EXTRA-UTERINE PREGNANCY. 
Case of Extra-Uterine Pregnancy. By John T. Darby, M. D., 
Professor of Anatomy and Surgery in the University of South 
Carolina, Columbia .* 
In presenting to the Association this beautifully mounted 
skeleton of an extra uterine foetus, and in giving the history 
of this interesting specimen, permit me to acknowledge my 
indebtedness to Dr. Addy, who was in charge of the mother, 
and to my friend, Dr. Lewie, of Lexington, who, as consult- 
ing Surgeon, performed the Operation for delivery. 
It is not my object to enter into the details of the several va- 
rieties of extra uterine pregnancy, as related in standard works 
on Obstetrics, in which the causes, effects, results and condi- 
tions incidental to this state are treated ; I would, however, 
say to those especially interested in this subject, that the clas- 
sical monograph of Campbell affords a vast fund of informa- 
tion, and can be consulted with profit. Such pregnancies as 
this specimen represents are always full of interest, and to- 
day the unusual occurrence of three cases, illustrating two 
forms of extra uterine foetation, are brought before the mem- 
bers. An opportunity for the consideration of this subject, 
as presented by the three cases, has never before occurred to 
this Association, and, I may add, is seldom realized by any 
Medical Society at a single meeting. 
I have listened with pleasure to the case reported by Dr. 
Evans, of Anderson, as showing a result in which nature was 
adequate, by a slow and painful process of ulceration into the 
rectum, to make an outlet, through which, in detached por- 
tions, an entire foetus was expelled, and at the same time the 
life of the mother was preserved. The specimen which Dr. 
Gibbes presents, and the report which he submits, is of that 
rare variety, (interstitial uterine pregnancy,) in which nature is 
inadequate to the development of the foetus, and which always 
terminates in the death of the mother. The report which I 
give is of that variety known as abdominal foetation, in which 
surgical interference promises more than in any of the four 
recognized forms, and although in this case operative measures 
were adopted for the preservation of the life of the mother, 
death was the unfortunate result, and from notes furnished 
by the physicians in charge, I herewith give the history: 
*Upon presenting this case, Dr. Darby was requested to write out his remarks for 
publication in Transactions of Medical Society.—Chairman of Committee on Publication. 2 
On February 21st, 1861, Dr. Addy visited Rachel, a negro, 
about thirty-four years old, who had given birth to five living 
children; she was suffering from labor pains, and was sup- 
posed to be seven months advanced in pregnancy. The os 
tincae were found to be natural, and as there was no tendency 
to dilitation, anodynes were given to prevent a miscarriage, 
and rest in bed enjoined for several days. Similar symptoms 
again occurring on the 22d of Feb., 1861, Dr. A. was called 
to visit Rachel, and after awaiting some hours the dilitation of 
the os he returned home, requesting that he should be sent 
for when labor was further advanced. Several weeks passed 
by before Dr. A. again saw his patient, and as there was a 
positive denial on the part of the woman and her friends that 
delivery had taken place, he believed that some fraud or de- 
ception had been practiced upon him. As the woman was 
attending to her usual duties on the farm of her mistress, no 
special examination was made at this visit. 
On the 4th of February, 1867, Dr. A visited Rachel and 
delivered her of a strong and finely developed girl. After 
the delivery, an enlargement, filling the right side, was noticed, 
and was believed to be an ovarian tumor. Rapid recovery 
followed the labor, and in twenty months afterwards, on the 
1st day of October, 1868, Rachel was delivered of a perfectly 
formed boy of good size, and of fair health and strength. 
This last labor, unlike that which had preceded it, was fol- 
lowed by great soreness and pain in the lower part of the 
abdomen with much restlessness and high fever. The tumor, 
still existing after the birth of this second child, was sup- 
posed to be the cause of the bad symptoms presenting, and 
an alterative and sedative treatment was adopted during the 
period of attendance. 
Four months subsequent to this last labor, at a visit, on 
the 30th of January, 1869, a large abscess was found over the 
site of the tumor; this was opened to the right of the 
median line, and a quantity of fetid pus was discharged. 
