of Rhodes. Spurious works Andronicus.

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

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was thus allowed to drop lower down into the pelvis, away from
the tube and ligament, a maneuver which, in his opinion, must
be executed to secure permanent relief. Covering all denuded
places was not less important. In one patient who had also
a chronic cystitis, cured by a vaginal cystotomy, he failed to
close the raw area as well as he should have done, and she was
still, now and then, having pain on defecation, undoubtedly
because of the reforming of adhesions. This was the only case
of the nine that, so far as he knew, had not been relieved.

DISCUSSION.

Dr. Henry T. Byford, of Chicago, stated that when a patient
presented herself with pelvic disease he always asked her whether
she had pain or not on defecation. Then he asked the question,
do you have any mucus in the stools? He thought he fre-
quently found mucus in the stools in such cases, but not the
abundant mucus which comes from a general colitis, nor the
tendency to tenesmus with mucus that comes from inflamma-
tion low down in the rectum. There was pain on defecation,
particularly when these patients were at all constipated, and
there was mucus in the stools. In connection with the symp-
toms, if the pain was in the iliac region there would be found
adhesions to the sigmoid flexure. In another class of patients
there was pain in the back, and no pain in the iliac region.

With regard to the size of the sigmoid flexure, these cases were
apt to occur in women who were constipated a great deal, and



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SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 301

who had a distended colon or sigmoid flexure, and the giving of
laxatives and perhaps strychnin and other remedies to tone up
the condition of the alimentary canal, with proper diet, would
be sufficient, rather than to think of any surgical procedure in
the ordinary cases.

Dr. Robert T. Morris, of New York City, stated that there
was one place where the surgeon should allow adhesions to
remain, namely, in his subliminal mind. There was no one
thing more often overlooked in his experience than peritoneal
adhesions and their influence. Dr. Royster liked to close raw
surfaces by continuous sutures. They saved time by one or two
methods. The commonest one which he had used was to sprinkle
aristol over the raw surface and wait until lymph accumulated
and engaged the aristol in a mesh. This acted as an obstacle
to further adhesion and he had found it satisfactory in his ex-
periments on animals. The other method was to use sterilized
animal membrane. That took a little longer, but in such cases
as Dr. Royster had described, aristol powder would engage
itself in the lymph coagulum, and present an excellent me-
chanical obstacle to re-adhesion.

Dr. Thomas S. Cullen, of Baltimore, stated that he had a
patient at the present time who had complained for five or six
years of severe constant pain in the left side. On opening the
abdomen he found the uterus perfectly normal. The tubes and
ovaries showed no alteration. There was no thickening of the
ureter. In making a closer examination of the sigmoid he found
it adherent to the entire left broad ligament, extending as far
forward as the round ligament. He adopted a procedure similar
to the one described by the author of the paper, that is, freeing
the adhesion as thoroughly as possible, and closing the raw
surface of the broad ligament by a continuous catgut suture,
and the raw surfaces of the rectum by interrupted suture, on
account of which slight tearing was not so likely to occur.

Dr. I. S. Stone, of Washington, D. C, stated in opening the
abdomen for tubercular peritonitis and allied conditions they
could never hope to separate all adhesions in such cases. It
would be folly to try to do it. There were many women who
had extensive adhesions, one organ being thoroughly adherent
to its fellow, yet there might be no pain on defecation, or pain at
any time. Where were they to stop in separating adhesions
when they had such cases as that? Not long ago a woman came
to him in Washington with a history of pain in the scar of a
former operation. She had been operated on in Paris by an
eminent surgeon; a consultation with three physicians was held.
There was pain in the cicatrix and that was about all the woman
could tell. The majority voted in favor of opening the abdomen
to release the adhesion. When the abdomen was opened a
slender adhesion of the omentum was found. The family was
told that adhesions were found and separated. What else could
they be told? The patient suflFered precisely the same as before



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302 TKANSACTIONS OF THE

the operation. He found he was getting excellent results from
.operating upon patients and placing the bowels in the very
best condition he could for continuous passage of flatus and
feces. He had separated adhesions of the sigmoid and in some
cases had been astonished to find not only the greatest improve-
ment, so far as pain and local distress were concerned, but in
the general improvement of the patient, when the sigmoid had
been sutured up out of the pelvis, where there should be contin-
uous passage of flatus and gas, instead of more or less obstruc-
tion, produced by a circular folding or duplication of the sigmoid
in the pelvis. Such an operation as that had given him more
comfort than the mere separation of adhesions.

