John Clarence Webster.

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COLUMBIA LIBRARIES OFFSITE

HEALTH SCIENCES STANDARD



HX00043583



ECTOPIC PREGNANCY.




NUNQUAM ALIUD NATURA, ALIUD SAPIENTIA DIGIT.



Ectopic Pregnancy



ITS ETIOLOGY, CLASSIFICATION, EMBRYOLOGY,
DIAGNOSIS, AND TREATMENT



BY



CLARENCE WEBSTER, B.A., M.D., F.R.C.P.Ed.,

ASSISTANT TO THE PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND
CHILDREN IN THE UNIVERSITY OF EDINBURGH.



Wn'H EIGHTY ILLUSTRATIONS OF NAKED EVE AND
MICROSCOPIC APPEARANCES.



EDINBURGH AND LONDON:

YOUNG J. PENTLAND.

1895.



EDINBURGH : PRINTED FOR YOUNG J. PENTLAND, II TEVIOT PLACE, AND
WEST SMITHFIELD, LONDON., E.C., BV SCOTT AND FERGUSON AND BURNESS AND COMPANY.



[A II rights reserved. ]



TO MY FRIENDS
A. H. FUEELAND BAEBOUK

AND

D. BEBBY HABT.



348450



Digitized by the Internet Archive

in 2010 with funding from

Open Knowledge Commons



http://www.archive.org/details/ectopicpregnancOOwebs



INTRODUCTION.



The subject of Ectopic Pregnancy has received a great deal of
attention during the last few years both in Europe and America.
Though the importance of the subject might be considered a
sufficient justification for the publication of a work which is
an embodiment of the recent advances made in our knowledge
of the nature and treatment of the condition, the author urges
a stronger plea, viz., that he is able to bring forward for con-
sideration a large body of original matter, based upon several
years' clinical and laboratory work.

He desires especially to call the attention of the embryologist,
and of the scientific teacher of Obstetrics, to the chapters on
Development. The detailed observations therein presented are
the outcome of a careful examination of a large amount of
material taken from the operation room and 'post mortem
theatre during the last six years. The investigations have
been carried on in the Laboratory of the Eoyal College of
Physicians, Edinburgh.

The author is also able, from an examination of the volumi-
nous literature which he has collected, to bring to the light
some interesting records of workers during the past three
centuries, which have for a long time been overlooked.

Throughout the book, the word "Ectopic" is used in pre-



viii INTR on UCTION.

ference to " Extra-Uterine." The former term was first used
by Eobert Barnes in 1873. It includes all gestations develop-
ing outside the uterine ca^dty, being therefore more com-
prehensive than the term " extra-uterine," which, in strictness,
cannot be held to include interstitial pregnancy.

Though CornuaX pregnancy is considered in this work, it is
not included in the classification of ectopic gestations, because,
of course, this form of pregnancy is developed in relation to the
cavity of the uterus, though the latter is mal-developed. It
is necessary, however, to describe the condition in connection
with ectopic pregnancy, because of the many resemblances
between them.

The author is deeply indebted to Professor Simpson, Drs.
Halliday Groom, Berry Hart, Freeland Barboui', and several
other friends for the material which he has obtained from
them; and also to Mr. Cathcart, Curator of the Museum of
the Ptoyal College of Surgeons, Edinburgh, for permission to
investigate the specimens of ectopic pregnancy in his care.

Several illustrations are taken from the publications of Berry
Hart, Orthmann, Bland Sutton, Sir Wm. Turner, and the
author. The great majority of the plates, however, are from
original water-colour drawings made by the author, and hitherto
unpublished.

My thanks are due to ]Mr. James Y. Simpson, M.A., for his
kind assistance in the revision of the proofs.



JOHX CLAEEXCE A^^BSTEE.



20 Chaklotte Sqxiaee,
February 1895.



CONTENTS.



CHAPTER I.

ETIOLOGY.



Place of fertilisation of ovum — Part played by epithelium of mucosa — -
Nature of menstruation — Changes in the non-pregnant tube — Decidual
reaction — Improbability of ovarian pregnancy, ... 1

CHAPTER II.

