of Rhodes. Spurious works Andronicus.

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

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low hemoglobin percentage. It has also been observed that
embolism and thrombosis has been alarmingly frequent during
the convalescence from such operations and, although to a less
extent, even before operation. Schenck(ii) believes the
anemia in such cases is a potent cause of that postoperative
complication and that no given hemoglobin percentage should be
considered a minimum.

Ureter O'Cystostomy. — ^Payne(i2) in performing this operation
loosened and depressed the corresponding kidney to lessen the
tension on the point of anastomosis. After animal experimenta-
tion I found this treatment feasible and tacitly recommended
it (13) to the American Gynecological Society. So far as I
know, Payne is the first to perform the operation on the human
and he reports it as having been successful. Whether the altered
position of the kidney will cause circulatory changes that will
lead to structural changes in that organ remains to be demon-
strated. Sampson (14) has shown the dangers of tension at the
new ureterovesical junction.

The Treatment of Retrodis placements of the Uterus, — Retro-
displacements of the uterus has continued to be a subject of
much speculation, more particularly in its etiology and treat-
ment. In a general way I may say that aside from traumatism
and abnormal anatomical development of the structures ad-
jacent to the uterus, such agents as habitual constipation,
habitual urinary retention, adhesions to it or to the appendages,
and the presence of various neoplasms, which act mechanically,
the backward displacements are regarded as only a feature of
splanchnoptosis. By several of our leading gynecologists ef-



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forts are made toward correcting the general peritoneal condition
rather than the local uterine displacement, and for the local con-
dition in this class of cases when it indicates surgical treatment,
various operations upon the supporting structures of that organ
are done rather than suturing it to the abdominal wall. The
latter mentioned procedure is probably to be used only in the
patients known to be sterile. Whether retrodisplacement of the
uterus, per se, is a condition of suflScient import to justify im-
periling a woman to the extent of opening the peritoneal cavity
has not been decided aflSrmatively.

Prolapse of the Uterus and Other Female Genital Organs. — Con-
siderable interest in the treatment of prolapse of the various
pelvic organs of women is generally manifested. These are
nearly always of traumatic origin, and relief requires redress to
surgery. Ward(i5) has given careful consideration of ovarian
prolapse, suggesting the treatment is essentially surgical and in
most instances requiring shortening of the infundibulo-pelvic
and ovarian ligaments. He expresses a preference for Barrow's
modification of Imlach's operation, which consists in shortening
those ligaments and drawing the ovary through a button-hole
made in the broad ligament above the round one. Dudley(i6)
recommends an operation for uterine prolapse and cystocele
that consists in severing the anterior vaginal wall from the
uterus, and the lower two-thirds of each broad ligament from it
with suturing of the two stumps of them together in front of the
cervix and bringing the vaginal flap over them. If cystocele
be present he removes a median section of this flap. Wat-
kins (17), in a paper read before the American Gjmecological
Society, April, 1909, recommends an operation for marked pro-
lapse of the uterus and bladder, which consists of separating the
uterus from all structures in front of it and the bladder from the
vagina which is split from the cervix to the urethra. The
Fallopian tubes are severed from the uterus and the body of the
latter organ brought below the bladder and sutured there.
Polk, at the same meeting, described an operation for exaggerated
cystocele, which consisted of making a suprapubic incision and
through it separating and elevating the bladder. Then the
fascia from both sides are brought together and sutured under the
bladder. C. P. Noble (18), regarding cystocele as a hernia of the
bladder into or through the vaginal opening and as a part of a
complex condition consisting of a laceration of the sacral seg-
ment of the pelvic floor with prolapse of the anterior and poste-



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rior vaginal walls and of the uterus, practises an operation for
relief, the essential features of which are curettage, amputation
of the cervix, when necessary; a longitudinal incision in the an-
terior vaginal wall through which the bladder is widely separated
from the uterus and the redundant vaginal wall is subjected to an
oval resection. The vaginal flaps are then sutured together and
to the bladder and uterus. Gilliam (19) for cystocele recom-
mends an operation that varies from any of these by less dissec-
tion above the vaginal wall but overlapping laterally the fascia in
that wall.

