TWO CASES 
OF 
Extra-uterine Pregnancy 
FROM EXAMINATION OF THE SPECIMENS. 
By CHRISTIAN FENGER, M. D., 
Surgeon Cook County Hospital, Professor of Pathology Chicago 
Medical College, Member American Surgical Association. 
[Report to the Chicago Gynecological Society, February 20th, 1885.] 
CHICAGO 
CLARK & LONGLEY, PRINTERS, i 
1885. * / Two Cases of Extra-uterine Pregnancy 
FROM EXAMINATION OF THE SPECIMENS. 
By CHRISTIAN FENGER, M. D., 
Surgeon to Cook County Hospital, Professor of General Pathology and 
Pathological Anatomy, Chicago Medical College. Member of the American 
Surgical Association. 
[Read before the Chicago Gynecological Society, Feb. 20th, 1885.] 
Mr. Chairman and Gentlemen of the Society: The exact 
anatomical diagnosis or minute classification of an extra-uterine 
pregnancy is easy enough in the early stages of the disease, 
but it becomes more and more difficult in the latter half and 
towards the termination of the pregnancy. 
In the earliest months of the pregnancy, it is only by acci- 
dent that a pathological specimen is found. Here the exact 
diagnosis is easy enough. From the third to sixth months, 
specimens are secured by operation or after death, as the result 
of haemorrhage from rupture, and here the diagnosis is still 
comparatively easy. 
In the latter half of pregnancy, from sixth to tenth months, 
the diagnosis, viz., exact location of fecundated ovum, be- 
comes often exceedingly difficult, next to impossible, on account 
of secondary changes, and often partial destruction of Fallopian 
tubes and ovaries, and still more difficult, if a fatal peritonitis 
has contributed to mask the normal anatomical features of the 
organs in question. 
The two specimens, sent to me for examination, belong to 
the class of late and consequently difficult cases, and in one of 2 
Fenger—Extra-uterine Pregnancy. 
[March, 
them the specimen was very much decomposed. Nevertheless, 
I think that a close examination of the specimens permits of a 
comparatively exact classification of the two cases; at least, of 
one of them. 
Before describing and demonstrating the specimens, permit 
me to recall to your memories the different forms of extra- 
uterine pregnancy. 
Extra-uterine Pregnancy.—The ovum is arrested somewhere 
in its normal passage from the Graafian follicle down to the 
cavum iitcri, or drops out of the passage, without or after 
rupture of the latter, into adjoining cavities or spaces. 
1. Ovarian Pregnancy.—The ovum remains in the ovary. 
Epi-ovarian Pregnancy.—The ovum develops on the ovary, 
having left the Graafian follicle. 
2. Abdominal or Peritoneal Pregnancy.—The ovum falls 
down into the peritoneal cavity, and does not enter the Fal- 
lopian tube at all. 
3. Tubal Pregnancy.— 
I. Tubo-abdominal or tubo-ovarian pregnancy. 
II. Tubal pregnancy. 
III. Tubo-uterine, or interstitial or mural pregnancy. 
4. Extra-peritoneal Pregnancy in the broad ligament after 
rupture of the Fallopian tube. 
5. Pregnancy in one side of a uterus bicornis. 
6. Secondary Abdominal or Peritoneal Pregnancy.—Ovary, 
tube, or even uterus (bicornis or normal) is ruptured, the foetus 
slips into the peritoneal cavity, but remains in connection with 
the primary sac. 
I shall first describe and demonstrate Professor Byford’s 
Case, No. 2. 
The uterus is large, four and a half inches long, three inches 
broad, at the fundus; the cavity also considerably enlarged. 
In left side of uterus and vagina, I find an incision open- 1885.] 
Fenger—Extra-uterine Pregnancy. 
3 
ing, three and a half inches long, closed with silk sutures, 
leading from the uterus and vagina into the sac, or as some 
members of the Society called it, the adventitious uterus. The 
sac can only be seen in fragments. Its wall is one to two 
lines thick, the outside partly covered with peritoneum, partly 
adherent to the surrounding organs, viz., bladder, uterus, 
omentum. The rectum I do not find. Right ovary and Fallo- 
pian tube are missing. 
