EXTRA 
UTERINE 
PREGNANCY. 
THE HISTORY OF—By Dr. G. W. Milteinberger. 
LAPAROTOMY FOR-with Report of a 
Successful Case, By Dr. T. A. Ashby. 
REVIEW AND DISCUSSION-By Dr. H. A. Kelly. 
XT A GENERAL DISCUSSION’' 
PAPERS READ BEFORE THE 
Obstetrical and Gynaecological Society, 
OF BALTIMORE CITY. 
January 14th and February nth, 1890. 
PUBLISHED BY ORDER OF THE SOCIETY. EXTRA 
UTERINE 
PREGNANCY. 
THE HISTORY OF—By Dr. G. W. Miltenberger. 
LAPAROTOMY FOR—with Report of a 
Successful Case, By Dr. T. A. Ashby. 
REVIEW AND DISCUSSION—By Dr. H. A. Kelly. 
L GENERAL DISCUSSION. 
PAPERS READ BEFORE THE 
Obstetrical and Gynecological Society 
OF BALTIMORE CITY. 
January 14th and February nth, i8go. 
PUBLISHED BY ORDER OF THE SOCIETY 
BALTIMORE, 
Press of GRIFFIN, CURLEY & CO. 
1890.  THE 
QbSTETRICAL & QyN/£COLOGICAL goCIETY 
OF BALTIMORE CITY. 
ORGANIZED OCTOBER, 1885. 
OFFICERS. 
P. C. WILLIAMS, M. D., President. 
W. E. MOSELEY, M. D., 1st Vice-President. 
B. B. BROWNE, M. D., .... 2d Vice-President. 
T. A. ASHBY, M. D., ....... Secretary. 
R. T. WILSON, M. D Treasurer. 
T. A. Ashby, M. D. 
Wilmer Brinton, M. D. 
B. B. Browne, M. D. 
F. E. Chatard, M. D. 
W. P. Chunn, M. D. 
W. S. Gardner, M. D. 
W. T. Howard, M. D. 
H. A. Kelly, M. D. 
Geo. W. Miltenberger, M. D. 
Jno. Morris, M. D. 
W. E. Moseley, M. D. 
T. F. Murdock, M. D. 
MEMBERS. 
L. E. Neale, M. D. 
C. O’Donovan, M. D. 
Thomas Opie, M. D. 
I. R. Page, M. D. 
C. H. Riley, M. D. 
Hunter Robb, M. D. 
G. Lane Taneyhill, M. D. 
P. C. Williams, M. D. 
H. M. Wilson, M. D. 
H. P. C. Wilson, M. D. 
R. T. Wilson, M. D. 
PRESIDENTS. 
G. W. Miltenberger, M. D., 1885-86. 
W. T. Howard, M. D. 1886-87. 
H. P. C. Wilson, M. D 1887-88. 
Thomas Opie, M. D., 18S8-89. 
P. C. Willams, M. D., 1889-90. 
Committee of Publication. 
G. W. Miltenberger, T. A. Ashby, G. Lane Taneyhill. ECTOPIC GESTATION, 
By G. W. MILTENBERGER, M. D. 
Professor of Obstetrics, University of Maryland. 
I have thought that it might be of some interest to the Society, to 
bring before it a crude history, somewhat hastily sketched, of Ectopic 
or Extra Uterine Pregnancy, and thus open for discussion, a subject 
replete with interest, not only to the professed obstetrist, but to every 
general practitioner. 
There are two striking abnormities of pregnancy ;—abnormity of 
numbers, constituting multiple or compound pregnancy ; abnormity 
or aberration of the site, at which the fecundated ovule becomes 
attached, and is, to greater or less degree developed, at a point entirely 
distinct and more or less distant from the uterine cavity. 
With the interests necessarily involved and its great practical im- 
portance, with the amount of study and research expended upon it, 
with the simplification of its history which has necessarily followed, 
and the improvement and greater certainty of its treatment, there is 
scarcely a subject, whose evolution and development, have been more 
sharply and clearly defined. 
With my duties as a teacher, I have been forcibly impressed, in 
connection with it, for the last ten or fifteen years, with the absolutely 
necessitated advance in instruction from year to year, and to note the 
almost prophetic foresight of the leaders of thought and action, and 
their more or less prompt fulfillment. 
Although our accurate knowledge with regard to it is of but com- 
paratively recent date, it has been sufficiently studied to enable us to 
gain a pretty distinct acquaintance with its natural history, its general 
etiology and mode of production, its progress and termination, its 
diagnosis and prognosis, and with the advance of abdominal surgery 
in the past few years to approach, at all events, very closely and upon 
well established grounds, its treatment at different periods and under 
different circumstances. 
The very first question which meets us at the outset, is as to its 
site of arrest and attachment, in different cases ; and this point of its 4 
natural history, has been of late years, much simplified. While neces- 
sarily from the normal course of the ovule from the ovary to the uterine 
cavity, the tubal variety is by far the most frequent, while for practical 
purposes it is only requisite to recognize the tubal, with its varieties, 
the tubo abdominal and the interstitial or tubo-uterine, the secondary 
abdominal and the sub-peritoneo-pelvic forms, we cannot with Mr. 
Tait, deny positively the occasional occurrence of ovarian and primary 
abdominal gestation. The researches of Spiegelberg and others, who 
have described cases in which they have found a.gestation cyst in the 
situation of the ovary, connected with the uterus by the ovarian liga- 
ment, with the presence of ovarian stroma in the wall of the cyst, and 
the fallopian tube intact and without any evidence of previous rupture, 
forbid our denying the existence of the ovarian form, although others 
insist the examinations have not been made with sufficient care and 
discrimination. 
As to the primary abdominal variety, while this has equally pos- 
itively been denied, while it has been and is asserted, that if the ovum 
unfecundated or when first fecundated falls into the peritoneal cavity 
it cannot there attach itself and will certainly be absorbed, as were the 
early embryos of the rabbit, introduced into that sac in other animals 
by Leopold; we have as positive proof of its presence the two remark- 
able cases of Lecluyse and Koeberle. In the former, that of Lecluyse, 
the woman had previously been the subject of Caesarean section. The 
wound had not perfectly closed, the fecundated ovule escaped through 
this opening into the peritoneum, had there attached itself and devel- 
oped. In the latter, (Koeberle’s,) a laparotomy had been performed, 
a portion of the cervix had been left, and the ovaries had not been 
disturbed. Abdominal pregnancy here followed and a fistulous com- 
munication was found through the cervix into the peritoneum. Here 
the ovum must have fallen into the serous sac, and the Spermatozoa 
have passed through the fistula, a necessarily primary abdominal preg- 
nancy being thus produced. For practical purposes though, it is only 
requisite to recognize the tubal, tubo-abdominal and tubo-uterine as 
primary, and the abdominal and sub-peritoneo pelvic as secondary, 
and as these last only follow an original tubal pregnancy, whose cyst 
has ruptured, and permitted the escape of the ovum, it is only the tubal 
variety, in one or other of the phases of its history that we need recog- 
nize, for surgical purposes. Unquestionably the simplest scheme 
ever proposed for these cases, and with some exceptions, the most 
truthful, and undeniably for practical purposes the best, is what has 
been called Mr. Tait’s “genealogical table’’ of ectopic gestation, as 
follows: 
I.—Ovarian, possible but not yet proved 5 
II.—Tubal, in free part of tube, is [a] contained in tube up to 
fourteenth week, at or before which time primary rupture 
occurs, and then the progress of gestation is directed into 
[i] Abdominal or intra-peritoneal gestation uniformly 
fatal [unless removed by abdominal section], primarily 
by hemorrhage, secondarily by suppuration of the sac 
and peritonitis. 
[c] Broad ligament 
or extra-peritoneal 
gestation ; 
[rf] may de- 
velop in broad 
ligament to 
full term and 
be removed at 
viable period 
as living 
child: 
[if] may 
die and be 
absorbed as 
extra - peri- 
toneal he- 
matocele; 
[/] may die and 
the suppurating ovum 
may be discharged at 
or near umbilicus or 
through bladder, va- 
gina, or intestinal 
tract; 
[£•] may 
remain qui- 
escent as 
lithopedion 
[h] may be- 
come abdominal 
or intra-perito- 
neal gestation by 
secondary rup- 
ture. 
III.—Tubo-uterine or interstitial is contained in part of tube 
embraced by uterine tissue, and, so far as is known, is uni- 
formly fatal by primary intra-peritoneal rupture [as £] before 
fifth month. 
Mr. Tait regards all cases as primarily tubal, while acknowledging 
the possibility of the ovarian form. 
His view is that “It takes two directions (a) into the peritoneum, 
which is the fatal form; and (b) into the cavity of the broad ligament, a 
form which yields the variety of ectopic gestation, which I propose 
to call the extra-peritoneal, which was called the sous-peritoneo-pelvi- 
enne variety by Dezeimeris, and which alone yields all the cases which 
go on to the period of viability, all the lithopedia, all the suppurating 
cysts discharging into bladder, rectum, etc., and also the cases which 
by secondary rupture of the ovum cyst get called abdominal preg- 
nancy.’ ’’ 
As to its frequency, it is very difficult to determine. According to 
Bandl, in 60,000 women, in seven years, in the three clinics of accouch- 
ment and gynaecology in Vienna, there were but five cases, one in 
12,000. But when we reflect that many women may present this con- 
dition, and by the early death of the ovum be relieved without sus- 
picion of its occurrence, and that many others may die from sudden 
rupture without a diagnosis of its cause, and when we recognize the 
great number which have been of late years published, we are forced 
to believe it of more frequent occurrence. 
Cause:—The cause may in many individual cases be obscure, but 
in general terms, we can say, that it may be produced by any condition, 
which prevents or renders difficult the passage of the ovule to the 
uterus, while it does not prevent the access of the spermatozoids to 6 
the ovule, or even where this obstacle is greater, there may be a pass- 
age of the sperm through the opposite tube (open) transmigration of the 
spermatozoa across the peritoneum, and the ovary of the opposite side 
thus be reached. The tube may be twisted or bent, its calibre be 
lessened by thickening ot its walls, by polypi or other growth within 
it, or by pressure from without, the result of tumors or of previous 
peritonitis. Just here in connection with this part of its natural history, 
its cause, the new pathology has still further simplified it. We know 
that the interstitial form is very rare; in all his cases, Mr. Tait up to 
date, November, 1889, had seen but a single case, and the tubo abdo- 
minal is also rare. Now this leaves in the vast majority the tubal only, 
in the free part of the tube as the primary seat. In almost all these 
women there has been a history of sterility either persistent or lasting 
for some time after previous pregnancies, showing that the generative 
organs were not in working order. We have learned of late years, and 
chiefly from the advance of abdominal surgery, the frequency of sal- 
pyngitis and that desquamative. The cilia are thus lost, whose action 
is towards the uterus, and their motive power over the ovum, must 
therefore cease, while as another result, the peristaltic action of the 
muscular tissue of the tube is also arrested or diminished. Therefore 
the ovule is arrested at some point of its course and is there attached. 
Now this fact remains, even it we cannot agree with some most dis- 
tinguished observers, that the action of the Cilia in health is to abso- 
lutely prevent the transit from without inward of the spermatozoids 
along the tube, and that it is only when thus diseased, that they can 
reach the ovum thus arrested in it. The ovarian cases positively dis- 
prove this last assertion, which is so strongly insisted upon by Mr. 
Tait and others. 
Speaking with all due respect, and from one so humble as myself, 
with almost bated breath, of one to whom the profession owes so much, 
and whose whole heart and soul, with his brilliant intellect, his most 
wondrous tactile skill, and almost marvelous dexterity, have been de- 
voted to the advance of science and of art, we are compelled to insist 
that these cases of ovarian pregnancy positively disprove Mr. Tait’s 
assertion, that conception normally takes place only in utero, and that 
the spermatozoids can never traverse the tube in its normal condition, 
on account of the cilia working in the opposite direction. He further 
states as a matter of logical sequence, that it is only after desquamative 
salpyngitis that the spermatozoa can reach the ovule in the tube, and 
therefore this is the cause of tubal pregnancy. 
Now it is positively known and has been for years (Bischoflf and 
others,) that the spermatozoa pass out through the tube upon the 
ovaries, and into the abdominal cavity in the lower animal. Mr. Tait 
asserts that in the lower animals the tubes differ from those in the 
human being, and have no cilia, while we know perfectly well they 7 
have. He further states that the destruction of the cilia by “desqua- 
mative salpyngitis would at once put the tube in a condition exactly 
similar to that of the uterus.” This is physiologically impossible. 
Anatomy, histology, pathology, all fully disprove it. The spermato- 
zoids can and do move by their own inherent force, at a rate variously 
estimated by Henle at one inch in seven and a-half minutes, by Sims 
to move their own length in one second, and Robin and others have 
seen them exerting sufficient power to push out of their way cells or 
crystals ten times their size. We recognize this inherent power, in 
those cases, which I have myself seen, where women have become 
pregnant, with an almost imperforate hymen, or with atresia vaginse so 
close as to leave only a very small fistulous tract leading to the uterus. 
One tube may be entirely closed and the ovum be impregnated by 
spermatazoa from the other tube. “Leopold tied the right fallopian 
tube in rabbits in two places and exsected a portion of the tube 
between the ligatures; the left ovary was carefully removed and the 
abdominal wound was closed. After recovery the rabbits were put to 
the male. In two such cases pregnancy followed.” Again the mass of 
authorities agree absolutely that the ovum, if unfecundated is short- 
lived, that the human ovum does not reach the uterus before the eighth 
to the tenth day after it has left the ovisac, in the bitch in eight or 
nine, in the guinea-pig in three or four, and if not impregnated loses 
its vitality before reaching the uterine cavity. While then desquama- 
tive salpyngitis does act frequently as such cause of arrest, the ovum 
is fecundated at the usual point, and it is not, as Mr. Taitsays, because 
the sperm cannot otherwise reach the tube. 
Natural history:—In each and every case, whatever be its site, 
and whatever be the history and character of the changes, anatomical 
or physiological of the tissue or organ to which it may become attached, 
the ovum itself, granting its vitality, its nutrition, its growth and de- 
velopment, must of necessity obey the same laws and develop in the 
same mode as in its normal situation, the uterine cavity. It grows 
and develops, it is nourished by its own vital powers. It must form 
the blastodermic membrane, it must have its amnion, and its allantois, 
it must produce its chorion with its villi and these villosites will at first 
cover the whole ovum, and later, will atrophy over the larger part of 
the chorion, will increase and hyperthophy on that part which is in 
contact with the nourishing tissue or organ, and form there and thus 
the foetal placenta. But, in regard to the structures to which it thus 
becomes attached, their natural history will vary according to their 
histology and their character. It is necessary for us only to consider 
these in the tubal form. And first as to the tubal form, under which 
we have but three varieties : tubal, tubo-interstitial, and tubo-abdomi- 
nal. In the first it is arrested at some point in the free portion of the 
tube. There.it is in contact with the mucous membrane of the oviduct. 8 
This, from the irritation of the living body in contact with it, becomes 
more vascular, thickened, swollen and hypertrophied ; differing, how- 
ever, as it does, from the uterine structure, we have merely as it were, 
a quasi-decidua serotina, there is no decidua reflexa, the chorial villi 
press and extend into its substance, come into contact with its enlarged 
vessels ; but we have no uterine sinuses, no such close relation between 
the blood of the child and that of the mother as we find in the true 
maternal placenta. The veins here have all their coats and the villi 
do not penetrate into their cavity. The tube may be closed to the one 
or the other side of the ovum, or it may remain open. Continuing to 
grow and increase in size, the chorial villi push through the mucous 
lining to the muscular coat, the latter expands as far as possible, its 
fibres are pushed apart and separated and finally, as a general rule, its 
resistance overcome, it ruptures with results more or less dangerous. 
