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Report of a Case of Myomectomy for an Interstitial Fibroid Complicated by a Very Early Pregnancy*
746
A:\iERICAN JOCRNAL OF OBSTE'I'HICS .~ND GYNECOLOGY
Gautier" also reports a ease, :md gin'S a [(•,ngthy discussion of the clinical fpatures. 1'here are no microscopic repcn·ts. Alvarez Colodrero10 reports two cases with symptoms like tl1e previous ones, but gi1•es 110 microscopic reports. IU<:FERENCES
(1) Keyes, E. L.: Urology, New York, 1928, Appleton, p. 426. (2) Morton, H. H.: Genito·Urinary Diseases and Syphilis, New York, 1924, Physicians & Surgeons Book Co. (3) Cabot, R. C.: Differential Diagnosis, Vol. 1, Philadelphia, 1916, Saunders. ( 4) Lowsle-y and Kerwin: Text Book of Urology, Philadelphia, 1926, Lea and Febiger, pp. 337. (5) Graeff, Karl F.: Beitrag Sur Kentniss Der Blasensyphilis, etc., 1906. (6) Duroux: Syphilis de Ia Vessic, These de Paris, 1913. (7) Morris, M.: Indiana M. J. 16: 5, 1897. (8) Schapiro, S. W.: Am. J. Surg. 29: 213, 1915. (9) Gootier, E. L.; Bull. Soc. franc. d 'urol. 6: 291, 1927. (10) Alvarez Colodrero, Jorge W., anil DiLella, Pedro: Semana me d. 1: 1380, 1930. 207 PHYSICIANS
AND
SURGEONS
BUII>DING.
REPORT OF A CASE OP MYOMECTOMY FOR AN INTERSTITIAL FIBROID COMPLICATED BY A VERY EARLY PREGNANCY* HIRAMN. VINEBERG,M.D., NEWYORK,N. Y. YOUNG woman, aged twenty-eight, married eighteen months, consulted me in No· vember, 1929. Briefly her history was as follows: Menstruated at thirteen, four weekly type, four to :five days' duration, moderate in amount and without much pain. She had never been pregnant. In ,June of the same year she was operated upon presumably for appendicitis, the surgeon finding only what was probably a normal appendix. He lengthened the incision upwards and downwards so as to make a thorough exploration. This revECaled an enlarged uterus, corresponding to the gravid organ at about ten weeks, due to an interstiti~d :fibroid. The growth involved the uterus in such a way that he deemed anything short of a hysterectomy was at all feasible. Not having obtained the consent for so radica.l a procedure, he closed the abdomen after having re· moved the appendix. The pain in the back from which she had been suffering continued and before seeing me, she had consulted a very prominent gynecologist who advised an operation but would not give much promise of being able to do anything but a hyst<>reetomy. I found a condition as above deseribed, the uterus now corresponding to about the twelfth week of IJregnancy. While unable to give her a definite promise of conserving the uterus, I expressed the opinion that I thought ;1 myomeetomy could be done and in any ease, I would make a very determined effort to do so. On January 13, 1930, at Mount Sinai Hospital, I opened the abdomen in the median line and delivered the uterus. At first sight it did not appear as if a eonservatin• operation could be done. The growth occupied the entire anterior wall and it was difficult, to discern the fundal part. On close inspection it was made out as a slight projection on the upper posterior surface of tl1e growth. The adnexa were normal in appearance, the left one being stretched over the growth so that the isthmus seemed to be pmt of it. My assistants were very positive it would not be possible to do a myomectomy. I decided, however, to make the attempt. I incised the peritoneum over the lower third of the g1·owth and carried this in a circular .fashion to the extent found necessary. With the handle of the scalpeltmd the fingers I enucleated it from below upwards. There then remained only the posterior wall and a narrow strip of anterior wall on either side. At the bottom of the wound was a narrow
A
*Read at a meeting of the New York Obstetrical Society, November 8, 1932.
