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has a fibroid, and she passes the second month, unless the fibroid
is too large, she does pretty well. As a rule, no operation is
needed : it depends on whether the growth of the fibroid obstructs
circulation. It is well to recognize that fibroids that do not
change the circulation will not, as a rule, interfere with the
pregnancy. I have seen the pregnant uterus imbedded between
three and four fibroids and have seen the woman do pretty well.

In one case in Belle vue, when she came in, we found the
uterus a mass of fibroids, and the child of three or four months
was between the fibroids. The most important thing is not to
assume that they are going to interfere with pregnancy. That
is, discovering the woman with fibroids, if she is married, it is
the doctor's duty to put her in condition to become pregnant.
Often by curetting you can put that woman in condition so that
she can become pregnant and will have a child.

I had a remarkable case in Brookljm not long ago. She was
a doctor's wife between three and four months pregnant. I
think some of the other doctors had seen it and they thought
it was impossible for her to have a baby. Two of the gentlemen
decided it would be better to remove the child. I saw her and
made up my mind if those fibroids had much to do with the
uterus the pregnancy would not have gone so far. There were
two or three as big as small lemons and others you could feel
quite easily of less size. I undertook to watch that woman and
deliver her of a healthy child near enough to full term for the
child to live. I delivered her of a child of nearly nine pounds
and perfectly healthy. I then treated her to secure rapid
involution and advised her to try again. She had the second
child about fifteen months afterward. She was at that time
forty-five years of age. The children are perfectly well. It
shows how remarkably tolerant the uterus is of fibroids. It is
perfectly practicable to take cases where the walls of the uterus
have fibroids in them, treating the cases when the woman is



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NEW YORK OBSTETRICAL SOCIETY.



659



sexually active, and have healthy children. I find fibroids do
not always grow. The fibroids in this case were apparently
smaller than during the labor. They seemed to grow with the
uterus, but afterward shrunk. A long study of fibroids has
satisfied me that they, hke other organic things, have their
youthful growth and their old age, and generally die at the time
of the menopause and become more dangerous after that. You
can assume, as a rule, that if the woman is pregnant and passes a
certain period, the fibroids are not likely to interfere.

Dr. Dickinson. — I know this case, and want to bear witness
to a striking instance of judgment confirmed. Here was an
elderly primipara having a bunch of fibroids, fist size, growing
rather rapidly, which apparently made a circle just at the top of
the cervix. The opinion of two Brooklyn men was it was not
safe to let her go on. Dr. Wylie believed that they would
be lifted out of the way. He delivered her easily. This was
one of the borderland cases. It was really a remarkably inter-
esting case.

Dr. H. J. BoLDT presented the report of a case of

SUPRA-VAGINAL AMPUTATION OF THE UTERUS WITH THE ADJOIN-
ING PYOSALPINGES AND INTIMATELY^ADHERENT
VERMIFORM APPENDIX.

As a rule, tubo-ovarian abscesses are more taxing on the
surgeon, so far as concerns the technic of their removal, than
ovarian tumors, or myofibromata of the uterus. In this par-
ticular instance the technic was unusually diflScult, which may
be appreciated when it required nearly an hour before the
intestinal adhesions were separated so that the fundus of the



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uterus could be felt. On the surface of the pyosalpinx, as may
be seen on the specimen, the vermiform appendix was so inti-
mately interwoven with the tubal tumor that it could only
with care be distinguished as a separate structure from the tubal
tumor. The entire adnexum was tightly adherent to the cavity



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660 TRANSACTIONS OF THE

of the true pelvis and the intestines, and that it was finally
enucleated without rupture must be considered very satisfactory.
The left adnexum was ruptured during enucleation, so that it is
now only about half of its original size.

It was thought best in this instance to do a radical operation
rather than try the almost impossible, a conservative operation,
although it might have been possible to retain a small piece of
the left ovary; the infection, gonorrheal in character, had
played such havoc with the patient's general condition that it
is doubtful whether she would be as likely to make as good a
recovery with such partial work, as with the intervention done.

The woman, Mary C, is only twenty-seven years old, married
five years; never pregnant; very profuse menstruation since the
time of her illness, which was of two years' duration. She
complained of the usual train of symptoms that women usually
have with such pathological changes, only somewhat more
exaggerated.

