of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 94 of 109)
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which may not have torn.

The cylinder-like placenta more completely unfolds and
presents at the vulva by a straighter edge as a smaller placenta
is delivered through a more greatly relaxed vaginal outlet.

CONCLUSIONS.

1. The placenta is commonly delivered as an inverted cone'
the fetal surface presenting; the membranes follow, reversed.

2. This may be called the normal mechanism because it
occurs in the majority of cases; it may be explained by the
action of the uterine forces upon the placenta in its common
position in th^ upper uterine segment, and it is attended by
expulsion of the membranes more often intact.

3. Uncommonly the placenta is delivered as a cylinder,
the edge or the edge and maternal surface presenting; the
membranes follow, their anatomical relations preserved.

4. This may be termed the abnormal mechanism because
it occurs in the minority of cases; it may be explained by the
action of the uterine forces upon the placenta in its uncommon
position in or encroaching upon the lower uterine segment; and
it is attended by the expulsion of the membranes often incom-
plete and detached to a greater or less degree.

4 Chestnut Street.



ECTOPIC GESTATION AT FULL TERM.

BY

GEORGE D. NUTT, M. D.,

Williamsport. Pa.

The two following cases which have come under my observa-
tion are worthy of report. They were tubal pregnancies at
full term with very little departure from normal pregnancy in as
far as the mothers* symptoms and feelings were concerned. In
each case at the end of the gestation period labor pains were
experienced which subsided with the death of the child.

Case I. — ^Mrs. N. S. was admitted to the Williamsport Hospital
September 29, 1902 and came under my care two days later. I
found the following history : Age twenty-five, American, married.
Family history negative; had typhoid fever eight years ago, and
has sufifered from neuralgia. Began to menstruate at eleven



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NUTT: ECTOPIC GESTATION AT FULL TERM. 907

years of age, the flow being very irregular and painful and lasting
about six days. She had two children, the last one five years
ago. Menstruated about three weeks ago.

Present Illness, — ^About two years ago she began to have pain
in the left iliac region for which she went to the Austin Hospital
and had some operation, probably a curettement. She felt
better for three or four weeks, when the pain returned and she
noticed a tumor growing rapidly in the left ovarian region. This
increased and she had to take to her bed in April. The mass
then diminished in size and she had some edema of the legs.
Before the tumor decreased she had severe pains; she now feels
weak and has pain down her thighs; is constipated, and has had
several attacks of flooding.

Examination. — ^There is a tumor, nodular and hard, with some
mobility, lying in her left side, attached to the uterus and hav-
ing every appearance of a large fibroid of the uterus.

The patient was kept under observation for a week. Her
temperature was normal, pulse from seventy \o ninety, and
respiration thirty.

October 24, opened the abdominal cavity and found a hard,
nodular, vascular tumor with some omental attachments. The
sigmoid was firmly attached to the side of the tumor and was
separated with some difficulty. The tumor pushed the uterus
to the right, the left ovarian artery passing directly over the
tumor to the uterus. On opening the tumor, I was surprised to
find a full-grown, partially macerated child, or, in other words,
a broad ligament gestation. The uterus was eroded or digested
about one-third, as were also some portions of the child. Re-
moved the sac and uterus, and carefully stitched the peritoneum
over the stump.

The patient did well, the temperature never rising above a
hundred, ancj she left the hospitaJ in five weeks. A more con-
nected history was obtained after operation.

She said in June, 1899, she first felt a tumor; her menses had
been regular, but she flooded nearly a month; July 12, was
curetted. Did not menstruate until April, 1900. On March 8,
had severe labor pains, some discharge and then the pain stopped;
the tumor grew less and she never felt any motion or sign of
fetal life. The case is interesting in that pregnancy had gone
to full term, labor pains had come on, lasting several days, then
the child died, remaining in the sac two years while nature was
trying to destroy it by maceration and absorption without any
rise in temperature. The attachment of the sac to the bowel
was quite firm, and evidently nature was preparing to expel it in
that way.

Case II was sent to the Williamsport Hospital by Dr. Traux
of Watsontown, Pa., who gives the following history:

Mrs. K., aged twenty-three, had one child born four years
ago last June, not an easy delivery, having had to use forceps.
She had at the time a slight tear which was repaired.



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908 nutt: ectopic gestation at full term.

