Part 4

Tait denied the possibility of Ovarian Pregnancy, or a pregnancy where the ovum fastened to the ovary itself and developed there, but five fully established cases of this kind have been reported. Dr. J. Whitridge Williams, professor of Obstetrics at the Johns Hopkins University, in his textbook on Obstetrics (New York, 1903), collects twenty-five cases of ovarian pregnancy, where five cases are certain diagnoses, thirteen highly probable, and seven fairly probable. In these twenty-five cases ten foetuses reached full term, but four of the five certain cases ruptured at early periods.

It was formerly thought that primary abdominal pregnancy is quite common; that is, that the ovum is implanted on some organ within the abdomen itself, apart from the uterine adnexa. This is now looked upon as very doubtful, and such cases are probably secondary; that is, secondary to a pre-existing tubal pregnancy which has ruptured without great maternal hemorrhage and let the foetus grow within the peritoneal cavity.

The common form of extrauterine pregnancy is the Tubal Pregnancy. The ovum may be stopped in any one of the three parts of the tube, and we find Interstitial, Isthmic, or Ampullar Pregnancy. From these primary types, by rupture, secondary forms sometimes arise,--Tubo-abdominal, Tubo-ovarian, and Broad-ligament Pregnancy.

The interstitial form, that is, where the ovum is arrested in that part of the tube which passes through the wall of the uterus itself, is the rarest of the tubal pregnancies. Rosenthal (Ein Fall intranturaler Schwangerschaft. Centralbl. f. Gyn. 1297-1305) found it in only three per centum of 1324 cases of tubal pregnancy. Some deem the Isthmic variety the commonest. Dr. Howard Kelly (Operative Gynaecology) says he never met a case of Interstitial or Ovarian pregnancy in his practice. The interstitial form is especially liable to rupture with suddenly fatal hemorrhage.

About one-fourth of the cases of tubal pregnancy end within the first twelve weeks by rupture of the Fallopian tube. If the embryo is implanted in the interstitial end of the tube, the rupture (into the uterus, or into the abdominal cavity, or into the broad ligament) takes place later,--about the fourth month, or even considerably after that time. The reason for {6} the delay here is that the uterus grows with the foetus. If the foetus breaks into the uterus (a very rare occurrence), it is either expelled through the vagina almost immediately or it goes on like a normal pregnancy.

Tait was of the opinion that every case of tubal pregnancy results in a rupture of the tube not later than the twelfth week, but this opinion is no longer held. Very rarely a tubal pregnancy goes on without rupture to full term, as in the cases reported by Williams, Saxtorph, Spiegelberg, Chiari, and a few others.

Three-fourths, about seventy-eight per centum, of the cases of tubal pregnancy result in what is technically called "tubal abortion" instead of rupture. In tubal abortion the connection between the embryo and the tube-wall is broken by effusion of blood. If the separation is complete the effused blood pushes the embryo out through the fimbriated end of the tube into the abdominal cavity, and then the hemorrhage of the mother commonly ceases. Such an extrusion of the foetus is called a complete tubal abortion. If the connection between the foetus and the tube-wall is only partly severed, the ovum remains in the tube, and the maternal hemorrhage goes on. This is called incomplete tubal abortion.

In incomplete tubal abortion the maternal blood may slowly trickle from the fimbriated extremity of the tube into the abdominal cavity, become encapsulated, and thus form an haematocele. If the fimbriated extremity of the tube is blocked, the blood accumulates in the tube and makes an haematosalpynx.

In complete tubal abortion the foetus dies; in incomplete tubal abortion the viability might depend on the injury done the placenta, but in almost every case of even incomplete tubal abortion the foetus dies as a result of its separation from the tubal wall, or from compression after the bleeding.

In cases of rupture of the tube in extrauterine pregnancy, if the foetus with its attachments is expelled from the tube into the peritoneal cavity or into the broad ligament, the embryo dies.

If the foetus or embryo itself alone is expelled into the abdominal cavity and the placenta remains attached to the wall of the tube and communicates with the foetus by the umbilical cord which runs through the tear in the tube, the foetus may {7} possibly live, provided the mother does not die from hemorrhage. If the foetus goes on growing in this case, we have an abdominal pregnancy. One such case is reported by Both where a fully developed foetus was found in the abdominal cavity even lacking all its membranes, which had been left in the tube, but a foetus will not live apart from its membranes within the maternal body.

When an embryo or foetus ruptures the tube and goes into the broad ligament, it may live or die according to the injury done its attachments to the tubal wall, but it ordinarily dies. Sometimes such a broad-ligament pregnancy ruptures again into the abdominal cavity. Because the bleeding is more likely to be confined within the folds of the broad ligament, the immediate danger of maternal death from hemorrhage is less in this than in other forms of rupture.

Concerning tubo-abdominal pregnancy the only remark to be made is that, owing to adhesions, it is often surgically difficult to remove such a growth.

If the foetus is expelled after rupture into the peritoneal cavity it dies, and if the hemorrhage does not kill the mother the dead foetus if small is absorbed; if large it becomes mummified, or it hardens into a lithopoedion, or it turns into a yellowish greasy mass called adipocere, or it putrefies. A lithopoedion may be carried for years. There are more than thirty cases reported which were carried from twenty to thirty years in the abdomen, and one case where a lithopoedion was carried for fifty years.

