Surgical Operations on the 
Pelvic Organs of Pregnant 
Women 
BY 
MATTHEW D. MANN, A. M., M. D. 
BUFFALO, N. Y. 
REPRINT FROM VOLUME VII. 
(Stweralogtcal GDratuSacttaiiS 
1883 610 Main St.; Buffalo, f/V. f.; dVov.; 1883. 
1/jear 
c/ send you, with my compliments, a copy of a. 
paper reprinted from, the transactions of the Sdmeri= 
can gynaecological Society. 
the data on which it is based were collected with 
considerable difficulty but are hardly sufficient to 
settle all the questions involved.. 
tt is proposed, to continue the investigation and, 
to this end t would most earnestly ash your aid. 
Brief notes of cases bearing on these questions will 
be gratefully received and acknowledged. 
References to published cases, which may have 
escaped my notice; will odso be very acceptable. 
Moping that you will be willing and able to help 
me in this matter; J am wi th greatest respect; 
Very Sruly 'iyours, 
B. % SURGICAL OPERATIONS ON THE PELVIC 
ORGANS OF PREGNANT WOMEN. 
[BY MATTHEW D. MANN, A. M., M. D., 
Buffalo, N Y. 
Whether or no it be best to operate on a pregnant 
woman is a question which will often force itself upon the 
attention of the surgeon. While sometimes the exigencies 
of the case will make clear his line of action for him, still 
he is certain to meet with occasions when he will be called 
upon to decide as to the propriety of operating, and where 
the nature of his decision will have a most important influ- 
ence on the welfare of his patient. These occasions, to be 
sure, are rare ; but this very rarity implies want of expe- 
rience, and leads the surgeon to desire some guide, or some 
reliable observations, by the study of which he may come 
to an intelligent and safe decision. If he seeks to be gov- 
erned by the rules of the books, or by the experience of 
others, he will find very little written to guide him, and very 
few recorded observations from which to draw conclusions. 
It is for the purpose of adding to our scanty stock of knowl- 
edge on this subject, and to enable us to deduce certain 
rules for our guidance in practice, that I have collected the 
cases here reported. 
As the pregnant woman has generally been considered 
by the operating surgeon as a sort of a noli me tangere, the 
reports of operations performed during this condition are 
necessarily rare, and the operations are either those done un- 
wittingly or those rendered imperative by the nature of the 
case. If this be so of operations in general, it is still more 
so if we limit our investigation to operations involving the 2 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
pelvic organs. We then find the material to be very scanty 
and widely scattered. To collect a sufficient number of 
cases, I addressed letters to certain prominent gynecolo- 
gists,1 asking for the results of their experience, and have 
been thus furnished with quite an array of cases never 
before published. 
A number replied that they had never met with any cases, 
and among these were some of our most busy operators. 
To the cases thus collected I have added some taken from 
our current literature, and a few from my own experience. 
My attention was first drawn to the subject by a case, to 
be detailed later, in which I repaired a torn cervix, and the 
woman, to my great surprise, bore twins at full term, about 
seven months later. This I at first considered a lucky 
chance, but since I have collected the material for this 
paper, have somewhat changed my mind. The question of 
performing ovariotomy during pregnancy presents so many 
points of a special nature, and has already received so much 
attention, that its discussion will be put outside of our 
present limits. 
The reasons why operations have been avoided during 
pregnancy are based on the varied and striking changes 
which take place in the woman’s organism with the advent 
of conception. I need only recall them to mind. The 
blood is altered both in its constituents and in its quantity. 
The red corpuscles become fewer, and the white more nu- 
merous. The blood also contains more of water and fibrine, 
and less of albumen and iron. To accommodate this 
changed condition of the circulating medium, the heart 
itself undergoes certain modifications. Its cavities are 
dilated, and there is hypertrophy of the left ventricle. As 
a result of the addition to the quantity of the blood, as well 
as the changes in the heart, we have increased arterial ten- 
sion. The glandular and nervous systems also undergo 
very marked alterations. 
1 To the gentlemen who have thus kindly interested themselves in 
my behalf I wish to extend my sincerest thanks. In many instances I 
know it involved a great deal of personal trouble, which is fully appre- 
ciated. MATTHEW D. MANN. 
3 
But it is in the genital organs that we find the greatest 
changes. With the fixation of the impregnated ovum in 
the uterine cavity there is renewed activity in the formative 
processes in all the organs involved in the nourishment and 
expulsion of the growing fetus. The uterus at once in- 
creases in vascularity, and its ultimate fibres begin to grow 
in every direction. The blood-vessels increase in size and 
number, while the lymphatics, which were previously 
small and unimportant, become greatly hypertrophied and 
increased in number. The connective tissue around the 
uterus, and in the broad ligaments, is also hyyertrophied 
and softened. Changes of the same nature take place co- 
incidently in the vagina. 
All these metamorphoses, both those in the general organ- 
ism and those in the special organs involved, would seem 
to invite accident in the event of an operation. The in- 
creased arterial tension, as well as the enlargement of the 
vessels, and the general softening of the tissues, would all 
seem to make probable the occurrence of more than the 
usual amount of hemorrhage, and make its arrest very diffi- 
cult. The enlarged lymphatics would certainly open the 
doors to the rapid and easy absorption of septic material, 
while the quickened cell growth, as well as the increase in 
the number of white corpuscles in the blood, might lead us 
to expect a considerable tendency to pus formation. 
But above all these a priori objections stands out — the 
great and undoubtedly real one—the danger of interfering 
with the growth of the product of conception, or, in other 
words, the danger of producing an abortion. There is little 
use in arguing about this, for the well-known differences 
which exist in individual tendencies and predispositions 
render all of our reasoning vain. As long as one woman 
aborts from a misstep while her neighbor goes through a 
severe accident without any interruption in the progress of 
the utero-gestation ; as long as this is so, —and we are un- 
able to explain the causes of the difference in the results,— 
so long will we be unable to predict with certainty the re- 
sults of an operation to be performed on the genitals of a 4 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
pregnant woman. But while this must in general be admit- 
ted, still, from a careful study of the physiology of the 
parts involved, and from the consideration of the results 
already obtained by operators, we may be able to give a 
certain amount of probability to our prognostications which 
will enable us to act intelligently in any given case. 
In addition to the changes already described as taking 
place in the uterus, we have the great change due to the 
presence in its cavity of a growing body. This of course 
produces a dilatation of the cavity pari passu with the growth 
of the ovum. In this dilatation, however, the cervix takes 
little or no part. While the cervical tissues increase to a 
certain extent, the growth is in no wise commensurate with 
the increase which takes place in the parts above the inter- 
nal os. By the end of the fourth month the cervix has 
attained its full size, and thereafter remains unchanged until 
the beginning of labor. These points, although long con- 
tested, are now very generally considered to be settled. 
With the growth of the cervix occurs that peculiar soften- 
ing of the tissues, which is so characteristic of the preg- 
nant condition. 
It will be seen then that an application may be made, 
even up into the cervical canal, without in any way neces- 
sarily involving the integrity of the ovum; and the same 
is true of a cutting operation, provided the internal os is 
not too nearly encroached upon. While this is true in a 
strictly anatomical sense, the peculiarities of the individual, 
already alluded to, or, in other words, the susceptibility of 
the reflex centres, introduce an element of uncertainty. 
As the uterus is left, the nearer we approach the vulva the 
less does this element of uncertainty enter into the case, the 
less danger is there of provoking uterine contractions. 
The stage of the pregnancy is also an important element 
in the question. It is generally well recognized that in the 
earlier stages, and at the menstrual epochs, uterine con- 
tractions are more easily excited, and abortions more apt to 
occur than in the middle periods. The same is true toward 
the end of pregnancy, though after the child is viable, its 
expulsion is a matter of less importance. MATTHEW D. MANN. 
5 
Having grouped together the arguments against operating 
on the genitalia of a pregnant woman, it would be unfair 
not to give the points which might be urged in favor of 
the choice of this time for operating. 
The greater amount of fibrine in the blood might, by in- 
creasing its coagulability, counteract the supposed hemor- 
rhagic tendencies. The increased cell growth might also be 
thought to favor repair and aid primary union ; and also in 
the case of plastic reparative operations to so aid the growth 
of the newly-formed connective tissue as to make it suffi- 
ciently strong to endure the strain necessarily brought to 
bear upon it in the labor. These are scarcely arguments, 
and would not count unless there were other and mightier 
reasons for choosing pregnancy as the time for operating. 
We have then two aspects of the question before us for 
discussion : The influence of pregnancy on operations in 
general ; and The effect which operations have on preg- 
nancy. First let us see what have been the results of 
operations on other parts of the body. 
The general feeling on the subject is doubtless well ex- 
pressed by Dr. Priestley when he says: “It is generally 
supposed that no operation should be performed during 
pregnancy, even removing a tooth.” Paget, however, says 
that pregnant women bear operations well. Cohnstein con- 
cludes, from the consideration of a number of cases, that 
repair goes on unimpeded, union by primary intention being 
rare, but suppuration sometimes very profuse. As regards 
the second question, Cohnstein found that after operations 
and injuries pregnancy terminated naturally in 54.5 per 
cent, of all cases. Massot concludes that ordinary surgical 
operations do not interfere with pregnancy, unless they ma- 
terially and permanently disturb the uterine circulation, or 
excite uterine contractions by reflex irritation. Verneuil 
has observed a great number of traumatic lesions in preg- 
nant women, and considers that temperature is the great 
factor in determining the results, whatever be the cause of 
the febrile action; if 40° C. (104° F.) be reached, as a gen- 
eral rule, abortion and death follow. M. Nicaise expresses 6 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
tire opinion that the nearer the lesion is to the genital 
organs, the greater is the danger of abortion, an opinion 
reechoed by nearly every writer on the subject, and sup- 
ported by Cohnstein’s statistics. In them he shows that 
of the 45.5 per cent, in which abortion occurred, in 32 per 
cent, the genito-urinary organs were involved in the opera- 
tion. In Massot’s statistics the percentage of abortions in 
the two classes of cases are about the same. He collected 
214 cases; of these 83 were accidents, and 131 operations. 