In December, 1908, she had her last menstrual period, morn-
ing sickness began about two weeks later and kept up for more
than two months. From this time on no unusual symptoms
developed, life being felt for the first time about the second
week in April.

About the third week in September, 1909, the patient was
taken sick, and was apparently in labor, having regular labor
pains which lasted for three weeks. During this time she was
tmable to lie down, was forced to sleep sitting in a chair, and upon
the slightest exertion suffered great pain. About five weeks
later she began to have another attack of what seemed to be
labor pains, but of milder character. At this time many small
clots of blood passed; also rather profuse hemorrhage at intervals
which kept up for four weeks, after which time the patient began
to feel better each day until when I was called to see her the first
time, December, 1909, she was up and doing her usual household
duties.

Patient claiified she had gone beyond full term, although her
former physician had advised her to the contrary.

Diagnosis of extrauterine pregnancy was made and confirmed
by Dr. Nutt, and she was admitted to the Williamsport "Hospital
and operated upon January 4, 19 10. The form and shape of the
child could be felt and we could trace the uterus pushed to the
left.

Entering the abdomen through a long median incision we
found a right tubal pregnancy, apparently starting from the
very end of the tube and penetrating and growing downward
under the peritoneum including the ovary in the wall or sac.
Numerous adhesions of the omentum and bowels were encount-
ered. The lower or under half of the uterus was firmly adherent
to the sac and muscular fiber radiated from the uterus at least
two inches over the sac. The child, which weighed nine pounds,
was undergoing maceration.

Hysterectomy had to be done first in order to cut off the blood
supply and remove sac. The sac was finally shelled out, except
a small portion about the right ovarian artery where it was
firmly imbedded deep in the pelvis, this part was brought to the
surface and firmly stitched to the peritoneum and drained; the
rest of the abdomen was closed. She made a very good recovery
and left the hospital in six weeks entirely well, except for a
small fistulous tract in the old sac.

430 Pine Street.



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baer: fibrqid tumor complicating pregnancy. 909



FIBROID TUMOR COMPLICATING PREGNANCY AND

RENDERING A CONTINUANCE OF GESTATION

DANGEROUS AND NATURAL DELIVERY

IMPOSSIBLE.*

BY
B. F. BAER, M. D.,

Professor of Gynecology in the Philadelphia Polyclinic and College for Graduates

in Medicine,
Philadelphia. Pa.

(With four illustrations.)

To retell an oft told tale may be trite and uninteresting, but
to remain alive and awake, it is necessary to keep constantly
drilling and rehearsing, so that the best discipline shall prevail
and the best success may be won.

If it goes without saying that it is a misfortune for a woman
to have a uterine fibroid, it will be at once admitted that the
misfortune becomes greatly multiplied when pregnancy is added
as a complication. This becomes especially true when the tumor
is situated in the lower uterine segment, and in the posterior wall,
or the broad ligament, in the consideration of which this commu-
nication is largely concerned.

Early in my medical career, it was my fortune to see two cases
of pregnancy complicated with fibroid tumor, in one of which
rupture of the uterus occurred during labor, followed by the
death of both -mother and child; the other where death resulted
from septic peritonitis in consequence of injury to the soft parts,
following instrumentation for dystocia caused by a blocking
fibroid. The child had perished during the labor.

The first case was attended by a midwife. To the other I was
related as an assistant.

This dreadful experience impressed upon me the fact that
pregnancy complicated with fibroid tumor was a most serious
condition; and investigation of the literature of the time soon
convinced me that I had only witnessed, in a concentrated form,
a disaster that was not uncommon in a period that has passed.

I found, among the latest and best authors of the time, that
Barnes and Playfair alike advised women with uterine fibroids
not to marry. Barnes wrote: "Happily, in a great number of
instances, fibroid tumor or myoma imbedded in the walls of the

♦Read before the American Gynecological Society, May 3 to 5, 1910.



