of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 12 of 109)
Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 12 of 109)
Font size
QR-code for this ebook


At autopsy the peritoneum, cecum, prostate, right kidney,
gall-bladder, liver, stomach, and the whole intestinal tract
were found to be perfectly normal, but in the abdominal wall at
the anterior edge of the right quadratus lumborum muscle
was found a mass which upon microscopical investigation proved
to be a mixed cell sarcoma.

This would be another case tending to prove the connection
of traumatism and development of malignant disease.

Dr. H. N. Vineberg had operated upon two similar cases;
in neither of these was there much difficulty in making a diagnosis.
One case was a very extensive one and he experienced some
difficulty in bringing together the muscles after the operation.
As a rule, one must go quite deep into the tissues in the removal
of such tumors. He did not recall any case of large hematoma
of the rectus muscle resulting from a fall.

Dr. S. Wiener said the suggestion made that the tumor
should have been aspirated in order to aid in making a diag-
nosis was a good one, but the blood was so thick and tar-like



Digitized by



Google



NEW YORK ACADEMY OF MEDICINE. 107

that it could have been accomplished only by the use of a very
large aspirating needle. Moreover, even if some blood had
been so obtained, they still would have considered that they
had to deal with a rapidly growing, hemorrhagic, solid neoplasm.
Dr. Arthur Stein reported a case of

HEMATOMETRA IN AN AGED WOMAN.

The patient was sixty-six years old, a widow, housekeeper.
She had had two children, the last thirty years ago. Her present
illness began two and a half years ago; she had to urinate four
and five times a day and three or four times at night. She had
difficulty in urinating and had to strain in order to start the
stream. She also had a burning sensation at the end of urination.
She had no increased thirst, no loss in weight, no loss in strength,
no bleeding, no leukorrhea, but she did have pain in the lumbar
region which was dull in character. There was no edema of the
legs. She noticed that her abdomen was getting larger. She
had an external hernia on the right side about the size of a hen's
egg. The external genitals were normal. The vagina was
senile; the cervix was about one-half inch long and pushed
backward. No body of the uterus could be felt. In its place
was a large, round mass with smooth surface, which had the size
of a median-sized cantaloupe. This was cystic and somewhat
movable. The tumor occupied the whole small pelvis, and
pressed down the anterior wall of the vagina. The diagnosis
made was either myoma of the body of the uterus, or monolocular
ovarian cyst with external inguinal hernia. A panhysterectomy
was performed through a Pfannensteil incision. When the
peritoneum was opened a large mass bulged into the wound and
was found to be an enlarged uterus. It was accidentally punctured
and blood of a chocolate-brown color poured out. It contained
about twenty ounces of blood, and the sac was left collapsed.
The whole uterus, as well as the adnexa, were removed, and the
inguinal hernia was closed in the usual way. The microscopical
examination showed nowhere any signs of malignancy in the
body of the uterus; this was quite different, however, with the
findings in the wall of the cervix. Instead of finding normal
cervical glands, there were columnar cells in many layers, in some
places still maintaining the glandular type; in others they had
undergone metaplastic changes and were transformed into cells
of the squamous type. After operation and microscopical
examination the diagnosis was a large hematometra and adeno-
carcinoma of the cervix. The patient made an uneventful
recovery.

In going over the literature of the past thirty-two years he
was not able to find a similar case. All knew that hematometra
was not at all common during the period of menstrual life or in
childhood. Its causes were manifold. It might occur in young
girls with an atresia of the vagina, or with an imperforate hymen,
or with misshapen genitals. In women who had born children



