[Extracted from the American Journal of the Medical Sciences for January, 1876.] 
TUBO-UTERINE OR INTERSTITIAL PREGNANCY. 
R. H. FITZ, M.D. 
(Read before the Boston Society for Medical Observation.) 
[with two wood-cuts.] 
Cases of interstitial pregnancy are so rare that each specimen which 
might suggest itself as one of this class should receive the most careful 
attention. This becomes all the more necessary as the criticism of pre- 
viously recorded cases, by subsequent observers, shows that the term has 
been loosely applied in many instances, especially to the earlier cases, 
though some of those more recently reported have been found equally open 
to the same charge. The very term suggests the seat of the ovum within 
the muscular structure of the uterus, and an empty uterine cavity with an 
adjoining, even a neighbouring sac, have often suggested the idea to be 
maintained. Such a specimen being thus named, theoretical explanations 
were hastily sought for, as that of Breschet, who suggested that the egg 
must have made its way into the open mouths of veins in the mucous 
membrane lining the cavity of the uterus; or that of Cazeaux, who could 
imagine a bifurcation of the Fallopian tube within the uterine wall, or a 
passage of the ovum into the canal of Gartner. 
An anatomical basis for the first of these conditions has never been 
observed, and, as the existence of the latter near the fundus of the adult 
human uterus may well be doubted, better grounds are required. Even 
did Gartner’s canal remain permanently open, it would be difficult to 
imagine the presence of the ovum within it, but such a possibility being 
granted, the anatomical relations with the adnexa of the uterus would be 
such that the question of tubal pregnancy rather than the interstitial form 
would have to be considered. 
Of the various forms of extra-uterine pregnancy the present may be 
considered the rarest. English authors have generally made use of the 
terra interstitial, supposing the ovum to have developed within the uterine 
wall. The term tubo-uterine implies primary development within the 
tube, and is of more general application. 
1 2 
The theories of origin previously alluded to being unsatisfactory, what 
should cause the detention of the ovum in its passage to the normal nidus ? 
Psychical causes have been imagined, as surprise during coitus, fear of 
surprise, or fear as to the result. Burdaeh and Lallemand1 have recorded 
three such cases, where the inference seemed justifiable to them. 
More clearly established mechanical causes are sought for than a mus- 
cular paralysis thus brought about, or a cessation of ciliary movements so 
produced. Observation and analogy find many such obstructions to the 
passage of the ovum, such as might be produced by strictures from within 
or without, or from pellets of mucus in the tube. The first thought would 
be that similar conditions should prevent impregnation. Yet this might 
not necessarily follow. Litzmann3 suggests that exfoliation of the ciliated 
epithelium would hinder the onward movement of the egg. That such a 
condition should result from inflammation of thd lining membrane of the 
tube seems quite plausible, and might be considered in a case of simple 
tubal pregnancy. But to permit tubo-uterine gestation the ovum must 
reach that portion of the canal intervening between the cavity of the 
uterus and the insertion of the tube into its wall. The catarrhal process 
which should affect the one part of the tube would be very likely to act 
upon the other. A too rapid growth of the ovum has also been suggested, 
ulcers, and swelling of raucous membrane of the tube, etc. In short, the 
ingenuity of the individual observer has been taxed to account for what 
is now generally considered to be the result, the detention of the impreg- 
nated ovum within that portion of the tubal canal seated within the mus- 
cular wall of the uterus. It would seem of trifling importance whether 
the uterine openings were closed early or late; that such may eventually 
occur, and in the indisputable cases must occur, is evident. Klebs3 would 
explain this occurrence by demanding a diverticulum communicating with 
the tube in which the ovum must lodge. 
Hecker* and Baart de la Faille5 have collected the cases of this curious 
condition, in part, for the purpose of educing such influences as might be 
suggested by comparison. Hecker’s paper appeared in 1859, up to which 
time he states that twenty-six cases had been published. Baart de la Faille, 
in 1861, eliminates from this series ten, which he considers incorrectly 
classified, leaving only sixteen to which the term could be properly applied. 