CLASSIFICATION.

Early described cases — Old classification — Opinions of old writers — Present

views — Author's arrangement, . . . . . .16

CHAPTER III.

VARIETIES STUDIED IN DETAIL.

Ampullar tubal pregnancy — Extra-peritoneal pregnancy — Sub-peritoneo-
abdominal pregnancy — Rupture into peritoneal cavity — Hsematoma
formation — Intestinal escape of foetus — Tubo-peritoneal pregnancy —
• Cases of doubtful nature — Hemorrhage into peritoneal cavity —
Sequelse of hsematocele — Effect of blood on peritoneum — Tubal
abortion — Hsemato-salpinx, . .... 33

CHAPTER IV.

VARIETIES STUDIED IN DETAIL continued.

Interstitial tubal pregnancy — Changes in interstitial pregnancy — In-
fundibular pregnancy — Comual pregnancy — Wandering of ovum —
Adipocere formation — Lithopsedion formation — Placenta after foetal
death, 75

CHAPTER V.

GENERAL CONSIDERATIONS.

Age — Side of the gestation — Repeated ectopic gestation — Plural ectopic

gestation — Intercurrent uterine gestation — Hernia of ectopic gestation, 105



X CONTENTS.

CHAPTER VI.

DEVELOPMENTAL CHANGES.

PAGE

Changes in the tube wall — Peritoneum — Muscular part of the wall —
Decidua vera — Decidua serotina — Changes in decidua — Decidua reflexa
— Relations between ovum and decidua — Pcetal epiblast — The chorion
— Placental chorion — Villi and decidua — Non-placental chorion — The
amnion, ........ 113

CHAPTER VII.

SYMPTOMS AXD SIGNS.

Symptoms resulting from the pregnancy ^er se — Periodic colicky pains —
Discharge of uterine decidua — Stirrage — Abdominal enlargement —
EcBtal movements — Changes in the uterus — Phenomena occurring at
full term — Spurious labour — Bimanual examination — Symptoms re-
sulting from complications — Pressure effects — Pain — Haemorrhage —
Suppuration — Death of fcetus, ...... 153

CHAPTER VIII.

DIAGNOSIS. /

Uterine pregnancy — Retroversion of the gravid uterus — Ovarian tumours
— Heematocele and hematoma — Inflammatory exudations — Malignant
disease — Spurious pregnancy, . . . . , .190

CHAPTER IX.

TREATMENT.

Injection of drugs — Compression of the gestation sac — Electricity —
Elytrotomy — Modern treatment — Tubal pregnancy — Interstitial preg-
nancy — Rupture into peritoneal cavity — Rupture into broad ligament
— Extra-peritoneal development — Secondary rupture — After spurious
labour — Suppuration, . . . . . . .207



LIST OF ILLUSTEATIONS.



I.— PLATES.

(From Dra.v;ings ly the Av.tJwr.)
Plate

I. — Pig. 1. Muscular wall of tube in full time pregnancy.

2. A mpuUary part of tube ^^dth abnormal mucosa, showing

decidual formation.
■3. Another of the same.

II. — Fig. 1. Ampullary part of tube with abnormal mucosa.
2. A small portion of normal ampullary mucosa.
•3. A small portion of normal tube wall between mucosal
fringes.

III. — Fig. 1. Decidual formation in tubal mucosa.

2. Normal fringe of mucosa.

■3. Fringe from tube showing decidual changes.

4. Decidual tissue torn up by blood.

IV. — Fig. 1. Decidual formation in tubal mucosa.
2. Another of the same.

V. — Fig. 1. Another of the same.

2. Another of the same, showing spongy layer of decidua.

VI. — Fig. 1. Decidual changes in tubal mucosa.
2. Another of the same.
•3. Gland spaces in compact layer of decidua.
4. Villus attached to decidua.
VII. — Fig. 1. Villus embedded in decidua.

