Ernest Watson Cushing.

Annals of medical practice online

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mediately become pregnant, and was mortified to find that very
soon her abdomen was much larger than the period of her preg-
nancy, which had advanced to two months when she came under
my observation. She had a freely movable pedunculated tumor,
which was very soft on palpation, and which was supposed to be
an ovarian tumor, some three or four inches in diameter. Ab-
dominal section was performed on the 3d, and on withdrawing the
tumor from the abdomen it was found to be a pedunculated oede-
matous fibroid. The pedicle was very small, and it was decided
to remove the tumor. In spite of the very free use of morphia,
the patient aborted on the fourth day after operation; otherwise
she made a good recovery, and was discharged on January 2,
1895. This patient subsequently became pregnant, and was de-
livered at term of a living child. When I last heard from her,
she was in good health, and had had no additional children.

Mrs. H., aged twenty-seven, nullipara, in good general condi-
tion, was admitted to the hospital June 5, 1895. She was some
six weeks' pregnant, and was admitted because of a tumor of the
left ovary, containing about a pint of fluid. The tumor con-
tained an unusual amount of solid matter, the cyst cavities being
small and the cyst walls unusually thick. It was also found that
she had a small right parovarian cyst. Abdominal section was
done on the 7th. The left uterine appendage and tumor were
removed, and the right parovarian cyst was peeled out of its bed,
leaving the ovary and tube intact. She made an uninterrupted
recovery, and was discharged July 2. The pregnancy pursued
an uninterrupted course, and a living child was bom at term.

Mrs. K., aged twenty-nine, primipara, was admitted to the hos-
pital February 27, 1897. She was pregnant three months, and
suffering from an ovarian tumor of the left ovary, containing
about one quart of fluid. Ovariotomy was performed on March
1. She made an uninterrupted recovery, and was discharged
March 27. The pregnancy pursued a normal course, and she was
delivered at full term of a living child.

Mrs. P., aged thirty-seven, mother of four children, was admits
ted to the hospital June 18, 1898. She was in fair general con^
dition, but very ansemic. The abdomen was well-filled with ^



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OPERATIONS DURING PREGNANCY. 507

krge fibroid, which was growing rapidly. There was reason to
suspect a pregnancy of two months. I was the more inclined to
operate because this had been advised by another gynecologist of
experience before the patient consulted me. The tumor was ap-
proximately five inches in breadth and ten inches in length . Hystero-
myomectomy was performed on the 20th.The patient made an un-
interrupted recovery and was discharged July 16. The patholo-
gist, Dr. Babcock, reports that the tumor mass was largely made
up of the intramural fibroid. A twin pregnancy of two months
existed. He adds: ^It scarcely seems possible that full term could
have been attained in the presence of so large a tumor.'' This is
the less likely in the case of a twin pregnancy, which was found
in this case.

The last abdominal section which I have done during pregnan-
cy I did during the current week, for obstruction of the bowels.
The patient was about forty-five years of age, a working-woman,
in bad general condition, that is to say, she was older in appear-
ance than in years; she had hard arteries, and looked like a woman
of fifty or fifty-five. The operation was done Friday, January
27, 1899. The patient's bowels had not been moved since the
preceding Monday. However, she had been about and suffered
no special inconvenience until Wednesday, that is, two days be-
fore the operation, when she began to vomit. The usual reme-
dies for the vomiting and for the non-movement of the bowels
were given; and, as her physician did not see her until Wednes-
day, there was no reason to suspect obstruction of the bowels; but
as these measures did not succeed in emptying the bowels and the
vomiting persisted, it was evident that she had obstruction. I
saw her first on Friday, when*she was constantly regurgitating the
greenish-black fluid which precedes fsecal vomiting, and perhaps
it was slightly faecal, but it was not distinctly or markedly so. Re-
peated efforts were made over two hours to unload her bowels by
irrigating the colon and by purgative enemas without any result,
hence operation was decided upon. There was very little to guide
one as to the location of the obstruction. There was nothing in
the hernial canals. Apparently, there was an undue dullness in
the right flank, and it was thought the patient might have an
ovarian tumor in the right side, or that the most probable cause
of the obstruction, if not due to tumor, would be appendicitis.
Therefore, the incision was made in the right semi-lunar line.
On opening the abdomen, we were confronted with the large ute-



