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found a spot to strip it, it separated without difficulty. Even
after the separation of the placenta, there was practically no
bleeding. Dr. Dorman's suggestion was certainly the correct
explanation. The lack of bleeding was due to the absolutely
perfect attachment of the placenta in the whole circumference in
this case. There had been no dragging oil the cord and very



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PLATE I AMERICAN JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN

MARCH, 1910



ENORMOUS FIBROID GROWTH OF THE UTERUS— VINE BURG



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NEW YORK OBSTETRICAL SOCIETY, 491

little manipulation of the uterus. When I turned the case over
to Dr. Pearson I knew the uterus was in good condition.

Dr. H. N. Vineburg presented the specimen and record of an

ENORMOUS FIBROID GROWTH (23 1/2 POUNDS) OF THE UTERUS.
HYSTERECTOMY. RECOVERY.

Mrs. H., aged fifty-five, widow three and a half years. Had
seven children, youngest seven and a half years old. Menopause
seven years ago. The patient had noticed several years ago that
her abdomen was large, but she paid no attention to it, inasmuch
as she had no pain nor discomfort from it. But of late the abdo-
men had increased so much in size that its weight alone was
causing her some distress. In addition she was beginning to
suffer from difficulty in breathing and from a sense of fullness at
the epigastrium, especially after eating. She was also experienc-
ing considerable difficulty in the movement of her bowels. It
was these subjective symptoms that induced her to consult her
family physician, Dr. M. Katzenberg, who kindly referred her to
me.

I found the patient looking older than her stated age,
and with her abdomen enormously distended as if she were
carrying triplets. The tumor reached the ensiform cartilage
and the lower border of the ribs on either side, and it gave rise
to a great protiiberance of the entire abdomen. On vaginal
examination the sound was found to pass into the tumor, and the
entire pelvis was filled with hard nodules, varying in size from a
hen's egg to that of a closed fist. The impression gained from
the examination and history was that the growth was of a malig-
nant nature, owing to its rather rapid growth of late, and owing
to the manner in which the nodules seemed fixed to the pelvic
walls. Still, the patient's general condition seemed good and I
was willing to entertain the opinion of the family physician that
the growth was a fibroid, and that the patient should be given the
chance of an exploratory laparotomy.

On July 19, 1909, I operated upon the patient at Mt. Sinai
Hospital. The abdominal section disclosed a huge fibroid
filling almost the entire abdomen and pelvis. It was surprising
to note what a small space was left for the intestines to occupy.
The operation offered many technical difficulties, owing to the
great size of the tumor and the numerous tortuous and greatly
dilated blood-vessels.

The patient withstood the operation remarkably well, and were
it not for a rather troublesome bronchitis no convalescence from
a laparotomy could run a more smooth course. The weight of
the tumor after removal was 23 1/2 pounds. The interest in
the case is that a woman should carry a large fibroid tumor within
her abdomen for so long a time and with comparatively little
discomfort, and that it should take on active growth after so
long a period of quiescence and after so long a period after the
cessation of the menstruation.



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492 • TRANSACTIONS OF THE

Dr. Broun. — At our October meeting I had occasion to pre-
sent a specimen of very early carcinoma of the cervix of very
considerable interest. I brought some slides to show the society
and failed to show the little island of epithelioma, and I stated
at the time I would request the pathologist of the Woman's
Hospital to help me out. At our last meeting the light was not
such as to allow the use of the microscope. I will ask Dr.
Jessup, the pathologist of the Woman's Hospital, to exhibit
these slides to anyone who wishes to see them.

The patient came under my care with a diagnosis of carcinoma
of the cervix. The appearance of the cervix was typical of
erosion, yet with the diagnosis of carcinoma, I requested Dr.
Jessup to make a frozen section of the excised cervix. He
failed to get any evidence of malignancy, so the operation
was completed in the ordinary way. Three or four days later the
pathologist reported the presence of malignancy in minute foci
in some of the sections from celloidin hardening. Hysterectomy
was done ten days later.

Dr. Barrows presented a case of

"dermoid CYST delivered THROUGH RECTUM AND ANUS BY
ADVANCING HEAD."

