A STUDY OF ECTOPIC PREGNANCY IN THE FIRST

THREE MONTHS.

H. M. LEE, M.D.,

NEW LONDON.

Ectopic Pregnancy (meaning misplaced pregnancy) or Extra-Uterine Pregnancy, so-called, includes all esses of pregnancy where the ovum, after becoming fertilized, develops outside of the cavity of the Uterus. This obviously does not include a pregnancy in one horn of a Uterus Bicornis, though such a pregnancy is in a certain sense misplaced or "Ectopic," yet, however, it is still in the Uterine cavity. Owing to peculiar if not faulty development, the Uterine cavity is misplaced, but not the pregnancy.

Removal of a fetus from the mother per abdomen was known to the very ancient peoples. It was accomplished by the Jews in very early times, and the Greeks, too, were familiar with it. It has been taken for granted that these early procedures were in cases where the fetus was in the mother's womb. Of these early operations, one occurring in 1500, performed by the sowgelder of Seigeheusen, who removed a child from his wife's belly is held by Simons, a surgeon to the Manchester Infirmary, in a monagraph published in 1792, as being a case of ectopic pregnancy. Be this as it may, we know that in the year 1540, Christopher Bain removed from a woman fetal parts and maternal structures, and that this was a case of ectopic pregnancy. From the history of the case and operation, we are given to understand that in this patient there was a sloughing mass which required merely a puncture to empty it of its contents, which were as above stated.

In 1591, Noierus operated for ectopic pregnancy; in 1594 Primerose operated upon a patient of Noierus, who had again become pregnant. This operation of Primerose was probably the first definitely planned and systematically carried out, surgical interference in ectopic pregnancy.

Again in 1694 Cyprian reports cases of ectopic preg. nancy. Simon in 1753 (Mem. de L'Acad, de Chir. Paris. Vol. 11, P. 308) mentioned that one indication for celiotomy was when the fetus was in the tube or abdominal cavity.

The first operation in America for Extra-Uterine Pregnancy was accomplished by Dr. Bard, of New York, in

1764.

There seems no doubt that all these operations were done in order that "a fetus which was outside the Uterine cavity might be taken from the mother," and probably we are safe in assuming that in all these cases the pregnancy had advanced well to term with death of the fetus and more or less sloughing of the sac and contents, before surgical interference was brought to issue. The fact that not till 1749 do we find record of an any operation being undertaken for hemorrhage due to ectopic gestation, bears out our assumption. In this year a Dr. Harber, an American surgeon, first suggested that operation should be done for rupture of the sac of extra-uterine pregnancy. However, this suggestion received little if any attention. Dr. Stephen Rogers, of New York, in 1866-1867 (Med. Record 1867, Vol. 2, P. 22) again brought before the profession the feasibility of celiotomy for rupture of the sac of ectopic pregnancy; and urged such procedure. M. Moreau, an accoucheur of Paris, in 1841 urged operation for rupture of the sac during spurious labor, but condemned it for early rup

ture.

It will be observed from the foregoing that up to the year 1850 little was done for this condition other than

opening what was practically an abscess and liberating the sloughing contents thereof.

In the year 1850, when the era of ovariotomy descended upon the medical world, history brings to light the fact that, when once the abdomen was attacked and the Ovary dealt with by the pioneers of Abdominal Surgery, then imbued with the brilliancy of their discovery, and with the future promising rewards still more brilliant, minds of the interested awoke and operation for rupture of an ectopic gestation sac was first suggested and shortly carried out.

Upon the brow of that distinguished English surgeon, Lawson Tait, should rest the laurels of success in the surgical treatment of ectopic pregnancy. By almost a miraculous series of circumstances, this brilliant man in the year 1887 reported thirty-five operations for rupture of a gestation sac in the early months, with the marvelous record of thirty-three recoveries. Tait thus taught the profession not only how to operate and when, but placed the operation for rupture of an ectopic gestation sac among the first surgical procedures as a life saving measure. And with Tait as a pioneer in this great achievement, this operation is now one which gives us most excellent results, saves many lives, and flashes with a brilliancy ever increasing, across the horizon of Abdominal Surgery.

ETIOLOGY.

Ectopic Pregnancy can occur at any time in the generative activity of the woman. It is found in the young and in those well advanced towards the climacteric. It may occur as the first pregnancy, or come after a number of normal pregnancies. It has been said to appear after a period of sterility existed some time, and history zseems to still favor this idea.

There may be a double ectopic pregnancy, or an ectopic may occur in conjunction with a normal pregnancy. It

has shown some disposition to recur in the same individual.

Little is known definitely, though much speculation has taken place as to the cause of causes of ectopic gestation. I think that it may be safely stated that the Etiological factor is far from a correct and definite solution.

Obviously so many conditions, both Physiological, Anatomical and Pathological necessarily must be considered, and, too, such vast endless theories present themselves, that not only are one's efforts balked, but even increased in obscurity, as along these lines investigations take place. If a superficial and rather limited view be taken of the subject, I believe we might be better off in this wise, that is, that in bringing forward certain evidence, we can more accurately appreciate how very meager is our knowledge.

It would be most interesting if our knowledge was positive as to where fertilization of the ovum takes place, whether in the Uterus, the Tube or even upon the surface of the ovary.

Experiments upon animals have proven beyond question that the male element makes its way to the most remote confines of the female generative organs. In animals killed directly after coitus, the male element has been found in abundance in the Fallopian Tubes and also upon the surface of the ovary. The definite knowledge that in certain animals fertilization actually takes place in the ovary, only lends more speculation to the subject. Well authenticated cases of impregnation of the human female by seminal fluid being placed upon the hymen, simply establishes the fact that not only is the spermatozoa hardy and of long life, but also must be endowed with relatively enormous motile power. It is of course questionable whether or not the same travelling into so remote regions can take place in the human female of the male element as we know does take place

in the lower mammalia. However, the assumption that a strong analogy must exist in these physiological processes between the human female and lower animals is at least reasonable.

Assuming then that fertilization of the ovum may occur in any portion of the tube, and accepting the theory of Caste that it must of necessity occur soon after the expulsion of the ovum from the Follicle, because of the extreme delicacy of the ovule, which is rendered useless very quickly not only by the inherent changes taking place in its substance, but also by becoming coated with the albuminous secretion of the tube, I beg to say that if this is so, I am not surprised that ectopic gestation takes place, but I am surprised that it does not take place more frequently.

I cannot believe that the ovum is so perishable, but am inclined more to the belief that the ovum is endowed with great vitality. As a matter of fact, we assume from the knowledge of the ovum of lower animals, that it is well supplied with nourishment, which could be accepted as meaning that a long life was expected, rather than a short one. The fact that the ovum has been known to find its way from the ovary on one side, to the tube on the other, thus travelling quite a surface of peritoneum, and at last becoming fertilized, seems to warrant the belief that it is quite tenacious of life.

The anatomical features of the tube presented to us for consideration would tend to our accepting the view that the spermatozoa are out of place in the tube, and at the same time bring to mind the fact that all seems to obtain for a rapid passage of the ovule into the Uterine cavity. The ciliated epithelium lining the tube, in its continual wave toward the Uterine cavity, would seem to at least handicap, if not prevent any tendency to the entrance of its lumen, by any object, even the spermatozoa. The