The Diagnosis and Treatment of 
Tubal Pregnancy. 
WITH HEP OUT OF A CASE. 
BY 
IRVING S. HAYNES, Ph.B., M.D., 
Adjunct Professor of Anatomy and Demonstrator of Anatomy, 
Medical Department of the University of the City of New 
York; Assistant Surgeon, New York Orthop cedi e Hospital; 
Member of the Society of the Alumni of Bellevue Hospital, 
of the County Medical Society, etc. 
REPRINTED FROM THE 
Neto Yorfc jfBeUfcal journal 
for December 15, 1894. Reprinted from the New York Medical Journal 
for December 15, 1894. 
THE DIAGNOSIS AND TREATMENT OF 
TUBAL PREGNANCY* 
WITH REPORT OF A CASE. 
By IRVING S. HAYNES, Ph. B., M. D., 
ADJUNCT PROFESSOR OF ANATOMY AND DEMONSTRATOR OF ANATOMY, 
MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE CITY OF NEW YORK ; 
ASSISTANT SURGEON, NEW YORK ORTHOPAEDIC HOSPITAL J 
MEMBER OF THE SOCIETY OF THE ALUMNI OF BELLEVUE HOSPITAL, 
OF THE COUNTY MEDICAL SOCIETY, ETC. 
Extra-uterine gestation occurs about once in twelve 
hundred cases of pregnancy. One writer states one to 
twelve thousand; another, one to three hundred and thir- 
teen. It is a somewhat rare condition, and one of very seri- 
ous import to the patient. If undiscovered until rupture 
has taken place, it is usually fatal, either from the haemor- 
rhage or from the septic conditions induced by it. If it is 
discovered previous to rupture, its removal is usually not 
very difficult and the attending dangers are slight. 
In this paper I shall confine myself to the tubal variety 
of extra-uterine foetation. 
The opinion of modern writers seems to be that all forms 
of extra-uterine impregnation, excepting ovarian, take place 
* Read before the Society of Alumni of Bellevue Hospital, October 
3, 1894. 
Copyright, 1894, by D. Appleton and Company. 2 
THE DIAGNOSIS AND TREATMENT 
in the tubes ; that later about forty per cent, of the ova 
are extruded from the tube, either into the abdomen or 
uterus, while sixty per cent, remain and develop as tubal 
pregnancies. 
In the tubal variety early rupture is the rule, followed 
usually by the death of the patient. However, if the diag- 
nosis of this condition can be determined previous to rup- 
ture, and an operation performed for the removal of the 
tube and its contents, the termination is usually successful. 
The whole interest, then, centers about the phenomena by 
which we are to make the diagnosis. 
As a rule, the symptoms of tubal pregnancy are the 
same as those of normal pregnancy up to the time that 
pain and irregular haemorrhage occur. Briefly recapitulated 
they are as follows: Morning sickness of the kinds usually 
described ; mammary changes, consisting of an increase in 
the size of the gland, tingling or other irritable sensations; 
enlargement of the areola; stoppage of the monthly flow. 
At this point appears the important symptom of pain. 
The pain is sudden, colicky, and felt in the iliac region of 
the side where the sac is situated. The pain is soon fol- 
lowed by a bloody flow, irregular in duration and recurrence. 
If an examination is now made, the uterus will be found 
somewhat enlarged, but to a less degree than in normal 
pregnancy. The cervix is also softened and the os slightly 
opened. The uterus may be crowded forward or to one 
side by a tumor behind or beside it. This tumor is oval 
or round, freely movable (if no adhesions have formed), 
elastic, tense, and sensitive. 
Before considering the diagnosis I will rehearse the 
history of my case : 
Mrs. F., aged twenty-eight years; married in July, 1893. 
History.-Was regular until January, 1894; should have 
been unwell about the 20th, but was not; had morning sickness OF TUBAL PREGNANCY. 
3 
so bad that she would throw up her breakfast at times; her 
breasts enlarged and became tender. 
There was no show in February. But in March she was 
taken with severe pain at about the time her monthly was due, 
followed by the discharge of considerable blood in which were 
"pieces of flesh" (clots and membranes). Bloody discharge 
continued for three weeks. Was regular in April and May. 
In June she did not menstruate. She had no morning sickness, 
but her breasts became larger and were tender. 
