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THE

ltT\ AMERICAN

& Medical
Serials

JOURNAL OF OBSTETRICS

Diseases of Women and Children

EDITED BY

BROOKS H. WELLS, M. D.

GEORGE W. KOSMAK, M. D.

VOLUME LXXIV.

July-December, 1916

NEW YORK

WILLIAIW WOOD & COMPANY

1916

1^G

As?

LIST OF CONTRIBUTORS.

Adachi, Kenji, Kyushu, Japan.
Babcock, W. Wayne, Philadelphia, Pa.
Bancroft, Frederick W., New York, N. Y.
Beck, Alfred C, Brooklyn, N. Y.
Bell, John Norval, Detroit, Mich.
BissELL) DouGALL, New York, N. Y.
Cadwallader, R., San Francisco, Calif
Caldwell, Wm. E., New York, N. Y.
Carstens, J. H., Detroit, Mich.
Cary, William H., Brooklyn, N. Y.
Chipman, Walter W., Montreal, Can.
Daniels, C. D., Philadelphia, Pa.
Donnelly, John, Philadelphia, Pa.
Doyle, Francis B., Brooklyn, N. Y.
Eastman, Joseph Rilus, Indianapolis, Ind.
Ely, Albert H., New York, N. Y.
Emge, LuDwiG A., San Francisco, Calif.
Epstein, J., New York, N. Y. '

Falls, Frederick Howard, Chicago, 111.
FiNDLEY, Palmer, Omaha, Neb.
FiNKELSTONE, B. B., Bridgeport, Conn.
FooTE, John, Washington, D. C.
FosKETT, Eben, New York, N. Y.
FouLKROD, Collin, Philadelphia, Pa.
Frank, Louis, LouisvUle, Ky.
Frank, Robert T., New York, N. Y.
Fullerton, Wm. D., Cleveland, O.
Gibson, Gordon, Brooklyn, N. Y.
Grasty, Thomas S. D., Washington, D. C.
McCloskey, Elsee P., Manila, P. I.
McPherson, Ross, Brooklyn, N. Y.
McNeile, Lyle G., Los Angeles, Calif.
Maier, F. Hurst, Philadelphia, Pa.
Maroney, Wm. J., New York, N. Y.
Miller, A. Merrill, Danville, 111.
Miller, G. Brown, Washington, D. C.
Moore, S. E., Minneapolis, Minn.
Moots, Chas. W., Toledo, O.
Pantzer, Hugo O., Indianapolis, Ind.
Pfaff, O. G., Indianapolis, Ind.
Plass, E. D., Baltimore, Md.
POLAK, John Osborne, BrookljTi, N. Y.
Prentiss, D. W., Washington, D. C.
Hall, Rufus B., Cincinnati, O.
Hadden, David, Oakland, Calif.
Hamilton, Ralph, Washington, D. C.

iv LIST OF CONTRIBUTORS

Heinebeeg, Alfred, PliUadelphia, Pa.
Hirst, Barton Cooke, Philadelphia, Pa.
Hirst, John Cooke, Philadelphia, Pa.
HORNSTEIN, Mark, New York, N. Y.
HussEY, Augustus A., Brooklyn, N. Y.
Hyde, Clarence Reginald, Brooklyn, N. Y
Kellty, Robert A., Philadelphia, Pa.
Kennedy, J. W., Philadelphia, Pa.
Knipe, Norman L., Philadelphia, Pa.
KoLMER, John A., Philadelphia, Pa.
Lavake, Rae Thornton, Minneapolis, Minn
Lindeman, Edward, New York, N. Y.
LoTT, H. S., Winston-Salem, N. C.

Rabinovitz, M., New York, N. Y.

Reder, Francis, St. Louis, Mo.

Reich, A., New York, N. Y.

Rice, Frederick W., New York, N. Y.

Riggles, J. Lewis, Washington, D. C.

RoNGY, A. J., New York, N. Y.

Rosenthall, Maurice I., Fort Wajiie, Ind.

Saliba, John, Elizabeth City, N. C.

Salzman, S., Toledo, O.

Schwarz, Henry, St. Louis, Mo.

Shoemaker, George Erety, Philadelphia, Pa.

Skeel, Roland E., Cleveland, O.

Slemons, J. Morris, New Haven, Conn.

Smead, Lewis H., Toledo, O.

Stein, Arthur, New York, N. Y.

Stewart, Douglas H., New York, N. Y.

Stone, I. S., Washington, D. C.

Sturmdorf, Arnold, New York, N. Y.

Sullivan, Robert Young, Washington, D. C.

Tate, Magnus, Cincinnati, O.

TiMME, Walter, New York, N. Y.

Williams, P. H., New York, N. Y.

Williams, Phillp F., Philadelphia, Pa.

Williamson, Her\'ey C, New York, N. Y.

Welz, W. E., Detroit, Mich.

Yates, H. Wellington, Detroit, Mich.

Ziegler, Charles Edward, Pittsburgh, Pa.

ZiMMERMANN, ViCTOR L., Brooklyn, N. Y.

American Association of Obstetricians and Gynecologists.

American Gynecological Society.

American Medical Association.

American Pediatric Society.

Brooklyn Gy^necological Society.

Medical Society of the State of New York.

New York Academy of Medicine.

New York Obstetrical Society.

Obstetrical Society of Philadelphia.

Washington Obstetrical and Gynecological Society.

TELE AlVTEIRIOAJSr

JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN.

VOL. LXXIV. JULY, 1916. NO 1.

ORIGINAL COMMUNICATIONS.

SURGICAL REPLACEMENT OF THE RETROPOSED
UTERUS.

BY
DOUGAL BISSELL, M. D., F. A. C. S.,

Attending Surgeon, Woman's Hospital,

New York.

(With four illustrations.)

There can be little difiference of opinion regarding the treatment
of the acute form of retrodisplacement of the uterus. This con-
dition occurs more often than is supposed, but is mistaken for some
other acute pelvic or abdominal lesion. The resulting pain is
usually severe at first, gradually lessening by rest and position until
the condition, unrecognized, passes into the chronic form.

The chronic form of retrodisplacerhent seems an ever-present
pathologic problem and as long as there exists a diversity of opinion
among students of gynecology regarding its surgical treatment,
further study is demanded.

Until September 3, 1901, my experience in the surgical correction
of retrodisplacements was confined to the operations then in vogue,
namely, shortening of the round ligaments through the inguinal
canal, ventral suspension and ventral fixation. My results in the
majority of cases were not satisfactory either in respect to position
or relief of symptoms. External shortening of the round Hgaments
was more or less successful but offered the objection that it did not
permit of the correction of obscure pelvic complications. When it
was accomplished with the addition of an abdominal section and
exploration of the pelvis, symptomatic results were markedly im-
proved. Ventral suspension frequently failed to permanently

2 bissell: surgical replacement of the retroposed uterus

correct the position and ventral fixation so limited the motion of
the fundus that the pregnant uterus at times did not develop
normally. My observations of the results of the work of other
operators convinced me that they were much the same as mine.
Such unhappy experiences stimulated me in the effort to devise
some method which would ensure both permanent replacement and

Fig. I. — The plan first adopted but abandoned because of the difficulty
of adjusting with exactness the ends of the round ligament, especially when
small.

normal mobility of the uterus and its adnexae, and afford at the
same time opportunity to correct associated abnormalities.

As far as I have been able to ascertain, shortening of the round
ligaments by excision of part of them and reuniting of their cut
ends and shortening of the broad ligaments by splitting their surfaces
and suturing each separate surface on itself had not been done prior
to igoi.

bissell: surgical replacement of the retroposed uterus 3

The plan first adopted (see Fig. i.) consisted in the removal of the
greater portion of the round ligament, leaving about 1.5 cm. of the
proximal portion and 1.5 cm. of the distal portion. This excision of a

Fig. 2. — The small cut shows the first step in the operation. Here the middle
portion of the ligament is drawn taut and split longitudinally. The larger cut
shows the second step or the complete splitting of the round ligament and separa-
tion of the surfaces of the broad ligament.

portion of the round ligament exposed the upper margin of the broad
Hgament where the line of cleavage could easily be found and the two
surfaces of the broad ligament were forced apart by blunt dis-

4 bissell: surgical replacement or the retroposed uterus

section. The ends of the round ligament were then united and
the surfaces of the broad ligament were folded upon themselves at

Fig. 3. — The small cut shows the third stage where a section of the anterior
and a section of the posterior split portions of the round ligament is cut away
from its broad ligament attachment and the remaining portions ready for
adjustment. The large cut shows the remaining split portions of the round
ligament adjusted, and the separated anterior and posterior surfaces of tfie
broad ligament folded upon themselves.

right angles to the direction of the round ligament and so sutured.
The amount of round ligament removed varied, but the newly
constructed ligament was approximately 2.5 cm.

bissell: surgical replacement or the retroposed uterus 5

This plan was followed for three years, then because of certain
recognized defects in the technic, resulting in six known failures
out of forty-three cases, it was abandoned. The chief difficulty was
that the exact apposition of the ends of the round ligament was
often most difficult, especially when the ligament was small. Out
of the foregoing plan the method I now employ was evolved.

With the present technic (See Figs. 2 and 3) the round ligament is
grasped near its center with two sponge forceps or bullet hooks.
These forceps are 2 cm. or more apart. Gentle traction is made
and the tense portion of the ligament between the forceps is split
through its middle longitudinally, the point of the knife passing down
between the surfaces of the broad ligament. Each split portion of
the round ligament is now grasped with a Sims-Tait forceps and the
sponge forceps or hooks released. The straight Mayo scissors is next
passed through the spHt in the round ligament and forced down
between the layers of the broad ligament and opened several times
so as to separate the surfaces. With the same scissors the longi-
tudinal division of the round ligament is continued on the distal
side to within close proximity of the infundibuliform process of the
ligament and on the proximal side to its uterine insertion. The an-
terior split portion of the round ligament is now severed about 1.5
cm. from the infundibuliform process and cut away from its broad
ligament attachment. The posterior split portion is severed about
1.5 cm. from its uterine insertion and cut away from its broad
ligament attachment. The cut end of each remaining spht portion
of the round ligament is sutured to its corresponding cut end with
silk or linen and the apposing lateral surfaces of the split portions
are held together by plain catgut No. o penetrating them at their
middle.

Thus reconstructed, the round ligament is about 2.5 cm. or less
in length and larger in diameter than it was previously. The
posterior surface of the broad ligament is now grasped at its middle,
folded upon itself, and penetrated at its base with a mattress suture
of No. I chromic gut, care being taken not to encroach upon the
Fallopian tube in passing the suture. When the mattress suture is
tied the posterior surface of the broad ligament is narrowed, the cut
edge of the fold is united with a continuous catgut suture. The
anterior surface is treated in the same way, care being taken not
to injure the uterine artery. By this technic the broad ligament
surfaces are shifted so as to make the outer or distal portion of the
anterior surface appose the inner or proximal portion of the posterior
surface, with the resulting narrowing of the entire ligament.

6 bissell: surgical reflacement of the retroposed uterus

As the mechanical and surgical principles of this procedure are
correct theoretically and practically, there is resulting no disturb-
ance of the anatoiBical relationship of the uterine adnexae. The
round ligament by this technic is shortened and the broad ligament
narrowed, not by union of their peritoneal surfaces, but by direct
union of their muscular and cellular tissues, and being thus re-
constructed are essentially the same as when originally created.
The maintenance of the uterus anteriorly is by this technic not
dependent upon the round ligaments alone, as is the case in many
procedures now in vogue, but upon both the round and broad
ligaments.

A temporary suspension of the uterus is done when the uterus is
found to be large and heavy. The technic employed is as follows:
a No. 2 chromic gut suture is passed through the right rectus muscle
and peritoneum near the lower angle of the abdominal wound. It
then penetrates the anterior surface of the uterus near the fundus,
emerging on the posterior surface at an opposite point. It then
penetrates the posterior surface at a point i cm. from where it
emerged and is passed through to the anterior surface, emerging
about I cm. from where it originally entered. The suture is then
passed through the peritoneum and the left rectus muscle near the
lower angle of the wound and tied, when the peritoneal opening is
closed. When the sustaining suture is tied, the unscarified peri-
toneum of the anterior fundal area is apposed to the unscarified
abdominal peritoneum. These apposed surfaces are, as a rule,
held together only so long as the resisting force of the suture lasts,
and does not result in a firm union. When the sustaining suture
begins to weaken, the partial filling of the bladder becomes an
important factor in forcing apart the surfaces. Should, however,
the union be firmer than desired, the development of the uterus in
pregnancy is not interfered with to the extent it would be if union
took place at the fundus or on the posterior instead of the anterior
fundal area (see Fig. 4).

I have had the opportunity to reenter the abdomen on two oc-
casions when this form of temporary suspension was made, and in
neither instance was there evidence of a suspension having been
done. Nor have any of the cases which became pregnant developed
serious complications during their labor.

The great advantage of this procedure when used in connection
with the shortening of the ligaments is that under all circumstances
it relieves strain upon the reconstructed ligaments until they are
firmlv united.

bissell: surgical replacement of the retroposed uterus 7

The main features ior consideration when studying the results of
operative work for the correction of retrodisplacements of the
uterus are the position, mobility of the organ, and the relief or
nonrelief of symptoms. In determining the position of the uterus an
empty bladder at the time of examination is essential. Permit me
to briefly relate a personal experience illustrative of this point. An
examination of one of my early cases was made by me when the
bladder was empty and the position of the uterus found normal.
I was so gratified with the result that I sent the patient to a gynec-
ologist of high repute interested in my work. The patient was
examined by him about two hours or more after I saw her. He
reported to me his disappointment in finding the uterus out of
position. The patient had had no opportunity between visits to

Fig. 4. — .\ suspension of the uterus which is the least liable to remain per-
manent. Care is taken not to injure the peritoneum of the fundus.

relieve herself and consequently there existed at the time the
examination was made by my friend a full bladder and a receded
uterus. The anterior position of the uterus was verified by me
at a subsequent examination when the bladder was empty.

I have had the opportunity to study the results of 185 cases
during the past thirteen years. They are sufficient to enable me to
form a definite opinion regarding the permanency of position, the
degree of mobihty and functioning of the uterus. These cases have
been subjected to the usual tests during a period of from one to
eleven years. Eight of these were failures with respect to position.
In six of the eight, the first technic described was followed. In

8 bissell: surgical replacement of the retroposeo uterus

one the fundus was suspended with chromic gut sutures in addition
to the shortening of the ligaments, and in one the present technic
alone was employed. Two of the six were cases complicated by
adnexal disease and pelvic adhesions. In three of the six recurrence
took place within two weeks after the operation, one recurred after
three months, in the other two the time of recurrence was uncertain.
As to exciting causes, two followed distention of the bladder, one
straining at stool and one the lifting of a heavy weight. But im-
proper execution of technic was doubtless the important factor in
these disastrous results.

I have had the opportunity to reopen the abdomen in seven cases;
four of these were for lesions which were not in any way associated
with the original condition. In one case the position of the uterus
was good, but dense adhesions existed between the bladder and the
anterior surface of the uterus. In two cases the position of the
uterus had recurred and in addition there were adhesions posteriorly.
In the four cases operated on for the correction of independent lesions
such as ovarian and fibroid tumors, or for intraabdominal e.xplora-
tion, it was impossible to tell that an operation had been done upon
the ligaments, the only difference between these and the normal was
that the ligaments were shorter and less relaxed. One of these cases
was opened seven or more years after the original operation, during
which time the patient had borne three children, and she was pre-
sented for examination at a meeting of the New York Obstetrical
Society held at the Woman's Hospital in 1909. In the case in which
the adhesions were found between the uterus, bladder and anterior
surface of the broad ligament, a modification of the technic
had been done, namely, suturing the folded anterior surface of the
broad ligament to the anterior surface of the uterus in addition to
sphtting and splicing the ligaments. This case was relieved of
convulsions for one year. On the return of the convulsions a year
after the first operation, I opened the abdomen again and removed
the uterus and adnexK. In the second case, with recurring pelvic
adhesions, fixation of the uterus to the abdominal wall was done
at the second operation, but in neither case were symptoms relieved.

The one case of failure operated on by combining the technic
of temporary suspension of the fundus and shortening the ligaments
will be considered later with the cases of pregnancy and labor. The
case which failed where the present technic alone was employed
should be related somewhat in detail. The patient left the hospital
earher than I usually allow such patients to leave, and as a pre-
cautionary measure, she living in the country awa}' from my im-

bissell: surgical replacement of the retroposed uterus 9

mediate supervision, I introduced a pessary, a procedure not my
custom, with the instructions that she return at a stated time to
have it removed. Three months after operation she presented
herself for examination with the same group of symptoms prior to
the operation and the uterus was found completely retrodisplaced.
She related the following history. Shortly after her return home,
feeling in the best of health, she removed the pessary, and when
menstruation began, apprehending a profuse flow as previously
existed, she packed the vagina with cotton, which had for many
years been her custom, and it may be incidentally stated that the
amount of cotton she was able to insert and retain would have done
credit to an expert packer. Eight weeks after operation she spent
a day in the city shopping and was careless regarding the evacuation
of her bladder. She became extremely tired on her return home and
from then on the old symptoms reappeared. She was a woman of
good mentality but opinionated and indifferent to advice. Though
improper care of herself may in great part have been responsible
for disastrous results, the failure must be credited to the operation
or operator.*

In cases where the uterus remained permanently replaced the
results with few exceptions were absolute relief of symptoms. Three
exceptions are worth noting; one of these was a case related above,
the convulsions returning within a year after operation. The other
two were not relieved until in each case the right kidney was fixed-
In one of the latter cases I opened the abdomen to determine if there
existed any obscure pelvic lesions. I found the uterus in perfect
position and demonstrated through the incision the low position of
the kidney.

The initial case of my study, operated on September 3, 1901,
stood the test of two labors successively and was reported on by a
committee of the New York Obstetrical Society both in 1901 im-
mediately after the operation, and in 1909, about two years after
her last labor. Another case stood the test of three labors and was
reported on by the same committee in 1909. I had the opportunity
immediately after presenting the latter patient for examination to
open her abdomen that I might determine the origin of certain
distressing symptoms which had recently arisen. Two very small
fibroids on the fundus and engorged veins in the infundibular pelvic
portion of the broad Hgament were the only abnormalities in the
pelvis. The uterus was in normal position and the ligaments normal.

* This case became pregnant one year later and was delivered at full term, since
which time I have not seen her for examination.

10 bissell: surgical replacement of the retroposed uterus

A right prolapsed kidney, which was noticed previous to exploration
was determined intraabdominally to be the only pathologic lesion
of sufficient importance to produce the existing symptoms. The
kidney was then fixed with permanent relief.

Nineteen labors were successfully terminated in fourteen women
and without recurrence of retroposition of the uterus save in one
instance. Forceps were used in three of the seventeen deliveries,
vagina! Cesarean section in one; the reason given by the attending
physician in each instance was uterine inertia. One of the cases in
which forceps was used was subsequently delivered by me without
the use of forceps. The single case in which retrodisplacement of
the uterus occurred was that of a woman who had been severely
injured by forceps in 'her first labor, previous to my operation for
retroversion. Injuries inflicted on the pelvic fascia at the time of
this labor were excessive, resulting in partial prolapsus of the
uterus and permanent and wide separation of the pubic bones.
The cervix and perineum were also badly injured. The result
following her labor after operation for correction of displacement
was a complete prolapsus of the uterus, and hysterectomy with
pelvic fascial repair was eventually necessitated. In one case
miscarriage occurred at the end of the third month, cause un-
known, but the position of the uterus was not affected.

In securing the histories of cases of movable retroposed uteri it
is not uncommon to find that eight or ten hours may elapse without
the patient evacuating the bladder and often without any distress
or desire to micturate. This fact is evidence in support of the
theory that when the pelvic organs are in normal relationship and
the normal capacity of the bladder is reached, the resistance offered
by the lateral ligaments and consequent tension upon them is an
important factor in arousing the consciousness of the existing con-
dition and a desire to micturate. To combat the ill effects of post-
operative distention of the bladder, I have resorted for several years
to frequent postoperative catheterization. The rule which I usually
estabhsh is: catheterization every sLx hours and before if the patient
expresses distress in the vesical region. If frequent passing of small
quantities of urine occurs, which is always suggestive of over-
distention, catheterization is immediately done to determine the
true condition of the bladder. Before catheterization, the tip of
the catheter is inserted in 15 per cent, solution of argyrol, which
prevents cystitis.

The correction of retrodisplacements through the intraabdominal
route affords opportunity to investigate and remove associated

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI 11

intraabdominal lesions and constitutes a decided advantage. But
intraabdominal methods which create false ligaments or utilize the
normal ligaments with resulting abnormal relationships of the pelvic
organs, while they may correct permanently the position of the
uterus and at times afford relief of symptoms, establish by the very
means of correction an ever-present possible source of serious
disturbance.

The criticism that might with justice be made of the technic
here advocated is that the preparation and adjustment of the
ligaments necessitate such exactness of work as to constitute an
objection.

219 West Seventy-mnth Street.

REPORT ON A CASE OF CARCINOMA UTERI TREATED

ACCORDING TO THE PERCY METHOD, WITH

AUTOPSY FINDINGS.*

BY
FREDERICK W. B.-VNCROFT, M. D.,

New York City.
(With nine illustrations.)

History. — Much has been written during the last decade upon the
susceptibility of carcinoma and sarcoma cells to low degrees of heat.
Clowes, in 1906, stated that tumor cells in vitro die when exposed to a
temperature of 45° C, while connective- tissue cells will survive,
although their growth is inhibited. Haaland has shown that car-
cinoma cells are more susceptible to heat than sarcoma cells, they die
after an exposure of one-half hour, to a temperature of 45° C. Loeb
has confirmed this. E. Vidal noted the arrested development of
tumors in four patients suffering from infection with a rise in tem-
perature above 40° C. He repeated these results in experiments
on animals. He suggested that the occasional benefits derived
from vaccines, etc., is due to the high temperature produced by the
body reaction. During and Grau believe the efliciency of the high-
frequency currents is due to heat alone.

On the other hand, M. Doyen has shown the death point of car-
cinoma cells is 55° C. Living connective-tissue cells are killed at a
temperature varying from 55° to 65° C. In 1912 Percy published his
report in regard to the treatment of carcinoma of the cervix and
uterus by low-temperature cauterization. He bases his operation

* Read at a meeting of the Section on Gynecology and Obstetrics of the
Academy of Medicine, January 25, 1916.

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

upon the premises: First, that a low grade of heat, about 45-50° C,
will kill carcinoma tissue, while living connective tissue and muscu-
lar tissue will survive. Second, that low degree of heat will penetrate
much farther than high.

His first premise, he assumes from a study of above-mentioned
experimental work of Haalard, Clowes, and Loeb. His second prem-
ise is deduced from experimental results obtained on pieces of dead
beef.

Percy found that with a very hot iron carbonization of the sur-
rounding tissues occurs, preventing heat conduction, and that coagu-
lation occurs only for a distance of J^ inch from the iron. On the
other hand, with a low grade of heat, coagulation occurs for a dis-
tance of 23.^ inches in all directions from the cautery iron. He has
devised a cautery which is attached to a rheostat so that he is able
to control the heat in the iron. He performs a laparotomy, ligates
on both sides the ovarian, and either the uterine, or internal iliac

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

arteries. The assistant then grasps the uterus in his hand and
through a water-cooled vaginal speculum the cautery is applied to
the neoplasm. The temperature of the iron should be so low, that
no smoke is produced, and that a gentle simmering of the tissue
occurs. It should take about one-half hour for the heat to pene-
trate to the periphery of the uterus. If the heat transmitted
through the uterus, causes discomfort, it is a sign that there is too
high a temperature. The assistant's hand also, acts as a gentle guide

Fig. 2. — Arc;i of mlliinimaloi\ rtaLl

to the iron. The cauterization is continued until the uterus is
movable, and all parts have been well exposed to the heating-iron.

Boldt, in a recent number of the American Journal of Obstet-
rics (Jan., 1916), has published a report of an autopsy of a case that
died eight days after the Percy operation. The cause of death was
general peritonitis. He stated that there were numerous viable
cancerous cells present in the uterine wall. In the uterine cavity an
eschar had liecn formed, a definite line of demarcation separated it

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

from the remainder of the uterus. Passing from the eschar toward
the periphery of the uterus, several zones were noted: i. A narrow
hemorrhage zone, with numerous inflammatory, fragmenting, and
seminecrotic cells scattered through it. 2. This zone gradually
passed into an inflammatory area where there were numerous poly-
and mononuclear leukocytes. 3. Beyond this, an area where the
cells of the mvometrium were viable but no living carcinoma cells.

Fig. 3. — Low-power view. Complete necrosis al lower right corner,
portion of field are numerous nests of cancer cells.

.At upper

4. A zone containing nests of cancer cells with nuclei and proto-
plasm well stained are observed in the myometrium, they show no
evidence of injury.

He concludes that there is no evidence that low grades of heat are
more efficacious than high-temperature cauterization.

REPORT OF author's CASE.

Woman, aged forty-three, admitted to Dr. Pool's service at the
New York Hospital on November 6, 1915.

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

Present Illness.— About July 26, 1915, patient was taken witn a
profuse flowing of blood from the vagina. It persisted for four
weeks. There were large clots of blood passed. After the cessation
of the hemorrhage there has been an intermittent bloody discharge
persisting to date. On admittance, patient complained of no pam
in the lower abdomen, but has pain in both "kidney regions." Had
no hematuria. General health good otherwise.

Menslnial History.— Beg^n at thirteen years. Always irregular,
occurring every two to seven weeks. Never dysmenorrhea or ex-

FlG. 4. — Area showing inaikcU UlUl

luscle and carcinoma cells.

cessive bleeding. Has had one pregnancy, perineum was lacerated
at that time and repaired. No miscarriages.

Past and Family Histories.— Unimportant.

Physical Examination.— V^ry obese woman, looks very anemic
and washed out, yet does not look acutely ill. General physical exami-
nation negative except for marked pyorrhea alveolans.

Pelvic Examination. -Ctrvix markedly lacerated and shows large
cauhflower-like growth on both lips. The tumor is soft, f"able and
bleeds easily. The fundus is fixed in the pelvis and there is marked

BANCROFT: REPORT ON A CASE OF CARCINOxMA UTERI

induration in both broad ligaments extending to the lateral pelvic
walls. No glands could be palpated in the iliac region.

Operation. Incision. — Right median from umbilicus to pubis.
Intestines were displaced upward by stringed pads. Through a
small slit in the peritoneum, the internal iliac artery was exposed.
A guy suture was placed about the ureter, for retraction and the
internal iliac artery ligated immediately next to its origin from the
common iliac, first on the right side, and then by a similar procedure

•\

Fig. 5. — Low power. ( an in.ima nests with nuclei and cell borders in fair
state of preservation. Surrounding connective tissue edematous. Fragmenta-
tion of nuclei-cell borders indistinct.

on the left side. The infundibulopelvic ligaments were then ligated,
and both tubes and ovaries were removed. The patient was then
brouglu down to the edge of the table and placed in the lithotomy
po.sition with wet towels over the abdominal wound.

Gradual manual dilatation of the vagina was performed untU it
was large enough to allow the entrance of a water-cooled speculum;
then with the assistant's hand on the uterus, an electric cautery of
the type advised by Percy, at a low grade of heat was applied to the
cervix. Bv this gradual cauterization, the carcinomatous tissue was

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

slowly destroyed so that it enabled the iron to penetrate almost to the
fundus of the uterus. After cauterizing for fifty minutes and when
the uterus felt to be soft, and the iron had gone up as far as seemed
advisable, the cautery was removed and the abdominal wound closed
injayers by the assistant.

Anesthesia. — Gas and ether. Time one hour and forty minutes.

Condition. — The patient left the operating room in a fair degree of
shock. She seemed to rally toward evening, and the first morning
after operation seemed in fair shape. Later in the afternoon, how-

FlG.

-Hif;li-1

iiw of Fig. 5.

ever, her temperature, pulse and respiration became worse and she
died about noon the following day.

No physical signs of hemorrhage or peritonitis.

The following is the report of the autopsy performed by Dr. Elser
of the New York Hospital.

Autopsy. Inspection. — Body of a very obese, well-developed,
rather short female. Rigor mortis absent e.xcept in legs. Post-
mortem lividity slight. Skin presents nothing unusual apart from

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

a recent sutured wound in median line of abdomen extending from
umbilicus to just above symphysis. Panniculus very abundant.
Musculature dark red in color, fairly well developed. Bony frame
normal. Superficial lymph nodes not palpable. Eyes, pupils
equal, moderately dilated, conjunctivae normal. Nose, mouth,
external ears present nothing unusual. Neck normal. Chest
symmetrical and well developed. Breasts large, cut section presents
nothing unusual. Abdomen moderately distended. Recent su-

Fig. 7. — Carcinoma cells well preserved. Connective tissue edematous. Nuclei
stain poorly. Cell borders indistinct.

tared wound as described above. External genitalia and extremi-
ties normal.

Peritoneum smooth and glistening throughout. No evidences of
peritonitis. Adhering to some of the coils of the small intestines
there are a few fragments of clotted blood and a small amount of
clotted blood is found in the pelvis. Mesenteric, omental and peri-
renal fat is very abundant. The fat in the neighborhood of the
tail of the pancreas shows a few small areas of fat necrosis.

Pleura. — -Normal apart from a few firm adhesions over right lower
lobe.

BANCROFT: REPORT ON A CASE OF CARCIMOMA UTERI

Thymus. — Absent.

Pericardium. — Normal.

Heart. — Heart small, weight lo ounces. Consistence unusually
soft and flabby. Right chambers are filled with clotted blood. Left
chambers contain only a small amount of clotted blood. Myocar-
dium pale red in color, very soft and friable in consistence. No
focal lesions.

Valves and orifices normal throughout. Arch of the aorta and
coronaries normal.

Fig. 8. — Cancer nests will

unaffected. Reticular structure.

Ltiiigs. — Both lungs are congested and edematous. No focal
lesions. Bronchi filled with a frothy fluid. Mucosa congested.
Bronchial nodes slightly swollen and edematous. Pulmonary
vessels normal.

Spleen. — Weight 5,^^ ounces. Capsule normal. Cut section pale
grayish red in color. Malpighian bodies small and indistinct.
Trabeculse not prominent. Pulp softer than normal.

Suprarenals. — Normal in size and appearance.

Kidneys. — Normal in size. Weight Sj-o ounces. Capsule strips

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

readily leaving a smooth pale red, somewhat opaque surface. Con-
sistence normal. Cortex normal in thickness. Markings fairly
distinct. Pyramids normal. Pelvis, ureters and bladder normal.

Pancreas. — Normal in size and appearance.

Liver. — Weight 2)^ pounds. Surface smooth, pale grayish red
in color. Consistence normal. Cut surface smooth, pale grayish
red in color. Markings are indistinct. No focal lesions.

Gall-bladder. — Gall-bladder is filled with dark green, rather thick
bile. Mucosa normal. Ducts patulous.

Fig. 9. — ^Cancer cells broken up. Ahirkcd edema. Surrounding muscle struc-
tures show distinct neuclei and cell outlines.

Gastrointestinal Trad. Esophagus. — Normal.

Stomach. — Stomach somewhat dilated. Mucosa is thick, has a
velvety appearance and is covered with mucus. The mucosa of
the remainder of intestinal tract is somewhat edematous and is
covered with mucus. Solitary and agminated follicles atrophic.

Appendix. — .'\ppendix presents nothing unusual. ^Mesenteric
nodes present nothing unusual.

Both internal iliac arteries have been tied off just beyond their
point of entry into the common iliac. The vessels just beyond the

BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI 21

ligatures are distended with blood. The internal iliac vein on the
left side is occluded with a fairly firm thrombus.

Ovaries and Tubes. — Absent.

Uterus normal in size. A median anteroposterior incision
dividing the uterus and vagina into halves reveals the following:
The greater part of the cervix of the uterus is replaced by an ulcerated
surface which encroaches upon and involves the upper part of the
vagina. The base of the ulcer is ragged and covered by a greenish-
gray sloughing material. Beneath this surface layer there is a
grayish-yellow, dry, finely granular, opaque zone measuring on the
average, 6 -mm. in thickness where the base of the ulcer is formed by
the body of the uterus, and diminishing in thickness and gradually
disappearing along the sides of the ulcer. Between this opaque zone
and apparently normal uterine tissue, there is a narrow congested
zone measuring from 3 to 4 mm. in thickness. The endometrium is
bluish red in color and edematous in appearance. The fundus of
the uterus presents nothing unusual apart from a small intramural
fibroid about the size of a hazelnut. A careful inspection of the outer
surface of the uterus and vagina after dissecting awaj' the adjacent
structures fails to reveal any changes which might be referred to
overheating of the structures. In dissecting the uterus from the base
of the bladder one passes through cancerous tissue. The bladder
wall proper shows no macroscopic cancerous involvement.

Films made from the ulcerated surface show an enormous number
of bacteria of various kinds, numerous Gram-positive cocci and
Gram-positive and Gram-negative bacilli of various sizes and shapes.

Concerning the actual cause of death in this case, there is some
doubt. The most probable diagnosis is sapremia or toxemia,
which accords with the symptoms of intoxication observed during
life. Of the internal organs, the heart shows the most marked
changes which might be attributed to the action of toxic agents.

Microscopical Examination of Utertis. — Proceeding from the center
toward the periphery five zones may be observed:

First, an area of necrosis of all the tissues — the eschar.

Second, an area of seminecrotic carcinoma and connective-tissue
cells, there is a moderate degree of edema in this region and there is
a very marked infiltration of polymorphonuclear leukocytes with a
relatively small number of mononuclear leukocytes. This is the
zone of inflammatory reaction.

Third, areas of carcinoma nests and muscular tissue. Here the
greatest variation of degree and type of reaction to the heat exists.
In places there are nests of well- organized carcinoma cells sur-
rounded by smooth muscle fibers that have lost their nuclear stain
and are infiltrated with edema — other areas show carcinoma cells
and muscular cells in equal stages of degeneration, while still other
areas show nests of carcinoma cells separated by edema — with
indistinct cell borders, and poorly staining nuclei. Numerous poly-
morphonuclear cells are seen in these nests, while the surrounding
smooth muscle cells seem very little affected. These various areas
are so interspersed that it is difficult to explain why in one area

22 BANCROFT: REPORT ON A CASE OF CARCINOMA UTERI

carcinomatous cells are more injured than the muscular cells, and in
others the muscle cells seem to have received the bulk of the injury.
In this area the capillaries are everywhere engorged with blood.

Fourth, an area of edema occurring in the region of the arcuate
arteries at about the junction of the outer and middle thirds of the
muscular walls of the uterus. The arteries are shrunken and are
only partly filled with blood, the veins are distended, the edema in
this region is very great. The smaller blood-vessels show hyaline
degeneration of their walls and the tissues in immediate proximity.

Fifth, muscular tissue distended by edema but otherwise unin-
jured, the edema extends to the peritoneum.

Microscopical sections of the internal iliac vein show thrombosis,
careful search of a section stained by Gram method failed to reveal
any bacteria. There is a slight infiltration of the clot by leukocvtes.

The liver shows evidence of acute congestion. The kidney shows
parenchymatous degeneration. Blood cultures taken from spleen
were sterile at the end of forty-eight hours.

Conclusions. — There is a mortality associated with the Percy
operation. The author's case died with symptoms pointing toward
a severe toxemia, and as the autopsy revealed no lesions due to
error in technic, the cause of death must be attributed to the opera-
tion itself.

A patient undergoing this operation is under the influence of the
anesthetic from one to two hours. She frequently suffers from shock
and the postoperative course is usually associated with a rise in
temperature to 103° to 104° F. for several days. Salpingitis, pelvic
abscess, and peritonitis are occasional complications. If the neo-
plasm has involved the bladder, a vesicovaginal fistula may occur.

As a therapeutic agent, the Percy operation must be considered
with radium and x-ray. It is unfortunate that no definite figures
showing the postoperative results of a large series, have been
published. Until this is done, it is impossible to compare its end
results with those derived from treatment with radium and .v-ray.

Percy claims that it stops the hemorrhage and offensive discharge.
He even thinks a few cases will go as long as five years without a
recurrence.

If the patient survives the operation, the sequeke are not severe,
on the other hand, while there is no immediate mortality to radium,
there are occasionally distressing, late complications such as severe
rectal tenesmus, proctitis, and rectovaginal fistulje. Radium
workers are most enthusiastic in regard to the results of treat-
ment, and time alone must decide the relative value of the three
procedures.

The main facts concerning the findings from the microscopical

fullerton: the significance of s\'philis in obstetrics 23

examination, may be summarized as follows: Certain islands of
cancer cells show advanced degenerative changes, reaching in many
instances, stages of necrosis and disolution. Others show milder
grades of degeneration, and still others have apparently not been
affected by the treatment.

The latter cells have all the appearances of viable carcinomatous
structures, but concerning the ultimate fate of even these well-
preserved cells, I do not wish to commit myself.

The intervening structures (I refer to the musculature and con-
nective tissue surrounding the island of cancer cells) have not wholly
escaped injury. I wish to make a special point of this factor, because
in reading over Percy's article, I was led to believe that the connec-
tive-tissue structures escaped injury almost entirely. My own ob-
servations, made it is true, on a single case, do not support this con-
tention. No claim is made that this controverts the excellent
experimental work of Haaland, Clowes, andLoeb, and the findings
observed by some a;-ray workers.

In a case such as this, too many extraneous factors must be con-
sidered such as: First, the difficulty of determining the viability of
the cells by their microscopic appearance. Second, the uncertainty
of knowing the exact temperature of the cautery, and third, the
influence exerted by infection, must be considered.

The author wishes to thank Drs. Pool and Isler for the privilege
of reporting this case.

8 East Fifty-fourth Street.

THE SIGNIFICANCE OF SYPHILIS IN OBSTETRICS.*

WM. D. FULLERTON, PH. B., M. D.,

Cleveland. Ohio.

(With four illustrations.)

The great importance of the role played by syphilis in the fre-
quent tragedies of reproduction, is only imperfectly understood and
not fully appreciated by even the most capable of medical investi-
gators. The negligible understanding or appreciation by the
immense audience of mankind for these tragedies is almost entirely
due to their ignorance, for which we. the medical profession at large,
are primarih' responsible.

The position of the medical profession as guardian of the public's
health, is the highest, most responsible and exacting, with which

*Read before the Cleveland .\cademy of Medicine, Jan. 7, 1916.

24 fullerton: the significance of s\thilis in obstetrics

any body of men could be honored. That this position carries with
it a vastly greater obligation than merely administering to those who
are already ill is clearly realized by both physician and public.
This is made evident by the great work being done by the medical
profession in preventive medicine, which includes research and ex-
perimental work, public hygiene, the recent marked attention paid to
occupational diseases, etc., in all of which labors they are given the
cooperation and means, not only of a few far-seeing institutions and
philanthropists, but of the public at large, through the approval and
support of their civic and state legislative bodies.

To insure public health and lower mortality, an enormous amount
of work is being done in obtaining better water supplies, pure food,
better milk, proper sewage disposals, reducing or eliminating occu-
pational and parasitic diseases, confining contagious diseases, and
reducing infant mortality through teaching activities and the very
ef35cient social service workers. In all of these vital movements the
medical profession has proven its efficiency in combating existing
detrimental conditions, and it is therefore singular, that it has done
so little toward diminishing the ravages of this noxious disease in
conjunction with pregnancy, during which period it is particularly
pernicious.

The failure of physicians to give the public a comprehensive
understanding of the significance of syphilis in reproduction is due
in part to their reluctance in speaking of either subject in public,
and to their timidity in questioning their patients on the possibility
of syphilis being the cause of disaster. The public is rapidly over-
coming any false modesty or prudishness in this regard, as is evi-
denced by the popularity of such plays as Brieux's "Damaged Goods,"
and, as to the patient, the physician having secured her confidence
may with tact almost invariably enlist her aid in working out a
correct diagnosis. It is of course essential that the physician realize
the prevalence and significance of syphilis during prengancy, and
that he be familiar with the more usual signs, symptoms and means
of diagnosis, which he should constantly look for and apply in his
obstetric practice.

Judging from my own observations and those of others, I feel
that many physicians do not realize the gravity of the situation, and
that they frequently overlook pathognomonic evidence of the dis-
ease, which if always borne in mind, would explain many of their
undiagnosed cases and change their diagnoses in many others.

It is my purpose therefore, though I claim nothing new, nothing
original, to put before you as briefly as possible a few reliable facts

FULLERTON: the significance of S\-PHILIS IN OBSTETRICS 25

regarding the association of syphilis and pregnancy, which I trust
may be of some use to all of you, and of great use to some of you.

The subject can be more comprehensively presented under the
several subheadings which I shall make, and concluded with a few
suggestions which, if followed, will aid in decreasing the prevalance
of this wide spread obstetric complication.

EFFECT OF PREGNANCY ON THE DISEASE.

When a' woman acquires syphilis during pregnancy, the initial
genital lesion, because of the increased vascularity, is usually larger,
more moist, softer, and more persistent, often lasting for twelve
weeks. Although the so-called secondary manifestations are fre-
quently scarcely noticeable (i),(2), they may develop earlier, and
be more pronounced than usual, the papules being larger, and the
pustular forms being more common at this time (3). The second-
aries on the vulva are the most pronounced; they are larger, more
persistent and prone to ulcerate. The constitutional symptoms are
more pronounced; the glandular enlargement is more marked; fever
is more common and slightly higher; and anemia and digestive dis-
turbances of a more severe degree are met with. Unexplained neu-
ralgias are common.

Tertiary S3^hilis is less affected by pregnancy than are the early
stages, although exacerbation of symptoms are common, quiescent
lesions may light up, and negative Wassermann test become positive
where there is no question of reinfection (which I believe to be ques-
tionable at any time).

It is now quite well agreed that syphilis must be active to give a
positive Wassermann reaction, and that a negative reaction does not
rule out a specific infection or indicate a cure. Accumulating clin-
ical experience shows, as Keys(4), Nonne(5), Boas(6) and others
have recently emphasized, that the Wassermann reaction is not
always reliable; a positive reaction, however, being more valuable as
an indication of the presence of syphilis than is a negative reaction as
marking its absence. This is particularly true of pregnant women,
who, before or early in pregnancy may give a strongly positive reac-
tion, and who without treatment, frequently give a progressively
weaker reaction as they approach term, about which time they may
give a negative reaction, and then within a few months following
delivery the reaction may again become strongly positive.

EFFECTS OF THE DISEASE ON PREGNANCV.

Without question syphilis is the most common disease met with
during pregnancy. The frequencj' of its occurrence is difficult

26 fullerton: the significance of syphilis in obstetrics

to estimate from the meager statistics on the subject, but from a
study of 10,000 consecutive cases, Williams(7) shows its presence in
over 3.5 per cent, between the seventh and tenth month, and this
figure would probably be increased to 5 per cent, if earlier and later
cases were taken into consideration.

Mall, Pearson and others, estimate that for every 1000 live-born
children there are 500 to 600 stillbirths; that is, products of gestation
expelled between the time of conception and the period of viability
(seventh month), or at a later period if born dead. (These figures
include very few, if any, induced abortions.)

SyphiUs is one of the most frequent causes of abortion and pre-
mature labor, 42 per cent, according to Morrow, and when such ter-
minations, especially the latter, are noted repeatedly in the same
patient, syphihs should always be suspected. The more recent the
infection and the more \drulent the disease, the earlier is the preg-
nancy interrupted. Frequently each succeeding pregnancy pro-
gresses a little closer to term before interruption, the women finally
giving birth to a full-term syphilitic child which usually dies in
infancy, and eventually to a child apparently normal, which may
or may not show the disease at a later period(8) .

When the disease was contracted many years previous to, or late
in the pregnancy, the effects on the pregnancy and the fetus are less
pronounced, and more often absent than when infection occurred
nearer the time of conception. Here it might be well to mention that
Mu]ler(9) has noted that only 15 to 20 per cent, of untreated women
who bore luetic children some years ago, give positive Wassermanns.

Syphihs is a common cause of sterility in either the male or the
female, Nonne's material(io) showing a 10 per cent, sterility in
syphilitic unions; where the graver lesions, as paresis, are present,
Haskell(ii) has reported a 45 per cent, sterility.

In eighteen syphilitic families Fournier counted 151 pregnancies
of which 85 per cent, ended in stillbirths, and Lepileur has stated
that the stillbirths in 130 women were increased from 3.8 per cent,
before infection, to 79 per cent, after infection. In Baltimore,
syphilis was found by Williams(7) to be the most common cause of
fetal death of children born after the seventh month and dying within
two weeks after birth. Of these deaths 26.4 per cent, were due to
S3T3hilis. Slemons(i2) on the Pacific Coast has recently confirmed
these figures. If we consider the premature children alone, syphihs
was the cause of 40 per cent, of their deaths. These figures do not
include macerated fetuses, of which fully 80 per cent, are generally
admitted to be syphilitic.

fullerton: the significance of syphilis in obstetrics 27

Labor is not materially influenced by syphilis. The contrac-
tions are sometimes poor; abnormal presentations are more common
because of the prematurity and frequent fetal maceration; induration
of the cervix from primary or secondary lesions may retard its dila-
tion; friabilit}' of the perineum is more marked and is increased by
vulvar cond\'lomata; however, the smaller size of the children and
ready healing of wounds, fully compensates for these occasional com-
pUcations due to syphilis.

M.A.TERN.A.L SYPHILIS.

Luetic women contribute to the frequent sterility of their union
through both ovular and endometrial changes, though these cannot
be specifically differentiated. Ovarian function would seem to be
continued, but in all likelihood either the ovum is Hberated from the
Graafian follicle in an unfertihzable condition, or, escaping this
change, it is fertilized, but on reaching the uterine chamber finds
the endometrial bed unsatisfactory for its implantation.

The nearer the time of conception the woman acquires her lues
the more certain is her child to be syphilitic and either aborted, born
prematurely, or at term with evidence of the disease. Even though
the mother acquire her infection in the last month of pregnancy,
according to Finger (13), her child acquires the disease before birth
in over half the cases. In Fournier's private practice, 44 pregnancies
in as man}^ women affected with recent syphilis, resulted in 43 fetal
deaths. He also states that 90 women infected by their husbands
became pregnant in the first year of married life, which he terms
I'annee terrible from the viewpoint of heredity, of these, 50 pregnan-
cies terminated by abortion or stillborn infants, 38 in the birth of
children which soon died, 2 in the birth of children who survived.

CoUes' law, 1837, states that a nons\-philitic woman may bear
a sj-phihtic child, by which through nursing, she cannot be infected.
This would admit of paternal infection of the fetus without maternal
infection, a theory to which the majority of recent observers are
strongly averse. Among their arguments upholding this objection
is the physical impossiblity of the spermatozoon containing the
Treponema within its head, the latter being three times the size of
the former; and also for the same reason, to the mere mechanical
transportation of the Treponema to the uterine cavity by the sper-
matozoon. However, accession to the uterine cavity by the spiro-
chete of the father needs no other explanation than their recognized
motility, by which means it can be readily understood, how, on being
carried to the upper vagina or cervical canal in the semen (14), it

28 fullerton: the significance of s^thilis in obstetrics

makes its own further ascent, and infects the mother either directly
through the endometrium or indirectly through the placenta.

Among clinical observations showing that fetal syphilis is rarely,
if ever, seen without maternal syphilis, is the fact that the mother of
a sj'philitic child may nurse her infant without showing signs of
subsequent infection, whereas the child would certainly infect any
nonsj'philitic woman. The explanation of this phenomenon is
that the mother is already luetic, although without having shown any
secondary lesions, but, nevertheless, infected, as is shown by her
Wassermann reaction, which Reitschel (25), Ledermann (26), and
others have shown is positive in 75 to 100 per cent, of such women,
and also by other immediate or latent clinical evidences of the dis-
ease. Such women will subsequently bear syphilitic children en-
gendered by a nonsyphilitic man. These mothers have not acquired
immunity, they have contracted the disease, and the finding of latent
tertiary lesions and even the spirochetae themselves in her body
tissues and secretions, quite definitely prove this point.

Instances are seen which would tend to show the admissibility
of Profeta's law, which states that a syphilitic woman may bear a
nonsyphilitic child. We have no absolute proof that these children
are not infected, but when we are not able to discover in them any
signs of the disease, and after years of observation no latent evidences
are observed, we conclude that they were not infected before birth.
Such cases, however, are comparatively rare and limited to instances
where maternal infection was acquired years previous to conception,
or else very late in pregnancy, though in the latter instance Finger
has shown that over half the children are infected before birth.
If the child becomes infected during the last few weeks before birth
there may be no clinical manifestations of the disease and the
Wassermann will usually be negative, as the time has been too short
for either to develop, both, however, will develop at a later period.

Syphilis, unrecognized in the male or female of the second gen-
eration, may be conveyed in a marked form to the third generation.

paternal syphilis.

The wives of 50 per cent, of paretics were found by Haskell(ii)
to be syphilitic and in them the disease usually existed as unrecog-
nized latent lues.

If the father be in the primary or secondary stage of the disease,
the wife is almost invariably infected with the consequences stated
above.

fullerton: the significance of s\t>hilis in obstetrics 29

The greater the period of time between paternal infection, and
marriage, the less likely is the husband to infect his wife. Even
though the husband is markedly luetic he may not immediately
infect his wife or beget a syphilitic offspring, and these statements
are borne out by the findings of Fournier, that with paternal syphilis
the offspring is infected onh^ half as often (37 per cent.), as when the
mother alone is infected. This also shows the relative danger of
maternal and paternal infection. When both parents are infected
the fetal mortality varies from 68 to 100 per cent.

FETAL syphilis.

Syphihs has been ascribed as an etiological factor in spina bifida,
hydrocephalus, icterus neonatorum, hemorrhagic disease of the
new-born, congenital defects, and so on, but it is probable that the
disease is more often coincident than etiological. As previously
stated, the syphilitic fetus is usually born prematurely, often still-
born and frequently macerated, and these factors alone, when met
with, should always arouse the physician's suspicions. Luetic
children either stillborn, premature, or at term, commonly show
evidences of the disease, among which the following are most
common.

The child is underdeveloped for the duration of pregnancy and
there is a marked decrease of subcutaneous fat, which gives it a
shriveled, wizened appearance. The skin is coarse, dry, drawn,
friable and of muddy yellow color. On the flexor surfaces, particu-
larly of the elbows, knees, and groins, the skin is ver}- apt to crack
and expose the corium, which, if the child be macerated, is of
reddish-purple color. On the palms of the hands and soles of the
feet the skin is often thick and glistening, and here especially, arc
macules and bullae most frequently seen. Macular and papular
cutaneous lesions, reddish-brown erythema of the buttocks and
pemphigus are often seen. Mucous patches in the mouth and nose,
also around the anus and vulva, and hemorrhages from the mucous
membranes, especially the nose, are not uncommon. Fissures of
the lips and anus are common. Of the visceral changes the more
common are the enlargement of the liver and spleen, the former may
equal one-tenth the body weight. In both of these organs there is a
marked increase in fibrous connective tissue and a small round-cell
infiltration. The liver shows a fatty change of the parenchymatous
cells. Ascites is not infrequently met with(i5). The lungs are
enlarged, heavier than normal, and show an increase in connective

30 ruLLERTOx: the significance of syphilis in obstetrics

tissue with round-cell infiltration. Frequently their alveoli are
more or less filled with desquamated degenerated epithelial cells.
There is a marked and characteristic thickening and irregularity of
Guerin's line (junction of the epiphysis and diaphysis of the long
bones), and of this I might mention that the .x-ray will give a very
satisfactory picture.

Spirochetae are found in great numbers in the liver, lungs, heart
and great blood-vessels, and failure to demonstrate them in these
tissues is due to faulty technic. For most satisfactory demonstra-
tion, the tissues should be immediately hardened in lo per cent,
formalin, and subsequently impregnated with silver nitrate according
to Levaditi's original method.

The syphilitic child may exhibit no lesions at the time of birth
but develops them later, usually within eight weeks, the so-called
late congenital lues. With this condition, coryza (snuffles), pem-
phigus and cutaneous eruptions, paronychia, marasmus, restlessness,
sleeplessness, mucous patches of mouth, anus or vulva, glandular
enlargement, etc., are of the greatest significance.

Raven(i6), Boas(6), and Mijller(9) have all pointed out that
very often new-born syphilitic children give negative Wassermann
reactions which later usually become positive. A possible explana-
tion of this fact is that immunizing bodies are not transmitted
through the placenta from mother to fetus, neither are such bodies
formed by the fetus until about the eighth month(24). Roux
emphasizes that this fact should be borne in mind and not lead one
to err in making a diagnosis. The percentage of positive reactions
increase with the age(i7), and the blood should not be taken before
the tenth day.

The large majority of syphilitic infants die in early childhood,
Hyde reporting that ii6 of 121 such children perished within the
first year, which figures, however, would seem above the average.
Fournier(i8), considering all children resulting from syphilitic unions,
collected 1500 cases from different sources which gave a fetal
mortality of 68 per cent., and of 77 per cent, in 491 of his own cases.
In both series all cases were included, even the most favorable.

The child of a syphilitic mother or father should never be nursed
by a nonsyphilitic woman, for, although it may show no signs of
the disease, it is almost always infected and will infect a healthy
wet-nurse. Neither should a syphilitic woman, or the mother of an
infected child, act as a wet-nurse, for her milk contains spirochetae
and will infect a healthj' child(i9). A syphilitic woman may nurse
an infected child with impunity for liersclf and her charge.

fullerton: the significance of syphilis in obstetrics 31

Luetic individuals may not show evidences of the disease until
it is exhibited as late congenital syphilis, wliich may be first recog-
nized as late as twenty-eight or forty years according to Fournier
and Oppenheim(2o) respectiv^ely, the maximum number of cases
being at ten to fifteen years.

Lack of space forbids discussion of the evidences of late congenital
lues, but among the more common I may mention interstitial
keratitis, epilepsy, idiocy and imbecility (17 to 60 per cent, as given
by different authors), chorea, cardio-vascular disease, skeletal
deformities as "saber legs," "scaphoid scapula" and "saddle nose,"
osteomyelitis, nephritis, perforation of the nasal septum or soft
palate, gummata, Hutchinson's teeth, psychopathic disorders, etc.

Placental Syphilis.

Syphilis produces many characteristic, if not pathognomonic
changes in the placenta, which, however, may vary in degree, so that
although a diagnosis may usually be made without difficulty,
occasional cases are met with which are of a border-line type and
require the clinical history, etc., to aid in the diagnosis.

In the more characteristic cases the placenta is increased in size
for the duration of pregnancy; its normal ratio of one-sixth to one-
eight the weight of the child may be increased to one-fourth or more.
The placenta is pale, fatty, edematous and of a yellowish tinge, and
if the child be macerated, is dull and greasy in appearance. Pro-
nounced infarction is a common finding. As observed by Frankel(2i)
in 1873, fresh specimens teased in saHne solution show marked
changes of the chorionic villi, which exhibit a decreased arborescence,
they are thickened and irregular in size, the ends of many villi show-
ing a distinct clubbing, and their vascularity is markedly decreased.
(Compare Figs, i and 2.) In section, besides the above-mentioned
changes, there is seen an increase in the density of the stroma, the
cells of which have lost their stellate appearance, are more closely
packed, are oval or rounded in outhne and resemble connective-
tissue cells. The blood-vessels are greatly decreased in caliber by an
obliterative endarteritis and an increase in the density of the stroma.
(Compare Figs. 3 and 4.) This latter change is often seen in the
umbihcal vessels, and in both locations is of great importance in the
production of the extensive placental infarction so commonly seen,
which in turn, at least in part, by diminishing the blood supply,
accounts for the poor development and frequent death of the fetus
with premature expulsion.

32 fullerton: the significance of syphilis in obstetrics

With proper technic, spirochete are not difficult of demonstration
in the placenta. As shown by the work of Wallich and Levaditi(22),
Schultz(23), and others, they are always present if the child is
syphilitic and should always be sought for if there is any question
of diagnosis.

I II I Xormal placenta at terra, fresh specimen teased in normal saline.
J he \illi .lie uniform and equal in diameter, their ends are rounded and show
no clubbing. The tissue is not dense though the vessels are not so distinct as
are often seen. (loo diameters.)

TRE.A.TMENT.

How soon after infection may a s_\-pliililic marry with reasonable
assurance of healthy offspring? Such a question is of vital impor-
tance and extremely difficult of a general answer. However, the
dictum of pre-Wassermann daj-s, that after five years of the disease
during the first three of which he had taken treatment, and during
the last two of which he had had no treatment, and shown no signs

fullerton: the significance of syphilis in obstetrics 33

of the disease, has proved to Keys(4) and many other observers
to be quite dependable. Although the Wassermann is less often
positive after such a course, it is, nevertheless, frequently persistent,
indicating the presence of active spirochetae in the body but not
their infectiousness. Therefore a persistent Wassermann is not a
contraindication to marriage if the above requirements have been
fumiled.

Fig. 2. — Syphilitic placenta about term, fresli specimen teased in saline.
There is less branching than in the normal, the villi are irregular in diameter,
some being quite thick, and the ends of many are distinctly clubbed. The villi
are irregular in outline and so dense that the blood-vessels cannot be seen

(loo diameters.)

With active treatment the Wassermann may become negative in
the first year of the disease, but this does not mean loss of infectious-
ness or the permissibility of marriage, as the Wassermann often
again becomes positive and clinical observations show frequent
infections.

WTienever a historv or evidence of the disease is discovered in

34 pullerton: the significance of syphilis in obstetrics

either parent, he or she should be put on vigorous specific treatment
irrespective of the presence or duration of any pregnancy. The
burden of proving the absence of infection in the mate of a syphiUtic,
is on the shoulders of the physician. Should the mate show evidence
or probability of the disease, similar treatment should be adminis-
tered.

Fig. 3. — Normal placenta at term, celloidin miUoi,- m.liik.I \mi1i liLina-
lo.xylin and eosin. Note the marked regularity in diameter and the pronounced
vascularity of the villi. The stroma is light and reticular in structure. (100
diameters.)

Salvarsan is more particularly useful in cutting short the primary
and secondary stages of the disease, but mercury and potassium
iodide should always be used for the imperative prolonged treatment.

Fortunately all of these drugs are transmitted to the fetus by the
placenta, by which means effective treatment may be administered
to the child in iitcro. .\fter birth the child should be treated indi-
vidually, inunctions of mercury being most satisfactory. The

fullerton: the significance of syphilis in obstetrics 35

mother should always continue treatment and nurse her syphilitic
child, who will obtain these specific drugs through her milk.

suggestions for minimizing the effects of syphilis from an
obstetrical viewpoint.

All physicians practising obstetrics should become familiar with
the signs and symptoms of syphilis in the placenta, fetus, and young

I-'iG. 4. — Syphilitic piairnla >liciHinu' rxirinic changes, celloidin sections
stained with hemato.xylin and eosin. Note the huge irregular villi, their dense
stroma of connective-tissue-like cells and the great decrease in vascularity.
The blood-vessels show beautifully the obliterative endarteritis. (100 diameters.)

children, as well as with the suggestive histories of the parents of
such children. The history of every pregnant woman should be
taken as early as possible in her pregnancy, and special emphasis
should be laid on her past history relative to evidence of infection,
such as genital sore, rash, sore throat, abortions, miscarriage, pre-

36 fullerton: the significance or syphilis in obstetrics

mature labor or the birth of children dying in early childhood, or
living with evidence of the disease. Whenever infection is in the
least suspected, the patient should be carefully examined for evi-
dence of the disease and a Wassermann made. In such cases the
husband should also be examined, and if found infected he should
be treated.

Every new-born child should be examined and watched for any
evidence of infection. Every placenta should be weighed, examined
macroscopically, and at least a freshly teased specimen examined
microscopically for evidence of the disease.

Especially in all obstetrical clinics, including both hospital and
out-door services, the same precautions should be taken, and the
careful examination of every placenta, both fresh and sectioned,
should be a part of the routine laboratory work. Special staining
for the Treponema should be done whenever infection is strongly
suspected, and thorough autopsies, whenever available, would be
most instructive.

Every case showing evidence of the disease either before or after
labor, should be impressed with the importance of continued treat-
ment. Charity cases should be referred to a free dispensary for
treatment and if they do not report regularly, the visiting nurses or
social service workers should exert their influence, enforced if neces-
sary by civil authority, to compel these patients to take treatment.

422 OsBORN Building.

LITER.A.TURE.

1. Williams, J. W. Text-book of Obstetrics, iqoS, 486.

2. Nonne, M. Syphilis und Nervensystem, Karger, Berlin,
1909, 546.

3. De Lee, Joseph B. The Principles and Practice of Obstet-
rics, 1913, 482.

4. Keys, Ed. L., Jr. Jour. A. M. A., 191 5, l.xiv, S04.

5. Nonne, M. Deidsch. Ztschr. f. Xervenlieilk, 191 1, xlii, 206.

6. Boas, H. Die Wasserman'sche Reaktion, Karger, BerUn,
1914.

7. Williams, J. W. Jour. A. M. A., 1915, Ixiv, 96.

8. Haberman, J. V. Jour. A. M. A., 1915, Ixiv, 1141.

g. Miiller, R. Deutsch. mcd. Wchnscbr., 1913, No. 45, 2229.

10. Nonne, M. Quoted by Haberman(8) .

11. Haskell, R. H. Jour. A. M. A., 1915, Ixiv, 890.

12. Slemons, J. Morris. Jour. A. M. A., 1915, l.xv, 1265.

13. Finger. Zeiitralbl. f. Gyn., i8g-j, No. 40, 1211.

14. Bab. Zentralbl. f.Gyn., iqoq, •,2-].

15. Fabrc et Bonnet! Abst. by Surg. Gyn., OI)st., 1915, .xx, 256.

16. Raven. Quoted by Haberman(8).

17. D'Aslros et Teissoniere. Marseille Med., 1912, xxii, 23.

REICH: VAGINAt-SUPRAVAGINAL HYSTERECTOMY 37

i8. Fournier, A. Treatment and Prophylaxis of Syphilis, p. 341,
Rebman, N. Y., 1907.

19. Uhlenhuth and Mulzer. Quoted by Friihwald; Dermat.
Wchnsclir., 1914, lix, 1319-

20. Oppenheim. Lehrbuch, Ed. 6.

21. Frankel. Archiv f. Gyn., 1873, v, i.

22. Wallich et Levaditi. Annates de gyn. et d'obsl., 1906, iii, 65.

23. Schultz, O. T. Jour. Med. Research, 1906, x, 363.

24. Trinchese, J. Deutsch. med. Woch., 1915, xli, No. 19, 545.

25. Reitschel, H. Med. Klin., 1909, No. 18, 658.

26. Ledermann, R. Deutsch. med. Wchnsclir., 1914, xl, 176.

VAGIN.^L-SUPRAVAGINAL HYSTERECTOMY.*

A. REICH, M. D.,

New Y'ork.
(With two illustrations.)

Three conditions are recognized at present in which vaginal-
supravaginal hysterectomy is indicated.

1. For the removal of the products of conception during the first
four months in tuberculosis of the progressive type.

2. In the presence of fibroids or general fibrosis of the uterus where
the Wertheim-Schauta operation for prolapsus uteri cannot be done
on account of the large size of the uterus.

3. For uterine hemorrhage which endangers life; in order to
definitely check the loss of blood with least trauma and least danger
to hfe.

Martin, in 1899, unintentionally performed this operation while
doing a myomectomy through the posterior culdesac. H. W.
Freund(i) in 1902, did the operation by chance extraperitoneally, as
it is done from above to-day. His first case was a unipara with a soft
myoma the size of a child's head. The uterus was retroflexed, with
severe psychic disturbance, the patient being most rational during
menstruation. Posterior colpotomy showed the tumor to be a ball
myoma involving the entire thickness of the uterine wall. The upper
portion of the fundus had to be removed, leaving a few centimeters of
it above the internal os. The intended myomectomy resulted in a
supravaginal hysterectomy, but the stump was not covered with
peritoneum. The second case was a tripara, forty years of age.
The uterus was large and he amputated the body with the adnexa in
the classic manner, covering the cervical stump with the bladder.

* Read before a meeting of the New York Academy of Medicine, February
24, igi6.

REICH: VAGINAL-SUPRAVAGINAL HYSTERECTOMY

In July, 1908, H. von Bardeleben(2) decided, in a case of pregnancy
with progressive tuberculosis, to cut an eliptical portion out of the
top of the fundus, taking away most of the placental site leaving
only a few centimeters above the internal os. He then closed the
uterine wound with five or six interrupted sutures, fastened the blad-
der on the posterior surface of the vaginal wound in the usual
manner.

Fig. I. — Appendages and uterine arteries tied. Loop about uterr
by forceps.

sacral held

He bases his indication on the observed fact that ordinary abor-
tion, with or without sterilization produced on women with progress-
ive tuberculosis — the cases being followed for a period of sbcteen
months — ^gave a mortality of 8 to 53 per cent., while with amputa-
tion the same class of cases gave a mortality of only 5 to 6 per cent,
during the same period.

In the Wertheim-Schauta operation ihe uterus has to act as a

REICH : VAGINAL-SUPRAVAGINAL HYSTERECTOMY

supporting wedge in the urogenital diaphragm. The success of the
operation does not therefore depend entirely on the correct technic of
the fixation but also on the size of the uterus. Stockel(3) says that
under ordinary conditions he has never found the uterus too large.
In case of fibroids he, with many American operators, prefers to do
a hysterectomy and utilize the broad ligaments as the support for the

-Showing stump of uterus with stitches introduced ready lor closure of
wound.

bladder and vagina. This latter procedure undoubtedly prolongs the
operation considerably.

The Pfannenstiel wedge resection is frequently accompanied by
oozing of blood, necessitating drainage. In a number of cases second-
ary hysterectomy has had to be resorted to to check the bleeding.

Alfred Lowitt(4) reports from Fleischman's clinic eight cases of
vaginal-supravaginal hysterectomy with satisfactory results. Vine-
berg(5) has operated on a number of cases. Rieck(6) of Altona-

40 REICH: VAGINAL-SUPRAVAGINAL HYSTERECTOMY

Hamburg and Fueth(7) report good results in preserving menstrua-
tion, leaving a few centimeters of the endometrium above the internal
OS in that class of young women who after all kinds of treatment
bleed persistently and are doomed to hysterectomy no matter what
the cause of the bleeding may be — myoma, metritis, arteriosclerosis,
neurosis, or ovarian dysfunction. We all know patients who hardly
have time to recover from the loss of blood from menstruation to
menstruation.

In the most severe cases hysterectomy may be absolutely indicated
but in the moderately severe cases, and they are the most frequently
met with, we are loath, and rightly so, to induce a premature
climacterium.

The production of the cessation of menstruation is looked upon
by various operators according to their radical or more conservative
incHnation. Statistics are not conclusive. Without considering
the complaints made voluntarily by the patient, or elicited by our
direct questioning, there is a fine psychical and physical process
connected with menstruation which we cannot e.xplain by our studies
and which perhaps the women themselves are not conscious of. A
woman without menstruation is not considered as of full value, either
by men or women, and no one knows whether such a young woman
develops in a different manner, leaving out of consideration the
changes in her true feminine thought and sensation, from those who
are in possession of their given functions. It is therefore wise to cure
the woman of the excessive bleeding with preservation of the men-
struation. This is best accomplished by leaving about 2 centimeters
of the fundus above the internal os.

Rieck recommends that the fundus uteri should be cut off on a
slant, leaving the posterior wall longer, so as to give more support to
the bladder, otherwise the operation does not differ from the one
done from above.

In a case of procidentia a ± -shaped incision is made in the anterior
vaginal wall, the bladder freely separated from the uterus and vagina,
the uterovesical fold opened and the fundus pulled down into the
vagina, while the bladder is held up with a trowel. The uterosacral
ligaments are plicated, leaving the last sutures in each long. A pair
of blunt forceps is pushed through the base of the broad ligaments to
catch the last suture attached to the uterosacral ligaments and
brings them out along either side of the cervix. The bladder is
fastened to the peritoneum of the posterior uterine wall at the level
of the internal os. The round ligaments and the tubes are then
ligated and divided, or, if necessary, the ovaries and tubes can be

REICH : VAGINAL-SUPRAVAGINAL HYSTERECTOMY 41

entirely removed. • The broad ligament is pushed down and the
uterine artery tied at the side of the uterus and as much of the fundus
is cut of as is necessary to make it fit the gap comfortably. Now
suture the round and broad ligaments to the stump of the fundus,
trim the vaginal flaps and suture the vagina along the entire anterior
wall of the uterus. Tie the two sutures that hold the uterosacral
ligaments in front of the cervnx and conclude the operation with a
good perineorrhaphy.

Illustrative cases:

Case I. — Mrs. B. S., fifty-eight years old, mother of six children,
was admitted to hospital in April, 1914. There was a large cysto-
cele and the cervi.x, which presented at the vulva, was eroded from
pressure of the clothing. The uterus was retroflexed and much
enlarged. B)^ keeping the patient in bed for a week, and giving her
alum douches, the ulceration was healed and we proceeded with the
Wertheim-Schauta operation. The enlargement at the top of the
fundus was found to be a fibroid the size of a lemon. The round
ligaments and tubes were tied off, the broad ligaments pushed down,
and the uterine artery tied at a point 3 centimeters above the
level of the internal os. The uterosacral ligaments were plicated
and the end sutures caught by a pair of forceps pushed through the
base of the broad ligaments and brought out alongside the cervix.
The fundus was amputated, the peritoneal edge of the bladder fast-
ened to the peritoneum at the posterior edge of the fundal stump
and the operation finished in the usual manner.

On examination, February 16, 1916, the patient considers herself
well and the anatomical result is excellent.

Case II. — Mrs. Sch., mother of four children, was operated upon
by me at the hospital, February, 1915. She had cystocele, recto-
cele, prolapsus uteri with the cervix presenting at the vulva, and a
large fibroid retroflexed uterus. As the uterus was too large to
allow the ordinary operation the fundus was removed by a slanting
incision as described above, and the operation finished as usual.
The anatomical and functional results are good.

24s West Twextv-foorth Street.

eeferexces.

1. Miinck. med. W ochenschr . , 1903, p. 150.

2. Zent.f. Gyn., No. 30, 1911.

3. Arch.f. Gyn., Bd. xci, Heft 3.

4. Zcnt.'j. Gyn., No. 3, 1912.

5. Surg., Gyn. and Obst., Dec, 1915.

6. Zent.f. Gyn., No. 3, 1912.

7. Arch. f. Gyn., Bd. xcii, Heft i.

42 ELY: ACIDOSIS COMPLICATING PREGNANCY

ACIDOSIS COMPLICATING PREGNANCY, WITH REPORT
OF A CASE CURED BY TRANSFUSION.*

ALBERT H. ELY, JNI. D., AND EDW.IRD LINDEM-AN M. D.

New York City.

A DISEASE which is occupying considerable prominence at the
present time in the realms of internal medicine is that of acidosis.
It could hardly be called a disease yet its symptom-comple.K and
the intricacies and many ramifications of the problem would cer-
tainly deserve such dignified appellation. Literally speaking it
can scarcely be called more than a condition or symptom. Ac-
cording to the latest conception it is a state of the blood that has
undergone considerable loss of alkaUne to neutralize excessive acid
products of deranged intermediary metabohsm. The acid sub-
stances thus formed are unsaturated fatty acids such as diacetic,
oxy-beta, butyric and acetone and in all probability lactic acid
is also concerned in some of these conditions. Under normal
conditions these acids are completely oxidized into carbon dioxide
and water. Occasionally the incomplete oxidation product acetone
may appear in the urine in small amount. An acid reaction of
the blood is incompatible with life. Oxidation can only take place
in a neutral or slightly alkahne medium. Hence there is a great
effort on the part of the human economy to retain all the available
alkali in order to maintain the normal degree of alkalinity of the
blood. The symptoms arising in acidosis are due entirely to the
withdrawal of the alkaline reserve from first, the blood, and second,
from the plasma bathing the cells. The unoxidized toxic products
that are intermediary in metabolism occur frequently in children
in starvation, diabetes, and to a slight extent in mild fevers. In
children the condition is most often met with in cyclic vomiting
and has been reported even in endemic form as in Manchester,
Vermont. The symptoms as they occur in children may be divided
into two stages: First, they are excited, restless, flushed and have
recurrent and persistent vomiting, which is unrelieved by the usual
methods, high fever, and acetone odor on the breath. The second,
or paralytic stage, there is dyspnea, deep sighing, respiration first

* Read at a meeting of the New York Obstetrical Society, February 8, 1916.

EI.V: ACIDOSIS COMPLICATING PREGNANCY

is rapid becomes deep and slow with coma, vomiting persists, the
abdomen becomes soft and scaphoid. The patient finally dies m
urgent dyspnea without cyanosis. In adults, the first stage is

usually absent. ■ , ■ c

For us to-night there is no condition of acidosis that is of more
vital interest than that which occurs during or after pregnancy.
Liver disease, as we all know, is quite common in pregnancy, and
the acidosis appearing in pregnancy must be regarded as a result
of deficiencv in the activities of the liver. Oxidase ferments are
formed in the liver and fed to the blood and lymph. Therefore
when the liver is injured, there is a deficiency in this oxidase, and
therefore the intermediary products of metabolism make their
appearance in the blood stream. Chemical processes take place
in the bodv very similarly to the reactions as they occur m the
test-tube and thev can be measured with just as much accuracy.
For instance, sulphur and phosphorus are constituents of the protein
molecules. These elements are acid-forming m character as
sulphuric, sulphonic and phosphoric acids, and in themselves effect
alkaline withdrawal for their neutralization. This is, however,
counterbalanced bv the ammonia radical. The proteins are more
directlv concerned with the problem in which we are mterested at
present In the protein metabolism, uric acid, creatinme, and
ammonia are present in the blood in very small amounts In
incomplete oxidation of protein, uric acid and ammonia would be
high This is found to be the case in diseases of the liver. It
should be recalled here that in the formation of urea the protem is
first reduced to ammonia and is then built up by the liver into
urea. Therefore, a large ammonia content in the blood may be
regarded as indicating defective liver metabolism. In acidosis the
demand for alkalies is so great that the ammonia is withdrawn
before it is converted into urea; hence a high ammonia content
would speak for an acidosis, and if incomplete protein metabolism
should prevail, there would be an accompanying increase of uric
acid and it would therefore be quite difiicult to difierentiate by the
ammonia, uric acid, and urea content of the blood between primary
liver disease and acidosis. Where all the constituents are low
and the ammonia high, it would point to an acidosis. The degree
of acidosis is best measured by Van Slyke's method of determming
the carbon dioxide absorption capacity of the blood plasma._ The
clinical picture in acidosis varies not with the amount elimina ed
but with the amount of acid substances retained Hence a urine
loaded with acid products may give rise to little or no chnical

44 ELY: ACIDOSIS COMPLICATING PREGNANCY

manifestations. On the other hand, in spite of large eliminations,
there may be large retention, with marked clinical signs. A urine
with a small amount of acid bodies may give rise to profound
clinical symptoms because of the marked retention. In acidosis
the kidney function is also interfered with and this in turn adds to
the chuical complexity of the case. Having analyzed our problem
in a general way the vital question for us and the patient is what
therapy can we offer for the alleviation and cure of the patient?
The chief alkalies concerned in the neutralization of the acid bodies
are sodium, potassium and calcium, sodium being the most im-
portant. Sodium carbonate, for this reason, has been the substance
administered and this has been given by the mouth, rectum, and in
severe conditions, intravenously. This sodium carbonate merely
neutralizes the acid bodies but does not prevent the continued
development of them. WTien given by mouth, it is often vomited
and if there is persistent vomiting, as often occurs, it cannot be so
given. By rectum, it is irritating. Hypodermoclysis of alkali
chars the tissues. The intravenous method while rapid is not
free of dangers. Some of the bicarbonate of soda is rapidly con-
verted into carbonate. The presence of an excess of sodium car-
bonate may jell the blood even though the administration be very
slow.

When one considers that the amount of alkali in the circulation is
directly proportional to the amount of plasma, any increase of plasma
would concomitantly furnish increased alkaUne capacity. Hence
blood transfusion deserves respectful consideration for this con-
dition. In blood transfusion the plasma content not only is in-
creased but the oxygen carrying capacity and oxidizing ferments
are also increased. The introduction of such blood is further
enforced by preceding alkalization of the donor. The absorption of
two intestinal tracts is obtained for the patient instead of one.
It requires little stretch of the imagination to perceive that in
such procedure we introduce alkali in an available form to the
patient. We increase the alkaline and oxygen capacity of the
patient. We furthermore increase the oxidizing ferments which
will go a great way in preventing the presence of the acid sub-
stances in the blood. Having constructed for you the basis of our
work it is my privilege this evening to present the cure of one case
based upon this structure.

Cliuica! History. — Mrs. M. D., aged twenty-four, one of five
children who have attained maturity. Grandfather and father
marked diabetics. Unusually intellectual and highly nervous

ELY: ACIDOSIS COMPLICATING PEEGXANCY 45

temperament. Married May, 1914, and became pregnant following
the next menstruation. Almost immediately after conception she
began to be nauseated and vomited so frequently that the case
was diagnosed as one of hyperemesis gravidarum. She was advised
by a noted obstetrician in London to have pregnancy terminated.
This was refused and after being under constant medical care for
four months, she returned to America and came under my ob-
servation. The whole period of gestation was marked by excessive
digestive disturbances and while at no time were there definite
nephritic symptoms, a varying amount of acetone and diacetic
acid presented in the urine. No blood analyses were made.

In March, 1915, she was delivered approximately at term with
normal labor and very small amount of chloroform of a normal
child. Great care was exercised in the artificial feeding of the
child but there have been symptoms akin to those observed in the
infants OTth cyclic vomiting and a mild acidosis has been present.

The patient began her second pregnancy September i, 191 5, five
months after the birth of her child. The first month no untoward
symptoms developed and the urine was normal. The beginning of
the second month acetone and diacetic acid were noted in the
urinary analysis and vomiting began. Her weight at this time
was 122 pounds and during the course of her pregnancy and fol-
lowing illness she lost 24 pounds. During October, 1915, at-
tention was directed to the treatment of acidosis by means of
alkaUes and colon irrigations, but without effect and as the preg-
nancy advanced the vomiting became more and more excessive and
none of the usual means employed in cases of h^^peremesis gravi-
darum gave any beneficial results. It is to be noted that thorough
examinations failed to find any abnormal condition in the pelvis
and that the urine contained no albumin or other indications of
any lesion of the kidneys. Hoping to tide over the duration of
pregnancy until into the third month, rectal alimentation was
resorted to, as was a hypodermoclysis of dextrose. The patient at
this time presented a picture of emaciation and profound toxemia,
yet had practically a normal pulse and never any fever or subnormal
temperature. On November 12, the thirteenth week of preg-
nancy, after consultation with Dr. E. B. Cragin, the uterus was
emptied. This abortion was followed by no symptoms of any
change in normal constitutional condition nor did it have any effect
upon the vomiting even though considerable blood was lost and
Murphy drip used.

We now began the blood analyses and because of the conditions
there shown, decided to employ the syringe method of transfusion.
This was done by Dr. Edward Lindeman, who, after making thor-
ough tests of the' blood of tw-elve donors in an effort to find a blood
compatible to that of the recipient, chose the husband of the patient.
For twenty-four hours before the transfusion, he, the donor, was
saturated with large doses of bicarbonate of soda. November 26
the transfusion was accomplished with no discomfort to the donor
and never have I seen such a miracle as was presented immediately

ELV: ACIDOSIS COMPLICATING PREGNANCY

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ELY: ACIDOSIS COMPLICATING PREGNANCY

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48 ELY: ACIDOSIS COMPLICATING PREGNANCY

in the condition of the patient. She, who a few minutes before had
been lethargic, with gray ashen facies and waxy fingers, became inter-
ested in everything about, tlie pulse completely changed its character,
and with moist tongue and pink lips she asked intelligent questions.

The transfusion was done at 12.30 p. M. by drawing 400 c.c. of
blood from the patient; iioo c.c. was then transfused from the
husband (donor) to patient, together with 300 c.c. of Lock's solution.
Beginning two hours after transfusion, patient was given one of the
predigested foods and continually after that nourishment was ad-
ministered every two hours and soda solution introduced into the
rectum every four hours. The patient vomited but three times in
the next twenty-four hours and after that was able to take the pre-
scribed diet and one of the iron preparations. December 2 another
transfusion was done with same donor, in the same manner as
above, except 760 c.c. was given and a relatively small amount of
Lock's solution.

Blood tests made at frequent intervals have shown the blood
free from acidosis and, except for a mild secondary anemia, is normal.
Convalescence has been progressive and the patient is now able to
do most of her usual avocations.

BLOOD
11X22
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12/20

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9.00
10.4
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0.66,?
0.46<'

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60
77
80
33

^OFPCAiMA

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94/

88/

60—110 6a.V-95i'

In considering the figures in the above table, the story is even
more striking than the statements of the clinical course. The blood
before transfusion runs low. A low blood urea is characteristic of a
patient on a starvation diet. Before transfusion there was per-
sistent vomiting and inability to take protein food stuffs, .\fter
transfusion, vomiting ceased, concomitantly there was increased
ingestion and tolerance of protein food stuffs. This was followed
by an increase in blood urea. On December 20, a month after
transfusion, the blood urea had increased to 32 milligrams per 100
c.c. volume, which is three times the amount present during the
starvation period. The patient was considerably emaciated be-
cause of her starvation. She was put on a high protein diet and
began to gain weight rapidly — hence the high nitrogen figures of
December 20.

The uric acid figures fall within the normal limits.

The creatinine may also be regarded within normal limits.

The blood ammonia unfortunately was not determined before
transfusion, but we have reason to suppose that it was quite high.
Three days after transfusion it was practically twice as high as the

ELY: ACIDOSIS COMPLICATING PREGNANCY 49

upper limit of normal. On this day the urine for the first time is
alkaline, although the acetone bodies were still present. The high
ammonia in the presence of low protein diet must be explained in
one or two ways or both.

I. The ammonia from endogenous metabolism is drawn upon
to neutralize acid before it can be built up into urea by the liver.

II. The liver may be so diseased that it is unable to build up
into urea the amount of ammonia that is offered to it.

III. Both factors may prevail.

On December 20, though the patient was on a high nitrogenous
diet, the blood ammonia was below normal, the actual quantity
approximating one-half the lower limit of normal. The urea at the
same time was high. These relative figures are indicators of good
hver function.

The sodium chloride shows no change worthy of comment.

The blood sugar before transfusion, which is, you recall, the
starvation period, is a little low. Whatever food the patient was
able to tolerate before transfusion was in the form of carbohydrate.
Immediately after transfusion all food stuffs were well tolerated, the
diet was increased and the blood sugar had increased concomitantly;
well -ft-ithin the normal limits.

Fats were not included in the diet.

On December 20, one month after transfusion, the patient was
on a high protein and low carbohydrate diet. At this time the blood
sugar runs very low approximating one-half the lower normal limit.

The most important and perhaps the most interesting figures in
the table are those of the CO2 per cent, content of the plasma.

The available alkali of the blood is in the form of sodium bi-
carbonate and is present practically in its entirety in the plasma.
Van Slyke has recently developed a simple method for the deter-
mination of the alkalinity of the blood, by the estimation of the
amount of CO2 gas that can be liberated from the plasma.

It has been found that where the CO2 content of the plasma is
below 65 per cent, the patient develops a state of acidosis. Above
65 per cent, no state of acidosis prevails.

Before transfusion, in the case under discussion, the CO2 plasma
content was 55 per cent., after transfusion the plasma content of
CO2 gas was 94 per cent. This marked increase cannot be regarded
in the light of simple law of averages after transfusion, because the
normal average is between 55 per cent, and 95 per cent. One must
conclude that something more than an averaging of the alkalinity
of two mixtures had taken place.

50 CALDWELL: L.-VBOR FOLLOWING VENTRAL SUSPENSION

CONCLUSIONS.

First. — That besides the generally accepted routine of frequent
urinary analyses during the whole period of pregnancy, in private
cases, this should be supplemented by the analyses of the blood
as being a more accurate test to elucidate the actual condition of
the patient.

Second. — That not only should blood of the donor and recipient
be compatible but, as illustrated by this case of acidosis and the
first time so far as known of its employment, the blood of the donor
should be alkalized by large doses of bicarbonate of soda before
transfusion.

Third. — That by the method of syringe transfusion we have a.
comparatively simple and safe means of treatment which produces
results not found with other known methods.

Fcmrtli. — That the timely use of this treatment may obviate the
necessity of emptying the uterus in cases of acute and severe acidosis
complicating pregnancy.

Fifth. — It is possible that with this method of treatment employed
not only in the severe tj'pe but in the lesser grades of acidosis of
pregnancy, we may do much to lessen the number of marasmic
infants whose mortality and morbidity is so great during the first
months and years of life.

A REPORT ON THREE CASES OF LABOR FOLLOWING
VENTRAL SUSPENSION.*

BY
WM. E. CALDWELL, .^L D.,

\ew York.

The deliberate li.xation of the uterus in the child-bearing woman
without sterilization is seldom or never done by careful operators.
Fixation of the uterus in the majority of cases now seen by ob-
stetricians has followed accidentally after various operations.
Suspension of the uterus, even with good technic, ends so frequently
in fixation, that Williams, so long an advocate of this operation,
has given it up. G. W. Kosmak read a very complete paper before
the New York State Medical Society in 1914, reviewing the entire
subject and reporting several fixations which followed difi'erent
operations for the correction of the misplaced uterus.

The great number of abortions, bladder disturbances, and painful
pregnancies which follow fixation, are well discussed in recent
literature. Postpartum hemorrhage is a constant danger. A
large number of placenta previas have been reported. The fact

* Read al a mcctin;; of the Xcw York Obstetrical Society, February S, ioi6.

CALDWELL: LABOR FOLLOWING VENTRAL SUSPENSION 51

that atypical presentations, especially of the shoulder, occur, is
to be expected and is due to the distortion of the uterus.

Long, hard, painful labors, early rupture of the membranes,
difficult dilatation of the cervix and early formation of a retraction
ring, with a marked thinning out of the posterior uterine wall,
very often cause complicated and dangerous deliveries.

Harris, in the Medical Brief of St. Louis, vol. xlii, 1914, after a
careful review of the literature, and from a series of his own cases,
concluded that a majority of polar presentations with the back
anterior, either end spontaneously, or with an easy forceps or breech
extraction after a long, hard labor.

The unsatisfactory^ painful labors, the marked thinning out of
the posterior wall, with resulting danger of rupture, has caused a
great number of the writers to advocate an early Cesarean section
in cases where the presenting part cannot be manipulated into the
brim, and where the labor fails to make a constant satisfactory
advance.

In performing Cesarean section, it is important to carefully
separate the adhesions, tying them off and freeing the uterus before
opening it, in order to prevent serious hemorrhage. The uterus
does not contract well unless the adhesions have been cut. We
have witnessed one case where the patient died on the table from
hemorrhage under these conditions. Where the adhesions are very
dense and there is danger of their re-forming, the sterilization of
the woman, or the complete removal of the uterus, must be seriously
considered. The danger from vaginal delivery is well illustrated
in Case I of the following three fatal cases.

Case I. — Mrs. S. M.; para-iv; aged thirty-eight; born in Italy.
Admitted February 10, 1915.

Family History. — Negative.

Previous Medical History. — Negative.

Obstetrical History. — She has had two full-term, living children,
delivered instrumentally, and one miscarriage four years ago at
the fifth month. Following this miscarriage, the patient had a
constant leukorrhea, frequently tinged with blood, backache,
headache, and loss of weight. She was operated on November 10,
191 1, at Bellevue Hospital. A curettage, perineorrhaphy and a
ventral suspension of the uterus was done. She was discharged
twenty-six days later in good condition.

Present Pregnancy. — The patient was under observation in her
home for several weeks before she was admitted. Except for a
slight albuminuria with a few casts and moderate swelling of the
feet, her pregnancy was uncomplicated. The fetus was in the
transverse position and although a vertex presentation was obtained

52 CALDWELL: L/VBOR FOLLOWING VENTR,4L SUSPENSION

on two or three occasions by external manipulation, it would im-
mediately return to the transverse.

She was admitted to Bellevue Hospital on the night of February
ID, 1915, in the fortieth week of her pregnancy with a slight bloody
vaginal discharge and having some pains, but they gave so little
discomfort that she slept most of the night.

Physical Exam'malion. — Temperature 98.6; pulse 76. Blood
pressure: systolic, 140; diastolic, 105. Feet and legs were slightly
edematous. Abdomen showed a scar from the symphysis to the
umbilicus about i inch in width. The abdomen was pendulous
and the uterus was firmly adherent to the scar. The uterus was
contracting at irregular intervals. Fetal movements were made out
and the fetal heart, although indistinct, could be heard. The cervix
was high, pointing directly backward and above the promontory;
partially softened and dilated to about two lingers. No presenting
part could be made out at that time. The diagnosis of the position
of the fetus, either by external or internal examination, was not
possible on account of the contracted condition of the uterus.

Six hours after admission, after a more careful examination, the
uterus was found to be tonically contracted, with a beginning
retraction ring. The membranes were ruptured. The cervix was
high, pointing directly backward toward the promontory, and
there was a dilatation of three fingers. Under an anesthetic, the
head and foot were found to be in the lower uterine segment, and
since it was impossible to bring the head into the brim, a slow
podalic version was done. The cord was not pulsating, but the
patient was in good condition so she was allowed to come out of
the anesthetic and a tight binder was applied to correct the pendulous
condition of the abdomen. In order to correct the direction of the
cervix, very slight traction was maintained on the child's foot.
The cervix was finally completely dilated, but in spite of very good
pains, the child did not advance. Under an anesthetic, a slow
breech extraction was then done and the after-coming head was
perforated and delivered. Immediately after the birth of the
child, there was a copious rush of blood and the patient went into
serious shock, the pulse becoming almost imperceptible. The hand
was introduced into the uterus and the placenta was quickly re-
moved, after which the bleeding stopped. A rapid examination
for rupture of the uterus was made. The cavity above the re-
traction ring was intact, but a tear of the cervix on the right side
was discovered. This was considered at the time to be not enough
to account for the serious shock, and it was supposed that some of
the adhesions between the uterus and the abdominal wall had given
way. A hot intrauterine douche was given and the uterus and
vagina were then firmly packed with iodoform gauze. In spite of
a saline infusion and other methods of treatment for the shock, the
patient did not react and died in a little less than two hours. There
was no further external bleeding.

On autopsy the anterior surface of the uterus was found to be
firmly attached to the abdominal wall by very dense fibrous

CALDWELL: LABOR FOLLOWING VENTRAL SUSPENSION 53

adhesions. There was a cervical tear on the right side, extending
obhquely upward for 12 cm., with a hemorrhage into the right broad
Hgament. A well-marked retraction ring was still present. The
tear was below the retraction ring and opened into the broad
ligament.

Case II. — Mrs. C. F.; aged twenty-six; para-i; married. Ad-
mitted on March 19, 1915.

Family History. — Negative. No history of venereal disease.

She was operated on in 190S, at which time the right ovary and
appendix were removed. She had a second operation the following
year for adhesions. She was operated on for the third time on
January 12, 1910, at the Woman's Hospital. The latter has kindly
sent me the following report of the operation. "Laparotomy;
separation of postoperative adhesions. Median incision, cutting
out old scar. ^lany adhesions of the abdominal wall. Right tube
and rem.ains of right ovary freed of adhesions. Left ovary cystic,
size of almond; not removed. Fundus freed and raised. Many
adhesions from sigmoid to the fundus and bladder; these freed with
greatest difficulty, requiring a lot of time and care. Serosa torn from
sigmoid in two or three places; sutured over with No. i plain catgut.
Abdomen closed."

She was again admitted to Bellevue Hospital on June 30, 1910
and remained until July 5, complaining of pelvic pains, backache
and headache. Again the uterus was found to be bound down by
adhesions, but no operation was performed. Apparently she
went to two or three hospitals during the five years before she came
to us the last time, still complaining of the same symptoms, but was
not again operated on.

She was admitted to Bellevue Hospital on March 19, 191 5, and
from her history was thirty-two weeks pregnant. She gave a
history of almost constant abdominal pain since her pregnancy
commenced, with frequent and painful micturition, frequent attacks
of vomiting, and three or four attacks of bleeding from the vagina.
For four hours before admission, she had intermittent and extremely
painful "contractions in the abdomen," with vomiting and a slight
bloody vaginal discharge. No history of the membranes having
ruptured.

On admission, pulse 120, temperature 98.6. Urine showed trace
of albumin, but no casts. The patient was fairly well developed
and nourished. The heart, lungs, liver and spleen were negative.
The abdomen was rigid and tender throughout. Stomach visibly
distended, but no marked intestinal distention was found.

The size of the uterus was about the thirty-second week of
pregnancy and was contracting at irregular intervals. The fetal
heart sounds were very indistinct; no fetal movements were made
out. The position was R. O. P. The uterus was adherent to the
abdominal wall from the symphysis to the umbilicus by an old scar
ij^ inches wide. The pelvis was normal. The cervix was high
above the promontory and was directed backward. The external
OS admitted one finger; the internal os was closed. There was a

54 CALDWELL: LABOR FOLLOWING VENTRAL SUSPENSION

slight bloody discharge. No presenting part was made out. The
membranes were intact.

The patient was given a quarter of a grain of morphine. She
vomited her cathartic and the enema was reported ineffectual.
She slept at intervals for the next six or seven hours, when the pains
became regular at three- to five-minute intervals and the vomiting
and retching became almost constant. The pulse rate varied from
no to 140. As there was no dilatation of the cervix after fourteen
hours of labor, a Cesarean section was decided upon. The length of
time that the patient was allowed to remain in labor was due to
the fact that the house surgeon did not recognize the serious nature
of the case and so did not report it to the attending staff. An
incision was made on both sides of the old scar and in dissecting it
out, an opening was made directly into the sigmoid which was
collapsed and adherent both to the scar and to the uterus. The
intestines, omentum, bladder and uterus were bound down by a
tremendous mass of adhesions as high as the umbilicus and all
landmarks were completely obliterated. In dissecting out the
adhesions and freeing the uterus, the gut was still further damaged.
After the uterus was freed, an ordinary Cesarean section was
performed, and a dead male child, weighing 4}^ pounds, was deliv-
ered. A simple hysterectomy followed. There was considerable
diiEculty in controlling the oozing and the patient's condition did
not warrant a repair of the gut. Both ends of the cut sigmoid were
clamped and sutured through the abdominal wound. The vomiting
continued in spite of gastric lavage. There was no movement from
the bowel and very little flatus was passed. Her condition became
steadily worse and she died about forty hours after the operation.

Case III. — Mrs. C. B., married, U. S., aged thirty-four; para-ix.
Admitted January 14, 1915.

Previous History. — Negative.

Obstetrical History. — She had had seven full-term, normal de-
liveries. On August 10, 1912, she was admitted to the Lying-in
Hospital in severe shock from a premature separation of the placenta.
On account of the undilated and sclerotic condition of the cervix, a
Cesarean section was performed. A full-term, dead fetus was
delivered. The patient made an uneventful recovery and was
discharged fifteen days after the operation. She had a temperature
of 104 on the fifth day, which came down gradually to normal.

She was admitted to Bellevue Hospital on January 14, 1915-
From her history she should have been in the thirtieth week of her
pregnancy.

Since the beginning of pregnancy she had frequent sharp, lancinat-
ing pains in her abdomen, followed occasionally by vomiting. She
had been admitted to two obstetrical hospitals for this reason, but
each time was discharged without relief. For the week before
admission to Bellevue Hospital, the attacks of pain had been more
frequent and she had a slight bloody vaginal discharge and could
no longer feel the child.

Physical Examination. — The temperature was 99.8, pulse 100.

CALDWELL: LABOR FOLLOWING VENTRAL SUSPENSION 55

The urine showed albumin and hyaline casts. The patient was
fairly well developed and nourished. The heart, lungs, liver and
spleen were negative. The abdomen was very much relaxed, and
there was an old abdominal scar about lo cm. long, with the center
about the umbilicus. There was a tumor mass about the size of
a seventh months' pregnancy which corresponded in size to her
history. The fetus could be felt apparently directly underneath
the skin. It was impossible to map out the uterus, either from above
or by vaginal examination. The cervix was hard, sclerotic, and
had a bilateral laceration. The internal os admitted the tip of a
finger, through which ballottement could be obtained. The posterior
wall of the uterus seemed fairly normal. The anterior wall could
not be mapped out. The cervix did not feel like the cervix of a
pregnant uterus. There was a fetid, blood-tinged discharge from
the cervix.

In the hope that the cervix would begin to soften so that it would
be possible to deliver through the vagina, the patient was kept
under observation from Januar\' 14th to the 29th. Twice during this
time there was considerable bleeding from the cervix, necessitating
packing. In spite of the packing, there were no uterine contrac-
tions. The foul discharge continued. From the 20th to the 29th,
when she was operated upon, the temperature varied from 100 to 102 ;
the pulse from 80 to no. There was a leukocyte count varying
from 12,000 to 25,000, with a polynuclear count from 80 to 85 per
cent.

A laparotomy was done on the 29 th. The old scar was dissected
out, opening directly into a sac containing a dead, macerated
fetus and foul-smelling pus and gas. The sac was adherent to the
small intestines, mesentery, bladder, rectum and side of the pelvis.
The posterior wall of the sac, at the lower portion, was made up of
the uterus; the rest of the sac was composed of fetal membranes
and inflammatory adhesions. The whole sac, including the uterus,
was gangrenous and was removed with great diiSculty and con-
siderable bleeding. Drainage was established through the vagina
and abdominal wound. The patient did not react from her opera-
tion and died on the following day.

In these cases the fixation of the uterus followed in the

First, a deliberate suspension of the uterus by an excellent
operator;

Second, inflammatory changes in the pelvis following repeated
operations, and

Third, an ordinary Cesarean section.

The first case bears out what the majority of gynecologists now
believe, namely, that the suspension operations of the uterus should
not be done during the child-bearing period without sterilization.
This case also shows the danger of vaginal delivery in such cases-
In spite of a very slow breech delivery, and although the after-coming

56 hirst: the training in obstetrics

head was perforated when it did not descend readily, still the uterus
was ruptured.

Case II should have been sterilized at her last operation in 1910,
considering the great number of adhesions and the damage which
had been done to the sigmoid at that time.

That Case III was a difficult problem In diagnosis is shown by the
fact that she had been admitted to two obstetrical hospitals before
she came to us and was discharged without operation. The diagnosis
should have been made sooner and the operation performed before
sepsis had advanced so far.

These three cases came on the service within a few weeks of each
other. Seven other cases of complicated labors due to fi.xation were
found in the recent histories of two hospitals and a great number
have been reported in the literature, which shows that these cases
occur rather frequently and that all operators on the pelvic organs
must take greater care in the future to prevent this serious com-
plication to labor, for, in spite of the remarkably few fatal cases
reported in the literature, I believe many of these women die.

THE TR.^INING IN OBSTETRICS THAT THE STATE

SHOULD DEMAND BEFORE LICENSING A

PHYSICIAN TO PRACTICE.*

BARTON COOKE HIRST, M. D.,

Philadelphia, Pa.

As good an inde.x as any other, of the civilization of a state, is its
law to protect women in childbirth from harm at the hands of un-
trained physicians.

Wherever the human race has reached its highest development,
these laws are intelligently framed, well administered and efficient in
attaining their purpose. Descending the scale of civilization they
show decreasing knowledge and wisdom until they disappear alto-
gether. Judged by this standard, the United States does not rank
high among civilized nations. As might be e.xpected the level of
civilization by this test varies in the different States. Some are
lower than others, but in none is anything like the same intelligent
care taken of that part of the community which most needs protec-
tion, as is exercised, for example, in Great Britain, Germany or
France.

* Read before the Obstetrical Society of Philadelphia, March 2, 1916.

hirst: the training in obstetrics

In many States and Territories, nothing is required but a theoret-
ical examination — the written answers to ten questions — for which
an applicant might cram with a quiz compend overnight, and might
then be launched on the community with the State's license to attend
women in childbirth, although he may never have seen a woman
in labor and is grossly incompetent to deal with even a minor
complication.

Besides consulting the last edition of the pamphlet on this subject,

No requirements except

Class A and B schools of

Requires the stand-

a theoretical

C on M.E.A.M.A.

but

ard of the Asso.

examination

no specific requirements

Amer. Med. Col-

as to cases on roster

lege

Illinois

Alabama

Arizona

West Virginia

Vermont

Maryland

New York

South Carolina

Oklahoma

Minnesota

Florida

Philippine Islands

Massachusetts (not even a degree)

Wisconsin

Washington

New Hampshire

Colorado

Georgia

Kentucky

North Carolina

Montana

Utah

Oregon

New Mexico (nothing but a

medical degree

from Class A and B schools) not even a|

theoretical examination.

Arkansas

District of Columbia

Hawaii. Idaho.

Indiana

Kansas. Maine,

Mississippi

Nebraska. Alaska.

Nevada

North Dakota, Porto Rico.

South Dakota

Tennessee, Wyoming.

Requires a specific number of cases but no
specifications as to roster

Ohio, s cases.

Rhode Island. lo cases and one year's interne-
ship in a hospital.

Pennsylvania. 12 cases, 6 in undergraduate
school. 6 in hospital year.

A specific number of cases and a certa
ber of hours on the roster

Virginia: 10 cases; 128 hours in third year, 64
hours in fourth.
Delaware. 6 cases; 180 hours. ,

Connecticut. 6 cases; ipS hours.

Louisiana, 6 cases; i8o hours.
Missouri, s cases; 160 hours of which 60 are
clinical.

Texas. 6 cases, 120 hours of lectures.
1 California, 165 hours on roster and 6 cases.

Iowa, 3 cases; 160 hours,
i Michigan, 6 cases; 160 hours on roster.
New Jersey has no specific requirements but
medical school must be registered as first class
by the Board of Licensure.

58 hirst: the training in obstetrics

published by the A. M. A., I have written to the secretaries of the
Boards of Licensure of all the States and Territories of the Union
and to the Secretaries of the Council on Medical Education of the
A. M. A. and of the association of American Medical Colleges.
The result of this inquiry is appended on the preceding page.

The Council on Medical Education "recommends" i8o hours on
the roster for obstetrics exclusive of time of attendance on sLx labor
cases. The association of American Medical Colleges requires wit-
nessing twelve cases, and personally conducting three, before, during
and after labor, under super\nsion.

If the general public could see what goes on in any one of the
large obstetrical clinics of this country; women admitted with rup-
tured uterus; with their intestines hanging out of the vagina so that
if they could walk, they might trip over them like a gored horse in a
Spanish bull fight; exsanguinated from a neglected placenta previa or
an overlooked ectopic pregnancy; infants torn limb from limb; their
heads pulled off and left in the uterus; forceps forced on the lower
uterine segment till their tips penetrate the vaginal vault; and so
on, through a catalogue of horrors; if, I say, the public knew the
facts, the boards of licensure throughout the country would be forced
to do the duty for which they were appointed by the State.

There are some exceptions to the disgraceful negligence of many
states as may be seen in the appended list of State requirements,
but even the best of these requirements is inadequate, judged by inter-
national standards. Our very highest demands would not qualify
a man to practise in the most civilized countries of the world.

Is there any good reason why our women should be afforded less
protection than is considered necessary in other countries? But it is
not our purpose, this evening, to criticise the rest of the United
States, however much we may deplore the semibarbaric laws of
many states in our common country. Our concern is with Pennsyl-
vania. It is gratifying that in some respects we have enacted a more
enlightened legislation on this subject than any other State. It is
particularly a source of pride to the Philadelphia Obstetrical Society
that we owe our advanced position in this matter to a board of
licensure whose president is our ex-president, fellow-member and old
friend, Dr. John M. Baldy. I, for one, have followed his intelli-
gent, self-sacrificing and progressive efforts to raise the standard of
medical education and practice in the State of Pennsylvania with
the greatest interest and the warmest sympathy. Knowing as we

hirst: the training in obstetrics 59

do from what has already been accomplished, that he and his board
are determined to afford the citizens of Pennsjdvania adequate pro-
tection from ill-trained physicians and incidentally to improve the
teaching and practice of medicine in the State, I felt sure, when this
meeting was organized, that he and any other member of the Board
who cared to attend, would welcome an interchange of views with
the teachers of obstetrics in the medical schools of the State; all of
whom are present to-night.

If I were a member of a Board of Licensure, the duty of my position
that would weigh heaviest on my mind would be the protection of
the child-bearing woman from mutilation, disability and death, due
to incompetent medical attendance. If I could without a catch in
my throat, but I never can, I would quote the magnificient perora-
tion of Oliver Wendell Holmes on what is due the woman about to
become a mother. Besides it would be a banality to quote what we
all remember so well. With the words of Holmes still ringing in
our ears as though they had just been spoken and animated by the
sentiment that inspired them let us see if it is not possible and prac-
ticable still further to improve our law regulating the amount of
practical training in obstetrics necessary to qualify a physician to
enter upon the practice of his profession.

In an investigation of the medical student's education in obstetrics
in America and Europe, undertaken for the American Gynecological
Society, followed by a personal inspection of the German, French and
British schools, I was particularly impressed with what has been
done recently in France as a model for our consideration. In that
country, the governmental requirements for a physician's license to
practise, until a few years ago, were about as archaic, provincial and
inadequate as ours are to-day. Owng to the intelligent interest in
the subject aroused by the efforts, I believe, of Professor Bar and
some of his colleagues in Paris, a notable reform was effected. The
present law requires four months daily attendance for three hours a
day on a clinic; sixteen days residence in the hospital and a personal
conduct of the delivery of at least twelve women. This regulation
takes into account an important educational feature either ignored
by our laws entirely, or in a few instances insufficiently provided
for. I refer to the uninterrupted attendance on clinical demonstra-
tions for a period of time; in France, four months. This is only a
third of the time required by the German and Swiss schools, but it
is enough in a large maternity to insure the demonstration of most
of the comphcations and the pathological consequences of the process
of generation. The mere attendance on five or six labors or on ten

60 hirst: the training in obstetrics

as in Virginia and Rhode Island or even twelve as in Pennsylvania,
insures nothing more than the training of a midwife. The chances
are in favor of all this small number being perfectly normal, so that
as far as the State knows, the physician might enter practice without
ever seeing forceps applied, version performed, the evacuation of a
uterus after abortion, not to mention such complications as eclampsia,
obstructed labor, postpartum hemorrhage, placenta previa, prema-
ture separation of the placenta, ruptured uterus, or other injuries
of the genital canal; and without ha\'ing witnessed the pelvic and
abdominal operations required for the complications and pathological
consequences of childbirth, immediate and remote.

This is one of the criticisms I would make of our present State law,
in which it is as defective as the law of any State and is inferior to
some of them. Michigan, Virginia and Missouri, for example,
expressly stipulate that a medical school must have given sixty hours
of clinical instruction in obstetrics, an absurdly insufficient time,
contrasted with the four months or, in our way of expressing it, the
360 hours in France, but better than nothing.

In this connection let me enter my protest against our custom of
chopping the medical curriculum up into hours like that of a primary
school, based on our antiquated system of the hourly lecture and to
express the hope that a reform in this particular may be brought
about by a wider knowledge of medical pedagogics. All clinical
teachers will agree with me that a three-hour period is necessary for
an adequate clinical demonstration: expressed in these terms the
highest demands of any of our States is for a three weeks' course in
chnical obstetrics! Exposed in all its nakedness by this method
of expression, is it strange that our medical degrees and licenses to
practise are regarded with contempt abroad?

Another thing I would criticise in our State law is the require-
ment that the applicant for a medical Hcense must have half his
practical obstetrical training in his hospital year after leaving the
medical school. What educational advantage can this arrangement
possibly secure? Its disadvantages are obvious. According to
this law, the majority of our medical graduates will get half of their
practical training in a hospital with a few beds set aside for child-
bearing women and in a service conducted by someone of necessarily
Hmited experience. I have recently come across two instances
of what might be expected from this plan. I heard the chief
of such a service dogmatically describe a grotesquely incorrect
treatment of one of the rarer accidents of childbirth based on an
experience with a single case and in another instance was told of a

hiest: the training in obstetrics 61

fatal hemorrhage in one of our smaller hospitals that could easily
have been prevented by proper management. Take the average
of the small maternities throughout the State with a service each of
about loo cases a year. It takes more than 300 normal cases to
furnish one of postpartum hemorrhage, eclampsia or adherent
placenta; 1200, one of placenta previa; 2000, one of premature
separation; 4000, one of ruptured uterus, so that three j-ears might be
required in such a hospital to demonstrate the treatment of post-
partum hemorrhage, adherent placenta or eclampsia, twelve years
that of placenta previa, twenty years that of premature separation
and forty years to give a single experience with ruptured uterus.

The medical and surgical services of these small hospitals are quite
different; every case admitted is a disease entity, conve>ing its
lesson and conferring experience in diagnosis and treatment.

Would not the result that it is the duty of the State to obtain,
be better reached, as in the rest of the civilized world, by fostering
the accumulation of the largest possible amount of clinical material
in the maternities of our medical schools and by insisting upon an
amount of time devoted to instruction that would insure a practical
knowledge of the best methods of dealing with all possible compli-
cations and sequels of labor. Our plan of diffusing clinical material
in driblets all over the State and then compelling our medical
students to obtain a part of their education in institutions that
cannot possibly give it in an adequate manner, would be condemned,
I think, by any expert in medical pedagogics.

No one should indulge in destructive criticism without having
something constructive to offer in place of what he condemns.

Of the medical schools of the State, two at least are prepared to
give an education in practical obstetrics including gyneology that
would beair criticism by international standards, the University of
Pennsylvania and the University of Pittsburgh. Take the former
of which I can speak advisedly. The course consists of sixty-four
didactic lectures, thirty-two hours of chnical conference, sixty hours
of clinical and operative demonstrations with individual instruction;
ten days residence in the hospital; ten days' residence in the out-
patient department,* with the privilege of two to three weeks'
voluntary residence each in hospital and out-patient department;
attendance on an average of twenty cases besides individual drill
in mannikin work, cystoscopy, palpation, pelvimetry, history taking,
etc. No student can leave the school without seeing numerous
examples of complications and their treatment.

• With an average of ten cases personally attended.

62 hirst: the training in obstetrics

Pittsburgh, I know, is equipped to offer its students at least as
much. Columbia, Washington University, ^Michigan and Harvard
are in the same class.

Now would not the State Board of Licensure more certainly obtain
the result which I am sure they are conscientiously desirous of
obtaining — namely, providing for the child-bearing women of the
State, physicians to whom such patients can be safely entrusted —
if they demanded of all schools an adequate equipment and time for
teaching this subject? It might be objected that some of the
schools of the state cannot yet meet the requirements that would
be insisted upon by the older civilized countries of the world, and
that their graduates would be unjustly barred from practice in this,
their own State. If so, would not the energy of the Board of Licen-
sure be better directed by recommending State aid to these institu-
tions, if they need it, to bring their facilities up to the required
standard, rather than to force upon every little hospital in the
State, a maternity department whether it is needed or not and to
insist that these small institutions should give the student a part of
his education which he could get much better in his medical school.

By our present law, a student of Columbia's medical department
who sees fifty deliveries and witnesses most if not all, the complica-
tions that he may have to contend with later, but who has not
supplemented his excellent education by personally attending
six cases of labor in some small maternity with inferior experience,
technic and equipment, is, as I understand it, barred from prac-
tice in this State. The same is true of a Harvard student who
attends on the average forty cases under expert superintendence.
A medical student in his summer hohday might take a three months'
course in the Lying-in Hospital of New York City with the largest
obstetrical service in the western hemisphere and then would be
compelled by our law to supplement this experience with a post-
graduate training that would often be worthless. And in our
own State, a graduate of the Universities of Pennsylvania and
Pittsburgh with a practical training that cannot be equalled else-
where in the State, must supplement it with a small amount of
additional practical training under inferior tutellage.

Another factor deserves consideration. Our whole s}stem of
medical education and state licensure in America is open to criticism
in its extraordinary lack of uniformity; no other country presents
such a spectacle.

Massachusetts, of all places, requires nothing, not even a medical
degree; New Mexico requires only a medical degree, nothing else;

KNIPE AND DONNELLY: TREATMENT OF ECLAMPSIA 63

while Virginia and Rhode Island have requirements that approach
those of the most intelligently governed countries. We, in Penn-
sylvania, are adding to this confusion worst confounded by adopt-
ing a system that I may safely predict will be imitated by no other
State.

Would it not be better to conform in principle to the system
already adopted by Rhode Island and Virginia, whose example
will probably be followed by other States, and would it not be
practicable to surpass the requirements of these States in practical
training by avoiding Virginia's error in overbalancing clinical
instruction by a superfluity of theoretical teaching. We would
then set a model for the rest of the States to follow; we would
make a uniformity of our State laws gradually attainable; we would
really guarantee to the citizens of the State, physicians of the
greatest efficiency; we would not admit some who were really not
qualified and exclude others who were eminently well fitted to
practice.

These questions have given me, whether rightly or wrongly,
great concern as one who has devoted a lifetime and an earnest, if
humble effort to improve that branch of medical education in
which we have been admittedly most deficient.

They are respectfully submitted for the consideration of my
colleagues, the teachers of obstetrics in Pennsylvania and the State
Board of Licensure.

182 1 Spruce St.

TREATMENT OF ECLAMPSIA.*

BY
NORMAN L. KNIPE, M. D., AND JOHN DONNELLY, M. D.,

Philadelphia. Pa.

We wish to present for your consideration a paper upon the treat-
ment of eclampsia, with reference especially to a description afid
a comparison of the treatments now in vogue in the larger clinics of
this country. For only in this way may it be possible, as I shall
point out to you, to come to some definite idea as to the best treat-
ment for this obstetrical calamity.

At the present time the treatment of eclampsia may be classified
as either radical operative treatment (and by that we mean ab-
dominal Cesarean section, vaginal Cesarean section and "accoucb-
ment force") or expectant symptomatic treatment.

* Read before the Obstetrical Society of Philadelphia, March 2, 1916.

64 KNIPE AND DONNELLY: TREATMENT OF ECLAMPSIA

Each plan has its earnest advocates. This is natural and to be
expected as it is in every problem in medicine, about which there
may be a difference in opinion.

And yet owing to the fact that we are accustomed to look to
surgery for quick results in so many pathological conditions, so
the operative treatment of eclampsia has become unduly popular
in the last five years, to the exclusion of older methods which
have been tried and not found wanting.

We believe that this is a mistake. We shall show you by the
analysis of eighty-three cases which have been treated during the
last five years in the University Maternity, that our results have been
better and our mortality lower than by any radical operative
treatment that we know of.

The treatment that is prescribed at the University Maternity
is as follows:

Lavage of the stomach; 2 ounces of castor oil given through
the stomach tube; twenty to thirty minutes sweat in the sweat
cabinet; hypodermic of morphia, gr. J^ is given if the convulsions
are violent or frequent; hypodermoclysis after the first sweat,
followed by proctoclysis midway between subsequent sweats;
venesection if systolic blood pressure is over 180 and more par-
ticularly, if the diastolic pressure is high; an initial dose of veratrum
viride (10 minims) followed by nitroglycerine gr. H^oo ^-t four-hour
intervals. Puncture of membranes if pregnant or in labor and
abstention from any operative interference to hasten delivery,
which we find is spontaneously terminated in from eight to ten
hours from the institution of treatment.

It is not our purpose to draw your attention to anything except
the treatment of eclampsia, but it is necessary to elaborate somewhat
on the type and severity of our cases, so that you may infer the
results of the treatment.

Of the eighty-three cases of severe toxemia of pregnancy treated in
the Maternity from 1910 to 1916, forty-eight had convulsions before
delivery. Of these we have a definite record of seventeen having
had convulsions after delivery also, btit as the details of some of the
records were rather poorly kept during this period, it is reasonable
to presume that there were more than seventeen cases in which the
convulsions continued after delivery because the eliminative treat-
ment was continued for quite some time.

Twenty-four had convulsions after delivery only. Of these, four
died, a mortality of 16.66 per cent.

Ten cases were admitted in various stages of their pregnancy with

KNIPE AND DONNELLY: TREATMENT OF ECLAMPSIA 65

severe toxemia and all the symptoms of impending eclamptic con-
vulsions. These cases were relieved by eliminative treatment and
either discharged before delivery or delivered without the onset of
convulsions.

Two cases were delivered by vaginal section — with one death
immediately after delivery.

Si.x cases died within a few hours after admission and after
delivery. Of these, four cases never revived from the state of coma
in which thefy were admitted.

One case died in a convulsion after being delivered.

Another case delivered before admission, died suddenly after
responding well to eliminative treatment. Postmortem showed
cerebral embolism.

Four cases had previous attacks of eclampsia. One case having
had convulsions in two former pregnancies.

Craniotomy was performed in one case.

One case died in the hospital one month after admission, of general
toxemia and nephritis.

The total mortality of these eighty-three cases, whether the deaths
occurred only fifteen minutes or one month after admission, was
fourteen or 16.8 per cent. If we exclude those cases dying within
twenty-four hours, but including the case dying a month afterward,
our mortality was five or six per cent.

It is hardly reasonable to include cases dying within twenty-four
hours in any statistics upon eclampsia. Even those favoring
Cesarean section in all cases, will admit that the ratio of their success
is in inverse proportion to the number of convulsions, and therefore
it is reasonable to assume that cases admitted so late in the disease as
to die within twenty-four hours, would be so saturated with toxemia,
that any operative procedure would be unavailable. Therefore,
I repeat, if we exclude those cases dying within twenty-four hours,
most of them within a few hours, our mortality is 6 per cent.

It may be well to draw your attention at this point, to a very
important fact, and that is, within the last five years there has
been a tendency on the part of those doing Cesarean section for
eclampsia, not to include cases of postpartum eclampsia, in their
statistics. As you have seen, those cases developing eclampsia
following delivery have been a considerable proportion of our total
number, namely, twenty-four out of eighty-three, and as you well
know, these postpartum case shave a higher mortality than those
developing convulsions before delivery. How, then, shall these cases
be treated?

66 KNIFE AND DONNELLY: TREATMENT OF ECLAMPSIA

Through the courtesy of Dr. Hirst, we have received personal
letters from some of the larger obstetrical services of the country,
as follows:

Dr. Markoe of the Lying-in Charity, of New York, tells us
that within the last five years they have had there 216 eclamptic
cases with thirty-eight deaths, a mortality of 17.6 per cent.

Dr. Markoe believes in Cesarean section in all primipara
with rigid cervix. In multipara, with previously lacerated pelvic
floors, he saj^s that it doesn't make much difference what kind of
delivery is done.

He believes that a pack in the cervix is a great irritation and does
not believe in manual dilatation.

He does not mention any routine treatment except catharsis and
irrigation of the bowel, and therefore we do not know what elimina-
tive treatment he advises or practices. It is his belief that, since
we do not know the cause of toxemia, each case should be treated
individually.

Dr. Cragin of the Sloan Maternity, New York, reports eighty-
three cases of eclampsia in 10,116 confinements, including in his
classification of eclampsia only those cases of toxemia, which have
had convulsions. Of this number there were thirteen deaths, a
mortality of 15 per cent. His routine treatment is as follows:

Colon irrigations; chloral by rectum; nitroglycerine hypodermat-
ically; an elastic bag has been introduced into the cervLx in prepara-
tion for delivery, very soon after admission. The treatment
by colon irrigation, etc., mentioned above, has been continued while
the bag has been softening and dilating. If the blood pressure has
continued high and the pulse rapid, veratrum viride has been
employed rather than venesection.

Dr. Ernest B. Young, of the Boston City Hospital, describes in
detail, 143 cases of threatened or actual eclampsia, with sixty
deaths, a mortality of 42 per cent. Two of these, however, died of
sepsis. Dr. Young describes the medicinal treatment in the Boston
City Hospital as follows:

Free catharsis; gastric lavage; control of convulsions by sedatives
(does not mention what), and ether; enteroclysis and hypoder-
moclysis and hot packs in some cases. He doubts the efficiency of
sweating. He rather favors manual dilatation which was employed
in forty-six cases. Three cases were delivered by vaginal Cesarean
section and they all died.

Dr. Newell, of Boston, writes to us that there have been seventy

KNIPE AND DONNELLY: TREATMENT OF ECLAMPSIA 67

cases of eclampsia with convulsions admitted to the Boston Lying-
in Hospital during the last five years, of whom eighteen died, a
mortality of 25^^ per cent. These cases were treated by different
members of Dr. Newell's staff in their own way and no routine method
of treatment was carried out. Therefore, as Dr. Newell himself
points out to us, the results obtained in the Boston Lying-in Hospital
are of little value statistically.

Dr. Newell describes his own method of treatment as follows:

"The question of immediate operation or preliminary treatment
and the method of delivery, in my opinion, depends on the condition
of the patient at the time of admission to the Hospital and her
history. The patients who are in active labor are delivered as soon
as the condition of the soft parts makes it possible, delivery being
hurried or not according to the recurrence of the convulsion seizures.
The patients who are not in labor ordinarily receive some preliminary
treatment directed toward the emptying of the intestinal tract and
to lessening the patient's sensibility to the irritating poison by the
use of morphia followed by induction, usually by means of a bag,
unless the cervi.x is very soft, or vaginal Cesarean section in case
it is unusually rigid, as soon as it responds to the preliminary treat-
ment, or if the condition gets worse in spite of treatment."

