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Abdominal Pregnancy as Observed in the Charity Hospital of New Orleans
ABDOMIKAL PREGNANCY AS OBSERVED I~ THE CHAR['fY HOSPITAL OF NEW ORLEANS By P.
GRAFFAGKINO,
M.D.,
NEW ORLEANS, I,A.
(From the Department of Gynecology,
Tlllan~
University.)
D
LRI~G the year 1920 the writer, in reviewing the cases of extra-
uterme pregnancy recorded at the Charity Hospital, New Orleans, from 1906 to 1920, found so many interesting cases of advanced extrauterine, or so-called abdominal, pregnancies, that he deemed it of some scientific value to record these cases, an added incentive being given by the fact that it was his privilege recently to have such a case come undrr his own immediate observation. Alfred C. Beck, in theJ ournal of the American jl'l edical Association, September, 1919, and John M. Maury, in Surgery, Gynecology and Obstetrics, November, 1920, have so thoroughly covered this subject that anyone intereflted in it should by all means read their reviews and their most valuable conclusions. In this paper I will record only those cases in which the diagnosis of advanced abdominal pregnancy was positively established by operation, x-ray, or the passing of fetal bones. From 1906 to 1920 approximately 18,835 casrs were admitted to the various gynecologic services of the Hospital, and among the cases recorded as extrauterine pregnancy, only eleven cases could be considered as positively filling thr ahove specifications. The firRt case is the writer's own, the others art' summarized from the Hospital rrcords. r.AS\·; 1.lorcrl female, age twenty. Occupation: housework. Previous history negative, menses regular, with severe dysmenorrhea. Married at 13, one child eight years old, normal delivery. No miscarriages. She had missed her periods for eight monills, thcm they l'cappea~erl three months prior to her admission. When they reappeared, shc states that she passed some sort of sac, and she felt life until this rcsumption of her periods. About ten days before admission her local doctor drained off a gallon of bloody fluid by inserting a trocar in the midline bctween the umbilicus and pubis. She had been lactating for threc months. Bowel func· tion rcgular, some nocturia. Phyical examination showcd the abdomen to be that of full term pregnancy, with parts palpable, but no heart sounds heard. Cl)adwick's sign present. Thc cervix was small and anterior lip was slightly softened, but not enough so for an advanced pregnancy. B~hind the pubis was a hard mass about the size of a fist, apparently connected with the cervix, and perhaps the fundus of the utcrus. Above the mass in the abdominal cavity was a large, irTeg~lar, hard mass, about the ~ize of a scven months' pregnancy. The x·ray report was that a fetus was prescnt within thc abdomen, with the head to the right; other laboratory reports ,wre negative. FOllr days after admiSSIOn, under ethpr,
71
7~
'rUE A:VIERICA:\, J()[;RXAL 01<' OBSTE'l'RlUS AXO GY~ECOLOGY
a Hledian incision was made, extending about two inches above the umbilit'u8. Within the cavity was found a lllrge sac containing a full trrm, macerated fetus, the position bping almost transverse, with the head in the right iliac fossa. The fetus was dl'livered without difficulty, but the placenta was intimately adhrrent to the fundus, and almost to the posterior surfaee of the uterus. It appeared to have undergone a waxy degeneration, and it was almost impossible to separate it from the uterus, so subtotal hystereetomy was done, taking off the fundus above the level of the tubes and ovaries. 'I'he sac, which had also undergone waxy degeneration, was so intimately adherent to the parietal peritoneum and the abdominal vise era, that most of it was allowed to remain in situ; what could be pee1cd off without injury to the sUl'rounding structures was removed. ClosUl'c without drainage. The patient made an excellent recovery, the wound healing by first intention, and was diseharged thirteen days after operation. The fetus weighed 2812.:12 1-,'111., ami was 45.72 eIll. long. was 11.0 em., B.P., 9.0 em. The placenta weighed 952.56 diameter, and 6.0 em. thick. The cord was :l5.56 cm. long.