This specimen also illustrates that even had it been previously
determined upon to do a radical operation, it could not have been
satisfactorily completed per vaginam, as was the case by the
abdominal route.

To be Continued,



TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.



SECTION ON OBSTETRICS AND GYNECOLOGY.

Meeting of December 23, 1909.
J. O. PoLAK, M. D., in the Chair.
Dr. a. Brothers reported two recent

CASES OF PELVIC SUPPURATION.

Case I. — ^Pelvic suppuration due to tuberculosis. The pa-
tient was twenty- three years old, and hati been married four
years. She had two children, both alive and well. She had
never had an operation. She began menstruating at the age
of thirteen ; her periods were regular, lasted three days, without
pain, with a moderate flow; her last menstrual period was two
years ago. Two months ago she complained of pain in the right
iliac region which was burning in character, and accompanied
by frequent and painful urination, and a marked leukorrheal
discharge. She had a few attacks of chills and fever. She
was treated expectantly with but little relief. One week prior
to admission to the hospital the pain in the right iliac region



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NEW YORK ACADEMY OF MEDICINE. 661

became worse, the leukorrheal discharge increased, and she
had chills and fever and vomiting. On admission there was
dyspnea. The leukocytes numbered 16,000 and the polymorph-
onuclears 85 per cent. A mass was readily palpated in the
right iliac region, and rigidity over the right rectus muscle was
present; there was also slight tenderness there, and slight pain
to the left side. The temperature curve ranged from 98 to 103®
F., and the pulse was between 90 and 120. A posterior vaginal
section was made on Noveipber 23, and half a dram of pus
wa^- obtained, not enough however to account for the size of
the mass. Subsequently there was rather a profuse purulent
discharge which lasted for several days. On December 2, a
laparotomy was performed. Dense and numerous adhesions
between the omentum, intestines, and adnexa were encountered.
The omentum and peritoneum were found to be studded with
small and numerous tubercles. On December 7 there were
9,000 white cells and 79 per cent, polymorphonuclears. Since
the operation the temperature had ranged from 99 to 104. The
pathologist reported this to be a case of miliary tuberculosis.
Since the operation the patient's condition remained about the
same except that there was less pain in the right side.

Case II. — ^Pelvic suppuration due to gonorrhea. This
patient walked about with temperatures ranging from loi to
103** F. She was twenty-one years old, married four years,
was never pregnant. Her menstruation begai} at the age of
fourteen, was always regular, and she had dysmenorrhea for
one day preceding the flow. She had a leukorrheal discharge
for the past three years. She was admitted to the hospital
November 5, 1909, complaining chiefly of dysmenorrhea, dysuria
during the past three months, and sterility. She was a well-
developed and nourished woman, without abdominal signs or
symptoms, but she had a temperature which ranged from 99*^
to loi to 102*^, and once to 103° F. The pulse rate was from
90 to no. Her husband admitted having contracted gonorrhea
about three months ago. On November 19 laparotomy was
performed. She had a very fat abdominal wall. Both tubes
were found to be involved in many adhesions to the parietal
walls, intestines, and omentum. The adnexa were enlarged,
thickened, and inflamed. A double salpingo-oophorectomy was
performed and a ventro-suspension for retroverted adherent
uterus. The patient made an uneventful recovery except for a
slight subcutaneous suppuration.

MYOMECTOMY FOR FIBROIDS OF THE UTERUS COMPLICATING
PREGNANCY.

Dr. Louis J. Ladinski reported this case. The patient was
thirty-one years of age, had been married ten years, and had had
no children. She had one abortion two months after her mar-
riage. She had not been pregnant since. She had had no