VINEBERG: MYOMECTOMY
747
slit extending from the fundus to the internal os. Through this the endometrium protruded slightly and I was struck by its marked purplish color and apparent thickness. This I attributed to the premenstrual change, the patient having menstruated three weeks before (Dec. 20 to 25). I coaptated the edges of the anterior wall with great care, taking pains to avoid the endometrium. The resulting uterus resembled the infantile organ in shape and size excepting it was longer. The patient made an afebrile recovery with primary union of the abdominal wound. But she felt poorly, had no appetite, was more or less nauseated and felt faint from time to time. On the fourth day after the operation there occurred a slight blood discharge, continuing for three or four days, which was looked upon as the menstrual period. The patient left the hospital January 26, two weeks after the operation. On February 11, two weeks later (four weeks after the operation), she came to the office and stated that she still felt weak and had had several fainting spells, and that on one occasion she passed from the vagina a mass of reddish color and about the size of a hen's egg, evidently a blood clot. March 4 she came again and stated that she had not menstruated as yet. She was positive that the time of the last sexual intercourse was on January 11, two days prior to the operation and that none had taken place since. I found the uterus soft and enlarged to the size of the gravid organ at about eight or nine weeks. Thinking there might be a retention of blood, due to constriction of the internal os as a result of the operation, I cautiously passed a sound beyond the internal os and there being no escape of hlood, it dawned upon me that the patient undoubtedly was pregnant at the time of the operation and that she was then probahly in the first or second week of gestation. The question then arose whether or not the pregnancy should be allowed to continue. I decided not to interfere, and was upheld in this opinion by my colleague and friend Dr. I. C. Rubin. I advised the patient to place herself under the service of the Woman's Hospital for prenatal care and deli1•ery. The pregnancy apparently progressed normally. She thought she felt life on April 21. On September 24 I found the fundus within a finger's width from the ensiform and the head low in the pelvis. I advised her to seek admission to the hospital at once for induction of labor. This advice was followed and she was admitted September 26. Castor oil and quinine were given but had no effect. The obstetrician-in-chief telephoned that he deemed a cesarean section should be done, as he feared the uterus would rupture when labor pains set in. He was kind enough, however, to be guided by my opinion to the contrary. The patient was, therC'fore, discharged the next day and instructed to return as soon as labor pains set in. Until then the movements of the fetus were very marked but apparently they ceased a day or two later for she no longer felt them. Two weeks later pains set in spontaneously and she was readmitted to the Hospital, October 11, where she delivered herself, after a labor of twenty-one hours, of a macer· ated fetus weighing 5 pounds, 13 ounces. The puerperium was uneventful. On March 9, 1932, the patient was delivered again at the Woman's Hospital at full term of a male child, weighing T\4 pounds. The labor was moderately difficult, lasting thirteen hours and necessitating low forceps. The puerperium was normal. In October I personally examined her in my office. The uterus was then of normal size an(l in proper position. The special features of the above case are: 1. The continuance of the early pregnancy despite the extensiYe operation on the uterus. 2. The difficulty at the beginning of arriving at the correct diagnosis. 3. The justification of the assumption that the uterine scar would safely withstand the strain of labor. The last normal menstruation occurred December 20 to 25. The first coitus after this was on the night of December 27, and had been repeated about twice a week until January 11, i.e., two days prior to the operation. Assuming even, therefore, that conception had taken place at the first cohabitation, the ovum at the tin1e of the operation could not have been older than seventeen days. That it had reached the uterine cavity
748
AMERICAN JOu'R!'
before that mny be safely assumed from the fact that the tubes had been carefully inspected and nothing abnormal noted, excepting that the left one was stretched over the growth and was very much thhmer in eonsequenee, and also from the appearance of the exposed endometrium. 1185 P AHK A VENCE.
COMPLETE PLACENTAIJ DETACHMENT WITH APOPLEXY OF THE UTERUS REQUIRING HYSTERECTOMY* DR.
