Case of Extra-Uterine Pregnancy. Reported by Carter P. John-
son, M. D., Professor of Anatomy and Physiology in the Medi-
cal Department of Hampden Sidney College, Richmond, Va.
The patient was a negro woman about 30 years of age, admit-
ted into the Infirmary of the Medical College, from Souria Coun-
ty, Va., on May 22d. The following history of her case, up to
the date of her admission, has been kindly furnished me, since the
operation, by Dr. William Beadles, her attendant Physician :
She had enjoyed good health until the commencement of the
present affection. She has been married for several years, but has
borne no children, though her catamenia had always made their
appearance regularly. She menstruated for the last time about the
1st of December, 1848. On the 18th of December, she was taken
with violent pain in the lower portion of the abdomen, recurring
in paroxysms and accompanied by nausea and vomiting. The
affection was referred by the physician in attendance “to the
uterus or its appendages, and was quite relieved in the course of
three or four days by pursuing a moderately antiphlogistic and se-
dative treatment.” For several months after this period, she had
repeated attacks of a similar character, and during the whole of
the ensuing year, she continued very unwell and poorly. In the
mean time a tumor made its appearance in the hypogastric region,
and went on gradually to increase in the same manner as the
uterine tumor inordinary cases of pregnancy. Her breasts also en-
larged, and towards, the latter period of her supposed pregnancy,
secreted a certain amount of milky fluid.
During the month of August, 1849, about the time she ex-
pected her confinement, she experienced a sanguineous discharge
from the vagina, accompanied by considerable pain. Thinking
herself in labor, she summoned a raidwife, and made her prepara-
tions in anticipation of the immediate occurrence of the expected
event. The pain, however, at one time severe, gradually subsided
and disappeared entirely in the course of three or four days. The
discharge, which was attended with the escape of coagula, con-
tinued about a week. About three weeks after this, she was
again seen by Dr. Beadles, in connection with Dr. Fox, and “was
found confined to her bed and helpless, mainly on account of having
phlegmasia dolensf of which she was relieved in the course of
a few weeks. From that time to the date of her admission, she
has been occasionally annoyed by pains in the loins and in the
region of the tumor. Within the last few months, these have
very greatly diminished, and since the beginning of the present
year, her general health has improved sufficiently to allow her
to walk about the neighborhood at short distances, not exceed-
ing a mile. She has frequently felt what she conceived to be the
movements of a child, and she states that she has continued to feel
them until within six weeks past.
At the date of her admission, the case presented the following
symptoms. Her general appearance was healthy, her skin soft,
pulse natural, secretions generally normally performed. The abdo-
men presents a large, globose tumor, remarkably uniform, looking
very much like a huge mammary gland, the retracted nipple being
represented by the umbilicus. The tumor is more prominent than
the uterine tumor at the ninth month of utero-gestation, and occu-
pies a higher position in the abdomen. When the patient is in
the erect position, the integuments are rendered very tender, and
the tumor is with difficulty circumscribed ; in the recumbent pos-
ture, the integuments being somewhat relaxed, it may be moved
slightly in all directions, and is discovered evidently not to fill up
the entire peritoneal cavity. Upon succussion, fluctuation is dis-
covered, though very obscure. The tumor presents no irregulari-
ty of surface, and impinges equally on both sides of the median
line.
An examination per vaginain gave no indications of any disease
of the uterus or of previous impregnation. A very obscure fluctua-
tion was perceptible through the walls of the vagina just behind
the posterior lip of the os uteri.
Upon consultation with my colleagues, Professors Gibson and
Tucker, (to both of whom I am very much indebted for valuable
assistance in the subsequent operation,) it was determined, as the
case was very obscure, and neither of us was fully satisfied as to
its true nature, to make an exploratory incision into the tumor,
and to be guided in the subsequent steps of the operation by the
information which such an incision would afford us.
Accordingly, on the 25th of May, at 11 o’clock, assisted by
Professors Gibson and Tucker, and Dr. Peticolas, and in the pre-
sence of a number of medical students, I proceeded to the ope-
ration.
The patient being placed upon her back, an incision was made
about one inch below the imbilicus in the linea alba, through the in-
teguments and superficial fascia for the space of about fifteen lines.
