was then brought into the wound with the patient in the extreme
Trendelenburg pasition. It was at once evident that the aneurism
could not be exsected without the preliminary removal of the uterus.
Pressure on the left iliac artery, over both ovarian arteries, and over
the right uterine artery had no effect in stopping the pulsation of
the aneurism. The tAvo ovarian arteries and the right uterine artery

'Mount Sinai Hospital Reports, vol. i., p. 266.



BRETTAUER : REPORT OF THE GYNECOLOGICAT. SERVICE— 1902. 455

were then tied and the entire uterus removed (Fig. 2), except a small
piece of cervix and uterine wall adjacent to the aneurism. The next
step consisted in ligating the left internal iliac artery with silk, upon
which the aneurism ceased its pulsation at once and what arterial
hemorrhage had been taking place stopped also. The aneurism was
deeply embedded in a mass of cicatricial tissue, the remains of the
former parametritis, and was but a mere shell surrounded by para-
metritic scars. Nevertheless, with arduous labor and patient dissec-
tion, the entire aneurism, with half an inch of the internal iliac
artery, was finally removed, and Avith these about half an inch of the
left ureter Avhich crossed the artery and was so firmly embedded in



Bristle in left hypogastric
artery which is partly
occluded by old clot.



Aueurism.




Bristle in ureter.



Fig. -4.



the aneurismal wall and in the cicatricial tissue that it could not be
separated from them. There was a great deal of venous hemorrhage,
which was controlled by clamps. The ureteral anastomosis was easily
accomplished by the invagination of the central end into the periph-
eral by means of two sutures which were guided through the bladder
into the urethra. The anastomosis Avas further enforced by a row
of circular sutures. The pelvis was packed with gauze, which was
carried in part into the vagina and in part through the lower angle
of the abdominal incision. The entire operation lasted over three
hours, and yet the patient left the table in fair condition.

Forty-eight hours after the operation signs of septic infection ap-
peared, and the patient died a week after the operation, despite all
efforts to save her, of septic peritonitis, which was verified by an
autopsy through the wound. The ureteral anastomosis was found
to be perfect.



456 MOUNT SINAI HOSPITAL REPORTS.

The fatal outcome of the case can be attributed to the great length
of the operation and its subsequent profound shock, and, further, to
the fact that the assistants were changed several times during the
operation, which probably accounts for some break in the asepsis.

This is but the second case recorded in gynecological literature of
an aneurism of the uterine artery, the first being the case of Mars.^
The present case having been reported in detail by Dr. Munde two
years ago (loc. cit.), it should be known in literature as his case.

Case VI. Intestinal Obstruction Due to Fibrous Band During
Pregnancy.— h. H., aged 31 years, admitted to the hospital October 22
with the following history, which was kindly given by the family
physician : Three years previous to admission the patient had given
birth to a healthy child and suffered after that from pelvic inflamma-
tion with abscess formation. After several months of illness she re-
covered and had complained only of obstinate constipation. Her
present illness dates back five days, when her physician was called
for nausea and abdominal pain. The patient being in the seventh
month of pregnancy, the symptoms were ascribed to that condition
and morphine was administered, followed by relief only for a time.
Forty-eight hours after onset violent vomiting again set in and the
patient began to bleed profusely from the vagina. The pain became
localized in the lower part of the abdomen. On vaginal examination
the cervix was found open and the placenta was felt laterally im-
planted. A diagnosis of placenta previa was made. The abdomen
was said to be relaxed, the only tumor palpable being the pregnant
uterus. Accordingly an accouchement force was practised, an in-
ternal version was done, and the child extracted. After the opera-
tion an extensive laceration of the cervix was noticed. Later, on the
same day, the patient vomited a great deal of bile-colored fluid and
again began to bleed from the vagina, which was packed and the
hemorrhage thus controlled. On the third day the pulse ranged be-
tween 104 and 120; the vomiting continued; the abdomen was lax,
but there was marked tenderness in the hypogastrium. On the fourth
day the pulse became more rapid, irregular, and weaker; the tem-
perature was 103° F. ; the abdomen became distended; pain and
vomiting continued; the bowels did not respond to enemata and had
not moved since the illness began. The patient now complained of
pain at the right border of the ribs, but there was nothing palpable,
in this region. On the fifth day there was no change, except that a
small, tender mass the size of an orange, dull on percussion, could be
felt in the right hypochondrium. In view of the fact that the lacera-
tion of the cervix was high up, and with a mass on the right side, the
condition of rupture of the uterus with hematoma in the broad liga-

'Mars. Wiener med. Woch., No. 37, 1891.



