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Henry J. (Henry Jacques) Garrigues.

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smaller, and may disappear altogether. Women afflicted with myo-
matous tumors of the uterus should not marry. If they become
pregnant, it is in harmony "with nature's own method to induce abor-
tion or premature labor, whenever the tumor is situated in such a
place or has such dimensions that great trouble may be anticipated
by allowing gravidity to go on till full term.

To operate for the removal of the myoma during pregnancy will
be likely to lead to miscarriage. Unless there are urgent symptoms
demanding immediate attention, such as liemorrhage or pressure on
the pelvic organs, it is better to delay operative interference until labor
sets in. After the end of the puerperium the question as to enuclea-
tion or hysterectomy or other treatment will present itself.

Diagnosis. — Pregnancy may be simulated by a myoma, and the
diagnosis is not always easy. As a rule, menstruation stops during
pregnancy, while in cases of myoma it goes on or is even increased
in amount and duration. The development is regular and more rapid.
The cervix and lower uterine segment become soft, the fluid in the
fetal sac gives a peculiar sensation of tense elasticity, and ballottement
may be elicited. The fetal heart-sound may be heard and fetal move-
ments heard, felt, and seen. A point of great value is the contrac-
tility of the gravid uterus, which may be made more marked by
dipping the palpating hand in ice-water. Tlie uterine souffle is of less
importance, since it maybe found with myomas. Nor is the presence
of milk in the breasts conclusive. The writer has seen milk produced
in a virgin by an intra-uterine injection of diluted lic|uor fern chloridi
to check hemorrhage from a myoma.

The diagnosis becomes particularly difficult if the two conditions
are combined, and, as we have seen, the detection of such a compli-
cation of pregnancy may be of great practical importance in regard
to the treatment to be adopted. A suspicion of such a coincidence
should be awakened by hemorrhages occurring during pregnancy.
The use of the uterine sound is, of course, not available. The ob-
stetrician must rely on the history of the case, the auscultation, and a
very accurate palpation.

Sarcoma and Carcinoma of the Uterus. — These are promiscuously
called cancer, but there is a fundamental difference in their anatomical
structure, the first being composed of round or spindle-shaped cells,
the latter of polyhedral epithelial cells arranged in alveoli separated
from one another by walls of connective tissue. Sarcoma rarely
attacks the cervix, and is, therefore, of less importance to us as ob-
stetricians than carcinoma, which has a predilection for that organ.
Both undermine the constitution, and sooner or later, in most cases



294 ABNORMAL PREGNANCY.

within a few years, lead to deatli. If, furtliermore, we take into con-
sideration that they may offer an unsurmountable obstacle to delivery
and that the foetus may inherit the tendency to, perhaps even the germ
of, the disease from the mother, there is only one thing to do when we
find cancer of the uterus in a pregnant woman. In this case it is not
sufficient to sacrifice the foetus. If we find the uterus in such a con-
dition that a radical operation is still possible, especially when com-
bined abdominal, vaginal, and rectal examination shows that there is
no swelling of the broad ligaments and the womb is freely movable,
total extirpation should be done at once.

The form of cancer with which the obstetrician most frequently
has to deal, either during pregnancy or during labor, is carcinoma of
the cervix. According to the period of pregnancy in which the cases
come under observation, we may distinguish three groups, which offer
different indications for treatment. "

The first group comprises the cases in which the unopened and
unemptied uterus can be extirpated from the vagina in the same way
as a non-pregnant uterus.^ This can, as a rule, be done without special
difficulty until the end of the fourth month, and has even been done
in the fifth and sixth. If the disease has spread too far to allow extir-
pation, a palliative operation, including abortion, should be performed.^

The second group is composed of most of the cases that are in
the fifth, sixth, and seventh month. The uterus is too large to pass
through the vagina while it contains the foetus. Under these circum-
stances different operations are available :

First. — Abortion or premature labor may be induced, and as soon
as the uterus is empty it is removed by vaginal section.

Second. — The whole uterus may be removed by abdominal sec-
tion, but this involves great danger of infecting the peritoneal cavity
with cancer germs, even if the cervix is curetted and cauterized before
the operation.

Third. — It is better to perform supravaginal amputation and sub-
sequently extirpate the cervix from the vagina.

Fourth. — Both the foetus and the uterus may be removed through
the vagina.

