ous and often fatal consequences, for the abdomen cannot well accommodate the gravid uterus and the ovarian tumor, both increasing simultaneously. The result is that the tumor is subject to much contusion and pressure, which have sometimes led to the rupture of the cyst, and the escape of its contents into the peritoneal cavity; at others to a low form of inflammation, attended with much exhaustion, the death of the patient supervening either before or shortly after delivery. The danger during delivery from the same cause, in the cases which go on to term, is also very great. Of thirteen cases of delivery by the natural powers, which I collected in a paper on "Labor Complicated with Ovarian Tumor," far more than one-half proved fatal. Another source of danger is twisting of the pedicle, and consequent strangulation of the cyst, of which several instances are recorded. It is obvious, then, that the risks are so manifold that in every case it is advisable to consider whether they can be lessened by surgical treatment.

The means at our disposal are either to induce labor prematurely, to treat the tumor by tapping, or to perform ovariotomy. The question has been particularly discussed by Spencer Wells in his works on Ovariotomy, and by Barnes in his Obstetric Operations. The former holds that the proper course to pursue is to tap the tumor when there is any chance of its being materially lessened in size by that procedure, but that when it is multilocular, or when its contents are solid, ovariotomy should be performed at as early a period of pregnancy as possible. Barnes, on the other hand, maintains that the safer course is to imitate the means by which Nature often meets this complication, and bring on premature labor without interfering with the tumor. He thinks that ovariotomy is out of the question, and that tapping may be insufficient and leave enough of the tumor to interfere seriously with labor. So far as recorded cases go, they unquestionably seem to show that tapping is not more dangerous than at other times, and that ovariotomy may be practised during pregnancy with a fair amount of success. Wells records ten cases which were surgically interfered with. In one, tapping was performed, and in nine ovariotomy; and of these eight recovered, the pregnancy going on to term in five. On the other hand, five cases were left alone, and either went to term, or spontaneous premature labor supervened; and of these, three died. The cases are not sufficiently numerous to settle the question, but they certainly favor the view taken by Wells rather than that by Barnes. It is to be observed that, unless we give up all hope of saving the child, and induce abortion, the risk of induced premature labor, when the pregnancy is sufficiently advanced to hope for a viable child, would almost be as great as that of labor at term; for the question of interference will only have to be considered with regard to large tumors, which would be nearly as much affected by the pressure of a gravid uterus at seven or eight months as by one at term. Small tumors generally escape attention, and are more apt to be impacted before the presenting part in delivery. The success of ovariotomy during pregnancy has certainly been great, and we have to bear in mind that the woman

1 Obst. Trans., 1867, vol. ix. p. 69.

must necessarily be subjected to the risk of the operation sooner or later, so that we cannot judge of the case as one in which abortion terminates the risk. Even if the operation should put an end to the pregnancy- and there is at least a fair chance that it will not do sothere is no certainty that that would increase the risk of the operation to the mother, while as regards the child we should only have the same. result as if we intentionally produced abortion. On the whole, then, it seems that the best chance to the mother, and certainly the best to the child, is to resort to the apparently heroic practice recommended by Wells. The determination must, however, be to some extent influenced by the skill and experience of the operator. If the medical attendant has not gained that experience which is so essential for a successful ovariotomist, the interests of the mother would be best consulted by the induction of abortion at as early a period as possible. One or other procedure is essential; for, in spite of a few cases in which several successive pregnancies have occurred in women who have had ovarian tumors, the risks are such as not to justify an expectant practice. Should rupture of the cyst occur, there can be no doubt that ovariotomy should at once be resorted to, with the view of removing the lacerated cyst and its extravasated contents.

Fibroid Tumors.-Pregnancy may occur in a uterus in which there are one or more fibroid tumors. During pregnancy they may lead to premature labor or abortion, to peritonitis, or they may cause so much pain and discomfort from their size as to render interference imperative. If they are situated low down, and in a position likely to obstruct the passage of the foetus, they may very seriously complicate delivery. When they are situated in the fundus or body of the uterus they may give rise to risk from hemorrhage, or from inflammation of their own structure. Inasmuch as they are structurally similar to the uterine walls, they partake of the growth of the uterus during pregnancy, and frequently increase remarkably in size. Cazeaux says: "I have known them in several instances to acquire a size in three or four months which they would not have done in several years in the non-pregnant condition." Conversely, they share in the involution of the uterus after delivery, and often lessen greatly in size, or even entirely disappear. Of this fact I have elsewhere recorded several curious examples; and many other instances of the complete disappearance of even large tumors have been described by authors whose accuracy of observation cannot be questioned.

