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J. A. (Joel Asaph) Allen.

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1. Read beforo the Gynecological and Obtttetrical Society of Baltimore.



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734 SELECTIONS.

epileptic attacks for over two years. Ovaries presenting this
appearance are not rarely seen in abdominal section. I am informed
that some surgeons simply extirpate the hematoma, stitch ap the
wound in the ovary, and drop the organ back into the pelvis. I
may be permitted to express doubt whether any good purpose is
served by this so-called *^ conservative " surgery. In all cases of
this kiud that have come under my notice, there were either adhe-
sions or displacements of the ovaries, which are among the recog-
nized indications for removal of these organs. Dr. B. F. Baer, who
is known as a very careful and conservative surgeon, says in refer-
ence to these cases :' ^^ Diseased ovaries, when due to hemorrhage
into the Graafian follicles to such an extent as to produce the con-
dition known as ovarian hematoma, should be removed. They
cause intense suffering and there is no other means of relief.^'

Dr. Mary A. Dixon Jones, of Brooklyn, and Dr. Francis Foerster
are of the opinion that hematoma of the ovary is preceded by con-
ditions termed by them "Gyroma " and " Endothelioma.'^ Indeed,
the latter writer, basing his opinion upon somewhat extended
microscopical study of ovaries, normal and pathological, claims
that " what previously was called a corpus luteum is invariably an
endothelioma.'' That the corpus luteum is an endothelial structure,
may be accepted without dispute ; that it should be called by a
name heretofore applied to a malignant new formation, or that the
consequences attributed by Foerster to this body hitherto consid-
ered so innocent, really follow in many cs^es, is, I think, open to
grave doubt. Chronic oophoritis and peri-oOphoritis, endarteritis
and sclerosis are mentioned as histological findings, and pain and
distress as clinical manifestations due to ovaries undergoing these
morbid changes.

Dr. Foerster connects the corpora lutea with the production of
hematoma as follows : << In my own experience a large number of
so-called corpora lutea of menstruation are endotheliomata of a
pathological type. They grow under the influence of a chronic
oophoritis without coming to a typical end, or gradually increas-
ing in bulk and frequently leading to the formation of hematoma
under incessant local and constitutional trouble.

It will, I think, be generally conceded that a hemorrhage into
an ovarian follicle, or into ovarian stroma, does not take place
when the ovary or the blood-vessels preserve their normal structural
integrity. Some nutritional change must have preceded the
hemorrhage. It is most reasonable to believe that this change is



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HEMATOMA OF THE OVARY. 735

in the blood-vessels of the ovary. Whether this nutritional dis-
turbance is due to new formations properly dignified by the names
" gyroma " and " endothelioma," or whether it is simply the result
of ohronic inflammation, is a question that must be referred to the
pathologists for further investigation. RoUin', who has recently
made a study of ovarian hematoma, gives chronic oophoritis as a
local condition antedating the hemorrhage.

While the occurrence of small collections of blood in the
Graafian follicles and minute extravasations in the ovarian stroma
is not infrequent, the cases of so-called ovarian apoplexy, where
the entire ovary is converted into a blood-cyst, varying from a
billiard-ball to a fetal head in size, are much more rare. The case
presently to be related shows, however, that there is no essential
difference between the two classes of cases.

The case referred to is as follows :

E. L. , born in United States, white, aged 21 years, single, was admit-
ted to the Maryland Hospital for the Insane, November 18, 1893. Until
a month before admission there had been no mental disturbance beyond
a few hysterical attacks of varying severity, sometimes accompanied by
convulsions. Her disposition was usually amiable, although she was of
rather unstable temper. Her habits were always industrious. So far
as was ascertained there was no hereditary pre-disposition to insanity.
The hysterical outbreaks were usually coincident with the menstrual
periods, and have only been present for the past four or five years. Up
to a year ago her physical condition was very good, but for three years
she has suffered with a good deal of pain during the catamenia. About
a year ago she consulted a gynecologist, under whose care she remained
for several months with apparent improvement. During the last three
or four weeks before admission, a great change in her behavior was
noticed. She became exalted, talkative, silly in conversation and
action. When admitted, she carried a large doll, which she caressed
and talked to in a childish manner. She was neat and cleanly in dress
and habits and never noisy or maniacal. No apparent sexual excite-
ment. At the end of two weeks she had lost all her delusions and was
apparently restored to her normal mental condition. At the approach
of the next menstrual period she became hysterical, had several con-
vulsions, foamed at the mouth, screamed, or lay with eyes staring or
closed. Reflexes normal. During these attacks she was unquestion-
ably conscious of what was going on around her. One evening she set
fire to her clothing, but the fire was promptly extinguished, and
only a slight superficial reddening of small areas of the skin was
produced. No serious results followed this attempt at self-destruc-
tion.



