of Rhodes. Spurious works Andronicus.

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

. (page 66 of 109)
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tation prevented the head from coming along, I made the trial to
turn down the Vertex; but that failing I delivered in the preter-
natural way.

Three mothers and three children saved out of four is certainly
uot a bad record in this dread puerperal eclampsia, and it cer-
tainly reflects no little credit on this obstetrician of the eigh-
teenth century that in four cases of version he saved three and
possibly all of the children.

Can we offer any better results or suggest any better line of



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650 TRANSACTIONS OF THE

treatment to-day than that advocated and successfully put into
practice by Dr. Smellie over one hundred and fifty years ago?

So it seems it sometimes does us a little good to take a peep
into these old and forgotten books. There are other pieces of
information contained in this same work, equally important and
equally interesting. It might repay you to hunt them up.



TRANSACTIONS OF THE NEW YORK
OBSTETRICAL SOCIETY.



Meeting held at the Woman's Hospital^ Janimry ii, 1910.
The President, R. L. Dickinson, M. D., presiding.

In accordance with the program adopted at a previous meeting,
the scientific session was exclusively clinical. A number of
patients who had been operated upon at the Woman's Hospital,
by Dr. J. Riddle GoflFe and Dr. Dougal Bissell, from one to six
years previously, were presented to illustrate the end-results.
The two operating-rooms were utilized simultaneously. Dr.
Goffe operating in one and Dr. LeRoy Broun in the other. Dr.
GoflFe demonstrated the technic of his operation for procidentia
uteri, complicated by cystocele and rectocele.

The patient gave the following history : Forty-one years of age,
married twenty years, and a mother of five children, the last be-
ing seven years of age. Her symptoms were those usually attend-
ing the condition announced. Upon examination a laceration
of the perineum of the second degree with rectocele presented,
also a well-marked cystocele. The uterus was large, retro verted,
and firmly bound posteriorly by adhesions, the cervix presenting
just inside the vulva. As the cervix was large, hard, and nodular,
due to an extensive bilateral laceration, and the fundus large
and hard, suggestive of fibroid degeneration, a hysterectomy
was decided upon.

The operation was begun by Dr. GoflFe, and was proceeded
with in accordance with the following description : Both lips of
the cervix were grasped by a strong traction forceps and firmly
dragged upon, a self-retaining posterior retractor or speculum
having first been inserted into the vagina. A transverse incision
was then made posterior to the cervix and Douglas' pouch
opened. Here firm adhesions were encountered between the
rectum and the uterus, reaching to the top of the fundus. By
the use of considerable force and persistent eflFort these were
separated and the uterus set free. The vaginal incision was then
extended around the entire cervix, and the bladder dissected



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NEW YORK OBSTETRICAL SOCIETY. 651

from the uterus up to the peritoneal reflection. In accomplishing
this a nice point in the technic was demonstrated, which con-
sisted in working in first from one side and then the other toward
the median line by dull dissection underneath the uterovesical
ligament, till the handle of the scalpel could be passed through
between .the ligament and the uterus. This brings the ligament
distinctly into view and it is readily cut. The importance of
this step resides in the fact that as soon as the ligament is cut
away the operator is sure that he is down upon the uterus and, in
dissecting off the bladder throughout the remainder of its attach-
ment, he is in no danger of his finger riding up on top of the liga-
ment and being forced into the bladder. The ligament was
then cut away and the dissection proceeded with by simply
pushing the bladder off of the uterus.

The edge of the transverse incision anterior to the cervix was
grasped either side of the median line by two artery clamps and
the bladder stripped off the anterior vaginal wall throughout
its entire extent reaching well out onto the fascia lata and up to
the base of the urethra. This was easily and quickly accom-
plished by a dull instrument called a spud, an invention of Dr.
Goffe. Everyone was impressed by the promptness and facility
with which this was accomplished. No hemorrhage demanding
attention was occasioned by this procedure. The clamps were
then removed, and the vaginal flaps were allowed to swing free.

No clamps were used upon the broad ligaments, but a No. 2
plain catgut suture was used, double, *to ligate the broad liga-
ments. A Deschamp needle being used, a continuous suture was
applied to each broad ligament, beginning at the base and reach-
ing up nearly to the ovarian arteries. The broad ligaments were
cut away successively as fast as the ligature was tied. The ends
of the ligatures were left long and hanging to an artery clamp.

