[Reprinted from the American Journal op Obstetrics and Diseases of 
Women and Children, Vol. XXI., September, 1888.] 
INTRALIGAMENTOUS TUBAL PREGNANCY; SUCCESSFUL RE- 
MOVAL BY ABDOMINAL SECTION OF A FOUR-POUND LIVING 
CHILD WITH ALL ITS APPENDAGES; MOTHER AND CHILD 
STILL LIVING AND IN GOOD HEALTH, JANUARY 15, 1889. 
BY • 
JOSEPH EASTMAN, M. D., 
Professor of Gynecology, Central College of Physiciajis and Surgeons; Corresponding Mem- 
ber Philadelphia Obstetrical Society, etc. 
Mrs. C., age 39, bore one child nineteen years ago. Suffered from fre- 
quent paroxysms of intense pain and rapidly increasing abdominal enlarge- 
ment, since her flow stopped last Christmas. 
She was admitted to my private hospital on July 9th ; operation July 10th. 
Abdominal inspection and palpation showed tumor extending from near 
pubes upwards, and to the right reaching near liver. Conjoined manipula- 
tion disclosed uterus normal in size, well up between tumor and symphysis 
pubis. There was not less than three inches of fat between integument and 
tumor. I failed to detect sound of fetal heart. Breasts not enlarged. Very 
little discoloration around the nipple. 
Abdominal section revealed extra-uterine pregnancy, tubal variety. 
The tube seemed to have much of the right broad ligament surrounding 
its uterine attachment, as if the tube had been originally beneath the peri- 
toneal fold of the broad ligament. 
The sack containing the child was a dark purple and tore open easily on 
the touch of small forceps. 
Placenta was nearly under line of abdominal incision, yet I was enabled 
to open sac and extract child without detaching much of its tissue. 
Any manipulation of the sac caused hemorrhage. I determined at once 
to remove tube and placenta in mass, and began by separating an adherent 
intestine and then an adherent omentum, being compelled to use pressure 
forceps and ligate five times before I reached and surrounded the tube with 
my fingers. 
By this time there was free hemorrhage from the margins of placenta and 
tube. 
I applied Eastman’s clamp below my fingers around the neck of the sac, 
and found by this means I could so constrict as to arrest all bleeding ; then 
cut off above clamp, and using No. 14 iron-dyed silk, quilted the pedicle 
(which the c amp had made for me) with cobler’s stitch. 
I washed out the peritoneal cavity with pure water (temperature 105°) three 
times, put in glass drainage tube, and closed wound with silk-worm gut, and 
found to my great satisfaction that the patient had suffered little shock. Her 
highest temperature was 102°. 
Bowels moved on third day, and drainage tube was removed on fifth day. 
She is now surely convalescent, with normal pulse and temperature. 
The child is well and growing as nicely as any infant I have seen. I am 
under lasting obligations to Dr. A. W. Pattison and my faithful nurses, the 
Misses Prough (sisters), for their efficient assistance in the operation ; also 2 
Eastman : Intraligamentous Tubal Pregnancy. 
to Dr. J. F. Barnhill, for his skillful administration of ether. There were no 
others present at the operation, as “ in a multitude of counsel, there is safety1 
to the Counsellors, but not to the counseled.” Drs. Todd, Waterman and 
Elder, of this city, in addition to those present at operation, examined the 
tube and child, ail concurring in the belief that the child was eight months, 
and that the tube had not ruptured. 
The only similar case which I have been able to find is the following, from 
the Am. Jour, of Med. Sciences, Feb., 1888.1 The two cases referred to by J. 
JThe mother and child are, at this date, August 14th, in good health. 
Grieg Smith (second edition “Abdominal Surgery ”) are not parallel. In 
Jessup’s case, no tube was removed, and in Martin’s case, while the tube was 
removed, the child was moribund. 
“At a recent meeting of the Society of Physicians of Vienna, Breisky re- 
ported the case of a woman, aged 30 years, who had given birth to a living 
child six years previous to her extra-uterine conception. She suffered from 
peritonitis after confinement, and never had been free from pelvic pains. 
