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such matters as are peculiar to practice in this country. These additions will be principally 
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standing its enlarged size, it is still maintained at the former very moderate price. 
7,E/Sif MAN’S MIDWIFERY—Revised Edition. 
ALSO, USTCUW READY. 
A TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. 
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MENT OF CHILDBED. For Students and Practitioners. By F. Winckel, Professor and 
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In one octavo volume of about 325 pages. EXTRA-UTERINE 
PREGNAN CY: 
ITS CAUSES, SPECIES, PATHOLOGICAL ANATOMY, 
CLINICAL HISTORY, 
DIAGNOSIS, PROGNOSIS, AND TREATMENT. 
BY 
JOHN S. PARRY, M.D., 
OBSTETRICIAN TO THE PHILADELPHIA HOs’O i .L, PHYSICIAN TO THE DEPARTMENT FOR THE DISEASE* 
OF WOMEN IN THE PRESBYTERIAN HOSPITAL, FELLOW OF THE COLLEGE OF PHYSI- 
CIANS OF PHILADELPHIA, VICE-PRESIDENT OF THE OBSTETRICAL 
AND PATHOLOGICAL SOCIETIES OF PHILADELPHIA, 
ETC. ETC. 
PHILADELPHIA: 
H E 2* E T 0. L E A. 
1876. Entered according to Act of Congress, in the year 1875, by 
HENRY C. LEA, 
in the Office of the Librarian, at Washington. All rights reserved. 
PHILADELPHIA 
COLLINS, PRINTER, 
70.3 Jayne Street. TO 
ALFRED STILLfi, M.D., 
PROFESSOR OP THE THEORY AND PRACTICE OP MEDICINE IN THE UNIVERSITY Op' PENNSYLVANIA, 
IN RECOGNITION OF HIS EMINENT POSITION 
AS AN 
AUTHOR AND TEACHER, 
AND OF 
HIS SCHOLARLY ATTAINMENTS, AND HIS SOCIAL VIRTUES, 
%\h iolunu 
IS RESPECTFULLY DEDICATED 
BY HIS 
GRATEFUL FRIEND, 
THE AUTHOR. PREFACE. 
Although extra-uterine pregnancy lias attracted a great 
deal of attention, and the serial literature of our profession is 
rich in the records of individual experience, the natural his- 
tory of the accident is not generally understood, while there 
is much difference of opinion in regard to methods of treat- 
ment. The personal experience of the author having taught 
him these facts, it occurred to him that the examination of a 
large number of recorded cases of misplaced pregnancy might 
lead to valuable results. He accordingly collected five hun- 
dred cases from various sources, and this work is based upon 
an analysis of these. The results of this investigation are 
now presented to the profession with the hope that they may 
lead to more certainty in the diagnosis and treatment of this 
accident. 
The author cannot close without acknowledging his in- 
debtedness to his friend Dr. Edward W. Watson, for aid in 
correcting the proof-sheets of his work, and for numerous 
valuable suggestions received during its preparation. 
J. S. P. 
1518 Arch Street, Philadelphia, 
December, 1875. CONTENTS. 
CHAPTER I. 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
In many cases cannot be determined—Influence of pelvic inflammation- 
inaptitude for conception frequently precedes a misplaced pregnancy 
—Hernia of the internal genital organs—Displacements and tumors of 
the uterus—Operations on the uterus—Moral and emotional causes— 
Twin conceptions—Diseases and deranged physiological action of the 
Fallopian tubes—Age—Number of the pregnancy . . . . 17 
PAGE 
CHAPTER II. 
THE CLASSIFICATION OF MISPLACED GESTATIONS. 
Often impossible to determine the species—Classifications of Dezeimeris, 
and Mr. Tait—Tubal pregnancy—Its varieties—Ovarian pregnancy— 
Its existence denied by Velpeau—Abdominal pregnancy, primary and 
secondary—The fertilization of ova, escaped into the peritoneal cavity 
—Vaginal pregnancy—Cases reported as such—Its existence not proved 
—The author’s classification—Relative frequency of different species . 31 
CHAPTER III. 
PATHOLOGICAL ANATOMY. 
First Stages op Pregnancy—Appearances when rupture of cyst has 
not occurred—Appearances after rupture—Quantity of blood effused— 
It bears no proportion to the extent of the rupture—Appearances of the 
foetal sac and adjoining parts—Mode of union between the ovum and 
the surface on which it develops—Tubo-uterine pregnancy—Changes 
in the uterus—The development of the decidua—The corpus luteum— 
Transmigration of the ovum 53 
CHAPTER IV. 
PATIIOLOGICAL ANATOMY—CONTINUED. 
Appearances in latter months of gestation and after its close 
—Vary with the length of time that the child has been retained—In 
tubal pregnancy—Spiegelberg’s case—Primary and secondary abdomi- X 
CONTENTS. 
nal pregnancy—Liquor amnii—The foetus—Its position, development, 
and sex—The placenta—Vascularity of the chorion in some instances 
—Species of the gestation cannot always be determined at the autopsy 
—Condition of the uterus—Changes which occur in the foetus when 
long retained—Side of the pregnancy 7? 
PAGE 
CHAPTER V. 
Those described by Petit—Division into three periods for study—Those 
of the first period—Colicky pains—Metrorrhagia—Expulsion of the de- 
cidua—Vaginal examination—Uterus is enlarged—Periuterine tumor— 
Ballottement—Examination by the urethra—Symptoms of second 
period—Existence of pregnancy no longer doubtful—Foetal movements 
—General symptoms—Physical signs—Abdominal enlargement on one 
side—Superficial position of child—Mobility of tumor—Auscultatory 
signs—Vaginal examination—Displacement of uterus—Post-uterine 
tumor—Detection of foetus by the vagina—Position of the bladder— 
Sounding the uterus—Mechanical effects of the gravid cyst—Labor at 
term—Secretion of milk—The pseudo-puerperal state which follows 
false labor—The child generally dies during or immediately after labor. 91 
SYMPTOMS. 
CHAPTER YI. 
After completion of term or death of the child—Diminution in size of the 
abdomen—Discharge of the contents of cyst through abdominal wall, 
bladder, vagina, and bowels—Intestinal and vesical fistulas—Offensive 
perspiration—Symptoms of rupture of the cyst in early months of 
gestation—Peritonitis is unusual after this accident—Pregnancy in a 
hernial sac—Twin conceptions in extra-uterine pregnancy—Pregnancy 
while carrying an extra-uterine foetus—Repeated extra-uterine preg- 
nancy 123 
SYMPTOMS—CONTINUED. 
CHAPTER YII. 
TERMINATIONS AND MORTALITY. 
Rupture of the cyst—Its frequency—Period at which it occurs—Duration 
* of life after—Recovery after it—Encystment of the etfused blood and 
the ovum by peritoneal inflammation—The child may be retained for 
an indefinite period after its death—It may remain almost unchanged, 
be mummified, converted into a litliopsedion or adipocere—Inflamma- 
tion and suppuration of cyst—Discharge of its contents through ali- 
mentary canal—Through the vagina and bladder—Through abdominal 
wall—Comparative safety of these modes of termination—Time at 
which the cyst begins to discharge its contents—Mortality—Causes of 
death—Comparative mortality of different species . . . .150 CONTENTS 
xi 
CHAPTER VIII. 
DIAGNOSIS. 
Errors are frequent—Before the foetal heart can be heard—Value of ■ 
various symptoms—From pelvic inflammations; pelvic haematocele— 
From pregnancy of an undeveloped uterine horn—After the foetal heart 
can be heard—Value of different symptoms—From normal pregnancy 
—Retroversion of gravid uterus—Rupture of uterus—After the death 
of the child—Value of different symptoms—From fibroid and ovarian 
tumors, and cancer of the fundus uteri—Use of trocar or aspirator for 
diagnostic purposes—From piliferous cyst of the ovary—Diagnosis of 
the species 173 
PAGE 
CHAPTER IX. 
THE PROGNOSIS. 
Always grave—Tubal, the least favorable—Ventral, the most so—Varies 
with the stage of gestation—A dead foetus may be retained for a long 
time without endangering the mother—Combined intra- and extra-ute- 
rine pregnancy—Pregnancy while carrying an encysted foetus - . 196 
CHAPTER X. 
TREATMENT. 
During the first half of pregnancy—Palliative measures—Radical treat- 
ment—Destruction of the ovum through the system of the mother— 
Extirpation of the sac—Puncture of the cyst—Its removal by section 
of the vagina—Galvanism and electric!ty—Injection of narcotics into 
the cyst—Compression of the tumor—The comparative value of these 
methods of treatment—Of rupture of the cyst—Gastrotomy after 
rupture 199 
CHAPTER XI. 
TREATMENT—CONTINUED. 
From the end of the fourth month until after labor at term—After term— 
Gastrotomy, operation to which the name is applicable—Historical facts 
—Mortality when left to nature, and after an operation, compared— 
Primary and secondary operations—An operation to save the child 
unjustifiable—No operation should be performed until the woman is 
restored from the pseudo-puerperal condition, unless under special indi- 
cations 222 xii 
CONTENTS. 
CHAPTER XII. 
TREATMENT—CONTINUED. 
Gastrotomy—Mode of performing—Influence of adhesions between cyst 
and abdominal walls on the result—Blood and other fluids should not 
be admitted into the peritoneal cavity—Extraction when child is adhe- 
rent to cyst wall—Management of the placenta—Vascularity of the 
cyst wall—Removal of the cyst wall—Gastrotomy by caustics—Treat- 
ment after gastrotomy—Gastrotomy after the death of the mother to 
save the child • 241 
PAGE 
CHAPTER XIII. 
TREATMENT—CONTINUED. 
Delivery by vagina—By incision of the rectum—When the cyst has 
opened through the abdominal wall—Through the vagina—Lithotomy 
to remove bones from the bladder—Removal of bones when the cyst is 
discharging by the bowel—Of tubo-uterine, combined intra- and 
extra-uterine, and of hernial pregnancies—Of labor with a retained 
extra-uterine child 256 
ERRATA. 
Page 23, I6th line, for “ singular” read similar. 
“ 23, 17th and 24th lines, for “ Koeberle” read Koeberle. 
“ 88, foot-note, 1st line, for “ Courday” read Courdray. 
“ 110, next to last line,, and p. 124, 1st line, for “ Prefect” read Perfect. EXTRA-UTERINE 
PREGNANCY. 
CHAPTER I. 
THE CAUSES OF EXTRA-UTERINE PREGNANCY. 
In many cases cannot be determined—Influence of pelvic inflammation—Inaptitude 
for conception frequently precedes a misplaced pregnancy—Hernia of the internal 
genital organs—Displacements and tumors of the uterus—Operations on the uterus 
—Moral and emotional causes—Twin conceptions—Diseases and deranged physio- 
logical action of the Fallopian tubes—Age—Number of the pregnancy. 
In many instances the cause of extra-uterine foetation can- 
not be determined. A young woman becoming pregnant for 
the first time, immediately after marriage, or a matron already 
blessed with a numerous family, may be the victim of this 
distressing accident, without our being able to discover any 
reason for it. In many other cases, however, the study of the 
past history of the patient may throw some light upon the 
subject. 
Pelvic inflammations, peri- and parametritis frequently cause 
extra-uterine pregnancy by producing constriction and dis- 
placement of the uterine appendages. Virchow has directed 
attention to this fact. In examining the specimens removed 
from a patient in 1873,1 such distinct evidences of previous 
pelvic peritonitis were discovered, the adhesions in which it 
had resulted were evidently of so long standing, that at the 
time the post-mortem was made they were deemed sufficient 
by the author to account for the aberrant gestation. Oldham2 
1 Cathcart, Phila. Med. Times, Dec. 27, 1873, p. 96, and Trans. Patholog. 
Soc. of Pliila., vol. iv., 1874, p. 182. 
2 Guy’s Hosp. Reps., 1845, p. 277. 18 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
attaches great importance to this cause. In his first case,1 
the gravid sac was found at the distal extremity of the tube, 
while close to the proximal end of the sac, the oviduct was con- 
stricted by an inflammatory band, which was wound round 
it like a ligature. Many other authorities have recognized 
inflammatory adhesions as a cause. Among them are Ilecker,2 
Tilt,3 Hicks,4 and Barnes.5 Siredey’s6 patient who perished in 
her third pregnancy, had pelvic peritonitis after her second 
confinement. Hooper’s7 became pregnant after having had a 
pelvic abscess which discharged through the vagina ; and Wor- 
ship’s,8 had an abscess to open into the rectum ten years before. 
Stutter9 and Roberts10 both note the fact that in their patients, 
peritonitis followed the confinement immediately preceding 
the extra-uterine pregnancy, and in Turner’s case evidences of 
old adhesive inflammation were found at the autopsy. The 
examples cited are sufiiciently numerous to show that consid- 
erable importance is to be attached to this cause. No doubt 
the history of many an attack of pelvic inflammation escaped 
notice in the examination of the patient, while the well-known 
tendency of this disease to be latent constantly prevents its 
recognition. In other cases, in which the gestation has pro- 
gressed to term, the evidences of pelvic inflammation if they 
had existed previous to conception, would of course be de- 
stroyed or be merged among the great mass of adhesions, which 
surround the extra-uterine cyst. 
Women who have become pregnant, with a child outside 
of the uterine cavity, frequently show a previous inaptitude 
1 Guy’s Hosp. Reps., 1845, p. 271. 
2 Monats. fur Geburts., 1859, quoted by Barnes, Diseases of Women, 8vo., 
Pkila. 1874, p. 366. 
3 Trans. Obstet. Soc. London, 1874, vol. xv. p. 155. 
4 Ibid., 1866, vol. vii. p! 169. 
5 Diseases of Women, 8vo., Pkila., 1874, pp. 366-7. 
6 These Inaugurate, Paris, 1860, p. 98. 
' Trans, of Med. Soc. of Virginia, 1872, p. 124. 
8 Trans. Obstet. Soc. of London, 1870, vol. xi. p. 211. 
9 Med. Times and Gazette, July 21, 1860, p. 55. After the labor preced- 
ing tlie extra-uterine pregnancy, peritoneal inflammation confined ker to bed 
for three months, after which she remained sterile for ten years. 
10 Trans. St. Andrew’s Med. Grad. Assoc , 1868, vol. i. p. 170. This patient 
had a bad “ getting up” after her previous labor. She was leeched and bled 
from the arm three times, and after this she was sterile for seven years. PREVIOUS STERILITY. 
19 
for conception. The interval between marriage and the first 
impregnation is frequently long. If the woman have borne 
children, a period of sterility frequently precedes the extra- 
uterine pregnancy. St. Morressy,1 Lobstein,2 Hughes,3 and 
Sager,4 have each observed an interval of five years between 
marriage and conception. Ramsbothain’s and Adams’s5 patient 
was married eight years, Grossi’s6 nine, Putnam’s7 ten, and Mr. 
F. Hutchinson’s8 and Perry’s9 patients each eleven years with- 
out conceiving. Bamberger’s10 patient had been twice married, 
and in all had passed between thirteen and fourteen years of 
matrimonial life without becoming pregnant. Jewett’s11 was 
sixteen, Poteau’s12 and Perry’s13 each eighteen, and Allport’s,14 
Painter’s,15 and Fothergill’s16 each many years married before 
they conceived. In these instances the extra-uterine was the 
primary conception. 
Among women who had previously borne children, Sinclair,17 
Tuffnell,18 and Roberts19 observed intervals of seven years be- 
tween the last normal and the extra-uterine conception. Tait20 
records a case of eight years ; Fleuriot21 and Barclay,22 each one 
1 Quoted by Duverney—CEuvres Anatomiques, Paris, 1761, t. ii. p. 350. 
2 Med. and Pliys. Journ. London, 1817, vol. xxxvii. p. 196. 
3 London Med. Gaz., 1850, p. 539. 
4 Detroit Rev. of Med. and Pliar., Aug. 1868. 
3 Med. Times and Gazette, July 21, 1860, p. 57, and Mr. Adams, Trans. 
Med.-Chir. Soc. London, 1861, vol. xliv. p. 1. 
6 Gaz. Medicate, January 17, 1846. 
7 Amer. Journ. Med. Sci., Oct. 1853, p. 348. 
8 London Med. Gaz., Nov. 7, 1835, and Lancet, Oct. 31, 1835. 
9 Nashville Journ. of Med. and Surgery, Feb. 1860, p. 159, from Boston Med. 
and Surg. Journ. 
10 Brit, and For. Med.-Chir. Rev., April, 1839, p. 562. 
11 Trans. New York State Med. Soc. 1872, p. 103. 
>2 Melanges de Chirurgie, p. 383. 
13 Journ. of Gynsecolog. Soc. of Boston, Sept. 1869, p. 140. 
14 Lancet, 1845, part ii. p. 430. 
15 Med. Repos., London, 1823, vol. xix. p. 461. 
16 Mem. Med. Soc. London, 1805, vol. vi. p. 107. 
17 Dublin Quart. Journ. of Med. Sci., Feb. 1853, p. 211. 
'8 Ibid. May, 1862, p. 462. 
19 Trans. St. And. Med. Grad. Assoc. 1868, vol. i. p. 170. 
i0 Med. Times and Gaz., Aug. 2, 1873, p. 119. 
21 Bull, de la Societe Anatomique de Paris, 1855. 
22 Med. Gazette, London, Sept. 13, 1850, p. 465. 20 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
of nine; Fill iter,1 Thompson,2 and Stiles,3 each one of ten; 
Huge,4 of eleven; Prof. A. Simpson,5 twelve years; Blache,6 
Drejer,7 and Janvrin,8 each one of an interval of thirteen years; 
Goodsir9 and Martin,10 each one of fifteen ; Marvin11 and Bern- 
ard,12 each one of sixteen years, and Johnson13 one of twenty 
years. Finally Boehmerus14 has recorded the history of a pros- 
titute who pursued her calling for the same period, without 
becoming pregnant, and then conceived, the child being extra- 
uterine. 
A sufficient number of examples have been cited to show, 
that erratic pregnancy is apt to occur in women who have 
become pregnant after having manifested an inaptitude for 
conception, either primarily or after they have borne one or 
more children. This fact does not appear to have attracted 
general attention, though in the analysis of a large number of 
cases it becomes very impressive. Barnes15 directs attention to 
the fact, that the interval between marriage and extra-uterine 
pregnancy in primiparous females is frequently long, in the 
following language: “It has been remarked that in many in- 
stances the subjects of tubal gestation had up to the time of 
such gestation been sterile.” Schrceder, however, is the only 
authority, so far as the author is informed, who is acquainted 
with the whole truth. After speaking of perimetritis as a 
frequent cause of sterility, he says : “A great number of extra- 
uterine pregnancies occurred in primiparae, who had lived for 
1 Med. Times, London, Sept. 10, 1853, p. 262. 
2 Lancet, Nov. 28, 1863. 
3 Pliila. Med. Times, April 4, 1874, p. 419. 
4 Berlin. Klin. Wocli., April 7, 1873; London Med. Record, May 7, 1873. 
5 Edinburgh Med. Journ., Sept. 1863, p. 270. 
6 Provincial Med. and Surg. Journ., May 28, 1842. 
? Medico-Chir. Rev., Jan. 1837. 
8 Atner. Journ. Obstet., Nov. 1874, p. 428. 
9 Duncan’s Annals of Med., 1802, vol. vii. p. 412. 
10 Revue Medicale, 1856, tome ii. p. 673. 
11 New York Med. Journ., Jan. 1849, p. 110. 
12 Lancet, 1844, vol. ii. p. 74. 
13 Phila. Journ. of Med. and Pliys. Sci., 1825, vol. xi. p. 120. 
14 Observat. Anatom. Rar., fascic. i. 1752—Campbell, Mem. on Extra-uterine 
Gestation, Edinburgh, 1842, p. 27. 
15 Diseases of Women, 8vo., Phila. 1874, p. 366. HERNIA OF THE TUBES AND OVARIES. 
21 
some years in sterile marriage; and also in very many pluri- 
parae, whose extra-uterine pregnancies had been preceded by a 
long pause in conception.”1 
In some cases, which have been described as tubal pregnan- 
cies, the passage of the ovum to the uterus would appear to 
have been impeded, by malformations of the internal genital 
organs—the gravid tube entering the womb at some point on 
the body, or even the cervix, of the organ. Selwyn2 and In- 
gleby3 describe and figure examples of gestation in which the 
gravid tube entered the cervix uteri. Hay4 saw the embry- 
iferous organ join thQ womb at the lower portion of its body. 
There is much doubt about the propriety of including these 
cases among those which are strictly extra-uterine, since they 
may have been instances of pregnancy in an undeveloped 
uterine horn. Kussmaul is of this opinion, and in his work on 
absence,malformation, and duplicity of the uterus, published at 
Wurtzburg in 1859, he cites Ingleby’s case as one of pregnancy 
in the “super-horn” of a uterus unicornis, mistaken for a 
tubal gestation. 
Hernia of some portion of the internal genital organs may 
sometimes cause extra-uterine gestation. Among live hundred 
cases, four examples of conception in hernial sacs have been 
recorded; one each by Skirvani,® Genth,6 Muller,7 and Gouey.8 
Another example of this occurred in the practice of Rektor- 
zik,9 but there is some doubt whether it was extra-uterine or 
not. Rektorzik himself believed that the child was in an 
1 A Manual of Midwifery, 8vo., N. Y., 1873, p. 130. 
2 Trans. Provincial Med. and Surg. Assoc., 1834, vol. iii. p. 232. 
3 Edinburgh Med. Journ., 1834, vol. xlii. p. 356. 
4 Trans. Obstet. Soc. London, 1865, vol. vi. p. 5. 
5 Nouvelle Encyclograpli. des Sciences Med., Oct. 1852. 
6 Verhandl. der ges. fur Geburtsk., Berlin, 1855, and Brit, and For. Med- 
ico-Cbir. Rev., Jan. 1857, p. 278. 
7 Allgem. Wien. Med. Zeitung, 1862, and Amer. Journ. Med. Sci., Jan. 
1863, p. 252. 
8 Obstet. Journ. of Great Britain and Ireland, July, 1873, p. 241. Copied 
from the Sloane MSS. This case, though mentioned last, occurred first, the 
woman being pregnant in 1706. 
9 (Esterr. Zt. 18—, 1860, New Syd. Soc. Year Book, 1861, p. 334, and Cin- 
cinnati Lancet and Observ., April, 1861, p. 228. Translated by Dr. D. S. 
Guns. 22 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
undeveloped uterine horn. The subject of hernial gestation 
will be more fully discussed in the sequel, and need not claim 
further attention at present. 
It seems not improbable that some of the ordinary uterine 
displacements may occasionally produce extra-uterine concep- 
tion by preventing the migration of the ovum along the Fallo- 
pian tubes. Meadows1 relates a case in point. A short time 
before the commencement of the gestation “ the uterus was 
rather low in the pelvis, the cervix being near the vulvar ori- 
fice, whilst the fundus was directed to the sacral cavity : there 
was slight retroflexion.” It is easy to imagine that in certain 
displacements, and especially in prolapsus, the calibre of the 
Fallopian tubes may be so much diminished as to impede the 
descent of the ovum. 
Tumors of the uterus and surrounding organs sometimes 
produce this accident by obstructing the Fallopian tubes. In 
a case of tubal pregnancy on the right side, Allport2 discovered 
a small fibroid tumor the size of a horse bean, at the junction 
of the tube and the sac, while a similar growth the size of a 
nutmeg was attached to the latter. Magrath3 describes a num- 
ber of fibroid tumors which were found in the uterus at the 
autopsy of his patient, and though the statements in the text 
hardly lead to the inference, the accompanying plate seems to 
warrant the conclusion that one of these tumours interfered 
with the descent of the ovum. Sinclair,4 who believed he was 
describing an ovarian gestation, found a fibroid tumor close to 
the gravid cyst, and Breslau5has recorded an example of tubo- 
uterine pregnancy, in which the uterine extremity of the tube 
was obstructed by an oval “ mucous polypus the size of an 
orange pip,” which that author believes prevented the escape 
of the ovum into the uterus. The case of Turnbull6 is the only 
other of the live hundred upon which these remarks are based 
in which tumors of the uterus, tubes, ovaries, and other pelvic 
1 Trans. Obstet. Soc. London, 1873, vol. xiv. p. 310. 
2 Lancet, 1845, vol. ii. p. 430. 
3 Trans. Obstet. Soc. London, 1860, vol. i. p. 101. 
Dublin Quart. Journ. of Med. Sci., Feb. 1853, p. 211. 
5 Monats. fur Geb., 1863, and Brit, and For. Med.-Chir. Rev., April, 1864, 
p. 551. 
6 Mem. Med. Soc. London, 1792, pp. 195-6. MENTAL INFLUENCES. 
23 
organs would appear to have given rise to extra-uterine feta- 
tion, and therefore it must be concluded that this is a rare 
cause of this accident. 
An unhealed section of the uterus, made in the operation of 
gastro-hysterotomy, has caused extra-uterine gestation. The 
single example of this occurred to Lecluyse.1 It was the 
second pregnancy of the woman. In her first she was de- 
livered by the Caesarean section. In her second the child died 
in the eighth month, and four days later gastrotomy was per- 
formed. The patient died on the tenth day after the opera- 
tion, and at the post-mortem examination, ah oblong opening 
was found upon the anterior surface of the uterus—the un- 
closed incision of the previous Caesarean operation, through 
which the fertilized ovum is supposed to have escaped into the 
abdominal cavity. 
A somewhat singular, and not less remarkable fact has been 
witnessed by M. Koeberfe2 This surgeon removed all the 
body and a part of the neck of the uterus on account of a 
fibroid tumor. The appendages of the organ were left because 
their extraction would have compromised the success of the 
operation. The patient recovered, but with a fistule through 
the cicatrix of the neck, by which the woman became preg- 
nant. She went to term, and died undelivered. As far as 
we know, the observations of Lecluyse and are with- 
out parallel in the history of misplaced gestation. 
Many have asserted that moral and mental influences may 
cause this accident. Astruc3 appears to have been the first 
to direct attention to this subject. He believed extra-uterine 
pregnancy to he more frequent among widows and young 
girls, indulging in hymeneal pleasures but who pretend to be 
chaste, than it is among married women. Among the recent 
authorities who have supported this opinion are Burdach,4 
Ramsbotham,5 and Chavasse.6 The latter says: “It is a sin- 
gular fact that more single women labor under erratic gestation 
1 Bull, de l’Acad. de Med. de Belgique, 1869. 
2 Keller, Des Grossesses Extra-uterines et plus specialement de leur traitment 
par la Gastrotomie, 8vo., Paris, 1872, p. 23. 
3 Traite des Maladies des Femmes, Paris, 1765, tome iv. p. 69. 
4 Traite de Physiologie, 8vo., Paris, 1838, tome ii. p. 355. 
6 London Med. Gaz., 1849, N. S. vol. viii. p. 651. 
6 Asso. Med. Journ., Nov. 30, 1855, p. 1072. 24 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
than married.” The facts upon which these assertions are based 
are not given, and we are aware of none which warrant them. 
The examination of a large number of cases will soon con- 
vince an impartial investigator, that Campbell is correct when 
he states1 that “ misplaced gestations have been most frequent 
not among the youngest class of individuals, but in those 
somewhat in advance of this stage of life, as also in women 
who have borne several children.” 
If it were possible to compare a large number of pregnan- 
cies in unmarried females with the same number occurring 
under the same circumstances as regards age, and other condi- 
tions in married women, it is quite possible that erratic gesta- 
tion would be found to be more frequent among the former 
than among the latter class, but this is by no means proved. 
During the past ten years several thousand women have 
become the mothers of illegitimate children in the wards of 
the Philadelphia Hospital, and not a single case of misplaced 
gestation has occurred among them. 
Allied to the influence of fear of discovery in the practice 
of illicit intercourse, to which Astruc directed attention, is 
the effect of emotional disturbances at or near the time of sex- 
ual congress. Some authors attach considerable importance 
to the influence of fright experienced during or immediately 
after the sexual act. Cases in which terror would appear to 
have produced extra-uterine gestation have been related by 
Marc,2 Guillemot,3 Godefroy and Everard,4 Lallemand,5 
Breyra,6 Baudelocque,7 Vieweg,8 Beclard,9 and Belliver.10 
1 A Memoir on Extra-uterine Gestation, 8vo., Edinburgh, 1842, p. 118. 
2 Dictionnaire des Sciences Medicates, 8vo., Paris, 1817, tome xix. p. 899. 
This patient heard the key of her door turn while in the arms of her lover. 
3 Revue Medicale, tome i. 1832, p. 458. A stone was thrown through the 
window during intercourse. 
4 Annales de la Med. Pliysiologique, 1827, vol. xii. p. 42. 
6 Observations Patliologiques, 8vo., Paris, 1825, p. 18. A stranger entered 
the woman’s room immediately after coitus. 
6 Arch. Generales de Med., tome xxviii. p. 208. 
7 Diet, des Sciences Med., tome xix. p. 399. 
8 Keller, Des Grossesses Extra-ut6rines, 8vo., Paris, 1872, p. 22. 
9 Archives Generales de Med., tome xxviii. p. 208. 
10 Ibid., 2d Serie, tome v. p. 652. A case is referred to in the Bevue Medi- 
cals, 1834, tome i. p. 430, in which the woman experienced a great fright 
during coitus, on the occasion of a fire in the neighborhood. EMOTIONAL DISTURBANCES. 
25 
In addition to these authorities who have made personal ob- 
servations, the influence of fright and strong passion at or 
near the time of coitus, is admitted as a cause by Bonnie,1 Bur- 
dach,2 Chaussier,3 Braehet,4 Pouchet.,5 Grimaud de Caux and 
Martin St. Ange,6 Armour,7 Kruger,8 and Dezeimeris.9 Some 
importance has been attached to this cause by Velpeau,10 Kel- 
ler,11 and Depaul,12 while its influence is denied emphatically 
by Longet,13Chailly-IIonore,14 Gardien,15and Cazeaux.16 It will 
be seen therefore that in point of numbers the weight of au- 
thority is in favor of the influence of emotional causes. When 
we add to those already mentioned, the strong names of those 
who, however erroneously, believe that from moral causes extra- 
uterine conception is more frequent among single than mar- 
ried women, the array of authorities becomes very strong. 
Though not of much practical importance, this matter is one 
of great interest, and hence we were induced to study the sub- 
ject with some care. At first no importance was attached to 
the matter, but closer study led to the conclusion that we can- 
not deny the influence of strong emotions, occurring during 
or shortly after intercourse, as a cause of extra-uterine preg- 
nancy. The exact relation which emotional disturbances bear 
to the production of misplaced gestation is not determined, 
but the observations of Lallernand, Marc, and others are too 
remarkable for us to avoid attributing some importance to 
fright, terror, and passion. 
Pouchet17 attributes the freedom of the lower animals from 
1 These a Paris, No. 181, 1822, p. 29. 
2 Traite de Physiologie, 8vo., Paris, 1838, tome ii. pp. 211, 355. 
3 Leqons Orales de Physiologie. 
4 Physiologie, p. 354. Quoted by Pouchet. 
5 Theorie Positive de l’Ovulation Spontanee, 8vo., Paris, 1847, p. 427. 
6 Histoire de la Generation de l’Homme, 4to., Paris, 1847, p. 251. 
' Glasgow Med. Journ., 1830, vol. iii. p. 160. 
8 Diet, de Medecine, 8vo., Paris, 1836, tome xiv. p. 410. 
9 Quoted by Grimaud de Caux and St. Ange, loc. citat. p. 252. 
10 Diet, de Med., 8vo., Paris, 1836, tome xiv. p. 410. 11 Loc. eitat. p. 22. 
12 Archives de Tocologie, 1874, tome i. p. 258. 
13 Traite de Physiologie, 8vo., Paris, 1850, tome ii. part iii. p. 179. 
14 Traite Pratique de l’Art des Accouchements, 8vo., Paris, 1867, p. 132. 
15 Traite Complet d’Accouchemens, Paris, 1824, vol. i. p. 527. 
16 Theoret. and Pract. Midwifery, 8vo., Phila., 1869, p. 598. 
11 Loc. citat. p. 427. 26 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
extra-uterine pregnancy to the fact that they do not become 
a prey to emotional disturbances. There is no doubt that dis- 
location of the ovum is much more frequent in the human 
female than it is among the females of the lower animals. In 
fact, it is in some way inherent to our species, though Coste1 
was in error when he declared it to be peculiar to woman.2 
It may be concluded, therefore, that mental and moral 
causes are not without their influence, but it is to be remem- 
bered that this terrible accident is much more frequently due 
to pathological changes in the internal sexual apparatus, than 
it is to emotional disturbances experienced at or near the time 
of coitus. 
Some writers upon this subject, and among them Coste, 
have advanced the opinion that not only mental and moral 
impressions received about the time of conception, but injuries, 
such as blows in the pelvic region inflicted about the same 
time, may prevent the germ from reaching the uterus. Gor- 
don Jackson3 has reported a case, in which the autopsy was 
made by Montgomery, who believed that the ovum was 
arrested in the tube by peritonitis, induced by a blow received 
one week after intercourse; and Chavasse4 believes that he 
has seen traumatic peritonitis produce a like result. He states 
that the patient fainted when she received the injury, and 
that she continued very ill from this time until her death. It 
1 Embryogenee Comparee, vol. i. p. 883. 
2 Poucliet states that he was familiar with hut four examples of extra- 
uterine gestation in the lower animals. These cases were recorded by Gras- 
meyer (De Fecundat. et Concept., etc., Gottinga, 1789) ; Cloquet (Bulletin de 
la Faculte de Med., tome vii. p. 28); Mollard (Comptes Rendus de’VEcole 
Veterinaire, Lyons, 1837) ; and Michon (Archives Generates de Med., tome 
iii.). Previous to this time it had been observed in the cow, sheep, hare, 
and dog. (See Campbell's Memoir, p. 3.) Nuck has produced tubal preg- 
nancy artificially in bitches by applying a ligature on the tube three days 
after copulation (Daynac, These a Paris, No. 71, 1825, p. 8); and more recently 
Adams has met with extra-uterine conception in a deer (Boston Med. and 
Surg. Journ., 1873). It is, therefore, evident that this condition is more fre- 
quent among the lower animals (see also discussion, Seance Acad, de Med. 
Paris, Sept. 1833) than Poucliet supposed ; but we see no reason to change 
the opinion advanced in the body of this work. 
5 Dublin Med. Journ., 1833. 
4 Assoc. Med. Journ., Nov. 30, 1855, p. 1072. TWIN CONCEPTIONS. 
27 
is not probable that direct injury is a frequent cause of extra- 
uterine conception, but there is no doubt much truth in the 
statement made by Barnes,1 that this abnormal gestation is 
more frequent among women who labor hard, than among 
those whose means will allow them to avoid excessive physical 
exertion. It is a striking fact, that the most remarkable 
examples of this accident, which have occurred in this country, 
have been met with among the negro women of our Southern 
States, while they were in a state of slavery. This fact is 
probably to be explained by supposing that severe exertion, 
during the first few days after conception, may alter the rela- 
tion of the tubes, ovaries, and uterus in such a manner as to 
prevent the descent of the ovum. 
Among five hundred cases of extra-uterine conception, col- 
lected without any selection, there were twenty-two cases of 
combined intra- and extra-uterine pregnancy. In other words, 
in round numbers, two ova were fertilized, at the same time, in 
one out of every twenty-three gestations. In addition to this, 
there were probably two cases, in which two germs were fecun- 
dated, and both remained outside of the uterus; but as these 
are somewhat doubtful, they are not included in the calcula- 
tion, and it may be assumed that twin extra-uterine pregnancy, 
both germs being developed outside of the uterine cavity, is 
certainly .very rare. Churchill, the highest statistical autho- 
rity upon obstetrics who has written in our language, says2 
that there is one twin in every seventy-five conceptions 
among British matrons; one in one hundred and eight among 
French; and one in every eighty-seven among German, or an 
average of one in ninety among the mothers of the three 
countries. From these data it would follow that twin concep- 
tions are about four times as frequent in extra-uterine as they 
are in normal foetations. The frequency of combined intra- 
and extra-uterine pregnancy has attracted the attention of 
Barnes,3 and he suggests that the two ova may obstruct each 
other in their descent to the uterus. The above facts seem to 
1 Diseases of Women, 8vo , Phila. 1874, p. 867. 
* Theory and Practice of Midwifery, 8vo., Phila. 1862, p. 430. 
3 Diseases of Women, 8vo., Phila. 1874, p. 367. 28 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
warrant the conclusion that there is some truth in the sug- 
gestion. 
Besides these causes there are others. These are various 
diseases of the Fallopian tube which may impede the descent 
of the ovum. Hodge supposes that mucous and lymphatic 
accumulations in the tube may give rise to the accident. It 
has been produced artificially in bitches by Huck,1 who ligated 
the Fallopian tube three days after copulation, and destroyed 
the animals on the twenty-first day, when he found that two 
ova had been arrested by the ligature. Barnes2 believes that 
temporary flexion may sometimes obstruct the oviduct, and 
thus lead to the arrest of the germ. 
Deranged physiological action of the tubes has been invoked 
to explain why the germ is unable to reach the uterus.3 Leish- 
man4 supposes that it may be due to spasm of the muscular 
coat of the tubes. Desormeaux5 believed the spasm to be due 
at times, to the violence of the voluptuous sensation during 
the coitus. Bianchi6 thought that the accident resulted from 
the spasm and movement produced by a new coitus after the 
fertile one. Bonnie7 also alludes to the abuse of coitus during 
the second and third week after conception. Paralysis, too 
great relaxation, and inaction of the muscular fibres of the 
canal have likewise been supposed to cause it. Congenital 
narrowness of the oviduct would have the same effect. 
Kiwisch8 has directed attention to the fact that the eggs 
which escape from the ovary cannot all reach the oviduct with 
equal facility. The ovules which are liberated from the upper 
portion and near the centre of the ovary, reach the tube more 
easily than those produced in Graafian vesicles developed on 
1 Lallemand, Observations Pathologiques, 8vo., Paris, 1825, p. 25, from 
Adenographise Curiosorum, cap. 7, p. 69. 
2 Diseases of Women, 8vo., Pliila., 1874, p. 369. 
3 Hodge, loc. citat. p. 528. Desormeaux (Diet, des Sciences Med., 8vo., 
Paris, 1829, tome vii. p. 269) believed that the descent of the ovum was 
sometimes arrested by antiperistaltic action of the tubes. 
4 Syst. of Midwif., p. 209. Ramsbotham holds the same opinions (System 
of Obstetrics, p. 567). 
5 Diet, des Sciences Med., tome vii. p. 269. 6 Ibid., p. 269. 
7 These a Paris, No. 181, 1822, p. 27. 
8 Klinische Vortrage, ii. 227, quoted by Depaul, Arch, de Tocologie, 1874, 
p. 258. AGE — NUMBER OF THE PREGNANCY. 
29 
the margins of the organ, and especially upon its posterior 
inferior portion. 
It is unnecessary to speak of the influence of malformations 
of the internal genital organs as a cause. This has already 
been alluded to when speaking of the fact that the Fallopian 
tubes have sometimes been thought to enter the womb at a 
point much lower than normal, even on the cervix of the organ. 
It is easy to understand the effect of this upon the migration 
of the ovule, but these cases are not examples of extra-uterine 
conceptions. They are pregnancies of an undeveloped uterine 
horn. 
Age.—Extra-uterine pregnancy may occur at any time 
during the child-bearing period, but it is not probable that the 
age of the woman exerts much influence in causing the acci- 
dent. Of the five hundred women whose histories have been 
made the subject of investigation, the youngest was aged 
fourteen, and the eldest forty-seven years at the time conception 
occurred. After the age of twenty the liability to the acci- 
dent steadily increases until the thirtieth year. Forty-four of 
862 women whose ages are stated were thirty years old. The 
next highest number, 29, occurred in persons 85 years old. 
Twenty-two of the victims of the disaster were 40 years old. 
After reaching this period of life the liability to extra-uterine 
gestation suddenly diminishes. The statement of the ages of 
500 patients illustrates these assertions. 
14 to 20 years 13 
20 to 30 “ 158 
30 to 40 “ 166 
40 to 47 “ 25 
Not stated 138 
The infrequency of extra-uterine fcetation before the twen- 
tieth, and after the fortieth year, is to be accounted for by the fact 
that in the one case the reproductive functions have not been 
called into operation, and in the other, the woman is approach- 
ing the period of life when their actions will be suspended. 
Number of the pregnancy.—In 500 cases examined, the 
number of the pregnancy is mentioned in 328, and not mentioned 30 
CAUSES OF EXTRA-UTERINE PREGNANCY. 
in 172. It is stated, however, that among the latter number 
there were 23 multiparse. Among these 351 women there were 
279 multipane and only 72 primiparae. These results support 
the statement of Campbell1 that extra-uterine pregnancy is most 
frequent in women who have borne several children, and it like- 
wise confirms the opinion of M. Depaul2 that anterior accouch- 
ments, that is to say, long-continued functional activity of the 
genital organs, and the diseases produced thereby, are not 
without influence on the production of extra-uterine pregnancy. 
Of the 279 multiparous women 81 were pregnant for the second, 
52 for the third, 38 for the fourth, 28 for the fifth, 21 for the 
sixth, 12 for the seventh, 7 for the eighth, 7 for the ninth, 3 
for the tenth, 2 for the eleventh, 3 for the twelfth, and 2 for 
the thirteenth time, while the number of their pregnancy is not 
mentioned in 23 instances. 
1 Loc. citat. p. 118. 
2 Arch, de Tocologie, 1874, tome i. p. 258. CHAPTEE II. 
THE CLASSIFICATION OF MISPLACED CONCEPTIONS. 
Often impossible to determine the species—Classifications of Dezeimeris, and Mr. Tail. 
—Tubal pregnancy—Its varieties—Ovarian pregnancy—Its existence denied by Vel- 
peau—Abdominal pregnancy, primary and secondary—The fertilization of ova, es- 
caped into the peritoneal cavity—Vaginal pregnancy—Cases reported as such—Its 
existence not proved—The author’s classification—Relative frequency of different 
species. 
In the study of a case of extra-uterine pregnancy, one of the 
most perplexing questions which may come up for decision is 
the determination of the class to which it belongs. This is 
true not only during the life of the patient, but even after 
death has ended the stormy scene and an examination of the 
cadaver is being made with all the care that skill and time can 
secure ; and with all the aid that the various instruments of 
modern science can furnish. Notwithstanding these common 
and almost insuperable difficulties which the pathological 
anatomist may encounter, even under the most favorable cir- 
cumstances, a large number of physicians do not hesitate to 
classify their cases, even when their patients have been carry- 
ing the products of a misplaced gestation for years ; when 
portions of a decaying, decomposing foetus are being discharged 
through ulcerated openings in the abdominal wall, rectum, or 
vagina ; or, even during the painful excitement and anxiety of 
the operation of gastrotomy. These remarks apply not only 
to the statements made by physicians who have observed but 
one case, but to those made by accoucheurs who have seen many. 
The result is that special treatises on obstetrics, as well as pe- 
riodical medical literature, teem with statements which are 
utterly unreliable, and which are calculated to mislead inves- 
tigators of this subject. It is entirely impossible to classify 
the various examples of this interesting condition which have 
been recorded, and we are not even now in possession of the 
data which will enable us to determine the relative frequency 32 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
of the various species of extra-uterine gestation. It is to be 
hoped that those who may meet with examples of it in the 
future will not be satisfied with recording their opinion— 
often entirely without value—that it belongs to a particular 
variety, but that they will publish a careful statement of the 
facts upon which their conclusions are based. 
We are now possibly in a position to determine the locali- 
ties in which an extra-uterine child may be developed, but 
even about this the opinions of various authors are of the most 
diverse character. Until the year 1824, three species—the 
tubal, ovarian, and abdominal, were generally admitted to 
occur. In this year Breschet added, what he supposed to be 
a new one, that which was afterwards known as interstitial 
pregnancy. In 1837 Dezeimeris1 made a new arrangement, and 
described no less than ten species, viz.:— 
1st. Ovarian pregnancy. 
2d. Subperitoueo-pelvic pregnancy. 
3d. Tubo-ovarian pregnancy. 
4tli. Tnbo-abdominal pregnancy. 
5th. Tubal pregnancy. 
6th. Interstitial tubo-uterine pregnancy (Grossesse tubo- 
uterine-interstitielle). 
7th. Utero-interstitial pregnancy. 
8th. Utero-tubal pregnancy. 
9th. Utero-tubo abdominal pregnancy. 
10th. Abdominal pregnancy. 
This classification is adopted by Moreau2 without any 
alteration, and by Chailly-Honord3 with but little. The 
location of the ovum is explained by the names, in 
the first, third, fourth, fifth, and tenth so-called species. The 
others may need a passing word in explanation of their sup- 
posed peculiarities. 
By subperitoneo-pelvic (sous-peritone-pelvienne) pregnancy, 
Dezeimeris intended to designate a variety in which the ovum, 
after quitting the ovarian vesicle, did not enter the Fallopian 
1 Journ. des Connaissances Med. Chir., Janv. 1887. 
2 Des Grossesses Extra-uterines, 12mo., Paris, 1858, p. 5. 
3 Traite Pratique de l’Art des Accoucliements, 8vo., Paris, 1867, p. 131. dezeimeris’ classification. 
33 
tube, nor fall into the peritoneal cavity, but, on the contrary, 
passed between the two folds of the broad ligament, and there 
developed. According to this view the product of conception 
is situated outside of the cavity of the peritoneum. That 
the ovum has been found in this location cannot be doubted, 
but when such is the case, there is every reason to believe, that 
it reaches this peculiar situation, through rupture of a tubal 
cyst, in which the integrity of the peritoneum was not dis- 
troyed, so that the ovum escaped between the two layers of the 
broad ligament, where it continued to develop. It is, there- 
fore, one of the terminations of an ordinary tubal gestation, and 
is unworthy of being elevated into a distinct species. 
Interstitial tubo-uterine {tubo-uterine interstilielle) pregnancy 
is the name used to designate a gestation in that portion of 
the tube which traverses the uterus, and is what in the sequel 
is called tubo-uterine. In this class Dezeimeris includes the 
cases of Schmidt of Vienna,1 and Albers of France.2 It is but 
a variety of tubal pregnancy, and should not be called a dis- 
tinct species. 
Utero-interstitial was used by Dezeimeris to designate the 
variety described by Breschet in 1824, and since called inter- 
stitial, intramural, or parietal pregnancy, under the impres- 
sion that, in this case, the ovum is developed in the midst of 
the tissues of the uterus itself. To explain the presence of 
the foetus in this singular situation, various theories have been 
propounded. The occurrence of such cases can hardly be 
doubted, but they are easily explained without the neces- 
sity of invoking the ingenious but baseless hypotheses of 
various writers on the subject. That the development of the 
ovum in a cavity formed in the uterine wall is primary, 
may be considered as decided in the negative, but that the 
product of conception may sometimes be found in the tissues 
of the uterus, as the result of a rupture of a pregnancy of that 
portion of the tube -which traverses the organ, can hardly be 
doubted. It is, therefore, only a termination of this subdi- 
vision of tubal conception, and is not a distinct species. 
1 M6m. et Observat. de l’Acad. Medico-Cliir., Vienne, 1801 
2 Moreau, loc. cit. p. 22. 34 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
By utero-tubal pregnancies, the same author meant those 
in which the ovum is developed partly in the uterine portion 
of the tube and partly in the cavity of the uterus itself, as was 
noticed by Feilitz, Bell, and Widney. This is, therefore, but 
an accidental variation of the tubo-uterine pregnancy. The 
same is true of the utero-tubo-abdominal species, which is the 
name applied to that variety in which the child is found free 
in the abdominal cavity, while the cord enters the tube, tra- 
verses it, and thus reaches the placenta, which is attached to 
the interior of the uterus, as has been observed by Patuna, 
Hey, and Hofmeister. This is only one of the terminations of 
that form of tubo-uterine gestation in which the ovum is 
developed partly in the cavity of the womb, and partly in the 
uterine portion of the oviduct. The sac in the latter ruptures 
some time during the evolution of the child, and allows it 
to escape into the peritoneal cavity, where its development is 
continued. 
In opposition to this minute anatomico-pathological classifica- 
tion of Dezeimeris, we have the simple one of Mr. Lawson Tait 
of London,1 who asserts that there are only two forms of mis- 
placed conception. In truth when the opinions of this author- 
ity are analyzed, we find that he only admits the occurrence 
of tubal pregnancy, and his other species are simply differ- 
ences in the manner, in which a gestation in the tube may 
terminate. In one the oviduct hursts, the peritoneum remain- 
ing uninjured, after which the ovum escapes into the broad 
ligament, between the folds of which its development continues. 
In the other instance the peritoneum is lacerated, as well as 
the walls of the cyst, and the ovum finds its way into the cavity 
of the abdomen. The first is the subperitoneo-pelvic preg- 
nancy of the French authors, and the latter is the secondary 
abdominal pregnancy of Boehmer. 
Prof. T. G. Thomas, of New York, has recently promulgated 
opinions in support of those of Mr. Tait. -He writes:2 “ I feel 
inclined to believe that, in the commencement of its develop- 
ment, the impregnated ovum never attaches itself to or draws 
1 Trans. Obstet. Soc. London, vol. xv. p. 156. 
2 New York Med. Journ., June, 1875, p. 562. TUBAL PREGNANCY. 
35 
its nourishment from any other parts than those lined by the 
mucous membrane of the uterus or tubes. Knowing, as we 
do, the delicate and subtile connection which the chorion 
establishes with the maternal tissues, it is certainly difficult 
to believe that an impregnated ovum falling free into the 
peritonea] cavity, or detained within the Graafian vesicle, 
can, with parts so unlike the lining of the uterus, establish 
relations almost identical with those wffiich are normal.” 
Tubal pregnancy is the only species about which authors 
agree. This is, doubtless, because it so often terminates in 
rupture of the cyst during the early months of gestation. 
The existence of ovarian and ventral gestations is admitted 
by good authorities, and denied by others equally reliable. It 
now remains for us to study the varieties of tubal conceptions, 
and to examine the possibility of the occurrence of ovarian, 
abdominal, and vaginal pregnancy. 
Tubal Pregnancy.—The ovum may be arrested and go on 
developing in any portion of the oviduct. The existence of 
this form of pregnancy was first recognized by Riolanus, the 
younger, who described it in his A?ithropographia, which was 
published in 1649. He.says, that in the year 1640, he recog- 
nized a tubal gestation in the body of a washerwoman in the 
service of Anne of Austria. If the progress of the ovum is 
checked in the pavilion of the tube, the cyst may contract 
adhesions with the ovary, and thus form the tubo-ovarian 
variety. At other times the ovum projects from the fimbriated 
extremity—the chorion being partially uncovered. This is 
the so-called tubo-abdominal pregnancy of systematic authors. 
It is to be noticed that in both instances the egg was origin- 
ally arrested in a portion of the tube, and that, therefore, they 
may be fairly considered as varieties of tubal pregnancy. 
The descent of a fertilized germ may be stopped anywhere 
between the pavilion and the point at which the oviduct 
enters the uterine wall. This is generally recognized as the 
type of the species, and is better understood than any of its 
varieties. It is probable that this is the locality in which 
extra-uterine ova are most frequently arrested. 
The ovum may be likewise developed in that portion of the 36 
CLASSIFICATION OF/MISPLACED CONCEPTIONS. 
tube which traverses the uterine wall. This has been de- 
scribed as a distinct species, and has been dignified with the 
name of “graviditas in uteri substantia” by Brescliet,1 who 
described it in 1824. Meyer2 afterward styled it “ graviditas 
interstitialisand still later Dr. Blundell3 applied to it the 
much more appropriate term of “ utero-tubular” gestation. 
Breschet’s observations were the first which directed general 
attention to this subject, though cases of so-called interstitial 
pregnancy had previously been described by Schmidt,4 Albers,5 
and Heidrich.6 The ovum in these cases was supposed to have 
been developed, as the names proposed by Brescliet and Meyer 
would indicate, in the substance of the uterus itself—in a cyst 
formed in its walls. Brescliet supposed that the ovum found 
its way into this abnormal position by a venous sinus; and 
Iiodge,7 who adopted the idea that the foetus was really de- 
veloped in uteri substantia, believed that in these cases some 
preternatural formation of this organ existed, or else that the 
mucous membrane had been destroyed by ulceration, or an 
abscess, and that the fertilized germ passed into a cavity 
formed by one or the other of these processes, that it was re- 
tained there, and the cyst walls completed by the healing of the 
injury. Cazeaux suggested that this dislocation of the ovum 
was due to its arrest in a diverticulum of the canal of that 
portion of the tube which traverses the uterus. Mauriceau 
and Baudelocque are said to have seen these diverticula. At 
other times, Cazeaux appears to have believed, that the acci- 
dent might be explained, by the existence in the human female 
of a canal analogous to that which Gafrtner, of Copenhagen, 
states he discovered in some of the lower animals. 
In discussing Dezeimeris’s varieties of extra-uterine preg- 
has been stated that the presence of the foetus in the 
tissues of the walls of the uterus cannot be denied, but it is 
1 Trans. Medico-Chir. Soc. London, 1827, vol. xiii. p. 33. 
2 Iiepert. General de Anat. et de Pliysiologie, etc., vol. i. 
3 Lancet, vol. xiv. p. 611. 
1 Mem et Observat. de l’Acad. Med.-Chir. Vienne, 1801. 
5 Quoted by Breschet, loc. citat. 
6 Arch, de Horn., Sept, and Oct. 1817. Quoted by Breschet, loc. citat. 
7 Prin. and Pract. of Obstet., 4to., Pliila. 1866, p. 529. OVARIAN PREGNANCY. 
37 
not necessary to resort to the theoretical explanations of Bres- 
chet, Cazeaux, Hodge, and others to explain this phenomenon. 
Various authors recognize the fact, that in the so-called inter- 
stitial pregnancy, the ovum is arrested in that portion of the 
tube which traverses the uterine wall, and Schrceder1 states, 
that when the foetus is found lodged in the tissues of the 
uterus, it reaches this abnormal position by rupture of its sac. 
This is, therefore, as has been previously remarked, merely 
a termination of a gestation in the uterine portion of the ovi- 
duct. It is, therefore, robbed of its mystery,and ceases to excite 
more wonder than conceptions in that portion of the tube 
which is outside of the uterus. This conception may be called 
tubo-uterine. This name fairly indicates the locality in which 
the germ is arrested. It is to be remarked here, that in this 
variety of tubal pregnancy, the author includes all examples 
of misplaced gestation, in which the product of conception is 
developed in the uterine portion of the tube alone, or in that 
and in the uterine cavity together. In the latter class are the 
cases of Feilitz and Widney, as well as those of Hey, Patuna, 
and Hofmeister to which allusion has previously been made. 
After what has been said, it is to be hoped that the high 
sounding names given by Breschet, Meyer, Ramsbotham, 
Hicks, and others, to this variety of tubal pregnancy, will soon 
cease to burden medical literature. They have too long im- 
peded the advance of knowledge, by implying that there is 
something mysterious and doubtful, about this class of cases. 
Had Breschet never prepared his paper, the literature of our 
profession would not have sustained any injury, and probably 
long ere this, the more correct name of tubo-uterine pregnancy, 
■would have been generally accepted as being in accordance 
with anatomical facts. 
Ovarian Pregnancy.—The possibility of the development 
of the ovum, in the ovary, was generally admitted until 1825, 
when Velpeau,2 after examining four specimens of alleged 
ovarian pregnancy, asserted that in three of the cases the ovum 
1 A Manual of Midwifery, 8vo., New York, 1868, p. 132. 
2 Dictionnaire de Medecine, 8vo., Paris, 1836, tome xiv. p. 399. Traite 
Element, de l’Art des Accouch., tome i. p. 196. ‘68 CLASSIFICATION OF MISPLACED CONCEPTIONS. 
was not situated within, but on the surface of the ovary. 
Farre and Thompson, in England, Geoffroy St. Hilaire and 
Pouchet,1 in France, and Willigk2 and Ilecker,3 in Germany, 
all support Velpeau’s position. The same views are sustained 
by Beclard,4 Valentin,5 and quite recently by Prof. Thomas6 
of jSTew York. This opinion is- based upon the belief, that 
the fecundation of the ovule is impossible, unless it has 
escaped from the ovary, and that there is no proof that the 
foetus or foetal membranes have ever been found in the tissue 
of the organ itself. The idea seems to have been that to fer- 
tilize an ovule in the ovary, the spermatozoa have to perforate 
the external coats of the organ, an inference which is without 
facts to support it. It is not difficult to conceive that the 
Graafian follicle might rupture, and the germ not escape. This, 
however, opens a channel by which the spermatozoa can reach 
the contents of the follicle and fecundate the ovule. When 
we remember the processes by which the escape of the ovule 
from the ovarian follicle is secured, it need occasion no surprise, 
that it should sometimes be retained, even after rupture of the 
vesicle of De Graaf has occurred. 
The weight of authority i3 in favor of the possibility of 
ovarian pregnancy. Unless it is concluded that M. de St. 
Maurice, who observed the first authentic case7 in 1682, was 
guilty of telling an absolute falsehood, or that he was not 
sufficiently informed to make his statements reliable, we must 
admit that lie is describing a case of ovarian fcetation. What- 
ever doubts had previously existed, they were settled by Gran- 
ville’s description3 of an example of this form of aberrant 
gestation. 
This description and the illustration of the case appear to 
leave nothing to be desired to establish the existence of this 
1 Theorie positive de l’Ovulation Spontanee, 8vo., Paris, 1847, p. 421. 
2 Prag. Vjlirtsclir. lxviii., quoted by Barnes, Diseases of Women, p. 375. 
3 Monats. fur Geb., Feb. 1859, and New Syd. Soc. Year Book, 1860, p. 
340. 
1 Traite Elementaire de Pbysiologie, 8vo., Paris, 1856, p. 1052. 
5 A Text-book of Physiology, 8vo., London, 1853, p. 643. 
6 New York Med. Journ., June, 1875. 
7 Phil. Trans., abridged edit., 4to., London, 1716, vol. iii. p. 214. 
8 Pbilosoph. Trans., vol. cxi. p. 107, and Graphic Illustrations of Abortion, 
etc., 4to., London, 1834, pi. viii. p. 27. ABDOMINAL PREGNANCY. 
39 
species of misplaced pregnancy. Marinus1 has more recently 
investigated the subject: and bas examined three preparations 
in the pathological museum of Wurzburg, which he believed are 
all indubitable examples of gravid ovaries. Just before this 
investigation was made public, Kammerer2 exhibited a speci- 
men of ovarian pregnancy to the Pathological Society of Yew 
York. The true nature of this case is beyond dispute. Still 
earlier than this, in 1853, another American, Dr. I. Gr. Porter, 
reported3 another case which appears without doubt to have 
been ovarian. A woman, aged twenty-eiglit years, died from 
rupture when between six and seven weeks gone in her fourth 
gestation. At the autopsy the left tube was floating free and 
pervious, but the left ovary, which contained the gravid sac, 
was as large as a hen’s egg. It cannot, therefore, be denied 
that ovarian gestation may occur, but there is reason to believe 
that it is comparatively rare. It is certainly much less fre- 
quent than tubal pregnancy. 
Abdominal Pregnancy.—The most serious problem in 
connection with this subject, is to decide the vexed ques- 
tion, whether a foetus cart or cannot be developed in the peri- 
toneal cavity, without having any connection with the mucous 
tract of the uterus or its tubes. The occurrence of ventral 
gestation is denied by Merriman,4 Rokitansky,5 Campbell,6 
Pyan,7 Churchill,8 Rogers,9 Tanner,10 Tait,11 and Barnes.12 On 
1 Journ. de Med. de Bruxelles, 1866, vol. xlii. p. 430. 
2 New York Med. Journ., 1866, p. 141. 
3 Amer. Journ. Medical Sciences, Jan. 1853. 
4 A Dissertatation on Retroversion of the Womb, 8vo., Pliila., 1817, p. 67. 
5 Patholog. Anat., 8vo., Pliila., 1855, vol. ii. p. 256. 
6 A Memoir on Extra-uterine Gestation, 8vo., Edinburgh, 1842, p. 22. 
7 Mem. de l’Acad. de Med., 1845 ; Revue Med., 1847. 
8 Theory and Pract. of Mid., 8vo., Pliila., 1862, p. 181. 
9 Extra-uterine Fmtation and Gestation, 8vo., Pliila., 1867, p. 10. 
10 Signs and Diseases of Pregnancy, 8vo., Pliila., 1868, p. 291. 
11 Trans. Obstet. Soc. of London, vol, xv. p. 156. 
12 Diseases of Women, 8vo., Pliila., 1874, p. 376. “ It appears to me doubt- 
ful whether abdominal gestation is ever primary, that is, whether the im- 
pregnated ovum ever attaches itself ab initio to some part of the peritoneum. 
. . . Probably abdominal gestation is always secondary upon tubal or ova- 
rian gesta'ion,” through rupture of the sac. 40 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
the other hand, it is admitted to occur by most of the recent 
authors of text-books on midwifery, and by Dezemeris,1 
Ilecker,2 and Behier,3 who have published original memoirs 
upon extra-uterine gestation. Velpeau asserts that he has seen 
two cases in which the foetuses had no connection whatever 
with either the ovary, the Fallopian tubes, or uterus. Ilecker4 
believes that it is the most frequent of all the varieties. 
Columbat5 does not think it very common, and M. Deneux6 
would seem to entertain the same opinion, since he believes 
that abdominal gestations are always fatal, and that all those 
extra-uterine pregnancies which go beyond the normal period 
are tubal. 
Dezeimeris,7 in imitation of authorities who preceded him, 
divides ventral pregnancies into two classes, the primary and 
secondary. By primary is meant that class in which the 
fcetus is developed at once in the peritoneal cavity, while in 
the second class, he includes all those cases in which the cyst, 
originally located in the tube or ovary, has ruptured, and the 
escaped foetus goes on developing in the abdomen. That this 
may occur cannot be doubted, though it lias been denied by 
Rogers8 that a woman ever survives rupture of the cyst. As 
this form of ventral pregnancy must claim further attention 
in the sequel, its consideration may be postponed for the pre- 
sent. The question now is, Can primary abdominal pregnancy 
possibly occur? It must be acknowledged that the known 
established cases are not numerous. Unless it be concluded, as 
some assert, that tubal gestations never reach term, and that 
those women who carry extra-uterine children beyond nine 
months, and finally get rid of them by the cyst opening into 
the bowels, vagina, or bladder, or through the abdominal 
walls, are examples of ventral conceptions, it must be admitted 
1 Journ. des Connaissances Med -Chir., Janv. 1837. 
2 Monat. fur Geb., Feb. 1859 ; New Syd. Soc. Year Book, 1860. p. 310. 
3 Gazet. Hebdom., No. 36, 1873. 
4 Loc. cit. Of 222 cases collected by this author he states that 64 were 
tubal, 26 interstitial, and 132 abdominal pregnancies. 
5 Diseases of Females, Meigs’ ed., 8vo., Phila., 1845, p. 576. 
6 Behier, Gaz. Hebdom., No. 36, 1873. 
i Loc. citat. 
8 Extra-uterine Foetation and Gestation, 8vo., Phila. 1867, p. 41. ABDOMINAL PREGNANCY. 
41 
that these are rare. Mention has already been made of the 
difficulty of determining the true nature of the case, even 
when every facility is afforded in making the post-mortem 
examination.1 The writer had ample opportunity to learn 
this, at the post-mortem of the patient of his friend, Dr. AY. C. 
Perkins,2 with whom he had previously seen the woman in 
consultation. The sac was composed of the proper foetal mem- 
branes alone at its upper anterior portion. The lower part was 
made up of the enlarged uterus in the middle line, and the 
broad ligaments and adjacent parts upon either side, while 
the attachments of the placenta were entirely outside of the 
pelvis, in the right and left lumbar regions and to the dorsal 
vertebrae. Careful examination of the specimen failed to 
reveal the situation of either of the Fallopian tubes or ova- 
ries, and hence it is utterly impossible to determine whether 
these were involved primarily or secondarily. 
Dr. Bedford3 says that the attachment of the placenta is the 
most certain guide to the variety of the pregnancy ; Courtail 
has found it inserted4 on the omentum and stomach, and we 
have the authority of Dionis5 for saying that Joury found it 
attached between the mesentery and colon in a case called 
ventral foetation. Hughes6 found the placenta attached to the 
omentum, and Mateeki7 has observed another case in which it 
had no connection with either the uterus or its appendages, 
all of which could be traced. The attachment of.the placenta 
to a portion of the peritoneum, however remote from the 
uterus, tubes, and ovaries, does not prove the existence of pri- 
1 “ On dissection even, the original organic relations of an extra-uterine 
ovum cannot in very many instances be unfolded, especially in cases of pro- 
tracted retention of the foetus, where, from pressure and chronic inflamma- 
tion, parts have united with the foetal cyst, which at one period had no 
connection with it.”—Campbell, Mem. on Extra-uterine Gestation, 8vo., 
Edinburgh, 1842, p. 19. 
2 Phila. Med. Times, 1872, and Amer. Journ. of Obstet., May, 1872. 
3 Prin. and Pract. of Obstet., 8vo., N. Y., 1861, p. 205. 
4 Nouvelles Observ. sur les Os, obs. x. 
6 Anatomie de l’Homme, p. 223. 
B London Med. Gaz., 1850, p. 539. 
7 Monats. fur Geb., May, 1866, and Brit, and For. Med.-Chir. Rev., Oct. 
1868, p. 525. 42 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
mary ventral pregnancy, though future observations may show 
that the greatest portion of the development of the foetus, in 
such cases, takes place after all connection with the proper 
generative tract has been severed. This assertion is proved by 
an observation reported by Dr. J. Braxton Ilicks.1 His patient 
died when four months gone, and after an attempt had been 
made to destroy the life of the foetus, by puncturing the cyst 
with a trocar. Some time before, she had recovered from 
symptoms of rupture. At the autopsy, the ovum was found 
in the retro-uterine pouch. On the left side of the uterus was 
a ruptured cyst, which contained purulent serum retained by 
pressure of the ovum. A committee of the Obstetrical Society 
of London, of which Barnes and Hicks were members, care- 
fully examined the specimen, and reported that they believed 
that the ovum had originally been contained in this cyst, that 
the latter had ruptured, that the ovum had escaped either sud- 
denly or gradually, without rupture of any bloodvessels, and 
consequently without any hemorrhage. The placenta was 
formed upon that portion of the membranes furthest from the 
cyst. 
The positive evidence of the occurrence of primary ab- 
dominal fcetation' may be summed up by reference to a few 
cases. Turnbull2 has carefully recorded and illustrated the con- 
ditions observed at the autopsy of a woman, who had gone to 
full term. No proper placenta was found, but the anterior wall 
of the cyst was very vascular though only one-tenth of an inch 
thick, the foetus being nourished by blood derived from the ves- 
sels of the mesocolon. The corpus luteum was in the left ovary, 
and the corresponding tube was obstructed by a pelvic tumor 
behind which it ran. Mitivid,3 Collins,4 Denny,5 and John- 
son,0 have each met with an example of extra-uterine fcetation 
1 Trans. Obstet. Soc. London, 1866, p. 95. 
2 Mem. of Med. Soc. of London, 1792, p. 192. 
3 Med. and Phys. Journ. of London, 1829, p. 275. The woman carried 
tlie child many years and died, set. 77. The cyst, which was free from the 
uterus and appendages, was attached to the mesentery and a loop of small 
intestine by bands of cellular tissue. 
4 Dublin Med. Trans., 1830, vol. i. part i. p. 118. 
6 Amei'. Journ. Med. Sci., July, 1850, p 49. 
6 Med. Exam. (Pliila.), Sept. 1850, p. 511. ABDOMINAL PREGNANCY. 
43 
in which the gravid cyst had no connection with the pelvis or 
any of its organs. Peters1 found the ovum adherent to the 
upper and anterior surface of the bladder, without any connec- 
tion with the uterus and its appendages. The patient had 
died at the end of the third month, from hemorrhage due to 
separation of the placenta. Leigh’s2 patient died after having 
carried the child for four years. The cyst was found attached 
to the omentum, while the internal genital organs were not 
involved. There is likewise reason to believe, that, though 
the cyst was connected with the uterus, Rupin’s3 case of twin 
pregnancy was abdominal. The placenta was situated at the 
fundus, the tumor being in the retro-uterine pouch, and so low 
down, that an attempt was made to deliver the woman, by 
incising the posterior walls of the vagina in the sixth month 
of pregnancy. After death nothing unusual was found about 
the Fallopian tubes or the broad ligaments. The right ovary 
was normal and contained a corpus luteum, while the left was 
somewhat atrophied. These cases, though they are but few ol 
the whole number of five hundred, afford strong evidence of the 
existence of ventral fcetation. They even fulfil all the require- 
ments of Campbell, one of the strongest opponents of the opinion 
that peritoneal pregnancy is possible. He says,4 “ Until a case can 
be produced in which neither an ovary nor a tube is involved 
in the adventitious cyst, we are justified in withholding our 
belief in the existence of ventral extra-uterine gestation.” 
Even Hicks’ case5 may be said to meet all these requirements. 
Though it belongs fairly to Dezeimeris’ second class of ventral 
fcetation, if the report of the London Obstetrical Society’s 
Committee be accepted as authoritative, it fully establishes 
the fact that the ovum may, after having undergone a certain 
amount of development, attach itself to the peritoneum and 
go on developing without any connection with the genital 
tract. If there were any further doubt about this matter, it is 
1 Med. Exam. (Phila.), May, 1848, p. 288. This case appears to have 
been twice reported by the same author—the second time in The Amer. 
Journ. of Med. Sciences, April, 1853, p. 550. 
2 Virginia Med. Journ., July, 1857, p. 30. 
3 Gaz. des H6p , No. 13, 1860, and Monats. fur Geb., Oct. 1860. 
4 Loc. citat. p. 138. 5 Loc. citat. 44 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
settled by Lecluyse’s1 case of extra-uterine pregnancy, caused 
by a fistulous opening on the anterior surface of the uterus, 
the result of a previous Ctesarean section, and through which 
the ovum escaped into the peritoneal cavity, where the child 
continued to develop for seven or eight months, the placenta 
being attached to the anterior surface of the small intestines. 
In this case the ovule was fecundated in the usual manner, 
and it descended by the Fallopian tube to the uterus, from 
which it escaped, but it establishes beyond possibility of 
doubt, that the germ may attach itself and live till it has 
completed the usual period of intra-uterine existence, without 
having any connection with the womb, tubes, or ovaries. This 
being proved, there is no difficulty in going a step further, and 
concluding, that, if the ovum is fecundated in the ovary and 
fails to enter the Fallopian tube, it may fall into the peritoneal 
cavity and there attach itself to the peritoneum, and continue 
its development until it is completed. The fact that ovarian 
pregnancy is possible, justifies the conclusion that the oviduct 
of the human female, unlike that of some of the lower animals, 
does not furnish the ovum, during its transit from the ovary 
to the uterus, with any elements which are necessary for its 
subsequent development. 
Though of little practical importance, it would be interest- 
ing to determine whether an ovule which had escaped from 
the ovary into the peritoneal cavity could be there fecundated. 
If this is possible, there is no reason why it should not attach 
itself to the peritoneum, and there grow and develop. At 
first sight such a view appears utterly unphysiological. It 
must be remembered that the elements of the future individual, 
furnished by both the male and female organs of generation, 
are but masses of germinal matter, or bioplasm, as it is styled 
by Beale. In this instance the bioplasm is endowed with the 
largest amount of formative and developmental force, but other- 
wise it is subject to the same laws which govern bioplasm 
found under other circumstances, and destined for less elevated 
purposes. Prof. Beale has also shown that this matter is capa- 
ble of maintaining its vital properties for considerable and 
1 Bull, (le 1’Acad. de Med. de Belgique, 1809. ABDOMINAL PREGNANCY. 
45 
even long periods if favorably situated. Ileat. and moisture 
are the essential elements for the preservation of its life, and 
these certainly exist in the peritoneal cavity, as well as in the 
canal of the oviduct and the cavity of the uterus. There is 
conclusive evidence that the spermatozoa may live for some 
time after ejaculation. Sims found them alive and “very 
active”1 in the cervical mucus forty hours after intercourse, and 
Percy2 discovered living spermatozoa issuing from the os 
uteri eight and a half days after the last sexual connection. 
Dr. J. R. Beck3 has recently attempted to show, that a pecu- 
liar rhythmical contraction and relaxation of the cervix and os 
uteri, which set in when the orgasm occurs, is an important 
factor in generation, by causing the semen to enter the uterus 
at once. Without denying the existence or the importance of 
this force, something must yet be attributed to the power of the 
spermatozoa to traverse the genital passages of the female by 
the forces inherent to them. The orgasm is not essential to 
conception, which may occur during sleep, as in the celebrated 
cases of Gooch and Cusack. The medico-legal fact that a woman 
may conceive without penetration, as in the example recorded 
by Tardieu4 in which conception followed lascivious tfilia- 
tions, the semen being habitually lost at the ostium vaginae, 
fully establishes the ability of the spermatozoa to travel long 
distances. The occurrence of ovarian pregnancy likewise 
demonstrates the same thing. That this transit may be quite 
rapid is proved by Sims’s5 observation, in which the spermato- 
zoa had travelled three and one-half inches, in the space of 
four hours. In the year 1838, Bischoff and Barry discovered6 
spermatozoa on the surface of the ovaries of bitches some time 
after copulation. Professor Austin Flint, Jr., says7 we know 
“that spermatozoids reach the ovaries and that they have 
been seen in motion on their surface, seven or eight days after 
1 Uterine Surgery, 8vo., N. Y., 1866, p. 374. 
2 Amer. Med. Times, March 9, 1861. 
3 St. Louis Med. Journ., Sept. 1872, and Amer. Journ. of Obstet., Nov. 
1874. 
4 Etude Medico-Legale sur les Attentats aux Mceurs, Paris, 1859. 
5 Uterine Surgery, 8vo., N. Y., 1866, p. 361. 
6 Wagner, Elements of Physiology, 8vo., London, 1844, p. 66. 
7 The Physiology of Man, 8vo., New York, 1874, vol. v. p. 342. 46 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
connection.” It therefore appears probable that the male ele- 
ment in reproduction may live for some time upon the surface 
of the peritoneum. If the secretion of this membrane was 
destructive to the life of the spermatozoa they would not be 
found in a condition of activity on the surface of the ovary 
seven or eight days after intercourse. Though Waldeyer has 
shown that this organ is devoid of a serous coat, no one will 
deny that the secretion of the peritoneum constantly bathes its 
surface, and even that of the interior of the pavilion. These 
facts, while they do not prove that fecundation can occur in 
the peritoneal cavity, make it extremely probable that it does 
sometimes happen. 
Vaginal Pregnancy.—It lias been asserted that the ovum 
may attach itself to the mucous membrane of the vagina, and 
thus grow and develop, practically, it may he said, outside of 
the body of the mother. This would appear to be too un- 
reasonable to be believed for a single instant, yet Plenck1 in- 
cluded this among the species of misplaced pregnancy. Duges2 
was in doubt about the matter. .Rokitansky3 mentions it, but 
states that its existence is problematical. 
The first notice of vaginal pregnancy is that of M. Roel,4 
who, in the month of July, 1765, was called to see a woman, 
named Girardat, in labor in the village of Villacourt, in Lor- 
raine. Labor had been in progress for some hours, the waters 
had been discharged, and the umbilical cord prolapsed. 
The child was found presenting by the back, and was at the 
inferior strait of the pelvis, while the head and feet were 
doubled up and were above the pelvic brim. A hard spherical 
tumor could be felt in the neighborhood of the mother’s um- 
bilicus. The child was withdrawn by the feet; it was dead 
and at term. The placenta was delivered, but the hardness 
near the umbilicus continued and led to the suspicion that 
the abdomen contained a second infant. Upon introducing 
the hand it was impossible to find the uterus. The woman 
died the next day. At the autopsy it was found that the 
1 Siemens de l’Art des Accoucliemens, 8vo., Lyons, 1792, p. 201. 
2 Dictiomiaire de Medecine et Chirurg., 8vo., Paris, 1838, tome ix. p. 317. 
3 Manual of Patliolog. Anatomy, 8vo., Pliila., 1855, pp. 256-7. 
4 Journ. de Medecine, Cliirurgie, Pbarmacie, etc., 1779, tome i. p. 55. 47 
VAGINAL PREGNANCY. 
abdominal tumor, discovered during life, was the uterus, which 
had undergone calcareous degeneration, and which was the 
size and nearly of the figure of the head of a young infant. 
The tubes were equally hard, and no trace of a rupture could 
be discovered. The upper part of the vagina is described as 
having been distended into a large pouch, the walls of which 
were ragged and gangrenous. In this the child was found. 
In the year 1839, Mackeprang1 was called to a primipara, 
who had been in bed during the past four months. He found 
her greatly exhausted. In the fourth month of pregnancy she 
was attacked with pains, and “a strong pressure downwards,” 
which was relieved by a sedative mixture. At this time a 
tumor appeared in the vagina, and continued to increase in 
size. “On examination this tumor was found about the size 
of the crown of a hat (hattepuls), protruding upon the middle 
of the woman’s thigh, and strongly pressing upon the intesti- 
num rectum.” One arm protruded from an opening behind and 
well down in the vagina. It was twisted off, and the child 
was withdrawn with the help of a hook. It was of seven or 
eight months’ development. The placenta was allowed to 
remain for fear of hemorrhage. The woman died two days 
later. 
In the third case (it is impossible to state who is the reporter),2 
the woman was four months pregnant. A circumscribed en- 
largement was discovered between the navel and pubes. The 
bowels and bladder were emptied with much difficulty. The 
foetus was found to be in a transverse position, and was de- 
livered by the feet. The shoulders were brought through the 
vulva with much difficulty, and the forceps were applied to 
deliver the head. The circumscribed tumor still remained 
after the birth of the child, and on examination this was found 
to be the uterus. The organ was retroverted, the os pointing 
towards the “abdominal integuments,” and closely embracing 
the cord. The accoucheur introduced some of his fingers into 
the os tincse and removed the placenta, which was adherent 
1 London and Edinburgh Med. Journ., April, 1845, p. 324, from Biblio- 
thek for Laerger, No. 1, 1844. 
2 Lancet, Nov. 11, 1843, p. 198, from CEst, Wochensch. and Med. Zeitung, 
No. 18, 1843. 48 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
to the neck, and all the rest of the internal surface of the 
uterus. The patient recovered. 
So far as the author is aware, this constitutes the sum of 
our knowledge in regard to this alleged species of erratic gesta- 
tion. It majr at once be concluded that, in the cases reported 
by Noel and Mackeprang, the foetus was developed outside 
of the uterus, but it does not, therefore, follow that the preg- 
nancy was vaginal. It is to be noticed that in both instances 
the anterior history is defective. Neither woman was seen by 
her medical attendant until immediately before her delivery. 
We therefore have no account of the development of this 
tumor in the vagina. Neither are we put in possession of any 
facts which will enable us to determine by what the product 
of conception was covered. If an ovum is developed in the 
vagina, it would, as in peritoneal pregnancy, be destitute of 
any coverings excepting its own membranes, the amnion and 
chorion. This would seem to be impossible in the vagina. 
If the tumors were found covered with mucous membrane, 
the difficulty is at once solved, and the cases could be placed 
with certainty in that class of extra-uterine pregnancy, which 
Dezeimeris has called subperitoneo-pelvic, and which is no- 
thing more than one of the terminations of tubal conception. 
This would appear to be the correct explanation of these two 
interesting observations. 
The third case cannot be disposed of so easily. In this the 
development of the placenta in the uterus insured the normal 
nutrition of the foetus. The results of secondary peritoneal 
pregnancies have demonstrated the fact, that the presence of 
heat and moisture, and a continuous regular supply of nutri- 
ment through the placenta, are all that is needful to insure 
the complete development of the child. It is proved beyond 
doubt, that the presence of the liquor amnii is not necessary to 
preserve its life and to insure its growth. Nor is it necessary 
that the membranes should preserve their integrity for its 
protection. It has been proved beyond possibility of doubt, 
that at an early stage in the pregnancy, the sac may rupture 
and allow the embryo to escape into the peritoneal cavity, 
where it is perfectly free excepting its attachment with the 
umbilical cord. If, under these circumstances, the connec- author’s classification. 
49 
tions of the placenta remain undisturbed, the development may 
continue, and in the end, be as perfect as in uterine pregnancy. 
The placenta may be attached in the uterus, and the child 
escape into the abdominal cavity, and there continue to live 
and grow, as has been already stated. 
These facts would lead us to conclude, that, if the child 
could be expelled from the uterus into the vagina, without 
disturbing the attachments of the placenta or rupturing the 
membranes, its life might be maintained for an indefinite 
period. The perils to which it would be subjected arise more 
from the exposed position, than from any difference between 
the functions of the uterine and vaginal mucous membranes. 
It is very difficult to believe that the product of conception 
could be retained in this locality for any length of time, when 
the woman is in the upright position. The phenomena, 
observed in this case, find a more reasonable explanation in 
the conclusion that the ovum was in reality developed within 
the retroverted uterus, that the foetal portion of it had been 
expelled in the usual manner, but, owing to the narrowness of 
the vagina, it had been retained in the upper portion of that 
canal. In the mean time the uterus contracted tightly upon 
the placental portion of the ovum, leading to its retention. 
It may, therefore, be concluded, that we have no reliable 
clinical evidence, that vaginal pregnancy is possible, and that 
there are good reasons for believing that it cannot occur. 
Author’s Classification.—From what has been stated, it 
may be concluded that there are three species of extra-uterine 
pregnancy. These may each be divided into several varieties, 
as expressed in the following schedule:— 
SPECIES. 
VARIETIES. 
Tubo-ovarian (the germ being arrested in the pavilion, 
which contracts adhesions with the ovary). 
Tubo-abdominal (germ arrested in the same locality. The 
tube may contract adhesions with neighboring organs. 
If it does not, the chorion may project into the abdominal 
cavity, with a part of its surface bare). 
Tubal proper (germ arrested between the pavilion and that 
portion of the oviduct which traverses the uterine wall). 
Tubo-uterine (germ arrested in that portion of the tube 
which passes through the uterus). 
Tubal 
pregnancy. 50 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
Ovarian 
pregnancy, 
Ovarian proper (germ contained in the ovary, that organ 
remaining free from adhesions). 
Ovario-tubal (germ contained in the ovary, which contracts 
adhesions with the pavilion of the tube).1 
Primary (ovum developed from the outset in the peritoneal 
cavity). 
Secondary (development commences in the tube or ovary, 
the cyst ruptures, ovum escapes, and continues to live and 
develop in the peritoneal cavity). 
Ventral 
or abdominal 
pregnancy. 
This division of the species into varieties is not without its 
practical hearings upon the prognosis and treatment of mis- 
placed gestations, as will appear in the sequel. 
Comparative frequency of the different species and 
varieties.—It is an exceedingly difficult matter to determine 
the relative frequency of the different species and varieties of 
extra-uterine fetation. Hecker,2 the author of one of the 
most important statistical papers upon this subject, states that 
of the 222 cases which he analyzed, 64 were tubal, 26 inter- 
stitial, and 132 abdominal. This, as well as the statements of 
other investigators, based upon researches of the same kind, 
must not be accepted as conclusive. In the present state of 
our knowledge, it is generally quite impossible to determine 
the portion of the genital tract in which the ovum is being 
developed, during the life of the patient. This statement ap- 
plies almost without exception to that large class of cases, in 
which recovery takes place, either through encysting of the 
fetus, its conversion into adipocere or calcareous matter, or its 
discharge through the abdominal wall, the alimentary canal, 
the vagina, or the bladder. Of Ilecker’s 64 cases of tubal 
pregnancy, only one is said to have lived; while of his 132 
examples of abdominal gestation, 76 survived. With our 
present facilities for arriving at the truth in regard to the 
location of the ovum, it is believed that we are not warranted, 
excepting in rare instances,3 in asserting that the ovum is de- 
1 This is the counterpart of tubo-ovarian pregnancy, and after the death 
of the patient it is often, indeed generally, impossible to determine whether 
the germ was arrested in the ovary or in the pavilion of the tube. 
2 Monat. fur Geb., Feb. 1859. 
3 Dela Faille {Monat. fur Geb., June, 1868, and Brit, and For. Med. Chir.- 
Rev., Oct. 1868) diagnosticated interstitial pregnancy in a woman under his FREQUENCY OF DIFFERENT VARIETIES. 
51 
veloped in any particular portion of the genital canal, unless 
we have the opportunity of making a post-mortem examina- 
tion. Even when this sad privilege is afforded, the records 
of many interesting observations bear witness to the fact, that, 
aside from the inherent difficulties of the subject, they have 
been conducted with so little care, that the results obtained are 
utterly unreliable. In the recorded histories of the various 
cases of extra-uterine pregnancy, the reader is often able to 
distinctly detect the coloring, which the teaching or precon- 
ceived opinions of the narrator have given to the facts. After 
excluding all cases of recovery by discharge through the ab- 
dominal wall, the alimentary canal, or genito-urinary tract, 
many cases of recovery after gastrotomy, in which the variety 
of the gestation was supposed to have been determined, during 
the hurry and dread of a critical operation, all cases of 
vaginal section which were not fatal, and all cases in which 
the appearances discovered at the autopsy were not described 
with sufficient care to warrant the deduction of correct con- 
clusions, we have the following as the result of an attempt to 
classify 500 cases of extra-uterine pregnancy :— 
The ovum being developed in the tube proper . . 149 
The ovum being developed in the pavilion : the tubo- 
ovarian, and tubo-abdominal varieties . . .34 
The ovum developed in uterine portion of tube : “ inter- 
stitial” or tubo-uterine pregnancy . . . .31 
Tubal 
214 
Ovarian 27 
Abdominal1 29 
Doubtful 230 
The above statement is of little value, but it is probably as 
nearly correct as any which has yet been made. The truth is, 
care, because he found that slight pressure on the uterus occasioned intense 
pain. The patient died when she was three months gone, and the diagnosis 
was verified by an autopsy. At a recent meeting of the Pathological Society of 
Philadelphia (Phila. Med. Times, 1874), Dr. Hodge related the history of a 
lady under his care, in which he and his father, the late Professor Hodge, 
diagnosticated tubo-uterine pregnancy. The uterus w'as dilated, and the child 
delivered pervicis naturales by rupturing the wall of the cyst felt through the 
uterus. This case is related in full in the chapter on treatment. 
1 Under this head are included only those cases which are believed to have 
been primary abdominal gestations. Secondary ventral pregnancies are in- 
cluded among those of the organ in which conception occurred. 52 
CLASSIFICATION OF MISPLACED CONCEPTIONS. 
that the profession is not in possession of any data, which will 
enable it to determine the relative frequency of the various 
forms of extra-uterine foetation. It is to be hoped that those, 
who have the care of patients suffering from this terrible acci- 
dent, will hereafter record their observations, especially those 
made post-mortem, in such a manner as to enable future 
workers in this fertile field, to gather a harvest, which will 
pay for the gathering. 
The above classification gives undue prominence to tubal 
pregnancy (considered as a whole). This is owing to the fact, 
that when the ovum has been arrested in the tube proper, (the 
portion of it between the pavilion and the uterus,) it is apt to 
terminate in death by rupture of the cyst at an early stage of 
gestation ; and that at this time the locality of the gravid 
cyst is easily determined at the autopsy. It is probable, how- 
ever, that pregnancy of this portion of the tube goes to term, 
much more frequently than is generally supposed—a subject 
which will be more fully discussed in the sequel. 
On the other hand, the tubo-ovarian and tubo-abdominal 
pregnancies of authors, and abdominal foetation, doubtless 
occur much oftener than 34 or 29 times in 500 extra-uterine 
conceptions. The same may also be true of ovarian gestation. CHAPTEE III. 
PATHOLOGICAL ANATOMY. 
First Stages of Pregnancy—Appearances when rupture of cyst has not occurred— 
Appearances after rupture—Quantity of blood effused—It bears no proportion to the 
extent of the rupture—Appearances of the foetal sac and adjoining parts—Mode of 
union between the ovum and the surface on which it develops—Changes in the uterus 
—The development of the decidua—The corpus luteum—Transmigration of the ovum. 
The appearances found after death vary greatly with the 
period of gestation at which the post-mortem examination is 
made. It is very rarely, indeed, that an opportunity is ob- 
tained to examine an unruptured cyst in the early stages of 
its development. Bussiere,1 Ollivier (d’Angers),2 and Stanley,3 
however, have been fortunate enough to be able to make such 
observations. 
The first of the cases occurred in France, in 1693. The 
woman had been condemned to death, and while awaiting 
execution had intercourse with one of her fellow prisoners 
and became pregnant. At the post-mortem, the fimbriated ex- 
tremity of the left Fallopian tube was found to be dilated into 
a cyst more than one inch in diameter. The dilated portion 
embraced the ovary so firmly, that the two structures could 
not be separated without injury to the tissues. The ovum 
was about the size of a hazel-nut. Ollivier’s patient died from 
rupture of some ovarian varices, while Stanley’s committed 
suicide by taking opium. The former was a right tubal con- 
ception, which occurred between five and six weeks before 
death. 