To these he adds one by Junge,6 an,d another observed by himself.7 A 
third is described by Poppel8 in 1868, who also calls attention to the case 
1 Czihak, Scanzoni’s Beitrage, vol. iv. p. 75. 2 Czihak, loc. cit., p. 77. 
3 Handbuch der Path,. Anat., p. 909. Berlin, 1873. 
4 Monatsscbr. f. Gebskde., xiii. 98. 5 Ibid., xxxi. 459. 
6 Ibid., 1865, xxvi. p. 241. 7 Loc. cit. 
8 Monatsscbr. f. Gebskde., xxxi. 208. of Schultze,1 in all twenty cases. Since this time Hicks,2 Lott,3 Edgar,4 
and Malraburg,5 have recorded cases where post-mortem examinations have 
been made. The last three cases, as reported, are not freed from the possi- 
bility of error in judgment. Twenty-one cases then remain, from which 
Yomdorfer’s6 maybe eliminated as suggesting the probable retention of the 
foetus in the uterine cavity. Further, Poppel is inclined to omit the cases 
of Schultze and Baart de la Faille from the list. Eighteen cases, with 
the present, nineteen, include those which have thus far been recorded, and 
to which the term may be unquestionably applied. The necessity for so 
much elimination indicates the difficulties in the way of diagnosis—a point 
which will be spoken of at greater length hereafter. 
Through the kindness of Dr. A. T. Davison, of South Boston, in 
whose practice the following case occurred, and who has generously pre- 
sented the accompanying specimen to the college museum, also through 
the politeness of Dr. M. F, Gavin, who has furnished me with an account 
of the autopsy, I am enabled to record this additional case. 
Dr. Davison writes : 
“Mrs.— , ast. twenty-six, is the mother of one child, aged six years. 
She has never had miscarriages, and has enjoyed good health until April, 1873, 
with the exception of vague pains in the right side for the past two years. 
“ Her first labour was very severe, lasting two days ; a uormal convalescence 
resulted. She considers herself to have become pregnant early in April, from 
the condition of the catamenia, and the subsequent occurrence of vomiting, 
together with pains referred to the right iliac region. This pain has been more 
or less constant since the time of supposed impregnation. Menstruation did 
not absolutely cease in April, a slight ‘show’ occurring at this time as well as 
in May. 
“My first visit was made June 15, 1873. She was lying upon her back in bed, 
the face flushed, knees drawn up, and an expression of agony depicted on her 
face. She stated that she had been suffering excruciating pains in the uterus 
for two hours previous to my arrival, and considered that a miscarriage was 
taking place. 
“A vaginal examination being made, there was no dilatation of the os, nor 
flowing, a slight degree of enlargement of the uterus alone being ascertained. 
“ Sulphate of morphia was ordered to be given at intervals of one hour till 
her pain should be relieved. 
“The following morning I again saw the patient. She occupied the same 
position as at the previous visit, and begged not to be moved. Pulse 100. 
She stated that after three doses of the medicine, each of one-fifth of a grain, 
she was relieved, and rested well during the night. At 7 A. M., while at- 
tempting to rise, the pain returned in the same place, and more severe than 
ever. She took two doses of the morphia, relief being obtained immediately 
before my visit, at 10 A. M. Five hours after I again visited her. 
“ She had not suffered from pain during the interval, but I found an extreme 
pallor of the face and lips, and a condition of marked collapse. 
“The stomach refusing to retain anything, I gave an injection of brandy. 
She sank rapidly, however, and died soon after, twenty-seven hours from the 
beginning of her symptoms. 
1 Wurzburg. Med. Zeitschr., iv. 1863, p. 178. 
2 Trans, of Obslet. Soc. 1868, p. 57. 
3 Sitzb. d. Ver. d. Aerzt. in Steirmark. 
4 St. Louis Med. and Surg. Journ. 1871. 
6 Oest. Jahrb., Jan. 1848. Scanzoni’s Beitr. 4, 107 
5 Hygeia, 1871, p. 436. 4 
“ Suspecting the case to be one of interstitial pregnancy, I obtained permis- 
sion for the autopsy, which was made seventeen hours after death. 