BRETTAUER: REPORT OF THE GYNECOLOGICAL SERVICE — 1902. 457

ment was at first suspected by me when. I saw the patient in consulta-
tion. During" the day this mass became larger.

During the evening of the fifth day, October 22, the patient was
admitted to the hovspital and immediately anesthetized. A vaginal
examination disclosed a right lateral laceration of the cervix. The
latter was soft and friable. The torn edges and the substance of the
cervix were gangrenous; the posterior vaginal vault was extensively
lacerated; the layers of the broad ligament were separated and con-
tained foul-smelling serum and blood. The uterus was soft and not
well contracted. On the right side of the abdomen a mass was felt,
the size of a cocoanut, elastic, easily palpable and movable. Aspira-
tion yielded a foul-smelling, bloody fluid. Through a transverse lum-
bar incision the mass was found to be intraperitoneal. The peri-
toneum was opened and the mass delivered. A complete obstruction
of a loop of small intestine was found, the obstructing element being
a very firm fibrous band ; the included loop of intestine was com-
pletely gangrenous and distended with the same foul-smelling fluid
w^hich was previously aspirated. The gangrenous loop was resected
and the afl:erent and eft'erent loops of intestine were sewn into the
wound. The patient Avent into collapse two hours after the operation
and died.

SYNOPSIS OF FATAL CASES.

Case I. Fibroids of Uterus: Diabetes. —A. M., 45 years old, died
December 31, 1901. Patient came to the hospital with a foul vaginal
discharge due to necrotic fibroids ; her urine contained from four to
six per cent, of sugar. She Avas not operated upon, but died in dia-
betic coma five days after adjiiission.

Case II. Fibroids of Uterus: Umbiliced Hernia: General Fibrino-
purulent Peritonitis. — E. S.. -34 years old, died January 4, 1902.
Patient came to the hospital complaining of prolonged, profuse
menstruation. Examination revealed a large fibroid uterus, for which
a hysterectomy was done on December 31, 1901. On account of the
marked adiposity and an adherent intraligamentous cyst which burst,
the operation was rendered difficult, requiring two hours, throughout
which the patient's condition was good. The raw surface left by the
removal of the cyst required drainage through the vagina. On the
second day after ojieration she developed all the symptoms of a
general peritonitis, of which she died on the fourth day after opera-
tion. A wound examination showed a general peritonitis with a small
Amount of sanguineous seropurulent fluid.

Case TIL Infeeted Hcmatoeele : Sepsis.— 'R. B., 27 years old, died
January 19, 1902. For three weeks before admission on January 15,



458 MOUNT SINAI HOSPITAL REPORTS.

patient complained of pains in the lower part of the abdomen, with
continual bleeding from the vagina, some fever and chilly sensations.
Examination revealed an hematocele, for which an anterior vaginal
section was done on January 18. In attempting to strip back the blad-
der it was denuded of its muscular coat, and the mucous membrane
prolapsed and presented in the wound. The hematocele was opened
and irrigated, foul-smelling, old blood clots and fresh blood coming
away. The cavity was then packed with gauze. The patient reacted
poorly. Her abdomen became distended, temperature 103.8° F., and
signs of a secondary internal hemorrhage made further intervention
seem necessary in spite of the septic condition. On January 19 a
laparotomy was performed. The hematocele cavity was again
emptied of its clots, and all bleeding stopped ; it was well walled off,
excepting at one point where a loop of intestine and a small section
of already gangrenous omentum protruded. This was resected and a
Mikulicz packing inserted. The patient required vigorous stimula-
tion on the table, never rallied, dying six hours after the second
operation.

Case IV. Tuhercular Perifonitif;: Exhaustion. — E. H., 36 years
old, died January 22, 1902. Patient entered the hospital in October,
1901, giving a history of tubercular peritonitis, substantiated by
physical signs. On November 6 an exploratory laparotomy was per-
formed by Dr. Munde. Omentum and intestine were found adherent
to the abdominal wall, and all the intestines well matted together;
very little free fluid was present. Several adhesions were broken
up in order to examine the tubes and ovaries. The patient developed
a fecal fistula, ascites became marked, and she gradually failed, dying
two and a half months later.

Case V. Fibroids of Uterus: Myocarditis.— B.. K., 52 years old,
died January 31, 1902. Abdominal hysterectomy was performed on
January 30. Before the operation the patient showed signs of myo-
carditis. Soon after operation her pulse became rapid, weak, and
irregular, and did not respond to stimulation. Temperature normal.
She died twelve hours after operation.

