ECTOPIC PREGNANCY.* BY
R. S.
Statham, M.D., Ch.M., F.C.O.G.,
Honorary Gynecologist, Lecturer in
Bristol Royal Infirmary; Obstetrics, University of Bristol; AND
H. L.
Shepherd, M.B., Ch.M., M.O.O.G.,
Obstetric Registrar, Bristol Royal Infirmary Obstetric Tutor, University of Bristol.
Ectopic pregnancy is of interest
an
by
no
means
for tlieir
necessary clinical material
rare,
success
depend so very largely early diagnosis that 110 apologies for reporting this series of cases.
and the results upon
members of
to most
Its incidence is
profession.
our
;
seem
The
this paper is based upon which consists of 85 consecutive cases at the Bristol Royal The latter were cases. and 15
Infirmary added
as
in
cases
The
private
they our
included three of the most
interesting
series.
frequency
has been assessed
of occurrence of
variously.
ectopic
Wynne14
pregnancy found it in
gynaecological patients admitted
1 3 per cent, of 22,500 to The Johns Hopkins -
analysis Philadelphia an
of
all
Hospital. Schumann9 made the pregnancies reported in
then obtained figures year, and from all the operators in the area, thus arriving at an estimated incidence of one ectopic in 300 pregnancies. *
A
Society 15
in
one
Paj>er read at a Meeting of the Bristol Medico-Chirurgical held in the University of Bristol on 12th November, 1930.
16
Drs. H. S. Statham
and
H. L. Shepherd
interest to note that up to 1876 this condition was considered a pathological curiosity, which had never been noted at many leading hospitals. But in 1883 Lawson Tait diagnosed and operated upon It is of
a a
some
of tubal pregnancy and reported his result in monograph,11 which started a long series of papers case
upon this most
interesting condition.
pregnancy results from some factor causing delay, or arrest, in the passage of the ovum from the Graafian follicle to the uterine decidua. The following
Ectopic
therefore occur, in theory at any rate : ovarian (1) Primary pregnancy, (2) primary abdominal implantation, (3) tubal implantation, (4) secondary
varieties
can
abdominal
or
implantations, (5) broad (6) pregnancy in an undeveloped
tubo-abdominal
ligament pregnancy,
horn of the uterus. Of these primary ovarian pregnancy is very rare, and the very existence of primary abdominal pregnancy is still denied by most authorities, although a very convincing case has been recently reported, and
Professor Rayner has kindly given me details of a case that he is about to publish, which seems quite
beyond dispute. Causation.
Any factors which
delay in the passage in its journey to the uterus be may originate an ectopic pregnancy. These may conveniently grouped as follows :?
of the fertilized
A. of
can cause
ovum
Persistent foetal convolutions Diverticula leading out of the
Congenital.?(a)
the tubes.
(b)
tubal lumen.3 (c) Accessory ostia, which do not These are said to communicate with the tube. be
fairly
by
us.
common, but have very seldom been
seen
Ectopic Pregnancy B.
17
Conditions
resulting fro?n previous attacks of salpingitis.?This theory was based upon the undoubted fact that very many tubal pregnancies follow upon an attack of pelvic peritonitis, especially if it be gonococcal in origin. It was believed that the ciliary action of the tubal mucosa was the lumen became that and destroyed
locally constricted, up but
so
that
a
spermatozoon could
pass
would be arrested oil its way developing down. These ideas were shown to be erroneous, and Opitz7 demonstrated the most likely causation. He showed that, as a result of previous salpingitis, the long tubal plicse tend to become adherent in places and so form conical pockets with blind ends, into which the ovum
C.
a
ovum
may pass and become arrested.
Webster12
theory regarded as
advanced
might phenomenon, basing pregnancy
be
that
a
an
tubal
atavistic
it upon the decidual reaction in the tube, which he considered a return to the primitive type of uterus. But Bland Sutton states that ectopic pregnancy does not occur in the lower animals though
Blair Bell has described it in rats?and there is
practically On
no
material
proof
of this
theory.
cause of tubal of tubal jDOckets pregnancy is probably the formation of on the and following presence accessory salpingitis,
ostia
the
whole,
the
commonest
and
congenital diverticula will fair proportion of the remaining cases.
account for
a
Varieties. The 100
varieties
cases
were
Primary
Vol. XLVIir.
this
..
