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many small degenerate nuclei; while other villi had normal
stroma with both the two layers of cells well defined. This ex-
amination showed the diagnosis to be plainly that of hydatidi-
form mole.

The patient reacted from the operation satisfactorily, but the
pulse remained rapid; there was some elevation of temperature
and considerable pain through the abdomen. In a short time
there was an escape of blood from the vagina, which continued,
being more marked at night than during the day. It was, there-
fore, deemed advisable in a week or so to investigate the interior
of the uterus again, so a cautious curettement was done. By
this curettement a dozen or more soft vascular, nodular masses
covered by endometrium of normal thickness and filled with
blood-vessels, were brought away. Microscopically the specimen
showed the epithelium undergoing more marked and active pro-
liferation than in the section of the mole. Notwithstanding the



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SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION. 309

fact that the second specimen showed a more active proliferation
of the cells of the epithelium, and, again, that in at least two
places these proliferating cells penetrated deeply into the endo-
metrium, both of which facts are indicative of the malignant
nature of a vesicular mole, the patient showed steady improve-
ment, gained in weight, the uterus contracted, the bleeding
ceased, and there were no indications of metastatic formation,
so that the more radical operation of hysterectomy was not
advised.

This patient was finally examined four months later and was
found to be in excellent general condition; had gained a number
of pounds in flesh, and had just passed through a normal men-
strual period. The vaginal examination showed the fundus to
be small, contracted and regular in contour.

Regarding the etiology, though this point was not definitely
settled, authorities rather lean to the belief that the primary
changes take place in the ovum, and that the endometritic
changes are only secondary.

Again, as regards the relation of hydatidiform moles to malig-
nancy, there were many points yet undetermined, but it was
agreed by all that there was a very close relationship between
the occurrence of hydatidiform mole and the appearance later
of a malignant neoplasm. The two special theories advanced
regarding the malignancy of the vesicular mole were, i. that
there were two distinct forms of mole, malignant and benign,
while the other theory was that all moles were malignant and
that the malignancy manifested itself through a portion of the
mole being left behind in the uterus. The percentage of decidu-
omata preceded by occurrence of vesicular mole was univer-
sally recognized as about 40 per cent.

The four most distinct symptoms in their order of positiveness,
though not always constantly present, were, i. the pink, watery
discharge; 2. enlargement in contour of uterus; 3. hemorrhage;
4. tenderness over the uterus; 5. presence of mole by internal
palpation.

A positive diagnosis could always be made if the discharge
contained any of the vesicles; the discharge was watery, blood-
stained in character, and when the vesicles were discharged with
it the picture had been aptly likened to "white currants floating
in red currant juice.*' Hemorrhage should always be taken
as an important Sign when occurring in a uterus whose size
was larger than expected for that period of gestation, or in which
the rate of the growth of the uterus had been noticeably rapid.
The second and third months were the most frequent ones in
which the hemorrhage occurred. Tenderness over the uterus
had been noticed as a distinctive occurrence in a number of cases.

The diagnosis was seldom positively made until the expulsion
of the mole or until its presence in the uterus was made out
through internal palpation; but the presence of the mole should
always be suspected on the appearance of the characteristic dis-



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310 TRANSACTIONS OF THE

charge or after a severe hemorrhage in an unduly enlarged, soft or
rapidly growing uterus. The main point regarding the prognosis
was that from lo to i6 per cent, of hydatidiform moles under-
went malignant degeneration; also, that in a certain number of
cases an early diagnosis following the very onset of symptoms
was absolutely essential for the permanent relief of the patient.

The author divided the treatment into the immediate and
ultimate. Under the first head came those cases in which a
positive diagnosis of the presence of a vesicular mole had been
made. In these cases it was universally agreed that the mole
should be removed immediately. The greatest care must be
exercised in not perforating the wall of the uterus; in fact, it
was advisable not to use any instrument, but to rely upon the
finger and gauze. The uterus should then be most carefully
explored with the finger for any particles of the growth cleaving
to the wall; then the cavity should be irrigated and lightly packed
with gauze.