Rupture in this tubal form generally occurs between the eighth and 
twelfth week, or before three months. 
Again death of the ovum may occur at a much earlier period, 
either from deficient nutrition, or from slight hemorrhages, severing 
its connections, which are here fragile ; or, on the other hand, the 
tube may yield without rupture and gradually expand until full 
term is reached. 
With the increased vascularization of the mucous and muscular 
layers of the tube, the peritoneal covering sympathizes, the vessels at 
that point enlarge and hypertrophy, a very active circulation is estab- 
lished. Nor does the uterus remain quiescent, it is at first displaced 
most often laterally, and more or less elevated ; later it is carried in 
front, if the fcetal cyst descends into Douglas’ Pouch. It preserves its 
form but increases in size, less however than in uterine gestation of 
like date, and the nearer the uterus the fcetal cyst the greater its 
size, the more remote, the less at corresponding periods. Not only 
does it thus augment in bulk, but we have the change in the mucous 
lining which hypertrophies and the decidua is formed of the same 
structure as in normal gestation. This decidua becomes detached and 
is thrown off, either in mass or in portions, chiefly when the ovum dies 
or the tube ruptures, or even when neither occurs, but the gestation 
continues to full term. 
In this history then we may observe in different cases :—the death 
of the fcetus ;—the rupture of the tube, or its development to term. 
Death of foetus.—The fcetus may succumb at any period, as before 
said. If it occurs at an early date, it may be entirely absorbed, as has 
been experimentally proved by Leopold, who placed in the peritoneum 
of an animal three young fcetus of the rabbit. Their tissues were soon 
invaded by leucocytes and absorbed without leaving any trace. If 
death occur at a later period, the foetus may be encysted and different 
results follow in different cases. 9 
Rupture usually occurring from the eighth to the twelfth week, 
may take place into the peritoneal cavity, or below, between the layers 
of the broad ligaments. If the former, the blood of course is effused 
into the peritoneal sac; it may be so profuse as to be promptly fatal to the 
mother, or life may be preserved for some days. Still further the 
hemorrhage may not be mortal, blood and fcetus pass into the cavity, 
may give rise to serous irritation, and plastic exudation which will 
localize it, there is a hematocele, The fcetus having died, absorption 
may take place and the mother recover. 
Where it breaks into the sub-peritoneal pelvic cellular tissue, the 
blood may be absorbed and the woman recover, or it may become the 
seat of future trouble, or again go on to term. 
In the interstitial variety, the connections of the ovum, are formed 
in the same way, the sac is formed of the musculature of the uterine 
wall, and it follows the same history. Rupture most frequently takes 
place before the end of the third month, but occasionally it persists to 
the fifth or sixth month, or even, though very rarely, to term. 
In the tubo-abdominal variety, the cyst is formed on one side, by 
the fimbriated extremity of the tube, the other surface of the ovum 
protruding into the abdominal cavity. Serous irritation is excited by 
its presence, exudation of lymph follows, coats the free surface and 
thus encapsulates it. Layer after layer may thus form as it enlarges,' 
until finally it may form connections with the most distant abdominal 
organs, kidney, spleen, liver, &c. We can easily understand how 
here and under these circumstances, though rupture may take place, 
it is far more likely than in the others to go to term. 
Ovarian Gestation.—Here, as I have before said, this form has 
been denied over and over again, but its occurrence has been positively 
proved, and in both of its varieties, external and internal. Indeed we 
cannot refuse to recognize it, when the ovary as such cannot be found, 
but the foetal cyst is attached to the uterus by the ovarian ligament; 
when ovarian stroma is seen stretched over its surface, as in ovarian 
cystoma ; when finally the tube evidently forms no part of it. Spiegel- 
berg found only nine; his own making the tenth. In 1881, Klein- 
wachter stated that two had been found since, so that the entire num- 
ber was then twelve. Leopold in 1882, reported a case, which accord- 
ing to him, was the fourteenth where the anatomo-pathologic proof of 
ovarian pregnancy was established. Another has been reported in 
1885 by Samson, making the number fifteen ; and to these may now be 
added, 1889, the case of Ashby, thoroughly examined and satisfactorily 
determined by so accurate, reliable and unimpeachable authority as 
Prof. Welsh of Johns Hopkins University. 
Here again rupture may take place in the earlier months, but it 
may also go to term. 10 
Abdominal Gestation.—With this, as I stated, we recognize two 
forms, primary and secondary ; the former of which is denied, but which 
I showed did at times exist. Here the fecundated ovule does not 
reach the tube, but falls into the cavity, to whose serous membrane it 
attaches itself, and goes on to grow and develop. In this case, the 
serous membrane may undergo no change, no pathological irritation is 
produced by the soft yielding little mass, but it acts as a physiological 
irritant, the subserous cellular tissue is hypertrophied and its vessels 
enlarged, as are those of sublying organs, and an excessively vascular 
area is thus produced, which acts the part of maternal placenta, and 
with which the chorial villi, the foetal placenta, come into contact. 
In some of these instances, in the absence of irritation, these do not be- 
come encysted, the ovum is perfectly Iree, except at the placental at- 
tachment, and we find only the amnion and chorion, without any other 
investment. Again serous irritation may be produced, there is effusion 
of lymph and an enveloping capsule is formed around it. Rupture 
may here occur, but, as you can easily see, it is more likely to go to 
term. 
In tubal pregnancy when rupture occurs, it far more frequently 
does so through that part of the tube .covered by peritoneum, the more 
so as this comprises by far the larger segment of its calibre, and the 
cyst or foetus, falls into the peritoneal cavity. But again, and this is 
one of its most interesting varieties, the tube may burst at that part 
uncovered by peritoneum, between the layers of the broad ligament, 
in contact with the sub-peritoneal pelvic cellular tissue, into which it 
escapes, and thus constitutes what has been usually termed sub-perito- 
neo-pelvic gestation, but by Mr. Tait most aptly named extra-peritoneal 
pregnancy. 
This title is thoroughly appropriate, as not only does the escape 
thus take place, outside of the peritoneum, without entering the serous 
sac or involving its continuity, but whether its vitality is lost in its new 
position, and is followed by absorption, if at an early period, or if in- 
flammation'be lighted up with suppuration and its escape through one of 
the neighboring canals or organs, or through the abdominal walls, or 
it continues to live and to go on to develop, it may be for four or five 
months, it may be to term, it and its results remain extra-peritoneal, 
unless there be a secondary rupture of this new cyst, into the abdomi- 
nal cavity. Where in these cases, suppuration follows, it may open 
into and through the bladder, the vagina or the rectum, the foetus 
coming away piece-meal, or the pus may burrow to the front of the 
abdomen, and there make its appearance externally, even as high as 
the umbilicus. And this is what you would naturally expect from your 
anatomical knowledge, that suppuration taking place between the 
folds of the broad ligament, would follow such route, and those cases, 
in which after four or five months the foetus dies and later the bones 11 
make their escape through these passages, are generally, if not always, 
instances of this extra-peritoneal form. Even when it goes on to term, 
it remains extra-peritoneal, pushing the peritoneum before and above 
it, as it enlarges, as has been perfectly well shown post-mortem, 
Berry Hart’s specimen proves it completely. And this is not only of 
exceeding interest, but is a most important practical point, as here 
when it goes on to term, or operative procedure is required before such 
time, the cyst and its contents are entirely outside the peritoneum, and 
that membrane need not be opened or wounded in extracting the 
foreign body. 
Results:—As this whole process is abnormal, so do we find abnor- 
mal terminations, which however differ much in different cases. As 
we have already seen (illustrated experimentally by Leopold), if the 
death of the ovum occur at an early period, it may be entirely absorbed 
and disappear. Even when death occurs somewhat later, the liquor 
amnii is absorbed, the cyst collapses and applies itself to the foetus, 
and the contents may be converted into a fatty mass, adipocere. 
Again, the fluid contents are gradually absorbed, and there is nothing 
left but the foetus or even only its skeleton and lime salts. The sac 
becomes infiltrated and forms at last a calcareous shell and constitutes 
a lithopedion. More rarely we find such calcareous shell, containing 
within it a foetus which retains fully its normal aspect and in which by 
careful examination, we can trace the normal histology of all the 
organs. 
A lithopedion, in the sense of a complete petrifaction, never ex- 
ists. It appears in three forms:—i. The fluid is absorbed, the cyst 
calcifies and the foetus mummifies. 2. The sac calcifies, as does also 
the foetal surface, where it may be in contact with the sac. 3. Where 
the foetus has escaped into the abdominal cavity and the salts are de- 
posited in the smegma and beneath it, the tissues within the chalky 
layers being mummified. In either of these cases or where the foetus 
has become converted into adipocere, it may be retained for many 
years, fifty or more, without further disturbance, but not usually, as 
accidents may arise at any time during its continuance. cause of 
these accidents is, in general, putrefaction. When the child dies in 
utero, while the membranes are intact, this does not occur neces- 
sarily, but in these cysts it comes on, in a large proportion of cases, 
most likely from the proximity of the intestines, with the fermentative 
matter they contain and their bacteria. We may thus have peritonitis 
or septicaemia, either of which, or the two conjoined may prove fatal. 
Inflammation of the sac is often followed by ulceration, the contents 
making their way externally by various routes. It is but rarely that 
they open into the peritoneum. It may be through the abdominal 
walls, possibly at the umbilicus or at some other point in the linea 12 
alba, or into one of the hollow viscera or canals, the vagina, the rec- 
tum, the bladder, the uterus, or even in one case by the stomach. If 
it be small, the whole may at once pass per rectum or vaginam, or 
piece by piece, occupying often a long time and then, if the woman 
does not sink with marasmus or exhaustion, recovery may ultimately 
ensue. I have already spoken of rupture and its results, sometimes, 
but rarely, as we have seen recovery ensuing, in the great majority death 
from shock, from hemorrhage, or from peritonitis. 
When it goes on to term, we have false labor, the extrusion of the 
decidua, if it has not previously been thrown off, and the child dies 
during the expulsive efforts. In the majority of cases, suppurative in- 
flammation then sooner or later is lighted up, and the woman dies 
from exhaustion, suppuration, peritonitis or septicaemia. Finally the 
dead foetus may remain, be converted into adipocere or a lithopedion, 
but very rarely. 
Symptoms and Diagnosis:—There is scarcely a single point in this 
whole history, which has given rise to more acrid discussion, than this 
question of diagnosis. While all acknowledge its difficulties and un- 
certainties, while errors, and of most serious character have occurred 
in the hands of the astute and skilful, the great majority of reliable ob- 
servers agree, that in a large proportion of cases, a diagnosis is possi- 
ble. Others and those chiefly of the modern school insist, that such 
diagnosis cannot positively be made, and unjustly attempt to support 
their view, by claiming that Mr. Tait says that he cannot make it. 
This Mr. Tait does not say ; he only states, that he cannot speak defi- 
nitely upon this point, inasmuch as, as a surgeon, he only sees these 
cases after rupture, and he has only seen one previous to rupture. 
The earlier symptoms are those of normal pregnancy, and indeed 
in some instances we may have no pathological symptoms until the 
gestation is somewhat advanced, or until rupture occurs. At first we 
have suppression of th*e menses, uterine enlargement, the changes 
in the mammae, the sympathetic disturbances of the stomach and 
intestines and of the nervous system. Even with multiparae they may 
recognize their pregnancy, but feel nothing which would cause them 
to look for anything abnormal. But this is not always so. The re- 
currence of the monthly flow for one or two periods is not uncommon, 
or they reappear irregularly after their suppression ; the flow may then 
be moderate, there may be a constant sero-sanguineous discharge, and 
finally, though but rarely a true hemorrhage. The uterus enlarges, 
the increase in size being not in proportion however to the date of 
pregnancy, and the organ being flattened and not rounded, differing in 
the different varieties, being largest in interstitial pregnancy, at times 
from four to seven inches, less in tubal, and still less in ovarian or 
abdominal. The neck also is somewhat softened, but not in propor- 
tion to the period in the given case. The decidua may be cast off, 13 
partially or entirely with the discharge, particularly at time of rupture, 
or it may remain in utero until term. The position of the organ is 
changed, pushed upwards or downwards, to one or other side, accord- 
ing to the seat of the sac, most frequently, forwards and upwards, be- 
hind and above the symphysis. With this, not often in the first month, 
but from the second month on, pains supervene, at times moderate, 
but often so acute and sharp, in some cases like colic, a sickening 
pelvic pain, that the woman cannot walk or stand ; again so violent, 
that the surface becomes cold and pale, bedewed with sweat, the pulse 
is small and thread-like, and syncope may supervene. 
We have thus far then the ordinary rational signs of pregnancy in 
the early months ; pain more or less severe, due probably to distension 
of the tube, apt to subside for a time only to recur ; and uterine hem- 
orrhage, irregular as to time and quantity, and containing shreds of 
membrane, portions of the decidua vera. 
With these signs, and the rather if we detect portions of decidua, 
there are strong grounds for suspicion which may be confirmed by bi- 
manual examination, under anaesthesia, if necessary. We can then 
trace the volume, the form, the situation of the uterus and the tumor, 
and the relations between them and the neighboring organs. We detect 
the uterus pushed to one or other side, or thrust forward, and the 
tumor on its side or behind it, more or less regularly oval, more tender 
on pressure and softer than the uterus, often with a sulcus between the 
two, which can be detected by the finger, and at times somewhat 
mobile, so that we may be enabled to ballot the whole en masse. If 
we can examine it from week to week, we find that it increases rapidly 
in size, much faster than the pregnant uterus. 
Thomas says : “The physical signs, which have sustained the 
validity of the symptoms, are—i. Increased size of the uterus, and 
displacement of it upwards, forwards or laterally. 2. Evidence of 
vacuity in it, yielded by the sound or tent. 3. The presence either to 
one side of the uterus or behind it, of a cystic tumor, somewhat pain- 
ful to the touch, rather immovable, giving to palpation the sense ol 
obscure fluctuation, and in some cases, yielding the sign of ballotte- 
ment. In a few of my cases this sign has been plainly distinguishable, 
but this has been an exception to the rule, and the absence of it should 
never be relied on, as evidence against the existence of the condition.” 
The vacuity of the uterus can be positively proved, by the use of the 
sound, or by dilatation of the os, and the introduction of the finger. 