..
abdominal pregnancy in
an
series
of
:?
pregnancy
implantation
Pregnancy
in
implantation
follows
ovarian
Secondary
Tubal
as
of
.
?
undeveloped
?
.
.
3 95
?
horn
1
.
.
1 c
No.
179.
Drs. R. S. Statham
18
and
H. L. Shepherd
specimen of primary ovarian pregnancy (No. 1) particularly fine one, in that the sac and embryo It has been reported in detail quite intact.
The was a were
elsewhere.
2
The patient had been treated for sterility of four years' duration by C02 insufflation, and became pregnant two months she developed typical symptoms months later. At of tubal pregnancy, and -an immediate operation was performed, the ovary with the ectopic pregnancy being removed. She has since been delivered of a normal child.
The existence of
ovarian pregnancy was strongly denied for many years by such eminent authorities as Tait and Bland Sutton, but in 1878 " rules" for the Spiegelberg laid down his four
primary
of this condition, viz. (1) the tube on affected side must be intact, (2) the foetal sac the must be in the position of the ovary, (3) the pregnancy
recognition must
be
connected to
ligament, (4)
the uterus
by the ovarian
true ovarian tissue must form its wall.
Since that date numerous cases have been recorded, and these include at least two in which pregnancy has terminated in the formation of lithopsedia (Santti). The three
were
very
of
secondary interesting clinically. cases
abdominal pregnancy
The first patient (No. 2) was between five and six months pregnant, and showed all the symptoms of acute appendicitis. The temperature was 102? and the pulse-rate 112, while there was a definite mass like a hen's egg in the right iliac fossa.
The fact that the pregnancy was very thin-walled was not noticed, and the case was diagnosed as pregnancy complicated At operation the an appendix abscess or pyosalpinx. by " " mass proved to be the fundus of the uterus pushed well back over to the right side by a thin-walled sac containing a foetus. The operation was rendered very difficult by dense adhesions, but the placenta was luckily situated in the pouch of Douglas and was removed intact. The patient made an uneventful recovery, but the child survived only twenty minutes.
Ectopic Pregnancy The second
19
was a primigravida who had missed taken with a sudden attack of pain and vomiting. She came into Bristol, seven miles, in a side-car. She was found to have a biggish uterus with a mass the size of a grape-fruit in the pouch of Douglas, which was diagnosed as a pelvic hsematocele. She refused operation as she had to go on haymaking, and this she did in spite of violent expostulations ! Twelve days later she returned, and at the operation twin foetuses were removed from the pouch of Douglas. The sac wall included the right tube and ovary ; the blood-clot round the sac was already infected, but she made a perfectly normal recovery.
patient (No. 3)
three periods, and
was
The third patient (No. 4) was admitted collapsed, and obviously had had an intraperitoneal haemorrhage. There was a soft mass in the pouch of Douglas. When the abdomen was opened a foetus and placenta were found lying on the back of the right broad ligament, and the placenta was firmly implanted into the back of the uterus and pouch of Douglas. The broad ligament contained old clot, and the case seems to have been
firstly
which
tubal gestation, then a broad ligament pregnancy re-escaped into the peritoneum, and gained a new
a
implantation True
for the second time.
tubal "pregnancy is
much
the
commonest
type of ectopic gestation. The implantation can The average interstitial, isthmic or ampullary. reported frequency is roughly interstitial 3 per be
cent., isthmic 20 per cent, and ampullary 77 per cent., and this series of cases approximates closely
to
these figures. In any variety the fertilized ovum enters the tube, and is arrested during its passage to the uterus by one of the causes already discussed. The trophoblast then settles down, either on a plica, or on the actual wall of the tube between two plicae, and then embeds itself
by
site is the
"
virtue of its
power. The common or between two of the plicae, found lying in the muscularis
penetrative
intercolumn ar,"
is very soon of the tube, and surrounded by a capsule of fibrin from blood-clot and degenerated, muscle tissue so
ovum
20
Drs. R. S. Statham
(corresponding pregnancy), In the
rare cases
H. L. Shepherd
Nitabuch's
to
which
and
separates
of
layer
in
a
normal
it from the tubal lumen.