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608 CHABLEJ

rus, it being seven months' prej
appendix, it was normal. The
all that could be made out was 1
much distended. However, '.
down into the pelvis, it seeme
that the woman was pregnant, t
adherent in, or at least to, the
hernia in the sense that the be
adherent to the old sac of a her
was quite difficult, because it vi
uterus was in the way, and the
femoral canal, and in trying to
the bowel was ruptured and ^
served at the time that all th
whereas, we are taught, if we 1
that the part of the boweh
should be collapsed. The
drainage. I would have drain
rus been in the way. The pati
admitted one finger. It seeme
stances, and I thought it best t
The bowels were moved four tii
developed peritonitis and died,
but there was also trouble wit
abdominal section, knowing thj
terial which she was vomiting,
in spite of that, large quantitie
during the operation, and moi
there was every reason to have
to the difficulties in the abdomt

After her death a post-morte
had some peritonitis; and als<
in the region of the sigmoid,
something to do with her deat
peritonitis.

My experience in this case, i
thing in the abdomen, except tl
and the difficulties of dealing ^
did find it, make me believe thj
when we are dealing with so se:
promptly do hysterectomy and



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OPERATIONS DURING PREGNANCY. 509

and then we cotdd proceed in a systematic way to do whatever is
necessary. I am inclined to believe that the patient would have
had a better chance for recovery had this been done.

I have seen a number of other operations during pregnancy.
One, the first operation I ever had the pleasure of seeing Dr.
Boyd do, was an ovariotomy in a pregnant woman. I assisted
him, and the patient made a happy recovery.

Another operation with which I was connected was a case of
appendicitis complicating pregnancy. I saw this with Dr. Boyd
years ago, before we knew much about appendicitis. In that
case the abscess was drained by Dr. Boyd, but the patient died.
Dr. Boyd will be able to give us the details of the case.

I saw another case of obstruction of the bowels with Dr. Long-
aker years ago, where the obstruction was brought about by the
fact that the bowel was adherent to the pregnant uterus. After
labor, when the uterus sank down into the pelvis it made traction
on the bowel and brought about obstruction. This patient died.

These cases constitute my full experience in abdominal surgery
in pregnancy.

Mrs. C, aged thirty, multipara, was admitted to the hospital
February 8, 1896, suflPering from a fistula in ano of some months'
duration. She was four months' pregnant. Believing that the
risks of a labor at term, complicated by puriform discharges in
contact with the peritoneum, was more serious than the risks of
abortion, the fistula was incised and sutured. The wound suppu-
rated, and it was subsequently necessary to pack it until it healed
by granulation. She was discharged April 7. The pregnancy
pursued a normal course, and at full term she was delivered of a
Uving child.

With reference to the general principles to guide one in opera-
tions during pregnancy, I believe that, undoubtedly, all ovarian
tumors which are recognized during pregnancy should be prompt-
ly removed, even quite late in pregnancy. The risks of operation
are much less than the risks of delay. All of us have been ob-
liged to operate after labor for peritonitis from the bruising of
ovarian tumors, and not only our own experience, but that of ev-
ery other surgeon, shows that the risks are very great when the
tumor is aDowed to obstruct labor. When this plan is followed
my opinion is that the tumor should be removed immediately at
the conclusion of labor.

Fibroid tumors, as already stated, I think should not be oper-



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510 CHAR

ated on by myomectomy dii
very special reason to the c<
tion are so great, and we
The only variety of fibroid t
remove would be a cortical i
pelvis, which could be gott
taken out in the later montl
ture labor occur, it would pr

With reference to conditi
about the genitalia which i
during pregnancy, I believe
risks of the operation are fai
the genital-canal soiled with

With reference to generi
body, it seems to me that tl
marked, that is to say, evic
tient's life or health would
the condition continue unti
to operate upon pregnant vi
apt to abort. The fear of I
other parts of the body is no
strongly to operation, I bel
applies especially to such dis
threaten life immediately or

The only condition to whi
of hemorrhoids. The teach
orrhoids is that they should I
are several serious conseque
I think this teaching should
know of one case in which tl
labor that the hemorrhoids si
more serious matter to have
the puerperium than to tie
nancy. I should not hesiti
rhoids during the last moni
would be healed before lab<
cological and Obstetrical Joi



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ABDOMINAL SECTION UNDER COCAINE ANiBSTHESIA. 511



ABDOMINAL SECTIOX UNDER COCAINE ANAES-
THESIA FOE KETKOVEKTED ADHERENT UTE-
EUS IN A CASE WITH MARKED CARDIAC
SYMPTOMS AND GOITRE.

