The Treatment of Extra-Uterine 
Pregnancy, Ruptured in the 
Early Months, by Vaginal 
Puncture and Drainage. 
BY 
Howard Kelly, M. D., 
Professor of Gynaecology in the Johns Hopkins 
University, Baltimore, Md. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for August, 1896. [Reprinted from the American Gynecological and Obstetrical Journal 
for August, iSg6.] 
THE TREATMENT OF EXTRA-UTERINE PREGNANCY, 
RUPTURED IN THE EARLY MONTHS, BY 
VAGINAL PUNCTURE AND DRAINAGE.* 
By Howard Kelly, M. D., 
Professor of Gynaecology in the Johns Hopkins University, Baltimore, Md. 
At a meeting of the Johns Hopkins Hospital Medical Society, 
October 23, 1893, I advocated the treatment of ruptured extra-uter- 
ine pregnancy by a vaginal opening for the removal of the products, 
followed by drainage. My first case was operated upon October 27, 
1892, and was one of the intraligamentary form. I made an explora- 
tory coeliotomy, and found a mass on the right side, fourteen by ten 
centimetres in size, to which the whole omentum was adherent, 
dragging down the transverse colon; there were also dense adhesions 
to the small intestine. The uterus lay to the left. The peritonaeum 
at the brim of the pelvis posteriorly passed directly on to the sac, 
without dipping into the pelvis, and anteriorly and laterally it was 
lifted up to such an extent by the sac that it lay in direct contact 
with the anterior abdominal wall four centimetres above Poupart’s 
ligament. 
As a complete enucleation of this subperitoneal mass was out of 
the question, I determined to drain it. The colon was first freed 
by tying the omentum off from side to side. A free incision was 
then made into the sac above Poupart’s ligament, and sixty cubic 
centimetres of fluid blood and two hundred and forty cubic centi- 
metres of clots removed. The sac was washed out and drained 
with gauze. There was no marked haemorrhage; the duration of 
the entire operation was thirty-seven minutes. 
* Read before the American Gynaecological Society, May 27, 1896, 
Copyright, 1896, by J. D. Emmet. M. D. Howard Kelly, M. D. 
The patient made an uninterrupted recovery, leaving the hos- 
pital on the thirty-second day. 
The next case occurred February 22, 1893. The patient, a stout 
woman, was anaemic and rapidly losing flesh, and had a dry tongue 
and lips and sore buccal surfaces. She suffered from difficult, pain- 
ful micturition, and was constipated, passing blood and mucus from 
the rectum. The abdomen was tender on pressure and markedly 
distended. The pelvis was choked with a tender mass, extending 
7.5 centimetres above the symphysis. 
The abdomen was opened March 1, 1893; the sac filled the 
right posterior quadrant of the pelvis where the peritonaeum ap- 
peared to go directly from the brim of the pelvis on to the top of 
the sac. 
I tapped the sac through the abdominal incision, and drew off 
some foetid gas; I then closed the puncture hole with two sutures, 
and explored by the rectum, but failed to find any opening there, 
although a few clots of blood escaped. 
I then made a free opening into the vault of the vagina and evacu- 
ated the clotted blood and placenta filling the sac, and drained it per 
vaginam. The patient made a rapid recovery, in spite of her bad 
condition. For two weeks there was some faecal discharge by the 
vagina. She left the hospital well in the sixth week. 
The next case is the one reported in the Johns Hopkins Hospital 
Bulletin for November, 1893. The patient was in a critical condition, 
with a feeble pulse, and on opening the abdomen I found such ex- 
tensive adhesions that enucleation under the circumstances was im- 
possible. 
The question therefore arose whether to abandon the case or 
to try the method so successful in the two previous cases. I decided 
upon the latter plan, and made a careful bimanual examination with 
one hand in the abdomen and the other in the vagina, outlining per- 
fectly the relations of the sac. I then pushed the tumor down and 
the vault of the vagina up until it met the sac, when I thrust a pair 
of sharp-pointed scissors into the tumor through the posterior cul- 
de-sac. The opening was enlarged to an inch in diameter, the 
debris of clotted blood evacuated and the sac washed out by means 
of a glass douche nozzle, and afterward drained with gauze. The 
patient made a rapid and complete recovery. 
I have since operated in this way on ten additional cases of extra- 
uterine pregnancy. The 2reatment of Extra-Uterine Pregnancy. 
3 
I have had, therefore, thirteen cases in all treated by vaginal 
puncture and drainage without any untoward sequelae. One patient, 
comatose when operated upon, died a few days later of nephritis. 
Class of Cases treated.—Cases suitable for this mode of treatment 
are the extra-uterine pregnancies which rupture in the early months, 
including therefore the vast majority of all cases. Since I have begun 
to follow this mode of treatment, all the cases which have come to 
me have been of this class. 
Vaginal puncture and drainage is not a suitable plan of treatment 
(a) in an unruptured extra-uterine pregnancy, or (b) in a recently 
ruptured one, or (c) in advanced extra-uterine pregnancy. 
I do not compare this operation with the removal per vaginam 
of the dead foetus presenting at the vaginal vault (elytrotomy) in an 
advanced pregnancy, followed by drainage of the sac, nor do I com- 
pare it with cases in which suppuration of the sac has occurred, 
which belong rather to the pelvic abscesses, although I treat both 
classes of cases in precisely the same way. These cases are referred 
to by Hermann (Trans. London Obstetrical Society, vol. xxix, p. 429), 
who states that, when the effusion of blood is followed by pyrexia, 
the indications for incision of the vagina are the same as those in 
hsematocele from any other cause. He says that, when interference 
is called for to arrest haemorrhage soon after rupture has taken 
place, abdominal section is more likely to succeed than vaginal. 
The class of cases to which I refer are not clearly defined by 
Hermann, and are the commonest of all; they are those in which a 
succession of ruptures has occurred, each time adding to the ac- 
cumulation of clots in the abdomen. 
I have only included one suppurative case with clots on my list, 
and that simply to report all the cases I have had. In the American 
Gynecological and Obstetrical Journal (May, 1896, p. 598), Dr. G. W. 
Reynolds reports a case of an extra-uterine pregnancy which he 
felt certain had ruptured into the broad ligament, and in which he 
removed a three months’ foetus with placenta and cord by a vaginal 
incision. A gauze drain was inserted, and the patient rapidly re- 
covered. 
1. Examination.—After a careful consideration of the history, a 
thorough examination of the extra-uterine sac is made bimanually, 
both by the vagina and by the rectum, in order to determine its exact 
relationship to the vaginal vault. 