Now while we avoid this, if possible, for fear of inducing abortion, if 
uterine pregnancy should exist, in addition to which in the most care- 
ful hands, the uterine walls thus softened, have been punctured, yet if 
symptoms are urgent, and interference really needed, we are then 
justified in resorting to this experimentum crusis. By two months or 
in the third, the tumor may be seen or felt above one or other groin. 14 
With these evidences we might a priori conclude that the diagnosis 
in the early months could be generally positively established, and un- 
doubtedly such diagnosis has in many cases been confirmed by the 
results, but in a large proportion it is not by any means certain. A 
retro-flexed gravid uterus, a uterine fibroid, an ovarian cyst, a hema- 
tosalpinx, have all been mistaken for tubal pregnancy. And again we 
do not often see such cases until rupture has taken place. While then 
as I have said, Mr. Tait is sceptical upon this point, and states he has 
not had sufficient experience in these cases before rupture, to speak ex - 
cathedra, while a large proportion of his followers deny that a positive 
diagnosis can then be made; even Dr. Thomas, who has had so much 
success in their electrical treatment, although it is true many have in- 
sisted that in these instances he was more than once mistaken in their 
character, writes: “After all that has been said with regard to the 
diagnosis of ectopic gestation, if must be added that a positive conclu- 
sion is very generally difficult and often impossible.” 
In a discussion in 1886 of a well known case successfully operated 
upon by Dr. Howard A. Kelly, then of Philadelphia, now of Johns 
Hopkins Hospital, Dr. R. P. Harris said : “ The case reported by Dr. 
Kelly had as clear a history as we ever find in the very early history of 
ectopic gestation, when it cannot be claimed that a positive diagnosis 
can be made.” After the fourth month, it is about the size of the two 
fists, and now and after, instead of the regular enlargement of the 
pregnant uterus, on or near the median line, it is more irregular and 
to one or other side. We now by palpation detect fluctuation or semi- 
fluctuation in it, with dullness over it upon percussion, and with care 
may be enabled to map out the foetus; this latter at times, but not by 
any means always, appearing to be directly under the examining hand. 
After this time, the fourth month, we may ballot the foetus in its sac, 
and by auscultation, we hear the bruit de souffle, and the sounds of 
the foetal heart, usually intensified. The fundus uteri can frequently 
be felt as a distinct mass on the fcetal tumor. The enlargement of the 
uterus and the softening of the neck are not in proportion to the dura, 
tion of pregnancy and body and neck of uterus are of course more or 
less displaced. By some it is claimed that here we have one positive 
sign. We know the value of Braxton Hick’s sign, the rhythmic contrac- 
tion of the pregnant uterus, and that by friction we can elicit it. In the 
extra-uterine-cyst, it is said, no such contraction is induced by fric- 
tion. But in tubal pregnancy somewhat advanced this sign may be 
elicited ; and hence with our knowledge of its natural history ; and 
the comparative infrequency of other forms ; we see how little we can 
depend upon this for a positive conclusion. 
Rupture; Symptoms, &c.—Rupture of the gestation cyst can 
scarcely be mistaken or unappreciated. Given a woman with, it may 15 
be, a history of previous sterility, who has had menstruation sup- 
pressed for a month or two, or more or less irregular ; who suffers an 
attack of severe intense abdominal pain ; at times saying that she 
has felt something torn within her, with prompt and severe collapse, 
cold, palid surface, bedewed with cold sweat, quick and feeble pulse 
becoming rapidly or gradually imperceptible, vomiting even in the 
recumbent posture, it may be with delirium or convulsions, we have 
every evidence of severe internal hemorrhage, and apart from trau- 
matism or imperfectly checked bleeding after operation, we know 
there is scarcely another cause for such loss The frequency of its 
occurrence is well shown by a statement made by so able a Pathologist, 
as Dr. Formad, Coroner’s Physician of Philadelphia, that in his post 
mortem work within a very short period he had found eighteen deaths 
due to ruptured tubal pregnancy, in all of which, in consonance with 
the uniform experience of Mr. Tait, it bad occurred before the twelfth 
week. 
Now, as I before remarked, this rupture may take place in that 
part of the tube covered by peritoneum, or that part not covered 
by peritoneum, but between the folds of the broad ligament. I can 
best give its natural history in the words of Mr. Tait. “On the 
walls of the tube, becomes developed an organ which weakens them— 
the placenta. The formation of large venous sinuses on the site of 
the implanted placenta diminishes the ability of the tube to distend, 
and it tears. This coincides with the formation of the ‘cake’ of the 
placenta. Up to a certain point the placenta is diffused as a villous 
layer, but in about the eighth week it becomes restricted to one spot, 
when you get what is called the placental cake. I do not know that 
the development of this placental cake has an all-powerful influence in 
determining the rupture, but it certainly exercises some influence. 
The rupture always takes place before the time of the limit of the 
formation of this placental cake,,and the time of the rupture is, there- 
fore, clearly limited to the twelfth week. I have never met with a 
specimen later than that. Now the rupture may take place in one of two 
directions. In one case the placental cake may have formed upon the 
site where the layers of peritoneum meet, or, on the other hand, it may 
form upon some part of the wall which is closely surrounded by peri- 
toneum. In the first instance, the rupture takes place into the broad 
ligament; in the latter, into the peritoneal cavity. Although I have 
been preaching on this subject for twelve years, I have failed to get my 
professional brethren to see what an enormous difference this makes 
in the subsequent progress of the case. It means that if this hemor- 
rhage takes place in the peritoneal cavity it is uncontrolled. If you 
put a bleeding surface under water, you remove one of nature’s great 
hsemostatics, coagulation. If you have bleeding into a confined space 
which is capable only of limited extension, especially if that space be 16 
filled by something that is capable of inducing coagulation, such as 
irregularly distributed muscular fibre, you have a strong means of 
arresting hemorrhage ; whereas, if the cavity be indefinite in its capac- 
ity there is a corresponding absence of the cause of coagulation. This 
is an explanation of the different endings of these cases. In rupture 
into the peritoneum the bleeding practically goes on unchecked. Every 
one knows that if a vessel has not been properly tied or if a ligature 
has slipped after ovariotomy, there are no means of checking the 
hemorrhage, because the blood does not properly coagulate, and a 
little vessel from an omental adhesion, which would not be of the 
slightest consequence in an amputation, would be sufficient to cause 
death after an ovariotomy. You have thus in the one case every pos- 
sible condition favorable to the continuance of the hemorrhage, while 
when the rupture takes place into the cavity of the broad ligament, 
you have all the conditions favorable to the arrest of the hemorrhage. 
Hence, the latter is rarely fatal. Here, then, we have a great natural 
difference between these two varieties of tubal pregnancy. One has 
no natural tendencies toward cure, and the other has all. In the one 
case you have to do with a patient who will die inevitably unless you 
interfere. In the other you have a condition which you may safely 
leave alone. In the one case you have hemorrhage into the perito- 
neal cavity, and in the other you have it extra-peritoneal into the broad 
ligament, and I think I have made it clear that the prognostic impor- 
tance of the two is as different as can well be.” 
You may ask if you can diagnose the one from the other ? You 
can, as, Mr. Tait has well shown. With the general and local evidences 
of loss of blood, if intra-peritoneal, you have hardly any signs, you 
palpate gently, and you have obscure fluctuation very difficult to 
make out even when the amount of effused blood is large. Percus- 
sion gives nothing very remarkable, you get dullness here and reso- 
nance there, but nothing to indicate positively what is the precise con- 
dition. Vaginally you feel an indistinct boggy swelling in Douglas’ 
Pouch, but there is nothing very clear about that either. The relations 
of Douglas’ Pouch are practically unaltered. 
In the extra-peritoneal variety, there may be, it is true, various 
causes, but in these cases of tubal pregnancy rupturing into the broad 
ligament, the signs are positive. You have a smooth, tense, rounded 
tumor in the pelvic region, sometimes reaching almost or quite up to the 
umbilicus. This is the broad ligament dissected upward and distended 
by the effused blood. There is distinct fluctuation. On vaginal ex- 
amination of the pelvis you have a condition which is absolutely dis- 
tinctive, viz : The whole of the roof of the pelvis is fixed and coming 
down from each side of the uterus, you have processes of induration 
extending. You have a more or less flat topped roof and pillars down 
each side which indicate the burrowing of the blood along the pelvic 17 
fascia. Then there is another condition almost certain to occur if the 
case be a severe one, viz.: Stricture of the rectum. Remember that 
the broad ligament comes off from the uterus, and it gradually opens 
one fold on either side of the rectum, and if blood dissects it up, one 
of the roads will be to the front of the gut and around it, and you have 
annular stricture of the rectum, which will not disappear for many 
months. Now let us go back to the history. First the history of 
sterility, then the suspicion of pregnancy. The patient thinks she is 
pregnant. There may be irregular discharges, sometimes profuse 
menorrhagia, but not often a clear history suggesting pregnancy. But 
if you have the actual condition what you wish to determine is, is the 
blood in or out of the peritoneum ? And this you can determine on the 
data which I have given you. If the symptoms are negative, then the 
hemorrhage is inside the peritoneum ; if otherwise, then outside. 
When the embryo has not died early, when rupture has not taken 
place, when the foetus still preserves its vitality to full term, when of 
course we expect it to be ovarian or abdominal, or even at times before 
this period, at the seventh or eighth month, we have what is called 
“false labor,” the symptoms and character exactly such as we see in 
veritable accouchement. The labor pains are of course the same as 
are produced by true uterine contractions, the os opens, there is more 
or less loss of blood, and if it have not been previously discharged, the 
decidua is now cast off and the foetus dies. That the contractions are 
in the uterus is fully proved by our recognizing them, with the hand 
placed over it, and it has been seen contracting when laparotomy has 
been, at such time performed. After these have ceased and the foetus 
dies, we may have the breasts swell as after normal labor, secretion of 
milk may come on and even a discharge simulating the lochia. 
Sometimes, though very rarely, the cyst ruptures during the false 
labor, but whether ruptured or not, the foetus now dies. 
Treatment.—As we have seen then, in every case of extra-uterine 
gestation, the prognosis is most grave, whatever may be the variety, 
and at all periods of its history, whether in the earlier months, or at a 
later period, when it approaches toward maturity, or after the death 
of the foetus. When to this is added the fact, that in some women 
there may be nothing to attract attention until rupture of the cyst 
occurs, and in many cases the difficulty of positive diagnosis even 
when under observation, we perceive that this is one of the most try- 
ing cases, which can be presented to us. Until the last ten or fifteen 
years, no generally received and recognized positive rules 
for their treatment and even in our latest text books, even those pub- 
lished in the last five years, there is so conspicuous an absence of 
clearness, that the most diligent student is unable to formulate dis- 
tinct and satisfactory views of its natural history or its treatment. Look- 
ing at its natural history we see at once, how insignificant a role must 18 
be played by any palliative treatment, and that any remedial means 
which offer hopes for the mother must be distinctly, and if possible, 
positively curative. 
Does nature here assist us in our determination, or point out to 
us in any way a curative intent ? It is evident from what we have seen, 
that the most favorable result, in all these cases, is the death of the 
foetus in the earlier months, and we thus have a positive indication 
from nature herself. 
In the very outset we must divide them as to treatment, into three 
classes: 
1. In the early months, say up to the fourth. 
2. From this time up to full term. 
3. After the death of the foetus. 
In the first period, up to the fourth month, the direct indication 
would be, and this has been borne out in practice, either to destroy 
the life of the foetus, leaving it in situ, or to remove by the knife both 
foetus and cyst. As to the use of medicines administered to the 
mother, as was at one time done, so utterly nugatory is it, that we 
need not waste time upon it. For this purpose, puncture of the cyst, 
injection into the sac of drugs toxic to the foetus, and the faradic or 
galvanic current have been the chief foeticidal means used of late 
years. 
Simple puncture of the cyst through the abdominal wall, through 
the vagina or the rectum, with the evacuation of the liquor amnii 
naturally presented itself, but in twelve cases collected by Maygrier, 
eight of the women succumbed to hemorrhage or peritonitis, while in 
one case (Fraenkel) despite the puncture, the withdrawal of nearly half 
an ounce of liquor amnii, and a hemorrhage, the pregnancy went on to 
term. Of all reported thus treated, the mortality is 66 per cent. 
More successful has been puncture with the injection of toxic drugs, 
atropia and morphia, chiefly the latter, but it has fallen into almost 
entire, if not absolute, disuse. 
Later than these and more reliable is the employment of the faradic 
or galvanic current, preferably the former, which we may claim in its 
present and proper mode, as purely American. Allen, of Philadelphia, 
1869 to 1871. Aveling claims the first successful case in England only 
as late as May, 1888. Before that period, 1870, electro-puncture had 
been resorted to, and of late Apostoli has recommended the use of 
galvano-puncture, without, however any personal experience with it. 
This however is fraught with danger, and I believe there is only one 
successful case on record. The sac now (Allen’s method,) is not punc- 
tured, but one pole being brought into proximity with the sac, by the 
vagina or rectum, preferably the latter, the other pole is placed over 19 
the top of the cyst above the groin. A daily stance of ten or fifteen 
minutes suffices, and so successful has it been and so thoroughly has it 
been brought to the notice of the profession in this country, chiefly by 
Dr. T. Gaillard Thomas, that up to the present time, it has been gen- 
erally received and adopted with us, as the foeticide in these cases. 
It has not been accepted abroad, but in America, we have had reported 
some forty cases, with but one death and that from hemorrhage follow- 
ing an application. In the great majority ot these cases, although it 
has been asserted that often the diagnosis was erroneous, the character 
of the reporters and the histories of the cases, prove, I think, its truth. 
One of the forty was reported by an honored member of this Socie ty, 
Dr. H. P. C. Wilson. But here, you see, while it may kill the child, 
and thus arrest the growth of it and its cyst, yet while the absorption of 
both may take place, as after the natural death of the foetus, yet both 
are left for a time, and may undergo those changes which have been 
traced after its death, and be liable to such further changes and dis- 
turbances as may lead to the death or the persistent invalidism of the 
mother. 
No woman is safe, as long as she bears within her, the result of an 
ectopic pregnancy. As yet then, or up to a very recent date, it has 
been here the most generally adopted plan, but in the past few years, 
the only positively and ultimately curative means, the entire removal 
of both cyst and foetus by laparotomy has been gradually growing into 
greater favor with the profession. This ought not to be more serious 
than the removal of the tubes and ovaries, and to the surgeon is surely 
the ideal method, leaving no foreign body to be disposed of and no 
serious after-effects to be feared. It is certainly taking a stronger hold 
upon the profession in this country and is the recognized procedure in 
Germany. Veit records seven successful cases and no failures. Dr. 
A. Martin says we have agreed to operate at once in our tubal cases, 
when diagnosed. Even in cases, where the symptoms and signs are 
not absolutely positive, but affording strong grounds for such diagnosis, 
as there is detected an abnormal tumor, an exploratory operation is 
here justifiable. When the sac is low down in the pelvis, when the 
foetus can be felt through it, particularly when the sac is thin, elytro- 
tomy, cutting through the vagina into the cyst, better with electro- 
cautery or Paquelin’s cautery has been resorted to at times with success, 
but of late years has been almost entirely discarded. Mr. Tait insists 
upon the utter unjustifiableness of the vaginal section and uses this 
strong language : “I shall never, under any circumstances whatever, 
attack a sub-peritoneal pregnancy from the vagina.” 
