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Dr. M. M. Stark closed the discussion. The classification
he presented was his own. There was one thing that nobody
seemed to have taken note of, at what age should menopause be
classed as premature? He placed this age at thirty. Cases
between the ages of thirty and forty were quite numerous; but
the cases that occurred under the age of thirty, in women who
were entirely well in every way, who were not robust or fat,
but in splendid health, were rare. There seemed to be many
cases of premature menopause without assignable cause. Dalton,
who had made many autopsies, came to the conclusion that pre-
mature menopause was connected with atrophic ovaries.

Meeting of February 24, 19 10.
S. M. Brickner, M. D., in the Chair,

Dr. William S. Gottheil reported

a case of erythema multiforme gestationis.*

Dr. James N. West said that since Dr. Gottheil had made a
diagnosis of erythema multiforme gestationis in a member of
his own family, he had two or three cases imder observation, and
was able to make the diagnosis because of the manner in which
Dr. Gorrheil illustrated the disease to him. The last case he
saw was in a baby three or four months of age. The parents
were very much worried, thinking the infant had some eruptive
fever. Dr. West made the diagnosis of erythema multiforme
gestationis; the disease ran three weeks and them disappeared.
Thanks to Dr. Gottheil, he was able to make the correct
diagnosis and could assure the parents that the child did not
have what they feared, some infectious fever. These cases
were of exceeding interest.

Dr. George H. Ballery inferred from Dr. West's remarks
that he was talking of a lesion that occurred under different
conditions; Dr. Gottheil said that the lesions occurred during
the period of gestation and that they depended upon the pregant
condition, disappearing when the pregnancy was concluded. This
was a peculiar form of the disease occurring during pregnancy.

Dr. Samuel M. Brickner said that skin lesions occurring
during pregnancy had interested him very much and he had
been fortunate enough to see different kinds of eruptions oc-
curring at this period, but had never seen an instance of ery-
thema multiforme gestationis. The only very serious case he
had ever seen appeared at the Mt. Sinai Hospital some years

♦See original article, p. 614.

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ago. About four years ago he had first described a peculiar
condition of the skin arising during pregnancy and from its
pathological picture simulated fibroma moUuscum, and hence
was named fibroma moUuscum gravidarum.* This had been
shown before the Section on Obstetrics and Gynecology, and
consisted in peculiar whitish, or brown, sometimes iDlack
wart-like excrescences upon the neck and under the breasts,
appearing during the early months of pregnancy and becoming
darker as pregnancy advanced, and then disappearing toward
the end of gestation or six or eight months later. In every
instance of this nature that he had seen, these excrescences
entirely disappeared after the pregnant state. Halbin of Vienna
about the same time described a condition that probably had
been seen before, an appearance of lanugo-like areas only oc-
curring during pregnancy. They probably were not very rare.
Only last summer Dr. Brickner had seen a patient with an in-
tense eczema which appeared during the last month of her preg-
nancy and which disappeared promptly after the birth of thechild.
Dr. William S. Gottheil said that although he had seen
many cases of erythema multiforme he had never before had
occasion to consider them in connection with pregnancy.




Dr. Herman Grad reported this case. Six months prior to
the woman's admission to the hospital she was told that she had
a tumor in the abdomen; the discovery of this growth was made
during a physical examination by a woman who examined her
for a position befor the Civil Service Board. Prior to this ex-
amination she was imaware of any trouble. She presented no
symptoms whatever except that she had to wear her corsets
somewhat looser and her dress fitted her tightly. The patient
was well nourished, somewhat pale in appearance, experienced
no pain, and was able to do her work. She slept well, had a good
appetite, and considered herself perfectly well. She applied at
the hospital for the removal of the tumor, because she herself
noticed an enlargement.

