I. Two Pregnancies following Removal of both Ovaries and Tubes. II. Two Peculiar Cases of Extra- Uterine Pregnancy. III. Effect of Hysterectomy upon the Vagina. BY S. C. Gordon, M. D., PORTLAND, ME. REPRINTED FROM THE American Gynaecological and Obstetrical Journal for July, X896. [Reprinted from the American Gynaecological and Obstetrical Journal for July, 1896.J I. TWO PREGNANCIES FOLLOWING REMOVAL OF BOTH OVARIES AND TUBES. II. TWO PECULIAR CASES OF EXTRA-UTERINE PREG- NANCY. III. EFFECT OF HYSTERECTOMY UPON THE VAGINA* By S. C. Gordon, M. D., Portland, Me. Two Cases of Pregnancy following Removal of Both Tubes and Ovaries. Case I.-Mrs. A. M. P., aged thirty-six. I have no history of her case prior to her operation, May 27, 1891, when she had both ovaries and tubes removed by a Fellow of this Society, James R. Chadwick. Dr. Chadwick writes me that his notes of the case being mislaid, he can not say whether both ovaries were removed or not. The patient and her husband understand that they were. " She did not men- struate regularly after the operation. Sometimes there would be two or three months between the periods, then regular for two or three months." She became pregnant about June 1, 1894, and was con- fined February 26, 1895. Since her confinement she has menstruated regularly, beginning two months after. She is now better than for several years before her confinement. Case II.-Mrs. R., aged thirty-three, had been an invalid for sev- eral years before operation-unable to do any kind of labor. For a year previous had been confined to bed nearly all the time. Stand- ing on her feet was attended with heavy weight in the pelvis and the dragging so characteristic of varicose veins of the broad ligaments and pelvic organs. Curettement and perinseorrhaphy gave some re- lief, but failed to restore her to health. Suffered from menorrhagia and much discomfort each month. In March, 1894, I removed both ovaries and tubes, and, so far as I knew, there were no fragments of * Read before the American Gynaecological Society, May 26, 1896. Copyright, 1896, by J. D. Emmet, M. D. 2 A C. Gordon, M. D. the ovary left. Each one of them was much enlarged and very flabby, the one on the right side being two inches and a half long and broad in proportion. She recovered promptly, but menstruated regularly each month after two or three months. In June, 1895, she ceased menstruation, and soon discovered she was pregnant. The period of gestation was marked by no peculiar symptoms, and she was deliv- ered of a healthy child March 12, 1896. In each of these cases there must have been some stroma of ovarian tissue left, but the question of curious interest is, By what means did it reach the uterine cavity ? The only explanation is that the tube, after being ligated, must have opened at the stump, thus allowing the ovum to pass through. I have seen the lumen of a varicose vein resume its normal caliber after hav- ing been ligated with catgut, absorption having taken place before the coats were destroyed. I presume the same may occur in the Fallo- pian tube. Tubal Pregnancy becoming Abdominal, Foetus continuing to live; Operation at about the End of Fifth Month, Foetus still Living. Case I.-Dr. G. F. Merrill, of Kennebunkport, called me some time in December, 1893, to see Mrs B., whom I found suffering from severe general peritonitis, with the following history : About three months previous she passed one menstrual period, but the next month had a slight show of blood, attended with some sharp pain. Six weeks be- fore I saw her she was taken with terrible pain in the lower abdomi- nal region, followed by almost profound collapse and a good deal of haemorrhage from the vagina, which continued at intervals up to the time I saw her. Severe peritonitis ensued, and a mass of exudate could be detected per vaginam. My diagnosis was tubal pregnancy, with rupture at the time of collapse. The condition of the patient and other circumstances seemed to warrant waiting, at least for a while. About six weeks after, she so far recovered that she was moved from her home at Kennebunkport to the Maine General Hos- pital during my service. Operation was made in the presence of many members of the staff. On opening the peritonaeum, a quite large gray tumor came into view. It was apparent through the walls be- fore the section. It lay in the general cavity, but entirely distinct from the Fallopian tube. It was found to contain a foetus, which gasped several times after removal, and apparently about five months advanced. The membranes containing the products of conception had evi- dently escaped from the ruptured Fallopian tube and become at- Tubal Pregnancy becoming Abdominal. 3 tached to the abdominal peritonaeum, where life was maintained. Mrs. B. recovered promptly with no serious complications. Both tubes and ovaries were removed, as the inflammatory process had practically destroyed them. This case undoubtedly belongs to the class so well known as primary tubal pregnancy, becoming abdominal by escaping from the tube and attaching itself to the abdominal peritonaeum and viscera, but I think it is rare in respect to the intensity of the shock, and via- bility afterward. As a rule, such cases result in the death of the foetus. Case II.