Stanley’s observation is of great interest, though it may be 
fairly asked, if the woman was really enceinte at the time of 
her death. There is no history of the pregnancy. The woman 
1 Pliilosoph. Trans., ab. ed., vol. iii. p. 605. 
2 Archives Generates de Med., 2d ser., tome v. p. 403. 
3 Trans. College of Physicians, London, vol. vi. p. 414. PATHOLOGICAL ANATOMY. 
was found insensible. Ho motive for suicide was known, ex- 
cept impregnation from illicit intercourse. At the autopsy, 
the uterus was found to be increased in size, and its cavity 
was lined by a soft, pulpy decidua, which was nearly half an 
inch in thickness. 
The cervix was filled with gelatinous matter. The append- 
ages were found to be unusually vascular. The bloodvessels 
of the broad ligament were greatly distended, and the Fallo- 
pian tubes were enlarged and very tortuous, from the pavilion 
until near their uterine termination. The lining mucous 
membrane was thrown into numerous loose folds. 
The pregnancy was supposed to be ovarian, and on the left 
side. Upon opening this organ a cyst was found. This is 
said to. have contained an ovum, which was simply in contact 
with the cyst wall, throughout two-thirds of its extent, and 
strongly adherent to it over all the remaining one-third of its 
surface. The chorion, amnion, and amniotic fluid are said to 
have been discovered, but no embryo could be found. . 
it is greatly to be regretted that the last statement is true, 
since some may call in question the existence of pregnancy. 
Had the embryo been found, the case would have been one 
of peculiar value, since the condition of the uterus and 
appendages, in a woman who perished in the early stages of a 
misplaced conception without rupture, is accurately described. 
The abridged account of Bussiere’s observation does not fur- 
nish the desired information, while Ollivier’s patient having 
been destroyed by hemorrhage from rupture of ovarian varices, 
the organs presented the same anaemic appearance which is 
found after rupture of the cyst. 
It is first necessary to decide whether or not the woman 
examined by Stanley was really pregnant. The great vascu- 
larity of the broad ligaments and Fallopian tubes, the increase 
in the size of the uterus, and above all, the existence of a 
decidua nearly half an inch thick in the interior of the organ, 
all strongly support the opinion that this was the case. The 
discovery of a cyst containing a sac consisting of two mem- 
branes, and which was adherent throughout one-third of its 
circumference, is strong corroborative testimony. The only 
thing that is needed to make this evidence complete, is, un- BEFORE RUPTURE. 
55 
fortunately, precisely what is wanting, the discovery of the 
embryo. However, the absence of this important structure 
among the contents of the ovular membranes, is not incom- 
patible with pregnancy. It is by no means impossible for the 
membranes to survive, and continue a certain form of develop- 
ment after the death of the germ. The frequent occurrence 
of hydatidiform degeneration of the chorion proves this fact. 
The phenomenon here described by Stanley, has likewise 
been seen in uterine pregnancy. During the past year, the 
products of several abortions, which occurred during the first 
few weeks after conception, have been exhibited to the Ob- 
stetrical Society of Philadelphia, in which the ovum, though 
otherwise perfect, contained no embryo. Dr. William Savery, 
of Bryn Mawr, presented two such specimens in a single even- 
ing. The presence of the decidua seems likewise to be conclu- 
sive evidence that impregnation had taken place in Stanley’s 
case. It is well known that a perfect cast forms in the interior 
of the uterus in certain forms of dysmenorrhcea, but in that case 
the history is entirely different from this. The coexistence of 
all the signs of impregnation, except the presence of the embryo, 
leads to the conclusion that, though the discovery of the latter 
is the crucial test, the woman had conceived, but the germ 
had died a short time afterwards, and that the development of 
the ovular membranes had not yet been arrested. 
This being granted, this case is the solitary example, among 
the five hundred that have been examined in the preparation 
of this work, which has been described with sufficient accu- 
racy to give a correct idea of the appearances of the genital 
apparatus in women, who die in the early stages of pregnancy, 
without rupture of the cyst. The duration of the gestation 
in this instance appears to have been uncertain, but it could 
not have been long, since the gravid ovary was not greatly 
enlarged. The most striking appearance presented by the 
organs concerned in reproduction was their extreme vascu- 
larity. This is analogous to what occurs after conception 
within the uterus, but it is reasonable to expect that when 
the ovum is arrested in its transit to the womb, and the nutri- 
tive irritation is removed from its normal seat to an abnormal 
one in the tube or ovary, the vascularity of the latter organs 56 
PATHOLOGICAL ANATOMY. 
would be found to be greater than when the ovum reaches the 
uterus. This fact is important in its bearings upon the occur- 
rence of rupture, and the hemorrhage that follbws as a con- 
sequence of it. 
After Rupture.—Before the period of quickening, death 
almost always results from rupture of the gravid sac. In con- 
sequence of the hemorrhage resulting from this accident, the 
cadaver is found to be pale and exsanguined. Upon opening 
the abdomen, the first thing which attracts attention, is the 
blood which has been effused. This may be either fluid or 
partly coagulated, and should always be removed with great 
care, so as to insure the recovery of the ovum if it has escaped 
from the foetal sac, and is free in the abdominal cavity. The 
blood is so very rarely found encysted, that this condition need 
never be expected to exist. The peritoneum is almost always 
found to be healthy. It is rarely inflamed, even if life has been 
prolonged for several days. 
The amount of blood poured out after rupture varies much 
in different cases. The quantity is sometimes very large. 
Watkins1 and Finnel2 found five pounds. Laidlaw wrote to 
Campbell,3 that he had seen between eight and ten pounds. 
Blizard,4 Ramsbotham,5 and Shurtleff,6 each found two quarts 
in the abdominal and pelvic cavities; Gavin,7 Flint,8 Fisher,9 
and McBride,10 each three. Hancox11 has seen four or five, 
Oaks,12 seven, and Finnel,13 ten quarts. In the last instance 
it was poured out in a few minutes. Dr. Clarke14 asserts that 
he found nearly a gallon in the abdominal cavity; while 
1 Buffalo Med. Journ., March, 1851. 
2 Med. Record (N. Y.), 1868, p. 76. 8 Loc. citat. p. 90. 
4 Trans, of Royal Soc. of Edinburgh, vol. v. 
5 Med. Gazette, 1849, N. S., vol. viii. p. 650. 
6 Nashville Journ. of Med. and Surg., Feb. 1860, p. 158. 
7 Lancet, 1840-41, vol. i. p. 135. 
s Nashville Journ. of Med. and Surg., Feb. 1860, p. 158. 
9 Ibid., p. 159. 
10 BuffaloJVIed. Journ., Jan. 1850, p. 467. 
11 Brit. Med. Journ., Dec. 17, 1859. 
12 Nashville Journ. of Med. and Surg., Feb. 1860, p. 160. 
3 New York Med. Journ., March, 1857, p. 237. 
14 Trans, of a Society for the Promotion of Medico-Chir. Knowledge, 8vo., 
London, 1793. AFTER RUPTURE. 
57 
Harris,1 and Cathcart,2 tell us that they respectively removed 
a half gallon and a gallon, at the autopsies of their pa- 
tients. Even these enormous quantities are said to have been 
exceeded. Hunt3 asserts that he has removed two and a half 
gallons from the abdomen of a woman, who died after rupture 
of a right tubal pregnancy of three months’ duration. The 
loss of blood may be so great as to necessarily result in death, 
but the shock resulting primarily from rupture of the cyst, 
and that which afterwards follows as the result of pressure 
from the effused blood, are no doubt important factors in 
brino-ino’ on the fatal issue. 
© © 
One of the most interesting facts in connection with this 
loss of blood, is that the amount discharged into the perito- 
neal cavity bears no proportion to the extent of the rupture. 
Some of the most severe hemorrhages occur when the orifices 
are very small. Bernutz and Goupil4 were aware of this fact. 
In Watkins’ case the rupture was only two lines in diameter. 
Clement records5 another in which the lesion was of the same 
size, though the abdominal cavity contained three litres of 
fluid blood and a large clot. In cases observed by Buck6 and 
Pierson,7 five pints and six pounds of blood flowed from 
orifices of the same length. Harris and Cathcart found the 
orifices but a trifle larger than this, and yet the one found a 
half gallon and the other a gallon of blood in the peritoneal 
cavity. The author very distinctly remembers the impression 
produced by the examination of the gravid cyst, removed from 
Dr. Cathcart’s patient. He had an opportunity of studying 
this carefully, and was very much impressed by the fact, that 
such a large quantity of blood could be discharged from such 
a small rent in a short time. It seems almost incredible that 
such’ a frightful hemorrhage could result from an injury so 
small in its extent. It is not without parallel however. 
1 Amer. Jjjurn. of Med. Sci., Jan. 1858. 
2 Phila. Med. Times, Dec. 27, 1878. 
3 Chicago Med. Examiner, 1870. 
4 Clin. Memoirs on Diseases of Women, N. S. Soe. Ed., 8vo., London, I860. 
5 Gaz. des Hopitaux, 1834, p. 245. 
6 Nashville Journ. of Med. and Surg., Feb. 1860, p. 159. 
i New York Med. Journ., July, 1859, p. 141. 58 
PATHOLOGICAL ANATOMY. 
Trousseau has directed attention to the fact, that in epistaxis, 
large quantities of blood may come from very small areas of 
mucous membrane. The author has seen the stomach dis- 
tended to its utmost capacity by a hemorrhage due to cirrhosis 
of the liver, and yet, has been unable to discover any orifice 
from which blood was discharged, in any portion of the mu- 
cous lining of the alimentary canal. 
As examples of more extensive ruptures, in which smaller 
quantities of blood were poured out, we may cite the cases of 
Blizard, two quarts from an orifice the size of a small quill; 
Thomas,1 six pints from a rupture one inch and a half long ; 
Gavin, three quarts from an orifice the size of a split pea; 
Lyman,2 two quarts from a rent one inch and a half long; 
Storer,3 three pints from an irregular rupture one-third of an 
inch iu length; McBride,4 three quarts from a wound that ad- 
mitted the finger; and Prof. Gibbes,5 one quart of blood from 
a lesion two and a half inches in length. 
It is a very interesting fact, that the hemorrhage from rup- 
ture of an extra-uterine foetal cyst is much greater than that 
which follows rupture of the uterus. It has been our bad fortune 
to meet with a number of examples of this melancholy accident, 
and in no instance was the quantity of blood effused surprisingly 
large, by no means so great as frequently follows the rupture 
of the cyst of an extra-uterine pregnancy. In Prof. Gibbes’ 
patient, the pregnancy was tubo-uterine. A careful examina- 
tion of the specimen, which he kindly permitted the author to 
make when at Columbia, S. C., in 1873, showed that the rent, 
which was a lacerated wound with irregular edges, was identi- 
cal in nature with that which occurs in rupture of the uterus. 
In many instances the lesions of the cyst of an extra-uterine 
fcetation have all the characteristics of an incised wound. At 
the autopsy of Dr. Cathcart’s patient, we were impressed not 
only by the amount of the hemorrhage, but also by the charac- 
ter of the laceration, which was an oval orifice about two lines 
in its greatest diameter, with sharply defined edges, as if a 
1 Med. Times, London, May 12, 1849, p. 570. 
2 of Med. and Surg., Feb. 1860, p. 161. 
3 Ibid., p. 162. 4 Buffalo Med. Journ., 1850, p. 467. 
5 Trans. Med. Soc. of South Carolina, 1872. AFTER RUPTURE. 
59 
portion of the peritoneal surface of the Fallopian tube had been 
removed with a punch. The hemorrhage resulting from such 
injuries as this one was, is likely to be much greater than that 
due to lacerated wounds of the cyst. The amount of the 
hemorrhage does not depend upon separation of the placenta. 
Some of the largest of these upon record have followed small 
injuries of the cyst with sharply defined edges, without ma- 
terial separation of the ovum, and without any disturbance at 
all of its placental portion. On the other hand, the cyst may 
rupture and the ovum or portions of it may escape without 
the loss of the excessive quantity of blood which has been 
observed in many cases. 
The partial or complete escape of the ovum through the rent 
does not increase the loss of blood, but, on the contrary, some 
of the most severe hemorrhages have followed minute ruptures 
of the cyst with complete retention of the product of concep- 
tion. Indeed it seems that complete discharge of the ovum is 
more favorable than its entire or partial retention. 
Rupture of the sac, during the first months after conception, 
has been supposed by many to be due to softening and slough- 
ing from inflammation of its walls, but the results of numerous 
post-mortem examinations, prove that there is no solid founda- 
tion for this opinion. It is generally the result of distension 
produced by the growing ovum in an organ not adapted for 
its development, and which, unlike the uterus, is not enlarged 
by vital changes, in proportion to the increase in the size of 
the product of conception. In other cases the autopsy shows, 
that the immediate cause of the accident is separation of the 
placenta, and hemorrhage into the cavity of the cyst, which 
gives way from internal pressure. 
After rupture in the early stages, the foetal sac presents ap- 
pearances which differ somewhat according to its location. 
Wherever it is situated the vascularity of the tissues involved 
is increased. Under the abnormal stimulus the bloodvessels 
of the part are increased, both in number aud size, but this 
may not be very apparent at the post-mortem examination, on 
account of the profound anaemia which results from the hemor- 
rhage, and which the internal organs share in common with 
all the tissues of the body. 60 
PATHOLOGICAL ANATOMY. 
The ovum, if arrested in that portion of the Fallopian tube, 
which is between the uterus and pavilion, has for its cover- 
ings the peritoneal, muscular, and mucous coats of that organ. 
If its progress is stopped in the uterine portion of the tube, 
the walls are additionally strengthened by a thicker layer of 
muscular tissue belonging to the uterus. If the pavilion alone 
is involved, only one portion of the ovum may he covered 
while the remainder may project into the peritoneal cavity, 
the chorion being entirely unprotected by any other tissues. 
At other times, as was observed by Bussiere, the fimbriated 
extremity contracts adhesions with adjoining organs, thus 
completing the cyst wall. 
It is the rule for pregnancy of the tube, or at least that por- 
tion of it which is between the uterine orifice and the pavilion 
of the organ, to terminate in rupture during the first period of 
the evolution of the ovum, or before the occurrence of quicken- 
ing. Under these circumstances the cyst is nearly always 
found to be free from adhesions, and its various coats can 
generally be demonstrated. The peritoneum rarely undergoes 
much change in this stage of the pregnancy. The muscular 
coat may be greatly thinned and atrophied, so that the retention 
of the ovum in its cavity is due almost entirely to the support 
of the peritoneum. As a rule, however, the muscular layer of 
the tube is found hypertrophied. Under the influence of the 
stimulus imparted by the presence of a vitalized germ in the 
cavity of the organ, the muscular fibres undergo hypertrophy, 
much as those of the gravid uterus do after a normal concep- 
tion. This process, however, is less rapid and energetic, than 
it is in the organ which was specially intended for the recep- 
tion and development of the product of conception. It cannot 
therefore keep pace with the increase in the size of the ovum, 
in consequence of which the muscular coat may present the 
appearance of being thinned and atrophied, even though the 
whole amount of muscular tissue may be increased. 
Dr. J. B. Hicks' reports that he found the outer layers of 
the tube contained some peculiar bands of connective tissue 
mixed with the muscular elements, in a woman who perished 
during the second month of gestation. 
1 Guy’s Hosp. Reports, 1860, 3d series, vol. i. p. 274. FORMATION OF THE PLACENTA. 
61 
One of the most interesting questions in connection with the 
pathological appearances of extra-uterine foetations in this stage 
of their development, is the determination of the nature of the 
connections which exist between the ovular and maternal tis- 
sues. It will be shown in the sequel that the villi of the chorion 
have to make their connections with the maternal tissues with- 
out the intervention of any deciduous membrane. Kussmaul1 
even asserts that the mucous membrane of the tube which is 
beneath the placental portion of the ovum may become com- 
pletely atrophied. Dr. Ilicks2 thus describes the microscopical 
appearances, presented upon the examination of specimens 
removed from a patient, who died of rupture of the cyst, under 
the care of Dr. Roper. The woman had menstruated for the 
last time on February 26th and the five succeeding days. She 
died on the 8th of the following April. Speaking of the sac 
which contained the foetus, he says: “The inner surface of 
this cavity was covered with the ciliated columnar epithelium 
proper to the mucous membrane of the Fallopian tube (and 
which it originally lined), and upon this surface the terminal 
tufts of the villi spread out, the epithelium remaining upon 
the parts not occupied by them. These terminations of the 
villi do not enter the substance of the tube wall, which was 
apparently too solid and dense, but seemed merely adherent 
to it, a very minute portion of plastic matter seeming to assist 
at the points of contact. The coats of the villi were single as 
far as could be detected, so that the placenta was purely ovular. 
That there was no maternal structure entering into the com- 
position of the placenta could be further proved by close ex- 
amination. The maternal vessels ramified beneath the epithe- 
lium-covered surface, where they could be seen in some places 
only slightly raised above the level. These capillaries were 
evidently enlarged and numerous, but not so much as the 
uterine decidual membrane.” 
In another case3 of tubo-uterine pregnancy in which the 
gestation was rather further advanced, not a trace of a de- 
cidual membrane could be found surrounding the chorion.4 
1 Quoted by Keller, loc. citat. p. 26. 
2 Loc. citat. p. 274. 3 Ibid., p. 276. 
4 The uteri of both of these women were lined by a decidua which had all 
the microscopical characters of that membrane in normal pregnancy. 62 
PATHOLOGICAL ANATOMY. 
The villi, as in the preceding case, “possessed only a single 
coat and spread over, but did not enter, the uterine tissue to 
which they were affixed. No membrane at that part was 
to be detected. Beneath the inner surface, immediately in 
contact with the villi, the uterine vessels spread themselves 
out, flattened, and so numerous that the whole substance 
must have been almost as one bloodvessel, only the delicate 
membrane of the vessels, separating the maternal blood from 
the villi where they are in contact.” From these statements 
it appears, that, at least in this early stage of misplaced preg- 
nancy, the maternal portion of the placenta is absent, and 
that there is no direct union between the foetal and maternal 
tissues. The villi of the chorion are applied to the mucous 
membrane of the tube, with which they contract adhesions, 
and the ovum is nourished by endosmotic action. 
A comparison of these conditions with those to be met with 
during the same stages of uterine gestation, reveals both im- 
portant differences and likenesses. Dr. George J. Englemann, 
of St. Louis, has recently investigated1 the changes which take 
place in the uterine mucous membrane after conception. After 
describing the process of cell-proliferation which results in 
the formation of the membrana decidua, he states that Prof. 
Keichert examined a uterine ovum, twelve or thirteen days 
after impregnation, and found that no connection existed be- 
tween the serotina and the ovum. 
Dr. Englemann himself found the union between the chorion 
and the hypertrophied mucous membrane to be very superfi- 
cial in the second month of pregnancy. The connection which 
existed was, however, twofold in its origin. It was partly 
“ owing to an agglutination of villi,” to slight depressions and 
projections on the decidua serotina, “ the parts being simply 
superimposed and cemented by a connecting medium of 
tenacious mucus and detached epithelium ; the continuity of 
the lining epithelium had been destroyed, and thus a more 
1 The Mucous Membrane of the Uterus, with special reference to the de- 
velopment and structure of the decidua?, 8vo., New York, 1875, and Amer. 
Journ. of Obstetrics, May, 1875. FORMATION OF THE PLACENTA. 
63 
favorable surface was presented for an agglutination of the 
approximating elements.” The second element in establishing 
the connection between the ovum and the mother is the active 
proliferation of the cells of the decidua serotina, which en- 
velops the delicate villi of the chorion in its growth. 
These very interesting observations of Englemann have 
additional interest from the fact, that they confirm those of 
Dr. J. Braxton Hicks, who has carefully described the connec- 
tions by which the ovum is attached to the interior of the 
uterus at this early period of its normal development. The 
latter author has likewise clearly called attention to the two 
forces which are concerned in establishing this union. Both 
agree that the uterine follicles play no part in this important 
process, and that the villi of the chorion, if they enter these 
glands at all, do so very rarely, and then only for a very short 
distance. 
It appears, therefore, that in extra-uterine pregnancy hut 
one force is concerned in establishing the connection between 
the ovum and the surface upon which it is engrafted. This is 
a vital adhesion between the villi of the chorion, and the tissue 
with which they come in contact, aided by the presence of 
more or less plastic material. It differs from the same process 
in the uterus in the absence of the decidua, the subovular por- 
tion of which—called the serotina—plays an important part 
in establishing a connection between the ovular and maternal 
tissues by means of the active proliferation of its cells. 
In pregnancy of the portion of the tube which is outside of 
the body of the uterus, the canal of the organ is generally 
found occluded, on both the proximal and distal side of the 
cyst after death from rupture. The contrary has been asserted 
by Gardien,1 who says that a communication is constantly 
formed between the cavity of the cyst and the uterus in these 
cases. Desormeaux2 almost repeats Gardien’s statements, and 
adds that the communication is sometimes very small, while 
at others the opening is notably dilated. Such a condition 
must be very rare, or, if common, it has escaped the notice of 
1 Traite Complet d’Accouchemens, 8vo., Paris, 1824, tome i. p. 523. 
2 Diet, des Sciences Medicales, Paris, 1829, tome vii. p. 270. 64 
PATHOLOGICAL ANATOMY. 
reporters of cases of rupture.1 It is rare even to find the tube 
recorded as patulous as far as the cyst, though Ilun2 has no- 
ticed this in a woman who was three and a half months gone 
when she died. 
This is a matter of some consequence, for the occlusion of 
the tube, discovered after death, has been erroneously looked 
upon as a cause of extra-uterine pregnancy, when it is only 
an effect. As a result of the irritative vital changes going on 
in the organ from retention of a fertilized germ, plastic matter 
is poured out into the tissues, and the canal of the oviduct is 
obliterated. 
There is one matter in relation to conceptions of that por- 
tion of the oviduct which is between the pavilion and the 
exterior of the uterus which demands a brief notice. Kuss- 
maul, in his work upon malformations of the uterus, already 
alluded to, asserts that the pathological appearances are often 
misinterpreted under these circumstances, and that pregnan- 
cies in the undeveloped horn of a unicorn uterus have often 
been mistaken for those of the tube proper. Indeed, Kuss- 
maul expresses3 the belief that “a very large proportion” of 
the cases, which have been described in medical literature as 
gestations of the tube, are nothing more than examples of con- 
ceptions in an undeveloped uterine horn. 
Pregnancies of the latter class run very much the same 
course as that pursued by those of the tube. They generally 
terminate in rupture, and the death of the woman shortly 
after the middle of gestation.4 Under these circumstances it 
1 It is an interesting fact, that in most cases of pregnancy in the rudi- 
mentary horn of a unicorn uterus, the fruit-sac is shut off from the Fallopian 
tube on one side, and the developed half of the uterus on the other. At the 
same time the corpus luteum and the ovum are found on the same side, lead- 
ing to the conclusion that the canal of the “super-horn” becomes occluded 
after impregnation has taken place. 
2 New York Med. Journ., Oct. 1869, p. 40. • 
3 Review of Kussmaul’s Work, Edinburgh Med. Journ., July, 1860, p. 59. 
4 Kussmaul has collected thirteen cases, all of which terminated in death 
by rupture between the fourth and sixth months. The largest number gave 
way in the fifth month—a later period than that at which tubal gestations 
generally burst. Luschka has reported a case in which rupture occurred as 
early as the tenth week. Fritze met with another in which, contrary to the MALFORMATION OF THE UTERUS. 
65 
is not generally a difficult matter to determine the true nature 
of the condition. If the gravid cyst is tubular, the oviducts 
on the two sides will be found entering the womb at oppo- 
site points, and at the usual position on the right and left 
halves of the organ. The uterus itself will be found sym- 
metrical and normal in its development. 
The uterus unicornis, or one in which only one of its primor- 
dial divisions has undergone complete development, is of a 
conical or cylindrical outline, and occupies an oblique position 
in the pelvis. One side, that furthest from the middle of the 
body, presents the concave outline of the developed uterus, 
but the opposite margin is convex. The rudimentary horn 
joins the developed portion of the organ somewhere on this 
convex side, it may be but a short distance below the tube of 
the opposite side in cases where the development of the 
“ super-horn” is moderately complete ; or, where the foetal con- 
dition is preserved, the junction may occur in the region of 
the cervix.1 
Ingleby, Selwyn, Day, and a number of others, have re- 
corded cases of death from rupture of the embryiferous sac, 
in which the pathological appearances just mentioned were 
found after death, and which were supposed by those describ- 
ing them to be examples of tubal gestations. The author 
has examined the records of the post-mortem appearances in 
a large number of cases of rupture in the early stage of preg- 
nancy of the tube, and he is unable to confirm the observation 
of Kussmaul, “that a very large proportion of the cases” 
described as tubal fcetations are, in reality, pregnancies in the 
undeveloped horn of a unicorn uterus. The appearances of 
this malformation are so striking, that it is not likely they 
would habitually escape observation. They are certainly 
usual rule, the fruit-sac did not rupture. The embryo died at the end of the 
fifth month, and was carried for thirty-one years, when suppuration occurred. 
(Barnes, Diseases of Women, 8vo., Phila. 1874, pp. 391-2.) 
1 It is even stated that the rudimentary horn may open into vagina, near 
the cervix of the developed half. Canestrini, Historia de Utero Duplici, 
Alterutro Quanto Graviditatis Mense Rupto, in Hungaria, A. D. 1781, in 
Cadavere ab auctore invento. Augusta; Vindelic, 1788, quoted by Kussmaul’s 
Reviewer (Loc. citat. p. 59). 66 
PATHOLOGICAL ANATOMY. 
rarely mentioned among the post-mortem appearances in cases 
recorded as tubal foetations. 
Tubo-uterine pregnancy presents some anatomical peculiari- 
ties with which it is important to be familiar. As in gesta- 
tions of other portions of the oviduct, the internal or uterine 
orifice of the tube may become occluded, as was noticed by 
Schmidt1 in the first example of this variety of tubal foetation 
ever recorded. Granville2 asserts that this is an invariable 
condition. In this he is in error, for the uterine orifice of the 
tube may sometimes remain patulous. Upon opening the 
right or gravid tube lengthwise, in a woman who had died 
when five months gone, Poppell3 exposed two cavities. The 
lower one was that of the uterus lined by a decidua. The 
upper one, the ruptured foetal sac, was divided from the lower 
of the two by a partition of muscular fibre, but communicated 
with it by an orifice which would admit the finger. The 
history of tubo-uterine pregnancies which go beyond the early 
months of pregnancy confirms this observation. 
The fruit sac, in all cases belonging to this variety, is formed 
of that portion of the oviduct which traverses the uterine wall. 
The portion exterior to this is rarely if ever involved. One 
wall of the cyst may give way at an early stage of the gesta- 
tion and allow the ovum to escape into the tissue of the uterus, 
where its development may be continued. 
After death from rupture in the early stages it is sometimes 
difficult to determine the exact locality of the embryiferous 
sac. Virchow has called attention to the fact that the posi- 
tion of the round ligament will aid in deciding this question. 
This structure leaves the uterus at the point where the Fal- 
lopian tube joins the organ. If the gravid cyst is outside of 
the attachment of the round ligament, the pregnancy is tubal 
simply. If inside of it, the embryo is either contained in the 
uterine portion of the tube, or the rudimentary horn of a 
double uterus. Baart de la Faille, who recognizes the diffi- 
culty of distinguishing a tubo-uterine pregnancy from a foeta- 
1 Mem. et Observat. de l’Acad. Med.-Chir. de Vienne, 1801. 
2 Graphic Illustrations of Abortion, 4to., London, 1834, p. 33. 
5 Monats. fur Geb., Feb. 1868, and Brit, and For. Medico-Cliir. Rev., Oct. 
1855, p. 559. THE UTERUS. 
67 
tion in a rudimentary horn, says that this may be done by 
remembering that, in the former case, there is a membranous 
wall, such as was observed by Popped, between the gravid 
sac and the uterine cavity ; while, if the ovum is contained in 
a rudimentary horn, the fruit sac is joined to the developed 
half of the uterus by a muscular band. 
In ovarian pregnancy the foetal cyst is devoid of a peritoneal 
covering. The researches ofWaldeyer have shown that the 
peritoneum is not prolonged over the surface of that organ. 
The chorion is in immediate contact with the interior of the sac. 
Rupture generally occurs during the first period of gestation. 
The opportunity to make a post-mortem examination of 
primary ventral gestations during the first months succeeding 
impregnation, rarely occurs; but when it does it will be found 
—the germ being free in the peritoneal cavity—that the cho- 
rion is unsupported during the earliest stages of the pregnancy 
by any other tissue. It projects uncovered into the peritoneal 
cavity, excepting on that part of its surface by which it becomes 
united to the serous membrane. 
The method by which the ovum establishes its connection 
with the maternal tissues in ovarian and primary ventral preg- 
nancies has not been studied, so far as we are aware, but it is 
not probable that the process differs in any way from that 
which has been described in connection with tubal gestations. 
The uterus after death from rupture in the early stages is 
found to be more or less enlarged. It always undergoes, to a 
greater or less extent, those changes which prepare it for the 
reception of the ovum. The organ is more vascular than nat- 
ural, and its cavity is often found to be lined with a decidua.- 
This is absent only when it has been discharged before the 
death of the patient. The cervix is filled with a plug of thick 
gelatinous mucus, precisely as it is in normal gestation. The 
uterus, although prevented from discharging its functions, 
prepares to do its work precisely as if the fertilized germ had 
entered its cavity. 
The development of the decidua demands more than the 
brief allusions which have previously been made to it, and it 
will be fully considered in this place, as this will enable the 68 
PATHOLOGICAL ANATOMY. 
reader to more readily understand some of the symptoms 
which will be discussed. v 
The development of the decidua in extra-uterine pregnancies 
has given rise to much discussion. Even at the present time 
opinions are very varied in regard to it, some contending that 
it is formed in the uterus in all cases, and others that it lines the 
extra-uterine gravid cyst. The most prominent advocate of 
the latter opinion is Dr. Robert Lee,1 who has insisted with 
great force that the decidua always surrounds the ovum. In 
this opinion he is supported by Churchill,2 Schrceder Van-der- 
Kolk, and Leishman.3 Barnes4 appears to entertain the same 
opinion, while Clarke,5 Virchow, Oldham,6 Kiwisch, Ramsbo- 
tham,7and Cazeaux8 believe that the decidua is always formed 
in the uterus. Hodge9 asserts that it is generally produced 
here, while Blundell, Granville,10 and Behier11 believe that it 
is sometimes, but not always, formed in the uterus. Barnes12 
also says, that in abdominal pregnancy, the decidua is not 
formed in the uterus,13 thus leading to the inference that in tubal 
gestations, the membrane is sometimes formed in the interior 
of the oviduct. To complicate the subject still further, Chaus- 
sier14 lias described a case in which he asserts that the uterus 
and gravid sac were both lined by this membrane, and Rog- 
1 Lond. Med. Gaz., June 5, 1840, p. 436, and Trans. Medico-Ckir. Soc. 
London, 1858, vol. xli. p. 137. 
2 Theory and Practice of Med., 8vo., Pliila., 1862, p. 186. 
3 Syst. of Mid., 8vo., Glasgow, 1873, p. 210. 
4 Dis. of Women, 8vo., Pliila.. 1874, p. 362. Speaking of rupture of the 
cyst, he says : “ Frequently the chorion and decidua remain attached to the 
sac.” On page 370 he asserts that “in the case of tubal gestation partial 
detachment [of the ovum] is very easy, owing to the scanty development of 
decidua.” 
5 Trans, of a Society for the Improvement, etc., 8vo., London, 1793, p. 216. 
6 Guy’s Hosp. Reps., 1843. 
7 Prin. and Pract. of Obstet. Med. and Surg., 8vo., Pliilada., 1865, p. 572. 
8 Bull, de la Societe Anatomique, Sept. 1836. 
9 Prin. and Pract. of Obstet., 4to., Pliila., 1866, p. 532. 
10 Graphic Illustrations of Abortion, etc., 4to., London, 1843, p. 31. 
11 Gaz. Hebdom., No. 86,1873. Loc. citat. p. 370. 
13 This author’s opinions seem to be somewhat undecided. Without posi- 
tively stating his position, it may be inferred that he believes that the de- 
cidua is formed both in the sac and in the uterus. 
14 Journ. de Med., May, 1814. THE DECIDUA. 
69 
ers,1 and Schrceder,2 both believe that the decidua is formed 
in both of these localities. 
Iti order to harmonize these diverse opinions, several facts 
must be taken into consideration. Dr. Lee’s views must be 
considered exceptional. They were at variance with those of 
many of his contemporaries,3 and were based upon recent post- 
mortem investigations and the examination of specimens 
contained in various London museums. Announced in 1840, 
Lee continued to publicly advocate the opinion that in extra- 
uterine fcetation, the cyst was always lined by a decidua for 
the space of eighteen years. As his views are diametrically 
opposed to those of equally competent observers, it must be 
concluded that there was an error of observation upon one side 
or the other. Clinical experience, and the examination of the 
records of many cases, lead to the conclusion that this was 
upon the part of Dr. Lee. It is greatly to be' regretted that 
the earnestness and energy expended in the support of these 
opinions were not directed in a channel in which they would 
have forwarded, and not have imjpeded, the advance of knowl- 
edge. 
Though Hennig has asserted4 that there is a greater sirni- 
1 Extra-uterine Fcetation and Gestation, 8vo., Phila., 1867. “As the evi- 
dence now stands, the decidua is as uniformly found surrounding the ovum 
in the tube as it is about the ovum in the cavity of the uterus.” (p. 10.) 
“ Dr. Robert Lee to the contrary notwithstanding, I am convinced, by the 
evidence afforded by a somewhat extended research, that an intra-uterine 
decidua is invariably formed in extra-uterine pregnancy.” It was because 
he supposed that the ovum must be surrounded by some product developed 
by the mucous membrane of the genital tract, that Rogers (see p. 17) was led 
to deny the occurrence of ventral pregnancy. Campbell’s views were very 
much the same. 
2 Manual of Midwifery, 8vo., N. Y., 1873, p. 130. 
3 Dr. Lee’s papers are based, especially the second, upon a re-examination 
of previously described specimens. When these views were promulgated 
they exerted a considerable influence. Clayton, for example, states (Lancet, 
1840-41, vol. xl. p. 654), in the account of the post-mortem of his patient, 
that the decidua was found in the uterus. This was undoubtedly true, but in 
the same journal (vol. xli. p. 28) he refers to the same case again, and denies 
that the decidua was formed in the uterus, and asserts that it surrounded the 
ovum. The change of opinion is explained by the fact that Dr. Lee had seen 
the specimen in the interval, and had succeeded in convincing Dr. Clayton 
that the facts were incorrectly reported. 
4 Monats. fur Geb., 1869. 70 
PATHOLOGICAL ANATOMY. 
larity between the behavior of the tubal and uterine mucous 
membranes than is generally believed, even he throws grave 
doubts upon the existence of an extra-uterine decidua in tubal 
pregnancies. It is no part of the function of the mucous 
membrane of the Fallopian tube, and still less, that of the 
membrane lining one of the G-raafian vesicles, to form a de- 
cidua. The latter is concerned in the development of the 
ovule, and the former in its transmission to the uterine cavity, 
where its growth and development are to take place. In the 
human female no important additions, either for the nutrition 
or development of the new being, are made in the oviduct. 
Heat and moisture are necessary for the maintenance of the life 
of the ovum during its descent, and these it is the office of the 
tube to furnish. In this particular, it is governed by the same 
laws that control germinal matter, whatever may be its endow- 
ments and in whatever situation it may be found. 
It is a well established fact that in extra-uterine, the uterus 
undergoes changes similar to those of normal pregnancy. 
Boehmerus1 long ago announced that the organ enlarged, be- 
came more vascular, and that a decidua was formed in its 
interior; in other words, that the changes, which ordinarily 
take place to fit it for the reception of the ovum, are not stop- 
ped by the arrest of the latter during its passage to the womb. 
In 1773, it was stated3 that during the previous winter 
Hunter had met with a case of tubal pregnancy in which 
death was due to rupture of the cyst. The uterus contained 
a decidua, and Hunter stated that this confirmed two theories 
previously announced by him, viz., that the decidua belongs 
to the uterus, and is formed in it, and that in pregnancy this 
organ is not enlarged mechanically by the growth of its con- 
tents. The opinion of this astute observer, thus plainly ex- 
pressed more than a century since, may be still accepted as 
the truth, and had others been equally careful in their inves- 
tigations, a great deal of useless discussion would have been 
avoided.3 
1 Observat. Anatom. Rar., 1752. 
2 Medical Commentaries, 8vo., London, 1773, p. 429. 
3 The credit of discovering that the decidua is formed in the uterus, in 
extra-uterine gestation, is by some given to Hunter. This is erroneous. It 
really belongs to Boelimerus. THE DECIDUA. 
71 
Much of the difficulty has arisen from the fact, that at 
the time of the death of the patient, even in the early stages 
of tubal pregnancy, the uterus is frequently found without 
any decidua in its cavity. Ollivier (d’Angers)1 and Flint2 
found it absent in women who died when they were six weeks 
gone, Marshall3 in one who was eight weeks gone, and Douchez4 
and Pize5 each record the fact, that they failed to find it in cases 
in which death occurred in the tenth week of gestation. The 
absence of a decidua in the uterus, when a post-mortem ex- 
amination is made, is no proof that it has not been formed in 
that organ. The failure to recognize this important fact has 
led to numerous errors. Its absence at the post-mortem ex- 
amination only shows, that the membrane has been previously 
discharged. This may occur piecemeal, with the hemorrhages 
which are so common in extra-uterine pregnancy, or it may 
be voided entire, with pain and other symptoms of abor- 
tion, which lead to the diagnosis of that accident.6 The 
1 Arch. Gen. de Med., 2d ser., tome v. p. 403. 
2 Nashville Journ. of Med. and Surgery, Feb. 1860, p. 158. 
3 Trans. Obstet. Soc. London, 1864, vol. v. p. 154. 
4 London Med. Gaz., Oct. 2, 1830, p. 11. 
6 Bull, de la Soc. Anatomique, 1853, p. 40. 
6 Towards the close of the third month something resembling a mole was 
discharged from the vagina. (Ucelli, Biblioth'eque Med., tome xxxviii. p. 
265 ; Journ. des Connais. Med.-Chir., 1837, p. 4.) When about two months 
pregnant, had much pain with vomiting and straining after exertion. A 
few days later the decidua was voided with hemorrhage. (Martin, Monats. 
fur Geb., Feb. 1868; Brit, and For. Med.-Chir. Bev., July, 1868.) When 
supposed to be six weeks pregnant she had vaginal hemorrhage and much 
pain. It is stated that the placenta was probably discharged at this time. 
(Finnel, Med. Record (N. Y.), 1868, p. 76.) The patient was about four 
months gone. Retroversion of the uterus was diagnosticated and an attempt 
made to induce abortion by introducing a catheter into the uterus, and the 
decidua was discharged. (Young, Trans. Med.-Chirurg. Soc. of Edinburgh, 
1829, vol. iii. p. 536.) A membrane was discharged when the patient was 
about four months gone, which was supposed to be an ovum. (Perkins, 
Phila. Med. Times, 1872, and Amer. Journ. of Obstet., May, 1872, p. 155.) 
In this instance the discharge of the decidua led Dr. Goodell, who saw the 
patient in consultation with Dr. Perkins, to conclude that she had aborted, 
and was at that time the subject of pelvic inflammation. The same 
woman was subsequently examined by the author, in consultation with 
Dr. P. The physical signs of pregnancy were then very manifest, and it 
was concluded that there was originally a twin conception, that one of the 72 
PATHOLOGICAL ANATOMY. 
discharge of the decidua en masse, is frequently accepted as 
confirmatory evidence of miscarriage, not only by the nurse 
but by the physician. 
On the other hand, though rarely, the decidua may be found 
at an autopsy made at the very close of gestation. This 
is proved by the fact that it has been expelled in the false 
labor, which nearly always occurs in extra-uterine pregnancy, 
at or near the completion of the normal period of gestation. 
James1 witnessed its discharge at the end of the seventh 
month. Pletzer,2 Hennigsen,3 and Hemard,4 have seen it re- 
tained to term, and cast off during spurious labor.5 Kajar’s6 
patient probably retained it eight weeks beyond the time 
when gestation was completed. 
The only testimony adverse to the conclusion that in these 
abnormal pregnancies the decidua is invariably formed in the 
uterus, and which is based upon observation, is that of Dr. 
Lee. Upon the opposite side are a number of accurate ob- 
servers, the weight of whose evidence is enough to convince 
us, that this veteran authority is in this matter biased in his 
opinion. Those who, like Rogers and Schrceder, believe that 
the decidua is formed both in the uterus and around the ovum 
—and those who, like Barnes and Tanner, seem to be in doubt 
about the matter, appear to derive their views from tradition, 
and not from the examination of pathological specimens. 
The truth in regard to this matter may be briefly summed 
up in the following propositions:— 
1. In all varieties of extra-uterine pregnancy a decidua 
ova had perished and been thrown off. Extra-uterine foetation was not 
suspected. 
1 North Amer. Med. and Surg. Journ., 1827, vol. iv. p. 283. 
2 Monats. fur Geb., April, 1867, and Brit, and For. Med.-Chir. Rev., Oct. 
1867. 
3 Arch, fur Gynakol., 1870 ; New Syd. Soc. Bien. Ret., 1869-70, p. 397. 
4 Lancet, 1844, vol. ii. p. 74. 
5 At the end of the ninth month “ something like a mole” was extruded from 
the uterus. (Noun. Journ. de Med.-Chir. et Pharrn., vol. xv. p. 51.) At 
the end of the ninth month, had labor-pains, which continued very severe till 
the end of the tenth month, when she expelled a “ mole” the size of a pul- 
let’s egg. (Lalanne, Annal. de la Med., Jul. 1825.) 
6 Med.-Chir. Rev., Jan. 1837, p. 208. 73 
THE CORPUS LUTEUM. 
forms in the uterine cavity, as in normal gestation, but none 
surrounds the ovum. 
2. The decidua is rarely retained until the completion of 
gestation, and thrown off during false labor. More frequently, 
if the patient goes to term, it is discharged during the early 
periods of pregnancy in small fragments, and without pro- 
ducing pain; or else it is expelled en masse with symptoms of 
miscarriage. 
3. The absence of a uterine decidua when death has oc- 
curred from rupture of the cyst, even in the early stages of 
pregnancy, is not proof that the membrane has not been 
formed, but simply that it has been expelled before the death 
of the patient. 
The Corpus Luteum.—Those portions of the uterine appen- 
dages, which are not involved in the foetal cyst, present no 
unusual appearances except ansemia in cases of death from 
rupture, and profound congestion in those in which death 
results from causes unconnected with the pregnancy. The 
corpus luteum is formed as it is after normal conceptions, and 
differs in no manner from that found in the ovary of women 
perishing during uterine pregnancy. 
Its presence is the rule, its absence the exception, especially 
in the early months of gestation. It is a curious fact, how- 
ever, that in a certain number of the cases of misplaced gesta- 
tion, the corpus luteum has been found in the ovary which is 
on the side opposite to that occupied by the gravid cyst. 
There is reason to believe that this, though not peculiar to 
them, occurs more frequently in extra-uterine than in normal 
pregnancies.1 Drejer, of Copenhagen, described2 an example 
of transmigration of the ovum, in 1837; Meigs, of Philadel- 
1 This phenomenon is not peculiar to the human female. Bischoff, in 1842, 
published a work called “ Die Entwicklung des Kunincheneirs,” in which 
he announced the fact that he had observed migration of the ovum in bitches. 
Later he wrote to Kussmaul that it often happens in the deer. See review of 
Kussmaul’s work, “ Yon dem Mangel der Yerkiimmerung und Yerdopplung 
der Gebarmutter,” etc. etc., Wurzburg, 1859. (Edinburgh Med Journal, 
1860, vol. vi. part i. p. 275.) 
2 Amer. Journ. of Med. Sciences, 1837. The case was one of pregnancy 
in a rudimentary uterine horn. 74 
PATHOLOGICAL ANATOMY. 
phia,1 one in 1839; and Oldham,2 of London, another in 1845. 
Stedman,3 Lee,4 Kussmaul,5 Shultze,6 Poppell,7 Saddler,8 and 
Sager,9 have likewise observed cases of extra-uterine foetation 
with transmigration of the ovum. 
Two explanations of this phenomenon have been offered, one 
by Oldhani10 and the other by Tyler Smith.11 According to 
the former, the tube of the opposite side, and the one in which 
the ovum is finally developed, reaches entirely across the pelvic 
cavity and grasps the ovary from which the germ is liberated. 
The latter believes that the ovum descends to the uterus 
through the tube on the side upon which it is developed, enters 
the womb, crosses its cavity, enters and ascends the opposite 
tube. We have not been able to discover any facts which sup- 
port the views of Smith, while Oldham’s explanation of this 
peculiar phenomenon is rendered extremely probable, not 
only by the anatomical peculiarities of his own case, but also 
by several observations which have been made by other writers 
upon this subject. Sager12 found both corpora lutea in his 
case of combined intra- and extra-uterine pregnancy in the 
right ovary, while the aberrant gestation was in the left tube. 
The right Fallopian tube was perfectly normal, except that the 
pavilion was practically bridled by some of its fimbrire being 
attached to the opposite side, so that the tube could not grasp 
the ovary. As death occurred in the eleventh week of gesta- 
1 Med. Examiner, Pliila., Nov. 9,1839, p. 709, and Obstetrics, 8vo., Phila., 
1852, p. 270. The reviewer of Kussmaul’s work, above alluded to, says that 
migration of the ovum “was first observed by BischofF.” Drejer and Meigs 
both preceded him, however, as will be seen by reference to the dates 
cited. 
2 Guy’s Hosp. Reports, 1845, p. 272. 
3 Boston Med. and Surg. Journ., 1856, p. 470. 
4 Trans. Medico-Cliir. Soc. London, 1858, vol. xli. p. 141. 
5 Two cases. Schmidt’s Jalir., No. 9,1859, and Brit, and For. Medico-Cliir. 
Rev., Oct. 1859, p. 555; Monats. fur Geburtsk., Oct. 1862, and Brit, and For. 
Medico-Chir. Rev., Jan. 1863, p. 271. 
6 Wurtz. Med. Zeitsch., 1863 ; New Syd. Soc. Year Book, 1864, p. 364. 
i Monats. fur Geb., Feb. 1868; Brit, and For. Med.-Chir. Rev., July, 1868, 
p. 253. 
8 Med. Times and Gazette, Aug. 5, 1865, p. 140. 
9 Michigan Univ. Med. Journ., Oct. 1870. 10 Loc. citat. 
11 A Course of Lectures on Obstetrics, 8vo., New York, p. 241. 
12 Tanner, Signs and Diseases of Pregnancy, 8vo., Pliila., 1868, p. 288. TRANSMIGRATION OF THE OVUM. 
75 
tion, there is no reason to believe that this pathological change 
occurred after the woman conceived. Farre has described a 
preparation which is in the Anatomical Museum of Cambridge, 
in which both tubes are simultaneously grasping the same 
ovary to which they have been attached by adhesions, and 
Rokitansky, in examining the body of a woman who died 
after uterine pregnancy, found the corpus luteum on the left side 
while the corresponding tube was much thinned, impervious, 
and its pavilion adherent to the sigmoid flexure of the colon. 
This eminent authority in pathological anatomy believed that 
this condition existed before pregnancy occurred, and that the 
ovum passed down by the tube of the opposite side. Oldham’s 
views are still further confirmed, by Luschka’s case of preg- 
nancy in a rudimentary uterine horn.1 The corpus luteum 
was on the left side, and the left horn was normal. The right 
or gravid horn ruptured in the third month. At the autopsy the 
latter was found to be connected with the opposite side by a 
round solid cord. There is no reason to believe that this was 
pervious at the time conception occurred, and hence the only 
explanation of the phenomenon is, that the ovum passed down 
upon the side opposite to that upon which it was developed. 
Intra-uterine transmigration of the ovum, as described by 
Tyler Smith, is supported by few if any facts. Its possibility 
is denied by Klob2 while Tanner3 appears to believe it can 
happen, and quotes Scanzoni’s case of pregnancy, in a left rudi- 
mentary uterine born, as demonstrating its occurrence. There 
is nothing, however, in the account of this case which makes 
it necessary to accept this explanation, and therefore the 
conclusion may be legitimately drawn, that, in the majority of 
instances at least, the ovum passes down the tube, opposite to 
the ovary in which it is developed, and that as yet we have 
no positive evidence that intra-uterine transmigration of the 
ovum ever happens. 
It may, however, be doubted whether it is necessary for the 
tube of the opposite side to be brought into actual contact with 
1 Monats. fur Geburtsk., Band xxii. p. 31, 1863. 
2 Wochenblatt d. Ztschr. d. k. k., Ges. d. A. in Wein, 1861. Quoted by 
Barnes, loc. cit. p. 369. 
3 Signs and Dis. of Preg., 8vo., Phila., 1868, p. 288. 76 
PATHOLOGICAL ANATOMY. 
the ovary, for this to occur. Kussmaul has asserted that it is 
not necessary for the fimbriated extremity and the ovary to be 
brought together, in order that the tube should receive the 
ovule. He believes that in the human female, as in the am- 
phibia, the germ has to traverse a portion of the peritoneal 
cavity in order to reach the oviduct. The force which enables 
it to make this short but perilous journey, is not inherent 
within itself, but, as Muller and Becker assert, it is probable 
that it is carried to the oviduct by a current, which constantly 
flows from the ovary to the pavilion. This explanation is not 
so unlikely as it may at first appear. That the cilia of the 
tube, constantly waving as they do, towards the uterine cavity, 
should create and maintain such a current, is neither impossi- 
ble nor improbable; and the idea that the pavilion must grasp 
the ovary in order to receive the egg before it can be trans- 
mitted, needs to be established by renewed investigation. 
These statements make Oldham’s explanation of transmigra- 
tion of the ovum more plausible, since it does not, as he sup- 
posed, involve actual contact between the ovary and tube of 
opposite sides. CHAPTER IY. 
PATHOLOGICAL ANATOMY—Continued. 
Appearances in latter months of gestation and after its close—Vary with the 
length of time that the child has been retained—In tubal pregnancy—Spiegelberg’s 
case—Primary and secondary abdominal pregnancy—Liquor amnii—The fcetus—Its 
position, development, and sex—The placenta—Vascularity of the chorion in some 
instances—Species of the gestation cannot always be determined at the autopsy— 
Condition of the uterus—Changes in the fcetus when long retained—Side of the preg- 
nancy. 
If the woman does not perish from rupture of the cyst 
during the first four or four and a half months of gestation, 
it is not likely that an opportunity will offer to inspect the 
body until at or near, or even some time after, the close of 
pregnancy. 
After term, or after the death of the child, the post-mortem 
examination reveals appearances which vary much with the 
length of time that the child has been retained. Upon open- 
ing the abdominal walls, the cyst may, or may not, be found 
adherent. If it is not, and the pregnancy is ovarian or tubal, 
the foetus will be found surrounded by the proper tissue of 
these organs. If these species frequently go to full term the 
fact cannot generally be ascertained at the post-mortem ex- 
amination. Spiegelberg has, however, met with and accu- 
rately described1 the appearances presented in a tubal gestation 
which reached the ninth month. The following are the chief 
facts of the case:— 
The patient was a peasant woman, aged forty-four years, 
who was pregnant for the fourth time. She reached term 
without having had any abnormal symptoms, when she was 
seized with slight labor-pains, which were “followed by con- 
vulsions, coma, and rapid prostration and death in a few days.” 
The urine contained albumen and casts. 
At the autopsy, the mature dead child was found with its 
1 New York Med. Journ., 1871, from Archiv fur Gynsekologie. 78 
PATHOLOGICAL ANATOMY. 
membranes, in a membranous sac, composed only of the Fallo- 
pian tube. This fact was confirmed by a careful microscopic 
examination made by Waldeyer. “Bundles of muscular tissue 
were found, the tissue of the ovary was recognized microscopi- 
cally, and, by careful manipulation, the folds of the right broad 
ligament were separated from one another up to the point 
where the sac commenced, which thus corresponded with the 
position occupied by the Fallopian tube, while a probe passed 
from the angle of the uterus into the sac along a short canal.” 
The placenta was situated on the anterior surface of the cyst, 
and death was due to separation of the placenta and hemor- 
rhage into the sac, its rupture, and peritonitis. 
In tubo-uterine gestations, the appearances described in the 
early months of pregnancy may persist to term without 
change, except such as results from the increase in the size of 
the product of conception. 
A portion of the ovum may sometimes be found in the 
uterus, while the remainder is in the abnormal tubal cavity. 
According to M. Mondat,1 M. Herbin met with an example 
of this in which the head of the child alone was found in the 
uterine cavity, while the trunk occupied the tubal cyst. Sim- 
ply a small portion of the ovum may be developed in the tube, 
as was observed by Bell2 in a woman who perished from hemor- 
rhage and peritonitis after delivery, when a part of the after- 
birth three and a quarter inches long was found adherent 
within the tube. The child may be developed in the uterine 
portion of the tube while the placenta is attached inside of 
the uterus. When the placenta occupies its normal position, 
the foetal cyst may burst, and the child continue to develop in 
the abdominal cavity, as was observed by Hey,3 Patuna,4 and 
Hofmeister.5 At the post-mortem examinations they each 
found the child free, excepting its attachment to the cord, 
which latter ran through the tube to join the placenta, which 
1 Arch. Generates de Med., tome ii. 2d serie, p. 67. 
2 London and Edinburgh Med. Journ., Nov. 1845, p. 817. 
3 In a tetter to Dr. Hunter, Med. Observations and Inquiries, 8vo., London, 
1766, p. 841. 
4 Ca/.eaux, loc. citat. p. 590. 
6 Rust's Magaz., 1823, vol. xv. p. 126 ; Campbell, loc. cit. p. 100. THE OVUM. 
79 
was attached in the uterus. There is no other means of ex- 
plaining these very curious and interesting observations than 
that just mentioned. In this way they are perfectly intelligi- 
ble, and the adoption of a reasonable explanation is preferable 
to Keller’s1 course, who, in imitation of Velpeau and others, 
denies their correctness. 
If the gestation is ventral, whether primary or secondary, 
the sac is composed of the ovular envelopes of the foetus alone, 
or conjoined with an adventitious membrane formed as the 
result of irritation and inflammation. In a few instances of 
secondary abdominal gestation, the child has been found in the 
abdomen, uncovered by any membranes or surrounded only by 
an adventitious cyst. The former was observed by Carl Braun,2 
and the latter by Bandl.3 Both were examples of tubal preg- 
nancies which had ruptured early, destroying the amnion and 
chorion, as well as the tube wall, but without disturbing the 
placental attachments, so that, the supply of nutriment not 
being cut off, the development of the foetus was not arrested. 
These are analogous to the examples of tubo-uterine pregnancy 
related by Iley, Iloffmeister, and Patuna, previously alluded 
to. Under these circumstances the shrivelled and altered foetal 
membranes are found lining the original embryiferous cyst, 
and forming a constricting hand, which has been described as 
resembling the falciform process of the fascia lata. This sur- 
rounds the orifice produced by the rupture which occurred in 
the early months of gestation, and from which the umbilical 
cord emerges to pass to the abdomen of the child. Under 
these circumstances the placenta is inclosed in a cavity, the 
opening into which is too small to allow the after-birth to 
pass through it. 
In the study of the pathological changes which are met 
with in extra-uterine pregnancy it should be remembered that 
the ovum presents no abnormal or peculiar appearances. The 
impregnated germ when it commences its growth and develop- 
1 Des Grossesses Extra-uterine, 8vo., Paris, 1872, p. 19. 
2 Trush, Letter from Vienna to the Clinic, March 2, 1872, p. 105. 
3 Wiener Med. Woch., Aug. 8, 1874, and London Med. Record, Oct. 21, 
1874. 80 
PATHOLOGICAL ANATOMY. 
ment in an abnormal position is endowed with the same vitality 
and formative force, which pertain to it when it has reached 
the interior of the uterus. This remark applies to all the 
stages of an extra-uterine foetation. 
Upon opening the foetal cyst the liquor amnii will be found 
to present its normal characters. Hodge1 says that the quan- 
tity is usually small. It may be abundant. Yelpeau quotes 
a case from Vassal in which there was dropsy of the amnion. 
The same has been noticed by Depaul.2 
The child may occupy any position in the sac. It may have 
its normal position with its head in the pelvis or on the brim. 
It may be transverse with its head in either iliac fossa, the 
back turned either towards the abdomen or back of the 
mother; or it may lie diagonally across the cavity, with one 
extremity of the foetal ellipse in an iliac fossa and the other in 
the opposite hypochondriac region. 
Hamilton3 has asserted that the children of erratic gestations 
“are always less than intra-uterine foetuses; they either do not 
receive so much nourishment as in the succulent uterus, or they 
generally come to their full growth long before their common 
term.” Marc4 says that they are generally poorly developed, 
but adds that there are exceptions to the rule, and that he met 
with one in 1802. Gardien5 entertained the same opinion, and 
Daynac6 thought that extra-uterine children were so poorly 
developed that there is little hope of saving them by gastrotomy. 
These opinions have been repeated by various writers since 
Daynac wrote in 1825. They arebased upon the belief that when 
developed outside of the womb, the foetus cannot obtain a suf- 
ficient quantity of nutritive matter.7 
It is doubtless true, that extra-uterine children frequently 
1 Principles and Practice of Obstetrics, 4to., Pliila., 1866, p. 532. 
2 Loc. citat. 
3 Outlines of the Theory and Practice of Midwifery, 12mo., Pliila., 1790, 
p. 89. 
4 Dictionnaire des Sciences Medicales, 8vo., Paris, 1817, tome xix. p. 402. 
5 Traite Complet d’Accoucliemens, 8vo., Paris, 1824, tome i. p. 543. 
6 These a Paris, No. 71, 1825, p. 20. 
7 “ Even when the gestation reaches the full time, it is extremely rare for 
the foetus to be alive ; it almost always dies for want of sufficient nutrition.” 
(Bedford, Prin. and Pract. of Obstet., 8vo., New York, 1861, p. 207.) DEVELOPMENT OF THE CHILD. 
81 
die before term, even when they are carried to it, but the rule 
is for them to live until the end of the ninth month, if the 
gestation is not terminated by rupture during its early stage. 
In these cases the child is by no means poorly developed. The 
weight has been recorded in but few instances, but some of 
these show that it may exceed the average. The infant re- 
moved from the abdomen of Helen Zopp by Patuna1 exceeded 
the usual size. The same is true of the case of Perkins,2 though 
the child was not weighed in either instance. Palmer3 and 
Chavasse4 have met with children which weighed seven pounds, 
death having occurred shortly after the completion ot term ; 
while Denman5 describes another, which weighed the same 
after having been retained for thirty-two years. Bayle’s6 
patient retained her child twenty-six years, and when she died 
it weighed eight pounds. At the end of eighteen months 
after conception, Lima7 removed a foetus weighing eight pounds 
and one-half by gastrotomy. At the autopsy of Dalrymple’s8 
patient, who died one year after the completion of term, 
the infant was found to weigh eleven and one-half pounds. 
Poliak9 does not state how much the children weighed in his 
case of combined intra- and extra-uterine pregnancy, but his 
testimony is important as a support to the statement that the 
product of a misplaced conception is not necessarily poorly 
developed. He says that the extra-uterine foetus was large, 
“ much larger and heavier than its yet living mate.” These 
1 Dezeimeris, loc. citat., and Cazeaux, loc. citat. p. 590. 
2 Pliila. Med. Times, March 15, 1872, and Amer. Journ. of Obstet., May, 
1872, p. 159. This statement is made upon the authority of the writer, who 
saw the patient with Dr. Perkins, before her death, and who was present 
when the autopsy was made. 
3 Med. and Surg. Reporter, May 29, 1869, p. 416. 
1 Association Med. Journ., Nov. 30, 1855. 
5 Engravings, No. 13, 1815, Campbell’s Memoir, foot-note, p. 53. 
3 Philosophical Trans., abridged ed., 4to., London, 1794, vol. iii. p. 222. 
7 This case appears to have been reported more than once. It appeared in 
the Gazetta Medica de Lisbon, March 1, 1860, and was copied by the British 
Medical Journal, May 12, 1860, p. 360. It again appeal'd in the Gazetta 
Medica de Bahia, May 25,1868, and was copied by the Amer. Journ. of Obstet., 
Aug. 1868, and a number of other journals. 
8 Trans. Med.-Chir. Soc. London, 1848, vol. xxxi. p. 163. 
9 St, Louis Med. and Surg. Journ., May 10, 1871. 82 
PATHOLOGICAL ANATOMY. 
facts, therefore, prove that the nutrition of the foetus may be as 
perfectly insured out of as within the uterus, and that in some 
instances the child exceeds the usual size by several pounds. 
Monsters are rarely met with among extra-uterine children. 
Duncan1 describes one child whose abdominal walls wTere im- 
perfectly developed. Hughes2 met with two small excrescences 
on the side of the head. Ilodge3 reports a case in which the 
upper portions of the child were distorted from pressure, the 
infant having been tightly jammed in the mother’s pelvis. 
Oulmont,4 in 1853, met with an anencephalic foetus which had 
been retained for many years, and Johnson mentions5 the fact 
that he has seen both feet clubbed. 
The most remarkable freak of development of which we 
have any account is that noticed by Dr. W. B. Smith,6 who 
found that the umbilical cord, instead of originating from the 
usual position, issued from the anus and went from thence to 
join a healthy placenta. The details of the post-mortem ex- 
amination are so circumstantially related, that though this 
statement, as far as we know, is without parallel, we cannot 
feel justified in denying its authenticity. It is remarkable 
that imperfect development and malformations are not more 
common among children developed outside of the uterus. 
The sex of the child is not very frequently mentioned in the 
records of cases. We find it stated, however, in 74 instances. 
Of these children 41, or 55.4 percent., were boys,and 33,or 44.6 
per cent., were girls. According to Hofacker,7 of 2000 children 
horn after intra-uterine pregnancy, 1037, or 51.9 per cent., were 
males, and 963, or 48.1 per cent., were females. These propor- 
tions are the same as those obtained from an examination of 
Simpson’s statistics. According to him,8 among 1436 children 
of whom the sex is mentioned in 1432, there were 739, or 51.7 
per cent., boys, and 639, or 48.3 per cent., girls. This shows a 
1 Med. Times and Gazette, July 20, 1872, p. 69. 
2 London Med. Gazette, 1850, p. 539. 3 Loc. citat. 
4 Moreau, Des Grossesses Extra-uterines, 12ino., Paris, 1853, p. 113. 
5 Med., Exam. (Pliila.), Sept. 1850. 
6 New York Medical Repository, 3d Hexade, vol. i., 1810. 
’ Tanner, Signs and Diseases of Pregnancy, 8vo., Pliila., 1868, p. 50. 
s Obstetric Memoirs and Contributions, 8vo., Pliilada., 1855, vol. i. p. 747. THE PLACENTA. 
83 
slight preponderance of males among children developed out- 
side of the uterus, but this slight difference is doubtless unim- 
portant. If a larger number was available for consideration, it 
is probable that it would be found that the normal proportion 
of the sexes is maintained amongst extra-uterine children. 
The result of this examination in regard to the sex of the 
child, effectually settles a theory of Prof. Hubbard, who 
advanced the opinion1 that sex is determined by the time at 
which fecundation takes place, males being begotten from one 
to ten days before, and females one to ten days after menstru- 
ation. In other words, he thought that sex depended upon 
the differences in the maturity of the ovule. He afterwards 
stated2 that extra-uterine children were all males, and that the 
fecundation of the ovum high up in the Fallopian tubes 
explains all the problems in regard to the etiology of this 
interesting accident. Unfortunately for the theory, it was 
based upon few facts. 
The umbilical cord is almost always normal in its formation. 
Turnbull3 has seen it become so slender within two inches of its 
placental termination as not to exceed a crow-quill in thickness. 
The placenta varies considerably in different cases. Ryan4 
says that it is broader and thinner, and that its vessels are 
comparatively smaller than in uterine pregnancy. Dezeimeris5 
makes the same statement, and Ryan believes that the child 
usually perishes after the third month, owing to the vessels 
being incapable of supplying it with a proper supply of blood. 
Of this there is not the slightest evidence. Burns6 thought 
that the placenta is broader and thinner, and Desormeaux7that 
it is thinner but denser than in normal gestation. Hodge,8 on 
the other hand, says that it is both thicker and firmer, and 
quotes Dr. Paul, who has seen it three inches in thickness. 
It is sometimes enormously broad, as was observed by Perkins,9 
* Buffalo Med. Journ., 1850. ' 2 Ibid., Sept. 1851, p. 215. 
3 Memoirs Med. Soc. of London, 1792, p. 195. 
4 Manual of Midwifery, 8vo., Burlington, 1835, p. 312. 
5 Journ. des Connaissances Medico-Chir., Janv. 1837. 
6 Principles of Midwifery, 8vo., Pliila., 1810, p. 104. 
i Diet, des Sciences Med., 8vo., Paris, 1829, tome vii. p. 269. 
8 Loc. citat. p. 532. 9 Amer. Journ. of Obstet., May, 1872. 84 
PATHOLOGICAL ANATOMY. 
and it would seem as if this were a necessary condition, since 
the organ is frequently attached to structures which are by no 
means naturally vascular, and hence the extent of surface has 
to make amends for deficient supply. In rare cases true pla- 
cental tissue appears to be absent. Turnbull1 has carefully 
described and illustrated an example of this. The portion of 
the foetal cyst lying above and in front, and which was not more 
than one-tenth of an inch in thickness, was more vascular than 
the rest. This vascularity extended downwards over the intes- 
tines and upwards over the lower portions of the liver and 
stomach. Vessels were also sent off to the mesentery, mesocolon, 
and the abdominal parietes, and in fact to a great part of the 
visceral contents of the abdomen. Dr. Turnbull says, in a foot- 
note, that the foetus derived its nourishment from the vessels of 
the mesocolon, “ for those of the umbilical cord ran into and 
anastomosed with the vessels of that part.” 
In some instances after the death of the child blood is ef- 
fused into and beneath the organ. The quantity thus poured 
out is sometimes very large.2 Perkins reports this placental 
apoplexy as appearing to have followed an injury received 
when the woman was near her term. 
The placenta may be attached to any portion of the surface 
of the peritoneum, within the ruptured foetal cyst whether it 
is ovarian or tubal, or lastly, within the uterus itself. Sivard3 
has seen it attached to the mesentery and colon of the left side ; 
Courtail4 to the omentum and stomach; Clarke5 to the kidneys 
and intestine ; Tilt6 to a great part of the mesentery, mesocolon, 
portions of the small intestines, and the two or three superior 
lumbar vertebrae; Hughes7 to the omentum ; Baldwin,8 Wilson,9 
and Koeberld10 to the anterior abdominal wall in the line of 
1 Loc. citat. p. 192. 
2 Perkins, loc. citat. ; Braun, The Clinic, March 2, 1872, p. 105. 
3 Chambon, Maladies des Femmes, 8vo., Paris, tome ii. part ii. p. 51.- 
4 Ibid., p. 51. 
5 Mem. Med. Soc. of London, 1792, p. 197. 
6 Med. and Pliys. Journ. of London, 1828, vol. lix. p. 897. 
7 London Med. Gazette, 1850, p. 589. 
s Southern Med. and Surg. Journ., Jan. 1839. 
9 Indian Annals of Med., Oct. 1855. 10 Keller, loc. citat. VENTRAL PREGNANCY. 
85 
the incision made either at the post-mortem examination or 
during an operation for gastrotomy. 
We are not aware that any injections have ever been made 
to demonstrate the circulation between the mother and the 
child. It would be interesting to do this. It would seem 
reasonable to infer from what has been observed in women 
who died during the early stages of pregnancy, that the ma- 
ternal tissues play but little part in the formation of the after- 
birth, and that the villi of the chorion have no other connec- 
tion with the maternal vessels, which are increased both in 
size and number, than that of close approximation to their 
surface to which they adhere. The nutritious fluids would 
therefore have to pass through two membranes, that of the 
bloodvessels of the mother and that of the villi of the chorion. 
We are not in a position, however, to intelligently discuss this 
question at the present time. The whole subject of the ana- 
tomy of the placenta demands renewed investigation, since 
Ilicks1 has denied the existence of the maternal sinus system 
described by Hunter, Goodsir, Reid, and others. 
It has already been stated that in tubal and ovarian preg- 
nancies the sac which contains the foetus is composed of the 
proper tissues of these organs, but in ventral gestation, whether 
primary or secondary, the matter is entirely different. In 
some instances the chorion may he at once exposed on opening 
the abdominal wall, notwithstanding the statements of Camp- 
bell2 to the contrary. 
When the impregnated egg falls into the peritoneal cavity 
it contracts adhesions, and as it grows these may increase 
until a considerable portion of the neighboring organs may 
become united to the chorion, and thus increase its strength. 
As in peritoneal pregnancy the ovum would naturally fall into 
the retro-uterine pouch, the uterus and its appendages are 
nearly always adherent to the chorion. This may lead to 
atrophy of the organs involved. The process by which these 
1 Journ. of Anatomy and Physiology, May, 1872, and Trans. Obstet. Soc. 
London, 1873, vol. xiv. p. 149. Prof. Turner (Journ. of Anat. and Physio- 
logy, Nov. 1872) denies the correctness of Hicks’ views, and in the main 
supports the opinions of Goodsir and Keid. 
2 Loc. citat. p. 136. PATHOLOGICAL ANATOMY. 
adhesions are formed is, probably, not absolutely inflammatory, 
but is analogous to those vital nutritive changes by which 
the ovum attaches itself to the lining membrane of the uterus 
in normal gestation. 
The external surface of the bare chorion presents a shining 
glistening appearance, or it may become obscured and its 
strength materially increased by deposits of lymph. In this 
case there is a true adventitious cyst. The walls of the sac 
are not generally very vascular, but large vessels may ramify 
over them, as was witnessed by Turnbull, Smith,1 Baudelocque,2 
and Blackman.3 The last found the vessels so large that he 
declined to proceed with the operation of gastrotomy after the 
abdominal walls had been opened. 
It should be borne in mind that, at the autopsy of a woman 
who has carried an extra-uterine child to or near term, it is 
often extremely difficult, nay more, it is absolutely impossible 
to determine the true seat of the pregnancy.4 Pressure and 
the other forces brought into operation by the ovum during 
its growth so change the relations, and even the structure of 
the organs that it is impossible to determine the original seat 
of the ovum. The uterine appendages are frequently found 
so thinned and atrophied that their recognition is difficult, or 
even impossible. This fact should be borne in mind, so that 
those who put their observations upon record may so accurately 
record the facts, that data may be gradually accumulated that 
1 Campbell, loe. citat. p. 60. 2 Ibid., p. 185. 
3 Amer. Journ. of Medical Sciences, July, 1845, p. 56. 
4 Jno. Hunter (Observations on Certain Points of the Animal Economy, 4to., 
London, 1792, p. 174), who believed-that there were three varieties of mis- 
placed pregnancy (ovarian, tubal, and abdominal), thought they could be 
distinguished from one another at the post-mortem examination. He says : 
“ The arteries and veins belonging to the part in which the child is contained 
must be enlarged ; which being the increase of a natural part, will be readily 
ascertained, and the nature of the case as readily determined. We may lay 
it down as a principle that when the spermatic artery and veins of either 
side is (sic) enlarged in an extra-uterine case, that the foetus is in the ovarium 
or Fallopian tube, since there are no other bloodvessels which supply these 
parts; and if any other system of vessels, as the mesenteric, are increased 
in size, while the spermatic are in a natural state, we may with equal cer- 
tainty conclude the foetus to be contained in the general cavity of the belly.” CHANGES IN CHILD FROM RETENTION. 
87 
will aid us in determining the comparative frequency of the 
species of misplaced gestations. 
It remains now to briefly allude to the condition of the 
uterus and appendages in women who die at term. The womb 
is more or less displaced. It is generally elevated, the cervix 
being carried towards and above the pubis. At the same time 
it is pushed to one side, though it is sometimes found in the 
middle line. Though the foetus is generally developed behind 
the uterus, it may lodge anterior to the organ, which is conse- 
quently pushed backwards and downwards. In rare cases even 
the bladder is found behind the vicarious uterus. The womb 
is enlarged in almost all instances. Very rarely, indeed, does 
it fail to undergo some nutritive change, but at term the organ 
is not often found larger than that of the fourth or fifth month 
of pregnancy, and at this time it rarely contains a decidua; 
this has usually been thrown off before death occurs. 
The autopsy of women who have lived some time after the 
death of the child, may reveal characters very different from 
those described. The foetus now either undergoes decomposi- 
tion, or the cyst shrinks, the liquor amnii being reabsorbed, and 
the product of conception lies quiescent in the abdomen. In 
the former ca,se the cyst walls will be found inflamed, and 
they may be partially or wholly destroyed. They may become 
attached to the surrounding organs, the bladder, vagina, intes- 
tinal canal, or, to the abdominal wall, by either or by all of 
which channels the cyst may be found discharging its decom- 
posing contents. The foetus may be found but little altered, 
or most of the soft parts and small bones may have disappeared 
before the autopsy is made. 
In the second case, in which the child remains a foreign body 
—but innocuous—the cyst wall may undergo either a carti- 
laginous or a calcareous degeneration. Cloquet1 records an 
example of cartilaginous change in the sac of a three months’ 
foetus removed from a woman seventy eight years of age. 
Morand2 saw the envelope partly cartilaginous and partly 
calcareous. Under the same circumstances the foetus may 
1 Revue Medieale, 1833, tome iv. p. 135. 
2 Memoirs do l’Aeademie Royale des Sciences, 1748- 88 
PATHOLOGICAL ANATOMY. 
undergo either of two changes. It may become the seat of the 
deposit of calcareous salts—ossified, the older writers termed 
it. It is then converted into a lithopeedion. This has been 
witnessed by Albosus,1 Van Sweiten,2 Amaud,3Majon,4Daynac,5 
hfebel,6 and many others. In other cases it is said that the 
foetus becomes converted into a matter like adipocere. This 
latter must be a rare alteration. Though frequently mentioned 
by systematic writers, we have been able to find but few facts 
in regard to it. In other cases the child simply dries up and 
becomes indurated and mummified, from absorption of its fluids, 
while in others it may remain almost unchanged year after 
year. The last is not the least strange ©f the terminations of 
extra-uterine flotation, for the child may be found as sound as 
if death had occurred immediately before the autopsy. 
It is of some interest to determine upon which side of the 
body extra-uterine pregnancy is the most frequent. This 
question presents the most interest in connection with tubal 
pregnancies. Various opinions have been expressed in regard 
to the frequency of misplaced conceptions on the two sides. 
Campbell,7 Hecker,8 and Barnes,9 all assert that tubal gestations 
are more frequent upon the left than the right side. Low and 
Lumpe10 believe that this is not only true of tubal, but like- 
wise of ovarian pregnancies. Barnes explains this opinion by 
supposing, that the left tube is liable to displacement from 
compression by the sigmoid flexure of the colon, which is situ- 
ated close to the tube, and is often distended by accumulations 
of feces and gas. On the other hand, Lyman11 believes that 
tubal fcetations occur more frequently upon the right than the 
1 “The Infant of Sens.” Madame Le Boursier du Oourday, Abrege de 
VArt des Accouchement, etc., 12mo., Paris, 1759, p. xxxvi , and Astruc, 
Traite des Maladies des Femmes, 12mo., Paris, vol. iv., 1765, p. 78. The 
case occurred in 1582. 
2 'Velpeau, Diet, de Med , tome xiv. p. 415. $ Ibid. 
4 Cruveilhier, Essai sur PAnatomie Patbologique, 8vo., Paris, 1816, tome 
ii. p. 180. 
5 These a Paris, No. 71, 1825, p. 16. 6 Campbell, ioc. citat. p. 45. 
" Loc. citat. 8 Monat. fur Geb.,Feb. 1859. 
9 Diseases of Women, 8vo., Phila., 1874, p. 865. 
10 Boston Med. and Surg. Jonrn., May 28, 1857. 
11 Nashville Journ. of Med. and Surgery, I860. SIDE OF THE PREGNANCY. 
89 
left side. In eleven cases analyzed by him, the foetal cyst was 
situated on the right side in eight, and on the left in three 
instances. May1 says “it is very remarkable that the right 
tube should be almost invariably that in which the pregnancy 
takes place,” and finally, Rokitansky states2 that of six speci- 
mens of tubal conceptions which had been preserved in the 
Vienna Museum at the time when he wrote, five were seated 
on the right and only one on the left side. The weight of 
authority is, therefore, in favor of the greater frequency of 
misplaced gestations on the left side, especially when the 
ovum is arrested in the Fallopian tubes. This opinion, how- 
ever, is not supported by an analysis of a large number of 
cases. Of 180 tubal gestations, the locality is mentioned in 
162. Of these, 92 were situated on the right, and 70 on the 
left side. In 149 of these tubal fcetations, the ovum was situ- 
ated in that portion of the oviduct which is exterior to the 
uterus, while in the remaining 81 it was developed in the part 
which traverses the tissue of the organ. These, therefore, 
belong to the variety called “interstitial,” or tubo-uterine. 
Of the first class the ovum was situated in the right tube in 
75, and in the left in 60 cases, while in 14 instances the side 
is not mentioned. Of the 31 examples of tubo-uterine gesta- 
tion, 17 were right and 10 were left pregnancies, the locality 
of the ovum not being stated in 4 instances. 
In ovarian gestation the ovum would seem to be more fre- 
quently developed on the left than the right side. Of 27 cases, 
the left was the gravid ovary in 15, and the right in 8, while 
the side is not mentioned in 4 cases. 
These facts show that tubal pregnancies occur with almost 
equal frequency upon the two sides of the body. The small 
number of cases of ovarian foetation analyzed would seem to 
show a preponderance in favor of the left side, but no import- 
ance is to be attached to this fact, since the number is not 
large enough to warrant us in drawing any conclusions. This 
statement is borne out by the results of the analysis of the 
tubal gestations included in the first hundred of the five 
1 Assoc. Med. Journ., Sept. 20, 1856, p. 820. 
2 Manual of Pathological Anatomy, 8vo., Phila., 1855, vol. ii. p. 256. 90 
PATHOLOGICAL ANATOMY. 
hundred cases upon which this work is based. This examina- 
tion seemed to indicate that the ovum was much more fre- 
quently arrested in its descent through the right than the left 
tube—more than in the proportion of 2 to 1. This greatly 
excited the curiosity of the author, and led him to speculate 
much in regard to the causes of the apparent discrepancy, but 
this led to no result, for the analysis of the whole number of 
tubal pregnancies, known to have occurred in 500 extra-uterine 
foetation8, corrected the error and furnished a new illustration 
ot the fact, that deductions drawn from statistics are value- 
less unless the numbers examined are large. 
O CHAPTEE Y. 
SYMPTOMS. 
Those described by Petit—Division into three periods for study—Those of the first 
period—Colicky pains—Metrorrhagia—Expulsion of decidua—Vaginal examination— 
Uterus is enlarged—Periuterine tumor—Ballottement—Examination by the urethra— 
Symptoms of second period—Existence of pregnancy no longer doubtful—Foetal 
movements—General symptoms—Physical signs—Abdominal enlargement on one 
side—Superficial position of child—Mobility of tumor—Auscultatory signs—Vaginal 
examination—Displacement of uterus—Post-uterine tumor—Detection of foetus by 
the vagina—Position of bladder—Sounding the uterus—Mechanical effects of the 
gravid cyst—Labor at term—Secretion of milk—The pseudo-puerperal state which 
follows false labor—The child generally dies during or immediately after labor. 
Before the middle of the last century a number of cases of 
extra-uterine pregnancy had been observed, and more or less 
accurately recorded, at least so far as the symptoms were con- 
cerned, though often without any correct knowledge of the 
condition which was being described. It was, however, finally 
established that a foetus could be developed outside of the 
uterus, and in the year 1770, Antione Petit1 asserted that 
misplaced pregnancy was characterized by the following pe- 
culiarities :— 
1. The menses, contrary to what is seen in normal gestation, 
continue to appear, but in smaller quantities, throughout the 
pregnancy. 
2. The breasts do not enlarge or secrete milk, as they do 
after uterine conceptions. 
3. The gravid tumor is situated on one side, the foetal move- 
ments are felt on the corresponding side, and the woman has 
unilateral varices, cramps, and oedema. 
If these statements could be verified the detection of extra- 
uterine gestation would be an easy task, but unfortunately for 
the comfort of the obstetric surgeon, scarcely one of them 
contains a grain of truth; yet, strange to say, the opinions of 
Petit influenced and impeded the progress of our knowledge 
1 Traite des Maladies Femmes, 8vo., Paris, tome ii. p. 88. 92 
SYMPTOMS. 
of this subject for more than half a century. Even Capuron1 
as late as 1823 enumerates this catalogue of symptoms, and 
evidently believed that they occur. From whence Petit de- 
rived his ideas it is impossible to say, for Astruc,2 whose work 
was accessible to him, taught doctrines much nearer the truth. 
Even Dionis, who belonged to the time when obstetrics was 
emerging from the hands of the midwives, had clearer no- 
tions3 in regard to extra-uterine gestation than Petit. 
It remained, therefore, for the writers of our own times to 
clear away the obscurity with which tradition and authority 
had surrounded this subject, and since Marc,4 Gardien,5 and 
others denied the correctness of Petit’s statements, facts have 
been accumulating; but even yet we find the deductions from 
them are too much biased by traditions and preconceived opin- 
ions. 
The symptoms of extra-uterine conception vary with the 
different stages of the gestation. They may be conveniently 
studied under three divisions:— 
1st. During the first months of pregnancy when the foetal 
heart is still inaudible. 
2d. After the period when the foetal heart can be heard, and 
until after the close of spurious labor at term. 
3d. After the termination of false labor, or the death of the 
foetus. 
First Period.—It is very important to study the symptoms 
of the first period, since it has been demonstrated that tubal 
gestation frequently terminates by rupture before the fourth 
month, and that if the pregnancy goes beyond this time, the 
probabilities are that the child will be carried until the time 
of gestation is completed. The first, class of cases remains 
to-day the opprobrium of obstetrical surgery. This is largely 
due to the obscurity which surrounds the symptomatology of 
this early stage of the accident. 
1 Cours Tlieorique et Pratique de Accoucliemens, 8vo., Paris, 1823, pp. 
675-6. 
2 Traite Maladies des Femmes, 12mo., Paris, 1765, tome iv. p. 73. 
3 A General Treatise of Midwifery, 8vo., London, 1719, p. 81. 
4 Diet, des Sciences Medicales, 8vo., Paris. 1817, tome xix. p. 403. 
5 Traite Complet d’Accoucliemens, 8vo., Paris, 1824. HYPOGASTRIC PAIN. 
93 
"We all know how uncertain and ill-defined the symptoms 
of the early stages of normal gestation are, and many authors 
of high standing assert that no peculiar symptoms follow an 
extra-uterine conception until the end of the first three or 
four months. That this may be true cannot be denied. Peri- 
odical medical literature contains the records of some facts 
which prove the correctness of this assertion, but this is by no 
means the rule. An extra-uterine gestation is frequently 
ushered in quietly enough, and during the first four or six 
weeks all may go well, but after this time symptoms super- 
vene, which in their violence are as unlike the signs of a 
uterine pregnancy as the surface of a stormy sea is unlike 
that of a dead calm. The one moves on with some sort of 
regularity, the discomforts of the condition appearing in a 
certain order, but the other follows no plan, and sets all order 
at defiance. 
The patient in the first instance supposes herself to be preg- 
nant, and during the first four or eight weeks nothing particu- 
lar occurs to warn her of her anomalous condition. The usual 
signs of this early period of gestation appear successively; or 
indeed she may enjoy better health than she did during the 
same period of previous pregnancies; when suddenly and with- 
out any warning the unfortunate victim of this terrible acci- 
dent is seized with a very characteristic symptom. This is a 
violent pain in the abdomen, usually called colic by the patient 
and her friends. The pain is seated in the hypogastrium, and 
is usually worse upon one side. It is extremely violent, pre- 
venting the woman from standing erect or lying stretched out 
in bed. It produces considerable and even profound prostration. 
The surface may become pale and cool, the skin covered with 
a cold, clammy perspiration, and the pulse small and thread- 
like. There may be vomiting, and the suffering may be so 
great as to cause syncope. The pain is apt to be associated 
with some, and even great tenderness in the hypogastric and 
iliac regions, which has led to the supposition that the patient 
was suffering from peritonitis.1 After a longer or shorter 
1 Peltzer, Monats. fur Geb., April, 1867, and Brit, and Foreign Medico - 
Chir. Rev., Oct. 1867, p. 541 ; Monod, L’Union Medicate, 1855. 94 
SYMPTOMS. 
period, varying from a few hours to a day or more, the pain 
disappears, and the patient may appear to be nearly restored 
to health. She is likely, however, to suffer more or less at all 
times, and if she does not, the calm is a deceitful one, for 
sooner or later the storm breaks out again, and she has a fresh 
accession of pain of the same terrible severity. These parox- 
ysms are renewed with more or less regularity at intervals 
varying from a few days to two or three weeks. Sometimes 
the attacks come on at regular intervals, as in the case re- 
ported by Cerise,1 in which the paroxysms occurred once a 
month. 
These pains rarely set in earlier than the end of the first 
month after conception, and their accession is sometimes post- 
poned until the fourth or fifth month, as has been noticed by 
Phillipart,2 Dreessen,3 Greenhalgh,4 Lalanne,5 and others. They 
generally, however, appear before this period. If rupture does 
not occur, the attacks of colicky pains may disappear some time 
after the fifth month of gestation. Sometimes, however, they 
recur towards the end of pregnancy, after the woman has 
enjoyed fair health during a long interval. Meadows6 has met 
with an example of this. During the early part of the preg- 
nancy the sufferings of the woman were very great. For 
several months she had good health, after which the old 
symptoms reappeared. In some instances the attacks of pain 
continue nearly or quite to the end of gestation. 
In many cases the paroxysms come on without assignable 
cause, but in others they appear to have a traumatic origin. 
Putnam states7 that his patient had four distinct attacks of 
severe pain, one of which followed coitus, while the other 
three occurred immediately after defecation. 
The cause of these severe paroxysms of pain is involved in 
1 Gazette des Hopitaux, No. 30, 1846. 
2 Ibid. 1865. 
3 Monats. fur Geburts., Feb. 1868, and Brit, and For. Med.-Cliir. Rev., 
July, 1868, p. 253. 
4 Med. Mirror, Nov. 1864, p. 689. 
5 Annales de la Med., Juillet, 1825. 
6 Trans. Obstet. Soc. of London, 1873, vol. xiv. p. 311. 
7 Amer. Journ. Med. Sci., Oct. 1853, p. 348. HYPOGASTRIC PAIN. 
95 
some uncertainty. A recent writer upon the subject attri- 
butes them to peritonitis.1 It is by no means proved that this 
is a correct explanation—indeed it is certain that in most 
cases some other cause produces this distressing symptom. 
Peritonitis has long been made to play an important part in 
the explanation of many of the phenomena connected with 
extra-uterine pregnancy. The truth is, that it is a rare com- 
plication of this condition until after the termination of the 
usual period of gestation, when it often plays a conserva- 
tive part by attaching the wall of the cyst to the abdominal 
walls or adjacent organs, and thus facilitates the piecemeal 
escape of the foetus. Post-mortem examinations of the bodies 
of women who have died from rupture of the cyst, and who 
have previously suffered severely from this symptom, have 
conclusively shown, by the absence of peritonitis, that it sus- 
tains a very unimportant part in the production of these attacks 
of colicky pain. The true explanation of the symptom is to 
be found in the wide differences between this and normal 
gestation. In the latter the ovum is developed in an organ, 
the size of which increases in proportion to the growth of 
its contents. This growth of the uterus, it is to be remem- 
bered, is not a mere mechanical effect of the increase in the 
size of the product of conception, but it is the result of vital 
nutritive changes, by which its tissues are entirely and mar- 
vellously altered. On the other hand, when the ovum is 
arrested in the ovary or Fallopian tube, it is developed in an 
organ which becomes distended mechanically by the growth of 
the foetus, and which, not being intended by nature to perform 
such an important function in the plan of the reproduction of 
our species, does not undergo those nutritive changes which 
will enable it to afford a nidus for the growing ovum. 
It appears probable that these paroxysms of colicky pain 
are produced by contractions of the foetal cyst. These can occur 
in Fallopian gestation, and the absence of the symptom in 
certain cases of misplaced fcetation, can be accounted for by 
the fact that there are no muscular fibres in the tissues sur- 
rounding the ovum. The pressure of the foetal cyst upon 
the contiguous structures may be another element in the pro- 
1 Duguet, Annales de Gynecologie, Paris, 1874, tome i. p. 387. 96 
SYMPTOMS. 
duction of this phenomenon, for Blass1 has observed that to 
place the woman upon the hands and knees, with the head 
depressed, will sometimes relieve the suffering. This can be 
accounted for by concluding that the compression of the sur- 
rounding tissues by the foetal sac is diminished. 
