Abdominal Section for Purulent Peritonitis Re- 
sulting from Ectopic Gestation. 
BY 
JAMES F. W. KOSS, M. IX, 
TORONTO, CANADA. 
REPRINTED FROM 
The American Gynecological Journal, Toledo, ()., 
JUNE, 1892 
THE BEE JOB HOOMS, TOLEDO, O. Clot in which Suppuration took place, and from which Pus Ruptured into Abdominal Cavity, 
Clot due to old Rupture of Ectopic Gestation. ABDOMINAL SECTION FOR PURULENT PERITONITIS RESULT- 
ING FROM ECTOPIC GESTATION.1 
BY JAMES F. W. ROSS, M. D., TORONTO, CANADA 
The study of ectopic gestation has brought to light many condi- 
tions that before were scarcely dreamed of, and the list of these has per- 
haps not yet been exhausted. The case presented to you to-day is one 
that in my experience is unique. I have now operated on the follow- 
ing cases of ectopic gestation: 
No. 1.—Extra-uterine fetation in a woman with a bicornuate 
uterus. Operation done two weeks after term. Recovery. 
No. 2.—Tubal gestation; rupture into the abdomen during a vaginal 
examination. Immediate summons to the house to find the woman 
collapsed. Operation three days later. Abdomen filled with blood. 
Recovery. 
No. 3.—Tubal rupture, evidently into the broad ligament. Opera- 
tion done owing to excessive uterine hemorrhage and for purposes of 
exploration. The sac washed out and drained and not removed owing 
to the difficulties encountered. Subsequent hemorrhage through the 
drainage tube for nearly two months, at times so free as to cause alarm. 
Recovery after six months. I examined the pelvis of this woman a 
few weeks ago, two years after operation, and found no trace of any ab- 
normality. Uterus freely movable. Complete absorption must have 
taken place. She is now about two months pregnant. 
No. 4.—A case of tubal pregnancy. Rupture of tube, and abdomen 
full of blood, with no resulting shock. Woman walking around until 
the morning of the operation. Recovery. 
No. 5.—A case of what appeared to be an abdominal pregnancy. 
The sac with the foetus was high up on the left side and imbedded 
among the intestines. Rupture had taken place into the abdominal 
cavity, and the foetus (that of about three months’ gestation ) died and 
was found at the operation in a partially decomposed condition. The 
intra-peritoneal hemorrhage had produced inflammatory action, and the 
blood had become shut off from the general peritoneal cavity, but com- 
municated with the foetal sac. This collection of blood began to 
suppurate and I saw the woman only in the last stage of septica3inia, 
after five weeks of intra-peritoneal suppuration. Operation was per- 
formed with but slight hope of benefit, and the patient sank and died 
in about thirty hours. The uterus and broad ligaments were examined 
after death, and I chuld not make out any connection between the 
foetal sac or suppurating cavity and the broad ligaments. 
No. 6—.This is the case I desire specially to bring before you 
to-day, and you will therefore be inflicted with the tedium of a detailed 
history. 
1, Read by invitation before the Section of Obstetrics and Gynecology of the Michigan State 
Medical Society, May 5th, 1893. 2 
Mrs. M., aged 24 years. She menstruated first at the age of 13 
years, and up to the time of marriage was in good health. On June 
24th, 1891, she married. On July the 3d or 4th she became unwell. 
She was regular until October when she went one week over her usual 
time. Menstruation then came on as usual, and four weeks after, in 
November, the menstrual flow again appeared. She does not know the 
exact date of the first onset of pain. When it did appear it was of a dart- 
ing character, passing from the right groin across the lower abdomen. 
She was doubled up with it and supposed that she was suffering from 
ordinary colic. As she put it, she “held herself together with her 
hands ” to obtain relief. The pain then left her, but soon came on 
again. On Thanksgiving day, in November, she was out driving, when 
there was a sudden invasion of pain accompanied by nausea, but with 
no vomiting. She hurried home, took a hot drink and went to bed. 
