the symptoms, the respite lasting for several months. The suprapubic
wound healed quickly. This might not have been thought a fit case
for galvanocautery, in any event, but the perineal operation might
have been considered with the probability that the bleeding would not
have been checked, and that the wound, being in cancerous tissue,
would never have closed.
In dealing with chronic obstruction at the neck of the bladder, the
primary step, then, should be suprapubic section. After tliis, accord-
ing to the condition of the bladder and the character. of the obstruc-
tion, the operation may proceed. If the case is one of prostatic "hypei"-
trophy, ' ' the second step should be selected according to the condition
of tlie patient and the character of the obstructing mass. Small
nodules obstructing the internal urethral orifice may be removed
either through the incision already made or through an additional
opening in the perineum, which may be left for drainage. Moderately
large masses Avhich can probably be enucleated may be removed either
from above or below, according to anatomical conditions, and the
superior wound wall then be found of great value, because it permits
an assistant to press directly upon the gland, forcing it within easier
access from below. If the patient is very old or feeble, or if he takes
the anesthetic badly, the operation of enucleation from above will
usually be found much speedier than the perineal dissection. Should
a very large prostate be encountered, it is not probable that it can be
enucleated from below.
If the prostate is very soft and hyperemic, or if it is of such a texture
that it cannot be enucleated, one has the choice of galvanocauterization
through the urethra (Bottini), through the perineal wound, or of re-
moval with the cutting forceps by conjoined manipulation.'^ In any
case the suprapubic wound will be of great service. Its disadvantag:es
I believe to be greatly exaggerated. The operation of opening the
bladder from above is quick, simple, and in my experience accom-
panied by little shock. Ilie mere cystotomy is far less bloody than
422 MOUNT SINAI HOSPITAL REPORTS.
the usual perineal section. When speed is the all-important element,
as it frequently is in old persons, it must be remembered that the
cystotomy takes only a few moments. The entire operation with re-
moval of the prostate is finished in from fifteen minutes to half an
The steps of the operation as I have performed it are briefly as
follows : Washing out the bladder, the catheter being left in the
emptied viscus. Incision of tlie tissues through the Jinea alba. Re-
traction of the recti. Inflation of the bladder with air, using an or-
dinary atomizer bulb fixed to the catheter. Palpation of the parts
through the wound, so as to judge of the size and shape of the bladder,
as well as the degree of inflation. Pushing up the peritoneal reflec-
tion. Opening the bladder betw-een two retracting sutures. Explora-
tion of the viscus with the finger, then by the eye, raising the pelvis
if necessary. Snipping the mucous membrane covering the most prom-
inent portion of the prostate. Enucleation of the gland with two fin-
gers of the left hand, w^hile an assistant with finger in the rectum
supports the parts. A perineal opening may or may not be made,
according to the exigencies of the case. I am of the opinion that,
when a capable nurse is to be in charge, the bladder and the lacera^
tion in its floor can be perfectly drained with the continuous siphon
apparatus without the opening from below. If perineal drainage is
decided upon, however, it is easy to cut down upon the beak of a
sound placed within the space left by the removed prostate, and
pushed against the tissues, so that it presents in the perineum.
In two of my operations I placed sutures of chromic catgut at either
side of the drainage tube, inverting the bladder wall after the manner
suggested Ity Gibson^ ; but in all of my cases time seemed an important
element, and anything which tended to lengthen the operation was
All patients should be prepared by free purgation and diuresis.
The latter is most important, and I attribute the fatal termination in
Case II. very largely to the fact that this precaution could not be
thoroughly carried out. The administration of urotropin and copious
draughts of water seems to be perhaps the best way in which this can
be accomplished, the urotropin acting as a urinary antiseptic as well.
It is my habit to continue the administration of the water until within
two hours of the time set for operation.
The principles of the scientific treatment of chronic prostatic ob-
struction are being steadily evolved. As with all diseases, so here.
LILIENTHAL: SUPRAPUBIC CYSTOTOMY. 423
each individual case must be treated according to its needs, and the
skill of the surgeon is not so much required in the carrying out of
his plan as in its proper and careful selection and elaboration. My
argument for suprapubic section is advanced with the hope of aiding
the cause of thoroughness and accuracy.
1. Van Buren and Keyes: Genitourinary Diseases with Syphilis, 1884. Ap-
pleton, p. 193.