'!'he F. O. diameter was 12.5 em. in
gIll.,
CASE 2. August, 1920. Colored female, aged thirty-one. Previous history negatiV('. She stated that she considered heTHelf eigllt and a half months pregnant, hut could not recall the date of her last menses. At no time had she had any feeling of faintness, sharp pain, or any symptom which would suggest tnbal pregnancy. Forty-eight hours before admission she considereil herself in labor, though the pains were cramping rather than bearing down. She was in bad condition when admitted, her pulse weak and rapid and she gave signs of exhaustion. The examination was negative, except for a hard mass at the left of the umbilicus, taken to he the fetal head. Operation the day after admission, under ether, in the midline. A full term, viable fetus, which live(l only a few hours was delivered, hut the placenta was very iirmly adherent and was not removed beeause of the fear of hemon-hagp. Closure with abdominal drainage. }<'oUowing operation she was \"ery restless, with pain, and WlUsea not relieved PVC II by gaRtric lavage. Her temperature ranged from 102° to 104°. On the sixth day she had a profuse hemorrhage through the wound, following removal of the drain. She was put on the table at oncc, almost cyanosed, and with a very poor pulse, and the placenta and membranes remoyed under nitrolls oxide. Saline infusion was given on the tahle, but her pulse ,,"as imperceptible at the conclusion of thc operation and ~he dip<1 five hours Intel'.
CAilE 3. This was a (',olored female, age ninety, who entered the Hospital Sept. 28, 1920, complaining of shortness of breath. The previous history was negative, menstrual history without incident. She had had no children, and had had her mPllopause at forty. It would be well to remark that the patient was of a low grade mentality, and her history was secured with difficulty. The physical examination revealed a hard mass fixed in the pelvis at the left, suggesting a fibroid, the other findings being irrelevant. Fourteen days after admission the patient died, the diagnosis after autopsy being cardiac hypertrophy and dilatation, acute nephritis, and chronic passh"e congestion of the liver and spleen. The peritoneal surface was smooth, moist and glistening, with a small amount of free fluid throughout. The uterus, which presented apparently a leiomyoma undergoing calcification, extended above the hrim of the pelvis, and wh~n opened, was found to be posterior to this mass described as a leiomyoma. The right tube and ovary were easily tracpd out, the left tnbe was obliterated and apparently surrounding
Gl{'U'~'A(JXIXO:
ABIlOyllXAI, PREGNANCY
the mass previously described. The left ovary was small. the mass revealed a calcified, well defined fetus.
Sagittal section of
CASE 4. Septemher,] 920. Colored female, age thirty-four. Occupation, housework. Previous history negative. Menstrual history regular. Accorcling to her statement, her menses were last seen eighteen days before admission, though her {ll'('sent trouble had begun ten months previously, with nausea, vomiting, and ~evpre pain in the left abdomen, which continued intermittently for two months. Two months later the pain continuetl in the right iliac and inguinal regions, and \VIIS stationary. About this time a mass appeared in the abdomen, which increased in size, and was slightly movable. The woman considered herself pregnant. .Examination was negative ext'ept for a large mass like a fibroid in the region of the liver. Vaginally, the een-ix was hard, and a mass was palpable at the left, which s('cmed to be the uterus.