The left Fallopian tube shows the following conditions : the 
uterine portion is of normal size, passable only for a thin probe, 
one-half mm. in diameter; at the distance of one-half inch 
from the fundus, it is wider, one-eighth of an inch in diameter, 
and so it continues for four inches ; then it suddenly dilates to 
one inch in diameter, continues so for one inch, and thereafter 
opens into the foetal sac, the wall of the latter going continu- 
ously over into the wall of the tube. 
Case II Fig. 1.—Anterior view of sac and pelvic organs, left Fallopian 
tube laid open except in its uterine portion. 
1. Uterus. 
2. Vagina. 
3. Bladder. 
4. Inside of foetal sac. 
5. Fallopian tube dilating and opening into the foetal sac. Fen g e r—Extra- it ten ne Pregnancy. 
[March, 
Case II Fig. 2.—Sac and pelvic organs seen from the left to show situa- 
tion of sac. 
x. The sac. 
2. Dilated end of Fallopian tube opening into or continuous with the wall 
of the sac which partially covers the following organs : 
3. Bladder. 
4. Uterus. 
5. Rectum. 
The left ovary cannot be found. Large shreds of the mem- 
branes of the ovum, viz., amnion and chorion, adhere to the sac 
here and there. Inside of sac is dark, brown-spotted, the color of 
decomposed blood. This condition is most pronounced in the 
part of the sac that covers the posterior wall of the bladder and 
the anterior and posterior walls of the uterus. On the uterus, 
the sac is thinner and more adherent (no sub-serous connective 
tissue) than on the bladder, where the wall of the sac is about 
two mm. in thickness, firm and movable against the bladder. 
From the condition in which we find the left Fallopian tube, 
I think it safe to conclude that the ovum has developed in its 
outer half, near the abdominal end of the tube. The funnel- 
shaped dilatation of the tube in this place and the thickening of 
its wall, which continues uninterruptedly as the wall of the 
foetal sac, prove the connection between the two cavities, and 1885.] 
Fenger—Extra-uterine Pregnancy. 
5 
this case of extra-uterine pregnancy would thus be of the tubo- 
abdominal variety. I believe that the ovum has commenced 
its development in the tube, and then, with or without rupture 
of the latter, has formed its sac on the surface of the pelvic and 
surrounding abdominal organs. In this respect, it might be 
classified as a secondary abdominal or peritoneal pregnancy, 
originating in the abdominal end of the left tube. 
Professor Byford’s Case, No. i—This case has a greater 
interest, partly because the specimen is in a good state of pres- 
ervation, and partly because some of its features seemingly 
point to one, others to another of the varieties of abdominal 
pregnancy. 
In this case, as will be remembered, laparotomy was per- 
formed, and part of the cyst, the placenta and the upper two- 
thirds of the uterus removed. I shall not undertake, here, to 
describe the child, as it is irrelevant to the matter in question. 
We find the uterine appendages of the right side, viz., broad 
ligament, ,round ligament, Fallopian tube and ovary normal, 
(vide Case i, Fig. I.) 
Case I Fig. i.—Anterior view of uterus, its appendices and the extra- 
uterine sac. Fenger—Extra-uterine Pregnancy. 
[March, 
1. Uterus laid open, fine silver wires passed through the uterine portion 
of both Fallopian tubes. 
2. Right Fallopian tube. 
3. Right round ligament. 
4. Right ovary. 
5. Left round ligament, enlarged but in normal position, viz., commenc- 
ing at upper corner of uterus. 
6. Ridge or the upper free border of the pocket (10) containing the left 
Fallopian tube through which silver wires (dotted lines) are passed. It is 
seen that the Fallopian tube only passes through the first two-thirds of the 
ridge, and then branches off, backwards and downwards (dotted line) to 
penetrate into the wall of the sac. 
7. Terminal end of the ridge—probably the left ligamentum ovarii. 
8. The sac. 
9. Place of the placenta. 
10. Pocket on upper posterior wall of sac. 
Cask I Fig. 2.—Inside of the extra-uterine sac seen from below. 
1. Uterus—transverse section of the neck, where the uterus was ampu- 
tated, shows the open cavity of the neck. 