Digitized by



Google



108 TRANSACTIONS OF THE

it might follow inflammatory conditions during the puerperal
state, or it might follow an inflammation of the vagina and
cervix. The most important feature in the case reported was
the fact that the patient had always menstruated regularly up
to her forty-sixth year when the climacterium set in. She felt
that her uterus was larger. One must assume that, twenty years
ago, the cervical canal became obstructed through senile invo-
lution and that during the three years in which the climacterium
was established the uterus became larger with each menstruation.
From her fortieth year up to her sixty-fourth year she felt
absolutely well in every respect. During the past two years she
complained of bladder troubles. He asked how they could
account for the bladder troubles detected only in the sixty-sixth
year of her life. The vessels were found in a high grade of
sclerosis during the operation; it might be possible that during
the strain one of the vessels of the uterine wall burst and poured
blood into the already distended uterine cavity. This would
account for the pressure against the bladder. Again, as they
were dealing with a carcinoma of the cervix, it was very likely
that during its slow growth some of the vessels of the uterine wall
became eroded and the blood had to pour into the uterine cavity.
It was yet to be solved why the patient was absolutely well for
about fifteen years after her climacterium.

Dr. Eugene Coleman Savidge reported a similar case. A
lady of position, sixty-five years old, came to his office apparently
presenting an ovarian cyst, which she wanted removed. To
learn position of the uterus, a sound was inserted, which was
immediately followed by a terrifying gush of dark unclotted
blood. He washed out the uterus, packed, and sent the patient
to a neighboring hotel in a cab. She made a good recovery,
the uterus coming down to nearly normal. Three years later,
when sixty-eight, she had a similar occurrence, the uterus was
again emptied as before. A third time the uterus filled up, the
patient only being seen when her tumor became evident to her.
There was no pathological report. There was no malignant
condition. The patient died of diabetes some distance from
New York about six years after first coming under notice.

the care of pregnancy and labor complicated by nervous
overdevelopment.

Dr. FRANKLIN'S. Newell of Boston read this paper. He
stated that there was a widespread theory in the medical pro-
fession as a whole that the duty of the obstetrician was satis-
factorily performed if the maternal life was saved. The life of
the child was usually considered as a secondary matter and the
after-health of the mother received little or no consideration
from the average practitioner. No man should feel that he has
conducted a case of labor properly in which a child which has
reached a viable age is lost when he has had personal charge of
the case throughout pregnancy and labor. A labor which



Digitized by V3OOQ IC



NEW YORK ACADEMY OF MEDICINE. 109

results in invalidism to the mother through lack of appreciation
of the conditions present, due either to physical injuries, which
have not received proper attention, or to nervous injuries through
a blind adherence to a conservatism, which demands non-
interference with natural proceses, must be counted as a failure,
and the obstetrician who can number many such cases in his
practice should consider most carefully whether the reason is not
his own unfitness for the work rather than the conditions which
are present in the individual patients. Many serious injuries
may be inflicted upon the child which may seriously affect its
after-health. Each injury must be considered as at least a
partial failure to conduct the case properly, unless before delivery
the possibility of such injury is considered and the choice of
treatment made freely with deliberate intent to run serious risks
for the child for the sake of lessening the risk to the mother.
The after-health of the mother is a consideration which should
receive serious attention in each individual case, but which is
seldom considered until too late. Each patient must be carefully
studied, particularly in relation to her power of standing pain
and what effect the long continued pain of labor may have upon
her after-life. The nervous history of the patient must be
studied to learn how she has endured such burdens as have been
laid on her in the past. Is she nervously equipped to undergo
what is usually a severe though not an overwhelming strain to
the normal woman. If these questions can be satisfactorily
answered the patient may properly be subjected to an ordinary
labor and we have nothing to do except to forsee, as far as
possible, the occurrence of possible complications of labor.