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910 baer: fibroid tumor complicating pregnancy.

uterus operates as a bar to conception; but when pregnancy does
supervene, the result is often disastrous. The tumor interferes
with the equable development of the uterus and therefore fre-
quently determines hemorrhage and abortion. And, perhaps,
this is a fortunate event; for delivery in the latter months brings
additional danger. Looking to future probabilities, we should
deprecate incurring the risk of another pregnancy. I believe
every experienced obstetrician would advise a single woman
known to have fibroid tumors in the uterus to avoid marriage;
with the doubtful exception of tumors seated in the fimdus."*

These were wise words, and most sotmd teaching; and they are
as true and applicable to the present time as when they were
written, more than thirty years ago. The only advance we have
made in the management of these cases is in the protection we
have been able to give them, by the operative measures that
have been established by the work of the gynecologist, in abdomi-
nal surgery. This, of course, has been a great gain, for by it
many thousands of lives have been saved; but it has not
often given the power to perform safely the fimction of child-
bearing.

Since that time I have been teaching that a married woman or
one about to marry and known to have uterine fibroids should
be advised as to the dangers, and that if she then desires protec-
tion it is our duty to give it, even to supravaginal hysterectomy,
if myomectomy does not give promise of safety.

Nature herself recognizes the danger and impropriety of
fecundation in the presence of fibroid tumor, as witnessed by the
frequent occurrence of sterility, miscarriage, or premature labor.
And it was mainly from miscarriage or premature labor that the
large mortality occurred in the period before these patients were
rescued by abdominal operation. At least four of the six cases
here recorded, and probably also the other two, would have
perished if such aid had not been given.

Dr. Wilmer Krusen,t in a recent paper, relates two strongly
illustrative cases in which the patients were profoundly septic
from degenerating fibroids due to traumatism from miscarriage,
whose lives were only saved by prompt supravaginal hysterec-
tomy under the most unfavorable conditions.

True, the location of the tumor has much to do with the
result; but, at best, a fibroid uterus is not a good breeding nidus;

* Robert Barnes, M. D., Obstetric Operations, London, 1875.
t Amer. Jour. Obst., March, 1910, p. 460.



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baer: fibroid tumor complicating pregnancy. 911

for the children that survive the ordeal of labor, or Cesarean
section at, or near term, are often so feeble from the circulatory
disturbances in the placenta that many of them die in infancy,
or early childhood; and this would seem to be in agreement with
the law that only the fittest should survive.

According to the statistics of Susserot, Nauss, and Lefour, as
quoted by our President, Dr. E. P. Davis, more than 50 per cent,
of the mothers and nearly 70 per cent, of the children perish as a
result of this complication. The later history of the mothers
who escaped death is not recorded, but it is fair to presume that
many sufifered death later, in consequence of another pregnancy;
and the after-history of the children saved would be interesting
and useful.

To be, as was the third Richard, "Sent into this breathing
world before (its) time, scarce half made up," is a misfortune of
immeasurable consequence! Should it be forced upon the
unborn, and the race deteriorated thereby? The battle against
the odds of life is difficult, even for the strongest.

We should also consider that the mothers who fortunately
escape with life are often so broken in health that, to regain it,
and immunity from further risk, they must, after all, go to
operation.

At the same time, I am aware that occasionally, when the
tumors are located in the upper zone, the gestation goes to term,
more or less normally; and that safe delivery of a normal child
is accomplished. The following "remarkable case" was related
at a recent meeting of the New York Obstetrical Society by our
distinguished Colleague, Dr. W. Gill Wylie.*

A doctor's wife, between three and four months pregnant, had
been seen by several other doctors and they thought it wise to
terminate the pregnancy. Dr. Wylie thought that "if those
fibroids had much to do with the uterus, the pregnancy would
not have gone so far. There were two or three as big as small
lemons and others of less size." He advised watching the
patient closely and waiting until near term. He then delivered
her of a nine-pound healthy child. "I then treated her to
secure rapid involution and advised her to try again. She had
a second child about fifteen months afterward. She was then
forty-five years of age."

The tumors in this case were small and were evidently rather
on the surface than interstitial. They were not located in a

♦Amer. Jour., Obst., April, igio.



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912 baer: fibroid tumor complicating pregnancy.

position where the circulation is much disturbed, as it is in the
vast majority of cases.

Therefore, I cannot endorse as wise teaching, the advice he
gives in the same discussion, that when, " discovering a woman
with fibroids, if she is married, it is the doctor's duty to put that
woman in condition so that she can become pregnant and will
have a child."

It will at once be seen how directly opposite is this teaching
to that expressed in the words which constitute the sentiment
of this communication. It is true, my paper relates to blocking
fibroids particularly, which are usually located in the lower zone
of the posterior wall or within the folds of the broad ligament.
This was true in five of the six cases.

