We once had occasion to examine a woman who had become very sick at a time when she imagined herself to be five months pregnant. The placenta she gave birth to was, according to several physicians, the pla centa of a five-months' pregnancy. The midwife, after waiting several hours for the foetus, tore the cord. In the fossa recto-uterinum we sub sequently found a tumor in which, by vaginal and rectal touch, we could plainly distinguish the head and limbs. It was the encapsulated fcetus. The exact contrary has also occurred, the foetus being born and the pla centa encapsulated in the tube or abdomen. (See Fig. 12.) Secondary Abdominal Pregnancy.
Those extra-uterine pregnancies in which the foetal sac bursts, and the woman not only survives, but the foetus, nourished by a placenta im planted in its usual site, continues its development in the abdominal cav ity, are of great interest. Patuna and Walter have recorded such a case; and we ourselves have during life diagnosticated a case as one of extra uterine pregnancy, and extracted an asphyxiated child by laparotomy, after the woman's death. The necropsy showed that the ovum had originally grown at the abdominal end of the tube; at the fourth month rupture had occurred, and the placenta remaining where it was, the foetus had established a second cavity for itself in the abdomen. The case is a peculiar one, and we will give its history briefly.
C. M., thirty-five years old, three children, entered the Lying-in In stitute November 20th, 1871. She was the first of the pregnant women that I examined. She looked thin and suffering, and told us that five years before she had an eight-pound child, and two and a half years ago one weighing seven pounds four ounces. Both were normal deliveries. At the beginning of April she menstruated for the last time, but lost much less blood than was usual. No hemorrhage since then. For the first two months of pregnancy she was well, but since then she has con tinually been suffering. At the third month abdominal pain began; she lost flesh and strength, and has been in the Rudolf's hospital most of the time since then.
I found the abdomen distended to the size of full term. Its largest diameter, taken two inches above the umbilicus, was fifty inches. Over the entire abdomen the percussion note was flat, and fluctuation was dis tinct everywhere. The abdominal tumor was distinctly divided by a deep furrow running from below, and on the left side upwards and to the right. In the furrow, which included the upper two-thirds of the abdomen, the child, some six pounds in weight, could be felt lying transversely with its head to the left. The heart sounds were audible somewhat to the left
of the ensiform cartilage, and the movements of the child left no doubt as to its being alive. There were no distinct upper boundaries to the tumor.
The lower tumor seemed to occupy the entire space between the crests of the ilia, and reached, as before said, two inches higher upon the right than upon the left side. It was elastic, especially to the right, and no foetal parts could be detected in it. Nor could any be felt by vaginal touch. The vaginal portion of the cervix was drawn behind the symph. oss. pub.; the cervix was soft, the os open, and I could introduce two fingers deeply into the cavum uteri. I could feel no amniotic sac, nor could I make out that the cervical canal communicated with the upper cavity which contained the fcetus.
Bi-manual examination showed an elastic tumor about the size of one's head, lying upori the right ilium; the left side of the uterus appeared to be empty. Two days later the sound was used; it entered four inches, and to the left. By cautious movement towards the tumor at the right of the uterus, the sound was easily passed in 8.8 inches, so that its point could be distinctly felt in the region of the umbilicus. This somewhat clouded the diagnosis of extra-uterine pregnancy, since, if we were mis taken as to the nature of the tumor at the left of the uterus, the sound may simply have been passed into an ordinary pregnant uterus, or into the dilated cavity of a uterus bicornis or duplex, or there might be an intrauterine as well as an extra-uterine pregnancy. At all events, we had to find out where the sound had gone to. We might have entered the tube, or perforated the uterus. This latter appeared quite probable. The uterine tumor which we felt might be the placenta, or, judging by its consistency, it might quite probably be an ovarian cyst. On Novem ber 29th the woman was again sounded in the presence of Professors Spiith and G. Braun. The sound entered ten inches, and was felt as be fore. The index finger could easily be introduced into the uterine cavity, and the fundus pressed down from without upon it. The organ was empty; and there was not either in the right wall, nor in the cervix or vagina, any opening which might speak for duplexity of the uterus. The tumor upon the right side we determined was an ovarian cyst. A piece of decidna two and a half inches square was cast off during the examination. The examination decided the diagnosis in favor of extra-uterine preg nancy with a well-developed foetus.