I Reprinted from Annals of Gyn/ecology and 
PjEDIATRY. January, 1891. 
A Case of Extra-Uterine Pregnancy; Operation at the 
Ninth Month; Recovery. 
BY ERNEST W. CUSHING, M.D., OF BOSTON, 
Surgeon of the Womans Charity Club Hospital. 
(With Plates 1 and 2.) [Annals OF Gynaecology and Podiatry, January, 1891.] 
PLATE I. 
Fig. i. 
Extra-Uterine Pregnancy at Ninth Month. 
A Half of Placenta, which lay External to Sac, and was in a State of Fatty Degeneration. 
B Half of Placenta, which lay in Sac, and was Alive and well supplied with Blood. 
C Twists in the Cord, which appear to have caused the Death of the Child. 
[See Page 214.] [Annals of Gynaecology and Podiatry, January, 1891.] 
plate n. 
Fig. 2. 
Extra-Uterine Pregnancy. 
The Reverse of previous Plate. Same explanation of letters. 
[See Page 214] A Case of Extra-Uterine Pregnancy; Operation at th£ 
Ninth Month; Recovery.1 
BY ERNEST W. CUSHING, M.D., OF BOSTON, 
Surgeon of the Woman s Charity Club Hospital. 
(With Plates i and 2.) 
On the 13th of October, 1890, in 
consultation with Dr. Frost, of Pea- 
body, Mass., and Dr. A. Kemble, of 
Salem, I saw a patient of the former, 
a woman of thirty-two years, who had 
been married over ten years without 
the occurrence of conception at any 
time. She had menstruated last in 
March, but there was an irregular 
discharge in April, lasting, with inter- 
missions, for several weeks. There 
were no subjective signs of preg- 
nancy at any time ; the breasts were, 
however, full and large, and contained 
abundant colostrum. 
Examination of the abdomen show- 
ed a large, irregular mass, somewhat 
to the right of the median line, and 
about the size of a child at term ; in 
the right iliac fossa there was a 
softer mass, completely filling it, and 
continuous with the main body of the 
tumor. This part of the abdomen 
was very painful, and a placental 
souffle could be plainly heard low 
down on the right, but the most care- 
ful ausculation failed to reveal any 
foetal heart-sounds. Dr. Frost, who 
had watched the case very carefully, 
and had noticed the placental souffle 
for more than a month, had never 
been able to detect any foetal heart- 
sound. 
Examination by the vagina showed 
a rounded mass of the size, shape 
and hardness of the foetal head, 
above and behind the uterus. The 
small cervix, which could be felt, 
high up, behmd the symphysis, ap- 
peared to be at right angles with this 
mass, which, therefore, seemed to be 
contained in the uterus. It did not 
seem possible to decide surely that 
pregnancy was present, in view of the 
utter absence of heart-tones, foetal 
movements, uterine contractions, or 
any subjective symptoms of preg- 
nancy. 
Nevertheless, it was agreed that 
the probability was greatest that there 
was a pregnancy, either extra-uterine 
or complicated by the presence of a 
tumor. As the woman was in good 
condition, able to be about, and well 
nourished, although suffering much 
pain, it was agreed to wait for some 
few weeks before attempting any op- 
1 Read by invitation before the Obstetrical Society 
of Boston. A CASE OF EXTRA-UTERINE PREGNANCY. 
eration, unless some condition should 
supervene calling for interference. 
On November 6th I again saw the 
patient in consultation, and learned 
that for some ten days her condition 
had been decidedly worse; there was 
more pain, she was confined to her 
bed, could not take nourishment, had 
some elevation of temperature, and 
in fact was running down. Careful 
examination showed that the tumor 
was not in the uterus, which was 
crowded to the left and toward the 
symphysis, and was of nearly normal 
size. The placental souffle was less 
distinct; fluctuation could be detected 
on the left of the tumor. It was 
agreed that probably extra-uterine 
pregnancy, with a dead foetus, was 
present, and that in any case imme- 
diate interference was required. 
Operation on November 8th, in 
presence of Drs. Frost and Kemble, 
and with the assistance of Drs. 
Brigham, Ingraham and Wolcott, of 
Boston. The median incision passed 
at the very border of the mass on the 
right, and the peritonaeum was found 
very thick and vascular. On passing 
the hand into the abdomen, it seemed 
as if the mass must be malignant, 
but on carefully working toward the 
left, and separating the adherent 
omentum over the fluctuating part of 
the tumor, the thin cyst suddenly 
ruptured and a large quantity of foul, 
yellowish fluid was discharged with a 
great gush. The stench was almost 
intolerable. A moment later, on en- 
larging the opening, a full-grown 
foetus popped out, breech first. It was 
dead and macerated. 
The upper part of the cyst was 
found to consist only of the amniotic 
membrane, with adhesions and ad- 
herent omentum, and very little of it 
could be removed. The lower part 
of the sac, however, was very thick, 
and apparently was formed of the 
Fallopian tube, firmly adherent to the 
tissues of the right iliac fossa. Half 
of the placenta was contained in this 
thickened part of the sac, and half 
was outside of it, extending on the 
under side of the abdominal wall to a 
little over the median line, and adher- 
ing to the omentum. This upper 
half of the placenta was in a state of 
fatty degeneration, and was easily re- 
moved, carrying with it the insertion 
of the cord, and tearing off so readily 
from the other half that I thought 
that I had the whole placenta re- 
moved. I was therefore distressed to 
find the other half reaching far down 
into the sac, rather firmly adherent, 
and bleeding when detached. Never- 
theless, I succeeded in removing it 
without serious haemorrhage, stuffing 
the sac with iodoform gauze. The 
insertion of the Fallopian tube, which 
joined the sac to the uterus, was now 
tied off, leaving the thick walls of the 
cup-shaped cavity free except at the 
bottom, and on the right low down. 
I did not think it safe to try to re- 
move this thick tissue, but gathered 
the upper margin of it into a sort of 
ring, which I sewed firmly to the 
lower part of the abdominal incision. 
The abdominal cavity was thoroughly 
washed out with hot Hygeia distilled 
water and two drainage tubes inserted; 
one, to drain the peritoneal cavity, was 
carried through a new small incision 
to the left of the main incision, and 
passed to the left of the sac down to 
the bottom of the space of Douglas. 
The other tube was carried to the 
bottom of the sac, and iodoform gauze 
was packed around it. One part of 
the sac, which could not be brought A CASE OF EXTRA-UTERINE PREGNANCY. 
up to the abdominal wall, was shut 
off from the abdominal cavity by the 
gauze very carefully. 
The recovery was uneventful. The 
abdominal tube was removed on the 
third day, and the tube from the sac 
was taken out at the end of a week. 
The cavity of the sac contracted rapid- 
ly, being kept thoroughly clean and 
always full of iodoform gauze. Aristol 
was also dusted into the sac very 
freely. It never suppurated, but con- 
tracted and filled up, until only a 
small sinus remained, which gradually 
closed. The patient left her bed five 
weeks after the operation.1 
1 January ist, patient has recovered entirely.