2. Compact layer of decidua.

3. Fcetal epiblast in relation to decidua.
VIII. — Fig. 1. Another of the same.

2 Villi in relation to decidua at full time.

3. Another of the same.

IX. — Fig. 1. Section through early placenta and tube wall.

2. Decidua reflexa, with amnion and chorion.



xii LIST OF ILLUSTRATIONS.

Plate

X. — Fig. 1. Decidua serotina.

2. Decidua serotina and trophospongia formation.

3. Another of the same.

XI. — Fig. 1. Foetal epiblast, absorbing decidual tissue.

2. Villus attached to serotina.

3. Changes in artery of decidua.

XII. — Section through tube wall and edge of placenta.

XIII. — Decidua refiexa and tube wall outside it.

XIV. — Fig. 1. Endothelial changes in blood-sinus of decidua.

2. Another of the same.

3. Membranes in relation to blended vera and reflexa.

4. Another of the same.

XV. — Fig. 1. Another of the same.

2. Villus in relation to decidua serotina.

3. Another of the same.

4. Another of the same.

XVI. — Fig. 1. Another of the same.

2. Another of the same.

3. Another of the same.

4. Foetal epiblast and early villus.

XVII. — Fig. 1. Reticulated fcetal epiblast in relation to decidua,

2. Blood-sinus of decidua in relation to intervillous space.

XVIII. — Fig. 1. Blood-space in decidua.

2. Amnion and chorion.

3. Another of the same.

XIX. — Fig. 1. Another of the same.

2. Another of the same.

3. Another of the same.

4. Another of the same.

XX. — Fig. 1. Early villus formation.

2. Another of the same.

3. Another of the same.

4. Section of early villus.

5. Another of the same.

6. Another of the same.

XXI. — Fig. 1. Villi in full time placenta.

2. Villi in relation to decidua at full time.

XXII. — Fig. 1. Superficial layer of uterine decidua in tubal gestation.

2. Deep layer „ ,. ,, ,, ,,



LIST OF ILLUSTRATIONS.



II.— FIGTJEES IX THE TEXT.



Fig.
1.



10.

11.

12.
13.
14.
15.



Sagittal lateral section (right) of pelvis, with subperitoneo-pelvic ges-
tation in right broad ligament. (Haet),

Sagittal mesial section of pelvis, with subperitoneo-peh'ic gestation
(Haet), .......

Sagittal mesial section of abdomen and pelvis, with advanced sub
peritoneo-abdomiaal gestation. (Haet),

Sagittal lateral section of abdomen and pelvis, with advanced sub
peritoneo-abdominal gestation. (Haet),

Another sagittal lateral section of the same subperitoneo-abdominal
case. (Haet), ......

Another sagittal lateral section from the same case. (Haet), .

Vertical mesial section of body, with tubo-peritoneal gestation, .

Transverse section of pelvis in tubo-peritoneal gestation, through fourth
sacral vertebra and subpubic ligament,

A higher transverse section in the same tubo-peritoneal case, made
through the junction of the first and second sacral vertebra and the
upper part of symphysis, ......

Another transverse section through abdomen in same tubo-peritoneal
case, made at level of junction of third and fourth lumbar vertebra.

Left tubal pregnancy, 1-2 months, longitudinal section. (Oethjianx),

Interstitial pregnancy. (Blajtd Sutton), . . . .

Pregnancy in a rudimentary horn. (Txjenee), .

Ruptured tubal pregnancy at end of second month. (Ban'dl), .

Sagittal mesial section of pelvis, with subperitoneo-pelvic gestation on
right side. (Haet), .......



36



40

41

42
43
54



56

57
71
77
88
165

183



Ectopic Pregnancy.



CHAPTEE I.

ETIOLOGY.



UxTiL recently the occurrence of Ectopic Gestation has been
attributed to the following conditions : —

1. Those mechanically interfering vnth the passa.ge of the ovum
to the uterus, e.g. : —

Peritonitic bands constricting the Fallopian tube ;

Poljpi in the tube lumen ;

Tumours of its wall ;

Tumours of surrounding parts pressing upon it ;

Abnormal foldings of its wall ;

Diverticula from the lumen in the wall ;

Displacements and hernia of the appendages.