Under ether, an exploratory laparotomy was done in the median line, and a mummified seven months' fctus was found free in the cavity. The placE'nta was attached to the body of the uterus and to the right tube. The fetus was removed, and supravaginal hysterectomy was done, with right salpingooophorectomy. The patient had gall stones, hut nothing was done in that region. She was discharged as cured sixteen days after operation. CASE 5. November, 1917. Colored female, aged twcnty-nine. Previous history ne/_,'·nti\'(,. ~Ienstrual hi~tory without incident. Seven children, the last being st illborn. At the time of allmission she considered herself almost nine months' pregnant. ThreE' months after the onset she saw blood for two days, otherwise shll had a normal course. Pivc days before admission she lJegan to have severe abdominal pains, whieh she · insisted were not labor pains, and from that time she saw blood. The physical examination was negative, except that the abdomen was pendulous. Petal pal't~ were palpable on the left, and the breech extended three fmgers above the umbilicus. On the right was a large, soft mass, apparently independent from the fetus. Vaginally, the head was well engaged in the pelViS, in the right oblique diameter, with the face under the pubis. Over the head was a thick membrane, apparently the posterior vaginal vault, and no cervical ring could be made out. The cervix could be felt high up behind the pubis, pushed to the right, and connected with a mass on the right of the abdomen, which was taken 10 be the pubis. Laparotomy was done under ether in the midline, and a dead, full-term fetus, weighing 5.88 pounds, was extracted, left salpingooophorectomy heing done also. The amniotic .sac was plastered over with omentum, which stripped off !'asily, and there were no adhesions to the intestines or abdominal wall. The uterus was large and boggy and pushed to the right, and about the size of a three months' pregnancy. The placenta was attached to the old ruptureil tube, the ovary, and the upper portion of the broad ligament, and nourished by the (ll"al'ian artery alld uterine anastomosis. The ovarian artery was hypertrophied to the size of the internal iliac. The patient was discharged as cured seventeen days aft!'r opl'!ation. CASE 6, October, 1916_ Coloreu female, age thirty-eight. Previous history negative, except for an attack of acute P. I. D. (T) two years previous, treated by uouches and rest in bcd. Menses regular, last seen eight months before. She had had leucorrhea all her life, but none for the last seven months. She had first felt life five months before admission, but had felt none for the last two weeks. For the last two months she had had unusual abdominal swelling, with a feeling of
74
THE AMERICAN JOURNAL O.I!' OBSTETRICS AND GYXECOI,OGY
tightness, pain in the right lower abdomen and lower back, and sensations of dizziness. She was poorly developed and nourished, heart rapid but regular, milk in the breasts, and the abdomen was so distended that the diaphragm was pushed upward. The walls were very tense and fluid seemed to be present. Vaginally, the cervix was almost obliterated and pushed to the right. There was a small mass at the left, probably the displaced uterus, or an ovary, Xo ballottement. Sbc days after admisRion laparotomy was done, under ether, in the midline, diselosing a large sac adherent to the abdominal wal! anteriorly. It was partiaUy freed :llld aspirated, revealing a blood-stained, brownish fluid, with yellow flocculi and shreds of tissue. The fluid was withdrawn by trocar. When the sac was opened, a full-term dead fetus was delivered, and the cord clampc(1. As the placenta WliS firmly adhrrcnt, it was not separated from the sac wall, but the sac was seized between clamps and freed from the entire ahdominal wall, omentum, intestines and mesentery. The omentum was ligated en masse and the sac delivered. In the pelvis were found two small fibroids to the left of the mass which was taken to be the uterus, at the right of which the sac arose. The cervix presumably Jed into this mass, as well as into the uterine cavity. The l('ft tube and ovary wer!' intact, the right could not be differentiated. 'fhe sac, the uterus, and the left tub,.' were removed en masse, and 1'1ter the cervix was removed, and a pack put into the vagina leading to the pelvis. The abdomen was also drained through a stab wound ill the left. The patient made a good rp('OH'I'y amI was diAeharged :18 ('ured twenty-pight days aftcr operation. CASg i. August, 191:). Colored female, age thirty-four, oe
GRA~'PAGXINO:
ABDOMIXAL PREGNANCY
75