2. British Medical Journal, 1887, p. 1104.
4. Deutsche Zeitschrift, 1887.
5. Fuller: Diseases of the Genitourinary System. Macmillan, 1900.
6. British Medical .Journal, 1900, March 24, p. 698.
7. Fuller: Ibid.
8. Gibson: Medical Record, January 12, 1901.
PAUL F. MUNDE, M.D.
Dr. Paul F. Munde was associated with the Mount Sinai Hospital
for twenty-four years. In 1878 he was appointed Gynecologist to the
Dispensary, and on the resignation of Dr. Emil Noeggerath in 1882
he was assigned to the charge of the hospital wards with the title of
Attending Gynecologist. This position he filled with conspicuous
fidelity and with growing fame to himself and to the hospital until
his death on February 1, 1902.
His surgical work was marked by the impress of his early training
with the Prussian army in the Franco-Prussian War, with the master
Scanzoni, and with the teachings of Sims and the older Emmet. By
his energy and by the broad view which he brought to his work, he
created a g;^mecological service in the Mount Sinai Hospital which
has become known among scientific men everywhere. Through his
contact and intimate acquaintance with the men prominent in his
specialty and with the literature of his subject, he succeeded in con-
stantly bringing his work abreast with modern gjmecological art and
frequently going beyond it.
To him was largely due the popularization of Alexander's opera-
tion in this country, and he w^as among the first to recognize the value
of, and to practise, Tait's flap-splitting operation for complete peri-
neal laceration. His operative technics were simple but efficient, and
during the performance of an operation he took particular pains and
pleasure that those about might understand what he was doing. His
clinics, always largely attended, became interesting for this reason
and for the clear exposition which he always gave of the pathological
In plastic work he found his most congenial work, and it is doubt-
ful if any gynecological surgeon could surpass him in these opera-
tions. The Tait operation, Stoltz's operation for cystocele and
Hegar's for rectocele, Emmet's operation for lacerated cervix, were
426 MOUNT SINAI HOSPITAL REPORTS.
his favorite procedures and seemed easy of performance in his hands.
For the relief of sterility in an anteflexed and stenosed uterus, dis-
cission and dilatation, with or without curetting, was his operative
measure of choice. He preferred abdominal to vaginal hysterectomy
and in his later years abandoned the stump operation altogether.
The bulk of his literary work was done during his connection with
the hospital. His "Minor Surgical Gynecology," which saw several
editions, was the result of his clinical experience there ; and when
Thomas desired a revised edition of his work to appear, he chose Dr.
Munde as the man of broadest experience and of ripest judgment
to perform the task for him. His occasional articles, too, were inspired
mainly by his public and private work at Mount Sinai, and some
of his most widely known contributions to medical literature were in-
spired by cases seen there. In his paper, "Twenty-five Years of
Gynecology at the Mount Sinai Hospital," the methods and results
of his service are set forth.
Perhaps the greatest service he rendered the gynecological world
was by his strong conservatism— this, too, at a time when the furor
operandi was heralded as a sign of progress, and when it required
moral courage of a high degree to oppose the dicta of men high in
the profession. Dr. Munde lived long enough to see his opinions
vindicated and to be able to feel that his influence had been cast in
the right direction, and that it was not the least element that made
for a change in professional opinion.
As an example of the perfect gentleman, of a man of untiring in-
dustry, who l)ore the most genuinely cordial and affectionate rela-
tions to his house staff and to his colleagues on the ]\Iedical Boafd,
whose tender consideration for the poorest as for the wealthiest pa-
tient made him widely beloved, whose standing enhanced that of the
hospital, Dr. Paul F. Munde will always live in the memory of those?
associated with him at Mount Sinai Hospital.
Paul F. Munde, M.D.,
Joseph Brettauer, ]\I.D., and Hiram N. Vineberg, M.D.,
On account of illness at the end of the year 1901, Dr. INIunde was
unable to make a report of his year's work or to select any part of it
for publication in this Report. As we were not on duty from Novem-
ber 1 to JMay 1, and therefore were not acquainted with the most inter-
esting cases which occurred during that period, it is with regret that
we are unable to report any cases treated during that time.
Dr. Brettauer was in charge of the service from May 1 to June 15
and again from September 1 to November 1. In the interval Dr. Vine-
berg was in charge.
The folloMdng tables are modelled upon the same plan as that fol-
lowed by Dr. Munde in previous Reports.
Synopsis of Diseases (632).
