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the line of division of the tumor, is the internal os uteri. Below this the tumor is
constricted by the lineailio-pectineal.

head at full term. It was immovably fixed. The cervix uteri
could not be found, being above the pubic crest. The hypo-
gastric and pelvic tumors seemed to be one mass. The parts
were very tender to the touch. Catheterization revealed reten-
tion of urine.



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baer: fibroid tumor complicating pregnancy. 917

The patient was placed in preparation. Rest and emptying
the bowels by enema and sulphate of magnesia removed the
tympany, so that on the following day the hypogastric tumor
could be more easily defined. It extended above the umbilicus
and was very tense. The pelvic tumor was still immovably
fixed. I now decided upon abdominal section.

An incision was made in the hypogastrium, when the upper
tumor was seen to be the pregnant uterus; it was so black from
venus stasis as to be apparently dead; the broad ligament veins
were especially congested and appeared on the point of bursting;
below was the pelvic tumor, wedged in the pelvis. Further
examination showed that the tumor occupied the posterior wall
of the uterus. Manipulative effort to dislodge the growth from
the pelvic cavity entirely failed, and I was compelled to use a
large volsella forceps; even then it required many anxious min-
utes of traction to dislodge it. I finally succeeded in doing so,
when the whole mass was delivered through the incision. Supra-
vaginal hysterectomy was then completed.

Examination of the remarkable specimen, as shown in the
photograph before you, reveals at once why I decided upon
hysterectomy rather than enucleation of the tumor, which I
had hoped to do, and thus save the life of the child by preserving
the uterus. The specimen shows that this would have been
impossible without also sacrificing the life of the mother (Fig. 2).
At one place, where the child's head is shown emerging, the uter-
ine wall is on the point of rupturing.

Case V. — Pregnancy Complicated with Fibroid and Ovarian
Tumor. Supravaginal Hysterectomy.

A. J., aet. thirty-three years, married, two children, youngest
three years; four abortions since; consulted me in September,
1908, for metrorrhagia, expulsive pains and pressure symptoms.
Bleeding had been continuous for several weeks.

She stated that she had missed two periods and also that
she had had two abdominal sections, one six years, the other six
months ago. Why, I did not learn.

Examination showed the pelvis entirely filled with a mass; it
seemed to be made up of the enlarged uterus, with a tumor on
the left side of it. The os uteri was patulous. Diagnosis, fibroid
and tuboovarian tumor with inflammatory fixation, complicat-
ing pregnancy. Miscarriage was imminent.

Operation, September 15, 1908. The uterus was found to be
larger than at the third month of gestation, crowded a little to
the right; the left ovary contained a tumor as large as the fist, all
forming one mass, because of inflammatory exudate and adhe-
sions. After the tuboovarian tumor was separated and removed
the uterus was found to contain a fibroid tumor.

Supravaginal hysterectomy was performed. Recovery.

Within the uterine cavity a dead product of two months was
found. A submucous fibroid tumor, larger than a duck's egg,
occupied the posterior wall; it was undergoing gangrenous
change.



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918 baer: fibroid tumor complicating pregnancy.

Case VI. — Pregnancy Complicated with Fibroid Tumor in the
Lower Zone and Broad Ligament; Blocking the Pelvis and Render-
ing Natural Labor Impossible. Abdominal Hysterotomy and
Hysterectomy at the Seventh Month.

Mrs. L., aet. forty-one years, was married at twenty-eight,
but had not been previously pregnant. She had suffered from
dysmenorrhea since puberty. After her marriage she had some
kind of local treatment for its relief but with little benefit. Later
she was treated for retroflexion of the uterus, and she was ** laid
up" on several occasions with what was probably pelvic peri-
tonitis. During the previous year she; had had metrorrhagia at
the menstrual periods. She then received some additional treat-
ment, probably intrauterine. After that she seemed better.
In December, 1908, the catamenia were absent and did not
reappear. In February, 1909, she was so ill that she was sent
to a gynecologist in a neighboring city. He informed her that
she had several fibroid tumors, and advised their removal. The
abdomen rapidly increased in size, and her sufferings became
progressively severe, so that she was almost constantly in the care
of her physician. Toward the end of May, she was conscious
of such commotion within the abdomen that she informed the
doctor she must be pregnant; he very naturally thought it un-
likely, because of the long sterility. But he was hurriedly called
one night to find the patient '*on the point of dying" from what
appeared to be heart failure; he then made a physical examina-
tion and found a moving child high in the epigastrium, and some
hard masses below. He now became convinced that a complicated
pregnancy existed. During the next two or three weeks there
were several similar attacks, only more severe. Dyspnea
also became so marked that she was afraid of the recumbent
posture.