Dr. Reuben Peterson reported in the American Journal of
Obstetrics for June, 1914, a review of a series of 283 cases of
eclampsia delivered by abdominal Cesarean section between 1908 and
19x3, by many different operators all over the world.

In this series there were seventy-three deaths, or a mortality of
25.79 psr cent. Previous to 1908, he reports 198 cases, with ninety-
five deaths, or a mortality of 47.97 per cent.

Of the important clinics abroad, Zweifel reports a series of eighty-
four cases between 1910 and 1915, treated by profuse venesection,
(at least 500 c.c. being taken) in association with Stroganoflf's
treatment with a mortality of 5.9 per cent.

Stroganoff reports 839 cases of eclampsia treated by his method
in different clinics (morphia, chloral and chloroform), with a mor-
tahty of 8.9 per cent.

It seems to us that from this brief resume of the results of the
different treatments of eclampsia, that the time has not yet come to
discard entirely those efforts which we have efficaciously directed
for years toward the elimination of the unknown toxemia.

Its etiology is as obscure to us now as it was ten or fifteen years
ago. We may only hope that someone will eventually find out by

68 sturmdorf: the teaching of gynecology

chemical, physiological or pathological investigation, the cause
of this dreadful complication of pregnancy.

When this time comes, we shall certainly be able to suggest a
treatment that will be more specific in character than any we now
practise and therefore I hope more successful.

2007 Chestnut Street.

THE TEACHING OF GYNECOLOGY TO THE ADVANCED
PUPIL.*

BY
ARNOLD STURMDORF, M. D., F. A. C. S.,

New York.

The pedagogics of gynecology in general and of postgraduate
gynecology in particular, present intrinsic obstacles to teacher and
student, that are not encountered in other specialized departments
of medicine and surgery.

Its diagnostic fundamentals demand, as an essential prerequisite,
the cultivation of a keen tactile perceptivity, which can be acquired
only among ample clinical facilities.

Such clinical facilities are circumscribed by obvious prohibitive
restrictions, which limit the utility of the average gynecological
patient for objective class demonstration, and create a relative
paucity in opportunities for specialistic cultivation.

He, to whom these initiatory obstacles have proven no hindrance,
will behold gynecology in the dawn of a new era.

The mechanistic empiricism that dominates the votaries of the
established practice, is slowly but surely merging into the realm of
the obsolete.

Surgical virtuosity alone no longer constitutes a gynecologist:
Healed incisions and operative correction of purely objective
deviations from hypothetical normals do not prove the cure, while
the use of symptomatic nosology does not establish a diagnosis.

We were taught to see a passive retention wedge in the "perineal
body" — where we now recognize an active myodynamic deflector
of intraabdominal pressure in the levator ani muscles.

The time is passing when "endometritis" encompassed the
beginning and end of all uterine pathology; when "reflex neurosis"
presented the shibboleth of its symptomatology and "curettage"
the slogan of its therapy.

* Read before a meeting of the Section on Obstetrics and Gynecology of the
N. Y. Academy of Medicine, February 24, 1916.

sturmdorf: the teaching of gynecology 69

Henricius in 1889 unwittingly laid the foundation of uterine
physiology, when he graphically demonstrated that the normal non-
gravid uterus is a rhythmically contracting organ; Leopold in 1874
blazed the path to its rational pathology when he revealed the myo-
metrial lymph channels; Kundrat in 1873 exposed endometritis as a
normal manifestation in pathological guise, thus transposing the
pathogenesis of its cardinal symptom, namely, hemorrhage, from
an anatomical to a biochemical basis.

This biochemical genesis projects its whole dominating hierarchy
of the internal secretions upon the gynecological horizon, where in
the haze of the "reflex neuroses," we begin to discern the lineaments
of insidious sepsis and toxicosis.

Current terminology, accurate and inaccurate, dominates our
concept and concept determines practice, so the term "metropathic
hemorrhage," for instance, links fact and fancy, the hemorrhage is
the fact, the "metropathic" — a fancy, nevertheless this term is
conventionally synonymous with hysterectomy, notwithstanding
that the purely functional nature of the hemorrhage as a result of
inefficient thyroid or pituitary metabolism has been demonstrated
in many cases successfully controlled by appropriate organo-therapy.

The same line of research will divert many a case of sterility from
utterly futile cervicoplastic operations, while on the other hand, the
controversy as to the clinical significance and choice of corrective
measures in uterine displacements will frequently find its solution
in the recognition of those skeletal abnormalities, congenital or
acquired, in which misdirected intraabdominal pressure induces
necessary cotnpensatory deviations from normal lines of visceral
topography.

These few phases from among the many will serve to indicate the
broadening scope and wider range of advanced gynecology.

The student must be taught to see beyond his finger tips: an
organism, not an organ is the object of his study. He must learn
to calculate in terms of gonad and endocrine denominators, to
balance and correlate — orthostatic, dynamic and biologic factors in
his clinical definitions.

He must be enabled to diflferentiate the gynecological manifes-
tations of systemic disorders from the systemic disturbances of
gynecopathic origin.

This wide diversit}^ in essential contributory and complemental
elements has not and cannot be crystallized to the concrete homo-
geneity of a text-book stage, so that an adequate proficiency in this

70 sturmdorf: the teaching of gynecology

technical complex must be sought among ample polyclinical facilities
under judicious guidance.

Individually, post-graduate students are ardent, earnest men who
seek knowledge at personal sacrifice; collectively, however, they
present a mental and technical heterodoxy, that ranges from special-
istic endowments down to an absolute lack in first principles — and
in the present status of post-graduate instruction, the teacher must
adopt a course that ranges from the needs of those who cannot locate
a fundus uteri, to those who seek the last word on the chemotaxis of
ovular nidation.

In the New York Polyclinic, each of six gynecological divisions,
conducts two clinics weekly, one operative and one ambulatory.

The morning sessions are devoted to details of surgical technic
and the incidental study of operative findings in their anatomic,
pathologic, symptomatic and diagnostic bearings.

It is the ambulatory clinic, however, with its wider range, that
aflfords opportunities for the discussion and elucidation of advanced
gynecological problems.

In the ambulatory division of my clinic, I have adopted a course
which meets as nearly as possible the requirements of those seeking
only a practical working knowledge as well as those interested in
the more academic phases of the subject.

My class is divided into sections of two members, each section
having its case assigned for examination under my supervision and
that of my staff.

Sounds and specula are discarded and the previously established
diagnoses and histories are withheld for the time.

The students are supplied with the blank forms, here reproduced,
on which their dictation of objective abnormahties are noted in
strict topographic sequence.

During the manual examination of the patient, any deficiency
in method or tactile perception on the student's part is corrected,
while his verbal delineation engenders differential precision.

Based upon these objective findings, the functional disturbances are
deduced and their incidental symptomatology postulated.

The whole class participates in the diagnostic equations thus
propounded, this elicits their individual conceptions and miscon-
ceptions, and affords the teacher opportunity to correct the latter
and amplify the former by elucidating those higher phases of the
subject embodied in the term "Advanced Gynecology."

The final conclusions are now compared with the history of the

STURMDORF: the XEACraNC OF GYNECOLOGY

N-fi

DEDUCTIVE GYNECOLOGICAL DIAGNOSIS ^ame

Topographic Sequence

Objective
Features

Functions
Involved

Symptoms
Deduced

Diagnosis

VULVA

INTROITUS

VAGINAL-CAN.AL

Os-outlines

CERVIX-UTERI , ^''*'''°"

FORM

Consistence

1 Direction

1 Size

FUNDUS-UTERI form

Consistence

I MOBILITY

Situation

ADNEXA ;?^^.

Consistence

MOBILITY

case and the diagnosis corroborated by ,the approximate coincidence
between the objective deductions and the subjective data.

Advanced gynecology was an art and is a science.

The teacher can demonstrate its practice and elucidate its theories,
but he cannot impart aptitude, and when all is said and done, he
becomes convinced, that advanced gynecologists are born and not
made.

51 West Seventy-fodrth Street.

72 polak: transperitoneal celiohysterotomy

TRANSPERITONE-^L CELIOHYSTEROTOMY.

BY
JOHN OSBORNE POLAK, M. Sc, M. D., F. A. C. S.,

Professor of Obstetrics and Gynecology, Long Island College Hospital,
Brooklyn, New York.

In ofifering this subject for your consideration, I do so with much
embarrassment, for here in Brooklyn our obstetricians have attained
such perfection with the classical operation by the general adoption
of a simple standard technic, that we approach an abdominal
delivery with little fear. Yet I am convinced after reviewing our
morbidity records at the Long Island College Hospital, that there is
room for improvement. Especially is this so in the "suspect"
class, where the morbidity has reached nearly 50 per cent. American
obstetricians have been slow to accept extraperitoneal section.
This is perhaps due to the more difficult technic which lengthens
the operation, and again the procedure is less theatric than delivery
by Sanger's classical method.

Extraperitoneal celiohysterotomy has, however, many definite
advantages over the classical section: First, the general peritoneal
cavity is not contaminated by any leakage of liquor amnii, as the
route of delivery precludes soiling owing to the suture of the peri-
toneum of the uterus to the parietal layer. Women who are long
in labor with ruptured membranes have numberless bacteria in their
uteri, many of which are pathogenic; the classical celiohysterotomy
exposes the peritoneum to infection from this source.

Second, subsequent deliveries may be done through the same scar
without entering the general peritoneal cavity, or the delivery may
be spontaneous without danger of uterine rupture, as the scar is in
the dilating segment, and not in the contractile part of the uterus.

Third, omental and intestinal adhesions are less frequent.

Fourth, the shock and postoperative gas complications are
decidedly minimized.

Fifth, should infection occur, the lesions found are parametric
or are extraperitoneal exudates which are competent to protect the
organ against the organism.

Extraperitoneal Cesarean section is not a new procedure, but
rather a revival of an old one, as it was first suggested by Joerg, as

polak: transperitoneal celiohysterotomy 73

early as 1809, and employed by Ritgen in 1821. Physick of Phila-
delphia recommended it to Dewees in 1824. From this time until
1870, when T. Gaillard Thomas revived the extraperitoneal method
of delivery, no mention is made of it. Badelocque had suggested
in 1823 the term gastroelytrotomy, which was adopted by Thomas
for his modified technic. In this procedure, an incision was made
above and parallel to Poupart's ligament, to the subperitoneal
tissues, and the peritoneum separated back from the abdominal wall
by blunt dissection, while the bladder was pushed to one side to
expose the cervix and vagina. The lower uterine segment thus
exposed was then opened and the child delivered by a circuitous
route through the incision in the flank. Infection was so common as
to finally cause the abandonment of the extraperitoneal route, and
again the method fell into disuse until 1906 when Frank, of Cologne,
reintroduced the extraperitoneal delivery, suggesting an improved
technic which has been modified by Doderlein, Sellheim and others
and is extensively employed in Germany. In America extraperi-
toneal section by the German technic has met with little favor.
Hirst and the writer prefer to employ the transperitoneal method of
Veit and Fromme, which when properly executed has all of the
advantages without the dangers of the older method. We have
elected this procedure in the cases which would formerly have come
in the Porro class and our results have been so satisfactory that we
are now using it in all cases requiring abdominal delivery.

It must be admitted that the classical section leaves much to be
desired, i.e., it is not safe where infection is present. E. P. Davis,
Peterson, and Williams insist that the section be followed by ex-
tirpation when the case has been handled. Second, postoperative
intestinal complications are frequent. This is particularly evident
if the intestines are handled or are eventrated during operation.
Third, peritoneal adhesions are frequent between the uterine wound
and the parietal peritoneum, fixing the uterus high in the abdomen.
Fourth, the uterine scar being in the contractile portion of the uterus,
may rupture in a subsequent labor. Fifth, there is still a definite
mortality of from i to 5 per cent., even in the best clinics.

In November, 1914, stimulated by Hirst's success, we began the
employment of the extraperitoneal route, in neglected cases, instead
of doing the Porro operation which is so emphatically endorsed by
E. P. Davis and Williams. Numberless modifications of the original
technic have been suggested, but they all fall into two general
classes: the true extraperitoneal, as illustrated by the technic of
Doderlein and Latzko, and the transperitoneal section as advocated

74 polak: tr.ansperitoneal celiohysterotomy

by Veit, Fromme, and Hirst. It is the latter which we have adopted,
and which I will attempt to describe.

The method is simple. With the patient in a moderate Trende-
lenburg posture, an incision 6 inches long is made to the right of the
median line, below the umbilicus. When the peritoneum is opened
the uterus is pushed into the wound, and the bladder reflection is
located and picked up between forceps and nicked, and then with
Mayo scissors run up and down in the subperitoneal tissues of the
lower segment, the bladder and visceral peritoneum are easily sepa-
rated. Forceps are then placed on the peritoneal reflection of the
uterus and that of the abdominal wall, and the visceral and parietal
layers united by a series of sutures. We use an interrupted figure of
eight suture of catgut, leaving the ends long. A forceps is placed
on each suture until tied. WTien these two layers of peritoneum
are united, the lower uterine segment is extraperitoneal and may
be entered without possible leakage into the general peritoneal
sac. In our first two or three cases we found that during the de-
livery the sutures at the upper angle tore away. To correct this
we have in our later cases sutured the uterus to the peritoneum and
fascia and thus fixed the uterus at its upper angle. The baby is
delivered in the usual fashion, the placenta extracted manually and
the wound in the uterine muscle closed with interrupted sutures of
chromic catgut. In infected cases it is our custom to place in the
uterus an iodine soaked gauze pack, which is removed via the cervix
and vagina at the completion of the operation. After the uterine
wound is closed, the two layers of peritoneum are united with a con-
tinuous suture. Thus is completed an extraperitoneal delivery and
an extraperitoneal closure.

Our experience is limited to eight cases, with no mortality. The
recovery is very prompt and the freedom from abdominal distress
has been impressive to those of us who have had experience in ab-
dominal operations.

Cellulitis and thrombophlebitis are possible complications which
may result from a too extensive separation of the visceral peritoneum
from the lower uterine segment. These accidents have not occurred
in our cases, but one cannot but appreciate that they are possible
sources of trouble as the operation is done through the thinned and
dilated portion of the uterus.

In extraperitoneal section we believe we have a procedure which
will replace the classical operation in all cases in which a test of labor has
been given. Its more general employment should reduce the mor-
tality in all classes, and give both mother and child a better chance.

beck: preventing subin\'Olution and retroversion 75

EXERCISE ON ALL FOURS AS A MEANS OF PREVENTING
SUBINVOLUTION AND RETROVERSION.*

ALFRED C. BECK, M. D.,

Brooklyn, N. Y.

In reviewing the literature one is amazed at the scarcity of articles
dealing with the latter half of the puerperium.

The proper time for the puerperal patient to remain in bed, the
correct posture for her while in bed, the value of bed exercises, the
relation of lacerations and subinvolution to retrodisplacements
and many subjects of a similar nature, are repeatedly discussed.
Our text-books are agreed as to the proper hygiene of the puerperium.
In fact, after consulting the current literature and our text-books on
obstetrics, one would never surmise from the lack of thought con-
cerning the puerperium that gynecology draws a large percentage
of its cases from obstetrics.

The various measures suggested by the numerous writers on the
hygiene of the puerperium have from time to time been employed in
the maternity wards of the Long Island College Hospital. Patients
have been allowed out of bed early, others have remained in bed as
long as eleven and twelve days. We have tried the Fowler position.
Mothers have sat up as early as the fourth day. They have taken
the dorsal, the lateral, the lateral prone and the prone position for a
considerable time during their stay in bed. Bed exercises have been
employed. The knee-chest position has been resorted to as soon as
the patient's condition would permit. Lacerations have been care-
fully repaired.

In spite of all of our efforts, our postpartum clinic continually
showed us the inefficiency of our methods. Many cases returned
with subinvoluted uteri and from 20 per cent, to 30 per cent, had
retroversions of varying degrees.

For some time these were considered the inevitable results of
childbirth and were accordingly treated by the usual methods.
Following the use of the median perineotomy considerable difiiculty
was encountered in treating these cases. The pelvic outlet so closely
resembled that of a nulliparous woman that a suitable pessary could

* Read before the Brooklyn Gynecological Society, Februarv' 4. 1916.

76 beck: preventing subinvolution and retroversion

be introduced only with the greatest difficulty. As many of our
postpartum cases which returned from the hospital were primiparae in
a large per cent, of whom perineotomy had been done, we were com-
pelled to seek some better means of preventing these troublesome
retroversions.

Believing that walking on all fours might have a beneficial effect,
this was tried. On the ninth day after labor each patient was
required to walk five or six yards on her hands and feet with the
knees held as stiffly as possible. On the tenth day the distance was
doubled and the exercise was performed in the morning and after-
noon. The walk was increased proportionally each day until
discharge, when the patient was advised to continue until she
returned to the postpartum clinic two or three weeks later. As the
clothing offers some little interference, they were asked to follow
these instructions in the morning before dressing and at night after
undressing.

The number of cases examined since beginning this procedure are
not sufficient to warrant final conclusions. However, the result
so far observed may justify their being reported. During this time
I have examined 102 women in the postpartum clinic, sixty of whom
were confined in their homes by our out-patient service and the
remaining forty-two were hospital cases.

All of the patients confined at home were multiparae. Many
had several small children and it was impossible to keep them in bed
more than three or four days. Of the sixty, twenty-seven or 45 per
cent, were found to have retroversions. Subinvolution was not
infrequent and in some the vaginal discharge contained blood.
Walking on all fours was not advised in any of these cases.

Of the forty- two patients who came from the hospital nineteen
were primiparae and twenty-three were multiparae. Twenty-five
had good pelvic floors while nineteen showed relaxed outlets. At
the time of discharge five cases showed poor involution and three
retroversion. All of these forty-two women had exercised in the
above manner for from one to three days during their stay in the
maternity ward. Ten or 24 per cent, returned with retroversions
in from one and one-half to two months after confinement. Five of
the ten, however, failed to continue the treatment at home and their
result does not merit consideration. Excluding these, only five
or 13.5 per cent, of the remaining thirty-seven who continued the
exercise in the prescribed manner showed retroversion on their
return.

The ten retroversions are of interest in that seven occurred in

KENNEDY: DYSMENORRHEA 77

primiparse in all of whom the pelvic floor offered excellent support,
while only three were observed in multiparae with relaxed vaginal
outlets.

The most noticeable change was observed in the involution.
Before instituting this treatment patients on their return to the
postpartum clinic, not infrequently showed marked subinvolution
and occasionally complained of the bleeding which accompanied
this condition. Not one of the cases in this series was found to have
a subinvoluted uterus and in most instances the uterus was consid-
erably smaller than was to be expected at the period of the puer-
perium at which the patient was examined.

How this mode of exercise produces these results I am unable to
state. Examination during the latter part of the second week of the
puerperium shows that while the patient is walking on all fours, the
fundus falls forward and out of the pelvis resting on the abdominal
wall slightly above the symphysis pubis, the cervix is carried pos-
teriorly and moves slightly with each step. There is a distinct
lateral rocking of the pelvis. Possibly this movement of the uterus
may stimulate contractions.

If it were possible to draw conclusions from a series of cases as
small as the one herein reported it would appear that the early
getting out of bed after confinement increases the tendency toward
retroversion; that the condition of the perineum has little bearing
on the question; that most of these poor results occur after the
second week postpartum at a time when patients are usually neg-
lected; and finally walking on all fours because of its simplicity
offers a means of preventing retroversion and subinvolution in those
patients who are not faithful in carrying out the more complicated
procedures.

DYSMENORRHEA.*

BY
J. W. KENNEDY, IM. D.,

Philadelphia. Pa.

Dysmenorrhea can be said to be a hyphenated subject, as it may
be considered as both a symptom and a condition.

I do not know any symptom which is more trying, or in which
we should be so guarded in our prognosis, as that of painful men-
struation.

* From the Clinic of the Joseph Price Hospital.

78 KENNEDY: DYSMENORRHEA

The condition requires the most careful investigation from a diag-
nostic standpoint, and is surgically most abused.

The subject recalls to me so many errors of commission from in-
diflFerent general surgical advice by those who have not given it
proper thought, that I am justified in saying there is still in existence
the specialty of gynecology.

To most operators, dysmenorrhea means in each and every case,
dilatation of the cervix irrespective of pelvic pathology or the true
character of the dysmenorrhea.

The etiology of dysmenorrhea in many instances is in doubt. I
know of no condition which may be so diversified in its sympto-
matology, as dysmenorrhea. In one patient may be found all the
mechanical conditions which would lead to an obstructive dysmenor-
rhea, yet the patient have a normal menstruation; the reversed con-
dition of affairs is equally true. In other words, dysmenorrhea is a
condition or symptom in which the local condition is much influenced
or dominated by the peculiar tj'pe of patient. The gynecologist
does or should know this and his advice be regulated by the same.
The high-strung or nervous type of woman will have a dysmen-
orrhea from a condition of the pelvic organs which would give a
normal menstrual flow in one of less tense nervous make-up.

The same may be said of the strumous type who often has a per-
sistent dysmenorrhea. I have always been opposed to the standard
classification of many subjects in surgery. It makes the minds of
young operators too mechanical in their views.

In m}^ consideration of the subject, I have in mind two forms of
dysmenorrhea only, namely, obstructive and spasmodic, with the
possible addition of membranous.

One may indefinitely extend his classification by adding to the two
forms, obstructive and spasmodic, any number of compound terms
such as ovarian, congestive, etc. Such classification only describes
that particular local condition which may aggravate one of the t>-pes
of obstructive or spasmodic dysmenorrhea. From a therapeutic
and diagnostic standpoint, I feel it is well to keep these complications
of the real condition in mind, as they influence one's advice as to
treatment.

OBSTRUCirVE DYSMENORRHE.\.

For a number of years I have felt that many cases classified as
obstructive dysmenorrhea, were not so in reality, that there were
few instances in which one could demonstrate any real obstruction to
the cervical canal, and that most of the cases classified as obstructive
dysmenorrhea, were in reality spasmodic.

KENNEDY: DYSMENORRHEA 79

I had arrived at this conclusion through my own error, which be-
came apparent when I attempted to dilate the cervix of a patient
in whom I had expected to find a stenosed canal, the operation re-
vealing a patulous one. It was made even more apparent to me
during operations on the infantile uterus in which I had expected
to find a stenosed cervical canal in the superlative degree, but uni-
formly found the internal os of the infantile uterus even more open
than the external one, and in reality more patulous than that of the
normal uterus.

I have never felt that malpositions of the uterus were a frequent
source of dysmenorrhea, other than they predisposed whatever
variety of dysmenorrhea the patient may have had, to exaggerated
symptoms incident to possible congested conditions of the pelvic
viscera. I do not feel that bending of the cervical or uterine canal
incident to a malposition is of sufficiently acute angle to cause true
obstruction. The thick walls of the uterine body are such as to
prevent obstruction from flexion. We have all seen the most exag-
gerated positions of retro- or anteflexion of the uterus, without
symptoms of any kind ; therefore, I am inchned to think dysmenorrhea
due to obstruction, is not in a sense anatomical, but either surgical
or pathological. For these reasons, the only two conditions I recog-
nize as obstructive dysmenorrhea are, one, due to either amputation
of the cervix or faulty repair of the same, and second, obstruction
incident to malignancy of cervix and uterus and possibly other tu-
mor formation or inflammatory condition. It has been necessary
for me to do vaginal hysterectomy, because of obstruction dysmen-
orrhea, on a good number of patients following amputation of the
cervix. Quite a number of patients have consulted me on account
of painful menstruation due to malignancy of the cervix which had
caused a mechanical stenosis. We have all seen cases of complete
stenosis of the cervical canal due to malignancy with a resulting re-
tention of blood, pus or uterine discharges; so I dismiss the subject
of the etiology of obstructive dysmenorrhea with the thought, that
practically all cases are either surgical or pathological in the sense of
tumor formation.

SPASMODIC DYSMENORRHEA.

A very large per cent, of cases with dysmenorrhea are of the spas-
modic variety. The true etiology and classification of dysmenorrhea
have been obscured because of the surgical treatment by dilatation
of practically all cases who consult us. Therefore, we have assumed,
if dilatation of the cervical canal relieves the condition, it must have

80 KENNEDY: DYSMENORRHEA

been one of obstructive dysmenorrhea. I do not feel that this is so,
as I have already pointed out in my discussion of obstructive dys-
menorrhea. It is true that dilatation will relieve a large per cent,
of cases of spasmodic dysmenorrhea, but it is not due to dilatation of
the cervical canal in the sense of producing a more patulous canal for
exit of uterine flow, but to relief of muscular spasm. You will
find a large per cent, of cases classified as spasmodic dysmenorrhea
reveal at time of operation practically no degree of stenosis; the
dilator enters and is withdrawn from the cervical canal with ease.
You will not relieve this patient by dilatation, the chance is the pa-
tient is suffering from pelvic visceral trouble which is exaggerated
at the menstrual period; therefore, diagnosed as a dysmenorrhea.

In most cases which are truly of the type of spasmodic dys-
menorrhea, when one attempts to remove the dilator from the cervix,
the operator notices there is a perceptible degree of resistance to the
withdrawal of the dilator. The cervix squeezes the instrument.

We obtain the best results from dilatation in cases which are
typical examples of spasmodic dysmenorrhea. I do not think we
have any knowledge of the true etiology of this peculiar spasmodic
condition of the lower uterine or cervical canal. There have been
a number of theories advanced regarding the cause of spasmodic
dysmenorrhea, none of which are clear or incontestable. That form
of dysmenorrhea, which seems to resist with extreme stubbornness
all kinds of treatment, is found in patients who have an infantile
uterus, which is so often accompanied by scanty menstrual flow.
I have never known just where to place this type of case. It is not
obstructive nor is it of spasmodic nature. As I have said, you will
find in dilating such a case, that the internal os is even more open
than in the normal sized uterus. This has been an observation I
have often made and have not as yet seen it referred to in literature.
The condition is truly not obstructive and you will also find that the
cervix yields easily to dilatation with no resistance to entrance or
withdrawal of the instrument, so it is not of the spasmodic variety.
Does the pain come from lack of hemorrhagic area on account of the
infantile or undersized uterus? You cannot say that the patient is
anemic in type, as I have seen the most magnificent specimens of
women with an infantile uterus, who have had the most extreme tyjie
of this variety of dysmenorrhea. It is in the dysmenorrhea of the
infantile uterus that we obtain the best results from insertion of the
stem pessary, and permitting the same to remain for weeks or months,
with the idea that the pessary as a foreign body by irritating the
uterus may produce a true hyperplasia and therefore increased size

KENNEDY: DYSMENORRHEA 81

of the uterus. Although I have resorted to this procedure a number
of times with good results, I must say I always have the greatest
apprehension of uterine infection. Even though the insertion of the
stem pessary of modern pattern is done with the greatest aseptic
precaution, I cannot but feel it is a possible source of infection. The
insertion of any foreign body into the uterus, packing or draining the
same, has never appealed to me. We must remember the vaginal
canal is not sterile, so that any form of drainage, pessary or any other
foreign substance inserted into the uterus is accompanied by the
possibility of infection. Cases of infection have been reported from
the stem pessary inserted for dysmenorrhea. Membranous dys-
menorrhea is given as a distinct type, but as I can imagine its being
a complication of either obstructive or spasmodic dysmenorrhea I
have not made a distinct classification of it. The finding of the mem-
brane confirms the diagnosis. However, I see no particular objec-
tion from the standpoint of pathology to make such separate distinc-
tion. I have always had an aversion to the exhaustive classification of
many of our subjects. If we were in a position to uniformly examine
the discharge from the uterus, we would find this organ more often
sheds its endometrium as a cast than we are led to suppose. I have
seen the most perfect casts of the uterine cavity or even more often
the membrane shed in halves. One should be guarded in giving
expert opinion regarding a suspicion of pregnancy in the unmarried
from a careless examination of these casts, as they can be easily
macroscopically confused with the decidua of pregnancy. We should
not give a macroscopical opinion which would in any way question
the chastity of woman. The finding microscopically of chorionic villi
with their surrounding syncytium is the only sufiicient proof of
pregnancy. Decidual cells have been found in membranes cast from
the unimpregnated woman.

Treatment. — The treatment of dysmenorrhea will try all of one's
patience from the standpoints of both surger\^ and medicine. The
surgical treatment varies from simple dilatation to hysterectomy.
Hysterectomy for painful menstruation should only be done after
all other remedies have been exhausted.

This radical step may be taken to prevent suicide, insanity or the
drug habit. Do not ever suggest hysterectomy unless you have tried
all other remedies and have made up your mind it is the only relief.
If you sugggested such a remedy to the patient she will often attempt
to force same upon you. These patients will submit to any extreme
means to be made comfortable from that helhsh ever-returning
monthly pain, as they term it.

82 KENNEDY: DYSMENORRHEA

For the treatment of obstructive forms of dysmenorrhea, the indi-
cations are clear, as I claim they are due to faulty surgery or tumor
formation. It will be necessary to remove the remaining portion of
the uterus after an amputation of the cervix which has been followed
by dysmenorrhea.

Hysterectomy is also indicated in the obstructive form incident
to tumor formation. I do vaginal hysterectomy in each case.

The treatment of spasmodic dysmenorrhea is dilatation of the
cervix which will permanently relieve a good per cent, of cases.
Some will return for a second or third dilatation, others are never
relieved.

In the discussion of dysmenorrhea of the spasmodic variety, as
in all forms of painful menstruation, the condition of the uterine
appendages and the constitution of the patient are often determining
factors of success or failure of operative treatment. Here even the
judgment of the most skilled gynecologist may be overtaxed. For
instance, if a painful menstruation is due to or aggravated by ovarian
congestion, the patient is relieved by the recumbent position or those
means which deplete pelvic congestion. A discussion along this line
may be carried into all of those conditions which influence general
health or local congestion. Do not give morphine for relief of
monthly pain; the reasons are self-evident. I believe antipyrin
will relieve painful menstruation more often than any other drug.

I close this interesting subject by saying, nurse the patient, do not
drug her. By the phase nurse the patient, I mean the practice of all
things which may be crystalhzed under the term, good judgment;
and good judgment may be neither surgical nor medical in application.

241 North iSih Street.

TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL SOCIETY 83

TRANSACTIONS OF THE AMERICAN GYNE-
COLOGICAL SOCIETY

Forty-First Annual Meeting, Held at Washington, D. C, May g,
lo, II, 1916.

The President, ]. Wesley Bovee, M. D., Washington, D.C, in the
Chair.

Dr. H.ARVEY W. Wiley, of Washington, D. C, delivered an
address of welcome, which was responded to by Dr. Edwasd P.
Da\ts, of Philadelphia.

SYPmLIS IN' its relation to obstetrical .A.ND GYNECOLOGICAL

practice.*

Papers were presented by Drs. Edw.4rd P. D.avis, Sigmund
Pollitzer, George Gellhorn and Hugo Ehrenfest.

THE frequency OF SYPHILIS IN OBSTETRIC PRACTICE.

Dr. J. Whitridge Williams, of Baltimore, stated that he had
not been able to prepare a formal paper which he intended to do.
What he would attempt to do was to follow up all cases during his
service within the last five years presenting any indications of
s\'philis. This would mean sending out social workers and bring-
ing the mothers back with their babies, without having Wassermann
reactions taken, and without examinations having been made, and
while this was being done he had not been able to complete the
work.

Last year, at the meeting of the Association for the Prevention
of Infant Mortality, he presented an analysis of the fetal deaths in
10,000 consecutive labors, including all children born after the
seventh month, those djdng at the time of labor and those dying
the first two weeks of the puerperium. Of these 10,000 cases,
there were 700 dead children; of these 700 dead children, roughly
speaking, 26 per cent, was due to syphilis. Probably as many
more were born alive and left the hospital at the end of two weeks
either with signs of congenital syphilis or developed the disease
later, so that he would say from his material in Baltimore that the
incidence of syphilis in connection with obstetrics was about 5
per cent. In his material he has had an unusual incidence in that
nearly half of the patients were colored women, and in his experience

* See this Journal for May.

TRANSACTIONS OF THE

in colored women syphilis was four or five times more common than
in the white. In white women syphilis was probably concerned in
about 2 per cent, of the cases and something like 8 or lo per
cent, in the black.

What he had hoped to be able to present this time as an analysis
of the cases occurring in the last five years, tracing out what happened
to the children born to syphilitic mothers, which did not die at the
time of birth and which left, the hospital shortly after they were
born. He was not able to make a definite statement at this time,
but he would endeavor to collect all of these cases and have the re-
port ready for publication in full in the Transactions of the Society
later.

THE SPECIFICITY OF THE WASSERM.A.NN REACTION.

Dr. Rudolf Buhman, of St. Louis, Missouri (by invitation), in
a paper on this subject referred to the frequency with which posi-
tive Wassermann reactions were obtained in diseases other than
syphilis, as per the numerous reports in the literature, which was
the incentive for his contribution.

The Wassermann reaction was made upon a series of cases, more
of which presented any clinical evidence of syphilis, and only a few
gave a vague history of the disease. The cases were selected from
the abundance of material furnished at the Barnard Free Skin and
Cancer Hospital.

The material investigated was divided into three groups:

TABLE I.— SKIN DISEASES.

Disease

Number

Negative

Positive

Weakly

Pityriasis rosea

Scabies

8
15

5
25

None
None
None
None

None
None

Eczema

None

Total

None

TABLE IL— MALIGNANT DISEASES.

Number j Negative Positive

Sarcoma

Malignant adenoma

Glioma of brain

Carcinoma

Total

136

None

None
None
None

AMERICAN GYNECOLOGICAL SOCIETY 85

TABLE III.— MISCELLANEOUS DISEASES.

Disease

Number Negative

Positive

Weakly

Trichinosis

Pernicious anemia . . . .
Hodglcin's disease
Sporotrichosis
Scarlet fever

Leprosy

Tuberculosis.

Malaria

Arthritis

Meningitis

Streptococcus infection

3
4
3
3

IS
6

3
4
3
3

None
None
None
None
None
3

None
None
None
None

None
None
None
None
None
None
None
None
None
None
None

Total

None

In Table I, comprising skin disease, there were 53 reactions
made, with negative results in all of the cases.

In Table II, comprising malignant diseases, of the 136 cases,
125 gave negative reactions, 9 positive and 2 weakly positive.
Of the 9 positive reacting cancer cases, 6 became negative, or
remained only weakly positive under syphilitic treatment. The
remaining 3 cases discontinued treatment or failed to return
for later observation. The 2 weakly reacting ones were carci-
nomas of the cervix.

A microscopical examination was made in every case for con-
firmation.

In Table III, comprising various diseases, 99 reactions made,
94 reacted negatively and 5 positively. Three of the 5 positive
reacting cases were tuberculous leprosy. The other 2 positive
reacting cases were tuberculosis of the lungs, and in neither case
could syphilis be excluded.

CONCLUSIONS.

A strong positive reaction, with proper controls and accurately
titrated reagents, was conclusive evidence of syphilis, excepting a
few diseases, which could easily be excluded clinically.

The diagnosis of syphilis could not be made upon a weakly positive
Wassermann reaction, without some clinical evidence of the disease.

A negative reaction did not exclude a syphilitic infection.

That malignant diseases did not give positive Wassermann
reactions.

OBSERVATIONS ON THE OCCURRENCE OF SYPHILIS IN THE UNIVERSITY
OF MICHIGAN OBSTETRICAL AND GYNECOLOGICAL CLINIC.

Dr. Reuben Peterson, of Ann Arbor, INIichigan, discussed this
subject under the following heads: Syphilis in the obstetric clinic;

86 TRANSACTIONS OF THE

history of lues and correspondence with the results of Wassermann
examinations; physical signs of syphilis; treatment during pregnancy
and its effect; the results of Wassermann examinations on new-born
infants; and syphihs in the gynecological clinic, after which he pre-
sented the following summary and conclusions:

1. Only by routine Wassermann tests will the obstetrician and
gynecologist best serve the interests of his patients.

2. Especially is this true in hospital practice where even careful
histories fail to arouse suspicion of latent syphilis.

3. Out of 2000 in-patients in the University Hospital, excluding
two services, the proportion of syphilitics was 6 per cent.

4. The nature of the hospital material wiU determine the per-
centage of lues, but in the average hospital the ratio will not be
far from 8 to 10 per cent, if the entire hospital population be included.

5. The same holds true for the proportion of syphilis in any
special clinic, the percentage varying according to the nature of the
material.

6. The percentage of lues in 381 cases in the University Maternity
was 4.7 as shown by the Wassermann reactions and expert physical
examinations.

7. In 18 cases of sj-philis among the number examined,
only 8 or less than half gave a history of lues.

8. In only the same number (8) were there positive physical
signs of lues.

9. As shown by the histories of the 18 cases, there is a
greater chance for the syphilitic mother treated by salvarsan and
mercury to give birth to a living full-term child than where no
treatment be given during pregnancy.

10. The new-born infants of the mothers so treated do not give
positive Wassermann reactions, although undoubtedly they are
syphilitic and later probably will show signs of the disease.

11. A certain proportion of the new-born children of untreated
syphilitic mothers will give positive Wassermanns.

12. Out of 290 gynecological patients subjected to the Wasser-
mann test, 22 or 5.6 per cent, gave positive reactions.

13. In only 5 of the 22 luetic patients was there a history of
syphilis.

14. Hence the importance of such examinations or a serious
general disease will be overlooked and the gynecological patient
will remain uncured.

SOME REMARKS ON THE RELATIONSHIP OF SYPinLIS TO MISCARRIAGE
AND FETAL ABNORMALITIES.

Dr. Fred L. Adair, of Minneapolis, ^Minnesota, read a paper
with this title which consisted of an analysis of 1005 obstetrical cases
in whom there were 2773 pregnancies. In this series there were
2422 full-term pregnancies, 197 abortions, 62 miscarriages, 84 prema-
ture births and 8 unclassified cases.

There were 76 stillbirths, and 16 fetal malformations. These

AMERICAN GYNECOLOGICAL SOCIETY 87

cases were studied for evidence of syphilis by the Wassermann reac-
tion, clinical and autopsy evidence.

In those cases giving a history of abortion there were 621 pregnan-
cies in 109 cases. There were 197 abortions in these cases or approxi-
mately I to every 3 pregnancies.

There were 13 syphilitic cases in whom there were 74 pregnancies
and 23 abortions, or approximately i to 3 In 83 cases
without evidence of syphilis, there were 464 pregnancies and 142
abortions, or about i to 3 Apparently pregnancy did not
end much more frequently during the first three months in those
affected with sj'philis than in those who were free from the disease.
There were 40 cases who had 62 miscarriages in 202 pregnancies or
approximately i to 3. There were 7 cases with syphilis who
had 10 miscarriages in 27 pregnancies, or about i to 3. There
were 30 cases without syphilis in whom there were 49 miscar-
riages in 161 pregnancies or approximately i to 3.

There were 68 cases with 84 premature births in 241 pregnancies
or I to 3 There was evidence of syphilis in about one-third
of these mothers. Congenital syphilis appeared in 5 of 50 infants
born in the hospital. Thirteen of the 50 were stillborn, in 4 of
which svphilis was demonstrated. This meant that S of 50
premature infants were proved syphilitic.

There were 66 mothers who had 76 stillbirths. The Wassermann
reaction was positive in about one-tenth of these cases. Four of
34 infants born in the hospital were proved to be syphilitic or about
I in 8.

Two of 16 deformed infants were born to sj'philitic mothers.
Thjere was evidence of syphilis in 2 of 11 cases of hydramnios.
Two of 5 cases of hemorrhage of the new-born were apparently due
to syphilis.

Dr. E. D. Plass, of Baltimore (by invitation), demonstrated
placental and fetal syphilis by numerous slides.

HOW CLOSELY DO THE WASSERMANN REACTION AND THE PLACENTAL
HISTOLOGY AGREE IN THE DIAGNOSIS OF SYPHILIS?

Dr. J. Morris Slemons, of New Haven, Connecticut, followed
with a paper on this subject. The author stated that the Wasser-
mann reaction in the mother's blood and the microscopic examina-
tion of the placenta were carried out in 260 consecutive confinements.
The results were classified as follows:

Group

Wassermana

Placenta

Number of cases

I...

II..
III.

IV..

Negative
j Positive
1 Negative
1 Positive

Negative
Positive
Positive
Negative

335
:o

I
14

88 TRANSACTIONS OF THE

There was absolute agreement between the serological test and the
result of study of the chorionic villi in 345 cases or 95 per cent.

Occasionally, i case in Group in, the placental findings were
more reliable than the Wassermann.

Of the 14 cases in Group IV, there were only 2 with a strongly
positive Wassermann (75 per cent, fixation). One of these was
definitely syphilitic, indicating that the Wassermann might be
more accurate than the placenta, and this was most likely to be true
in postconceptional s>-philis. The other patient with a strongly
positive Wassermann almost certainly was not suffering from
syphilis, but from a general streptococcus infection.

The other cases in Group IV presented from 25 to 50 per cent,
fixation (8 cases gave a single plus and 4 cases a double plus. Ten
patients with eclampsia or allied autointoxications presented mild
fixation and the phenomenon must be attributable to the metabolic
disturbance. In 2 cases, with none of the familiar symptoms of
autointoxication, there was slight fixation. The cholesterol content
of the blood did not account for the serological phenomenon.

Accurate chagnosis of sj'philis in obstetrical patients required
both the Wassermann reaction and the study of the placenta. The
freshly teased chorionic villi should be examined routinely. If
their appearance raised the suspicion of s}T)hilis, hardened and
stained sections of the placenta must be studied and the Wassermann
reaction in the mother's blood must be determined. Irrespective
of the teased \alli, both these observations should be made whenever
the fetus was premature, macerated or stillborn.

EXPERIMENTAL S\-pmLIS.

Dr. F. W. Baeslack of Detroit, Michigan (by invitation), stated
that the causal relationship of the treponema pallidum to lues was
established by (a) the observation of the occurrence of the organisms
in the syphilitic lesions incident to the various stages of the disease.
The distribution of the paUida in the lesions of acquired and con-
genital syphilis (b). The successful inoculation of lower animals
from human lesions, thereby producing syphilis experimentally in
rabbits, monkeys and other animals. The methods employed and
a discussion of the character of the lesions; and the observation of
generalized syphilis in experimentally inoculated animals (c). The
growing of the treponema pallidum in culture media free from con-
tamination, and the transfer of these cultures through many genera-
tions and the successful inoculation of lower animals with the culti-
vated organisms; also the loss of virulence of the organisms against
the lower animals after extended cultivation, and the cultural char-
acteristics and morphology of the pallida (rf). Immunological
studies; pseudoprimary lesions, and true reinfection, as well as
superinfection as expressed in the lesions in the various stages of
syphilis, did not harmonize with the conception of immunity.

The author referred to attempts at immunization by means of
pallida vaccines. He spoke of the occurrence of agglutinins in the

AMERICAN GYNECOLOGICAL SOCIETY 89

serum of animals treated with suspensions of dead pallida, as well as
the absence of immunity, as demonstrated by the ability to rein-
oculate animals which had recovered spontaneously or subsequent
to treatment. Reference was made to the altered reactivity of the
body, and a possible explanation offered for the occurrence of the
lesions peculiar to the various stages of syphilis.

SYPHILIS OF THE BODY OF THE UTERUS

Dr. Charles C. Norris of Philadelphia, Pennsylvania, said
that it was only since the discovery of the spirochffita pallida and the
development of the Wassermann test that the true frequency of
syphilis had been recognized. Probably i to 4 per cent, of women
were syphilitic. The disease was rare in the body of the uterus.
Theoretically chancres might occur in the body of the uterus as the
result of spermatozoic infection and this avenue of ingress might
account for some of the cases of syphilis which developed without
demonstrable primary sore. No chancre had, however, ever been
demonstrated in this location. Some authors beheved mucous
patches might occur in the endometrium. This, however, was
unproven.

There were two varieties of syphilitic endometritis: (a) gummatous,
and (b) a less characteristic form in which the blood-vessels were
especially affected. Syphilis of the myometrium occurred as gumma
and a diffuse metritis, the most characteristic lesions of which were
in the blood-vessels. Many cases were reported as syphilis on in-
sufficient grounds. Hemorrhage in the form of menorrhagia was a
frequent symptom. Leukorrhea and pain occurred. The author
reported the following case:

Patient, aged thirty-six years; married twelve years; iii-para;
last child seven years ago. Six years ago the woman contracted
syphilis, and since then had had tlaree miscarriages, two, three, and
five months respectively, the last one six months ago. Patient was
under mixed treatment until nine months ago. Menorrhagia de-
veloped five months ago. Hemorrhages were profuse, and produced
severe anemia with its accompanying symptoms. When she was
brought to the hospital she had been bleeding twelve days. Phys-
ical, abdominal and pelvic examinations were negative. Hemo-
globin, 52; red blood count, 5,000,000; white blood count, 4500.
Wassermann reaction strongly positive. Diagnostic curettage was
resorted to during which the fundus was perforated. Because of
the age of the patient, three living children, history of intractable
bleeding and perforation of the uterus, a supravaginal hysterectomy
was performed. Her convalescence was normal. Salvarsan was
administered. A pathological examination of the specimen showed
the uterus normal in size and shape, but so friable that its walls could
be squeezed through at any point with thumb and forefinger. His-
tological examination showed endometrium slightly thickened and
infiltrated with chronic inflammatory products. There was angio-
sclerosis of the vessels.

90 TRANSACTIONS OF THE

The myometrium was more or less inflamed, and there was much
edema. There was marked angiosclerosis of vessels and complete
obliteration of some. The inner coats of the vessels were chiefly
affected. The lymphatic spaces were dilated. In many fields the
muscle fibers were partially separated from one another.

The diagnosis of syphilis in this case was not positive as spiro-
chstas were not demonstrated or searched for. The etiology was not
suspected, and the Wassermann report was not secured until
some days following the operation by which time the specimen had
been fixed in formahn solution, thereby making the demonstration
of the spirochasta pallida very difficult.

The diagnosis was based upon the following: That the patient
contracted s}-philis years ago, and since then had had three mis-
carriages; that the symptoms referable to the uterus developed three
months after cessation of antisyphilitic treatment, and one month
after the last miscarriage; that these were the symptoms usually
produced by sj^jhilis of the uterine body; that the histological find-
ings, especially the blood-vessel changes, were those of syphilis.
The hemorrhage and discharge were not the result of pyogenic in-
fection following a miscarriage, as they did not occur with either of
the two former miscarriages, but developed one month after the last.

These facts led the author to ascribe the uterine lesions to sj'philis.
Three similar cases were recorded in the literature.

The author's paper contained a review of the literature of syphilis
of the uterus to date.

SYPHILITIC FEVER IN RELATION TO GYNECOLOGICAL AND
OBSTETRICAL PRACTICE.

Dr. Frederick J. Taussig of St. Louis, Missouri, stated that the
rare mention of this symptom in gynecological literature was out of
proportion to the comparative frequency of its occurrence. A posi-
tive diagnosis of syphilitic fever could only rarely be made, but the
diagnosis could be made with great probability in certain groups of
cases.

The author divided syphilitic fever into:

1. Secondary s\-philitic fever occurring at the outbreak of the
eruption, lasting usually only three to four days with a rise of tempera-
ture to 99.5 or 100°. Fournier estimated that the symptom
occurred in 20 per cent, of all s\'philitics.

2. Late secondary syphilitic fever might complicate pregnancy or
gynecological conditions; it was usually prolonged with a higher
degree of temperature. The writer cited several cases, one of which
had been diagnosed as typhoid. In these cases the diagnosis was
based upon the positive history and evidence of a syphilitic infec-
tion, the e.xclusion of other febrile diseases, and the immediate and
permanent results of antisyphilitic treatment.

3. Tertiary syphilitic fever was of greater diagnostic importance
than the two previous groups because the symptoms and history of
syphilis were often absent and only the 4 plus Wassermann pointed

AMERICAN GYNECOLOGICAL SOCIETY 91

the way to an interpretation of the continuous fever. Eighty-three
cases of tertiary syphilitic fever occurring in literature were analyzed,
including one case in the author's experience in which pelvic gum-
mata were responsible for the fever.

The cause of syphilitic fever was. in all likelihood, to be found in
the entrance of spirochete toxins, in addition to the organisms
themselves, into the circulation. Probably individual predisposi-
tion was also an important factor in the rise of temperature. The
fever occurring occasionally after injections of mercury or salvarsan
when it might be fairly assumed large quantities of endotoxins were
liberated from the dead spirochetes, was additional confirmation of
the toxic interpretation of syphilitic fever.

The author summarized as follows:

1. The diagnosis of s\'philitic fever could rarely be made with
absolute certainty, but we should more often consider it as a possi-
bility and institute antiluetic measures in suitable cases.

2. Secondary syphilitic fever occurred in a mild form in 20 per
cent, of patients at the outbreak of the rash and at times was pro-
longed and more severe in its course.

3. Late secondary sj^jhilitic fever was occasionally seen in a pro-
nounced form after confinement or in gynecological patients.

4. Tertiary syphilitic fever was practically never due to syphilitic
lesions in the female genital tract. One such case was reported by
the author. It might, however, complicate a gynecological or
obstetrical condition, and owing to the difficulty of locating the site
of the tertiary lesion, lead to a wrong diagnosis as to the cause of the
fever. All doubtful cases should be subjected to a Wassermann test
and, if positive, given antiluetic treatment.

S- Syphilitic fever was probably due to the reaction of the body to
the toxins produced by the spirochete which under certain circum-
stances or in certain individuals gained an entrance to the circulation.

Dr. J. Whitridge Williams, of Baltimore, Maryland, had been
interested in the subject of syphilis ever\^ since he had had charge
of the obstetrical service in the Johns Hopkins Hospital. From
that time every placenta which had gone through his hands had
been examined microscopically, and he had in this way made a
diagnosis of syphiUs with great accuracy and satisfaction to him-
self long before the Wassermann reaction was discovered and long
before the spirochete was known.

One of the things that interested him in Dr. Pollitzer's paper was
the positive stand he took against Colles' law. Colles' law was the
dictum that stated a woman might have syphilitic children
by a sj'philitic father and be immune to syphihs herself, and before
the Wassermann reaction was discovered that was generally believed,
but after the Wassermann reaction had been discovered, and it was

92 TRANSACTIONS OF THE

found that the great majority of the women representing Colles'
law had a positive Wassermann, the question arose how could that
be explained. It meant that these women had latent syphilis or it
meant something was transmitted to them through the fetus which
gave a positive Wassermann. In Germany the position was taken
that these women had latent s}-philis; therefore, the sj'philitic chil-
dren did not occur from the fathers at all, but from the mothers,
and the tendency had been in the last few years to deny Colles'
law absolutely. He thought the tendency to do away with Colles'
law entirely was probably a step in the wrong direction.

He cited the case of a colored woman, who had changed her name
on several occasions, and who had a very unique obstetric experience.
She had had seventeen full-term labors, all but two of which occurred
in his service. This woman had had sixteen babies, because she had
twins once, under his observation. The first two labors occurred
elsewhere. She then had three perfectly normal labors, large babies,
normal placenta. Her sixth pregnancy resulted in double ovum
twins, one child being born alive, with a perfectly normal placenta,
while one child was born dead, with a syphihtic placenta, and the
autopsy made by a pathologist showed a diagnosis of congenital
lues. Following that twin pregnancy she had eleven other babies
in his service; every baby was born alive; every baby weighed over
8 pounds, and every placenta was normal. This syphihtic baby
was the only one which died either at the time of labor or in the
first few years of hfe.

When he came to inquire into the woman's history, he found that
she was perfectly frank in saying that she had had sexual intercourse
with a lover at the same time that she had sexual intercourse with
her husband, and when he traced the lover's history he found he was
a syphilitic under treatment in the genitourinary dispensary. It
was his belief in this case the woman had an example of superfecunda-
tion bv her husband, her normal man, and the s}-philitic lover was
the father of the sj'philitic child. This woman never presented any
sign of syphilis after a Wassermann test. He got repeated Wasser-
manns and they were constantly negative.

This was the most conclusive case with which he was familiar as
being in favor of Colles' law.

Dr. Brooke M. Ansp.ach, of Philadelphia, in speaking for Dr.
Williams, of Philadelphia, stated that he (Dr. Williams) and Dr.
Kolmcr had been interested in the incidence of syphilis that occurred
in gynecological cases and had taken a series of 300 patients in the
gynecological and obstetrical services of the hospitals with which
they were connected and had found a positive reaction in 22.6 per
cent. He would not present all of the notes written by Dr. Williams,
but Dr. Williams was particularly interested in the relatively high
percentage of positive reactions observed in the following conditions:
A positive reaction was obtained in 75 per cent, of stillbirths; 50
per cent, in rectal disease; 43 per cent, in abortions; 36 per cent,
in pelvic inflammatory cases; 16 per cent, in fibroid tumors of the
uterus, and 17 per cent, in cases of pregnancy.

AMERICAN GYNECOLOGICAL SOCIETY 93

There seemed to be a decided difference between negresses and
white women. In the negresses there were 35.8 per cent, positive
reactions as compared with 22.2 per cent, in the white women.
Some of these reactions, which were put down as positive, he thought
were weakh' positive, and his impression was that must be an error,
and that the incidence of the percentage of syphihs would not be as
high as it seemed at present.

So far as gross conditions in the pelvis were concerned, lesions of
the uterus, tubes and ovaries in relation to syphihs, he did not see
why we should expect many lesions there, although sj^Dhihs was a
constitutional disease and not local. One might look for gonorrhea
or for infections of tumors, and the principal manifestations in the
secondary stage or the surface manifestations. In a certain class
of cases in the Philadelphia Hospital there was seen a lot of external
manifestations of s}.TDhihs about the external genitaUa, but in private
practice he had almost never seen them.

Dr. Collin Foulkrod, of Philadelphia, in referring to syphiUtic
fever recalled having seen one case, and this was observed quite a
number of years ago in out-patient work in Philadelphia. In the
first part of pregnancy the patient developed fever, which was
diagnosed as tj^Dho-malarial. The patient was cared for and
observed for six weeks until finally the conclusion was reached that
the fever was due to syphihs without any antis)T3hihtic treatment
having been given at the time. Patient was given a dose of salvarsan,
but it was not repeated for a week or ten days at which time the fever
was running 101.2°. After finding the patient was losing ground
they decided to give another dose of salvarsan, which was done,
and the next day the temperature came down to normal and
remained so. Patient passed through a normal convalescence.

Dr. Fred L. Ad.alr, of Minneapolis, Minnesota, stated that there
were two points he did not make in his paper, one of which was in re-
gard to hydramnios. He had found two cases out of eleven asso-
ciated with s^-philis, in one of which there were definite evidences of
congenital sj-philis. In association with hemorrhage of the new-born
out of five cases he found two that were definitely syphilitic. This
was an important point, and while it had not received attention other
than casually, he did not think it had been sufficiently emphasized
that sv-philis was a fairly frequent accompaniment, if not the cause,
of hemorrhage in the new-born.

Relative to habitual abortion, he had had only three cases of well-
marked habitual abortion, but in none of these was he able to
demonstrate syphilis by the Wassermann test or other reactions.

The incidence of syphilis in his series of cases was between 5
and 6 per cent. The incidence of sj'philis in the macerated fetuses
was appro.ximately 50 per cent. In the still births the cases in
which s>T5hilis was demonstrable made up approximately 25 per
cent., and in premature births approximately 15 per cent.

Dr. J. Morris Slemons, of New Haven, Connecticut, pointed
out that the diagnosis of syphilis was made too frequently in early
infancy. This opinion depended upon the fact that he kept in close

94 TRANSACTIONS OF THE

touch wth infants after they were given up by the obstetrical depart-
ment, and he found frequently that in the pediatric clinic the appear-
ance of snuffles or sore buttocks or skin lesions was without further
evidence simply considered enough to say that the child had con-
genital syphilis. It was for this reason the obstetrician should
supply the pediatrician with every particle of available evidence
which was at his disposal. The placenta should be examined in
every case. If one depended upon the placenta alone, he would
miss some of the cases. On the other hand, if the Wassermann
reaction was depended on diagnosis would be made too frequentl}^
of syphilis and under such circumstances both tests should be made.

Dr. Frederick J. Taussig, of St. Louis, Missouri, had occasion
to see a patient in the city hospital in whom there were secondary
manifestations of syphilis with a four plus Wassermann in which
there were whitish plaques upon the cervix. A piece of the cervix
was removed for histological examination and a typical histological
picture of leukoplakia was presented.

Dr. Hugo Ehrenfest, of St. Louis, Missouri, spoke on the
question of paternal infection, saying it had in some respects been
considered in their joint essay. Dr. Davis defended the point of so-
called paternal infection and the possibility of an infected spermato-
zoon entering the ovum, in this way starting an infection in the
forming fetus. Dr. PoUitzer probably more in harmony with present-
day views objected to that conception. He pointed out the work
of Muratow and others to assume the possibility that the spirochete
could enter the ovum with the spermatozoon. He said they men-
tioned among other things in their joint paper the fact that spiro-
chete could be found in the cervical secretion, but the woman at that
time did not have any evidence of syphilis. They had made smears of
the cervix in one case and found tj-pical spirochetce. He ordered a
Wassermann taken and found a four plus Wassermann and the
husband was, at the same time, in a hospital with s^-philis, although
the woman had no evidences of syphilis at the time.

As to the use of salvarsan. Dr. Davis warned against it in
pregnancy and s}^hilis. He was not able to give any particular
figures. In the case that was mentioned by Dr. Taussig and Dr.
Foulkrod, the patient was at the end of the eruptive stage, she hav-
ing been treated for t>-phoid. She was kept on salvarsan during
that pregnancy and carried to full term. In the City Hospital of
St. Louis, they had used salvarsan for the treatment of syphihs in
pregnancy, and he was personally under the impression that
salvarsan did not show any particular deleterious effect upon the
fetus.

Dr. George Gellhorn, of St. Louis, Missouri, in referring to the
paper of Dr. Norris, said he was glad to see that Dr. Norris had
accepted the suggestion that the so-called syphihiic menorrhagia
had nothing to do with the uterus itself, and that it depended almost
altogether not upon the local lesion of the ovary but upon the
systemic poisoning which the spirochete had upon the function of
the ovary. The case, however, of syphilis of the uterus did not seem

AMERICAN GYNECOLOGICAL SOCIETY 95

convincing to him. Here was a patient who had had syphihtic infec-
tion and subsequent lues, she had had three abortions, the last
one of the three taking place five months previous to the date of her
entering the hospital. Upon dilating and cureting the uterus was
perforated. The friability of the uterus need not necessarily be
considered sj'philitic. More convincing proof should be adduced
to show that the changes in the uterus were absolutely sj^Dhilitic,
for the histological picture of the syphilitic uterus was not pathog-
nomonic. There were the same changes in the blood-vessels and
perivascular infiltration in all chronic inflammations, and he would
rather think the perforation in this case was due to the abnormal
friability brought about by the repeated miscarriages which had
occurred in a fairly short period of time.

The reason why primary chancres were not observed more fre-
quently in the uterus, tubes and ovaries, was obviously due to the
affinity of the spirocheta pallida for squamous-cell epithelium.

As to the infectiousness of physiological secretions in a syphilitic
woman, it was known that syphilitic affections, sj^hilitic ulcers
and chancres were full of spirochetse and were, therefore, highly
infectious. But if a woman was syphilitic and had no local mani-
festation upon the vulva, the vagina or the cervix, she yet might
be highly infectious. Rosenberg had succeeded in finding spiro-
chetce in four cases in the cervical secretion in an otherwise normal
uterus, and Dr. Gellhorn had succeeded twice in demonstrating
spirochetas in women who had absolutely no local manifestations
upon the genital tract, and in whom the cervical secretions were
absolutely clear and normal. The practical value was evident.

Hereafter more attention must be paid to the routine examina-
tion of the physiological secretions in syphihtic women. The time
was not far distant when a practical examination of cervical
secretions would be just as much a routine as the search for gonococci.

THE VARIATIONS IN THE BLOOD SUPPLY OF THE OVARY AND THEIR
POSSIBLE OPERATIVE IMP0RT.4NCE.

Dr. John A. Sampson, of Albany, New York. — The study of
the blood supply of the ovary was undertaken for its anatomical
interest and for its bearing on conservative ovarian surgery, when a
tube was removed without removing the ovary of that side, or the
uterus was removed leaving one or both ovaries. The intrinsic
blood-vessels of the ovary and resection of that organ were not
considered.

The material consisted of six fetal tubes and ovaries and thirty
adult ones in which the arteries had been injected with bismuth,
and ten adult tubes and ovaries in which the veins had been injected.
The specimens were studied by means of stereoscopic radiographs,
and for the sake of comparison ink tracings were made of the blood-
vessels on prints, using the stereoscope as a guide in following the
course of the individual vessels. The prints were then bleached,
leaving the tracing.

96 TRANSACTIONS OF THE

The terminal portion of the uterine artery presented variations
in its branching and distribution of those branches. This artery
directly or indirectly through its branches supphed a varying por-
tion of the ovary in all, the entire tube in six, the greater portion of
the tube in twenty-three, the round ligament and greater portion
of the broad ligament in all but one.

In twenty-four of the thirty specimens the ovarian artery on
approaching the ovary divided into two main branches, a lateral
tuboovarian or tubal branch and a mesial ovarian, the latter
anastomosing with the ovarian branch of the uterine. In six speci-
mens the lateral tubal branch was absent. The ov-arian artery
supplied a varying portion of the ovary in all, the distal portion
of the tube in twenty-four and portions of the broad Ugament in
all, but the latter to a lesser degree than the uterine.

The actual blood supply of the ovary was a divided one, uterine
and ovarian. In twenty-six of the thirty specimens the uterine
supplied the proximal portion of the ovary and the ovarian the
distal. The four specimens (four of six in which the lateral ovarian
branch to the tube was absent), the lateral tubal artery arose from
the main tubal artery (uterine artery) and supphed the distal por-
tion of the ovary, taking the place of the lateral tuboovarian
branch from the ovarian artery. In these four specimens the
distal portion of the ovary was supplied by the uterine, the middle
by the ovarian and the proximal by the uterine.

The blood supply of the broad ligament being both uterine and
ovarian, the usual blood supply of the tubes being both uterine and
ovarian, as the arteries of the broad ligament communicated with
each other and with those of the tube and round ligament, and as
the tubal arteries communicated with each other, all those struc-
tures must be looked upon as containing a potential blood supply
to the ovary. Thus the uterine and ovarian arteries communicated
with each other not only through the well-known uteroovarian
anastomosis, but also through the above-mentioned vessels.

The actual venous outlet of the ovary was partly through the
ovarian veins, partly through the uterine. Its potential venous
outlet was evident in the various communications between the
venous channels of the uteroovarian plexus, the free anastomosis
of the veins of the broad hgament and tube, and the communication
of the plexus with the epigastric vein of the round ligament.

The removal of the tube always encroached upon the potential
blood supply of the ovary and when the distal pole of the ovary was
supplied by the tubal artery (four of thirty specimens), the actual
blood supply of that portion of the ovary might be cut off.

Anatomical studies suggested that if it was necessary to remove
a tube without removing the ovary, it should be done with the least
possible disturbance of the broad Ugament, and even then occasion-
ally the blood supply of the distal pole of the ovary would be cut
off; also in hysterectomy with conservation of the ovary the
accompanying tube should be saved, if possible.

AMERICAN GYNECOLOGICAL SOCIETY 97

DISCUSSION.

Dr. Robert L. Dickinson, of Brooklyn, stated that a point in
vaginal hysterectomy was to save the uterine artery as it ran up the
side of the uterus, so that in most of the chronic cases of metritis
with incurable menorrhagia, in doing a vaginal hysterectomy one
purposely left the side of the uterus, whipping over and over by the
continuous stitch which he had published, sewing the two edges of
the uterus together and leaving the uterine blood supply to nourish
the ovary in such cases as were pointed out bj^ Dr. Sampson. This
was also feasible in the hysterectomies by the vagina for the removal
of fibroid tumors which did not involve the broad Hgaments.

Dr. Hugo Ehrenfest, of St. Louis, referred to the blood supply
in the attempt to preserve the function of the ovary, and asked
Dr. Sampson whether this question had not a very important
bearing upon the unfortunate sequelae in the preservation of such
ovaries, very small cystic ovaries, etc.

Just before he left St. Louis to attend the meeting he did a
laparotomy on an old case of tuberculosis of the tube in which one
ovary was preserved and transformed into a troublesome cystic
ovary. If such a tube was removed, would not the blood supply
thrown into the ovary be a cause of cystic degeneration?

Dr. William M. Polk, of New York, said the very complete
demonstration made by Dr. Sampson upon the blood supply had
undoubtedly brought him in close connection with the nerve supply,
and especially with the forces of the sympathetic nervous system
which, centering as they do about the lower portion of the posterior
aspect of the cervico-uterine region, bore materially upon the nutri-
tion of the entire region, and must be more or less injured in any
operation done for removal.

Dr. Sampson, in answering the question of Dr. Ehrenfest, said
it was impossible to study the effect on the ovary as regards inter-
fering with its blood supply. Chnical experience had taught us
that in conservative ovarian surgery cystic ovaries might arise which
would subsequently require operative interference. He could not
tell the exact effect on the ovary from interfering with its blood
supply. He undertook these studies primarily for their anatomical
interest and they seemed to have some surgical importance.

As to the nerves of the pelvic organs, he had tried to study them
for several years, but had not been successful. He had rather
confined himself to the study of the blood supply because he got
more out of it, but he had not been successful in studying the nerves
and the lymphatics.

incontinence of ltiine in women.

Dr. Howard C. Taylor, of New York City, said that incontinence
of urine would be found frequently if patients were asked direct ques-
tions regarding it. Without direct questions, women would speak

98 TRANSACTIONS OF THE

of the leakage only if the incontinence was sufficiently marked to
cause constant wetting. For some years, both in private and
hospital work, he had made a record of the patient's control of the
urine a part of the routine history. The degree of this control had
been recorded as normal, fair, poor or lost. A normal control needed
no explanation. A fair control was one that was normal e.Tcept on
special occasions, such for example as overdistention of the bladder,
temporary vesical irritability, times of mental or physical fatigue,
etc. A poor control was one that allowed the urine to escape on
any special abdominal strain, such as coughing, laughing, sneezing,
or with active exercise, such as golf, tennis, etc. Such patients were
wet most of the time. When the control was lost the urine con-
tinually dribbled from the patient and practically no urine was
retained in the bladder. Obviously this classification was arbitrary
and inexact and one class merged with another.

To determine the frequency of disturbance of control of the urine
in women, he had examined the records of 1006 cases in the gyneco-
logical service of the Roosevelt Hospital. The results of this
examination were given. It was found that the control was normal
in 79.4 per cent., fair in 6.8 per cent., poor in 12.4 per cent., and lost
in 2.0 per cent. That was, in about 15 per cent, of patients admitted
to a gynecological service in a general hospital, the inefiicient control
of the urine was such that the leakage constituted a disagreeable
symptom to the patient.

The nature of the pelvic lesion for which the patient applied for
relief was found, as would be expected, to influence the percentage
of cases of abnormal urinary control. Abnormal urinary control
was found in 13 per cent, of the inflammatory, 20 per cent, of the
fibromyomata and 45 per cent, of the prolapse cases.

The treatment of incontinence of urine due to lesions inside the
sphincter was to relieve the irritability of the bladder. The incon-
tinence of urine in these cases was temporary and was easily cor-
rected. The lesions in the sphincter vesicae itself which caused
urinary incontinence and which required definite treatment were the
partial destruction and overstretching of the muscles. The treat-
ment of incontinence of urine due to actual destruction of the
sphincter muscle consisting in exposing and reuniting divided ends
of the sphincter muscle. The operation was always diflicult and
the prognosis was uncertain. A successful case of this kind was
reported by Brickner. It might also be necessary to reconstruct
the urethra. The operation which he usually performed for over-
stretching of the sphincter vesicae for incontinence of urine was
one that was intended to produce an infolding of the sphincter
vesic£e and the adjacent parts of the neck of the bladder and urethra.
This was accomplished by two or more mattress sutures of fine
chromic catgut which included about one-third of the circumference
of the urethra. No attempt was made to expose the sphincter
muscle itself, but the fibrous tissue in its immediate ^dcinity was
included in the sutures.

Illustrative cases were cited.

AMERICAN GYNECOLOGICAL SOCIETY 99

The author drew the following conclusions: i. While incon-
tinence of urine was due to a lesion of the sphincter vesica only,
it was relatively an infrequent sj'mptom. 2. Incontinence of urine
due to the sphincter vesicae associated with other lesions was a
frequent and important condition. 3. In pelvic operations for
lesions associated with incontinence of urine as a symptom, care
should be used to remove all drag or downward traction on the
anterior vaginal wall and frequently to infold the sphincter vesicse.

DISCUSSION.

Dr. Frederick J. Taussig, of St. Louis, stated that in severe
cases of urinary incontinence there was often complete obstruction
of the urethra. He had had occasion to try a rather unusual
experiment. A patient had been operated on three times by
prominent surgeons in Philadelphia and Baltimore, and the operative
problem was very difficult. There was no sphincter to be found and
no urethral wall to make a plastic upon. He, therefore, thought it
worth while to utilize the anterior portion of the levator ani muscle
from one side, and pulling it underneath the vagina wall, bringing
it directly in the urethra and fastening it on both sides with catgut,
being careful to preserve the blood supply of the muscle thus
transplanted. The operative result, while not perfect, was a great
improvement on anything done before, in that the patient was
able to retain from 5 to 6 ounces of urine.

Dr. Taylor's recommendation of the use of a pessary coincided
with his own experience.

Dr. Philander A. Harris, of Paterson, New Jersey, had per-
formed different operations from year to year for the rehef of incon-
tinence. First, the twisting operation of the urethra, then vertical
cutting and horizontal sewing, gathering the tissues beneath the
urethra, and his experience had not been very satisfactory. He
had ceased performing such operations about eight or nine years ago
and was now resorting to topical applications.

Dr. Herman J. Boldt, of New York City, referred to the technic
for determining the exact location of the sphincter. While the mush-
room catheter was a very exact method of determining the precise
point where the urethra entered the bladder, where we had the vesical
sphincter it was a soft structure and did not give us exactly what we
wanted, and he had therefore resorted to the following measure:
the bladder should be distended and then an ordinary glass catheter
used, and at the point where we introduce it, the catheter should
penetrate the sphincter where the contents of the bladder came out;
this point was noted and an exact measurement taken to see exactly
where the vesical sphincter was located, and having obtained the
measurements one could cut down and get the sphincter.

As to the sutures, on one occasion, about three years ago, he had
a case of extensive injury of the bladder involving the neck so that
half of the vesical sphincter was destroyed. He found that he was
able to get, at the first attempt at surgical intervention, a satis-

100 TRANSACTIONS OF THE

factory result, but he took a very large bite around the vesical
sphincter and tied the sutures over a small glass catheter, using two
or three sutures. It did not make any difference whether one took
the extreme vesical end of the bladder with the spliincter or not;
one could take the vesical end near the sphincter and leave a part
of the urethra, that is, the nearest part of the urethra to the sphincter.
His results had been that about one-third of these patients which
Dr. Taylor had classed under poor control or no control would be
cured.

Dr. Thomas J. Watkins, of Chicago, confined his remarks to
cases encountered in the study and treatment of prolapse of the
uterus. If the urethra was not much displaced, the extent and
nature of the displacement could be determined by pressing the
urethra up toward and in the line of the cervix, and the extent to
which the urethra could be so displaced was equal to the amount of
displacement.

In placing the sutures for prolapsus he had placed them so that
when they were tied the urethra would be drawn up to a point where
it was comparatively fixed, which was normal with the urethra.
If the sutures brought the urethra up to the point where it did not
move much, then it was fair to assume the urethra was put back into
its normal location. This fixture had been in the bad cases of pro-
lapsus after the menopause where the transposition operation had
been done, the sutures having drawn the urethra up, going through
the fundus of the uterus. In some of the other cases during the repro-
ductive period loops of the round ligaments had been satisfactorily
used for that purpose. In a few cases the upper part of the cervix
or the lower uterine segment had been used. There were some
unsatisfactory results, but in others it had shortened the anterior
vaginal wall. As to the results, it was invariably found that the
partial incontinence of urine had been relieved.

Dr. Robert L. Dickinson, of Brooklyn, stated that in cases of
incontinence of urine in females it behooved the gx'necologist and
cystoscopist to examine every case. In using the Kelly cystoscope
one could tell whether there was dilatation or spasm of the upper
part of the urethra. Where the element of spasm had occurred
dilatation should be resorted to.

Dr. George H. Noble, of Atlanta, Georgia, said that not infre-
quently young women suffered from urinary incontinence on account
of hypothyroidism, and he had found that these patien ts would do well
under the administration of thyroid extract alone. I n older women,
in whom there were slight lesions in the pelvis, particul arly relaxa-
tion, where the urethra rotated under the pubic arch, there might
or might not be displacement of the uterus. Relaxation and rota-
tion of the urethra under the pubic arch put the veins upon a certain
amount of tension so that they did not empty themselves. The
nerve supply and nutrition were interfered with, there was a certain
amount of edema, and a certain amount of relaxation of the muscle,
etc. In such cases, carrying back and anchoring the urethra behind
the pubic arch by one of the many methods in use or by the inter-

AMERICAN GYNECOLOGICAL SOCIETY 101

position operation, or anchoring the rectovesical fascia, would
enable these patients to empty their bladders.

Dr. Gideon Brown Miller, of Washington, D. C, had had
two or three cases of very troublesome bladders following the
interposition operation. If one took a woman with an irritable,
chromically inflamed bladder, and disturbed its blood supply and
normal relations by putting the uterus under the trigonum, so to
speak, he would naturally expect an increase of the symptoms,
and in two cases he had had the symptoms were markedly increased
by the interposition operation.

Dr. Tay£or, in closing, pointed out that in addition to drawing
up the urethra, he would emphasize the advisability of infolding
the sphincter. Drawing up the urethra would cure a great per-
centage of these cases, and the percentage of cases could be increased
if in addition the sphincter was infolded at the same time.

PRESIDENTIAL ADDRESS: NOTES ON THE PAST, PRESENT AND EUXUEE
OF GYNECOLOGY, OBSTETRICS AND ABDOMINAL SURGERY.

Dr. J. Wesley Bovee, of Washington, D. C, in his presidential
address referred to the work and ingenuity of Sims in the treatment
of vesicovaginal fistulas, which, he said, would ever serve as a
stimulus for the disheartened struggling against formidable agencies
in various and devious avenues of study of the mysteries of the
living human body and the amelioration of its ailments. The work
of his faithful pupil, Bozeman, in this sphere cannot but arouse
admiration. Even Sims was not entirely uninfluenced by besetting
disappointments and surgical failures, for he was known to have
become so disheartened in his work in the south that he sold his
property and arranged to embark elsewhere upon a business career.
Had not the New York clothing merchants not violated their con-
tract at this juncture most likely medicine would have been deprived
of the aid of this wonderful man and the human family of the benefit
of his medical researches.

The plastic work of the eldest Emmet, and the great work of
Thomas, Polk and Fordyce Barker would always be appreciated.
The plastic perineal surgerj' of J. Collins Warren, the round ligament
operations for the rectification of posterior uterine displacements,
associated with the names of Dudley, Mann, Wylie, Simpson,
G. H. Noble, Andrews and others remained familiar to us all. Not
to refer to Hodge, Parvin, Meigs and Oliver Wendell Holmes was
to slight obstetrics with its other great geniuses.

We must recall with American pride the impetus to urinary surgery
given by Kelly who popularized direct cystoscopy and ureteral and
renal exploration by its aid as well as the advanced work of several
Americans in the scientific treatment of urinary diseases. The work
of Goffe and Baer invoked a great advance in the surgical treat-
ment of uterine fibromata. C. P. Noble, by his careful and laborious
study into the complications and degenerations of these neoplasms
rendered an invaluable service.

102 TRANSACTIONS OF THE

Of the splendid work of the past gynecology had not neglected
the great subject of cancer. This disease as it affected women was
almost limited to their reproductive organs. The uterus was the
organ most commonly invaded by it. Probably Wrisberg and
Montaggia were the first to recommend total hysterectomy for its
eradication. Marshall, in 1783, and Langenbeck, in 1813, were the
first to perform this operation, though, in their cases the uterus
protruded from each patient. In 1814, Gutberlet recommended
hysterectomy by a special suprapubic method. In 1822, Sauter,
of Constance, first performed vaginal hysterectomy for cancer of
the uterus, in situ. Recamier, in 1829, recommended a special
plan of vaginal hysterectomy and the following year Delpech pro-
posed a combined abdominal and vaginal procedure. To the lover
of medical history it was interesting to read the comments upon
these operations made by medical writers during the next few years.

Of obstetrics one must speak with considerable reserve. The
untrained obstetrician had been the weak spot in our preparedness.
The famous teachers — Parvin, Barker and others did not, to a
desirable extent, impress our profession with the importance of this
specialty. This, no doubt, was in part due to its being a heritage
from the midwife, who had striven to claim it as a possession. In
later years an earnest effort had been made by a few very efficient
teachers to secure to obstetrics a proper recognition. The vigorous
propaganda by WOliams had probably aroused the medical schools
to an appreciation of the necessity for much better facilities for
real teaching of obstetrics.

In abdominal surgery the dread of dire results from sepsis, ignor-
ance, shock, hemorrhage and several other former causes of need-
less mortality had nearly vanished. While problems in this field
of endeavor remained unsolved, diseases of the abdomen were much
better understood than formerly. Various aids were now being
employed to assist in the diagnosis or treatment of pehdc and ab-
dominal diseases, and he would dare say they would have notable
extensions. The Rontgen ray had greatly assisted in the discovery
and location of adhesions, neoplasms, ulcers and stasis of the
stomach and intestine, determining the presence or absence of biliary,
renal and ureteral calculi and indeed, with the ureteral catheter,
was an extremely reliable agent for determining whether urinary
calculi above the bladder existed. We were justified in believing it
would prove of great value in diagnosing pregnancy and various
abdominal and pelvic tumors.

The treatment of cancer of the uterine cervix continued to receive
the very earnest attention of gynecologists and special activity in
the general subject of cancer during the past three years had been
enthusiastically aided by this society. Thus far the cause of cancer
had not been found and no doubt this must be discovered before
we might reasonably expect to gain a mastery over this dreadful
disease. Its behavior, as influenced by radium and long con-
tinued, slightly elevated temperature. The use of certain rays from
radium seemed to retard its progress and perhaps completely de-

OBSTETRICAL SOCIETY OF PHILADELPHIA 103

stroyed it, while other rays from it were thought to induce the dis-
ease. If the latter was a fact we might well refuse to believe, for
the present, that cancer was of microbic nature.

In abdominal and pelvic surgery at its present stage of develop-
ment, probably no more important matter was before us than the
prevention and correction of intraperitoneal adliesions. A propa-
ganda on this subject should result in untold lessening of human
suffering.

Surelv, there were very many grave problems to be solved in
the fields of endeavor gynecologists represented, but he was fully
confident this society would in the future maintain in that work the
prestige that had come from the high character of work it had
performed.

{To he continued.)

TRANSACTIONS OF THE OBSTETRICAL
SOCIETY OF PHILADELPHIA.

Meeting of March 2, igi6.
The President, William R. Nicholson, M. D., in the Chair.
Dr. Barton Cooke Hirst read a paper on

THE training IN OBSTETRICS THAT THE STATE SHOULD DEMAND
BEFORE LICENSING A PHYSICIAN TO PRACTISE.*

DISCUSSION.

Dr. Edward P. Davis. — With much that is contained in Dr.
Hirst's paper, I am in full accord. The questions suggested by this
paper are complex, and many points must be considered.

Undoubtedly the clinical side of instruction in obstetrics needs
further development, and the point of the paper is weU taken
that time allotted for such instruction is much too short. At
least three consecutive hours should be given for such teaching.

In what way can this instruction be best accompUshed: If
we look for the ideal, out-patient service, so far as actual conduct
of confinement is concerned, may well give place to systematic
clinical instruction in properly equipped maternities. It would
be quite as logical for a department of surgery to send its students
to the houses of the poor to diagnosticate abscess, dislocation,
fracture or beginning inflammation; a department of medicine might
for the same reasons, send students to diagnosticate pneumonia,
t>-phoid, and beginning tuberculosis, at the home of patients. _ It
is alleged as the great reason for out-patient obstetric practice,

* See original article page 56.

104 TRANSACTIONS OF THE

that the student learns to overcome difficulties which can be met
in no other way; but he is forming habits at this time, and these
habits should be made where things are done in the best manner,
and not in the worst. He should form his habits by practice under
instruction in the maternity, and he will have, after graduation,
ample time and opportunity to perfect or revise these habits in the
first years of his own practice. With modern tendencies in charitable
work and medical education, the time will come when out-patient
medical service of all kinds will be largely reduced to the work of
the social service department, and when the actual treatment of
cases of all sorts will be conducted in the hospital. A further and
great advantage of hospital treatment is the fact that an instructor
can be always available at a hospital, whereas such are the un-
certainties of confinement with an out-patient service, that a
considerable number of confinements occur before an instructor
can reach the patient.

So far as the work of the State Board goes, I believe Dr. Baldy's
conception of the situation is eminently correct, that the first
duty of the State is to its citizens, and that teaching interest in
medicine must cooperate with the State Board to that end. The
best service will not be rendered to parturient women until there
is in the State a considerable number of competent obstetricians
besides those that are found in the principal teaching centers.
We endeavor to teach surgery to our students, and hope that but
few will become surgeons. The list of The American College of
Surgeons looks very large, but in comparison with the lists of the
College of Surgeons of England it is not unduly large. It is true
that surgery has grown enormously in America, but we have a
large country and a large population, and obstetrics has not by any
means obtained the same growth. The public needs competent
obstetricians in all parts of the State. A certain number of men
will qualify themselves to do obstetric surgery safely and success-
fully. These men will become attached to various hospitals through-
out the State, in their maternity departments. The action of
the State Board in causing the establishment of maternity wards
in all hospitals will greatly aid the development of good obstetric
service. These hospitals and their attending obstetricians will
form centers of professional growth, and centers of efficient service
for the population. While the smaller hospitals cannot be the
centers of teaching for a large number of students because they
have not the number of cases seen in the cities, yet these hospitals
will render important service to the State in educating the local
profession and giving relief to patients. The best interests of the
population and of the profession, alike, so far as the development of
good obstetric practice is concerned, will be served bj' the action of
the State Board in this regard.

There are economic reasons for the renewed interest in obstetrics
as a rational means of conserving the population. The waste
of human life at present is so enormous that the economic value of
human life has become greater. No method of conserving a popula-

OBSTETRICAL SOCIETY OF PHILADELPHIA 105

tion can be found so eificient as the proper development of adequate
obstetric service.

Dr. George M. Boyd. — The question of the advance in the
teaching of obstetrics is one of moment and interest. When we
think of the progress that has been made since the daj's of the rudi-
mentary training us older men received back in the So's, theoretical
and without practical instruction, we know that there has been a
great gain in this branch of medicine. I am in accord with what
Dr. Hirst has said. I feel, however, that we must create a standard,
that we rnust aim as high as possible, and that until we can work
in uniformity, until there exists in each State the same requirement,
it will be impossible to make the progress we desire. I feel that in
the State of Pennsylvania we are a step in advance of some of the
others in first requiring a year of hospital practice and part of that
time given to obstetric work. The difficulty encountered in the
majority of schools teaching medicine is that the student is not under
our direct control; he does not live within the walls of the hospital.
The hospital year provides in a measure for this defect. While the
obstetrical material may be limited in the hospital year the student
is in the hospital and has a practical knowledge of the cases. To
repeat I feel, that in teaching obstetrics the schools should aim at a
standard as high as it can possibly be, and that it should be hved up
to. Even in the small hospital there may be seen a variety of inter-
esting cases. I endorse what Dr. Hirst has said of the importance
of clinical work and the amount of time that should be given to
that part of obstetric teaching. I feel, however, that the didactic
course is important, for there is a large part of the teaching of
obstetrics that cannot be carried out in the clinic. I have enjoyed
the paper and believe that we cannot have a uniformity of teaching
until the same requirements for the practice of medicine exist in
all States.

Dr. Alice Weld Tallant. — It is with great pleasure that we
listen to any proposition for the improvement of obstetrical teach-
in in this country; it is certainly one of the places in which the
greatest need exists, and anything that can be done in this direc-
tion in this State or in any other is for the welfare of the whole
country. It is true as Dr. Hirst has said, that we in America are
far from being able to congratulate ourselves upon the require-
ments in obstetrics. So far as the State of Pennsylvania is con-
cerned we may, at least, congratulate ourselves that there is_ a
minimum requirement, since so many States do not have even this;
it is something to have the requirement of twelve cases. In regard
to dividing the cases between the undergraduate years and the
interne year, I do not understand that the minimum undergraduate
requirement of six cases carries with it a stipulation that the col-
leges shall not give more than these cases. It is perfectly true that
to see a large number of complicated cases is of great value, but it
is very necessary to emphasize the value of actual contact with the
patient. One may watch a forceps or a version case, but it is
very different to do it oneself; in the same way, many of the cases

106 TRANSACTIONS OF THE

which the students see are a help in certain ways, but not the help
that comes from the work which they have actually done for them-
selves. Dr. Davis takes exception to the out-patient practice. I
feel, however, that the training connected with the out-patient
practice of obstetrics, in which the students meet emergencies,
accept conditions as they find them and bring success out of un-
favorable surroundings, is the kind that will be of the greatest help
to them when they go out as physicians into places in which the
hospitals are not at hand; not only in the foreign field, but in our
own country. It is very easy to practise obstetrics in well-appointed
hospitals, but many of our students are going into the homes of
patients and must make the best of what they find. In our work at
the Woman's Medical College I always feel that the out-patient
work is of the greatest value.

So far as the State requirements are concerned, practically all
our students are already delivering twelve cases in their under-
graduate course, but I do not feel that it can do any harm to have
six more required after they graduate. We lay as much stress as
possible on the practical side; all medical schools do at present.
I think that the cases conducted during the college years in a certain
way of more value than the same number of cases conducted after
graduation, for the reason that in the colleges the cases are conducted
according to certain teaching principles laid down in the school.
Internes in hospitals do not get as much teaching as they should;
the staff, with the best will in the world, may be unable to teach the
internes who are in the hospitals, so that they are not given ex-
perience under the proper supervision. For that reason I feel that
to increase the requirement in the medical school would be of the
greatest value. The State has made a fine start in requiring the
number of cases that it does, and I have no doubt that it intends to
require more as the j'ears go on, and the sooner it requires more, of
course, the better. Another help in the improvement of obstetrics
would be the establishment of teaching fellowships in colleges, such
as we are offering at the Woman's Medical College this year, whereby
students may obtain special instruction in obstetrics following their
undergraduate training.

These are the chief points that have occurred to me in following
the discussion thus far. I do feel that our State has made a good
start, but I feel, too, that it needs to go ahead, farther, as I have
no doubt it will. Any increase in the requirements of college training
is to be welcomed in whatever way brought forth.

Dr. John E. James.- — I wish to go on record first of all by
stating that I am in absolute accord with the statements which
Dr. Hirst has made. I feel that Dr. Hirst has brought forth a
subject exceedingly timely. The points Dr. Hirst mentions be-
speak an ideal condition for obstetric teaching that must eventually
give higher standards in the teaching of obstetrics in the different
colleges and improve the practice of obstetrics among the general
practitioners of medicine. It is the consensus of opinion among
medical educators that emphasis should be placed upon the value

OBSTETRICAL SOCIETY OF PHILADELPHIA 107

of practical training in the thorough equipment of the medical
student. This being true, whether a student can obtain sufficient
bedside instruction in the undergraduate year without the sup-
plementary training in the recognized hospital depends upon the
number of hours which the college curriculum gi\-es the student
and also upon the clinical material available for teaching purposes.
The number of hours devoted to the clinical and didactic instruc-
tion in obstetrics is decidedly below that which it should be. I,
therefore, feel that the law of the State of Pennsylvania in de-
manding the hospital year supplemental to undergraduate study is
a most vitally essential educational adjunct. The greater amount
of practical training we give our students the greater will be the
reduction in mortality and morbidity — and I believe the morbidity
rate is to be considered equally with the mortality — and we shall
see a lessened amount of poor obstetrics among general practitioners.
Many objections will be raised regarding the hospitals to which men
shall go for this supplementary training. The men in charge of
the so-called, maternity hospitals in many instances are not of
sufficient caliber to give the supplemental training. Likewise many
of the hospitals have not sufficient clinical material for instruction.
I believe, however, that the hospitals can be brought up to the
proper standard by the board of licensure or other board legally
appointed. Under present conditions I feel that the position of the
Pennsylvania Board of Licensure in demanding a hospital year is
a most excellent one. I feel that they should go one step farther
and designate by proper control the different hospitals to which
the students should be sent for their supplementary teaching.

Dr. J. M. Baldy. — There is nothing that would give me higher
pleasure than to be able to attain the ideal and to attain it at once.
My experience in the last five years of this work has been that
when I have gone after the ideal I have lost the whole gist of that
which I was after. Idealism is not attained in leaps and bounds,
but by evolution. Now I am in hearty sympathy with all the
essayist has had to say regarding what ought to be. The question
is, can we get, and are we going to get something until we get the
ideal. It must be borne in mind that the teacher in the school
has one viewpoint, that the administrator in the State has another.
The State should prod on the laggard, but should not set a pace
beyond which all can reasonably go. The State is not legislating
alone to educate the interne, but to secure the best medical care
for the people of the State. The education of the interne, however,
reacts upon the people of the State, although his education is a
mere incident. I at first thought the solution of this whole matter
was very simple, but many things are to be considered in order to
accomplish results. I think the essayist himself has not thoroughly
understood the Law of Pennsylvania. By it the Bureau of Licensure
is not tied down as are all the other States by hard and fast acts of
Assembly. There is an element of discretion allowing the Bureau
to advance the standard as rapidly as in their judgment is advisable.
If the time has come when the medical schools of the State have

108 TRANSACTIONS OF THE

performed that which the State requires, then the Board of Licensure
will go another step and yet another. That which the State has
been doing in the hospitals has been looked upon in two ways, and
must not be confused. It is supplementing the work of the medical
school. The requirement of the hospital is a minimum of six ob-
stetric cases: so the Act says; a maximum is to be at the discretion
of the Bureau of Licensure. The Bureau is ready to advance to-
ward that maximum if the schools of the State are. The people
of the State are entitled to a proper practice of obstetrics. We are
well aware they are at present abominably served by some of the
men on the hospital staffs. The interne often goes out of the
school infinitely better prepared to give that service than many on
the staffs of many of the hospitals. The State realizes that fully 50
per cent, of the doctors in the State are not fit to teach obstetrics.
This requirement of six cases in hospitals is only a beginning
and whether we shall succeed in our endeavors to standardize the
hospital properly depends upon whether we shall have the back-
ing of such a body as this; we need the backing of the best element
of the profession. The work we are trying to do is not meant to
take the place of the undergraduate school. If I am assured to-
night by any of the teachers of medical schools that they are full}^
meeting the requirements of the six cases, within a few days we shall
have under consideration the increase of the requirement to twelve
and when the time is ripe, this will be increased to twenty. I
do not mean that every school must follow; but, if five can do so,
the others will have to, unless they can show us that it is impossible.
It is up to the medical schools to say when the advance shall be
made. The doctors in the State in the small communities need
proper teaching. There should be installed in all hospitals a
certain number of obstetric beds with competent men and then
the community could be educated to go to those beds and not to
the midwife. Dr. Davis struck the keynote. How are we to get
better service to the State if we do not turn out better obstetricians,
and how shall we train these men if they are not given opportunities
after leaving the school. This was illustrated by an incident in
my own town of Danville and is typical of the whole situation:
A young man who had been graduated from the University of Penn-
sylvania Medical School, said to me, "Dr Baldy, what's the use of
your Bureau requiring us to take all the laboratory and scientific work
we have to take at the college, when we never have an opportunity
to use this knowledge." As you give them opportunities they will
develop themselves and will give the towns good obstetrics as well
as good surgeons and they will be teachers themselves to the younger
men who come to them as internes. We cannot accomphsh that
in a day or in a year. We are endeavoring to lay so solid a founda-
tion that when the politicians put us out we will have left a heritage
upon which the profession can build forever afterward.

Dr. James Wright Markoe, N. Y. — This subject interests me
greatly. Twenty-six years ago the work of the Lying-in Hospital
in the City of New York started from a pecuHar circumstance.

OBSTETRICAL SOCIETY OF PHILADELPHIA 109

Connected as I was with the College of Physicians and Surgeons
as house surgeon of the Sloane Maternity Hospital, I found on going
to Boston that they had an out-patient department where they
taught the students practical obstetrics and I came back very
enthusiastic over the idea and presented it to the College of Phy-
sicians and Surgeons, but they said the proposition could not he
carried out. I called attention to the same service done here in
Philadelphia, and still they insisted upon it that it was not prac-
ticable, so I started this thing then with the idea of giving out-
door education in obstetrics. Twenty-six years have gone by.
Through the indoor and outdoor services of that hospital have
passed 100,000 cases; we have educated some six or seven thousand
students although we are not connected in any way with any
institution. Students come to us — undergraduates and graduates
from all colleges and from all States in the United States. They
come because we give them something they cannot get anywhere
else. This may sound egotistical, but it is not, for we have the
most abundant clinical material in New York of any city as it is
the largest city of the United States, and therefore must have more
clinical material. The question comes up in Pennsylvania, of how
to educate the students? My one thought all these years has been
for the medical men, alone in the country who are without aid and
without consultants within easy reach. I want to give such men
a knowledge of obstetrics which will not make them capable of doing
a hysterectomy as perfectly as Dr. Hirst or Dr. Davis will do it,
but will make them competent to take care of any ordinary cases
so that their mortality will be no higher than the general run of the
best maternity hospitals. I believe that it can be done by teaching
these men at the bedside. I do not agree with Dr. Davis that the
out-patient department is of no value. I think the very fact that
a man has to take care of a woman where there is nothing at hand
but water — and very often that is dirty water — is a very great
education. We in the Lying-in Hospital have done this under the
strict supervision of as well-educated instructors as we can get.
By our plan a man goes to a case and is followed in an hour by an
instructor. He is visited every two hours by that instructor, and
if he makes any mistakes they are corrected by the instructor, and
each student sees from twenty to thirty cases in that way. The
first part of their service is given in the hospital where they see a
large number of complicated cases from which they have a good idea
of their duties in the out-patient department. I have had letters
from ex-students saying they would not take a thousand dollars
for the experience gained in the tenement houses. We have reduced
the mortality in these cases managed by our students considerably
below the mortality of the physicians, taking all physicians in the
City of New York. We have a great deal better mortality than the
run of doctors in the City of New York, notwithstanding that
these cases are taken care of by students. When I look back over
those twenty-six years and think of the very few teaching insti-
tutions there were then in the United States and think of the ob-

110 TRANSACTIONS OF THE

stetricians we have sent throughout the towns and cities of this
country, I feel proud of the progress made. I do not belittle the
fact that we must seek much greater progress but if the State of
Pennsylvania, or any other State, will guarantee that their students
graduate with a knowledge of what the fundamental principle of
obstetrics should be by practical bedside instruction indoor and
outdoor it will have accomplished a wonderful amount of work
in the right direction.

Dr. Alexander Marcy, Jr. — Personally I have been very much
interested in listening to the papers read and to the discussion
following. The sentiment has been quite in keeping with our idea
in New Jersey as to what should be required before a license to
practise medicine shall be granted. I am free to confess that
Pennsylvania at the present time is just a little in advance of New
Jersey along this particular line. We in New Jersey have hereto-
fore been leaders in medical licensure and in our requirements,
and I think our law at present is second to none in the country,
excepting in some particulars. I think Pennsylvania has rather
"put it over on us" in this matter of hospital standardization and
requirements for the teaching of obstetrics. This year, however,
after July i, we do require in New Jersey a year of interneship
before a person will be allowed to come before the Board for ex-
amination. We have not, however, stipulated the number of
hours he should take in practical obstetrics or the number of cases
he shall attend before he comes before the Board. From what I
have heard to-night I think we shall have to amend our law, and I
think we shall make the number of cases twenty-five.

Dr. Adolph Koexig, of the State Bureau of Medical Education
and Licensure, Pittsburgh: I did not intend to make any remarks
here to-night, but came simply to listen and to gain some ideas.
I do feel, however, that I should commend the statements which
Dr. Davis has made here to-night; they appeal to me as being good
common sense and in keeping with the situation as it exists at the
present time. It is an easy matter to say that we should have things
ideahstic. I am thoroughly in accord with everything that Dr.
Baldy has said. As a Bureau, we are absolutely a unit on these
things, believing that they are evolutionary. Such an example
of inefficiency on the part of an obstetrician as was mentioned
by Dr. Hirst is an arraignment against the college graduating such
men.

I regret that the Bureau of Medical Education and Licensure has
no way of sizing up the personal equation of a candidate or of in-
vestigating his ingenuity. That is something which should be
done by the college, and I believe is now being done. Twenty to
thirty years ago or less the intellectual status of a candidate for
the study of medicine was never inquired into by the colleges.

I am thoroughly in accord with the requirements regarding ob-
stetrical experience in the hospitals. The Bureau is standardizing
them and investigating their ability to give the opportunity for
the acquisition of such experience. An approved hospital stands

OBSTETRICAL SOCIETY OF PHILADELPHIA 111

between the school and the general practitioner. If the college
thinks the present number of required cases right the Bureau I
am sure will not object. These hospitals carry the graduate to the
time when he will be upon his own responsibility — even though he
may not have the highly qualified teacher to supervise, he still has
some one to fall back upon when he gets into trouble. That is a
condition very much better than the old situation.

I am very glad to be here and to have heard what has been said,
and I am heartily in accord with most of the sentiments e.x[)ressed,
especially so with what Dr. Baldy has said.

Dr. Richard C. Norris. — I think this meeting has been well
worth while; it has clarified the atmosphere, and has given us all,
clearer ideas of what this law established by the State means.
Every one will agree, that the higher the college raises its standard
in obstetric teaching the better. Unless internes are properly
trained in their early experience in obstetrics, they cannot expect
to be masters in the art and science of that branch. The orthopedic
man, the eye man, the general surgeon, the internist, the laboratory
— all clamor for the same advance in their departments while the
roster is crowded beyond the student's endurance, and there must
come a time when medical students, to be better educated along
all lines, will have to use the hospitals for a final year of instruction
and experience. The State says to the obstetric-teaching institu-
tion, raise your standards as high and rapidly as you will, and we
will meet them. They are doing their best now, and they will do
better. When we come to study the relationship of the State law
as to the year's interneship in the hospital, the paramount question
at issue to my mind is the advantage to the community. The
matter must be viewed in its relation to the teaching institution,
to the student, to the community and to the doctor. As. Dr.
Baldy has said the matter is in process of evolution, and no State,
not even Pennsylvania, could at once make a law that would meet
all these conditions and satisfy every one concerned. Dr. Baldy
has also brought out the essential point of the benefit not only to
the student, but to the doctor. You will remember that in the
earlier days the great surgical operations came to Agnew and Gross
who had established teaching centers and developed their art.
Those conditions no longer prevail. Hospitals now exist in each
community, and have created able surgeons. Where there is a
hospital there is a need for a surgeon; when there is a maternity
there is need for an obstetrician, and that need will create the sup-
ply. So I can see that hospitals compelled by the State to have
obstetrical departments, will find the morale, the skill and the
experience of their obstetrical staffs increasing rapidly just as surgery
has been developed in those hospitals in the recent past. There is
no question to my mind that this movement is one to uplift the
educational standards of our State in regard to the student and the
doctor. If obstetric surgery is developed to its highest point it
must be done in our hospitals. Let a man leave his school having
seen a large number of Cesarean sections, unless he has had personal,

112 TRANSACTIONS OF THE

close range experience, such as he gets in the hospital working with
the surgeon, he is not well trained in that particular operation. He
must be trained in surgery to meet the demands of modern obstet-
rics since advances in the latter have been largely surgical. As I
have heard the paper and discussion this evening, I have realized
more f ulh' that Pennsylvania has put a powerful lever under medical
education and especiallv under obstetrical education, and that
as time goes by we shall see more and more the benefits resulting
to the profession and to the community and I believe that the ob-
jections raised by Dr. Davis to the out-patient department will
disappear. In the past the woman had to be treated in her home;
the student had to be taught the care of the woman in her home.
While the public is being educated to the advantages of hospital
obstetrics there will be less and less demand for out-patient obstetric
work. However, until every woman seeks hospital service, out-
patient training for the medical student cannot cease to have its
value. Bearing upon this subject, only to-day I had the Chief
Resident Physician at the recently created Maternity Department
of the Methodist Hospital look over our records. The new State
law brought this department into existence. Since April 19, 1915,
we have had 127 confinement cases; five high forceps; seven low
forceps; two vaginal Cesarean sections; four abdominal Cesarean
sections; three podalic versions; seven induced labors; two crani-
otomies; one cleidotomy; one ruptured uterus; twelve cases of
eclampsia. That one, hitherto, general hospital should have this
amount of obstetric surgery to teach five men, shows how valuable
this new law is to hospital internes and to obstetrics. Had these
cases been in the University Hospital or other college hospitals
more students would have seen them, but the knowledge acquired
by these five men has been of greater value to them since they
actually helped in the work at close range. It is, however, out in
the country, in the small community, that this kind of emergency
obstetric work will drift more and more into the hospitals equipped
for maternity work. I believe we should uphold the hands of our
State Board; should ask the colleges to raise their standards higher
and higher, and at the same time the State Board should see to it
that the hospitals throughout the State are just as efficient in their
obstetric departments as in their laboratory and research work, for
which the State has set a standard.

Dr. Seneca Egbert. — What I may say is from the standpoint
of the Dean who has to keep in touch with the schedules of the
various students. I listened to Dr. Hirst's paper with a great
deal of pleasure. While the six (or twelve) cases are the minimum
number required, I do not believe there are many schools in the
State in which the number of cases participated in does not much
exceed this amount. The opportunities at the Lying-In Charity
Hospital in this city are by no means small, and when we consider
the work given here to the medical student in addition to that of
the various teaching institutions, we must acknowledge that the
number of obstetric cases seen and cared for by the average student

OBSTETRICAL SOCIETY OF PHILADELPHIA 113

is considerably above that required by the State law. From the
standpoint of the school it would seem that so long as it is under the
regulations imposed by the various governing bodies, such as the
Council on ]\Iedical Education which have no legal control but
much moral influence, we can do little else than we are doing. At
the recent meeting in Chicago of the Council on Medical Education,
one of the speakers proposed that some of the present teaching hours
be cut out to give the students more time for reading and recreation.
From the fact that a medical student has over a thousand hours of
scheduled work a year you can get an idea of what he is supposed
to do. He must also do a lot of work at night. It seems to me
there is chance for possible improvement in rearranging our schedule
that obstetrics may be taught in a compact way for a certain part
of the senior year. Regarding hospitals, why should there not be
established throughout the State certain obstetric hospitals to which
men from other hospitals might go for a certain portion of the
hospital year and for which the time could be counted as part of
that year?

Dr. Charles P. Noble. — We all should feel reassured by what
we have heard to-night. Thirty-two years ago I entered the
practice of medicine as a student and teacher of obstetrics. For
five years I was connected with the old Lying-in Charity. I think
it is true that it fell to my lot — not through any merit of my own —
to do the first clinical teaching of modern obstetrics in the United
States. Just by accident I attended the first course of demon-
stration of modern obstetrics ever given in the United States in
1883. My teacher was Dr. Neal of Baltimore. Coming to Phila-
delphia a youth I very promptly became the first assistant at the
Lying-in Charity and so it fell to me to give that first course. That
was in 1S84 or '85. Now the contrast between the obstetrics taught
in the United States to-day and that of that time is very gratifying.
In spite of the fact that there is very much that should be modified,
we are to be congratulated that in one generation so much has been
gained. I should also like to congratulate the Philadelphia Ob-
stetrical Society upon the way it has trained its members in speak-
ing. I have not had the pleasure of hearing many of these men
speak for a number of years and I think that they have all greatly
improved in my absence. I am quite in sympathy with the pur-
port of most that has been said to-night. Certainly with what Dr.
Hirst said I am in sympathy, because it is the wish to have here
in the United States the ideal which they have all over Europe,
except perhaps in England. On the other hand, I believe that Dr.
Baldy is quite right in that all through the country these hospitals
which have been small comparatively' have been the means of train-
ing surgeons competent to deal with all kinds of work. It will
also be true that in the' departments in the smaller hospitals
obstetrics will be much better taught and practised throughout
the community.

Dr. Charles Edward Ziegler, of Pittsburgh. — I am in entire
agreement with the position taken by Dr. Hirst — that the student

114 TRANSACTIONS OF THE

should receive his practical training in obstetrics before graduation
and not during his year of interne service in such hospital as he
may happen to enter. Certainly practical instruction in obstetrics
should be regarded as an indispensable part of the student's under-
graduate medical education. The teaching of the fundamentals
in any branch of clinical medicine is a serious business and to take
it out of the hands of trained, responsible teachers and turn it over
to poorly or indifferently trained practitioners — too busy and too
little concerned to give the matter more than passing consideration
— is in my opinion a very grave mistake. Successful and effective
teaching is developed and is to be found only in institutions where
teaching is seriously, systematically and deliberately done under
careful supervision and control. It is generally conceded that the
standards in both the teaching and practice of obstetrics in this
country are very low— the lowest in fact of all the clinical branches
of medicine. Improvement must begin with the medical schools
which alone may be depended upon to set the standards. To
transfer even a part of this work to the general hospitals through-
out the state, over which the medical schools have no supervision
and no control, will in my opinion accomplish two things: First,
it will prevent the fullest development of great obstetric teach-
ing institutions so much needed in this country and second, it will
lower rather than elevate the standards not only of the teaching
but also of the practice of obstetrics.

I am in full sympathy with the work of standardization of the
hospitals of the state which is now being carried on so efficiently
under Dr. Baldy. In my opinion, however, it should be done, not
for the purpose of providing better clinical teaching for students
during their fifth or hospital year, but largely, if not solely, for
the purpose of securing better medical work on the part of both
the attending and interne staffs of the hospitals. I am inclined to
the belief, moreover, that on the whole better results would be
secured by adding a fifth year to the undergraduate instruction
in the medical schools, to be spent in the hospitals which are an
organic part of or under the control of the medical schools. During
this clinical year, three months should be spent in the obstetric
hospital and dispensary services which are a part of the department
of obstetrics of the school of medicine. With rising standards in
medical education and corresponding reduction each year in the
number of graduates, it will be increasingly difficult for the hos-
pitals, whether good or otherwise, to secure internes under the plan
so long in existence. At present, recent graduates in medicine
enter hospitals very largely for the clinical experience which they
hope to receive and the hospitals accept them very largely because
of the free service which they are expected to render. The result
is that the internes do not receive the training which they should
and the hospitals receive poor service. The time is fast approach-
ing when to secure and hold internes, hospitals will have to pay
something for their services and this they can well afford to do after
the internes have spent a year of undergraduate clinical work under

OBSTETRICAL SOCIETY OF PHIL.^DELPHIA 115

competent teachers and in favorable surroundings. Such internes
would be of real service to the hospitals and as a result would be
given wider opportunities for experience, to say nothing of the
influence which they would have in elevating the standards of practice
in the hospitals which they serve.

Under present conditions of four years of undergraduate in-
struction in this State, the student should spend several weeks during
his fourth year in a well-equipped and properly conducted ma-
ternity hospital and dispensary. Such institutions should be
teaching and research institutions in the fullest and broadest sense
of the terms, with a large amount of obstetric material freely and
constantly available for the purpose. The teaching staff and there
should be no other, should consist of full-time workers only, who
should be paid salaries sufficiently large to make them independent
of all other work. This condition of affairs is essential if the teach-
ing is to be maintained at its maximum efficiency and the obstetric
material fully utilized as it presents itself. When we speak of
clinical teaching in obstetrics, we do not refer alone to formal
clinical lectures given in an amphitheater, before a score or a hundred
students, so many hours a week. On such occasions only cases
available at the time can be used so that but a very small part of
the clinical teaching can be given in this way, even though well
given and most valuable when it occurs. Since labors occur during
all hours, both day and night, at irregular, uncertain and unexpected
times, olsstetric teaching from the clinical side must necessarily
be a continuous performance irrespective of eating, sleeping, recrea-
tion and study. Each labor case must be utilized to the fullest
to teach and to learn all that it offers in order that the student may
have the largest opportunity possible during the hmited period
assigned to him for his practical work; and also because by using
each and every case as a teaching case, the complications and
unusual things are thereby the most certainly discovered and util-
ized to the great advantage of both teacher and student, to say noth-
ing of the incalculable benefit to the patient. I am well aware that
competent obstetricians cannot be trained by undergraduate
instruction alone. On the other hand, much more can and should
be done for undergraduate students in obstetrics than has as yet
been done in this countr}'. I am likewise aware that the four years
of undergraduate instruction in medical schools is already so fully
occupied that not much more can be diverted from other subjects
for obstetrics. With a system of intensive teaching such as I have
described, much more can be given the student, however, than he
now receives. During the time of his service, the student should
be given ample opportunity for the examination of pregnant women
including vaginal examinations, abdominal palpation, auscultation
and pelvimetry. He should follow case after case through labor
from beginning to end, always under the most careful supervision
and instruction of trained teachers. He should not only be allowed
to observe deliveries, but should conduct them as well under super-
vision "and instruction. Opportunity should be given also for

116 TRANSACTIONS OF THE

repeated vaginal examinations on parturient women — each case of
labor being used to the fullest extent for teaching and practice —
with due regard, however, for the strictest asepsis. The student
should follow most carefully the puerperal convalescence of every
patient in the hospital at the time of his service, especially those
whose deUveries he has witnessed or conducted. The care of the
babies should form an important part of the hospital instruction.
Bathing, care of the eyes, the giving of enemata, the doing of re-
tractions or circumcisions, inspection of the stools and the modifica-
tion of cows' milk for infant feeding should all come in for con-
sideration in the most practical manner. At the close of his hospital
service the student should enter the dispensary service, where under
close supervision he should be required to care for pregnant, par-
turient and puerperal women, following the technic, as far as may
be practicable, which he has learned in the hospital.

In our work at the Magee Hospital, three students are on duty
at a time. Each student gives the anesthetics for four cases during
the close of the second stage; as second assistant, he counts the fetal
heart sounds, observes the character, duration and frequency of the
pains and controls the fundus and uterine contractions during and
following the third stage of labor for four cases; and as senior as-
sistant, he assists with the ninth case and finally delivers under
supervision and instruction, the tenth, eleventh and twelfth cases
in his service. At the close of his service in the hospital, the student
is sent into the out-patient service where he conducts four more
cases under supervision and instruction. He is thus present at a
minimum of sixteen cases of labor, seven of which he has personally
conducted under instruction and supervision. If his work thus
far has been satisfactory he is then permitted to conduct alone
and upon his own responsibility as many additional cases as he
has the time and inclination for.

This briefly is the method followed in teaching practical ob-
stetrics to undergraduate students at the University of Pittsburgh.
During the coming year we shall have not less than 1500 cases of
labor available for teaching purposes. If sufficient time were avail-
able we could give to each of the twenty-five members of the present
fourth year class the opportunity to conduct personally, under
supervision and instruction, twenty-five cases of labor. And this
is what we hope, sooner or later, to accomplish for our students
before graduation.

Dr. Hirst, closing. — I have two things to say: I shall go from
this meeting with an even greater admiration for the work done by
my old friend, Dr. Baldy, than before I came to it. I fear I do not
deserve Dr. Noble's congratulations, for I seem not to have made
myself clear. The one thing which I wanted to make clear was
the defect in our laws, in not requiring an adequate amount of time
to be given to the study of clinical obstetrics on the roster. That
is what I would hke our legislators to take into account, in addition
to cases attended.

OBSTETRICAL SOCIETY OF PHIL.'UJELPHIA 117

Dr. Norman L. Knipe and Dr. John Donnelly read a paper on

THE TREATMENT OF ECLAMPSIA AND ITS RESULTS.*
DISCUSSION.

Dr. James Wright Markoe. — Dr. Knipe's paper is most interest-
ing and it makes me blush to think of the results he has obtained
when my results have been so bad. In going over my records in
the Sloane Maternity Hospital I found the history of a fatal case of
eclampsia treated in June, i88S, when I was an interne there. The
patient was a girl of seventeen and was moribund when brought
into the hospital. She was given lo minims of Magendie's solu-
tion which dose was repeated; I sat up all night and gave it to her,
55 minims in aU. Her heart action grew weak and we then gave
her some whiskey. Her temperature rose to 108.2 and we for this
gave her 60 grains of antipyrin, but her temperature did not
come down, so we gave her 60 grains more. She got a little more
morphine and a good deal of chloroform and I do not know what
other drugs, I think possibly some croton oil. I sent for the attend-
ing obstetrician, Dr. Partridge, and he came and did a Cesarean
section, obtaining a macerated fetus; the woman then died. That
was twenty-eight years ago, and that kind of treatment is sometimes
given, barring the antipyrin, in these present days. Now, what
was the etiology of that case? There is no doubt about it now — ■
it was a true toxemia of pregnancy — a condition which we still
know little about. Some of you may remember the studies of these
cases made by our Dr. Welch, who was a most careful observer of
this condition. He suggested that there might be some changes
caused in the blood-vessel walls by the toxins weakening the walls
and allowing the migration of the blood into the tissues. Be
that as it may, these are cases that are occurring in all services, I
believe in localities under certain atmospheric conditions. Last
year I had the United States weather reports brought to me and every
day, every toxemia case or of threatened eclampsia was written
on the back of the weather report, and I propose to find some man
— and I believe there is such a man who will interpret weather con-
ditions— who can help me trace any possible connection between
atmospheric conditions and eclampsia. We have those cases of
eclampsia which no treatment will help. We had one this week;
my first assistant treated her with the morphine treatment in the
very latest and approved method, but she died. I cannot show any
such statistics as Dr. Knipe has shown to-night. In 100,000
admissions, we had in these cases a mortality of 24.3 per cent.
That, however, is not a fair statement because in the first 250 cases
we had a mortahty of thirty plus. In eclampsia some cases will
get well, no matter what you do; others, no treatment will touch.
I have not made up my mind what is the best treatment. However,
in the case of every woman with eclampsia coming into the hospital

* See original paper page 63.
9

118 TRANSACTIONS OF THE

whether or not she has had convulsions, I put into her stomach as
large a dose of castor oil as I can with the idea of getting it through
the bowel if possible. Whether you give morphine or not I am
satisfied that chloroform and chloral do harm. Whether morphine
has the effect of reducing the convulsive action and thereby curing
the disease, or whether it has an effect upon elimination b\' the kid-
neys and other organs is a question that I cannot solve because I
have not had enough cases to convince me. Last week I had two
eclampsia cases; one died immediately and the other got well,
both on the morphine treatment. We are now using this treatment
to see what can be done in a certain series of cases.

I think the paper is most interesting and that the statistics and
results are splendid.

Dr. Edward P. Davis. — ^Like Dr. Markoe, I have tried the various
methods of treating eclampsia, and agree with him in recognizing
it as an expression of toxemia. So diverse and complex is the
toxemic process that statistics on this subject are especially mislead-
ing. Toxemia includes the pernicious nausea of early pregnancy,
and terminates in the fulminant process which may or rriay not be
attended by convulsions. In truth, one may for some time have
very favorable results in the treatment of this condition, provided
one is moderate in whatever he does, but then will come a series of
cases where the toxemic process is especially severe, and these
patients will die, no matter what is done for them.

In the present stage of our knowledge, unquestionably the best
results are obtained by treating in the most vigorous and efficient
manner, the toxemic process. No greater mistake can be made than
to immediately deliver, by some obstetrical operation, every patient
coming under the observation of an obstetrician, and suffering
from the toxemia of pregnancy. The number of convulsions is not
a decided element in the case, nor is blood pressure, for some cases
with high pressure recover, and others with low pressure die. Nor
does the occurrence of labor end the danger, for some of the most
rapidly fatal cases develop after the birth of the child.

In treatment, one will do well to avoid depressing agencies of
every sort, and to use anesthetics as little as possible. Bleeding
followed by intravenous saline transfusion, lavage of the stomach
with the introduction of calomel and soda, copious irrigation of the
bowels, and the securing of as much fresh air as possible for the
patient, are of great practical value. Should labor develop, it
should be assisted, but not forced. When there is no tendency to
labor, the uterus should remain undisturbed. In very rare cases,
with mother and child in fairly good condition, an undilated and
undilatable cervix and birth canal, is delivery by section advisable.

At least two weeks must elapse after the delivery of a patient
suffering from fulminant toxemia before her recovery is assured.
Gangrenous pneumonia and acute mania may result fatally.

Dr. Barton Cooke Hirst. — There is a curious fashion at present
to decry the advantages of sweating in eclampsia. This, I think,
is a mistake. The objection is based upon the theory that the

NEW YORK OBSTETRICAL SOCIETY 119

toxins of eclampsia are of a kind that cannot be well eliminated
and are concentrated if the patient is sweated. But this theory does
not tal^e into account the fact that all cases of eclampsia are also
cases of acute parenchymatous nephritis in which the kidneys cease
to act. The urine is very scanty and solid with albumin. In such
a case no general physician would omit elimination by sweating.
I have found that sweating is an extremely efficient adjuvant of
treatment and that it is a mistake to overlook it.

Dr. James. — I have little to add, simply to say that in threatened
eclampsia, tjie preeclamptic stage, the absolutely conservative
treatment to my mind is the ideal; namely, to leave the uterus ab-
solutely alone. The treatment of the case of true eclampsia I
think involves a study of the individual case regarding the time of
delivery. In a general way I would favor early emptying of the
uterus selecting the most conservative procedure. I agree with
Dr. Hirst upon the question of sweating. We should get rid of
the so-called toxic state. With the sweating we may associate
gastric lavage and washing out of the intestines. I would also use
morphia, which has quite a potent value. Chloroform I believe
is contraindicated.

Dr. John C. Hirst. — If we advise immediate and forcible de-
livery in eclampsia much work will be done in private houses and
under unsatisfactory conditions, thereby giving an added danger
of surgical shock and septic infection. I would regard, therefore,
the dictum of routine forcible delivery in private houses a very
real danger. The number of convulsions is not, I think, an im-
portant element in the mortality. One patient in the University
Hospital had been taken with convulsions in her own home. She
had them rather actively for twelve hours. At the end of this
time she was taken to the hospital when she had 199 others and
recovered. She thus had a total of over 250 convulsions, and in
spite of this, the case terminated favorably.

TRANSACTIONS OF THE NEW YORK
OBSTETRICAL SOCIETY.

Stated Meeting, February 8, 1916.

The President, Dougal Bissell, M. D., in the Chair.
Dr. Geo. W. Kosiiak reported a case of

gangrene of THE SIGMOID .-VETER NORM.AL L.ABOP.

The patient was a para-ii, whose first pregnancy ended as a
miscarriage at the fourth month. She had applied for care during
her confinement to the Outdoor Department of the Lying-in Hospital

120 TRANSACTIONS OF THE

and developed false labor pains on December 20, 1915. The cervix
was one finger dilated and thick, the head not engaged, fetal
heart good, temperature and pulse normal. The patient was seen
again about nine hours later when an examination showed the head
engaged, membranes ruptured and cervix three fingers dilated.
The labor progressed without incident and at 4.40 p. M. dilatation
was complete, a spontaneous labor taking place at 7.15 p. m. A
second-degree lateral tear was repaired with three chromic- and one
silkworm-gut sutures. After dehvery the temperature and pulse
were normal and the patient was left by the attendant in good
condition. Wlien visited the following morning her condition was
the same but when visited again at 5 p. m. the temperature was 102,
pulse 160, abdomen tympanitic with marked rigidity on the left
side. The family said that this condition of collapse came on during
the afternoon without warning. The patient was immediately
transferred to the hospital and arrived in a condition of pronounced
collapse. The pulse was faint and irregular, the abdomen somewhat
distended but not tympanitic and the patient was passing watery
movements involuntarily. In view of the extreme collapse she was
stimulated and no further treatment attempted. Vaginal ex-
amination showed the uterus well contracted, no tears in the cervix
or vaginal vault and lochia of normal appearance. The patient
complained of slight abdominal pain. An examination the next
morning showed the general condition improved and the distention
not increased. An exploratory laparotomy was done on the after-
noon of December 21 by Dr. Asa B. Davis. Upon opening the
abdominal cavity in the median line a thin straw-colored fluid with
slight odor was discharged. The small intestines were slightly
distended and examination of the descending colon showed a
condition of advanced gangrene extending from the brim of the
pelvis to the straight portion, about 14 inches in length. No
evidences of perforation were found. The uterus, tubes and ovaries
were apparently normal. A moderate amount of thin puru-
lent fluid was present in the lower abdomen and in view of the
patient's poor condition nothing further could be done e.xcept to
insert gauze and rubber tube drains in either flank and through
the culdesac. The patient failed to rally from her collapse and died
about two hours after operation. An examination through the
abdominal wound confirmed the operative findings. A careful
inspection of the mesenter}' failed to show any evidence of thrombosis.
The gall-bladder, pancreas, spleen and liver seemed to be normal as
far as palpatory evidences were concerned. The sigmoid could
readily be pulled down into the pelvis and a possible e.Kplanation
of the gangrene of the descending colon in this case is that it was
due to pressure by the fetal head in coming through the brim
resulting in a bruising of the tissues and cutting off the blood supply.
A careful search of the coils of small intestine showed merely a few
patches of lymph but no evidence of perforation or general peri-
tonitis. The case is of interest, showing the possibility of such un-
foreseen complications during labor and the difficulty of making

NEW YORK OBSTETRICAL SOCIETY 121

an early diagnosis. The collapse with rise of temperature pointed
to a possible perforation of one of the hollow viscera and even if an
exploratory laparotomy had been done earlier it would not have been
possible to have afforded the patient any relief.

