THE BRISTOL
nDebico==Cbirui'oical Journal
JUNE, 1892.
EXTRA-UTERINE PREGNANCY.
BY
A. E. Aust Lawrence, M.D., C.M. Aberd.,
Physician Accoucheur to the Bristol General Hospital, Lecturer on
Midwifery and Diseases of Women at the Bristol Medical School.
My desire in this paper is to present, as briefly and in as
practical a manner as I can, the very important subject
of Extra-uterine Pregnancy, or, as it is sometimes called,
Ectopic Gestation.
In a communication like this there is no need to
discuss the anatomy, physiology, or pathology of the sub-
ject. These points are all set forth in many well-known
and excellent handbooks. It matters very little to a
woman whether the ovum is impregnated in her ovary,
her Fallopian tube, or her uterus, but it does matter to
her where the ovum develops. For all practical purposes
the abnormal site of development to be considered is the
Fallopian tube, and, with very few exceptions, this is the
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Vol. X. No. 36.
74 DR- A- E- AUST LAWRENCE ON
seat of the pregnancy, which we may have to treat under
the heading of extra-uterine gestation.
To facilitate consideration of the subject, I have made
four classes of cases:
1. Cases in which nothing can be done. The first
intimation of anything abnormal existing in these cases
is the sudden onset of alarming symptoms, such as
abdominal pain, collapse, and death. The post mortem
examination reveals a Fallopian tube distended and burst,
with free hemorrhage into the abdomen. I have not yet
met with a case of this description, but there have been
many recorded. The patient dies in a very few minutes,
or, at the most, in an hour or two.
2. Cases in which the patient survives the primary
rupture, and in which the ovum escapes from the Fallopian
tube and develops in the abdominal cavity. Two of my
cases are examples of this kind.
3. Cases in which the patient does not die immediately,,
but gets repeated attacks of pain, &c., due to repeated
bleedings from the ruptured tube or foetal structures.
Three of my cases are examples of this variety.
4. Cases in which all the evidence points to ectopic
gestation, but in which serious symptoms do not occur
more than once, from the fact that with the primary
rupture of the tube and escape of blood either into
the broad ligament or free into the abdomen the ovum
perishes, and the hemorrhage does not return; or there
may be only distension of the tube with blood and no
rupture. These cases require no active treatment. I am
sure I have seen several cases of arrested ectopic gesta-
tion recover completely without operation. It is most
important to be able to distinguish between this set
of cases and the set in which repeated bleedings do
EXTRA-UTERINE PREGNANCY. 75
occur, and the patient's chance of recovery hangs on the
diagnosis.
I shall now briefly relate my cases, and then empha-
sise the important points which help us to diagnose?first,
the nature of the case, and, secondly, the class of case.
E. R., aged 27, came to my out-patient room in the
Bristol General Hospital, in January, 1888, complaining
of great abdominal and pelvic pains, from which she had
suffered for twelve months. She had missed one period
at this date, and was suddenly taken ill with severe pain
in the abdomen and faintness. I found an irregular
tumour lying across the lower abdomen, and it could be
felt per vaginam; and through the rectal wall I distinctly
felt a foot of a foetus free in Douglas' pouch.
I opened the abdomen, and removed a six months'
foetus which had been dead some months. The foetus
was free in the abdominal cavity. I brought the umbilical
cord out of the wound, leaving the placenta untouched at
the back of the uterus. The cord came away at the end
of ten days; the wound closed at the end of a month;
the placenta became absorbed, for at the end of six
months I examined her, and found no trace of the
placenta, which had been distinctly felt as a large retro-
uterine swelling.
