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normal columnar epithelial cell to that of atypical stratified
pavement epithelium, showing a tendency to extension of the
epithelial infiltration beyond the acini. In places the excess-
ive epithelial proliferation showed itself in the form of new
acini of irregular character. This is typical of adenocarcinoma.

CONCLUSION.

1. It is all-important for us to consider a profuse leucorrhea
or hemorrhage after menopause as serious.

2. We should not be satisfied to allow nature to take its
course when these symptoms persist, even if a curettage does
not show malignancy.

3. Metastasis is less frequent in carcinoma of the corpus
uteri than in cancer of the cervix, hence the former is more
amenable to treatment.

4. An early diagnosis made, a complete hysterectomy done, a
favorable prognosis can be given.

308 Majestic Building.



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CARSON: PSEUDO " VIABLE ABDOMINAL PREGNANCY." 481



A CASE OF PSEUDO '* VIABLE ABDOMINAL
PREGNANCY."*

BY
SHELBY C. CARSON, A. M., M. D.,

Greensboro, Alabama.

That we should profit by our mistakes has been long taught,
but the fact is not commonly realized that an honest error in
diagnosis is of more genuine advantage to the one making it
than is the smooth, even, successful issue. It is on the ^me
philosophical principle that "The man who fails is worth ten
fellows that never try." When there is time, as is often the
case, for study, consultation, and investigation the incentive
draws forth our energies, quickens our perceptions, and makes
us keenly alive to the responsibilities resting upon us. All
avenues of information are greedily sought, explored, and di-
gested, and as a result a wonderful fund of knowledge, which
perhaps would have otherwise escaped us, is treasured up for
future service. Therefore, so long as our patients do not suffer,
instead of being cast down and discouraged, we should regard
our painstaking errors as *' Apples of gold in pictures of silver."

The error in diagnosis that so exercised my thoughts for some
time was along the line of abdominal pregnancy. As the matter
has long since terminated in the outflow of an excessively large
amount of liquor amnii and the birth of a twelve-pound infant
per vias "naiurales, it probably should be considered a *' closed
incident" were it not that it is still a puzzle as to why there
should have been any mistake at all, and that it was the means
of instructing the writer on some points that may be of interest
to others. It is only a reasonable inference that one who had
enjoyed a fair portion of general practice for a long term of
years was, at least, ordinarily posted in all pertaining to normal
pregnancy, while, on the other hand, quite an unusual experience
in extrauterine pregnancies prevented his being a novice in
such cases. Your attention is called to the fact that it is viable
abdominal pregnancy — not that very common form, the tubal
variety — now under consideration. And this brings up the first
interrogation in my mind. Are all cases of extrauterine preg-

♦Read before the Southern Medical Association, New Orleans, Nov. 12, 1909.
7



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482 CARSON: pseudo "viable abdominal pregnancy."

nancy compelled to take place where they will give pain at
period of rupture?

In the present instance the only break apparently in the
chain of, symptoms was the absence of pain at any time. I
reasoned that as there had been no pain — sudden and acute —
there had been no rupture, and if all cases were of necessity at
first tubal then this could not be Extrauterine.

Williams, in his work on Obstetrics, says : " The great majority
of abdominal pregnancies were secondary in character, having
resulted from ruptured tubal pregnancy.'* I had only a few
months previously opened the abdomen and amputated a badly
ruptured tube for a lady whose life was saved by the projection
of the placenta from the tube into the cavity of uterus, thereby
rendering this patulous for the free drainage of the macerating
fetus and secundines. As an analogy I argued that at the other
end of the tube — in the meshes of the fimbriae — conception might
occur and adhesions gradually and imperceptibly, as it were,
fasten themselves without pain upon the pelvic contents. In a
very few days after the first examination of my patient I at-
tended the Atlanta session of this association and took occa-
sion to consult gentlemen of prominence on the point of pain
at the inception of all cases, and was assured that it ^was not an
element necessarily.

If any known method of determining a diagnosis was omitted,
save that of etherization, I am ignorant of it, and there was no
apparent excuse for anesthesia. Opportunities for examinations
were not lacking. I suppose she submitted to a rigid search at
six or eight different periods, and at one time I made it conveni-
ent to compare her on the same day with two othef patients
who were normally pregnant and at the same period in their
term.

