13 
A Case of Extra-uterine Gestation; Intra- 
PERITONEAL RUPTURE IN PIFTH WEEK; OPERA- 
TION Five Weeks After Rupture; 
Recovery* 
B. F. BAER, M. D. 
Intra-peritoneal rupture of an ectopic gestation sac is so con- 
stantly attended with the death of the patient from haemorrhage 
that when the accident occurs and the patient does not die, we are 
apt to be sceptical regarding the character of the rupture unless 
opportunity is afforded of learning the true condition by abdomi-' 
nal section, as in the case whose history I here relate. 
Mrs. E. L., aged 28, entered puberty at the normal age, and had 
always, previous to the present illness, enjoyed good health; she 
was married seven years ago and has had four children at the full 
term after normal labors. The oldest child was 6 years and the 
youngest 15 months of age at the time the patient came under obser- 
vation. She nursed all of her children and had Aveaned the young- 
est in June, 1890. On July 20th, she menstruated, but in August 
her catamenia failed to appear. For this reason she considered that 
she was again pregnant. On September 15th, after some unusual 
exertion with the seAving-machine, she experienced a pelvic fulness 
and distress, and felt that she Avas about to menstruate. At 10 
o’clock the following night, while preparing for bed, she Avas taken 
Avith violent pain in the left iliac and hypogastric regions, Avith retch- 
ing, vomiting and purging. She was found shortly afterward lying 
on the floor in a state of collapse and apparently dead. But she 
soon began to shoAv signs of life, and after being placed in bed stim- 
ulants were administered, which so restored her that a physician 
was not at once called. 
During the remainder of the night and the next day she had con- 
siderable pain in the pelvic and hypogastric regions, Avith constant 
rectal and vesical tenesmus. The lower portion of the abdomen was 
visibly distended, especially on the left side. The patient continued 
to grow worse, and on the morning of the 17th, thirty-six hours 
after the first attack, a physician was called, who diagnosed “ mala- 
rial fever and gastric disturbance.” She remained in bed until the 
20th, suffering severe labor-like pains almost constantly, accompan- 
ied by chills and fever. On tAvo occasions during the five days from 
the onset of the stormy symptoms and the latter date, “ a mass 
like a thin piece of meat ” (uterine decidua) was expelled from the 
uterus. From this, together with the pain and haemorrhage, the 
patient concluded that she had miscarried and was, therefore, 
from the Transactions, Philadelphia Obstetrical Society, February, 
1891. 14 
through with her trouble. Accordingly, on the morning of the 21st 
she arose and went about, resuming her domestic duties. A few 
hours afterwards she was seized with pain, as at first, and was again 
lifted into bed. This attack, however, was not so severe as the first 
one had been. 
Dr. B. Trautmann was now called, and after investigation decided 
that the history and symptoms all pointed to rupture of an extra- 
uterine gestation sac. 
He found the left iliac and lower abdominal regions considerably 
distended. The patient was extremely blanched and without per- 
ceptible radial pulse. He at once advised a consultation and asked 
the husband to go for me. But as the patient slowly rallied again, 
his advice was not followed, and consultation was deferred. Two 
days later she was much improved and blood at this time commenced 
to flow slightly from the uterus. This continued for a week and 
appeared to be a normal menstruation, indicating that the embryo 
was probably dead. The abdomen continued Very tender, and 
she had considerable pelvic pain, with recurring chills and rise 
of temperature. On October 4th she had another attack of 
severe pelvic pain attended with slight metrorrhagia. After this, 
as soon as she could be removed, she was sent to the Hospital of the 
Philadelphia Polyclinic, where I first saw her on October 13th. 
At this time there were extreme pallor of the surface and 
considerable emaciation. The heart action was very feeble, and 
there were daily afternoon rigors, followed by slight elevation of 
temperature. 
Physical Signs.—Vaginal touch revealed the uterus displaced to 
the right and anteriorly by a mass which occupied the left side of 
the pelvis and the pouch of Douglas. The tumor was quite irregu- 
lar below, where it appeared to be connected with the broad liga- 
ment and the posterior surface of the uterus by a broad, sessile 
attachment. Its upper portion, as shown by the combined vagino- 
hypogastric palpation, was rounded and more circumscribed and 
extended into the left iliac region. The mass was slightly mobile 
above, but fixed below. There was slight fluctuation in the circum- 
scribed portion, but the lower irregular portion was rather boggy 
than otherwise, and gave the suggestion of coagulated, semi-organ- 
ized blood and lymph. 
The history and physical signs made it quite clear that a tubal preg- 
nancy had existed, and that rupture into the peritoneal cavity had 
occurred at the time of the first attack, on the night of September 
15th. The strongest point against a diagnosis of intraperitoneal 
rupture was the fact that the patient was alive; for it is the 
present well-founded belief that unless prompt surgical measures are 
taken to ligate the open vessels by abdominal section, the patient 
almost invariably succumbs to the occult haemorrhage. The fortu- 
nate accident to which this patient probably owed her life will be 
shown in the specimen. 15 
This case was now in very much the same condition in which a pa- 
tient is left after the embryo has been killed by electricity. She had 
a dead product of conception in her abdominal cavity. She was for 
this reason in far more danger than if the same dead product had 
been in the uterine cavity, because in the former condition she was 
helpless, Avhile in the latter the uterus might empty itself spontane- 
ously. I believe that there is not one among us who would be will- 
ing to leave a dead product within the uterus indefinitely to nature. 