2. Those interfering vAth the ijeristaltic axtion of the tv.he, e.g. :■ — ■

Adhesions between the tube and neighbouring parts ;
Thickening of its walls by inflammation.

3. Those destroying the cilia/ry action of the epithelial cells lining
the tubal mucosa, e.g. : —

Endosalpingitis.
I think it is unnecessary to mention various mental and
moral conditions, e.g., fright, strong passion, &c., at time of



■2 ETIOLOGY.

coitus, cited bj Astruc,i Eamsbotham,- Baudelocque,^ and others,
as causes of ectopic gestation.

A careful analysis of these various conditions, hitherto
described as the causes of tubal pregnancy, leads to the con-
clusion that the Adews current in regard to the subject are hazy
and indefinite, their acceptance involving numerous contra-
dictions as well as certain assumptions which are based entirely
upon speculation, and, in some instances, not in accordance with
facts. One of these assumptions is to the effect that in normal
pregnancy the o"s^im becomes fertilised in the Fallopian tube ;
another, that this always takes place iii the uterus. A very
widely held \iew is that a fertilised ovum will grow in a tube
with a healthy normal onucosa if it m.erely be prevented by some
mechanical obstruction from reaching the uterine cavity; another
assumption of more recent origin is that this cannot take place,
but that development will only occur when the epithelium of
the mucosa has been destroyed by inflammation.

That the above tabulated conditions have been founded upon
observations is undoubtedly true. To associate them in some
way with the occurrence of the tubal pregnancy is natural;
hut to establish ther/i as the vJtimate or essential faxtors in its
causation is aMything hut logical.

It is my endeavour in this chapter to analyse carefully the
relationship which these conditions bear to ectopic gestation,
and to endeavour to allot to them their true proportional values
as factors in its causation. In addition, I desire to bring
forward some new observations in the hope of removing many
of the difficulties connected with the subject, and of establishing
a more scientific basis for its future investig-ation.



1 "Traits des Maladies des Femmes," Paris, 1675, tome iv., p. 69.
- Load. Med. Gaz., 1849, N. S., vol. viii., p. 651.
^ "Diet. d. sc. med.," tome xix., p. 399.



PLACE OF FERTILISATION OF OVUM. 3

It is necessary, in the first place, to consider one question
which has an important bearing on the subject, viz., where
the spermatozoa fertilise the ovum. It is generally believed
that their meeting place is normally the Fallopian tube.
Lawson Tait, Wyder, and a few others, believe that it is the
uterine cavity; they hold that the ciliary action of the
epithelium of the tubal mucosa prevents normally the sper-
matazoa from passing into the tubes.

Mr. Tait's words ^ are : — " The uterus alone is the seat of
normal conception ; as soon as the ovum is affected by the
spermatozoa it adheres to the mucous surface of the uterus ;
the function of the ciliated lining of the Fallopian tubes is
to prevent spermatozoa entering them, and to facilitate the
progress of the ovum into the proper nest ; . . . the plications
and crypts of the uterine mucous membrane lodge and retain the
ovum either till it is impregnated or till it dies or is discharged."

Without referring to the lower mammals, regarding which
but scanty observations have been made, facts derived from
the study of ectopic human pregnancy furnish evidence in
favour of the view that spermatozoa can make their way from
the uterine cavity into the tube lumen, whose lining epithelium
may be healthy. It is not uncommon to find an early tubal
pregnancy in the outer end of a tube whose inner end is
perfectly normal. Such cases have been examined by Bland
Sutton,2 Martin,^ Veit,* myself, and others. This being so, it is
difficult to know why fertilisation may not take place in the tube
in any number of cases where the parts are entii'ely healthy.

That it may also take place within the uterine cavity cannot,
of course, be denied. The truth is probably that the sperma-

1 "Diseases of Women and Abdominal Surgery," 1889, vol. i., p. 439.

2 " Surgical Diseases of the Ovaries and Fallopian Tubes," 1891, p. 310.

