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had been my intention, after removing entire all the bones possible per rectum through the accidental opening, to crush the remaining larger ones, the tables of the cranium, and so effect their extraction.
I desire to call the attention of the Association to the following points, and to ask for their discussion:
1. Do experience and theory justify the conclusion that extra-uterine pregnancy of the tubal variety, continuing until full term, is rare?
2. What surgical interference would have been advisable in this case, both with and without the light revealed by the autopsy?
I here present for inspection by the Association the fætal bones as removed both ante mortem and post mortem, and, if acceptable, shall place them, together with the sac and parts adjacent, as removed from the body, in the museum of the New York Woman's Hospital.
DR. I. E. TAYLOR, of New York County, referred to a case which occurred in Bellevue Hospital, the patient being eight and a half months advanced in pregnancy. He was sent for, as she had “ fainted,” but she died just as he arrived. Post-mortem examination showed tubal pregnancy, eight and a half months advanced, and death had taken place from hæmorrhage proceeding from a vessel of the Fallopian tube. The specimen was placed in the Wood Museum. He said that the literature of the subject shows that cases advanced to that stage are very rare.
EXTRA-UTERINE PREGNANCY, WITH AN ACCOUNT OF TWO CASES AND THEIR
By NATHAN BOZEMAN, M. D., of New York County.
Read November 19, 1884.
I THINK I am safe in saying that it has been only by the closest and most careful study of the diagnosis of some of the graver diseases of women, that surgeons have been enabled to surmount the difficulties of treatment and to give to the department of gynæcology those brilliant practical results in which our own country claims so large a share. This fact finds illustration in the advances made in the study of uterine and ovarian tumors, of the various injuries incident to parturition and their complications, and, more recently, of the necessities of prompt laparotomy in connection with tubal pregnancy. The manner in which this high aim of scientific thought has been carried out and the results thereof utilized in the several lines of investigation indicated, it is not my purpose on the present occasion to discuss. I propose simply to speak of the dangers of extrauterine pregnancy, its treatment, and the importance of early and accurate diagnosis in this condition, as illustrated by two interesting cases of this abnormity, which have recently come under my observation. .
The dangers of extra-uterine pregnancy dependent upon anatomical conditions, resolve themselves, practically, into, first, the immediate, and, second, the remote. The immediate dangers are those arising, within the earlier months of pregnancy,
from the lodgment and growth of the impregnated ovum in some portion of one or the other of the Fallopian tubes, the dangers of the lodgment always decreasing in the ratio of its approximation to the abdominal extremity. The remote dangers are those pertaining to the impregnated ovum, as regards its growth and development, possibly to full term, in its relationship with the ovary alone, with the ovary and fimbriated extremity of the Fallopian tube jointly, or with some point in the peritoneal cavity, whether before or after the death of the fætus, or in connection with normal pregnancy as a complication.
With regard to the study of the diagnosis of tubal pregnancy and the immediate dangers arising from rupture of the cyst and the resulting hæmorrhage, I feel warranted in stating that a more important and practical impulse was given the subject in 1867 than at any time before, by the late Dr. Stephen Rogers, of this city (" Transactions of the American Medical Association "); and, for the deductions then made as to the proper kind of treatment, science is certainly under lasting obligations to him.
It is true that Dr. Rogers contributed no astounding record of successful clinical results from his careful study and observations in connection with the subject; but what he did leave as a precious heritage to us, was his earnest conviction that the immediate dangers above indicated should always be met and combated by a prompt resort to the operation of laparotomy and the controlling of hæmorrhage wherever found in the abdominal cavity, a principle of practice which has been fully recognized and appreciated only within the last year or two.
I confess it was the close study of the diagnosis as found embodied in his able memoir that first imbued my mind with the importance of the subject and determined me to make an application of the teachings therein inculcated, whenever an occasion offered.
Notwithstanding the great strides that have been made in gynæcology since the date of Dr. Rogers's publication, comparatively little has as yet been accomplished toward placing the important principle of practice enunciated by him upon a
sound basis and disarming tubal pregnancy of the terrors that have so long surrounded it.
To Mr. Lawson Tait, of England, more than to any surgeon in any country, we are indebted for successful clinical results, which not only stamp the procedure with a value never dreamed of by Dr. Rogers, but at once place it in the foremost rank as regards practical availability and usefulness. In an article entitled “Five Cases of Extra-uterine Pregnancy operated upon at the Time of Rupture” (“British Medical Journal,” June 28, 1884) he says: “I desire to place on record this, the first series, as I believe, of cases of extra-uterine pregnancy operated upon at the time of rupture—that is, from the tenth to the thirteenth week.” After speaking of the difficulty of diagnosis and the doubts arising therefrom as to the propriety of operative interference in this class of cases, he further says: “If, however, it be found that the patient has been eight weeks or more without a period, that there is a pelvic inass fixing the uterus and on one side of it, and that sudden and severe symptoms of pelvic trouble come on, the rupture of a tubal pregnancy may be at once suspected, and if an operation is to be done, and it clearly ought to be done, it must be done without delay.” In conclusion, in speaking of the pathology and of the results obtained by him, he says: “These cases all confirm the view of the pathology of extra-uterine pregnancy which I advanced many years ago, that in origin it is always tubal, and that its varieties depend merely on the direction in which rupture occurs. These results also confirm the soundness of the policy of interfering early in such cases, for four cases out of the five have been easily and completely cured of one of the most formidable conditions of pregnancy."
Nearly a year ago Dr. Charles K. Briddon, of this city, recorded (“ Annals of Anatomy and Surgery" for Dec., 1883) a most interesting case of tubal pregnancy, in which rupture of the cyst occurred in the eighth week, and he was called upon to operate (Oct. 29, 1883), under circumstances truly appalling, on account of the suddenness and profuseness of the hæmorrhage. He says: “Part of the ovum, one inch and a quarter
in diameter, was found protruding from a rent in the left Fallopian tube close to its uterine extremity.” The patient, a young and healthy woman, died at the end of forty-seven hours. So far as I know, this was the first operation of the kind performed in this country.
Strange to say, it was only two or three weeks after reading Mr. Tait's article, that I was called upon (August 21, 1884) to operate in my first case of tubal pregnancy, after an experience in the profession of more than a third of a century. This case, and another of abdominal pregnancy, to which I was called in consultation only a month later, form the basis of this communication.
I shall not here point out particularly the line of practice by which the remote dangers of abdominal pregnancy are to be met. Dr. T. G. Thomas and other writers have already brought this part of the subject prominently before the profession and have shown excellent clinical results.
The next question relates to the prevention of the immediate dangers of extra-uterine pregnancy by the employment of electricity. This principle was first applied by Bachetti, of Italy, in 1852, by Braxton Hicks, of England, in 1866, and, in our own country, by Joshua B. Allen, of Philadelphia, in 1869. (See an article entitled “Electricity in Extra-uterine Pregnancy,” by Henry J. Garrigues, A. M., M. D., “Trans. of the Am. Gynæcological Society,” 1882, p. 184.) The practice has for its object the early destruction of the life of the growing fætus, and, consequently, the prevention of rupture of the tubecyst. The proposal of such a method of treatment and the almost universal satisfaction that has attended its employment up to the present time must be regarded as the strongest evidence that could possibly be offered of the close study of the subject and of the great value of the principle. It is to be clearly seen, from the acknowledged success attending the employment of the principle, especially in tubal pregnancy, that, in skillful hands, it will at no distant day supersede entirely the plan of quietly trusting to luck, by which so many valuable lives have been sacrificed. But the difficulties surrounding this practice,