implantation
on a
plica the
ovum
will, of course, be entirely surrounded by the epithelial lining of the tube, and its area of expansion is then strictly limited. If the implantation takes place in the
narrow
isthmic
portion
of the tube
early
"
"
rupture
will occur, but an ectopic pregnancy situated in the ampullary end may expand its capsule into the tube to a much greater extent before any severe symptoms A slight but definite decidual reaction supervene. occurs in the tube, and decidual cells have been found scattered over the capsule of the ectopic pregnancy in 13- 15 but no true decidua really exists many cases, as a definite structure. The chorionic tissue and placental formation in the tube do not differ from those in intra-uterine gestation, with the exception of the fact that chorionic degeneration is common.5 This was well seen in several of our cases, and the changes in the case of ovarian
pregnancy (No. 1.) were fully studied and illustrated 2 by Fraser in the report upon it. While these changes are taking place in the tube the uterus is also undergoing a characteristic reaction. Definite decidual formation occurs and has been very
fully studied.8 When decidua is expelled in
foetal death supervenes the small scraps accompanied by
bleeding, but
occasionally
complete
it
may
uterine cast
be
(Case No. 59).
passed
in
a
Termination. A tubal pregnancy may terminate in a waj^s: (a) formation of a tubal mole,
abortion,
(c)
intraperitoneal
ligamentary rupture.
rupture,
variety of (b) tubal (d) intra-
Ectopic Pregnancy
21
(a and b) can be grouped together as internal rupture of the capsule," while the second pair (c and d) represent external rupture of the capsule." (a) Tubal mole.?In this condition the blood from the maternal vessels?which have been eroded by the The first two varieties "
"
the lumen of the tube, while the not completely detached. Clotting then occurs round the ovum with resulting fibrosis, and this process being repeated at short intervals results in the formation of a mole. The mole is usually
trophoblast?enters ovum
itself is
expelled into the peritoneal cavity
at
a
later date, mole are
though occasionally fibroid remnants of found at operation which must have been in the tube for years. a
(b) Tubal abortion is naturally
most
common
in
ampullary implantation, and consists of the expulsion of the ovum which has been completely detached by the blood. The ovum and blood are forced into the peritoneal cavity by the contractions of the intact portion of the tube. The colic and accompanying bleeding render it a matter of great difficulty to
distinguish
between
abortion
tubal
and
tubal
rupture.
firmly round the fimbriae of the tube and form a peritubal hematoma." (c) Intraperitoneal rupture.?In this condition the In
some cases
the blood will clot "
capsule of stretched tube, which encloses the ovum, is so eroded and thinned by the trophoblast that it gives way, and very severe bleeding may take place into the peritoneal cavity, which will produce all the classic symptoms of an abdominal catastrophe. In so severe, and the not is cases the many bleeding blood clots about the affected portion of the tube and produces the paratubal hematoma. In other cases
Drs. R. S. Statiiam
22
and
H. L. Shepherd
clotting will take place in the pouch of Douglas, giving rise to a pelvic hematocele." It must be noticed "
that the real
of the
cause
is erosion, and so the term
bleeding
distension of the tube
and
wall, rupture "?long established in our nomenclature?is really a misnomer. As about four-fifths of the tubal surface is covered with peritoneum, it is natural to find this variety much commoner than the next,
not "
viz.
:?
(d) Intraligamentciry rupture.?Here the tube gives way at a point on its wall which is lying over the tissues of the broad
the broad
ligament
hsematoma."
ligament. The blood passes into and distends it, forming a " pelvic
In addition to the above varieties there are three very rare terminations which are occasionally seen. In a few cases of intraperitoneal rupture the ovum be
may
to grow,
reimplanted in the pelvis and continue so produce a secondary abdominal "
and
pregnancy," including the pregnancy." Three cases
so-called are
"
tubo-abdominal (Nos. 2,
here recorded
3 and 4). The ovum in the case of intraligamentary rupture may reimplant itself within the layers of the broad ligament and develop in that situation. Both these may go to full time ; and viable, but deformed infants, have been removed at We have had no case of this at the Royal
varieties
usually term.
