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cadaver before opening and have never seen it pass the sigmoid.

Dr. Tuttle. — ^The question is, do the injections go up? Does
skiagraphy disclose the true condition? To my knowledge I
have introduced bismuth into the solution and found a most
beautiful picture of the appendix and colon filled with bismuth.

With regard to the point made by Dr. Vineberg, there is only
one way of telling whether the rectum has been properly emptied.
You might ask. How do you prepare your patient for a rectal
examination? They have their ordinary movement without
a laxative or enema, come into my office and then I examine
and see if they have emptied their rectums, whether after the
movement a little fecal matter remains there causing absorption.
Then I wash them out and make further examination.

With regard to the strictures produced by an inflammatory
mass, they are all of large caliber; they can only be diagnosed
by palpation; they do not obstruct; they simply give pain. It
is not a stricture of such caliber as to obstruct.

Dr. Dickinson, in the Chair. — I am sure I voice the opinion
of the whole Society when I express without a formal vote the
thanks of the New York Obstetrical Society to Dr. Tuttle for
his instruction to us.



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794 TRANSACTIONS OF THE



TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.



SECTION ON OBSTETRICS AND GYNECOLOGY.

Meeting of March 24, 19 10.

S. M. Brickner, M. D., in the Chair.

Dr. Herman J. Boldt presented the following specimens:

UTERINE tumor WITH BILATERAL OVARIAN TUMORS.

The patient, B. K., aged thirty-four years, complained of
abdominal distention which had gradually increased during the
last three years. In appearance the woman was extremely
emaciated; in fact, she looked cachectic. The abdomen was very
prominent and seemed like a large abdomen with a little withered
woman less than four feet in height attached behind it. Men-
struation was regular, at intervals of four weeks and from four
to five days' duration, moderate loss of blood. The abdomen
was distended by a tumor practically up to the diaphragm,
yet there was no interference with respiration. In the lower
abdomen the tumor was solid, and bimanually it seemed to be
uterine. A positive diagnosis was not made. The problematical
diagnosis was: uterine tumor with malignant changes, and
ovarian tumor.

On opening the abdomen the adhesions to the tumor were
found to be universal, so that, from a technical point of view,
the intervention was diflScult, particularly the extirpation
of the cervix, which was deemed essential, because of the clinical
diagnosis of probable malignancy of the uterine tumor. The
ovarian tumors contained thick yellow fluid; the left cyst was
the larger. The pathologist's diagnosis is : subserous fibromyoma,
papillary cystomata, and double hematosalpinx. On March
7 the woman was operated, and on the' following day she was
out of bed. Since the tenth she has been about on her feet, feel-
ing very well. On the eleventh day she left the hospital, but
the plaster scultetus binder was not removed until yesterday.
The patient has markedly improved in appearance since oper-
ation.

FIBROID TUMOR OF THE OVARY.

W. M., aged forty-five years. Abdomen greatly distended
with ascitic fluid, and also complained of pain in the lower



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NEW YORK ACADEMY OF MEDICINE. 795

abdomen. Menstruation irregular; seven to eight da)rs' duration.
The clinical diagnosis was that the great amount of ascites was
caused by a pedunculated fibroid, which was freely movable and
caused peritoneal irritation. The presence of an interstitial
myoma was not considered to bear on that symptom. Because
of other conditions it was considered best to employ spinal
analgesia, but that was insufficient so that some ether and gas
were necessary. The supposed pedunculated fibroid proved to
be a fibroid tumor of the left ovary. Whether a degeneration
has taken place must be determined by the pathologist, who
will get the tumor for examination to-morrow.

FIBROMYOMATOUS UTERUS.

The tumor was also removed yesterday from a patient of
forty-three years. She complained of pressure symptoms in
the lower abdomen, particularly on the right side, and of frequent
micturition. It is the generally accepted view that when
myomata cause sufficient symptoms for the patient to seek
medical advice, that usually there is an indication for removal
of the tumor.

LARGE OVARIAN CYST MISTAKEN FOR PREGNANCY.

It is likely that because the woman had omitted her menstrual
period for seven months, which had never previously occurred,
that the erroneous diagnosis of seven months' pregnancy was
made. The tumor corresponds to a uterus about that period
of gestation. The consultation was requested to determine
why no fetal movements had been noticed.

DERMOID TUMOR WITH TWISTED PEDICLE.