Pressure Conditions Within the Abdomen. — R. R. Smith(2o)
has been investigating experimentally this subject and has con-
cluded, first, that atmospheric pressure within and without the
abdomen is almost exactly balanced, any variation at any point
being caused by factors to be enumerated. There is no special
universal positive pressure which has so frequently been assumed.
Physiological increase or decrease of volume is attended by in-
significant or no changes in pressure — that is, the balance is
practically maintained. A marked increase of volume from
pa^thologic conditions often takes place without disturbing the
balance, though varying in diflFerent subjects. Second, hydro-
static pressure at any point within the abdomen varies with the
position of the body and the depth of the superimposed organs.
Third, negative pressure at uppermost points is .possible under
certain conditions where the walls of such uppermost points are
rigid. In the upper part of the abdomen when the position of
the body is upright, a negative pressure may exist, which has
more or less to do with the support of the viscera. Smith found
that intraabdominal pressure from coughing, sneezing, defe-
cation, labor, and many movements of the body is transmitted
in all directions and without diminution to every part of the con-
tents and interior of the abdomen. So far as it goes it is evidence
only to a slight degree of the existence of a so-called constant
intraabdominal pressure downward upon the uterus and
appendages.

The Influence of Corsets and High-heeled Shoes on the Symptoms
of Pelvic and Static Disorders, — Of great interest to the gyne;colo-
gist is the work done by Reynolds and Lovett(2i) and described
by them at the April, 1909, meeting of the American Gynecologi-
cal Society. They have reached a plan for ascertaining auto-
matically the center of gravity of the living human body at all
times and in all attitudes. They believe abdominal ptoses are



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frequently the result of static conditions, and therefore if such
conditions are not rectified therapeutic failure is apt to follow
surgical operations done for the relief of such ptoses. But, as
faulty static conditions are sometimes results of pelvic condi-
tions, such as inflamed and adherent appendages or uterine
fibroids, it is plain that such conditions must receive proper
treatment. They have found a properly fitting corset does not
carry the center of gravity forward while a badly fitting one
does so carry it. The high-heeled shoe, with the heel placed in
the middle of the foot, as practically all of them are placed, does
not, in the presence of a properly fitted corset, throw the center
of gravity forward, so that, while such shoes are harmful to the
feet, they are not injurious to the back or viscera of a properly
corsetted woman. They have found that static backache is
usually relieved by proper corsets, and this eflfect is attributed
partly to the splinting of over-strained and irritable muscles
and partly to the tipping back of the whole body. Reynolds
and Lovett state that "so far as their observations have gone
they believe the most frequent cause of static backache is to be
found in a center of gravity too far forward, thus inducing ex-
cessive muscular eflfect in the lower back to maintain equilib-
rium; and the relief of such backache by proper corsets, and oc-
casionally by high-heeled shoes, is explained by their influence
on the position of the center of gravity." I believe this work is
of far-reaching value and will greatly assist in determining
logical treatment in pelvic displacements as well as spinal and
dorsal affections.

The Prevention of Postoperative Abdominal Adhesions. —
During the past three years considerable attention has been
given to preventive treatment of various troublesome sequelae of
abdominal and pelvic operations. Blake(22), after animal ex-
perimentation, oflFers the opinion that adhesions thus caused can
to a moderate degree be prevented by the harmless plan of
putting into the peritoneal cavity one to four drams of absolutely
sterile oil. Gellhom(23) employed lanolin unsuccessfully.
Webster(24) and Byford(25) believe the most successful plan is
to improve the operative technic by handling the peritoneum
less and leave the smallest possible area of denuded peritoneum.
It seems more than probable that these contentions of Webster
and Byford comprise about all, with our present knowledge, we
can do to prevent these adhesions.