In considering the conditions which exist to-day we must
recognize that the modern civilized woman is a doubtful risk
nervously although she may be physically well equipped. It is
therefore an important part of our professional duty to lessen
the strain during pregnancy and labor by every means which
modern surgical science has given to us, in order that the great
event of her life may leave no serious after-effects. Tradition
has been a large factor in obstetrics for many years and still
continues to be so. This is because pregnancy and labor have
so long been considered as natural physiological processes.
This should be the case, but the changes which have taken
place in the nervous organization of our modern woman,
particularly the overeducated and overcivilized are so great that
a large proportion have ceased to be natural women. The ner-
vous organization has overshadowed and in many cases dwarfed
the physical development. Every patient brought up under
the conditions of our city life should be considered as abnormal
unless she can be proved to be normal by the most searching
examination. The small pay for obstetrical work among general
practitioners and the fact that they frequently do the work only
as a means of building up a family practice account for the' scant
attention that these matters generally receive. The careful



Digitized by



Google



110 TRANSACTIONS OF THE

mensuration of the pelvis is admitted at the present time to be
a part of the duty of every obstetrician, but the majority of
practitioners lose sight of the fact that it is not the absolute size
of the pelvis, except in rare cases which is important, so much as
the relative size as compared with the individual child.

It is important to estimate the muscular power in the indi-
vidual patient to find out whether a given patient is likely to be
able to deliver herself without undue exhaustion, or whether the
muscular power will fail before delivery is accomplished and
operation become necessary on an exhausted patient. Another
factor to be considered is the probable nervous resistance of the
patient, whether she is liable to have a nervous explosion at the
time of or shortly after labor, even though not physically exhausted ,
and whether the effect of pain and the exhaustion of labor may
not have a lasting serious influence on her after-life. In the
modern society woman these points are of considerable impor-
tance. It is necessary in each case to learn what the patient's
previous life has been. In many cases it will be found that she
has been subjected to such educational and social strain at the
time of puberty and later that she is merely a bundle of nerves,
reacting out of all proportion to every slight impulse even though
she may be physically well developed. In addition to the im-
proper conditions under which she has lived, the strain of enter-
ing society often has a serious effect. Such exercise as she has
taken has been at the expense of proper rest and recuperation,
and has been simply an added burden rather than a relaxation.
It is estimated in Boston that the majority of girls who enter
society have at least one or more nervous breakdowns, demand-
ing a modified rest cure, before reaching the age of twenty-five,
the time at which a woman should be at the height of her powers.
The same may be said to be true of a large proportion of college
women. A third group of women are those which have always
been sickly and delicate, and who would never have reached
maturity except for unusual care. The preservation of the unfit
and the constant overstrain of those originally fit produce a
similar result and produce a class of women who are bad sub-
jects for pregnancy and labor. Another class which should
receive careful attention are those who have shown no definite
weakness before pregnancy and in whom during pregnancy no
definite pathological conditions can be discovered, but who
develop a lack of accommodation, if so it may be called, to
pregnancy. These are the women who suffer from minor
toxemic conditions, prolonged vomiting, and who do not improve
physically during pregnancy as every woman should, but who
are in a distinctly worse condition at the end than at the begin-
ning of pregnancy. Often they are women who were unwilling
or unable to take proper exercise during pregnancy and who
came to labor in a poor muscular condition. It must be remem-
bered that the cardiac muscles suffer in proportion to the
general muscular condition, and acute cardiac dilatation with



Digitized by



Google



NEW YORK ACADEMY OF MEDICINE. Ill

its concomitant symptoms is a frequent result of the strain of
labor.

The general indications to be met in the treatment of unfit
parturient women at the present time may be divided into
prophylaxis and palliation. There could be no question but
that the pernicious influence of early education was one of the
most serious factors with which we had to deal. The social
standard was so definitely set that a girl's education was crowded
into a few years so that she could be turned out as a finished
society product at a definite age with all the modern accom-
plishments, and this necessitated a system of hot-house educa-
tion at a time when the girl was undergoing her greatest physical
development. It was manifestly impossible to change such a
system at once; but few parents would be socially so ambitious
as deliberately to sacrifice their daughter's welfare if the risks
were carefully pointed out and the means for minimizing the
damage furnished.