The ultimate treatment had to do especially with the appear-
ance of malignancy following the occurrence of hydatidiform
mole. The greatest caution and watchfulness for the indications
of malignancy were to be exercised in the ultimate treatment of
the patient, who should be carefully watched and examined at
intervals irrespective of her apparent improved condition or
freedom from all symptoms. If there was any invasion of the
vagina or vulva the nodule should be removed and histological
examination made. If there were any distinct lesion of malig-
nancy found to be present in these nodules, immediate removal
of the uterus was indicated. At least, once a month or more
following the expulsion of a vesicular mole, the uterus should be
throughly examined and cautiously curetted, and the scrapings
examined microscopically. If the specimen thus obtained from
the uterus suggested the slightest active proliferation of the
chorioepithelium, the patient should be continually watched
or the uterus removed at once.

OFFICERS.

The following officers were elected for the ensuing year: Presi-
dent, Dr. W. O. Roberts, Louisville, Kentuckey; First Vice-
President, Dr. Joseph C. Bloodgood, Baltimore, Maryland;
Second Vice-President, Dr. Lewis C. Morris, Birmingham,
Alabama; Treasurer, Dr. Wm. S. Goldsmith, Atlanta, Georgia;
Secretary, Dr. Wm. D. Haggard, Nashville, Tennessee.

Nashville, Tennesse, was selected as the place for holding the
next annual meeting.



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NEW YORK ACADEMY OF MEDICINE. 311



TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.



SECTION ON OBSTETRICS AND GYNECOLOGY.

Meeting of November 26, 1909.
J. O. PoLAK, M. D., in the Chair.

LIPOMA OF THE LABIUM MAJUS.

Dr. a. Sturmdorf presented this specimen. This was one
of the rarest of gynecological affections and represented a most
unusual dystocia. Up to 1906 Kelly could collect only twenty
cases from the scattered literature; these he tabulated in the
Johns Hopkins Hospital reports, Vol. 3, page 321. He stated
that **no writer had as yet recorded more than a single instance
in his own practice." In this published series of cases, Kelly's
was the only one in which the tumor obstructed the vaginal out-
let during labor.

Lipomata of the labia majora presented the same character-
istics as lipomata elsewhere. Their density and resistance de-
pended upon the predominance of their fatty or fibrous elements.
They might project from a broad base involving the whole
labium, as in this case, or the growth might be suspended by a
more or less attenuated pedicle which in one case extended up-
ward into the inguinal canal, simulating a hernia.

Goodell of Philadelphia reported a case in which the growth,
springing from a broad pedicle, extended to the patient's knees.
Headley of Melbourne removed a lipoma of the labium majus
which weighed twenty-four pounds.

The tumor Dr. Sturmdorf presented was extirpated from a
primipara, thirty-six years old, who was referred to him in labor
because of an obstructed outlet. She claimed that she had
carried the growth for eight years without discomfort. The
tumor was quite hard and resisting, very slightly movable,
attached by a broad base involving and obliterating the
outlines of the left labium majus. Its surface was transversed
by an extensive network of tortuous and dilated veins. It
measured 12.5 cm. in length, 10.5 cm. in diameter and 29.5 cm.
in circumference.

The fetal head was pointing at the vaginal outlet; here it
was arrested by the projection of the growth on the left, and an
old anchylosis of the hip- joint on the right.

The removal of the growth permitted the prompt sponta-
neous delivery.



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312 TRANSACTIONS OF THE

ADENOCARCINOMA OF THE CORPUS UTERI.

Dr. a. Sturmdorf. Palmer Findley stated that in carcinoma
of the body of the uterus one saw a great variety of histological
forms. In general there were found the adenocarcinoma, the
alveolar, and very rarely the squamous celled type.

Adenocarcinoma might assume a type sometimes spoken of as
malignant adenoma^ i.e., a glandular overgrowth in which the
greatly increased glands invaded the musculature of the uterus.
It was difficult to differentiate such an early malignant adenoma
from an advanced type of hyperplastic glandular endometritis,
termed benign adenoma.

The specimen submitted presented the typical form of adeno-
carcinoma where, in addition to irregularity in outline and
great increase in the number of glands, the epithelium prolif-
erated, forming multiple irregular layers invading, but limited
to, the corporeal structures of the uterus.