Vulva (3 cases). Rectocele 27
Epithelioma 1 Atresia 1
Cyst of vulvovaginal gland 1 Cystic tumor of floor of vagina. . 2
Kraurosis 1 Senile vaginitis 2
Burn of cervix, vagina, and
Urethra and Bladder (14 cases). vulva 1
Caruncle 2 Enterovaginal fistula; general
Vesicovaginal fistula 1 peritonitis 1
Vesicoabdominal fistula 1
Urethrovaginal fistula 1 Rectum (7 cases).
Ureteroyaginal fistula 1 Hemorrhoids 4
Urethral stricture 1
Gonorrheal urethritis 2
Cyst of urethra
Retention of urine ' 1
Chronic cystitis 3
Fistula in ano 1
^ Rectovaginal fistula 2
Cervix (77 cases).
Perineum (25 cases).
Laceration : . . . . 25 Lacerated cervix 63
Vagina (56 cases). Hypertrophy 1
Cystocele 22 Carcinoma 2
MOUNT SINAI HOSPITAL REPORTS.
Body (242 cases).
Retroversion and retroflexion... 39
Retroflexion and pregnancy 1
Retained secundines and incom-
plete abortion 24
Anteflexion and stenosis (steril-
Inversion v^^ith adherent necrotic
Double uterus and vagina with
Hydatidiform degeneration of
Ovaries (62 cases).
Abscess and salpingitis 23
Double ovarian tumor and preg-
Tubes (56 cases).
Chronic salpingitis 29
Ectopic pregnancy 14
Tubercular salpingitis 1
Pelvic Peritoneum and Cellular Tis=
sue (44 cases).
Pelvic peritonitis 26
" abscess H
" hematoma 6
" exudate with laceration of
Miscellaneous (50 cases).
Pericholecystitis and appendici-
Carcinoma of liver 1
Chronic catarrhal appendicitis. . 6
Dystocia from adhesions of uter-
us to abdominal wall; rupture
of abdominal wall
Strangulated femoral hernia. . . .
Tumor of omentum
Burn of thigh
Acute intestinal obstruction. . . .
Puerperal psychosis with cata-
Synopsis op Operations (510),
Vulva (4 operations).
Excision for kraurosis
" of vulvovaginal cyst.
" " tumor
Urethra and Bladder (7 operations).
Excision of urethral cyst 1
Dilatation of urethra 1
Excision of caruncle 2
Plastic for vesicovaginal fistula. 1
" " rectovaginal fistula.. 1
Catheterization under anesthesia 1
Perineum (27 operations).
Vagina (50 operations).
Anterior colporrhaphy 22
Posterior colporrhaphy 27
Excision of cyst of vaginal fioor. 1
Rectum (4 operations).
Uterus (300 operations).
Cervix (85 operations).
Discission and dilatation 7
Dudley's plastic 13
Exploratory section 1
Body (215 operations).
MUNDE : REPORT OF THE GYNECOLOGICAL SERVICE— 1901. 429
Vaginal fixation for retroversion Hysterectomy for carcinoma. ... 2
and cystocele 2 Hysterectomy, vaginal, for other
Incision for pyometra 1 causes 10
Hysterectomy, abdominal, for fib- Vaginal fixation of round iVga-
TT 4. '1 lij' ' '■' ' V ' ' y ' ment for retroversion 4
Hysterectomy, abdominal, for ^ ^ -. j.
ggpgjg 2 Laparotomy and myomotomy. ... 1
Hysterectomy, vaginal, for sep- " foi" ventral fixation. ?
sis 1 Morcellement of fibroid 1
Ovaries and Tubes (59 operations).
Laparotomy for ovarian tumor and abscess 40
" " parovarian cyst 1
" " ectopic gestation 6
Vaginal section for ovarian cyst 1
" " " salpingo-oophoritis 5
" " " ectopic and pelvic hematoma 6
Miscellaneous (64 operations).
Laparotomy for tubercular peritonitis 2
" " general peritonitis 1
Exploratory laparotomy 5
Laparotomy for cholecystotomy 3
" " appendicectomy 9
" " secondary hemorrhage 1
Enterotomy for intestinal paresis 2
Suture of ruptured abdominal wall 2
Vaginal section for pelvic abscess 18
Incision of pelvic abscess ^. 8
Accouchement force for dystocia , *. 1
Anesthesia for examination 2
" " dressing i 1
Suture for hemorrhage (cervical) 4
Rassini for inguinal hernia and shortening of one round ligament 1
Radical cure of femoral hernia 1
Skin graft 2
Causes of Death.