At present the question was how to deal with the patients
who came to them for care. Each patient had to be studied in
order to determine the class to which she belonged. If the pa-
tient was considered absolutely or relatively unfit, extreme care
must be used throughout pregnancy to guard against possible
complications. The hygiene of her life must be absolutely
regulated and she must be treated as though pregnancy and labor
were pathological conditions. Many of these cases when the
time for delivery approached could be recognized as unfit to go
through the strain of ordinary labor, even though early opera-
tion be practised to diminish the risk, the question of pain and
exhaustion being serious matters for the individual. Many of
these patients would stand operation well, though a long con-
tinued strain would predispose to physical or nervous collapse.
There remained in these cases the choice of operation, whether
the patient should be delivered by Cesarean section with no
indications except her general condition, or by dilatation of the
cervix and extraction by forceps or version.

In the cases on the borderline and in those in whom it was
calculated that no definite harm would result from labor much
might be done toward lessening the pain and exhaustion by the
early use of anesthetics, ether or chloroform, or at such time in
the first stage as the patient seemed in need of relief, morphine
and scopolamine being employed in carefully graded doses. The
advantages of surgery should be employed in these cases and
the patient delivered instrumentally at the earliest moment
possible without the risk of undue damage. This time will
come earlier in the practice of an expert than in that of the
general practitioner, and could only be determined by the esti-
mate of the individual case, as to when the risk in operation is
less than the danger of permanent damage by prolongation of
labor.

Another important part of the care of the obstetrical case is



Digitized by



Google



112 TRANSACTIONS OF THE

the supervision of the convalescence and the repair of the damage
caused by labor. The custom of allowing patients to get up
at the end of ten or twelve days was pernicious. Three weeks'
rest in bed after confinement was none too long to insure a good
result. After the tenth day much might be done to keep up the
strength and improve the general condition by properly regulated
exercises. Malpositions and lacerations should be properly
attended to before the patient gets up, and if there is any tend-
ency to subinvolution the patient should be kept quiet until
satisfactory involution has taken place. In moderate cervical
lacerations it is wiser to delay operation until it is ascertained
whether they are giving symptoms or not. If the previous
history contains no clue to the individual case and if the general
nervous and physical conditions are fairly satisfactory, the
patient should be allowed to go into labor, an attitude of careful
watchfulness maintained, and labor terminated by operative
means at the first indication of failure. This meant that the
physician and not the nurse should have personal charge of
the patient from the beginning of her labor. In multiparas the
history of previous labors should be carefully ponsidered. In
primiparae the age of the patient was an important factor in
determining the course of treatment. If the life of the child
seemed of paramount importance it was legitimate to advise
such operation as would insure the life of the child, even though
there might be no indications present for the operation. It
was clearly recognized to-day that the elective Cesarean section,
performed before labor begins, carries with it nothing more than
the ordinary mortality and morbidity of accident when per-
formed by a competent surgeon, and may unhesitatingly be
recommended to patients who are in the class where the life of
the child is of extreme importance. The indications for this
operation should be widely extended as it is distinctly an opera-
tion to be performed on those who are considered unfit for the
strain of labor and in whom it is feared that pelvic injury at the
time of delivery may produce invalidism. There is no reason
why we should allow the traditions of obstetrics, which origi-
nated when surgery was in a questionable position, to continue
to govern our choice of treatment at a time when abdominal
surgery on uninfected cases can be considered almost without
risk.

Dr. Edwin B. Cragin said that all who practised obstetrics
in New York had to deal at times with the problem presented
by Dr. Newell — the safe delivery of a woman whose nervous
condition apparently unfitted her for maternity. He hoped that
one coming from the Hub, the center of intelligence, was going
to tell them how to bring up girls to make them suitable for
maternity. Massachusetts was a State with four large colleges
for girls; therefore, he thought that one coming from that State
was well fitted to tell them how to solve the problem. The
most important part of the paper he believed referred to pro-



Digitized by VjOOQIC



NEW YORK ACADEMY OF MEDICINE. 113

phylaxis; the facts were that in cases with this sensitive, high
tension nervous system, the woman often simply ** pressed the
button" and then expected the obstetrician to do the rest.
The problem was how to overcome this faulty development.