3 "Ueber ektop. Schwang.," Berl. klin. Wchnschr., 1893, Nr. 22.
* Ztschr.f. Geburtsh. u. Gynah, Stuttgart, bd. xxiv., p. 2.



4 ETIOLOGY.

tozoa are capable of working their way into both uterus and
tubes, fertilising the ovum wherever they chance to meet it.

Another important question to be considered is the follow-
ing : — is tliere, any grouTid for supposing that a feHilised oium can
develojj in the normal mucosa, of the Fallopian tvlie .? That such
a thing is possible has long been believed, especially by those
who have insisted on the importance of mechanical obstruction
as a cause of tubal gestation.

If the genital tract be studied phylogeneticallv, it is found
that in the lowest animals there is no marked distinction
between o'^iduct and uterus : that,, in higher forms, each lateral
tube becomes differentiated into an upper oviduct portion and a
lower uterine portion ; and that, in the very highest forms, the
lowest portions blend into a single uterus. In these highest
mammals only the uterus is able normally to furnish the place
of development for the ovum : the upper ends of the original
lateral tubes, i.e., the oviducts or Fallopian tubes, though
remaining in continuity wdth the uterus, retain only the power
of carrying the ovum from the ovary to the uterus. The tubal
mucosa and that of the uteras {corpus uteri) behave differently
in the reproductive process — the foiTaer is passive, the latter
active : the one undergoes no important changes, the other
reacts markedly to the genetic influence, becoming transformed
into the decidual tissue, which is, it must be believed, essential
to the attachment and development of the young o%Tim.

The differentiation is as well marked as that between the
lining membranes of the oesophagus and stomach. There is
no more authority for supposing that the normal tube can
perform the function of the uterus than for believing that the
oesophagus can perform that of the stomach. In each of these
cases the evolution of structural differences has been accom-
panied by marked functional differentiation.



PART PLAYED BY EPITHELIUM OF MUCOSA. 5

!N"o doubt the resemblance between the epithelial cells of
the uterine and tubal mucous membranes and their direct
continuity have helped to establish the assumption that the
ovum can develop in relation to one set as well as in relation
to the other. Such an assumption is, of course, entirely un-
warranted, because structural similarities do not necessarily
imply physiological harmonies or identical reaction tendencies.

Moreover, all recent work, e.g., that of Minot,^ Hart and
GuUand,- myself,^ and others, goes to show that the lining
epithelium of the mucosa, both in tubal and uterine gestation,
plays an entirely negative part as regards the development of
the ovum.

Next, what is to be said regarding the statements that the
ovum can develop in the tube only when the lining epithelium
has been destroyed by inflammation ?

It might be sufficient, in refutation of this belief, only to
mention those cases of tubal pregnancy in which no inflamma-
tory or other diseased condition is found in the mucosa. ]\Iore-
over, in some of the cases in which inflammation is found,
there can be no doubt that it follows upon the disturbances in
the tube attendant upon the development of the gestation.
This has been strongly urged of late by Martin,-* w4iose recent
observations have led him to give up his older views '" regarding
the part played by endosalpingitis in causing tubal pregnancy.

Bland Sutton*^ is of the opinion that the so-called causal
relation between desquamative salpingitis and tubal gestation
is mere speculation which contains an element of truth, but
does not hold in all cases. He points out that wdiere the
inflammation is so severe as to destroy the tubal epithelium,

^ "Uterus and Embyro," Journ. Morphol., Boston, April, 1889.

" Rep. Lah. Roy. Coll. Phys., Edin., vol. iv. ^ See Chapter on Development.

■* Op. cit., vide supra.

^ Ztschr. f. Gehurtsh. u. Gyndk., Stuttgart, bd. xiii., p. 298. *> Op. cit., p. 309.



6 . ETIOLOGY.

stricture and occlusion of the outer end of the tube usually
occur as well ; it is very rare to find tubes denuded of their
mucosal epithelium and with a patent fimbriated end.

One might also justly state that, whereas inflammation in
the endometrium is not favourable to the development of
uterine gestation, so inflammation in the tubal mucosa is un-
favouraUe to the development of a tubal pregnancy.