This discharge continued until the 20th of May, 1869, when 
through the orifice a erdhial bone presented itself and a 
diagnosis was readily made. At this stage, Dr. Lewie was 
called in consultation, and an operation being agreed upon, 
he performed it in the following way : An incision eight 
inches in length was made, extending from the right of the 
umbilicus, and a little above it, to the crest of the ilium, and 
corresponding to the long diameter of the orifice, through 
which the bone was presenting. In the middle part of this 3 
incision the abdominal muscles were, to some extent, 
destroyed by ulcerative action. Through the opening was 
delivered a male foetus, contained in a cyst and partially 
decomposed. The cyst was attached firmly to surrounding 
organs, and separated the foetus as it lay within it, from any 
contact with the viscera, to which it was itself united. The 
placenta floated in the cystic cavity, was partially decomposed, 
and weighed five ounces; and the umbilical cord much 
softened, was separated from the placenta, and measured in 
length five inches. On account of the altered condition of 
the cystic walls, the locality of attachment of the placenta 
could not be positively defined. Immediately on delivery of 
the cystic contents, the entire contents of the stomach emptied 
themselves into the cavity of the cyst, through a ragged, 
jagged opening, two inches in width. This orifice was situated 
on the anterior surface of the stomach, corresponding to a 
point about the middle of the greater curvature, and was at 
once closed with silk sutures. Despite all precautions to pre- 
vent the food making its way through this opening into the 
cystic cavity, it continued as fast as swallowed to pour from 
the stomach into the cyst, and the patient from starvation 
thus produced, died on the seventeenth day following the 
operation. There was an improvement in the general symp- 
toms, shown in the relief from pain and by there being no 
fever, as had existed for several months prior to the operation. 
Dr. L. states that he never saw less constitutional irritation 
expressed, not so much as generally follows a natural delivery 
occurred, and “ that it is his belief, that could food have been 
retained in the stomach the patient would have recovered.” 
It will be noticed from the history of this case, that from 
the first visit of Dr. A. to the birth of the girl, a period of 
six years and eighteen days elapsed ; that there was an in- 
terval of twenty months between the birth of the boy and the 
previous labor when the girl was delivered ; and that from 
the first visit, to the operation for the delivery of the extra 
uterine foetus was eight years one month and twenty-nine 
days. If we agree with Dr. A., that at his first visit the 
woman was seven months advanced in pregnancy, then the 
whole period, from the time of conception to the removal of 
the foetus, is nine years less three months. It is my opinion, 
however, that at the first visit the woman was five instead of 
seven months advanced in pregnancy, and that the labor pains 
occurring four months subsequently were those efforts which 
nature always sets up for the expulsion of the child at full 4 
term, provided it be alive, whether it be within or without the 
uterus. If this view is correct, and it accords with the ex- 
perience of those who have noted especially this variety of 
pregnancy, it follows that from conception to delivery covers 
a period of eight years and seven months, and shows a dif- 
ference of two months between the calculation of Dr. A. and 
myself, which is of little moment. The period of retention of 
this specimen in its ventral bed is not remarkable when com- 
pared with some other reported cases, and yet it ranks high, 
for in seventy-five cases recorded by Campbell, showing that 
the period varied from three months to fifty-six years, I note 
that one* only was carried nine years. It is worthy of note, 
also, that during the period of retention two children, a boy 
and a girl, were born, and not until after the birth of the former 
did local or general symptoms of inflammation occur. After 
the natural delivery of the boy, on October 1st, 1868, great 
pain was experienced and an abscess formed on the site of the 
tumor; but up to that date the woman attended to her customary 
duties without complaint, and with not more difficulty than 
is usually incidental to the pregnant state. From October 
1st, 1868, to the opening of the abscess, January 30th, 1869, 
and even up to the delivery of the foetus on May 20th, 1869, 
there was continuous pain, producing, with the suppuration 
and ulcerative action following, much constitutional disturb- 
ance. The extraction of the foetus forthwith lessened these 
conditions, and but for the unfortunate rent in the stomach, 
the operation would probably have been crowned with suc- 
cess. It is due to the physician who performed the opera- 
tion to state that the orifice in the stomach was produced by 
ulceration. Adhesions bound the cyst to surrounding organs, 
and after the opening of the abscess through the abdominal 
wall, atmospheric influence at the point where the cyst and 
stomach were united, had produced a weak part by inflam- 
* Note.—Retention in 75 Cases, by Campbell. 