HUNTEB ROBB, M.D.^

Professor of Gynecology, Western Reserve University, and Gynecologist
to Lakeside Hospital, Cleveland, Ohio.

The following case is of interest for several reasons. Quite an
extensive operation was performed under cocaine anaesthesia; the
abdomen was opened, the adherent retroverted uterus was re-
leased, brought forward and stitched to the abdominal wall. As
a result the patient was entirely relieved of the local symptoms
namely, the backache and pelvic discomfort of which she had
complained for over a year. At the same time her general condi-
tion improved, the cardiac symptoms became less pronounced and
the goitre diminished considerably in size. The history of the
case is briefly as follows:

The patient, a married woman aged 33, presented herself at
the gynecological clinic at the Charity Hospital two years ago
complaining of backache and of general pelvic discomfort. On
examining her at that time I found the vaginal outlet much re-
laxed, the uterus being in marked retroposition and adherent;
both ovaries were prolapsed and could be felt lying in the pouch
of Douglas. At this time also cardiac symptoms and the presence
of a goitre were noted and she was consequently referred to my
colleague, Dr. J. P. Sawyer, who treated her for this condition
with some apparent improvement. One year later the patient re-
turned to me with the request that I would undertake some opera-
tive procedure for the relief of her backache and the pelvic symp-
toms. On examination I found the pelvic structures in much the
same condition as they had been on the previous occasion. It was
impossible to obtain a complete history as the patient was a Pole
and spoke and understood very little English. She was admitted
to the Lakeside Hospital, October 10th, 1898, at which time the
following notes were made:

The vaginal outlet is much relaxed; the vaginal walls are pro-



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512 HUNTER ROBB.

lapsing. The cervix uteri points towards the symphisis puhis.
The uterus is in a retroverted position; it is somewhat enlarged
and adherent. The ovaries are prolapsed. The general physical
examination gives the following:

The patient is of medium size, somewhat poorly nourished and
rather anemic. The lips and mucous membranes are a little pale.
Tongue coated. The pupils are equal and react to light and ac-
commodation. The eyeballs protrude slightly. Pulse 130 to
the minute, regular and of a good volume; tension high. There
is a goitre which involves both the right and left lobes of the thy-
roid gland; the right lobe is the larger. On inspection marked
pulsation is evident over both lobes. On palpation a distinct thrill
can be felt over both lobes; more marked in the left. On auscul-
tation a hum is heard over both lobes and over the right a distinct
musical tone. The circumference of the neck over the most en-
larged point of the goitre measures 34.2 cm. (13J inches). The
horizontal measurement of the swelling is 14 cm. (5^ inches); the
vertical, 6.3 cm. (2^ inches). The thorax is emaciated, the ribs
are prominent. The intercostal spaces are wide and the costal
angle is acute. Expansion is good and about equal on both sides.
Chest clear on percussion. Breath sounds normal. The apex
beat of the heart is in the fourth space inside the nipple line.
Relative dullness at the third rib and at the left sternal line.
A well defined systolic murmur can be heard all over the chest
but is most marked at the apex. The second sounds are clear.
Hepatic and splenic dullness is normal. The borders are not pal-
pable. The kidneys cannot be felt. The abdominal muscles are
relaxed and there is a marked tenderness in both iliac regions.
There is some tenderness over points in the line of the tibia; there
is some oedema of the legs which is increased after walking. The
urine shows nothing abnormal.