Of the 131 operations, 62 involved the genital organs, and 
69 did not. Of the 62, 41 recovered, 66.1 per cent, and 19 
aborted, 30.6 per cent. While of the 69 general operations, 
47 recovered, 68 per cent., and 21, or 30.4 per cent., aborted. 
These, then, are the general conclusions to which previ- 
ous investigators lead us. As far as operations on the pelvic 
organs are concerned, they are based on too few cases to be 
at all conclusive, and fail to lay down any rules for practice. 
I propose, therefore, to examine all the cases which are ac- 
cessible, grouping them according to the organs which they 
involved, and try to draw some practical lesson from their 
consideration. 
Abscesses of the vulva are not very uncommon during 
pregnancy. Cohnstein and Massot have collected a number 
of cases as follows :— 
One case by Grenser, successful. 
Two by Verneuil; first case (144),1 abortion and death ; 
patient was in the sixth month. There was in this case an 
abscess of the ovary and tube, probably due to the same 
cause as the abscess of the vulva, namely, gonorrhea. This 
ruptured into the peritoneal cavity and caused death. There 
was, however, an angeioleucitis and lymphadenitis starting 
from the labial abscess, which may have been the cause of 
the abortion. Second case (146), in seventh month ; was 
successful. Despres (145), two cases successful. Petit, one 
case (147), in the fourth month. Spontaneous rupture, re- 
OPERATIONS ON THE VULVA. 
1 Numbers after cases refer to Massot’s work. MATTHEW D. MANN. 
7 
covery. Five cases in all, with one abortion followed by 
death. The others healing quickly, and without accident. 
Tumors of the Vulva. Cohnstein finds a case recorded 
by Simon, in which the lower half of the right labium was 
amputated for a large sarcoma in the second month of the 
pregnancy. The wound healed rapidly, and the pregnancy 
was not interfered with, but the sarcoma returned before 
labor set in. 
Dr. Parvin1 reports a very interesting case, as follows : — 
“ The patient, about twenty-four years old and pregnant for 
the first time, was found to have a large labial cyst. The tumor 
was first noticed at the age of fourteen, about the time of the first 
menstruation, but grew very slowly until after marriage. When 
she became pregnant it grew very fast, doubling in size within 
three or four months. I saw her when about four months ad- 
vanced in pregnancy ; removed about one third of the cyst wall, — 
after exposure and evacuation of its contents, — and then filled 
the cavity with lint. The patient did well, and did not miscarry. 
The tumor was the size of a large orange.” 
Dr. Paul F. Munde sends me the following: — 
“ A colored woman, aged twenty-four, had borne four children, 
and had one miscarriage. During her first pregnancy, six years 
before, she noticed an enlargement of the labia. It subsided 
after the birth of her child, but during the second pregnancy it 
again developed. When seen it was of the size of the fist. It 
involved the nymphae, clitoris, and labia majora. From being 
ulcerated it caused a great deal of pain. She was then four 
months pregnant. In view of the probable rapid growth of the 
mass (which was recognized as an elephantiasis of the vulva), 
and on account of the suffering it caused, its removal was deter- 
mined upon in spite of the known pregnancy. The operation 
took place June 18. Elastic ligatures were used over three 
needles, transfixing the tumor transversely. The mass was then 
excised above the ligatures. There was no hemorrhage. After 
the removal of the ligatures, a dozen or so spurting arteries were 
1 Dr. Parvin also reports a case of amputation of the breast for can- 
cer, and of the leg for malignant disease, with good results in both 
cases, and without inducing abortion. 8 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
caught and tied, and the wound closed by twelve sutures. Union 
almost by first intention, except in the tracks of the ligatures, 
which came away on the tenth day. No interruption of the 
pregnancy.” 
A somewhat similar case is reported by Churchill (157). 
The patient was in the seventh month. The nymphae and 
clitoris were hypertrophied, forming three large tumors, the 
central one being as large as a turkey’s egg. This tumor 
only was removed, by ligatures and excision, three days 
afterward. The patient recovered perfectly. 
Massot (156) quotes from Aubenas an account of a large 
lipoma of the vulva. It weighed three pounds, was re- 
moved, and patient made a good recovery. 
Of Venereal Warts or Vegetations of the vulva, Massot 
has collected a number of cases. 
Velpeau (148), in 1845, removed an enormous vegetation. 
Considerable hemorrhage followed, and some days after 
abortion with recurrence of hemorrhage; recovery. 
Gailleton (149) reports three cases where he removed 
vegetations unwittingly during pregnancy ; two of his cases 
miscarried. 
Chassaignac (150) had a case where, after trying acetic 
acid and Vienna paste, he used a great number of ligatures. 
The patient was five months advanced, and made a good 
recovery without miscarriage. In a second case (151) at 
the third month he used the linear ecraseur with satisfac- 
tory results ; no hemorrhage or abortion. 
Demeaux (152) met with a case where the vegetations, in 
two masses, reached from the mons veneris to the peri- 
neum, each one as large as a man’s fist. The operation was 
performed in the fifth month, the tumors being excised and 
the hemorrhage stopped with difficulty with perchloride of 
iron. The hemorrhage recurred in the night, and again 
the next day. The wound was all healed on the eighth 
day, and the patient was finally delivered at term. 
Demeaux (153) also operated on a mass as large as a fist. 
The patient recovered quickly and went to term. 
Despres (154) reports a case of a “ bouquet de vegetations ” MATTHEW D. MANN. 
9 
as large as the head of an adult. The patient was twice 
operated upon when in the fifth month ; hemorrhage was 
considerable, but she recovered and went her full time. 
He reports also (155), that he has removed very large vege- 
tations from six patients, being from three to seven months 
advanced. All were primiparae, and from seventeen to 
twenty years of age. None of them aborted. 
Violet and Tilleaux also report two cases each, in which 
they removed large vegetations without accident. Total, 
nineteen cases of vegetations of the vulva, with three mis- 
carriages. Unfortunately, of the cases which miscarried 
we have no details. 
Here we have twenty-eight cases in which operations of 
more or less severity were performed on the vulva, and in 
only four instances were there any bad results ; the others 
recovered without interruption of the pregnancy. As has 
been already said, one of the fatal cases was so from com- 
plications not connected with the operation. 
THE PERINEUM. 
The operation of Perineorrhaphy is so very common that 
it is not at all surprising that a certain number of opera- 
tions performed during pregnancy are reported. Dr. Good- 
ell met with two cases, one three months pregnant. She 
went to term, and, by making bilateral incision, he saved 
the raphe. The other went to term, but the effect on the 
restored perineum is unknown. He noticed a good deal of 
hemorrhage during both operations. 
Dr. J. R. Chadwick sends a case as follows: — 
“ The patient was one in the country, whom I had never seen 
before. Two weeks later, after she had suffered from severe ab- 
dominal pain, I was hastily summoned, with the information that 
the operation seemed to be a success, but that the attending 
physician had that morning discovered something resembling a 
sloughing coil of intestines protruding from the vulva. This he 
had carefully pushed back. On uncovering the woman I found 
a two and a half months’ fetus hanging by the navel-string. I 
have since learned that, in extracting the placenta, a part of the 
united perineum was torn out.” 10 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
Dr. G. R. Shepherd, of Hartford, Conn., sends me the 
following very interesting case : — 
“Mrs. A., aged twenty-eight, mother of two children, sustained 
a double laceration of the cervix in her first confinement, the per- 
ineum being also torn completely through the sphincter. The 
extent of the injury was recognized at the time, but no immediate 
surgical measures were adopted beyond confining the knees with 
a bandage, and consequently her second pregnancy, at the expi- 
ration of fourteen months, found her with the lips of the uterus 
widely separated and everted, though entirely covered with healthy 
mucous .membrane. The sphincter ani was unable to retain 
either flatus or moderately fluid evacuations. She did not mis- 
carry with her second child, but was confined at full term. Six 
months later she presented herself for operation upon the cervix. 
Menstruation had recurred, though irregularly, during her second 
lactation, and consequently I found it impossible to know just 
when to expect it; but as her stay in the city was necessarily lim- 
ited, I operated on the 20th of September, 1881, a little over six 
weeks from the last menstrual period. Pregnancy not being sus- 
pected, the uterine sound was carried to the fundus at the time of 
the operation, and again two weeks later, when the stitches were 
removed. The nausea and vomiting that followed the operation 
were very annoying, and continued to recur every few days for 
two or three weeks after the removal of the stitches. Her breasts 
began to enlarge and became sensitive, and, when I decided to 
operate upon the perineum on the 18th of October, she was feel- 
ing quite confident (and I very strongly suspected) that she was 
pregnant.” 
“ Both operations were successful, and pregnancy progressed 
without interruption. She left for the West in November. Her 
husband, a physician, watched her carefully, and wrote me, after 
the period of quickening, that he expected her confinement early 
in May, 1882, and stated that in her condition it was a great com- 
fort to have the complete control of her sphincter, which the op- 
eration had given. In March she decided to return East for her 
confinement, but while on the way was attacked with pneumonia, 
and died at Montreal. I observed no greater care in this case 
than is my custom, and noted nothing at the time of the opera- 
tion that was at all unusual. Regarding the question of hemor- 
rhage, I can simply state from memory that, if anything, there 
was less than usual, though not markedly so.” MATTHEW D. MANN. 
11 
It may be objected to this case that it is not a fair one 
to draw conclusions from. A woman who, while pregnant, 
could bear the passage of the sound to the fundus on two 
different occasions could hardly be made to abort. 
Dr. Reamy gives the history of two cases as follows : — 
Case I. — Mrs. F., aged twenty-eight, mother of two children, 
the youngest thirteen months old. During her first labor she 
suffered a laceration of the perineum, dividing the external sphinc- 
ter, but not the recto-vaginal septum. She consulted me March 
i, 1879 ; was then suffering from the symptoms usual after such 
an accident. Deformity of the vaginal entrance very marked, 
also considerable prolapse of the posterior vaginal wall. Vaginal 
contractility much impaired, greatly annoyed by the escape of 
wind from the vagina, especially when lying upon the side. 
Uterus slightly prolapsed ; slight erosion of os. Much mental 
depression. Perineorrhaphy decided upon. Operated April 3, 
1879 ; five sutures removed on the eleventh day ; results perfect. 