If the foetus putrefies it causes fatal septicaemia in the mother, or a perforating abscess, unless it is successfully removed.

There are various abnormalities of the uterus, and in these pregnancy resembles in effect extrauterine pregnancy. An abnormal uterus may be unicornis, didelphys, pseudodidelphys, bicornis duplex, bicornis septus, bicornis subseptus, bicornis unicollis, or bicornis unicollis with a rudimentary horn. The impregnated ovum may fasten in the rudimentary horn and be blocked there; then the usual result is rupture within the first four months, with fatal hemorrhage unless the bleeding is immediately checked by coeliotomy and ligation.

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As to diagnosis in Ectopic Gestation, Williams (op. cit.), one of the authorities at present on the subject, says: "A positive diagnosis is occasionally made before rupture, but in the vast majority of cases the condition escapes recognition until symptoms of collapse point to the probability of rupture or abortion. In advanced cases careful examination will usually disclose the real condition of affairs, and when full term has been passed the history is so characteristic that mistakes should hardly occur."

In the American Ecclesiastical Review for January, 1898 (vol. ix., n. i), Father Rene I. Holaind, S. J., published the answers of many physicians to six questions concerning extrauterine pregnancy. Among these physicians were Thomas Addis Emmet, Barton Cooke Hirst, Howard A. Kelly, W. T. Lusk, T. Galliard Thomas, Mordecai Price and his brother Joseph Price, William Goodell, and Lawson Tait,--all eminent authorities on this subject. The second question submitted was: "During pregnancy, at what time and by what means can a differential diagnosis be made between intra and extra-uterine pregnancy, and between abnormal gestation and pelvic or other tumour?"

In answer to this question Dr. Emmet said: "There can be no absolute certainty as to the existence of pregnancy in any case until the pulsation of the foetal heart can be detected. [After the eighteenth or twentieth week of gestation.] . . . A diagnosis is difficult in all cases of abnormal pregnancy, but an expert can, within a reasonable degree of certainty, arrive at a knowledge of the existing conditions between the second and third month."

Dr. Hirst said: "In almost all cases of advanced gestation the differential diagnosis can be made. In early cases it is not always possible unless conditions be favourable."

Dr. Howard A. Kelly said: "The differential diagnosis between intra and extrauterine pregnancy can usually be made from the sixth week up to the end of pregnancy. It is more easily made from the tenth to the twelfth week on." Writing in the American Text Book of Obstetrics (Philadelphia, 1896), he says: "In the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. . . . {9} The diagnosis of ectopic gestation after the death of the foetus is largely dependent upon the clinical history; if this be deficient, the diagnosis is frequently impossible."

Dr. Lusk said: ".... The frequent discovery of the dead ovum in a tube when there has been no suspicion of pregnancy shows the difficulty of a diagnosis." In his text-book (The Science and Art of Midwifery, New York, 1890) is this remark: "Sometimes the diagnosis can only be decided by the introduction of the sound or a finger into the uterus, the physician assuming the risk of premature labour, should he find his supposition of extrauterine pregnancy an error." This means that sometimes the diagnosis is impossible without running the risk of causing abortion of a normal uterine pregnancy.

Dr. Thomas said, "After the second month the diagnosis is perfectly possible." This was also the opinion of Dr. Mordecai Price; and Dr. Joseph Price holds that the diagnosis can be made "after the third month, by exclusion." Dr. John F. Roderer, quoting Lawson Tait, says that "the diagnosis between intra and extrauterine pregnancy can not be made with certainty before rupture, nor can it be determined exactly whether an enlargement of the tube is either an ectopic pregnancy or some form of tumour."

Dr. Goodell's opinion was, "A differential diagnosis can rarely be made positively at any stage of extrauterine pregnancy."

The diagnosis, then, is difficult; and for the ordinary practitioner, the average physician, who does perhaps ninety-five per centum of the medical work of the world, the diagnosis is often impossible. There is no greater expert than Dr. Thomas Addis Emmet, and he says the diagnosis is difficult. Others hold that the diagnosis can be clearly made, and they speak truly as regards themselves, but ordinary skill finds the diagnosis almost impossible in many cases. Mordecai Price (The Pennsylvania Medical Journal, vol. viii. p. 223) in one year saw four cases which he and other physicians diagnosed as ectopic pregnancies with rupture of the tube. When the abdomen had been opened, uterine pregnancy was discovered with a ruptured tube in each case, and all the women died.

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The first positive diagnosis of unruptured tubal pregnancy was made by Veit in 1883, and the first one made in America was by Janvrin in 1886, eight years before Father Holaind's article was written. Before 1883, only eleven years in advance of the same article, when Lawson Tait performed the first coeliotomy for the purpose of checking hemorrhage from a ruptured tubal gestation, extrauterine pregnancy was as mysterious as the old "inflammation of the bowels," which turned out afterward to be appendicitis. Hence common skill in the difficult diagnosis of ectopic gestation can not be looked for.