Dr. W. p. Carr, of Washington, D. C, stated that they had
all seen cases in which there were a great many adhesions and
no pain, and in other cases where there was a slight adhesion
with a great deal of pain. It was the situation of the adhesion
and not the extent of it that caused trouble. A patient experi-
enced great pain where there was a slight strong adhesion at-
tached to a small area of some movable organ; whereas, in the
case of an extensive adhesion to a large surface the weight was
sustained without any pain whatever. The most painful ad-
hesions had been those where there was a small band pulling
on some point of a movable organ. He had seen a number of
such cases, and had relieved the patient by separating the ad-
hesion not larger than a lead pencil. On the other hand, large
adhesions, especially around the liver and the stomach, did
not seem to produce any pain.

Dr. Royster, in closing the discussion, said that he was very
glad Dr. Byford mentioned the discharge of mucus, because
that was very important. The question then arose, in such a
case was not the intestinal condition the cause of adhesion
rather than the pelvic disease? Where the adhesion was due
to intestinal stasis the discharge of mucus was a prominent symp-
tom, but where it was secondary to pelvic disease, mucus was
not a prominent symptom.

THE TREATMENT OF ADVANCED EXTRAUTERINE PREGNANCY.

Dr. Reuben Peterson, of Ann Arbor, Michigan, in his paper
drew the following conclusions: **i. Wherever conditions per-
mit, operation for the removal of the gestation sac is indicated
in the first half of an extrauterine pregnancy since, at this period,
the mother is in great danger from rupture and sepsis, and the
chances for the survival of the fetus are very poor. 2. During
the latter part of an extrauterine gestation the chances of rup-
ture and a fetal hemorrhage are very much less (4.8 percent.),
and the chances of the survival of the fetus are very much greater.
3. While malnutrition and malformation of the extrauterine
child are more common than with the fetus under normal con-
ditions, they are not frequent enough to contraindicate attempts
at saving its life; hence, under favorable surroundings, when the



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SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 303

patient can be watched, she should be allowed to go within two
or three weeks of term before operation. 4. Since the maternal
mortality is more than twice as great after operation in ad-
vanced extrauterine pregnancy where the placenta is left be-
hind, its removal should be one of the cardinal principles of each
operation. 5. In the discoid variety of placenta, where only a
small surface of this organ is not attached, the blood supply
must be controlled either by tying the vessels or by compression
of the aorta before an attempt be made to remove the placenta.
6. When, for any reason, removal of the placenta is impossible,
the sac should be switched and the placenta shut oflF from the
peritoneal cavity by gauze. 7. Dependent drainage through
the vagina should be secured whenever possible."

DISCUSSION.

Dr. Henry T. Byford, Chicago, said with regard to the risk
to the mother, if we could save a few mothers by operating early
in cases of extrauterine pregnancy, those mothers would fur-
nish more youngsters to help populate the earth than those
we help to save at term. If it were the case of his wife, he
would not be anxious to have a child bom that was deformed
or crippled, because such a child would not be a comfort to
anyone. He was a good deal like the Spartans in this respect.
They had good reason for doing what they did.

Dr. Thos. S. Cullen, Baltimore, said that Dr. Peterson had
pointed out that it was rare to find the fetus in the early months
of extrauterine pregnancy. He had in the hospital at present a
woman in whose case the fetus at about the third month popped
out as he opened the abdomen, and lived for nearly half an
hour. The development of the hands and feet was perfect.