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662 TRANSACTIONS OF THE

Operation of any kind. After her last menstruation five months
ago, she began to spot and complained of slight abdominal
pains. About October 20 the pains became more severe, and
she was confined to her bed. The doctor who was then called
in made a diagnosis of ** tumor complicating pregnancy, " and
advised her removal to the hospital for observation. Two
days later this was done, and she remained there three weeks.
She grew steadily worse, the abdominal pains became more
severe and frequent, the abdomen increased in size and she
gradually grew worse from day to day. After two weeks' obser-
vation she was anesthetized; when she emerged from its influ-
ence she was told that a uterine tumor had been removed. This
procedure did not, however, improve her condition, and after
another week of expectant treatment she was sent home. On
November 28 Dr. Ladinski again saw her in consultation and had
her admitted to Beth Israel Hospital. She then complained of
abdominal pains, extreme weakness, headache, nausea, and
vomiting. She was markedly anemic, almost cachectic. The
red cells numbered 2,400,000 and the hemoglobin was 40 per
cent. The white cell count was 9,200, small mononuclears
23 per cent, and polynuclears j'j per cent. On palpation of the
abdomen there was noted a distinct, hard, irregular mass occu-
pying the lower part, and especially marked on the right side.
There was distinct evidence of free fluid in the peritoneal cavity.
The uterus was enlarged to about twice its natural size and
pushed upward and to the left by the mass.

This case presented unusual clinical features which made the
diagnosis exceedingly difficult. However, after considering the
various possible diagnoses it was decided that one of two condi-
tions existed, namely, papilloma of an ovary with ascites, or
advanced extrauterine pregnancy. Operation was performed
on December 4, 1909. As soon as the peritoneal cavity was
opened an immense amount of free, old, dark-colored blood
escaped. This fluid was evidently not due to a rupture, but was
the result of a diapedesis into the peritoneal cavity from the con-
gested abdominal viscera. The mass proved to be a gravid sac,
containing a five months' living fetus. The placenta was at-
tached for the greater part to the omentum, the small intestine,
the right and left adnexa, from all of which it was separated
without any great difficulty. A large gauze drain was intro-
duced posterior to the uterus, and die abdominal wound was
closed in layer sutures. During the operation the patient re-
ceived intravenous saline infusion of 14,000 c.c.

This was a case of tubal pregnancy originally which, after
rupture or abortion, was converted into an abdominal pregnancy.
The fetus was a monster and presented a globular pedunculated
mass, about the size of a hen's ^%g, springing from a pedicle
which extended from the ensiform cartilage to the pubes in the
median line. The mass was everywhere covered with a thin
translucent layer of peritoneum through which might be seen



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NEW YORK ACADEMY OF MEDICINE. 663

the intestines, the liver and the heart, which, after the operation,
pulsated for fully twenty minutes. Upon opening the covering,
the sac was seen to contain the entire liver and stomach, small
and large intestines, the spleen, the pancreas, ureters, upper
part of the bladder, and the heart. All these structures passed
into the cavity through a defect in the anterior wall. The right
half of the diaphragm was entirely missing. The diaphragm
had lost its anterior and right attachments to the chest, and was
dislocated downward so that part of it was within the tumor.
The fetus presented the following deformities: There was an
imperforate anus; both feet were held in a position of extreme
equinus valgus; there was an edema of the posterior part of the
neck, the occiput and the frontal regions.

The term monstrosity might be applied to any variation in
the normal development of the human fetus. Their great variety
and the impossibility of establishing sharply defined divisions
made the classification of fetal deformities very difficult. Many
classifications had been made, but that of Saint-Hilaire was the
one most commonly employed. The specimen presented by
Dr. Ladinski was a celosoma associated with a prolapse of the
heart into the hernial sac and an absence of the anal orifice,
conforming in some respects to the type designated as agenosoma
by Saint-Hilaire.

Dr. William S. Stone was very much interested in these
cases of tubal pregnancy which later went on as abdominal;
such cases often ruptured between the layers of the broad liga-
ment. The cases he had seen were all hospital cases and the
diagnosis had always been fraught with difficulty. It was quite
surprising in spite of the amount of information they had in
these extreme cases how difficult the diagnosis after all is. Dr.
Stone asked in regard to her menstrual history; was it regular
during the past few months and prior to the operation?

Dr. Ladinski replied she had amenorrhea and then spotting
for some time.

When he had removed the fetus he immediately proceeded to
remove the placenta. The placenta was very closely attached to
the abdominal viscera, but he felt it would be better to remove
it in iotOy and his result justified him in doing it. Twenty-four
hours after operation he removed the drain, which was left in
merely to check the parenchymatous oozing. The wound healed
by primary union.

