkof, now of St. Petersburg, prepared the way for this very complete enucleation, by operations 21 and 26, in which the location and attachments of the placenta prevented the removal from being as satisfactory in character. By these three methods of exsection, no doubt in the future, many of the fatal difficul- ties of the past may be overcome and the women saved. To peel off the placenta is almost certain to produce death, whether the child be extracted alive or after it has been some time dead; but to tie and cut, carefully and by slow progressive steps, may be done in some cases in which the attachments of the placenta will admit of it. The operators who have failed in saving theii' patients, after the re- moval of living and viable ectopic foetuses, will be seen, by an examina- tion of my table, to have been, with a few exceptions, those whose names have so often appeared in connection with other more hopeful and successful forms of abdominal surgery. When men, such as Koeberle, Greenhalgh, Spiegelberg, Schroder, Litzmann and Stadfeldt were unsuccessful, it may be taken as evidence that there were very great difficulties to be contended with, either in the condition of the patient, the anatomical relations of the parts to be removed or both. What the operators had to contend with will be found in the important column in the table headed: Condition of the woman at the time of the operation. Some may think it unwise to have operated under such adverse and almost hopeless circumstances; but what better can be done until the improved acumen of the student of obstetrical diagnosis shall fit him to discover the ectopic character of a pregnancy at an early day? Besides, we are to reflect: 1, that the woman in a large proportion of cases believes herself to be normally pregnant, and does not call in a physician, or present herself at a maternity, until her health 8 HARRIS, EXTRAUTERINE PREGNANCY. has failed or a josetzdo-labor has actually commenced; and 2, that she will not submit to have the living foetus exsected until compelled to do so by pains, emaciation and other evidences of ill health, and by a con- sciousness of the fruitless character of her labor. The term operation by election can hardly ever apply to these cases, for the reason that the surgeon has very little choice in the matter when called to consider what is to be done ; he must operate, or see the woman die undelivered. There are cases, and these have been far more numerous, in which no opportunity is given to operate until after the ^seitdo-labor has terminated in the death of the foetus; when the whole character of the case changes, and there may be no occasion for haste, which may be fatal; but time may be allowed for certain important alterations in the placenta and its vascular connections, which being accomplished, its spontaneous separation may be effected with a greatly reduced risk after foetal extraction. If the operation after foetal death, provided this has existed for at least ten weeks, can be performed with so much less danger than during its life; and if so few children are ultimately saved; it may be asked: Why not wait until the child is dead, and then operate ? This plausible and puzzling question once presented itself to a company of three physi- cians in this city, who were in daily attendance upon a lady in pseudo- labor. She passed through the labor, the child died, her condition became apparently more favorable; they were waiting for the opportune time, when grave symptoms appeared, followed by her death in half an hour. In the thirty cases I have tabulated, the condition column does not give much encouragement for waiting, but rather the contrary. Many women have, however, in time past escaped all dangers under the false labor, and have even carried the dead foetus for years in compara- tive health; or have had it removed by abdominal or vaginal section, because of some physical disability resulting from it. But such cases rarely fall into the care of a fully competent obstetrician during the labor, and the attendant called in expects the woman to deliver herself, and waits for this event, until too late to save the foetus. A realization of the dangers of ectopic pregnancy has given rise to a desire to arrest the development of the foetus at an early day; and after various plans have been tried, two are still considered worthy of confi- dence, viz., faradization or galvanism, to destroy the foetus; and exsec- tion of the entire cyst to accomplish the same end more effectually. Gynecologists are divided in opinion as to the choice to be made of the two plans, in any given case before rupture, one party claiming that electrical foeticide is not only dangerous as a method in itself, but leaves the foetus in loco to give subsequent trouble; and, at the same time, that extirpating the foetal cyst, generally Fallopian, can be done at a moderate degree of risk, and will leave the woman free from the foreign HARRIS, EXTRAUTERINE PREGNANCY. 