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786 SELECTIONS.

After the period was over, her normal mental condition returned,
but she did not improve physically. She lost appetite, had nausea and
became thin and anemic.

The pains in the iliac region persisted and became especially severe
on the left side. Occipital headache, rhachialgia and pains in the limbs,
with attacks of nausea and vomiting, were also present.

On January 18, 1894, a vaginal examination demonstrated an elastic
swelling behind and to the left of the uterus, which was exquisitely
sensitive to the touch. To the right there appeared to be an enlarged
and prolapsed ovary. The uterus was adherent posteriorly, but some-
what movable.

The clinical diagnosis of adherent uterus, prolapsed ovary on the
right and cystic ovary or ovarian abscess on the left side was made, and
an operation for the relief of these conditions recommended to her, and
her consent readily obtained. Inasmuch as she was, and had been for
some weeks, entirely rational, her own consent was considered sufficient
authority to proceed.

Abdominal section was done on January 28, 1894. Passing two
fingers through the incision down to the fundus, this was found
adherent, the tubes and ovaries on both sides being also bound
down by adhesions. After carefully separating the latter, the right
ovary, enlarged to the size of an English walnut, was brought up,
ligated together with the thickened tube close to the uterus, and
removed. In place of the left ovary was a cystic tumor as large as
a mandarin orange, which ruptured as it was brought out of the abdomi-
nal wound, and discharged a lot of softly-coagulated blood. My first
thought was of an ectopic pregnancy, but, as an examination of the
specimen will show, this was a mistake and an unjust suspicion. After
the tube and remains of the cyst were ligated and removed, the perito-
neal cavity was flushed out with hot, distilled water, and the abdomi-
nal wound closed with Silkworm gut sutures. No drainage.

The subsequent course was uneventful, except that on the second
day the temperature rose to 101 degrees F., and the pulse to 102. After
a purgative enema of magnesium sulphate and glycerine, this slight
disturbance vanished.

The stitches were removed on the seventh day and the wound was
found dry and thoroughly united. Patient out of bed on the twenty-
first day.

Since the operation the patient has suffered no pain, is cheerful and
industrious, not hysterical and has gained flesh. Her mental condition
apparently normal. The patient was discharged entirely recovered
March 15, 1804.

The walls of the blood cyst are apparently composed of oyarian
stroma ; the tube is somewhat thickened, but contains no pus.



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HEMATOMA OF THE OVARY. 1Sl

The right ovary, on section, shows two blood-clots about the size of
hazel nats, apparently occupying unruptured Graafian follicles.
This case seems to show, on the two sides, examples of two forms
of ovarian hematoma which are, however, rarely associated in the
same individual. If any conclusion can be drawn from a single
case, it is that the rather common follicular hematoma and the
infrequent ovarian apoplexy are identical in origin.

Winckel' refers to three cases of follicular hemorrhage into the
ovaries after severe burns. The burn which my patient received
about a month before the operation might be considered sugges-
tive, if it had been more serious. The firm adhesions were, however,
evidence of a longer duration, at least of the local inflammatory
condition.

Of the more recent cases reported, is one by Doran in Vol.
XXXII. of the Transactions of the London Obstetrical Society.
Doran considered it a hemorrhage into the ovarian stroma from rup-
ture of a follicle. The cyst wall was one-eighth of an inch thick and
consisted of ovarian stroma. Dr. Mund6* briefly reports a case of
hematoma of both ovaries, one being the size of an orange and the
other of a hen's egg. Dr. £. E. Montgomery,^ in commenting on
this case, refers to a similar one under his observation. Dun-
can reports a case in which there was hematosalpinx in connection
with the ovarian hematoma. The history of the case suggests
ectopic pregnancy, which seems, however, to have been excluded.

