EXTRA-UTERINE PREGNANCY. 
BY 
Homer Gage, M. D., 
WORCESTER, MASS. 
REPRINTED FROM THE 
American Gynecological and Obstetrical Journal 
for November, 1896. [Reprinted from the American Gynecological and Obstetrical Journal 
for November, 1896.] 
EXTRA-UTERINE PREGNANCY* 
Homer Gage, M. D., Worcester, Mass. 
So much of the recent literature upon this subject is occupied in 
advancing and defending new theories in regard to such questions 
as where impregnation normally takes place, what determines the 
lodgment of the ovum in the uterus or tube, the transmigration of 
the ovum, etc., that I think oftentimes the points of importance 
which have been really and finally determined, and which are of 
the greatest practical interest and value to us as physicians and 
surgeons, are lost sight of. I trust that you will pardon me there- 
fore for bringing forward one or two matters in connection with 
this subject which were perhaps already sufficiently familiar to 
you, but which seem to me to deserve all the emphasis we can give 
them. 
In the first place, we must regard it as settled—and it is of the 
greatest importance in the successful management of these cases 
surgically—that an extra-uterine pregnancy is probably always a 
tubal pregnancy. For the establishment of this fundamental prin- 
ciple in the pathology of ectopic gestation the profession must ac- 
knowledge its indebtedness to the brilliant work of Lawson Tait, 
who, in his treatise on this subject, published in 1888, said: “ What- 
ever difference of opinion in these matters there may be, there can 
be but a uniform consensus of belief to this effect: that by far the 
greater number of cases of ectopic gestation are tubal. I believe 
that they are really all tubal, and in this consists the novelty of my 
views on the subject.” So completely has this opinion come to be 
accepted by subsequent investigators that we find Webster, in the 
full monograph which he has recently published, beginning the 
classification of the subject in this way: “Ectopic gestation—pri- 
* Read before the Miller's River Medical Association, May 7, 1896. 
Copyright, i896j- D*, M« D. 2 
Homer Gage, M. D. 
marily tubal, in all cases so far as known.” Tait regarded ovarian 
pregnancy as possible but not proved. Webster goes even further, 
and believes that the ovum can develop only upon the mucous 
membrane of the uterus or tube; that ovarian, and all other forms 
of extra-uterine pregnancy, are primarily impossible. Just as the 
use of the terms typhlitis, perityphlitis and paratyphlitis, typhlo- 
enteritis, etc., have had to be abandoned in the face of the demon- 
stration that all these conditions originate in the appendix, so the 
complicated and confusing classifications of extra-uterine preg- 
nancy into tubal, ovarian, tubo-ovarian, abdominal, etc., have had 
to give way before the accumulated evidence of abdominal surgery, 
and the resulting more exact knowledge of pelvic pathology. 
Not only is it established that practically all cases of extra- 
uterine pregnancy begin their development in the Fallopian tube, 
but it seems further established that an overwhelming preponder- 
ance of all cases occupy in the beginning the free part of the tube, 
and that those cases which develop in that part of the tube which 
is included in the horn of the uterus, although occasional, are very 
rare. 
A second point of equal importance is, that in all cases the tube 
must sooner or later rupture, from its overdistention by the grow- 
ing ovum. Its rupture is always attended by hsemorrhage. This 
haemorrhage may occur from the upper and free surface of the tube, 
and therefore into the general peritoneal cavity; it may occur from 
the fimbriated end, whence it may escape into the free abdominal 
cavity; or, if occurring slowly, may be shut off by adhesions be- 
tween the tube, the ovary, and the broad ligament; or it may occur 
from that part of the tube which is included between the two layers 
of the broad ligament, in which case it is necessarily smaller in 
amount, and immediately less serious in its consequences. 
In the first form, where it escapes into the free abdominal cavity, 
it gives rise to an intraperitoneal haematocele. In the second form, 
where it escapes into the adhesions between the ovary and tube or 
into the broad ligament, it gives rise to an extraperitoneal haemato- 
cele. The first form is almost always, if not always, fatal to the 
further development of the foetus. In the second form, the develop- 
ment of the foetus may continue, even to full term, or it may be 
destroyed by secondary haemorrhages into the placenta or into the 
general peritoneal cavity by secondary rupture of the sac. 