DISCUSSION.

Dr. Robert T. Frank said: "I was not here at the beginning of
the reading of the report but in my experience the difficulties are
more often seen before rather than after labor.

"I suppose the Society remembers a case reported a number of
years ago by Dr. Brettauer, which I recall very vividly, where the
patient was brought into Mount Sinai Hospital about eight months
pregnant, I think, with symptoms of intestinal obstruction. For a
number of hours she refused operation, but finally she was persuaded
to allow herself to be delivered and delivery was induced very
promptly. She was a multipara, the child was small, and im-
mediately after delivery a volvulus was found. The patient was
in an extremely bad condition and the only method that could be
applied was the quick one of eventrating the bowel. She finally
recovered after a stormy illness.

"Several days ago I saw a patient who was three weeks before
her term. She had had pyelitis early in her pregnancy and again
had developed another attack of pyehtis, this time on the left
side. At the same time she had intractable vomiting, for which I
could find no definite cause, and she, furthermore, passed very little,
if any, flatus. Enemata were practically ineffectual. In con-
sequence of this mixed feature I was very much in doubt whether
or not I was confronted with an intestinal obstruction as the indi-
cations for delivery were rather clear. I induced labor and during
the twenty-four hours before delivery this vomiting kept up in-
cessantly. Her urine was full of indican and full of acetone, but as
soon as the fetus had been delivered there was a free discharge of
gas per rectum and the vomiting had stopped. Three days have
now passed. Whether there was some slight obstruction due to the
head pressing on some part of the intestinal tract, or whether the
obstruction was secondary to the pyelitis, plus a little toxemia, I
am unable to say. At all events, it is quite clear that we are oc-
casionally confronted with symptoms, particularly during the
latter part of pregnancy, which are hard to distinguish and which
really force us to induce labor in order to distinguish."

Dr. Franklin A. Dorman presented a

REPORT OF a CASE OF FIBROMA OF CERVDC OBSTRUCTING LABOR.
CESAREAN SECTION, WITH HYSTERECTOMY.

Patient, M. R., negress, single, para-i, twent3'-eight years old.
Menses began at thirteen, regular every twenty-eight days, moderate
flow, five days' duration, occasional pain, of late flow somewhat pro-
fuse. Last menses April 15, 1915. Labor pains began January 20 in
the afternoon. Entered the hospital on the following day. The pains
were irregular, far apart and of poor quahty. Late in the afternoon of

122 TRANSACTIONS OF THE

January 22 the cervLx was dilated one and one-half fingers, the pains
were occurring once every fifteen minutes. At 5.30 p.m. a No. i bag
was inserted. This increased the frequency of pains to ten-minute in-
tervals. Four hours later the bag came through and a No. 3 bag was
introduced. As there was no further progress after the expulsion of
this bag, the case was seen by me on the forenoon of January 23.
Patient was in good condition and although the membranes had rup-
tured twenty-four hours before, the fetal heart was good. The pelvic
measurements were spines 24, crests 26, obliques 21, external con-
jugate 20, diagonal conjugate 10.5, true conjugate 9. The cervix
now admitted four fingers but was thick. The head was high. A
fibroid the size of a golf ball could be felt in the anterior wall near the
fundus. A Cesarean section was performed and a seven pound
infant delivered. The uterus showed the presence of four fibroids
of varying sizes. One small one projected into the lumen of the
uterus, another in the posterior wall of the cervix and was evidently
the cause of the dystocia. Because of the presence of the fibroids
and the previous long dry labor and instrumentation the uterus
was removed by supravaginal hysterectomy. The specimen shows
a fibroid the size of an olive in the cervical segment. The fibroids
were undoubtedly the cause of poor uterine muscular action, and the
cervical fibroid plus the pelvic flattening caused the obstruction.

DISCUSSION.

Dr. Austin Flint, Jr.: "Some years ago I had occasion to do a
Cesarean section, while attached to the Staff of the Lying-in Hospital,
for fibroid of the cervix and the woman didn't get well. I had oc-
casion, at that time, to look up the statistics, which were not so
voluminous as they are now, and I was very strongly under the im-
pression that it was much better, so far as the prognosis was con-
cerned, to do a hysterectomy following the operation of Cesarean
section for fibroids, than it was to sew up the uterus and preserve
it. I do not remember the figures now because it is a good many
years ago, but I was wondering whether in the discussion of this
subject, if there be any further discussion, it is the general knowledge,
the general impression, that it is better to do a hysterectomy follow-
ing Cesarean for fibroids rather than to try to do the more conserva-
tive operation.

Dr. Edwin B. Cragin: "I think that we could even go a step
farther than Dr. Flint seemed to go. I believe, from my e.xperience,
that it is safer to do a hysterectomy after Cesarean section if there
are many fibroids in the uterus rather than to run the risk of further
trouble, so if I have a case with a number of large fibroids in the
uterus and have to do a Cesarean, I prefer to take the uterus out.

By Dr. Austin Flint, Jr.: "I mean the question of immediate
prognosis; that it is better for the woman."

By Dr. Ed\mn B. Cr.\gin: "During the puerperium?"

By Dr. Austin Flint, Jr.: "Yes."

By Dr. Edwin B. Cragin: "That is as I understand it."

Dr. Brooks Weli.s wished to put on record a case illustrating
a danger of leaving a uterus containing fibroids after Cesarean

NEW YORK OBSTETRICAL SOCIETY 123

section. The patient was a multipara of fourty-four, who had borne
two children; the first died at birth, the second was born after a nor-
mal labor and is now living. For several years the patient has had
a fibroid in the posterior wall of the uterus which caused no menstrual
disturbance or discomfort. Was asked to see her by Dr. Guion, of
New Rochelle, when she was nearly at term. We found a fibroid
nearly the size of a clenched fist obstructing the pelvis and, as this
could not be displaced, decided to do a section at the beginning of
labor. To this the patient assented, but would not consent to a
hysterectomy, though the risk of leaving the fibroid was explained.
The skin of her entire body was covered, as it had been in each of her
previous pregnancies, with flat purplish red papules of lichen, with
many vesicles and some pustules, crusts, and numerous scratch
marks. There was intense and constant itching. This rash
had been treated by two prominent dermatologists with no apparent
benefit, and as in former pregnancies did not disappear until the end
of the puerperium. Three hours after the beginning of labor Dr.
Wells with Dr. Guion's assistance did the section at the New Rochelle
Hospital, dehvering a living child.

On admission to the hospital the temperature was loo and pulse
1 20. The next day the temperature reached 101.2, with a pulse
of 112. On the fourth day the temperature was normal, with a pulse
of 88. On the seventh day it rose to 102.6, with pulse of 120, and
until the fourteenth day ranged between 99 and 105.6, with a pulse of
from 96 to 128, the pulse being of good quality and only 108 at the
time of the highest temperature. During this week she had five
chills. On the sixteenth day the temperature reached normal with a
pulse of 72. The abdominal wound healed without suppuration,
and there was no evidence of any trouble about the uterine wound.
There was no abdominal tenderness or distention at any time.
The lochia were normal. Blood culture was negative. On the eighth
day the white cells were 18,000, with a differential polynuclear of
84 per cent. The urine remained normal.

The patient did not feel badly, except that she was bothered
by the severe itching and complained of general aching during the
periods of high temperature.

Was the patient's condition caused by a toxemia by absorption
from the fibroid, or from the skin condition, or from a surgical in-
fection?

We felt at the time that the high temperature was due to absorb-
tion of toxic material from the fibroid.

At the present time the fibroid can be palpated but is insignificant.

Dr. Henry C. Coe: "I was reminded of a patient who attended
the Polyclinic about twenty-five years ago. She came regularly for
a year or two and was a useful example to the students because she
had a small nodule in the lower segment, anteriorly, about the size of
an English walnut, which could be easily felt. I lost sight of her
for three or four years. When I was asked to see her again she was
eight months pregnant and the tumor had increased to the size of a
baseball. Although this was in the preaseptic days a Cesarean
section was performed with a successful result. I did not venture

124

TRANSACTIONS OF THE

to do a supravaginal amputation on account of the high mortaUty
which then attended this operation. Two years later the patient
was admitted to my service at the General Memorial Hospital
suffering from double pyonephrosis and general septic infection,
which resulted fatally — a striking commentary on one of the possible
dangers of impacted libroids; the tumor had doubled in size and
compressed both ureters."

Dr. Frank A. Dorman: "I had two motives in doing a hyster-
ectomy in this case. First, I had the same feeling voiced by Dr.
Flint and Dr. Cragin, that a fibroid or several fibroids are a dangerous
element in an involuting uterus, particularly after Cesarean section,
and, secondly, I felt that it was a distinct menace to the woman to
leave the uterus in a case which had been examined in one hospital
and then sent to another, being in labor two days while dilating bags
and various manipulations were employed. For these reasons I
did the hysterectomy."

Dr. E. H. Ely read a paper on

acidosis in pregnancy, with report of a case treated by
transfusion.*

Dr. Edward Lindemann spoke by invitation as a guest of the
Society and after describing the technic of blood transfusion de-
veloped by him, continued as follows: " I think that the presentation
of this case is somewhat an illustration of some of the things that
might be done with such a method of procedure.

"After developing this system of transfusion my next interest
was centered in determining the relative compatibility of blood for
patients. In the first eighteen cases that I had transfused no
blood tests were made. There was not a single case of incompati-
bility or hemolysis, and one naturally with an experience of eighteen
cases, would suppose that blood tests were superfluous, unnecessary
and meaningless. I was simply very fortunate. The subsequent
cases, however, were not quite so fortunate. Some cases of in-
compatibility had occurred, so I took the position that I would re-
fuse, except under the most urgent circumstances, to transfuse
without first having preliminary blood tests. In making these
preliminary blood tests I found that my percentage of reactions in
terms of chills and fever, was approximately 33 per cent. There
was a number of cases free from chills and fever and yet the same
system of transfusion was used. The question was, could there be
anything in the s\'stem of transfusion that might be responsible
for the chills and temperature which were present in some patients
and not present in others? This was found upon investigation not
to be the case. Further, a number of cases occurred in which blood
tests had been made and yet hemolj'sis had occurred. In each one
of the cases where hemolysis had occurred where hemoglobin or
hematoporphyrin appeared in the urine in small or large quantities,
the blood was subsequently referred to other scrologists who knew
nothing of the circumstances, and in each instance it was found that

* For original article see page 42.

NEW YORK OBSTETRICAL SOCIETY 125

the first serologist was in error. In other words, laboratory workers
had their Umitations and it is only by constant vigilance that
these cases of hemolysis can be eliminated. I finally got to the
stage where I was even unwilling to submit my tests to any other
serologist, so I did the tests myself. The results were as follows:

"Sometimes it requires one donor, sometimes two donors, some-
times three donors, sometimes twelve donors, sometimes twenty
donors, sometimes forty donors and as many as seventy donors were
tried before I was willing to accept one for a certain case. It may
be possible to obtain the right blood in the first case tried, but in one
case it took seventy donors before the right one was obtained.
ChiU reactions in personally supervised cases were reduced from
33 per cent, to 8 per cent, and even that 8 per cent. I think can
be somewhat reduced with increased care. There was not a single
case of hemolysis and not a single untoward result from transfusion
in the last 200 cases which I tested myself. I think this demon-
strates that hemolysis and posttransfusion reactions that occur
are due to errors in the laboratory that can be avoided by the most
careful kind of work.

"After satisfying myself with the compatibility of the blood
my next interest was centered in blood transfusion therapy. Hav-
ing a valuable measure at our disposal, what is it good for? I have
tried it out in a large variety of cases."

At this point in the discussion, the doctor referred to a paper
which he wrote on this subject a year or two ago in which he pointed
out the possibility of altering the blood of a donor to meet the need
of a given case. Continuing, he said:

"This is the first case of the kind that I have met with and here
we have something which, for want of a better word, is nothing
short of dramatic, not only in its scientific aspects, but also in its
clinical manifestations. If you look at the temperature chart in
this case you wU see that this patient had a Uttle fever, which is
characteristic of adults in acidosis, and at the point where she was
transfused, we get a little serum reaction indicated by the tem-
perature. In the second transfusion we get a serum reaction again
after which the temperature runs practically flat. As we pointed
out in the paper more striking are the figures in the other charts.
Urine analyses can only give us an idea of what the patient is putting
out and not what he has within. What is making the patient sick
is not always what is put out, but what is retained.

"We are indebted to Cyrus Field for his very careful analysis of
the blood. Dr. Ely has already commented on it. I cannot say
very much more on those charts. The most important figures are
the figures of the carbon dioxid absorption: the patient jumped
from 55 to 94 per cent. It cannot be accounted for by the simple
law of averages. It must be due to something which has actually
happened in the patient. For instance, the donor has a blood
alkalinity of 80 or 90 per cent, and mixing it with 55 per cent,
alkahnity of the patient's blood we get, perhaps, 65 or 70 per cent,
average. What has happened there is this: the blood of the donor

126 TRANSACTIONS OF THE

had been highly alkahnized. This high alkalinization was mani-
fested by one fact, namely, that two days after the donor was
tapped and iioo c.c. of blood were removed, the hemoglobin which
should have been 70 per cent, registered 115 per cent, on the Dare
scale. In acidosis the blood is very light, the effect of alkali on the
blood is to deepen the red tint of the hemoglobin. In the alkalinized
donor the amount of hemoglobin was the same as a nonalkalinized
donor .similarly tapped and yet the effect of the alkali on the donor
was such that it caused it to register 115 per cent, instead of 70
per cent.

"In talking this over with some of the chemists and clinicians
in town I was told that it was impossible to increase the alkalinity
of the blood, and if increased it would be incompatible with life."

After a reference to hydrogen iron, the doctor continued, saying:
"I subjected this problem to experiment in order to prove the point
I made because I was certain that something had happened to that
blood, and I was certain that no blood could have registered 115
per cent, when it should have registered 70 per cent, (this experi-
ment will be reported in full elsewhere) unless there was something
intrinsic which had occurred in the blood, so I took a man and gave
him what I thought were the same doses of sodium bicarbonate that
were given to the donor in this case. Blood and urine analyses
were made before the administration of the alkali and analyses were
made in subsequent periods, at the end of two hours, at the end of
four hours, at the end of eight hours and at the end of twenty-
four hours. It was impossible to get any variation in the CO2
content of the plasma and it was also impossible to get any
variation in the actual sodium present by reducing the blood to
an ash and measuring the amount of sodium obtained from such
an ash. It looked a bit disappointing. One thing, however, was
noted and that was that the urine was very alkaline and this alka-
linity appeared very shortly after the administration of the sodium
bicarbonate. In measuring the amount of bicarbonate given to
the donor and to the man on whom I e.xperimented it was found
that I was giving this man practically 40 per cent, of the amount
that had been given to the donor in this case. Furthermore, it
was found that the alkali was eliminated so fast that unless we got
the blood at shorter intervals the alkali would appear in the urine
before we had a chance to measure it in the blood, so a second man
was put to the test. He was fed 20 grams of alkali in one dose.
He received his first dose at ten o'clock in the morning and his
last dose at midnight of the same day. It was fed to him every two
hours and at the end of the eighth dose of alkali in the form of
sodium bicarbonate, amounting to 160 grams, which in grains is
2400, the blood was taken at intervals from this man. Before the
administration of the alkali the carbon-dioxid plasma registered in
terms of carbon-dioxid content, 0.66. Twenty minutes after the
fourth administration of alkali it registered i.oi, which is a higher
degree of alkalinity than any one of us in this room here possesses.
At the end of forty minutes he had 1.03, a trifle higher than at the

NEW YORK OBSTETRICAL SOCIETY 127

end of twenty minutes. Now, the next significant point is that at
the end of an hour and ten minutes he had 0.97 of carbon-dioxid
content. The next morning lie had 0.89, showng that this alkahnity
at first rises very high in the blood and then gradually disappears.
It was furthermore evident that it was necessary to give such a huge
amount of alkali that the kidneys were unable to excrete all the
amount offered to them, so the alkali must necessarily be present
in the blood. The hydrogen iron concentration had diminished from
0.78, which is practically normal, to 0.7756. The actual milligrams of
sodium in the entire blood have not as yet been analyzed. I expect
to have that finished in the course of the next few days, but these
figures prove the case, and if one were to sit down and write figures
in order to prove his case no more ideal figures could be offered to
you than these which have been proven in this experiment. We
have here a new method of treating what is one of the most helpless
conditions of aberrant intermediary metabolism. The administra-
tion of alkali, as we pointed out in the paper, is possible by mouth,
by rectum, under the skin and into the veins. When your patient
vomits persistently the amount of alkali that the patient can take
into the stomach is decidedly limited. If the alkali is administered
by the rectum a mucous colitis after a time is set up and the ab-
sorption and retention of the alkali is markedly diminished. In-
troduced under the skin it is very painful and causes a charring of
the tissues. When you overalkalinize the blood the blood is apt
to be converted into a jelly. Introduced into the blood stream some
of the bicarbonate is converted into carbonate and it is impossible
to measure in milligrams the amount of carbonate that you can
safely put into the blood."

The doctor concluded his remarks by citing a case which he had
in Connecticut several years ago in which the administration of
sodium bicarbonate resulted in the patient's blood being converted
practically into a jelly, and this after the second administration.
In that case the doctor stated he had been instructed to give 30
grams of sodium bicarbonate per liter.

Dr. Robert T. Frank, said: ''The questions arising in this
case are rather complicated. In the first place, is this a case simply
of acidosis? Ordinarily in acidosis during pregnancy emptying
the uterus is followed, either promptly or fairly promptly, by
recovery or death. Here this patient lingered at least twelve days
with practically no improvement after the operation, and yet
she did not die. That in itself is somewhat different from usual.

Q. " I would like to ask Dr. Ely what her hemoglobin was before
the transfusion. Was it high? Was it low?"

A. "It was low, about 55 per cent, or 60 per cent.; I have for-
gotten."

" Evidently not very low.

Q. '■\\Tiat did the urine show? Were there any particular
abnormaUties in the urine?"

A. "No. The usual analyses did not show any."

"It seems to me that it is verv hard to determine whether this

128 TRANSACTIONS OF THE

is a simple case of acidosis uncomplicated by some other condition,
as, for example, a grave liver involvement.

"The interesting question is, What did the transfusion do in this
case? I agree fulh' with those clinicians and chemists who told
Dr. Lindeman that the blood alkalinitj' cannot be changed. The
mechanism which governs the alkalinity of the tissues and of the
blood is one of the most important factors upon which the welfare
of the individual depends; it is a very clever one and a very complete
one. There is a coarse mechanism by which large quantities of
acid can be taken care of dependent in the main upon the quantity
of sodium and calcium and magnesium in the blood. In addition
to this, there is a very finely balanced, minute mechanism, which is
due to the fact that phosphoric acid is combined with sodium and
hydrogen in such fashion that you can have a sodium acid phos-
phate, the symbol of which would be NaH2P204, or it can change
into Na2HPo04. In other words, by adding the acid radicle or
discarding a hydrogen atom the compound becomes either alkaline
or acid. This is a very delicate mechanism. Of course, it is possible
temporarily to poison individuals by enormous doses of bicarbonate
of soda such as Dr. Lindeman used in his experiments. That such
poisoning of the donor is either wise or will be efficient in trans-
fusion I very much doubt because the slight increase of actual
alkali which is transmitted by the transfusion is so minute that the
mechanism of the recipient will at once balance this slight increase
in alkalinity. In other words, if the transfusion works in these
cases (and this case while striking, of course, is only a single in-
stance), if numerous further instances can be adduced the theory of
its action must be explained in some way other than by simple
alkalization. The reason I asked whether the hemoglobin of the
donor was very low is that through her prolonged illness there might
have been produced an anemia which was relieved by transfusion.
"The second thing I want to call attention to is this: These
acid products, after all, although they are acute poisons, only act
in an extremely limited way. They are simply indicators of the
profound and deeper change present in the liver. The liver is
unable to perform its functions. Consequently these acid products
occur in the blood and in such quantities that they no longer can be
ehminated.

"Then I want to warn against using chemical figures which in
the one case are derived from a patient in a condition of acute
starvation and in the second figures from a patient who is receiving
plenty of nourishment. The only figures of proof would be such,
for instance, obtainable in animals, in which you have a starved
animal in a condition of acidosis and, on the other hand, a normal
animal starving, but not yet in a condition of acidosis. The com-
parison is not fair because the conditions are different.

Dr. Austin Flint, Jr.: "I feel I cannot contribute anything to
the discussion except to say that the case presented is unique. The
paper opens up a field to obstetricians which so far hasn't been
opened up at all, and it seems to me, it holds out a promise which

NEW YORK OBSTETRICAL SOCIETY 129

might help us in conditions of acidosis of pregnancy, which, as we
all know, is a serious thing. I am particularly interested in this
because I have had a patient in the last week who is pregnant
showing acetone and diacetic acid, very persistently, with traces of
albumin in the urine. I saturated her as much as I could with alka-
lies by mouth, which she took well, and I am glad to say that after
four or five days of such saturation the urine became, first, neu-
tral and now alkaline and the diacetic acid has disappeared, much
to my relief. She had no casts or evidences of kidney disease.
I do not know whether if I hadn't been able to change her urine
and the albumin persisted, it would have been necessary to termi-
nate the pregnancy.

"I think we ought to feel very grateful to Dr. Ely for bringing
this before us for our instruction and for further study."

Dr. J. Milton Mabbott, in discussion, said: "I would like to
refer to the statement made by Dr. Frank and to ask for information
as to whether he stated, or intended to state, that oxidation occurs
in the liver; the oxidation of other things besides proteids, oxidation
of sugar, for instance, whether it doesn't occur in the tissue cells
throughout the body. Does Dr. Frank intend to convey the idea
that the oxidation of sugar, or glucose, in the system occurs in
the liver?"

Dr. Frank: "No. What I meant was that oxidation is limited
to the liver. It takes place in the cells and all other structures in
the body, but the main metabolic intake is taken care of in the liver
before it reaches the rest of the body through the circulation."

Dr. M.vbbott: "Then, of course, the pancreas is instrumental
in furnishing to the blood hormones or internal secretions, elements
which the tissue cells throughout the body absolutely require in
order to enable them to oxidize certain products — at any rate, sugar.
That, I think, has been demonstrated by experiments at the Rocke-
feller Institute."

Dr. a. H. Ely: "I have nothing to add so far as the physiological
chemistry is concerned. I presented the paper believing that it
opened up a field that would be interesting to all of us. There are
even mild degrees of acidosis that sometimes try us and certainly in
private practice these cases can be and should be more constantly
kept under observation. I feel that with knowledge and ability to
aid us in not only finding a means of relieving suffering but perhaps
saving life we should do so. As I brought out my conclusions it
seemed to me that while this case presented an unusually severe
acidosis it is well worthy of further investigation and particularly
one that this Society ought to be tremendously interested in.

Dr. Lindeman can answer Dr. Frank with regard to certain of his
ideas relative to the effect of alkalization of the blood in his experi-
ments."

Dr. Edward Lindeman, in a further discussion, said: "When
a state of acidosis takes place there is something interfering with
the intermediary metabolism. We can localize that to a considerable
degree in the liver. When we give an alkali we simply neutralize

130 TRANSACTIONS OF THE

the acid. In transfusion oxidases are introduced, thus we attempt
to repair the break in the chain and reUeve the hver of the toxic
effect of the unoxidized unsaturated fatty acids in the blood. By
introducing oxidized substances present in the normal blood we
appear to more completely oxidize what the liver cannot do.

"Dr. Frank said that the amount of alkali that can be put there
is very small and he agrees with the chnicians and chemists with
whom I spoke regarding the alkalinity of the blood. Fortunately I
showed these same figures to the same clinicians and chemists
yesterday and they agreed with me that according to the figures, it
can be done. These figures cannot tell a false story.

" I mentioned the fact that before alkalization the donor had 0.66
of carbon dioxid of plasma. That has nothing to do with sodium
phosphate or any other kind of phosphate. It shows what sodium
bicarbonate was present in the plasma and that is an index of the
alkahnity of the blood. The second figure after alkalization was
1. 01. In other words, the alkalization of the blood was increased
almost 53 per cent. If that isn't sufficient or too small an amount,
I think our case of alkalinizing the donor must fall. But I am rea-
sonably certain it will not."

Dr. Wm. E. Caldwell read a paper on

A REPORT ON THREE C.\SES OE L.ABOR FOLLOWTNG

VENTRAL SUSPENSION.*

DISCUSSION.

Dr. Edwin B. Cr.\gin said: "Some years ago I read a paper
before the American Gynecological Society relating some experi-
ences that I had had with fixation first and then with suspension
and reached the same conclusion, that neither a fixation nor a
suspension was a safe operation on a woman in the child-bearing age,
and although most of the members recognized the danger of a fixa-
tion, they hadn't at that time recognized the danger of a suspension.

"It is no discredit to a late surgeon of this city. Dr. Frank ^larkoe,
to say that Dr. Markoe and I had a case in common. Recognizing
the danger of a fixation and realizing the importance of another
child in this family, he performed a ventral suspension in the most
careful way and with a beautiful surgical result and I dehvered that
woman in her first pregnancy after his suspension. It was an easy
delivery and we both felt that the suspension in that case had been
a great success, and yet her next pregnancy brought the result
shown here to-night. The suspension had become a fixation in the
meantime and I had to take her to the Sloane and perform a Cesarean
section, so, in the first place, we have to recognize that a fixation is
not safe and, in the second place, that a suspension may become a
fixation and give all the dangers of a fixation.

"Before I sit down there is just one thing more that I would like
to say and that is this: some women are peculiarly prone to adhesions

* For original article see page 50.

NEW YORK OBSTETRICAL SOCIETY 131

in the abdomen, whatever operation we do, and even in such an
operation as the GilHam, which I have done over 500 times, I have
had one case in which a man in Boston had to perform a Cesarean
section where the fundus was adherent to the abdominal wall, although
the fundus was not intentionally suspended and it was not inten-
tionally touched.

Dr. Hir.\m N. Vineberg: "May I ask Dr. Cragin to define to us
the difference between a ventral fixation and a ventral suspension?"

Dr. Cr.a.gix: "May I answer that question now? I am simply
taking the definition made by Kelly who devised his operation of
suspension after he knew the dangers of fixation where we used to
suture the fundus not only to the subperitoneal tissue and the peri-
toneum, but to the fascia. Kelly in his operation sutured the fundus
only to the peritoneum of the abdominal wall and subperitoneal
tissue, the sutures not passing through the fascia. That was the
distinction made by Kelly in his effort to avoid the dangers from
fixation."

Dr. Vixeberg: "I do not think that is a good definition. I
don't think it makes much difference after all whether you pass your
sutures through the fascia or peritoneum. The difference as I
understand it and as it was formerly understood, was that when you
did a ventral fixation you scarified the anterior wall and removed or
cut away the peritoneal covering of the uterus and got an adhesion
between the muscular body of the uterus and the fascia of the recti.
In fact, the peritoneum was left uncovered at that point. It is a
fixation in the lesser sense and was known as Czerny's operation."

Dr. Austin Flint, Jr.: "I must confess that I rise again to speak
with some diffidence, having risen several times before, but my excuse
is that I am familiar with all the cases as they occurred in my service
in the hospital.

" There are two points brought out by the paper which I think will
partly account for the reason that the subject was worked up.
One is the prevention of such a condition, and the second is. What
are we going to do with this condition when it exists? I don't think
there is much room for a discussion of the prevention. Nobody
ought to fix the uterus in the child-bearing period unless the patient
is sterilized. There is only one other point in the matter of preven-
tion and that is, when we find such conditions as were present in the
second case — dense adhesions all over the abdomen and ovarian
disease — we should take into account the possibility of the woman
becoming pregnant and try to prevent that possibility by divi-
sion of the tubes or some other method of sterilization during the
operation.

"A more interesting question is. What are we going to do when you
have to deal with the case of a woman in pregnancy with a mass of
adhesions between the abdominal wall and uterus?"

At this point in the discussion Dr. Flint referred to the question
of delivery by Cesarean section or by way of the vagina, the latter
method on the theory that it is safer.

Continuing, he said: "In this series one patient was delivered

132 TRANSACTIONS OF THE

through the vagina and two had Cesarean sections. All three died.
I have had one other case where a woman died after Cesarean section
for adhesions between the uterus and abdominal wall.

"In the first case reported in the paper, the baby was dead, and
the leg was down in the vagina and it seemed (I saw the case with
Dr. Caldwell and the other members of the staff) that it would be
easy to extract that dead child through the vagina, using a moderate
amount of force, more safely than we could operate on her by
Cesarean section. The adhesions were tremendously dense, cover-
ing the whole anterior surface of the abdomen. I would like to
emphasize the fact that a great deal of gentleness was used because
we knew of the conditions present, and still she died in an hour or
two and it was impossible by ordinary digital examination to find
any rupture of the uterus. Rupture of the cervix? Yes, but we
see lots of cases with torn cervices and the women do not die.

"In the other two cases Cesarean section was the alternative
chosen. It wasn't that they died because of the Cesarean section,
but because of the tremendous amount of abdominal complication
existing in addition to the uterine adhesions, intestinal adhesions,
lots of them, and in the last case a condition of sepsis before the
woman came to operation. I happened to remember that in another
hospital where she was discharged she refused operation and went
home and, as can be said of so many of these desperate cases, she
turned up at Bellevue as a sort of last resort.

"A thing that might be brought out in this discussion is, What is
the safest procedure to follow in such cases when dense adhesions
exist? That is. What is the best way to deliver a woman who has
dense adhesions following one of the operations for uterine suspen-
sion or filiation? That, it seems to me, is a problem that is still
unsolved." At least as far as any hard and fast rule is concerned.

Dr. William S. Stone: "Dr. Flint brought out a point which
leads me to say that I believe that all these cases should be in-
dividualized in regard to their method of dehvery, but, as he explains
in his first case, the presence of a leg in the vagina is not altogether
a satisfactory indication for delivery per vaginam. It depends
upon how much more than the leg is in the pelvis and it seems to
me that such an indication has accounted to a great extent for much
of our bad operative obstetrics; that is to say, it is a temptation to
think that because there is some small part of the fetus in the pelvis
we can disregard the serious conditions above, and I believe it would
be impossible to give any general advice on the best way to treat
such cases. The cases that have been reported to-night vary
tremendously in the actual conditions present when operation had
to be performed."

Dr. William P. Pool said: "The definitions of the operations
of ventrosuspension and ventrofixation which have been given do
not conform to my previous ideas of these operations. I have be-
lieved that ventrosuspension is performed by bringing about an
attachment between the uterus and the peritoneum of the anterior
abdominal wall, but that ventrofixation rcc^uires that the fundus be

NEW YORK OBSTETRICAL SOCIETY 133

brought through the peritoneum and sutured firmly to the under-
side of the muscle, while the peritoneum is sewed about it.

"It seems to me that the specimens shown to-night do not make
out a good case against ventrosuspension during the child-bearing
period, because there has been something more than mere suspension
in each one of them. The adhesions exhibited in all of these cases
indicate a considerable degree of peritoneal inflammation, and are
not at all typical of the normal condition following the usual ventro-
suspension. We have had experience with a considerable number
of labors following ventrosuspension without dystocia, and I have
also had the opportunity to see the results in three cases where the
abdomen had been reopened for some other cause. In these cases
the uterus was not in direct contact with the abdominal wall, but
was suspended to it by a false ligament which allowed a considerable
degree of mobility. This is what ventrosuspension aims at, and we
beheve that such cases do not have dystocia. The point of the
operation is to avoid fixation, and to get a true suspension of that
character."

Dr. George W. Kosmak said: "There is just one point that
might aid us in attempted prognosis in these cases which Dr. Flint
referred to. At the Lying-in Hospital we have had quite a number
of them and from past experience the position of the cervix and head
always gives us some indications as to the probable outcome of the
delivery. In two of my own cases which I reported in the paper
referred to, a ventral suspension was done after the manner of Kelly
and in both instances a delay occurred in the engagement of the
head, but the cervix was in the axis of the birth canal. In both of
those cases waiting a little while and stimulating the pains finally
resulted in pushing the head into the pelvis and delivery by the
natural passages took place. In the other cases which we have had
at the hospital in which we found it necessary to do a Cesarean
section, the cervix was inverted in the posterior position and the
head would not come into the birth canal because the axis of the
uterus was in such a position that engagement could not take place.

"I think it might be a safe rule to follow that if the cervix is in
the line of the birth canal and the head engages, a delivery through
the natural passages is possible, whereas if the cervix is posterior
and remains so, no attempt should be made to dehver the fetus by
the natural passages, because if you do, whether by version or other
means, you are bound to produce in almost every instance a rupture
of the uterus.

"In a few cases of this kind in which I have done abdominal
Cesarean section, where adhesions took place between the fundus
and abdominal wall, the results were very good. I didn't lose any
of the cases. The last one was only a few weeks ago, a Greek woman,
previously operated on in Greece, probably a Kelly operation.
This was followed by rather extensive adhesions and the uterus was
so fixed to the anterior abdominal wall that I did an extraperitoneal
Cesarean section through the line of adhesions. On opening the
abdomen I found that, although there was a strong band between

134 TRANSACTIONS OF THE

the lower segment and the abdomen, the upper adhesions were
almost made up of omentum; at least, the omentum had slipped
down between the uterus and abdominal wall. There was no post-
partum hemorrhage and although a part of the abdominal wound
became infected, very good final result was obtained. In that case
the cervix was high up posteriorly and there was no attempt at
engagement of the head, so, personally, I feel that the fact noted
would be a fairly safe method of diagnosing the eventual delivery
in these cases."

TRANSACTIONS OF THE BROOKLYN
GYNECOLOGICAL SOCIETY.

Meeting of February 4, 1916.

The President, Dr. William P. Pool, in the Chair.
Dr. L. Grant B.aldwin reported a case of

inoperable cancer of the cervix with amenorrhea.

Mrs. X., aged forty-two, Italian, married seventeen years and
never pregnant, consulted me for amenorrhea. Twenty-three
months ago she had amenorrhea for twelve months. Following
this she menstruated regularly for seven months. When I saw
her she had not menstruated for four months and for this alone she
sought advice. The most rigid questioning failed to bring out any
evidence of pregnancy or of spotting at any time during these periods
of amenorrhea. There was no irritation about the pudendum or
other evidence of a vaginal discharge, the existence of which she
positively denied. The examination revealed the cervix completely
involved with cancer to the vaginal junction, with fixation of the
uterus. She was well nourished and had no symptoms whatever
of malignant disease. The lesson is that, even with amenorrhea, a
woman may have cancer of the cervix.

Dr. Alfred C. Beck reported

TWO instances of weak uterine scars following
cesarean section.

CAse I. — Mrs. A. R., aged twenty-seven, Italian, was delivered
two years ago by Cesarean section. After having been in labor
for twenty-four hours the patient was sent to the hospital by a
midwife who had been in attendance. Examination on admission
showed the fetus presenting by the vertex with considerable over-
riding. The pelvis was generally contracted, the diagonal conjugate
measuring 9 cm. Conservative Cesarean section was performed.
The puerperium was febrile. On the seventh day the wound

BROOKLYN GYNECOLOGICAL SOCIETY 135

showed infection and opened up down to the peritoneum. After
six weeks the mother and child were discharged in good condition.
Four months later the patient returned to the clinic with a hernia
at the site of the abdominal incision. In July, 1915, she reappeared
at the clinic when it was discovered that she was about three months
pregnant. On Jan. 6, 1916, abdominal examination through the
hernia showed a thinned-out area in the anterior wall of the uterus
as a result of which fetal parts could be very easily outlined. As
the patient was within ten days of term it was thought unwise to
allow her to remain at home and run the risk of rupture of the
uterus when labor commenced. She accordingly entered the
hospital where, on the following day, a second Cesarean section was
performed. The anterior surface of the uterus and the omentum
were densely adherent to the abdominal wall and the uterine
scar was found to be very much thinned out. The uterus was
entered through these adhesions, making the operation extra-
peritoneal. The puerperium was uneventful and the mother and
child left the hospital in twenty-two days.

Case II. — Mrs. A. G., aged twenty-seven, Italian. The previous
pregnancy, in 1914, was complicated by eclampsia. She was
brought to the hospital after the third convulsion. Because of the
fact that she was a primipara at term, with a large fetus and not in
labor a Cesarean section was done. The puerperium was afebrile
after the third day. The mother and child left the hospital on
the twenty-tifth day. On Jan. 26, 1916, this patient again entered
the hospital in labor. Examination showed the fetus lying obliquely
with the breech in the left iliac fossa and the head in the right
upper quadrant. The cervix was almost fully dilated and the
membranes were intact. Under anesthesia it was found impossible
to move the head in any direction and it was thought that it was
bulging through the thinned-out scar of the previous Cesarean
wound. The membranes were ruptured, a foot was brought down
and the child was delivered by breech extraction. During the
extraction the lateral mobility of the head was restricted until the
breech had descended sufficiently to allow the head to be pushed
out of the bulging portion of the uterus in which it was held. Un-
fortunately the uterine cavity was not explored because of the fear
of infection.

DISCUSSION.

Dr. Hussey. — In regard to the doctor's last remark about
toxemia, I am reminded of a case in which I did a Cesarean section
in a primipara seven or eight years ago for eclampsia, the first done
in Brooklyn, I think, and which I reported here. The point I
want to bring out is, that although she was not a very large woman
and had a justo-minor pelvis, she later deUvered herself of a second,
third and fourth baby without any trouble. The question of post-
cesarean scar difficulties is a most interesting one. I have had several
unfortunate results with these cases. I have operated on four cases
for rupture, three of our own and one from another hospital. Two

136 TRANSACTIONS OF THE

of these cases ruptured with the third child and one with the fourth.
Ever}- woman who has had a Cesarean is a risk in subsequent
labors. I do not know how we can tell how thin the scar is or
what the danger is but we must be prepared for rupture and every
such case should be delivered in a hospital.

Dr. Commiskey. — The first of Dr. Beck's cases comes under the
head of the possibly infected women and those of us who have
access to the larger clinical facilities come in contact with them not
infrequently; and it is just here that opinions and experiences
differ as to the best method of treatment. It has been my plan in
these instances to make a large incisioii, deliver the uterus out of
the abdomen, close the abdominal wall temporarily by means of
clamps behind the uterus and protect the peritoneal cavity with
several large pads or sponges. The uterus is then incised, emptied,
sutured and washed with saline externally, the field of operation
redressed and the uterus returned to the abdominal cavity. The
results have been most encouraging.

The second case brings to my mind an instance of a woman
delivered by Cesarean section of her first child after a test of labor;
during her puerperium she ran a low fever for several days
but nothing definite could be found; fourteen months later she de-
livered herself spontaneously of a full term infant, weighing eight
ounces less than the first child at birth. On palpating her uterus
through the abdominal wall within eight hours of delivery, a cleft
or furrow three inches long and one-half inch wide could easily be
felt in the anterior uterine wall; a diagnosis of incomplete rupture
of the uterus at the site of the former incision in the uterus was
made. Her temperature and pulse remained normal and there
was no excessive bleeding, so she was allowed to go for ten days at
which time a hysterectomy was done. The uterus showed an
incomplete rupture as diagnosed, her recovery was normal.

Dr. Beck. — In the first case the placenta was quite close to
the scar. In the second the position of the placenta was not deter-
mined and we did not palpate the scar.

Dr. Earl H. Mayne reported a case of

cesarean SECTION FOR ACCIDENTAL HEMORRH.AGE.

He was called on the 23d of December to see a woman who was
seven months pregnant. At twelve o'clock that day she had started
to bleed and her physician was sent for, who found her bleeding
moderately. He packed the vagina but the bleeding commenced
again and he repacked her, the last packing controlling the hemor-
rhage about two hours. When the hemorrhage commenced again
the doctor sent the patient to the hospital. About seven p. M.
she began to bleed profusely. Dr. Mayne saw her about eight
o'clock when they said she had lost about a quart of blood. On
examination he found a very small os, through which it was im-
possible to introduce one finger. The patient was in bad condition.
Taking into account the condition of the cervix it was decided to

BROOKLYN GYNECOLOGICAL SOCIETY 137

do a Cesarean section. A three and one-half pound baby was
delivered. The placenta was almost entirely detached and there
was fully a quart of blood and clots in the uterine cavity. The
patient went home on the fourteenth day. This woman had had
three children at full term. Whether the vaginal packing had any
thing to do with the continuance of the hemorrhage cannot be
stated.

Dr. Alfred C. Beck read a paper on

EXERCISE ON ALL FOURS AS A MEANS OF PREVENTING SUBINVOLUTION
.'^ND RETROVERSION.*

DISCUSSION.

Dr. Hyde. — I had an opportunity this summer of watching some
of the cases under Dr. Beck's care and the results were interesting.
The only case in which there was a failure was one in which the
patient confessed that she had not followed instructions. The
knee-chest position has been one of the points which has interested
me and I have seen cases where this position has not brought about
good results, particularly in retroversion because of neglect to properly
instruct the patient. There are very few who understand the knee-
chest position: they simply ask the patient to assume that posture
in bed and expect that to bring results. To be effectual the perineum
must be retracted and air admitted to the vagina. I instruct the
nurse how the perineum must be retracted, and with virgins I
often take a glass catheter and let air into the vagina while the
patient is in the knee-chest position. It would seem to me that
active physical exercise must increase the heart action and better
the circulation in the uterus. I do not see how walking on all
fours can do it except by improving the circulation and thus stimu-
lating involution.

Dr. Gibson. — One interesting point brought out by Dr. Beck is
the care of the woman in the third and fourth weeks of her puer-
perium. This is the period which is most often neglected. We
will often examine a woman at the end of the second week and find
the uterus in good position and at the end of a month find it retro-
verted and subinvoluted. I have made it a rule to insert a pessary
at the end of the second week which is worn for three months and
the results have been most satisfactory. It is much easier for the
woman to wear a pessary than it is to get her to carry out these
exercises.

Dr. Baldwin. — We have all gotten beyond the teaching of my
college days that six weeks is the time it takes for the uterus to
involute. There are cases in which the process is completed in ten
to fourteen days. I believe that the placing of a pessary at the end
of fourteen days will bring good results. If the uterus is kept in
position it will involute.

Dr. Beck. — Regarding the use of the knee-chest position, the
great difficulty is that it is very uncomfortable, and patients will

* For original article see page 75.

138 TRANSACTIONS OF THE

not continue its use after leaving tlie hospital. With the class of
patients we have to treat I believe the knee-chest position is out of
the question. Of the five failures, three of the patients did not
exercise more than five days, so in reality there were only two
failures in thirty-four cases which is almost as good as the pessary
can do. Not infrequently the patient forgets to come back after
the pessary is inserted.

Dr. John O. Polak read a paper on

TRANSPERITONEAL CELIOHYSTEROTOMY. *
DISCUSSION.

Dr. Pomeroy. — Have there been enough cases operated upon in
this fashion to determine the ultimate result of the anterior fixation
and the relation of this fixation to the technic of a possible later
Cesarean section? Also is this procedure to be used for all Cesarean
sections rather than attempting to make a selection of cases? These
are propositions that take time to decide and must be considered in
judging of its value as a standard procedure?

Dr. Holden. — Dr. Pomeroy has brought out an important point;
it is inadvisable to do this operation in all cases, but only in the
cases that have been examined too many times before being sent
to the hospital. I think this operation is superior to the Davis
operation.

Dr. Hussey. — I cannot discuss an operation which I have not
performed. I am reminded of a case I operated upon about a
month ago. She had been in labor four days. The membranes
were ruptured and the baby was dead. She had a pelvis through
which I felt I could not deliver with an embryotomy. The pulse
was 150 and the temperature was elevated. I did a Cesarean sec-
tion. She was in such poor condition that I did not feel like taking
out the uterus. She made a very good recovery.

Dr. Pol.ak. — Dr. Hirst has discarded the classical operation and
now has a record of thirty-one cases of this operation without a
death and without suppuration. He is an enthusiast but true as
regards his statistics. I spoke of this matter before the Lying-in
Hospital men the other night but they think the A. B. Davis opera-
tion which they are using is just as safe. No other clinics that I
know of in this country have used it. Regarding the fixation of the
uterus. The first case reported was operated upon by Dr. Holden.
This woman has her cervix fastened to the lower angle of the wound,
the body of the uterus is retroflexed. We made the fixation a little
too low. Of the other five cases, one is still in the hospital, four
have the uterus in good anteversion. Regarding the criticism of
this method, the English do an anterior fixation of the body of the
uterus for relrodisplacement without complications in subsequent
pregnancies. Perhaps you remember Charles Green's paper in
1910 against sterilization. I had the privilege of presenting the
paper on sterilization in Cesarean section. He wrote against it on

* For original article see page 72.

NEW YORK ACADEMY OF MEDICINE 139

the ground that he could fix the uterus and do his subsequent
Cesarean without opening the peritoneal cavity. In the case which
Dr. Beck has reported to-night where the omentum came down over
the scar with adhesions to it and the parietal peritoneum, all we
did was to split the omentum and deliver the child through the
hole, an extraperitoneal procedure. Regarding suture of the
uterine peritoneum at the upper limit of the incision to the fascia;
this procedure fixes the uterus snugly against the parietal peritoneum
and prevents the peritoneal surface tearing away and allowing
amniotic leakage during delivery.

TRANSACTIONS OF THE NEW YORK ACADEMY
OF MEDICINE.

SECTION ON OBSTETRICS AND GYNECOLOGY

Stated Meeting of January 25, 1916.
Dr. Geo. W. Kosmak, M. D., in the Chair.

SARCOMA OF THE OVARY COMPLICATING THE PUERPERIUM.

Dr. George L. Brodhe,\d made this case report. The patient
was a negress, eighteen years old, who presented herself at the pre-
natal clinic of the Harlem Hospital on September 9, 1915. The his-
tory was negative, nothing abnormal was found in the abdominal
examination, and on October 25, 1915, at term, the patient was
delivered normally of a living child, with moderate hemorrhage and
no laceration. On the day following delivery, the condition was
good, the temperature 100.5° F- On the second day following deliv-
ery, the temperature was 101.4°, pulse 96 and she had no complaints.
On the third day following delivery the temperature rose to 102.5°,
pulse 132, and the patient complained of pain and tenderness in the
abdomen. The left side of the abdomen was soft and slightly tender,
but there was marked tenderness and rigidity in the right inguinal
and lumbar regions, in the epigastric and upper umbilical regions.
The leukocytes were 17,000, the polynuclear count 88 per cent.,
lymphocytes 12 per cent. On the fourth day, the temperature rose
to 103.2°, pulse 130, the tenderness and rigidity increased, and vag-
inal examination showed some tenderness in the fornices. For the
next seven days, until the day of operation, the temperature varied
usually between 101° and 103°, and after the operation remained
normal. Various diagnoses were made by the surgical staff but
finally on November 2, eight days after delivery, a mass could be
palpated in the right lower quadrant, tender, elastic, and slightly
movable, and a diagnosis of abdominal tumor was made. The blood
count now showed leukocytes 21,000, polynuclears 74 per cent., the
urine showed a faint trace of albumin and there was a positive

140 TRANSACTIONS OF THE

glucose reaction. The patient was transferred to the service of Dr.
I. S. Haynes who performed laparotomy and found a sarcoma of the
right ovary measuring 15X8X6 cm., bluish in color, with greatly
dilated veins. The patient made an uninterrupted recovery, and
left the hospital in good condition.

The report of the pathologist was as follows: Specimen an
ovarian tumor, size of a child's head, very soft in consistency, brownish
red in color, smooth capsule, slightly lobulated and showing fibrous
bands. Cut section showed reddish granular appearance and no
surface markings. The microscopical section showed spindle cells
very numerous with fairly well-stained nuclei and somewhat granu-
lar necrotic protoplasm, the tumor apparently outgrowing its blood
supply. The vessels were few and thrombosed. The cells were
arranged around them in a radiating manner very like a perithe-
lioma. The fibrous tissue was very slight in amount. The diag-
nosis was spindle-celled sarcoma.

CESAREAN SECTION FOR UTERINE INERTI.A AND CONTR.\CTED PELVIS.

Dr. George L. Brodhead reported the case of a patient, twenty-
eight years old, married, who became pregnant for the first time
about February i, 1915, and the confinement was estimated for
about November i, 19 15. She was a strong, healthy woman, and
the external measurements were spines, 23, crests, 27.5. The trans-
verse at the outlet was 8 cm., and the promontory could not be felt.
On November 13, 191.5, labor began at 8 p. m., positive R. O. A., head
above the brim. On November 15, at 9 a. m., the cervix was thin,
and admitted one finger, the pains being irregular, and the vertex was
still above the inlet; the cervix admitted two fingers, and the patient
was discouraged, having had pains for eighty-six hours. The inem-
branes were still intact and the fetal heart strong. A careful exami-
nation showed a moderately large head floating above the brim, and
a moderately contracted pelvic inlet. Under the circumstances, the
uterine inertia being marked, it was deemed advisable to perform
Cesarean section. The usual incision was made, 3 inches above
and 3 inches below the navel, and a living child weighing 7%
pounds was extracted. The recovery was uneventful, mother and
child leaving the hospital in excellent condition.

VAGINAL CESAREAN SECTION FOR BLIGHTED OVUM.

Dr. George L. Brodhead reported the case of a woman, nineteen
years old, who was married in March, 1915, and had her last men-
struation on March 27. About July i, she began to bleed and was
treated for threatened abortion; the bleeding continued for about
eight weeks when it ceased. The family physician sent her to Dr.
Brodhead on November 19, 1915, stating that the uterus had not
changed in size since July. Upon examination the uterus was appar-
ently enlarged to the size of a three months' pregnancy, and the
patient was informed that in all probability the pregnancy had

NEW YORK ACADEMY OF MEDICINE 141

proceeded normally until about July i when the fetus died, and
the uterus had been unable to expel the blighted ovum. The patient
consented to operation, and a vaginal section was done. A placenta
of about three months' development was removed, the fetal sac was
distinct, but no trace of the fetus could be found, absorption having
taken place. Since this patient was operated on, another patient
had aborted in the Harlem Hospital service, the seven to eight
weeks' ovum having remained In utcro for about four months.

The condition while rare was met with frequently enough to
make one gaarded in a prognosis of a supposed threatened abortion;
for, while bleeding might entirely cease and the patient feel per-
fectly well again, the uterus would not increase in size, and sooner or
later would be emptied of the blighted ovum.

DISCUSSION.

Dr. Howard C. Taylor asked Dr. Brodhead if he said that there
was no fetus found and, therefore, was it absorbed? Could a fetus
be absorbed in the interior of the uterus?

Dr. Brodhead replied that that was his impression as he had seen
a number of blighted ova of various periods of development with no
trace of the fetus and many of those patients had been very care-
fully observed. In this instance the sac was intact and there was
quite a little fluid present, but the fetus, of course, might have
escaped.

Dr. Alfred M. Hellman said that he had a similar case to the
last one reported by Dr. Brodhead. The patient had one profuse
hemorrhage and complained of cramp-like pains at night. There
was no dilatation of the cervix. Although she was sk months preg-
nant, the uterus was the size of a four months' pregnancy. He
doubted the history given. She was observed for one week or ten
days and then sent home. Ten days later she returned stating that
her pains were worse and that there was a slight discharge stained
with blood. He again examined her and found no apparent change
and no cervical dilatation and she was sent home for another week.
She was watched for five weeks in all and still there was no increase
in the size of the uterus. Knowing that she was pregnant and that
the fetus must be dead he introduced two rectal bougies and packed
the cervix and vagina with gauze for thirty-six hours, when she
delivered herself of a good-sized placenta, undergoing cystic degen-
eration. The placenta looked like a multitude of small parovarian
cysts.

Dr. Herm.WsN J. BoLDT had seen many cases where the ovum
had advanced to two or three months and yet he could find no trace
of the fetus at all. The size of the placenta corresponded to a two
or three months' pregnancy.

Dr. Brooks H. Wells had seen several cases in which the sac
was apparently intact and yet no fetus could be demonstrated and
he took the ground that the fetus had died at an early stage, and
had become absorbed.

142 TRANSACTIONS OF THE

Dr. Francis W. Langstrotii, Jr., reported the case of a woman
who had the most profuse hemorrhage he had seen in years, the
blood filling three or four vessels. He dilated the cervix under
general anesthesia. The cervix was closed, not dilated at all and it
did not seem that anything could come away except blood. He
found a large amount of placental tissue but could not find any fetus
at all. The miscarriage was at the third month estimating according
to her last menstrual period. The very profuse hemorrhage came
on suddenly only after a slight show the previous night.

Dr. Geo. W. Kosmak, referring to Dr. Brodhead's first case,
said that very often malignant growths in the ovary could not be
diagnosed by their symptoms and in most cases the diagnosis was
not made until the pathological report of the excised ovary was
received. In one of his cases what was believed to be a cystic ovary
was removed during the course of a laparotomy and the subsequent
pathological examination showed it to be carcinomatous. The
patient had been under observation for almost two years and no
recurrence had been noted. It has been claimed that in every
instance where malignant disease of one ovary is present, the other
one should be simultaneously removed, even if not apparently
involved. Dr. Kosmak believed that in view of his experience
he would hesitate to follow this procedure.

Dr. Howard C. Taylor believed that in such cases, especially
where the woman was anxious to have children, she would prefer
to take the risk and not sacrifice the other ovary.

EARLY RESULT IN A CASE OF CARCINOMA OF THE CERVIX UTERI

PRESENTATION OF PATIENT AND SPECIMEN.

Dr. James A. Corscaden reported this case and presented the
patient and specimen. The Chairman appointed Dr. Wells and
Taylor a committee of two to examine and report upon the case, q.v.

discussion.

Dr. F. C. Holden said that many years ago he had the pleasure
and privilege of being one of Dr. John Byrne's house surgeons, and
he like all the others who associated with Dr. Byrne and his work
became very enthusiastic about it. He was wholly in accord of
the recent writing of Dr. Boldt to the effect that the only advantage
the Percy method had over that of Byrne was in that the abdomen was
opened by the former. Dr. Byrne labored under many disadvan-
tages in that his work was done in the preaseptic age when the
opening of the abdomen was of a great deal more magnitude than
it is to-day. He was of a very inventive turn of mind and the
instruments and battery used by him were of his own design. The
battery was of a licjuid type and it was necessary to constantly agitate
the tluid while it was being used to insure sufficient heat. Dr. Byrne
never used a bright red heat on either the cautery knife or dome but
always worked with a dull red heal. Had he lived one or two

NEW YORK ACADEMY OF MEDICINE 143

decades later, Dr. Byrne would have made some very valuable addi-
tions to his original work.

At the Greenpoint Hospital they recently had a case of extensive
carcinoma of the cervi.x which seemed suitable for the Percy opera-
tion. Both tubes and ovaries were removed and both the internal
iliac arteries ligated with heavy silk ligatures. This was followed
by long slow cautery application as advised by Percy. When this
case was examined two weeks postoperative it was discovered that
there was still some carcinoma tissue remaining. Four weeks after
the first operation the abdomen was again opened and it was interest-
ing to note that the iliac arteries were still closed completely below the
ligated points. Again slow cautery application was made, and up to
the present time this patient has shown a decided improvement in
general condition.

Dr. Byrne's work was very frequently followed by extensive
hemorrhage at the time the separation of the slough, and Dr. Holden
felt that inasmuch as the abdomen is opened in conjunction with
the Percy method it is advisable always to litigate the internal iliac.

Dr. Hermann J. Boldt said that he knew nothing that was superior
to the treatment devised by Byrne and he believed that all the credit
for this method of treatment of cancer of the uterus was due to Byrne.
Percy had given them a method — by opening the abdomen — which
enabled them, however, to make use of a more thorough procedure.
That was true, but to claims of superiority of the low-grade over the
high-grade heat was, in his opinion, a myth. The high grade of heat
would penetrate as far as the low grade. When one used the degree
of heat Byrne did, the work could be done more rapidly and it was
as safe as the low degree of heat, if the abdomen was opened, so that
the electrode could be controlled.

REPORT OF THE COMMITTEE APPOINTED BY THE CH.\IRM.\N TO EXAM-
INE THE P.\TIENT PRESENTED BY DR. CORSCADEN.

Dr. Howard C. Taylor said that the results of the operation to
him seemed to be very good. The circular scar was present and the
parts were soft with no induration. On the finger after examination
was found a slight amount of blood, showing that probably there was
a return of the disease. He felt that if they could always get as good
a result in these cases as in the one he just examined, the operation
would be a very valuable one. The Percy operation differed from
the Byrne operation only in that he opened the abdomen and in the
degree of heat employed. Both Byrne and Percy laid great stress
upon employing a low grade of heat. Outside of the mere opening
the abdomen Dr. Taylor did not think the method of Percy differed
from that of Byrne.

Dr. Frederick C. Holden asked Dr. Taylor what he would do
with such a case now.

Dr. Taylor replied that he would let her alone.

Dr. Brooks H. Wells, the other member of the Committee ap-
pointed by the Chairman to examine the woman and report, said

144 TRANSACTIONS OF THE

that the patient had a rather smooth funnel-shaped vagina. At the
upper end of the vagina about the small scar was a small area of
infiltration which gave the impression that the carcinoma was still
making progress. As a palliative measure the operation had been
successful. The question came up, What were they going to do
with these patients who began to bleed again? He thought that in
the patient just examined the bleeding would come back in two or
three months. In these inoperable cases Dr. Wells had found
acetone applied after Gellhom's method gave great relief, stopping
the bleeding, controlling the sepsis and odor, so that the patients
improved greatly, gaining in color and strength which lasted a long
time.

Dr. George H. Mallett said that there were three methods of
treating these cases, first, open the abdomen and do as Percy did and
apply the heat again; second, use radium; and third, the applica-
tion of the .T-ray. By any of these methods the terminal stage might
be postponed, the patients have months or years of comfort.
Remarkable statistics had been given following the use of radium
in these cases.

Dr. Corscaden said that the result of Dr. Taylor's examination
showed the condition of the woman to be practically the same as it
was three weeks after the operation. Whether the condition had
really changed very much he was unable to say. She had been given
x-ray exposures to the abdomen for the glands, and whether these
had anything to do with keeping it quiescent or not, he did not know.
He was waiting for any sign of increase in growth before undertaking
further steps.

Dr. Fredk. W. Bancroft read a paper on

REPORT OF A CASE OF CARCINOMA UTERI TREATED ACCORDING TO THE
PERCY METHOD.*

THE R.ADICAL ABDOMIN.AL OPER.ATION FOR CARCINOMA OF THE UTERUS.

Dr. Howard C. Taylor read this paper. He said that if they
excepted certain superficial growths of a low degree of malignancy,
there was no cure for cancer which was accepted by the profession
other than its complete removal by surgical means. Though there
had been promising results from the use of other agents such as
radium, .x-rays and the cautery, these results were not such that their
use would be advised for a limited growth in a patient constitution-
ally suited for an operation for its removal. Personally he believed
there was a distinct value in the use of radium, x-rays and the
cautery in cancer of the uterus. The use of them was still experi-
mental and sufficient time had not yet elapsed to prove the perma-
nency of the results reported from their use. The number of the
cases treated by these agents that would remain cured beyond the
five-year limit was uncertain and until more definite cHnical statistics
were available, the use of them would be largely limited to the

*For original article see page ii.

NEW YOEK ACADEMY OF MEDICINE 145

inoperable cases, and the earlier cases would be treated by some
surgical operation for the removal of the growth. The surgical
removal of cancer was a mode of treatment about wliich they had
definite knowledge, and it was not to be abandoned until they had
something that was certainly better with which to replace it. There
was no doubt that the use of radium and .v-rays had modified the selec-
tion of cases suitable for operation. The abdominal route rather
than the vaginal was the first choice of most operators. There were
certain cases, however, that were approached more easily through
the vagina than through the abdomen on account of the size of the
vagina and the thickness of the abdominal wall. A fat abdominal
wall adds greatly to the difficulty of any abdominal operation
and in a contraindication for a radical abdominal hysterectomy. If
there was a combination of thick abdominal wall and a wide vagina
with a prolapsed uterus, the vaginal route should be selected. Per-
sonallv he preferred the abdominal route for all cases except those
equal in which there was a fat abdominal wall and a wide vagina.

Dr. Taylor asked what was the difference between a simple and
radical abdominal hysterectomy for carcinoma of the uterus.
Theoretically there was a great difference, practically one merged
into the other. In one operation vessels were ligated close to the
uterus and no attempt was made to remove any of the pelvic con-
nective tissue; in the other operation the ureters were exposed, the
vessels were ligated outside of the ureters close to the pelvic wall
and a large amount of pelvic connective tissue and a large portion of
the vagina were removed. In favorable cases the theoretical radical
abdominal hysterectomy could be performed and a large amount of
pelvic connective tissue and the vagina removed. This added
greatly to the chances of a permanent cure of the case. There was
no doubt, however, that any series of radical abdominal hysterec-
tomies contained cases that did not differ in the amount of tissue
removed from a series of simple hysterectomies by the same
operator. The extent of the operation performed for the removal
of any malignant growth was limited by two factors, the risk
to the life and the amount of mutilation of the patient. In the
radical operation there was a distinct risk to the patient. It
was a more extensive operation requiring more time, complication
during and after the operation were more frequent, and a higher
primary mortality was a necessary result.

The higher primary mortality of the radical operation was not due
entirely to the operation itself. For a simple hysterectomy the
growth must practically be limited to the uterus itself, while a con-
siderable involvement of the broad ligaments was not an absolute
contraindication to the radical operation. For growths of the same
extent in patients in whom the radical operation was not contra-
indicated because of constitutional disease or a thick abdominal
wall, Dr. Taylor believed that the primary operative risk was only
moderately greater for the radical than for the simple hysterectomy
and was not sufficient to outweigh the advantages of the more
extended operation. After the ureters had been isolated the radical

146 TRANSACTIONS OF THE

operation could often be done with little more difficulty than a
simple hysterectomy. In his own cases the primary mortality was
about 15 per cent. Pie believed the mortality would be less in the
future with a more careful selection of cases. The injuries to the
ureters are accidental division, ligation and sloughing. He did not
believe that the ureters were accidentally divided or ligated as
frequently in the radical as in the simple hysterectomy, and it was
surely discovered in the former and might not be in the latter.
Sloughing or necrosis of the ureters was an accident of the radical
operation which never occurred in a simple hysterectomy. In a
series of 500 cases of Wertheim's there was sloughing of the ureters in
thirty cases; in live it occurred in both ureters. The most frequent
result of this accident was a ureterovaginal fistula. The cause of the
necrosis of the ureter in most cases was the interference with the
blood supply during the operation. Injuries to the bladder more
frequently follow the radical than the simple hysterectomy. Paraly-
sis of the bladder requiring catheterization was of frequent oc-
currence after the radical operation. Kidney infection frequently
followed bladder infection, and injection was favored by the con-
dition of the ureters. To the same extent that the lesions of the
bladder and ureter were more frequent in the extended operation, the
real complications would be more common. Bleeding most fre-
quently occurred from the radical operation and might be exceedingly
difficult to control. The ligation of the anterior trunk of the
internal iliac arteries would diminish the amount of the hemorrhage.
It was probable that the risk of infection was no greater in the radical
than in the simple hysterectomy for a carcinoma of the cervix uteri
of the same extent.

As to the results, statistical and theoretical evidence favored the
radical operation. From the European clinics large series of cases
were reported showing a much higher percentage of permanent
cures than had been obtained by any other operation. The more
extensive an operation for a malignant growth, the greater were
the chances of a permanent cure if the patient survived the operation.
This was true of cancer in the uterus as in other organs.

In conclusion Dr. Taylor said that his treatment of carcinoma
of the cervix uteri was as follows: (i) For the favorable cases, a
patient in a good general condition, an abdominal wall without an
excess of fat, and no associated pelvic lesion to increase the operative
risk and a limited growth, he advised the radical operation. (2)
For a limited growth in a patient who was a bad risk on account of
general or local conditions, he advised usually a simple abdominal
hysterectomy, occasionally a vaginal hysterectomy. (3) For the
so-called inoperable case, he advised radium, .v-rays and the cautery.
In this class because of the favorable reports that were published
following the use of radium, .v-rays and the cautery, he included cases
that formerly he submitted to operation. If after the use of radium,
.r-rays or the cautery the case became operable he removed the
uterus.

NEW YORK ACADEMY OF MEDICINE 147

DISCUSSION ON THE PAPERS OF DRS. BANCROFT AND TAYLOR.

Dr. George H. Mallett said that he was very much interested in
hearing the report of Dr. Bancroft's case of death following the
application of heat by the Percy method, and also was very glad to
hear Dr. Taylor's presentation of the treatment of carcinoma of the
cervix. One of the strong points in favor of the Percy operation is
its low primary mortality; but since life insurance companies
figure an average of 2 per cent, mortality for all abdominal opera-
tions, it is not surprising that a death will sometimes follow this pro-
cedure in the most skilful hands.

Thirty years ago heat was the only operative means used in the
treatment of carcinoma of the cervix. In 1882 Pawlik reported 136
cases operated upon by Braun with an operative mortality of 7 per
cent, and 9 per cent, of cures.

In 18S5 Baker of Boston reported to the American Gynecological
Society that he had amputated the cervix in three cases of carcinoma
with the galvanic ecraseur and ten years later reported that two of
these were still alive. In 1892 Byrne reported eighty-one cases where
the whole cervix was involved, and upon whom he had operated with
heat. There was no mortality. Of these thirty-one were lost sight
of. Eighteen lived over five years. Considering all of the thirty-
one lost to have died in less than five years after the operation, he
would still have 20 per cent, of cures. Of the cases treated by radi-
cal hysterectomy Wertheim had an operative mortality of 19 per
cent., Reiss, whom Dr. Taylor mentioned, had 30 per cent., while
one of the most prominent operators in this country lost 40 per cent,
of his first twenty cases. In a paper read by Thomas Wilson before
the Clinical Congress in London last year, in speaking of the diffi-
culties of the radical operation, he stated that the results of the first
ten cases operated upon should not be counted against an operator as
he was only gaining the necessary experience.

In 1897 Dr. Mallett assisted Dr. Byrne in his operation upon a
patient at the General Memorial Hospital. He used his battery and
instruments as described by Dr. Holden. The operation required
about two hours for its performance. On the third night following,
this patient had a profuse hemorrhage, and required uterine and
vaginal packing; however she had no reaction and went out in good
condition. Thirteen years later this patient was still living. Percy
had placed this operation upon a more scientific basis. Opening the
abdomen was of distinct advantage, because it permitted the oper-
ator to control the heat when applied to the uterus. Ligation of the
blood-vessels of the pelvic organs was also an important feature;
because it produced a "stavation" of the growth as advocated by
Dawbarn and prevented secondary hemorrhages.

In many of Dr. Mallett's cases in addition to the heating, radium
was used but not as a routine. The cases referred to the cancer
hospitals are almost without exception inoperable and are sent
there either to die or for palliation of their symptoms, namely; hem-
orrhage, profuse fetid discharge and pain. Formerly, these cases

148 TRANSACTIONS OF THE

were treated with the actual cautery, acetone, gauze packing, mor-
phine and their relief was of very short duration and an effort was
made to get them out of the hospital while they were yet able to go.
Since using this method of applying heat the results had been much
more satisfactory. They all stood the operation remarkably well.
There was little or no shock and scarcely any pain, and without
exception they had the appearance the da\' after the operation of
having had a minor operation performed. Dr. Mallett had per-
formed this operation twenty-three times. There had been no
operative mortality and with very few exceptions, the relief of symp-
toms while temporary had been enough to justify the operation.

When he started this work, in his enthusiasm he used it in some
unsuitable cases; as, in two patients with recurrences after hysterec-
tomies had been performed. At that time he did not know that Dr.
Percy had advised against this and had devised a special operation
for this class of cases. Two cases were operated upon by this method
where the primary growth was in the anterior wall of the vagina and
bladder. It is needless to say that the results in these cases were not
satisfactory.

He has one case under observation that was sent to the hospital by
a prominent surgeon as inoperable. She was operated upon by this
method sixteen months ago. She is now absolutely free from all
symptoms. The uterus is not much larger than one's thumb and is
freely movable. In another case after this operation, although she
was considered inoperable, she has been free from all symptoms for
nine and a half months. Radium was also used after this operation.
In another case after the heating and radium were used she had a
recurrence after eleven and a half months. After recurrences. Dr.
Mallett had opened the abdomen and performed the operation a
second time in one case and had applied the heat in another without
opening the abdomen again. These operations were too recent to
note the results.

It would be a wonderful thing, and he hoped that it would be
proved to be true, as claimed by Percy, that the heated iron would
kill the cancer cells within a radius of from i}^ to 2)^ inches.
Balfour of Mayo's clinic has stated that in sixteen cases where the
heat had been used and the uteri removed one month later that in
thirteen of these there were found no live cancer cells. That report
was certain!}- encouraging. However, we are not yet ready to cast
aside all other operative procedures, especially when we can combine
the use of radium and .%--ray with them.

Dr. ]\Iallett said that he was glad that Dr. Taylor had empha-
sized the severity of the radical operation and had mentioned the
complications that often accompanied it.

Dr. Corscaden said that the treatment of these cases should be
excision of the uterus; they not only hoped to get the gross mass out
but the microscopical cells as well. When the tumor reached the
stage where it could not be so excised, then any method which would
improve the patient was justifiable. There were two factors to be
considered, namely, the local and the general effect upon the growth;

NEW YORK ACADEMY OF MEDICINE 149

whether the heat applied was of high degree or of low degree, and
whether the heat in the instrument would reach further in one
method than in the other, this was a matter of exact observation.
What had been shown was interesting in that both pathological proc-
esses were presented, of first the greater susceptibility of muscle
and, second, the greater susceptibility of carcinoma.

Another factor that had not been talked upon enough was general
immunity; this was one factor that had been proven by direct experi-
ments upon animals, experimental cancer in rats. Murphy had
shown what a great factor the lymphocytes were in immunity.

Another factor was the fact that whatever serum therapy was
used, or synthetic chemical, there was always a high body tempera-
ture. Just what produced it as yet they could not tell. They
remembered the equanimity with which some of the surgeons
viewed certain infections in carcinoma, and especially after oper-
ations upon the breast. Some stated that they would rather have
an infected wound than one that was clean. He referred to Coley's
work with the streptococci of erysipelas.

Percy's treatment he believed to be very much indicated in these
cases, but he was not ready as yet to say that this treatment afforded
better results than did radium. It produced a leukocytosis and
raised the body temperature. There was not only a local leukocy-
tosis but a general leukocytosis. The polymorphonuclears and the
number of lymphocytes were greatly raised at the same time. Radio-
therapy was often of great value in these cases.

Dr. Brooks H. Wells said it was difficult for him to criticise the
very admirable paper of Dr. Taylor because Dr. Taylor's experience
was, as related in his paper, practically identical with his own. The
tendency during the past decade had been to restrict the indications
for the radical operation. If the disease was found in the early
stage, when one felt reasonably sure he could remove it entirely by
the radical operation, the radical operation should always be done
and one would get most satisfactory results. On the other hand, if
the disease had progressed to a point where it could not be entirely
removed, the question would arise whether the radical operation
should be attempted at all. The question of operation at the
extremes was easy to decide; in the intermediate case the decision
might be difficult. In advanced cases the cautery followed by either
the .T-ray or radium often gave excellent palliative results, while in-
complete surgical removal often led to more rapid spread of the
disease. In doubtful cases the decision should lean toward the radi-
cal procedure, for we all occasionally saw cases go on to permanent
cure after demonstrably incomplete removal of the cancer. It
was widely realized that a certain amount of immunity was pro-
duced in these cases and the speaker was in hopes that we would soon
be taught more about this immunity and how it was produced.
Eighteen years ago he had operated upon a patient for the removal of
a carcinomatous uterus. Examination of the tissues removed showed
that carcinomatous cells extended beyond the cut edges. This
patient was well to-day and was an example of a number of such

150 TRANSACTIONS OF THE

cases that he had seen. Instances such as these make us realize the
importance of this immunity and should carry a certain weight in the
decision for or against operation. However, when all was said, the
most important hfe-saving factor in all cases of cancer was early
recognition, and about this there was yet much to be learned and
taught.

Dr. Hermann J. Boldt said that only last week he operated upon
a patient who had been sent to him two weeks ago by a surgeon
well known to them all, who said the patient would be entirely well
in one week. This patient subsequently saw Dr. Brettauer who told
her that he was in no position to make a diagnosis until an excision
had been made and a piece of the tissue submitted for e.xamination.
Two days after she came to see Dr. Boldt and he told her the same as
did Dr. Brettauer. Neither of them knew that the other had seen
this patient. She finally consented to have a piece removed for
diagnostic purposes. She had a well-marked adenocarcinoma. He
did not make careful rectovaginoabdominal examination until
attempting a radical operation. He then found that the patient
was practicalh- inoperable. But bearing in mind the fact that one
did not know when carcinoma was fit for a radical operation or not,
he opened the abdomen and did some extensive intraabdominal work
and verified what Dr. Brettauer and he had believed existed. The
diagnosis might have been made earlier.

Apropos of the radical operation, he thought that Dr. Taylor had
struck the keynote in what he had said regarding simple hysterectomy
and radical operation. Nineteen out of twenty cases done now and
called radical operation were nothing more than simple hysterec-
tomies. To do this work thoroughly was not a simple matter at all;
it was a difficult operation. They had not yet had sufficient experi-
ence with it. Dr. Boldt went even further than Dr. Mallett who
said the first ten cases should not be counted against the man;
twenty-five cases should not be counted against him. It was a
dangerous and difficult piece of work. Laying bare the ureters was
not so difficult, but on freeing them to the bladder, the difficulty com-
mences. Free venous bleeding occurred occasionally. Dr. Taylor
was correct in saying that there was one class of cases in which the
vaginal operation was to be preferred, cases with extreme obesity.
If he had to deal with a very obese woman he did not care to try the
abdominal route. The methods to be employed in these cases
should be studied further and they must have more experience in
order to enable them to do the operation properly.

In regard to the destruction of the carcinomatous tissue by the
cautery, Dr. Mallett had stated that if they could destroy the cells
from I or 2 inches away from the site of the application of the
cautery, the results would be excellent, but he used the word
"if." Whether they used the high degree of heat or the low degree
the carcinomatous cells were destroyed but a short distance from the
cautery.

Tying the blood-vessels was a method which the late Dr. Pryor
advocated for the relief of the symptoms, bleeding and lessening the

NEW YORK ACAtoEMY OF MEDICINE 151

discharge and making the patient more comfortable. The cautery
operation he believed to be one of the best, the most vakiable thera-
peutic agent that they possessed, for the palliative treatment.

So far as radium was concerned he did not hesitate to say, judging
from reports, that it was of the utmost value. Unquestionably
much more could be achieved with the use of radium than many of
them believed. Alany patients who were considered inoperable
became operable by the use of this agent, as reported by men of
unquestionable veracity.

Dr. Willi^vm S. Stone said that he had had the opportunity of
observing some of Dr. Mallett's work with the Percy operation. In
one case, which he had examined several months after the operation
had been performed, there were no gross evidences of carcinoma in
the pelvis. He had also seen Dr. Percy himself perform two
operations, in both of which, through the courtesy of Dr. Mallett, he
had the opportunity of making an examination immediately before
and after the operation, and that he was much impressed with the
immediate result of this procedure. In one case, for example, in
which the left broad ligament was extensively involved, rendering
the uterus immovable, this thickening and hardening at the com-
pletion of the operation had almost completely disappeared, and the
uterus moved more freely. The truth is that it is a desiccating proc-
ess, taking the water away from the tissues and reducing the bulk
of tumor tissue. The examination of these patients immediately
after operation might lead one to think that they were then suitable
for the radical operation. But he was also impressed with the fact
that the operation was not a minor affair. As with the radical
operation one should hesitate very much before attempting it,
unless he has a comprehensive knowledge of the extension of the
disease and all the conditions which make it applicable. To be safe
and efBcient, it required an operator who was well acquainted with
the disease and the technic. Dr. Stone expressed his enthusiasm
for the possibilities of the use of radium, especially in cases of
carcinoma of the corpus uteri, but thought that the so-called
Percy operation offered an additional therapeutic resource in certain
advanced cases, in which neither the radical operation nor radium
could be applied.

Dr. H.\rold C. Bailey said that when the carcinoma was well
beyond the broad ligament, Percy's operation would not result in
success. The operation, however, was distinctly palliative.

Dr. Emily Dunning Barringer said that the use of the cysto-
scope was very valuable in helping to clear up some of the border-
land problems. In certain cases of uterine carcinoma, the growth
progressed forward into the bladder region out of all proportion to
the parametrial involvement. If these cases had a preliminary cysto-
scopy they would probably be considered inoperable and become a
factor in reducing postoperative mortality. The bleeding that occur-
red from the bladder had interested her very much. She questioned
whether this might not be due to a rupture of a varicose vein in the
bladder wall. In certain cases even if there be no definite carcinoma

152 BRIEF OF CURRENT LITERATURE

of the bladder there may be a very large varicose vein in the bladder
mucosa due to pressure of the adherent carcinoma. The manipula-
tion necessary in removing the growth may have stirred up such a
varicosity and started the hemorrhage. Owing to a possible
pressure of the growth on the ureters in cases of uterine carcinoma,
Dr. Barringer suggested that a prehminary phenosulphonaphthalein
test might be of value in estimating a possible case of postoperative
renal insufficiency. She asked Dr. Taylor if any of his postoperative
mortality was due to this cause.

Dr. Taylor closed the discussion. In answer to Dr. Barringer's
inquiry he said he could not recall an instance among his cases in
which death was caused by renal insufficiency. He thought that
her suggestion regarding rupture of varicosities in the bladder
causing the hemorrhage was correct in the case he reported ; at least
it was a reasonable one.

With regard to the mortality following the Percy operation, a case
that Percy himself did at the Womans' Hospital some two or three
years ago died. Percy acknowledged that there was a definite
mortality accompanying his operation.

It might be better to give the credit of this operation to Byrne;
the part added by Percy was that of opening the abdomen enabling
one to do more thorough work. The late Dr. Pryor was the first to
suggest and to ligate the blood-vessels.

In regard to the treatment of carcinoma of the cervix in general an
operation was practically the only means of cure, and radium, the
a;-ray and the cautery of only palliative value.

The mortality of the operation should not be questioned too much.
If in one series of cases there was a lo per cent, risk considered and a
lo per cent, cure, and in another series of cases treated by a difTerent
method there was a 40 per cent, risk and a 40 per cent, cure, any of
them would prefer the 40 per cent, risk with its 40 per cent. cure.

BRIEF OF CURRENT LITERATURE.

Histological and Physiopathological Experiments on the Internal
Secretion of the Pancreas in Pregnancy. — A. Falco {Ann. di.
Ostet. e gin., Jan. 31, 1916) gives a careful resume of the previous
experiments made with reference to the internal secretion of the
pancreas, details the experiments made by him on pregnant women,
and gives his conclusions. The islands of Langerhans in pregnancy
present to histological examination a diminution of their activity.
Total pancreatectomy in guinea-pigs during or at the end of preg-
nancy does not cause glycosuria, but on the contrary causes all the
other symptoms of pancreatic diabetes. This absence of glycosuria
seems not to be caused by the internal secretion of the fetal pancreas;
it appears to be the effect of either the utilization of sugar on the
part of the fetus or the presence in the maternal blood of a placental

BRIEF OF CURRENT LITERATURE 153

ferment. Experiments executed with injection or ingestion of
placental pulp would seem to show that the placenta has a large
part in the metabolism of carbohydrates.

Postpartum Care of the Perineum. — Plass (Johns Hopkins
Hospital Bulletin, April, 1916) describes the technic employed in
the maternity wards of the Johns Hopkins Hospital, in which all
irrigation of the perineum with antiseptic solutions is omitted.
Two groups of cases were compared, in one of which the usual routine
treatment was employed and in the other simple cleansing with
tap water and soap and a wash cloth by the patient herself when
possible. In both groups the morbidity was practically the same.
In another series in which perineorrhaphy was done, better results
attended the cases in which no antiseptic irrigations were employed,
a greater number of satisfactory healings taking place in the latter
class. The author concludes that macroscopic cleanliness alone
gives better results than the use of antiseptic solutions and also
effects a considerable saving of time.

The Time of Conception. — Siegel {Deutsche med. Wchnschr.,
19 1 5, No. 42) presents a study based on observations made in 100
pregnant women in which the day of an isolated intercourse could
be determined. This was rendered possible by the conditions re-
sulting during the war. The author believes that conception can
only take place during the first twenty-one days after the last
period and that the most susceptible time is before the sixth day.
In no case could conception be established after the twenty-first
day, so that he- thinks it is safe to say that the postmenstrual period
is the most favorable time for fertilization. During the premen-
strual period it is probable that the swelling of the mucous mem-
brane interferes with the process. It is also assumed that the
follicles rupture between the seventh and fourteenth day after the
beginning of menstruation. The spermatozoa require from one
to two days to reach the ovary and rapidly perish in the peritoneal
cavity. The author assumes therefore tliat successful conception
takes place about two days after coitus.

Organic Extracts as Oxytoxics. — Kohler (Zenlralbl. f. Gyndk.,
1915, No. 51) has made a series of observations on pregnant women
in whom the injected extracts of thyroid, mammary gland, thymus,
pancreas, ovary, corpus luteum, testes, placenta, and intestinal
mucosa were employed. A series of thirty cases were subjected to
the experiments all of which were in the first stage of labor with
less than two fingers' dilatation of the cervix. In nineteen cases the
women were at term and in seven less than five months. There
were also several cases of abortion. It would appear from these
experiments that all the organic extracts exert practically the same
effect and that labor pains are accelerated with few exceptions by
all of these extracts. The author believes moreover that the
pituitary preparations are not any more effective than those
which he employed. In the majority of cases the pains appeared
within ten minutes and gradually became more severe and regular.
In cases where they ceased after an interval they could be readily

154 BRIEF OF CURRENT LITERATURE

renewed by further injection. In no case were more than three
administrations necessary before labor occurred. In four in-
stances an operative delivery was necessary for various reasons un-
connected with the administration of the drug. In the cases in
which a negative effect resulted it is probable that an individual
idiosyncrasy was present such as has been observed after the in-
jection of pituitary preparations. In none of the cases were the
children effected nor were any abnormalities noted after labor.

Labor in Young Girls. — Specht {Zenlralbl. f. Gyndk., 1916, No.
3) presents an extended study based on the material of Stoeckel's
Clinic at Kiel among which there were eighty-one primiparae of
less than sixteen years of age in a total of 10,350 labors (0.78 per
cent.). He found that the menstruation in these young mothers
appeared earlier than usual, that the development of the pelvis
seemed to be in advance of that associated with this early age and
that the length and weight of the children increased with the age
of the mother, the male infants being very much larger than the
females. Among the favorable factors associated with pregnancy
in these young girls were the less frequent disturbances of preg-
nancy, shorter labor, infrequent peritoneal lacerations, lessened
hemorrhage, a lower fetal morbidity and likewise a lessened maternal
morbidity and mortality in the puerperium. Among the unfavor-
able features in this class of cases he found a more frequent occur-
rence of eclampsia, breech presentations, uterine inertia, and
premature labor. It seems, therefore, in agreement with other
reports that labor in young girls is as a general thing of a favorable
character and although some disadvantages exist in comparison
with older primiparae, these are outweighed by the favorable features
already referred to.

Extra -and Transperitoneal Cesarean Section.^Baisch {Zentralbl.
f. Gyndk., 1915, No. 44) as the result of his personal observations
in a series of thirty-two cases in which the transperitoneal cervical
Cesarean section was done believes that the operation is less danger-
ous and more successful than the extraperitoneal procedure. The
author believes that the good results are due to the simplicity of
the operation in which the uterus is approached through the supra-
symphyseal incision and opened in the middle line low down to above
the upper border of the bladder. The wound in the uterus and
abdomen is closed without drainage.

Megacolon as an Obstruction to Labor. — Jaschke {Zentralbl.
/. Gyndk.. 1915. No. 43) reports a case in which a Cesarean section
was found necessary because of the presence of a pelvic tumor which
was diagnosed as an incarcerated cervical myoma that had also re-
sulted in constipation. On opening the abdomen the uterus was
found displaced to one side and the greater portion of the abdominal
cavity occupied by an enormously enlarged colon, the lower portion
of which simulated the pelvic tumor previously diagnosed. The
intestinal wall was thick and hard, and the cavity seemed to be
tilled with gas and large hard and soft fecal masses. .\n enormous
stool was obtained on the fourth day but on the sixth day a collapse

BRIEF OF CURRENT LITERATURE 155

suddenly occurred and the patient died. At autopsy the extent
of the enlarged colon was confirmed and the entire mucous membrane
was covered with ulcers. The author believes that the case was
one of megacolon of which the occurrence associated with pregnancy
is most unusual. Whether this condition was congenital or acquired
could not be determined.

Menstrual Symptoms during Pregnancy. — Pok {Gyn ak . Rundschau ,
vol. X, Nos. 3 and 4, 1916) presents his series of observations made
on si.x cases in which apparently normal periods occurred during
the first four months of pregnancy. The writer beheves that
this condition is due to the hyperemia in the domain of the uterine
and pelvic veins which appears regularly at monthly intervals
and leads to a congestion with increase of blood pressure in the
vessels. This finally results at a point of lessened resistance in the
appearance of hemorrhage which persists as long as the hyperemia
remains. In the cases referred to by the author cervical erosions
seemed to be the source of the bleeding. This phenomenon is not
true menstruation and although regular, disappears in the later
months of pregnancy. The subjective symptoms of pregnancy may
therefore be interfered with until the appearance of the fetal move-
ments. In certain cases marked hemorrhages of this kind may lead
to abortion or premature labor.

. Organic Extracts in the Treatment of Amenorrhea. — Kohler
{Zentralbl. f. Gyndk., 1915, No. 38) employed a series of extracts
of organs which do not apparently bear any relation to the genitals
in the belief that the effect of the same was not specific in char-
acter, but that it depended on a common chemical basis present
in the extracts of all the organs. The effect on patients presenting
an amenorrhea was stated to be favorable and the author is inclined
to the belief that the contained amino group in these organic extracts
is responsible for the effect.

Saprophytic Organisms as the Cause of Purulent Vaginitis. —
Hoehne {Zentralbl. J. Gyndk., 1916, No. i) refers to the assumed
harmless character of the truhomonas in the vagina and reports a
series of cases in which purulent conditions were undoubtedly due
to the presence of these organisms, all others being excluded. In
this series of twelve cases both in nonpregnant and pregnant women
the characteristic discharge was thin, profuse, foamy, and of a yel-
lowish color, which invariably produced extensive irritation of the
surrounding skin. Small ulcers and warty growth^ frequently result.
Gonococci were never found in these cases, but the trichomonas
vaginalis was invariably demonstrated in about 30 per cent, of both
pregnant and nonpregnant women out of a series of over 200 ex-
amined. The diagnosis depends on the finding of the organisms
in the moist preparation, for if allowed to dry the characteristic
appearance is lost. The examination is best made with a trace of
the fresh secretion in a drop of physiological salt solution, when the
movements of the cilia can readilv be seen.

156 BRIEF OF CURRENT LITERATURE

GYNECOLOGY AND ABDOMINAL SURGERY.

Retroflexion of the Uterus. — A. Falco {Ann. di ost. e gin., Dec,.
1915) discusses the causation of retroflexion of the uterus, its symp-
toms, and treatment. He gives the causes as loss of tone of the
uterus, and relaxation of the round ligaments. If retroflexion occurs
in pregnancy it is due to an abnormality of the function of the uterine
muscle, assisted by the relations of the various organs contained in
the pelvis, and lesions of the parametrium, especially the vesico-
uterine ligaments. The author does not admit that the round liga-
ment allows the uterus to fall backward. It should draw the uterus
forward. If it cannot do this, it is because it is stretched and relaxed.
Another group of retroflexions are due not to inflammation or puer-
peral conditions, but may be called primary. They are produced by
conditions which cause relaxation of the uterus and all its ligaments.
Another set of cases result from congenital deformities of the uterus.
There may be congenital shortening of the anterior vaginal wall.
The symptoms of retroflexion are disturbances of the menstrual
function, menorrhagia and metrorrhagia, due to the obstruction to
the flow of blood past the flexion and the consequent congestion.
Pain is a frequent symptom. Metritis accompanies the retroflexion.
Pain is present in the lumbar region, with a sensation of weight in
the pelvis. The author does not believe that every case of retro-
flexion demands operation. A considerable number of these patients
may be relieved by the use of a well-fitting pessary. If operation
is to be done, shortening the round ligaments plays an important
part, and is satisfactory. The author does not believe that the
Adams-Alexander operation predisposes to abortion or premature
labor. Of thirty women operated upon by this method in the clinic
of the author only three had recurrence of the displacement.

Treatment of Acute Gonorrheal Tube Infections. — R. C. CofTey
{Surg.. Gyn. and Obst., 1916, xxii, 228) holds free drainage to be the
most important thing in the treatment of gonorrhea. It is quite possi-
ble that a much larger percentage of tubes infected with gonorrhea may
be saved and restored to normal function if seen early and treated
surgically with a large protected quarantine pack, which at once
gives free drainage and prevents the peritoneal surfaces from sur-
rounding and sealing up the tubes during the first active inflammation,
than can be done by the so-called but misnamed conservative treat-
ment. The quarantine pack used after removal of gonorrheal pus
tubes makes the operation just as safe in the acute stage as during
the interval, and saves the patients much suffering and many com-
plications such as destruction of the ovaries, connecting the abscess
with the rectum or bladder, and the formation of troublesome adhe-
sions, as well as minimizing the chances of a chronic incurable dis-
charge from the uterus. The quarantine pack is placed as follows:
On opening the abdomen the fluid and spilled pus is sponged out with
dry gauze. The intestines are packed entirely out of the pelvis.
The entire pelvis is exposed to direct view by the use of malleable
retractors. If the tubes are firmly sealed they are removed by exci-

BRIEF OF CURRENT LITERATURE 157

sion down to the uterine mucosa with any infected portion of the
ovary, leaving the healthy portion to be healed as a result of the
drainage. The retractors are held in place and gauze wicks the size of
a finger (not folded like the folds of a fan) are laid straight side by
side entirely across the abdomen, putting sometimes twenty or
thirty of these wicks, reaching to the bottom of the pelvis and gradu-
ally extending up the side of the pelvis, making a solid wall of
gauze. After these wicks have been placed carefully a sheet of
gutta-percha tissue of four or six layers is placed above the gauze, care
being taken that the tissue goes entirely across the lower part of the
cavity, absolutely shutting off all possibility of contact of the intes-
tines with the gauze drainage. If the tubes are not sealed, the
quarantine is placed without removing them. The open ends of the
tubes are left in contact with the gauze. The wicks and the rubber
tissue in certain cases are then turned toward the patient's face,
exposing the uterus and bladder, and another folded sheet of six or
eight layers of gutta-percha tissue is carefull)' inserted between the
gauze and the fundus of the uterus, this practicalh' surrounding the
gauze and making a completely protected pad. This second gutta-
percha sheet should not prevent the open tubes from coming in
contact with the gauze. In just six full days after the pack is
placed, the wicks are withdrawn, leaving the rubber tissue. On the
fourteenth day the rubber tissue is removed, and according to the
case a small rubber tube which is tapered at the point is inserted, or
drainage is omitted. It usually takes such wounds about five weeks
to heal. For four weeks the patient is kept in bed, preferably on the
back most of the time.

Chronic Urethritis in Women. — W. F. Shallenberger {Jour. A . M.
A., 1916, Ixvi, loii) urges that the female urethra be given more
attention as the possible seat of trouble, especially in cases of obscure
pelvic pain, and emphasizes the importance of chronic urethritis as
the cause of symptoms in many cases in which it has often been over-
looked. He suggests nerve-blocking of the urethra in intractable .
cases, not only for the relief that may possibly be given, but also as a
means of diagnosis, for, if we get cessation of pain by blocking off
the urethra, we can be reasonably certain that it is the seat of the
trouble. It could likewise be used to lessen the pain in cystoscopic
examinations in patients in whom the urethra was sensitive and ten-
der. He infiltrates the paraurethral tissue with a solution of novo-
cain, ^0.3 per cent., with quinine and urea hydrochloride, 0.5 per
cent.

DEPARTMENT OF PEDIATRICS.

TRANSACTIONS OF THE AMERICAN PEDIATRIC
SOCIETY.

Twenty-eighth Annual Meeting, Held at Washington, D. C, May 8,
9, lo, 1916.

The President, Rowland G. Freeman, M. D., of New York, in the
Chair.

PRESIDENTIAL ADDRESS.

Dr. Ro^VLAND Godfrey Freeman, New York City. — "There is
an agent of wonderful power and value to the pediatrician, the use
and action of which is little appreciated, fresh air. By fresh air as
a therapeutic agent we mean moving and cool out-of-door air. The
air of the still, hot, humid dog day of summer is little better than
that of the crowded, hot room in winter. Fresh, moving, cool, out-
of-door air stimulates the appetite, induces quiet sleep, brings color
to the cheeks, and increases the resistance of the organism to infec-
tion. In seeking an explanation of the action of fresh air on the
human body we find the claim that fresh, cold air raises materially
the blood pressure. This claim, however, has not been confirmed
by subsequent investigations, and we seem driven to the position
that the favorable action of fresh air on the organism is due to the
absence of the deteriorating effects of closed rooms. In the fresh
air the body has the advantage of normal conditions, while any modi-
fication of this furnishes increasingly serious results from air stag-
nation. The idea that air which has been breathed by other people
is unhealthy probably arises from the unpleasant odor of closed and
crowded rooms, and from symptoms elicited by extremes of this
sort. The symptoms produced by closed places are depression,
headache, thirst and diSicult breathing. The elements producing
these results were supposed to be a diminution of the oxygen and
an increase of the carbon dioxide, with the possible appearance in
such an atmosphere of a really poisonous i)roduct from the expired
air. Experiments, however, have for the most part discredited this
theory. The amount of oxygen in crowded, closed rooms is not
depleted to a danger point, nor is the amount of carbon dioxide in-
creased to such a point. Efforts to find a poisonous element in such
air have been made from time to time with negative results. In
158

TRANSACTIONS OF THE AMERIC.'VN PEDIATRIC SOCIETY 159

1883, Hermans of the Hygienic Institute in Amsterdam, concluded
that the discomfort of crowded places was due to inability of the
body to cool itself in a hot, moist atmosphere. These symptoms
then are due to stagnant, hot, moist air surrounding the body, and
v\dll be accentuated in people wearing heavy, impervious clothing
that prevents access of moving air to the skin. It is evident then
that we should wear as little clothing as is consistent with comfort.
The result of these elaborate observations is, in brief, that fresh air
is good, not because it supplies oxygen, not because it is not over-
loaded by carbon dioxide, not because it contains no poisonous ele-
ment, but because it allows the body to exist under such circum-
stances that it can control its moisture and temperature. In the
application of these newly developed facts to our daily work in
pediatrics we have to combat the traditional fear of drafts and the
habit of many people of living in close, hot rooms. It is only by the
brilliant results obtained in certain diseases, notably tuberculosis
and pneumonia, by the use of fresh air, that we are able oftentimes
to obtain the fresh air for our children which they need for the preser-
vation of health and their proper development. I beUeve that the
cold air of winier is much more stimulating and produces better
results in children than the mild air of spring and autumn. The
best results from fresh air are obtained by keeping the children out
of doors day and night. j\Iany of our pediatricians have confused
fresh air with cold air. Out-of-door sleeping porches enclosed on
three sides and roofed, but open to the south, furnish the best fresh
air at night, while in the daytime balconies and rooms without heat
and windows \\dde open supply the air we need. It is evidently not
enough, however, that we should have this fresh air, but we should
also look to the clothing to see that our children are not sealed in
heavy, impervious covering so that the skin is unable to rid itself
of the heat and moisture. Where it is impossible to obtain such
complete out-of-door exposure, the best substitute in cold weather
has seemed to me to be in rooms with cheese-cloth screens in the
windows. They allow a moderate access of air without the presence
of drafts. Other methods of ventilation consist in patent ventila-
tors put under the lower sash. It is only during the existence of
marked changes of temperature between indoors and outdoors that
epidemics of colds exist, for during the summer we have practically
an immunity to colds and they only occur when our houses are closed.
In New York our epidemics of colds usually begin in November and
December.

"Premature infants who show a subnormal temperature in cool
air should be kept in an air temperature that will preserve the normal
body temperature. This warm air must be a freely moving, warm
air, rather than the dead air found at the bottom of a box. I am
not sure whether such cold, fresh-air treatment is applicable to cases
with kidney lesions or with severe heart lesions. The most impor-
tant application of this fresh-air treatment is to build up the vitality
and resistance to disease of frail children. I beUeve that rachitis is
entirely a disease of housing. It exists, not in tropical countries

160 TRANSACTIONS OF THE

where people live out-of-doors but in colder climates where people
house themselves in winter. The symptoms develop in winter only
and the severe cases that we see are entirely confined to the children
of races that have been accustomed to warm climates where the
families do not house themselves in winter. Italians and colored
people and other people accustomed to tropical climates should be
warned that they must give their children fresh air in winter if they
would have them survive and develop properly. In all the acute
infectious diseases I think there is now a general acceptance of the
advantage of fresh air, excepting perhaps in measles and scarlet
fever. In tuberculosis and in pneumonia there is no question of its
advantage.

"It would seem that some explanation is due as to why, if all
these statements are true, cliildren are still housed and many adults
have a panic if a breath of cold air strikes the back of their neck or
their bald heads, while children who are brought up without fear of
cold enjoy it wherever it strikes. The supposed production of
catarrhal inflammations in adults by exposure to cold air, if it really
exists, exists only on account of suggestion. These people have
been brought up to such a fear of fresh air that every infection of the
upper air passages to which they succumb they attribute to this
health-giving influence. It is sincerely to be hoped that many of the
coming generation may be brought up under different ideas and may
be less dependent on hot, offensive, stagnant air for the supposed
comforts of life. There is evidence enough to show that many dis-
eases are favorably influenced by this simple and safe measure.
Why don't you use it? Some are afraid, some won't take the trouble.
Many children are allowed to become sick from housing and children
may be seen dying in closed wards of many of our best hospitals
who might have been saved had they been put out-of-doors."

RECENT PROGRESS IN OUT KNOWLEDGE OF THE PHYSIOLOGICAL
ACTION OF ATMOSPHERIC CONDITIONS.

Dr. Frederic S. Lee, New York. — "Two weeks ago to-day, in
the physiological laboratory of the Columbia School of Medicine,
Dr. Eastman and I made experiments the results of which have
changed our ideas concerning the physiological action of atmos-
pheric conditions. It had long been the custom to ascribe to chem-
ical components of the atmosphere the bad effects of living in air
that had already been breathed by human beings. The discovery
of oxygen and carbon dioxide early in the last century gave a great
stimulus to this motion, and it became firmly fixed in the minds of
chemists, physiologists and physicians, as well as the educated masses,
that air that had once been breathed was chemically vitiated and
rendered unfit for human use by the lack of oxygen, the accumula-
tion of carbon dioxide, and the presence of an organic poison of
unknown nature. No sooner had this notion become widely ac-
cepted than the laboratories began to demonstrate the inadequacy
of the supposed proof of the notion. To cut a long story short, we

AMERICAN PEDIATRIC SOCIETY 161

now know that, except under very unusual circumstances, the harm-
fulness of respired air is not due to its chemical components. The
harmf ulness of li\'ing in confined air is found in certain physical rather
than chemical features — the air is too warm, too moist, and too still;
and if it has not these physical features it is not harmful. We all
have sat in crowded assemblies, we all have experienced the hot,
humid, still days of an American summer. We all know the effects
of such air on our sensations. In what respect is hot, humid, still
air harmful? To answer this question we must consult the records
of many researches, chiefly on human beings, but partly on animals,
that have been undertaken since Hermane, more than thirty years
ago, observed that in crowded theaters and churches his own bodily
temperature rose. The most recent of these researches is that of
the New York State Commission on Ventilation, which has been in
progress for the past two and a half years and is not yet completed.
Notwithstanding that man is supposed to be a homothermal organ-
ism, there is a certain relationship between his bodily temperature
and the temperature of his environment, even under the ordinary
conditions of living. This has been shown b}' the New York Com-
mission, which found that during the months of June and July the
rectal temperature of its subjects at 8 A. m., lixang in their own homes,
was conditioned by the average atmospheric temperature of the
previous night. Tlae variation of the bodily temperature was about
1° F. for 20° F. of atmospheric temperature, although it is probable
that the degree of variation can be modified by the clothing. The
Commission further found that, whatever the bodily temperature
of its subjects might be, it was lowered by confinement in an atmos-
phere of 68° F. and 50 per cent, relative humidity, and raised by
confinement at 75° F. with the same humidity, or still more by 86° F.
with 80 per cent, humidity. The final average bodily temperature
in a certain series of observations, where the subjects were confined
in the observation chamber for from four to seven hours were:

68° F. (20 . 0° C.) 50 per cent, humidity 98 . 0° F. (36 . 7° C.)

75° F. (23 . 9° C.) s° per cent, humidity 98 . s° F. (36 . 9° C.)

86° F. (30.0° C.) 80 per cent, humidity 99-3° F. (37.4° C.)

Haldane and others have shown a greater elevation of bodily
temperature in more extreme atmospheric conditions, and have
pointed out the accompanying hangers of heat stroke. The rela-
tion between bodily temperature and external cold has not been so
fully studied, but enough is known to warrant the statement that,
in normal indixaduals at least, the bodily temperature can be to a
considerable degree controlled by controlling the temperature and
the humidity of the surrounding air. It is altogether probable that
the same is largely due to febrile diseases. External temperature
exerts likewise a definite effect on the circulatory system. The rate
of the heart beat is increased in warm, humid, and decreased in cool,
dry air. The New York Commission found the average rate of its
subjects confined in an atmosphere of 86° F. and 80 per cent, relative

162 TRANSACTIONS OF THE

humidity to be 74, and in an atmosphere of 86° F. and 50 per cent,
humidity 66. Eastman and I have seen the pulse rate increase by
39-from 67 to 106 — as the temperature of the air surrounding the
subject rose from 74 to 110° F. and the humidity from 58 to 90 per
cent. The important and involved topic of the relation of atmos-
pheric conditions to blood pressure I must leave until the abundant
data that have been accumulated by the New York Commission
have been subjected to a more careful examination than has as j-et
been possible. Atmospheric conditions e.xert on the respiratory sys-
tem effects of various kinds. On the rate of respiration a moderate
degree of heat and humidity seems to be without effect, but there
is some evidence that more extreme conditions cause a quickening
of the breathing, and this is probably accompanied by more shallow
respirations. The more extreme conditions too appear to result in
a lowered concentration of carbon dioxide in the air of the pulmonary
alveoli, although I cannot yet quote figures to demonstrate this.
The matter is, however, important, since a lowered carbon dioxide
signifies an increased content of hydrogen ions, in other words in-
creased acidity in the blood. Eastman and I are now investigating
this point with much interest. The mucous membrane of the respira-
tory tract is markedly aft'ected by atmospheric conditions. Ex-
posure to heat causes increased swelling, redness and secretion in the
nasal mucosa, and these effects are more marked when the hunudity
of the air is high. Exposure to cold reverses the effects. Little can
be said at present regarding the action of atmospheric conditions on
the nervous system. The New York Commission has expended
much time and effort in endeavors to detect a possible influence of
atmospheric variations between moderate limits on the ability to
do mental work. The subjects were given such phychological tests
as cancelling arithmetic figures, adding figures, mentally multiplying
three-place by three-place figures, typewriting, and more complex
mental performances which involve choice and judgment. The
range of atmospheric variation was from a lower limit of 68° F. and
50 per cent, relative humidity, and the upper limit of 86° F. and 80
per cent, humidity. In some cases the air was kept quiet, in others
by motion by electric fans. In neither the young men nor the young
women subjects of these tests could there be detected any relation
between atmospheric conditions and either the accuracy or the
amount of mental work that was performed. The relation between
atmospheric conditions and metabolic phenomena is not yet eluci-
dated. A topic that is inviting is the possible relationship between
atmospheric conditions and bacterial infections. Most of the ex-
perimental observations that have here been made relate especially
to the action of temperature on the course of infections, and it has
generally been found that high external temperature with accom-
panying pronounced increase of bodily temperature checks the
progress of infections that are already existing. Somewhat lower
temperatures (30° F.-35° F.) on the other hand, seem to favor the
multiplication of the bacteria and the advance of the disease."

AMERICAN PEDIATRIC SOCIETY 163

SOME STUDIES ON THE MODE OF INEECTION IN PYELITIS OF INF.ANCY.

Dr. Rich.ard M. Smith, Boston. — "There have been two antago-
nistic theories to explain the mode of infection of the kidney in
pyelitis of infancy; one maintains that infection takes place through
urethra, bladder and ureters; the other that the infection comes by
means of the blood and lymphatics. Before discussing the relative
merits of these two theories it might be observed that the disease
is much more common in female than in male infants, the proportion
being nearly, three to one. The organism most frequently causing
the disease is the colon bacillus, the percentage varying from 50 to
90 per cent. Directly against the ascending theory of infection are
the facts that colon bacilli have never been shown to pass up the
normal unobstructed ureter and that the colon and tubercle bacilli
have been introduced repeatedly into the bladder and in the presence
of a normal mucous membrane were excreted without causing dam-
age of any kind. Ascending infection occurs only in the presence
of obstruction to the outflow of urine and cannot occur if the sphinc-
ter of the ureter is normal. The theory of kidney infection by the
blood and lymphatics rests upon much surer ground. The work of
Thiel and Embleton seems to show that bacteria may pass to the
kidney by the lymphatics alone, appearing first in the fat capsule
and being distributed through the kidney. If bacteria appear in
the urine, that is if they have passed through the kidney, they must
have reached the kidney by the blood stream. This latter procedure
is what occurs in pyelitis so that there must be a blood infection.
The direct sympathic connection between the colon and the right
kidney, which is the kidney most frequently affected in unilateral
infection, had led some writers to believe that bacteria pass directly
from the intestine to the kidney by these lymphatic vessels. This
probably occurs and gives rise to infected kidney but not to pyelitis
as we see it in infants. Pyelitis may follow this condition by second-
ary blood infection. The usual mode of infection in pyelitis is
somewhat as follows: From the intestinal tract or some other source
bacteria get into the lymphatics and then into the blood or possibly
directly into the blood. They are transferred by the blood to the
kidney. They may pass out of the body through the kidney with-
out doing any harm or they may set up an infection at their point
of excretion. They may during their passage through the kidney
cause more or less damage to the various portions of the organ. An
infection of the kidney may take place by an extension inward from
the pelvis, probably by lymphatic channels. The blood infection
in nearly all the acute infectious diseases is so well known that no
proof is needed for its support. The colon bacillus has been found
in the blood by several investigators. The blood infection was al-
ways early in the disease disappearing later as in typhoid fever.
The infection of the pelvis of the kidney from within, that is by
bacteria brought to it by the blood and excreted seemed established
and satisfied all the conditions except in offering an explanation for
the greater frequency of the disease in females. This explanation

164 TRANSACTIONS OF THE

is not hard to find for no mention has been made of a very important
source of Ij'mphatic and blood infection of the kidneys, namely, the
pelvic organs. The lymphatic vessels draining the pelvic organs
are connected by free anastomosis with the kidneys. These vessels
drain through the thoracic duct into the blood. The female genital
organs with the close proximity to the urethra, vulva, vagina, rec-
tum, and the semiclosed character of the parts offers every advan-
tage for the entrance and growth of colon bacilli and other bacteria.
"I have made seventy-one cultures from the vagina, vulva and
urethra of forty infants and young children. One infant six hours
old and all over eighteen hours, except one infant six days old and
all showed growth from vaginal culture. All the vulvar and urethral
cultures were positive. The first organisms to appear were strepto-
cocci and staphylococci and then small bacilli, not colon. Colon
bacilli were found in vaginal cultures of infants as early as the fifth
day. My findings are in accord with those of Schmidgall who found
the vagina of new-borns sterile ten out of thirteen times and by the
second day a profuse growth of cocci. The colon was isolated twelve
times out of twenty-one in new-borns after the second day. She
showed also that the vaginal secretions did not kill off the pathogenic
organisms. A possible source of infection with colon bacilli or other
bacteria is certainly present in the female vulva, urethra and vagina
and a slight trauma may easily accomplish the entrance of organisms
into the lymphatic vessels and blood and thus to the kidney. The
source of infection in pyelitis, in the majority of instances, males
and females together, is the gastrointestinal tract. Some cases may
arise from infection in the skin, teeth or tonsils, or in some local
septic process. Many cases in females, accounting for the greater
number in this sex as compared with the males, may arise from bac-
teria entering the blood often via the lymphatics from the urethra,
vulva, or vagina."

DIET AND GROWTH IN INFANTILE SCURVY.

Dr. Alfred F. Hess presented this study, in which he called
attention to the fact that scurvy almost never developed among
breast-fed babies, but was encountered among those who were fed
on cow's milk and more especially those who received in addition
some of the proprietary foods which were so commonly resorted to
in the preparation of milk formula;. There had been considerable
difference of opinion as to whether pasteurized milk could induce
the scorbutic condition. In its report, in 191 2, the Commission on
Milk Standards stated that pasteurization did not destroy the chem-
ical constituents of milk and that it was not altered by exposure to
heat under 145° F. for thirty minutes. In order to test the validity
of this statement Dr. Hess made a test among a certain number of
inmates of an infant's home, where all babies were fed on Grade A
pasteurized milk which had been heated to 145° F. for thirty minutes.
The babies had been receiving orange juice in addition which was
discontinued. No other change in the diet was made. Almost all

AMERICAN PEDIATRIC SOCIETY 165

the babies who did not receive orange juice developed a more or less
marked form of scurvy, whereas those who continued to receive
orange juice remained entirely free from this disorder. Most of
these infants had been in the institution from birth so that their con-
dition both before and subsequent to the change could be thoroughly
observed. The results of this investigation were published some
two 3'ears ago and were questioned by some who were loathe to
believe that pasteurized milk could in any way lead to scurvy and
hence the observations were extended somewhat during the subse-
quent year.' The results were the same, so the writer feels safe in
saying that a diet of pasteurized milk leads to the production of
scurvy in infants unless some antiscorbutic food is also given. The
scur\'y' met with in infants fed on pasteurized milk was, as a rule,
not of the florid type met %\-ith in infants fed for months on a pro-
prietary food, but might be described as latent or rudimentary.
There was a gradually increasing pallor, a failure to gain in weight,
the development of some petechial hemorrhages, and in more marked
instances, the subperiosteal hemorrhages. It would seem probable
that this insidious type of the disorder was far more common than
was generally recognized by physicians and that there were many
infants suffering from slight nutritional disturbances which might
be ascribed to this cause. When the pasteurized milk was replaced
by raw milk the scorbutic condition improved, although it might be
added that raw cow's milk was by no means comparable to orange
juice as an antiscorbutic. It is not to be inferred from these con-
clusions that the use of pasteurized milk is fraught with danger,
but merely that it is an incomplete diet for babies and must be given
with antiscorbutic food. There are also secondary factors contrib-
uting to the development of scurvy, such as the individual variation
depending upon hereditary characteristics, that is upon the amount
of antiscorbutic material which the infant brings with it when it
comes into the world. Secondary food factors also seemed to play
a part. Malt preparation seemingly predisposes to scurvy and it
seems that there is an intimate relationship between the develop-
ment of scurvy and the amount of carbohydrate in the dietary.
The sovereign cure for scurvy is orange juice, which is efiicacious
even when boiled for ten minutes; potato, one of the best antiscor-
butics for adults, may be used in infant feeding where orange juice
cannot be readily obtained. For this purpose milk can be diluted
with potato water, one tablespoonful of mashed potato to i pint
of water, instead of the usual cereal decoction. In connection with
this work observations were carried out to ascertain the effect of
infantile scurvy on growth. This study embraced an interval of
one year or more. Three periods might be distinguished in this
investigation: a preliminary period of about three months, during
which time the infants were weighed daily and measured every two
weeks; a period embracing four months during which time the in-
fants received a liberal diet of pasteurized milk and cereal, which
differed from the previous period only in the fact that no orange
juice was given; and an after period, lasting about six months, which

166 TRANSACTIONS OF THE

dated from the time when orange juice or some other antiscorbutic
was again added to the food. During the period when the anti-
sorbutic was discontinued particular attention was given to furnish-
ing a sufficient quantity of food, and more cereal was given or the
strength of the milli mixture was increased. It was found that
althougli the infants continued to gain in most instances for a few
weeks following the discontinuance of the orange juice, they soon
reached a stationary plane and for months were unable to rise above
this level, but increased in weight promptly when the antiscorbutic
food was again added to their diet. It is very probable that infants
cease to gain in weight at about eight months of age, during the
third quarter of the first year of life for the want of this essential
addition to their food, and fail to progress until mbced feeding is
begun some months later. At present the rule m.ay be said to be
to add fruit juices to the infant's diet at about the sixth month, but
it would seem that it should be given as soon as possible. There
is no reason why a baby should not receive orange juice when
a month old, and there are strong arguments in favor of such a
procedure.

A number of infants in this group were also measured and as a
result it was found that scur\y not only had a direct effect upon the
weight but also upon the growth in length. This fact was of greater
biologic interest than failure to gain in weight, for growth in length
is a physiological impulse to which the individual clings with great
tenacity, and it is rarely affected even when other functions are held
in abeyance. Lack of growth, however, did not always play an
essential part in the constitution of scurvy. Orange juice was found
to be a corrective for the lack of growth as well as for the failure to
gain in weight in this series of cases.

DISCUSSION.

Dr. L. Emmett Holt, New York. — ^"For several years past it
has seemed to me that scurvy has been on the increase and during
the last year this impression has been confirmed. We all realize
the advantages of pasteurized milk but it has certain disadvantages
which we should recognize. It is time that we as pediatricians ex-
press our disapproval of the present tendency of health boards to
require the pasteurization of all milk. Such a course would be a
mistake; it should not be made impossible to get pure, adequately
certified raw milk. In considering the subject of scurvy we must
take into consideration the fact that other factors beside pasteurized
milk play a part. We must give due weight to the factor of heredi-
tary predisposition. After all there are comparatively few cases of
scurvy due to pasteurized milk among the poor because it is quite
customary for them to give fruit and vegetables and other foods to
babies at a comparatively early age. Ten or twelve years ago nearly
all the cases of scurvy could be traced to proprietary foods and now
they nearly all come from boiled milk. The number of cases is
undoubtedly increasing or we would not be having this discussion.

AMERICAN PEDIATRIC SOCIETY 167

Physicians should be prepared to recognize scurw when it comes
under their observation. During the past year I have seen four
cases that were not recognized until epiphyseal separation had taken
place. We must emphasize the fact that .if pasteurized milk is used
we must also use an antiscorbutic and use it early and continually."

Dr. Charles Herrmax of New York said: "Dr. Hess has said
that orange juice retains its antiscorbutic properties even when
boiled while milk does not. This raises the question whether some-
thing more than heat may not enter into the problem."

Dr. S.amuel S. .^d.ams of Washington, D. C, said: "All know
that I am opposed to the commercial pasteurization of milk, and
I hope the Society will take this question up and protect against
the tendency to pasteurize all milk. The commercial pasteurization
of milk is dangerous. Within the last ten days four cases of scurvy
due to pasteurized milk furnished by the City of Washington, have
come under my observation. In one instance I asked a dairyman
to send raw milk. He did not do it and I asked him why. He said
because the raw milk was bad. It would be quite as reasonable to
buy a rotten steak because the butcher tells us it will not hurt us if
it is cooked as it is to buy dirty milk and think it is all right because
it has been heated. I am not opposed to the home pasteurization
of milk."

Dr. a. D. Black.ader, Montreal. — "I would like to emphasize
the importance of pasteurized milk as a cause of infantile scurvy.
I have had two instances in infants in which the symptoms were
obscure, chiefly scurvous symptoms, associated with a lack of growth
but there were none of the classical symptoms of scurvy. In both
of these cases there was a rapid disappearance of the symptoms
immediately folloviing the administration of orange juice. When
I saw these cases I thought I had found something new, but I will
give Dr. Hess credit for having shown that this subacute form of
scurvy is due to a deficiency of vitamines in the food of these young
infants."

Dr. HexryL. K. Sh.aw, Albany. — "I am in a position to see the
reports of the various milk-borne epidemics which have occurred as
a result of the use of raw milk in New York State. There have been
seventeen epidemics directly traceable to milk. Septic sore throat
and not tuberculous is the dangerous disease conveyed by raw milk.
In one of these epidemics there were seventy cases of septic sore
throat. Some cases of this infection have been very serious and even
fatal, and I think that a comparison of the e\'idence would show that
the danger of scurvy is not comparable to that of septic sore throat.
Scurvy is a disease very easily cured or prevented by the use of
orange juice which can be safely added to the infant's diet after the
third month."

Dr. PERcrv.AL J. E.atox, Pittsburgh. — "I want to support the
statements that Dr. Hess had made. Commercially pasteurized
milk is not what one would really call pasteurized milk. Commercial
pasteurized milk is milk that had been subjected to superheated
steam at a pressure of 15 pounds and this is really sterilized milk.

168 TRANSACTIONS OF THE

When one uses properly sterilized milk much better results are
obtained than with the commercial product. The best method is to
get properly certified milk and to sterilize or pasteurize it at home.

Dr. Samuel McC. Hamll, Philadelphia. — ^Dr. Hess has not said
anything against pasteurized milk, he has said that pasteurized milk
is a necessity to-day. I do not think it is necessary to come to the
defense of properly pasteurized milk. But there is a tendency
toward requiring the pasteurization of all milk and if this was done
one could no longer get good raw milk, hen-ce it seems that we should
take some action. The medical profession is largely to blame for
the attitude of health officers and dairymen; they are not prepared
to give good certified milk. There is also some confusion as to just
what good pasteurized milk means, and in any action taken by this
Society it should be definitely stated what pasteurized milk means.
I believe in the pasteurization of milk because we know that, while
pasteurization to-day is frequently unsatisfactory, it is done in a
better way than formerly. In Philadelphia in most instances it is
done efficiently. The dangers of pasteurized milk are not to be
compared with those of raw milk. Scurvy is a disease that is
easily controlled and cannot be compared with the diseases that are
milk borne."

Dr. Henry Heiman, New York. — "We should have laws to
govern the commercial pasteurization of milk. There is no way to
tell whether we are getting pasteurized or sterilized milk. The
probability is that when the mother gets pasteurized milk she gives
it another pasteurization. One can give 5 drops of orange juice
to a baby at the age of one month and other fruit juices as well, such
as pineapple; this will furnish the missing link."

Dr. Philip V.an Ingen, New York. — -"In connection with the
emphasis that has been placed on the increase of scurvy since the
introduction of pasteurized milk mention should also be made of
the decrease in the infant death rate that has taken place as a result of
the use of pasteurized milk."

Dr. Maynard Ladd, Boston. — "I have seen a half dozen cases
of scurvy in babies presumably taking raw milk and found that the
milk had been overheated at the time it was warmed for feeding,
so that these children were practically getting pasteurized milk."

Dr. Hess, in closing the discussion, said: "I feel that the conclu-
sion could not be drawn from his paper that pasteurized milk is not
advantageous. The only conclusion that can be drawn is that
pasteurized milk is not a complete food and all that is necessary to
make it a complete food is to give orange juice or potato water, but
not the potato water made from commercial potato flour. There
is also a predisposition to scurw which must be taken into considera-
tion. Under the same conditions some develop scurvy and some
do not, just as in beriberi, some get it and some under like conditions
do not. As to whether an infant develops scurvy may depend on
the mother and what food she has taken during pregnancy. Dr.
Heiman has asked why boiling destroys the vitamines in milk and
not in orange juice. That seems to depend on the medium in which

AMERICAN PEDIATRIC SOCIETY 169

the boiling takes place. The vitamines are not destroyed by boiling
in water but are in fats such as the fats contained in milk. I had a
control series which were fed orange juice and none of them developed
scury\'. In the children that developed scurv\^ the feeding of raw
milk produced a sharp reaction and an increase in weight.

"As to what a vitamine is, Dr. Funk has isolated them from
various food stuffs; they are nitrogenous substances. The term is
good as indicating the essential part they play in growth and
nutrition.