The tendons of the abdominal muscles were then carefully incised
until they were completely divided ; the finger was then passed in,
and came in contact with what I took to be the omentum very much
thickened, on breaking through which, an entrance was effected
into a cavity, from which from twelve to sixteen ounces of sero-
purulent matter was discharged. On examining the interior
of the cavity with the finger, a solid body was felt on both sides
of the median line, distinctly moveable ; the incision however was
not large enough to permit a satisfactory examination as to its cha-
racter.
At this stage of the operation, a consultation was again held,
and at the suggestion of Dr. Gibson, it was determined to prolong the
incision so as to enable us to extract the contents of the cavity, if
practicable. Before proceeding further, an attempt was made to
place the patient under the influence of chloroform, but was desist-
ed from at her earnest entreaty. I then carried the incision down-
wards to within an inch of the pubes, and upwards about two
inches above the umbilicus, when upon opening the lips of the
wound a large and well grown foetus was discovered compactly
stowed away in this extra-uterine cavity. The head of the child
looked towards the left iliac fossa, the breach towards the right hy-
pochondriac region, the back towards the abdomen of the mother;
the thighs were flexed upon the abdomen, and the legs upon the
thighs. With but little difficulty, the foetus was separated from
its singular resting place, and delivered. The cord, which was en-
tirely flaccid and bloodless, attached itself to the inner portion of
the sac along the lower part of the anterior parietes of the abdo-
men on the left side- The placenta was atrophied to a considerable
extent, and was attached along almost the whole of the anterior
and upper portion of the sac. Its removal constituted the next
stage in the operation, and was accomplished by separating, first
those portions along the edges of the incision, by insinuating the
fingers between them and the sac to which they were attached, and
then effecting its removal precisely as we would remove an adher-
ing uterine placenta. The vessels passing between the placenta, and
the walls of the containing sac were very numerous, but were, and
apparently had been, for some time, completely impervious, present-
ing, as the placental mass was torn off, the appearance of small
fibrous cords.
Having separated the placenta, the cavity which contained the
foetus and its appendages was found to be surrounded by a very
dense sac of plastic lymph, intimately adherent to the parietes of
the abdomen anteriorly, but superiorly, posteriously and inferiorly,
completely separating the cavity and its contents from the
abdominal and pelvic viscera.
During the operation, an artery, a lateral branch of the left epi-
gastric, about the size of the epigastric under ordinary circum-
stances, was cut and required a ligature.
Having cleansed the cavity as thoroughly as possible, the edges of
the wound were brought together by sutures and adhesive straps,
a large bandage firmly applied, and the patient put to bed in a
very comfortable condition, having borne the protracted operation
with great fortitude. She was ordered seventy-five drops of lauda-
num in a little brandy and water.
The child was very fully developed and perfectly formed, except
that both feet presented “talipes volgus,” the left slightly, the
right to a considerable extent. The posterior fontanel was com-
pletely closed, the anterior was nearly as much open as usual.
Its weight, with the placenta, which weighed only a few ounces,
was nine pounds. It had evidently been dead for some time, as
was inferred from the state of the placental bloodvessels, from the
cod, from the condition of the skin, the cuticle being separated in
mrost parts of the body, and from the eyes, which were deeply
sunken in the orbits. There was no fcetor.
At 7 o’clock P. M. patient was quiet, had not slept, but was
comfortable—pulse 94 ; skin cool and moist.
May 26th. Passed a quiet night, sleeping during the latter part;
skin moist but warm; tongue moist and clean; pulse 102,
soft and compressible; abdomen, soft and not tender to the touch ;
severe soreness about the wound ; at 9 P. M. sleeping quietly ;
respiration good.
27th. Passed a comfortable night, sleeping throughout; per-
spired freely; tongue moist and furred ; pulse 120; respiration
somewhat hurried ; abdomen flaccid and entirely free from pain ;
wound looks well. At 12 o’clock had slight chilliness ; 9 o’clock
P. M., perspiring freely ; pulse 140 ; respiration more hurried;
severe uneasiness in head ; no pain in the abdomen. Ordered Calo-
mel grs. xv., Rhubarb grs. x. M. To be taken immediately.