2. The right Fallopian tube. 
3. Right round ligament. 
4. Right ovary. 
5. The wall of the sac. 
6. Inside of sac, with 
7. Place of the placenta right behind the neck of the uterus. 
8. Accessory placenta places. 
9. Large vessels on and in the inside of the sac. 
10. Place where the outer layer of the wall of the sac is separated from 1885.] 
Fenger—Extra-uterine Pregnancy. 
7 
the inner layer because the wall has been cut obliquely here at the operation, 
xi. Probe in the left Fallopian tube. 
12. Oval opening on the inside of the outer layer of the sac, viz., termina- 
tion of the Fallopian tube or cross-cut of the Fallopian tube just before it 
(probably) opened into the cavity of the extra-uterine sac. 
Case I Fig. 3.— Sagittal section through the uterus and the sac showing 
the pocket on the posterior wall of sac. 
1. Uterus. 
2. Cavum uteri. 
3. Space (dissected) between posterior wall of the uterus and anterior wall 
of the sac. 
4. Place of the placenta on inside of sac behind the uterus. 
5. Wall of the sac. 
6. Posterior wall of the pocket, that is, the tubular or Fallopian fold of the 
left broad ligament. 
7. Left Fallopian tube, cross-cut showing its lumen. 
8. Pocket between 5 and 6. 
The uterus, amputated about the middle of the neck, is of 
normal size, viz., the cavity, one and one-quarter inches between 
the two uterine orifices of the Fallopian tubes. Farther down, 
one inch, still lower down one-half inch, and in the neck 
one-fourth inch, broad. The average thickness of the uterine 
wall is one-half to three-fourths inch. To the left and behind 
the uterus and in uninterrupted connection with its surface 
is the sac or adventitious uterus. Fig. I shows the uterus and 
sac seen from the anterior side. From the anterior surface 
of the sac, one-fourth inch from the left corner of fundus, is 
the left round ligament; it is enlarged, one-fourth inch in diam- 8 
Fenger—Extra-uterine Pregnancy. 
[March, 
eter. On the upper surface of the sac, behind and to the left of 
the fundus uteri, is a pocket covered with peritoneum, two 
and one-half inches broad, three to three-and-a-half inches 
deep (vide Case i, Fig. 3). Case 1, Fig. i10. 
The upper free border of the pocket, or broad ligament, forms 
a somewhat thickened ridge, which runs in an arch, first to the 
left backwards, then to the right, then divides into two branches, 
a lower one that runs downwards and to the right, an upper 
one that runs forwards to the left, pointing toward the left corner 
of the uterus. The ridge contains the left Fallopian tube (vide 
Figs. 1, and 3). The tube is seven inches long—the same as 
the right tube. It runs to the left backwards, in an arch, and then 
bends to the right downwards and backwards; here it leaves 
the broad ligament, and the canal enters the wall of the sac. 
How it terminates, if on the inside of the posterior wall of the 
sac (vide Case 1, Fig. 2), or not, cannot be made out for cer- 
tain, because the sac is cut off here ; but as there are no fimbrice 
it does not open outside of the sac, and has undoubtedly- 
opened into the foetal cavity. 
The uterine portion of tube is of normal size, only permit- 
ting the passage of a very fine probe. The median portion of 
the tube is normal, perhaps slightly dilated, three to five lines 
wide. 
The termination of the tube in the wall of the sac, Fig. 2n, 
is an oval opening, one-fourth inch in diameter, the borders of 
which are perfectly smooth, no fimbrice visible anywhere. 
Of the left ovary, no trace can be found. The sac is clad on 
the outside with the peritoneum, and is smooth. 
The wall of the sac is from one to eight mm. thick, 
white and firm. The thickest part of the sac is right behind 
the fundus uteri, one-fourth to one-half inch in thickness, and 
there the tissue, viz., fibers of the uterine tissue of upper surface 1885.] 
Fenger—Extra-uterine Pregnancy. 