"As to the' \dtality and general condition of the children upon
whom our conclusions are based, these children have been under
our care in most instances from birth and the environment is good.
These children compared very favorably in every respect with nor-
mal healthy children elsewhere."

SARCOMA OF THE KIDNEY TREATED BY X-RAY'.

Dr. Alfred Friedlander, Cincinnati. — "It is generally accepted
as axiomatic that the only hope in cases of sarcoma of the kidne}^
in childhood lies in early nephrectomy. Even with this procedure
the mortality is very high on account of the likelihood of metastases,
even in those cases in which the operation itself is well borne.

This child, four years of age, was admitted to the pediatric service
of the Cincinnati General Hospital on October 20, 191 5. The his-
tory was one of increasing languor and lassitude, with loss of appe-
tite and anemia. Except for the condition of the abdomen the
physical findings were not of moment. The entire left abdomen
was filled by a tumor, extending from the costal margin in the nipple
line to 3 cm. above the symphysis. The tumor extended i cm.
to the left of the umbilicus. It was hard, distinctly nodular, ap-
parently not tender to pressure, and could be moved forward by
pressure from behind. Urinalysis on admission showed distinct
microscopic hematuria. The blood showed a secondary anemia.
Fluoroscopic examination with the colon partly filled with gas showed
a sharply defined dark shadow in the region normally occupied by
the kidney. The :v-ray plate of the lungs for the characteristic
metastatic sarcomatous shadows was negative. X-ray treatments
were given because of the apparent hopelessness of the case. These
were given with the Coolidge tube on the front, back, and side of
the tumor at each treatment, twenty treatments being given at
intervals of about a week. The dosage was graduated, beginning
with a treatment lasting ten seconds at a distance of 8 inches and
a spark gap of 9 inches and increased to fifty seconds at a distance
of 8 inches and a spark gap of 9 inches. Before each cv--ray treatment
the child was given full doses of potassium citrate for a day. There
was no toxemia nor increase of the blood in the urine. After the
seventh treatment it was noticed that the tumor had decreased very
markedly in size. Later the child had an attack of influenza and
then one of measles and death occurred. Autopsy showed sarcoma
of the left kidney with small metastases in both lungs and in the liver.

170 TRANSACTIONS OF THE AMERICAN PEDIATRIC SOCIETY

"The pathologist's report was presented which stated that the
stained sections showed the most widespread and generally diffuse
necrotic changes with no evidence of inflammatory reaction. Even
the stroma showed degenerative changes, associated with irregular
areas of edema. The parenchyma was almost completely necrotic
and showed almost no evidence of structure. In the areas in which
some tumor structure persisted the appearances were those of alveo-
lar sarcoma, and in these areas short spindle cells and round cells
were present, chiefly the latter. The fact that the whole necrotic
process was so widespread in so large a tumor mass; that there was
no evidence of vascular thrombosis in the main vessels, and no evi-
dence of infarction; and the fact that the degenerative process ap-
peared to be a gradually progressive one indicated that the .r-ray
treatments were at least partially the cause of retrogression. This
was a particularly unfavorable case and it seemed justifiable to say
that if nephrectomy was contraindicated in a case of sarcoma of
the kidney the .v-ray should be given a thorough trial."

TR.^NSIENT ABDOMINAL TUMOR IN A CHILD OF FIVE YE.ARS, WITH
REDUNDANT COLON.

Dr. Edgar P. Copeland, Washington, D. C. — ^"The complaint
in this case was the periodic occurrence of an abdominal tumor and
the brief history is as follows: The patient was the only child of
young and healthy parents. The child was delivered by instru-
ments after a tedious labor. The infant was normally nourished
until two days after birth, when a promising lactation for some reason
failed. After this the child ran the gauntlet of proprietary foods
which was continued well into the second year. He sat up at five
months, began the eruption of teeth at eight months and walked at
nineteen months. With the exception of frequent attacks of rhi-
nitis the boy escaped all the diseases peculiar to childhood, progressing
in a fairly normal manner to the age of three and one-half years.
His present illness began in December, 1914, approximately a year
before mv first examination; he became suddenly ill in the night,
with extreme nausea, severe vomiting and the appearance of a
rounded tumor in the hj^jogastrium, simulating a distended bladder.
To judge from the description, the vomiting was simply bile-stained
gastric juice, and at no time stercoraceous. The tumor was elastic,
but not specially tender to touch. There was no history of previous
disturbance in the regularity of the bowel. There was no fever.
The physician called in at this time made a diagnosis of intussuscep-
tion and had completed plans for an immediate removal of the pa-
tient to the hospital for operation. Returning a few hours later he
was much surprised to that the mass had spontaneously disappeared
and the patient recovered. Since this initial appearance, these
attacks have occurred at varying intervals, seldom less than three
weeks and on several occasions as long as six weeks apart. They
have varied in the severity of associated symptoms and likewise in
duration, seldom lasting over two days. The tumor has invariably

REVIEW 171

appeared first over the region of the bladder, moved about the ab-
domen spontaneously and finally disappeared. Its appearance had
always been associated with nausea and vomiting, and its disappear-
ance with a pronounced paroxysm of abdominal pain.

"At the time of my first examination, I found the patient in bed
Ijdng on his back, thighs partially flexed. The attack was several
hours old and there was still some nausea. Presenting in the hj^po-
gastrium was a smooth rounded tumor about the size of an orange,
elastic but not tender to the touch, and dull on percussion. It was
palpable by rectal examination and suggested strongly a distended
bladder. It was possible, without undue force, to manipulate the
tumor about the entire abdomen. There was a fairly well pro-
nounced beading of the ribs. The pulse was rapid but regular.
The temperature was normal. The leukocyte count was 11,500.
The von Pirquet and Wassermann tests were negative. Under re-
stricted feeding and large enemata slowly administered, the mass
spontaneously disappeared. An examination of the abdomen sub-
sequently was absolutely negative.

"The clinical history, in the light of the .v-ray findings, would
seem to justify the assumption that the phantom tumor is the result
of a temporary kinking of the redundant colon (or sigmoid), incident
to its displacement to the right which is followed by either fecal or
gaseous distention in the loop. When the loop fills itself to a certain
point, it swings gradually to the left and automatically unkinks
itself with a disappearance of the tumor mass."

REVIEW.

Nervous Children. By Beverly R. Tucker, M. D. Professor
of Neurology and Psychiatry, Medical College of Virginia; Con-
sulting Physician of the Juvenile Court, Richmond, Virginia;
Physician of the Tucker Sanatorium; Neurologist to the City
Hospital; Consulting Neurologist to the State Epileptic Colony,
etc. Small 8vo. Illustrated, pp. 147. Boston: Richard G.
Badger. Toronto: The Clark Co., Ltd., 1916.
This little book is attractively written and simply expressed.
It aims to give its readers a clear understanding of the fundamental
principles underlying the rearing of children from the standpoint
of their nervous and psychic development, in the hope that this
knowledge will enable the physician, the teacher, the mother, the
nurse, not only to understand the normal as well as the nervous
child, but to train it to avoid the neuropsychopathic pitfalls which
are found everywhere along its path.

172 BRIEF OF CURRENT LITERATURE

BRIEF OF CURRENT LITERATURE.

DISEASES OF CHILDREN.

Eiweissmilch and its Adjuvants. — E. Glanzman {Jahrbuch. f.
KinderheiL, Oct., 1915) says that the value of "eiweissmilch"
depends on the presence of soapy stools. There are several groups of
cases of this nature. In one group these stools occur with the pres-
ence of a large amount of alkaline earths and alkalies in the intestine,
giving a dry, shiny stool. A disturbance of the metabolic balance
takes place and there is a reduction in weight. Soapy stools are the
cardinal symptom of disturbed metabolism. In one group of cases
which show disturbed metabolism the addition of carbohydrates to
the diet without any change in the concentration of the food will put
an end to the soapy stools. In a second group the carbohydrates
produce no improvement for presence of too much fat is another
factor. The fat produces a strongly alkaline secretion of the intes-
tinal walls and the large glands. We must seek to hinder fermenta-
tion of the carbohydrates by reducing the amount of whey. By
reducing the whey the amount of fat is well borne though whey alone
never causes soapy stools. Casein is another factor in the production
of the soapy stool. In buttermilk we have, with a high concentra-
tion of whey, also a high relative and absolute amount of casein,
which may lessen the stimulative fermentative influence of the whey.
With increased concentration of the milk in a feeding mixture the
influence of casein to prevent fermentation is increased over the
ferment-stimulating whey. In an albumin-rich medium the fat
tolerance rises in spite of the contained whey. From buttermilk
enriched with cream is but a step to full milk. Constipation with
soapy stools may occur under this diet. The high concentration of
the casein is the cause of the constipation. In adding rennet to milk
there is a splitting of casein into albumin whey and paracasein.
When this precipitates large amounts of calcium phosphates are
carried down with the fat. These paracasein calcium combinations
act as catalyzers in the production of earthy alkaline phosphate fat
soaps. A similar action takes place through an addition of inorganic
calcium solution. An increase of albumin acts like an increase of
fats. It causes an increase of alkaline albumin-rich intestinal juice.
This medium nourishes a proteolytic flora and does not allow of the
growth of fermentation bacteria. The fermentation is prevented by
putrefaction of the intestinal juice. In another group of cases the
soapy stools are prevented by reducing fat and albumin at the same
time, and using malt-soup, which contains but one-third milk.
The soapy stool is the usual result of strongly alkaline reaction in the
intestine. The alkaline reaction arises first from the reduction of the
carbohydrates (milk sugar); second, from the reduction of the whey;
third, from an enriching with freshly prepared casein which prevents
a primary fermentation of the carbohydrates; fourth, by reduction
of whey. Eiweissmilch fulfils all the requirements. The dift'erent

BRIEF OF CURRENT LITERATURE 173

forms of disturbance found in these children are merely steps in one
and the same process, beginning with disturbances of metabolism
and ending in decomposition and alimentary intoxication. We must
get these cases in an early stage of the disturbances, when we can
easily cure them. Eiweissmilch is the best means we have for
treating these cases after human milk. By its use we may cure the
child without a reduction of fats and carbohydrates which would be
dangerous to life. The value of "eiweissmilch" is that it so soon
and so surely establishes a tolerance for carbohydrates without reduc-
tion of fats. • By the use of "eiweissmilch" we produce a change in
metabolism, and by adding carbohydrates we cure it. To stop the
decomposition as soon as possible is the central problem. We add
sugar up to 5 or 6 per cent., and if necessary a cereal. This acts as a
palliative only to assist the "eiweissmilch" in establishing a true
balance. Indications for the use of "eiweissmilch" are dyspepsia,
decomposition, alimentary intoxication, infections causing disturb-
ances of nutrition, intolerance of carbohydrates, disturbances from
constitutional conditions, exudative diathesis, neuropathic, psycho-
pathic and spasmophilic cases. In all forms of fermentation diar-
rheas "eiweissmilch" is indicated. It should never form a per-
manent diet and should not be given to normal children. Indi-
vidualization of cases and physiological knowledge are necessary to
its successful use.

Acute Otitis Media in Infancy and Childhood. — W. R. P. Emer-
son {Bosl. Med. and Surg. Jour., 1915, clxxiii, 616) records five
cases to represent the most common types of aural complication.
In none of the five were there symptoms of earache. In two cases
the symptoms were all abdominal, in one meningeal, and in two
general, associated with fever. In all of these cases the diagnosis of
acute otitis media was made by routine examination of the ear
drums. These cases are used to emphasize the fact that in every
case of contagious disease and of affections of the respirator}^ tract in
children, measures should be inaugurated at once to keep the naso-
pharynx clear and so maintain drainage through the Eustachian
tube. In such cases the ear drum should be inspected at every visit
of the physician to his patient. An electric ear instrument gives a
clear picture of the drum with a minimum disturbance of the child.
In cases of otitis media when the symptoms and the local condition
do not improve under treatment the drum should be incised without
waiting for bulging or pus.

Speech Sign of Congenital Syphilis. — W. B. Swift (Bost.Mcd. and
Surg. Jour., 1Q15, clxxiii, 619) says that congenital syphilis can
cause a faulty or incomplete development of vocal cords that results
in vocal monotony and harshness in both conversation and weeping.
As spirochetosis has been of late offered to cover all the lesions of
syphilis he proposes as a name for this sign scaphoid vocal cords and
spirochetotic harshness.

Fetal Rigor Mortis. — ^Lorenzo Castriota {Ann. di os/et. e gin.,
Dec, 1915) details a case of stillborn infant which showed at birth
distinct rigor mortis. This is a very unusual condition. After a

174 BRIEF OF CURRENT LITERATURE

careful review of the studies which have been made of the cause of
rigor mortis the author gives the following explanation of its presence
at birth. All the facts given show the relation of rigor mortis to
muscular contraction. Possibly cadaveric muscular rigidity may be
a phenomenon independent of the nervous system and connected
only with the muscles themselves. The contraction may be an
exaggeration of the normal muscular tone, and this depends on the
continuous action of the nervous system. Brown-Sequard afSrmed
that the latent life of the nervous system was the cause of rigor
mortis. Later researches contradict this opinion. Catabolic pro-
ducts are undoubtedly factors in the postmortem rigidity. There
are variations of acidity between the fresh and the rigid muscles.

Clinical Study of Children in Relation to Tuberculous Exposure. —
In a clinical study of 22S children in relation to tuberculous exposure
controlled by the cutaneous von Pirquet test, J. B. Manning and
H. J. Knott (Amer. Jour. Dis. Child., 191 5, x, 354) find that, contrary
to the findings of Fishberg, children living in tuberculous milieu
and those with no known contact with consumptives show marked
diSerences; those living in tuberculous surroundings reacting in
ratio of about 2 to i of those living in an environment not known to
be tuberculous. Further, they find the number of positive reactors
in the entire series is only 42.9 per cent. They also find that the
number of children between ten and fiiteen years reacting positively
to the cutaneous tuberculin reaction, in a series in which the majority
of the children are from tuberculous homes, is 58.1 per cent., far
below the figures of Hamburger, 95 per cent., and von Pirquet, 93
per cent. These discrepancies are due, in their opinion, to com-
munity characteristics of climate, housing and sanitation.

Typhoid Fever in Children — Presenting an analysis of 308 cases of
typhoid fever in children. K. G. Percy {Bost. Mc'd. and Surg. Jour.,
1916, clxxiii, 565) finds that it is a relatively common disease in
childhood and far more prevalent in infancy than formerly supposed.
Symptomatically it is ushered in very much as in adults, with head-
aches, fever, malaise and abdominal pain as the most frequent
symptoms. In this series and in a large collected series from the
literature, the spleen is enlarged in 71 per cent, of all cases; rose
spots are seen in 61 per cent.; positive Widals are seen relatively
early in 88.2 per cent.; the white blood count is below 10,000 in
73 percent.; the fever lasts an average of twenty-five days; relapses
occur in 1 1 .8 per cent, intestinal hemorrhages in 4. 2 per cent, perfora-
tion of intestines in 1.2 per cent., complications in 10.6 per cent., and
the mortality is 5.3 per cent. A diet, bland, high caloric, and suited
to ihe individual need of each patient, is most important. Hydro-
therapy seems to have a vital place in the treatment of the febrile and
delirious stage of the disease. Enemata are essential in a high per-
centage of cases. Stimulants and other symptomatic drugs are to be
used as need arises, for typhoid is a disease, cured not by medicine,
but by good nursing and keen, sensible therapy.

Management of Enuresis. — The method of management of enu-
resis, whether it be diurnal of nocturnal, or both, that has given the

BRIEF OF CURRENT LITERATURE 175

best results in the experience of A. Newlin {Arch. Pcdiat., 1915,
xxxii, 753), consists in the simple procedure of anticipating the
involuntary act by a voluntary emptying of the bladder. To be
successful, the attendant must devote herself exclusively to the child
day and night for the tirst three or four days. If the enuresis occurs,
say, on average of every two hours, she is instructed to put the child
on the chamber every hour for the first twelve hours. If she finds
the clothing wet at any such time the hour is noted on the chart. At
night the child is lifted almost as frequently up to eleven o'clock or
midnight; after that every second hour is usually all that is neces-
sary for the first night. On the second day she is guided by her chart
of the previous day and may extend the length of time between the
voluntary urinations, always, however, anticipating the hours
marked as "Wet" on the day before, placing the child on the cham-
ber at least a half hour before the time indicated. Thus in each
succeeding day the intervals are longer. Usually in moderately bad
cases from the time that the regime is started enuresis ceases entirely
and by the end of a week, in at least the milder cases, the child will
go from eleven o'clock at night to six in the morning without wetting
the bed.

Etiology of Tetany. — Reviewing the literature and describing
their metabolic and clinical studies. A. Brown and A. Fletcher
(Amcy. Jour. Dis. Child., 1915, x, 313) say that tetany may be pro-
duced by high carbohydrate foods which have been subjected to heat
up to or over the boiling-point. The monthly incidence of tetany is
probably due to a disturbance of the gastrointestinal tract (consti-
pation), decreased internal combustion and the comparative safety
from diarrhea in feeding high carbohydrate foods during the cold
months. A diagnosis of tetany is suggestive when there is manifest
kidney inactivity in constipated infants fed heated foods of high
carbohydrate content. As a result of this improper feeding there is
produced a disturbance of the body salts. At the height of the
disease there is an almost complete retention of sodium and potas-
sium (the irritating salts) and a great loss of magnesium. As
improvement ensues there is an increased flow of urine accompanied
by a relief of the constipation, during which the stored-up sodium and
potassium are rapidly lost. This salt disturbance may be remedied
first by purgation, second by diuresis, third by the administration of
cod-liver oil and phosphorus to build up the calcium content, and
fourth by a change of diet. The severe spasms or convulsions may
be temporaril}- relieved by subcutaneous injections of a solution of
magnesium sulphate.

Ajitagonism between the Lactic Acid and the Spore-bearing
Organisms in Milk.- — W. S. Kiester (Joints Hopk. Hasp. Bull., 1915,
xxvi, 365) finds that heating market milk to temperatures ranging
from 55° C. to 65° C. for thirty minutes results in a destruction of
many of the lactic acid and intestinal bacteria, and in such samples
sporulating bacteria can always be found on the plates poured within
twenty-four hours. After this time the lactic acid and the intes-
tinal bacteria become the predominant species in the milk. The

176 BMEF OF CURRENT LITERATURE

disappearance of the spore-bearers is to be attributed to the growth of
the lactic acid organisms in some instances, to Bacterium welcJiii in
others, and possibly is due to their combined action. At 67° C. the
lactic acid and intestinal bacteria are usually completely destroyed
and in milk heated to this temperature the spore-bearing organisms
multiply rapidly from the start, but may at times yieM to the
"gas bacillus" in which case aerobic cultures may be sterile.

The Protection of Infancy during the First Five Months of the
European War. — A. Pinard {Ann. de gyn. et d'obsl., Nov.-Dec,
1915) says that the Central Oihce of Assistance for Mothers and
Infants arose out of the necessity for protecting infant life in a time
of war, when many women found themselves pregnant against their
will, and were liable to attempt to sacrifice their infants. Its object
is to give to every woman pregnant or having an infant under three
months old social, medical and legal protection. Delegates were
installed in eleven "mairies" of Paris where such mothers would be
found. These delegates were furnished with lists of the places where
rehef could be given. The first obstacle that was encountered was
the small number of milk cattle that were to be had in the neighbor-
hood of Paris, from which milk for the artificially fed infants could
be had. The result was a severe epidemic of diarrhea in August and
September. Hence there arose the necessity of giving to every
mother encouragement to nurse her child. To every wife of a
soldier was given daily a sum sufficient to buy food for each child.
During these five months of war 3876 illegitimate infants were
registered at the "mairies" in Paris. These women had no claim on
military assistance because they were unmarried. Many of them
found themselves in the street without means of livelihood. In
1914 a law was promulgated to assist such women. This took care
of 5743 children during five months of war. Another assistance
came by the "secours de chomage," which aided women whose hus-
bands had been killed in the war, or lost in any way, giving to the
head of a family 60 francs a year for each child over thirteen months of
age. The medical protection consisted in all day chnics at all the
maternity hospitals. In three of these establishments 20,000 con-
sultations with pregnant mothers were given. 12,303 infants were
cared for in public maternities. The total births during the same
period were 16,579, therefore 74 per cent, were under public care.
All these mothers were able to nurse their infants. The author
considers the mother who cannot nurse her infant as a monster.
The "bon de nourrices" allowed the mother to place her child with
a wet-nurse at the expense of the state. This is a vicious measure
since it allows the mother to leave her child. It has worked untold
harm to the infants. Under these measures of assistance the mor-
tality of the mothers has decreased, the number of infants born dead
has diminished, and the number of abandoned infants is less.
Further assistance should be given to these illegitimate infants by
legitimizing them all.

^7?
THE A IvrERIO AJST

JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN.

VOL. LXXIV. AUGUST. 1916. NoT

ORIGINAL COMMUNICATIONS.

THE DUCTLESS GLANDS AND THEIR RELATION TO THE

TREATMENT OF FUNCTIONAL GYNECOLOGICAL

DISEASES.*

BY
M. RABINOYITZ, M. D., F. A. C. S.,

Adjunct Gynecologist Beth Israel Hospital, Gynecologist Sydenham Hospital,
New York.

Functional gynecological disorders and their treatment by means
of organic extracts, constitute two of the most difficult chapters in
gynecic medicine for study and mastery. Up to about ten years ago,
our knowledge concerning their pathology and therapy was based
chiefly upon speculative reasoning and empiricism. Within the
past decade, e.xperimental physiology and biochemistr}' have
blazoned the way toward more accurate, rational and scientific
methods of diagnosis and treatment. As clinicians we measure
the value of experimental research by the degree of its therapeutic
applicability. I might therefore enumerate the different func-
tional disorders and the organic extracts that may be employed in
each of them, and consider my task done. Were I, however, to do
this, without offering some explanation of the philosophic back-
ground that reflects these results, you would be lost in the maze of
independent facts, instead of getting a good perspective and being
able to see the picture as a whole. To obtain a lasting impression,
we will step far enough back, and consider the following points
I. What is a Functional Disease?
II. What is Internal Secretion?

* Read before the Eastern Medical Society. June ii, 1915.

178 R.\BINOVITZ: THE DUCTLESS GLANDS

III. The Physiology and Physiological Pathology of the Gonads and
of Some of the Endocrine Glands imth Which They are in Close
Functional and Chemical Correlation.

IV. Ovarian Extracts, and the Functional Diseases in Which They
May be Employed with Satisfactory Results.

V. Conclusions.

I. What is a Functional Disease? — Nurtured in the school of cel-
lular pathology, we have been taught to classify diseases into organic
and into functional. By the former we understand morbid phe-
nomena, which present distinct tissue changes of macro- or micro-
scopic nature. Under the latter heading we group that large
class of deviations from the normal which are unaccompanied by
structural alterations. Having no concrete pathology, the study of
functional diseases has not received as serious consideration as was
given to the organic class, and as a consequence their treatment is
either empirical, or what is worse, not having been properly diag-
nosed, therapeutic methods suitable for the latter class, have been
applied to the former, with the most disappointing results to both
physician and patient.

In the light of modern medicine this nomenclature is no longer
tenable. To speak of functional disturbances in the sense that they
have no pathology, is erroneous and unscientific. Progressive
medicine teaches us daily, that other causes besides pathological
tissue changes, may be the etiological factors of disease. Rich-
ets, (66) definition of the processes of life, that " the li\ang being is
a chemical mechanism and perhaps nothing else," opens before us
new vistas of medical thought. May we not assume that the defi-
nite pathological metamorphosis observed in organic disease, are
in reality the end results of a preceding functional disorder, whose
progress has escaped our notice, due to our scientific limitations?
Are not the recent studies in cancer drifting toward biochemical
disturbances as the cause of malignant growth? We must therefore
think of disease in the terms of either morphological or ph\sio-
chemical pathology.

Modern psychology furnishes an excellent example of the sound-
ness of this assertion. Meyer(43) avers, that "from the point of
view of science, behavior and mental activity, even in its implicit
or more subjective forms, is not more subjective than the activity
of the stomach, or the heart, or blood serum, or cerebrospinal fluid
or knee-jerk."

Now then, if psychology ceases to be a puzzle, no longer resisting
the objective methods of science, why shall not the functional dis-

RABINOVITZ: THE DUCTLESS GLANDS 179

turbances, the purely subjective disorders in the genital sphere, be
submitted to the same forms of study? Why shall not the modern
clinician, like the psychologist, who is adhering closer and closer to
psychophysical parallelism, which carries him in his studies of the
mind, far beyond what is done in the physiology of the brain, why
shall he not, in his studies of sterility, amenorrhea, dysmenorrhea,
idiopathic uterine hemorrhage, precocious or delayed sexual matura-
tion, etc., be carried beyond the confines of cellular pathology,
into the realms of biochemistry, and there seek solutions for the
ds orders which have hitherto baiHed his antiquated methods of
inquiry? These biochemical changes may reside within the genera-
tive tract, or in regions remote from it, but to which it is functionally
and chemically in close relation.

Functional diseases therefore possess a distinct and definite pathol-
ogy, just as well as the organic, only of a different nature, structural
in the latter instance, and physiochemical in the former; and while
morphologic changes are quite readily detected, many of the
biochemical alterations are so subtle in nature, that with the
present scientific aids at our command some of them still remain
unrecognized.

II. What is Internal Secretion? — Academically it is of interest to
note that Hippocrates, Celcius, and some of their contemporaries
have entertained views upon this physiological problem. In 1855
this subject received its scientific impetus from Claude Bernard (6),
when he studied the secretions of the liver. He for the first time
employed the term "secretion interne." Since then this question
has undergone repeated scientific filtrations, its final crystallization
however has not been completed as yet. Let us consider its most
important theories and facts.

If by internal secretion we mean, as did Novak (57), the inter-
change of metabolic products between the blood and the tissues on
the one hand, and between the tissues and the blood on the other,
then we would have to ascribe this property to all the tissues and
organs in the body. This would in no way differ from the ordinary
intercellular exchange that is constantly going on in the organism.
Advanced physiological research demands a more hmited definition.
By internal secretion we mean the property possessed by a set of
special and highly differentiated organs, to produce biologic sub-
stances, which when absorbed into the blood in normal amounts,
are capable of maintaining the organism at par; but which, when
their activity is either diminished or increased, will cause a disturb-

180 RABINOVITZ: THE DUCTLESS GLANDS

ance in the bodily functions terminating in disease, which will be
characteristic of the special gland or glands so involved.

The organs endowed with these properties are grouped under the
heading of the "endocrine system." It includes the hypophysis,
the pineal gland, the thymus, the thyroid, the parathyroids, the
kidneys, the adrenals, the intestinal mucosa, the pancreas, the
aortic glands, the uterus, the ovaries, the parovarium, the placenta,
the testicles, and the coccygeal gland.

The ductless glands differ from all other secreting organs in this
respect, that the products of their activities are not poured out
through distinct anatomical channels, as is the pancreatic juice, or
the bile, but reach the circulation in all probability through lym-
phatic absorption. Another distinguishing physiological feature of
these organs is, that their function is chiefly controlled by the sym-
pathetic nervous system, and only secondarily and in a minor degree
by the cerebrospinal nervous system. The last mentioned fact has
been proven experimentally by Knauer (34) and by Goltz (30).
The former has transplanted the ovaries under the skin, without
causing atrophy or involution of the uterus for a considerable length
of time. The latter has transected the spinal cord of animals, who
conceived and carried young thereafter normally.

The biochemical products elaborated by the ductless glands, may
be divided according to Biedl(7) into two main groups: (a) Products
which are necessary for the function of other organs, like glycogen;
[b) Secretions, which Starling(7i) calls "hormones" or activators;
i.e., substances which are capable of influencing through the medium
of the blood, the functions of remotely lying organs.

Regarding the nature of these hormones a good deal is still un-
known. With the exceptions of "adrenaline," which was first iso-
lated by Takamine(77) in 1901, and of "spermine" produced by
A. Poehl, of Petrograd, we still use products of the entire gland,
as did Brown-Sequard(8) in 1899, when he injected himself with
testicular extract.

These biochemical limitations are undoubtedly at the bottom of
the many contradictions and uncertainties that still overshadow the
field of organotherapy. With the rapid advances made in biochem-
istry, these difficulties are being gradually surmounted, and we are
obtaining from time to time, not only purer, but also more numerous
products, thus constantlj' widening the field o( our activities.

Besides the biochemical imperfections in the organic products at
our disposal, there is another factor which militates against uniform
results in their clinical application, namely our inability to properly

RABINOVITZ: THE DUCTLESS GLANDS 181

determine in man}' cases, the exact "interglandular reciprocity" or
"chemical correlation" that exists. Pineless(62) was the first one to
call attention to the mutual relation that exists between the glands
of internal secretion. Falta(2 2), Rudinger(67), and Eppinger(i9)
have corroborated this fact experimentally. They have shown that
disturbed function in one of the ductless glands, is capable of upset-
ing the physiological equilibrium of other glands in the endocrine
system.

The nature of these disturbances expresses itself in various forms.
The partial or complete loss of function of one gland causes another
gland to hyperfunctionate and increase in size, if that one has exerted
upon it an inhibitory influence; or the latter will hj'pofunctionate
and atrophy, if the former has influenced it in an acceleratory manner.
This increased or diminished activity on the part of any one of
the ductless glands, whether the result of either experimental or
clinical removal of another gland, or due to pathological processes
within the same or other glands, can be regulated by the adminis-
tration of extract or hormones of the same or other glands, provided
we know the exact reciprocal relation that is existing between the
glands in question.

Based upon these observations, Okintschitz(6o) has classified the
glands of internal secretion into two main groups: (i) Synergists
or glands whose hyperfunction and hypertrophy follows the re-
moval of another gland, or hypofunction and atrophy of the
same gland after the administration of extracts of the other.
(2) Antagonists or glands in which hypofunction and atrophy ensues
after the removal of another gland, or hyperfunction and hyper-
trophy of the same gland when extracts of the other are administered.

Having oriented ourselves in the fundamental principles under-
lying the theories of internal secretion, we shall now proceed to a
consideration of the normal and abnormal workings of the endocrine
glands individually.

III. The Physiology and Physiological Pathology of the Gonads and
of Those Glands of Internal Secretion with Which They are in Close
Functional and Biochemical Correlation. — The working hypotheses
upon which this fascinating study is based are in the main two,
clinical and experimental. Clinically we note the following points:
{a) The morbid phenomena pursuant to disease of one or more of
the ductless glands, {b) The therapeutic value of the extracts of
these glands, (c) The symptoms that follow the removal of part or
the whole of one or more glands during operation. Experimentally,
the following observations are recorded: (a) What effect the removal

182 RABiNOvaTz: the ductless glands

of part or the whole of any one gland will have upon the organism as
a whole, or upon the structural and functional properties of the
other glands, (b) The results of the administration of extracts of a
gland, with or without its previous removal, or the removal of
another gland or glands, (c) The effects of homotransplantation.
(d) The effects of heterotransplantation.

THE OVARY.

The normal function of the ovary depends upon a perfect phys-
iological balance among its three structural components, the
follicular apparatus, the corpus luteum, and the interstitial gland.
It is necessary to consider these morphological units separately,
in order to be able to trace the various ovarian disturbances to their
proper sources.

I. The follicle apparatus is genetically the earhest ovarian struc-
ture, it makes its appearance during intrauterine life. Functionally
the primordial ova reach the height of their activity at puberty,
when they mature, burst, and give rise to the formation of the corpus
luteum. This process is termed ovulation. It denotes that the
procreative abilities of the female are fully established, evidenced by
a complete development of the se.x organs, the sex instinct, and by
an involution of the thymus and the pineal glands. In the vast
majority of cases, ovulation is accompanied by a periodic discharge
of blood from the uterus, known as menstruation. For a time
the question as to which of the two phenomena just described is the
cause, and which the effect, has caused a good deal of controversy.
Physiological research and abundant clinical data have finally es-
tablished the fact that ovulation may take place without menstrua-
tion, but the latter never without the former.

The generative faculties thus kindled at puberty, burn brightly
up to middle age, then they flicker dimly to the end of this period,
when they are finally extinguished at the menopause. At this time
also menstruation which has heralded the blossoming of sexual life,
now announces its withering and decay, it ceases.

As soon as impregnation has occurred, follicular function becomes
temporarily suspended. The Graafian follicles, as was shown by
Seitz(72), may continue to grow during pregnancy, but they do not
ripen. Ovulation and menstruation are inhibited. Normally this
momentary loss of follicular function calls for no therapy. If,
however, this transient inhibition is continued beyond the physio-
logical time limits, then clinical manifestations, such as hyperinvolu-

RABINOVITZ; THE DUCTLESS GLANDS

183

tion, protracted amenorrhea, lactation atrophy, and relative sterility
appear.

Castration in the young results in an arrested development of the
genitalia, in an ablation of sex characteristics, producing the eunu-
choid type. After puberty, the removal of the ovaries, either ex-
perimentally in animals, or clinically in the human, on account of
pathological complications, causes an atrophy of the genitalia,
amenorrhea, permanent sterility, and a train of nervous phenomena,
known as the molimina of menopause.

The disturbances arising from natural or acquired ovarian hypo-
function may be entirely relieved, or ameliorated by the adminis-
tration of ovarian extract, or through ovarian transplantation.
Aschner(i) has produced an arbitrary menstrual flow in animals and
man with follicular extract and by means of ovarian transplanta-
tion. Morris (48) has succeeded in curing a case of sterility by
transplantation. Martin(42) is somewhat less sanguine about the
results of ovarian grafting. He nevertheless entertains bright
hopes for the future, when the technic of this procedure will be-
come more refined, and points out the lesson, that the results of
autotransplantation are far more encouraging than are those of
homotransplantation. Okintschitz(6o) has succeeded in delaying
uterine atrophy in castrated rabbits by injecting them from time to
time with biovar (follicular extract), but has failed to obtain similar
results with luteovar (corpus luteum extract). The same observer
has proven clinically, that ovarian hypofunction is most favorably
influenced by follicular extract, and hyperfunction by corpus luteum
extract. His experimental results are so striking that I have tabu-
lated them for ready perusal:

Series No. i. — Nonpubescent Rabbits.

No. of
[rabbits

Extract
injected

2-|

None

Biovar

Proprovar

Luteovar
None

S3
0

Time of
killing

Measurements
at operation

Measurements
at autopsy

2 months
2 months
2 months
2 weeks
2 months
2 months

7.0 X 0.3 cm.

7.0 X 0.35 cm.
7.3 X 0.3 cm.
7.3 X 0.3 cm.
7.0 X 3-5 cm.

.0 X 0.13 cm.
.0 X 0.25 cm.
.3X0.2 cm.
.3 X 0.2 cm.
.5 X 0.25 cm.
■4 X 0.33 cm.

184 rabinovitz: the ductless glands

Series No. 2.- — Pubescent Parous Rabbits

Yes

None

Yes

Proprovar

Yes

Proprovar

Yes

Oroprovar

Yes

Luteovar

Yes

Luteovar

6,S

None

2 months

3 weeks

1 month

2 3^ months

1 month
2}^ months

2 months

]8.o X 0.4 cm.
'7.5 X i-S cm.
75 X 35 cm.

7.5 X 3 . 5 cm.

7.6 X 0.35 cm.
7.6 X 0.3s cm.

|6. 5 X 0.3 cm.
I7.0 X 3.5 cm.
7.0 X 35 cm.
7.0 X 3-5 cm.
6.5 X o. IS cm.
j6.s X o.is cm.
'7.8 X 0.4 cm.

The lessons learned from these experiments are: (a) The uterus
will undergo atrophy after castration, and this atrophy is more
marked in nonpubescent than in the pubescent parous rabbits.
{b) Subcutaneous injections of biovar or proprovar will to a great
extent prevent this atrophy, especially in the younger animals,
(c) Luteovar is not possessed of these properties.

Notwithstanding these and many more clinical and experimental
facts, all of which tend to show that the follicular element is the
factor in the ovary, which governs, influences, and maintains sexual
development, with its sequellae, ovulation, menstruation, and fecun-
dation; other investigators have tried to ascribe some of these
properties to the corpus luteum. Fraenkel(24) claims that he has
caused cyclical h}^eremia and menstrual changes in the endometrium
by the administration of corpus luteum extract. Meyer(45),
Ruge(68) and Schroeder(74) came to the support of this view, and
have attempted to show that there exists a parallelism between
the morphological phases in the corpus luteum and the varying
structural changes in the endometrium during a menstrual cycle.

The prevailing clinical, experimental, and genetic evidences do
not coincide with the views just quoted. For if sexual develop-
ment and activity depend upon the corpus luteum, then this struc-
ture should have been present in the ovary at the earliest period of
its formation. The uterus reaches the full degree of its develop-
ment before puberty. Graafian follicles grow even during intra-
uterine life. Runge(69) avers that he has found this to be the case
in 30 per cent, of cases; but they do not mature, hence no pos-
sibility for corpora lutea to form, and functionate. The report of
Prochownik(63) that he has found a corpus luteum in a child three
years old is simply a medical curiosity.

Additional light has been shed upon this question by Biedl(7)
and Tandler(78), who have demonstrated the fact, that continued
amenorrhea in cows was due to the persistent corpus luteum, which
inhibited follicular function; for as soon as the corpus lut-eum was

R.4BIN0VITZ: THE DUCTLESS GLANDS 185

destroyed, menstruation and fecundation have immediately
returned.

Without culling many more examples from the vast literature, we
may conclude by saying, that the power which promotes the de-
velopment of the sexual organs in early life, and helps to maintain
their acti%'ity later on, is inherent in the follicular apparatus.

II. The Corpus Luteum. — ^This structure appears in the ovary
after the ripening of the Graafian follicles has commenced. It is
formed by the cells of the membrana granulosa and during its
evolutionary and involutionary periods, presents definite structural
characteristics. These have been most thoroughly studied and
described by Meyer(45), K-Uge(68), Miller(46) and Frank(25). A
detailed consideration of these morphological phases would carry
us beyond the scope of this paper. For our present purpose a mere
enumeration of them would suffice. They are in brief: (a) the pro-
liferative period, (6) the period of vascularization, (c) the period of
ripeness, and {d) the period of regression.

The cyclical changes in the endometrium, which have been
studied, first by Kundrat and Engelmann(35), and later on most
painstakingly described by Hitchmann and Adler(3i), have been
subdivided into four states, the premenstrual, the menstrual, the
postmenstrual, and the interval. According to some observers, a
functional relationship exists between the cycHcal changes in the
corpus luteum, and those of the endometrium. The true physio-
logical significance of these morphologic synchronisms is still un-
established, owing perhaps to the clinical difliculties that such a
study offers, in being unable to observe simultaneously, the struc-
tural changes in the endometrium and in the corpus luteum. We
shall therefore leave this mooted problem, and proceed to a con-
sideration of better known facts.

Ovulation as is well known may terminate either menstruation
or pregnancy. Two types of corpora lutea would thus be formed:
(a) corpus luteum spurium, in the former instance, {b) corpus
luteum verum, in the latter case. The histological differentiation
between the two types has of late been the subject of close in-
vestigation, and since it is of practical importance it deserves our
attention. Aschoff(2) states that the corpus luteum of early
pregnancy contains no free blood, or only minute traces thereof,
while the corpus luteum of menstruation shows distinct hemorrhages
during the period of vascularization. Miller(46) laj^s stress upon
the presence of colloid material in the corpus luteum during the earlj-
months of pregnancy, which may also be found in the granulosa

186 R.\B1N0VITZ: THE DUCTLESS GLANDS

during the puerperium. Calcium deposits also occur quite fre-
quently up to the fifth month of pregnancy. Marcoty(47) adds
another differential point; he states that the corpus luteum of preg-
nancy contains no fat, or only a small amount of it, while the
corpus luteum of menstruation shows distinct fat infiltration.
Besides the academic value of these differential points, they are also
of importance in forensic medicine, as they assist in diagnosing the
existence and the period of gestation.

The corpus luteum begins to functionate as soon as it becomes a
structural entity. As early as 1874 Gustav Born, quoted by Vin-
cent (80), surmised that the corpus luteum might be an organ of
internal secretion. From hazy notions we have gradually arrived
at certainties, and to-day the functions of the corpus luteum are
almost axiomatic. Its chief properties are:

1. To sensitize the uterine mucosa, producing the cychcal changes
of menstruation.

2. To prepare a favorable soil for the nidation of the impregnated
ovum, by inhibiting temporarily, further follicular ripening, and thus
the occurrence of the estrus (Loeb, 39).

3. To foster the implanted ovum during the early weeks of preg-
nancy and to exert this influence upon it throughout the entire
period of gestation. Loeb(39) and Fraenkel(24) have shown
experimentally that operative removal of the corpus luteum during
the first six weeks of pregnancy will cause abortion or an absorption
of the ovum. The writer has had several cases that have proven
this truism. It is therefore advisable not to operate on ovarian
tumors complicating pregnancy, before the third month of gestation,
unless urgent reasons dictate otherwise.

4. To counteract to a great extent the noxious effects of pregnancy.
Some clinicians are now availing themselves of this fact, and are
emploj'ing corpus luteum extract in the treatment of toxemia of
pregnancy.

III. The Interstitial Gland. — In 1863, Pfluger(65) described the
presence of epitheloid-like cells containing fat in the stroma of mam-
malian ovaries. He considered these cells to be either storehouses
of fat for the follicles, or as fatty degenerations of ovarian elements.
Pfltiger's report it seems has aroused but little interest, for we find
that it was not until 1902, when Limon(4o) and Bouin(9) for the
first time described a similar structure in human ovary, that the
attention of physiologists has been attracted to its importance.

Morphologically these cells are arranged according to Limon(4o),
in an orderly fashion, in the form of strands, along the course of

RABINOVITZ: THE DUCTLESS GLANDS 187

blood-vessels, and bear a close resemblance to the adrenal, and to
the corpus luteum cells. This grouping suggests glandular formation,
hence their function is most probably secretory. The term "in-
terstitial" has been assigned to these masses of cells, on account of
their pecuhar situation, being found most frequently in the connec-
tive-tissue interstices. In the cortex of the ovary, the interstitial
cells are scattered, due to the presence of the folhcles and the corpora
lutea, while in the medullary portion they are more compact, richly
vascularized, so that each cell is surrounded by capillaries, almost
on all sides.

Many other investigators have followed up the researches of Limon
and Bouin and have arrived at various conclusions. Fraenkel(24)
after examining the ovaries of forty-five different species offered
the following conclusions: (a) The interstitial gland is inconstant in
its occurrence, especially in the higher types of mammals, in monkeys
and in man. (b) It varies in its distribution from time to time,
being well organized and occupying the whole ovarian structure at
one time, and consisting of but a few scattered cells at another time,
(c) Owing to the fact that it is genetically a derivative of the end
products of follicular degeneration, its physiological significance is
doubtful.

Wallart(8i), R. Meyer(45), and Keller(36) state that during
pregnancy there is an increase of the interstitial elements in the
human ovary. Seitz(74) on the other hand considers the appear-
ance of these cells as due to the hyperemia of gestation, and not to
an hyperplasia of interstitial elements.

Other factors which prevent and inhibit the development of the
interstitial gland are inanition, poisoning, and hypofunction of
correlated glands of the endokrine system. Experiments on dogs
have shown that animals who under normal conditions present this
structure before puberty most regularly, fail to do so when subjected
to hunger, wasting diseases, or when deprived of other glands of
internal secretion, which have influenced it antagonistically.

Aschner(i) in his recent exhaustive studies takes exception to
Fraenkel's views. He claims that the interstitial gland of the ovary
is ontogenically as well as phylogenetically a distinct morphological
entity, and that it has a reciprocal relation to the corpus luteum.
The time when it is most predominant is during the first year of life,
it then begins to regress step by step, up to time of puberty, when
with the formation of the first corpus luteum it disappears altogether.
Aschner also suggests that the term "pubertatsdruse" is more

188 ILABINOVITZ : THE DUCTLESS GLANDS

descriptive of this structure than the term "interstitial," which has
been used hitherto.

In cases of hydatidiform mole, andchorioepithelioma, Stoeckel(76)
and Boshagen(io) claim to have found the interstitial gland, while in
other pathological conditions, such as inflammatory disease of the
adnexa, myoma, chlorosis, etc., did not lead to its formation.

The interstitial gland of the ovary is therefore a structure of early
life, puberty marks the end of its existence, and its occurrence in the
ovaries of the adult constitutes one of the rarest histological findings.
About the role it plays in the realm of internal secretion we have as
yet no positive knowledge. Based upon morphologic premises, we
may say that its physiological properties, if any, are in the main
concerned with the formative period of life, and its influence upon
vital processes after puberty is hardly conceivable.

Epitome of Ovarian Functions. — Experimental investigations, mor-
phologic studies, and chnical observations thus far obtained, warrant
these deductions:

(a) The female sexual gland is a compound organ, containing
three structural elements, two of which, the follicle apparatus and
the corpus luteum, are permanent in their existence, while the third,
the interstitial gland, if at all present, may be found only in the
ovaries of the very young.

{b) The ovary contains two distinct active principles, the Graafian
follicle extract and the corpus luteum extract.

(c) The intraglandular relations of the ovary are synergistic, the
interglandular relations vary, depending upon which of the two
structural elements we are considering, for they bear different
reciprocities to the rest of the ductless glands.

{d) Sexual development and maturation is to a great extent de-
pendent upon the follicular apparatus.

(e) The corpus luteum becomes physiologically important after
impregnation has occurred; it continues to exert this influence during
pregnancy, and in a lesser degree throughout the period of lactation.

THE PLACENTA.

In addition to being the essential nutritive and respiratory organ
of the fetus, the placenta also exerts an acceleratory influence upon
the uterine hypertrophy and hyperplasia during pregnancy. This
function it performs by virtue of its active principle or hormone,
"chorin." Okintschitz(6o) experimented with placental extract
upon castrated rabbits, and has been convinced that uterine atrophy

RABINOVITZ: THE DUCTLESS GLANDS 189

could be prevented with far greater success by the subcutaneous
injections of chorin, than with biovar or proprovar (follicular ex-
tract). Halban(32) has shown that morphologically, the chorionic
cells and those of the cumulus oophorus resemble each other very
closely.

The structural similarities between the chorionic cells and parts
of the ovary make their functional correlation more intimate.
Hence the reason why the placenta is capable of supplementing the
follicular function with greater efficiency, when the latter's activities
are temporarily suspended. The interglandular correlation between
the placenta and the follicular apparatus, as far as their influence
upon the uterus is concerned is synergistic, and antagonistic to the
corpus luteum.

Since chorin is a more powerful agent in producing uterine
hypertrophy than the extracts obtained from the Graafian follicles,
would it not be advisable to employ it, instead of the latter, when we
desire to produce an enlargement of that organ, as in cases of under-
developed uteri, infantile type. In cases of functional amenorrhea,
it is also likely to produce beneficial results, for we have recently
learned that the uterine mucosa as such also plays an important role
in the phenomenon of menstruation, by reacting upon the ovaries.

THE MAMMARY GLAND.

The mammary glands like the uterus owe their development and
growth to the follicular portion of the ovary. During gestation
they undergo hypertrophy preparatory to their hyperfunction
at the time of lactation. By what power or influence is this increase
in size and function brought about? It is probable that during
gestation their progressive growth may in part be influenced by the
placenta. During lactation, however, the placenta has ceased to
exist, the follicular function is also in abeyance, and the only gonad
that is persisting is the corpus luteum. To this gland then must the
acceleratory or antagonistic properties relative to the mammary
glands be ascribed.

Clinically we note that the onset of menstruation in a lactating
woman diminishes or totally stops the flow of milk. Conversely,
prolonged lactation has a tendency to defer the return of the men-
strual periods. How is this alteration of function accomplished?

The intraglandular relation between the corpus luteum and the
Graafian follicles is synergistic, i.e., inhibitory. Therefore, during
lactation, when the corpus luteum is in ascendency, the follicular

190 RABiNovnz: the ductless glands

function is inhibited and no menstruation occurs. On the other
hand, as soon as the follicular function is rehabilitated, the power of
the corpus luteum wanes, it is no longer able to exert its antagonistic
or acceleratory influences upon the mammary glands, and milk
secretion stops.

These physiological facts lead us to the conclusion that the inter-
glandular relation between the mammary glands and the ovary is
"antagonistic" to the follicular apparatus up to puberty, and to
corpus luteum during gestation and especially so during lactation.

In relation to the uterus, the mammary glands bear distinct
"synergistic" properties. During lactation uterine contractions are
most common, and if nursing is persisted in for too long a period,
hyperinvolution, with the subsequent lactation atrophy occurs.
Okintschitz(6o) has injected castrated rabbits with "mammin"
(mammary gland extract) and has noted that it hastens uterine
atrophy. Mammin is therefore a potent adjuvant to the corpus
luteum in causing a diminution in the size of the uterus, and forms a
physiological antithesis to"chorin" (placental extract) which supple-
ments the follicular function in enhancing and maintaining uterine
hypertrophy.

Since mammin and luteovar exert the same influence upon the
uterus, functional menorrhagia or metrorrhagia will be greatly
benefited by corpus luteum therapy; by inhibiting follicular function,
mammin will also yield gratifying results by causing uterine con-
tractions and atrophy. It also seems plausible to employ in cases
of mammary hj'pofunction, besides the extracts of the same gland,
also the extracts of its antagonist, the corpus luteum, which will
accelerate its function.

THE THYROID GLAND.

Castration causes an enlargement of the thyroid gland. If
castration is followed by the administration of follicular extract,
the thyroid will retain its physiological proportions. The therapeutic
employment of corpus luteum extract does not prevent the thyroid
hypertrophy subsequent to castration. Pregnancy also causes an
increase in the size of the thyroid.

From our knowledge of glandular reciprocity, the above quoted
experimental and clinical facts place the ovary and the thjToid in
the category of synergists; in reality, however, they are antagonists.
Let us unravel this paradox.

In Basedow's disease, the hyperfunction of the thyroid may or
may not be accompanied by hypertrophy of the gland. Chrus-

RABINO^^TZ: the ductless glands 191

talew(i2) has shown that sections taken from thyroids in cases of
Grave's disease contained but little colloid, which was in a state of
liquefaction, it stained poorly, and in some places it was wanting
altogether. The follicular epithelium on the other hand showed a
marked proliferation, which indicated hyperf unction. Kraus(37)
explains the paucity of colloid in the thyroid in cases of Grave's as
due to a rapid discharge of the thyroid products into the blood
and the lymph channels.

The enlargement of the thyroid observed after castration, or during
pregnancy, must be viewed in the light of retention hypertrophy and
not of hyperfunction. For these thyroids do not present an hv'per-
plasia of the epithelial, lining of their acini. The manner in which
this enlargement is brought about is as follows:

Since "antagonists" influence each other in an acceleratory
manner, castration removes the stimulating influence upon the thy-
roid, this gland ceases to be as active as before, or the organism as a
whole, does not require as much of its secretions as it did hitherto,
hence a temporary passive and relative hyperproduction of colloid
ensues, with the resulting increase in the size of the thyroid. Preg-
nancy causes the same changes in the thyroid gland, due to a tem-
porary suspension of ovarian function.

That the theory of retention hypertrophy is correct, is evidenced
by the clinical facts that thyroid hypertrophy accompanying preg-
nancy, or the one following castration, does not present symptoms
of hyperthyroidism. The simple enlarged thyroids of multiparas
is another well-known observation.

The interglandular relation existing between the thyroid and the
mammary gland is also antagonistic. This is borne out e.xperi-
mentally, for injections of mammin help in maintaining the
colloid accumulations in the thyroid in its highest degree of relative
hj-persecretion.

To sum up then we may state that " the interglandular relation
between the thyroid on the one hand and the ovary and the mam-
mary gland on the other is "antagonistic," although positive his-
tological and clinical data are still wanting. Based upon this
partial truth, we may assume that cases of hypoovarism could be
benefited by thyroid therapy, as well as cases of hypothyroidism
should receive in addition to thyroid extract also follicular extract.

THE PITUITARY BODY.

Directly behind the chiasm, suspended by a thin, soft stem, known
as the infundibulum, is an irregularly round gray mass, the hypophy-

192 R.\BINOVITZ: THE DUCTLESS GLANDS

sis. It lies in the hypophyseal fossa of the sella turcica, and is
composed of two lobes, an anterior and a posterior.

Embryologically, the anterior lobe is developed from the epiblast
of the buccal cavity, the posterior lobe from the embryonic brain.

Histologically, the anterior lobe is composed of three types of cells,
eosinophiles, basophiles, and basal cells. These cells bear a quan-
titative relation to one another, in the order just enumerated. The
posterior lobe consists of nerve tissue.

Highly differentiated structurally, the pituitary body possesses a
still more complex physiology. Before puberty, the function of
the hypophysis is to assist in part the as yet incompletely developed
ovary, in promoting sexual maturation, it also maintains growth
equilibrium. Cushing(i5), Ascoli and Lagnoni(4) have shown that
hypophysectomy performed before puberty, will inhibit the develop-
ment of the genitalia, it will retard body growth, causing dwarfism,
and produce a clinical entity known as Frohlich's syndrome(26) or
dystrophia adiposito genitalis.

After puberty, the removal of the hj^Dophysis will cause adiposity,
sluggishness, atrophy of the genitalia, loss of hair, and finally gly-
cosuria, coma and death.

Hypophyseal hypofunction, resulting from functional or organic
disturbances produces symptoms analogous in character to those
following the experimental removal of this gland, only of a more in-
siduous type.

Pituitary hyperfunction will cause an enlargement of the skeleton,
resulting in the well-known disease acromegaly in adults, or gigan-
tism with precocious sexual maturity in the young.

Since over- or underactivity of the hypophysis is capable of
influencing the growth and the development of the sexual organs in a
definite and direct measure, physiological disturbances in sexual
glands ought to reflect upon the pituitary with equal certainty and
constancy.

Castration causes an enlargement of the pituitary body (anterior
lobe) with a consequent hyperfunction, expressing itself in an
increase in the size of the body. Fichera (27), Tandler (79), and
Meyer(52) have found that this hypertrophy is due to an hyperplasia
of the eosinophiles. Okintschitz (60), on the other hand, reports
that castration is followed by an increase in the size and number of
the basal cells.

Pregnancy also produces an enlargement of the hypophysis (an-
terior lobe). Comte(i4) was the first one to note this phenomenon.
Erdheim and Stumme(2o) have described the histological changes

RABINOVITZ: THE DUCTLESS GLANDS 193

that take place in the pituitary during gestation as follows: there
is an increase in the size and number of the basal cells, their limiting
membranes become more distinct, granules appear within the proto-
plasm which stain with various dye stuffs. So constant are these
structural changes that the term "Schwangerschaftszellen"has been
given to these cells. The hypertrophy in the pituitary is at times so
marked, that by its pressure on the chiasm it may cause hemianopsia.
This has occurred twice in the writer's experience. The hj'perfunc-
tion of the pituitary during pregnancy, manifests itself by the general
enlargement of the body, especially of the extremities and the face,
thus resembling a mild form of acromegaly.

Another clinical fact worthy of note is, that while the enlargement
of the thyroid during pregnancy does not mean hj^erthyroidism, and
the hypertrophy of the hypophysis at this period does not indicate
acromegaly, yet it seems that the mild irritations set up in these
glands after repeated hypertrophies will, in some cases, lead at last
also to an hyperfunction. Hyperthyroidism and acromegaly are
therefore more frequently seen in multiparae than in nulliparae,
and with greater preponderance in those multiparae who have borne
their young at short intervals.

Castration followed b}' injections of chorin (placental extract),
which simulates follicular extract in some of its physiological prop-
erties, causes an increase in the eosinophiles of the anterior lobe
of the pituitary. Injections of luteovar fail to influence the his-
tological changes in the pituitary, and the gland presents the same
appearance as does the one of the castrated, but not injected animals.
Okintschitz(6o) agrees with other observers on the question of
hypertrophy and hyperplasia of the pituitary that follows castra-
tion, but differs from some on the point as to which of the three types
of cells in the anterior lobe undergo structural changes under various
physiological and pathological states.

This divergence of opinion is not only limited to the histological
phase of the problem, but the views on the relations of the ovary and
the pituitary to metabolism are also at variance. Thus Alder (5),
Christofoleti (16), and Munzer(s3) consider the interglandular
relations between the ovary and the hypophysis to be antagonistic,
on account of the contrasting influences they exert upon bony
growth and adrenal glycosuria. From the morphologic studies,
however, we know that the hypertrophy and hyperplasia that
takes place in the hj'pophysis after castration, or when the follicular
function is temporarily suspended, places these two glands rather in
the class of "synergists."

194 RABINOVITZ: THE DUCTLESS GLANDS

Another potent reason why our knowledge concerning the inter-
glandular reciprocity between the pituitary and the ovary is still
shrouded with many uncertainties, is the totally different anatomy
and physiology of its -two lobes. So far we have established the
fact, based upon structural and functional data, that the ovary and
the hypophysis are synergists, but we know practically nothing of
the biochemistry of the anterior lobe that makes these results
possible. On the other hand, we know that the posterior lobe
possesses a definite hormone "pituitrin," which is able on raising,
the blood pressure, to contract involuntary muscles, to strengthen
the heart, to promote diuresis, and to cause uterine contractions
in a most pronounced form. Pharmacodynamically then, we are
well posted about the properties of the posterior lobe, but we are
still in the dark about its interglandular correlation. Experimental
physiology has thus far added nothing definite on this point. Re-
moval of the posterior lobe seems to cause no detrimental results,
although Cushing(i5) claims that it is essential to life.

THE PINEAL BODY OR EPIPHYSIS CEREBRI.

This is a flattened, pear-shaped body which hes below the splen-
ium of the corpus callosum in the transverse cerebral fissure. Its
base is in front and is connected with the diencephalon through the
habenula; the ape.x lies posteriorly and hangs freely down over the
corpora quadrigemina of the mesencephalon enclosed by pia mater
and united to the tela choroidea of the third ventricle.

Embryologically considered, the epiphysis is a vestigial remnant
of a primitive dorsal eye. It is doubtful whether at any time in the
process of evolution of the vertebrates, the pineal eye has ever func-
tionated. Biedl(7) states that the pineal body undergoes involution
at about the seventh year of life, when it is replaced by connective
tissue hyperplasia and a deposit of lime known as "acervulus"
or brain sand.

The anatomical inaccessibility and the doubt of its being pos-
sessed of internal secretory properties, on account of its embryologic
derivation, have for a long time served as deterring factors in the
experimental study of the physiology of the pineal gland. Within
the past decade many of these difficulties have been surmounted, and
the experimental physiologists have been able to contribute a good
deal of interesting, though as yet, not conclusive information, about
the normal and abnormal functions of the epiphysis.

The morphological tissue changes to which this gland is heir, run

RABINOVITZ: THE DUCTLESS GLANDS 195

the gamut of morbid anatomy. In the researches of Neuman (58),
Weigert (83), and Falta(23) we find recorded that almost ever)' form
of tumor formation has affected this gland, the teratoma, however,
being predominant. This disease has a predilection for the male sex,
and occurs chiefly during the first seven years of life.

The symptoms caused by tumors of the epiphysis are (a) local and
(b) trophic. The study of the former group belongs to the domain of
neurolog>^, so- we will consider the latter. The nutritional disorders
that manifest themselves as a result of pineal tumors are: a rapid
increase in the length of the body, a gain in adiposity, and sexual and
mental precocity.

Extirpation of the pineal gland have given varied results in the
hands of different investigators. Biedl(7) and Dandy(i8) have
noted no physiological disturbances in the pinealectomized animals,
who have survived the operations from three to eight weeks. They
are of the opinion that the epiphysis is not essential to life, and that it
possesses no endocrine properties. Foa(29) reports a retardation of
growth and mental development after epiphysectomy for the first
three months following the operation, but that there was a hyper-
development of the generative organs and the secondary sex char-
acteristics. In about eight to twelve months later these animals
appeared to be as normal as the controls. Exner and Boese(2i)
reported that in the six animals, out of the ninety-five experimented
upon, who have lived up to puberty, no somatic or sexual defects
were discernible.

The feeding experiments of Dana and Berkley (17), McCord(5s),
and Sarteschi(75), of pineal substance to animals and human beings,
have resulted in an increase of weight, in an improved mental state,
and in sexual precocity.

Injections of pineal extracts intravenously by Ott and Scott(6i),
have given results, as far as the circulatory apparatus was concerned,
similar to those obtained from corpus luteum extract. After an
initial depression there follows a prolonged rise of blood pressure,
without any alteration in the pulse rate. It also causes a vaso-
dilatation of the kidneys, thus increasing diuresis. The pregnant
uterus shows marked contractions, but it has no effect upon the
virgin uterus. The functions of the mammary gland are most
favorably influenced by intravenous injections of one-third of a
grain of pineal substance, which has produced a marked increase of
milk secretion.

Castration causes an atrophy of the pineal gland, although Sar-
teschi(75) could not verify this fact with his experiments. Weigh-

196 R.\BINO\^Tz: the ductless glantjs

ing carefully the clinical and the experimental data at our command,
regarding the physiology of the pineal body, we find ourselves be-
tween two extremes, the nihilism of Dandy(i8) who denies any phys-
iological importance to this gland, and the more conservative views
of Marburg(56), who has attempted to formulate a distinct pineal
clinical entity. He classified all epiphyseal disorders under three
headings: (a) hypopinealism, characterized by an hypertrophy of
the genitals, (b) hyperpinealism, typified by adiposity, and (c)
apineahsm, manifested by cachexia.

• The later view is the one accepted by most authorities, and from
the structural changes that take place in the genitalia after pine-
alectomy, or after the natural involution of this structure, and vice
versa, the changes that are seen in pineal gland after oophorectomy,
lead us to conclude that their interglandular correlation is "syner-
gistic," for it is apparent that the pineal gland during its e.xistence
has exercised an inhibitory influence upon the sex organs.

THE THYMUS.

It is only within recent years that the thymus has been considered
as part of the endocrine system, endowed with functions of internal
secretion.

Its main function seems to be the production of lymphoc3^tes,
especially during early life. Bang(ii) has found from five to six
times as man}- nuclear elements in the thymus than is contained
in other lymphatic structures. After birth the thymus begins to
enlarge, it grows slowly up to the second year, when it begins to
atrophy and is replaced by fatty degeneration.

Experimental thymectomy has been performed by Klose and
\'ogt(38), Matti(54), and others, with the following results:
After a lapse of two to four weeks there ensued a diminution in
the size of the extremities, the bones became softer, ossification and
dentition was delayed, adiposity has increased, finally cachexia,
somnolence, loss of coordination, coma and death.

Castration has caused delay in the involution of the thymus, and
Tandler and Gross(78) have described an hyperplasia of the thymus
in eunuchs.

The chnical syndrome, status lymphaticus, has always been
ascribed to an hyperfunction of the thymus. Since Kopp's descrip-
tion of this affection in 1855, nothing new has been added by succeed-
ing investigators to the knowledge of this disease. Falta(23) states
that there are cases of enlarged thymus without an accompanying
status lymphaticus, or a status thymicus.

RABIN OVITZ: THE DUCTLESS GLANDS 197

The destruction of this organ by new growths or inflammatory
processes fail to show functional disturbances in the organism. The
only grave clinical condition that is caused by the hyperplasia of the
thymus are mechanical in nature, causing pressure symptoms upon
the trachea. This being the only condition when thymectomy as a
therapeutic measure is indicated. Under no other circumstances is
such a procedure justifiable, for the terminal sequences of thymec-
tomy are most serious.

About the hormone of the thymus we know nothing. Feeding
experiments and hypodermic injections of thymus substance, in cases
of thymectomy have aggrevated the symptoms, so the physiological
status of this gland could not be learned from this study. Clinical
attempts to cause hyperthymism have also failed.

For the present we must be contented by concluding that the
thymus is in all probability a lymphopoietic organ, exerting also
an inhibitory influence upon sexual maturation, as evidenced by its
atrophy with the onset of puberty. Its interglandular relation to the
ovary is therefore "synergistic."

THE ADREN.^LS.

The first definite account of the adrenals with illustrations of them
was given by Eustachius in 1563. Addison in 1849 described a dis-
ease known by his name to this day, which is due to a tubercular
affection of the adrenals. Brown-Sequard in 1856 performed the
earhest extirpation of the adrenals, all the animals died shortly there-
after. He concluded that death in these animals was not due to
adventitious lesions connected with the operation, but to a depriva-
tion of adrenal secretions. The adrenals are therefore essential to
hfe. Vincent(8o) among other investigators coincides with this
view.

Histologically the adrenals consist according to the description of
Mitsukuri(5i) of two parts, a cortical portion derived from the meso-
blast, and a medullary portion formed from the peripheral part of the
sympathetic system.

The physiology of these anatomical units has as yet not been fully
established. The only positive knowledge we possess is about the
pharmacodynamic properties of its active principle "adrenaline,"
which is contained in the central nervous structure of the gland.

The only sources upon which we can draw, at the present time, for
information in order to estabhsh the interglandular relation between
the adrenals and the gonads are the pharmacodynamic properties of
3

198 RABIN OVITZ: THE DUCTLESS GLANDS

these glands. Adrenaline raises the blood pressure, and promotes
proteid and fat metabolism. The follicular portion of the ovary
manifests the same properties. The adrenals undergo hypertrophy
and hyperplasia during pregnancy, and although Okintschitz(6o)
could not verify this in his experiments, the prevaiUng opinion is in
favor of the above mentioned view. Since the adrenals increase in
size and hyperfunctionate when ovarian function is inhibited, as it
occurs during gestation, the interglandular relation between the
adrenals and the ovary ought to be "synergistic." Aschner(i)
fully agrees to this supposition, and explains it on the inhibitory
power exerted by the sexual gland upon the chromatin system, which
in turn affects the nervous system.

In what way can this knowledge about the adrenals be apphed
clinically? It is an axiom, that in eclampsia the blood pressure rises,
and the greater the toxicity of the poisons circulating in the maternal
blood, the higher does the arterial tension mount, finally twitchings
and convulsions may develop. Are not the chnical manifestations in
eclampsia an expression of a conversion of potential into kinetic
energy by the organism, in its attempts to defend itself against the
invasion of the noxes of abnormal gestation? Is not the "kinetic
drive" of Crile(i3) but a response by the economy to mechanical,
chemical, bacterial or psychic traumata? Are not the lesions found
in the hver, in the kidney and in the brain identical in both condi-
tions, shock and eclampsia? In which of the glands of internal secre-
tion is this motive power, which can inhibit or augment these out-
bursts of oxidation, stored away? Crile claims that it is in the
adrenals, and in his treatment of shock advocates morphine as
a remedy par excellence, both as a prophylactic and as a remedial
agent. Morphine accomphshes this, not only by diminishing the
apperceptive and perceptive properties of the central nervous system,
but also by inhibiting the adrenal output. Stroganoff in Russia and
Stillwagen in this country, have obtained gratifying results in the
treatment of eclampsia with morphine; in all probability, by keeping
the adrenals under control.

If eclampsia and shock produce the same pathological changes in
the kidneys, liver, and brain; if they manifest closely allied clinical
phenomena; and if they yield to the same therapeutic agents; then
both of them must either cause, or be caused by, adrenal hyperfunc-
tion. To inhibit the excessive output of adrenaline still further, it
seems but rational to add to our morphine therapy an organic pro-
duct of synergistic properties. In this case ovarian extract would
suit best. My reasons for suggesting the extract of the entire ovar-

RABINOVITZ: THE DUCTLESS GLANDS 199

ian gland are twofold. First, to obtain the synergism of the folli-
cular apparatus, second, to replenish the corpus luteum deficiency,
which is perhaps responsible for some of the toxemias of pregnancy.
We have as yet no data from which to draw conclusions as to its
efficacy; on theoretical grounds it appears to be plausible.

rV. Ovarian Extracts and the Functional Diseases in Which They
may be used with Satisfactory Results. — In order not to overstep the
gynecological boundaries, I have limited myself to a consideration of
the ovarian extracts only, and shall present this phase of the problem
in a very brief and succinct manner, so that you may readily refer to
it and make use of the information it bears with ease.

A. Diseases to be Treated with Follicular Extract. — Cases of hypo-
ovarism: (a) Amenorrhea, (b) Sterility, (c) Infantilism, (d) Dys-
menorrhea, (e) Metabolic disturbances, especially the tendency
toward adiposity, (/) Chlorosis, (g) The molimina of natural and
artificial menopause, (h) H\'perthyroidism, (i) Dystrophia adi-
posogenitalis, and (_;') Status thymicolymphaticus.

B. Diseases to be Treated with Corpus Luteum Extract. — i. Cases
of hyperovarism : (a) Functional menorrhagia or metrorrhagia,
ib) Increased sexual appetite, (c) Osteomalacia.

2. Cases of hjqDoluteism: (a) Emesis gravidarum, and other forms
of toxemia of pregnancy, such as eclampsia, etc.

v. CONCLUSIONS.

1. Functional gynecological diseases should be studied objectively
and not subjectivel}' only; applying the same methods of investiga-
tion as are employed in the detection of organic disorders.

2. The pathology of functional diseases is outside the realm of
cellular morphology. It invades the fields of physiolog>' and bio-
chemistry. Many of these disturbances are so subtile in nature,
that they escape detection by the present means at our disposal,
and some will probably never be solved.

3. To define a disease as functional we must be assured that all
organic factors have been eliminated. For just as much harm may
be done by submitting organic cases to functional therapy as by
appljang surgical treatment to some functional diseases.

4. It is not sufficient to merely ascertain which gland of the endo-
krine series is responsible for certain functional disturbances, but it
is also essential to be informed about the interglandular relation
that this gland bears to the other ductless glands under normal and
abnormal states.

200 R.\BINOVITZ: THE DUCTLESS GLANDS

5. Owing to the intra- and interglandular reciprocity that exists
between the ductless glands, a functional disease is in its final analy-
sis never a uniglandular, but a polyglandular malady. It is true
that the predominant symptoms are characteristic of the disturbances
of the gland that is mainly affected, but the concomitant disturb-
ances are just as important, and are due to the involvement of other
ductless glands, which have been acted upon by this particular gland,
and which in turn react upon it.

6. The ideal in organotherapy will be reached when, (a) Functional
diseases will be properly diagnosed, (b) When the organic products
offered for sale will be standardized and possess a stable physiolog-
ical potency, (c) When the active principle not only of each gland, but
of the different parts of the compound glands, such as the ovary, the
hypophysis and adrenals, will be isolated.

7. If in m}' humble attempt to present before you the lights that
illumine the field of functional gynecological disorders, and also the
shadows that still obscure many of its important phases; if in this
attempt, I have succeeded to arouse in you sufficient enthusiasm to
give this subject closer observation than you have been accustomed
to do in the past, my efforts have been well spent. Because from
your failures and successes in the treatment of these disorders, the
laboratory worker draws his inspiration and guide, how to improve
upon his successes, and how to correct his errors. Be persistent and
optimistic in your efforts; in spite of some failures, it will surely lead
somewhere, indifference and pessimism will positively lead nowhere.

1261 Madison A\^nue.

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RABINOVITZ: THE DUCTLESS GLANDS 201

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27. Fichera. Sur rhj-pertrophie de la glande pituitaire consecu-
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202 RABINOVITZ: THE DUCTLESS GLANDS

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39. Loeb, L. Uber die Bedeutung des Corpus Luteum fiir die
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47. Marcoty, A. Uber das Corpus luteum menstruationis und
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48. Morris, R. T. The Ovarian Graft. N. Y. Med. Jour., p.
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49. MacCallum. The Teaching of Pathological Physiology.
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50. Meltzer, S. J. Schilddriise, Epithelkorper und die Base-
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51. Mitsukuri, K. On the Development of the Suprarenal
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52. Mayer, E. Uber die Beziehungen zwischen Keimdriisen und
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53. Munzer. tJber der zerebrale Loccalisation des Geschlechts-
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54. Matti, H. Untersuchungen iiber die Wirkung experimen-
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RABINOVITZ: THE DUCTLESS GLANDS 203

55. McCord, C. P. The Pineal Gland in Relation to Somatic,
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56. Marburg, O. Zur Kenntnis der normalen und pathologischen
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62. Pineless. Die Beziehungen der Akromegalie zum Myxodem
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204 SLEMONS: RESULTS OF ROUTINE STUDY OF THE PLACENTA

80. Vincent, S. Internal Secretions and the Ductless Glands,
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THE RESULTS OF A ROUTINE STUDY OF THE
PLACENTA.*

J. MORRIS SLEMONS, M. D.,
New Haven, Connecticut.

While I was a member of the staff of The University of Cali-
fornia Hospital it occurred to me that, if the pediatrician might
begin the instruction of his classes in the nursery of the Woman's
Chnic, several useful purposes would be served. At first practical
difficulties were encountered but Dr. WiUiam P. Lucas, Professor
of Pediatrics, and myself were convinced that the principle which
gave the pediatrician the opportunity to direct the care of newly
born infants was sound; and we agreed to try the experiment. Our
original plans required modification, especially because the care of
the lying-in woman and her infant are not independent problems.
But, precisely for this reason the obstetrician finds the counsel of
his colleague valuable and, conversely, the pediatrician profits by
information in the obstetrical history. Wishing to secure the fullest
benefits from cooperation we decided to make joint-rounds twice
a week and discuss questions relating to the common welfare of the
mother and her infant. This arrangement guaranteed the success
of our venture.

More fully than I had realized, these consultations taught me
that the course of pregnancy influences postnatal development.
The conscientious obstetrician should e.xhaust every source of
information regarding fetal development and should place the facts
at the disposal of the physician who will supervise the care of the
infant during the early years of its life. If this principle is accepted
— and I do not see how it can be questioned — the obstetrician wiU
consider it his duty to examine the placenta in more detail than is
customary.

* From the Department of Obstetrics and Gynecology, Yale Medical School.
Read at a Meeting of the New York Obstetrical Society, March 14, 1916.

SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA 205

Intimately associated with fetal growth, the placenta may
present phenomena which will influence the treatment the infant
should receive. While such instances are exceptional and the pla-
centa is normal, generally, certain knowledge of the latter fact
provides one assurance that extrauterine existence was not begun
with a handicap. On the other hand, if infant development does
not progress as it should the placental examination has unusual
value. In the' case of prematurely born and stillborn infants as
well as when the infant dies within the early weeks of life careful
study of the placenta is indispensable to accurate diagnosis.

To-day, even in well-organized clinics the placenta is given slight
attention. At the bedside a cursory examination is made to
determine whether a portion has been retained; and, perhaps, the
organ is weighed but further observations are not made. Some-
times no attention is paid to it. Upon a recent visit to a clinic used
for the instruction of students in a medical school of the first rank,
I found the only piece of scientific apparatus owned by the depart-
ment of obstetrics and gynecology was an incinerator placed con-
veniently to the delivery room so that the placenta might be got
rid of as quickly as possible. You will agree, I am sure, that this
attitude is not extraordinary.

Obviously, in the hospital laboratory the examination of the
placenta will be most thorough, but we have arrived at a period
when the practitioner who owns a microscope may make useful
observations. And, probably fuller knowledge of the structure
and function of this organ will add to its importance in the inter-
pretation of clinical manifestations. Antenatal pathology, as yet
poorly endowed with facts, depends for its development in great
part upon the solution of placental problems. Even where struc-
tural phenomena as infarcts have been satisfactorily explained, their
underlying cause, their physiological significance, and their relation
to fetal complications have hardly been guessed at. Other rudi-
mentary facts remain obscure, and upon demonstration may
radically change our conception of the manner in which the placenta
performs its work.

My remarks based upon 600 placentte collected from consecutive
deliveries in the University of California Hospital relate to the
pathology of the organ. No doubt a greater frequency of unusual
cases is encountered in hospital than in private practice. On that
score, objection may be raised to my conclusion that the placenta
always deserves careful study. Yet routine is necessary that no
abnormality may be overlooked. In my own case when attending

206 SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA

patients delivered at their homes, if the placenta had been routinely
subjected to careful study, I should not have been mthout the
explanation for a number of fetal deaths.

GROSS ANOMALIES.

Multiple pregnancy (twins) 3 Extensive infarction 4

Abnormal shape of placenta 3 Placental cysts i

Two vessels in cord 2 Succinturiate placenta 10

Velamentous insertion of cord i Partial retention membranes 17

In forty-one instances naked-eye examination of the placenta
revealed abnormalities. Some of them could not have been over-
looked, but in a hurried examination others would have escaped
attention. Thus, in two cases the presence of a single artery in
the umbilical cord was not detected until the specimens reached
the laboratory. Clinically, one of the infants presented a number
of deformities, and at autopsy only one hypogastric artery was
found. Also, in the other case there was a perforated interven-
tricular septum, though the infant lived and gained normally in
weight.

In the case of velamentous insertion of the cord a living child
was born. A fatal issue, as you know, is not expected from this
anomaly unless the fetal vessels pass near the internal os, vasa previa,
which, though not in this series, I have twice observed. In one case
on account of rupture of an umbilical vessel antepartum hemorrhage
occurred. Examination of the placenta demonstrated that the
hemorrhage was fetal. In the other case as the head entered the
pelvis the placental circulation was blocked; this infant also was
stillborn.

Succinturiate lobes were encountered in ten instances; they may
be expected in between i and 2 per cent, of all cases. As they are
a well-known cause of bleeding and frequently become infected, the
usefulness of determining whether or not the placental tissue has
been completely expelled from the uterus, requires no emphasis.
Nevertheless, it is pertinent to remark that in thoroughness the
examination at the bedside is not likely to approach that made
in the laboratory. And, bedside observations are less apt to be
recorded; frequently, therefore, a poor memory is depended upon
when definite records are needed for the interpretation of puerperal
complications.

Portions of the membranes were missing in seventeen instances;
six occurred in the first fifty cases. Later the complication was
much less common. Usually, too hurried or vigorous conduct

SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA 207

of the third stage of labor accounts for this complication. My
clinical assistants soon learning that the laboratory checked their
work were encouraged to acquire a more perfect technic. To learn
how cases are conducted when they cannot be personally supervised,
I can recommend as one important means, complete placental records.
Another useful observation pertains to the stained microscopic
sections. The blood-vessels in the chorionic villi often furnish a
clue to the time when the cord was tied. If the ligature is not
placed until pulsations cease the blood-vessels in the villi are rela-
tively empty; on the contrary, if they are congested we may usually
assume that the cord was tied earlier than it should have been.
Occasionally, I have seen an interne surprised when upon the
evidence afforded by the microscope he was fairly accused of being
in a great hurry to bring his case to a conclusion. Also, in the
instruction of students the comparison of placental sections where
the cord was tied early with others where it was tied after pulsa-
tions ceased provides convincing evidence that the infant benefits
when the latter procedure is adopted.

MATERNAL COMPLICATIONS.

Premature separation S Manual removal of placenta 3

Placenta previa i Abdominal pregnancy (term) i

The interpretation of a number of maternal complications depends
upon the placenta, and we have encountered ten such cases.

In the event of premature separation our interest is to learn how
much of the placenta is thrown out of function, what relation the
location and the size of the separated area bears to the severity of
the hemorrhage, and what region, if any, is most prone to become
separated prematurely? This complication does not always have
the same effect upon the fetus, though frequently it is fatal. Among
the cases reported here only one terminated with the birth of a
living child. In a great measure the result for the fetus is deter-
mined by the degree of separation; but may not other factors be
involved? It is my impression that the comphcation is less serious
for the fetus when the separation is cofined to the circumference
than when it penetrates the center of the placenta, even though no
greater area is involved. However, with so few observations a
dogmatic statement is undesirable.

Not only a better understanding of defective but also of normal
placentation proceeds from the study of abnormal cases. Accord-
ingly, intimate investigation of placenta previa is well repaid and
likewise the investigation of a placenta which separates too early,

208 SLI^MONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA

or one which is retained. In the event of a subsequent pregnancy
such information may serve as a guide for the proper treatment,
and indeed did aid us in one instance. A multiparous woman with
a history of puerperal infection, when first my patient, suffered from
a serious hemorrhage during the third stage of labor. The placenta
was removed manually. The firm attachment was explained by
fibrous adhesions between the uterus and a portion of the placenta.
When eighteen months later, anticipating the same compUcation,
the patient entered the hospital for the birth of her fifth chUd,
Cesarean section with supravaginal hysterectomy was performed
The pathological condition which existed in the previous preg-
nancy was again found and justified the operative treatment.

Very frequently an intimate study of the placenta con-
tributes to a clearer understanding of the physical condition of
the fetus. For example, when delivery occurs prematurely the
placental findings are significant, for in that case the question of
syphUis may always be fairly raised. Such a possibihty we con-
sidered from various angles in seventeen premature deliveries where
the fetus was between 30 and 40 cm. long and weighed between
1000 and 2000 grams. In sis instances the diagnosis of sv^Dhihs
was established; in the others it was excluded. All the s}'phLlitic
infants died; the mortahty among an equal number of premature
infants born of mothers suffering from eclampsia or allied intoxica-
tion was 50 per cent.

PREMATURE INFANTS.
(Weight 1000 to 2000 grams; length 30 to 40 cm.).

Cause Living Died

6 Syphilis 6

6 Maternal toxemia 3 3

I Pyelitis i

I Extensive infarction i

3 Undetermined i 2

Unless glaring symptoms of some other disease are present there
is a tendency to regard as sj'philitic every premature infant. Ob-
viously, this is incorrect; in our small series syphiUs was present
in roundly a third of the cases. The diagnosis was established
upon the evidence afforded by both the placenta and the Wasser-
mann reaction. The results of these tests, as I have found in a
series of consecutive deliveries, closely agree, but before discussing
this point let us review the evidence upon which the diagnosis of
placental syphilis rests.

SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA 209

Contrary to the teaching of the past generation which lacked
accurate means of investigation, it is unsafe upon the gross appear-
ance of the placenta alone to base a diagnosis of syphilis. When
the fetus has died some time before its birth, no matter what the
cause, the placenta may be very firm, may have a gray, anemic
color and the maternal surface may have a greasy appearance. Nor
do large placenta always denote syphilis. Labourdette(i) has
also demonstrated that, as a sign of s^-philis, less importance than
we had supposed attaches to the relationship between the weight
of the placenta and the weight of the fetus. In cases where this
disease could be excluded through the history and a negative Wasser-
mann reaction he found the ratio not infrequently 1:5, 1:4,
and occasionally 1:3. The relationship appears somewhat more
reliable when applied to premature infants, but in these circum-
stances it is important to remember that prior to term the placenta
normally weighs more than a sixth of the weight of the fetus.

More trustworthy evidence of syphilis is found in the chorionic
vilh. When freshly teased in normal salt solution or water and
examined microscopically, if syphilis is present, the vUli are enlarged,
opaque, and irregular in shape with swollen ends. Characteristic-
ally, also, the blood-vessels are not apparent in many of the villi.
While such findings are suspicious they should be verified by the
examination of properly fixed, hardened, and stained sections before
the diagnosis of s\^hilis is positively made.

Stained sections mainly show huge, dense villi, but they provide
a more satisfactory opportunity than the fresh viUi for observing
the blood-vessels. There the pathological process seems to begin;
the wall of the vessel is the scat of an endarteritis which frequently
obliterates its lumen. The enlargement of the villi is due to pro-
liferation of the stroma. So rarely may spirochete be demonstrated
that clinically the procedure has not proven useful.

With these histological changes as a criterion for syphilis we have
examined 600 placentje: the findings warranted a positive diagnosis
in fourteen cases. At first we did not request a Wassermann test
routinely but later through the kindness of Dr. L. S. Schmitt
who carried out the serological tests, a Wassermann reaction was
made upon every woman who was a patient in the obstetrical ward
of the hospital. Therefore, I am able to report the results in 260
cases where the placental findings were controlled by the Wasser-
mann upon the mother. These cases fall naturally into four
classes.

210 SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA

COMPARISON OF THE WASSERMANN REACTION AND THE
PLACENTAL FINDINGS

Group

Wassermann

Placenta

Number Cases

Negative

242

Positive

III

Negative

Positive

Negative

In Groups I and II which include 249 cases (95 per cent.) there was
absolute agreement between the Wassermann reaction and the
placental histology.

The single case in Group III in spite of the negative Wassermann
test must be regarded as syphilitic. This woman, twenty-seven
years of age, had four consecutive miscarriages. The pregnancy we
observed ended spontaneously at the eighth lunar month. The
fetus, 40 cm. long, weighed i960 grams; the placenta weighed
480 grams and the chorionic villi were definitely syphilitic. At
autopsy upon the fetus organic lesions characteristic of congenital
syphilis were found. Therefore, excepting the result of the Wasser-
mann, all the evidence pointed to the presence of syphilis. The con-
clusion, then, must be that occasionally the placenta enables such a
diagnosis to be made when the Wassermann reaction is negative.

However, this case does not constitute a new criticism of the
Wassermann reaction. Serologists agree that syphilitic individuals,
even when suffering from secondary manifestations may not show a
positive reaction, and as time passes the likelihood of a negative test
gradually increases.

Group IV comprising ten cases is not so discordant as would at
first appear, for a strongly positive Wassermann reaction (-|-4--|-)
was obtained only in two instances. One of these patients was
suffering from a streptococcus infection which probably waS
responsible for the reaction. At least the Wassermann test alone
indicated that the case was syphilitic. No history of a specific
infection could be obtained, and the chorionic villi were normal.
On the other hand, the fetal surface of the placenta was the seat of
an inflammatory infiltration; streptococci were found in the sub-
amniotic connective tissue. This organism also was present in
microscopic sections of the cord and on the third day of the puer-
perium was isolated from the uterine cavity. The infant died of
hemophilia; at autopsy the lesions of congenital syphilis were
not demonstrable. Therefore, the positive Wassermann in this
case would not seem attributable to syphilis. Occasionally, in the
course of scarlet fever analagous results have been obtained.

SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA 211

Almost certainly, the second case in which the Wassermann
reaction was strongly positive but the placental findings negative,
was syphilitic. On Sept. 5 and again at the time of delivery on
Nov. 18, 1914 the serological test was positive. Furthermore, the
mother gave a history of specific infection eight months previously
and had not been treated. The maceration of the fetus made it
impossible to identify the lesions of congenital sj-philis; stains for
spirochetse were not made.

The teased, chorionic villi were suspicious of sj-philis, though the
stained sections were negative. It may be, however, that other
areas of the placenta would have presented the characteristic
evidence of syphilis, for it is a well-known fact that normal areas
may occur in sx^ihilitic placentae. Certainly, in this case the weight
of evidence favors the diagnosis of syphilis and also favors the
conclusion that occasionally the Wassermann reaction is more
trustworthy than the placental histology.

In the eight remaining cases of Group IV, the Wassermann reac-
tions were faintly positive. The serologist reported six results as
a single +, and two as a double +. To my mind it is significant
that every one of these patients was suffering from a toxemia of
pregnancy with albuminuria. Yet, the severity of the intoxication
did not determine the degree of fixation presented by the serological
test. Thus, a double + was once reported when the albuminuria
was of a mild grade, and, on the other hand, several times a single
+ occurred when the albuminuria was severe.

A second Wassermann test unfortunately was never made. That
precaution must be taken before it is said certainly that a toxemia
of pregnancy may explain a faintly positive Wassermann reaction.
However, it seems likely that the result of the test may be so
explained. Thus, in none of the eight cases could a history of
syphilitic infection be obtained. The placentas were normal, and
the infants were healthy. When discharged from the hospital
they were in excellent condition. Four weeks later they were
visited and none of them had developed stigmata of congenital
sj^hilis. From the available information it seems that these infants
were not syphilitic, though a longer period of observation would be
required to estabhsh the fact absolutely. Taking all the evidence
together it is little short of certainty that the faintly positive Wasser-
mann of these mothers was not due to the usual cause.

The frequency with which the Wassermann reaction is positive
during toxemia of pregnancy, and the question of its association
with a definite type of autointoxication are interesting problems.

212 SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA

The limited data at hand does not permit an uncompromising view,
but is is pertinent that among the 260 cases upon whom serological
observations were made there were twenty-two patients suffering
from albuminuria and in fourteen the Wassermann reaction was
negative. Approximately, then, in every third case a positive reac-
tion obtained. Whether syphihs underlies these toxemias is a ques-
tion which may be raised but it seems more likely that some sub-
stance in the blood, referable to the metabolic disturbance, causes
slight fixation when an examination is made according to the
Wassermann technic.

To summarize briefly the conclusions reached from the analysis
of 260 cases, in the first place, it is clear that the chief source of con-
fusion in the interpretation of the Wassermann test during preg-
nancy lies in the presence of an autointoxication attended by
albuminuria. The suggestive reaction which frequently accom-
panies this toxemia must be attributed — as serologists generally
attribute slight degrees of fixation — to some condition independent
-of syphilis. Classifying these cases of toxemia as negative for
syphilis and also taking into account the cases in which Wasser-
mann and placenta were both in agreement we have arrived by
each method of investigation at the same result in 257 instances or
nearly 99 per cent, of the cases.

Contradictory results were present in three cases. One of them
yielding a positive Wassermann was suffering from a streptococcus
puerperal infection and, it would seem, not from syphilis. This
disease, however, was certainly present in the remaining two cases
in one of which the Wassermann was negative while the placenta
was positive; in the other the Wassermann was positive but the
placenta negative. Accordingly both examinations were required
to make sure the diagnosis.

The microscopic examination of the umbiHcal cord is without
great practical value toward establishing the diagnosis of syphUis.
Only in rare instances as Emmons(2) has shown may spirochetae be
demonstrated there. Moreover, exudative inflammation of the um-
bilical vessels which Bondi(3) regarded specific for syphilis may be
quite independent of this disease. In an analysis of 400 obstetrical
cases Simmonds(4) definitely established the presence of syphilis in
forty instances and only half of these cases presented inflammatory
changes in the umbilical cord. On the other hand, in tliirty-two
cases where syphUis could be excluded oomphalitis was present.
The etiological factor was not determined by Simmonds but prob-

SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA 213

ably, as in similar cases we have studied, (s) bacteria have gained
entrance to the cord through the placenta.

Generally, placental bacteremia occurs in cases in which the
membranes have ruptured prematurely, either at the onset of labor
or at least several hours before delivery. The frequency of this
complication is notably increased in cases of abnormal presenta-
tion, of contracted pelvis, and of elderly primiparae, and there-
fore, is more often seen in hospitals than in private practice. How-
ever, since my attention was directed to the complication and the
placenta has been studied with reference to it, I have been surprised
at its frequency.

The lesion consists of an acute exudative inflammation beginning
upon the fetal surface of the placenta and since the fetal blood-
vessels cross this region they are quickly involved. By appropriate
staining methods bacteria may be demonstrated in the subamniotic
connective tissue, at times also in the walls of the fetal blood-vessels.
Perhaps, because the time interval is not sufficient, in most instances
the infection does not spread to the decidua, and the villi are rarely
involved. Evidently the bacteria enter the placenta from the
amniotic cavity. Infection of the amniotic fluid occurs because
the membranes have ruptured prematurely and vaginal examination
leads to the contamination of the amniotic cavity.

The mechanism has become much clearer since we have learned
that when the membranes rupture prematurely the amniotic epi-
thelium loses its cuboidal form and becomes tall and narrow. The
basal attachment of the cells is considerably restricted. The nuclei
are dislocated upward and at times actually forced through the cell
membrane. These alterations seem to be merely the expression of
mechanical forces referable to the retraction of the uterus. From
the histological picture it is evident that the function of these cells
is greatly impaired, or absolutely terminated, and in the course
of time they are desquamated for longer or shorter stretches leav-
ing the amniotic connective tissue uncovered. Probably, through
these portals the bacteria gain entrance to the placenta.

FETAL AND EARLY INFANT DEATHS.
(Weight over 2000 grams; length over 40 cm.).

Syphilis 7 Toxemia of pregnancy 2

Birth injury 6 Enlarged thymus i

Premature separation placenta 4 Pneumonia i

Placental bacteremia 4 Abdominal pregnancy i

Congenital heart lesion 3 Undetermined 4

As the placental invasion is usually limited to the amniotic

214 SLEMONS: RESULTS OF A ROUTINE STUDY OF THE PLACENTA

surface of the placenta the comphcation is more likely to be serious
for the infant than for the mother. Not infrequently infection of
the fetus leads to its death either shortly before or within a few days
after it is born. If my experience is not unusual, as a cause of
fetal death placental bacteremia is outranked only by syphilis and
birth injuries.

Since the lesions depend for recognition upon the study of his-
tological section, routine study of the placenta for the purpose of
demonstrating bacteria should be undertaken whenever intrapartum
fever occurs or when labor is prolonged after the membranes rupture.
By this means the presence of bacterial infection may be demon-
strated in cases where otherwise the cause of fetal death would
remain undetermined.

RECAPITULATION.

Gross anomalies 41 rases Premature infants 17 cases

Maternal complications 10 cases Question of sj'philis iS cases

Death of infant ^3 cases Placental Bacteremia 4 cases

Recapitulating the results of the study of 600 placentas, we have
found that appro.ximately one of five or six specimens presented
some departure from the normal or required examination to eluci-
date clinical manifestations on the part of the mother or the infant.
Moreover, when the placenta was normal the pediatrician was
interested in the fact, for this information made it more certain
that the infant began life with a clean bill of health.

In well-organized clinics the careful study of the placenta should
be insisted upon not only at the bedside but also in the laboratory.
Such rigid requirements cannot be exacted of the practitioner but
if he wishes not to overlook important data he should supplement
bedside observations with study of the placenta in his laboratory.
It should be weighed and measured, gross abnormalities noted,
fresh tissue teased, and the chorionic villi studied microscopically.
These data should be recorded and thus become more reliable, if
in the puerperium some complication develop which requires for its
interpretation a knowledge of the placenta.

When the teased villi suggest the presence of s>^hilis the placenta
should be sent to a pathological laboratory and stained sections
prepared to establish the diagnosis. Simultaneously a VVassermann
test upon the mother's blood should be made. Similar precaution
is advisable if delivery occurs prematurely. At times a diagnosis
of syphilis will be the result, but more frequently the investigation
will remove all suspicion of that disease. Finally, if the infant is

rice: postpartum hemorrhage 215

stUlborn or dies within the first few days of extrauterine life study
of the placenta should be comparable in painstaking care to that
given the organs at an autopsy.

REFERENCES.

1. Gros, Placentas et Syphilis. Paris Thesis, 1913.

2. The Diagnostic Value of the Search for Spirocheta Pallida
in the Umbilical Cord of the New-born. Boston Med. and Surgical
Journal, 19 10, clxii, 640-641.

3. Die syphilitischen Veranderungen der Nabelschnur. Arch. f.
Gynadk., 1903, Ixix, 223-248.

4. Nabelschnurentziindung und Syphilis. Virchow's Archiv,
1912, ccix, 146.

5. Placental Bacteremia. Jour. A. AI. A., 1915, Ixv, 1265-1268.

POSTPARTUM HEMORRHAGE.*

FREDERICK W. RICE, M. D.,

Adj. Obstetrician Bellevue and Manhattan Maternity Hospitals.
New York City.

A STUDY of the cause, prevention and treatment of postpartum
hemorrhage must be based on an understanding of the physiological
processes involved. Were it not for the wonderful protection
provided by nature, no child could be brought into the world
without sacrificing the life of the mother.

From the fifth month of pregnancy certain changes are taking
place in the mother's blood. At term we find a definite increase
in the total quantity of blood in its cellular elements, especially
leukocytes and in its coagulability. The need of these changes
becomes apparent when we consider what takes place during the
third stage of labor.

Throughout labor there is a gradual change in the structure
and arrangement of the muscle bundles in the uterus caused by the
uterine contractions. In the second stage there is a gradual adapta-
tion of the body of the uterus to conform to the fetus in its descent.
This is accomplished by a thickening of the uterine wall due to the
overlapping and rearrangement of the muscle bundles, actual
shortening of some of the fibers, and is called retraction.

The cavity of the uterus diminishes gradually as the fetus is ex-
pelled through the parturient canal. Following delivery of the

* Read before a meeting of the New York Obstetrical Society, April 11, 1916.

216 rice: postpartum hemorrhage

child, the uterus contracts until the cavity is practically obliterated.
During this time, the placenta remains attached to the uterus and
the placental site diminishes in area. The uterine wall at the
placental site does not contract and retract equally with the rest
of the uterus.

In the normal case, following the dehvery of the child, there inter-
venes a variable period of from three to five minutes during which
the uterus is passively contracted. With the reappearance of the
active contractions, the placenta separates from the uterine wall
at a central point, the separation beginning in the deep layer of the
decidua. During relaxation hemorrhage occurs at this point from
the torn sinuses. At the next contraction still further separation
is brought about by the blood being forced laterally. Owing to the
firm attachment of the placenta at its margins, the accumulating
retroplacental blood forces the center of the placenta away from the
uterine wall, causing inversion of the placenta. The placenta,
on being expelled from the uterus, appears at the vulva with the
fetal surface presenting and the blood lost during the separation
enclosed within the membranes. This method of separation, al-
though described first by Baudeloque, is known as Schultze's
method.

In other cases there is a slight loss of blood during the time of
separation. Here the placenta is usually separated first from the
margins, and is expelled rolled on itself with the lower margin
appearing first at the vulva.

The latter method, known as Duncan's method, is not as common
and is more apt to be seen where there is a premature separation
due to severe contraction during the second stage, where there is
traction from a short cord or where too vigorous massage of the
uterus has been employed immediately following dehvery. After
separation of the placenta, the contractions of the uterus continue
until the placenta and its membranes, with the accompanying
clots, have been expelled from the cavity.

During the separation of the placenta, the amount of blood
lost from the open sinuses is kept at a minimum by certain changes
that are taking place in the uterine wall at the placental site. Near
the end of pregnancy a change in the structure of the terminal
arteries supplying the sinuses has occurred. The external and
middle coats have disappeared and the walls are composed now
only of endothelium.

These vessels and sinuses are surrounded by muscle bundles
extending both longitudinally and circularly. During the con-

kice: postpartum hemorrhage 217

tractions of the uterus, following the delivery of the child, these
muscle bundles at the placental site undergo retraction. This
shortening of the muscle fibers mechanically cuts off the lumen of
the enclosed thin-walled sinuses and blood-vessels. At the same
time, the contraction of the uterus compresses the arteries as they
enter and pass through the wall to reach the placental site, and
the blood current is almost completely cut off during uterine con-
traction. In performing a Cesarean section, anemia of the uterus
is often observed following the action of pituitrin.

After the expulsion of the placenta, the uterus remains in tonic
contraction. This firmly contracted uterus, together with the
quickly formed clot at the placental site, normally prevents further
loss of blood.

The term "postpartum hemorrhage" is applied to an excessive
loss of blood during and shortly after the separation and expulsion
of the placenta. It is rather difficult to estimate when the normal
amount lost becomes abnormal. The amount flowing from the
vagina during the separation and expulsion of the placenta in a
normal case should be less than i pint. In operative cases there
is no practical method of accurately measuring the amount lost.
We can only estimate this by the rate of flow or the persistency of
the oozing. By the use of a specially constructed bed, Ahlfeld
collected blood during several thousand labors. He concluded that
the average loss was about 400 c.c, but a much larger amount might
be lost by healthy women without serious effects. He found that
the normal amount varies directly with the size of the placenta, and
that the size of the placenta varies directly with the size of the
chUd.

Zangemeister reported observations on 2930 normal cases in
1910. He found that loss up to i pint had no serious effects on
the patient. The average loss was 170 c.c. Ten per cent, were
over 200 c.c. and 5.3 per cent, over 500 c.c.

It should be our aim in handling every case to limit the loss
of blood to a minimum. At times even a moderate amount has
serious effects, namely, inability to meet the demands of nursing,
excessive nervousness, loss of sleep and appetite, with a resulting
lessened resistance to any complications that might develop.

Cragin, in his text-book, reports 20,000 deliveries at the Sloane
Maternity, with a frequency of one in ten, but he considers hemor-
rhage to have occurred when the amount lost has been estimated
over 16 ounces.

At the Manhattan Maternity, postpartum hemorrhage occurred

218 rice: postpartum hemorrhage

in 2 22 cases during 13,000 deliveries, an incidence of one in 58 cases.
Some of these were delivered on the outdoor service, where, as far
as possible, the same technic was employed as in the hospital.
Out of 222 cases there were four deaths.

Generally speaking, hemorrhage can be ascribed to one of three
causes: first, lacerations, second, inefficient contraction and re-
traction, and third (fortunately rare, but when present serious),
hemophiliac diathesis.

Lacerations of the cervix which are not extensive enough to
enter the broad ligament and cause rupture, are rarely, if ever, a
cause of serious hemorrhage. Moderate hemorrhage occurred in
eight cases not associated with placenta previa. Three of these
necessitated suture. The others required only hot vaginal douches;
the bleeding in the latter cases was controlled, no doubt, by firmer
uterine contractions caused by action of the douche.

In two cases of ruptured uteri in which the lacerations extending
into the broad Hgament were carefully packed, the extent of the
laceration was not diagnosed sufficiently early to render possible
the employment of more effective means. Therefore, in all cases
where hemorrhage is clearly due to laceration of the cervix, it is
of greatest importance to explore quickly the extent of the injury
before attempting to control the bleeding by packing. In many
cases after firm uterine contraction is obtained, hemorrhage of the
cervix can be checked by firm packing, but if the tear has invaded
the broad ligament, the tampon alone will be ineffective and valuable
time and a great amount of blood may be lost.

Perineal and vaginal lacerations do not often cause serious hemor-
rhage. One case of laceration of the perineum and one of laceration
involving the veins of the vestibule caused profuse hemorrhage until
controlled by suture.

Inefficient contraction and retraction usually means atony of the
uterus. The cause of this atony, or inefficient contraction, may be
general or local. Under the first division, there were forty-seven
cases where the cause of hemorrhage was due to prolonged labor.
In twenty of these cases the average length of time of labor in primi-
para cases was forty-seven hours and twenty-five minutes and
twenty-three hours and nine minutes for multipara cases. Where
delivery is operative, we must also consider the effect of shock and
anesthesia in some of these cases. Chloroform over a long period
seems to have an influence in causing atony following delivery.
Fifty-nine per cent, of the cases were multipara. No conclusions

rice: postpartum hemorrhage 219

could be drawn regarding the age of the patients. The proportion at
dififerent periods seemed to be about the same as normal cases.

Under the local cause of atony, the most common was something
within the uterus which interfered with normal contraction, such as
retained placenta, membranes or clots. In seventy-six cases, hemor-
rhage was associated with retained placenta. The placenta was
wholly or partially adherent, partially separated, or free but retained,
as is seen in a condition known as "hour-glass contraction." Blood
clots alone were a frequent cause of atony.

In seventeen cases the placenta was reported to be completely
adherent. This seems too large a number as the condition is
rare. It is usually due to a chronic endometritis. If the placenta
is completely adherent no hemorrhage can occur, as no sinus is open.
In these cases the hemorrhage occurs during the manual extraction
which was necessary to separate the placenta from the uterine wall.

More commonly do we find the placenta partially adherent.
With part of the placenta separated, the uterus cannot expel the
adherent portion, nor contract to cut off the open sinuses. Profuse
hemorrhage results. If only a small part of the placenta is adherent,
this may be retained and the remainder expelled. The part retained,
usually a cotyledon, may prevent persistent retraction with a
resultant hemorrhage. The type of bleeding in these cases, as in
the case of clots, is excessive and persistent oozing.

In three of our cases, the part of the placenta retained was the
accessory part of the placenta succinturiata. If the uterus is not
explored at the time and the part removed, late or secondary hemor-
rhage may result. In four cases hemorrhage occurred between
the seventh and eleventh day. A small fragment of retained
placenta was the cause in each case. In one of these, the hemorrhage
was almost sufficient to cause a fatal result on the seventh day.

In twenty-five cases, retained membranes, in proportion to their
bulk, prevented proper contraction and retraction. The chorion
is more apt to give trouble than the amnion or decidua. The cause
of retention is often too early expression of the placenta. When
the placenta has had time to separate, the membranes are rarely
retained.

In nine cases, hour-glass contraction developed. This is caused
by undue relaxation of the uterus and a formation of a contraction
ring in the lower uterine segment. Hemorrhage taking place, the
upper segment becomes ballooned. In three of these cases, disten-
tion was sufficiently great to cause symptoms of shock. Anesthesia
relaxes the contraction sufficiently to allow the hand gradually to enter

220 rice: postpartum hemorrhage

and deliver the placenta and clots, thus allowing the uterus to
contract. All of these cases occurred on the outdoor service.
With proper management of the third stage, the condition should
not develop.

Twins and hydramnios are usually considered to be a cause ol
atony of the uterus by producing overdistention. In 175 cases of
twins, there were only three cases where bleeding was reported,
and in these cases labor was prolonged and difficult. Hemorrhage
occurred in two cases complicated by hydramnios. Both of these
conditions are more important as factors causing prolonged labor
than as the direct cause of uterine atony.

Fibroids in two cases were a cause of atony by interfering with
contraction.

Too rapid extraction is often a cause of hemorrhage when
sufficient time is not given the muscle bundles in which to
rearrange themselves.

The most severe type of hemorrhage occurred in placenta previa.
Excessive bleeding following delivery was reported in fifty-seven
out of seventy-five cases.

The sources of the hemorrhage were the placental site and lacera-
tions of the cervix. The latter were frequent and often serious.
The cervical tissues are rendered unusually vascular by the location
of the placental site in the lower uterine segment and more friable by
the infiltration of the villi.

The fibers in the lower uterine segment have not the retractive
power of those above the retraction ring, so that immediately follow-
ing the separation of the placenta the sinuses and terminal arteries
remain open.

Hemorrhage is controlled by obtaining firm uterine contraction,
because the blood supplying the sinuses enters the uterus above the
retraction ring. But where there has been some laceration of the
tissues, the firm contraction above is not sufficient, and firm packing
must be used to control the bleeding from the torn sinuses.

In the management of placenta previa cases, we should bear in
mind that the amount of blood lost previous to and during the
first stage of labor must be kept at a minimum. When patients
have lost a large quantity of blood before entering the third stage,
we find the bleeding in some cases impossible to control. The
blood seems to have little or no power to clot. There were two
deaths in the fifty-seven cases of postpartum hemorrhage due to
placenta previa.

Case I. — Placenta previa, history No. 42. Patient was thirty-

rice: postpartum hemorrhage 221

nine years old; para-ii; when brought to hospital was bleed-
ing profusely and in shock. Examination showed the cervix a
little over two fingers dilated and the placenta centrally situated.
Under anesthesia the cervix was dilated with a Pomeroy bag, and
full dilatation was obtained at the end of one hour and fifteen minutes.
A stUlborn child was delivered by version and breech extraction.

On account of hemorrhage, the placenta was manually extracted.
An intrauterine douche was given and the uterus firmly packed with
gauze. An infusion of 1500 c.c. was given. Hemorrhage continued
in spite of the firm packing. The patient died within an hour.

It was learned later that the patient had bled profusely for two
hours before coming to the hospital.

Case II. — Placenta previa, history No. 69. Patient was twenty-
six years old; para-iii. Pregnant thirty-six weeks. Had slight and
intermittent bleeding during the month previous to coming to the
hospital. On the day previous to admission had a sudden, profuse
hemorrhage which was controlled by vaginal packing. On the
morning of the day she was admitted to the hospital, packing was
removed and a few hours later a second profuse hemorrhage oc-
curred. The vagina was packed and the patient taken at once to
the hospital. A few hours later, in the hospital, the cervix was
found to be three fingers dilated and soft. The patient was
taken to the operating room and, under an anesthetic, podalic
version was done and a leg pulled down into the cervix. During
this maneuver the placenta was detached and removed. A slow
breech extraction was now done and as the head approached the
cervix, it was perforated and delivered. After a hot intrauterine
douche the uterus was packed with gauze. In spite of ergot and
pituitrin the uterus continued to relax; there was constant oozing
through the packing. There seemed to be no attempt at clotting.
In spite of stimulation the patient died at the end of two hours.

From the moment the diagnosis is made, placenta previa cases
must be under constant observation. This can be done practically
only in a hospital. Manual or instrumental dilatation, where the
placenta is partial or complete, cannot be done without lacerations.

Early induction will limit the loss of blood previous to labor.

We must avoid operative delivery until the cervix has become
fully dilated.

In marginal and lateral varieties, early rupture of the membranes
was sufficient to control bleeding in many cases and allowed spon-
taneous delivery. This method failing, we pack or use Voorhees
bags. The bags are to be preferred; they control bleeding, aid in
dilatation and tend to keep up the contraction. The gauze pack-
ing, unless introduced under anesthesia, will not control hemorrhage
in every case; repacking may be necessary, and there is greater
danger of infection.

Of nine cases where antepartum packing was used, five had

222 rice: postpartum hemorrhage

temperature during puerperium. There was no temperature in
any one of five cases where bags were used.

In complete or partial varieties we may control bleeding by
tamponade, bags, or pulling down a foot.

Tamponade is more apt to fail in controlling bleeding than
either of the other two methods. Failing by tamponade, we are
more apt to attempt manual extraction and rapid delivery to prevent
further loss of blood.

By the use of bags, or by pulling down a foot, we allow the cervix
to dilate slowly with the possibility of spontaneous deUvery.

In eighteen of the seventy-five cases of placenta previa, the de-
livery was spontaneous. There was hemorrhage in eleven of these
cases, or 6i per cent. In fifty-six cases some operative method of
delivery was used and hemorrhage followed delivery in forty-six,
or 82 per cent.

In most cases proper management of the third stage of labor will
prevent an excessive loss of blood.

Immediately following the birth of the child, in a normal case,
the uterus needs little or no attention. When there is slight bleed-
ing at this time, the uterus should be gently massaged until con-
traction takes place. This, in a majority of cases, is sufficient to
control the hemorrhage. The tendency at this time is to do too
much rather than too little.

Of 1006 cases, on the outdoor service, at the Manhattan Maternity,
where birth of the child occurred before the arrival of the doctor or
student, in only three cases hemorrhage was reported as being excessive.

There is a great tendency on the part of the students or the
internes during their first month's service to pay too much attention
to the uterus during the period immediately following delivery.
They know they should keep their hand on the fundus during the
third stage, but the mistake they make is this: instead of allowing
the hand to rest lightly on the fundus, to make sure that it does not
relax and become overdistended with blood, they immediately
begin to knead the uterus, thus causing tonic contraction of the
uterus. They forget the period of rest needed by the uterus before
it begins to contract and separate the placenta.

Too early massage of the uterus causes partial separation of the
placenta; bruises the wall of the uterus and sets up irregular con-
tractions; breaks up the retroplacental hematoma, thus delaying
and interfering with the normal physiological process; and causes
retention of both placenta and membranes.

At the Manhattan, the routine management of the third stage is

rice: postpartum hemorrhage 223

so arranged that the attendant during this period is occupied with
the care of the baby. In the hospital the nurse, and on the out-
door service a student, is assigned to watch the fundus.

After the pulsation of the cord has ceased, the attendant is
occupied with tying the cord, lubricating the baby thoroughly with
sterile albolene, wiping off the baby with a sterile towel, applying a
dressing to the cord, putting on the binder, and treating the eyes
with a solution of argyrol.

If, during separation of the placenta, slight hemorrhage occurs,
the nurse is instructed to make gentle massage of the uterus to
promote firmer contraction. No attempt is made to expel the
placenta until the e.xpiration of at least twenty minutes.

Experience quickly teaches one to recognize by grasping the
fundus whether the placenta has been expelled from the cavity of
the uterus or not. This expulsion is shown by a smaller, firmer and
more movable uterus, the ascent of the fundus and descent of the
cord.

The ideal course would be to leave the expulsion of the placenta
to the voluntary efforts of the mother, but it is impractical. As
this often consumes several hours, some assistance is usually neces-
sary to effect the complete expulsion.

Having satisfied ourselves that the placenta has been separated,
we should instruct the patient to bear down during the time that
the uterus is contracting. Voluntary efforts failing, the uterus
should be massaged until firm contraction takes place. Then, by
pushing downward in the direction of the canal, we force the
placenta, lying in the lower dilated uterine segment and upper
vagina, to descend. As the placenta reaches the lower part of the
vagina, usually the patient completes its expulsion by bearing
down.

The placenta, lest the membranes be torn, is supported by the
hand as it leaves the vulva. The complete membranes and about
6 to 8 ounces of blood clots accompany the placenta.

If part of the membranes are caught in the contracted cervix, or
are adherent to the decidua, gentle traction is made on the mem-
branes without twisting. If, at the same time, the fundus is pushed
back at intervals, it tends to lessen the kink in the cervix. If too
vigorous traction has been made and the membranes have been
torn, the remaining secundines may be completely removed by the
use of an ordinary sponge-holder.

The placenta and membranes should be carefully examined
at once, and if any part of the former is absent, the uterus should

224 rice: postpartum hemorril^ge

be explored. It is not necessary to explore for retained membranes
unless more than one-half have been retained.

No douche or medication is given unless indicated.

The nurse keeps the uterus firmly contracted for one hour.
During this time she is instructed not to remove her hand from the
fundus and to keep up firm contraction by gentle massage whenever
the uterus relaxes. She reports at once any signs of excessive
bleeding as shown by frequent observation of the vulva pads.

An abdominal binder is applied solely for the comfort of the
patient. In our opinion it has no effect on the action of the uterus.

During the first twenty-four hours the pads are changed as
often as necessary; in normal cases once in every four hours. Ex-
cessive oozing during the first twelve hours is almost always due to a
clot in the uterine cavity. Vigorous massage and pressing down-
ward of the uterus expels the clot and prevents further hemorrhage.

During the first six hours following delivery the patient is in-
structed to lie on her back with knees together. Careful watch of
the bladder will prevent overdistention which displaces the uterus
upward and to one side, causing relaxation and hemorrhage.

During the first three days of the puerperium the patient should
be protected as much as possible from anything which might cause
excitement.

The most important point in the treatment of hemorrhage
postpartum is prompt recognition of the source of the bleeding.
Hemorrhage from a tear in the cervix is always of bright color,
follows immediately after the delivery of the child, and persists
after firm contraction of the uterus.

Pituitrin gives prompt and satisfactory results in most cases,
ergon and ergotol do not act as promptly, but the effect seems to
last longer.

In cases where the placenta is partially separated, if the bleeding
is not controlled by contraction of the uterus, the placenta must
be expressed immediately. This failing, manual extraction is
indicated. With proper precautions as to asepsis, this can be done
without much danger. Of 13,000 cases it was necessary in 100 cases,
and in only 3 was it followed by a temperature above loi, and no
case above 102.

Where hemorrhage does occur, in the large majority of cases, it

is controlled quickly by prompt and vigorous massage of the uterus

followed by hot vaginal and intrauterine douching, and by pituitrin

or some preparation of ergot which is given deep into a muscle.

If there is a tendency for the uterus to relax following this treat-

rice: postpartum hemorrhage 225

ment, we feel sure of maintaining contractions by introducing gauze
packing into the uterus and vagina. Fifty of the 222 cases were
packed with failure in only three. In some cases, especially placenta
previa, packing was done immediately following delivery as a
preventive measure.

We must bear in mind that the effect of the packing is due not
to the action of the gauze, but to the contraction of the uterus
obtained by the act of inserting the gauze into the uterine cavity.
The firm pressure of the gauze in the uterus maintains the contrac-
tion. The very act of packing stimulates contraction and stops
hemorrhage. If the gauze has been firmly packed into the uterine
cavity, we may be sure that the contraction will be maintained.
Besides the pressure of the gauze against the placental site, hemor-
rhage is controlled by its action as an aid in coagulation of the
blood.

If the uterus is packed improperly we do not control bleeding,
but the packing tends to increase the hemorrhage. Packing fails
in those cases where the gauze is not carried to the upper part of the
uterine cavity, and in such cases acts in the same manner as retained
clots by preventing contraction and retraction. In three cases
packing failed to control hemorrhage.

Case III.— Vertex, L. 0. A., No. 6458.

Patient was twenty-two j-ears old; para-i. She had a long second
stage, but delivered spontaneously. At the end of forty-five
minutes there was evidence that the uterus had little or no contractile
power and the placenta was delivered by Crede's method. Follow-
ing this there was persistent oozing which continued for one hour,
in spite of hot douches, ergot and pituitrin. At the end of this time
the patient was beginning to show evidences of loss of blood, although
the pulse rate was not over 100. The quality of the pulse was soft
and small. It was decided to pack the uterus.

Before this could be done the patient suddenly became very rest-
less and the pulse more rapid and weak. Owing to the serious con-
dition of the patient the uterus was packed without an anesthetic.
At the same time an infusion was given. By the time the packing
was completed, and the infusion given, the pulse and general ap-
pearance had greatly improved. One-eighth grain of morphine was
administered, the bed elevated, and heat applied. During the next
hour, after the slight initial improvement, the pulse suddenly dis-
appeared, and the patient died within a few minutes. Examination
showed that the gauze had not been carried well up into the fundus
and that it was saturated with blood. There was considerable
amount of blood in the vagina which showed no evidence of clot-
ting. There was no laceration of the uterus or cervix.

As the patient was exhausted from long labor, she should have
been packed early, as soon as it was evident that there was a tend-

226 WILLIAMS: PSYCHIC VAGINISMUS

ency on the part of the uterus to relax. If the packing had been
done earlier an anesthetic could have been given and the gauze
carried well into the uterine cavity. As it was, the gauze was in-
sufficient in amount to produce contraction, and as a result the
loosely packed gauze increased the hemorrhage.

An infusion before we are sure that bleeding is under control
does harm by increasing blood pressure and diminishing coagulability
of the blood.

Where the patient is suffering from effects of severe hemorrhage,
recovery is more rapid by allowing the patient absolute rest by a
small dose of morphine, applying heat and by increasing the fluids
by frequent small quantities of water by mouth.

It should be our aim in handling every case to limit the loss of
blood to a minimum. At times even a moderate loss has serious
effects, namely, inability to meet the demands of nursing, excessive
nervousness, loss of sleep and appetite, with a resulting lessened
resistance to any complications that may develop.

PSYCHIC VAGINISMUS, WITH A REPORT OF TWO CASES.*

P. H. WILLIAMS, M. D.,

New York City.

That there exists a condition characterized by spasmodic contrac-
tion of the muscles situated about the vagina, reflex in character,
which is termed vaginismus, may be taken for granted. Whether,
as Dudley beUeves, it is a symptom only, due, as he says, "to
appreciable or ... . unknown causes," or is an actual chnical
entity, is a matter for debate, which I have no desire to enter into at
the present time.

Vaginismus has been defined as a "reflex spasmodic contraction
of the constrictor ani, the levator ani, and adjacent muscles;" but
it may be added that the reflex spasm is out of all proportion to the
exciting stimulus and generally spreads to other muscles, involving
the adductors and extensors of the thigh and the muscles of the
trunk, causing opisthotonos.

Now, in spite of the well-recognized characteristics of this con-
dition, one is somewhat surprised on examining the literature
and case reports on the subject, to find that the term vaginismus
has been erroneously extended to cover a wide variety of condi-
tions, varying all the way from the slight discomfort of the newly
married to painful coitus due to tender masses in the culdesac of
Douglas, and from kraurosis vulvae and senile vaginitis to irritable

• Read before a meeting of the New York Obstetiecal Society, April ii, 19 1().

WILLIAMS: PSYCHIC VAGINISMUS 227

urethral caruncle. Now with any of these conditions vaginismus
may be present as a symptom or may be superimposed as a resulting
neurosis, continuing after the cause is removed, but loosely to class
many cases of dyspareunia as vaginismus seems to me to be an
abuse of terms.

In order to define our subject more accurately, let us first exclude
from consideration all cases of dyspareunia per se, for it is self-evi-
dent that the term dyspareunia, meaning painful intercourse, must,
in the very nature of the thing, presuppose the possibility of coitus —
as well discuss dysentery accompanied by complete constipation, or
dysmenorrhea with the absence of the menstrual phenomena —
for in vaginismus the act of coitus is impossible of performance.

Dyspareunia, we believe, should be classified according to its
etiologj- and the situation of exciting cause, as: (i) Internal (or
superior), where the cause is high up, as, for example, painful or
tender masses in the culdesac, or inflamed tubes, or sensitive
adhesions in retroversion, etc.; (2) External (or inferior), where the
cause is below the internal genitalia, as, for example, tender condi-
tions about the outlet, fissures, irritable caruncles, painful conditions
about the hymen.

In all these cases of dyspareunia there is a more or less easily
ascertainable cause, the removal of which should produce a cure;
but in none is there that characteristic reflex contraction precluding
coitus, which is characteristic of vaginismus.

Having defined vaginismus, let us attempt a classification accord-
ing to its etiological factors.

Pozzi names three particular types, those showing:

1. Hyperesthesia with contraction;

2. Hyperesthesia without contraction;

3. Contraction without hyperesthesia.

His second type (hj^peresthesia without contraction) appears
to be a phase of dyspareunia, for the very definition of vaginismus
as a muscular contraction excludes this type.

His third type (contraction without hyperesthesia) seems to be
true or psychic vaginismus.

