A CLINICAL CONTRIBUTION 
TO THE 
TREATMENT 
OF 
TUBAL PREGNANCY. 
BY 
T. GAILLARD THOMAS, M. D. 
NEW YORK: 
D. APPLETON AND COMPANY, 
54 9 & 551 BROADWAY. 
1875. A CLINICAL CONTRIBUTION TO THE TREAT- 
MENT OF TUBAL PREGNANCY. 
No condition which develops itself in connection with ges- 
tation is attended by greater or more inevitable dangers than 
that in which the impregnated ovum attaches itself to tissues 
outside of the uterus. The vast majority of women thus af- 
fected lose their lives from sudden rupture of the vicarious 
uterus in which the foetus exists, while others, after passing 
through long periods of suppuration and discharge of the foe- 
tal remains, die from exhaustion or the absorption of septic 
elements. It is true that a certain number have recovered, 
but none have done so without exposure to very imminent 
risks, and generally after prolonged suffering. 
Authors have apparently vied with each other in dividing 
and subdividing this abnormal development into varieties sub- 
ordinated to the exact position in which it occurs, some making 
even as many as ten of these. After careful examination of every 
case of extra-uterine foetation to which I have had access, I am 
unable to substantiate the position, and yet I feel inclined to 
believe that, in the commencement of its development, the im- 
pregnated ovum never attaches itself to or draws its nourish- 
ment from any other parts than those lined by the mucous 
membrane of the uterus or tubes. Knowing as we do the 
delicate and subtle connection which the chorion establishes 
with the maternal tissues, it is certainly difficult to believe 
that an impregnated ovum, falling free into the peritoneal cav- 
ity, or detained within the Graafian vesicle, can, with parts 
so unlike the lining of the uterus, establish relations almost 
identical with those which are normal. Velpeau and others 
have warmly contested the validity of ovarian pregnancy. One 
recent author, in sustaining it, mentions as a ground for it the 4 
fact of the foetal ball being covered by peritonaeum. As it has 
been demonstrated that the ovary is not covered by perito- 
naeum, this argument loses much of its force, and a resort to it 
shows how much in want of proof the position really is. Even 
the presence of the fibrous tunic of the ovary around the ovum 
could be simulated by an envelopment by the flattened organ, 
somewhat like that of the decidua reflexa in the uterus. 
It is certainly possible that an impregnated ovum, caught 
in the fimbriae of a tube, could develop between tube and 
ovary, flattening the latter, and in time attaching itself to it, 
so as to give many of the appearances of ovarian pregnancy. 
This Velpeau claims to be the true explanation of cases reported 
as ovarian. In the same way, the fimbria attaching tube to 
ovary being broken, the latter, holding in its grasp the impreg- 
nated ovum, may fall into the peritoneal cavity, where the 
vascular chorion soon establishes a firm connection with the 
peritonseum or omentum, rendering the tubal relation entirely 
insignificant. 
Interstitial pregnancy is, of course, only a variety of tubal 
pregnancy, that part of the tube being involved which passes 
through the uterine wall. 
It may be said that all this is unproved. To this I would 
reply that the usually accepted theories are by no means sat- 
isfactorily settled; that the view here advanced is far more 
rational and in accordance with physiological laws; and that 
it is offered entirely in the character of a suggestion for future 
investigation. 
With these prefatory remarks, I will now proceed to relate 
the following case, which has called them forth : 
On the 4th of February, 1875, I was requested to visit 
Mrs. C., in Elizabeth, N. J., in consultation with Drs. Green 
and Crane, of that city. I found the patient to be a refined 
and educated lady of thirty-two years of age, of medium 
height, who, up to three weeks before the date above given, 
had enjoyed excellent health. 
The history given me of her existing illness was the 
following: on the 25th of October Mrs. C. had menstruated 
for the last time, and within three weeks from that date the 
gastric symptoms of pregnancy had shown themselves. About 5 
the 24th of November a very slight discharge of blood took 
place from the vagina, but neither in duration nor char- 
acter did it resemble the menstrual flow. From this time 
until three weeks before I saw her, all of the symptoms of 
pregnancy had gradually developed themselves, and the pa- 
tient, who had been sterile during a married life of six years, 
had believed herself to be now really pregnant. 