I first saw the patient in Philadelphia, June 23. I shall not
soon forget the picture of appeal and anxiety and distress, which
were expressed upon the countenance and conveyed by the
general attitude of this patient, when she entered my office and
said, '* I must have relief, for my heart does not seem to have
room enough to act."

I found that the child was carried almost entirely above
the umbilicus, feet upward, and I concluded that the syncope,
the dyspnea, the nervousness, and the general distress were
probably due to the hammering of the child's feet upon the
solar plexus and the diaphragm. The hypogastrium con-
tained numerous hard tumors, one nearly as large as a child's
head, low in the right ilium, and dipping into the pelvic brim.
Per vaginam, another hard tumor, larger in size, was blocking the
pelvis, but more to the left. It appeared to be fixed, as if from
old inflammatory adhesions. The cervix uteri could only be
located by drawing a little on the imagination. It seemed to be
between the two larger tumors, but out of reach. The gestation
was estimated at about seven months. The patient was admitted
to a private room in the Polyclinic Hospital.



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baer: fibroid tumor complicating pregnancy. 919

I had hoped to find that the symptoms had been exaggerated
by the patient, and that by rest and remedies the gestation
might be carried along toward term. But in this I was dis-
appointed. After three days of observation I was persuaded
that in the interest of both mother and child operation was
necessary. This was done June 27. I was ably assisted by
Dr. W. R. Roberts and Dr. R. L. Mitchell.

After the abdominal incision, the fundus of the uterus only



A
Fig. 3. — Case VI. Anterior view. A. Pelvic portion of tumor, which was fixed
by strong old inflammatory adhesions. B. Broad ligament tumor. C. Body of
uterus with many small tumors. Above* A umbilical cord is seen issuing from the
internal os uteri.

was with difficulty made to emerge, because of fixation below.
Without wasting time hysterotomy was at once done, the knife
passing around and through a number of small tumors. A
feeble, half-cyanosed child was delivered and handed to an
assistant for resuscitation. There was very little hemorrhage,
as Dr. Roberts was constricting the vessels with his left hand.
I did not detach the placenta, for it occurred to me that it was



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920 baer: fibroid tumor complicating pregnancy.

unnecessary and would only lead to a loss of time; and that the
squalor and hemorrhage attending its separation would be a disad-
vantage. This is a point in the technic which I found of value,
and it should be remembered. The next step brought my atten-
tion to the pelvic tumors, and showed me that one was situated
low, within the broad ligament, with attachment to the side of the
uterus, near the cervix. Another was fixed by old inflammatory
adhesions, deep within the pelvic cavity. This confirmed the
view, previously formed, that natural labor was impossible.
Hysterectomy was now completed and the incision closed.



Fig. 4. Case VI. Posterior view.

The patient stood the operation well and awoke from the
anesthesia, happy in the relief obtained, as expressed by both
voice and countenance. She made a smooth recovery. The
child was feeble at delivery but seemed to thrive for a few days,
then gradually declined, and died at the end of two weeks.

The specimen shown in the photograph is a remarkable one,
in that all of the larger tumors are in the lower zone, and one of
them within the folds of the broad ligament. The upper zone
also contained many tumors, but they were smaller (Figs. 3
and 4).

Finally, if the patient is pregnant when first seen we must, of



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KELLY: TREATMENT OF AN ANTEUTERINE PELVIC ABSCESS. 921

course, decide from the conditions what should be done to save
the child, just as in any other serious disease of the pregnant
woman; but the obstetric rule, established long ago, that the
mother must be given the preference when both are in jeopardy, *
remains.

If the tumors occupy the upper zone, or if they are small and
subperitoneal, the prospect of saving the child will be greatly
improved; and it must be given every chance. At the same
time, I believe that impregnation in the fibroid uterus is a
danger that should not be encouraged.

21 15 Chestnut Street.