Infirmary. Finally,
"
"
may be formed, and be later. This discovered years condition seems to be much rarer than it used to be, probably owing to the a
lithopsedion
great improvement
in
early diagnosis
which has taken
place. In
one
of
our cases
(No. 100) the pregnancy occurred
Ectopic Pregnancy in
a
rudimentary horn,
at the fourth
month,
and gave rise to violent
although
110
23
bleeding
symptoms
at all
had occurred till that time. Diagnosis.
obviously two very different conditions to be diagnosed as ectopic pregnancy, viz. (1) cases of severe intraperitoneal bleeding, and (2) those in which the loss of blood is slight, or has taken place into the tube or broad ligament only. In the first class there is no difficulty in deciding that a very acute abdominal catastrophe has occurred. The patient is blanched, sweating, and cold. The pulse There
are
is thin and rapid. in the flanks, and
Free fluid can be demonstrated usually there is well-marked air
hunger. In these cases the diagnosis is fairly obvious, while there is never any question as to the urgent necessity of operative interference.
It is in the second group of cases that the difficulty of diagnosis arises. Wynne14 states that at Johns Hopkins only 46 per cent, of cases were correctly diagnosed in 1919, while Brady1 in 1923 found it had improved to over 70 per cent, in the same clinic. The correct diagnosis of an ectopic pregnancy is obviously of the greatest importance, and every case operated as having been saved from upon early can be
regarded
grave disaster ; for it is quite impossible to foresee the occurrence of a tubal mole or abortion in place of a tubal rupture. In the first place, we regard the history of a missed period as of little importance. Brady1 found it present a
in
50 per cent, of his cases, and in this series in six had not definitely missed any period at all,
only
one
while in many more this history was doubtful. The complaint of irregular attacks of sharp pain of a colic
24
Drs. R. S. Statham
type is
much
a
more
and
H. L. Shepherd
important symptom, and when this
accompanied by irregular uterine bleedings?usually small in quantity?the diagnosis may be considered to be practically established on the history alone. On pelvic examination it is usually possible to distinguish a mass which is very tender, to one side of the uterus, or in the pouch of Douglas, often associated with enlargement of the uterine artery of that side which can easily be felt pulsating in the fornix affected. The uterus itself will be enlarged and softened and suggests an early pregnancy. In some cases small clots of blood may be felt in the pouch of Douglas. The attacks of colic are due, of course, to the bleeding into the tube and small intraperitoneal haemorrhages, while the vaginal bleeding is the result of the attempts at getting rid of the degenerating decidua, and occurs coincidently with the colic, due to the tubal bleeding which has killed the embryo. A
is
sign which is sometimes of great value, and much vaunted by French gynaecologists, is the rising pain," "
in about 45 per cent, of this series. It consists of passing up from the pelvis and running to the right shoulder, where it persists as a steady
present a
dull ache
ache. In
opinion any woman who has suffered with colic and irregular uterine haemorrhage of attacks should be at once diagnosed as a suspect ectopic pregnancy, and be placed under close supervision. If no alternative and certain diagnosis be found, she our
should be treated
by abdominal section without undue
delay.
operated
series of 29 cases at the upon on the evidence of
found 26
ectopic pregnancies,
In
a
ovarian
cyst, and
1
1
Royal Infirmary, history only, we
pyosalpinx,
normal pregnancy
;
1 twisted an
error
Ectopic Pregnancy rate in
25
of 10 per cent., but only 3-5 per cent, when the question of the need of an operation is considered, and this fully justifies the unnecessary
diagnosis
operations. There is
one
point which cannot be
too
these
unless
insisted upon, and that
vaginal examination possible
in
is the very real
to open the abdomen at
cases,
heavily
danger of it
is
once.