Consultation, was positively and repeatedly denied me. Had
I availed myself of anesthesia it would have eliminated one of
the remarkable coincidences that go to make up this peculiar case.
I refer to an extreme tenderness or sensitiveness to the touch —
enough to make the patient complain bitterly — something that
does not ordinarily obtain, but, strange to say, is mentioned by
men of experience as a prominent symptom of ectopic gestation.

It vsras this that delayed — till a much later period — a resort to
that valuable aid to diagnosis mentioned by Werder, of Pitts-
burg, viz. : the thrusting of the finger-point through the softened
and usually patulous internal os — a safe procedure. An ad-



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CARSON: PSEUDO "VIABLE ABDOMINAL PREGNANCY." 483

vanced case of abdominal pregnancy should present no really
difficult features in diagnosis. The very irregular outlines of
the tumor — its angularities, so to speak; the very sensation
conveyed to the hand by touch and motion as though it were
immediately under the abdominal skin; the ability to grasp
with the finger-tips a knee or an ankle and move it freely to and
fro; to hear the heart sounds just beneath the ear; to trace by
palpation without hesitancy the bony leg, the flaccid abdomen,
the firm chest-wall, and locate the head in the lower pelvis; then
with the finger, per vaginam, easily map out the sutures and
fontanels just through the mucous membrane of the vaginal
fornix and by a little pressure get the characteristic resilience of
the cranial bones; to find the cervix soft and patulous, the
uterus slightly enlarged and separate from the tumor — should
furnish ample ground for a conclusion. Possibly it may be an
exaggerated picture of a genuine case and yet to an eminent
degree were all these factors present in my case, which was not
a case, with the exception of the uterus being distinct from the
the tumor; though on one occasion with the examination, having
in view this point alone, I was fully convinced that it was sepa-
rate. In addition to this the mother — an intelligent, refined,
healthy woman of twenty-eight years — noticed that the move-
ments of the child at night "were just beneath the bed clothes:
so different from her former pregnancy." I confess that I would
have made my diagnosis from the examination through the ab-
domen alone. However, notice that even the history is calcu-
lated to confirm the error. The patient had aborted her first
conception at two or three months — said to have been a ** fleshy
mole." Her second pregnancy (with twins) terminated at full
term with general edema, convulsions, forceps delivery, loss of
one child. Her first menstrual molimen after this occurred
about the twelfth month; then at irregular times — sometimes
missing two months in succession — until she finally missed
entirely in June, eighteen months after the birth of the twins.
When she was five months pregnant she was sent to me by her
regular family physician for a diagnosis, bringing from him a
letter calling my attention to the slight enlargement of the uterus
and the open condition of the os.

Only after I had thoroughly investigated by many avenues of
information did I learn that there are rare atypical instances
of normal pregnancy when the uterine walls are as thin as paper,
when the lower third of the uterus is firmer than the other por-



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484 CARSON: pseudo "viable abdominal pregnancy.**

tion — so simulating extrauterine pregnancy — that the nicest
discrimination is required to differentiate between the two.