At the date of the operation menstruation, which, had been quite 
regular for several months, was due in fifteen days. It did not, 
however, appear, and time proved that she was pregnant. She 
was delivered January 5, 1880, of a healthy child — weight, nine 
pounds — without any laceration of the perineum. I obtained 
from her and her husband the following facts : Previous to the 
operation, her child had been weaned three months. Her hus- 
band had been absent during the three weeks immediately pre- 
ceding the operation, arriving at home April 1. Connection took 
place on the nights of the 1st and 2d ; the operation was on the 
3d of April. Intercourse was not again had until six weeks sub- 
sequently. The child was born two hundred and seventy-four 
days from the date of the operation. Consequently, insemina- 
tion, if not pregnancy, occurred before the operation was done. 
While this can hardly be called an operation during preg- 
nancy, still it illustrates very forcibly the strength of the 
new adhesions formed during this period, there having been 
no rupture of the new perineum, notwithstanding a nine 
pound child. 
Case II. — Mrs. G., aged twenty-four, mother of one child two 
years old, came under my care in January, 1881. She was two 
months advanced in pregnancy, and was reduced to a mere skel- 12 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
eton, having vomited daily, often as many as twenty times a day 
for the past month. She was of the poorest class, and consulted 
me at the Good Samaritan’s Hospital. The perineum had been 
torn at her labor through the anal sphincter, the rent in the 
bowel extending half an inch, but the internal sphincter was, of 
course, not totally destroyed. Her condition, however, had been 
miserable, for, as she was compelled to wash for a living, uterine 
prolapse, with all its concomitants, had occurred. Pessaries had 
proved to be of no use. At the examination I found the os pro- 
truding slightly beyond the external vulvar wall, considerably 
eroded, with some leucorrhea. As she could not leave her family 
to enter the hospital, I determined to operate at her home. After 
keeping her in bed but one week, with the hips elevated and 
daily applications of cotton pessaries saturated with glycerine, 
carbolic acid, and tannin, the condition was so far improved that 
I operated, doing my own modification of Emmet’s operation for 
restoring the perineum in cases involving the bowel. Vomiting 
ceased within twenty-four hours after the operation. The sutures 
were allowed to remain fourteen days. The result was perfect. 
She was kept in bed for three weeks after the removal of the su- 
tures. The uterus was supported by a hard rubber bow pessary 
until the fifth month of gestation, when it was no longer needed. 
Vomiting never returned, and her general health became good. 
I delivered her of a male child weighing nine and a half pounds, 
August 21. There was very slight laceration of the perineum, of 
no importance. It was due to the fact that I had carried the 
base of the perineal body very far forward in the operation for 
its restoration. 
This case not only shows the harmlessness of operating 
on the perineum during pregnancy, but it also gives us an 
indication for operating, and, like the previous case, illus- 
trates the behavior during labor of a perineum only six 
months old, and made during pregnancy. 
The late Dr. J. C. Nott met with a case of which the 
following is an abridged account: Mrs. L., aged thirty-seven, 
excessively fat and very short, general health very poor, 
two children, the last twelve years before. At that time 
the perineum was torn down to the sphincter ani. When 
seen she had not menstruated for eight years. The uterus MATTHEW D. MANN. 
13 
was very small, the uterine sound passing only two inches. 
A large cicatrix over the perineum was in a state of extreme 
hyperesthesia. Following two sponge tents a slight bloody 
flow occurred, but was not repeated. Four months later 
the perineum was operated upon, Drs. Sims and Thomas 
assisting. Pregnancy unsuspected. But Dr. Nott says : 
“ Even if I had suspected pregnancy, I think the operation 
would have been justifiable, as her general health demanded 
relief, and it was clear to my mind that she could not, in 
her condition, carry a child to term.” Union was solid, and 
the soreness and morbid sensibility disappeared. “ Has 
not felt so well for years.” Two months after the operation 
she aborted. Dr. Nott was charged with ignorance and 
malpractice in this case, because he did not know that she 
was pregnant, and because he operated during pregnancy. 
The experience of later operators, already detailed here, 
fully justifies Dr. Nott, when he says : “Although I would 
not have performed the operation without a consultation if 
I had been aware of pregnancy, still I believe her case to 
be a strong exception to the general rule forbidding it, and 
would unhesitatingly have advocated the operation.” With 
the results now before us it would hardly be necessary to 
call the consultation. The occurrence of the abortion at so 
late a date after the operation could not possibly have been 
attributed to its effects. Dr. Sims, in speaking of this case, 
declares that he has repeatedly performed the operation on 
pregnant women, and would not have hesitated here for a 
moment. 
In Dr. Chadwick’s case there is no certainty that the 
abortion depended on the operation on the perineum. Al- 
though Dr. Chadwick does not state it, there is a possi- 
bility that he passed the sound, and that the abortion was 
due to that fact. 
These six cases, if we throw out Chadwick’s, are strongly 
in favor of the harmlessness of operations upon the per- 
ineum of a pregnant woman, should the occasion arise. 
All that were delivered seem to show that we may expect 
the newly-formed perineum to successfully withstand the 14 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
shock of labor. Dr. Reamy’s second case and Dr. Nott’s 
case both give indications for the performance of the opera- 
tion during pregnancy. 
Venereal Warts in the vagina as well as on the vulva oc- 
curring during pregnancy are apt to increase very rapidly, 
and may be so numerous as almost to be a cause of ob- 
struction during labor. The first case of the kind I ever 
saw I treated with palliatives, astringents, etc., being fearful 
of serious results if I attempted to remove the growths. 
Later, however, emboldened by the success of my operation 
on the cervix of the pregnant uterus, I determined to oper- 
ate. A young woman who had acquired gonorrhea shortly 
after being impregnated for the first time offered an oppor- 
tunity. My reasons for operating were, that the warts were 
so numerous and large as to almost block up the vagina. 
I found it impossible to cure the gonorrhea while the warts 
were there, and feared that if left until labor set in, the dis- 
tensibility of the vagina would be interfered with, and that 
the advancing head would tear off the growths, leaving open 
the mouths of the lymphatics and blood-vessels, by which 
the absorption of septic material would be favored. I 
feared also for the child’s eyes, if the infective discharges 
were left, and also that the disease might extend into and 
through the uterus, producing a pelvic peritonitis. I had 
no difficulty in scraping out the growths with the curette 
and my finger. The hemorrhage was rather free, but was 
readily checked by introducing a large cylindrical speculum, 
and painting the whole vaginal surface with a forty-grain 
solution of nitrate of silver. A few other applications of 
silver were made in the same way, and the patient was en- 
tirely cured, and went through her confinement without 
difficulty. 
Dr. Chamberlain, at a meeting of the New York Obstet- 
rical Society (April 19, 1881), spoke of having seen exten- 
sive venereal vegetations removed, under very similar cir- 
cumstances, from the vulva and vagina without bad results. 
VAGINA. MATTHEW D. MANN. 
15 
Hildebrandt mentions a case by Levy, of Munich, where, 
after removal of the warts, he cauterized the base with 
nitrate of silver, and washed out the vagina with lead water. 
The patient made a good recovery, but four weeks later 
there appeared on various parts of the body numerous wart- 
like excrescences, which remained until delivery, and disap- 
peared soon after. Hildebrandt declares that he has fre- 
quently seen these growths disappear during the lying-in 
period, with cleanliness and rest; but for the reasons 
already given I should prefer to remove them at once. 
The cases detailed here, together with those already men- 
tioned in speaking of operations upon the vulva, in which 
the same indications exist, would seem to offer basis enough 
for such a conclusion. 
Applications. — For the relief of the very troublesome dis- 
charges which sometimes cause a great deal of annoyance 
during the later months of pregnancy, and which I have 
considered as due in part, at least, to increased vaginal con- 
gestion and exudation, I have a number of times used ni- 
trate of silver solutions in the way already indicated, with 
only good results. 
Of operations on the vagvia proper there are not many 
to report. Cohnstein remarks that he has never seen any 
bad results follow the puncture of small cysts in the vaginal 
walls. Dr. Protheroe Smith mentions having punctured an 
abscess as large as an orange in the posterior vaginal wall, 
at the sixth month of pregnancy, without bad results. 
Dr. Bixby sends me the report of a case of vaginal poly- 
pus : — 
“ The tumor was nearly as large as a fist. The subject a stout, 
full-blooded woman. Notwithstanding the employment of an 
ecraseur, the hemorrhage required the tampon. I saw the case 
in consultation. A few days later I learned that she had mis- 
carried at the third month, greatly to my surprise, as I had not 
the faintest suspicion of pregnancy. Others had seen her before 
me, and possibly for differential diagnosis the uterine sound may 
have been used. She made a good recovery.” 
It is too bad that some of the conclusions to be drawn 16 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
from this case are invalidated by the uncertainty as to the 
passage of the sound. This applies to many of my cases, 
as in very few of them was the pregnant condition sus- 
pected. Massot has collected a number of cases of this 
sort. One (158) was an obdurator hymen, cut in the third 
month, without any bad results. He has collected also 
three cases of polypus of the vagina. The first (160) 
was a woman aged twenty-three, in the seventh month of 
pregnancy. The tumor was outside the vulva, but was at- 
tached by a long pedicle to the posterior wall of the vagina ; 
it was much larger than a hen’s egg. It was tied, and cut 
on the fourth day afterwards. Recovery complete. The 
second case (161) was in Dr. McClintock’s practice in 1857. 
Woman in the ninth month of pregnancy. Tumor attached 
to the posterior wall of the vagina. It was the size of a 
small hen’s egg, and was sloughing. It was removed, and 
the patient returned home. Labor came on in a month 
after the operation, and the patient died in thirty-four 
hours, apparently of what we would now call septicemia. 
There was an ulcer on the posterior wall of the vagina, 
where the tumor had been. The third case (162) was six 
months pregnant. The tumor was attached by a large, firm 
pedicle to the anterior wall of the vagina, and was the size 
of a duck’s egg. The pedicle was tied, and the tumor cut 
off. She recovered, and was delivered at term. 
Dr. C. C. F. Gay, of Buffalo, kindly sends me a reference 
to a case published by him, with notes of the subsequent 
history of the case. Mrs. G., aged thirty-five, had had pro- 
cidentia complete for thirteen years ; had had five children, 
three of them since the occurrence of the procidentia. 