To take this question up in a practical manner, they must
consider first the girl from thirteen to eighteen years of age.
It must be admitted that she was often overworked in the schools
during her developmental period, t.g., during the first years of
her menstrual life. One could see any day such a girl walking
up Fifth Avenue, carrying home a large bundle of books to study
late in the evening, when she needed time for rest and develop-
ment. This certainly did not tend to make her fit for maternity.
The next question which arose was, what were they going to do
with the girl when she reached the age of eighteen? Were
they to say that she should not go to college? What was the
alternative? This was a question Dr. Cragin was much inter-
ested in. He had compared the life of the girl in the city after
leaving the preparatory school with the life of the girl in college
and especi^dly in one of the colleges in the State Dr. Newell
came from, and he said the comparison resulted in favor of the
college life.

The alternative was bridge whist, afternoon teas, late hours,
etc. If one asked the educators of girls to-day what the chances
were for a girl with a college education, as compared with one
without it, they would tell at once that the better chances rested
with the girl with a college education. They had an immense
advantage. If a young girl wished to teach school, she must
have a college diploma. Even if a library position was asked
for, the girl with a college diploma was given the preference.
Therefore, if a girl could obtain a college education without
injury to herself, let her have it. Personally he said he had
overcome his objection to a college life for girls, and for the
reason that the alternative, especially here in New York, was
no better.

Dr. Cragin viewed the matter from another standpoint, which
was the training of the man who was to do the obstetric work
under the conditions mentioned by the reader of the paper.

Years ago obstetrics and gynecology, perhaps also diseases
of children, were practised and taught by the same man; later,
as gynecology developed, it became separated from obstetrics,
as 5ie older men doing the obstetric work had usually gone into
it from general medical practice without surgical training, and
the younger men with surgical training were attacted to gyne-
cology. Now with the increased demand for surgical skill in
obstetrics the two subjects were coming together again. In
watching the men on the staff at the Sloane Maternity he had
noticed that in general the man who had come from a surgical
service made a better obstetrician than one from a medical
service. In looking forward, the obstetrician of the future
must be the obstetric surgeon — one who has had gynecological
8



Digitized by



Google



114 TRANSACTIONS OF THE

trainings and is able to deal with any complication affecting the
pelvic organs.

When one came to the problem Dr. Newell had presented so
concretely as to what they should do with those cases who were
only able to *' press the button " and who were tired out in the first
stage of labor, Dr. Cragin said he did not believe that in New
York they would be willing to consider such a woman unfit for
labor without a trial. Personally he did not think that one
could tell before hand whether a young woman with so-called
overdeveloped nervous system was unequal to the strain of labor
or not. A great many woman, very frail-looking, would go
through labor without the slightest trouble. The muscles of
her pelvic floor would relax and she would be able to deliver
herself without difl&culty. Whereas, on the other hand, a
robust woman, one who rode horse-back, one who exercised a
great deal, with a pelvic floor very rigid, would often have a
much more difl&cult labor. Prior to the first labor Dr. Cragin
could not tell how such a woman was going to pass through it.
He agreed, however, that in a certain number of cases, where
previous labors had shown that the woman was unable to deliver
herself. Cesarean section was justifiable. In some cases, if
the baby's life was to be saved. Cesarean section was the only
alternative.

The whole question resolved itself into a careful observation
of both the mother and baby ; the preparation of the obstetrician
to enable him to deal with surgical complications as they arose,
and the realization that the work of the obstetrician requires
skill in the use of other instruments than the obstetric forceps.

Eugene Coleman Savidge. — ^There must first be pregnancy
in the nervously over-developed before it can be managed. If
women are overcivilized enough, there will be none to manage.
On the other hand, if they are properly educated maternity will
begin and end easily and naturally.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 12 of 109)