Rupture of the cyst.—During this period of which we have been 
speaking, the first four months, as we have seen, we meet with the 
most serious and dangerous of its accidents or complications, rupture 20 
of the cyst, hemorrhage, peritonitis, and septicaemia. We have traced 
its natural history, its symptoms and diagnosis, and have noted its most 
imminent peril. 
What then shall we do ? 
We know that in the vast majority of these cases, if the hemor- 
rhage be into the peritoneum, although in some rare instances the 
hemorrhage has ceased, and recovery from the immediate danger has 
ensued, we from bitter experience, have no right to expect it in the 
individual case. We equally well know that drugs of any kind or to 
any extent are utterly futile. We know that the conservatism or 
rather the expectancy of a previous day, the application of ice to the 
abdomen, the compression of the vessels indirectly by hand or 
compress, the administration of opium to relieve pain, of stimulants 
to rally and sustain the failing powers of life, are equally of no avail. 
Of five cases thus treated as reported by Dr. T. Gaillard Thomas, four 
died. 
Are we to stand by with closed hands, passively watching the 
doomed and dying sufferer certainly lost ? Mere common sense and the 
fixed surgical law to cut down upon and ligate a wounded vessel alike 
protest against it, and point at once and inevitably to the proper course 
to pursue. At once and under all circumstances, open the abdomen, 
ligate the broad ligament and the fallopian tube, make the peritoneal 
toilette, in a word, perform a laparotomy. And here when we have 
opened the abdomen, however great the amount of effused blood 
within it, do not wait to remove this, but at once pass the hand down 
to the fundus uteri, as a guide, trace to the one and the other side 
the fallopian tube, and finding the rent, ligate tube and ligament and 
only after remove the contents. 
To the end of 1887, Mr. Lawson Tait, that inimitable surgeon, 
had thus treated twenty-one of these cases with twenty recoveries ; by 
the end of 1888 his cases ran up to thirty-eight with thirty-four lives 
saved, and to November, 1889, he had operated upon forty-seven. 
This, as I have said, where the cyst has ruptured through the perito- 
neum and the hemorrhage is into the serous cavity. 
But where the tube has ruptured at the part uncovered by perito- 
neum, between the layers of the broad ligament, and the blood has 
poured into the sub-peritoneal pelvic fibro cellular tissue, constituting 
a true pelvic hematocele, our course should differ. When it is in the 
peritoneum, as we have said, there is no natural means for its arrest, 
or to promote coagulation; here, on the contrary, it is confined, it in- 
filtrates the cellular tissue, coagulation is favored and a clot is formed. 
The knife should be confined to intra-peritoneal hemorrhage. If the 
loss be extra-peritoneal, into the pelvis, if we open through the 
vagina, we only favor further loss, while without the knife, it will cease 
and later be absorbed. 21 
When this first period, of four months, has safely passed, there is 
but little danger of rupture. These include with the older authors 
abdominal and ovarian cases, but according to the views of Mr. Tait, 
they are all extra-peritoneal. Here it is generally conceded, that 
unless urgent symptoms present on the part of the mother, no inter- 
ference should be instituted until after the child is viable, or if possible 
not until term. 
If we leave it to nature, at term we have false labor, with the death 
of the child, and later the risk of peritonitis, of suppuration and ulcer- 
ation, of septicaemia and may then be obliged for the mother’s safety 
to resort to surgical means for the removal of the offending body. 
Now shall we wait lor the death of the child, and then probably have 
to perform a secondary laparotomy, or shall we attempt to save both 
mother and child, by what has been called a primary laparotomy ? By 
secondary laparotomy, the mortality has been only about thirty per 
cent. But every instinct, human and professional, would lead us to 
attempt to save both ; provided, of course, we did not markedly in- 
crease the danger to the mother. What then does experience teach 
with regard to primary laparotomy, so-called, where mother and child 
are both living, and we essay to save both lives ? 
To November, 1887, Dr. R. P. Harris had collected twenty-seven 
cases of primary laparotomies with but three recoveries of the mother, 
showing the chances of preserving the life of the mother to be but one 
in nine, for the child one in two, and a still less proportion for the 
latter living for any length of time. One of these cases in 1880, was the 
well-known case of our most respected member, Dr. H. P. C. Wilson, 
which was rendered of still greater interest, in that it was an instance 
of double pregnancy, the intra-uterine and extra-uterine child going on 
to term together. This history is contained in the admirable resume 
of such cases by another of our valued members, Dr. B. B. Browne. 
As occurring since 1881, Dr. Harris has collected ten cases, with 
four recoveries and six deaths of mothers. Five children survived. 
Mr. Tait has reported seven cases with six recoveries. This last record 
would exceed the result in secondary operations, which, as stated, 
give seventy per cent, of recoveries of the mothers. 
Mr. Tait says : “ I therefore advocate the principle of saving a 
child, who has survived the catastrophe of the primary rupture of the 
tube by being extruded into the broad ligament. If its existence is 
recognized during life, the mother ought to be carefully watcned till 
the false labor sets in, just as we watch for a case of puerperal hysterec- 
tomy, and seize the onset of labor or its early stage as the most favor- 
able time for both mother and child. From this point of view, there- 
fore, neither the time selected nor the details of the proceeding will 
be influenced save by two considerations ; not to operate before the 22 
child is likely to be viable, provided, the delay necessary does not 
prejudice the mother; and not to delay at all after the death of the 
child.” 
The dangers of this operation are from hemorrhage, from peri- 
tonitis and from septicaemia. 
The two last, may, to a certain extent, be guarded against, but as 
to the first, while judgment and care may do much, it cannot always 
be avoided. In about one in every six cases, the placenta is attached 
to the anterior abdominal wall, when the very first incisions may pro- 
duce an uncontrollable loss. Even after the operation, the placenta, if 
left, separating from the sac, may lead to hemorrhage more or less 
considerable, more or less continuous. For a long period of time, it 
has been held to be a prime and absolute rule, not to interfere with or 
attempt to remove the placenta. 
In uterine pregnancy, with the severance of the placenta, we have 
contraction of the uterine wall, we have prompt closure of the open 
mouths of the severed vessels, but here we have no such base, the 
maternal surface is neither contractile nor retractile, and such sep- 
aration must of necessity be followed by hemorrhage. Here again, 
however, we find of late years some change in practice. In one of the 
cases, in Harris’ first table in 1887, and it was the only one, by Lazare- 
wicz, and successful, the cyst and placenta were drawn out and pursed 
up in the abdominal wound. 
In Prof. Aug. Breisky’s case, which was a success, the placenta 
was removed, and in four recent successful cases, collected by Harris, 
the placenta was removed in three. 
Even with all its dangers, with the good results of the last few 
years, with the advance of abdominal surgery, with the improved 
technique of the operation, and keeping in mind the dangerous con. 
dition in which the woman is left, with the necessary death of the 
child after false labor at term, there seems to be a gradually growing 
disposition in the profession, toward primary laparotomy, thus giving 
a chance for life to both mother and child. 
Treatment in the third period after the death of the child.—Here 
we have seen whether its death occurs in the latter months or at term, 
the liquor amnii may be absorbed, and the conversion take place into 
a lithopedion, which may continue for years, in some instances over 
fifty, without dangerous results. But, as I have said, no woman is at 
any time safe, who is a subject of extra-uterine pregnancy ; in this 
case, a death in life, and far more frequently the foetus undergoes de- 
composition, suppuration is lighted up, with peritonitis or septicaemia. 
Two symptoms are invariable in extra-uterine gestation which has 
gone past the period : A “show” during false labor, and a diminution 
of size after false labor. (Parry and Tait.) 23 
If we perform a secondary laparotomy soon after the death of the 
foetus, we have the same danger, as in a primary laparotomy, from 
hemorrhage, and we have no positive means of determining at what 
time the placental changes have become such as to prevent this risk. 
According to Litzman, the placental circulation is not entirely arrested 
until the fourth or fifth month ; therefore, if there are no complications, 
no dangerous disturbances, we should not operate until after that 
period. On the other hand, Mr. Tait says : “Not to delay at all after 
the death of the child.” Greig Smith says : “If the foetus is quies- 
cent, operation, although advisable, is not urgent.” 
With dangerous troubles existing or threatening, we would operate 
without regard to time, and are justified in so doing by statistics, inas- 
much as in secondary laparotomies the chances are nearly or quite 
seventy per cent. 
When suppuration has taken place and the sac has opened exter- 
nally, or into one of the hollow viscera, abdominal section is impera- 
tive, and Mr. Tait insists most strongly upon laparotomy. ECTOPIC PREGNANCY. 
/ 
WITH REPORT OF A SUCCESSFUL CASE-LAPAROTOMY. 
By Thomas A. Ashby, M. D., 
Fellow of American Gyn&cological Society, Professor of Diseases of 
Women in the Baltimore Medical College, etc. 
In a study of the treatment of ectopic pregnancy we find a most 
striking illustration of the important service which operative surgery 
may render in clearing up our knowledge of the physiology and 
pathology of the different organs and apparatus of the human economy. 
In former years physiological and pathological studies were hedged 
in by many unknown quantities and by the vague and uncertain 
light of obscure surroundings and conditions. To-day we approach 
the study of all problems with a clearer light and keener appreciation 
of their relation to experimental observation. In this way the obscur- 
ity which surrounded the study of the subject of fcetation has been 
chased away ; both its physiology and pathology have been worked out 
and simplified by the actual proof of clinical demonstration. What 
was at one time a mysterious phenomenon is now a simple and easily 
demonstrated relation of cause and effect. 
The ancients were grossly ignorant of the finer adjustments of 
the laws of ovulation and impregnation. They were unable to account 
for the cause and nature of those disturbances which resulted in ectopic 
pregnancy. This darkness and ignorance not only prevailed down to 
very recent years, but still holds, in a modified degree, up to the very 
present day. The accepted theories concerning the laws of impreg- 
nation and implantation, are speculative, to say the least, and we can- 
not feel sure that such theories are tenable in the light of the evidence 
now being offered through clinical observation and study. 
It has been taught by physiologists that the contact between the 
ovum and spermatozoon takes place on the ovary itself, or as the ovum 
enters the tube. For this statement I have the authority of Bischoff, 
Foster, Dalton, Flint, Yeo, Carpenter, Chapman, Cazeaux and Lusk. 
This theory of contact between the elements makes it necessary 
that the spermatozoon should pass through the tube until it meets the 
ovum, and here arouse those nutritive forces, which result in fcetation. 25 
The impregnated ovum is now expected to travel through the close 
and tortuous passage of the tube until cast into the uterus, which has 
been prepared in advance for its reception. The explanation offered 
for the passage of the spermatozoon through the tube is defined by 
Carpenter as due to “its inherent power oi movement,” or as Foster 
expresses it, “first, to their inherent vibratile activity, and second, to a 
retrograde peristaltic movement traveling from the uterus along the 
tubes.” The passage of the ovum through the tube is secured by the 
movements of the cilia lining its mucous surface, and possibly by a 
peristalsis in the tube itself. Accepting these thories we find a direct 
conflict of mechanical principles. A force which is capable of driving 
an impregnated ovum along a narrow and tortuous tube offers no re- 
sistance (according to this theory,) to the passage of the spermatozoon 
in its efforts to reach the ovum. Why the spermatozoon should be 
expected to undertake this long and hazardous journey through four 
inches of tube, defended by millions of cilia, we see no satisfactory 
reason for in law or function. It seems too true that the place of con- 
tact has been defined by analagous studies, by suppositious deductions, 
and not by actual demonstration. We may therefore question, as has 
been done by one of England’s greatest abdominal surgeons, Mr. Tait, 
whether the dictum of a physiological ovarian and tubal insemination 
should not be set aside, and this result be accounted for on the ground 
of a pathological sequence. 
The results following a study of intra-pelvic surgery certainly go 
far to prove that the physiological field for the union of the male and 
female elements is the uterine cavity, that only through pathological 
changes in the tube itself does this contact become possible in any 
other locality. How this position stands reconciled to accepted opin- 
ions upon this subject the limits of this paper will not permit me to 
explain at any greater length. I may assume with Mr. Tait that the 
cilia of the normal tube stand sentinel, as it were, against every ad- 
vance of a spermatozoon whilst they move forward the ovum with 
earnest toil until it has been cast into the proper soil for its insemina- 
tion, and for the further development of its nutritive energies. Destroy 
these sentinels at their post of duty by an inflammatory process and 
the explanation of a natural law becomes a positive demonstration. 
It has been shown, and further studies will in my opinion confirm the 
fact, that the primal cause of ectopic gestation is a desquamative sal- 
pingitis. Other causes, may, it is true, act in exceptional ways to 
effect the same result, but in the manner explained as in no other, are 
conditions made so favorable for irregular insemination and implanta- 
tion. The laparotomy ward and the dead-house both offer abundant 
proof of the tubal origin of every variety of ectopic gestation, the 
only exception being a possible occurrence of ovarian implantation in 
very rare instances. The various sub-classifications all revert directly 26 
or indirectly to this primary source of implantation. Not is it difficult 
to explain the abdominal and tubo-ovarian varieties upon this hypoth- 
esis. In aid of a more simple physiological and pathological law, we 
may with perfect deference to facts, assert that, clinically speaking, the 
surgeon has to deal originally with but one type of extra-uterine fceta- 
tion, and that he must approach the removal of this condition in its 
primary manifestations from the single standpoint of an intra-abdomi- 
nal procedure. It seems to me there is no other rational ground upon 
which to stand than the accepted position that ectopic gestation belongs 
to the class of morbid growths with a well defined clinical history, and 
therefore, that the condition as clearly calls for an abdominal section 
as the pus tube, ovarian cyst, or other intra-abdominal growths. 
The great frequency with which tubal pregnancy occurs can only 
be explained upon the hypothesis of a pathological influence. A nor- 
mal tube most undoubtedly resists a false and abnormal implantation. 