If the cancer is not operable and the child is near the period of
viability, we may wait a short time so as to give it a chance ; but if
hysterectomy can be performed, it ought to be done at once, without
regard to the child, for the carcinomatous degeneration spreads rapidly
during pregnancy.

The third group encompasses the time when the child is viable.
If the child is viable and the carcinoma operaJole, it is best to perform

^ Gamgues, Diseases of Women, third ed., pp. 510-515.
2 Ibid., p. 543.



DISEASES OF THE GENITAL ORGANS. 295

conserv^ative Caesareaii section, close the uterus, tie the ovarian ves-
sels, and then extirpate the empty uterus from the vagina.

If the child is viable but the cancer not fit for a radical operation,
the cervix should be curetted and cauterized, and thereafter the woman
delivered by Cpesarean section.

If the case does not come under observation before labor has
begun and the cancer is operable, it may be possible to deliver a living
child per vias naturales, either by means of a high forceps operation
or podalic version followed immediately by extraction ; but in order
to gain room for the extraction of the child it may be necessary, after
having loosened the uterus from the vagina and the bladder, to split
the uterine wall in the median line or the anterior and posterior wall
from six to ten inches above the internal os. This has been called
vaginal Cesarean section. After the removal of the child the uterus
itself is extirpated through the vagina.

If the pelvis is so narrow as to make vaginal manipulations diffi-
cult, the total abdominal hysterectomy is indicated.

The immediate result of hysterectomy for carcinoma cervicis is
satisfactory in so far as recovery from the operation is concerned, but
it is quite exceptional that the patient lives more than three years
after the operation.

The same method has been used in the sixth and seventh months
of pregnancy, the anterior wall of the uterus being incised, the foetus
extracted, and then the uterus extirpated from the vagina.

The vaginal operation has the advantage of avoiding infection
during the operation and an abdominal cicatrix ; but if the child is
alive, its chances are much better if it is delivered by abdominal
Caesarean section, whatever may be decided as to the best way of
removing the uterus.

Ovarian Cyst. — Diagnosis. — Many a poor girl has been exposed to
the suspicion of having sacrificed her virtue when in reality she was
suffering from an ovarian cyst. The physician should, therefore, use
every means of clearing the diagnosis. As a rule, menstruation stops
in pregnancy and continues in the person who has an ovarian cyst.
The ovarian tumor grows more slowly than the pregnant uterus. It
may be felt as a separate mass only indirectly connected by a pedicle
with the uterus, while in pregnancy tumor and cervix are so inti-
mately connected that they move together. Pregnancy is character-
ized by numerous signs, especially the fetal heart-sound and the uter-
ine souffle, fetal parts may be felt, fetal movements may be observed,
ballottement may be produced, the cervix and lower uterine segment
are softened, the vagina has a purplish color, often a drop of fluid
may be pressed from the breasts, — all of which signs are lacking in
connection with an ovarian cyst.



296 ABNORMAL PREGXAXCY.

But a pregnant uterus and an ovarian cyst may be found com-
bined and make the diagnosis ver)^ difficult. Tliis complication of
pregnancy is not very rare, and may influence the treatment consider-
ably. It may occur even ^vhen both ovaries form large tumors, and
so much more so when only one is affected. As a rule, there is no
menstruation. Tlie ovarian tumor may be known to have existed
before pregnancy began. Otherwise only a most careful abdominal
and vaginal examination, combined with due reference to the oft-
named symptoms, can clear up the diagnosis. When the presence
of one child is made out, the investigation must next be directed
towards the second mass, with a view to ascertain whether the case
is simply one of t^^ins or of uterogestation combined Avith an ovarian
tumor.

The complication mth an ovarian cyst may give rise to intolerable
suffering, on account of the distention of the abdominal wall and
compression of the thoracic organs. The growing uterus may cause
torsion of the pedicle of the ovarian cyst, an extremely dangerous
condition.

