A FURTHER CONTRIBUTION TO THE STUDY OF FULLTERM ECTOPIC GESTATION.*

EDWIN B. CRAGIN, M.D., NEW YORK.

In May of this year I presented to the American Gynecological Society a paper on "The Treatment of Full-Term Ectopic Gestation: Should not the Child receive more Consideration?"†, and in that paper reported three cases of this condition, operated upon during the sixteen months ending in November, 1899. In one of these three cases the child was delivered alive; in the other two the children were dead at the time of operation. This evening I have the pleasure of reporting another case in which mother and child are both living, and the child shows no malformation:

Mrs. K. W., age 33; German; admitted to the Sloane Maternity Hospital, October 16, 1900, with the following history:

She had been married eight years; always healthy. She had had one miscarriage at six weeks shortly after marriage, and another at four months, two years ago. Her menstruation had been regular, of three-days' duration; amount slight and with little pain. There is no history of endometritis, or pelvic trouble of any kind. She had her last regular menstruation in January, 1900. In February she flowed for two weeks. In March she had a severe attack of abdominal pain, which kept her in bed one week. After this she was well through her pregnancy except for alternating constipation and diarrhoea. "Life" was felt in the latter part of June. She had had pains in the back for two weeks before admission, and for 48 hours before admission she had suffered with severe pains in the abdomen. She was brought to the hospital in an ambulance. On admission her pulse was 120. Abdominal examination was negative on account of tympanites and rigidity of the abdominal muscles. Vaginal examination showed the vertex low down in posterior cul-de-sac, almost on the perinæum. High up behind the symphysis the examining finger could just reach the posterior lip of the cervix, but could not enter the cervical canal. It was at first thought that the case was one of incarcerated retroflexed uterus, with the posterior wall extremely attenuated. As delivery per

Read before the New York Obstetrical Society, Nov. 13, 1900'
The American Journal of Obstetrics, June, 1900.

vaginam seemed impossible it was determined to open the abdomen and deliver from above. It was then found that the case was one of full-term ectopic gestation, within the folds of the left broad ligament, pushing the uterus high up against the anterior abdominal wall and dissecting the peritonæum from the posterior surface of the uterus. As a result of the 48 hours of spurious labor the ectopic sac was found ruptured and the neighboring intestines covered with fresh fibrin stained with meconium. The point of rupture was rapidly enlarged with the fingers and the living child extracted, which is here presented. (See Fig. 1.) The placenta was chiefly attached to the upper part of the left broad ligament, and it was found that the maternal vessels supplying the area could be ligated.

The intestines were glued all over the surface of the sac by recent peritonitis. The uterus was so incorporated with the sac that it was decided to remove the uterus, sac and placenta en masse.

The patient was in poor condition when brought to the operating table, but with the help of a saline infusion given during the course of the operation she rallied well and has had a smooth convalescence. The abdominal sutures were removed on the ninth day and union was primary. The baby was kept in an incubator for one week and then for one week in cotton. It is now four weeks old and for the last two weeks has been out of cotton. At birth it weighed 5 pounds. It now

weighs 5 pounds and 7 ounces, a gain of seven ounces above its birth weight. The mother has been able to furnish from her breasts only a portion of its nourishment, the child requiring supplemental nursing. In the paper presented to the American Gynecological Society my conclusions were as follows:

Ist. The viable ectopic fœtus is worth saving.

2d. Within the limitations outlined in the paper, attempts to save the child do not seriously increase the mortality or morbidity of the mother; hence,

3d. In the treatment of full-term ectopic gestation the child should receive more consideration than it at present enjoys.

My additional experience gained from the case presented this evening still further convinces me of the truth of the above conclusions. The recovery of the four mothers and the saving of the two living children, whose photographs are here presented (Figs. 1 and 2) are certainly strong arguments in favor of the plan pursued.

While I believe that in the majority of cases the placenta will be so attached that it is safer not to remove it at the primary operation, occasionally, as in the case here presented (Fig. 1) the attachment will be such that the maternal blood supply can be ligated and the placenta safely removed. Of course, when this is possible and primary union obtained, the gain is great.

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EDITORIALS.

ORGANIZATION FOR MEDICAL DEFENSE.

Agitation in Minnesota regarding a Medical Defense Union seems likely to result in success. Very great commendation should be given Dr. Donald B. Pritchard of Winona, through whose efforts the subject was brought under discussion and through whose interest and industry the profession in Minnesota appears to have been brought to the point of really forming such an organization. The object of the Union is the defense of its members in alleged malpractice suits. Its membership is not to extend beyond the confines of the State and is of course limited to physicians of good repute, membership in a medical society possibly being a prerequisite. Naturally, in order to preserve its standing such an organization could not undertake the defense. of genuine malpractice, nor indeed would it care to do so, but only of justly defensible cases, so many of which are merely blackmailing / schemes. The suitability of a case for defense is to be decided by a Council; but in the instance of an unfavorable decision by that body the member may appeal to a committee of arbitration to be composed of three members, one chosen by the Union, one by the defendant and one by the members already chosen; and the decision of this com

mittee is to be final. If the case be found properly defensible the society will undertake all the expenses of the suit. No compromise whatever will be allowed and the defendant must agree to be guided in the defense absolutely by the society. The society does not attempt to pay the fine if an adverse verdict be rendered. In the first place, the knowledge of such an agreement would be likely to act as a stimulus to such suits with patients themselves and particularly with the lawyers that seek such cases as speculations; also it would be likely to influence a jury to find a verdict for the claimant and quite possibly a larger verdict than otherwise. However the society will spare no expense in fighting the case in the first instance and then, if an adverse verdict be found, will appeal the case to a higher court, where it would be likely to get a much fairer decision than with an average jury. Regarding fees, an initiation fee and annual dues were at first suggested; but we believe that the present plan is for each member to pay an initiation fee of five dollars and to pledge himself to pay ten dollars more when called upon to do so by the directors, though it is not expected that such an assessment will be necessary.

In Canada a similar plan is under discussion by the MedicoChirurgical Society of Montreal. Their idea is to form a Defense Association of the entire Dominion through branch associations in each province. Their proposed arrangement as to fees is embraced in the following resolution, which we quote:

"That the conditions of membership shall be the payment of an entrance fee of $5.00, and no subsequent regular annual fee, save if it be found at any time that the amount obtained from these entrance fees is insufficient to cover the cost of defending cases in any given year; that then the membership be assessed throughout the Dominion, the sum not to exceed two dollars ($2.00) per annum. That failure to respond to this assessment within one month shall, ipso facto, remove said practitioner from membership and from benefits of such association, and for renewal of such membership the consent of the central council alone shall be effectual, and payment of entrance fee with assessment in arrears shall be required."

A Medical Defense Union has existed in London for several years. The solicitor's report of that organization for the year 1899, quoted by Dr. Pritchard, shows that every case tried during the year was won by the Union. In both 1898 and 1899 the membership was largely augmented, five hundred new members being added during the latter year. Of course more cases came under the consideration of the Council, but the deterrent effect of the Union is shown by the fact that