Kolpotomy cases are known in which both mother and child have been saved after vaginal opening of the sac. Campbell remarks that the results therefrom are much more favorable to the mother than those of gastrotomy. In nine cases three were success fnl, both as regards mother and child; in two the mother only was saved; in one the child alone survived; and the three others terminated fatally for both mother and child.
Sometimes in advanced extra-uterine gestation a large segment of the ovum occupies the pelvic cavity, the head or buttock of the child de presses, softens, and thins out of the posterior vaginal vault, as in normal pregnancy. It is then probable that the festal sac is largely adherent to the walls of Douglas's pouch. Is it not proper in these unusual cases, to deliver by head or feet, after a vaginal incision ? Gaillard Thomas reported on April 15th, 1884, to the New York Gynecological Society, that he found this condition of things three times in thirty cases; and he incised, and extracted the foetal head with the forceps successfully. Thomas showed that if, as in case 17, pains set in and no artificial aid was rendered, the foetus always died.
_ In the opposite case, however, when the sac lies high up, we cannot counsel an opening through the vaginal vault; the adhesions are liable to be ruptured, and hemorrhage into the peritoneal cavity occur. Laparot omy is therefore preferable.
We have ourselves observed a case which seemed very favorable for kolpotomy. In Fig. 17 is a schematic drawing of it, and we append a short history.
A woman twenty-nine years old was admitted October 7th, 1874. Had had two children normally, the last seven years ago. Seven months ago the menses ceased for two months, returned once, and then disappeared permanently. She was often sick during these seven months, pains, fever, swelling of the abdomen, and latterly constipation and inability to pass water troubling her. Two months ago she first felt life, and on October 18th we first heard heart sounds. The pelvis was filled with an indefinite fluctuating tumor, the lower border of which, pressing down wards before it the posterior cervical lip and the vaginal septum, could be felt between the tuberosities of the ischia. The upper border of the tumor reached to the navel. The uterus was displaced forwards and up wards, and could be distinctly felt through the abdominal walls. The
anterior lip of the os uteri was opposite the middle of the symphysis; while the posterior lip could be felt below the tubera ischii, as a small prominent fold. In this way the posterior uterine wall measured 9.2 inches. On the afternoon of the 28th of October, violent pains appeared at times, and by the 30th they had assumed regular " bearing-down" features, while a bloody and mucous fluid flowed from the uterus.
The pains increased, and became unbearable. Peritonitic symptoms with increasing meteorism set in. The dilated intestines had by Novem ber 5th so displaced the fetal sac and the posterior cervical and vaginal wall, that the tumor could be seen by separating the labia, while the cervical and vaginal walls were so thin that a finger could easily have been passed through them. With an ordinary pair of scissors the poste rior cervical and vaginal wall was split for four inches; the fcetus, weigh ing seventy-four ounces, was in the second transverse position; it was turned and extracted. At the same time the placenta and the greater portion of the membranes were removed, there being much hemorrhage. A drainage tube was placed in the wound, and one also into an opening made into the sac above the bladder; and the cavity was washed out with lukewarm water. The woman rallied, and felt fairly well next day; but her temperature soon rose, and she died upon the evening of the 7th.
Post the epigastric abdominal region is a dirty, brown fluid exudate. Between the uterus and the posterior abdominal wall is a cavity the size of a man's head, bounded above by adherent intestines, omentum and abdominal wall, and below by Douglas's Its inner surface was covered with a dirty, bloody exudation, and at the left and anteriorly, showing the placental site, were large open veins.
The walls of the enlarged uterus measured four-fifths of an inch; its anterior wall was 4.8 and its posterior wall 6.4 inches long. The ante rior neck of the cervix was two inches long, and showed the changes usual in this condition. The neck posteriorly was 4.2 inches long, and showed the incision 3.2 inches in length. The body and the upper part of the cervix contained decomposing remains of the decidua.