Most women die a few hours or a few days after this occurs, and even if they survive the first hemorrhage, they succumb to the subsequent peritonitis. We must therefore make every effort to recognize the affec tion as early as possible, and begin appropriate therapeutic measures.
Laparotomy while the Fetal Sac i8 diagnosis positively made before rupture, we have the choice of two modes of procedure: We may open the abdominal cavity and treat the extra-uterine ovum exactly according to the rules of ovariotomy; and there is no reason why we should not attain as good results as in that operation. Since, how ever, it is often impossible to decide upon the exact seat of an extra uterine pregnancy, we might happen upon an interstitially located ovum, and have difficulties in the treatment of the pedicle. But similar and still greater difficulties occur in the treatment of large uterine fibromata, and are overcome; and they certainly can be overcome in these cases also.
But we will only rarely have occasion to do this operation in the early stages, before rupture has occurred. For not only is the diagnosis very difficult, but the women believe themselves pregnant in the ordinary way, and have no occasion to seek medical aid.
But sometimes the symptoms are so different that the physician has occasion to see the patient, and make the diagnosis; and for these cases the best and most rational operation is laparotomy and treatment of the sac according to the rules of ovariotomy and myomotomy. Judging by the anatomical preparations before us, most cases being tubal, the operation should be an easy one at an early period; thus the cases shown in Figs. 9 and 10 could have been removed with a few ligatures, and the lives of the women saved.
J. Veit has demonstrated the possibility of diagnosis and cure of tubal pregnancy at an early date. On February 22, 1884, he showed to the Obstetrical and Gynecological Society of Berlin a tubal pregnancy of three months duration, where he had performed laparotomy and easily removed the sac. The fwtus made repeated attempts at inspiration when its skin was irritated. On May 23, 1884, he showed a second tubal sac removed during life in the same way. Both women recovered easily. Lawson Tait, according to J. Veit, has only lost one out of seven early cases thus operated upon. In the discussion which followed, C. Schroder also pronounced himself in favor of an early operation in tubal preg nancy.
Laparotomg after Rupture of the most cases the rupture occurs suddenly and without warning; only after it has occurred is the physician called, and but too often does he stand at the bedside doubtful and hesitating. Compression of the aorta, which has been recommended, requires considerable muscular strength, and the presence of not too thick abdominal walls; the coagula are disturbed when the hands are changed as they must be, and the method is of but doubtful value. For the symptoms of internal hemorrhage we can only use the usual remedy, cold abdominal applications, clysters of ice-water, the introduction of small pieces of ice into the vagina, rest, wine, a few drops of oil of cinna mon and other stimulants. From the deep seat and sizo of the ruptured
vessels it is difficult to conceive that cold exercises any influence upon the hemorrhage. The application of Esmarch's bandage to the extremities is also of doubtful value, since the more the blood is squeezed out of the extremities, the greater appears to be the hemorrhage from the ruptured vessels.
We agree with Kiwisch in the opinion that, since death can hardly be averted in any other way, it is proper to open the abdominal cavity and stop the hemorrhage directly.
For we have ourselves seen a man with a tubal sac which ruptured at the second month (Fig. 9), live four hours after laparotomy was first proposed, and in most of these cases death only occurs five or more hours after rupture.
This proposal of Kiwisch's was made at a time when the results of ovariotomy were by no means so favorable as they are to-day; and we can certainly remove from the peritoneal cavity such dangerous contents as blood, liquor amnii and fragments of tissue.
As to the manner of procedure we cannot do better than to reproduce Kiwisch's exact words: " In the first place the abdominal cavity must be freely opened (six to eight inches) with the usual precautions along the Linea alba. The peritoneal incision might at first be made only a few lines in length, and by the introduction of a warm sound and careful pressure, a certainty of the presence of blood in the peritoneal cavity be obtained. If there is blood, the opening should be completed, and the pelvic contents made thoroughly accessible. Next we must find the bleeding point. The hand is to be introduced into the abdomen, and the uterus lifted up, and, if it is not itself the seat of an interstitial preg nancy, its appendages are to be carefully followed out on the side of the tumor. It may be necessary first to remove the effused blood. The rupture discovered, the ovum or its remains are to be at once extracted. If the ovum is already in the abdominal cavity, its removal may be deferred till later. In accordance with the structure of the seat of hem orrhage the bleeding point must be seized with a forceps and wholly or in part tied with long ligatures, or, if the edges of the wound need it, they must be united by a fine needle and moderately thick silk. If, as will most often probably be the case, this does not suffice to check the hemor rhage, we might in tubal cases extirpate the entire sac, using the same procedure as the ovariotomists do. After hemorrhage has entirely ceased we can proceed to thoroughly remove the effused blood by means of fine warmed sponges, and then replace the intestines and close the abdominal wound, passing the ends of the ligature out through it." There is but little to add to these regulations of Kiwisch's. As in the modern ovariotomy operation, we will cut the ligatures off short and guard the woman against septic infection by the well-known precautions. The difficulty in the diagnosis and the fact that other affections, especially bwmatocele, often have very much the same symptoms of internal hemor rhage, will limit the applicability of the operation.