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man, Dickinson, Kellogg, and others say about the evil results of
corset-wearing, we have the proof that enteroptosis does fre-
quently exist in people who never saw nor used any method
of constricting the waist.*

• Smith says Becher and Lenhoff examined twenty-four Samoan women and
found a number of enteropterics among them. Noble also has found that Ara-
bian women, who do not 'wear corsets, have enteroptosis.



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stone: enteroptosis. 239

The typical enteropteric is the toiler who probably has had
numerous children, and who is lean, nervous, and generally un-
happy. Loss of fat in the mesentery or elsewhere behind the
peritoneum may well be considered a cause of ptosis, and it is the
restoration of this fat that appears to attend the recovery of
patients who have the acquired variety of the disease. The
absorption of fat may be equivalent to a prolongation or stretch-
ing of connective tissue in the so-called ligaments which sustain
the viscera which is comparable to that which sustains the pelvic
organs in position. We have every reason to believe that cer-
tain predisposing causes exist prior to or independent of puberty,
or the time when young women begin to wear corsets. These
conditions favor the development of enteroptosis, and especially
so when tight lacing, numerous pregnancies, and a life of toil,
either one or all combined, are added to them.

Intraabdominal Pressure. — Many volumes would be required
to contain all that has been said about intraabdominal pressure.
We often hear of its importance, but think we may for the most
part dispense with the philosophy of its action, if not with the
entire subject. The practical fact is that we are concerned with
the force exerted in all directions when either fluid or air is
compressed.* The abdominal viscera are confined in a position
which permits their displacement forward and downward when
the waist-line is compressed by bands or corsets. Obviously
the posterior and upper abdominal walls (so-called) are sub-
stantially firm and only yield slightly to compression or force,
hence the supposition that external pressure results in prolapse
of some of the abdominal organs. The evils of corset-wearing
are obvious enough when the young and immature girl has her
thorax constricted while yet developing, and while the ribs and
costal cartilages are still yielding and pliant.

Symptoms, — We may with confidence quote G16nard who
spoke of this disease as "universal.*' The association of dys-
peptic, nervous, and anemic or chlorotic symptoms will first
attract our attention. Loss of weight with poor nutrition ap-
pears to drive patients to seek treatment. We see many neu-
rotic patients who think some slight uterine discharge or perhaps
a retro-displacement the chief cause of their suffering, but who
have enteroptosis in greater or less degree. Replacement of
the uterus will not always cure the symptoms. There is an

•Smith well says, "There is no special universal poative pressure from
within," as has been asserted.



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240 stone: enteroptosis.

association of gastric hyperacidity, constipation, and vague
abdominal and pelvic distress, besides the usual headaches,
backaches, and leukorrhea. Such patients are particularly
susceptible to impressions, and often think they have ovarian
or appendicial disease. Occasionally we see alternate consti-
pation and diarrhea in these cases, and find medical or dietetic
treatment thereof very unsatisfactory.

Diagnosis. — Our duty is first to decide between organic or
constitutional disease and displacement of the viscera. The
importance of excluding acute or chronic changes in the stomach,
gall-bladder, or other organs cannot be overestimated when we
examine these cases. We have seen patients with nearly all
of the apparent symptoms of enteroptosis, who had gall-stones
or pyloric stenosis or dilated stomach, without general visceral
ptosis. Obviously, we would find these conditions without
changes in the body form, such as are frequently seen in enter-
optosis. The clinical history should render mistakes very im-
probable, and our exact measures by which we can ascertain the
size of the stomach and the position of both stomach and intes-
tines gives us almost absolutely certain results. In office ex-
aminations the detection of a movable right kidney is always
considered sufficient ground for further examination of the size
and position of the stomach. This is easily done by using the
sedlitz mixture, or even by having the patient drink a glass of
water, provided the stomach is known to be empty. Our plan
is simply to try succussion with the patient in the supine position,
then again after drinking a glass of water, when the area of
resonance is easily made out and the difference made by the
residual gas noted. Finally, if necessary, the bismuth test with
the skiagraph picture can be used if further information is
desired.