This explanation accounts for the fact, that in the intervals 
between the paroxysms the woman may enjoy moderate or even 
perfect comfort. As the growth of the ovum is less interfered 
with in abdominal gestations than it is in those of the ovary 
or tube, it may be that this symptom occurs especially in the 
latter species of misplaced pregnancy. The records of ven- 
tral conception, however, are so few that we are not warranted 
in accepting this statement as proved at the present time. 
Tubal pregnancy may go to term without producing this 
pain, for Speigelberg’s2 patient reached the end of her ninth 
month without experiencing any abnormal symptoms. This 
symptom has attracted the attention of numerous writers upon 
this subject, but a comparatively small number have attached 
any diagnostic importance to it. Heim,3 Campbell,4 Blun- 
dell,5 Rogers,6 and Barnes,7 however, assign it a place in 
the symptomatology of misplaced conception. This subject 
will claim attention in the discussion of the diagnosis of the 
condition, so that the consideration of the value of the symp- 
tom may be postponed for the present. 
Another important phenomenon of this early stage of extra- 
uterine gestation is hemorrhage from the vagina. The fre- 
quency of this symptom no doubt led Petit8 to the erroneous 
conclusion that the menses were not suppressed under these 
circumstances, an opinion in which he was supported by 
1 Keller, loc. citat. p. 47, from Monats. fur Geb., iii. p. 148. 
2 Arcliiv. fur Gynsekol., 1871, and New York Med. Journ., July, 1871, 
p. 86. 
3 Keller, Des Grossesses Extra-uterines, 8vo., Paris, 1872, p. 45. 
4 A Memoir on Extra uterine Gestation, 8vo., Edinburgh, 1842, p. 121. 
5 Principles and Practice of Obstetrics, 8vo., London, p. 478. 
6 Extra-uterine Fcetation and Gestation, 8vo., Pliila., 1867. 
' St. Tlios. Hosp. Reports, 1870, and Diseases of Women, 8vo., Pliila. 
1874. 
8 Loc. citat. p. 88. METRORRHAGIA. 
97 
Turnbull1 and others. Velpeau2 and Keller3 say that there are 
many exceptions to this rule. It is an important question, 
however, to determine whether the sanguineous vaginal dis- 
charge, so frequently present in this condition, is really men- 
strual or not. Goupil4 and Stoltz* assert that it is not, but 
that it is metrorrhagic. This opinion appears to be correct, for 
the former has shown that under these circumstances the flow 
loses its periodicity entirely, that it occurs at uncertain and 
irregular intervals, like the colicky pains. This fact did not 
escape the keen observation of Madame La Chapelle.6 
This vaginal hemorrhage sometimes consists of dark-colored, 
coagulated blood. Sometimes it is attended with the dis- 
charge of the decidua en masse, or in pieces so small that 
they can only be detected by microscopical examination, as has 
been remarked by Scanzoni. Metrorrhagia is, however, not a 
constant attendant of displaced pregnancy.7 Goupil believes 
that it is more constant in those cases which end by rupture 
during an early stage of the gestation than it is in those which 
go to full term and recover. Dugeut8 believes that cases of 
the latter class are nearly all abdominal feetations, and suggests 
that metrorrhagia is a symptom which belongs to ovarian and 
tubal pregnancies. In the present state of our knowledge we 
are not in a position to either accept or reject this opinion. It 
does not seem improbable, however, that future observation 
may prove that it is correct, and that after ventral conception 
the woman is likely to have hemorrhage only when the de- 
cidua is discharged. Before and after this period it would not 
be so liable to occur. 
If metrorrhagia does not set in earlier, it is very likely indeed 
to make its appearance immediately before rupture of the cyst 
takes place. Barnes9 writes that “a condition that favors and 
1 Memoirs of Medical Society, London, 1792, vol. iii. p. 185. 
2 Diet, de Medecine, yol. xiv. p. 411. 3 Loc. citat. p. 45. 
« Clin. Memoirs on Diseases of Women, N. S. Soc. Ed., London, 1860, 
vol. ii. p. 266. 
5 Nouv. Diet, de Med. et de Chir. Pratique, Paris, 1873. 
6 Goupil, loc. citat. p. 266. 7 Rogers, loc. citat. p. 18. 
8 Annales de Gynecologie, tome i., 1874, p. 335. 
9 St. Thos. Hosp. Reports, 1870, N. S., vol. i. p. 371. 98 
SYMPTOMS. 
gives warning of the impending rupture is the hemorrhage 
which so constantly precedes it.” It, however, frequently 
attends the attacks of severe colicky pain, which occur pre- 
vious to rupture, and as women who manifest these symptoms 
may go to the full term of pregnancy, it may be concluded that 
while rupture should always be feared under these circum- 
stances, the occurrence of even very severe pain and hemor- 
rhage combined, need not lead the medical attendant to de- 
spair of his patient carrying her child to term, and even far 
beyond it. 
This hemorrhage is due to a variety of causes. It is no 
doubt often owing to general congestion of the internal geni- 
tal organs, the result of the profound irritation to which they 
are subjected. At other times it is probably due to the sepa- 
ration of the ovum from the cyst walls.1 An additional and 
important cause is the separation of the decidua which lines 
the uterus, and which maybe thrown off at any time from the 
commencement to the end of pregnancy. 
The expulsion of the decidua in one mass, during the early 
stages of the gestation, is attended with expulsive pains and 
all the other symptoms of abortion. The woman is often 
supposed to have miscarried, or to have expelled a mole or 
blighted ovum. Not only does the patient frequently commit 
this error, but likewise her nurse and even medical attendant. 
All such bodies discharged by the vagina should be carefully 
examined by the physician to determine whether they do or 
do not contain an ovum. The want of care in this particular 
has often led to errors that might have been easily avoided. 
During this time the woman experiences, in addition to the 
symptoms just alluded to, the usual signs of pregnancy. These 
are well known, and it is not necessary to do more than speak 
of them. It is to be remembered, however, that in this 
anomalous condition the fact that the woman believes herself 
enceinte is not without its value.2 These women will often 
persist that they have conceived, notwithstanding that the 
opinion is discouraged by their medical attendant. It is a 
well-known fact that, in other conditions, as in spurious preg- 
1 St. Tlios. IIosp. Reports, 1870, 1ST. S., vol. i. p. 371. 
2 Bernutz and Goupil, loc. citat. p. 265. VAGINAL EXAMINATION. 
99 
nancy, this idea has conrplete control of the mind of the 
woman, but this state is so different from extra-uterine con- 
ception that there is no difficulty in distinguishing between 
them. 
Vaginal examination furnishes some important information 
even in the early stages of the pregnancy, and an attempt to 
make the touch should never be omitted. It will not be 
demanded until violent pains, or hemorrhage, or both together, 
have directed attention to the fact that there is something 
abnormal about the woman’s condition. When these occur 
they warrant and demand a full physical examination. As 
the pain is apt to be attended with extreme tenderness, it is 
often impossible to make a satisfactory investigation of the 
pelvic organs. If the examination can be fully completed, 
it will reveal the fact that the uterus has undergone, to a 
greater or less extent, those changes which affect it in 
ordinary pregnancy. Hunter1 was among the first to notice 
this fact. Most authorities agree in the opinion that the 
increase in the size of the uterus is the general rule in extra- 
uterine gestation. Campbell2 says that it occurs with few 
exceptions. Burns acknowledges that this change follows in 
tubal and ovarian pregnancies, but is doubtful about its 
existence in ventral. Gardien,3 Marc,4 and Baudelocque5 
appear to have entertained the same views. Levret6 believed 
that the uterus enlarged more in tubal gestations and in those 
abdominal pregnancies in which the placenta was attached to 
the exterior of the womb. Depaul,7 one of the most recent 
and authoritative writers upon this subject, adopts the same 
opinion, while Bdhier8 acknowledges that enlargement of the 
uterus does occur, but thinks that it is not the general rule. 
1 Med. Commentaries, Edinburgh, 8vo., London, 1773, p. 429. 
2 Loc. citat. p. 107. 
3 Traite Cemplet d’Accouchmens, 8vo., Paris, 1824, tome i. p. 530. 
4 Diet, des Sci. Medicales, 8vo., Paris, 1817, tome xix. p. 405. 
5 Ibid., p. 456. 
6 Desormeaux, Diet, des Sci. Med., 8vo., Paris, 1829, tome vii. p. 271. 
7 Archives de Tocologie, Paris, 1874, p. 262. 
8 Gaz. Hebdom , No. 36, 1873. 100 
SYMPTOMS. 
He looks upon it more as an accident than as a necessary 
condition of extra-uterine gestation. What difference the 
various locations of the ovum in a misplaced conception may 
have upon the development of the womb, is a question 
which must be left for future observers to decide. So far as 
we are at present informed, we seem to be justified in expect- 
ing to find the uterus more or less enlarged in all the species 
of extra-uterine fetation. There are rare, exceptional cases, 
however. Morley1 and Kelly2 report having met with them. 
Morley’s patient died from a tubal pregnancy when she was 
between five and six months gone. Duncan,3 on the other 
hand, calls attention to the fact that the womb may appear, 
by measurement, to be unaltered in size, when such in real- 
ity is not the case. This gentleman found, on passing the 
uterine sound, that it did not enter beyond the usual distance 
of two and a half inches; yet, after death, the uterine walls 
were found to be thickened and the whole organ considerably 
enlarged. 
The increase in the size of the uterus is not equal to 
that of a uterine pregnancy of the same duration, though 
Simmons4 is said to have examined a case of tubal gestation 
in which the organ was found enlarged in the same proportion 
that it would have been if the ovum had been in its cavity. 
This, however, is by no means the usual condition, especially 
in those cases which nearly or quite reach the full term of 
gestation. In the early stages, however, the normal relation 
between the development of the uterus and the ovum which it 
ought to contain, may be nearer the normal standard ; but of 
this we have no more than presumptive evidence. Whatever 
may be true of this stage of the gestation, there is no doubt, 
that, while the uterus is augmented in size, its development 
is arrested before term is reached. Campbell’s5 remark, that 
the size of the organ does not equal that of the fifth month of 
gestation, will he found to be true in nearly every instance. 
1 Provincial Med. and Surg. Journ., June 25, 1851, p. 267. 
2 Med. Obs. and Inq., 8vo., London, 1797, vol. iii. p. 44. 
3 Edinburgh Med. Journ., Jan. 1864, p. 670. 
4 Thos. C. James, North Amer. Med. and Surg. Journ., 1827, p. 278. 
5 Loc. citat. p. 107. VAGINAL EXAMINATION. 
101 
Besides this increase in size, the uterus may be found to be 
deviated from the normal position by the presence of a tumor 
on one side, behind, or even in front of the organ. If the 
patient is not too tender, this tumor can sometimes be recog- 
nized at a very earljr period. Thomas1 discovered it at the 
third, and Siredey2 at the end of the first month of gestation. 
The mass is elastic, fluctuates, or semi-fluctuates; and, by 
ballottement, shows that it contains a solid body floating in 
liquid.3 The tumor may be more or less firmly fixed, or it 
may enjoy considerable mobility. The presence of a tumor is, 
of course, a very important physical sign of the condition 
which is being described ; and if the other symptoms, of which 
mention has been made, have previously manifested themselves, 
the discovery of a periuterine enlargement, associated with 
increase in the size of the uterus, removes almost all uncer- 
tainty in regard to the diagnosis. If the tenderness is so 
great as to preclude a satisfactory examination of the pelvis, 
the woman may be thoroughly anaesthetized before the ex- 
ploration is commenced. The danger of retching succeeding 
the administration of ether is the only objection to this means 
of diagnosis. 
Although Siredey discovered the foetal tumor at the end of 
the first month, others have not had this good fortune, in 
many cases, probably, because the physical examination of the 
pelvis and lower portions of the abdomen has either been 
omitted entirely, or not been made with sufficient care. Every 
experienced gyntecologist knows that very small enlargements 
in the neighborhood of the uterus can often be detected by 
careful manipulation. Still it must be acknowledged that a 
small foetal sac is recognized with difficulty in the early periods 
of gestation. Dr. Noeggerath,4 of New York, has, however, 
proposed a new method of exploration which promises to 
furnish important additions to the information obtained by 
the vaginal and rectal touch. He proposes rapid dilatation of 
the urethra so as to allow the finger to be introduced into the 
bladder, through which the ovaries, Fallopian tubes, broad 
1 New York Med. Journ., 1875, p. 563. 
2 These a Paris, 1860, p. 98. 3 Thomas, loc. citat. 
* Amer. Journ. of Obstetrics, May, 1875. 102 
SYMPTOMS. 
ligaments, and the fundus of the uterus can be efficiently and 
quickly examined by the aid of the fingers of the other hand 
in the vagina or the rectum. There is great reason to hope 
that this ingenious addition to our methods of investigation 
may greatly aid in detecting the periuterine tumor in the 
early stages of extra-uterine gestation. 
Symptoms of Second Period.—The symptoms of extra- 
uterine pregnancy become more marked in the second stage 
of gestation, after the woman has quickened and the foetal 
heart becomes audible. The question as to the actual exist- 
ence of pregnancy is now easily settled, so that the location of 
the ovum is the only point which needs to be decided. During 
this period, the ordinary signs of pregnancy continue. The 
colicky pains may persist or entirely disappear. After the 
fourth month their severity is generally materially dimin- 
ished, if they do not cease to occur. After these pains have 
completely disappeared, they may again be renewed in the last 
two months of gestation, as has been already stated was ob- 
served by Meadows, of London. 
Tlie woman will frequently assert that she feels the foetal 
movements upon one side, and in the latter months of gesta- 
tion they sometimes become extremely painful. This has been 
noticed by Mayor,1 Zais,2 and Boinet.3 Mason4 has seen them 
so strong as to make the woman scream with agony; and Iley5 
states that he has seen them so violent in the latter months of 
pregnancy as to induce a return of the colicky pains which 
had appeared in the second month after conception. Cyprianus 
and Chambon6 speak of the foetal movements as appearing 
more vigorous to the woman than in normal gestation. As 
term is approached, at or near the time of spurious labor the 
child perishes. This is not unfrequently attended with symp- 
toms which attract the attention of the mother. These con- 
sist in a series of violent, disorderly, and even painful move- 
1 Instruction surl’Art des Accoucliemens, 8vo., Lausanne, 1828, p. 218. 
2 Revue Medicale, tome ii., 1831, p. 108. 
3 Archives de Tocologie, Paris, 1874, p. 125. 
4 Medical Examiner, Pliila., Jan. 1846, p. 25. 5 Loc. citat. p. 314. 
6 Maladies des Femmes, 8vo., Paris, partie ii. tome ii. p. 52. EXAMINATION OF THE ABDOMEN. 
103 
ments on the part of the child, after which they cease entirely. 
The foetus is often spoken of as giving a violent struggle at 
this time. Messer,1 Petersen,2 Tueffard,3 Boinet,4 and Du bond5 
have all directed attention to this symptom. The last of these 
authors says that these violent efforts of the child caused the 
mother much suffering. This symptom is by no means con- 
stant in its occurrence. 
The metrorrhagic discharge may continue during this stage, 
or it may not. There is no doubt about the fact that this, as 
well as the paroxysmal pains, may disappear during the second 
part of the evolution of the foetus, or, indeed, that in excep- 
tional cases they may be absent throughout the whole period 
of gestation. If the decidua has been thrown off during the 
early months of pregnancy, metrorrhagia is exceedingly apt to 
be absent during this stage. 
O o 
The breasts undergo the usual changes. They enlarge, milk 
is secreted, and the areolse are altered as after conceptions in 
which the ovum is developed within the uterus. The mam- 
mary signs are sometimes typically developed. 
Examination of the Abdomen.—Upon inspection the enlarge- 
ment is generally found to be mainly upon one side. In- 
stead of having the normal oval outline of the gravid uterus, 
the transverse is often greater than the perpendicular diame- 
ter of the foetal tumor. Sometimes the head and breech of the 
child form projections, visible to the eye, in either flank. It 
must not be forgotten, however, that the abdominal enlarge- 
ment may present no departure from the natural outline. The 
fcetal movements are sometimes visible on inspection. M. Koe- 
berld has seen6 them so strong that they moved the bedclothing 
which was over the woman. Keller7 asserts that the umbili- 
cus, instead of being pushed forward as in normal pregnancy, 
is strongly retracted. This needs corroboration. We have 
always seen it pouting, as in uterine gestation. The abdominal 
brown line and umbilical areola may or may not be developed. 
Palpation adds to the information obtained by inspection, 
1 Campbell’s Memoir, p. 70. 2 Dublin Med. Press, Aug. 10, 1859. 
3 Amer. Journ. of Medical Sciences, Oct. 1849, p. 522. 
4 Loc. citat., p. 125. 5 Ibid., p. 644. 
6 Keller, loc. citat. p. 48. 7 Ibid., p. 47. 104 
SYMPTOMS. 
when the tenderness of the parts will permit a thorough ex- 
amination in this manner. By this means the foetus can often 
be felt to be very superficially situated in the abdomen. It 
sometimes appears as if the skin only was between the hand 
and the child. This sign, however, has but little value as an 
indication of misplaced pregnancy. 
The gravid uterus, it is well known, enjoys more or less 
mobility, but, according to Duboud,1 an extra-uterine foetal 
cyst is fixed in the cavity of the abdomen. Doubtless this is 
often the case, and when it is so it may be of considerable diag- 
nostic value. There are exceptions to the rule, however. 
Mounsey2 says that he has seen the “burden” fall from one side 
to the other as the woman changed her position. This ex- 
treme mobility continued for the ten years during which the 
child was carried after the end of the normal term of preg- 
nancy. The author has seen the extra-uterine tumor as mov- 
able as in normal gestations, at least until the end of the 
seventh month in one case, and in another, seen two weeks 
after term, the mobility was nearly as great as that of a gravid 
uterus at the end of the ninth month. Just after the tumor 
emerges from the pelvis, a mass may be felt somewhere in the 
hypogastrium, generally in the iliac fossa opposite to that in 
which the child is developed. This is the fundus of the en- 
larged uterus, and it may lead the patient to believe that the 
tumor originally started on that side and afterwards changed 
its position to the opposite side.3 As pregnancy advances the 
fundus uteri can frequently be made out by careful palpation, 
as a hard pear-shaped body on the anterior surface of the gravid 
sac. It may form a projection which is visible on inspection. 
Auscultation reveals the same sounds that are heard in nor- 
mal pregnancies. These are sometimes remarkable for their 
intensity. Attention has been directed to the fact by Martyn4 
arid Spencer Wells. When exhibiting the specimens removed 
from Dr. Perkins’ patient to the Obstetrical Society of Phila- 
1 Archives de Tocologie, 1874. 
2 Philosophical Trans., ab. ed., 4to., London, 1745, p. 1012. 
1 Duboue, loc. citat. p. 581. 
4 Trans. Obstet. Soc. London, 1870, vol. xi. p. 57. VAGINAL EXAMINATION. 
105 
delphia, the author remarked,1 that, though he had examined 
many pregnant women at the Philadelphia Hospital, he had 
never listened to a placental murmur which was so intense. 
A short time since we saw a lady, who was carrying an extra- 
uterine child, in consultation with Hr. E. L. Huer, and Profes- 
sors Ellerslie Wallace and William Goodell. She was at that 
time two weeks beyond term, and the child had died during 
spurious labor. Hr. Huer, who had charge of the patient,stated 
that, when he first auscultated the abdomen, he was astonished 
at the intensity of the placental bruit, which was the loudest 
he had ever heard. The placenta appeared to be located in 
the left iliac fossa and corresponding lumbar region. Keller2 
believes that this sound is rarely heard in misplaced pregnan- 
cies, and adds, that when it is, the placenta is inserted on the 
anterior abdominal wall. This is by no means true, for in 
Hr. Perkins’ case, just alluded to, in which the sound was so 
remarkable for its intensity, the organ was attached to the 
posterior surface of the cyst over the right flank and vertebral 
column. 
Preternatural intensity of the sounds of the foetal heart or 
the placental bruit, ought always to excite suspicion and lead 
to a careful physical examination of the woman in whom they 
are discovered. 
Vaginal Examination.—Upon vaginal examination in this 
stage of gestation, the uterus will be found to he enlarged, 
but upon careful investigation it will be ascertained that the 
development is not in proportion to the duration of the preg- 
nancy. This is a very important fact, and is especially notice- 
able in the latter months. By combined internal and external 
examination, the length of the organ can be accurately deter- 
mined, when the fundus can be felt above the pelvis on the 
anterior surface of the foetal cyst. The neck will be found 
more or less softened, enlarged, and otherwise altered, as after 
normal conceptions, but especially in the latter months it may 
be noticed that these changes are not in proportion to the 
duration of the pregnancy. Compared with what it should 
1 Amer. Journ. of Obstet., May, 1872, p. 150. 
2 Loc. citat. p. 48. 106 
SYMPTOMS. 
be at this time, the cervix is small, firm, and hard, and pre- 
sents most of the characteristics of a non-impregnated womb. 
The uterus is generally found to be displaced. It may be 
pushed to either side, when the bladder often shares in the dis- 
location.1 In rare cases the organ is pushed downwards in the 
pelvis and retroverted, or it may even protrude at the vulva.2 
The most frequent deviation of its position is for it to be 
carried to one side and at the same time to be pushed forwards 
and elevated above the pubis, where it is found in contact 
with the anterior abdominal wall, so that it can only be 
reached with the greatest difficulty.3 The uterus is frequently 
not found until after repeated efforts have been made.4 This 
displacement of the os, pregnancy having previously been 
decided to exist, is a sign of great value, and should always 
lead the medical attendant to subject his patient to careful 
examination. 
During this period of the evolution of the foetus a tumor 
forms in the vagina. This is generally situated behind the 
uterus, but it may sometimes be in front, as has been noticed 
by Depaul.5 In the last stages of gestation the post-uterine 
tumor may completely till the pelvis, displacing the uterus in 
the manner previously described. Rupin6 saw the action of 
the bowels completely suspended by pressure at the end of the 
sixth month. The enlargement in the pelvis may fluctuate or 
semifluctuate. In other instances portions of the foetus may 
be felt through the vaginal walls. These may be so thin as 
to make it appear as if there was almost no tissue between the 
child and the examining finger. Johnson7 reports the fact, 
1 Duboue, loc. eitat. 2 Dr. King, Campbell’s Memoir, p. 76. 
3 Armour, Glasgow Med. Journ., 1830 ; Scott, Trans. Obstet. Soc. Lon- 
don, vol. xv. p. 140 ; Stiles, Pliila. Med. Times, April 4, 1874 ; Mainwaring, 
Trans, of a Society for tlie Improvement of Medical and Chirurgical Know- 
ledge, 1800, vol. ii. p. 290; Young, Trans. Medico-Chir. Soc., Edinburgh, 
vol. iii. p. 536 ; Bonnie, These a Paris, 1822. 
1 Perkins, loc. citat. ; Colman, Med. and Phys. Journ., London, 1799, p. 
262 ; James, North Amer. Med. and Surg. Journ., 1827, p. 283 ; King, Rich- 
mond Med. Journ., Sept. 1868 ; Denny, Amer. Journ. of Med. Sciences, 
July, 1850, p. 49. 
5 Loc. citat. s Gazette des Hdp., No. 13, 1860. 
7 Pliila. Journ. of Med. and Phys. Science, 1825, vol. xi. p. 120. VAGINAL EXAMINATION. 
107 
that upon vaginal examination he found the tissues interposed 
between the finger and the child’s head to be so thin, that the 
sutures and posterior fontanelle could easily be traced upon 
its surface. Hodge1 felt the spinous process of the vertebrae 
through the vaginal wall. This superficial position of the 
foetus, as discovered by vaginal examination, is not peculiar 
to extra-uterine pregnancy. Pajot2 has recently directed at- 
tention to this fact. The child may or may not be detected 
by ballottement through the vagina. Efforts to effect this 
will often be successful, however, though the tenderness of the 
parts frequently interferes materially with the examination. 
Evesque3 states that he has seen excessive uneasiness produced 
by mere contact of the finger with the os uteri. 
Vaginal examination will sometimes reveal the presence of 
peculiar symptoms. According to Marc,4 Baudelocque met 
with a foetal cyst, which contained a large number of vessels 
the pulsations of which were very strong and could be felt upon 
all the parts of the tumor, which were accessible through the 
vagina. This symptom is rarely mentioned by those who 
have observed cases of misplaced gestation, yet it is known 
that the cyst walls are sometimes very vascular, as was wit- 
nessed by Turnbull5 and Blackman.6 The latter abandoned 
the operation of gastrotomy on account of the large size and 
great number of the vessels which he found in the anterior 
wall of the foetal sac after he had opened the abdomen. 
ISTot only have the pulsations of the maternal arteries been 
detected by vaginal examination, but Low and Lumpe7 assert 
that they have felt the foetal pulse through the vagina, a “new 
sign” of extra-uterine pregnancy, to which they attach great 
diagnostic value. They believe, that, “on account of the posi- 
tion of the ovum and the peculiar arrangement of the vessels in 
these extraordinary cases, it would probably be possible, in most 
' Loc. citat. 
2 Des Causes d’Erreur dans le Diagnostique de la Grossesse; Annales de 
Gynecologie, Paris, 1844, p. 212. 
3 These a Paris, 1806; Campbell, loc. citat. p, 63. 
1 Dictionnaire des Sciences Medicales, 8vo., Paris, 1817, p. 402. 
5 Loc. citat. 
6 Amer. Journ. of Medical Sciences, July, 1845, p. 56. 
7 Boston Medical and Surgical Journ., May 28, 1857, p. 328. 108 
SYMPTOMS. 
if not all instances, to discover some pulsating artery belong- 
ing to the foetal vascular apparatus, if sufficient time be taken, 
and the examination is made with great care.” The fact 
which Low and Lumpe have recorded is very curious, and 
does not seem to have attracted any attention. Ho other 
observer, so far as we are aware, has confirmed these state- 
ments. The sign cannot have much diagnostic value, for the 
simple reason that the child is frequently so situated, that it 
can only be touched with great difficulty by the vagina, or 
indeed if it occupies a transverse position in the abdomen, and 
the retro-uterine tumor is of considerable size, it cannot be 
reached at all. In other instances the woman is afflicted by 
such exquisite tenderness, that this examination is impossible. 
The detection of the foetal pulse depends only upon the degree 
of attenuation of the tissues intervening between the finger 
and the portion of the child which is in the pelvis. Allusion 
has already been made to the fact, that excessive thinning of 
either the vagina or abdominal wall is no indication of the 
existence of misplaced gestation. It appears probable there- 
fore, that the “new sign” noticed by Low and Lumpe is rarely 
present, and that when it is, it has not the great diagnostic 
value which they attached to it. 
At the time that the vaginal examination is made, a cathe- 
ter should be introduced into the bladder in order to deter- 
mine whether it occupies its normal position or not, and if it 
does not, the direction of its displacement, which Duboue, of 
Pau, believes always corresponds to that of the uterus. It 
may sometimes be pressed to one side when the womb forms 
a portion of the anterior wall of the sac, and maintains its 
position in the median line. The author has been a witness of 
this fact. In rare cases the bladder takes a position below and 
behind the foetal tumor, as was observed by Goodbrake.1 
Vedder2 has seen it adherent to the anterior abdominal wall, so 
that, even when empty, it would have been wounded by an 
incision, made to perform the operation of gastrotomy. 
During the examination of the organs of the pelvis, it is 
important to decide positively whether the uterus is empty or 
1 Boston Med. and Sura;. Journ., July 5, 1860. 
2 Amer. Med. Times, June 15, 1861. MECHANICAL EFFECTS. 
109 
not. This done, pregnancy having been previously determined 
to exist, the symptoms become positive, and the condition of 
the woman is put beyond all doubt. This can only be deter- 
mined by the use of the sound, a mode of exploration which 
should not be resorted to without due caution. In the first 
stages, before the foetal heart can be heard, and when the 
results of ballottement are negative, the use of the sound, if 
permissible, would be attended with much more important 
results. In the second stage, after the existence of pregnancy 
has been determined, it is not generally so important to accu- 
rately decide whether the uterus is empty or not, since the 
indications are to allow the pregnancy to go on to full term. 
This mode of examination is not without some sources of error. 
Duboue thrust the sound through the posterior wall of the 
uterus, into the peritoneal cavity, and thus confirmed his erro- 
neous conclusion that he had to deal with a uterine pregnancy. 
A short time since the author saw, in consultation with her 
attending physician, a young lady, who had an abdominal 
tumor which resembled a gravid womb. The foetal heart and 
placental bruit could not be heard, though the foetus could be 
felt so plainly through the abdominal wall, and was so super- 
ficial in its situation, that it led her physician to suspect that 
it was extra-uterine. The woman was near full term, but her 
medical attendant passed the uterine sound very cautiously. 
It went up nearly five inches. The patient went to term and 
was happily delivered of her child. The passage of the sound 
by no means always leads to a premature labor. Schroeder 
was well aware of this fact. He says,1 “ in utero-gestation the 
sound may pretty easily pass between the membranes and the 
uterine wall, and . . abortion is by no means the usual 
consequence of a careful introduction of the sound.” 
A physical exploration of the rectum may be resorted to to 
confirm or add to the information obtained by vaginal exami- 
nation. The post-uterine tumor will be felt pressing upon the 
intestine, and the child can sometimes be felt within it. 
The mechanical effects of the gravid cyst are those of. any 
other tumor of the peritoneal cavity. It may press upon 
the various delicate tissues of the abdomen and pelvis, and 
1 Manual of Midwifery, 8vo., New York, 1873, p. 135. 110 
SYMPTOMS. 
thus produce much discomfort and uneasiness, or even severe 
pain. (Edema of one or both of the lower extremities occasion- 
ally, though not very frequently, results from pressure on the 
larger venous trunks of the pelvis and abdomen. 
It may press upon the bladder and render the discharge of 
urine difficult and painful, or arrest the flow entirely, as was 
witnessed by Bergeret.1 The rectum may be so narrowed as 
to lead to obstinate constipation, or discharge from the in- 
testine may be entirely arrested. Craighead2 has seen the 
bowels completely obstructed in combined intra- and extra- 
uterine pregnancy at the end of three months. J. Hall Davis3 
witnessed the same thing in a left tubal gestation at four, and 
Tendering and Rupin,5 each at six months. 
Labor at Term.—If extra-uterine pregnancy is prolonged 
until the end of the normal period of gestation, it is the rule 
for the woman to have pains identical in all particulars with 
those of labor at the end of normal pregnancy. The pains of 
this spurious labor have the natural, intermittent periodical 
character, so that the patient, the midwife, and even the phy- 
sician in attendance, are not undeceived until a vaginal ex- 
amination is made by the latter. Even then, accoucheurs have 
more than once failed to recognize the true state of affairs, and 
important obstetrical operations have been proposed, and even 
attempted, under the impression that the foetus was contained 
in the uterus. In rare cases, spurious labor does not occur at 
the end of gestation. Observations of this kind have been 
recorded by Prefect,6 Ramsbotham and Adams,7 Ilanius,8 Tait,9 
Atlee,10 Edgar,11 and Perkins.12 
1 Recueil Periodique, tome xiv. p. 289. 
2 Amer. Journ. Medical Sciences, Jan. 1850, p. 114. 
3 Trans. Patholog. Society, London, 1853, vol. iv. p. 230. 
* New York Med. Journ., July, 1873, p. 97. 
5 Gaz. des HOpitaux, No. 13, 1860. 
6 Cases in Midwifery, 8vo., Rochester, 1783, vol. ii. p. 161. 
7 Med. Times and Gazette, July 21, 1860, p. 57, and Mr. Adams, Trans. 
Medico-Chir. Soc. London, 1861, vol. xliv. p. 1. 
8 Dublin Journ. Med. and Chem. Sci., 1835, vol. vi. p 158. 
9 Trans. Med.-Chir. Soc. London, 1873, p. 219. 
10 Diagnosis of Ovarian Tumors, 8vo., Pliila., 1873, p. 194. 
11 St. Louis Med. and Surg. Journ., 1871, p. 306. 
12 Phila. Med. Times, March 15, 1872, p. 223, and Amer. Journ. of Obstet., 
May, 1872, p. 155. LABOR AT TERM. 
Ill 
In some instances the pains come on prematurely, as in normal 
pregnancy. Hope,1 Meadows,2 Davies,3 James,4 and Aubinias5 
saw them occur at the end of the seventh month. In Ileys’6 
patient they set in when she was eight months gone. On the 
other hand, there is some reason to believe that this false labor 
may be delayed for some time after the end of gestation. 
Ramsay7 states that he saw it commence at the end of eleven, 
and Gordon,8 at the end of thirteen months. Delayed labor 
in extra-uterine pregnancy is rare, however. 
The duration of this spurious labor varies considerably. 
Macartney9 describes the pains as lasting eight hours ; Rarns- 
botham10 and King11 twenty-four hours. In other cases they 
may be prolonged much beyond the usual time. Maclarty12 saw 
them continue five days ; Stergerthal13 and Chevillon14 each 
seven days; Otto,15 twelve days; Bosseut16 for two weeks; and 
Bouquet17 has seen the symptoms of labor continue more or 
less severe for three weeks. The severity of the pains appears 
to be different at different times in the same patient. They 
may gradually increase in intensity until they assume the 
characters of those belonging to the second stage of labor, and 
then gradually subside. Their severity, of course, varies 
much in different persons. Sometimes they are fugitive and 
comparatively trivial, so that it is difficult to recognize their 
true nature; while at other times they are of the most severe 
' Med. and Phys. Journ., London, 1801, vol. vi. p. 860. 
2 Trans. Obstet. Soc. London, 1873, vol. xiv. p. 310. 
3 Lancet, Feb. 19, 1831, p. 7u2. 
4 North Amer. Med. and Surg. Journ., 1827, vol. iv. p. 283. 
5 Gazette Medicale, No. 44, 1862. 
6 Med. Observ. and Inquiries, 1769, p. 341. 
7 Med. Repository (New York), 1804, p. 221. 
8 Medical Commentaries, 1794, p. 323. 
9 Dublin Journ. Med. and Chem. Science, 1835, vol. vii. p. 412. 
10 Medical Times (London), Nov. 13, 1852, p. 481. 
11 Richmond Med. Journ., Sept. 1868. 
12 Med. Commentaries, 1793, vol. xvii. p. 481. 
13 Philosophical Trans., ab. ed., 4to., London, 1734, vol. vi. p. 554. 
14 Gaz. Med. de Paris, Mai 29, 1858. 
15 North Amer. Med. and Surg. Journ., 1827, vol. iv. p. 285. 
16 New England Journ. of Med. and Surgery, 1817, p. 184. 
17 Recueil Periodique de la Soc. de Med. de Paris, tome iii. p. 63. 112 
SYMPTOMS. 
type, and tax the poor patient’s powers of endurance to the 
last degree. 
In certain cases, though not very frequently, this spurious 
labor is repeated at intervals of variable duration. Cotton1 
records an example in which the second attack of pain set in 
twelve days after the commencement of the first. In Simon’s2 
and Baeza’s3 patients it recurred at the end of a month, in 
Iley’s4 in six weeks, while Dr. William Smith5 states that a 
woman under his care had pains like those of labor three 
times, first at the end of gestation, then ten ■weeks later, and 
lastly three months from that time. Blundell6 asserts that he 
has seen labor-pains recur at intervals for years, and Schmidt7 
reports a case of three years’ duration, in which they recurred 
at eight distinct periods. Dr. John W. McIntosh8 has met 
with a most singular example of repetition of labor-pains; 
he says that in 1852 he saw a woman who had “ been suffering 
seven years at regular intervals indicating the usual period of 
gestation, the pains continuing thirty-six to forty-eight hours. 
Each confinement, so called, was terminated by a discharge of 
bloody mucus per vaginam, which affording relief, she was 
able in a few days afterwards to resume her domestic duties.” 
Cazeaux refers,9 without giving any authority, to a similar 
case, in which the pains returned at a period corresponding to 
the usual term of pregnancy for ten years. 
This unavailing labor is usually, though not invariably,10 
attended with a hemorrhagic discharge from the vagina. In 
rare cases the loss of blood may be profuse, as witnessed by 
James11 and Tenderini.12 The latter gentleman states that his 
patient fainted, and that he was forced to arrest the hemor- 
1 New York Med. and Pliys. Register, 1822, vol. i. p. 325. 
2 Philosoph. Trans., abridg. edit., 4to., London, 1756, yol. x. partii. p. 1016. 
3 New Sydenham Society’s Bien. Retro., 1867, p. 397. 
' Med. Obs. and Inquir., 1769, p. 341. 
5 Campbell, loc. citat. p. 49. 6 Lancet, Aug. 16, 1828, p. 612. 
7 Cazeaux, Theoret. and Pract. Midwifery, 8vo., Phila., 1869, p. 594. 
8 Southern Journ. of Med. and Pliys. Science, 1853, vol. i. p. 244. 
9 Loc. citat. p. 594. 
;0 King, Richmond, Medical Journ., Sept. 1868. 
11 North Amer. Med. and Surg. Journ., 1827, vol. iv. p. 283. 
12 New York Med. Journ., July, 1873, p. 97. LABOR AT TERM. 
113 
rhage with a tampon. This metrorrhagia is sometimes pre- 
ceded by separation of the decidua, as has been witnessed by 
Prof. James, Hemard,1 Hennigsen,2 Lalanne,3 and many others. 
The separation of this structure and its discharge during the 
spurious labor are not, however, the cause of the vaginal hemor- 
rhage, which occurs at the same time. This loss of blood 
occurs in women who have discharged the decidua with symp- 
toms of abortion during the early months of gestation, as well 
as in those who have repeated false labors, such as occurred to 
the woman whose history has been published by McIntosh. 
This false labor and vaginal hemorrhage are followed in 
many instances by a vaginal discharge, which resembles more 
or less closely the lochia which succeed a normal parturition. 
This discharge is not always bloody, and lasts several days. 
That this ineffectual labor should occur at the end of the 
ninth month of extra-uterine gestation is a very interesting and 
curious fact. Janvrin4 thinks that its occurrence indicates 
that the pregnancy belongs to the interstitial variety. There 
is very good evidence that this is not true. There is nothing 
to lead to the belief that it is peculiar to any single species of 
erratic gestation. We have reason to conclude that it occurs 
alike in all the forms when the full term is reached. This 
fact has an important and interesting bearing upon the deter- 
mining cause of labor when the pregnancy is normal. This 
was recognized by Dr. Ramsay at the beginning of this 
century. He says,5 that, “ from the regular appearance of labor 
at or near the end of nine months in extra-uterine as well as 
in uterine pregnancy, we have not reason to conclude that 
labor is excited by any faculty of the uterus, but by some 
state or quality of the child.” More importance may be at- 
tached to this idea, when it is remembered, that, though the 
uterus undergoes certain changes in extra-uterine fcetations, 
analogous to those occurring after normal conceptions, and 
1 Lancet, 1844, vol. ii. p. 74. 
2 Archiv. fur Gynsekologie, 1870; New Sydenham Society’s Bien. Retros., 
1889-70, p. 397. 
3 Annales de la Medeclne, Juillet, 1825. 
1 Amer. Journ. ofObstet., Nov. 1874. 
5 Medical Repository, New York, 1804, p. 326. 114 
SYMPTOMS. 
though a decidua is formed in its cavity, labor-pains supervene 
at the end of the usual period of gestation, whether this decidua 
has been discharged or not, at some time anterior to the super- 
vention of the parturient effort. 
Indeed it would seem that the fact, that it is the rule for 
labor to occur at or near term in cases of extra-uterine gestation 
which are prolonged to that period, overthrows all theories 
based upon the view that the determining cause of labor has 
its seat in the uterus. In 1819, Power1 proposed his “ reflex 
sphincter” theory, comparing the uterus to the bladder and 
rectum. In 1855, Brown-S^quard2 advanced the ingenious idea 
that the uterine action was set up by the accumulation of car- 
bonic acid in the blood circulating in the organ. In 1871, Dr. 
A. F. A. King,3 of Washington, D. C., promulgated the view 
that it was due to mechanical distension of the uterus by the 
child; and in the next year Dr. C. C. P. Clarke,4 of Oswego, K. 
Y., proposed the theory, that the determining cause of labor is 
“a spontaneous separation of the decidua,” which “thus becomes 
a foreign body in contact with the inner surface of the uterus,” 
and as such excites reflex contraction of this organ. The history 
of misplaced gestation seems to present insuperable objections to 
the acceptance of any of these opinions. Under these circum- 
stances labor comes on when there is no child to irritate the ute- 
rine “sphincter,” when there is no reason to believe that there 
is any accumulation of carbonic acid in the bloodvessels of the 
organ, when its cavity is not distended by a mature child, and 
when it is not excited to reflex contraction by a separated, ripe 
decidua in its interior. 
It would appear, therefore, that we have to look outside of 
the uterus for the determining cause of labor. Possibly it may 
be found in the ovary, as suggested by Dr. Tyler Smith, and 
possibly in some “ state or quality of the child,” as Ramsay sup- 
posed, or in some condition of the placenta. 
The cause of labor-pains at the close of extra-uterine gesta- 
1 Cazeaux, loc. citat. p. 281. 2 Ibid., p. 282. 
3 Amer. Journ. of Obstetrics, Feb. 1871. Dr. S. C. Busey (Ibid., May, 
1871) criticizes and, we think, effectually disposes of Dr. King’s views. 
‘ Ibid., Feb. 1872, p. 577. CAUSE OF LABOR PAINS. 
115 
tion has never been accurately determined. Velpeau and 
Marc1 believed them to be due to contractions of the fcetal cyst, 
while Duges and Dezeimeris2 thought they originated in 
uterine contractions. The sac, it is said, has been seen and felt 
contracting by Marc and Baudelocque.3 Barnes, Davis, and 
Cayley4 have found muscular fibres in the walls of the sac, but 
this was in a case of tubo-ovarian pregnancy. There is no 
doubt but that the cyst may contract in tubal and interstitial 
gestations, but it is so thin and the muscular fibres are so feebly 
developed that we can hardly account for the severe pains 
which occur in these cases by attributing them to contractions 
of the cyst wall. If it is true that this phenomenon is not 
peculiar to tubal gestations, but occurs alike in those of the ovary 
and abdomen, it is at once apparent that we must seek another 
explanation of their production. Upon this point there is 
some, but not much, clinical evidence. Turnbull5 records the 
fact that he has seen the uterus dilate under the influence of 
these pains so that it would admit several fingers, and Galli6 
has seen the organ relax so that he could pass his finger into 
the cavity of the womb and assure himself that it was empty. 
The most important evidence which we have in regard to 
this matter is that furnished by Mr. Scott.7 lie operated upon 
Dr. Meadows’ patient when she was in the throes of false 
labor at the end of the seventh month. After the abdomen was 
opened he observed that the uterus was contracting regularly 
and at intervals, as in normal labor. The opinion of the 
reporters of the case that the pregnancy was tubal may be 
questioned, but even granting that it was, the observation of 
Mr. Scott, and the fact that spurious labor occurs in both 
primary and secondary ventral, as well as in extra-abdominal 
gestations,8 warrant us in concluding that these pains, like 
1 Diet, des Sciences Med., 8vo., Paris, 1817, tome xix. p. 402. 
2 Diet, de Med. et de Chir. Pratiques, 8vo., Paris, 1833, tome ix. p. 316. 
* Diet, des Sciences Med., 8vo., Paris, 1817, tome xix. p. 407. 
4 Barnes, Diseases of Women, 8vo , Phila., 1874, p. 378. 
5 Mem. Med. Soc. of London, 1792. 
6 Diet. des. Sciences Med., 8vo., Paris, 1817, tome xix. p. 407. 
7 Trans. Obstet. Society, London, 1873, yol. xiv. p. 370. 
8 Skirvani, loc. citat. 116 
SYMPTOMS. 
those of normal parturition, are due to contractions of the 
uterus. 
In connection with labor at the close of extra-uterine preg- 
nancy, it is important to remember that it rarely ends in 
rupture of the foetal cyst. There is no doubt that this may 
occur, but it is so rare that it should be allowed no weight in 
deciding for or against operative interference. This error was 
committed by Mr. Scott.1 The great dread of most who have 
written upon this subject is inflammation of the peritoneum. 
Btiheir2 believes that this labor often ends in rupture of the 
cyst and death of the mother from peritonitis. In this opinion 
he is by no means alone, but there appears to be no clinical 
evidence to sustain the assertion. The sac, as before stated, 
rarely ruptures at this time, and when it does so it gene- 
rally opens either into the uterus, rectum, or vagina. Peri- 
tonitis plays but a small part in the pathology of extra-uterine 
pregnancy at this period of its development. Writers upon 
this subject have believed that it ought to be a frequent com- 
plication, and have, therefore, concluded that it was so. 
Under the influence of false labor the cyst of a tubo-uterine 
fcetation has in a few instances opened into the uterus, after 
which the child has been expelled by the uterine effort. The 
first instance of this happy result appears to have been re- 
corded by Laugier.3 The patient was his own wife. This lady 
became pregnant for the fourth time in September, 1771. 
Symptoms of labor appeared June 17th following. On the 
24tli there was severe hemorrhage, and the hand was passed 
into the uterus, when the bag of waters was felt, with the 
leg and foot of the child protruding into the uterine cavity 
through the orifice of the right Fallopian tube which clasped 
the leg at the knee. The bag of waters was ruptured, and a 
re-examination confirmed these observations. An unsuccessful 
attempt was made to grasp the second foot. Traction was 
made upon the one which protruded until the thigh was de- 
livered, when the other leg was brought down. The body 
now refused to advance, when the hand was introduced, and it 
1 Meadows, loc. citat. 2 Gazette Hebdom., No. 36, 1873. 
3 Archives Generates de Med., tome xxviii. p. 332. RUPTURE OF THE CYST DURING LABOR. 
117 
was found that the tube had contracted upon the head of the 
child. The delivery was finally accomplished. There was 
hemorrhage, and the hand was introduced and the placenta 
removed. 
Dr. J. Braxton Hicks has seen1 the child expelled spon- 
taneously in a case of premature labor, when the woman was 
five and a half months gone. The tubo-uteriue cyst opened 
into the uterus. His patient unfortunately perished from 
rupture of the peritoneal surface of the cyst four days after 
delivery. Prof. Hicks was not aware of Laugier’s experience, 
and believed his case to be unique. Dr. Widney,2 of California, 
has since then made a somewhat similar observation. His 
patient was delivered spontaneously at term. The placenta 
did not separate. The hand, passed into the uterus, discovered 
the orifice of the right tube two inches in diameter. This led 
into a cavity with regular walls, and which contained the 
after-birth, which was removed. It is not certain that in this 
instance the child may not have been developed in the uterus 
and the placenta only in the tube. 
Other varieties of misplaced pregnancy may terminate by 
rupture into other hollow organs. Giffard3 has seen the whole 
child expelled by the bowel between the fifth and sixth months. 
Yardley and Sansbury,4 of Philadelphia, witnessed the expul- 
sion of the body of a five months’ extra-uterine foetus, the cyst 
of which had ruptured into the rectum. Unfortunately the 
sphincter ani seized the child by the neck, and traction gave 
so much pain that it could not be borne. It was before the day 
of anaesthetics, and the narrators appear to have been somewhat 
puzzled for a time, but they were not long in determining 
upon a method of treatment. The application of force from 
without having proved unavailing, they concluded to apply it 
from within, and to do this gave the woman a dose of castor oil, 
and thus purged her of her child, for it came away with the 
first dejection. 
' Trans. Obstet. Soc. London, 1868, vol. ix. p. 57. 
2 Boston Med. and Surg. Journ., March 0, 1871. 
3 Cases in Midwifery, 8vo., London, 1794. 
* North Amer. Med. and Surg. Journ., 1826, vol. i. p. 292. 118 
SYMPTOMS. 
Clark1 saw labor come on near term. The next day the hairy 
scalp of the child could be felt in the rectum, the waters having 
previously escaped by that channel. Dr. Clark passed his 
whole hand into the bowel, and putting his fingers into the 
child’s mouth, extracted the head of a seven months’ foetus per 
anum. After this the body and secundines were expelled spon- 
taneously. Dr. Clark’s patient recovered, but not without 
some sloughing of the anus and perineum. 
Examples of rupture of the cyst into the vagina during labor 
have been reported by Charlton and Williams,2 Emmons,3 and 
Huguier.4 In the first case the rupture was mistaken for the 
dilated os uteri. The head presented ; the child, which was 
at term, was easily turned, but could not be extracted. In the 
second patient the presentation was “high and out of reach,” 
when a violent pain suddenly brought a hand into the vagina. 
Various unsuccessful efforts were made to turn the child, which 
was at term, apparently with the impression that the fcetation 
was intra-uterine. In Iluguier’s case the termination was more 
happy. The woman had reached term. Extra-uterine preg- 
nancy had been recognized, and the patient was being carried 
to the operating room to have gastrotomy performed, when the 
vagina ruptured and the child was spontaneously expelled. 
In an analysis of five hundred cases, these are the only illustra- 
tions of rupture of the cyst during labor which have occurred, 
and in not a single instance has it opened into the peritoneal 
cavity.5 It will, therefore, be seen that the continuity of the 
cyst walls is rarely destroyed by labor—so rarely, indeed, that 
1 Philadelphia Med. Museum, 1806, vol. ii. p. 292. 
2 London Med. Gazette, 1843-44, vol. xxxiii. p. 43. 
3 Boston Med. Magazine, July, 1833, and Baltimore Med. andSurg. Journ., 
1833, vol. i. p. 231. 
4 Lancet, Nov. 20, 1852. 
5 Matthews (Atlanta Med. and Surg. Journ., Aug. 1872) has reported a 
case in which it is possible that rupture into the abdominal cavity may have 
occurred during false labor. He says that the last pain “ continued for forty 
minutes, without any seeming relaxation.” During this pain a noise was 
distinctly heard by all present, like “something bursting in the abdomen.” 
It was felt by the woman. After this the pains ceased. At the autopsy the 
abdomen was found to contain some coagula, and “ the Fallopian tube 
seemed to have been lacerated obliquely.” SECRETION OF MILK. 
119 
neither our prognosis nor treatment need be influenced by its 
possibility. 
Hot only are the organs designed by nature to insure the 
development of the foetus sympathetically excited in extra- 
uterine pregnancy, but those which are intended for the nour- 
ishment of the child after its birth are likewise called into 
activity. Hence, we find this unfruitful labor followed by 
the secretion of milk in the breasts, a fact which was noticed 
as early as 1678.1 The milk has its usual characters, though 
there are some exceptions to this rule. Turnbull2 has seen it 
bear “a much nearer resemblance to pus than milk.” The 
quantity is not less than after natural delivery, and it is 
sometimes excessive.3 The secretion may continue for only 
a few days, or it may be prolonged much beyond the usual 
period of lactation. Bell4 and Percival5 have seen it continue 
for several years, and Cazeaux6 asserts that it has been known 
to persist for thirty years, during which time the woman did 
not menstruate. A most curious statement in regard to this 
secretion is made by Mounsey.7 His patient carried her extra- 
uterine child twelve years. At the end of eleven years a 
swelling formed at the navel, which the woman opened with 
an awl. One year later the opening was enlarged, and por- 
tions of the child extracted at intervals, until it was all re- 
moved. Dr. Mounsey says that after her delivery “her breasts 
swelled and she gave milk in plenty for two months, in 
quantity, color, and consistence, as after delivery at the proper 
time.” 
From these facts it appears that the victim of an extra-ute- 
rine pregnancy, at the close of the ordinary period of gestation, 
1 Mad. Le Boursier duCourdray, Abrege de l’Art des Accouchemens,etc., 
12mo., Paris, 1759, p. xxxvi. 
2 Mem. Med. Soc. of London, 1792, vol. iii. p. 185. 
* Hanius, Dublin Journ. Med. and Cliem. Sci., 1835, vol. vi. p. 158 ; John- 
son, Med. Times and Gazette, June 8, 1872, p. 655; Macartney, Dublin 
Journ. of Med. and Cliem. Science, 1835, vol. vii. p. 412; Lalanne, Annales 
de la Med., Juillet, 1825. 
4 Med. and Pkilosoph. Comment, of Edinburgh, 8vo., London, 1774, vol. 
ii. p. 77. 
5 Medical Commentaries, 1774, p. 77. 6 Loc. citat. p. 594. 
? Pkilosoph. Trans., ab. ed.* 4to., London, 1756, vol. x. part ii. p. 1012. 120 
SYMPTOMS. 
is in a state which approaches very closety to that of a woman 
after normal labor. She first has pains, similar in their 
characters to those of true labor. These are accompanied in 
most cases by a hemorrhagic vaginal discharge, which persists 
after the spurious labor is over, and takes the place of the 
lochia, while to complete the analogy, the functional activity 
of the mammary glands is established at the usual period after 
the cessation of the pains. Excepting that the child has not 
been expelled, the condition of the woman differs but little 
from that which succeeds normal labor. She is in a pseudo- 
puerperal state, and in many particulars demands the same 
treatment that a woman actually delivered does. She is in a 
condition in which the liability to inflammatory diseases of 
the abdominal and pelvic cavities is increased, while her sus- 
ceptibility to the effects of septic and purulent infiltration of 
the blood is probably likewise augmented. The recognition 
of the fact that the woman’s condition approaches so closely 
to that which follows normal labor, is extremely important. 
The failure to appreciate this truth has led many accoucheurs 
to subject their patients to methods of treatment which are 
proper only after the woman has been fully restored from her 
pseudo-puerperal state. 
The influence of the spurious labor upon the child is a mat- 
ter of some interest. It is probable that the labor pains them- 
selves have but little effect upon the foetus, as long as the cyst 
walls remain intact. When the ordinary period of gestation 
is reached, no matter whether labor supervenes or not, it is 
probable that the infant experiences a more or less profound 
change. It has now reached the full period of its develop- 
ment, and the placenta is undergoing those changes which 
prepare it for separation. Notwithstanding these facts, it has 
been stated that the child does not always die at this time. 
The case of Polinus, who asserted that a healthy boy was 
discharged spontaneously by an abscess in the right hypo- 
chondrium some time after the termination of the usual 
period of gestation, and also that of Schmidt, who, accord- 
ing to Meissner, extracted a child still living from an abdo- 
men in which it had been carried three years, are, of course, 
not worthy of belief. It is, however, the opinion of a number DEATH OF THE CHILD AT TERM. 
121 
of competent observers, tlmt the life of the foetus may be 
maintained for some time after the termination of the usual 
period of gestation. Tanner1 and Leishman2 apparently credit 
this opinion ; Cazeaux3 and M. Depaul4 assert it positively. 
Grossi5 has reported a case in which he states that foetal move- 
ments were felt by himself and his consultants until twenty- 
three months after the cessation of the menses. Starley6 
mentions the fact, that his patient and her friends felt the 
child move for nearly seven weeks after the birth of the 
intra-uterine infant at term, in a case of twin conception. 
This is the only clinical evidence which the examination of 
five hundred cases has furnished in favor of the opinion that 
an extra-uterine child may live beyond the usual period of 
o-estation. Nothing- need be said about the value of such tes- 
timony. It is well known how easily physicians may be 
deceived in regard to foetal movements. When some one re- 
cords the fact that he hears the foetal heart for a considerable 
time beyond the normal period of pregnancy, the subject will 
demand careful investigation. In the present state of our 
knowledge it seems more reasonable to conclude, that the pro- 
longation of the life of the foetus is apparent, not real, and 
that there has been an error in determining the time at which 
conception occurred. There is also to be considered the fact 
that the natural term of gestation may be considerably pro- 
longed. Ramsay, in consequence of the almost regular appear- 
ance of labor at or near the end of the ninth month in cases of 
extra-uterine as well as intra-uterine pregnancy, has suggested 
(as has already been mentioned) that labor is caused “by some 
state or quality of the child.” This “quality of the child” may 
be supposed to be a change which has prepared it to commence 
a new mode of existence, in which its feeble life has to be 
carried on independent of its mother. There is reason to believe 
that the foetus lives but little longer than the time when this 
1 Signs and Diseases of Pregnancy, 8vo., Phila., 1868, p. 296. 
2 Syst. of Midwifery, 8vo., Glasgow, 1873, p. 212. 
3 Theory and Pract. of Mid., 8vo., Phila., 1869, pp. 592-596. 
4 Archives de Tocologie, Sept.. 1874. 
6 Gazette Medicale, Jan. 1846. 
6 New York Med. Journ., March, 1873. 122 
SYMPTOMS. 
condition of ripeness is reached, if such an expression may be 
allowed. 
The fact that some of the children which have been carried 
beyond the usual term have been found to be .remarkably 
large, does not prove that they lived and grew beyond the 
usual time in the vicarious uterus. Excessive development 
may be accounted for, when it occurs, in the same manner as 
in uterine gestations. 
It has been reported, as an evidence of prolonged vitality 
of the child, that the jaws contained several teeth. This like- 
wise is testimony of no value, since it is a well-known fact that 
children sometimes cut teeth before birth. The author has 
seen a child born with four. 
Attention has already been directed to the fact that the 
death of the child may be attended with violent struggles, or 
even convulsive movements upon its part. These are felt by 
the mother, and may annoy her greatly, or cause her extreme 
pain. CHAPTER YI. 
SYMPTOMS—Continued. 
After completion of term or death of the child—Diminution in size of the abdomen— 
Discharge of the contents of cyst through abdominal wall, bladder, vagina, and 
bowels—Intestinal and vesical fistule—Offensive perspirations—Symptoms of rupture 
of the cyst in early months of gestation—Peritonitis is unusual after this accident— 
Pregnancy in a hernial sac—Twin conceptions in extra-uterine pregnancy—Preg- 
nancy while carrying an extra-uterine foetus—Repeated extra-uterine pregnancy. 
We have now followed the progress of extra-uterine preg- 
nancy to the completion of the ordinary term of gestation, but 
the accident has a history which extends beyond this, and 
often covers a very long period. It is a well-known fact that 
an extra-uterine child may be retained for an indefinite time. 
Nebel1 had a patient who lived to be over ninety-one years of 
age, and who had carried the product of a misplaced concep- 
tion for fifty-five years. Though the presence of an encysted 
foetus is not incompatible with life, and even with comfort and 
usefulness, the woman who bears such a burden with her is iu 
constant danger of the cyst taking on inflammatory action 
which will greatly endanger, and may even destroy her. 
The changes which occur in the economy of the woman 
after the death of the foetus, which, if it has not occurred 
before, takes place during or shortly after the close of false 
labor, will be best understood by studying them somewhat in 
the order of their occurrence. As the woman commences to 
regain her non-puerperal state, a very important change takes 
place in the size of the abdomen. This diminishes more or 
less, but the woman does not regain her natural proportions 
as long as she continues to carry the child. With the death 
of the foetus the secretion of the amniotic fluid ceases. Not 
only is this the case, but it is either partially or entirely reab- 
sorbed. This is an important symptom, and is rarely absent. 
1 Campbell, loc. citat. p. 45. 124 
SYMPTOMS. 
Prefect1 and Gunning,2 however, have seen the abdomen re- 
main unchanged in size after the woman had reached term, 
while Bell,3 Mr. P. Hutchinson,4 Bamsbotham,5 and Mr. 
Jonathan Hutchinson,6 have each seen the belly continue to 
enlarge after the termination of the usual period of gestation. 
Mr. J. Hutchinson, aware of the almost uniform occurrence of 
diminution in the size of the abdomen, was strongly influenced 
by its absence in concluding that his patient was not pregnant, 
but had an ovarian tumor; while Hr. Meadows7 admits that 
he did not attach sufficient importance to the absence of this 
symptom in the poor patient from whom he attempted to re- 
move a fibro-cystic tumor of the uterus and a cancer of the 
omentum, supposing the mass to be an extra-uterine foetus. 
"When the amniotic fluid is not reabsorbed, but, on the con- 
trary, continues to increase in quantity after the close of preg- 
nancy, the cyst may fluctuate very distinctly. This has been 
noticed by Mr. Jonathan Hutchinson and others. The true 
importance of this diminution in the size of the abdomen will 
become apparent in the discussion of the diagnosis of misplaced 
gestation after the death of the foetus. 
After this, the product of conception may become desiccated 
or mummified, or it may be converted into a substance resem- 
bling adipocere. At other times calcareous matter is found in 
its tissues or upon its surface, while the same alteration may 
take place in the cyst-walls. These processes have elsewhere 
claimed attention, and need not be more than alluded to here. 
The woman is liable to have an attack of peritonitis at any 
time after the death of the child, or after the close of the 
usual period of gestation. This is not generally severe. In- 
deed, there is good reason for believing that the disease is 
usually latent, and when it is not so, it is almost always of a 
subacute type. The process is often conservative in its charac- 
1 Cases in Midwifery, 8vo., Rochester, 1783, yol. ii. p. 161. 
2 Med. and Pliys. Journ. of London, vol. xlix. p. 311. 
3 Med. Commentaries, Edinburgh, vol. ii. p. 77. 
4 London Med. Gazette, Nov. 7, 1835, p. 169. 
5 Med. Times (London), Nov. 13, 1852, p. 481. 
6 Lancet, July 9, 1873, p. 71. 
7 Trans. Obstet. Soc. London, vol. xv. p. 145. INTESTINAL AND VESICAL FISTULA. 
125 
ter, and attaches the sac to the various surrounding organs and 
to the abdominal wall. In this way nature prepares for the 
discharge of the contents of the foetal cyst in those cases in 
which the child does not become mummified, or is not con- 
verted into a lithopaedion, or into adipocere. 
In those instances in which the gestation terminates by the 
cyst opening through the abdominal wall, bladder, vagina, or 
bowels, pus, the decomposing flesh, and the bones of the child 
are discharged in larger or smaller quantities. When the 
sac opens through the bladder, the unfortunate woman suffers 
from all the symptoms of stone. If the communication is with 
the vagina or rectum, she has the symptoms of vaginitis or 
inflammation of the lower bowel. The latter is frequently 
attended with a diarrhoea. The inflammatory complication is 
the result of the irritation produced by the putrid discharges 
as well as by the mechanical effects of the bones. When due 
to the latter it may be so severe as to produce sloughing and a 
recto-vaginal fistule.1 The other effects are those which would 
be expected from a foreign body in any one of these organs. 
They are pain, a sense of weight and heat, and, in the case of 
the rectum, violent tenesmus. Occasionally, after communica- 
tion with the intestinal canal is established, the foetal cyst, 
which had been previously dull, becomes resonant on percus- 
sion from the admission of gases from the bowel.2 
When the sac opens into the rectum or bladder, and through 
the abdominal wall, in the same woman, fecal and urinary 
fistula may result, forming a very interesting complication of 
these methods of termination. 
Suppuration in an extra-uterine cyst more frequently pro- 
duces intestinal than vesical fistule. The former may occur 
spontaneously, or may be produced during an operation for 
the relief of the patient. Illustrations of the first class have 
been recorded by Saxtorph,3 Drake,4 Houston,5 Adams,6 Che- 
1 Dr. John Smith, Med. and Philosoph. Commentaries of Edinburgh, 8vo., 
London, 1778, p. 314. 
2 Hicks, Trans. Obstet. Soc. London, 1868, vol. ix. p. 93. 
3 Schmidt’s Jahr., 1857, and New York Med. Journ., May, 1858. 
4 Philosoph. Trans., ab. ed., 4to., London, 1756, vol. x. part ii. p. 1019. 
5 Ibid., ab. ed., vol. vii. p. 555. 
6 Brit, and For. Medico-Chir. Kev., Jan. 1873. 126 
SYMPTOMS. 
villon,1 Davis,2 Dubou£,3 Baeza,4 and Blandina de Barros.5 It 
occurred as the result of gastrotomy to Debenham,6 Darby,7 
Hooper,8 and Ilicks.9 The latter cases may be divided into 
two classes. In the first, intestinal fistule is the necessary 
result of gastrotomy in a person in whom the foetal tumor has 
previously communicated with the intestinal canal. Hooper’s 
and Hicks’s cases belong to this class. In Darby’s patient the 
stomach was unhappily ruptured during the operation ; while 
Debenham had the misfortune to wound the intestine in try- 
ing to remove some foetal bones, which were adherent to the 
cyst, through an enlarged fistulous opening. 
This subject is one of considerable interest in connection 
with the result of erratic gestation either with or without 
gastrotomy. Drake says, that after the child was discharged 
through an abscess, near the navel, whatever the woman took 
into her stomach was passed half digested by the fistulous open- 
ing, for six months. The character of the food affected the diges- 
tion. Coarse bread was voided without much change, while 
white bread and other articles of better quality were dis- 
charged half digested. In this instance, therefore, the com- 
munication with the intestinal canal must have been situated 
high up in the tube. It is probable that this was likewise 
true with Davis’s patient. lie also noticed that the fistule 
discharged a fluid, like bile. 
Of the thirteen women who presented this complication, only 
two died. Onq perished from starvation, the opening being 
into the stomach,10 so that everything she took passed at once 
into the cyst. The other died from exhaustion. It appears, 
therefore, that, contrary to what might be reasonably expected, 
the appearance of feces, among the discharges from the abdo- 
minal opening of an extra-uterine gravid cyst, does not make 
1 Gaz. Med. de Paris, May 29, 1858. 
2 Dublin Med. Press, Dec. 18, 1861, p. 423. 
3 Archives de Tocologie, 1874, tome i. p. 578. 4 Loc. citat. 
5 Bull. Generale de Tlierapeutique, 1874, p. 324. 
6 Pliilosoph. Trans., 4to., London, 1753, vol. xlvii. p. 92. 
7 Trans. State Med. Assoc. South Carolina, 1872. 
8 Trans. Med. Soc. of Virginia, 1872, p. 121. 
9 Trans. Obstet. Soc., London, 1868, vol. ix. p. 97. 
10 Darby, loc. citat. EFFECTS OF SUPPURATION. 
127 
the prognosis more unfavorable. On the contrary, such cases 
usually recover, though the track by which the intestine com- 
municates with the abdominal wall may continue open even 
after the patient is otherwise perfectly restored.1 
But one other instance of fecal discharge through a fistulous 
orifice, occurred among the 500 cases which we have examined. 
Dr. Colman,2 finding that the cyst had ruptured into the 
vagina, five months after term, dragged a full-grown child 
through the orifice, without enlarging it, otherwise than by the 
traction exerted. The next day feces were discharged by the 
vagina, but the woman recovered. 
Vesico-abdominal fistula is very rare. It only occurred 
once in five hundred cases, and this was reported by Daeza.3 
Urine and feces were both discharged through an opening 
which formed at the navel, yet the woman recovered. 
During the discharge of the decomposing child through the 
rectum, vagina, bladder, or abdominal wall, the mother is 
subjected to all the dangers which result from the absorption 
of purulent and putrid matter. The same may occur before 
the sac has opened externally, if inflammation in the cyst walls 
and adjoining parts has gone on to suppuration. 
Hence, during this stage of the disease, the symptoms of 
pyaemia may be added to those properly belonging to the 
extra-uterine pregnancy. 
During the period of discharge, the woman is liable to be- 
come profoundly exhausted. Anaemia, hectjc, and night 
sweats may supervene, so that the mother’s vital powers are 
insufficient to effect the work of elimination. When unaided 
by art this process is apt to be very tedious. Mounsey4 and 
Diamantophulous® enlarged fistulous openings into the abdo- 
minal wall one year after their formation. Johnston6 saw the 
process continue through the same channel for three years, and 
1 Davis, loc. citat., and Duboue, loc. citat. The latter states that there is 
a slight bloody discharge from the fistula at each menstrual period. 
2 Med. and Phys. Journ., London, 1799, vol. ii. p. 262. 
3 New Syd. Soc. Bien. Ret., 1867. 
4 Philosoph. Trans., abridg. ed., vol. x. part ii. p. 1012. 
5 Monats. fur Geburt., Nov. 1857, and Brit, and For. Medico-Chir. Rev., 
April, 1858, p. 555. 
6 Edinburgh Med. Journ., Nov. 1857, p. 137. 128 
SYMPTOMS. 
Levan1 for a “ long time,” before he interfered. Hicks2 per- 
formed gastrotomy one year after communication with the 
bladder was established. Petersen3 saw death occur from 
exhaustion two years after an opening had formed in the same 
organ, and fourteen months after discharge had commenced 
by the bowel. Bosseut4 performed lithotomy, and success- 
fully removed nearly one hundred and fifty foetal bones from 
the bladder, four years after elimination had commenced 
through that channel. Dr. Davies5 saw foetal remains voided 
by the bowels for two years; Dr. Samuel Smith6 for two years 
and a half, when the patient died; and Dr. John Smith7 states 
that he has seen the discharge from the bowels continue for 
four years in women who finally recovered. 
After the patient has reached term, and during the time 
when nature is preparing to eliminate the foetal remains, the 
body sometimes exhales offensive odors. Conant8 has seen the 
perspiration become so offensive that all of the woman’s atten- 
dants deserted her. Food was passed to her through a window. 
This discharge sometimes diminishes the contents of the cyst. 
Hale9 has seen the abdomen of a woman a little more than 
two years pregnant, considerably reduced in size in a single 
night with no sensible evacuation to account for it, excepting 
a profuse and exceedingly fetid perspiration. Blandina de 
Barros10 and Adams11 both observed a very bad odor exhaled 
from the body. Bronson12 has also seen the respiratory mucous 
membrane as well as the skin give off a “ peculiar odor,” in a 
woman who retained her child a few months beyond term. 
However interesting and curious these facts may be, the skin 
' Trans. Penn. State Med. Soc., 1867, 4tli series, part iii. p. 219. 
2 Guy’s Hosp. Rep., 1862, p. 133. 
3 Dublin Medical Press, Aug. 10, 1859. 
4 New England Journ. of Med. and Surg., 1817, p. 134. 
5 Lancet, Feb. 19, 1831, p. 702. 6 Campbell, loc. citat. p. 61. 
7 Medical and Philosoph. Commentaries of Edinburgh, 8vo., London, 1778, 
p. 314. 
8 New York Med. .Tourn., 1865, p. 140. 
9 Boston Med. and Surg. Journ., 1857, vol. lv. p. 413. 
10 Bull. Generale de Therapeutique, 1872. 
11 Gazette Med. de Paris, Aug. 1872. 
12 Amer. Med. Monthly, 1860, p. 481. SYMPTOMS OF RUPTURE OF THE CYST. 
129 
and respiratory mucous membrane rarely eliminate any pro- 
ducts of the decomposition of the foetus which render their 
secretions offensive. The symptom has been found to be pre- 
sent in only one per cent, of the cases which we have analyzed. 
Symptoms of Rupture of the Cyst.—By no means every 
woman who becomes pregnant with a child outside ot the 
uterus carries it to term. R"ot more than half of them do this. 
The largest portion of the other fifty per cent, are the victims 
of rupture of the cyst—one of the most terrible accidents that 
can happen to a woman. The symptoms of this are well 
marked. The patient has probably had various attacks of 
colicky pain, as well as the other symptoms previously de- 
scribed, which have led her to believe that something was 
amiss in connection with her present pregnancy. She now 
suddenly has a new accession of pain in one iliac fossa, usually 
associated with metrorrhagia. At the moment of rupture the 
woman feels as if something had been torn inside of her.1 She 
then becomes very weak; her skin is cool and pale, often 
covered with a clammy cold sweat; her pulse is almost obliter- 
ated. She frequently faints, and the syncope is often of the 
most terrible character, the depression being profound. Convul- 
sions and delirium may supervene, or the intellect may remain 
perfectly clear. In short, the patient has all the symptoms of 
violent shock succeeded by those of hemorrhage, for which the 
slight loss of blood by the vagina is by no means sufficient 
to account. The abdominal pain is very severe. Sometimes 
the abdomen visibly enlarges, as has been observed by Tucker,* 
Finnel,3 and Lobstein.4 Tucker also adds that he detected 
fluctuation. With this is associated dulness on percussion, or 
the latter may be present when there is little or no increase in 
the size of the belly.5 Rogers6 appears to think that enlarge- 
ment of the abdomen can generally be detected after rupture 
1 Ingleby, Edinburgh Med. Journ., 1834. 
2 Med. and Pliys. Journ. of London, 1813, vol. xxix. p. 448. 
J New York Med. Journ., March, 1857, p. 237. 
1 Med. and Phys. Journ. London, 1817, vol. xxxvii. p. 196. 
5 Rogers, Extra-uterine Fcetation and Gestation, 8vo., Phila., 1867, p. 15 
s Ibid., p. 27. 130 
SYMPTOMS. 
of the cyst. If such is the case, it has escaped the notice of 
almost all writers on this subject. 
If metrorrhagia has not preceded1 the symptoms of rupture, 
it quickly follows them in almost all instances. Syncope has 
been mentioned as one of the phenomena of this accident. It 
may occur at the moment of laceration, or some time later. 
When it supervenes early it is generally due to the shock from 
the injury, but afterwards it may be owing to the anaemia. It 
is often impossible to determine to which of these causes it is 
due. It is doubtless sometimes the result of their combined in- 
fluence. The fainting is frequently repeated, the woman being 
revived only to fall into another death-like swoon. There is one 
point in connection with this symptom which calls for a few 
remarks before dismissing the subject. Speaking of syncope, 
Goupil says2 that it seems to be constant no matter where the 
seat of rupture may be; and, again, he asserts3 that “ It is the 
first in the series of events which announce with certainty in- 
ternal hemorrhage.” Both of these statements are incorrect. 
Rupture of the foetal cyst, though frequently followed by syn- 
cope, often happens without it. On the other hand, the occur- 
rence of fainting during the progress of extra-uterine preg- 
nancy does not indicate internal hemorrhage with any certainty. 
It may attend the attacks of colicky pain which are so character- 
istic of this condition. Campbell4 was aware of this, and it has 
been confirmed by other writers.5 It is important to remember 
1 Roper, Trans. Obstet. Soc. London, 1866, vol. vii. p. 167 ; Barnes, Ibid., 
p. 168 ; St. Thomas’s Hospital Reports, 1870 ; and Diseases of Women, 8vo., 
Pliila., 1874; Goupil, Clin. Memoirs on Diseases of Women, New Syd. Soc. 
ed., 8vo., London, 1866, vol. i. p. 246. 
2 Loc. citat. p. 267. 3 lb., p. 268. 
4 Loc. citat. p. 104. He speaks of “ pains in different parts of the abdo- 
men, sometimes so intense as to excite syncope, or even convulsions, and to 
be uncontrollable by the most powerful doses of opium.” 
6 Putnam, Amer. Journ. Med. Sciences, Oct. 1853, p. 348 ; Shurtleff, Nash- 
ville Journ. of Med. and Surgery, Feb. 1860, p. 158 ; Hooker, Ibid., p. 161 ; 
Purdy, New York Med. Times, June, 1863, p. 261, though there was not 
syncope at the time of rupture which occurred at the end of the second month 
of gestation ; Burci, Gaz. Med. Ital., 1857, and Med. and Surg. Reporter, 
Feb. 1858, p. 112 ; Hughes, London Med. Gaz., 1850, p. 539 ; Perry, Journ. 
of Gynsecolog. Soc. of Boston, Sept. 1869, p. 140. Evesque, These a Paris, 
1806, speaks of having seen faintings commence near the end of the second SYMPTOMS OF RUPTURE OF THE CYST. 
these facts,for Bernutz and Goupil attach much diagnostic value 
to the occurrence of syncope, but it will be seen, from what has 
been said, that this opinion is entirely without foundation. 
Allusion has already been made to the changes that may 
take place in the condition of the abdomen, its sudden increase 
in size with fluctuation, and it now remains only to speak of 
the information which may be gained by vaginal exploration, 
made after the symptoms of rupture have supervened. A 
tumor has rarely been found. The uterus may sometimes be 
pushed from its natural position by a mass, either on one side 
or behind it, but rarely in front of it. If this tumor has been 
previously discovered, or is found after the supervention of 
the symptoms of rupture, it is a cardinal fact. It is well known 
that the worst hemorrhages frequently come from cysts in 
which the ovum is still retained, and which do not collapse, 
though they may give rise to a hemorrhage which will be fatal 
in a short time. Consequently, this tumor should be sought 
in all cases in which the pregnancy has progressed far enough 
for it to have formed. This, Siredey has proved, is as early 
as the end of the first month. 
The accumulation of blood in the pelvic cavity may give 
rise to a sense of fulness, which can be felt through the vagina 
and behind the uterus, but no distinct tumor will be found 
unless the patient lives long enough for the peritoneum to be- 
come inflamed and for the effusion to become encysted. Then 
all the physical signs of pelvic hsematocele will disclose them- 
selves. 
The cause of the various symptoms of rupture is difficult to 
determine. The tableau which they make is a composition 
which owes its origin to the combined effects of shock and 
loss of blood. Intimately associated as these are, it is difficult, 
and often impossible to determine the part which each plays 
in bringing about this terrible array of symptoms. To this 
state Barnes1 has given the name of “abdominal collapse,” 
and mentions the fact that it can be distinguished from the 
month of gestation, and continue till the woman died of rupture when three 
and a half months gone. Syncope produced by colicky pain is mentioned by 
a number of other authors. 
1 Diseases of Women, 8vo., Phila., 1874, p. 362. SYMPTOMS. 
collapse resulting from injuries of the chest by the absence-of 
oppression in respiration, and from that due to wounds of the 
head by the preservation of the mental faculties. 
The patient may perish almost immediately after this acci- 
dent. This, however, is not the usual result, and the woman 
may live for several days. When this is the case reaction sets 
in after some hours, when another set of symptoms supervene, 
which it is important to interpret correctly. The belly en- 
larges, becomes tympanitic and tender; the circulation is ex- 
cited, and the temperature elevated one or two degrees; in 
short, the patient has all the symptoms of acute peritonitis. 
Almost all writers upon this subject have described this dis- 
ease as a result of rupture. Velpeau1 believed that it de- 
stroyed the patient from the second to the fourth day after the 
sac gave way, if it did not lead to encystment of the effused 
blood and escaped ovum. Hodge,2 Schrceder,3 Cazeaux,4 Chail- 
ly-IIonor6,5 Tanner,6 Depaul,7 and Campbell,8 all believe that 
peritonitis is a cause of death after rupture. Leishman9 says 
that it is a very violent and dangerous complication, and 
Barnes10 states that “ it usually supervenes rapidly. A few 
hours’ time is often enough to light up almost universal peri- 
tonitis.” It is therefore evident that the very highest authori- 
ties assign peritonitis an important place among the destructive 
consequences of rupture. In this they are supported by the 
symptoms which succeed the effusion of blood, but in opposition 
to this apparent clinical fact we have the sad results of too 
many post-mortem examinations. 
1 Diet, de Med., 8vo., Paris, 1836, vol. xiv. p. 417. 2 Loe. citat. p. 531. 
3 Loc. citat. p. 131. 4 Loc. citat. p. 596. 
5 Traite Pratique de l’Art des Accouchemens, 8vo., Paris, 1867, p. 135. 
6 The Signs and Diseases of Pregnancy, 8vo., Phila., 1868, p. 298. 
7 Archives de Tocologie, 1874, tome i. p. 10. 
8 The opinions of this author are based upon imperfect observations. He 
writes (p. 131), that, “when the foetus and other parts of the ovum have been 
dislodged from their envelope, they may then excite violent inflammation of 
the ambient organs which, with the hemorrhage, may destroy the patient.” 
He then refers to the cases of Drs. A. Smith, Messer, King, and others, re- 
lated in his own memoir, in which there was no rupture, but peritonitis 
without it. 
9 Loc. citat. p. 213. 10 Loc. citat. p. 363. PERITONITIS AFTER RUPTURE OF THE CYST. 
138 
Bernutzand Goupil, who have investigated the consequences 
of effusion of blood into the peritoneal cavity with great care, 
say1 that when it is due to rupture of a vicarious uterus “ the 
peritoneal complications are much less than one would at first 
have fancied.” Rogers2 even goes further than this, and de- 
nies that peritonitis ever occurs as a result of rupture. This 
opinion is too absolute. It is said that in December, 1872, 
an instance of death from this cause, was reported to the 
Societe Anatomique of Paris.3 Another has been observed by 
Switzer. The cases of Tilt, West, Duncan, Bright, and Stiles 
will be alluded to when speaking of encystment of the escaped 
ovum. The only other evidence which we have to offer, to 
show that the peritoneum may become acutely inflamed 
under these circumstances, is the statement of Wright,4 that 
he found evidences of it in a woman who died in fourteen 
hours after the supervention of the symptoms of rupture. 
There appears to be something (probably it is the loss of blood) 
which prevents the frequent occurrence of inflammation of the 
peritoneum, as a sequel of this accident. It is so rare under 
these circumstances that the possibility of its supervention 
need scarcely be taken into consideration. This fact is not 
only interesting, but it is important, since a number of com- 
petent authorities assert that one of the methods of recovery 
after rupture is secondary encystmeut of the foetus. 
A woman under the care of Dr. Elliotson5 died on the 
third day, and the peritoneum, instead of being inflamed, was 
found to be very pale. The patients of Craighead6 and Whit- 
well7 each lived three days after the symptoms appeared, and 
yet no mention is made of peritonitis. Sager8 and Selwyn9 
are candid enough to admit that they diagnosticated inflam- 
mation of the peritoneum under these circumstances. The 
1 Loc. citat. p. 269. 2 Loc. citat. p. 39. 
* Le Mouvement Medicale, No. 2, 1873, and London Medical Record, 
Feb. 26, 1873, p. 119. 
4 Med. Times and Gazette, Jan. 9, 1869, p. 34. 
6 Trans. Medico-Chir. Soc. London, 1827, vol. xiii. p. 51. 
6 Amer. Journ. Med. Sciences, Jan. 1850, p. 114. 
i Brit. Med. Journ , March 24, 1860, p. 225. 
8 Detroit Rev. Med. and Pharm., Aug. 1868. 
* Trans. Provincial Med. and Surg. Association, 1834, vol. iii. p. 232. 134 
SYMPTOMS. 
former states that the symptoms supervened on the morning 
after the accident. Although life was prolonged three days 
and a half after the gravid sac gave way, there was not a trace 
of peritonitis. The same condition was found after death in 
four days in the cases of Robbs1 and Harbert,2 and after six 
days in that of Barnes.3 Much additional negative evidence 
could be produced if it was deemed necessary. There are few 
things in regard to extra-uterine pregnancy which excite 
more surprise than the rarity with which peritonitis is noted 
upon examination after death from rupture of the foetal cyst. 
The practical conclusions that may be drawn from a careful 
investigation of this subject, are— 
1. That peritonitis is a rare sequel of rupture of the cyst, 
and even when pain, tenderness, and other symptoms of this 
affection supervene after the escape of the ovum, they do not 
necessarily indicate the existence of inflammation. 
2. Peritonitis so rarely follows rupture of an extra-uterine 
gravid cyst, that the possibility of its occurrence need not be 
taken into consideration in the decision of any questions re- 
lating either to prognosis or to treatment. 
Pregnancy in a Hernial Sac.—In discussing the causes 
of extra-uterine fcetation, hernia of a portion of the internal 
genital organs was mentioned as one. Bovin and Duges sug- 
gested that this might give rise to misplaced gestation. Four 
undoubted cases have been reported among the number ex- 
amined. The first of these occurred in 1706, and the patient 
was under the care of a French surgeon named Gouey. The 
observation seems to have been forgotten till Dr. J. H. Ave- 
ling, who has done much to interest the profession in the 
history of obstetrics, rescued it from among the Sloane MSS., 
it being an extract from the fifth part of “ La Veritable Chi- 
rurgie dtablie sur l’exph’ience et la raison par le Sieur Louis 
Leger de Gouey,” which was printed at Rouen in 1716.4 The 
1 London Med. Gaz., March 19, 1836, p. 983. 
2 West. Journ. of Med. and Surgery, 1849, p. 110. 
3 St. Thos. Hosp. Repts., 1870, N. S., vol. i. p. 365. 
4 Obstet. Journ. of Great Britain and Ireland, July, 1873, p. 241. It is 
also quoted by Sprengel (Hhtoire de la Med., tome viii.), as a case of Caesa- 
rean section. PREGNANCY IN A HERNIAL SAC. 
135 
patient was an unmarried girl, and this tumor becoming 
troublesome, Gouey concluded to operate, supposing it to be a 
hernia. A three months’ male foetus was removed alive, and 
duly christened according to the custom of the Catholic church. 
The mother recovered. The narrator of the case is so evidently 
at fault in his anatomy, that it is impossible to determine in 
what portion of the genital organs the ovum was situated. 
The second case was published by Skirvani.1 In October, 
1850, a woman who had suffered from an imperfectly developed 
left inguinal hernia from childhood, felt a round body fall 
into the sac while in the act of stooping. Two months later 
movements were detected in the tumor. She had labor-pains 
at term, and April 24, 1851, an incision five inches long was 
made over the tumor, which reached to the knees. A living 
child was extracted, but it died in an hour. The mother re- 
covered. 
In 1855, Genth2 reported the third case. The patient had 
an inguinal ovarian hernia. She became pregnant with her 
fourth child early in 1852. When she was between four and 
five months gone, the tumor was incised, and a living child 
removed. The placenta was partially detached; the mother 
lost much blood, but recovered. 
The remaining example of this singular accident was re- 
corded by Muller.3 The patient, who was the victim of right 
inguinal hernia, conceived and went to term, at which time 
the child was removed by incision. The mother died from 
hemorrhage. Keller4 alludes to a hernial gestation which was 
reported by Widerstein. We have been unable to obtain the 
particulars of the case. The patient is said to have had a con- 
genital hernia of the ovary, and she experienced such severe 
pains that Widerstein decided to operate. The foetus was 
removed, and the mother recovered rapidly. A similar obser- 
1 Nouvelle Encyolograph, des Sciences Med., Oct. 1852. 
2 Yerhandl. der Ges fiir Geburtsh., Berlin, 1855, and Brit, and For. Med.- 
Chir. Rev., Jan. 1857. 
3 Allgem. Wien. Med. Zeitung, 1862, and Brit, and For. Med.-Chir. Rev., 
Jan. 1863. 
4 Des Grossesses Extra-uterines, etc., 8vo., Paris, 1872, p. 20, from 
Schmidt’s Jahrbucli, 1853, b. lxxx. p. 10, 38. 136 
SYMPTOMS. 
vation was recorded by Rektorzik,1 who, however, while 
acknowledging the pregnancy to have been extra-abdominal, 
denies that it was extra-uterine. He believes that the child 
was contained in one horn of a bilocular uterus. The swell- 
ing appeared in the right inguinal region immediately after 
pregnancy commenced, and gradually increased in size until 
term, when the tumor reached to the knees. The child, which 
was saved, was removed by operation, but the mother died 
comatose on the same evening. 
Keller2 asserts that extra-abclominal pregnancy occurs 
especially in crural hernia. In the cases mentioned the pro- 
trusion was by the inguinal ring in four—those reported by 
Skirvani, Genth, Muller, and Rektorzik—while the species is 
not mentioned by Gouey and Widerstein. That Keller’s 
opinion is not sustained by facts, is proved by the study of the 
history of hernia of the uterus and its appendages. This can 
take place through the inguinal ring, crural arch, or obturator 
foramen.3 It would seem reasonable to infer that the first of 
the three varieties wTould be found the most common, since the 
round ligament passes through the internal abdominal ring, and 
traverses the inguinal canal to be lost in the labia majora. Thus, 
as it were, a channel is preserved for the escape of the uterus or 
some of its appendages. We believe that, contrary to the asser- 
tion of Keller, escape by the inguinal is more frequent than 
by the crural ring, and that consequently hernial pregnancy is 
more frequently inguinal than crural. M. Lallemaud4 has seen 
the unimpregnated uterus protrude twice. In one the hernia 
was inguinal, and in the other crural. Choppart5 has met with 
an inguinal hernia of the uterus, with the left tube and ovary of 
the same side,and Cruveilhier,6 one which was crural. Fischer,7 
' (Esterr. Zt., 18, 1860 ; New Syd. Soc. Year Book, 1861, p. 334. 
2 Des Grossesses Extra-uterines, etc., 8vo., Paris, 1872, p. 20. 
* Tanner, Signs and Diseases of Pregnancy, 8vo., Phila., 1868, p. 476. 
4 Dictionnaire des Sciences Medicales, 8vo., Paris, tome xxxi. p. 226. 
5 Courty, Traits Pratique des Maladies de P Uterus, 8vo., Paris, 1866, p. 
717. 
6 Ibid., p. 717. 
7 Annales de la Chirurgie Franqaise et Etrangere, Paris, 1842, tome v. p. 
249. PREGNANCY IN A HERNIAL SAC. 
137 
and Ledesma,1 have seen the impregnated uterus protruding 
through the inguinal ring, making it necessary to deliver the 
child by section of the tumor and uterus. In two other hernise 
of the gravid womb, observed by Kennedy,2 and Murray,3 the 
organ escaped at the umbilicus.4 
Protrusions of the uterine appendages, through the abdomi- 
nal wall, are likewise chiefly inguinal. Mr. Percival Pott’s5 
celebrated case, in which both ovaries were removed, seems to 
have been of this class. Oldham6 has likewise reported two 
examples of extrusion of these organs through the inguinal 
canal. Tanner,7 alludes to an instance in which the Fallopian 
tubes escaped. To sum up the results of this investigation, 
we find that in seventeen hernias, of the whole, or parts of the 
internal genital organs of the female, the escape took place at 
the inguinal ring in ten, at the crural ring in three, and at the 
umbilicus in two women, while the species of the hernia is not 
mentioned in two instances. This result corresponds in the 
main with that reached by Deneux,8 in his investigations in 
regard to ovarian hernia. Among these he found the crural to 
be to the inguinal, as one to nine. This certainly does not 
support M. Keller’s statement that extra-abdominal or hernial 
pregnancy is most frequently crural. 
