When a gravid tube is detected before rupture, the operation is practically that of oöphorectomy: and is simple and safe.
When the operation is required in consequence of the bursting, or abortion, of an early gravid tube, great promptness is often required on the part of the surgeon to prevent the patient dying from hæmorrhage, and although the operation in these circumstances is really an oöphorectomy, it often has to be performed in the patient’s room as an emergency operation and without the elaborate surroundings of a modern operating theatre.
Fig. 7. A Gravid Fallopian Tube. There is a hole in the gestation-sac, and tufts of villi project through it. The patient was in the seventh week of her tenth pregnancy when she was seized with abdominal pain and died in ten hours from hæmorrhage. (Museum of St. Bartholomew’s Hospital.) Natural size.
There are few accidents which test the skill, nerve, and resource of a surgeon more than cœliotomy for a suspected intraperitoneal hæmorrhage from a gravid tube, and few operations are attended with such brilliant results. Surgeons are often astonished to find a large amount of blood in the pelvis due to a small perforation in a gestation-sac no bigger than a cherry (Fig. 7).
Operation. In removing tubes of this kind it is necessary to apply the ligature on the uterine side of the rent in cases of rupture of the tube, but when the rent involves the wall of the uterus the opening will require the application of a mattress suture for its complete closure. In some rare instances of the interstitial variety of tubal pregnancy, the uterus has been so involved that in order to effectually control the bleeding it has been found necessary to remove the uterus.
After the pedicle has been safely ligatured and the blood removed, the abdominal incision is sutured as described on [p. 9]. When the shock due to the bleeding and operation has been great, it is sometimes judicious to pour one or two pints of saline solution at the temperature of 102° F. direct into the abdominal cavity.
The majority of cases of internal bleeding from gravid tubes in the early stages are submitted to operation at periods varying from a few hours, days, weeks, or even months, after the primary bleeding.
When the tube bursts, the hæmorrhage may not be so profuse as to induce death; and the woman, recovering from the shock, does not manifest such grave symptoms as to demand surgical aid. The consequence is that the patient sometimes remains for several weeks under palliative treatment (unless a renewal of bleeding kills her), and at last she seeks surgical advice. Appreciation of the true nature of the case leads to operation.
In such cases, when the abdomen is opened, the free blood in the abdominal cavity is easily removed by sterilized dabs of absorbent material. The damaged tube and ovary are removed as in oöphorectomy. When there is much free blood care must be taken that no clots are left in the iliac fossæ. When the blood has remained in the belly for several weeks after rupture, it is judicious to insert a small drain for a few days. The importance of removing blood and blood-clot from the peritoneal cavity is demonstrated on [p. 98].