On the 16th of July she was taken with pain, followed by a 
bloody flow. The pain was felt in the external genitals and peri- 
naeum, never in the iliac fossa, and disappeared with the onset 
of the haemorrhage. The flow continued three days, and then 
gradually subsided. In just a week (July 23d) the attack re- 
turned in exactly the same way. First, severe pain in the ex- 
ternal genitals, followed by the haemorrhagic discharge. She 
came to my office on the evening of the 23d and gave the above 
history. I suspected extra-uterine pregnancy, and made an ex- 
amination with that in mind. The uterus was enlarged to the 
size and shape of a large pear, about three or three and a half 
inches long and correspondingly increased in girth. It had set- 
tled well down into the pelvis, but was freely movable in all 
directions without pain. No enlargement of the tubes could 
be felt, though special effort was made for this purpose. There 
was a thick discharge on the finger, looking and smelling like 
menstrual blood. 
Diagnosis.-I told the woman that she was pregnant, 
and was inclined to think that I had one of those patients 
that lose blood once or twice at the beginning of their preg- 
nancy. 
I gave some two-grain ergotin pills to take every four hours, 
and ordered rest in bed. She reported on the 25th that the 
bleeding had ceased. From this time until the 17th of August 
I was on my vacation. On the 29th she called and said that the 
haemorrhage had not returned until the 1st of August (nine days 
after the second attack). Then it began again as bad as ever, 
preceded by severe pain in the same region as before. The pain 
lasted longer than with the first two seizures. The haemorrhage 4 
THE DIAGNOSIS AND TREATMENT 
continued three days and then stopped. She used the ergotin 
pills during this time. In a week the same proceedings were 
repeated, with the exception that the pain and loss of blood were 
continuous up to this time (August 29th). 
I did not make an examination at this time as the case seemed 
to be one of abortion, but told the woman to go home and in 
the morning I "would operate, intending to curette and pack the 
uterus. In the morning preparations were made for this opera- 
tion. 
Dr. Dearden administered ether. When the patient was 
thoroughly anaesthetized, as a preliminary precaution I made a 
careful examination. This was what wras disclosed: The cervix 
was hard and the os firmly contracted; the uterus normal in 
size and freely movable. No mass was felt at the left of the 
uterus, but as soon as the fingers were carried to the right side 
a movable tumor was found. It was close to the uterus and 
connected with it, though the fingers could be carried up be- 
tween the two. It was of the size of a hen's egg, elastic, not 
boggy, and with a smooth surface. 
My diagnosis was extra-uterine pregnancy of the tubal 
variety, and it was confirmed by Dr. Dearden. The administra- 
tion of ether was stopped and preparations were made for the 
more serious operation, which, after half an hour, was under- 
taken, with Dr. Wright to administer the anesthetic and Dr 
Dearden to assist me. Mention of the operation will be deferred 
until considering the treatment of tubal pregnancy. 
As before stated, the interest centers about the question 
of diagnosis. If that is plain, the successful termination of 
the case lies within the reach ©f the physician and patient. 
All writers are unanimous in stating that the diagnosis is 
comparatively easy after rupture has occurred ; and they are 
just as fully agreed that the diagnosis is difficult and uncer- 
tain previous to this undesired event. The chief purpose 
of this paper is to ask the questions, Can tubal pregnancy 
be diagnosticated previous to rupture ? If it can, what are 
the pathognomonic signs ? and to record the answers of OF TUBAL PREGNANCY. 
5 
various writers. The time of rupture is important to deter- 
mine. Playfair (8) states it as from the fourth to the 
twelfth week, rarely later. Pozzi (16) says early rupture is 
the rule, in most of the cases during the second month. 
The size of the ruptured cyst is usually that of a hen's egg. 
My case had gone anywhere from seventy to ninety 
days and the sac had not ruptured. I do not think that 
rupture would have been long delayed, as the sac was very 
thin and tore slightly while I was removing it. 
It is evident that we must make the diagnosis previous 
to the beginning of the third month, and it would be better 
if it could be accomplished before the middle of the second 
month. 
I will introduce some quotations from men who have 
had to do with this condition. 