Shortening the Period of Postoperative Rest in Bed, — Boldt(26),



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following the practice and plan of Ries, advocates keeping
patients after operations, particularly abdominal, in bed but a
few days. The abdomen is immobilized by zinc oxide plaster
in strips six inches in width applied in the form of a Scultetus
bandage and the patient allowed to remain in bed but one to
three days after operation. A few abdominal surgeons follow
this plan quite faithfully, while a larger number have shortened
the period of postoperative rest in bed to eight to ten days and
using no special immobilization plan. The advocates of early
postoperative rising claim as an afl5rmative argument, that
early rising markedly lessens the danger of phlebitis, embolism,
and thrombosis. Frederick(27) claims patients should be kept
in bed after operation for sixteen to twenty-one days, as complete
union in the abdominal wall requires two weeks and that us-
ually exhaustion from the former disease and operation require a
longer rest. Frederick's position is regarded as being the logical
one. In this connection Kafif's article (2 8) entitled "Phlebitis
Following Abdominal Operation** is of interest. He states
phlebitis occurs in 2 per cent, of all abdominal operations, and
that in many instances it is merely an extensive aseptic blood
clot, but that generally it receives a mild form of infection in-
troduced into the wound at the time of the operation and in turn
invades the walls of the vein. Other conditions, he holds, such
as an abnormal plasticity of the blood and stagnation of the
blood current be present in order that thrombosis may be the
result of surgical traumatism. These points have been utilized
by him as a basis for recommending the shortening of the post-
operative period in bed.

Artificial Vagina, — ^J. F. Baldwin(29) has devised an operation
for making an artificial vagina in cases of congenital or acquired
absence of that organ. His plan is to utilize a portion of the
sigmoid flexure of the colon or a loop of the ileum for this pur-
pose. In the one operation he did the ileum was used. He
first opened the abdomen and made from above a vagina; next,
catching a loop of the intestine in a clamp inserted from the
vagina, it is dragged downward to the skin of the perineum.
The upper ends of the loop are cut oflf and leaving its mesentery
intact to insure a good blood supply, the continuity of the in-
testinal tract was made by end-to-end anastomosis. One end of
the isolated loop is sutured about the site of the servix uteri
(the uterus was removed) and the other end of it was closed.
Next the loop was opened below and the cut edges sutured to the



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skin of the perineum. At the end of six weeks the resulting
double vagina was made single Jby means of a pressure clamp.
Whether the resulting condition can withstand the test of preg-
nancy and labor has not, so far as I know, been determined.

Spinal Anesthesia. — Spinal anesthesia has fallen into dis-
repute in America. Reynolds (30) reports a case of sudden
death from it, and others have recorded fatal results from its em-
ployment. Newell (31) extols its use in labor, his conclusions
being based upon 123 cases he personally conducted.

Perineorrhaphy, — ^The surgical treatment of perineal injuries
has for a quarter of a century been a field for many explorers who
have received a stimulus from studies of the complex mechanical
conditions present in the perineum, particularly after injury.
In the United States the past three years have been no exception,
and as a result many gynecologists have devised new operations
or modijQed old ones of perineorrhaphy. It is not fitting that all
these should be here mentioned, and I will refer to but one,
Watkins(32) claims as advantages for his operation that the ex-
ternal sutures are all distant, one-half inch or more, from the
anus and consequently minimize the danger of infection; that the
skin and connective tissue about the anus are not constricted;
that the muscle is sutured individually; that no danger of sub-
sequent recto-vaginal fistula exists, and that a relatively slight
amount of suflFering follows the operation. Studdiford(33)
claims to demonstrate the presence of involuntary muscle
fibers in the perineum. The influence this discovery may have
on our knowledge of the functions of the perineum and its re-
pair cannot now be estimated.

obstetrics.

The advance in obstetrics during the past three years has been
very notable. Cragin(34) states these advances have been in the
directions of, first, a better knowledge of obstetric pathology;
second, a better knowledge of the mechanical problem of de-
livery; and third, a better procedure. . Newell(35) considers the
subject of "The Effect of Overcivilization on Maternity" and in-
sists a new type of women, considered physically, is the outcome
of subjecting young girls to the many exactions incident to the
training or so-called fitting for social position. The indoor life
and nerve-tension prevents their physical perfection for maternity,
and this clearly demonstrated when that function is in progress.
He indorses the recommendation of Reynolds(36) and Davis(37)



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that delicate nervous women had better be delivered by Cesarean
section than be subjected to the ordeal of labor.