Extra-uterine conception was followed by chronic peritonitis; fetal move- 
ments were perceived at five months, when the pains lessened. Breisky 
diagnosed intra-ligamentous, tubal pregnancy. On examination by palpa- 
tion, the uterus could be felt, lying in front of the tumor. By vaginal ex- 
aminaton, the true pelvis was found to be empty, the vagina drawn toward 
the left. The tumor was at the right of the uterus, the fetal parts could be 
outlined, and the heart-sounds heard. 
“ The operation was performed at the end of eight months of pregnancy. 
After a central incision, the fetal sac presented in the wound; it was stitched 
to the abdominal wall by four sutures ; at its thinnest point, an opening was 
made, and the child was rapidly extracted. It weighed over five pounds, 
was asphyxiated, but was promptly resuscitated. The four flaxation sutures 
were then removed ; the sac was drawn out, ligated at its junction with the 
uterus, and removed. Externally the adhesions were but partially broken 
up, as the sac was adherent to the intestines and omentum. The sac, pla- 
centa, and membranes were removed, and the wound drained and sutured. 
The mother recovered perfectly in three weeks. 
“ The sac presented a considerable development of muscular tissue, and 
seemed mostly developed from the serosa; the placenta was large, and 
showed adherent lobules. 
“ Three weeks after delivery, the child died from inflammation of the um- 
bilical vein—a termination not to be ascribed to the operation. 
“ Breisky claims this is the first case of the successful removal of the living 
fetus, with all its appendages, in extra-uterine pregnancy. From the con- 
sideration of three cases previously operated upon by him, Breisky believes 
that in advanced cases of extra-uterine pregnancy, when the fetus lives, we 
should extirpate the entire sac. To await the formation of a lithopedion is 
not admissible, as perforation of the bladder or intestine, or septic infection 
may result.— Wiener rnedizinische Presse, No. 48,1887.” REMARKS ON PELVIC PERITONITIS, 
AND ON MY YEAR’S WORK IN ABDOMINAL SURGERY. (FORTY CASES.) 
From my experience of the past year, I feel warranted in emphasizing the 
importance of inflammations of the pelvic peritoneum, a disease very fre- 
quently overlooked, and more common than any other disease of woman’s 
pelvis. Pelvic cellulitis, according to the text-books, more frequently follows 
child-birth than pelvic peritonitis. Post-mortem examinations, and within 
the past few years abdominal sections, are making it more apparent that 
without some pre-existing peritonitis, the trauma of child-birth, and many 
other causes heretofore mentioned, would less frequently result in inflam- 
mation of the cellular tissues. Winckel found in thirty-three per cent, of 
of autopsies (for all diseases) well-marked inflammation of some portion of 
the pelvic peritoneum. Of live hundred and seventy-live post-mortem ex- 
aminations, the same author found in one hundred and eighty-two cases 
well-marked disease of the Fallopian tubes. This is an instructive state- 
ment, and should lead to the early and efficient medical treatment of salpin- 
gitis, which so frequently extends to other structures in consequence of the 
movements and periodical engorgement of the tubes. Nearly all post-mor- 
tem examinations of the chest show inflammation and adhesions of some 
portion of the serous lining. This being true, how much more likely 
would we be to find the results of inflammation in the serous covering of the 
female pelvis, a structure vastly more complicated anatomically, and physi- 
ologically much more abused. With a pathology until within the past few 
years little understood, therapeutics are vague and unsatisfactory. 
The sharp, stitch-like pains felt by young ladies before, during and after 
menstruation are, as in the chest, significant of more or less inflammatory 
adhesion of the serous covering of some portions of pelvic structure. The 
term pelvic peritonitis may be applied to a circumscribed spot, or signify 
“ co-existence of perimetritis, perisalpingitis,peri-oophoritis, pericystitis and 
periproctitis.” (Winckel.) 
The delicate silken membrane becomes opaque at first, and adheres to 
the same membrane nearest in contact; as the uterus, rectum, tubes, blad- 
der, each recurring attack strengthening and extending the adhesions. Se- 
rum poured out undergoes chemical changes, forming abscesses in the 
broad ligaments, between coils of intestines, and by its progressive work of 
destruction materially impairing functions, sometimes causing complete in- 
testinal obstruction, or again abscesses discharging into bowel, vagina, or 
through the external integument, seriously complicating ultimate cure. 
