Summary 2. Longo, L. D., Caillouette, J. C., and Russell, K. P.: Fibrinogen deficiencies in pregnancy. Obst. Gynec. 14:97-106, July 1959. 3. Jackson, D. P., Hartmann, R. C., and Busby, T.: Fibrinogeno- penia complicating pregnancy; clinical and laboratory studies. Obst. The obstetric problems that can be complicated Gynec. 5:223-247, March 1955. by an acquired fibrinogenopenia have been pre- 4. Clark, J. F., and Bennett, R.: Superimposed toxemia, abruptio placentae, hypofibrinogenemia, acute renal shutdown and paralytic sented. The obstetric problems showing the highest ileus complicating case of pregnancy hypertension. Am. J. Obst. incidence of fibrinogenopenia have been reviewed. Gynec. 78:1169-1171, Dec. 1959. 5. Kinch, R. A. H.: Hypofibrinogenemia in pregnancy and puer- Current theories on the mechanism of the fibrino- perium. Am. J. Obst. Gynec. 71:746-753, April 1956. genopenia syndrome have been presented. A brief 6. Barno, A., and Freeman, D. W.: Amniotic fluid embolism. Am. J. Obst. Gynec. 77:1199-1210, June 1959. outline of the diagnosis and management of these 7. Reilly, C. T., and Zito, A. J.: Hypofibrinogenemia and ABO heterospecific pregnancy; preliminary report. Am. J. Obst. Gynec. cases has been presented. One case of abruptio 77:375-381, Feb. 1959. placentae complicated by an acquired hypofibrino- 8. Glueck, H. I., et al.: Afibrinogenemia in pregnancy apparently due to degenerating leiomyoma. Obst. Gynec. 18:285-290, Sept. genemia and a Couvelaire has been reviewed 1961. in detail. 9. Koren, Z., Zuckerman, H., and Brzezinski, A.: Placenta previa accreta with afribinogenemia; report of 3 cases. Obst. Gynec. 18:138-145, Aug. 1961. 10. Novak, E., and Novak, E. R.: Gynecologic and obstetric pa- 1. Greenhill, J. P.: Obstetrics. Ed. 12. W. B. Saunders Co., Phila- thology, with clinical and endocrine relations. Ed. 4. W. B. Saunders delphia, 1960. Co., Philadelphia, 1958.

Case report: Uterine descensus and cervical cancer

WALTER C. MILL, D.O.,° Denver, Colorado Review of the case

The patient was a 48-year-old woman, still men- struating regularly, who gave a history of low Cytologic screening procedures have been of great backache, sensation of weight in the , urinary value in the detection of cervical cancer in its frequency and burning, and stress incontinence curable stages. Wide-scale screening among the during the past year. She had had five pregnancies, female population holds the potential for practically with one miscarriage and four live births, two of eradicating this disease, provided women can be these by cesarean section. Tubal ligation had been motivated to take advantage of the opportunity. carried out at the time of the last section. There Physicians have long been concerned about the was no history of increase in , fact that cervical cancer is likely to progress to an and menses had always been normal. Aside from incurable stage without showing any symptoms, the pelvic condition, her only other health problem or with symptoms masked by chronic pelvic dis- was chronic asthma. comforts. In the case reported here, it was fortunate At the time of her admission to the hospital the that such discomforts became serious enough to patients temperature, pulse, and respirations were send the patient to her physician. What appeared normal; her blood pressure was 150/100 mm. Hg, to be an uncomplicated matter of uterine descensus, and she weighed 160 pounds. Results of physical with stress incontinence, turned out to be a surgical examination were entirely normal except for some problem involving acute appendicitis, tenderness in the lower abdomen. Gynecologic of the uterus, , , and squamous- examination showed the uterus to be normal in cell carcinoma of the , grade 2. Since the size and position, tender on palpation, and descend- neoplasm was not yet invasive, surgical excision ing to grade 2 position on abdominal pressure; and postoperative x-ray therapy held every hope grade 2 cystocele and rectocele were noted. The of permanent cure. cervix showed a minimal degree of erosion. The °Address, 885 S. Colorado Blvd. condition of the uterus was interpreted as repre-