The general symptoms of this variety of misplaced preg- 
nancy appear to differ somewhat from those of extra-uterine 
gestations, which are intra-abdominal. The tumor may be both 
painful and sensitive, but the paroxysmal attacks of abdominal 
pain and colic, which have been spoken of as so characteristic 
1 Tanner, loc. citat. p. 480. 
2 Observations on Obstetric Auscultation, Dublin, 1838, p. 40. 
3 Trans. Obstet. Soc. London, 1860, vol. i. p. 77. 
4 Sennert (Medic. Practica, lib. iv. sect. 2, chap. xvii. p. 654), Nicholas 
Polinus, Ruysch (quoted by Simon, Mem. de V Acad. Boy ale de Chirurgie, 2d 
ed., 8vo., Paris, 1819, tome ii. p. 230), and Saxtorph (Bibliotheque Medic , 
tome ii. p. 2), have each reported examples of hernia of the impregnated 
uterus, but it appears to be uncertain whether the organ escaped through the 
inguinal or crural ring. See, also, Bovin, and Duges, Traite Pratique des 
Maladies de V Uterus, 8vo., Paris, 1833, tome i. p. 168. 
5 The Chirurgical Works of Percival Pott, 8vo., London, 1779,vol. ii. p. 210. 
6 Proceedings of the Royal Soc. London, 1857, vol. viii. p. 377. 
7 Loc. citat. p. 479. 
* Recherches sur la Hernie de l’Ovarie, Paris, 1813. SYMPTOMS 
of misplaced pregnancies in organs which are not intended to 
undergo any amount of distension, are absent. The patient is 
inconvenienced chiefly by the locality and size of the tumor. 
Rektorzik reports this as reaching to the knees. Skirvani 
mentions the interesting fact that his patient had pains like 
those of labor at term. The physical signs are those of an 
extra-abdominal tumor with a narrow pedicle; in Genth’s case 
the size of a little finger. The fetus itself and its movements 
can be felt in the mass, while the sounds of the child’s heart, 
and the placental murmur, can be heard on auscultating it. 
Gouey mentions the fact that at three months he was able to 
feel the pulsations of the umbilical cord, though he was not 
aware of the nature of the sensation. 
Hernial pregnancy occurs in one out of every one hundred 
and twenty-five cases of extra-uterine gestation. Of the five 
cases which we have analyzed, three lived and two died. 
Widerstein reports an additional recovery, making the mor- 
tality 33.3 per cent. Hone of the cases were left to nature, 
all the children being removed by section of the tumor. 
Twin Conception in Extra-uterine Gestation.—This 
subject has already been alluded to in connection with the 
causes of misplaced pregnancy. Attention was then called to 
the fact that twin conceptions are much more frequent in 
extra-uterine than they are in normal gestations. It is a 
striking fact, however, that both children are rarely developed 
in the same locality. In a large majority of these plural con- 
ceptions one ovum finds its way into the interior of the uterus, 
while the other is arrested at some point in its descent. This 
fact, as already mentioned, has led Prof. Barnes1 to believe 
that twin conception is one cause of extra-uterine foetation. 
The proposition may probably be stated more correctly by 
saying that erratic gestations are more frequent after multiple 
than single conceptions. 
But two examples of twin pregnancy, in which both ova 
remained outside of the uterus, occurred in the five hundred 
1 Loc. citat. p. 367. TWIN CONCEPTION. 
cases examined. The first happened in 1756, and was recorded 
by Dr. Thomas Bell.1 The patient, Ellen Noon, went to full 
term in her first pregnancy, and retained her children for 
eight months subsequently, when an opening, which had formed 
at the umbilicus, was enlarged, and the bones of two infants 
extracted. The second case was reported by Rupin2 in 1860. 
His patient died after an attempt to remove the children by 
section of the vagina at the end of the sixth month of preg- 
nancy. 
Dr. W. B. Smith,3 in 1810, reported the results of an exami- 
nation of the body of a colored woman, forty years of age, 
who had died of “ chest disease.” It is stated that a foetus 
was found in each ovary, and the record appears to be reliable. 
The only suspicious statement about the case is, that it is said 
that in the child in the left ovary, the umbilical cord, instead 
of taking its usual origin, issued from its anus. The case is 
circumstantially related, but unfortunately not a word is said 
of the anterior history of the woman, and we are left in per- 
plexing doubt as to whether the two conceptions were simul- 
taneous or not. While wanting these facts the case cannot be 
cited as a twin pregnancy. It may have been an example of 
two extra-uterine gestations occurring at different times in 
the same woman. 
Trezevant4 possibly met with a twin conception, both 
children remaining extra-uterine. If so, one ovum perished 
at an early period. The woman died when she was between 
six and seven months advanced in her gestation. Dr. Treze- 
vant, in describing the post-mortem appearances, says: “ Upon 
removing the membranes from their attachments for the pur- 
pose of extracting the placenta, I was struck with the appear- 
ance of a large vesicle about the size of a walnut on the outer 
surface of the membranes of the foetus. Upon opening this a 
small foetus, of about from four to six weeks old, was discov- 
ered.” The author adds that it was perfect, and showed no 
signs of decay. He then proceeds to describe the foetus so 
1 Med. Comment., Edinburgh, vol. ii. p. 72. 
2 Gaz. des HOpitaux, No. 13, 1860. 
3 New York Medical Repository, 3d Hexade, yoI. i. 
4 Medical Recorder, 1825, vol. viii. p. 464. 140 
SYMPTOMS. 
particularly that it is impossible to doubt the existence of the 
second ovum. The only explanations of the facts which pre- 
sent themselves are that this body was the dead and retained 
foetus of a previous extra-uterine pregnancy, or that it was a 
twin conception, both ova remaining extra-uterine, and one 
having perished in the early stages of its development.1 
Medical literature contains the records of few facts which 
throw light upon this curious and interesting observation. 
The only case in which analogous anatomical appearances 
were discovered is that recorded by Haydon,2 who found an 
encysted ovum of eight weeks, and a recent foetus of six 
months’ development in the abdomen of the same woman. 
In this instance, however, there was a distinct history of a 
previous pregnancy, with symptoms of rupture and recovery. 
This is wanting in the history of Dr. Trezevant’s patient, and 
therefore it seems not unreasonable to conclude that his case 
was an illustration of twin pregnancy, both children being 
extra-uterine. We have, therefore, two, and possibly three 
instances of multiple conception in which both ova were arrested 
in their transit to the uterus in five hundred cases of extra- 
uterine gestation. 
In the same number there were no less than twenty-one3 
multiple impregnations, one child being developed within, 
1 The reporter believes that the very rare and interesting phenomenon 
which he describes is an example of superfoetation. This opinion does not 
need to be combated. 
8 Trans. Obstet. Soc. London, 1864, vol. v. p. 280. 
s These are reported by : Cooke, Trans. Obstet. Soc. London, 1864, vol. v. 
p. 143 ; Sager, Michigan Univ. Med. Journ., Oct. 1870, p. 456 ; Argles’ 
Lancet, Sept. 16, 1871, p. 394; Salle, New Orleans Med. Journ., Oct. 1860, 
p. 727; Duverney, CEuvres Anatomiques, vol. ii. p. 355 ; Wliinnery, Amer. 
Journ. of Med. Sci., April, 1846, p. 351 ; Ott, Prag. Med. Wochenschr. 12, 
1864 ; Taffnell, Dublin Quart. Journ. of Med. Sci., May, 1862, p. 462 ; Mad. 
La Chapelle, Pract. des Accoucli., tome iii. p 152; Loudon, Campbell’s Me- 
moir, p. 65 ; Craighead and Hodge, Amer. Journ. of Med. Sci., Jan. 1850, 
p. 114 ; Sinks, Leavenworth Med. Herald, Feb. 1873 ; Pennefatlier, Lancet, 
June 20, 1863, p 688; Buck, Bost. Med. and Surg. Journ., 1856, vol. liii. 
p. 371; Low and Lumpe, Ibid., 1859, p. 328; Starley, New York Med. Journ., 
March, 1873, p. 299 ; Poliak, St. Louis Med. and Surg. Journ., May 10, 1871; 
Gordon, West. Journ. of Med. and Surg., Oct. 1848 ; Sattertkwait, New 
York Med. Journ., 1872, vol. xvi. p. 387 ; Tebbets, Nashville Journ. of Med. INTERCURRENT UTERINE PREGNANCY. 
and the other outside of the uterine cavity. These form a 
very interesting group of cases, not only on account of the 
diflieulty in diagnosticating the condition, but in regard to 
their management when they reach term. Of the twenty-one 
women alluded to, fourteen died and seven recovered—a mor- 
tality of 66.66 per cent. The death-rate of the five hundred 
cases analyzed was 67.20 per cent. It, therefore, appears that 
the coexistence of intra- and extra-uterine pregnancy does not 
increase the risks of the mother. 
Under these circumstances the woman may carry both 
children to term, when the one contained within the uterus 
may be born in a natural manner, as has been reported by 
Satterthwait, Poliak, Loudon, Whinnery, Gordon, and Starley. 
Other women, as the one attended by Cooke, have very diffi- 
cult labors, because the extra-uterine cyst and its contents 
encroach upon the pelvic cavity. At other times the intra- 
uterine child perishes. In Argles’ patient it died at the end 
of the second month, though the extra-uterine foetus continued 
to live for five months longer. In Sinks’ case the uterine 
child perished when six months old. In other instances the 
woman died from rupture of the extra-uterine cyst with or 
without abortion taking place. If the uterine child is expelled 
and the woman recovers, the misplaced gestation progresses as 
if it had been uncomplicated by uterine pregnancy. 
Pregnancy while carrying an Extra-uterine Foetus.— 
If an extra-uterine child, carried beyond term, becomes en- 
cysted, the condition is not incompatible with pregnancy. Of 
twenty-two women, seven became pregnant once, eight twice, 
four three times, one four times, and two five times while 
carrying extra-uterine children. In many of these instances 
labor was perfectly easy and normal. It has terminated before 
the physician could reach his patient. The extra-uterine child 
and Surg., Feb. I860, p. 160; Deocene, Gaz. des Hdpitaux, 1852, p. 147; 
Pelliscliek, ffisterich. Zitschr. f. Prakt. Hielkunde, 1865. 
Since this page was written McGee has reported (Richmond and Louisville 
Medical Journ., March, 1875, p. 811) another example of combined gesta- 
tion. The extra-uterine child was discharged by the bowel, and the intra- 
uterine one by the natural passages, near the end of the fourth month. 142 
SYMPTOMS. 
sometimes forms an obstacle to the birth of the recent uterine 
conception. The management of this complication will claim 
attention when the treatment is considered. 
Of course the occurrence of intra-uterine pregnancy while a 
foetus is contained in the abdomen materially increases the 
dangers of the woman. The excitement incident to the con- 
dition, and the succussion and compression of the tumor during 
labor, are very liable to lead to inflammation and suppuration 
of the cyst. 
The tumor resulting from the misplaced conception may 
produce very distressing mechanical effects during a subsequent 
normal gestation. Gordon states that he had the care of a 
woman1 who bore five children while carrying one which had 
become encysted. During the first four pregnancies nothing 
remarkable occurred, but in the fifth the tumor was pressed 
downward into the pelvis, where it obstructed the bowel to 
such an extent as to render defecation impossible until it was 
pushed up with the' finger. Hennigsen2 observed a displace- 
ment in the opposite direction. The woman’s sixth conception 
was misplaced. She survived, and two years later she con- 
ceived again. As the uterus increased in size the tumor 
resulting from the previous gestation was pushed up as high 
as the liver. As a consequence, the woman suffered greatly 
from dyspnoea, so that it was necessary to induce premature 
labor when she was between seven and eight months gone. 
After the child was born the tumor returned to its original 
position in the lower part of the abdomen. A few days later 
it suppurated, and death occurred from pyaemia. 
It is of interest to determine whether a woman ever becomes 
pregnant with an intra-uterine child during the first nine 
months after an extra-uterine conception. As the uterus is 
empty, it might be thought that this would not be an unlikely 
occurrence. The question is of interest on account of its bear- 
ing upon the possibility of superfoetation. Dr. Matthews 
Duncan3 has shown that in uterine conceptions the cavity of 
1 Western Journ. of Medicine and Surgery, October, 1848. 
8 Arcliiv. fur Gynsekologie, 1870, and New Sydenham Society’s Bien. Ret- 
rospect, 1869-70, p. 897. 
1 Researches in Obstetrics, 8vo., Edinburgh, 1868, p. 171. INTERCURRENT UTERINE PREGNANCY. 
143 
the womb does not become closed for several months; not 
until the ovum becomes large enough to bring the decidua 
reflexa in close and firm apposition with the decidua vera. 
This does not take place until some time in the third or fourth 
month, and during all this period repeated impregnation is 
supposed to be possible by many competent observers. In extra- 
uterine pregnancy the cavity of the uterus uever becomes closed. 
The decidua reflexa is not formed. The canal of at least one 
of the Fallopian tubes may remain patulous, and nothing ob- 
structs the ascent of the spermatozoa when deposited in the 
vagina except the plug of tough mucus which fills the cervix. 
This is not enough to prevent impregnation, since it is not 
more thick nor more dense than the accumulated secretion of 
that part in some non-gravid women. The decidedly greater 
preponderance of twin conceptions in misplaced than in normal 
pregnancy, with the fact that it is only very rarely that both 
ova are developed outside of the cavity of the uterus, would 
appear to support the conviction that impregnation may occur 
during the normal period of gestation with a misplaced child. 
However, there appears to be no clinical evidence to support 
this opinion. The cases of combined intra- and extra-uterine 
pregnancy rarely present any considerable difference in the 
size and development of the two ova. When they are unlike, 
the one occupying the normal position is usually the larger 
and stronger. We know of one case, that of Dr. Poliak,1 
in which the extra-uterine child is reported to have been 
better nourished than its intra-uterine fellow. After stating 
that the latter was well developed, Dr. Poliak says that the 
former was “ much larger and heavier than its yet living mate.” 
It seems probable also that the function of ovulation is sus- 
pended after conception. The occurrence of a discharge of 
blood from the vagina during the evolution of a misplaced 
ovum is no indication that the ovaries still continue to maturate 
and discharge ova. The blood thus lost is not menstrual but 
metrorrhagic. The periodicity of the discharge is not main- 
tained. It may, therefore, be fairly concluded that we have no 
evidence that repeated impregnation ever occurs in extra- 
1 St. Louis Med. and Surgical Journ., May 10,1871. 144 
SYMPTOMS. 
uterine pregnancy during the usual period of gestation. Even 
after this has been completed, a second impregnation does 
not occur until the woman regains her natural condition and 
those phenomena which belong to the pseudo puerperal state 
have disappeared. It is clearly wrong to call a conception which 
occurs after this time a super-foetation, as is done by Leishman.1 
Repeated Extra-uterine Pregnancy.—Women have 
been known to bear more than one extra-uterine child. 
Primerose observed2 this in 1594. There was an interval of 
about three years between the pregnancies. Davis- refers3 to 
a case in which two cysts were found after the death of the 
woman. Each contained a well-developed child which had 
been carried for seven years. It may be that this was a twin 
conception. Dr. Gabriel King4 has seen two misplaced gesta- 
tions in the same woman with an interval of three years between 
them. Campbell5 quotes from the Journal de Medecine, Chirur- 
gie, Pharmacies etc., 1785, the history of a woman whose eigh- 
teenth conception was erratic. She recovered and retained the 
child thirty-three years, and died at the age of seventy-five 
years. At her autopsy it was found that “the abdomen con- 
tained an ovoid mass weighing five and a half pounds, composed 
of perfectly dry cartilaginous structures, inclosing a mature 
male foetus, with its funis and placenta. After the removal 
of this last, another body the size of a hen’s egg, also car- 
tilaginous, containing a foetus the size of one of two months, 
was found to the left side of the uterus.” This likewise may 
have been a twin conception. Yarnier and Mangin,6 in the 
Journal de Medecine, 1786, state that they made a post-mortem 
examination of a woman who died aged 74 years, and they 
found what they believed to be a double ventral pregnancy. 
M. Galiay7 has known a woman to conceive two extra- 
1 A System of Midwifery, 8vo., Glasgow, 1873, p. 198. 
2 De Mulierum Morbis et Symptomatis, lib. iv. p. 316. 
3 Principles and Practice of Obstetric Medicine, 4to., London, 1836, vol. ii. 
p. 937. 
4 Edinburgh Med. Essays and Observations, 1742, p. 441. 
6 Loc. citat., foot-note, p. 55. 
6 Moreau, Des Grossesses Extra-uterines, 12mo., Paris, 1853, p. 115. 
7 Gazette Medicate de Paris, July 29, 1837. REPEATED EXTRA-UTERINE PREGNANCY. 
145 
uterine children. In the interval between the two pregnan- 
cies, the product of the first was evacuated through the rectum, 
after which she enjoyed good health for five or six years, when 
she conceived again. This child was also located outside of 
the womb, and, like the first, was finally discharged through 
the bowel, after which the woman regained her health. 
In 1850, Dr. F. Brown reported1 that he had the care of a 
woman wdio, after having aborted a number of times, finally 
carried a child to term, but it proved to be extra-uterine. 
Two years later she conceived again. At the end of the sixth 
month symptoms of labor came on, after which the cyst opened 
through the abdominal walls. The orifice was enlarged and 
the bones extracted. 
In 1853, M. Oulmont had under his care, in the Ilopital 
de la Salpetri5re,2 a woman aged thirty-one years, who had 
never borne any children, and who died of rupture of the cyst 
when she was three months gone. At the autopsy the pro- 
duct of the recent conception was found in the pavilion of the 
tube on the right side. A second tumor was found at the 
extremity of the left tube. It was smaller than the one on the 
right side, and contained a small anencephalous foetus, which, 
after an attentive examination, M. Oulmont concluded was the 
result of a conception some years before. 
The only remaining example of repeated extra-uterine fceta- 
tion, of which the author has any knowledge, is one reported 
to the Obstetrical Society of London, in the year 1863, by Dr. 
FT. J. Hay don.3 It is to be regretted that the clinical history 
of the patient is not more complete, but the case is so inter- 
esting that the particulars are inserted in full. S. C , a 
young woman servant, died after a few hours’ illness, from 
rupture of the sac of a tubal fcetation. Between four and five 
years before, she was supposed to have been pregnant and to 
have aborted, but no foetus was 'seen. At this time she was 
very dangerously ill, and for some time not expected to live. 
The man with whom she had been intimate went to sea 
because he believed her to be pregnant. “About six months 
1 St. Louis Med. and Surg. Journ., May, 1850, p. 205. 
1 Moreau, loc. citat. p. 110. J Transactions, vol. v. p. 280. 146 
SYMPTOMS. 
before her death he returned, and a fresh intimacy took place, 
and he again neglected her shortly before her death, which 
was supposed to have been caused by poison taken to procure 
abortion. Ho evidence, however, was elicited at the inquest 
on this point; but she complained twenty-four hours before 
her death of pain in head, stomach, and bowels, though she 
did not seem in very great pain. She continued in a very low 
state the whole time of her illness, during which she had 
several fits, and died twenty-four hours after the commence- 
ment of the attack. It should be stated that there was no 
medical evidence of the symptoms during life, and, therefore, 
their character is very imperfectly described. 
“ The post-mortem examination showed all the organs 
healthy, except the uterus and appendages, which are de- 
scribed in the report below.” 
Dr. Tyler Smith and Dr. J. Braxton Hicks were appointed 
by the Obstetrical Society to examine this specimen, and they 
reported the result as follows:1 “Uterus nearly four inches 
long, two inches wide. The walls proportionately thick. In- 
terior of uterus lined with a very thick decidual membrane, 
now easily separable. This layer is quite as thick as is found 
in normal gestation at its fullest development, and, under the 
microscope, is found to possess the elements of the decidua of 
pregnancy. It is uncertain whether the so-called Montgomery 
cups are present. 
“ The left ovary and Fallopian tube are normal in position 
and structure. The right tube, however, passes off from the 
uterus, at one and a half inches below the fundus; while that 
on the left at only three-quarters of an inch, which gives the 
appearance as if the right tube arose from the middle of the 
uterus. The length of the right is much greater than the left, 
being, including the sac (to be described below), four and a 
half inches, while the other is only three inches. This is by 
no means owing to the development of the sac itself, for 
whereas the distance from the uterine end of the ovary to the 
uterus on the left is three-quarters of an inch, that on the right 
is two and a half inches. 
1 As tliis case is a very remarkable one, the author has presented the re- 
port in full, notwithstanding its defects of style. DR. HAYDON’S CASE. 
147 
“Extra-uterine Sac.—At about one and a half inches from 
the uterus, in right side, the tube is dilated into a sac, now 
about three inches in diameter, probably originally globular in 
form when full. The walls are made up throughout of hyper- 
trophied muscular fibre, and the thickness varies much in dif- 
ferent parts; that near the uterus being almost half an inch 
thick, while at the outer part, where there is a rupture, it is 
reduced to the thickness of parchment. Through this rupture 
the foetus and appendages escaped. The ovary was twice the 
size of the other, and attached to about the middle third of 
the sac. A corpus luteum was found in it approaching the 
development of that of a six months’ normal pregnancy, except 
that the centre was already filled with a white structure, and 
seemed to have possessed a well-defined border to the cavity. 
Its color was also very pale and feebly shown, so as almost to 
escape observation. It was probably thus influenced by the 
death of the foetus at a period before it had gone through the 
full changes of a normal corpus luteum. 
“ The other ovary possessed no such structure. 
“ The foetus which had escaped was the size of that of about 
a three months’ pregnancy, inclosed in its own ovular sacs, the 
principal part of the placenta escaping with it. A clot also is 
appended, probably was found within the sac, and took part 
in increasing its tension. The head is flattened, scarcely any 
bony structure to be felt, and the whole had a shrivelled ap- 
pearance, and had been dead some time before the mother 
died. 
“ So far there is nothing unusual in the case; but appended 
to the edge of the rent in the sac is a small, irregular, solid 
mass of the size of a large walnut, which, upon examination, 
proves to be a small foetus, packed very tightly within a mem- 
brane, the base of which is adherent to the outside of the sac by 
firm membranous adhesions, which form a narrow pedicle. It 
is our opinion that it is attached to the exterior of the sac. 
By changing its position it appears distinctly to be so, although 
at first sight there is some difficulty in distinguishing, inas- 
much as it is fixed on the edge of the rent. 
“ This opinion is much confirmed by the fact that a band 
which comes from the other Fallopian tube is attached to the 148 
SYMPTOMS. 
pedicle in such a manner as to show it could not have been but 
outside. 
“ As regards the inclosed foetus, the scapula can be plainly 
seen on either side with the bones of the arm. A section was 
made through the dorsal aspect in middle line, the vertebrae 
were partially formed, and the cavity of the cranium, inclosing 
a granular yellow mass, full of plates of crystals. 
“ The muscular tissues on the back of scapulae retained their 
fibrous sheaths, still possessing much toughness. There was 
no trace of any ovular structures beyond the inclosing mem- 
brane. 
“From hence we infer the following :— 
“ 1. That some time since, the patient had conceived extra- 
uterine ; that the foetus was attached to the fimbriated ex- 
tremity of the Fallopian tube in such a manner as not to form 
impediment to subsequent conception. That this foetus died 
at about the second month of pregnancy, inclosed still in its 
ovular structures, that it then dwindled gradually away to its 
present state, the chorion villi being absorbed. 
“ 2. That at a later period, probably some six months before 
death, she again conceived, also extra-uterine, but the ovum 
had this time descended to the middle of the tube, that it was 
there arrested, lived about three months, and then died, three 
months after which the sac bursted. 
“ It appears probable that the position and length of the 
Fallopian tube were owing to a congenital abnormal arrange- 
ment of the parts. It seems improbable that the development 
of one side of the uterus could have been the cause, inasmuch 
as the interior of the uterus was perfectly symmetrical, and 
the walls of equal thickness.” 
This observation of Dr. Haydon is of great interest, and the 
report of Drs. Smith and Hicks greatly increases the value of 
the case. It appears to be probable that the first conception 
was truly extra-uterine, and that it occurred in the fimbriated 
extremity of the tube. It is not certain, however, that the 
second conception was not in an undeveloped uterine horn. 
The gravid Fallopian tube is described as being longer than 
its fellow, and as entering the uterus one inch and a half below 
its fundus. The fact that this organ was symmetrical in its REPEATED EXTRA - UTE RINE PREGNANCY. 
149 
development would appear to show that the anatomical pecu- 
liarities belonged to the tube alone. It is much to be regretted 
that nothing is said in regard to the position of the round 
ligament, but this uncertainty does not rob the case of its 
interest. The occurrence of tubal pregnancy ; the probable 
rupture of the cyst at the end of two months ; the recovery of 
the woman, and her subsequent illegitimate intimacy with the 
same man; her second conception, with death from rupture, 
and the discovery of two ova on the same side at the autopsy ; 
all make a picture which we believe to be unique. 
On rare occasions the abdomen may contain more than two 
extra-uterine children. Campbell1 refers to two cases in which 
it inclosed three children at one time. Both women recovered ; 
the decomposed foetal structures being discharged through 
orifices in the abdominal walls. 
The only other case which we can cite as a possible example 
of repeated extra-uterine pregnancy, is that of Dr. Smith, to 
which allusion has already been made, and in wdiich a child is 
said to have been found in each ovary. The woman escaped 
death from the pregnancy, and finally perished from “ chest 
disease.” 
It is a remarkable fact that Dr. Haydon’s was the only 
patient who died from the misplaced conception out of the 
whole number of cases of repeated extra-uterine pregnancy to 
which reference has been made. It would appear, therefore, 
that the repetition of this accident does not materially in- 
crease its dangers. 
1 Loc. citat. p. 111. CHAPTER VII. 
TERMINATIONS AND MORTALITY. 
Rupture of the cyst—Its frequency—Period at which it occurs—Duration of life after— 
Recovery after it—Encystment of the effused blood and the ovum hy peritoneal 
inflammation—The child may be retained for an indefinite period after its death— 
It may remain almost unchanged, be mummified, converted into a lithopeedion or 
adipocere—Inflammation and suppuration of cyst—Discharge of its contents through 
alimentary canal—Through the vagina and bladder—Through abdominal wall— 
Comparative safety of these modes of termination—Time at which the cyst begins 
to discharge its contents—Mortality—Causes of death—Comparative mortality of 
different species. 
Most writers upon this subject have devoted a separate 
chapter to the consideration of the various terminations of 
erratic conception. This is not one of the least interesting 
questions which claim consideration in connection with the 
accident, whether viewed with regard to the marvellous cir- 
cumstances under which life is sometimes preserved, or the 
frightful rapidity with which it is destroyed in other cases. 
An extra-uterine fcetation may terminate, in its early 
stages, in rupture of the cyst. After the middle of gestation 
it may end in the death of the child, which may become 
encysted, and, after undergoing various alterations, it may 
remain as an innocuous foreign body. At other times the 
foetus decomposes, and is discharged by the sac communicating 
with the alimentary canal, vagina, or bladder; or the forma- 
tion of an opening on the surface of the abdomen. 
Rupture of the Cyst. — The gravest accident that can 
happen to the victim of misplaced pregnancy is rupture of the 
gravid cyst. This is attended with the most alarming symp- 
toms, and frequently terminates in death within a short time. 
The almost universal opinion of the profession is, that this 
accident is uniformly fatal, and, if not so, that we have no 
reliable means of combating its dangers. True, some have RUPTURE OF THE CYST. 
151 
raised their voices and used their pens to advocate surgical 
interference, but as yet no one has been bold enough to hazard 
an operation under the circumstances. Operative interference 
is condemned by the highest authorities upon the subject, and 
he who would subject a woman, under these circumstances, to 
the dangers of gastrotomy, would have to possess the courage 
of McDowell and his immediate followers. The subject, how- 
ever, is worthy of careful investigation; indeed, this is one of 
the most practical questions which the student of the clinical 
history and the results of extra-uterine pregnancy can investi- 
gate. 
In order to appreciate the various influences which must be 
considered before the question is decided, several other mat- 
ters must be investigated. The time at which the cyst gave 
way in the 174 cases of rupture which occurred in the 500 
studied is stated in the following 
Table showing the period of Rupture of the Cyst. 
Time of gestation. 
Species of the pregnancy. 
Tubal pregnancy. 
Ovarian. 
Abdomi- 
nal. 
Doubtful 
Tubal 
proper. 
Ovario- 
tubal. 
Tubo- 
uterine. 
3 weeks .... 
i 
4 “ . . . . 
2 
i 
5 “ . . . . 
1 
6 “ . . . . 
14 
1 
i 
8 “ . . . . 
25 
1 
i 
1 
9 
4 
1 
10 “ . . . . 
12 
2 
2 
3 months . . . 
19 
1 
10 
3 
1 
8£ “ .... 
10 
1 
1 
4 “ . . . . 
8 
i 
3 
i 
H “ .... 
4 
.... 
5 “ . . . . 
2 
i 
2 
3 
“ .... 
1 
l 
1 
1 
6 “ . . . . 
3 
1 
i 
i 
“ .... 
.... 
i 
7 “ . . . . 
1 
l 
8 “ . . . . 
i 
1 
l 
8£ “ .... 
.... 
l 
9 “ . . . . 
l 
i 
15 “ . . . . 
l 
Doubtful .... 
io 
i 152 
TERMINATIONS AND MORTALITY. 
This exhibit fully confirms the prevalent opinion upon this 
subject. Rupture, especially in tubal pregnancy, whatever 
may be its form, generally occurs before the end of the fourth 
month. In 26 of the cases, the accident supervened at the end 
of the second month. After this there appears to be a period of 
comparative safety, which lasts till the end of the third month, 
at which time there were 30 cases of rupture. After the end 
of the fourth month it is much more rare, but it may occur at 
any time up to the end of gestation, or even after it in rare cases. 
Ths earliest period mentioned is three weeks. This case 
was reported1 by the late Dr. Cathcart, of Philadelphia, and is 
certainly of great interest. Rokitansky has known rupture to 
occur within a fortnight after conception.2 
The period during which life was prolonged is mentioned 
in 113 of the 174 deaths from rupture of the cyst. Of these, 
39 died in ten hours or less. Of the 39, three expired almost 
immediately, and three others lived only two hours. Twenty 
women lived between 10 and 18 hours, and 29 between 18 and 
42 hours after rupture. Of the remaining 25, 10 died at the 
end of the second day; 5 at the end of the third ; 1 in two 
and a half days; 1 in three and a half days ; 2, each at the 
end of the fourth, sixth, and seventh days; 1 at the end of 
the eighth day; while another did not succumb for two weeks. 
Of the whole 113 women, 81 had died at the end of twenty-four 
hours after rupture is supposed to have occurred ; while at the 
end of forty-eight hours, only 15, or a little more than 13 per 
cent, of the whole number, were alive. This is certainly suffi- 
ciently terrible, especially when we remember that many of 
these women were stricken down when they believed them- 
selves to be in perfect health. Ro disease could destroy life 
more quickly than this sometimes does. It may hurry its vic- 
tim out of existence as rapidly as the assassin’s knife or the 
most terrible of all nature’s convulsions. 
Pyan,3 Clayton,4 Godefroy and Everard,5 and others, have 
1 Pliila. Med. Times, Dec. 27, 1873, and Trans. Patliolog. Soc. of Pliila., 
1874, p. 182. 
2 Manual of Pathological Anatomy, 8vo., Pliila., 1855, vol. ii. p. 256. 
3 Memoirs de l’Acad. Roy. de Med., Paris, 1845. 
4 Lancet, 1840-41, p. 654, and Ibid., 1841-42, p. 28. 
5 Annales de la Med. Pliysiologique, 1827, vol. xii. p. 39. RECOVERY AFTER RUPTURE OF THE CYST. 
153 
been called upon to make post-mortem examinations for the 
coroner under these circumstances. Bovin and Duges1 give 
the results of the autopsical examination of a woman who 
appears to have died of extra-uterine pregnancy. She was 
exhumed several days after burial, because her husband was 
suspected of having destroyed her. Eilliter’s2 patient was 
found dead in bed by the side of her husband; and Koner3 
has reported the history of a woman whose demise was so sud- 
den that she was supposed to have been poisoned by arsenic. 
Notwithstanding the frightful rapidity with which death 
closes the scene, in many of these cases, there yet remains the 
small percentage which makes a struggle for existence, and 
lives beyond the most fatal period which succeeds the accident. 
Some writers apparently believe that recovery after rupture 
is not infrequent, and among these is Churchill.4 Others 
think recovery possible, hut not frequent. Ramsbotham5 and 
Campbell6 entertain this opinion, while, on the other hand, 
Rogers, the author of the most important memoir on extra- 
uterine foetation which has ever been written in this country, 
asserts7 most positively that no case of recovery after rupture 
has been recorded, and that we have no evidence whatever that 
it can occur. Examples of alleged recovery have been reported 
by Ingleby,8 Evory Kennedy,9 Barnes,10 and Wellington.11 The 
true nature of all of these is involved in more or less doubt. 
The observation of Ingleby is the most important, and is the 
only one of the four which was known to Dr. Rogers. Camp- 
1 McDonnel, Med. Mirror, Jan. 1866, p. 8. 
8 Med. Times, London, Sept. 10, 1853, p. 264. 
* Encyclog. des Sciences Med., Fevrier, 1837. 
4 Having spoken of sudden death, this author adds : “ But there are many 
exceptions to such prompt terminations. The patient may survive the 
shock, hemorrhage, and subsequent inflammation, and the parts may accom- 
modate themselves to the presence of the foetus, so that the patient shall 
recover a certain amount of health, and suffer hut little local inconvenience ; 
nay, she may even again conceive and bear children.”—Theory and Pract. 
of Mid., Phila., 1862, p. 185. 
6 Loc. citat. 6 Loc. citat. p. 126. 
i Extra-uterine Foetation and Gestation, 8vo., Pliila., 1867, p. 41. 
8 Edinburgh Med. Journ., 1834. 
6 Brit. Med. Journ., Jan. 23, 1869, p. 67. 
10 St. Tlios. Hosp. Reports, 1870. 11 Boston Med. and Surg. Journ., 1873. 154 
TERMINATIONS AND MORTALITY. 
bell1 believed this to have been a true example of extra-uterine 
gestation, and with the light which is thrown upon it by 
some cases which appear to have been unknown to Hr. Rogers, 
and others which have since been published, we are unable to 
see the force of the latter’s criticism. The fact that an ob- 
server so accurate as Hr. Ingleby was, says that the decidua 
was expelled with symptoms of rupture, is of considerable 
importance, and goes far to support his views, though Rams- 
botham appears to attach no value to this fact, he 
before Rogers, expressed the opinion that it was not an exam- 
ple of survival after rupture. In regard to the cases of Ken- 
nedy, Barnes, and Wellington, it is useless to say a word. 
There is nothing in their histories which would lead us to be- 
lieve that they might not have been pelvic hematoceles. 
The conviction that recovery may sometimes follow rapture 
of the cyst rests upon more important testimony than that 
furnished by the observations just mentioned. The onus of 
disproving it must rest upon Rogers, Bernutz, and others, who 
deny the possibility of its occurrence. Mention has already 
been made of what Hezeimeris and others have called second- 
ary ventral pregnancy. More than a century since, Patuna 
recorded the famous case of Helen Zopp, in whose abdomen 
he found a child unenveloped by any membranes, and con- 
nected with its parent by means of the cord and placenta alone, 
the latter of which was attached to the interior of the fundus 
uteri. In 1769, the equally famous case of Mr. Hey was made 
public in a letter to Dr.¥m. Hunter,2 and a similar observation 
was made by Ilofmeister in 1821.3 The conditions discovered 
at the post mortem examinations of these two women did not 
differ from those found in the case of Patuna, except that in 
the latter, the membranes of the ovum had been destroyed, 
while they were intact in the cases of Hey and Ilofmeister. 
In all of these cases the sac of a tubo-uterine pregnancy4 had 
been ruptured, but the attachments of the placenta had not 
1 Loc. citat. p. 126. 
2 Med. Observations and Inquiries, London, 1769, p. 841. 
3 Rust’s Mag 1823, vol. xv. p. 126; Campbell, loc. cit. p. 100. 
4 Rogers (loc. cit. p. 24) calls these ovario-tubal pregnancies ; upon what 
grounds it is impossible to determine. RECOVERY AFTER RUPTURE OF THE CYST. 
155 
been destroyed, and hence the embryo went on developing as if 
nothing had happened. 
Precisely the same thing may occur in gestations of that 
part of the oviduct, which is situated between the pavilion and 
the portion of the tube which traverses the uterine tissues. 
In 1864 Hill mann1 reported what was probably an example of 
secondary abdominal pregnancy, in which the child was re- 
moved some time after the completion of term by enlarging 
an abdominal fistula. Dr.Hillmann evidently failed to under- 
stand what he observed, and he suggests that the peritoneum 
may have discharged the functions of the foetal membranes. 
Rogers,2 wlio cited this observation of Hillmann’s, was likewise 
uninformed in regard to this mode of termination, since he 
doubts the accuracy of the observations of the reporter, and 
believes that the phenomenon was apparent, not real, and was 
due to adhesions between the foetal membranes and the peri- 
toneum. If any one continues to entertain doubts that the 
appearances described by Hillmann can occur, these are effect- 
ually disposed of by the observations of Braun3 and Bandl.4 
The former had under his care a patient who died at the full 
term of an extra-uterine pregnancy. At the autopsy the pla- 
centa, which was very large from interstitial hemorrhage, w7as 
found attached to the right Fallopian tube. Upon following 
the umbilical cord downward, it was found to enter a tumor in 
the right tube and to be surrounded by the ruptured shrivelled 
foetal membranes. Excepting the attachments of the cord, the 
foetus, which weighed ten pounds, was free in the abdominal 
cavity. There were evidences of both old and recent peritonitis 
discovered at the autopsy. The patient died in November. In 
the preceding July she was an inmate of the Vienna Hospital, 
where she was treated for peritonitis. 
A very similar condition was discovered at the autopsy of 
Bandl’s patient. The right ovary and tube were involved iu 
1 Berlin. Klin. Wochen., Nov. 21, 1864, and Brit, and For. Medico-Chir. 
Kev., 1865. 
2 Loc. citat. pp. 12, 13. 
3 Related by Dr. T. Trusli in a letter to the Clinic, Mar. 2, 1872, p. 105. 
* Wiener. Med. Woch., Aug. 8, 1874, and Med. Times and Gaz., Sept. 19, 
1874. 156 
TERMINATIONS AND MORTALITY. 
a tumor six inches long, five broad, and four thick, which was 
situated partly in the true, and partly in the false pelvis. This 
tumor contained the placenta, and its walls were composed of 
firm layers of a substance 3' to 4' in thickness. Facing the 
uterus, and just under the brim of the pelvis, there was a round 
aperture in the tumor. It was one inch in diameter, with 
sharp edges, which closely resembled those of the falciform 
process of the fascia lata, and through it the funis passed to 
join the placenta. Surrounding and projecting from this 
orifice were the ruptured, corrugated, shrivelled membranes, 
while the foetus, which weighed eight pounds, was contained 
in an adventitious cyst of pseudo-membranes. 
There is no reason to doubt that these two cases are, as their 
narrators believe, examples of rupture of the cyst, and subse- 
quent development of the child, and that of Prof. Braun is of 
especial interest because the date of the accident is fixed with 
tolerable certainty by the severe symptoms which followed, 
and necessitated the admission of the patient into the Vienna 
Hospital. 
In all the examples of survival after rupture which are 
authentic, and to which allusion has been made, the cyst 
wall, with or without the foetal membranes, gave way with- 
out seriously disturbing the. attachments of the placenta. The 
advocates of the opinion that this accident is always fatal 
may possibly object to these examples being cited as illustra- 
tions of recovery. It has been shown that the extent of the 
lesion in rupture has very little influence upon the issue of the 
accident, or even upon the rapidity with which death follows. 
Some of the most insignificant solutions of continuity in the 
walls of the sac are the soonest followed by death. Hence there 
is little to be drawn from this argument. 
Less positive but almost equally convincing evidence is to 
be deduced from another class of cases, the occurrence of which 
is denied by Rogers and his followers. Allusion is made to 
those in which the embryo escapes from the sac and becomes 
encysted. Switzer has reported a case as tubal pregnancy, 
which Tilt1 looks upon as an example of rupture producing 
1 Uterine and Ovarian Inflammation, p. 73. RECOVERY AFTER RUPTURE OF THE CYST. 
157 
hsematocele. The patient lived ten days, and died of perito- 
nitis. Study of this history confirms the idea that it was an 
extra-uterine gestation, especially when it is remembered that 
“a layer of plastic lymph lined the cavity of the uterus.” 
Bernutz agrees1 with this opinion. Bright2 has recorded an 
example of secondary encystment of the embryo, from the 
effects of which the patient died in six months. The embryo 
escaped when the woman was three months gone. The cavity 
from which it escaped was discovered. Stiles3 has known a 
woman to live nearly to term, the cyst having given way when 
she was three and a half or four months advanced in her gesta- 
tion. There can be no doubt about the formation of a secon- 
dary sac in this instance. Dr. Evory Kennedy4 had charge of 
a woman whose history is not so reliable, but in whom it 
seems not improbable that an extra-uterine foetus underwent 
secondary encystment. She had symptoms of rupture when 
three months gone, and lived for eighteen years, when Dr. 
Churchill discovered an orifice in the roof of the vagina, 
through which pus was discharging. This was enlarged, and 
a foetus of three months’ development extracted. West has 
seen5 a woman live seven days after she came under observa- 
tion, with a tumor produced from rupture of a tubal cyst of 
two months’ development and secondary peritonitis. At the 
autopsy it was found that the foetus had escaped entire. The 
pelvic cavity was filled with coagulated blood which had 
moulded itself among surrounding organs and set up secondary 
peritonitis. Dyce6 reports an instance of death from rupture, 
in which the symptoms had supervened upon the reception of an 
injury six weeks before the woman’s admission into the hospital. 
She lived three days after coming under observation, during 
which period she improved, when, immediately after Dr. Dyce 
had dictated her history, she suddenly collapsed, and died in 
1 Clin. Mem. on Dis. of Women, N. Syd. Soc. Ed., 8vo., London, vol. i. p. 
196. 
* London Med. Gaz., Dec. 6, 1828, p. 29. 
* Pliila. Med. Times, Apr. 4, 1874. 
4 Brit. Med. Journ., Jan. 23, 1869, p. 68. 
5 Edinburgh Med. Journ., Dec. 1853. 
6 Med. Times and Gaz., Aug. 11, 1860, p. 137. 158 
TERMINATIONS AND MORTALITY. 
nine minutes. At the post-mortem some recent peritoneal 
adhesions, and more than sixty ounces of blood, fluid and 
coagulated, were found in the abdominal cavity. A portion 
at least of this blood must have been effused before the patient 
came under the care of Dr. Dyce. It is impossible to believe 
that the large quantity could have been poured out in nine 
minutes, even though the rent in the gravid cyst would admit 
a finger. Dr. Duncan, of Edinburgh,1 reports the history 
of a woman who was two months gone, without having had 
any of the usual indications of having conceived, excepting 
suppression of the menses. She was then seized with all the 
symptoms of pelvic hsematocele, and the usual physical signs of 
this accident supervened. A month later, when she appeared 
to be recovering, the tumor formed by the encysted blood, and 
which could be felt in the hypogastric region, suddenly burst, 
producing general peritonitis, which proved fatal in a short 
time. At the autopsy the encysted hematocele was found, 
and in it the ruptured extra-uterine cyst and a two months’ 
ovum. The only other record with which we have met bear- 
ing upon the subject of secondary encystment of the child is 
one by Mr. Tilt.2 The report is indefinite in many particulars, 
and it cannot be accepted as affording any evidence in favor of 
the statement that recovery may follow rupture. The records 
of the 500 examples of extra-uterine fcetation which have been 
examined, contained no other evidence than the foregoing, that 
recovery may follow rupture, excepting Ilaydon’s case and two 
observations made respectively by Prof. Sager, of the Univer- 
sity of Michigan, and Dr. J. Braxton Hicks, of London. The 
former gentleman3 was called to a woman who was five or six 
weeks pregnant, and who had all the symptoms of rupture of 
an extra-uterine cyst. She reacted in six hours, and continued 
to do well until the morning of the fourth day, when, contrary 
to Dr. Sager’s directions, she insisted upon getting out of bed to 
micturate, and died shortly afterward. In a conversation with 
Prof. Sager in regard to this subject, he stated that it appeared 
1 Edinburgh Med. Journ., Jan. 1864, p. 670. 
* Med. and Pliys. Journ. of London, May, 1828. 
* Detroit Rev. of Med. and Pliar., Aug. 1868. RECOVERY AFTER RUPTURE OF THE CYST. 
159 
as if the woman might have recovered if she had rigidly 
obeyed directions. The observation of Dr. Hicks1 is more 
important, since it involves less speculation. This case has 
already been alluded to. The patient died, when four months 
pregnant, of internal hemorrhage, the result of an attempt 
to destroy the foetus by puncturing it with a trocar. About a 
fortnight before her death she had some symptoms of rupture, 
but these were not distinctive. At the post-mortem the cyst, 
which had originally contained the ovum, was found ruptured; 
and outside of it, having formed new connections, was the 
perfect ovum with its placental attachments, on the side oppo- 
site the opening into the cyst and to the posterior surface of 
the uterus. There is no reason why pregnancy should not 
have progressed to term in this instance, and there seems to 
be no other method of explaining the conditions found at the 
post-mortem examination than that mentioned. 
This completes the evidence in favor of the possibility of 
recovery after rupture of an extra-uterine gravid cyst. To 
sum it up, we have the following facts:— 
1. That in gestations of the tube, wherever located, the cyst 
may rupture, and the woman go to full term. The foetal mem- 
branes may remain intact, as in the cases of Hey and Ilofmeis- 
ter, or they may be ruptured, when the child is free in the ab- 
dominal cavity, as in the cases reported by Putuna, Braun, 
and Bandl. In both instances the placenta remains undis- 
turbed, and in both, the children may be as well developed as 
in uterine pregnancy. 
2. In these cases there may or may not be peritonitis leading 
to secondary encystment of the foetus. 
3. Rupture of the gravid cyst in the early stages of extra- 
uterine pregnancy may be followed by encystment of the 
ovum and effused blood by peritoneal inflammation, as in the 
cases of Bright, Stiles, West, and Duncan. Under these cir- 
cumstances it is proved that the woman may live for several 
months, and it is not unphilosophical to conclude that she may 
recover. 
4. Rupture of an extra-uterine cyst may occur during the 
early period of gestation, the ovum escape, and attach itself to 
1 Trans. Obstet. Soc. London, 1866, yol. vii. p. 95. 160 
TERMINATIONS AND MORTALITY. 
some portion of the peritoneum, and then continue its develop- 
ment, as is proved by the observation of Dr. J. Braxton Ilicks. 
In the light of these facts the statements of Rogers1 and 
Bernutz,2 that this accident is invariably fatal, cannot be ad- 
mitted. It is now important to determine the frequency with 
which recovery occurs. From a careful examination of this 
subject it must be acknowledged that a happy termination of 
rupture of the Cj7st is exceedingly rare. There is little doubt 
that it is more common than is supposed by some. On the 
other hand, it is equally certain that restoration to health is 
much less frequent than other equally competent authorities 
have supposed. The rule is that these melancholy cases end 
in death. Notwithstanding the examination of the records 
of 500 cases, no additional testimony can be presented in favor 
of occasional recovery after rupture of the cyst in an extra- 
uterine fcetation. 
Tubo-uterine gestations may sometimes terminate more 
favorably than those of the portion of the oviduct exterior to 
the uterine walls. The cyst generally gives way at or before 
the end of the fourth month, the rupture occurring outwardly 
through the peritoneal surface of the sac. In rare instances 
the uterine surface may give way, after which the child may 
be born by the natural passages, as happened to Feilitz, Lau- 
gier, and Hicks. 
Changes which follow Retention of the Foetus for a 
long Period.—After the completion of the usual period of 
pregnancy in those women in whom the sac is not ruptured, 
the liquor amnii ceases to be secreted, and that which has 
been previously formed is reabsorbed. 
In consequence of this the cyst walls contract, and are ap- 
plied closely to the surface of the child. They may or may 
not be strengthened by inflammatory adhesions. If the pro- 
duct of conception is to remain as an innocuous foreign body, 
the cyst may undergo one of several changes, or it may remain 
much as it was at the close of gestation. In the former case 
1 Loc. citat. p. 41. 
* Clin. Mem. on Dis. of Women, N. Syd. Soc. Ed., 8vo., London, 1866, 
vol. i. p. 242. CHANGES IN THE RETAINED CHILD. 
161 
it may be converted into substances resembling either cartilage 
or bone, or both these changes may occur in the same case. 
In the year 1748, Morand1 exhibited to the Academie JRoyale 
des Sciences a cyst and child which had been removed from a 
woman who died in the IIotel-Dieu de Joigny in July, 1747. 
The foetal sac, which was nearly two lines in thickness, had 
undergone calcareous change in some parts, and cartilaginous 
in others. The child had remained thirty years in the abdomen 
of its mother. In some instances the sac becomes so hard that 
much force is required in order to break or cut it. 
TJnder these circumstances the foetus may be found in one 
of several conditions. In the first place it may remain almost 
unchanged, even after a long time has elapsed. Francis Bayle2 
has recorded the history of a woman, of Toulouse, who became 
pregnant in 1652, and died in 1678. Upon opening her abdo- 
men a child, weighing no less than eight pounds, was found in 
it. Though somewhat changed, it had not undergone any 
putrefaction, and had no bad smell, even after it had been 
kept three days out of the mother’s belly. Children have 
been removed from the abdomen many months after their 
death, as fresh and plump, and with the same color and con- 
sistence, as if they had just died. 
At other times, the 'fluids being reabsorbed, the infant is 
greatly compressed, and converted into a hard, mummified 
mass. The most remarkable change is that in which calca- 
reous salts form on their surface or in their tissues, and they 
become “ ossified” or “ petrified,” according to the older writers 
upon this subject. This was noticed in 1582 in a child taken 
from a woman of Sens,3 and which had been carried by its 
mother for twenty-eight years.4 Hebei5 found the child “ pet- 
1 Memoires de l’Acad. Roy. des Sciences, 1748. 
2 Philosophical Transactions, abridged ed., 4to., London, 1794, vol. iii. p. 
222. 
3 Johannis Albosi, Ohservatio Lithopsedii Senonensis, Senonis, 8vo., 1582, 
and Astruc, Traite des Maladies des Femmes, 12mo., Paris, 1765, tome iv. 
p. 78. 
4 In 1659 this child, it is said, was contained in the cabinet of Frederick III., 
King of Denmark.—Madame Le Boursier du Courdray, Abrege de V Art des 
Accouchement, etc., 12mo., Paris, 1759, p. xxxvi. 
5 Campbell, loc. citat. 162 
TERMINATIONS AND MORTALITY. 
rified,” after having been carried fifty-five years. Majon1 
found a foetus of three months’ development, which had under- 
gone calcareous alteration in a woman who died when seventy- 
eight years of age. Cruveilhier in his magnificent work, 
Anatomie Pathologique du Corps humain,2 describes and illus- 
trates the appearances presented by a child removed from the 
body of a woman who had carried it for many years. Its 
surface was incrusted with calcareous matter. When the pro- 
duct of conception undergoes this change, it is said to be con- 
verted into a lithopsedion.3 This transformation appears to be 
rare. Calcareous salts are not unfrequently deposited in the 
walls of the foetal sac, when the child has been carried for a 
long time, but it appears to be unusual to meet with this 
alteration in the tissues of the infant itself. This fact is in 
accordance with what we now know of the methods by which 
calcareous degeneration is produced in living tissues. That 
these salts should be deposited in the walls of the sac is not 
strange, since throughout its whole life this continues to be 
nourished by the maternal fluids. In the child, however, 
vital changes cease when its circulation is arrested, so that if 
calcareous salts are formed on its surface or in its dead tissues, 
they must be the result of chemical processes alone. 
The foetus sometimes undergoes another alteration. In this 
case it becomes converted into a friable fatty substance like 
adipocere. Denny4 has published the history of a woman 
whose child underwent this change. He describes the tissues 
as having the appearance of lard. The conversion of the 
child into adipocere appears to be more rare than for it to 
become incrusted with calcareous matter. Under all these 
circumstances the child is converted into an innocuous mass, 
which may be carried by the mother for an indefinite period. 
1 Cruveilhier, Essai sur l’Anatomle Pathologique, 8vo., Paris, 1816, tome 
ii. p. 180. 
2 Tome i., xviii., Liv. pi. vi. 
3 Simpson says (Dublin Med. Press and Circular, Sept. 24, 1862, p. 306), 
that Smellie, when speaking of a child which had undergone this alteration, 
made the curious mistake of stating that the case was reported by Dr. Litho- 
psedion. 
4 Amer. Journ. of Medical Sciences, July, 1850, p. 49. DISCHARGE OF THE CHILD. 
Discharge of the Child through the Bowel, Bladder, 
Vagina, or Abdominal Wall.—If the cyst does not become 
quiescent it inflames and suppuration occurs. The child now 
becomes more or less altered. During this process the woman 
may perish either directly from the inflammatory complica- 
tion, or from the absorption of the putrid materials which 
result from decomposition. Within certain limits, however, 
inflammatory action is conservative. How, for the first time, 
peritonitis plays an important role in the clinical history of 
extra-uterine gestation; but it is generally peritonitis of a sub- 
acute rather than an acute type, which produces adhesions 
between the c}rst and the adjoining organs including the an- 
terior abdominal wall. This is the first step which nature 
makes to repair the error that has been committed. This 
completed, an attempt is made to throw off the child, and 
the cyst opens into the alimentary canal, vagina, bladder, or 
externally upon the abdominal wall. Air being thus admitted 
into the cavity of the cyst, the decomposition of its contents 
goes on rapidly until the soft parts are destroyed. 
When the cyst communicates with the alimentary canal, it 
may open into any part of the large intestine, but the passage 
is generally through the rectum or sigmoid flexure. Petit,1 
Moreau,2 and Chailly-Honore,3 all say that an extra-uterine 
foetal cyst may open into the stomach, and its contents be dis- 
charged by vomiting. They do not state the facts upon which 
they make this assertion, and there is nothing in what they 
have written to lead us to believe that any one of them has 
witnessed such an occurrence. We but one instance 
in which the cyst and stomach communicated. This is re- 
corded by Prof. John T. Darby.4 The cavity which contained 
the child had opened through the abdominal wall, when Dr. 
Darby enlarged the orifice and extracted the foetus. He adds, 
“ Immediately after delivery of the cystic contents, the entire 
contents of the stomach emptied themselves into the cavity of 
the cyst, through a ragged, jagged opening, two inches in 
1 Traite des Maladies Femmes, 8vo., Paris, tome i. p. 90. 
2 Traite des Accouchemens, 8vo., Paris, 1841, tome ii. p. 366. 
3 Traite Pratique de l’Art des Accoucliemens, 8vo., Paris, 1867, p. 135 
4 Trans. State Med. Assoc, of South Carolina, 1872, p. 97. 164 
TERMINATIONS AND MORTALITY. 
width.” The rupture was closed with sutures, but the patient 
died from starvation, which it would seem must always follow 
this accident, if the woman survives the inflammation pro- 
duced by the discharge of the contents of the stomach in the 
foetal cyst. Schroeder says,1 that Raneyer saw gastric fistula 
result from the sac opening through the abdominal wall, but 
he does not state that the pieces of a decomposed child were 
discharged by vomiting. The elimination of the soft parts of 
a putrid decaying child in this manner, is almost too disgust- 
ing to think of, and we have not been able to find any instance 
of its occurrence, notwithstanding the statements of Petit, 
Moreau, and Chailly-IIonore. 
Communication of the cyst with the bowel, however, is a 
frequent occurrence. In the cases which we have analyzed, it 
happened sixty-nine times. Of the 500 cases which form the 
basis of this work, 248 went to or beyond term, and of these 
the cyst opened into the bowel 65 times, or in 26.20 per cent. 
Of the 69 cases, 45 recovered by discharge of the foetus, and 
24 died before this could be accomplished, a mortality of 34.78 
per cent. 
The cyst may communicate with the bowel by one, or several 
openings. Adams2 and Will3 have each observed three, and 
Jules Cloquet4 has seen no less than five. 
The child has been spontaneously expelled entire through 
the rupture into the bowel in a few instances, and in others it 
has been forcibly extracted through the same channel by the 
medical attendant. The cases of Giffard, Yardley, and Clark 
have already been mentioned. Of these, Giffard’s was the only 
one in which the child was expelled without some help from 
the medical attendant. A like observation has been made by 
Dr. Peck.5 His patient was four months gone, and the child 
escaped while she was at stool. In addition to Clark, Patuna6 
has also extracted a full term child by the rectum, after the 
1 Manual of Midwifery, 8vo., New York, 1873, p. 133. 
2 Loc. citat. 
3 Edinburgh Med. Journ., Aug. 1854. 
4 Pathologie Chirurgicale, 4to., Paris, 1831. 
5 Medical and Surgical Reporter, April 9,1870, p. 294. 
6 A Dissertation on Retroversion of the Womb, by Samuel Merriman, 8vo., 
Phila.,1817, p. 44. DISCHARGE OF THE CHILD. 
165 
cyst had opened into it. His patient had conceived twenty 
months before. 
The cyst opens into the vagina much more rarely than into 
the bowel. It occurred spontaneously in 12, or 4.83 per cent., 
of 248 women who had gone to term or beyond it. Of these, 
seven recovered and five died, a mortality of 41.66 per cent. 
Communication with the bladder occurred in 9 of the 248 
women, or in 3.62 per cent. Of these, 4 recovered and 5 died, 
a mortality of 55.55 per cent. 
Lastly, the contents of the fcetal sac were evacuated through 
the abdominal wall in 40, or 16.12 per cent., of the 248 cases. 
Of these, 30 recovered and 10 died, a mortality of 25 per cent. 
The opening may form in any part of the lower and middle 
region of the abdomen, but it is most frequent about the um- 
bilicus and in the middle line just below it. 
It will thus be seen that the foetal sac opens most frequently 
into the intestinal canal. Hext to this, communication with the 
exterior occurs oftenest through the abdominal wall. Though 
the latter is 10 per cent, less frequent than the former, it is 9 per 
cent, less fatal. The cause of this difference is easily deter- 
mined. Pus and other decomposing foetal matters poured into 
the lower bowel irritate and inflame the mucous membrane, 
while the mechanical difficulties in discharging the long 
and flat bones by this channel are so apparent that it is not 
needful to do more than to allude to them. Rupture of the 
cyst into the vagina and bladder is a less common occurrence 
than either of the others, and the above results would appear 
to show that it is likewise more fatal. Of the two, discharge 
of the contents of the sac through the bladder is the most to 
be dreaded, for, according to these results, this is 11 per cent, 
more fatal than opening into the rectum, while by the vagina 
the mortality is only 7 per cent. more. 
These results are based upon numbers too small to make 
them at all reliable. They are precisely opposite to the con- 
clusions reached by M. Puech, the accuracy of whose figures 
is vouched for by Courty.1 According to this authority, 5 of 
23 women in whom the cyst opened into the vagina died, a 
mortality of 21.73 per cent. He found that communication 
1 Traite Pratique des Maladies de 1’Uterus, 8vo., Paris, 1866, p. 996. 166 
TERMINATIONS AND MORTALITY. 
with the bladder was less fatal than with the vagina, only 3 
out of 17 women having died after this happened, a mortality 
of 17.64 per cent. In the main, however, our own results 
confirm the conclusions of Mattei,1 who has analyzed 100 
eases of extra-uterine pregnancy which had gone to term or 
beyond it. He concludes that discharge through the abdo- 
minal walls is the most frequent, and states that it happened 
in 38 per cent, of all the cases, but it occurred spontaneously 
in only 21 of these, the remainder being operations for gas- 
trotomy. By the bowels, bladder, and vagina, he found the 
percentage to be respectively 30, 8, and 7 per cent. Daynac2 
believed that the elimination of the foetus through the abdo- 
minal Avails was the most unfavorable of these terminations. 
The investigations of Mattei, Puech, and the author prove, 
however, that the woman is subjected to a considerable increase 
of danger when the discharge takes place by the bowel. In- 
deed, Mattei is probably correct in his statement that this is 
the most unfavorable of all the various terminations of an old 
extra-uterine pregnancy. Our own investigations would appear 
to show that the elimination of the foetus by the bladder or 
vagina is more fatal, but the figures are too small to warrant 
us in accepting their results as final.3 
1 Gazette des Hopitaux, No. 110, 1860. 
2 These a Paris, No. 71, 1825, p. 14. 
3 The results obtained by Puecli, Mattei, and the author may be compared 
in the following table :— 
Channel of elimination, etc. 
No. of 
cases. 
Frequency 
of occur- 
rence in 
per cent. 
Died. 
Mortality 
in 
per cent. 
Mattei .... 
21 
21.00 
1 
4.76 
Abdominal walls 
Puecli .... 
28 
4 
14.27 
1 Author .... 
40 
16.12 
10 
25.00 
t Mattei .... 
30 
30.00 
19 
61.29 
Intestinal canal . 
; Puecli .... 
69 
24 
38.78 
' Author .... 
05 
26.20 
24 
34.78 
Mattei .... 
7 
7.00 
2 
28.57 
Vagina. . . . 
Puecli .... 
23 
5 
21.73 
’ Author .... 
12 
4.83 
5 
41.66 
C Mattei .... 
8 
8.00 
2 
25.00 
Bladder . . . 
; Puecli .... 
17 
3 
17.64 
[ Author .... 
9 
3.62 
5 
55.55 DISCHARGE OF THE CHILD. 
167 
It is, however, a fact that the opening of the foetal cavity 
into the vagina is very likely to terminate in disaster unless 
art intervene. One would suppose that this would be one of 
the most favorable channels by which the debris of an extra- 
uterine foetus could be discharged. It is the natural outlet 
for the child. The size of the canal is specially adapted for 
its expulsion, and there is no tightly contracted irritable 
sphincter at its outlet. 
It is not difficult to believe that the passage of the putrid 
soft parts and bones of a decomposing foetus into the bladder 
would give rise to serious trouble. When this occurs, the 
unhappy woman becomes the subject of all the symptoms of 
stone. These may be greatly aggravated not only by the 
irritating character of the fluids which find their way into the 
organ, but likewise by the large number of bones, any one of 
which may become the nucleus of a stone. Bosseut1 removed 
no less than 146 foetal bones from the bladder by lithotomy. 
In some instances the fcetal cavity opens by more than one 
channel in the same patient. Worship2 and Simon3 have 
seen the rectum and vagina; Adams,4 Drake,5 Chevillon,6 and 
Wier,7 the bowel and abdominal wall; Hemard,8 Petersen,9and 
Morlanne,10 the rectum and bladder opened into in the same 
woman. As though enough havoc had not been worked in 
these instances, Baeza11 and Shultze12 state that they have seen 
these cysts discharging at the same time by three channels, 
the bowels, bladder, and abdominal wall. Under exceptional 
circumstances, the contents of extra-uterine foetal cavities may 
1 New England Journ. of Med. and Surgery, 1817, p. 134. 
2 Pliilosopli. Trans., ab. edit., 4to., London, 1756, vol. x. part ii. p. 1015. 
3 Ibid., p. 1016. 
* Gazette Med. de Paris, Aug. 1872, and Brit, and For. Medico-Cliir. Rev., 
1873. 
5 Philosopk. Trans., ab. ed., 4to., London, 1756, vol. x. part ii. p. 1018. 
6 Gaz. Med. de Paris, Mai 29, 1858. 
7 Medical Times (London), Nov. 8, 1851, p. 496. 
8 Lancet, 1844, part ii. p. 74. 
9 Dublin Med. Press, Aug. 10, 1859. 
10 Recueil Periodique, tome xiii. p. 63. 
11 New Syd. Soc. Bien. Retros., 1867, p. 397. 
12 Brit, and For. Medico-Chir. Rev., Oct. 1867. 168 
TERMINATIONS AND' MORTALITY. 
make their way to the surface by fistulae through the perineum. 
Chailly-Honore1 says this is one of their outlets; and the late 
Dr. Yardley,2 of Philadelphia, has recorded an observation of 
this kind. 
The time at which the foetal sac opened into the bowel, va- 
gina, bladder, or through the abdominal wall is not as accu- 
rately stated in many histories as would be desirable. Cases 
have already been alluded to in which this event occurred 
from one to four months before the termination of the ordinary 
period of gestation, but always, so far as can be ascertained, 
after the death of the child. These cases, as well as those in 
which the communication was established during labor, are 
excluded from the following 
Table showing the time at which the Cyst opened after the completion 
of the ordinary term of Pregnancy. 
Duration of pregnancy. 
Bladder. 
Vagina. 
Bowel. 
Abdominal 
wall. 
Total. 
1 to 6 months 
1 
18 
5 
24 
6 to 12 
tt 
2 
3 
5 
1 to 2 
years 
2 
2 
8 
12 
2 to 3 
tt 
3 
2 
1 
6 
3 to 4 
tt 
1 
3 
4 
5 to 6 
tt 
i 
1 
2 
4 
6 to 7 
tt 
.... 
1 
1 
7 to 8 
tt 
1 
i 
2 
8 to 9 
It 
.... 
1 
1 
2 
10 to 11 
tt 
1 
1 
2 
14 to 15 
tt 
i 
1 
• • . • 
2 
15 to 16 
tt 
1 
.... 
1 
16 to 17 
tt 
2 
2 
18 to 19 
tt 
i 
.... 
1 
19 to 20 
tt 
• • • • 
i 
1 
31 to 32 
tt 
— 
l 
1 
5 
6 
32 
27 
70 
This examination shows that the sac ma}r open in either of 
the directions mentioned, at any time between one month and 
thirty-two years after the completion of gestation. Hillmann3 
1 Traite Pratique del’Art des Accoucliemens, 8vo., Paris, 1867, p. 135. 
2 Amer. Journ. of Med. Sci., April, 1846, p. 348. 
3 Berlin. Klin. Woch., Nov. 21, 1864, and Brit, and For. Medico-Chir. 
Rev., 1865. MORTALITY. 
169 
reports an instance in which it occurred at one month after 
term, and two after the death of the child. The event is most 
frequent, however, between the first and sixth months, while 
the second period of frequency is during the second year. In 
the remaining periods the figures are so small as to give them 
but little significance. 
Mortality.—In 500 cases the result is stated in 499. Of 
these 336 died and 163 recovered,a mortality of 67.20 percent. 
The following table shows the cause of death iii the 336 fatal 
cases. 
Rupture of cyst 174 
Pregnancy 16 
Exhaustion 54 
Peritonitis 24 
Hemorrhage 4 
Hemorrhage into cyst after puncture to destroy the child . 1 
“ into cyst 8 
“ from separation of placenta .... 8 
“ after vaginal section 1 
“ from separation of placenta in gastrotomy . 1 
“ secondary, after gastrotomy .... 1 
Hsematocele 2 
Septicaemia 4 
Intestinal obstruction (from tumor) 8 
Sloughing of cyst 1 
Traumatic inflammation of cyst ...... 1 
Starvation from rupture of stomach during gastrotomy . 1 
Convulsions 2 
Malacosteon 1 
Shock after gastrotomy 1 
Not stated 26 
From causes unconnected with gestation .... 7 
In this catalogue of mortality rupture of the cyst heads the 
list with the fearful number of 174 out of 329 deaths, the 7 
not directly due to pregnancy being excluded. In other words, 
52.88 per cent, of all the women who die from extra-uterine 
fcetation perish from rupture of the gravid cyst. This fact 
deserves to be made prominent. It is asserted by some good 
authorities that this accident is uniformly fatal,1 and though 
1 Rogers, loc. citat., and Med. Record (N. Y.), 1867, vol. ii. p. 22. 170 
TERMINATIONS AND MORTALITY. 
an attempt has been made to show that there are good reasons 
for believing that women have survived it, this cannot be 
regarded as other than an exceptional occurrence. Recovery 
is so rare after rupture, that the physician has no right to allow 
the fact that it may occur to influence him in deciding upon a 
plan of treatment. 
Sixteen deaths are assigned to pregnancy. This may de- 
serve a passing notice. They would possibly have been more 
correctly classified if they had been included under the head 
of exhaustion,’as all the other deaths may be said to have been 
due to “pregnancy.” Under this head, however, are included 
those cases in the histories of which no cause of death is 
assigned by the author, and in which the post-mortem appear- 
ances are faithfully described. The women went to term and 
perished at this time or a little later. 
The single example of death from hemorrhage after punc- 
ture with a trocar to destroy the foetus is reported by Dr. J. 
B. Hicks.1 A second element, vomiting from the chloroform 
administered to perform the operation, may have had some- 
thing to do in bringing on the fatal issue. 
Of the two cases of hsematocele, one was reported by Fleu- 
riot,2 and the other by Ollivier (d’Angiers).3 In the first in- 
stance the pregnancy was tubal, and on the right side. The 
hsematocele was ovarian, and the hemorrhage was from the 
side opposite the pregnancy. In the second the blood was 
effused from tubo-ovarian varices, the pregnancy being in the 
right tube. In these cases the effusion of blood may have been 
entirely unconnected with pregnancy, but when we remember 
the tendency of this to produce pelvic congestion, and that the 
tube in both cases contained the ovum, it does not seem im- 
proper to include these as deaths from extra-uterine pregnancy. 
Dr. J. M. Duncan has likewise reported4 a case of extra-uterine 
pregnancy in which the death of the patient resulted from the 
rupture of an encysted hsematocele, but, as the gravid cyst 
was found within the cavity which contained the blood, and as 
1 Traais. Obstet. Soc. London, 1866, vol. vii. p. 95. 
2 Bull, de la Soc. Anatomique, Paris, 1855, p. 399. 
3 Archives G6nerales de M6d., 2d serie, tome v. p. 403. 
4 Edinburgh Med. Jouru., Jan. 1861, p. 670. MORTALITY OF THE VARIOUS SPECIES. 
171 
this was ruptured, the death was really due, though remotely, 
to the latter. 
The single instance of death from starvation was due to 
rupture of the stomach during gastrotomy, and is recorded 
by Dr. John T. Darby.1 
The 7 deaths from causes unconnected with gestation oc- 
curred in women who had not reached term, and were due to 
hanging,2 phthisis3 (in two instances), suicide,4 cholera morbus,5 
and in two cases to causes not definitely stated. It is more 
than probable that in most of these, the patients would have 
succumbed from rupture of the cyst or exhaustion, if they had 
not been hurried off by violence or intercurrent disorders. 
Of the comparative mortality of the various species of extra- 
uterine fetation, it is impossible to form any correct opinions 
until their relative frequency is determined by careful post- 
mortem observations. The opinion has long prevailed that 
tubal pregnancies are peculiarly fatal, and there can be no doubt 
that it is correct. Of 149 cases in which the ovum was located 
in that portion of the tube which does not traverse the tissues 
of the uterus, 145 died. This, however, may give a very in- 
correct impression of the mortality of tubal pregnancy, but it 
certainly confirms the views held by high authorities. Many 
writers seem to have a vague impression that they may go to 
term, while others flatly deny that this can occur.6 Authentic 
cases, however, have been reported by Cheeseman,7 Cooke,8 Spie- 
1 Trans. State Med. Assoc, of South Carolina, 1872, p. 97. 
2 Bussiere, Phil. Trans., abridged ed., vol. iii. p. 605. 
3 Armour, Glasgow Med. Journ., 1830, vol. iii. p. 154. The duration of the 
pregnancy is uncertain ; the pelvic organs appear to have been a mass of 
disease. Bedford, Prin. and Prac. of Obstet., 8vo., N. Y., 1861, p. 208. The 
woman died when she was seven months gone. 
4 Stanley, Trans. College of Phys. London, vol. vi. p. 414. 
5 Hodge, Prin. and Pract. of Obstet., 4to., Phila., 1866, p. 529. Died when 
seven months gone. 
6 Mr. Lawson Tait {Lancet, Aug. 2, 1872, p. 169) says, “I have satisfied 
myself that not a single instance of so-called Fallopian pregnancies at full 
term, recorded in literature to which I have access, really deserves the 
name;” and Goodell {Phila. Med. Times, Jan. 10, 1874, p. 236) has asserted, 
that, “ When an extra-uterine pregnancy goes to full term, he believes it to 
he always ventral and never tubal.” 
7 Lancet, Sept. 14, 1861. 
8 Trans. Obstet. Soc. London, 1864, vol. v. p. 143. 172 
TERMINATION'S AND MORTALITY. 
gelberg, Bandl, Braun,1 and Saxtorph.2 Mr. Jonathan Hutchin- 
son3 has likewise reported a case, but as Mr. Lawson Tait 
remarks,4 though on insufficient grounds, there may be doubts 
about its having been a tubal conception. Of the five authen- 
tic cases of gestation of this species which reached term, in 
two, Cheeseman’s and Cooke’s, the product of conception was 
situated at the fimbriated extremity of the tube. They are 
therefore robbed of their interest, for it is not difficult to under- 
stand how the ovum, when its descent is arrested in this 
locality, may go on developing until it attains the ordinary 
size of the intra-uterine foetus. Bandl’s and Braun’s cases 
were secondary abdominal pregnancies, the tube and foetal 
membranes having ruptured during the early stages of gesta- 
tion, after which the development of the child was continued 
in the peritoneal cavity. 
There remain therefore but two authentic cases, according to 
many authorities, of primary tubal gestations which reached 
term. These are those of Saxtorph and Spiegelberg. The 
particulars of the first have not been fully recorded. 
That the Fallopian tube is capable of being so distended as 
to furnish a nidus for a full-grown foetus is proved beyond 
doubt by Spiegelberg’s observation, and the only important 
question in this connection is whether this does not occur 
much more frequently than is generally supposed. 
It is probable that ovarian pregnancies likewise generally 
terminate in death by rupture, during the first few months of 
gestation. This, however, cannot be positively stated. The 
gravid ovary may contract adhesions with some of the adjoin- 
ing organs, so that the foetal sac may be strengthened sufficiently 
to retain its contents to term. 
It appears reasonable to conclude that of all the species the 
mortality of ventral pregnancy is the lowest. The fact that 
no organ is distended in these cases to afford a covering for the 
growing ovum supports this opinion. 
1 Reported by Dr. T. Trush, in a letter to the Clinic, March 2, 1872, p. 
105. 
2 Quoted by Spiegelberg, loc. citat. 
* Lancet, July 19, 1873, p. 71. 4 Ibid., Aug. 2, 1873, p. 169. CHAPTER VIII. 
THE DIAGNOSIS. 
Errors are frequent—Before the foetal heart can be heard—Value of various symptoms 
—From pelvic inflammations ; pelvic haematocele—From pregnancy of an undeveloped 
uterine horn—After the foetal heart can be heard—Value of different symptoms— 
From normal pregnancy—Retroversion of gravid uterus—Rupture of uterus—After 
the death of the child—Value of different symptoms—From fibroid and ovarian 
tumors, and cancer of the fundus uteri—Use of trocar or aspirator for diagnostic 
purposes—From piliferous cyst of the ovary—Diagnosis of the species. 
The history of misplaced gestation abounds in illustrations 
of errors in diagnosis committed by the most eminent and 
experienced men. Some of the most remarkable errors are 
those in which uterine has been mistaken for extra-uterine 
pregnancy. Women have more than once, only very narrowly 
escaped being subjected to grave surgical operations, by the 
child being born by the natural passages. It is well known 
that Heim of Berlin,1 who, Montgomery says, “was considered 
the Magnus Apollo on all questions” concerning this accident, 
induced the celebrated Diffenbach to open the abdominal 
cavity to remove an extra-uterine foetus, when the woman was 
not even pregnant. The operation was performed August 5, 
1828, solely upon the authority of Dr. Heim. A careful ex- 
amination of the history of the woman, who fortunately 
recovered, does not reveal reasons sufficient to have led to 
this diagnosis. 
In the same year another woman is said to have been ope- 
rated on in Berlin, who, the gastrotomy proved, was not 
carrying an extra-uterine child, but was suffering from an 
intestinal tumor. But a few years since, Meadows, of London, 
performed the same operation only to find two tumors, one 
uterine and the other omental. Keller quotes Schreyer as 
authority for saying that two physicians, who thought they 
1 Montgomery, An Exposition of the Signs and Symptoms of Pregnancy, 
8vo.,Pliila., 18o7, p. 331. 174 
THE DIAGNOSIS. 
had recognized an extra-uterine pregnancy, made prolonged 
attempts to deliver by the forceps. Failing in this they opened 
the abdominal cavity, and as they found no infant, they re- 
commenced their labors with the forceps. The result was not 
the most happy, as the woman died. The autopsy revealed the 
presence of a fibrous tumor of the uterus. 
All experienced obstetricians are fully aware of the fact that 
the diagnosis of pregnancy is often attended with difficulties. 
It is generally acknowledged to be unwise to assert positively 
that a woman has conceived, unless the foetal heart can be 
heard or the child be detected by ballottement. It is not to 
be expected, therefore, that the detection of this condition 
when the ovum is being developed outside of the cavity of 
the uterus, is attended with fewer difficulties. 
The subject may be considered under three sections: first, 
the diagnosis before the foetal heart becomes audible; secondly, 
from this period until the death of the child before or at 
term; and thirdly, after the foetus has perished. 
Before the Foetal Heart can be heard.—By many it is 
supposed to be impossible to detect extra-uterine gestation 
until it is several months advanced. There is reason to be- 
lieve, however, that it may be discovered at a much earlier 
period than is generally supposed. As tubal pregnancy is the 
most frequent species, and as it generally ends in death from 
rupture in the early stages of gestation, it is of the utmost 
importance to be able to distinguish it before this occurs, in 
order, if possible, to prevent this unhappy accident. Extra- 
uterine pregnancy is by no means an uncommon accident, yet 
it rarely falls to the lot of one person to see many cases, and 
he is, therefore, generally taken at a disadvantage. The care- 
ful study of the records of a large number of cases shows that, 
in the early stages, extra-uterine gestation runs a moderately 
uniform course, and that if the ovum is developed in an organ 
which is capable of undergoing only a moderate amount of 
distension, it will give rise to symptoms which attract the 
attention of the woman to her condition, and lead her to 
believe that there is something unusual about her pregnancy. 
For several weeks, from six to eight, she may not experience BEFORE FOETAL HEART CAN BE HEARD. 
175 
any peculiar symptoms. She has from the first a conviction 
that she has conceived. If with this are associated colicky 
pains, located in the hypogastrium, or one iliac fossa, of the 
most severe character, producing collapse more or less profound, 
with or without syncope ; if these pains come on in paroxysms 
or have violent exacerbations at more or less regular intervals, 
with a bloody discharge from the uterus, the existence of extra- 
uterine pregnancy should always be suspected. If symptoms 
of abortion supervene with the discharge of a decidua, or if 
the phenomena of rupture of the cyst follow the symptoms 
just enumerated, it is the duty of the woman’s medical adviser 
to treat her as if she were carrying an extra-uterine child. 
There is no other kpown condition which is attended with 
the peculiar assemblage of symptoms to which attention has 
been directed. Dr. Rogers1 believes these phenomena to be of 
great diagnostic value. Speaking of the “ periodic and more 
or less severe spasms of pain usually described as colic,” he 
says that they are “almost pathognomonic,” and adds, that if 
they are “accompanied by sanguinolent and by occasional 
clotty discharge from the uterus, they are almost certainly in- 
dicative of extra-uterine pregnancy. When these two signs 
follow and accompany the signs of pregnancy, ... it will be, 
to use the mildest term, very unwise to regard them otherwise 
than of the greatest significance, for I do not doubt that in 
eight cases of them, at least, in every ten, extra-uterine preg- 
nancy will sooner or later be found to exist.” A woman may 
sometimes have many of the symptoms of the condition being 
discussed, during an attack of dysmenorrhcea, but the anterior 
history of that disease is entirely different from that of mis- 
placed pregnancy. 
Attention must be given to each detail, and, when all these 
indications present themselves, the chances are so greatly in 
favor of the existence of extra-uterine gestation, that the prac- 
titioner is justified—nay, it is his duty—to treat his patient 
as if its existence had been proved. A more extended clini- 
cal experience will probably show that the existence of mis- 
placed gestation can be detected quite as easily, if not more 
1 Loc. citat. p. 14. 176 
THE DIAGNOSIS. 
easily, than normal pregnancy in its early stages. The one 
pursues an irregular, and the other a regular course. The 
severe symptoms of an erratic conception can scarcely fail to 
attract attention. 
If there have been no evidences of either miscarriage or 
rupture of the cyst, combined vaginal and abdominal exami- 
nation may reveal the presence of a tumor by the side of the 
uterus, a sign of the highest importance; but unfortunately 
there is generally so much tenderness of the parts at this 
stage of the pregnancy, that it is useless to attempt to de- 
rive any knowledge from a physical examination, unless the 
patient be anaesthetized. The administration of ether, the 
anaesthetic generally used in America, and the only one 
which should be employed, is not unattended with danger, 
since the vomiting which it so often causes may lead to rup- 
ture, the most fatal of all the terminations of misplaced con- 
ception. But, under the circumstances, the aid of anaesthesia 
may be invoked for diagnostic purposes. The dangers of the 
condition are so numerous and so terrible that no means 
should be left untried to discover the true condition of a 
woman suspected to be the victim of this unfortunate accident. 
This advice is given upon the principle that the greater of 
two evils is the one to be avoided. Every known precaution 
should, of course, be taken both before and after its adminis- 
tration, to prevent the unpleasant effects of ether. Much may 
be done by moral influences to prevent the patient from strug- 
gling ; while the proper use of food before, and the adminis- 
tration of bromide of potassium, and other remedies after it, 
may in a great measure control the vomiting. 
The discovery of a tumor by the side of the uterus, in 
which the sign of ballottement can be detected, removes all 
doubts. Dr. Thomas1 has recognized a three months’ foetus 
by ballottement, and says that he has been able to demonstrate 
the presence of the child in this manner in three out of four 
cases which he has seen. In order to be able to recognize 
pregnancy by ballottement, it is necessary that the foetus 
should have attained a certain size, and that the walls of the 
1 New York Med. Journ., June, 1875. BEFORE FfflTAL HEART CAN BE HEARD. 
177 
cavity by which it is inclosed be thin enough to allow it to be 
felt through them. Ballottement is not always an available 
sign of uterine pregnancy in its early months. Gardien says 
it can be appealed to at the end of four and a half months ; 
Cazeaux,1 Tanner,2 and Leishman3 at the end of the fourth 
month. Montgomery writes very plainly regarding this sub- 
ject : “ My experience leads me to say that although we may 
occasionally succeed in performing re-percussion during the 
fourth month, it is not in general likely to be decidedly satis- 
factory until that month is complete.”4 From what has been 
said it will be seen that Dr. Thomas detected this physical 
sign earlier than is usually done in uterine pregnancy. It is 
to be remembered, however, that Hodge5 says that the child 
can be discovered by ballottement in the third month. It is 
not, however, to be wondered at, that this method of examina- 
tion may be found useful at an earlier period in erratic than 
in normal fetation, owing to the fact that the tissues inter- 
posed between the examining finger and the embryo may be 
both thinner and softer than they are in intra-uterine preg- 
nancy. Hicks has distinguished the pelvic extremity of a 
child through the vagina at the end of three and a half months.6 
The fetal tumor can frequently be recognized by careful bi- 
manual palpation shortly after the second month. Gifiard7 
did this long ago, and Siredey8 detected it only one month 
after the commencement of pregnancy. Bcehmer9 discovered 
the peri-uterine enlargement at three months in a case of sup- 
posed ovarian gestation. These results were obtained by the 
ordinary methods of examination. If they are not satisfac- 
tory, the patient should be examined through the bladder, as 
recommended by Dr. Hoeggerath,10 of Hew York. According 
to this plan, the urethra is rapidly dilated, after which the 
1 Loc. citat. p. 246. 2 Loc. citat. p. 121. 
3 A System of Midwifery, 8vo., Glasgow, 1873, p. 174. 
4 Signs of Pregnancy, 8vo., Pliila., 1857, p. 171. 5 Loe. citat. p. 76. 
6 Trans. Obstet. Soc. London, 1866, vol. vii. p. 06. 
7 Cases in Midwifery, 8vo., London, 1734, p. 153. 
8 These a Paris, 1860. 
9 Observat. Anatom. Rar., fascic. i.—Halse, Magdeburgicse, 1752. 
10 The Vesico-vaginal and Vesico-rectal Touch. Anew method of examin- 
ing the uterus and its appendages, Amer. Journ. of ObstetMay, 1875, p, 123 178 
THE DIAGNOSIS. 
index finger of one hand is passed into the bladder, and the 
index finger of its fellow into the vagina or rectum, by which 
means the fundus uteri and tubes can be readily examined. We 
have a great deal to hope for from this method of examination, 
in the detection of extra-uterine pregnancy; and as the uncer- 
tainty of diagnosis is the great impediment to the adoption of 
any rational plan of treatment, we look forward with great 
interest to the results of the suggestion made by Dr. Noegge- 
rath. Depaul1 is not correct, therefore, in saying that extra- 
uterine gestation cannot be diagnosticated during the first 
three or four months of pregnancy. The tenderness of the 
tissues, which is so often present, is the greatest impediment 
to its early detection. 
It must not be forgotten, however, that the woman may go 
to term without presenting any unusual symptom.2 Fortu- 
nately, under these circumstances, she does not seek medical 
advice until after the existence of pregnancy can be determined 
by hearing the sounds of the child’s heart. 
During the first months, extra-uterine pregnancy has been 
mistaken for pelvic inflammation by Goodell,3 Agnew,4 and 
others.® The extreme tenderness to touch, movement, and in 
respiration which are sometimes present, might lead to this mis- 
take, especially when the woman is supposed to have aborted, 
as was the case with Dr. Perkins’ patient, who was seen at 
different times by Drs. Goodell and Agnew, the one calling her 
disease pelvic peritonitis, and the other pelvic cellulitis. This 
error can easily be avoided by a careful examination of the 
1 Archives de Tocologie, 1874, vol. i. p. 261. 
2 Dr. J. W. Craddock {Med. Exam., Phila., May, 1846, p. 286) reports that 
nothing remarkable happened during the gestation, which went to term. 
Goodbrake {Boston Med. and Burg. Journ., July 5, 1860) says that the only 
unusual symptom presented by his patient, who went to term, was difficulty 
in urinating. Hancox {Brit. Med. Journ., Dec. 17, 1859) states that the first 
stage of pregnancy was normal, but, when the woman was in her seventh 
month, she was injured by a man who raped her, after which she was never 
well. Conant {New York Med. Journ., 1865) ; Emmons (Boston Med. and 
Surg. Journ., July, 1833) ; Spiegelberg {loc. citat.), and M. Briquet {Be- 
cueil Periodique, tome xiii. p. 63) all report that their patients arrived at 
term without experiencing any abnormal symptoms. 
3 Amer. Journ. of Obstet., May, 1872, p. 156. 4 Ibid.,p. 150. 
5 Greenhalgh, Medical Mirror, Nov. 1864, p. 689. 179 
FROM PELVIC HEMATOCELE. 
clinical history of the patient. Pelvic peritonitis and pelvic cel- 
lulitis are attended by no such symptoms as those described as 
characterizing the early stages of an extra-uterine foetation. 
There is wanting the conviction on the part of the woman that 
she is pregnant. The pain of pelvic inflammation may be some- 
what paroxysmal, but the exacerbations are periodical, return- 
ing with the menstrual periods; in fact, are new outbreaks of 
the disease induced by the excitement of the genital organs in 
the performance of this function. Moreover, the t umors formed 
in the two conditions differ. The one is cystic, and contains 
fluid and solid contents. The other, if it contain any fluid, 
merely fluctuates. The retro-uterine tumor of extra-uterine 
pregnancy, and the fulness of pelvic peritonitis felt in the same 
position, give such different sensations when they are examined 
by the vagina, that it is difficult to see how this mistake can 
arise. 
Extra-uterine gestation may be occasionally confounded 
with pelvic hsematocele. It may sometimes be impossible to 
distinguish between them. Duncan1 relates the history of a 
woman who one month before her death had all the symptoms 
of intra-peritoneal hemorrhage. The process of encystment 
was going on with every prospect of recovery, when the tumor, 
which reached three inches from above downwards, suddenly 
burst, producing fatal peritonitis. At the autopsy, the pri- 
mary hemorrhage was found to have been due to the rupture 
of an extra-uterine foetal sac. Barnes2 has likewise met with 
blood effusion from the same cause, which became encysted. 