Treatment. — The simultaneous growth of the pregnant uterus and
an ovarian cyst will, in most cases, be a source of so much discom-
fort, or even be attended by such dangers, that interference is called
for during pregnancy. Three methods are then at our disposal :
1, artificial abortion or induction of premature labor; 2, tapping the
cyst; 3, ovariotomy. The writer does not think this complication
is sufficient to indicate artificial abortion, the other means being at
our disposal. If possible, we should wait until the child is viable,
preferably even until the thirty-sixth week of pregnancy, and then
induce labor. Tapping has given excellent results as a palliative
measure, to be followed by ovariotomy after the puerperium is over ;
and there is no serious objection to it, provided it is performed
by a man prepared to do ovariotomy if untoward sequences should
develop. Ovariotomy has been performed many times during preg-
nancy. The dangers of the operation are very slightly increased ; but
often it is followed by miscarriage. It is, therefore, best to postpone
it until after the puerperium, and during pregnancy be satisfied with
induction of premature labor or tapping the cyst,^ or at least to defer
the operation until the child is fully viable.

Operations during Pregnancy. — In general, operations should as
far as possible be avoided during pregnancy, on account of the danger
of producmg abortion. It seems that interference with the rectum is
particularly liable to have this effect. As to the genitals, the farther
[he seat of the operation is removed fi'om the uterus the less is the

^ As for the modus operandi see Garrigues, Diseases of Women, third ed.,

pp. 197, 640.



DISEASES OF THE GENITAL ORGANS. 297

danger of provoking abortion. Sometimes, however, operations may
be imperatively indicated by the pregnancy itself, as in cases of ectopic
gestation ; or the advantages to be obtained by an early operation may
be so great that it should be performed, even if we have to sacrifice
the child, — for instance, the removal of an ovarian cyst or the extir-
pation of the cancerous uterus. I also allow minor operations on the
teeth, such as filling of carious cavities and even avulsion, if the
affected tooth causes much distress.

§ 5. Displacements. — Anteflexion. — Anteflexion of the uterus
opposes a much more serious obstacle to impregnation than one
would expect, w^hen one thinks of cases of pregnancy occurring under
the most unfavorable circumstances, — for instance, stenosis of the
hymen or vagina, leaving only a hardly visible aperture for the en-
trance of the spermatozoids, or even total atresia, and communication
between the uterus and the rectum, through Avhich latter organ copu-
lation took place. Still, there cannot be any doubt about the correct-
ness of the statement that anteflexion is a barrier to conception, since
we are so often consulted by women with this deformity who are
in perfect health, but sterile, and the excellent effect of operations
by which an easier access to the uterine cavity is opened for the
spermatozoids.

Again, if a woman suffering from anteflexion conceives, there is
danger of miscarriage or severe vomiting during pregnancy, which may
interfere so much with the general nutrition that it becomes necessary
to induce abortion artificially.

On the other hand, pregnancy, if it goes on to term, is the radical
cure for anteflexion.

There is not much to be done for anteflexion during pregnancy,
except to recommend the dorsal posture and after the end of the third
month, when the fundus of the uterus reaches the abdominal wall, the
use of an abdominal supporter. Excessive vomiting will be considered
later.

Anteversion is hardly of any interest to the obstetrician. It offers
little obstacle to conception and hardly any to the rising of the impreg-
nated womb, except when this has been artificially fastened to the
vagina in operations for retroflexion, in which case it may give rise to a
most formidable complication of labor, which will be considered later.^

Retroflexion of the Uterus. — In retroflexion the genital canal
seems to have a direction more favorable to conception than in ante-
flexion. While patients afflicted with the latter quite commonly are
sterile, those in whom the uterus is bent the other way often have
large families. As a rule, the uterus rises gradually out of the pelvic

^ Antedisplacemeuts are described in Garrigues, Diseases of Women, third
ed., pp. 453-465.



298



ABNORMAL PREGNANCY.



cavit}^ and the retroflexion changes into the physiological anteflexion ;
but sometimes the retroflexecl uterus becomes impacted, and then we
have to deal with a very dangerous condition (Fig. 259).

The first symptom that brings the patient to seek the advice of the
doctor is, as a rule, retention of urine. Constipation is also present
and some pelvic pain. On vaginal examination the retroflexed en-
larged uterus is felt pressing on the rectum. In neglected cases the
whole mucous membrane of the bladder has been thrown off in one
piece by a diphtheritic process in the submucous connective tissue.
The pregnancy may terminate in spontaneous abortion or the bladder

Fig. 259.
C



sip




Impaction of retroflexed gravid uterus. (Schatz.) £ U, retroflexed uterus ; R, rectum ; B. bladder ;
C, cer\-ix uteri ; V, vagina ; U, urethra ; S P, sj'mphysis pubis.

may rupture and the patient die from peritonitis, uraemia, gangrene of
the bladder, or septiceemia.

