A New Classification 
POSSIBLE TERMINATIONS 
OF TMB 
or 
l:\lra-Utcrinc Gestation. 
By W. A. Newman Dour and. M.D, 
I untrue tor In tpM.i Polyclinic. 
Ucpriot Irum 
Thl; AMIiHICAN I MIRAIMSI. 
February, Reprint from the “ American/Therapist^” 
FmuuixkrV, l&flr- 
A New Classification 
OF TMI- 
POSSIBLE TERMINATIONS 
OF 
Extra-Uterine Gestation.* 
Hy W. A. Newman Doklanu, M.D. 
Instructor in Gynecology, l*hlla<lHpMa Polyclinic. 
My only apology for selecting as my 
topic the subject that has just been an- 
nounced, is the avowedly chaotic condi- 
tion of its literature, which it seems to me 
renders justifiable an attempt to evolve 
therefrom a system and order. As we 
* Read before the barton Cooke Hirst Ob. 
stetrical Society, and contributed to the Amer- 
ican Therapist. 2 
all know, ectopic pregnancy has but com- 
paratively recently assumed the promi- 
nence in abdominal surgery that is now 
generally recognized, and with our grow- 
ing knowledge of a pathological state that 
is unique in its relationship to the broad 
fields of obstetrics and gynecology, form- 
ing as it does the connecting-link between 
the two—a purely obstelrical condition de- 
manding a purely surgical treatment— 
there has sprung up a vast amount of 
literature, much of which is but tautologic 
and but a small proportion of any intrinsic 
value. Having had occasion during the 
past few weeks to inquire into the ques- 
tion of the possible terminations of an 
extra-uterine gestation, I have endeavored, 
primarily merely for my own edification, 
to group the numerous pathological fea- 
tures that are from time to time revealed 
upon the operating-table, or at the bed- 
side. The classification which I now 
offer is nothing more than a rational ar- 
rangement of phases of the disease that 3 
are well-known to all surgeons actively 
engaged in abdominal work. The de- 
ductions that I have drawn seem to be le- 
gitimate and I trust will bear further 
scrutiny. 
Briefly, then, I And that in any given 
case of ectopic pregnancy, there are but 
three methods by which nature unaided 
can terminate such a gestation ; these, 
enumerated in the order of their frequency, 
are : first, rupture with hemorrhage and 
frequently death ; second, death of the 
product of conception, the so-called spon- 
taneous cure; and third, continuance of 
the pregnancy to term. 
Without entering into an elaborate study 
of these terminations and their respective 
pathological features, it becomes neces- 
sary to consider each separately for a 
moment in order to develop their various 
manifestations. 
I. Rupture.—This, by far the most com- 
mon termination of an ectopic pregnancy 
wherever situated, will, of course, in the 4 
case of ovarian and abdominal varieties 
take place directly into the abdominal 
cavity; in interstitial pregnancy it may 
occur either into the abdominal cavity, 
into the layers of the broad ligament, or 
very rarely into the uterine cavity. The 
varieties of tubal rupture, while numer- 
ous, may be grouped into two main clas- 
ses, namely, external rupture, including 
those in which there is complete rupture 
of the tubal walls as well as of the walls 
of the gestation-sac, and internal rupture, 
including those in which there is rupture 
of the walls of the gestation-sac only 
without coincident rupture of the tubal 
walls. 
Under the first heading, external rup- 
ture, may be mentioned the following dis- 
tinct sub-divisions, instances of which 
have been accurately reported by authen- 
tic witnesses. These arc enumerated in 
about the order of the frequency of their 
occurrence: 
(i). Rupture of the sac-wall with pro- ffuse hemorrhage into the abdominal cavity * 
and speedy death. This is undoubtedly 
the most common form of rupture, its 
usual site being the upper and posterior 
portion of the lube. The hemorrhage is 
unlimited in this variety. 
5 
(2). Rupture 0/ the sac-wall with limited 
effusion 0/ blood into circumscribed spaces 
between bands off inflammatory lymph. In 
this form of rupture are produced the so- 
called pelvic and abdominal hematoceles. 
For many years these limited effusions of 
blood were unrecognized as bearing any 
relationship to a preceding ectopic gesta- 
tion, and it has only been within the past 
decade that this truth has been positively 
demonstrated. The most common situa- 
tion in which the hematocele is found is 
Douglas’s cul-de-sac, where it constitutes 
the so-called retro-uterine hematocele ; if, as 
rarely occurs, the blood accumulates in 
the vesico-uterine pouch, the condition is 
termed an ante-uterine hematocele. Other 
hemorrhagic accumulations have been 6 
noted in the immediate vicinity of the 
broad ligaments, or wherever inflamma- 
tory adhesions may have formed between 
the pelvic or abdominal viscera. 
(3). Rupture 0/ the sac-wall with effus- 
ion of blood into the meshes 0/ the broad 
ligament. This constitutes what has been 
termed hematoma 0/ the broad ligament. 