The reflection of the peritoneum between the uterus and the
bladder was then broken through by the finger, and freely torn
across. By grasping the round ligament between the index
finger, which was carried posterior to it, and the thumb in front,
the fundus was drawn into the vagina, the cervix meantime
being carried back into the hollow of the sacrum and freed from
the volsellum. This maneuver was facilitated by the previous
section of the anterior vaginal wall without which it would have
been impossible owing to the size of the uterus. Beginning at
the free border of the broad ligament, a continuous suture was
applied and continued down until it met the ligature previously
applied from below up, the ligament being cut away with each
succeeding stitch, first one side and then the other. The ovaries
and tubes, being free from disease, were not interfered with.

The next step consisted in stitching together the broad liga-
ments from either side across the pelvis. This was accomplished
in the following manner: The bladder, being elevated upon a
trowel, brought into view the broad ligaments, allowing each
round ligament on the proximal side of the ligature to be grasped



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652 TRANSACTIONS OF THE

by an artery clamp and brought out into the median line. These
were then stitched together with a continuous suture of linen
thread from the round ligaments down. The suture being
passed in such a manner that the peritoneal surfaces were brought
into contact, the ligatures and stumps being turned posteriorly.
The object of this was to afford a smooth peritoneal surface upon
which to spread out and stitch the base of the bladder. Three
separate sutures of forty-day chromic gut No. 2 were passed,
catching up the tissues of the broad ligament — one in the
median line catching the round ligament and one, two inches to
the right, and another to the left of this, penetrating both
walls of the broad ligaments. Each needle was left attached
to its suture as passed, and allowed to hang out of the vagina.
These sutures were then passed through the base of the bladder
beginning with the middle one and the others in succession and
then tied. The points in the base of the bladder through which
they were passed were selected as follows: By repeated trials
a point in the middle line of the base of the bladder was caught
in an artery clamp and carried up to the point of insertion of the
middle suture, which when held there would cause the base of the
bladder to take a straight line from the base of the urethra to the
suture point in the broad ligament. Through this point the
middle suture was then passed and tied. Points were then
selected about one and one-half inch to the right and left of this
median point and at equal distances from the base of the urethra,
and through them the other sutures were passed and tied.
This spread out the base of the bladder on the face of the broad
ligaments and held it fixed in position. The anterior vaginal
wall with its fascia was then cut away either side of the median
incision sufficiently to draw the fascia lata taut under the base of
the bladder. Interrupted sutures were applied through the
vaginal wall and fascia, thus closing the anterior incision, the
last one being carried through the broad ligaments just under-
neath the attachment of the bladder.

The principle involved in this operation for the relief of
cystocele is that it employs nature's plan of suspending organs
from above by ligaments, rather than by supports from below.
The spreading of the base of the bladder and fixing it there also
follows nature's scheme, for the base of the bladder physiologically
takes no part in the contraction or the expansion of the bladder
as it empties and fills. Since the complete development of this
operation it has given entirely satisfactory and permanent
results.

The perineum was then repaired for the relief of the rectocele,
a narrow strip of gauze passed into the culdesac, the vagina
firmly packed with gauze, and the operation was complete.

The operator explained that this procedure was followed by
no unpleasant symptoms referable to the bladder. As a rule, the
patients voided urine naturally after twenty-four or thirty-six
hours, and were out of bed at the end of two weeks.



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NEW YORK OBSTETRICAL SOCIETY. 653

Meeting of February 8, 1910.

The President, R. L. Dickinson, M. D., in the Chair,

Dr. George Gray Ward, Jr., presented the specimen and
reported a case of

PAPILLARY CYST ADENOMA OF THE OVARY I INJURY TO THE URETER
WITH IMPLANTATION INTO FUNDUS OF THE BLADDER.

Miss C. S. was referred to me by Dr. Kast in November, 1908,
suffering from an abdominal growth. She was forty-eight years
of age and had reached the menopause, her last menstruation
having occurred nine months previously.