Case VI. Abortion: Pelvic Peritonitis.— X. S., 24 years old, died
February 19, 1902. Four days before admission the patient aborted
and was curetted on the same day. Two days later she was again
curetted. She was suffering from severe abdominal pain, chills, fever,
and vomiting. On admission to the hospital on February 18 she was
practically moribund and beyond the possibility of any surgical inter-
vention.

Case VII. Uterine Fibroid: Apoplexy (Post-operative).— M. L.,
46 years old, died February 21, 1902. Patient was admitted to the



BRETTAUER: REPORT OP THE GYNECOLOGICAL SERVICE — 1902. 450

hospital oil February 18, when an abdominal hysterectomy for fibroids
was performed. The patient reacted well after operation, except
for a somewhat irregular pulse. On February 21, at 11 :40 p.m., she
suddenly had a clonic spasm of the right side of the body, respiration
became stertorous, pulse imperceptible, and she died within ten
minutes.

Case VIII. Postpartum Streptococcemia ( N 0)i-traumatic) .—¥ . G.,
26 years old, died March 5, 1902. Two weeks previous to admission
the patient was normally delivered of a full-term child. Since de-
livery had had chills and fever. Admitted to the hospital on Februaiy
28. Examination revealed an enlarged soft uterus with a Avide-open
cervix. Patient ran a continuous high temperature, became uncon-
scious on the second day after admission, and died three days later.
Blood culture revealed streptococci.

Case IX. Uterine Fibroids; Diseased Appendages ; Post-operative
Sepsis. — C. B., 40 years old, died May 1, 1902. Patient entered the
hospital on April 25 and had an abdominal hysterectomy performed
on April 28. At this time a catgut was being tried in the hospital
which was prepared in a new way. Two days after operation the en-
tire abdominal wound was found to be broken down and suppurating.
The patient died of sepsis on May 1.

Case X. Aneurism of Uterine Artery. — See Case V. of Special
Cases, page 454.

Case XI. Douhle Pyosalpinx; Post-operative Sepsis.— J. F., 29
years old, died May 16, 1902. Patient was admitted to the hospital
on May 11 with a diagnosis of diseased appendages. She was oper-
ated upon for the latter on May 14 by median laparotomy. The dis-
eased tubes on the left side were adherent to the sigmoid and the
i-ectum. In trying to shell out the mass a rent in the peritoneum
was made in the sigmoid flexure about two inches long; this was
sewed with fine catgut and the appendages were removed. The tube
on the right side was found adherent to the cecum and was excised
in the same way. Soon after operation the patient developed symp-
toms of sepsis and died two days later. The postmortem examination
showed no general peritonitis ; the posterior surface of the uterus
was covered with slightly adherent intestines. The coil which was
denuded of peritoneum during operation and was covered with meso-
colon was found permeable, but slightly strictured, no leakage from
the intestine having been possible. The spleen and liver were soft.

Case XII. Puptured. Ectopic Gestation; Post-operative Slwck. —
H. L., 36 years old, died June 2, 1902. Patient entered the hospital



460 MOUNT SINAI HOSPITAL REPORTS.

on May 30 with an indefinite history of pain in the right iliac fossa;
no vaginal bleeding, no other symptoms. Examination revealed .t
wide-open, soft cervix. On June 2, at 5 p.m., she was curetted and
sent back to the ward. Half an hour later she suddenly developed
all the symptoms of shock and internal hemorrhage. Since there was
no hemorrhage, a lajoarotomy was done and a ruptured tubal preg-
nancy wa.s found on the right side, with considerable blood in the
abdominal cavity. Although the patient was vigorously stimulated
and received several infusions, she died half an hour after the second
operation.

This patient was curetted by the house surgeon before an examina-
tion had been made by me. Most probably rupture occurred during
the performance of the curettage.

Case XIII. Pyosalpinx and Peritonitis ( Post-operative ) .~R. K..
30 years old, died June 25, 1902. Patient was operated upon for
pyosalpinx on June 17. Dui-ing the operation the tube burst and
the pus was car-efully mopped up. Since the peritoneal cavity was
well walled off by packings, no drain was inserted and the abdominal
wound was closed. A week later the patient died of peritoneal sepsis.

