Page images
PDF
EPUB

pectant treatment until signs of mischief become apparent? As this kind of waiting is as dangerous as the early operation in severe cases, and means to lose the advantage gained by the avoidance of an early operation, it clearly becomes our duty to anticipate such harm; yet not by operating early and recklessly in all severe cases, but by selecting such as have ceased to improve, are not being perceptibly absorbed, and are large enough to interfere with the functions of the pelvic organs, or the general comfort and usefulness of the patient. As long as the tumor is shrinking and becoming harder, no matter how slowly, we may expect that the fluid is being absorbed and the clot will, with rest in bed, disappear in the same way, notwithstanding local irritation, reflex symptoms, and debility, and hence should delay operating. If, however, the tumor remain boggy or doughy, and undimished in size, showing that the fluid has not been absorbed, and the local symptoms, instead of partially subsiding, increase, with fever, emaciation, etc., it may, of course, become necessary to evacuate soon after the first menstrual period. As said before, these are the exceptional or neglected

cases.

S

But there will sometimes occur histories like that of Mary in which, after a few months, the tumor will still be elastic and boggy, the symptoms gradually improve under rest in bed, and the final absorption be not improbable; but in which poverty, want of care, necessity of working, and the like, may render an evacuation desirable and fully as free from risks as the expectant plan under such unfavorable circumstances. Indeed, if the acute symptoms have passed off, and several months of invalidism can be saved by evacuation, the patient should have the benefit of an operation at the time when it is so free from danger.

As to the method of operating, I would not give the preference to that of Apostoli and Doléris, because two operations are required (one for the galvano-puncture, and the other for the breaking up, or scooping out, of the mass after separation of the eschar), because the formation of such an opening large enough to introduce the finger would involve the destruction of too much tissue, and because the use of the curette through a small opening is not devoid of danger. Their method is the ideal one for hard, inelastic tumors, but such hematoceles seldom require an operation until they commence to soften. Zweifel's method of

procedure, viz., to first incise the vagina, check the hemorrhage, and then open the sac, is preferable. But, on account of the danger of troublesome hemorrhage from incision, it is better to puncture, and then tear the vaginal wall with a dilator until the rent will admit two fingers. The sac-wall may be opened in the same way, or, if any difficulty is experienced, may be incised. Retro-uterine hematoceles in cases where the cul-de-sac of Douglas has been previously obliterated should, I believe, be attacked by puncture and dilatation per rectum, when possible, rather than by abdominal section. The difficulty would be but little greater than the dilatation of the fistulous opening of a pelvic abscess.

The plan adopted in the case reported, but only imperfectly executed, of breaking up the entire clot, but avoiding any scraping of the walls of the cavity, proved to be as efficient as imperfect curetting, and vastly less dangerous than a thorough curetting of the cavity walls. Following this careful avoidance of the production of irritation, antiseptics may be tried strong enough to be thoroughly efficient, viz.: hydrarg. biniodide, 1: 3,000; bichloride, 1: 2,600; carbolic acid, 1 to 2 per cent; or their equivalent. If they cannot be used of this strength, they may be used oftener-three to five, instead of two or three times a day. The finger can be used as a dilator, and be passed daily through the openings both in the vagina and cyst-wall. The possibility of the presence of an extrauterine pregnancy, ovarian tumor, serous peritonitis, fibroid or fibro-cystic tumor of the uterus, etc., makes it advisable always to use an aspirating needle previous to using the knife.

Abdominal section for such tumors as cannot be safely reached through the vagina or rectum is purposely left out of consideration, as a different set of dangers are involved, and a separate discussion would be required.

Schroeder's "Weibliche Geschlechtsorgane" (1886), which was received after this paper was completed, contains the following paragraph, p. 482:

"The evacuation of the tumor may become necessary when it causes unendurable difficulties, when it remains stationary for some time, and, above all, when fever, etc., indicate that its contents are septic."

A CASE OF INDUCTION OF PREMATURE LABOR.

BY

SIDNEY DAVIS, M.D.,

Petersburg, Pa.

THE following case is reported as an illustration of the manner of exciting labor before term, in which respect it may prove instructive to the profession :

Received a letter from Mr. M., May 19th, 1885, requesting me to deliver his wife, inclosing a short note from Dr. J. Cheston Morris, of Philadelphia, in which he advised premature labor two or three weeks before her regular time for delivery, stating that, on making an examination of Mrs. M., he had found a certain amount of contraction of the pubic arch. After receiving this letter, I requested Mr. M. to call. I then gathered the following history of his wife's case.

Four years previous, his wife, being about to be confined, he sent for their family physician on Thursday. This physician was with her until Sunday, and then, as her strength began to fail, another physician was called, and after a consultation they decided to apply the forceps. These instruments were kept on for a certain length of time-how long exactly the husband did not know -they failed to deliver with forceps, and then performed craniotomy, and after some delay she was delivered of a male child weighing over thirteen pounds. After this delivery, the lady was in such a condition that one of the physicians expressed it as his opinion that she would not live an hour.