TREATMENT OF AN ANTEUTERINE PELVIC ABSCESS
BY SEQUESTRATION AND DRAINAGE.

BY

HOWARD A. KELLY, M. D.

Baltimore, Md.

(With four illustrations.)

ANTEUTERINE absccsscs, that is to say, abscesses situated
somewhere between the round ligaments and the uterus behind,
and the pubic bones and symphysis in front, and having, there-
fore, some close relation to the bladder, are among the rarer
forms of gynecological infection, and I have only seen a small
group of them in a long experience. Such abscesses may rise
from one of several sources : the Fallopian tube forming a pyo-
salpinx may be displaced over in front of the uterus with or
without a backward uterine displacement, the abscess may be
mural, located in the anterior uterine wall at some point below
its comu, or, again, it may be lodged in the cellular tissues
(subperitoneal) between the uterus and the bladder. It is often
hard in these cases to define exactly the position of the abscess
before the more direct inspection of the structures, as the bi-
manual examination may only reveal a more or less confused
thickening to the right or to the left of the median line. When
the abscess is situated more median, and is large and fluctuates,
it may then be quite evident to the examiner that it is located
between the uterus and the bladder, and his clear surgical instinct
may at once suggest that he should proceed to open the anterior
vaginal culdesac with a view of draining it there. After open-
ing the abdomen in other cases and detecting the exact location
of the abscess, the operator may also then deem it wiser not to
open the abscess cavity from above, but, under the guidance of



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922 KELLY: TREATMENT OF AN ANTEUTERINE PELVIC ABSCESS.

abdominal inspection and under the control of the fingers in the
abdomen, to open the anterior vaginal wall and make the drain-
age through in this direction. When the abscess is a small one^
and when it is well limited, he may deem it perfectly safe to open



^ ^ '




Fig. I. — Uterus in retrodisplacement. Abscess above with adherent omentum.

it above transperitoneally, perhaps aspirating first, and then, after
cleaning out the cavity thoroughly, to proceed to sterilize it by
an application of pure carbolic acid followed by absolute alcohol,,
after which the walls must be curetted out or excised and closed
by suture. This plan of treatment is well adapted to the smaller




Fig. 2. — Shows the extent of the abscess in front of the uterus, and on the right
side, as seen through the abdominal incision.

abscesses. I had a case last December in which there was a
large abscess extending from beyond the median line on the
left well over on to the right side, filling out the right anterior
quadrant to the pelvis, in which I adopted yet another plan..



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KELLY: TREATMENT OF AN ANTEUTERINE PELVIC ABSCESS. 923

The large infected area with its accumulated pus was so located
that it could not be reached conveniently from below, so I
opened the abdomen, walled off the affected area with gauze,
evacuated the abscess, and then drained it from above after
marsupializing or shutting off this portion of the abdominal
cavity so as to obviate all danger of extension of the infection
as a postoperative peritonitis. The patient was a young woman
of twenty-eight, brought to me by Dr. Dew of Lynchburg, Va.
She had had one child and began in November with irregular
bleedings which continued until January, when a dilatation and
curettage was done. In January, although the bleeding ceased,
she began to have an offensive discharge and signs of septic
infection. This continued until I saw her toward the end of




Fig. 3. — The abscess opened and cleaned out. The round ligaments on either
side are united to the anterior abdominal wall to the right and to the left of the
symphysis. Another stitch drawing each cornu of the uterus forward to the abdomi-
nal wall further contracts the pouch in which the abscess lies.

February, 1910; when, finding a well-defined tender mass to the
right of a retrofiexed uterus, and in view of the septic history, I
urged immediate operation.

The abdomen was thoroughly cleansed and the incision made;
the omentum which was adherent in front was freed, the uterus
was found in retroflexion, and the uterine tubes and the ovaries
normal; Douglas' culdesac was patulous. The vermiform ap-
pendix was attached to a mass which lay anterior to the uterus
and between it and the bladder, more on the right side. A
superficially inflamed but otherwise intact appendix was freed
and removed after the usual manner. The abdominal cavity
was then carefully packed off with gauze on all sides and the
abdominal incision protected, when the abscess in front of the



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924 KELLY: TREATMENT OF AN ANTEUTERINE PELVIC ABSCESS.

