Ectopic Pregnancy in the Later Months.1 
JOSEPH TABOR JOHNSON, M.D., 
WASHINGTON, D.C. 
The treatment of extra-uterine 
pregnancy in the earlier months is no 
longer a vexed question. So little 
has been accomplished by either 
medicine or electricity, that the laity, 
as well as the great bulk of the pro- 
fession, has come to regard coeliot- 
omy, and total removal of the gesta- 
tion sac, as the surest and safest 
treatment. 
Electricity, especially in cases of 
doubtful diagnosis, and in districts 
remote from skilled operators, has its 
advocates, and very properly so, as 
much less harm will be accomplished 
by its use, than by unskillful surgery, 
in an unsafe environment. No doubt 
exists in any well-informed mind as 
to the advisability of the radical 
operation in all ruptures of the gesta- 
tion sac, even in the desperate cases. 
To. wait for reaction while internal 
haemorrhage is exhausting vitality, 
and resorting to opium and stimu- 
lants, is no longer practiced by intel- 
ligent men. The folly of this worse 
than inaction has had such a ghastly 
array of fatal results, that it would 
take a brave man to counsel delay. 
But the case is different when 
ectopic pregnancy has passed beyond 
the fifth month, and the child is 
known to be viable. 
The possibility of favorable de- 
velopment and the final removal of a 
live child greatly complicates the situ- 
ation, and the question may, and often 
does, assume ethical and theological 
aspects, which may possibly never be 
definitely settled. Where these con- 
siderations embarrass an already dif- 
ficult surgical indication, the solution 
of the problem will ever remain more 
difficult than where simply doctors 
disagree. If it were certain that this 
developement would proceed without 
accident, after the ectopic pregnancy 
had passed the rubicon of the first 
half of gestation, there would be little 
doubt of the wisdom of delay, but the 
possibilities are so great of a sud- 
denly fatal termination, that no de- 
pendence can be placed in this doc- 
trine of chance, which amounts to 
worse than gambling with human 
lives entrusted to our care. Unfor- 
tunately for the child, we can only 
1 Read before the section of Gynaecology and Abdo- 
minal Surgery of the First Pan-American Medical 
Congress. 2 
JOSEPH TABOR JOHNSON. 
be reasonably sure of the present 
moment, so far as our patients are 
concerned, and I am glad see the 
brightening indications that point to- 
ward the same opinion which the pro- 
fession has reached in regard to pla- 
centa praevia. 
Few well-informed men live in this 
age who do not believe that the wo- 
man’s only safety lies in the complete 
evacuation of her uterus at the earliest 
possible moment when the placenta 
is praevia, after a diagnosis has been 
made. 
The roads marked “delay,” “leave 
to nature,” and “expectant treat- 
ment,” are so filled with tombstones, 
bereaved relatives and friends, that 
the deluded and timid advocates of 
these delusive and fatal practices find 
little room to navigate their lonely 
way. 
Medicine not beingan exact science, 
we are unable to promise favorable 
results in all cases, but with the 
recent wonderful advancements of 
abdominal surgery, we can do much 
more than our fathers could to save 
human life, even when threatened by 
the dangers of advanced ectopic preg- 
nancy. 
The great difficulty in dealing with 
the placenta has deterred many from 
operating until two or three months 
after the child was known to be dead, 
and the placental vessels are so cer- 
tainly atrophied as to avoid the danger 
of haemorrhage. Even in these cases 
the doctrine of chance has not a few 
advocates. Some women have lived 
many years with a mummified foetus, 
and have finally died of something 
else. Others have survived the re- 
sults of decomposition, abscess and 
discharge of foetal bones through 
bladder, vagina, rectum and abdom- 
inal wall, and why cannot more wo- 
men survive these clangers ? But the 
statistics of Shauta clearly show that 
many have died from the immediate 
effects of visceral perforation, or from 
the exhaustion resulting from ulcera- 
tion and discharge, or remained per- 
manent invalids. 