I wish, however, to consider this statement as part of a more
comprehensive idea which has been strongly urged of late, more
particularly by Lawson Tait,^ and also by Berry Hart,^ viz., that
the human ovum can graft itself only on a connective tissue from
which the covering epithelium has been removed. Mr. Tait holds
especially that in normal uterine pregnancy this supposed
necessary raw surface is prepared by menstruation, as was first
suggested by Pfliiger, and in tubal pregnancy by endosalpingitis.
In referring to the uterus he used the words " a healthy mucous
surf ace freshly denuded. ; " and in reference to the tube he says
that " a desquamative salpingitis could put the mucous lining
of the tube into a condition exactly similar to that of the
uterus." This statement is open to the criticism that, while
a resemblance might possibly be pointed out between an
endometrium partially denuded and an early acutely inflamed
mucosa, there is not a very close resemblance in the case of
chronic inflammatory surface.

That these authors are right in insisting upon the passive
and unimportant part played by the epithelium of the mucosa,
both in the case of tubal and uterine pregnancy, cannot be too
strongly urged. All the latest embryological investigations
give support to the view that the attachment and early de-
velopment of the ovum takes place entirely in relation to the
subepithelial connective tissue of the mucosa. I take excep-

i Op. cit., p. 439. - " Selected Papers," 1893, p. 61.



PART FLA YED B Y EPITHELIUM OF MUCOSA. 7

tion, however, to the explanation of the early establishment of
this relationship in normal pregnancy, on account of the great
difficulties in the way of believing that menstruation is the
process essential to the removal of the epithelium and the
consequent laying bare of the connective tissue. These diffi-
culties are as follows : —

1. Pregnancy may occur in a girl before the onset of men-
struation, at a time, therefore, when the mucosa cannot be
denuded by that process.

2. It may occur late during the period of lactation when
there is no menstruation and after the mucosa has been com-
pletely renewed.

3. It may take place at the menopause during a period of
amenorrhoea.

4. Pregnancy may occur in the rudimentary horn of a mal-
formed uterus, menstruation never having taken place in that
horn {vide p. '92).

5. It may occur in periods of amenorrhoea associated with
diseased conditions, e.g., ansemia, phthisis.

6. Clinical experience of cases of pregnancy following a single
coitus shows that the ovum may begin to develop at any time
— not necessarily immediately after menstruation. {Evidence
in regard to this point, hoivever, is of douUfid significance, oiving
to the uncertainty in our knowledge as to hoiu long the spermatozoa
may remain in the genitcd tract, and hoto long the ovum may take
in some cases to reach the uterus.)

7. In the great majority of the mammals menstruation does
not take place, and in many of them we know that the early
ovum develops in relation to the connective tissue of the mucosa,
the superjacent epithelium being removed by the ovum itself.

Indeed, it is not at all necessary to look to menstruation as
the process by which the epithelium is removed. The absorptive



8 ETIOLOGY.

power of the trophoblast or outer layers of the fcetal epiblast
is an important factor in bringing about its disappearance. My
recent studies in early tubal pregnancy lead me to believe that
this is also accomplished partly by another agency, viz., the rapid
changes in the connective tissue of the mucosa leading to the
formation of the decidua vera, causing the covering epithehum
to be stretched and broken up.

Regarding the exact nature and significance of menstruation
we are still ignorant. The opinion of Hirsch,^ Sla^'ianski,^
Eeeves Jackson,^ Lawson Tait,-^ and others, that o%'ulation and
menstruation are entirely independent of one another, can
scarcely be disputed. The recent work of Heape-^ is confirmatory
of this behef ; he examined the genitals of Semno'jJithccus cntellv.s
in forty-two cases of menstruation, and found that only in two
was there any evidence of a discharge of ova from the ovaries. It
seems certain that ovulation does not necessarily take place during
menstruation, and that menstruation is not due to o^'nlation.

The views of Leopold and ]\Iironoff,^ who have lately worked
at this subject, are as follows : —


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