Treatment — It is well to promise but little when one is called
upon to treat a case of enteroptosis which is either of congenital
origin or acquired in early life. Here we would have changes in
body form which would be extremely difficult to overcome.
Hence it should be our province to relieve these patients
and make their lives bearable or condition comfortable.
The nonoperative cases include those who are essentially neu-
rotic or who have extremely pronounced symptoms without much
ptosis. We have, however, hesitated and declined operation
upon a patient with only fairly movable kidney and slight enter-
optosis who was soon after apparently cured by another surgeon



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stone: enteroptosis. 241

by means of a nephropexy. I am convinced that he unwittingly
did more and builded better than he knew by fixing the hepatic
flexure of the colon and the pylorus at a higher level.

In the acquired variety of enteroptosis we find the greater
number of cases which may yield to treatment either by surgical
or nonsurgical means. We believe the vast majority of the
patients can be relieved by treatment if they submit to the
methods which have been found useful. In any event, we tnsty
employ some one of the various means of abdominal support,
combined with the posture method. We have noticed the won-
derful benefit of the bandage which may have failed to support
the kidney or stomach, but produced good psychological results.
Anything to restore fat, such jsls the rest treatment with feeding
and massage, will be of great service to these patients.

The posture treatment includes the high pelvis position, which
can always be used for an hour or more before going to sleep at
night. Finally all of these methods, in order to be of the least
benefit, must be practised upon intelligent patients who will
understand the importance of the various suggestions made
by the physician, and who will cooperate with him.

The Selection of Cases for Surgical Treatment, — ^The usual
means of cure, such as diet, rest, position, bandage, etc., having
been tried, what shall determine us to seek surgical aid? Ob-
viously enough, many of the results of child-bearing or enterop-
tosis mainly acquired by labor of any kind or muscular weakness
of the abdominal walls may generally be relieved by surgical
methods. Those results of childbirth which nearly always occur
in an enteropteric, such as uterine and bladder displacements,
are amenable to surgical treatment and prove among the most
beneficial of all gynecological operations, provided the operator
fully realizes the full extent and nature of the changes he pro-
poses to relieve. The cure of a pendulous belly by a restoration
of the abdominal muscles and fascia to their former anatomical
position is essentially a successful and much needed operation.
It may be good surgery to remove some of the superfluous fat
during operations for diastosis of the recti, as the external fat
is n ot only a burden but prevents perfect muscular
development.

Certain investigations by Metchnikoff and others show the
bacterial origin of many intestinal diseases and especially in-
testinal dyspepsias. He (Metchnikoff) has proposed to ex-
tirpate the colon as an unnecessary appendage to the alimentary



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242 stone: enteroptosis.

canal. May it not be possible that some method of restoring
the colon to its position may save some patients from a more
dangerous operation? We have all seen the admirable results
of operative treatment of dilatation of the stomach due to pyloric
obstruction; and, personally speaking, some of the happiest
results we have ever seen in intestinal surgery have come from
replacement of some prolapsed portion of the large bowel where
its function could be properly performed. The appropriate oper-
ations upon the stomach itself include those which may reduce
the size of a greatly dilated organ, such as pyloroplasty or
gastrojejunostomy. Next in importance would be one of the
methods of making a sling of the omentum as proposed by
Coffey or Beyea, and practised by many surgeons, notably by
the May OS and J. G. Clark.

We have had one successful suture case where the stomach
was secured to the anterior abdominal wall, but the inclination
in surgical thought is away from this method.

We think enough has been said of nephropexy to leave that
for the present.

The suture of the gall-bladder to the abdominal wall greatly
assists in sustaining a prolapsed liver, and we have on several
occasions tried to secure the formation of adhesions between
the right lobe of the liver and the peritoneum under the ribs
adjoining.

Operations upon the colon to restore its outline appear most
successful, and we fully endorse the position of Dr. Clark and those
who incline to the belief that malpositions of the colon and sig-
moid are responsible for many of the obstruction cases, the cases
of bowel impaction, and even those cases where there is alternate
constipation and diarrhea. It is possible that many of these
prolapses of the large bowel may be investigated with tube or
bismuth ^-ray and that we may ultimately discover some
method of successfully treating these obstinate cases by surgical
means.