The physical examination showed a woman well nourished
who presented an abdominal tumor, filling the entire abdominal
cavity, but the bulk of the mass was situated in the upper
abdomen. The tumor felt hard and unyielding. There was
dullness on percussion all over the abdomen. There was an
area of tympanitic percussion between the liver dullness and that
of the tumor. There was a tympanitic sound on percussion on
the right and left side of the abdomen below, as well as over
the pubic region. Pelvic examination showed the pelvis to be
free of the tumor. The uterine adnexa were normal, and the
uterus was prolapsed to the second degree. The cervix and
*Amer. Jour. Obst., Feb., 1906.

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perineum were lacerated. A diagnosis was made of a tumor
in the upper abdomen, the nature of which was doubtful, but
it was thought that probably the tumor was of pancreatic
origin. Kidney tumors could be excluded by the situation of
the mass and by palpation.

On November 2, 1909, the abdomen was opened by Dr. Grad's
Chief, Dr. P. F. Chambers. The incision was made in the median
line just above the umbilicus. It was then found that the tumor
was postperitoneal, adherent to the transverse colon, and filling
the entire upper abdomen. Pushing the stomach up toward the
diaphragm and reaching as far under the liver as the hand could
reach, an attempt was made at enucleation. During this proce-
dure the tumor ruptured, causing a severe hemorrhage. The
enucleation was rapidly completed, and then it was found that
there was a rent in the transverse colon an inch in diameter.
This was immediately repaired with a double row of sutures of cat-
gut. There was a moderate hemorrhage from the layers of the
mesocolon, which required careful suturing for its control. The
transverse colon was dropped back into place, the torn peritoneal
surfaces repaired with fine catgut, and the abdomen was closed
without drainage. The patient left the operating table in ex-
cellent condition with very little shock.

For seveml da)rs after the operation the patient showed con-
siderable gastric disturbance manifested by nausea and frequent
vomiting. The temperature remained practically normal. The
bowels moved spontaneously on the third day. The abdominal
wound healed by first intention. The patient left the bed in two
weeks, but for some time after she suffered with nausea and vomit-
ing, and at times it was difficult for her to retain her nourishment.
After some weeks this gastric irritability subsided and she was
dismissed from the hospital in good condition. She lost very
little in weight, was able to eat solid food, and no new symptoms
arose. The abdomen was flat and the incision looked normal.

The pathologist reported that it was difiicult to make a decision
as to the nature of the tumor, but the nearest diagnosis he could
arrive at was that i( was a fibrosarcoma [arising from the trans-
verse colon and invading the transverse mesocolon. The clinical
symptoms were not indicative of a malignant tumor; and, there-
fore, a definite diagnosis could not at present be arrived at.


Dr. Robert T. Frank reported an instance in which a tumor
appeared in the same situation as did the one reported by Dr.
Grad. This tumor was also ^lid, was retroperitoneal, and was
situated between the stomach and the transverse colon. When
Dr. Frank operated upon the patient, the tumor seemed fluctuat-
ing, but the introduction of an aspirating needle was followed
by a very severe hemorrhage. He was content to simply ex-
cise a piece of this tumor and submit it to the pathologist. The
pathologist reported that the growth was a fibrosarcoma prob-

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ably of pancreatic origin. Sarcomata of pancreatic origin, as tbey
all knew, are quite frequent. In this case there was nothing to
be done because it would have been impossible to enucleate the

Dr. H. Grad said that in his case the pancreas was not invaded
at all; the pathologist could not find anything that resembled
pancreatic tissue.