9 growth as an element of danger. The electrical advocate states that his method is devoid of danger; that the fcetal mass becomes absorbed ; and that the health of the woman in not endangered by the remnant of the fcetal growth. He, at the same time, also regards the proposition to exsect as one of much greater peril, aud one that may in some instances be attended with insurmountable difficulties. Whichever plan of operation is selected, it is essential that a correct diagnosis should be made, and the character of any discovered abnormal growth decided upon before it is commenced. To make a reliable differ- ential diagnosis in a case of ectopic pregnancy is not a simple matter, and can rarely be done in a few minutes, for not only must every sensible and sympathetic sign be duly weighed, but the history of the case taken and considered in connection therewith. By these means a chain of evidence may be obtained that will show by exclusion how impossible it is that a given intrapelvic growth discovered by palpation can be other than a product of impregnation. To make such a diagnosis is much more the work of an obstetrician than of a surgical student. Mr. Tait cannot believe that this can be done in more than one case out of three; but many obstetrical observers hold a very different opinion, particu- larly in this country, where special studies have been made of many cases prior to rupture. This accident may occur too early to have been preceded by any symptoms to excite attention, as has twice happened in this city, where the ovum could not have been developed beyond three weeks, or between the end of one menstrual epoch and the beginning of the next one. But in the average of cases time enough is given before laceration to produce size of growth for palpation, and symptoms, sensible and sympathetic, now well known as characteristic of ectopic gestation when taken in connection with a history indicative of this condition. Regarding the question of preference from a neutral standpoint, I am prepared to examine the two named foeticidal methods upon their relative merits as thus far exhibited, first stating my belief, that if it is morally proper to exsect the fcetal mass, it is equally so to destroy the foetus in situ. o Two important questions naturally arise, viz.: 1. Which is the more immediately dangerous-electric foeticide, or exsection of the ectopic foetal mass ? 2. Is there any remote danger to be apprehended from the presence of the dead foetus ? These can only be answered by a long array of facts which have not yet been produced. So far as known to me, the electric foeticidal operation has been performed in the United States and Canada forty times, with one death, and in that case a second attack of hemorrhage took place from a large superficial artery in the cyst wall, which vessel had bled nine days before until the patient bore the evidences of it. Exsection of the entire growth was certainly indicated here. Although laparotomy can be performed 10 HARRIS, EXTRAUTERINE PREGNANCY. a great many times in succession without a death, as witness the results of ovariotomy and oophorectomy under some operators: Is it at all likely that this more difficult and complex operation can be undertaken with the same degree of impunity ? If all ectopic foetal cysts w'ere favorably located, and their existence discovered at an early date, no doubt a skilful operator might be able to exsect them with a moderate degree of mortality; but such is not the case, and the knife must be used at times under circumstances of great difficulty and danger. Prof. August Martin, of Berlin, advocates the exsective operation at all periods, and has performed it quite a number of times with marvellous success, even up to seven months of gestation in one case (XXI., of Table). But there are few Prof. Martin's ; and ectopic mishaps will occur in places in which even the average surgical skill cannot be com- manded. Theoretically, there are many reasons for preferring exsection to faradization and galvanism, and I, for one, should be glad to be convinced that the immediate removal of the foetus from the pelvic or abdominal cavity can be accomplished, even in our large cities, or at locations where skill can be commanded, with but a trifling degree of danger. The second question can only be answered by a collective record of the subsequent medical histories of the forty-five or fifty women in whom electric-killed foetuses have become foreign bodies, to be the pro- ducers of much, little or no disturbance. That a very young foetus is capable of being almost entirely absorbed, after it has been destroyed by electricity, appears probable from careful explorations and from ex- periments on the lower animals; but what are the capabilities for pro ducing injury of a dead foetus of three or four months' development? Steps will be taken by a competent