The advantage of treating the placenta in this manner has
been forcibly demonstrated in this case by the primary union, and
by the short convalescence. If the case had been tamponed
it would have required a long siege of drainage with a prolonged
convalescence, and the final result, because of the probable
presence of peritoneal adhension with its consequent after-effects,
could not be compared with that obtained here. The additional
hemorrhage caused by the removal of the placenta was incon
sequential in comparison.



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664 TRANSACTIONS OF THE

Dr. Eugene H. Pool reported a case of

UNILATERAL TWIN TUBAL PREGNANCY.*

Dr. Herman Grad had seen one case of twin tubal pregnancy.
The patient was brought to the hospital in a state of collapse.
She had a very bad internal hemorrhage. Upon opening the
abdomen two small fetuses floated out of the incision from the
abdominal cavity. The hemorrhage was terrific, and the patient
died before she was removed from the operating-table. He
said he had never seen such an alarming hemorrhage. This was
the only case of twin ectopic he had ever seen.

PREMATURE MENOPAUSE.

Dr. Meyer Maurice Stark said that the term menopause as
generally understood applies to a collection of phenomena appear-
ing with the cessation of menstruation and comprehends the
whole process of senile involution of the generative organs. These
phenomena may manifest themselves over a period varying
from one to ten years. Anatomically the generative organs
are the first seat of the involution process, but later the whole
body takes part in it. Currier has classified the changes as
those resulting from the menopause, those causing the meno-
pause, and those coincident with the menopause. In a series of
autopsies performed by Dalton in the study of the corpus lu-
teum it was found that the first atrophic changes appear in the
ovaries. Progressive with the changes in the ovaries there is
noticed in the uterus first congestion and hyperplasia, followed
by atrophy. The Fallopian tubes shrink and become shorter,
the fimbriae gradually disappear, the vault of the vagina con-
tracts, the vagina becomes shorter, the introitus becomes nar-
rower, and the secretions become changed and diminish in
quantity. The pubic hairs become straighter, the labia minora
contract and sometimes disappear; the mammary glands begin
to shrink, frequently only after a preliminary fatty enlargement.
The anatomical changes which produce the menopause are found
mostly in the ovaries. Statistics are plentiful as to the usual age
at which the menopause occurs. Many authorities cite cases oc-
curring at advanced age. It is however the consensus of opinion
that any menstruation after the age of fifty-three should be looked
upon as pathological. From an inspection of statistics it is found
that in one-half of all cases the menopause occurred between the
ages of forty-five and fifty; in one-fourth of all cases it occurred
between the ages of forty and forty- five; in one-eighth of all cases
between the ages of thirty-five and forty, and in one-eighth of all
cases between the ages of fifty and fifty-five. Most authors
agree that the earlier menstruation begins the longer it is likely
to continue. The average duration is estimated by Tilt as
thirty-two years. Menstruation that ceases before the age of
forty is irregular, and when before thirty it is premature.

♦ See original article, page 606.



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NEW YORK ACADEMY OF MEDICINE. 665