But the rare instances in which the development of the foetus Extra-Uterine Pregnancy. 
3 
continues, and the still rarer ones in which a living cnild has been 
successfully delivered, are altogether too few to justify us in con- 
sidering for a moment the life of the child. The importance of a 
ruptured tubal pregnancy and its attendant haemorrhage lies in 
the terrible danger to the mother. And this danger is further en- 
hanced by the possibility—I ought rather to say probability—of a 
secondary rupture, even should she survive the first. Primary rup- 
ture occurs most commonly within the first three months. Tait 
says that he has seen no case of ruptured tubal pregnancy—that is, 
primary rupture—either in his own practice or in any of the muse- 
ums, in which there was evidence to show that it was over the 
twelfth week. Parry and Webster, while agreeing that in the major- 
ity of cases rupture occurs during the first four months, state that 
it may take place at any time during the succeeding months of the 
pregnancy. In all of my own cases in which it is possible to set 
the time at all accurately, rupture occurred within twelve weeks. 
The secondary rupture may occur at any time from a few days to 
several weeks, or even months, after the first. 
A third point of very great practical interest in the study of these 
cases lies in the change which it has wrought in our views about 
pelvic haematocele. In the fifth edition of Thomas’ Diseases of 
Women, published in 1880, is a list of eleven possible causes of intra- 
pelvic haemorrhage, and among these ectopic gestation occupies 
a very inconspicuous and apparently unimportant place. On the 
other hand, Tait states that he has never seen intraperitoneal haem- 
atocele that was not due to a ruptured tubal pregnancy. And very 
many cases of extraperitoneal haematocele have undoubtedly been 
tubal pregnancies which have ruptured between the folds of the 
broad ligament. Both Parry and Webster unite in recognizing 
it as by far the most important cause of both forms of pelvic haemor- 
rhage; and the latter says that “ the formation of pelvic haematoma 
and haematocele, apart from the rupture of an ectopic gestation, has 
come to be regarded as a rare occurrence.” It is hard for many of 
us to give up the old idea of menstrual blood backing up into and 
through the Fallopian tube, but the hard fact remains that, wher- 
ever such a haemorrhage has been investigated, its origin has almost 
always been found in a ruptured extra-uterine pregnancy. 
Abdominal surgery, then, has taught us that extra-uterine preg- 
nancy stands in much the same relation to pelvic haematocele that 
appendicitis does to acute peritonitis in the male. 4 
Homer Gage, M. D. 
I have thus directed your attention, perhaps rather tediously, 
to these few points, that seem to me to underlie the attitude of 
modern surgery toward this horrible accident. In review, they are 
briefly: First, that all extra-uterine pregnancies are tubal preg- 
nancies; second, that all rupture, generally within the first few 
weeks of the pregnancy, and that rupture is attended by haemor- 
rhage, which unchecked is a most fatal accident to the mother as 
well as to the foetus; and third, that pelvic haematocele is, at least in 
the great majority of cases, the result of such a rupture. 
Permit me now to ask your attention for a moment to the clin- 
ical symptoms of extra-uterine pregnancy. 
When rupture takes place, as it ordinarily does from the sixth 
to the tenth week, the patient may be entirely unconscious of the 
fact that she is pregnant at all, and, even if the suspicion of preg- 
nancy exists, there is ordinarily no reason to suppose that the ovum 
is not normally situated within the uterine cavity. Our attention 
is therefore rarely called to these cases before the rupture of the sac. 
There are, however, one or two conditions whose existence in cases 
of probable pregnancy ought, I think, always to be made the sub- 
ject of most careful investigation. They are, first, irregular haem- 
orrhage, not the persistence of the catamenia, as was from the time 
of Petit to Parry the generally accepted sign of extra-uterine foeta- 
tion, but an irregular, bloody vaginal discharge, small in amount, 
at times associated with clots or membranes. Such a discharge ex- 
isted for one or two weeks before primary rupture in two cases 
that have come under my observation; and I believe that its pres- 
ence, if called to the physician’s attention, should always lead to a 
careful pelvic examination, and, if associated with tubal enlarge- 
ment, the probability of an extra-uterine pregnancy should immedi- 
ately suggest itself to the examiner. 