Tubal gestation must therefore be the rarest of occurrences under 
physiological conditions. Assuming that desquamative salpingitis is 
at the very root of ectopic gestation, the door is opened for a simple 
and clear understanding of this abnormality. The spermatozoon in 
his travels reaches the uterine orifice of the tube, and here stands 
on watch for the approaching ovum. An entrance to the tube is 
opposed by the mechanical action of the cilia and by the anatomical 
structure of the tube itself; but remove these mechanical impedi- 
ments and its vibratile action is sufficient to carry it along the tube 
until access to the ovum is obtained, either during its passage along 
the tube or as it escapes from its follicle in the ovary. Contact be- 
tween the two elements now occurs ; the progress of the fecundated 
ovum is now impeded, both by its altered size and by the absence of 
the cilia, which otherwise would impel it forward and cast it into the 
uterus. The ovum finds a convenient soil for implantation in the close 
walls of the tube, and here, under conditions favorable to its develop- 
ment, it establishes relations and produces results in accord with its 
environment. The tube offers for the time being all of the conditions 
favorable to the growth of the ovum, but from its very thin walls and 
imperfect anatomical arrangements for continued development, a point 
is soon reached when its attenuated muscular fibres and peritoneal 
covering are overstretched, and rupture of its walls is inevitable. The 
most common seat of rupture, according to Mr. Tait, is through the 
surface of the tube into the peritoneal cavity. One of the several re- 
sults here ensues. The ovum is cast out of the tube by complete or 
incomplete separation, and in accordance with the uncertain elements 
of this result, perishes or goes on to further development under other 
conditions of environment. It will be noted here that rupture of the 
tube does not necessarily imply a rupture of the foetal sac, and that 
this latter accident at once limits the stage of embryonic development. 27 
How often this history of complete separation in the early weeks 
of tubal gestation is repeated we have no way of determining, but there 
can be little doubt of the fact that tubal pregnancy is much more fre- 
quent than has been supposed. Its clinical and pathological history 
arouses such gentle disturbances in many cases where rupture occurs 
during the first six or eight weeks of gestation that few data are avail- 
able for a statistical comparison. The milder forms of intra-pelvic 
haematocele, those minor conditions of shock, intra-pelvic pain, local- 
ized peritonitis, and of associated febrile disturbances, could undoubt- 
edly be referred in numerous instances to the causative influence of a 
ruptured and aborted tubal gestation were it permissible to approach 
the treatment of the symptoms mentioned by abdominal section. For- 
tunately nature is able to deal so successfully with this condition, in so 
many cases, that suspicions as to the cause of the intra-pelvic trouble 
may not even be aroused. 
As the weeks of tubal gestation advance before rupture takes place, 
the foetal ball assumes a more active and threatening attitude. Its 
presence may be more distinctly recognized, the symptoms dependent 
upon its growth become more pronounced, and the clinician is con- 
fronted with a problem of difficult solution and uncertain behavior. 
Associated with the local growth is the history of a pregnant state, 
positive or undecided as the case may be, but all the more perplexing 
when a somewhat enlarged and altered uterus raises the doubt as to 
the exact location of the foetal development. At this period of gesta- 
tion the question of diagnosis is both grave and difficult, yet there are 
indications and suggestions which aid in its solution. The existence 
of a growing mass in the neighborhood of the uterus, the presence of 
intra-pelvic pain, the history of the patient prior to conception, the 
position, size and relation of the uterus to the growth, all undoubt- 
edly indicate an ectopic tumor. Whether such indications warrant an 
interference at this stage of investigation, individual judgment and ex- 
perience must decide. One of several methods of dealing with this 
uncertain and unsatisfactory class of symptoms and physical conditions 
deserves consideration. These are the so-called typical cases in which 
the electricians claim a safe and sure result by the use of the Faradic 
current. Assuming the correctness of their diagnosis, they proceed to 
arrest the foetal growth by the destructive influence of the current, and 
this end presumably accomplished, they leave nature to dispose of the 
resultant. The fallacy of this line of action is not difficult to expose. 
First.—The question of diagnosis is not answered by the method 
employed in those cases which go on to recovery. The results of this 
method are purely circumstantial, and clinical experience can be ad- 
duced to show the utter unreliability of the evidence offered in support 
of the value of electricity when a positive demonstration and confir- 
mation of the condition have been made. I may incidentally refer to 28 
the case of tubal gestation reported as cured by Dr. Mann, ol Buffalo, 
N. Y., subsequently operated upon by Dr. Wylie, of New York, and 
the intra-pelvic condition found to be a hydro-salpinx which had been 
thus incorrectly treated. All who know Dr. Mann need not be told of 
his acuteness as a diagnostician and of his skill as a surgeon. The 
error which he fell into must occur whenever a diagnosis is based upon 
insufficient proof and is not subsequently confirmed by tational methods 
of investigation. It should occur to every thinking mind that the 
electrolytic method is irrational and in no sense free from grave com- 
plications and dangers in the presence of an ectopic pregnancy. In 
the absence of this condition its employment asserts no positive 
result. 
Second.—The resultant of an ectopic pregnancy arrested by elec- 
tricity is an unsafe quantity subsequently to be accounted for after the 
foetal death. That it is safely disposed of in many cases of reputed 
cure by the use of the current goes without saying in those circum- 
stantial cases of assumed diagnosis. That this safe result does always 
follow in cases where an actual gestation was in force we have numer- 
ous illustrations. Mr. Tait has shown that the death of the foetus does 
not necessarily mean the death of the placenta, that this tissue may re- 
main in the tube and subsequently become a source of danger from its 
growth, and from haemorrhage or septicaemia. But, independent of 
the risk involved from the presence of a dead foetus and its appurten- 
ances left after the use of electricity, there are immediate dangers 
which must be considered. Dr. J. E. Janvrin, of New York, has re- 
ported a case in which he destroyed the foetus by electricity after three 
applications, given on three successive days, and in which the patient 
suddenly died from a profuse haemorrhage from a small artery located 
upon the peritoneal covering of the tube. It is a well recognized fact 
that the use of a strong current may cause a rupture of the tube and 
foetal sac at the time of its application, and occasion a dangerous if 
not a fatal condition. No one would think of using electricity after a 
tubal rupture has taken place, for here it can render no possible service. 
Its value, if it has any value at all, must be confined to a very narrow 
field, and be limited to those cases of doubtful diagnosis observed 
during the very earliest weeks of pregnancy. 
Whilst I desire to maintain a courteous respect for the opinions of 
those observers who place confidence in the use of electricity it does 
seem to me that an honest regard for rational methods forces the sur- 
geon to deal with ectopic pregnancy from one of two standpoints. First, 
he may remain passive in the presence of the growing mass, and hold 
himself in readiness to act the very moment a positive indication is 
offered or, second, he may anticipate a positive indication by immediate 
action. We have, therefore, to consider the advantages of an abdomi- 
nal section at the time of actual rupture, or subsequent to this event, 29 
or an abdominal section in anticipation of the rupture. That a tubal 
rupture will take place sooner or later, there remains little doubt, the 
exceptions being too infrequent to be considered as contra-indicating 
a course of action. 
It has been shown that in the act of rupture several routes are 
chosen, and a clinical history follows in accordance with one or the 
other of these plans. Mr. Tait has simplified this study by designat- 
ing the result as an intra and extra-peritoneal rupture. In the first 
instance the tube ruptures into the peritoneal cavity, whilst in the 
latter rupture takes place into the folds of the broad ligament. In this 
latter variety, should the amnion be thrown out of the tube intact and 
its placental attachment remain undisturbed, pregnancy continues. 
The ovum goes on developing until the sac formed by the peritoneal 
folds is overdistended and secondary rupture takes place. This sec- 
ondary rupture now becomes an intra-peritoneal one, and the same 
results are likely to ensue, as in the case of the primary intra peritoneal 
variety, viz : intra-peritoneal haemorrhage, shock and probable death. 
Maternal death, it is true, is not the necessary result of intra-peritoneal 
rupture in the early weeks of gestation. The result to the foetus is 
problematical. It is asserted that the abdominal variety of ectopic 
gestation is the result of tubal rupture in those exceptional cases in 
which the foetal sac has not been torn and placental attachment has 
not been disturbed. 
A careful study of ectopic pregnancy in its various stages of de- 
velopment up to and after the period of rupture presents such a pic- 
ture of abnormality and of imminent danger to the woman, that we 
may approach the treatment of the condition with the strongest con- 
viction of the importance of immediate action. The only uncertain 
quantity in the equation seeking solution is the single one of diagnosis. 
Just here we meet with those extremes of opinion which the most care- 
ful observers are prone to present. Mr. Tait, with characteristic 
frankness, the outcome of an unprecedented experience, asserts that a 
positive diagnosis cannot be made prior to tubal rupture, and under 
these presumable circumstances with no reliable certainty, until the 
abdomen has been opened and the ruptured foetal sac and contents are 
found. As opposed to this view, Dr. Horace T. Hanks has stated that 
a positive diagnosis can be made in 95 per cent, of cases we are called 
upon to attend (Transactions American Gynecological Society, 
Vol. 13, page 368), prior to tubal rupture. 
The facts of the case seem plain to one who will collaborate the 
experience of those who have treated ectopic pregnancy by these sev- 
eral methods. The electricians, who prove nothing by their methods 
of supposed foeticide, are most positive of an accurate diagnosis, whilst 
those men who open the abdomen and seek to confirm their opinions 
by direct proof are far less positive of the diagnosis until the evidence 30 
is presented in this manner. With the former class of observers the 
supposed arrest of fcetal development is confirmatory proof of unerr- 
ing judgment ; with the latter class the suspicion is confirmed by actual 
demonstration. The statistical value of the two methods of treatment 
is about as reliable as the rationale of the two methods of diagnosis. 
I must side with those who ask for a visible sign, and not with those 
who accept conclusions upon unreliable testimony. 
Practically speaking, the surgeon who starts out to find a tubal 
pregnancy, must rely upon symptoms and indications and then seek to 
verify his suspicions by direct proof. At the very outset of this still- 
hunt for ectopic pregnancy, we are confronted with the fact that in the 
fewest number of cases prior to the eighth week are there present, 
either symptoms or indications calling attention to the condition until 
it has been announced by shock, pelvic pain, collapse and unmis- 
takable evidences of intra-abdominal haemorrhage. In other words, 
tubal rupture has actually taken place in advance of grave suspicion. 
In the very early weeks, if symptoms are present they are for the most 
part speculative, and therefore largely unreliable. In point of fact 
there is no reliable route to an accurate diagnosis, except through an 
abdominal incision. We have therefore the most logical ground for 
making an exploratory incision with a view to diagnosis and removal of 
the fcetal sac prior to its rupture. 
Laparotomy is, in my judgment, positively indicated the moment 
a growing intra-pelvic tumor is found, and especially so when the 
symptoms and history point to a pregnant state. 
The operation of primary laparotomy, it has been claimed, was 
performed for ectopic pregnancy for the first time in this country by 
Dr. Jos. Price, of Philadelphia, in September, 1887. The proposition 
to establish the primary operation as a legitimate surgical procedure 
originated with Dr. J. E. Janvrin, of New York City, in 1886. The 
operation performed by Dr. Price may be regarded as purely acci- 
dental. Dr. Price presumed that he was dealing with a pyo-salpinx, 
and in removing this supposed condition, discovered that he had re- 
moved a tubal gestation. Whilst the credit of the first successful case 
has been conceded to him; the plan and purpose of the operation must 
be referred to the prior suggestion made by Dr. Janvrin.* 
I have asserted in this paper that we have the strongest grounds 
for making an abdominal section the very moment the pregnant con- 
dition is suspected or positively determined. Any other method of 
dealing with extra-uterine pregnancy simply invites further complica- 
tions and embarrassments. If this statement holds good for primary 
♦Since the foregoing was written I have been informed by Prof. Howard A. Kelly, 
of the Johns Hopkins Hospital, that he did the primary operation on March 20th, 
1886, and removed a small fetus 4% inches in length, in the intact right tube. This 
patient recovered, and in January, 1887, was delivered of a living female child. 31 
laparotomy, it applies with far stronger emphasis to those cases in 
which a rupture of the sac has occurred. Here we are brought face to 
face with positive symptoms, and no postponement seems justifiable 
unless it be in those exceptional cases in which haemorrhage and shock 
are insignificant and septic trouble does not follow, but even here we 
are again inviting danger by an over-confidence in the reparative forces 
of nature. 
I have previously stated that a rupture of the tube into the perito- 
neal cavity or into the folds of the broad ligament does not neces- 
sarily destroy the viability of the foetus. The primary rupture may be 
followed by mild and harmless symptoms, and we may hastily assume 
that no further trouble will occur. This may prove true, and yet in 
other less favored cases the growth of the foetus continues until secon- 
dary rupture supervenes with alarming if not fatal results. This latter 
result happened in Mr. Tait’s early experience, and it is by no means 
an improbable winding up in those cases which have successfully 
weathered through a primary rupture. That the foetus will continue 
to develop after tubal rupture, whether primary, secondary or tertiary, 
is an established fact, hence it cannot be assumed because shock and 
haemorrhage do not prove of sufficient urgency to demand a laparotomy 
at the time of rupture, that no further trouble will supervene. 
The woman is by no means safe so long as she carries around in 
her pelvis a living foetus, or a dead one with its secundines, blood clots 
and injured tubal appurtenances. If she escapes trouble, the result 
must be attributed to uncommon constitutional vigor and fortunate 
combination of circumstances, and not to the workings of a co-ordi- 
nated and reliable reparative process. 
The following case will illustrate the behavior and subsequent con- 
duct of these cases of ectopic pregnancy after tubal rupture, and the 
necessity for a laparotomy to dispose of the results after the foetus has 
long perished. 
Mrs. D., aged twenty-five years, married five years, mother of one child, aged 
four years. Health good up to February, 1889, and menstruation regular. Menstru- 
ation ceased in February and March. She suspected that she was pregnant, but 
there were no positive symptoms referable to this condition. The last of March she 
was seized with violent pains in the left ovarian region Her family physician, Ur. 
George R. Graham, of this city, was called in, and upon examination detected a 
small movable tumor to the left of the uterus and very low in the pelvis. He sus- 
pected a tubal pregnancy, placed his patient in bed, and kept a close watch over 
her case. 
On April 9th, Mrs. D., was seized with violent pain in the region of the left ovary 
which was followed by a slight shock and collapse. Dr. Graham was called in, and 
found that the tumor had disappeared. Next morning menstruation reappeared, 
but pain continued. I was invited to see the case in consultation, and after hearing 
the histoiw, was strongly in favor of Dr. Graham’s diagnosis. Chloroform was ad- 
ministered and a thorough examination made. No satisfactory condition could be 
made out. There were some slight indications of a small movable tumor to the left 
of the uterus deeply seated in the pelvis. 
An expectant plan of treatment was advised, and the patient carefully watched 
for indications for interference. Through rest in bed the pain soon disappeared, 
and in a few days the patient was able to resume her domestic duties. She con- 
tinued well until the first week in June. At this time violent pain returned in the 
left ovarian region, and her suffering became so marked that anodynes failed to re- 
lieve the increasing distress. This continued until June the loth, when I was 32 
again invited to see the case. At this time a small movable mass was felt in the left 
pelvic region. The patient had emaciated, was growing exceedingly nervous, was 
debarred from all domestic occupation, and insisted upon some method of relief. 
After stating the probable cause of trouble, a laparotomy was proposed and promptly 
accepted. 
O11 June nth, with proper assistance I made an exploratory incision, and upon 
introducing the index finger succeeded in finding a tumor mass in the pelvis to the 
left of the uterus. The incision was enlarged, and after some difficulty the tumor 
was brought into the field of vision. In attempting to draw it through the incision 
the sac ruptured and several ounces of clear ascitic looking fluid escaped. The 
mass was then drawn through the opening, ligated and removed. It proved to be a 
blood clot in the left ovary, partially ruptured into the folds of the left broad liga- 
ment. The clot was not larger than a walnut, but was enclosed in the cyst which I 
had ruptured The patient made a prompt recovery, and was free from pain within 
twelve hours after the removal of the tumor: The specimen was presented to Prof. 