Then, who can tell how rapidly the fibroids may grow after
impregnation in the most favorably appearing cases? A
remarkably rare instance should not be made the precedent.

As long as the clock is going the pendulum will swing from
one extreme to the other; and this is necessary to mark the
progress of time. But in science, when the pendulum is swung
to the extreme degree it does not mark progress. Neither is it
best, if it were possible, to take a middle course.

Take the one side or the other, and then by discussion our
knowledge will grow by discovery of the truth. The figurative
"middle of the road" is like the twilight, in which you can see
the object, but cannot distinguish the dog from the wolf or the
friend from the foe.

Read carefully the cases appended, and think about this
important question.

Fibroid tumor is also a cause of extrauterine pregnancy.
My first case of this disease was caused by a small tumor blocking
the left Fallopian tube at its junction with the uterine comu.

Both ante- and postpartum hemorrhages are also dangers to
be considered.

Case I. — Multiple Fibroid Tumor of the Uterus, Complicating
Pregnancy, Hemorrhage and Miscarriage. Myomectomy and
Oophorectomy,

The patient was twenty-seven years of age in January, 1891.
Several years previously she began to flow more freely at the
menstrual periods, and later had metrorrhagia two or three times
a month. A year before she noticed several '* lumps" in the
lower abdomen. The last menstrual period had occurred in
September, and soon after she began to sufiPer from pelvic
distress, rectal and vesical pressure, etc. Early in January,



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baer: fibroid tumor complicating pregnancy. 913

expulsive pains and hemorrhage became severe, and for the
latter symptoms mainly she sought relief.

Examination of the abdomen revealed a number of tumors,
apparently connected with the uterus. Per vaginam, a large,
rather hard tumor occupied the hollow of the sacrum. The
cervix was almost out of reach of the finger, behind the symphysis
of the pubes. The os uteri was patulous and a portion of the
fetal membranes presented. The indications seemed clear.
Under anesthesia the miscarriage was completed, but with some
difficulty, because I could not elevate the pelvic tumor which
occupied the posterior wall of the uterus.

The patient made slow progress toward recovery and three
weeks later, after abdominal section, I removed three cocoanut-
sized tumors from the upper zone. They were more or less
pedunculated. The pelvic mass was wedged and there were
recent inflammatory deposits around it and the appendages
which were considerably enlarged. I considered it safer at that
stage of my experience to remove the appendages, leaving the
uterus and pelvic tumor. The patient made a stormy recovery;
and I resolved that I would try to do better with the next case.
Supravaginal hysterectomy should have been done at once,
before the miscarriage was completed.

Case II. — Supravaginal Hysterectomy for Fibroid Tumor
Complicating Pregnancy and Rendering Labor Impossible.

Mrs. H., aged thirty-seven years, was married in February,
189 1. Menstruation had become rather profuse during the
preceding two years, but the patient considered herself in good
health until five months after her marriage, when she began to
experience pelvic pressure symptoms. Her catamenia had been
suppressed in June. About September i, she began to suffer
with severe pain in the pelvis, along the course of the sciatic
nerves, and with rectal and vesical tenesmus. I saw her on
September 28, in consultation with Dr. F. L. Horning and Dr.
J. S. Baer, of Camden, N. J. She was extremely anemic and
appeared to be in great distress. The abdomen was distended
by an irregular tumor which extended above the umbilicus.
The tumor mass was larger on the right side and was connected
with a pelvic tumor by an hour-glass constriction. The mass on
the right side was rather globular and conveyed a boggy, semi-
fluctuating sensation, while that in the pelvis was quite firm,
apparently solid. Vaginal examination revealed a firm, hard
tumor, as large or larger than a child's head. It entirely filled
the pelvic cavity and was immovably fixed. The cervix uteri
could not at first be found but it was finally located above the
transverse ramus of the pubic bone, and almost out of reach of
the finger. Combined palpation showed the globular mass on
the right side to be continuous with the cervix. There was a
well-marked uterine bruit. Diagnosis, fibroid tumor compli-
cating pregnancy and rendering labor impossible.

The great suffering and danger made it imperative that steps



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914 baer: fibroid tumor complicating pregnancy.

should at once be taken for her relief, and she was transferred to
the Polyclinic Hospital.

