In the cases in which we consider the vaginal incision appropriate, there is no difficulty in carrying it out. The uterus is pressed forwards and upwards, the vaginal vault and cervix are depressed and thinner, and can be cut without danger of injuring other parts with scissors or bistoury. The hand can then be passed through the wound into the cavity of the ovum, and the child extracted by the feet. If the head sticks, we may, following Kiwisch and Gaillard Thomas, apply the forceps. The cord is then to be tied level with the surface of the wound with a disinfected thread, and iodoform gauze stuffed into the vagina and wound. Naturally no attempt is to be made to remove the placenta, only those membranes and shreds of tissue which appear at the level of the wound are to be taken away. A few days later we may try by gentle traction whether we cannot remove the placenta without special hemorrhage.
Under these circumstances the peritoneal cavity is usually not opened by the operation, on account of the multiple adhesions of the sac. If no attempt is made to remove the placenta the women will lose but little blood. The large incision permits the free outflow of discharges, and everything is in the most favorable condition for healing. If the secre tions begin to smell, and fever appears, we should freely inject disinfect ing fluids, or apply drainage if necessary.
c. After the Death of the Foetus.
If the foetus dies before or after it is viable, the symptoms may be various.
In the minority of cases there is more or less illness, and, usually with the symptoms of a circumscribed peritonitis, the foetus becomes encapsu lated. All authorities from Kiwisch down are of the opinion that under these circumstances operative interference is not allowable, since many women enjoy perfect good health after encapsulation, conceive repeatedly, and even have normal deliveries. Even Gaillard Thomas now (April, 1884) agrees with us. But most often Nature does not succeed in encap sulating the fcetus, and in her endeavors to eliminate it, more or less dan gerous processes occur. There is constant suppuration, and the life of the woman is continually in the gravest danger. The pus may point in the vagina and rectum, or perforate these cavities, but Nature only rarely succeeds in eliminating all the foreign matter unaided.
The danger is greater the larger and more fully developed the dead fcetus is. Latterly there have been objections made to the expectant mode of treatment, but all authorities agree that operation is to be post poned until we are certain that the placental circulation has stopped. Litzmann places the proper time at five to six months after death, while Werth would operate in ten to twelve weeks. Schroder, who is inclined to favor active measures, has seen a smart hemorrhage from the placental site nine weeks after the death of the fcetus.
For not only are the dangers of the operation far less when the pla cental circulation hag ceased, but, as Litzmann and Werth have proven, they are just as great before that time as they were during foetal life. Litzmann has collected thirty-three cases from original sources, in which laparotomy was done a longer or shorter time after the death of the fcetus. The very important faot was clearly brought out, that, in the first ten of these cases, in which the operation was done eight days to five weeks after the death of the fcetus, the placental circulation bad not stopped, and violent hemorrhage occurred during the operation, or during the gradual detachment of the placenta; eight of these ten women died. In the re maining 23 cases laparotomy was done six weeks to one year after the death of the fcetus, six of these 23 women died. Werth collected 25 similar
eases, and eight of them died.
According to the relation of the sac the operation will resemble now an easy and now a difficult ovariotomy. It will always be better, when possible, to extirpate the entire foetal sac, as has several times been done successfully. Schrtider is of the opinion that it will more often succeed than we now believe.
If the sac is adherent to the anterior abdominal wall, and if total ex tirpation is inadvisable or impossible on account of extensive adhesions with neighboring parts, it would seem to be proper to open the sac under 7 strict antiseptic precautions and provide for thorough drainage. If after the abdominal incision we find that the sac is not attached to the anterior bladder wall, we can, according to Schroder, adopt Volkmann's method of dealing with echinococcus cysts; the abdominal wound is filled with salicylated cotton, and the sac is opened at a later time, when adhesion with the abdominal wall has occurred.
If the case only comes under observation when Nature has already begun the elimination of the foetus, we must encourage the process with all the surgical means at our disposal. If pus or the foetus depresses the vaginal vault, it may be proper to do a kolpotomy; if nature shows signs of an attempt to eliminate the foetus per rectum, it may be right to assist extraction in that way; or we may endeavor to keep open sinuses, or even dilate them, and extract the foetus wholly or piecemeal ourselves. It has often been possible by enlarging the point of rupture in the anterior ab dominal wall to extract a well-preserved or a macerated child or bony parts. In the same way foetal bones have been extracted from the vagina, the rectum, and more rarely the bladder. The longer these natural efforts at elimination last the more adhesions are there of the sac; and the open ing of the abdominal cavity is not much to be feared in later operative procedures.
The results of cases operated upon late are very favorable. Accord ing to Parry, in cases in which perforation was imminent, or had already occurred, only three women out of thirty-two died.
Past experience shows us that we need not fear active operative inter ference in these cases; and it is to be recommended that incision of the abdominal walls or the vagina, or the enlargement of fistulous tracts, be not shrunk from when nature points out the road of elimination. The suppurating sac left after total or partial extraction of the foetus is to be treated as an ordinary abscess cavity.
d. In- Pregnancy in a Rudimentary Cornu of the Uterus.
Since out of thirty of these cases twenty-three ended fatally in rupture during the first six months, laparotomy is certainly indicated just as soon as a diagnosis has been made. For the rest the rules are those laid down for extra-uterine pregnancy. Judging from the specimens in the museums, the operation will usually be an easy one (see Fig. 14). In cases of ad vanced pregnancy the operation has been done four times according to. Sanger.
These cases are: 1. 1865, by Koberle: Gastrotomy or Caesarean section, twenty-one months after death of foetus. Adhesion of the rudimentary cornu to the anterior abdominal wall; cure. 2. 1880, by Salin: Diagno sis only during operation. Removal of supernumary cornu after Porro; cure. The woman conceived again. 3. 1881, Litzmann-Werth: Woman septic at time of operation; Porro, death. 4. Sanger: Diagnosis before operation. Twenty-one years old; III-para, operation nine weeks after death of seven months foetus. Removal of cornu without rupture; sym peritoneal suture. Cure without reaction in twenty-two days. The woman bore children twice afterwards.