One of the patients in this series (No. 30) was examined in the ward with great care, and almost at once complained of a severe pain. Within three minutes the pulse ran up to 120 and she became pale and collapsed. She was rushed into the theatre, and the abdomen was opened and the bleeding dealt with ; but she lost quite li pints of blood during the few minutes involved in her on to the table and under
getting
the amesthetic. Also, a number of years ago, a case was admitted to a surgical ward at the Royal Infirmary and examined there in bed. The same events occurred, and the patient died before the abdomen could be opened, although there was only a few minutes' delay.
It
desirable
seems
tentative
the
make
to
the
history, diagnosis of an ectopic pregnancy examination confirmation vaginal by delay patient is in hospital, or a nursing home, where she can be operated upon immediately, if on
and to till the
necessary. The chief abortion. "
differential diagnosis
In this series of
immediates," and of these
cases
ten
is from
56
were
were
incomplete
not
obviously
actually diagnosed
products" and curetted, i.e. an error of 18 per cent. The true diagnosis was made in eight of these cases while the patient was on the table, and In the two the abdomen was immediately opened. as
"retained
(Nos. 63 and 97) the condition was diagnosed and both patients died, being the only
remaining not
cases
deaths in the series. It is of interest to note that one of these cases (No. 63) was both an ectopic and an
Drs. R. S. Statham
26
and
H. L. Shepherd
intra-uterine pregnancy. We have found the most to be the fact that colic-like differential helpful points
pain is very unusual the uterus is actually contents, while the
incomplete abortion, unless expelling its bleeding is very much more profuse in
in the process of
tubal pregnancy. Also no swelling can be felt in the broad ligament or in the pouch of of in the case abortion. there In cases where Douglas is a large pelvic hematocele it is possible to mistake
than is usual in
a
swelling for a retroverted gravid uterus, and attempts to reduce it may have diasatrous results (No. 2G). The hematocele may also be mistaken for a
the
twisted ovarian cyst. A case of abortion from
operation
as
observation of a As an aid to introduction of
Douglas
may
for
with
lead colic
was
saved
ectopic gestation by the chance
blue line."
diagnosis in very doubtful cases the an exploring needle into the pouch of
give valuable information. Treatment.
Operation is the only possible form of treatment, the diagnosis lias been made. Even if the to a tubal abortion, it is much safer symptoms point to open the abdomen immediately. Two of these were diagnosed as cases of tubal abortion by competent observers, and yet were found to be early tubal ruptures at operation, and might have bled violently
once
at any minute.
In
remove
possible, tube. three
with
it is our custom to the affected tube and retain the ovary when
cases
slight bleeding
and it is most
important
to
inspect the other unduly rare, and
Twin tubal pregnancy is not of triplets have been recorded.
cases
Also, the
Ectopic Pregnancy other tube may be
The
occurrence
so
diseased
of
an
to
as
intra
-
27
require removal.
uterine
and
tubal
pregnancy at the same time is comparatively frequent. Novak6 records 276 cases, and it occurs twice in our series In
(No. 50 and 63). one
case
occurred in
second tubal pregnancy of the tube removed at a
in this series
the
stump
a
previous operation for ectopic pregnancy (No. 34), a condition of which Hasselblatte3 reports 21 cases. Four of this series had had previous tubal pregnancies
the other side (Nos. 7, 66, 68, 85).* This is quite a usual percentage. Smith10 analysed 144 cases, and on
found that 80 (56 per cent.) became
pregnant again.
Of these 23 were ectopic (28 6 per cent), or 16 per cent, of the whole 144 cases. Other authorities give similar figures, so that Sampson and Smith consider it quite justifiable to remove both tubes at the first operation. ?
This is not
our
custom.
ruptured tubal pregnancy with severe bleeding immediate operation is, of course, indicated, and whenever possible a blood transfusion should be given during the operation. This has a most dramatic effect, and undoubtedly saved the lives of three of In
our
cases
cases.
of
Before
the
abdomen
is
opened
two
Carwardine intestinal clamps are placed ready. The abdomen is opened and the hand is at once plunged down into the and the mass of clot and tube
pelvis, grasped and clamped on both sides, so as bleeding. This should always be done,
bleeding
often
opened, and *
as
it is useless to
Since this paper
was
read
on
as
as
stop the furious
the abdomen is
try and mop
it away
the 12th November another case of
at the Bristol pregnancy has been operated upon list of cases as No. 13 on the in the which is included Infirmary,
repeated
Royal
begins
soon
to
tubal
first occasion.