Pozzi proceeds to state that two conditions are necessary for the
production of vaginismus: "first, great nervous excitability, and,
second, some irritation of the external genitals which serves as a
starting point for the exaggerated reflexes .... thus producing
h}T)eresthesia and contraction." Thus, after stating that the con-
dition may exist without hyperesthesia or contraction, as the case
may be, he makes the combination of hyperesthesia and contrac-
tion the chief characteristic of the disease — so it is seen how easily

228 WILLIAMS: PSYCHIC VAGINISMUS

the confusion of terms comes about and how soon loose terminology
may result in loose diagnosis and ineffective treatment.

Audrey of Toulouse, in a really admirable article, "Sur les dys-
pareunies vaginales," puts into one class cases due to vaginitis or
vulvitis (our external type of dyspareunia), and into a second class
those cases showing what lie terms the "essential syndrome of
vaginitis." The latter he again subdivides into:

1. Cases of neuralgia of the vulva, and

2. Cases of true vaginismus (vaginisme vraie) or what we have
called psychic vaginismus.

The cases of neuralgia of the vulva are distinguished from dys-
pareunia due to vulvitis by the absence of inflammation or "the
extreme insignificance of the lesions of the mucosa;" and from true
vaginismus by the "continuance of the painful phenomena, or,
rather, by the fact that the painful phenomena exist in the absence
of coitus or any attempt at coitus." He therefore insists that the
attempt at coitus causing the spasm is the determining factor in
the diagnosis of " true vaginismus, " i.e., the fear of coitus rather than
the pain of contact must be the causative factor in true vaginismus.

Hirst, after defining vaginismus, states that "in the examination
of some subjects, no evidence of spasm in the constrictor muscles
of the vagina appears. It is only the nervous excitation of the
attempted intercourse that excites the spasm." Here he recognizes
the possible absence of tenderness as a causative factor, and the
predominance of the neurotic or psychical element in certain cases.

Personally, I should prefer to divide the cases of vaginismus into :

1. Organic, i.e., those which depend upon some ascertainable
cause, such as a tender myrtiform caruncle, irritable hymen, ulcer
or fissure about the vulva or lower vagina, etc., and

2. Those cases where there is no ascertainable pathological lesion
about the external genitaha, not failing to remember that from
repeated efforts at intercourse a condition of extreme irritability
about the introitus may be set up in the second class, or that an
actual neurosis may result from a very small lesion in the mucosa
in the organic type in a highly neurotic individual.

The two cases which seem to illustrate this second or psychic
type of vaginismus occurred in my private practice and are espe-
cially interesting because the causative psychic factors were easily
ascertained in each case, and, the fear being removed, a permanent
cure resulted in each case, without recourse to operation. I shall
omit all the unimportant details.

Case I.— Mrs. M.; aet. twenty-four; applied first April, 191 1,
when convalescing from the influenza; very indefinite as to her chief

WILLIAMS; PSYCHIC VAGINISMUS 229

complaints. I found a tubercular lesion in her left apex and sent
her back to her family doctor, who sent her to the Adirondacks.
She returned, cured of her pulmonary trouble, in September, 191 2.

After three calls, at none of which could I discover why she
came, she confessed that although married since April 19 10 (nearly
two years and a half) , she had never been able to endure coitus.

Previous History. — Negative, except above. She admitted that
she had always been a supersensitive, impressionable girl, subject
to "blues."

Menstrual History. — Normal; twenty-eight day type; four days
unwell, with slight pain of a crampy character the first daj\

Present Illness. — Married, April, 1910, to a chauffeur employed
in the same family with her; for several weeks before her marriage,
another member of the same household, who was a widow, had tried
to frighten her with tales of the pains and discomforts of married
Ufe, until at one time she had decided to break her engagement
because of the fear created by these stories, but was dissuaded by
the other servants. After marriage, all attempts at intercourse
were futile. At the approach, there was a contraction of the parts,
approximation of the thighs, straightening of the legs, and arching
of the back; if the attempt were persisted in several times there
had been a general convulsion followed by unconsciousness, so alarm-
ing that a physician had been hurriedly called.

Operations. — April, 1910: E.xamined by Dr. McC. under general
anesthesia, who ''broke her hymen." May 10, 1910: Same
physician, under general anesthesia, "cut a band, " whatever that
may mean. May, 1910, one month after marriage, examined under
general anesthesia, by Dr. B., and declared normal. September,
1910, Dr. F. operated under general anesthesia and cut away the
remains of the hymen, and dilated with packing and a glass plug.
There was a long after-treatment, about which she is very hazy,
having had convulsive attacks whenever the doctor tried to examine
her. September, 191 2, two years later, she was unimproved, and
still in her original condition.

First examination unsatisfactory; patient exhibited symptoms of
vaginismus of extreme type first, before, and later, as soon as the
examining finger touched the vulva.

Second examination (preceded by codeinas sulph., gr. }/2, and
sodium bromide, gr. xx) ; was able to introduce one finger up to the
cervix.

Third examination (preceded by the same medication, with the
addition of a solution of anesthesin in warmed albolene to the vulva
and vagina) very satisfactory. Vulva, vagina, and cervix normal;
uterus small, anteflexed, approaching the infantile type.

Diagnosis. — Vaginismus, without tenderness or organic lesions.

Treatment. — Advised to cease attempts at coitus for three months,
and told that her trouble was entirely mental and that she must
overcome it herself.

April, 1913, revisited my oflice. There was no improvement.
She was sent to Dr. Habbermann at the Vanderbilt CUnic for
hypnotic treatment. Dr. Habbermann hypnotized her eight differ-

230 WILLIAMS: PSYCHIC VAGINISMUS

ent times, each time suggesting to her that there was no real reason
for her trouble.

June 15, 1 913. The patient came to my oi£ce stiU unrelieved.
I then spent some time explaining in detail about her case, and appar-
ently convinced her that her trouble was past.

September 12, 1913. Patient returned from the country cured.
She declares that hypnotism had nothing to do with her cure, but
that I had convinced her at our last meeting.

March 20, 1916. Patient continues well, Uving a normal married
life, in spite of a slight dyspareunia, due to a slightly tender
prolapsed ovary.

Case II. — Mrs. W.; aet. thirty-five; referred by Dr. Brainard
Wheelock, July 14, 1914. Chief complaint: Had never been able
to have coitus.

Family History. — Negative.

Menstrual History. — Formerly regular; twenty-eight day type;
with no pain, and of four to five days' duration. At present, type
every three weeks, with excessive pain and moderate menorrhagia.

Previous History. — As a girl, was hysterical and very sensitive to
criticism; at times, self-accusatory. Very devout Cathohc; easily
impressed by others. Had worn a plaster cast for tuberculous
disease of the spine for eighteen months, followed by a steel brace
for two years. Married, November, 1911, while still wearing the
brace. She had had a psoas abscess before marriage, which has now
healed. Dr. Whitbeck had advised her against marrying, on account
of the dangers of possible pregnancy, but in spite of this advice she
married after making an agreement wdth her husband to forego all
sexual intercourse. Tliis strange agreement was lived up to, but
with some difficulty, and with an immoderate expenditure of will
power. Coitus was never attempted until she was declared entirely
cured and child-bearing was considered safe.

Typical symptoms of vaginismus appeared at the first attempt,
and have persisted to date.

Examination. — General physical examination, negative. Vag-
inal examination unsatisfactory at first, on account of mild reflex
reaction.

July 21. Examination (preceded by bromide gr. xx, and codeine
gr. 3'2. taken half an hour before), very satisfactory; genitals
normal; no tender spots; uterus normal. I spent about an hour
trying to convince the patient that her trouble was entirely imagi-
nary and caused by a fear which had now been removed.

March 6, 1915. Patient visited my office and was found to be
five months pregnant.

July 4, 1915. Delivered normally of a female child by Dr. E. J.
Davin.

Now the inferences which may be drawn from these two cases
are:

I . That there are cases of true vaginismus whose causative factors
are not local but mental. In Case I, the inhibiting impulse was
conscious rather than subconscious at first, and had been imparted
by suggestion from a second person. In Case II, the inhibiting

WILLIAMS: PSYCHIC VAGINISMUS 231

influence was caused by a long-continued suppression of a natural
impulse by the exercise of will power, and after the cause for the
voluntary conscious suppression was removed the performance of
the act was inhibited subconsciously.

Both cases resembled hysteria and may be considered true phobias
(as Audrey considers them) ; at any rate, their psychic origin cannot
be doubted. The followers of the Freudian school would undoubt-
edly have traced the neurosis to some suppressed desire of a sexual
character in early youth, but fortunately in these cases the causes
were evident.

2. As to diagnosis: Many writers advise immediate examination
under an anesthetic to ascertain, among other things, if there are
any tender spots, etc., in the genital tract — but how one can ehcit
tenderness in a completely anesthetized patient passes my under-
standing. Examination should be tried gently without any anes-
thetic at first, and anesthesia should be resorted to only after
patient efforts have failed. A point that I failed to mention is
that if tenderness is present it may be elicited by the patient her-
self, for in this form, as a rule, there is no reaction when the patient
uses a douche or other form of vaginal medication. I had patient
No. I apply the anesthesin and albolene herself.

If tenderness or local lesion exists, then examination under ether,
immediately followed by such operative procedures as are indicated,
is advisable. The case would then fall under the class of organic
vaginismus.

In all cases, the diagnosis should be made only after an exhaustive
psychic examination, as the treatment depends upon the mental
condition of the patient.

3. As to treatment: Case I had ample and varied surgical
treatment. It would seem as if in many of these cases the sugges-
tive effect of a surgical operation might itself work a cure, and I
have no doubt that many cases of cure have been attributed to an
operation when the psychic effect was the main factor. Case II
had no surgical treatment. Case I was cured, I have no
doubt, by h>-pnotic suggestion, in spite of her belief to the contrary.
Case II was cured by the removal of her inhibition, by auto-sugges-
tion if you please, but at any rate by suggestion of some kind. The
cure was the more easily accomplished because the original condition
was due to a logical self-inhibition.

Whether the cases are to be classed with the phobias as is done by
Audry; with the hysterias, as Dercum of Philadelphia does; or as
subconscious inhibitions, due to suppression of conscious desires
and impulses, as taught by Freud, I leave to the psychiatrists to
decide. At any rate, for our purposes, they can be considered
neuroses; and I feel sure that, being psychic in origin with no or-
ganic basis, they should be considered neurological rather than
surgical cases.

REFERENCES.

Audry. La Pro\ince Medicale, vol. xxiv, p. 191.
Pozzi. Treatise on Gynecology, Chap, xxxviii.
Hirst. Diseases of Women, p. 194.

232 foskett: a study of ectopic gestation

Dudley. Diseases of Women, p. i86.

Cornell. Montreal Medical Journal, vol. .xxii, p. 915.

Godfrey. Quarterly Medical Journal, vol. cxl.

Kelly. Amer. Jour, of Obst., vol. x.\xviii, p. 829.

Herman. Lancet, 1895, vol. ii, p. 1436.

Kohnke. Orleans Parish Medical Society, 1894, p. 55.

Dercum. Hysteria. Sajous' Encyclopedia, vol. v.

249 West Seventy-second Street.

A STUDY OF 117 CASES OF ECTOPIC GESTATION.*

(From the Service of Dr. Henry C. Coe, Bellevue Hospital.)

BY
EBEN FOSKETT, M. D., F. A. C. S.,

New York City.

This paper is a study of the cases of ectopic gestation in the
service of Dr. Henry C. Coe, 3d Gynecological Division of Belle-
vue Hospital, and covers the period from July, 1897, to January
I, 1 916, thus overlapping into the present service of Dr. W. E.
Studdiford.

One hundred and seventeen patients have been operated on as
follows:

Dr. Coe, 24; Dr. Austin Flint, Jr., 7; Dr. VV. E. Studdiford, 53;
Dr. Eben Foskett, 33.

The subject of ectopic gestation has been quite thoroughly
studied and discussed, yet it holds its interest for the gynecologist.
Many cases are easy of diagnosis. Other cases call for the most
careful study and days of observation, and a few are found only at
the time of operation.

In making a diagnosis in a suspected ectopic, too much value
must not be placed on any one symptom. The case as a whole must
be studied and the history, symptoms, blood count, and physical
examination all receive due consideration, and then in case of doubt
a vaginal section will definitely settle the question.

In this paper we have made a study of the various symptoms and
facts to see if they coincide with the established views in cases of
ectopic gestation, and our results follow:

Among these patients 104 were married, 8 were widows and 5 were
single. Six were under 20 years of age, 39 were 20 to 25; 37 were
25 to 30; 23 were 30 to 35; 10 were 35 to 40; and 2 were over 40.

Previous Venereal History. — Seventeen of the 117 patients gave a
distinct history of gonorrheal infection, 7 of them having it at the
time of operation, the other 10 having had it some years before.

Four had syphilis and one of them had it in secondary stage at

* Read before the Society of the .Mumni of Bellevue Hospital, December, 1915.

foskett: a study of ectopic gestation 233

the time of operation, combined with gonorrhea. Only in sixteen
cases did the patients complain of leucorrhea.

While this seems a small proportion of venereal cases we must
bear in mind that many women have gonorrhea without being aware
of the nature of their trouble, so it is probable that the above number
is only a part of the specific cases.

Previous Pregnancies. — Of 117 patients, 90 had been pregnant
before. Of the' 90 patients, 52 had had children at term only, 34
had a history of abortions and children at term, and 4 had had
abortions only.

Of the abortion cases, 5 admitted they were induced; and i patient
had a history of 8 induced abortions; 5 were curetted following the
abortion.

Of the deliveries at term, 3 were instrumental, and i a version;
2 were curetted after delivery, and 3 were septic after.

It is noted that about one third of the patients had previous
abortions. To the writer it would appear that these abortions and
their sequelae would be a more common cause for the development
of ectopic than venereal disease.

Date of Last Pregnancy. — Of the 90 pregnancies antedating the
ectopic 5 were more than 10 years before; 26 were 5 to 10 years
before; 24 were from i to 5 years before; 26 were i year or less. In
10 date not recorded. It is also noted that many women who had
not been pregnant were married for many years at the time of ectopic.

Regular Menstrual Periods before Ectopic. — One hundred and five
patients called their menses regular, 9 were irregular, some having
2, and some 6 and 8 weeks between their menstrual periods, 3
were not recorded, 21 only complained of pain during previous
menstrual periods, 7 called the flow profuse and 3 scanty.

Missed Menstrual Period at Tinu of Ectopic. — Seventy-seven of the
117 had a definite history of missing one or more menstrual periods,
31 did not give history of missing a menstrual period, i had a contin-
uous flow for 4J4 months, and in 8 the date of menses was not
recorded. Five patients were nursing babies at time of onset and
of these, 3 had had regular menses preceding ectopic, and 2 had
not menstruated.

Attempted Abortion in Ectopic Patients. — Twelve of the patients
thought themselves pregnant. Seven of these attempted to induce
abortions, one by injecting glycerine into the uterus, 3 by medicines
given by doctors, one went to a doctor who dilated the cervix, and
2 inserted foreign bodies into the uterus.

Symptoms. — The classical symptoms of ectopic gestation are pain,
hemorrhage, faintness, vomiting and collapse.

234 foskett: a study of ectopic gestation

In this group of cases, pain was present in all and usually was
described as colicky or cramp-like in character. In most patients
there were periods of freedom from pain in which some of them could
go about their household duties.

In i8 patients the pain began during a regular menstrual period.
In 7 pain began a few daj's after cessation of a regular menstrual
period, and in 77 after missing a regular period.

Uterine bleeding was present in all of the cases and in many was
intermittent in character. Four of the patients were curetted for this
symptom before coming under our care, and 2 had had a second
curettage before being sent to the hospital.

Vomiting and fainting were present in 62 patients. Collapse
was noted in 40 patients. Eight of the patients fell in the street in
collapse, and several were picked up by ambulances under such
conditions and usually brought to Bellevue with some other diag-
nosis. One patient was in 2 hospitals before coming to BeUevue,
and I was refused by 2 ambulance surgeons.

ChLUs were present in 12 patients. Sixteen complained of
bladder symptoms and 14 of rectal symptoms due to pressure.

The Urine in Ectopic Cases. — One patient had sugar in urine
and made a good recovery. One had i per cent, of albumen in
the urine, and 23 had a trace of albumen.

Leukocytosis in Ruptured Tube Cases. — Ten showed over 20,000
leukocytes, the highest being 32,000, 6 showed 15 to 20,000 leukocytes,
II showed 10 to i5,oooleukocytes, loshowed under 10,000 leukocytes,
in 12 count was not made, total 49 cases.

Leukocytosis in Tubal Abortion and Tubal Pregnancies. — Seven
showed over 20,000 leukocytes, 4 showed 15 to 20,000 leukocytes, 20
showed 10 to 15,000 leukocytes, 28 showed under 10,000, in 9 count
was not made, total 68 cases.

We have found the blood count to be of value. If we are making a
differential diagnosis between a pelvic abscess, a pyosalpinx or acute
appendicitis, a low leukocyte and polynuclear count points to an
ectopic, rather than to an infection.

The leukocytosis is high in those cases having a severe hemorrhage
into the peritoneal cavity.

In 17 cases with severe hemorrhage, including both tubal abor-
tions and ruptured tubes, a leukocytosis above 20,000 was present.
These patients were all operated on soon after admission or soon after
the rupture when it occurred in the ward.

Tills leukocytosis comes on early and disappears in 24 to 48 hours.
In this it differs from the secondary anemias where the leukocytosis
comes on late and persists.

foskett: a study of ectopic gestation 235

The polynuclear count in these patients ranged from 8i to 92 per
cent, and averaged 86 per cent. This point is well illustrated in
case No. 115, who had a rupture of the tube and hemorrhage into
the peritoneal cavity while in the ward, and a hurried operation.
She had a leukocyte count of 10,000 and a polynuclear count of
75 per cent, on admission. One hour after the onset of the rupture
with hemorrhage the leukocyte count was 20,000 and the polynuc-
lear count 86 per cent.

In looking up the literature on this point, we find that Dr. Carl
Levinson in the Journal American Medical Association (April, 1915),
called attention to this and he quotes Dr. Quevain, who reports one
such case, and Dr. Hoesle who reports 3. .

The hemoglobin is often from 35 to 40 per cent, in the hemorrhage
cases, and in the case of an interstitial ectopic in our service, was
but 10 per cent, the day after operation.

1^ umber of Palieiits with Rupture of the Tube. — Forty-nine of the 117
patients had an actual rupture of the tube. Eight of these ruptured
between the folds of the broad ligament ; 2 of these had secondary rup-
ture carrying the fetus and blood into the peritoneal cavity. Sixty-
four of the 117 were tubal abortion cases, either blood or all the con-
tents of the tube being expelled from the fimbriated end of tube. Four
were unruptured tubal pregnancies with no bleeding from the tube.

Location of gestation sac in tube was interstitial in i ; isthmian in
64; ampullar in 52.

Tube Involved. — The gestation was in left tube in 74 of the patients.
Right tube in 43.

Time in Hospital before Operation. — Of the 64 tubal abortions and
4 tubal pregnancies, 5 were operated on as soon as possible after
admission to the hospital . Fifty-nine others were in an average of 5 )^
days before operation. The average time in hospital after operation
was 21 days. In the ruptured tube cases 13 were operated on as soon
as possible on admission. Thirty-four were in an average of ^14. days
before operation and the average time in hospital after operation
was 24 days.

Currettage in Ectopic Patients. — Curettage of the uterus was done
in 37 of the 117 patients. Six cases showed a large uterine cavity,
seven showed hypertrophied mucous membrane. Four showed shreds
of decidual tissue. The only patient throwing off a decidual cast
from the uterus was not curetted but expelled it spontaneously
after the operation.

We now regard curettage as of little help in the diagnosis and
seldom curet the patients.

Posterior Colpolomy. — In cases of doubtful diagnosis a posterior

236 foskett: a study of ectopic gestation

vaginal section is made. This was done in 47 of tlie 117 cases.
Forty-six showed free blood, usually with clots, in the peritoneal
cavity. In only i case was the diagnosis not verified by this means and
when laparotomy was done this was found to be an intraligamentous
rupture.

Dr. Coe has made it a practice to close this incision with a suture
before opening the abdomen, thus eliminating the possibility of
later infections by this route. We believe vaginal section to be a
valuable means of deciding if the case is ectopic.

When to Operate. — -The question of when to operate is an important
one. Most of the cases of tubal abortion are not urgent, although a
few are because of hemorrhage.

The patients with rupture of the tube are of a more serious type
due to the great loss of blood and consequent shock to the system.

The writer is of the opinion that the safest procedure is to operate
promptly when the diagnosis is made whether it is a tubal abortion
or a rupture of the tube with severe hemorrhage. In this way we
will avoid an occasional rupture in the ward with its severe symp-
toms, and the best interests of the patient will be served.

Previous Operations. — Three patients had salpingo-oophorectomy
for diseased tube several years before. One patient had one tube and
ovary removed at another hospital 3 months before and was not
relieved of her symptoms tiU operated on here for ectopic. Two
patients had previous ventral suspensions.

Operations for Ectopic Gestations. — Three patients had vaginal sec-
tion only with gauze drainage, 8 patients had hysterectomy, 3 being
supravaginal and 5 complete; 88 had ovary and tube removed for the
ectopic, 13 had salpingectomy only, 5 had resection of tube only,
a total of 117.

While resection of the tube has been done in this service 5 times,
it is our belief that it is wiser to remove all of the tube, for several
cases have been reported of ectopic occurring in the remaining por-
tion of the same tube afterward.

Operations for Complications of Ectopic. — Thirty-two patients had
disease of uterus and adne.xa of opposite side, requiring operation, 2
fibroids in uterus, 4 had hematosalpinx in other tube, i being so large
it was the cause of the hysterectomy, 11 had pyosalpinx or salpingitis,
2 had adhesions about tubes, i had an intraligamentous cyst, 6
had cystic ovary, and 7 had both ovaritis and salpingitis. These
were operated on according to indications, some afi'ording cause for
hysterectomy, others for conservative or radical operations on
tubes and ovaries. Four were operated on for backward displacement
of uterus.

foskett: a study of ectopic gestation 237

Thirty-four of the above patients had appendectomy, 5 because
appendix was adherent to the gestation sac, 3 because of chronic
inflammation, and 27 as a routine measure.

Recovery without Operation. — The question may be asked, "Do
patients with ectopic recover without operation?" Undoubtedly
some do recover, but many of them are not relieved of pain. This
is shown by the history of case No. no. This patient had severe
pain at home for one month, the pain coming on during a menstrual
period, and was then removed to a hospital with diagnosis of fluid in
the abdomen. For this she was treated without operation for two
months and improved. She went home. After some months she
came to Bellevue out-patient department and a mass was felt in
the tube. For this she was operated on. It proved to be an old
blood clot, distending the fimbriated end of the tube, yellow in color,
which the pathologist proved to be ectopic.

The second case No. 113 had a hard clot in the tube and the fim-
briated end of tube was adherent to the ovary. Patient was under
our care 3 weeks before operation and the tube was decreasing in
size. This undoubtedly would not have progressed if she had not
been operated on.

Complications after Operation. — Two cases of ruptured tube had
pneumonia, one being followed by pleurisy with efi'usion, and re-
covered. Phlebitis occurred in 4 cases, one having it in both legs.
Four patients developed pelvic abscess following operation and all
were relieved by vaginal section and drainage.

Mortality. — Two patients died following operation; the first in
1900 and the second in 1908. The first patient was in an apparently
septic condition when admitted, with high fever; a vaginal section
only was done because of her condition. Autopsy showed she
originally had a rupture of tube into broad ligament followed by a
secondary rupture of a macerated and infected fetus into the
abdominal cavity.

The second case was a private patient of the writer and was
operated on 2 hours after first seen and 7 hours after the onset
of first symptom. She had a very small opening in the tube where
rupture took place and yet had the abdomen full of fluid blood, none
of it being clotted. While the usual methods of transfusion and
infusion were done the patient did not react and passed away next
day. It is beheved that the lack of clotting power in the blood had
something to do with the result in this case.

After History of Patients. — Five patients are known to have been
pregnant after the ectopic, one of whom miscarried at five months.

One was operated on for ventral hernia following the ectopic.

238 DANIELS: LATERAL CONTRACTION OF THE PELVIS

So far as we have known none of these patients have had any
serious trouble in the peKds after.

Two have been under our care for syphilis contracted after Iea^^ng
the hospital.

This series of cases dates back seventeen years. The experience
of those years has been of value to the visiting staff.

Patients to-day are not treated just as they were seventeen years
ago.

In this study of our operative procedure we note that there is
greater conservatism now about removal of uterus and adnexa.

Hysterectomy was done in 6 of the first 22 cases and in only 2 of
the last 94 cases.

Vaginal drainage was done in 14 of the first 45 cases, and it was
used in only 4 of the last 72 cases.

121 West Seventy-third Street.

A NEW AND ORIGIN.'VL METHOD OF CALCULATING THE

REQUIRED POSTERIOR SAGITT.AL DIAMETER OF

THE OUTLET IN A LATERAL CONTRACTION OF

THE PELVIS.

C. D. DANIELS, M. D.,

Philadelphia, Pa.
Instructor in Obstetrics, University of Pennsylvania.

Statistics have been published in this country by J. W. Williams
and H. K. Thoms, which show the frequency of contractions of the
transverse diameter of the pelvic outlet. They state this to be the
most frequent contraction met with in white women. Williams
also states that "the prognosis depends not so much upon the actual
narrowing of the pubic arch or upon the distance between the tuber
ischii as upon the relation between the latter and the posterior
sagittal diameter."

He gives the following table and states that spontaneous labor
would be exceptional with the following measurements (head aver-
age size).

Transverse of outlet Posterior sagittal

8.0 75

7.0 8.0

6.S 8.S

6.0 9.0

5-S 100

It is known that as the transverse of the outlet is decreased the
posterior sagittal diameter must increase in order to insure delivery

DANIELS: LATERAL CONTRACTION OF TEE PELVIS 239

by the natural passages. There has been given no method of cal-
culating just how much increase there must be.

I would like to suggest a method by which this may be readily
calculated.

There is a triangular area of which the transverse of the outlet is
the base, posterior sagittal the altitude, tip of sacrum the apex.
The area of this I would call the index of the posterior plane of the
outlet.

If we take Klien's measurements' as a working basis for practical
purposes, using lo in place of 9.95 cm., we find that the index
equals 55 (normal). It is possible to have an average size child
born with no more serious operation than forceps if this is contracted
down to 33.3.

The case having the smallest contraction of which I know is that
reported by Siemens, transverse of outlet 6.5, posterior sagittal
10.25; which gives the above index, 33.3 (forceps).

After measuring the transverse of outlet, the posterior sagittal
required may be calculated by this formula:

X equals increase in posterior sagittal.

(10 + x) transverse of outlet . , , . ,
= 55 for normal relation between

the two measurements.

(10 + x) transverse of outlet . ... ,
= 33.3 for a relation between the

two, down to which a normal birth may be expected.

Simplified the transverse of the outlet times the posterior sagittal
divided by 2 should equal 33.3 or more, in order to expect natural
birth (including forceps).

Transverse
outlet

Post, sagittal

Index of post, plane of outlet

Calculated post.

sag. Lowest

limit

8.0

1
! 7-3

300

33-3

8.33

7-0

8.0

28.0

33-3

9-5

8.5

27.6

33-3

10. 25

6.0

9.0

27.0

33-3

II . I

10. 0

27-5

33-3

12.12

With these figures (given by J. W. Williams) With these figures calculated
spontaneous labor is exceptional. ; bj' above method spontane-

ous labor should be expected.

'Transverse of outlet 11. o

Posterior sagittal 9 . 95

Anterior sagittal 6.0

Anteroposterior n-S

240 hussey: management of pregnancy and l.4bor

As observations are further carried out, I would not be surprised
if these measurements become altered, but the method of calculating
I believe to be correct.

Above is a table by this method of calculation, giving the lowest
limit of the posterior sagittal in which normal birth may be expected
in pelves of the same transverse of outlet as given in Williams' table.

247 South Thirteenth Street.

MANAGEMENT OF PREGNANCY AND LABOR
COMPLICATED BY HEART DISEASE.*

AUGUSTUS A. HUSSEY, M. D., F. A. C. S.,

Brooklyn. N. Y.

The woman with an organic heart lesion differs from the normal
woman in her relation to child-bearing in that the balance of her
circulation is insured by a limited amount of reserve force. This
latent power of the heart muscle which determines the circulatory
capacity of the individual may be compared to a bank deposit, and
it may be said that cardiac solvency depends upon the preservation
of the integrity of this reserve. If the original deposit is large and
the drafts upon it are small and infrequent, solvency is main-
tained. If the reserve is small and the drafts are large or frequently
repeated, the account is quickly depleted and the patient becomes a
cardiac bankrupt. Pregnancy and labor make drafts upon this
reserve fund; but the size of the drafts depends upon the character
of the pregnancy and labor, and upon the way in which they are
managed. The physician becomes the trustee of his patient's
cardiac reserve, and it is his duty to keep drafts upon it within limit
that will insure its integrity. In order to do this he must estimate
for every patient, first, the amount of reserve force which her heart
possesses; and second, the probable size of the draft which pregnancy
and labor will make upon it. As the reserve force of every heart is
different and changes during the life of the individual, and as the
character of every pregnancy differs in the demands which it makes
upon the circulation, it is apparent that every case presents a problem
which must be solved independently.

The estimation of the reserve force of the heart is a technical
procedure. It is based upon the character of the lesion, the presence
or absence of degenerative changes in the heart muscle and blood-
vessels, the functional capacity of the kidneys, lungs, and digestive
organs, and upon the past history and present condition of the
circulation. Its value depends upon the accuracy with which it

•Read betore a meeting of the Brooklyn Gynecological Society, April 7, 1916.

HUSSEY: M.A.NAGEMENT OF PREGNANCY AND LABOR 241

is made. Our first duty then in the care of a pregnant woman with
organic heart disease is to enlist the services of an experienced
internist.

The estimation of the size of the draft which pregnancy and labor
will make upon the patient's heart is based upon the following data;
her age and general condition, the functional capacity of her kidneys,
digestive organs and lungs, the character and condition of her
parturient canal, is she a primipara? if a multipara, have her past
labors been easy? and finally her social and financial condition must
be considered. If she be poor and forced to do her own housework
and perhaps care for her children, the strain will be materially
greater than if she be rich and have unlimited service at her command.

Having determined with as much accuracy as possible the fore-
going factors, the obstetrician's problem is how to keep the size of
the drafts within the Hmits of his patient's circulatory solvency.
The standard practice which governs the treatment of pregnancy
comphcated by organic heart disease is summarized by Blacker in
the advice to treat the heart disease without regard to the pregnancy
until the break in compensation is seen to persist and then to termi-
nate the pregnancy. The standard practice which governs the
treatment of labor comphcated by heart disease is to refrain from
interference until signs of distress appear and then to end labor by
operative means.

This plan would seem to work well from the obstetrician's point
of view. The statistics of Blacker, French and Hicks, Fellner
and others, show that the majority of women with compensated
heart disease, go through pregnancy and labor without signs of
decompensation.

But is it equally satisfactory from the patient's standpoint? It
is a significant fact that the majority of fatahties occur not during
pregnancy or labor but days, weeks, or months later. The obstet-
rician has not correctly gauged the size of the draft which he has
permitted his patient to draw against her cardiac reserve, and she
has been left a bankrupt. The statistics do not show this fact for
they are based on hospital records, and corrected only to the end
of two or three weeks postpartum. Is the obstetrician justified in
concluding that his management of his case has been satisfactory
when he dehvers a viable baby from a li^dng mother and dismisses
both from his hospital service and from his thoughts at the end of
two or three weeks? Has he not a further duty to perform, namely,
to attempt to extricate his patient from her perilous position with
the least possible diminution of her life expectancy? To accomphsh

242 hussey: management of pregnancy and l.'^bor

this result he must overlook no means at his disposal of reducing the
strain of pregnancy and labor.

The means at the obstetrician's disposal for safeguarding the
cardiac reserve of the patient may be discussed under the following
headings:

1. Care during pregnancy.

2. Termination of pregnancy.

3. Prevention of future pregnancy by steriUzation.

4. Protection of the heart from strain during labor.

5. Supervision and direction of the patient's muscular activity
after labor.

1. Care during Pregnancy. — The cardiopath must be regarded as
obstetrical cripple and watched with unceasing vigilance. She is
more prone to toxemia than the woman with a normal heart and the
functions of her digestive organs, skin and kidneys must be
carefully looked after. Fresh air is of prime importance, for the
oxygenation of her blood is below the normal. Her exercise should
be carefully regulated to the capacity of her circulation. Her diet
should be strictly supervised. Her lungs should be examined at
frequent intervals. MacKenzie's sign of failing circulation, the
presence of rales over the base of the lung of the side upon which the
patient sleeps, should be recognized and its significance heeded.

2. Interruption of Pregnancy. — Throughout the course of every
pregnancy compUcated by heart disease, the necessity for the prema-
ture termination of the pregnancy must be borne in mind and its
indications watched for. Blacker states: "I am of the opinion
that there are more cases in which the induction of abortion or
premature labor is good treatment than is generally supposed."
The accepted ruUng is that, when the signs of broken compensation
persist in spite of appropriate treatment, the uterus should be
emptied. At the first sign of failing circulation, the patient should
be placed at rest and given appropriate treatment for the strengthen-
ing of her circulation. Here the aid of the internist is of the utmost
importance. Should circulatory failure occur early in pregnancy,
should it occur in a patient who has previously sufifered from symp-
toms of broken compensation, or in a patient with mitral stenosis
or with myocarditis, interruption of pregnane}' is imperative; for
under these conditions the cardiac reserve is so slight that one can
be reasonably sure that it will not bear the strain of pregnancy and
labor. If the signs of broken compensation appear later, and if the
patient is young, if the heart muscle is healthy, if broken compensa-
tion has not previously existed, if the patient can be placed at rest

hussey: management of pregnancy and labor 243

in a hospital, pregnancy may be allowed to continue with the hope
of getting a viable baby, unless the symptoms persist or get worse.
But, under these conditions, it should always be understood that
the delivery must be operative and unaccompanied by muscular
strain.

Before discussing the method of terminating pregnancy, I will
consider the question of steriUzation for the protection of the
patient against the dangers of future pregnancies. The recupera-
tive power of a heart that has suffered from broken compensation
is always diminished. Especially is this true of mitral stenosis.
It is diminished by age; by the presence of degenerative changes in
the heart muscles, blood-vessels and kidneys. When it has-once
occurred, its recurrence is to be anticipated. The indication for
interruption of pregnancy may therefore be taken as the indication
for the prevention of future pregnancies. To extricate a woman
from the present peril, but to make no provision for protecting her
from its return, is not good therapeutics. Neither is it wise to throw
the burden of prevention of pregnancy upon the patient. The fear
and anxiety which this entails cannot fail to have a most unfortunate
effect upon her health. Most authorities recommend steriUzation
when the uterus is emptied by abdominal section.

If we accept the dictum that when interruption of pregnancy is
indicated, steriUzation is imperative, it becomes necessary either to
modify the operative procedure by which we are accustomed to
terminate pregnancy or to subject the patient to two operations.

Fellner and HeUendal recommend excision of a portion of the
FaOopian tubes at a subsequent operation when the uterus is emptied
by the vaginal route.

Anders recommends emptying the uterus by abdominal hyster-
otomy even in the early months of pregnancy; and resection of the
tubes at the same time. He reports fifteen successful operations
in advanced heart, kidney and lung disease.

The surgical procedures at our disposal for the termination of
pregnancy are, induction of abortion or premature labor; dilatation
and curetment, operative removal of the ovum by vaginal or
abdominal hysterotomy, and Cesarean section. Induction of
abortion is open to the objection that it is uncertain, slow and pain-
ful and, while it seems conservative, it is really not so, for it uses up
more cardiac energy than the other methods that seem at first
thought more dangerous.

Induction of labor may be indicated in certain multiparae with
relaxed and roomy vaginas where short and easy labor is to be

244 hussey: management of pregnancy and l.\bor

expected, and where delivery can be quickly terminated if necessary.
Dilatation and curetment is limited in its application to the first
two months of gestation. It is preferable to induction of abortion.
Emptying the uterus by vaginal hysterotomy is the method pre-
ferred by many between the second and sixth months of gestation.
It is better adapted to the conditions met with in multiparae than in
primiparae. Emptying the uterus by abdominal hysterotomy has
the advantages that it can be employed at any period of utero-
gestation, in multiparje and primiparae with equal ease and offers the
opportunity of simultaneous sterilization. It is preferred to vaginal
hysterotomy by Kriess, and by Anders who reports fifteen cases in
which he has used it with success. Cesarean section is the operation
of choice at or near term where the conditions are not favorable for
an easy vaginal delivery, where the cardiac reserve force is slight,
and where simultaneous sterilization is desirable. In our choice of
a method we must be guided in every case by the conditions that are
present. The period of uterogestation, the condition of the patient's
circulation, and the relative advantages of the vaginal or abdominal
route should be considered.

3. Sterilization. — When possible it is desirable to choose a method
by which the uterus can be emptied and sterilization performed at
one sitting. The abdominal operations have the advantage of per-
mitting simultaneous sterilization. They suffer from the disad-
vantage of slightly added shock and increased risk of postoperative
complications. The vaginal operations have the disadvantage that
they are Hmited to the early months of pregnancy, are difficult in
primipara, and necessitate a second operation for sterilization, unless
local conditions are such that a simultaneous sterihzation can be
done by resection of the tubes through an incision in the anterior
fornix.

4. Protection of the Heart from Strain during Labor. — No matter
how slight the lesion from which the patient suffers, no matter how
well she has passed through her pregnancy, no matter how much
reserve force her heart muscle possesses, it is the duty of her attend-
ants to reduce by every means available the strain of labor upon her
circulation. For though she may possess sufficient reserve force in
her heart muscle to carry her through a long and difficult labor,
it would be criminally negligent to allow her to waste it unneces-
sarily, for upon its conservation depends the length of her life. The
duration of labor must be short. Pain, anxiety, and muscular effort
are exhausting, and must be reduced to the lowest limits. Expulsive
efforts in the second stage must never be allowed. How then shall

hussey: management of pregnancy and labor 245

labor be managed? When compensation has suffered but slightly
or not at all during pregnancy, and when an easy delivery may be
predicted, it will be safe to allow the patient to go into labor. The
first stage should be conducted as painlessly as possible with the aid
of morphine and scopolamine and with the patient in bed.

The second stage should be replaced by operative extraction under
anesthesia. The third stage should not be hastened. After the
third stage is terminated, a compress and tight abdominal binder
should be apphed. If in the first stage of labor, the heart action is
embarrassed by pressure of the abdominal tumor as sometimes
occurs in hydramios or multiple pregnancies, immediate relief may
be obtained by rupturing the membranes and draining off the water.
If the first stage does not progress as rapidly as seems desirable, it
may be hastened by the use of dilating bags. It at any time during
labor the circulation of the patient becomes embarrassed, rapid
operative deliver}^ under anesthesia is indicated. If compensation
has suffered during pregnancy or a previous labor, if a prolonged or
difiicult labor is expected and the reserve force of the heart is slight,
as in mitral stenosis or myocarditis, operative delivery should replace
labor. Cesarean section should be the method of choice and
sterilization should be performed at the same time.

Anesthesia and Analgesia. — Heart cases bear anesthesia better
than pain and muscular effort. Hence some form of analgesia or
anesthesia is indicated in every case. Morphine and scopolamine
are ideal in many cases. By the progress of nerve blocking, they
protect the heart from shock. They should always be used in
some degree. Supplemented by local anesthesia when needed this
method will adapt itself to the indications of many cases. Ether
is well born unless there is a tendency to bronchitis or pulmonary
edema. It has the disadvantage that it may cause vomiting or
struggling. It should always be preceded by morphine. Local anes-
thesia is recommended by Webster, preceded by morphine, and sup-
plemented by ether or gas-oxygen when necessary.

Medication. — The internist should determine the indications for
medication before and during and after labor. His estimate of the
condition of the circulation and the reserve force of the heart should
be given due consideration when deciding upon the time and method
of interference.

5. After-care of the Patient. — -The need of appropriate medication,
prolonged rest, and carefully graduated exercise, must not be over-
looked. The patient should not be dismissed from observation

246 htssey: management of pregnancy and labor

when her hospital convalescence is ended. She should be transferred
to the care of her medical advisor.

The following cases have been selected as illustrative of some of
the points which have been emphasized in the paper.

Pregnancy complicated by mitral stenosis allowed to continue.
C. W., aet. twenty-four, in the third month of her first pregnancy,
was referred to my service at the Brooklyn Hospital for considera-
tion of termination of pregnancy. Her chief complaint was rapid
heart action and nervousness. She had suffered from chorea
when a child. She has had symptoms for one year. They have not
become worse during the past three months. Examination by the
internist showed a well-nourished woman, weight 103 pounds. Her
lungs are sound. The functions of her kidneys and digestive organs
are normal. She has no sign of circulatory derangement. Her
thyroid gland is somewhat enlarged. Her heart is normal in size;
left border 10 cm. from midsternal line. Right border at right
sternal margin. There is a presystolic thrill at apex. Diastolic
shock is felt over base. Her pulse is 100 to 120. Her blood pres-
sure is 145 systolic 90 diastolic. Diagnosis, mitral stenosis with
regurgitation.

In deciding upon a plan of treatment for this patient the follow-
ing points were given consideration. Her heart lesion, mitral steno-
sis, is an unfavorable one. A blood pressure already above the
normal and a trace of albumin in the urine still further complicate
the situation. On the other hand, she is young. Her heart muscle
is sound. Compensation is perfect. She is not any worse now than
she was before pregnancy began. She will never be in a more favor-
able condition to carry a pregnancy to term. It is estimated
that her cardiac reserve is sufficient for the strain of this pregnancy,
provided toxemia of pregnancy can be avoided. If she goes through
to term, it is planned to deliver her by Cesarean section and sterilize
her at the same time, because she is a primipara and her heart re-
serve force is not estimated to be sufficient for a long labor, and
because it is desirable to sterilize her, as the care of more than one
child would be a greater burden than her heart could bear.

2. The following case shows how the reserve force diminishes with
age and frequent pregnancies, and how the burden of an abnormal
pregnancy or difficult labor will break the compensation which
has been sufficient for a normal pregnancy and an easy labor.

Mrs. A. M., admitted to the Bushwick Hospital on Jan. 24, 1916,
in labor at the end of the eighth month of her thirteenth pregnancy.
She has pains every five minutes. She suffers with dyspnea, ortho-
pnea, dizziness, and spots before her eyes. Her respiration is rapid
and labored, her color is dark, her lips and nails blue, her limbs and
face swollen, her abdomen enormously distended. Her heart is
enlarged to right and left. The apex beat is diffused. There is a
loud blowing, systolic thrill at the apex transmitted to tlic axilla.
There are sibilant sonorous rales over the chest, and many moist

hussey: management of pregnancy and labor 247

riles over the bases of the lungs. The uterus is large, tense, and
greatly distended. The perineum is relaxed, vagina roomy, cervix
soft, thin, and dilated three fingers. Membranes tense and bulging.
She had rheumatism when young. Otherwise good health. Has
had no heart symptoms until the present pregnancy. Has had
twelve easy labors without cardiac distress. At the sixth month of
the present pregnancy she suffered with dyspnea, edema of Hmbs, and
precordial pain. She recovered after three weeks in bed.

Diagnosis. — ^Labor comphcated by mitral incompetency with
broken compensation.

Treatment. — She was given morphine and scopolamine and
digalin by hypo, and the membranes ruptured. A certain amount
of relief was obtained in this way. She was kept under the influence
of morphine and scopolamine, the heart supported by large doses
of digalin and she was allowed to proceed. After four hours she was
delivered of triplets. She made a normal convalescence. Her heart
rapidly regained tone. She left the hospital in good condition. She
now does her own housework without dyspnea.

3. Operative delivery and sterilization are indicated where
decompensation has occurred in previous labors.

R. S.,aet. twenty-four, was referred to my service at the Brooklyn
Hospital in the ninth month of her second pregnancy, on AprU 13,
1914. She suffered from dyspnea, headache, sleeplessness, and
spots before the eyes. She had had rheumatism when sixteen years
of age. She was sick for six months at that time. She has had
dyspnea ever since. When her first baby was born, interference
was needed on account of weak heart action. Since the beginning
of this pregnancy, the dyspnea has been worse. She has been in bed
for several weeks under treatment. Physical examination by an
internist showed her heart enlarged to the right border of the sternum.
The left border was 4 inches from the midsternum. There were
no murmurs; the second pulmonic was accentuated. The rate was
130. The blood pressure was 95 systolic and 76 diastolic. The
pulse was regular.

Diagnosis. — Pregnancy ninth month complicated by rheumatic
myocarditis.

In view of the fact that she had had trouble with her heart during
her first confinement, and that she is now in a much worse condition
than she was then, it was thought that she would not go through a
second labor without considerable risk of life and almost a certainty
of doing irreparable damage to her heart muscle. Therefore on the
nineteenth day of May she was put to sleep with morphine and hyos-
cine, taken to the operating room, and under light ether anesthesia,
deUvered by Cesarean section. Her tubes were excised at the same
time to prevent future pregnancy. She stood the operation well.
She made a normal convalescence. Her heart improved rapidl}^
She was discharged on the sixteenth day postpartum, improved. Her
baby lived. Her doctor reports that she is in good condition now.
She does her own housework. She has no dyspnea and sleeps well.

248 hussey: management of pregnancy and labor

4. Early termination of the pregnane}^ is often necessary to save
life. The following report illustrates the course of such a case.

R. C, aet. thirty-one, was referred to my service at the Brooklyn
Hospital, Jan. 28, 1911. She complained of dyspnea, orthopnea,
marked sweOing of extremities. She was in the seventh month of
her third pregnancy. Seven years ago, shortly after her second
child was born, she contracted acute articular rheumatism with
endocarditis. Nine months ago she had a recurrence. Since that
time she has had dyspnea on e.xertion. Since the pregnane}- began,
the dyspnea has been steadily increasing. For a month she has had
marked swelling of legs. She has been in bed a week. She has
received cardiac tonics and restricted diet without improvement of
the symptoms. On admission she presented the picture of advance
cardiac decompensation. She was cyanotic. Her breathing was
rapid and labored. She could not lie down in bed. Her pulse was
about 100 while at rest and of poor quality. Her heart was enlarged
to right and left. There was a rough sj'stolic murmur at the apex,
transmitted to the axilla. The bases of both lungs showed marked
edema. The urine was scant but normal.

The diagnosis of pregnancy in the seventh month with chronic
endocarditis and mitral insufiSciency with advanced decompensation
was made. She was given heart tonics and kept at rest for a week
without improvement. Labor was then induced by inserting a tube in
the uterus. She was given small doses of morphine and hyoscine
and large doses of digitalis. After six hours of pains a small fetus
was delivered. During the labor the pulse ranged between no and
130. The baby was stillborn. The puerperium was uneventful.
Compensation returned to some extent. When she was trans-
ferred to her home under her family physician's care, she was com-
fortable in bed. She could lie down or sit up without dyspnea.
Her doctor reports that she now does her housework but has slight
dyspnea on climbing the stairs. The ultimate prognosis for this case
is bad. She should not be allowed to become pregnant again. If
she becomes pregnant, the uterus should be emptied as soon as the
diagnosis is made, by an anterior hysterotomy and the tubes should
be resected through the anterior fornix to absolutely insure against
a future pregnancy.

5. Frequently the kidneys are involved as well as the heart, and
the indications for termination of pregnancy becomes imperative.
The following case combines the chnical features of heart and kidney
involvement.

A. D., aet. twenty-eight, admitted to my service at the Brooklyn
Hospital April 24, 1914, in the beginning of the ninth month of her
fourth pregnancy, suffering with dyspnea, orthopnea, edema of
the limbs. She had acute articular rheumatism eight years ago,
and has had dyspnea on exertion ever since. Her symptoms have
been growing worse since the early months of this pregnancy. She
had been in bed for several weeks. The examination reveals marked

hussey: management of pregnancy and labor 249

edema of legs, pulsation of the veins of the neck. Visible heart beat
4^-^ inches to left of midsternal line. Right border of heart is at
right sternal line. There is a rough systolic murmur at apex trans-
mitted to the back. The blood pressure is 208s. and i2od. The
urine is scant, sp. gr. loio, contains albumin and granular and hyaline
casts.

Diagnosis. — ^Pregnancy ninth month, complicated with mitral
incompetency of rheumatic origin. Secondary nephritis. Indica-
tions:

a. To terminate the pregnancy.

b. To support the heart during the labor.

c. To reestablish compensation.

d. To treat the nephritis.

After a week of rest, tonics and ehminative measure, induction
was done. On March 31st, at 10.45 ^- ^- ^ bag was inserted, the
patient returned to bed. At 3 p. m. of the same day the mem-
branes ruptured. Five minutes later the baby was delivered spon-
taneously. The patient's condition during labor was good. The
puerperium was normal. Compensation returned. She left the
hospital in good condition. She has not consulted her family phy-
sician since. The prognosis in this case is made worse by the kidney
condition. If she becomes pregnant again, it will be justifiable to
terminate the pregnancy as soon as the diagnosis is made, and do an
operative sterilization.

6. In mitral stenosis the margin of reserve force in the heart is
small. Compensation is easily disturbed. When it is once broken,
the danger of a fatal termination is greatly increased, and the patient
must be guarded against every form of exertion and excitement.

M. K., aet. twenty-seven, admitted to my service at the Brooklyn
Hospital on Nov. 12, 191 2, in the seventh month of her second
pregnancy. She suffered with dyspnea, orthopnea, cyanosis, and
edema of the legs. She had rheumatism when a child. She had
never been strong. She has a small flat pelvis with a contracted
outlet. She had lost her first baby during an operative delivery some
years ago. Since the fifth month of the present pregnancy she has
suffered with dyspnea. She has been in bed under treatment most
of the time since then. She has already declined to have the preg-
nancy interrupted. She has had one serious attack of pulmonary
edema, about a month ago. Physical examination by the internist
shows a mitral stenosis with a broken compensation. The bases of
both lungs are congested. She was kept in bed and given heart
tonics. She improved gradually. She was allowed out of bed on
the 29th of November, but had to return at once on account of rapid
heart action and severe respiratory distress. On the 9th of Decem-
ber she got out of bed without permission, and the effort brought on
an attack of acute pulmonary edema. Her pulse during this
attack went to 160. She became badly cyanosed and lost con-
sciousness. She recovered after venesection. In view of the fact
that she could not sit up without danger of death, it was deemed

250 htjssey: management of pregnancy and l.-vbor

inexpedient for her to be allowed to go into labor. In view of the
fact that she had a small pelvis, it seemed best to deliver her by
Cesarean section. Her pulmonary edema made ether an unsafe
anesthetic. It was, therefore, decided to operate under morphine-
hyoscine and local anesthesia. She was given one H. M. C. tablet
on the evening before the operation. She slept all night. She was
still drowsy in the morning when she was given a second tablet. She
fell into a sound sleep and two hours later was operated upon. She
stood the operation well. At no time was she in any danger. Her
pulse was slower when she returned to the ward than when she went
to the operating room. Her baby lived. She improved gradually,
and was dismissed from the hospital on the thirty-fifth day
postpartum.

She was sent to an institution where she could be watched and
protected from strain. She is now so well that she is able to support
herself and baby by manual labor. At the time of the operation
her tubes were resected so she is in no danger of another attack of
broken compensation from pregnancy.

CONCLUSIONS.

1. The problem of the management of pregnancy and labor
complicated by heart disease must be solved independently for every
case.

2. It is based not on the character of the lesion alone, but upon the
relation of the reserve force of the heart to the amount of strain
which the pregnancy and labor under consideration wiU make upon it.

3. That by the combined efforts of the experienced internist and
obstetrician, much may be done, not only to reduce the immediate
mortaUty but to lessen the subsequent morbidity.

4. That operative deliveries are conservative in that they save
the reserve force of the patient.

5. That sterilization is indicated more frequently than it is
practised.

6. That an immediate mortality of 12 to 50 per cent, as is vari-
ously reported, is too high, and is due to tardy recognition of the
condition, unwise delay in terminating pregnancy, and the use of
too conservative methods in the management of labor.

REFERENCES.

Anders. Monatssch.f. Geburtsh. u. Gynak., 1914, xi, 443.

Blacker. Brit. Med. Jr., 1907, vol. i, p. 1225.

Bannister. J. Bright. Land. Lancet, Aug., 1914.

Eisenback. Beitr. z. Geburtsh. u. Gynak., 1913, x\x, 39.

French and Hicks. Quoted from Blacker.

Fellner. Monatssch. /. Geburtsh. u. Gynak., Berk, 1901, xvi, 370.

Hallendal, Med. Klinik., Berl., 1907, 763.

Hirschfelder. Diseases of the Heart and Aorta.

zimmermann: pregnancy complicated by cancer of cervix 251

Holmes, R. W. St4rg., Gyn. and Obstet., Aug., 1914, 253.

MacKenzie. Diseases of the Heart.

Newell, S. F. Surg., Gyn. and Obstet. , May, 1907, 610.

Pankow. Deutsch. Gesellsch.f. Gyndk., Halle, May, 1913.

Webster. Tr. Am. Gyn. Soc, 1913, xxxviii, 223.

167 Hanxock Street.

PREGNANCY COMPLICATED BY CANCER OF THE
CERVIX.*

VICTOR L. ZIMMERMANN, A. M., M. D., F. A. C. S.
Brooklyn, N. Y.

It is fortunate indeed that pregnancy in the cancerous mother is
of rather rare occurrence. Pregnancy is even comparatively rare
in women suffering from extragenital cancer, both from the fact
that the disease usually affects those past the menopause, the highest
percentage being between the ages of fifty and sixty, and also be-
cause the anemia and cachexia, as a rule, suspend menstruation and
ovulation. Likewise the irregular, bloody, and almost continuous
acrid and fetid discharge, and the occlusion of the canal by the
growth, militate strongly against conception. Therefore the
patients who show this complication are those in whom cancer de-
velops early in life, and in these young people the disease is par-
ticularly rapid and mahgnant.

There are now few who dissent from the general proposition that
the occurrence of pregnancy in a woman suffering from any form of
malignancy has a tendency almost always to hasten the ravages of
the disease. The same is true of tuberculosis or any wasting disease,
and is more generally the rule in growths of the breast and uterus,
on account of the increased blood supply in these organs during
gestation. The already wasted system is unable to stand the burden
and strain of prolonged gestation, and there results either a spontane-
ous interruption of pregnancy, or, if nature fails to come to the rescue,
the pregnancy continues at the expense of the debilitated system,
the growth makes rapid advance, and the woman shortly succumbs.
This was demonstrated to me lately in a lady who came under my
care, who developed a cancerous growth in the breast during her
fifth pregnancy. It was first noticed at the seventh month and grew
very rapidly. It was removed during the eighth month by a radical

* Read at a meeting of the Brooklyn Gynecological Society, April 7, 1916.

252 zimmermann: pregnancy complicated by cancer of cervix

operation. I delivered her at term of a small but healthy child, but
she died of a recurrence of the growth in eighteen months.

During the puerperium growths of the cervix advance even more
rapidly than in the months the fetus is in the uterus. This is well
recognized but not very satisfactorily e.xplained, unless it be in-
fluenced by the general weakness usually experienced for a few weeks
after labor.

Cancer of the cervix complicating pregnancy occurs probably
once in about 1200 cases, although there is a wide variation in the
figures of different observers. Cohnstein, Olshausen, and G. H.
Noble have collected a series of cases abroad and in this country.
In the records of the last 3000 cases in the Low Maternity of the
Brooklyn Hospital, it occurred twice. The growths are about
equally divided between adenocarcinoma and the squamous-celled
carcinoma. Some of the older obstetricians inclined to the belief
that carcinoma of the cervix did not have much material effect on
the course of the pregnancy, and that while abortion might result,
it was not as frequent as might be expected, this is due to the fact that
the growth confined to the cervix does not interfere with the expan-
sion of the uterus. Of Cohnstein's cases only 29 per cent, had a
premature e.xpulsion of the fetus. AU of these writers noted the
fact that gestation may be prolonged much beyond the usual limit.

The threat or occurrence of abortion or miscarriage may, in some
instances, lead to the discovery of the disease. This is shown by
the following case history, occurring in my service at the St. Mary
Hospital.

Mrs. A., Italian, thirty-seven years of age, the mother of six
children, was admitted to the St. Mary Hospital suffering from
irregular spotting of sLx months' standing. Her baby was two and
one-half years old, her previous health had been robust, and her
labors easy. She began by having two months of irregular, bloody
discharge and a little, thin leukorrhea. She frequently noticed a
bloody discharge after coitus, but no pain. She had not lost
appetite or weight. She missed here regular periods for two months
and then began a bloody discharge at intervals of six to seven days,
until her admission to the hospital. Three days before admission
she began to have some cramps in the lower abdomen and greatly
increased hemorrhage, and was sent in with diagnosis of threatened
miscarriage. E.xamination showed an enlarged and congested an-
terior lip of the cervix, the appearance of which was shiny and
smooth. The posterior lip was very much enlarged and springing
from it was a growth of cauliflower appearance extending into the
edge of the vagina on the left side. The os was patulous and
admitted the tip of the index-finger. The body of the uterus
was not very freely movable, soft, and the size of a four months' ges-

ZIMMERMANN : PREGNANCY COMPLICATED BY CANCER OF CERVIX 253

tation. As miscarriage appeared imminent and hemorrhage was
quite profuse, the vagina was tightly packed with gauze. The fol-
lowing morning the packing was expelled together with the products
of conception. For several days the bleeding was free but not ex-
cessive and did not require packing. At the end of two weeks the
uterus was fairly well involuted, but tender and of limited mobility,
and a small mass was palpable in the left broad ligament. On
account of the evident invasion of the disease beyond the limits of
the cervix proper, I decided to do a hysterectomy rather than a
Byrne operation. The cervix was freed from the vagina as much as
possible with the cautery knife and the pouch of Douglas was opened.
Then the abdomen was opened above and the operation completed
by the usual method of panhysterectomy. Her recovery was good
and she left the hospital in good condition, and my hopes were high
for a complete cure. Within eight months she had a recurrence and
died within the year with general involvement of the remaining
structures in the pelvis.

It seems hardly necessary to say that in this condition the prog-
nosis is extremely grave. One writer (Charpentier) says that if
pregnancy develops during cancer of the cervix it has a favorable
influence upon the disease, but if cancer has its beginning after con-
ception, the disease makes rapid progress. The dangers at delivery
are measurably increased from hemorrhage, rupture of the uterus,
and sepsis. Cohnstein's mortality was 12 per cent, in mothers
and 39 per cent, in children going to delivery at term.

The diagnosis should be easy if the case is seen early, but the same
delay in examination is experienced here as in uncomplicated cases
of uterine cancer. Women having a monthly flow during preg-
nancy shoidd be looked upon with suspicion, and rigidly investi-
gated. The disease might be mistaken for placenta previa or small
accidental hemorrhage.

Treattnent. — Early months. Cullen in his book on cancer of the
uterus epitomizes a short chapter on cancer of the uterus and
pregnancy as follows: "Whenever an operable carcinoma of the
cervix is detected a radical operation should be performed at once.
By delay we shall probably sacrifice the mother's life and at the
same time have only a limited chance of saving the child." This
probably expresses the views of most of the gynecologist-obstetri-
cians of the present time, provided the gestation is under four
months. However, few will fail to be guided by the views and wishes
of a mother anxious for a living child, who is willing to assume the
explained risks she is incurring in carrying her child to term.
Vaginal hysterectomy at this time seems to be the method of choice.
The induction of abortion or premature labor as a preliminary to

254 zimmermann: pregnancy complicated by cancer of cervix

radical operation I hold to be not permissible owing to the grave
risk of sepsis and hemorrhage. If the uterus has successfully
emptied itself and been followed by fair involution, and only if the
disease is strictly confined to the cervix, has the Byrne operation any
place in the treatment of cervical cancer at this stage.

Later Months. — In the American Text-book of Obstetrics, Davis
states that if the patient is seen for the first time advanced beyond
four months, delay may be advised in the interest of the child,
provided the tissues about the uterus do not become involved.
In the latter case, viz., involvement of periuterine tissues, I am
thoroughly in accord with Coe when he states that the interest of
the child is then paramount, as the permanent cure of the mother
is improbable and the child may be saved. Amputation of the
cervix by any method, or scraping away of diseased tissue, as a
paUiative measure, at any time during pregnancy, as advised by
some, I consider impossible, without inducing miscarriage and
probable sepsis, which are dangerous.

If conservative treatment is decided upon on account of the far
advanced disease, or in the child's interest, it will take the form of
styptic and cleansing applications to the diseased cervix.

Of the methods of delivery at or near term the best is Cesarean
operation, followed immediately by panhysterectomy. In this we
fulfill the double indication of getting a viable child, and take
the best measures to cure the disease and prolong the life of the
mother. If the disease has advanced so far as to be classed as
inoperable, where the bladder, rectum, or parametrium has been
involved, it would probably be best to deliver by Cesarean, allow the
woman to take her chance with sepsis and later subject her to
treatment by the Percy method.

This typical case occurring recently in the gynecological-obstetrical
service of the Brooklyn Hospital well illustrates some of the points
in clinical history and treatment.

Mrs. L., service No. 3620, an Austrian, thirty-eight years of age,
was admitted to the Low Maternity on the service of Dr. A. A.
Hussey, January 14, 1914. She had had four normal labors and the
puerperia had not been complicated. She had no irregular bleeding
or leucorrhea, had had a regular monthly flow of blood and did not
suspect pregnancy until quickening occurred. She did not consult
a physician until labor began a little before the eighth month when
she was immediately referred to the hospital. Examination at that
time showed a well-nourished woman, normal heart, lungs, kidneys,
and liver. The abdomen was protuberant and soft and the uterus
enlarged to about seven and one-half months. Vaginal examina-

zimmermann: pregnancy complicated by cancer of cer\ix 255

tion revealed a parous outlet and vagina, the cervix was hypertro-
phied, with a hard ring about the cervix nearly ij^ inches thick,
and thicker in the anterior than the posterior Hp by about 3^ mch.
It had a hard, cartilaginous feel, but was not broken down. The
head was at the inlet and she was having hard uterine contractions
every two minutes. On account of her inability to dilate the cervix
after six hours of hard labor, and in the presence of evident malig-
nancy, it was decided to deliver her by the Cesarean operation.
This was done in the usual manner, except that the entire uterus
was delivered from the abdomen before the child was removed.
The child was a female and weighed 4 pounds, 12 ounces. After
removal of the placenta a few sutures were inserted in the incision
in the uterus and a pan-hysterectomy proceeded with. The bladder
was separated in the usual manner from the cervi.x and vagina,
and the entire uterus and about i inch of the vagina were removed.
The vessels were ligated, the raw surfaces covered and a vaginal
pack inserted below the peritoneum. On examination the specimen
was pronounced epithelioma of the cervbc. The woman made a good
recovery, except for a slight wound infection, and is reported in
good condition at the present time.

In the treatment of these cases even after viability, we must not
lose sight of the feasibility of the vaginal Cesarean operation, fol-
lowed immediately by vaginal hysterectomy. While we have had
no experience with this procedure it would seem that it could be
accomplished with less difficulty than it would appear to involve.
In the vaginal Cesarean operation we have noticed how easily the
bladder is separated from the vagina and cervix, also how readily
the uterus comes down to the outlet after delivery of the child.
Fritsch brought out this operation when he did a vaginal hysterec-
tomy for cervical cancer immediately after delivery of a child at
term by forceps. He says the operation is done with ease and the
surrounding tissues are readily recognized; the uterus stretched to
an enormous length during removal.

From the study, then, of our two cases, we might be allowed to
conclude:

1. That a routine examination of every case early in pregnancy
would result in the diagnosis of cancer of the cervix, if present.

2. That women having atypical bleeding during pregnancy, as
well as those having a regular monthly flow of blood during gestation
should be regarded with suspicion and rigidly investigated.

3. That if discovered under four months the consensus of opinion
is that radical operation be advised after the true state of affairs
has been made known to the patient and her family.

4. That if discovered after the fourth month the child may be

256 chipman: the teacher's inheritance

allowed to go to viability and then an abdominal or vaginal Cesarean
operation performed, followed immediately by panhysterectomy.

5. That the induction of abortion or miscarriage as a palliative
measure is not permissible.

271 ST0YVESANT AvENL'E.

THE TEACHER'S INHERITANCE.*

WALTER W. CHIPMAN, M. D., F. R. C. S., F A. C. S.,

Montreal, Canada.

Mr. Chancellor, Members of the University, Trustees of the Magee
Hospital, Ladies and Gentlemen:

This is for me a great occasion — a great pleasure, a great honor,
and a greater responsibility. I may thank you for the pleasure,
and I do thank you for the honor, I cannot thank you for the
responsibility. My thanks are respectfully tendered to your great
university, and to the Board of Trustees of this hospital whose work
we are come to inaugurate.

We are here to-day to celebrate the opening of the Magee Hospital
and in these introductory exercises we, each one of us, are proud to
participate. Such a celebration marks always two things, it marks
a present achievement, and a promise of things to be achieved. A
great thing has been done. This splendid hospital has been built
and equipped, and there remains for the future the great work, the
great life-work, which it is to do. Accordingly, we stand to-day in
this inauguration at the division-point between preparation and
accomplishment, between promise and fulfilment — in the present
between the past and the future. On such occasions our first
privilege and our first duty I take it, is always to remember the past;
to be not unmindful or forgetful of the work of those who have gone
before. So it is that the names of the Honorable Christopher Lyman
Magee, and that of his mother Elizabeth Steel Magee, are continually
in our minds to-day. This hospital is essentially the work of their
hands and their hearts, and through all the many years which it
shall live, and in all the great work which it will do, these two names
shall be specially remembered. For the hospital and its work will
always remain for these two, the mother and the son, a great me-
morial. There is something peculiarly appropriate, I think, that

* Address delivered at the dedication of the Elizabeth Steel Magee Hospital.
Pittsburgh, October 27, 1915.

chipman; the teacher's inheritance 257

this hospital, the gift of a mother through her son, should be devoted
to the service of women — -to the great mother service. It is some-
where written that the highest service which one generation can
bequeath another is that of a mother to her son.

We remember also with gratitude and appreciation the wisely-
advised and well-ordered efforts of the several trustees of this behest.
I can imagine no more onerous or self-denying ordinance than that
of a trustee. Often it is, alas, an unsatisfactory and a thankless
business. In the present instance, however, only our highest
appreciation and our best thanks are due. I heartily congratulate
the thirteen gentlemen who so successfully have in this institution
embodied, not only the spirit, but also the letter of the final testa-
ment. "There shall be admitted to this hospital aU females who
may apply thereto for lying-in purposes," reads one clause in the
Will. Considering rather the spirit of this instruction, the Trustees
very wisely, I think, have widened its scope. It is a Lying-in
Hospital, but it is more than this. For not only is it to care for the
woman during her pregnancy and parturition, but it is to minister to
her in aU the many ailments and disabilities to which her motherhood,
actual or potential, renders her Uable. Accordingly the Elizabeth
Steel Magee Hospital is a hospital devoted exclusively to women.
And, in its care of these, its tradition is, I am thankful to say, the
old tradition written long ago in the dust, the lesson of that great
charity, "he that is without sin . . . let him first cast a stone."

The Magee Hospital needs no description from me. The hospital
itself, its aims and aspirations, have been admirably set forth by the
several speakers this morning. Best of all, in no uncertain words,
it speaks for itself. In very truth, it is the latest word in hospital
architecture, and is, I think, the best and the most complete clinic
of its kind in the world to-day. This plain statement makes the
highest praise.

And this hospital is a gift, not only to the public which it serves,
but to the medical profession that serves it. In the most complete
sense it is a double gift; for in benefiting the one — the public — it of
necessity benefits the other — the profession. And again, in a large
and special sense it is a bequest to general medicine; for while it is
natural and true that it profits first the profession of Pittsburgh,
to some extent this profit is shared by the whole profession through-
out the world. Accordingly we, the disciples of medicine how-so-
far scattered, are of this legacy the residuary legatees. We feel
assured that it is held by us, and for us, as a sacred trust; we know

258 chipman: the teacher's inheritance

that it shall profit us only if we give good and faithful account of our
stewardship.

Let us say at once, then, that we are specially grateful; and in the
name of the profession, let us say, and re-say it, that we are grateful
especially that this hospital is a teaching school. On its corner-
stone we are thankful that we may read, "For the Healing of the
Sick, and the Proper Teaching of the Healers of the Sick." By
this teaching, not only is the measure of its work and usefulness
enormously increased, but for this very reason there is a secure
guarantee that this work will be adequate and progressive. The
fact that a hospital is a teaching school is in our day sufficient to
save its soul.

In a very special sense, and under new and ideal conditions, this
hospital is to teach. It will care for and heal the sick, and will do
this better, more faithfully and conscientiously, from the very fact
that it is teaching others to heal the sick. In all this work, the
healer will be the teacher, and this is as it should be. Such a hospital
constitutes for the teacher no small part of his inheritance. Its
bequest to him is generous, and in all equity its demands of him are
great. True, it is only part of his inheritance, the material part;
it is the body of his inheritance which, if it be a living body, must be
quickened by that greater part, the spirit, the animus, or the soul.
It is of this complete inheritance — the body and the soul — that I
now wish to speak.

It is of course the medical teacher who chiefly concerns us.

Even in a scholastic sense we live in troubled and heart-searching
times, for things are by no means right in an educational way.
For the last two decades education in general, and medical education
in particular, have been subject to revision and repute. Everywhere
there has been academic unrest and dissatisfaction. Several of our
universities have already encountered almost a Mexican Revolution
and the general professorial peace, peradventure the slumber, has
been grievously broken. It is our educational system that has been,
and continues to be, at fault; and the whole movement is an impeach-
ment of our pedagogic methods.

The Carnegie Foundation for the Advancement of Teaching and
Lord Haldane's Commission on University Education, have been in
the English-speaking world, portents of the coming reformation.
Whereas of the reformation itself, the formation of the American
College of Surgeons has been, perhaps, the most conspicuous feature.
Already there has emerged a growing realization of the momentous

chipman: the teacher's inheritance 259

importance of the profession of teaching. For only slowly and at
this eleventh hour, are we coming to regard it as the greatest and the
most important of all the professions. At last the teacher, the
trained, hving professional teacher, is in sight of his own. From
first to last the quarrel has been with old traditional methods of
teaching, methods from which the hfe has long since departed, and
which can be safely numbered with the dead. And, as in other
reformations, this is but an effort, a determination, to bring all
teaching, and the teaching profession, into closer contact with living
things, with the actual reahties of hfe. The whole experience is
dynamic; for all these things, the criticism, the unrest, and the
change, are but a stirrage, a sign of coming life.

Medical education, especially in America, has experienced to the
full this pedagogic renaissance. In all our medical schools there has
been, not only growth, but indications of greater growth. Medical
education to-day is not of the same number, street, or city as it was
even ten years ago. And the change, I take it, is assuredly for the
better, and the movement is only at the beginning.

Abraham Flexner, a great educationahst, has told us that in the
United States "medical education includes something of which
is best, and all of what is worst to be found among civilized na-
tions." He has very ably compared the German school of medical
education with the English school, has amply demonstrated their
respective merits and defects, and has definitely indicated that
America should profit from them both. We are to build our own
educational system, and here as in all building, a right selection of
the materials is aU-important. According to Flexner, the one point
of real superiority in American conditions is their great plasticity.
The whole educational world is before us, and we may make of our
own institutions exactly what we wish. It is for us to work out our
own system, our own academic salvation.

There are, it is true, many faults in our medical education, but I
think it may be said that, even in these very faults, perhaps by very
reason of them, there are strong and imperious indications of virility
and growth. We may not always be quite sure where we are going,
but we know we are on the way.

And all this activity makes for a sign in medical education. It is
the very spirit of the times in which we live — the Zeitgeist.

And our modern medical teacher is alive to all this. For it is or
should be the mainspring of his conduct, the very spirit and inspira-
tion of his inheritance. It is of this inspiration, of this spirit that
I shall first speak.

260 chipman: the teacher's inheritance

/. The Teacher's Spiritual Inheritance. — The teacher who inherits
must show good and sufficient proof of his inheritance, and this
must, of necessity, become articulate in him in a twofold way:

(i) The effect in himself as an individual unit, as a teacher; and

(2) Its influence upon him as a university colleague in the correla-
tion of his work.

(i) The effect in himself as an individual unit, as a teacher.

It may be true that a good teacher is born and can scarcely be
made; it certainly is true that he is not nearly so numerous as he
professes to be. I undertake to say that not one of you has met the
man, or the woman, who confessed himself a bad or even an indif-
ferent teacher. Whatever else we can or cannot do, it is a universal
obsession that we can teach. For in a sense teaching is merely the
giving of advice, and in this the high Gods attest a world-wide pro-
ficiency. Accordingly, there is much ground for Shaw's borrowed
aphorism, " those who can, do; those who can't, teach." Moreover,
as regards our university positions, we, good, bad, or indifferent
teachers, hold our positions for life, or during a very moderately
good conduct. I have heard it said that it is very difficult for a
family to change its physician; I know it is almost impossible for a
university to retire a professor. So, speaking generally for the
universities in America, they must accept us in our life-times, for
there is no getting rid of us.

While it is not given to us all to be good, it is certainly given to us
all to be better; and a definition may be of service just here. The
definition is this: A good teacher is one who is the embodiment of
the experimental or scientific method, and whose teaching makes for
power rather than for mere information.

Professor Richard M. Pearce, of Philadelphia, in an address
delivered some three years ago, has very forcibly pointed out the
importance of the experimental method in the everyday work of
the teacher, and its great possibilities in the development of both
the science and the art of clinical medicine. This able address must
be forall teachers, and especially clinical teachers, an inspiration. Its
whole substance may be summed up in Samuel Butler's famous
phrase, directed to the student: "Don't learn to do, but learn in
doing." It is only in doing that the student can develop power,
can truly learn. This is the principle that should inspire and animate
all our teaching, and all our intercourse with students; for, failing
here, our best efforts do nothing but conspire toward their intel-
lectual death. Accordingly, the full understanding of this fact, and

chipman: the teacher's inheritance 261

the adoption of such a method, is no small part of the teacher's
spiritual inheritance.

Though the great truth of the coordination of head and hand was
enunciated more than a hundred years ago when Novalis said:
"We only know in so far as we do — ^and make," its general applica-
tion to medical education has been long delayed. It is, however,
the breath of the modern spirit, and there is no doubt that we owe its
advent to the laboratory and to methods of research.

In accordance with this modern method the teacher engages the
student, from the beginning to the end, in research, and there is no
end. For the student this research begins rightly enough with
himself; with his own mental processes, in order that he may learn
his natural bent, may come to know his own mind and the peculiar
individual way in which it works. Even here he learns in doing, for
he is only carefully encouraged and directed. And this experi-
mental, this inductive method, he then turns upon his work, and
S3'stematically applies it to the problems of the whole curriculum.
For this method is not only for the preliminary — the so-called scien-
tific subjects, but especially for all the later, larger, and more com-
plex problems of his clinical work. It is in diagnostic methods, and
in the recognition and treatment of disease, that it reaches its chief
attainment. It is in very truth the method of a life-time — the life-
time method.

And it seems to me that this should represent both the limits and
the scope of undergraduate research. In all conscience both are
wide enough to suit the most talented and the most ambitious.
None save the very exceptional student — and I have never met
him — should in his undergraduate days be urged, or even encouraged,
to undertake a so-called "original research." This is in my opinion
an educational blunder, for he who builds well makes first his foun-
dations broad and sure.

Again, medical teaching is to heal the sick, and this must never
be forgotten; this is its aim and we simply remind ourselves that this
has been through all the ages its great tradition. From first to last,
in word and deed, it is the whole spirit of our inheritance. And this
tradition is specially strong to-day, for in Heaven's name, the
present world has need of us. It is this humanitarian spirit that
always must inspire our teaching work, for, while we coordinate the
head and hand, we must not forget the heart. These three, the
head, the hand and the heart, make the complete trinity of the man;
and in the laboratory or at the bedside it is these three we teach.

So, by all these things, the individual teacher shall be known as

262 chipman: the teacher's inheritance

being really possessed of a spiritual inheritance. "What you are
thunders so loud I can't hear what you say!" There will be with
his inmost self-repeated communion, a general stock-taking of his
teaching gifts; for however painful the process, the time is ripe for
self-criticism and self-knowledge. As a teacher he will obtain
inspiration and assistance from his fellow-teachers; and he will do
in his own department his level best. And at the last his school
shall say of him, not only was he a teacher, but pure scientist or
clinician, he was a man. "Ripened in wisdom, walking as a phy-
sician;" he was articulate of his spiritual inheritance.

In illustration thereof there arises naturally before us the remem-
brance of Charles Sedgwick Minot, whose untimely death occurred
nearly a year ago. When we contemplate the department of com-
parative anatomy in the Harvard Medical School, and recall what
this has meant to scientific medicine in America, it is almost impos-
sible to beheve that in 1880 Minot began here with eighteen micro-
scopes and an annual appropriation of fifty dollars. Once again,
truth is stranger than fiction. In the highest sense Minot was a good
teacher, and a conspicuous embodiment of the spirit of his time.
The inspiration of his example is no small part of the American teach-
er's inheritance.

(2) Its influence upon him as a university colleague in the
correlation of his work.

Not a single teacher but the several teachers of the faculty make
the school; it is a joint, or jointed, work. If the teacher be thor-
oughly imbued with the spirit of his time, and be not bhnd to his
inheritance, he will, in managing his own department, unselfishly
consider the interests and the needs of the whole curriculum. In
sporting phrase, this is team work; in the business world, it is
organization.

Speaking generally, our medical faculties are far too large, in each
we sufi'er from a plethora of teachers, and the educational method
has become special and isolated. It is but human nature to magnify
our own importance, and somewhat to overlook the value of others.
There is, so far as I know, no medical faculty not surpassingly rich
in human nature. The very constitution of these faculties has been
partly responsible for this; for the service of the professor is often
largely voluntary, there is no central government, and each in his
own department is a law unto himself. I believe that government
by democracy, even when bad, is the most advanced government;
in its highest form, as an efficient commonwealth, it demands much
from the average man. Our medical faculty is essentially a democ-

chipman: the teacher's inheritance 263

racy, and I trust it will ever remain so; accordingly its demands from
the average teacher are great. For as a teacher, not only must he
do his own work well, but he must subordinate his work, cooperate
on every side with his colleagues. His own work is no longer to be
insular and egoistic, but is to be by his own efforts completely
merged into the general whole. Such a man must of necessity main-
tain close comradeship with the work of his colleagues; general
results will become visible; and of necessity there will ensue a right
proportion. In this way the general and the special work will quite
naturally correlate itself. No longer will the class-room be utterly
ignorant of the laboratory, and the laboratory be as a stranger in a
strange land. Instead there will be secured that complete unity
which alone makes for efficient work. Nothing is work in any
faculty than incessant quarrel; and a wrangling colleague is a per-
petual nuisance.

In this model faculty the curriculum would represent a mutual
policy for which all would be more or less responsible. The wide and
lamentable chasm between the hospital and the laboratory, the so-
called pure scientist and clinician would be forever bridged. Each
would know the method of, and borrow from, the work of the other.
For they both are concerned more or less closely in the great service,
and that service is the healing of the sick.

All this may sound somewhat Utopian, but it is after all only the
promise of our inheritance. The medical faculty of the future and
of the near future must achieve some such unified and cohesive
method. If we do not do it ourselves, we will be ignominiously
compelled to do it; and though I remember that in any organization
reform comes hardly from within, but is usually of the nature of a
compelling force from without, the promise of this self-reform is the
very vital part of the teacher's inheritance.

//. The Teacher's Material Inheritance. — The richness of this
inheritance is well exemplified in the institution which we open to-
day. I can imagine no fuller and more soul-satisfying legacy than
that to which Professor Ziegler is heir. A hospital wonderfully
equipped, with all known facihties for the care of the sick, for careful
investigation, and for teaching work, has fallen to the lot of few
professors. And when we add to this an adequate staff of paid
assistants, and a generous recognition as regards himself that the
laborer is worthy of his hire, we seem to have arrived at an academic
millenium. The refreshing part of the whole business is that the
conditions are untrammelled, and that, while clinical facilities are
abundant, there is ample equipment for investigation and research.

264 chipman: the teacher's inheritance

There are two special features of this material inheritance which are
deserving of fuller remark. The one the establishment of clinical
teaching on a full-time or university basis, and the other the fusion
into one department of obstetrics and gynecology — the so-called
Frauenklinik. In America both these conditions are modern; and
with them both there can be no serious contention or disagreement.

(i) By the adoption of the full-time system we secure in the widest
and best sense, professional teaching. The teacher will teach not
only in the class-room and at the bedside, but in the laboratory and
museum; his whole day and his entire energies will be devoted to this
work. No longer will he be driven and distraught by the captious
demand of private practice; no longer compelled, in the words of
John Hunter, to go and earn the damned guinea. It is true he
may engage to some extent in practice, and this, I take it, is a
great salvation. For in this way he will not become entirely
divorced from the work-a-day side of things. Humanity inside
a hospital is one thing, and is comparatively easily managed; out-
side a hospital it is entirely another. I believe that a necessary
preliminary in the training of any medical professor should
include always some years in the actual practice of medicine. By
reason of this actual dealing with men — and verj' especially with
women — he comes to know them on their human side — a knowledge
which will forever savor his teaching. A knowledge of human
nature is an absolute essential to the successful practice of our
profession, and it is the practice of medicine that we are always
endeavoring to teach.

(2) In respect of the Frauenklinik there can be, I think, but one
opinion, for it makes for unity and coordination. Obstetrics and
gynecologj^ are not only sister-subjects, but they are twin-sisters;
for together they express the sum-total of a woman's sexual life.
The one — Obstetrics — represents the discharge of normal function,
while the other. Gynecology — embraces the vicissitudes to which,
unfortunately, this normal function is liable. Accordingly, the
combined clinic treats of this genital system both in health and
disease, and a knowledge of the two is interdependent. A modern
obstetrician must be a gynecologist, whereas a knowledge of obstet-
rics makes for good and conservative pelvic surgery. The argument
that one man cannot practice both obstetrics and gynecology,
because there are only twenty-four hours in the day, no longer
obtains in this full-time system. Placed on this university basis,
the professor of obstetrics and gynecology may in his service practice
both, and find ample time for teaching and research. And his

ZIEGLER: the ELIZ.-tBEXH STEEL MAGEE HOSPITAL 265

teaching in these two subjects, in my opinion, gains enormously,
for not only is it economical of time but in an admirable and natural
way it correlates the work. Moreover, there is, the gods be thanked,
one teacher and one subject less in the medical curriculum.

This, then, is the teacher's inheritance — our own inheritance.
Of its two aspects, the spiritual and the material, there can be no
question which is the more important; for the spirit alone can
quicken and viviiy.

The realization of this inheritance is certainly not of to-morrow,
for educational Rome was not built in a day. The Magee Hospital
is a corner-stone in this great city, and we congratulate Professor
Ziegler and his colleagues upon their noble inheritance.

As medical teachers we remember that we serve not only the pres-
ent but also the far-reaching line of the coming generations; for we
are told that the country whose inhabitants shall not say "I am
sick" is exceeding far off.

THE ELIZABETH STEEL MAGEE HOSPIT.\L AND ITS
WORK.*

BY
CHARLES EDWARD ZIEGLER, M. D., F. A. C. S.,

Pittsburgh, Pa.

The words which have just been spoken of Christopher Lyman
Magee constitute an appropriate and loving tribute to a great and
good man. Mr. Magee was a man of rare spiritual and mental
endowments and of a charming personality. He was a loyal friend,
a good citizen and a generous benefactor. But the best thing that
will ever be said of him is that he loved and appreciated his mother
and in her name gave all he possessed for the cause of humanity.
As a result the Elizabeth Steel Magee Hospital will ever be regarded
as a monument to Mr. Magee as well as a memorial to his mother.
Because of the nature of the work which the hospital will do, how-
ever, it becomes more than this. It is essentially a hospital for
women and as such is dedicated to the tender administrations of
childbirth and maternity and to the treatment of diseases peculiar
to women. In no other way could the double purpose which Mr.
Magee had in mind have been so effectively accomplished. The
son loved the mother because of what the mother, in fulfilling the

* Presented at the dedication of the Elizabeth Steel Magee Hospital, Pitts-
burgh, October 27, 1916.

266 ziegler: the eliz-.vbeth steel magee hospital

sacred obligations of maternity, had done for the son. What more
fitting then than that the son should dedicate to the memory of the
mother a work which lessens the sufferings and risks of childbirth
and adds to the joys and efficiency of motherhood.

Although the nature of the hospital to be erected was not definitely
specified by Mr. Magee in his will, the presumption was that it would
be a general hospital. A careful study, however, of the local hospi-
tal conditions at the time the provisions of the will became operative,
revealed the fact that fully 30 per cent, of the beds in the general
hospitals of the city were unoccupied. It was thus perfectly plain
that for some time to come at least, there would be no need for
additional general hospital accommodations. It so happened that
a clause in the will directed that there be admitted to the hospital,
"all women applying for admission thereto for lying-in purposes."
So much of the will was thus perfectly plain — namely that the hospi-
tal was to be, in part at least, a maternity hospital. On the basis of
this fact and realizing the great need of hospital accommodations
for lying-in purposes in this community, the trustees decided to build
a hospital exclusively for women. This decision was reached,
however, only after most mature deliberation. Letters were sent to
a number of the leading obstetricians in the country holding the
chairs of obstetrics in certain medical schools. Replies were
received from all of them and were unanimous in recommending:
(i) That the hospital should care for both maternity cases and cases
of diseases of women; (2) that there should be but a single head in
the person of a medical director, and (3) that the proposed hospital
should be made a teaching institution operating in affiliation with
the School of Medicine of the University of Pittsburgh. It was
pointed out that obstetrics and diseases of women naturally and
logically belong together and that their separation into two specialties
is detrimental to both and most especially to obstetrics; and that
since obstetrics is a branch of surgery, the obstetrician cannot
teach and practice it successfully unless he is trained also in the sur-
gery of all the conditions peculiar to women. It was further pointed
out that in Germany where obstetrics and gynecology have reached
their greatest development, the combination exists in the famous
"Frauenkliniks" or hospitals for women, all of which are university
teaching institutions in charge of university professors as their medi-
cal directors. A committee of the trustees later visited a number of
the gentlemen from whom letters had been received with the result
that the decision was soon reached to establish the proposed hospital
along the lines of the recommendations received.

ziegler: the Elizabeth steel magee hospital 267

Five years have passed since the permanent organization of the
hospital was effected and the architect selected. Work on the plans
was begun on Jan. i, igri; ground was broken on Jan. 12, 1914, and
the completed buildings were turned over by the contractors to the
trustees but a few days ago. I shall not speak of the construction
and equipment of the new buildings as the general pubHc will be
given an opportunity to inspect them this afternoon. Suffice it to
say that they are admirably suited for the purposes to which they
will be put. There will be accommodations for 140 adult patients
and eighty-five babies. The cost including the furnishings and
equipment and the residence of the medical director, wUl be about
$700,000.00.

During the preparation of the plans and the erection of the new
buildings, the work of the hospital has been carried on in the old
Magee homestead which was altered and equipped for the purpose
and opened for the reception of patients on Jan. 19, 1911. During
the period of four years and nine months over 2000 women have been
admitted for treatment and 1800 babies have been born. The work
has grown far beyond our ability to care for it. During the past two
years we have been compelled to turn away patients almost daily
because of our limited accommodations. It is confidently expected
that the new buildings with their greatly increased capacity will
likewise soon be filled.

Of interest also since closely affiliated with the Magee Hospital
is the Pittsburgh Maternity Dispensary which cares for confinement
cases in the homes only. The four physicians, five nurses and social
worker constituting its staff, are caring for about 100 confinement
cases a month and making over 1000 visits a month in the homes of
the poor of Pittsburgh.

The need for such institutions as the Magee Hospital, not only in
Pittsburgh but elsewhere throughout the country, may best be
appreciated by reference to the present day status of obstetrics.
It is generally conceded that the standards in obstetric practice are
the lowest of all the clinical branches of medicine. In emphasis of
this fact it need only be recalled that approximately 50 per cent, of
all the confinements occurring in this country annually are in the
hands of midwives. Of the 15,000 confinements occurring in Greater
Pittsburgh last year, over 5000 were cared for by midwives. In no
other branch of medicine and of surgery in particular, are uneducated,
nonmedical individuals permitted to practice. It is stated upon
competent authority that about 8000 women die annually in the
United States from childbed fever — a preventable disease — and

268 ziegler: the Elizabeth steel magee hospital

that fully as many more perish from other accidents and complica-
tions of childbirth. In addition to those who lose their lives untold
thousands are crippled, incapacitated and invalided as the direct
result of ignorance and neglect. It is variously estimated that from
50 to 75 per cent, of women seeking relief from affections peculiar
to their sex, do so because of ignorance or neglect during and follow-
ing the births of their children. And yet every specialist in obstet-
rics knows from results in his own practice that all but a very small
percentage of this mortality and morbidity is inexcusable and pre-
ventable by the proper management of obstetric cases. Be it
understood, however, that the blame rests not alone with the mid-
wives. Much may justly be laid at the doors of incompetent
physicians who do httle, if any better work, than the midwives.

The only excuse that there can be for midwives and incompetent
physicians in the practice of obstetrics is the matter of compensation.
Because they are unable to pay for anything better, the work among
the poor has very largely been left to midwives and incompetent or
inexperienced physicians. Even with people in more comfortable
circumstances the choice of an obstetric attendant is all too fre-
quently determined by the size of his fee. Many such women there
are, who know the meaning of good obstetric care and would gladly
employ the trained obstetrician, but he costs more than they can
pay and so they content themselves with less competent practi-
tioners. We hear much of race suicide and that women no longer
are willing to have children. Be this as it may, there can be not the
slightest question but that thousands of women best fitted to bear
children and to assume the responsibiUties of motherhood, would
gladly have children and more of them were they able to carry the
financial burden which would be thereby imposed.

The problem then is how to secure efficient training in obstetrics
for students of medicine and how to provide for women of every
social and financial standing, competent obstetric care for what
they are able to pay. I beheve that tlie problem of good obstetrics
will ultimately be answered very largely through education of the
public. It will remain for the medical profession to demonstrate
the needs and possibilities of good work, largely through results in
practice, and to point the way for the training of competent obstetric
practitioners, but the people themselves must be brought to the
point where they will demand good service and be ready and willing
to provide the means. We have poor obstetrics in practice very
largely because the teaching is poor in this important branch of
medicine. And the teaching is poor very largely because the people

ziegler: the Elizabeth steel magee hospital 269

do not give the moral and financial support to teaching hospitals
that they should. This is especially true of maternity teaching
hospitals and dispensaries. It is the rule for the lay public to object
to undergraduate students in medicine attending confinement cases,
"experimenting" as they so fondly call it. These same objectors
usually think very well of physicians as a class and the better they
are trained the more highly they think of them when it comes to
members of their own families; but the student in training, they have
only contempt for him. They forget that it is the same individual
who is the student to-day that is the practitioner to-morrow,
licensed to handle anything in obstetrics that comes along and that
whether he kills or cures the same law protects him which has
licensed him to do just what he has done.

The whole thing is a mistake and the public should be made to
understand this. It should be regarded as the duty of every citizen,
if for no other reason than that of the safety of his own family, to
insist that students of medicine be not only supplied with ample
obstetric material, but that they be required also to use it in gaining
knowledge which is indispensable to safety and efiiciency in practice.
The average practitioner who gains his experience alone and on his
own responsibility after he enters private practice, rarely if ever,
becomes a skilled obstetrician; and should he ever become so, the
chances are very great that he has gained his knowledge at the cost
of much invalidism and of a number of deaths. If physicians must
acquire experience in obstetrics, let them, before they are licensed
to practice, do so under competent supervision and instruction where
they will at least do no harm.

The cry that is raised against using hospitals for teaching pur-
poses is an empty one. The fact is that every hospital that is worthy
of public support and patronage is inevitably a teaching hospital.
Recent graduates in medicine and nurses in training enter hospitals
with no other purpose in view than to learn, and just so soon as
hospitals deny them this opportunity they leave and the modern
hospital cannot get along without them. Patients instead of being
harmed are immeasurably helped by systematic teaching since their
ills are thereby the more certainly and carefully studied; and since
those who have charge of them are usually among the best advised
physicians in the community, they receive the very best care that is
to be had.

It is the purpose of those responsible for the policies of the Eliza-
beth Steel Magee Hospital, to make it a thoroughly efficient, scien-
tific and helpful institution. Its first and last thought will be for

270 hornstein: rarer forms of toxemia of pregnancy

the best interests of its patients and whether rich or poor its aim
will be to give them the best that modern medicine affords and for
what they are able to pay. As a teaching institution it will send the
gospel of good obstetrics far and wide and through the physicians
and nurses trained within its walls, will be the means of providing
competent obstetric care for thousands of women who will never see
the hospital and who will be reached in no other way. As a research
institution it will add to our knowledge of obstetrics and gynecology
and thus be of enduring service to humanity.

In contemplation of the generosity, the sympathy, the goodness of
heart and the wisdom displayed by Mr. Magee in his magnificent
gift to his fellow beings, we have a true and imperishable image
of the man. Well may we join in saying of him as was said of
"The greatest Roman of them AH:" '"His life was gentle and the
elements so mixed in him, that nature might stand up and say to
all the world, 'this was a man.'"

RARER FORMS OF TOXEMIA OF PREGNANCY.

(Report on cases of Chorea Gravidarum and Polyneuritis
Gravidarum.)

MARK HORNSTEIN, M. D.,

New York City.

The term to.xemia of pregnancy has come to be taken as almost
synonymous with those syndromes of hepatic and renal disturb-
ances associated with hyperemesis, acute yellow atrophy of the
liver and eclampsia, the commoner complications of the pregnant
state. There are several varieties of into.xications of pregnancy
which, though by no means less serious, are not so well recognized by
the general practitioner in this country. Not only is this due to the
rarer occurrence of these conditions, but also to the fact that they
are apt to be regarded as coincidental complications of the gravid
state rather than a poisoning of the system brought on by preg-
nancy. Te.xt-books on obstetrics make mention of such conditions
as chorea, multiple neuritis, salivation, and various skin lesions as
probably due lo toxemia. Kcator reports the case of a primi-
gravida who was in the third month of pregnancy when she com-
menced to vomit and developed purpuric hemorrhages and hemo-
philia. The symptoms became severe so that pregnancy had to be

hornstein: rarer forms of toxemia of pregnancy 271

interrupted and, after resort to transfusion, the woman recovered.
The writer has known two primigravida3 who complained several
times of hematemesis without other symptoms.

There is practically a unanimity of opinion at present that the two
more important of the rare complications of pregnancy — chorea
and polyneuritis gravidarum — are intoxications brought on by a
disorder of the metabolism incident to the gravid state.

Chorea Gravidarum. — It is likely that some of the milder cases of
chorea occurring during pregnancy are not reported, being con-
sidered as cases of simple chorea. This is more true of those giving
a history of childhood chorea, especially when occurring in a young
primigravida. Of those giving such history, however, it will be
found that some had their attack at or near the onset of men-
struation, as has been the case with the patient reported below,
in whom the previous chorea might also have been due to a toxemia
following a perversion of the function of menstruation. It is im-
portant therefore to distinguish between ordinary chorea associated
commonly with tonsillitis, endocarditis or arthritis, and chorea
gravidarum, which rarely shows any heart lesions even when it
terminates fatally.

There are few anatomic changes found in chorea of pregnancy.
Some pathologists have found old and recent valvular vegetations,
congestion at the base of the lungs, and exudation of bloody serum
over the surface of the brain.

The symptoms do not seem to differ from those found in Syden-
ham's chorea except in degree of severity. There are usually no
premonitory signs, the first thing noticed is restlessness and soon,
twitchings of the fingers of one hand, usually the left. The move-
ments spread to the upper part of the arm and the whole extremity
undergoes the typical rotary choreic motions. The other extremities
are soon involved and there is great restlessness, even the trunk
being affected. There is difficulty in the taking of food and the
patient has to be fed. As the case progresses there is insomnia,
irritability, pallor, and exhaustion. There is seldom fever, but,
when present, it is said to denote that the prognosis is bad. Var-
ious psychoses may complicate the situation, the more common
being maniacal outbreaks. There are recurrences in about 15 per
cent, of subsequent pregnancies.

Several English observers, like Croft, Wall, Andrews and Shaw
seem to be the most optimistic as regards prognosis and most
conservative in treatment. Croft reported ten cases from the
Hospital for Women and Children of Leeds during a few years.

272 hornstein: rarer forms of toxemia of pregnancy

They all recovered; two being treated by abortion and eight were
allowed to proceed in pregnancy. Wall and Andrews reported
twenty-eight cases in eleven years at the London Hospital; all
were treated conservatively, and two died. Shaw cited eleven
cases in four years of which only two, those in whom pregnancy was
interrupted, died; the others were allowed to go to term. From
the above figures chorea seems to be more common in England than
in Germany, for Engelhard found only two cases among 19,910 con-
finements at the Utrecht Frauenklinic in ten years, while Hannes
saw only one in twenty-five years.

The majority of cases occur in primipar^e, but it may come on in
multiparse for the first time, and it may recur in subsequent preg-
nancies, and sometimes in a more severe form than before. The
time of onset is more often the period between the second and fifth
month, but it has come on soon after the disappearance of men-
struation, and as late as the puerperium. Birnbaum quoted the
statistics of Buist, in which

108 occurred during the first three months,
30 occurred during the second three months,
25 occurred between the seventh and ninth month and
II occurred during the puerperium.

From the same series, 59.3 per cent, occurred in primipara and
22.4 per cent, in secondiparae. Nearly 70 per cent, were between
the ages of eighteen and twenty-four.

As regards prognosis and treatment, the cases found in the
literature of the last five years do not offer sufficient data for guid-
ance. Of twenty-two cases reported during this interval by var-
ious writers, excluding those already quoted, the results were as
follows:

Died Recovered

Pregnancy artificially interrupted: 11 8 3

Pregnancy not interrupted: 11 S 6

Of those treated conservatively, one was cured by an injection of
salvarsan, one, showing a positive Wassermann, recovered, and one
was cured by the injection of 20 c.c. of serum from a pregnant
woman. Apparently these were mild cases while those in which
pregnancy was interrupted were severe, or abortion was resorted
to late. In only one case (Lepage) was abortion produced as early
as seventeen days from the onset of symptoms, without avail.
In 1898 Shrock published a series of cases showing:

hornstein: rarer forms of toxemia of pregnancy 273

Of 9S which went to term 8 died in labor

Of 19 ending in spontaneous premature labor 9 died postpartum

Of II ending in spontaneous abortion 2 died postabortum

and II died undelivered 11

Of 136 cases treated conservatively, 22 per cent, or 30 died.

In 9 cases premature labor was brought on 3 died

In 9 cases abortion was brought on, of which i died

Of 18 cases treated radically, 22 per cent, or 4 died

but of those where abortion was brought on, in other words where
pregnancy was terminated early, only one-ninth died. Some
German authorities advise early evacuation of the uterus as soon
as the diagnosis is made. Lepage, in reporting one case, collected
thirty-three fatal cases and compares the method of treatment fol-
lowed. Of this number, twenty were treated conservatively, and
thirteen were subjected to the emptying of the uterus. His cases
were collected from the literature covering the period between 1839
and 1909.

Case I. — A. N., para-i, aged twenty-two, Bohemian, seen April 23,
1 91 5. Patient has had no illness except an attack of sore throat at
the age of twenty and a mild attack of chorea at the age of twelve
simultaneous with the onset of menstruation. This attack lasted
ten days and has never recurred until the present.

On January 20, 191 5, she missed her menses and continued in
good health until March 24, when she began to experience twitchings
in the left hand, soon spreading up to the arm and becoming more
forcible and rotary in character. Within a few days the whole left
side of the body became affected, and at the end of two weeks the
whole body was involved. The contractions were becoming
constantly stronger and more frequent, and were excited by the least
disturbance; the taking of food was becoming difficult, the patient
had to be fed, and sleep was irregular and disturbed. In three
instances she had mild attacks of unconsciousness, lasting a few
minutes; there was little headache, and no vomiting; the bowels
moved daily, and there was no difficulty with urination. During
the fourth week the speech became scanning, and there was increas-
ing pallor.

Physical examination revealed a rotary motion of the eyes, vision
was not impaired, and the reactions were normal. The throat,
heart and lungs were normal; there was a slight enlargement in the
region of the thyroid; the fundus uteri extended to 2 inches below the
umbilicus. The superficial and deep reflexes were somewhat exag-
gerated, there was no Babinski's sign and no ankle clonus, but the
mentality was sluggish. The blood examination was negative, except

274 hornstein; rarer forms of toxemia of pregnancy

for anemia; the hemoglobin being 65 per cent. The temperature was
99.5, the blood pressure 125 millimeters mercury or hg.

The treatment consisted of complete rest in bed, milk, buttermilk,
cream, broths, eggs, and plenty of water; the administration of
arsenic, bromides, chloral, iron and, at night, a dose of opium.
There was no improvement, the appetite diminished, and there was
almost complete absence of sleep. The choreic movements were
becoming stronger, the pallor more pronounced, and the mental
condition duller. She also was harder to manage, as she grew more
excitable. It was then decided to terminate the pregnancy. On
April 27, at 9 a. m., under mild ether narcosis, the lower segment
and cervix uteri were packed with sterile gauze impregnated with a
solution of bichloride of mercury, i : 1000, and this was supported with
a vaginal pack. At the end of twenty-four hours the gauze was
taken out and the products of conception removed.

There was marked improvement after packing of the uterus, and
again, after the uterus was empty. Improvement from now was quite
rapid, the twitchings having disappeared at the end of three days,
when the patient could sleep throughout the night. She was dis-
charged eight days postabortum, well and out of bed, and there has
been no recurrence up to this date (December 15, 1915).

POLYNEURITIS GRAVIDARUM.

This affection, though not as common as chorea of pregnancy, is
probably not as rare as the scarcity of cases in the literature would
indicate, some of the cases being attributed to intoxications with
exogenous poisons.

The actual nature of the poison is as obscure as that of the more
common toxemias of pregnancy. Some cases have been preceded by
hyperemesis, while few have been accompanied by thyroid insuffi-
ciency. From a study of the few cases found in the literature cover-
ing the last five years, it appears that the condition is as common in
multiparas as it is in primiparae. The symptoms commence more
often during the third, fourth or fifth month and are characterized
by an acute multiple neuritis affecting all the extremities, some more
than others. In some, at least, the toes and fingers suffer less than
the rest of the limbs; there are often sensory disturbances like tin-
gling and burning sensations, and some impairment of sensibility.
There is seldom involvement of the sphincter control, though this has
been reported, and there is loss of reflexes. If the case progresses,
atrophy of the affected muscles sets in and the patient becomes
bedridden. If the paralysis sets in late in pregnancy, recovery may
be looked for, since the causal factor is removed before there is time
for the development of atrophy. Thus, Farani reports a case in
which polyneuritis preceded by diarrhea, and edema of the legs set in
near the end of the eighth month of gestation; the patient went to
term, had a spontaneous labor, and made a complete recovery.
When the onset is early in pregnancy, however, the paralysis may
persist for life, if the intoxication continues. In such case the

hornstein: rarer forms of toxemia of pregnancy 275

advisability of inducing abortion is to be carefully considered, and
the employment of the electric current, for the purpose of ascertain-
ing the condition of the muscles, will be very important. Seige
reports the case of a primigravida aged twenty-three, who was
affected with polyneuritis in the third month, after persistent vomit-
ing which lasted ten weeks; the vomiting ceased in the fourth month
and the patient made a slow, but full recovery. The neuritis in
this case was attributed to the marked cachexia which followed
the vomiting. Of thirty-four cases collected by Hoesslin sixteen
gave histories of marked vomiting. Spire reported one case and
collected five others which had no vomiting. In Spire's case,
the onset was in the sixth month, with cramps followed by poly-
neuritis, incontinence of urine and feces, pigmentation of the skin
of the face, and rapid pulse. Premature labor was induced in the
seventh month and the woman recovered very slowly, although the
paralysis and pregnancy had only coexisted about six weeks.

Case II.* — R. C, para-iii, aged twenty-four, born in U. S.; pre-
vious illness: measles. Menses started at thirteen and were always
normal. No exposure to alcohol or lead; both children are healthy.

The patient came under observation when seven months pregnant.
She was then bedridden, all the extremities were paralyzed and more
or less atrophied, especially the lower extremities, and right upper;
there was very little power in the toes and fingers, none in the right
leg and arm. She gave the following history: In November, 1914,
when in the third month of gestation, she was seized with headache,
dizziness, vomiting, and loss of power in the right arm and left foot.
The next day, she lost her power of speech and power of left hand
and right leg. There was no sensory aphasia and no loss of conscious-
ness, no disturbances of sensation, of the special senses or of sphincter
control. After three days the speech came rapidly back and she
experienced slight cramps in the legs and numbness and tingling
in the arms and legs. The left hand gradually improved and, under
treatment with the electric current, there was some improvement in
the other extremities. There was at no time facial paralysis. There
were no convulsions.

Examination of the blood for the Wassermann reaction proved
negative and, as the process seemed to be arrested at the time she
was first seen, there was no indication for interference with preg-
nancy. The electric treatment was continued and she was allowed
to go to term, when she was delivered by the aid of "low forceps"
of a normal baby. At this time there was fairly good motion in the
left hand but the other limbs were of slight use.

Outcome: December 15, 1915, very little additional improve-
ment, patient is still unable to make much use of legs and right arm.

BIBLIOGRAPHY.

Hannes, V. Prakt. Ergebn. d. Geburl. u. Gyn., Bd. iii, p. i, 1911,
Engelhard, J. L. B. Zeitschr. fiir Geburl. 11. Gyn., Bd. vii, op. 727
1911.

* I'rom the service of the Free Out-door Maternity Clinic.

276 babcock: treatment of tragic forms of rupture

Chotzen. Berliner klin. Wochenschr., No. 14, 191 2.

Kramer. Berliner klinisclie Wochenschr., No. 14, 1912.

Haertel. Jahresbericht d. Geb. u. Gyn., 1912, p. 557.

Berecz. Jahresbericht d. Geb. u. Gyn., 191 2, p. 529.

Nicolauer. Berliner klinische Wochenschr., No. 14, 191 2.

Seige. Deutsche Mediz. Wochenschr., No. 22, 1911.

Dieckman. Zentralblalt f. Gyn., "No. 22, igii.

Courant. Zentralblatt f. Gyn., No. 22, 1911.

Fraipont. Scalpel et Liege Medical, 1913.

Birnbaum. Prakt. Ergebn. d. Gebiirt. u. Gyn., 191 1.

Albrecht. H. Zeitschr.f. Gebnrt. u. Gyn., p. 677, 1915.

Muhlbaum, A. Prakt. Ergebn. d. Geburt. u. Gyn., 1914.

Kolde, W. Cenlralblatt f. Gyn., p. 989, 1914.

Potocki et Sauvage. Bull, de la Soc. d'Obst. et deGyn., Paris, 1913.

Lepage. Annal. de Gyn. et d'Obst., 1913.

Keator, H. M. Amer. Jour, of Obst., 1912.

Apert et Rouillard. Bull, et Mem. de la Soc. d'Hop. de Paris, p.

389, 1913-
Pinard. Bull, de la Soc. d'Obst. et deGyn., Paris, 1913.
Croft. British Medical Journal, p. 872, 1910.
Wall and Andrews. British Medical Journal, p. 223, 1914.
Shaw, William F. British Medical Journal, p. 223, 1914.
Farani, A. Zentralblatt f. Gyn., p. 802, 1914.
Kaufman. Jahresbericht d. Geburt. u. Gyn., p. 541, 191 2.
Spire. Bull, de la Soc. d'Obst. et de Gyn. de Paris, p. 500, 1913.
Seige. Deutsche Med. Wochenschr., No. 22, 191 1.
1427 Madison Avenue.

THE TREATMENT OF TRAGIC FORMS OF RUPTURE IN

ECTOPIC PREGNANCY BY VAGINAL SECTION AND

THE APPLICATION OF A CLAMP.

BY
W. WAYNE BABCOCK, :M. D.,

Surgeon to the Samaritan and Garretson Hospitals,
Philadelphia, Pa.

The predominant condition present when a tubal pregnancy
ruptures or a tubal abortion occurs is that of intraabdominal
hemorrhage. This hemorrhage tends to continue until the patient
is shocked or exsanguinated, and at times is fatal.

The reports of coroner's physicians and the experience of many
surgeons show that in certain cases the hemorrhage is not self-
limiting, but tends to continue or recur until the patient dies.
Despite the experimental studies in animals indicating that death
does not follow from hemorrhage when the ovarian arteries are

b,\bcock: treatment of tragic forms of rupture 277

divided or the abundant clinical evidence that under rest and nar-
cotics spontaneous arrest of the bleeding occurs in many cases of
extrauterine pregnancy, the fact remains that there are certain
so-called tragic cases in which the patient usually dies, unless the
hemorrhage is controlled by operative intervention.

Unfortunately, no method of examination has yet been devised that
will enable one to accurately prognosticate those cases in which the
bleeding will cease spontaneously and those in which it will progress
to a fatal issue. Early operation especially is suggested for those
patients whose alarming and progressive symptoms lead one to
fear a tragic form of rupture. It is important, however, that the
measures taken to arrest the bleeding do not in themselves destroy
the patient. A patient with a ruptured ectopic pregnancy suffers
from a shock produced first by the loss of blood, and second, from
the shock produced reflexly by the peculiar irritant action of the
blood upon the peritoneum. The irritating action of the blood
upon the peritoneal surfaces is evidenced by tenderness, pain,
nausea or vomiting, and rapid fall of blood pressure, which imme-
diately follows the contact of blood with the peritoneum. This
shock from the mere contact of blood with the peritoneal surface
is a normal protective reflex, designed to so lower the blood pressure
as to diminish the bleeding. It is a very important but ignored
factor in increasing the danger of tubal rupture.

In patients dying from a ruptured ectopic pregnancy, much less
blood may be found in the abdominal cavity, than is lost without
very alarming general symptoms, during a miscarriage or labor.
The shock, therefore, produced by the contact of blood with the
peritoneum is one of the great sources of danger from intraabdominal
hemorrhage. When to this is added the further irritation and shock
produced by the exposure of the peritoneum to air, irrigation,
sponging and handling, the balance may be turned against the
patient.

In the treatment of ruptured tubal pregnancy by an abdominal
section, therefore, the patient suffers with shock from loss of blood,
plus that from the peritoneal reflex, and, finally, has added the shock
of the operation with the inevitable exposure of the peritoneum to the
air, and to the handling, mopping, and possibly washing of peritoneal
surfaces in the endeavor to free the abdominal cavity of liquid and
clotted blood.

I think that there is no doubt that in many cases this superadded
shock of an abdominal section is the important factor in determining
the patient's death. It is true that many patients die without any
8

278 babcock: treatment of tragic forms of rupture

operation, but it seems likewise to be true that many patients die
more rapidly and more sureh' because the operation is done, while
it is now recognized that a large proportion recover under a simple
expectant treatment.

The ideal treatment for ectopic pregnancy should be the immediate
control of the bleeding area without increasing the shock by expos-
ing the general peritoneal cavity. Fortunately, this may be ac-
complished by a method so simple as to be capableof an apts.lica-
tion without trained assistance, with but few instrumenp and
without special preparation, and even in the patient's own home.
During the past ten years all the patients who have come under
our care with alarming symptoms from ruptured extrauterine preg-
nancy have been treated in this manner, and there has been no
mortality from the operation. In a total of twenty-four cases, in
one instance the patient died about two weeks after the opera-
tion from pneumonia. In no instance was a secondary' operation
necessary, and the final conditions of the other patients has been
gratifying.

The contrast between the results obtained by this method and
those I have obtained from abdominal section is such, that I am
convinced that this is the safest method yet proposed for the
treatment of at least the tragic forms of rupture. The method is
as follows:

Anesthesia. — For most of our patients spinal anesthesia has been
employed, novocaine or stovaine being the drugs used. While
our results have been satisfactory, in cases of severe shock, spinal
anesthesia as it is usually employed is dangerous, and, as a rule,
a light ether anesthesia should be preferred.

Operation. — The patient is placed in the lithotomy position, the
usual vaginal preparation made, a posterior weighted vaginal
speculum introduced, the cervix grasped by a tenaculum forceps
and pulled downward and forward, the posterior vaginal fold
behind the cervix located, and the culdesac opened in the median
line by thrusting a pair of sharp-pointed scissors tlirough this line
toward the posterior uterine wall. The scissors is opened and
withdrawn, and the index-finger of each hand introduced through
the incision, and by traction the incision into the posterior culdesac
is widely enlarged. The escaping blood is disregarded, two fingers
are immediately introduced into the culdesac and swept to each
side of the uterus locating the tubal enlargement. The diseased tube
is freed by sweeping the fingers about it, and when thoroughly
isolated it is pulled down through the vaginal incision. This

babcock: treatment of tragic eorms of rupture 279

maneuver may be accomplished by the sense of touch alone. In
some instances, to expedite the separation of a very high appendage,
we have introduced a hand into the vagina, in others a ring or small
sponge forceps has been guided by the finger and used to grasp and
pull down the tube. The anterior vaginal wall being lifted by a
trowel, the affected tube with the ovary is pulled well down into
the vagina and a clamp applied close to the uterus. It is obvious
that the clarhp must be applied proximal to the point of bleeding.
In one of our cases the pregnancy involved the cornu of the uterus,
and after excising the tube, the area was closed by sutures. If the
patient's condition permits, ligatures may be applied to the broad
ligament proximal to the affected portion of the tube and to the
ovary. As a rule, this has little advantage over the simple applica-
tion of the clamp. The tube and ovary distal to the clamp may now
be cut away but care must be taken to leave a sufficiently large
pedicle and to see that the friable tissues do not slip from the grasp
of the clamp. Where the patient is in extremis nothing but the
appHcation of a clamp need be done at this time. A piece of gauze
sufficiently wide to fully occupy the vaginal incision is intro-
duced into the pelvis high enough to isolate the clamp from the
intestinal coils and to prevent the edges of the vaginal incision from
coming together. A second strip of gauze is introduced between the
vaginal wall and the clamp. As a rule, no large vessels are divided,
and the vaginal incision does not require ligature or suture. Irriga-
tion of the abdominal cavity should not be employed nor should
any special effort be made or time wasted in the endeavor to remove
blood or clots from the cavity. The blood will gradually drain away
after the patient has returned to bed.

The vaginal incision, application of the clamp and insertion of
the gauze drainage strips may all be accomphshed in from three to
ten minutes, and the patient is returned to bed with the hemorrhage
controlled, and with little increase in the preexisting shock. Usually
we have not been able to determine that the patient's condition
has been made any worse by the operation. Although some of
our patients were nulUpara and the small diameter of the vagina
interfered with the liberation and exposure of the tube, in no instance
was it necessary to abandon the vaginal route. In such cases,
however, those not familiar with the technic of vaginal section may
find the method difiicult.

In the after-treatment, one should avoid excessive hydremia by
the overuse of hypodermoclysis or saline transfusion. E.xcessive
stimulation and other disturbing factors should likewise be avoided.

280 cadwallader: strangulated ovarian cyst

As soon as the patient's condition will permit, the head and shoulders
are moderately elevated to favor drainage. Liquids are administered
by the bowel soon after the operation, and by mouth as soon as the
retentive power of the stomach returns.

At the end of forty-eight hours the clamp is cautiously opened
}/'2 inch, rotated ninety degrees in each direction and removed.
There is no special advantage, and probably some increased danger
in using a hgature instead of the clamp. The gauze is removed on
the fourth or fifth day, and usually does not require replacement.
The abdominal blood gradually drains through the vagina, or may,
in part, be absorbed. It is very important to aid elimination by the
daily use of saline laxatives as Soon as the patient's condition
warrants it.

The patient may sit up in bed at the end of a week or ten days, and
in favorable cases go home in a few days later. The shortest stay
in the hospital was eight days; the longest forty days. The mean
duration of hospital treatment was about twelve da,ys. The gauze
is usually removed about the fourth or fifth day, and as a rule, is
not replaced. In one instance an assistant removed the gauze about
twenty-four hours after operation, and there was prolapse of the
intestinal coils into the vagina. In this case only was a second
packing introduced.

To summarize, the method suggested enables one to immediatelj'
confirm the diagnosis and check the hemorrhage of tubal pregnancy
by a simple, rapidly executed operation, with little invasion of the
abdominal cavity, with little or no increase of preexisting shock, and
with an armamentarium so simple that the operation may be per-
formed on the bed of a country farmhouse.
2033 W.\LNUT St.

CESAREAN SECTION FOR STRANGULATED OVARIAN
CYST COMPLICATING LABOR.

BY
R. CAD\V.\LLADER, A. M., M. D.,

Professor Obstetrics and Abdominal Surgery, College of Physicians and Surgeons,
San Francisco, Calif,

Mrs. a. W., aged twenty-two, entered the San Francisco Hos-
pital, Jan. 17, 1916. Her family history was negative. She was a
well-developed and well-nourished woman near the end of her first
pregnancy. Her last menstrual period was May 3, and her cal-
culated time of labor, February 10.

cadwallader: strangulated ovarian cyst 281

She stated that her gestation was normal and that she had been
perfectly well until ten days ago when, after two days of uneasiness,
she was taken with a sharp pain in the right lower quadrant. There
had never been any prior attacks. This pain was steady, severe and
accompanied by tenderness. There was no fever, constipation or
tympanites. The movements of the child hurt her very much and
she could not lie on the right side. This attack lasted for several
days and then disappeared rather suddenly. After two days of free-
dom from suffering it returned on the i6th with increased severity and
she entered the hospital the ne.xt day after a sleepless night.

Upon her entrance the pulse and temperature were normal, but
soon began to rise steadily. I examined her soon after her admis-
sion. She was pregnant as stated, no cervical dilation, vagina
normal, all venereal history denied. The head was presenting and
lifting this up relieved the pain. The left side was free from all
tenderness but the right was very sensitive. Pressure of the head
to the right gave her much suffering. There was a marked tender-
ness over McBurnay's point and any pressure on the abdomen that
pushed the uterus to the right, intensified the pain. A bimanual
examination elicited an ill-defined sense of there being some mass in
the pelvis above the head, but she was too tender to permit its real
palpation. The abdomen was relaxed. She complained of a con-
stant severe pain, intensified by every movement of the child.

I decided to apply hot compresses, put on a snug abdominal
binder and watch her for a few hours. This gave but little relief
and on the 19th I had a consultation. She had had two sleepless
nights and all her symptoms were aggravated. The chart showed a
steady rise of pulse and temperature. My consultant inclined to the
diagnosis of appendicitis and to this I, with reservation, concured.
To me it seemed strange that if it were appendicitis it had not been
set up earlier in her gestation or given some previous trouble.
Her blood pressure was normal and no leukocytosis was present. We
agreed that in the light of two days of pain with an increasing pulse
and temperature there must be a pathologic condition of sufiicient
severity to amply justify surgical interference and because of her
near labor this would have to be preceded by a Cesarean section.

The same evening a Cesarean section was done and a 7 -pound
male infant extracted. It was noticed on opening the abdomen that
there was an extra amount of fluid present and some congestion of
the peritoneum.

On turning the uterus over an ovarian cyst with a pedicle several
inches in length was found, dark brown and almost gangrenous. It
was strangulated by three distinct turns to the right. Its pedicle
was transfixed, ligated and the cyst removed. The appendix was
some 5 inches long, very thick and congested and was removed.
The peritoneum contigubus to the cyst was generally congested.
The left tube and ovary, the latter bearing a corpus luteum, were
normal and were left. She was not sterilized.

Her recovery was uneventful except for an unusual degree of dis-
tention from gas. She nursed her baby, temperature never ran

282 STEWART: FRIED WOUND DRESSINGS

over the usual surgical fever; she was in a chair the tenth day;
stitches were removed the eleventh day. She was discharged Feb-
ruary 2, having been walking about the ward for several days.

She called to see me at my ofSce with the baby on February 21,
saying she was never in better health, but worried because the baby
was vomiting after each nursing. It was merely getting more milk
than it could hold.

240 Stockton St.

FRIED WOUND DRESSINGS.

BY
DOUGLAS H. STEWART, M. D., F. A. C. S.,

New York City.

This brief article is inspired by the following facts:

1. The American Journal of Obstetrics published a paper
entitled "Wound Dressings," February, 1916.

2. Inquiries abounded. The nearest source was a man from the
next street: the farthest. The Baptist Mission Hospital in Hanyang,
via Hankow, China. The Medical Press of Dublin pubHshed the
paper in full, with credits, March 29, page 286.

3. If this present writing does not answer all questions fully and
thereby cause the inquiries to cease, then the writer will be compelled
to have form letters printed embodying the answers, and he will
mail those to the questioners.

4. The Censor has delayed and opened the letters from British
sources, therefore, the author must be under suspicion of some sort
which The American Journal of Obstetrics really owes it to
him to remove; at least it might attempt to remove that suspicion
by pubhshing an inconsequential but necessary explanation, such
as this is meant to be.