9 
of fundus, is continuous with the wall of the sac ; however, on 
the posterior surface of neck and fundus, the tissue of uterus 
is not continuous with the sac, but the latter is separated from 
the uterus by a short layer of connective tissue, that permits 
of dissection and leaves the posterior surface of uterus and wall 
of sac with smooth surfaces. This is the place where the pla- 
centa was situated. (Figs. 27 and 34.) The inner surface of the 
sac has an uneven, ragged or velvety appearance, most 
ragged over the site of the placenta, close to and behind the 
neck of the uterus. Outside of this region, there are numerous 
islands of uneven, ragged appearance, with more smooth spots 
between them. Several large vessels, one-fourth inch in di- 
ameter (vide Fig. 29), are found, partly free, partly adherent to 
the inside of the sac. 
A microscopic examination of the wall of the sac shows the 
following : 
a. In the site of the placenta. 
1. An inner layer of free cotyledons or fimbrice. 
2. A layer of maternal tissue, with cross cuts of the cotyle- 
dons, imbedded in cavities (whether lymph spaces or blood ves- 
sels, I am unable to decide, but they look to me like venous 
blood vessels) tightly surrounding them. 
3. A heavy layer of connective tissue bundles, interspersed 
with some organic muscle bundles. 
4. Peritoneum. 
b. A thick spot in the wall, near the peripheral opening of 
the Fallopian tube into the sac, which I examined to find ova- 
rain tissue, presents exactly the same appearance as a. 
c. A thin place in the sac, some distance from placenta and 
tube, gives, 
1. An inner layer of areolar connective tissue without 
cotyledons. 10 
Fenger—Extra-uterine Pregnancy. 
[March, 
2. A median heavy layer of connective tissue bundles and 
bundles of organic muscle fibers. 
3. Peritoneum. 
d. A third place in the sac presents the same layers as a. 
Nowhere in the wall of the sac, is any trace of ovarian 
tissue to be found. 
In considering the anatomical diagnosis of this case, I shall 
have to take into consideration mural, ovarian, tubo-ovarian 
and tubo-abdominal pregnancy. 
1. Can it be a mural or interstitial pregnancy ? The con- 
tinuity of the sac (in the site of the placenta) with the upper 
surface of the fundus belongs to the signs of mural pregnancy. 
The uterine portion of the Fallopian tube is of normal length 
and width, consequently, the ovum cannot have lodged and 
developed here. However, a persisting “Gartner’s duct” 
might, perhaps (it is doubtful), form a lateral branch of the 
tube and run in the wall of the uterus. Baudelocque, 
“ the nephew,” claims that a mural pregnancy can take place 
when the fecundated ovum lodges in this blind branch. 
Kleinwachter, in his article, “Tubal Pregnancy,” in Eulen- 
burg’s Pincyclopedia, remarks that this statement of Bau 
delocque’s has yet to be proved. 
Aside from Gartner’s duct, there is another anatomical anom- 
aly that might give rise to a mural pregnancy, outside of the 
uterine portion of the Fallopian tube. Through the kindness 
of Professor Jaggard, of Chicago, my attention was called to 
this variety. The ovum may develop in a branch of a bifurcated 
Fallopian tube. Iiennig* (Die Krankheiten der Eileiter und die 
Tubar-schwangerschaft) has an illustration showing a canal 
branching off from the Fallopian tube in the lateral wall of the 
uterus; the branch turns downwards and inwards in the uterine 
* Lusk—“ The Science and Art of Midwifery.” 1885.] 
Fenger—Extra-uterine Pregnancy. 
wall, and opens into the cavity of the uterus at the internal 
os. If the ovum is arrested in this branch, a mural pregnancy 
results. The sac will push the broad ligament and the appen- 
dices outwards and upwards, and we will expect, as in the 
ordinary mural pregnancy, to find Fallopian tube and ovary on 
the outside of the sac, and further, we must expect that the round 
ligament should be dislodged outwards some distance from 
the border of the uterus. Consequently, in our case, we cannot 
admit a bifurcated Fallopian tube as the seat of the pregnancy. 
But supposing a mural pregnancy had taken place here, and 
consequently the uterine portion of the Fallopian tube could 
be found open outside of the sac : then we demand in this case 
certain conditions, that cannot very well be dispensed with, 
and they are the following : 
The abdominal end of the Fallopian tube, together with 
the ovary, must be found somewhere on the outer wall of the 
sac, and opening into the peritoneal cavity. 