Most authorities speak also of intermittent pelvic pain, in cases 
of supposed early pregnancy, as sometimes an indication of the 
extra-uterine variety. I have never met with this, nor has it been 
mentioned by any of my patients as having attracted their atten- 
tion. However, I believe that if noted, it, as, in fact, any other in- 
dication of unusual pelvic disturbance, should be made the occa- 
sion for immediate and careful pelvic examination, with a special 
reference to the condition of the tubes. The fact remains, however, 
that in the great majority of all cases not only will the physician 
have no opportunity of examination, but the patient herself will Extra - Uterine Pregnancy. 
5 
have no warning until the tube ruptures, and a fatal haemorrhage, 
perhaps, occurs before assistance can be summoned. 
Intraperitoneal rupture is at once associated with the symptoms 
of shock and internal haemorrhage; sudden, severe pain in the ab- 
domen; faintness; collapse; weak, rapid pulse; blanched counte- 
nance, with, perhaps, dullness across the lower abdomen, with 
great tenderness. Death may follow within a very few hours, or 
may be delayed a day or two. Such an accident is, as we shall see 
later, almost uniformly fatal. The rupture of the sac into the broad 
ligament is attended by sudden severe pain, vomiting, faintness, 
and a lesser and more transitory condition of shock. Physical ex- 
amination will disclose a fixed, immovable tumor within the pelvis. 
Such a tumor may entirely disappear by absorption, or the ovum 
may continue to develop, even to full term, when a condition of 
spurious labor, so called, occurs, and the child, if undelivered, dies. 
This represents the two extremes—immediate absorption or con- 
tinued development. Instances of the latter condition are certainly 
rare; of the former, are probably much more common than we have 
been formerly aware. I think, however, that the majority of cases 
follow a course between these two; the ovum is not destroyed at 
first, but its further development gives rise to repeated haemor- 
rhages, perhaps still further distending the folds of the broad liga- 
ment, or even bursting through into the peritoneal cavity, and giv- 
ing rise to an accident as serious as primary intraperitoneal rupture 
itself. If the patient escape this accident, there is still the serious 
danger of suppuration and septicaemia. The chance of getting a 
living child is too remote to be considered, even from the stand- 
point of the child; and the dangers of secondary rupture and sup- 
puration are so serious to the mother that the cases of extraperito- 
neal, as well as intraperitoneal, rupture are more safely dealt with 
by surgical interference, though, of course, the same emergency 
seldom arises in one as in the other. 
Of the prognosis in intraperitoneal rupture Goupil says: “ It is 
but too true, I fear, that we are authorized in saying that all the 
cases of intraperitoneal haemorrhage arising from extra-uterine 
pregnancy end in death. In fact, all the cases that I have quoted 
terminated in death. Generally, it has taken place in a few hours 
or days, and, although death has been delayed for six months, it is 
wholly exceptional.” 
Parry collected one hundred and forty-nine cases and one hun- 6 
Homer Gage, M. D. 
dred and forty-five deaths. And Webster says that “ in the majority 
of cases of rupture death will occur within twenty-four hours unless 
an operation be performed.” Death occurs most commonly from 
direct loss of blood, though, as pointed out by Richardson, it often 
happens that, when the amount of blood lost is comparatively small, 
the peritoneal shock is in itself a sufficient cause of the fatal result. 
The only escape from this terrible mortality lies in a prompt surgi- 
cal interference and the arrest of haemorrhage. I believe, further, 
that most of the cases of extraperitoneal rupture should also be 
subjected to abdominal section; that the operation should be de- 
layed in these cases only long enough to allow the patient to rally 
from the primary shock; and that further delay subjects her to 
greater danger from secondary rupture or suppuration than is in- 
volved in the operation itself. 
I desire now to report seven cases to illustrate some of the points 
which I have tried to impress upon you. 
Case I.—M. M., aged twenty-seven years; married. Entered 
the Worcester City Hospital, September 23, 1891. No previous ill- 
ness. Confined with her first child in the previous July. Not very 
well since. Soon after the convalescence began to complain of 
pain in the right inguinal region, and to notice gradual distention 
of abdomen. Examination of the heart and lungs was negative. 