I am reminded here of a case which I saw about twelve years
ago in the service of late Dr. A. F. Erich at the Maryland Woman's
Hospital. The patient was a white, single woman, 35 years of age.
The tumor, supposed to be an ovarian cystoma, was about the size
of a fetal head, and when brought to the abdominal incision and
tapped with the trocar, thick, black blood was evacuated. The
patient died of purulent peritonitis about the fifth day, and at the
autopsy a perforation of the rectum was found. How this was
produced could not be cleared up. It may have been torn through
in separating adhesions. A number of apparently similar cases, in
which the cyst ruptured and caused death from septic peritonitis,
are recorded by Bemutz and Goupil, but most of these were proba-
bly eases of extra-uterine pregnancy.

An ovarian hematoma may rupture and give rise to a pelvic
hematocele. In other cases the bleeding may continue and the
patient die of hemorrhage. The most serious danger from rupture
is, however, peritonitis and sepsis. I am informed by Dr. Joseph



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738 SBLECTIONS.

Price that the contents of an ovarian hematoma are usually exceed-
ingly virulent and liable to cause septic peritonitis, if the blood-
cyst is allowed to rupture within the peritoneal cavity.

The diagnosis of ovarian hematoma cannot be definitely made
before abdominal section. Even when rupture occurs and a hema-
tocele is formed, the diagnosis rests between several conditions,
often differentiated with the greatest difficulty, even after operation.

The only rationally indicated procedure is removal of the
affected organ by abdominal section.

REFERENCES.

1. Proceedings Philadelphia Obstetrical Society, June 12, 1898.

2. Frauen Krankheiten, 2 Aufl.. p. TOi).

3. Anuriean Journal of Obstetrics, June, 1800, p. 038.

4. Sajous* Annual, 1801, II., G. 40.

5. Ibid. 1806, II., G. 6.

— Maryland Medical Journal,



Breech Presentations. — Etienne reports a series of fifty breecb
labors, with viable fetuses, with no infantile mortality — a remark-
able result, considering the usually accepted mortality of 10 per
cent, or even 25 to 33 per cent. (Hegar) in primiparous cases.
Etienne^s cases were conducted in the Nancy lying-in hospital
between 1888 to 1891 ; there were seventy-six cases in all; but
twenty-six were rejected in which the fetus was either dead ante>
partum or non-viable. The secret of the success in the Nancy clinic
is a skilfully exerted suprapubic pressure during the extraction,
whereby the extension of the head and the slipping up of the arms
are prevented. This is no new manoeuver ; it has long been taught
in the best schools, and its importance is occasionally emphasized
in journal articles. It is probable that the usual mortality, while
partly due to a general want of obstetric skill, is almost entirely
attributable to the want of intelligently applied vis a tergo while
the operator is making traction on the child's legs and trunk.
Unquestionably well directed pressure in the proper axis on the
fundus uteri through the abdominal walls will almost invariably
prevent the extension of the head and the upward'displacement of
the arms ; and consequently it should be an invariable rule of prac-
tice that the obstetrician should have with him, during the second
stage of breech cases, a skilled assistant. It is not enough to send
for assistance after the arrest of the head has taken place, for then
it is too late« We are confident that if the above rule is conscien-
tiously followed, the fetal prognosis in breech cases will be greatly
improved. — Columbus Medical Journal.



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THE NATIONAL MEDICAL SOCIETIES. 739

BUFFALO MEDICAL AND SURGICAL JOURNAL

A MONTHLY REVIEW OF MEDICINE AND SURGERY.

EDITORS:
THOMAS LOTHROP, M. D. - - WM. WARREN 'POTTER, M. D.

All communications, whetlier of a literary or business nature, should be akidressed
to the managing editor: 284 FRANKLnr Strkbt, Buffalo, N. Y.

Vol. XXXIIL JULY, 1894. No. 12.

THE NATIONAL MEDICAL SOCIETIES.

The Spring meetings for the year 1894 have been held, and the
work of the societies has passed into history. The medical jour-
nals are publishing the papers, and will continue to do so until all
have appeared, which, probably, will occupy most of the available
space for the remainder of the year.