Mrs. G., thirty-eight years old and the mother of four children,
was seen by me on November 2 1 , in consultation with Dr. Morris
Klein. Dr. Klein reported to me that he had seen the patient
first the day previous when she had advanced well into her
fifth labor. The os was completely dilated, but the progress of
the head was interrupted by a soft, boggy mass behind and
below the cervix. He, with the assistance of a young medical
friend, applied forceps and delivered a living child without much
difficulty.

As the child's head was drawn through the vaginal outlet
there was delivered through the rectum a mass somewhat larger
than the fetal head.

Believing that they were dealing with a prolapsed rectum.
Dr. Klein and his medical friend attempted to reduce the mass.
In their efforts at reduction the mass was punctured and material
which they believed to be feces escaped. They closed this open-
ing with a catgut ligature, and when morning came, a few
hours later, called me in consultation. The tumor proved to be
a dermoid cyst, the characteristic caseous material filled with
hair, having been mistaken for fecal matter.

The woman was in good condition, with a temperature of 102®,
and a pulse rate of 90, and some slight distention and tympany
of the abdomen. I transferred her to the Har Moriah Hospital
and opened her abdomen at once. The pelvis was filled with
blood clots, and the whole peritoneal floor had been carried away
by the advancing dermoid cyst of the right ovary. The rectum
was torn open for its entire length down to within two inches of
the anus. The uterus was about twice the normal size, and was



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NEW YORK OBSTETRICAL SOCIETY. 493

filled with multiple fibroids. I tied off the pedicle and delivered
the tumor from below, having attached a long clamp forceps to
the cyst before opening the abdomen in order to facilitate deliv-
ery and lessen, if possible, dangers of infection. I then repaired
the injuries to the right broad ligament and the rectum as well
as could be done from above, and packed the rectal tear from
below. The bowels were kept constipated for four days, at which
time the packing was removed, and they moved normally with-
out assistance.

The patient has made an uneventful recovery, and has been
discharged from the hospital well.

DISCUSSION.

Dr. Jewett. — I was cognizant of a case a few years ago in
which in a forceps extraction a dermoid cyst was brought down
in advance of the head through the vaginal wall. The cyst was
ruptured, but no infection followed, most of the contents having
escaped externally.

Papers w'ere read as follows:

Dr. E. W. Pinkham.

ethical questions involved in abortion.*
Dr. W. p. Pool.

the differential diagnosis and treatment of abortion. f

discussion.

Dr. Edgar. — In the old days, when I went on a two years'
service as interne at Bellevue, we were in the height of an ultra-
radical treatment of abortion. No abortion was allowed to be
treated expectantly at that time. Every abortion was consid-
ered to be an incomplete abortion. So every one was promptly
curetted along the lines laid down at that time for the treatment
of incomplete abortion.

In the spring and summer of 1888 I served six months under
Winkel in Munich, and at that time he was in the height of his
ultra-conservative treatment of abortion. An abortion, whether
it was complete or incomplete, was left entirely alone in the wards
to empty itself, and if any of the gentlemen who served as internes
at that tipae were here to-night, they would bear me out that
it made a most unfavorable impression upon all those who
watched the ultra-conservative treatment of incomplete abortion.
A large number became sapremic, and quite a number became
frankly septic. The odor in some of them would become some-
thing awful, and not even then was interference inaugurated.
Somewhat later I collected between two anid three hundred
cases of early abortion, that is within the first twelve weeks,

* See original article, page 413.
tSee original article, page 421.



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494 TRANSACTIONS OF THE

all of which occurred in tenement houses, and a large number
were undoubtedly criminal cases. Every one of those was
promptly curetted. We had excellent results from this radical
treatment, not one of those cases did we lose. We cannot
recollect any prolonged sepsis, although we received a good many
of those cases who were at the time septic.

So the interest in the discussion to me centers around the
point how we are going to get the uterus clean if we decide to
curette it. I cannot conceive of anyone cleaning out the decidua
at the twelfth week or later with the gloved finger. It is simply
an imperfect operation, imperfectly done. Very little, if any-
thing, is brought away. No more can I conceive of cleaning
the uterus out with the smooth curette, or even a wire curette.
It slips over the membranes and we do little or nothing in re-
moving material unless it be a septic uterus and the material
is soft.