Lusk (1) : The diagnosis of extra-uterine foetation is 
based on the existence of the signs of pregnancy, exclusion 
of an ovum within the uterine cavity, and the presence of a 
tumor external to the uterus. ... A tubal swelling and 
enlargement of the uterus, associated with suppression of 
the menses, often followed after a brief period with parox- 
ysmal pains radiating from the side of the pelvis upon 
which the affected tube is situated, and with the expulsion 
of the uterine decidua at the end of the second or in the 
course of the third month, is to be regarded with suspicion. 
But a tubal sac may be caused by a number of pathological 
conditions. Uterine changes in the early months are in- 
constant. These sometimes correspond to those of ordi- 
nary uterine gestation, but often there is neither percepti- 
ble enlargement nor cervical softening to indicate preg- 
nancy. 
Ross (2): The vagina may be of a purplish color. 
Cervix perhaps soft and patulous. Uterus pressed forward 
or backward to one side or the other. An irregular swell- 6 
THE DIAGNOSIS AND TREATMENT 
ing that feels like no other swelling, neither a pus-tube nor 
ovary, that feels knotty and boggy, will be found in its 
neighborhood. Sometimes the mass is smooth, rounded, 
and freely movable. Some claim the tumor pulsates, but 
other pelvic enlargements also give the sense' of pulsation 
to the examining finger. 
Vertsinski (3), in a Russian journal quoted in the Lan- 
cet, calls attention to one characteristic symptom in the 
differential diagnosis between tubal gestation and oophori- 
tis, which had been described by Thomas as far back as 
1873, fell into oblivion, and in 1889 was resurrected by 
Professor Lebedeff. The symptom is the varying size of 
the tumor in inflammatory conditions of the tubes and 
ovaries. The tumor is sometimes as large as an orange, 
while on other occasions, and often in a few days only, can 
hardly be defined. 
This periodical variation in size is closely connected 
with menstruation and ovulation. 
Smith (6): The physical signs, and these with reference 
to the earlier months, would be the development of the 
uterus with the accompanying displacement, according to 
the size and situation of the fruit sac. Cervix is usually 
patulous and dilated; uterus empty ; tumor beside or be- 
hind the uterus, of nearly fluid consistence, tense and 
tender. ... A positive diagnosis can not be made within 
the first eight weeks without an exploratory incision. 
Hughes (12) and Smolsky (13): The size of the womb 
should be compared with the size it should be at the sup- 
posed period of pregnancy. Careful search should be made 
in the neighborhood of the Falloppian tube, fundus of the 
womb, and ovaries, and if an enlargement is discovered, so 
much the better. The question is then, What is tumor due 
to ? Can be answered by inquiring into the previous history 
of the case, and by carefully comparing the symptoms of OF TUBAL PREGNANCY. 
7 
the disease which it might resemble with the symptoms of 
pregnancy. The size of the tumor should be compared 
with the size that the foetal sac should be at the supposed 
time of gestation. Smolsky states that in tubal pregnancy 
the sac in the first month reaches the size of a pigeon's 
egg; in the beginning of the second, the size of a walnut; 
midway between the second and third, that of a hen's egg ; 
in the third month, that of a fist; in the fourth month,, 
that of two fists. All writers agree upon the mammary 
changes that take place, and that they are similar to those' 
that take place during normal pregnancy. 
Regarding the symptoms of pain and bloody flow, Lusk 
says that paroxysmal pains are frequent in other forms of 
tubal disease, and menstrual disturbances are common phe- 
nomena in uterine derangements. 
Ross states that some have no pain. Others agree that 
pain is the rule, and is felt over the site of the affected 
tube.-Laurence (4), Lewers (5), Smith (6), Playfair (7 
and 8), Chillingworth (10), Hunter (14), Banga (15), Pozzi 
(16). In my case the pain was severe, but grew easier 
as soon as haemorrhage started. The situation of the pain 
differed from that of any case I have seen recorded, in that 
it was never felt over the tube, but always in the external 
genitals. I have taken the precaution to make this point 
certain. 
Haemorrhage follows in every case. Its duration is un- 
certain and its return irregular. As a similar flow occurs in 
diseases of the uterus and its appendages, it is not a special 
sign of tubal pregnancy. 
My patient bled at intervals of a week for four weeks. 