I pursue the following method in performing this operation: 4 
Howard Kelly, M. D. 
2. Position of Patient.—The patient is then put into the lithotomy 
position, and the vagina thoroughly cleansed. 
3. Fixing the Cervix.—The posterior lip of the cervix is caught 
with tenaculum forceps and drawn slightly forward. 
4. Opening the Sac.—With the index finger resting on the promi- 
nent part of the sac posterior to the cervix to act as a guide, a pair 
of sharp-pointed scissors is thrust through the septum into the sac, 
taking care to follow the line of the axis of the pelvis. If this is not 
done, there is risk of puncturing the rectum by carrying the points 
too far back. If the rectum lies near to the vaginal vault, it is best to 
protect it from injury by the middle finger resting on the sac in the 
bowel and the index finger on the vaginal vault, thus straddling the 
perinseum. If the sac does not lie so close to the vaginal vault as to 
be easily felt there, it may often be brought into relationship with it 
by the pressure of an assistant’s hand above when the puncture may 
be made. 
5. Enlarging the Opening.—When the scissors have entered the 
sac they are spread and withdrawn wide open. This makes the hole 
bigger. A uterine dilator is then introduced, and the opening 
stretched to 1.3 to 3.5 centimetres in diameter. 
6. Opening the Sac.—As soon as the scissors are spread, a little 
stream of dark telltale blood runs down the vagina confirming the 
diagnosis. After dilating the opening, the sac is emptied of blood 
clots, placenta, and foetus by the index and middle fingers. This is 
done with extreme care, using the fingers within the sac, and assist- 
ing their action by the other hand employed outside to make counter- 
pressure through the abdominal wall. In this way the sac is freely 
handled, its various parts kept within reach, clots are detached, and 
the contents removed until nothing but a shell remains—all without 
opening the peritoneal cavity. 
Should the peritonaeum be opened accidentally, no harm will 
result if the sac is well cleaned out and efficient drainage is used. 
If the fingers possess a good tactile sense, the rough limiting 
walls of the sac and the adhering clots will be easily differentiated. 
I have several times recognized the firm, round tube casts, and 
brought them out broken up; the rounded sides of the pieces showed 
plainly that they had formed part of a cylinder. 
7. Washing out the Sac.—lf the sac is well closed off from the 
peritonaeum, it is a help in bringing away the blood clots to wash The Treatment of Extra- Uterine Pregnancy. 
5 
it out at intervals with a normal salt solution; I do this also at the 
end of the cleansing process, before packing. 
8. The Gauze Drain.—The sac is then drained by a strip of plain 
or washed iodoform gauze, about three centimetres wide, stuffed 
loosely into its cavity with a packer. The gauze must fit loosely, 
so as not to stop the outward flow. 
9. After Care.—I leave the gauze in for three or four days, dur- 
ing which time there may be a free serous flow. I then day by day 
withdraw it, and in from five to seven days remove it altogether, and 
then daily wash out the sac with a boric-acid solution, putting a piece 
of gauze into the opening each time to keep it from closing too fast. 
In this way the sac contracts and closes in from two to six weeks, 
often without any evident suppuration, and in all cases without any 
marked purulent discharge. 
In four cases out of the thirteen I opened the abdomen before 
evacuating and draining the sac, by the vagina in three of them, and 
above Poupart’s ligament in one. I did this in the first two instances 
expecting to enucleate the mass by the abdomen, but, finding that 
this would greatly endanger the patient’s life, I turned to the vaginal 
route. 
With my present established technique I find it but rarely neces- 
sary to open the abdomen. I did this, however, in one of my most 
recent cases (No. XII), in my Sanatorium, because the history of 
rupture was so negative, and the encysted mass of blood at the left 
uterine cornu formed such a well-defined tumor, that I felt doubtful 
whether it might not be an unruptured extra-uterine pregnancy. 
On opening the abdomen, and finding the sac well covered in by 
sigmoid, rectal and vesical adhesions, I evacuated it per vaginam, 
and drained it as usual. 
The Advantages of this Operation.—The one great advantage is, 
that, in accordance with the most recent and best gynaecological 
practice, none of the pelvic structures are removed while the haema- 
toma is opened, evacuated, and drained. I would anticipate any ob- 
jection by stating that my patients have all recovered perfect health, 
and there have been no untoward sequelae. 
A further advantage of great importance is the fact that a seri- 
ous abdominal operation is often avoided, and the adhesions walling 
the sac in are let alone, while it is simply, quickly, and safely opened 
by the vagina. 6 
Howard Kelly, M. D. 
In several of my cases the patients were in such condition that 
they could not have survived any prolonged abdominal operation. 
The vaginal operation in this way reduces the mortality. 
The dangers of the operation are (i) the possibility of a mis- 
taken diagnosis, (2) the risk of opening the peritonaeum, and (3) the 
risk of a fatal haemorrhage, (4) as well as the liability to sepsis 
through the open vaginal vault. 
Although I made a correct diagnosis of extra-uterine pregnancy 
in each of the thirteen cases here reported, I diagnosed this condition 
in two cases where it did not exist. 
One was a dermoid cyst about as big as my fist, which I punc- 
tured, evacuated, and removed, and the other was a pelvic abscess, 
which I also opened and drained. Both cases recovered. 
Haemorrhage is the most serious risk incurred, and the query 
naturally arises why it does not more frequently follow the opem 
ing of the sac, the detachment of the clots, and the relief of the pres- 
sure they afford the sac walls. The answer to this must be that 
the vessels are filled with firm thrombi, and all tendency to active 
bleeding is past. 
In the history of the patient who bled persistently from the vagi- 
nal puncture, necessitating the immediate removal of the sac by the 
abdomen, there was nothing to indicate anything different from 
the five preceding or the six cases following. She was forty-one 
years old, the mother of six children, the youngest two years and a 
half old. About three months before I saw her, at a menstrual period, 
she was suddenly seized with a sharp pain in the lower abdomen, and 
became very faint, without losing consciousness. There was a mere 
“ show ” at the time, but after the pain she had a free bloody dis- 
charge for four weeks. The abdomen was enlarged and tender, and 
she had three attacks after the first, and was compelled to go to bed 
each time. I found her greatly debilitated and ansemic, with con- 
stipation, and a pulse of 100. A large globular mass filled both sides 
of the pelvis, being especially prominent on the right side. 
The sac was punctured by the vagina, and the clotted blood and 
a three months’ foetus removed. This was followed by a free dis- 
charge of bright arterial blood, which oozed persistently out of the 
incision, and could not be controlled by packing. 