The pedicle of the tumor was twisted three and a half times
from left to right, and caused the sudden intensification of pain
in the lower abdomen. Twisting of the pedicle in dermoid
tumors is a comparatively rare accident, and for this reason the
case is reported.

UTERUS WITH ADNEXA REMOVED PER ABDOMEN.

The technical difficulties encountered .during the operation
may readily be appreciated when the specimen is looked at,
particularly the suppurating ovarian tumor with its thickened
walls on the right side. It is particularly in such cases that the
early mobility of patients is of special value.

PAPILLARY CYSTOMA OF THE OVARY.

The specimen well illustrates the objection that is had by
most operators, particularly in Germany, to decreasing the size
of an ovarian tumor before extirpating it. As a rule, it is pref-
erable to remove tumors in their entirety, if possible.



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796 TRANSACTIONS OP THE

DERMOID TUMOR COMPLICATING PREGNANCY AT THE THIRD

MONTH.

The tumor was adherent to the floor of the pelvis and it was
believed it might interfere with normal delivery. Its removal
was followed by a smooth convalescence.

LARGE CYST-ADENOMA OF THE OVARY.

The tumor had given rise to periodical attacks of pain in the
lower abdomen and to some ascites. The patient, aged thirty-six
years, had been told that the neoplasm did not require interven-
tion, but it would probably disappear spontaneously. This
suggestion was probably caused by an erroneous diagnosis
having been made, namely, a fibroid had been diagnosed, which
diagnosis was perhaps due to the solid consistency of the greater
part of the tumor, associated with profuse menstruation, and
unfortunately there are still medical men who believe in the
almost invariable benignancy of fibromyomatous tumors.

UTERUS AND ADNEXA REMOVED PER VAGINAM BECAUSE OF

RECURRENT ATTACKS OF PELVEOPERITONITIS AND

MENORRHAGIA.

The patient, aged forty years, had been ill several years and
treatment had been without beneficent result. The pathological
change consists in an increase of the connective tissue and a
thickening of the blood-vessels.

MYOMATOUS UTERUS.

This specimen shows the danger sometimes resulting from
the use of a curet to stop the bleeding in some instances of
myomata. The tumor took on active inflammatory changes
and in a small area perforated the serosa of the uterus, probably
by traumatism due to too vigorous use of the curet. The
convalescence was tedious.

DISCUSSION.

Dr. Boldt asked if any members of the Section had noted
the occurrence of ascites in cases of ordinary and malignant
fibroma of the ovaries.

Dr. Leroy Broun said he had seen one case; the micro-
scopical examination showed that it was a pure fibroma and
not malignant.

Dr. Brooks H. Wells said that apropos of Dr. Bold t*s case of
a tumor simulating pregnancy, he recently had seen a patient
with a degenerating myoma which had deceived many physi-
cians. This patient went to a clinic with the statement that
she was pregnant. When examined she was found to have a
tumor about the size of a seven months' pregnancy, which the
doctor diagnosed as a soft myoma. The woman was sent to



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NEW VORK ACADEMY OF MEDICINE. 797

a hospital, the abdomen was opened, and then the operator
said, " Fve made a mistake; this is a pregnancy,'' and closed the
wound. She was told that she was pregnant and that the
baby would be bom in a few weeks. After this she visited
several obstetricians and surgeons, all but one of whom con-
firmed her idea of pregnancy, the exception telling her that
the had a c)rst. Finally she appeared at Dr. Wells' clinic at
the New York Polyclinic Hospital and stated that she had
carried her baby fourteen months and wondered why it had
not been bom. Her abdomen was then the size and shape
of a full- term pregnancy, and with masses in the tumor that
simulated the parts of a child. She was rather a stout wo-
man, her breasts were well developed, but there was no milk
secreted. The cervix was hard; there was no violet discol-
oration at the introitus. A supravaginal hysterectomy was
done by Dr. Wells and the tumor removed. The patient was
allowed out of bed on the third day and went home on the
eighth after operation.

Examination of the tumor after operation showed it to be a
myoma undergoing degenerative changes, so that over most of
its area it was so soft to palpation as to suggest fluid. On section
it was almost diffluent, yellowish-gray in color, with, in parts,
rounded masses of normal myoma tissue.

