As we have stated, the uterus may be displaced in various ways by the tumor; it may be raised, or depressed, or pressed to one or the other side; it is most easily demonstrated when the ovum is developing in Douglas's cul-de-sac, and the womb is pushed forwards and upwards.
The uterine sound may be used to ascertain the size of the viscus and the absence of the product of conception from its cavity. But it should only be employed when we already feel certain that the organ is empty, as otherwise it might easily lead to abortion. Nor must we lose sight of the softness of the uterine walls in extra-uterine pregnancy. As a rule bi-manual examination will give us more certain information than will the sound.
To decide whether the tumor near the uterus is the foetus it will be necessary either to recognize its contents by palpation, or to hear the foetal heart sounds. This also can probably be most readily accomplished when the ovum is developed in the abdominal end of the tube, and, having sunken into the cavum recto-uterinum, can be readily reached with the finger from vagina or rectum. We were able in this way to follow exactly in one case the development of the ovum from 31 to over 4 months. Before the third month, even under these most favorable circumstances, the contents of the fist-sized tumor could not be recognized; we could only assert the probability of an extra-uterine pregnancy from the con comitant signs of gravidity. At first the lower periphery of the tumor lay somewhat lower than the ostium externum uteri, and pushed the pos terior vaginal wall down and the uterus upwards and to the right. Both uterus and tumor were but little movable. A distinct furrow separated the one from the other, and by the beginning of the fourth month the tumor had the feeling of a cyst in which was a movable solid body. Towards the end of the fourth month we could plainly get ballottement from vagina and rectum. This rendered our diagnosis extremely probable, especially in conjunction with the other signs of pregnancy.
But other tumors may resemble a fetal sac in all these respects, and the practitioner will do well not to make an absolute diagnosis of extra uterine pregnancy until he can appreciate the certain signs of foetal life, active movements, and the heart sounds. In the above case we heard
the heart-beats two weeks later, and the woman began to feel life; and this rendered the diagnosis a positive one Since in most cases which come under early observation the ovum has developed in the abdominal end of the tube and consequently remains, so long as its size permits, in greater or less part within the pelvic canal, it is probable that at the third and fourth month many cases will behave as in two which we observed. In these cases the fcetal sacs had fallen into Douglas's and had displaced the uterus forwards and upwards, just as a hwmatocele would have done. Since the uterus is often mark edly laterally displaced also, we will probably be able to decide upon the side of the abnormal development. Thick abdominal walls will of course render bi-manual examination difficult; but if necessary a rectal examina tion may be used to enlighten us, always bearing in mind the fact that the sac enveloping such a foetus is very delicate and may easily bo ruptured by inconsiderate manipulation.
If the extra-uterine pregnancy lasts over the fourth month, the ovum will be as large as two fists. If now the abdominal parietes are not too thick, we may with care make out the contours of the kettle by percussion and auscultation, and even feel its separate parts.
The further advanced the extra-uterine pregnancy, the less informa tion can we obtain from rectal and vaginal examination as compared with abdominal palpation, since the product of conception lies higher the larger it gets. But through the abdominal walls we may then feel the contour of the child, appreciate its voluntary movements by touch and sight, and hear the fcetal heart-sounds. There are, of course, many exceptions to this. Thick abdominal wall, manifold adhesion of the fcetal envelopes, and the occasional thickness of the capsule of the ovum, may prevent acourate definition. But in all the cases that we have observed it was easy to make out all these points. Occasionally, even in advanced preg nancy, we may be able to appreciate per vaginam the fcetal head or the limbs.