uterus was widely opened from side to side, evacuating 15 or
20 c.c. of pus containing diplococci, not intercellular, which
failed to grow on the culture media. After emptying the abscess
the walls of the irregular cavity were then curetted. On account of
the infiltration of the surrounding tissues I could not be sure that
all infection had been eliminated, so I proceeded to shut off
(to extraperitonealize as it were) the entire abscess area by
suturing the round ligaments with catgut to the anterior abdomi-
nal wall, beginning near the internal inguinal ring and coming




Fig. 4. — The uterus drawn forward by the sutures uniting the round ligaments
and the comua to the anterior abdominal wall, leaving a narrow opening between
the uterus and the symphysis through which the iodoform gauze drain envelo|>ed in
protective b inserted down into the abscess cavity.



in toward the recti. The cornua of the uterus were also fastened
up to the abdominal wall. The body of the uterus itself was not
so sutured. This left a little crack between uterine body and
abdominal wall through which an iodoform drain, covered
with protective, was inserted down into the abscess cavity and
leading out down through the lower end of the abdominal
incision.

An opening was also made in Douglas* culdesac and a small
drain brought out there into the vagina. The abdomen was
then closed in layers down to the drain. The dressing was changed
on the second day, on the fourth the vaginal drain was taken out>
and on the sixth the abdominal drain was removed. There was
no elevation of temperature subsequent to operation. The



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MURRAY: VAGINAL CYSTS AND THEIR HISTOLOGY. 925

wound healed perfectly and closed by the first of February.
Examination showed the uterus held well in place. By this
operation I limited the infection to the point from which it
originated and then, as I was unable to remove the sac, which
was located in the tissues between the bladder and the uterus, I
drew up the uterus, reconstituting the vesical fossa, and pro-
ceeded to turn it into a pocket or a culdesac by attaching the
round ligaments and the cornua to the abdominal wall above
the horizontal pubic rami on either side. This temporary
pocket lasts long enough to offer a perfect protection to the peri-
toneum at large, but is not permanent.

I cannot think of a securer way to handle similar cases.

14 18 EuTAw Place.



VAGINAL CYSTS AND THEIR HISTOLOGY.

BY
GRACE PECKHAM MURRAY, M. D.,

Member of the American Medical Association. New York State Medical Society.
Academy of Medicine^ew York County Medical Society, New York Neu-
rological Society. Women's Medical Association. Professor Adjunct
in Women's Diseases, New York Post-Graduate
School and Hospital, etc..
New York.
(With two plates and seventeen illustrations.)

The rarity of vaginal cysts is conceded by all writers on the
subject and coincides with the experience of gynecologists who in
private and dispensary practice handle hundreds not to say
thousands of cases. The case which is reported in this paper is
the only one which has come under my observation. In fact
the vagina, considering the traumatisms to which it is subjected,
is singularly free from neoplasms of all kinds. I have had only
one case of carcinoma of the vagina, by which I mean having its
origin in the vagina and confined wholly to its tissues, and can
recall only one case of polypus.

The patient was a healthy young Irish woman of thirty. She
came to the clinic at the New York Post-Graduate Medical School
in the fall of 1907. She returned again in June 3, 1908. She
had then been married six years. She had had two children and
no miscarriages. Her labors were normal and her oldest child
was four years old and the youngest was two years. The tumor
troubled her two months before her last child was born. She
noticed it a year or two before her marriage, but it had not given
her inconvenience, nor was it very large. She menstruated first
when she was fourteen, and was always regular except when



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926 MURRAY: VAGINAL CYSTS AND THEIR HISTOLOGY.

nursing her children, menstruation lasting four days. She had
no clots nor pain except when she got her feet wet. She felt well
when menstruating except for a headache at the base of the brain.
She had leucorrhea after her period. She had been constipated
since her children were born, but did not need laxatives before.
Her urine was normal. Complained of nervousness, but said she
drank a great deal of tea.

Upon examination a growth was found presenting at the vulva
size of a hen's egg, which resembled a prolapsed uterus or recto-
cele. It was found to be an elastic tumor with slight fluctuation.
It was implanted upon the posterior wall of the vagina, midway
between the cervix and the vulva, starting about one inch below
the cervix. It had a base about two inches in diameter. The
cervix was small and the uterus was retroverted. The utero-
vesical ligament was shortened. (See Plate I and Fig. i.)