Dr. W. Gill Wylie, speaking in response to Dr. Boldt's
question about fibroids causing ascites, did not believe that
they did except under exceptional conditions. Fibroids did
not seem to interfere with the circulation; when ascites occurred
when fibroids were present, it was in all probability due to some
complication which caused an irritation of the peritoneum.

Dr. Wylie was especially interested in the presentation of
the specimen which showed the injury done by the too vigorous
use of the curet. He thought it should be very strongly
insisted that we should not curet the uterus when fibroids
were present.

Dr. C. C. Sichel reported a number of cases:

HEMATOSALPINX.

A woman, forty-one years old, was admitted to the hospital
February 8, 1909, complaining of pain in the right side of her
abdomen; it was constant and shot down into the right leg.
She was constipated and vomited. Her temperature was
99.3°. The abdomen was opened and he found a pedunculated
hematosalpinx. This probably contained water at first, and
later blood. It was entirely separated from the broad ligament.
Not only was it pedunculated, but it was twisted six or seven
times. The patient made an uneventful recovery.

PYOSALPINX.

A woman, twenty- three years old, was admitted to the
hospital December i. She had an acute double pyosalpinx.



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798 TRANSACTIONS OF THE

with involvement of the broad ligament. There was sepsis,
with high temperature. Both tubes and ovaries were removed,
the latter being cystic. The report of this case was of interest
because, although particularly careful in tying off the hemor-
rhagic points, some bleeding occurred. He placed in a small
drain. One hour after leaving the hospital the patient was
pulseless and the dressings were saturated with blood. It
required hot rectal salines and other measures before the pulse
could again be detected. She finally made a good recovery.

ECTOPIC GESTATION.

A woman, thirty-seven years old, was admitted to the hos-
pital March 19. A diagnosis was made of a ruptured ectopic
gestation. She had all the symptoms of an internal hemorrhage,
although the radial pulse was felt. Upon opening the ab-
domen, it was found to be full of blood and clots. The sac was
not ruptured, and the only explanation for the hemorrhage was
that it came from the fimbriated extremity.

RUPTURED PYOSALPINX. DEATH.

The woman entered the hospital with all the symptoms of a
diffuse peritonitis; all that was done was to open the abdomen
and remove much pus. At autopsy there was found a pus tube
which encircled the rectum almost completely and which had
ruptured. The condition was one of long standing, and the
walls of the tube were very thick.

DISCUSSION.

Dr. Herman J. Boldt said at one time it was said that a
spontaneous rupture in cases of pyosalpinx could not occur;
very few cases had been reported in which rupture occurred
prior to operation. It would be very interesting to know the
cause of the rupture in the case reported by Dr. Sichd.

Dr. Sichel replied that the woman was in extremis when
seen, and, therefore, no history could be obtained.

A catheterizing cysto-urethroscope.

Dr. Leo Buerger presented this instrument, and demon-
strated its use on a patient. He had overcome the shortcom-
ings of the Goldschmidt instrument. This new instrument
consisted of a sheath, obturator, and telescope. The sheath
was provided with a detachable beak, a small fenestra, and two
irrigating cocks. An illuminating prism was employed. The
advantages of the instrument are: i. A perfectly normal view
of the ureters, trigone, neck of the bladder, and posterior ure-
thra can be obtained; 2. the amount of irrigation is reduced to
a minimum; constant irrigation is unnecessary; intermittent
injection of a little fluid suffices; 3. the small window makes



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NEW YORK ACADEMY OF MEDICINE. 799

rotation of the instrument possible and injury to the urethra
is avoided; 4. by means of a new type of prism perfect illumi-
nation is provided and upright images are produced.

DISCUSSION.

Dr. Arthur Stein said, after Dr. Buerger's interesting and
instructive demonstration, I wish to add a few remarks con-
cerning urethroscopy in the female. Though I have only used
this instrument for three weeks, I have already become con-
vinced of its great value and superiority over other instruments
of similar kind.

Up imtil the present time Valentine's urethroscope was
probably the most practical one for the use of the gynecologist.
It consists of a tube similar to Kelly's, with a small lamp at its
forward end. The field of vision is small and as the instrument
becomes hot quickly, an examination for any length of time is
impossible, especially as regards the bladder. Another dis-
advantage of Valentine's instrument is that the physician has
to get too close to the patient.

Things are different with Buerger's urethroscope. In this
the lamp is so situated that burning is impossible, and thus
we can take our time about examining the urethra and can
also inspect the empty bladder.