It took six persons to lift her on a sheet when she had to be moved, because, as her husband expressed it, she was so sore and pained. She was confined to her room at this time for two months, troubled all this time with constant dribbling of urine, due, her physician said, to a fistula. At the end of this time she made a trip to Philadelphia, and consulted Dr. Morris, when there was found to be no fistula, but that the neck of the bladder had beeu injured and lost all tone from long pressure of the child's head. Dr. Morris had her use the catheter every four hours. This broke up the dribbling, and from that time she regained her health perfectly.

I requested Mr. M. to bring his wife to her father's, who lives in an adjoining town, only three miles from me, and connected with my house by telephone. This I desired because he lived too far away for me to leave my practice the length of time I expected to be detained on the case. Mr. M. brought his wife to her father's on the 3d of July; I saw her on the 4th, found her in splendid

condition physically, which she had been all through her pregnancy. Made my first examination on the morning of the 5th; found the occiput the presenting part; the cervix rather low down and tilted very much to the left side.

She stated that her full term would be up on the 25th of July. After taking everything into consideration, I decided to appoint the morning of the 10th to induce premature labor.

I directed her to take a physic on the evening of the 8th. At this visit I requested the family to allow me the privilege of calling Dr. D. P. Miller, of Huntingdon, as consulting physician at what time I should deem proper. Called on the morning of the 10th; Mrs. M. received me herself at the door and seemed to be in excellent spirits. To use her own words, she was willing to go through anything if only I would give her a live child. I will state here that one of the most agreeable features in her case was the fact of her being a woman who was not easily alarmed. At 9 A.M. I introduced a sponge tent into the cervix, two inches long, one-half inch in diameter at the butt, with curved forceps, tamponed the vagina with a good-sized sponge, and placed a bandage over the external parts. I then put her under the influence of quinine, which was kept up steadily all through the case. I informed husband and wife that it would take at least three days before the delivery would be accomplished, and that they should both make up their minds to that fact, so as to avoid all possible anxiety.

After introducing the sponge tent, I told her that she should not expect any pain for six hours, and in the mean time to make herself as comfortable as possible.

At about 3 P.M. pains began of a cutting character and kept up at the rate of one every fifteen minutes. These I did not interfere with till about 12 M., when I found they were becoming less frequent. I then removed the sponge tent and found the os dilated to the size of a silver quarter. I then introduced a Molesworth dilator into the cervix, and gradually dilated it with warm water. This brought on pains at regular intervals of five minutes. At 6 A.M. of the 11th, removed dilator and found os dilated to size of silver half-dollar; pains at regular intervals and bag of waters protruding.

I now telephoned for Dr. Miller to meet me between 11 and 12 A.M., which he did. On making examination at that time, found the os gradually dilating, with pains assuming more of a bearingdown character. We then decided to let nature pursue her course for the present and not interfere.

At 10 P.M. we decided to take some rest, leaving orders with nurse to call me if pains altered any in character or frequency. Was called at 4 A.M., and found the pains less frequent. On examination, found the os dilated larger than a silver dollar. Held a consultation with Dr. Miller, and we decided to give her half a teaspoonful of Squibb's ergot, two doses at intervals of twenty minutes. This had the effect of bringing on very severe bearing

down pains, which continued until 9:30 A.M., when we decided to break the bag of waters and apply forceps. Dr. Miller then placed Mrs. M. under the influence of Squibb's ether, and I applied the forceps, and with the assistance of Dr. Miller delivered her safely of a live girl baby weighing ten pounds, which had to be resuscitated. By 10:30 A. M. had the mother comfortably fixed in bed. Gave her a teaspoonful of ergot immediately after the delivery. I then ordered regular doses of quinine which were kept up until the fifth day. There was not the least unfavorable symptom from one day to another. Lochial discharge faded out gradually; milk made its appearance on third day, and all through there was not any rise of temperature. Patient rested well, without complaining of any pain or tenderness over the abdomen. She was able to leave her bed on tenth day, and declared she was gaining flesh. Baby nursed from the start and thrived right along. Four weeks after the delivery, without my full sanction, she declared she would go home, as she was feeling perfectly well; this she accomplished successfully, a distance of thirteen miles, in a carriage.

Both mother and baby have been doing well ever since; it is now over a year, and the mother is the picture of health.

I was not induced to report this case by the thought of communicating anything new to the profession, but simply as a young man at the foot of the ladder. I thought it might be encouragement to other young men to attempt what to them might appear a very hazardous procedure, but which is really a comparatively simple operation if carefully managed. It was not the first case I was present at, but was the first I had charge of. A very important point in a case of this kind is, that the physician must give it his exclusive attention, letting his practice go, whether it takes three days or more. On consulting books of authority on this subject, you will find a great variety of methods for inducing premature labor recommended, each one of which is strongly recommended by the originator. But probably, of all, there is none safer than the process of dilatation by means of tents; whether it could be depended on completely, is another question. It might prolong the case and make it more tedious, but it will certainly excite contractions of the uterus, and has the advantage of dilating the os to sufficient size to permit the use of one of the large Molesworth dilators. I would, of course, like to have the Molesworth dilators to fall back upon, but I would not be afraid to give the tents a fair trial if I were ever called to another case. one case at which I was present, the Molesworth dilators were used from the start, the occiput was presenting and

In

« PreviousContinue »