The history of the case in brief was as follows: The patient
was a widow, fifty years of age. The family history was negative.
She had had two children, eighteen and twenty years ago; the
labors were normal. She never miscarried. Fifteen years ago
she had malaria. Her menstruation began at the age of thir-
teen; it was of the twenty-eight day type, lasting two or three
days without discomfort. The menopause occurred twelve
years ago. The patient claimed that, barring annoyance from
a vaginal discharge, altematingly leukorrheal and bloody,
existing for ten years, she had never experienced discomfort or
pain.

On examination, the cervix presented a normal appearance;
the uterus was somewhat enlarged and boggy; the adnexa were
free. An examination of the scrapings prompted a total hys-
terectomy, this was performed June loth of this year. The
extirpated uterus presented the following features, according
to the pathologist's report.

The specimen consists of uterus and a small strip of vagina
attached. The uterus measures 9 cm. in length, 6.5 cm. be-
tween the cornua, and 4.2 cm. in thickness. The uterine canal
is the seat of a granular friable papillary tumor mass, made up
of innumerable small elevations raised above the surface from
a fraction of a millimeter to several millimeters, and continuous
below in a common base. By coalescence of some of these,
larger knob-like elevations have formed.

The mucosa of the body of the uterus is entirely replaced by
the cancer growth, which extends as far down as the internal os,
and there stops, leaving the cervical canal and vagina free from
involvement.

The tumor extends for quite a distance into the wall of the
uterus, in places composing one-half of the wall thickness, but
in no place does it reach the surface.

Sections show a typical adenocarcinoma, made up of glandular
spaces of varying shapes and sizes, lined by one or many layers of



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NEW YORK ACADEMY OF MEDICINE. 313

cells, irregularly placed upon one another. The tumor pene-
trates deeply the muscle tissue. It is preceded and surrounded
in its down growth by an infiltration through the muscle tissue
of many leukocytes and small, round cells and plasma cells.
The marked proliferation of the gland epithelium has produced
many bizarre forms of glandular spaces. The cells lining the
spaces are of the high columnar epithelium type, resembling
those found in the uterine mucosa. Mitotic figures are not
uncommon. Degeneration has taken place in many areas and
degenerated cells fill many of the spaces.

Carcinoma of the corpus uteri, and especially adenocarcinoma,
is extremely insidious and slow in its development, and, as
in this case, usually many years elapse before symptoms point-
ing to the possible existence arise. Fortunately, these growths
were not very prone to metastases and a complete hysterectomy
holds out the greatest probability of permanent cure.

INTERSTITIAL ECTOPIC PREGNANCY AND TUBO-OVARIAN ABSCESS
IN THE SAME PATIENT.

Dr. a. Sturmdorf. вАФ The patient was twenty-eight years of
age, married four years, and stated that she had never before
been pregnant, that she had never been confined to her bed
by illness, and insisted particularly that she had never suffered
from any gynecological affection whatsoever. Her menstrua-
tion began when she was fifteen, and was rather scant, somewhat
painful, and was frequently delayed from three to six days.

She had last menstruated regularly seven weeks prior to his
first examination, and she admitted that when two weeks over-
due, suspecting pregnancy, she submitted to an attempt at artifi-
cial abortion. This resulted in merely producing an irregular,
occasionally profuse, painless flow which had continued during
the following four or five weeks. Her temperature was normal,
her pulse was slightly accelerated, and anemia was not very
marked. The hemoglobin percentage was 65 and there was no
leukocytosis. There was no abnormal tenderness.

Upon examination, the uterus appeared normal in dimensions
and consistence, immovably attached to its left side was an
irregularly shaped, soft, elastic mass filling the left lower pelvis.
The right side presented nothing abnormal. The history, the
symptoms, and the mass seemed to make the diagnosis of ectopic
pregnancy a logical conclusion.

Abdominal section, however, revealed the uterus to be com-
pletely embedded in extensive organized adhesions. The mass
to the left which had been interpreted as the gestation sac proved
to be an old tubo-ovarian abscess, while the junction of the oppo-
site comual area with the tubal isthmus presented the soft
bulging of the existing ectopic shown in the specimen.

