=Treatment.=--The treatment of tubal pregnancy is operative. It may be considered under the following heads: Before primary rupture; At the time of rupture; After rupture.
_Before Primary Rupture._--If the physician is so fortunate as to recognize a tubal pregnancy before primary rupture, he should without delay remove the affected tube and the contained ovum. The operation is simple, is attended by no more danger than that accompanying an ordinary salpingo-oöphorectomy, and the woman is saved the imminent dangers associated with a developing tubal pregnancy. There are no circumstances under which it is proper to follow an expectant treatment.
Most of the cases of unruptured tubal pregnancy that have been operated upon were not recognized until the abdomen had been opened. The operation was performed under the diagnosis of pyosalpinx, hematosalpinx, or some other tubal disease. The cases show the value of the general rule to operate without delay for all gross diseases of the tubes.
_At the Time of Rupture._--Many cases of tubal pregnancy are first seen at the time of rupture. In such cases celiotomy should be performed without delay. The condition is most urgent in intraperitoneal rupture, but it is the safest rule to operate immediately, whether the rupture be intraperitoneal or extraperitoneal. It is unwise to wait for reaction. The physical depression in such cases is due more to hemorrhage than to shock, and it is in accord with general surgical principles to arrest hemorrhage at once.
Rupture usually takes place before the twelfth week, and the whole product of conception, with the tube, may readily be removed. Hemorrhage usually ceases as soon as the proximal and distal ends of the ovarian artery are ligated. The ligatures may be placed about the ovarian artery, at the pelvic wall, and at the uterine cornu, as the first steps of the operation, before any attempt is made to remove the mass. It may be necessary to close the rent in the broad ligament by a series of sutures.
_After Rupture._--If the woman survive, and is first seen after primary rupture, one of two conditions will be present--a destroyed or a developing extra-uterine pregnancy. If the fetus has died and gestation has ceased, the woman is exposed to the various dangers that attend the presence of such a foreign body in the abdomen. If the fetus has died during the earlier months, it may have been absorbed and spontaneous cure may take place. Even a dead full-term fetus has been carried in the abdomen for years without producing a fatal result to the mother. It seems safest, however, in all such cases to operate as soon as the condition is recognized. The rules of abdominal and pelvic surgery apply to such cases. The placenta of a dead fetus may be removed without fear of uncontrollable hemorrhage.