lVL
L. LEVENTHAL, CHICAGO, ILL.
HIS patient was a primipara, thirty years old, who was admitted to the Michael Reese Hospital at 4:45 P.M. on Dooember 4 on the obstetric service of Dr. I.ackner. At 2 P.M., one-half hour after a normal bowel movement, she had severe pain in the abdomen associated with dizziness on standing. Her last menstrual period had occurred on March 18. No fetal movements were felt following the onset of the pain. In her past history there were two induced abortions in 1924 and 1927. The patient was last seen at the clinic one week before admission at which time her blood pressure was 110/80, the urine was negative, and she was feeling :tine. On admission the patient had a blood pressure of 140/90; the urine showed 3-pluR albumin with a few granular casts; temperature was 99.4 o, pulse 76, respiration 22. The color of the skin and mucous membranes wa.s good. The patient felt quite well except for some abdominal pain. The red count on admission was 3,750,000 and hemoglobin was 75 per cent. Blood chemistry was noTmal. The uterus was the size of a full term pregnancy and was in a state of constant contraction. The cervix was effaced with 2 em. dilatation. Since the patient's condition was good it was decided to use conservative treatment. On the following morning, having been quite well during the night, the patient began to appear very pale and :restless. Pulse was 84, temperature 99.8, red count 2,170,000 and hemoglobin 50 per cent. The fundus was somewhat hard and of a woody consistency. Cesarean section was performed at this time with the diagnosis of bleeding into the uterus. The abdomen on opening contained about 16 ounces of free serous fluid. The uterus was very hard and markedly hemorrhagic and presented the appearance of a large twisted ovarian cyst. A low cervical cesarean section was performed and a macerated fetus delivered. The uterine cavity was filled with black blood clots. The uterine wall was markedly infiltrated with blood. Because of the marked bleeding and the apparently hopeless condition of the uterus and the condition of the patient, it was decided to do' a supracervical hysterectomy. The operation was followed by an intravenous infusion of i500 c.c. of whole blood. The patient left the operating room in good condition. Three days after operation her red count was 1,810,000, with a hemoglobin of 50 per cent. Another transfusion of 300 c.c. of whole blood was given for the anemia and the patient left the hospital eleven days after operation in good condition.
T
ABSTRACT OJ;, DISCUSSION DR. RUDOLPH W. HOL~fES.-1 am glad Dr. Leventhal did not say he had a case of abruptio placentae because the term has been objectionable to me since I coined the term ablatio placentae in 1901. Abruptio implies that the condition has a violent, sudden onset which is only true in something like 10 per cent of cases: in •Presented at a meeting of the Chicago Gynecological Society, December 16, 1932.
A:\iERICAN JOCRNAL OF OBSTE'I'HICS .~ND GYNECOLOGY
Gautier" also reports a ease, :md gin'S a [(•,ngthy discussion of the clinical fpatures. 1'here are no microscopic repcn·ts. Alvarez Colodrero10 reports two cases with symptoms like tl1e previous ones, but gi1•es 110 microscopic reports. IU<:FERENCES
(1) Keyes, E. L.: Urology, New York, 1928, Appleton, p. 426. (2) Morton, H. H.: Genito·Urinary Diseases and Syphilis, New York, 1924, Physicians & Surgeons Book Co. (3) Cabot, R. C.: Differential Diagnosis, Vol. 1, Philadelphia, 1916, Saunders. ( 4) Lowsle-y and Kerwin: Text Book of Urology, Philadelphia, 1926, Lea and Febiger, pp. 337. (5) Graeff, Karl F.: Beitrag Sur Kentniss Der Blasensyphilis, etc., 1906. (6) Duroux: Syphilis de Ia Vessic, These de Paris, 1913. (7) Morris, M.: Indiana M. J. 16: 5, 1897. (8) Schapiro, S. W.: Am. J. Surg. 29: 213, 1915. (9) Gootier, E. L.; Bull. Soc. franc. d 'urol. 6: 291, 1927. (10) Alvarez Colodrero, Jorge W., anil DiLella, Pedro: Semana me d. 1: 1380, 1930. 207 PHYSICIANS
AND
SURGEONS
BUII>DING.