The os protruded two and a half inches beyond the vulva. 
She was operated upon in June, 1871, according to Em- 
met’s method for narrowing the anterior vaginal wall. 
Union was perfect, and the patient relieved of her pro- 
lapse. Seven months later she was delivered of twins, at 
full term, one dead and one living. Dr. Bartow, who at- 
tended her, is under the impression that the newly attached 
tissues were torn apart at the labor. In 1876 she was seen MATTHEW D. MANN. 
17 
by Dr. Bartow, and the procidentia was found to be as 
bad as ever. 
If stenosis of the vagina, due either to bands or a circu- 
lar stricture, is discovered during pregnancy, Cohnstein 
advises that they should at once be cut with the probe- 
pointed bistoury, and says that no harm is likely to come of 
it. Verneuil’s case, to be related later, leads to a rather 
different conclusion. At a meeting of the New York Obstet- 
rical Society, Dr. F. Barker related a case where the most 
marked cicatricial contraction of the vagina gave way, and 
easily dilated before the advancing head. This would seem 
to show the uselessness of operating in such cases before 
labor sets in. Dr. Campbell’s second case of vesico-vaginal 
fistula bears upon this point, and corroborates Dr. Barker’s 
views. He writes of this case : “ This rapid softening and 
stretching of nodular tissue (cicatricial) in the vagina on 
the occurrence of labor I think I have seen remarked upon 
by authors, though I cannot recall by whom. Occlusions 
of the vagina from inflammatory and traumatic causes are, 
I think, far more common in the African race than in the 
white. I have had many cases in negro women, and none 
in white, except in connection with a vesico-vaginal fistula. 
I was requested to operate on a favorite servant of a planter 
for occlusion of the vagina, many years ago. She was preg- 
nant, and the operation was thought necessary to admit of 
safe delivery. She was taken in labor at term, and was 
delivered without difficulty, and so rapidly that the phy- 
sician did not arrive until it was over. If there be a con- 
genital atresia the case would be different, and might call 
for an earlier operation. Herzfeld reports a case, but the 
atresia was only discovered two weeks before labor, and was 
left until labor began, when it was torn with the fingers 
and the forceps applied. 
Of seven operations on the vagina, only one resulted in 
an abortion. The result in Massot’s second case is hard to 
explain, and it is difficult to say how much the old ulcer 
had to do with the fatal result. Hemorrhage seems to have 
been the principal difficulty, but in only one case (Bixby’s) 18 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
was it severe. The method of operating in the other cases 
of tumor (ligature) may have had something to do with the 
results obtained. 
Vesico-vaginalfistula operations during pregnancy make 
rather a bad showing. Dr. H. F. Campbell, of Georgia, 
reports to me two cases operated upon unwittingly in the 
second and third months of pregnancy, as follows : — 
Case I. — I was requested to operate upon a case of vesico- 
vaginal fistula in a colored woman (mulatto), aged thirty. She 
had had several difficult labors, but had not borne a living child. 
In her last labor forceps had been used, late in the protracted 
labor, and it was after this parturition that the fistula was ob- 
served. Bozeman’s operation was performed, by which a consid- 
erable opening was perfectly closed. The hemorrhage was very 
severe, and much trouble was experienced in arresting the flow, 
to effect proper approximation. This was explained some five 
or six weeks after, when quickening took place, and the woman 
was found, unexpectedly to herself and to the physicians, to have 
been pregnant at the time of the operation. I do not remember 
any symptoms after the operation simulating labor pains, or pains 
threatening abortion. Being unaware of her condition, if such 
symptoms occurred they were not recognized. 
Dr. Joseph A. Eve, who had charge of the case, had deter- 
mined, in view of the woman’s contracted pelvis and her uniform 
dystocia, to practice induced labor at the seventh month. It is 
my impression that spontaneous premature labor occurred at a 
viable period, and the woman was safely delivered, for the first 
time, of a living child. She did well after that labor, but died 
after a subsequent one, at full term, in childbed. 
Case II. — Mrs. J. was the subject of a vesico-vaginal fistula, 
with considerable opening, near the has fond of the bladder. 
The accident resulted, I have no doubt, from delay in applying 
forceps when imperatively demanded. I failed in my first opera- 
tion on account of fibrous bands distorting the vagina and drag- 
ging on the line of union. Only a small portion of the fistula 
remained open. After some six months or more, she returned 
for a second operation. I found the vagina still imperfectly pre- 
pared for the operation, the obstructing bands being a little less 
troublesome than before. Being apparently in the best of health, 
and in good condition otherwise, as I thought, for the operation, MATTHEW D. MANN. 
19 
I concluded to attempt the closure of the fistula. The ordinary 
operation, with silver-wire sutures, was performed. The bands 
were relieved by incision and stretching. Much troublesome 
bleeding attended every step of the operation, in contrast with 
the former one, in which no very serious hemorrhage had taken 
place. This we attributed, at the time, to the free incision of 
the constrictions. The sutures were finally satisfactorily applied, 
and the patient put comfortably to bed, with Sims’ catheter in 
the bladder. Before we left the house, she began to complain 
of great distention of the bladder. Though bloody urine had 
flowed freely through the instrument, there was no blood in the 
vagina from the incisions ; and not suspecting any unusual hem- 
orrhage, we attributed her discomfort to other causes than disten- 
tion of the bladder with blood. Returning some two hours after- 
ward, we found the patient in an alarming condition. She com- 
plained of distention more than ever. She was extremely feeble, 
pulse almost imperceptible, skin cold and clammy. She was nau- 
seated, and had vomited frequently. There was a large quantity 
of blood in the urinal, with but little or no urine. The vagina 
was filled by the distended bladder, which projected as a tumor 
at the hypogastrium. We made efforts at breaking up the clots, 
with the view of washing out the bladder, but the process was too 
slow and uncertain, in view of her low condition and the prob- 
able continuance of the hemorrhage into the bladder. The su- 
tures were therefore removed as rapidly as possible, and the 
finger introduced into the bladder through the fistula, and the clots 
broken up and washed out with fresh warm water, and then iced 
water was used against the bleeding. So low was the patient 
that I did not dare to leave her, even after the bleeding had ap- 
parently ceased, without means to secure her against further loss 
of blood. Pledgets of lint, soaked in moderately strong solu- 
tions of Monsell’s salt, were passed from the vagina through the 
fistula into the bladder, packing and distending the opening so 
as to compress the cut edges. She made a good recovery, and 
returned home. Though not suspecting it at the time, Mrs. J. 
must certainly have been in the early period of pregnancy. 
Shortly after returning home she felt motion. Refusing induced 
abortion, she was allowed to go to full term, and returned to 
Augusta to be delivered, by Dr. Eve and myself. I knew the va- 
gina was terribly obstructed by the fibrous bands and adhesions, 
and I had a helpless horror of the approaching event, — catas- 20 
SURGICAL OPERA TIONS ON PREGNANT WOMEN 
trophe, as I considered it. Labor came on suddenly, and she sent 
for Dr. Eve and myself, at the same time. We had expected a 
most protracted and difficult obstructed labor : first, because the 
former labor had required forceps; and secondly, because of the 
occluded condition of the vagina. When I arrived, Dr. Eve was 
already on the ground, but, with all his readiness, he had failed 
to be “in at the birth,” which it seemed to me was likely also 
to be the death. Labor had been accomplished with the most 
fearful suddenness. We found the woman almost dead, — cold 
and pulseless, as if after a most exhausting hemorrhage. We 
found that she had not bled excessively, and we both came to 
the conclusion that her condition was the result of shock, depend- 
ent on the rapid labor, under circumstances so adverse, namely, 
the condition of her vagina and the existence of the fistula. 
The patient recovered, but the fistula remains unhealed. 
This is certainly a most remarkable case. It is contrary to 
the general expectation that such a hemorrhage should not 
have resulted in an abortion, nor should vve expect so pre- 
cipitate a labor in a vagina so constricted as this must have 
been. 
M. Verneuil reports a case of a strong, robust country 
woman admitted to the hospital in November, 1875. Her 
last labor was eighteen months before, and since then she 
had suffered from a vesico-vaginal fistula. There was a 
sort of diaphragm across the vagina. As this was quite 
thin, he tore it with the aid of a speculum and his fingers. 
Two or three days later there was edema of the labia ma- 
jora. The vagina was congested, with abundant bad-smell- 
ing secretion. Vulva very tender and swollen. She was 
ill three weeks. On her recovery she insisted upon an op- 
eration. This was done January 12th, five sutures were 
introduced, and all went well until the third day. Then 
there was a slight bloody discharge, which soon became a 
hemorrhage, with large clots, and an ovum of the second 
month was expelled. Stitches were removed January 16th. 
Union complete, notwithstanding all. Verneuil remarks 
that the case shows both the danger and the harmlessness 
of pregnancy in its effects on operations. MATTHEW D. MANN. 
21 
W. Schlesinger met with a case in which the woman had 
been delivered six months before, by craniotomy, with the 
result of a large vesico-vaginal fistula. She had not men- 
struated since confinement, but denied pregnancy. The 
cervix was greatly diseased, and, owing to the position of 
the fistula, was much in the way, bleeding profusely at the 
prick of the tenaculum. While the stitches were being put 
in, a great amount of edema of the cervix and vaginal 
walls was developed. The operation lasted an hour, and 
was completely successful. The patient remains well, hav- 
ing gone through her labor at term without difficulty. She 
must have been from two to three months pregnant at the 
time of the operation. 
Massot mentions a case (159) of fistula, treated by Rey- 
bard’s forceps or clamp. The patient was three and a half 
months pregnant, and aborted the night following the op- 
eration (the clamp being removed at that time). The 
continued presence of an instrument in the vagina, irrita- 
ting the vagina and cervix, may have affected the result. 
Pregnancy was unsuspected. 
Here we have five cases operated upon: two in the sec- 
ond month, two in the third, and one in the fourth. Two 
aborted; in two there was no union; the rest succeeded, 
but in two cases after a severe hemorrhage. Hemorrhage 
more or less severe, once nearly fatal, is mentioned in four 
of the cases. Such results are not very favorable, and 
would hardly induce any one to perform the operation dur- 
ing pregnancy, except from the most pressing necessity. 