W. H. Welch of the Johns Hopkins Hospital, lor examination. I herewith present 
Prof. Welch’s most instructive report. 
EXAMINATION OF SPECIMEN OF OVARIAN OR TUBO-OVARIAN FCETATION 
REMOVED BY DR. T. A. ASHBY. 
The specimen when received had been hardened in alcohol so that some allowance 
for shrinkage must be made in the measurements given in this report. 
The specimen is composed of the lateral extremity of the Fallopian tube, the 
ovary, a sac containing blood coagula and ftetal membranes, and a unilocular cyst 
with the corresponding part of the ligamentum latum. These constituents form a 
single mass removed by cutting through the Fallopian tube, broad ligament and 
adhesions. 
The-Fallopian tube measures twelve ctm. in length. Its ovarian fimbriated ex- 
tremity can no longer be recognized, being lost in the wall of the total sac and 
ovary. The lumen is obliterated after the tube becomes incorporated with this wall. 
The lumen in the remainder of the tube is patent and of normal dimensions. The 
remnants of old fibrous adhesions are present on the peritoneal covering of the 
tube. 
The ovary, the total sac and the altered ovarian extremity of the Fallopian tube 
form one continuous mass, the main part of which is composed of the ovary and 
total sac. This mass measures 6lA ctm. in length, ctm. in width |antero-pos- 
terior] and four ctm. in third diameter, the whole mass being irregularly oval. 
The outer layers of the ovary are continued into the outer wall of the total sac. 
This sac, which has been widely opened, measures three ctm, in diameter, and pro- 
jects from the uterine and the superior part the ovary. It is adjacent to a corpus 
luteum measuring two ctm. by one ctm. and presenting a festooned margin around 
a central blood clot of yellowish brown color. Microscopically, the festooned mar- 
gin presents the character and arrangement of cells usually found in corpora lutea. 
The wall of the total sac averages about 3 or 4 mm. in diameter and presents a 
cavity containing a large quantity of extravasated blood. In this extravasated 
blood and in the margins of the central cavity are present typical branching chorion 
villi, so unmistakable that there caii be no doubt of their nature. No trace of the 
embryo itself can be found in the already opened sac. As a part of the wall of the 
total sac. the ovary containing Graafian follicles, the before mentioned corpus 
luteum and microscopically numerous ova in abundance are present, measuring 3 
ctm. in length and 15 mm. in width. . ....... 
As already mentioned, the lateral extremity of the Fallopian tube is lost in the 
wall of the sac, and here the lumen disappears, not being continuous with the in- 
terior of the foetal sac. , . , 
There is a*thin walled unilocular cyst, already opened, lined by cylindrical 
epithelium provided with cilia, situated between the layers of the broad ligament, 
and in contact with the Fallopian tube. This sac is 6 ctm. in diameter and appears 
to be a parovarian cyst. . , . , . .. , 
Diagnosis: There is no doubt that the case is one of ovarian totation. It is not 
possible to exclude positively the participation of the wall of the tube in the forma- 
tion of the sac containing the total remnants, so that the case may be possibly a 
tubo-ovarian pregnancy. . . 
The parovarian cyst is without any relation to the extra-uterine fcetation. 
William H. Welch. 
Nov. 1, 1889. EXTRA-UTERINE PREGNANCY. 
REVIEW AND DISCUSSION, 
by H. A. Kelly, M. D. 
Gynecologist and Obstetrician to Johns Hopkins Hospital. 
The paper which has just been read before the Society, by Dr. 
Miltenberger, is remarkable for its conciseness, its accuracy and at the 
same time the fulness with which it deals with the most important 
questions connected with this subject. I regret, for the sake of the 
discussion, that I cannot take issue with Dr. Miltenberger on many im- 
portant points. His practical knowledge of the subject, and his wil- 
lingness to accept the most advanced position regarding the neces- 
sity for an early surgical relief, are all that any surgeon could demand. 
Historical. 
The subject of extra-uterine pregnancy has within the last fifteen 
years provoked such active discussion and called forth so many valu- 
able memoirs, that it has evidently proven difficult for most investi- 
gators to get through the mass of recent work to find out that some 
good work has been done as far back as the century before the last. 
One of the earliest plates of an extra-uterine pregnancy is that of 
Mauriceau (*) which is accompanied by a very satisfactory descrip- 
tion of a case which he saw in the hands of another. I copy Mauriceau’s 
plate ; and his description, which is not inferior to some of those 
presented in the text-books of to-day. You will see by the following 
what an admirable account he gives. (Fig. i.) 
It runs as follows : “History of a woman in whose abdomen 
there was found, after death, a small foetus about 2x/i inches long, 
together with a great qua?itity of coagulated blood. The history of 
this case deserves to be carefully examined into to decide whether 
the foetus, (as believed by many) was generated in the ejaculatory vessel, 
called the tube of the womb. 
“ On the 6th of January, 1669, in the village Corrari, I saw in the 
hands of a chirurgus called Benedict Vassal, a uterus, the picture of 
which is shown at the end of this chapter, which the same Chirurgus 
had a short time before removed from the body of a woman aged 32, 
who died after three whole days of torture with the most agonizing 
pains in the stomach, through which she had fallen into frequent faint- 
ing spells and the most violent convulsions. 
♦Mauriceau, Paris, 1671, Page 60 No. i.—Mauriceau’scaseof ruptured Tubal Pregnancy in the year 1669. T is the detached 
foetus. N N the Round Ligament. P, the outer portion of the Right Tube. O, the Ovary. 
L, is the Sac, ruptured on its free border, from which the foetus has escaped. SSS repre- 
sent the original outline of the Uterus, Tube and Round Ligament. H, is the Left Tube. 
F, the Left Ovary, and E, the Left Round Ligament. A A are the thickened walls of the 
Large Uterus, which has been laid open, the inner surface of which is seen at B. D, is the 
Vagina. 35 
“This woman had borne eleven children at term, but in her twelfth 
pregnancy, at about 2% months the womb dilated in the direction of 
the right horn, and unable to stand distension, ruptured. The foetus 
was cast out at once and found among the intestines of the mother with 
a great quantity of coagulated blood in the whole lower abdomen. Many 
physicians, chirurgi and other students of nature did as did we our- 
selves, betook themselves to this chirurgus to see this uterus (which 
he showed for a prodigy, persuading them that it was formed in the 
ejaculatory vessel, which Fallopius calls the trumpet of the womb.) 
They believed at once, without any more investigation, that this was 
just as the said chirurgus told them, and that this case confirmed 
stories of a like nature narrated by Riolanus. However, I examined 
the parts of that uterus most carefully and attentively, and it was known 
to me that those who had fallen into this opinion were in the error 
whither the chirurgus was leading them, and for this reason, at that 
very time, I took a drawing of the womb as it then was, and this is a 
more faithful, true drawing than that which the chirurgus caused to be 
engraved on brass after an entire month, at a time when the uterus 
retained almost nothing of its primitive form, and was spoiled by the 
handling of a thousand men or more who had seen the uterus, pulled 
it, disturbed it, turned it inside out that they might examine it.” * * 
“Many have brought forward this case to prove to us that the testes” 
(ovaries)” of women are full of little ova which at the moment of coitus, 
freeing themselves and emerging from the body proper of the testes” 
(ovaries) * ‘are borne into the uterus through the tube afterwards to serve 
for the generation of the foetus : and one of these so-called ova had by 
chance remained in the tube of this woman, instead of passing forward 
into the uterus, and that this was the cause of her death. Regnus 
Graaf among others holds this opinion, for the confirmation of which he 
brings forward the figure of this uterus which he painted from this case 
which the chirurgus of whom l have spoken, had already given to the 
public ; as one finds it on the 260th page of his book on the generative 
organs of women ; but any who will, carefully and without prejudice, 
examine the following figure which is most faithful and faultless and at 
the same time examine into our reasons, will find that we have given 
another demonstration and that we believe that to be the true 
explanation.” (Translated from Latin.) # 
Although Mauriceau gave such a good description of the case, 
he did not believe that it was a true tubal pregnancy, but considered 
it a hernia from the right horn of the uterus. 
This is clearly an extra-uterine pregnancy, but it is open to some 
doubt as to whether it is tubal or interstitial. 
This case was, strange to say, the source of an acrimonious 
discussion, and it would seem that here started the heritage of strife 
which has followed extra-uterine pregnancy for over two hundred years. 
The best plates which I have ever seen of the abdominal form of 
extra-uterine pregnancy are these life-size plates in the work of 
Deutsch, published in 1792, (1) which I here exhibit to the Society, 
tv Fig. 2.] 
(x) De Graviditate Abdominali singulari observatione ad tab, IV. aeneas illus- 
trata, cum quibusdam ad historiam litterariam additamentis, etc., Halse 1792, C. F> 
Deutsch. i ;i ~°‘ 2' nC-a.se.®n ®?ut“c‘V*n ‘he year .792 Abdominal Pregnancy. Child is seen lying by the side of the mother, whose abdomen has been 
l;ud open. I t is still attached by the cord to the Placenta, w hich is implanted in the lower part of the Abdominal Cavity. The colon H F K 
aud the small intestines K fc, F b are seen pushed *ip above, the right and left lobes of the Liver B and C also visible. 37 
The next important step was taken by Schmitt,f followed by 
Breschet,* who discovered and gave a careful description of the inter- 
stitial form. 
In 1826 appeared this work by Pfaff of Leipsic, with a series of ad- 
mirable plates exhibiting the pathology, with a number of speci- 
mens, of the interstitial pregnancy. 
Loschge (2) was the first to recognize the subperitoneal form. 
The following case here figured is an excellent clear observation 
by J. Guentz, Lipsiae, 1831. [v. Fig. 3.] 
A young woman, 20 years of age, was brought into the Clinic suf- 
fering from severe abdominal pains. She died, and at the post mortem 
the foetus was found in the abdomen ten inches long from head to heels. 
Dezeimerisf followed next with an elaborate classification based on 
a scientific analysis of a number of cases. The subperitoneal form 
was not, however, first described by Dezeimeris as usually ascribed, 
but by Loschge. 
In spite of all this good work in the description of the various 
forms of extra-uterine pregnancy, as well as in the attempt to furnish a 
scientific classification, it has remained for a later day to subj'ect the 
cases to the test of careful microscopic study, by a closer analysis de- 
termining more accurately the species, which have in the past been 
seriously confounded. 
Much harm has been done and our progress seriously retarded 
through the long useless discussion provoked by the unwarranted as- 
sertions of some writers that there was but one primitive form of extra- 
uterine pregnancy. 
The dawn of a new era in the critical examinations of the speci- 
mens date from the work of Prof. Werth of Kiel, entitled “ Beitrage 
zur Anatomie und zur Operativen Bshandlung der Extrauterinschwang- 
erschaft, Stuttgart, 1887.” So difficult is the anatomical exam- 
ination of advanced cases that I feel that no present writer is fully 
competent to pronounce upon the origin and present site of cases of 
advanced extra uterine pregnancy who has not carefully studied this 
work. 
Where does extra-uterine pregnancy occur ? . It may start in one 
of five places—1, in the ovary, 2, free in the abdominal cavity. 
3, between the ovary and the tube. 4, in the tube, and 5, in that part 
of the tube lying within the uterine wall. 
Origin. 
tBeob. der K. K. Med. Chir. Joseph Acad in Wien Bd. 1, 1801, 
•Mem. Sur une nouvelle espece de gross, extra-uterine." Paris, 1828. 
(2) Arch. f. Med. Erfahrung Bd. 2. v. Werth Beit z. Anat. & z. Operativ. Behand- 
der Extrauterinschwangerschaft, Stuttgart, 1887. 
tjour. des Comais, med. chir, 1836. No. 3. Guentz’s case, I.eipsic, in the vear 1831. The Extra-uterine Foetus is here seen still attached by its cord to the ruptured left tube, which is 
filled withcoagula. The Ovary and fimbriated extremity of the tube are well shown just above the legs of the foetus. The enlarged Uterus is seen in 
the middle, and on the right side the Ovary and Tube are shown intact. 39 
Possibly the ovum may primarily become impregnated and rest in 
the FREE ABDOMINAL CAVITY. 
The ovarian form of extra-uterine pregnancy, in which the im- 
pregnation takes place within the ovary and in which the ovary 
develops a sac containing the foetus, undoubtedly occurs, and it is 
to Dr. Miltenberger’s credit that he recognizes the fact. This is clearly 
proved by Leopold’s case in which after it had been carried for 35 
years, he removed a lithopaedion in the ovary. 
To determine an ovarian pregnancy it is necessary microscopically 
to recognize the tube with its fimbria intact on the surface of the tumor. 
The tumor must hold some such relation to the surrounding parts, as 
does an ordinary ovarian cystoma. It is of the utmost importance to 
show the connection of the tumor to the uterus on the inner side by 
the ovarian ligament, a point as important here as the relation of the 
round ligament in the diagnosis of the interstitial form. 
Microscopically the discovery of ovarian tissue, corpora lutea, and 
Graafian follicles in the walls of the tumor complete the demonstration. 
All of these requirements have been met. 
The tubo-ovarian form of extra-uterine pregnancy is one difficult 
to demonstrate, and until recently, justly subjected to much doubt. 
I think that the case presented by Dr. Ashby of the Society, however, 
lends much to the probability of its occurrence. This form must be 
rare and when it occurs most probably ruptures early. 
That the ovum may become impregnated in the Tube, in ampulla 
or isthmus, all recognize, and that the secondary tubal forms are the 
sub-peritoneal and the intra-peritoneal, are equally conceded. 
The Interstitial form ,of pregnancy, where the ovum lodges in 
the narrow portion of the tube, lying within the uterine walls has been 
repeatedly demonstrated since the days of Schmitt, in 1801. It is well 
to remember that this form may terminate in one of three ways : 
first, by rupture and death, second, by becoming uterine and going 
on to term, or third, by going on to term in situ. 
The tubal pregnancy is practically the most interesting because of 
its greater frequency, but it would be about as irrational to neglect the 
other forms as to ignore the existence of dermoid cysts because 
ovarian cysts are so common. 
The Causes of Tubal Pregnancy. 
The simplest idea is that absence of cilia within the tube must 
seriously retard the progress of the ovary towards the uterus. I' do 
not, however, attach great importance to this fact in view of more 
probable causes to be mentioned, and have seen the cilia on the 
epithelium of the tube in a case of extra-uterine pregnancy advanced 
beyond term, upon which I operated a few days since. 40 
I consider the observations ofFehling and Leopold showing that 
polypi are frequently found in the tube of more importance, although 
we cannot say how important jintil we know just how common polypi 
are in normal tubes. I do attach far more importance, however, to the 
fact that every week I find in the operating room tubes bound down in 
the pelvis, or crossed by fibrous bands with the fimbriated extremities 
glued down to the ovary so as to be incapable of receiving the ovum 
except from a very limited area. I can readily see how such adhe- 
sions may cause an obstruction and an ileus of the tube, and thus pre- 
vent the onward progress of the ovum. 