Where they expected to find the ectopic they found an abscess.
Where they expected nothing they found the most dangerous
form of ectopic pregnancy. Furthermore, the complete absence
9



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314 TRANSACTIONS OF THE

of all signs and symptoms pointing to the existing extensive
results of previous infection were worthy of comment.

ON THE INDUCTION OF LABOR AND MANUAL DILATATION OF THE
CERVIX BY HARRIS'S METHOD.

Dr. H. M. Little of Montreal, Canada, read this, the paper of
the evening. He said that during the past few months the
tabulation of the statistics of some forty cases of eclampsia and a
compilation of the medical report of the Montreal Maternity
Hospital for the past year had given him an opportunity to
become familiar with certain features of the general work which
had impressed him strongly. Two of these features which stood
out strongly and seemed most worthy of attention were, the
results of the induction of labor, and those of accouchement
forc6 by the Harris's method!

Records of 3,000 cases in Montreal showed an average of about
1 1 per cent, of contracted pelves. During the past year he found
that with eighty-seven contracted pelves there were seventy
normal labors, and but seventeen instances of dystocia. That
is, 80 per cent, of the labors terminated without interference.
If they considered that normal labors occurred in 80 per cent, of
the 1 1 per cent, of all cases in which the pelvis was more or less
contracted, it was a simple deduction to see that pelvic dystocia
was to be expected in about one of fifty cases; and if they excluded
from these, those in which forceps or version might be employed
with advantage, the chances of serious pelvic dystocia were seen
to be extremely remote. Owing to the success of certain ad-
vances along surgical lines, pubiotomy and the various modifica-
tions of abdominal section, they owed the favorable reception
of two other operations, multiple incisions of the cervix and the
so-called vaginal Cesarean section. It was on account of the
widespread notice that these two operations had obtained that
he brought before the Section the results gained by two other
and older operations which had fulfilled all purposes. He re-
ferred to the favorable results gained by the induction of labor
and manual dilatation of the cervix.

Dr. Little said he had been impressed by the number of cases
of dystocia on account of the birth of a child unusually large or
exceedingly heavy, even though the pelvis was normal.

Vaginal Cesarean section had been recommended in cases
where the cervix was rendered abnormal by carcinoma, fibroids,
or extensive scars. It had also been suggested in cases of eclamp-
sia, placenta previa, heart disease, nephritis, chorea, vomiting
of pregnancy, tuberculosis, and intrapartum infection.

Labor had been induced forty-five times in the series of 3,000
cases. The method employed was as follows: The vulva was
first shaved and cleansed. The cervix was exposed and its an-
terior lip was fixed with a tenaculum. The bougie used was
a moderate-sized rectal tube, about 25 cm. long, in which
holes, about 3/10 cm. in diameter, were made [at intervals of



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NEW YORK ACADEMY OF MEDICINE. 315

about 5 cm. This was fibced upon a flexible metal director
inserted about 5 cm. from its tip. The metal director served to
hold the bougie steady during its passage into the cervix, and
after director and bougie had passed into the cervix the director
was steadied and the rubber tube shoved up between the mem-
branes and the uterus by means of long forceps. The director
was then reinserted into the next opening of the tube, passed up
until it was well within the cervix, and the tube again shoved off
up into the uterus. In this way it was possible to pass in the
tube as if it were solid and yet allow the freest of excursion once
it had gotten between the uterus and the membrane. The soft-
ness of the tube precluded the possibility of perforation of the
uterus and the membranes were never ruptured. The average
time from the introduction of the bougie till the onset of labor
was six and a half hours. In spite of the early onset of pains
in the majority of the cases, it was found necessary to interfere
for the completion of labor in about one-half the cases. Nineteen
of the forty-five cases died, but as the operation was in by far
the greater number of cases undertaken in the interest of the
mother, this showing was relatively good, particidarly when
the deaths were analyzed.