As yet I have not had suflScient experience with it to say much
concerning the normal and pathological appearance of the
urethra. Of one thing, however, I am certain, gonorrheal
and other inflammations can be studied with ease; the same is
true of tumors of the urethra. Only a few days ago, while
examining a case of acute urethritis, I saw a small mucus polyp
in the posterior wall of the urethra, and never before have I
seen so distinct and large a picture.

Buerger's instrument has still another and important ad-
vantage over the others — ^it makes possible the examination of
the absolutely empty bladder, without the slightest annoyance
to physician or patient. Heretofore this was impossible, except-
ing under great difficulties. The instrument is indispensable,
therefore, in cases of vesicovaginal fistula. • As we need not
fear touching the bladder wall with the instrument we are able
to study the very act of the bladder emptying itself. The
bladder can be partly filled and then the patient may empty
it at will. The wall will be seen to contract slowly, the muscle
bundles standing out as to give one the impression of a trabec-
ulated bladder. The relaxation can also be observed most
beautifully. In short we are in a position to study the physiology
of the bladder and in this way will be better able to study its
pathology.

One word about the picture itself: it is upright in contra-
distinction to the usual cystoscopic picture, which is inverted.

Buerger's instrument is of great value and though I have had



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800 TRANSACTIONS OF THE

but a short experience with it, I feel certain that no one will
regret having given it a trial.

AN IMPROVED MODIFIED KELLY CYSTOSCOPE.

Dr. H. D. Furniss presented this instrument which carried
a small electric light at its inner end.

CYSTITIS, AND SO-CALLED CYSTITIS.

Dr. Arthur Stein read this paper.*

DISCUSSION.

Dr. W. Gill Wylie emphasized the necessity for a correct
diagnosis. A great many cases were sent to him because of
supposed bladder trouble when there was no trouble there at all.

Dr. Herman J. Boldt believed that all present could say that
they had learned something from the instructive paper read
by Dr. Stein. A large number of patients who complained of
bladder symptoms had no pathological condition demonstrated
by the cystoscope. Many of their symptoms were caused by
irritation of the nerves supplying the base of the bladder, and
in this particular class of cases he found that much good would
result from overdistending the bladder with boric acid solution
or water; this procedure gave good results, especially when
combined with what he called " vibration of the neck of the
bladder."

Dr. Gustave Seligman had had a number of cases upon
which he had operated and was astonished to find how often
there was an involvement of the bladder from the abdominal
side; there might be found carcinoma of the bladder, extending
to it from without, and yet with no bladder symptoms. As to
the frequency of such cases, he would not venture an opinion,
but there were many striking instances in which one would
expect bladder symptoms, and yet none would be complained of.

Dr. Seligman asked in regard to the frequency of urination
not at the end, but at the beginning of pregnancy.

Dr. Brooks H. Wells wished to emphasize the point which
seemed to him to be the crux of the situation — the importance
of accurate diagnosis. This was not only important in diseases
of the bladder, but was important in every department of gyne-
cology and obstetrics. To make a diagnosis of cystitis it was
not only necessary to make a careful bimanual examination of
the patient, but it was also necessary to make use of the micro-
scope, the cystoscope, and possibly the ureteral catheter; then,
and only then, was one in a position to give an intelligent opinion
of the condition. Bladder symptoms could be produced by any
condition producing pressure or tension on the structures
connected with the base of the bladder; by any condition which

♦ See original article, page 769.



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NEW YORK ACADEMY OF MEDICINE. 801

caused congestion or pain in the adjacent structures, as the
rectum, the parametrium, the tubes, or ovaries.

Dr. Wells reported an interesting case of a woman whom
he had recently seen. She complained of very frequent mic-
turition only in the daytime and a diagnosis of cystitis had
been made by another physician. The microscopical examina-
tion of the urine was negative; the cystoscope showed the bladder
to be normal. But the bimanual examination revealed ad-
hesions posterior to the uterus. Dr. Wells said: "There is no
cystitis present, but the frequency in micturition is probably
caused by the tension of these old adhesions." The patient
went home and a woman friend said to her: '*It is useless to
go to a doctor any more; wear a rubber urinal as I do." The
patient did so and the frequent micturition ceased. The point
Dr. Wells wished to call attention to was that when we thought
there was some slight organic or physical basis for an irritable
bladder, there might be some mental or psychical condition
behind which should not be overlooked, and vice versa.