I therefore at once opened the abdomen, and, finding the tubes 
and ovaries so densely matted together with the uterus, I removed 
them all by hystero-salpingo-oophorectomy, bringing up the ectopic The Treatment of Extra- Uterine Pregnancy. 
7 
sac with its placenta; seven hundred cubic centimetres of salt solu- 
tion was infused into the cellular tissue to make up the loss of volume 
in the circulation. 
The patient was discharged on the twenty-ninth day completely 
recovered. 
On account of the possibility of this accident, I insist that the 
operator should always be prepared to open the abdomen if neces- 
sary when he undertakes to evacuate the sac by a vaginal open- 
ing. 
The following carefully prepared records of my cases have been 
arranged by Dr. J. E. Stokes, of the Johns Hopkins Hospital: 
Case I.—Mrs. F. B. W., admitted October 23, 1892, aged twenty- 
two years; white; married one year; O-para; no miscarriages. 
Past Health.—Good. Had diphtheria when quite young; no 
sequelae noted. For last year has been feeling “ drowsy ” and “ out 
of sorts.” 
Menstrual History.—First menses, fifteenth year; regular; 
monthly flow scant, lasting six days; pain marked first day. 
History of Present Complaint.—Patient last menstruated twelve 
weeks ago—i. e., six weeks before present attack. Menstruation 
normal. Early morning of the day of the attack patient had a slight 
bloody discharge per vaginam; later during that morning, while 
walking across the yard, was seized with a sudden, sharp pain in 
right iliac region. She immediately went to bed, the pain continu- 
ing for the following five hours. No chill; nor did she appreciate 
any rise of temperature. The attacks of pain have been more or 
less constant, though diminished in severity and frequency, of late. 
The last marked attack was ten days ago, lasting four hours. 
Immediate Condition.—Anaemic; slight bloody discharge; pain 
in right iliac region, paroxysmal in character; urine normal. 
Diagnosis.—Extra-uterine pregnancy; right tubal rupture. 
Operation, February 7, 1892.—(1) Exploratory coeliotomy, fol- 
lowed by (2) extraperitoneal incision into sac above Poupart’s liga- 
ment. Removal of 240 c. c. of clotted blood. Pack introduced; 
time, thirty-seven minutes. 
1. Median incision 10 cm.; walls very vascular; peritonaeum 
dark, blackish in appearance; 60 c. c. fluid blood in cavity. Sac 
exposed on right side invested by whole omentum, which displaced 
transverse colon downward. Sac globular, about 14 cm. by 10 cm., 8 
Howard Kelly, M. D. 
corresponding to normal position of tube. Flat, vascular, dense ad- 
hesions to small intestines; peritonaeum from brim of pelvis poste- 
riorly goes directly over on to sac, and laterally over on to abdomi- 
nal wall about 4 cm. above Poupart’s ligament. Whole omentum 
doubly ligated and cut off close to transverse colon. 
2. Lateral incision 2 cm. above and parallel to Poupart’s liga- 
ment, 5 cm. in length. Deep epigastric artery and vein exposed 
at its middle and ligated; sac opened; 240 c. c. clotted blood and 
shreds of membranes evacuated; sac washed out; no fresh haem- 
orrhage. Pack introduced: iodoform gauze, five pieces, 44 cm. in 
length. Pack removed eighth day, small amount of bloody dis- 
charge coming away. 
Convalescence uninterrupted. Discharged thirty-second day. 
Result, well. Slight sinus an inch to an inch and a half in depth 
at seat of lateral incision. 
Case ll.—Mrs. L. C, admitted February 22, 1893, aged thirty- 
five years; white; married fourteen years; Vl-para, children aged 
from twelve and six years. Labors easy; usually in bed a week; no 
post-puerperal trouble; no miscarriages. 
Past Health.—Has always been perfectly healthy. 
Menstrual History.—First menses, eleventh year; regular; 
monthly flow normal in amount, lasting three to seven days; pain- 
less. 
History of Present Complaint.—Missed menstrual flow in No- 
vember—i. e., three months ago. In December, at the time when 
regular period should appear, she first began to have severe bear- 
ing-down pains, resembling those of labor, and at the same time 
passed three clotted, fleshy masses. Since the passage of these clots 
has had a constant thick, blackish discharge from vagina. At the 
same time pain has been sharp, cramplike in character, with a severe 
backache, compelling patient to remain most of the time in bed. 
For last three days discharge has been yellowish in color. 
Immediate Condition.—Has lost flesh rapidly; appetite poor; 
tongue dry and red; buccal surfaces of cheek sore; lips dry and 
cracked; ansemic; slight yellowish tint to skin; bowels very con- 
stipated; micturition difficult and painful. Urine thick and very 
yellow in appearance; on analysis, normal. At times passes blood 
and mucus from rectum. Abdomen exceedingly tender and sensi- 
tive to pressure. 
Night before operation patient became greatly excited, rising The Treatment of Extra-Uterine Pregnancy. 
9 
up in bed, moving head from side to side, working arms and legs 
up and down, and crying. Condition one of marked excitability. 
Examination.—Abdomen markedly distended; resonant, except 
over lower part, where the resonance is impaired; outlet relaxed. 
Cervix just within outlet superficially soft, but in fact quite hard. 
Uterus seems to be anteflexed, fixed in position. Pelvis on right and 
left side posteriorly, filled up with a mass which extends up above 
pelvis about three inches, most marked on right side; very sensi- 
tive. 
Diagnosis.—Extra-uterine pregnancy; right tubal rupture into 
rectum. 
Operation, March I, 1893.—1. Exploratory coeliotomy, with in- 
spection of sac. 2. Puncture and drainage of sac per vaginam. 
(1) Incision 12 cm. through very fat walls 8 cm. thick. Sac on 
right side filling right posterior quadrant of pelvis, top of sac pass- 
ing directly over on to peritonaeum above brim of pelvis. Also 
no cavity posteriorly, but anteriorly to sac depth of pelvis but little 
affected. Uterus flat on right of cyst. Tapped sac, drawing off 
foetid gas. Closed tap hole with two silk sutures, then examined 
per rectum. This was followed by free flow of small clots. No open- 
ing could be felt lowrer, although cyst was hard on rectum above 
utero-sacral ligaments. 
(2) Free opening next made into vault of vagina; clots and pla- 
centa cleaned out; sac packed to drain per vaginam. 