Supposing that the ovary, for some reason or other, was not 
found and the abdominal end of the Fallopian tube was oblit- 
erated and buried in the wall of the sac, we might yet have 
had a mural pregnancy. 
In this case, however, the Fallopian tube opens into the 
wall of the sac. If it has opened into the foetal cavity, it can 
not be seen on this specimen. (However it looks as if it had 
probably done so.) 
The round ligament in mutal pregnancy is expected to be 
pushed outwards some distance from the side of the uterus. This 
might be different if the ovum could develop in the posterior 
wall of the uterus; but this possibility has never been proved. 
Gartner’s duct does not run in the posterior wall, but from the 
parovarium first in the broad ligament (in the same fold as the 
Fallopian tube), then in the muscular substance of the lateral 12 
Fenger—Extra-uterine Pregnancy. 
[March, 
border of the uterus and down on the side of the vagina where 
it terminates blindly. 
The sac can be dissected off from the posterior wall of the 
neck and fundus uteri, which looks as if the sac developed on 
the posterior surface and not in the posterior wall of the uterus. 
Thus, although the positive proof against mural pregnancy, 
viz., the opening of the Fallopian tube into cavity of the sac, is 
wanting (the fault of the specimen), then as all signs of mural 
pregnancy are absent, except the apparent continuity of sac wall 
and uterus, I shall declare against mural pregnancy. 
The microscopic examination of Dr. Byford’s Case (No. I), 
(our second Case) does not give any points as to the solution 
of the question of mural or tubo-ovarian pregnancy; the sac 
here consists just exactly of the same elements as I have found 
in a case of abscess of the broad ligament, in a wall as thick as 
the sac in its thickest parts. The presence of organic muscle- 
fiber in the sac, and the continuity or connection between the 
muscle-fiber of sac and uterine wall is of only secondary diag- 
nostic significance, for the following reason : the organic mus- 
cle fiber or cell belongs to the proletaires (so to say) amongst 
the tissues ; it is of the connective tissue class, can be formed and 
found everywhere where connective tissue is formed and found. 
In fibro-myomata or myo-fibromata, it is often impossible to 
determine what is a muscle cell and what is a spindle-shaped 
connective tissue cell. Consequently, continuity between mus- 
cle-fiber in sac and muscle-fiber of the uterus does not mean 
that the former originated in the latter. 
The next question then is this: Is it an ovarian, tubo-ovarian 
or tubo-abdominal pregnancy ? 
In an ovarian pregnancy, we require, (i.) that the Fallopian 
tube does not participate in the formation of the sac (Klein- 
wachter). (2.) Ovarian tissue is found in the wall of the sac. 1885.] 
Fenger—Extra-uterine Pregnancy. 
13 
(3.) That there is a connection between the sac and the uterus 
through the ligamentum ovarii. 
Of a tubo-ovarian pregnancy, we would require (1), that the 
peritoneal end of the Fallopian tube participates in the forma- 
tion of, that is, opens into the sac, (2), the ovary may be intact, 
but it may also have been used up in the formation of the sac 
and have disappeared either entirely or only remnants may be 
found in the wall of the sac. 
(It is easy to see how difficult it may be to find microscopic 
remnants of ovarian tissue in the wall of a sac one hundred 
times or more the size of a normal ovary). 
As near as we, in my opinion, are able to to come to an exact 
diagnosis in this case, I should pronounce it a tubo-ovarian 
pregnancy. 
The exact location of the spot where the fecundated ovum 
. j*v 
has commenced development, it is of course impossible to 
prove to satisfaction. Still there is one interesting feature in 
this case, which, in my opinion, throws some light on this point. 
This is the pocket, the blind pocket, on the upper wall of the 
sac behind the uterus, (vide, Fig. i10, and 3s.) As before stated, 
the upper side of the posterior wall of the pocket, viz., the 
ligamentum latum, or the Fallopian fold of this ligament, 
forms a circular figure, commencing at the left border of the 
fundus and terminating at about the same point; from the con- 
nection between the middle and outer third, a branch goes off 
downwards and to the right. The Fallopian tube is contained 
in the first two-thirds of the ridge and in the branch. The 
final third of the ridge, that does not contain the tube, but runs 
back towards the left corner of the uterus, would, in my opinion, 
correspond with the ligamentum ovarii. (Case I, Fig.i7) The for- 
mation of the pocket, clad with the peritoneum and having as 
upper border, the above-described ridge, can, in my opinion, 14 
Fenger—Extra-uterine Pregnancy. 