Hemorrhage from operations on the vagina is just what 
we might expect. The extreme vascularity of the vagina 
during pregnancy, giving rise to a peculiar bluish color, has 
often been noticed, and is laid down in the books as one of 
the cardinal signs of pregnancy. It stands for the red flag 
of danger. 
RECTUM. 
Operations on the rectum seem to be somewhat dan- 
gerous. 
(104) converted a recto-vaginal fistula into an 22 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
ano-perineal fistula in a woman three months pregnant. 
No bad results followed, and the patient was delivered at 
term. 
Dr. Engelmann is the only one, as far as I can learn, who 
has boldly advocated operating on a fistula during preg- 
nancy. His case was a large, transverse recto-vaginal fis- 
tula, which had previously been operated upon by Dr. 
Greiner, of St. Louis. As the doctor wished Dr. Engel- 
mann’s assistance in the second operation, and as he was 
about to leave town for a long stay, he advised operating 
at once, although the woman was between five and six 
months advanced. “ The operation was successful, healed 
kindly, and was not ruptured in the following delivery, 
which occurred at term. The patient was a strong, healthy 
woman, and has remained well since.” 
Compare this with a case by Dr. Cazin, in which he per- 
formed forcible dilatation of the sphincter ani, for fissure of 
the anus, in a young girl, and where abortion followed 
quickly, she being in the early stages of pregnancy. A 
similar case is reported by M. Rey. That abortion does 
not always follow this operation we learn from a case of Dr. 
Gayet (102), where he dilated, not only with the fingers, 
but with the speculum. The woman was five months preg- 
nant, went to term, and was delivered of a healthy child. 
Cohnstein relates two cases : one seen by Mauriceau, and 
the other done by Richet. In Mauriceau’s case, the opera- 
tion for fistula in ano in the eighth month was made, and 
Richet cut a stricture of the rectum in the third month. 
In each case the ovum was expelled, and in the first the 
death of the mother followed. Massot thinks a dose of 
croton oil given after the operation might be held ac- 
countable for the result in Richet’s case. 
Why there should be such a tendency to abortion in these 
cases is hard to say, but the facts gathered here should put 
us on our guard against interference with the lower part of 
the rectum during pregnancy, especially during the early 
months. MATTHEW D. MANN. 
23 
BLADDER. 
The operations on the bladder of which I find reports 
are not very numerous. Dr. Goodell has used forcible dila- 
tation to relieve irritability of the neck of the bladder a 
number of times without any harm resulting. Dr. Byford 
successfully resorted to the same procedure for the re- 
moval of a Hodge pessary (open lever?). Dr. Tremain, 
U. S. A., tells me that he has removed a urethral caruncle 
in a pregnant woman without any trouble following. 
An operation which might be called for at this time is 
that for stone. This would be demanded not only for relief 
of the symptoms, but because its presence might prove an 
obstruction to labor. If small, experience shows that it 
could be removed by way of the urethra; but if too big to 
pass easily by this channel, crushing would seem to be the 
best way of getting rid of it. 
McClintock and Phillippe have extracted stones through 
the urethra in cases respectively at the fourth and seventh 
months of pregnancy. In neither case were there any bad 
results. Thomas performed lithotomy on a woman twenty- 
seven years old, in the fourth month. She went to term. 
The stone in this case was very large. The woman recov- 
ered perfectly, but was delivered of a dead child. This 
could scarcely have been the effect of the operation. 
Massot finds reported three cases of stone extracted 
through the urethra during pregnancy without any bad re- 
sults ; one was five, one six, and the other seven months 
advanced. Dr. Reamy writes that he has removed, by cys- 
totomy, in a woman six and a half months pregnant, a 
double hair-pin. It was incrusted, and resisted efforts at 
extraction per urethram. The incision was left open, and 
healed spontaneously in a very short time. The woman 
went to term without any trouble. Massot refers to a case 
where cystotomy was done by Verneuil in the third month 
of pregnancy with perfect success. Indications not given. 
The dangers of labor with a stone in the bladder are so 
great that, encouraged by these results, we should certainly 
operate in every case. 24 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
Thus far we have considered only what might be called 
the accessory organs. The main organ, that which contains 
the growing ovum, is the one which we should a priori 
be the least inclined to touch. It is the one, however, 
which has been most subjected to operative proceedings. 
In this connection I shall treat, not only of the severe op- 
erations, but of the minor as well ; for, although of very 
little importance under ordinary circumstances, they may 
be of great moment if done during the pregnant condition. 
Applications to the Cervix. I have received two commu- 
nications on this subject from the same city, but con- 
taining such diametrically opposite views that, coming as 
they do from men high in the ranks of the profession, I 
must present them to the reader side by side. 
Dr. H. P. C. Wilson, of Baltimore, writes: — 
The most remarkable surgical operation on the neck of the 
uterus which I have,performed was in the case of a woman about 
forty years of age, mother of eight living children, and several 
miscarriages. In her last pregnancy she began bleeding from the 
uterus with the advent of pregnancy, and bled so profusely all 
the time that, although she was in the hands of two of our best 
physicians, nothing could be done to arrest it. At six months 
I was called in to bring on an abortion to save her life. She 
was so feeble and bloodless that I refused to produce an abortion 
then, hoping to carry her to term. At seven months I was forced 
to bring on the abortion to save her life. I did not see her again 
until last October, when she came to me, stating that she was 
again pregnant, and wished for an abortion. I refused to operate, 
and began mopping out the cervical canal with chromic acid, 
Monsel’s solution, and glycerine, and Churchill’s solution of io- 
dine, using one application at one time, and another the next. I 
passed my mop carefully just within the internal os. In two months 
the erosion and varicose condition of the vessels in the cervical 
canal was cured. The woman has had no bleeding since, is well, 
and going on naturally to term. I have seen no such case before. 
We were at a loss to know, in the first instance, where the blood 
was from, but after I produced the abortion I was certain that 
UTERUS. MATTHEW D. MANN. 
25 
it came from the cervix and cervical canal; and I then stated to 
the gentleman with whom I was in consultation that if she be- 
came pregnant again I would treat her just as I have now de- 
scribed. 
This is certainly a very striking case, but audi alteram 
partem. 
Dr. W. T. Howard writes : — 
In treating the so-called granular erosion about the cervix dur- 
ing pregnancy, in my earlier gynecological practice, in applying 
carbolic acid, Churchill’s tincture of iodine, etc., I have had 
some three or four cases to cast off the product of conception. 
I am so entirely satisfied that the abortion was caused by the 
applications that I now never use them under such circumstances. 
In my lectures I always warn students never to apply caustics 
to the cervix in pregnancy, so strong are my convictions of the 
great danger of producing abortions, notwithstanding the recom- 
mendation of high authorities to use them for the purpose of re- 
lieving nausea and vomiting. 
Dr. Howard cites two cases recently observed in his 
practice, in one of which abortion was evidently induced 
by tincture of iodine applied by another physician to relieve 
a condition resembling, only less severe, the case described 
by Dr. Wilson. In the other, the uterus was apparently 
induced to throw off a dead ovum, retained more than three 
months, by a free application of carbolic acid to the eroded 
cervix. 
Dr. M. O. Jones, of Chicago, has advocated the applica- 
tion of nitrate of silver to the cervix for the treatment of 
vomiting during pregnancy. He uses the solid stick, and 
cauterizes the whole vaginal portion of the cervix, not to 
cure an abrasion, but as a sort of derivative. He reports 
five cases, all cures. 
Dr. Sims gives his approval to this method, and says that 
it has relieved a number of cases in his hands. It is, I am 
informed, the standard treatment to-day in the wards of 
Professor C. Braun, of Vienna. It is in use by many practi- 
tioners. Lusk advises a ten per cent, solution to be brushed 
on the cervix, and makes no mention of any danger of pro- 
ducing an abortion. 26 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
My own experience is confined to a few cases. In one I 
applied pure carbolic acid to the cervix, and just within the 
external os, in the second month, and this was followed by 
the expulsion of the ovum. In several cases I have used 
a strong solution of nitrate of silver without bad results. 
If we seek an explanation of the differences in the expe- 
riences of various authorities mentioned, may we not find 
it in the character of the materials applied ? Carbolic acid 
and iodine are highly diffusible substances, as well as vio- 
lent poisons to all forms of life, especially the lower. If we 
consider the fetus, in its earlier stages, as belonging to the 
lower forms, and take into consideration the rapidity with 
which the agents named are absorbed, especially by denuded 
or abraded surfaces, we can easily see how continued doses 
of such a poison as carbolic acid, or one large dose, may, 
by killing the fetus, cause an expulsion of the ovum. Dr. 
Howard mentions as his principal agent, iodine and carbolic 
acid. Dr. Jones uses nitrate of silver, a substance which 
is not particularly poisonous, and which by its peculiarity 
of forming insoluble compounds with albuminous bodies is 
absorbed very slowly, or not at all. But even this latter 
agent may, and perhaps has, produced abortions. In these 
cases we must suppose that the result was accomplished by 
irritating the nerves, and thus exciting uterine action in an 
organ peculiarly susceptible. To be sure, Dr. Wilson’s 
case is against this theory, but then it must be taken as an 
exception which proves the rule. 
We may class all caustics which, like nitrate of silver, 
produce only local effects in the same category. If we 
do, we get an additional argument from the researches of 
Courty. Speaking of the treatment of granular condition 
of the cervix, he says, “ An indication for the actual cau- 
tery exists in every case of granular cervix. It exists 
exceptionally in pregnancy, for formidable accidents, such 
as uncontrollable vomiting, appear to be caused or kept up 
by the granular condition. I have long ago demonstrated, 
not only the harmlessness and usefulness of cauterization 
of the cervix with the red-hot iron during pregnancy, but MATTHEW D. MANN. 
27 
also the accomplishment of normal parturition in these 
cases after the use of the cautery.” Cohnstein gives as 
his experience that nitrate of silver is harmless, and con- 
siders the potential cautery as without danger, but quotes a 
case from Broca, where the second application of the hot 
iron brought on an abortion, with fatal peritonitis. 