In order to relieve the pelvic condition it was decided to re-
lease the adherent uterus. The operation was performed October
10, 1898, at Lakeside Hospital. Owing to the general condition
of the patient it was thought better to employ local ansesthesia.
Eight minims of 5 per cent solution of cocaine having been in-
jected beneath the skin, an incision was made in the median line
down to the muscle sheath. Eight minims more were injected at
different points along the median line into the muscular struc-
tures and the incision was then carried into the peritoneal cavity.
The adhesions binding the uterus down to the rectum were then



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REVIEW OF GYNECOLOGY. 6 IS

separated without any apparent discomfort to the patient. It is
CO be noted, however, that even slight traction upon the ovaries
seemed to produce considerable pain. The uterus was brought
forward and stitched according to the ordinary suspension meth-
od. The peritoneum was closed by means of a continuous cat-
gut tuture; chromicized catgut was used for the fascia and a con-
tinuous subcutaneous catgut suture for the skin incision. The
patient made an uninterrupted convalescence and left the Hos-
pital November 8, 1898, 29 days after her admission. At the
time of her discharge, she was entirely free from backache and
from all pelvic discomfort. The circumference of the goitre on
October 20, was 33 cm. (13 inches) and on October 25, 31.8 cm.
(12^ inches). When she left the hospital on November 8, It
measured 12 inches, a reduction of one inch in 29 days. The
pulse at the time of her admission varied between 106 and 150.
After the operation the rate gradually diminished and at the time
of her discharge it averaged about 104. The diminution in the
size of the goitre and the slowing of the pulse was probably in the
main due to prolonged rest in the horizontal position, and perhaps
also to some extent to the tincture of digitalis which was given in
small doses — 10 drops twice a day after the fifth day after the op-
eration. On the whole it may be safely said that the patient has
received marked benefit, and up to the present time (February
14, 1899) there has been no return of her former symptoms.
— (The Cleveland Medical Gazette, February, 1899.)



REVIEW OF GYNECOLOGY.

Diagnosis of the Placental Site. G. Leopold (Centralblatt
fiir Gyndholy No. 12, 1895) says the following communication
should be studied in connection with Bayer's observation in the
diagnosis of the placental site in No. 7 of this year's Centralblatty
and, in my opinion, ought to bring about an understanding as re-
gards this matter:

In the first place, Bayer errs in his assumption that the first case
in which my diagnosis was definitely made before the operation
dates from June 5, 1886. The wholly characteristic course of the
tubes converging forward and upward in posteriorly seated



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514 REVIEW OF G^

placenta was already assumed and
section on November 28, 1884, s
the Arbeit en aus der Dresdener
words "previously made diagnosis
ly set down, and the diagnosis was
According to the description, whi
cannot be the least doubt that the
ly as in all later cases in which th
difficulties.

In case Bayer is not convincec
fourth Csesarean section which li
the course of the tubes and round
determined by me through exte
peated by a most careful drawing
is to be found today in the corres
leaves out nothing in the way oi
exactly to Fig. 2 of my article oi
and upward converging course of
placenta is represented.

The statement and drawing fu
have been occupied with this subj

In similar fashion we succeede
tion (January 10, 1886) in our C(
seated above and to the left, and
diagnosis based upon the forwai
adnexa. "At the left of the uterui
right on its longitudinal axis) w
doughy consistence," which corres
at my fourth Csesarean section, wj
proved to be such after opening tl

In the eighth Csesarean section (.
of the placental site was erroneo
case (March 14, 1886), as may be
anatomical interdependence of th(
was so characteristic that coincide]
of.

All these citations are repeatec
journals of my assistants and exte
such clear communications, that
diagnosis was definitely made wa
Miinchner Congress, did he not re



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REVIEW OF GYNECOLOGY.



516



I am utterly unable to recall his communication in Munich be-
fore a Society meeting. And if I failed at that time to mention
my own investigations in this department, it was because they
were incomplete, needing plenty of time to ripen, especially since
they have to be studied in the living.

After all, it was not through Bayer that I was also influenced
toward these studies, but the repeated Csesarean operations, the
dangers of hemorrhage in artificial premature delivery, my
anatomical studies of the placenta, and my sketches m^de during
the constant practice of external investigation which told me that
through observation on the living and specimens of the hitherto
unilliimined region of placental site must clearness be attained.

In consequence thereof must I most decisively emphasize that
in advance of Bayer and independently of him I have formulated
this axiom on the diagnosis of placental site through my own in-
vestigations in the living, "if the tubes converge forward and up-
ward the placenta is seated at the rear; if they run parallel to the
axis of the corpus uteri — the woman being recumbent — then the
placenta is seated in front.''