The urine was normal. The abdomen much distended; dull on 
percussion; transmitted impulse showed presence of fluid in the 
abdominal cavity. Her legs and ankles were slightly swollen. She 
remained on the medical side until October 12th, when she was 
transferred to my service. Operation on the 15th. Incision below 
the umbilicus opened into a cavity, shut off from the general peri- 
toneal cavity by adhesions, containing six quarts of muddy fluid 
and two quarts of what looked like rotten sponge, but which, on 
examination, proved to be decomposed blood clots. The cavity 
was irrigated and drained, and she was discharged well on the 14th 
of November. 
Case II.—C. H., aged thirty years; married; an Arabian. En- 
tered the Worcester City Hospital, September 21, 1893. She had 
been seen outside the hospital by Dr. W. R. Gilman, who found her 
in a state of shock from internal haemorrhage, and the diagnosis 
of ruptured extra-uterine pregnancy was made and operation ad- 
vised, but refused. During the next four weeks she had had irregu- 
lar uterine haemorrhage, with pain and steadily increasing abdomi- Extra -Uterine Pregnancy. 
7 
nal enlargement. She had a systolic murmur at the heart’s apex, 
transmitted into the axilla. The abdomen was symmetrically en- 
larged, containing fluid, and one week after her admission to the 
hospital there were evidences of effusion in both pleural cavities. 
Her pulse was very rapid and feeble, her temperature hectic, and 
her general condition very unfavorable. She was transferred to 
my service on the 8th of October. Incision revealed about a pint 
of very offensive muddy fluid and two pints of decomposed blood 
clots similar to that in Case I. Cavity was irrigated and drained, 
and she was discharged well on the 20th of November. 
Both of these cases illustrate, I think, the natural course of 
extraperitoneal hsematocele which has undergone suppuration. In 
the first instance the existence of an extra-uterine pregnancy may, 
perhaps, be doubted, although no other cause could be found to 
account for the haemorrhage. In the second case there could be no 
question about the diagnosis; and the very unfavorable condition 
of the patient at the time of operation is an example of what may 
follow neglected hsematocele. Once the existence of a haemorrhage 
is fully established and the sense of fluctuation definitely obtained, 
I can see no advantage in waiting for its possible absorption and 
running the risk of suppuration, with systemic infection, as in this 
case. Certainly, if sufficient aseptic precautions are observed, the 
danger of opening and washing out an haematocele ought to be 
practically nothing. 
Case III.—M. S., aged forty years; a widow. Entered Worces- 
ter City Hospital, November 3, 1890. A stout, healthy-looking 
German, always well and strong. Had one child, who was about 
twenty years old. Five or six months ago said to have been kicked 
in the abdomen, and soon after noticed a bunch in left inguinal 
region, not painful. For six weeks this has been increasing rapidly 
in size, and has been very tender and painful. Has been aspirated 
twice within the last month, and several ounces of blood withdrawn. 
Last catamenia four weeks ago. In the left inguinal region was a 
bunch as large as two fists, not adherent, smooth, flat on percus- 
sion, and somewhat movable, semi-fluctuating, and very tender. 
Vaginal examination showed uterus in normal position, apparently 
not connected with tumor. At half-past nine the next morning 
complained of sudden pain in the abdomen. Became semi-con- 
scious, extremities cold, pulse very feeble. Temperature, 96.6°. 
Under free stimulation she rallied somewhat, and at four in the 8 
Homer Gage, M. D. 
afternoon I made an incision above and parallel to Poupart’s liga- 
ment. On opening the peritoneal cavity, a large amount of clotted, 
dark blood escaped, the examination having disclosed a smooth, 
round, fluctuating tumor occupying the lower part of the abdo- 
men, in the median line. Median incision then made nearly to um- 
bilicus, through which immediately escaped a foetus, apparently in 
the fourth month, followed by immense clots of blood. A ruptured 
sac was found connected with the uterus and tube of the left side, 
adherent to everything in the pelvis, and containing the placenta. 