It has been stated, however, that peritonitis, by which means 
alone intra-peritoneal blood effusions can become encysted, 
rarely follows the rupture of an ectopic gestation, while it is 
a fact generally acknowledged, that such collections of blood 
do not become perceptible to the finger in the vagina, until 
after they have been encysted. How, non-encysted intra- 
peritoneal effusions of blood, or, as Barnes3 styles them, “cata- 
clysmic” hsematoceles, generally arise from one of three causes— 
ovarian disease, rupture of the uterus, or rupture of an extra- 
uterine foetal cyst. Though examples of rupture of the uterus 
1 Edinburgh Med. Journ., Jan. 1864, p. 670. 
2 Diseases of Women, 8vo., Pliila., 1874, p. 512. 3 Ibid., p. 506. 180 
THE DIAGNOSIS. 
during the first four months of gestation have been reported,1 
this accident is so rare as to be thrown out of consideration. 
In “cataclysmic” hsematocele from ovarian disease, there 
is the previous history of the disorder of the ovary. If the 
ovarian disease have not been such as to produce previous 
symptoms, as in the case reported by Ollivier (d’Angiers),2 in 
which death followed in seven hours after rupture of ovarian 
varices, the diagnosis cannot be made. It is interesting to 
remember, however, that Ollivier’s patient was also pregnant, 
and that the product of conception was contained in the 
right Fallopian tube. Bernutz says,3 that ovarian hsematocele 
generally occurs without menstruation or metrorrhagia, and that 
at the outset of the attack there are two distinct groups of 
symptoms, the one referable to internal hemorrhage, the other 
to inflammation of the abdominal serous membrane, without 
any of the signs of dysmenorrhoea. These symptoms con- 
joined point strongly to ovarian hfematocele. It is needless 
to point out the distinctions between this condition, and the 
symptoms of rupture of a misplaced pregnancy. The error 
can only arise in the extremely rare cases in which an intra- 
peritoneal effusion due to the latter becomes encysted, and in 
these it would lead to no bad results, for if this should occur 
the case should be treated as one of haematocele, having no 
connection with extra-uterine pregnancy. 
During the early stage of gestation, extra-uterine pregnancy 
may likewise be confounded with conceptions in the rudiment- 
ary horn of a double uterus. These cannot be distinguished 
from each other during the life of the woman. They run much 
the same course, but conceptions in an undeveloped horn ter- 
minate by rupture rather later than those in the tube. That 
these conditions cannot be distinguished from each other 
during life need excite no surprise, when it is remembered 
that it is difficult to do this even at a post-mortem examina- 
tion. Taking the round ligament as a guide, as proposed by 
Virchow, two of the cases figured by Kussmaul in his work 
! H. Cooper, Brit. Med. Journ., 1850. 
2 Loc. citat. p. 403. 3 Loc. citat. vol. i. p. 188. AFTER THE FfflTAL HEART CAN BE HEARD. 
181 
as pregnancies of a rudimentary horn were not such, but 
examples of tubal gestation.1 
As both of these varieties of pregnancy pursue much the 
same course, and as that of a rudimentary horn generally 
terminates in rupture, though at a rather later period than 
one of the tube, nothing would be gained if the diagnosis could 
be made during the life of the patient. The indications for 
treatment are the same under both circumstances. 
After the Foetal Heart can be heard.—The question of 
pregnancy has been settled by hearing the foetal heart or by 
the discovery of the child by ballottement, and thus one source 
of difficulty has been removed. The diagnosis is based upon 
the symptoms which have already been alluded to as character- 
izing the first half of pregnancy, conjoined with those which 
are developed as the gestation progresses. The pain may or 
may not continue, but the sympathetic signs of pregnancy 
become more marked. The gravid tumor is usually devel- 
oped upon one side of the uterus, which it deflects either to 
the right or left, or pushes forwards, towards and above the 
pubis, so that the os is reached with difficulty or cannot be 
found at all. Associated with this is retro-uterine fulness. 
If the head or breech present they will be likely to be felt 
through the vagina, but if the child occupy a transverse posi- 
tion in the foetal cyst the retro-uterine projection will be found 
to fluctuate more or less perfectly. The cervix uteri in the 
mean time, though somewhat enlarged and more soft than 
natural, is found to be hard, firm, and not developed in 
proportion to the duration of the pregnancy. These signs 
make an extra-uterine gestation exceedingly probable. If 
with them is conjoined the history of a previous abortion with 
discharge of the decidua, the diagnosis is morally certain, 
and the introduction of the sound to measure the depth of the 
uterus is justifiable. If the length of this organ does not 
correspond with the development of the gravid tumor, and if 
the uterus is found to be empty, the diagnosis is absolute. If, 
when the woman reaches term, false labor supervenes, and is 
1 Barnes, loc. citat. p. 393. 182 
THE HIAGNOSIS. 
followed by the secretion of milk and a bloody discharge from 
the vagina like the lochia, it is also certain, as there is no other 
known condition which gives rise to this assemblage of symp- 
toms. Pseudo-pregnancy resembles it in the presence of false 
labor-pains at term, but in this the ordinary signs of gestation 
are absent, while there is no abdominal tumor, and no secretion 
of milk. 
Depaul, who believes that extra-uterine conception cannot 
be diagnosticated until after the first three or four months of 
gestation, depends entirely upon the physical signs. lie does 
not appear to attach any importance to the rational symptoms 
of the early stages, and relies upon the following symptoms, it 
being premised that the existence of pregnancy is not called 
in question : the deviation of the uterus; the disproportion 
between the development of that organ and the duration of 
pregnancy; the development of the gravid tumor on one side 
instead of in the middle of the abdomen, as in normal preg- 
nancy ; the small amount of liquor amnii; the superficial 
position of the foetus, the head and pelvis of which form pro- 
jections appreciable by sight or touch ; the abnormal shape of 
the gravid tumor, the transverse diameter of which is often 
greater than the vertical. 
It will not be improper to carefully study the different signs 
to which M. Depaul and the author have attached diagnostic 
importance. Many of those relied upon by M. Depaul are of 
but little value when taken singly, and while clinical records 
show that this eminent authority has been very successful in 
his attempts at diagnosis, a critical examination of the physi- 
cal signs upon which he bases his conclusions will show that 
they are very unreliable. The neck of the uterus may some- 
times be displaced and a foetal tumor appear to be developed 
upon one side, in consequence of lateral deviation of the uterus. 
In this case, however, the organ and its contents can be re- 
turned to their natural position by changing the posture of 
the woman, or by manipulation, while an extra-uterine foetal 
tumor is said by Duboue to be generally fixed in its abnor- 
mal position. This, however, is not an infallible sign, as the 
1 Loc. citat. pp. 522-8. AFTER THE FCETAL HEART CAN BE HEARD. 
183 
author has had reason to learn. He has seen the gravid sac 
in a woman seven months gone, in a misplaced pregnancy, as 
movable as the uterus in a normal gestation of the same dura- 
tion. Moreover, the movements imparted to the fundus of 
the vicarious uterus were distinctly perceived to be trans- 
mitted to the cervix by the finger in the vagina. The small 
amount of the liquor amnii and the superficial position of the 
foetus, whether distinguished through the abdomen or vagina, 
are of no value whatever. On the contrary, the latter has led 
to frequent errors. Mr. Spencer Wells1 and M. Pajot2 both 
recognize this fact. The writer met with an example of thin- 
ning of the abdominal walls a few years since which was 
exceedingly puzzling. He was asked by Dr. E. W. Watson 
to see a young woman, to decide the nature of an abdominal 
tumor, which was the size of a seven and a half or eight months’ 
gravid uterus. Upon making pressure upon the enlarged abdo- 
men a foetus was felt receding from beneath the finger, against 
which it immediately rebounded. It was so superficial in its 
situation, that it appeared impossible to believe that there was 
anything more than the skin of the abdominal wall interposed 
between the fingers and the child. The os uteri was small, 
and could be reached with difficulty through the long narrow 
vagina. Besides the abdominal ballottement there was not a 
single indication of pregnancy. Neither the foetal heart sounds 
nor the placental bruit could be heard, and the mammae were 
like those of a virgin. A few weeks later this patient gave 
birth to a living child after a natural labor. 
Projections of the abdomen produced by the head or breech, 
as well as the transverse position of the child, whether perceived 
by sight or touch, which M. Depaul looks upon as important 
physical signs, are, taken alone, of no value whatever. If the 
head, as is often the case, be at the brim or even in the pelvis, 
1 Trans. Obstet. Soc. London, 1864, vol. v. p. 151. He says that he has 
repeatedly been summoned when it was thought that gastrotomy might be 
necessary, “ but in every case the child had proved to be within the uterus ; 
although from the extreme thinness of the abdominal walls and uterus, in 
some cases the child seemed to be covered by scarcely anything more than 
skin.” 
2 Annales de Gynecologie, Paris, 1874, tome i. p. 215. 184 
THE DIAGNOSIS. 
the contour of the foetal tumor will be normal. On the con- 
trary, every accoucheur knows how often the child occupies a 
transverse position in normal pregnancy. A year ago the writer 
examined a woman about noon by abdominal palpation, and 
diagnosticated a transverse position. That night she fell into 
labor and was delivered by spontaneous evolution. 
The signs mentioned at the commencement of this section 
are much more reliable than those relied upon by M. Depaul. 
.Retro-uterine fulness associated with displacement of the os 
uteri forwards and upwards, even above the pubis, is of the 
greatest importance. Under these circumstances the diagnosis 
will be aided by the detection of a hard pyriform body upon 
the anterior surface of the foetal cyst. This is the body of the 
uterus. In addition to these symptoms Duboue1 attaches great 
importance to deviations of the bladder and rectum. In cases 
in which it is desirable not to explore the interior of the uterus, 
he states, that pregnancy having been determined to exist, and 
it being uncertain whether it is intra- or extra-uterine, marked 
displacement of the bladder and rectum in the same direc- 
tion shows that the uterus has been forcibly carried with them, 
a fact which tends to confirm the existence of extra-uterine 
pregnancy. Of course this symptom would be of no value if 
the patient were not seen until after the death of the foetus, or 
if from any other cause the existence of pregnancy could not 
be ascertained positively. An ovarian or other pelvic tumor, 
large enough to displace the uterus, would have the same effect. 
Extra-uterine has been mistaken for normal pregnancy 
during the latter half of gestation. M. Tarnier,2 Depaul,3 and 
Duboud4 have fallen into this error, and the latter, as well as 
Charlton and Williams,5 and Emmons,6 have undertaken to 
perform grave operations under the idea that the child was in 
the uterus. The author has mistaken extra-uterine for normal 
gestation simply from a want of a true appreciation of the 
symptoms which presented themselves and which pointed so 
! Loc. citat. p. 656. 
2 Boinet, Arch, de Tocologie, 1874, p. 126. 
3 Ibid., p. 336. The woman had dropsy of the amnion. 
4 Ibid., p. 578. 
5 London Med. Gazette, 1843-44, vol. xxxiii. p. 43. 
8 Baltimore Medical and Surg. Journ., 1833, vol. i. p. 231. 185 
FROM NORMAL PREGNANCY. 
strongly to the true condition that it ought to have been 
recognized. The opposite error, of mistaking uterine for mis 
placed pregnancy, is much more common, and more dangerous 
in its results, on account of the temptation to resort to surgical 
interference; a course which would be wrong under any cir- 
cumstances, for an extra-uterine gestation which has passed 
four and a half months will probably go safely to term. M. 
Pajot1 says that a woman was some years since presented 
to the Societe de Chirurgie of Paris, who had been pronounced 
to have an abdominal pregnancy by the most eminent men of 
that city. M. Dubois examined her and diagnosticated a nor- 
mal pregnancy. She was naturally delivered some time later. 
In 1860, M. Pajot says he saw a woman said by competent 
men to be the victim of this accident. They were misled by 
finding the foetus lodged immediately beneath the surface of 
the abdomen, and the head located very superficially in the 
vagina, so that it appeared to be covered by nothing but the 
vaginal wall. However, by carefully examining the uterus M. 
Pajot found that the neck had undergone some of the changes 
usual to pregnancy, and pronounced the gestation uterine, which 
proved to be correct. M. Huguier2 had decided upon perform- 
ing gastrotomy the next day, and his patient was delivered 
spontaneously during the evening of the day upon which he 
decided an operation to be necessary. This errror can be 
avoided by careful examination with reference to the symptoms 
to which attention has been directed, and especially by remem- 
bering the counsel of Pajot, and carefully comparing the 
changes in the cervix uteri with the size of the gravid tumor. 
If the former has undergone alterations, which at all correspond 
in the degree of their development with the duration of preg- 
nancy, the child will be found to be within the uterus. It is 
a noticeable fact, that, when normal has been mistaken for mis- 
placed pregnancy, the location of the child has nearly always 
been very superficial. It has already been shown that this 
alone is not of any value as a sign that the child is not con- 
tained in the uterus. 
1 Des Causes d’Erreur dans le Diagnostique de la Grossesse ; Annales de 
Gynecologie, Paris, 1874, tome i. p. 212. 
2 Depaul, loc. citat. p. 269. 186 
THE DIAGNOSIS. 
To mistake extra-uterine gestation for retroversion of the 
gravid womb is an error that may be .easily committed. 
Merriman1 believed that most of the reported examples of this 
accident at term, were illustrations of posterior uterine dis- 
placement or of retention of a foetus which had escaped into 
the peritoneal cavity through a rent in the uterus. Ivrohn, 
Bonnie,2 Capuron, Lisfranc,3 White,4 Young,5 J. Hall Davis,6 
and A. II. Smith,7 all speak of having committed this error. 
Depaul says, that Dolbeau and Charpentier made the same 
mistake.8 Armour9 relates a case of ovarian pregnancy, in 
which attempts were made to reduce the supposed uterine 
dislocation by a surgeon who was called in consultation. 
Davis and Goodell,10 both tried to bring on labor under the 
supposition that the foetus could not be born spontaneously, 
owing to the abnormal position of the womb. Bonnie states, 
that in his case violent efforts were made to replace the tumor 
under the mistaken idea that it was the fundus uteri, and 
failing in this, it was tapped. Lesouef asserts, that the tumor 
was likewise tapped in a woman who was seen by Dupuytren, 
Lisfranc, Dubois, and Maygrier. Two days later, the foetus, 
which was four months old, was passed by the rectum. 
Barnes11 has seen the cyst produce retention of urine and oc- 
clusion of the bowel, leading to the belief that the gravid 
uterus had become retroverted. On the other hand, M. Bailly12 
states that Depaul and others supposed a retroverted gravid 
uterus at five months to be a misplaced pregnancy. 
The only way in which these errors can be avoided, is by 
a careful investigation of the rational and physical signs 
1 A Dissertation on Retroversion of the Womb, 8vo., Phila., 1817. 
2 These a Paris, No. 181, 1822, p. 86. 
3 Capuron, Revue Medicate, 1888, tome iv. p. 136. 
4 Medical Commentaries, vol. xx. p. 254. 
6 Trans. Medico-Cliir. Soc. Edinburgh, 1829, vol. iii. p. 536. 
6 Trans. Obstet. Soc. London, 1871, vol. xii. p. 332. 
7 Amer. Journ. of Obstetrics, May, 1872, p. 161. 
8 Archives de Tocologie, tome i. 1874, p. 340. 
8 Glasgow Med. Journ., 1830, vol. iii. p. 156. 
10 Amer. Journ. of Obstetrics, May, 1872, p. 155. 
11 Loc. citat. p. 365. 
12 Archives de Tocologie, 1874, p. 731. 187 
FROM RUPTURE OF THE UTERUS. 
presented by the patient. The colicky pain, with profound 
prostration and occasional syncope, will be found to be absent 
in retroversion. In the latter we do not have metrorrhagia, 
which is so frequent in erratic gestation. Retention of urine 
is much more frequent in the early stages of pregnancy with 
posterior displacement of the womb, than it is when the child 
is being developed outside of the uterine cavity. The latter 
is attended with difficulty and pain in urinating at times, but 
rarely produces retention. 
Upon physical examination the uterus can be more or less 
completely isolated by Sims’s bimanual manipulation, when 
it will be found that the fundus of the organ does not occupy 
the normal position. On the other hand, in extra-uterine fce- 
tation when not of the tubo-uterine variety, the tumor will be 
found to be adjacent to, but distinct from the uterus, the fun- 
dus of which can frequently be felt in front of the gravid cyst. 
It must be acknowledged, however, that the differential diag- 
nosis in these cases is often very difficult. In some instances 
time alone will clear up the mystery. The fact that so many 
experienced and deservedly eminent obstetrical authorities 
have been misled in the diagnosis of these conditions shows 
that the greatest care should be exercised in investigating the 
symptoms before coming to a conclusion. The same fact 
teaches that the errors of others should be viewed leniently. 
Any person may commit the same blunder, but it appears 
reasonable to believe that a critical examination will generally 
lead to correct conclusions. Errors in diagnosis are more fre- 
quently due to want of observation than to any want of knowl- 
edge. 
During the progress of spurious labor at term, extra-uterine 
pregnancy has been mistaken for rupture of the uterus. Ed- 
mundson1 fell into this error. When seen, the woman had 
been sixty-six hours in labor. Various efforts were made to 
pass the hand into the uterus, but they all failed. The woman 
died. Don Francisco le Flores Moreno, of Cadiz,2 states that 
he was called to a woman in labor at term. She had been for 
1 Med. Times, London, July 12, 1846, p. 287. 
Annales de la Med. Pliysiologique, 1828, tome xiv. p. 583. 188 
THE DIAGNOSIS. 
some time under the care of a midwife, who asserted that she 
had felt the head of the child presenting, but that it had sud- 
denly disappeared in the midst of a severe pain. Moreno 
diagnosticated rupture of the uterus. A large number of 
gentlemen were called in consultation, but the error was not 
corrected until the autopsy was made. The mistake was 
ascribed to the statements of the midwife, who seems to have 
been a competent and experienced woman. The narrator 
appears to infer that she did not find the head presenting, but 
it is probable that she was perfectly correct in her observa- 
tion, and that the child suddenly changed its position in the 
cyst. 
This error is to be avoided by a careful examination of the 
uterus, when the os will be found to be displaced in most in- 
stances, and always to be much less developed than it should 
be at the full term of pregnancy. In this way the midwife 
who had charge of Dr. Kelly’s patient would have avoided the 
mistake of opening the retro-uterine tumor in labor, under the 
impression that it was the bag of waters. 
Diagnosis after the Death of the Child.—If the patient 
is not seen until after the death of the child, the diagnosis of an 
extra-uterine pregnancy may he very difficult. Many years may 
have intervened before the woman comes under notice. Of 
course, if the cyst has opened into the bowels, bladder, or 
vagina, or a fistule has formed through the abdominal wall, 
there will be little or no trouble in arriving at a correct con- 
clusion. Difficulty will arise only when the cyst has not 
ruptured, or, having opened into the bladder or into the rectum 
out of reach, it has not discharged any of its solid contents. 
Under these circumstances, a correct conclusion can be reached 
by carefully sifting the clinical history. Ho point is too minute 
for examination. As a rule, it will be found that all such 
women have a firm conviction that they were pregnant when the 
abdominal tumor made its appearance. Though more than 
a score of years may have passed, they will not have abandoned 
the idea that they still carry a child somewhere in the abdo- 
minal cavity. Such women will nearly always give the history 
of labor at or near term, attended with uterine hemorrhage, FROM FIBROID AND OTHER TUMORS. 
189 
and followed by the secretion of milk; after which they will 
assert that the abdomen diminished in size, and that this 
diminution steadily continued until the tumor reached the 
dimensions presented when the patient comes under observa- 
tion. This association of phenomena is very characteristic, 
and, when they are all present, erratic gestation should always 
be suspected. The diminution in the size of the abdomen after 
labor is a most important symptom. 
Under these circumstances, extra-uterine pregnancies have 
been supposed to be tibroid tumors,1 ovarian cysts,2 and cancer 
of the fundus uteri.3 Fibroid and ovarian tumors may be 
distinguished from extra-uterine pregnancy by the absence of 
the symptoms of pregnancy during the early stages of their 
development, the absence of false labor at or near the end of 
nine months, and the steady, regular increase in their size 
after the end of the usual period of gestation. It is true that 
there may be difficulties in arriving at a correct conclusion. 
Meadows4 performed gastrotomy to remove an extra-uterine 
child which he supposed had been carried for sixteen years, 
and found a fibro-cystic tumor of the uterus with cancer of the 
omentum. This woman confidently believed that she was 
pregnant at the time that her disease commenced. As is so 
frequently the case in spurious pregnancy, she pertinaciously 
maintained this idea, and, under the delusion, simulated labor 
occurred at term. Dr. Meadows, however, found no retro- 
uterine fulness; and the woman made the positive statement 
that the abdomen did not diminish in size after this false 
labor. This latter fact ought to have awakened very grave 
suspicions, and to have led to a very careful examination of 
1 Gueniot, Bulletin de la Societe Anatomique de Paris, 1865; Depaul, 
Arch, de Tocologie, 1874, p. 270; Peaslee in Janvrin’s case, Amer. Journ. 
ofObstet., Nov. 1874. 
2 Ramsbotham in Mr. F. Hutchinson’s case, Medical Gazette, London, 
Nov. 7, 1835, p. 169 ; Mr. Jonathan Hutchinson, Lancet, July 19, 1873, p. 
71 ; Jacquemier and Perrin in Boinet’s case, Archives de Tocologie, Pax-is, 
1874, p. 126 ; Atlee supposed that Stiles’s patient “ was either pregnant or 
suffering from an ovarian tumor,” Phila. Med. Times, April 4, 1874. 
3 Atlee, General and Differential Diagnosis of Ovarian Tumors, 8vo., 
Phila., 1873, p. 194. 
4 Trans. Obstet. Soc. London, vol. xv. p. 145 190 
THE DIAGNOSIS. 
the patient. Taken in connection with the absence of a retro- 
uterine tumor, it would have justified a different conclusion. 
Mr. Lawson Tait1 relates a very interesting history in which 
he mistook multilocular cystic disease of both ovaries for 
extra-uterine pregnancy. He had previously diagnosticated 
ovarian disease, but the patient misled him, at a second ex- 
amination, by giving a very clear history of pregnancy, and a 
missed labor several years before. She, however, added that 
she had no uterine hemorrhage at this time, and that her size did 
not diminish after it. Mr. Tait, who fully recognizes the value 
of these two symptoms, says that he was unable to harmonize 
the physical signs with the clinical history, and hence he 
draws the following practical conclusion, that, under these 
circumstances, “ we should place very little confidence in the 
statements of patients if they are not in harmony with the 
physical signs.” 
While attaching great importance to the diminution of the 
size of the abdomen after the termination of the usual period 
of gestation with or without spurious labor, it must not be 
forgotten that there are exceptions to this rule. The cases of 
the two Hutchinsons as well as a few others have already been 
cited. These exceptions are rare however, and when they occur 
Mr. Jonathan Hutchinson believes that a patient examination 
will enable a correct conclusion to be reached. He says:2 “ If 
another case of like obscurity should come under my care, in 
which, on examination with the patient on her back, no solid 
substance could be detected, I would at once make the woman 
support herself on her hands and knees, and in that position I 
have no doubt that the foetus if present would be felt.” This 
suggestion of a resort to abdominal ballottement may prove 
successful in removing doubts in regard to the nature of the 
condition in those rare cases in which the amnion continues 
to secrete after the death of an extra-uterine foetus. In this 
instance the very distinct fluctuation assisted greatly to mis- 
lead Mr. Hutchinson. 
The same rules which enable us to distinguish extra-uterine 
pregnancy, coming under notice after the death of the child, 
1 Trans. Obstet. Soc. London, vol. xv. p. 135. 
2 Lancet, July 19, 1873, p. 72. USE OF THE TROCAR FOR DIAGNOSIS. 
191 
from fibroid tumors of the womb and ovarian cysts, apply 
with equal force to its diagnosis from cancer of the fundus 
uteri. Indeed the natural history of malignant disease shows 
that it so rarely invades this portion of the organ, that such a 
mistake seems scarcely possible. 
Encephaloid disease of the liver, mesentery, omentum, and 
ovaries has been mistaken for an extra-uterine child in at least 
one instance.1 The patient was seen by Sir Philip Crampton, 
Drs. Beatty, Montgomery, Kennedy, Labatt, Churchill, and 
Bellingham. The tumor was found after the birth of her 
fourth child, and all the gentlemen named believed that it was 
an extra-uterine foetus. This opinion appears to have been 
based upon the outline of the tumor, which was so nearly 
identical with that of a foetus, that, “as the abdominal walls 
were very thin, it appeared impossible to be deceived.” An 
operation was advised, and at this juncture Mr. J. M. O’Ferral, 
surgeon, saw the patient, and after a careful examination pro- 
nounced the tumor to be malignant. The skill and tact in 
examination, and the knowledge of the natural history of 
disease shown by the last gentleman in connection with this 
case, are greatly to be admired. 
It is to be remembered that this was supposed to be a com- 
bined intra- and extra-uterine conception. In the sequel it will 
be shown that the author thinks that it is conclusively proved 
that the primary operation of gastrotomy, or other surgical 
measures are not to be resorted to unless very rarely, and when 
there are special and important indications for interference. 
The proper course under these circumstances would, therefore, 
be to wait until time removed the difficulties in diagnosis. 
If the extra-uterine tumor is foetal, it will probably diminish 
in size by absorption of the liquor amnii, while, if it is a cystic 
ovary or malignant disease, it will remain stationary or con- 
tinue to grow. 
In cases of doubt, the foetus being dead, the trocar has been 
used to draw off some liquor amnii in order to confirm the 
diagnosis. This practice cannot be too strongly condemned. 
Unless it has been decided to operate immediately for the re- 
1 Medical Times, London, Jan. 19, 1845, p. 841. 192 
THE DIAGNOSIS. 
moval of the foetus, the use of the trocar is utterly unjustifiable. 
A few, but very few women have long survived its use. Mr. 
Jonathan Hutchinson,1 in a clinical lecture upon this subject, 
says that this practice “is in itself attended by great danger, 
nor shall I deal honestly with you or myself if I do not can- 
didly admit, that, with due care and patience, I do not think 
that paracentesis ought to be necessary in a case of foetal 
tumor simulating ovarian dropsy.” Mr. Hutchinson reached 
this conclusion after having been so unfortunate as to see 
fatal peritonitis follow the use of the trocar in his hands. 
Hr. Cardeza’s patient was tapped after consultation with Dr. 
W. L. Atlee of Philadelphia,2 on November 19th, and the 
latter gentleman performed gastrotomy five days later. As 
soon as the cyst was opened, “there was a rush of offensive 
gas.” Jordon3 used the aspirator for diagnostic purposes, the 
woman, there is every reason to believe, having no bad symp- 
toms at the time. She was given chloroform, the puncture 
made, and two hours after “complete collapse came on.” 
Speaking of the use of the aspirator under these circumstances, 
Dr. Jordon remarks: “The doubts cast on my diagnosis, and 
the variety of opposing views in regard to the nature of the 
case, which unfortunately resulted in the use of the aspirator, 
were nearly the cause of the patient’s death.” 
Scott4 resorted to the use of the same instrument, apparently 
for the purpose of withdrawing some fluid from the cyst to 
relieve pain and tension rather than to confirm his diagnosis. 
At 8 o’clock on the evening of the next day, the woman’s 
condition, which previous to aspiration had been good, was 
very serious. There were symptoms of blood poisoning, and 
the tumor, which had previously been dull on percussion, had 
become tympanitic, though there was no communication 
between the sac and the intestinal canal. Gastrotomy was 
performed at once, and on opening the cyst a quantity of gas 
escaped. His unfortunate patient died of septicaemia thirty- 
one hours later. 
1 Lancet, July 19, 1873, p. 72. 
2 Pliila. Med. Times, Jan. 10, 1874, p. 236. 
3 Trans. Obstet. Soc. London, vol. xv. p. 131. 
4 Ibid., vol. xv. p. 142. PARACENTESIS FOR DIAGNOSTIC PURPOSES. 
193 
When the author met Drs. Perkins and Goodell in consul- 
tation, in regard to the patient of the former, he wished to tap 
the retro-uterine tumor to confirm the diagnosis. This he now 
believes was an error, and both the gentlemen mentioned, very 
properly objected to the procedure. Two days later, however, 
at another meeting, both consented to the measure, and Dr. 
Goodell drew off" three or four fluidounces of undecomposed 
liquor amnii. This gentleman has stated1 that this was done 
“with great relief to the patient.” “The next day,” Dr. Per- 
kins writes,2 “she was sitting up and talking to her friends 
most of the day.” The same night, however, she was taken 
ill, and “from this time she had constant pain, high fever, 
great prostration,” and died three days later. This certainly 
does not speak well for the “ great relief to the patient” from 
tapping the cyst. Notwithstanding the slight diminution of 
pressure, the poor woman died only three days later. The 
post-mortem, however, did not furnish any evidence that de- 
composition had commenced in the cyst. Monod3 performed 
paracentesis about three years and a half after the completion 
of term. The first operation was performed in September, 
and three pints of odorless, yellow, thick fluid were withdrawn. 
Eight days later it was necessary to repeat the operation, 
when much pus and some hair were found mingled with the 
fluid which escaped. The last and seventh puncture was 
made on the 13th of January following, when a large quantity 
of foetid pus was discharged. Four days later the woman died. 
Mr. Jonathan Hutchinson4 was so unfortunate as to lose his 
patient from peritonitis resulting from paracentesis. 
It must be acknowledged, however, that in a few instances 
no bad results have followed this practice. Ramsbotham5 
withdrew sixteen ounces of dark-brown fluid from a foetal sac 
in 1851. The woman was relieved and attended to her 
domestic duties for more than seven months afterward. Ho 
fresh fluid was effused, but the woman died in less than a year. 
1 Pkila. Med. Times, Jan. 20, 1874, p. 286. 
2 Amer. Journ. of Obstet., May, 1872, p. 157. 
3 L’Union Medicale, 1855. 4 Loc. citat. p. 71. 
5 Medical Times (London), Nov. 13, 1852, p. 481. THE DIAGNOSIS. 
McCullough1 employed paracentesis twenty-one months after 
the commencement of pregnancy, and removed thirty-six pints 
of a fluid which resembled pale ink. Seven months later the 
cyst opened through the abdominal Avail, and the decompos- 
ing child was removed by enlarging the orifice, after which 
the patient recovered. Notwithstanding the success of tap- 
ping in the hands of Ramsbotham and McCullough, facts 
show that it is a dangerous proceeding, and that neither the 
trocar nor aspirating needle can be safely used for diagnostic 
purposes. Puncture with either is liable to be followed by 
collapse, peritonitis, or septicaemia, either of which may prove 
fatal. Under no circumstances, should either be used unless 
the medical attendant is prepared to perform gastrotomy at 
once, if the fluid withdrawn is found to be amniotic. 
Piliferous cyst of the ovary has frequently been mistaken for 
an ovarian conception. Tandy,2 Swineburne,3 and Blandin,4 
have each made this mistake. Many years ago our country- 
man, Dr. Detwiller, reported5 what he believed to he a com- 
bined intra- and extra-uterine pregnancy. The latter was 
nothing more than a piliferous ovarian cyst, yet this case is 
quoted by almost all writers upon this subject as a genuine 
example of conception outside of the uterus. Campbell6 and 
Velpeau7 both fell into this error. It is only necessary to call 
attention to this fact. It is now generally known that the 
presence of steatomatous matter, hair, teeth, and even bones 
in the interior of an ovarian cyst, is not an indication that the 
woman in whom such a growth is found has ever been preg- 
nant. This question will hardly present itself for solution 
during life, for these errors have resulted from a misinterpre- 
itation of post-mortem appearances. 
The Diagnosis of the Species of an Extra-uterine 
Pregnancy.—If it is difficult to detect extra-uterine preg- 
nancy, it is yet more so to determine whether the product of 
1 British American Journ. of Med. and Pliys. Sciences, Oct. 1845, p. 174. 
2 St. Louis Medical and Surgical Journ., Jan. 1850, p. 15. 
3 Trans. New York State Med. Assoc., 1860, p. 102. 
4 Ibid., 1864, p. 432. 5 Phila. Journ. of Med. and Surg. 
6 Loc. citat. p. 31. 
.7 Dictionnaire de Med., 8vo., Paris. 1836, tome xiv. p. 417. OF SPECIES OF EXTRA-UTERINE PREGNANCY. 
195 
conception is being developed in the ovary, tube, or peritoneal 
cavity. Indeed it may he said to be practically impossible 
to decide this question. If colicky pain and metrorrhagia 
are absent and the gestation pursues a comparatively normal 
course to the completion of term, it is probable that the ovum 
is in the abdominal cavity. This is not always the case, how- 
ever, for Spiegelberg has seen tubal pregnancy go to term with- 
out producing any peculiar symptoms. On the other hand, 
there is good reason for believing that ventral conceptions 
sometimes produce the most violent colicky pains. Further- 
more, these would be very likely to be absent when the ovum 
is arrested in the fimbriated extremity of the Fallopian tube. 
Pregnancy of the portion of the tube outside of the uterus, 
and of the ovary, would on the other hand, in most instances, 
give rise to severe paroxysmal pain and metrorrhagia. jN'oeg- 
gerath’s method of exploration by dilating the urethra may 
lead to some definite results in the study of this subject. 
The tubo-uterine variety may produce a tumor which may 
be proved to be a part of the uterus, as was noticed by Prof. 
R. W. Gibbes,1 of South Carolina, and which he concluded 
to be a fibroid tumor. De la Faille2 correctly diagnosticated 
tubo-uterine pregnancy in one instance because he found the 
pain very intense upon lightly pressing the uterus. The true 
value of this symptom is not determined. 
It, therefore, appears that at the present time we possess no 
information which will enable the physician to make more 
than a shrewd guess in regard to the species of an extra-uterine 
conception during the life of his patient. 
1 Trans. State Med. Assoc. South Carolina, 1872, p. 49. 
2 Monats. fur Geb., June, 1868, and Brit, and Foreign Medico-Chir. Rev., 
Oct. 1868. CHAPTER IX. 
THE PROGNOSIS. 
Always grave—Tubal, the least favorable—Ventral, the most so—Varies with the stage 
of gestation—Dead foetus may be retained for a long time without endangering the 
mother—Combined intra- and extra-uterine pregnancy—Pregnancy while carrying 
an encysted foetus. 
The prognosis of extra-uterine pregnancy is always grave. 
When the germ is arrested in that portion of the tube which 
is between the pavilion and the uterus, it is generally supposed 
to be invariably fatal by rupture, before the end of pregnancy. 
The observations of Saxtorpb and Spiegelberg, already cited, 
disprove this. It is probable that the prognosis of this variety 
is less grave than is generally supposed; that is, that it may 
go to term more frequently than is usually believed. Of this, 
however, there is no absolute proof. Although there is reason 
to believe that rupture of the cyst may end in recovery, this 
happens so rarely that for purposes of treatment it should 
always be looked upon as fatal. This is true not only of tubal, 
but of ovarian and tubo-uterine pregnancies as well. On the 
whole, however, in the tubo-uterine variety the prognosis is 
more favorable than in pregnancy of the ovary, or of the por- 
tion of the tube between the uterus and the pavilion, since 
the cyst may sometimes open into the uterine cavity, as was 
observed by Laugier, Feilitz, and Hicks. There is reason to 
hope that the prognosis of this variety may yet be rendered 
more favorable by art, if our skill in diagnosis can only be 
brought to such perfection as to determine its existence before 
the occurrence of fatal rupture. 
Of all the varieties of extra-uterine gestation, that of the 
abdominal cavity is the most favorable. This is owing to the 
fact that there is no impediment offered to the growth of the 
ovum. Unlike tubal and ovarian gestations, no tissues are 
distended which are unable to bear pressure. 
The prognosis varies materially with the stage of gestation. THE PROGNOSIS. 
197 
It is much graver in the first than it is in the latter half of 
pregnancy. If a woman reaches the middle of the fourth 
month without rupture, it is probable that she will go to 
term. Her having reached this period is an indication that 
the ovum has engrafted itself in an organ that will bear dis- 
tension, or else that it is in the peritoneal cavity. At term, 
when false labor-pains supervene the prognosis is for a time 
more unfavorable. This period of increased fatality continues 
until the woman’s system has, in a measure, recovered from 
the pseudo-puerperal condition which is induced. During the 
pseudo-puerperal state that follows term, the woman may some- 
times die suddenly with symptoms of collapse. The author 
met with an illustration of this fact a short time since. He 
saw a lady in consultation with Drs. Duer, Wallace, and 
Goodell. She had reached term two weeks before. Her con- 
dition was serious, though there was no reason to anticipate 
sudden death. After having been unusually cheerful during 
the morning, symptoms of profound collapse came on sud- 
denly and without apparent cause in the afternoon, and termi- 
nated fatally in a few hours. 
After the death of the foetus, and the restoration of the nor- 
mal condition of the system, the retention of an extra-uterine 
foetus is not incompatible with a long and useful life, but a 
woman is never free from danger while she is carrying an 
encysted child. Violent exercise, injuries, blows, strainings, 
and similar mechanical irritations may be the exciting cause 
of inflammation of the sac at any time. Hence, violent pain, 
with fever and evidences of inflammation following these, 
always demand a cautious prognosis. 
Depressing diseases, as any of the continued fevers, or local 
affections which induce a profoundly typhoid condition, en- 
danger the woman by impairing the nutrition of the cyst, and 
leading to destructive inflammation. 
The discharge of the contents of the foetal cyst through the 
rectum, vagina, bladder, or abdominal wall, frequently ends 
in recovery, and the last is the most favorable of these termi- 
nations. Its prognosis is not rendered more unfavorable by 
the occurrence of fecal fistule. 
Of these various terminations, the discharge of the contents 198 
THE PROGNOSIS. 
of the sac through the rectum is the most unfavorable. 
Though the vagina is the canal through which the child 
naturally enters the world, the communication of the cyst 
with this channel appears not to be as favorable as might be 
supposed. 
The occurrence of profound prostration, hectic, or septicaemia 
during the process of elimination, is always a grave indica- 
tion. It should never be forgotten, however, that a woman 
in this condition may recover under the most extraordinary 
circumstances. 
Combined intra- and extra-uterine pregnancy is not more 
unfavorable than when only one germ is fecundated, and that 
is developed outside of the womb. 
Hernial or extra-abdominal gestation, which is at the same 
time extra-uterine, is one of the most favorable varieties both 
as regards the life of the mother and child. As the latter can 
be removed without opening the abdominal cavity, its life 
can generally be saved without materially increasing the dan- 
gers of the mother. In all other varieties the life of the child 
is to be considered as inevitably lost, unless it can be saved by 
gastrotomy after the death of the mother. 
The supervention of pregnancy in a woman who is carrying 
an encysted extra-uterine child, while it may produce no bad 
symptoms, always increases the danger of the woman. The 
throes of labor may displace and bruise the cyst, and lead to 
inflammation, suppuration, and purulent or putrid contamina- 
tion of the blood at a period when the woman is least able 
to resist these unhappy influences. The natural history of 
erratic pregnancy appears to warrant the conclusion that the 
life of a woman who conceives a uterine child while carrying 
one outside of the womb, is not so much endangered by acci- 
dents occurring during labor as it is by those which may 
follow it. Experience proves, however, that a woman may 
safely give birth to a number of infants while carrying an 
encysted foetus in her abdomen. CHAPTER X. 
THE TREATMENT. 
During the first half of pregnancy—Palliative measures—Radical treatment—Destruc- 
tion of the ovum through the system of the mother—Extirpation of the sac—Punc- 
ture of the cyst—Its removal by section of the vagina—Galvanism and electricity— 
Injection of narcotics into the cyst—Compression of the tumor—The comparative 
value of these methods of treatment—Of rupture of the cyst—Gastrotomy after 
rupture. 
The treatment of extra-uterine pregnancy varies with the 
stage of gestation. It may, therefore, be considered under 
three heads: 1. During the first four months; 2. During the 
remainder of the usual term of gestation ; and, 3. After that 
period, or after the death of the foetus. 
Treatment in the First Period.—This may be considered 
under two heads, palliative, and curative or radical treatment. 
The first is highly important. A great deal was said in the 
description of the symptoms about colicky pains. It is gene- 
rally for the relief of these that the physician is first called to 
see the patient. They can be relieved by narcotics, of which 
opium is the best. This should be given in large doses, and 
the quantity should be large enough to induce the desired 
effect, which is, complete relief from pain. Contractions of 
the foetal cyst being the probable cause of these pains, they 
indicate that the pregnancy is tubular rather than abdominal, 
and that rupture of the cyst is impending; therefore they 
should be relieved as promptly as possible in order to avert 
this deplorable calamity. Dr. Campbell says1 that these pains 
are sometimes so severe as “ to be uncontrollable by the most 
powerful doses of opium.” Under such circumstances they 
might be arrested by the administration of anaesthetics; but 
these can never come into general use for the management of 
this troublesome symptom, because their administration en- 
1 Loc. citat. p. 104. 200 
THE TREATMENT. 
dangers rupture of the cyst, by causing the patient to struggle 
while the effects are being induced, or passing off. The 
vomiting which so often follows anaesthesia may have the 
same effect, and thus the remedy may hasten the very danger 
which it was given to prevent. The opium may be adminis- 
tered either by the mouth or hypodermically. The rapid 
action of the latter makes it preferable. At the same time 
strong sedative applications should be made to the abdomen, 
and the patient should be kept as quiet as possible. The de- 
pression which accompanies these outbreaks of pain is some- 
times so profound as to call for the administration of powerful 
stimulants. These must be given as required. 
Constipation and difficulty in urinating are to be met, with 
the usual remedies. Purgatives must be administered with 
great caution, however, and all drastic cathartics are to be 
avoided. The straining which they produce may result in 
rupture of the sac. A patient who is suspected to be carrying 
an extra-uterine child should be instructed to avoid all sudden 
exertion, straining at stool, lifting heavy weights, or any labo- 
rious occupation. She should likewise avoid anything likely 
to excite the emotions. 
The radical or curative treatment of extra-uterine pregnancy 
in the first months of the evolution of the foetus, is a matter 
of great importance. If our knowledge were sufficient to 
enable us to distinguish abdominal from tubal pregnancy, 
the former might be allowed to progress to term, since it is 
known to frequently recover. In tubal gestation it is not 
proved that this happy event can be anticipated. Rupture 
of the cyst will probably occur and end fatally before the end 
of the fourth month. To prevent this, and save the life of 
the woman, it has been proposed to destroy that of the foetus. 
Eo question of morality can enter into the consideration of 
this subject. There is no hope that the child will become 
viable, and if it should live as long as this, the history of the 
operation' of gastrotomy for its relief shows that the results 
are so fatal to the mother, that the accepted custom of obstet- 
rics, to save hers, as the more valuable life, when one has to be 
sacrificed, applies here with great force. If extra-uterine 
pregnancy has been diagnosticated, there is no doubt about DESTRUCTION OF THE OVUM. 
201 
the propriety of destroying the life of the ovum, if this can be 
done without increasing the dangers of the mother. The 
various measures that have been proposed to accomplish this, 
will be separately considered. 
Destruction of the Ovum through the System of the 
Mother.—It was proposed by Yon Ritgen1 to effect this by 
depressing the vital powers of the mother. He subjected the 
woman to a sort of “ cura famis” while at the same time he 
administered purgatives and ergot. He reports an alleged 
cure by this method. It never came into general use, for the 
obvious reason that clinical experience teaches that the state 
of the mother’s health has little effect upon the nutrition of 
the foetus. Phthisical patients frequently bring fat, well-nour- 
ished children into the world. Cazeaux2 proposes to effect the 
same end by copious and repeated bleedings. Iodide of potas- 
sium3‘and mercurial frictions4 have also been used under the 
same circumstances. Barnes5 has suggested giving strychnia 
so as to produce the minor toxical effects on the mother, and 
on account of the well-known destructive influence of the virus 
of syphilis upon the foetus in utero, asks, if syphilization would 
be justifiable. Janvrin6 used hypodermic injections of ergotine 
in his case, under the idea that he had to deal with a tubo- 
uterine (interstitial) pregnancy, though it is impossible to 
determine upon what grounds he based his conclusion. He 
believes that the final discharge of the child by the bowel was 
hastened by the influence of this drug, though there is not 
the slightest evidence that the conclusion is correct. All of 
these measures will be found alike unavailing. Barnes’ sug- 
gestion of syphilization cannot be too strongly opposed. Almost 
every one has seen women, though badly infected with this 
disease, bring forth living, though diseased children, and the 
1 Neue Zeit. fur Geb., 1840, ix. p. 206. 
2 Tlieoret. and Pract. Midwifery, 8vo., Phila., 1869, p. 601. 
* Keller, Des Grossesses Extra-uterines, 8vo., Paris, 1872, p. 54. 
4 Schlesier, Casper’s Wochenschrift, 1845, No. 81 ; Moreau, Des Grossesses 
Extra-uterines, 12mo., Paris, 1853, p. 120. 
5 Diseases of Women, 8vo., Phila., 1874, p. 373. 
6 Amer. Journ. of Obstetrics, Nov. 1874, p. 433. 202 
THE TREATMENT. 
wonderful persistency with which an ovum is sometimes re- 
tained in uterine pregnancy, under the most hopeless circum- 
stances, leads us to infer that syphilization would not always 
prove successful in destroying the life of the child. Besides 
this, the moral objections to the practice would appear to be 
insurmountable. Janvrin’s proposition to use ergotine by 
hypodermic injection must be condemned. Its utility in 
bringing on contractions, in a uterus in a state of quiescence, is 
very uncertain, but granting that its action is certain, and that 
it will always induce contraction of the cyst, this is precisely 
what is not to be desired. % Rupture of the sac is the most 
unfortunate result of extra-uterine pregnancy; the one acci- 
dent of this singular slip of nature which has never been re- 
lieved; and all drugs, the action of which would hasten this 
in the slightest degree, cannot be too sedulously avoided. 
Extirpation of the Foetal Sac.—Keller1 says that' Heim 
and Osiander proposed to remove the foetal tumor by the bis- 
toury. He does not tell us where they proposed to make the 
incision. In later times, Brown,2 Routh,3 Playfair,4 Meadows,5 
and Greenhalgh6 in England, and Darby7 in this country, have 
proposed to perform gastrotomy, and extirpate the sac before 
rupture occurs. This operation is condemned by Hewitt8 and 
Spencer Wells.9 There is no doubt that it is possible, but it 
has never been performed. Mr. Wells, whose opinions on all 
questions appertaining to abdominal surgery are of the highest 
value, opposes it, on the ground that women who are the sub- 
jects of extra-uterine pregnancy frequently recover. How- 
ever, if the diagnosis of misplaced gestation was certain in 
any case, and it could be proved that the gravid cyst was 
situated in the ovary or in the Fallopian tube, the operation 
would be perfectly justifiable. In the first species the ovary 
1 Loc. citat. p. 54. 
2 Transactions Obstet. Soc. London, 1870, vol. xi. p. 8. 
3 Ibid., p. 61. 4 Ibid., p. 61. 
6 Ibid., 1872, vol. xii. p. 271. 6 Ibid., p. 273. 
7 Trans. South Carolina State Med. Assoc., 1872, p. 102. 
8 Trans. Obstet. Soc. London, 1872, vol. xiii. p. 273. 
9 Ibid., p. 273. PUNCTUKE OF THE FOETAL CYST. 
203 
alone would have to be removed, and the operation would be 
simply that of ovariotomy. In the other case the foetal sac 
might be extirpated, or if this wTas not possible, the supra- 
cervical portion of the uterus and its appendages could be re- 
moved, with a better prospect of the woman’s recovery than 
she would have after rupture of the cyst. The great impedi- 
ment to operative interference, is the difficulty in diagnosis. 
Puncture of the Foetal Cyst.—In 1864, Sir James Y. 
Simpson1 put on record the fact, that he had punctured a foetal 
cyst through the vagina, and evacuated the liquor amnii in a 
woman six months gone, with the hope that the life of the 
foetus would be destroyed. For two days the patient did well, 
but on the morning of the third day she was extremely ill, 
and died before night, the sounds of the foetal heart being 
heard till the last. In 1865, Hicks,2 of London, punctured 
the sac through the vagina in a woman three and a half 
months gone, not writh the intention of withdrawing the 
liquor amnii, but to destroy the foetus by direct injury with 
the trocar. This he succeeded in doing, but his patient died 
of internal hemorrhage on the fifth day. In 1867, Green- 
halgh3 tried the same method, his patient being between three 
and four months advanced in her gestation. The “ hair 
trocar” was introduced through the vagina on October 8th, 
and fifteen drachms of liquor amnii were withdrawn. The 
patient did well until Oct. 27th, when she had a rigor, hypo- 
gastric pain, and a sanious discharge from the vagina, followed 
by the expulsion of some eoagula and the decidua, after which 
she did well. On the third of the following November, he 
could -hardly discover a trace of the extra-uterine swelling. 
Greenhalgh was unaware that this treatment had been pre- 
viously proposed and employed. On the 5th of July, 1867, 
the late Dr. Tanner4 resorted to vaginal puncture for the same 
purpose. He was unaware of the operations of Simpson 
and Hicks, for he believed his case “ to be unique.” His 
1 Edinburgh Med. Journ., March, 1864, p. 865. 
2 Trans. Obstet. Soc. London, 1866, vol. vii. p. 95. 
3 Lancet, March 23, 1867. 
4 Signs and Diseases of Pregnancy, 8vo., Pliila., 1868, p. 306. THE TREATMENT. 
patient continued desperately ill until August 8th, when 
she passed the decomposing foetus by the bowel, immediately 
after which she began to improve. Several months later, 
Martin1 reported that he had punctured the cyst through the 
abdominal wall, when the pregnancy had lasted about three 
months. The woman died. In a recent discussion before the 
Obstetrical Society of New York, Prof. T. G. Thomas stated2 
that he had twice punctured the sac to arrest the progress 
of extra-uterine pregnancy. Both women died, one from 
secondary hemorrhage, and the other from septicaemia. An 
extended examination of the literature of extra-uterine preg- 
nancy has not led to the discovery of any other efforts to 
arrest the growth of the ovum by this method. The result 
certainly is not what might have been hoped for from such an 
operation. Of the seven women only two recovered, and one 
of these, whose history is reported by Dr. Tanner, cannot be 
said to have been benefited by the operation. She continued 
desperately ill for a month, when the cyst opened into the 
rectum and discharged its contents by the bowel. It is an 
important fact that the child was decomposing. Greenhalgh 
alone may be said to have been successful. This is certainly no 
very flattering exhibit for puncture of the cyst, especially when 
it is remembered that Sir James Y. Simpson heard the foetal 
heart beat until the death of his patient. It, therefore, appears 
that the death of the foetus is not insured by the discharge of the 
liquor amnii. The history of extra-uterine pregnancy proved 
long since that the presence of that fluid was not necessary to 
insure the complete development of the child outside of the 
uterus. Reference to the examples of development of the 
foetus after rupture of a tubal pregnancy, the placenta remain- 
ing intact, will fully demonstrate this fact. The practice is 
not without danger to the mother. It has been stated, in 
speaking of the diagnosis of extra-uterine gestation, that the 
trocar should never be used for that purpose without it is the 
intention to remove the foetus at once, either by gastrotomy 
or another operation. To admit air into an extra-uterine foetal 
1 Monats. fur Geburtsk., Feb. 1868, and Brit, and For. Medico-Chir. Rev., 
July, 1868. 
2 Amer. Journ. of Obstet., Nov. 1875, p. 522. REMOVAL OF THE EMBRYO. 
205 
cyst is always a dangerous proceeding. It leads to decomposi- 
tion of the fluid and solid contents, with rapid blood poisoning 
and death, if the offending cause is not removed. If the 
foetus is destroyed in the early stages, the hope for the patient 
is that it will become encysted, and remain quiescent through- 
out the rest of her life. To do this, it is necessary in most 
instances, to maintain the integrity of the cyst walls. Punc- 
ture with a trocar or aspirator does not, therefore, hold out 
any hope of success. 
Removal of the Embryo by Section of the Vagina 
with the Galvanic Cautery.—Prof T. G. Thomas,1 of New 
York, has very recently proposed and successfully practised a 
new operation for the removal of all of the contents of the 
foetal cyst, which, with slight modification, promises to lead to 
important results. On Feb. 7, 1875, Dr. Thomas operated on 
a woman three months gone in the following manner: She 
was etherized and placed in the left lateral position on a table 
which stood before a window admitting a strong light. A 
Sims speculum was introduced into the vagina. “ Through 
this,” continues Dr. Thomas, “ the cyst to the left of the uterus 
could be distinctly palpated. Now fixing a long-handled 
tenaculum in the cervix uteri, and another in the vagina, near 
the left ilium, this part was by them put on a stretch so as to 
make that side of the canal a triangle, the base of which was 
over the cyst, and the apex at the vulva. Assistants held 
the tenacula during the operation. Taking the platinum knife 
of the galvano-caustic battery, which was brought to a white 
heat, I now passed it gently over the base of the triangle de- 
scribed as created in the vagina, carrying it from one tenacu- 
lum to the other. By repeating this, the vaginal wall, over 
the lower segment of the cyst, was slowly cut through. In six 
minutes the cyst was opened by the incandescent knife, and a 
straw-colored, slightly pinkish fluid was thrown out with such 
force as to fly into my face and over my clothing. 
“ Thus far no blood whatever had been lost. I now passed 
my index finger into the cyst, and felt a foetus lying horizon- 
1 New York Med. Journ., June, 1875. 206 
THE TREATMENT. 
tally with the head towards the ilium, and the feet towards 
the uterus. Passing in the middle finger likewise, I caught the 
feet between the two, and turning the foetal body, drew them 
through the artificial os which I had created, and delivered 
the child from the vicarious uterus which it occupied. The 
cord was then cut, and 1 proceeded to deliver the placenta by 
gentle traction and detachment as is done after natural labor. 
Thus far thirteen minutes had been consumed.” 
After a little more than half the placenta had been sepa- 
rated, a very severe hemorrhage set in, so that Dr. Thomas had 
to tear off the separated portion, and inject a solution of sub- 
sulphate of iron into the sac. This instantly checked the loss 
of blood, but left the sac filled by coagula and a portion of the 
placenta. The woman was put to bed in twenty-eight minutes 
after the commencement of the operation. On the fourth day 
symptoms of septicaemia set in, but they yielded to the treat- 
ment adopted. On the fifteenth day the portion of the pla- 
centa which remained came away. 
This is the most important contribution which has recently 
been made to the treatment of extra-uterine gestation in its 
early stages. Dr. Thomas hoped to avoid peritonitis by opening 
the sac by an incision made between the folds of the broad 
ligament. By this means the serous membrane escaped injury. 
The incandescent knife prevented hemorrhage, and he hoped 
to avoid septicaemia by removing all of the cystic contents, the 
placenta included. Here the distinguished operator, with all 
due deference to his great experience and well-known skill, it 
seems to the author committed a serious error. By attempting 
to remove the placenta he nearly realized the sad experience 
of Baudelocque, whose patient died at once from hemorrhage, 
and by the necessity of suspending the operation, and inject- 
ing the subsulphate of iron he may have induced the septi- 
caemia, and thus subjected his patient to the very dangers 
which he was seeking to avoid. 
In all these operations the placenta should be left in situ. 
Experience has proved that the danger of immediate hemor- 
rhage from its removal is greater than that of secondary 
hemorrhage and septicaemia, which may result from allowing 
it to remain. With this single modification the operation of 207 
GALVANISM AND ELECTRICITY. 
Hr. Thomas appears to promise much for the earl}' relief of 
certain cases of extra-uterine gestation. By this means the 
cyst can be opened without fear of hemorrhage. If the foetal 
tumor is distinctly retro-uterine, it can be done with great 
readiness. If it is tubal, there is reason to hope that the knife 
can be carried up between the folds of the broad ligament, and 
the cyst opened without disturbing the peritoneum. The 
drainage of the sac is fairly insured by position, while it can 
be easily washed out by disinfectant solutions. By these means 
we have reason to hope that septicaemia can be avoided, even 
though the placenta is left to come away in decomposing pieces. 
We have every reason to believe, at least, that trusting to these 
measures is less dangerous than to run the risk of fatal hemor- 
rhage or rupture of the cyst by removal of the placenta. 
Galvanism and Electricity.—In 1857 Baehetti, of Pisa,1 
announced the fact that four years before, he had caused the 
death of the foetus, by inserting needles into the cyst, and pass- 
ing through them an electro-magnetic current. The tumor, 
which was the size of a man’s fist, gradually contracted to 
that of a pigeon’s egg. Moreau, in his work, Des Grossesses 
Extra-nterines, published in the same year, 1858, in which 
Baehetti first employed this method of treatment, gives Yoille- 
mier the credit of having suggested its use. Burci2 has re- 
cently reported another successful case in which the growth of 
the foetus was arrested by electro-puncture. 
Cazeaux3 suggested that electric shocks through the cyst 
would kill the child. Hicks,4 of London, and Allen,5 of Phila- 
delphia, have each tried the method. Hicks placed one pole of 
a galvanic battery in the vagina and the other over the tumor 
on the abdominal wall. This was tried twice, and the foetal 
movements ceased during the application of the current, but 
returned afterwards. Hr. J. G. Allen has been successful 
in two instances. He applied one pole of an ordinary electro- 
magnetic machine to the tumor in the vagina through an ordi- 
1 L’Union Medicale, 1857. 
2 Bull. General de Therapeutique, 1872, p. 276. 3 Loc. citat. p. 601. 
4 Trans. Obstet. Soc. of London, 1866, yol. vii. p. 96. 
6 Araer. Journ. of Obstet., May, 1872, p. 161. 208 
THE TREATMENT. 
narv glass speculum, the other being applied to the surface of 
the abdomen over the foetal cyst. 
Dr. Barnes1 rejects Bachetti’s plan of using electro-punc- 
ture, and prefers that suggested to Lesouef by Duchenne. 
The latter believed that the discharge from a Leyden jar 
produced profound local stupor with lessened calorification 
and dimunition in the activity of the capillary circulation. 
He directs that the excitors should be covered Avith a thick 
coating of wax, the terminal bulbs only being left bare. One 
is to be passed into the rectum in contact Avith the tumor, 
being careful to avoid the lumbo-sacral plexus of nerves, Avhile 
the other is passed into the vagina and brought in contact 
Avith the anterior inferior part of the cyst. Keller opposes the 
use of electricity in any form, because he believes that there 
is danger of the current bringing on contraction of the cyst 
or the surrounding muscles, and producing separation of the 
placenta and its consequences. This objection is not Avithout 
force. The experience of Hicks likewise proves that an 
electric current by no means surely destroys the product of 
conception. Therefore this method of treatment cannot be 
relied upon in all cases, yet the happy results obtained by Allen 
prove that it may be effectual. This appears to be preferable 
to Bachetti’s method of electro-puncture. 
The Injection of Narcotic Substances into the Cyst.— 
This method of destroying the foetus was proposed by Joulin2 
in 1863, and Avas successfully put in practice by Friedreich3 
one year later. The latter injected one-tenth of a grain of 
morphia the first time. Two days later, when the cyst AA7as 
smaller and not so tender, one-sixth of a grain Avas injected. 
Four injections of the same quantity were made afterwards. 
The only doubt about this case is in regard to the diagnosis. 
The history is not sufficiently clear to make it certain that the 
pelvic tumor was not inflammatory. Kceberld4 Avas successful 
with a solution of the hydrochlorate of morphia and the 
1 Diseases of Women, 8vo., Pliila., 1874, p. 371. 
* Keller, loc. citat. p. 56. 
8 Med. Times and Gazette, Jan. 21, 1865, p. 71. 
4 Keller, loc. citat. p. 77. COMPRESSION OF THE TUMOR. 
209 
diagnosis was placed beyond doubt in this case by the dis- 
charge of a small quantity of liquor amnii. An accident 
occurred in this instance, for upon removing the instrument 
there was considerable hemorrhage, and, notwithstanding pres- 
sure was made, there was some blood effused into the abdominal 
walls. Joulin believed that the narcotic solution might 
sometimes be thrown into the embryo, when its death would 
be nearly instantaneous. In other cases it is thrown into the 
foetal cyst, poisoning the amniotic fluid by which the child 
is surrounded. The injection of narcotic substances is recom- 
mended by Behier, Tanner, and Keller. Tanner recommends 
that half a grain of morphia be thrown into the cyst by a 
hypodermic syringe. 
Koeberld has made an important and very interesting observa- 
tion in regard to the future of his successful case. The ovum did 
not become encysted, but appeared to have been completely 
reabsorbed. This treatment, if adopted, should be resorted to 
as early as possible, so that this happy result may be realized. 
Of the true value of narcotic injections into the cyst we can say 
nothing. The facts in our possession are not enough to make 
any deductions valuable. As yet it cannot be said to count 
more than one success—that of M. Koeberle. There are too 
many doubts about M. Friedreich’s statements to warrant their 
unquestioned acceptance. 
Compression of the Tumor.—Mai in1 has proposed to de- 
stroy the foetus by compressing the tumor. He recommended 
the use of bags of sand. It is useless to discuss this measure. 
It is at best uncertain, and the hypogastric region is generally 
so tender that it cannot be borne, while there is danger of sepa- 
rating the placenta and causing rupture of the cyst. 
From this summary of the results of the various efforts 
which have been made to destroy the life of the foetus, in the 
early stages of its development, it at once becomes apparent 
that but little has yet been done in this direction. Notwith- 
standing the attempts that have been made to settle the thera- 
peutics of this stage of misplaced pregnancy, experience will not 
1 Keller, p. 59. 210 
THE TREATMENT. 
yet warrant the adoption of any positive rules in regard to it. 
From a careful investigation of the history of these attempts, 
it appears, however, that all measures that necessitate wound- 
ing the cyst without removing the child are not without danger 
to the woman. They are not, however, to be condemned for 
this reason. Every important operation in surgery involves 
in itself more or less risk, and grave mutilations are daily and 
properly practised, in the hope of saving life, when it is well 
known that if they are not successful they will shorten it. 
In considering this question it becomes us, therefore, to deter- 
mine, if possible, whether the risks of the therapeutic measure, 
though they may be grave, may not be less than those which 
follow when the accident is abandoned to nature. This it is 
at present impossible to determine. Future experience must 
decide the question. 
In the mean time, the facts now in our possession indicate 
that the child ought to be either removed entire, or the cyst 
be allowed to remain uninjured. The results of tapping the 
tumor to remove the liquor amnii sustain this statement. 
It is further borne out by the unhappy consequences which 
followed aspiration in the hands of Jordan and Scott. For 
the same reason Bachetti’s proposition to resort to electro- 
puncture, and Joulin’s to inject narcotics into the sac to de- 
stroy the child, while they have not yet proved fatal, and are 
not to be hastily condemned, should be employed with a full 
knowledge that puncture of the cyst may interfere with the 
desiccation of the foetus, so that it will remain in the abdomen 
an innocuous foreign body. This is the operator’s hope when 
he resorts to this method of treatment. The natural history 
of misplaced gestation teaches that the happy experience of 
Koeberle, in regard to the resorption of the solid portions of 
the ovum, is not likely to be very frequently realized. For 
these reasons, if the author was to be called to a case of extra- 
uterine pregnancy, at a time when the child could be destroyed, 
he would, while not condemning the injection of narcotic sub- 
stances into the cyst, prefer the use of electricity, as employed 
by Dr. J. G. Allen, of Philadelphia; or else he would remove 
the child by section of the vagina with the galvano-eautery, as RUPTURE OF THE CYST. 
211 
performed by Professor Thomas, of New York, with this ex- 
ception, that he would leave the placenta in situ. 
The dread of wounding the cyst, expressed in these pages, 
may seem to many entirely unnecessary. Clinical experience 
alone must settle this matter; but as the hope of restoring 
these women to health depends upon converting their imma- 
ture children into innocuous masses of foreign matter, it seems 
reasonable to believe that this can best be done by preserving 
the integrity of the cavity which contains them. The admission 
of air could hardly fail to result in decomposition of the liquor 
amnii and foetus ; and clinical experience has proved that this 
danger is not overcome even by the aspirator. Therefore, 
notwithstanding the dangers of producing rupture of the cyst 
by electricity, and of secondary hemorrhage and septicaemia 
supervening after complete removal of the child, it would seem 
that these methods of treatment offer the best chances of 
success. 
Treatment of Rupture of the Cyst in the early Stages 
of Pregnancy.—In speaking of the result of this pitiless 
termination of extra-uterine gestation, it was stated that so 
few recover from it, that all hope of such a happy result is to 
be dismissed in considering the treatment. No doubt, notwith- 
standing the statement of Rogers to the contrary, a few women 
have recovered, though the number is very small—so small 
that when one is called to a case of the kind, it is his duty to 
look upon his unhappy patient as inevitably doomed to die, 
unless he can by some active measures wrest her from the grave 
already yawning before her. The history of human injury and 
disease presents no condition parallel to this one. However 
fatal the disorder, science and art have found some means of pro- 
longing life or “ smoothing the stormy passage to the grave.” 
A bleeding vessel, through which the red stream of life is 
rushing away, can be ligated. A gangrenous limb, which is 
destroying its possessor by sending its poisonous emanations to 
the remotest regions of his body, can be amputated. A can- 
cerous breast, which is sapping the vitality of its victim hour 
by hour, can be removed with the prospect of temporary relief. 
An aneurism, that places life in constant jeopardy, can often 212 
THE TREATMENT. 
be cured by proximal or distal ligation. The tumultuous ac- 
tion of a heart organically diseased may be quieted till nature 
restores the balance,'after which the person may enjoy a long 
and even a useful life. Even phthisis now counts its many cures; 
but here is an accident which may happen to any wife in the 
most useful period of her existence, which good authorities 
have said is never cured ; and for which, even in this age when 
science and art boast of such high attainments, no remedy 
either medical or surgical has been tried with a single success. 
From the middle of the eleventh century, when Albucasis de- 
scribed the first known case of extra-uterine pregnancy, men 
have doubtless watched the life ebb rapidly from the pale 
victim of this accident as the torrent of blood is poured into 
the abominal cavity, but have never raised a hand to help 
her. Surely this is an anomaly, and it has no parallel in the 
whole history of human injuries. The fact seems incredible, 
for if one life is saved by active interference it may be trium- 
phantly pointed to as the first and only instance of the kind 
on record. In the whole domain of surgery—for we cannot 
look to other than surgical measures under the circumstances 
—there is now left no field like this. In this accident, if in 
any, there is certain death. IIow often do we see persons 
recover from injuries which their surgeons tell them will be 
mortal if they do not submit to a grave and terrible operation, 
and which with a dogged determination they refuse to have 
performed, preferring to perish rather than to suffer such grave 
bodily mutilation ; or else, with a keener instinct, they foresee 
a happier result and get well notwithstanding the evil prog- 
nostications of the surgeon, and in defiance of all the laws 
which, as man with his fallible knowledge supposes, govern 
human injuries. But in rupture of an extra-uterine foetal sac, 
in the early stages of pregnancy, a whole lifetime—a whole 
century—is not enough to enable one person to make two 
errors in regard to the prognosis of this accident. 
The only remedy that can be proposed to rescue a woman 
under these unfortunate circumstances is gastrotomy—to open 
the abdomen, tie the bleeding vessels, or to remove the sac 
entire. This treatment was suggested by Dr. W. W. Ilar- GASTROTOMY AFTER RUPTURE OF THE CYST. 
218 
bert1 in 1849, and again by Dr. Stephen Rogers, of New 
York, in a paper read before the American Medical Associa- 
tion in 1866.2 In 1858, M. Alexis Moreau3 emphatically con- 
demned gastrotomy under these circumstances, because he 
believed that the hemorrhage could not be arrested, and that 
opening the abdomen, and allowing air to enter it, would in- 
crease the peritonitis which, he supposes, always follows the 
effusion of blood resulting from rupture of an extra-uterine 
foetal sac. For these reasons he says all operative interference 
is contraindicated. Desormeaux,4 Moreau,5 and others long 
since advised gastrotomy for rupture of the cyst, but it must 
be remembered, that by this, they meant rupture during the 
spurious labor, which occurs at or near the end of the ninth 
month of gestation. The first suggestion of performing gastro- 
tomy to save a woman dying from early rupture of the cyst 
came, so far as we know, from our countryman Dr. Harbert, 
while to Rogers belongs the credit of formulating the argu- 
ments in favor of this practice and bringing them prominently 
before the profession. Since he wrote, the same plan of treat- 
ment has been advocated by Meadows, Hewitt, Gtreenhalgh, and 
Playfair, in a discussion before the Obstetrical Society of Lon- 
don.6 Koeberl^,7 Behier,8 Schrceder,9 and Atlee10 countenance 
the proceeding, but no person has yet performed gastrotomy for 
the relief of this accident. The great impediment to the adop- 
tion of this treatment is the uncertainty of diagnosis. This 
subject has been fully treated of in its appropriate place, and 
1 Western Journ. of Med. and Surgery, 1849, 3d series, vol. iii. p. 110. 
After describing a case of rupture, he says : “ Whether the Caesarean opera- 
tion would promise anything in similar cases were the diagnosis made in 
time, is an inquiry that can only be answered by observation and ex- 
perience.” 
2 Trans. Amer. Med. Assoc., 1806, and Extra-uterine Foetation and Gesta- 
tion, etc., 8vo., Phila., 1867. Also Medical Record, New York, 1867, vol. 
ii. p. 22. 
3 Loc. citat. p. 123. 
4 Diet, des Sciences Medicales, 8vo., Paris, 1829, tome vii. p. 273. 
5 Traite Pratique des Accouchemens, 8vo., Paris, 1841, tome ii. p. 367 
6 Transactions, 1872, vol. xiii. pp. 270, 1, 2. 
7 Keller, loc. citat. 8 Loc. citat. ,9 Loc. citat. p. 136. 
10 Phila. Med. Times, Jan. 10, 1874, p. 236. 214 
THE TREATMENT. 
it is only necessary to add here, that if these symptoms present 
themselves and are followed by the sudden appearance of those 
of rupture, the diagnosis is so reasonably certain that the per- 
formance of gastrotomy is imperatively demanded. 
Another influence that has deterred surgeons from resorting 
to this operation under these circumstances, is the dread of not 
being able to arrest the hemorrhage after the abdomen has 
been opened. Doubtless this will often be found to be diffi- 
cult, and it may be, sometimes impossible, but under these 
circumstances the ovary, the tube, or even the whole uterus 
can be removed. Women have recovered from this mutilation, 
and it is certainly not more fatal in its results than to leave 
rupture of an extra-uterine foetal cyst to nature. The indica- 
tions now are, that extirpation of the uterus is shortly to take 
its place on the list of legitimate operations. 
Pean and Urdy,1 have placed hysterotomy in a new position 
by their brilliant successes. They have saved no less than 
seven out of nine women upon whom they have operated. 
Many of these must, under less radical treatment, have been 
abandoned to a slow and painful death from hemorrhage and 
suppuration in the fibroid tumors by which they were afflicted. 
In some of their cases the adhesions were very numerous, and 
would have deterred less bold operators. The study of the 
reports of their operations, in which these adhesions were so 
formidable, and a consideration of the almost reckless manner 
in which they broke them down, cannot but lead us to the 
belief that the operation of gastrotomy for rupture of the sac 
of an extra-uterine fcetation, cannot be more dangerous ; while 
it holds out an equal prospect of recovery. If success does 
not crown his effort, the surgeon has not the painful knowl- 
edge, as after ablation of the uterus for fibroid and other 
tumors, that he has shortened the life of his patient by a single 
day. 
It should be remembered that rupture usually occurs before 
the end of the fourth month, and that in many of these cases, 
the contents of the cyst are discharged and float freely in the 
1 Hysterotomie. De 1’Ablation partielle ou totale de l’Uterus, par la Gas- 
trotomie, 8vo., Paris, 1873. GASTROTOMY AFTER RUPTURE OF THE CYST. 
215 
blood in the peritoneal cavity. It is also an established fact, that 
in early rupture the most severe hemorrhage occurs in those cases 
in which the contents of the cyst do not escape, and the blood 
flows from an orifice, sometimes so minute, that this is one of 
the most singular facts known in connection with extra-uterine 
pregnancy. This and the well-established fatality of the acci- 
dent, warrant the conclusion that the woman’s chances of life 
will not be lessened by enlarging the opening and removing 
the ovum. In gastrotomy for rupture of an extra-uterine foetal 
cyst in the early stages of pregnancy, there need be no inde- 
cision about the method of dealing with the placenta. From 
the nature of the bleeding surface arises the chief difficulty 
in controlling the hemorrhage. If this was from a single 
vessel, it could be easily ligated, and the ligature brought out 
at the angle of the wound. In this case, however, the bleed- 
ing may come from the interior of a morbidly vascular cyst, 
and from a large surface. The only method of dealing with 
it is to ligate it, to remove it en masse, or to cauterize it. Here 
the suggestion of Dr. Sims, made with reference to ovariotomy, 
may be useful. In that operation he has proposed,1 and has 
used fine silver wire for tying the pedjcle. This he has demon- 
strated may be returned to the peritoneal cavity, where it soon 
becomes encysted, and where it may remain innocuous for an 
indefinite length of time. The objection to the silver wire is 
that it has to be twisted, a method of tightening, not so reli- 
able for arresting hemorrhage as tying. Silk, or carbolized 
catgut, being animal substances, may be used, cut oft* short, 
and closed up in the peritoneal cavity. Since Professor Nathan 
K. Smith2 of Baltimore, originated the intra-peritoneal method 
of treating the pedicle in ovariotomy, in 1821, ligatures have 
frequently been allowed to remain in the abdominal cavity 
after operations. Peaslee3 has left fifteen, and Keith4 thirty in 
successful cases, and they never gave any trouble. Pean and 
1 New York Med. Journ., December, 1873, and April, 1873. 
2 Amer. Med. Recorder, Jan. 1823. 
3 Amer. Journ. of Med. Sciences, July, 1864, p. 50, and Ovarian Tumors, 
etc., 8vo., N. Y„ 1872, p. 431. 
4 Edinburgh Med. Journ., Dec. 1867, p. 525. 216 
THE TREATMENT. 
Urdy,1 however, have exceeded both. They allowed no less 
than forty to remain in one instance, and the cure was perfect. 
Spiegel berg and Waldeyer2 have experimented upon the effects 
of small foreign bodies, allowed to remain in the peritoneal 
cavities of bitches, from which they excised portions of the 
uterus and Fallopian tubes. They concluded that silk and 
hemp could be thus used without danger; that they did not 
lead to any acute local peritonitis, and that mortification of 
the tissues surrounded by them did not follow, but that the 
ligatures left were capsulated and became innocuous. Thus 
one great objection to gastrotoiny for the relief of rupture of 
an extra-uterine cyst has been removed by the results of ovari- 
otomy and by direct experiment. 
The bleeding surface may be secured in tubal pregnancy 
by passing a double silk ligature through the broad ligament 
below the tumor and tying one strand on either side of the 
foetal cyst. Thus a V-shaped portion of the ligament may be 
securely ligated. Portions of the cyst might be removed by 
the knife if they were loose and there appeared to be danger 
of their sloughing. If the pregnancy was ovarian the organ 
might be ligated and rerpoved. Tubo-uterine gestations offer 
the greatest difficulties, and it may be that they are not adapted 
to this method of treatment, since a portion of the uterus would 
have to be included in the ligatures, but even this is not 
incompatible with recovery. Dr. Alfred Wiltshire, of Lon- 
don,3 after the removal of an ovarian tumor, found that the 
originally short pedicle was too rotten to hold the clamp or 
ligature. As a dernier* ressort the right half of the uterus 
was transfixed and tied with a stout silk ligature. • The 
patient began to improve “from the hour of the operation,” 
and she “ uninterruptedly recovered without a rigor or the 
formation of a single drop of pus, the wound having united 
by first intention.” 
It is not unreasonable to hope that the galvano-eautery may 
be used to arrest the hemorrhage. The great objection to 
1 Loc. citat. p. 204. 
2 Virchow’s Archives, 1868, and T. Spencer Wells, Diseases of the Ovary, 
8vo., New York, 1873, p. 363. 
3 Trans, of the Patliolog. Soc. of London, vol. xix. p. 295. GASTROTOMY AFTER RUPTURE OF THE CYST. 
217 
its use is that it can only be obtained in large cities. It is 
preferable to the actual cautery, which leaves minute particles 
of oxide of iron in contact with the tissues. It is not neces- 
sary to plunge a metal heated to white heat into the peri- 
toneal cavity, though this has been successfully and safely 
done during the operation of ovariotomy. After the peritoneal 
cavity has been opened, the uterus and appendages can be 
drawn through the wound and the cautery applied. Injury 
to other tissues is thus avoided. Spiegelberg and Waldeyer, 
in the experiments before alluded to, removed portions of the 
uterus in bitches by the galvanic cautery, and proved that after 
this mutilation, the cauterized tissues do not become gangre- 
nous and do not injure neighboring tissues, providing only that 
tthe abdominal cavity is kept perfectly closed. In the ninth 
volume of Langenbeck’s Archives, Dr. Malowsky, of St. 
Petersburg, published1 the results of some observations which 
confirm those of Spiegelberg and Waldeyer. He experimented 
on dogs, rabbits, and cats, using sometimes the galvanic and at 
others the actual cautery. Dr. Malowsky’s experiments are of 
intense interest in their practical bearing, since he carefully 
studied and described the changes by which the capsulation 
takes place. lie injected vermilion into the blood through the 
jugular vein, and as the substance is taken up by the white 
corpuscles, he was enabled to study the part which these play 
in the process. 
It is possible that the galvanic cautery may be the best agent 
for arresting hemorrhage, in tubo-uterine pregnancy, after 
rupture. The great disadvantage of this instrument is that 
it is not always at hand, but if it cannot be had, the hot iron 
may be substituted if ligation cannot be successfully employed. 
There appears to be no reason why the galvanic cautery 
may not be still further utilized in the treatment of this terrible 
accident. After the abdomen is opened the uterus and its 
appendages can be drawn through the wound, and as much 
tissue as is necessary removed by it without fear of hemor- 
rhage. If it is necessary to remove the uterus, section should 
1 Spencer Wells, loc. citat. p. 369. 218 
THE TREATMENT, 
be made through the cervix, as recommended by Pean and 
Urdy, after which the stump should be fixed between the 
folds of the incision, in the same manner that ovariotomists 
fasten the pedicle of an ovarian tumor. Dr. J. R. Chadwick, 
of Boston, has used1 Mr. Spencer Wells’ ovariotomy clamp for 
this purpose. 
If the hemorrhage cannot be arrested without resort to this 
grave mutilation, there need be no doubt about the propriety 
of removing the supra-cervical portion of the uterus. The 
woman’s life may be looked upon as inevitably lost unless it 
can be saved by surgical measures, and the recent successes of 
M. Pean prove2 that this operation is scarcely more dangerous 
than that of ovariotomy. This surgeon has now operated 
twenty times, with fifteen recoveries. 
If the uterus is extirpated, the ovaries should be removed 
at the same time, in order to prevent the danger of another 
misplaced conception. M. KeeberR’s experience, though 
without parallel, teaches a valuable lesson in regard to this 
matter. 
In ovarian pregnancy the gravid sac can be removed with- 
out difficulty. The operation is simply that of ovariotomy. 
In tubo-uterine gestation the question to be decided, after 
opening the abdominal cavity, is whether to remove the 
ruptured cyst with the neighboring parts, or whether to extir- 
pate the whole of the supra-cervical portion of the uterus. 
The latter would probably be the better course, the stump 
being fixed in the angle of the wound. 
The galvanic cautery is not necessary for the performance of 
this operation, and the author is not aware that its use has 
ever been suggested in extirpation of the uterus. Surgeons, 
who have practised this procedure, have contented themselves 
with bringing the organ and some of the adjoining parts out 
at the angle of the wound, and with constricting these by wire 
ecraseurs, strong cords, and ovariotomy clamps to prevent 
bleeding, after which the diseased portion of the organ has 
been boldly removed. We believe, however, that the use of 
the galvanic cautery is destined to play a prominent part in this 
1 Boston Med. and S'urg. Journ., Nov. 4, 1875_ 2 Chadwick, Ibid. GASTROTOMY AFTER RUPTURE OF THE CYST. 
219 
operation, when it comes, as we think it will at no distant day, 
to assume an importance in the management of intractable 
forms of fibroid tumors, not unlike that of ovariotomy in 
regard to ovarian growths. 
The advice to perform gastrotomy after rupture of the cyst 
will no doubt be received with many misgivings, and it may 
elicit criticisms similar to those of Daynac,1 in 1825, in regard 
to gastrotomy for the removal of the mature child. This 
writer scarcely countenances the operation, which he says is 
recommended with much assurance by those who have never 
had occasion to practise it. There is nothing unreasonable in 
the recommendation which is here made, and there is no reason 
to believe that it will be impossible to arrest the hemorrhage 
after the abdominal cavity is opened. It will not be arrested 
unless this, or some other equally bold measure, is resorted to. 
It is at least morally certain that if the practical surgeon had 
to arrest bleeding from a similar surface on the exterior of the 
body, he would find some means of doing it, and in these days, 
when abdominal surgery has attained such a high degree of 
perfection, it appears to be simply criminal to sit idly by and 
see a woman die from rupture of an extra-uterine foetal cyst 
without attempting to save her. 
Another objection that has been urged against the operation, 
is the danger of opening the peritoneal cavity. This needs 
but few comments. The triumphs of the American operation, 
ovariotomy, first executed by McDowell, tried and tested by 
the two Atlees, whose efforts were afterwards so ably seconded 
by Peaslee, Sims, Kimball, and Dunlap in America, and Clay, 
Keith, and Wells in Great Britain, have demonstrated that 
the traditional idea of the danger of wounding the perito- 
neum is but an idle fancy. The experiences of the late civil 
war have proved the same thing. Gunshot wounds of the 
abdomen were found not to be necessarily mortal, but, on the 
contrary, a large proportion recovered. The legitimacy of the 
operation is not to be questioned because many may die who 
have been subjected to it. Kot being a surgeon, the writer 
1 These a Paris, No. 71, 1825, p. 19. 220 
THE TREATMENT. 
cannot be accused of being a partisan for operative inter- 
ference. That he is not, will become apparent in discussing 
the merits of gastrotomy for the removal of extra-uterine 
children at or after the full term of gestation. This matter 
should be examined in a practical, common-sense way, and 
when the results of other grave surgical operations are ex- 
amined it will be found that they often terminate in death. 
Amputation at the hip-joint is recognized as a proper pro- 
cedure. It is terribly fatal, yet it is performed for the remo- 
val of malignant tumors of the thigh, which, a knowledge of 
the natural history of disease, long since taught surgeons, would 
return in a few months and destroy the patient, even if he 
survived the removal of so large a portion of his body. 
The question is not, Will the patient die after the operation ? 
It is, Will she live if abandoned to nature? This was an- 
swered in the sobs and sorrows of stricken households long ago. 
Are the dangers of opening the peritoneal cavity less than 
those of the rupture ? The history of abdominal surgery and 
that of the condition which is being discussed teach us that 
they are infinitely less. 
Another objection urged against the operation is, that it 
has to be performed when the patient is exhausted both by 
shock and hemorrhage. This is worthy of examination. It 
has already been shown that the phenomena of rupture are 
complex in their origin, due to injury to the tissues and the 
loss of blood. It has likewise been shown that the wound in 
the sac is often small, incredibly so when its dreadful results 
are considered. This fact leads us to believe that the shock 
is not due so much to the injury to the tissues from rupture, 
as it is to the presence and mechanical effects of the blood 
which is effused into the peritoneal cavity. After the symp- 
toms of shock, come those which are due to the ansemia that 
results from the hemorrhage. These views are advanced with 
full knowledge of the profound effects produced by injuries of 
the genital organs, and after full consideration of the fact 
that these are apt to be attended by symptoms out of propor- 
tion to the destruction of their tissues. Tf it be true that the 
symptoms of shock are largely owing to the effusion of blood 
into the peritoneum, a hemorrhage which clinical experience 221 
GASTROTOMY AFTER RUPTURE OF THE CYST. 
has abundantly proved will only be arrested with the destruc- 
tion of life, what can be more reasonable than to attempt to 
remove the blood already poured out, and to arrest its further 
discharge? Besides this, in these days when anaesthetics are 
given for even trivial operations, the increase of the shock will 
not be material. 
This operation, therefore, appears to be feasible; at least no 
one has demonstrated its impracticability, and in these days 
when Durham removes the kidney, Pean and Kceberle the 
spleen, and Billroth the larynx successfully, this procedure 
ought to be tried. The details of the operation, the length of 
the incision and its position, will have to be determined. 
The division of the abdominal parietes should be sufficiently 
extensive to insure facility in operating, and to enable the 
surgeon to remove all the blood which is effused into the peri- 
toneal cavity. CHAPTER XI. 
TREATMENT—Continued. 
From end of fourth month until after labor at term—After term—Gastrotomy—Opera- 
tion to which the name is applicable—Historical facts—Mortality when left to 
nature, and after an operation, compared—Primary nnd secondary operations—An 
operation to save the child unjustifiable—No operation should be performed until 
the woman is restored from the pseudo-puerperal condition, unless under special 
indications. 
If the patient have passed beyond the fourth month, rup- 
ture of the cyst is much less likely to occur than it was before. 
Indications are now to be met as they arise, the patient’s 
strength is to he maintained, and she is to be made as com- 
fortable as possible. When labor comes on, the pain is to be 
controlled by large doses of opium, and the patient carefully 
watched. No operation should be performed unless the cyst 
has ruptured or the mother’s condition become so desperate 
that she must inevitably perish. These are the only conditions 
under which gastrotomy is to be thought of at this period, for 
reasons which will be shown when discussing that operation. 
There can be no doubt about the propriety of performing it 
when the cyst has ruptured, because the condition then 
becomes analogous to that due to rupture of the uterus. It 
should never be forgotten that the cyst rarely gives way 
during the pains of the false labor which occurs at term. 
After the termination of the usual period of gestation, 
various measures have been proposed for the relief of this ac- 
cident. These are of course chiefly surgical. They will next 
claim consideration. 
Gastrotomy.—We have now reached the consideration of 
this very important measure in the treatment of extra-uterine 
pregnancy. Many cases of alleged gastrotomy are scattered 
here and there throughout periodical literature. Cornax,1 it has 
1 Sue, Essais sur l’Art des Accoucliemens, 8vo., Paris, 1779, vol. ii. p. 62. GASTROTOMY. 
223 
been erroneously stated, was the first who practised this opera- 
tion. He is said to have done it in the middle of the sixteenth 
century. Abraham Cyprianus, Professor of Anatomy and Sur- 
gery, is said to have performed it! at Lonvade in December, 
1694. Even Yelpeau quotes2 the operation of Cyprianus, as 
well as the same performed by others, as illustrations of gas- 
trotomy, and many others have fallen into the same error, both 
before and since his day. Even now there is much confusion 
in regard to this subject, since all cases in which the abdomen 
is incised, are often reported as examples of gastrotomy. This 
is essentially wrong. If the cyst has contracted adhesions 
with the anterior abdominal wall, and has opened by one or 
more orifices upon its surface, the matter is a very simple one. 
Nature has indicated the wa}r in which she desires to get rid 
of her encumbrance, and enlarging the orifice is an operation 
of little gravity. Confusion is worse confounded by including 
section of the vagina3 with gastrotomy. The author’s learned 
and venerated teacher, the late Professor Hodge, has commit- 
ted this mistake.4 At the outset, therefore, it is to be distinctly 
understood that the term gastrotomy is used in this work only 
when speaking of cases in which the operation has been per- 
formed upon women whose abdominal walls remain intact, 
whether the cyst have contracted adhesions or not. 
The earliest ease which we have been able to find upon 
record, is that of Primerose,5 who operated in October 1594. 
The history of this patient has become classical. She was 
twice pregnant with extra-uterine children—first in 1591, and 
again some time before 1594. The cyst of the first child opened 
spontaneously through the abdominal wall. The fistula was 
enlarged, and this child extracted by Jacob Noierus, a surgeon. 
This operation proving successful, Primerose removed the 
1 Letter to Dr. Tlios. Millington, Amsterdam, 1707. 
2 Diet, de Med., 8vo., Paris, 1836, tome xiv. p. 419. 
3 Velpeau again falls into error, and includes among cases of gastrotomy 
one performed by “Ring,” and reported in the Med. Repository, New York, 
vol iii. This undoubtedly refers to the remarkable success of Dr. John King, 
of Edisto, South Carolina, who saved both mother and child by incising the 
vagina. 
4 Loc. citat. pp. 533-535. 
5 De Mulierum morbis et symptomatis, lib. iv. p. 316. 224 
THE TREATMENT. 
second infant by gastrotomy two months later. It is easy to 
imagine how he was led to perform the second and more 
hazardous operation. Felix Platerus1 reported another suc- 
cessful case only three years later. After this we have found 
no indication that the operation was performed for more than 
a century. In 1714 Calvo2 reported a case in France, and in 
1764 Bard3 another in this country. 
Mr. John Bard was a surgeon in New York, and we know 
of no one who operated in this country before him. The 
patient was a Mrs. Stagg, the wife of a mason, and the opera- 
tion was performed several years before it was published, for 
Mr. Bard communicated an account of it to Dr. Fothergill, in 
a letter, which was dated on the 25th of December, 1759. 