Stoneleigh Court.



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ramdohr: malpresentation a symptom op dystocia. 243



MALPRESENTATION OR MALPOSITION NOT THE
CAUSE, BUT THE SYMPTOM OF DYSTOCIA.*

BY

C. A. VON RAMDOHR, M. D.,

Professor Emeritus of Obstetrics in the New York Post-Gradtutte Medical School and

Hospital; Constilting Obstetrician to the Lying-in Department of

the Poet-Gradute. and to St. Mark's Hospitals; Visiting

Gynecologist to the German Poliklinik, etc.

What do we understand by dystocia, i.e., diflScult labor?
One party considers a labor diflScult when it takes ten hours;
another one at five hours' duration. At our present trend in
which we consider labor not a physiological process but a surgi-
cal disease, we have a great deal more dystocia than we had
twenty years ago when asepsis was in its infancy, and in each
too early operation the operator had to pay his penalty by his
results obtained.

Conservative members of the profession might wait hours
and hours in knowing the reason why labor does not progress
and in the general run have better results than the quick operator.
Nothing is more diflScult and again more to the point than inter-
fering only for the proper indication at the proper time. Any-
body who has mastered this science is away above the
Cesarean section specialist with fifty cases to his credit.

All obstetrical operations are easy if performed for the proper
indication at the proper time. If otherwise performed, the
operator very frequently has to change his plans and thereby
proves himself an embryo at the art and science of midwifery.

Ask any student, **What do you do in a case of transverse
presentation" and without hesitation, 999 times out of a 1,000,
he would answer, "I would turn." And the next answer to the
question ** Suppose you could not dislodge the presenting part,"
he would reply "decapitate."

He, like the majority of the present-day practitioners, would
not reason why there is a malposition or a transverse presenta-
tion. If maternal pelvis and the fetus are of normal size, and
no other exceptional condition present, there would always be a
so-called first position, i.e., vertex occipo-iliac left. The nearest
part of the fetus is the liver, and given a slanting surface and
salt solution, the right side will fall on the anterior surface of the
uterus; while the next heaviest part, the head, will present itself

* Read before the East Side Medical Association.



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244 ramdohr: malpresentation a symptom of dystocia.

with the occiput to the left. Now, if this does not happen, as it
does in 95 per cent, of all cases, it is not the malposition which
is at fault but a reason why the normal presentation does not
apiiear. Absolutely contracted pelvis might be the cause of a
shoulder presentation, but under such circumstances no version
and extraction, not even a decapitation, would be possible.
Cesarean section only could be accepted. Thus it is not the
malpresentation or malposition, but the underlying condition
which may be remedied or may give the clue to operative
interference.

Suppose a brow presentation occurs, the indication would
be (a natural confinement being impossible) to make a face or
vertex out of it if possible, or turn. But the cause of this brow
presentation might be a nonengageable hydrocephalus, and
neither of the just mentioned operations would be of any avail.

Now dystocia is observed at 6 a. m. or 6 p. m. when the general
practitioner wants to go home after a night's or a day's vigil.
Some of the leaders of the midwifery class have demonstrated
again and again that a Cesarean section is an operation without
danger to the patient if performed at the elected time in a lying-in
hospital; and his pupils try to follow his footsteps in private
practice with disastrous results. I occasionally have the honor
of being invited to such operations and the operator will say:
*'Here we have a contracted pelvis, therefore, we perform
Cesarean section.*' Noboby except perhaps the young house
surgeon has estimated the measurement and nobody of the
hoi polloi knows the reason why this operation should be indi-
cated or another.

Dystocia is a relative idea. If things do not progress to the
obstetrician's fancy he may call that a difficult labor.