About the 15th of January, during the night, the patient, 
who for some days before this had experienced some uneasi- 
ness in the left iliac fossa, was awakened from sleep by a severe 
" cramp " in this region. In a short time this increased to a 
pain which became agonizing in character, and Dr. Crane was 
sent for. He found her suffering so severely that the forehead 
was bathed in perspiration, the pulse small and rapid, and the 
countenance pinched. Only after the free and repeated use 
of morphia subcutaneously, was this attack relieved. On the 
next day the patient was free from this paroxysm, but felt a 
great deal of soreness over the left iliac fossa, and this part 
was tender to the touch. During the next five days this state 
of things continued, and at the end of this time another par- 
oxysm of severe pain occurred which, like the first, was re- 
lieved by the free hypodermic use of morphia. 
After this attack the patient was not again free from pain 
until I saw her, and was most of the time confined to her 
bed and kept under the influence of morphia, which was re- 
peatedly injected hypodermically. At intervals of several 
days the severe attacks of pain which I have described would 
come on, and last for five or six hours, passing off under the 
influence of morphia used as above mentioned. 
Upon my visit at 4 p. m. on the 4th of February, I found 
that Mrs. C. had had, in all, five paroxysms of pain, and was 
never entirely free from suffering. So great was this when she 
walked across her room, which she did very rarely, that she 
would bend the body sharply forward to avoid putting the 
abdominal muscles into a state of tension. During the three 
weeks of suffering which I have described, she had become 
emaciated, the eyes were somewhat sunken, and below them 
were dark semicircles. She was somewhat under the influ- 
ence of morphia, and felt no great pain when she kept per- 6 
fectly quiet. Her mind was, however, greatly disturbed by 
the fear of the recurrence of what she termed " the cramp." 
The temperature w'as at this time normal, the pulse small and 
quick, the appetite almost abolished by the persistent use of 
morphia, and the bowels very much constipated. 
A physical examination revealed the following state of 
things: the uterus appeared somewhat enlarged to conjoined 
manipulation, measuring three and a half inches from the os 
externum to the fundus, was in the position of right oblique 
anteversion, and was not so movable as normal; the vagina 
was soft, elastic, and enlarged as it is during pregnancy ; to the 
left of the uterus I found, by vaginal touch, a tense, elastic cyst, 
which filled the whole iliac fossa, pressed the uterus to the 
right, and extended downward as low as a point a little below 
the os internum. Upon conjoined manipulation this cyst was 
found to be as large as the uterus in the third or third-and-a- 
half month of pregnancy. It was sensitive to the touch, 
slightly movable upon upward pressure, and, upon carefully 
practising ballottement upon it, I could feebly but distinct- 
ly get the evidence of a very light body w'hich was thrown 
upward and fell upon the floor of the sac. No doubt existed 
in my mind as to the recognition of this fact, and it was only 
after its recognition that I ventured to probe and measure the 
uterine cavity. Upon it I based the diagnosis which I then 
made of left tubal pregnancy at the end of the third month 
of development. 
From the period of pregnancy, the repeated attacks of 
severe paroxysms of pain, the tenderness upon pressure, and 
the apparent tenseness of the distended sac, I was convinced 
that the occurrence of rupture was imminent, and urged im- 
mediate surgical interference. The husband and relatives of 
the patient were naturally very greatly perturbed at the an- 
nouncement which I made, more especially since I was unable 
to hold out any bright prospect of recovery, even if operative 
procedure were resorted to. 
On the 5th of February, one day after my visit, Dr. Marion 
Sims went out to see the patient; on the 6th Mr. C. called to 
request me to act as my judgment dictated in reference to the 
case; and on the 7th I performed the operation, which I now 7 
proceed to describe. On Sunday, the 7th, in company with 
Drs. J. E. Blake, J. B. Hunter, and S. Beach Jones, I went 
to Elizabeth, prepared to remove the foetus by elytrotomy. 
The weather was intensely cold, the thermometer being at zero 
in Elizabeth. At the house of the patient we were met by Dr. 
Crane, Dr. Green being detained by a case of midwifery. 