Accouchement forc^, or so-called ** bloodless*' dilatation of the
crevix by Harris's method, had been employed on fifty-two
occasions; two more cases were added where dilatation was
accomplished by means of the Pomeroy bag. The indications
were, eclampsia, fifteen cases; to terminate labor after induction,
eight; placenta previa, eight; toxemia, to shorten labor, four;
danger to the mother or child during labor, nine; prolapse of
the cord, three; transverse presentation, two; fever intrapartum,
two; extreme rigidity of the cervix, one; other causes, two; a
total of fifty-four cases. There were five deaths, three cases
of eclampsia, one case of placenta previa, and one after pu-
biotomy. In the fifty-two cases operated on by the Harris's
method but fourteen, or 29 per cent., escaped without a certain
amount of laceration. In the two cases in which the Pomeroy
bag was used there was more or less tearing of the cervix. Two
dangers of manual dilatation, hemorrhage and infection, had
not been noted to any extent. A total of twenty-eight normal
puerperiums in forty-nine cases, 57 per cent., was not unsatis-
factory, particularly as seven of the eight moderately high tem-
peratures after the use of Harris's method were noted three
times in association with placenta previa, twice where they
had high fever before the operation was undertaken, once in
a case of pyelonephritis, and once after the placenta had been
removed manually.

CONCLUSIONS.

It would be seen that the induction of labor and occasionally
the completion of labor by manual dilatation offered an alter-
native to surgical procedures in the treatment of many of the



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316 TRANSACTIONS OF THE

graver complications of labor. These two operations not only
were simple but were capable of application under almost
any circumstances and were so simple that they might be em-
ployed by a practitioner even without the aid of assistants.

When carefully employed they were practically devoid of
danger and had the advantages of being not only of wide appli-
cation but of almost universal use in that the manual dilatation
of the cervix must be completely employed as a preliminary to
either operation with forceps or version.

Where carefully employed the maternal mortality should be
nil, though particularly in the induction of labor there might
occasionsdly be deaths from too long delay before labor was
induced.

The same however would apply no matter how the patient
was delivered, for once the bougie was inserted it was but a short
time until the patient either delivered herself spontaneously or
could be delivered by other methods.

Dr. J. Clifton Edgar congratulated Dr. Little upon the
general conservative atmosphere that pervaded his paper. It
had always been interesting to note the factors which influenced
us in making a selection of a method for inducing premature
labor, and he thought that precedent had something to do with
this selection. Local prejudice also had something to do with
it. One's experience also came into play. It seemed to Dr.
Edgar that if one had much experience with the use of the bag
of Champetier de Ribes in the induction of premature labor,
he would cling to this method. However, the method pro-
posed by Dr. Little, a modified Krause method, appealed to him,
although there was connected with it a certain amount of un-
certainty. Dr. Little used a large bougie and introduced it high
into the uterus and caused the induction of labor within an aver-
age of six and a half hours; usually the maximum of time for
the induction of labor was twenty-four hours. Dr. Edgar said
he would take pleasure in ordering two or three of these rectal
tubes and try them; this seemed to him to be rather a conserva-
tive way of inducing labor. Whatever method for inducing
labor was employed, Krause's or any other, it seemed to him
that it depended upon the intrinsic irritability of the uterus-
Take for instance two cases, one a primipara, the other a multi-
para; introduce in each the same sized bag; in each case the primi-
para may have labor induced before the multipara much to one's
surprise. In some instances there would occur a very short
labor. In others a very long one. It was the condition of the
uterus itself that counted, and not so much the method employed.
The general results obtained by Dr. Little he considered excellent,
and especially in the care of the cardiac cases. One should
endeavor to shorten the second stage of labor in such cases.

With regard to accouchement forc6, an old expression was that
"all roads lead to Rome" and all methods employed become
after all a personal equation; all these methods have their use;



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NEW YORK ACADEMY OF MEDICINE. 317

one would get good results with one method, and another person
woidd get similar results with another method. Dr. Edgar
obtained his best results with the use of the Pomeroy bag in
accouchement forc6. His experience, however, had been very
similar to that of Dr. Little; one could not rely upon the Pomeroy
bag to open up the uterus three and a half or three and three-
quarter inches within an hour without lacerating the cervix.

Dr. Edgar said he was in accord with the reader of the paper
in his statement that in obstetrical emergencies which demanded
very rapid dilatation of the cervix, the choice of operation should
depend upon the condition of the cervix. It was rather inter-
esting, however, that in New York they met with cervices that
were very resistent, and it seemed to him that there should be
no choice of any one method. It was to be borne in mind at all
times it was the rigidity of the cervix that was to be overcome,



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 32 of 109)