Convalescence rapid and uninterrupted. For the first two weeks 
succeeding operation had discharge of fsecal matter per vaginam. 
Discharged on sixth week, well; no pain; little or no vaginal dis- 
charge for a week; mental condition normal. 
Case lII.—M. S. L., admitted September 15, 1893, aged twenty- 
seven years; white; married eleven years; IV-para, from eight to 
four years; labors easy, non-instrumental; remained in bed four- 
teen days; no post-puerperal difficulty: two miscarriages; no trouble. 
Past History.—Good; scarlet fever during adult life; has done 
“ farm work ” for several years. 
Menstrual History.—First menses about fourteenth year; regu- 
lar; monthly flow scant, lasting three days; no pain. 
History of Present Complaint.—Patient menstruated on July Ist 
—i.e., nine weeks before present trouble; flow was moderate in 
amount, lasting three days; pain more marked than ever before 
—dull, aching in character, through abdomen generally. August, Howard Kelly, M. D. 
menstrual flow absent, though had pain, and abdomen seemed 
swollen. In September flow commenced; was very profuse, but 
was not accompanied by any pain. Took medicine to check it; no 
lumps or clots. At no one time has patient had any severe parox- 
ysm of pain, nor has she felt faint. The pain which started up in 
August—at the time she should have had her “ period,” and which 
has continued up to present time—has been a burning, stinging- 
one in character, with a pressing-down sensation through hypo- 
gastric region. 
Immediate Condition.—Patient pale and somewhat ansemic; 
bowels constipated; no urinary difficulty; analyses normal; pulse, 
125; temperature, 100.60. Talks very irrationally at times; seem- 
ingly in a semi-delirium condition. 
Examination.—Abdomen markedly distended; skin above um- 
bilicus cracked and fishlike in appearance; darker than surround- 
ing area; greatest fullness in epigastric region. 
Mensuration.—From umbilicus to ensiform, 16 cm.; from um- 
bilicus to pubes, 17 cm.; greatest circumference at umbilicus, 
76.5 cm. On palpation, whole abdomen softish and sensitive. In 
suprapubic region there is a hard and very sensitive mass extend- 
ing about 11 cm. above pubic arch. Examination per vaginam 
abandoned on account of extreme tenderness. 
Operation.—Puncture and drainage of sac per vaginam; dura- 
tion, eight min. -(-. Patient first examined under ether. Promi- 
nence over symphysis about BX6 cm., and raised about 2 cm. 
Tympanitic on percussion. Per vaginam, cervix crowded forward 
in pelvis, and posterior to this an ovoid, • bulging, fluctuating 
mass, apparently, on percussion, in direct relation to prominence 
over symphysis. Then bulging mass posterior to cervix aspirated 
and about 120 c. c. fluid blood evacuated. Sharp-pointed scissors 
then plunged in and withdrawn, opened, discharging blood and 
“ handfuls ”of dark and slate-colored clots. Prominence in abdo- 
men then almost disappeared. Opening posterior to cervix then 
made about 4 cm. broad. Sac washed out with glass irrigating 
nozzle, followed by escape of large clots. Cavity collapsed; found 
to fill whole pelvis and to rise up in abdomen several centimetres 
above superior strait. Walls smooth. Pack not introduced into 
cavity, vagina being only packed. No haemorrhage. 
Diagnosis.—Extra-uterine pregnancy, tubal. The Treatment of Extra-Uterine Pregnancy. 
11 
Convalescence uninterrupted. Pack removed second day, per- 
fectly sweet. Marked diminution in pain. The night of the second 
day patient had a slight haemorrhage; no systemic effect noted. 
After this, patient’s improvement was marked and continuous. 
Discharged on thirty-sixth day, well. Face full; complexion good; 
mental condition normal; no pain; no vaginal discharge; “ feels 
well and strong.” 
Case IV.—Mrs. L. S., admitted February 27, 1894, aged twenty- 
six years; white; married four years; O-para; no miscarriages. 
Health since marriage much the same as before it. 
Past History.—Has lived rather a sedentary life; has been strong 
and active. Two uncles and one aunt died of tuberculosis, one 
great aunt of cancer. 
Menstrual History.—First menses at eleventh year; regular; 
monthly flow scant, lasting five days; no pain. 
History of Present Complaint.—Patient last menstruated two 
weeks ago; flow freer than usual, but no pain. Flow in December 
last—i. e., three months ago—was very slight. In January, the suc- 
ceeding month, not any at all. Up to November, 1893, menstrual 
history was normal, periods occurring about first week in every 
month. November, it appeared on the 14th, same as usual, save it 
was offensive, only having been so once or twice before. Felt per- 
fectly well; no pain. In December menstruated on 22d; less in 
quantity; still offensive; three weeks overdue. On the night of the 
29th, while playing cards, feeling perfectly well, patient bent over the 
table to make a “ play ”; just as she did so was seized with a sharp, 
shooting pain, knifelike in character, in left hypogastric region, 
which seemed to pass from front to back. Previously to this parox- 
ysm had had no tenderness or sensitiveness in this region. Pain 
was so acute that it made patient start up. She immediately became 
giddy, everything was blurred before her. She did not completely 
lose consciousness, but was compelled to lie down, however. After 
a moment or two the acute pain ceased, followed by a dull aching 
and feeling of soreness through that side, which became slightly 
easier by next morning. During the night patient had a slight 
haemorrhage from vagina; no casts or clots passed. Patient re- 
mained in bed the following day on account of pain and nausea. 
On the night of the 31st, two nights subsequent to the initial 
paroxysm—patient during this time having been more or less under 
the influence of an opiate, as pain and tenderness over entire abdo- Howard Kelly, M. D. 
men were so marked—she got up from her bed to urinate, and 
remembers just having placed herself upon the vessel, after which 
she knew of nothing until she found herself in bed. She was 
not conscious of any increase in the pain or any feeling of faint- 
ing. She had been found lying upon the floor unconscious, face 
pale and blanched, and had been put to bed; feeling of weakness 
was not marked. During following month no flow; pulse fair; 
temperature, 103°; abdomen exceedingly painful and tender, very 
tense and hard; bowels constipated; would lie on her back with 
knees drawn up; marked nausea and vomiting. In February pa- 
tient became better. Flow freer than usual. 
Immediate Condition.—Well nourished; bright complexion; 
urination painful and frequent; analyses normal; locomotion pain- 
ful and difficult; slight offensive leucorrhoeal discharge; pain dull, 
aching in character, in left ovarian region, extending down thigh; 
area of hardness in abdomen to right of median line; temperature, 
990; pulse, 100. 