Her weight was about 100 pounds, she had a very sallow,
muddy complexion, was markedly emaciated, and gave every
appearance of cachexia. She had been a sufferer for years
from digestive disturbances and had been sent to Dr. Kast for
her gastric symptoms. Since her menopause she had been losing
strength and weight, and her digestive disturbances and
constipation were much increased. She also complained of
some abdominal pain. Examination disclosed a nodtdar growth
in the lower abdomen about the size of a six months' pregnancy.
The uterus was very small and pushed out of the pelvis and to
the right, and the growth was firmly imbedded in the true pelvis
which it practically filled.

I operated upon the patient in the Woman's Hospital on
December 3, 1908, in the presence of Dr. Grad, of this Society,
and several others. On opening the abdomen, free greenish,
fluid was present and the tissues appeared bile-stained, and
some papillomatous masses were found on the peritoneum.

The growth was extensively adherent and was intraligament-
ous in development. It was enucleated with considerable
diflSculty, the uterus and appendages and as much of the broad
ligament as possible were removed. It was found that the
left ureter had been involved in the lower pole of the growth be-
tween the layers of the broad ligament, and that, in making
traction upon the mass, the ureter had been drawn up and severed
in cutting the tumor free.

As it was not possible to find the distal end of the ureter, and
as the proximal end could be made to reach the lateral wall of
the bladder, the best procedure was to make a ureterovesical
implantation.

The method employed was that of Pajme, of Norfolk, which
has been described by him in the Journal of the American Medical
Association, for October 17, 1908, and which I show you here,
the accompanying illustrations of the method making it very
clear. The end of the ureter was split up on two sides forming
separate flaps which were sutured to the inside of the bladder
wall with through-and- through sutures, and the margin of the
bladder opening was sutured to the periphery of the ureter.
A cigarette drain was passed from the site of the anastomosis



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.654 TRANSACTIONS OF THE

into the vagina and the whole field of the grafting was covered
over with the flaps of the broad ligament, making it extraperit-
oneal. A sound was passed into the bladder through the
urethra to act as a guide and to facilitate the operation. A
self-retaining catheter was used to prevent distention of the
bladder. The patient made an excellent recovery, being out
of bed on the fourteenth day. A slight leakage of urine through
the vagina was observed several days after the operation when
the drain was removed, which I attributed to there being per-
haps a little too much tension on the ureter or to the drain hav-
ing become adherent to the ureter and the union being inter-
fered with when it was removed. In a few days this leakage
became lessened and was entirely stopped several weeks after
the operation and has given no trouble since.

The pathological report showed the tumor to be a malignant
papillary cyst adenoma of the ovary.

The patient gained in weight and health until last December,
when she had a bloody vaginal discharge and began to lose
weight and strength. A sinus was found in the vaginal vault
from which material was curetted and which the pathologist
reports as carcinoma of an adenomatous type.

The methods of making the implantation of a ureter are the
common methods of uniting the severed end flush with the
bladder wall, mucosa to mucosa, which is prone to stenosis
through subsequent contraction; the Van Hook method of
splitting the ureter on one side and flaring the end, and thus
uniting the ureter into the bladder; and the oblique method as
first advocated by Witzel, which is an attempt to imitate the
natural implantation of the ureter. This latter method has in its
favor the fact that it is stronger than |the others just mentioned
and therefore is preferable if there is any degree of traction on
the ureter. However, some operators claim that it is liable to
contraction with resulting stenosis.

The method of Payne, which I employed in this case, has also
the advantage of being very strong owing to the flap sutures
penetrating the entire vesical wall, and, according to Payne,
leaves a more patent ureter than the other methods. But one
of its most important advantages is the avoidance of the neces-
sity of any instrument in the bladder to draw down and hold the
ureter in place while the anastomosis is being made, as the flap
sutures, which are very easy to place, act as tractors and draw
the ureter firmly into position when they are tied, enabling the
operator to finish the suturing without difficulty.

Payne reports two cases in which he has used this method
with satisfactory results. He states that firm union takes place
between the external connective- tissue coat of the ureter and
the mucosa of the bladder, but that if there is any fear of failure
of union on the part of the operator, he can easily resect a little
of the mucous membrane on each side of the bladder incision.