But again the cause may be a hydrocephalus, a twin preg-
nancy, or a pendulous abdomen or monstrosity, and in either
case the cause ought to be considered before going on with an
operation. A hydrocephalus will need a puncture, a twin preg-
nancy may need the extraction of the other fetus first, a pendu-
lous abdomen needs support, a monstrosity may need dismem-
berment; but you see a brow presentation does not indicate by
any means the mode of operating. Again, a face presentation
usually means that the fulcrum for some reason has been mis-
placed, and therefore the attempts at changing it into a vertex
presentation will be futile unless the uterus pushed over by
adhesions, tumors, etc., would be replaced once and kept replaced



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stockard: malformation identical in both arms. 245

until violent good pains would make the occiput engage and
stay engaged. In such cases I personally have never succeeded
in converting a face into a vertex unless everything was in apple-
pie order, and the operation would have been done by nature
instead of the clumsy hand of the obstetrician. If malpositions,
brow, face, shoulder should occur before strong labor pains
have set in, as temporary accidents (other causes having been
excluded) they will right themselves if the conservative capable
obstetrician is there to watch for the moment when peremptory
version is decided.

Take a funis presentation; that again is a sign that something
has gone wrong. You are told to replace it; put the patient
in the position a la vache and wait for the engagement of the
head. You will lose a great percentage of your children if you
adhere strictly to this doctrine. The umbilical cord cannot
come down unless there is reason for it and that usually is a
contracted pelvis. Given, exceptionally a perfect pelvis and a
normal head, such an accident may happen, but unless pains are
good, strong, and regular a version of the part and quick extrac-
tion are the only things which will give you a chance to save
the child.

I have given you my opinion concisely, but with latitude to
show what I am driving at.

1. A superficial diagnosis of presentation and position doesn't
make an ideal diagnosis.

2. Look for the underlying cause which produces the mal-
position.

3. Having made your diagnosis you have your indication for
the proper operation which is always easy to perform at the
proper time.

243 East Eighteenth Street.



A CASE OF MALFORMATION IDENTICAL IN BOTH

ARMS.

BY

CHARLES R. STOCKARD, M. S., PH. D.,

Assistant Professor of Embryology and Experimental Morphology, Cornell Medical

School. New York City.

(With one Illustration.)

During the past summer I observed an infant in Montgomery
County, Virginia, which exhibited such striking modifications in
the structure of its arms that I shall briefly describe it in the



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246 stockard: malformation identical in both arms.

following note. The description can only be given from a super-
ficial examination, since the child is still alive.

This female infant was born during the first week of August and
weighed at birth only two pounds. She increased in weight
steadily and after five weeks weighed three and one-half pounds.
I carefully examined the child when five and eight weeks old and




Fig. I. — A child two months old with both arms deformed in an identical
manner. Elbow-joint ankylosed. One forearm bone and only one metacarpal
and one digit consisting of two segments and possessing a nail.

found a most peculiar structural condition. The entire body was
weak and poorly nourished, the bones being distinctly outlined
in the thoracic region. The circulation was sluggish and the
blood insufficiently aerated as was indicated by the bluish color
of the body, particularly the face and lips. The voice was weak,
but it suckled vigorously at regular intervals. The trunk and
lower limbs were normal in shape but extremely small and poor.



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stockard: malformation identical in both arms. 247

The head showed a decided prognathous condition. The lower
jaw was small, its lips and gums closing some distance behind the
projecting upper jaw thus leaving the mouth cavity open. The
eyes were normal but the lids were inflamed and a pus-like sub-
stance was constantly accumulating. This condition of the lids
began when the child was about ten days old.

The arms present the most striking structural modifications.
The upper arm appears normal until the elbow-joint is reached,
here an ankylosis or some unusual structure prevents the free
movement of the forearm so that it remains in a flexed position
and cannot be extended. A loose fold of skin extends for several
centimeters between the upper and forearm, suggesting the
patagium of a bird's wing. So far as a superficial examination
can show the forearm has only one bone, presumably the radius
for reasons to follow. The condition of the carpus bones cannot
be determined though the narrowness of the wrist region would
lead one to suppose that only one or two existed. One metacar-
pal and one two-jointed finger is all that represents the hand.
This digit is probably a thumb, since two instead of three digital
segments are present; it also approaches a thumb in size and pos-
sesses a wide flat nail. If this is the thumb I concluded that the
forearm bone was more probably the radius than the ulnar.