Examination.—Abdomen full, symmetrical; no linese albicantes; 
on palpation, walls thick, extending from umbilicus to pubes, and on 
either side, about 10 cm., is felt a hard, smooth mass, non-fluctu- 
ant; abdomen elsewhere negative. Per vaginam, outlet slightly 
relaxed; cervix within 2 cm. of outlet; lips flattened and soft. 
Uterus anterior to a mass slightly enlarged; the mass fills entire 
pelvis; somewhat movable, smooth surfaces, non-sensitive; seems 
to extend slightly more to right side; lateral structures not out- 
lined. 
Diagnosis.—Extra-uterine pregnancy. Tubal rupture. 
Examination under Ether.—A cystic tumor, convex above and 
almost rising to umbilicus, about 14 X 18 cm., more on right side. 
Fluctuation more or less boggy. Per vaginam, whole pelvis choked 
by mass which is distinctly fluctuant and projecting down into pos- 
terior fornix, jamming uterus in anteposition behind symphysis, 
so that cervix is felt about 3 cm. behind outlet, and fundus verti- 
cally above this, with surprising distinctness. 
Operation, March 1, 1894.—Puncture, evacuation, and drainage 
of sac per vaginam; duration, fifteen minutes. Sac supported by an 
assistant with flat of hand above, while anterior lip of cervix was 
caught and drawn down moderately, when it was held by another 
assistant. Then a pair of sharp-pointed scissors was “boldly” thrust 
into sac, 3 cm. posterior to cervix, upward and in a curved direction, The Treatment of Extra- Uterine Pregnancy. 
first toward third sacral vertebra and then toward superior strait. 
On opening scissors, immediately there gushed out black-brown 
fluid, followed by pale-brown clots. Then large, blunt scissors were 
introduced, and opened in sac, dilating it 3.5 cm. from side to side; 
free exit of large quantity of black fluid and clots, sac falling together 
as contents were discharged. Finger introduced and sac palpated 
bimanually with one finger on abdomen. Its lateral walls and vault 
found everywhere lined by brown blood clots, but separated from ab- 
dominal cavity by adhesions. Posterior surface of uterus showed 
uterine body enlarged about once and a half. Sac cavity washed 
out with glass catheter and packed loosely with iodoform gauze. 
No haemorrhage save slight flow at last of bright blood. 
Convalescence.—Pack removed third day. Small amount of 
blood, serous discharge, non-offensive. Has had some severe parox- 
ysms of pain at times. On sixth day patient felt so well that she sat 
up. Had boric-acid douches every other day, followed by intro- 
duction of small pack. On tenth day patient took a few steps. On 
twelfth day complained of pain, more or less shooting in character, 
through abdomen generally. Face pale. That afternoon pack 
removed and irrigation commenced. As pack was withdrawn, a 
small amount of purulent discharge followed. When the douche 
was commenced it was noticed that the return flow was very slight, 
containing particles of necrotic material. Suddenly patient 
screamed out, complaining of very acute pain; became very pale, 
bathed in a cold sweat; hands and nails blanched; eyes glassy in 
appearance; pulse became weak and of small volume. Pain re- 
ferred to left hypogastrium, just above umbilicus. By early even- 
ing patient was in a condition of collapse. Abdomen opened 
through median line. Marked and diffuse peritonitis. Cavity filled 
with watery, milky fluid. Lateral incisions then made in either 
flank; peritonaeum attached to skin to promote drainage, and gauze 
in flanks and center above. Patient’s convalescence from then on 
was uninterrupted, slow but steady. 
Result.—Discharged on her fifty-fourth day, well. Almost no 
discharge from vagina. Drain tracts in abdomen healed. 
Case V.—Mrs. E. W., admitted October 1, 1894, aged thirty- 
three years; white; married twice; I-para, by first union, ten years 
of age; no miscarriages. O-para, no miscarriages, by second union. 
Past History.—Had small-pox at five years; pneumonia at seven 
years. As an adult health has been very good. 14 
Howard Kelly, M. D. 
Menstrual History.—First menstruated at twelve years of age. 
Regular, monthly, until marriage, when flow came on every three 
weeks or so. 
History of Present Complaint.—Last period commenced about 
six weeks ago, and has continued constantly up to present time. 
Flow not very copious; clear at times, again thick and clotted. 
About same time was taken with severe pains in lower abdomen, 
and especially left side; was compelled to go to bed; these pains 
have continued right along, accompanied by severe backache. 
Immediate Condition.—Has lost flesh within last week; feels 
weak and greatly debilitated; tongue coated; no urinary difficulty; 
pulse only of fair volume; temperature normal. 
Diagnosis.—Extra-uterine pregnancy. Tubal rupture. 
Operation, October 4, 1894.—Exploratory coeliotomy; closure 
of abdomen; puncture of sac per vaginam elected. Abdominal in- 
cision over mass, pushing forward lower abdominal wall to 6 cm. 
above symphysis. Fundus uteri elevated, exposed at summit of 
mass directly behind abdominal wall. Posterior to this, pelvis 
choked with inflammatory mass indistinct in its relations on ac- 
count of general intestinal adhesions; these flat and vascular, bleed- 
ing on slightest separation. Pelvis choked on all sides with mass 
adhering to walls, rectum, and uterus. On account of universal 
fresh adhesions of small and large intestines, vaginal route elected. 
Sharp-pointed scissors plunged in through posterior fornix, fol- 
lowed by discharge of fluid (dark claret-colored) and clotted blood 
—about a quarter of a litre in amount. Incision dilated; sac washed 
out and packed with iodoform gauze. 
Convalescence uninterrupted. 
Case Vl.—Mrs. S. M., admitted September 13, 1895, aged forty- 
one years; white; married twenty years; Vl-para; youngest child 
aged two years six months; labors not difficult; five miscarriages; 
no trouble noted. 
Result.—Discharged, well, on twenty-first day. 
Past Health good. 
Menstrual History.—First menses at fifteenth year; regular until 
of late; flow free, lasting five to six days; slight bearing-down pains 
for first two days. 
History of Present Complaint.—About three months ago patient 
was seized with sudden sharp pain in lower abdomen. She became 
very faint, but did not lose consciousness; she was compelled to go The Treatment of Extra- Uterine Pregnancy. 
to bed, her abdomen becoming enlarged and tender. The attack of 
pain came on at the time for her regular “ sickness,” which had 
simply been a “ mere showing ” for the two preceding months. 