pains, and about five months after this attack she had seen bones projecting through the abdominal wall in the region of the umbilicus. She came to the Hospital with a bottle of fetal bones, and the presumption was that she had removed them herself. Physical examination showed a large ulcer near the umbilicus, which presented a foul discharge, and from which a tiny bone was then projeeting. Under ether this ulcerated sac was opened, without entering the peritoneal cavity, and the remains of the skeleton of what appeared to be a four months fetus were removed. There was a communicating passage between this sac and the lower bowel, which later closed spontaneou~ly. She was discharged thirteen days after operation, but returned to the clinics for treatment until the superficial sinus was completely closed. CASE 10. April, 1907. Colored female, age twenty-eight, occupation, housework. Tlds woman was admitted with a very vague history of some large mass in the lower abdomen, associated with high temperature. Operation was advised by her local physieian, who doeH not seem to have considered her pregnant. Vaginal examination, under ether, revealed a condition reRembling pelvic abscess, but when an attempt was made to puncture the mass, the sponge holder was withdrawn with a fetal arm. Immediate laparotomy was done in the median line, and two dead feti of diffel'ent ages were removed. The history is most disappointing, giving absolutely no further data concerning them. The patient herself, aiter a stormy convalescence,. was discharged as cured on the sixty-first day after operation. C,\SE 11, November, 1906. Colored female, age 26, occupation housework. Xothing of note in her previous history, menses always regular. She was admitted with a diagnosis of prohahly dead fetus. The external conjugate was 19 em., the intercristal 25 and the interspinous 24. Vaginally the cervix was found to be hard and elongated, hypertrophied and not patulous. A mucopurulent discharge was present. Sixteen days after admission laparotomy was done, under ether, in the median line, and a dead, full term fetus was found, covered with membranes that were adherent to the bowels, uterus and appendages. The fetus was first removed, and then a large mass, evidently the placenta, with a large, organized clot of blood, whi",h had bee Ollie en(oysted in the fimbriated extremity of the left. tuhe, ,,'as ligated and removed en ma8.~e. 'rhe adherent membranes were removed pi('('.(' by piece, and because of the dense adhesions, right oophorpctomy with partial right salpingectomy was also done. The patient made a good rpcovery and was diseharged as cured twenty-piglit da~'H after operation.
Summarizing these eleven eases, it is interesting to note that in eYer,)' instance the patient was a colored woman. The ages range from 20 to 90, in the la»t instance the diagnosis being established by postmortem many years after the pregnancy occurred. It is also interesting to note that the only fatality in the series of operated cases occurred in the only case where the fetus was viable. In the other cases, where the operation was deferred beyond term, or where the child was taken before the patient was at term, the results were uniformly suece»sful, proying that abdominal section, where the diagnosis of ahdominal pregnancy is established, has no higher mortality than ordinal'~' gynecologic surg('ry, provided the operation is timed correet]y.
GRAFFAGKINO,
M.D.,
NEW ORLEANS, I,A.
(From the Department of Gynecology,
Tlllan~
University.)
D
LRI~G the year 1920 the writer, in reviewing the cases of extra-
uterme pregnancy recorded at the Charity Hospital, New Orleans, from 1906 to 1920, found so many interesting cases of advanced extrauterine, or so-called abdominal, pregnancies, that he deemed it of some scientific value to record these cases, an added incentive being given by the fact that it was his privilege recently to have such a case come undrr his own immediate observation. Alfred C. Beck, in theJ ournal of the American jl'l edical Association, September, 1919, and John M. Maury, in Surgery, Gynecology and Obstetrics, November, 1920, have so thoroughly covered this subject that anyone intereflted in it should by all means read their reviews and their most valuable conclusions. In this paper I will record only those cases in which the diagnosis of advanced abdominal pregnancy was positively established by operation, x-ray, or the passing of fetal bones. From 1906 to 1920 approximately 18,835 casrs were admitted to the various gynecologic services of the Hospital, and among the cases recorded as extrauterine pregnancy, only eleven cases could be considered as positively filling thr ahove specifications. The firRt case is the writer's own, the others art' summarized from the Hospital rrcords. r.AS\·; 1.