Fcetus retained 3 months in 2 instances, 4 months in I, 5 months in 1, 9 months 
in 2. 
Fcetus retained 15 months in 3 instances, 16 months in 2, 17 months in 2, 18 
months in 7, 
Fcetus retained 1 year in 5 instances, 2 years in 8, 3 years in 7, 4 years in 4. 
Fcetus retained 5 years in 1 instance, 6 years in 2, 7 years in 3, 9 years in 1. 
Fcetus retained 10 years in 3 instances, II years in 2, 13 years in 1, 14 years in 2. 
Fcetus retained 16 years in 1 instance, 21 years in 1, 22 years in 1, 26 years in 2. 
Foetus retained 28 years in 1 instance, 31 years in 1, 32 years in 1, 33 years in 1. 
Fcetus retained 35 years in 2 instances, 48 years in 1, 50 years in X, 52 years in 1. 
Foetus retained 55 years in one instance and 56 years in one other. 5 
matory action, which gave way on the extraction of the 
foetus. 
At times, falls and blows are the exciting causes of inflam- 
mation in cysts of this nature, and we have as an end in some 
•cases, ulceration, bringing about a communication between 
the cavity of the cyst and surrounding parts. Violent mus- 
cular exertion, such as witnessed in labor, and as sometimes 
is seen in vomiting, coughing, and defecating, act as exciting 
causes for producing a similar condition. Causes accidental 
and natural, as described, can, when put into operation, pro- 
duce inflammation in a cyst containing a foetus, where for 
years no such effects arising, little or no inconvenience other 
than the size of the tumor is experienced. The physical for- 
mation of certain parts of the foetus, as the angularity of the 
knee and elbow, compared with the rotundity of the shoulder 
and buttock, would, under pressure, act differently in ex- 
citing inflammation of the cyst. The communication made 
by ulcerative action, between the cyst and other organs, may 
or may not prove beneficial, according to the organ involved. 
Thus in the case of a communication existing between the 
sac and stomach, death would be the inevitable consequence; 
and so, too, if there was communication with the small intes- 
tines. An ulceration from the sac through the coecum, 
woulcf, in all probability, end in death, on account of the long 
tract for the passage of head bones; and so, too, the most 
serious consequences arise, whenever the sac and bladder 
communicate. In the case reported by Dr. Evans, we have 
an example, in which the ulceration from the cyst cavity into 
the rectum, proved beneficial. May it not be that in cases 
similar to this, where the foetus has been expelled piecemeal 
through the rectum and the life of the mother preserved, that 
the pressure of the head upon the rectum, in its bony site, 
from violent efforts of the diaphragm and abdominal muscles, 
in various natural functions, cause this to be one of the most 
frequent outlets for the delivery of the extra uterine foetus ? 
The cause of inflammatory action in the case of Rachel, was 
evidently due to the muscular efforts during her last labor. 
To the time of this labor no pain had been experienced in 
the tumor for seven years—that is from the date when nature 
endeavored to expel the misplaced foetus, to the delivery of 
the boy on October ist, 1868. Immediately following that 
labor, great pain commenced in the lower part of the abdo- 
men, and serious constitutional disturbance existed from the 
formation of an abscess directly over the left parietal bos, as 6 
the discoloration from exposure through the abdominal open- 
ing is plainly marked on that bone of the specimen exhibited* 
Nature endeavored to give relief through the abdominal 
walls, a mode in which recorded cases show singular and 
remarkable instances of the total expulsion of the foetus, the 
closing of the cyst, the healing of the outlet, and the recovery 
of the mother. The process is slow at such times, and the 
continuous drain from suppuration and decomposition of the 
cystic contents, render it obligatory in all cases where such 
conditions arise, to assist nature in the delivery of the foetus, 
as affording a better chance for life, and giving comfort by 
relief from the fetid discharges. In this case, provided the 
foetus was not attached to the cystic wall by adhesions, which 
at times exist, and had the operation for delivery been per- 
formed when the abscess was opened, or at least before 
atmospheric influence had changed the cystic walls by inflam- 
matory action, the weak point in the stomach which gave way 
might not have occurred, and the life of the mother might 
have been preserved. 