In frying bandages at the Knickerbocker O. P. D., the nurse uses
an ordinary gas flame from a two-burner gas stove; upon the top of
such a stove she places a toaster to prevent burning the lard. Then
in a deep but narrow stewpan or an agate pail she places a saucer
bottom up to prevent the bandages coming in contact with the
metal bottom. Upon the saucer she places four pounds of lard,
turns on the gas, lights the flame and melts the lard. Using a long
bullet forceps she picks up a drop or two of water, occasionally,
and drops it into the molten lard because when the latter "spits"
the temperature is correct (300° or over). Then she takes
\vii)es which have been done up in packages of four and tied mth
thread. These she puts into the boiling lard, which, after the habit

STEWART: FRIED WOUND DRESSINGS 283

of boiling lard, is still and does not bubble. On contact, the air is
driven out of the bandages and the whole boils furiously, especially
at the edges of the wipes (points of contact). As soon as the boiling
becomes less vigorous another package is added and then another
until the pail or receptacle is filled to within two inches of the top.
Inasmuch as the wipes float they must be submerged by pushing
them under with the long forceps. When the can is sufficiently
full a saucer should be placed on top of the wipes and a piece of
gauze put in as an indicator. WTien the latter has become a light
brown, but not charred, merely slightly scorched, then the flame is
turned off and the whole allowed to stand and cool to i8o°. A
sterile towel is spread over an enameled dish or wash basin, the
wipes picked up with the bullet forceps and laid therein and the whole
covered either with the same towel folded or with an additional
one.

The results of placing wipes which are impregnated with lard
and which have been subjected to a temperature of 340°, over
one hundred degrees above the boiling point of water, maybe easily
foretold. They are germless and will not adhere to wounds. Any-
one who has fried doughnuts can readily fry wipes. The question
is often asked: "Will an oil {e.g., oUve oil) answer as well as lard?"
The present writer can see no reason why it should not, but the
lard-fried bandages proved to be so good that he was never temp-
ted to investigate the properties of the oils for this purpose.

The common mistakes made by a green hand are due to the
facts here enumerated:

1. Does not know what boiling lard looks like.

2. Does not turn out the flame if the lard begins to burn.

3. Uses too much heat after the lard is raised to boiling.

4. Does not know that water in boiling lard will spatter.

On each and all of which any good cook can give valuable advice.

One questioner wishes to know: "If aristol is put on a wound
will the fiied dressing work?" Ans.: Perfectly well. The dressing
will dissolve the aiistol, but this is no disadvantage. Aristol is
perfectly soluble in melted lard but the heat turns it into iodine
and the latter is soon driven off. With care the hot wipes may be
powdered with aristol; this turns into iodine and sinks into the
fabric leaving the characteristic stain (red brown). There is no
advantage in this. The idea is to prepare a nonsticking germless
wound dressing or drain. Careful frying does this admirably and
unfailingly. Success depends on the cook.

128 West Eighty-sixth St.

284 TRANSACTIONS OF THE

TRANSACTIONS OF THE NEW YORK
OBSTETRICAL SOCIETY.

Meeting of March 14, 191 6.
The President, Dougal Bissell, M. D., in the Chair.
Dr. Edward W. Pinkham reported a case of

CESAREAN SECTION FOR DYSTOCIA DUE TO DOUBLE UTERUS AND
FIBROIDS.

The patient Mrs. M. S., married four years, aged thirty, was first
seen on December 12, 1915. She gave a liistory of a spontaneous
miscarriage two years ago at two months. Her last menstruation
occurred during the last week of May, 1915, and life was felt the
latter part of October. The patient was a well-developed woman
with normal pelvic measurements. Bimanual examination showed
an enlarged uterus extending about three fingers above the umbihcus
and several hard masses on the left of the uterus. There were two
vaginal canals and two distinct cer\'ices. The patient was admitted
to the Woman's Hospital on February 14, 1916, in labor. Examina-
tion showed the cervix on the right side slightly patulous, while the
OS on the left side admitted the forefinger. The pains, which were
irregular and without much force, continued through the day and
until the next morning when they became regular and stronger.
Examination on the morning of the i6th showed practically no
dilatation of the right cervLx, while the left was a little more patulous.
During a pain the uterus assumed a distinctly elongated shape and
it was almost entirely on the right side. The masses on the left
side were apparently causing a dystocia and on consultation with
Dr. F. A. Dorman a Cesarean section was decided upon and per-
formed. A live baby weighing 5 pounds 3 ounces was extracted.
E.xamination shov/ed a distinct uterine body on the left side about
the size of a large pear joining the pregnant half at the level of the
internal os. There were two pedunculated fibroids attached to the
same and a normal tube and ovary. The accompanying diagram
shows the anatomical arrangement and the .x-ray picture the duplex
formation of the organs.

DISCUSSION.

Dr. Edwin B. Cragin, in opening the discussion said: ''There
are several interesting features about a uterus didelphys, such as
this is, complicating labor. It has been my misfortune to meet

NEW YORK OBSTETRICAL SOCIETY 285

with two of these cases and it is just the didelphys type that
causes trouble. In my first experience the unimpregnated half so
narrowed the canal that in delivering through the impregnated half
a rupture occurred between the two halves and I had to open the
abdomen and remove the smaller obstructing half and sew up the
rent. In the second one I had the same dystocia as that shown by
the reader of the paper and I did as he did, a Cesarean section.

Fig. I. — Pinkham — Double uterus.

It is well to bear in mind that while a uterus septus or bicornis gives
ver}- little dystocia as a rule, a uterus didelphys may from its unim-
pregnated half, give practically the same dystocia as a fibroid and
that often Cesarean section is the best way to solve the problem."
Dr. Hir.\m N. Vin'eberg. — "I am very much interested in this
case because of the fact that about three weeks ago it was my lot
to deliver a woman with a uterus didelphys, as far as I could make
out. She had two distinct vaginas and two cervices, and when
she came to me the first time she was about eight weeks pregnant

286

TRANSACTIONS OF THE

and I could make out the larger uterus on the left side and the
smaller one on the right side. She went on to full term without any
mishap and had a perfectly normal delivery. The right half gave
no trouble. The head as it came down tore away the septum.
I had absolutely no trouble with it then. The only difference noted
from the ordinary case was that on the second or third day the
woman had a slight temperature and on compressing the right half
(that is, the uterus that was unimpregnated) there was a good deal

Fig. 2. — Pinkham — Double uterus and fibroids.

of decidual membrane expressed, but in other respects the patient
made a perfect recovery."

Dr. Brooks H. Wells.— " There have been quite a number of
cases reported in the literature of pregnancy in one or the other
horn of a uterus didclphys. Sixteen years ago I reported four
cases before this Society, and at that time I looked up tlie literature
and found over loo cases reported. Since then I have had several
other cases where pregnancy has occurred in a uterus didclphys.
In one where there was a very perfectly separated pair of uteri
with double vagimc and originally a double imperforate hymen,

NEW YORK OBSTETRICAL SOCIETY 287

labor went on normally except that the central band in the vagina,
which ran all the way up to the cervix, was pushed down in front
of the baby's head so that it became necessary to divide the band.
One point which has not been brought out in the discussion is the
great hability to uterine rupture in these cases."

Dr. J. Milton Mabbott, — "I recall two unreported cases at-
tended by me. One was a private patient in the old Nursery and
Child's Hospital. The other was a patient in private practice.
Both were delivered at full term without any unfavorable incident.
The septum of the vagina; was allowed to rupture with the progress
of the head without artificial help. The deliveries in the first
pregnancies were both normal. The second case (the one in private
practice) was so normal after delivery that I assumed that a future
delivery would probably be simpler than normal; but the woman
assured me that if she became pregnant again she would come
back to New York, she then being about to go to California to
join her husband. About two years later she came back and had
such an easy delivery that, being called early in the morning,
I was at the house within an hour and the baby was born upstairs
as I was ringing the door bell downstairs. So those are two cases
that I can add and the three deliveries were perfectly normal."

Dr. Edward W. Pinkham. — "The only thing I would say in
answer to Dr. Vineberg is that we gave this patient a good long trial
to see if she couldn't dilate the os and have a normal delivery
through the normal channel, but there was no attempt at all of
the right os to open. Evidently it was being pushed over to the
other side by the tumors, and if there had been no dilatation from
the time she began to have her regular pains until we had the con-
sultation, it seems to me that the baby couldn't be born in any other
way except by pursuing the procedure which I did."

Dr. Hiram N. Vineberg. — "I would just like to add one thing.
In the unimpregnated uterus when labor was fairly well advanced,
that is, when the cervix of the left uterus was dilated, the cervix
was dilated to the extent of almost one iinger and it dilated so that
I could insert a finger up to the internal os. I don't know whether
any one else has noticed that in these cases."

Dr. LeRoy Broun presented a report on

SPINDLE- and giant-celled POLYPOID SARCOMA OF THE UTERUS.

Miss E. B., aged seventy, was admitted to the Woman's Hospital
with a history of normal menstrual conditions and a menopause at
fifty-four. Since September, 1915 the patient had had an irregular
bloody vaginal discharge which gradually increased in amount.
A general discomfort in the lower abdomen was complained of and
although no loss of weight occurred the general physical condition
seemed poor. The heart showed a distinct systolic murmur but no
hypertrophy. There was a marked trace of albumin present but
no casts. The blood count showed 4,160,000 red cells and 70 per
cent, hemoglobin, with a normal white cell count. Pelvic ex-
amination showed an atrophied senile vagina and a tumor apparently
filling the pelvis. During the manipulations of the bimanual

288 TRANSACTIONS OF THE

examination an abundant purulent discharge resulted. A com-
plete abdominal hysterectomy was done after the patient had
been in the hospital a month, on February lo, 1916, which was
followed by an uninterrupted convalescence. The physical con-
dition was greatly improved at the time of the patient's discharge
about a month later.

The pathologist's report on the specimen was as follows:

Diagnosis. — Sarcoma uteri polyposum fusi and gigantocellulare.

Macroscopical: Uterus with both adnexa, cervix was received
separately. Uterine body is balloon shaped and measures 13 cm.
in diameter. Uterine myometrium is about 8 mm. thick. The
uterine cavity is greatly enlarged. From the lateral portion of the
uterine mucosa arises a polj'poid tumor mass of oval shape measur-
ing 10 X 8 cm. The surface is yellowish in the portion adjoining
the mucosa. The tip is dark red. On section the lower portion of
the conical tip is purple grayish, the portion nearer the mucosa white,
fibrous and hard. The cervix which was received separately shows
no marked changes. Adnexa are of normal appearance. A sub-
serous myoma of about 3 cm. diameter shows a completely calcified
capsule.

Microscopical: Section of the polypoid tumor shows that the
largest part of the tumor is composed of spindle cells of different
sizes. The enormous variety of the nuclei as regards size and
staining properties, numerous giant cells of an irregular type
scattered in the tissue and masses of mitoses give the section the
appearance of intense optical unrest. Necrotic tissue between these
portions. No normal fibers nor muscular tissue in any part of the
section.

The pathologist did not regard the specimen as a sarcomatous
change of a myomatous tumor but as a sarcoma of the musculature
of the uterus which in its development took on a polypoid form.

Dr. Hiram N. Vineberg reported a case of

STREPTOCOCCEMIA, LEFT OVARI.\N STREPTOCOCCIC ABSCESS AND

STREPTOCOCCIC LYMPII.\NGITIS AND PHLEBITIS OF THE

UTERUS. PANHYSTERECTOMY. RECOVERY.

M. C, aged seventeen years, married twelve months, was
admitted to his service at Mt. Sinai Hospital, Feb. 16, iqi6. Seven
days before, she had had a normal delivery, on the third day, post-
partum, she had a severe chill followed by high fever, which per-
sisted to the time of her admission. With the onset of the chill the
patient suffered with cramps in the lower part of the abdomen.
On the morning of admission, temperature was 104.6°, pulse 120,
respiration 32. The young patient was very stout and her general
appearance cjuite good. The uterus reached to the umbilicus and
leading from the right cornu, a small oblong, hard mass could be
indistinctly palpated. There was considerable tenderness at this
point. Nothing abnormal was detected on the left side. At mid-
night, temperature 98.4°, pulse 90. Feb. 17, a. m. temperature
104.8°, pulse 120.

NEW YORK OBSTETRICAL SOCIETY 289

At lo.oo A. II., the interior of the uterus was gently gone over with
a dull curet by my associate Dr. Sol. Wiener and several shreds
of tissue were removed. This was followed by an intrauterine irri-
gation of weak iodine solution. Half an hour later, a blood culture
was taken, this showed, within twenty-four hours, numerous
colonies of hemolytic streptococci.

At '5.00 p. M., the patient had a very severe chill, lasting an hour
and ten minutes, the temperature at 8.00 p. M. reached 106°, pulse
120, respiration 34. A blood count taken at the same time of the
blood culture, showed white cells, 14,000; polynuclears, 81 per cent.;
lymphocytes, 19 per cent.; hemoglobin 65 per cent. At midnight,
temperature had fallen to 101.8°, pulse 112. Feb. 19, a. m. tem-
perature 104.2°, pulse 140, respiration 32. In view of the positive
blood culture and the local conditions present, favoring the assump-
tion of a septic thrombophlebitis, it was Dr. Vineberg's opinion that
the only chance of saving the patient, lay in a total hysterectomy
with ligation of the involved vein or veins. Accordingly, a pan-
hysterectomy was performed on Feb. 19, at 10.00 a. m., the tenth
day postpartum.

On opening the abdomen, a considerable quantity of tinged serum
was found free in the peritoneal cavity. A tongue of omentum was
adherent to the right cornu of the uterus. This constituted the mass
that was felt on bimanual examination. There were no adhesions
or exudates, elsewhere. The left ovary appeared rather large,
but not until later, during the manipulations in performing the
hysterectomy, was it detected that pus was exuding from its surface
and, that there was an escape of pus from the uteroovarian ligament.
Fortunately, at the outset of the operation, the intestines were care-
fully protected by gauze compresses and packings. The operation
offered considerable technical difficulties, particularly, in the excising
of the uterus, together with the cervix, owing to the great obesity
of the patient and to the inadvertence of an interne who failed to
catheterize the patient on the table. Nevertheless, the patient with-
stood the operation particularly well. The skin and fat layers were
merely strapped together with adhesive strips and drained with a
strand of gauze.

Feb. 20 and 21, first and second day postpartum, temperature
ranged from io3°-i05°, pulse 120-144. Patient had a severe
bronchitis. Feb. 22, 23, and 24, temperature ranged from ioi°-io3°,
pulse 116-124. The abdominal wound showed very extensive sup-
puration of the fat layer. On this being freely laid open and wet
dressings applied, the temperature fell almost to normal, within
a few days and the patient, now is up and about and the wound
almost healed. A blood culture taken Feb. 21, two days after opera-
tion, was entirely negative.

Report from the Pathological Laboratory.

Specimen consists of uterus and both adnexa. Uterus is about
the size of a five days' postpartum uterus. The mucosa and uterine
wall show no particular variation from that expected in the uterus
of this type. Both tubes are normal. The right ovary if normal

290 TRANSACTIONS OF THE

shows numerous microcysts. No evidence of inflammation. The
right ovarian vessels are open. The left tube is normal. The left
ovary is markedly edematous showing at its hilus an abscess cavity
about 1.5 cm. in diameter, which extends into the mesovarium
beneath the peritoneum and has perforated through the meso-
salpinx. The vessels on this left side contain fresh blood clot. On
section, this edematous left ovary is riddled with small purulent foci.

Microscopical examination shows the presence of multiple ovarian
abscesses, one large one at the hilus extending into the mesovarium
and mesosalpinx. A few of the lymphatics and veins of the uterus
contain organisms in chains (streptococci.) The placental site
shows extensive necrosis, numerous streptococci, especially on the
surface. (Placental site situated on the left fundal wall.) The
lymphatics and veins of the broad hgament also contain cocci, as do
the abscesses and surrounding tissue.

Comments. — It will be seen that, although the clinical picture
pointed to septic thrombophlebitis, none of the veins showed
thrombosis, in spite of the fact that they contained streptococci.
This can be explained by the very marked virulence of the cocci,
inasmuch as was demonstrated by V. Bardelbein's {Archiv f. Gyn.,
p. 83, 1907), experimental researches that when the microorganisms
are very virulent, they pass directly through the veins without
producing an}' local disturbance and enter the general blood current.
The local action of the microorganisms on the left side (the ovary
and mesovarium) finds its explanation in that the lymph vessels also
were involved. Hence, the occurrence of the abscesses in the ovary
and mesovarium. It is interesting to note in the pathological
report that the placental site was situated on the left fundal wall.

In this case, had no operation been done and the streptococcemia
had not, of itself, proved fatal, there can be but slight doubt that a
general peritonitis would have developed within a short time, as the
abscesses in the left ovary and mesovarium were ready to burst and
discharge their contents into the general peritoneal cavity, for
there were no adhesions in this area and the omentum was drawn
far away from that side, by the only adhesion present, to the right
ovarian vessels. Already the toxines liberated had caused a large
amount of free serous fluid in the peritoneal cavity and it needed
only the setting free of the germs themselves to bring about a
Joudroyante septic peritonitis. There would have been present
then, the rare combination of streptococcemia and septic peri-
tonitis, such as occasionally is found described in the literature.
A study of the clinical liistory, together with that of the pathological
report on the specimen, should, in our opinion, convince any un-
biased mind that the operation saved the life of the patient.

DISCUSSION.

Dr. Edwin B. Cragin, in opening the discussion, said: "I would
like to congratulate Dr. Vineberg on the result of this case. At the
same time I should hate very much to have it go out as the con-

NEW YORK OBSTETRICAL SOCIETY 291

sensus of opinion of this Society that many cases of puerperal
infection are to be treated by hysterectomy. Dr. Vineberg, I think,
deserves credit for saving this woman's Ufe, and yet if that procedure
were followed very often a great many women would be killed that
otherwise would get well and a great many would be unsexed that
otherwse would retain their generative organs. The cases that
can be saved in a general puerperal infection by hysterectomy I
believe are very few. A great many of them that look as though
they were going to die wiU get weU. There are a few cases where
there are abscesses located in the uterus, where Nature is able
to circumscribe the process, which you will save by hysterectomy,
but I think the mortality is always exceedingly high from this
procedure. I know I have lost three out of five and I believe that
the number in which it is indicated is so exceedingly small that it
must be considered a very rare indication; that the majorit}' of
cases will do better if let alone — simply elevating the head of the
bed for drainage, giving them plenty of fresh air and not doing
harm by opening new avenues of infection; that the cases that are
benefited are usually those at the end of several weeks where Nature
has been able to localize the process; that it is very rare that you will
save them in the first week or the second week. Occasionally
in the third or fourth or fifth you -will be able to save them if you
get at the localization of the process in the uterine wall, but I think
that unless you can get evidences of localization of the process, as
I think very likely Dr. Vineberg did by feeling a mass at the horn
of the uterus in this case and can feel that there is an abscess in the
uterus, I think the uterus had better be let alone."
Dr. W. H. W. Knipe presented a report of a case of

PUERPERAL STREPTOCOCCEinA. RECOVERY.

The patient, aged thirty-four years, a para-vii whose previous
history was uneventful except that for one month previous to her
admission to the hospital she had been confined to her bed at home,
sent for the ambulance because of pains low down in the abdomen
upon both sides, chills and fever. The ambulance surgeon upon his
arrival at the patient's home delivered her of a strong living female
child on January lo, 191 6. During the next day the patient was
brought to Gouverneur Hospital because there was no one at home
to care for her. Upon arrival at the hospital patient's temperature
was normal, pulse 106, blood pressure 115; she was fairly well
developed and nourished but her face was very pale and anemic.
Within forty-eight hours her temperature rose to 105° F. and pulse
to 144, and vaginal examination showed the fundus of the uterus
six fingers above pubis, hard and contracted, but on either side of
the pelvis were felt hard fibroid-like masses which were immovable,
not particularly sensitive, which seemed to merge into the lower zone
of the uterus and which were designated as diffuse pelvic celluhtis.
The lochia was normal in character and amount, the urine from a
catheterized sterile specimen showed numerous pus cells, otherwise

292 . TRANSACTIONS OF THE

normal, acid, sp. gr. loiS, no albumin, no sugar, no casts. The
blood showed a leukocytosis of 17,400 with a polynuclear count of
87 per cent. A blood culture was sterile at the end of eighteen hours,
but after forty-eight hours' incubation a growth appeared which
was finally and definitely isolated as streptococcus hemolyticus.
A second blood culture taken four days later also showed after
forty-eight hours' incubation a growth of streptococcus hemolyticus.
A third blood culture taken thirteen days after admission to the
hospital showed no growth and a fourth culture taken twenty-four
days after admission showed no growth. The temperature chart
shows a typical septic temperature ranging between 99° F. and
106° F., with decided chills lasting half an hour sometimes twice
a day, sometimes once in two or three days. The patient's pulse
varied between 90 and 144 and she maintained she felt pretty well
and complained only of the chills and the sweats which followed.
Upon the thirty-seventh day in the hospital the patient's tem,-
perature became normal and remained so and she was discharged on
the fifty-third day with a uterus of normal size and position. The
pelvic cellulitis had entirely disappeared on the right side of the
pelvis but on the left side there still remained a small amount
of induration.

The treatment in this case consisted in conserving the patient's
natural resources by forbidding meddlesome interference and con-
sisted of posture (Fowler's position) to help drainage of the uterus,
forced liquid feeding, cold fresh air in the room, an ice cap to the
abdomen, some vaginal douching to secure superficial cleanliness
of the vagina and the use of urotropin and sodium benzoate for the
pyelitis which was also present in this case.

Dr. Robert T. Frank, in discussion, said: ''There are two points
that I would like to emphasize. The first one is that a blood culture
taken a short time after anj^ uterine interference is apt to be mis-
understood because any uterine interference in a septic case com-
monly spreads bacteria in the blood stream. The question then
arises as to whether these bacteria are able to multiply in the blood
or not. Clinical observations have shown that a blood culture taken
a few hours after intrauterine irrigation may be positive and that
the patient's blood twenty-four hours later remains sterile. There-
fore, a blood culture should always be taken previous to any
interference.

"The second point is that, although the prognosis in streptococcic
bacteremia is grave, still it need not necessarily be fatal, and that
particularly in those cases in which local foci, such as ovarian
abscess, pyonephrosis or any other abscess develop, the prognosis
is much improved."

Dr. Asa B. D.wis. — "I would like to endorse the sentiments that
have been expressed here to leave these cases alone. I am very
positive about that after watching them for a number of years, and
a good many of them, and we get better results from not doing a
hysterectomy, not tearing off the veins and not adding to the load
that the patient already has. We don't curet them and, so far as

NEW YORK OBSTETRICAL SOCIETY 293

we are able to, we put them on the roof, raise the head of the bed
and place an ice bag over the abdomen. We don't douche them.
We do insure drainage. We do insure emptying of the intestine
and then such diet is given as we can get them to take — a mild diet
suiScient for nutrition, stimulation when necessary and beyond
that we let them alone.

"Operations do not save many Hves in these cases. I think that
they destroy a good many. I have tried to convince myself of cases
that were suitable to operate upon for pelvic phlebitis and I failed
to find one. I think that at the time a pelvic phlebitis is present the
harm has already gone beyond that area.

"I'm not a pathologist or a bacteriologist, but we do seem to find
cases of streptococcemia of different virulence where we recover
bacteria from the blood and yet a considerable number of these cases
will get well. I think that is the experience we had while Dr. Harror
was trying out the magnesium sulphate solution. For a while he
got excellent results, then there came a group of cases where there
was apparently no result at all; so it was a negative aid, but for a
time we appeared to be getting results from that method of treatment.
I recall two cases of abscess of the lung, streptococcemia, where the
abscess ruptured out through the bronchi and yet they recovered.
One of them was in the hospital seventy-nine days and the other was
there eighty days. They were very sick women. At times we got
positive cultures from the blood, but at times they were absent,
then they recurred.

Dr. John O. Polak. — "I have been very much interested in the
report of Dr. Vineberg's case and the treatment employed because
it is so different from the plan of treatment which we have been
following and I cannot but feel that with the pathology he cited
that this was a case that would have gotten well if it had been let
alone. I feel that he is to be congratulated on the fact that the
patient got well in spite of his surgery rather than he saved her life
by surgery. I say this frankly because it has been my privilege
to operate on a large number of patients who have been in our service
during their acute infection with very much the same history as he
has given, at periods of from six months to two years and I have been
able to see the inside of the abdomen in these cases and what wonder-
ful protection Nature is able to give with the aid of the omentum.
In the case which the doctor described the omentum was already
attached and together with the sigmoid would probably have isolated
the ovarian abscess. We have twenty cases all of which were care-
fully cultured, where hemolytic bacteria were recovered both in the
uterus and in the blood, with but two deaths, treated by the method
Dr. Davis has spoken of. These cases have been worked up very
carefully by my associate, Dr. Beck, and I feel that if we can show
a series of cases like this which are checked up bacteriologically that
we are safer in helping Nature's processes with fresh air and with
posture than we are to submit them to radical operation and it is
surprisingly few of these cases that need any operation whatsoever
and when they do, it is after the acute process has disappeared and
9

294 TRANSACTIONS OF THE

we have a localized focus of pus. In this series there were seven
who were operated for local collections of pus by vaginal incision,
or an incision just above Poupart's ligament, and I feel that we
ought to make it very clear that the best prognosis in these cases
is not operation and not interfereing with the uterus; and we go
so far as this: that while we culture the inside of the uterus in
every miscarriage that comes into the hospital, we have never
introduced a curet in our service if the culture shows bacteria of
the staphylococcus or streptococcus type."

Dr. George G. Ward, Jr. — "I would like to ask Dr. Vineberg
if in closing he will tell us what his results have been in other cases.
He has, I think, been interested in this method of treating strepto-
coccus infections and has operated I believe on a number of cases.
I think most of us would be interested to know the number of cases
in which he has employed this treatment and the number of cases
in which he has had such a good result as in this one. I think he
is to be congratulated on the excellent result obtained in this case,
but I feel, as the others do, that the patient got well in spite of the
surgery."

Dr. J. Milton M.abbott. — "From a very small experience, I
would like to say that I do believe there is something in the vaccine
treatment, which may be advantageous and helpful in a few cases
and I think probably is harmless in all if we use a proper vaccine
subcutaneously in the connective tissue, for the purpose of pro-
ducing what, in a general way, may be considered an opsonin. I
think perhaps that the obstetric teachers of our time have done as
the medical men have — they have become too nihilistic on the side
of therapeutics, and I believe that the vaccine treatment of bac-
teremia should be used and have a further trial before it is condemned
so generally, as it seems to be at the present time."

Dr. Hiram N. Vineberg. — "I expected these remarks here
to-night. I am not at all surprised and am glad that they have
been made because I should hate to be the means of conveying the
impression through this Society or through myself that I believe
this operation is one that is indicated very often. I can illustrate
to you how seldom I think it is indicated by saying that this is the
tirst case I have operated on in two years and I see quite a number of
cases of various kinds in our wards, some of them such as have been
described here to-night, where I have opened abscesses through the
abdomen or have let them alone, and, to satisfy my Brooklyn
friends, I have elevated the bed, which I do not think does much
good, and employ all the customary measures, but we are sometimes
influenced perhaps by the case that we see before and perhaps that
is what influenced me here. About two months before I had seen
a young woman with pretty nearly about the same history as this
one. She was a relative of a doctor and was delivered by a very
good man. I think that forceps were used. She was seen by me
on the sixth or seventh day with a high temperature and she had a
little bit of tenderness on the left side. I advised the people to
send her to the hospital for observation and told them that these

NEW YORK OBSTETRICAL SOCIETY 295

cases were of such a character that they required careful watching.
I heard nothing further about the case until four or five days later
(at which time she had been sent to the hospital) when I was called
up and told to go and see her and do what I thought was indicated
under the existing conditions. I found a most florid general peri-
tonitis and, of course, I refused to do anything. She was seen by
Dr. Flint in consultation. They were very anxious that I should
do something, if only to make a posterior vaginal incision, but I
dechned to do so and stated that if Dr. Flint would give it as his
opinion that such an incision should be made I would be willing
to do it, but that it was against my advice. She died that night
from a virulent peritonitis. She was practically moribund and I
haven't any doubt but the conditions were not unlike those present
in the case reported to-night.

Dr. Polak, like most of the other gentlemen, did not follow up the
history of my case very closely or he would have known that the
tongue of omentum was adherent on the right side where there was
no abscess but that the abscess was in the ovary and the pus so near
the surface that it broke through while I was tying off the vessels
on the right side. It seemed as if the pus would have escaped into the
general peritoneal cavity within a short time had no operation been
performed, and I am as positive as one can be in a case of this kind
that the pus would have escaped from that ovary in a short time,
and if she hadn't died of the streptococcemia she would have died
from general peritonitis, and while I feel confident that that would
have been the result in this case, still, at the same time, I am in
thorough accord with the most of the gentlemen who have spoken
here to-night that it is not an operation that is often indicated and
whenever I do this operation it is one which I do with a great deal
of hesitation.

"So far as the curettage is concerned, I would say that while,
personally, I don't think I would perhaps have done it myself, still
from the care with which it was done I do not believe any harm
resulted, and I doubt whether in thirty minutes bacteria could have
spread into the general system.

"I may conscientiously repeat that I feel this woman's life was
really saved because this ovary would have burst and she would
have gotten up a general peritonitis, because there were no adhesions
on this side and the omentum was drawn over toward the right side.

"In regard to my results, I wish to say that I do not operate
on very many such cases, as I have said before. I haven't looked up
my statistics. I think I have operated on twelve cases. Seven or
eight recovered and I think there were only three or four that I
have operated upon that did not recover."

Dr. J. Morris Slemons, New Haven, Conn., then read by
invitation, a paper entitled:

THE results of ROUTINE STUDY OF THE PLACENTA.*
For original article see page 204.

296 TRANSACTIONS OF THE

DISCUSSION.

Dr. Robert T. Frank, in opening the discussion, said: "It has
rarely been my pleasure to listen to a more well-balanced paper,
balanced between laboratory investigation and clinical observation,
and this paper fully proves that such a dual investigation is sure to
give results.

"Dr. Siemens has shown us the great importance of examining
full-term placentas. I am sure that he is hkewise in favor of
examining placentae obtained at an earlier period, for instance
after abortion. If he keeps on with these examinations even
more important facts will be elicited. Doubtless in time he will
come across a placenta which v/iU show some abnormality and
the patient from whom the placenta has been obtained will eventu-
ally develop a chorioepithelioma. Should he be fortunate enough
to obtain such a specimen, he may be able to throw hght upon one
of the darkest subjects in pathology.

"There are one or two points on which I might feel like disagree-
ing with Dr. Siemens. One of these is that the hilly situation of
San Francisco has much to do with premature detachment, because
here in New York, where hills are perhaps not quite as frequent, I
have seen an equal number of premature separations in a much
smaller series of cases.

"As far as the interpretation of syphilitic placentae is concerned,
I think that with the Wassermann and with the very readily deter-
mined bone changes in the fetus it would hardly pay to make a very
painstaking examination of the placenta. Of course in a routine
examination, such as Dr. Siemens has made, which will at some
future time serve as a basis and a standard, this is necessary. I can
fully agree with Dr. Siemens when he says that the placenta is an
organ which will richly repay further study, that it has been treated
in a very stepmotherly fashion, and that its clinical, its micro-
scopical, its chemical (in which Dr. Siemens did seme work a number
of years ago) and its physiological investigation will prove of in-
creasing importance."

Dr. J. Morris Slemons. — "I had hoped that there would be
some discussion of the Wassermann reaction in cases of pregnancy.
Our series of cases is small and I am net sure that we have all the
facts. It seems upon the evidence we have that the Wassermann
and the placenta agree in 99 per cent, of cases. If this prove true
it is very gratifying information. What has interested me par-
ticularly is the faintly positive Wassermann in cases of toxemia.
I wonder if any one else has been impressed by that experience.
As far as I knew it has not been commented upon.

"It is certainly a great pleasure to be here and I thank yeu very
much for the cordial reception you have given me."

NEW YORK OBSTETRICAL SOCIETY 297

Meeting of April ii, 1916.
The President, Dougal Bissell, M. D., in the Chair.
Dr. Geo. Gray Ward, Jr., reported a case of

CONGENITAL ABSENCE OF THE LEFT OVARY AND FALLOPIAN
TUBE.

Anomalies of the female generative organs, while not rare, are
always of interest and therefore, should be recorded in the literature.
The following case came under my observation, November, 1915.
Mrs. H. K., aged twenty-four, married five years; of medium height
and slender build, family history negative and of neurotic tempera-
ment, consulted me on account of burning and aching pain in the
region of the right ovary. It annoyed her considerably at night,
also on standing. She was also anxious to have children. She had
never had any serious illness; menstruation established at fourteen
years, a regular twenty-eight-day type of seven days' duration with-
out pain and moderate quantity. She had never been pregnant. She
had a moderate amount of leukorrhea and suffered with hemo»rhoids.
The pain complained of was distinctly located in the right lower
quadrant of the abdomen.

The examination showed her to be normally developed with
thin and relaxed abdominal muscles, with moderate prolapse of the
right kidney and some ptosis of the stomach and intestines. Tender-
ness over McBurney's point. Pelvic examination showed the ex-
ternal genitals of a nulliparous woman normally developed. Two
or three external hemorrhoids. The vagina was normal, uterus
moderately anteflexed, of normal size and movable. There was
marked tenderness of the right tube and ovary; the left tube and
ovary were recorded as negative. The vaginal and cervical smears
were also negative.

Diagnosis of chronic right salpingo-oophoritis, probable chronic
appendicitis and endocervicitis, with moderate degree of enteroptosis
was made, and an operation was advised.

On November 12, 1915, I operated upon her, doing a divulsion
and curettage and hemorrhoidectomy. The abdomen was opened
and the right ovary was found to be undergoing cystic degen-
eration with areas of interstitial oophoritis. The ovary was the
size of a plum and the tube was normal. The examination on the
left side showed complete absence of left tube and ovary. A small
stub one-quarter of an inch in length was observed at the side of the
uterine cornua. The top of the left broad ligament was simply an
extremely thin membrane. The appendix was found to be the site
of a chronic appendicitis and contained several large concretions. A
smooth unattached stone-like body about ?^ inch X J^ inch in
width was found lying in the culdesac of Douglas.

Owing to congenital absence of the left adnexa, it was necessary
to conserve the right ovary, so resection of the diseased area was

298 TRANSACTIONS OF THE

made leaving ovarian tissue tlaat was apparently healthy about the
size of a normal organ. The appendix was removed and the abdo-
men closed. The patient made a nornial recovery.

The laboratory report showed chronic oophoritis, and the "stone"
which I had at first thought might be a wandering ovary, proved
to be simply a calcareous gland.

DISCUSSION.

Dr. LeRoy Broun. — "I would Hke to ask the doctor if that
was associated with a normal-sized uterus."

Dr. George G. Ward, Jr. — ■" It was. The uterus was perfectly
normal in size and there was no abnormality about it whatsoever.
The menstrual function in this woman was practically normal."

Dr. Ralph M. Beach reported a case of

FETAL DE.A.TH DUE TO EIGHT COILS OF UMBILICAL CORD .ABOUT THI.
NECK.

The following case coming into the writer's experience seemed
unique enough to be reported. Mrs. C. was delivered by me
of her first baby three and one-half years ago, a difficult forceps.
The baby died at the end of one month of some infection of the
neck, the nature of which I do not know, the case having passed
from under my observation. One year later I performed a cervical
and pelvic floor repair and a Webster-Baldy operation on the
uterus. Her second pregnancy was normal except for considerable
pain over the uterus at times, which I took to be due to irregular
stretching ligamentous attachments. One week before term, the patient
experienced excessive movement on the part of the baby. She said
this was so marked during the night that she could not sleep, and
the baby seemed to be moving in every direction. The next morn-
ing the baby had quieted down, fetal life was still present and noth-
ing occurred until the onset of labor, when, with the first pain all
signs of life disappeared. Pains were irregular for eighteen hours and
strong for the last six hours while she was under my observation.
No fetal heart was heard on my first examination. The baby rotated
from R. O. P. to O. A. without any difficulty and was born dead
with eight coils of cord about the neck. Contrary to the text-book
teachings there was not the slightest amount of extension of the
head.

The interesting features about this case are whether the Webster-
Baldy and pains during pregnancy had any bearing on the condition,
the excessive motility one week prior to term and the fetal death
with the first uterine contraction.

DISCUSSION.

Dr. Asa B. Davis, in opening the discussion, said: "There is one
point as a causation for the coiling that I think was not brought out.

NEW YORK OBSTETRICAL SOCIETY 299

and that is the excessive amount of amniotic fluid, so that the
child has freedom to move about. Dr. Beach brought out the
danger to the child. I think there is still danger to the mother.
We may have a cord that is long and wrapped about the child and
made relatively short as one of the causes of accidental hemorrhage.
I have- seen this in several cases."

Dr. George G. Ward, Jr. — -''I can report a case that bears out
what Dr. Davis has just said about the danger to the mother of a
shortened cord. A httle over three weeks ago I had a case, a primi-
para, and when she went into labor it was accompanied by sudden
severe hemorrhage which was undoubtedly an accidental hemor-
rhage. The presenting part did not enter the pelvis at all and it
looked as though we would lose the child, if not the mother, if the
ordinary measures were employed, as haste was evidently necessary.
I did a Cesarean section and delivered an 8-pound child without diffi-
culty and both mother and child made a good recovery. In this
case the placenta was on the battle-dor type; that is, the cord was
inserted into the margin of the placenta and it was coiled around
the body of the child and was thus greatly shortened and when labor
started the traction on the placenta caused the accidental hemorrhage.

It is unusual to do a Cesarean section for accidental hemorrhage
but I felt sure it was the best procedure in this case as it was in a
hospital. Perhaps Dr. Davis, who has done so many Cesarean
sections, can tell us of his experience with this method of treatment."

Dr. Asa B. Dams. — "I have done several of those cases and my
assistant in twenty-four hours last September had two cases where
I believe he saved the mother's life by doing a Cesarean section
promptly. One child was dead, but that was the quickest way to
get it out. The other child was saved and both of the mothers were
saved."

Dr. Hermann Grad. — "I had a fetal death from a cord around
the neck, but in this case the cord was wound around the neck three
times. The neck was very much compressed and the mother said
that ten days before she noticed an excessive motion in the abdomen,
and two or three days later she felt no life. The baby was born
dead. There was an excessive amount of fluid in this case also, as
Dr. Davis has called attention to."

Dr. James D. Voorhees. — -"I can report a permanent injury to
a child after being born with a cord wound around its neck six times.
This child was born barely alive. There was intense congestion of
the face and head, hemorrhages into the conjunctivae, and one
hemorrhage into the anterior chamber of the eye. The hemor-
rhage in the anterior chamber did not absorb and produced a
permanent opacity in the eye. The child bears this mark to-day,
being, I think six or seven years of age. Otherwise, the child seems
to be perfectly developed and healthy."

Dr. Dougal Bissell. — "A long cord coiled around the neck is
dangerous only when the several coils convert it into a short cord;
that is, four loops can be as dangerous as eight provided that all the
slack in the cord has been taken up by the coiling. When this is

300 TRANSACTIONS OF THE

the case the danger to obstruction in the circulation of the cord
during the passage of the child through the birth canal is very great.
The very short cord looped once around the neck or over the
shoulder is equally as dangerous. I vividly recall a case which I had
the misfortune to attend where a short cord looped about the neck
resulted in death. The labor was overdue ten days and was then
induced. The child was delivered with forceps after great dilSculty.
The heart action failed to be heard five or more minutes before
delivery. The difficulty of the delivery proved to be due to the
looping of a very short cord about the neck causing great tension
upon it when the child's head was pulled upon, resulting in obstruc-
tion to the circulation in the cord and death of the child. A long
cord looped about the neck without resulting tension may serve
advantageously by preventing prolapse of the cord."

Dr. Ralph M. Beach, in closing the discussion said: "One
interesting feature about this case is this excessive motility of the
fetus. I don't think we are apt to pay enough attention to this
in the latter months of pregnancy. I saw a patient in my ofiice
about ten days ago, with a distinct vertex presentation and six
days later she went into the hospital in labor and had a breech. She
told me that two days before, she had felt all through the night, a
lot of motion, turning of the baby, as she thought, and apparently
the baby had turned at that time from a vertex to a breech. There
can be no doubt about that diagnosis. It was the first time in a
primipara that I had seen a baby change from a vertex to a breech
ten days before delivery."

Dr. Reginald M. R!awls reported a case of

INJURY TO THE FEMALE GENITALLA. IN COITUS, WITH REPORT OF A
CASE OF VULVORECTAL FISTULA.

Mrs. L., aged forty-three, admitted to Dr. LeRoy Broun's
service at the Woman's Hospital, January 23, 191 5. She was
poorly developed and ill nourished and complained of incontinence
of feces for nine years. First menstruation at sixteen years,
always regular but scant. Claims to have had an accidental
abortion when three months married.

External genitals normal except a rather high introitus and an
intact, rather thickened, annular hymen whose foramen admitted
one finger. In the fossa navicularis was a transverse fistula into the
rectum which admitted two fingers. The anterior and posterior
vaginal walls were in contact and it was necessary to make a vaginal
examination by the aid of sight to prevent the fingers from entering
the rectum. The vagina, cervix, uterus and rectum were otherwise
normal. The levator ani and sphincter ani intact.

The patient gave the following history as to the cause of the
fistula. She was married at the age of thirty-four years, and says
that her husband was of average size, of temperate habits and
very considerate in his marriage relations. Attempts at inter-
course the first night attended with pain and bleeding which lasted

NEW YORK OBSTETRICAL SOCIETY 301

a week. During the second week, at the third or fourth attempted
coitus, there was severe pain which caused the patient to faint.
Next day, she was unable to control her bowels and there was
considerable bleeding. For two years there was always painful
intercourse and for the first three or four weeks of married life, there
was always considerable bleeding after coitus.

Her husband died at the end of seven years and was never told
that he had made a false passage.

Operation. — ;In considering an operation for this case, I deter-
mined to attempt a cure without severing the sphincter ani although
the fistula was so close to this muscle as to make the result prob-
lematic. The sphincter ani was thoroughly dilated, the edges of the
fistula were freshened and the vagina and vulva were separated
by blunt dissection from the rectum. Then with three sutures, one
on either side and one in the center used as tractors, the fistulous
opening in the rectum was pulled down outside of the anus and
interrupted sutures of fine linen were used to approximate the mucosa
and the underlying fibrous coat of the rectum. These sutures were
tied with their knots in the lumen of the rectum. Then from above,
the tissues between the rectum and the vulva were brought together
with interrupted chromic-gut sutures and the edges of the levator
ani were brought together by two sutures to reinforce the fistula.
The skin was closed wuh silkworm-gut sutures and the hymen was
cut away and the mucosa brought together with catgut. The
patient made an uninterrupted recovery except for a small sinus
which eventually closed.

The interesting points in this case are, the woman was compara-
tively young, thirty-four years of age, when the injury occurred;
there was no congenital nor acquired abnormality except a thickened
hymen and a rather high introitus. While we cannot exclude other
trauma as the cause of the fistula, it would seem that the hymen or the
vagina or both would have been lacerated if the fingers or an instru-
ment had been used. On the other hand, we are unable to exclude
a congenital defect in the vulva-rectal septum, although there was
no evidence of rectal malformation. Harris in a study of Hirst's
case which is similar to this case, says that he has seen rectal cases
with a malformation corresponding to the site of the fistula in the
fossa navicularis. Nevertheless, we must recognize coitus as the
direct cause of the fistula in my case.

DISCUSSION.

Dr. Hermann Grad, in opening the discussion said: "I had
the pleasure of seeing this case of Dr. Rawls and it certainly was a
very curious condition. As I remember the fistula easily admitted
two fingers, starting right beneath the vagina and extending into
the rectum, but the sphincter anus was not destroyed. When I
examined this case I observed at the time that the tissues between
the fistula and the vagina were very firm, it may be that the trans-
versus perinaei muscle was excessively developed and that the force
exerted deflected along this rigid surface."*

302 TRANSACTIONS OF THE

Dr. Brooks H. Wells, said: "About a year ago, at a certain
hospital with which I was connected, one of the assistants in scrub-
bing a patient's vagina before an operation, with soap and a piece
of gauze over the two fingers, ruptured the vagina and I was called
to repair it. I thought at first that the man had been unduly
rough, but when I went to put stitches into this torn posterior
culdesac it was found to be so tender that the slightest bit of trac-
tion on the stitches would pull them through the tissues, and putting
a traction of probably not more than 2 or 3 ounces would
cause the stitches to cut through, so in that case there was evidently
some very unusual cause for this remarkable softness of the tissues."

Dr. Frederick W. Rice read a paper on

POSTPARTUM HEMORRHAGE.*
DISCUSSION.

Dr. George L. Brodhead, in opening the discussion said: "Dr.
Rice has brought up a great many interesting points which may well
be discussed. I was very much interested in the high percentage of
hemorrhage in his placenta previa cases. It seems to me, as he says,
that lacerations of the cervix and lower segment are, in many
instances, the cause of the more frequent hemorrhages. I think if
we could handle these cases a little more carefully and think a little
less of the child and a little more of the mother, we would probably
have very much better results as far as the mother is concerned.
Sometimes, even though the child is dead, an effort is made to extract
it rapidly; not enough time is allowed for the cervix to completely
dilate. I have seen this happen over and over again, where one
might say the cervix was almost deliberately torn in the effort to
deliver quickly instead of allowing the necessary time for proper
dilatation. The only result of that (and there is only one result)
is a laceration of the cervix and hemorrhage. I think in these
cases of placenta previa where the patient has already lost a good
deal of blood, it is safer to pack, as a rule, than to run the chance of
having a hemorrhage succeeding delivery. In my experience harm-
ful results from leaving in retained membranes have been very much
exaggerated. During my first year at the Sloane Hospital it was
our custom to remove all portions of retained membrane and I
can remember many weary hours spent in trying to get out portions
of retained chorion. During my second year I made up my mind
that I would not enter the uterus for retained membrane, and
results seemed equally good. In my private and hospital work ever
since I have always followed the procedure of leaving retained
membrane alone. The chorion weighs about 3 or 4 drams and that
is nothing more or less than the equal of perhaps a small blood clot
lor which we would certainly not enter the uterus. The membrane
comes away in small pieces, or in debris with the lochia and I doubt
very much whether we can attribute postpartum hemorrhage to

* I'or original article sec page 215.

NEW YORK OBSTETRICAL SOCIETY 303

the retention of membrane. I think one of the most important
things in the prophylaxis of postpartum hemorrhage is giving ergot
or pituitrin immediately after the birth of the child and not wait-
ing until the end of the third stage. It requires, by mouth, twenty
to thirty minutes for ergot to act; therefore, if we are going to
give the drug we ought to give it immediately after the birth of the
child, twenty or thirty minutes before the placenta is expelled. I
have seen a number of instances where in previous confinements the
patient had bled a great deal, ergot having been given after the end
of the third stage. In a subsequent labor I followed the procedure
of giving pituitrin or ergot immediately after the birth of the child
^vith very different results, and I am convinced that the time to
give ergot or pituitrin is immediately after the birth of the child,
before hemorrhage has occurred. I cannot recall any instance
in which the immediate use of ergot or pituitrin has been followed by
bad results."

Dr. Asa B. Da\is. — "As Dr. Brodhead has just said, this paper
has brought up a great many interesting points connected with
postpartum hemorrhage. One is that even small pieces of placenta
may be so situated, left behind, that they will cause hemorrhage.
I remember an instance a good many years ago where we found a
small piece of placenta, probably not more than a centimeter and a
half in diameter, but it was probably so located that it kept open
one of the sinuses and we had persistent postpartum hemorrhage
until its removal, after which the hemorrhage ceased.

"There is another point that the speaker has brought out and that
is the matter of packing in these cervical tears. I don't think
enough attention is given to the futility of packing in those
severe tears, and I am sure that a great many women have lost
their lives by relying upon that method of packing in hemorrhage.
I have seen it happen in a number of cases which I can recall. We
cannot pack against arterial bleeding from the cervix and above.
What has usually happened? The fact that there is thought
to be a necessity for packing indicates that a great deal of blood
has been lost before, and packing is applied to this not overre-
sistant area, and. therefore, the uterus and vagina are usually packed
and the hemorrhage is concealed for a time, but continues; the
gauze is moistened and ceases to exert pressure at the site of the
bleeding and after an hour or so we are conscious of the fact that
the woman is bleeding again through the gauze and repacking is
sometimes done. Whereas if we would recognize the futility of
this and even if we cannot get good apposition of the tissue, place
a few large sutures with the idea of stopping the hemorrhage, rather
than to get good repair, in that way hemorrhage may be efficiently
checked."

"There is another point with regard to the packing of the uterus
in the correct and incorrect method. There is an accident that
occurs that was not mentioned, and that is the uterus may dilate
above the packing. I have seen a few instances of that and I
undoubtedly believe had it not been recognized and compression

304 TRANSACTIONS OF THE

applied, the uterus manipulated and compressed down upon the
packing, the patients would have lost their lives. You can pack
the uterus completely full, yet it will expand above the packing.

"There was one other point which I forgot to mention and that
is a type of hemorrhage which we see which is not very profuse and
which if it is prolonged for any time becomes dangerous. We find
it with the patient in the lithotomy position, and we apply methods
of treatment, hot douches and that sort of thing, and still the bleed-
ing keeps on, whereas if we place the patient in the horizontal
position with the knees together, the hemorrhage will stop. I
think that is due to the fact that the blood-vessels are congested by
the flexure of the thighs upon the abdomen, but in the prone
position the circulation regains its equilibrium and the hemorrhage
ceases."

Dr. Henry C. Coe. — " It seems to me that if we are to apply
ordinary surgical rules in these cases, instead of wasting time by
using gauze in accessible venous and arterial hemorrhage in other
localities, it is better to pass deep sutures beneath the vessels.
I never think of wasting time with douches, but introduce my whole
hand in order to locate the source of the hemorrhage and pull down
the uterus, and if I have any doubt at all about its origin from the
cervix or other soft parts t suture. I have seen cases in which
alarming hemorrhage was entirely controlled by suturing where
great time would have been lost in packing. Of course packing is
necessary in cases in which the uterus is relaxed. I would introduce
a pack at once with my whole hand and not use an instrument,
making pressure, as well as traction."

" I was much interested in Dr. Brodhead's statement that he gave
ergot or pituitrin before the placenta was expelled, as I have always
taught my students not to give it until the uterus was entirely
empty."

Dr. Austin Flint. — "I think this is an important subject to
bring before the members of the Society. It struck me that there
are two or three things which might be amplified in the discussion.
Packing is valuable when properly done, but dangerous when im-
properly done. It must be carried up to the fundus. I have used
packing very moderately as far as frequency is concerned. I
regard packing for postpartum hemorrhage more as a prophylactic
measure, to prevent the repetition of hemorrhage, rather than a
measure to control a hemorrhage that is active. If you have post-
partum hemorrhage from the placental site in a relaxed uterus, you
should cause the uterus to contract, and again the rational thing to
do to prevent repetition of hemorrhage is to keep the uterus retracted,
or at its normal size, and the best way to keep it retracted is to pack
it, rather lightly, but thoroughly with iodoform gauze or sterile
gauze. Apply the gauze up to the fundus. In that way I think
it is one of the most valuable procedures that we have to save the
woman from the dangers of repeated postpartum hemorrhage and
hemorrhage that recurs.

"Dr. Rice brought out the value of packing in placenta previa.

NEW YORK OBSTETRICAL SOCIETY 305

At Manhattan Hospital, where we have all been working for a good
many years, at one time we packed as a routine procedure for
placenta previa and got ver}' good results, and then for a time we
gave it up and used it only in cases of placenta previa followed by
postpartum hemorrhage. Then we went back again to packing as a
routine procedure and we again got very good results. In the treat-
ment of postpartum hemorrhage from the standpoint of preventing
it, we now pack in placenta previa cases. From the standpoint
of prophylaxis as I have gone over it in other cases, the treat-
ment of a threatened postpartum hemorrhage is most important.
As one acquires more skill in the practice of obstetrics, less fre-
quently does one meet with postpartum hemorrhage, 'there are
certain conditions where we feel that hemorrhage is hkely to occur,
such as rapid emptying of the uterus, overdistention of the uterus,
twin pregnancies and the frequency with which hemorrhage occurs
in operative dehvery, all those are conditions which make one feel
that they are the cases in which hemorrhage may occur, and one
takes measures to prevent it, and, consequently, as time goes on,
hemorrhage occurs less and less frequently. There are, however,
certain cases, such as hemophiliacs, where ordinary measures will
not answer. In those cases you must use unusual measures to see
that the uterus retracts and stays retracted during the third stage
and you should promptly deliver the placenta rather than let it stay
for as long a time as in normal cases.

"There are a great many smaller points which I will not take up
the time of the Society in going over. I only want to emphasize
what Dr. Rice brought out very well, namely, the value of packing,
not only for the control of postpartum hemorrhage, but also for the
prevention of such a condition."

Dr. Hiram N, Vineberg.- — " I wish to mention a case of secondary
postpartum hemorrhage occurring twelve days after a rather difficult
delivery with forceps, in which there was a primary postpartum
hemorrhage due to a pretty severe tear on both sides of the cervix,
which was controlled rather promptly by suturing. In the first
instance the patient was very much exsanguinated and was given an
intravenous infusion of salt solution and made a good recovery.
She was allowed up on the eleventh day and on the twelfth day she
was up for an hour or so. Just after taking supper she felt a rush
of blood coming from the vagina and sent for me. I happened not
to be at home and reached there without any instruments. The
patient was practically exsanguinated. I packed her with what
gauze I had at hand and Was ver}' glad that she did not die then
and there. We sent for assistance and gave an intravenous saline
infusion, but still there was no pulse to be felt at the wrist. The
patient complained constantly of air hunger and was vomiting, and
I felt that if something were not done for her she would die. Fortun-
ately I was able to get some one to give an intravenous blood trans-
fusion which worked wonderfully well and the patient immediately
got some color in her lips and we could feel her pulse. By that time
the packing had become wet and blood was trickling through. I

306 TRANSACTIONS OF THE

determined not to leave the patient until the source of the hemor-
rhage was found and arrested. Against the advice of all the men
who were called in from the neighborhood (there were no consultants,
but six or seven men and they all begged me to leave the patient
alone, saying that she would die if I did anything to her), I decided
to try to stop the hemorrhage. The patient was stout and I had
considerable difficulty to expose the parts. In removing the gauze
from the vagina I found a good sized blood-vessel on the right side
of the cervix where former suturing had been done. Evidently the
vaginal wall had eroded over this blood-vessel and it was bleeding
at a great rate. I succeeded in ligating the bleeding vessel and the
patient made a good recovery. I felt that if I left the house that
night without arresting the bleeding the patient would surely have
died, but what really saved her was the fact that we were able to do
a prompt blood transfusion. The brother of the patient, a robust
individual, gave his blood for this purpose. We used about 500 c.c.
by the citrate method. The only bad result following the transfu-
sion was a severe chill which the woman experienced. She had no
hematuria, but did have an albuminuria for several days following
the transfusion.

" I recently had another experience which, fortunately, turned out
better than we had anticipated. The patient was a young woman
who was very stout, a primipara with a distinct hemophiliac history
and the daughter of a hemophiliac, she herself bleeding from the nose,
eyes and mouth and having menstruation of a profuse type. She
had a difficult labor but everything passed over smoothly; that is,
she had not lost any more blood than the ordinary individual.
There was a persistent occipitoposterior and I had to apply the
forceps when the head was on the perineum and the perineum was
torn extensively and was sutured. This is the twelfth day and there
have been no signs of any trouble. The child was a female, and
although the forceps were used there was very little traction made
but on the third day after delivery one of the child's cheeks became
enormously swollen and it seemed that the swelling was increasing
to a very great extent. The baby was not able to nurse and kept
crying constantly. A serologist was called in consultation and he
advised giving the baby a blood transfusion. This was done and
the hemorrhage into the cheek has evidently ceased and the little
patient is making a nice recovery. There was a slight scratch on the
inside of one of the ankles, which continued oozing, not to a great
extent, but it could be controlled, showing that the baby is a
hemophiliac also."

Dr. Harold Bailey. — "One point in the etiology of postpartum
hemorrhage occurs to me. I think that massage of the uterus imme-
diately after delivery of the placenta should be discarded. The
uterus is a muscle and is not supposed to remain in contraction
indefinitely. If it is let alone it contracts and then relaxes. After
constant massage immediately upon relaxing it contracts again and
finally the muscle becomes tired out and very considerable relaxation
occurs with hemorrhage.

NEW YORK OBSTETRICAL SOCIETY 307

" If there is a postpartum hemorrhage of any considerable amount,
no time should be lost in instituting treatment by packing. We
should introduce a speculum or the hand, for the purpose of locating
the bleeding and if it is from the uterus it should be packed at once,
and at the same time that the hemorrhage occurs I think pituitrin
should be injected. Going into the question of late postpartum
hemorrhage, on the twelfth, fifteenth or even the twenty-fourth day,
I believe that the uterus should be thoroughly curetted. I had
a case recently with a very severe hemorrhage and in scraping out
the uterus a large piece of placental tissue was removed and on
examination it was found that there was considerable development
of syncytial cells."

Dr. Ralph H. Pomeroy. — " There has been a great deal of dis-
cussion of placenta previa hemorrhages here to-night which is a
rehashing of old stories. I have been looking for some new things.
I have been struck by three new points which have perhaps helped
me to get a clear understanding of the subject. They are enlight-
ening, but not final.

" One thought that was presented by the reader of the paper is
that in the management of placenta previa postpartum hemorrhage,
he accepted the proposition that he must have a contracted muscula-
ture of the uterus in order to cut off the active arterial circulation
to the bleeding point. It would appear to be pretty definite that
hemorrhage from an unretracted lower uterine segment in placenta
previa postpartum hemorrhage more likely comes from the vaginal
trauma, and must be controlled by packing, and one cannot really
in the contraction and recontraction of the upper part of the uterus
control that situation.

"Another point that I want to ask a question about is as to whether
Dr. Flint, in speaking of routine packing for postpartum hemorrhage
in placenta previa said that the packing was carried out from the
fundus down or only in the lower part of the uterus."

Dr. Flint. — "From the fundus down, doctor."

Dr. Pomeroy. — "I want to exclude from the two or three state-
ments I wish to make any consideration of the purely surgical post-
partum hemorrhages — those due to lacerations of the cervix and
lacerations of the vagina and vulva.

"In talking to students and to people whom we advise it is
absolutely necessary to get into their minds the distinct character
of hemorrhages from the placental site and the necessity of having
a clear comprehension of how to deal with them.

"The next thought is that we must make an absolute division in
our own minds between the cases in which postpartum hemorrhage
may be reasonably expected and those in which it is totally unreason-
able to expect it, and we start with the proposition that a uterus
that has not been overdistended primarily, that has not been the
subject for exhaustion, for prolonged labor, or an anesthetic, or
multiparity, may be considered able to take care of itself, for nobody
tampers with the second stage.

"Dr. Beach and others of us who have been working over in

308 TRANSACTIONS OF THE

Brooklyn have thoroughly thrashed out the proposition that there
is such a thing as a conservative letting alone of the third stage, but
you must have excluded the types I am referring to. That doesn't
clear up the entire matter because that has to be dealt out to students
and midwives and juniors and all kinds of men who are the temporary
house surgeons or house obstetricians, because if we tell them that
no case will bleed seriously and that you don't do anything in the
third stage but let the patient alone, our house surgeon, sooner or later,
shows incompetence to identify the cases that are potentially
dangerous.

"Now, most of us have gotten to the point where we don't see a
great number of labor cases through their labors. We see them after
some disastrous condition has developed and we get out of the habit
of thinking of this classification and frequently when we do think of
postpartum hemorrhage we think of a disastrous condition follow-
ing postpartum hemorrhage that ought never to have occurred in
the first place."

Here the doctor referred to the prevention of postpartum hemor-
rhage, and, continuing, he said:

"There is no good uterus but an empty uterus and a uterus once
emptied of its contents totally should never be allowed to expand or
dilate without being lifted up bodily out of the pelvis into the
upper abdomen, thereby making traction on the uterine arteries.
Have the vaginal vault packed full of gauze into the uterus and
watch the fundus and hold it between the two hands as a whole
uterus and puU it out of the field. I have never seen a uterus
managed in this way get away from me."

Dk. Frederick W. Rice, in closing the discussion, said: "Dr.
Brodhead's remarks on pituitrin are interesting. In looking over
the cases of retained placenta, seventy-six cases, a large number of
these received an injection of pituitrin during the second stage.
I don't think it ever did any harm. If it caused retention of the
placenta even for an hour, I do not think it would necessarily mean
postpartum hemorrhage, but delayed separation.

"In regard to Dr. Bailey's remarks relative to massage, I think
that is often a mistake. It is wrong to massage the uterus during
the period when it should be separating the placenta, because
I think that massage then really acts the same as ergot or pituitrin —
produces tonic uterus and delays separation.

"Dr. Pomeroy's remarks in regard to what we must tell the students
are interesting. It has always been a question with me what to tell
the students in regard to packing. I feel that if they ever attempted
in a case that really needed packing, to control the hemorrhage
without having sufficient training, they would do more harm
than good.

In regard to our knowledge of the condition of the patient before
the third stage, and in estimating whether hemorrhage will take
place or not, as in twins and hydramnions by causing overdistenton
of the uterus, I don't think these have so much effect in causing
postpartum hemorrhage as they do in producing a prolonged labor.

NEW YORK OBSTETRICAL SOCIETY 309

We have had only two postpartum hemorrhages in 175 cases of
twins. At this point in the discussion the doctor commented on the
question of twins and hydramnions producing a uterine inertia
and the uterus at the beginning of the third stage not being pre-
pared to do its work properly. In regard to letting the third
stage alone, it is interesting to note that out of 1006 cases that
precipitated in the outdoor service hemorrhage occurred in only
three cases and then it was not serious enough to endanger the
patient or child. There is usually somebody in the house who knows
how to prevent overdistention in these cases by keeping a hand
above the fundus until the doctor arrives."
Dr. Percy Williams read a paper on

PSYCHIC VAGINISMUS, WITH REPORT OF TWO C.A.SES.*
DISCUSSION.

Dr. Henry C. Coe, in opening the discussion, said: "I would
like to suggest as an aid to the mental suggestion the use of the old-
fashioned Sims' dilators, beginning with the very smallest size
and giving the patient three sizes to introduce herself. I have used
these in two cases quite similar to those mentioned by the reader of
the paper. By first introducing a small and then the larger ones
the patients were convinced that there was no real obstacle to
coitus."

Dr. Brooks H. Wells. — I have had very recently under my care
a case of purely psychic vaginismus. The patient was a young
woman who before marriage had read and been told a good deal
about the discomforts that would follow marriage and who was in
deadly fear of becoming pregnant. Penetration occurred the first
night after marriage and was extremely painful to both. Since, there
have been many attempts at intercourse but no penetration. She
had been given large doses of bromide with no benefit, and inter-
course had been unsuccessfully attempted while she was deeply
under the influence of morphia and alcohol. On being brought to
me she showed a typical condition; there was extreme contraction
of the muscles of the pelvic floor, with adduction of the thighs follow-
ing the approach of the examining finger. It was impossible to make
any examination until the woman was deeply anesthetized, when it
was possible to pass three fingers into the vagina and to dilate the
vaginal orifice and pass in the whole hand without tearing the mu-
cosa. The dilatation had no efi^ect on the vaginismus, and as the
internal pelvic organs were normal, I decided the matter was purely
psychical, and treated her by passing twice a week, first a very small
and then larger specula until after a month a rectal bougie three and
a haK centimeters in diameter could be inserted without pain. To
prove that she could easily allow intercourse she was then allowed
to take the bougie home and pass it herself. In spite of that, though
she could pass the bougie easily and was convinced there was no
obstacle, yet when her husband came anywhere near her she got the

* For original paper see page 226.

310 TRANSACTIONS OF THE

same old spasm. Several weeks later, after the next menstrual
period, the husband called up and said: "Everything is all right."

Dr. William M. Ford. — "Within the past six weeks I have
seen two cases of typical psychic vaginismus. The first had been
married a year and a half and had never succeeded in having inter-
course. Inspection showed a thin imperforate hymen just admitting
the tip of my index-finger. The other case was that of a young
woman who had been married nine months and had never succeeded
in cohabiting and in this instance the hymen was exquisitely sensi-
tive and the opening in the hymen was just large enough when
stretched to the utmost to admit of the passage of my index-linger
when well anointed with vaseline. Upon succeeding in this, that is,
in introducing my finger, I was tempted to make a further examina-
tion of the pelvic contents with the result that I found the woman
was four months pregnant. As these two cases came under my
observation within the past six weeks, and as I have seen others
occasionally, I infer that the condition is not particularly rare."

Dr. H.^rold Bailey. — "Before turning these cases over to the
psychiatrist or specialist in nervous disorders I think we ought to
consider another method because, associated with another, I have
seen two cases cured by forcibly dilating the vulva. Both cases
were followed by intercourse and pregnancy and both are now well.
One case was so severe that attempts at intercourse in the first
few weeks of marriage had led to intercourse through the rectum
rather than through the vagina. The first case went through her
labor without any trouble, but had through her pregnancy symp-
toms of vaginismus, on examination. The second case had a breech
delivery and a severe laceration of the perineum."

Dr. Hermann Grad. — "I believe the classification given by Dr.
Williams is a very good one. I am convinced that there are cases
of vaginismus due to organic disturbances and also to purely mental
conditions. This was shown to me in a patient of mine, a young
lady, who said that she simply could not have any intercourse
with her husband, although she desired it. She was forced into
marriage with her husband against her will. After a while her
husband died and .she married another with whom she had absolutely
no vaginismus. It was purely a mental state that prevented her
from having proper intercourse."

Dr. William H. W. Knipe. — "I saw a case in my office where
the woman had been married for fourteen years and yet had never
had complete intercourse with her husband. Her hymen was still
intact. Fortunately, she is now pregnant and that will cure the
condition."

Dr. William P. Pool.— "It was Kelly, I think, who has classified
these cases as hysterical where there is a voluntary etTort at repul-
sion, such as adduction of the thighs, which is not infrequently
encountered in attempts at examination; and the cases as local
where there is an involuntary contraction, or what appears to be an
involuntary contraction, of the muscles of the pelvis, and states
that only the latter cases are subject to local treatment."

BROOKLYN GYNECOLOGICAL SOCIETY 311

Dr. Dougal Bissell. — "I can add another case of psychic vagin-
ismus to those reported here to-night. A case of a married woman
where intercourse was not accompHshed until several years after
marriage because of intense pain on approach. The marriage
was one of convenience, the woman not deciding to accept her
suitor until ten years after courtship began. After years of physical
and mental distress, Thomas' vaginal glass dilators of varied sizes
were used. One intercourse was then permitted and soon after a
child was born. The child was delivered persistent occipito-
posterior, the vagina was badly torn and the repair was not altogether
satisfactory. Although two of the examiner's fingers can be passed
into the vagina without occasioning the least distress the same
difficulty is now experienced as before the use of the dilators when
intercourse is attempted."

Dr. p. H. Williams, in closing the discussion, said: This dis-
cussion has brought forth many interesting facts. I wish only to
repeat what I have tried to make clear in the paper, namely, that
after all cases of vaginismus, in contradistinction to dyspareunia,
have been investigated and those suitable have been treated by
surgical means, there remains a not unconsiderable proportion
which are not organic and whose symptoms are not helped by surgical
treatment. These cases I term psychic and are best treated as
neuroses or phobias. I do not advocate turning cases of vaginismus
over to the psychiatrist as one member suggests, for a competent
gynecologist ought to be able to treat these cases himself.

The crux of the matter is in the diagnosis, which can only be
reached by exclusion and the use of infinite patience. The treatment
follows the diagnosis logically. Most of the cases cited seem to me
to be cases either of dyspareunia or organic vaginismus, but I think
we have all had cases where an organic basis for the symptoms is
impossible to determine.

TRANSACTIONS OF THE BROOKLYN
GYNECOLOGICAL SOCIETY.

Meeting of April 7, 1916, the President, W. P. Pool, M. D., in the
Chair.

Dr. Leo. S. Schwartz reported a case of

CONGENITAL ABSENCE OF THE EXTERNAL EAR.

This baby, seven weeks old, was born without any evidence of
an external ear on the left side except a small portion of the lobule.
The baby was otherwise healthy and there was no history of
deformity in the family. If the .v-ray examination showed an
internal auditory canal this would have to be opened up later and
a plastic operation done. There were no abnormal happenings dur-
ing the labor.

312 TRANSACTIONS OF THE

Dr. F. C. Holden reported the following cases of

ECLAMPSIA.

I. Mrs. M. M., aged thirty-seven. Patient was brought to the
hospital, December lo, 1915, 11.30 a. m., semi-comatose, and
history was obtained from the husband.

Patient had been in excellent health until four years ago, when
she had a miscarriage, followed by a severe infection. She was ill
for several weeks at that time. Last full-term pregnancy was ten
years ago. Present pregnancy, the last period was about eight
months ago. Patient had been fairly well until the evening before
admission, she had been under the observation of a physician, who
had constantly found a small amount of albumin in the urine. The
evening before admission, patient began to have severe headache
and sense of depression in the chest; she was unable to lie down,
and walked about all night. She became much worse and was
brought to the hospital. The patient was a rather obese middle-
aged woman, semi-conscious, breathing sterterously. She appears
to understand questions, but could not answer. Pupils contracted,
equal, reacted to light and accommodation. There is a slight
palsy of the left side of the face. Patient was quite restless, she
tossed right upper and lower extremities about, but the left side was
immobile. The face was quite puffy. The heart showed no
apparent enlargement, sounds slow, regular and forceful, no murmurs.
There was a shght accentuation of second aortic.

The respirations were vesicular, with many moist rales, large and
small, particularly in the posterior portion of the chest. Pulse,
50, regular, good volume, moderate tension. The abdomen was
obese, fundus reached to four lingers' breadth below the ziphoid.
A small child was present in L.O.A. position, fetal heart 146. The
left lower extremity was spastic, with great increase in the reflexes.
There was edema of both feet and legs. Babinski and ankle clonus
on both sides, more marked on the left. The blood pressure, on the
right side was 155, on left 140. Patient was catheterized, and about
2 ounces obtained. Urine boiled almost solid and was full of
casts of all descriptions.

Immediately on admission patient was wrapped in hot blankets
and surrounded with hot-water bags, was given three drops of croton
oil. She began to perspire somewhat, but general condition did
not improve, patient becoming more comatose, breathing more
sterterous, large rales appearing in the chest and throat. Since it
was felt that the patient was suffering from a severe nephritic
toxemia, and was rapidly getting worse, and since it was apparently
necessary to empty the uterus as soon as possible, it was decided to
do a vaginal hysterotomy, which was done about two hours after
admission. A live child about four to sue weeks premature was
obtained. Patient was returned to the ward in condition no worse
than before operation. Patient did not rally, breathing continued
sterterous and chest gradually filled up. Pulse was 140, blood
pressure 142, directly postoperative. Patient failed rapidly and
in spite of all stimulation died at 8 p. m.

BROOKLYN GYNECOLOGICAL SOCIETY 313

2. A Polish woman, aged thirty-two. Admitted January 25, 1916
at 9 A. M. Patient comatose and history obtained from husband.
Patient had had the last period about seven months ago, and had
had a normal pregnancy until three days before admission. At
this time she began to complain of headache, which continued off
and on until evening before admission. Patient also vomited several
times. About 6 p. M. on the evening before admission, patient
began to have rather severe pain in the abdomen and a midwife
was called. Patient was considered in labor and was put to bed.
At midnight pains ceased and patient fell asleep. About 4 a. m.
the husband of the patient was awakened and found her in a con-
vulsion, after which she remained unconscious. From that time
until admission to hospital at 9 a. m. she had seven more convul-
sions, and continued unconscious between them. Just before admis-
sion an outside physician had attempted to manually dilate the cervix
with ether anesthesia.

On admission, a well-nourished woman, deeply comatose, breath-
ing sterterously, reacted only to strong stimulation. There was
considerable edema of the face and eyelids. Pupils were moderately
contracted, but reacted to light. There was marked effusion of the
ocular conjunctiva. Heart and lungs negative. Abdomen showed
a uterus extending just above the umbilicus, small fetus in L.O.A.
Heart sounds not heard. There was moderate edema of the feet
and legs. Pulse varied from 96 to 120, regular, high tension.
Vaginal examination showed a nuUiparous introitus, cervical canal
about 2 cm. long, small bilateral laceration. External os admitting
one finger into the uterus. Patient was catheterized, and about 6
ounces of urine obtained. This boiled soUd, contained numerous
hyaline and granular casts. During the vaginal examination, the
woman had a slight general convulsion. The patient was imme-
diately surrounded with hot blankets and water bags, was given
veratrum viridi, TTl.v., stomach lavaged and magnesium sulphate 2
ounces left in stomach. Patient immediately began to eliminate well,
perspired freely and shortly afterward had two large fluid defecations.
Blood pressure, however, rose to 200 mm., but after venesection
with 16 ounces of bleeding was done, this dropped to 168.

It was now decided to introduce a Vorhees' bag and to try to induce
a rapid labor. However, while patient perspired freely and had
several large fluid bowel movements, she did not recover conscious-
ness and had only an occasional uterine contraction. At 3.30 p. m.,
three hours after the introduction of bag, it was decided to do an
anterior vaginal hysterotomy. Patient was accordingly taken to
operating room, and under light ether anesthesia, a vaginal hyster-
otomy, followed by version and extraction, was done. Just before
operation, blood pressure was 168, pulse ioa-120. After operation,
blood pressure rose to 175, pulse 120-130.

Patient still continued comatose, slightly restless at times and
did not improve. At 8.30 p. m., blood pressure had risen to 217
mm., and veratrum viridi Til. v. given by hypo. One hour later
blood pressure dropped to 192 mm.

During the night following the operation, patient continued

314 TRANSACTIONS OF THE

comatose, edema of face and conjunctivae became more marked,
patient perspired freely, and several times voided small amounts
involuntarily.

There was little change in patient during the day following opera-
tion and coma deepened. Blood pressure ranged about 170, in spite
of all treatment and continued thus until e.xitus. About midnight,
two days after admission, temperature rose to 108° F., pulse
gradually grew weaker, lungs became full of moist rales, and patient
expired at 1.40 p. m. 1/28/16. Eighty-two hours after first
convulsion.

Autopsy findings, moderate edema of brain with few punctate
hemorrhages. Slight enlargement of liver, with slight amount of
perilobular degeneration. Large white kidney — parenchymatous
degeneration.

DERMOID CYST.

Miss A. W., aged forty, menstruated first at fourteen. Twenty-
eight-day type. Four-day habit. No pain. First seen April i,
1916, when the following history was obtained:

In June, 1915, after rising in the morning she was suddenly seized
with severe abdominal pain, especially located on the right side,
approximately at McBurney's point. This pain was followed
by persistent vomiting. She was told at the time that she had ap-
pendicitis. A few days' rest in bed and she was about again. She
had had five similar attacks up to the present time. On Saturday
morning, April ist, immediately after getting up she was seized with
excruciating pain followed by vomiting, as on the previous attacks.
Temperature was 100, pulse 90, some rigidity of the right rectus.
By rectoabdominal examination, a fluctuating tumor was found
extending across the abdomen, side to side and to within 3 cm. of
the umbilicus. As the pain had then subsided, the only treatment
was an ice bag, quiet, and starvation. On Wednesday, April 5th,
she entered the Brooklyn Hospital. Catheterization was done to
eliminate the possibility of distended bladder. Blood count showed
leukocytes 26,000, polynuclear 85 per cent. Blood count done to-day
21,000 and 86 per cent., temperature not above 99 since entering
hospital, nor pulse above 90. Through a long right rectus incision
extending from the symphysis to i inch above and to the right of the
umbilicus, a large ovarian cystoma 18 X 10 cm. was removed. The
walls of this tumor were very intensely ingorged and ecchymotic.
The fimbriated extremity of the Fallopian tube had appearance
resembling a tubal abortion. Right salpingo-oophorectomy was
done and the abdomen closed in layers. The specimen here pre-
sented was incised and a large amount of thick yellow turbid fluid
evacuated and two balls of hair found, and in the cyst wall a small
hard bony substance can be felt.

DISCUSSION.

Dr. Hussey. — I saw a case of eclampsia go from just before noon
on a Tuesday to noon on Friday and recover, a little over seventy-

BROOKLYN GYNECOLOGICAL SOCIETY 315

two hours. This patient was delivered after the third convulsion.

Dr. Beach. — One eclamptic at the Williamsburg Hospital had
thirty-nine convulsions after delivery during the course of eighteen
hours and recovered. She was comatose about three days.

Dr. O. Paul Humpstone presented a case of

OVARIAN CYST WITH TWISTED PEDICLE COMPLICATING PREGNANCY.

Mrs. — — ■ — ' — , Methodist Episcopal Hospital, aged twenty-nine,
U. S., white, para-i, was admitted to my service with the following
history.

Her family and past history was negative. Her menstrual history
began at twelve, always regular, five or six days. No pain, normal
flow, after marriage the same.

She was married eight months and then missed her period and
suffered the symptoms of pregnancy.

She first consulted me when five months pregnant and in a routine
examination a mass was discovered the size of a large orange behind
the uterus dipping into the culdesac and the diagnosis of a com-
phcating ovarian cyst was made.

She was told of the complication and desired very much not to
have anything done which might terminate the pregnancy, so it
was determined to allow the case to progress to term if possible and
then to deal with the situation as might be necessary. She went on
to the seventh month and first week, and was suddenly seized while
in bed at night with severe cramping pain on the left side and the
back. Examination showed considerable tenderness over the whole
abdomen and some rigidity from peritoneal irritation. Shght pain
continued but not like labor pains and the next day on a diagnosis
of twisted pedicle cyst, she was prepared for laparotomy. Upon
opening the abdomen the cyst was found to be as large as a man's
head twisted and dark colored. It was impossible to displace the
uterus and deal with the cyst so a hysterotomy was done and the
baby and placenta removed and the uterus sewed up and then the
cyst was very easily dealt with, by ligation of pedicle and removed
in toto.

The patient made an uneventful convalescence. The baby
weighed 3 pounds and i ounce, but died from atelectasis six hours
after operation.

The case is of interest to us in this particular: When a diagnosis
of ovarian cyst is made during pregnancy the best time to deal with
it is at once, if we had done an ovariotomy at once when we first saw
this case the uterus would not have interfered with our removal of
the cyst. True she might have aborted, but increasing experience
and case reports show that single ovariotomy during pregnancy
generally does not lead to abortion if proper precautions are taken.

DISCUSSION.

Dr. Pomeroy. — Two months ago I removed a dermoid cyst about
the size of a goose egg, from a patient five months pregnant. The

316 TRANSACTIONS OF THE

tumor could be felt per vaginum adherent in the deep pelvis to the
left of the cervix. It was removed through a small left rectus inci-
sion at the level of the fundus. The patient has every prospect of
having her baby at the usual time. There could not possibly be any
twisting of the pedicle in this case because the local adhesions charac-
teristic of dermoid cysts prevented rotation. It could easily have
been removed vaginally but the risks of causing an abortion, and the
indeterminate nature of the mass made it more sensible to remove it
as we did.

Dr. Holden. — My e.xperience is the same as that of Dr. Hump-
stone. I believe that all such growths should be removed at once
where they are large enough to give symptoms. In the last six
months I have seen two of these cases. One at the Greenpoint
Hospital had a large cyst adherent to the abdominal wall. The
other was sent to the Long Island College Hospital and proved to
be similar to the one in Dr. Humpstyne's case. The patient aborted
three weeks postoperative.

Dr. Victor L. Zimmermann read a paper on

PREGNANCY COMPLICATED BY CANCER OF THE CERVIX.*
DISCUSSION.

Dr. Hussey.— My experience is limited to the single case which
Dr. Zimmermann has recited. It was a most instructive one in
many ways and the diagnosis was suspected before examination.
She was examined at anotlier hospital two months before coming to
us and was reported to be in normal condition, so the growth was
evidently of a rapid character. A point of interest that I might
bring out is that while we were doing the operation, an examination
of a piece of the growth was made by the pathologist by frozen sec-
tion, and the hysterectomy followed his report, which confirmed the
clinical diagnosis.

Dr. Walter B. Chase. — I desire briefly to report a case of cancer
of the cervix which came under my care twenty years ago, and
perhaps if I read the published report it will better portray the con-
dition: During March, 1896, a married woman, multipara, aged
forty-two, came under my observation with t^-pical cancer of the
cervix, accompanied with extensive involvement. Hemorrhage was
violent and the patient was cachectic. She was greatly exsangui-
nated and very weak. She entered St. Johns Hospital in March and
I did a high galvanocautery amputation as soon as her health per-
mitted. She made a slow but satisfactory recovery as far as the
healing and local symptoms were concerned, and after two or three
months she was able to resume her family duties. In November of
the same year she entered the Bushwick Hospital for extirpation of
a large gland of Bartholin. At this time there was no sign of the
return of the cancerous growth. On June 16, 1897 she reentered
the Bushwick Hospital being seven months pregnant. The disease

* For original article, see page 25 '•

BROOKLYN GYNECOLOGICAL SOCIETY 317

had returned, springing up around the old stump. After watching
its behavior, I feared, from the hardening and infiltration of the
uterine and continuous structures, labor might induce rupture of the
uterus, and on July i8th, at the eighth month of pregnancy, I remov-
ed the diseased growth, which encircled the uterine outlet, by the
thermocautery. No shock followed and the patient was delivered
of a healthy living child on August 6. Her convalescence from the
confinement was satisfactory, as was the healing after the cautery.
She enjoyed good health for nearly a year. Then the growth reap-
peared and she entered the Central Hospital June 21, 1898, and I
removed as far as possible the cancerous mass which had returned.
The heahng was not satisfactory and she died a few weeks later from
a cerebral embolism, which only anticipated the inevitable result of
her condition. Dr. Spence hoped to be present to-night and report
a case of a woman of great interest, two and one-half months preg-
nant, in which he first used the thermocautery and burned away a
large portion of the cervix, and then did a panhysterectomy; and
directly after I did a prophylactic radiation in the hope of preventing
a recurrence of the trouble.

Dr. Pool. — I may add to the cases reported here another of the
same kind. A number of years ago there was treated in Dr. Jewett's
clinic a case of pregnancy about term, complicated by extensive
adenocarcinoma of the cervix. A Cesarean operation was done
and the uterus removed. At the time of the operation, I recall,
there was little infiltration about the cervix, but at the time of her
discharge, several weeks later, there was an extensive infiltration
throughout the pelvis, which was believed to be at least in part
mahgnant. She left the hospital in bad condition and against
advice. I had the opportunity to examine this patient about a
year later, and to my surprise, found her in good general health and
comfort. There was still some evidence of pelvic exudate, but it
had almost disappeared. Whether she had a recurrence later, I
do not know.

Dr. Zimmermann. — -The case related by Dr. Chase is very
interesting, but he could hardly have done a high amputation of the
cervix after Byrne, if pregnancy occurred later, as the internal os
and part of the corpus are removed by that method. The vaginal
hysterectomy by Fritsch was done after delivery with forceps, and
not after hysterotomy.

Dr. a. a. Hussey read a paper on

THE MANAGEMENT OF PREGNANCY AND LABOR COMPLICATED BY
HEART DISEASE.*

DISCUSSION.

Dr. Lohman. — Dr. Hussey has asked me to discuss this paper, but
after listening to the able presentation of the subject which he has
made I confess that he has not left much to say. There are several

' For original article, see page 240.

318 TRANSACTIONS OF THE

points that might be emphasized. I should like to take exception
to the statement regarding the diagnosis of broken compensation
in pregnancy. We all know that the normal pregnant woman may
have dyspnea, with swelling of the legs and the other common signs
of heart involvement and it is not always easy to determine the exact
cause. I think that many of the patients have edema of the base
of the lungs, together, sometimes, with enlargement' of the heart,
enlargement of the liver, rapid irregular pulse, and I think these
symptoms should be looked for rather than edema and dyspnea.
The literature shows very definitely that most organic heart lesions,
in pregnancy, go unrecognized and probably most go through labor
without difficulty. One point in the diagnosis that Dr. Hussey
has mentioned which impressed me is the pronounced tendency of
these patients to toxic symptoms. I think that the majority of
cases I have seen of cardiac failure in pregnancy have shown toxic
symptoms; high blood pressure, i8o mm. to 200 mm., especially in
mitral stenosis, showing cyanosis, dyspnea and edema. This is
easy to understand because organic heart diseases cause injury to
the parenchyma of the other organs, particularly to the kidneys,
and when the extra effort is thrown upon them the toxemia is the
result. I saw one case of dilated heart, where pituitrin was used
when the pressure was high. The heart became more dilated and
the patient's condition became very precarious. Under these
circumstances, particularly where there are toxic symptoms, vene-
section has impressed me as best, and if an operation is performed
the loss of blood is often beneficial. I have seen several of Dr.
Hussey's cases where he has done Cesarean section and several with
less radical treatment and the results of the former have been very
much better, not only in the lessened amount of strain upon the heart
at the time of delivery but in a very much smoother puerperium.
Usually these cases of labor with cardiac failure, even when carefully
guarded by "Twilight Sleep" in the first stage and rapid delivery
in the second stage, have a bad time of it for the first eight or ten
days, hanging between life and death, and require careful watching.
If these cases could have the proper care during the whole of the
pregnancy, as Dr. Hussey suggests, the maternal mortality would be
reduced to the vanishing point and the 50 per cent, mortality of
the children greatly reduced.

Dr. Cornwall. — The question, what to do in pregnancy com-
plicated by a heart lesion, is not always an easy one to answer, but
we can only rely to a certain extent upon general principals. If
there is a mitral stenosis, signs of loss of compensation, even slight,
are of grave significance, and usually constitute an indication to
terminate the pregnancy. If there is a history of previous loss of
compensation in a patient with mitral stenosis who is pregnant but
shows no signs of loss of compensation, the indication to terminate
the pregnancy should, in my opinion be considered imperative. If
a patient with mitral stenosis who gives no history of loss of com-
pensation in the past become pregnant, she can be allowed to go
on under strict observation and careful regulation of life and espe-

BROOKLYN GYNECOLOGICAL SOCIETY 319

dally diet; but at the first sign of heart strain she should be delivered
of the burden of gestation. That some patients with mitral stenosis
can bear children with impunity, or seeming impunity, is evident
from experience: I have certainly seen cases of mitral stenosis
which gave a history of several pregnancies without loss of com-
pensation. But in this serious heart condition it is always best if
the case is at all doubtful, to let the judgment be influenced by con-
siderations of safety. Of the other valvular lesions, mitral incom-
petence is the most common, and the least dangerous. Considerable
leeway can be allowed a pregnant woman with this lesion when it
shows signs of decompensation, but here every prophylactic measure
should be observed and decompensation that shows signs of becom-
ing intractable to treatment is an indication for terminatmg the
pregnancy. . Aortic valve lesions are usually very dangerous to the
pregnant woman, though comparatively infrequent. The principles
that obtain in mitral stenosis would seem to be applicable to them.
Myocardial degeneration is sometimes a difficult condition to esti-
mate in its relation to pregnancy, but fatty overgrowth may not
necessarily be of much importance. In fact, pregnancy has been
suggested as a method of training the muscle in this form of fatty
heart. In the care of patients with any form of cardiac weakness
regulation of the metabolic burden is of the first importance, and
that, of course, is effected through the diet.

Dr. Beach. — I have been very much interested in the paper as
I have recently taken a mitral stenosis case through pregnancy and
labor, and it is the last time I will attempt it. This patient came
to me when she was two months pregnant, and when I discovered
the lesion I advised emptying the uterus, but she refused. I made
every effort to carry the case through. We regulated her mode of
life, especially in the matter of exercises, but by the time she was
seven months pregnant she could hardly walk. In the last two weeks
she could not get up and down stairs, and was short of breath even
in going about her apartment. There was some cough and bloody
expectoration. The heart was i6 cm. across, blood pressure about
130, no edema. We took her to the hospital a few days before
the time of delivery and put her on tonics. When she went into
labor she immediately had hard pains, was dyspneic, cyanotic,
and nervous. I gave her morphine, one-quarter, and later some
scopolamine and morphine, and then waited to determine what to
do later. Ori examination I found five fingers' dilatation and the
head almost at the outlet, and we let her proceed. We could tell
absolutely the beginning of the second stage by her appearance for
as soon as she began to have bearing-down pains she became cyanotic.
We then discovered that the position was an occiput posterior and
after giving ether I did a manual rotation and delivered, which was
comparatively easy. Before the baby was out sand-bags were placed
on the abdomen above the fundus, and the patient was placed in a
partial sitting position. She collapsed immediately after delivery,
the blood pressure dropped to 80 mm. She was given camphor
and pituitrin, and placed in the Trendelenburg position. Two hours

320 TRANSACTIONS OF THE

later the blood pressure was loo mm. and four or five hours later it
was 1 20 mm. Later she complained of the pressure of the bags, as
we had perhaps 50 pounds of sand on her. I took one bag off and
inside of five minutes the blood pressure was down to 104 mm. We
kept the sand on for forty-eight hours and then gradually reduced it,
and at present she has only a tight binder. In regard to the nursing
of the child, the internist said he did not see why she should not
nurse the baby. She is only a slip of a girl and it is a question
whether she should nurse or not. One point which Dr. Hussey did
not bring out and that is spinal anesthesia. I have had five cases.
I remember one case of Dr. Luria's in which I emptied the uterus
under spinal anesthesia with a good recovery. At the Methodist
Hospital Dr. Humpstone had a case which he treated by spinal
anesthesia which made a good recovery. I believe the morphine
and scopolamine method, followed by spinal anesthesia to be the
ideal anesthesia in cases where the uterus is to be emptied by
abdominal or vaginal Cesarean section.

Dr. Humpstone. — I believe that cases of mitral insufficiency need
not be considered unless there is a break in compensation during the
pregnancy. My experience is that the internists do not see the
patients in their homes very often, and we usually get a conservative
opinion. I beheve the determination of the labor must rest always
with the obstetrician, not with the internist, who may tell us in
what condition the heart is, but we must be the ones to decide. The
woman with myocarditis shows very httle toxic symptoms and goes
along to the seventh month and then the heart dilates and she dies,
and this is particularly seen in patients with fibroids. In the matter
of delivering these cases, I want to say that what Dr. Beach states
is my belief. I would rather use the spinal anesthesia in mitral
stenosis with broken compensation.

Dr. Polak. — I feel as Dr. Humpstone does about the internist
in many instances. We have come to look at these cases of broken
compensation as serious problems. While I am not so radical as
to believe that all of these cases should be aborted, I believe with Dr.
Hussey that they should be observed with great care. There are
three points to consider:

1. The woman with such a lesion who has had a child is not in as
good condition (notwithstanding the statement of Dr. Cornwall), as
the woman who has not had a child, for every childbirth is a strain
upon the heart.

2. Early cases who have heart defects and who are pregnant and a
break has occurred either before or during this period should be
watched. We may carry them through to seven and one-half or
to the eighth month, they should never be allowed to go to full term
or to go through labor.

3. The class where we meet the trouble for the first time during
the labor. I agree with Dr. Hussey that they do not bear the strain
of labor well and such a case should be operative. We have found
that it is extremely dangerous in any of these cases to attempt induc-
tion unless that induction is proceeded by complete amnesia. I do

AMERICAN GYNECOLOGICAL SOCIETY 321

not know of anything that disturbs the heart so much as apprehen-
sion and excitement, and I believe in the use of morphine and scopol-
amine. We have had a large number at the L. I. C. Hospital
and have gotten good results by carrying them through with the
aid of morphine and scopolamine. As soon as delivery through the
vulva has commenced we have bled them and have begun to stimu-
late them with camphor and used pressure on the abdomen with
large sand-bags. Those points are clear. These patients do not
stand nitrous oxide well, but if well morphinized ether and oxygen
and stimulation do the work. I do not believe in bleeding them from
the uterus, most of the trouble from engorgement is on the right side
of the heart. Section has been done on five cases and they have all
resulted favorably for mother and child. The objection to section
is that empti^nng the uterus suddenly produces shock. It is, how-
ever, less of a strain and with the proper use of sand-bags will bring
them out with less shock. Dr. Hussey's conclusions should be
brought to the attention of the general practitioner, who, as a rule,
does not know what it means to have a heart lesion go through the
strain of labor.

Dr. Hussey. — I think Dr. Beach is right in saying he would not
try to carry another case of mitral stenosis with broken compensa-
tion through labor. It would be safer to operate without the patient
knowing anything about it, by putting her to sleep at night with
morphine and operating in the morning. Anxiety and worry are
almost as bad as physical strain in these cases. '^lorphine numbs
the patient so that she does not worry. Spinal anesthesia is men-
tioned by several writers. I have had no experience with it myself.
It would seem to me to be dangerous in some forms of heart disease
as it is said to depress the circulation. Nitrous oxide alone is
dangerous but with oxygen it is safe. I do not think one should
take a radical position and abort all cases of mitral stenosis. The
problem we have to study is based not on the particular heart lesion
but on the condition of the patient, what is the heart reserve and its
relation to the burden of this pregnancy and labor.

TRANSACTIONS OF THE AMERICAN
GYNECOLOGICAL SOCIETY.

(Continued from page 103.)

THE USE OF THE X-RAY IN UTERINE HEMORRHAGE.

Dr. Robert T. Frank, of New York City, said the .r-ray treat-
ment was indispensable in gynecology, but under strict indications
and limitations. The rays worked mainly by destroying ripening
ovarian follicles, primordial follicles showing great resistance. WTien
no ripe follicles were present, menstruation ceased. In fibroids
there might also be a first effect on the tumor.

322 TRANSACTIONS OF THE

Fractional exposure implied frequently repeated treatments of
small amount. This took more time, but permitted of finely graded
dosage. Intensive treatment by use of small multiple fields per-
mitted of rapid attainment of amenorrhea.

The rays could be used in all functional hemorrhages (menorrhagia
or metrorrhagia) in which expert examination revealed normal pelvic
organs, and in which the curetings were free of malignant changes.
This saved the uterus of adolescents and women in their sexual
ripeness, because the bleeding could be "toned down." It also
saved women in the preclimacteric age from operation, if they were
bad operative risks.

He used the .i:-ray in about 5 per cent, of fibroids. Only 45 per
cent, of fibroids required any treatment. Bleeding was most
readily cured by raying. In order to permit of the safe employment
of .T-rav, he postulated that no cases should be rayed in which a
suspicion of carcinoma or sarcoma could be entertained, that no
complications, such as ovarian or adnexal tumors, were present;
that no urgent symptoms were present. This limited the treatment
to clear cases of uncomplicated fibromyoma. Preference should be
given to the rays when extreme psychical unrest or severe cardiac,
renal or pulmonary disease contraindicated operative measures.
The expense entailed by raying precluded its use except in well-to-do
patients or in endowed institutions.

precXncerous changes in the uterus.

Dr. William S. Stone, of New York City, attempted under this
title to express the evolutionary character of the different types
of cancer of the uterus as beginning in definite benign lesions, such
as erosions, leukoplakia and glandular hyperplasia, which showed
variable quantities and qualities of epithelial overgrowth and meta-
plasia that might differ little from the regenerative activity seen in
the benign lesions, or after a longer or shorter time might show
atypical features that were differentiated with difficulty from the
alterations we knew typified malignant neoplasms. To such patho-
logical changes he thought the term precancerous might be appro-
priately applied, as they appeared to represent changes that were
neither cancerous nor noncancerous, but were in the stage of becom-
ing cancer. Their relation to the development of a cancerous growth
was shown by the fact that their morphological features included,
in different comljinations of quantity and quality, the numerous
histological criteria upon which the diagnosis of a fully established
cancer was made, lacking only in some instances the features of
destructive activity and purpose. The strongest support of that
question was derived from the reproductions of types which were
seen in the different stages of their progress. In his material, for
example, he found the atypical features of a healing erosion de-
termined by the original type of the lesion- -simple, papillary, fol-
licular and the atypical types again reproduced in the different types
of fully established uterine cancer. There were atypical erosions
which were prototypes of either an epidermoid cancer or a papillary

AMERICAN GYNECOLOGICAL SOCIETY 323

adenocarcinoma. There were leukoplakias which were prototypes
of adult acanthomas. There were glandular hyperplasias which
led to adenoma or adenocarcinoma. Finally, there were focal areas
of leukoplakia, combined with adenomatous hyperplasia, which
might well furnish an origin for tumors designated as adenoacan-
thomas. In short, for each type of fully developed carcinoma there
was a corresponding type of benign and intermediary change.

The literature had been critically reviewed, showing increasing
evidence confirmatory of the sequence of benign lesions in the uterus
and cancer, but the efforts to define their histogenic relation had been
limited to a few writers. In order to more fully verify the assump-
tion that morphological features of intermediary stages existed, a
close cooperation between the clinician and the pathologist would be
required. For the present, it was no argument against such an
assumption because no tumor process was present or followed in a
given case. The evidence in the literature was already sufficient
to show that a fully established cancer might exist for a certain time
without giving gross evidence of its presence, and numerous cases
were recorded in which the curet had completely removed the
disease. There was no reason to assume that precancerous changes
without treatment must always develop into malignant growths.
Different types of fully established tumors had a different capacity
to grow and destroy rapidly or slowly, and it did not seem reasonable
to assume that a developing cancer had the same momentum that
a fully established tumor possessed. In the study of beginning
cancer of the uterus several authors had directed attention to the
fact that a certain type of early cancer might spread superficially
over a wide area before showing marked invasive features, and it
had occurred to the author that such a mode of growth might account
in some measure for the extent of the process before it received the
attention of the clinician. With the description of the author's
cases there were sufficient clinical data to show the practical side
of the problem, that the decision regarding the proper therapeutic
procedure in such cases should be assumed by a competent clinician.

THE CLESIICAL COURSE OF CANCER IN THE LIGHT OF C.A.NCER RESEARCH.

Dr. Harvey R. Gaylord, of Buffalo, New York, Director of the
State Institute for the Study of Malignant Disease, said cancer was
not one disease but a group of diseases. The various types of
sarcoma in chickens caused by filterable viruses had taught us that
there were neoplasms with specific agents which determined the
character of tumor. Progress required that cancer of different
organs must be treated as individual diseases and studied indi-
vidually. The study of immunity to inoculated cancer threw new
light upon the clinical course of the disease. Successful surgery,
x-ray and radium treatment were all dependent upon immunity.
Early operation owed its success to the fact that immune reactions
in spontaneous cancer were strongest in the early stages of the
disease. The effect of chloroform and ether anesthesia and loss of
blood dependent upon surgical operation was shown to exercise a
destructive effect upon the immunity.

324 TRANSACTIONS OF THE

THE TREATMENT OF CANCER OF THE UTERUS.

Dr. John G. Clark, of Philadelphia, Pennsylvania, said the
treatment of cancer of the uterus might be classified under three
divisions: (a) The radically operative; (b) the radical use of the
cold cautery, and (c) the use of radium or mesothorium.

Statistics as to surgical results were now upon a definite basis and
demonstrated a higher percentage of cures from the radical ab-
dominal operation than ever achieved by the less radical vaginal
and abdominal methods; in rebuttal might be offered the much
higher primary mortahty and the greater number of disabUng
sequelae from the former over the latter. The dangers of the
radical operation were great even in the hands of the expert and
prohibitive when performed by the surgeon of Hmited experience.
Many so-called radical operations were mere makeshifts, the patient
being subjected to the greater hazards without any appreciable gain
over the simpler methods by an attempt to execute an operation
which fell lamentably short of an ideal standard.

As yet, the use of the cold cautery was in the proving ground and,
as already demonstrated, was a procedure which to be successful
must be radical and would, therefore, be attended with a high
primary mortahty as well as serious sequelae. It must, therefore,
show a higher percentage of ultimate cures to make it a worthy
competitor of the radical operation.

In an experience of over two years, radium had given encourag-
ing promises, first, as a palliative remedy, and, secondly, as a tenta-
tively curative one. It was in no sense a miraculous panacea, for a
very definite percentage of cases was not helped and the malig-
nant process did not appear to be even halted but might actually
be expedited. The sequels, however, following its judicious em-
ployment were comparatively insignificant as compared with the
foregoing methods, and, therefore, if the patient was not helped she
was at least spared the added miseries of unfortunate accidents.

Because radium was not a dependable agent in all cases, and be-
cause as yet the type of cancer which would be helped could not be
forecasted, surgical measures must still be invoked, but might be
supplemented by radiozation. The dictum of the last few years,
"In case of doubt, extirpate the uterus," was now modified, for in
all such instances we now applied radium. Thus far, in no instance
had hysterectomy been performed when radium had acted bene-
ficially, for it was not logical that an operation could accompUsh
anything further. As experience now pointed, it would appear that
radioactive agents were to serve as an excellent supplementary
remedy to surgery, offering better results in the operative cases and
a definite hope to the inoperable.

XgiE ^TENDED OPER.\TION FOR CARCINOMA OF THE UTERUS.

Dr. Reuben Peterson, of Ann Arbor, Michigan, presented the
following summary and conclusions: i. Further experience with

AMERICAN GYNECOLOGICAL SOCIETY 325

the radical abdominal operation for cancer of the uterus confirmed
the belief that it was an exceedingly dangerous procedure and would
always be attended by a high primary mortality. 2. Even if the
percentage of operability of cases of cancer of the uterus markedly
increased in this country and elsewhere, there would always be border-
line cases attended by a high primary mortality. 3. This was true
because it was not always possible, even with the greatest care
in examination of the patient prior to operation, to estimate the
extent of the disease. 4. Errors in judgment meant death from
shock if the disease was too far advanced, or failure to complete the
radical removal of the cancerous uterus. 5. However, in spite of
a high primary mortality it was the only procedure, with the possible
exception of the extended vaginal operation, which held out any
reasonable promise of a permanent cure. 6. Primary and end
results of the radical operation for cancer of the uterus must be con-
sidered together in order to judge of the good accomplished in a
given series of cases. 7. Unless the operation could be radical the
end results would be poor, and if they were radical the primary
mortality must be high. 8. If the end results were poor the burden
of proof was upon the radical abdominal operator to show why he
did not choose a much safer paUiative procedure. 9. Since 191 2,
experience with fourteen ordinary panhysterectomies for cancer
of the fundus showed worse primary and end results than in eleven
cases previously reported where radical removal was performed.
10. That showing and the results following removal of fundus
carcinoma by various methods in the Wertheim Chnic as reported
by Weibel, led to the conclusion, that, because carcinoma of the
fundus was more easily cured than when the cervix was involved,
we were not justified in thinking it could be treated any less radi-
cally than carcinoma of the cervix. 11. The primary mortality in
fifty-nine cases of cancer of the cervk and fundus treated by the
radical abdominal operation was 25.4 per cent. 12. The extent of
the involvement in cancer of the uterus could be determined
definitely only after the abdomen had been opened. If the par-
ametria were not too much involved and the condition of the
patient's kidneys, heart and blood-vessels warranted a prolonged
and depressing operation, it was justifiable to attempt the radical
operation. 13. During the past four years 124 cases of cancer of
the uterus had been seen in the university and private clinics.
The disease was so far advanced in thirty-six cases that operation
was refused and nothing was done. The cautery method was tried
in fifty-eight cases and proved valueless except as a palliative
procedure. 14. In spite of attempts to educate the public regard-
ing cancer, the cases of cancer of the uterus seen during the past
four years were more advanced than had formerly been the case.
15. The end results in fifty-one patients operated upon five or more
years ago were most gratifying. Combining fundus and cervix cases,
twenty-seven of the fifty-one patients were alive and well after five
years or 56.2 per cent, of all the cases operated upon, while 69.2
per cent, of all these surviving the operations were aUve after five

326 TRANSACTIONS OF THE

years. i6. Of forty cases of cancer of the cervix operated upon
live years or more ago eighteen of those surviving the operation were
alive and well to-day. Thus 47.3 per cent, of the total number
remained cured after five years, while 62 per cent, of those sur-
viving the operation remained cured. 17. Those percentages were
obtained by Wertheim's formula where patients dying of intercurrent
disease or those lost track of were subtracted from the total number of
operative cases or from the number surviving. 18. The length of
time elapsed since the operations upon the eighteen patients who were
alive and well varied from five up to thirteen years. There was every
reason to think these patients were permanently cured, although one
patient did have a recurrence and died between five and six years
after the radical operation. 19. In spite of the high primary mor-
tality, the end results in those surviving the operation encouraged us
to continue with the procedure in suitable cases.

A RESUME OF RESULTS IN THE RADIUM TREATMENT OF THREE

HUNDRED AND FORTY-SEVEN CASES OF CANCER OF THE

UTERUS AND VAGINA.

Dr. Howard A. Kelly and Dr. G. F. Burnam, of Baltimore,
Maryland, after seven years' experience and with a full knowledge
of similar work in other parts of the world could now say without
hesitation that the use of radium in sufficient quantities greatly
enhanced the chance of permanent recovery of patients with uterine
and vaginal cancers.

In early and good operable cases the use of radium combined with
operation added greatly to the chance of recovery without a recur-
rence. This was shown in a series of twenty such cases in which they
had as yet seen no recurrence. The most remarkable fact about the
radium treatment of uterine and vaginal cancers was that it often
cleared up those cases which had extended too far locally and became
firmly fixed to the pelvic wall; in other words, cases which were
utterly inoperable.

They had had 327 patients, including border-line cases, cancer fixed
to the pelvic wall, great massive cancers choking the pelvis, and
many where there were general metastases and the radium was used
to bring relief alone. Over 20 per cent, of this remarkable group
had been apparently cured.

They did not pause here to dwell upon the great alleviation
afforded a large number of those who were not cured, but where
discharges stopped, pain ceased, and health was built up.

Their conclusion then was that radium had come to stay and was
the most efficient agent in treating these forms of cancer.

THE PROBLEM OF HEAT AS A METHOD OF TREATMENT IN INOPER.\BLE
UTERINE CARCINOMA.

Dr. J. F. Percy, of Galesburg, Illinois, said there were three
stages to be recognized in the development of the cautery in the

AMERICAN GYNECOLOGICAL SOCIETY 327

treatment of carcinoma of the uterus; first, where it was merely
used to stop hemorrhage and limit offensive discharge. Second,
the galvanocautery excision of the cervix uteri, developed by the
late Dr. John Byrne, of Brooklyn, N. Y. In this technic a high
degree of heat was used sufficient to cut the tissues. Third, in the
dissemination of a coagulating degree of heat through the widest
area possible of the cancer mass, with no attempt at immediate
excision of the parts (Percy).

The technic of Byrne was not designed for the advanced inoper-
able cancer patient, the one in which the uterocervical junction was
fixed, with extensive malignant and inflammatory infiltration of
both broad ligaments and the parametrium. As classified to-day,
Byrne operated only in the first steps of cervical cancer involvement.
He deplored the use of the cold steel knife in cervical cancer and
forty-four years ago referred to it as "a comparatively fruitless
procedure at best." This was just as true to-day, without the pre-
liminary use of heat, as it was in his day. The cases treated by Byrne
with his galvanocautery excision of the cervix were the type of
cases, a large proportion of which would be considered by surgeons
qualified to do it, suitable for the Ries-Wertheim treatment of
to-day.

Percy's technic brought us back to the days before Byrne, to the
treatment of the otherwise hopeless case, and in addition he stated
that his technic opened up new possibilities in the way of further
improved results. The author hinted at something not mentioned
in his paper in the following: The stage of operability with his
present technic was easily 90 per cent., and he confidently expected
that, if the promise which he saw in his work was realized in the
further development of the use of heat in cancer, the stage of opera-
bility would be without limit in strictly pelvic cancer. He would
not have us believe, however, that the ideal was mere operability.
Back of it all was the hope and promise of results never before
obtained by any method so far developed in that disease which had
always stood as a synonym for incurableness — pelvic cancer.

In conclusion, the author re-emphasized first that the Percy technic,
so called was not a cautery operation. He removed nothing. The
tissues, following the application of the moderately low degrees of
heat, were literally coagulated and slowly dissolved.

It usually took two weeks for a healthy granulating surface to
appear beneath the gradually dissolving mass of inert cancer
debris. Second, the operation of Byrne was a high galvanocautery
incision of the cervix. There could be but little penetration of heat.
Byrne recognized this when he advised that the surface left after
the removal of the gross mass be seared over with the cautery knife,
in order to get all the heat penetration possible. But Byrne never
thought of applying heat to the degree of obtaining penetration suffi-
cient to render movable the fixed tissues in the pelvic basin. If the
fixed tissues, malignant and inflammatory, were not made freely
movable, as they were normally, the heat penetration was not suffi-
cient, and, therefore, was ineffective. Third, to coagulate a large

328 TRANSACTIONS OF THE

mass of uterine cancer required from thirty to sixty minutes, and
if the broad hgaments still remained stiff, or fixed, an additional ten
minutes. Fourth, in his effort to emphasize the importance of
avoiding the burning temperatures, he feared that he had led many
surgeons to the opposite extreme, and that they were trying to
destroy the activity of an inoperable mass of cancer with a tempera-
ture so low that days, rather than hours, would be required to make
the heat effective. Byrne fried his tissues, while Percy broiled or
Pasteurized them. The Byrne technic was based on the use of
heat as an acute process; that of Percy was not acute, but chronic,
both as to time and degree. Heat, more heat, and yet more heat;
but heat; not fire; broiling, not frying; not roasting, but curdling;
Pasteurizatiorf, not desiccation; coagulation, not carbonization.

In its practical application the whole technic could be summed
up in the one statement; "do not carbonize the tissues, for in the
degree that this is done, in that degree is heat penetration inhibited;
and heat penetration is the vitally essential thing." A gentle
simmering sound only should be heard when the ear was placed near
the vaginal water-cooled speculum. This simmering sound was
produced by a temperature above 45° C. (113° F.). Heat in
cancer, operable or inoperable, or as a prehminary to the use of the
cold steel knife, had with its present development, come to stay.
It offered more, in the way of cure, in the early case, than any other
treatment so far devised. In the late case it promised surcease
from suffering, with a prolongation of life that was most hopeful.

But more than all else, we had not yet fully learned the technic of
most effectively destroying cancer of the accessible regions of the
body by heat. When we did, another chapter would be written in
the history of man's contest with his physical ills that would com--
pare very favorably with anything so far accomplished along the
lines of scientific endeavor.

HIGH HEAT VERSUS LOW HEAT IN THE TREATMENT OF CANCER OF THE
UTERUS.

Dr. Herman J. Boldt, of New York City, said that he had ex-
pressed himself fully on the relative value of high degrees of heat
compared' with low degrees of heat as a palliative therapeutic agent
in the advanced stages of cancer of the uterus, in an article published
in the American Journal of Obstetrics and Diseases of Women,
for January, 1916, and judging from the communications that he had
received from physicians who had had experience with the treat-
ment, his position was amply justified. It was also corroborated
by another autopsy, in addition to the one that he had, by Dr.
F. W. Bancroft, of New York.

He did not wish to be understood as detracting from the usefulness
of low heat, but it should be reserved principally for a second applica-
tion, after rapid destruction had been accomplished with high heat,
and the charred eschar that was caused by the high heat had been
thrown off; and for those cases in which the cancer had so far

AMERICAN GYNECOLOGICAL SOCIETY 329

advanced that the proper application of high heat would endanger
the bladder or rectum. The danger from secondary hemorrhage was
not less with low heat than with high heat. No evidence had been
presented that showed the superiority of one method over the other.

Heat, properly used and applied in correctly selected cases, some-
times gave remarkably good palliative effects. But it had been
conclusively shown that cancer cells were not destroyed any appre-
ciable distance from the surface of application, certainly not deeper
with low heat than with high heat. This was proved by the
examination of tissues procured at the autopsies mentioned.

Dr. Charles Mayo, when discussing the paper alluded to, pub-
lished in the American Journal of Obstetrics, asserted that the
proof of the deep destruction of low heat as shown in cases that
had been operated upon in the Mayo Chnic, lay in the fact that at
the time of cauterization the disease had too far advanced for the
patients to be operated upon radically, but later the uterus became
mobile and was extirpated, and when these uteri were examined bj'
the pathologist, he failed to find any evidence of malignant disease
in them. This hj^othesis was not acceptable to Dr. Boldt as valid
proof, since the mobility might have become impeded by an inflam-
matory process, which, as the result of the heat treatment, became
dried out, as it were, and mobility of the uterus resulted; a result
seen also when high heat was used. The inflammatory infiltration
might subside, but the carcinomatous infiltration remained. To
disprove this it was necessary for the operator, when the abdomen
had been opened, to remove a part of the suspicious infiltrated area
in the pelvis a reasonable distance away from the cervix, and have
it examined by a competent pathologist. If that showed cancer
nests, and the uterus became mobile subsequently, so that a radical
operation might be done, and the specimen then removed by a
radical operation failed to show cancer elements in the parametria,
we were in a position to grant the deep destruction of cancer elements
by the heat applied, but not until such proof had been shown.

Attention was called to those instances in which recovery followed
when a simple extirpation of the uterus had been done, despite some
parametrial infiltration, and in which, after a period of a few months,
a re-examination failed to show any evidence of infiltration. He
recalled two such cases.

abdominal myomectomy and hysteromyomectomy by
morcellation.

Dr. Charles G. Child, Jr., of New York City, stated that in the
surgical treatment of the fibroid uterus the multiplicity of the
tumors and the large size of the tumor mass often added very
materially to the difficulty of removal. "The larger the tumor the
larger the incision," was the time-honored dictum. He believed
that these operations might be greatly facilitated by decreasing the
bulk of the tumor mass as the removal proceeded, and that this
method of removal meant greater safety to the patient.

330 TRANSACTIONS OF THE

As the size of the tumor decreased with its removal, a large
incision was unnecessary. He, therefore, employed the transverse
suprapubic incision, 3 to 5 inches in length. The transverse inci-
sion was the one of election for three important reasons: First,
because it gave a maximum exposure of the field of operation with
a minimum exposure of the abdominal viscera; the intestines lay
well protected by the upper flap; second, because of the freedom
from postoperative hernia; and third, because it yielded a higher
percentage of primary union than did the median line incision.

The author described the method of making and closing the
incision.

He presented a series of fifty cases from his records, with a brief
analysis of some of their most salient points. These were consecu-
tive and not selected cases, and while the number was compara-
tively small, yet he felt that the series covered pretty well the field
of fibroid pathology and gave a very good idea of the value of this
technic.

Chronic adnexal disease was encountered in 22 per cent, of the
cases: adherent appendix, 19 cases; retrodisplacement, 2 cases; intra-
ligamentous cyst, 2 cases; fibroids, twisted pedicle, 2 cases;, acute
inflammation, i case; calcareous degeneration, 3 cases; necrosis,
4 cases, and early pregnancy, i case.

Myomectomy was performed nine times and hysterectomy forty-
one times.

The author drew the following conclusions. The advantages of
myomectomy or hysteromyomectomy by morcellation were many.
The original morcellation by the vaginal route enjoyed great popu-
larity because of the smoothness of the subsequent convalescence
and freedom from postoperative complications, both immediate
and remote. The abdominal removal of these tumors by morcella-
tion now that we had to-day so improved our abdominal technic gave
just as smooth a convalescence and just as great a freedom from
complications as was secured by the vaginal operators in the past.

The advantages of the technic which he outlined might be con-
sidered both from the point of view of the patient and of the surgeon.
To the patient it afforded greater safety, a shorter and a smoother
convalescence. This was by reason of tlie fact that as the surgeon
worked practically extraperitoneally the intestines were kept out
of the way without resource to laparotomy pads, thus was the intra-
peritoneal traumatism minimized and postoperative shock, disten-
tion or peritonitis was seldom, if ever, seen. In hysteromyomectomy
the danger of secondary hemorrhage from shpped ligatures on the
broad ligaments was very materially decreased because of the ease
with which the relaxed broad ligaments could be hgated. The
smaller incision and the stronger resulting scar, especially when the
transverse incision was used, reduced to a minimum the danger of
hernia. The high percentage of primary union resulting when the
transverse incision, was closed with noninfectable suture material,
meant a much shorter hospital residence. A large granulating
median line incision, where primary union had not been secured.

AMERICAN GYNECOLOGICAL SOCIETY 331

meant a prolongation of the convalescence by many weeks, with a
good prospect of a subsequent hospital stay when the ventral hernia,
almost certain to occur in such a case, was operated upon.

Relative to the advantages to the surgeon, during the greater
part of the operation the tumor was in contact with the abdominal
wall, and the work was extraperitoneal. Thus was the surgeon able
to see definitely each pathological condition as it arose, and to take
the necessary time to meet the indication, for by this technic the
length of lime which the patient was under the anesthetic was not
nearly of the importance that it was when a large median line incision
had been made with all the consequent e.xposure of intestines, and
the use of laparotomy pads that went with the older technic. In
hysteromyomectomy the ease with which the broad ligaments could
be ligated, and the cervix removed when a complete hysterectomy
was necessary, was very marked. Although the transverse supra-
pubic incision might be so small as to handicap many an operator
at the start, still as skill in anything was acquired only by repetition,
so here with experience one became quickly proficient.

A STUDY OF THE PATHOLOGY IN ITS RELATION TO THE ETIOLOGY
WITH THE END RESULTS OF TREATMENT OF STERILITY.

Dr. John Osborn Polak, of Brooklyn, New York, defined sterility
as the inability on the part of a woman to produce a living child.
In this study, which was a personal review of 788 case histories
of patients from the writer's private experience, he attempted first
to analyze the many etiological factors which had entered into the
causation of this symptom; second, to discuss the treatment of the
individual case based upon an etiological diagnosis, and finally sum-
marize the end results, with the hope that the paper might add
something to the already overwritten but unsolved subject.

The passage of the spermatozoon through the cervix was de-
pendent upon the activity of the particular spermatozoon and the
amount, character and reaction of the glandular secretion from the
cervix. Acids in very weak dilutions were destructive to the sper-
matozoa and thick mucopus acted as an almost insurmountable
barrier to the progress of the male element.

The proper transit of the ovum from the ovary to the uterus
required a healthy patent Fallopian tube.

The conditions of the tube which might impair the transmission
of the impregnated ovum were either congenital or acquired. On
arriving in the uterus, the impregnated ovum located in the decidual
bed prepared for its nourishment, which was usually situated just
below the uterine ostium of the tube on the anterior or posterior
wall of the uterus, and unless the endometrium had been the seat
of disease the ovum developed at the site of its primary implantation.

In managing the cases of sterility, he began with a thorough
investigation of the life and functions of both contracting parties.

The reaction of the vaginal and cervical secretions was thoroughly
investigated and the presence of gross pathology in the fornices

332 TRANSACTIONS OF THE

noticed. A Wassermann test was made in all of those who pre-
sented themselves with histories of abortions or premature labors
with or without death of the fetus.

The treatment in all cases was directed toward the correction
of the existing causative lesion. In the first class, this included the
employment of alkaline douches, of the graduated dilators, the
Baldwin or Davenport stem, discission of the cervix, after the
methods of Dudley or Pozzi, amputation of the cervix and correction
of uterine displacements.

In the second class both local and operative measures were
employed. In ten cases of large ovarian cyst, unilateral oophorec-
tomy resulted in eight of the women becoming pregnant. Of twenty
uncomplicated retroversions, eleven were repositable and could be
maintained in position with a pessary. Six of these women became
pregnant. Nine because of a deep posterior invagination of the
cervix could not be held in place with a support. These were
operated by the Webster-Baldy or Gilliam technic and a Dudley
discission. Of these, five became pregnant.

Infravaginal hypertrophy of the portio had given not only the
best surgical cures, but amputation of the hypertrophied portion
of the cervix had been followed by pregnancy, the women going to
full term in each of five cases.

In the second class made up of 183 women presenting some
evidence of the results of an infective process, postpartal, postabortal,
or gonococcic in origin, pregnancy had been relatively frequent. Of
the 104 women subjects of endocervicitis with a mucopurulent dis-
charge, only twenty-one became pregnant. Eight conceived as a
result of one local treatment in which the mucus plug was removed
with a bicarbonate paste, and the canal swabbed with iodized phenol.
Three became pregnant promptly after the glands were destroyed
with the cautery, and ten following the persistent use of the
carbonate of soda douche.

Of the ninety cases which were found to have results of infective
processes in the tubes, uterosacral ligaments, and cervical canal,
the intrauterine and tubal pregnancies were equally divided, there
being three of each. The abdomen was opened in all of these patients
because of the history, and not because of the gross pelvic findings.
There was invariably present a liistory of infection, with sterility,
dyspareunia and local discharge. Tubal ablations were done thirty-
five times, resections thirty-one times, and freeing of adhesions in
thirty. Two ectopics occurred in resected tubes, against three
intrauterine pregnancies. One ectopic occurred in a freed tube, but
no uterine pregnancy. Of the fifty-four fibroids, myomectomy was
done in twenty and hysterectomy in thirty-four. Six pregnancies
occurred following myomectomy, four going to term. Following the
ten unilateral oophorectomies for large ovarian cysts, eight women
became pregnant.