REPORT OF A CASE OP MYOMECTOMY FOR AN INTERSTITIAL FIBROID COMPLICATED BY A VERY EARLY PREGNANCY* HIRAMN. VINEBERG,M.D., NEWYORK,N. Y. YOUNG woman, aged twenty-eight, married eighteen months, consulted me in No· vember, 1929. Briefly her history was as follows: Menstruated at thirteen, four weekly type, four to :five days' duration, moderate in amount and without much pain. She had never been pregnant. In ,June of the same year she was operated upon presumably for appendicitis, the surgeon finding only what was probably a normal appendix. He lengthened the incision upwards and downwards so as to make a thorough exploration. This revECaled an enlarged uterus, corresponding to the gravid organ at about ten weeks, due to an interstiti~d :fibroid. The growth involved the uterus in such a way that he deemed anything short of a hysterectomy was at all feasible. Not having obtained the consent for so radica.l a procedure, he closed the abdomen after having re· moved the appendix. The pain in the back from which she had been suffering continued and before seeing me, she had consulted a very prominent gynecologist who advised an operation but would not give much promise of being able to do anything but a hyst<>reetomy. I found a condition as above deseribed, the uterus now corresponding to about the twelfth week of IJregnancy. While unable to give her a definite promise of conserving the uterus, I expressed the opinion that I thought ;1 myomeetomy could be done and in any ease, I would make a very determined effort to do so. On January 13, 1930, at Mount Sinai Hospital, I opened the abdomen in the median line and delivered the uterus. At first sight it did not appear as if a eonservatin• operation could be done. The growth occupied the entire anterior wall and it was difficult, to discern the fundal part. On close inspection it was made out as a slight projection on the upper posterior surface of tl1e growth. The adnexa were normal in appearance, the left one being stretched over the growth so that the isthmus seemed to be pmt of it. My assistants were very positive it would not be possible to do a myomectomy. I decided, however, to make the attempt. I incised the peritoneum over the lower third of the g1·owth and carried this in a circular .fashion to the extent found necessary. With the handle of the scalpeltmd the fingers I enucleated it from below upwards. There then remained only the posterior wall and a narrow strip of anterior wall on either side. At the bottom of the wound was a narrow
A
*Read at a meeting of the New York Obstetrical Society, November 8, 1932.
VINEBERG: MYOMECTOMY
747
slit extending from the fundus to the internal os. Through this the endometrium protruded slightly and I was struck by its marked purplish color and apparent thickness. This I attributed to the premenstrual change, the patient having menstruated three weeks before (Dec. 20 to 25). I coaptated the edges of the anterior wall with great care, taking pains to avoid the endometrium. The resulting uterus resembled the infantile organ in shape and size excepting it was longer. The patient made an afebrile recovery with primary union of the abdominal wound. But she felt poorly, had no appetite, was more or less nauseated and felt faint from time to time. On the fourth day after the operation there occurred a slight blood discharge, continuing for three or four days, which was looked upon as the menstrual period. The patient left the hospital January 26, two weeks after the operation. On February 11, two weeks later (four weeks after the operation), she came to the office and stated that she still felt weak and had had several fainting spells, and that on one occasion she passed from the vagina a mass of reddish color and about the size of a hen's egg, evidently a blood clot. March 4 she came again and stated that she had not menstruated as yet. She was positive that the time of the last sexual intercourse was on January 11, two days prior to the operation and that none had taken place since. I found the uterus soft and enlarged to the size of the gravid organ at about eight or nine weeks. Thinking there might be a retention of blood, due to constriction of the internal os as a result of the operation, I cautiously passed a sound beyond the internal os and there being no escape of hlood, it dawned upon me that the patient undoubtedly was pregnant at the time of the operation and that she was then probahly in the first or second week of gestation. The question then arose whether or not the pregnancy should be allowed to continue. I decided not to interfere, and was upheld in this opinion by my colleague and friend Dr. I. C. Rubin. I advised the patient to place herself under the service of the Woman's Hospital for prenatal care and deli1•ery. The pregnancy apparently progressed normally. She thought she felt life on April 21. On September 24 I found the fundus within a finger's width from the ensiform and the head low in the pelvis. I advised her to seek admission to the hospital at once for induction of labor. This advice was followed and she was admitted September 26. Castor oil and quinine were given but had no effect. The obstetrician-in-chief telephoned that he deemed a cesarean section should be done, as he feared the uterus would rupture when labor pains set in. He was kind enough, however, to be guided by my opinion to the contrary. The patient was, therC'fore, discharged the next day and instructed to return as soon as labor pains set in. Until then the movements of the fetus were very marked but apparently they ceased a day or two later for she no longer felt them. Two weeks later pains set in spontaneously and she was readmitted to the Hospital, October 11, where she delivered herself, after a labor of twenty-one hours, of a macer· ated fetus weighing 5 pounds, 13 ounces. The puerperium was uneventful. On March 9, 1932, the patient was delivered again at the Woman's Hospital at full term of a male child, weighing T\4 pounds. The labor was moderately difficult, lasting thirteen hours and necessitating low forceps. The puerperium was normal. In October I personally examined her in my office. The uterus was then of normal size an(l in proper position. The special features of the above case are: 1. The continuance of the early pregnancy despite the extensiYe operation on the uterus. 2. The difficulty at the beginning of arriving at the correct diagnosis. 3. The justification of the assumption that the uterine scar would safely withstand the strain of labor. The last normal menstruation occurred December 20 to 25. The first coitus after this was on the night of December 27, and had been repeated about twice a week until January 11, i.e., two days prior to the operation. Assuming even, therefore, that conception had taken place at the first cohabitation, the ovum at the tin1e of the operation could not have been older than seventeen days. That it had reached the uterine cavity
748
AMERICAN JOu'R!'