Dr. James N. West read a paper on


Repair of a lacerated perineum is an operation of such minor
character, and so frequently performed, that it is my belief that
the real importance of it is by no means appreciated, even by
many of those who do the operation most frequently. When we
consider the group of pathological conditions which may follow a
laceration through the levator ani and destruction of the support
given by this muscle, "the diaphragm of the pelvis," we must
realize its importance. When we consider that this injury occurs
to the mothers whose duty it is to assume the labors of the house-
hold and the care of the children, and who find it necessary to
bear so many of the real physical burdens of existence, we must
again realize the enormous importance of it to the individual.
If we will place ourselves in the position of the unfortunate woman
who has the support of the pelvic contents destroyed and con-
sider what happens when she lif t$ a burden or takes a deep breath
or performs any act in which the muscles of the abdomen play an
important part, we must realize the sense of weakness which she
must feel. With every effort at lifting a weight she feels as
though the pelvic organs were coming down and out of the body.
And this indeed is true to a certain extent, because with lacera-
tion of the levator ani muscle and fascia and preservation of the
sphincter ani, even the act of defecation tends to draw the uterus
downward and backward, and force the rectum forward through
the hiatus created by the laceration. This force, continuing to act
constantly, by degrees leads, as a rule, to retroversion of the uterus
and to pushing forward of the rectum into a rectocele, to descent
of the anterior vaginal wall and the formation of acystocele, and
often eventually to a prolapse or procidentia uteri. All these
evils with their associated pathological conditions of hypertrophy
of the cervix, erosions, irritation of the bladder, and other symp-
toms more or less associated, follow naturally as a result of the
descent of the pelvic organs. We have, therefore, in this injury,
allaceration of the vaginal wall through the levator ani muscle and
fascia and the perineum, a condition which calls for an operative
technic which shall restore the torn parts in order to prevent
the occurrence of the sequelae incident to such an injury.

A recent work on gynecology states that thirty-three different
operations have been described for the repair of a lacerated
perineum. Does this mean that the repair is so easy that it
can be satisfactorily accomplished in thirty- three different ways?

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Or does it mean that the operations usually performed have been
so unsatisfactory that, in their efforts to reach out for a better
operation, thirty- three different methods have been devised?
I believe the latter is true. If we have a remedy that is a
specific for a given disease, we will use that remedy exclusively
to all others, because it is a specific. And if we have any one
operation which shall give entire satisfaction in repairing these
lesions of the vaginal wall and perineum, we would certainly not
have thirty-three different operations described for this purpose.

In my efforts to repair this injury, I try to relieve my mind
of any thought of any particular pian's operation, but to make
a study of each individual case, because each case must be
operated upon according to the injuries which are found. In
order to understand the exact nature of the operation to be
performed, we must understand the anatomy of the structures
to be operated upon. We must appreciate what each little
retraction of tissue means. We must recognize the change in
the relation of the anus to the fixed parts, namely, the pubis
and the meatus urinarius. One of the most evident effects of
laceration through the levator ani is a dropping back of the
anus toward the coccyx. The usual measurement in the average
woman from the meatus urinarius to the anus is from one and
three-quarters to two inches. The usual measurement where
the levator ani has been lacerated is about three inches. Our
operation must be so devised and executed that when com-
pleted the normal distance from the anus to the meatus shall
have been practically restored.

I was first led to the adaption of the technic to be described
by my failure in some of the operations as formally performed
and by seeing a fair proportion of the cases upon which I had
operated return after a time, varying from a few months to a
year, with practically the same deformity as that which had
existed at the time of operation. This led me to think that in a
certain number of cases at least I had failed to bring together
the tissues which should have restored the parts to their normal
relations. I began to study the action and situation of the
levator ani in normal vaginae. I found that it lay about three-
quarters of an inch within the orifice of the vagina and that a
certain portion of it seemed to pass down and incorporate itself
with the vaginal wall, giving a sphincter-like action which held
the posterior vaginal wall in contact with the anterior. This
conclusion was reached after studying the situation of the muscle
in unlacerated vaginal walls and comparing them with those
in the lacerated vaginal walls. So that now the first step in the
repair of these lacerations is to carefully study the situation of
the levator ani and of the more superficially situated muscles.
I found that, in the vast majority of cases, the central decussating
fibers of the levator ani have been torn apart. Oftentimes
no scar is evident at the site of the separation, but the fasciculus
of the muscle can be definitely followed along the side of the

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vagina, and the rectum can be seen to force itself forward between
these bands.

The operation in its conception is most simple. Its execution
at first was a little difficult tmtil experience had taught me
not only how to pick up this fasciculus of the muscle and the
fascia with the suture from the sense of touch, but also that it
could very easily be done by the sense of sight.