The chief object of this paper is to 
recommend the removal of an extra- 
uterine foetus in all cases as soon as the 
diagnosis is made, and the gestation 
sac and placenta whenever possible, 
whether it be the second, fourth, 
seventh or ninth month. If the child 
can be saved victory is still greater. 
As in placenta praevia, the dangers 
increase with the developement of 
the placenta. The greater surface to 
bleed the more the danger from 
haemorrhage. In some cases it may 
turn out to be safest to follow stand- 
ard authority, and leave the placenta 
undisturbed, with its tied cord pro- 
truding from the lower end of the 
wound, and subsequently remove it 
after its circulation has dried up ; or 
if no sepsis occurs, it may be left to 
come away piece meal, or become en- 
cysted and absorbed, as occurred in 
two cases reported by Lawson Tait. 
In May of this year Lusk reported 
thirteen cases, including one of his 
own, where coeliotomy had been per- 
formed with the foetus living, in the 
second half of ectopic pregnancy, 
viz.: to those of Breisky, Brown, 
Eastman, Jessup, Rein, Lazarewitsch, 
Lusk, Martin, Olshausen, Shauta, 
Taylor, Treub and John Williams. A 
study of these pioneer cases and their 
careful analysis by Lusk shows that 
in the evolution of this operation we 
are already getting beyond the realm 
of chance in dealing with the pla- 
centa, and are successfully attacking ECTOPIC PREGNANCY IN THE LATER MONTHS. 
3 
its entrenchments in the rear by 
enucleation and ligation of its ves- 
sels beyond the placenta, the general 
ooze from the united small vessels 
and torn surfaces being compressed 
by packing with iodoform gauze after 
the separation and delivery of the 
after-birth. 
Lusk saved his patient by vigor- 
ously compressing the abdominal 
aorta while completing the placental 
separation and a final packing of 
gauze in a Mikulicz pouch. 
Jessup and Taylor left the placenta 
untouched, with cord hanging out the 
lower angle of the closed abdominal 
incisions. In Jessup’s case the putres- 
cent placenta was two months and a 
half in discharging itself and curing 
the patient. 
In Taylor’s, the abdomen had to be 
reopened on the twelfth day on ac- 
count of the gangrenous condition of 
the cord and symptoms of septicaemia. 
The haemorrhage following the sep- 
aration of the after-birth “ was with 
difficulty controlled by the pressure 
of a large sponge, wetted with a dilute 
solution of perchloride of iron.” It 
took her three and a half months to 
get “quite well.” 
Lusk says: “ Both these cases be- 
long to the domain of miracle, and do 
not invite imitation.” 
Olshausen, by tying the vessels in 
the broad ligament beneath the pla- 
centa, was able to remove it com- 
pletely without haemorrhage. 
Fernwald found the placenta at- 
tached not only in the folds of the 
broad ligament, but to the under side 
of the uterus. He tied the vessels in 
the ligament, and clamped and re- 
moved the portion of the uterus which 
bled; a few stitches and some iodo- 
form gauze saved the day. The patient 
was discharged cured in two days 
more than two months. 
John Williams’ and Treub’s cases 
did not vary much from Jessup’s and 
Taylor’s. 
Martin first deliberately and inten- 
tionally tied the vessels beneath the 
placenta and by the side of the uterus 
in the seventh month of ectopic preg- 
nancy, and removed this organ with- 
out loss of blood. He closed the sac 
above and drained through an open- 
ing below, punched through the cul- 
de-sac into the vagina. 
Breisky and Eastman both operated 
successfully in the eighth month, 
removing the entire ovum. They 
ligated the vessels under the placenta. 
Eastman “ was able to clamp the 
uterine end of the tube and the broad 
ligament, and to cut away the portion 
which contained the ovum.” 
In February, 1890, Professor Rein, 
of Kiew, successfully enucleated from 
the peritoneum an eight-months’ foe- 
tus, with placenta and membranes, 
in the same manner as we enucleate 
an intra-ligamentous ovarian tumor. 