“ Dr. Gavin states: ‘ Body well nourished but exceedingly pallid. Rigor 
mortis well marked. The abdomen slightly swollen. The peritoneum trans- 
parent and free from all signs of inflammation. Its cavity filled with clotted 
blood, of recent origin, intermingled with the small and large intestines. A 
large quantity of dark-coloured, liquid blood filled the pelvic cavity. In all six 
tin basinfuls of fluid and clotted blood were removed before the organs were 
examined. 
“ ‘The stomach, intestines, spleen, liver, kidneys, and bladder were free from 
morbid changes. The other organs were not examined. I send the uterus 
and appendages.’ ” 
I received the specimen in admirable condition on the following day, 
Fig. 1. 
The uterus was considerably enlarged, more or less kidney-shaped (see 
Fig. 1); apparently composed of two portions; the upper oval, rather 
larger than a hen’s egg, inclined to the left, the lower presenting the 
general appearance of a uniformly enlarged nterus. On the right the dis- 
tinction between the two portions was distinctly marked, on the left, how- 
ever, there was merely a continuous surface and border. The peritoneum 
was continuous over the two portions, the muscular wall seemed also con- 
tinuous, there being no line of demarcation. The cervix elongated and 
hypertrophied, the os externum open, appearing as a transverse slit. The 
lips enlarged. At the extreme upper portion of the mass, towards the 
posterior surface, a circular hole existed nearly one-half of an inch in dia- 
meter, the edges jagged, everted, exceedingly thin. Directly beneath this 
opening there was seen a foetus (the back) inclosed within the membranes 
(see Fig. 2) ; also several villous masses. The peritoneal surface in the 
immediate vicinity of this opening was injected and covered with a delicate 
false membrane. 
The relation of the Fallopian tubes and ligaments to the uterus was 
striking. They were attached much higher on the left side than on the 
right, to the upper third. On the right side they were united at the junc- 
tion of the middle and lower thirds of the mass. 
The insertion of the left round ligament was at the outside of the uterus 
and foetal sac, separated at this point from the insertion of the Fallopian 
tube by a space of one and one-quarter inches. The corresponding dis- 
tance on the left side was three-quarters of an inch. 5 
The organ was exceedingly pale, containing but little blood ; numerous 
fibrous adhesions were formed about the ovaries and tubes, especially on the 
right side. In the left ovary a recent corpus luteum was found. 
Fig. 2. 
Before the uterus was opened the following measurements were taken. 
The length of the entire mass, inches; the shortest distance between the 
attachments of the Fallopian tubes, 5 inches. The left tube stt inches 
long, the right, 6 inches. The left ovarian ligament 1 inch, the right, fl- 
inches in length. 
The greatest transverse diameter of the uterus, 4 inches. From the 
middle of the anterior lip of the uterus to the attached portion of the 
right tube, 4 inches ;to that of the left, 5f inches. These are to be under- 
stood as surface measurements. The organ was opened from behind by a 
longitudinal incision extending to the fundus of the uterus, from the ter- 
mination of which two lateral cuts were made in the direction of the 
attachments of the Fallopian tubes ; that to the left passed directly over 
the foetus, which was found enveloped in the membranes. 
The uterus was seen to be considerably enlarged and symmetrically so, 
excluding the portion containing the foetus. The cervical canal, inches, 
the uterine cavity inches long. From the inner opening of the right 
tube to the foetal membranes, at a right angle, to the longitudinal axis of 
the uterus, inches. The greatest thickness of the uterine wall was f 
of an inch. The length of the ovum, inches. The lining membrane 
of the uterus was very much swollen, pale, and soft. The surface 
roughened, often folded, velvety. The cervix contained a viscid hyaline 
mucus, the arbor vitae indistinct. 