In the last few years I have come to feel myself the same
way as regards the sharp curette. We see instances where we
have a dead ovum and that decidua is attached to the uterine
wall so firmly that an ordinary curette makes little or no impres-
sion on that decidua, and so in the last two years I have been
using what will sound radical perhaps to members of this Society
— a sharp curette which is serrated. I have them made in Paris.
It is not my idea; the French have been using them for some years,
and it is a very finely serrated instrument. I do not use it
firmly, but use enough force to secure a hold on the membranes.
My belief is that with a finely serrated curette you can empty a
uterus with less traumatism because you do not use so much
pressure or weight. I have even used it in the last three months.
• One case I had a few days since — a retained placenta. I waited
three hours and then she leaked so much that I expressed the
placenta, but all the membranes were retained. I let her rest
up a little and then gave an anesthetic. I took the serrated
curette and with very little force applied to the uterine wall I
could readily remove the membranes. It took two or three
movements to get them out. The smooth curette would not
have touched those membranes. It sounds very radical to use
a serrated curette to remove membranes, but you can do just
as much harm with a knife if it is improperly used, but with
the serrated curette you can secure the membranes with little
or no traumatism to the uterus.

I think there are cases which do not need curettage, but from
my standpoint it is much safer to curette even if there is ap-
parently a complete abortion, and many of us believe that this
never occurs. It is always safer to do a straightforward curet-
tage and make sure you have no retention in the uterine cavity.
I am rather inclined to use a curette on septic early abortion. I
think it can do a great deal of harm in breaking down the line
of demarcation, but in the early months, when the deciduae are
removed with the curette, recovery is almost always prompt.



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NEW YORK OBSTETRICAL SOCIETY. 495

Dr. Jewett. — ^The argument of Dr. Peterson cited by Dr.
Pool does not appeal to me. The uterus at abortion is not
quite comparable to the uterus at term. It is less easily infected.
I have always believed that instrumentation in the presence
of fresh living tissue in the uterus is less dangerous than even
skilled interference in the presence of sepsis.

I make two classes of cases:

1. When the pregnancy has not gone beyond about two and
one-half months the uterus is readily emptied in about eight
minutes. Only enough dilatation is required to pass a Keith
clamp. With the latter most of the ovum is brought away.
The work is then finished with a sharp curette. Even though
a few minute shreds of decidua may sometimes remain behind,
I have seen no trouble from them in the absence of primary
sepsis. They are soon swept out in the discharge.

2. At three months or later gradual dilatation is necessary.
Dr. Collyer. — ^There are practically three forms of abortion.

One is spontaneous, relieved without medical assistance, another
will get well without operation; the last is where hemorrhage
or sepsis is likely to occur on account of retained secundines, and
that requires instrumentation. The sharp curette has given
me the best results, and in septic abortion, in my opinion, there
is only one thing to do, remove the septic material as quickly as
possible. Disinfect the uterine cavity, inserting a strip of iodo-
form gauze for drainage. I desire to bring out the fact, that it
is dangerous in some hands to use any instrument in the uterus.
A sharp curette has been known to go through the fundus uteri,
so has a dull curette, but it is a question who uses it. In dilating
the uterus there are many uteri which will rupture on very slight
pressure, and a rupture into the broad ligament is attended
with a great deal of hemorrhage, and it is something to be cau-
tioned against. As to letting an abortion alone, I have had the
dangers illustrated to me on many occasions.

When abortion begins I believe the physician should stretch
the cervix and empty the uterus as soon as possible with a
curette to prevent probable subsequent dangerous hemorrhage
or sepsis.

Dr. Vineberg. — I learned one thing in dispensary practice,
i.e., that spontaneous abortion almost invariably will not go to
sepsis. It was surprising to see women in the lower ranks of life
coming there in the early stages of pregnancy in various grades
of abortion; some in which abortion had not really occurred,
but only threatened; some cases of partial abortion; some of
retained decidua, but almost invariably when there had been no
instrumentation and no examination there was no fever and no
sepsis.