Case XIV. Abscess of Broad Ligament and Pyopneumothorax. —
B. L., 30 years old, died June 30, 1902. On entering the hospital, ^lay
9, the patient gave a histoiy of chills and fever and abdominal pain,
following childbirth. Examination revealed a mass on the right
side of the cervix and pus coming from the cervix. On May 17 a
pelvic abscess was evacuated and drained. A week later the vaginal
incision was enlarged, but no further pus Avas obtained; still the pa-
tient ran a septic temperature. Blood cultures were negative. On
June 11 she developed signs of pnevnnothorax, of which she finally
died.

Case XV. Tuberculosis of Uterus and Adnexa; Post-operative
Shock. — G. F., 37 years old, died August 3, 1902. Patient was ad-
mitted to the hospital on July 29. On August 2 a hysterectomy
Avas performed. In removing the left appendages a profuse hem-
orrhage occurred, due to separation of the layers of the broad liga-
ment. On account of the poor condition of the patient, a thorough
investigation into the cause of the bleeding could not be made. Pack-
ing was resorted to. The patient reacted poorly and failed to respon-l
to vigorous and repeated stimulation. She died twelve hours after
operation.

Case XVI. Uterine Polyp; Uterine Fihroids; Post-operative
Shock.— li. L., 42 years old, died August 14, 1902. The patient en-
tered the hospital July 31. Examination revealed a large uterus with



BRETTAUER : REPORT OF THE GYNECOLOGICAL SERVICE— .1902. 4G1

a nodule in the anterior wall ; a large, soft cervix presenting in its
middle a red, hard mass three-quarters of an inch in diameter. On
August 1 the polyp was removed by torsion and the uterus curetted.
A few days after the operation the patient began to run temperatures
ranging from 99° to 103° F. Examination showed a mass on the
right side of the abdomen. On August 13 the mass was opened and
a considerable amount of pus evacuated. At the same time a vaginal
hysterectomy was done by morcellation. She died twenty-four hours
after operation.

Case XVII. Maligtiant Endocarditis; Streptococcemia . — '^. H., 28
years old, died September 15, 1902. Patient entered the hospital on
September 14 in a comatose, septic condition with a temperature of
104° F. and pulse 140. Physical examination revealed nothing but a
systolic murmur at the apex of the heart and subconjunctival and
subcutaneous hemorrhages. Vaginal examination was negative.
Blood cultures revealed streptococci. The postmortem examination
showed a malignant endocarditis involving the mitral valve.

Case XVIII. Carcinoma of the Ascending Colon; Betroperitoneal
Abscess.— H. K., 72 years of age, died October 15, 1902. The patient
Avas admitted on September 17 with chronic intestinal obstruction
due to carcinoma of the ascending colon. An ileosigmoidostomy, by
means of a INIurphy button, was done on September 18, after which
the patient had no further obstruction of the bowels. The patient
finally died on October 15 in a cachectic condition. The postmortem
examination showed an ulcerating carcinoma of the ascending colon,
with a posterior perforation into the retroperitoneal tissue, causing
a large abscess cavity with necrotic walls.

Case XIX. Appendicitis; General Peritonitis. — G. D.. 18 years
of age, died October 29, 1902. Patient entered the hospital on Oc-
tober 25 with a history of appendicitis. Examination showed a dis-
tended, tender abdomen, with marked tenderness in both iliac regions.
An appendicectomy was performed and a small ovarian cyst Avas also
removed. A general peritonitis with free fluid Ava.s found. The pa-
tient died four days after operation, of a general peritonitis.

Case XX. Intestinal Obstruction Due to Fibrous Band During
Pregnancy; Intestinal Resection.— See Case VI. of Special Cases, page
456.

Case XXI. Premature Lahor ; Septic Endomefritis.—'R. G., 28
years old, died May 19, 1902. Patient developed an acute sepsis after
a premature labor. She was admitted to the hospital on ]\Iay 16,
curetted, and died on May 19.



462 MOUNT SINAI HOSPITAL REPORTS.

Case XXII. Pelvic Abscess; Post-operative General Peritonitis.—
S. B., 25 years old, died June 7, 1902. Patient was admitted to the
hospital on June 2 for acute pelvic peritonitis with abscess forma-
tion. On June 4 an abdominal incision was made, and an abscess in
the broad ligament burst during manipulation. The peritoneum be-
came accidentally contaminated. After the operation the patient
developed- a general peritonitis and died on June 7.

An analysis of these cases shows that they naturally group them-
selves primarily into two divisions— those which were operated upon
and those which were not. Of the latter group, Cases I., VI., VIII.,
XVII., and XXI. were not subjected to operation, and all came into
the hospital suffering from sepsis or were moribund at the time of
admission. Five cases are thus at once deducted from the total ot
twenty-two deaths.