First Step: Denudation. — As a rule the land-marks adopted
are fairly distinct and satifactory. For the upper land-mark we
take a point in the center of the vagina at a position where the
anterior and posterior walls come in contact, usually about two
and one-half inches from the fourchette, depending somewhat
upon the extent of the rectocele. At this point a suture of a
No. 3 catgut doubled is passed through the mucous membrane
so as to get a firm hold upon it, to act as a land-mark and for
purposes of traction. Coarse catgut is used in order that it may
not tear out in the handling. The lower land-marks are the two
lowest carunculae myrtiformes on each side. Beginning at the
left caruncle myrtiformis, a strip of mucous membrane is cut way
up to the upper land-mark in the vagina. Without cutting off
the strip of mucous membrane, a corresponding strip is cut way
down to the right caruncle myrtiformis. This process is con-
tinued until a complete denudation has been made down to the
fourchette. This forms a triangular denudation with the apex
up in the vagina a distance perhaps two and a half inches, and
its base, representing the perineum or fourchette, from one
canmcula myrtiformes to the other. Up to this point the
denudation and the operation are practically the same as
practised by Hegar, and known as "Hegar's operation."

Second Step: Picking up the Levator Ani Muscle, — ^This step
in the operation is perhaps the most important one and is one
that is not so easily performed until one has become accustomed
to recognizing the levator ani muscle both by the sense of touch
and sight. The muscle is picked up first on the left side close to
the side of the rectum and at the lowest point at which it can be
felt. The suture passes from above downward on the left side,
and out toward the side of the pelvis, gathering up distinctly
the muscle near and at the side of the rectum, then crosses over
and passes from below upward on the right side gathering in
the corresponding bundle of muscle and fascia. This suture is
then tied so as to bring the fasciculus of the levator ani in front
of the posterior vaginal wall. Two continuous sutures are taken
with the same suture to bring together the little fold of tissue
which has been formed by tying the first suture. These sutures
are not carried down sufficiently far to allow the cut ends to
present upon the perineal surface; in other words, they are to
remain buried. I have found that the best suture for this pur-
pose is No. I forty- or twenty-dav chromicized catgut, tied with
three knots so that the ends may be cut very short; thus leaving
as little foreign body buried as possible.

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The next step consists in making a similar row of sutures a
little higher in the levator ani muscle and thus bringing together
a little broader band of muscle in front of the vaginal wall and in-
corporating with it the firm band of levator ani muscle and fascia.

Third Step. — Bringing together the mucQUS membrane from
the apex of the denudation downward.

We next begin at the apex of the triangle and bring together
the denuded surface of mucous membrane until we come to the
bridge of tissue formed by the united levator ani muscle, with
interrupted sutures of No. 2 chromicized gut. These sutures
are passed down to the bottom of the sulcus formed by traction
upon the carrying thread, and lie about one-third of an inch apart
At this point a deviation is made in the manner of passing the
sutures. They no longer go to the bottom of the sulcus, but
pass in deeply enough to bring together the mucous membrane
and a little of the cellular tissue beneath it, disregarding the
deeper tissues. The object of making these sutures shallower
than those higher up is to build up a symmetrical vaginal wall
and not to bind the mucous membrane down to the deeper tissues,
thus causing the vagina to remain permanently gaping. The
hiatus, which is left by the failure to carry these sutures to
the bottom of the sulcus, is overcome by a diflferent set of sutures
passing in at a different angle to be described later.

The last of these sutures lies about one-third of an inch within
the vagina from the carunculae myrtiformes.