Next morning she rose and went around as usual, but felt very sore 
across the lower abdomen. She could not straighten herself up. She 
felt weak, but did not faint, nor was there any cold perspiration. The 
next attack affected her right leg; the pain shot down the inner side of 
the right thigh. Menstruation appeared as usual; there was nothing 
abnormal to be noticed about her menstruation. The pains were similar 
to, though much more severe than those of a monthly period. Frequent 
desire to urinate now came on and the urine was of a brownish color. 
Defecation was perfectly normal. The suffering was so great that she 
frequently cried with it. Her husband became very uneasy, and said 
that something must be done to relieve her, and her physician, Dr. 
Cuthbertson, called me in to see her in consultation. She was so nervous 
that no satisfactory examination could be made without using an 
anaesthetic, and chloroform was administered. A distinct mass was to 
be felt in a very unusual position right behind the pubic bone on the 
right side, and between the bladder and the uterus. It seemed to be 
fixed to the bladder. The posterior cul-de-sac was empty and the left 
parametrium clear. The case was a very puzzling one. There were no 
symptoms of pregnancy present. The uterus was not enlarged, but was, 
in fact, smaller than the virgin uterus in most females. Menstruation 
had been perfectly regular with the exception of the few days of delay 
of the period in October. I was first called to see her about the 7th of 
December, and advised tentative measures. She appeared to suffer so 
much, from her own story and that of her husband, and to have so 
little systemic disturbance, according to the account of her physician, 
that 1 felt unable to venture any opinion. Ectopic gestation was talked 
of, but not positively asserted to be present. 
Pus tube was also taken into consideration, but was not thought to 
be indicated by the symptoms. Her physician leaned toward a diag- 
nosis of parametritis, but I pronounced such a disbelief in this 
disease, except in very rare cases following some definite cause, that he 3 
became doubtful of the correctness of his diagnosis. It is true that the 
text-books tell us that a mass found between the uterus and bladder is 
usually a deposit due to cellulitis. But my cases of cellulitis have 
not borne out the opinions of the books, but have proved to be cases of 
actual intra-peritoneal disease. I did think, however, that at last I had 
a case of true cellulitis and therefore hesitated before advising a 
laparotomy. She refused to come into the hospital under my care until 
she had enjoyed the usual Christmas festivities. She was admitted on 
the 7th of January, 1892. Temperature and pulse normal. She seemed 
to be very nervous, but otherwise appeared in perfect health. The 
hardness in the right inguinal region could be distinctly felt by firm 
pressure with the finger tips, pressing from above toward the pelvic 
cavity. Three days after her admission I found her suffering from 
slight pain in the “ old spot,” as she called it, and with a slight eleva- 
tion of temperature. This was on a Saturday. On Monday she was in 
about the same condition, but not requiring any opiate. I was unable 
to see her again until Wednesday evening, when, while passing hurriedly 
through my wards, I was struck with her appearance. On looking at 
the temperature chart I found that her temperature had gone up sud- 
denly the evening before to 103° and pulse to 115. She had been sud- 
denly attacked with vomiting and this had continued all night. She 
lay with her knees drawn up, face pinched, and two hot water tins had 
been placed in bed beside her. The evening before she had had a rigor. 
The abdomen, though excessively tender all over, was perfectly fiat. 
No distention was as yet to be noticed. On passing my finger tips 
down to feel the hardness I found that it had to a great extent disap- 
peared, and at once diagnosed the rupture, of what I now supposed to 
be a pus tube, into the abdomen. After reprimanding those in charge 
for not having apprised me of her condition the day before, I ordered 
her immediate preparation for operation early next morning. Fearing 
the difficulty to be encountered in the vomiting following the anaesthe- 
sia, I ordered a large dose of calomel, to be followed by two or three 
Seidlitz powders and enemata until thoroughly effective, so that the full 
benefit of purgatives would be obtained while the stomach was reten- 
tive. This large dose did not have any more effect than the ordinary 
dose given before laparotomy as a matter of routine, and next morning 
the abdomen was markedly distended. I felt sure of my diagnosis of 
ruptured tube and general peritonitis the night before, though I now 
know that others thought that I was too hasty in coming to a conclu- 
sion. But when morning came and the distention was so visible, I felt 
reassured. I felt some anxiety when making the incision, before a 
critical audience of doctors and students, until the peritoneal cavity 
was opened and the pus gushed out. I had operated on several cases 
of purulent general peritonitis before, but not until the diagnosis was 
made easy by the distention ajjd rapid pulse and the patient was past hope (as I now know) of recovery. The mass felt before operation was 
now found surrounded by chocolate-colored decomposed blood and pus, 
and to my astonishment it shelled out with the greatest of ease. I 
found curled behind it a dilated tube and, after ligating, removed it. 