May 28th. Has been quiet during the night, though she has
slept but little; pulse 120; skin soft and warm; tongue cleaner
and moist; abdomen flaccid and free from pain ; wound looks
well and is discharging slightly; medicine has not operated.
Ordered enema of gruel and sweet oil. 9 o’clock P. M. Enema
has brought awrny two copious and consistent passages, giving
great relief to the patient; head easy ; pulse 120 ; skin moist; re-
spiration 30.
29th. Slept well after 12 o’clock. This morning had another
consistent evacuation; feels very comfortable; pulse 112;
tongue moist; skin cool, and less tendency to perspiration ; slight
giddiness of head ; no pain of the abdomen ; wound looks well
and discharges moderately ; in the evening pulse rose to. 120.
30th. Slept well; countenance improving; pulse 106; tongue
cleaner ; wound discharging, but not abundantly ; appetite improv-
ing ; no uneasiness of head ; bowels opened during the day,
31st. and June 1st. The ligature and all the sutures re-
moved.
5th. Has continued to improve in every respect up to this time,
with the exception of slight sore throat, which is now relieved.
The wound is discharging freely healthy pus, the edges have a
florid and healthy appearance ; pulse 96 ; ordered infusion of hops,
a wine-glass full three times a day.
Sth. Appetite improving ; wound looks well; at its upper por-
tion the opposite edges have adhered; discharges a considerable
quantity of healthy pus ; pulse 98 and more feeble. Ordered Vai-
let’s proto-carbonate of iron 5 grs. three times a day, more nutri-
tious animal diet, and the wrnund to be dressed with dilute solution
of chlorinated soda.
9th. Bowels been affected during night; has some griping
pains, but no tenderness on pressure over abdomen ; pulse 102 ;
tongue looks well ; infusion of hops discontinued ; diet restricted
to chicken and light vegetable food.
10th. Diarrhoea continues; has had four or five small, light
colored and thin passages, containing some mucus, streaked with
blood, during the night, accompanied by griping pains. Ordered
calomel grs. 3, opium gr. |, every three hours ; gum water to be
used freely; diet, boiled milk and rice.
11th. Took three of the pills ordered yesterday; had no passage
after taking the first pill, until daybreak this morning, when the
diarrhoea returned; had five passages by 8 o’clock; pulse 120;
countenance anxious ; temples sunken ; tongue moist and clean;
thirst considerable ; skin cool, and tendency to perspiration ; grip-
ing pains about lower portion of abdomen; no tenderness on pres-
sure. Ordered to continue treatment prescribed yesterday.
12th. Has had four dark thin evacuations by 8 o’clock this
morning; countenance looks better; not so much relaxation of
skin ; pulse 120 ; ordered sesquinitrate of iron, twenty drops three
times a day, and infusion of serpentaria, half a wine-glass full every
three hours. 10 o’clock P. M. ; passages still frequent; color
lighter; tenderness over right lumbar, and upper portion of
right iliac regions ; respiration somewhat laborious.
13th. Evacuations still continue, character same as yesterday;
pulse 120 and more feeble ; countenance indicative of exhaustion;
temples very much sunken; emaciation considerable; wound for
the last two days has discharged less freely ; edges not so florid.
Ordered milk toddy, a table spoonful every two hours; serpentaria
and carbonate of iron continued. 2o’clockP. M. diarrhcea continuing,
ordered acetate of lead, grs. ij., opium, gr. | every two hours; arrow
root boiled in milk for diet. 10 o’clock P. M.—has had but one
evacuation since 2 o’clock; feels more comfortable and less feeble,
and has eaten a bowl of arrow root.
14th. Had four evacuations during the night; wound looks
more unfavorable, -the purulent discharge has almost ceased, and
is replaced by a small quantity of dark, thin and offensive fluid,
having very much the appearance of the alvine discharges. Treat-
ment of yesterday continued. 10 o’clock P. M.: has had seven or
eight passages; pulse more feeble and very rapid; profuse per-
spiration.