She entered the service of Dr. James N. West at the Post-
Graduate Hospital, and was operated upon by him on July ii,
1908. He made an incision through the mucous membrane over
the tumor and the cyst was shelled out. It broke in the attempt.
The cavity was obliterated and the wound was closed. The uterus
was straightened by means of an Alexander's operation. The
patient made an uneventful recovery and was discharged August
15. She presented herself at the clinic early in the following
October. The site of the incision could neither be seen nor felt.
The uterus was in normal position.

Vaginal tumors offer little of interest except from the stand-
point of their origin. This gives them a paramount interest and
which, because of their rarity, makes it important that each case
should be presented to the profession and its histological ap-
pearance noted and studied. The symptoms to which they give
rise are singularly lacking in gravity. Not a few may exist
without ever disturbing those who have them, or their being
aware of their presence, or indeed being perceptible if small upon
digital examination. It is not until they attain considerable
size or upon becoming pedunculated and appear at the vulva that
they are noticed, or when they have become large enough to
interfere with coition or labor that the patients seek advice.

The matter of diagnosis is simple. In only one instance could
a mistake have serious import. One should be careful to dif-
ferentiate between them and a hernia into the vagina, records
of such cases having been given. Although such an occurrence



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PLATE I AMERICAN JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN

June. 1910



\'aginal C\>.t Frcscruiiig ai \'ulva. — Pkckham Murray.



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MURRAY: VAGINAL CYSTS AND THEIR HISTOLOGY. 927

is of great rarity, tumors originating from the ureter may also
be taken for vaginal.

The vaginal cysts are not important from a surgical point of
view. They are easily extirpated and healing takes place readily
as seen in this case just reported which in a little more than two
months after the operation left not a trace of its ever having



V



Fig. I. — Schematic representation of tumor in situ.

existed. The same thing occurs often when the cysts are simply
opened and the contents evacuated. When the tumor is
situated on the anterior wall, care has to be taken not to injure
the ureters or the bladder.

The location of the cysts may be either on the anterior or
posterior wall as well as lateral. Burner de la Roche in his



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928 MURRAY: VAGINAL CYSTS AND THEIR HISTOLOGY.

Thfese de Paris says that those on the anterior wall predominate.
They are generally solitary. They may be multilocular, but
as a usual thing they are unilocular. They are ovoid in form or
globular.



Fig. 2. — Section from middle of posterior wall of vagina of a girl sixteen years old.



Fig. 3. Fig. 4.

Fig. 3. — Section from lower third of posterior wall of vagina of child twenty-two
days old. (Sharp border toward connective tissue made of c>'lindrical epithelium.
Inner portion pavement epithelium.)

Fig. 4. — Shows a closed crypt with a lumen in the middle. (\^eit.)

Rutherford gives the following table:

Anterior wall. Posterior wall. Lateral.

Graefe 29 21 11

Winckel 19 H H

Johnston 60 57 18

Rutherford C^'^"^) 25 15 4



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MURRAY: VAGINAL CYSTS AND THEIR HISTOLOGY. 929

Burner de la Roche believes the anterior wall is more frequently
affected because of its proximity to the ureters (the remains of
the Wolffian bodies). Takahasi and Lee consider the anterior
and posterior walls equally affected. Von Preussen and Fro-
ment think the posterior walls are equally affected. All authori-
ties agree that they are rare upon the lateral walls.

The growth of the cysts is said by all observers to be very



Fig. 5. — A. crypt lined throughout with flattened epithelium. B. Connective
tissue. C. Muscular tissue. D. Low columnar nonciliated epithelium lining
interior of cyst wall. (Rutherford.)

slow. In the case reported there had been no change in six
months. That it is influenced by pregnancy would be expected,
as is shown in this instance. Excessive coitus will also cause
them to grow. Winckel states that they grow very slowly,
requiring many years to become the size of a hen's egg. Furst
records one which took five years to grow, and Tillaux tells of
one that was under observation for twenty-two years.

They are covered with the mucous membrane of the vagina.
5



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930 MURRAY: VAGINAL CYSTS AND THEIR HISTOLOGY.

If this were thick, they might remain for years in the same condi-
tion, but if it were thin, or the contents of the sac pressed upon
the membrane, it would be gradually thinned and a spontaneous
rupture take place, the fluid passing off through the vagina,



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 95 of 109)