before that mny be safely assumed from the fact that the tubes had been carefully inspected and nothing abnormal noted, excepting that the left one was stretched over the growth and was very much thhmer in eonsequenee, and also from the appearance of the exposed endometrium. 1185 P AHK A VENCE.
COMPLETE PLACENTAIJ DETACHMENT WITH APOPLEXY OF THE UTERUS REQUIRING HYSTERECTOMY* DR.
lVL
L. LEVENTHAL, CHICAGO, ILL.
HIS patient was a primipara, thirty years old, who was admitted to the Michael Reese Hospital at 4:45 P.M. on Dooember 4 on the obstetric service of Dr. I.ackner. At 2 P.M., one-half hour after a normal bowel movement, she had severe pain in the abdomen associated with dizziness on standing. Her last menstrual period had occurred on March 18. No fetal movements were felt following the onset of the pain. In her past history there were two induced abortions in 1924 and 1927. The patient was last seen at the clinic one week before admission at which time her blood pressure was 110/80, the urine was negative, and she was feeling :tine. On admission the patient had a blood pressure of 140/90; the urine showed 3-pluR albumin with a few granular casts; temperature was 99.4 o, pulse 76, respiration 22. The color of the skin and mucous membranes wa.s good. The patient felt quite well except for some abdominal pain. The red count on admission was 3,750,000 and hemoglobin was 75 per cent. Blood chemistry was noTmal. The uterus was the size of a full term pregnancy and was in a state of constant contraction. The cervix was effaced with 2 em. dilatation. Since the patient's condition was good it was decided to use conservative treatment. On the following morning, having been quite well during the night, the patient began to appear very pale and :restless. Pulse was 84, temperature 99.8, red count 2,170,000 and hemoglobin 50 per cent. The fundus was somewhat hard and of a woody consistency. Cesarean section was performed at this time with the diagnosis of bleeding into the uterus. The abdomen on opening contained about 16 ounces of free serous fluid. The uterus was very hard and markedly hemorrhagic and presented the appearance of a large twisted ovarian cyst. A low cervical cesarean section was performed and a macerated fetus delivered. The uterine cavity was filled with black blood clots. The uterine wall was markedly infiltrated with blood. Because of the marked bleeding and the apparently hopeless condition of the uterus and the condition of the patient, it was decided to do' a supracervical hysterectomy. The operation was followed by an intravenous infusion of i500 c.c. of whole blood. The patient left the operating room in good condition. Three days after operation her red count was 1,810,000, with a hemoglobin of 50 per cent. Another transfusion of 300 c.c. of whole blood was given for the anemia and the patient left the hospital eleven days after operation in good condition.
T
ABSTRACT OJ;, DISCUSSION DR. RUDOLPH W. HOL~fES.-1 am glad Dr. Leventhal did not say he had a case of abruptio placentae because the term has been objectionable to me since I coined the term ablatio placentae in 1901. Abruptio implies that the condition has a violent, sudden onset which is only true in something like 10 per cent of cases: in •Presented at a meeting of the Chicago Gynecological Society, December 16, 1932.