If Mayrhofer's views are correct the entire theory of an ovular migra tion falls to the ground; the corpus luteum might be found upon either side, since it would belong not to the impregnated egg, but to some sub sequent ovulation. We would only be forced to admit migration in those cases in which the ovary corresponding to the pregnant tube or uterine horn was entirely wanting; in which case Mayrhofer (there is but a single one, Weber's migration case No. XIII.) himself must admit it. But since even in this case the tube on the ovarian side was very short 21 inches, while it was longer on the other side (4-1 inches), Mayrhofer seems inclined to regard the anomaly as due rather to an adherence of the right tube to the left ovary than as due to ovular migration.
We ourselves agree in part with Mayrhofer's criticisms, since we have several times failed to find those regular changes in the corpus luteum which are described as characteristic of the various stages of pregnancy. We have often sought in vain for a true corpus luteum in women who had died during pregnancy or shortly after delivery. We cannot therefore regard it as absolutely settled that the finding of a so-called corpus luteum venni while the ovum has developed in a rudimentary horn of the uterus or the tube on the opposite side as proof positive of ovular migration.
Conrad, Langhaus and Leopold, do not agree with Mayrhofer, and regard the above cases as true examples of migration of the ovum.
Diagnosis.—There are no special symptoms which occur during the early development of an ovum implanted outside the uterus, and the physician will seldom be in a position to diagnosticate this dangerous occurrence early.
But under certain circumstances it does seem possible to recognize the condition positively and at an early stage. These are present when the abdominal walls are thin; when all the uterine signs of pregnancy are well marked; when the body of the uterus is not as large as it ought to be at that period; and when there is a large tumor in one or the other tube. Of course there might well be hydropsy of the tube; but if it chanced that we had examined the woman's genitals before, and could exclude such a tumor, we might, I think, succeed in diagnosing a tubal pregnancy at the third month. But interstitial pregnancies, and certain forms occurring in rudimentary uterine oornua could hardly be diagnos ticated in their early stages.
Sudden and violent internal hemorrhage after previous good health in a pregnant woman, together with the passage of decidua, will warn as that extra-uterine pregnancy is present.
If the woman survive such an early rupture, the effused blood some times forms a tumor larger than the foetal sac itself. This often renders
the diagnosis almost or quite impossible between a simple htematocele and an early extra-uterine pregnancy.
But when the ovum has attained the size of the third or fourth month, and when the recurrent circumscribed peritonitides cause symptoms not usual in normal pregnancies, the physician may be led to suspect the existence of the malady in question.
But very careful and long-continued examinations with all the meth ods at our disposal will be necessary before this suspicion becomes a certainty. We will endeavor to sketch the development of such a diag nosis.
As soon as the suspicion is awakened that the woman may be suffering from extra-uterine pregnancy, we need, first, an exact anamnesis and exploration for our diagnosis. As usual this consists in determining the existence of pregnancy, and deciding upon the existence of a foreign tumor besides the uterus in the pelvis.
The woman will tell us that pregnancy has occurred. Absence of the menses and the usual nausea will be present; but we must not be misled by the subsequent appearance of bloody vaginal discharges. Swelling of the breasts, relaxation and hyperemia of the genitals, and especially the swollen condition of the vaginal portion of the cervix as seen with the speculum; the enlargement and softening of the entire womb, as revealed by bi-manual examination; the softening of the cervix; all these will tell a practised observer that conception has occurred.
Once certain of this, and finding that the size of the uterus does not correspond to the supposed stage of pregnancy, we must search for a tumor near the womb. If we find it, it is a further starting-point in our diagnostic progress.
We have now to prove that the tumor in question contains the foetus, and that the uterus is empty. For this purpose careful bi-manual palpa tion by vagina, rectum, and abdominal wall is to be undertaken, narcosis being employed, if necessary. This portion of the diagnotfis is often extremely difficult; for the extra-uterine growth lies so close to the womb, is so little movable, and the uterus itself is so soft, that it is hard to tell whether the tumor does not belong to the uterus itself. But sometimes, when in a non-sensitive woman we have thin abdominal walls and a wide vagina, the diagnosis is not so difficult. Sometimes, on the other hand, it is almost impossible, and we will long remain in doubt as to whether we have an intra-uterino or an extra-uterine pregnancy to deal with.