Sac was freed from its adhesions. Pedicle was tied with silk and 
cut off. Abdomen flushed out with hot saline solution. Wound 
closed with drainage. On the following day haemorrhage began 
from the wound so profuse as to necessitate reopening the abdo- 
men, and its source, though difficult to find, seemed to be traced 
to a general oozing from the floor of the pelvis. Haemorrhage se- 
cured by packing with iodoform gauze. Pulse, however, never fully 
recovered its strength. Abdomen became much distended, and she 
died at three o’clock on the following day—I think of peritonitis, 
as well as from the result of the haemorrhage. 
This case illustrates the course of an extraperitoneal rupture, 
with continued development of the foetus and secondary rupture of 
the sac into the peritoneal cavity. I think, in the light of further 
experience, that under similar circumstances another time I would 
simply stitch the sac to the abdominal wound and pack with gauze. 
I believe that in that way the danger both of haemorrhage and of 
infection would have been avoided. And the experience of others 
has certainly shown us that the sac treated in that way collapses and 
eventually disappears. 
Case IV.—Mrs. T., aged twenty-eight years, of Putnam, Conn. 
Was seen with Dr. F. A. Morrell, March 29, 1894. She had been 
married seven years. Had never been pregnant. Never very 
strong, and one year before had a cough which lasted so long as 
to raise the suspicion of its tubercular origin. This has, however, 
disappeared. Her catamenia began at fourteen years; were always- 
regular. Eight years ago, after a severe fall, catamenia came as 
usual, stopped, and two or three days later she had a severe haem- 
orrhage. The same experience at next period. No irregularity 
since. Flow has been becoming more scanty. Was unwell last on 
the 23d of January. Some slight nausea and little pain in the 
breasts, and some pelvic discomfort followed. Has not felt well Extra - Uterine Pregnancy. 
9 
since. When she had passed the February period she consulted a 
physician, who gave her a tonic. On the 12th of March she began 
to flow a little, not bright red, but dark, inodorous, with some pain, 
and these conditions had existed until yesterday. Did not feel well 
all day. Toward night had a sudden, severe pain in the abdomen, 
relieved by subcutaneous injection of morphine. A second attack, 
with collapse, at four this morning, when it seemed as if she would 
die at once. The abdomen was painful all over. No local tender- 
ness. Soon became much distended. Her mind was clear. She 
was much exsanguinated. Rallied very slightly under persistent 
subcutaneous injections of brandy, digitalin, nitroglycerin, and mor- 
phine. Vomiting began with the first attack, and has continued 
through the morning. At two o’clock in the afternoon, pulse, 126; 
temperature, 99.8°. Pale, bloodless, and very weak. Vomiting 
every few minutes. Abdomen uniformly distended, though not very 
tense. No localized area of resistance or tenderness. Vaginal ex- 
amination showed the cervix pushed over to the left side, while to 
the right of it the anterior vaginal wall was bulging with a hard 
body, as if the body of the uterus was pressed to the right, direct- 
ing cervix to the left. Nothing posteriorly. Immediate operation 
advised and consented to. 
On opening the peritoneal cavity a large amount of blood 
gushed out. Uterus was found pushed to the right, enlarged to 
the size of six or eight weeks. Left tube enlarged and ruptured on 
its upper surface, and readily delivered through the wound with 
the ovary. It was ligated and removed. One quart of clots and 
fluid blood was scooped out of the abdominal cavity. Patient was 
in a state of collapse, but seemed to rally some after the abdomen had 
been filled with hot water. Wound closed with glass drainage-tube. 
In spite of the extreme shock, she rallied slowly, but steadily, until, 
on the fifth day, the glass drainage-tube not having been removed, 
a fsecal discharge was found in the wound. This seemed to come 
from the point on which the glass drainage-tube rested. Intestines 
had been considerably distended with gas, and I think the fsecal 
fistula was caused by the pressure of the tube. It closed spontane- 
ously in about two weeks. Patient’s recovery was otherwise un- 
eventful. The specimen, of which I present you with a drawing 
(Fig. 1), was thus described by Dr. Baker, the pathologist of the 
Worcester City Hospital: 
“ The tube measures nine centimetres in length, and contains. 10 
Homer Gage, M. D. 
an ovoid dilatation, being two centimetres from the cut end and 
terminating 1.5 centimetre from the fimbriated extremity; its 
greatest circumference is nine centimetres. On the upper surface, 
at the point of greatest dilatation, is a rupture through the walls 
of the tube 2.5 centimetres long, through which protrudes a blood 
clot the size of a walnut. The cavity of the tube at the place of 
dilatation is lined with a thin, membranous sac completely filled 
with blood clot. No foetus could be found, but microscopical ex- 
amination of a portion of blood clot near the peritoneal wall showed 
numerous characteristic villi. The ovary is of normal size, and con- 
tains a corpus luteus half an inch in diameter. 