C. D., aged 31. I saw this patient in the country. She
went to her full time with a living child in her abdomen,
and apparently ordinary labour set in; the os uteri dilated
in the usual way, and it was only at this stage that her
real condition was discovered. During the whole of her
gestation she had general abdominal pains, but there was
no definite history of the usual severe symptoms indica-
ting primary rupture of the tube. This may not have
occurred. I saw her late one evening, and just before
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76 DR. A. E. AUST LAWRENCE ON
my arrival the child ceased to move and died. As the
child was dead, I advised, under the circumstances,
that she should be kept in bed for two or three weeks
and then brought into the hospital. Had the child been
alive, I should have operated at once; but as it was dead,
I deemed it wise to give time for the placental circulation
to lessen. The patient was brought into the hospital, and
I opened her abdomen, and found a full-term child free
in the peritoneal cavity. I removed it, and fixed the end
of the cord outside the abdomen. At the end of fourteen
days the cord came away, and the wound healed. At the
end of the month, as the temperature began to rise, the
wound was re-opened, and a piece of placenta came away.
I passed my finger down the sinus, which I had well
washed out with boracic lotion. The discharge, in spite
of all, became very offensive, and the patient died of
septicaemia. The post mortem examination showed the
remaining part of the placenta to be loose in a sac
formed by inflammatory adhesions of intestines, &c.
From the consideration of these two cases, together
with one of Mr. Greig Smith's and one of Dr. Champneys',
I am inclined to say that the proper treatment of the
placenta in these abdominal gestation cases (that is, where
it cannot be removed as part of a gestation sac) is to tie
the cord close down to the placenta, clean out the
abdominal cavity, insert a glass drainage-tube for a day
or two, and then let the wound close. The placenta
may give no further trouble, but be absorbed, as it was in
my case, and I believe in Mr. Greig Smith's case on which
he operated about the same time that I did. But if
symptoms of septic trouble arise, the abdomen should be
opened again, and the placenta removed if possible. In
my case, it might have saved the woman, and I think
EXTRA-UTERINE PREGNANCY. 77
also in Dr. Champneys' case, which ran a course very-
similar to my own. We all know the great danger of
attempting to separate the placenta consists in the
hemorrhage; and cases have been recorded where, after
some months, attempts to remove the placenta have been
followed by death from hemorrhage. But I consider we
should explore if septic symptoms set in, and, if possible,
remove the placenta, or, at all events, well drain that
portion of the abdominal cavity where it is situated.
The three cases remaining were all examples of the
class of early rupture of the tube and hemorrhage occur-
hgray@example.com.
The first (R. L.) was brought into the hospital with
the history of having missed one period, and having been
taken with great pain in the abdomen and faintness two
days before. On her way in she had attacks of violent
pain. I suspected extra-uterine gestation, and opened
her abdomen. I found the diagnosis was correct; but
all the parts were so matted together that I could not
remove the damaged organs, and she died a few days
after the operation. The post mortem examination re-
vealed the exact nature of the case, and the specimen I
showed at the Bristol Medico-Chirurgical Society last
year.
The fourth case (S. W., aged 24) illustrates the great
advantage of early consultation. This woman missed one
period, and when the second should have come on she was
taken with severe abdominal pain and faintness, but in a
few hours she appeared quite well. She was, however, sent
into the hospital. I examined her, and found a swelling
as large as a small hen's egg to the left of the uterus. I
suspected Fallopian gestation, and arranged, if any severe
symptoms occurred, that I would open the abdomen.
78 DR. A. E. AUST LAWRENCE ON
During the night severe pains in the abdomen and faint-
ness set in. The next morning she appeared pretty well.
I found the swelling to the left of the uterus had dis-
appeared, and instead of it there was a general fulness
behind and at both sides of the uterus, and the lower
abdomen also had a distinct line of resistance for a
couple of inches above the pubes, and extending laterally
to the iliac spines. I felt sure I was justified in opening
the abdomen, and did so, and found at least a quart of
blood free and the ruptured tube. I removed the tube,
washed out the abdomen, and drained it for three weeks,
as broken-down blood-clot came away daily. She made
a perfect recover}'. I consider that drainage is most
important in these cases. Her first symptoms were due
to sudden distension of, and not rupture of, the tube; the
next attack of pain, &c., was coincident with the rupture
of the tube and escape of blood into her abdomen.
