Werth, a pupil of Litzmann, has collected seven additional cases, in one of which only (A. Martin) the mother's life was saved. For this reason, and because the results of laparotomy are far better after the foetus is dead, Werth objected at the Copenhagen Congress of 1884 to any operation being undertaken for the purpose of saving the infant's life, and argued that we should rather await its death.
We ourselves think that since the life of mother and child have been saved, the operation is a proper one, and our efforts should be directed to improving the method of operation. Judging by the post-mortem findings in our own case, laparotomy and extirpation of the sac with the placenta would not have been difficult to accomplish.
As to the time of operation, Kiwisch long ago noticed the danger of waiting for expulsive pains, and no time should be so lost. We ourselves have seen the beginning of the pains mark the turning-point in the woman's fate; and we hold that operative interference should take place as soon as the end of the pregnancy appears to have been reached.
Our choice of operation depends upon the situation of the sac. In most advanced cases the greater part of the foetus is above the pelvic brim; an abdominal incision is the most suitable procedure.
Laparotomy.—This operation is to be performed entirely according to the rules of ovariotomy. The Linea alba marks the line of incision. The chief danger of the operation while the child is alive lies, as Litzmann has shown, in the relations of the placenta and the placental circulation. If the placenta is attached to the anterior sac wall, and we can hardly ascer tain that until we have made the incision, a very serious hemorrhage will inevitably occur. In fact most of the cases operated upon have perished from this cause. We must either avoid this hemorrhage, or control it. And nowadays, when much greater technical difficulties in operations upon abdominal tumors and organs have been overcome, it is to be hoped that we will succeed in this also. We might puncture the ovum in another place, quickly enlarge the foetal sac, and extract the child, after passing an elastic ligature around the placenta; or perhaps by enlarging the abdominal incision we might be able to open the sac at some other place; or we might after puncture push the placental vessels to one side, put an elastic ligature around them, open the sac, extract the child, and extirpate the whole membranous bag Already the entire sac has been extirpated successfully after the child has died and the placental circula tion has ceased, by Litzmann, Biliroth, Knowsley Thornton, and Schroder; and by many of these authorities the removal of the entire sac with the living child is regarded as a not entirely unfeasible operation.
If the placenta is implanted at the lumina or the opposite wall of the fatal sac, as is most often the case, the technical difficulties are far less. Those cases in which the sac is so adherent to the anterior abdominal wall that the peritoneal cavity is not opened, are naturally the most favorable. It would probably then be correct to leave the sac undisturbed after extraction, tying the cord near the placental insertion, and treating the cavity as an abscess, close the upper part with sutures and put a drainage tube in its inferior angle. Schroder recommends vaginal drainage when ever the site of the placenta will permit it. If portions of the sac are not adherent to the abdominal wall it may be necessary, if entire extirpation is not accomplished, to suture the edges of the fragments into the abdominal wound. A. Martin once successfully closed the remaining portion of the sac with sutures after putting a drainage tube in the abdomen. W. A. Freund has recommended that the sac be filled with equal parts of tannin and salicylic acid so as to keep the placenta aseptic until it is cast off.
A. Ramsbotham told us long ago that no attempt should be made to re move the placenta. There is no contractile force in the tissue to which it is attached, and any such act will be followed by an alarming hemor rhage. A. Martin has once succeeded in surrounding the seat of inser tion of the placenta with a ligature, and controlling the hemorrhage.
Subsequent to the operation we must take great care that no injurious secretions are allowed to collect, and that purulent remains of the embryo find free outlet through the abdominal wound. We will often have puru lent collections, especially in Douglas's If possible they should be evacuated by puncture or incision.