The flow lasted for three days, until the last attack, when 
it became continuous. There is one point in the history of 
the cases reported that is brought out distinctly by Lewers 
and Hughes. It is the fact that these patients may have 8 
THE DIAGNOSIS AND TREATMENT 
aborted a short time previous to the tubal conception. In 
my case there was an abortion when the patient was two 
months and a half pregnant, and two months and a half 
before the abnormal impregnation. 
Concerning the expulsion of the decidua or its removal 
by the curette, Smith lays this force upon it, that in proper 
hands the curette will clinch the diagnosis. Hughes says 
the presence of the decidua is a symptom of great impor- 
tance. Lusk states that the expulsion of the decidua, al- 
though a valuable sign, is not a constant occurrence. 
From these quotations we see that there are no pathog- 
nomonic symptoms for the diagnosis of tubal pregnancy. 
The symptoms as they occur are, first, the morning 
sickness or other neurotic disturbances common to normal 
and abnormal pregnancies alike. Then there are the mam- 
mary changes that are alike in both cases, consisting of en- 
largement, sensitiveness, secretion of milk, widening of the 
areola. The monthly period is missed. The woman thinks 
herself pregnant. In from two to three or four weeks 
after the monthly period is passed she is suddenly seized 
with an attack simulating colic. The pain is usually 
felt in the pelvic region, in either of the iliac fossae, or, as 
in my case, in the external genitals. 
The pain gets easier with the onset of a bloody dis- 
charge. The haemorrhage lasts from two to four days, re- 
curring at weekly periods or oftener. Later it may become 
continuous. If an examination is made about the second 
month you will find the cervix soft and the os somewhat 
open. The uterus will be increased in size. You may find 
the tube enlarged or you may not. In the light of my sin- 
gle case, I should think it good practice to give ether and 
make a more thorough examination than can be done with- 
out it. The tube must have been enlarged at my first ex- 
amination, though I did not find it so, and I was examining OF TUBAL PREGNANCY. 
9 
especially for extra-uterine pregnancy. Later there will be 
no difficulty in making out an oval, elastic tumor with a 
1. The ovary. 2. The fimbriated extremity of the tube. 3. The uterine ex- 
tremity of the tube, into which a straw has been inserted. 
smooth surface at the side and closely joined to the uterus. 
The tumor may be sensitive to pressure. Blood will be 10 
THE DIAGNOSIS AND TREATMENT. 
found upon the examining finger that looks and smells like 
menstrual blood. 
At this later examination the uterus may be smaller in 
size than it was at the first one. In my case this difference 
in size was especially noticeable. At the first examination, 
finding no tumor about the uterus, I had no hesitancy in 
1. Rupture over the placental site. 2. Uterine end of the tube, with a straw 
inserted. 3. Fimbriated extremity of the tube. 
telling the woman she was pregnant. In the second the 
diminished size of the uterus was manifest at once. It 
was of about the normal size, and the cervix was hard and 
the os firmly contracted. The changed condition in the 
uterus was due primarily to the situation of the develop- OF TUBAL PREGNANCY. 
11 
ing ovum, and secondarily to the ergotin she had taken. 
At this point the question arises, Would it not be a means 
1. Ovary, showing the corpus luteum of pregnancy. 2. Amniotic cavity. 
for diagnosis to give ergot for a few days in order to see if 
in a supposed case of abnormal pregnancy the uterus did 12 
THE DIAGNOSIS AND TREATMENT 
return to its normal size ? If it did, you would be certain 
that the ovum was without the uterus. At this second ex- 
amination the enlarged tube was easily felt, its oval outline 
determined, its close connection with the uterus demon- 
strated, and its freedom from adhesions evident. To be 
sure, the patient was under the influence of ether, but this 
■emphasizes the statement that the examination is more sat- 
isfactory when the patient is in an unconscious state, and 
physical conditions not manifest when she is conscious may 
be very distinct then. The absolute demonstration of tubal 
pregnancy is possible only by an exploratory coeliotomy. 
This operation is practically without risk, at least it is to 
be preferred to a continuance in a state of uncertainty re- 
garding the exact diagnosis, since the danger of rupture is 
so great in case there is a fecundated ovum in the tube. 
Treatment.-Three methods of procedure have been 
advocated : The first, by the injection into the sac through a 
hypodermic needle of solutions of morphine, atropine, or 
strychnine. The dangers attending this seemingly simple 
operation are so great that it is performed no longer. 