Drs. R. S. Statham
28
before the to
see
light
clamps
H. L. Shepherd
and
As it is not
applied.
are
if the bowel is adherent to the sac,
bowel
gut which
clamps,
which do
injury
110
possible
we use
these
to any adherent
may be included in their grasp.
The blood
rapidly removed, for which we prefer a suction apparatus, and then the mass between the and clot
clamps
are
is
inspected
and the tube
It is
habit to
removed. blood, for
our
and
pregnancy
the clot and
remove
although it has been stated that the blood with benefit to the patient, we reabsorbed be will cannot but think it is a peritoneal irritant and forms an excellent nidus for sepsis. We have 110 experience
using the blood baled from the peritoneum for transfusion into the patient's vein, which is highly spoken of by many German authors. Rapidity of operation is essential, and immediate steps must be
of
taken to combat shock. heated blanket invaluable. as
We find an electricallyA saline infusion is given
required. We have had
experience of operating upon viable broad ligament pregnancies. Finally, a smear should be examined for gonorrhoea and a Wassermann test done during convalescence. no
Results. Out
of
this
occurred, being remainder
2
per a
100
cent,
of
cases
the
good
recover}^ collected figures of of
operated cases as against 87 treated by expectant methods. The deaths were as follows. uterine abortion, badly infected,
5-7 per
deaths
two
total. and
with the showed a death-rate
comparable which
made
of
series
per cent,
The
this
is
Schauta, cent,
in
in
cases
Case No. 63 had an intrawell as a tubal pregnancy.
as
Ectopic Pregnancy
29
Peritonitis followed the curetting. Laparotomy three days later was followed next day by death from general peritonitis. Case No. 97 was diagnosed as retained products." The temperature was 101? on admission, curetting was followed "
by
acute
and
peritonitis,
on
laparotomy twenty-four
later a necrotic broad ligament pregnancy followed from general peritonitis. On the
diagnosed
cases,
was
found.
therefore, the mortality
hours Death
was
nil.
Summary. In
summarizing
been
faced,
series
owing
our
series of 100
cases
we
have
the great difficulty, classification of those cases which do not show a definite tubal rupture. These cases rank high in our with
viz.
one
The condition found showed a thin tube distended with a blood-clot, but no definite gap in the tube wall. Although many of these would have eroded through in a short time, we have thought it advisable to classify them as " tubal abortion," as the far term "intratubal to
early diagnosis.
preferable
rupture," advocated by Berkeley and Bonney, is in general use. 98
Total cases, 100.?Died, 2 98 per cent.
=
2 per cent;
not
recovered,
=
Site of Ectopic Pregnancy.?Ovarian, 1 ; abdominal, 3; tubal, 88 (intestinal, 4; isthmic, 3; ampullary, 80; stump, 1) ; broad ligament, 7; rudimentary
horn,
1.
Termination.?Abortion,
(intraperitoneal,
38
Clinical aspects
collapsed, Chief
; on
broad
mole, 5 ; rupture, 45 ligament, 7).
45
;
adwissio?i.?Collapsed,
32
;
not
63.
symptoms
haemorrhage,
43
;
in not
collapsed
tumour, 26.
cases:
pain, 55;
30
Drs. R. S. Statham
and
H. L. Shepherd
Previous
ectopic prxgnancies.?4 Age.
20
years
21-30
1
..
,,
..
31-40
?
..
41
?
41
or over
Not stated
..
case
0
cases
1
34
?
2
4
?
3
20
?
4
cases.
Parity. .
.
..
..
.
.
25
cases.
32
,,
13
?
13
?
7
?
8
,,
5 and over
Not stated Years since last
delivery.
2
Weeks since last
?
regular
period. 10
1 year 2 vears
3
?
4 5
?