On January 14th, 1791, this operation was performed upon 
this side of the Atlantic for the second time, the subject of it 
being a Mrs. Cocke, the wife of a Virginia planter. The opera- 
tion, which was done by Dr. William Baynham,4 a country phy- 
sician, was entirely successful. The same gentleman operated 
with the same happy result upon a negro slave on February 
6th, 1799.5 This was the fourth American gastrotomy for 
the removal of an extra-uterine foetus. The third one was 
performed by McKnight, and communicated to the famous 
Dr. Lettsom, by Dr. Mease of Philadelphia, and published6 in 
1795. Dr. Baynham’s cases are well worth attentive study. 
They illustrate the intrepidity and good judgment so often 
displayed by the provincial surgeon, who, separated by long 
distances from his fellows, often has to act in the greatest 
emergencies without the counsel which he may earnestly 
desire. Almost a quarter of a century passed before the 
operation was repeated in this country. On the 6th day 
of October, 1823, it was again performed by Dr. Wishart,7 
> De partum Corporis Humani, Structura et usa, 1597. 
2 Histor. de Acad. Roy. des Sciences, 1714, p. 29. 
3 Med. Observ. and Inquiries, 8vo., London, 1764, vol. ii. p. 369. 
4 New York Med. and Pliilos. Journ., Jan. 1809, vol. i. p. 161. 
5 Ibid., p. 165. 
B Mem. Med. Soc. of London, 1795, vol. iv. p. 342. Dr. Charles McKnight 
lived in the State of New York. It is impossible to fix the time at which he 
operated. He was not living when Dr. Mease wrote to Dr. Lettsom. 
7 Phila. Journ of Med. and Physical Science, 1825, N. S., vol. i. p. 129. GASTROTOMY. 
225 
likewise a country practitioner. The sixth American opera- 
tion was performed on February 7th, 1846, by Dr. A. H. 
Stevens of Hew York,1 a man who had all the advantages of 
a metropolitan experience. 
Like all the major operations on the abdominal cavity, gas- 
trotomy, for the extraction of an extra-uterine child, has been 
advocated and condemned with equal warmth. Even to-day 
there are some who appear to be undecided in regard to its 
merits, and there are many who deservedly occupy high 
positions in the profession, who are undecided about the 
method of conducting the operation. The operation is con- 
demned by Blundell,2 Burns,3 Meigs,4 Chailly-Honore,5 and 
Hodge.6 Others speak very guardedly about the matter, 
among whom are Levret, Sabatier,7 Columbat,8 Cazeaux,9 and 
Leishman.10 These names all occupy an honorable position in 
the annals of obstetric science, and the very guarded position 
which Meigs, Hodge, Cazeaux, and Leishman occupy, will no 
doubt continue to influence many minds for a long time to 
come. In order to throw some light upon this subject, and to 
determine whether this opposition is groundless or not, it is 
necessary to know the mortality among women who carry an 
extra-uterine child to or beyond term, and who are left to 
nature, as well as the death-rate among those subjected to an 
operation. This we will make an effort to determine. 
In the 500 cases analyzed for this work, 248 women went 
to or beyond term. The following table shows the rate of 
mortality among them, those subjected to an operation being 
included:— 
1 New York Journ. of Med. and Collat. Sci., May, 1846, p. 341. 
1 Lancet, Aug. 16, 1828, pp. 612-13, and Obstetrics, 8vo., London, p. 
480-1. 
s Principles of Midwifery, 8vo., Phila., 1810, p. 166. 
4 Obstetrics, the Science and Art, 8vo., Phila., 1852, p. 271. 
5 Traite Pratique de l’Art de Accouchemens, 8vo., Paris, 1867, p. 136. 
5 Loc. citat. p. 533. 
• De la Medecine Operatoire, 8vo., Paris, 1832, tome iv. p. 481-2. 
8 Diseases of Females, 8vo., Pliila., 1845, p. 582. 9 Loc. citat. p. 602. 
10 A System of Midwifery, Glasgow, 1873, p. 216. 226 
THE TREATMENT 
Mortality of Extra-uterine Pregnancy reaching and gassing beyond 
term—Cases of Operation being included in the calculation. 
Duration of gestation. 
Lived. 
Died. 
Doubtful. 
Total. 
Mortality in 
per cent 
9 months 
13 
45 
1 
59 
76.27 
9 to 12 months 
13 
17 
30 
56.66 
12 to 18 
44 
15 
17 
32 
53.12 
18 to 24 
44 
10 
9 
19 
47.36 
2 to 5 years . 
19 
11 
30 
36.66 
5 to 10 
44 
11 
7 
18 
38.88 
10 to 15 
u 
8 
3 
11 
27.27 
15 to 20 
u 
4 
5 
9 
55.55 
20 to 25 
44 
1 
4 
5 
80.00 
25 to 30 
u 
2 
1 
3 
33.33 
30 to 35 
u 
4 
2 
6 
33.33 
35 to 40 
44 
2 
• . • • 
2 
40 to 45 
u 
2 
• • • • 
2 
50 to 55 
u 
2 
2 
55 to 60 
u 
1 
.... 
1 
60 to 65 
41 
1 
1 
Doubtful . 
14 
4 
18 
22.22 
122 
125 
1 
248 
50.4 
The striking feature of this table is the high mortality at 
the ninth month. Only one out of every four women lives 
whose pregnancy terminates at this time. After this the 
mortality rapidly diminishes, falling 20 per cent, among 
those gestations which terminate within the succeeding three 
months. After this it remains comparatively stationary. 
Of these 248 women, 60 were subjected to operations of 
various sorts, including 43 gastrotomies, 5 sections of the 
vagina, 1 section of the rectum, 3 gastrotomies by caustics, 
2 sections of hernial sacs, 1 uterotomy,1 1 attempt at version, 
2 deliveries by traction in tubo-uterine gestation, and 2 cases 
of gastrotomy and Ctesarean section combined. The following 
table shows the mortality following these various operations 
at different periods at and after the full term of gestation:— 
1 This name is applied, for want of a better, to an attempt which Dr. Cald- 
well (Edinburgh Medical and Surgical Journal, Jan. 1806, p. 22) made to 
extract a foetus by a crucial incision of the posterior wall of the cervix and 
body of the uterus. GASTROTOMY. 
227 
Table shoicing the results of Operative Interference in 60 Cases of 
Extra-uterine Pregnancy. 
Duration of Pregnancy. 
Lived. 
Died. 
Total. 
Mortality in 
per cent. 
9 months 
8 
9 
17 
52.94 
9 to 12 months 
1 
7 
8 
87.50 
12 to 18 “ 
11 
5 
16 
31.25 
18 to 24 “ 
3 
1 
4 
25.00 
2 to 5 years 
5 to 10 
4 
2 
6 
33.33 
1 
1 
10 to 15 “ 
3 
3 
20 to 25 “ 
i 
1 
100.00 
Doubtful 
3 
l 
4 
25.00 
34 
26 
60 
43.33 
In estimating the value of operative interference, three cases 
of death should be deducted from this result. These are two 
gastrotomies performed by Cerise1 and Atlee2 respectively, in 
each of which the proper time for operating was allowed to 
pass, interference being decided upon only when the women 
were actually in articiilo mortis. In the third case, Dr. Cald- 
well cut down upon the tumor by making a crucial incision 
through the posterior wall of the uterus. His patient was 
sixty years of age, and had carried her extra-uterine child for 
more than twenty years, when she had a great deal of pain, 
which led Dr. Caldwell to operate. The foetus was found in- 
crusted with calcareous matter, which was perforated, and an 
ineffectual effort made to drag the child into the world by 
a crotchet. The patient died the next day. This operation 
cannot be characterized as other than highly improper. If 
it be allowable to deduct these cases from the mortality, the 
death-rate would be lowered to 38.33 per cent. 
By deducting these sixty operations from the 248 cases in 
the first table, we obtain a comparative estimate of the mor- 
tality of extra-uterine pregnancy, which has reached or passed 
beyond the normal period of gestation without operative 
interference or other treatment than that based upon general 
indications. This result is shown in the following 
1 Gaz. des Hopitaux, No. 30, 1846. 
1 Phila. Med. Times, Jan. 10, 1874. 228 
THE TREATMENT. 
Table showing the Mortality of Extra-uterine Pregnancy, reaching 
or passing beyond Term, and left to nature. 
Duration. 
Lived. 
Died. 
Doubtful. 
Total. 
Mortality in 
per cent. 
9 months 
5 
36 
1 
42 
85.71 
9 to 12 months 
12 
10 
22 
45.45 
12 to 18 
4 4 
4 
12 
16 
75.00 
18 to 24 
44 
7 
8 
15 
53.33 
2 to o 
years. 
15 
9 
24 
37.50 
o to 10 
4 4 
10 
7 
17 
41.17 
10 to 15 
44 
5 
3 
8 
37.50 
15 to 20 
44 
4 
5 
9 
55.55 
20 to 25 
44 
1 
3 
4 
75.00 
25 to 80 
44 
2 
1 
.... 
3 
33.33 
30 to 35 
44 
4 
2 
6 
33.33 
35 to 40 
44 
1 
1 
40 to 45 
44 
2 
2 
50 to 55 
44 
2 
— 
2 
55 to 60 
44 
2 
2 
60 to 65 
44 
1 
1 
Doubtful 
11 
3 
14 
21.42 
88 
99 
1 
188 
52.65 
This death-rate, 52.65 per cent., may, therefore, be assumed 
to be the ordinary mortality of extra-uterine pregnancy going 
to term or beyond it without operative interference. It will be 
seen by comparison of the three tables that this mortality is 
over 9 per cent, higher than that of those patients who were 
subjected to an operation for the removal of the child, while it 
is only 2 per cent, higher than the death-rate of the whole 248 
cases under consideration. Having a basis for comparison, the 
results of gastrotomy can now be intelligently considered. Mr. 
Jonathan Hutchinson1 and Hr. H. Lloyd Roberts,2 of England, 
have already given considerable attention to this subject, and 
have tabulated all the cases of gastrotomy which they have 
been able to discover. The investigations of Hr. Roberts are 
open to criticism in some particulars. His eighteenth case, 
which was a hernial pregnancy, reported by Genth, and his 26th, 
which was of the same kind, reported by Rektorzik, ought not 
to be included among gastrotomies. The opening of an extra- 
1 Medical Times and Gazette, July, 1860. 
3 Trans. St. Andrew’s Med. Grad. Assoc., 8vo., London, 1868, vol. i. p. 
170. GASTROTOMY. 
229 
abdominal cyst is a much less dangerous proceeding than the 
opening of one which is intra-abdominal. We have also ex- 
cluded Ko. 19 of Dr. Roberts’ list. This case was reported by 
Rousseau,1 and the child was removed by cauterization of the 
abdomen, a method of delivery which will be separately con- 
sidered. Every effort has been made to include in the following 
tabulated statement of the results of gastrotomy, only those 
cases to which this term is properly applied. It is very diffi- 
cult to avoid errors of this kind. Though we believe this to 
be the largest collection which has ever been made, it is doubt- 
less incomplete. We have excluded some cases which have 
been believed by others to be genuine gastrotomies. Among 
these is that of Buhl, included by Keller2 in his list. The 
original account could not be procured, but the examination of 
various abstracts of the case led to the conclusion that it had 
ruptured through the abdominal walls. 
The following is a tabular statement of 62 cases of gas- 
trotomy. 
Table showing the Results or 62 Gastrotomies for the Removal 
of Extra-uterine Children. 
a. Primary Operations, in which are included all Operations per- 
formed during or at the end of Gestation. 
No of case. ] 
Authority. 
© 
< 
g) 
o 
o’ 
Duration 
of preg- 
nancy. 
Adhesions 
of cyst. 
Manage- 
ment of 
placenta. 
Res’lt. 
Remarks. 
<D 
A 
© 
-d 
13 
o 
1 
Paul B. Calvo, 
9 months 
D. 
D. 
Died 11 days after the operation. 
Hist, de l’Acad. 
Roy. des Scien., 
1714, p. 29 
2 
Mr. Clarke, Mem. 
Few days 
Removed 
D. 
D. 
Death due to hemorrhage from 
Med. Soc. Lou., 
beyond 
removal of the placenta. 
1792, p. 176 
term 
3 
Novara, Nouv. 
38 
5 
9 months 
Left 
D. 
L. 
Mother died of a “low fever.” 
Jour. Med.-Chir 
Operation performed Feb. 1814. 
et Phar., 1822, 
tome xv. p. 52 
4 
Ibid., tome x. p. 
21 
9 months 
D. 
D. 
The mother died 18 days after 
500 
and the child 3 days before the 
operation. 
5 
Schreyer, Monats. 
3 
9 months 
No 
Removed; 
L. 
L. 
Recovery was rapid though there 
fur Geburt., xiv. 
separated 
was some inflammatory re- 
p. 283. Keller, 
spontane- 
action on the third day. 
loc. cit. p 70 
ously 
6 
Schwank, Arch. 
9 months 
L. 
L. 
Gen. de Med., 
June, 183S 
1 Bull. General de Therapeutique 
, Mai, 1855. 
* Loc. citat. p. 83. 230 
THE TREATMENT. 
No. of case. 
Authority. 
9 [ 
bfl! 
| No. of preg. 
Duration 
of preg- 
nancy. 
Adhesions 
of cyst. 
Manage- 
ment of 
placenta. 
Res 
<D 
© 
£ 
It. 
*6 
% 
Remarks. 
7 
Wilson, Indian 
Annals of Med., 
Oct. 1855 
23 
6 months 
D. 
D. 
The operation was not com- 
pleted. The placenta was found 
attached to the anterior wall 
in the line of the incision, and 
the hemorrhage was so profuse 
that the operation had to be 
abandoned. 
8 
Cerise, Gaz. des 
Hopitaux, No. 
30, 1846 
3S 
9 
9 months 
Left. 
D. 
D. 
The operation was performed 
when the woman was dying. 
9 
Deocene, Gaz des 
Hop., 1852, p 175 
2 
9 months 
L. 
D. 
Combined intra- and extra-ute- 
rine pregnancy. The intra- 
uterine foetus was removed by 
Caesarean section. The case is 
analogous to that of Dr. Salle, 
No. 15. 
10 
Stutter,Med.Times 
and Gaz , July 
21, 1860, p. 55 
40 
5 
9 months 
Yes 
Left 
L. 
D. 
Placenta loosened, and was re- 
moved en masse on the fifth 
day. 
11 
Eamsbotham and 
Adams, Medical 
Times and Gaz., 
July 21, 1S60, p. 
59; Trans. Med.- 
Chir. Soc. Lond., 
1861, p. 1 
28 
1 
9 months 
No 
Left 
L. 
D. 
Child died at 6 months ? Placenta 
large. Cord came away on 
fourth day. Greater part of 
wound healed by first inten- 
tion. 
12 
Greenhalgh, Med. 
Mirror, Nov. 
1864, p. 689 
Lecluyse, Bui. de 
l’Acad. de M6d., 
Belgique, 1869; 
Brit, and For. 
Med.-Chir. Rev., 
Jan. 1870 
40 
2 
8 months 
and one 
week 
D. 
L. 
Died in 32 hours. The child 
lived but a few minutes. 
13 
28 
2 
7 or 8 
months 
Left 
D. 
D. 
The extra-uterine pregnancy due 
to a fistulous opening in the 
anterior wall of uterus Died 
from peritonitis on tenth day. 
On fifth day after operation the 
placenta was decomposing, and 
a portion of it was cut away. 
14 
W. D. Hooper, 
Trans. Med. Soc. 
of Virginia, 1S72, 
p. 121 
30 
3 
223 days ? 
Yes 
L. 
D. 
The cyst had burst into the 
bowel. 
13 
E. P. Salle, New 
Orleans Med. 
Journ., October, 
1860, p. 727 
22 
9 months 
D. 
L. 
Combined extra- and intra-ute- 
rine pregnancy. It was sup- 
posed to be extra-uterine 
alone. Gastrotomy was per- 
formed, and child was remov- 
ed, after which the gravid 
womb was brought to view. 
The uterine child was removed 
by sectioft of the uterus. Both 
children were saved. The mo- 
ther died in three days, pro- 
bably of septicaemia. 
16 
A. Meadows, 
Trans Obst. Soc. 
London, 1873, p. 
310 
23 
1 
7 months 
None 
Removed 
D. 
L. 
Died of hemorrhage and shock 
from removal of placenta and 
portions of the cyst. Child 
died the next day. 
17 
Plaignaud, Mas- 
lieurat, and Du- 
bois, Journ de 
M6d.Chir.Phar., 
etc., 1811, vol. 
xxii. p. 437 
30 
Short time 
after term 
Decom- 
posing 
D. 
D. 
Had labor at term, during which 
the child died. Died two days 
after the operation. At the 
autopsy the cyst was found to 
be gangrenous. 
18 
Briickert, Rust’s 
Magazine iil. p. 1 
9 months 
No 
D. 
L. 
The cyst had ruptured during in- 
effectual labor, and had given 
rise to peritonitis of which she 
died on the third day. 
19 
Matfield, Neue 
Zeitsch., i. 134, 
1827; Keller, loc. 
cit. p. 70 
9 months 
No 
Left 
D. 
L. 
Died on the 20th day, of hemor- 
rhage and peritonitis. The ope- 
ration was performed on the 
eighth day of labor. 
20 
Doumoulin, Gaz, 
Med. de Straus- 
bourg ; Keller, 
loc. cit. p. 72 
9 months 
D. 
D. 
The patient was in extremis 
when M. Kceberle,_who was 
the operator, was c •jl. The 
child was removed asphyxiat- 
ed, but could not be saved. The 
operation was long and diffi- 
cult, and the mother died a 
short time afterwards. The 
placenta was attached to the 
anterior wall of the abdomen. GASTROTOMY. 
231 
b. Secondary Operations, including all those in which the Child had 
been retained some time after its death. 
© 
1 
to; 
1 
Duration 
Manage- 
Res’lt. 
O 
© 
25 
Authority. 
© 
< 
© 
© 
25 
of preg- 
nancy. 
© 
T3 ° 
< 
ment of 
placenta. 
Mother. 
Child. 
Remarks. 
21 
Primerose, De mu- 
lierum morbis et 
symptomatps, 
Lib. iv. p. 316 
30 
8 
L. 
D. 
This woman was twice the vic- 
tim of extra-uterine pregnancy 
—first in 1591 and again in 
1594. The first cyst discharged 
spontaneously through the ab- 
domen, after which the open- 
ing was enlarged and child re- 
moved. Second foetus removed 
two months later, Oct., 1594. 
22 
Platerus, De par- 
tium corporis hu- 
mani, structura 
et usa, 1597 
2S 
3 
Some time 
beyond 
term 
L. 
D. 
A small swelling the size of an 
acorn had formed near the 
umbilicus, but the cyst had not 
ruptured. 
23 
Jno. Bard, Med. 
Obs. & Inquiries, 
Svo. Lond., 1764, 
vol. ii. p. 369 
2 
More than 
a year 
beyond 
term 
Not found 
L. 
D. 
The abdomen fluctuated when 
the operation was performed. 
24 
Bononensi, Insti- 
tut., 1767; Obs., 
1532, p. 363 
2 
7 weeks 
after d’th 
of child. 
D. 
D. 
The child was supposed to have 
been contained in the left tube. 
25 
Will’m Baynham, 
New York Med. 
and Phil.Journ., 
1809, vol. i. p. 54 
3 
10 years 
after term 
Yes 
L. 
D. 
The patient was a Mrs. Cocke, of 
Virginia, who was operated on 
June 14, 1791. 
26 
March!, Comment, 
de Rebus, 1793, 
tom. xxxv. p. 289 
3 months 
after term 
D. 
D. 
Died thirty-eight days after the 
operation. 
27 
McKnight, Mem. 
Med. Soc. Lond., 
1795, p. 342 
13 months 
beyond 
term 
Yes 
Could not 
be found 
L. 
D. 
This is an American case, which 
was communicated to Dr. Lett- 
som by Dr. Mease, of Philadel- 
phia. 
2S 
Wm. Baynham, 
New York Med. 
and Phil Journ., 
1809, p. 165 
18 months 
child died 
at term 
Left 
L. 
D. 
The operation performed Feb. 6, 
1799. The placenta and cord 
came away in a fortnight. 
29 
F. Hutchinson 
Lond. Med. Gaz., 
Nov. 7, 1835 
28 
1 
14 months 
beyond 
term 
Left 
L. 
D. 
The patient was tapped thirty 
days before the operation. 
30 
Mathieu, Annales 
de la Chirur., 
Sept. 1841 
38 
4 
18 months 
Removed 
L. 
D. 
Operation Aug. 27, 1836. Child 
19 inches long 
31 
Johnson, Med 
Exam. (Phila.), 
Sept. 1850, p. 511 
1 
18 months 
Yes 
Removed 
D. 
D. 
Death due to exhaustion and pe- 
ritonitis. This is probably No.* 
17 of Roberts’ table. 
32 
G. C. Blackman, 
Amer. Jour. Med 
Sci., July, 1845, 
p. 56 
35 
IS months 
D. 
D. 
The operation was not completed 
because on exposing the cyst it 
was found so vascular that it 
was deemed dangerous to in- 
cise it. 
33 
E. Whinnery, 
Ibid.,April, 1846, 
p. 351 
2 
4 years 
beyond 
% term 
No 
L. 
D. 
When the cyst was opened, the 
patient was so faint that the 
operation was discontinued. 
Twelve days later the patient 
pulled the fcetus away herself. 
34 
A.H. Stevens, New 
York Journ. of 
Med. and Collat. 
Sciences, May, 
1846, p. 341 
23 
1 
10 years 
beyond 
term 
L. 
D. 
The cyst had opened into the 
bowel. Operation performed 
February 7th, 1S46. 
35 
Tueffard, Amer. 
Jour. Med. Sci., 
Oct. 1849, p. 522 
40 
6 
12 months 
Yes 
L 
D. 
The child died at end of sixth 
month. The cyst had opened 
into the vagina The head had 
contracted adhesions with the 
intestines (Keller). 
36 
Bradley & Rogers, 
N. Orleans Med. 
Jour., Sept. 1851, 
p. 276 
28 
8 
19 months 
L. 
D. 
Child died at the end of the 7th 
month. The incision extended 
from two inches above the 
umbilicus to the pubis. 232 
THE TREATMENT. 
€> 
fefi 
a, 
Duration 
M 
Manage- 
Res’lt. 
O 
© 
Authority. 
6 
to 
* 
Ps 
O 
© 
of preg- 
nancy. 
Adhesio 
of cys 
ment of 
placenta. 
Mother. 
*d 
2 
o 
Remarks. 
37 
Wishart, Phila. 
Jour, of Med. and 
Phys. Sciences, 
1825, N. S., vol. 
i. p. 129 
28 
11 months 
Removed 
D. 
D. 
Died of peritonitis on the fifth 
day. Operation performed Oct. 
6, 1823. Child weighed 1 lb. 
7 oz., and the placenta 2 lbs. 
5 oz. 
38 
Goodbrake, Bost. 
Med. and Surg. 
Journ., July 5, 
1860, p. 466 
43 
10 
3 years 
and 6 
months. 
D. 
D. 
Died from pyaemia? Incision in 
linea alba from the umbilicus 
to the pubis. 
39 
J. F. da Silva 
Luvia or Lima, 
Brit. Med. Jour., 
May 12, 1860, p. 
360 
18 
18 months 
Yes 
D. 
D. 
Lived nineteen days, and died of 
peritonitis. Child weighed Si 
pounds. 
40 
J. B. Hicks, Guy’s 
Hosp. Rep., 1862, 
p. 128 
32 
2 
Retained 
several 
m’ths be- 
yond term 
None 
Could not 
be found 
D. 
D. 
The cyst had ruptured into the 
rectum. When opened fetid 
gas escaped. Died in twelve 
hours, of exhaustion. 
41 
J. B. Hicks, Ibid,, 
1862, p. 133 
40 
4 years 
beyond 
term 
Yes 
L. 
D. 
Cyst had ruptured into bladder. 
Gas escaped when it was open- 
ed ; urine escaped by the ex- 
ternal wound the 17th day. 
42 
Baeza, New Syd. 
Soc. Bien. Retro- 
spect, 1867, p. 397 
42 
17 months 
L. 
D. 
There is possibly some doubt 
about this having been a case 
of extra-uterine pregnancy. 
The cyst consisted of several 
pouches, and communicated 
with the uterus. Water thrown 
into the cyst to cleanse it es- 
caped by the os uteri. It is 
possible that the child was re- 
tained in utero. 
43 
Phillipart,Gaz des 
Hdp. 1868, Brit 
& For. Medico- 
Chir. Rev. April, 
1866, p. 535 
30 
1 
19 months 
L. 
D. 
The child's head was so closely 
adherent to the cyst that it was 
impossible to remove the whole 
of it. Some bones were re- 
moved, and a few days later 
the remainder of the child was 
extracted with a hook. 
44 
M'Carthy, London 
Hosp. Reports, 
1866, p. 301 
32 
5 
13 months 
Yes 
Left 
D. 
D. 
The operation appears to have 
been performed when the pa- 
tient was in articulo mortis. 
She lived but an hour after it 
was performed. 
45 
J. B. Hicks, Trans 
Obst. Soc. Lond., 
1863, p. 93 
26 
6 months? 
Yes 
L. 
D. 
The cyst communicated with the 
intestine, and had become re- 
sonant on percussion. 
46 
D. L. Roberts, 
Trans. St. An- 
drew’s Med.Grad. 
Ass., 1868, p. 170 
30 
2 
18 months 
Not found 
D. 
D. 
Died from peritonitis and putrid 
absorption. 
47 
Lawson Tait, 
Trans. Medico- 
Chir. Soc. Lond., 
1873, p 219 
29 
13 months 
None 
Left 
L. 
D. 
The cyst was stitched to the ab- 
dominal incision by a continu- 
ous tailor’s stitch, thus closing 
the peritoneal cavity. 
48 
Thomas, Med. and 
Surg. Reporter, 
Oct. 25, 1873, p. 
297 
3 
2 years 
D. 
D. 
Operated on by Dr. Emmet. Died 
in ten days. 
49 
Depaul, Obstet. 
Journ. of Great 
Britain, May, 
1S74, p. 836 
32 
2 or 3 
months 
beyond 
term 
Yes 
Left 
D. 
D. 
Died of hemorrhage on the eighth 
day after the operation. 
50 
W. L. Atlee, Phila. 
Med. Times, Jan. 
10, 1874, p. 235 
28 
2 
12 months 
Left 
D. 
D 
The operation was performed 
when the patient was in arti- 
culo mortis. 
51 
Hildanus, Camp- 
bell’s Memoir,p.6 
45 
12 
25J mos. 
L. 
D. 
The cyst was about to burst. 
52 
W. R. Jordon, 
Trans. Obst. Soc. 
Lond., vol xv. p. 
130 
29 
1 
11 months 
Left 
L. 
D. 
Placenta was immediately in the 
line of the incision. 
63 
Jno. Scott, Ibid., 
vol. xv. p. 140 
32 
1 
12 months 
Left 
D. 
D 
Died in thirty-one hours. GASTROTOMY. 
233 
® 
tc 
© 
Duration 
Manage- 
Res’lt. 
o 
O 
© 
Authority. 
d 
be 
< 
P< 
o 
o 
of preg- 
nancy. 
Adhesio 
of cys 
ment of 
placenta. 
1 Mother. 
2 
3 
o 
Remarks. 
64 
Zais, Revue Medi- 
cals, 1831, tome 
xi., p. 107 
35 
2 
10 months 
Yes 
Left 
L. 
D. 
A flstule persisted for five months 
after the operation. 
55 
Keller, Des Gros- 
sesses extra-ut6- 
rines, 8vo.,Paris, 
1872, p. 6. 
44 
2 
15 months 
Yes 
Left 
L. 
D. 
The peritoneum was opened to 
the extent of 3 or4 millimetres 
at the inferior angle of the 
wound. M. Koeberlb was the 
operator. 
56 
Keller, Ibid., p. 10 
22 
1 
14 months 
Yes 
Left 
L. 
D. 
Placenta was attached in median 
line, and was cut through. The 
peritoneal cavity was opened 
at superior part of the incision. 
The cyst and abdominal walls 
were stitched together. M. 
Kceberlb operated. 
Died from pyjemia. Appears to 
have had peritonitis at term. 
57 
De Bouillon, Bui. 
de la Faculty, 
1821 
20 
11 months 
Yes 
Left 
D. 
D. 
58 
VeyeldeCannstatt, 
Gaz. Med., 1840 
Few w’ks 
after 
term 
Yes 
Removed 
D. 
D. 
Removal of placenta followed by 
excessive hemorrhage, which 
was arrested with great diffi- 
culty. Though adherent, the 
cyst was extracted in pieces. 
59 
B. W. Sawyer, 
Boston Med. and 
Surg. Jour., Nov. 
12, 1874, p. 461 
6 
3 years 
No 
D. 
D. 
The placenta was largely decom- 
posed. Its remnants were re- 
moved. The woman died the 
next day, of exhaustion and 
blood-poisoning. 
c. Nature of Operation doubtful, the duration of the Pregnancy not 
being definitely stated. 
6 
bC 
© 
i- 
Duration 
Manage- 
Res’lt. 
© 
o 
© 
25 
Authority. 
X 
bC 
<5 
© 
o 
25 
of preg- 
nancy. 
Adhesio 
of cys 
ment of 
placenta. 
Mother. 
Child. 
Remarks. 
60 
Schmidt’s Jahr., 
1843 
Partly 
removed 
D. 
D. 
Cause of death uncertain. Quoted 
from Roberts. The 16th case of 
his table. 
61 
Duckert, Med. 
Times, London, 
Nov. 20, 1849, p. 
99 
4 
Removed 
putrid 
L. 
D. 
During pregnancy was gored by 
an ox. Three months later an 
abscess had formed, but had 
not opened when gastrotomy 
was performed. 
62 
Pank, Allg. Wien 
Med. Zeit. and 
Brit, and For. 
Med.-Chir. Bev., 
1862, p. 554 
L. 
D. 
The woman was well in 2 weeks. 
No. 29 of Roberts’ table, from 
which it is quoted. 
Of the 62 cases here tabulated, 30 lived and 32 died, a mor- 
tality of 51.61 per cent. It is doubtful, however, if this can 
be accepted as the true mortality after gastrotomy. The 
question of the propriety of performing the operation in the in- 
terest of the child will not engage attention here. This result 234 
THE TREATMENT. 
is to be compared with that of the third table in this chapter, 
which shows the mortality of extra-uterine 
pregnancy left to nature, or to speak more correctly, allowed 
to progress without operative interference until nature had 
pointed out the way in which she intended to effect elimina- 
tion by forming openings either through the abdominal walls, 
bowels, vagina, or bladder. Of these women, 52.65 per cent, 
perished, a mortality of only one per cent, in favor of gastro- 
tomy. This is certainly a very poor showing for surgical in- 
terference in this unhappy accident, and one which the author 
was as totally unprepared for as any of his readers will be. 
Let us before coming to any conclusions analyze the facts 
which we have collected a little more closely. The table is 
divided into three sections. The first includes all primary 
operations, or those in which the life of the child was con- 
sidered in determining the time for interference, or in which 
the operation was performed shortly after its death at or near 
term. 
In the second category are placed all operations performed 
some time after the death of the child, and when the system of 
the mother had recovered to a great extent from its puerperal 
condition. The results of primary and secondary operations 
have been examined with some care by various authors on 
extra-uterine pregnancy, but the comparative merits of the two 
operations are as yet undetermined. Ryan taught1 that gastro- 
tomy should only be resorted to “ after the seventh month of 
gestation when the viability of the infant is-certain.” Plenck2 
recommends it only when the child is alive. Capuron,3 Marc,4 
Duges,5 Flores Mareno,6 Chambon,7 Gardien,8 Velpeau,9 Desor- 
1 Manual of Midwifery, 8vo., Burlington, 1835, p. 310. 
s Elemens de l’Art des Accouchemens, 8vo., Lyons, 1792, p. 202. 
3 Cours Theorique et Pratique des Accouchemens, 8vo., Paris, 1823, p. 
682. 
4 Diet, des Sci. Med., 8vo., Paris, 1817, tome ix. p. 412. 
5 Diet, de Med. et Cliir. Pratiques, 8vo., Paris, 1833, tome ix. p. 324. 
6 Annal. de Med. Physiologique, 1828, tome xiv. p. 541. 
7 Maladies de la Grossesse, 8vo., Paris, tome ii. p. 72. 
8 Traite Complet d’Accouchemens, 8vo., Paris, 1824, tome i. p. 536. 
9 Diet, de Med., 8vo., Paris, 1836, tome xiv. p. 419. GASTROTOMY. 
meaux,1 and Baudelocque,2 all recommended it after the child 
was viable and in the interests of both mother and child. This 
opinion was expressed with emphasis in the days when abdo- 
minal surgery was in its infancy. The wonderful and glorious 
triumphs of the ovariotomists of this country and Europe had 
not yet proved that the abdominal cavity could be subjected 
to severe mutilation with hope of recovery. The opposition 
with which this operation was met, as well as the authoritative 
experience of many who have been quoted, gives great weight 
to their opinions. The recommendation of the authorities 
just cited has been supported more recently by Armour,3 
who, though condemning gastrotomy in the main, says that if 
the woman was at term he “ would not willingly” allow the 
child to die without making an effort to save it. Protheroe 
Smith4 would operate when the child is viable. Meadows5 
writes: “To me it seems an imperative duty when we know 
that we have not only a living, but,according to all experience, a 
viable child say at the seventh month and upwards, we should do 
our very utmost to rescue that life from its position of danger.” 
He then adds that “resort to gastrotomy is to be . . . the recog- 
nized and orthodox rule in all cases of ... . extra-uterine 
pregnancy when the child is living and has arrived at what 
is termed a viable age.” Behier believes that the operation 
should be performed without hesitation “ when the woman 
is at term, and a living infant extracted.” In a discussion at 
the Obstetrical Society of London in 1864,6 Greenhalgh said, 
that, if he had known that the abdominal tumor of Mr. Cook’s 
patient had contained a living child, he would have performed 
gastrotomy, have saved the child, and given the mother a 
chance of recovery. Hr. J. Braxton Ilicks7 supported this 
opinion, and added that if the infant had been dead he would 
not have operated. Khvisch and Keller likewise recommend 
gastrotomy to save the child. In addition to these we have 
1 Diet, des Sciences Medicates, 8vo., Paris, 1829, tome vii. p. 273. 
* L’Art des Accouchemens, 8vo., Paris. 1796, tome ii. p. 460. 
* Glasgow Med. Journ., 1830, vol. iii. p. 164-5. 
4 Trans. Obstet. Soc. London, 1864, vol. v. p. 319. 
* Ibid., 1873, vol. xiv. p. 315. 
5 Transactions, vol. v. p. 152. 7 Ibid., p. 152. 236 
THE TREATMENT. 
the authority of four experienced ovariotomists in favor of the 
primary operation. These are Mr. I. Baker Brown,1 Mr. Tait,2 
Dr. W. L. Atlee,3 and Koeberld.4 This operation is therefore 
advised by the highest authorities of this century, and certainly 
where two human lives are in such great jeopardy it is no small 
thing to save one, even if it is that of a tender infant whose 
chances of reaching maturity are small. Notwithstanding the 
possibility of realizing this happy result, and even of saving 
both mother and child, as has been done a few times, the 
primary operation cannot be too emphatically condemned. 
It is not too much to say that this procedure adds only 
another danger to a life already trembling in the balance, 
which the delusive hope of saving the uncertain life of a child 
does not warrant us in assuming. This statement is a strong 
one, and it needs to be so when made in opposition to the 
high authorities who have been quoted, many of whom are 
deservedly known wherever the science of medicine is taught. 
In support of the views just stated, let us compare the mor- 
tality which follows extra-uterine pregnancy left to nature 
and that which follows primary gastrotomies. In the 62 cases of 
abdominal section tabulated, 20 were performed at or before 
the end of the ninth month. Of these no less than 14 died, a 
mortality of 70 per cent. In the third table, on page 228, show- 
ing the mortality of 188 cases of extra-uterine gestation left to 
nature, or at least subjected to no serious operation, 99 died, 
a mortality of 52.65 per cent., or 17.35 per cent, less than 
if they had been subjected to gastrotomy with the hope of 
saving the child. In other words, nearly one out of every 
four mothers operated on with the hope of saving her extra- 
uterine infant, dies, not from the terrible accident of which 
she is the victim, but from the knife of the surgeon, who is 
deluded into the idea that art is safer than nature. Surely, 
to warrant us in assuming such a fearful responsibility, it 
must be shown that the chances of saving the child are great 
enough to outweigh the risks to which its mother is to be sub- 
jected. In the 20 primary operations which we are consider- 
1 Surgical Diseases of Women, 8vo., London, 1866, p. 359. 
1 Trans. Medico-Chir. Soc. London, 1873, vol. xvi. p. 222. 
* Pliila. Med. Times, Jan. 10, 1874, p. 235. 4 Keller, loc. citat. GASTROTOMY. 
237 
ing, 8 children lived, and 12 died, a mortality of 40 per cent. 
OnQ of the living children survived but a few minutes. Con- 
sidering the lives of the mother and child as equally valuable, 
we have 40 persons, of whom 25 died, a mortality of 62.50 per 
cent., or 9.85 more than the mortality among the mothers if 
the difficulty had been left to nature. When we remember 
that not one in every five of those infants extracted alive can 
live to reach maturity, the facts here stated become still more 
impressive, and certainly must deter surgeons from increasing 
the dangers of their unhappy patients by subjecting them to 
a severe and bloody operation. 
The fact that a woman carrying an extra-uterine child 
should be allowed to regain her non-puerperal condition, as 
nearly as possible, before being subjected to this important 
operation, has been recognized by a few writers. Turnbull,1 
at the beginning of the last decade of the last century, discussed 
gastrotomy in a manner which shows that our knowledge of 
this subject has advanced but little since his day. He recom- 
mends the postponement of the operation if possible to that 
period when nature makes some effort to expel the foetus by 
the formation of fistulous openings. This is the time of elec- 
tion, but if the patient is sinking, exhausted from the irrita- 
tion, without pointing out the way by which the foetal remains 
are wont to be expelled, he advises the operation. This is 
the period of necessity. Daynac2 emphatically condemns 
the primary operation but recommends secondary gastrotomy, 
when he hopes to find the cyst adherent. Ramsbotham3 recom- 
mends the operation “ when the foetus has been some time 
dead, for experience has taught us that a fatal event, as far as 
the woman is concerned, has almost always, if not invariably, 
followed every operation undertaken with the intention of 
saving the child’s life while it yet lived, or performed soon 
after its death.” Hr. Tanner’s4 opinions upon this subject are 
expressed in no vague terms. He says that “ gastrotomy should 
never be performed with the object of preserving the foetus. 
1 Mem. Med. Soc. London, 1792, pp. 210-9. 
! These a Paris, No. 71, 1825, p. 21. 
3 Medical Times, London, Nov. 13, 1852, p. 482. 
4 Signs and Diseases of Pregnancy, 8vo., Phila., 1868, p. 309. 238 
THE TREATMENT. 
Indeed, if adopted at all, it ought not to be resorted to until 
some time after the child’s death ; when the system of the 
parent, though affected by the irritation set up by the foetus, 
has been restored as nearly as possible to the condition of the 
non-pregnant state.” This is a reiteration in a more forcible 
manner of the views expressed by Campbell1 towards the mid- 
dle of the present century. Mr. Jonathan Hutchinson,2 who 
has carefully investigated this subject, holds the same opinion, 
and he is supported in it by Roberts,3 Leishman,4 Playfair,5 
and lastly Mr. Spencer Wells.6 In the discussion before the 
Obstetrical Society of London, previously alluded to, Mr. Wells 
questioned the morality of Hr. Hicks’s statement that the rule 
of practice should depend upon the child’s being alive or dead. 
With a dead child a woman may live many years, and Mr. 
Wells thought it hardly right to subject her to such a danger- 
ous operation with the slender chance of saving the child. 
This is a protest of great force, coming as it does from the 
most renowned among those who practise abdominal surgery. 
It appears to be conclusive that primary gastrotomy for the 
relief of extra-uterine pregnancy is an unjustifiable opera- 
tion, and that instead of diminishing, it increases the dangers 
of the mother. Operations performed at this period ought not, 
therefore, to be taken into consideration in computing the 
mortality of gastrotomy. 
It now remains to study the results of the secondary opera- 
tion. Thirty-nine examples of this have been tabulated, of 
which 22 were successful and 17 unsuccessful, a mortality of 
43.58 per cent. It will be remembered that the death-rate of 
extra-uterine gestation treated without active interference 
was 52.65 per cent., or 9 per cent, in favor of the operation. 
A portion of this mortality, however, did not belong to the 
operation. McCarthy and Atlee operated upon women in 
1 Memoir on Extra-uterine Gestation, 8vo., Edinburgh, 1842, p. 150. 
* Surgical Measures in Extra-uterine Pregnancy, Holmes’s System of Sur- 
gery, 8vo., London, 1864, vol. iv. p. 514, and Lancet, July 19, 1873, p. 70. 
3 Trans. St. Andrew’s Med. Grad. Assoc., 1868, vol. i. p. 173. 
1 A System of Midwifery, 8vo., Glasgow, 1873, p. 126. 
8 Trans. Obstet. Soc. London, 1866, vol. vii. p. 5. 
6 Ibid., vol. v. p. 152. GASTROTOMY. 
239 
articulo mortis, who were practically dead before surgical 
measures were resorted to, and the latter, some days before 
performing gastrotomy, subjected his patient to paracentesis, 
a very dangerous procedure in any case of extra-uterine 
gestation. Veyel de Cannstatt removed the placenta, and .not 
satisfied with this took away the adherent cyst in pieces, a 
measure which is entirely unjustifiable, and almost certainly 
destroys the patient’s chances for recovery. The three deaths 
mentioned may, therefore, be fairly deducted from the mor- 
tality of the secondary operation; two, because gastrotomy 
was performed too late to do any good, and one because it was 
improperly done. We have, therefore, for consideration 36 
cases with 14 deaths, or a mortality of 38.88 per cent., or 13.77 
per cent, in favor of performing the secondary operation 
rather than to trust to nature. We may, therefore, conclude 
that secondary gastrotomy for extra-uterine pregnancy affords 
the mother increased chances of life. It is not, however, to be 
resorted to indiscriminately. It should be postponed as long 
as possible—until there is some very obvious indication for in- 
terference. The views of Campbell, Tanner, and llamsbotham 
upon the advantages of postponing the operation have already 
been quoted, but of all writers Mr. Jonathan Hutchinson has 
summed up this question in the fewest words. He gives1 the 
following practical rule as regards treatment: “That extra- 
uterine foetation cysts ought not to be meddled with in any 
way, either by puncture or incision, until suppuration has 
occurred and an abscess fistula has been formed.” It is true 
that this reliance on the efforts of nature is not flattering to 
the self-conceit of the surgeon. By following this advice he 
is not deprived of the use of the knife, for when the pus ap- 
proaches the surface it may be liberated by incision, or if the 
cyst has opened spontaneously the fistule is to be enlarged and 
all its contents removed at once. In this, however, the ope- 
rator becomes but nature’s helpmate, following as she leads, 
and the operation which he performs is degraded from the 
important and dangerous procedure, gastrotomy, to the simple 
and not dangerous performance of opening a large abscess. 
1 Lancet, July 19, 1873, p. 70. 240 
THE TREATMENT. 
Mr. Hutchinson’s rule must not be too universally applied. 
Jacquemier has pointed out the fact that sometimes the autopsy 
reveals nothing to account for the death of the woman, there 
being neither rupture, hemorrhage, peritonitis, nor the process 
of elimination going on in the cyst. Death in such cases ap- 
pears to he due to exhaustion of the vital powers. The author 
has seen an illustration of this in which the anterior abdom- 
inal walls stripped smoothly off the cyst, which was intact and 
which did not show the slightest traces of inflammatory action. 
Such women ought not to be allowed to perish without mak- 
ing an attempt to save them. To wait until nature makes 
her sign in an effort to eliminate the foetus, is to subject the 
woman to certain death. The chance of saving such patients 
is infinitely less than if there had been sufficient inflammatory 
action to unite the abdominal and cyst walls, but the lives of 
such ought not to be abandoned in despair. Such cases are 
fortunately uncommon, and if the medical attendant of the 
victim of extra-uterine pregnancy, who has reached or gone 
beyond term, will only be willing to content himself with 
meeting the indications as they arise, relieving the labor-pains 
when they come on at term, and supporting his patient’s 
strength when she has passed this period, without subjecting 
her to prolonged and frequent manipulations or torturing her 
with probes, sounds, and trocars, he will save more human 
lives, and will be called upon less frequently to perform gas- 
trotomy, and more often to open abscesses and to enlarge 
fistulse to extract decomposing children. CHAPTER XII. 
TREATMENT—Continued. 
Gastrotomy—Mode of performing—Influence of adhesions between cyst and abdominal 
walls on the result—Blood and other fluids should not be admitted into the perito- 
neal cavity—Extraction when child is adherent to cyst wall—Management of the 
placenta—Vascularity of the cyst wall—Removal of the cyst wall—Gastrotomy by 
caustics—Treatment after gastrotomy—Gastrotomy to save the child after the death 
of the mother. 
Before resorting to the operation of ga3trotomy for the 
extraction of an extra-uterine child, the condition of the 
woman should be made as favorable as possible. Her bowels 
should be opened one or two days before the operation, after 
which a dose of opium may be administered to allay all excess 
of irritation. In these days no one would think of resorting 
to such a grave surgical procedure without anaesthetizing his 
patient, but every possible precaution should be taken to pre- 
vent subsequent vomiting. 
The incision, unless there are special indications to the con- 
trary, should be made in the median line, and in the manner 
recommended for the performance of ovariotomy. The same 
precautions should be observed to prevent blood finding its 
way into the peritoneal cavity, or into that of the foetal cyst. 
The incision should be long enough to insure facility in ex- 
tracting the child, providing this does not involve cutting 
beyond the adhesions and exposing the peritoneum. Rather 
than incur this danger, the child should be broken up and ex- 
tracted piecemeal. The operator should always be provided 
with strong scissors and forceps for this purpose. If the adhe- 
sions are sufficiently extensive to allow a long incision to be 
made, the child can generally be seized by the feet and readily 
extracted. 
There are several questions which demand careful study in 
connection with this operation. Prominent among these are 
the presence or absence of adhesions between the cyst and 
abdominal walls, and the method of managing the placenta. 242 
THE TREATMENT. 
Adhesions.—The presence or absence of adhesions between 
the sac and the anterior abdominal wall exercises an import- 
ant influence upon the result of the operation of gastrotomy. 
If the cyst wall is connected with the abdominal parietes, the 
success of the operation is much more certain. Of the 62 
cases of gastrotomy tabulated, the presence or absence of ad- 
hesions is mentioned in oidy 24. In 17 of these they were 
present, and in 7 they were absent. Of the former, 11 lived 
and 6 died, a mortality of 85.29 per cent. Of the latter, only 
three recovered and four died, a mortality of 57.14 per cent., 
a difference of 21.85 per cent, in favor of the presence of adhe- 
sions. These figures are small, but, with our present facilities, 
a larger number cannot be presented. While the examination 
of a larger number of cases might materially affect these 
results, common sense teaches us that the union of the cyst 
with the abdominal wall renders the prognosis of the opera- 
tion much more favorable, but reference to the results shows 
that if the operation is imperatively demanded by the condi- 
tion of the patient, the absence of adhesions ought not to pre- 
vent a surgeon from operating. 
The diagnosis of adhesions is uncertain. Hicks says,1 that 
the surgeon can make tolerably sure of securing an adherent 
surface by strict attention to the spot of greatest tenderness 
on pressure. It is highly important during the removal of a 
putrid foetus not to extend the incision beyond the connections 
of the cyst and abdominal walls, and in order to avoid this 
the same authority advises that a small opening be made, the 
finger passed into the cyst in order to feel from within for 
evidences of adhesions. The incision should be enlarged in 
accordance with information thus obtained. So important is 
it not to open the peritoneal cavity, in cases where there is 
a putrid decaying foetus, that there is no doubt that Hicks2 
is correct in saying, that, even if there are large vessels in the 
line of the incision in the abdominal walls, it is better to 
divide them than to expose the peritoneum. 
M. Kceberle has twice opened3 the peritoneal cavity, in both 
1 Trans. Obstet. Soc. London, 1868, p. 100. 2 Ibid., p. 100. 
5 Keller, loc. citat. pp. 8, 12. ADHESIONS. 
243 
cases, by his efforts to extract the infant by the feet. To avoid 
this the child has to be removed with some care. It may be 
extracted by the head if that part should present in the line of 
the incision, hut generally it may be easily removed by seizing 
the feet and withdrawing it, as in the Csesarean operation. 
Precisely the same principles should guide the operator in both 
instances. If the adhesions are limited and the child decom- 
posing, it would be better to extract it piecemeal rather than 
open the peritoneum. If the foetus has undergone little change, 
there may be some difficulty in disintegrating it under the 
circumstances, so that the operator has to act in accordance 
with the peculiarities of the case immediately under his care. 
Some who have been greatly impressed with the wonderful 
and rapid advances of abdominal surgery, since McDowell per- 
formed the first operation for removal of the ovary in 1809, 
may wonder at so much stress being laid upon the importance 
of preserving the integrity of the peritoneum. It is not the 
section of that membrane which is so dangerous, but it is the 
contact with it of the altered liquor amnii and other contents of 
the cyst, rendered putrid by the decomposition of the foetus. 
The surgeon, in performing gastrotomy for the extraction of an 
extra-uterine child, should be just as desirous of preserving the 
peritoneum from contact with these putrid fluids and solids, 
as he is to prevent the escape of the contents of a polycystic 
tumor into the abdominal cavity in operating for ovariotomy. 
If no adhesions are found on cutting through the abdominal 
walls, or if the cyst is torn in removing the child, the wound in 
the latter should be stitched to the abdominal parietes through- 
out its whole length. Mr. Lawson Tait1 did this by a continu- 
ous tailor’s stitch in a woman upon whom he successfully 
operated four months after the close of gestation and in whom 
the cyst was not adherent. M. Koeberld2 resorted to a some- 
what similar measure after accidentally exposing the perito- 
neum in a patient in whom the cyst was adherent. In this way 
the peritoneum may be protected from putrid discharges. 
1 Trans. Medico-Cliir. Soc. London, 1873, vol. lvi. p. 219. 
2 Keller, loc. citat. p. 13. THE TREATMENT. 
Adhesions between the Child and the Sac.—Before pro- 
ceeding further a few additional remarks should be made in 
relation to extraction of the child after the cyst has been 
opened. At this point of the operation a difficulty may arise 
about which most writers on this subject have been silent. If 
an extra-uterine child have been retained for a long time, dif- 
ferent portions of its body may contract more or less intimate 
adhesions with the cyst in which it is contained. Mr. Tait1 
was so impressed with the difficulties and dangers that might 
arise from this accident, that he recommended the primary 
operation. Phillipart2 in performing gastrotomy found the 
child’s head so adherent that it was impossible to extract the 
foetus entire. Several bones were brought away and the patient 
watched. Hectic supervened, and she was in great danger, 
when the remainder of the foetus was extracted with a hook. 
Pletzer,3 Hicks,4 and Tueffard5 have described similar adhesions 
between portions of the child and its cyst, but one of the most 
remarkable recorded examples of this complication came under 
the notice of Hr. F. H. Gordon.6 His patient was in labor at 
the end of the sixth pregnancy succeeding the one which was 
extra-uterine, the tumor resulting from which, prevented the 
descent of the uterine child. Hr. Gordon incised the vagina 
freely and applied the forceps to the extra-uterine infant, but 
could not extract it. He then perforated and made traction in 
various ways without effecting anything. The vaginal incision 
was enlarged until it was four inches long, and the right index 
finger was passed into the rectum and the left into the wrnund, 
when they were applied like the blades of the forceps on either 
side of the encysted child’s neck, and traction made during a 
strong pain. The child was expelled and held in contact with 
the vulva, when the cause of the delay was found to be adhe- 
sions between the child and the sac in which it was contained. 
1 Loc. citat. p. 222 
2 Gazette des Hap., 1865, and Brit, and For. Medico-Cliir. Rev., April, 
1866, p. 535. 
3 Monats. fur Geb., April, 1867, and Brit, and For. Medico-Cliir. Rev., 
October, 1857. 
4 Trans. Obstet. Soc. London, 1862, p. 132. 
5 Amer. Journ. Med. Sci., Oct. 1849, p. 522. 
6 Western Journ. of Med. and Surgery, Oct. 1848. MANAGEMENT OF THE PLACENTA. 
245 
Thcse were three in number, one appeared to be the atrophied 
cord, and the others were fleshy bands, which were surrounded 
with tapes and divided. The tapes were then seized and trac- 
tion made, when they were found to run into a fleshy mass 
five inches wide and an inch and a half thick, attached to the 
posterior wall of the sac above the brim of the pelvis and to the 
right side. The tapes were removed and the wound was closed, 
after which it healed by first intention. After the operation 
the labor-pains ceased, and recurred two days later, when the 
uterine child was born naturally and easily in less than two 
hours. The woman recovered as rapidly as after natural la- 
bor. This remarkable experience of Dr. Gordon shows how 
extensive and strong these adhesions may become, and the 
measures which he adopted inform us of one method of treat- 
ment, while Phillipart’s practice illustrates another. Which is 
the preferable, future experience must determine. It is certain, 
however, that these adhesions must be dealt with carefully, for 
Debenham,1 in attempting to remove some foetal bones which 
were found to be adherent on enlarging an abdominal fistule, 
tore open the intestines so that feces were discharged through 
the incision for several weeks. 
Management of the Placenta.—The propriety of re- 
moving the placenta during the operation of gastrotoiny has 
been warmly discussed. As the same rules should govern the 
operator, whether he is performing gastrotomy, enlarging an 
abdominal opening, or extracting by section of the vagina, 
this subject will be fully discussed in this place and not referred 
to again. 
The dangers which arise from separating the placenta have 
exercised an important influence in preventing the general 
adoption of operative measures for the relief of extra-uterine 
pregnancy. It was the fear of hemorrhage from the removal 
of this large body from a non-contractile surface, which 
made Levret and many of his successors condemn gastrotomy. 
The removal of the placenta certainly appears to be attended 
with very great danger. The part to which it is attached 
necessarily becomes very vascular, and there is no hope of 
Pliilosoph. Trans., 4to., London, 1753, vol. xlvii. p. 92. 246 
THE TREATMENT. 
arresting the hemorrhage by the ordinary mechanical means 
on account of the extent of the surface and its situation, often 
in the deepest parts of the abdominal or pelvic cavities. The 
application of astringents, as the salts of iron, is equally unsatis- 
factory, besides being dangerous, because they leave indurated 
masses of blood and tissues which have to be discharged from 
the deepest parts of the largest serous cavity in the body 
despite the impediments which oppose it. On the other hand, 
if the after-birth is allowed to remain, it has to be removed 
by disintegration, when there is the same difficulty in drainage 
which was spoken of in connection with the discharge of 
coagula formed by the application of astringents. This leads 
to blood poisoning, pyaemia or septicaemia, the most formid- 
able complications of operative surgery. Between the dangers 
of these two distressing alternatives, removing the placenta or 
leaving it in situ, the operator has to choose in attempting 
to relieve a woman of an extra-uterine child. Professional 
opinion is still unsettled as to which plan to adopt. Roberts1 
is disposed to advise the extraction of the after-birth, if this 
can be accomplished without much difficulty, in order that 
one great source of irritation should be removed. Mr. Clarke2 
found the placenta adhering to the kidneys, intestines, and 
neighboring organs. He removed it, and the hemorrhage 
was mortal. The same result occurred to Meadows,3 and 
excessive hemorrhage and death followed in Yeyel de Cann- 
statt’s case.4 Baudelocque, the nephew, operated, on a 
woman seven months gone, by vaginal section, and removed 
the placenta, producing a frightful hemorrhage which he was 
unable to arrest, and from which his unfortunate patient 
perished in a short time.5 The recommendation to remove 
the placenta has very recently been practically indorsed by 
the high authority of Prof. T. G. Thomas. In February 
of this year6 this accomplished operator attempted to remove 
1 Trans. St. Andrew’s Med. Graduates Assoc., 1868, vol. i. p. 173. 
2 Mem. Med. Soc. London, 1792, vol. iii. p. 197. 
3 Trans. Obstet. Soc. London, 1873, p. 310. 
4 Gazette Medicale, 1840, and Keller, loc. citat. p. 86. 
5 Grandval, These a Paris, No. 223, 1832, p. 9. 
6 New York Med. Journ., June, 1874, p. 563. MANAGEMENT OF THE PLACENTA. 
247 
a feet us from a woman three months gone, by vaginal incision. 
Upon attempting to extract the placenta the hemorrhage be- 
came so profuse that he had to stop when the separation was 
a little more than half completed. The injection of the sub- 
sulphate of iron into the cyst arrested the bleeding, and after 
an attack of pyaemia the woman fortunately recovered. 
The placenta was left in situ by Baynham1 in his brillant 
operations in the latter part of the last century. Turnbull2 
wrote upon this subject as follows: “My firm opinion is that 
the separation and expulsion of the placenta should always 
be left to nature, for the extraction will generally be fatal from 
the hemorrhage following it.” He then adds that he would 
leave the maternal portion of the cord hanging out of the 
wound, and make traction on it at intervals. Nothing has 
been added to this teaching after the lapse of more than three 
quarters of a century. Baudelocque,3 the elder, Gardien,4 and 
in later times Tanner,5 Ilicks,6 Meadows,7 Hutchinson,8 Tait,9 
Barnes,10 and Kceberld11 have practically repeated the same 
recommendation. 
1 New York Med. and Philosoph. Journ., 1809, p. 162. 
* Memoirs Med. Soc. London, 1792, p. 211. This writer entertained very 
singular views in regard to the management of the third stage of labor. In 
a foot-note (Ibid., p. 213) he says that in normal labor “ It is a standard, in- 
variable rule with me” to “use the gentlest efforts in delivering the after- 
birth ; if these do not succeed, to leave its separation to nature.” Dr. 
Turnbull was surgeon to the Eastern Dispensary, and in four years 1500 
women were delivered there. He says : “ I can honestly declare that during 
that period, neither in private nor in public practice have I experienced any 
inconvenience from its retention, although in some instances it has been re- 
tained three, four, or five days before it has entirely been expelled.” 
3 L’Art des Accouchemens, 8vo., Paris, 1796, tome ii. p. 460. 
4 Traite Complet d’Accouchemens, 8vo., Paris, 1824, tome i. p. 537. 
5 Signs and Diseases of Pregnancy, 8vo., Pliila., 1868, p. 311. 
6 Trans. Obstet. Soc. London, vol. v. 
7 Ibid., 1873, vol. xiv. p. 316. It is a curious fact that Dr. Meadows re- 
commends this course, believing that the suggestion was new, and that 
when the child was removed the placenta and cyst would lose their vitality 
and atrophy. 
8 Med. Times and Gaz., 1860, and Holmes’ Syst. of Surgery, vol. iv. p. 514. 
9 Med. Times and Gazette, August 2, 1873, p. 119. 
10 Trans. Obstet. Soc. London, vol. xiv. p. 325. 
11 Keller, loc. citat., pp. 8, 13. This writer repeats the opinions of his 
teacher, p. 68. 248 
THE TREATMENT. 
In the operations performed, in the cases the histories of 
which have been examined to prepare this work, the method 
of managing the placenta is mentioned 52 times. These com- 
prise 23 gastrotomies, 4 dilatations of abdominal listulse, 2 gas- 
trotomies by cauterization, 8 sections of the vagina, 7 deliveries 
by the rectum, either spontaneously or by force, 4 spontaneous 
deliveries in interstitial pregnancy, and 3 sections of hernial 
sacs. In two other cases, one a section of a hernial sac and 
another an incision of the posterior vaginal wall, an attempt 
was made to separate the placenta, but the effort had to 
be abandoned on account of the terrific hemorrhage which 
followed. Of these 52 cases, the placenta was wholly or par- 
tially removed 24 times, and allowed to remain 28 times. Of 
those in whom it was removed, 12 recovered and 12 died, a 
mortality of 50 per cent. Of the 28 women in whom the 
placenta was left in situ, 10 died, or a mortality of 35.71 per 
cent., or 15.29 per cent, in favor of leaving the organ. The 
cause of death after removal of the placenta was peritonitis in 
3 women, an abscess between the diaphragm and liver in 1, 
primary hemorrhage in 3,1 rupture of the cyst2 in 1, while 
another was only operated on when the patient was in articulo 
mortis. Of the women in whom the placenta was allowed to 
remain after operation, 1 died from “ low fever,” 1 was coma- 
tose at the time of the operation, and died so, shortly after- 
ward,3 1 perished from exhaustion, 1 from rupture of the cyst 
four days after spontaneous delivery,4 2 from pyaemia, 3 from 
secondary hemorrhage,5 and the remainder from unknown 
causes. 
1 Baudelocque, Grandval, These a Paris, No. 223, 1832, p. 9. Muller, 
Hernial pregnancy in which the placenta was removed after opening the sac, 
Allgem. Wien. Med. Zeituug, 1862, and Brit, and For. Medico-Cliir. Rev., 
Jan. 1868, p. 273. Meadows, Trans. Obstet. Soc. London, 1873, vol. xiv. p. 
310. 
2 Mr. Lawson Tait, Med. Times and Gaz., Aug. 2, 1873, p. 119. The cyst 
was ruptured during extraction after section of the vagina. 
3 Rektorzik—a hernial pregnancy—New Syd. Soc. Year Book, 1861, p. 334. 
4 Dr. J. Braxton Hicks, Trans. Obstet. Soc. of London, 1868, p. 57. It 
was a case of tubo-uterine pregnancy, and the cyst opened into the uterus. 
5 Two of the cases were reported by Depaul, Obstet. Journ. Great Britain, 
March, 1874, p. 836, and Arch, de Tocologie, 1874. The other was recorded MANAGEMENT OF TIIE PLACENTA. 
249 
The deaths which concern us most are those from peritonitis, 
pyaemia, and hemorrhage. The latter are really the most 
important. Of 24 women operated on for the removal of an 
extra-uterine child, three died outright from hemorrhage 
resulting from the removal of the placenta; while Genth1 and 
Thomas2 had to desist from their efforts to remove the after- 
birth, when the act was partly accomplished, on account of 
the terrific hemorrhage. The frequency wdth which primary 
hemorrhage has occurred in these cases shows that the danger 
is too great to be lightly assumed. Few men are willing to 
take the responsibility of performing an operation in which it 
is known that there is great danger of the patient bleeding to 
death without the surgeon being able to prevent it. 
Among the deaths of those in whom the placenta was al- 
lowed to remain, there are likewise three from hemorrhage; 
occurring in Rupin’s patient on the third day after vaginal 
section, and in two of Depaul’s on the eighth and twelfth days 
after the operation. In one of the latter,3 M. Depaul was unable 
to find the source of the hemorrhage at the autopsy. It would 
seem, therefore, that secondary is nearly as dangerous as 
primary hemorrhage. This view is more apparent than real. 
Secondary hemorrhage rarely occurs as a sequel to any opera- 
tion for the relief of an extra-uterine foetation. Rupin’s is the 
only illustration of it from separation of the placenta among 
the cases examined. Secondary hemorrhage from spontaneous 
expulsion of the placenta occurs only once to every five hemor- 
rhages due to forcible separation of that organ. Putrid infection 
is, therefore, the great danger which results from allowing 
the placenta to remain in situ. If this could be removed with 
the after-birth, the recommendation to separate the latter 
would carry considerable weight. As there is no proof of this, 
the conclusion is irresistibly forced upon us that the placenta 
should be left after the removal of an extra-uterine foetus, and 
the tendency to pysemia and allied disorders combated by in- 
by Rupin, Gaz des Hopitaux, No. 18, 1860, and Brit, and For. Medico-Chir. 
Rev., Jan. 1861, p 268. 
1 Brit, and For. Medico-Chir. Rev., Jan. 1857, p. 278. 
2 New York Med. Journ., June, 1875. 
3 Arch, de Tocologie, 1874. 250 
T HE T REATME NT. 
jections into the cavity of the cyst, and the other means now 
in vogue among ovariotomists. The danger of hemorrhage 
from removal of the placenta is so great that the practice of 
the younger Baudelocque, Meadows, and Thomas is utterly un- 
justifiable. Besides hemorrhage, rupture of the cyst is another 
danger which may follow attempts to remove the placenta after 
section of the vagina. 
The placenta may separate at any time between the operation 
and the eighth or tenth day following it. The cord should be 
left hanging from the wound, and traction may be made upon 
it occasionally, to see whether separation has occurred, and to 
hasten it if it has not. 
The location of the placenta should be determined, if possible, 
before commencing the operation of gastrotomy. It has been 
found attached to the anterior abdominal wall, directly in the 
line of the incision, by Wilson,1 Ross Jordon,2 and Koeberle.3 
Baldwin4 also found the placenta attached to the anterior 
abdominal wall when making the autopsy of his patient, and 
it was wounded in the very first incision, which was made two 
inches above the umbilicus. Wilson was forced to abandon 
the operation on account of the severe hemorrhage which fol- 
lowed the incision of the attachments of the placenta. Jordon 
and KceberR both allowed the organ to remain, and the latter 
cut through it. Their patients recovered. 
A somewhat similar accident happened to Blackman.5 lie 
was forced to abandon the operation after opening the abdomi- 
nal walls on account of the great vascularity of the cyst wall. 
Turnbull accurately describes the appearances observed at the 
post-mortem examination of a woman who died five months 
after the completion of gestation. The engraving which ac- 
companies the text shows the vascular anterior wall of the 
cyst; and it is not difficult to imagine, that, had gastrotomy 
been resorted to in this instance, it would have been followed 
by severe hemorrhage. There appears to be no reason why 
these vessels could not be tied whether the cyst is adherent or 
free. Vascularity of the cyst walls would not appear to be a 
1 Indian Annals of Med., Oct. 1855. 
2 Trans. Obstet. Soc. London, vol. xv. p. 130. * Keller, loc. citat. 
* Southern Med. and Surg. Journ., 1839. 5 Loc. citat. p. 56. GASTROTOMY BY THE USE OF CAUSTICS. 
251 
complication as dangerous as the attachment of the placenta 
in the line of the incision. 
At the same time that the position of the placenta is being 
ascertained, that of the bladder should not be forgotten. A 
catheter must be introduced, and the urine withdrawn before 
the operation is begun. This is not enough, however. The 
position of the bladder should be determined with certainty. 
Vedder,1 at the post-mortem of a patient who died at full term, 
found this organ adherent to the abdominal wall. It reached 
midway between the pubis and umbilicus, and, had gastrotomy 
been performed, it would have been opened by the incision. 
Removal of the Cyst Wall.—Removal of the cyst wall 
in whole or in part has been recommended by Mr. Spencer 
Wells, and practised by Meadows and Yeyel de Cannstatt. 
Upon both occasions death followed, with reason to believe that 
the shock produced by the removal of the cyst may have had 
something to do with the fatal result. What advantage is to 
b'e derived from such a course is not stated, and we do not hesi- 
tate to advise allowing the cyst to remain, whether it is free 
or adherent. If the former, it has already been stated that it 
should be stitched to the abdominal wall, in order to shut 
off the peritoneal cavity. 
Gastrotomy by the use of Caustics.—Behier states2 that 
Rousseau and Beauvoisin have proposed to remove extra- 
uterine children by means of caustics applied to the abdo- 
minal wall in imitation of Recamier’s plan of evacuating 
hydatid cysts of the liver. This operation has been performed 
a number of times in France, and was attempted by Playfair3 
in England, but it does not appear to have met with much 
favor outside of the country in which it was proposed. The 
recommendation antedates the time of Rousseau, for Evesque, 
whose thesis was published in 1806, advises4 the evacuation of 
1 Amer. Med. Times, June 15, 1861, p 884. 
8 Gazette Hebdom., No. 86, 1878. 
! Trans. Obstet. Soc. London, 1866, vol. vii. p. 1. 
4 Daynac, These a Paris, No. 71, 1825. 252 
THE TREATMENT. 
the cyst by forming an issue on the tumor. In 1822 Bonnie1 
advised the application of irritants to the abdominal wall to 
produce an abscess, after which the foetus was to be extracted 
piecemeal. In 1852 Rousseau2 carried this recommendation 
into effect, and successfully delivered a child which had been 
retained some time beyond the usual period of gestation. 
Since that time the operation has been repeated by Monod,3 
Martin,4 Boinet,5 Depaul,6 and Duboue of Pau.7 This measure 
is proposed to avoid opening the peritoneal cavity, and hence 
it has been selected when adhesions were supposed to be absent. 
Vienna or Canquoin’s paste has been employed. Boinet in- 
cised the skin before making the application, while others 
applied it directly on the surface. It has to be put on repeat- 
edly, the dead tissue or eschar being removed before each 
fresh cauterization. Boinet and Duboud each made two 
applications of the caustic at intervals of two days. Martin 
made five in fifteen days, while in Rousseau’s case the treat- 
ment had to be continued for a whole month. After two or 
• 
more cauterizations, the cyst is to be opened with a knife, and 
the child extracted entire or in pieces. The caustic has 
generally been applied in the median line, but Rousseau, feel- 
ing the head of the child in the left iliac fossa, opened the 
cyst at that point. Two of the six women on whom the 
operation has been completed, died, one from hemorrhage, and 
the other from pyaemia. 
The merits of this method of removing an extra-uterine 
child remain to be tested. It has not yet been resorted to 
sufficiently often to warrant any conclusions in regard to 
its usefulness. It is certainly a great advantage to secure 
adhesions between the cyst and abdominal walls before open- 
ing the former. To secure this by cauterization of the abdo- 
men the patient has to be subjected to more or less prolonged 
1 These a Paris, No. 181, 1822, p. 31. 
2 Bull. Generale de Therapeutique. Mai, 1855. 
3 L’Union Medicale, 1855. 
4 Revue Medicale, 1856, tome ii. p. 673. 
5 Archives de Tocologie, Paris, 1874. 
6 Ibid., p. 11, and L’Union Medicale, No. 19, 1869. 
7 Archives de Tocologie, 1874, tome i. p. 577. TREATMENT AFTER GASTROTOMY. 
253 
suffering, and the danger of blood poisoning from the absorp- 
tion of putrid materials from the sloughing surface. It does 
not appear to be too much to say, that for these reasons gastro- 
tomy by caustics should be limited to those cases in which 
adhesions are supposed to be absent. It remains, therefore, to 
compare the results of this procedure with those of stitching 
the cyst to the abdominal wall, as practised by Mr. Tait. 
Treatment after Gastrotomy whether by Knife or 
Caustics.—The patient who has undergone gastrotomy, either 
by immediate incision or by means of caustics, is subjected 
to many of the dangers which may follow ovariotomy. She 
may perish from shock or collapse in the first instance, or later, 
from peritonitis—acute or subacute—and septicsemia. These 
are marked by their usual symptoms, and are in no wise pe- 
culiar to this.operation. The patient is much in the position 
of one who has just been subjected to an operation for the 
removal of the ovary. The abdominal opening is a large one, 
and from the angle of the wound the umbilical cord projects, 
taking the place of the pedicle in those ovariotomies in which 
the clamp is used. The patient should therefore be treated 
much as one who has been subjected to that operation. It is to 
be remembered, however, that, unlike ovariotomy, gastrotomy, 
for extra-uterine gestation, involves the separation and removal 
of a large decomposing mass from the abdominal cavity with- 
in a few days after its performance. This necessarily implies 
more or less accumulation of putrid matter in the cavity of the 
cyst, the collection of which does not cease with the removal 
of the cause, but the detritus continues to be discharged from 
the surface to which the placenta was attached for some time 
after its separation, just as the lochia are thrown off' after labor 
in a normal gestation. Hence a patient who has been operated 
on for the removal of an extra-uterine child is subjected to 
peculiarly unfavorable influences, as regards blood poisoning, 
and, as after ovariotomy, these cannot be overcome by position. 
The patient should, therefore, be most carefully watched in 
order to prevent the occurrence of the formidable results of 
purulent or putrid absorption. 
The prevention of these, we believe future experience will 254 
THE TREATMENT. 
teach, is to be accomplished by the same means that have been 
recently adopted to prevent and relieve them after ovariotomy. 
In 1855, Dr. Peaslee1 recommended the use of intra-peritoneal 
injections for this purpose. Ilis plan can be employed to make 
intra-cystic injections after gastrotomy for the cure of an ex- 
tra-uterine fcetation, and we have reason to hope with the same 
good results. If the fluids accumulate in the lower part of the 
cyst, they can be pumped out by a syringe. Whether Sims’s2 
plan of drainage through the posterior cul-de-sac of the vagina, 
by means of puncture and the insertion of tubes, can be advan- 
tageously utilized in the after-treatment of these cases, is a 
question for future experience to decide. The prevention of 
this complication is the most important matter which will 
occupy attention after this operation. 
The vomiting, tympany, and other symptoms are to be re- 
lieved in the usual manner. For information upon this subject 
the reader may consult special treatises on ovariotomy, those 
of Atlee, Peaslee, and Wells. 
Gastrotomy after Death of the Mother.—Grastrotomy has 
been performed a few times, after the death of the mother, in 
the interest of the child. Hofmeister,3 Casaboti,4 and Shultze, 
resorted to it and removed dead children. In the case reported 
by Casabon the infant was baptized under condition. Braun,5 
and Bandl,6 have each extracted a child, immediately after 
the death of its mother, who breathed a few times, but neither 
lived. Though success has not thus far crowned these efforts, 
gastrotomy should always be resorted to in the interest of a 
viable and living child, on the sudden death of the mother. 
It should of course be performed with all the precautions that 
1 American Journ. of Obstet., Aug. 1870, and Ovarian Tumors, their 
Diagnosis and Treatment, 8vo., New York, 1872, p. 509. 
2 On Ovariotomy, 8vo , New York, 1873, reprinted from the New York 
Med. Journ., Dec. 1872, and April, 1873. 
3 Loc. citat. 
4 Monthly Journ. of Med. Sciences, Edinburgh, Feb. 1847, p. 633. 
6 Dr. Trush, Letter to the Clinic, March 2, 1872, p. 105. 
6 Wiener Med. Woclien., Aug. 8, 1874, and London Medical Record, 
Sept. 12, 1874. GASTROTOMY AFTER DEATH OF MOTHER. 
255 
are usually observed when the woman is alive. This course 
will continue to be necessary until we are furnished with a 
certain sign of death. The post-mortem examination of the 
woman should not be proceeded with immediately after the 
removal of the child, as has been done in several instances. CHAPTER XIII. 
TREATMENT—Continued. 
Delivery by vagina—By incision of the rectum—When the cyst has opened through the 
abdominal wall—Through the vagina—Lithotomy to remove bones from the bladder 
—Removal of bones when the cyst is discharging by the bowel—Treatment of tubo- 
uterine pregnancy—Of combined intra- and extra-uterine pregnancy—Of labor with 
a retained extra-uterine child—Of hernial pregnancy. 
Another measure which has been proposed for the removal 
of an extra-uterine foetus, is incision of the vagina through 
Douglas’s pouch. Dr. Charles Kelly1 proposed this in 1756, 
and believed that the child might be easily extracted, when 
the head was engaged in the cavity of the pelvis and pushed 
down the posterior vaginal cul-de-sac. Attention has already 
been directed to the fact that in some instances the foetal parts 
can easily be detected through the vagina, and that the tissues 
which separate the linger of the accoucheur and the foetus, 
are exceedingly thin. When such a condition presents itself, 
it would seem to be a very simple matter to open the cyst 
with a bistoury, and to extract the foetus by traction. This 
procedure would appear to have a very manifest advantage 
over gastrotomy, since it insures drainage while it does not 
compromise the peritoneum Marc2 believes the operation to 
be preferable to gastrotomy when the head presents low 
down, and its different parts can be distinguished by vaginal 
examination. Bonnie3 says that a child can be delivered in 
this manner. Dewees4 preferred it to gastrotomy, and recom- 
mended the primary operation in the interests of the child. 
Velpeau,5 and Cazeaux,6 prefer it to gastrotomy, the former 
1 Med. Observations and Inquiries, 2d ed., 8vo., London, 1797, p. 44. 
2 Diet, des Sciences Med., 8vo., Paris, 1817, p. 412. 
3 These a Paris, No. 181, 1822, p. 27. 
4 Essays on Various Subjects connected with Midwifery, 8vo., Phila., 1823, 
pp. 335-6. 
5 Dictionnaire de Med., 8vo., Paris, 1836, tome xiv. p. 420. 
6 Loc. citat. p. 602. DELIVERY BY VAGINA. 
257 
when the ovum is developed in the retro-uterine peritoneal 
cul-de-sac, and the latter when the head can be felt in the 
vagina during expulsive efforts in labor at term. Velpeau 
recommends operating before labor comes on, and Cazeaux 
after it has set in. Daynac,1 and Tanner,2 think that the ope- 
ration should not be performed unless some prominent portion 
of the child’s body can be traced through the vaginal wall. 
Voillemier3 prefers it to gastrotomy. Ramsbotham,4 after 
speaking of gastrotomy and its fatality when performed to 
save the child, thus alludes to section of the vagina: “The 
results have been more encouraging indeed when the foetus has 
been cut down upon through the coats of the vagina, its head 
or foot being distinctly felt by an examination through that 
canal.” Campbell5 believes that under the same circumstances, 
division of the vagina is preferable to incising the abdominal 
walls. 
Vaginotomy has, on the other hand, been opposed by Mr. 
Lawson Tait,6 who says, that it “should always give place to 
abdominal section as being more scientific and less risky.” 
Keller7 speaks doubtfully about the matter, but on the whole 
is disposed to decide in favor of gastrotomy. 
We are in possession of but little clinical experience to de- 
cide this vexed question. Campbell says, that “ in nine cases 
in which the vaginal incision was practised, three mothers and 
their infants were preserved ; in two instances the mother 
only recovered ; on one occasion the child was saved, and in 
three cases both mother and child perished,” or, five out of 
nine mothers, and four out of the same number of children. 
Tanner8 says, that in ten operations, six mothers and three 
children were saved. The writer has been able to collect 
lifteen cases. In these, nine of the mothers died and six 
lived, a mortality of 60 per cent. Of the children only two 
were saved. Ten of these operations were primary, and were 
1 These a Paris, No. 71, 1825, p. 22. ! Loc. citat. p. 311. 
* Med. Times and Gazette, Oct. 16, 1841, p. 33. 
4 Med. Times, London, Nov. 13, 1852, p. 482. 5 Loc. citat. p. 151. 
6 Med. Times and Gazette, Aug. 2, 1873, p. 119. 
7 Loc. citat. p. 151. 8 Loc. citat. p. 311. 
17 258 
THE TREATMENT. 
reported by King,1 Kormann,2 Caignou,3 Lauverjat,4 Baude- 
locque,5 De Lisle,6 Horman,7 Rupin,8 Tait,9 and Thomas.10 One 
secondary operation which has been previously alluded to,11 has 
been performed by Gordon12 in order to deliver a uterine child 
in a subsequent pregnancy. The remaining operations were per- 
formed byDubois,13Simpson,14 Agnew,15 and an unknown author 
quoted by Campbell.16 
The operation of Dr. John King is one of the most remark- 
able on record. He was an American, and practised his pro- 
fession at Edisto, South Carolina. He incised the vagina at 
term, and had the happiness to save both mother and child. 
Rupin and Thomas operated before the gestation was complete, 
the former at the end of the sixth and the latter at the end of 
the third month of gestation. It is to be distinctly under- 
stood that cases in which a fistula in the vagina was enlarged 
for the extraction of an extra-uterine foetus are not included 
as examples of vaginal section. In this work the term is re- 
stricted to those operations in which the retro-uterine cul-de- 
sac was intact at the time the incision was made. 
The number of cases of section of the vagina cited will not 
warrant us in drawing any conclusions in regard to the com- 
parative merits of this operation and gastrotomy, which will 
not be subject to modification from future experience. The 
results do not appear at all favorable to vaginal incision. It 
has been already stated that the mortality following this opera- 
tion is 60 per cent. It has been shown also that the death-rate 
1 Medical Repository, New York, 1818, p. 388, and An Analysis of the 
Subject of Extra-uterine Foetation, etc., 8vo., London, 1818. 
2 Quoted by Keller, loc. citat. p. 79, from Arch. Generates de Med, 1829. 
3 Keller, p. 79, from Lancette tome ii. 
4 Sabatier, De la Medecine Operatoire, 8vo., Paris, 1832, tome iv. p. 454. 
5 Grandval, These a Paris, No. 223, 1832, p. 9. 
6 Bull, de la Societe Med. de Emulation, May, 1813. 
7 Trans. Medico-Chir. Soc. London, 1827, vol. xiii. p. 348. 
8 Gaz. des H&pitaux, No. 13, 1860. 
9 Med. Times and Gazette, Aug. 2, 1873. p. 119. 
10 New York Med. Journ., Jan. 1875, p 563. 11 Page 
12 Western Journ. of Med. and Surg., Oct. 1848. 
13 Yoillemier, Med. Times and Gazette, Oct. 16, 1841, p. 33. 
14 Edinburgh Med. Journ., Sept. 1863, p. 270. 
15 Phila. Med. Times, Jan. 23,1875, p. 270. 16 Loc. citat., foot-note, p. 70. DELIVERY BY VAGINA. 
259 
of extra-uterine pregnancy, not actively interfered with, is 52.65 
per cent. Therefore it may be inferred that 7.35 per cent, of 
the women delivered by incising the vagina and who died^ 
would have lived if their medical advisers had been willing- 
© 
to have trusted to nature. This showing is not favorable to 
surgical interference. Section of the vagina appears, however, 
to be more favorable than primary gastrotomy, the mortality 
after which is 70 per cent. 
The causes of death are the same as in abdominal section, 
with the addition of rupture of the cyst. This accident hap- 
pened to Mr. Tait. After the removal of the placenta some 
intestines protruded into the sac. Prof. Agnew had a similar 
experience in Dr. E. Wilson’s patient, upon whom he operated. 
After the death of the patient the cyst was found to commu- 
nicate with the peritoneal cavity, into which the injections 
used to wash out the sac were supposed to have escaped during 
the life of the patient. 
If this operation is resorted to, it should be confined to cases 
in which some portion of the child, and especially the head, 
presents in the pelvis. The vagina should be incised over the 
most prominent part, and the child extracted as in ordinary 
deliveries. Hermann used a crotchet. King withdrew it by the 
forceps aided by abdominal pressure, and Horman perforated, 
after which he withdrew the child by the forceps and blunt 
hook. The placenta should be left in situ. This is more 
necessary after vaginal section than after gastrotomy, since the 
removal of the after-birth endangers the integrity of the cyst 
walls. The wound should be left open to give egress to the 
discharges and to the placenta when it separates. Delivery by 
vaginal incision, if resorted to at all, should be confined to cases 
in which adhesions are supposed to be absent, and in which 
either the cephalic or pelvic extremities of the child can be felt 
through the canal. If the child occupies a transverse position 
in the abdomen, and has to be delivered by version, gastrotomy 
should always be performed in preference to section of the 
vagina, in order to prevent rupture of the cyst wall. There is 
no inducement, however, to repeat this operation. Experience 
thus far indicates, that, notwithstanding the brilliant success 
which has happily followed it in a few instances, the chances 260 
THE TREATMEMT. 
of the woman recovering are not so great after vaginal incision 
as they are after gastrotomy. 
Delivery by incising the Rectum.—Extra-uterine chil- 
dren have been spontaneously expelled by the rectum,1 but this 
is a rare occurrence. Bonnie2 quotes a case from the Bulletin 
de la Faculte de Paris, 1813-1814, in which this organ was 
incised to effect the delivery of a child. The woman, who was 
28 years of age, appears to have been near term, and the 
vagina was closed by compression. The head of the child 
was felt pressing upon the rectum, which was incised, after 
which the child’s head was broken up and the bones removed. 
The trunk was extracted entire, the anus dilating sufficiently 
to allow it to pass. The process occupied more than five 
hours. The placenta was delivered in the same way, and the 
woman recovered. There is nothing to lead to the repetition of 
this operation. It has not yet met, nor is it likely to ever meet 
with favor. It has no advantage over section of the vagina, 
while delivery by this narrow channel, which was never meant 
to give passage to the foetus, is much more difficult than by 
the vagina, the capacity of which is adapted to its functions. 
Hothing is said in this place about the enlargement of an open- 
ing by which an extra-uterine cyst has communicated with 
the bowel. This will claim attention in discussing the manage- 
ment of extra-uterine pregnancy without active interference. 
Treatment after the Death of the Foetus at Term.— 
After the termination of spurious labor the patient should be 
sedulously watched, but the province of the physician is to 
relieve symptoms rather than to interfere actively. The results 
of surgical intervention have proved that the expectant treat- 
ment is the most successful. This does not imply, however, 
that the medical attendant has nothing to do. Pain is to be 
relieved by narcotics, and the patient’s strength sustained by a 
generous diet and tonics. Inflammatory complications about 
the abdomen are to be relieved by the usual means, with the 
recollection that within certain limits these are conservative in 
1 Giffard, Cases in Midwifery, 8vo., London, 1734 ; Yardley and Sansbury, 
North Amer. Med. and Surg. Journ., 18.6, vol. i. p. 292. 
1 These a Paris, No. 181, 1822, p. 33. TREATMENT AFTER DEATH OF FCETUS AT TERM. 
231 
their operation, since they attach the foetal sac to the adjoining 
organs or to the abdominal wall, and thus prepare the way 
for the elimination of the foetus and the fluid surrounding it. 
If septicaemia, peritonitis, or exhaustion endangering life, or 
rupture of the cyst should supervene, gastrotomy is indicated. 
Otherwise nature should not be interfered with until she in- 
dicates the channel by which elimination is to be effected, and 
then the surgeon should accept the position of her helpmate. 
If the sac opens through the abdominal wall, the orifice should 
be enlarged and the foetus or its debris extracted. This is an 
operation which is not fatal, yet it has never been generally 
adopted. It does not seem to have met with the same favor as 
gastrotomy. Among the 500 cases analyzed, it has only been 
performed thirty-two times. The following table shows the 
results of the operation:— 
Table showing the Results of Enlarging the Opening after the Cyst 
had opened through the Abdominal Wall. 
Duration 
of pregnancy. 
Result. 
1 
Lived Died. 
Total. 
Cause of death. 
9 months' 
i 
1 
9 to 12 “ 
3 
3 
12 to 18 “ 
6 
i 
7 
“Abscess” between liver and 
18 to 24 “ 
3 
3 
[diaphragm.2 
2 to 5 years 
8 
8 
5 to 10 “ 
4 
1 
5 
Starvation from rupture of stomach du- 
10 to 15 
1 
1 
[ring the operation.3 
15 to 20 “ 
i 
1 
Suppuration of cyst after labor, and 
30 to 35 “ 
i 
. . 
1 
[phthisis.4 
Doubtful 
■ 2 
2 
29 
3 
32 
The death-rate after this operation was therefore 9.37 per 
cent., yet this mortality was by no means due to the surgical 
measure under consideration, but, on the contrary, represents 
the mortality which will occur in spite of it. The procedure 
is unattended with danger, and saves life by removing a source 
1 In these cases the child died some time before the end of gestation. 
1 Ramsay, loc. citat. p. 221. 3 Darby, loc. citat. p. 97. 
4 Hale, Boston Med. and Surg. Journ., 1857, vol. lv. p. 413. 262 
THE TREATMENT. 
of putrid infection, and greatly shortens the duration and the 
suffering of the eliminative process. The operation is there- 
fore one of little danger, while great advantage can be derived 
from it. It has been successfully performed by a butcher,1 the 
orifice being extensively enlarged. Flexman2 preferred to 
dilate the orifice with a sponge tent, after which he success- 
full}7 removed the foetal bones. In some instances it is not 
necessary to even enlarge the opening if a portion of the foetus 
can be seized so that traction can be made in accordance with 
mechanical principles. Dr. Gabriel King3 relates the history 
of a woman from whom a footman pulled a foetus, after 
which, on looking through the aperture, he saw the bones of 
another child, the product of a previous conception, inclosed in 
a sac. The late Prof. Dunglison4 removed a foetus entire and 
at term, in this manner. Bronson5 drew one which was decom- 
posing, through an opening one inch and a half wide which 
had formed three days before. 
In the same manner when the cyst opens into the vagina the 
orifice may sometimes be enlarged and the child extracted. 
Churchill6 treated Kennedy’s patient in this manner, and 
removed a three months’ child after eighteen years’ residence 
in the body of its mother. In a recent discussion before the 
Dublin Obstetrical Society, Athill and Churchill7 stated that 
the woman was still living. Drage8 dilated the vaginal opening 
with the forceps and removed the bones, while Colrnan9 sim- 
ply resorted to traction and dragged a mature foetus through 
the orifice in the vagina without any previous enlargement 
either by dilatation or with the knife. 