In rare cases a part of the posterior wall of the uterus remains in
the pelvis, a condition called partial retroflexion of the gravid iderus.
Then the uterus and the fostus are felt partially above the symphysis
and partially in the vagina. This condition, as a rule, does not offer
any difficulty, but may exceptionally end in abortion or premature
labor between the sixth and the eighth months.

Treatment.— Yiv?,i the bladder should be emptied with the catheter.
Next, the faulty position of the uterus should be corrected as soon as
possible. In most cases this can be done by placing the woman in
Sims's position and introducing the index and middle finger with the
volar surface turned back towards the physician. The replacement



DISEASES OF THE GENITAL ORGANS.



299



should be tried in the corners of the pelvis, in front of the iliosacral
joint, where there is most space. If it does not succeed, the patient
should be placed in the knee-chest position (Fig. 260) and a cotton



Fig. 260.




Genupeetoral position. (H. F. Campbell.)



tampon held in forceps should be substituted for the fingers. When
the uterus has been replaced, it should be kept in its new position
and prevented from falling back again by means of a large Hodge-
Emmet or Albert Smith pessary (Fig. 261), which should be worn
till the end of the fourth month, when the uterus has acquired such
dimensions that it can no longer become retroflexed.

If the uterus is not easily replaced, the patient should be anaesthet-
ized. If manual reposition through the vagina does not succeed, the
hand may be passed through the rectum, which sometimes is more
effective, and replacement may be seconded by pulling the cervix
down from the vagina with the fingers or bullet-forceps.

Another principle, that of steady elastic pressure, has been suc-
cessfully applied to the reposition
of the retroflexed uterus. It may
be exercised by means of Brauiri's
colpeurynter or any other rubber
bag such as the one delineated in
Fig. 417. After having been disin-
fected it is introduced into the va-
gina against the fundus uteri and
filled with as much sterilized water
or lysol emulsion as the patient can
bear. If the patient cannot urinate, the urine is drawn with catheter
or the bag is momentarily emptied. The same principle is employed
more effectively in Aveling\s repositor. This consists of a little hard-
rubber cup which presses against the fundus, and an S-shaped rod
which protrudes from the vulva and carries pressure made at the



Fig. 261.




IIoditre-Kmmet pessary.



300 ABNORMAL PREGNANCY.

lower end up in the direction of the pelvic axis. To this lower end
are attached four elastic cords which are drawn through rings fastened
to a binder surrounding the abdomen. Two of the cords are brought
forward and two backward, enabling us to press in the right direction.
This apparatus has the advantage over the colpeurynter that the
distention of the vagina, which is not only painful but also might cause
abortion, is avoided.

If all attempts at reposition are fruitless, the uterus should be
punctured from the vagina and the liquor amnii aspirated, whicli, as a
rule, gives immediate relief from pressure, but is soon followed by
abortion.

Retroversion of the uterus is comparatively rare, and if a retro-
verted uterus becomes impregnated it gradually changes into retro-
flexion or retroflexion combined with retroversion.^

Prolapse and Procidentia of the Uterus.^ — No case of pregnancy
in a completely prolapsed uterus at term is known, but the condition
has been observed and described at an earlier stage. On the other
hand, pregnancy in a partially prolapsed uterus which still remains
in the vagina and the pelvis is not very rare. Sometimes the pro-
lapse is more apparent than real, a considerable hypertrophy of the
cervix, especially the supravaginal portion,^ making the cervix appear
outside of the vulva, while the body of the uterus is in or above
the pelvis.

When the uterus grows, as a rule, it is drawn up until it is so large
that it cannot re-enter the pelvic brim, so that women with this afflic-
tion are comparatively free from it during their pregnancy, and preg-
nancy and labor pass off without disturbance.

In the earlier months of pregnancy the uterus may by some acci-
dent be suddenly propelled outside the body. Then it becomes
oedematous, blood is extravasated around or in the ovum, and the
woman aborts.