15th. Has had two evacuations during the night, which are rather
more consistent, and have a singular slate color; countenance
rather better; wound discharging as yesterday ; the interior of the
sac looks dark, and is offensive; the upper and lower portions of
the wound have healed, leaving an opening in the middle about
two and a half inches in length, communicating with the interior
of the sac. Directed that the sac should be syringed out with a
solution of chlorinated soda, and the wound dressed with a fer-
menting poultice ; patient to take beef-tea and milk toddy, a table
spoonful of each every alternate hour ; carbonate of iron as before,
and acetate of lead and opium pro re nata. 10 o’clock P. M., has
had nine small evacuations similar in color to the last, but without
pain ; has taken 14 grs. acetate of lead, and If grs. of opium since
morning.
16th. Diarrhoea continues; wound presents same appearance
as yesterday. Ordered calomel grs. iij., camphor grs. ij., opium grs. |,
every three hours ; injections of laudanum and starch if diarrhoea
is not controlled ; stimulus and nutriment as before. 10 o’clock
P. M.: has taken four of the pills; has not had the injection ; pas-
sages not so frequent as yesterday; the last one about the consist-
ence of thick gruel; dark slate color. Pulse more feeble and ra-
pid; skin cool and covered with perspiration ; tongue becoming
dry, and articulation indistinct. Ordered to double the quantity of
stimulus.
17th. Pulse rapid, very feeble and thready ; skin more relax-
ed and cooler; tympanitis has appeared for the first time ; all
remedies discontinued, except the milk toddy, two table spoonsful
of which, to be given every half hour. During the day, the tympani-
tis increased very rapidly. She gradually sunk and expired about
fifteen minutes past 12 o’clock at night.
Post mortem, made ten hours after death. Body a good deal
emaciated; abdomen very tympanitic. Upon making a section
through the linea alba from the sternum down to the foetal sac, the
cavity of the peritoneum was exposed, and, with the slight excep-
tions presently to be mentioned, was found free from disease ;
there was no effusion either of fluid or of gas in this cavity, while
the intestines were greatly distended with the latter.
The viscera occupying the six upper regions of the abdomen
were all healthy, and for the most part were found in their usual
positions. The viscera occupying the hypogastric and iliac re-
gions, were displaced upwards and backwards by the pressure of
the foetal sac, which lay below and before them, occupying the
greater portion of the hypogastric, and a part of the umbilical and
the two iliac regions. The small intestines were simply pushed
upwards, and were healthy; thecoecum and ascending colon were
pushed slightly upwards and backwards ; the transverse colon oc-
cupied its usual position ; the descending colon did not reach its
usual inferior limit, but rested upon the left upper portion of the sac,
along the whole superior surface of which the sigmoid flexure was
extended from left to right, and to which it was firmly adherent.
On reaching the right-side of the sac, the colon gradually passed be-
hind it, and making its way downwards and to .the left, terminated
as usual in the rectum. On laying open the lower part of the
colon and the rectum, the former was found considerably thickened
in consequence of the effusion of lymph, which bad caused its ad-
hesion to the sac, the mucous membrane was softened, and, in the
rectum, very much congested ; a few points of ulceration and some
patches of lymph were observed, but there was no communication
between the interior of the intestine and the sac.
The sac itself was perfect, presenting no communication with
either the abdominal or the pelvic cavity, Its whole internal sur-
face was black and soft, and emitted a most offensive, gangrenous
odor. It had contracted very much since the operation, except at
its inferior portion, which had probably been distended by the secre-
tions continually gravitating to that point, Its anterior wall was
intimately adherent to the anterior parietesof the abdomen; its su-
perior wall supported the sigmoid flexure; its posterior wall was in
contact with the rectum.
The uterus and its appendages were found compressed between
the lower posterior portion of the bladder and the anterior and in-
ferior wall of the sac. The uterus itself was perfectly normal in
form, size and structure, with the exception of three small fibrous
tumors found in the substance of its walls ; two in the anterior, one
in the posterior portion. A small quantity of gelatinous matter
was seen protruding from the os tincae, and extending up the cavi-
ty of the neck of the uterus. It presented no indication of previous
impregnation. The right ovary was normal, though rather smaller
than usual; the right Fallopian tube occupied its usual situation;
the fimbriated character of its outer extremity could not be distin-
guished, owing to effusion around it; its canal was pervious at its
uterine extremity for about one half of its length, but was com-
pletely impervious along its ovarian extremity. On the left side
the Fallopian tube was rendered completely impervious, and the
left ovary entirely concealed by the dense effusion of lymph which
occupied the whole of the broad ligament of that side.