The sac first shelled out lay in the lateral pouch, with tire uterus behind 
and on its inner side, and the bladder on its anterior and inner side. 
The tube lay fixed along the peritoneal fold that constitutes the utero- 
sacral ligament. The cul-de-sac of Douglas was empty and the uterus 
and bladder were free from adhesions except where coming into imme- 
diate contact with the mass. After shelling out the first sac I was 
agreeably surprised to find that there was no hemorrhage. Usually the 
hemorrhage is alarming until the uterine end of the tube is ligated. I 
now washed the pus from behind the liver and spleen, from in front of 
the kidneys, from among the non-adherent intestines, with gallons of 
hot water passed through the largest sized Tait’s trocar from a large 
douche pail. I have irrigated many an abdomen, but never scoured 
one out so thoroughly before. A drainage tube was placed to the 
bottom of the cavity from which the sac was shelled and not to the 
bottom of Douglas’ pouch. The patient was put to bed in a weak con- 
dition. Within twenty-four hours the fluid coming from the abdomen 
became clearly serous and of a straw color. It was not purulent after 
the washing out, until about the third day after the operation, when it 
became very evident that the newly formed tissue lining the cavity from 
which the sac was shelled out was breaking down. Intra-abdominal 
washing was now carried out every two hours through the drainage 
tube. The serum must have been excessively poisonous. It irritated 
the fingers just like a very sour solution of nitric acid and water. For 
one and a half inches around the wound, in spite of antiseptic powders 
and dressings, the skin took on a reddish, glazed, almost erysipelatous 
appearance and numerous red lines, looking like the branches of a tree, 
could he traced for another inch away from its margin, running into 
the healthy skin. These were septically infected capillaries. 
The bowels were extremely obstinate. After the operation the dis- 
tention increased and was almost too much for us. Hourly enemata of 
castor oil, soapsuds and turpentine were given, and calomel, compound 
cathartic pills, Seidlitz powders by the mouth, and these were later on 
fortified by parvules of aloin, belladonna and strychnia (Aloin, gr. 
belladonna, gr. \ ; strychnia, gr. sx0) every four hours. 
I never saw the effects of increase or diminution of distention to 
such advantage. If the purgatives were omitted for a time, the disten- 
tion would increase and the patient would complain of pain, and the 
pain was entirely absent as long as the bowels were only moderately 
inflated. Convalescence was slow and anxious, and it is partly to bring 
this fact before you that I am presenting this case to-day. If cases of 
peritonitis are to be saved by operation, no half-way measures will suffice, and even after the offending nidus of infection is removed the 
patient will have a hard struggle for life. But, without operation, 
such cases must surely die; and if only five per cent, are saved, we are 
assuredly snatching five people from the very edge of the grave. Only 
a few days ago I had an interesting chat with the lady, and she told me 
that she had never felt better in her life. 
On examining the specimens, I found that the dilated tube was the 
seat of an ectopic gestation and that the placenta was still in situ; that 
the fetation had only advanced ( as far as one could judge by compar- 
ison with other cases) to about the sixth or seventh week; that no fetus 
could l)e found; that the sac, shelled out so readily, was an organized 
blood clot, with firm walls, in an advanced state of change to fibrous 
tissue; that the centre of the clot had broken down and become puru- 
lent; that a rupture of this pus had occurred into the abdominal cavity 
and had set up the intra-peritoneal inflammation. 
Many lessons may be learned from such a case as this and cases 
such as those mentioned previously. 
First.—An ectopic gestation may rupture either into the abdominal 
cavity or into the broad ligament, and become so completely absorbed 
as to leave no trace of its previous existence and this absorption will 
be carried out without the use of electricity. 
Second.—Such rupture may be immediately dangerous from excess- 
ive hemorrhage, or remotely dangerous from subsequent suppuration. 
