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County Council of Lanark: Twelfth Annual Report of the County and District Medical Officer, 1902. Glasgow: R. Anderson. Modern Methods in the Surgery of Paralyses, with Special Reference to Muscle-grafting, Tendon-transplantation, and Arthrodesis, by A. H. Tubby, M.S.Lond., F.R.C.S.Eng., and Robert Jones, F.R.C.S.E. Illustrated by 93 Figures and 58 Cases. London : Macmillan & Co., Limited. 1903. (10s net.)

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THE

GLASGOW MEDICAL JOURNAL.

No. V. NOVEMBER, 1903.

ORIGINAL ARTICLES.

THREE CASES OF ECTOPIC PREGNANCY RECENTLY OPERATED UPON.1

By J. M. MUNRO KERR, M.B., C.M., F.F.P.S.G., Obstetric Physician, Maternity Hospital; Assistant to Professor of Midwifery, Glasgow University; Dispensary Physician for Diseases of Women, Western Infirmary.

CASE I. Case of tubo-ligamentary pregnancy-Collapse— Death.

Mrs. H. M'G., aged 23, was admitted to the Western Infirmary on 12th August, 1902, while I was on duty in Professor Cameron's ward. So collapsed was she that no history could be obtained beyond the story that she considered herself about three months pregnant, had suffered for some for some weeks from a sanguineous vaginal discharge, and three days ago took a severe pain in the abdomen, which had continued ever since.

On palpation, a large and very tender swelling could be detected in the right iliac region; it was quite firm and immovable. On bimanual examination, it was closely applied to the uterus, which was enlarged and displaced to the left. The diagnosis lay between extra-uterine pregnancy, with Specimen shown and notes read at a meeting of the Glasgow Medico-Chirurgical Society held on 20th February, 1903.

No. 5.

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Vol. LX.

effusion of blood into the broad ligament, for there was no evidence of free blood in the abdominal cavity, and a tumour of the uterine appendages with a twisted pedicle.

I operated at once, and found on opening the abdomen no free blood, but the right broad ligament enormously distended, and its upper limits pushed up to about the level of the umbilicus by a large collection of effused blood. I opened into the mass, removed the gestation sac you see, cleaned out as much clot as possible, packed the cavity with gauze, stitched the edges of the sac to the lower end of the abdominal wound, and closed the abdomen. She was given some stimulant by the rectum, and a pint of saline was injected into the cellular tissue beneath the breast shortly after operation. She rallied from the operation, and the following day seemed much better. After thirty hours, however, she began to sink, and died. There was no fresh bleeding.

The case was a typical tubo-ligamentary pregnancy, but the amount of effusion was enormous, and much greater than I have ever seen in such cases. The delay of three days-for there is no doubt the bleeding began three days before, when the sudden pain came on—was unfortunate. Cases of acute hæmorrhage stand the operation much better immediately after the bleeding than after a day or two, when they have slightly rallied.

CASE II. Tubal pregnancy-Intraperitoneal rupture of sac-Abdominal section-Recovery.

Late on the evening of 23rd December, 1902, I was asked by Dr. Brodie and Dr. Duff, of Wishaw, to come out the following day to see a patient of the former, and be prepared to operate, as they considered the case one of ruptured extrauterine pregnancy. When I reached the patient, I found her much collapsed and blanched, with a pulse about 140. A hard, tender swelling, reaching to about 3 inches above the pubis and extending up the right side, could be readily detected. The swelling and general condition of the patient had remained much the same during the previous twenty-four hours. The history, which Dr. Brodie has kindly furnished me with, is as follows:

"Mrs. W., aged 32, is the mother of four children. Her youngest child is four, and her oldest twelve years. She has had no miscarriages or uterine troubles, menstruation ceased in the middle of October, but, about the month of December, a sanguineous discharge began to come from the vagina. During October and the first half of November, she felt

remarkably well, but about the middle of November she was seized with a most violent attack of shivering, which lasted most of the night. A fortnight later (30th November), she had severe cramps in the left iliac region, and similar attacks of pain occurred again on 7th December. About a week later, the sanguineous discharge from the vagina made its appearance. By that time, also, a tender swelling could be detected in the left ovarian region. On 22nd December, she was seized with severe pain, and became collapsed."

As

Diagnosis of ruptured extra-uterine pregnancy was made by Dr. Brodie and Dr. Duff. With that diagnosis I entirely agreed when I saw the patient on the 24th. Abdominal section was performed in the patient's home. As regards the operation, there was nothing of very special note. The ruptured tube which I show was ligatured and removed. much blood-clot as possible was cleared away, the abdominal cavity washed out with normal saline solution, and the abdominal wound closed in layers. The patient's recovery was uninterrupted, except for a little suppuration round two of the stitches.

CASE III. Ovarian pregnancy-Intraperitoneal hæmorrhage-Abdominal section-Recovery.

On 9th January, I was asked to see Mrs. M'D., a patient of Dr. Wilson, of Greenock. She had come to Glasgow to spend the Christmas holidays, but delayed going home on account of one or two attacks of abdominal pain, which she attributed to errors in diet.

The following is her history:-She is 27 years of age, has been married for two years, and has one child, now 11 months old. She nursed the child for three months, but had to give it up, as the supply of milk was not sufficient. During the whole time of lactation she menstruated regularly. On 20th November, she became unwell for the last time, and as she had no period in December, she began to consider herself pregnant. Not that she had any symptoms, only, about the end of December, she occasionally had shooting pains through the breasts. There was no sickness or vomiting. She began to feel unwell on New Year's day, especially in the evening, when she had backache and pain in the lower part of the abdomen. The pain was in the form of spasms, but did not seem quite to resemble intestinal colic, although she thought that was the cause of her discomforts. She had a second severe attack of pain on the night of 8th January. Between these two attacks, she did not feel well, felt often