The uterine wall about the foetus is less than two lines in thickness, 
moderately translucent. That portion intervening between the uterine 
cavity and the membranes was composed of spindle-shaped muscular cells, 
and contained numerous venous sinuses. 
The wall of the foetal sac was made up of involuntary muscular tissue, 
and large veins, sinuses, were cut across in making the section previously 
spoken of. The inner surface of this wall was roughened, connected here 
and there with the chorion by villi. Nothing resembling a decidua was 
observed. 
The posterior surface of the chorion was bald, elsewhere bearing nume- 
rous villous tufts. The head of the foetus was directed towards the ute- 6 
rine cavity, in the direction of its breech, the inner opening of the tube. 
The size of the foetus corresponded with that of one of ten weeks. Clotted 
blood was found between the villi in the immediate vicinity of the hole in 
the uterine wall. 
The canal of the extra-uterine portions of both Fallopian tubes patent. 
The left terminated abruptly at its union with the uterus, this end being 
slightly dilated. 
The innermost portion of the left tube was opened from the uterine 
cavity. It was found to be an inch in length, apparently terminating in 
a fibrous cord, intimately connected with which were several villi. 
The course of this portion of the tube was upwards and outwards, in that 
portion of the uterine substance lying above the foetus. The inner, lowrer 
portion of the wall was exceedingly thin, continuous with the foetal sac. 
The distance between these two ends of the intra-uterine portions of the 
tube was 2 inches. The lining membrane of the tube, intra- as well as 
extra-uterine, was homogeneous, smooth, and shining, without a trace of 
decidua. 
In the majority of instances of this curious anomaly hitherto reported, 
the foetus has been found outside of its sac. An additional interest is 
therefore derived from the present specimen, and too detailed an examina- 
tion could hardly be made. That the diagnosis is not without difficulty, 
has already been shown by the necessity of elimination in the previously 
recorded observations. 
The question would arise whether this might not be a case of tubal 
pregnancy, or one occurring in a rudimentary horn ? An argument in 
favour of the former view might be derived from the fact that the tube on 
this side was shorter, by one-half an inch, than its fellow. It is to be 
remembered, however, that a like dissimilarity exists with regard to the 
ovarian ligaments. It is also well known that such relations often exist, 
in many instances to be attributed to conditions occurring during foetal 
life, deviations of development. Pathological changes might be offered 
as an explanation were it to be considered that the irregularity occurred 
after birth. Evidence of such is lacking. 
Positive testimony against the view is derived from the evident conti- 
nuity of the uterus and the foetal sac, and the presence of muscular tissue 
in the latter, also from the relations of the round ligament. Hyrtl has 
shown that this is a true prolongation of the uterus, and Kussrnaul1 
has called attention to the necessity of its being between the uterus and 
the foetal sac in tubal pregnancy, while in interstitial pregnancy it would 
arise from the surface of the sac, at the outside, as in the present instance. 
So simple as this means of differential diagnosis may seem, it is yet uni- 
versally conceded as sufficient. 
Why, then, is this not an impregnated rudimentary horn? 
In a uterus of this character one might expect to find evidence of ir- 
1 Yon dem Mangel, der Verkmnmerung und Verdoppelung der Gebarmutter, etc. 
Wurzburg, 1859. Poppel, loc. cit., p. 209. regular development as regards the shape of the uterus, the insertion of the 
ligaments, indications of an incomplete septum, all of which are lacking. 
The cavity of the uterus is apparently normal, the ligaments are sym- 
metrically attached, making due allowance for the presence of the ovum. 
The walls of the uterus too are symmetrically thickened. Of greater 
weight is the evidence furnished by the examination of the Fallopian tube. 
The inner end, very much elongated, is found to be directly continuous 
with the uterine cavity, and to pass outwards in the tissue of the uterus, 
forming the envelope of the foetus. Hence one has the cavity of the 
uterus entire, with its two Fallopian tubes symmetrically communicating, 
and in the proper position. Of equal value is the appearance of the 
lining membrane of the right tube. Poppel1 has previously called attention 
to this point, one which is of like importance with the relations of the 
round ligament. When pregnancy goes on in the uterus bicornis, the 
decidua formation takes place as in the usual conditions. At least such 
is probably the case, for Kloba states that in most, if not in all cases of 
pregnancy in the one horn, the raucous membrane of the other is likewise 
developed as a decidua. 
