“Case of Extra- Uterine Fetation.
June 5th, 1820—I assisted Dr. Parrish in the examination of the body of Mrs. Henrietta Ware, widow of the late Captain David Ware, near the Swedes’ Church, Swanson street, Philadelphia.
Autopsy twenty-four hours after death. The patient had been under the care of many physicians during the long period of suffering to which she had been subjected; whose opinions of the case were various, none apparently being convinced of the true state of the patient. The last prescribing physician was Dr. Thomas T. Hewson, who was absent from the city when the patient died.
The history of the case, which we received from the friends of the patient, is as follows. Seventeen years ago, that is to say, in the year 1803, Mrs. Ware was married. At the usual final period of gestation, Dr. Dunlap was consulted as accoucheur, who, upon examination, declared that none of the usual symptoms of approaching labour could be distinguished, notwithstanding the regular occurrence of pain, &c.—and the tumor was referred to some other cause, to ovarian dropsy, or enlargement of some other part. Professor Wistar was subsequently consulted, who concurred in the opinion of the accoucheur; and the patient was treated accordingly, but without relief.
The uterine system soon resumed its natural function, and the patient had only ceased to menstruate three months previous to death. The disease finally assumed a hectic form, which eventually terminated a life of much anxiety and pain.
The patient herself, as well as her most intimate friends, always insisted that a living child had existed in utero, a conclusion to which they were led by what they conceived to be indisputable evidence. Although the patient had continued for many years in the connubial state, she never subsequently conceived. Her body was examined at her own request.
Autopsy.—On the examination of the abdominal tumor externally, the existence of bone within was evident to the touch. On grasping the integuments, which had become extremely thin from absorption, the bones of the foetal cranium could be made to overlap each other. There existed two small fistulous openings through the linea alba, just below the umbilicus, through which there had been for some time an extremely fetid discharge; the integuments adhered firmly over the anterior part of the tumor, particularly at the upper portion.
The tumor occupied a central position in the abdomen, but forced, by long continued pressure of the muscles, deep into the cavity of the pelvis, and measured about seven inches in diameter.
Some portions of intestines adhered to the sides of the tumor; these were left attached, and the whole mass removed from the body. The bladder occupied its usual position. The uterus was perfectly natural in size and structure—not the least appearance of a cicatrix was observable on opening its cavity; on the right side, the fallopian tube, the ovary, and ligamentum rotundum were natural: on the left, the ovary had either been removed by pressure and absorption, or destroyed in the dissection; the os tincai and vagina were also of natural appearance.
On opening the sack, the contents proved to consist of a full grown male fetus, presenting the position of a breech presentation, or fourth position of Baudelocque. It was more or less destroyed by putrefaction in those parts which had been exposed to the fistulous openings in the sack: the parietal bones were nearly bare, the scalp being nearly destroyed ;—the soft parts in general, as well as the cartilaginous epiphyses, were destroyed or altered in texture in those parts most exposed to the influence of the external air—previous to the openings into the sack, and consequent admission of atmospheric air, the whole fetus was doubtless in a perfect state of preservation. The brain filled the cranium, and the dura mater and pia mater presented nearly a natural appearance;—the brain was soft, and of a reddish complexion; the chin and face were bent upon the thorax, and by pressure had left an indentation upon the sternum. These parts remained in the most perfect state of preservation, all the features being perfectly natural.
The skin of the face, breast, and abdomen, was of a dark dirty-white colour, the integuments of the same parts being of considerable firmness. The thighs were thrown upwards so as to cover the forehead: the genital organs, together with one hand and one foot, were well preserved. The spine and ribs, and all such bones as are early ossified, were perfectly sound. The sack was next removed and separately examined; it was less than one-half the thickness of a gravid uterus, thinned by ulceration in some places, entirely ulcerated through in others: two valvular openings penetrated the tendons of the abdominal muscles; two others communicated with the cavity of the intestinum ilium, which was attached to the right side of the tumor by means of its portion of mesentery, for the length of fifteen inches; the upper portion only of the gut itself adhered to the sack, through which was the ulcerated opening above mentioned. Through these passages the fetus might in time have been gradually expelled or discharged by the efforts of nature alone, had not the system sunk under the effects of irritation. On the inner side and upper portion of the sack, near to the opening into the gut, was observed the placenta, considerably diminished in size, it is true, and altered in texture, though entire; it was of a whitish colour, and of almost a carti’aginous consistence; directly opposite to the placenta, on the outside, the sack firmly adhered to the iliac portion of the mesentery, about one inch clear of the gut. The umbilical cord, that portion of it next the placenta, was destroyed, but several inches of it remained attached to the umbilicus; one turn was also left around the neck of the fetus. On the inner side of the sack, in several places, was observed some calcareous lamellated incrustations. The preparation was preserved in spirits, and remains in the cabinet of Dr. Hewson.
In this rare and melancholy case, it is much to be regretted that the true situation of the patient was not immediately comprehended, as the Caesarian operation appears to have been not only justifiable, but would have been attended with but comparatively little danger, provided the adhering portions of the sack were left in the abdomen : but the difficulty of ascertaining the nature of the tumor in the early stage, must have been considerably augmented by the thickness of the abdominal parietes in a natural state, or previous to their partial absorption from pressure. The lungs of the fetus were of a healthy appearance and structure; the liver was small, but not deranged in structure: the remaining viscera were natural. The present case, perhaps, constitutes the only instance of real extra-uterine fetation on record ; that described as such by Mr. Turnbull, appears more like a case of rupture uteri. (Vide Mem. of Lond. Med. Soc. Vol. III. p. 176, which refers to fifty or sixty cases of extra-uterine fetation and rupture uteri, not one of which was abdominal, or came to full period.)”
Medical and Physical Researches, by Richard Harlan, 1835, page 594
Medical and Physical Researches, by Richard Harlan, 1835, page 594