Diseased appendages; peritonitis 1
Double salpingo-oophoritis; pelvic peritonitis (operated) 1
Carcinoma of ovaries; cachexia 1
Sarcoma of ovaries ( operated ) ; pelvic peritonitis 1
Pyosalpinx; septic metritis 1 1
Ectopic gestation (operated) ; bronchopneumonia 1
Pyometra (operated) ; general peritonitis 1
Fibroids and torsion of uterus (operated) ; peritonitis 1
Pelvic exudate and abscess 1 1
" abscess; general peritonitis 1
Post-abortive pelvic peritonitis 1
" general peritonitis 1
Puerperal sepsis 2
" " hysterectomy 1
" " septic pneumonia 1
" eclampsia 1
Rectovaginal fistula; pneumonia; sepsis 1
I'elvic hematocele; ulcerative carcinoma of intestines; perforation; gen-
eral peritonitis 1
Intestinal obstruction 1
430 MOUNT SINAI HOSPITAL REPORTS.
Case I. Secondary Hemorrhage due to Slipping of Ligature Fol-
lowing Post-vaginal Section for the Removal of Ovarian Cyst; Re
covery. — E. B., 20 years of age, married, nullipara, was admitted on
May 23 for prolapse of enlarged left ovary. After curettement a
posterior section was made on May 29. The enlarged ovary was
easily brought down, the pedicle found and tied with ordinary catgut
of medium size. The peritoneal opening was narrowed by a suture at
either angle, and a strip of gauze left for drainage. The patient was
removed to the ward and nothing unusual was noticed. About two
hours and a half after the operation it was reported that she was
bleeding slightly from the vagina and that there was a gradually fail-
ing pulse. The patient Avas immediately brought back to the operating
room and showed all signs of acute anemia. It was therefore decided,
in view of the nature of the operation, to waste no time in searching
for the source of hemorrhage from below. Abdominal incision re-
vealed the pelvic cavity full of blood from the actively bleeding left
ovarian artery, the ligature having become loosened. In a few minutes
the pedicle was tied and the abdominal cavity flushed with hot saline
solution, and the incision closed with through-and-through sutures.
The patient rallied well within a few hours and improved steadily until
her discharge on June 20.
The interesting features of this case are that it is the only case in
which I have used catgut for a ligature and the only case in which a
pedicle ligature has slipped. The reason I used catgut was because
at the time we were employing for general surgical purposes a catgut
which I had been led to believe was absolutely reliable, and the op-
portunity for its use was convenient. In view of my experience with
catgut for pedicle ligatures, I took special care to tie the ligature
accurately. It probably slipped on account of the diminished tension
after replacement of the broad ligament in the pelvic cavity. For-
tunately the consequences of this accident were not fatal.
Case II. Myomectomy During Early Pregnancy, with Subsequent
Normal Delivery.— "Ei. U., 35 years of age, mother of one child 8 years
of age, was admitted on June 18. She had menstruated regularly until
April 6, and again on April 21 lasting imtil April 27. She was under
treatment for several months for abdominal pain which was ascribed
to a freely movable right kidney. For some time she had noticed a
mass in the right iliac region. It gave rise to no discomfort until the
cessation of her menses; after that it increased materially.
On examination the uterus was found to be slightly enlarged, soft,
contracting under the examining finger. The abdominal mass, the size
of a child's head, was freely movable. A pedicle arising from the
right hom of the uterus could be distinctly made out. A diagnosis of
MUNDE : REPORT OF THE GYNECOLOGICAL SERVICE — 1901, 431
probable pregnancy with fibroid was made and the patient was
operated upon on June 19.
The fibroid wrs removed, the pedicle excised and its edges sewed to-
gether Avith silk. Convalescence was uninterrupted and rapid. At
no time were there any signs of uterine contractions or hemorrhage.
The patient was discharged in July and on February 2, 1902, passed
through a normal confinement.
The interesting feature in this case was the absence of any bad
effect of the operation on the already existing pregnancy.
Case III. Suppurating Intraligamentous Ovarian Cyst; Hysterec-
tomy : Becovery. — J. G., 25 years of age, married ten years, mother of
one child 21^ years old. About eight months ago, after a delay of
from one to two weeks, she suffered from metrorrhagia, for which she
was curetted. Several weeks previous to admission she suffered from
pain in the lower part of the abdomen, and also noticed a swelling in
the left side which gradually increased in size.
Examination showed a mass, the size of a child's head, in the left
side of the abdomen; it was rather tense, pseudo-fluctuating, and
slightly movable. Bimanual examination revealed the uterus directly
behind this mass and apparently not closely connected with it.