6
?
7
?
1-2
4
cases.
10
3-4
18
?
..
11
5-6
20
? ?
?
?
5
7-8
25
?
?
8
9-10
5
3
11-12
12
15
13-16
5
13
17-20 20 and
..
more
or
Not stated
cases.
..
.
.
?
1
case.
3
cases.
Lactating
2
,,
Not stated
5
..
over
Ectopic Pregnancy
31
Symptoms.
"5
^ c3
jI
03
Qj
fl
K
20
A.
21
A.
50
A.
Primary Ovarian. ^
23
0
it
++
0
0
0
Tubes insufflated four months previously.
R.
Secondary Abdominal. ^
4
37 i
n
38
??
!
22-}-
0
4-
0
12
0
+
OR.
r
-f-
JO
0
0
+
j
-f
lived Child twenty minutes. Placenta on right broad
ligament. Broad ligament pregnancy ruptured into peritoneal cavity and placental tissue and living foetus in pouch of Douglas.
R,
19 ! A.
Tubal Pregnancy.?Immediate Operations.
10
11 i2
3? it
3.> ax
1
,?7
k r
J?
36 36 33 Or
19 20 21 22
23
24 25 2r 6
1
J
1
On
,7
-
2S ll
oi?
3^ ,
9'-
5 7 12
!
0
;66
9
9
;!0
2s t
30
!
!
?,i
0 0 2 3 3 1
j
1
1
H 8 7 *
A ? ? ? ? 8
:
I * 2(5 3 2 0 2 ? 1 ^ 1.4 : 3 7 I
+ + +
+ l + + I +
I
00'+
j
++ 24? "Xi ? 7 ? ? 12 5
?
I
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I
+ +
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9
10
+ I + + I 0
*
3 8 I + 12 + 5 7 I+ + 2 46 +
|
I
I
I
+ + 0 0
6 16
+
0
+ -f- R. L. +
+ 0 0
0 j + I
I
1
0 0 +
L.
+ + R. L. 0 L. : 0 L. 0 R. + + + R. ' + +; L. R. ' + 0 R. I ? ++
0 | + 0 1 + 0 | 0 0 ++, 0 I + I 0 + 0 + 0 1 + 0 +
j
Intravenous saline
Rupture Rupture Rupture
two at Hull. Interstitial also interuterine pregnancy. Isthmic years
! Rupture Rupture Rupture Rupture Right
Rupture1 i
Rupture
Rupture!
Rupture Rupture Rupture
ectopic
Previous
J
..
tube
ligated
Blood transfusion Intravenous saline
also ..
..
j Intravenous saline, vide No. 68.
R. Rupture ; R. Rupture j *Lactating R. j Rupture | Tubo-ovarian pregnancy ? Rupture: R. Rupture L. Rupture j L. Rupture : Intravenous and saline R. i Rupture , R. ! Rupture I Ruptured when retroversion was reduced. i||
j
j
j
A. A. A.
ago
j
j
30 16 21
29 A. 20 A. 26 A. 18 I A. 17 A. 29 A. 14 A. 24 A. 17 A. 29 A. 21 13 15 23 14 21 18 28 14
A. A. A. A. a. A A. A. A.
32
Drs. R. S. Statham
H. L. Shepherd
and
Symptoms. o O r*
Q
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^
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a>
?5
,
T3 OJ
H
L
Abortion
(1) Curetted and removal of septic intra-uterine abortion.
(2) Peritonitis 3 days later?laparotomy and removal of septic tubal 12
0
+
+
+ +
+ +
+ 0
5.0
+
0
R
Abortion
abortion. Drainage. Curetted, but diagnosed on
table.
tosalpinx 6 9
o 0
R. R.
Abortion Abortion
Vide ^No.
L
Abortion
Curetted 3 weeks previ-
40.
Previous
ectopic.
ously
for
6
+
0
0
L.
Abortion
4
+
0
0
R.