The same author states3 that in tubal pregnancy a true decidua re flex a 
does not occur, though the mucous membrane becomes developed into folds, 
apparently for the reception of the villi. Should a decidua of this char- 
acter form it must rapidly disappear, as neither in the case of Poppel nor 
in the present one does any evidence of such exist. 
Further, that portion of the tube to be distinctly recognized as such, 
bears a membrane in no way differing in appearance from that occurring 
in the unimpregnated conditions. 
It can be easily seen that the openness of the uterine end of the tube 
lessens this difficulty, as in the more obscure cases of foetation in a rudi- 
mentary horn no communication with the uterine cavity exists. 
This observation can be regarded as applying alone to that portion of 
the tube lying within the uterine wall, as a decidua has been noticed in 
connection with tubal pregnancies, and Scroeder4 agrees with HennigHhat 
the tube may form a dense decidua. 
Klob9 speaks of the presence of a peritoneal fold in uterus bicornis, ex- 
tending from the anterior wall of the rectum, between the two halves of 
the uterus, to the fundus of the bladder. This fold has been previously 
noticed, and should be sought for in cases of suspected interstitial preg- 
nancy. Nothing of this nature is to be seen in the present specimen. 
1 Loo. cit., p. 215. 
2 Path. Auat. der Weibl., Sexual Organs, p. 31. Wien, 1864. 
3 Loc. cit., p. 524. 
4 Lelirb. d. Geburtshulfe, p. 211, Bonn, 1871. 
8 Monatsscbr. f. Geburtskde. 33, p. 265. 3 Op. cit., p. 31. 8 
Baart de la Faille1 has deduced, from the comparison of the seventeen 
cases collected by himself, that the pregnancy occurred nine times on the 
right side. In eleven of the cases the women had previously borne chil- 
dren. A fatal termination occurred in all; in two between six and twenty- 
four hours; in five after twenty-four hours. The duration of the preg- 
nancy was— 
6 weeks ...... in one case 
8“ “ “ 
10-12 “ “six cases 
16 “ “ one case 
Longer than 16 weeks . . . . “ five cases. 
The fatal termination in the vast majority of cases results from rupture 
of the sac and hemorrhage—the latter usually intra-abdominal. Hicks’s 
case shows that the foetus may be expelled through the natural passages, 
a communication between the uterine cavity and that of the sac being 
established. 
Much more frequently, however, the foetus escapes into the abdominal 
cavity, its subsequent history not differing from that of other forms of 
extra-uterine pregnancy. The difficulty of diagnosis during life is so 
apparent that the expediency of operative measures would be governed by 
similar rules to those applied to ordinary cases of abdominal pregnancy. 
An opening in the sac might be made from the peritoneal cavity or from 
that of the uterus. The condition of the wall between the sac and the 
uterus would suggest the probability of dangerous hemorrhage were it 
opened. Expulsive efforts on the part of the sac might be attended with 
rupture of the exceedingly thin wall and subsequent intra-abdominal hem- 
orrhage, as occurred in the case reported by Hicks. 
This result would not militate against perforation from within, as rup- 
ture may have taken place before the communication with the uterine 
cavity had been made. A further method of operation has been suggested 
by Friedreich,2 and successfully carried out by him. Having established 
the diagnosis of tubal pregnancy, he made repeated injections of mor- 
phia into the sac by means of the subcutaneous syringe, with the hope 
of destroying the ovum. A favourable result followed; the tumour dimin- 
ished in size, and the patient left the hospital well. The diagnosis, un- 
fortunately, was inferential, formed by exclusion ; the result of the method 
of treatment, however, was most satisfactory. 
1 Loo. cit., p. 463. 
2 Virch. Arch., xxiv. p. 312.