The treatment will vary with the size and position of the tumor, and every case must be treated on its own merits, since it is not possible to lay down rules that will apply to all cases alike. A full report of all recent cases will be found in Dr. John Phillips's paper, which shows how serious the results often are. If the position of the tumor be such as to to render it certain to obstruct delivery, the production of early abortion is perhaps the best course to pursue. It is not without serious risks, but probably less than allowing pregnancy to proceed to term.

1 Obst. Trans., 1869, vol. x. p. 102; 1872, vol. xiii. p. 288; 1877, vol. xix. p. 101. The Management of Fibro-myomata complicating Pregnancy and Labor." Brit. Med. Journ., 1888, vol. i. p. 1331.

ous and often fatal consequences, for the abdomen cannot well accommodate the gravid uterus and the ovarian tumor, both increasing simultaneously. The result is that the tumor is subject to much contusion and pressure, which have sometimes led to the rupture of the cyst, and the escape of its contents into the peritoneal cavity; at others to a low form of inflammation, attended with much exhaustion, the death of the patient supervening either before or shortly after delivery. The danger during delivery from the same cause, in the cases which go on to term, is also very great. Of thirteen cases of delivery by the natural powers, which I collected in a paper on "Labor Complicated with Ovarian Tumor," far more than one-half proved fatal. Another source of danger is twisting of the pedicle, and consequent strangulation of the cyst, of which several instances are recorded. It is obvious, then, that the risks are so manifold that in every case it is advisable to consider whether they can be lessened by surgical treatment.

The means at our disposal are either to induce labor prematurely, to treat the tumor by tapping, or to perform ovariotomy. The question has been particularly discussed by Spencer Wells in his works on Ovariotomy, and by Barnes in his Obstetric Operations. The former holds that the proper course to pursue is to tap the tumor when there is any chance of its being materially lessened in size by that procedure, but that when it is multilocular, or when its contents are solid, ovariotomy should be performed at as early a period of pregnancy as possible. Barnes, on the other hand, maintains that the safer course is to imitate the means by which Nature often meets this complication, and bring on premature labor without interfering with the tumor. He thinks that ovariotomy is out of the question, and that tapping may be insufficient and leave enough of the tumor to interfere seriously with labor. So far as recorded cases go, they unquestionably seem to show that tapping is not more dangerous than at other times, and that ovariotomy may be practised during pregnancy with a fair amount of success. Wells records ten cases which were surgically interfered with. In one, tapping was performed, and in nine ovariotomy; and of these eight recovered, the pregnancy going on to term in five. On the other hand, five cases were left alone, and either went to term, or spontaneous premature labor supervened; and of these, three died. The cases are not sufficiently numerous to settle the question, but they certainly favor the view taken by Wells rather than that by Barnes. It is to be observed that, unless we give up all hope of saving the child, and induce abortion, the risk of induced premature labor, when the pregnancy is sufficiently advanced to hope for a viable child, would almost be as great as that of labor at term; for the question of interference will only have to be considered with regard to large tumors, which would be nearly as much affected by the pressure of a gravid uterus at seven or eight months as by one at term. Small tumors generally escape attention, and are more apt to be impacted before the presenting part in delivery. The success of ovariotomy during pregnancy has certainly been great, and we have to bear in mind that the woman

1 Obst. Trans., 1867, vol. ix. p. 69.

must necessarily be subjected to the risk of the operation sooner or later, so that we cannot judge of the case as one in which abortion terminates the risk. Even if the operation should put an end to the pregnancy- and there is at least a fair chance that it will not do sothere is no certainty that that would increase the risk of the operation to the mother, while as regards the child we should only have the same result as if we intentionally produced abortion. On the whole, then, it seems that the best chance to the mother, and certainly the best to the child, is to resort to the apparently heroic practice recommended by Wells. The determination must, however, be to some extent influenced by the skill and experience of the operator. If the medical attendant has not gained that experience which is so essential for a successful ovariotomist, the interests of the mother would be best consulted by the induction of abortion at as early a period as possible. One or other procedure is essential; for, in spite of a few cases in which several successive pregnancies have occurred in women who have had ovarian tumors, the risks are such as not to justify an expectant practice. Should rupture of the cyst occur, there can be no doubt that ovariotomy should at once be resorted to, with the view of removing the lacerated cyst and its extravasated contents.