There are two other methods of treatment applied to the 
cervix during pregnancy which demand notice. Although 
not now so much the fashion to apply leeches as it was 
formerly, still it is practiced to a certain extent, and it is 
recommended as a preventive of abortion. Tilt speaks 
of it, and says : — 
“ Leeches may be very useful in preventing abortion, when it 
has been repeatedly caused by a severe inflammatory condition 
of the neck of the womb, with distended varicose veins. Under 
such circumstances it is well to apply from four to six leeches to 
the womb, at two or three successive menstrual periods. By so 
doing I have repeatedly conducted pregnancy to its full term 
in women who had previously always miscarried.” 
He quotes Whitehead as abundantly illustrating the 
utility of this plan. Dr. J. Henry Bennet is also strongly in 
favor of this plan. Tilt mentions one or two cases where 
abortion followed, but seems to doubt the causative effect 
of the leeching, except in one case, where the leeches got 
into the canal. 
Among the methods which have been brought forward 
for relieving that most distressing complaint, the vomit- 
ing of pregnancy, that suggested by the late Dr. E. Cope- 
man, of England, for a time, at least, attracted much atten- 
tion. It consists in dilating the external os and canal with 
the finger carried in as far as the first joint, care being taken 
to avoid going far enough to disturb the integrity of the os 
internum. Its author considered the method as infallible, 
and published some striking cases in support of his views. 
Others reported successful cases, but abortions following 
its employment were also reported. Dr. J. Marion Sims met 
with an abortion, but thinks the result came from the wom- 
an having the habit of aborting, she having had two mis- 
carriages previously. 28 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
With neither of these last two procedures have I had 
any experience. The treatment of abrasions of the cervix 
with solutions of nitrate of silver is now so well understood 
and so frequently practiced that'it may be considered as a 
settled and legitimate therapeutic measure. Most of those 
who advocate it, however, deem it necessary to put in a 
word of caution; nevertheless, I have been unable to find 
a single recorded case where abortion was unquestionably 
due to this treatment. The application of leeches and of 
the actual cautery, while they seem not to be dangerous in 
the hands of their advocates, and may, to a certain extent, 
be beneficial, are seldom demanded in practice. 
Copeman’s method is one which requires so much skill 
and judgment for its application that it can never be safe 
in the hands of the general practitioner, and will not come 
into the general use which the enthusiasm of its originator 
predicted. ' 
Trachelorrhaphy. — One of the most interesting facts in 
this connection is that Emmet’s operation for lacerated 
cervix may be performed during pregnancy without neces- 
sarily interfering with the integrity of the ovum. The first 
case, which came to my notice, was in my own practice. 
Mrs. E., multipara, applied for relief at the New York Dis- 
pensary, November 9, 1877. She was very weak, suffering 
so severely as to be scarcely able to walk into the consult- 
ing-room. She stated that her last menstruation was on 
September 20th. On examination I found the cervix 
exquisitely tender, so much so as to make an examination 
very painful. The whole cervix was red and denuded, 
and the seat of a deep bilateral laceration. No satis- 
factory examination of the body of the uterus could be 
made, except enough to notice that it was nearly in posi- 
tion and a little enlarged. I explained to her the neces- 
sity of an operation for her permanent relief. A month 
was spent in making arrangements and in preparatory 
treatment, during which time I made no digital examina- 
tion. December 10th I operated, Dr. Munde assisting. 
The condition of the cervix was greatly improved, but it MATTHEW D. MANN. 
29 
was still tender and somewhat denuded. I noticed that 
the tissues were very soft, and that the hemorrhage was 
greater than usual. Five sutures were introduced, and dur- 
ing the time that they were in there was a profuse puru- 
lent discharge from the vagina, such as I have never before 
or since seen to follow this operation. Union was com- 
plete, and the relief of the symptoms perfect. March 8th 
she returned to say she was not well, and upon examination 
I found an ulcer on one side of the cervix, round and deep. 
This I considered to be chancroidal, as her husband had 
contracted a chancroid on his glans penis while his wife was 
in the hospital. This yielded to treatment, and I saw no 
more of her until the summer, when she came in to say that 
she had recently given birth to twins. I saw them: they 
were well-developed children. The cervix was not torn, 
and only showed a depression on the side where the chan- 
croid had been. 
The next case which I met with was in the practice 
of Dr. Munde. While attending Dr. Munde s patients at 
the Woman’s Hospital, out-department, for him, during 
his absence, I saw Mrs. S., aged thirty, having one child. 
As the uterus was plainly to be felt in the posterior vaginal 
pouch, I made the diagnosis of retroversion. Dr. Munde 
examined her a few weeks after, and diagnosed probable 
pregnancy, merely from softness of the cervix and slight 
enlargement of the uterus. There was a bad bilateral lacer- 
ation of the cervix. As the uterus did not seem to grow, 
the idea of pregnancy was given up, and Dr. Munde oper- 
ated upon the cervix during July, 1878. Menstruation had 
been very irregular for some time, and there were no ra- 
tional signs of pregnancy. The operation was successful, 
and the stitches were removed, leaving a virgin cervix. 
Twelve or fourteen days afterward, as Dr. Munde was again 
absent, I was called to attend the woman, and delivered her 
of a three months’ fetus, which had evidently been dead for 
some time. The cervix was again torn by the passage of 
the child. The woman made a good recovery. Dr. T. A. 
Emmet operated for a double laceration during the second 30 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
month, pregnancy unsuspected. She made a good recov- 
ery, went to full term, and had no trouble afterward. 
Dr. Reamy also sends notes of a case as follows: — 
Mrs. J. B., aged thirty-four ; married six years ; mother of two 
children, eldest three years, youngest nine months. During her 
first confinement, which was tedious, and the delivery instrumental, 
she suffered a severe left lateral laceration of the cervix. Before 
the second pregnancy occurred, she was placed in my charge. As 
she was suffering from most of the symptoms which usually fol- 
low such conditions of the cervix, I urged an operation. Her 
husband would not consent. I was surprised to hear of her preg- 
nancy, as the local conditions rendered it improbable. I attended 
her at confinement. Labor quick and easy, but she remained in 
poor health, was anemic, and suffered from exhaustive leucorrhea. 
I saw her again July io, 1880. Examination showed erosion 
of the posterior lip, considerable hypertrophy, ;jnd marked indu- 
ration, especially at the bottom of the laceration, where there 
was a large cicatricial plug. The laceration was quite extensive, 
and the erosion more especially of the posterior lip, which bled 
at the slightest touch. I feared approaching malignancy. An 
operation was again urged, and cheerfully agreed to. She had 
not menstruated since her last confinement. There were no signs 
of pregnancy, and it was scarcely considered. I operated Au- 
gust 3d, and found the bleeding more profuse than usual. Four 
silver sutures were introduced. Result was perfect. The pa- 
tient’s health improved rapidly, and soon fetal movements were 
unmistakable. I delivered her of a perfectly developed child, 
weighing eight pounds, March 18, 1881. Labor natural and 
easy. The os dilated promptly and safely, and was not torn at 
all. Labor terminated in three hours after the first pains. The 
patient must have been in the second month of pregnancy at the 
time of the operation. 
Dr. Goodell says that he performed the operation for a 
lacerated cervix, unwittingly, on a pregnant woman, who 
had apparently menstruated a week before ; but six days 
after the operation, a six weeks’ ovum forced its way through 
and tore open the wound. 
These, with Dr. Shepherd’s case, already reported, make 
a total of six cases in which the operation was done. In MATTHEW D. MANN. 
31 
four the results were perfect in every way, while the other 
two aborted and tore open the freshly united wound. In 
my own case, I am sure the sound was not passed, as I for- 
got to take the instrument with me. It is, I believe, the 
general custom to pass the sound both before and after the 
operation, so that it is altogether probable that, in the cases 
which aborted, the abortion was due to this cause. Dr. 
Shepherd says that it was twice done, but, curiously enough, 
no abortion followed. 
These cases are of great interest, in that they show what 
treatment a pregnant uterus will stand without being ex- 
cited to contraction, provided the interference is confined 
to the cervix. The only practical deduction which we may 
make is that if we find a case of “ habitual abortion,” 
where the habit evidently depends upon a torn cervix, and 
where the woman is already pregnant, we may still hope to 
save the ovum by a careful performance of this operation. 
The operations were all done in the early months of preg- 
nancy, and, as in the operation on the perineum, union oc- 
curred in every case. 
Polypi of the Cervix. — Small mucous polypi of the cer- 
vix may be twisted or snipped off during pregnancy, and 
the bleeding points touched with an astringent. Dr. H. P. 
C. Wilson mentions having done this frequently, and other 
cases are reported, especially one by Tanner. But this op- 
eration, slight as it is, is not devoid of danger. Dr. Lusk 
met with a case where he snipped off a polypus not larger 
than a good-sized pea, which protruded from the cervix and 
caused profuse leucorrhea. The patient was two and one 
half months advanced in pregnancy. She was seized with 
pains on leaving the doctor’s office, and aborted a few hours 
afterward. 
As showing how these cases can be safely treated, it 
may be interesting in this connection to mention a case 
reported by Dr. Horace Williams. A small polypus of 
the cervix was discovered in the third month of preg- 
nancy. It gave rise to some hemorrhage. The doctor 
asked the opinion of the Philadelphia Obstetrical Society 32 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
as to its removal. The verdict was unfavorable, so he 
treated it with a strong application of tannin, after which 
the hemorrhage ceased, and, two months later, no traces of 
the polypus could be seen. 
Large Polypi, which may be mucous, but which are more 
generally fibroid in character, present a more complicated 
problem for solution. That these tumors may cause very 
serious trouble during pregnancy and labor cannot be 
doubted. Under the influence of the increased nutritive 
energies which involve the parent organ at this time they 
often increase very rapidly. During pregnancy, the prin- 
cipal symptom which is indicative of their presence is hem- 
orrhage. The flow may be continuous or periodic, and to 
this cause may be attributed many of those curious cases 
of menstruation during pregnancy. If they do not cause 
any trouble beforehand in labor, they may present an actual 
obstacle to the passage of the child, or, on being torn off, 
may cause a considerable hemorrhage of an obstinate char- 
acter. Again, the extreme and long-continued pressure to 
which they are subjected may cause their death, with break- 
ing down of the tissues, fetid discharges, absorption, and 
septicemia. 