71
7~
'rUE A:VIERICA:\, J()[;RXAL 01<' OBSTE'l'RlUS AXO GY~ECOLOGY
a Hledian incision was made, extending about two inches above the umbilit'u8. Within the cavity was found a lllrge sac containing a full trrm, macerated fetus, the position bping almost transverse, with the head in the right iliac fossa. The fetus was dl'livered without difficulty, but the placenta was intimately adhrrent to the fundus, and almost to the posterior surfaee of the uterus. It appeared to have undergone a waxy degeneration, and it was almost impossible to separate it from the uterus, so subtotal hystereetomy was done, taking off the fundus above the level of the tubes and ovaries. 'I'he sac, which had also undergone waxy degeneration, was so intimately adherent to the parietal peritoneum and the abdominal vise era, that most of it was allowed to remain in situ; what could be pee1cd off without injury to the sUl'rounding structures was removed. ClosUl'c without drainage. The patient made an excellent recovery, the wound healing by first intention, and was diseharged thirteen days after operation. The fetus weighed 2812.:12 1-,'111., ami was 45.72 eIll. long. was 11.0 em., B.P., 9.0 em. The placenta weighed 952.56 diameter, and 6.0 em. thick. The cord was :l5.56 cm. long.
'!'he F. O. diameter was 12.5 em. in
gIll.,
CASE 2. August, 1920. Colored female, aged thirty-one. Previous history negatiV('. She stated that she considered heTHelf eigllt and a half months pregnant, hut could not recall the date of her last menses. At no time had she had any feeling of faintness, sharp pain, or any symptom which would suggest tnbal pregnancy. Forty-eight hours before admission she considereil herself in labor, though the pains were cramping rather than bearing down. She was in bad condition when admitted, her pulse weak and rapid and she gave signs of exhaustion. The examination was negative, except for a hard mass at the left of the umbilicus, taken to he the fetal head. Operation the day after admission, under ether, in the midline. A full term, viable fetus, which live(l only a few hours was delivered, hut the placenta was very iirmly adherent and was not removed beeause of the fear of hemon-hagp. Closure with abdominal drainage. }<'oUowing operation she was \"ery restless, with pain, and WlUsea not relieved PVC II by gaRtric lavage. Her temperature ranged from 102° to 104°. On the sixth day she had a profuse hemorrhage through the wound, following removal of the drain. She was put on the table at oncc, almost cyanosed, and with a very poor pulse, and the placenta and membranes remoyed under nitrolls oxide. Saline infusion was given on the tahle, but her pulse ,,"as imperceptible at the conclusion of thc operation and ~he dip<1 five hours Intel'.
CAilE 3. This was a (',olored female, age ninety, who entered the Hospital Sept. 28, 1920, complaining of shortness of breath. The previous history was negative, menstrual history without incident. She had had no children, and had had her mPllopause at forty. It would be well to remark that the patient was of a low grade mentality, and her history was secured with difficulty. The physical examination revealed a hard mass fixed in the pelvis at the left, suggesting a fibroid, the other findings being irrelevant. Fourteen days after admission the patient died, the diagnosis after autopsy being cardiac hypertrophy and dilatation, acute nephritis, and chronic passh"e congestion of the liver and spleen. The peritoneal surface was smooth, moist and glistening, with a small amount of free fluid throughout. The uterus, which presented apparently a leiomyoma undergoing calcification, extended above the hrim of the pelvis, and wh~n opened, was found to be posterior to this mass described as a leiomyoma. The right tube and ovary were easily tracpd out, the left tnbe was obliterated and apparently surrounding
Gl{'U'~'A(JXIXO:
ABIlOyllXAI, PREGNANCY
the mass previously described. The left ovary was small. the mass revealed a calcified, well defined fetus.