Whether 'the work accomplished will constitute a contribution
to medical literature that will advance the science and art of medi-
cine, remains to be determined when the record shall be completed
and the transactions published. Some idea, however, as to the
quality of the work done has been foreshadowed by the synopsis
published in the several medical weeklies.

The Congress of American Physicians and Surgeons, that
embraces several of the special associations, met in Washington, May
29, 30, 31 and June 1, 1894, and gathered together something over
400 of the representative specialists of the country, and this organi-
zation may properly be designated as the medical << Four Hundred."
It may be expected that the work done in Washington will prove, for
the most part, of a scientific nature, yet there must be necessarily
some chaff even among the best quality of wheat, but the
separator — the medical journals of the land — will soon get in its
work.

This Congress has one great essential feature of commendation
— namely, that it devotes its entire time to the consideration of
scientific papers, and does not allow medical politics to interfere
with its work. It has no code of ethics to wrangle over, and yet
its members are gentlemen ! Its executive committee performs
the entire business part of its work, even to. the choosing of its



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740 EDITOBIAL.

oflScers and to designating its subordinate committees. It permits
no sideshows to attract its members, and its model is worthy of
imitation.

Let as turn to the other side of the picture. The American
Medical Association goes junketing across the continent and
appoints its meeting in San Francisco, in the year of the greatest
financial distress that the country has experienced since antebellum
days. Ordinarily speaking, from a business standpoint it would
be considered poor policy to appoint a meeting at such a distance
in such a year. But one need not go so far in search of the real
object without finding it. Last year, at Milwaukee, it found itself
<;onf routed with constitution and code amendments that its old
masters feared to meet in the East, where the majority has been
«teadily growing against them.

If there is anything the Nestors of the American Medical Asso-
ciation dread, it is a change in its code of ethics. These men can-
not recognize or contribute to the progress that is everywhere
around them taking place. So it seeks to dodge the question by
appointing the meeting in San Francisco, in the expectation that
few from the East would attend, and, as if to make tbis more cer-
tain, the date was fixed so near the meeting of the Washington
"Congress as to practically prevent attendance upon both. At San
Francisco, a majority of the committee was in favor of revision,
and so, as it proved, was a majority of its members. This was
shown by the fact that 151 votes were cast in favor of, and 64
against, revision, but the astute chairman, one of the old hard-
shells of the Association, announced that a three-fourths vote
was required to change the constitution ; so the proposition was
defeated, hence everything stands as before the San Francisco
meeting.

The aggregate attendance was about 600, a large proportion of
which came from the Pacific slope. Some of the section meetings
were poorly attended, necessitating the consolidation of a few,
and the work of the Association, as a whole, fell below the aver-
age standard.

Dr. Donald Maclean, of Detroit, was chosen president, and the
next meeting was appointed to be held in Baltimore, beginning on
the first Tuesday of May, 1895, with Dr. Julian J. Chisholm, of
Maryland, as chairman of the committee of arrangements. Let us
hope fhat the Baltimore meeting will result in a work of redemp-
tion for the American Medical Association.



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TOPICS OF THE MONTH. 741



TOPICS OF THE MONTH.



The New Orleans sewerage system was inaugurated April 18, 1894^
with imposing ceremonies in the presence of the mayor, public
officials and a large concourse of representative citizens. It seems
strange that this delightful and populous city should have surface
drainage until the closing years of the nineteenth century. This
has been a great drawback to its advancement, but we now pre-
dict that within a few years New Orleans will become the most
populous and representative city in the South. The establishment
of this new system of sewerage is largely due to the efforts of Dr.
Joseph Holt, whose fame as a sanitarian is known throughout the
world. He has been very properly selected as the president of the
new sewerage company, which is a guarantee that its work will be
prosecuted with promptitude to a successful issue.