Payne reports that he has been able to find seventy-seven



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NEW YORK OBSTETRICAL SOCIETY. 655

cases of ureterovesical implantation reported in the literature
up to the time of his writing (October, 1908).
There must be many cases that have not been reported.

DISCUSSION.

Dr. Grad. — I was present when Dr. Ward operated on this
case. It seems to me that this method is very practical, that is
to say, if you can bring the ureter anjrwhere within reach of the
bladder you are sure of making a good, thorough anastomosis.
I have tried it in one case where, during a hysterectomy for
carcinoma, the ureter was injured. Six months later I implanted
the ureter into the bladder by the method Dr. Ward has described,
with a good result. If the ureter happens to be a little short
one can gain a little distance by liberating the bladder from its
bed, so I think this method of implantation is a very practical
one and a very good tmion can be obtained as a result of such a
method.

In Dr. Ward's case the operation was unusually difficult, be-
cause there was some tension on the ureter.

Dr. H. D. Furniss. — In operations requiring dissection close
to the ureter or where the ureter is abnormally placed, it is well
to take precautions against such an accident and to render it
easily recognized should such an accident occur. Passing a
bougie or catheter renders the recognition easy. Some time
ago I advocated the injection of methylene-blue or indigo-
carmine before operation, so that injuries of the ureter could
be more easily detected (escape of colored urine). The first
ureter I catheterized was subsequently cut by accident; it was
repaired on the catheter, and no trouble followed.

In the last year I have seen three cases of implanted ureters,
the one just reported by Dr. Ward, one by Boldt, and a case
operated by myself. In Dr. Boldt's case both ureters can be
plainly seen. On the right side the ureteric orifice looks much
like the orifice of an old sinus with its bit of granulation tissue;
from this side I was unable to see any urine escape. (Later,
both ureters were catheterized, and both kidneys found to be
fimctionating properly. On the left side the catheter passed
an obstruction just beyond the ureteric orifice; this was followed
by a steady stream, until two drams were collected. After
this the flow was intermittent, as is usual.)

My case was first seen as one of supposed incontinence. A
ureterovaginal fistula was found. This was repaired by a
plastic operation turning the ureter into the bladder. Six
months after the operation no evidence of urinary flow was
seen from the implanted ureter.

In many of these cases of implanted ureter there is subsequent
contraction of the new ureteric orifice, with atrophy of the
kidney, unaccompanied by hydronephrosis.

Recently in cystoscoping Dr. Boldt's case I noted that the old
ureteric orifices appeared smaller than usual, that there were



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656 TRANSACTIONS OF THE

no movements of these orifices, and that they remained open for
some time after the introduction of a catheter (lack of tone).

Dr. Ward. — It occurred to me just as Dr. Fumiss has said
that we might not know for certain whether the kidney is
functionating or not. This particular case I cystoscoped in
my oflSce. I was not able to find the implantation. Later on,
I had Dr. Fumiss cystoscope her and it was a question whether
we fotmd anything, although with the water cystoscope we
thought we fotmd something. We know that if we put a
ligature aroimd the ureter that nothing very terrible happens in
many cases. The kidney atrophies and goes out of business
and the patient goes ahead with the other kidney. There may
not be necessarily a great disturbance. Therefore, perhaps in
some of these implantations, we may have obstruction and
kidney atrophy. I am not absolutely positive that that kidney
is fimctionating. The patient is passing a normal quantity of
urine and is perfectly well.

Dr. Dickinson. — Would not these be just the cases for color
test?

Dr. Furniss. — I used the color test in the case of Dr. Boldt's,
but I hurt the woman so much I was not able to use it again.
I used the color test in the case from Plainfield and there I was
not able to find any evidence of ureteral flow at all.

Dr. Brettauer. — What hurt the woman?

Dr. Furniss. — I injected a 4-per-cent. indigo-carmine solution
into the buttock and that gave much pain for four days.

Dr. Howard G. Taylor reported a case of

FIBROMA uteri. PREGNANCY. MYOMECTOMY.