Contractions of the Pelvic Outlet. — Contractions of the pelvic
outlet have not been accorded the importance they deserve, and
Williams(38), from two unpleasant experiences resulting from
this deformity, was led to carefully measure the pelvic outlet in
the 1,200 patients in the obstetric service of Johns Hopkins
Hospital. He has divided these contractions into groups, viz.,
typical, generally contracted, and complicated funnel pelves.
In the first type the superior strait is essentially normal, while
the inferior is contracted, the narrowing occurring in either the
antero-posterior or transverse diameter, or in both simultane-
ously, as described by Schanta. In the generally contracted
variety, the entire pelvis is smaller than normal, while the in-
ferior strait is narrowed to a greater extent than is usual in
t)rpical justo-minor pelves. In the third group are included a
small number of flat or rachitic pelves, in which the outlet con-
traction is superadded to the typical deformity. He has limited
the term contracted to those cases in which the transverse diame-
ter of the outlet is reduced to or below 8 cm. or the distance be-
tween the lower margin of the symphysis and the tip of the
sacrum falls below 9 cm. He found 122, falling within this
category, of the 1,200 examined; eighty-three of these were
typical funnel pelves (6.92 per cent)., thirty-four generally con-
tracted funnel pelves (2.83 per cent.), three generally contracted
rachitic funnel pelves (0.25 per cent.) and two flat rachitic
funnel pelves (0.17 per cent.). Klein believed a definite estimate
of the capacity of pelvic outlet contractions could be made by
considering the outlet as two triangles, the base of each of which
was a line drawn between the ischial tuberosities and the apices
of them being at the anterior margin of the tip of the sacrum and
at the lower margin of the symphysis. An antero-posterior line
that bisected these two triangles was termed for them anterior
and posterior sagittal diameters. Williams offers some inter-
esting data based upon the application of the measurements of
these diameters to the 1,200 pelves examined. Of the sixty-nine
cases of typical funnel pelves available for study it is found that
the outlet contraction, per se, necessitated operative interven-
tion in eleven instances (16 per cent.) — ten low forceps and one
pubiotomy. In the twenty-nine cases of generally contracted
funnel pelvis delivered at full term, operative intervention was
necessary for the contraction in four of them (14 per cent.). His



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24 bovee: gynecology and obstetrics in the united states.

conclusion drawn from his experience in these 1,200 cases are:
I. Funnel-shaped pelves frequently give rise to more or less
serious dystocia, are an important factor in the causation of deep
perineal tears, and occasionally convert what promise to be easy
low forceps deliveries into most diflScult and dangerous opera-
tions. 2. Typical funnel pelves, in which the usual external
measurements as well as those of the superior strait are normal,
while the distance between the ischial tuberosities measures 8 cm.,
or less, were observed in 6.92 per cent, of 1,200 consecutive preg-
nant women, and occurred with equal frequency in both the
white and black race. 3. Generally contracted funnel pelves,
in which shortening of the usual external measurements as well
as of the diameters of the superior strait is associated with a dis-
tance of 8 cm. or less between the ischial tuberosities, occurred in
1. 19 per cent, of the white and 4.91 per cent, of the colored
women, being four times more frequent in the latter. 4. Typi-
cal funnel pelves constituted 55.7 per cent, of all cases of pelvis
deformity in white, as compared with 17.8 per cent, in colored
women, and therefore are of especial practical importance in the
former. 5. While a shortening of the transverse diameter of the
outlet to 8 cm., or less, indicates the existence of a funnel pelvis,
it should be regarded merely as a danger signal; as the possibility
of dystocia will depend upon the relation between its length and
that of the posterior sagittal diameter. The latter is the dis-
tance from the center of the former to the tip of the sacrum,
and must increase in length as the transverse diameter becomes
shortened. 6. Typical funnel pelves are apparently due to the
presence of six vertebrae in the sacrum — so-called high assimila-
tion, which so changes the relations at the sacro-iliac joints as to
permit the lower portions of the innominate bones to approach
one another. In the generally contracted type the outlet
contraction probably represents only an exaggeration of the
faulty development which characterizes the entire pelvis. 7.
In view of the frequent occurrence of funnel pelves, palpation of
the pubic arch should form an integral part of the examination of
every pregnant woman. Whenever it appears to be narrowed,
the distance between the tubera ischii should be measured, and
when it is 8 cm., or less, the length of the anterior and posterior
sagittal diameters should also be determined. Only by so doing
can one avoid being occasionally placed in the unenviable pre-
dicament of being obliged to resort to a serious obstetrical
operation after having assured the patient that her pelvis was