After the paroxysm of pain she had a free bloody discharge for four 
weeks containing blood clots. The bleeding ceased for two weeks, 
then began again, lasting three weeks. Since the first paroxysm, 
three months ago, patient has had three similar ones, each con- 
fining her to her bed for about a week. Pain most severe on left 
side. Non-aching in character, save when a paroxysm comes on; 
then it is very acute. 
Immediate Condition.—Greatly debilitated; has lost flesh; bowels 
constipated; face pale and anaemic; temperature, 990; pulse, 100. 
Examination.—Outlet relaxed; veins purplish; cervix softened; 
at once shades off into a large mass, filling both sides of pelvis, but 
especially prominent on right side; mass globular, tense, and ap- 
parently slightly fluctuant, resembling—to touch—uterus in preg- 
nancy. 
Operation.—Puncture of sac per vaginam, followed by profuse 
haemorrhage. Subsequent coeliotomy on account of profuse haem- 
orrhage. Point of greatest fluctuation in posterior cul-de-sac punc- 
tured with sharp scissors, followed by the removal of a 3 + -months 
foetus, and a profuse discharge of dark bloodlike fluid. In a few 
moments the fluid became very bright in color and showed that a free, 
fresh haemorrhage had been started up. This could not be controlled 
by packing, and, as it was so profuse, it was deemed expedient to 
go into the abdomen. Median-line incision made; free blood found 
in cavity, and which oozed out of incision. Patient’s condition by this 
time plainly showed that no time could be lost, so left side was 
quickly tied off. Then a hystero-salpingo-oophorectomy was done 
according to Dr. Kelly’s method. The ectopic sac and placenta 
rolled up and out. Patient’s pulse had reached by this time 160, so 
700 c. c. salt solution infused into radial artery. 
Diagnosis.—Extra-uterine pregnancy. Tubal, right, ruptured. 
Convalescence slightly interrupted. On fifth day, pack removed, 
drain having been very effective, as outer piece (third) was well 
saturated. On removal of gauze, no fluid oozed out. A fibrinous 
exudate covered the piece first introduced into sac. Five days later, 
without any apparent cause, temperature reached 103°; patient 
seemingly doing very well. Next day temperature 104°; no 
chill; little or no pain. One small drain introduced into sac. Tem- Howard Kelly, M. D. 
perature gradually coming down to normal. From then on, con- 
valescence rapid and uninterrupted. 
Result.—Discharged, twenty-ninth day, well. 
Case Vll.—Mrs. E. N. W., admitted December 14, 1895, aged 
twenty-eight years; white married two years; I-para, aged twelve 
months; labor normal; remained in bed four weeks, on account of 
a slight tear of perinseum, which was immediately repaired; no mis- 
carriages. 
Past Health.—Never healthy; since puberty has been very nerv- 
ous. When sixteen years of age had a fall which hurt her back, and 
has suffered some with backache ever since. Six years ago she was 
in bed nine weeks with nervous prostration. When eighteen had 
a congestive chill, said to have been due to “ uterine trouble.” 
Menstrual History.—First menstruated at twelve years of age. 
Regular, save four months following labor. Before her period of 
gestation she usually suffered with dull aching pain in lower abdo- 
men, not definitely localized, beginning with flow and lasting one 
or two days. Some backache. Flow scanty; duration, three to 
four days. Since labor, has had little or no pain. 
History of Present Complaint.—Last menstruated November 19th 
—i. e., twenty-five days ago. Period previous to this one nearly 
six weeks before. One day, while ascending stairs, she had a sharp 
pain in lower abdomen, not localized, lasting one to two hours. 
She then went out of doors for a walk, having no especial discom- 
fort. On following day, while walking, had another attack of pain 
similar to the first one, though somewhat more severe; this lasted 
twenty-four hours. It was during this attack that her menstrual 
flow commenced, the pain ceasing as the menstrual flow became 
well established. There was nothing peculiar about flow, which 
lasted five days. She felt comparatively well for several days suc- 
ceeding cessation of flow, when suddenly one day, while she was 
standing at the table, but making no unusual exertion, she had a 
sharp, cutting pain in lower abdomen, not localized; felt as if 
“ something had given way,” this being followed by a gush of “ pure 
blood from vagina”; nothing peculiar in the appearance of the 
blood. The pain continued for nearly thirty-six hours very severe; 
the pain at first was more in left side, then seemed to move over 
to right, and has continued ever since, though somewhat less in 
severity. About a week ago noticed swelling in left lower abdo- 
men about size of a small egg. This seemed to decrease a little The Treatment of Extra- Uterine Pregnancy. 
17 
in size after a few days. At the time of severe pain, and following 
it, bowels moved frequently; abdomen became quite tender; pulse 
never went over 106. 
Immediate Condition.—Slightly anaemic; tongue coated; mic- 
turition frequent and painful; urinary analyses normal; pulse, 100; 
temperature, 98.6°; pain in lower abdomen; uterine haemorrhage. 
Diagnosis.—Extra-uterine pregnancy. Tubal, left, ruptured. 
Operation.—Puncture of sac per vaginam; 750 c. c. blood co- 
agula; removal of left tube cast; drainage. Exploratory puncture; 
no flow through canula, owing to its becoming clogged with a co- 
agulum. Scissors then plunged in; then, opening, sac dilated with 
fingers in median line posterior to cervix, 3 cm. wide. Evacuated 
750 c. c. clots like currant jelly. Whole pelvis choked, but no open- 
ing into abdomen. Uterus was pushed forward on left. Large 
clots, adhering to wall of sac, pulled over by fingers. Whole evacu- 
ation throughout assisted by abdominal hand; masses at times 
even expressed this way. Tubal cast felt like hard cylindrical mass 
on left side, high up; removed with fingers and delivered at vaginal 
incision by grasping it with Museaux forceps and making deep 
pressure into pelvis from above. No haemorrhage from sac at all, 
but oozing from recto-vaginal sseptum;this had to be checked by 
catgut sutures. Sac lightly packed with gauze. 
Convalescence uninterrupted. Pack removed fifth day. 
twentieth day, well. 
Case VIII.—Mrs. E. 1., admitted January 25, 1896, aged thirty- 
one year; white; married eleven years; IV-para, youngest six 
years; labors normal; puerperia normal; no miscarriages. 
Past Health good. 
Menstrual History.—Menses began at eleven years; only fairly 
regular; duration, three days. Has always suffered much pain with 
flow. Since present complaint commenced, flow has been profuse, 
containing numerous clots. 