It will be seen by the foregoing 
evidence, that as in ovariotomy, hys- 
terectomy and appendicitis, this oper- 
ation is undergoing the various stages 
of evolution, resulting finally in the 
saving of more than a dozen women 
and a number of children. We are 
in a position at least to say, that wo- 
men far advanced in ectopic preg- 
nancy need not be left without sur- 
gical operation outstretched to help 
them and their worse than unborn 
children; and on the theory that 
“what man has done, man may do,” 
we can now advise, with a clearing 
conscience, coeliotomy and complete 
removal of the foetus, placenta and 
membranes. 4 
JOSEPH TABOB JOHNSON. 
Though a large majority of these 
operations have been done abroad, 
Eastman and Lusk have added lustre 
to the already bright reputation of 
American surgery by their brilliant 
operations. There is much ground 
for the hope and belief that Pan- 
American surgeons may equal, if not 
excel, in this, as well as in other 
branches of abdominal surgery. 
I beg your indulgence to the narra- 
tion of the brief histories of two 
cases in which I operated—in one 
eight and in the other twelve months 
after conception. 
In the first case the patient was 
aged 32, the mother of three children. 
Her periods had been regular for 
several years. After missing two 
months she had all the symptoms of 
tubal rupture, and was dangerously 
ill for several weeks. After recovery 
her abdomen began to enlarge upon 
the same side, and continued to grow 
for five months. She had some of the 
symptoms of pregnancy, but no one 
thought in the country where she 
lived that she really was with child. 
Seven months from the first missed 
period she began to fail in health, 
and was treated for malaria and sub- 
sequently typhoid fever followed by 
peritonitis. She came to Alexandria 
for better treatment and came under 
the care of Drs. Jones and O’Brian, 
who requested me to see her in 
March last, after discovering an ab- 
dominal tumor. 
I found an invalid, pale and emaci- 
ated, with a pulse of 130 and a tem- 
perature 96° in the morning and 104° 
in the afternoon, with night sweats, 
frequent chills, no appetite and unable 
to walk out of the house. 
She had a well-defined tumor in 
her left side, which we all believed to 
be undergoing suppuration and to be 
the cause of all her troubles. She 
was thoroughly septic. No one made 
a positive diagnosis, but all agreed 
that an operation afforded the best 
chance of recovery. The usual pre- 
parations were made and the abdo- 
men opened in a relative’s house in 
Alexandria. 
Most extensive adhesions were en- 
countered in all directions. A fluctu- 
ating point in the tumor was tapped 
and a quart or more of the offensive 
gray-colored fluid came away. In 
proceeding with enucleation of the 
tumor my fingers tore into the sac 
and a child’s foot and leg protruded. 
The opening was enlarged and a 
• macerating and decomposing eight 
months’ foetus was easily removed 
with the placenta. The specimen is 
now preserved in the Army Medical 
Museum. It was found to be impos- 
sible to cleanse the sloughing sac and 
stitch it to the abdominal wall, as I 
wished to do, as it tore open in 
several places and putrilege was 
freely admitted to the abdominal 
cavity. Much time was spent in 
separating dense adhesions from the 
bladder, uterus and ligament. The 
abdominal cavity was finally made 
clean and the wound closed with a 
glass drainage tube left in. The patient 
never rallied and died on the next 
day. I believe now, if a correct diag- 
nosis had been made and the sac 
incised, the foetus and placenta rap- 
idly removed, and the sac well 
stitched to the peritoneum, cleansed 
and packed with gauze, the patient 
would have recovered. 
Case II.—Mrs. B., aged 36, mother 
of two children, the youngest 11 
years of age, menstruated in the 
latter part of March, 1892. Early in ECTOPIC PRECNANCY IN THE MATER MONTHS. 