When to operate is a mooted question among the best of men.
At the jfirst blush the arguments in favor of an immediate section
strike me very forcibly. For instance : the mother, having our
first consideration, having already undergone several months of
burden-bearing, will still be compelled to endure a gradually
increasing burden, will have added to this the mental anxiety
which a knowledge of her precarious condition would naturally
engender, besides the actual danger to life from a constantly
dreaded rupture, will be forced to submit herself to a rigid
surveillance by a competent surgeon. Again, her strength has
not been exhausted and therefore she is a better subject for
operation. The fetus is not so well developed, the sac has not
its most extensive adhesions and enormous ramification of blood-
vessels; therefore the danger from hemorrhage is not so great.
Notwithstanding this seductive line of thought, my instinctive
abhorrence of a destruction of the fetus together with the great
desire to bring into the world a living child saved me from an early
operation which, in the light of the final denouement, would
have been, to say the least, rather embarrassing. Since the
subject of a living child has been broached, it might be of interest
to further inquire into the advantage to be gained, even though
it were practical under the circumstances. How long will it
survive and how will it rank in the ** survival of the fittest"?
It is a well-established fact that the products of such pregnancies
are almost uniformly feeble, maimed, deformed little specimens
of humanity that perish in a brief time. Of necessity statistics
are meager. I have knowledge of only one authority — Sittern —
who states that out of 122 births of this nature only sixty-three
survived the first month. Of three cases reported by Werder,
of Pittsburg, one case only lived to the fourth day. At least
one living adult has reached the age of twenty. All of Werder's
were badly deformed. My personal experience as to deformity
is confined to one case — an autopsy. I saw this mother one
week before her death from sepsis and made a correct diagnosis
as revealed by autopsy. This was something over ten months
from her time of conception. The child, as I raised it from a
pool of pus, struck me as remarkably well developed. Some
years subsequently I removed all the bones of the skeleton
from the abdomen of a negress who dated her pregnancy fully
three years from that time. The bones indicated no deviation



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CARSON: PSEUDO "VIABLE ABDOMINAL PREGNANCY." 485

from the normal. Nevertheless, the fact that a deformity so
frequently exists is attributable to several obvious reasons,
such as the absence of the protecting walls of the uterus and
the substitution of those of the relaxed pendulous abdomen;
that it is so exposed to pressure from external sources as well
as of the internal organs; that in the last months the amniotic
fluid is to a large measure absorbed.

Some surgeons have allowed the latter reason to induce them
to operate at seven and one-half or eight months, but experiertce
has taught that the feebleness of the infant at this early period
more than counterbalanced the gain. So in deciding upon the
time to operate, even with this slim expectancy, the child has
some demands upon us, especially as the mortality is not in-
creased to any marked degree by waiting. In my own mind
after due deliberation the conclusion was reached to await the
completion of her term. The only danger to the mother would
arise from a secondary rupture of the sac which, as I had seen
a negro woman when fully seven months pregnant in this abnormal
manner making an active hoe-hand in the field without accident,
I consider rather remote. Sittern estimates this secondary
rupture at something like 7 per cent. Strange to say, and yet
not so strange either because it was the only source of fear to
myself, the uncontrollable hemorrhage which may result from
an efiFort at separating the placenta from its attachments has
forced a limited number of surgeons to await the death of the
child, even two or three months afterward, when the placental
circulation is destroyed and the large, frightful vessels are
thrombosed or obliterated.

Being thoroughly conscientious in the whole matter and cor-
respondingly impressed with the magnitude of the responsibility
resting upon me, I had consulted several of the most prominent
men in the profession throughout the States and had definitely
marked out my plan of procedure. The patient, closely watched
in the interim, was to enter the sanitarium one month before
her time. At the first approach of labor she would be prepared
as for any other capital operation. The contemplated incision
through the walls, the rupturing of the sac and the escape of a
small quantity of water, the clamping of the cord with forceps
and the extraction of the child created no apprehensions, but it
certainly did appall me when I thought of encountering a
placenta and sac with unknown and uncertain attachments,
possibly covering the uterus and tubes, the broad ligament,



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486 CARSON: pseudo "viable abdominal pregnancy."

even the bowels themselves, filled with vessels approximately
the size of the finger and liable to exsanguinate the patient
within the briefest time.

Those who have experienced the rush of blood in a severe
placenta previa can form a slight conception. Therefore I
pondered well the three different methods now employed, and
tried to devise others.