There are seventeen cases recorded of operation by this 
method, with eleven deaths (references 17 and 18). The 
death rate is sufficient to condemn the operation. 
"Second, the treatment by electricity. This is a method 
chiefly used in this country ; no foreign writers advise it, 
except the Russians (references 17 and 18). Some writ- 
ers here are so enthusiastic over the use of electricity that 
they advise it exclusively. However, its use is not without 
danger. Three deaths and four serious accidents are re- 
■corded against it (18). The action of the current may 
cause rupture of the tube, an occurrence not to be de- 
sired. Moreover, if the result is pronounced satisfactory 
at the time, a mass is left behind that may not entirely dis- 
appear ; it is a true foreign body that may become encysted OF TUBAL PREGNANCY. 
13 
and partially absorbed, yet which ever remains as a menace 
to the life of the patient, because it may become the seat 
of tubercular or malignant growths or break down and pro- 
duce septic infection. 
The third method is the removal of the tube and its 
contents by a median coeliotomy. 
Werth's suggestion (18), that ectopic pregnancy is al- 
ways to be regarded as a malignant growth and treated as 
such, is to be followed in preference to the use of an in- 
jection or electricity. 
Early operative treatment is almost always successful. 
The only danger peculiar to the operation when performed 
previous to rupture is from the haemorrhage that follows 
an unintentional rupture of the sac. But this can easily 
be guarded against and arrested if it happens. 
There are no special directions for the operation. The 
strict rules of modern aseptic operations are to be followed. 
Suture the abdominal layers separately, closing the wound 
tightly, without a drain. 
If the intestines have been handled much, or there have 
been numerous adhesions to break up, I should think that 
Dr. Wiggin's (19) plan of flooding the abdominal cavity 
with a hot normal saline solution would be of great benefit. 
As we are not dealing with ruptured tubes I will not 
refer to the difficulties met with in those cases. 
The patient I had was operated upon after the above- 
described plan. 
The history was uneventful and recovery perfect. The 
recovery was delayed slightly by the gaping of the wound 
and its healing by granulation and cicatrization. 
The specimen was oval, with a smooth surface, and of 
the size of a hen's egg. On section it shows a central cav- 
ity-the amniotic cavity-surrounded by a layer composed 
of organized blood-clot or chorionic growth. 14 
DIAGNOSIS AND TREATMENT OF TUBAL PREGNANCY. 
There was no distinctly formed foetus. The specimen 
is an exact reproduction of one illustrated in the Interna- 
tional Medical Annual for 1893, page 445, Fig. 58. 
The ovary shows the corpus luteum of pregnancy. 
References. 
1. William T. Lusk. N. Y. Journal of G. and Obs., No. 2, 
vol. vii, 1891, p. 78. 
2. J. F. W. Ross, of Toronto. Am. Journal of Obs., No. 1, 
1893. 
3. Vertsinski. Lancet, 1892, p. 16. 
4. Austin Laurence. Trans, of the Obs. Soc. of London, 
1892-'93, p. 439. 
5. A. H. N. Lewers. Lancet, March 10, 1894. 
6. J. F. Smith. N. Y. Journal of G. and Obs., 1893-'94, 
p. 400. 
7. W. S. Playfair. London Obs. Trans., vol. xxxiv, 1892. 
8. Same in System of Midwifery. 
9. J. Bland Sutton. London Obs. Trans., vol. xxxiv, 1892. 
10. C. J. Cullingworth. London Obs. Trans., vol. xxxiv, 
1892. 
11. W. T. Helmuth. N. Am. Journal of Homa., 1894, 
p. 370. 
12. D. Hughes. In the Trans, of the Internal. Congress of 
Obs. and Gyn., 1894, p. 641. 
13. Smolsky. Quoted by Hughes. 
14. C. H. Hunter. In a paper read before the Minnesota 
Academy of Medicine, February 1, 1893. 
15. Henry Banga. Transactions of the Chicago Gynaecologi- 
cal Society, published in the Am. Journal of Obs., 1893, p. 135. 
16. Pozzi. Medical and Surgical Gynaecology, vol. ii. 
17. Internatonal Medical Annual, 1893, p. 447. 
18. Quoted by Pozzi. 
19. F. H. Wiggin. Med. Record, August 11, 1894, p. 168. The New York Medical Journal. 
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