Abortion
Left
3 16 4
+
+ 0 +
7 4
5 12
+ 0
0 4 3 0 6 1 0
4 + ' 0 12 I + + 4 0 + 3 + + 6 ; + : +
+
4+0 ' 6 + +
0 0
5 2
+
0 1 1 2
H 10
H
1 2 1 3
1 4 3
4 3 7 1 1
l'j ? 6 3 8
0
V?L. XLVIII.
+
+
+ +
+
:
+ +
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:
0 0 0
0 0 0 0
f + 0 0
6 0 + ? ! + ! + 12 0 + ? 0 + : 3 + +
0 0 + + 0
0 ! + + +
0
6 8
+
!
No. 179.
ovarian.
Double
salpingectomy.
Abortion Abortion on Abortion Curetted, diagnosed table. Abortion Left ovarian dermoid Abortion Curetted and diagnosed on table. Abortion Abortion Abortion Abortion Abortion Abortion extruding Abortion Polypus through cervix, hysterectomy. ovarian Rupture Small left ..
0 0
0
7+0 6
0 0 0
ectopic.
+
o o
L. L. R. R. L. R. L.
L. R.
Rupture Rupture Rupture
L. L.
Mole Mole
24 14 11 18 35 31 30 21 17 21 21 16 21 18
vide
Curetted and diagnosed
21 18 22 18 23
Appendicectomy Previous
ectopic,
No. 62.
Rupture Mole Mole
23
22 23 17 18
Rupture Rupture R.
17 14
chronic Sub-
uterine sepsis. total hysterectomy. Previous Vide No. 17.
1
18
Left hasmaalso removed.
on
Right
table. tube
ligated
also
20 17
34
Ectopic Pregnancy
j"? j
|-a
I
Symptoms.
a -p
i
'pce
|
O G
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1
6
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0
H
Broad Ligament Pregnancies. 35
93
12
+
+
+
I ?
94
?
95
!++
R-
Broacl
Ligament
venous
I
?
1
G
j
0
+
3
+
+
;
+ j
0
!
0
+
R.
30
2
V
-f1
43
97
3
12
+
4-
0
0
| Ligament
L.
+
+
0
L.
Ligament Broad
Ligament
36
98 99
j
27 :
?' 0
j
27
1
'
Curetted as intra-uterine abortion. 2 days later acute peritonitis. Gas, macerated and pus, foetus in broad liga-
8 ,
+
11 I +
+
j
+
++ 0
16
+
0 0
R. R.
Broad
| Ligament
Appendix
removed
16
Broad
0
0
in
+ +
Rudimentary Horn. L.
Rupture Ruptured left rudimentary
REFERENCES. 2 3 4 5 5 6 7 8 9 10 11 12 13 14 15
i
P-
Brady,
Johns
Hopkins Hosp. Bull, 1923,
xxxiv. 152.
Fraser & Statham, Jour. Obst. and Gyn. Brit. Evip., 1927, xxxiv. 788, Hasselblatte, Acta Obst. et Gyn. Scandin., 1927, vi. 211. McNally, Amer. Jour. Obstet., 1926, xii. 303. Meyer, Surg. Gyn. and Obstet., 1919, xxviii. 293. Contribution to Embryology, 1920, ix. 327. Novak, Surg. Gyn. and Obstet., 1926, xliii. 26. Opitz, Ztschr. f. Geb. u Gyn. Stuttg., 1902-3, xlviii. 538. Sampson, Trans. Amer. Gyn. Soc., 1913, xxxviii. 121. Schumann, Extra-uterine Pregnancy, Monograph, 1921. Smith, Surg. Gyn. and Obstet., 1914, xviii. 684. Tait, Lecture on Ectopic Pregnancy, 1888. Webster, Ectopic Pregnancy, 1895. Williams, Whitridge, Obstetrics, 1930, p. 789. Wynne, Johns Hopkins Hosp. Bull., 1919, xxx. p. 15. Young, Edin. Med. Jour., 1909, iii. 118.
Meyer,
24
Ligament
horn with abdomen full of blood.
1
s
A'
ment.
?
Pregnancy 100
I A-
? "
23
Broad
Ligament
28
21 1 A-
L. | Broad
,
1
saline.
Broad
;
96
Secondary rupture into Intraperitoneum.
11
A'