“ Diagnosis.—Ectopic pregnancy of left Fallopian tube, with 
rupture.” 
Fig. i. 
This case illustrates the primary intraperitoneal rupture of tubal 
pregnancy, the severest and most dangerous of all forms. They 
are the most difficult cases to deal with, because the collapse seems 
to contra-indicate any operative procedure until there shall have 
been some reaction; and yet we must recognize that the haemor- 
rhage is very possibly, perhaps probably, continuing. With such 
a condition in any more accessible part of the body, there could be 
no question of the necessity for immediately securing the source 
of the haemorrhage, and I fail to see why the same reasoning should Extra - Uterine Pregnancy. 
11 
not now apply to these cases of tubal rupture. Certainly some of 
the most brilliant results of recent abdominal surgery are to be 
found in just this class of cases. And although hopeless opera- 
tions, which, as Dr. Richardson has said, “ bring odium upon sur- 
gery and reproach, perhaps deserved, upon the surgeon,” are always 
to be avoided (and some of these cases would seem to fall under 
that category), still, I think that increased familiarity with ab- 
dominal surgery and increased facility in the technique and the 
rapidity of operating, make it, at least in a great many of these 
cases, not only advisable, but imperative, to operate. In this par- 
ticular case, I believe that a further delay would only have made 
the difficulties and dangers still greater, and perhaps have been 
fatal to the patient. 
Case V.—Miss H., aged twenty-eight years. Entered the 
Worcester City Hospital, December 12, 1895. Catamenia regular. 
On December 6th was seized with sudden, severe pain in abdomen 
and vomiting, and since then has been confined to the bed. She 
had previously had slight attacks of abdominal pain, lasting for a 
few minutes only, and not severe enough to cause her to give up 
her work. The abdomen was tense, very painful, quite prominent 
in the center, everywhere tender, but especially so in the epigas- 
trium. Abdominal pain and tenderness continued, with occasional 
vomiting, until the evening of December 21st, when the pain be- 
came very much more severe. Vomiting very considerably in- 
creased in frequency. Her face became pale and drawn, her pulse 
very rapid. On the 22d she was somewhat exsanguinated, pulse 
very rapid—no—but of better strength. Abdomen showed in- 
creased resistance and increased tenderness on the left side. Median 
incision made on the 23d of December, and, upon opening the peri- 
toneal cavity, a large amount of dark blood escaped, followed by 
many large clots. The right Fallopian tube was found to be very 
much enlarged and ruptured, but not bleeding. It was tied off, 
pedicle cauterized, the abdominal cavity irrigated with a sterilized 
salt solution, and closed without drainage. Her recovery was un- 
eventful. 
“ Specimen is a right Fallopian tube, which is enlarged to a 
diameter of 3.5 centimetres, being slightly largest at the fimbriated 
extremity. 
“ There is a complete rupture of the tube wall on its under sur- 
face at the outer part, including the fimbriated extremity, for a dis- 12 
Homer Gage, M. D. 
tance of 4.5 centimetres, and a blood clot widely separates the edges 
of the tube wall at the point of rupture. 
“ Section through the wall and membranes beneath show clearly 
the amnion and chorion and numerous villi, which in many places 
have been torn apart by blood clot. The foetus is not in the clot 
which filled the tube, nor was the ovary attached to the specimen 
removed. 
“ Diagnosis.—Ectopic pregnancy, occurring in the right Fal- 
lopian tube, with rupture and escape of foetus.” 
In this instance an intraperitoneal rupture was not immediately 
fatal, and possibly the effused blood might have been absorbed; 
but, as has been stated, in view of the danger of secondary rupture 
or possible suppuration, the immediate operation was advised and 
carried out. I believe that it involves less danger than she would 
have been subjected to by further delay. 