and

Fibroid Tumors.-Pregnancy may occur in a uterus in which there are one or more fibroid tumors. During pregnancy they may lead to premature labor or abortion, to peritonitis, or they may cause so much pain and discomfort from their size as to render interference imperative. If they are situated low down, and in a position likely to obstruct the passage of the foetus, they may very seriously complicate delivery. When they are situated in the fundus or body of the uterus they may give rise to risk from hemorrhage, or from inflammation of their own structure. Inasmuch as they are structurally similar to the uterine walls, they partake of the growth of the uterus during pregnancy, frequently increase remarkably in size. Cazeaux says: "I have known them in several instances to acquire a size in three or four months which they would not have done in several years in the non-pregnant condition." Conversely, they share in the involution of the uterus after delivery, and often lessen greatly in size, or even entirely disappear. Of this fact I have elsewhere recorded several curious examples; and many other instances of the complete disappearance of even large tumors have been described by authors whose accuracy of observation cannot be questioned.

The treatment will vary with the size and position of the tumor, and every case must be treated on its own merits, since it is not possible to lay down rules that will apply to all cases alike. A full report of all recent cases will be found in Dr. John Phillips's paper, which shows how serious the results often are. If the position of the tumor be such as to to render it certain to obstruct delivery, the production of early abortion is perhaps the best course to pursue. It is not without serious risks, but probably less than allowing pregnancy to proceed to term.

1 Obst. Trans., 1869, vol. x. p. 102; 1872, vol. xiii. p. 288; 1877, vol. xix. p. 101. The Management of Fibro-myomata complicating Pregnancy and Labor." Brit. Med. Journ., 1888, vol. i. p. 1331.

In several instances, either the removal of the tumor itself by abdominal section (myomectomy), or the removal of the tumor and the gravid uterus (Porro's operation), has been resorted to on account of the grave concomitant symptoms, and with a fair measure of success. If the tumor is well out of the way, interference is not so urgently called for. The principal danger then is that the tumor will impede the postpartum contraction of the uterus, and favor hemorrhage. Even if this should happen, the flooding could be controlled by the usual means, especially by the injection of the perchloride of iron. I have seen several cases in which delivery has taken place under such circumstances without any untoward accident. The danger from inflammation and subsequent extrusion of the fibroid masses would probably be as great after abortion or premature labor as after delivery at term. It seems, therefore, to be the proper rule to interfere when the tumors are likely to impede delivery, and in other cases to allow the pregnancy to go on, and be prepared to cope with any complications as they arise. The risks of pregnancy should be avoided in every case in which uterine fibroids of any size exist, the patients being advised to lead a celibate life.

CHAPTER IX.

PATHOLOGY OF THE DECIDUA AND OVUM.

Pathology of the Decidua.-Comparatively little is, unfortunately, known of the pathological changes which occur in the mucous membrane of the uterus during pregnancy. It is probable that they are of much more consequence than is generally believed to be the case; and it is certain that they are a frequent cause of abortion.

One of the most generally observed probably depends on endometritis antecedent to conception. When the impregnated ovule reached the uterus, it engrafted itself on the inflamed mucous membrane, which was in an unfit condition for its reception and growth. A not uncommon result, under such circumstances, is the laceration of some of the decidual vessels, extravasation of the blood between the decidua and the uterine walls, and consequent abortion at an early stage of pregnancy. As this morbid state of the uterine mucous membrane is likely to continue after abortion is completed, the same history repeats itself on each impregnation, and thus we may have constant early miscarriages produced. It does not necessarily follow, however, that the pregnancy is immediately terminated when this state of things is present. Sometimes a condition of hyperplasia of the decidua is produced, the membrane becomes much thickened and hypertrophied in consequence of proliferation of its interstitial connective tissue, and