I agree with the gentlemen that in those cases which are sep-
tic, and where there are products of conception in the uterus
I should use the sharp curette. My experience has been that
the vast majority get well promptly, as soon as the uterus is



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496 TRANSACTIONS OF THE

thoroughly emptied. In the few cases in which the infection
has passed beyond the uterus a fatal result usually follows, no
matter what is done.

Mr. Almuth C. Vandiver read a paper on the

LEGAL RESPONSIBILITIES AND PROTECTION OF OPERATOR AND
CONSULTANT IN CASES OF CRIMINAL ABORTION.*

DISCUSSION.

Dr. Coe. — Is a physician attending a case of suspected
abortion, where death is imminent, obliged by law to summon
the coroner to take an antemortem statement?

Mr. Vandiver. — No, sir, not until the death occurs.

Dr. Coe. — Why do the coroners, especially one of them who
is full of pernicious zeal, assume that the law gives them the
right to threaten with arrest, or to otherwise persecute, a physi-
cian who omits to have such an antemortem statement?

Mr. Vandiver. — There is no statute making it necessary.
It applies only in the case of death, and in my opinion the pro-
fessional privilege prevents him from inviting in the coroner
until after the death of the patient, unless he wants to protect
himself from the stupidity of the police and coroners. If it is
his first visit to a stranger I think that his own judgment
would direct him to notify the coroner at once.

Dr. Studdiford. — At Belle vue we get a good many cases of abor-
tion, those of incomplete and septic. A great many of them are
undoubtedly criminal cases. The rule of the hospital is that the
coroners must be notified in all these cases, and we very fre-
quently have them in the wards to take ante-mortem state-
ments. If such a rule is not followed it often leads to a great
deal of difficulty between the coroners, the house staff, the at-
tending physician, etc. Supposing you are called to a case out-
side the hospital where it is very evident the woman is suffering
from abortion. The history is vague. You are convinced that
something is being concealed, and the probabilities are that
criminal abortion has been performed. Is it advisable in such
a case to report that case to the coroner for an antemortem
statement?

Mr. Vandiver. — I should say yes, doctor, because you expose
yourself to some annoyance in the event of the patient dying.
In the case of the hospital I fancy the rule is because the hospital
is a coordinate branch of the government.

Dr. Edgar. — Supposing a physician were called in a case of
septic abortion, and had every reason to believe it was a criminal
case, I would like to ask whether he should consider it advisable
to report it to the coroner. I understand there is no law which
would require it to be reported to the coroner.

Mr. Vandiver. — He should report it for his own protection
only on account of the stupidity of the officials, as it frequently

♦ See original article, page 429.



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NEW YORK OBSTETRICAL SOCIETY. 497

has occurred since I have been counsel to the medical society, and
before that time, that physicians who subsequently were dis-
charged have been arrested by the police, simply because they
were the last physician attending the patient and they had not
made their report to the coroner.

Dr. Krug. — I would like to ask a question regarding ectopic
gestation. Is a woman, according to the laws of the state of New
York, considered pregnant when she is carrying a child outside
the womb? Now, if an attempt at abortion had been made and if
it were found the woman has an ectopic gestation when the con-
sultant is called in, does the law of the State of New York say
anjrthing about that?

Mr. Vandiver. — It says if it is necessary to save the life of the
woman or child it is not abortion. There is some doubt between
lawyers as to the exact meaning of the law.

Dr. Krug. — What is the status of the man who has previously
attempted to produce an abortion in that case of ectopic gestation?

Mr. Vandiver. — In my opinion he is guilty whether she is
pregnant or not.

Dr. Jewett. — ^The law permits the interruption of pregnancy
because it is necessary to save the woman's life. Yet it is
common practice to induce abortion when indicated only for
the amelioration of the patient's condition. We feel justified
in doing it merely to forestall the serious impairment of some
important function, as for example the eyesight. I wish to ask
Mr. Vandiver if he would think it advisable to attempt to secure
legislation with a view of legalizing the latter practice.