It becomes, then, our duty, in every case in which such a 
tumor is discovered during pregnancy, to decide at once as 
to its removal. We have to balance on the one hand the 
danger which we may encounter if we remove it, and on the 
other, the risks of leaving it. Besides the danger to be 
anticipated in child-bed, the presence of the tumor, either 
by causing severe hemorrhages or by its mechanical ac- 
tion, may bring on an abortion. On the other hand, inter- 
ference may provoke abortion, either directly, or by the 
high temperature following the absorption of septic mate- 
rial from the large suppurating surface likely to be left. 
This latter danger depends upon the size of its attachments, 
while the danger of direct abortion depends rather upon 
their seat. Let us see what have been the results thus far 
obtained. 
Dr. Lusk reports having removed a polypus as large as MATTHEW D. MANN. 
33 
an egg from the cervix of a woman seven months advanced, 
with good results. A periodic flow which had lasted 
throughout pregnancy ceased after the operation. Dr. 
Jenks writes that he has met with one case. “It was a cel- 
lular polypus, about three inches in length. The woman 
was in the fourth month of pregnancy, and had been com- 
plaining of frequent floodings of late. I found the polypus 
protruding beyond the os internum, and apparently at- 
tached above it, quite a distance. I passed a wire 
around it up to the os internum, and removed it without 
interfering with pregnancy, as she went to full term.” 
Cohnstein has collected fourteen cases. The results were 
as follows : In two cases, in which the tumor was cut off 
with scissors, abortion followed at once in one ; the other 
went to full term. Torsion was used three times without 
abortion. The other nine cases were operated upon by the 
ligature, and Cohnstein remarks that the results show that 
in the first three months the operation may not only lead 
to abortion, but “ that fatal peritonitis follows with rela- 
tive frequency. In the later months the results are favor- 
able both to mother and child.” Unfortunately, he gives 
no figures for these nine cases. We are thus compelled to 
throw them out, and we may do so the more readily be- 
cause they were operated by a method now nearly obsolete. 
Massot refers to a case (180) by Aston Key, where a 
tumor as large as a small apple was removed by ligature. 
It separated with the tumor on the second day. The pa- 
tient was imprudent, and got up the next day, when pains 
came on, and abortion followed. Metro-peritonitis set in, 
and she died on the fourth day after the miscarriage. 
West (i81) excised a fibrous polypus, as large as a hen’s 
egg, from the anterior lip. The patient was pregnant, 
made a good recovery, and, six months afterward, was deliv- 
ered at term. There was some hemorrhage. 
We then have nine cases from which to draw conclu- 
sions. Of these nine, six were successful. Three of them 
were in the third month, one in the fourth, and one in the 
seventh. One of those in the third month miscarried, 34 
SURGICAL OFERA TIONS ON PREGNANT WOMEN. 
Demarquay and Saint-Vel, in writing of fibroids in preg- 
nancy, say there should be certain favorable conditions, 
one of which is that the tumor should be pediculated and 
prominent in the vagina (compare Dr. Jenks’s case), and 
also that it promises to be, later, a cause of dystocia. They 
prefer the and add : “ The excision of the polypus 
is the only operation which we ought to take into consider- 
ation in cases of metrorrhagia. Besides being radical, it 
proves less likely to provoke abortion than the tamponade. 
In the majority of recorded observations of ligature and 
excision of polypi of the neck, pregnancy has not been in- 
terrupted ; but since such results have obtained, interven- 
tion ought to be only from necessity.” As to when the ne- 
cessity arises, the condition of each case must determine. 
They refer to two cases where large fibroids of the neck 
were enucleated during pregnancy. One was by Danyau, 
in the sixth month. The tumor filled the whole pelvis, and 
had its seat in the posterior lip. Child dead, and extracted 
by version ; recovery. The other was by Braxton Hicks : a 
multipara, in labor twelve hours. Large tumor filling the 
posterior part of the pelvis, situated in the posterior lip of 
the womb. Enucleation without any hemorrhage ; child 
and mother living. I am unable to present any more cases, 
but from the few here given it may be seen that, in a case 
demanding interference, on account of either hemorrhage 
or threatened abortion, the removal of the polypus will 
offer a fair chance of relief without danger to the child. 
Whether every case should be operated upon at once on 
its discovery, as a precaution against possible danger, we 
have not the means of deciding. I should give it as my 
opinion that it would be better to wait, under such circum- 
stances, until later in the pregnancy, but to operate before 
labor set in. The method of operating which we should 
choose would be by the galvano-cautery wire. 
Cancer of the Cervix. — The questions which interest us 
in regard to this unfortunate complication of pregnancy 
are: Should an operation be undertaken in the earlier 
months, for the removal of the growth ? What are the MATTHEW D. MANN. 
35 
chances for the mother and child in case an operation is 
done ? What will be the result if it is left alone ? The 
only form of uterine cancer which is liable to exist during 
pregnancy is that which affects the cervix. In a majority 
of instances the growth of the ovum is not interfered with. 
Nor is this so unfortunate as might at first seem, for it has 
been found that an abortion does not much help matters, 
and that the mother’s life is not greatly prolonged by it. 
The dangers of abortion are also very great. The treatment, 
then, resolves itself into the question, Shall we remove the 
growth in the early stages, or let the pregnancy and the tumor 
go on together ? If pregnancy goes on, it may result in the 
death of both mother and child, and is quite likely to be 
fatal to the former. The increase in the nutritive energies 
of the uterus is generally shared by the tumor (exception- 
ally it remains quiescent), and it may grow to such a size 
in a short time as to render the passage of the child im- 
possible. In such a case we are compelled to resort to 
Caesarean section, in the interests of the child, the mother’s 
chance for life, under any circumstances, being so small as 
to be practically of no account. If not an absolute hin- 
drance to labor, it still may cause severe hemorrhage, and 
induce other complications, which may result in the loss of 
both lives. Thus there is every inducement to early opera- 
tion, if this can be done with a fair chance of success. That 
this can be done without especial danger, and that such 
practice is good and justifiable, the following cases seem to 
show. 
Dr. C. Godson reports a case in which he removed a 
large cauliflower excrescence in the sixth month, with the 
The patient, a multipara, went to term, and was 
delivered of a living child. Two years later she was again 
confined. A dead child was extracted by version, but the 
patient died, thirteen days after, of exhaustion. 
Dr. Munde adds two cases to the list: — ' 
Case I. — Mrs. H., aged thirty-four, three children. When 
seen (1875) she had been flowing for six months. An examina- 
tion revealed a large cauliflower growth (epithelioma) of the 36 
SURGICAL OPERATIONS ON PREGNANT WOMEN. 
cervix. The hemorrhage was so profuse on examination that 
the vagina was immediately tamponed. No bimanual examina- 
tion was made, on account of the flow. The mass was amputated 
in two slices by the galvano-cautery wire ; time, twelve minutes. 
There was no hemorrhage at the time of the operation. On the 
night of the sixth day after the operation violent pains set in, 
with hemorrhage, and were followed by the expulsion of a two to 
three months’ fetus. The placenta was retained, and had to be 
removed by the curette. The patient made a good recovery from 
the operation and the abortion. Pregnancy was not suspected. 
Case II. — Mrs. D., aged forty-one, ten children and four 
abortions. Had been flowing for three or four months. Flow 
never profuse. Her general health was good. A vaginal exami- 
nation showed a soft, very pulpy mass, the size of a large lemon, 
attached to the posterior lip of the cervix. The anterior lip was 
healthy. No bimanual examination was made, as the diagnosis 
of epithelioma was clear, as also the possibility of removing it 
entirely, at least macroscopically. Pregnancy was not suspected. 
April 12, 1882, the mass was removed by the galvano-cautery 
wire, close to the posterior vaginal cul-de-sac. Time occupied in 
the removal, seven minutes. No hemorrhage. The vagina and 
cervix looked blue, which was attributed to the presence of the 
tumor. The patient made a good recovery from the operation. 
She was examined again on several occasions by the speculum. 
The last time was June 25th, when the exceedingly blue color 
of the labia was again noticed. A bimanual examination then 
revealed the head by ballotment, and the fundus reached nearly 
to the umbilicus. The motion of the child had been perceptible 
to the patient for some three weeks. She was evidently five to 
six months pregnant, and consequently must have been in the 
third month at the time of the operation. The growth had not 
reappeared. 
Cohnstein has collected four instances where amputation 
of cancer of the cervix was performed in the earlier months, 
and in only one did an abortion follow. 
Thus we have seven cases, with two abortions, but recov- 
ery from the abortion in each case. In no instance was the 
return of the growth, before the confinement, noticed. This 
is certainly a very encouraging showing, but unfortunately 
this method of treatment is applicable to but few cases, MATTHEW D. MANN. 
37 
from the fact that the tumor is not apt to be discovered in 
time. It should lead us, however, in multipart no longer 
very young, to make an examination during pregnancy 
even for a slight hemorrhage or a persistent discharge, 
even though the discharge be not offensive. I have now 
given every case of operation on the pelvic organs during 
pregnancy, records of which I have been able to obtain. 
Having no preconceived ideas, no opinions to sustain, I 
have tried to draw my conclusions in as fair a spirit as pos- 
sible, and in formulating them shall give only those points 
which seem to be justified by the facts. The conclusions 
to which I have come may not seem to others to be the 
correct ones ; but be this as it may, the facts are here, and 
each one may judge for himself. In looking over the cases, 
the reader must have been struck by the number of times 
that pregnancy was overlooked. This was doubtless some- 
times due to carelessness, sometimes to the entire absence 
of all symptoms pointing to the existence of a fetus in 
utero, and sometimes to the impossibility of detecting preg- 
nancy in its earlier stages. 
In adding up the cases for the purpose of taking a gen- 
eral percentage, for the sake of making some comparisons, 
I have omitted all cases which could not be strictly called 
operative. Where it is stated that such and such an opera- 
tion was done several times, I have translated “ several 
times ” as twice. In this way I count a total of ninety 
cases. 