Operation, October 2, 1891. After anesthesia, I endeavored
to dislodge the tumor and elevate it into the abdominal cavity,
with the hope that the pregnancy might go to term, but failed,
and therefore decided to open the abdomen. Incision exposed
the pregnant uterus. The organ was resting on the tumor, being
connected with the latter by a pedicle about two inches in diam-



A
Fig. I. — Case II. A. Myoma. B. Pregnant sac.



eter. The left broad ligament and the tube and ovary w^ere
stretched over the pelvic mass. After great instrumental
effort the tumor was released from the pelvis. The propriety
of removing the tumor and leaving the pregnant uterus was now
considered, but further examination showed that the organ con-
tained several other malignant-looking tumors. I therefore deter-
mined upon hysterectomy. The operation was completed by the
method and technic described by the writer in the papers read



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baer: fibroid tumor complicating pregnancy. 915

before the Society in 1892 and 1893.* She made an uninter-
rupted recovery, being apparently convalescent from the
beginning.

I saw this patient last week, nearly nineteen years after the
operation. She has remained in good health. (Fig. i.)

Case III. — Fibroid Tumor Complicating Pregnancy. Hemor-
rhage and Miscarriage. Supravaginal Hysterectomy.

Mrs. E. H., aet. thirty-six years. Married, April, 1902. The
periods had been rather profuse since marriage until September,
when suppression occurred. Soon after, pelvic symptoms, in-
creasing in severity, were present; and about the middle of
December metrorrhagia and pain began and continued more or
less severe. I saw her in consultation with Dr. J. W. Parsons,
of Canton, Pa., December 28.

Examination revealed an irregular, hard mass in the lower
abdomen. Per vaginam, the os uteri was found rather patulous,
with fetal membranes presenting at the internal os. Tempera-
ture was elevated and the pulse rapid. The patient was septic.
Miscarriage was inevitable, but it was deemed unwise to try to
remove the product through the cervical canal.

She was admitted to my private hospital and supravaginal
hysterectomy was performed early in January, 1903. There
were several orange-sized tumors, one submucous, but sessile, two
interstitial. The uterine cavity contained a four months dead
product. The submucous tumor was undergoing gangrenous
change. Recovery.

Case IV. — Fibroid Tumor in the Posterior Wall of the Uterus ^
Complicating Pregnancy. Pelvic Incarceration Rendered the
Continence 0/ Pregnancy Dangerous and Labor Impossible. Supra-
vaginal Hysterectomy at the Fifth Month.

Mrs. D., of Virginia, aet. forty years, was married on June i,
1905, and did not menstruate afterward, although the periods had
been regular before. Symptoms of pregnancy were soon present,
and in August she began to suffer from pelvic distress. The
symptoms gradually increased and a month afterward she was
compelled to consult a physician. Examination at this time
revealed what was thought to be a retroflexed pregnant uterus;
and several attempts were made, twice under anesthesia, at dis-
lodgment of the supposed pregnant uterus from the pelvis.
Failure resulted, and the patient was left in a worse condition.
At this time, late in October, she was brought to Philadelphia by
her former physician. Dr. E. H. Gingrich of Lebanon, Pa., and
placed in my care. Dr. Gingrich had made a diagnosis of com-
plicated pregnancy.

She presented a picture of extreme suffering, was emaciated,
pale, and jaundiced. There was a sense of fullness and pressure
in the pelvis and lower abdomen, which was agonizing. Dys-
pnea was so marked that she could not occupy the recumbent
posture. There were retention of urine and rectal obstruction.

* Supravaginal Hysterectomy without Ligature of the Cervix, in Operation for
Uterine Fibroids. A new method. By. B. F. Baer, M. D., Transactions, American
Gynecological Society, 1892 and 1893.



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916 baer: fibroid tumor complicating pregnancy.

Examination revealed a distended abdomen and a rounded,
rather symmetrical tumor, occupying the lower portion. Per
vaginam, a hard mass completely filled and blocked the pelvis.
Its size, shape, and consistency resembled that of the child's



Fig. 2. — Case IV. A. Head of fetus emerging at jwint in anterior wall where
rupture was imminent. B. Left ovary. C. Right ovary. Between B and C, in



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 94 of 109)