Some two or three years ago he reported a case of abdominal
pregnancy where he did not know at the time of the operation
what he was dealing with. There was a large mass which filled
two-thirds of the abdomen. Over the surface was the trans-
verse colon, and the [omentum was adherent everjnvhere.
The uterus was normal in size. There was a pus tube on the
right side. The mass on the left side was removed. He thought
he had to deal with a dermoid. On opening the specimen it
proved to be a full term extrauterine pregnancy which had
lain in the abdomen for four years. It was adherent to the
mesentery of the transverse colon. He turned the colon in on
itself, made a sort of funnel, and established vaginal drainage.
The final outcome was perfectly satisfactory.

Dr. Walter C. G. Kirchner, St. Louis, reported a case in
which pregnancy (extrauterine) went on to term. It was
interesting to note that in this case the conditions simulated
very much those of normal pregnancy. When first observed
it was found that the patient had a tumor-like mass on the
right side in the ovarian region, which grew and became central,
and the surgeon who saw her at the time advised operation.



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304 TRANSACTIONS OF THE

The woman feared this condition and fell into the hands of a
number of physicians who treated her for a miscarriage. The
tumor was of such a nature as to incapacitate her, and she was
obliged to remain almost constantly in her room. When preg-
nancy was at full term and the usual labor pains came on, she
having had eight children and stated that this condition was
similar to that of previous confinements, the physician, thinking
she was in false labor, decided to wait. She came to the hospital
three days later with a prolapsed uterus and greatly edematous
cervix. An emergency existed, and section was made. A sac
filled the abdomen; the placenta was adherent anteriorly to the
sac, and a healthy and living child was delivered. The child
weighed six and three-quarter pounds and was well developed.
With the exception of a slight asymmetry, there were no de-
formities. The child was over a year old now and was in good
health. The sac was quite easily enticleated except for a few
adhesions, omental and intestinal. The appendix was adherent
to the sac.

Dr. J. Wesley Bovee, Washington, D. C, had never operated
on a living full-term or nearly term ectopic pregnancy. He had,
however, operated on three advanced cases. In one case preg-
nancy had gone on to thirteen months with a dead fetus. His
impression was that the sooner cases of ectopic pregnancy were
operated on the better. In every advanced case he would
operate as soon as he could aiter seeing them. He would not
wait for the development of the fetus at full term. His im-
pression was that the proportion of malformations was much
greater than the author had given in his statistics.

Dr. H. a. Royster, Raleigh, North Carolina, had had three
cases of full-term extrauterine pregnancy. In neither one of
the three was the diagnosis made during the life of the fetus.
All the patients got well. The first one was complicated with
intrauterine pregnancy, also at term. In this case he had to
marsupialate the sac on account of intestinal adhesions. The
second one was mistaken for a normal pregnancy and allowed
to go on for two months beyond term. The patient was in a
dreadful condition from which she was saved by desperate means.
In a third case the fetus had been in the abdomen for four
years, and was regarded as a fibroid tumor, movable, and some-
what shrunken.

Dr. Lewis C. Morris, Birmingham, reported the case of a
women who had gone on to term, no diagnosis having been
made. Labor pains had started, and it was thought she was in
normal labor until it was found nothing was doing and an obstet-
rician made a diagnosis of abdominal pergnancy. She was sent
to the hospital five days after false labor pains with this diagnosis.
The physician-in-charge stated that the child was living during
the time of the false labor pains. She lived seven miles from
Birmingham; was sent across the country to the hospital in a
wagon, and was in fairly good condition. She entered the hospi-



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SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 305

tal with a rapid pulse and some evidences of hemorrhage. He
was telephoned for and as he walked into the hospital he found
that the resident physician had done a postmortem Cesarean
section with the idea of saving the child. The child died soon
after the onset of false labor pains. There was undoubtedly
separation of the placenta, probably on account of the transit of
the patient from across the mountains to Birmingham. He
cited this case with a view of emphasizing the importance of not
waiting in these cases after the onset of labor pains, as the dan-
ger from hemorrhage in postponed operations was great.

Dr. Joseph PjticE said that in these cases if surgeons operated
early, they would avoid a high mortality.