I beg the indulgence of the members to express my views 
briefly, in regard to operating in certain cases of extra uterine 
pregnancy. In that variety known as tubal foetation, could it 
positively be determined that this state existed, operative 
measures for the extraction of the foetus, would, in my opin- 
ion, be legitimate. In from three to five months, by rupture 
of the sac, death must ensue at once from hemorrhage or 
from the peritoneal inflammation resulting, so that an opera- 
tion for relief would not be more hazardous than when per- 
formed for extirpation of fibro-cystic and pylo-cystic growths 
of the broad ligament, or for solid tumors of the ovary and 
uterus. The impossibility by any means yet known for posi- 
tively determining tubal pregnancy excludes the knife before 
rupture of the sac, and subsequent to this condition, from the 
rapidly fatal consequences of hemorrhage, one could hardly be 
in time by an operation to give a chance for life. In the 
interstitial variety, of which Dr. Gibbes shows such a beauti- 
ful specimen, the same objections arise as have been given in 
the tubal form, with perhaps the greater difficulty of diagno- 
sis added. In these two varieties, unless the foetus dies at a 
very early age and becomes encysted, death is almost certain, 
as statistics show that in ioo cases reported, per cent, 
represents the death rate. 
The ovarian variety involves great difficulties in diagnosis 
in the early stages, but the opportunity for judging this 7 
condition by auscultation could be more readily done than 
in either the tubal or interstitial forms : for the foetus generally 
reaches an age in which the action of the heart could be 
determined. As death is the result, as a rule, in this variety, as 
in the other two, and from similar causes, there would be to 
my mind less danger to life to perform ovariotomy, than to 
await the chances of some happy circumstance, which might 
cause the foetus to be innocuous. In the constant improve- 
ment we may see almost daily, for performing the operation 
of ovariotomy as well as in the subsequent treatment, there 
is no ground for objecting to. this measure as a mode for 
preserving life in this variety of extra-uterine pregnancy. 
The abdominal variety presents the most favorable form for 
diagnosis and for treatment. The foetus often develops to 
full size and can be distinguished in its outline through the 
abdominal walls ; by digital examination in the rectum and 
the vagina certain parts at times are readily recognized and a 
diagnosis is made easy ; the foetal heart sends forth its natural 
sounds and marks this tumor distinctly from those of a 
different nature. Should the foetus grow to the full term of 
gestation, the pangs of labor come on as when carried in the 
womb ; with no outlet in its misplaced home, it dies and may 
light up an inflammation in a little while, disastrous to the 
mother, or it may remain for years, giving no pain, doing 
no harm, and in nowise endangering life. There is no 
doubting what should be done when the expulsion of the 
foetus is about to take place through certain parts, as the 
rectum or the abdominal walls; all will agree, that the slow 
process by which nature attempts to relieve the mother, 
from mere tediousness and attendant effects, the vital powers 
would be worn away, and as a relief, the surgeon should 
give a helping hand. Should operative measures be used 
prior to a manifestation by suppuration or ulceration as an 
outlet for the foetus ? This is a point of grave importance 
and difficult to decide. Whenever the foetus is dead and no 
symptoms of irritation are shown, it would be absolute reck- 
lessness to do otherwise than leave it undisturbed. When 
the living foetus is giving pain prior to the full term of gesta- 
tion, and exciting apprehension that even more serious 
consequences might result in the efforts to dislodge itself 
from the sac, I would unhesitatingly advise that galvano- 
puncture needles be inserted through the cyst and, as did 
Bachetti, of Pisa, take its life away, by passing a galvano- 
electric current. Should the full term of gestation be allowed 8 
when we have such an important aid as galvanism to prevent 
it ? The situation could be no worse after the death, and by 
legitimately taking the life of the foetus, it might be that 
all bad symptoms would cease and the mother enjoy life for 
many years. 