Before detailing the treatment of this case, I would remark 
that few cases of extra-uterine pregnancy have, during their 
early and progressive stages, been brought to a favorable con- 
clusion by surgical means. For this there are four good 
reasons: 1. The doubt which usually attends diagnosis; 
2. The danger of attending invasion of the peritonaeum; 
3. The dangers arising from septic absorption from reten- 
tion of the foetus or its envelopes; and, 4. The certainty 
of grave haemorrhage from opening into the extraordinarily 
vascular nest in which the foetus is contained. To meet the 
indications the following plans have been those generally 
adopted: 1. The operation of gastrotomy has been prac- 
tised, that the foetal mass might be removed like an ovarian 
tumor; 2. The liquor amnii has been drawn off by a very 
delicate trocar, in order to diminish tension and check the 
growth of the cyst; 3. The foetus has been killed in situ 
by the passage of strong currents of electricity, or the injec- 
tion into the sac of strong narcotics, like atropia or morphia, 
with the hope that nature might, at a future time, cause its 
discharge, with the contents of the abscess which it usually 
creates. 
The first procedure is attended by the dangers of perito- 
nitis and haemorrhage; and the second and third by those of 
haemorrhage into the sac, septicaemia, and subsequent forma- 
tion and discharge of an abscess located just under the peri- 
tonaeum. By the process which I now proposed to adopt, I 
hoped to avoid the dangers of peritonitis by opening the foetal 
sac by the vagina, passing up to it between the folds of the 
broad ligaments. Haemorrhage, I thought, might be in great 
degree prevented by cutting into the sac by means of a knife 
rendered incandescent by a powerful current of electricity. 
And by complete removal of both foetus and placenta, and 
thorough drainage of the sac by carbolized injections through 8 
a tube of glass or silver, kept in it, and discharging its 
contents by the vagina, I was sanguine of avoiding septicaemia, 
I proceeded to adopt the plan from which I hoped for 
these results in the following manner: the patient having 
been etherized by Dr. Blake, was placed upon a table before 
a window admitting a strong light, in the left lateral position, 
and Sims's speculum introduced. Through this the cyst to the 
left of the uterus could be distinctly palpated. Now, fixing 
a long-handled tenaculum in the cervix uteri, and another in 
the vagina near the left ilium, this part was by them put on a 
stretch so as to make of that side of the canal a triangle, the 
base of which was over the cyst, and the apex at the 
Assistants held these tenacula during the operation. Taking 
the platinum knife of the galvano-caustic battery, which was 
brought to a white heat, I now passed it gently over the base 
of the triangle described as created in the vagina, carrying it 
from one tenaculum to the other. By repeating this the va* 
ginal wall, over the lower segment of the cyst, was slowly cut 
through. In six minutes the cyst was opened by the incan- 
descent knife, and a straw-colored, slightly-pinkish fluid was 
thrown out with such force as to fly into my face and over my 
clothing. 
Thus far no blood whatever had been lost. I now passed 
my index-finger into the cyst, and felt a foetus lying horizon- 
ally with the head toward the ilium, and the feet toward the 
uterus. Passing in the middle finger likewise, I caught the 
feet between the two, and, turning the foetal body, drew them 
through the artificial os which I had created, and delivered 
the child from the vicarious uterus which it occupied. The 
steps of the procedure exactly resembled those adopted in or- 
dinary podalic version. The foetal body advanced steadily 
until the arms reached the opening; then arrest occurred un- 
til they were swept out. The head was then arrested, and I 
strove to liberate it by manipulation and traction. Failing 
in this, I applied a pair of long-handled placental forceps, and 
at once it was extracted. The cord was then cut, and I pro- 
ceeded to deliver the placenta by gentle traction and detach- 
ment, as is done after ordinary labor. Thus far thirteen min 
tites had been consumed. 9 
At this point, the first difficulty which had attended the 
operation, showed itself. This was due to want of knowledge 
on my part as to the exact manner in which the placenta is 
attached in tubal pregnancy. Foreseeing this difficulty, I had 
carefully looked for information in the literature of the sub- 
ject, but could find none which was of any practical value. I 
feared to detach the placenta with any degree of force, for the 
reason that I might, I thought, tear through the wall of the 
sac, and.thus open into the peritonaeum. For this reason, I 
proceeded less rapidly and vigorously than I should otherwise 
have done. When I had separated a little over half of the 
placenta, a very severe haemorrhage took place, and so much 
was the patient's condition depreciated by it in the two or 
three minutes of its duration, that I was unwilling to delay 
for the removal of more. Tearing the detached portion off, I 
passed a large gum-elastic catheter into the sac, and injected 
a solution of the persulphate of iron into it. This I was very 
sorry to be forced to do, but the hazard of delay was too great 
to allow of any other course. The flow of blood was instantly 
checked, but this was attained at the sacrifice of perfect-drain- 
age, and the leaving of the sac full of coagulated blood, and a 
portion of the placenta. Instead of inserting a drainage-tube, 
I was forced to substitute a long tent of carbolized cotton, satu- 
rated with a solution of persulphate of iron. 