Causation.—Congenital defects may so retard, modify or complicate men- 
struation as to cause inflammation of the serous covering of the undevel- 
oped organ. The brain-cramming of our school system has much to answer 
for in retarding the development of the pelvic organs in young girls. 
Mr. Tait speaks of the eruptive fevers interfering with the proper develop- 
ment of the epithelial lining of the tubes. My limited experience furnishes 
several cases where abdominal section proved the existence of well-marked 4 
Eastman : Remarks on 
disease of the Fallopian tubes, the clinical history leading us unmistakably 
back to scarlatina which had so affected the epithelium of the kidney as to 
produce the well-known dropsical sequlae of that disease. Recently demon- 
strated facts show that the Fallopian tubes undergo important changes at 
puberty; they become more highly vascular, there is increased development 
of their longitudinal libers, and their mucous lining is covered with ciliated 
epithelium. Organs anatomically so complex as the Fallopian tubes surely 
have a susceptibility to disease far greater than has been heretofore believed. 
Let us emphasize, then, the important causative relations borne by febrile 
disease to arrest of development of the pelvic organs in girls, organs imper- 
fectly developed being vastly more susceptible to disease than those per- 
fectly developed. 
Saenger, of Leipsic, Noeggerath, of New York, and others, have empha- 
sized the importance of gonorrheal virus as a cause of pelvic peritonitis. I 
must dissent from the extreme views of these men; at the same time I often 
shudder for the marriageable young ladies, when I remember what a large 
per cent, of marriageable young men have suffered from gonorrhea and have 
been imperfectly cured, or rather not cured at all. Few of them consult 
competent experts, but, on the contrary, get some “clap mixture ” from a 
friend or druggist, ignorant of the fact that a skillful adaptation of a given 
remedy to the particular stage of the disease marks the measure of its suc- 
cess. In applying for a policy irr life insurance, the applicant must honestly 
state all the diseases he has had. If a false statement is made, the policy 
may be forfeited. Oh, that parents could secure from young men truthful 
statements as to all the diseases they have had, when they ask the hands and 
hearts of their marriageable daughters ! 
The teaching heretofore extant that gonorrhea in the female is less serious 
than in the male is wrong, and must be rewritten. I agree with Van Buren 
and Keyes who say “ gonorrhea sends more to the tomb than syphilis,” and 
let me add my belief that the same foul virus sends twice as many women 
to the grave as men. While the female urethra is less likely to suffer, the 
Fallopian tubes and ovaries furnish a secret lurking-place for the gonococcus, 
where its work of destruction is beyond the reach of remedial agents, at a 
stage of the disease when total annihilation could be hoped for. Means used 
to prevent conception, especially cold-water injections used after coition, 
cause many cases of tubal and ovarian inflammation. Induced abortion also 
produces much disease and many deaths from peritonitis. 
Treatment.—Opium is the remedy in the beginning. It should not be con- 
tinued in chronic cases, for fear of “ the opium habit.” Hot applications 
over the lower part of the abdomen, combined with hot antiseptic vaginal 
douches, with a Hildebrandt douche, this instrument enabling us to use 
water ten or fifteen degrees hotter than can be borne by the external parts, 
while it carries off the water without the aid of the bed-pan. It was not my 
purpose, however, to speak of treatment, except in the advanced stage of the 
disease, and by surgical means. 
In case where each recuring menstrual period rekindles the inflamma- Pelvic Peritonitis. 
5 
tion, Battey and Tait have suggested the removal of the uterine appendages 
to relieve the pelvis of its periodical congestion, by bringing on the meno- 
pause. This is undoubtedly a warrantable operation in some cases, when all 
other means have failed. Some argue that the operation is being done too 
often. My limited experience induces me to believe that, where the uterine 
appendages have been unnecessarily removed once, ten women bave gone 
down to the grave whose lives could have been saved by timely removal of 
the appendages, if the same were done by skillful hands. 
