EXTRA-UTERINE PREGNANCY.
The treatment of extra-uterine pregnancy may be summed up in one word—operation. The only question is when and how, and in settling this question the precise stage in development which the pregnancy has reached must be taken into account.
r.U nrubtured Tubal condition is rarely diagnosed, mainly because there are no symptoms which would lead the patient to suppose that she is not normally pregnant, and should seek advice. When it is diagnosed the removal of the pregnant tube either by the abdominal or vaginal route should be urged without delay, as there is the ever-present risk of rupture taking place with a fatal result from hmmorrhage.
2. Intratitbal Rupture of the Ovisac, with Death of the Ovum.--This condition may be diagnosed when the patient gives the history of 6 to 8 weeks' amenorrhoea, followed by pain in the affected side, possibly accompanied by some collapse, and followed by the characteristic brownish shreddy vaginal discharge. The further course of the case may be in one of the following ways: The ovum may be expelled from the tube completely and the bleeding may cease, leaving the ovum with a few clots in Douglas's pouch to be absorbed. This is a rare result, and cannot be diagnosed with certainty.
It is much the wisest plan to inspect the tube through the abdomen or vagina, to remove it if still bleeding, and to dear out all clots.
The ovum may be expelled from the tube, or may be retained in the tube in whole or in part and the bleeding mar continue, the effused blood oozing through the abdominal ostium of the tube and accumulating in the pelvis, forming a pc/eic haPpiatoce/e, walled in by a layer of fibrin attached to the pelvic peritoneum below and to coils of intestine above. There is the probability of this luemorrhage going on for a long time; when it has finally ceased a large mass of clot is left in the peritoneal cavity; its absorption will be both slow and incomplete. There is considerable risk that it will be infected from the bowel, leading to abscess formation, and there is a certainty that in the most favourable event the pelvic contents will be glued together by dense adhesions. To avoid these dangers and inconveniences the hmmatocele should be dealt with surgi cally either by way of the abdomen or vagina, the clots turned out, and any bleeding-point secured.
The ovum infiltrated with blood may remain in the tube (tubal mole) and the hcemorrfrage may erase. This may be regarded as a favourable result, hut he would be a bold man who would take on himself to say that a pregnant tube, even after the death of the ovum and in the absence of signs of active hxmorrhage. had lost its capacity for mischief. There
still remains the possibility of further haemorrhage or of sepsis, and the wisest plan is to remove the tube.
3. Estratubal these cases the ovisac ruptures through the wall of the tube into the peritoneal cavity. The accident is attended with sudden shock, pain and collapse, and usually with the signs of internal hxmorrhage, so severe as to threaten the life of the patient. The clinical picture presented is that of an " acute abdomen," and such cases are constantly mistaken for cases of " fulminating appendicitis " or of rupture of an internal iscus. In most cases the diagnosis may be made by observing the signs of internal hiemorrhage, and by the acute tenderness in Douglas's Pouch on vaginal examination. Immediate operation is indicated to secure the bleeding vessel and to save the patient. While a surgeon is being procured the practitioner should direct his efforts to the furtherance of the preliminary preparations for an operation. An attempt should be made to rally the patient by sub mammary injection of normal saline solution; 4 gr. of morphia may be administered hypodermically, and the foot of the bed should be raised so as to maintain the circulation in the head and upper part of the body. It is best to avoid internal stimulants for fear of increasing the haemor rhage.
4. Rupture of the Ooisac without Death of the rare cases after the rupture of the ovisac the placenta retains its attachment to the wall of the tube sufficiently to maintain the nutrition of the foetus, which may go on to develop for the customary period, lying loose in the ab dominal cavity or enveloped in false membranes. The placenta con tinues to grow and spreads over the pelvic organs and peritoneum, possibly gaining attachment to the intestines. At term spurious labour sets in, of course without result, the fcetus dies, and the placenta shrivels up. The dead foetus may become mummified or calcified or may become the centre of a suppurating mass with the liquefaction of its soft parts and the gradual extrusion of its bones through fistula' leading to the skin or into internal organs. Such a case, if seen in the earlier months, should be operated on at once for fear of separation of the placenta and hemorrhage. If seen in the later months, it is probably wiser to defer operation until a week or two after spurious labour has set in, so as to allow of the placental sinuses becoming thrombosed and so obviate the risk of serious hwmorrhage following the removal of the placenta.