Third.—That such suppuration may be due to a decomposition of 
the fetal structures or may occur in the centre of an organized clot, in- 
dependent of any such decomposition. 
Fourth.—That a sudden attack of peritonitis may be due to the 
rupture of such a suppurating clot into the peritoneal cavity, and that 
this may be a much more frequent cause of peritonitis than we have 
ever believed it to be. 
Fifth.—That the usually accepted symptoms of ectopic gestation 
may be almost entirely absent when ectopic gestation is present. 
Sixth.—That operation for the cure of purulent peritonitis must be 
done early, before extreme distention is present. 
Seventh.—That in obscure cases of acute general peritonitis lapar- 
otomy is a correct and justifiable procedure, if carried out by some one 
accustomed to abdominal surgery, with a sufficiency of trained help to 
carry on the vigorous measures that constitute the after treatment. 
In preparing a paper to present to your flourishing society, I con- 
sulted the Secretary of this section and offered him several subjects on 
which I was ready to write and he chose this one. My intention was 
to present something short and practical and I have endeavored to keep 
within reasonable bounds. If you have been disappointed, your Secre- 
tary must shoulder the responsibility. And now, before closing, I would 
like to reiterate opinions I have expressed elsewhere. The surgical treatment of obscure intra-peritoneal disease is as yet in its infancy. 
We are prepared to make a few mistakes for the sake of the benefit that 
must accrue to mankind from the vast amount of actual accurate in- 
formation that we will obtain. To operate on a patient with an enorm- 
ously distended abdomen, cold hands, rapid, thready pulse, and in a 
profoundly septic condition is unwise. If the patient dies—as they 
always do—people at once ask themselves the very reasonable question: 
“ Why did the doctor operate?” Well, why did he operate? Because 
everything else had been tried and failed; he operated as a last resource. 
This should not be. Operation should be instituted in all cases of 
peritonitis that do not show signs of improvement, and in which the 
origin of the disease is veiled in obscurity, for purposes of diagnosis, 
before all chance of relief from the operation is removed. Opening into 
a peritoneum, already the seat of a violent inflammation, cannot add to 
the inflammation already present. For every attack of peritonitis I 
believe there is a cause, and we will find the cause if we look for it in the 
proper way. Guessing at the cause from without the abdominal walls 
will not help us. If any of you have carried out experimental work on 
the abdomen of the dog, you must frequently have been amazed at the 
intra-peritoneal condition found after pistol shot wounds of this cavity. 
The abdomen is full of fieces, blood, and even worms, after a very few 
minutes. Intestines are smashed to pieces in many places. We are 
convinced that such an abdomen, in a dog, after such an injury, should 
l)e opened at once. If this is true of the abdomen of a dog, it is equally 
true of the abdomen of a man. Our methods of dealing with such in- 
juries after the abdomen is opened are not yet as perfect as they will be 
ten years hence, but the}? are better than the “ no method ” treatment of 
calling to see the patient three or four times a day, with or without con- 
sultants, of giving him opiates to relieve his pain, and buoying ourselves 
up with the hope that the bullet, or the knife, or the kick, or other violent 
injury did no serious damage. And then when the patient is handed 
over to the undertaker we console ourselves, and endeavor to console 
the friends of the deceased, by saying that all was done that could be 
done. I can point out to you three surgeons who lost three sons 
from appendicitis. Surgeon No. 1 lost his eldest son before the opera- 
tion was instituted for the relief of this condition. Surgeon No. 2 lost 
his only son—himself a physician—after the operation had been per- 
formed. Surgeon No. 3 lost a lad, scarcely four years of age, after oper- 
ation for perforation of the appendix and purulent peritonitis had been 
performed—but too late. Each surgeon learned a life-long lesson that 
has been of practical value to him since, and has enabled each of them 
to save lives that would otherwise have been sacrificed. 
Many a young practitioner, when brought face to face with a case 
of acute peritonitis or a case of abdominal injury, strong with the faith 
that is within him, is forced by the overpowering weight of circum- stances to stay his hand and to let the golden opportunity slip by. If 
these feeble utterances are of value in reassuring any such, I shall feel 
more than amply repaid for coming so far to express them.