-Mrs. M., aged thirty-five, mother of three children, last two (twins) born about eight years before she came under my care. Has not been pregnant since. Since September, 1895, she failed to menstruate at the usual time. In October, while away from home, was taken with quite a severe pain, lasting but an hour Or two, fol- lowed by haemorrhage from the vagina for one day only. It was profuse for a part of the day, but no severe collapse or exhaustion fol- lowed. I think she was confined to the house but one day. On her way to her home from Boston to eastern Maine she stopped at Port- land to consult me. I saw her but a few minutes, and, as all haemor- rhage had ceased and she was suffering from no special pain or con- stitutional symptom, I advised quiet, and if any symptoms developed to inform me. I made no careful examination at the time. During the following two weeks she had some pain and a slight sero-san- guinolent discharge. She came to Portland, and under the influence of ether I found an enlarged tube of the right side, for which I ad- vised abdominal incision. Curetting at this time, one week after, I made an exploratory incision and found a tube very much enlarged by haemorrhage from the mucous coat, in the center of which was a foetus about six weeks advanced. The haemorrhage was all within the peritoneal coat, but the tumor made up from the clot was as large as a medium-sized orange. She had salpingitis after the birth of her twins, leaving an infected uterus and appendages. So I made a complete hysterectomy, from which she recovered rapidly and is now in perfect health, a condition not enjoyed for eight years. My experience in this class of cases confirms me in the belief that hysterectomy is always justifiable and demanded. The peculiarity of this case is in extensive haemorrhage within the tube, while the peritoneal coat did not rupture. 4 S. C. Gordon, M. D. Effect of Complete Hysterectomy upon the Vagina. One of the objections to complete hysterectomy that has been urged by the opponents of the operation is that it has a tendency to, and actually does, shorten and deform the vagina. That it also de- stroys the arch by removing the cervix, which, when left, acts as a sort of keystone. This, if true, would certainly be a very grave objec- tion, and it is only by close observation that we can establish the truth or falsity of it. In 1892, at the meeting of the American Medical Association, I read a short paper entitled Hysterectomy without Pedicle, in which I advocated the complete extirpation of the uterus. In the discus- sion which followed this paper, and in many of the papers on hys- terectomy which have been published since, I frequently find this objection stated. Most operators leave the cervix, closing the peri- tonaeum over it. Practically, Dudley, Goffe, and Baer make the same operation, and, so far as I have consulted authorities, the weight of opinion leans to this method. Since Jacobs read his paper on vaginal hysterectomy last year before this Society, the " fad " seems to be to make the vaginal opera- tion, and therefore necessarily the cervix is removed. If the same objection holds good as existed against removing the cervix when the abdominal route was chosen, surely these men are doing an immense deal of harm. In my opinion, there is a much greater objection in this respect to the vaginal operation. To remove the uterus by this route the parts concerned are necessarily put upon the stretch and pulled down to the greatest degree possible, and consequently the tendency is to shorten the vagina after complete closure takes place. By the tech- nique which I have employed in hysterectomy the broad ligaments are constantly drawn up (as soon as cut) by the over-and-over con- tinuous suture. When the operation is completed by this method, the vagina is elevated above the normal position and closed by the same suture continued from the brdad ligament. By this simple operation the vagina is actually lengthened by so much as it is drawn up by the suture. That this condition really obtains I have demon- strated by examinations immediately after the operation. For the past two years I have examined as many cases that I have made this operation upon as I could, and have made inquiries of several of my professional brethren in reference to this point of shortening the vagina. Effect of Complete Hysterectomy upon the Vagina. 5 I have found no case of shortening or other deformity except in two or three cases where the cervix was not removed. I have found a marked atrophy of the vagina, but whether due to the operation or not I am unable to say. So far as I have been able to learn from others, their observations agree with mine. I am therefore led to believe that the objection is one of theory rather than of actual dem- onstration. I am rather inclined to believe also that the weight of the remaining cervix, in the incomplete operations, has a tendency to prolapsus of the roof of the vagina.