There are certain circumstances in which it appears to me 
that gastrotomy is advisable, and in presenting them for con- 
sideration, I well know the views of some high obstetrical 
authorities opposed to them. The experience which has been 
obtained through ovariotomy within the last ten years, 
especially teaches that the fears which have been expressed 
against opening the peritoneal cavity, do not longer weigh 
against this operation. The mortality in degree to the magnitude 
of the operation, is not so great as among some of the capital 
operations where no serous membrane is involved ; moreover, 
the antiseptic method now adopted for treating the peritoneal 
cavity subtracts greatly from the dangers incidental to the 
operation of gastrotomy for any purpose for which this oper- 
ation may be required—be it performed, for disease of the 
womb and its appendages, or for the extraction of the foetus 
within or without the uterus. The rarity of extra uterine 
pregnancy as compared with other conditions for which gas- 
trotomy is now often undertaken renders our experience 
limited, and the dread entertained by the majority of authors 
on this subject, causes them to state that the life of the mother 
is more endangered by extraction of the foetus, than by leav- 
ing it to the operations of nature. It must be admitted that, 
to a great extent, this view is true, when, from statistical infor- 
mation, we compare the cases in which operations have or 
have not been performed, but marked changes in the last ten 
or twelve years for treating tumors by abdominal section now 
exist, and, in my opinion, former dangers are so much lessened 
as to legitimize operations for the delivery of the extra 
uterine foetus, under the following circumstances : ist. When 
rupture of the cyst has taken place, and rapidly fatal conse- 
quences do not follow from hemorrhage. 2d. When after 
awaiting the death of the foetus, or after killing it by galvano- 
electric puncture as proposed, should symptoms supervene 
which endanger life. 3d. When, at the full term of gestation, 
the child is known to be alive. 
In the last condition the operation should be undertaken 
for the preservation of both the mother and the child. 
Further, does not nature show us in many recorded cases, 
where the foetus has obtained an outlet by ulcerative action 9 
through certain parts, that the life of the mother is some- 
times preserved? It does seem that the surgeon might imi- 
tate her in this action for relief, especially, when through the 
abdominal parietes adhesive inflammation could, by caustic 
applications, bind the peritoneum with the cyst to the point 
selected as an outlet for extraction of the foetus, and not more 
danger be incurred, than when hydatid cysts of the liver are 
emptied by similar treatment. Might it not be, too, that in 
the abdominal variety of extra uterine pregnancy, when the 
period of gestation is almost at an end, by bringing about 
adhesive inflammation between the cyst, peritoneum and ab- 
dominal walls, the foetus could be delivered alive, and the life 
of the mother be in no more danger than when nature delivers 
it dead ? Should this mode for delivery not be adopted, and 
the knife instead, by direct incision, be used for entering the 
cystic cavity, the foetus, unless bound to the walls of the sac, 
should at once be extracted. If alive, adhesions would not 
probably be found; and, if dead, a few days atmospheric 
influence would soon detach the foetus, and permit it to be 
taken away. The placenta should never be removed so long 
as found attached; the cord should be cut close to the pla- 
centa and securely tied with two stout ligatures, the ends of 
which brought out of the incision, would furnish a ready 
method for the drainage of the cyst. The same styptics as 
used during operations upon the womb and its appendages, 
when an abdominal incision is made, would here be advisable,' 
and similar anti-septic measures for cleansing the cyst from 
putrescent matters, as are now adopted for treating the peri- 
toneal cavity after ovariotomy. 
It will be noticed, that the three cases reported to-day 
occurred in negroes, and in addition, I would mention a 
fourth, in which a negro slave of this city, passed piecemeal 
by the rectum an entire foetus and subsequently lived for 
many years. The subject of extra uterine pregnancy is 
surrounded with difficulties on all sides and at every point; 
the causes and progress of this form of conception from 
beginning to end, is a field in many parts unexplored by the 
Physiologist and the Gynecologist; the production of ele- 
mentary tissues microscopically perfect and of the various 
complex organs and of all that goes to compose the foetal 
organism, as well as that retrograde metamorphosis which at 
one time will change the foetus into a mass of fatty matter, 
and at another, by calcification, make it as hard as stone, 
are alike wonderful to the Anatomist and Pathologist. The 10 
effects of the several varieties of this abnormal type of preg- 
nancy upon sui rounding parts, the symptoms attendant, the 
terminations presented and the treatment to be adopted, are 
of scientific interest to each one of us; and when we examine 
the specimen now before us, and see that even the ossicles 
of the ear are not wanting to complete its perfection as an 
osseous whole, we can but recognize our weakness in the 
strength of those forces which nature at times conservatively 
sets up to give perfect form and life to man outside of his 
mother’s womb.