In twenty-eight minutes from the commencement of the 
operation, the patient was put to bed, her head kept low, the 
foot of the bedstead elevated about six inches, ten drops of 
Magendie's solution of morphia injected subcutaneously, per- 
fect quiet established, and a milk-diet ordered. 
The foetus being examined, was found to measure six and 
a half inches ; and the placenta, which resembled closely one 
developed in utero, looked like one of three or three and a 
half months of growth. As it was not entire, it was not 
weighed or measured. 
After this, all went well until the evening of the fourth 
day, when I withdrew the tent of cotton, and symptoms of 
septicaemia soon showed themselves. These yielded to con- 
stantly-repeated injections into the sac of carbolized water, at 
the end of a week. On the seventh day after the operation, 
2 10 
slight hsemorrhage took place from the sac, but was without 
difficulty controlled by the addition of a small amount of solu- 
tion of persulphate of iron to the carbolized water. 
On the fifteenth day the remaining portion of the placenta 
came away spontaneously. On the sixteenth day evidences 
of an embolus in an unimportant vessel of the arm showed 
themselves, which created a small abscess, and about the same 
time fears were entertained that phlegmasia dolens was devel- 
oping. These last, however, proved delusive. Subsequent to 
this period, no evil symptom showed itself, the patient suffer- 
ing only from fecal impaction, probably the result of inter- 
ference with defecation by the obstruction exerted by the tu- 
mor, and the interference with peristalsis effected by the large 
amounts of morphia taken. 
Six weeks after this operation, I examined by vaginal 
touch, and was surprised to find the opening made by the in- 
candescent knife so completely closed that I found difficulty 
in ascertaining its exact location; and ten weeks after it, upon 
visiting Elizabeth to see another patient, I had the satisfaction 
of seeing Mrs. C. in her parlor receiving company, and pre- 
senting an appearance so markedly in contrast with that pre- 
sented by the haggard and emaciated patient of February 7th, 
that, even after conversing with her, I was scarcely able to 
identify her as the same individual. 
The appreciation of the sign of ballottement, which greatly 
aided me in arriving at a positive diagnosis in this case, has 
served me an equally valuable purpose in two others. On no 
single sign, however, should undue reliance be placed. Dur- 
ing the first sixteen years of my practice, I saw no case of extra- 
uterine pregnancy. At the end of that period, I saw four in 
one month. During the past seven years, I have met with 
nine. Three of these I saw after rupture of the sac, the pa- 
tients being in articulo mortis ; two were put beyond ques- 
tion by gradual discharge of foetal bones; in four cases I suc- 
ceeded in making a diagnosis as positive as that which is de- 
tailed in this paper. In these, a certain conclusion was arrived 
at by coincidence of the following conditions: (a.) The exist- 
ence of the gastric, mammary, and pelvic symptoms of preg- 
nancy ; (6.) A uterus smaller than should exist at the sup- 11 
posed period of gestation ; (<?.) A sensitive tumor to one side 
of or behind the uterus; and (<Z.) Pains extending from the 
pelvis down one thigh. 
In three of these four cases I so distinctly obtained the 
sign of l/allottement as to be willing to lay a great deal of 
stress upon it in arriving at a decision, and in all of them hav- 
ing arrived at a conclusion with a good deal of positiveness, I 
did not hesitate to employ the uterine sound to assure myself 
of the position, capacity, and state of vacuity of the uterus. In 
a doubtful case dilatation of the cervical canal by tents would 
prove a valuable means of entirely excluding normal pregnan- 
cy. True, such a method would insure an abortion, if normal 
pregnancy existed, but if the probabilities were strongly in 
favor of extra-uterine pregnancy, and surgical relief appeared 
practicable in case of its existence, it would be a diagnostic 
resource not only legitimate but obligatory.