If will be observed that in twenty cases (22.2 per cent.) 
abortion followed the operation, and that four patients died. 
These results are better than those arrived at by Cohnstein 
(45-5 Per cent, of abortion), where all sorts of operations 
and injuries were included, and compared favorably with 
Massot’s statistics, — one hundred and thirty-one opera- 
tions of all kinds, with forty abortions (30.2 per cent.). 
But it would be hardly fair, therefore, to conclude that 
operations on the pelvic organs give a more favorable 
result during pregnancy than operations upon other parts 
of the body. 38 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
Nature of Operation. 
Number. 
Abortions. 
Deaths. 
Venereal warts of the vulva . 
19 
3 
Venereal warts of the vagina 
3 
- 
Elephantiasis of the vulva 
2 
- 
- 
Sarcoma of the vulva .... 
1 
- 
- 
Lipoma of the vulva .... 
1 
- 
- 
Cyst of the vulva 
1 
- 
— 
Abscess of the vulvo-vaginal gland 
5 
1 
I 
Unruptured hymen .... 
1 
-■ 
- 
Polypus of the vagina .... 
4 
1 
I 
Cyst of the vagina .... 
1 
- 
- 
Abscess of the vagina 
1 
- 
- 
Stenosis of the vagina 
1 
- 
- 
Anterior elytrorrhaphy . 
1 
- 
- 
Vesico-vaginal fistula 
5 
2 
- 
Urethral caruncle . 
1 
- 
- 
Dilatation of urethra for stone, etc. 
5 
- 
- 
Cystotomy 
2 
- 
- 
Recto-vaginal fistula 
2 
- 
- 
Stricture of the rectum . 
1 
1 
- 
Fissure of anus 
3 
2 
- 
Fistula in ano .... 
1 
1 
I 
Ruptured perineum .... 
7 
1 
- 
Polypus of cervix (small) 
3 
1 
- 
Polypus of cervix (large) 
7 
3 
I 
Lacerated cervix 
6 
2 
Cancer of cervix 
6 
2 
90 
20 
4 
The number of abortions is certainly very small; strik- 
ingly so if we throw out operations on the rectum, and 
cases where the bad result might be properly attributed to 
causes outside the operation itself. It is really astonishing 
to find that such operations as those for torn cervix and 
perineum, or for the removal of large polypi and cancerous 
growths of the cervix, have such a small per cent, of abor- 
tions. If we examine carefully all cases where abortions 
occurred, we should find that many of them were not di- 
rectly due to the operations. 
Tiie history of the three cases where abortion followed 
the removal of venereal warts from the vulva are too short 
to allow of any study. The case where abortion and death 
followed the opening of an abscess of the vulva will be 
referred to when considering the deaths. The death fol- MATTHEW D. MANN. 
39 
lowing the amputation of a vaginal polypus was not pre- 
ceded by an abortion, but followed labor at term. The 
abortion, after a similar operation, lies open to the suspicion 
of having been caused by the passage of the uterine sound. 
The same is true of the two cases of lacerated cervix, 
and one of ruptured perineum. One of the cases of vesico- 
vaginal fistula was operated upon by a clamp, which was 
left in the vagina, and to this, in part at least, the occur- 
rence of the abortion may be attributed. 
Four abortions follow five operations on the rectum. 
The abortion following the excision of a small polypus of 
the cervix must be attributed to the excessive sensibility 
of the uterus in this case. Thus more than half of the 
abortions might perhaps have been avoided, had the opera- 
tors refrained from operating on the rectum, and had they 
in other cases been cognizant of the condition of their pa- 
tients. The remaining cases (a little more than io per 
cent.) must be set down against the operations; but this is 
a very small proportion, and one which should not cause us 
much anxiety in case we are called upon to operate during 
pregnancy. It is generally supposed that severe hemor- 
rhage predisposes to abortion. This, however, is not borne 
out by the authorities who have studied the subject, and by 
the histories of these cases. Where the hemorrhage was 
freest, as for instance in one of Dr. Campbell’s cases, there 
did not seem to be any tendency to abort. Massot comes 
to this conclusion from the study of a number of uncom- 
plicated hemorrhages, and quotes with approval the conclu- 
sion of M. Brume, who says : “ The efficacy of hemorrhage 
as a cause of abortion cannot be admitted without more 
proof.” 
The number of fatal cases is hardly larger than would 
have been probable in a like number of similar operations 
on non-pregnant women, and is probably less than would 
have occurred among these same women had no operation 
been performed upon them at all. One death followed the 
opening of a vulvar cyst, but could be fairly attributed to 
the coincident rupture of a cyst in the tube of the ovary. 40 
SURGICAL OPERA TIONS ON PREGNANT WOMEN 
In Key’s case, death from metro-peritonitis followed an 
abortion, but the latter was apparently due to carelessness 
on the part of the patient. Nicaise’s case is without de- 
tails ; while the fatal result in the case reported by Massot 
did not occur until labor came on at term. A polypus of 
the vagina was removed by ligature early in the ninth 
month, and the resulting ulcer may have had something to 
do with causing the fatal septicemia. 
In all the plastic operations, union by first intention oc- 
curred even when a previous operation had failed. Of the 
case in which the period of pregnancy is stated, there were 
thirteen before the third month, twenty-six in the third, 
seven in the fourth, six each in the fifth, sixth, and seventh 
months, and one each in the eighth and ninth months. 
More than half the operations, then, were performed in the 
first four months, the time when abortions are supposed to 
occur most easily, — a supposition which is supported by 
the facts; for all the abortions of which the date is given 
occurred on or before the third month, except two; one of 
these was in the sixth month, the other in the eighth. 
If now we sum up our conclusions in the form of propo- 
sitions, we may say : — 
1. Pregnancy is not so decidedly a bar to operations on 
the pelvic organs as is generally supposed. The results, 
however, vary with the operation and the organ operated 
upon. 
2. Union of denuded surfaces is the rule, and the cica- 
tricial tissue formed during the earlier months of pregnancy 
is strong enough to resist the shock of labor at term. 
3. Operations on the vulva involve very little danger 
either to mother or child. 
4. Operations on the vagina are likely to cause severe 
hemorrhages, but are not otherwise dangerous. 
5. Venereal warts and vegetations of large size and non- 
syphilitic are best treated by removal, whether they occur 
in the vagina or are confined to the vulva. 
6. Applications of nitrate of silver and astringents of 
this class may be made with safety to the vagina and cervix. MATTHEW D. MANN. 
41 
Diffusible poisons, like carbolic acid and iodine, should not 
be used pure or in strong solutions for such applications. 
7. Operations upon the bladder and urethra are not dan- 
gerous, or likely to be followed by abortion. 
8. Operations on the rectum involving the sphincter ani, 
even if slight in their character, are dangerous. 
9. The operation for vesico-vaginal fistula should not be 
undertaken during pregnancy, as the dangers of hemor- 
rhage and abortion are considerable. 
10. Plastic operations on the cervix and perineum may, 
if necessary, be undertaken in the earlier months of preg- 
nancy with a fair prospect of success, and with a good 
chance that the results may not be impaired by labor. 
11. Small polypi of the cervix may best be treated by 
torsion or strong astringents. If cut, there is some danger 
of abortion following. 
12. Large polypi may, if causing hemorrhage, be re- 
moved at once, with a fair chance of good results. If not 
doing any harm, then removal is best left until near the 
close of pregnancy. 
13. Cancer of the cervix discovered during pregnancy 
should, if possible, be removed at once. 
Note. — As a great deal more material is necessary in order to de- 
cide whether these conclusions are correct, it is earnestly requested 
that those having notes of cases bearing on the points discussed in 
this paper will send them to the author. 
LITERATURE. 
Priestley. — Obstet. Jl., Gt. B. and I., vol. iii., p. 48. 
Cohnstein — Ueb. chirurg. Operat. bei Schwang. 
Volkmann’s klin. Vortrag. No. 59. 1873. 
Massot — De l’influence des traumatismes sur la grossesse. 
Paris, 1873. 
Verneuil — Gazette med. de Paris, p. 262, 1876; also in Massot. 
Verneuil — Gazette med. de Paris, March 18, 1876. 
Nicaise — Gazette med. de Paris, March 18, 1876. 
Tillaux — Gazette mdd. de Paris, March 18, 1876. 
Nott — Am. Jl. Obstet., vol. ii. p. 637. 
Hildebrandt — Billroth, Handbuch d. Frauenkr., 8te Abschn., 
pp. 48 et seq. 42 
SURGICAL OPERATIONS ON PREGNANT WOMEN 
P. Smith — Lancet, Oct. 22, 1871. 
Herzfeld — Wien. med. Pres., 1868, No. 34. 
In Am. Jl. Obstet., vol. ii. p. 134. 
Schlesinger— Centralblt. f. Gyn., No. 25, 1882, p. 398. 
Cazin — Gaz. med. de P., 1876, p. 285. 
Rey—Gaz. med. de P., 1878, p. 480. 
Thomas — Lancet, vol. i., No. 2, 1839. 
M. O. Jones — Lancet, May, 1878, p. 216. Notes by Dr. Sims. 
Courty — Traite prat, des mal. de l’uterus, 12th ed., p. 773. 
Tilt — Uterine Therapeutics, N. Y., 1864, p. 45. 
Copeman — Brit. Med. Jl., 171. 
Sims — Archives of Med., vol. iii., p. 269. 
Lusk— Science and Art of Mid., p. 119, 262. 
Tanner — Signs and Dis. of Preg., p. 456. 
Williams — Am. Jl. of Obstet., vol. viii., p. 171. 
Demarquay et Saint-Vel — Traite clin. d. mal. de l’uterus. Paris, 
1876. 
Danyau — Arch. gen. de medecine, April, 1851. 
Braxton Hicks—Lancet, July 30, 1870. 
Godson — Obstet. JL, Gt. Brit, and I., vol. iii., p. 47. 
Gay — Buffalo Med. JL, vol. xi., 1870, p. 7. 
Personal communications were received from the following 
gentlemen : Drs. Billings, Bixby, Byford, Campbell, Chadwick, 
Emmet, Engelmann, Gay, Goodell, Howard, Jenks, Lusk, Munde, 
Parvin, Reamy, Shepherd, and Wilson.