One hundred and thirty-two uterine, and three ectopics, were the
sum total of pregnancies occurring in 358 women in whom conception
was a probability, or 37 per cent.

AMERICAN GYNECOLOGICAL SOCIETY 333

The study showed first, that a very large number of the steriHty
cases applying for relief, had no chance whatever of becoming preg-
nant, for the reason that the pathology was such as to make concep-
tion impossible. Second, that the male was largely responsible
for the poor results in treatment. Third, that there was a definite
chemicophysiologic factor in conception, at present unexplainable,
which was a cause of preventing conception. Fourth, that operative
procedures on the uterus, except amputation of the hj'pertrophied
portio, had but a slight influence on the end results in the treatment
of sterility, and, finally, that each case must be individulized and
both contracting parties carefully studied before any treatment was
inaugurated.

THE CONSTITUTIONAL FACTOR IN GYNECOLOGY AND OBSTETRICS.

Dr. Charles P. Noble, of Philadelphia, read a paper -ndth this
title in which he presented the following conclusions: i. The
theory of en\dronmental, constitutional hypoplasia or arrested
development from unfavorable environment, operating at any
period from the preconceptional state of dual hfe in the ovary and
testis, to that of the youthful period in ontogeny, which was
presented to the profession as a medical hj^jothesis, in 1908, and
which the writer believed to be proven upon human clinical and
pathological evidence, was now shown to be equally supported by
the clinical and pathological facts of antenatal pathology, and by
the facts of comparative pathology; and to be demonstrated by the
facts of experimental teratologj-. 2. The wisdom of the fathers of
medicine, as expressed in their discriminating analysis of the facts
of the hereditary nature of the diatheses or dyscrasias, together with
the theory of environmental hypoplasia, constituted the law of
devolution in its relation to medicine. 3. In order to obtain a
comprehensive understanding of the practice of medicine, it was
necessary to reject such of the teachings of Virchow and of his fol-
lowers as were fallacious, and to combine the clinical wisdom of the
fathers of medicine, from Hippocrates down, with the known facts
of experimental medicine, and their correct interpretation, and
thus to arrive at the true point of view from which to rtudy and to
deal with the clinical problems, which were the concern of practi-
tioners of medicine, and of each of its specialties. 4. The consti-
tutional factor in gynecology and obstetrics, as was equally true of
the other departments of medicine, was the chief element in the
clinical problems which confronted the practitioner, in deahng with
disease, and with atypical organs and tissues and their functions.
5. The recognition, comprehension, and employment of the fore-
going principles would greatly enlarge the powers of the practitioner
of medicine in diagnosis, prognosis, and in therapy, enabling him
to avoid many common, if not habitual, errors, and positively to
substitute generally nutritional and developmental measures for
the local measures currently employed, and thus to effect a cure,
instead of the amelioration, of his patients' condition, when due to

334 BRIEF OF CURRENT LITERATURE

environmental arrest. Furthermore, it would enable him to give
scientifically based advice as to methods of living, when the biological
type of the patient was recognized; to promote the development of
environmentally arrested patients, and to enable them to maintain
their health, by living within their particular potential or capacity
to produce energy, instead of attempting to live as was physiological
for typical individuals, but which would cause disease in the arrested
or hereditary and environmental devolutes. 6. There remained,
unsolved, two questions: i. The process of mechanism whereby
atypical morphology and function of environmental origin in ascend-
ants became, at least, hereditary in descendants. Apparently, its
solution would be found in the facts of the maleficent consequences
of urbanization in human stocks, which escaped extermination by
degeneration and disease, and the variations or adjustments which
ensued, whereby acquired immunity was attained; and similar facts
concerning the consequences of the long continuance, over genera-
tions, of other unfavorable environment, such as insufficient nourish-
ment, malaria, the hookwork, and food deprived of some element
necessary to nutrition, or so mistreated as to be relatively poisonous.
It might become demonstrated by subjecting short-lived animals to
definite, unfavorable environment, for twenty or more generations,
and observing and correlating the facts thus obtained. Facts from
biology as to species of animals and plants subjected for generations
to inimicable environment, would also aid in the solution. 2. The
eradication of degeneracy and its prevention would probably find
its solution in the development of euthenics, and in the segregation,
or the sterilization of individuals manifesting the more marked
degrees of degeneracy, more especially of the hereditary types.

IMMEDIATE COMPLETE AMPUTATION OF THE UMBILICAL CORD.

Dr. Robert L. Dickinson, of Brooklyn, New York, said the only
operation done on every human being should have principles of
modern surgery and primary union applied to it. These were the
avoidance of mass ligature, of slough, of closing the hernial opening
by granulation scar, of amputation above the known line of demarca-
tion, of choosing a sloughing process instead of a swift aseptic healing.
One should bury the fine suture ligature about the base of the skin
cuff; draw up the cord, amputate with one clip of the scissors through
the upper margin of the skin; tie, inrolling.
[To he cunliniicd.)

BRIEF OF CURRENT LITERATURE.

obstetrics.

The Influence of Pituitary Feeding upon Growth and Sexual
Development. — Goctsch (Bull. Johns Hopkins Hospital, February,
1916) presents the results of an experimental study with the dried

BRIEF OF CURRENT LITERATURE 335

powdered extract of the pituitary gland and the corpus luteum. which
was fed to young rats. The sex glands were subsequently examined
and observations also made upon growth, weight, development
and breeding. It was found that when fed in doses of o.i gram daily
no gain in weight resulted, the appetite was lost, peristalsis was
increased and certain nervous manifestations take place, including
muscular tremors and weakness in the hind limbs. The latter
symptoms were believed to be due to the posterior-lobe element in
the pituitary gland extract for they were similarly produced by
using posterior-lobe but not by using anterior-lobe extract. When
the whole gland is fed for a period of from "twenty-live to forty days
it causes a more rapid growth and development than in the control
animals or in cases where the corpus luteum extract and equivalent
dosage was employed. The ovaries, tubes, and uteri of the animals
were larger, more vascular and edematous, and the ovary was found
matured from one to two months before normal sexual maturity,
showing active ovulation and Graafian-foUicle formation. A similar
precocious development was noted in the male sex glands. The
feeding of pituitary anterior-lobe extract caused increased weight
and more vigorous body growth than in the control and there is a
similar earlier and more active genital development. The extract of
the pituitary posterior lobe, even with prolonged administration
does not have any stimulating effect on growth or the development
of the sex glands and if given in too large doses cause loss of weight,
increased peristalsis and enteritis. Corpus luteum extract when
fed to the male causes a tendency toward the deposition of fat, but
when fed to the female rat was found to be equally as stimulating as
the whole pituitary gland, but not so stimulating as the equivalent
weights of anterior lobe. This extract has a stimulating influence
upon the female sexual development, however, wich is manifested
by increased development and activity of the sex glands and in-
creased vascular formation. The author believes that benefit may
be obtained in cases of lessened function of the ductless glands by
the oral or hypodermic administration of these extracts. It is also
possible that conditions of over activity of one of the ductless glands
could be treated with extracts of another of the endocrine series
possessing an opposing and inhibiting action.

Nitrogen Metabolism during Pregnancy. — K. M. Wilson's
(Bull. Joints Hopk. Hosp., igib, xxvii, 121) observations on the
nitrogen metabolism were made in three normal pregnancies: in
one patient for a period of four weeks, from the tenth to the four-
teenth weeks of the pregnancy. The other two patients were studied
for the last 133 and loi days of their respective pregnancies and also
for a short time in the puerperal period. He finds that in the
perfectly normal pregnant woman, storage of nitrogen begins at a
much earlier period than has hitherto been supposed; possibly the
organism may acquire the capacity for storing nitrogen from the
very beginning of the pregnancy. In the early months this storage
is far in excess of the actual needs of the developing ovum, and the
excess must be added to the general maternal organism. Storage of

336 BRIEF OF CURRENT LITERATURE

nitrogen continues throughout the entire duration of pregnancy,
being most marked during the last few weeks, when the fetal needs
are at a maximum. The nitrogen stored is greatly in excess of the
actual needs of the developing ovum, so that, apart from the amount
needed for the hypertrophy and development of the genitalia and
breasts, a large proportion of the nitrogen stored is added to the
general maternal organism as "Restmaterial," though, concerning
the form in which this reserve is stored, we are unable to make any
positive statement. The nitrogen capital of the maternal organism
is thus increased, though the reserve supply may possibly be entirely
exhausted during the puerperium and period of lactation. In the
healthy woman, who goes through a normal pregnancy, the period
of gestation does not necessarily represent a "sacrifice of the in-
dividual for the sake of the species," but may actually be a period
of gain. There is a relative increase in the percentage of urinary
nitrogen excreted in the form of free amino-acids, though not
necessarily an absolute increase in this form of nitrogen. There is
also a tendency for the percentage of ammonia nitrogen to become
increased during the last weeks of pregnancy, although at other
times during the pregnancy there is practically no variation from
the percentages noted in nonpregnant individuals upon a similar
diet.

Duration of Nursing Period in Women of the United States. —
Analyzing the statements of 2S19 mothers in the records of the
Children's Hospital, Philadelphia for the last fifteen years, A. G.
Mitchell {Joiir. A. M. A., 1916, Ixvi, 1690) finds that in the poorer
class of city women there has been no decUne in breast feeding in
the last fifteen years. The women of the poorer class compare
favorably in the period of lactation with the women of the more
prosperous class in this country. The women of this country com-
pare favorably in the period of lactation with European women.
The average period of lactation in children entered at the hospital
was six months. Twenty per cent, of the women did not nurse thier
children; 80 per cent, nursed one week or longer; 55 per cent, nursed
three months or longer; 42 per cent, nursed six months or longer;
34 per cent, nursed nine months or longer; 27 per cent, nursed a
year or longer, 9 per cent, nursed eighteen months or longer, and 2
per cent, nursed two years. On account of the greater susceptibility
of artificially fed babies to gastrointestinal and nutritional disturb-
ance, the infants brought to the hospital were, in the large majority
of cases, bottle fed at the time of their entrance there. The con-
clusion is inevitable that the figures given represent the minimum
of lactation.

GYNECOLOGY AND .ABDOMIN.VL SURGERY.

Bacteriology and Experimental Production of Ovaritis.^E. C.
Rosenow and C. H. Davis {Jour. A. M. A., 19 16, Ixvi, 1175) record
the results of cultures made from tissues and the cystic fluid in a
series of ovaries removed at operation, cite a few illustrative cases,

BRIEF OF CURRENT LITERATURE 337

and give the results of animal experiments made with some of the
strains isolated. The following facts support the view that strepto-
cocci isolated from the chronic lesions when there was no history of a
previous acute infection, as well as those causing acute infections of
the ovary, are carried to these structures by the blood more often
than is generally believed:

I. The occurrence of fibrocystic degeneration of the ovaries in
which the usual streptococcus was isolated in pure form in young
women w-ith. imperforate vagina. 2. The history of tonsillitis
followed by symptoms of pelvic infection in a number of patients in
series. 3. The not uncommon occurrence of pelvic infection follow-
ing anginal attacks during the menstrual period. 4. The far more
frequent occurrence of so-called idiopathic streptococcal peritonitis
following anginal attacks, in the female than the male, which,
according to Wilder, is due to the occurrence of a primary hemato-
genous ovaritis and a secondary peritonitis. 5. The absence of
colon bacilli in all but three ovaries in series, a fact contrary to expec-
tations if local invasion occurred commonly. 6. The frequent con-
currence of appendicitis, cholecystitis and arthritis in these patients,
diseases proved to be due usually to streptococci from a distant focus
of infection. The writers have isolated streptococci, often in pure
culture, and demonstrated them in the tissues in the areas showing
infiltration, roughly in proportion to the amount of tissue reaction in
a large proportion of the ovaries studied. Two of the strains isolated
showed a marked affinity for the ovary in two species of animals (rab-
bit and dog) producing hemorrhage and leukocytic infiltration (pre-
cursors of sclerotic changes) in and surrounding the Graafian folhcles
and in the ovarian tissue stroma containing interstitial cells in the
fully developed corpus luteum in a pregnant rabbit. Hence, the
conclusion seems warranted that fibrocystic degeneration of the
ovary even in the absence of previous acute infection is due commonly
to a low-grade hematogenous infection by streptococci having elect-
ive affinity for these structures. Owing to the fact, however, that
the number of bacteria found is relatively small and that the experi-
mental lesions in the ovary are not due to an overwhelming growth,
it is clear that while excision and resection of ovaries is indicated in
some instances, it should no longer be done without due regard to
the existence of chronic foci of infection which may serve not only as
the place of entrance but also as the place for the bacteria to acquire
the peculiar properties necessary to infect the ovary. Eradication
of primary foci of infection might in some instances prevent pre-
mature sclerotic degeneration of the ovary.

DEPARTMENT OF PEDIATRICS.

TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.

Special Meeting on Infantile Paralysis held July 13, 1916.

The President, Walter B. James, M. D., in the Chair.

This meeting was lield in Aeolian Hall as the Academy of Medicine
could not accommodate the large number of attendance.

WHAT WE KNOW ABOUT THE TRANSMISSION OF INFANTILE
PARALYSIS.

Dr. Simon Flexner. — Infantile paralysis is caused by the inva-
sion of the central nervous system by a minute, filterable micro-
organism which is now secured in artificial culture and as such is
distinctly visible under a high-powered microscope. The virus of
infantile paralysis exists constantly in the central nervous organs
and upon the mucous membrane of the nose and throat and in the
intestine of persons suffering from the disease. Less frequently it
occurs in the other internal organs and it has as yet not been dis-
covered in the circulating blood of patients.

The employment of ordinary bacteriological tests have proved
futile because of the difficulties attending the artificial cultivation
and identification of the microorganism. However, the virus can
be detected by inoculation tests upon monkeys, which animals
develop a disease corresponding to infantile paralysis in human
beings. Thus it has been shown that the mucous membrane of the
nose and throat of healthy persons who have been in intimate contact
with acute cases of the disease may become contaminated, and that
such persons may, without becoming ill themselves, convey the in-
fection to others, chiefly children, who develop the disease.

The virus has an apparently identical distribution irrespective of
type or severity. We know that the virus leaves the infected human
body in the secretions of the nose, throat, and intestines, and also
escapes from healthy contaminated persons in the secretions of the
nose and throat. Entrance of the virus usually occurs by way of
the nose and throat. Multiplication of the virus then occurs, after
which it penetrates to the brain and spinal cord by way of the lym-
phatic channels connecting the upper nasal membrane with the
33S

TRANSACTIONS OF THE NEW YORK ACADEMY OF MEDICINE 339

interior of the skull. Whether the virus enters the body in any other
way is unknown. The virus, thrown off from the body mingled with
the secretions, withstands the highest summer temperatures for a
long time, complete drj'ing, and even the action of weak chemicals,
such as glycerin and carbolic acid. Mere drying of the secretion,
therefore, affords no protection. The possibility of converting the
dried secretions into dust which can be easily breathed into the nose
and throat, makes drying a potential source of infection. Weak
dayhght and darkness favor the survival of the virus, while bright
dayhght and sunshine hinders its growth.

Since epidemics of infantile paralysis arise during the summer
months, the blood-sucking insects have been suspected of conveying
the disease. Experiments indicate that the biting stable fly can
withdraw the virus from the blood of the infected monkeys and
reconvey it to the blood of healthy ones. More recent experiments
have failed to confirm this. The ordinary fly may become con-
taminated with the virus contained in the secretions of the body and
serve as the agent of its transportation to persons and to food with
which it may come into contact. Domestic flies experimentally
contaminated with the virus remained infected for forty-eight hours
or longer. While our present knowledge excludes insects from being
active agents in the dissemination of infantile paralysis, yet they
fall under suspicion as being the potential mechanical carriers of
the virus of that disease.

Poultry, pigs, cats and dogs have especially come under suspicion
as possibly distributing the germs. Experiments, however, have
proven these animals are not carriers of the disease.

Studies carried out in countries in which infantile paralysis has
been epidemic all indicate that in extending from point to point, the
route taken is that of ordinary travel. This is equally true whether
the route is by water or land. This confirms the evidence elsewhere
obtained that human beings and their activities are the chief dis-
tributing agencies.

The virus of infantile paralysis is destroyed more quickly in the
interior of the body than, in some cases, in the mucous membrane
of the nose and throat. It has been found that in monkeys the virus
might disappear from the brain and spinal cord within a few days to
three weeks after the appearance of the paralysis, while at the same
time it is present on the mucous membrane mentioned. Six months
is the longest period after inoculation in which the virus has been
detected in the mucous membrane of the nose and throat of the
monkey. In an instance of the human disease, the virus was de-
tected in the mucous membrane of the throat five months after its
acute onset. This is conclusive evidence of the occurrence of oc-
casional chronic carriers of the virus of infantile paralysis.

Great variations or fluctuations are known to occur not only in
the number of the cases, but in the intensity of the disease. The
extremes are represented by the occasional instances of infantile
paralysis known in every considerable community and the instances
in which in a few days or a few weeks the number of cases leaps into

340 TRANSACTIONS OF THE

the hundreds, and the death rate reaches 20 per cent, or more of those
attacked. Not all children and relatively few adults are susceptible
to the disease. Young children are more susceptible, generally
speaking, than older ones, but no age can be said to be absolutely
insusceptible.

The period of incubation is subject to v/ide variations. In some
cases it has been as short as two days, and in others as long as two
weeks or even longer. The usual period does not exceed eight days.
The period at which the danger of communication is probably great-
est is during the very early and acute stage of the disease. This
statement is made tentatively, since it is made from inference, rather
than from demonstration.

One attack of infantile paralysis confers immunity. Passive im-
munity has been conferred on monkeys, but its effect is uncertain,
and its brief duration renders it ineffective for protective immuniza-
tion. Yet some success has been achieved in the experimental serum
treatment of inoculated monkeys. Blood serum from recovered
or protected monkeys or human beings, has been injected into the
membranes about the spinal cord, and the virus inoculated into the
brain. The injection of the serum must be repeated several times.
The results of this treatment are said to be promising. The monkey
alone seems capable of yielding an immune serum, but the monkey
is not a practical animal from which to obtain supplies.

From our present knowledge, certain practical deductions may be
drawn. Since human beings are the chief mode of conveying the
virus, and since the domestic fly may be grossly contaminated with
the virus and might deposit it on the nose and mouth of a healthy
person, or upon food, our efforts should be directed against these
sources of infection. The discovery and isolation of all those ill
with the disease and the sanitary control of those who have been
associated with the ill would best protect the public. Children
infected should be removed to a hospital. In the event of doubtful
diagnosis, the aid of the laboratory is to be sought since even in
the mildest cases changes will be detected in the cerebrospinal fluid
removed by lumbar puncture. If the effort is to be made to control
the disease by isolation and segregation of the ill, then these means
must be made as inclusive as possible. It is obvious that in certain
homes isolation can be carried out as effectively as in hospitals.
It is now too early to calculate the death rate of the present epidemic,
but it may prove much lower than it now appears to be. Our knowl-
edge of the disease is much greater now than in 1908, and the forces
in the city now deahng with the epidemic are better organized than
ever. The outlook should not be regarded as discouraging.

THE CLINIC.'\L TYPES OF THE DISEASE.

Dr. Henry Koplik. — Poliomyelitis is primarily an epidemic
disease; as a sporadic condition it has attracted very httle notice.
All the epidemics which have thus far been recorded resemble each
other very closely. An attempt to connect this disease with the

NEW YORK ACADEMY OF MEDICINE 341

occurrence of cerebrospinal meningitis has developed into a belief
that poliomyelitis is an entity, clinically occurring in epidemics in
the late spring to late autumn and following the regular sporadic
occurrence of the disease in Umited numbers in the months foDowing
the winter and reaching into the late spring up to the time of the
epidemic outbreaks. Epidemics of this disease have been known to
skip a year and to always crop up in the place of its original occurrence
which should give the thoughtful a hint as to its possible cause
and epidemiology. In all the epidemics thus far recorded, the
symptomatology and clinical tj-pes have been much the same.
Though most of the scientitic knowledge of the clinical types of
poUomyelitis is borrowed from Swedish and Norwegian observers,
Medin and Wickman, the first inkling of the epidemic nature of the
disease was voiced by Colmer, an American physician, who in
1 841 observed some form of paralysis in a child and obtained the
history that in the locality in which the patient lived several similar
cases had occurred and most of them had recovered. Following
him, Caverly in 1894 described an epidemic in Vermont; Taylor and
Chapin later on observed the epidemic nature of the disease. Aside
from these observers, much of the clinical knowledge at present is
due to Medin who described the clinical types of acute epidemic
poliomyelitis in 1884 before the International Congress, much to the
astonishment of most pediatricians who still retained the simple
picture as retained in older text-books, of pohomyelitis anterior as a
simple, infantile paralysis. In all, forty-two epidemics have been ob-
served in America and on the Continent and this alone should estab-
hsh the tendency of pohomyelitis to occur in epidemic form at certain
seasons and remain sporadic until the time arrives for a new outbreak.
The disease selects the young as its victims. Out of 886 cases in the
epidemic of 1907, 571 were below three years of age, 771 below five
years and three were under six months of age. In the present epi-
demic, the youngest case I have seen was four and a half months old
and absolutely breast-fed. The most susceptible period is from one
to three years of age. There are four principal tj'pes which can be
chnically fully described and proven by laljoratory methods: the
abortive, the bulbospinal, the cerebral, and meningeal, and the bulbo-
pontine types. Wickman has described a neuritic type. These
types can all be understood when poliomyelitis is regarded from
the standpoint of an acute, infectious disease, involving certain parts
of the general nervous structures, causing certain definitely marked
pictures and there stopping, or going on to involve at one stroke the
whole cerebrospinal axis and in this way causing a debacle of the
whole substratum of the nervous economy. It is through the abort-
ive tj^pe of the disease that these cases are spread to others. This
type is that which does not go on to paralysis, recovers and does not
leave the host injured as to the muscular motor apparatus. This
type can be recognized so as to leave no doubt as to its distinct
identity. A child of five years of age is attacked with a headache,
slight malaise and an attack of vomiting lasting five days, intense
pain in both lower extremities radiating to the soles of the feet and

342 TRANSACTIONS OF THE

worse at night, slight pain in the nape of the neck, lassitude, cere-
bellar gait on walking, increased reflexes in the lower extremities,
rectal temperature above 100.5°. In ten days the pains have dis-
appeared, the child is well and wants to go out and play. The abort-
ive cases present prodromata such as headache, weakness, diminished
reflexes and pain in the nape of the neck, with or without vomiting
and fever, and still do not present paralysis and recover. The spinal
or bulbospinal type is the most common and gives the disease its name.
The patient has an attack of vomiting and sUght fever and within
twenty-four hours the mother observes the child cannot move one or
the other extremity. These forms may have no fever, but it is
possible in giving the history the mother may have overlooked the
symptoms of fever, malaise and such indisposition as peevishness,
which may have preceded by a few days the paralysis. In other cases,
the paralysis appears gradually. Pain may continue to be quite
severe, especially when the extremities are moved. The paralysis
may spread and involve not only the remaining lower extremit}"-,
but the upper extremities, the muscles of the back and respiratory
muscles of the thorax and possibly the muscles of the abdomen.
As a rule, in the purely spinal cases, the paralysis appears and
does not spread in the great number of cases. In others, it may
spread from the extremities and involve the whole trunk, even to
causing bulbar paralysis of the respiratory centers. But after the
tenth day, paralysis is not apt to spread to the bulbar medulla,
though cases have been known to die after the fifteenth day. Men-
ingeal and cerebral types should be combined because of the cerebral
symptoms which give rise to a picture closely simulating meningitis.
The meningitic form of pohomyehtis runs its course with cerebral
symptoms. A child of three is taken with vomiting for forty-eight
hours, followed by rigidity of the neck with pain on flexion of the
head, Brudzinski's sign and reflex, Kernig's sign, sopor and
Macewen's sign which may be slightly marked; also diminished knee
reflexes. Some patients may improve after a day or two, the fever
may abate and they may even be about and then have a recrudes-
cence of fever, sopor, rigiditj', dehrium, irritabiUty, extreme hyper-
esthesia and pain in the nape of the neck. In some cases the only
palsy may be ocular; in others a slight facial palsy may be present
which may be combined with a weakness in one or other extremity.
.\fter a week, the patient becomes brighter. There is still, however,
marked ataxia and Romberg's sign. As convalescence is estab-
Ushed, the ataxia is the last symptom to disappear. The hydroceph-
alus and abnormal mental state may remain for some time after
the temperature is normal. On recovery, there is a slight strabismus,
ataxia, optic neuritis. In one group of cases I have seen unilateral
ophthalmoplegia with hemorrhages into the retina. In lumbar
puncture lay the differentiation in the form of pohomyelitis from
cerebrospinal meningitis. The bulbar or pontine form of the disease
deserves notice as a distinct form. An mfant, breast-fed, thirteen
months of age, was attacked with fever and vomiting. The fever
continued into the afternoon of the following day when the mother

NEW YORK ACADEMY OF MEDICINE 343

noticed a flatness on the right side of the face. The temperature
continued at 102.4°, the infant was bright, laughed and played in
the crib, but there was a tired look about the face and eyes. The
knee reflexes were increased; otherwise there was no paralysis that
could be demonstrated. In another case, ten days before the
patient, aged twenty-one months, was seen, he was taken with high
fever and vomiting, there were some green movements. The fever
continued, in a less degree, to the ninth day when the mother noticed
that the right side of the face was flat, there were tremulous move-
ments of the head and arms and the patient was restless. There was
constant jactitation of the head and insomnia; rigidity of the neck,
but no palsies of the extremities; on the contrary, the patient ex-
hibited great strength in both. In other cases, the outcome was not
so favorable; there was an involvement of the nuclei which control
deglutition and respiration. In these cases the patient may be lost
by paralysis of the respiratory centers. The neuritic type included
those cases in which pains in the extremities became a leading
feature of the chnical picture. Some of these cases developed paraly-
sis; others did not. They were referred to under the head of abortive
cases. The symptoms given justify a lumbar puncture in order to
establish the character of the fluid which in pohomyelitis shows a
lymphocytic cytology and an increase of globuhn. The examination
of the bood was very uncertain. As to prognosis, the low mortality
of 10 per cent, applied to children below eleven years of age and 27
per cent, among older children and adults. Twenty per cent, of all
cases completely recover and the younger the child the better the
prognosis.

Dr. James. — ^The following question has been handed up:
"Would you advise the removal of adenoids or enlarged tonsils
during this epidemic?"

Dr. Koplik. — I would say "No" most decidedly.

ABORTIVE AND NONPARALYTIC CASES, THEIR IMPORTANCE AND THEIR
RECOGNITION.

Dr. George Draper. — Cases are designated as abortive when
attention is centered on the paralysis as the chief symptom of
pohomyelitis, but as our knowledge grows it has become increasingly
evident that in deahng with acute anterior pohomyelitis we are
deahng with a general infection that presents a great variety of
manifestations. The cases that escape paralysis are just as im-
portant from the standpoint of the spread of the infection as the
paralyzed cases and infinitely more dangerous. The cases that have
hitherto been called "abortive" should be called "atypical," if we
consider those that develop paralyses as typical. Unfortunately,
there is no possible way at the present time of determining the
number of cases that are not paralyzed. Undoubtedly the number
varies greatly in different epidemics. There are certain indications,
however, that lead us to believe that the number of cases without
paralysis is considerable. It has been said that it is extremely rare

344 TR.\NSACTIONS OF THE

to see more than one case of poliomyelitis in a family, but a very
careful investigation where there has been one case in a family
frequently shows that another child has had mild symptoms, as
fever, general malaise and vomiting. Furthermore pathological
studies show that there may not only be lesions in the spinal cord
but that the viscera and the entire lymphatic apparatus may be
involved and we may find palpably enlarged lymph nodes. This is
additional evidence that we are deaUng with a general infectious
disease.

In general all cases fall into the following groups: i. Gastro-
intestinal. 2. Respiratory. In these we may have the symptoms
of influenza, cough, lung signs and pains in the bones and joints.
3. Febrile. 4. A type characterized by symptoms of meningismus.
5. The t\'pe in which paralysis occurs. In the first three tj^es we
may have sHght transient paralyses. In the type showing paralysis
we may have as prodromal symptoms any or all of the prodromal
symptoms of the other tj^es. The intensity of the symptoms is
no guide to the prognosis. In this connection it is of interest that
in fatal cases more extensive lesions of the cord have sometimes been
found than were indicated by the symptoms. That there should
have been this general degeneration of cord without manifestations
suggests that we may have lesions in the milder cases that do not
give clinical evidence of their existence. Wickman's and MiiUer's
groups studied at autopsy brought out this fact. In times of epi-
demic every one is alive to these symptoms, but it is not enough that
the physician should say this is or is not a case of poliomyelitis.
In suspicious cases lumbar puncture should be made and the spinal
fluid e.xamined. There is usually an increase in the lymphocytic
count and a very large percentage of polymorphonuclears, which
change within twelve to twenty-four hours into mononuclears and
in three or four days we have a leukocytosis. The albumin and
globulin content of the fluid are increased, but less than in tuberculous
meningitis.

The diagnosis is therefore based on gastrointestinal, respiratory,
and febrile symptoms. WTiere we find the latter a search should be
made for transient weakness and mild degrees of paralysis, and for
local muscle tenderness. One point of value in diagnosis is the
anterior spinal flexion sign. It is a very striking thing that before
paralysis sets in the spinal flexion sign is definitely present, and this
is probably responsible for the stiff neck and Kernig's sign. The
sign is elicited by having the child place his hands under his thighs
and then flexing his trunk forward, doubling him up.

In conclusion, it may be said that there is no question but that
these at}-pical cases of poliomyehtis exist. They must be recog-
nized and herein lies the problem. In learning to recognize them a
double advantage will result. They, as moving sources of contagion,
will be controlled, and cases which are destined to be paralyzed will
be recognized in the preparalytic stage and helped, when help is
discovered, and possibly saved from an oncoming paralysis.

NEW YORK ACADEMY OF MEDICINE 345

THE PRESENT EPIDEMIC — THE TYPES WHICH IT PRESENTS.

Dr. Louis C. Acer, Brooklyn. — Much that is suggestive may be
brought out from our experience in the hospitahzation of an im-
mense number of cases. From June 20 until July 12 we cared for
320 patients with poliomyelitis in the Kingston Avenue Hospital.
The resident staff were thus brought face to face with a large number
of serious problems and a large amount of work has been
accomphshed.

Something has been done in the study of the infectivit}'' of the
disease, but the degree of infectivity has not yet been decided. Dr.
Draper has spoken of the large number of abortive cases and in this
class of cases we have more proof of the infectivity of poliomyelitis
than we had before the epidemic of 1907. In this connection I would
like to report the two following examples. On July 2 a child was
taken sick with convulsions, vomiting and fever and recovered. On
July 3 another child in the same family was stricken with the acute
fulminating type of the disease and died within forty-eight hours.
On July 4 an older member of the family developed the disease.
A second group of cases was as follows. On June 29 a child became
ill with the abortive type. On June 30 a second child came down
with the fulminating type' of the disease and death followed. On
July s a third case occurred in this same family, which, in this
instance, was followed by paralysis. There must be a large number
of cases of the abortive type that are not recognized. In the
Kingston Avenue Hospital we have at least eight series of cases
where there have been two or more cases in the same family. A
great many more instances of this kind] would have been found if
we had more complete statistics in 1907. About the only statistics
that we have on this point are those published by Wickman and
Medin. That there are practically no cases among the colored is
borne out by our experience; among our 350 cases there has been no
colored child. The incidence of the disease is practically the same
in all nationalities.

There is no material enlargement of the liver or spleen, except in
some fulminating cases. We found only two cases of enlarged Hver
in sixty-seven cases. The age incidence in the present epidemic is
practically the same as in the epidemic of 1907. It is a peculiar
fact that in epidemics in this country the age incidence is lower
than in those on the other side. In eighty-one cases, forty-six
occurred between the ages of two and five years; twenty- two between
the ages of one and two years; eight between the ages of six and
twelve, and three between one and six months. We had two adult
cases in this group, one in a woman twenty-eight years of age and
one in a pregnant woman of twenty-one years.

We found as usual that the lower extremities are most frequently
paralyzed. In a group of sixty-four cases examined the lower
extremities were involved in thirty-nine instances; in seven instances
the upper extremities; in five there was facial paralysis, and in

346 TRANSACTIONS OF THE

thirteen cases the only definite symptom was marked paralysis of
the muscles of the back. There were two typical ataxic cases.

The fulminating fatal cases gave the most pronounced symptoms.
We had one peculiar and unusual case in a boy of eleven years. He
was a well-nourished, well-developed child and when brought into
the hospital his only symptom was markedly labored breathing.
He asked for a drink of milk and it was noticed that there was a
slight blur to his speech. He was unable to drink on account of
pharyngeal paralysis. His diaphragm was completely paralyzed.
The labored breathing was accomplished by the thoracic muscles
alone. He stood up in his crib and was able to use his arms and
hands, and his back showed no evidence of paralysis. He gradually
became weaker and died five hours after entering the hospital.
Another case of the fulminating tN^pe showed a general paralysis,
practically all the skeletal muscles were effected, and there was
marked respiratory paralysis. In both of these cases the heart was
not affected. We have been trying artificial respiration immediately
after death and in some instances have succeeded in bringing back
the color after death had apparently set in. We still hope that in
some cases something may be accomplished by this method. We
employed the apparatus which Dr. Meltzer has been using at the
Rockefeller Institute.

We may also speak of the meningitic tj'pe. We had one older boy
who was wildly delirious. He had complete paralysis of one leg and
one eye was totally blind. There was an alteration in his condition
from deep meningeal coma to active maniacal delirium.

We have had six croup calls, that is, summons to intubate, and
when we have reached the patient we have found respiratory
paralysis and poliomyelitis.

It is sometimes extraordinary to see the rapid improvement in
these cases. We have had small bottle-fed babies who were unable
to take their milk at first and are now able to hold the bottle and
feed themselves.

Our experience has absolutely convinced us that the only place
to take care of children with poliomyelitis is in a hospital, unless the
conditions of the hospital can be exactly reproduced in the home.

LABORATORY AIDS IN THE DIAGNOSIS OF POLIOMYELITIS.

Dr. Josephine B. Neal. — It is well known that sporadic cases of
poliomyelitis are frequently seen when no epidemic exists. Because
of this fact, during the past six years, it has been the lot of the
Meningitis Division of the Department of Health to study both
chnically, and by means of laboratory methods, many cases of this
disease before the present epidemic occurred. Most of the cases
seen by us, both before and during this epidemic, have been atypical
and we have, therefore, been compelled when endeavoring to make
a diagnosis, to consider our laboratory findings with more than
ordinary care. As with most such procedures, the answers which
the laboratory returns to our questionings furnishes us with evi-
dence that is corroborative only and by no means absolutely diag-

NEW YORK ACADEMY OF MEDICINE 347

nostic. Perhaps, one of the most interesting experiments employed
in the study of poUomyelitis has been the inoculation of monkeys
by means of washings from the respiratory and elementary mucous
membrane. This was first successfully performed by Kling,
Petterson and Wernstedt in 1911. It has since been repeated several
times. Dr. DuBois, Dr. Zingher and I obtained washings from the
nose and throat from an abortive case two weeks after the incidence
of the sickness. With these we produced typical poliomyelitis in
monkeys. In sections of the brain, from one of these monkeys, a
few globoid bodies similar to those described by Flexner and Noguchi
were found. A report of this work appeared in the Journal of the
A. M. A., January, 1914.

Another laboratory method of some diagnostic value is the so-
called neutralization test. In this, serum from the suspected case
in the stage of recovery is mixed with an old fatal dose of an active
virus. These are incubated and later injected intracerebrally into
the monkeys. Failure of the disease to develop indicates that the
virus has been neutralized. This test, however, does not furnish
conclusive evidence of poliomyelitis for sera from nose known to
have been free from a recent attack of the disease has sometimes
successfully neutralized the virus. It is, however, quite obvious
that laboratory methods requiring the use of monkeys are both too
complicated and too expensive for ordinary diagnostic use.

A study of the blood picture was exhaustively made by Peabody,
Draper and Dochez of the Rockefeller Institute. It was shown that
there existed a varying increase in leukocytes and a polymorpho-
nucleosis. This is characteristic of so many other diseases that it is
of little help in diagnosis.

The procedure which we find to be our most reliable and valuable
aid in the recognition of poliomyelitis is the e.xamination of the
spinal fluid. In the first twenty-four to forty-eight hours after its
onset, poHomyelitis must be differentiated from the early stages of
epidemic meningitis or mild purulent meningitis and also from a
meningism accompanying pneumonia or other infection. The
clinical pictures presented by these above-mentioned diseases are
quite similar and it is in the distinguishing between them that the
examination of spinal fluid affords us the most valuable information.
In the early stages of poliomyelitis, the spinal fluid is clear or rarely,
it may be slightly cloudy. It often shows a good fibrin web forma-
tion. There is a slight to moderate increase of albumin and globuUn
and also of the cellular elements. The reduction of Fehlings is
prompt. Those poliomyelitic fluids which are cloudy present a
polymorphonucleosis which may run as high as go per cent, but which
we usually find to be about 60 per cent. As a rule, however, 80
per cent, or more of the cells are mononuclears. In examining such
fluids we have frequently observed the presence of large mononuclear
cells which we believe to be in a measure characteristic of polio-
myelitis. We are now studying these by means of the various
differential stains in the hope that our research in this direction may
develop something of positive diagnostic significance.

348 TRANSACTIONS OF THE

Two rare tj^jes of spinal fluids sometimes occur in poliomyelitis
when hemorrhagic process has been more than usually extensive.
The first of these is of the true hemorrhagic character, the red blood
cells being evenly diffused throughout the fluid. When collected in
successive tubes, the specimens are all hemogenous showing no
change in the intensity of the hemorrhage. This serves to differ-
entiate it from bloody fluids obtained by the accidental puncture
of a vein. The second of these rarer fluids illustrate the so-called
syndrome of Froin. It has a characteristic yellow color and coag-
ulates spontaneously.

The spinal fluid from early cases of purulent meningitis shows a
varying degree of cloudiness, except in very rare instances when it
may be clear. A greater increase in albumin and globulin is usually
found here than occurs in poliomyelitis with a poorer reduction of
Fehlings. The cells in these fluids of purulent meningitis are 90
per cent, or more polymorphonuclears and the etiological organism
is found except in the mildest cases. In certain mild cases of menin-
gitis probably of epidemic variety the meningococci may never be
positively demonstrated in the fluid. In purulent meningitis due to
other organisms, these practically always appear later. In one
instance, I have seen a clear fluid from an early case of epidemic
meningitis. This was of about eighteen hours standing. Although
the cellular reaction was so shght, the meningococcus is demonstrated
to be present in the fluid by smear and culture.

The fluid in meningism is increased in amount but practicall}'
normal in character.

When seen a week or more after the onset, cases of poHomyeUtis
especially if presenting cerebral symptoms must be differentiated
from tuberculous meningitis. The spinal fluid in both these condi-
tions is clear and increased in amount. The albumin and globulin
content of both is also increased, but usually in poliomyelitis, the
increase of both these last-named elements is not so great as occurs
in tuberculous meningitis. The reduction of Fehlings is usually
better and, here let me say, that many tuberculous fluids give a
good reduction of Fehlings though the contrary has been stated.
The cellular element is also usually less in poliomyelitis. In both
conditions at this stage there is ordinarily a mononucleosis, although
in some acute cases of tuberculous meningitis there is a polymorpho-
nucleosis. If, however, as may happen occasionally, the increase of
albumin and globulin is greater than'usual and the reduction of Fehl-
ings is not so prompt, then the determination of the disease must
wait upon the results of animal inoculation if it has been impossible
to demonstrate tubercle bacilli in fluids.

A detailed study of the spinal fluids of pohomyelitis examined at
the Research Laboratory was made by Dr. H. I. Abramson. of the
Meningitis Division and published in the Am. Journ. of Dis. of
Children, Nov., 1915.

In brief, then, a spinal fluid increased in amount and showing a
slight to moderate increase in albumin and globuHn, a good reduc-
tion of FehUng's solution and a varying cellular increase mostly

NEW YORK ACADEMY OF MEDICINE 349

mononuclear makes the diagnosis reasonably certain in fairly early
cases of suspected poliomyelitis. A slightly cloudy fluid occurring
very early in the disease must be differentiated as noted above from
a similar fluid in an early purulent meningitis. Fluids from the
cerebral or encephalitic type of poliomyelitis sometimes may be
differentiated from fluids of tuberculous meningitis only by animal
inoculation.

■ THE IMPORTANCE OF THE PRESENT EPIDEMIC.

Dr. Haven Emerson. — We are not able as yet to present our
records in complete form. Thus far they show the date on which the
cases have been reported instead of following the usual plan of giving
the date of onset of the disease. For instance, in May only five
cases were reported, while fifteen more cases which had their onset
in May were not reported until in July. In June we see the rapidly
rising incidence of the disease, beginning about June 20 and increas-
ing until the highest point was reached about July 11. Since that
time there has been a recession observed, but we cannot say it is
permanent as yet. A study of the death rates for the city as a whole,
of diphtheria, scarlet fever, measles and diarrheal disease during the
last six years and the first six months of this year show that the
number and the mortality of cases of poliomyelitis during this epi-
demic as well as during the period covered by these statistics, has
been small by comparison. During the first six months of 1916 there
were 884 deaths from diarrheal disease and fifty-seven from polio-
myelitis. The community looks with complacency on the former
while it is panic stricken over the latter. The interest at the present
time is in the psychological state of the lay public. The reason for
this is probably because this is the first epidemic of poliomyelitis
in this city in which the disease has been made reportable and also
the first in which there has been an effort at hospitalization. We
acknowledge that our present method of attempting to control the
disease is frankly an experiment. At the outset of the outbreak the
Health Department was confronted with two alternatives. The one
was secrecy, whether we should simply see what could be done by
the medical control of cases without publicity. The other alternate
was publicity which offered a better prospect of a real control of the
disease. We decided in favor of publicity and hospitalization. As
a result there has been an undue fright on the part of the public
probably due to our unusual method of approaching the problem.
Reporting cases was new, placarding houses was new, and hospital-
ization was new. In 1907 it was not until November that the epi-
demic that was then drawing to a close was studied. While that
epidemic was in progress no study was made of it. In November,
1907, the Pediatric and Neurological Sections of the Academy of
Medicine appointed a committee to make a study of the disease,
but they were not active at the time the cases were coming down.
In that epidemic there were probably 2500 cases. There were 700
cases accurately studied and the mortality among these was 27 per
cent. The average mortality as estimated in foreign epidemics has

350 TRANSACTIONS OF THE

been from 7 to 10 per cent. During the present epidemic about
2600 cases have been reported but only about 1600 of these have
proved to be true cases of poliomyelitis. It is estimated that the
total death rate in the epidemic of 1907 was 5 per cent.; during the
present epidemic it has been 18.7 per cent. The most important
factors in dealing with the disease are early diagnosis, isolation, and
putting all cases under early orthopedic and neurological observa-
tion. This method may save the individual and the public from the
future burden that permanent crippling implies.

At least 99 per cent, of the children affected in this epidemic have
been born since the last epidemic. It has been estimated that 917
cases have been under five years of age and that 14 per cent, of those
affected have been between five and ten years of age. About
99 per cent, have been under ten years of age. About 403 cases
have shown paralysis. In about 50 per cent, of the cases the paraly-
sis made its appearance in the course of a few days after the onset
of the disease. The longest period after the onset at which paralysis
has made its appearance was sixteen days. In between 5 and 8
per cent, of the cases there are secondary or subsequent cases in the
same family that may be traced to the primary case. When we get
a second or third case in the course of three or four days it is safe to
classify it as a secondary case. These facts are important since the
public was not previously impressed by the infectious nature of the
disease.

We can only suspect a person of being a carrier since we are unable
to prove it as can be done in diphtheria and tj^phoid fever carriers.
Thus it has been a question whether one has a right to interfere with
a supposed carrier. It is to be hoped that this epidemic will clear
up some of these doubtful questions.

This epidemic has also been the first opportunity we have taken
to make use of concerted action on the part of the hospitals. This
will probably result in a plan for cooperation in the future and will
favor scientific advance in the study of disease. I would like to
indicate that our experience has shown us the necessity of a hospital
having a staff suited to meet the needs of these patients. Such a
staff should include a laboratory diagnostician, a neurologist, an
orthopedist and a pediatrician. I would urge hospitals likely to
have these cases to organize a staff of this type for dealing with this
epidemic. We can also make use of social service organizations to
a greater extent than in other conditions. There is need of concen-
trated follow-up home work of all patients. This will be a great
need for years after they have left the hospital. Many hospitals in
the city are receiving cases of poliomyelitis. Quarantine and the
services of Ellis Island have been placed at the disposal of the Health
Department. This cooperation among the hospitals is a notable
contribution to our progress and will probably result in some per-
manent plan that may be put to service en such occasions in the
future

There is nothing more discouraging than to meet with cases like
the following which was met on July 4. On coming to a house we

NEW YORK ACADEMY OF MEDICINE 351

were met by a small boy who was limping. We were led up-stairs
by the boy and there found a younger brother who also limped. We
were told that the baby which was sick had been sent out of doors
in the carriage. This mother had seen no physician, though all three
children were in the acute stage of infantile paralysis. She did not
think these children were very sick because they got about so quickly.

There is another point of importance which shows the degree to
which the medical profession wiU sacrifice itself to the public health.
Many instances have come to my knowledge where physicians have
for the time being lost their entire practice because they have been
taking care of cases of infantile paralysis and their patients have been
afraid to come to them. I would like to ask other physicians to see
that such men do not suffer because of their willingness to sacrifice
themselves for the welfare of those who have needed their services.
I hope that wherever you meet this attitude of fear on the part of
patients you will discourage it.

In closing I wish to appeal to the medical profession, for their
cooperation in early diagnosis and the early reports of cases for no
health department, however efficient, can control an epidemic
and secure proper police enforcement of its regulations without this
cooperation. It is to be hoped that as a result of this meeting we will
have many previously undetected cases promptly reported to the
Department of Health.

DISCUSSION.

Dr. William H. Park. — I have very little to add, only one or two
points that I would like to emphasize. I wish to speak along the
line on which Dr. Flexner has spoken. He and Dr. Noguchi have
added much that is new to our knowledge of poliomyelitis and we
have been applying what they have taught us. Up to the present
time we know that the sick person is the one responsible for most of
the contagion and that the carrier also spreads the disease. It is
not spread in any other way so far as we know. There is no known
carrier as a fly or insect. We do know that the sick person, the
carrier, and filth that has been contaminated by the sick person or
carrier may convey the contagion. If an insect is found to be a
carrier it will probably be in a subordinate degree. It will be very
difficult to prove that an animal that has been inoculated is a carrier
of the infection. I believe that even if we could detect the carrier
of poliomyelitis as we do those of diphtheria, typhoid fever and pneu-
monia we would not act differently than we are doing. We have the
knowledge necessary to detect diphtheria and pneumonia carriers
and yet we have done little with this knowledge to prevent these
diseases. It is not in lack of knowledge that the difficulty of con-
trolling the carrier lies. From what has been done in other lines it
is possible that we may learn to do more with vaccines or serums, but
at the present time we have no knowledge that we can offer. We
have just begun to study and to work along these lines and it is
probable that in six months from now we may be able to announce
some disco\-eries.

352 TRANSACTIONS OF THE

Dr. Walter B. James. — A doctor from the midst of the infected
district has asked what the modern treatment for poliomyeHtis is.
Someone else has asked if it is safe to care for cases of poUomyehtis
in a general hospital.

Dr. Haven Emerson. — We have found that it is perfectly safe
to admit cases of pohomyelitis to a general hospital. There all
sanitary precautions are carried out and there have been no instances
of doctors, nurses or attendants being infected.

Dr. Henry Koplik. — It is very difficult to speak about the treat-
ment of a disease the cause of which is still under investigation.
The treatment of the disease at this time can be only symptomatic.
There may be a destruction of parts of the nervous system or the
process may go on to a destruction of the entire cerebrospinal system.
The patient should be isolated and kept absolutely quiet. Anyone
in attendance on a patient should wear a gown and on leaving the
patient should cleanse his hands. Other children should be kept
away from the patient. Absolute quiet is important and should be
emphasized, and also rest. A German physician in Munich has
recommended that the patient be placed in a Bradford frame and
thus kept absolutely quiet. Together with absolute quiet the patient
should have plenty of fresh air and an easily assimilable diet. The
bowels should be attended to. As to medicine, I have no particular
remedy except the remedies supposed to have an effect on the
general nervous system. Liberal doses of urotropin have been
employed but whether this has any definite value cannot be said for
as yet we have not established its utility.

The question may be brought up as to lumbar puncture. In the
first place the mere mechanical removal of a certain amount of
fluid which is toxic may be of some benefit. In the second place it
gives the opportunity to make a diagnosis, and in the third place it
reheves pressure. It is from the pressure that we get Macewen's
sign.

If paralysis starts in, it is a relief to the patient to keep his hmbs
absolutely quiet and in some cases a cast may be applied to prevent
contracture. We can sometimes see when the cast is removed that
it has overcome the contracture of the muscles. This contracture
may return later and then the patient may be referred to the ortho-
pedist. For the symptoms referable to the nervous system, anody-
nes, as chloral and the bromides, may be administered, but not opium
unless it is absolutely necessary. Charcot has recommended the
intramuscular injection of strychnine as soon as the pain and fever
have stopped. The question has been asked as to how strychnine
acts, it may be stated that it causes an increase in mechanical irri-
tability of the muscle. The child bears quite large injections.
One-fortieth of a grain daily may be given over a period of thirty
days, selecting different groups of muscles for the injections. Many
cases, however, have regained their power without injections, and
many do not, so it is very difficult to give an accurate judgment as
to the utility of these injections or as to when to use them. Warm

NEW YORK ACADEMY OF MEDICINE 353

baths sometimes prove a great blessing if they can be given without
moving the patient too much.

Massage sometimes seems to aggravate the condition; in other
ijistances it seems to relieve the pain. In some little patients iodide
of potassium in large doses seems to have an anodyne effect, indeed
this effect has been almost miraculous in a few cases. The pain
seems to be reheved much more by iodide of potassium than by other
remedies. The great variety of peculiar mostrums that have been
recommended should not be used on these children. There should
not be too much activity in the treatment of these cases as one may
injure the patient. The most important thing to keep in mind is
the necessity for absolute quiet. No attempt should be made to
increase the tonicity of the muscles until the active stage of the
disease is passed.

Dr. Leon Louria, Brooklyn. — There is nothing to be said
that has not been laid before you. I have been interested in the
advances that have been presented by those who have given this
subject many years of study. Your attention was especially called
to those cases that do not show any paralysis. I would like to speak
mainly upon this subject. The epidemic can only be stopped by an
early recognition of those cases that do not lead to paralysis. We
must revise our medical nomenclature so that we may include and
treat poliomyelitis without paralysis. Some cases have no symp-
toms of paralysis. In a few cases I have noticed a very interesting
occurrence. A child would be taken ill with some indefinite febrile
manifestation and sore throat, be treated in the ordinary way and
seem to recover, only to have a recurrence in three or four days
when it would get the definite symptoms of poliomyelitis and a
definite paralysis. If the disease had been recognized and the child
placed in bed and given the opportunity to rest that the nervous
system required and was not exposed to the additional trauma
consequent upon activity, the virus would not exert as great an effect.
The same treatment should apply to the abortive form of the disease
as was given to the paralytic form and in this way the develop-
ment of paralysis might be prevented. I have seen two or three
cases in the same family. In two instances in which the disease was
of the abortive type, two weeks later the disease in the same child
became more severe and a definite paralysis developed with perma-
nent deformity. There is no doubt that the disease is carried
from the sick to the healthy child, while those in attendance on
the sick are likely to bring the disease to others, that is, they are
carriers of the disease, and they may create a focus of disease. A
healthy person may travel into an infected district, become contami-
nated, and then implant the virus in another locahty. Scientists
all agree that the disease is transmitted by direct contact and thus
children that are slightly ill and whose illness is not properly inter-
preted are a prolific source of the disease. If we are assembled here
that we may be prepared to help the health authorities in their
endeavor to control this disease we should be called upon to make

354 TRANSACTIONS OF THE

an early diagnosis and not to take lightly those ailments that may
be abortive tj'pes of pohomyelitis.

Dr. Samuel J. Meltzer. — -The several papers presented this
evening failed to cover one essential phase and that is the treatment
of the disease. The reason for it is to be found, perhaps, in the dis-
couraging fact that there is at present practically no treatment for
poliomyeHtis. I wish to bring forward three promising therapeutic
measures based essentially upon personal work. However, since I
have only five minutes at my disposal, my remarks must be of neces-
sity dogmatic and very brief. To gain time I have put them down in
writing. My practical suggestions have to be introduced by the
following considerations. Any inflammatory focus is surrounded at
the periphery by zones of hyperemia, exudation and edema. Thir-
teen years ago, in experimenting upon rabbitts' ears, we found that
an injection of adrenahn reduces an entire inflammatory sweUing to a
very small focus in the center. The peripheral zones of edema and
active hyperemia disappear completely for some time. Several
years ago Dr. Auer and I found further that an intraspinal injec-
tion of adrenalin into monkeys produces a long-lasting effect upon
the blood pressure, longer than by any other method of adminis-
tration; more than one hour may pass before the blood pressure
returns to normal. On the basis of these observations and on the
further plausible assumption that the early stages of the paralytic
effects in pohomyelitis are not caused by the chief inflammatory
focus but by the peripheral zones of active hyperemia, exudation and
edema, I induced Dr. Clark, then working under Dr. Flexner at the
Rockefeller Institute, to make the following experiments. Monkeys
dying from experimental poliomyelitis received intraspinal injec-
tions of adrenalin. The beneficial effect was most striking. Ani-
mals which were paralyzed and moribund at the time of the injec-
tion were seen several hours later eating bananas which they held
themselves. The paralytic conditions were strikingly improved and
the life of the animals was prolonged in some cases for several days.
The animals finally died; but in this series of Dr. Clark's experi-
ments, all animals received reliably fatal doses of the virus. It is
important to bear in mind that the mortality in human infantile
paralysis is generally not more than 25 per cent. Death is usually
due to respiratory paralysis. It is highly probable that in many
instances the respiratory paralysis is not produced by the chief
inflammatory focus, but by the extensive peripheral zones of exuda-
tion and edema, which are surely capable of interfering with the vital-
ity of the nerve centers controlling the respiratory mechanism.
If the exudation and edema could be removed for some time, the life
of a few or of many cases might be saved, namely, if in these cases it
should just happen that the ascending progress of the actual inflam-
mation came to a standstill. On the bases of these facts and con-
siderations I recommend the injection of adrenalin intraspinally in
every case of infantile paralysis, the injection to be repeated from four
to six hours. The procedure may save life, and in sur\'iving cases
it may reduce the extent of the final lesion. There is no danger to

AMERICAN PEDIATRIC SOCIETY 355

this procedure. Monkeys stood well as large a dose as 2 c.c. in a
single injection. However, in human infantile paralysis the injec-
tions should be begun with a dose of 0.5 cc. of adrenalin until more is
learned about the effects. One suggestion is to administer artificial
respiration by means of our apparatus for pharyngeal insufflation as
soon as the patient shows a degree of unconsciousness and respira-
tory insufficiency. It is an easy and rehable procedure. The second
suggestion is, to administer oxygen under pressure in a respiratory
rhythm by an apparatus which I have recently devised and used on
human beings in several instances. It abolishes rapid cyanosis and
may save life. It may even act specifically on the virus of polio-
myelitis. I shall not attempt to enter upon a description of either
of these apparatus, nor on the mode of their application and on the
experience we had with them.

TRANSACTIONS OF THE AMERICAN PEDIATRIC
SOCIETY.

{Continued from page 171.)

REPORT OF A CASE OF INFLUENZA IN AN INFANT WITH. TWO UNUSUAL
COMPLICATIONS, PURPURA AND SUBCUTANEOUS EMPHYSEMA.

Henry T. Machell, Toronto. — "This baby when seen in consul-
tation was six and one-half months old and had always been well
and healthy, weighing 15 pounds before the present illness. The
child was taken ill with grip on March 28 and was seen by Dr. More
on April 6, at which time there was present a well-developed lobar
pneumonia of the right base. The child's temperature was 104° F.,
pulse 140, and respirations 60. In addition there was a purpuric
rash over parts of the body, the face, particularly the chin, the
shoulders, arms, chest, legs and feet. The petechiae varied in size
from a mere dot to one patch on the left shoulder the size of a
ten cent piece. Another patch on the left cheek was slightly smaOer.
These large spots had a punched-out feeling to the palpating finger
as though they had previously contained fluid. The skin was
unbroken and there had been no discharge.

"The mother stated that this rash had been present from the first
appearance of the illness. There was a cough which was neither
frequent nor violent. On the 13th of April the attending physician
noted a slight swelling at the sides of the neck, under the chin and
down over the upper part of the chest. The swelling continued to
increase until two days later when I was called to see the child again.
At this time the child's condition with reference to temperature,
pulse and respirations had improved and the lung had about cleared
up. The petechial spots had increased in number especially about
the chin, the shoulders, and the forearm. The swelling around the

356 TRANSACTIONS OF THE

neck, cheeks and chest had increased to such an extent that the chin
was crowded upward and the head forced backward. It was tense,
tympanitic and crackling under the fingers. This swelling was
symmetrical in size and obviously emphysematous.

"The emphysema gradually improved, and within five days from
the time I saw the patient it had almost disappeared. On April
19'the child had an extra severe coughing spell when the emphysema
suddenly became more marked, his breathing became embarrassed,
and he died within twenty-four hours. An autopsy was not allowed.
Purpura as a complication of influenza so far as I can find in the
records of the Academy of Medicine of Toronto is not mentioned.
In the Lancet, January, 1890, under the title ''Occurrence of Rash in
Influenza," H. P. Hawkins was able to quote seven cases with a
rash in 1000 cases of influenza at St. Thomas' Hospital in London.
From the description of these cases some were undoubtedly medicinal
rashes. It must be concluded that purpura as a compUcation of
influenza is infrequent. Emphysema is mentioned in a few te.xt-
books as occurring occasionally in pertussis, bronchitis, etc., but I
have not seen it mentioned in connection with influenza."

A BRIEF REPORT OF SIXTY BLOOD EXAMINATIONS IN INFANCY, WITH
A REVIEW OF THE RECENT LITERATURE OF THE BLOOD IN INFANTS.

Dr. H. M. McClanahan and Dr. A. A. Johnson, Omaha, Neb. —
" This investigation was made in an institution which takes infants
for adoption and is primarily a home and not a hospital. We have
studied the current literature in the EngUsh language for the period
of 1910 to 1915, inclusive, and have abstracted the articles on this
subject. After going over this literature we decided to Hmit our
work to the relative percentages of the white cells, since there were
only two articles dealing with this phase of the subject. The first
of these is by Schloss {Archives of Internal Medicine, vol. vi, p. 658,
1910). He calls attention to the variations in the percentage of the
different varieties of leukocytes in apparently normal infants. This
is in line with our experience. His percentage of eosinophiles
averaged higher than in our series. Second, Mitchell {Jour.
Diseases of Children, vol. ix, p. 358, 1915) studied the leukocyte
count during digestion in bottle-fed infants. He studied fifty infants
making a count every half hour after every feeding until the next
feeding. His conclusions were that leukocytosis occurred constantly
in only 12 per cent, of the cases. In 32 per cent, of the cases it
occurred occasionally, and in 56 per cent, leukopenia occurred con-
stantly. In the present series the blood was taken from the infants
without regard to the time of feeding. The counts were made in a
total of eighty-one infants, ranging in age from three weeks to one
year. The counts were made by Dr. Johnson and Dr. Moore and
as their work was done independently it was necessary to elimi-
nate ten infants upon whom the count was made twice. There was
considerable difference in the counts of small and large lymphocytes

Lymph.

Polys.

Trans.

AMERICAN PEDIATRIC SOCIETY 357

between the two observers. In the tabulation the large and small
were grouped into one class. The following table shows the results :

Age ' Cases

Under 2 months 20

2 to 4 months 17

4 to 6 months 3

6 to 8 months ' s

8 to 10 months 6

10 to 12 months 17

Dr. Johnson counted the slides from twenty of these cases two
months after the first count.

Schloss quotes the following percentages of eosinophiles, averaged
from one to six-month-old infants, and five si.x- to twelve-month-old
infants who were acutely ill had hemoglobin more than 50 per cent.;
these suffered from no condition recognizable as a cause of eosino-
philia. For infants one to six months the maximum percentage of
eosinophiles was 9.35; minimum 0.35; average 3.59. For infants
three to twelve months old, the average was 0.76 per cent. These
findings indicate remarkable oscillation. Rosenstern found eosino-
philes above 3 per cent, in none of six normal breast-fed infants, but
in artificially fed infants the percentages varied from 0.7 to 4 per
cent. The highest percentages were in infants from two days to
two weeks old. He calls attention to the pronounced variation in
percentages of the different varieties of leukocytes in apparently
normal infants and that there is a uniform increase of polymorpho-
nuclears and decrease of lymphocytes with advancing age. In
apparently normal infants the percentages are frequently above
the normal for adults, but rarely above 5 per cent, and never above
6 per cent.

Dr. Oscar M. Schloss, New York.—" Up to the present time few
blood counts have been made on normal children. It is desirable
to have the normal count as a basis for the interpretation of the
count in pathological conditions. I have made some counts which
showed the same thing that Dr. McClanahan had called attention
to, namely, that it is a matter of great difficulty to establish a normal
average for the white cells since they showed a very great variability.
It is also very difiicult to classify the large and small lymphocytes.
In these counts it would be more accurate to state the maximum and
the minimum than to attempt to state an average."

THE CREATININ AND CREATIN CONTENT OF THE BLOOD IN CHILDREN.

Drs. Borden Veeder and Meredith, St. Louis. — "There is
comparatively little data on the creatinin and creatin content of the
blood, though there have been some studies of the creatinin-creatin
13

358 TRANSACTIONS OF THE

content of the blood in nephritis. The iigures obtained by Folin
and Denis, Myers and Fine, and Meyers and Lough differ widely.
Because of the difference in the creatin-creatinin metabohsm in
adults and children, as measured by their content in the urine, we
decided to test the blood of a number of children with different
clinical conditions and compare the results with the total non-
protein nitrogen of the blood. Folin and Denis found that the con-
tent of non-protein nitrogen in the blood of a healthy adult was from
22 to 26 mg. per 100 c.c. Later they published determinations made
in a large number of clinical conditions which showed that there is a
definite increase or retention of the nonprotein nitrogen in nephri-
tics with uremia and that greater variations are found in the blood
of hospital patients. Slightly higher values were not necessarily
associated with renal disturbance. These findings have been con-
firmed bv a number of observers. There was an increase of from
4 to 6 mg. after a fuU meal, and usually a slight increase in acute
infections. In nephritics the content might vary from normal to
ten times normal, the high values being found in actual or impending
uremia. In children the nonprotein content did not vary in any
marked degree from the adult. Tileston and Comfort made deter-
minations on fifty-one children with a variety of clinical conditions.
Normal children gave values of from 20 to 34 mg. per 100 c.c.
Only one case, a child with acute nephritis, showed a definitely in-
creased value 63 mg. per 100 c.c. In this case the content became
normal with the disappearance of the uremic symptoms. The rest
of the observations were on children with acute and chronic infec-
tions in whom normal values were found. In normal infants the
nonprotein nitrogen content has been found to vary between 23
and 44 mg. per 100 c.c. by Schultz and Pettibone, whose observa-
tions were made on nine infants from one-half hour to ten days old.
The methods used in the present study were those of Folin and Denis
for the nonprotein nitrogen and of Folin for the creatin and creatinin.
Determinations were made on seventy children. Many of these,
particularly those with scarlet fever, were tested a number of times.
The blood was taken early in the morning before the children had
had their breakfast, and thus some twelve hours after the children
had had their last meal. The cases are grouped into normals,
scarlet fever at the time of the exanthem when there was an eleva-
tion of temperature, afebrile scarlet fever in the first week, and a
number of examinations made in the third week of convalescence
when the urinary findings were negative. In addition a number of
miscellaneous conditions were also investigated. The creatinin
figure for normal children varied between 0.58 and 3.44 mg. per 100
c.c. In ten children the figure was under 2 mg. and in two above.
The febrile scarlet fever cases varied between i.oS and 3.82 mg. but
with one-half above 2 mg. and none under i. The highest figure
in the early febrile case was 2.78, but in one-half the cases the con-
tent was a little over 2 mg. Like variations were encountered in
the miscellaneous conditions. There was no specific retention in
any of our cases, although as a whole the figure for the creatinin

AMERICAN PEDIATRIC SOCIETY 359

content of the blood in children is somewhat higher than for the
adult. A comparison of the creatinin content with the nonprotein
nitrogen has been made, and the results tabulated. As a general
rule, both the nonprotein nitrogen and creatinin were within the
same general limits as had been found for normal adults, and as
Tileston found for the nonprotein nitrogen in children, although
the average figures for both are a little higher in children. We have
studied six cases of nephritis.

The retention figures in these were not high and but one case was
fatal. This was not a uremic case. The nonprotein nitrogen was
not increased in two cases and the creatinin was normal in three.
In one case with a low nonprotein figure the creatinin was high and in
two an opposite condition held. As the nephritis in a given case
improved the amount of retention decreased. One of the cases
cited illustrated this. A number of cases of scarlet fever were fol-
lowed from the stage of the acute exanthem until desquamation
was completed and tests were made weekly for five weeks. None
of the fourteen cases foUowed developed a typical postscarlatinal
nephritis in the third or fourth week. After the acute febrile period
was over there was usually a slight fall in the nonprotein nitrogen
and creatinin although in the second week a few showed a slight in-
crease. One severe toxic case which died in the third week showed
an increasing retention. The kidney in this case showed acute
fatty degeneration. There is no apparent relationship between the
amount of creatin and creatinin. We have found much less creatin
in the blood of children than FoUn reports having found in adults
(about lo mg. per loo c.c). We found in the blood of children,
rarely over 5 mg. per 100 c.c. and the figures for the total creatin-
creatinin was rarely over 6 mg. This is interesting in view of the
fact that creatinin is found in the normal urine of children and is
not present in the urine of adults. We have been unable to find
any specific relationship between the amount of creatin and creatinin,
or any relation between the amount of creatin and the clinical con-
dition. There is no fixed relation between the total nonprotein
nitrogen and the creatinin-creatin content. Determinations made
on a child starved for other purposes, showed a slight increase in
the content of all three substances during the period of starvation.
In a few experiments made with reference to the effect of diet and
copious water drinking the results seemed to show that these factors
were negligible in these cases. Several children were placed on a
fixed creatin-free diet for six days and an analysis of both urine and
blood made daily after the second day. In the first case both the
absolute and relative amount of creatinin of the blood varied quite
considerably, while in the second it was quite uniform. What
mechanism controlled the relation between the amount in the blood
and the quantity of the urine they were unable to ascertain."

THE HOSPITAL CARE OF PREMATURE INFANTS.

Dr. L. E. LaFetra, New York. — "This paper is a resume of my
personal experience in the observation and treatment of these cases.

360 TRANSACTIONS OF THE

During the past two years there have been admitted to the infants'
wards of Bellevue Hospital 278 premature infants. Of these 13 are
still in the wards and 265 have been discharged. There is perhaps no
other institution, either here or abroad, that has so many such cases.
The mortality among these infants is very high but most of it occurs
during the first few days after admission to the hospital. But a
great deal could be done even for the smallest and feeblest of these
infants. The records of the last 200 cases show that 30 were saved,
and discharged as cured, that is strong enough so that their mothers
could care for them successfully. Of the 170 that died in this last
200 cases, 90 died on the first day, many witliin an hour or so of
admission; 28 more died on the second and third days, making 118
that died within the first three days. The smallest infant that was
discharged cured had an admission weight of 2 pounds 13^^-^ ounces.
The baby remained in the hospital seven months and weighed 5
pounds 6J-^ ounces at the time of discharge. Three years ago, while
visiting the children's clinics on the Continent, I learned that the
smallest premature infant they had successfully reared in Paris
weighed 800 grams. It is most unusual that a baby weighing less
than 23^ pounds is saved. The greatest majority of infants ad-
mitted to the premature wards have a history of uterogestation
between seven and seven and one-half months. In this respect it
must be remembered that the history must not be depended upon.
Taking the averages of infants at six, seven and eight months utero-
gestation, it will be found that there are many exceptions. The
causes of prematurity, aside from mental and physical shock, are
syphiUs, some acute clisease in the mother, extreme youth of the
mother, or of both parents and connected with this, illegitimacy.

"The occurrence of twins or triplets, or other multiple pregnancies,
is a very important factor. Aside from the small size and weight of
these infants they show extreme muscular feebleness which extends
even to the muscles involved in sucking and swallowing. In many
instances this is the underlying cause of fatal inanition. Another
symptom manifested by nearly all of these babies is a temperature
far below normal. The skin is imperfectly developed and the sub-
cutaneous fat is deficient or lacking, so that the infant radiates more
heat proportionately than an infant of normal size. Again the heat-
regulating center seems not to be in satisfactory operation, of that
the baby is thermolabile, that is very susceptible to the heat chances
of its environment. These babies also show a tendency to attacks
of cyanosis and are extremely susceptible to all sorts of infection.
The skin and mucous membranes are very permeable to germs so
that extreme care is necessary to prevent abrasions and to avoid
contagion from other persons or from contaminated clothing or
apparatus. Absorption from the gastrointestinal tract of dele-
terious substances whether as the result of fermentative processes in
the intestines or of germ infection may cause profound and even
fatal disturbances in a very short time. General sepsis may arise
from this source or may come from the umbilical wound or from an
abrasion of the skin.

AMERICAN PEDIATRIC SOCIETY 361

"In the general management of these children the aim is so far as
possible to reproduce the conditions of intrauterine hfe. The baby
should be kept in an even temperature approximating that of the
human body and should be shielded from all sorts of external shocks,
whether thermal or mechanical. The skin should be protected from
chance of contagion and injury and the eyes should be protected
from light. The inhaled air should be moist, comparatively warm,
and as free as possible from germs. The food should be such as to
require the least possible amount of digestive effort on the part of the
baby. As to the use of the incubator, my experience with most
incubators and their methods would lead me to advise against their
use. The plan of setting apart a small room as an incubator room is
much more satisfactory in every way. Here the baby does not have
to undergo any chilhng when the clothing is changed. The most
complete incubator rooms have the air drawn in from outdoors, in
cities preferably from the roof, then warmed, filtered, and moistened.
The temperature of the room is regulated automatically. Such an
installation is quite expensive.

"Probably the most satisfactory incubator is that devised by Dr.
Edwin B. Cragin and described in the Journal of the American Medical
Association for September 4, 1914. At BeUevue on account of the
prospect of a new Childrens' Ward a very simple and inexpensive
premature ward has been devised. The sunny corner of a ward
facing south was partitioned off and double windows and transoms
installed. The number of radiators was increased. Ventilation
was secured by means of the transoms and the door leading into the
rest of the ward. The premature ward has a capacity of ten beds and
a cubic air space of 1000 feet per crib. Moisture is obtained by
keeping a large pan of water simmering on an electric stove. After
much experimenting we found that the babies did best when kept
in a temperature of 76° F. to 80° F. with a humidity of 60 to 70 per
cent. Incidentally we have found the warm room of great advantage
in managing feeble infants that are not premature. The premature
baby should be handled only when necessary to change the gauze
diaper. The clothing should be the simplest possible. Babies
weighing less than 4 pounds should be wrapped in cotton and
kept so swathed until the temperature remains constantly at normal
and the weight has risen to 4 or 4}^ pounds. After the initial sponge
bath and oiling no bath should be given for four or five days; then a
sponge bath may be given every other day for a few days and then
every day. In order to feed these babies we must often put the food
into their mouths and even into their stomachs. In general the
most satisfactory method of feeding these babies is to use the Breck
feeder. After the warm food is placed in the tube the nipple is put
into baby's mouth. This has the advantage of teaching the baby
to draw upon the nipple but without exhausting the baby's strength.
Feeding by the medicine dropper is not so satisfactory, because it
does not teach the baby to suck. In some cases the baby cannot
swallow satisfactorily and then it is necessary to resort to gavage.
It is found that the baby is less likely to vomit if the tube is passed

362 TRANSACTIONS OF THE

through the nose. The food most suitable and that requiring the
least digestive eSort is breast milk. At Bellevue three wet-nurses
are kept constantly to supply Vjreast milk for the premature babies.
In all private cases an effort should be made to secure good breast
milk, either from some maternity hospital or, better, from a wet-
nurse kept in the house with her infant, the latter to keep the breast
milk from drying up. The milk is to be expressed from the breast
two or three times a day and a requisite amount mixed with either
whey or barley water or granum as a diluent and then fed to the
baby from a Brack feeder. At Bellevue we use one-half breast
milk and one-half whey at first, i ounce being given every one and
one-half to two and one-half hours, depending upon the size of the
baby and its stomach capacity. If it is impossible to obtain breast
milk a cow's milk modification using 6 per cent, top milk as the
basis and diluting with whey or gruel made from Imperial granum,
or both. Five ounces of 6 per cent, milk, lo ounces whey and 5
ounces Imperial granum are used to make a 20-ounce mixture. To
this is added milk sugar or dextro-maltose J^ to i)-^ ounces. The
number of calories per kilogram required by the premature baby is
much higher than for babies at full term. It is necessary to increase
the calories to one and one-fourth to one and one-half times the
ordinary requirements. An important apparatus in the premature
room is the oxygen tank all coupled up and ready for instant use in
case of cyanotic attacks. As to prognosis, the weight is the best
criterion we have but we must not despair of even the smallest
babies. If a baby has survived for a week it has a better chance
to live, no matter what the weight, since the fact of having survived
that long augurs a good constitution."

DISCUSSION.

Dr. Borden Veeder of St. Louis said: "We have a premature
ward in the St. Louis Hospital in which the heat is furnished from
an adjoining closet and the ventilation by means of a transom. We
keep the temperature at from 80° to 88° F. and the babies wear
scarcely any clothing. A great many of the babies get more than
125 calories daily; some get as much as 185 calories. We have also
observed that sometimes after a baby has gained for a time it does
not gain so rapidly and that then if it is dressed as an ordinary baby
is dressed and put out into the ward the weight would begin to go
up again."

Dr. Julius P. Sedgewick of Minneapolis said: "Dr. Le Fetra has
spoken of a short interval between feedings, one and one-half to
two hours, but others have been able to employ a four-hour interval.
There is probably a difference in the technic of the feeding that
accounts for the success with the four-hour interval. The four-
hour interval can be used and has some points in its favor."

Dr. LaFetra of New York said: "I have not been success-
ful with the long interval between feedings and would be glad to
have Dr. Sedgewick give us some of the points in the technic by

AMERICAN PEDIATRIC SOCIETY 363

means of which they have been successful with the four-hour interval.
When I used the four-hour interval the child did not get sufficient
food in twenty-four hours and it seems evident that there was
something in the technic that we did not know."

Dr. Sedgewick said: "There is one point with reference to get-
ting enough food into these children and that is that they can be
given more food than the stomach capacity would indicate. We
do not use as much as i8o calories, but usually from 120 to 150,
and we have no trouble in administering this amount. If the child
cannot take it in the ordinary way it is given by tube. We always
use breast milk and the amount given depends upon the size of the
baby. We usually go slowly at first, starting by giving feedings of
from 10 to 15 c.c. five times daily, making about 75 c.c. a day.
This amount is increased as rapidly as the baby can bear it. We
have no rule of giving so much at such and such a time, but are
guided entirely by the heeds of each individual child."

Dr. B. Raymond Hoobler of Detroit said: "It is possible to
devise an incubator that could be installed in a home. This may
be done with a clothes basket and barrel hoops, arranged to make a
tent, and covered with blankets. The heat can be furnished by
ground-glass electric-light bulbs and the child's eyes protected from
the light by black cloth interposed between the child and the light.
With such an arrangement the temperature in the tent can be kept
very constantly between 85 and 90° F."

FURTHER EXPERIENCES WITH HOMOGENIZED OLIVE-OIL MIXTURES.

Dr. Maynard Ladd, Boston. — "In February, 1915, before the
New England Pediatric Society and in June before the American
Pediatric Society, I called attention to the possible uses of the homo-
genizing machine of M. Gaulin of Paris, for purposes of modifying
milk for difiicult cases of feeding, especially those showing intolerance
for fat. Homogenization of liquids of different densities consists in
reducing the constituent elements to such a physical condition that
they will no longer separate but will maintain a permanent and even
composition throughout the mixture. It is possible by this process
to improve the emulsion of a modification of cow's milk so that it will
be even finer than that of breast milk without altering in any way the
chemical properties of the milk. There is reason to believe that such
a milk may be better digested and assimilated. More interesting
is the possibility of substituting some other fat than cow's milk fat
in cases of malnutrition, in which it is often difficult to give fat
enough to make a child gain normally in weight without precipitating
sooner or later a digestive crisis. The principal difference between
the fat of cow's milk and that of breast milk is in the size of the fat
globules and the proportion of volatile fatty acids. The nonvola-
tile fats are made up mostly of olein and palmatin in both cow's milk
and breast milk. Olive oil is almost wholly olein and palmatin and
free from volatile fatty acids. It was my suggestion, therefore, to
use olive oil to obtain the fat percentages in modified milk mixtures
and so to eliminate the volatile fatty acids; and also by homogeniza-
tion to secure an emulsion as fine or finer than human milk. The

364 TRANSACTIONS OF THE AMERICAN PEDIATRIC SOCIETY

milk sugar and proteins were to be obtained from skimmed milk as
usual, and additional carbohydrates in the form of dextrin-maltose
and starch prescribed according to the usual indications.

"This method of feeding has been applied to thirty-seven cases, the
present series including the subsequent histories of the cases reported
last year. A normal healthy baby gains, according to a high standard
of growth, an average of 1S.7 ounces per month. In this series of
thirty-seven cases, whose average gain on previous feedings was 5
ounces per month for a period of 6.3 months, the average gain per
month was 18.15 ounces on the homogenized olive-oil feeding. The
average period of feeding was 4.7 months, a sufficient time to de-
termine its permanent effects. The improvement in the babies'
general condition has been as striking as the gain in weight. Vomit-
ing and sour regurgitation, when present as symptoms, quickly sub-
sided. The child improved in strength, in the quality of its fat,
and in the development of its functions, as one would expect it to
do in normal successful feeding. In some cases the mixture was
heated to 212° F., in others given unheated. Limewater was usually
given in amounts of 5 to 10 per cent, of the total mixture, but not
as a matter of routine. The percentage of olive oil was almost
invariably started at 1.50 and did not exceed 3.50 per cent. The
total carbohydrate was usually started at about 5 per cent, and never
exceeded 7 per cent. The proteins were started at 1.50 per cent,
and seldom exceeded 2 per cent. Hunger is the safest guide to the
child's tolerance to the amount of fat it is taking. This method of
dealing with fat intolerance and other cases of difficult feeding is
applicable in cities supplied by milk laboratories and in hospitals
which will incur the e.xpense of installing a homogenizing machine.

"Owing to the courtesy of Dr. Bowditch, Dr. Wyman made use of
the suggestion that olive oil homogenized milk mixtures be used in
the early days of convalescence from diarrheas due to indigestion and
fermentation. The general scheme of treatment was as follows:
After the initial period of catharsis and starvation, a fat-free lactic
acid milk, diluted two-thirds or one-half was given. If the infecting
organism proved to be of the Flexner or Shiga tj^pe, dextri-maltose
was added up to 4 or 5 per cent, and sometimes barley water. If
the gas bacilli was present no carbohydrates were added. .After a
period of several days, when the acute febrile disturbance showed
signs of subsidence, olive oil was homogenized with the lactic acid
milk, in percentages of i.oo, 1.50 and if well tolerated 2.00; this
added considerably to the caloric value of the food and prevented
or lessened the loss of weight which occurred in such cases. There
were nineteen cases of infectious diarrhea, fifteen of the Flexner
type bacillus, one of the gas bacillus type, and three undetermined.
Four cases died giving a mortality of 22 per cent., about the same
as in the other services. Of the fifteen cases that lived, eight were
in the hospital for an average of twenty-one days and each lost over
their entrance weight about 15 ounces. Seven were in the hospital
on an average of fourteen days each and gained an average of 10.7
ounces over their entrance weight. The average net loss of all the

BRIEF OF CURRENT LITERATURE 365

fifteen surviving cases was therefore only 3 ounces over the entrance
weight. It seems from this series of cases that ohve oil homogenized
can be given safely after the acute febrile stage has passed and in
the period of convalescence and is more eflfective in making up the
loss of weight than the fat of cow's milk.

"A study of the fat metabolism of infants fed on homogenized
milk was carried out at the Boston Floating Hospital by Dr. C. H.
Laws of the University of Michigan. There were four cases. The
result of the experiments in these might be objected to because of the
artificial conditions imposed by the experiments but the results of
the clinical cases extending over a period of nearly five months, on
an average, were of decided significance and justify the belief that
homogenization of milk mixtures and the substitution of olive oil
for cow's milk fat offers an additional and valuable resource in
infant feeding in cases of difiicult digestion with malnutrition."
[To be continued.)

BRIEF OF CURRENT LITERATURE

DISEASES OF CHILDREN.

Spinal Fluid in Poliomyelitis. — The material for a report by H. L.
Abramson (Amer. Jour. Dis. Child., 1915, x, 344) is taken from the
records of the meningitis department of the New York City Board of
Health and consists of forty-three cerebrospinal fluids from twenty-
nine patients. He finds that the cerebrospinal fluids of poliomyelitis
and encephalitis show abnormal changes in practically all cases, but
present no specific characteristics. Fluids from cases of encephalitis
generally show a higher albumin-globulin content than do the fluids
of myelitis or of the abortive cases. Fehling's solution is reduced by
all fluids but not in equal degree. Examination of the spinal fluid is
the most important factor in clearing up the diagnosis in abortive
and preparalytic cases.

Diagnosis of Scurvy.— A. Brown (Arch. Pediat., 191 5, xxxii,
744) states that the absence of subperiosteal hemorrhage, as shown
by Rontgen examination, does not exclude scurvy, as it has been
shown that recently extravasated blood is very radiable and only
when the disease is well advanced and some organization of the clot
has occurred does it e.xhibit itself on the .^•-ray plate. The first
definite evidence of scurvy is the appearance in the radiogram of the
"white line" which precedes the occurrence of the hemorrhages and
indicates an increased density at the junction of the epiphysis and
diaphysis. A high temperature with a polymorphonucleosis is not
incompatible \\ath a scorbutic condition, but occurs, on the other
hand, only in the severe and most advanced cases, where a faulty
diagnosis of pus is apt to be made, in which cases the presence of the
"white line" is a valuable aid to diagnosis. The association between
scurvy, rickets, tetany and beriberi is very intimate. The produc-
tion of these various ailments occurs through the improper handling
of our food stuffs, altering the constituents in such a way as to com-

366 BRIEF OF CURRENT LITERATURE

pletely upset proper balance of mineral salts within the organism.
Why rickets is produced in one case, tetany in another and scqryy in
another it is impossible to state. In rickets the loss of calcium is
definite, while the evidence at hand shows that in tetany, sodium and
potassium act as the irritating salts and calcium and magnesium as
the sedatives. In scurv>^ the calcium retention is unexplained.

Mild Diabetes in Children. — D. Riesman (Anier. Jour. Med. Set.,
1916, cli, 40) says that the fatality of diabetes in early life is an axiom.
However, an increasing number of observations seems to show that
juvenile diabetes need by no means be a mortal disease. Reporting
four illustrative cases, he says that there exists a mild tj^pe of dia-
betes in childhood and adolescence. The disease is peculiar in its
tendency to occur in several members of the same family. The
glycosuria is usually moderate, although nervous excitement and
other disturbing factors may augment it. Other diabetic symptoms
are often slight and may be wanting. The disease is not progressive
and may remain stationary or end in apparent recovery. In its
general features, it corresponds to the so-called renal diabetes.

Acute Cerebellar Ataxia in Children.— J. P. C. Griffith {Amer.
Jour. Med. Sci., 1916, ch, 24) reports a case of acute cerebellar ataxia
in a child of five years. The noteworthy features in this case were
rapid development of symptoms without discoverable cause, unless
possibly the child had suffered from influenza; a very uncommon
degree of nystagmus; ataxia of the extremities; disturbance of sen-
sorium; affection of speech; slight increase of reflexes, and rapid
recovery, complete in one month from the onset. The symptoms
on the whole point chiefly to some disorder of the cerebellum. The
writer abstracts 17 cases from the literature. Analyzing these and
his own case, he finds that the immediate apparent causes of the
attacks are divided into scarlet fever, 2 cases; measles, 3; t^-phoid
fever, 4; pertussis, 2; influenza, i; poliomyelitis (?), i; epileptiform
convulsions, i; trauma, i; dysentery, i; not discovered, 2. The
preponderance of acute infectious diseases is very evident. Only
I case followed trauma. Ten of the patients were boys and 8 girls.
The age at the time of onset ranged from three and a half years to
twelve years, 10 of the patients being six or more years of age.
That the condition present is in fact dependent upon a lesion of the
cerebellum is, in a way, an assumption. The complex of symptoms
based upon the composite of all the cases seems sufiicient, however,
to warrant a behef in the cerebellar origin. Disturbances of the
sensorium were present in the early states of a large number of cases.
All these may be classed among the symptoms common to any severe
intracranial lesion, or they might be the evidence of a complicating
disturbance in other regions than the cerebellum. Some affection
of mentality, apart from unconsciousness, was present in 12 instances.
In most of these it was of brief duration, but in a few it persisted in
some form for a longer time. In such it, of course, indicated lesions
elsewhere than in the cerebellum alone. The affection of speech
might with propriety be considered an exlracerebellar disturbance,
but certainly in some cases at least, and perhaps in most of them,
seems not so much to depend upon an involvement of the centers

BRIEF OF CURRENT LITERATURE 367

for speech as upon an inability to articulate properly — an ataxic
condition. There is a distinct tendency to increase of the reflexes
in this disorder, pointing toward the cerebellar involvement. In
general it is a fair conclusion that the inability to walk or to use the
arms depended upon the ataxia rather than upon paresis. The
ataxia was noted in every instance; in the legs in all, in the arms it
appears to have been present in all but one case. Anesthesia is
mentioned in 2 instances, and more or less loss of control of the
sphincters in 3. These symptoms are, of course, not cerebellar.
Nystagmus is recorded in but 5 cases. Although it is probable that
there exists a cerebellar nystagmus, the symptom is certainly pro-
duced by lesions of other regions as well. In seven cases entire
recovery ensued. There is every reason to believe that in most
instances few if any evidences of the disease remain.

Citrated Whole Milk. — E. Pritchard {Practitioner, 1916, xcvi,
144) beheves that the "citrated whole-milk" method is physiologic-
ally unsound, because it allows no latitude for adaptation to the
individual's digestive, assimilative, metabolic, and secretory activ-
ities, and that its use imposes obligatory modification of the infant.
Secondly, that it affords little scope for the study of the influence of
variations in the diet. Thirdly, that if the principles of percentage
feeding are understood, a satisfactory food can be synthesized in a
great variety of ways to satisfy the physiological requirements of
any particular child; and fourthly, that dried milk, if properly modi-
fied and of good quality, has all the advantages, and few of the dis-
advantages, of so-called dairy milk.

Predisposition to Tuberculosis.— Paul Reckzch {Arch. f. Kindcr-
hcil., Bd. 65, Heft iii-iv, 1916) says that the known importance of an
early diagnosis of tuberculosis teaches that we must begin at baby-
hood to seek for symptoms and signs of this disease, and continue to
seek it throughout childhood and puberty if we would prevent its
later ravages. The ubiquitous tubercle bacillus infects many; in
some there is no evident lesion; in others the lesion remains latent,
and in still others the lesion shows itself plainly and is progressive.
Anatomical examinations show that these latent lesions, which have
never caused any symptoms, exist in many persons. This suggests
the production by these early lesions of immunity to later infections.
Predisposing factors to tuberculosis are found in underfeeding, over-
work and other infectious diseases. These factors may act in the
parents and through them on the unborn child, even when the par-
ents have no evident tuberculosis. The larger number of relatives
in a family who have had tuberculosis the greater predisposition the
child has to tuberculosis. Descendants of tuberculous parents suc-
cumb to consumption more often than descendants of normal parents.
They show easy infection by other germs as well as the tuberculous
germ. In large families it is found that the younger members, to
whom is given less of the mother's vitality, oftener die of tuberculosis
than in other families. Where we have this predisposition the chil-
dren also oftener have other infections such as diphtheria and scarlet
fever. If both parents have died of tuberculosis the child is more
predisposed than if one only had died of the disease. The nearer the

368 BRIEF OF CURRENT LITERATURE

birth of a child comes to the death of the parent the greater is the
predisposition and the death rate in the children. In such famihes
three-fourths of the deaths are from tuberculosis. Children having
latent infections in the lymph system easily take other infections,
especially those of the respiratory organs and convalescence is slower
than in normal children.

New Means of Securing Coagulation. — Rudolph Fischl (Arch. f.
Kinderheil., Bd. 65, Heft iii-iv, 1916) has made a study of the possi-
bility of securing hemostasis by the use of an extract of the lung
substance applied locally to the point of hemorrhage. The experi-
ments were made at the University Clinic of Prague and the extracts
were made with the assistance of the Luitplod chemical factory in
Munich. He analyzes coagulation, showing that it is due to a ferment
which is contained in the organs as well as in the blood. The means
he has used to produce coagulation is a cytozyme or thrombokinase
obtained from the tissues, of which the lung substance is the most
useful. After experimenting on the action of this substance in vitro
and showing its coagulating power he experimented on animals and
showed the same factors to be present here. He gives a careful
resume of the work done and published by various authors on this
subject and then details his own experiments. During the past two
years he has made use of twenty different lung extracts from dogs
and other animals. The preparation was made from blood obtained
from the carotid artery by means of a glass canula. He demon-
strated its efSciency in causing coagulation in animals even in severe
injuries of the internal organs, but it was practically impossible to
obtain a sterile extract. He therefore attempted to obtain the same
substance in a dry state, and fourteen different specimens of dried
extracts were tested. The author concludes that we possess in the
substance of the lung, whether used as a moist or a dry extract, a
means of causing coagulation of blood in vitro and in animals. The
question then came up what portion of the lung substance held this
property, whether the juice, the salts, the lipoids, etc. As yet it is
impossible to solve this problem. Experiments on animals have
shown that it is possible to stop parenchymatous hemorrhages by
means of tampons soaked in a solution of the dried lung extract and
that it is difficult to pull away the coagulum thus formed. The ac-
tion is very quick and permanent. By a ten-second tamponade it
was possible to stop bleeding from the hver, spleen, or kidneys, and
it did not recur. In a dog hemorrhage from the inferior vena cava
was stopped in this manner. The author with PifB made use of
this extract as a hemostatic in ear and nasal operations, and it
allowed operations hitherto impossible of accomplishment within the
skull. In an eight-year-old hemophilic who had hemorrhage from
the cavity from which a tooth had been drawn, and who had con-
tinued bleeding for three days in spite of all attempts at hemostasis,
the hole in the alveolar process was tamponed with wadding soaked
in the extract, and the flow of blood stopped almost at once. The
hemorrhage did not return after removal of the cotton. The author
exhorts other medical men to try this method and to report their
results.

THE A TVTEIlIOAJvr ^^^

JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN.

VOL. LXXIV. SEPTEMBER. 1916. NO 3.

ORIGINAL COMMUNICATIONS.

I. ADENOCARCINOMA OF THE CORPUS UTERI: NEARLY

COMPLETE REMOVAL BY THE CURET.* 2. ECTOPIC

CHORIOEPITHELIOMA OF THE PELVIS.

BY
ROBERT T. FRANK, A. M., M. D.,

Associate Gynecologist, Mt. Sinai Hospital,

New York City.

(With four illustrations.)

Adenocarcinoma of the body of the uterus is the most benign
form of cancer encountered in the female genital tract. Various
authors estimate the percentage of recurrence after operation at
from 0-60 per cent.(i). Most cases, if operated on at an early
stage, remain cured after simple vaginal hysterectomy, because
extension to the pelvic lymphatics and the adnexa or metastatic
disseminations are late and rare.

The diagnosis of carcinoma of the corpus uteri is tentatively made
from the history of metrorrhagia (especially if bleeding starts up
after onset of the menopause), but it must regularly be confirmed
by the microscopic examination of the curetings obtained. Other
clinical signs, such as increase in size of the uterus, foul discharge,
large irregular cavity and bleeding upon introduction of the sound
are uncertain, because small necrotic fibroids, placental rests or
purely hyperfunctional changes, alone or in combination, may give
quite similar symptoms.

The curetings of adenocarcinoma of the uterine body are char-
acteristic because of the type of cell (distinguishing it from the
more malignant cervical adenocarcinoma"), the frequent occurrence

* Specimen presented before the X. Y. Obstetrical Society.

370 frank: adenocarcinoma of the corpus uteri

of several layers of cells of varying size with nuclear irregularity,
and the irregular convoluted and distorted gland forms (far more
marked than the premenstrual physiological changes). If, in addi-
tion to a considerable amount of curetings, invasion of the uterine
wall can be demonstrated in the curetings, it is usually safe to
predict that the growth is extensive and of considerable duration,
because ordinarily the curet removes only the surface of the growth
and does not reach the musculature unless deep and extensive
erosion has occurred.

Fig. I. — Section fmni \ iihiminnus (.iiri'tiiij;>, ^hovvin;; adcncKaninoma of the
corpus uU-ri.

On the other hand, adenocarcinoma of the uterus has been com-
pletely removed b\' the curet according to various authors(2),
and possibly in one or two instances has been iiermanenlly cured
by mere curettage (?).

The case reported below shows ihat such criteria, as the degree of

frank: adenoc.-vrcinoma of the corpus uteri

371

invasion, cannot be forecast from either the amount of material
obtained grossly, or the apparent invasion of the uterine wall as
seen microscopically in curetings. It furthermore shows that
repeated curettage might well prove negative, unless a considerable
interval elapsed between the first and second operation.

Mrs. F., was referred to me on Nov. lo, 1915, by Dr. N. B. Waller.
The patient was a widow, fifty years of age, the mother of two
children. Fcir one year she had suffered from severe menorrhagia
and metrorrhagia, the bleeding being continuous for the last three

Fu;. 2. — The onlx- portion of the uterine wall found showing a. small area of
carcinoma (center of the picture!.

months. On Nov. 6 curettage was performed by Dr. Waller. The
voluminous curettings were examined by Dr. H. Celler, who reported
adenocarcinoma of the corpus uteri. I personally also e.xamined
the sections, and found a papillary adenocarcinoma, which in spots
became almost alveolar, and apparently invaded the stroma of the
uterus (Fig. i). From the sections I diagnosed an advanced stage
of the disease.

The patient proved to be a very fat woman (more than 240 pounds),
pale, but otherwise in good condition. The uterus was about the
size of a two months" pregnancy, antiflexed and held rather rigidly
in place by parametrial scars. In spite of the technical difficulties
to be anticipated, I proceeded to perform a vaginal hysterectomy

372 frank: adenocarcinoma of the corpus uteri

sLxteen days after the diagnostic curettage. On account of the inelas-
ticity and friability of the parametria the vaginal route had to be
abandoned and the operation was completed through an abdominal
incision. Oozing proved almost uncontrollable, so that iinally
firm packing, led out through the vagina, reinforced by vaginal packs,
placed within a ring of Ochsner clamps grasping the vaginal edges'
was resorted to. The pelvic peritoneum was closed and the ab-
domen sutured. The patient left the table in poor condition. She
oozed for twenty-four hours per vaginam. The clamps were
removed after forty-eight hours. A large vesicovaginal leak then
at once became evident, which closed spontaneously after ten days
under the use of a permanent catheter. On the tenth day mild
phlebitis of the right leg developed. In spite of these numerous
complications the patient recovered and is now well.

Upon opening the uterus several small intramural fibroids were
found in the one cornu. The endometrium had apparently not yel
regenerated. There was no erosion of the uterine wall, and upon
gross examination no evidence of carcinoma could be seen. On the
posterior wall just above the internal os, an area about i centimeter
square appeared somewhat velvety. From this region and numerous
other areas sections were cut by Dr. Thalheimer.

Fortunately for our peace of mind, a small portion of the area
above the cervi.x microscopically showed adenocarcinoma with
slight invasion of the musculature (Fig. 2). In a few adjacent spots
small accumulations of cancer cells were found in the deeper lym-
phatics of the myometrium.

Epicrisis. — Curettage performed by another physician showed
voluminous adenocarcinoma with invasion of the uterine wall.
After a prolonged and difficult hysterectomy, from which the patient
almost lost her life, the uterus obtained appeared to show only a few
small fibroids! Only after careful search were small microscopic
areas of cancer found. The case recorded above is of interest
because it bridges the gap formed by such cases as were reported
by Ladinski (1. c.) in which no carcinoma could be found after
curettage (and in which, therefore, the question of a mistake in
diagnosis or a mixing up of specimens in the laboratory, always
arises). The surgeon is necessarily put upon the defensive when an
organ removed for malignant disease shows no gross lesions, and
should microscopic examination prove negative, as might well
happen, a degree of unpleasant uncertainty remains. Perhaps this
fact accounts for the rare appearance in the literature of reports of
similar cases.

2. ECTOPIC CHORIOEPITHELIOMA OF THE PELVIS.

This case is instructive clinically. Because of incompleteness it
is of less value to the pathologist than its rarity warrants.

frank: adenocarcinoma of the corpus uteri

373

Past History. — Mrs. R. A. Surg. No. 159942, was admitted to
the First Gynecological Service of Mt. Sinai Hospital (Attending
Gynecologist Dr. J. Brettauer) on Dec. 13, 1915, with the following
history.

Aged thirt3'-two years, married. Menstruation began at age of
fourteen years, and was regular until five months ago. Pregnancies
were six in number, three children, the last four and one-half years
ago, three abortions, the last one and one-fourth years ago. All
abortions occurred before the second month of gestation; curettage
performed after last miscarriage.

Fig. 3. — Typical chorioepithelioraa invading the pelvic cellular tissue.

Present History. — -For the last five months the patient's health
has been poor. Her menses occurring irregularly every sLx to
seven weeks, were moderate in amount. She complained of a
moderate amount of pain in the lower abdomen and some backache.
For the last two weeks she has been in bed because of malaise, pain
in lower abdomen and moderate degree of fever. There has been
slight pain on urination, the bowels have been constipated.

Examination. — The following abnormalities were found: Con-
siderable emaciation, a blowing systolic murmur at the apex; tender-
ness in the right lower abdominal quadrant on deep palpation;
a deep cervical tear, uterus enlarged and firmly fixed, behind and to

374

frank: ADENOCARCIXOitA OF THE CORPUS UTERI

the right of it a fluctuating mass, reaching into Douglas' culdesac
with upper limit undefined.

Subsequent Course. — The patient was observed for eight days,
during which time the mass increased in size, and the temperature
rose to ioi°. Vaginal aspiration, to determine whether the mass
to be dealt with was a pelvic abscess, was decided upon.

Operation. — Under anesthesia the mass was felt low down in the
right fornix, the size of an orange. On aspiration through the
posterior forni.\ pure bright blood was obtained without much suc-
tion. The forni.x was at once incised, allowing exit to a solid stream
of arterial blood.

Fig. 4.-

-Same 'al higher magnification showing chorioepilhelionia tissue in
ch:>sc proximity to a large blood-vessel.

Immediate suprapubic incision was made while an assistant
exerted pressure against a big vaginal gauze tampon. Fine adhe-
sions between sigmoid and uterus were separated. Enormous
hemorrhage from the depth of the pelvis, apparently arising from
the right {)elvic wall, in the neighborhood of the right sacrouterine
ligament, not controllable by strong jjressure, was encountered.
In order to open up the depths of the broad ligament widely, a
rapid clamp hysterectomy and right salpingo-oophorectomy were
])erf()rmed. In the mcaiuvhile pressure on the bleeding area, intra-

frank: adenocarcinoma of the corpus uteri 375

venous infusion of 525 of saline solution and transfusion of 5 12
of blood by the citrate method were resorted to to offset the uncon-
trollable hemorrhage.

As no spurting vessels could be seen the aorta was compressed,
and a ragged area, about the size of a silver dollar, was exposed
in the region where the sacrouterine ligament, ureter and division
of the internal iliac vessels are situated. The tissue looked like
torn placenta. As the sole means of controUing the bleeding,
deeply placed chain ligatures were passed around the area. Con-
siderable of the tissue was removed. The clamps were replaced
by ligatures and the abdomen closed with through-and-through
sutures.

The patient never recovered consciousness and died shortly after
completion of the operation. Autopsy was refused.

Pathological Report. — The uterus was of moderate size, the endo-
metrium normal. The right ovary and tube were, likewise normal.
The tissue removed from the pelvis was reported typical chorio-
epithelioma. Through the courtesy of Dr. F. S. Mandlebaum,
Pathologist of Mt. Sinai Hospital, the entire tissue was turned over
to me. It was cut in serial sections. In no spot did villi show.
Everywhere Langhans's cells and syncytium, invading the pelvic
cellular tissue, appeared.

Epicrisis. — Clinically the tragic suddenness of the hemorrhage
and its rapid fatal outcome are most striking. A patient prepared
for the minor operation of opening a pelvic abscess was dead less
than one hour after the aspiration had been begun. The patho-
logical report, however, showed that the patient was suffering
from a malignant condition.

Pathologically several interesting questions arise. The primary
site of the tumor could not be found. The uterus, both macro-
and microscopically was normal, and showed no decidual reaction.
The right ovary and tube were likewise negative. The left ovary
and tube were found grossly negative at operation and were distant
from the site of the lesion.

Either primary or secondary peritoneal (abdominal) implantation
of an ovum can be excluded by the fact that serial section of the
invasive portion of the mass showed no villi. Etiologically one
of the previous gestations must be considered. During the preg-
nancy fetal cells must have been carried away and deposited by the
blood stream at the site found at operation. Here the chorioepi-
thelioma had developed, small repeated hemorrhages occurring and
being encapsulated in Douglas' culdesac as happens in ectopic
gestation. Although the tragic outcome was hastened by the opera-
tion, death would have necessarily ensued, because radical removal
of the growth could not have been accomplished.

Q83 Park Avenue

376 WILLIAMSON: GENERAL EDEMA OF THE FETUS

REFERENCES.

1. Doederlein and Kronig. Operative Gyndkologie, 1912, 3d
Edition, p. 54S. Permanent cures in corpus carcinoma as reported
by various German clinics. The lowest percentage of cures is that
of Olshausen 40 per cent. Leopold, Landau and also Doederlein
report 100 per cent, of permanent cures. Of the eighteen authors
quoted, only five report less than 60 per cent, of cures.

Cullen, T. S. Cancer of the Uterus, 1909, p. 645, reports 66 per
cent, of cures.

2. Ladinski, L. J. Surgery, Gynecology and Obstetrics, March,
1915, p. 325. Complete Removal of Adenocarcinoma of Uterus
by Exploratory Curettage.

REPORT OF A CASE OF GENER.\L EDEMA OF
THE FETUS.*

BY
HERVEY C. WILLIAMSOX, M. D.,

New York City.
(With one illustration.)

B.ALLANTYNE, of Edinburgh, who has had the most experience
with this interesting subject, says: "General dropsy of the fetus
was the disease which in 1887 first attracted my attention to the
study of antenatal pathology, and since that year I have had the
extraordinary opportunity of examining eleven specimens of| this
malady, and have published the results of the examination of several
of them. The result of all these opportunities and of all tliis
writing is, that I now feel far less certain about the pathogenesis of
this disease than I did shortly after I had examined my first
specimen."

Ballantyne's definition is very good. "A morbid condition of
the fetus, characterized by general anasarca, by the presence of
fluid effusions in the peritoneal, pleural, and pericardial sacs, and
usually by edema of the placenta, and it results in the death of the
fetus or infant before, during or very soon after birth."

Ballantyne found sixty-eight cases in the literature and Schumann
in a recent paper reported thirty-eight additional cases.

Schumann divides the cases in two groups: "(i) those cases in
which edema is due to some mechanical or structural defect in
the fetus or its membranes, and (2) those due to toxemia of the
mother and secondarily of the fetus, without any morphological
defect necessarily present." My case belongs to the latter class.

As to the etiology I would again quote Ballantyne: "Provisionally
it may be supposed that general edema of the fetus may arise in

* Read at a meeting of the Society of Alumni of Be'ilcvue Hospital, .\pril
5, 1916.

WILLIAMSON: GENERAL EDEMA OF THE FETUS 6 1 i

the later months of fetal life, from maternal causes; possibly con-
ditions which increase the blood pressure in the placenta by causing
structural changes in the maternal and (secondarily) in its fetal
parts, may thus lead to backward pressure and transudation of
serum in the fetal body. Again it may be supposed that in early
fetal or late embryonic periods, structural anomalies may arise in
the fetus (heart, kidney, liver, blood) which will directly produce the
dropsy as it is produced in the adult, although with slight modifica-
tions and exaggerations on account of the pecuharities of the intra-
uterine environment. These fetal conditons it may yet be found
possible to trace back again to morbid maternal states; and it may
even be that maternal or paternal conditions existing in the sexual
cells before impregnation may be potent to direct the life of the
impregnated ovum into abnormal manifestations. Let us here leave
this subject; it is clear that it is obscure; this alone is clear."
The history of this case is as follows:

Mrs. G. B. M. Referred by Dr. Henry Wolfer. Nativity,
Born in U. S. of German parents. Aged thirty years, para-iii.
She was last unwell January 15, 1915, was due October 22, 1915, but
was delivered Aug. 24, 1915, or at about seven months.

Family History. — Father died thirteen years ago in Manhattan
State Hospital of paresis. He was bedridden for the last six months.
Mother is living and well, as are two brothers and one sister. One
sister died when twenty-five years of age from peritonitis following
a miscarriage.

Childhood Diseases. — Scarlet fever and diphtheria when eight
years of age, no history of complications. Pneumonia when eleven
years of age, no complications.

Menstrual History. — Began at fifteen years, regular, moderate
amount, has shght pain in the back. After marriage five years ago,
was somewhat irregular until after the first baby was born two years
and four months later.

Obstetrical History. — One full-term child delivered by low forceps
January 8, 1913. Child is living and well. She was treated
with irrigations for cystitis for three months after this delivery.
One full-term child delivered spontaneously August 11, 1914. This
baby died about one hour after birth, but as no autopsy was per-
formed the cause is not known. It was apparently healthy.

Present History. — Seven weeks before her admission to the hospital
her abdomen enlarged rather suddenly. She became aware of
this enlargement by her inability to fasten her corsets one morning.
Two weeks before admission her lower extremities became edematous
and she had several quite severe headaches. At times she did not
see well, there was a cloud before her eyes; this would pass in a
few minutes. She was also nauseated at times but did not vomit.

Ten days before admission the urine contained a moderate trace
of albumin and a few granular casts. The blood pressure was

378

WILLIAMSON: GENERAL EDEMA OF THE FETUS

138 mm. The extremities were edematous. On the day before
admission the lower extremities were markedly edematous, the
abdomen was large, the uterus tense, pyramidal in outline. It
was very difficult to palpate the fetus. Blood pressure, i-;JsO-
There was no albumin in the urine.

She was admitted to the hospital August 23, iqiS-
Labor. — The membranes were ruptured artificially to induce labor;
sixty-five ounces of amniotic fluid escaped. The cervix was soft,

two fingers dilated. Labor progressed satisfactorily until the head
reached the outlet, and as there was some delay Elliott's forceps
was applied. The head was spherical and soft, it felt like a breech.
It was in a L. O. P. position and was delivered transversely. There
was marked dystocia caused by the enlarged body and it was de-
livered after ruj)ture of the cervical ligaments and fracture of one
humerus. Premature female infant weighing 8 pounds, was gener-
ally edematous, and made no attempt at respiration.

The placenta was large, thick, and edematous. It was round

WILLIAMSON: GENERAL EDEMA OF THE FETUS 379

25 cm. by 24.5 cm. The cord was edematous. 44 cm. long, centrally
inserted. Its weight was ,3 pounds 8' 2 ounces.

Postpartum. — The patient complained of sev'ere headache im-
mediately after delivery and four hours later had a convulsion.
She had six convulsions at intervals of about two hours, between
them she was fairly clear. The usual eliminative treatment was
given: croton oil TTlii, colon irrigations, and one hot pack. After
the last convulsion ether was given and a venesection and infusion
performed. About 6 ounces of blood was withdrawn and a little
over a pint of saline given.

Puerperiiim. — Following the infusion she made a rapid and un-
eventful recovery.

Urine. — On the 24th (day of the convulsions) contained 0.25
of one per cent, of allmmin by Esbach, and a moderate number of
granular casts. On the 27th there was a moderate trace of albumin
but no casts, and on the 30th only a trace of albumin.

Wassermann reaction negative.

On October 16, 1915. She weighed iii^fe pounds (about her
normal weight). B. P. ^^^^O- The urine was negative.

PATHOLOGICAL REPORT.*

Autopsy Notes. — Body of a well-formed but premature female
infant. There is a general edema of the skin and muscles, and
much straw-colored fluid in the serous cavities.

There is a wide separation of the fifth and si.xth cervical verte-
bra; and rupture of all the spinal ligaments and spinal cord, and lac-
eration of cervical muscle. The tissues of the neck are infiltrated
with blood.

The spleen is much enlarged and smooth apparently slightly
edematous.

Liver normal. Adrenals soft, and light in color. Kidneys
small, pale. Lungs atelectatic. No signs of syphilis.

Anatomical Diagnosis. — The condition suggests an edema and
intoxication of renal origin, primary in the mother.

Microscopical E.xaniination. — Liver: In the greater part of this
organ the liver cords appear indefinite in outline and the cells
show marked granular degeneration. There is diffuse myeloid-
ization of nearly the entire organ, maintaining the blood-forming
function of fetal life. This condition suggests an early parenchy-
matous degeneration in the undeveloped liver of a premature infant.

Spleen: Malphigian bodies and trabecula are imperfectly de-
veloped. There is a diffuse myeloidization of the entire organ.
The capillaries are dilated, and the pulp shows excessive pro-
duction of myelocytes, that is a continuation of the blood-forming
function, which is normal in fetal life.

Kidneys: The cortex appears poorly differentiated. The glom-
eruli are small and the cells of the capsule are difficult to differentiate
from the cells in and on the tufts. In certain areas of the cortex the

* I am indebted to Dr. E. S. L'Esperance for the pathological report.

380 EASTMAN: A CASE OF CARCINOMA OF THE CECUM

tubules have apparently remained of the fetal type, and have not
enlarged into true glomeruli. This gives an edematous appearance
to this portion of the kidney. In the medulla there is apparently an
increase in interstitial tissue associated with small undeveloped
tubules. The cells of the fully developed tubules are swollen and
show earlv granular degeneration. The capillaries are dilated
and contain a high percentage of myelocytes and normoblasts.
The whole organ suggests the undeveloped renal structure fre-
quently observed in a premature infant and in this case associated
with early parenchymatous degeneration.

REFERENCES.

1. Ballantyne, J. W. Manual of Antenatal Pathology and
Hygiene. Edinburgh, 1902.

2. Schumann. A Study of Hydrops Universalis Fetus. Amer.
Jour. Obst., 1915, vol. Ixxii, No. 6.

47 East Fifty-eighth Street.

A CASE OF CARCINOMA OF THE CECUM IN A GIRL
TWENTY-THREE YEARS OF AGE.

BY
JOSEPH RILUS E.\STMAX, M. D.,

Indianapolis, Indiana.
(With three illustrations.)

Changes in the organism which are due to age are usually consid-
ered among the etiologic factors in carcinoma. It is well known
that cancer may appear at birth or during early youth, yet the defi-
nite relationship of malignant proliferating processes to mature age
justify the common view that carcinoma is a disease of advanced
life. Schmidt of Innsbruck(i) remarks that this is a peculiarity
which does not apply to a single one of the many known infectious
processes and therefore serves as another argument against the para-
sitic theory of cancer.

It is interesting to study the gradual changing of opinion regarding
the relation of age to cancer. Writers of a few generations ago while
they recognized the greater frequency of cancer in the years of
advanced maturity found a surprisingly large proportion of malig-
nant neoplasms in youthful persons. Thus, si.xty years ago, Walshe
in 772 cases, including cancers of all kinds, found that seventy-eight
of these occurred in individuals between twenty and thirty years
of age, and Paget's oft-quoted table pretends to show that the ratio
of cancer between the years of twenty and thirty to cancer at all ages
is as one to twenty-five (circa).

EASTMAN: A CASE OF CARCINOMA OF THE CECUM 381

Paget's book on surgical pathology was written in i860 and
although he himself makes rather clear distinction between malig-
nant fibrous tumors with elongated caudate or oat-shaped cells and
tendency to local recurrence on the one hand and malignant epithe-
lial growths on the other, it is safe to say that not all of those who
contributed to his statistics were able to make the same differentia-
tions, confounding in all probability the sarcoma of youthful persons
with carcinoma. Twenty-five years later when the histologic dis-
tinctions between sarcoma and carcinoma had become generally
known, Struempell averred that "Darmkrebse kommen vorzugs-
weise wenn nicht ausnahmslos im hoheren Alter vor."

A little later, 1895, Tillmanns spoke of carcinoma of the intestine
as essentially a disease of advanced life. In the last two decades
when careful microscopical examination of all neoplasms has come
to be the rule in all clinics, it has been observed that although car-
cinoma must still be looked upon as a disease of mature age, never-
theless extreme youth does not preclude the possibility of cancer, for
example of the intestines, even in children.

Garrod (quoted by Levings in his book on tumors) reported a case
of carcinoma of the sigmoid in a girl of twelve and Czerny a similar
case at thirteen.

Nothnagel observed a carcinoma of the cecum in a boy of twelve
and Schoning, two cases of rectal carcinoma in girls seventeen and
eighteen years of age. Levings resected the rectum in a girl of
twenty-two for carcinoma and quotes Clas as having noted a simi-
lar case in a boy aged three years, but unfortunately he gives no
references.

The theory of Thiersch, who presupposes a disturbance of the
equilibrium between epithelium and connective tissue as a predis-
posing factor in the etiology of carcinoma, is based upon his view of
the unequally rapid aging of these two different tissues. Schmidt
assumes "that in more advanced age, under the influence of local
circulatory disturbance, cell-complexes may at times degenerate,
thereby losing their higher characteristic properties, instead of which
there comes to the fore, unhindered, a tendency — corresponding to
an elementary function — to multiply." Long-continued alterations
in the metabolic processes are probablj- also related to the gene-
sis of carcinoma.

Concerning the origin of carcinoma of the large intestine, Rib-
bert(2) denies the possibility of the development of cancer in normal
mucous membrane. Such malignant epithelial neoplasms always
arise in a mucous membrane: (a) changed by polypoid growth, or

382 EASTMAN: A CASE OF CARCINOMA OF THE CECUM

(6) in areas altered by inflammation, or (c) from detached epithelial
rests.

Wechselmann emphasizes the important relationship of polyposis
of the colon to carcinoma. Verse, quoted by Ribbert (ibid.),
found twenty-two cases of polyposis of the colon associated with
carcinoma. He observed, however, two additional cases in which
polyps were in the colon while the carcinoma was in the small intes-
tine. Others, including Quenu, Landel, Tanberg and Hart have
found polyposis in association with carcinoma.

Cancer of the cecum in a girl of twenty-three is of interest not
merely because of the academic fact of the rarity of the condition
alone but also for practical reasons concerning diagnosis and treat-
ment because of the possible confusion in differential diagnosis owing
to the prejudice against the assumption of the presence of carcinoma
in one so young.

author's case.

Family History. — There had been no dyscrasias in the family, no
malignant neoplasms, no lues, and tuberculosis. Both parents
are living. A younger sister had passed through a severe attack of
appendicitis with abscess formation and spontaneous rupture into
the bowel; apparent recovery without operation.

Personal History. — Patient had always enjoyed average health but
had always been slender with somewhat subnormal musculature.
She had escaped the severer infectious diseases of childhood. She
was a stomach weakling and accustomed to take only easily digest-
ible food.

History of Present Ulness. — Patient had suffered for about six weeks
with what had been diagnosticated chronic appendicitis. Anorexia
and nausea had been present and considerable ditTiculty had been
experienced in preventing fecal stagnation. The temperature had
hovered at about loo and the pulse about no. There had been a
lo.ss in weight of about 5 kilograms. On two occasions, one about
ten days before operation and the other two days before operation,
fresh blood was discharged by the bowel.

Status Prasens. — Patient was pale. The musculature was flabby;
the tongue was coated and the breath offensive, the temperature 99
and the pulse no, respirations normal. There was a tender mass at
the site of the cecum. It was found by palpation over the thin
abdominal parietes to be rough and angulated and in size about 10
cm. in each dimension. It was movable.

Operation. — The aiidomen was opened by a right pararectal
incision and the tumor exposed. It extended upward from the
ileocecal valve on the inner side of the ascending colon. There was
no involvement of lymph nodes. It was considered that the growth
misjhl be a simple intlammaior\- tumor such as is not rare in the

EASTMAN': A CASE OF CARCINOMA OF THE CECUM

383

cecal wall. But what with the history of hemorrhage and the
angulated surface of the growth it was believed to be carcinoma,
therefore, the terminal ileum, the cecum and nearly all of the ascend-
ing colon were removed and an ileocolostomy made at the hepatic
flexure.

Gross Appearance of Tumor. — The appearance of the neoplasm
in the gross after being split suggested carcinoma in so much as it
was nonencapsulated and intiltrating in character and quite hard.
Enlarged lymph nodes were present.

EOCAECAL
LVE

LUMEN OF ILEUM

Fig. I. — Diagram showing location of infiltration ;
ascending colon.

:)\vth in wall of cecum and

Microscopical Examination. — Dr. H. R. Alburger, former Professor
of Pathology in the Indiana University School of Medicine, reported
the following: "The cecal wall is densely infiltrated with a new growth
of apparently epithelial origin which is invading the connective
tissue and even the postperitoneal fat. The growth consists of large
irregular cells without appreciable intercellular substance arranged
in irregular columns with conspicuous endothelial lined spaces
between them. The cells have round, oval and irregular nuclei,
many of which are vesicular. Some contain included cells of
lymphoid type and there is a dense peripheral infiltration of lym-
phocytes about the areas invaded. The picture is one which so
closely reproduces that seen in carcinoma of the mammary gland

384 EASTMAN: A CASE OF CARCINOMA OF THE CECUM

that we are of the opinion that the cells are of epithelial rather than
endothelial origin. Diagnosis: Carcinoma of the cecum.

Dr. V. H. Moon, Professor of Pathology in the Indiana University
School of Medicine, also made sections of the tumor and states that
it is unquestionably carcinoma.

The gross specimen was sent to Dr. Joseph Colt Bloodgood of
Johns Hopkins University who reports as follows:

Fig. 2. — Lmv-ptjwcr photomicrograph of neoplasm shown in Fig. i, 2^ obj.
(Shapiro, Baltimore).

Microscopic Study:

Section I. — Tumor. Alveoli of cells of the glandular type.
Size of alveoli vary. Almost everywhere these grandular cells are
producing mucoid or colloid material. The tumor beneath the
cells has intiltration of lymphoid cells of various types. Diagnosis,
colloid cancer.

Section II. — ^Adjacent gland, which in the gross seemed to be
involved. This shows that this gland has at one side an area of
colloid cancer.

EASTMAN: A CASE OF CARCIXOMA OF THE CECUM

385

Section III. — Gland near tumor, in the gross apparently involved.
Under microscope, no evidence of cancer.

Section IV. — Glands at some distance from tumor in cecum.
No evidence of metastasis.

Section V. — -Described as a polyp-like mass at the base of the
tumor. This shows colloid cancer and a bit of mucous membrane
of the cecum. The mucous gland is slightly hj'pertrophied and
shows the tumor had broken through mucous membrane.

Section VI. — Base of appendix — shows walls slightly thickened,
no infiltration with cancer.

Fig. 3. — High power photomicrograph m . .11 1 in. ma of cecum and ascending
colon, fg obj. (.Shapiro, iiallimore).

Section VII. — From tumor showing necrotic areas. This sec-
tion is similar to Section I and in addition we see on the surface of
the tumor mucous membrane with hypertrophied mucous glands.
The areas of necrosis are apparently areas of the tumor in which
the cancer cells have disappeared, leaving a slightly eosin staining
connective tissue with here and there lymphosites. Apparently
this is an indication of nature's attempt at the distribution of the
tumor cells we frequently find in colloid cancer but apparently it
was never able to destroy the entire renter.

The tumor itself had various differential staining. The Mallory's

386 sturmdorf: congenital and acquired retropositions

stain shows that the connective tissue is rather scanty and the
tumor is very cellular.

The Van Gieson's Stain. — The stroma stains red and the cells
rather brown. This brings out the structure better than eosin and
hemoto.xylin, but does not show the colloid material as well.