History of Present Complaint.—Last menstruated ten days ago; 
flow profuse. In September, 1895—i. e., four months ago—while 
sewing, she had a feeling of fullness in left lower abdomen, and 
severe pain of rather sharp character. At this time patient had quite 
a profuse offensive leucorrhoeal discharge. For about a year pre- 
viously patient had been treated with applications and tampons for 
some supposed uterine trouble. After this first attack, which lasted Howard Kelly, M. D. 
an hour, she felt fairly well until next day, when a similar parox- 
ysm of pain came on, and the following day still another, even more 
severe than the others, and lasting several hours. Every few days 
pain, paroxysmal, returned for two weeks or so. Then her physi- 
cian commenced making applications. After this time she began 
to bleed, continuing until about Christmas—ten weeks. The par- 
oxsms of pain continued also, and during these she would pass 
rather large quantities of blood. She grew then slightly better; 
was able to go to the doctor’s office. After every application she 
suffered intensely. About two weeks ago she had a sudden attack 
of very violent pain in the whole lower abdomen, and has suffered 
intensely up to present time. Abdomen became exceedingly ten- 
der; would have to lie with thighs well flexed on abdomen, straight- 
ening them out causing much pain. 
Immediate Condition.—Fairly well nourished; mucous mem- 
branes pale; face has a troubled expression; patient lies moaning 
with pain referred to right ovarian region. Micturition exceedingly 
painful. Has of late had much nausea and vomiting. Pulse, 135, 
weak; temperature, 102°. 
Examination.—Outlet relaxed. Uterus, left lateral, flexed on 
pelvic floor. Mass lies to right and does not seem to touch Douglas’ 
pouch, but to right spherical in contour, being about 10 cm. in 
diameter, seeming to lie in front of broad ligament. 
Diagnosis.—Extra-uterine pregnancy. Tubal rupture, sup- 
purative, right. 
Operation, January 27, 1896.—Puncture of sac per vaginam. 
Evacuation of large number of clots. Removal of well-formed 
foetus. Drainage. Usual vaginal incision made, posterior to cervix, 
upward and to the right. Then opening enlarged. After bringing 
away numerous blood clots, Dr. Kelly said he felt the foetus. At 
the same time he brought it out. Sac irrigated and lightly packed 
with gauze. 
Convalescence slow. Temperature almost immediately dropped 
to normal, and pulse steadily improved. But patient suffers at times 
with acute pain in right ovarian region and painful defecation. 
Discharged thirty-sixth day. Save a feeling of soreness through 
abdomen, and more or less dull constant pain, patient’s condition 
was excellent. Vaginal examination disclosed some slight thicken- 
ing along right broad ligament, but no mass. The Treatment of Extra-Uterine Pregnancy. 
19 
Case IX.—Mrs. L. P., admitted February 4, 1896, aged twenty- 
six years; white; married five years and a half; O-para; no mis- 
carriages. 
Past Health.—Not very good. When quite small had “ conges- 
tion of lungs, liver, and brain.” Had diphtheria at sixteenth to 
seventeenth year of age. 
Menstrual History.—Menstruated first at fourteen years of age; 
never regular; intervals up to three months ago varied from two 
to six weeks. For three months there has been irregular haemor- 
rhages. Pain has always been burning, bearing down in charac- 
ter, for first two days or so, over whole abdomen and down thighs; 
only recently has it become localized. Usually flow lasted seven 
days. Since it has become constant; pain much worse in right 
ovarian region. 
History of Present Complaint.—In 1887 had an attack of very se- 
vere abdominal pain, but no fever, nor other signs of any inflam- 
matory trouble. Since marriage has had profuse and painful men- 
struation, more marked than before. Three months ago she began 
to have irregular haemorrhages. These would last variable lengths 
of time. The last one has continued since December 22d, flow 
being quite profuse, dark, and clotted. Accompanying these haem- 
orrhages were attacks of severe burning and bearing-down pains; 
occasional nausea. Did not obtain any history of a decided cessa- 
tion of menses for any definite space of time. 
Immediate Condition.—Fairly well nourished; lips and mucous 
membranes not a good color; has a profuse leucorrhoeal discharge, 
non-offensive nor irritative. Micturition painful; bowels consti- 
pated. Abdomen tender and sensitive to gentle pressure. Pulse, 
no, not strong; temperature, ioo° to ioi°. 
Examination.—Most noticeable fact was the necessity of a dif- 
ferential diagnosis between an extra-uterine sac and a fibroid. 
This was done by careful bimanual examination, obtaining a sense 
of elasticity and some slight impression of fluctuation. Mass filled 
posterior pelvis, rather more on right side, and was intimately ad- 
herent to whole posterior uterine surface. On left side, in crack 
between mass and wall, left tube and ovary felt normal. On right, 
at uterine cornu, intimately connected, could be felt mass, with 
tube flat on top of it. 
Diagnosis.—Extra-uterine pregnancy. Tubal, ruptured, third 
month (?). 20 
Howard Kelly, M. D. 
Operation, February 5, 1896.—Vaginal puncture of sac; evacua- 
tion of blood coagula. Vaginal incision made by sharp-pointed scis- 
sors; then opening sac dilated 2,\ cm.; removal of a fair amount of 
blood clots and a female foetus; sac washed out and packed with 
gauze. 
Convalescence.—For first three days temperature and pulse 
greatly influenced; temperature reached 103° on second and third 
nights, then gradually dropped to normal and remained so. 
Rcsidt.—Discharged, twenty-first day, well; pelvis clear. 
Case X.—Mrs. M. C., admitted February 14, 1896, aged twenty- 
nine; white; married four years; O-para; no miscarriages. 
Past Health good. 
Menstrual History.—First menstruated at fifteen years of age; 
regular; monthly flow scant, generally bright red in color, lasting 
seven days; pain severe on first day. 
History of Present Complaint.—Last period January 23d, rather 
more free than usual; no clots; lasted four days, accompanied by 
severe pain on the first day; no definite history obtained. Since 
marriage flow has been more profuse than formerly and more pain- 
ful. Accompanying the periods she has had paroxysms of severe 
cramplike pain, followed by increase in flow, abdomen becoming 
sore and tender. Patient consulted physician more on account of 
abdominal pain at time of menstrual flow than for any definite 
symptom of present trouble. 
Immediate Condition.—Well nourished; mucous membranes 
pale; no urinary trouble; defecation only slightly painful; pulse, 
100; temperature, 99.30. 