Of the patients who died of shock, Cases X. and XX. are discussed
at length under the heading of Special Cases. Case XII. died of
hemorrhage due to a ruptured tubal pregnancy which was not recog-
nized, as described in the history, while Cases XV. and XIX, were
weak and miserable patients, debilitated by their long suffering from
tuberculosis. Case IV. died of exhaustion from the same cause, while
an active myocarditis aecounted for the death of Case V., and Case
VII. died of a typical apoplexy for which the operation was un-
doubtedly the exciting cause. Case XVII. suffered from carcinoma
with a perforation of the intestine, and Case XIX. entered the hos-
pital Avith her fatal peritonitis. In all these cases the death of but
one (Case XII.) can be attributed directly to the operation, unless
we regard the operative intervention in Case VII. (apoplexy) as
having been directly responsible for the patient's death. This gives
us a total of thirteen cases out of twenty-two deaths in which the
fatal issue would have occurred even if no surgical manoeuvre had
been practised.

Of the remaining eight cases, in all of which death intervened
from sepsis (all but Case III., who entered the hospital in a septic
condition), the fatal result in Cases XI., XIII., XVI., and XXII.
is to be assigned directly to the operation, in Case XIII. a ruptured
pyosalpinx being the starting point of the fatal sepsis. In Case II.
fat necrosis was responsible for the fatal issue. In Case IX. the evil
result was correctly attributed to the use of catgut which had been
sterilized by a new method and which gave equally unsatisfactory



BRETTAUER: REPORT OF THE GYNECOLOGICAL SERVICE— 1902. 463

results in the other branches of the surgical service. Case XIV.
died of a pyopneumothorax which cannot be attributed in any way
to the treatment the patient received.

Of all the twenty-two deaths, therefore, there are but five which
can be directly traced to operation; that is, but five in which the
patient died as the result of the treatment, although even in some of
these instances a fatal termination to the disease might have followed
at a more remote time. Seventeen deaths were thus unavoidable and
are to be assigned, not to the operative measures pursued, but to the
diseases or conditions from which the patients suffered.



A SERIES OF NINE CONSECUTIVE CASES OF ECTOPIC

GESTATION.

By Hiram N. Vineberg, M.D.,

ADJUNCT GYNECOLOGIST.

During my term of service in the summer of 1902 there occurred
nine cases of ectopic gestation that were subjected to operation. As
each case presented some feature of interest, I thought it might be of
value to narrate the histories of the series, making such comments
as the facts of the individual case might call forth.

Case I. — R. Z., aged 27 years; married three years; no children;
one miscarriage two years ago, cause unknown. Admitted to the hos-
pital August 16, 1902.

Last menstruation occurred three weeks ago. For some time past
the patient has complained of pain in the right iliac region. Four
weeks ago this pain grew worse and for two days there was incessant
vomiting. The pain has continued.

On bimanual examination the uterus was found to be in a forward
position. On the right side of the uterus and posterior to it a resist-
ing globular mass, about the size of an orange, was felt. Shortly
after the examination the patient was seized with a sharp, lancinating
pain in the lower part of the abdomen. These pains persisted and
about one hour later there was a slight uterine bleeding. On ex-
amination the tumor which had been felt before was no longer pres-
ent; instead one felt a soft, fluctuating, irregular mass filling the
pelvis posteriorly and pushing the cervix forward. The pulse be-
came very frequent (104) and was rather small. Dr. M. CI. Seelig,
the house surgeon, properly diagnosed intraperitoneal hemorrhage
and notified me at once. I responded immediately and on my arrival
found the local condition had changed as above noted. The patieni
showed marked signs of anemia. She was at once taken to the
operating room and prepared for laparotomy. On opening the abdo-
men there was a free escape of fre.sh blood and blood clots. The right
tube and ovary were seized and brought into the incision, and it was
found that the tube was the seat of an ectopic gestation at the am-
pulla portion. The tube and ovary were ablated, the blood clots
removed as rapidly as possible, and the abdomen closed with tier
sutures. The patient rallied promptly and made a good recovery.



VINEBKRG : ECTOPIC GESTATION. 465

In the foregoing case there was no dehiyed nor irregular menstrua-
tion—the sine qua nan, according to some authors, of ectopic gesta-
tion. The menses had been regular, the last regular menstruation
liaving occurred three weeks before admission to the hospital. The
patient had had pelvic symptoms for several months, as manifested
by pain in the right groin. On examination a semi-fiuctuating tumor
is found behind and to the right of the uterus. AAQiat was more