The hemorrhage in this case is necessarily 
limited, that is, as long as the distended 
tissues of the broad ligament maintain 
their integrity. In many cases the pres- 
sure from the accumulated blood is so 
great that the thin layer of peritoneum 
yields, and the confined blood finds vent 
into the abdominal cavity (secondary ab- 
dominal hemorrhage). A fatal result of- 
ten follows this accident. 
In the second group, internal rupture, 
arc likewise found a number of subdivis- 
ions, that are also presented in about the 
order of their frequency. These are as 
follows: 7 
(i). Rupture of a large vessel in the 
sac-wall with profuse hemorrhage into the 
gestation-sac itself and death of the embryo. 
This condition is described by some writ- 
ers under the term hematoma of the sac. 
Such an accident need not necessarily re- 
sult fatally to the woman, but always re- 
sults in the death of the product of con- 
ception. Usually it occurs early in gesta- 
tion, and is therefore, as a rule, followed 
by absorption of the ovum. 
(2). Rupture of the outer or pelvic wall 
of the gestation-sac without coincident rup- 
ture of the tubal wall, with profuse dis- 
charge of blood into the abdominal cavity 
through the fimbriated extremity of the tube. 
This rather rare termination of tubal preg- 
nancy has been very appropriately termed 
by Bland Sutton, tubal abortion. The 
hemorrhage may be excessive and may be 
repeated at varying intervals of time un- 
til the excision of the tube. 
(3). Rupture of a large vessel with ef- 
fusion of blood into the sac walls themselves 8 
without penetration into the abdominal cavity 
or into the meshes of the broad ligament. 
This condition is known as hematoma o/ 
the tube, and is not, as a rule, accompanied 
by a profuse loss of blood. The ovum 
dies and undergoes a process of atrophy 
and partial absorption. 
(4). Rupture 0/the inner or uterine sac- 
wall with discharge 0/ the contents 0/ the 
gestation-sac into the uterine cavity whence 
they are expelled as in an ordinary abortion. 
This, the opposite of tubal abortion, and 
which may be termed interstitial abortion, 
since it is possible for it to occur only in 
cases of the so-called interstitial or tubo- 
uterine pregnancy, is an exceedingly rare 
termination of tubal gestation, and is even 
claimed by many writers never to occur. 
11. Death 0/ the Product 0/ Concep- 
tion.—This event will be followed by 
varying results, according to the period at 
which embryonic death occurs. If this 
happens prior to the third mouth of gesta- 
tion, there follows complete cessation of 9 
the signs of pregnancy, with subsidence of 
any and all of the symptoms of the ab- 
normal condition that may have been 
present. The ovum undergoes a process 
of absorption, and it and the gestation-sac 
may be entirely removed so that no trace 
of either as such can be found. There re- 
mains, however, a chronically diseased 
and distorted condition of the tube. This 
constitutes the so-called spontaneous cure 
of the extra-uterine gestation that is 
thought to occur in about one-third of the 
cases of this abnormal condition. Should 
embryonic death occur subsequent to the 
third month of pregnancy, as is the case 
usually in ovarian or abdominal preg- 
nancy, and may exceptionally be noted in 
tubal gestation, such a termination as the 
preceding could not be expected. Under 
these circumstances there will follow an 
absorption of the liquor amnii with par- 
tial atrophy of the gestation-sac, while 
various changes, such as maceration, cal- 
cification resulting in the formation of a lithopedion, mummification, adipocera- 
tion, or putrefaction, may take place in 
the fetus itself; or the entire gestation-sac 
may be converted into a large abscess- 
cavity, which may eventually rupture into 
the peritoneal cavity, the bowel, the blad- 
der, or through the abdominal wall, sub- 
jecting the woman to all of the risks of 
septic peritonitis, septicemia and exhaus- 
tion from fetal and other fistula;. 
111. Continuance of the Pregnancy to 
Term.—'This, when it occurs, usually takes 
place in an abdominal or ovarian gesta- 
tion, although it is quite possible for a 
tubal pregnancy to be carried to term, the 
walls of the tube undergoing an enormous 
dilatation and the gestation-sac forcing its 
way down between the layers of the broad 
ligament to the pelvic floor, and then dis- 
secting up the the posterior peritoneal re- 
flection, behind which it continues to de- 
velop without interruption. Necessarily, 
this is an exceedingly rare termination of 
ectopic gestation. When it occurs the woman falls into labor at the normal ex- 
piration of pregnancy, but owing to the 
abnormal circumstances the pains are in- 
effectual, gradually passing away, and a 
variety of missed labor results with its 
peculiar sequela;. 
As a risutni of the foregoing, permit me 
to tabulate these terminations of extra- 
uterine pregnancy as follows : 
I. Rupture. 
1. External, 
(1) Into the abdominal cavity. 
(2) Into the abdominal cavity between 
bands of adhesions (pelvic or abdominal 
hematocele). 
(3) Hematoma of the broad ligament. 
2. Internal. 
(1) Hematoma of the sac. 
(2) Tubal abortion. 
(3) Hematoma of the tube. 
(4) Interstitial abortion. 
11. Death of the Product of Conception. 
(1) Before the third month (spontaneous 
cure). 
(2) Alter the third month. 
11. Continuance of the Pregnancy to Term. 
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