Fourth Step. — Bringing together the perineum with silver wire

The next suture which completes the union of the vaginal
mucous membrane we may conveniently call the "crown su-
ture;" it passes in opposite the top of the denudation under
the caruncula myrtiformes and comes out just beneath the last
catgut suture. This suture, together; with the others which
complete the union of the perineum, is of silver wire. It is usu-
ally necessary to use from four to five silver wire sutures. These
sutures should be passed with a carrying thread, and a No. 28
wire is the best size. They pass in radiating toward a common
center which is deep within the denuded area and corresponds
with the portion of the levator ani which has last been brought
together with the buried sutures. The action of these sutures
radiating as they do to a common point in the levator ani is to
draw the anus forward and to bring the perineal body into accu-
rate contact. They pass deeply into the tissues and gather up a
substantial body of the elastic tissues of the perineum proper.
The ends of the wires are drawn taut and twisted at right angles,
and each has a perforated shot placed upon it about one-eighth
of an inch from the line of union. This completes the operation.

The results in these cases have been extremely satisfactory.

Since I have followed this method of restoration of the levator ani,

when torn in the center, there have been no cases of break-down

of the perineum, and the examination afterward shows as a rule


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that the anterior and posterior walls of the vagina lay in accurate
contact, and that the sphincter-like action of the levator ani is
completely restored. In several cases which have been repaired
in this manner I have had the opportunity to see the effect of
subsequent labor and, as a rule, there is no serious tear of the peri-
neum; the perineum seems to bear the strain of labor remarkably
well. In some instances a sUght superficial tear has occurred
which has been immediately repaired. In other words, because
it has been torn before it does not necessarily follow that a sub-
sequent labor will be followed by laceration of the levator ani.


The after-care of the patient is almost as essential to success
as the technic of the operation.

The patient should be allowed to pass her water, and after each
urination the parts should be irrigated lightly with a solution of
boric acid.

The bowels should be moved at the end of forty-eight hours,
with calomel, followed in six hours by salts. Every day there-
after a soft or liquid movement should be assured. If for any
reason the bowels have failed to move and an enema should have
to be given it should be a small one and given with great care.
The following enema will usually prove effective: Inspissated
ox-gall 3ss, glycerine 5i, mag. sulph. 5ii, warm water enough
to make 12 ounces. The parts should always be gently and
carefully cleansed after the bowels have moved.

Douches should not be given unless a discharge should appear;
in this case the douche should be of one-half strength peroxide
of hydrogen followed by 2 per cent, carbolic. This may be re-
peated every second day if necessary.

The stitches should be removed on the twelfth day and the
patient may get out of bed on the fifteenth day.

The operation should not be performed if any septic condition
exists in the pelvis.


Dr. Chas. Jewett said that the thirty-three operations to
which Dr. West had alluded should not be taken as indicating
confusion in the surgery of the pelvic floor, but rather as the
different steps in the process of evolution by which we have
reached the technic employed by most of us. The aim of the
modem operation, of which Dr. West's is a type, is to restore
the levator ani muscles to something like their normal relation
to each other.

The principal muscles concerned are the pubo-coccygei.
These muscles sweep from the posterior face of the pubic bone
on either side, and passing backward, laterally to the vagina and
rectum, go to the coccyx. They may be compared to the recti
abdominis. Just as in the latter the space between them,
except when perforated for the transmission of the tubular

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viscera, is bridged by fascia. This fascial bridge may be looked
upon as a conjoined tendon entirely similar to that between the

The essential character of most perineal lacerations is a rent
in this conjoined tendon at one or both sides of the vagina.
The rent results in diastasis of the levators and consequent
displacement of pelvic floor and viscera. The modem reparative
technic is an attempt to correct the diastasis.

My method of procedure is somewhat similar to that of Dr.
West. My denudation is not a mere denudation, but a resection
of a part of the posterior vaginal wall. The shape, like Dr.
West's, is practically that of the Hegar operation. The dissection
of vaginal wall from the rectocele is most easily and rapidly done
with the probe-pointed scissors of thcvMayo's. A longitudinal
fold of the vaginal wall is picked up with tissue forceps, near the
junction of skin and scar tissue. This is cut across and the
scissors are pushed well up through this incision between vaginal
wall and rectocele to the highest point of the displacement.

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 68 of 109)