Pregnancy and Operative Surgery: Their Mutual Relations

1889 Boston Medical and Surgical Journal  
titeri as may be free from adhesions. Scliiicking, stating that the ordinary method of stitching the uterus to the abdominal wall does not produce firm enough adhesions to secure it permanently, proposes to accomplish the result by stitching tin: fundus directly to I hat portion of the peritoneum which is reflected backward from the pubic arch forming the anterior pelvic floor; that is, the anterior peritonea] roof of the vagina. A special needle is employed, by which the stitch is carried up
more » ... rough the cervical and uterine canal, passing through the fundus and then forward and downward until it emerges into the vagina, where it is tied and remains until there is a decided adhesive peritonitis set up. Tho blhdder is to bo pushed one side by a sound manipulated by an assistant. Scliiicking states that in twelve cases the stitch passed through the bladder instead of beside it three times, without leaving any bad results. I have purposely alluded in tho briefest way to separating the, adhesions of backward displacements when laparotomies are performed for the removal of diseased tubes and ovaries, because it would carry this discussion outside the strict limits of my subject. My own view apon the question is, that unless there are such decided symptoms of trouble from the displacement as leave no room for doubt, it is better to let the uterus alone. If it is decided to attempt its replacement, secure it forward by one of the methods of shortening the round ligaments rather than by ventral fixation. SUMMARY. From the results of my own operating I have drawn for my guidance the following rules : -Be sure that the displacement is the cause of the symptoms. Never resort to operative measures without first exhausting all forms of non-surgical treatment in so far as they .may be applicable to the case under consideration. An adhesive backward displacement of the uterus demands for its cure, first, separation of its adhesions ; second, ¡interior fixation. Separation may be accomplished, first, by forcible divulsion without opening the abdomen ; second, by laparotomy and subsequent divulsion or cutting. The advantages of the first method aro that in suitable cases the patient is exposed to few dangers beyond a simple traumatic peritoneal inflammation. The advantages of the second are that it supplements tho first; assuming greater risks it strives for greater successes ; the adhesions being dealt with more openly, any accident that may ¡irise is more easily remedied ; it can be employed in cases to which the first is inapplicable. It superadds, however, the dangers of a laparotomy. A backward displacement which is free originally or which has been freedfrom its adhesions may be secured forward. First, by shortening of tho round ligaments, either by tho Alexander-Adams or Wiley method; Second, by fixation of the uterus to the peritoneum of the ¡interior abdominal wall, or to that of the anterior pelvic floor (Scllticking's method). Of the four operations, the only one not involving interference with the peritoneum is the Alexander-Adams. I believe that it should be selected, from my own experience of its successful results. I make an exception, that if for any other reason the abdomen has been opened, Wiley's operation may perhaps prove its equal. These round ligament operations leave the uterus in practically a normal position, without undue tension on tubes, intestines, or blood-vessels. There is no danger of faecal listuhu or incarceration of the intestines ; no interference with subsequent pregnancies. Permanent successful results do not depend upon adhesions or suspensory stitches, and the uterus is left movable, not fixed. Lecturer on Diseases of Women, P.S.M.I.; Fellow American Gynecological Society, etc. An impression exists generally among tho laity, doubtless derived originally from the profession, that ¡ill operative surgery upon the pregnant woman should bo avoided. This extends even to the extraction of teeth, however much the patient may suffer from them. Undoubtedly, this caution on the part of the profession, arose previous to tho days of anaesthetics, . from a fear that the shock to tho nerve centres would induce abortion. That some foundation for this may have existed iu those days is probably true. Even as lute as the time of Velpeau we find him saying that " ¡ill operations upon the pregnant woman should, if possible, be postponed." That no such cause for fear should now exist is apparent from tho many operations that are being reported in the current medical literature; and vet, while there is much less to fear from the minor operations than before the days of aniesthelics, there always remains the danger from septicaemia, which becomes a powerful cause of abortion or premature labor. I should hesitate much more on this account than any other when called upon to decide in a given case of pregnancy, requiring operative measures. It is more especially with reference to operations upon tho pregnant uterus and its appendages that this paper is written. That ovariotomy has been made with impunity upon the pregnant woman has been demonstrated many times. Removal of the ovaries and tubes, both by accident and design, has shown that operations involving parts very near the uterus, while in tho pregnant condition, do not endanger foetal lite. Trachelorraphv, even, has been made upon the pregnant uterus, and the patient has still gone on to tho completion of her term of gestation. Of course many of these operations have been done without the fact of pregnancy being known at the time, but like many other valuable truths in medicine, they have been good object-lessons to the practitioner and the profession. The following case may serve to guide some future worker in the path of safety for his patient: -Mrs.-, aged thirty-five, always regular, missed her periods in October and November last, and manifested some other signs of pregnancy. The pelvic pain, particularly in the right side, became frequent and severe, so that her physician, Dr. J. F. Thompson, brought her to me for consultation. Examination disclosed a small tumor in the right sido of the pelvis, somewhat elastic to the touch, while the cervix and os had all the appearance and feel of a pregnant uterus. Directly in the middle line, rising a iittle above the pubes, was a growth very much resembling in shape and size the fundus uteri at the end 1
doi:10.1056/nejm188910171211603 fatcat:dhdlvgfz75bzpjbj33fasx7eje