Let those who condemn salpingo-o<>phorectomy carefully consider the fol- 
lowing propositions, using anatomical, physiological, pathological, and thera- 
peutical common sense in so doing. If the ovaries and Fallopian tubes 
could, like the male testical and epididymis, descend during early life, and 
remain within reach of poltices, iodine, suspensory bandages, etc., and if 
they were free from the regular monthly engorgement which all the pelvic 
organs are subject to, they, too, might be relieved of congenital defects, phy- 
siological abuses, the destructive sequelae of mumps, the fevers of childhood, 
and the pernicious gonorrheal virus, before disorganization had so far ad- 
vanced as to warrant their removal. When inflammation has gone on to 
suppuration, whether pus has been discharged by the rectum, vagina, or not, 
the treatment instituted by Mr. Tait is a valuable means of cure, namely, 
opening the abdomen, draining the abscess (whether in broad ligament or 
between coils of intestines) from its fountain source, stitching peritoneal 
margins of abscess to abdominal wound, and putting in a drainage tube. 
There are many such cases with pus discharging from the rectum, or cul-de- 
sacs of vagina, safely curable by this method of treatment. I must say, 
after some experience in this method of treatment, that I prefer it to 
either plunging in a bistoury or trocar high up, or dilating vagina or rectum, 
and dilating the sinus even if the same is in reach, which it frequently is 
not, for the important reason that the former treatment in expert hands is 
less dangerous. Martin’s method of drainage through Douglas’ pouch may 
be more suitable in some cases. 
CASES. 
Case I.—Pelvic abscess originating from pelvic peritonitis, communicating ivith 
rectum. Over one quart of fetid pus removed from broad ligament at time 
of operation. Abscess sac stitched to wound. Glass drainage tube. Cure in 
seven weeks. Dr. A. W. Patterson was present at operation. 
Case II.—Abscess had been discharging by rectum. A pint of puss removed 
at operation. Abscess sac stitched to abdominal wound. Recovery perfect 
in five weeks. Dr. L. L. Todd present at operation. 
Case III.—Chronic peritonitis following severe colic. Abdominal cavity filled 
with inflammatory products, uniting the large and small intestines, in many 
places, into one common mass. Complete intestinal obstruction for six days. 
Separated adhesions of bowels, removing large quantities of pus from be- 
tween coils of bowels. Drainage. Abscess sac stitched to abdominal wound. 
Recovery complete. Dr. J. F. Barnhill was present at operation. 6 
Eastman : Remarks on 
Case IV.—Chronic salpingitis and ovaritis, appendages firmly adherent to 
broad ligament. Disease of thirteen years’ duration. Removed appendages, 
used drainage. Patient says she “ feels better than for a dozen years,” and 
has gained twenty-five pounds in weight. Dr. C. S. Boynton present at 
operation. 
Case V. —Extensive chronic peritonitis. Age 42. Abdomen nearly as much 
distended as at full term of gestation. Five pus cavities between the coils 
of intestine contained in all a quart of pus. Two cavities communicated 
by a common opening with sigmoid flexure of colon, through which pus had 
been discharging since last March. Separated adhesions in some places eignt 
inches long. Abscess sac stitched to wound. Washed out cavity, peppered 
freely with iodoform, put glass drainage into sinuous opening, well down 
into colon. There were fecal discharges through drainage tube, and for sev- 
eral weeks after its removal. Patient cured returning to home Worthington, 
Ind., December 17th, 1887. Dr. L. P. Mullinix, of Worthington, present at 
operation. 
Case VI.—Large pyo-salpinx. Age 80. Patient lived twenty miles from city, 
and could not be brought to hospital. Pelvic peritonitis involving ascend- 
ing colon, bladder, uterus, and numerous knuckles of intestine. Organs 
named were massed together as one, producing complete obstruction of 
bowel. Operation one of emergency. Separated enough adhesions to re- 
lieve obstruction, bowels afterwards acting freely. Death from shock in 
twenty-four hours. Disease of six months’ duration. Earlier operating 
would, perhaps, have saved life, as patient was much reduced by long-con- 
tinued vomiting. Dr. H. S. Herr, of Westfield, present at operation. 
Case VII.—Peritonitis, extensive cobweb adhesions on nearly all pelvic organs, 
distending abdomen as much as a fifteen pound ovarian cyst. Separated adhe- 
sions, letting out as much as three pints of pus from the different cavities 
formed by adherent bowels. Recovery. Dr. A. W. Patterson present at op- 
eration. 
