Part 15 (1/2)

Sir Spencer Wells had removed a large, multilocular ovarian cyst from the left side of the patient, when he felt what was supposed to be a cyst of the right ovary. When tapped it was found to be a gravid uterus, in which pregnancy had advanced to near the fifth month. Caesarean section was at once performed and the patient recovered.

Injuries of this kind are rarely likely to happen now, for the clumsy ovariotomy trocar is pa.s.sing out of use.

[Ill.u.s.tration: FIG. 24. DIAGRAM REPRESENTING A GUNSHOT INJURY OF THE UTERUS. The woman was aged 28, and in the seventh month of pregnancy.

The bullet was extracted from under the skin on the left side, four inches behind the anterior superior spine of the ilium. The line A B represents the track of the bullet. (_British Medical Journal_, 1896, vol. i, p. 332.)]

=Bullet-wounds of the pregnant uterus.= These are very rare, and, like rupture of the uterus, liable to be complicated with injury of the intestines; it is for this reason that the canon of surgery applicable to penetrating wounds of the abdomen should be practised in these circ.u.mstances, and the patient submitted to cliotomy.

When the gravid uterus is penetrated by a bullet there may be little bleeding on account of the contracting property of the uterine tissue.

In some instances amniotic fluid stained with blood escapes. In operating, the anterior as well as the posterior surface of the uterus should be carefully examined in order to determine if the bullet pa.s.sed through this organ. In some instances the ftus has been injured by the bullet. When free bleeding follows a bullet-wound of the gravid uterus the haemorrhage is usually due to damage of blood-vessels connected with the intestines.

The best method of dealing with the uterus in such conditions is undetermined, but a study of the few reported cases indicates that the best results follow cliotomy, with suture of the perforated intestine and the hole or holes in the uterus. The patients usually abort. In Prichard's case (Fig. 24) hysterectomy was performed, but the patient died.

Even in some apparently desperate cases good consequences follow the conservative operation, as the following reports demonstrate:--

In a case under the care of Albarran, the patient was aged nineteen years and in the fifth month of pregnancy when shot. There were four perforations of the small intestines, and the mesenteric artery was wounded. He resected 20 centimetres of small intestine. A loop of umbilical cord protruded through the bullet-hole in the uterus; this was resected and the ends of the cord tied. The patient miscarried a few hours after the operation, but recovered.

Baudet reported a case in which there were four perforations of the small intestine: he sutured the wounds in the uterus and the holes in the bowel; the woman aborted some hours after the operation, but recovered.

In a case under Robinson's care the bullet entered the uterus and penetrated the right shoulder of the ftus. The patient, who was in the eighth month of pregnancy, quickly miscarried. The bullet was found in the debris. The patient not only recovered, but reconceived, and gave birth to another child in the following year.

=Stab-wound of the pregnant uterus.= Examples of this kind of injury are rare, but some of the recorded cases are remarkable. Guelliot has recorded the details of a case in which a pregnant woman was stabbed in the b.u.t.tock. The knife pa.s.sed through the great sciatic notch, and penetrated the uterus and the child's skull. The woman miscarried of a dead ftus next day. The great sciatic nerve was injured, but the woman recovered, though she remained lame.

Steele recorded an example where a woman, six and a half months pregnant, stabbed herself in the lower abdomen with a knife; she was taken to a hospital and kept at rest until the wound healed. Six weeks after the injury the woman was delivered of a live male child, normally developed, but much of the child's large and small intestines protruded through an opening in the abdomen. The jejunum was completely severed as a result of the stab. Steele attempted to deal with this extraordinary lesion surgically, but the child died a few hours later.

REFERENCES

ALBARRAN. Plaies multiples de l'intestin et de l'uterus gravide par balle de revolver. _Bull. et Mem. de la Soc. de Chirurgie de Paris_, 1895, xxi. 243.

BAUDET, R. Plaies de l'intestin et de l'uterus gravide par balle de revolver. _Bull. et Mem. de la Soc. de Chir. de Paris_, 1907, x.x.xiii. 779.

BLAND-SUTTON, J. A Clinical Lecture on the Treatment of Injuries of the Uterus. _The Clinical Journal_, 1908, x.x.xi. 289. On two cases of Abdominal Section for Trauma of the Uterus. _The Am. Journal of Obstetrics_, 1907, lvi.

BRAUN-FERNWALD, R. VON. uber Uterusperforation. _Zentralbl. f. Gyn._, 1907, x.x.xi. 1161.

CONGDON, C. Abdominal Section for Trauma of the Uterus. _The Am. Journal of Obstetrics_, 1906, liv. 618.

DONALDSON, H. J. An unusual Obstetric Complication, causing the removal of 126 inches of Small Intestine. _Surgery, Gynaecology, and Obstetrics_, 1908, vi. 417.

DUDLEY, P. Discussion on Accidental Rupture of the Non-parturient Uterus. _Trans. Am. Gyn. Soc._, 1905, x.x.x. 21.

GUELLIOT. Coup de couteau ayant penetre a travers l'echancrure sciatique jusqu'a l'uterus gravide et jusqu'au ftus, &c. _Societe de Chirurgie_, 1886, xii, 337.

HARRIS, R. P. Cattle-horn Lacerations of the Abdomen and Uterus of Pregnant Women. _The Am. Journal of Obstetrics_, 1887, xx. 673.

IVANOFF, N. De l'etiologie, de la prophylaxie et du traitement des ruptures de l'uterus pendant l'accouchement. _Annales de Gynecologie_, 1904, 449.

JAKOB, J. Gefahren der intra-uterinen instrumentalen Behandlungen.

_Zentralbl. fur Gyn._, 1906, x.x.x, No. 19, 561.