The patient was operated upon by Dr. Munde on March 5. A cystic
mass Avas found occupying the entire left lower half of the abdomen ;
it Avas inti-aligamentous and its peritoneal covering Avas slightly ad-
herent to the omentum. On inserting a trocar the contents Avere
found to be thick pus. In attempting to enucleate the mass the sac
Avas torn in seATral places and a large quantity of pus escaped over
the field of operation and into the abdominal cavity. Hysterectomy
Avas done, the right oA^ary being left. The pelvis Avas drained through
the vagina Avith iodoform gauze. Through-and-through sutures united
the abdominal incision. A fcAA^ days after the operation a large mass
AA'as noticed to the left of the incision ; this proved to be an abscess in
the abdominal AA'all. After drainage of this abscess Avas instituted,
recovery Avas uninteriiipted, and the patient was discharged on April
Dr. Munde, having tried to enucleate the intraligamentous cyst for
some time, Avas compelled to leave the operating room and requested
Dr. Brettauer, Avho AA'as present by accident, to take his place. By this
time two hours had been consumed, and the condition of the patient
Avas such that further attempts at enucleation Avould have unduly
prolonged the operation; hysterectomy was therefore done as being
the quickest AA'ay of finishing the operation. The opposite broad liga-
ment Avas tied, the uterus amputated, and the mass, together witli
the iTterus, easilv removed.
432 ' MOUNT SINAI HOSPITAL REPORTS.
In the absence of a bacteriological examination it is to be assumed
that the contents of the cyst were sterile, as convalescence was com-
paratively uneventful. It is more than likely that the patient had a
simple ovarian cyst at the time she was curetted for incomplete abor-
tion and that infection occurred at that time.
Case IV. Incomplete Abortion; Suspected Tuhal Pregnancy ; Ova-
rian Cyst. — L. W., 21 years of age, married eight months, was ad-
mitted October 22. Menstruation regular, last on July 11. Felt per-
fectly well until October 1, when she was seized with a sudden severe
cramp in the lower part of the abdomen, accompanied by slight
bleeding. These sj^mptoms abated soon, only to return a week later
with renewed severity. At this time the patient recalled the dis-
charge of a membranous mass accompanied by profuse flow.
On examination the uterus was found corresponding in size to a
six-weeks pregnancy, soft, and with a patulous os. There was slight
bleeding. To the right and partly behind the freely movable uterus
a tender mass the size of an orange could be felt, apparently inde-
pendent of the uterus.
The patient was narcotized, the uterus curetted, and a large quan-
tity of debris and a two-months fetus were removed. The uterus was
packed. A posterior vaginal incision w^as then made and an ovarian
cyst was removed. The peritoneal opening was drained. Recovery
The interesting feature in this case was the differential diagnosis
between intrauterine pregnancy accompanied by ovarian cyst and
extrauterine pregnancy. Of course, while a positive diagnosis was im-
possible before curettement, the real condition was immediately demon-
strated after the uterus had been cleaned out. At the time I assumed
that the case was clean and did the posterior section for the removal
of the ovarian cyst, with the idea that, taking into consideration the
physical signs, tubal gestation could not be positively excluded. As
a routine practice I would undoubtedly prefer, in similar cases, to
postpone removal of the tumor until a later date.
Case V. Papilloma ; Recurrence Two Years after Removal of Ap-
parently Benign Ovarian Cyst. — F. W., 49 years of age, eight chil-
dren, three abortions, admitted June 17. INIenstruation at 14, always
regular, profuse; last nine months ago; last pregnancy nine years ag:o.
On September 25, 1899, she was operated upon by Dr. Brettauer by
abdominal section for the removal of a large multilocular cyst of the
right ovary, which was followed by an uneventful recovery. The
specimen presented the typical characteristics of colloid cyst with
MUNDE: REPORT OF THE GYNECOLOGICAL SERVICE — 1901. 433
innimierable partitions. There were no vegetations of a papilloma-
tous character to be seen, and therefore, unfortunately, a micro-
scopical examination was not made. The left ovary was left in situ,
being normal, although rather atrophic. The patient was well for
eighteen months after the operation. She then noticed a slight in-
duration in the scar of the abdominal wound, but paid but little at-
tention to it. On June 17, 1901, she again presented herself, and I
found in the lower part of the abdomen a distinctly circumscribed
tumor which occupied the entire length of the scar and appeared to
be closely adherent to it, being movable only with the abdominal