This journal has worked hard for many years to deserve the con-
fidence of the profession at home and abroad, and particularly has
it aimed to further the interests of medicine in Western New York.
Its loyalty to Buffalo and the physicians who reside here cannot be
questioned, as its record for nearly fifty years indicates. Our
friends will bear testimony to the fact that we rarely refer to our-
selves in the Journal pages, but we cannot refrain from printing
the delicate and appreciative compliment that the Kansas City
Medical Itidex pays us in its issue of May, 1894, in the following
paragraph :

Dr. H. BroDSOQ Gee, of Rochester, N. Y., has begun the publication
of the New York State Medical Reporter, under the plea that the medi-
cal profession of that section of the State has no *' medium" in which
to present report of the work of excellent local practitioners. One is
at a loss to understand why the Buffalo Medical and Surgical
Journal (one of the best medical journals in America) should not be
regarded as a representfitive of the physicians of Western New York ;
but if Dr. Gee can make his journal pay, there is no reason why it should
not be published. The initial number is a very creditable one.



The Health Department of New York City has issued an important
circular relating to tuberculosis. The circular contains the report
of Dr. Herman M. Biggs, made last year, together with certain
orders and recommendations issued by the health department.
The trend of the circular is to furnish information to the people



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742 EDITORIAL.

relating to the oommunicability and preventability of consumption.
There is much food for thought in the following paragraph taken
from the letter of Dr. Cyrus Edson, chairman of the sanitary com-
mittee of board of health, addressed to the Hon. Charles G. Wilson,
president, and made a part of the report :

First. Tuberculosis is a communicable disease and is distinctly
preventable. Second. It is acquired by direct transmission of the
tubercle bacilli from the sick to the well, usually by means of the dried
and pulverized sputum floating as dust in the air. Third. It can be
largely prevented by simple and easily applied measures of cleanliness
and disinfection.

Among the important features of this report is the action taken
by the board of health in regard to apartments occupied by con-
sumptives, which embraces the following order :

Consumption is a communicable disease. This apartment has been
occupied by a consumptive, and has thus become infected. It must not
be occupied by persons other than those now residing here until an
order of the board of health, directing that it be cleansed and renovated,
has been complied with.

Name of occupant

Floor No Street.

This notice must not be removed until the order of the board of
health has been complied with.

The department proposes to issue circulars from time to time
covering all the various phases of the question of tuberculosis and
its prevention for the education of the people in regard to these
matters. This is a wise and timely precaution and similar action
ought to be taken in Buffalo.



The New York Academy of Medicine has appointed a committee,
composed of Drs. Daniel Lewis, George Henry Fox and S. T. Arm-
strong, to confer with the Constitution Convention now in session
in regard to such changes in the constitution as may be necessary
to protect medical interests in the State of New York. We shonld
like to see this committee augmented by one representing medical
societies in Buffalo and Erie county. There are many changes that
ought to be made with reference to the conduct of the public health
offices throughout the State as well as the oflSce of coroner. It is
high time that medical men bestirred themselves on these and other
questions pertaining to the public health and the prevention of



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TOPICS OF THE MONTH. 743

disease, and we consider it opportune to confer with the constitu*
tional revisers, to the end that any essential changes in the funda-
mental law may be made under the sanction of that astute body.



It would be a great pity to have the annual appropriation for the
library of the Surgeon Oeneral's office reduced by $3,000, which is
proposed by the present appropriation committee of the House of
Representatives. It has become pretty well known that the present
Congress, feeling itself unable to cope with large questions, has
turned to the consideration of petty details, upon which it is wast-
ing much valuable time. But it is beyond the comprehension of
«ven the best friends of this body that it should propose to do so
contemptible a thing, as to curtail the valuable educational work
of the Surgeon General's office.



The second annual report of the Jennie Casseday Infirmary for
Women, a private hospital, located at 912 Sixth street, Louisville,
Ky., is received. It was established in 1801, and formally opened
April 12, 1892, for the treatment of women suffering from diseases
peculiar to their sex. Dr. L. S. McMurtry is the surgeon in
<;hargef and during the year covered by this report eighty-nine
surgical operations have been made, with but two deaths. A num.
ber of these patients were brought to the Infirmary upon matresses,
in extreme conditions, but operation was refused in no case, no
matter how perilous the state. The two deaths occurred after
abdominal section in extremely desperate cases, one suffering with
a large cancerous tumor.

This record is one that demonstrates the propriety of special
training and preparation for the work, and indicates that a skill



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 74 of 78)