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pallor, vertigo, fainting, nausea, vomiting, rapid and weak pulse, jerky breathing and air-hunger, cold extremities, etc., she suffered from agonizing, paroxysmal pain, sudden in onset and referred to the lower abdomen. Associated with this were general abdominal tenderness and distension, soon followed by pelvic and supra-pubic tumefaction, rather more marked on the left side. No exciting cause, such as over-exertion or strain, could be found for the first attack, and there were none for the subsequent ones, as she was kept rigidly in bed on her back and perfectly still. For the two weeks following the first collapse there was but little uterine flow. During the amenorrhoea, she suspected pregnancy and complained of soreness of the breasts, which, however, was the usual forerunner of menstruation. Morning sickness, discoloration of the nipples and linea alba, or objective breast enlargement were not noted, and nothing was passed at any time which could justify the diagnosis of abortion or resembled the decidua.

Operation was undertaken on Nov. 17, because of the recurring collapses, with each of which the tumor increased perceptibly in size, the intensifying anemia, which had become alarming, and a progressive zig-zag temperature, which had attained a dangerous height.

A pelvic examination was made under anæsthesia immediately before the operation, previous manipulation having been rather unsatisfactory on account of the extreme tenderness. There was a bilateral cervical tear, the uterus being in good position and but s lightly enlarged; its cavity was empty. No tubal or ovarian tumefaction or displacement was made out, nor was such found after the a bdomen was opened. Above the uterus and distinctly separable from it, in spite of a vague sense of fulness throughout the pelvis, extending to either side of the median line, but to the left especially, was a soft, elastic tumor, tympanitic in spots, and, while movable superficially, apparently attached near the sacral promontory.

A median incision showed the pelvis filled with loose clots, but no changes about the uterus and adnexa beyond a few soft, inflammatory adhesions. The bleeding was found to come from a rent on the outer side of the meso-colon of the upper rectum and sigmoid flexure, which was enormously distended with blood, as was the mesentery of several neighboring intestinal coils, forming a tumor fully as large as an adult head.

The clots were evacuated as thoroughly as possible through the mesente ric rent, the cavity washed out and carefully stuffed with iodoformi gauze; this, in turn, surrounded by a protective abdominal pack, after the pelvis had been cleaned out, and the wound partly closed with sutures. There was considerable oozing from the clot cavity, which was readily controlled by the gauze pressure.

The immediate effect of the operation was to bring down the temperature from 103 degrees plus to the vicinity of 100 degrees, about which it kept for nearly a month. There was no further intraabdominal hemorrhage, but a profuse metrorrhagia appeared on the evening of the operation and continued intermittingly and with decreasing freedom for about four weeks, lasting off and on, then, for nearly two months. On the ninth day all the gauze was removed and the cavity thoroughly washed out with hydrogen peroxide and sublimate solution. This was repeated, as needed, until healing by granulation was complete. A number of clots came away, others organized, and still others broke down, but no untoward symptoms resulted. In picking out the loosening coagula, an occasional oozing was observed, but this was readily controlled by replacing the pack.

A recent examination shows a good cicatrix without any sign of hernia; the bowel functions are normal and digestion excellent. The anemia has disappeared and she has regained her florid complexion. The uterus is in good position and not at all fixed, menstruation being regular and as before the accident in duration and quantity

The symptoms in this case naturally point very strongly to extra-uterine pregnancy, and although I find in my record book that Dr. Shoemaker and I were inclined to believe, at our consultation previous to the operation, that the hemorrhage was of traumatic origin, yet I hardly think we were justified in our conclusion by the premises.

What more characteristic picture of abdominal hemorrhage can there be than these sudden attacks of severe, agonizing pain, recurring from time to time, associated with the constitutional signs of bleeding and a progressive anemia? The ensuing localized peritonitis was shown by exquisite tenderness, distension, and a fever which became dangerous in character. At a previous consultation with another physician, what were considered septic spots were noted, and led to the discussion of a possible complicating typhoid. The tumor, too, was deceptive and totally unlike, either in location or mode of spread, other abdominal hemorrhages that I have met with ; such, for example, as slowly-bleeding, ruptured kidneys, inesenteric hemorrhage in a subject of Bright's, etc. It was low enough down to be deemed pelvic, only distinctly separable from the

uterus under anæsthesia after the organ was drawn down, this being especially perceptible by examination through the rectum. While above the womb, it extended well to the left side and steadily and rapidly increased in size until readily appreciated by sight and superficial abdominal touch. Added to this was the vague impression of free fluid or clots in the pelvis. Even more significant and apparently completing the ectopic picture was the coincident discharge of blood from the uterus, preceded by a missed menstrual period, irregular in quantity and recurrence, and protracted over a long space of time. While no decidua in the shape of uterine casts or in bits were found, still their expulsion is apt to precede the metrorrhagia, and it was possible that they had been cast off before the nurse or even the doctor was in attendance. So, too, the uterus could have contracted, as it usually does after expelling the decidua. In attempting to account for this uterine hemorrhage, a coincident abortion naturally suggests itself. It is possible that expulsion took place before she came under observation, but certainly after that time such an occurrence could not have escaped notice. As before stated, the uterus was found empty at the operation, and the character of the discharge gave at no time a suspicion of being lochial, simply decreasing in quantity gradually until it ceased. Appearing as it did with the intra-abdominal hemorrhage, subsiding during rest and gradually disappearing during recovery, it would appear that the uterine flow was dependent upon the coincident congestion of the pelvic vessels.