Treatment. — The prolapsed uterus should be brought back to its
place, and in so doing we should take particular care to bring the
fundus forward, as otherwise it is very apt to go backward and consti-
tute a retroflexion. This reposition is, as a rule, easy enough, but not
so the retention. The vagina being enormously dilated and softened,
and all tissues that normally hold the uterus in place being relaxed,
the uterus sinks down again. Common pessaries find no support.
Sometimes a large thick rubber ring (Mayer's pessary) may be able to
retain the uterus in place, or a cup and stem pessary attached to an
abdominal supporter may be able to do so. If not, the patient must

'^ Information about the retrodisplacements is found in Garrigues, Diseases
of Women, third ed., p. 464 and following.

Mbid., p. 478. ' Ibid., p. 446.



DISEASES OF THE GENITAL ORGANS. 301

be kept in a recumbent position until the uterus becomes so large that
it can no longer fall down.

When the cervix is so much hypertrophied that it may be expected
to oppose a serious obstacle to the passage of the child, it may be
amputated during pregnancy.

CEdema of the Cervix. — During pregnancy, labor, and even after
delivery, the cervix may become (^edematous and form a large soft
swelling. It is rather towards the end of pregnancy than in the first
months that this condition has been observed. The patients complain
that something is coming out of their genitals during straining or in
walking, which again disappears during rest. Besides they may be
constipated or find difficulty in urinating.

At the vulva, partially protruding from it, is found a tumor of red
or bluish color, soft, reducible on pressure, which proves to be the
swollen cervix. The finger may be introduced through the cervical
canal, which is found much elongated and measuring from three to
four inches.

The cause of this oedema is not always clear, but sometimes pressure
exercised by a tumor in the pelvis on the lower uterine segment
accounts for it. The disappearance of the swelling during the recum-
bent position distinguishes it from hypertrophy, and the normal situa-
tion of the fundus from prolapse.

The condition is of importance since it is apt to lead to premature
labor.

Treatment. — The swelling should be reduced by pressure in the
recumbent position, and then a couple of tampons should be placed in
the vagina and kept in place with a T bandage. The patient should
be kept in a recumbent position, and if she is constipated her bowels
should be moved.

Partial (Edema. — Sometimes the oedema affects only a part of the
cervix, especially the anterior lip. Thus a tumor may be formed that
interferes with the birth of the child.

Hernia Uteri, or Hysterocele. — In exceedingly rare cases the
uterus is found forming the contents of a hernia, femoral, inguinal, or
umbihcal.

The foetus may be carried to term in this abnormal situation ; but
if the case comes under observation during pregnancy before the child
is viable, the uterus should be cut down upon and removed by abdo-
minal hysterectomy.^

At the end of pregnancy, the uterus should be incised and the
child taken out as in Caesarean section performed when the uterus is
in the abdominal cavity. As to the uterus, it may either be left till
after involution has diminished its volume and blood supply or

^ Garrigues, Diseases of Women, third ed., p. 517.



302 ABNORMAL PREGXAXCY.

replaced into the abdominal cavity or extirpated at the level of the
cervix, — Porro's operation, ^vhich will be described later.

The pregnant uterus may be found in a ventral hernia, which may
have existed before impregnation took place or which may have been
formed during pregnancy by the distention of the gromng uterus.
These cases are not rare in women upon whom laparotomy has been
performed.^ Either the edges of the wound were not properly brought
together, or suppuration set in, or the cicatrix formed at the time
became wider and thinner by subsequent intra-abdominal pressure.
In these cases the recti muscles separate in the median line, and form
concave edges when the woman lies on her back and tries to raise
her chest. In the gap we feel under the thinned skin the abdomi-
nal contents — intestines, uterus, ovaries and tubes — with unusual
distinctness.

For these patients there is nothing to be done except to let them
wear a well-fitting abdominal supporter. After their puerpery the
gap in the abdominal wall may be closed by a secondary operation,
in which case union of the aponeurosis by the cobblers stitch is partic-
ularly recommendable.^

Ectopic Gestation. — As we have seen above, the fertilized ovum
is destined to be embedded in the mucous membrane of the uterine
cavity, but, unfortunately, by one of the saddest errors of nature, it
may also develop in the ovary or the tubes. This condition used to
be known as extra-uterine pregnancy; but since the development
may take place in that part of the tube that traverses the uterine
wall, the modern name ectopic gestation is preferable. It is by no
means a rare condition, as appears by a research of medical journals
during the last thirty years and the material that comes under ob-
servation in hospitals, lying-in institutions, and the private practice



Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 27 of 80)