Sagittal section of
CASE 4. Septemher,] 920. Colored female, age thirty-four. Occupation, housework. Previous history negative. Menstrual history regular. Accorcling to her statement, her menses were last seen eighteen days before admission, though her {ll'('sent trouble had begun ten months previously, with nausea, vomiting, and ~evpre pain in the left abdomen, which continued intermittently for two months. Two months later the pain continuetl in the right iliac and inguinal regions, and \VIIS stationary. About this time a mass appeared in the abdomen, which increased in size, and was slightly movable. The woman considered herself pregnant. .Examination was negative ext'ept for a large mass like a fibroid in the region of the liver. Vaginally, the een-ix was hard, and a mass was palpable at the left, which s('cmed to be the uterus.
Under ether, an exploratory laparotomy was done in the median line, and a mummified seven months' fctus was found free in the cavity. The placE'nta was attached to the body of the uterus and to the right tube. The fetus was removed, and supravaginal hysterectomy was done, with right salpingooophorectomy. The patient had gall stones, hut nothing was done in that region. She was discharged as cured sixteen days after operation. CASE 5. November, 1917. Colored female, aged twcnty-nine. Previous history ne/_,'·nti\'(,. ~Ienstrual hi~tory without incident. Seven children, the last being st illborn. At the time of allmission she considered herself almost nine months' pregnant. ThreE' months after the onset she saw blood for two days, otherwise shll had a normal course. Pivc days before admission she lJegan to have severe abdominal pains, whieh she · insisted were not labor pains, and from that time she saw blood. The physical examination was negative, except that the abdomen was pendulous. Petal pal't~ were palpable on the left, and the breech extended three fmgers above the umbilicus. On the right was a large, soft mass, apparently independent from the fetus. Vaginally, the head was well engaged in the pelViS, in the right oblique diameter, with the face under the pubis. Over the head was a thick membrane, apparently the posterior vaginal vault, and no cervical ring could be made out. The cervix could be felt high up behind the pubis, pushed to the right, and connected with a mass on the right of the abdomen, which was taken 10 be the pubis. Laparotomy was done under ether in the midline, and a dead, full-term fetus, weighing 5.88 pounds, was extracted, left salpingooophorectomy heing done also. The amniotic .sac was plastered over with omentum, which stripped off !'asily, and there were no adhesions to the intestines or abdominal wall. The uterus was large and boggy and pushed to the right, and about the size of a three months' pregnancy. The placenta was attached to the old ruptureil tube, the ovary, and the upper portion of the broad ligament, and nourished by the (ll"al'ian artery alld uterine anastomosis. The ovarian artery was hypertrophied to the size of the internal iliac. The patient was discharged as cured seventeen days aft!'r opl'!ation. CASE 6, October, 1916_ Coloreu female, age thirty-eight. Previous history negative, except for an attack of acute P. I. D. (T) two years previous, treated by uouches and rest in bcd. Menses regular, last seen eight months before. She had had leucorrhea all her life, but none for the last seven months. She had first felt life five months before admission, but had felt none for the last two weeks. For the last two months she had had unusual abdominal swelling, with a feeling of
74
THE AMERICAN JOURNAL O.I!' OBSTETRICS AND GYXECOI,OGY
tightness, pain in the right lower abdomen and lower back, and sensations of dizziness. She was poorly developed and nourished, heart rapid but regular, milk in the breasts, and the abdomen was so distended that the diaphragm was pushed upward. The walls were very tense and fluid seemed to be present. Vaginally, the cervix was almost obliterated and pushed to the right. There was a small mass at the left, probably the displaced uterus, or an ovary, Xo ballottement. Sbc days after admisRion laparotomy was done, under ether, in the midline, diselosing a large sac adherent to the abdominal wal! anteriorly. It was partiaUy freed :llld aspirated, revealing a blood-stained, brownish fluid, with yellow flocculi and shreds of tissue. The fluid was withdrawn by trocar. When the sac was opened, a full-term dead fetus was delivered, and the cord clampc(1. As the placenta WliS firmly adhrrcnt, it was not separated from the sac wall, but the sac was seized between clamps and freed from the entire ahdominal wall, omentum, intestines and mesentery. The omentum was ligated en masse and the sac delivered. In the pelvis were found two small fibroids to the left of the mass which was taken to be the uterus, at the right of which the sac arose. The cervix presumably Jed into this mass, as well as into the uterine cavity. The l('ft tube and ovary wer!' intact, the right could not be differentiated. 