The mucous membrane of the bladder was congested around
the internal orifice of the urethra.
The folds of the peritoneum passing between the uterus and the
rectum, were pushed on each side by the foetal tumor, and presented
themselves in the form of large cysts, one on each side, containing
eight or ten ounces of yellow serum, mixed with portions of
lymph.
Thoracic viscera healthy, with the exception of old plueral ad-
hesions on the right side. The lungs were very much blanched.
The heart presented slight deposits of fat on its surface ; otherwise
normal.
Remarks. This adds another to the numerous cases of abdomi-
nal pregnancy already reported by Diemerbroeck, Esquirol, Moreau,
Velpeau and others, and affords another proof, were any now want-
ing, that impregnation of the ovum and its full development may
take place entirely independent of the uterus and the Fallopian
tubes. The cause of the escape of the impregnated ovum in this
case into the abdominal cavity is probably inexplicable. It is true
that the post-mortem examination revealed a condition of things,
which, had it existed at the time of impregnation would readily ac-
count for it; I mean the occlusion of the Fallopian tubes; but we
have every reason to believe that this was the result of inflammation
set up in consequence of the escape of the ovum into the abdomen,
and therefore not concerned in producing that result.
A portion of the history of this case is important. The patient
menstruated for the last time about the first of December. Adopt-
ing the ovular theory of menstruation, she was in all probability
impregnated about the 6th or 7th of December. On the 18th she
wras seized with symptoms, which the result shows were caused by
inflammation of the lower portion of the peritoneum, which, we
may fairly conclude, was the result of the attachment of the vivified
ovum to the surface of that membrane. The period then from the
impregnation to the attachment of the ovum to the inside of the peri-
toneum w’as from the 7th to the 18th of December, an interval of 11
days. I am not aware that any case hitherto reported establishes
this fact. This case also contradicts the statement of Cazeau,
(Cazeau’s Midwifery, 2d part, p. 144,) that incases of primary
abdominal pregnancy, no adventitious sac is thrown around the
ovum, who explains this supposed fact by stating in the language of
M. Deseimeris, “ qu’ un corpuscle aussi peu volumineux, aussi sim-
ple, aussi fragile, ne peut provoquer qu’ une excitation tr&s legere
sur lequel il s’arrete, et que le champ de cette excitation ne peut
depasser les limites du contact du petit corps etranger.” That the
advent of “ this little foreign body” into the cavity of the abdo-
men was sufficient to cause very violent inflammation was proved by
the attack which the patient had on the 18th of December, and
that this resulted in the formation of a distinct and complete sac
was proved by the result of the operation and of the post mortem
examination.
Another interesting point in the history of this case is the un-
usual length of time that the foetus must have lived. Velpeau
(Dictionnaire de Medecine, vol. 14, Art. Grossesse Extra-Uterine,)
says, “that extra-uterine pregnancy, usually terminates before
the fifth month by the death of the foetus or by the rupture of the
cystand again, “It is rare that the foetus continues to live beyond
the 3d or 4th month.” In this case the development was fully as
great as at ordinary term, and the weight of the foetus was nearly
two pounds greater than the average weight of a full grown foetus.
May not indeed the foetus have continued to be nourished and to
grow, subsequently to the termination of the ninth month? I
can conceive of no reason why it should not, unless it be that the
compression to which it was subjected by the contraction which
took place at the close of the ninth month was sufficient to cut off
its circulation, and thus to produce its death ; and this we can
scarcely suppose, as these contractions were exerted upon a sac
filled with fluid, and were moreover so feeble as not to produce a
separation of any portion of the placenta. The cause of death in
these cases previous to the rupture of the sac is a most interest-
ing subject, and one upon which the profession has but little infor-
mation. In opposition to the views of Velpeau, the statistics given
by Dr. Campbell in his essay on this subject, would show that it is
not uncommon for the foetus to live during the full term of utero-
gestation. “In ninety-eight cases,” he says, “in which we can de-
cide, or nearly so, on the period of pregnancy, the foetus in
seventy-nine patients died at the close of nine months, or soon
thereafter.”
