The woman was fairly well while in the institution, walking upstairs to the second story three hours after this last sounding. Laparotomy was refused.
On Decem.er 1st some more decidua came away with expulsive pains. Peritonitis set in, and the woman died December 3rd at noon. I extracted a living child by a regular laparotomy. The infant breathed three times, and died.
Nest day Dr. Kundrat performed the post mortem. In the abdominal cavity were ninety ounces of a dirty serous fluid; but no membranes of the child (which weighed eight pounds) could be found. The omentum was adherent to the anterior abdominal wall, the peritoneum was injected and covered with fibrinous effusion. On lifting the small intestine we could see the secondary cavity, in which the foetus had lived for many mouths. The anterior and lateral walls of this cavity were formed by the abdominal wall, which was covered with a pseudo-membranous effusion .2 inches thick. The posterior and upper walls were formed to a small extent by the posterior abdominal wall, but mostly by the intestines, large and small, which were matted together by pseudo-membranous plates and bands. The uterus lay to the left, and reached 3.2 inches above the pel vic brim. It was 5.2 inches long, and near the right tubal ostium showed the place where the sound had perforated. The left ovary was of nor mal size. The right, half as large, was attached, together with the right Fallopian tube, to a tumor six inches long, 4.8 inches broad, and four inches thick. This tumor lay mostly upon the right ilium, but projected into the pelvis. It was united to the posterior vaginal wall by dense ad hesions, and contained the placenta. Its walls were dense, and two to three lines in thickness. Towards the uterus, at the level of the pelvic brim was a round hole one inch in diameter, the sharp border of which reminded one of the falsiform process of the fascia lata. Through it the umbilical cord passed to the placenta. Around the opening were the wrinkled brownish yellow remains of the decidua, evidently belonging to an earlier period of the pregnancy.
These cases are very rare; in most instances the fetus dies at the mo ment of rupture, or soon after.
One termination of tubal pregnancy, which is interesting from an anatomical point of view, and does not appear to be so very rare, has been described by Kiwisch. As a rule the dilated tube ruptures towards the peritoneum. But in some cases it breaks along the attached border, and the gradually works its way into the layers of the broad liga ment, and thus the foetal envelopes are reinforced by a layer of muscular fibres. Loschge long ago described a similar case; Beaugrand mentions it (glob), and Deceimeris called this pregnancy " Grossesse sousperitonee plvienne."
While at one side of the uterus an extra-uterine pregnancy is going on, the tube upon the other side may be patent, and a uterine as well as an extra-uterine pregnancy occur. Such cases do not seem to be of rare occurrence, and, according to Schroder, have been recorded by GOss mann, Pollischeck, Cook, Sager, Landon. Pollak, Argles, Rosshirt, Clarke, Pennefather. In the two latter cases the termination was favorable for the mother. Rosshirt removed, three days after the easy delivery of the intra-uterine child, the extra-uterine one by vaginal incision and the for ceps. It was dead, and the mother perished from hemorrhage into the foetal sac. II. P. C. Wilson removed an extra-uterine child by laparot omy twenty-five days after the natural delivery of an infra uterine one at term. An intra-uterine fretus may also be removed by premature expul sion, while another continues its development in the abdomen.
After an extra-uterine pregnancy has terminated in the formation of a lithopwclion, the woman may again become pregnant. She may have a normal childbirth, or the extra-uterine foetus may form an obstacle to delivery, or the pregnancy may cause inflammation in the abdominal sac. Thus Anna Muller, the mother of the lithopcedion of Leinzell, had two healthy children afterwards; and Hugenberger of Moscow did a Caesarean section on account of the hindrance to delivery offered by the mass; and Dr. Possi of Gratz, three times procured abortion for the same cause. Barnes relates a case as follows: "A woman twenty-eight years old, who had had one child, became pregnant again. At the end of the ninth month pains set in; but they gradually relaxed, the swelling diminished, and a hard, painless tumor remained behind upon her right side. The woman conceived again, and bore a healthy child at term. The tumor seemed unaffected, but five days later high fever set in, with diarrhoea, pain in the tumor, and profuse, foul-smelling sweats. After nine weeks fluctuation was distinct in the tumor, it was opened, a large amount of foul-smelling pus came out, and a fully-developed foetus was extracted through the wound. The placenta was cast off with suppuration, the woman suckled her child, and got well." Similar cases of pregnancy after calcification of the foetus have been recorded by Faber, Johnstohn, Day, Stolz, Terry, Hennigsen, Haderup and Greenhalgh (two cases). In Haderup's cases the bones of the extra uterine foetus were evacuated by the rectum, while the regular pregnancy ending in normal birth was going on.