Case VIII.—Pelvic peritonitis involving all pelvic organs Three sinuous 
openings in and near rectum, and one in vagina. Opened abdomen at night 
by coal oil lamp (being » n emergency case). Drained cavity in broad liga- 
ment. Patient recovered. Dr. J. E. Morrow assisted. 
Case IX.—Removal of ovaries and tubes for dysmenorrhea, which had been 
accompanied by most excruciating cephalalgia. Patient had been in insane 
asylum for a year. Tubes sharply flexed and firmly held by contracting 
bands of inflamed peritoneal covering of tube and broad ligament; conse- 
quently tubes were immoveable, and absolutely impervious. Patient re- 
covered from operation and is now sound mentally. Dr. A. Maxwell was 
present. 
Of the forty abdominal sections made during the year ending May 10th, ’88, 
in nine cases the pathological condition found had originated in pelvic peri- 
tonitis ; hence the title of the paper, and the comments on pelvic inflamma- 
tion. 
Of my total year’s work, sixteen sections were for abdominal tumors. Of 
this number four were for fibroids of the uterus weighing five, seven, and 
eight pounds respectively. One for fibroid of the ovary weighing six 
pounds. The remaining sections were for cystic and fibro-cystic ovarian 
tumors. Pelvic Peritonitis. 
7 
In a number of these eases, the tumors were large with extensive adhe- 
sions, notably one woman, whose weight in health was ninety pounds, 
traveled here from Oskaloosa, Iowa, with a cyst, which together with its 
contents weighed fifty-two pounds, adherent to entire anterior surface of 
abdomina wall as high as the liver on the right and the spleen on the left, so 
that absolute flatness on percussion was continuous with the organs named. 
First noticed tumor six years ago. She made a complete recovery, though I 
removed more than one-third of the combined weight of woman and tumor 
She had been tapped several times, the last tapping nearly proving fatal. In 
another case, the cyst and contents removed by tapping at the time of opera- 
ting, and ten days before, weighed seventy-five pounds, the tumor being ad- 
herent to abdominal parietes and omentum. Patient could not be removed 
to my hospital, so I took an experienced nurse and operated at her home in 
Martinsville, Ind. She made a complete recovery, although she could not 
have weighed over seventy-five pounds after the removal of the seventy-five- 
pound tumor. 
Two of my sections were cholecystotomies. Eight were for pelvic absces- 
ses. Three were exploratory incisions, finding cancer in two of the cases. 
Ten sections were for removal of the uterine appendages in pelvic inflam- 
mation and other causes. One section was for hernia. 
I have had three deaths from abdominal section during the year. One al- 
ready reported. The second was an exploratory incision in a patient with 
forty pounds of fluid in the abdominal cavity, a ruptured ttyst of left ovary, 
and well-marked mitral regurgitant murmur over heart. The fluid continued 
to pour out through drainage tube, patient dying seventy-two hours after op- 
eration. exhausted from the drain, and failure of the crippled heart. In the 
third case, a ruptured cyst with fifty pounds of fluid were found in the per- 
itoneal cavity. Patient was in a hectic condition, vomiting for several weeks. 
Stomach retained fluid food after operation. She suddenly died from heart 
failure twenty-four hours after operation. This woman had taken over one 
hundred bottles of “ Warner’s Safe Cure,” hoping thereby to remove her tu- 
mor! I saw the empty bot'les in the backyard. Shall we not, in view of 
such cases in the State of Indiana, continue our missionary work of publish- 
ing cases to the end that we may convince practitioners, and they their 
patients, of the advantages of early operating, and the dangers and deaths 
from delay ? 
These forty cases, added to twenty-five reported to the Indiana State Med- 
ical Society last year, make a total of sixty-five. In my twenty-five cases 
reported last year, I reported five deaths, twenty per cent, of mortality. 
This year, in forty cases, three deaths or seven and one-half per cent, mor- 
tality. From July 18th, 1885, to October 27th, 1887, I opened the, abdomen thirty- 
four times consecutively without a death. If by this showing some good woman’s 
life (perchance a mother’s) shall be saved by abdominal section, that other- 
wise, fearing the operation, would have delayed until there was no hope, the 
author will feel that the apparent self-glorification in this report is excusable.