investigator for ascertaining the secondary dangers experienced and present degree of health exhibited by the women in whom electrical foeticide has been performed. It may be urged that proof of the existence of a fatal growth has not been well established in many cases; but this is a question of doubt, which simply brings in dispute the ability of a number of well-known American ob- stetricians and gynecological practitioners to make a differential diag- nosis, which they claim they can do. Many who have questioned this ability are, at the same time, advocates of the early exsective opera- tion. Do they propose to operate upon a conjectural diagnosis, and determine the true nature of the growth by its examination after re- moval ? It is quite possible for an abdominal surgeon of large experi- ence to have had his attention very little directed to cases of ectopic gestation prior to rupture, and to the signs which indicate such a condi- tion to the obstetrical observer: Is he wise in disputing the ability of men, who, by a special study and larger field of observation, claim to be able to do what he feels that he cannot ? Tactile sense is of great HARRIS, EXTRAUTERINE PREGNANCY. 11 value in abdominal surgery, but of itself is of little use in determining a growth to be of foetal origin. Electricity and exsection are both on trial, the former in the advance from the number of tests. It has superseded the more dangerous ex- pedients of aspiration and toxic injection, and has now only the new rival of exsection, which promises to be fully tried in the near future. We are satisfied that electricity will kill the foetus; that when dead it will diminish in size, and the fluid in the cyst be absorbed; but here we stop for the present until the subsequent history of the cases has been looked up and reported. Thus far the innocence of the exsective operation is largely hypo- thetical except as to the cases of Martin and Veit, of Berlin.1 We have in this country a number of bold abdominal operators, chiefly young men, who strongly advocate exsection, and who I hope will be able to prove by actual results the claims they have made for this in- viting substitute : inviting, because it at once eradicates what electricity only destroys and retains, it may be to give trouble at a later day. The earlier exsection is attempted, the more easy it is to perform ; but when adhesions begin to form the difficulties of removal commence, and these grow and increase more and more with every additional month of development. In the later cases the abdomen must be largely incised ; its cavity should be illuminated by an electric light; no parts should be peeled off or adhesions separated by the fingers; bloodvessels and vascular parts are to be tied and then cut step by step until the placenta is slowly separated. The cyst may not require such care in removal, as its adhesions may be the result of circumscribed peritonitis; but there are cases in which the cyst and its connections will be found dangerously vascular, and only to be treated as the placenta requires. The whole mass must be removed, or secondary hemorrhage will almost certainly ensue with a fatal result. Until the abdomen is opened the operator can form only a conjectural idea of the difficulties he may have to encounter, if the foetus is advanced to or beyond the fourth month, as everything will depend upon the location and vascular connections of the placenta. In the later months the operation will be little less difficult than when the foetus is at full maturity, and it may become a question whether two lives cannot be saved by waiting until the foetus is fully viable. Much will depend upon the condition of the woman, who may not be in a state of health to wait; in which event the operation should be performed at once, and the exsection made as entire as practicable. As the electrical advocates do not recommend their system for cases after the fourth month, exsection must be the rule, and the time of choice that which promises most favorably. 1 Veit has operated seven times prior to rupture, and saved all of the cases. It will be of interest to know what symptoms indicated the necessity for the operations, and whether he was able to make satisfactory diagnoses before opening the abdomen. 