Examination.—Outlet slightly relaxed; cervix pointing at out- 
let; fundus immediately beneath abdominal wall; posterior to ute- 
rus is a peculiar boggy mass, which is not connected with uterus; 
fills Douglas’ cid-de-sac. This mass does not seem to be distinctly 
fluctuating, but has a peculiar boggy sensation. It rises three fin- 
gers’ breadth above fundus uteri, is slightly movable, and gives 
decided sensation of an extra-uterine sac; immediately beneath the 
surface small, hard projections are felt. 
Diagnosis.—Extra-uterine pregnancy. Tubal, ruptured; intra- 
ligamentary (?). 
Operation, February 17, 1896.—Puncture of sac per vaginam; 
evacuation; drainage. Most prominent point on mass, posterior 
to cervix, selected as point for puncture; scissors thrust into sac, The Treatment of Extra-Uterine Pregnancy. 
21 
evacuating a pint of thick grumous material and great number of 
clots. Sac distinctly encapsulated, and not communicating with 
abdominal cavity. Cavity thoroughly irrigated and packed. 
Convalescence uninterrupted; most rapid. 
Result.—Cured, discharged, fourteenth day, excepting slight in- 
duration in either fornix; pelvis clear. 
Case XL—Mrs. C. (seen by Dr. Kelly, February 18, 1896, in con- 
sultation with Dr. C. Hummed and Dr. Coover at her home in Penn- 
sylvania), aged thirty years; white; married; V-para; oldest child 
seven years, youngest, fifteen months. Labors: first, doubtful, may 
have been instrumental; second, multiple pregnancy; twins; both 
living at birth; no miscarriages. 
Past Health.—Robust woman until present attack. 
Menstrual History.—First menstruated at about fourteenth year; 
irregular first to fifth months. After birth of first child flow did not 
return for fifteen months; nursed child. More or less pain has ac- 
companied flow. 
History of Present Complaint.—One month ago, while menstru- 
ating, went out to dinner; flow had been on then for three weeks, 
about as usual in character. While sitting at the table, was seized 
by a violent, cramplike pain in lower abdomen, agonizing in sever- 
ity; was not localized; felt very faint, but did not lose conscious- 
ness; became profoundly blanched; returned to her home, flow be- 
coming much less—a mere “ leak ”—for next two weeks; got up 
next morning and went to church; returning home, went to bed for 
a day or so; on getting up, was unable to remain out of bed for 
more than a few hours, felt so exhausted. Ever since has had re- 
peated attacks of pain in afternoon and early morning, not marked 
as the morning wore on. .Pains acute; traveled over entire abdo- 
men. 
Immediate Condition.—Patient lies with eyes closed; impossible 
to arouse her or secure her attention in any way; constantly moan- 
ing, intermingled now and then by a sharp outcry; skin and mu- 
cous membranes blanched; face and lips of a livid hue; eyes 
sunken and dull; pupils contracted; marked evidence of pain on 
pressure over lower abdomen; for last four days has had inconti- 
nence of urine; trace of albumin present, absent heretofore; bowels 
usually constipated, though easy to move. For last week patient 
has been in a semi-comatose state; has not recognized her family; 
has had delusions of “ cats,” etc., being in her room. Pulse has 22 
Howard Kelly, M. D. 
been running from 80 to no, very small in volume; temperature, 
990 to ioi°. 
Examination.—Abdomen normal in size; distinct sense of re- 
sistance over whole lower abdomen, half way to umbilicus, 
but no vaulted prominence per vaginam; mucous membrane nor- 
mal in color; cervix normal in size; small; no secretion from 
“os” posterior to cervix; pelvis filled from side to side with irregular, 
somewhat boggy mass; well-defined resistance to pressure; no fluc- 
tuation; no hardness, as in suppuration; uterus appears to be an- 
terior to mass. 
Diagnosis.—Extra-uterine pregnancy, tubal. 
Operation, February 18, 1896.—Puncture of sac per vaginam; 
evacuation of a litre of blood clots, with large amount of fluid 
blood; drainage. Patient in a most precarious condition; deliri- 
ous, weak, and a very small, rapid pulse. With sharp-pointed scis- 
sors vaginal incision made posterior to cervix; then dilated enough 
to admit four fingers; an exceedingly large number of blood clots 
evacuated—one half litre—not counting the fluid blood; sac then 
irrigated and lightly packed with gauze. Patient stood operation 
well, and reacted from the anaesthetic nicely; pulse about 120; no 
haemorrhage. 
Convalescence.—Patient’s mental condition better, but she never 
became entirely rational. Her pulse improved, and temperature 
came down to nearly normal, then went up a degree or so. She 
seemed to do fairly well for first four days, though on sixth day she 
died, apparently uraemic. 
Result.—-Death, sixth day. 
Case XII.—F. S., white, married four years; nullipara; no 
miscarriages. 
Last regular menstruation four months and a half ago. 
Present Condition.—Not anaemic; constipated; locomotion pain- 
ful; rapid pulse; paroxysmal pains; constant haemorrhage; tumor 
in left ovarian region. 
Onset of Symptoms.—Sudden; bloody discharge from vagina, 
followed by cessation of menses and pain. 
Examination.—Abdomen somewhat tense; fundus deflected to 
right; a hard circumscribed mass extending well up into left broad 
ligament. 
Operation, May 9, 1896.—Emptying of sac per vaginam; evacu- 
ation of coagula; foetus delivered; irrigation of sac; gauze drain. 
Convalescence normal. Vaginal Section for Extra-Uterine Pregnancy. 
23 
Case XIII.—Mrs. T. E. (Sanatorium), aged twenty-six years; 
white; married three years and a half; 11-para, twenty-eight and 
ten months. First labor difficult; in house ten weeks; complicated 
with grip; second labor easy. 
Last regular menstruation January 1, 1896, first since last period 
of gestation commenced; since Ist of January has had flow 
monthly, but of irregular date. 
Onset of Symptoms.—Not sudden, but of steady development; 
first return of menstruation followed by acute attacks of pain, some- 
what paroxysmal, unlike any accompanying menstrual pain before. 
Present Condition.-—-Thin, not anaemic; pain in left side. 
Examination.—Mass on left side, attached to the uterus, but 
movable, independently; indistinct sense of fluctuation, unlike 
either an abscess or an ovarian tumor. Vagina slightly bluish. 
Operation.—Abdomen opened and sac found covered by strong 
bladder, sigmoid, and rectal adhesions; sac opened and evacuated 
per vaginam under guidance of a hand in the abdomen; gauze 
drain; recovery without febrile reaction. Returned home in twenty- 
three days.