[March, 
be explained if the ovum has been arrested and commenced 
development in the ligamentum “ infundibulo-ovarianum ” 
(Henle) between the fimbrice that line the sulcus leading from 
the distal end of the ovary to the ostium abdominale of the 
tube. If the ovum is developed here, it can, with the vessels 
of the chorion, first, reach the abdominal ostium of the tube, and 
thus permit the tube to open into the sac. Second, it can reach 
down on the lower or posterior surface ot the ovary, and thus 
during its growth lift up the ovary at the same time as it destroys 
it, but in lifting it up, preserve and enlarge the peritoneal fold 
or pocket that normally exists between the posterior sur- 
face of the peritoneal fold containing the Fallopian tube and the 
anterior surface of the peritoneal fold containing the ovary and 
the ligamentum ovarii. 
In case the fecundated ovum, from the ruptured Graafian 
follicle, had dropped down below the ovary, and had been 
arrested or taken hold on the peritoneal surface of 
Douglas’ fossa or on posterior surface of ovary, if a develop- 
ment in such a way and place is possible, the pocket could 
be formed of course, but we could not expect to have the Fal- 
lopian tube open into the wall of the extra-uterine sac. If the 
pocket in question is formed in cases where the ovum has 
been arrested in the peripheral end of the tube, I do not know, as 
my access to original literature on this subject has been 
extremely limited, and the common text and hand-books, of 
course, do not contain anything like a detailed description of 
any of the cases in question. 
In the proceedings of the meeting of the Gynecological 
Society of December 19th, 1884, Professor W. H. Byford is 
recorded to have said, (Chicago Medical Journal and Exam- 
iner, Jan., 1885, p. 64) as follows: in the first Case (our Case No. 
II, where operation was performed), he thought that the fecun- 
dated ovum had passed through the tube, but found some Fenger—Extra-uterine Pregnancy . 
15 
diverticulum in the uterine cavity, had passed into the uterine 
wall and developed in this region, pushing the wall before it. 
The muscular element of the sac was directly continuous with 
the uterine muscle. Further, p. 64-65 : “It is not necessary for 
the production of mural pregnancy that the tubes be involved.” 
A Diverticulum in the uterine wall that would permit the 
ovum to develop down between the muscle in the wall, is as 
far as I know, not known or proved, but such a condition 
might be accepted in a proved mural pregnancy in which 
the Fallopian tubes were not involved. 
A Gartner’s Duct, as place of development for the ovum, is 
not proved either. But accepted as a possibility, let us see 
what would be the consequence. The ovum would be arrested 
either in the extra- or the intra-uterine portion of the duct. (I 
do not know of any communication opening between Gartner’s 
Duct and the Fallopian tube; does it exist?) If developed in 
the extra-uterine portion of the duct, that runs in the Fallopian 
fold of the broad ligament, the formation of the pocket in this 
Case (No. I) would be impossible. The ovary might disappear 
and the tube might run in the wall, but ought to open into the 
abdominal cavity. 
If developed in the intra-uterine portion of Gartner’s Duct, 
we would expect to have the Fallopian tube and the ovary 
intact on outside of sac, just the same as in mural pregnancy 
from the uterine portion of the Fallopian tube. How great 
value in diagnosis of mural pregnancy, the fact has, that the 
muscle of the uterus is continuous with the muscle of the 
sac, I do not know; but in this case, apparently only the layers 
of the surface of the uterus are continuous with those of the sac, 
and in mural pregnancy I would rather expect to have the 
deeper layers participate also. 
In conclusion, I shall proffer my thanks to the Society for 16 
Fenger—Extra-uterine Pregnancy. 
[Mar.,1885. 
the honorable task entrusted to me, and ask its pardon in that 
the material in question, and the literature at my disposal 
have not enabled me to give a more satisfactory report of the 
matter. 
214 East Ohio Street, Chicago.