[Reprinted from The Medical News, May 26, 1894.] 
EXTRA-UTERINE PREGNANCY SIMULATED BY 
A SMALL TUMOR OF THE OVARY; 
OPERATION; RECOVERY. 
By WILLIAM H. MORRISON, M.D., 
OF PHILADELPHIA. 
The possibility of diagnosticating extra-uterine preg- 
nancy before rupture of the sac has in the past received 
considerable discussion, but at present the generally 
accepted opinion is that such a diagnosis cannot be 
made with any great degree of certainty. A case on 
which I recently operated illustrates with such force the 
uncertainties attending the diagnosis of ectopic gesta- 
tion that it seems worthy of record. 
The patient, Mrs. X., thirty years of age, the mother 
of four children, has been under my personal observa- 
tion for a number of years. In November, 1893, that is 
five months ago, she had a miscarriage at two or three 
months, from which she recovered without incident, 
with the exception that a slight tendency to bleed con- 
tinued. For this I curetted the uterus some two weeks 
later. In the repeated examinations made at this time, 
nothing abnormal was detected in the pelvis. Following 
the miscarriage, menstruation recurred every twenty- 
four days, until February, when the period which should 
have commenced February 27th did not appear until 
March nth, twelve days overdue. It, however, pre- 
sented nothing unusual as far as the patient observed. 
Two weeks later, March 27th, she was taken with sharp 
recurring pains in the lower part of the abdomen, some- 2 
what more severe on the right side. After a few hours 
these passed away, to reappear on the following day. 
With the pains there was a slight discharge of blood 
from the vagina. It was at this time (March 28th) that 
I was called. The pain, while acute, did not seem to be 
of great severity. There was no shock, no alteration in 
temperature, no disturbance of pulse. There was ten- 
derness over the whole of the lower part of the abdomen 
not especially localized. There was no gastric or fn- 
testinal disorder to explain the abdominal tenderness. 
Vaginal examination showed the uterus to be slightly 
enlarged. On the right side of the pelvis nothing ab- 
normal could be discovered, but to the left of the uterus 
and low down was a globular mass, apparently one and 
a half or two inches in diameter, which seemed to be a 
cyst. It was quite tender on pressure, but could be dis- 
placed upward to a certain extent. This mass while in 
contact with the uterus Was distinct from it. A sound 
introduced into the uterus gave a measurement of three 
inches, and as it was removed brought away two or 
three shreds of thin membranous tissue. 
A diagnosis of cystic tumor in the pelvis, probably an 
extra-uterine pregnancy, was made, the condition of 
affairs explained to the patient and her husband, and 
operation advised. This was acquiesced in, and on 
March 31st I opened the abdomen and removed a tumor 
which was found to be the left ovary in a state of cystic 
degeneration. The tube was normal. The right ovary 
was brought to the abdominal incision, but as it was 
small and presented no evidence of disease, it was 
allowed to remain. The after-course of the case was 
uneventful and the recovery complete. The enlarged 
ovary was ovoid in shape, and about two inches in its 
longest diameter. It contained three cysts. At its outer 
extremity was a small cavity containing about twenty 
minims of dark fluid blood, evidently due to a recent 
hemorrhage. This probably was the explanation of the 3 
sharp abdominal pains. A second small cyst at the op- 
posite extremity was filled with clear, watery fluid, while 
the bulk of the tumor was made up of a cyst containing 
amber-colored gelatinous material. 
While this case presents nothing unusual from a patho- 
logic point of view, it does offer features of interest 
from a diagnostic and therapeutic standpoint. The 
points bearing upon diagnosis may be stated as follows: 
i. A woman in whom the more common causes of 
suppurative tubal disease, namely, specific infection and 
septic contamination, could be excluded. 
2. The fact that she had been submitted to examina- 
tion within a few months and no pelvic tumor found. 
This I consider a strong point in connection with the 
diagnosis. 
3. A delay of nearly two weeks in the appearance of 
the menstrual flow. 
4. The occurrence of repeated, sharp, intermittent, 
abdominal pains, with a bloody discharge from the 
uterus. 
5. Enlargement of the uterus and the removal of 
shreds of membrane from its interior. 
6. The presence of a movable, globular, elastic, sen- 
sitive mass at one side of the uterus. 
These facts, while rendering the diagnosis of unrup- 
tured tubal pregnancy sufficiently certain to demand 
prompt interference, were, as the sequel shows, not suffi- 
cient to justify an absolutely positive diagnosis. 
In the treatment of ectopic gestation, aspiration of the 
sac, the injection of various agents into it, and the ap- 
plication of electricity, have been recommended and are 
still advised by some. In the present instance, such 
treatment, on account of the close relation of the tumor 
to the vaginal wall, would have been readily applicable, 
but, as the operation demonstrates, would have been use- 
less if not injurious. 
The lessons which this case teaches are: first, that an 4 
absolutely positive diagnosis of unruptured extra-uterine 
pregnancy is not possible, no matter how distinctive the 
symptoms and physical signs may appear to be; and 
second, that until an absolutely positive diagnosis is 
reached, such treatment as aspiration or injection of the 
sac is not to be considered.