Mr. Vandiver. — I should think it would be inadvisable for
the reason that the professional abortionist would take advant-
age of it. The burden of proof that the necessity exists is upon
the accused, and laws are drafted to cover the whole people, and
where there are exceptional cases the prosecuting officials are
intelligent enough generally not to bring indictment against a
reputable practitioner. He can show that what he has done is
in the best interests of the patient. I should think legislation
would be inadvisable. In my judgment the statute should be
made clearer, more decisive, especially in the matter of the use of
instruments.

Dr. Coe. — If this law is interpreted strictly would we not
all be "doing time" ? (Laughter.)

Mr. Vandiver. — If all laws were strictly interpreted you
would all without a doubt be in prison.

Dr. Brettauer. — That the statute ought to be changed
proves a case I had some time ago. A young woman was ad-
mitted to my service at the hospital. A criminal abortion had
been performed upon her. The woman was curetted, and six days
afterward she developed tetanus and died promptly. We re-
ported that case to the coroners' and the district attorney's
offices. The district attorney sent a representative and the
coroner ca;me himself. Each one separately had an antemortem
8



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498 TRANSACTIONS OF THE

statement from the patient, and finally the doctor was confronted
and pointed out by the patient as the performer of the abortion,
a well-known abortionist of this town. This man was discharged ;
he could not be held because the only possible way of convicting
him would have been the finding of the tetanus bacilli on the
instruments which were used to induce abortion. At least
that was the coroner's explanation.

Mr. Vandiver. — A bill introduced in the legislature a year or
so ago, abolishing the coroners, should have passed. It is legis-
lation that most officials who have to do with the criminal courts
would approve. If the coroners were abolished and the duties
vested in physicians, and these physicians attached to the board
of health, we would have a system which would work out to the
advantage of the profession and the people. The judicial duties
now discharged by coroners could be, and generally are, dis-
charged by magistrates, and the medical duties ought to be
discharged by physicians under the supervision of the board of
health. Then you would not have the arrests of physicians
except under the order of the court. No reputable practitioner
would be arrested in the early hours of the morning and kept
in jail until he could get bail some time the next day.

Dr. Broun. — As I understand the matter our duty to our-
selves is that when we are called to a case of abortion, and we
have reason to think it induced, in order to prevent any unpleas-
ant occurrences we should notify the coroner of being called to
such a case. Unless the patient wishes to make an antemortem
statement, the coroner's office is not interested in the matter.
The notification of the physician before undertaking any opera-
tion that might be needed is a safeguard against annoyances
in the event of the patient's death.

Mr. Vandiver. — Yes, that is right.

Dr. Brickner. — At Mt. Sinai Hospital it is the rule to report
all cases of abortion to the board of health, which takes such
action as it sees fit. For instance, last July a patient was ad-
mitted to our service on Sunday night at 2 o'clock with the
following history: On Saturday morning, when about six weeks
pregnant, she had gone to a physician in Brooklyn, whom she
named, and he had introduced an instrument into the uterus
and gave her instruments to introduce Saturday night at home,
which she did as best she could. On Sunday morning she was
seized with a chill. Her temperature rose to 106°. Sunday
night she was admitted to Mt. Sinai Hospital. She was curetted
very early Monday morning and most putrid contents taken
away. Monday evening she died. The case was reported to
the board of health and the matter was presented to the coro-
ner. Nothing was ever done to the physician. He was iden-
tified, was known by name and address, was found, and was
recognized by the patient.

I know that other cases have been reported, but so far as I



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NEW \ORK OBSTETRICAL SOCIETY. 499

know no action has ever been taken against the physicians
even when they have been identified.

Dr. VineB£rg. — ^These antemortem statements, are they
taken by the coroner? Is anyone else present at the time he
takes these statements?

Mr. Vandiver. — Sometimes. The practice varies.

Dr. Vineberg. — Because I understand one of the coroners
made a rule that he be allowed alone with the dying woman,
and in two or three instances I know the coroner made it very
hot for the doctor who had been in attendance. The woman
had, so the coroner said, given him a statement incriminating
the doctor, which the doctor said was false, as he had not done
the things he was accused of in the alleged antemortem state-
ment. It seems to me that undue privilege was given to the
coroner.

Mr. Vandiver. — ^The practice varies with each coroner. They
may take the statement alone by themselves, but there is no
legal warrant for it.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 50 of 109)