[Reprinted from the American Gynaecological and Obstetrical Journal 
for February, 1895.] 
REMARKS ON ECTOPIC PREGNANCY* 
By Charles P. N©9<£e, JM. -D. 
In this communication I shall hot discuss the subject of ectopic 
pregnancy in a systematic manner, but desire to call attention only to 
certain points concerning it. My experience with ectopic pregnancy 
embraces twenty-five cases, fourteen of which were seen within one 
year. This would indicate that cases of ectopic pregnancy do not 
constitute a constant percentage of one's operations. During the year 
in question about fifteen per cent, of the abdominal sections done 
were for ectopic pregnancy, whereas in the previous year only two 
per cent, of such cases were met with. Prior to this exceptional run 
of cases ectopic pregnancy had been present in between three and 
four per cent, of my abdominal sections. 
I had the curious experience of doing three successive coeliotomies 
for ectopic pregnancy in four days, and of having four women in the 
hospital at the same time, who were convalescing from operations done 
for this condition. This undoubtedly was a very curious if not a 
unique experience. 
All of the twenty-five cases were instances of tubal gestation. Of 
these the tube was unruptured in four, in twenty rupture had taken 
place, and in one a tubal abortion was under way. 
The case of abortion was of interest because of the peculiar form 
of the blood clots which filled the pelvis. These were coiled up much 
as though they had been ground through a sausage machine. The 
ovum was located about the inner third of the tube. Haemorrhage 
was caused by partial separation of the ovum. The blood clotted in 
the tube, and the clot was forced out as a sausage-shaped mass, by 
the continuance of the haemorrhage. 
* Read before the Philadelphia Obstetrical Society, January 3, 1895. Charles P. Noble, M. D. 
2 
In nineteen of the cases, a diagnosis of ectopic pregnancy was 
made (including two in which it was strongly suspected) before the 
operation, and in six the condition was supposed to be some other 
morbid condition of the uterine appendages, such as tubo-ovarian 
inflammatory conditions, or adherent ovarian tumors. Of the cases 
in which a diagnosis was made (one strongly suspected), three of 
♦ hem were instances of unruptured tubal pregnancy, and seventeen 
(two strongly suspected) of cases in which rupture had taken place 
(including the case of tubal abortion). In two of the cases a diag- 
nosis of ectopic pregnancy had been definitely abandoned, because of 
the absence of symptoms supposed to be characteristic of rupture, 
and the operation was done with a diagnosis of pelvic tumor. 
Following the dictum of Mr. Tait, the doctrine has become cur- 
rent, that a diagnosis of ectopic pregnancy before rupture is impos- 
sible, and that the diagnosis of this condition after rupture is ex- 
tremely simple. My own experience does not bear out this view. 
In two of the cases embraced in this report, a diagnosis of unrup- 
tured ectopic pregnancy was made, and operation urged. In one case 
the operation was done, and an ovum of from four to six weeks' 
growth was found in an unruptured tube. The diagnosis was con- 
firmed by Dr. Piersol of the University of Pennsylvania. In the sec- 
ond case operation was refused. In about a week after the operation 
was urged rupture took place, followed by an enormous internal haem- 
orrhage. Operation was then done, with a fatal result. In one ocher 
case in which rupture had not taken place, the diagnosis was not 
made, not because the symptoms were not sufficient, but because they 
were not carefully looked for. This patient had had a number of 
attacks of pelvic peritonitis, and was supposed to have had one of 
her "old attacks." As operation had been repeatedly urged for the 
tubal disease, which was known to exist, it was now accepted, and 
done without further study of the case. In one other case of unrup- 
tured tubal pregnancy, the diagnosis was considered uncertain, and 
to be either an adherent ovarian cyst or a tubal pregnancy. That is 
to say, in the four cases of unruptured tubal pregnancy which have 
come under my notice ; in two of them a positive diagnosis was 
made ; in a third it was suspected; and in the fourth, while the diag- 
nosis was not made, it was not because the symptoms did not warrant 
it, but because they were not carefully looked into. 
Of the cases of ruptured tubal pregnancy with haemorrhagb into 
the peritoneal cavity, a diagnosis was made in seventeen cases, in three 
cases it was not even suspected, and in two cases this diagnosis was Remarks on Ectopic Pregnancy. 
3 
ruled out because of the absence of symptoms supposed to be char- 
acteristic of the condition. 