'fhe sac, the uterus, and the left tub,.' were removed en masse, and 1'1ter the cervix was removed, and a pack put into the vagina leading to the pelvis. The abdomen was also drained through a stab wound ill the left. The patient made a good rp('OH'I'y amI was diAeharged :18 ('ured twenty-pight days aftcr operation. CASg i. August, 191:). Colored female, age thirty-four, oe
GRA~'PAGXINO:
ABDOMIXAL PREGNANCY
75
pains, and about five months after this attack she had seen bones projecting through the abdominal wall in the region of the umbilicus. She came to the Hospital with a bottle of fetal bones, and the presumption was that she had removed them herself. Physical examination showed a large ulcer near the umbilicus, which presented a foul discharge, and from which a tiny bone was then projeeting. Under ether this ulcerated sac was opened, without entering the peritoneal cavity, and the remains of the skeleton of what appeared to be a four months fetus were removed. There was a communicating passage between this sac and the lower bowel, which later closed spontaneou~ly. She was discharged thirteen days after operation, but returned to the clinics for treatment until the superficial sinus was completely closed. CASE 10. April, 1907. Colored female, age twenty-eight, occupation, housework. Tlds woman was admitted with a very vague history of some large mass in the lower abdomen, associated with high temperature. Operation was advised by her local physieian, who doeH not seem to have considered her pregnant. Vaginal examination, under ether, revealed a condition reRembling pelvic abscess, but when an attempt was made to puncture the mass, the sponge holder was withdrawn with a fetal arm. Immediate laparotomy was done in the median line, and two dead feti of diffel'ent ages were removed. The history is most disappointing, giving absolutely no further data concerning them. The patient herself, aiter a stormy convalescence,. was discharged as cured on the sixty-first day after operation. C,\SE 11, November, 1906. Colored female, age 26, occupation housework. Xothing of note in her previous history, menses always regular. She was admitted with a diagnosis of prohahly dead fetus. The external conjugate was 19 em., the intercristal 25 and the interspinous 24. Vaginally the cervix was found to be hard and elongated, hypertrophied and not patulous. A mucopurulent discharge was present. Sixteen days after admission laparotomy was done, under ether, in the median line, and a dead, full term fetus was found, covered with membranes that were adherent to the bowels, uterus and appendages. The fetus was first removed, and then a large mass, evidently the placenta, with a large, organized clot of blood, whi",h had bee Ollie en(oysted in the fimbriated extremity of the left. tuhe, ,,'as ligated and removed en ma8.~e. 'rhe adherent membranes were removed pi('('.(' by piece, and because of the dense adhesions, right oophorpctomy with partial right salpingectomy was also done. The patient made a good rpcovery and was diseharged as cured twenty-piglit da~'H after operation.
Summarizing these eleven eases, it is interesting to note that in eYer,)' instance the patient was a colored woman. The ages range from 20 to 90, in the la»t instance the diagnosis being established by postmortem many years after the pregnancy occurred. It is also interesting to note that the only fatality in the series of operated cases occurred in the only case where the fetus was viable. In the other cases, where the operation was deferred beyond term, or where the child was taken before the patient was at term, the results were uniformly suece»sful, proying that abdominal section, where the diagnosis of ahdominal pregnancy is established, has no higher mortality than ordinal'~' gynecologic surg('ry, provided the operation is timed correet]y.