The reader of the paper collected eleven cases during the
years 1907 and 1908 from the clinic at the Beth Israel Hospital
and had collected forty-eight cases from literature, and of these
Edward Krieger cites thirty-five. Of these thirty-five cases
three occurred at the age of twenty-one years, two at the age of
twenty-two, one at the age of twenty-three, one at twenty-four,
two at twenty-five, one at twenty-six, three at twenty-seven,
three at twenty-eight, three as twenty-nine, and sixteen at
thirty. Dr. Stark has collected in addition to these twenty-
four cases. Wherever recorded in these cases, the examination
of the genitals revealed conditions not dissimilar to those ap-
pearing at the normal menopause. Whether or not these latter
conditions are the result or the cause of menopause is not at
all clear unless we accept the findings of Dal ton, that the first
signs of atrophy begin in the ovaries and become quite marked
before the uterus begins to diminish in size. . And thus the uterus
comes to be regarded as the retrograde metamorphosis of a
gland which has become functionally useless. The changes,
therefore, in the ovarian parenchyma are important factors in
the question under consideration. It has been observed that
in acute febrile diseases and in the exanthemata the parenchyma
of the ovaries suffered sympathetic changes and these same
primary changes resulted in a cessation of menstruation.
Courty has cited three cases in which the menopause ensued
after cholera. That hyperplasia resulting from frequently
succeeding pregnancies should result in early menopause is
evident, when the inevitable retrogressive change following
such hyperplasia is considered. Meyer reports a case in which
after six successive pregnancies, menopause ensued at the age
of twenty-nine. Here the defective enervation due to the
anemia of numerous pregnancies stands in a causative relation.
Such agencies as peritonitis and the excessive involution seen
in lactation are given as etiological factors. It is indeed a re-
markable feature that psychical influences should have a per-
manent damaging effect on the menstrual mechanism. Several
of the cases reported by Zilt and Walters were attributed to
fright and sudden affliction. Bomer and others give heredity
as an occasional cause of prematurity. Obesity was thought
by Kisch to be the cause and not the result of the early cessation
of menstruation. Currier states as a constant rule that a woman
under thirty who becomes obese usually suffers from amenor-
rhea or dysmenorrhea and in addition is usually sterile. It is
a noted fact that many women begin to take on flesh at or after
the menopause or, in other words, at a period coincident with
sterility. This fact is a feature in many of the cases cited in this
paper. The tendency seems to have been the rule in nearly
all of our cases and in most of those where the physical condi-
tion was mentioned. Sterility and amenorrhea are the matters
concerning which the patients with early cessation usually seek
advice. Literature abounds however in numerous cases in



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666 TRANSACTIONS OF THE

which pregnancy has occurred after complete cessation, and
this not only in early cases but even in typical ones. Piron tells
of a woman who aborted a two months' fetus at the age of seventy-
two. In Tilt's series of forty-nine cases of menopause be-
tween the ages of twenty-nine and thirty-nine, there was an
average of three children in twenty-six married women; of the
eight married ones in the present series four bore children. The
occurrence of eleven cases out of 3,301 who presented themselves
at the Beth Israel Clinic in the years 1907 and 1908 shows a
frequency of one in 300, by no means an insignificant percentage.
None of the usual causes cited figured in this series of cases.
The absence of previous or subsequent local or constitutional
disease is the rule. They seemed to be from the outset types of
irregular or scanty menstruating in which the ovarian function
has worn itself out, so to speak, without impairing the health
of the patient.. Whether this is due to faulty development in
the generative organs cannot be said, though it is difficult to look
at the cases in any other light than as presenting an unnatural
condition due to a defect or disease of some kind. Only those
are included in the series who have been under observation for
two years or those in whom the function of menstruation has
been absent for four years.

Dr. Herman J. Boldt said that the instances in which
heredity was a factor in premature menopause, so far as his
observations went, were comparatively few. He had seen a
number of cases in which the menopause was established
prematurely, below the middle twenties, but it was impossible
to tell definitely just what the cause was. However, in most
of the instances that had been under his observation, there were
atrophic changes, and in about 25 or 30 per cent, there had been
the results of traumatic lesions — ^namely, indiscrete curetting;
but puerperal infections also played an important part.

Dr. Hermann L. Collyer believed that the statistics pre-
sented were to be criticized; undeveloped uteri could not be
compared with perfectly developed uteri. These cases that
were reported as having an early menopause at twenty-one
were unfortunately in women without a perfectly formed uterus
and ovaries.

He believed that in the classification of the cases of early
cessation of menstruation, there should be three, viz.: i. Un-
developed uteri; 2. traumatic injuries to the uterus; 3. diseased
uteri by specific causes, either gonorrheal or syphilitic. He
did not think it was right to include in the statistics those cases
of undeveloped uteri because menstruation was liable to cease
at any time in such cases.

Dr. Hermann Grad said he had not made great study of
the subject under discussion, but there were three things that
should be noted, viz.: i. Menstruation was irregular from its
beginning; 2. these women had a tendency to become fat; they
also had a masculine appearance, with robust and oftentimes



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NEW YORK ACADEMY OF MEDICINE. 667

clumsy bodies; 3. when menstruation was irregular and they
had bom children, traumatism was frequently at the bottom
of the cause of the premature menopause. No doubt many
cases were due to undeveloped uteri and ovaries as well.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 67 of 109)