5 
May, while at the house of a friend, 
she was suddenly seized with violent 
pains in the hypogastric region, pass- 
ing backward to the rectum. A 
physician was summoned who gave a 
hypodermic of morphia and made hot 
application to the abdomen and peri- 
neum. One month later there was 
a similar attack. There had been no 
appearance of the menses. On ex- 
amination, the physician found a 
large mass between the vagina and 
rectum which was very sensitive to 
the touch and which he thought to 
be a tumor. She informed the phy- 
sician that she thought she might be 
pregnant, but in this view he did not 
concur. Several attacks of less se- 
verity occurred at intervals of about 
three weeks. Early in August move- 
ments of the foetus were felt, and 
this, of course, established the exist- 
ence of pregnancy. 
In the latter part of November 
there was said to be an escape of 
liquor amnii. On the fifth of Decem- 
ber about a pint escaped, and there 
was evidence of the onset of labor. 
After this date no signs of foetal life 
were manifested. On the twenty-third 
of January it was determined to bring 
on labor, and a gum catheter was intro- 
duced ten inches and permitted to re- 
main thirty-six hours, when another 
was substituted for a similar period 
without provoking uterine contrac- 
tions. After consultation the patient 
was etherized and the cervix dilated 
until the smallest sized Barnes’ bag 
could be introduced, but beyond this 
nothing larger could be inserted. 
The doctor said he introduced his 
finger into the dilated uterus and felt 
the child. 
No labor followed these efforts, 
and the lady decided to come to 
Washington, where I saw her, Feb- 
ruary 23, at her father’s house. Ex- 
ternal examination of the abdomen 
revealed the foetus lying in an oblique 
position, the larger and lower extrem- 
ity being in the right iliac fossa, the 
smaller to the left and above the iliac 
crest. Internal examination detected 
cervix apparently corrugated in a 
longitudinal direction. The patient 
was kept under observation, and 
March 16 she called at my office for 
further examination. Her pulse had 
ranged for weeks from 90 in the morn- 
ing to 120 in the afternoon. Through 
the speculum I passed a sound two 
inches, but could not make it pass 
further. March 21, Dr. F. C. Smith 
was called in consultation with Dr. 
Joseph Tabor Johnson. 
The existence of intra-uterine preg- 
nancy was doubted until the physician 
who had had charge of the case stated 
that he had actually felt the child in 
iitero when he introduced his finger 
after the dilation with Barnes’ bag. 
Dr. Johnson thought, notwithstand- 
ing the history given by the Nova 
Scotia physicians, where Mrs. B. 
resided, that the case was one of ab- 
dominal pregnancy, and Dr. S. C. 
Busey was added to the consulta- 
tion. He could not decide whether 
the foetus was inside the uterus or 
not. With two fingers against the 
cervix it was felt to move when the 
tumor was pushed about with the 
other hand applied externally. The 
patient was now twelve months preg- 
nant. 
She came to my private hospital 
April 6, 1893, and was anaesthetized 
on the following day and the uterus 
demonstrated to be empty and of 
normal size. I familiarized myself 
as much as possible with the tumor 6 
JOSEPH TABOR JOHNSON. 
and its environment. A week later 
I opened the abdomen in the pres- 
ence of Drs. Adams, Bowen, Smith, 
Fry and Stone. The omentum was 
adherent to the tumor, but easily 
separated. Passing my hand down 
into the right iliac fossa, I found to 
my delight that the mass was not 
adherent, and immediately lifted the 
bulk of the tumor out of the abdo- 
men. The uterus and right ovary, 
tube and broad ligament were free. 
The foetus had developed in the left 
tube until rupture, and then in folds 
of the left broad ligament. From 
underneath the unbroken gestation 
sac was enucleated and rolled out on 
the table; only one vessel needed 
ligation. Much of the ligament was 
trimmed off and ligated close to the 
uterus. No cleansing of the cavity 
required and no drainage tube. Ab- 
domen quickly closed and patient put 
to bed in half an hour. 
She sat up on the twenty-first day 
and went home on May 18, one 
month from the date of her operation, 
and recent letters report her per- 
fectly well. She lives near Halifax, 
where her husband is the American 
Consul. 
Upon opening the specimen it was 
found free of amniotic fluid, and con- 
tained a full term foetus with its 
placenta and membranes, which is pre- 
served in the Army Medical Museum 
in this city.