Attempts have already been made, however, to save a woman's life under these desperate circumstances. Bozeman reported to the Medical Society of New York on November 19, 1884, a case in which the symp toms of internal hemorrhage leading him to suspect the rupture of the sac of a tubal pregnancy, he quickly did a laparotomy, and extirpated the right ruptured tube. But he did not succeed in averting death. On May 8, 1885, C. Schroder presented a specimen to the Berlin Obstetrical and Gynecological Society where he did the same operation after the rupture of an extra-uterine sac at the third month. Fa tus and placenta lay in Douglas's oil-de-sac. The right uterine appendages, which were the seat of the ovum, and to which were adherent the omentum and the mesentery of the small intestine, were extirpated. The patient was very anaemic, and an unfavorable result was to be anticipated.
Our second method is to prevent the development of the ovum by puncturing the sac and evacuating the liquor amnii, or by injecting agents to destroy the foetus, or by electricity.
Puncture of the Fetal Sac.
Baudelocque and Querin proposed vaginal puncture, and Delisee and Kiner in 1818 carried it out. (J. Baart de la Faille.) Kiwisch gives the credit of first proposing it to Basedow, and recommends that while the abdominal walls are gently pressed downwards from without, the sac is to be punctured from the deepest place in the posterior vaginal wall with a long, curved trocar, and the liquor amnii evacuated.
Since that time the operation has been successfully performed several times. Greenhalgh has punctured at the beginning of the fourth month, and E. Martin at the fifth month through Douglas's cul-de-sac. In the latter case the foetal bones were subsequently expelled per rectum. In Martin's second case, which was first seen at the end of the third month, the spindle-shaped tumor of the left tube was punctured in the same way through the posterior vaginal wall; and Stolz and lioberle have success fully done it also.
There have been, however, unfortunate cases, and several observers of large experience warn us against puncture of the sac. The patients of Simpson and Braxton Hicks died, and so did a woman whose case we observed ourselves, and in which Carl v. Braun did the operation.
I admitted a woman thirty-eight years old to the clinic on June 20, 1871, with the suspicion that she was suffering from extra-uterine preg nancy. Three years previously she had had one normal birth; and on the 28th of February last she had last menstruated. About the middle
of April she began to bleed, and this had continued to the present time with but short intervals. There had lately been considerable pain, for which morphine injections had been used. The pelvis was at first filled with an elastic painful tumor, the upper border of which could be dis tinctly felt above the pelvic inlet. During the seven weeks for which we observed the growth of the tumor, the uterus was crowded more and more upwards and to the front, so that finally the vaginal portion was 1 of an inch above the pubic arch. The cervix was voluminous, soft, and open; the finger could be passed 1+ inches above the external os. The upper periphery of the tumor was now midway between symphysis and navel; the uterus could be both felt and seen through the abdominal walls. There was occasionally a little blood. The uterus, now sounded, was found to measure 4.4 inches. August 10th I obtained ballottement, and a few days later was able to hear the fcetal heart sounds; but the woman could feel no life.
The sac was punctured August 15, and over two pints of liquor amnii were evacuated through Douglas's cul-de-sac. The next day the woman had violent bearing-down pains, during which we could distinctly feel the uterus becoming harder and softer through the abdominal walls. Four days later there was fever and slight meteorism; on the 21st and 22nd chills with temperatures of 101° and 102°. The pains eventually became so bad that injections of morphine up to the 31st were required twice daily. The patients died with all the symptoms of peritonitis on Sep tember 7th. The autopsy revealed peritonitis; uterus empty, six inches in size; in the cavum recto-uterinum was a fcetal sac the size of a man's head, and covered with pseudo-membranes, which was adherent to the left tube and the atrophied ovary on either side. It contained a mace rated foetus of 5+ months.
Gaillard-Thomas, who has seen thirty cases of extra-uterine pregnancy, warns us not to puncture the sac; he has lost three women, he says, in whom he allowed himself to be persuaded to do the operation.
So that we cannot to-day recommend puncture of the sac. Rennert has shown that in some cases there occurs detachment of the placenta and hemorrhage into the fcetal sac; and the history of early laparotomy is already such as to lead us to prefer it to the operation in question.