The first, that of taking on a state of ** innocuous desuetude**
an'd awaiting the death of the child, was discarded at once as
being surgically untenable because it surely denied life to one
and subjected the other to the gravest danger through absorption
of the decaying fetus. Having once opened a mother who lost
her life in this way and viewed the half gallon or more of pus
in which the child, not yet touched by decay, was lying, there
was no temptation to adopt this course. The other extreme,
the radical operation, attacking the entire attachments and
separating them in toio appeals strongly to the surgical sense,
because the abdomen can then be closed at once without further
apprehension; but unfortunately certain contingencies arise that
prevent the boldest and best surgical skill from accomplishing
this desired termination. For instance: the nearer you approach
the placental site the greater the danger. This placenta is
supplied mainly by the ovarian and uterine arteries. Of course
the first thought is to securely clamp these vessels. But sup-
pose the placenta is attached over the entire surface of the
uterus, the tubes and the broad ligaments entirely obscuring
these from view, thereby preventing the clamping of these vessels.
Would you risk the compression of the abdominal aorta after
the delivery of the fetus? Some would, but I confess, though
my personal experience is m/, that I would have very little
faith in the success of digital or manual compression of such an
important vessel and I would be fearful that a metal band,
such as that of Halstead, or of clamps covered by rubber would
destroy the integrity of the vessel-walls since they would perhaps
need to remain for some time. Therefore, taking all these
matters into consideration, I had decided to quickly make the
incision through the abdominal walls, rupture the sac, clamp
and sever the cord near the placenta, pass the child to a nurse
and carefully inspect the surrounding conditions. In case the
attachments were limited and the ovarian and uterine arteries
were accessible I would clamp these and finish the operation by
total removal. In case the conditions were otherwise and the



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arteaga: ectro-hemimelia of the right upper extremity. 487

life of the mother greatly endangered by further interference, I
would adopt the intermediate course which is practised more
often, viz. : the removal of as much of the sac as possible, suturing
the remnant to the edge of the peritoneum, closing the upper
portion of the wound and introducing gauze drain into the
cavity, changing them as became necessary, until the separation
of the sac. It is true that I would exist in fear and trembling
until it did separate, but the danger of sepsis I imagine would
be less imminent than the danger of sudden death from hemor-
rhage in the first instance.

Fortunately for the patient, about two months before her
expectancy expired, I was able to feel, with the point of my
finger through the internal os, the membranes and the fetal
head; then came a relaxation from a nervous strain which
doubtless was more gratifying to her than even to myself.



ECTRO-HEMIMELIA OF THE RIGHT UPPER
EXTREMITY.

BY

JULIO F. ARTEAGA, M. D.,

Havana, Cuba.

(With two illustrations.)

A Cuban woman of the lower class, aged forty, with negative
family and personal histories, multipara, gave birth to a child



Fig. I.



perfectly developed except for the absence of the right hand and
almost the whole forearm on the same side.

There being no cicatricial or raw tissue in the stump, with



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488 TRANSACTIONS OF THE

a normal placenta and membranes, and the nondelivery of the
missing parts, indicated that it was not a case of spontaneous
intrauterine amputation by amniotic bands or faulty disposition



Fig. 2.

of cord, but merely a case of arrest in the development of one
extremity.
The radiograph confirmed the diagnosis.



TRANSACTIONS OF THE NEW YORK
OBSTETRICAL SOCIETY.



Meeting of December 14, 1909.

The Presidenty Robert L. Dickinson, M. D., in the Chair.

Dr. Charles Clifford Barrows presented the history of a
case of

ACUTE COMPLETE INVERSION OF THE UTERUS.

The patient, Mrs. B., a primipara in her fortieth year, consulted
me about a year ago because of sterility. Examination showed
a markedly retroverted uterus which I restored to its normal
position by shortening the round ligaments after the method
suggested by Alexander. She soon became pregnant and went
to term without an untoward symptom of any kind.

On October 24, 1909, after a normal labor I delivered her of a
live child. Low forceps were applied when the head was on the
perineum, delivery being somewhat retarded by the rigidity of
the soft parts. The uterus contracted well, and I turned the
delivery of the placenta over to my assistant, Dr. Henry Pearson,
while I was busy getting ready to repair a slight perineal lacera-
tion. Before the placenta had been delivered Dr. Pearson



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NEW YORK OBSTETRICAL SOCIETY. 489

called my attention to the fact that he could no longer feel the
fundus, The patient was lying across the bed, with knees flexed,
and had just recovered from slight chloroform anesthesia. The
placenta was protruding from the vulva, and examination showed
as once that the uterus was completely inverted with the placenta
attached at its fundus. I detached the placenta quickly, grasped
the fundus and carried it well up to its normal position. This was
easily accomplished, and the uterus contracted promptly and re-
mained so, the patient having an uneventful puerperium.

