June 10.—Was easy and free from pain when we first saw her: the souffle is heard over a smaller extent; in the centre of the space where it is heard it is as remarkably loud as ever, but it gradually becomes indistinct towards the circumference. As she was able to rise we examined her standing: the os uteri is exceedingly high up to the left sacro-iliac symphysis, so that it can scarcely be reached; the cervix is short, the lips somewhat larger than usual, and the whole very firm and immoveable. The anterior portion of the uterus, to be felt through the vaginal parietes, is somewhat firmer and larger than usual: on pressing the tumour in the left hypogastrium, this appeared to lie altogether anterior to the uterus. Little motion is communicated to the os uteri when this is moved.
June 20.—Has been in much suffering since last report; much emaciated; complains of a fetid taste in the mouth; bowels inclined to be purged; stools of a whitish purulent appearance; tongue clean; pulse tolerably natural; has continued to pass portions of fibrinous matter from the vagina, mixed with bloody mucus, since last report. The hard globular swelling at the left side of the abdomen is more distinct at times: the hand can almost pass round it: it has the precise feeling of the head; the mass which lies across the abdomen is also more distinct: the souffle is heard over a much smaller space and is diminished in strength.
June 27.—Much the same, except that, after severe bearing down and tenesmus, she has passed a considerable quantity of blood from the rectum and vagina. The little prominences on the right side, presumed to be the extremities, are remarkably distinct, like two heels or knees.
July 18.—No material change has taken place since last report; she has suffered from irregular attacks of pain, and has had repeated discharges of blood from the vagina, which always give relief; is weaker than usual, and feels exhausted from the continued character of the pain; abdomen less swollen; the globular mass on the left side is lower and much nearer to the median line; the little prominences on the right are also lower, and nearer the median line; the whole mass appears much more compressed together and nearer to the pubes; it is extremely painful on the left side, and at the most painful spot the skin is red and inflamed; the bowels, appetite, &c. are natural; pulse feeble, but regular; scarcely any trace of souffle to be heard.
Shortly after this she left the hospital, and for some time continued to enjoy tolerable health, occasionally suffering from severe paroxysms of abdominal pain; the abdomen diminished considerably in size, and the various prominences became indistinct.
In May, 1839, she was again admitted in a state of great exhaustion from constant severe pain. The abdomen had diminished still more, and a portion of the mass had descended between the uterus and rectum; the constipated bowels were moved with great difficulty, but with much relief. The symptoms gradually diminished, and she was discharged in the first week of the following August.
In January, 1840, she returned to the hospital, all her former sufferings being greatly aggravated. The abdomen had subsided still farther; early in February she passed a quantity of putrid purulent matter from the rectum, after which the abdomen diminished considerably. The pain appeared to be chiefly situated in the upper part of the rectum, accompanied with severe bearing down, and on examining per vaginam the mass was felt deep at the posterior part of the pelvic brim: the debility and emaciation increased, and she died early in February. Our notes of the post mortem examination were as follows:—
Much emaciated, abdomen concave, but on pressing it the tumour can be felt at the brim of the pelvis. On opening the abdominal cavity, the mass was found adhering firmly to the neighbouring intestines, and on the right side to the soft linings of the pelvis: it was of an irregular form, with spots of livid vascularity in different parts: on the upper and left side of it, fetid purulent matter was seen exuding from a small orifice. The uterus was below, its fundus pushed over to the left side. On separating its adhesions, and attempting to raise the sac from the pelvis, the half-softened parietes gave way, and the decomposed putty-like mass of the fœtus became visible; the cranial bones were at the left side; the feet were still distinct on the right side; the whole was immersed in a quantity of thick fetid pus, and there were no traces either of umbilical cord or placenta.
Cases of ventral pregnancy have been recorded where the child has remained in the mother’s abdomen without producing any dangerous symptoms, and where she has again become pregnant in the natural way. The earliest instance of this sort was recorded so long ago as by Albucasis. A very interesting case of this nature is described by Dr. Bard of New York. (Med. Obs. and Inquiries, vol. ii. p. 369.) It was the patient’s second pregnancy; at the end of nine months she had pains, which after a time went off; the tumour gradually diminished somewhat, and in about five months after she conceived again, and in due time was delivered, after an easy labour, of a healthy child. “Five days after delivery she was seized with a violent fever, a purging, suppression, pain in the tumour, and profuse fetid sweats:” an abscess formed in the abdomen, which was opened, and a vast quantity of extremely fetid matter was discharged; the opening was enlarged, and a fœtus of the full size was extracted. Dr. Bard “imagined the placenta and funis umbilicalis were dissolved in the pus, of which there was a great quantity.”
It becomes a question of deep interest whether it be really possible to save the patient and the child in cases of ventral pregnancy, by performing gastrotomy. The separation of the placenta from the walls of the cyst can only be effected with much difficulty and hazard; indeed, we are at a loss to conceive how it can be removed with any degree of safety, where the child has been found alive. The attachment in these cases was more than usually firm, and it has been left to undergo that process of solution which has been described in Dr. Bard’s case. In all the cases where gastrotomy has been performed some time after the child’s death, little or no trace of the placenta has been found, but in its place a quantity of ill-conditioned purulent matter, which was excessively fetid.