JOURNAL A.O.A., VOL. 61, MAY 1962 743 senting adenomyosis. Results of blood studies were therapy was started on the tenth postoperative day, essentially normal; urinalysis disclosed 3 to 4 and the patient was discharged 2 days later, to leukocytes per high-power field, with epithelial continue treatment as an outpatient. She has been cells, motile bacteria, and a few crystals. seen at intervals since the operation, and there has In view of the patients age, the procedure of been no evidence of pelvic symptoms or of ex- choice appeared to be a total , to re- tension of the carcinoma. move the weight and strain that caused the cys- tocele and rectocele, and incidental appendectomy. Discussion The decision and the reasons for it were discussed with the patient, and preparations were made for Although in this case the first inkling of carcinoma the operation. came after the operation had been completed, the In view of the asthmatic condition, spinal anes- procedure and its results probably would not have thesia with Pentothal sodium was chosen, to avoid been different had the diagnosis been made ahead irritation of the lung fields. At operation the ap- of time. If the indications for hysterectomy had not pendix was found to be elongated, clubbed at the been so clear-cut, further diagnostic procedures distal end, and filled with fecal material. It was would have been carried out. Erosion of the cervix, apparent that the ovaries were normal and would even when it is minimal, should always be viewed not have to be removed. The uterus was mottled with suspicion; this condition signifies tissue changes in appearance, and the anticipated cystocele and that seem to lead frequently to cancer, especially rectocele were found. The bladder was dissected as the patient approaches the climacteric. free from the anterior surface of the uterus, and There is still considerable difference of opinion the uterus and cervix were then removed in toto regarding the choice of for marked uterine from the vaginal vault. The vaginal vault was closed descensus with its attendant discomforts and dis- and the endopelvic brought together over tortion of other organs. In the case described above, the vaginal stump. The cardinal were the patient was still premenopausal. At the age of attached to the top of the vaginal vault and the 48, however, she could well be considered beyond bladder was then brought up and attached over the child-bearing period; moreover, there was evi- the vaginal stump. The mesoappendix and ap- dence that the uterus itself was diseased. It is on pendix were clamped and severed, and the cecum the young woman with a normal uterus that the closed. The abdomen was closed and the patient conflicting opinions center. If she desires more repositioned for repair of the rectocele. For this children and if the pelvic muscles have adequate the vaginal mucosa was incised above the rectum tone, an operation to suspend the uterus may be and dissected free. The levator muscles were successful, at least for a time. But if she has gone brought together with interrupted sutures of single- through repeated , attempted restoration strand 00 chromic, and the vaginal mucosa was of the uterus may quite possibly produce more then trimmed and brought together; at the close symptoms than it relieves. Years ago, Graves epito- of the operation the was approximately 5 mized the problem in one comment: "Patients with inches in depth. It was apparent that the intra- this type of are usually multiparous worn- abdominal procedure had taken care of the cys- out women, to whom the removal of the uterus is tocele. a blessing."1 In recent times this concept of a The pathologists report confirmed the acute "patient-centered" philosophy has ably been set appendicitis and uterine adenomyosis, and disclosed forth by an osteopathic physician. 2 Such a concept the presence of neoplastic growth along the endo- in no way condones haphazard surgery, but rather cervical canal and at the external as, with minimal calls for a careful weighing of other factors beside invasion of the myocervix. The pathologists diag- the strictly surgical considerations. nosis was squamous-cell carcinoma, grade 2. The In the case described above, conditions fortu- patient was immediately informed and a tumor nately were such that the surgical procedure did not board consultation was called. It was the opinion come into question. The results were gratifying in of this board that no further operative procedure that the patient was relieved not only of her current would be necessary, in view of the evidence from nagging discomforts but also of a much greater the pathologic sections of a noninvasive lesion, but hazard to her future. Her case points up the obli- that the patient should be given a cancerocidal gation physicians have to be constantly alert in the dosage of deep x-ray therapy. war against cancer. The patients postoperative course was good; her asthma was adequately controlled by osteopathic 1. Graves, W. P.: Gynecology. Ed. 3. W. B. Saunders Company, Philadelphia, 1924. manipulation and Tedral therapy, and healing of 2. Eby, B. E.: Non-pathological hysterectomy—philosophical dis- the incision proceeded without difficulty. X-ray cussion. California Clinician (Calif. Osteop. A.) 54:367-372, Nov. 1958.