This patient was admitted to my service at the Roosevelt
Hospital in July, 1909. She was thirty-two years of age, had
been married for two years, and had never previously been
pregnant. She menstruated regularly every twenty-eight days
for five days moderately in amount. The last menstruation
was on March 23, 1909. On examination the uterus was found
to be increased to the size of a four months' pregnancy and in
front and to the left of it a soft mass about five inches in diame-
ter. The diagnosis was made of an ovarian cyst associated with
pregnancy. It is my opinion that an ovarian cyst can be re-
moved during pregnancy with little danger of an abortion and,
further, that the danger of trouble from the cyst either from
twisting during the pregnancy or from direct injury during con-
finement is considerable and therefore I advised an operation.
The abdomen was opened in the middle line by a six-inch incision.
The tumor was found to be a soft fibromyoma of the uterus
about six inches in diameter and was removed. The bed of
the tumor was about four inches [in diameter and |was closed
with interrupted sutures partly of plain catgut and partly
chromicized. For twenty-four hours after the operation, the



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NEW YORK OBSTETRICAL SOCIETY. 657

patient had some contracting pains, but none of importance, and
made a smooth recovery.

Dr. Ward, the resident physician of the Sloane Maternity
Hospital, said that she was delivered^with high forceps on January
26, 1 9 10, of a child which weighed nine pounds and one ounce.
The membranes ruptured early in her confinement and she had
a marked degree of uterine inertia, the uterus not showing any
eflScient contractions. The patient did nicely while at the
Sloane Maternity Hospital.

DISCUSSION.

Dr. Boldt. — I would say with regard to myomectomies
during pregnancy that, so far as my observation is concerned,
if only the most necessary manipulation is done to the uterus,
I believe the operation is not only justifiable but indicated in
some instances, and also that then, with proper care, there is
not as much danger of a premature delivery or miscarriage as we
were formerly led to believe.

Dr. Goffe. — The technic of refraining from manipulation of
the uterus in these cases is most important. To my mind it is
the element of success in the procedure. I recall two cases I
have had in the last few years. A woman at the seventh month
of pregnancy, with a large pedunculated tumor growing from the
right side of the uterus, came to me with symptoms of obstruction
of the bowels. A coil of intestine had become incarcerated
between the steadily enlarging fundus and the tumor near its
pedicle. I operated, removing the tumor, and releasing the
intestine. She went on to full term without any trouble what-
ever. Another case. A woman came to me from St. John's,
Newfoimdland. Her physician had discovered at the eighth
month that she had a fibroid tumor about the size of a base-
ball, growing on the anterior lip underneath the bladder. I
operated through the vagina, very easily reaching the tumor
and removing it. I sent her home in two weeks. She had
oAly been home five days when the baby was bom without
any difficulty.

I have now at the Woman's Hospital a woman pregnant
four and a half months upon whom I operated two weeks ago
last Friday, on a diagnosis of fibroid of the uterus complicating
pregnancy. It proved, however, to be a dermoid cyst. Of
course, that is another matter. I merely speak of it in this
connection, as a tumor complicating pregnancy. She is get-
ting along very nicely.

Dr. Brettauer. — Dr. Taylor started to operate on this
woman with the intention of removing an ovarian cyst, which
is a progressive growth and ought to be removed' at any time.
As for fibroids during pregnancy, it has been my experience
that they very little interfere with pregnancy. Of course, there
are instances where fibroids actually prevent natural childbirth.
The child simply cannot pass the large fibroid which blocks
6



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658 TRANSACTIONS OF THE

the way. I have two cases in mind at present where I re-
moved such fibroids and confined the woman at term afterward,
but, as a rule, I would be in favor of not operating upon a
woman who is pregnant and who has fibroids, if no strict in-
dication is present.

That the pregnant uterus can be handled to a great extent
without being the worse for it, I have proved only a short time
ago when I had to operate upon a woman five months pregnant
who had an acute appendicitis with perforation and gangrene,
where I found the necrotic right ovary in the abscess cavity
with a big fetal concretion. One of the abscess walls was formed
by the pregnant uterus. The uterus was covered with a plastic
exudation and the abscess was very deep. In looking for the
appendix the uterus had to be held back by the assistant for
some time and with considerable force. The woman did not
miscarry.

Dr. Wylie. — It is a fact if a woman becomes pregnant and



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 66 of 109)