The patient stated that she distinctly felt what she conceived to
be the movements of the child, up to within a short time before the
operation, not longer, she was sure, than six weeks. Now from
what has been already stated with regard to the condition of the
foetus and the placenta, it is highly improbable that the child was
not dead some months before that period. If so, then these
movements must have been produced otherwise than by the child,
chiefly no doubt by the abdominal parietes ; partly, it is possible
by the sac itself. This fact sustains, as far it goes, the ingenious
views, lately promulgated on this subject, by Dr. Tyler Smith, and
goes far to discredit, the value of these movements as diagnostic
signs of the life of the child.
I conclude this paper with one other remark. Under the cir-
cumstances, ought the operation to have been performed, or would
it have been better to have left the case entirely to the manage-
ment of nature ? When we look at the result of the case, and
find ourselves forced to the melancholy conclusion that, through
our agency, the life of this poor woman has been certainly shorten-
ed, we naturally shrink from the immense responsibility which the
discharge of our professional duty, as we have conceived it. has
devolved upon us. In deciding, however, upon the propriety of a
serious operation, the only questions which the surgeon has to
consider are, whether, 1st, the operation is necessary to the well
being of the patient; and 2d, whether the patient is willing to
encounter the attendant risk for the chance of ultimate recovery.
In this case the patient was perfectly willing to have the operation
done, after being fully apprised of its danger. That the opera-
tion was necessary for the well-being of the patient, I infer from
the history of a vast majority of those cases which have been suf-
fered to run their course without interference—ulceration, dis-
charge of a portion of the contents of the sac, and death from irri-
tative fever, briefly describing them. That such would have been
the result in this case, and that within a short period, I infer from
the decomposition of the foetus and from the adhesions between
the colon and the sac which had taken place. The only hope
therefore of permanently relieving the patient was by the opera-
tion, and the period selected for it was the most favorable which
had occurred since her impregnation. All danger from hemorrhage
was avoided by the impervious condition of the placental blood-
vessels—the sac was still perfect, and could therefore be incised
without any danger of injuring the proper cavity of the peritoneum,
and the general health of the patient, recovered from the previous
attacks of peritoneal inflammation, had not yet begun to suffer from
the effects of the decomposition of the foetus. Under the circum-
stances, I conceive that the operation was not only justifiable, but
was demanded as promising a very fair chance of ultimate re-
covery, to one who, without it, was doomed to a certain and mise-
rable death. By reference to the history of the case, it will be
seen that up to the 9th of June, sixteen days after the operation,
the patient continued to do well. At this period, a marked change
took place in the weather, producing a decided tendency to affec-
tions of the alimentary canal throughout our city. Is it not fair to
conclude that this cause, acting upon an individual predisposed to
such an affection by the immediate contiguity of a large suppurat-
ing sac, was mainly instrumental in producing the fatal result ?
In this connection Velpeau (Zoc. cfZ.) says—“It is true that, prac-
ticed in desperate cases, as it” (gastrotomy) “has hitherto been, it
has not always prevented death. I think, however, with Desor-
meaux, that if had recourse to early, when the formidable assem-
blage of inflammatory symptoms, has not yet been developed, before
peritonitis itself constitutes a fatal disease, it will save a great num-
ber of women.” Again, “with the operation, death is but too pro-
bable; without it, it is nearly certain.” And Colombat (Diseases
of Females, p. 583) says, “we believe that the operation ought
to be performed even after the rupture of the cyst, and that in
general we ought not to wait until the symptoms of peritonitis
shall have developed themselves, because in that case we are al-
most sure to see the mother and child perish, wThen, by operating
earlier, we might, perhaps, have saved both”
Note.—According to the statistics given by Dr. Campbell in
his essay above referred to, the operation of extraction in these
cases has been remarkably successful. He tells us, “that of thirty
cases in which gastrotomy was performed, twenty-eight patients
recovered. Such success, greater than that -which attends ordi-
nary amputations of the extremities, would afford a strong indi-
cation for the operation.”