This experience appears to be a sufficient warrant for disputing 
the currently received dictum concerning the diagnosis of ectopic 
pregnancy. So far as my experience goes, the cases in which rupture 
had not taken place were as easily diagnosed as those in which it had 
taken place. I believe that in a large percentage of cases, whether 
rupture has or has net occurred, the symptoms and physical signs are 
so characteristic, that the diagnosis is just as certain as in any other 
form of pelvic disease. On the other hand, in a considerable per- 
centage of cases, neither the physical signs nor the symptoms are suf- 
ficient to enable even a careful, trained observer to arrive at a posi- 
tive diagnosis. He may " suspect " the condition, or he may think 
that the condition is "either ectopic pregnancy or a pelvic tumor," 
but he is not able to give a definite opinion. Still another class of 
cases will be met with, in which the symptoms are not at all sugges- 
tive of ectopic pregnancy, even though rupture has taken place. The 
usual menstrual history is absent; the pains supposed to be charac- 
teristic are absent, or else are of so indefinite a character as not to 
be distinctive ; and the faintness and collapse supposed to charac- 
terize rupture does not take place. I have had three such cases, in 
which there was no ground to make a diagnosis of ectopic pregnancy, 
and yet operation disclosed this condition, with rupture and internal 
haemorrhage. 
In the twenty-five cases there were four deaths. All of these cases 
were desperately ill at the time of operation. In the first, the preg- 
nancy had advanced to near the fourth month, and the abdomen was 
so filled with blood that it was protuberant as in abdominal dropsy. 
The patient was blanched, and had a rapid pulse. She died within 
thirty-six hours, in hyperpyrexia. The conditions present in the sec- 
ond case that died were very similar to those in the first, except that 
the pregnancy was not so far advanced. The patient lived nearly a 
week, and died apparently of exhaustion, from acute anaemia. The 
third patient who died was moribund at the time of operation, the 
abdomen being even more distended with blood than in the first two 
cases. These three cases belong to a special class-those in which 
the rupture is followed by an enormous and sudden internal haemor- 
rhage, the bleeding being so free that there is no opportunity for a 
haematocele to form. The fourth patient who died had general septi- 
caemia at the time of the operation, having a temperature of 105°. 
The haematocele had suppurated, the entire pelvis was covered with a 4 
Charles P. Noble, M. D. 
slough, and the left broad ligament and pregnant tube were distinctly 
gangrenous. She died at the end of a week of general septicaemia. 
In this case the death was due to septicaemia present before the oper- 
ation, and the local conditions were such that recovery was impossi- 
ble. The other three deaths were distinctly due to the enormous and 
sudden haemorrhage which had taken place. All the other cases re- 
covered, including those in which rupture had not taken place, and 
those in which the rupture had been followed by moderate haemor- 
rhage, presumably from small vessels, so that there was an opportu- 
nity for the blood to clot and an haematocele to form. All the cases 
in which the pelvis was filled with clots, even though considerable 
free blood was present, recovered-the explanation being, in my 
judgment, that the bleeding had been from small vessels, and had 
extended over a considerable period of time, perhaps occurring on 
different days, or during different weeks, so that the drain upon the 
circulation was not sudden, and time was afforded for the blood- 
making organs to supply to a greater or less extent the loss which had 
been suffered. 
At this time I wish to say only a word concerning the principles 
which should be followed in operating. First, the operation should 
be done as soon as the diagnosis is made. Second, the principles 
which apply to all pelvic surgery are equally applicable to cases of 
ectopic pregnancy, in which the condition of the patient is good. 
Third, when an operation is done upon a patient in extremis, rapidity 
in operating is essential to success. Nothing should be attempted 
which is not absolutely essential. The opposite appendage should 
not be removed unless it is plainly an immediate menace to life. The 
pregnant tube should be rapidly separated from its adhesions, ligated 
and removed, and this should be followed at once by free irrigation of 
the peritoneal cavity. The abdomen should be left full of water, as 
this plan saves the time necessary to dry the peritoneal cavity by 
sponging, and also supplies the vessels with fluid, to make good in 
part the loss they have sustained. Drainage should always be used 
in this particular class of cases. It is my purpose to use transfusion 
in all such cases in the future, although I have not done so in the 
past. These patients die of acute anaemia. Death is largely due to 
the fact that there is not enough fluid in the vascular system to main- 
tain life.