After rupture into the bladder lithotomy has been per- 
1 Campbell, loc. citat. p. 46, from Pliilosopli. Trans., vol. viii. 
2 D. D. Davis, Principles and Practice of Obstet. Med., 4to., London, 1836, 
vol. ii. p. 947. 
3 Edinburgh Med. Essays and Observations, 1742, p. 441. 
4 Med. Intelligencer, May 15, 1839, and Med. Examiner, Phila., 1839, p. 
761. 
6 Amer. Medical Monthly, 1860, p. 480. 
3 Brit. Med Journ., Jan. 23, 1869, p. 68. 
7 Dublin Journ. of Medical Science, April, 1875. 
8 Trans. Obstet. Soc. London, 1861, vol. ii. p. 254. 
9 Med. and Pliys. Journ., London, 1799, vol. ii. p. 262. TREATMENT AFTER DEATH OF FCETUS AT TERM. 
263 
formed by Josephus,1 Bosseut,2 Thompson,3 and Morlanne.4 
The first of these performed the supra-pubic operation, and it 
ended fatally. Bosseut removed one hundred and forty-six 
bones, together with a stone the size of an olive. Thompson 
opened the bladder through the vagina, the incision involving 
the urethra. The arms, legs, pelvis, and part of the skull were 
drawn from the sac into the bladder and then removed. 
After communication with the rectum had been established 
Johnston5 made an unsuccessful effort to enlarge the opening. 
Dr. William Smith6 did this successfully to remove a parietal 
bone. Goodsir7 and Amussat8 have each removed the most of a 
decomposing foetus through the anus, taking it away in pieces. 
Nicholas Patuna9 removed a portion of the foetus large enough, 
and so little decomposed, that the sex of the child could be 
determined. In 1806 Clark10 recorded the fact that he passed 
his whole hand into the bowel, and putting his finger into the 
child’s mouth made traction and extracted the head per anurn. 
The body and secundines were expelled spontanously some time 
after. The next day the anus had contracted to the natural 
size, but on the third day it, as well as the perineum, began to 
slough. On the ninth day the parts were healing, but the 
fourchette was destroyed. On the 24th of December, 1848, 
Marsden11 passed his hand far up the bowel and extracted a 
child eighteen inches long, well formed, but decomposed about 
the head and left arm. In 1863, Dr. J. Matthews Duncan12 passed 
his hand into the rectum, in imitation of Prof. Simon’s13 method 
of examining that organ, and delivered a child which was 
1 Med. and Phys. Journ., London, 1805, vol. xiv. p. 519. 
2 New England Journ. of Med. and Surgery, 1817, vol. vi. p. 134. 
3 Lancet, Nov. 28, 1863. 4 liecueil Periodique, tome xiii. p. 70. 
4 Edinburgh Med. Journ. 1857, vol. ii. p. 137. 
6 Campbell, loc. citat. p. 51. 
7 Duncan’s Annals of Med., 8vo., 1802, vol. vii. p. 412. 
8 London and Edinburgh Monthly Journ., Dec. 1841, p. 917. 
9 Dissertation on Retroversion of the Womb, by Samuel MeiTiman, 8vo., 
Phila., 1817, p. 44. 
10 Phila. Med. Museum, 1806, vol. ii. p. 292. 
11 Medical Chronicle, May, 1855. 
12 Edinburgh Med. Journ., July, 1863, p. 183. 
13 Amer. Journ. of Obstet., Feb. 1873, p. 568. THE TREATMENT. 
near term and still contained in its cyst, as in breech presenta- 
tions. In two days the sphincter had regained its functions 
so that, though affected with diarrhoea, the patient no longer 
soiled her bed. During the past year Janvrin1 passed his hand 
into the bowel to remove the bones of a decomposed foetus 
from the cyst. Both Duncan and Janvrin followed the sugges- 
tion of Simon, apparently with the idea that the application 
of his method of examination to the delivery of an extra- 
uterine child was a new measure. In it, however, they had 
been preceded by an American, Dr. Clark, nearly three-quarters 
of a century. 
This review of what men have done is useless if it leads to 
no practical results, if we cannot learn from it something of 
what we should do when the foetal cyst opens into the bladder, 
vagina, or rectum. If the process of elimination is taking 
place through the bladder, many of the smaller bones may be 
removed without having to resort to lithotomy. It is Avell 
known that the female urethra is very dilatable, so much so 
that much of the debris can he simply extracted with the 
forceps after this is done. Leishman states2 that some years 
since, Prof. Gf. II. B. M’Leod removed the bones of a foetus 
from the bladder by dilating the urethra. It is possible that 
the long flat ones might be cut with blunt scissors, and ex- 
tracted piecemeal. If not, the choice lies between the opera- 
tions of lithotomy and gastrotomy. If the cyst is not adherent 
the former might be preferred, hut if the sac is found to be 
united to the abdominal wall, gastrotomy will be found less 
dangerous, as the larger incision, which can be made in this 
operation, renders the extraction of the parts of the foetus easy 
without endangering the integrity of any delicate organs. 
After the sac has commenced to discharge its contents 
through the vagina, loose bones and portions of the decom- 
posing soft parts which appear at the orifice, can be seized 
with the forceps and removed. The operation of enlarging 
the orifice is easily performed, and generally safe if rude manip- 
ulations are avoided in removing the foetus. The danger of 
1 Amer. Journ. ofObstet., Nov. 1874, p. 428. 2 Loc. citat. p. 217. TREATMENT AFTER DEATH OF FCETUS AT TERM. 
265 
rupture of the sac, an accident which happened to Tait when 
removing an undecomposed child, should never be forgotten. 
In enlarging an orifice in the roof of the vagina, the operator 
is sure of room enough to extract the child, which can be 
removed piecemeal. 
By the rectum the matter is different. Any bones and pieces 
of the child which can be reached should be removed the 
fingers or forceps. The patient should be etherized and the 
hand passed into the bowel, when, if the communication with 
the cyst is large enough, it may be carried into this and the 
child removed, as was done by Clark, Marsden, and Duncan. 
The last two have proved that this can be done safely. The 
sloughing which followed Clark’s manipulation may have 
been due to the pressure that the parts endured before the 
body was spontaneously expelled. It is not so much the 
degree as the duration of pressure which injures in these 
cases. Immediate extraction is therefore to be preferred, 
after which there is every reason to hope that the functions 
of the sphincter ani will be restored as rapidly as was ob- 
served by Dr. Duncan. This application of Simon’s method 
of diagnosis promises much for the relief of extra-uterine 
pregnancy when the sac has ruptured into the rectum. It 
will frequently enable the medical attendant to remove the 
bones and soft parts of a decomposing foetus, or, in some in- 
stances, even the child entire, thus diminishing suffering and 
removing the dangers of blood poisoning. 
It is important, however, to determine whether this treat- 
ment is adapted to all cases in which the cyst opens into the 
bowel. It is probably not, for in some instances the commu- 
nication is so high up that the difficulties of removing the 
foetus in pieces or entire by the rectum, are so increased as to 
make the operation dangerous. In other cases the opening 
into the bowel is so small as not to allow the child to pass 
unless the orifice has been previously enlarged. It is a 
question whether it is safe to do this. It would appear that 
incising vascular parts in a canal in which concealed hemor- 
rhage is greatly to be dreaded, is a proceeding not to be resorted 
to lightly. Most operators have preferred gastrotomy under 
these circumstances, and we believe justly. The operation is 266 
THE TREATMENT. 
imperatively indicated when the orifice by which the cyst 
communicates with the bowel is of such a character that the 
foetus cannot be extracted through it, and symptoms arise 
which show that the mother’s life is in jeopardy. 
Tubo-uterine Pregnancy.—There are some special ques- 
tions which remain to be discussed in relation to the manage- 
ment of misplaced gestation. What has already been said in 
regard to treatment would not apply to the tubo-uterine 
variety of the accident, providing the diagnosis was made 
during the life of the woman. The delivery of the women 
under the care of Laugier, Feilitz, and Ilicks by the natural 
passages, has suggested the hope that this variety of extra- 
uterine gestation can be relieved when term is reached, with a 
prospect of saving the child. 
It is not too much to hope that under these circumstances 
the womb can be dilated and the child removed by incising 
the septum which divides the true and the vicarious uterine 
cavities. This has already been accomplished by Dr. II. 
Lenox Hodge, of Philadelphia. The history of the case has 
never been put upon record, and through the kindness of Dr. 
Hodge the author is enabled to make it public. It is narrated 
in the language of Dr. Hodge. 
Case of Tubo-uterine Pregnancy. Labor brought on by dilating 
Os Uteri, at about the eighth month. Child delivered jper vias 
naturales and lived about 10 hours. Mother recovered. 
“On June 11, 1867, Dr. Swing, of Cains, near Parkersburg, 
Pennsylvania, brought bis patient, Mrs. S., to the city for 
ray opinion in consultation. Upon examination, I found the 
uterus anteflexed, somewhat congested, and an enlargement at 
its side which was thought to be ovarian. A uterine probe 
was passed into the cavity of the uterus, and the diagnosis of 
the position of the uterus and its size thus verified. On Mon- 
day, Oct. 11, I again saw the patient. Dr. Swing had brought 
her to the city for another consultation on account of marked 
changes in her condition. 
“ She is a married woman, 35 years old, and the mother of TU BO-UTERINE PREGNANCY. 
267 
four children. Her general health is good. Her last child was 
born January, 1866. She nursed the child until May, 1867. 
During lactation, she did not menstruate until January, 1867, 
and then only in January, February, and March. The inter- 
val between the last two was only two weeks. Since then she 
had not menstruated. 
u She now suffers much from pain in the abdomen, and feels 
movements like those of a foetus, only, she says, ‘ more powerful,’ 
and they cause her to feel sick. She has also had great irrita- 
bility of the bladder. There has been ‘ sick stomach’ more or 
less for several months. She noticed in J uly that the abdomen 
was enlarging. The enlargement continued to increase until 
about three weeks ago. The abdominal tumor is now irregu- 
lar in outline, and arises to about one and a half inches above 
the umbilicus. Movements can be felt below and to the right; 
and in the same position a rapid and feeble sound can be heard 
like that of a foetal heart. The abdomen was sensitive to the 
touch. Upon making a vaginal examination the neck of the 
uterus was found softened, and the os dilated so as to admit the 
end of the finger. 
“ On Tuesday, Oct. 15, my father, Prof. Hugh L. Hodge, saw 
her in consultation writh Dr. Swing and myself. In order to 
make the examination as complete as possible, the patient was 
etherized. My father passed his hand into the vagina, and 
his linger into the uterus. He found the cavity of the uterus 
empty, the fundus depressed especially toward the right Fallo- 
pian tube. He distinctly felt the foetus, as it were, in the 
walls of the uterus and only separated by a delicate membrane 
from the cavity. He also felt the foetal movements. In the 
opinion of each of us it was a case of extra-uterine pregnancy 
of the interstitial variety, and it was thought that the foetus 
was one of about 8 months, and still living. It was decided to 
secure rest for two or three days after this examination, and 
then attempt to deliver, under the influence of ether, by dilat- 
ing the os uteri, then to be guided by development of the 
case as it progressed, but if necessary to divide the membrane 
which appeared to separate the foetus from the uterus, and to 
accomplish delivery with as little effort on the part of the 
mother as possible. Ether was given not only to prevent pain 268 
THE TREATMENT. 
but also to lessen as much as possible uterine contraction. It 
was not known how thin the different parts of the sac con- 
taining the child might be, and the danger of rupture into the 
peritoneal cavity was feared. For the same reason, it was not 
thought safe to allow the labor to be postponed any longer, 
and it was hoped that if done now the life of the mother might 
be saved, and possibly also that of the child. 
“ Wednesday, Oct. 16. She took yesterday a grain of opium, 
and has remained in bed. She has suffered but little pain, but 
has discharged some blood from vagina. 
“Thursday, Oct. 17. She met me down stairs, but since 
yesterday has suffered severe pain and is scarcely able to walk. 
She says that she has often had such attacks at home. To- 
morrow was appointed for the operation. 
“ Friday, Oct. 18. Present, Prof. Hugh L. Hodge, Prof. Pen- 
rose, Dr. Latta, Dr. Hutchinson, Dr. Swing, and myself. 
“ The os uteri was dilated by means of Barnes’ dilators. 
They acted efficiently, and as the os dilated labor-pains began. 
Owing probably to uterine contractions induced in part by the 
examination made on Tuesday, and in part by the forcible 
dilatation of the os to-day, the sac containing the foetus had 
greatly descended and approached the os. 
“ Ether was administered by Dr. Hutchinson. Upon auscul- 
tation of the abdomen the foetal heart was still heard, though 
the sounds were feeble. The urine was withdrawn by a ca- 
theter. 
“Then scratching through the structures covering the foetus, 
I extracted the child, presenting the breech, by passing a blunt 
hook over the thigh. It was the right sacral posterior position 
of the breech. The placenta was also easily delivered, and 
with but little hemorrhage. 
“After birth the child soon began to breathe, and its color 
became perfectly good. Its circulation and respiration, how- 
ever, were feeble, and it only lived about ten hours. The devel- 
opment of the child was moderately good for a foetus of eight 
months. 
“ Saturday, Oct. 19. Tenderness over abdomen. Slight 
delirium. Temperature high, but skin moist. Pulse about 
112. INTRA- AND EXTRA-UTERINE PREGNANCY. 
269 
“ Sunday, Oct. 20. Increase of pain in abdomen. Delirium 
continues. Pulse 116. Tongue moist and slightly coated. 
Skin moist. 
“ Monday, Oct. 21. Less abdominal tenderness. Mind more 
natural. Pulse 108. Tenesmus has occurred and causes con- 
siderable distress. 
“ Tuesday, Oct. 22. Diarrhoeal discharges and still some 
tenesmus. 
“Wednesday, Oct. 23. Ho tenesmus. Slept well. Pulse 
99. Skin good. Mind perfectly right. 
“Friday, Oct. 25. Continues to improve. Hopain. Pulse 
84. To-day she was able to pass her urine without the use of 
a catheter. 
“ Friday, Hov. 1. Gains strength. Is able to sit up in bed. 
“After this she steadily improved, and on Saturday, Hov. 9, 
returned home. The treatment during these three wTeeks 
following the birth of the child consisted of diaphoretics, ano- 
dynes, and tonics, including sulphate of quinia, as the symp- 
toms seemed to demand.” 
Treatment of Combined Intra- and Extra-uterine Preg- 
nancy in Labor at Term.—As a rule labor progresses nor- 
mally in these cases until the intra-uterine child is born. 
Loudon,1 Pennefather,2 and Satterthwait,3 report that the 
extra-uterine tumor was not discovered until after the labor. 
Starley,4 Poliak,5 and Gordon,6 state that the labor was normal 
in their cases. Deocene,7 and Salle,8 resorted to gastrotomy 
to remove the extra-uterine children at term, when intra-ute- 
rine pregnancy was discovered and the children removed by 
incising the uterus. But one difficult labor occurred amongst 
the twenty-one cases of combined intra- and extra-uterine preg- 
nancy which the writer has examined. This happened under 
thecareof Mr.Cooke,9of London,and he says that three methods 
of delivery suggested themselves to Dr. Greenhalgh and himself. 
1 Campbell, loc. citat. p. 65. 2 Lancet, June 20, 1863, p. 688, 
* New York Med. Journ., 1872, p. 387. 4 Ibid., March, 1873, p. 299. 
5 St. Louis Med. and Surg. Journ., May 10, 1871. 
6 Western Journ. of Med. and Surg., Oct. 1848. 
7 Gaz. des HOpitaux, 1852, p. 147. 
8 New Orleans Med. Journ., Oct. 1830, p. 727. 
9 Trans. Obstet. Soc. London, 1864, vol. v. p. 146. 270 
THE TREATMENT. 
These were displacement of the tumor and delivery by version, 
craniotomy, and Caesarean section. The tumor so completely 
filled the brim, that its antero-posterior diameter was dimin- 
ished to less than two fingers’ breadth, and hence perforation 
was inadmissible. It was therefore determined to anaesthetize 
the woman, and to attempt to displace the tumor so that the 
child, felt above the brim, could descend. This was accom- 
plished with some difficulty, after which the child was turned 
and safely delivered. This method of delivery may be avail- 
able in some instances, while in others, there being room 
enough for its use, and the extra-uterine tumor being im- 
movable, the perforator may be employed. If the pelvic 
diameters are so much encroached upon by an immovable 
tumor that there is no hope of delivery in any other way, the 
abdomen should be opened and the children removed by 
section of the sac and uterus, as has been done by Salle, with 
the result of saving both children and losing the mother, and 
by Deocene, who saved the mother and lost the children. 
The last question for consideration in connection with this 
subject, is the proper method of treatment to be adopted after 
the safe delivery of the intra-uterine child. Primary gastro- 
tomy has been recommended for the extraction of the extra- 
uterine foetus. This treatment should be emphatically con- 
demned. The risks of this operation during the parturient 
condition have been shown to be so great that, counting the 
child’s life as equal to the mother’s, more human lives will be 
saved by expectancy than by active interference. No matter 
how loud the beatings of the foetal heart may be, the surgeon 
should withhold his hand until all hopes of the mother’s life 
have been dissipated, when his art may intervene to save the 
child if it be still living. 
Treatment of Labor in a Woman carrying an Encysted Child. 
—The same principle that guides the accoucheur in the man- 
agement of labor in combined intra- and extra-uterine preg- 
nancy will serve him here. Elevation of the tumor and extrac- 
tion by version or the forceps, perforation, and the Csesarean 
section are the resorts. The remarkable success of Gordon by 
vaginal section raises the question whether that operation had EXTRA-UTERINE HERNIAL PREGNANCY. 
271 
not better be performed, in preference to the Caesarean section, 
if the pelvic or the cephalic extremity of the child is engaged 
in the pelvis or at the superior strait. 
It is an interesting fact, however, that these labors are 
rarely difficult. They have repeatedly terminated before the 
obstetrician could reach his patient. 
Treatment of Extra-uterine Kernial Pregnancy.— 
Hernial pregnancy is more interesting as a clinical curiosity 
than of importance in its bearings upon the consideration of 
extra-uterine gestation. It is of some moment in connection 
with the operation of gastrotomy, however. Roberts has in- 
cluded Genth’s, and Rektorzik’s cases in his tabular state- 
ment of the results of gastrotomy. This we believe to be open 
to serious criticism. The operations which Gouey, Skirvani, 
Genth, Muller, Rektorzik, and Widerstein performed, there 
is reason to believe were by no means so grave as that of 
abdominal section for the removal of a child developed out- 
side of the uterus, especially if the cyst is not adherent. In 
the operation for the removal of a child contained in a hernial 
sac, the abdominal cavity remains intact, even though the 
cyst has a peritoneal covering. The operator acts with more 
freedom, conscious that the blood and other fluids, liberated 
by his incisions, cannot find their way into the hidden recesses 
of an important cavity, there to decompose and set up perito- 
nitis or to poison the blood by their absorption after decompo- 
sition. These operations have, therefore, been excluded in the 
study of the results of gastrotomy. 
An examination of the few cases of extra-uterine hernial 
pregnancy which have occurred, seems to warrant the conclu- 
sion that gestation should be allowed to go to term, and that 
the child should be removed at that time by section of the sac, 
with the hope of saving both the mother and the infant. In 
this it differs from the other forms of extra-uterine gestation, 
which it has been shown are to be treated solely with regard 
to the welfare of the mother, and without any reference to 
the safety of the child. In all the cases, which we have been 
able to discover, the child has been removed by section of the 
sac, with the result of four recoveries and two deaths. Of 272 
THE TREATMENT. 
these, one, that of Rektorzik, may be fairly excluded, as the 
woman was past recovery at the time of the operation, and 
died comatose a few hours afterwards. The child, however, 
which was at term, was saved, and was healthy at the time the 
case was reported. Muller’s patient died of internal hemor- 
rhage. Skirvani likewise removed a living child, but it died 
in a few hours. These operations were all performed at term. 
Gouey and Genth also removed living, but not viable, chil- 
dren, the former operating when the woman was three, and 
the latter when she was between four and five months gone. 
In the management of the placenta the same rules are to 
guide the operator as in gastrotomy. Gouey, Skirvani, Genth, 
and Muller removed it. The patient of the last died of in- 
ternal hemorrhage, which might possibly have been avoided 
if the after-birth had been left. Genth did not fairly succeed 
in removing the placenta. After having partly separated it, 
he was forced to desist on account of the frightful hemorrhage 
which followed. In Gouey’s case it separated almost sponta- 
neously. In allowing the placenta to remain in extra-abdo- 
minal pregnancy, there is not so much danger as when the 
foetation is at the same time extra-uterine and intra-abdominal, 
because in hernial gestations the foetal sac is much more under 
control, and can be kept clean much more readily. The fluids 
resulting from the decomposition of the after-birth can be 
much more easily washed out, than when they are formed in, 
or gravitate into the deeper portions of the abdominal cavity. INDEX. 
Abdomen, auscultation of, 104 
diminution in size of, after term, 
123 
enlargement of, irregular, 103 
examination of, 103 
Abdominal collapse, 131 
fistula;, enlargement of, 261 
pregnancy, 39, 79, 85 
Hicks’s case, 43 
Lecluyse’s case, 44 
pathological anatomy of, 79 
primary, 40 
secondary, 40 
wall, discharge of foetus through, 
163 
Adhesions between child and sac, 
244 
of cyst, 242 
Adipocere, conversion of foetus into, 
88, 162 
Age, 29 
Aspirator, use of, for diagnosis, 192 
Author’s classification, 49 
BLADDEE, adhesions of, 108 
discharge of foetus through, 163 
displacement of, 87, 108 
examination by, 101 
Bussiere’s case, 53 
CAN CER, abdominal, diagnosis 
from, 191 
of fundus uteri, diagnosis from, 
190 
Causes, abuse of coitus, 28 
age, 29 
chapter on, 17 
emotional disturbances during 
coitus, 24 
hernia of internal genitals, 21 
inaptitude for conception, 18 
injuries after coitus, 26 
malformation of genitals, 21 
mental influences, 23 
number of pregnancy, 29 
operations on uterus, 28 
pelvic inflammation, 17 
spasm of tubes, 28 
tumors of uterus, 22 
twin conceptions, 27 
Causes— 
uterine displacements, 22 
Caustics, gastrotomy by, 251 
Child. See Foetus. 
Chorion, appearances of, 86 
Classification of, author’s, 49 
chapter on, 31 
Dezeimeris’s, 32 
Tait’s, 34 
Thomas on, 34 
Combined intra- and extra-uterine 
pregnancy, 27, 138, 141, 198, 269 
Comparative frequency of species, 50 
Conception, inaptitude for, 18 
uterine, during period of gesta- 
tion, 142 
Corpus luteum, 73 
Cyst. See Sac. 
DEATH, causes of, 169 
Decidua, 67 
development of, around ovum, 68 
in uterus, 68 
Lee on, 68, 69, 72 
discharge of, 71, 72 
during labor, 112 
Delivery, by incision of rectum, 260 
of vagina, 256 
Development of child, 80, 82 
Dezeimeris’s classification of, 32 
Diagnosis, after death of child, 188 
after foetal heart is audible, 181 
before foetal heart is audible, 174 
chapter on, 173 
Depaul on, 182 
errors in, 173 
from cancer of fundus uteri, 190 
fibroid tumors, 189 
normal pregnancy, 184 
ovarian tumors, 189 
pelvic liaematocele, 179 
pelvic inflammation, 178 
pregnancy in rudimentary 
horn, 180 
retroversion of gravid womb, 
186 
rupture of uterus, 187 
of species, 194 
use of aspirator for, 192 
use of trocar for, 191 274 
INDEX. 
Electricity, destruction of 
ovum by, 207 
Emotional causes of, 24 
Fecal fistuie, 125 
Fertilization of ova in perito- 
neal cavity, 45 
Fibroid tumors, diagnosis from, 189 
Foetal heart, intensity of sounds of, 
104 
movements, 102 
pulse felt by vagina, 107 
Foetus, calcareous changes in, 161 
changes in, from retention, 87, 
88, 124, 161, 162 
conversion of, into adipocere, 88, 
124, 162 
lithopaedion, 88, 124, 162 
death of, at term, 120 
development of, 80 
discharge of, through abdominal 
wall, 163 
bladder, 163 
bowel, 163 
vagina, 163 
influence of labor on, 120 
mummification of, 88, 124 
position of, in sac, 80 
prolonged vitality of, 122 
retention of, 160 
sex of, 82 
superficial situation of, 104 
G1ALVANISM, destruction of ovum 
f by, 207 
Gastrotomy, 222, 225 
adhesions of child to sac, influ- 
ence of, 244 
of cyst, influence of, on re- 
sult, 242 
after death of mother, 254 
at or after term, 255 
before rupture, 202 
by caustics, 251 
for rupture of cyst, 212 
management of placenta in, 245 
method of performing, 241 
mortality after, 233, 236, 238 
primary, 234 
removal of cyst wall during, 251 
secondaxy, 238 
table of cases of, 239 
treatment after, 253 
HiEMATOCELE, pelvic, 131 
diagnosis from, 179 
Haydon’s case, 145 
Hernia of genital organs, a cause, 21 
Hernial pregnancy, 134 
. Genth’s case of, 135 
Gouey’s case of, 134 
Hernial pregnancy— 
Muller’s case of, 135 
physical signs of, 138 
prognosis of, 198 
Skirvani’s case of, 135 
symptoms of, 137 
treatment of, 271 
Hicks on the formation of placenta, 61 
Hodge’s case, 266 
Hunter on development of decidua, 70 
Hypogastric pain, 93 
absence of, 96 
cause of, 94, 95 
time of appearance, 94 
traumatic origin of, 94 
INTERSTITIAL pregnancy, 36 
1 Intestinal fistulax, 125 
LABOR at term, 110 
cause of, 114, 115 
delayed, 111 
discharge of decidua during, 112 
duration of, 111 
hemorrhage from vagina after, 
112 
influence of, on foetus, 120 
premature, 111 
repeated, 112 
rupture of sac during, 116 
treatment of, 2|0 
vaginal discharge after, 112 
Lee on the decidua, 68, 69, 72 
Liquor amnii, 80 
absorption of, after term, 123 
Lithopfedion, 88, 162 
Lithotomy to remove foetal bones, 262 
Lungs, fetid exhalations from, 128 
Malformation of genital or- 
gans a cause, 21 
Mammae, changes in, 103 
secretion by, 119 
Mechanical effects of foetal tumor, 109 
Mental causes of, 23 
Metrorrhagia, 96, 103 
causes of, 98 
time of appearance, 97 
Milk, secretion of, at term, 119 
Monsters, rarity of, 82 
Mortality, 164, 165, 169, 226, 227, 228 
after gastrotomy, 223, 236, 238 
causes of, 169 
of different species, 171 
\JARC0TIC injections to destroy 
i\ ovum, 208 
Noeggerath, examination by bladder, 
101 
Number of pregnancy, 29 INDEX. 
275 
OLDHAM on transmigration of 
ovum, 74 
Ovarian pregnancy, 37, 85 
Kammerer’s case of, 39 
Porter’s case of, 39 
side on which developed, 89 
St. Maurice’s case of, 38 
tumors, diagnosis from, 189 
Ovum, characters of, 79 
transmigration of, 73 
PATHOLOGICAL anatomy, chap- 
ters on, 53, 77 
appearances after rupture, 56 
after term, 77 
before rupture, 53 
Pelvic luematocele, 131 
diagnosis from, 179 
inflammation a cause of, 17 
diagnosis from, 178 
Peritoneal cavity, fertilization of ova 
in, 45 
Peritonitis, after rupture of cyst, 132 
at close of gestation, 124 
Perspiration, fetid, 128 
Placenta, 83 
attachments of, 84 
formation of, 61 
Hicks on, 61 
management of, in gastrotomy, 
245 
Placental apoplexy, 84 
bruit, intensity of, 104 
Poppel’s case of tubo-uterine, 66 
Pregnancy, combined intra- and ex- 
tra-uterine, 138 
extra-uterine repeated, 144 
in a hernial sac, 134 
in rudimentary horn, 64, 180 
side of, 88 
while carrying an extra-uterine 
child, 141 
Primary abdominal pregnancy, 40 
Prognosis, chapter on, 196 
of combined intra- and extra- 
uterine, 198 
of hernial, 198 
Puncture of fcetal cyst, 203 
RECTUM, delivery by, 117, 260, 263 
by incision of, 260 
discharge of foetus through, 163 
examination by, 109 
Repeated extra-uterine pregnancy, 
144 
Retention of foetus, 160 
changes from, 160 
in sac, 160 
Retro-uterine fulness, 106 
Retroversion of gravid uterus, diag- 
nosis from. 186 
Rudimentary uterine horn, pregnancy 
in, 64 
Rupture of cyst, 56, 116, 132, 153, 
129, 150, 169, 212 
amount of hemorrhage from, 
56 
character of the rent, 58, 59 
duration of life after, 152 
during labor at term, 116 
gastrotomy for, 212 
mortality from, 169 
period at which occurs, 60, 
151 
peritonitis after, 132 
recovery after, 153 
symptoms of, 129 
treatment of, 211 
of uterus, diagnosis from, 187 
SAC, calcareous changes in, 87, 124, 
161 
cartilaginous changes in, 124,161 
communication oi, with adjoining 
organs, 87, 125, 168 
with bladder, 125, 163 
frequency of, 165 
mortality of, 165 
with bowel, 125, 163 
frequency of, 164 
mortality of, 164 
with stomach, 163 
with vagina, 125, 163 
frequency of, 165 
mortality of, 165 
discharge of, through abdominal 
wall, 163 
frequency of, 165 
mortality of, 165 
inflammation of, 87 
removal after gastrotomy, 251 
Secondary abdominal pregnancy, 40 
Sex of child, 82 
Side of pregnancy, 88 
Skin, offensive discharges from, 128 
Smith on transmigration of ovum, 74 
Species, 49 
comparative frequency of, 50 
determination of, at autopsy, 86 
diagnosis of, 194 
Spiegelberg’s case of tubal, 77 
Stanley’s case, 53 
Stomach, communication of, with sac, 
126 
Super foetation, 142 
Symptoms, after foetal heart is audi- 
ble, 102 
term, 123 
auscultatory, 104 
before foetal heart is audible, 92 
changes in uterus, 105 
chapters on, 91, 123 276 
INDEX. 
Symptoms— 
diminution in abdomen after term, 
123 
displacement of uterus, 106 
enlargement of uterus, 99 
examination of abdomen, 103 
foetal movements, 102 
foetal pulse felt by vagina, 107 
hypogastric pain, 93 
intensity of foetal heart sounds, 
104 
of placental bruit, 104 
intestinal fistula, 125 
metrorrhagia, 96 
mobility of gravid tumor, 104 
of hernial pregnancy, 137 
offensive perspiration, 128 
peri-uterine tumor, 101 
Petit on, 91 
pulsation in vagina, 107 
retro-uterine fulness, 106 
rupture of cyst, 129 
superficial position of child, 104 
vaginal examination, 99, 105 
vesical fistula, 127 
Syncope after rupture of cyst, 130 
from hypogastric pain, 93 
TAIT, classification of, 34 
Terminations, chapter on, 150 
Transmigration of ovum, 73 
Treatment, after death of foetus at 
term, 260 
gastrotomy, 253 
chapters on, 199, 222, 241, 256 
compression of tumor, 209 
delivery by rectum, 263 
by section of vagina, 256 
destruction of ovum, 201, 209 
by bleeding, 201 
by electricity, 209 
by ergot, 201 
by galvanism, 207 
by iodide of potas., 201 
by mercurial frictions, 
201 
by strychnia, 201 
by syphilization, 201 
extirpation of foetal sac, 202 
gastrotomy, 202, 212, 222 
after rupture, 212 
before rupture, 202 
lithotomy, 262 
narcotic injections into cyst, 208 
of combined intra- and extra-ute- 
rine, 269 
of hernial pregnancy, 271 
of rupture of cyst, 211 
of tubo-uterine pregnancy, 266 
palliative, 198 
puncture of foetal sac, 203 
Treatment— 
radical, 200 
section of vagina, 205, 256 
Trocar, use of, for diagnosis, 191 
Tubal pregnancy, 85, 85 
cases which reached term, 171 
side on which developed, 89 
Spiegelberg’s case, 77 
Tube, changes in, 68 
Tubo-uterine pregnancy, 37, 66, 78, 
195, 117, 266 
development of child after 
rupture, 78, 
diagnosis of, 195 
Hicks’s case of, 117 
Hodge’s case of, 266 
Laugier’s case of, 116 
pathological anatomy of, 66 
spontaneous delivery in, 116 
treatment of, 266 
Tumor, detection of, 101 
examination of, by bladder, 101 
the mechanical effects of, 109 
time when can be discovered, 101 
Twin conceptions, 27, 138 
a cause of, 27 
pregnancy, 138 
UMBILICAL cord, 83 
Umbilicus, changes in, 103 
Uterine sound, use of, 109 
Uterus, changes in, 105 
displacement of, 87, 106 
a cause of, 22 
enlargement of, 99 
operations on, a cause, 23 
pathological appearance of, 67, 
87 
rupture of, diagnosis from, 187 
tumors of, a cause, 22 
VAGINA, delivery by incision of, 
256 
detection of foetal pulse through, 
107 
discharge of foetus through, 163 
enlargement of fistulse in, 262 
pulsation in, 107 
rupture of cyst into, 118 
section of, 205, 256 
by galvanic cautery, 205 
Vaginal examination, 99, 205 
indications for, 99 
in second stage of pregnancy, 
105 
superficial position of foetus 
discovered by, 106 
pregnancy, 46 
Varieties of, 49 
Ventral pregnancy, 39, 79, 85 
Vesical fistule, 127 HENRY C. LEAAS 
(late lea & elanchard’s) 
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“Journal” may be made at the risk of the publisher, by forwarding in registered 
letters. Address, 
HENRY C. LEA, 
Nos. 706 and 708 Sansom St., Philadelphia, Pa. 4 
Henry C. Lea’s Publications—(Dictionaries). 
JJUNOLISON [ROBLEY), M.D., 
Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 
MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry, Notices of Climate and of Mineral Waters; Formulae for 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Duhglison, M.D. In one very large and hand- 
some royal octavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. 
(Just Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relations, 
and thus to render the work, an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 
Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation. During the tin years which have elapsed since the last revision, the additions 
to the nomenclature of the medical sciences have been greater than perhaps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 
A book well known to our readers, and of which 
every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
in the advancing science whose terms it defines. For- 
tunately, Dr. Richard J. Dunglison, having assisted his 
father in the revision of several editions of the work, 
and having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
edit it, not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited—to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to stale that more 
than six thousand new subjects have been added in the 
present edition. Without occupying more space with the 
theme, we congratulate the editor on the successful 
completion of his labors, and hope he may reap the well- 
earned reward of profit and honor.—Pliila. Med. Times, 
Jan 3, 1874. 
About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sine qua non. In a 
science so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. It 
was because Dunglison’s met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have the alterations and additions been 
so great. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 
letter, while the derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 
may safely confirm the hope ventured by the editor 
“ that the work, which possesses for him a filial as well 
as an individual interest, will be found worthy a con- 
tinuance of the position so long accorded to it as a 
standard authority.”—Cincinnati Clinic, Jan. 10,1874. 
We are glad to see a new edition of this invaluable 
work, and to find that it has been so thoroughly revised, 
and so greatly improved. The dictionary, in its pre- 
sent form, is a medical library in itself, and one of 
which every physician should be possessed.—IV. T. Med. 
Journal, Feb. 1874. 
With a history of forty years of unexampled success 
and universal indorsement by the medical profession of 
the western continent, it would be presumption in any 
living medical American to essay its review. No re- 
viewer, however able, can add to its fame; no captious 
critic, however caustic, can remove a single stone from 
its firm and enduring foundation. It is destined, as a 
colossal monument, to perpetuate the solid and richly 
deserved fame of Robley Danglison to coming genera- 
tions. The large additions made to the vocabulary, we 
think, will be welcomed by the profession as supplying 
the want of a lexicon fully up with the march of sci- 
ence, which has been increasingly felt for some years 
past. The accentuation of terms is very complete, and, 
as far as we have been able to examine it, very excel- 
lent. We hope it may be the means of securing greater 
uniformity of pronunciation among medical men.—At- 
lanta Med. and Surg. Journ., Feb. 1874. 
It would be mere waste of words in us to express 
our admiration of a work which is so universally 
and deservedly appreciated. The most admirabl* 
work of its kind in the English language.— Glasgow 
Medical Journal, January, 1866. 
A work to which there is no equal in the English 
language.—Edinburgh Medical Journal. 
Few works of the class exhibit a grander monument 
of patient research and of scientific lore. The extent 
of the sale of this lexicon is sufficient to testify to its 
usefulness, and to the great service conferred by Dr. 
Robley Dunglison on the profession, and indeed on 
others, by its issue.—London Lancet, May 13, 1865. 
It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references.—London Medical Gazette. 
JJOBLFN (.RICHARD D.), M.D. 
A DICTIONARY OF THE TERMS USED IN MEDICINE AND 
THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M.D., Editor of the “American Journal of the Medical Sciences.” In one large royal 
12mo. volume of over 500 double-columned pages j cloth, $1 50 ; leather, $2 00. 
It is the best book of definitions we have, and ought always to be upon the student’s table.—Southern 
Med and Surg. Journal. Henry C. Lea’s Publications—{Manuals). 
5 
T?OD WELL {G.F.), F.R.A.S., Sfc. 
A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
many illustrations : cloth, $5. 
fTEILL {JOHN), M.D., and JUMITH {FRANCIS O.), M.D., 
Prof, of the Institutes of Medicinein the Univ. of Penna. 
AN ANALYTICAL COMPENDIUM OF THE VARIOUS 
BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly bound in 
' leather, with raised bands, $4 75. 
The Compendof Drs. Neill and Smith is incompara- 
bly the most valuable work of its class ever published 
In this country. Attempts have been made in various 
quarters to squeeze Anatomy, Physiology, Surgery, 
the Practice of Medicine, Obstetrics, Materia Medica, 
and Chemistry into a single manual; but the opera- 
tion has signally failed in the hands of all up to the 
advent of “ Neill and Smith’s’ ’ volume, which is quite 
a miracle of success. The outlines of the whole are 
admirably drawn and illustrated, and the authors 
are eminently entitled to the grateful consideration 
if the student of every class.—N. 0. Med. and Surg. 
fournal. 
There are but few students or practitioners of me- 
licine unacquainted with the former editions of this 
tnassuming though highly instructive work. The 
vhole science of medicine appears to have been sifted, 
is the gold-hearing sands of El Dorado, and the pre- 
cious facts treasured up in this little volume. A com- 
plete portable library so condensed that the student 
j may make it his constant pocket companion.— West- 
> ern Lancet. 
TTARTSHORNE {HENRY), M. D., 
Professor of Hygiene in the University of Pennsylvania. 
A CONSPECTUS OF THE MEDICAL SCIENCES; containing 
Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25; leather, $5 00. (Lately Issued.) 
The work before ns has already successfully assert- 
ed its claim to the confidence and favor of the profes- 
sion ; it but remains for us to say that in the present 
edition the whole work has been fully overhauled 
and brought up to the present status of the science.— 
Atlanta Med. and Surg. Journal, Sept. 1874. 
The work is intended as an aid to the medical stu- 
dent, and as such appears to admirably fulfil its ob- 
ject by its excellent arrangement, the full compilation 
facts, the perspicuity aud terseness of language, 
and the clear and instructive illustrations in some 
parts of the work—American Journ. of Pharmacy, 
Philadelphia, July, 1874. 
The volume will be found useful, not only to stu- 
dents, but to many others who may desire to refresh 
their memories with the smallest possible expendi- 
ture of time.—N. Y. Med. Journal, Sept. 1874. 
The student will find this the most convenient and 
useful book of the kind on which he can lay his 
I hand.—Pacific Med. and Surg. Journ., Aug. 1874. 
T UDLOW {J. L.), M.D. 
'a MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 
Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 
/TANNER {THOMAS HAWKES), M.D., 8>-c. 
1 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
&c. In one neat volume small 12mo., of about 375 pages, cloth, $150. 
By reference to the “ Prospectus of Journal” on page 3, it will be seen that this work is 
offered as a premium for procuring new subscribers to the “American Journal of the Medical 
Sciences.” 
Taken as a whole, it is the most compact vade me- 
cum for the use of the advanced student and junior 
practitioner with which we are acquainted.—Boston 
Med. and Surg. Journal, Sept. 22, 1870. 
It contains so much that is valuable, presented in 
so attractive a form, that it can hardly be spared 
even in the presence of more full and complete works. 
Its convenient size makes it a valuable companion 
to the country practitioner, and if constantly car- 
ried by him, would often render him good service, 
and relieve many a doubt and perplexity.—Leaven- 
worth Med. Herald, July, 1870. 
The objections commonly, and justly, urged against 
the general run of “compends,” “conspectuses,” and 
other aids to indolence, are not applicable to this little 
volume, which contains in concise phrase just those 
practical details that are of most use in daily diag- 
nosis, but which the young practitioner finds it diffi- 
cult to carry always in his memory without some 
quickly accessible means of reference. Altogether, 
the book is one which we can heartily commend to 
those who have not opportunity for extensive read- 
ing, or who, having read much, still wish an occa- 
sional practio i rei-inder.—N. Y. Med. Gazette, Nov. 
10, 1870. 6 
Henry C. Lea’s Publications—-(Anatomy). 
STRAY {HENRY), F.R.S., 
Lecturer on Anatomy at St. George's Hospital, London. 
ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 
H. V. Carter, M. D., late Demonstrator on Anatomy at St. George’s Hospital; the Dissec- 
tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 909 
pages, with 465 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- 
ther, raised bands, $7 00. {Just Issued.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-hooks, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 
Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
price, rendering it one of the cheapest works now before the profession. 
The illustrations are beautifully executed, and ren- 
der this work an indispensable adjunct to the library 
of the surgeon. This remark applies with great force 
to those surgeons practising at a distance from our 
large cities, as the opportunity of refreshing their 
memory by actual dissection is not always attain- 
able.— Canada Med. Journal, Aug. 1870. 
The work is too well known and appreciated by the 
profession to need any comment. No medical man 
can afford to be without it, if its only merit were to 
serve as a reminder of that which so soon becomes 
forgotten, when not called into frequent use, viz., the 
relations and names of the complex organism of the 
human body. The present edition is much improved. 
—California Med. Gazette, July, 1870. 
Gray’s Anatomy has been so long the standard of 
perfection with every student of anatomy, that we 
need do no more than call attention to the improve- 
ment in the present edition.—Detroit Review of Med. 
mnd Pharm., Aug. 1870. 
"From time to time, as successive editions have ap- 
peared, we have had much pleasure in expressing 
the general judgment of the wonderful excellence of 
Gray’s Anatomy.—Cincinnati Lancet, July, 1870. 
Altogether, it is unquestionably the most complete 
and serviceable text-book in anatomy that has ever 
been presented to the student, and forms a striking 
contrast to the dry and perplexing volumes on the 
same subject through which their predecessors strug- 
gled in days gone by.—R. ¥. Med. Record, June 15, 
1870. 
To commend Gray’s Anatomy to the medical pro- 
fession is almost as much a work of supererogation 
as it would be to give a favorable notice of the Bible 
in the religious press. To say that it is the most 
complete and conveniently arranged text-book of its 
kind, is to repeat what each generation of student* 
has learned as a tradition of the elders, and verified 
by personal experience.—R T. Med. Gazette, Dec. 
17,1870. 
&MITH (HENR Y H.), M.D., and JJORNER ( WILLIAM E.), M.D., 
Prof .of Surgery in the Univ. of Penna., &c. Late Prof, of Anatomy in the Univ. ofPenna., <6 c. 
AN ANATOMICAL ATLAS, illustrative of the Structure of the 
Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 
The plan of this Atlas, which renders it so pecu- I 
Marly convenient for the student, and its superb ar- j 
tistical execution, have been already pointed out. We j 
must congratulate the student upon the completion 
of this Atlas, as it is the most convenient work of I 
the kind that has yet appeared; and we must add, 
the very beautiful manner in which it is “got up ” 
is so creditable to the country as to be flattering to 
our national pride.—American Medical Journal. 
QHARPEY ( WIT LIAM), M.D., and Q UAIN (JONES £ RICHARD). 
HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 
Leidv, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two 
large octavo volumes, of about 1300 pages, with 511 illustrations; cloth, $6 00. 
The very low price of this standard work, and its completeness in all departments of the subject, 
should command for it a place in the library of all anatomical students. 
JJODGES (RICHARD 31.), M.D., 
Late Demonstrator of Anatomy in the Medical Department of Harvard University. 
PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 
one neat royal 12mo. volume, half-bound, $2 00. 
The object of this work is to present to the anatomical student a clear and concise description 
of that which he is expected to observe in an ordinary course of dissections. The author ha* 
endeavored to omit unnecessary details, and to present the subject in the form which many years’ 
experience has shown hfci to be the most convenient and intelligible to the student. In the 
revision of the present edition, he has sedulously labored to render the volume more worthy of 
the favor with which it has heretofore been received. 
HORNER’S SPECIAL ANATOMY AND HISTOLOGY. 
Eighth edition, exten»ively revised and modified. 
In 2 vols. 8vo., of over 1000 pages, with more than 
300 wood-cuts: cloth, $6 00. Henry C. Lea’s Publications—(Anatomy). 
7 
WILSON [ERASMUS), F.R.S. 
A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 
by W. H. Gobekcht, M. D., Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages; cloth, $4 00; leather, 
$5 00. 
The publisher trusts that the well-earned reputation of this long-established favorite will be 
more than maintained by the present edition. Besides a very thorough revision by the author, it 
has been most carefully examined by the editor, and the efforts of both have been directed to in- 
troducing everything which increased experience in its use has suggested as desirable to render it 
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
tomy. The amount of additions which it has thus received may be estimated from the fact that 
the present edition contains over one-fourth more matter than the last, rendering a smaller type 
and an enlarged page requisite to keep the volume within a convenient size. The author has not 
only thus added largely to the work, but he has also made alterations throughout, wherever there 
appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
the number of illustrations, of which there are about one hundred and fifty more in this edition 
than in the last, thus bringing distinctly before the eye of the student everything of interest or 
importance. 
fJEATH (CHRISTOPHER) F. R. C. S., 
Teacher of Operative Surgery in University College, London. 
PRACTICAL ANATOMY: A Manual of Dissections. From the 
Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jelferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 678 pages, with 247 illustrations. Cloth $3 50 ; 
leather, $4 00. (Lately Published.) 
Dr. Keen, the American editor of this work, in his 
preface, says: “In presenting this American edition 
of ‘Heath’s Practical Anatomy,’ 1 feel that 1 have 
been instrumental in supplying a want long felt for 
a real dissector's manual,” and this assertion of its 
editor we deem is fully justified, after an examina- 
tion of its contents, for it is really an excellent work. 
Indeed, we do not hesitate to say, the best of its class 
with which we are acquainted ; resembling Wilson 
in terse and clear description, excelling most of the 
so-called practical anatomical dissectors in the scope 
of the subject and practical selected matter. . . . 
In reading this work, one is forcibly impressed with 
the great pains the author takes to impress the sub- 
ject upon the mind of the student. He is full of rare 
and pleasing little devices to aid memory in main- 
taining its hold upon the slippery slopes of anatomy. 
—St. Louis Med. and Surg. Journal, Mar. 10, 1871. 
It appears to us certain that, as a guide in dissec- 
tion, and as a work containing facts of anatomy in 
brief and easily understood form, this manual is 
complete. This work contains, also, very perfect 
illustrations of parts which can thus be more easily 
inderstood and studied; in this respect it compares 
favorably with works of much greater pretension. 
Such manuals of anatomy are always favorite works 
with medical students. We would earnestly recom- 
mend this one to their attention; it has excellences 
which make it valuable as a guide in dissecting, as 
well as in studying anatomy.—Buffalo Medical and 
Surgical Journal, Jan. 1871. 
JAELLAMY {E.), F.R.O.S. 
THE STUDENT’S GUIDE TO SURGICAL ANATOMY: A Text- 
Book for Students preparing for their Pass Examination. With engravings on wood. In 
ono handsome royal 12mo. volume. Cloth, $2 25. (Just Issued.) 
We welcome Mr. Bellamy’s work, as a contribu- 
tion to the study of regional anatomy, of equal value 
to the student and the surgeon. It is written in a 
clear and concise style, and its practical suggestions 
add largely to the interest attachiug to its technical 
details —Chicago Med. Examiner, March 1, 1874. 
We cordially congratulate Mr. Bellamy upon hav- 
ing produced it.—Med. Times and Gaz. 
We eannot too highly recommend it.— Student's 
Journal. 
Mr. Bellamy has spared no pains to produce a real- 
ly reliable student’s guide to surgical anatomy—one 
which all candidates for surgical degrees may con- 
sult with advantage, and which posseses much ori- 
ginal matter.—Med. Brens and Circular. 
JLfACLISE {JOSEPH). 
SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one 
volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best 
style and beautifully colored, containing 190 figures, many of them the size of life; together 
with copious explanatory letter-press. Strongly and handsomely bound in cloth. Price 
$14 00. 
We know of no work on surgical anatomy which 
•an compete with it.—Lancet. 
The work of Maclise on surgical anatomy is of the 
highest value. In some respects it is the best publi- 
cation of its kind we have seen, and is worthy of a 
place in the library of any medical man, while the 
student could scarcely make a better investment than 
this.—The Western Journal of Medicine and Surgery. 
No such lithographic illustrations of surgical re- 
5ions have hitherto, we think, been given. While 
he operator is shown every vessel and nerve where 
*n operation is contemplated, the exact anatomist is 
refreshed by those clear and distinct dissections, 
which every one must appreciate who has a particle 
of enthusiasm. The English medical press has quite 
exhausted the words of praise, in recommending this 
admirable treatise.—Boston Med. and Surg. Journ. 
fJARTSHORNE [HENRY), M.D., 
J.J. Professor of Hygiene, etc , in the Univ. ofPenna. 
HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- 
tion, revised. In one ro.yal 12mo. volume, with 220 wood-cuts; cloth, $1 75. (Just Issued.' 8 
Henry C. Lea’s Publications—(Physiology). 
MARSHALL {JOHN), F. R. S., 
aU. Professor of Surgery in University College, London, Sec. 
OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIYE. 
With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large 
and handsome octavo volume, of 1026 pages, cloth, $6 50 ; leather, raised bands, $7 50. 
In fact, in every respect, Mr. Marshall has present- 
ed us with a most complete, reliable, and scientific 
work, and we feel that it is worthy our warmest 
commendation.—St. Louis Med. Reporter, Jan. 1869. 
tive, with which we are acquainted. To speak ol 
this work in the terms ordinarily used on such occa- 
sions would not be agreeable to ourselves, and would 
fail to do justice to its author. To write such a book 
requires a varied and wide range of knowledge, con- 
siderable power of analysis, correct judgment, skill 
in arrangement, and conscientious spirit.—London 
Lancet, Feb. 22, 1868. 
We doubt if there is in the English language any 
compend of physiology more useful to the student 
than this work.—St. Louis Med. and Surg. Journal, 
Jan. 1869. 
It quite fulfils, in our opinion, the author’s design 
of making it truly educational in its character—which 
is, perhaps, the highest commendation that can be 
asked.—Am. Journ. Med. Sciences, Jan. 1869. 
There arefew, ifany, more accomplished anatomists 
and physiologists than the distinguished professor of 
surgery at University College ; and he has long en- 
joyed the highest reputation as a teacher of physiol- 
ogy, possessing remarkable powers of clear exposition 
and graphic illustration. We have rarely the plea- 
We may now congratulate him on having com- 
v v d uiaj uvrr vvugi oii/uiciio uiin ou nu » lug vurn- — ~ —, ■ ■ « 
pleted the latest as well as the best summary of mod- sure of being able to recommend a text-book so unre- 
ern physiological science, both human and compara- servedlyasthis.—British Med. Journal, Jan. 25,1868. 
pARP ENTER (WILLIAM B.), M.D., F.R.S., 
Examiner in Physiology and Comparative Anatomy in the University of London. 
PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 
cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new 
American from the last and revised London edition. With nearly three hundred illustrations. 
Edited, with additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of 
Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo 
volume, of about 900 large pages, handsomely printed; cloth, $5 50 ; leather, raised bands, 
$6 50. 
With Dr. Smith, we confidently believe “that the 
present will more than sustain the enviable reputa- 
tion already attained by former editions, of being 
one of the fullest and most complete treatises on the 
subject in the English language.” We know of none 
from the pages of which a satisfactory knowledge of 
the physiology of the human organism can be as well 
obtained, none better adapted for the use of such as 
take up the study of physiology in its reference to 
the institutes and practice of medicine.—Am. Jour. 
Med. Sciences. 
We doubt not it is destined to retain a strong hold 
on public favor, and remain the favorite text-book ia 
our colleges.— Virginia Medical Journal. 
The above is the title of what is emphatically fk« 
great work on physiology; and we are conscious that 
it would be a useless effort to attempt to add any- 
thing to the reputation of this invaluable work, and 
can only say to all with whom our opinion has any 
influence, that it is our authority.—Atlanta Med. 
Journal. 
r>Y THE SAME AUTHOR. 
PRINCIPLES OF COMPARATIYE PHYSIOLOGY. New Ameri- 
can, from the Fourth and Revised London Edition. In one large and handsome octavo 
volume, with over three hundred beautiful illustrations Pp. 752. Cloth, $5 00. 
As a complete and condensed treatise on its extended and important subject, this work become* 
a necessity to students of natural science, while the very low price at which it is offered places it 
within the reach of all. 
KIRKES ( WILLI A M SENHO USE), M.D. * i 
A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, 
M.D.,.F.R.C.S. A new American from the eighth and improved London edition. With 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $3 25; leather, $3 75. (Lately Issued.) 
Kirkes’ Physiology has long been known as a concise and exceedingly convenient text-book, 
presenting within a narrow compass all that is important for the student. The rapidity with 
which successive editions have followed each other in England has enabled the editor to keep it 
thoroughly on a level with the changes and new discoveries made in the science, and the eighth 
edition, of which the present is a reprint, has appeared so recently that it may be regarded as 
the latest accessible exposition of the subject. 
On the whole, there is very little in the book 
which either the student or practitioner will notflnd 
of practical value and consistent with our present 
knowledge of this rapidly changing science ; and we 
have no hesitation in expressing our opinion that 
this eighth edition is one of the best handbooks on 
physiology which we have in our language.—N. T. 
Med. Record, April 15, 1873. 
This volume might well be used to replace many 
of the physiological text-books in use in this coun- 
try. It represents more accurately than the works 
of Dalton or Flint, the present state of our knowl- 
edge of most physiological questions, while it is 
much less bulky and far more readable than the lar- 
ger text-books of Carpenter or Marshall. The book 
is admirably adapted to be placed in the hands of 
studen.s.—Boston Med. and Surg. Journ., April 10, 
1873. 
In its enlarged form it is, in our opinion, still the 
best book on physiology, most useful to the student. 
—Phila. Med. Times, Aug. 30, 1873. 
This is undoubtedly the best work for students of 
physiology extant.—Cincinnati Med. News, Sept. ’73. 
It more nearly represents the present condition of 
physiology than any other text-book on the subject.— 
Detroit Rev. of Med. Pharm., Nov. 1873. Henry C. Lea’s Publications—(Physiology). 
9 
f)ALTON (J. C.), M.D., 
Professor of Physiology in the College of Physicians and Surgeons, New Yorlc, &c. 
A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 
of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. Cloth, $5 50; leather, $6 50. (Now Ready.) 
From the Preface- to the Sixth Edition. 
In the present edition of this book, while every part has received a careful revision, the ori- 
ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
new material. Although the whole field of physiology has been cultivated, of late years, with 
unusual industry and success, perhaps the most important advances have been made in the two 
departments of Physiological Chemistry and the Nervous System. The number and classification 
of the proximate principles, more especially, and their relation to each other in the process of 
nutrition, have become, in many respects, better understood than formerly ; though it is evident 
that this fundamental part of physiology is to receive, in the future, modifications and additions 
of the most valuable kind. 
The additions and alterations in the text, requisite to present concisely the growth of positive 
physiological knowledge, have resulted in spite of the author’s earnest efforts at condensation, 
in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- 
pographical arrangement has accommodated these additions without undue enlargement in the 
bulk of the volume. 
The new chemical notation and nomenclature are introduced into the present edition, as hav 
ing now so generally taken the plaee of the old, that no confusion need result from the change. 
The centigrade system of measurements for length, volume, and weight, is also adopted, these 
measurements being at present almost universally employed in original physiological investiga- 
tions and their published accounts. Temperatures are given in degrees of the centigrade scale, 
usually accompanied by the corresponding degrees of Fahrenheit’s scale, inclosed in brackets. 
New York, September, 1875. 
A few notices of the previous edition are subjoined. 
The fifth edition of this truly valuable work on 
Human Physiology comes to us with many valuable 
improvements and additions. As a text-book of 
physiology the work of Prof. Dalton has long been 
well known as one of the best which could be placed 
in the hands of student or practitioner. Prof. Dalton 
has, in the several editions of his work heretofore 
published, labored to keep step with the advancement 
in science, and the last edition shows by its improve- 
ments on former ones that he is determined to main- 
tain the high standard of his work. We predict for 
the present edition increased favor, though this work 
has long been the favorite standard.—■Buffalo Med. 
and Surg. Journal, April, 1872. 
An extended notice of a work so generally and fa- 
vorably known as this is unnecessary. It is justly 
regarded as one of the most valuable text-books on 
the subject in the English language.—St. Louis Med. 
Archives, May, 1872. 
We know no treatise in physiology so clear, com- 
plete, well assimilated, and perfectly digested, as 
Dalton’s. He never writes cloudily or dubiously, or 
in mere quotation. He assimilates all his material, 
and from it constructs a homogeneous, transparent 
argument, which is always honest and well informed, 
and hides neither truth, ignorance, nor doubt, so far 
as either belongs to the subject in hand.—Brit. Med. 
Journal, March 23, 1872. 
Dr. Dalton’s treatise is well known, and by many 
highly esteemed in this country. It is, indeed, a good 
elementary treatise on the subject it professes to 
teach, and may safely be put into the hands of Eng- 
lish students. It has one great merit—it is clear, and, 
on the whole, admirably illustrated. The part we 
have always esteemed most highly is that relating 
to Embryology. The diagrams given of the various 
stages of development give a clearer view of the sub- 
ject than do those in general use in this country; and 
the text may be said to be, upon the whole, equally 
clear.—London Med. Times and (fazette, March 23, 
1872. 
Professor Dalton is regarded j ustly as the authority 
in this country on physiological subjects, and the 
fifth edition of his valuable work fully justifies the 
exalted opinion the medical world has of his labors. 
This last editionis greatly enlarged.—Virginia Clin- 
ical Record, April, 1872. 
riTJNGLISON (ROBLEY), M. D., 
■A A Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 
HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 
extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 
T EHMANN (C. G.). 
PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
tion by George E. Dat, M. D., F. R. S., &c., edited by R. E. Rogers, M. D., Professor of 
Chemistry in the Medical Department of the University of Pennsylvania, with illustrations 
selected from Funke’s Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, cloth, $6 00. 
T> Y THE SAME AUTHOR. 
MANUAL OF CHEMICAL PHYSIOLOGY. Translated from tbe 
German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory 
Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- 
vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, 
doth, $2 25. Henry C. Lea’s Publications—(Chemistry). 
10 
ATTFIELD [JOHN], Ph. B., 
Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Ac. 
CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; 
including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revised 
hv the author. In one handsome royal 12mo. volume; cloth, $2 75; leather, $3 25. 
(Lately Issued.) 
No other American publication with which we are 
acquainted covers the same ground, or does it so well. 
In addition to an admirable expose of the facts and 
principles of general elementary chemistry, the au- 
thor has presented ns with a condensed massof prac- 
tical matter, just such as the medical student and 
practitioner needs.—Cincinnati Lancet, Mar. 1874. 
We commend the work heartily as one of the best 
text-hooks extant for the medical student.—Detroit 
Rev. of Med. and Pliarm., Feb. 1872. 
The best work of the kind in the English language. 
—N. Y. Psychological Journal, Jan. 1872. 
The work is constructed with direct reference to 
the wants of medical and pharmaceutical students ; 
and, although an English work, the points of differ- 
ence between the British and United States Pharma- 
copoeias are indicated, making it as useful here as in 
England. Altogether, the book Is one we can heart- 
ily recommend to practitioners as well as students. 
—E. Y. Med. Journal, Dec. 1871. 
It differs from other text-hooks in the following 
particulars : first, in the exclusion of matter relating 
to compounds which, at present, are only of interest 
to the scientific chemist; secondly, in containing the 
chemistry of every substance recognized officially or 
in general, as a remedial agent. It will be found a 
most valuable hook for pupils, assistants, and others 
engaged in medicine and pharmacy, and we heartily 
commend it to our readers.—Canada Lancet, Oct. 
1871. 
When the original English edition of this work was 
published, we had occasion to express our high ap- 
preciation of its worth, and also to review, in con- 
siderable detail, the main features of the book. As 
the arrangement of subjects, and the main part of 
the text of the present edition are similar to the for- 
mer publication, it will be needless for ns to go over 
the ground a second time ; we may, however, call at- 
tention to a marked advantage possessed by the Ame- 
rican work—we allude to the introduction of the 
chemistry of the preparations of the United States 
Pharmacopoeia, as well as that relating to the British 
authority. — Canadian Pharmaceutical Journal, 
Nov. 1871. 
Chemistry has borne the name of being a hard sub- 
ject to master by the student of medicine, and 
chiefly because so much of it consists of compounds 
only of interest to the scientific chemist; in this work 
such portions are modified or altogether left out, and 
in the arrangement of the subject-matter of the work, 
practical utility is sought after, and we think fully 
attained. We commend it for its clearness and order 
to both teacher and pupil.—Oregon Med. and Surg. 
Reporter, Oct. 1871. 
JPOWNES [GEORGE), Ph.D. 
A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 
Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by Robert Bridges, M. D. In one large 
royal 12mo. volume, of about 850 pp., cloth, $2 75 ; leather, $3 25. (Lately Issued.) 
This work is so well known that it seems almost 
superfluous for ns to speak about it. It has been a 
favorite text-hook with medical students for years, 
and its popularity has in no respect diminished. 
Whenever we have been consulted by medical stu- 
dents, as has frequently occui’red, what treatise on 
chemistry they should procure, we have always re- 
commended Fownes’, for we regarded it as the best. 
There is no work that combines so many excellen- 
ces. It is of convenient size, not prolix, of plain 
perspicuous diction, contains all the most recent 
discoveries, and is of moderate price.—Cincinnati 
Med. Repertory, Ang. 1869. 
Large additions have been made, especially in the 
department of organic chemistry, and we know of no 
other work that has greater claims on the physician, 
pharmaceutist, or student, than this. We cheerfully 
recommend it as the best text-book on elementary 
chemistry, and bespeak for it the careful attention 
of students of pharmacy.—Chicago Pharmacist, Aug. 
1869. 
Here is a new edition which has been long watched 
for by eager teachers of chemistry. In its new garb, 
and under the editorship of Mr. Watts, it has resumed 
its old place as the most successful of text-books.—- 
Indian Medical Gazette, Jan. 1,1869 
It will continue, as heretofore, to hold the first rank 
is a text-book for students of medicine.—Chicago 
Ved. Examiner, Aug. 1869. 
fin LING (WILLIAM), 
Lecturer on Chemistry at St. Bartholomew's Hospital, Ac. 
A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use 
of Medical Students. With Illustrations. From the Fourth and Revised London Edition. 
In one neat royal 12mo. volume, cloth, $2. 
(1.ALLOWAY [ROBERT], F.O.S., 
'-a Prof, of Applied Chemistry in the Royal College of Science for Ireland, Ac. 
A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 
don Edition. In one neat royal 12mo. volume, with illustrations; cloth, $2 50. (Just 
Issued.) 
The success which has carried this work through repeated editions in England, and its adoption 
as a text-book in several of the leading institutions in this country, show that the author has suc- 
ceeded in the endeavor to produce a sound practical manual and book of reference for the che- 
mical student. 
Prof Galloway’s books are deservedly in high 
esteem, and this American reprint of the fifth edition 
(1869) of his Manual of Qualitative Analysis, will be 
acceptable to many American students to whom the 
English edition is not accessible.—Am. Jour, of Sci- 
ence and Arts, Sept. 1872,. 
We regard this volume as a valuable addition to 
the chemical text-books, and as particularly calcu- 
lated to instruct the student in analytical researches 
of the Inorganic compounds, the important vegetable 
acids, and of compounds and various secretions and 
excretions of animal origin.—Am, Journ. of Pharwt,, 
Sept. 1873, Henry C. Lea's Publications—(Chemistry). 
11 
JDLOXAM (C. L.), 
Professor of Chemistry in King's College, London. 
CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 
don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- 
tions. Cloth, $4 00 ; leather, $5 00. (Lately Issued.) 
It has been the author’s endeavor to produce a Treatise on Chemistry sufficiently comprehen- 
sive for those studying the science as a branch of general education, and one which a student 
may use with advantage in pursuing hischemical studies at one of the colleges or medical schools. 
The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders 
the work especially useful to those who are being educated for employment in manufacture. 
We have in this work a complete and most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such.—Boston Med. and Surg. 
Journ., May 28, 1874. 
Of all the numerous works upon elementary chem- 
istry that have been published within the last few 
years, we can point to none that, in fulness, accuracy, 
and simplicity, can surpass this; while,in the num- 
ber and detailed descriptions of experiments, as also 
in the profuseness of its illustrations, we believe it 
stands above any similar work published in this coun- 
try The statements made are clear and con- 
cise, and every step proved by an abundance of ex- 
periments, which excite our admiration as much by 
their simplicity as by their direct conclusiveness.— 
Chicago Med. Examiner, Nov. IS, 1873. 
It is seldom that in the same compass so complete 
and interesting a compendium of the leading facts of 
chemistry is offered.—Druggists' Circular, Nov. ’73. 
The above is the title of a work which we can most 
conscientiously recommend to students of chemistry. 
It is as easy as a work on chemistry could be made, 
at the same time that it presents a full account of that 
science as it now stands. We have spoken of the 
workasadmirably adapted to the wants of students ; 
it is quite as well suited to the requirements of prac- 
titioners who wish to review their chemistry, or have 
occasion to refresh their memories on any point re- 
lating to it. In a word, it is a book to be read by all 
who wish to know what is the chemistry of the pre- 
sent day.—American Practitioner, Nov. 1873. 
Among the various works upon general chemistry 
issued, we know of none that will supply the average 
wants of the student or teacher better than this.— 
Indiana Journ. of Med., Nov. 1873. 
We cordially welcome this American reprint of a 
work which has already won for itself so substantial 
a reputation in England. Professor Bloxam has con- 
densed into a wonderfully small com >ass all the im- 
portant principles and facts of chemical science. 
Thoroughly imbued with an enthusiastic love for the 
science he expounds, he has stripped it of all need- 
less technicalities, and rounded out its hard outlines 
by a fulness of illustration that cannot fail to attract j 
and delight the student. The details of illustrative > 
experiment have been worked up with especial care, 
and many of the experiments described are both new 
and striking.—Detroit Rev. of Med. and Pharrn., 
Nov. 1873. 
One of the best text-books of chemistry yet pub- 
lished.—Chicago Med. Journ., Nov. 1879. 
This is an excellent work, well adapted for the be- 
ginner and the advanced student of chemistry.—Am. 
Journ. of Pharrn., Nov. 1873. 
Probably the most valuable, and at the same time 
practical, text-book on general chemistry extant in 
our language.—Kansas City Med. Journ., Dec. 1873. 
Prof. Bloxam possesses pre-eminently the inestima- 
ble gift of perspicuity. It is a pleasure to read his 
books, for he is capable of making very plain what 
other authors frequently have left very obscure.— 
Va. Clinical Record, Nov. 1S73. 
It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
cyclopedia within the limits of a convenient volume, 
and has done so without penning the useless para- 
graphs too commonly making up a great part of the 
bulkof many cumbrous works. The progressive sci- 
entist is not disappointed when he looks for the record 
of new and valuable processes and discoveries, while 
the cautious conservative does not find its pages mo- 
nopolized by uncertain theories and speculations. A 
peculiar point of excellence is the crystallized form of 
expression in which great truths are expressed in 
very short paragraphs. One is surprised at the brief 
space allotted to an important topic, and yet, after 
reading it, he feels that little, if any more, should 
have been said. Altogether, it is seldom you see a 
text-book so nearly faultless.— Cincinnati Lancet, 
Nov. 1873. 
Professor Bloxam has given us a most excellent 
and useful practical treatise. His 666 pages are 
crowded with facts and experiments, nearly all well 
chosen, and many quite new, even to scientific men. 
. . . It is astonishing how much information he often 
conveys in a few paragraphs. We might quote fifty 
instances of this.—Chemical News. 
WOHLER AND FITTIG. 
VY OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 
ditions from the Eighth German Edition. By Ira Reuben, M.D., Ph.D., Professor of 
Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo. 
of 550 pp., cloth, $3. 
As the numerous editions of the original attest, this work is the leading text-book and standard 
authority throughout Germany on its important and intricate subject—a position won for it by 
the clearness and conciseness which are its distinguishing characteristics. The translation has 
been executed with the approbation of Profs. Wohler and Fittig, and numerous additions and 
alterations have been introduced, so as to render it in every respect on a level with the most 
advanced condition of the science. 
J£0 WMAN {JOHN E.), M. D. 
PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 
by C. L. Bloxam, Professor of Practical Chemistry in King’s College, London. Sixth 
American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
pp. 351, with numerous illustrations, cloth, $2 25. 
THE SAME AUTHOR. (Lately Issued.) 
INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 
ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- 
oas illustrations. In one neat vol., royal 12mo., cloth, $2 25. 
KNAPP'S TECHNOLOGY ; or Chemistry Applied to 
the Arts, and to Manufactures. With American 
Additions, by Prof. Walter B. Jobasos. In two 
very handsome octavo volumes, with 600 wood 
engravings, cloth, $0 00 12 
Henry O. Lea’s Publications—{Mat. Med. and Therapeutics). 
pARRISH [EDWARD), 
Late Professor of Materia Medica in the Philadelphia College of Pharmacy. 
A TREATISE ON PHARMACY. Designed as a Text-Book for the 
Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegakd. In one 
handsome octavo volume of 977 pages, with 280 illustrations; cloth, $5 50; leather, $6 50. 
(Lately Issued.) 
The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au- 
thor, have postponed the preparation of this new edition beyond the period expected. The notes 
and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegand, 
who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- 
ence which have been introduced during the last ten years. It is therefore hoped that the new 
edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard 
text-book and work of reference for all engaged in the preparation and dispensing of medicines. 
Of Dr Parrish’s great work on pharmacy it only 
remains to he said that the editor has accomplished 
his work so well as to maintain, in this fourth edi- 
tion, the high standard of excellence which it had 
attained in previous editions, under the editorship of 
its accomplished author. This has not been accom- 
plished without much labor, and many additions and 
improvements, involving changes in the arrangement 
of the several parts of the work, and the addition of 
much new matter. With the modifications thus ef- 
fected it constitutes, as now presented, a compendium 
of the science and art indispensable to the pharma- 
cist, and of the utmost value to every practitioner 
of medicine desirous of familiarizing himself with 
the pharmaceutical preparation of the articles which 
he prescribes for his patients.—Chicago Med. Journ., 
July, 1874. 
The work is eminently practical, and has the rare 
merit of being readable and interesting, while it pre- 
serves a strictly scientific character. The whole work 
reflects the greatest credit on author, editor, and pub- 
lisher It will convey some idea of the liberality which 
has been bestowed upon its production when we men- 
tion that there are no less than 280 carefully executed 
illustrations. In conclusion, we heartily recommend 
the work, not only to pharmacists, hut also to the 
multitude of medical practitioners who are obliged 
to compound their own medicines. It will ever hold 
an honored place on our own bookshelves.—Dublin 
Med. Press and Circular, Aug. 12, 1874. 
We expressed our opinion of a former edition in 
terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen into 
competent hands. It is a book with which no pharma- 
cist can dispense, and from which no physician can 
fail to derive much information of value to him in 
practice.—Pacific Med. and Surg. Journ., June,’74, 
With these few remarks we heartily commend the 
work, and have no doubt that it will maintain its 
old reputation as a text-book for the student, and a 
work of reference for the more experienced physi- 
cian and pharmacist.— Chicago Med. Examiner, 
June 15, 1874. 
Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lan- 
guage has emanated from the transatlantic press. 
“Parrish's Pharmacy” is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work never becomes merely locai in its fame. 
Thanks to the judicious editing of Mr, Wiegand, th<s 
posthumous edition of “Parrish” has been saved to 
the public with all the mature experience of its au- 
thor, and perhaps none the worse for a dash of new 
blood.—Lond. Pharm. Journal, Oct. 17, 1874. 
UTILLE {ALFRED), M.D., 
Ej Professor of Theory and Practice of Medicine in the University of Penna. 
THER APEUTICS AND MATERIA MEDICA; a Systematic Treatise 
on the Action and Uses of Medicinal Agents, including their Description and History. 
Fourth edition, revised and enlarged. In two large and handsome 8vo. vols. of about 2000 
pages. Cloth, $10; leather, $12. (Just Issued.) 
The care bestowed by the author on the revision of this edition has kept the work ont of th© 
market for nearly two years, and has increased its size about two hundred and fifty pages. Not- 
withstanding this enlargement, the price has been kept at the former very moderate rate. 
It is unnecessary to do much more than to an- 
nounce the appearance of the fourth edition of this 
well known and excellent work.—Brit, and For. 
Med.-Chir. Review, Oct. 1875. 
For all who desire a complete work on therapeutics 
and materia medica for reference, in cases involving 
medico-legal questions, as well as for information 
concerning remedial agents, Dr. Stilld’s is '■'■par ex- 
cellence" the work. The work being out of print, by 
the exhaustion of former editions, the author has laid 
the profession under renewed obligations, by the 
careful revision, important additions, and timelyre- 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher.— 
St. Louis Med. and Surg. Journal, Dec. 1874. 
The pi'ominent feature of Dr. Stilld's great work 
is sound good sense. It is learned, but its learning 
is of inferior value compared with the discriminating 
judgment which is shown by its author in the dis- 
cussion of his subjects, and which renders it a trust- 
worthy guide in the sick-room.—Am. Practitioner, 
Jan. 1875. 
From the publication of the first edition “ Stilld’s 
Therapeutics” has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work iu the lan- 
guage, and its presence supplies, in the two volumes 
of the present edition, a whole cyclopedia of thera- 
peutics.—Chicago Medical Journal, Feb. 1875. 
The magnificent work of Professor Stille is known 
wherever the English language is read, and the art 
of medicine cultivated ; known so well that no enco- 
mium of ours could brighten its fame, and no unfa- 
vorable criticism could tarnish its reputation.—Phil- 
adelphia Med. Times, Dec. 12, 1S74. 
The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profession, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the physician. The edition before ns 
fully sustains this verdict, as the work has been care- 
fully revised and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and croton-chloral, nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pounds, gelseminum, and other remedies.—Am. 
Journ. of Pharmacy, Feb. 1875. 
We can hardly admit that it has a rival in the 
multitude of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician’s library; not, indeed, as 
fully representing the present slate of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of the 
question.—Boston Mtd, and. Surg. Journal, Nov. 5. 
1874. Henry C. Lea’s Publications—(Mat. Med. and Therapeutics). 
13 
QRIFFITH (ROBERT E.), M.D. 
A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
ing and Administering Officinal and other Medicines. The whole adapted to Physiciam and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, by John M. 
Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. Tnonelarge 
and handsome octavo volume of aboutSOO pages, cloth, $4 50 ; leather, $5 50. (Just Issued ) 
This work has long been known for the vast amount of information which it presents in a con- 
densed form, arranged for easy reference. The new edition has received the most careful revi- 
sion at the competent hands of Professor Maisch, who has brought the whole up to the standard of 
the most recent authorities. More than eighty new headings of remedies have been introduced, 
the entire work has been thoroughly remodelled, and whatever has seemed to be obsolete has been 
omitted. As a comparative view of the United States, the British, the German, and the French 
Pharmacopoeias, together with an immense amount of unofficinal formulas, it affords to the prac- 
titioner and pharmaceutist an aid in their daily avocations not to be found elsewhere, while three 
indexes, one of “Diseases and their Remedies,” one of Pharmaceutical Names, and a General 
Index, afford an easy key to the alphabetical arrangement adopted in the text. 
The young practitioner will find the work invalu- 
able in suggesting eligible modes of administering 
many remedies.—Am. Sourn. of Pharm., Feb. 1874. 
Our copy of Griffith’s Formulary, after long use, 
first in the dispensing shop, and afterwards in our 
medical practice, had gradually fallen behind in the 
onward march of materia medica, pharmacy, and 
therapeutics, until we had ceased to consult it as a 
daily book of reference. So completely has Prof 
Maisch reformed, remodelled, and rejuvenated it in 
the new edition, we shall gladly welcome it baek to 
ourtable again beside Dunglison, Webster, and Wood 
■& B&che. The publisher could not have been more 
fortunate in the selection of an editor. Prof. Maisch 
is eminently the man for the work, and he has done 
it thoroughly and ably. To enumerate the altera- 
tions, amendments, and additions would be an end- 
less task; everywhere we are greeted with the evi- 
dences of his labor. Following the Formulary, is an 
addendum of useful Recipes, Dietetic Preparations, 
List of Ineompatibles, Posologieal table, table of 
Pharmaceutical Names, Officinal Preparations and 
Directions, Poisons, Antidotes, and Treatment, and 
copious indices, which afford ready access to all parts 
of the work. We unhesitatingly commend the book 
as being the best of its kind, within our knowledge. 
—Atlanta Med. and Surg. Journ., Feb. 1874. 
To the druggist a good formulary is simply indis- 
pensable, and perhaps no formulary has been more 
extensively used than the well-known work before 
us. Many physicians have to officiate, also, as drug- 
gists. This is true especially of the country physi- 
cian, and a work which shall teach him the means 
by which to administer or combine his remedies in 
the most efficacious and pleasant manner, will al- 
ways hold Us place upon his shelf. A formulary of 
this kind is of benefit also to the city physician in 
largest practice.—Cincinnati Clinic, Feb. 21, 1874. 
The Formulary has already proved itself accepta- 
ble to the medical profession, and we do not hesitate 
to say that the third edition is much improved, and 
of greater practical value, in consequence of the care- 
ful revision of Prof. Maisch.—Chicago Med. Exam- 
iner, March 15, 1874. 
A more complete formulary than it is in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly less essential to the practitioner 
who compounds his own medicines. Much of what 
is contained in the introduction ought to be com- 
mitted to memory by every student of medicine. 
As a help to physicians it will he found invaluable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind. 
—The American Practitioner, Louisville, July, ’74. 
PLLIS {BENJAMIN), M.D. 
XVTHE MEDICAL FORMULARY: being a Collection of Prescriptions 
derived from the writings and practice of many of the most eminent physicians of America 
and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
tion, carefully revised and mu eh improved by Albert H. Smith, M. D. In one volume 8 v@. 
of 376 pages, cloth, $3 00. 
-pEREIRA {JONATHAN), M.D., F.R.S. and L.S. 
1 MATERIA MEDIC A AND THERAPEUTICS; being an Abridg- 
ment of the late Dr. Pereira’s Elements of Materia Medica, arranged in conformity with 
the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
Druggists, Medical and Pharmaceutical Students, &c. By F. J. Farre, M.D., Senior 
Physician to St. Bartholomew’s Hospital, and London Editor of the British Pharmacopoeia; 
assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to the 
Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S., Chemical 
Operator to the Society of Apothecaries. With numerous additions and references to the 
United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
printed pages, with 236 illustrations, cloth, $7 00; leather, raised bands, $8 00. 
DUNGLISON’S NEW REMEDIES, WITH FORMULAE 
FOR THEIR PREPARATION AND ADMINISTRA- 
TION. Seventh edition, with extensive additions. 
One vol. 8vo., pp. 770; cloth. $4 00. 
WH AT TO OBSERVE AT THE BEDSIDE AND AFTER 
Death in Medical Cases. Published under the 
authority of the London Society for Medical Obser- 
vation. From the second London edition, 1 vol. 
royal 12mo., cloth. #1 00. 
iHRISTISON’S DISPENSATORY. With copious ad 
’’t.ions. and 213 large wood-engravings. By R 
Bolesfeld Griffith, M.D. Oae vol. 8vo., pp. 1000 
cloth. $4 00. 
CARPENTER’S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. E. Condte, M.D., and 
explanations of scientific words. In one neat 12mo. 
volume, pp. 178, cloth. 60 cents. 14 
Henry C. Lea’s Publications—(Pathology, die.). 
T>R UNTON (T. LA UDER), M.D., 
Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, &c. 
A MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 
INCLUDING THE PHARMACY, THE PHYSIOLOGICAL ACTION, AND THE THE- 
RAPEUTICAL USES 0E DRUGS. In one neat octavo volume. (Preparing.) 
TpENWICK (SAMUEL), M.D., 
A- Assistant Physician to the London Hospital. 
THE STUDENT’S GUIDE TO MEDICAL DIAGNOSIS. From the 
Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo., cloth, $2 25. (Just Isstted.) 
Of the many guide-books on medical diagnosis, 
claimed to be written for the special instruction of 
students, this is the best. The author is evidently a 
well-read and accomplished physician, and he knows 
how to ’each practical medicine. The charm of sim- 
plicity is not the least interesting feature in the man- 
ner in which Dr. Fenwick conveys instruction. There 
are few hooks of this size on practical medicine that 
contain so much and convey it so well as the volume 
before us. It is a hook we can sincerely recommend 
to the student for direct instruction, and to the prac- 
titioner as a ready and useful aid to his memory.— 
Am. down, of Syphilography, Jan. 1874. 
It covers the ground of medical diagnosis in a con- 
cise, practical manner, well calculated to assist the 
student in forming a correct, thorough, and system- 
atic method of examination and diagnosis of disease. 
The illustrations are numerous, and finely executed. 
Those illustrative of the microscopic appearance of 
morbid tissue, &c., are especially clear and distinct. 
—Chicago Med. Examiner, Nov. 1673. 
So far superior to any offered to students that the 
colleges of this country should recommend it to their 
respective classes.—N. O. Med. and Surg. down., 
March, 1874. 
This little booh ought to be in the possession of 
every medical student.—Boston Medical and Surg. 
Joum., Jan. 15, 1874. 
fl R EEN (T. RE NR Y), M. D., 
Li" Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School. 
PATHOLOGY AND MORBID ANATOMY. With numerous Illus- 
(Lately Published.) 
We have been very much pleased by our perusal of 
this little volume. It is the only one of the kind with 
whioh we are acquainted, and practitioners as well 
as students will find it a very useful guide; for the 
information is up to the day, well and compactly ar- 
ranged, without being at all scanty.—London Lan- 
cet, Oct. 7, 1871. 
It embodies in a comparatively small space a clear 
statement of the present state of our knowledge of pa- 
trations on Wood. In one very handsome octavo volume of over 250 pages, cloth, $2 50, 
thology and morbid anatomy. The author shows that 
he has been not only a student of the teachings of his 
confreres in this branch of science, but a practical 
and conscientious laborer in the post-mortem cham- 
ber. The work will provea useful one to the great 
mass of students and practitioners whose time for de- 
votion to this class of studies is limited.—Am. Journ. 
of Syphilography, April, 1872. 
GLUGE’S ATLAS OF PATHOLOGICAL HISTOLOGY. 
Translated, with Notes and Additions, by Joseph 
Leidy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 
LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological, Etiological, and Therapeu- 
tical Relations. In two large and handsome octavo 
volumes of nearly 1500 pages, cloth. $7 00. 
HOLLAND’S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 500, cloth. &3 60. 
LAYCOCK’S LECTURES ON THE PRINCIPLES 
and Methods of Medical Observation and Re- 
search. For the use of advanced students and 
junior practitioners. In one very neat royal 12mc. 
volume, cloth. $1 00. 
BARLOW’S MANUAL OF THE PRACTICE OP 
MEDICINE. With Additions by D. P. Cordis, 
M D. 1 vol. 8vo., pp. 600, cloth. $2 50. 
TODD’S CLINICAL LECTURES ON CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pages, 
cloth. $2 60. 
.CfTURGES (OCTAVIUS), M.D. Cantab., 
LD Fellow of the Royal College of Physicians, &c. Ac. 
AN INTRODUCTION TO THE STUDY OF CLINICAL MED- 
ICINE. Being a Guide to the Investigation of Disease, for the Use of Students. In one 
handsome 12mo. volume, cloth, $1 25. (Lately Issued.) 
T)A VIS (NATHAN S.), 
Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 
CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; 
being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
handsome royal 12mo. volume. Cloth, $1 75. (Lately Issued.) 
VTOKES (WILLIAM), M.D., D.C.L., F.R.S., 
A—' Regius Professor of Physic in the Unix, of Dublin, Ac. 
LECTURES ON FEVER, delivered in the Theatre of the Meath Hos- 
pital and County of Dublin Infirmary. Edited by John William Moore, M.D , Assistant 
Physician to the Cork Street Fever Hospital. In one neat octavo volume. (Preparing.) 
To appear in the “ Medical News and Library” for 1875. Henry C. Lea’s Publications—{Practice of Medicine). 
15 
WLINT {AUSTIN), M.D., 
A- Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. T. 
A TREATISE ON THE PRINCIPLES AND PRACTICE OF 
MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 
edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 
pages; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Just Issiied.) 
By common consent of the English and American medical press, this work has been assigned 
to the highest position as a complete and compendious text-book on the most advanced condition 
of medical science. At the very moderate price at which it is offered it will be found one of the 
cheapest volumes now before the profession. A few notices of previous editions are subjoined. 
Admirable and unequalled. — Western Journal of 
Medicine, Nov. 1869. 
Dr. Flint’s work, though claiming no higher title 
than that of a text-book, is really more. He is a man 
of large clinical experience, and his book is full of 
such masterly descriptions of disease as can only be 
drawn by a man intimately acquainted with their 
various forms. It is not so long .since we had the 
pleasure of reviewing his first edition, and we recog- 
nize a great improvement, especially in the general 
part of the work. It is a work which we can cordially 
recommend to our readers as fully abreast of the sci- 
ence of the day.—Edinburgh Med. Journal, Oct. ’69. 
One of the best works of the kind for the practi- 
tioner, and the most convenient of all for the student. 
—Am. Journ. Med. Sciences, Jan. 1869. 
This work, which stands pre-eminently as the ad- 
vance standard of medical science up to the present 
time in the practice of medicine, has for its author 
one who is well and widely known as one of the 
leading practitioners of this continent. In fact, it is 
seldom that any work is ever issued from the press 
more deserving of universal recommendation.—Do- 
minion Med. Journal, May, 1869. 
The third edition of this most excellent book scarce- 
ly needs any commendation from us. The volume, 
It stands now, is really a marvel: first of all, it is 
excellently printed and bound—and we encounter 
that luxury of America, the ready-cut pages, which 
the Yankees are ’cute enough to insist upon—nor are 
these by any means trifles ; but the contents of the 
book are astonishing. Not only is it wonderful that 
any one man can ha ve grasped in his mind the whole 
scope of medicine with that vigor which Dr. Flint 
shows, but the condensed yet clear way in which 
this is done is a perfect literary triumph. Dr. Flint 
Is pre-eminently one of the strong men, whose right 
to do this kind of thing is well admitted ; and we say 
no more than the truth when we affirm that he is 
very nearly the only living man that could do it with 
such results as the volume before us.— The London 
Practitioner, March, 1869. 
This is in some respects the best text-book of medi- 
cine in our language, and it is highly appreciated on 
the other side of the Atlantic, inasmuch as the first 
edition was exhausted in a few months. The second 
edition was little more than a reprint, but the present 
has, as the author says, been thoroughly revised. 
Much valuable matter has been added, and by mak- 
ing the type smaller, the bulk of the volume is not 
much increased. The weak point in many American 
works is pathology, but Dr. Flint has taken peculiar 
pains on this point, greatly to the value of the book. 
—London Med. Times and Gazette, Feb. 6, 1869. 
T)Y THE SAME AUTHOR. 
ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 
TOPICS. la one very handsome royal 12mo. volume. Cloth, $1 38. (Just Issued.) 
CONTENTS. 
I. Conservative Medicine. II. Conservative Medicine as applied to Therapeutics. III. Con- 
servative Medicine as applied to Hygiene. IV. Medicine in the Past, the Present, and the Fu- 
ture. V. Alimentation in Disease. VI. Tolerance of Disease. VII. On the Agency of the 
Mind in Etiology, Prophylaxis, and Therapeutics. VIII. Divine design as exemplified in the 
Natural History of Disease. 
TWA TSON (THOMAS), M. D., £c. 
r LECTURES ON THE PRINCIPLES AND PRACTICE OF 
PHYSIC. Delivered at King’s College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustr- 
ations, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Pennsylv- 
nia. In two large and handsome 8vo.vols. Cloth, $9 00; leather, $11 00. (Lately Published,.) 