We would remove what is now a foreign body, likely to undergo 
decomposition and destroy the patient from septic absorption, if not 
from haemorrhage. But if either were left to nature, it should be 
the intra-uterine rather than the extra-uterine product. Both, how- 
ever, should be promptly removed. 
Laparotomy was advised, and the operation was performed on 
October 20th. An incision less than two inches in length was made 
in the median line of the hypogastrium, and one finger introduced. 
The tumor was found in the left iliac and pelvic regions, imbedded 
in a mass of lymph and semi-organized blood. There was also con- 
siderable free blood in a state of commencing disorganization, but 
there was not any odor of decomposition, although the character- 
istic odor of the placenta was very marked. I began by dissecting 
the ovum from its loose attachments, and was then able to trace its 
connection with the Fallopian tube, and through this with the uterus, 
the latter organ being at first masked beneath a large quantity of 
blood and lymph. In a very few minutes I was able to deliver this 
beautiful specimen through the incision. Examination showed it to 
be the ovum and Fallopian tube, with a healthy ovary hanging from 
its lower surface. The broad ligament was transfixed and ligated, 
the mass cut away, and the pedicle dropped. The blood and lymph 
were then removed from the pelvic cavity by means of the fingers 
and a small sponge in the grasp of a long forceps, when the incision 
was closed. Neither irrigation nor drainage was considered neces- 
sary. 
The patient bore the operation well, and made an uninterrupted 
recovery, her temperature never reaching 100°. She went home 
within four weeks and remains well. 
Examination of the specimen shows that rupture had taken place 
along the upper border of the Fallopian tube, the haemorrhage occur- 
ring from this point only, and that the ovum itself did not rupture 
or become entirely separated from its connection with the tube, and 
it still remains attached by its lower surface ; to this fact may be 
attributed the non-fatal character of the haemorrhage. Bleeding 
occurred from the detached portion of the placental surface ; the 
undetached portion of the ovum then acted as a plug and prevented 
further haemorrhage. 
The specimen shows the amniotic sac laid open by section. The 
embryo, which is probably not more than four or five weeks of age, 
is suspended by its cord in the upper portion of the sac. 16 
A question of the greatest importance relates to the management of 
these cases at the time that rupture occurs. Would it have been 
wise to have performed laparotomy in this case, had an opportunity 
been given, on the night of September 15th, when the patient was 
in collapse from haemorrhage ? We might ask, “Is it wise, when 
called to a patient who is bleeding to death, to ligate the vessel from 
whence the blood is flowing?” There is no doubt that the law of 
immediate action is the safe one to follow, as a rule, but when the 
source of the haemorrhage is in such location as an extra-uterine ges- 
tation sac, the law must not be obeyed so implicitly as when the haem- 
orrhage is taking place from the femoral artery, for instance, for there 
is always an uncertain quantity existing, as was proved in the case I 
am reporting, and which might weigh strongly against immediate 
action. If the patient has rallied, and there is not any evidence of 
a continuance of haemorrhage, it might be wise to wait, but at the 
same time constantly to watch the patient. Operation during the 
shock, or immediately afterward while the patient is still weak, is 
more apt to be fatal. But it is very difficult to advise or to lay down 
an absolute rule in these cases. Each case must be decided on itg 
merits, and he who has had the largest experience should be the 
safest guide. Could we diagnose such a condition as is exhibited 
in this specimen, it would be always proper to wait until the patient 
had recovered from the shock before operating, but this we are una- 
ble to do. 
Practically, all cases of extra-uterine pregnancy are tubal and 
rupture into the peritoneal cavity. It is affirmed by Tait that rup- 
ture into the broad ligament often occurs ; but for anatomical rea- 
sons and from my own experience,! believe this must be rare. It would 
be fortunate if rupture into the broad ligament always occurred, for 
it is said the patient is then more likely to recover. This would be 
especially true if the rupture occurred early in the gestation, as the 
embryo would then be more likely to die and disappear spontane- 
ously. If the embryo did not die, it might then, according to this 
view, go on developing within the folds of the broad ligament, and 
even reach the period of viability or term. The question of differ- 
ential diagnosis between intra-peritoneal and intra-ligamentous rup- 
ture would be one of great value if this theory were true, because 
then more time might be given to deliberate.. The diagnostic 
points of peritonea] rupture are the profound shock and collapse 
which result from the great amount of haemorrhage, with often the 
death of the patient. If a patient has fully rallied after presenting 
symptoms of rupture, careful physical examination would possibly 
serve to differentiate between the two forms. In the case of intra- 
lii;amentous haemorrhage, the swelling would correspond to the 
distended broad ligament, and the blood would be confined within 
the limits of the fascia and surround the rectum, causing stricture 
of that organ. If, on the other hand, the haemorrhage was intra- 
peritoneal, there would be bulging of Douglas’ pouch, and the loose 
blood would be limitless.