I believe it worth while to report this case. i. Because of
the extreme rarity of the accident. Quoting from Edgar's
translation of Winckel's Text-book of Midwifery, Denham found
only one acute inversion in 100,000 deliveries in the Dublin
Rotunda, and C. V. Braun had not a single case in 250,000
deliveries.

2. Because of the uneventful recovery of the patient, the
mortality from this accident being usually quoted at from 50
per cent, to 70 per cent.

3. Because of the absolute lack of symptoms. There was
positively no bleeding at all, there were no symptoms of shock,
the patient made no outcry, and when questioned after the reduc-
tion of the inversion, evidently did not realize that anything
unusual had occurred.

Her skin was normal, her pulse rate was unchanged, her
pupils were not dilated, and there was no anxiety or uneasiness
of any kind.

Bobert Bell and J. C. Reeve as quoted by Winckel have re-
ported cases without shock or hemorrhage, but Winckel says
that these cases are extremely rare.

So far as I have been able to discover in my search of the
literature of the subject, no such case as this one entirely devoid
of hemorrhage or subjective symptoms of any kind has been
reported.

DISCUSSION.

Dr. Dorman. — I think the explanation of the lack of hemor-
rhage was in the complete attachment of the placenta and the
prompt reduction of the inversion. About six months ago I
delivered a woman the second time, it was her third delivery.
The first labor had been a very difficult breech. The second
was two years ago, and was a breech presentation which I cor-
rected before labor. At the time of the last labor she came to
the hospital again a breech, and I manipulated this fetus the
day she was supposed to be at term and made a vertex presen-
tation, this required a little effort and there may have been
some trauma to the uterus, but shortly after that she went into
labor. It came on very rapidly. The house staff delivered her
and by the time I got there they were massaging the uterus for
hemorrhage. The placenta had been extracted. We suspected
something peculiar. The uterus failed to contract, the bleeding



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490 TRANSACTIONS OF THE

continued, and on examination I found the condition a complete
inversion. There had been no traction on the cord; the uterus
had turned inside out. The uterus was replaced, and tamponed
for twenty-four hours. She made a good recovery.

Dr. Edgar. — I do not think there are many cases of complete
inversion reported which recover. I have had one complete
inversion of the uterus. I was called by a physician who tele-
phoned that the uterus had turned inside out. I got there within
twenty minutes after the call came. He had hot towels around
the uterus for some reason. I gave the patient a little chloroform
and replaced the uterus and she promptly died of shock. I
think forty minutes would be the outside limit of time before
it was replaced. The cause of that inversion was unquestion-
ably a too vigorous application of Credo's method. They
waited thirty minutes in this case and then made a very
vigorous application of Credo's method; the attending physician
said the uterus slipped from between his fingers and then the
nurse called attention to the fact that the uterus lay between
the thighs of the patient.

Dr. Vineberg. — Some six years ago a patient was brought
into Mount Sinai Hospital with a very high temperature. It
was twelve or fourteen days after delivery. She was supposed
to have a fibroid tumor which was sloughing. There was a
putrid r ass protruding at the vulva which had a very offensive
odor. I began to remove this thing and finally it proved to be a
complete inversion of the uterus which had been present since
delivery with the greater part of the placenta attached and under-
going sloughing. The temperature was 104°, general condition
fairly goo I did a vaginal hysterectomy, and she made a good
recovery.

Dr. Dickinson. — ^The Chair would like to add one case of
complete recovery from inversion of the uterus; the return of
the uterus being immediate and the patient recovering.

Dr. Barrows. — I am particularly interested in the remarks
of Dr. Dorman because I was surprised that there was no hemor-
rhage. This uterus was entirely outside the vulva and the attach-
ment of the placenta could be followed around very easily with-
out any difficulty some distance at least from the woman's soft
parts. It was easy to recognize what had taken place, and my
effort was to reduce it just as promptly as possible, but it was the
first opportunity I ever had to study the attachment of the pla-
centa in the Hving subject. It was a beautiful attachment; the
sloping from the uterine tissue was almost imperceptible. It
was without any line of demarcation, but immediately when I



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 49 of 109)