Before I saw the case that I have just related, I saw,
with a medical friend, a similar one, and it was the
experience I gained from that case that helped me to
diagnose my own; and it was the knowledge I gained by
watching Mr. Greig Smith operate on that patient that
enabled me to operate on my own case with such good
results. That case began, like mine, with a swelling at the
side of the uterus; but when I saw the patient this had
disappeared, and I found a localised swelling behind the
uterus (not at the sides of the pelvis), the uterus pushed
up against the pubes, the os soft. I made an error in the
diagnosis, and considered that it was a case of retro-
flexion of an early gravid uterus. Two days after I saw
her again, and then the retro-uterine swelling had extended
to the sides of the pelvis; and I then suspected extra-
uterine gestation, with ruptured Fallopian tube and free
EXTRA-UTERINE PREGNANCY. 79
bleeding into the abdomen. Mr. Greig Smith then saw
the case with us, and agreed in the suspicion; but as the
patient's condition was fairly, good, and the diagnosis
doubtful, we agreed to wait. A further hemorrhage took
place, and the patient was operated on. I simply mention
the case as it shows how very easy it is to mistake a
retro-uterine hemorrhage, with displacement forward of
the uterus, for a retroflexed gravid uterus. I have seen
and treated at least 50 cases of retroflexion of the gravid
uterus, and yet, in spite of that, I mistook the nature of
the case. I did not attach enough importance to the
fact mentioned to me, that there was, to begin with, a left
lateral swelling.
Previous to my last case, I saw, in consultation
with another medical friend, a case with the history of
suspected pregnancy and recurring attacks of pain in the
abdomen, faintness, &c. When I saw the patient she
was very pale, and the abdomen swollen. I diagnosed
ruptured tubal pregnancy, and advised operation, which
was done and the diagnosis confirmed, the abdomen being
full of blood.
The fifth case I believe to be one of ectopic gestation.
The woman had missed one period, and thought herself
pregnant. She was suddenly seized with abdominal pain
and faintness. There was distinct evidence of a large
hsematocele, both per vaginam and by abdominal ex-
amination. I kept her quiet a few days, and then she
had a very severe attack of pain and her temperature
ran up. I opened her abdomen, and found recent
peritonitis with effusion, and a small black blood-clot
in the fluid. I suspected at once leakage of an en-
cysted hasmatocele, probably decomposing. With great
difficulty, I broke through the roof of the hsematocele
80 DR. A. E. AUST LAWRENCE ON
(formed by intestines matted together and fixed to the
uterus, bladder, &c.), and evacuated about two pints of
blood and blood-clot. I removed the tube and the ovary,
from the surface of which free bleeding was going on, owing
to the adherent intestines, &c., being torn from it. I broke
away, in fact, a piece of ovarian capsule, with, I believe,
the fimbriated end of the Fallopian tube attached to it,
forming a gestation sac. I drained the abdomen for ten
days, and she made a perfect recovery.1 Whether this
was originally an ectopic gestation which caused the
hemorrhage or not, I cannot be absolutely sure ; but I con-
sider it was, and most likely a tubal-ovarian gestation.
Under any circumstances, I consider that when we have
a large hematocele showing signs of becoming purulent by
rise of temperature, &c., it is our duty to open, wash out,
and drain the cavity.
Shortly after this case I had another, where there was
a suspicious history of pregnancy and then sudden abdo-
minal pain and faintness, and for days persistent pain
and high temperature. I suspected ectopic gestation, and
opened the abdomen and found a large firm swelling,
reaching from the brim of the pelvis half-way up to the
umbilicus, consisting of bladder and intestines and effused
products of inflammation. No uterus, ovaries, or tubes
could be found; and in spite of persistent endeavours
to open the swelling, I could not succeed. Two days
after the operation, the patient passed per rectum a large
quantity of broken-down blood or pus, and died after
ten days with symptoms of septicaemia. The post mortem
examination showed a very large cavity behind the
uterus and one tube, which Mr. Morton examined and
1 Mr. Morton kindly made an examination of the specimens in these
two last cases.
EXTRA-UTERINE PREGNANCY. 8l
considered to give evidence of having been the seat of
ectopic gestation.
The points which help us in the diagnosis of tubal
pregnancy may be thus summarised:
1. History of the Patient.?Often there has been for
some years sterility, pointing most likely to tubal disease.