Dr. Rufus B. Hall, Cincinnati, said the earlier an operation
was done for extrauterine pregnancy the better it was for the
mother. Whether the operator should wait for the viability
of the child and try to save the life of the child would depend
in the future as in the past on the judgment of the operator.
The control of hemorrhage in the far advanced cases added more
to the safty of the mother than anything the essayist had sug-
gested. If one expected to save the mothers in the far advanced
cases the placenta must be removed. In those cases in which
it was impossible to remove the placenta the mortality was high,
say 60 per cent, or more, from sepsis because the placenta
sloughed and drainage could not be provided for. He was con-
vinced that a larger number of these patients could be saved
than was saved if the plan was adopted to sacrifice the uterus,
as suggested in the paper, where the placenta was located in the
|>elvis, where it did not get its blood supply high up in the in-
testine or mesentery.

ABDOMINAL CESAREAN SECTION FOR PUERPERAL ECLAMPSIA.

Dr. Lane Mullally, of Charleston, South Carolina, in his
paper reported four cases of puerperal eclampsia. The first two
cases were brought into the hospital with the usual history of
eclampsia, each having had convulsions for about six hours
before being admitted. The first case was delivered under
anesthesia by dilatation, instrumental and manual, and high
forceps, and the second by similar dilatation and version, each
case occupying from one to two hours. In the first case convul-
sions continued for twelve hours when the patient died. The
second case had several convulsions after delivery and recovered .
The third case was a multipara with considerable scar tissue
in the cervix, was anesthetized, and an hour or more uselessly
spent in attempted dilatation. Finding it impossible to dilate
the cervix, he determined upon abdominal Cesarean section,
preferring this to vaginal Cesarean section and delivered the
child in seven minutes. The whole operation, when completed,
occupied twenty-seven minutes. The case was a six months'
pregnancy and the child was dead when delivered; in fact, the
child was dead before the operation was begun. In the fourth



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306 TRANSACTIONS OF THE

case of full term pregnancy the woman had convulsions every
fifteen minutes. In this case he did an abdominal Cesarean
section at once, delivered the child in six minutes, closed the
wound, and the patient was returned to the ward in twenty-six
minutes from the time operation began.

Recently abdominal Cesarean section with the perfect technic
of the present day had materially lowered the maternal mortality
and the operation was selected not only on this account, but also
for the reason that it oflFered better advantages in saving the life
of the child than many of the intrapelvic methods of delivery.
The operation was far less dangerous than high forceps, version
and, he believed, vaginal Cesarean section. Granting rapid
evacuation to be the rational treatment, he contended that it
was best accomplished by abdominal Cesarean section.

DISCUSSION.

Dr. Reuben Peterson was quite in accord with the essayist
that in eclampsia, after all other methods had been tried, the
uterus should be emptied as quickly as possible. He took issue
with him, however, in the operation to be selected. First, he
had always contended that an obstetric operation must be one
which met the needs of the general practitioners at large, and
if it did not, it was of very little value because only compara-
tively few operations were performed in hospitals; therefore,
that principle should be kept in mind in advocating obstetric
operations at large. There were certain vital objections to urg-
ing that obdominal Cesarean section for eclampsia be performed
by the general practitioner. First, the general practitioner was
not always in the habit of entering the peritoneal cavity.
Second, his technic had not been perfected to such a degree
that he could do it safely, and for that reason alone, in a large
number of cases of eclampsia where operative means were neces-
sary to empty the uterus, it was better to do so from below.

He concurred with the essayist in condemning manual dilata-
tion in rigid cervices, but he thought we should confine the criti-
cism to that particular class of cases. The general practitioner
would do much better by resorting to manual dilatation where he
could do this easily. Vaginal Cesarean section was suitable only
for those cases of rigid cervices where it was not a question of
an hour and a half or two or three hours to dilate the cervix
sufficiently to permit the delivery of the child. When we came
to compare vaginal Cesarean section with abdominal Cesarean
section he did not think the essayist was right in his comparison
of the two operations. Vaginal Cesarean section was not a
difficult operation to perform if one was cognizant of the technic.
It could be performed in about as short a time as abdominal
Cesarean section, and with far less risk. Of course, if the
voman's pelvis was contracted the operation must be done
through the abdomen, but even in the hands of the general prac-



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SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 307

titioner he thought there would be far less damage by vaginal
Cesarean section than in attempting to dilate a rigid cervix.