Case VI.—Mrs. C., aged twenty-seven years. Referred to me 
by Dr. M. F. Fallon, May 21, 1894, and entered my service at St. 
Vincent’s Hospital on the 30th. Has been married fourteen months. 
No children and no miscarriage. Catamenia always regular, but 
little pain, and no excessive flow. Last catamenia January 20th. 
Eight weeks later, without having had any symptom of pregnancy 
other than having missed her February period, was taken one Sun- 
day afternoon with severe cramps in bowels, nausea and vomiting. 
Sat up Monday, but was seized again on Tuesday. From that time 
was in bed about four weeks; abdominal pain, tenderness, and lame- 
ness in right iliac region, nausea and vomiting. Once or twice a 
slight show of blood, and once a small mass as large as a filbert, 
which was supposed to be blood clot. Then much better for two 
weeks, though nausea and occasional vomiting persisted. No swell- 
ing or tenderness of breasts. At the end of two weeks pain suddenly 
came on again, with faintness and collapse. Friends thought she 
would die before the doctor could arrive. Since then pain and 
vomiting have gradually ceased. Had a little show, and on the 
23d of May passed another little piece of clot, which, on examina- 
tion by Dr. Baker, proved to contain decidual cells. 
For a week past has improved very much in general appear- 
ance; tumor no larger. 
Pale, somewhat emaciated; tongue lightly coated; heart and 
lungs normal; abdomen not distended, somewhat fuller on right 
side than on left; here it is somewhat tender, and, on deep palpa- Extra - Uterine Pregnancy. 
13 
tion, presents definite tumor; hard, sharp outline, not at all movable. 
Per vaginam, cervix hard, pointed, turned to the right; right 
side of vagina filled with hard mass; continuous, with tumor above, 
immovable. 
Was kept quiet in bed until general condition decidedly im- 
proved, although local condition remained about the same. At the 
operation the omentum and intestines were found adherent to a 
mass in the pelvis, which, upon being separated, proved to be an 
amniotic sac containing foetus, and filled with blood clot partly 
organized. It was composed of the right Fallopian tube, very much 
distended, and apparently communicating with right broad liga- 
ment. This mass, including much of the broad ligament, was tied 
off and removed. Patient’s convalescence was uninterrupted. I 
present also a drawing of this specimen (Fig. 2), with the patholo- 
gist’s report: 
“ Specimen consists of an enlarged right Fallopian tube and 
ovary. 
This hole 
made acci- 
dentally in 
removal. 
'Placenta 
filled 
with 
blood 
clot. 
Fig. 2. 
“ The tube measures 9.5 centimetres, the whole of the removed 
portion being an ovoid-shaped dilatation, with a circumference of 
16.5 centimetres. The tube is ruptured in a straight line on its upper 14 
Homer Gage, M. D. 
surface throughout a length of four centimetres, through which 
protrudes a mass of blood clot. The cavity of the tube contains a 
flattened foetus eleven centimetres in length, it being in first month 
at the time of its death, and a placenta which occupies most of the 
cavity on account of the haemorrhage which has occurred in it. 
Apparently all of the haemorrhage occurred into the placenta. The 
ovary is flattened and bound to the under surface of the tube near 
the uterine end, but there is no evidence of a corpus luteus. 
“ Diagnosis.—Ectopic pregnancy of right Fallopian tube, with 
rupture.” 
Case VII.—Mrs. K., aged thirty-four years. Was seen Septem- 
ber 9, 1895, in consultation with Drs. Burnett and Generoux, of 
Webster, and was removed to St. Vincent’s Hospital on the follow- 
ing day. She was a stout, healthy German, accustomed to hard 
work. No previous illness. Married seventeen years; one child 
sixteen years old, and one miscarriage ten years ago. Catamenia 
always regular, not painful; flow scanty. In May catamenia ap- 
peared only as a very slight, pinkish discharge, and during the next 
four weeks had pain all the time. Was up and about, but kept hot 
applications on abdomen. In June had the same slight, pinkish flow, 
and took some medicine that made her flow a little more for two 
or three days. Pains continued, but were not severe. Last of July 
she had a severe haemorrhage, lasting one week; discharged large 
clots. Two days later abdomen much distended, pain more severe, 
and was for the greater part of the time confined to the bed. 