The dangers of tubal pregnancy have been very variously esti- 
mated. While one author (n thinks that 98% ot all cases die when left 
to nature, and some even go so far as to speak of it as necessarily fatal, 
another (2) estimates that 76 cases out of 132 cases terminate favorably 
when left alone. 
J. Veit* in his paper on retro uterine haematocele estimated that of 
146 cases 28 % were ruptured tubal pregnancies, of which 7 out of 33 
died, that is to say 21 %. 
We are hardly in a position yet to determine the actual percentage 
of mortality in extra-uterine pregnancy when left alone. There is at 
present in the English speaking race, too much of a tendency to 
account all cases of haemato-salpinx or haematocele as extra-uterine 
pregnancies without further question. The published cases also are 
for the most part those which have died suddenly'or to which attention 
has been called by the operation, when it is always presumed that the 
patient would have died had not the operation been performed. This 
part of the subject certainly needs a more careful sifting. 
The danger of rupture in the different periods of extra-uterine 
pregnancies is well shown in the table compiled by Hennig in which 
he finds in a series of 64 cases, that 
5 ruptured in the first month, 
22 in the second, 
17 in the third, 
16 in the fourth, 
8 in the fifth, 
1 in the sixth, 
1 in the seventh, 
1 in the eighth, 
1 in the ninth, and 
2 in the tenth month. It must be borne in mind, however, that 
few cases come to the latter months, and that rupture then does not 
constitute the chief danger. 
Danger of Tubal Pregnancy. 
i Puech. 2 Hecker 
•Eileiterschwangerschaft Stuttgart, 1884, p. 14. 41 
Relative value of Mother and Extra-uterine Child. 
In view of the great dangers threatening the mother, at all times, 
in the course of an extra-uterine pregnancy, in view of the very 
small probability, not one in thousands, of the birth of a living child at 
term, in view of the still smaller probability of the delivery of a healthy 
and well formed child, and in view also of the frightful dangers to 
the mother consequent upon the birth of a living fully developed extra- 
uterine child, I would insist that the extra-uterine sac must from the 
moment of its discovery to its complete extirpation be looked upon as 
a malignant mass. I would insist that the whole consideration through- 
out, from beginning to end, should simply and solely be the welfare of 
the mother. 
Can we make a diagnosis in these cases is a question which is 
every day being asked and often discussed with much heat. 
I will answer here from experience. In many cases the diagnosis 
can be made with certainty ;—a certainty approaching that attained in 
the diagnosis of ovarian cyst—or fibroid tumor. • 
I know that it can be diagnosed because I have myself positively 
diagnosed the condition in several instances and verified the diagnosis 
by operation. 
Given a woman with cessation of menstruation for two or three 
months, with some enlargement of the uterus and the formation of a 
cystic tumor lateral to the uterus, with the appearance of milk in the 
breasts, with the expulsion of a membrane resembling a cast from the 
uterus, associated with or followed by unusual pains in the lower ab- 
domen, followed by a shrinkage of the sac,—given these data and 
you have a set of signs simulated by no other condition than extra-uter- 
ine pregnancy. These are the signs upon which I based my diagnosis 
in Mrs. B’s case, in 1885. 
Diagnosis. 
Report of Cases. 
Mrs. B., age 22, married three years, had had one child and one 
premature still-birth. The child was born eleven months previously, 
since which time she had had constant pain in the right leg. She ap- 
plied to me early in December, 1885, stating that her monthly sickness 
had been regular up to July; from July until the middle of November 
she had not menstruated. Menstruation came on in the middle of 
November with a discharge of something like a piece of flesh. In October 
she had noticed a lump on the right side low down which had pained 
her severely ; the pain was constant until the flow came on when it was 
relieved. I found a slight amount of milk in the withered breasts and 
a little wax on the nipples, and at my first examination I discovered a 
very smooth tense elongate tumor anterior to the cervix lying far back 
in the sacral hollow. The tumor was easily felt over the whole 
extent of the anterior vaginal wall ovoid and moderately movable,—ex- 
tending above, half-way to the umbilicus, it had a peculiar tense fluc- 
tuant feeling. The uterus lay small and retroposed, reclining in the hol- 
low of the sacrum. 42 
At her next visit she thought she must be pregnant as she had felt 
slight movements. I then did not feel the uterus so clearly, and 
thought that I must be dealing with an extreme anteflexion of the 
pregnant uterus. 
On the sixteenth of December, a month after the last flow, she had 
a slight bloody discharge without pain, again on the twelfth of January 
she had a free, colored discharge lighter than regular menstruation ; 
On the eighth of March she had a regular free flow lasting five days. 
A note on the thirteenth of March states the following : “uterus 
small low down in the hollow of the sacrum. On raising finger to 
anterior vaginal wall an ovoid, tense cyst felt on the right side, about 
12 cm. in length, by 7 cm. in breadth. The axis of the cyst lies in the 
plane of the superior strait ; its anterior extremity lies at the symphysis 
pubis to the right, and its posterior extremity is at the right cornu 
uteri. A well defined sulcus lies between the tumor and uterus, which 
are connected by a short but easily recognizable pedicle. The tumor 
is very sensitive to pressure ; It is very smooth, and has a remarkable 
rubber-ball elastic feeling; there is much tenderness on the leftside 
low down where there is an indistinct worm feeling about the retro- 
posed cornu uteri.” 
The tumor when first seen had extended out of the pelvis half- 
way up to the umbilicus, and had therefore very markedly diminished 
in size while under observation. The diagnosis of an extra-uterine 
pregnancy, was positively made and invitations were sent to Drs. R. P. 
Harris, Charles H. Thomas, Paris G. Clark, Hunter Robb and Walter 
C. Freeman, to be present at an operation for extra-uterine pregnancy. 
The operation was performed on the twentieth of March, 1886. I felt it 
necessary, at that time, in deference to the conservative views held 
relative to abdominal surgerv to carefully formulate my reasons for 
operating in a case presenting no symptoms of immediate danger. 
My reasons were these : 
First, The patient was suffering constant pain, and in a deterior- 
ated condition of health on account of the tumor. 
Second, Being an extra-uterine pregnancy there was danger of 
later suppuration, in spite of the fact that the foetus was dead. 
Third, I urged that the right to operate to remove an extra-uterine 
cyst, although quiescent, was fully equal to the right to remove a der- 
moid cyst of the same size. 
Fourth, I urged the facility and the safety of the abdominal op- 
eration as recently improved, and 
Fifth, After the operation I called attention to the pasty and un- 
healthy looking condition of the contents of the sac. 
The patient after proper preparation was placed under the influ- 
ence of ether and an incision made, beginning one inch above the 
pubis, and extending to within an inch and a half of the umbilicus, 
fat an inch thick. The linea alba felt under the finger 
like a cord discovered by this land mark it was easily opened, the 
peritoneum nicked, thfe incision enlarged and the fingers passed in, com- 
ing at once in contact with the smooth surface of the tumor. Upon 
slipping the fingers down into the pelvis, the uterus was found to be a 
depressed, softish mass displaced to the left, with its body anteflexed. 
The tumor was a uniformly smooth ovoid mass lying within the pelvis 43 
with its anterior pole at the symphysis, v. fig. 4. It was delivered 
through the abdominal cavity with some little difficulty as it was so 
smooth, round and movable, that at first it slipped around in the pelvis 
like a ball in a cup, in spite of every effort to elevate it. It was finally 
brought through the incision bv passing two fingers in front and under 
it and thus throwing up the anterior pole, revolving it a little on the 
axis of its attachment to the broad ligament and then drawing open 
the abdominal incision and pressing the walls down on either side, 
when the tumor slipped out. The pedicle an inch and a half in length, 
lay on the upper margin of the right broad ligament. The tumor thus 
arose from the free surface of the tube about midway .between its 
uterine and fimbriated extremity. The ovary and the whole of the 
tube were raised with the tumor and altogether transfixed and tied off 
with a silk ligature. The abdominal cavity was drained, and the in- 
cision closed with silk worm gut sutuies. The entire duration of the 
operation was 40 minutes. The patient made a good recovery. 
As soon as the unruptured extra-uterine tumor was removed Dr. 
Thomas incised it, a hand protruded and the bones of the head were 
seen in the opening. The placenta was cut through on the free surface 
of the tumor. The foetus was a shrunken but well formed male, 12 cm. 
long from vertex to rump. (v. Fig. 5.) It had a brownish exsanguine 
appearance. The cord was 5 inches in length, twisted from right to 
left, the sac was ovoid, 3 inches long, of a dull reddish color on re- 
moval. The walls averaged about 3 mm. in diameter. I regret that I 
cannot give a fuller description of the specimen which has been 
unaccountably lost 
I saw her again on the 25th of October, 1886, when she was six 
months pregnant, the uterus up to the navel, and the umbilical circum- 
ference 92 cm. The abdominal scar was broad and deeply pigmented. 
There was no pigmentation about a small scar situated laterally at a 
point from which a tumor had been removed in childhood. 
I delivered her again in January, 1887, at term, after a difficult for- 
ceps labor. 
Another case, that of Mrs. G., which I spoke of as being under 
treatment at the time I reported Mrs. B’s case was also seen by Dr. 
Harris, and a positive diagnosis of extra-uterine pregnancy was made. 
This woman refused operation, passed through a period of great suf- 
fering and several attacks of internal bleeding. The sac, which when 
she first came under observation in February, 1876, filled the pelvis, 
crowding the uterus forward, behind the symphysis and extending 
nearly up to the umbilicus, diminished rapidly in size until in the mid- 
dle of April, when the note states that the uterus was normal in shape, 
anteflexed, and a softish mass lay behind, which might easily escape 
detection. Dr. Harris and I both considered this a case of natural 
cure. 
The next patient was a mulatto woman who had survived the 
period of rupture, and the bloody mass left in the pelvis had undergone 
suppuration. The diagnosis was here made by Dr. J. M. Anders, of 
Philadelphia, and I removed at operation a rotten mass of tube and 
ovary at the right broad ligament, handfuls of clots of blood breaking 
down into pus and the whole of the gangrenous omentum up to the 
transverse colon. This patient was in a very weakened state at the 
time of the operation and her pulse remained over 150 for three days. 
Dr. Anders called two days after the operation to learn when she had 
died. He found that she was recovering, and she is now well. No. 4 shows the relation of parts in the case of Mrs. B. upon looking down 
into the Pelvis through the Superior Strait U is the Uterus. OV the Ovaries, and 
T the outer extremity of the Tubes. Ku. T is the large unruptured Extra Uterine 
Sac springing from the Right Tube, lying with its anterior extremity behind the 
Symphysis Pubis, and the posterior at the right Sacro-iliac Junction. 
No. 5 is a representation of the foetus in my own case, that of Mrs. 8. in which 
I removed an unruptured Tubal Sac. 45 
The next case was one of extensive haematocele formed by rup- 
tured tubal pregnancy in the early months. She was a patient of Dr. 
C. P. Noble. Dr. Noble called me in consultation and we both di- 
agnosed an extra-uterine pregnancy which was confirmed at the oper- 
ation by finding a large piece of the placenta clinging to the wall of 
the tube. This patient also recovered. 
My most recent case was an operation on the 6th of May, 1890, in the 
presence of 32 spectators in the Gynecological operating-room in the 
Johns Hopkins Hospital. These gentlemen had been invited to witness 
an operation for extra-uterine pregnancy, and before beginning, I stated 
“ that this case was positively one of extra-uterine pregnancy,” further 
stating that ‘‘I had always insisted upon the possibility of diagnosing 
some cases with certainty; and if this should not prove to be a case of 
extra-uterine pregnancy, I would never again contend that it was possi- 
ble to diagnose the condition.” The operation was proceeded with, 
and a fully developed foetus removed from among the intestines, which 
had escaped from a ruptured tubal pregnancy on the right side. The 
woman was an unmarried mulatto who had never borne a child. She 
had some milk in her deeply pigmented, withered breasts. Her flacci 
abdomen was full of scars, evidences of its former distention. The 
vaginal outlet showed a torn hymen but no caruncles. I felt the 
womb behind the symphysis and found a tumor behind it extending 
from the floor of the pelvis up into the left hypochondrium. In this 
mass it was thought that foetal parts could be felt. 
She stated that up to October, 1889, her abdomen had been very 
much swollen. Since October it had diminished to its present flaccid 
condition. She also presented a distinct history of cessation of mens- 
truation, with an irregular return of the flow’. There was no history 
of any spurious labor pains. A full account of this important case will 
appear in the Johns Hopkins Hospital Reports. 
Treatment of these cases. 
The treatment is that of a malignant tumor. Get it out as soon 
as you can consistently with the safety of the mother. 
The old treatment by injection of the sac was an interesting and 
rational experiment of the earliest workers. 
It is to America’s credit that before the time of antiseptic surgery, 
her surgeons devised a comparatively harmless, satisfactory and suc- 
cessful mode of treatment in the use of electricity. It was a stupid 
error to tirade against this method of treatment upon the gratuitous 
assumption that needles were stuck into the sac. A little more ac- 
quaintance with literature would have prevented this serious error, 
and the silly accusations based upon it. I am glad that Dr. Milten- 
berger has again called attention to it. 
I have no fault to find with those who use electricity in the earlier 
months while holding themselves in readiness to perform an abdomi- 
nal section upon the appearance of the first untoward symptom. It is 
well adapted to those cases which have ruptured into the broad liga- 
ment, and are very difficult to enucleate. These are cases where we 
want to stop the growth of the fcetus, and where we need not be in 
haste to operate. 46 
I believe it would in all cases be best to extirpate at once all sacs 
offering a distinct pedicle. The question as to the best mode of 
treatment in the latter months while the foetus is still living, is under 
judgment and I confess I have not positively made up my mind about 
it. 
To summarize again, the extra-uterine pregnancy is a foreign body 
which should be removed as soon as safe to the mother. 
Determine as accurately as possible its presence. 
If favorable, (pediculated) operate at once. 
If there is a recent rupture with profound shock, it will require 
great nicety of judgment to determine whether to operate at once or 
wait until the patient has rallied a little ; err on the operative side. 
If it is a broad ligament rupture, stop the growth by electricity 
and wait. 
If later, after the sixth month, it is admissible to watch the case 
until term, to operate aseptically, to remove the foetus with the sac 
and placenta if possible, if not, to remove the foetus and close the 
abdomen without drainage. 
The following is a list of papers exhibited to the Society by Dr. 
Kelly, in the discussion of Dr. Miltenberger’s essay. 
Aschern, Heinrich—Wurzburg, 1841. Ueber den Sitz der Placenta 
in den Muttertrompeten. 
Annacker, Ernest—Berlin, 1887. Zur Behandlung der Extrauter- 
inen Schwangerschaft. 
Beaucamp, Eugene—Stuttgart, 1884. Ueber Tuboovarialschwan- 
gerschaft. 
Baurngarten, Robert—Berlin, 1883. Ueber einen Fall von Extra- 
uteriner Schwangerschaft. 
Buckmaster, A. H.—Brooklyn, (207 Clinton St.,) 1888. Case of 
extra-uterine pregnancy ; Embryo destroyed by a twenty milliam— 
pere current without interruptions ; together with remarks on the best 
manner of using electricity for this purpose. 