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bovee: gynecology and obstetrics in the united states. 25

normal. 8. Fortunately the great majority of labors compli-
cated by funnel pelves end spontaneously. In the lesser degree
of contraction low forceps may give satisfactory results, while in
the more pronounced cases the operation of choice is Cesarean
section at the end of pregnancy, or pubiotomy after the head has
reached the pelvic floor. It is quite evident that more thorough
pelvimetry and its study in conjunction with the puerperal his-
tories will furnish data for a revision of our ideas as to diagnosis,
prognosis, and treatment of pregnancy.

The Effects of Ventrosus pension of the Uterus on Pregnancy and
Labor, — E. B. Cragin(39) has found maldevelopment of the
uterus during pregnancy as a result of limitation of the mobility
of that organ after the ventrosuspension operation has been per-
formed. These deformities lead to dystocia not infrequently.
He says the most common forms of dystocia thus produced are :
I. A malpresentation of the child, especially a transverse pre-
sentation which was noted in fifteen of twenty-one cases of Ces-
arean section for this condition collected by Lynch (40) and oc-
curred in all five of the cases operated on by Cragin. 2. An in-
■efifectual labor with the cervix undilated and high up. This high
position of the cervix is noted in most of the cases demanding
Cesarean section. 3. An obstructed labor, the obstruction being
produced by the thickened anterior wall of the uterus. Cragin
says ventrosuspension which allows a normal delivery in the first
pregnancy following operation may subsequently become a
ventrofixation and produce dystocia so marked as to positively
indicate Cesarean section in the next labor. J. Whitridge
Williams (41) reports his experience with the treatment of dysto-
cia from ventrosuspension of the uterus, and states that while he
does not think the operation is always a bad one yet he believes
it should only be done during fertility by experts, as when the
operation is finished no one can tell whether the uterus will be
fixed or suspended from the abdominal wall. Other procedures
have been to a considerable degree substituted for this operation
in fertile women.

Primary Ovarian Pregnancy, — Norris and Mitchell report a
case of primary ovarian pregnancy(42) and, added to several
others reported in this country during the past few years, makes
quite an array for America. J. C. Webster is probably the only
one to report two cases, and it is unique that both his cases were
in the practice of one physician in a small Wisconsin town.
Were anyone to view those two specimens, mounted, no skepti-



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26 bovee: gynecology and obstetrics in the united states.

cism regarding the possibility of the existence of the condition
would remain.

Primary Implantation of the Ovum in the Pelvic Peritoneum. —
Hirst and Knipe(43) have added to our knowledge of implanta-
tion of the ovum in the abnormal positions. They claim to have
found an instance of this character in a woman of thirty-one years
who had one child after a normal labor some months before. On
operation, free blood in moderate quantity was found in Douglas'
pouch. On the posterior surface of the left broad ligament was
a spherical tumor, with a small orifice on its surface from which
was exuding blood. The tubes, ovaries, uterus, and remainder of
the broad ligaments were perfectly normal. The tumor was
covered by peritoneum and contained a small embryo. Microsco-
pical examination of the capsule found it to consist of an inner and
an outer layer of fibrous connective tissue between which an ex-
tensive extravasation of blood had occurred, chorionic villi were
seen protruding from the orifice.

Treatment of Ectopic Pregnancy, — A considerable degree of con-
servation in the surgical treatment of ectopic pregnancy after
rupture or tubal abortion has been secured. Among the chief
advocates of delay are Robb and F. F. Simpson. Robb states
that the advice usually given to operate as soon as the diagnosis



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 3 of 109)