For three weeks has had flow, with chills and very severe ab- 
dominal pain; some vomiting. A pretty constant discharge for 
two or three days from rectum; character undetermined. 
Her temperature was ioi°; pulse, 120; tongue coated, moist. 
Expression pinched and anxious. The abdomen was very much 
distended; tympanitic above; dull in lower half; distention more 
marked on left side, where it was exquisitely tender, and seemed 
hard and resistant. P. V. vaginal vault very tender; uterus crowded 
to front and immovable; posterior cul-de-sac bulging, and seemed 
to be fluctuating; from rectum a constant discharge of glairy, sticky 
fluid mixed with faeces. 
Temperature was persistently high, and, upon consultation with 
Dr. Leonard Wheeler, a probable diagnosis of pelvic abscess from 
pus tube diagnosed. 
Under ether, I first made puncture into the posterior cul-de-sac of Extra - Uterine Pregnancy. 
15 
the vagina, and obtained a little of a thick, clear, glairy fluid, much 
like that which escaped from the rectum. I then made a median ab- 
dominal incision, and came upon an irregular mass filling the pelvis 
and lower part of the abdomen, occupying all of the left side and part 
of the right. It was situated behind the uterus and broad ligament, 
lifting them well up out of the pelvis against the outer abdominal 
wall, and was adherent to their posterior surfaces, as well as to the 
intestines. It was very irregular in outline, part fluid and part solid. 
Around its upper border were many little thin-walled cysts con- 
taining a thin brown fluid. These were of various sizes, and their 
walls in many instances seemed to be made up by intestinal adhe- 
Fig. 3. 
sions. The mass on the left side seemed to be composed of matted 
intestines, with very firm adhesions which could not be broken down. 
From the part of the mass in the median line and to the right I suc- 
ceeded in enucleating this specimen, which had a pedicle on the 
right corner of the uterus, and included the right tube and ovary. 
In enucleating it, I opened a cavity on the left side leading down 
into the pelvis, and containing a large quantity of thick, green, foul- 
smelling pus. This was washed out and drained through the outer 
wound. From it, at different times, have escaped pieces of decom- 
posed blood clot resembling those found in Cases I and II. I be- 16 
Homer Gage, M. D. 
lieve that the specimen represented a right-sided tubal pregnancy, 
that rupture took place about August ist, and that the haematocele 
was subsequently infected through the intestinal walls. The abscess 
continued to discharge until the last of October, gradually but 
steadily diminishing. It finally closed completely, and she has been 
well ever since. 
I present also a drawing of this specimen (Fig. 3), with the 
pathologist’s report: 
“ Specimen consists of the right Fallopian tube and ovary. 
“ The length of the tube is eleven centimetres, the tube being a 
large, flattened mass with a circumference of 22.5 centimetres. Its 
walls are friable, and ruptured in several places in removal, the 
point of original rupture being a stellate opening on the upper sur- 
face of the tube, near the uterine end, about three centimetres in 
length. On opening the cavity of the tube, there is seen a male 
foetus sixteen centimetres long, about three months old at time of 
death, with an enormously enlarged placenta from haemorrhage 
into it. Section of the tube wall showed a thickening everywhere, 
except at the point of rupture, where it was greatly thinned. The 
ovary is greatly flattened, and does not show any corpus luteus. 
“ Diagnosis.—Ectopic pregnancy of right Fallopian tube, with 
rupture.” 
In both of these cases rupture had taken place primarily into 
the broad ligament; in No. 6 there was a history of secondary rup- 
ture six weeks after the first, but, as no blood was found in the peri- 
toneal cavity, there is, I think, every reason to suppose that it was 
due to secondary haemorrhage into the broad ligament, and not to 
an intraperitoneal rupture. In No. 7 the tube ruptured into the 
broad ligament without destroying the life of the foetus; a secondary 
rupture into the peritoneal cavity destroyed the life of the child, and 
gave rise to the large haematocele which had been converted into an 
abscess. Both illustrate the probability of secondary rupture, the 
dangers that are likely to complicate it, and the chance of being 
obliged ultimately to interfere. I think such interference should 
come more properly in anticipation of such complications as soon 
as the presence of a tubal pregnancy, ruptured or unruptured, has 
been recognized.