It Is a subject for congratulation and for thankful- 
ness that Sir Thomas Watson, during a period of com- 
parative leisure, after a long, laborious, and most 
honorable professional career, while retaining full 
possession of his high mental faculties, should have 
employed the opportunity to submit his Lectures to 
a more thorough revision than was possible during 
the earlier and busier period of his life. Carefully 
passing in review some of the most intricate and im- 
portant pathological and practical questions, there- 
suits of his clear insight and his ealm judgment are 
now recorded for the bene fit of mankind, in language 
which, for precision, vigor, and classical elegance, has 
rarely been equalled, and never surpassed The re- 
vision has evidently been most carefully done, and 
the results appear in almost every page.—Brit. Med. 
Journ., Oet. 14, 1871. 
The lectures are so well known and so justly 
appreciated, tbat it is scarcely necessary to do 
more than call attention to the special advantages 
of the last over previous editions. The author's 
rare combination of great scientific attainments com- 
bined with wonderful forensic eloquence has exerted 
extraordinary influence over the last two generations 
of physicians. His clinical descriptions of most dis- 
eases have never been equalled; and on this score 
at least his work will liye long in the future. The 
work will be sought by all who appreciate a great 
book.—Amer. Journ. of Syphilography, July, 1872. 
We are exceedingly gratified at the reception of 
this new edition of Watson, pre-eminently the prince 
of English authors, on “Practice.” We, who read 
the first edition shall never forget the great pleasure 
and profit we derived from its graphic delineations 
of disease, its vigorous style and splendid English. 
Maturity of years, extensive observation, profound 
research, and yet continuous enthusiasm, have com- 
bined to give us in this latest edition a model of pro- 
fessional excellence in teaching with rare beauty in 
the mode of communication. But this classic needs 
no eulogium of ours.—Chicago Med. Journ., July, 
1872. 
fiUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising 
Treatises on the Nature and Treatment of Diseases, Materia Mediea and Therapeutics, 
Diseases of Women and Children, Medical Jurisprudence, &c. &e. In four large super-royal 
octavo volumes, of 32M double-columned pages, strongly and handsomely bound in leather, 
$15; eloth, $11. 16 
Henry C. Lea’s Publications—(Practice of Medicine). 
fTARTSHORNE {HENRY), M. D., 
A A Professor of Hygiene in the University of Pennsylvania. 
ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 
CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 12.mo. volume, 
of about 550 pages, cloth, $2 63; half bound, $2 88. (Just Issued..) 
The thorough manner in which the author has labored to fully represent in this favorite hand- 
book the most advanced condition of practical medicine is shown by the fact that the present 
edition contains more than 250 additions, representing the investigations of 172 authors not re- 
ferred to in previous editions. Notwithstanding an enlargement of the page, the size has been 
increased by sixty pages. A number of illustrations have been introduced which it is hoped 
will facilitate the comprehension of details by the reader, and no effort has been spared to make 
the volume worthy a continuance of the very great favor with which it has hitherto been received. 
The work is brought fully up with all the recent 
advances in medicine, is admirably condensed, and 
yet sufficiently explicit for all the purposes intended, 
thus making it by far the best work of its character 
ever published.—Cincinnati Clinic, Get. 24, 1874. 
We have already had occasion to notice the previ- 
ous editions of this work. It is excellent of its kind. 
The author has given a very careful revision, in view 
of the rapid progress of medical science.—N. Y. Med. 
Journ., Nov. 1874. 
Without doubt the best hook of the kind published 
in the English language.—St. Louis Med. and Surg. 
Journ., Nov. 1874. 
As a handbook, which clearly sets forth the essen- 
tials of the PRINCIPLES AND PRACTICE. OF MEDICINE, We 
do not know of its equal. — Va. Med. Monthly. 
As a brief, condensed, but comprehensive hand- 
book, it cannot be improved upon.—Chicago Meet. 
Examiner, Nov. 15, 1874. 
PA VY (F. W.), M. D., F. R. S., 
Senior Asst. Physician to and Lecturer cm. Physiology, at 6tuyrs Hospital, &e. 
A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- 
ders and their Treatment. From the second London edition. In ons handsome volume, 
small octavo, cloth, $2 00. 
TJT THE SAME AUTHOR, (dust Issued.) 
A TREATISE ON FOOD AND DIETETICS, PHYSIOLOGI- 
CALLY AND THERAPEUTICALLY CONSIDERED. In one handsome octavo volume 
of nearly 600 pages, cloth, $4 75. 
Introductory Remarks on the Dynamic Relations of Food—On the Origination of Food—The 
Constituent Relations of Food—Alimentary Principles, their Classification, Chemical Relati ons, 
Digestion, Assimilation, and Physiological Uses—Nitrogenous Alimentary Principles—Non-Ni- 
trogenous Alimentary Principles—The Carbo-Hydrates—The Inorganic Alimentary Principles— 
Alimentary Substances—Animal Alimentary Substances—Vegetable Alimentary Substances— 
Beverages—Condiments.—The Preservation of Food—Principles of Dietetics—Practical Dietetics 
—Diet of Infants—Diet for Training—Therapeutic Dietetics—Dietetic Preparations for the Inva- 
lid—Hospital Dietaries. 
SUMMARY OP CONTENTS. 
/CHAMBERS (T. K.), M.D., 
v/ Consulting Physician to St. Mary's Hospital, London, Ac. 
A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- 
NESS. In one handsome octavo volume. Cloth, $2 75. {Naur Ready.) 
In compilingthis small but comprehensive manual 
Dr. Chambers has laid the profession under a debt 
of gratitude to him. He writes on the subject like 
one who has given his mind to it, and therefore is 
entitled to speak with authority. As a pioneer, Dr. 
Chambers deserves much credit; he has opened up a 
new field of which others will no doubt avail them- 
selves. Taken altogether, this work is one which 
gives, in an agreeable form, much valuable informa- 
tion on a most important subject, and ought to have 
a large sale both in the profession and out of it.— 
London Med. Record, May 19, 1875. 
In thorough mastery of the subjects upon which he 
writes, and in the happy command of language to 
convey Ms meaning in the fewest possible words, he 
is certainly unexcelled and rarely equalled by any 
writer in the English language. It is altogether a. 
work of rave excellence, and should, as it doubtless 
will, speedily find a place on the table of every phy- 
sician.— The N. T. Sanitarian, June, 1875. 
This work is a substantial addition to our standard 
works, and not only should the neat little volume- 
find a place in the most restricted libraries, but its 
contents ought to be read, marked, learned, and in- 
wardly digested by each practitioner, until they 
have become woven into the web of the ordinary 
every-day thought of all medical men who truly love 
their profession.—Land. Practitioner, June, 1875. 
THE SAME AUTHOR. (Lately Published.) 
RESTORATIVE MEDICINE. An Harveian Annual Oration. With 
Two Sequels. In one very handsome volume, small 12mo., cloth, $1 00. 
TJRINTON (WILLIAM), M.D., F.R.S. 
ON THE DISEASES OF THE STOMACH; with an 
Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
tion. With illustrations on wood In one handsome octavo volume of about 300 pages 
cloth, $3 25. 
pox (WILSON), M.D., 
J- Holme Prof, of Clinical Med., University Coll., London. 
THE DISEASES OF THE STOMACH: Being the Third Edition of 
the “Diagnosis and Treatment of the Varieties of Dyspepsia ” Kevised and Enlarged. 
With illustrations. In one handsome oetayo volume, cloth, $2 00. {Just Issued.) Henry C. Lea’s Publications. 
17 
TjlLINT [AUSTIN), M.D., 
A Prof essor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. T. 
A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 
AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 
Dr. Flint chose a difficult subject for his researches, 
and has shown remarkable powers of observation 
and reflection, as well as great industry, in his treat- 
ment of it. His book must he considered the fullest 
and clearest practical treatise on those subjects, and 
should be in the hands of all practitioners and stu- 
dents. It is a credit to American medical literature. 
—Amer. Journ. of the Med. Sciences, July, 1860. 
We question the fact of any recent American author 
in our profession being more extensively known, or 
more deservedly esteemed in this country than Dr. 
Flint. We willingly acknowledge his success, more 
particularly in the volume on diseases of the heart, 
in making an extended personal clinical study avail- 
able for purposes of illustration, in connection with 
cases which have been reported by other trustworthy 
observers.—Brit, and For. Med.-Chirurg. Review. 
In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and judi- 
cious. Considering the present state of science, snch 
a work was much needed. It should be in the hands 
of every practitioner.—Chicago Med. Journ. 
With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, the 
most valuable practical work of its kind.—N. O. Med. 
News. 
£T THE SAME AUTHOR. 
A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Seoond and revised edition. In one handsome ootavo volume 
of 595 pages, cloth, $4 50. 
Dr. Flint’s treatise is one of the most trustworthy 
guides which we can consult. The style is clear and 
distinct, and is also concise, being free from that tend- 
ency to over-refinement and unnecessary minuteness 
which characterizes many works on the same sub- 
ject.—Dublin Medical Press, Feb. 6, 1867. 
The chapter on Phthisis is replete with interest; 
and his remarks on the diagnosis, especially in the 
early stages, are remarkable for their acumen and 
great practical value. Dr. Flint’s style is ciear and 
elegant, and the tone of freshness and originality 
which pervades his whole work lend an additional 
force to its thoroughly practical character, which 
cannot fail to obtain for it a place as a standard work 
on diseases of the respiratory system.—London 
Lancet, Jan. 19,1867. 
This is an admirable book. Excellent in detail and 
execution, nothing better could be desired by the 
practitioner. Dr. Flint enriches his subject with 
much solid and not a little original observation.” 
Ranking's Abstract, Jan. 1867. 
T>Y THE SAME AUTHOR. (Just Ready.) 
PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume. 
This volume, containing the results of the author’s extended observation and experience on a 
subject of prime importance, cannot but have a claim upon the attention of every practitioner. 
POLLER (HENRY WILLIAM), M. D., 
A Physician to St. George's Hospital, London. 
ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 
Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
English edition. Ip one handsome octavo volume of about 500 pages, cloth, $3 50. 
WILLIAMS (G. J. B.), M.D., 
Senior Consulting Physician to the Hospital for Consumption, Brompton, and 
TTTILLIAMS (CHARLES T.), M.D., 
’ Physician to the Hospital for Consumption. 
PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- 
ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat 
octavo volume of about 350 pages, cloth, $2 50. (Lately Published.) 
He can still speak from a more enormous experi- 
ence, and a closer study of the morbid processes in- 
volved in tuberculosis, than most living men. He 
owed it to himself, and to the importance of the sub- 
ject, to embody his views in a separate work, and 
we are glad that he has accomplished this duty. 
ifter all, the grand teaching which Dr Williams has 
for the profession is to be found in his therapeutical 
chapters, and in the history of individual cases ex- 
tended, by dint of care, over ten, twenty, thirty, and 
sven forty years.—London Lancet, Oct. 21, 1871. 
LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, 
of 500 pages. Price $3 00. 
SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol. 8vo., pp. 254. $2 25. 
WALSHE ON THE DISEASES OF THE HEART AND 
GREAT VESSELS. Third American edition. Ill 
1 vol. 8vo., 420 pp., cloth. $3 00. 18 
Henry C. Lea’s Publications—(Practice of Medicine). 
ROBERTS ( WILLIAM), M. I)., 
-*■*' Lecturer on Medicine in the Manchester School of Medicine, Ac. 
A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 
EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond American, from the Second Revised and Enlarged London Edition. In one large 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately 
Published.) 
The author has subjected this work to a very thorough revision, and has sought to embody in 
it the results of the latest experience and investigations. Although every effort has been made 
to keep it within the limits of its former size, it has been enlarged-by a hundred pages, many 
new wood-cuts have been introduced, and also a colored plate representing the appearance of the 
different varieties of urine, while the price has been retained at the former very moderate rate. 
The plan, it will thus be seen, is very complete, 
and the manner in which it has been carried out is 
in the highest degree satisfactory. The characters 
of the different deposits are very well described, and 
the microscopic appearances they present are illus- 
trated by numerous well executed engravings. It 
only remains to us to strongly recommend to our 
readers Dr. Roberts’s work, as containing an admira- 
ble resumi of the present state of knowledge of uri- 
nary diseases, and as a safe and reliable guide to the 
clinical observer.—Edin. Med. Jour. 
The most complete and practical treatise upon renal 
diseases we have examined. It is peculiarly adapted 
to the wants of the majority of American practition- 
ers from its clearness and simple announcement of the 
facts in relation to diagnosis and treatment of urinary 
disorders, and contains in condensed form the investi- 
gations of Bence Jones, Bird, Beale, Hassall, Prout, 
and a host of other well-known writers upon this sub- 
ject. The characters of urine, physiological and pa- 
thological, as indicated to the naked eye as well as by 
microscopical and chemical investigations, are con- 
cisely represented both by description and by well 
executed engravings.—Cincinnati Journ. of Med. 
T>ASHAM ( W.R.), 31. D., 
Senior Physician to the Westminster Hospital, &c. 
RENAL DISEASES: a Clinical Guide to their Diagnosis and Treatment. 
With illustrations. In one neat royal 12mo. volume of 304 pages, cloth, $2 00. 
The chapters on diagnosis and treatment are very 
good, and the student and young practitioner will 
find them full of valuable practical hints. The third 
part, on the urine, is excellent, and we cordially 
recommend its perusal. The author has arranged 
his matter in a somewhat novel, and, we thiuk, use- 
ful form. Here everything can be easily found, and, 
what is more important, easily read, for all the dry 
details of larger books here acquire a new interest 
from the author’s arrangement. This part of the 
book is full of good work.—Brit, and For. Medico- 
Ohirurgical Review, July, 1870. 
The easy descriptions and compact modes of state- 
ment render the book pleasing and convenient.—Am. 
Journ. Med. Sciences, July, 1870. 
TINCOLN (D. E.). M.D., 
" Physician to the Department o f Nervous Diseases, Boston Dispensary. 
ELECTRO THERAPEUTICS; 1 Concise Manual of Medical Electri- 
city. In one very neat royal 12mo. volume, cloth, with illustrations, $1 50. (Just Issued.) 
The work is convenient in size, its descriptions of 
methods and appliances are sufficiently complete for 
the general practitioner, and the chapters on Electro- 
physiology and diagnosis are well written and read- 
able. For those who wish a handy-book of directions 
for the employment of galvanism in medicine, this 
will serve as a very good and reliable guide.—New 
Remedies, Oct. 1874. 
It is a well written work, and calculated to meet 
the demands of the busy practitioner. It contains 
the latest researches in this important branch of med- 
icine.—Peninsular Journ. of Med., Oct. 1874. 
Eminently practical in character. It will amply 
repay any one for a careful perusal.—Leavenworth 
Med. Herald, Oct. 1874. 
This little book is, considering its size, one of the 
very best of the English treatises on its subject that 
has come to our notice, possessing, among others, the 
rare merit of dealing avowedly and actually with 
principles, mainly, rather than with practical details, 
thereby supplying a real want, instead of helping 
merely to flood the literary market. Dr. Lincoln’s 
style is usually remarkably clear, and the whole 
book is readable and interesting.—Boston Med. and 
Surg. Journ., July 23, 1874. 
We have here in a small compass a great deal of 
valuable information upon the subject of Medical 
Electricity.—Canada Med. and Surg. Journ., Nov. 
1874. 
TEE [HENRY), 
Prof, of Surgery at the Royal College of Surgeons of England, etc. 
LECTURES OX SYPHILIS AND OX SOME FORMS OF LOCAL 
DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one 
handsome octavo volume : cloth; $2 25. (Now Ready.) 
CONTENTS. 
Lectures I., II., Ill- General. — IV. Treatment of Syphilis—V. Treatment of Particular 
and Modified Syphilitic Aifections—VI. Second Stage of Lues Venerea; Treatment—VII. Lo- 
cal Suppurating Venereal Sore ; Syphilization ; Lymphatic Absorption ; Physiological Absorp- 
tion ; Twofold Inoculation—VIII. Urethral Discharges : different kinds ; Treatment; Conclu- 
sions of Hunter and Ricord—IX. Prostatic Discharges—X. Lymphatic Absorption continued ; 
Local Affections ; Warts and Excrescences. 
DIPHTHERIA; its Nature and Treatment, with an 
account of the History of its Prevalence in vari- 
ous Countries. By D. D. Sladf., M.D. Second and 
revised edition. In one neat royal 12mo. volume, 
cloth, $1 25. 
LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I.A., Physician to the Meath 
Hospital. In one vol. 8vo., cloth, $2 50. 
A TREATISE ON FEYER. By Robert D. Lyons, 
K C C. In one octavo volume of 362 pages, cloth, 
$2 2a. 
CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS BvC. Handfield Jonbs, 
M.D., Physician to St. Mary’s Hospital, &c. Sec- 
ond American Edition. In one handsome octavo 
volume of 348 pages, cloth, $3 25. Henry C. Lea’s Publications—(Venereal Diseases, etc.). 
19 
T> UMSTEAD {FREEMAN J.), M.D., 
■AA Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 
THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Third edition, 
revised and enlarged, with illustrations. In one large and handsome octavo volume of 
over 700 pages, cloth, $5 00 ; leather, $6 00. 
In preparing this standard work again for the press, the author has subjected it to a very 
thorough revision. Many portions have been rewritten, and much new matter added, in order to 
bring it completely on a level with the most advanced condition of syphilography, but by careful 
compression of the text of prmdous editions, the work has been increased by only sixty-four pages. 
The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a 
complete and trustworthy guide for the practitioner. 
It is the most complete book with which we are ac- 
quainted in the language. The latest views of the 
best authorities are put forward, and the information 
is well arranged—a great point for the student, and 
still more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
the treatment of syphilis by repeated inoculations, are 
very fully discussed. London Lancet, Jan. 7, 1871. 
Dr. Bumstead’s work is already so universally 
known as the best treatise in the English language on 
venereal diseases, that it may seem almost superflu- 
ous to sa v more of it than that a new edition has been 
Issued. But the author’s industry has rendered this 
new edition virtually a new work, and so merits as 
much special commendation as if its predecessors had 
not been published. As a thoroughly practical book 
on a class of diseases which form a large share of 
nearly every physician’s practice, the volume before 
us is bv far the best of which we have knowledge.— 
N. Y. Medical Gazette, Jan. 28, 1871. 
It is rare in the history of medicine to find any one 
book which contains all that a practitioner needs to 
know; while the possessor of “Bumstead on Vene- 
real” has no occasion to look outside of its covers for 
anything practical connected with the diagnosis, his- 
tory, or treatment of these affections.—N. Y. Medical 
Journal, March, 1871. 
flULLERIER [A.), and T>UMSTEAD {FREEMAN J.), 
Surgeon to the Hdpital du Midi. Professor of Venereal Diseases in the College of 
Physicians and Surgeons, N. Y. 
AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 
Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 
per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
We wish for once that our province was not restrict- 
ed to methods of treatment, that we might say some- 
thing of the exquisite colored plates in this volume. 
—London Practitioner, May, 1869. 
As a whole, it teaches all that can be taught by 
means of plates and print.—London Lancet, March 
13, 1869. 
Superior to anything of the kind ever before issued 
on this continent.—Canada Med. Journal, March, '69. 
The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published.— 
Dominion Med. Journal, May, 1869. 
This is a work of master hands on both sides. M. 
Cullerier is scarcely second to, we think we may truly 
say is a peer of the illustrious and venerable Ricord, 
while in this country we do not hesitate to say that 
Dr. Bumstead, as an authority, is without a rival. 
Assuring our readers that these illustrations tell the 
whole history of venereal disease, from its inception 
to its end, we do not know a single medical work, 
which for its kind is more necessary for them to have. 
—California Med. Gazette, March, 1869. 
The most splendidly illustrated work in the lan- 
guage, and in our opinion far more useful than the 
French original.—Am. Journ. Med. Sciences, Jan.’69. 
The fifth and concluding number of this magnificent 
work has reached us, and we have no hesitation in 
saying that its illustrations surpass those of previous 
numbers.—Boston Med. and Surg. Journal, Jan. 14, 
1869. 
Other writers besides M. Cullerier have given us a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There is, 
however, an additional interest and value possessed 
by the volume before us ; for it is an American reprint 
and translation of M. Cullerier’s work, with inci- 
dental remarks by one of the most eminent American 
syphilographers, Mr. Bumstead.—Brit, and For. 
Medico-Chir. Review, July, 1869. 
JfILL {BERKELEY), 
Surgeon to the Lock Hospital, London. 
ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In 
one handsome octavo volume ; cloth, $3 25. 
Bringing, as it does, the entire literature of the dis- 
ease down to the present day, and giving with great 
ability the results of modern research, it is in every 
respect a most desirable work, and one which should 
find a place in the library of every surgeon.—Cali- 
fornia Med. Gazette, June, 1869. 
Considering the scope of the book and the careful 
attention to the manifold aspects and details of its 
subject, it is wonderfully concise. All these qualities 
render it an especially valuable book to the beginner, 
to whom we would most earnestly recommend its 
study; while it is no less useful to the practitioner.— 
St. Louis Med. and Surg. Journal, May, 1869. 
The most convenient and ready book of reference 
we have met with.—N. Y. Med. Record, May 1,1869. 
Most admirably arranged for both student and prac- 
titioner, no other work on the subject equals it; it is 
more simple, more easily studied.—Buffalo Med. and 
Surg. Journal, March, 1869. 
yEISSL {H.), M.D. 
COMPLETE TREATISE ON VENEREAL DISEASES. Trans- 
lated from the Second Enlarged German Edition, by Frederic R. Sturgis, M.D In one 
octavo volume, with illustrations. (Preparing.) 20 
Henry C. Lea’s Publications—(Diseases of the Shin). 
WILSON [ERASMUS), F. R.S. 
rrON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 
enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. 
A SERIES OF PLATES ILLUSTRATING “WILSON ON DIS- 
EASES OF THE SKIN;” consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most of 
them the size of nature. Price, in extra cloth, $5 50. 
Also, the Text and Plates, bound in one handsome volume. Cloth? $10. 
No one treating skin diseases should be without 
a copy of this standard work.—Canada Lancet. 
We can safely recommend it to the profession at 
the best work on the subject now in existence ir 
the English language.—Medical Times and Gazette 
Mr. Wilson’s volume is an excellent digest of the 
actual amount of knowledge of cutaneous diseases; 
it includes almost every fact or opinion of importance 
connected with the anatomy and pathology of the 
skin.—British and Foreign Medical Review. 
Such a work as the one before us is a most capital 
and acceptable help. Mr. Wilson has long been held 
as high authority in this department of medicine, and 
his book on diseases of the skin has long been re- 
garded as one of the best text-books extant on the 
subject. The present edition is carefully prepared, 
and brought up in its revision to the present time. In 
this edition we have also included the beautiful series 
of plates illustrative of the text, and in the last edi- 
tion published separately. There are twenty of these 
plates, nearly all of them colored to nature, and ex- 
hibiting with great fidelity the various groups of 
diseases.—Cincinnati Lancet. 
JfY THE SAME AUTHOR. 
THE STUDENT’S BOOK OF CUTANEOUS MEDICINE and Dis- 
eases op the skin. In one very handsome royal 12mo. volume. $3 50. 
JlTELIGAN (J. MOORE), M.D., M.R.I.A. 
A PRACTICAL TREATISE ON DISEASES OF THE SKIN. 
Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M.D. 
In one neat royal 12mo. volume of 462 pages, cloth, $2 25. 
Fully equal to all the requirements of students and their value justly estimated; in a word, the work i* 
young practitioners.—Dublin Med. Press. fully up to the times, and is thoroughly stocked with 
Of the remainder of the work we have nothing be- ™08* 'n*'orina^on' Hew York Med. Record, 
yond unqualified commendation to offer. It is so far Jan. 15, 1867. 
the most complete one of its size that has appeared, The most convenient manual of diseases of the 
and for the student there can be none which can com- skin that can be procured by the student.—Chicago 
pare with it in practical value. All the late disco- Med. Journal, Dec. 1866. 
veries in Dermatology have been duly noticed, and 
THE SAME AUTHOR. 
ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 
volume, with exquisitely colored plates, &e., presenting about one hundred varieties of 
disease. Cloth, $5 50. 
The diagnosis of eruptive disease, however, under 
all circumstances, is very difficult. Nevertheless, 
Dr. Neligan has certainly, “as far as possible,” given 
a faithful and accurate representation of this class of 
diseases, and there can be no doubt that these plates 
will be of great use to the student and practitioner in 
drawing a diagnosis as to the class, order, and species 
to which the particular case may belong. While 
looking over the “Atlas” we have been induced to 
examine also the “Practical Treatise,” and we are 
inclined to consider it a very superior work, com- 
bining accurate verbal description with sound view* 
of the pathology and treatment of eruptive diseases, 
—Glasgow Med. Journal. 
A compend which will very much aid the practi- 
tioner in this difficult branch of diagnosis. Taken 
with the beautiful plates of the Atlas, which are re- 
markable for their accuracy and beauty of coloring, 
it constitutes a very valuable addition to the library 
of a practical man.—Buffalo Med. Journal. 
fflLLIER {THOMAS), M.D., 
Physician to the Skin Department of University College Hospital, &e. . 
HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 
Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. 
Cloth, $2 25. 
We can conscientiously recommend it to the stn- 
dent; the style is clear and pleasant to read, the 
matter is good, and the descriptions of disease, with 
the modes of treatment recommended, are frequently 
illustrated with well-recorded cases.—London Med. 
Times and Gazette, April 1, 1865. 
It is a concise, plain, practical treatise on the vari- 
ous diseases of the skin ; just such a work, indeed, 
as was much needed, both by medical students and 
practitioners. — Chicago Medical Examiner, May, 
1865. 
ANDERSON {McGALL), M.D., 
-Li- Physician to the Dispensary for Skin Diseases, Glasgow, Ac. 
ON THE TREATMENT OF DISEASES OF THE SKIN. With an 
Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. (Lately Published.) 
GUERSANT’S SURGICAL DISEASES OF INFANTS 
AND CHILDREN. Translated by R. J. Dungli- 
bon, M.D. 1 vol. 8vo. Cloth, $2 50. 
DKWEES ON THE PHYSICAL AND MEDICAL 
TREATMENT1 OS'CHILDREN Eleventh edition. 
1 voi. 5vo. of 54S pages. Cloth, $2 80. Henry C. Lea’s Publications—-(Diseases of Children). 
21 
&MITH (J. LEWIS), M. D., 
' Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. 
A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 
CHILDREN. Third Edition, revised and enlarged. In one handsome octavo volume. 
(Preparing.) 
In presenting to the profession the second edition of his work, the author gratefully acknow- 
ledges the favorable reception accorded to the first. He has endeavored to merit a continuance 
of this approbation by rendering the volume much more complete than before. Nearly twenty 
additional diseases have been' treated of, among which may be named Diseases Incidental to 
Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, 
and the various forms of Paralysis. Many new formulae, which experience has shown to be 
useful, have been introduced, portions of the text of a less practical nature have been con- 
densed, and other portions, especially those relating to pathological histology, have been 
rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid 
an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of 
the page, the number of pages has been enlarged by more than one hundred. 
227 West 49th Street, New York, April, 1872. 
The work will be found to contain nearly one-third more matter than the previous edition, and 
it is confidently presented as in every respect worthy to be received as the standard American 
text-book on the subject. 
From the Preface to the Second Edition. 
Eminently practical as well as judicious in its 
teachings.—Cincinnati Lancet and Obs., July, 1872. 
A standard work that leaves little to be desired.— 
Indiana Journal of Medicine, July, 1872. 
We know of no book on this subject that we can 
more cordially recommend to the medical student 
and the practitioner.—Cincinnati Clinic, June29, ’72. 
We regard it as superior to any other single work 
on the diseases of infancy and childhood.—Detroit 
Rev. of Med. and Pharmacy, Aug. 1S72. 
We confess to increased enthusiasm in recommend- 
ing this second edition.—St Louis Med. and Surg. 
Journal, Aug. 1872. 
fJONDIE [D. FRANCIS), M. D. 
W A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 
Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, cloth, $5 25 ; leather, $6 25. 
The present edition, which is the sixth, is fully up 
to the times in the discussion of all those points in the 
pathology and treatment of infantile diseases which 
have been brought forward by the Germau and French 
teachers. As a whole, however, the work is the best 
American one that we have, and in its special adapta- 
tion to American practitioners it certainly has no 
equal. — New York Med. Record, March 2, 1868. 
WEST {CHARLES), M.D., 
* ' Physician to the Hospital for Sick Children, Ac. 
LECTURES ON THE DISEASES OF INFANCY AND CHILD- 
HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ■ leather, $5 50. (Just Issued.) 
The continued demand for this work on both sides of the Atlantic, and its translation into Ger- 
man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- 
sively felt by the profession. There is probably no man living who can speak with the authority 
derived trom a more extended experience than Dr. West, and his work now presents the results of 
nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
cases which have passed under his care. In the preparation of the present edition he has omitted 
much that appeared of minor importance, in order to find room for the introduction of additional 
matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 
Of ail the English writers on the diseases of chil- 
dren, there is no one so entirely satisfactory to us as 
Dr. West. For years we have held his opinion as 
judicial, and have regarded him as one of the highest 
living authorities in the difficult department of medi- 
cal science in which he is most widely known,— 
Boston Med. and Surg. Journal. 
Y THE SAME AUTHOR. (Lately Issued ) 
ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- 
don, in March, 1871. In one volume, small 12mo., cloth, $1 00. 
JgMITH (EUSTACE), if. B., 
Physician to the Northwest London Free Dispensary for Sick Children. 
A PRACTICAL TREATISE ON THE WASTING DISEASES OF 
INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) 
This is in every way an admirable book. The 
inodest title which the author has chosen for it scarce- 
ly conveys an adequate idea of the many subjects 
upon which it treats. Wasting is so constant an at- 
tendant upon the maladies of childhood, that a trea- 
tlse upon the wasting diseases of children must neces 
sarily embrace the consideration of many affections 
of which it is a symptom ; and this is excellently well 
done by Or. Smith. The book might fairly be de- 
scribed as a practical handbook of the common dis- 
eases of children, so numerous are the affections con- 
sidered either collaterally or directly. We are 
acquainted with no safer guide to the treatment of 
children’s diseases, and few works give the insight 
into the physiological and other peculiarities of chil- 
dren that Dr. Smith’s book does.—Brit. Med. Journ., 
April 8, 1871. 22 
Henry C. Lea’s Publications—(Diseases of Women). 
fJJE-E OBSTETRICAL JOURNAL. [Free of postage for 1876.) 
THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 
Including Midwifery, and the Diseases of Women and Infants. With an American 
Supplement, edited by J. V. Ingham, M.D. A monthly of about 80 octavo pages, 
very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
cents each. 
Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- 
rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. 
Collecting together the vast amount of material daily accumulating in this important and ra- 
pidly improving department of medical science, the value of the information which it pre- 
sents to the subscriber may be estimated from the character of the gentlemen who have already 
promised their support, including such names as those of Drs. Atthill, Robert Barnes, Henry 
Bennet, Thomas Chambers, Fleetwood Churchill, Matthews Duncan, Graily Hewitt, 
Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Tyler Smith, Edward J. 
Tilt, Spencer Wells, Ac. Ac. ; in short, the representative men of British Obstetrics and Gynae- 
cology. 
In order to render the Obstetrical Journal fully adequate to the wants of the American 
profession, each number contains a Supplement devoted to the advances made in Obstetrics and 
Gynaecology on this side of the Atlantic. This portion of the Journal is under the editorial 
charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, books for re- 
view, Ac., may be addressed, to the care of the publisher. 
**.* Complete sets from the beginning can no longer be furnished, but subscriptions can com- 
mence with January, 1875, or with Vol. II., April, 1874. 
qyROMAS (T. GAILLARD), M. D., 
Professor of Obstetrics, &c., in the College of Physicians and Surgeons, N. Y., Ac, 
A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 
edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 
800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 
The author has taken advantage of the opportunity afforded by the call for another edition of 
this work to render it worthy a continuance of the very remarkable favor with which it has been 
received. Every portion has been subjected to a conscientious revision, and no labor has been 
spared to make it a complete treatise on the most advanced condition of its important subject. 
A work which has reached a fourth edition, and 
that, too, in the short space of five years has achieved 
a reputation which places it almost beyond the 
reach of criticism, and the favorable opinions which 
we have already expressed of the former editions 
seem to require that we should do little more than 
announce this new issue. We cannot refrain from 
saying that, as a practical work, this is second to 
none in the English, or, indeed, in any other lan- 
guage. The arrangement of the contents, the admi- 
rably clear manner in which the subject of the dif- 
ferential diagnosis of several of the diseases is 
handled, leave nothing to he desired by the practi- 
tioner who wants a thoroughly olinical work, one 
to which he can refer in difficult cases of doubtful 
diagnosis with the certainty of gaining light and 
instruction Dr. Thomas is a man with a very clear 
head and' decided views, and there seems to be no- 
thing which he so much dislikes as hazy notions of 
diagnosis and blind routine and unreasonable thera- 
peutics. The student who will thoroughly study 
this book and test its principles by clinical ohserva- ! 
tion, will certainly not he guilty of these faults.— I 
London Lancet, Feb. 13, 1875. 
The latest edition of this well-known text-book 
retains the essential characters which rendered the 
earliest so deservedly popular It is still pre-emi- J 
nently a practical manual, intended to convey to 
students in a clear and forcible manner a sufficiently 
complete outline of gynsecology. In a word, we 1 
should say that any one who intended to make a 
special study of gyntecology could hardly do better 
than to begin with a minute perusal of this hook, and 
that any one who intended to keep gynsecology sub- ] 
ordinate to general practice, should hardly fail to | 
have it on hand for future reference.—N. Y. Med. 
Journ , Jan. 1875. 
Reluctantly we are obliged to close this unsatis- 
factory notice of so excellent a work, and in conclu- 
sion would remark that, as a teacher of gynsecology, 
both didactic and clinical, Prof. Thomas has cer- 
tainly taken the lead far ahead of his confreres, 
and as an author he certainly has met with unusual j 
1 and merited success.—Am. Journ. of Obstetrics, 
j Nov. 1874. 
| This volume of Prof. Thomas in its revised form 
| is classical without being pedantic, full in the details 
j of anatomy and pathology, without ponderous 
| translation of pages of German literature, describes 
distinctly the details and difficulties of each opera* 
; tion, without wearying and useless minutise, and is 
in all respects a work worthy of confidence, justify- 
j ing the high regard in which its distinguished au- 
thor is held by the profession.—Am. Supplement, 
Obstet. Journ., Oct. 1S74. 
Professor Thomas fairly took the Profession of the 
j United States by storm when his book first made its 
appearance early in 1S68. Its reception was siinply 
enthusiastic, notwithstanding a few adverse criti- 
cisms from our transatlantic brethren, the first large 
edition was rapidly exhausted, and in six mouths a 
second one was issued, and in two years a third one 
was announced and published, and we are now pro- 
mised the fourth. The popularity of this work was 
j not ephemeral, and its success was unprecedented in 
| the annals of American medical literature. Six years 
is a long period in medical scientific research, but 
Thomas’s work on “Diseases of Women” is still the 
leading native production of the United States. The 
order, the matter, the absence of theoretical disputa- 
tiveness, the fairness of statement, and the elegance 
of diction, preserved throughout the entire range of 
the book, indicate that Professor Thomas did not 
overestimate his powers when he conceived the idea 
and executed the work of producing a new treatise 
upon diseases of women.—Prop. P allen, in Louis- 
ville Med. Journal, Sept. 1874. 
Upon looking the work over, we think we can ea- 
sily see why it should he popular. It is clear and 
simple in style, and, in the best sense of the word, 
practical. The arrangement is also natural, and is 
especially full in the therapeutical department In all 
our reading of such works as this we know of none 
other in any language the t has made a more favor- 
able impression on our mind.—Chicago Journ. of 
Nervous and Mental Diseases, Jan 1875. Henry C. Lea’s Publications—(Diseases of Women). 
23 
JTODGE (HUGH L.), M.D., 
J.J. Emeritus Professor of Obstetrics, <ire., in the University of Pennsylvania. 
ON DISEASES PECULIAR TO WOMEN; including Displacements 
of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 
From Prof. W. H. Btford, of the Rush Medical 
College, Chicago. 
The book bears the impress of a master hand, and 
must, as its predecessor, prove acceptable to the pro- 
fession. In diseases of women Dr. Hodge has estab- 
lished a school of treatment that has become world- 
wide in fame. 
Professor Hodge’s work is truly an original one 
from beginning to end, consequently no one can pe- 
rnseitspages without learning something new. The 
book, which is by no means a large one, is divided into 
two grand sections, so to speak: first, that treating of 
the nervous sympathies of the uterus, and, secondly, 
that which speaks of the mechanical treatment of dis- 
placements of that organ. He is disposed, as a non- 
believer in the frequency of inflammations of the 
uterus, to take strong ground against many of the 
highest authorities in this branch of medicine, and 
the arguments which he offers in support of his posi- 
tion are, to say the least, well put. Numerous wood- 
cuts adorn this portion of the work, and add incalcu- 
lably to the proper appreciation of the variously 
shaped instruments referred to by our author. As a 
contribution to the study of women’s diseases, it is of 
great value, and is abundantly able to stand on its 
own.merits.—N. T. Medical Record, Sept. 15,1868. 
TXTEST (CHARLES), M.D. 
V LECTURES ON THE DISEASES OF WOMEN. Third American, 
from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75 ; leather, $4 75. 
As a writer, Dr. West stands, in our opinion, se- 
cond only to Watson, the “Macaulay of Medicine 
he possesses that happy faculty of clothing instruc- 
tion in easy garments; combining pleasure with 
profit, he leads his pupils, in spite of the ancient pro- 
verb, along a royal road to learning. His work is one 
which will not satisfy the extreme on either side, but 
it is one that will please the great majority who are 
seeking truth, and one that will convince the student 
that he has committed himself to a candid, safe, and 
valuable guide.—N. A. Med.-Ohirurg Review. 
We have to say of it, briefly and decidedly, that it 
is the best work on the subject in any language, and 
that it stamps Dr. West as the facile princeps of 
British obstetric authors,—Edinburgh Med. Journal. 
JA ARNES (ROBERT), M. D., F.R. C.P., 
Obstetric Physician to St. Thomas's Hospital, &c. 
A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. In one handsome octavo volume of about 800 pages, with 
169 illustrations. Cloth, $5 00; leather, $6 00. {Just Issued.) 
The very complete scope of this volume and the manner in which it has been filled out, may 
be seen by the subjoined Summary of Contents. 
Introduction. Chapter I. Ovaries ; Corpus Luteum. II. Fallopian Tubes. III. Shape of 
Uterine Cavity. IY. Structure of Uterus. V. The Vagina. VI. Examinations and Diagnosis. 
VII. Significance of Leucorrhcea. VIII. Discharges of Air. IX. Watery Discharges. X. Puru- 
lent Discharges. XI. Hemorrhagic Discharges. XII. Significance of Pain. XIII. Significance 
of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diagnosis and Treatment. 
XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor- 
ders. XVIII. Amenorrhoea. XIX. Amenorrhcea (continued). XX. Dysmenorrhcea. XXI. 
Ovarian Dysmenorrhoea, Ac. XXII. Inflammatory Dysmenorrhcea. XXIII. Irregularities of 
Change of Life. XXIV. Relations between Menstruation and Diseases. XXV. Disorders of Old 
Age. XXVI. Ovary, Absence and Hernia of. XXVII. Ovary, Hemorrhage, Ac., of. XXVIII. 
Ovary, Tubercle, Cancer, Ac., of. XXIX. Ovarian Cystic Tumors. XXX. Dermoid Cysts of 
Ovary. XXXI. Ovarian Tumors, Prognosis of. XXXII. Diagnosis of Ovarian Tumors. XXXIII. 
Ovarian Cysts, Treatment of. XXXIV. Fallopian Tubes, Diseases of. XXXV. Broad Liga- 
ments, Diseases of. XXXVI. Extra-uterine Gestation. XXXVII. Special Pathology of Ute 
rus. XXXVIII. General Uterine Pathology. XXXIX. Alterations of Blood Supply. XL. 
Metritis, Endometritis, Ac. XLI. Pelvic Cellulitis and Peritonitis, Ac. XLII. Haematocele, Ac 
XLIII. Displacements of Uterus. XLIV. Displacements (continued). XLV. Retroversion and 
Retroflexion. XLVI. Inversion. XLVII. Uterine Tumors. XLVIII. Polypus Uteri. XLIX. 
Polypus Uteri (continued). L. Cancer. LI. Diseases of Vagina. LII. Diseases of the Vulva. 
Embodyingthelongexperience and personal obser- 
vation of one of the greatest of living teachers in dis- 
eases of women, it seems pervaded by the presence 
of the author, who speaks directly to the reader, and 
speaks, too, as one having authority. And yet, not- 
withstanding this distinct personality, there is noth- 
ing narrow as to time, place, or individuals, in the 
views presented, and in the instructions given; Dr. 
Barnes has been an attentive student, not only of Eu- 
ropean, but also of American literature, pertaining to 
diseases of females, and enrichedyhis own experience 
by treasures thence gathered ; he seems as familiar, 
for example, with the writings of Sims, Emmet, Tho- 
mas, and Peaslee, as if these eminent men were his 
countrymen and colleagues, and gives them a credit 
which must be gratifying to every American physi- 
cian.—Am. Journ. Med. Set, April, 1874. 
Throughout the whole hook it is impossible not to 
feel that the author has spontaneously, conscientious- 
ly, and fearlessly performed his task. He goes direct 
to the point, and does not loiter on the way to gossip 
or quarrel with other authors. Dr. Barnes’s book 
will be eagerly read all over the wo rid, and will 
everywhere be admired for its comprehensiveness, 
honesty of purpose, and ability. — The Obstet. Journ. 
of Great Britain and Ireland, March, 1874. 
DEWEES’S TREATISE ON THE DISEASES OP FE 
MALES. With illustrations. Eleventh Edition 
with the Author’s last improvements and correc 
tions. In one octavo volume of 538 pages, with 
plates, cloth. S3 00. 
CHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
8vo., pp. 450, cloth. $2 50. 
ASHWELL’S PRACTICAL TREATISE ON THE DIS- 
EASES PECULIAR TO WOMEN. Third American, 
from the Third and revised London edition. 1 vol. 
8vo., pp. 528, cloth. $3 50. 
ttEIGS ON THE NATURE, SIGNS, AND TREAT- 
MENT OP CHILDBED PEYER. 1 vol. 8vo., pp. 
365, cloth. $2 00. 24 
Henry C. Lea’s Publications—(Midwifery). 
TTODGE [HUGH L.), M.D., 
Emeritus Professor of Midwifery, Ac., in the University of Pennsylvania, Ac. 
THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 
The work of Dr. Hodge is something more than a 
simple presentation of his particular views in the de- 
partment of Obstetrics; it is something more than an 
ordinary treatise on midwifery ; it is, in fact, a cyclo- 
paedia of midwifery. He has aimed to embody in a 
single volume the whole science and art of Obstetrics. 
An elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
is left unstated or unexplained.—Am. Med. Times, 
Sept. 3, 1864. 
We should like to analyze the remainder of this 
excellent work, but already has this review extended 
beyond our limited space. We cannot conclude this 
notice without referring to the excellent finish of the 
work. In typography it is not to be excelled; the 
paper is superior to what is usually afforded by our 
American cousins, quite equal to the best of English 
books. The engravings and lithographs are most 
beautifully executed. The work recommends itself 
for its originality, and is in every way a most valu- 
able addition to those on the subject of obstetrics.— 
Canada Med. Journal, Oct. 1864 
It is very large, profusely and elegantly illustrated, 
and is fitted to take its place near the works of great 
obstetricians. Of the American works on the subject 
it is decidedly the best.—Edinb. Med. Jour., Dec. ’64. 
We have examined Professor Hodge’s work with 
great satisfaction; every topic is elaborated most 
fully. The views of the author are comprehensive, 
and concisely stated. The rules of practice are judi- 
cious, and will enable the practitioner to meet every 
emergency of obstetric complication with confidence. 
—Chicago Med. Journal, Aug. 1864. 
More time than we have had at our disposal since 
we received the great work of Dr. Hodge is necessary 
to do it justice. It is undoubtedly by far the most 
original, complete, and carefully composed treatise 
on the principles and practice of Obstetrics which has 
ever been issued from the American press.—Pacific 
Med. and Surg. Journal, July, 1864. 
We have read Dr. Hodge’s book with great plea- 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. The 
great attention which the author has devoted to the 
mechanism of parturition, taken along with the con- 
clusions at which he has arrived, point, we think, 
conclusively to the fact that, in Britain at least, the 
doctrines of Naegele have been too blindly received. 
—Glasgow Med. Journal, Oct. 1864. 
*** Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 
J1ANNER (THOMAS H), M.D. 
ON THE SIGNS AND DISEASES OF PREGNANCY. First American 
from the Second and Enlarged English Edition. With four colored plates and illustrations 
on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
The very thorough re vision the work has undergone 
has added greatly to its practical value, andincreased 
materially its efficiency as a guide to the student and 
to the young practitioner.—Am. Journ. Med. Sci., 
April, 1868. 
With the immense variety of subjects treated of 
and the ground which they are made to cover, the im- 
possibility of giving an extended review of this truly 
remarkable work must be apparent. We have not a 
single fault to find with it, and most heartily com- 
mend it to the careful study of every physician who 
would not only always be sure of his diagnosis of 
pregnancy, but always ready to treat all the nume- 
rous ailments that are, unfortunately for the civilized 
women of to-day, so commonly associated with the 
function.—N. Y. Med. Record, March 16, 1868. 
We recommend obstetrical students, young and 
old, to have this volume in their collections. It con- 
tains not only a fair statement of the signs, symptoms, 
and diseases of pregnancy, but comprises in addition 
much interesting relative matter that is not to be 
found in any other work that we can name.—Edin- 
burgh Med Journal, Jan. 1868. 
WAYNE (JOSEPH GRIFFITHS), M. D., 
Physician-Accoucheur to the British General Hospital, Ac. 
OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition with Additions by E. R. Hutchins, M. D. With Illustrations. In one 
neat I2mo volume Cloth, $1 25 ( Lately Issued.) 
See p. 3 of this Catalogue for the terms on which this work is offered as a premium to 
subscribers to the “ American Journal of the Medical Sciences.” 
It is really a capital little compendium of the sub- 
ject, and we recommend young practitioners to buy it 
and carry it with them when called to attend cases of 
labor. They can while away the otherwise tedious 
hours of waiting, and thoroughly fix in their memo- 
ries the most important pi-actical suggestions it con- 
tains. The American editor has materially added by 
his notes and the concluding chapters to the com- 
pleteness and general value of the book.—Chicago 
Med. Journal, Feb. 1870. 
The manual before us contains in exceedingly small 
compass—small enough to carry in the pocket—about 
all there is of obstetrics, condensed into a nutshell of 
Aphorisms. The illustrations are well selected, and 
serve as excellent reminders of the conduct of labor— 
regular and difficult.—Cincinnati Lancet, April, ’70. 
'phis is a mostadmirablelit.tle work, and completely 
answers the purpose. It is not only valuable for 
young beginners, but no one who is not a proficient 
in the art of obstetrics should be without it, because 
it condenses all that is necessary to know for ordi- 
nary midwifery practice. We commend the book 
most favorably.—St. Louis Med. andSurg. Journal, 
Sept. 10, 1870. 
A studied perusal of this little book has satisfied 
us of its eminently practical value. The object of the 
work, the author says, in his preface, is to give the 
student a few brief and practical directions respect- 
ing the management of ordinary cases of labor ; and 
also to point out to him in extraordinary cases when 
and how he may act upon his own responsibility, and 
when he ought to send for assistance.—N. ¥. Medical 
Journal, May, 1870 
\\TINCKEL (F.), 
• ' Professor and Director of the Gynecological Clinic in the University of Rostock. 
A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 
MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of 
the author, from the Second German Edition, by James Read Chadwick, M D. In one 
octavo volume. (Preparing.) Henry C. Lea’s Publications—(Midwifery). 
25 
TEISHMAN [WILLIAM), M.D., 
Regius Professor of Midwifery in the University of Glasgow, &c. 
A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 
PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
and Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to the 
Philadelphia Hospital, &c. In one large and very handsome octavo volume of over 700 
pages, with about two hundred illustrations. (Preparing.) 
This is one of a most complete and exhaustive cha- 
racter. We have gone carefully through it, and there 
is no subject in Obstetrics which has not been con- 
sidered well and fully. The result is a work, not 
only admirable as a text-book, but valuable as a work 
of reference to the practitioner in the various emer- 
gencies of obstetric practice. Take it all in all, we 
have no hesitation in saying that it is in our j udgment 
the best English work on the subject.—London Lan- 
cet, Aug. 23, 1873. 
The work of Leishman gives an excellent view of 
modern midwifery, and evinces its author’s extensive 
acquaintance with British and foreign literature ; and 
not only acquaintance with it, but wholesome diges- 
tion and sound judgment of it. He has, withal, a 
manly, free style, and can state a difficult and compli- 
cated matter with remarkable clearness and brevity. 
—Edin. Med. Journ., Sept. 1873. 
The author has succeeded in presenting to the pro- 
fession an admirable treatise, especially in its practi- 
cal aspects ; one which is, in general, clearly written, 
and sound in doctrine, and one which cannot fail to 
add to his already high reputation. In concluding 
our examination of this work, we cannot avoid again 
saying that Dr. Leishman has fully accomplished 
that diflicult task of presenting a good text-book upon 
obstetrics. We know none better for the use of the stu- 
dent or junior practitioner.—Am. Practitioner, Mar. 
1874. 
It proposes to offer to practitioners and students 
“A Complete System of the Midwifery of the Present 
Day,” and well redeems the promise. In all that 
relates to the subject of labor, the teaching is admi- 
rably clear, concise, and practical, representing not 
alone British practice, but the contributions of Con- 
tinental and American schools.—N. Y. Med. Recoi'd, 
March 2, 1874. 
The work of Dr. Leishman is, in many respects, 
not only the best treatise on midwifery that we have 
seen, but one of the best treatises on any medical sub- 
ject that has been published of late years.—Land. 
Practitioner, Feb. 1874. 
It was written to supply a desideratum, and we Will 
be much surprised if it does not fulfil the purpose of 
its author. Taking it as a whole, we know of no 
work on obstetrics by an English author in which the 
student and the practitioner will find the information 
so clear and so completely abreast of the present state 
of our knowledge on the subject.— Glasgow Med. 
Journ., Aug. 1873. 
Dr. Leishman’s System of Midwifery, which has 
only just been published, will go far to supply the 
want which has so long been felt, of a really good 
modern English text-book. Although large, as is in- 
evitable in a work on so extensive a subject, it is so 
well and clearly written, that it is never wearisome 
to read. Dr. Leishman’s work may be confidently 
recommended as an admirable text-book, and is sure 
to be largely used.—Lond. Med. Record, Sept. 1873. 
JJAMSBOTHAM (FRANCIS H.), M.D. 
THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. Y. Keating, M. D., 
Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 
We will only add that the student will learn from 
It all he need to know, and the practitioner will find 
it, as a book of reference, surpassed by none other.— 
Stethoscope. 
The character and merits of Dr. Ramsbotham’s 
work are so well known and thoroughly established, 
that comment is unnecessary and praise superfluous. 
The illustrations, which are numerous and accurate, 
are executed in the highest style of art. We cannot 
too highly recommend the work to our readers.—St. 
touis Med. and Surg. Journal. 
To the physician's library it is indispensable, while 
to the student, as a text-book, from which to extract 
the material for laying the foundation of an education 
on obstetrical science, it has no superior.—Ohio Med. 
and Surg. Journal. 
When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot but 
envy the student of the present day the aid which 
this work will afford him.—Am. Jour, of the Med. 
Sciences. 
(JR UR CHILL (FLEETWOOD), M.D., M.R.T.A. 
ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 
American from the fourth revised and enlarged London edition. With notes and additions 
by D. Francis Condie, M. D., author of a “Practical Treatise on the Diseases of Chil- 
dren,’’ Ac. With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00; leather, $5 00. 
pARRY (JOHN S.), M.D., 
Obstetrician to the Philadelphia Hospital, Vice-Prest. of the Obstet. Society of Philadelphia 
EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 
DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
(.Preparing.) 
MONTGOMERY’S EXPOSITION OF THE SIGNS I 
AND SYMPTOMS OF PREGNANCY. With two j 
exquisite colored plates, and numerous wood-cuts. | 
In 1 vol. 8vo., of nearly 600 pp., cloth. $3 75. I 
RIGBY’S SYSTEM OF MIDWIFERY. With Notes 
and Additional Illustrations. Second American 
edition. One volume octavo, cloth, 422 pages. 
$2 50. 26 
Henry C. Lea’s Publications—{Surgery). 
61ROSS (SAMUEL D.), M.D., 
Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 
and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In the 
present revision no pains have been spared by the author to bring it in every respect fully up to 
the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
nearly one-fourth, notwithstanding which the price has been kept at its former very moderate 
rate. By the use of a close, though very legible type, an unusually large amount of matter is 
condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
This, combined with the most careful mechanical execution, and its very durable binding, renders 
it one of the cheapest works accessible to the profession. Every subject properly belonging to the 
domain of surgery is treated in detail, so that the student who possesses this work may be said to 
have in it a surgical library. A few notices of the previous edition are subjoined :— 
It must long remain the most comprehensive work 
on this important part of medicine.—Boston Medical 
and Surgical Journal, March 23, 1865. 
We have compared it with most of our standard 
works, such as those of Erichsen, Miller, Fergusson, 
Syme, and others, and we must, in justice to our 
author, award it the pre-eminence. As a work, com- 
plete in almost every detail, no matter how minute 
or trifling, and embracing every subject known in 
the principles and practice of surgery, we believe it 
stands without a rival. Dr. Gross, in his preface, re- 
marks “my aim has been to embrace the whole do- 
main of surgery, and to allot to every subject its 
legitimate claim to notice;” and, we assure our 
readers, he has kept his word. It is a work which 
we can most confidently recommend to our brethren, 
for its utility is becoming the more evident the longer 
it is upon the shelves of our library.—Canada Med. 
Journal, September, 1865. 
The first two editions of Professor Gross’ System of 
Surgery are so well known to the profession, and so 
highly prized, that it would be idle for us to speak in 
praise of this work.— Chicago Medical Journal, 
September, 1865. 
We gladly indorse the favorable recommendation 
of the work, both as regards matter and style, which 
we made when noticing its first appearance.—British 
and Foreign Medico-Ohirurgical Review, Oct. 1865. 
The most complete work that has yet issued from 
the press on the science and practice of surgery.— 
London Lancet. 
This system of surgery is, we predict, destined to 
take a commanding position in our surgical litera- 
ture, and be the crowning glory of the author’s well 
earned fame. As an authority on general surgical 
subjects, this work is long to occupy a pre-eminent 
place, not only at home, but abroad. We have no 
hesitation in pronouncing it 'without a rival in our 
language, and equal to the best systems of surgery in 
any language.—JY. Y. Med. Journal. 
Not only by far the best text-book on the subject, 
as a whole, within the reach of American students, 
but one which will be much more than ever likely 
to be resorted to and regarded as a high authority 
abroad.—Am. Journal Med. Sciences, Jan. 1865. 
The work contains everything, minor and major, 
operative and diagnostic, including mensuration and 
examination, venereal diseases, and uterine manipu- 
lations and operations. It is a complete Thesaurus 
of modern surgery, where the student and practi- 
tioner shall not seek in vain for what they desire.— 
San Francisco Med. Press, Jan. 1865. 
Open it where we may, we find sound practical in- 
formation conveyed in plain language. This book is 
no mere provincial or even national system of sur- 
gery, but a work which, while very largely indebted 
to the past, has a strong claim on the gratitude of the 
f uture of surgical science. —Edinburgh Med. Journal, 
Jan. 1865. 
A glance at the work is sufficient to show that the 
author and publisher have spared no labor in making 
it the most complete “System of Surgery” ever pub- 
lished in any country.—St. Louis Med. and Surg. 
Journal, April, 1865. 
A system of surgery which we think unrivalled in 
our language, and which will indelibly associate his 
name with surgical science. And what, in our opin- 
ion, enhances the value of the work is that, while the 
practising surgeon will find all that he requires in it, 
it is at the same time one of the most valuable trea- 
tises which can be put into the hands of the student 
seeking to know the principles and practice of this 
branch of the profession which he designs subse- 
quently to follow.—The Brit. Am.Journ., Montreal. 
THE SAME AUTHOR. 
A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 
AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 
i. 468, cloth, $2 75. 
SKEY’S OPERATIVE SURGERY. In 1 vol. 8vo. 
cloth, of over 650 pages ; with about 100 wood-cuts. 
$3 25. 
COOPER’S LECTURES ON THE PRINCIPLES AND 
Practice of Surgery. In 1 vol. Svo. cloth, 750 p. $2. 
GIBSON’S INSTITUTES AND PRACTICE OF SUR- 
GERY. Eighth edition, improved and altered. With 
thirty-four plates, in two handsome octavo vol- 
umes, about 100O pp., leather, raised bands. $6 50. 
MILLER (JAMES), 
MuL Late Professor of Surgery in the University of Edinburgh, &c. 
PRINCIPLES OF SURGERY. Fourth American, from the third and 
revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
two hundred and forty illustrations on wood, cloth, $3 75. 
THE SAME AUTHOR. 
THE PRACTICE OP SURGERY. Fourth American, from the iast 
Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, cloth, 
$3 75. 
&ARGENT (F. W.), M.D. 
° ON BANDAGING AND OTHER OPERATIONS OF MINOR 
SURGERY. New edition, with an additional chapter on Military Surgery. One handsome 
royal 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Cloth, $1 76. Henry C. Lea’s Publications—(Surgery). 
A SHHURST [JOHN, Jr.), M.D., 
Surgeon to the Episcopal Hospital, Philadelphia. 
THE PRINCIPLES AND PRACTICE OF SURGERY. In one 
very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 
cloth, $6 50; leather, raised bands, $7 50. (Lately Published.) 
The object of the author has been to present, within as condensed a compass as possible, a 
oomplete treatise on Surgery in all its branches, suitable both as a text-book for the student and 
a work of reference for the practitioner. So much has of late years been done for the advance- 
ment of Surgical Art and Science, that there seemed to be a want of a work which should present 
the latest aspects of every subject, and which, by its American character, should render accessible 
to tne profession at large the experience of the practitioners of both hemispheres. This has been 
the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- 
torily. 
' Its author has evidently tested the writings and 
experiences of the past and present in the crucible 
of a careful, analytic, and honorable mind, andfaith- 
fully endeavored to bring his work up to the level of 
the highest standard of practical surgery. He is 
frank and definite, and gives us opinions, and gene- 
rally sound ones, instead of a mere resume of the 
opinions of others. He is conservative, but not hide- 
bound by authority. His style is clear, elegant, and 
scholarly. The work is an admirable tex-tbook, and 
a useful book of reference It is a credit to American 
professional literature, and one of the first ripe fruits 
of the soil fertilized by the blood of our late unhappy 
war.—N. Y. Med. Record, Feb. 1, 1872. 
Indeed, the work as a whole must be regarded as 
an excellent and concise exponent of modern sur- 
gery, and as such it will be found a valuable text- 
book for the student, and a useful book of reference 
for the general practitioner.—N. Y. Med. Journal, 
Feb. 1872. 
It gives us great pleasure to call the attention of the 
profession to this excellent work. Our kno wledge of 
its talented and accomplished author led us to expect 
from him a very valuable treatise upon subjects to 
which he has repeatedly given evidence of having pro- 
fitably devoted much time and labor, and we are in no 
way disappointed.— Phila. Med. Times, Feb. 1, 1872. 
JJOLMES [TIMOTHY], M.D., 
Surgeon to St. George's Hospital, London. 
SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
some octavo volume of about 800 pages, with over 400 illustrations. (Nearly Ready.) 
piRRIE ( WILLIAM), F. R. S. E., 
•A Professor of Surgery in the University of Aberdeen. 
THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 
John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 31® 
illustrations, cloth, $3 75. 
TJAM IL TON (FRANK H.), M.D., 
Professor of Fractures and Dislocations, Ac., in Bellevue Hosp. Med. College, New Yorlc. 
A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS. Fifth edition, revised and improved. In one large and handsome octavovolume 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75. (Nearly Ready.) 
This work is well known, abroad as well as at home, as the highest authority on its important 
subject—an authority recognized in the courts as well as in the schools and in practice—and 
again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
author has thus had the opportunity of making have enabled him to give the most careful consid- 
eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever 
of value has been added in this department since the issue of the fourth edition. It will there- 
fore be found considerably improved in matter, while the most careful attention has been paid 
to the typographical execution, and the volume is presented to the profession in the confident 
hope that it will more than maintain its very distinguished reputation. 
A few notices of the previous edition are subjoined :— 
Prof. Hamilton has a world-wide reputation as the 
author of a Treatise on Fractures and Dislocations, 
which it is safe to say has no equal in the English 
language.—Buffalo Med. and Surg. Journ., Nov. 
(872. 
The best work on the subject now published.—Am. 
Journ. of Med. Sci., Jan. 1873. 
It is undoubtedly the best on those subjects in the 
English language. — Nashville Med. and Surg. 
Journ., Dec. 1872. 
it is not, of course, our intention to review, in ex- 
tenso, Hamilton on “Fractures and Dislocations.” 
Eleven years ago such review might not have been 
out of place; to-day the work is an authority, so well, 
so generally, and so favorably known, that it only 
remains for the reviewer to say that a new edition is 
just out, and it is better than either of its predeces- 
sors.—Cincinnati Clinic, Oct. 14, 1871. 
Undoubtedly the best work on Fractures and Dis' 
locations in the English language.—Cincinnati Meet- 
Repertory, Oct. 1871. 
We have once more before us Dr. Hamilton’s admi- 
rable treatise, which we have always considered the 
most complete and reliable work on the subject. As 
a whole, the work is without an equal in the litera- 
ture of the profession.—Boston Med. and Burg. 
Journ., Oct. 12, 1871. 
It is unnecessary at this time to commend the book, 
except to such as are beginners in the study of this 
particular branch of surgery. Every practical sur- 
geon in this country and abroad knows of it as a most 
trustworthy guide, and one which they, in common 
with us, would unqualifiedly recommend as the high- 
est authority in any language.—N. Y. Med. Record, 
Oct. 16, 1871. 28 
Henry C. Lea’s Publications—{Surgery). 
LiRICHSEN (JOHN E.), 
■*-* Professor of Surgery in University College, London, etc. 
THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 
gical Injuries, Diseases, and Operations. Revised by the author from the Sixth and 
enlarged English Edition. Illustrated by over seven hundred engravings on wood. In 
two large and beautiful octavo volumes of over 1700 pages, cloth, $9 00 ; leather, $11 00. 
{Lately Issued.) 
Author’’s Preface to the New American Edition. 
“ The favorable reception with which the ‘ Science and Art of Surgery’ has been honored by the 
Surgical Profession in the United States of America has been not only a source of deep grati&ea- 
tion and of just pride to me, but has laid the foundation of many professional friendships *hat 
are amongst the agreeable and valued recollections of my life. 
“I have endeavored to make the present edition of this work more deserving than its predecessors 
of the favor that has been accorded to them. In consequence of delays that have unavoidably 
occurred in the publication of the Sixth British Edition, time has been afforded to me to add to this 
one several paragraphs which I trust will be found to increase the practical value of the work.” 
London, Oct. 1872. 
On no former edition of this work has the author bestowed more pains to render it a complete and 
satisfactory exposition of British Surgery in its modern aspects. Every portion has been sedu- 
lously revised, and a large number of new illustrations have been introduced. In addition to the 
material thus added to the English edition, the author has furnished for the American edition such 
material as has accumulated since the passage of the sheets through the press in London, so that 
the work as now presented to the American profession, contains his latest views and experience. 
The increase in the size of the work has seemed to render necessary its division into two vol- 
umes. Great care has been exercised in its typographical execution, and it is confidently pre-. 
sented as in every respect worthy to maintain the high reputation which has rendered it a stand- 
ard authority on this department of medical science. 
These are only a few of the points in which the 
present edition of Mr. Erichsen’s work surpasses its 
predecessors. Throughout there is evidence of a 
laborious care and solicitude in seizing the passing 
knowledge of the day, which reflects the greatest 
credit on the author, and much enhances the value 
of his work. We can only admire the industry which 
has enabled Mr. Eriehsen thus to succeed, amid the 
distractionsof active practice, in producing emphatic- 
ally the book of reference and study for British prac- 
titioners of surgery.—London Lancet, Oct. 26, 1872. 
Considerable changes have been made in this edi- 
tion, and nearly a hundred new illustrations have 
been added. It is difficult in a small compass to point 
out the alterations and additions; for, as the author 
states in his preface, they are not confined to any one 
portion, but are distributed generally through the 
subjects of which the work treats. Certainly one of 
the most valuable sections of the book seems to us to 
be that which treats of the diseases of the arteries 
and the operative proceedings which they necessitate 
In few text-books is so much carefully arranged in- 
formation collected.—London Med. Times and Oaz., 
Oct. 26, 1872. 
The entire work, complete, as the great English 
treatise on Surgery of our own time, is, we can assure 
our readers, equally well adapted for the most junior 
student, and, as a book of reference, for the advanced 
practitioner —Dublin Quarterly Journal. 
T)RVITT [ROBERT), M.R.C.S., frc. 
PRINCIPLES AND PRACTICE OF MODERN SURGERY. 
A new and revised American, from the eighth enlarged and improved London edition. Illus- 
trated with four hundred and thirty-two wood engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 
All that the surgical student or practitioner could 
desire.—Dublin Quarterly Journal. 
It is a most admirable book. We do not know 
when we have examined one with more pleasure.— 
Boston Med. and Surg. Journal. 
In Mr. Druitt’s book, though containing only some 
seven hundred pages, both the principles and the 
practice of surgery are treated, and so clearly and 
perspicuously, as to elucidate every important topic. 
We have examined the book most thoroughly, and 
can say that this success is well merited. His book, 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and clas- 
sified, and of being written in a style at once clear 
rnd succinct.—Am. Journal of Med. Sciences. 
(T. J.). 
ON THE DISEASES, INJURIES, AND MALFORMATIONS OF 
THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, 
from the fourth and enlarged London edition. With handsome illustrations. In one very 
beautifully printed octavo volume of about 300 pages, cloth, $3 25. 
niGELO W (HENRY J.), M. D., ' 
Professor of Surgery in the Massachusetts Med. College. 
ON THE MECHANISM OF DISLOCATION AND FRACTURE 
OP THE HIP. With the Reduction of the Dislocation by the Flexion Method. With 
numerous original illustrations. In one very handsome octavo volume. Cloth, $2 50. 
T A WSON [GEORGE), F. R. 0. S., Engl, 
•A-J Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorflelds, Ssc. 
INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 
diate and Remote Effects. With about one hundred illustrations. In one very hand- 
some octavo volume, cloth, $3 50 
It is an admirable practical book in the highest and best sense of the phrase.—London Medical Times 
and Gazette, May 18, 1867. Henry C. Lea’s Publications—(Surgery). 
29 
T>RYANT {THOMAS), F.R.C.S., 
Surgeon to Guy’s Hospital. 
THE PRACTICE OF SURGERY. With over Five Hundred En- 
gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, 
cloth, $6 25 ; leather, raised bands, $7 25. (Lately Published.) 
Again, the author gives us his own practice, his 
own beliefs, and illustrates by his own cases, or those 
treated in Guy’s Hospital. This feature adds joint 
emphasis, and a solidity to his statements that inspire 
confidence. One feels himself almost by the side of 
the surgeon, seeing his work and hearing his living 
words. The views, etc., of other surgeons are con- 
sidered calmly and fairly, but Mr. Bryant’s are 
adopted. Thus the work is not a compilation of 
other writings; it is not an encyclopaedia, but the 
plain statements, on practical points, of a man who 
has lived and breathed and had his being in the 
richest surgical experience. The whole profession 
owe a debt of gratitude to Mr. Bryant, for his work 
in their behalf. We are confident that the American 
profession will give substantial testimonial of their 
feelings towards both author and publisher, by 
speedily exhausting this edition. We cordially and 
heartily commend it to our friends, and think that 
no live surgeon can afford to be without it.—Detroit 
Review of Med. and Pharmacy, August, 1873. 
As a manual of the practice of surgery for the use 
of the student, we do not hesitate to pronounce Mr. 
Bryant’s book a first-rate work. Mr. Bryant has a 
good deal of the dogmatic energy which goes with 
the clear, pronounced opinions of a man whose re- 
flections and experience have moulded a character 
not wanting in firmness and decision. At the same 
time he teaches with the enthusiasm of one who has 
faith in his teaching; he speaks as one having au- 
thority, and herein lies the charm and excellence of 
his work. He states the opiuions of others freely 
and fairly, yet it is no mere compilation. The book 
combines much of the merit of the manual with the 
merit of the monograph. One may recognize in 
almost every chapter of the ninety-four of which the 
work is made up the acuteness of a surgeon who has 
seen much, and observed closely, and who gives forth 
the results of actual experience. In conclusion we 
repeat what we stated at first, that Mr. Bryant’s book 
is one which we can conscientiously recommend both 
to practitioners and students as an admirable work. 
—Dublin Journ. of Med. Science, August, 1873. 
Mr. Bryant has long been known to the reading 
portion of the profession as an able, clear, and graphic 
writer upon surgical subjects. The volume before 
us is one eminently upon the practice of surgery and 
not one which treats at length on surgical pathology, 
though the views that are entertained upon tnis sub- 
ject are sufficiently interspersed through the work 
for all practical purposes. As a text-book we cheer- 
fully recommend it, feeling convinced that, from the 
subject-matter, and the concise and true way Mr. 
Bryant deals with his subject, it will prove a for- 
midable rival among the numerous surgical text- 
books which are offered to the student.—N. ¥. Med. 
Record, June, 1873. 
This is, as the preface states, an entirely new book, 
and contains in a moderately condensed form all the 
surgical information necessary to a general practi- 
tioner. It is written in a spirit consistent with the 
present improved standard of medical and surgical 
science.—American Journal of Obstetrics, August, 
1873. 
XXTELLS ( J. SOELBERG), 
' f Professor of Ophthalmology in King’s College Hospital, &c. 
A TREATISE ON DISEASES OF THE EYE. Second American, 
from the Third and Revised London Edition, with additions ; illustrated with numerous 
engravings on wood, and six colored plates. Together with selections from the Test-types 
of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 
pages j cloth, $5 00 ; leather, $6 00. (Lately Published.) 
The continued demand for this work, both in England and this country, is sufficient evidence 
that the author has succeeded in his effort to supply within a reasonable compass a full practical 
digest of ophthalmology in its most modern aspects, while the call for repeated editions has en- 
abled him in his revisions to maintain its position abreast of the most recent investigations and 
improvements. In again reprinting it, every effort has been made to adapt it thoroughly to the 
wants of the American practitioner. Such additions as seemed desirable have been introduced 
by the editor, Dr. I. Minis Hays, and the number of illustrations has been largely increased. The 
importance of test-types as an aid to diagnosis is so universally acknowledged at the present day 
that it seemed essential to the completeness of the work that they should be added, and as the 
author recommends the use of those both of Jaeger and of Snellen for different purposes, selec- 
tions have been made from each, so that the practitioner may have at command all the assist- 
ance necessary. Although enlarged by one hundred pages, it has been retained at the former 
very moderate price, rendering it one of the cheapest volumes before the profession. 
A few notices of the previous edition are subjoined. 
On examining it carefully, one is not at all sur- 
prised that it should meet with universal favor. It 
is, in fact, a comprehensive and thoroughly practical 
treatise on diseases of the eye, setting forth the prac- 
tice of the leading oculists of Europe and America, 
and giving the author’s own opinions and preferences, 
which are quite decided and worthy of high consid- 
eration. The third English edition, from which this 
is taken, having been revised by the author, com- 
prises a notice of all the more recent advances made 
in ophthalmic science. The style of the writer is 
lucid and flowing, therein differing materially from 
some of the translations of Continental writers on this 
subject that are in the market. Special pains are 
taken to explain, at length, those subjects which are 
particularly difficult of comprehension to the begin- 
ner, as the use of the ophthalmoscope, the interpre- 
tation of its images, etc. The book is profusely and 
ably illustrated, and at the end are to be found 16 
excellent colored ophthalmoscopic figures, which are 
copies of some of the plates of Liebreich’s admirable 
atlas.—Kansas City Med. Journ., June, 1871. 
T A VRENCE (JOHN Z.), F. R. C. S., 
Editor of the Ophthalmic Review, &c. 
A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 
Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In 
one very handsome octavo volume, cloth, $2 75. 
For those, however, who must assume the care of | 
diseases and injuries of the eye, and who are too j 
much pressed for time to study the classic works on 
the subject, or those recently published by Stellwag, 
Wells, Bader, and others, Mr. Laurence will prove a 
safe and trustworthy guide. He has described in this 
edition those novelties which have secured the confi- 
dence of the profession since the appearance of his 
last. The volume has been considerably enlarged 
l and improved by the revision and additions of its 
I author, expressly for the American edition.—Am. 
I Journ. Med. Sciences, Jan. 1870. Henry C. Lea’s Publications—(Surgery, &c.). 
30 
rPHOMPSON (SIR HENB Y), 
A Surgeon and Professor of Clinical Surgery to University College Hospital. 
LECTURES ON DISEASES OF THE URINARY ORGANS. With 
illustrations on wood. Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. (Just Issued.) 
My aim has been to produce in the smallest possible compass an epitome of practical knowl- 
edge concerning the nature and treatment of the diseases which form the subject of the work ; 
and I venture to believe that my intention has been more fully realized in this volume than in 
either of its predecessors.—Author's Preface. f 
THE SAME AUTHOR. 
ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 
THE URETHRA AND URINARY FISTULAS. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
(Lately Published.) 
JJY THE SAME AUTHOR. (Just Issued.) 
THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY 
AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 
355 pages, with thirteen plates, plain and colored, and illustrations on wood. Cloth, $3 75. 
FT A YL OR (ALFRED S.), M.D., 
A Lecturer on Med. Jurisp. and Chemistry in Gfuy’s Hospital 
MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 
by John J. Reese, M.D., Prof, of Med. Jurisp. in the Univ. of Penn. In one large 
octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Just Issued.) 
In preparing for the press this seventh American edition of the “ Manual of Medical Jurispru- 
dence” the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of 
consulting the sheets of the new edition of the author’s larger work, “ The Principles and Prac- 
tice of Medical Jurisprudence,” which is now ready for publication in London. This has enabled 
him to introduce the author’s latest views upon the topics discussed, which are believed to bring 
the work fully up to the present time. 
The notes of the former editor, Dr. Hartshorne, as also the numerous valuable references to 
American practice and decisions by his successor, Mr. Penrose, have been retained, with but few 
slight exceptions ; they will be found inclosed in brackets, distinguished by the letters (H.) and 
(P.). The additions made by the present editor, from the material at his command, amount to 
about one hundred pages; and his own notes are designated by the letter (R.). 
Several subjects, not treated of in the former edition, have been noticed in the present one, 
and the work, it is hoped, will be found to merit a continuance of the confidence which it has so 
long enjoyed as a standard authority. 
THE SAME AUTHOR. (Now Ready.) 
THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 
DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 
volumes, cloth, $10 00; leather, $12 00. 
This great work is now recognized in England as the fullest and most authoritative treatise on 
every department of its important subject. In laying it, in its improved form, before the Ameri- 
can profession, the publisher trusts that itwill assume the same position in this country. 
1 THE SAME AUTHOR. New Edition—Now Ready. 
POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 
MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. 
This work, which has been so long recognized as a leading authority on its important subject, 
has received a very thorough revision at the hands of the author, and may be regarded as a 
new book rather than as a mere revision. He has sought to bring it on all points to a level 
with the advanced science of the day; many portions have been rewritten, much that was of 
minor importance has been omitted, and every effort made to condense a complete view of the 
subject within the limits of a single volume. Dr. Taylor’s position as an expert has brought 
him into connection with nearly all important cases in England for many years. He thus speaks 
with an authority that few other living men possess, while his intimate acquaintance with the 
literature of toxicology on both sides of the Atlantic, renders his work equally adapted as a 
text-book in this country as in Great Britain. 
Poisons.—Absorption and Elimination—Detection—Action—Influence of Habit—Classifica- 
tion ot Poisons—Evidence of Poisoning—Diseases resembling Poisoning—Inspection of the Dead 
Body—Objects of Chemical Analysis—Moral and Circumstantial Evidence in Poisoning, &c. Ac. 
Irritant Poisons.—Mineral Irritants—Acid Poisons—Alkaline Poisons—Non-Metallic Irri- 
tants—Metallic Irritants—Vegetable Irritants—Animal Irritants. 
Neurotic Poisons.—Cerebral or Narcotic Poisons—Spinal Poisons—Cerebro-Spinal Poisons 
Cerebro-Cardiae Poisons. 
CONTENTS. Henry C. Lea’s Publications—(Psychological Medicine, &c.). 
31 
rrUKE (DANIEL HACK), M.D., 
A- Joint author of “ The Manual of Psychological Medicine,” Ac. 
ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 
THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Just Issued.) 
The object of the author in this work has been to show not only the effect of the mind in caus- 
ing and intensifying disease, but also its curative influence, and the use which may be made of 
the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- 
ject have long been familiar to the profession, but no attempt has hitherto been made to colleot 
and systematize them so as to render them available to the practitioner, by establishing the seve- 
ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate 
medicine the means which have been employed so successfully in many systems of quackery, the 
author has produced a work of the highest freshness and interest as well as of permanent value. 
J2LANDF0RD (G. FIELDING), M. D., F. R. C P., 
-•A Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 
INSANITY AND ITS TREATMENT: Lectures on the Treatment, 
Medical and Legal, of Insane Patients. With a Summary of t"he Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages; cloth, $3 25. 
This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- 
tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of 
more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- 
formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment 
be called upon to take action in relation to patients. 
It satisfies a want which must have been sorely 
felt by the busy general practitioners of this country. 
It takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particular attention to this feature 
of the book, as giving it a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 
actually seen in practice and the appropriate treat- 
ment for them, we find in Dr. Blandford’s work a 
considerable advance over previous writings on the 
subject. His pictures of the various forms of mental 
•disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
ordinary manuals in the English language or (so far 
as our own reading extends) in any other.—London 
Practitioner, Feb. 1871. 
1yiNSLOW (FORBES), M.D., D.G.L., #c. 
rrON OBSCURE DISEASES OF THE BRAIN AND DISORDERS 
OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
phylaxis. Second American, from the third and revised English edition. In one handsome 
octavo volume of nearly 600 pages, cloth, $4 25. 
TEA (HENRY <?.). 
SUPERSTITION AND FORCE: ESSAYS ON THE WADER OF 
LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, 
Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; cloth, $2 75. 
(Lately Published.) 
We know of no single work which contains, in so 
small a compass, so much illustrative of the strangest 
operations of the human mind. Foot-notes give the 
authority for each statement, showing vast research 
and wonderful industry. We advise our confreres 
to read this book and ponder its teachings.—Chicago 
Med. Journal, Aug. 1S70. 
As a work of curious inquiry on certain outlying 
points of obsolete law, “Superstition and Force” is 
one of the most remarkable books we have met with. 
—London Athenceum, No v. 3, 1866. 
He has thrown a great deal of light upon what must 
be regarded as one of the most instructive as well as 
interesting phases of human society and progress. . . 
The fulness and breadth with which he has carried 
out his comparative survey of this repulsive field of 
history [Torture], are such as to preclude our doing 
justice to the work within our present limits. But 
here, as throughout the volume, there will be found 
a wealth of illustration and a critical grasp of the 
philosophical import of facts which will render Mr. 
Lea’s labors of sterling value to the historical stu- 
dent.—London Saturday Review, Oct. 8, 1870. 
As a book of ready reference on the subject, it is of 
the highest value.—Westminster Review, Oct. 1867. 
nf THE SAME AUTHOR. (Lately Published.) 
STUDIES IN CHURCH HISTORY—THE RISE OF THE TEM- 
PORAL POWER—BENEFIT OF CLERGY—EXCOMMUNICATION. In one large royal 
12mo. volume of 516 pp. cloth, $2 75. 
The story was never told more calmly or with 
greater learning or wiser thought. We doubt, indeed, 
if any other study of this field can be compared with 
this for clearness, accuracy, and power.— Chicago 
Examiner, Dec. 1870. 
Mr. Lea’s latest work, “Studies in Church History,” 
fully sustains the promise of the first. It deals with 
three subjects—the Temporal Power, Benefit of 
Clergy, and Excommunication, the record of which 
has a peculiar importance for the English student, and 
is a chapter on Ancient Law likely to be regarded as 
final. We can hardly pass from our mention of such 
works as these—with which that on “Sacerdotal 
Celibacy” should be included—without noting the 
literary phenomenon that the head of one of the first 
American houses is also the writer of some of its most 
original books.—London Athenceum, Jan. 7, 1871. 
Mr. Lea has done great honor to himself and this 
country by the admirable works he has written on 
ecclesiologicaland cognate subjects. We have already 
had occasion to commend his “Superstition and 
Force” and his “History of Sacerdotal Celibacy.” 
The present volume is fully as admirable in its me- 
thod of dealing with topics and in the thoroughness— 
a quality sofrequently iackingin American authors— 
with which they are investigated.—N. Y. Journal of 
Psychol. Medicine, July, 1870. 32 
Henry C. Lea’s Publications. 
INDEX TO CATALOGUE. 
American Journal of the Medical Sciences . 1 
Abstract, Half-Yearly, of the Med Sciences . 3 
Anatomical Atlas, by Smith and Horner . . 6 
Anderson on Diseases of the Skin . . .20 
Ashton on the Rectum and Anus . . . .28 
Attfield’s Chemistry 10 
Ashwell on Diseases of Females . . . .23 
Ashhurst’s Surgery 27 
Barnes on Diseases of Women . . . .23 
Bellamy’s Surgical Anatomy .... 7 
Bryant’s Practical Surgery 29 
Bloxam’s Chemistry • 11 
Blandford on Insanity 31 
Basham on Renal Diseases 18 
Brinton on the Stomach 16 
Bigelow on the Hip ... .28 
Barlow’s Practice of Medicine . . . . 14 
Bowman’s (John E.) Practical Chemistry . . 11 
Bowman’s (John E.) Medical Chemistry . 11 
Brunton’s Materia Medica 14 
Bumstead on Venereal 19 
Bumstead and Cullerier’s Atlas of Venereal . 19 
Carpenter’s Human Physiology .... 8 
Carpenter’s Comparative Physiology ... 8 
Carpenter on the Use and Abuse of Alcohol . 13 
Chambers on Diet and Regimen . . . . 16 
Chambers’s Restorative Medicine . . . 16 
Christison and Griffith’s Dispensatory . ] 13 
Churchill’s System of Midwifery . . . ‘ 2p 
Churchill on Puerperal Fever . . . '23 
Condie on Diseases of Children . . . ‘21 
Cooper’s (B. B.) Lectures on Surgery . . ’26 
Cullerier’s Atlas of Venereal Diseases . ‘ 19 
Cyclopedia of Practical Medicine ... ‘ 15 
Dalton’s Human Physiology .... ‘ 9 
Davis’ Clinical Lectures . . . . • 14 
Dewees on Diseases of Females ... -23 
Dewees on Diseases of Children . . . -20 
Druitt’s Modern Surgery • 28 
Dunglison’s Medical Dictionary . . . • 4 
Dunglison’s Human Physiology . . . • 9 
Dunglison on New Remedies . . . • 13 
Ellis’s Medical Formulary, by Smith . . -13 
Erichsen’s System of Surgery . . . -28 
F’enwick’s Diagnosis .14 
Flint on Respiratory Organs I7 
Flint on the Heart .17 
Flint’s Practice of Medicine ..... 15 
Flint’s Essays .15 
Flint on Phthisis 17 
Fownes’s Elementary Chemistry . . . -10 
Fox on Diseases of the Stomach . . . . 16 
Fuller on the Lungs, &c .17 
Green’s Pathology and Morbid Anatomy . . 14 
Gibson’s Surgery .26 
G luge’s Pathological Histology, by Leidy . . 14 
Galloway’s Qualitative Analysis . . . .10 
Gray’s Anatomy 6 
Griffith’s (R. E.) Universal Formulary . . 13 
Gross on Foreign Bodies in Air-Passages . . 26 
Gross’s Principles and Practice of Surgery . . 26 
Guersant on Surgical Diseases of Children . . 20 
Hamilton on Dislocations and Fractures . . 27 
Hartshorne’s Essentials of Medicine . . .16 
Hartshorne’s Conspectus of the Medical Sciences 5 
Hartshorne’s Anatomy and Physiology . . 7 
Heath's Practical Anatomy 7 
Hoblyn’s Medical Dictionary .... 4 
Hodge on Women 23 
Hodge’s Obstetrics 24 
Hodges’ Practical Dissections .... 6 
Holland’s Medical Notes and Reflections . . 14 
Holmes’s Surgery 27 
Horner’s Anatomy and Histology ... 6 
Hudson on Fevers 18 
Hill on Venereal Diseases 19 
Hillier’s Handbook of Skin Diseases . . 20 
Jones (C. Handfield) on Nervous Disorders . 18 
PAGE 
Kirkes’ Physiology 8 
Knapp’s Chemical Technology . . . H 
Lea’s Superstition and Force . . . .31 
Lea's Studies in Church History . . . .31 
Lee on Syphilis 18 
Lincoln on Electro-Therapeutics . . . . 18 
Leishman’s Midwifery 2-5 
La Roche on Yellow Fever 14 
La Roche on Pneumonia, &c I7 
Laurence and Moon’s Ophthalmic Surgery . . 29 
Lawson on the Eye 28 
Laycock on Medical Observation ... 14 
Lehmann’s Physiological Chemistry, 2 vols. . 9 
Lehmann’s Chemical Physiology .... 9 
Ludlow’s Manual of Examinations ... 5 
Lyons on Fever ....... 18 
Maclise’s Surgical Anatomy 7 
Marshall’s Physiology 8 
Medical News and Library 2 
Meigs on Puerperal Fever 23 
Miller’s Practice of Surgery 26 
Miller’s Principles of Surgery . . . .26 
Montgomery on Pregnancy .... 25 
Neill and Smith’s Compendium of Med. Science . 8 
Neligan’s Atlas of Diseases of the Skin . . 20 
Neligan on Diseases of the Skin . . . .20 
Obstetrical Journal 22 
Odling’s Practical Chemistry . . . .10 
Parry on Extra-Uterine Pregnancy . . .25 
Pavy on Digestion 
Pavy on Food .1® 
Parrish’s Practical Pharmacy . . . .12 
Pirrie’s System of Surgery 27 
Pereira’s Mat. Medica and Therapeutics, abridged 18 
Quain and Sharpey’s Anatomy, by Leidy . 
Roberts on Urinary Diseases. . . • .18 
Ramsbotham on Parturition .... 25 
Rigby’s Midwifery .2-5 
Rodwell’s Dictionary of Science .... 5 
Swayne’s Obstetric Aphorisms . . . .24 
Sargent’s Minor Surgery . . . . .26 
Sharpey and Quain’s Anatomy, by Leidy . . 6 
Skey’s Operative Surgery ..... 26 
Slade on Diphtheria ,18 
Smith (J. L.) on Children ... . . 21 
Smith (H. H.) and Horner’s Anatomical Atlas j 6 
Smith (Edward) on Consumption . . . I7 
Smith on Wasting Diseases in Children . ' 21 
Still6’s Therapeutics '12 
Sturges on Clinical Medicine . . . [I-1 
Stokes on Fever "14 
Tanner’s Manual of Clinical Medicine ..' 5 
Tanner on Pregnancy . . . . ’ 24 
Taylor’s Medical Jurisprudence . 
Taylor’s Principles and Practice of Med Jurisp" 80 
Taylor on Poisons . . ..." 80 
Tuke on the Influence of the Mind . . "81 
Thomas on Diseases of Females . . . ‘22 
Thompson on Urinary Organs . . . 89 
Thompson on Stricture ‘ 80 
Thompson on the Prostate . . . . ' f? 
Todd on Acute Diseases . . . . . " ,7 
Walslie on the Heart "i- 
Watson’s Practice of Physic . . . . • J? 
Wells on the Eye • 
West on Diseases of Females ... 23 
West on Diseases of Children . . . • “ 
West on Nervous Disorders of Children . • 21 
What to Observe in Medical Cases . . *18 
Williams on Consumption . . . . • 17 
Wilson’s Human Anatomy . .... 7 
Wilson on Diseases of the Skin . . . . j® 
Wilson’s Plates on Diseases of the Skin . • 
Wilson’s Handbook of Cutaneous Medicine • 
Winslow on Brain and Mind . . . .81 
Wohler’s Organic Chemistry . . . . 
Winckel on Childbed • , 
Zeissl on Venereal . . • . . . . .19 
PAGE 
For “The Obstetrical Journal,” Five Dollars a year, see p. 22.