Thus one of the forearm bones is absent and all of the hand
except one metacarpal and the thumb. The point of particular
interest is that both arms present exactly the same condition.
Club or stump arms are commonly found but not of this peculiar
type, and I have been unable to find any case recorded where
both arms presented deformities identical in detail.

The parents were illiterate mountaineers and refused to per-
mit a photograph to be made. I can only present a sketch
which conveys an idea of the peculiar appearance of this monster
(Fig. I).

The father was about thirty-five years of age and had been
weak and epileptic until he was twenty-five years old. He also
used alcohol freely. The mother is well developed and healthy,
and is in no way dissipated. They both claim never to have had
a venereal disease. They have three other children, six, four,
and two years old respectively, all normal in size and appearance.

It may seem futile to speculate as to the cause producing such a
monster, but it is diflScult to conceive how poor nutrition or de-
fects in the placental arrangement could have caused the larger
part of both hands to fail to form and yet have allowed the



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248 smith: two cases of tubal pregnancy.

thumb to develop. Evidence indicates that by far the larger
proportion of monsters result from abnormal external condi-
tions acting on the developing embryo. This case of arm de-
formity, however, would seem rather to be classed as a variation
or sport resulting from an un.usual germ cell probably derived
from the father, and possibly due to his weak physical condition
or inebriate practices which would tend to cause his germ cells to
be surrounded by an unusual chemical environment. There is
much experimental evidence favoring such a supposition.



TWO CASES OF TUBAL PREGNANCY.*

BY

A. LAPTHORN SMITH, B. A., M. D., M.R C. S.(England),

Fellow of the American, British, and Italian Gynecological Societies, Surgeon-in-chicf of

the Samaritan Hospital for Women ; Gynecologist to the Western

Hospital and to the Montreal Dispensary.

Montreal, Canada.

In the aggregate many thousands of lives have been snatched
from death by the early operation for ruptured tubal pregnancy.
Many thousands more might be saved if the family doctor would
keep on the lookout for these cases and if the moment he suspects
the presence of this terrible danger in a woman under his care
he would call in the help of a specialist to decide the momentous
questions of diagnosis and treatment. One of the best means
of increasing the number of physicians who can detect this
obscure condition is for the specialist to report every case as it
occurs and to give the symptoms before, and the findings at the
operation. By this means alone the writer has trained some
twenty or thirty of his medical friends to keep on the lookout
for tubal pregnancy and appendicitis. Some of the older ones,
like Dr. Sylvester, have sent me nine cases already diagnosed,
Dr. Warren has sent me five or six. and Dr. Johnson and
Dr. G. T. Rose have each sent me three or four. Other younger
ones have diagnosed one or two; while another group of still
younger ones, while not able to diagnose tubal pregnancy, are
able to suspect something wrong and send them to me for diag-
nosis and operation. Most of these latter suspect appendicitis.
Of course if their treatment of appendicitis were the rest cure,
it would be a terrible mistake to leave a woman for nine days
with a hemorrhage going on in the abdomen. But as their
conception of appendicitis is removal of the appendix which
entails the opening of the abdomen, it makes very little difference
whether they make an exact diagnosis or not; the only important

♦ Read before the Medico-Chinirgical Society of Montreal, Feb. 4, 1910.



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smith: two cases of tubal pregnancy. 249

thing about it being to suspect one of these two things and to
rush the abdominal surgeon there without an hour's unnecessary
delay.

I do not consider it any disgrace even for myself who have
operated on fifty-one cases of tubal pregnancy with three deaths
to have opened fifteen other women for tubal pregnancy and
found something else. These were fifteen mistakes that I am
very proud of because in each and every one of them a life was
saved which otherwise would almost surely have been lost.
One, for instance, was a twisted ovarian cyst with a hemorrhage
of half a gallon of blood into it, giving all the symptoms of some
terrible catastrophe going on in the abdomen. Others, again,
were cases of leaking tuboovarian abscesses sufiiciently serious
to give a low temperature and a high pulse. While several



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 25 of 109)