The time of rupture may appear early, if we judge it by the three weeks of amenorrhæa, as it rarely occurs before a month or more, but exceptions are often met with. For instance, I have seen one case of ovarian pregnancy, in which, judging from the size of the miniature hemorrhage-producing mass, fecundation must have been very recent indeed. It is not uncommon to have one or two normal menstruations after an ectopic, as well as normal, gestation has begun, and this equally true of the cause of rupture, which, while usually attributed to an over-exertion, strain, fall, etc., not infrequently occurs while the patient is at rest. This was the case in the recurrences in this case.

Of the other signs of pregnancy, none were noted which could be relied upon, on account of the age of the possible gestation and the complications present. Thus, the breast discomfort was that usually experienced at her menstrual periods; the nausea was not characteristic and easily accounted for by the pelvic peritonitis and sepsis, while her own suspicion of being pregnant, although emphatically expressed, does not carry much weight. As to vaginal discoloration, if present so early or produced by intra-pelvic pressure, it was beyond recognition by the average visual acumen.

Turning to the history of the patient, we find that she had carried a child to term, then had aborted twice, and finally completed a pregnancy six years previously. This is the usual history of ectopic gestations, but, strange to say, in my experience with seven cases treated by abdominal section, to which should be added two treated as pelvic hæmatoceles, three were first pregnancies, and, so far as I could learn, women who had been free from previous pelvic disease. While this patient had never suffered from attacks of pelvic peritonitis and presented no gross or tangible tubal lesions, there was reason to believe that the cervical tear and a probable moderate subinvolution might have given rise to a catarrhal endometritis, as well as a salpingitis. She had been under Dr. Shoemaker's observation ever since her marriage.

Even when the abdomen was opened and the mass of clots scooped out, the appearance was that ordinarily found in ectopic cases, and it was not until the point of mesentericrupture was discovered that the origin and cause of the hemorrhage were recognized. The pressure upon the mesentery was so great that it is a source of surprise to me that the intestine had not become gangrenoús, or at least atonic. The bowels, however, were kept moving both before and after the operation, without unusual difficulty under the circumstances, that is to say, in view of the pelvic peritonitis and abdominal section. It is naturally to be regretted that the injured vessel was not recognized; whether it was one of the iliacs or mesenteries, it is impossible to say, the impression made from the oozing being that it was venous.

I felt, in view of the great distortion and the enormous extent of the extravasation, as well as on account of the miserable condition of the patient, and the fact that we did not have hospital conveniences and appointments, that reasonable evacuation and pressure-pack were sufficient. The latter seemed to control the oozing completely and continued to do so throughout the recovery.

A careful examination of the literature at my command fails to show an exactly similar case, and I feel that this one should be recorded for this reason as well as for its diagnostic interest.

FIBRO-MYOMATA UTERI.*

By NATHANIEL W. EMERSON, M.D.,

Boston, Mass.

PART II.

Indications for Operation.

A

S to the indications for operation the fact that the patient seeks

advice is of some moment, and when that advice is repeatedly sought with assurances that "something must be done,” and with the reasonable certainty that others will be consulted until some sort of satisfaction is found for the patient, it assumes to our mind the position of a legitimate factor to be considered, with others, in determining the line of procedure. Thus frequent and persistent hemorrhage, with or without profuse leucorrhæa; pain, especially when indicating local peritonitis; painful and frequent urination; uncomfortable pressure upon and sometimes pain of the heart, lungs or s!omach; defective nutrition; progressive anemia; persistent and increasing incapacity and malaise; and rapid growth and marked deformity, especially in young women, with an absence of any particular counter-indications, afford sufficient cause for extirpation, even if life itself is not immediately threatened. Of course, if life is endangered almost any risk is justified, and such cases are hardly debatable. The same may be said of tumors complicated by ovarian growths, and where they in turn are complications of an already existing pregnancy; but it is wiser to attack such cases before life is at stake, and the object of this paper is largely to keep such cases upon debatable ground.

If it can be shown that the death rate from all operable cases, and those needing an operation is lower than if all cases were left to themselves, the question is brought near to a solution. The fatal cases are apt to be among the worst and most unfavorable for interference, while many of them could have been successfully undertaken at an earlier stage. It is true that many of the worst cases do not cause death if left to themelves, but they do cause incapacity and suffering far beyond what should be borne, and are sometimes

*Read before the New York State Society, at Syracuse, 1898.

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