There is the history of supposed pregnancy, on account of
a period having been missed. But if no period has been
missed, it must not be concluded that pregnancy does not
exist; for in cases of tubal gestation, particularly where
the tube is diseased, and even in normal uterine preg-
nancy there may be a periodic uterine hemorrhage, and,
therefore, the non-missing of a period must not be held as
conclusive of the absence of gestation. It is most impor-
tant to get as accurate a history as possible from the
patient or her friends.
A sudden attack of abdominal pain, faintness, and
sickness, occurring in a woman who has had no definite
local ailment which might have given rise to the symptoms,
must be considered serious. If this sudden attack has
been preceded by the missing of one or more periods, it is
gravely suspicious of ectopic gestation; and if there is a
recurrence of the attack in a few days or a week or two,
it is still more suspicious.
2. The Examination of the Patient.?The woman may
be, or may not be, very anaemic : this depends on the loss of
blood, or on the recent or late occurrence of her primary
attack. A woman with a large effusion of blood into the
abdomen would be pale at whatever stage she was seen;
but a woman may be very pale and collapsed with only a
very slight loss of blood, simply from shock, as occurred in
one of my cases where simple distension of the tube
without rupture caused collapse.
82 DR. A. E. AUST LAWRENCE ON
The abdominal examination helps to a certain extent,
especially where the effusion of blood is great. A swelling
is recognised as coming up from the pelvis to a varying
height in the abdomen; and if there is any sudden increase
of this swelling, with the symptoms of pain, &c., it is
very suspicious of fresh bleeding. Of course, all bladder
complications must be excluded, and, by the history, all
abdominal disease previous to the onset of the present
symptoms.
A good deal can be learned from a vaginal examination,
but it is almost impossible even for the most experienced to
diagnose the case simply on this examination alone. I
have already mentioned the case where I concluded I had
to deal with a retroflexed uterus, and many cases at the
outset have been regarded in this way. The great
thing to do is, not to try to make too exact a diagnosis.
If the mass behind the cervix uteri seems to be the
fundus (and in some cases it feels rounded and continuous
with the cervix uteri), a change of position may remedy
the displacement if it exists. If there is a very painful
swelling by the side of the uterus, and if in a few days
this is lost in a general pelvic swelling with acute symp-
toms, it may be assumed that there is a ruptured tube,
with or without pregnancy.
The most difficult case I have had to diagnose lately
was that of a lady who came to Clifton to be under my
care. She had a history of missing two periods. She
had a rounded swelling to the left side of the uterus, and
one posterior to the uterus; the os was soft. She also
had had two or three attacks of uterine hemorrhage. I
thought it was retroflexion of the gravid uterus, with
diseased ovary and tube fixed to the side of the uterus;
but I could not say that it was not a retroflexed non-
EXTRA-UTERINE PREGNANCY. 83
pregnant uterus with a Fallopian gestation. I was
helped in the diagnosis by the absence of anything like
severe pain or shock, which she must have had if the
swelling by the side of the uterus was a pregnant tube;
for she must have had pain from the distension of the tube,
although it may not have been ruptured. Another point
in her history helped me. She had been under my care
some years before, with chronic pelvic pains. I made her
assume the left lateral position, and in the course of a
week the fundus uteri resumed its normal position, and
the lateral swelling remained for two months as it was
when I first saw her, and I have no doubt it was a chronic
inflammatory condition of the left tube and ovary. Her
pregnancy was uterine, and progressed normally.
One fact relied on is the passing of a cast of the
uterus. This is generally coincident with the cessation of
the abnormal pregnancy. The uterus when pregnancy
takes place forms the usual decidual lining, and when the
pregnancy is interrupted it casts off this lining; but by
itself it is not a trustworthy sign, as it is so liable to be
mistaken for early abortion, and in consequence the gravity
of the case is entirely overlooked.
The whole diagnosis may be summed up in a few words,
i should say that when a previously healthy woman misses
one or more periods and is taken with acute abdominal
pain and fainting, and these symptoms recur at short in-
tervals, and the vaginal examination reveals a retro- and
peri-uterine hematocele, either extending or not up into
the abdomen, it is imperative to open that abdomen with-
out delay.


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