So far as sepsis was concerned, where the peritoneal cavity
was not opened, and there was no need of doing this in vaginal
Cesarean section, the dangers of sepsis would be less from an
operation done below than from above.

Dr. I. S. Stone, Washington, D. C, stated that in view of
what had been said relative to early operation where, for instance,
a woman was supposed to have a pelvis which would permit of
the extraction of the child at eight and a half months in a case
of eclampsia, the vaginal Cesarean section seemed to be the
preferable procedure, for the reason that there were a number of
men who could do the operation more safely from below than
from above. The operation suggested by the essayist was
proper in certain hands. There were some men who did not
know and who had never learned surgery by the vagina, and
these men could do better work through the abdomen. There
were a number of men in every locality who were capable of do-
ing the vaginal operation. On the other hand, there were men
who favored Cesarean section in every instance of complicated
labor. He did not think this was right. It was very desirable
to let women have children as normally as possible, and the
vaginal or abdominal operation should only be done after other
methods had failed. Again, there were women who objected
very seriously to repeated operations through the abdomen for
the extraction of the child.

Dr. Joseph Price thought Dr. Stone was in error with ref-
erence to intelligent women not consenting to the abdominal
route for the delivery of the child. Take the wife of an intelli-
gent physician or dentist, who had attained the age of thirty
or thirty-five before she got married, and in the midst of modem
conventional methods of living and great stress, we could find
that late conceptions were favorable to the development of
eclampsia and also to surgery. Such an intelligent woman
would accept a wise presentation of the method of delivery.
Wonderfully good work had been accomplished by vaginal
Cesarean section, and the vaginal operators were men who had
served a long apprenticeship in extirpation of the uterus and in
the repair of accidents incident to parturition. Such men were
eminently capable of doing good vaginal work, and when other
methods of delivery had been tried and failed, he would not
hesitate to trust any of these men to do either a vaginal or ab-
dominal Cesarean section.

the symptoms AND ULTIMATE TREATMENT OF HYDATIDIFORM
DEGENERATION OF THE CHORION, WITH REPORT OF A CASE.

Dr. J. E. Stokes, Salisbury, North Carolina, stated that as
the process of hydatidiform degeneration of the chorion was a
rare condition and followed not infrequently by a most malig-
nant and rapidly growing neoplasm, immediate recognition



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308 TRANSACTIONS OF THE

of which was essential to the relief of the patient вАФ ^the report
of a single isolated case might not be without clinical value and
of pathological interest.

The patient was a young, white, married woman, age nineteen
years. Family and past histories negative, while the menstrual
history was normal to within three months of her present illness.
For the first six months after marriage the patient had her
periods regularly. Then she had amenorrhea for three months,
with the. following symptoms : The presence of a thin watery
blood-stained fluid, which started two weeks after the first
period was missed, then ceased up to within a few weeks of
present illness, when it became of a dark red color, hemorrhagic
in character. There was headache with nausea and vomit-
ing, dull aching pain over the entire body, with sharp cut-
ting paroxysms of pain through lower abdomen. One night
suddenly there was a profuse flooding, a pint or more in quantity,
from the vagina. There was also considerable pain of a bearing-
down expulsive character through the pelvis. Patient became
extremely pale; pulse 140, weak and irregular, with some rise
of temperature and cold clammy external surface. Vaginal
examination showed the fundus enlarged much beyond the size
of a four months' pregnancy. Owing to the unusual size of
the uterus for that period of gestation, the profuse hemorrhage
following a previous watery blood-stained fluid and the pain
immediately over the uterus and the elevation of temperature,
the uterus was emptied.

The specimen obtained, on gross appearance, consisted of
myriads of glistening cysts. These vesicles hung in bunches,
grape-like in appearance. A few of them were covered by thin
gray fleshy substance, while the cysts were firmly distended
with a clear viscid fluid.

The histological examination showed the chorionic villi of a
degenerate appearance. The syncytial layers of many villi were
absent and the stroma was of a myxomatous character, with



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 31 of 109)