Cramer, Hermann—Berlin, 1886. Uber Tubenschwangerschaft. 
Czempin—Deutsche Medicinische Wochenschrifl, Nov. 27, 1886. 
Treatment of Martin’s cases. 
Zwei Falle von Extrauterin schwangerschaft, Heilung nach Lapa- 
rotomie. 
Cams, Atbertus Gustavus—Lipsice, 1841. De Gravidittffe Tubo- 
Uterina seu Interstitiali. 
Deutsch, Christ. Fridericus—Ha\ae, 1792. De Graviditate ab- 
dominali, singulare observatione ad Tab. IV, Aeneas Illustrata, cum 
Quibusdam ad Historiam Litterariam Additamentis, hue Facientibus, 
etc. 
Boring, Heinrich August— Halle, 1872. Ueber Tubenschwan- 
gerschaft. 47 
Dreessen, Adolphus Bernhardus Claudius—Kilise, 1867. Nonnulla 
de Graviditate Abdominali. 
De Drost-Hulshoff, Jos.—Berlin, 1819. De Gravid. Extrauterina, 
I—D. 
Diemerbrceck—Opera omnia medica et anatomica. Ultrajecti, 1685, 
page 135, foetus in tubis concepti et formati. 
Eastman, Joseph—Indianapolis, 1888. Intraligamentous Tubal 
Pregnancy; successful removal by abdominal section of a four pound 
living child with all its appendages. (Photo, of mother and child.) 
Ehm, Franz—Greifswald, 1888. Ueber die operative Behandlung 
der ectopischen Schwangerschaft mit Beriicksichtigung eines Falles 
von Laparotomie bei vorgeschrittener Graviditas extrauterina nach 
dem Absterben der Frucht mit conservativer Behandlung des Frucht- 
sackes und Ausgang in Genesung. 
Falk, Edmund—Berlin, 1887. Ein Fall von Tuboovarialschwang- 
erschaft. 
Galie, Georg—Breslau, 1885. Ueber Nebenhornschwangerschaft. 
Galezowski, Bronislaus—Breslau, 1869. Eine ausgetragene Tub- 
enschwangerschaft. 
Glahn, John vore—Berlin 1888. Ueber Extrauterinschw. 
Guentz, Justus—Lipsiae, 1831. De Conceptione Tubaria Duabus 
Observationibus Lipsiae Nuper Factis Illustrata. 
Heineken, Gustav—Halle, 1881. Ueber Extrauterinschwanger- 
schaften mit Beriicksichtigung eines Falles von Laparotomie bet 
Graviditas ovaria. 
Held, Eredericus Ferdinandus—Lipsiae, 1834. De Graviditate 
Extra uterina Primaria, accedit Observatio Graviditatis Abdominalis 
Primariae cum Descriptione Lithopaedii Inde Exorti. 
Hoick, Rudolf— Berlin, 1887. Ueber Abdominalgraviditat. 
Haake, Julius Hermannus—Lipsiae, 1859. Nonnulla De Graviditate 
Abdominali Adjectus est Graviditatis Abdominalis Casus. 
Hennig—Centralblatt fiir Gyniikologie, Nov. 26, 1888. Ueber 
Tubenschwangerschaft, Hiimatocele, Extirpation beider Befunde. 
Haasio, Guilielmo Andrea—Lipsiae, 1826. De Graviditate in Sub- 
stantia Uteri seu Interstitiali. 
Kregeloh, August—Greifswold, 1869. Ueber Extrauterinschwan- 
gerschaft. 
Jockwer, M.—Dusseldorf, 1877. Ein Fall von Graviditas mter- 
stitialis. 
Klau, Hugo—Berlin, i88r. Ueber die Therapie bei Extrauterin- 
schwangerschaften. 
Langner, Karl—Greifswald, 1886. Ein Fall von ausgetragener 
Tuboabdominal schwangerschaft. 
Leopold, G.—Centralblatt fiir Gyniikologie, No. 3, 1879. Leipzig 
Ueber die Polyen der Tubenschleimhaut bei interstitieller Schwanger- 
schaft. 48 
Lober, Guastav—Jena, 1886. Ein gliicklich geheilter Fall von 
Extrauterin schwangerschaft. 
Laupus, F.—Gottingen, 1876. Ein Fall von graviditas extrauterina 
mit Ausgang in Genesung, 27 Jahre nach ihrem Keginne, durch Elimi- 
nation und Extraction der Foetalknochen per rectum. 
Moreau, M. Alexis—Paris, 1853. Des Grossesses Extra-Uterines. 
Meyer, Adolf— Erlangen, 1874. Ein Fall von Extrauterinschwan- 
gerschaft mit gliicklichem Ausgang. 
Maass, Adolf— Berlin, 1887. Beitriige zur Tubenscliwangerscliaft. 
Muller, fu/ius— Strassburg, 1884. Ueber die Diagnose der Extra- 
uterinschwangerschaft. 
Nomiig, Paul— Berlin, 1880. Beitrag zur Kasuistik der Extra- 
uterinen Graviditat und deren Ausgang in Lithopadionbildung. 
Otto, Heinrich—Griefswald, 1871. Ueber Tuben schwangerschaft 
mit Beriicksichtigung eines F3lles von Graviditas tubaria molaris 
hydatidosa. 
Oiltmann, Heinrich—Bonn, 1885. Ueber Graviditas tubaria. 
O'Hara, Michael—Phila., 9th International Med. Congress, Vol. 
II. Operative Interference in Early Extra-uterine Pregnancy. 
Pauly, Wolff— Berolini, 1838. I)e Graviditate Extrauterina Ad- 
jecta Casus Historia. 
Sassman, Ernst— Erlangen, 1880. Ein Fall von interstitieller 
Schwangerschaft. 
Simon Hugo— Berlin, 1885. Die Graviditas tubo-uterina sive in- 
terstitialis, belechtet an der Hand des Kuge’ schen Symptoms des 
Fundusdrehung. 
Saxinger, Dr. fohann—Tubingen, 1875. Ein Fall von giinstig 
abgelaufener Bauchschwangerschaft. 
Sommer, Ferd. Bernard Guil.—Gryphiae, De Graviditate 
Extrauterina, Accedit Descriptio Memorandae Cujusdam Gravidiiatus 
Tubae Faloppianae Sinistrae. 
Sachs, f.—Berlin, 1881. Ueber die Indication zur Laparotomie 
bei Extrauterinschwangerschaft. 
Strobach, Waldeck— Berlin, 1887. Ueber Behandlung des Frucht- 
sackes und der Placenta bei laparotomierter Graviditas extrauterina. 
Tait, Lawson—Critique of Lancet, Jan. 19, 1889. Lecture on 
Ectopic Pregnancy and Pelvic Haematocele. 
Veit, f.—Geburtshilflich-gynakolog. Gesellschaft, 1877. Ueber 
den Zusammenhang der Hamatocele mit der Tuben schwangerschaft. 
Veit, f.—Stuttgart, 1884. Die Eileiter-schwangerschaft. 
Werth, Beitr. 2 Anat. and 2 Operativ. Behand d. Extrauterin- 
schwangerschaft, Stuttgart, 1887. GENERAL DISCUSSION. 
REMARKS BY DR. P. C. WILLIAMS. 
Mr. Chairman.—I feel under great obligations to Drs Miltenberger, 
Ashby and Kelly for the very elaborate and able papers they have 
given us on this very important and interesting subject. 
In May, 1889, I reported to this spciety the follow ing case, which I 
now request permission to repeat, in order that I may call attention to 
one or two important features of the case. 
1st. In reply to Dr. Kelly’s question, “can extra-uterine pregnancy 
be recognized with certainty?” the following case shows conclusively 
that it can. 
A Case of Tubal Pregnancy Terminating Spontaneously Per 
Vaginam.—By P. C. Williams, M. D. 
January 29, 1889, I was called to see Mrs. B., whom I had attended 
in 1888 for a severe vaginismus, which was greatly relieved when I left 
Baltimore in September, 1888. I found Mrs. B much improved in ap* 
pearance since I had seen her in September. She had gained much in 
strength, had an excellent color, and was able to exercise with more 
comfort than she had done for many months. I was surprised when 
she told me that she thought she was pregnant, and she desired me to 
ascertain whether it was true. 
Upon inquiry she informed me that she had menstruated freely about 
the middle of October-*had not menstruated in November or Decem- 
ber—but during that time had decided leucorrhoeal discharge, which 
was frequently colored either red or brown. At the time of my visit 
(Jan. 29th) her strength and appetite were good, her figure plump and 
full, and her color excellent. There was also increased fulness of the 
mammary glands—but there was no “morning sickness,” no nausea at 
any time. 
External examination revealed nothing special, except enlargement 
of abdomen and tenderness over the pubic region. 
Examination with speculurfi revealed vagina and labia of natural 
color, the cervix uteri normal in size, but rather soft to the touch ; the 
os uteri patulous and emitting a free mucous discharge. Under these 
cicumstances I felt satisfied that she was not pregnant, and so expressed 
myself to her. 
She still insisted that she was pregnant, and wished me to explain 
her failure to menstruate during the past two months, and her increased 
fulness of abdomen and breasts. This I was unable to do. 50 
During the month of February I kept her under observation. 
During that time there was a gradual and steady increase of more or 
less bloody mucus, accompanied with pain of considerable severity, 
which she always located “in the region of the bladder.” 
During the latter part of February I found increased fulness and 
hardness over the pubic region, extending toward the left side, and I 
then thought that I could detect the outline of a foetus. Further in- 
vestigation proved this to be true. 
After careful external examination I inserted two fingers of my 
left hand into the anterior “cul-de-sac,” and then by steady pressure 
upon the abdomen with my right hand I could distinctly feel a tumor 
descend upon them, and I could readily produce abdominal ballotte- 
ment. By cautious pressure with my hands—one in the vagina and 
the other on the abdomen—I could distinguish the outlines of the body 
and limbs of the foetus. Being thus satisfied that she was preguant; 
and also feeling convinced that the foetus could not be in utero, I de- 
termined to settle that question. Accordingly I inserted a vaginal 
suppository about two inches long—which I had been using to allay 
the pain—into the cavity of the uterus. It entered the os with great 
facility, and this induced me to introduce my finger in utero ; which 
proved beyond all doubt that the uterus contained no foetus. This 
convinced me that it was a case of extra-uterine pregnancy. 
Furthermore, the constant increase of bloody discharge from the 
vagina led me to suppose that I had to deal with a case of tubal preg- 
nancy—with the foetus just outside the left horn of the uterus. This 
bloody discharge continued with more or less abundance during the 
month of March, and about the 20th of the month the pain became 
more and more severe, and it required large doses of opium to restrain 
it within the limits of endurance. 
At this juncture, viz., early in March, I communicated my opinion 
to Prof. Howard, and I told him that I would probably have to call 
upon him to relieve my patient by a laparotomy. Being anxious to 
save my patient the burden of thinking over the impending operation, 
I determined not to inform her family of her grave condition until cir- 
cumstances would demand active intervention. Finding, however, 
that my reticence subjected me to very severe criticism from her 
friends outside of her family, I concluded that I ought to explain the 
situation to her husband. 
This I did fully on the evening of March 30th. Early the next 
morning, April 1st, her husband came for me, and said that his wife 
had suffered intensely all night, and that the anodynes could not con- 
trol the pain. I went with him immediately, thinking that the time 
for the laparotomy had come. 
When I reached the house I found her suffering great agony. I 
at once put her under chloroform, and proceeded to examine per 
vaginam. I introduced my finger in utero, and to my great surprise 
and unutterable relief, I discovered that the foetus had descended into 
the uterus, and that my patient was in labor. After three hours she 
expelled a foetus about four months old, which gave feeble evidences 
of life and then expired. The placenta was extracted by gentle trac- 
tion upon the cord. This was followed by slight hemorrhage, which 
gradually diminished under the use of ergot until it assumed the quan- 
tity and quality of ordinary lochial discharge. 51 
For some days there remained an area of induration, about half 
the size of my hand, in the left iliac region. This induration gradually 
decreased in area, until to-day (May ioth) there is a hardness resembling 
a tumor about the size of an English walnut, a little to the left of the 
median line, and about half way between the umbilicus and the pubis. 
With this exception my patient has returned to her normal condition, 
and I hope will soon be able to resume her household duties. 
Thus has terminated favorably a case unique in my experience ; 
and one that caused me grave anxiety for many weeks. 
Some of my friends, in whose judgment I have great confidence, 
have questioned the accuracy of this diagnosis, and have stated that 
the pregnancy was interstitial and not tubal. I am not surprised at 
this opinion, in view of the termination of the case. It is hard to ex- 
plain the method by which the fcetus was pushed into the cavity of the 
uterus if it were outside of that organ. That it was outside admits of 
no question, because exploration with the vaginal suppository, and 
also with the finger proved beyond question that it could not have 
been in the cavity of the uterus. 
Furthermore, the bi-manual examination showed conclusively 
that the foetus was in the tube. 
Had it been in the left horn of the uterus—or had it been in- 
terstitial, the impression made upon the hand inserted in the cul de sac 
would have been entirely different. You would have been conscious 
of tissue, more or less thick, intervening between the foetus and the 
inserted hand. 
In the case before us there was no such feeling. On the contrary, 
the distinctiveness of the ballottement, the extreme thinness of inter- 
vening tissue, the perfectly clear outline of the foetus, which could be 
distinguished as readily as if you had it in your hand, all indicated 
beyond doubt that it was a true tubal pregnancy. 
It is difficult to describe the distinctiveness of the signs referred to 
15ut it seems to me that no one could have felt them without reaching 
the same conclusion that I did. 
It will not do to say that it could not have been tubal, because it 
was pushed into the uterus, and was expelled per vaginam. 
It will not do to say that such a result is impossible. 
However difficult it may be to explain the mode in which this was 
accomplished, yet here is a case in which the fact cannot be denied. 
The case is one of great rarity, and of corresponding interest and 
therefore I thought it worthy of being reported, and this is my apology 
for bringing it before you a second time. 52 
Dr. Wm. P. Chunn had seen one case of extra uterine pregnancy. 
As the history and pathology of these cases had been already discussed 
he would not enter into those subjects, but would simply add the case 
to those already recounted to show the termination which sometimes 
results when nothing is done. The woman in this case presented the 
usual history of pregnancy up to a short time before examination. 
She had amenorrhoea for a number of months, the breasts were 
swollen and secreted milk, and the areola was largely developed. She 
was certain that she was pregnant, but complained that she felt no . 
motion of the child, and that shortly before coming for advice the 
breast had fallen and that the secretion of milk had ceased. Upon 
bimanual examination an indistinct enlargement was felt to the right 
of the uterus, and the uterus itself felt soft and velvety. No diagnosis 
was made, and the case drifted into other hands. Septicaemia became 
fully developed and after a week or two the woman died. At the 
post mortem an extra uterine fcetus was found undergoing decomposi- 
tion which was evidently the cause of death. This was a number of 
years ago and rules were not so well laid down for the treatment of 
such cases as at present. 
REMARKS BY DR. WM. P. CHUNN.