12 HARRIS, EXTRAUTERINE PREGNANCY. Thus far I have directed attention to exsection by abdominal incision only ; but it may not always be advisable to operate in this way, for the reason that nature may point to the vagina as a more eligible outlet. If the foetus presents by the head, behind or at the side of the cervix, and the covering parts are distended over it, this may be taken as an indica- tion that delivery should be accomplished by vaginal incision, and, if far advanced, by the forceps. I have in my possession a record also of thirty vaginal deliveries, in only two of which was the foetus living and viable, and in both instances the child and mother were saved.1 These thirty cases include five in which rupture into the vagina had taken place, and ten in which the foetus had been carried from eleven months to twelve years. Of the whole thirty women, twenty recovered. Six were operated upon at full term, four of the foetuses being dead, and five of the women, with the two living children already mentioned, were saved. In the two operations of Drs. King and Mathieson, in which the women and children were saved, the placenta was peeled off and removed without serious hemorrhage, a solution of perchloride of iron being applied as a styptic in the latter ; but an attempt to do the same, in a pregnancy of about three and one-half months, by Prof. T. Gaillard Thomas, of New York, placed the life of the woman in great jeopardy, and he was forced to desist.2 Two forms of ectopic gestation appear distinguishable in these cases, viz., the subperitoneal of Dezeimeris, to which the King and Mathieson cases are believed to have belonged and the intraperitoneal, also origin- ally tubal, but developing within the pelvic peritoneum and upward in the abdominal cavity. In the latter variety there may or may not be an enveloping foetal cyst. In a case operated upon in this city by the late Dr. Albert II. Smith,3 the intestines were united to produce a form of sac, which broke open at the top, and the foetus, which had escaped, was found beneath the transverse colon; the result was fatal. In another Philadelphia case, in which the foetus was dead and weighed ten pounds, and the woman was doing well for a week, a mild antiseptic wash was used (as the discharges were slightly fetid), which entered the peritoneal cavity through an open cyst and produced violent peritonitis, resulting in rapid death, The possibility of the cyst being imperfect should oblige an operator to use only warm distilled water for intra- abdominal irrigation in these cases. The vagina should be opened by puncture and tearing to avoid the risk of hemorrhage, or by the thermo-cautery knife, except in cases in which it has become much thinned by continued pressure, when it may 1 New York Repository, 1817, pp. 388-394. Transactions Obstetrical Society, London, vol. xxvi., for 1884, pp. 561-569. 2 New York Medical Journal, 1875, pp. 561-569. 3 American Journal of Obstetrics, 1878, vol. xi. p. 825. HARRIS, EXTRAUTERINE PREGNANCY. 13 be incised. As this form of operation will not admit of the sub- ligation and exsection of the placenta for the want of space and light, it will be wiser to wait until spontaneous separation takes place. The primitive operation of exsection by abdominal incision, as per- formed with such success by Dr. J. Veit, of Berlin, must take precedence of that made suddenly necessary by the bursting of the cyst, as intro- duced by Mr. Tait; for the reason that the performance of the first will prevent the possibility of an accident, which often produces death before an operation for the arrest of the hemorrhage can be performed. The contest between exsection and electricity in cases of ectopic pregnancy of two months or ten weeks standing, will in all probability end largely in favor of the former. It has become a popular measure in Germany, where the other has never met with any favor, and it may eventually be regarded as a promising method of treatment in the United States. The question of relative fatality no doubt favors the side of electricity; but there are other points to be considered, which may in a measure outweigh the danger of a fatal issue, if in the future this degree of risk be shown, as the result of a series of cases, to be of moderate measure. The antagonism between very early exsection and the use of electricity must in time diminish, as there must be circumstances which will lead unprejudiced operators to select one or the other method in a given case. Men of surgical inclinations will no doubt prefer the knife to electricity, and vice versa. The question of the possibility of diagnosis, claimed as non-proven by the results of electricity, will be settled beyond peradven- ture when the knife and the eye are brought to bear in establishing evidence. 329 South Twelfth St., Philadelphia. THE MONTHLY PUBLICATION OF The American Journal of the JVJedical 0cience£. Subscription Rate Reduced to $4.00 per Annum. T T(J\ITH the issue for January, 1888, The American Journal of the Medical Sciences \kj began the cultivation of the larger field of usefulness which awaited its change from a Quarterly to a Monthly. For sixty-seven years it has developed with American Medi- cine, until to-day both are honored wherever medical science is esteemed. The progressive spirit of the age is, however, no longer to be satisfied with the less frequent means of communication, and consistently with itself, The American Journal has recognized the fact by a trebled frequency of publication. 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