The progress of my investigations appears from the follow-

^^g: First from the establishment of my axiom in cases four,

®®^en, eight and ten; then from mention of same in Korn's work

_^ Artificial nremature birth in 1887, and in Buschbeck's work on

jct which is contained in the first volume of the

ler Dresdener Frauenklinik at the beginning of



^^



le year appeared Palm's work (Zeitschrift f.
ynak,y Cd,; xxv) in which is to be learned when
3r first published his investigations on the placental
re comprised in a single brief notice found in
col. Klinik (Strassburg, 1885), p. 463. This men-
er's comprehensive work "Zur Morphologic der
so hidden that it'^is pardonable to overlook it It



to my relatively meagre observations on anatomi-
eri there appears to be a constant relation between
ite and insertion of the tubes, the latter extending
1 the afterbirth is on the anterior wall, and when
iterior wall remaining laterally or rather directed
ibly points for the diagnosis of the placental site
at from study of the living."



i



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516 KEVIEW OF GYNECOLOGY.

We extract this mention that his observations have been but
limited, and that therefrom data might possibly be gained.

Later on he has "repeatedly made the diagnosis of the placental
site from his practice and elaborated a metl
found no opportunity to extend his studies suJ
use."

After all both of us, Bayer and myself, ha^
so often occurs, occupied ourselves with th(
each of us has been led to the correct judgmc

When I read Palm's work in the second
volume of the Zeitschrift and saw the active
mer scholar, Miillerheim, had taken in the '
to expect that the investigations which Miill
learned and practiced in Dresden would ha
least once in Palm's work.

On the contrary, there is the silence of dea
Palm's work.

I leave it to the reader how this procedui
terized. In any case, I have expressed mys<
in saying "that I was very sorry that Miillerhei
in mind of these investigations (p. 162)."

It would have been better if Bayer had h
rest upon him.

I confess now that having read Palm's w<
marks, I am under the impression that Miill
of my diagnosis of placental site first incited
gations and lead the latter to the same principl
had been developed by me during 1884-1886
uary, 1899).

Abdomino-Vaginal Expression of the
Treatment of Abortion

In Le Progres Medicale, Sepfember, 1898
method of removing retained secundines in ^
abortion, which is deserving of serious attenti
out the risks of using a metal curette for deti
centa in these cases, and maintains that tih
should be used. Forceps he considers equal!
of opinion that this instrument should never
the uterus for the removal of placental remaii
eral cases in which the uterine walls have be



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517

>eing dragged into
always fatal,
placenta and the
ingers passed into
3e completely de-
, it should be torn
to facilitate its ex-
, which he names
and is passed into
are placed in the
>n the hypogastri-
h is completely re-
round the fundus,
3r wall of the ute-
centa and decidua
the palm of the
T^ix will only admit



he uterine mucous
lital apparatus has
mges included un-

ritis which is asso-
gnized as the pre-
^hich the uterus is



' m



ions of the uterus, l,

nisms. Staphylo- I

been found to be i

!?

re one, forming a
bis; it occurs most
ty to sixty. Such
►er, the remainder
i^-five to fifty, and

the disease is prob-
sence of the usual



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518 REVIEW OF GYNECOLOGY.

causes of endometritis (childbirth, contagion, etc.), but also in the
peculiar anatomical condition of the generative organs at this pe-
riod of life. Thus we find the cervix becoming smaller and small-
er until it scarcely projects into the vagina, and may indeed, be
represented by an orifice lying flush with the vaginal culs-de-sac;
the cervical canal, the internal and external os all become nar-
rowed, sometimes to such an extent as to render the passage of a
sound difficult. The vagina, moreover, becomes contracted, and
often presents circular or semi-circular cicatricial bands, especial-
ly in the posterior cul-de-sac running to the posterior lip of the
cervix. It must be remembered that these anatomical modifica-
tions not only act as a defence against the penetration of infectious
matter from the outside, but also tend to keep pent up within the
uterine cavity the secretions of the mucous membrane; these will
tend to decompose there, and give rise to general infection.

Symptoms, — One of the first symptoms of senile endometritis
is a semi-purulent, yellow or greenish discharge, often streaked
with blood and occasionally offensive ; the discharge is sometimes
continuous, sometimes intermittent. Metrorrhagia is not rare,
and is occasionally so marked as to give rise to what is described
as the hemorrhagic form of the disease; the loss of blood is, how-
ever, rarely great, and never by itself constitutes a grave symp-
tom.

The disease is usually but slightly painful, the subjective symp-
toms being limited to a feeling of weight in the hypogastrium and



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