Dr. H. D. Furniss had seen two or three cases of carcinoma
of the bladder, an extension of the disease from the uterus,
which had not produced bladder symptoms. Retroversion
of the uterus causing bladder symptoms had often been men-
tioned; in the majority of these cases, however, there would
be found a coincident urethritis. He had come to the con-
clusion that in many cases of retroversion, pelvic adhesions,
and urethritis the cause was the same, usually the gonococcus.

Recently he had seen two cases of severe cystitis due to
trouble in the kidney: in both cases there was a mild pyelitis
present.

Dr. Robert L. Dickinson said the use of the cystoscope had
given them the ability to make a diagnosis, but had not done
much for them in the way of the treatment of cystitis. Among
the conditions that were not cystitis and which gave symptoms,
residual urine was worthy of consideration; also varicosities
at the base of the bladder and erotism. He thought that this
general principle might be enunciated concerning outside tumors
and growths and inflammations, etc., that one can do almost
anything to any part of the bladder so long as he left the base
of the bladder alone.

Dr. Leo Buerger said that not long ago he saw a very inter-
esting case. The patient was a woman, very nervous and
erotic; she had been operated upon three years ago, when she
was catheterized for the first time, and ever since she had had
bladder symptoms. The cystoscope revealed nothing ab-
normal. She first urinated every two hours, then every hour,
and, two years after the operation, she urinated every fifteen
minutes. The urine was perfectly clear. She was again cysto-
scoped and there was found at the sphincter, corresponding
to the trigone, what he thought at first to be a papilloma. How-
ever, it was found that on either side there were two small granu-
6



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802 BRI£F OF CURRENT LITERATURE.

lations. These were cauterized with the electrocautery and
gradual dilatation was employed for four weeks and the patient
had been relieved of her symptoms. This case illustrated how
a small lesion which under ordinary circumstances should not
cause trouble could give rise to distressing symptoms.

Dr. Samuel M. Brickner called attention to one condition
that had not been mentioned and which would cause frequent
micturition, the increasing size of a pregnant uterus. A retro-
flexed uterus also might cause an unusual frequency in urination
as well as great pain.

Dr. Arthur Stein, closing the discussion, speaking of irri-
table bladder, said that some gentlemen had tried to eliminate
that expression, because it did not indicate anything.

He agreed with what was stated about the symptoms adhe-
sions gave rise to. He had seen many cases wherein he could
find no troubles in the bladder which gave bladder symptoms.

With regard to the frequency of urination at the beginning of
pregnancy, he thought this was due to the increased supply of
blood to the pelvic organs more than to any influence of nervous
reflexes.

With regard to what had been stated about bladder symptoms
and retroflexed uteri, he wished to report an interesting case.
Several years ago a patient was brought into the hospital with
a very much distended abdomen. -Aiter several examinations
the cervix was detected, but not the body of the uterus because
of the presence of a large tumor which bulged into the vagina.
The upper part of the tumor extended to the ribs. Attempts
were made several times to pass the catheter, but without success.
The patient's condition being very serious, something had to be
done, and upon opening the abdomen there was found a three
months' pregnant uterus which was retroverted. The tumor
which reached to the ribs was the overdistended bladder. The
bladder was emptied, the uterus was replaced, and an unevent-
ful recovery followed.



BRIEF OF CURRENT LITERATURE.



obstetrics.



Significance of Atypical Metrorrhagia and Alterations of the
Endometrium in Relation to the Development of Malignant
Tumors of the Ovary. — ^Emilio Alfieri {Folia Gin,, 1909, vol. iii,
Fasc. Ill) bases his observations of the relation of atypical
metrorrhagia and malignant tumor of the ovary upon the
cases seen by him between 1902 and 1908 at the Gjmecolog-
ical Clinic in Pa via. He examined seventy cases of tumor of
the ovary or parovarium, fifty- two benign, and 18 malignant,
the histories of which are given. His conclusions are that



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BRIEF OF CURRENT UTERATURE. 803

metrorrhagia accompanying the development of an ovarian
tumor, especially after the menopause, is an indication of
probable malignity. Still it is not a sufficient element for
a positive diagnosis, and may be absent in malignant tumor
or present in the benign type. It is not always an indica-



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 82 of 109)