The Safranin Stain. — The differentiation is not as distinct. The
colloid does not take the stain.

With iron and hemotoxylin we also get a good differentiation.
These sections show numerous areas in whicli the cancer cells have
disappeared.

Postoperative History. — The operation was made on October 12,
191 5, since which time there has been no clinical evidence of recur-
rence. There are no symptoms of obstruction, no tumor is palpable.
The patient has gained steadily in weight.

references.

1. Schmidt, Diagnosis of the Malignant Tumors. Rebman,
N. Y., 191,5.

2. Ribbert, Das Karzinom des Menschen.

CONGENIT.\L AND ACQUIRED RETROPOSITIONS OF

THE UTERUS: THEIR DIFFERENTIATION AND

RELATIVE SIGNIFICANCE.*

.VRNOLD STURMDORF, M. D., Y. \. C. S.,

Clinical Professor of Gynecology, N. Y. Polyclinic Medical School and Hospital;
Associate Surgeon "Woman's Hospital, New York,

New York City.

(With seven illustrations.)

Approximately 18 per cent, of all gynecological patients present
a retrodisplaced uterus.

Barbour and Watson estimate one fifth of this number as con-
genital in origin, qualifying their statement however by admitting
that: ''It is difficult to estabhsh the congenital nature of these
cases, but should a uterus be found retroverted in a nuUiparous
patient, without any history of inflammation or other cause suffi-
cient to produce retroversion, should it measure only 2.12 inches
by sound and on being replaced show a tendency to resume its
retroverted poise, we are justified in assuming that it has developed
in that position."

These admittedly vague dilTerciUial criu-ria. eml)od\- in their

* Presented hoforc the Gynecological Section, X. V. .\cadomy of Medicine,
.-\pril ^5, 1016.

sturmdorf: congenital and acquired retropositions 387

very paucity, the crux of the cHnical problem presented bv uterine
displacements in general to-day.

In the first place, a retrodeviated uterus, whether in a nulli-
parous or multiparous patient, "without evidence of inflammation
or other cause sufficient to produce the displacement," would be
classified according to prevailing clinical custom as a simple or
uncomplicated malposition, regardless of its probable congenital
nature.

Such classification has a most significant therapeutic bearing, for,
accepting the axiomatic postulate, that all uncomplicated uterine
retrodisplacements are devoid of symptoms or clinical significance,
it follows, that to differentiate the congenital from the acquired
retrodisplacements, is to exclude any attempt at correction of the
displacement as such in over one-fifth of the cases.

On the other hand, a congenitally retrodisplaced uterus is not
necessarily "nulliparous," nor immune to — "inflammatory and
other complications capable of producing retroversion," it may,
like any other uterus, measure more than "2^^ inches by sound,"
so that the congenital origin of its retroposition must be established
through existing pathognomonic factors, that are constant and
remain unaltered by complicating elements which tend to efface the
characterizing syndrome formulated by Barbour and Watson.

As a matter of fact, it is that very class of patients, with their
congenital deviations obscured by superposed parturitional and
infectious complications, in which dift"erentiation is most essential.

In seeking to establish such a constant pathognomonic factor,
it is necessary to recognize, that the malposition does not represent
simply a congenital uterine retroversion, but a congenital retro-

388 sturmdorf: congenital and acquired retropositions

version of the entire pelvis, with resultant compensatory dystopia
of its contents.

Dickinson and Truslow characterize the general skeletal poise
of these cases as "the Gorilla type," in which — -"the pelvis is
rolled or rotated backward and downward, the plane of its inlet

Fig. 2. — ^The depth of the lumbar hollow presents the relative measure of the
sacrovertebral angle, and the degree oi sacrovertebral angulation determines
the dip of the pelvis.

making with the horizon an angle more acute than that of the
normal type."'

In other words, with normal spinal contours, the axes of the
abdominal and pelvic cavities form almost a right angle, while
in the stature under consideration, there is a marked flattening of
the sacrovertebral angle, resulting in an approximation of these
axes toward the vertical, so that the thrust of intraabdominal
pressure is expended in a more direct line on the pelvic viscera.

sturmdorf: congenital and acquired retropositions 389

This flattening of the sacrovertebral angle, is regularly evidenced
by a corresponding obliteration of the normal lumbar curve and the
measure of its resultant approximation to the vertical, constitutes
a pathognomonic index in differentiating congenital from acquired
retrodisplacements of the uterus.

To obtain this measure, the patient with back exposed, assumes
her natural standing attitude, while the edge of an ordinary 18-
inch desk ruler, held vertically in contact with the most prominent
spinous processes of the dorsal and sacral convexities, spans the
intervening lumbar hollow.

The distance in millimeters, from the deepest point of this hollow
to the edge of the ruler presents our index.

The spinous processes of the dorsal and sacral convexities, are
invariably and distinctly palpable under all degrees of adiposity
and statural deviations, while the extreme simplicity of the method
and means enables any one to substantiate the uniform accuracy
of the index and elicit the significance and indications of its clinical
bearings.

In an extensive series of observations, the index ranged from
12 to 45 millimeters: an excess of 45 millimeters indicates patho-
logical lordosis, a condition the opposite to that under consideration,
of more obstetric and less gynecological importance.

An index of 30 millimeters, marks the extreme minimum
compatible with normal anleversion of the uterus: from 25
milUmeters down, the existence of congenital retroversion, may be
positively predicated in nearly every case prior to its bimanual verifica-
tion and this, regardless of midtiparity and the other complicating
factors that obliterate the differentiating criteria formulated by Barbour
and Watson.

A uterus congenitally retroverted before conception, will in-
variably resume its retroverted position after delivery, when the
demonstration of a minus index will reveal the congenital nature
of the displacement to the exoneration of the accoucheur.

The application of the lumbar index will establish over one-
half of all retroversions, complicated and uncomplicated as con-
genital, instead of one-fifth as hitherto accepted.

The rare exceptions to the rule will, on closer investigation,
reveal an exostosis of the sacral promontory; a recession of the
pubes which foreshortens the conjugate diameter; a strained and
deceptive pose assumed by the patient during measurement or an
acquired anteversion from pathological concomitants: for it is
only reasonable to suppose, that, just as a normally poised uterus

390 sturmdorf: congenital and acquired retropositions

may become retroverted, so a congenitally retroverted one may
become anteverted without invalidating the utiUty of the index.

It must be emphasized, that congenital retroversion as such,
is essentially only a part of a compensatory adaptation of the
pelvic contents, to abnormal static conditions through unstable
spinal poise; that the depth of the lumbar hollow is the relative
measure of the sacrovertebral angle; that the degree of sacro-
vertebral angulation determines the dip of the pelvis and that
a certain degree of such pelvic dip is essential to the normal topog-
raphy of its contents.

It is a fundamental law in dynamics, that the direction of a given
force or body impelled Ijy such force, impinging against a resistant

Fig. 3. — In an abdominal cavity of normal skeletal configuration a true ver-
tical in contact with the sacrolumbar angulation will impinge against the inner
face of the symphysis pubis at its lower border. This vertical represents the
initial direction of intraabdominal pressure at the pelvic brim.

plane, becomes deflected in a fi.xed and definite manner, the degree
of deflection being governed by the angle of the resisting plane.

This law finds familiar exemplification in the mechanism of
labor, when the initial direction of the expulsive force becomes
deflected by the pelvic planes, impelling the fetus through the
devious axes of the parturient channel.

The same law governs in establishing and maintaining visceral
equilibrium against the displacing force of gravity and intra-
abdominal pressure; but for the influence of deflecting planes,
every erect biped would prolapse his abdominal contents into
the pelvis from whic ii they must eventually extrude.

sturmdorf: congenital and acquired retropositions 391

In an abdominal cavity of normal skeletal configuration, a
true vertical, in contact with the sacrovertebral promontory,
will impinge against the inner face of the symphysis pubes at
its lower border, the sacrovertebral promontory is situated 3)^
inches above the svmphysis. so that, the vertical line representing

Fig. 4 — Upward and backward rotation of the pelvis elevates the pubes and
lowers the sacrum, which latter thus forms the posterior instead of the upper
wall of the pelvic cavity, altering the direction of the sacro-uterine ligaments —
their horizontal pull tending to hold the uterus backward instead of suspending
it from above.

the initial direction of intraabdominal pressure at the pelvic brim,
passes over and not into the pelvic cavity.

In other words, the posterior abdominal wall terminating at
the sacrovertebral angle is 3^^ inches shorter than the anterior,
which ends at the symphysis pubes; dynamically the pelvic cavity
thus presents a separate communicating chamber or elbow, hollowed
out of the posterior abdominal wall, with the sacrum as an inclined

392 sturmdorf: congenital and acquired retropositions

roof, from which the uterus is suspended by its sacrouterine
ligaments. The inchned sacral surface deflects intraabdominal
pressure, just as it deflects the presenting fetal pole during labor.
Omitting all further consideration of the reciprocal and har-
monious deflections exercised by the pelvic floor musculature,
and the uterus with its ligamentous e.xtensions, the details of which
are fully elaborated in my previous publications, it will suflice here
to state, that normal deflection reduces an intraabdominal pressure
of 80 millimeters at the pelvic brim, to 60 millimeters at the
cervix, 40 millimeters in the vagina and 20 millimeters at the vuh-ar

wl!«^^^v

Normal or neutral type of posture. Distinguishing features are: (i) line of gravity of
body passes through important pivotal points; C2I the pelvis is balanced in equilbruim on
the heads of the thigh bones; (3) this relation of important pivotal points with the line of
gravity and this balance of the pelvis prevents muscle and ligament strains, and (4) the
rear perpendicular touches the middle back and the buttocks.

Fig. 5. — Modified from Dickinson and Truslow.

outlet: the resultant intrapclvic pressure thus resembles a placid
pool at the edge of a whirling current.

G. H. Noble corroborates these lindings and Dr. J. R. GotTe
states that: "It was not till I read Dr. Sturmdorf 's paper, that I
realized the wide application of the principle of deflecting planes
both as a retentive and expulsive clement."

Accepting the principle of deflection as fundamentally applicable
to our problem, it follows, that every deviation from the normal in
the angle of the deflecting surfaces presented by the symphysis and
sacrum, must induce a corresponding deviation in the direction of

sturmdorf: congenital and acquired retropositions 393

intraabdominal pressure with resulting visceral displacement or,
to put it tersely, every abnormal pelvic tilt must create a corre-
spondingly abnormal uterine tilt.

A flat sacrolumbar angle with vertical pelvis is normal in early
childhood, but abnormal in the adult.

If an infant be placed on its back and its legs be drawn down
from their habitual attitude of semiflexion, it will be noticed, that
the range of extension is limited by the absence of the lumbar curve
and pehic incline: when gain in muscular development enables the

A. — Kangaroo type of posture. Distinguishing features are; (l) Most pivotal structures
of the trunk are carried in front of and those of the lower extremities behind the line of
gravity; (2) the pelvis rotates forward downward; (3) the forward carried trunk puts strain
on the spinal and pelvospinal ligaments and muscles and tends toward forward displacement
of abdominal and pelvis viscera. Wavy lines indicate muscles relaxed, double lines show
muscles in action.

B. — Gorilla type of posture. Distinguishing features are: (il Most of the pivotal
structures of the trunk are carried back of and those of the lower extremities in front of
the line of gravity: t2' the pelvis rotates backward downward: (3) the backward carried
trunk puts its own variety of strain on the spinal and pelvospinal ligaments and muscles
and tends toward backward and downward displacement of the abdominal and pelvic
viscera. Wavy lines indicate muscles relaxed; double lines, those in action.

Fig. 6. — Modified from Dickinson and Truslow.

infant to stand, the erector spinas draws tlie trunk upward against
the resistance of the iliopsoas group and ligaments of the hip-joint,
bending the lumbar spine into its physiological curve.

In other words, under normal development, the erect attitude is
attained by flexure of the lumbar spine, the pelvis maintaining an
inchne of sixty to sixty-five degrees, the tip of tlie coccyx being on a
level with the lower border of the symphysis pubes: under abnormal
developmental conditions, the upright pose is induced principally

394 sturmdorf: congenital and acquired retropositions

by an upward and backward rotation of the pelvis on the hip-joints,
carrying the axis of its inlet toward a vertical from a horizontal
line.

In such a vertical pelvis, the only tenalile position for the uterus
is one of retroversion.

The upward and backward rotation of the pelvis, elevates the
pubes and lowers the sacrum, which latter, thus forming the posterior
instead of the upper wall of the pelvic cavity, necessarily alters the
mechanism of the sacrouterine ligaments, their horizontal pull
tending to hold the uterus backward against the depressed sacrum,

Fig. 7. — The edge of an eighteen inch ruler heUl vertically in contact with
the most prominent spinous processes of the dorsal and sacral convexities spans
the lumbar hollow. The distance in millimeters from the deepest point of the
hollow to the edge of the ruler presents the "lumbar index".

instead of suspending it from above as in the normal. Further-
more, intraabdominal pressure, inadequately deflected, thrusts the
loose intestinal coils into the pelvic cavity and against the anterior
surface of the uterus, crowding it into the space of least resistance
offered by the sacral hollow.

The whole clinical import of congenital retroversions is centered
in their intra- and extrapelvic complications, not in the uterine
displacement as such.

The continuous attitudinal strain on the sacroiliac joints, the

sturmdorf: congenital and acquired retropositions 395

erector spiniE and iliopsoas muscles, induces pelvic symptoms, that
simulate and are generally attributed to the retroversion.

Operative gynecology to date, records over one hundred detailed
methods for the correction of uterine retrodisplacements, every one
of these methods, at the hands of its promulgator, will undoubtedly
convert the retroposed into an anteroposed uterus; but notwith-
standing their faultless uterine poise, many of these patients will
continue to suffer as before operation — and some more so.

Baldy states: "In my opinion nine-tenths of the operations
performed on women for retrodisplacements are uncalled for — ■
and further, the possible number of retrodisplacement operations
performed in this country is limited only by the number of females
in existence."

We have already stated, that congenital retroversion is a com-
pensatory necessity and it follows that any procedure, which con-
verts such a retroversion into an anteversion, converts a compen-
sated into a decompensated visceral equilibrium within the pelvic
cavity.

Clinically, the lumbar index will reveal two classes of congenital
retrodisplacements, namely — the complicated and the uncompli-
cated.

Leaving the retroversion as such unmolested, the g3-necologist
should aim to eradicate all coexisting intrapelvic complications,
thus converting the complicated into an uncomplicated case.

It cannot be overemphasized, that patients with uncomplicated
congenital retroversion, suffer through a constant attitudinal strain
in maintaining their unstable skeletal poise within the lines of
gravity, the congenital retrodisplacement of the uterus, in contrast
to the acquired form, being an accompaniment and not a cause of
the suffering.

These cases must be treated on purely mechanical and orthopedic
principles, the details of which find full elaboration in the appended
literature; during and complemental to the general orthopedic
measures, a properly molded pessary, inserted — not with the object
of anteverting the uterus, but to act as an artificial ledge at the
deficient sacral promontory in the deflection of intraabdominal
pressure — will afford much relief during the necessarily prolonged
period of mechanical treatment.

Our fundamental conceptions of uterine poise, normal and
abnormal, have not as yet attained to any concrete finality and
barring the occasional allusion to the existence of congenital retro-
displacements and their probable dependence upon conditions of

396 sturmdorf: congenital and acquired retropositioxs

general visceroptosis, the clinical significance of such displacements,
and their diagnostic, etiologic and therapeutic contrast to the
acquired form, find no elucidation in the literature of the subject.

The wide diversity in the nature of the two conditions, presenting
practically identical symptoms, demands their clinical differentia-
tion— such differentiation necessitates a differentiating factor of
pathognomonic constancy.

I know of none that fulfills this essential requirement, aside of the
lumbar inde.x depicted above, which, for its simplicity, facility and
appro.ximate accuracy, should constitute a routine part of every
gynecological examination.

51 West Seventy-fourth Street.

REPEREXCES.

Barbour and Watson. Gynecological Diagnosis and Pathology.
Edinburgh, 1913.

Dickinson, Robert L. and Truslow, Walter. Averages in Attitude
and Trunk Development in Women and Their Relation to Pain.
Jour. Am. Med. Assoc, vol. lix, 1912, p. 413.

Sturmdorf, Arnold. Perineum, Perineorrhaphy and Prolapse.
Med. Record, X. Y., April, i, 1905.

Sturmdorf, Arnold. Observations on Nephroptosis and Nephro-
pexy. A'. Y . Med. Record, Jan. 13, 1906.

Sturmdorf, Arnold. Perineorrhaphy in Principle and in Practice.
Amer. Jour. Obst., vol. Ixvi, No. 3, 191 2.

Noble, G. H. Intraabdominal Dynamics and ^Mechanical
Principles involved in the Cause of Backward and Downward
Displacements of the Uterus. Surgery, Gynec. and Obstet., vol. xx.
No. I, 1915.

Goffe, J. Riddle. Intraabdominal Pressure. Trans. .Imcr. Med.
Assoc, June, 1912.

Baldy, J. Montgomery. The Surgical Treatment of Retroversion
of the Uterus. Sitrjj., Gynec. and Obstet., vol. xx, 1915.

Goklthwaite J. E. The Relation of Posture to Human Effi-
ciency and the Influence of Poi.se on the Support and Function of
the Viscera. Boston Med. and Surg. Joitrn., Dec. 9, 1909.

Reynolds, Edward and Lovett, R. W. An E.xperimental Study
of Certain Phases of Chronic Backache. Journ. Am. Med. Assoc.
March 26, 1910.

Reynolds, Edward. The Etiology of the Ptoses and Their Rela-
tion to Neurasthenia. Journ. Amer. Med. Assoc, Dec. 3, 1910.

Smith, R. R. Enteroptosis with Special Reference to its Etiology
and Development. Journ. Amer. Med. Assoc, Nov. 26, 1910.

ADACHI: AN INTERESTING CASE OF SYNCYTIOMA MALIGNUM 397

AN INTERESTING CASE OF SYNCYTIOMA IVLALIGNUM.

BY
KENJI ADACHI, M. D.,

Assistant in the Gynecological Clinic of the University of Kyushu. Japan.
(With four illustrations.)

Mrs. T. I., forty-five years of age, father died of cancer of the
stomach, mother still living and in good health.

History. — Puberty at eighteen; menstruation very regular, lasting
one week, considerable quantity with no pain. Marriage at eighteen.
Three pregnancies, all normal. One abortion at three months,
about two years ago. The last menstruation unknown.

History of Present Illness. — About one year ago from no account-
able cause a considerable hemorrhage occurred, accompanied by pain
in the abdomen and extending into the right lower limb. These
hemorrhages continued through the year, lasting for a period of one
month each, with an interval of twenty days between. As the hem-
orrhage increased, the patient was curetted at a certain hospital
with no effect, and was then brought to the clinic.

Status. — The patient was thin and anemic, no change in the lungs,
the heart showed no other abnormal signs than an anemic souffle. The
liver was not palpable, and the kidneys not enlarged. The vaginal
examination showed that the uterus was retroverted and at the
right side, but entirelv isolated, a tumor the size of a goose-egg was
felt.

The surface of the tumor was rough and showed pulsation.
Applying the stethoscope to this part of abdominal wall a high
souffle was audible. The parametrium of the same side was a little
infiltrated. The uterus was normal size and had no extraordinary
signs.

Diagnosis. — Suspecting that the tumor might be an aneurysm of
the iliac vessels or sarcoma ovarii (which has abundant vessels)
the patient was accepted in the clinic. As the tumor increased in
size the debility increased in proportion. When pressed upon the
pain extended into both the lower limbs and the anal region. Patient
daily lost appetite and became unable to sleep, and at the last
greatly emaciated. Death shortly followed. The topographical
necropsy showed that the tumor adhered closely to the bowel and
the soft parts of the right pelvic wall. The tumor with all the
internal genitals taken out is shown in the figure given below.

Specimen. — The tumor is ovoid and the size of a child's head,
located right behind the uterus and the surface rough.

From the anatomical relations it is evident that the right ovary
itself became a part of the tumor, because the ovary of that side is
nowhere to be found.

398 ADACHi: AN INTERESTING CASE OF SYNCYTIOMA MALIGNUM

The tumor mass substitutes about half of the right uterus wall.
Upon closer investigation the knots mentioned below extend to the
tumor substance itself. The tumor has a thin capsule which, in
places, can be stripped off easily. On cutting, the cut surface is
mottled red and brown. The tumor is nearly solid, but has numer-
ous cystic spaces of different sizes containing coagulated blood.
The tissue itself is very brittle. The tube belonging to the right
ovary extends over the tumor, and is very much enlarged, i6 cm. in
length, and occluded, but not densely adhered to the tumor. The
fimbria have no remarkable changes except a little edema. The
appendages of the other side are not at all changed, not occluded.

Uterus. — A little enlarged, normal shaped and consistent except
where substituted with tumor masses, but on the cut surface of the

. Fig. I. — Showing relation of tumor to uterus and tubes.

median line we see in the upper part of the posterior wall two ovoid
pea-sized knots, close to each other. One is relatively white, the
other a dirty gray color. Likewise in the upper part of the ante-
rior wall are two very small white-colored knots close to each other.
The distance of the former knots from the top of the cavum uteri is
about I cm. (the entire thickness of the posterior wall 1.8 cm.). The
distance of the latter knots from the same place is about i cm. (the
entire thickness of the anterior wall 1.6 cm.). Mucosa uteri shows
no macroscopical changes. In the anterior lip of the cervix a knot
the size of a pea is found in the submucous layer. The mucous
membrane jusl above the knot is slightly brown in color. Otherwise
no considerable changes. The vagina shows no peculiarities.

Microscopic E.vaminalion. — (i) Tiimor.-Thc capsule of the tumor
is very thin and consists of parallel connective-tissue fibers. The

ADACHi: AN INTERESTING CASE OF SYNCYTIOMA MALIGNUM 399

capsule sends a few thin strands of connective tissue into the sub-
stance of the tumor, but they are very slender and are lost almost
immediately below the surface. A great number of blood-vessels
are seen in this connective tissue and are filled with fresh blood.
The greater part of the tumor consists of coagulated blood. No
healthy ovarian tissue is to be found. Tumor elements are syncytial
masses and Langhans's cells. The areas between the groups of
tumor cells are occupied with degenerated protoplasmic masses,
fibrin and polymorphonuclear leukocytes. Many veins are stopped
with tumor cells. The typical syncytial masses and Langhans's
cells, the extensive hemorrhages and necrotic areas left no doubt
about the diagnosis Chorioe pithelioma malignum.

Fig. 2. — A. Cut surface of the tumor. B. Cut surface of the uterus.

(2) Tube. — E.xtending over the tumor. Blocks taken from several
parts are free from tumor or other remarkable pathological condi-
tions, except the extensive and intensive infiltration of leukocytes.
No decidual reaction.

(3) Appendages of the Other Side. — No pathological findings.

(4) Uterus. — The knots in the muscle tissue show the same micro-
scopical appearances, except that in the necrotic parts there are seen
some capillary vessels and fibroblasts. Some of the smaller veins are
stopped with tumor elements. The mucosa uteri shows no patho-
logical signs, no decidual reactions.

From the above mentioned facts I think the syncytial knots in the
uterine wall are primary, from which the tumor was formed. The
tumor elements were transported from the interstitial knots through

400 ADACHI: AX INTERESTING CASE OF SYNCYTIOiL\ MALIGN'Uil

the vessels (these are stopped with tumor cells and lead to the tumor)
into the vein plexus of the right parametrium. It is conceivable
that in this network of vessels the elements of the tumor might be
caught very easily and here propagate. And at the same time the
tumor elements may have been transported to the right ovary and
the ovarian tumor formed. As above mentioned the tumor was, in

the beginning of the clinical course, right behind the uterus, entirely
isolated, the size of a goose egg, and the parametrium of the same
side a little infiltrated. So the transported tumor cells in the two
different parts (in the vein ple.xus and the ovary) were gradually
propagated and finally melted into each other making a definite
tumor.

lavake: action of high carbohydrate diet and oxygen 401

NOTES ON THE PROTECTIVE ACTION OF HIGH CARBO-
HYDRATE DIET AND OXYGEN UPON THE LIVER
CELLS IN EXPERIMENT.AL CHLOROFORM
POISONING, WITH ITS POSSIBLE
APPLICATION IN PREECLAMPTIC
TOXEMIA.*

BY
RAE THORNTON LAVAKE, M. D.,

Instructor in Obstetrics and Gynecology, University of Minnesota,
Minneapolis, Min.
(With eleven illustrations.)

It has been known for many years that chloroform poisoning
produces a lesion of the liver similar to that found in certain cases
of eclampsia. In 1909 Howland and Richards produced this typical
lesion in dogs. The lesion consists primarily of a central necrosis
of the liver lobule with a fatty degeneration extending with dimin-
ishing intensity toward the periphery of the lobule. So similar was
this lesion to that found in certain cases of eclampsia that Cragin
and Hull felt that the administration of chloroform to patients
suffering from pre-eclamptic toxemia or eclampsia might aggravate
the possibly existing liver lesion. Dr. Cragin guided by this supposi-
tion found that under the use of chloroform in deUvering toxemic
women at the Sloane Hospital for Women, New York City, there
were fifty cases of eclampsia in 5264 deliveries whereas under the use
of ether there were fifty cases in 6863 deliveries, "suggesting at least
the possibiHty that chloroform in some cases so increased the hver
lesion as to increase the number of those having convulsions. The
mortality with chloroform used was 30 per cent, as against a 12 per
cent, mortality with the use of ether.

The central position of this lesion has always seemed remarkable
and has raised the insistent question, why should the central cells
show change before the peripheral? In fact if the toxic substance
enters the lobule by way of the portal vein and the hepatic artery
why should not the first cells attacked be the first cells to show

* From the laboratory of the department of Obstetrics and Gynecology
University of Minnesota. Read before the Minnesota Pathological Society,
March 21, igi6.

402 lavake: action of high carbohydrate diet and oxygen

change? If the cells making up the liver cords are similar structur-
ally and functionally at the center and at the periphery of the lobule
then to account for the central change we must postulate that some
change takes in the blood in its sinusoidal passage from the periph-
ery to the center of the lobule which so influences the central cells
as to render them more vulnerable to the attacking toxic substance.
From a broad chemicophysiological standpoint the most probable
changes would be a diminution in oxygen and carbohydrate content.
If the diminution in oxygen and carbohydrate content could render
the central cells more vulnerable to attack the therapeutic value of
o.xygen and carbohydrate administration naturally suggests itself.

With this inference in view, before laying out my experiments
I reviewed the literature of experimental chloroform poisoning and
found that Opie and Alford in the Journal of the American Medical
Association, March 21, 19 14 has published a work which seemed to
bear out this theory so far as the carbohydrates were concerned.
Opie and Alford showed that if rats were given a dose of chloroform
known to produce the typical liver lesion and death, if one group
were placed upon a high carbohydrate diet, another on a high proteid
diet, and a third on a fat diet, the average length of life of the
animals of the carbohydrate group was four and two-third days,
the proteid group three days and the fat group one and four-fifth
days. Microscopic examination of the livers of those having
received the carbohydrate-high diet, in this case oatmeal and cane
sugar, showed a central lesion of one-fourth to one-third the total
radius of the lobule, whereas the livers of the animals having
received meat and fat showed as much as four-fifth degeneration.
This suggested to them the protective action of carbohydrates and
they considered that carbohydrates might be found to influence
favorably the course of the pathological conditions caused by chloro-
form and pregnancy whereas fat might cause grave trouble. In
another series of experiments they showed that carbohydrates and
proteids were more protective than carbohydrates and fats.

I have repeated the experiments of Opie and Alford following
their outline as nearly as possible and although varying .'^lightly
in results, no doubt because of shght variance in chloroform dosage,
diet and general conditions, the results were practically the same.

Twelve rats were used: four suet-fed, four meat-fed, four oatmeal
and cane sugar. IMixture of one part chloroform and two parts
petroleum liq., administered to rats subcutaneously. Dosage i c.c.
to every 100 gm. in weight. Suet-fed rats died in average of two
and two-third da\s. Onl\- one of the meat-fed rats died. .AH

lavake: action of high carbohydrate diet and oxygen 403

of the oatmeal and cane-sugar rats lived. General appearance and
actions of the oatmeal- and sugar-fed rats better than meat and fat-
fed rats. This difference was most markedly appjarent between the
oatmeal- and sugar-fed rats and the fat-fed rats.

Comparison of the livers of the rats that died showed about
same extent of necrosis, namely, one-half of the lobule. Two con-
trols on a high carbohydrate diet showed slightly less necrosis but
not as appreciable as in the experiments of Opie and Alford, but the
higher percentage of carbohydrate rats living would lead one to
postulate a less severe lesion. At the end of fourteen days I com-
pared the hvers of the surviving rats and found no central necrosis.
Complete regeneration had taken place. Whipple and Sparry
showed this regeneration beautifully in their article appearing in the
Johns Hopkins Bulletin, igog.

One rat fed on cane sugar alone died on the fifteenth day and
showed no central necrosis. This rat survived the chloroform
poisoning but starved to death. The nitrogen equilibrium must
be maintained.

These experiments suggest the advisability of a diet high in
carbohydrates and low in fats and proteids but high enough in
proteid constituents to sustain nitrogen equilibrium.

Recognizing, but waiving until proved, the possible incorrectness
of the inference that a therapeutic protective of aid in chloroform
poisoning might prove of equal value in those cases of toxemia and
eclampsia sometimes known to display a similar lesion, this experi-
mental data would suggest the advisability of decreasing fats and
proteids in pre-eclamptic toxemia. A milk diet has been used most
widely but this is relatively high in fat and low in carbohydrate.
A diet of oatmeal sugar and whey appear to be more logical. Rice
might be used instead of oatmeal as having a lower fat and higher
carbohydrate content. Reid Hunt in his work upon "The Effects
of Restricted Diet and Various Diets upon the Resistance of Animals
lo Certain Poisons," points out by experiments, the great value of
rice. He gives the impression of favoring oatmeal as it may stimu-
late the activity of the thyroid gland with beneficial effects. This
theory of thyroid stimulation by an oatmeal diet was brought out
Ijy Watson. Thus Reid Hunt believes that from his experi-
ments and those of Watson it seems probable that it is possible to
influence in a specific manner by diet one of the most important
hormones in the body. The question as to whether the food would
affect the human organism as it does the animal must be left to
future study. Hunt believes that the probabilities are that it

404 lavake: action of high carbohydrate diet and oxygen

would. The possibility of thyroid insufficiency in the toxemia
of pregnancy has been cited by Nicholson, Lange and others.

Reid Hunt calls attention also to the great value of rice and oat-
meal in maintaining nitrogen equilibrium as found by Rubner.
In feeding these toxemic women the nitrogen equilibrium must be
considered. Thus with an oatmeal, sugar and whey diet we would
maintain the nitrogen equilibrium and increase the protective power
of the diet by a high carbohydrate and low fat content.

Permit me to cite a case, seen lately, as bearing upon the dietary
phase of the question. This patient had been advised not to eat
too many sweets during pregnancy. She had a flat pelvis and it
was thought that if there could be any relation between carbohydrate
ingestion and the weight of the child in this case the physician would
be on the right side. Toward the end of pregnancy, to satisfy a
voracious appetite, she drank large quantities of milk with the
addition of cream. Tliis woman developed a toxemia and had one
convulsion. From the standpoint of the above deductions from
experimental evidence this woman had been upon an incorrect
protective diet. Another phase of this same case was interesting
from the standpoint of possible hypothyroidism. During preg-
nancy this patient took on 23 pounds above the weight of the
child. After labor she returned to normal weight in a few
weeks. I have seen so much thyroid instabihty in Minnesota and
have seen so many cases comparatively speaking, develop here in
pregnancy that I wondered if her increase in weight could have
been a manifestation of hypothyroidism of mother and child. If
an oatmeal diet, according to Watson, will stimulate the thyroid
of young animals, might it not stimulate the thyroid activity of
both fetus and mother?

One finds that the theory accounting central liver pathology to
a difference between the blood at the center and at the periphery
of the lobule has been considered for years. Opie in his illuminat-
ing article upon "Zonal Necrosis of the Liver," published in 1904 in
the Journal of Medical Research, vol. xii, notes this explanation.
Before considering experimental data upon this point in chloro-
form poisoning permit me to recall conditions obtaining in the later
months of pregnancy. In these months we have increased pres-
sure on the diaphragm, increased demands for oxygen by the rapidly
growing fetus and also if there is any tendency to cardiac insufficiency
and stasis the central cells of the liver lobule would be the first to
sufifer from lack of o.xygen. It is suggestive that hydramnios and
twins seem to predispose to toxemia and eclampsia, also that

lavake: action of high carbohydrate diet and oxygen 405

Experiment i. — After administration of chloroform rat A was placed in a
cage in the fresh air. Rat B was allowed to suffocate under a large bell-jar.
Latter rat died in thirty-six hours, whereupon rat A was immediately kiUed and
the livers compared. The fresh-air rat shows less central necrosis and degenera-
tion and mitotic figures absent in the suffocated rat suggests more rapid regenera-
tion.

406 lavake: action of high carbohydrate diet and oxygen

eclampsia is more frequently seen in primipara than in multipara,
the former having previously unstretched abdominal walls with

Experiment

consequent increased pressure upon the diaphragm. That the
increased pressure may be assumed appears to be supported by
the earlier lighlcning in primipara. It is suggestive that the

lavake: action of hioh carbohydrate diet and oxygen 407

death of the child often reheves the toxemia, at least tem-
porarily. May it not be that at least three of the salutary effects
of delivery are: reUef of pressure on the diaphragm, throwing
the child upon its own mechanism for oxygenation, and the rehef
of venous stasis with a resulting freer oxygenation of the central
hver cells? If so, oxygen would be indicated in these cases. Pos-
sibly the treatment of pumping o.xygen into the udders of cows
suffering from milk fever, thought to be analogous to eclampsia in

Experiment 2. — Same as Experimenl i except that one-half the dose of chloro-
form was given and a control rat not having had a dose of chloroform was suffo-
cated under the same bell-jar with the chloroformed rat. When the latter rat
died in twenty-six hours his mate under the bell-jar was still lively though
breathing in a labored manner. Two remaining rats were immediately killed
and the ]i\ers of the three compared. The liver of the rat A not having had the
chloroform did not show a central necrosis. No change of any kind was seen.
The liver of the chloroformed and suffocated rat C showed more extensive
degeneration and necrosis than did that of rat B having fresh air.

women, may have the chemical basis of increased oxygen for hver
cells to sustain it. Stroganoff advocated the use of o.xygen in
eclampsia seemingly to attempt to counteract the evident cyanosis
during the convulsions. It may well be that one of the deadly
effects of the convulsions is the increase of hver-cell degeneration
caused by decreased oxygen content. In our desire to isolate
these eclamptics in quiet rooms we are not always careful about
proper ventilation. If deductions can be drawn from the following

408 lavake: action of high carbohydrate diet and oxygen

experiments I believe that the open-air treatment should obtain in
pre-eclamptic toxemia and eclampsia as in sepsis.

Experiment 3. — Rat A. Chloroiorm and Irtsh air. Rat B. Chloroform and
suffocation as in Experiment i. Increase in degeneration and necrosis in suffo-
cated rat apparent.

In the following exi)criments rats were used, and chloroform was
Iho poison administered. The rats were placed upon a corn diet.

lavake: action of high carbohydrate diet and oxygen 409

Chloroform and suffocation.
'" Experiment 4. — Same as Experiment 3. Increase in degeneration and necro-
sis in suffocated rat is apparent. Dark mass in center of both 3 and 4. B con-
sists of necrosed liver cells and venous congestion. High power of same liver
given below.

410 lavake; action of high carbohydrate diet and oxygen

Experiment 5. — Rat .1 was ou a meal diet and survived the chloroform
poisoning. Rat B, on same diet and survived. On thirteenth day rat B was
suffocated. Died in twenty-si.\ hours at which time rat A was killed and two
livers compared. Hoth show complete regeneration. No apparent diflerence
between A and li.

KxpERlMENT 6. — Same procedure as in Experiment 5 performed on two rats
on a diet of oatmeal and sugar. Same complete regeneration and no apparent
difference between fresh air and suffocated rat.

findley: rupture of the cesarean scar 411

Conclusions: Lack of oxygen without a circulating poison causes
no apparent change in the staining reactions of the central cells of
the liver lobule, at least after twenty-six to thirty-six hours. Lack
of oxygen during the action of chloroform poisoning causes a marked
increase in the central degeneration and necrosis is the liver lobule.

The kidneys of the rats dying from chloroform poisoning showed
a degeneration of the epithelium of the convoluted tubules but the
pathology was not as prominent as in the liver. Also the increase
in degeneration in the kidneys of the suffocated rats was not so
appreciable.

In closing let me say that I am thoroughly cognisant of the in-
conclusiveness of these notes and discussions due to the comparative
small number of the experiments and to the use of many assumptions.
I have taken the hberty of reporting these notes in order to stimulate
early experimental and chnical confirmation or refutation. I
believe that Opie and Alford are justified in believing that a high
carbohydrate diet might be of marked value in preeclamptic toxemia
and my experiments point to the fact that the administration of
oxygen, as advocated empirically by Stroganoff, or treatment in the
open air may have a rational pathologic basis for support.

RUPTURE OF THE SCAR OF A PREVIOUS CESAREAN
SECTION.

BY
P.4LMER FINDLEY, M. D.,

Omaha, Nebraska.

A YOUNG woman was admitted to the Charite Frauenklinik of
Berhn in June, 1915. Two years before she had been Cesareanized
at term for a rachitic pelvis. She was in the seventh month of
gestation, and was bleeding moderately from a marginal placenta
previa. The assistant in charge of the "Kreisszimmer" was of ihe
opinion that a second Cesarean section should be performed, and
accordingly the case was submitted to Prof. Franz, who commented
upon the wide abdominal scar, but gave no consideration to the
possible existence of a defective uterine scar. He counciled against
Cesarean section, and gave orders to insert a hydrostatic bag, and
after dilatation of the cervix to perforate the head and extract the
fetus. These instructions were carried out, and with the second

412 findley: rupture of the cesarean scar

uterine contraction the patient went into collapse. The fetus was
distinctly recognized to be free in the abdominal cavity.

The patient was rushed to the operating room and within thirty
minutes the uterus was removed together with the escaped fetus and
blood. Death followed within two hours from shock.

A study of the removed specimen revealed a rent directly through
a median scar low on the anterior surface of the uterus and largely
within the thinned lower uterine segment. It was evident that the
uterine scar, as well as the abdominal scar, had become infected
following the initial Cesarean section. There was but a thin fibro-
muscular bridge between the serosa and atrophied mucosa.

In commenting upon the case before the clinic, Prof. Franz said
that in the future he would make his incisions high on the uterine
body where the muscular development is the greatest, and would
advise Cesarean section upon every pregnant woman who bears the
scar of a previous section.

A few weeks later I saw Prof. Jardine in the Glasgow Maternity
perform a Cesarean section before the onset of labor, because of the
existence of a very thin uterine scar. At the same clinic two uteri
with ruptured scars were exhibited by Prof. Samuel Cameron.

These observations enlivened my interest in the question of rup-
ture of the Cesarean scar, and has led to a review of the literature
for the purpose of determining whether or not one Cesarean section
calls for another in event of a subsequent pregnancy. I confess at
the onset to have entertained a prejudice in favor of repeated Cesa-
rean section in all cases to forestall a possible rupture, but as the work
developed in my library I was led to conclude that such a position is
untenable.

In earlier years, when indifferent asepsis and haphazard suturing
were practised, we are informed by Krukenberg, in his classical work,
that fully half the scars ruptured in subsequent labors. This is in
marked contrast to the brilliant results following the adoption of the
improved method of suturing proposed by Sanger in 1882. From
1882 to 1895 Sanger collected reports of 500 cases without a single
rupture. From 1895 to 1900 three cases of rupture were recorded
and from igoo to 191 1 there were forty cases of rupture and eight of
serious dehiscence of the scar recorded. Wyss observes that this
increase in the number of ruptures is not chargeable to the growing
popularity of Cesarean section, but is perhaps due to departure from
the tried and proved method of suture of Sanger. While it is true
that the exact lechnic of Sanger is not followed in late years, yet
the essential princi])les of the method of suture are generally ob-

findley: ritptupe of the cesarean scar 113

served, and it is fair to assume that marked deviations from these
principles laid down by Sanger have largely accounted for the in-
crease in the number of ruptures. These principles are tier suturing,
sutures which pass through the entire thickness of the uterine mus-
culature and placed close together, infolding of the serosa to prevent
the formation of adhesions, exclusion of the decidua in the sutures
to prevent the interposition of the decidua between the severed
muscle fibers, and finally the tying of all sutures tightly to allow
of subsequent relaxations and contractions of the uterus without the
formation of gaps in the uterine wound. If the above conditions
are maintained and the wound remains aseptic there is e\-ery rea-
sonable assurance that there will be firm muscular union with little
development of scar tissue. Such a wound healing should favor-
ably insure against rupture in event of a subsequent pregnancy.

The character of the suture material, so long as it is sterile, does
not seem to enter into consideration. As expressed by Olshausen
and Bumm a proper wound healing depends less upon the suture
material than upon the method of suturing. In former years poor
quality of catgut would give way and still earlier fine silver wire was
known to cut through.

Doubtless the greatest factor in the production of insecure wound
healing is septic infection. In this connection we are reminded that
too often conservative Cesarean sections are performed in the pres-
ence of sepsis when sterilization or Porro operation would have been
the wise choice. Furthermore, we have to reckon with latent gon-
orrheal infections (Wyss) and with retained lochia (Jolly) as sources
of infection. This brings us to the admission that there is no positive
assurance of obtaining a perfect wound healing whatever the method of
suturing or whoever the surgeon. The uterine scar is an unknown
factor in all cases.

The transverse fundal incision, introduced by Fritsch in 1897, has
apparently had more than its share of failures in respect to firm
healing of the uterine wound. Vogt reported six ruptures in fundal
scars. Couvelaire, in his report of fifty cases of rupture of the scar,
finds seventeen of this number were through fundal scars. In 1910
Dahlmann reported twenty-six cases of rupture through fundal scars.
In view of these reports, and considering the relative infrequency of
the Fritsch operation as compared with the classical operation of
Sanger, we are led to agree with Everke that transverse fundal
incisions are relatively insecure. Wyss says that introduction of
the transverse fundal incision has not lessened the danger of rupture,
and Scheffzek remarked that the unusual tissue distortion, especially

414 findley; rupture of the cesarean scar

in the fundus in puerperal involution, makes firm union of the scar
problematical.

As to the integrity of the scar in extraperitoneal and cervical
Cesarean sections, experiences and opinions differ widely. Judg-
ment must be withheld until a larger number of repeated pregnancies
following these procedures are on record. Frank reported <S, Sell-
heim 5, Litschkuss 12, Alow 30, and Rohrbach 93 cases of cervical
Cesarean section which have stood the test of labor without rupture,
and Vogt concludes that rupture of the scar in the cervix is of rare
occurrence.

On the other hand, Routh says cervical and extraperitoneal Cesa-
rean sections are not in favor in England. Traugott, Bumm, Gob-
dardt, Sellheim, and Wolf report marked thinning of cervical scars
with impending rupture, and Wyss assumes a skeptical attitude on
the dependability of these scars, and expresses the opinion that a
bad cervical scar is more dangerous than a fundal scar because of
the marked thinning of the lower uterine segment in labor. Chiaji
finds thinning of extraperitoneal scars has occurred in 17 per cent,
of cases, and concludes that no security is afforded in subsequent
pregnancies. Finally, we have the word of Leopold that classical
Cesarean section, with its good results for mother and child, remains
the most efficient operation, and which alternative procedures will
never supplant or restrict.

Numerous authors have described the manner of healing of the
uterine wound. A fibrinous deposit forms on the cut surfaces, and
beneath this are newly formed connective-tissue cells. If the wound
is kept in perfect coaptation, and free of infection, muscular regen-
eration will effect a complete muscular union, making the scar invisi-
ble to the naked eye and scarcely discernable under the microscope.
Perfect coaptation may be prevented by infection, by the giving way
of sutures and by the alternating contractions and relaxations of the
uterus in the presence of loosely tied sutures. Not infrequently the
wound opens up at one or more points in the scar. With the separa-
tion of the cut surfaces small hematomata are formed and later are
replaced by connective tissue with little or no muscle fiber. Such
a scar presents a locus minoris resistentia, but it is remarkable to
note that they are so often capable of resisting the forces of labor.
Couvelaire says 75 per cent, of these defective scars will stand the
test of labor without rupture. Uleroabdominal fistulae have devel-
oped in a number of instances as a result of insecure knots and in the
same manner dehiscences of the entire uterine wound has occurred.
Where silk has been used, fistula- may make their appearance several

riNDLEY: RUPTURE OF THE CESAREAN SC.AJR 415

months after Cesarean section and may persist indefinitely. The
ovum has been known to attach itself to such fistulje and form a her-
nial protrusion of placenta and membranes. In these weakened
scars a fibromuscular bridge separates the serosa from mucosa.
Occasionally there is an entire absence of muscle fiber. The con-
nective tissue may be scant, leaving little more than the serosa and
atrophied mucosa to withstand the forces of labor. When catgut
is used the sutures will usually be absorbed in thirty to sixty days.
Studdiford found chromic sutures practically unabsorbed six and a
half years after their insertion. In a number of instances silk sutures
have been known to disappear.

Mason and Williams made a series of experiments on pregnant
cats and guinea-pigs to determine the relative strengths of scar and
normal uterine wall. Weights were suspended from sections of the
uterine wall containing linear scars and it was found that rupture
invariably occurred in the muscle and not in the scar, thereby con-
firming the cHnical observations of Schauta, who says that with
modern closure of the wound rupture will more likely occur outside
the scar. In a number of instances the rupture was observed to
start in the scar and to extend through the musculature at the side
of the scar.

In 50 multiple Cesarean sections performed in the New York
Lying-in Hospital, Harrar finds no visible scar or no thinning in 42,
thin scars in 4, partial rupture in 2, and complete rupture in 2.

That placental implantation in the scar predisposes to rupture is
the opinion of Dahlmann, Vogt, Couvelaire, Schick, Blind, Wyss,
Ekstein, Fischer, and Werth. Vogt found the placental insertion in
the scar in 9 of 22 recorded cases, Couvelaire in 8 of 9 cases, Dahl-
mann in 8 of 15 cases. Werth and Ekstein likened the influence of
the placenta upon the underlying scar to the trophoblastic function
of the placenta in ruptured tubal pregnancy. Decidua and chorionic
structures have been observed to penetrate the fibromuscular bridge
to the serosa. Fischer, in referring to the relative frequency of rup-
ture in transverse fundal incisions, expresses the opinion that the
probable explanation lay in the frequency of placental implantation
at the fundus.

Few authors advocate sterilization following Cesarean section
unless by the urgent request of the husband and wife. Numerous
authors have reported their second, third, fourth, and even fifth
Cesarean section on the same individual, and Charles did his sixth
Cesarean on the same woman. This may be taken as an expression
of confidence in the integrity of the scar. Notably exceptions to

416

FIXDLEV: RUPTURE OF THE CESAREAN SCAR

No. Date.

Operator or
reporter.

Indication
for C. S.

Time of
rupture.

Location
of C. S.

Interval Placental site.

between

C. P. and

rupture. , In C. S. ] In rupture.

1895

Koblank

Rachitis

Term

Median

4 yrs.

In incision

1896

Guillaume

Rachitis

7mos.

Median

3yrs.

1897

Woyer

Rachitis

Median

3 yrs.

In incision

In .soar

4
5

1900
190O

Targett
Schneider

Transv. posi-
tion: tetanus
uteri
?

Term

Median
MaJian

2 >TS, ' 7

7
7

6 1901

Everke

Ill

Median

4jTs. 7

In tear

7 1902

Galabin

7 7

1
8 1903

L. Meyer

Lumbokypho-

Term

Transv.
fundal

4 yrs. 7

In tear

1904
1904
1904

Jardine

Kerr

Ekstein

Rachitis

IV
IV

7
33

Term
Term
Term?

Transv.

fundal
Transv.

fundal

3 yrs.
3 yrs.

7
?

In tear

1904

Sohutte

Eclampsia

Term?

Median

lyr.

1904

1905
1905

Ribemont-Des-
saignes and
Rudaux

Henckel
(Prussmaim)

Werth

Rachitis
Racliitis

III
III

Term

Term
8mos.

Median
Median

2 yrs.

3 yrs.
12 yrs.

7
7

7
In tear

1905

Sehink

Contr. pelvis

III

Term

Transv.
fundal

3 yrs.

In region of
soar

17 ! 1905

Wyder
(Chalewsky)

Contr. pelvis;
trans, posi-
tion

Term?

Median

O JTS. ?

l.S ' 1906

Wilton

(Mabbott)

Contr. pelvis

Term?

Transv.
fundal

2yrs. ! ? ' 7

19 1906

A. Martin

Eclampsia

III

7mo8.

Median

2 yrs. 7 j 7

20 ..

21 1907

22 1907

Couvelairc

Paddock

Schneider

Contr. pelvis

Contr. pelvis
Rachitis

III

36
25

Term

Term
Term?

Median

7
Median

IjT. 4

moe.

2 yrs.

7
7

In scar

7
7

23 1 1908

Hartmann

(Franzj

Rachitis

Term?

Transv.
fundal

1 yr. 8

In incision

In soar

findley: rupture of the cesarean scar

417

Method of

Results.

Therapy.

Remarks.

suture in C. S.

Mother.

Child.

References.

Silk and oatgut
Tier?

2 layers silk
?

Reoovered
Reoovered

Died
Recover I'd

Reoovered

Reoovered
Reoovered

Reoovered

?
Reoovered
Died

Recovered

Reoovered

Reoovered
Reoovered

Recovered

Reoovered

Reoovered
Lived?

Reoovered

Dead

Dead twins
Dead

Dead

Lived
Dead

Lived

?
Dead
Dead

Dead

Dead
Dead

Lived
Lived?

Dead?

Suture
Hystereotomy

Porro
Porro

Porro

Porro
Porro

Suture with
silk

Porro

Laparotomy
and drainage

Porro

Suture
Porro

Suture

Porro

Suture with
ohromio oat-
gut

Resection soar
and suture

Porro

Porro
Suture

Vaginal hys-
terectomy

Febrile oonvalesoenoe
after C. S.; scar much
thinned.

Convalescence after C. S.
febrile; decidua extend-
ed to peritoneum in
ruptured scar

Fever after C. S.

Normal oonvalesoenoe

Ztsohr. f. Geb. u.
Gyn., Bd. xiv.

Zentralbl. f. Gyniik.,
1896.

Monats. f. Geb. u.

Gyn., 1897. Bd. vi.
Trans. London Obst.

Soc., 1900, vol. xUi.

enough?

Vereinsbeilage, p.
179.

Sanger"
?

3 layers catgut
?

Tubes ligated at time of
C. S.; ulcerating ven-
tral hernia at time of
rupture

Febrile oonvalesoenoe
after C. S. with pelvic
exudate: soar very weak

Gyn.. 1901. Bd. xiv,
British Med. Jour.

Kasuis. meddelelser.
BibUotek f. Laeger.

Zentralbl. f. Gyn.

Trans. London Obst.

3 layers oatgut
ami silk

Silk in peri-
toneum

2 layers oatgut

2 layers oat-gut

2 layers iiatgut

No fever after C. S.;
deoidua invaded soar
in its entire length:
rupture atter vomiting

LTtero-abdominal fistula
after C. S.; uterus ad-
herent to abdominal
wall

Soo.
Zentralbl. f. Gvn.,
1904.

Monats. f. Geb. u.
Gyn.

Deoidua growing into
scar; soar very thin

Placenta and fetus in
abd. cav.; muscle union
of entire soar but
serasa not united?

nriU : f.^v-T aftiT rup-

|. wT :ill.r (". S.
Fr\cT^fLcr CS.

d'obst. gyn. et ped.,

Paris.
Ztaohr. f. Geb. u.

Gyn., 190.1, Bd. liv.
Berl. klin. Wohnschr.

Nr. 27.

Zentralbl. f. Gyn.,
1903.

Korresp.-Blatt. f.
Sohweiz.-.\erzte and
Chalewsky, Inaug.
Diss., Zurich, 1907.

?
2 layers oatgut

Normal oonvalesoenoe

Fever after C. S.; rupture
just to right of soar

1907, vol. XX.

Med. Klin., Nr. 13.

Ann. de Gyn., 1906,

2 serie.
IlUnois Med. Jour.

il layers catgut

Normal convalescence;
tubal sterihzation.

Soar consisted practically
of serosa and invaded
with deoidua; rupture
in centre; version and
forceps dehvery

Miinohen. med.

\Vooh.,1907.Nr.41
Ztsohr. f. Geb. u.

Gvn., Bd. 8; Zent.

L'Gyn., Nr. 3.

418

findley: rupture of the cesarean scar

Operator or
reporter.

Indication
for C. S.

Time of

Location
of C. S.

Inter\-al
between
C. S. and
rupture.

Placental site.

No. Date.

rupture.

In C. S.

In rupture.

1908

L. Meyer

Sarooma saori

Term

Transv.
fundal

Syrs.

26
27

1908

1908
1908

Lobenstine

Foumier
Brodhead

Rachitis

7
V

7
35

7
Term7

Median
over fun-
dus

Transv.
fundal

Median

2j-rs.
7

2}TS.

7
7

1909

Weber fWeil)

Contr. pelvis

Term?

Transv.
fundal

lyr.

In incision

1909

Nacke

Contr. peKia

III

Term?

Transv.
fimdal

4yrs.

In soar

1910

Richter

7mos.

1910

Dahlmann

Cervix myoma

Transv.
fundal

1 yr. 8
mos.

In region of

1910

DablmaDn

Vaginal varices

Term?

Transv.
fundal

2 JTS.

In incision

■

1910

Dahtmauu

Rachitis

Term?

Transv.
fundal

3 JTS.

1910

Soheffzek

Contr. flat pcl-

Term?

Classical

3yrs.

■>

1911

Jeannin

8i mos.

Median

IJT.

1911

Sohiok

Edema vulva;
eclampsia

III

Term

Transv.
fundal

5 yrs.

In tear

I9I1

MoPharson

III

In labor

Median

In incision

1911

Eermanu

1911

Cooq and
Massay

Flat pelvis

III

1. Trans,
fundal.
2. Med-
ian

5 yrs.
after
2dC.

In tear

1911

UiiterUTger

Kclampsia

Term?

Transv.
fundal

2yra.

findley: rupture of the cesarean scar

419

Chromic oatgut
3 layers eatgut

Died 17
days later, i
pneumcnia

Recovered

Died
Recovered

Dead
Lived

? j Died

3 layers catgut Died

2 Jayers silk;
1st inuluding
deoidua

3 layers catgut

" Exact suture" ',
Reindeer ten-
don

Supravaginal
hysterec-
tomy
Vaginal hys-
terectomy
j ^'aginaI hys-
I teerotomy
Total hyster-
ectomy

Suture of tear

Porro

Postmortem

Hysterectomy

Febrile convalescence
after C. S.; ventral
hernia

Rupture extended from
OS internum to fundus
mid-line.

Rupture followed induc-
tion of labor with bougie

Supravaginal
amputation

Rupt. found on manual
removal of placenta:
plao. invasion of soar;
death due to pul.
embolism

Utero-abdominal fistula
developed four months
after C. S.

Fever after C. S. with
pelvic exudate; rem-
nants of oatgut sutures;
deoidua extended to
serosa

Mucosa extended to
serosa; fistula dev. one
mo. after C. S., due to
silk suture; healed on
its removal.

Fever after C. S.; no
symptoms of rupture
before operation; soar
in unruptured part very
thin

Fever after C.S.;abdom.
suture infection; soar
adherent to abdom.
wall and ruptured in
entire length

No fever after C.S.; rup-
ture in spite of weak
Ialx>r pains; scar thick
enoe of com-
icle healing
d extraction;
then found
■nta in abdo-
i'v; ri:;f[)psy;

pk-te

niptun

L'Obstetrique. Lan-
nee, February.

Bull, de la soo. de

gyn.. April 16.
Am. Jour. Obst., Ivii.

Weber. Beitr. f. Geb.

u. Gyn., Bd. xv;

Weil, Inaug. Diss.,

Munich.
Zentralbl. f. Gyn.,

Monatsoh. f. Geb.
Gyn., Bd. xxxii.

Monatsoh. f. Geb.
Gj-n., Bd. xxxii.

Ztsohr. f. Geb. u.
Gvn., Bd. kvii,

mt.3.

Deutsob. med. Wui.'h.

snar very tliiu; re
tion of tubes
Rupture in region of S'

" C. Am. Jour. Obstet.,
Lofl 1911,kiii, 3.

Acad, de med. de

j hclL'iqur., v. Cooq.,

Ru,„ur

. n, .ln„

fuiiib

scar uiily

No fever after C. S.; vagi-
nal hysterectomy; rup-
ture then found in old
soar, whioh was very
thin

Monatsch. f. Geb. u.
Gyn., Bi. xxxiv,
Heft 3.

420

findley: rupture of the cesare.\n scar

Operator or
reporter.

Indication
for C. S.

Time of

Location

Interval Placental site,
between

No. Date.

rupture, of C. S.
incision.

C.S.and
rupture.

loC. S.

In rupture.

1912

Schwartz

Eclampsia;
edema vulva

Smos.

Transv.
fuudal

3JJTS.

1912

Ramos

Eclampsia

11?

8Jmos.

Transv.
fimdal

li yrs.

1912

v.HerfF(Wyss)

Edema vulva;
eclampsia

About
term

Median

1 yr. 8

In tear

1912

Wyss

Rachitis

Term

Classical

3 yrs. 3

In incision

On poste-
rior wall

1912

Jolly

Rachitis

Term

Median on
posterior
wall

1 yr. 3
mos.

Anterior
wall

1912

Hofmeier

(Fischer)

Contr. pelvis

Simos.

1. Traniiv.
fundal;
2. ?

6 yrs.

1. In inci-
sion; 2. 7

Partly over
tear

47 1912

Davis
(Harrar)

Flat pelvis

VIII

In labor

Median

2 yrs.

In tear

48 1912

Davis
(Harrar)

Contr. pelvis

llmos.

All longi-
tudinal

3 years
after
3dC.

1914

Wolff

Rachitis

Term

Cervical e.\-
tendins
into body

IjT.

1913

Davis

Kyphotic
dwarf

7 I

In labor

Median
through
fundus

lyr.

1913

Wcisschadcl

(Evcrke)

Contr. pelvis

117

Term

Transv.
fundal

4 yrs.

1914

Walls

Dwarf

7mos.

lyr.

Over stiar

1914

Walls

Contr. pelvis

Tenn

findley: rupture of the cesarean scar

421

Results.

Method of

Therapy.

Remarks.

suture in C. S.

References.

Mother.

Child.

3 layers oatgut

Recovered

Supravaginal

SUght fever on third day

Mnnatsoh. f. Geb. u.

amputation

after C. S.; rupture
through entire length of
soar; fetus and placenta
in abdominal cavity

G>-n., Bd. XXXV,
Heft 5.

Silk

Recovered

Dead

Supravaginal

Four days after C. S. ab-

Revue de la olin. obs.

amputation

dominal wound sepa-
rated with eventration;
at rupture fetus and
placenta in abdominal

et gyn., January
and February, 1912
ref..Ztschr. f. Gyn.,
1913, Nr. S.

2 layers silk

Recovered

Dead

Porro

cavity

Rupture aftfir vomiting;
scar thin in fundal
region only of mucosa
and serosa; syncytial
invasion of scar

Fever after C. S.; scar

Beitr. f. Geb. u. Gyn.
Bd. xvii. Heft 3.

2 layers oatgut

Recovered

Lived

Porro

Beitr. f. Geb. u. Gyn.

thin in places; some

Bd. xvii. Heft 3.

muscle fibers in more
solid part of soar
Fever after C . S. ; deoidua

2 layers c^rgut

Recovered

Lived

Supravaginal

Arch. f. Gyn., Bd.

amputation

extended to serosa; un-
ruptured part of soar
showed complete mus-
cle union
Fever after C. S,; at 2d

97. Heft 2.

1 deep silk;

Died

Dead

Supravaginal

Ztschr. f. Geb. u.

3 layers cat-

amputation

C. S. soar found to be

Gi-n.. 1912, Bd.

gut

thin; no fever after 2d;
complete rupture of
scar which consisted of
serosa only with deoidua
and syncytial tissue

Ixx, Heft 3.

Recovered

Lived

Resection of

CHarrar) Am. Jour.

Obst., 1912. Ixv, 5.

suture

Died

Dead

Hysterectomy

Fever after 3d C. S.;
complete muscle regen-
eration; rupture be-
tween two of the scars;
overtime fetus and
placenta in abdominal
cavity

Fever after C. S. with

(Harrar) Am. Jour.
Obst.. 1912, Ixv, 5.

2 layers oatgut

Recovered ;

Dead

Total hystcr-

Ztsohr. f. Geb. u.

cerebral

eotomy?

utero-abdominal fistula;

Gyn.. 1914. Bd.

embolism

rupture through scar

Ixxv, Heft 3.

on tenth

which was thin with

day

decidua extending al-
most to serosa

Died

Dead

Suture

Normal oonvalesoenoe
after C. S.; rupture of
entire soar; fetus and
placenta in abdominal

Trans. Am. Assn.
Obstet. and Gyn..
1913. xxvi. 43.

Recovered

Supravaginal

Fever after C. S.; com-

Monatsch. f. Geb. u.

amputation

plete rupture of soar;
fetus and placenta in
abdominal cavity; scar
of serosa only

Gyn.. 1913. Bd.
xxxvii. Heft 2.

Died

Dead

Supravaginal
amputation

Jour. Obstet. and

Gyn, Brit. Emp.,

1914. xxvi, No. 4.

Dead

Supravaginal

Soar long, wide and thin,

Jour. Obstet. and

amputation

and about to give way;
small opening in lower
angle of scar; section
showed no degenerative
changes to account for

Gyn. Brit. Emp.,
1914, xxvi, No. 4.

rupture

422

findley: rupture of the ces.\rean scar

Date,

Operator or
reporter.

Indioation
for C. S.

Time of
rupture.

Looation
ofC.S.
inciaon.

Interval
between
C.S.and
rupture.

Placental site.

No.

In C. S.

Id rupture.

HII4

Shaw

T r

Term7

20 mos.

In tear

1914

Breitstein

Term?

1<I14

Franz

Raohitis

7 mos.;
plao.
previa

Median
(low)

lyr.

Not in tear

1903

Futh (Kretz)

lyr.

1914

Applegate

Contr. pelvis

Median

18 mos.

1913

Webster
(Davis)

Nephritis

Term?

Median

1914

Hillis, D. S.

Eclampsia

II?

Labor

Median

IJT.

I9I5

Williams, J. W.

Contr. pelvis

Ill

7 mos?

Median

I yr. 2

1914

MiUer (Jeff.)

Failure of head
to engage

■

In labor
full
term

Median

Right of in-
cision

Over soar

1915

Miller (Jeff.)

Slight contrac-
tion

In labor
full
term

Median
(low)

lyr.

Not in tear

this viewpoint are Jardine, Opitz, and Govrich, who advocate sterili-
zation after the second Cesarean section.

John T. Williams, in writing on, "Delivery by the Natural Pas-
sages following Cesarean Section," takes issue with Breitstein, Couve-
laire, Marioton and others who are committed to the rule of "once
a Cesarean section, always a Cesarean section." He says: "When
a uterus has been sutured with care and there has been no subsequent
infection the Cesarean scar will be strong enough to withstand the
distention of a full-term pregnancy and even the strain of a full-

findley: rupture of the cesarean scar

423

Results,

Method of

Therapy.

Remarks.

suture in C.S.

Refsrencps.

Mother.

Child.

Reoovered

Dead

Supravaginal

Entire soar ruptured;

Jour. Obstet. and

amputation

section showed increase
in fibrous tissue but
insufficient to aooount
for aocident

GjTi. Brit. Emp.,
1914, xxvi. No. 4.

Hysterectomy

After C. R. a 2d labor
ternunated per viam
naturaiera; rupture in
third pregnancy.

Jour. Am. Med.
Assn., 1914, Ixii,
689.

Died

Dead

Hysterectomy

Induction of labor bv
bag; rupture in a half
hour of entire length of
soar, which was thin
and only fibromusoular
tissue

Not reported; per-
sonal observation.

2 layers

Reoovered

Porro Fever after C. S.; pla-

Zentralbl. f. Gyn. (1),

centa not found (?);

ref., Wvss. Beitr. f.

pathologioal insertion

Geb. u. Gyn., Bd.

of plaocnta (?)

xvii. Heft 3.

Died

Dead

Hystereotomy

Fever after C.S.; in hos-
pital two months; soar
very thin, showing
e\'idenoe of poor

Not reported; per-
sonal oommunioa-
tion.

Died

Dead

None; rupture

No history obtainable;

Surg.. Gyn. and

found at

induction of labor with

Obstet, July, 1913.

autopsy

bag, version, and ex-
traction; dead fetus;
died two hours later;
autopsy revealed rup-
ture along entire soar
and extending toward
left tube

3 layers catgut

Reoovered

Dead

Suture

Rupture in soar through
entire length; rupture
two hours after onset
of labor

Not reported.

Recovered?

Dead

Supravaginal

Fever after C. .S.; rupture

Not preported; per-

amputation

probably ooourred two
days before operation;
no suggestion of rup-
ture; intaot sao and
placenta in abdominal
oavity
Ruptured on operating

sonal oommxmioa-
tion.

3 layers 20-

Died

Dead

Suture of rup-

Not reported.

day cat^t

ture

table in preparation
for C. S.; death from
shock in three hours;
fever course after C. S.

Recovered

Dead

Suture of rup-
ture

Fever course following
C. S.; prolonged labor;
entered hospital after
rupture: pituitrin given
by midwife prior to

Not reported.

rupture.

term labor." He bases his conclusions upon the records of thirty-
two cases reported by Van Leuwen with additional cases of his own.

In none of these cases did the scar rupture during pregnancy or
in the delivery through the natural passages.

Among the safeguards against rupture through the scar of a
Cesarean section is the relative sterility of these cases. It is esti-
mated that less than half of them again become pregnant. Further-
more, it is noted that a long interval between the section and sub-
sequent pregnancy adds to the security of the scar. Asa B. Davis

424 findley: rupture of the cesarean scar

tells us that he believes rupture of the scar could have been prevented
in all of his cases had a timely Cesarean operation been possible.
Second only in importance to timely intervention by repeated
Cesarean section when there is reason to beheve that the uterine
scar is defective or where obstruction exists to the passage of the
fetus, is the avoidance, as far as possible, of all intrauterine manipu-
lations such as versions, the application of forceps, the introduction
of hydrostatic bags, tampons and pituitrin.

Inasmuch as the great majority of all cases (75 per cent.) that have
ruptured ran a fever course following the Cesarean section, I would
formulate the rule that all such cases call for serious consideration
in event of a subsequent pregnancy.

Repeated Cesarean sections are said by many to give better
results than primary Cesarean section, because of the frequent
presence of adhesions which wall oS the general peritoneal cavity
and make it possible to deliver the baby without entering the free
abdominal cavity. Such a case I recently witnessed in Polak's
clinic at the Long Island Hospital of Brooklyn. Brodhead and
Sinclair suggest ventrofi.xation of the uterus by suturing the uterus
outside the margins of the wound to the parietal peritoneum. In
thirty cases reported by Sinclair, pregnancy was terminated without
untoward symptoms. But, as Wyss observed, ventrofi-xation has
been followed by rupture, and it remains for the future to determine
the merits of the procedure. Certainly it is not in line with recog-
nized surgical procedure. We can scarcely hope to have the good
fortune of Bar, who has seen no disturbance to mother or fetus from
adhesions.

The following data are deduced from the foregoing tables of case
reports:

AGE.

In thirty-seven cases, where ages are given, rupture occurred in
twenty-one between the ages of twenty to thirty and fourteen be-
tween thirty to forty.

NUXrBER OF CESAREAN SECTIONS PERFORMED PRIOR TO RUPTURE.

55 cases had i C. S.
6 cases had 2 C. S.
2 cases had 3 C. S.

INDIC.'\TIONS FOR C. S. PRIOR TO RUPTURE

In a total of 49 cases there were:
32 for contracted pelvis.

findley: rupture or the cesarean scar 425

I for lumbokyphosis.
I for sarcoma of sacrum.
I for vaginal varices.
ID for eclampsia.
I for transverse position with tetany uteri.
I for transverse position with contracted pelvis.
I for nephritis.

PARA.

Ruptures occurred in:
2d pregnancy in 23.
3d pregnancy inn.
4th pregnancy in 3.
5th pregnancy in 4.
6th pregnancy in 2.
Sth pregnancy in i .

TIME OF RUPTURE.

Time of rupture was mentioned in the reports of 52 cases:
In 41 cases at full term.
In 6 cases at seventh month.
In 2 cases at eight month.
In 3 cases at eight and one-half months.
In 1 case at eleventh lunar month.

INTERV.^L BETWEEN C. S. AND RUPTURE.

9 between i and 2 years.
22 between 2 and 3 years.
6 between 3 and 4 years.
4 between 5 and 6 years
I in 8 years
I in 12 years.

LOC.\TION OF C. S. INCISION.

In 53 cases:
2ii were median
20 were transverse fundal.

METHOD OF SUTURE IN C. S.

In 36 cases there were:

Tier sutures in 29 (22 of catgut alone, 3 of both catgut and silk,
4 of silk alone).

426 findley: rupture of the ces.\rean scar

Typical Sanger suture in i.
Peritoneum alone sutured with silk in i.
"Exact" suturing with reindeer tendon in i.
Silk used but manner of suture not recorded in i.
Catgut used but manner of suture not recorded in i.

placental site in c. s.

Mentioned in lo cases.

Incision made over placenta in 98.

Placenta on anterior wall in 2 at side of incision.

PLACENTAL SITE IN RUPTURE.

Mentioned in 20 cases.

In or near the tear in 18 cases.

Not in tear in 2 cases.

TREATMENT OF RUPTURE.

Suture of wound in 15.

Porro in 19.

Vaginal hysterectomy in 3.

Total abdominal hysterectomy in 2.

Supravaginal hysterectomy in 11.

Laparotomy and drainage in i.

Rupture found at autopsy in 2.

Unmentioned in 4.

results to MOTHER.

Mentioned in 59 cases.
41 recovered.
16 died.

2 died on tenth and seventeenth days (cerebral embolism,
pneumonia).

47 mentioned.
34 died.
13 lived.

results to child.

GENERAL REMARKS.

Fever followed C. S. in 24 cases.

Decidua mentioned as invading scar in 10 cases.

findley: rupture of the ces.\rean scar 427

Syncytium mentioned as invading scar in 2 cases.

Scar mentioned as very thin in 17 cases.

Scar with complete muscular regeneration in 4 cases.

In only one case did normal labor intervene between C. S. and
rupture.

Uteroabdominal fistulse developed in scar of C. S. in 4 cases.

Tubal sterilization done in 2 cases following suture of rupture.

Rupture mentioned as following induction of labor by bag or
bougie and by version and extraction in 5 cases.

In one case pregnancy and rupture followed ligation of tubes at
time of C. S.

In one case rupture occurred while patient was being prepared
for Cesarean section.

Conclusions. — i. A perfectly healed Cesarean wound may be
rehed upon to resist the forces of labor, but in view of the fact that
the integrity of the wound is an unknown factor in all cases we are
constrained to exercise the utmost caution in the conduct of every
case in pregnancy and labor following Cesarean section.

2. Failure to secure perfect healing is accounted for by departure
from the principles of suture proposed by Sanger and by septic infec-
tion of the uterine wound. If we are to obtain the uniformly good
results in respect to wound healing that were obtained in the decade
following the introduction of the Sanger method of suture, we must
not deviate from these principles.

3. The possible existence of latent gonorrheal infection may defeat
the most painstaking efforts to secure perfect wound heahng. Hence
it follows that the healing of a Cesarean wound is always an uncertain
factor.

4. When Cesarean section has been followed by a fever course
the uterine wound should be regarded as insecure in event of a sub-
sequent pregnancy, and should call for a repeated Cesarean section
at the onset of labor.

5. Sterilization and hysterectomy should replace conservative
Cesarean section when infection is known to exist. The alternative
invites faulty wound heahng, if not more disastrous results.

6. Transverse fundal, extraperitoneal, and cervical incisions have
not lessened the Uability of rupture in subsequent labors, but, on the
contrary, have probably increased the hazard.

7. The possibility of rupture of the scar following Cesarean section
does not justify steriHzation, but rather calls for the exercise of
masterly control in event of a subsequent pregnancy. All such
cases should be hospital cases and labor should be anticipated by

428 findley: rupture of the cesarean scar

timely repetition of Cesarean section at the onset of labor if the
uterine wound is known to be defective or if some cause for obstruc-
tion to the delivery of the child through the natural passage exists.
Version, high forceps, uterine tampons, hydrostatic bags, and pitu-
itrin should never be employed in the presence of a Cesarean scar.

8. Finally, we may conclude that in view of the evidence that not
more than 2 per cent, of ruptures occur in subsequent labors, we are
not justified in voicing the slogan "once a Cesarean section, always a
Cesarean section," neither are we to rely explicitly upon the integrity
of the uterine scar in any case. Furthermore, we would conclude
that the liability of rupture is a real danger and should stand as an
argument against the increasing tendency to widen the scope of
elective Cesarean operations.

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RESULTS FROM PITUITARY EXTRACT IN OBSTETRICS.

WITH REPORT OF CASE OF RUPTURE OF THE

UTERUS FOLLOWING ITS USE.*

LYLE G. McNEILE, M. D.,

Professor of Obstetrics, College of Physicians and Surgeons, Medical Department, Univer-
sity of Southern California; Attending Obstetrician, Los Angeles County Hos-
pital; Attending Obstetrician, Maternity Cottage; Supervising Obstetrician,
Obstetrical Division. Los Angeles Health Department.

Los Angeles, California.

Beginning with its introduction into obstetrics, in 1909, pituitary
extract has passed through all of the intense enthusiasm which the
profession always displays toward any new drug producing pro-
nounced physiological action. The early literature circulated by
prominent pharmaceutical houses in which it was claimed that
after immense clinical and laboratory experimentation, it was now
marketing an oxytocic which could be used in any case, and during
any stage of labor, without bad results, was doubtlessly responsible
for many of the reported ill-etTects following its use.

But this initial enthusiasm was gradually replaced by a saner
conception of the uses of the drug in obstetrics, and the final status
of the drug is beginning to become fairly well established.

It is disheartening, however, to find in the recent literature an
article by a prominent gynecologist in which, disregarding prac-

* Read before Los .\ngeles Obstetrical Society, .Vpril 11, 1916.

mcneile: results from pituitary extract in obstetrics 433

tically all of our recently acquired knowledge of the contraindica-
tions to its use, he advocates, with very few exceptions, its use
in nearly every case.

As an example illustrating the effects of the drug when given
indiscriminately and without very careful study of the individual
case, I shall give the history of a case of rupture of the uterus, which
occurred in our out-patient clinic:

"Dispensary 1957, Hosp. 29533, Mrs. D., aged twenty-three,
para-iv, nativity Mexico. Applied for dispensary service De-
cember 20, but was not seen until 9.30 a.m., December 21, two and
one-half hours after the onset of labor. The following history was
obtained:

No history of rickets, syphilis, gonorrhea, heart or lung condi-
tions. No history of injury or operations.

Menstruation began at ten years, was regular of the twenty-eight-
day type, lasted three days, amount of blood stated as moderate,
menstruation not associated with pain. Date of last menstruation
not known.

Patient was married in 1910 at the age of eighteen. History of
previous pregnancies negative.

History of First Labor, 191 1. — Delivered at home by private
physician. Patient was in active labor for forty-two hours and
was delivered with forceps. The indication was not stated. The
baby lived. Mother was in bed for fourteen days after confinement,
and states that her physician told her that she did not run any
temperature at the time. Recovery was good except for pain in
right thigh, dating from this pregnancy. This is said to be so
severe that at times she can scarcely walk.

History of Second Labor, 191 2. — Spontaneous delivery, weight
of child not stated, but said to be a good-sized baby. Puerperium
normal.

Third Labor in 1914. — Delivered at home by private physician.
Duration of labor ten hours. (Her physician states that he applied
low forceps after the head had been on the perineum for one hour,
and easily delivered a 7-pound living child. The puerperium was
uneventful.)

History of present pregnancy negative regarding headache,
edema, dizziness, epigastric pain.

History of Present Labor. — First stage began December 21,
1915, at 7 a.m. The pains were of moderate severity occurring
regularly at ten-minute intervals. The membranes ruptured spon-
taneously at 8.30 A.M. before the arrival of physician.

The externe on the out-patient service arrived at 9.30 a.m., and
after the usual preparation, consisting of sponge bath, close clipping
of pubic hair, thorough scrubbing of area between ensiform and
knees with green soap and water, followed by external douche of
Liq.-Cresolis Comp., examined the patient, recording the following
findings.

434 mcneile: results from pituitary extract in obstetrics

Temperature 98, pulse 80, hard bearing-down pains, lasting
one minute, occurring regularly at five-minute intervals. Ex-
ternal examination showed a cephalic presentation, left occipito-
anterior, the fetal heart being heard in the lower left abdominal
quadrant, 145 per minute, regular and strong. The woman was
a strong-looking Mexican, weight 145 pounds, height 5 feet 4^-^
inches, pelvic measurements as follows:

Interspinous 21 cm., intercristal 25^-^ cm.

Bitrochanteric 29 cm., external conjugate 21 cm.

Internal Examination. — Well-engaged head, sagittal suture in
the right oblique, small fontanelle anterior to the left, cervix com-
pletely effaced and dilated to three fingers.

Second internal examination, two hours after the first, showed
complete dilatation and effacement, head well engaged below the
ischial spines, position L. O. A.

At 11.45 A.M. the pains began to decrease in severity and the
patient did not seem to be making any progress, and at 12.15,
one hour after the second internal examination, the pains being
very weak, the case was reported to me and an injection of i c.c.
of extract of the pituitary body was advised. This was given
at once. Five minutes after the hypodermic injection, external
examination showed uterus in tetanic contraction, which in two
minutes was followed by relaxation, and a complaint by the patient
that "she felt like a spring had broken in the abdomen and the
baby had slipped back." She now complained of pain in the
epigastric region and in the chest. Patient seemed comfortable
and rather listless, and the nature of the complication not being
recognized, no report was made by the externe until 3 p.m., when
Dr. A. A. Blatherwick, Assistant Attending Obstetrician, was
asked to see the case. Maternal pulse 120, fetal heart not heard.

On external examination Dr. Blatherwick found a soft abdomen,
no dulness in flanks, fundus uteri at the ensiform, fetus in the left
occipitoanterior position, head in inlet but movable. Maternal
pulse 120, fetal heart not heard.

Patient did not appear to be in serious condition. An absolute
diagnosis of rupture of the uterus could not be made, so under light
ether anesthesia a very easy forceps delivery was done. Time
required for the delivery was ten minutes. Child was a well-de-
veloped female, weight 7}^ pounds, stillborn.

With external hemorrhage as an indication, manual extraction
of the placenta was done forty-five minutes after delivery. The
placenta was found outside of the uterus, in the abdominal cavity.
After delivery of the placenta uterus contracted well, and there
was no external bleeding of any consequence.

Patient entered Los Angeles County Hospital at 7.20 p.m., exactly
seven hours after the rupture had occurred.

Examination on admittance: Pulse 138, semi-comatose, abdomen
distended, fundus at the umbilicus, moderately contracted. Patient
complains of air hunger but no pain. Diagnosis: rupture of uterus,
complete, immediate operation advised and accepted.

mcxeile: resi'lts from pituitary extr.^ct in obstetrics 435

Operation December 21, 1915, 7.30 p.m. Anesthetic, ether,
by the open-drop method. Ten centimeter median hne incision,
below the umbiHcus. On opening the peritoneum abdominal cavity
was found well distended with fresh blood. A transverse rupture
of the lower uterine segment was found, extending from one broad
ligament to the other. The edges of the uterine muscle were so
badly lacerated that I deemed it best to do a supravaginal hys-
terectomy. The case was drained with one large cigarette drain,
through the lower angle of the abdominal incision.

Postoperative History. — Drain was removed in thirty-six hours;
maximum temperature was 102.6 on the fifth day. Sutures were
removed on the ninth day, and patient allowed to be up in the
wheel chair. Patient was discharged on the twenty-first day after
the operation and left the hospital.

Final examination January 26, 1916, thirty-six days after opera-
tion. Well-healed scar below umbilicus, length 7 cm., slightly
wider at lower angle. Vaginal examination: very small cervix,
with a slight bilateral laceration, very high up in the pelvis. The
right side of the pelvis seemed to be flattened out, and to lie nearer
the median line than the left side. The external oblique diam-
eters were taken at the final examination, and found to be "right
oblique" 22 cm., "left oblique" 20 cm. From the last lumbar
spine to the right anterior superior spine measured 16.5 cm. and
to the left anterior superior spine 18 cm. The diagnosis was an
obliquely contracted pelvis of Naegele.

In this case the conditions present before the drug was given
were a well-engaged head, complete dilatation, ruptured membranes,
and a decrease in the strength of the uterine contractions. The
fault to be found with its use in this case lay in the nonrecog-
nition of an obliquely contracted pelvis.

There are a great number of cases appearing in the literature
in which the following complications have followed the use of the
drug: postpartum atony of the uterus, fetal asphyxia, maternal
collapse, eclamptic convulsions, tetanus uteri, premature separa-
tion of the placenta, and rupture of the uterus.

Mundell has collected reports of seven maternal deaths from
rupture of the uterus following its use. He also mentions the
case reported by Herz, in which the patient was a primipara of
twenty, weak and anemic, and in the first stage when extract of
pituitary was given. She had a flat rhachitic pelvis, and had been
in labor for two days. In this case the vaginal portion of the cervix
was entirely torn off from the anterior wall of the uterus, but there
was no rupture communicating with the peritoneal cavity. The
child was delivered spontaneously, and both mother and baby re-
covered. The treatment was expectant.

Mosher, in Surgery, Gynecology and Obstetrics, reports a death

436 mcneile: results from pituitary extract in obstetrics

following the use of pituitrin in a case in which a transverse pre-
sentation was present. Rupture of the uterus and immediate
death of mother and child followed.

Huggins, in The American Journal of Obstetrics, mentions a
complete rupture of the uterus in a multipara in which there was no
abnormahty of the pelvis, and whose previous obstetrical history
was normal. From the statement of the attending physician,
Huggins was inclined to believe that there had been some mal-
position of the head, with resulting delay at the brim. Dilatation
was complete when the drug was given. Rupture of the uterus,
with complete supravaginal amputation of the organ, occurred
five minutes after administration of the pituitrin. The patient
died in five days of general peritonitis.

ZuUig, in Muenchener medicinische Wochenschrift, reports a case
of rupture of the uterus in a multipara (para-xiii) whose previous
labors had always been instrumental, and usually had been termi-
nated with a craniotomy. The diagonal conjugate was 10.5 cm.
Induction of labor at term, followed by a hypodermic of extract
of pituitary body resulted in a complete rupture of the uterus.
.\ complete hysterectomy was done at once, the patient finally
recovering.

Zullig also reports four additional cases collected from the foreign
literature, in all of which the rupture was followed by the death of
the mother.

From a careful study of the literature we are able thus to sum-
marize the following authentic cases of rupture of the uterus follow-
ing the use of pituitary extract:

Reported by Cases Deaths Recoveries

Mundell 7 7 o

Herz I o I

Mosher. i i o

Huggins 1 I o

Zullig 5 4 I

McNeile i o i

In the services of the division of obstetrics, Los Angeles Health
Department, the Maternity Cottage and at the Los Angeles County
Hospital, covering about 1000 deliveries each year, we began the
use of the pituitary extract at the time of its introduction into
obstetrics in 1909.

During the first year after its introduction, and before any definite

mcneile: results from pituttary extract in obstetrics 437

contraindications had been noted, the drug was used indiscrimi-
nately, witliout very much regard for any specific indications, and
with no definite idea of insisting upon certain conditions being
present before the drug was administered. But as the number of
our cases in which the drug was used began to grow, and the results
of its use were noted, we began to realize the extreme potency of the
drug with which we were dealing, and to formulate certain indica-
tions and conditions which should always be present before the use
of the drug was considered. In this Clinic we have also experi-
mented extensively with the dosage of the drug, under practically
all of the conditions under which we believe its use is indicated.

In this series of cases, the drug has been administered approxi-
mately three hundred times. We have noted in this Clinic many
cases in which the complications reported by other observers have
followed the use of the drug. Of these complications we have
noted several cases of tetanus of the uterus. These cases have
followed the use of the drug in doses of from 5 minims in two
instances to i c.c. in several other cases. We do not believe that
the currently accepted statement that the injection of extract of
pituitary body produces only rhythmical and physiological contrac-
tions of the uterus has any basis when the many cases of tetanus
of the uterus, as reported by well-trained observers, have been care-
fully considered.

The drug in our hands has not given satisfactory results when used
in primiparc We have noted more tendency toward tetanic
contractions of the uterus in primiparae than in multiparae. In a
large proportion of cases these tetanic contractions have not been
succeeded by normal rhythmical contractions and the use of the
drug has been followed by a low forceps operation. Again in
primiparae we have noted an extremely large number of cases in
which the use of the drug has been followed by fetal asphyxia.
In none of these cases, however, was the result fatal to the child.

We do not believe that the drug is indicated in any case of tox-
emia of pregnancy, particularly in the cases of preeclamptic toxemia
associated with high blood pressure.

We have noted in several cases, particularly in those of prolonged
labor and in multiparae in which several pregnancies have followed
in rapid succession, that postpartum atony of the uterus frequently
followed the use of the drug and in several cases an alarming post-
partum hemorrhage has resulted. From the observed results in
this Clinic we have formulated the following conditions:

I. Complete dilatation and efifacement.
6

■438 mcneile: resxilts from pituitary extract in obstetrics

2. The membranes must be ruptured.

3. Presentation should be longitudinal.

4. In cephalic presentations there should be no deflection of the head
and the drug should only be used in vertex and breech presentations.

5. There should be no disproportion between the presenting part
and the pelvis. Before the use of the drug the previous obstet-
rical history should be carefully considered and special emphasis
should be paid to the consideration of any operative deliveries.
An accurate knowledge of the internal pelvic measurements, of the
contour of the pelvis and of the measurements of the outlet is
essential.

6. The presenting part should be completely engaged. In this
paper we consider engagement as being complete only after the
greatest diameters of the presenting part have passed below the
pelvic inlet. The term does not bear any reference to fixation of
the head.

The object of this paper is then to call attention to the extremely
large number of unfavorable results which have been reported
following the use of the drug. This drug has absolutely no place
in normal obstetrics. As an extremely active oxytocic in properly
selected cases it has no equal. To attempt to use the drug indis-
criminately as has been advised recently by the gynecologists referred
to will result in a great injury to many patients and will ultimately
lead to an undeserved condemnation of the drug.

REFERENCES.

1. Mundell. Amer. Jour. Obst., 1916, vol. Ixxiii, No. 2, 306.

2. Herz. Zentralbl. f. Gynak., 1915, xxxvii, No. 20.

3. Mosher. Surg., Gynec. and Obst., 191 6, xxii, No. i, 108.

4. Huggins. Amer. Jour. Obst., 1916, Ixxiii, No. i, 88.

5. ZuUig. Muench. med. Woch., June i, 1915, No. 22.

6. Espent. Muench. med. Woch., 1913, No. 32.

7. Stocker. Schweiz. Korr. BL, 1914, No. 52.

8. Luning. Schweiz. Korr. BL, 1915, No. 14, S. 433.
626 Marsh- Strong Building.

GIBSON: PELVIC DISEASE AND MANIC-DEPRESSIVE INSANITY 439

THE RELATIONSHIP BETWEEN PELVIC DISEASE AND
MANIC-DEPRESSIVE INSANITY.*

GORDON GIBSON, M. D., F. A. C. S.,

Brooklyn. N. Y.

In a previous paper (i) the writer called attention to the fact that
several reports regarding the effect of surgical operations performed
on insane women were erroneous and misleading because no attempt
had been made to classify the psychoses met with. Two excep-
tions to this statement are the papers pubhshed by Broun(2) and
Taussig(3).

In considering the cases operated upon at the King's Park State
Hospital we have grouped the various psychoses into two divisions.
The first division includes all the psychoses characterized by
dementia or intellectual enfeeblement. Perkins(4) calls these the
maUgnant psychoses. It includes general paresis, dementia precox
and a few cases of epileptic dementia, constitutional inferiority
and Korsakoff's polyneuritic psychosis. There are i6o cases in
this group and none of them were benefited mentally by the
operative procedure, which again bears out our contention, pre-
viously made, that no woman suffering with one of these forms
of insanity will be benefited by an operation for pelvic disease.

The importance of this statement is easily grasped. To the con-
sultant it means, when he is asked whether or not an operation on
an insane woman will be beneficial, that he should first determine
what psychoses is present, and that if she has one which is char-
acterized by dementia his answer should be in the negative. Any
operation performed on a patient with a malignant psychosis is done
simply to improve the physical condition.

Twelve cases which were diagnosed as allied to dementia precox
have been discharged as improved, but as they do not fall into the
above group they will not be considered. Three cases of epileps}^
with excitement have been discharged improved, but as they did
not show dementia they also will be disregarded as far as this
classification is concerned.

* Read before a meeting of the New York Obstetrical Society, May 2, 1916.

440 GIBSON: PELVIC DISEASE .\ND MANIC-DEPRESSIVE INSANITY

Taking up the second division for discussion we find an entirely
different set of pictures. In this group we have placed the various
benign psychoses, those not characterized by dementia. The most
important of these are manic-depressive insanity and its allied
forms, undifferentiated depression, involution melancholia, Krae-
pelin's paranoia, hysterical insanity, and the psychasthenic and
neurasthenic states. The most common of these is manic-
depressive insanity and it is this form which we wish to discuss.

Manic-depressive insanity is manifested by attacks having a
double characteristic, a tendency toward recovery without intellec-
tual enfeeblement, and a tendency toward recurrence. There are
three types, the maniac, the depressed and the mixed. A descrip-
tion of these types is outside the scope of this paper. It is a common
form of insanity, about 15 per cent, of all commitments falling into
this class. Heredity is present in 80 per cent, of the cases according
to Kraepelin(5). One of the most characteristic facts is that mani-
acal attacks are almost invariably preceded by periods of more or less
depression. Another significant fact is that these people do not
perceive the phenomena of the external world in their true aspect.

It is a matter of common observation that some women, who are
not insane, who have pelvic disease are apt to have periods of depres-
sion, or the blues, of varying intensity. These attacks often dis-
appear when the pelvic pathology is removed. The difference
between the blues of a sane woman and the depression of a manic-
depressive is often only a question of degree. This depressing effect
of pelvic lesions may be just as pronounced in a woman with a handi-
capped psychic system as it is in one who is normal. We know that
the brain is constantly receiving impressions from the external world
and that a normal individual reacts in a manner which we consider
normal and that an individual who has manic-depressive insanity
reacts abnormally. We also know that certain individuals break
down under the strain of external conditions. We also know that
neurasthenics are more susceptible to internal or somatic impulses
than normal individuals. Therefore it is quite possible that manic-
depressives are influenced by pathological impulses arising in the
pelvis. We know that the pelvic viscera are richly supplied with
fibers of the sympathetic and autonomic systems and we may assume
that disturbances of these systems have some effect on handicapped
psychic systems.

The skeptic will at once confront us with the fact that the attacks
are characterized by a tendency toward recovery. This is un-
doubted, but what brings on the attacks? Of course there is the

GIBSON: PELVIC DISEASE AND MANIC-DEPRESSIVE INSANITY 441

tendency to recur but in a great many cases some direct exciting
cause can be determined. A single drink of whiskey has brought
on attacks. Emotional strain, physical strain, the strain of labor
and the puerperium have all been found to be exciting causes.
It may be that the constant irritation of pathological somatic
impulses acting on a handicapped psychic system may precipitate
an attack. Our idea was to see if we could shorten the attacks and
increase the period of sanity between the attacks in women who
had manic-depressive insanity by removing any pelvic pathology
which might be present. This of course will take some time as
individual cases must be studied for periods of some years. How-
ever our results have been of such a nature as to justify certain
fairly definite conclusions.

Taussig has pointed out that pelvic lesions are more frequent in
women with manic-depressive insanity than in women with other
psychoses. This is true, but may be accounted for, partially at
least, by the fact that these women are discharged from the hospitals
when they have recovered from an attack and while at home are
exposed to the etiological factors of pelvic disease.

In this series of cases it was found that depression was more
often met with than mania. This corresponds with Broun's find-
ings, 78 per cent, in his cases, 70 per cent, in ours. The most com-
mon lesions found in the cases of King's Park were lacerations of
the cervix and perineum, retroversions and retroflexions and the
results of inflammatory processes. Some new growths were found
but the proportion is small. A certain proportion of the cases began
to improve immediately after the operation and in some the improve-
ment was so rapid that we believe that the operation had something
to do with it.

The previous report which covered the first 100 cases operated
upon included twenty-six cases of manic-depressive insanity.
These are reviewed again in this discussion. From May i, 1908, to
Dec. 31, 1915, 1064 women with manic-depressive insanity have
been admitted to the King's Park State Hospital. These have
all been examined, either by myself or by the resident on the
gynecological service. Of these 160 were found to have lesions
which required operation. Many others had local treatments
instituted. On account of the difiiculty encountered in obtaining
permission, from the relatives, to operate only fifty-six of these have
been operated upon. Thirty-six of these have been discharged as
recovered. Six have been readmitted with other attacks and will
be discussed later.

442 GIBSON: PELVIC DISEASE AND MANIC-DEPRESSIVE INSANITY

The following table shows the time which has elapsed since the
operations upon the thirty cases which have not been readmitted.

I yr.
3

i}4 yr-

2 yr.

3yr-

4yr.

syr.

6 yr.

7yr.

8yr.

Twenty-five of these were operated upon during their first attack
and it remains to be seen whether they have other attacks, and, if
they do, what the character and length of the attacks are and how
long they remain sane between attacks. Four cases were operated
upon during the second attack and one during the third. These
are abstracted briefly:

1. M. O., operated upon during second attack for retroversion.
Three months between first and second attack, six years since second
attack.

2. C. M., operated upon during second attack for lacerations of
the cervix and perineum and retroversion. Four months between
first and second attack, five years and four months since second
attack.

3. B. D., operated during second attack for lacerations of the
cervix and perineum and retroversion. Six weeks between first
and second attacks, four years since second attack.

4. A. J., operated upon during second attack for retroversion.
Twenty-one months between first and second attacks. Twenty-
four months since second attack.

5. M. S., operated upon during third attack for laceration of the
perineum and retroversion. Two and one-half years between first
and second attack, six months between second and third, one year
since third attack.

It will be seen that the first three cases have remained well for
a longer period since the operation that elapsed between the first
and second attacks. The other two have been discharged too
recently to justify any comment.

Six cases have been readmitted with an attack since the operation:

I. R. M., admitted March 30, 1909. She was depressed, made
no voluntary movements, was forced to take food and medicine,
was retarded in speech and movement, had hallucinations of sight.
Operation for lacerations of cervix and perineum and retroversion
on May i, 1909. She was discharged recovered on Dec. 7, 1909,
the attack having lasted eight months. She remained well for
four and one-half years and was readmitted on June 4, 1914 with
an attack of the mixed type. She was depressed, had hallucina-
tions of hearing and at times was violent and resistive. At present
her mental condition is much improved and she is evidently recover-
ing from this attack which has lasted nearly two years. During the

GIBSON: PELVIC DISEASE AND MANIC-DEPRESSIVE INSANITY 443

period of four and one-half years which elapsed between the attacks
she had three children. The uterus at present is moderately retro-
verted but is easily placed in position and the perineum is consider-
ably relaxed. Certainly the operation did this woman no good but
I think we are justified' in thinking that the three children in rapid
succession may have had something to do with the second attack.

2. E. N., admitted Nov. 27, 1893, with an attack of the mixed
type which lasted four months. She was well for seventeen years
and was again admitted on Aug. 17, 1911, with a mixed attack which
lasted three months. Five and one-half months after this she was ad-
mitted with her third attack of the mixed type which lasted seven
months. During this attack she was operated upon for a lacera-
tion of the perineum and retroversion on Aug. 12, 191 2. This at-
tack lasted eleven months and two months later she had a fourth
attack which lasted nine months. She was discharged on February
24, 1914, and has remained well for two years, a longer period than
that which elapsed between the second and third and the third and
fourth attacks. It remains to be seen what she will do. The only
thing that can be said here is that the last attack was not as severe
as the previous ones.

3. A. A. First attack in March, 1885, which lasted two months;
interval of five years. Second attack in 1890 which lasted two
months; interval of three years; third attack of five months, duration
in 1893 followed by five years of sanity; fourth attack of one month
in 1898 after which she was well for ten years. She was operated
upon for laceration of the perineum, retroversion and a cyst of the
right ovary during the fifth attack which lasted for ten months in
1910. She was well for five years and was admitted for the sixth
time on the second of June,' 1915. She was mildly hyperactive,
distractable, flippant, made unreliable statements, was slightly
irritable but her orientation was intact. She is still in the hospital
and is almost recovered. This attack is not quite so severe as the
previous ones but the operation has not helped her much if at all.
The physical result of the operation is good.

4. C' B. Operation during third attack for retroversion; two
attacks since; no benefit from the operation.

5. M. K. Operation for lacerations of cervix and perineum and
cyst of the left ovary during the third attack; two attacks since;
no benefit from the operation.

6. R. S. Operation for lacerations of the cervix and perineum
during the sixth attack; two attacks since; no benefit from the
operation.

It will be observed from the above abstracts that when the patient
has had several attacks and the disease has become well organized
that operation has little or no effect.

There have been seven cases of involution melancholia operated
upon during this period which deserve mention. DeFussac(6)
gives the percentage of recoveries in this psychosis as 32 per cent.

444 GIBSON: PELVIC DISEASE AND MANIC-DEPRESSIVE INSANITY

In our cases four have recovered, two are unimproved three and
five years respectively after the operations and one died of myo-
carditis five years after being operated upon. This giv-es a per-
centage of recoveries of 57 per cent. However, the series is too
small to justify any very conclusive statement.

CONCLUSIONS.

1. No mental improvement may be expected to follow an opera-
tion performed on the pelvic organs of a woman who is suffering
from a psychosis which is characterized by dementia.

2. An operation for the correction of lesions in the pelvis is justi-
fiable in a woman who has manic-depressive insanity and some
improvement may be hoped for if the operation is performed in the
first or second attack.

3. The pelvic pathology is not the cause of the psychosis but
may act as the exciting cause of an attack in a woman of neuropathic
stock.

4. The effect of the operation may be an indirect one by improving
the general physical condition of the patient.

REFERENCES.

1. Gynecological Operations upon the Insane. .Y. I'. Med.
Jour., Feb. 13, 1915.

2. A Preliminary Report of the Gynecological Surgery in the
Manhattan State Hospital. Am. Jour, of Insanity, vol. Ixii, 407.
Operations for Relief of Pelvic Diseases of Insane Women. LeRoy
Broun. Am. Jour. Med. Sci., vol. cxxxi, No. 2.

3. Gynecologic Disease in the Insane and its Relationship to
the Various Forms of Psychoses. F. J. Taussig. Jour. A. M. A.,
vol. Ixi.

4. The Relation of Pelvic Diseases to Mental Disorders. Anne
E. Perkins. Psychiatric Bull. X. Y. State Hospitals, vol. ix, p. 26.

5. Manual of Psychiatry. DeFursac. Trans., RosanofiE, p. 338.

6. Manual of Psychiatry. DeFursac. Trans., Rosanoff, p. 307.
1 76 State Strket. «

maroney: sarcomatous change in uterine fibroids 445

SARCOMATOUS CHANGE IN UTERINE FIBROIDS.*

WM. J. MAROxXEY, M. D.,

Assistant Visiting Gynecologist to St. Vincent's Hospital: Assistant Visiting Obstetrician
to The New York Foundling Hospital,

New York City.

The occurrence of sarcoma in uterine fibroids was first clearly
described by Virchow(i) in 1862. During the past twenty years
there has been a marked increase in the number of cases reported,
due in all probability to wider appreciation of its occurrence in
fibromyomata and a more careful histological examination of the
excised tumors.

The published statistics of the percentage of cases, in which
sarcomatous changes are found in fibroids, varies rather widely.
Miller(2) in a search of the literature collected 9750 cases of fibro-
myomata with 1.9 per cent, sarcomatous changes. Noble(3) col-
lected 2274 with 1.4 per cent.; of the 3,^7 cases under his personal
supervision he found but two sarcomata, about 0.6 per cent. Kelly
and Cullen(4) report 1400 myomata with 17 sarcomata, 1.2 percent.
Alicke(5) reports 17 cases from Leipzig with a percentage of 4 per cent.
Deaver and Pfeiffer(6) made a study of 345 fibromyomata and found
1.2 per cent. Winter(7) reports two series. The first 500 cases, with
microscopical examination of the suspicious spots and found 3.2
per cent. The second series of 253 cases were sectioned systematic-
ally and sarcomatous change was found in 4.3 per cent. Geist(8)
reported twelve cases of sarcomata in a series of 250 fibromyomata
at Mt. Sinai Hospital, giving a percentage of 4.8. The last sixty-
eight cases in the gynecological service at St. Vincent's Hospital
have been examined by Dr. Symmers at the University and Bellevue
Medical College. Sections have been made from all the tumors
with particular attention to suspicious spots. Sarcomatous change
was found in one fibroid.

Statistics compiled from collected reports of cases must neces-
sarily show a more or less wide variance from those derived from a
series of several hundred cases systematically examined in one
laboratory. Then, too, the diagnoses from histological findings in
suspicious growths must be a matter of individual interpretation.

* Read before a meeting of the Xew York Obstetrical Society, May 2, 1916.

446 maroney: sarcomatous change in uterine fibroids

Kelly and CuUen report seventeen suspicious cases in which they
did not feel justified in making a positive diagnosis. Dr. W. L.
StrongCg) says: "The only safe criterion for the diagnosis of sarcoma
of the uterus is in filtrative and destructive growth. Mere richness
in cells, mitoses and even irregularities in size of cell, do not constitute
sarcoma."

The discrepancies between the figures of 1.2 per cent, and 4.8
per cent, may be accounted for in part by considering the number
of cases from which statistics are computed and partly by the differ-
ence of opinion as to what shall be regarded as a diagnostic criterion
for histological diagnosis. For clinical purposes it would seem
that 2 per cent, would be a conservative estimate of the number of
fibroids which undergo sarcomatous change. That is, 2 per cent,
of the fibroids in women who have symptoms which lead them to
seek surgical aid, and not of the total number who have fibro-
myomata.

Etiology. — Unfortunately nothing but negative results have as
yet been obtained in the study of the etiology of mahgnant growths.
These sarcomata occur most frequently after the menopause, though
cases have been reported in 3-oung women between the ages of twenty
and thirty. They have been found in both single and married
women.

Pathology. — The macroscopic changes are usually so slight that
they are seldom recognized. The growth may be diffuse, peduncu-
lated, cystic or racemose. The racemose form of the cervix;
diffuse, friable and bleeding, simulates cancer. Malignant growths
are found subperitoneal, interstitial and submucous.

Schreiber(io) says that metastases in otherwise operable cases
are rare but that the growth may spread with lightning rapidity
to the surrounding pelvic structures. Three of Kelly and CuUen's
seventeen cases coming to autopsy showed metastases. Hen-
nicke(ii) reports a case with extreme thrombosis of the veins of the
right broad ligament and the right spermatic vein, extending almost
to the level of the kidney. The sarcomatous thrombosis was formed
not through coagulation from the sarcoma cells which had their
origin in the connective tissue of the fibromyoma but through
degeneration of the adventitia of the vessel wall and outgrowth into
the lumen of the veins.

It is unusual to find primary sarcomatous change in more than
one area of the myomatous tissue. These changes are described
as having their origin in the interstitial tissues of the fibroid, the
adventitia of the blood and lymph vessels and from the muscle cells.

M.AJIONEY: sarcomatous change IK UTERINE FIBROIDS 447

Those which develop from the interstitial tissue or adventitia are
called myosarcomata. They are tumors with two distinct com-
ponents, a myoma and a sarcoma, both growing independently.
The sarcomata which develop by changes from normal muscle cells
are called myoma sarcomatodes. They are myomata that have
become sarcomatous. Williams(i2) was first to describe the
latter variety and Geist has traced the transition in two of his
cases.

Macroscopically, when the lesion is distinct enough to be recog-
nized, it presents a yellowish-white homogeneous gelatinous tissue
replacing the pinkish-white tissue of the myoma, with its coarse
fibrous arrangement. At times the sarcoma has a porous appearance
or it may contain large and small cyst-like spaces. Occasionally the
tumor is soft and resembles brain tissue and from its surface a con-
siderable amount of fluid may be squeezed. In advanced growths
hemorrhages sometimes take place or there are areas of liquefac-
tion and necrosis giving the tumor a mottled appearance of a
yellowish or brownish color. The sarcomatous changes usually
begin in the central portion of the myoma. Later pure sarcomatous
nodules may be found scattered throughout the uterine walls.

Histologically, spindle cell, round cell, mixed and giant cell types
are found. The spindle cell and mi.xed tj'pes are most common.

The cHnical signs and symptoms are not distinctive. Cachexia
is seldom present except in the late stages with pelvic involvement or
metastases. The usual symptoms of uterine fibromyomata are
present.

The diagnosis is rarely made before and in but few cases at the
time of operation. As a rule, it is only after careful microscopical
examination that sarcoma is found. In thirty cases reported by
Gessmer(i3) all were diagnosed after operation. Winter made the
diagnosis in only one of eleven cases. Warnekross(i4) reported
seven cases in all of which diagnosis was made after operation. Two
of the twelve cases reported by Geist were diagnosed during
operation. The others after careful macroscopic examination.

The treatment is surgical. When sarcoma can be diagnosed
or even suspected, before or during the operation, the indication is
for panhysterectomy. As the glands are rarely involved, a dissection
as wide as that done for uterine cancer is not indicated.

The absence of diagnostic signs and the difiiculty in recognizing
sarcomatous change by macroscopical examination have given rise
to the practice of doing a panhysterectomy in all cases where
hysterectomy is indicated for fibromyomata.

448 iiaroney: sarcomatous change ix uterine fibroids

A study of the case reports of sarcomata in fibroids shows that
recurrence after panhysterectomy is almost as frequent as after
supravaginal hysterectomy. As metastases are infrequent, recur-
rence is not as common as in carcinoma. If panhysterectomy is
adopted as a routine treatment for iibromyomata by the average
surgeon, the increased mortality would more than offset that result-
ing from an occasional recurrence of sarcoma after the supravaginal
operation where sarcoma was not suspected. With careful sys-
tematic examination of all fibroids in the pathological laboratory
the surgeon can, when a positive diagnosis is made, perform a
secondary operation for removal of the cervical stump.

It has also been recommended that a competent pathologist be
present at operations for fibroids, so that, if sarcoma is found or
suspected, a panhysterectomy with excision of parametria may be
done.

The provision for frozen sections during operations hardly seems
practical. In many of the sarcomatous cases a careful systematic
search of many sections is required. The resulting delay and the
difficulty of making a histological diagnosis from frozen sections
compared to paraffine sections, are points to be considered in
weighing its usefulness during operation.

Case Report. — Mrs. C, white, aged fifty-two, married. Admitted
to service of Dr. Aspell at St. Vincent's Hospital September 12,
1915. Discharged October 27, 191 5. Chief complaint: sanguinous
vaginal discharge, pain in lower abdomen and back. Has been
married twenty-five years and has had two children but no mis-
carriages. Menses began at seventeen, regular, lasting from five
to six days with moderate flow. Menopause five years ago at age
of forty-seven. Two years ago the patient began to have occasional
"spotting" and later at irregular intervals profuse bloody discharge.
Pain in lower abdomen and back began ten months ago. Well
nourished, very nervous. But little if any loss of weight. Vaginal
examination: outlet relaxed, cervix normal size, hard. Uterus
appears to be symmetrically enlarged and about the size of an
orange. Diagnosis: Fibroid uterus. Operation September 15,
1915. Supravaginal hysterectomy. The uterus, about the size
of a two months' pregnancy, was bisected after removal and a diag-
nosis of diffuse interstitial fibromyomata of the posterior wall
made. No evidence of disea.se in the appendages or appendix.
The patient made a good postoperative recovery. Three days
later a report was received, from the pathologist, Dr. Symmers,
with a diagnosis of sarcomatous transformation of uterine fibroid.
The following day the patient had a slight chill, her abdomen was
distended and she complained of great pain in the right lower ab-
dominal quadrant. Temperature 102.2°. For the next three days

maroney: sarcomatous change in uterine fibroids 449

the temperature ranged between 102 and 103.8°. She continued to
complain of pain and was extremely tender over right lower quadrant
of abdomen. She was again taken to the operating room on Sep-
tember 21, si.x days after the first operation. Incision was made
over region of appendi.x and entrance was gained through thick
adhesions to large pocket of pus in the region of appendix and right
tube. No search was made for the appendix. The abscess cavity
was drained through the abdomen and vagina by cigarette drains.
On September 28, one week after the second operation, there was
a fecal discharge from the incision over the appendix. The patient
left the hospital on October 27. Both wounds were healed.
Another operation for removal of the cervix was not thought
advisable at this time.

Microscopic examination of paraffine sections removed from the
growth in this case, reveals the presence of a richly cellular tumor
made up of a framework of smooth muscle fibers in the intervals
between which are large and small groups of round cells. The cells
are intermediate in size between a lymphocyte and the ordinary
cell of the large round cell-sarcoma. Each cell is provided with a
small, compact, often peripherally placed, nucleus and a relatively
large amount of smooth, pinkish cytoplasm. Bloodvessels are fairly
numerous.

The source of the infection could not be determined. Kelly
and Cullen call attention to the increased danger of infection
following operations on sarcomatous growths.

Diagnosis. — Sarcomatous transformation of uterine fibromyoma;
round-cell sarcoma.

I wish to express my thanks to Dr. John Aspell for the privilege
of publishing the case report and to Dr. Symmers for the pathological
report.

conclusion.

The possibility of sarcomatous change in fibroid uteri should
always be considered.

.\s soon as the uterus is removed during operation, it should
be bisected and carefully inspected for any evidence or suspicion
of malignant change.

After operation sections should be made and carefully examined
by a competent pathologist.

Panhysterectomy for uterine fibromyomata is indicated only
when sarcomatous change is diagnosed or suspected.

REFERENCES.

1. Virchow (quoted by Geist). Amer. Jour. Obst., vol. Lxix.

2. Miller. Surg., Gyn. and Obst., March, 1913.

450 miller: etiology of sterility in women

3. Noble. Fibroid Tumors of the Uterus. Jour. Amer. Med.
Assoc, Dec, 1906.

4. Kelly and Cullen. Myomata of the Uterus. W.B.Saunders,
Phila. and London, 1909.

5. Alicke. Sarcoma Uteri. Leipzig. B. Georgi, 1900.

6. Deaver. A Year's Work in Hysterectomy.

7. Winter (quoted by Noble).

8. Geist. The Clinical Significance of Sarcomatous Change in
Uterine Fibromyomata. Amer. Jour. Obst., vol. Ixix.

9. Strong. Discussion of Paper: The Clinical Significance of
Sarcomatous Change in Uterine Fibromyomata. Geist.

10. Schreiber (quoted by Kelly and Cullen).

11. Hennicke. tJber einen Fall von Sarcoma Uteri mit ausge-
dehnter sarcomatoser Thrombose der Venae Uterinas und der
Vena Spermatica. Halle A. S.. C. A. Kemmerer & Co., 1902.

12. Williams (quoted by Geist).

13. Gessner (quoted by Geist).

14. Warnekross. (quoted by Geist).
40 East Si.xty-second Street.

ETIOLOGY OF STERH^ITY IN WOMEN.*

G BROWN MILLER, M. D.,

Washington, D. C.

In considering the causes of sterility in women, I thought it might
be of more interest to you to give my personal experience than to
discuss the subject in a general way. My cases, which have been
the most carefully studied, accurately recorded and whose subsequent
histories best followed up, have been private cases. I have, there-
fore, taken the records of these patients complaining of "sterility"
and tabulated the result of my investigation. Some of these
patients complained of other symptoms, but sterility was the one
prominent symptom and at times the only one for which they sought
relief. In all doubtful cases, the husband was examined by a genito-
urinary specialist, and where he was at fault, the case was ruled out
from the number given here. For illustration, if the woman had
a double pyosalpinx due to gonorrhea, it matters not if the husband
is sterile. The woman could not have children by that husband or
any other man. If, however, I could find no definite cause for
sterility on the part of the woman and the husband was sterile, the
woman was absolved from blame. The term "sterile" is applicable
to any woman who is in the child-bearing period in life, has sexual

*|Rea(l before the Joint Meeting of the Washington Obstetrical Socicty[and
the Obstetrical Society of Philadelphia at Philadelphia, .-Vpril 6, ipi6.

miller: etiology of sterility in women 451

relations, does nothing to prevent conception, and does not have
children. It is subdivided into primary and secondary, absolute
and relative. Primary sterility means that the woman has always
been sterUe; secondary sterility that she was at one time and is no
longer capable of child-bearing. Absolute sterility means the impos-
sibility of conception, while relative sterility may mean that the
woman has borne one or more children and does not again conceive,
or that she cannot give birth to a living child. Thus a woman who
habitually miscarries as the result of a uterine fibroid, may be as
sterile as one who has an infantile uterus. In several of my cases,
the patients have been sterile in their second marriage although
they had borne children to their first husbands. In classifying
my cases these are regarded as cases of sterility for that is the
reason why they seek medical advice.

I have in my private records 120 cases of sterility. In diagnosing
the causes of sterilit\' in these cases, I have considered ofily tangible
evidences. I have not included in my classification such subdi-
visions as obesity, anemia, alcoholism, incompatibility of tempera-
ment, abnormal vaginal secretion, thyroidism, want of sexual feel-
ing, too frequent intercourse, etc. I feel that our ideas regarding
them are largely speculative and as I cannot afford to experiment
or make mistakes which can be avoided in my private work, I
consider only those causes about which I feel we have definite
knowledge.

Again, where there is a certain cause of sterility and an uncertain
one, I classify the case under the first heading. Certain cases fall
under more than one heading. As an illustration, where a patient
has fibroid tumors and adherent but not closed tubes, I would classify
the case under both conditions. Of course there may be room for
individual opinions, as to the cause of the sterility in these particular
women. All that I can assert with certainty in some of them is that
the condition named was present; in some it was the evident cause of
the sterility, in others, it may have been only an accompaniment.

The largest number of cases fell under the heading of inflammation
of the Fallopian tubes. I know that this is contrary to the general
belief, but nevertheless in my opinion it was true in my cases.
Twenty-five had gonorrheal salpingitis with closure of the fim-
briated end of the tubes: twelve had tubal disease (salpingitis or
tubal adhesions) due to a puerperal (streptococcic) infection: six
cases were due to an infection which originated in the vermiform
appendix and secondarily involv^ed the tubes: two were due to
adhesions the result of an old tubal pregnancy, and one was

452 miller: etiology of sterility in women

tuberculosis of the tubes. Thus we had forty-six cases where
the sterility was due to tubal closure or inflammation.

Besides these cases, I saw a number of women who did not com-
plain of sterility because they knew that they could not conceive as
their uterus, tubes and ovaries had been removed for these condi-
tions. I believe that in the future, a more careful study will place
more cases of sterility in the class of tubal disease.

The next largest number of cases (thirty in number) fell under the
classification of acute anteflexion with evidences of a narrow or
tortuous cervical canal. Many of these undoubtedly belong in
some other category. Some conceived after dilatation of the cervical
canal, and some in whom no treatment was instituted also after-
ward con ceived. Some possibly had a faulty vagina or abnormal
secretions, or there may have been some incompatibility of tempera-
ment on the part of the husband and wife. I believe that in most
of these cases, that there is a faulty development of the uterus.
These are the cases which give rise to many of the theories of etiology
of sterility, are the subjects too frequently of unwarranted operations,
and in whom some test like that of Hiihner promises to be of value.

Fibroid tumors seemed to play an important role in the etiology
of sterility. There were twenty-five cases complaining of sterility
in which I found fibroid tumors present in the uterus. When
marriage takes place after the woman has reached the age of thirty
years, these tumors certainly play an important role in the causation
of sterility. In a number of the cases repeated miscarriages had
occurred; in a few, the pregnant uterus had to be removed, but in the
majority, I believe that an unhealthy condition of the uterine
mucosa prevented conception. In one case where the operation
took place during the menstrual period, I found that the menstrual
blood was regurgitating through the tubes, one of which was closed
forming a hematosalpinx. I am convinced that a considerable
number of diseased tubes which are found accompanying these
tumors are due to the above-mentioned condition, and the sterility
is due, in a certain number of cases, to this closure of the tubes.

There were eight cases of retroposition of the uterus without any
other abnormality which could be detected. I have definitely con-
vinced myself that this is the cause of the sterility in a large propor-
tion of such cases. One patient had given birth to a premature
infant six to eight years before and was anxious to have another
child, but had not conceived. After an operation to hold up the
retroverted uterus, she promptly conceived and bore a living child.
Another patient who had been married two or more years and who

miller: etiology of sterility in women 453

had not had a child, was found to have the same condition. Among
others, she consulted one of your prominent gynecologists here, a
suspension of the uterus was done and she conceived the first time
sexual intercourse took place after the operation.

There were three cases of maldevelopment of the uterus (infantile
uterus). One, at times, makes mistakes in such cases. I recall one
woman in whom the uterus was apparently about two-thirds the
normal size, whose periods were very infrequent and scanty, who
had had a dilatation and curettage done with no apparent result, and
who after several years conceived and bore a healthy child and who
is again pregnant. But when the uterus is extremely small, and when
there is little or no menstrual flow, and where the patient has never
been pregnant, this can be regarded as a definite cause of sterility.

There were four cases of imperforate hymen, and two of vaginismus.
In the cases of the imperforate hymen, there had never been an
entrance into the vagina, and while conception is possible without
this, I believe it can be put down as a definite cause of this com-
plaint. The cases of vaginismus both conceived after I had done
a plastic operation upon the entrance to the vagina. In five cases,
an ovarian tumor had been removed, and in four, the sterility was
due to a double ovariotomy for dysmenorrhea.

There were two cases of endocervicitis, one of cervical polyp,
one of enlarged cystic cervical glands, and one of sv^Dhilis. There
were no certain cases of maldevelopment of the tubes or ovaries.

You have perhaps noticed that I have not included in my classifi-
cation many of the supposed causes of sterility. Narrowing of the
upper portion of the vagina has been especially dwelt upon recently.
I have never been able to convince myself that this condition had
anything to do with sterihty and I would certainly warn against
operations to remedy this supposed cause without the most careful
study of the case. Obesity, anemia, the a;-ray, wasting diseases,
and climatic conditions certainly cause cessation of the menses, at
times, and undoubtedly can be considered as causes of sterility.
Some of the others, such as abnormal acidity or alkalidity of the
vaginal secretions, incompatibility of temperament, want of sexual
feeling, spasmodic contraction of the uterine ligament, thyroidism,
acromegaly, etc., I know nothing about and regard many of them as
fanciful.

One or two are worth investigation; for example, sterility due to

an abnormal reaction of the vaginal or cervical secretions. In regard

to most of them, our knowledge is too meager to be of any value in

determining their truth. Medical theories not based upon proof,

454 stone: the lessened fertility of women

are liable to lead us into grave errors. I cannot afford to experi-
ment upon my private patients and my statistics may appear too
conservative. In regard to the etiology and sterility, the sper-
matozoa test of Hiihner promises to be of practical value in individual
cases. It has its limitations and will, in many cases, lead us into
error, but it is well worth investigation if, as he says "'several hours
after sexual intercourse we find live spermatozoa in the cervical
secretion, we can absolve the man from blame, and know that the
cause of sterihty is due to some abnormality higher up in the woman's
genital tract." It will be by such practical tests as this by which we
wiU make advances in our knowledge of this subject — not by
theorizing.

1730 K Street, N. W.

THE LESSENED FERTILITY OF WOMEN, ESPECL\LLY
A]\IERICAN WOMEN*

I. S. STONE, ?il. D.,
Washington, D. C.

The study now being made in certain countries, including our
own, of the infertihty of women, will throw light upon the various
means of limiting the birth rate. That such practices have greatly
reduced the birth rate in the United States, especially among native
women, is admitted by nearly everyone with interest enough in the
subject to read available literature. That selfishness, luxury, and
perhaps erratic philosophy, are largely responsible for this condition
of affairs seems to us beyond question.

In accordance with my instructions I shall briefly consider the
fertility or fecundity rather than the sterility of women.

It is impossible to give a connected statement of results of studies
of this question which have been made in the more civilized countries.
The number of children born has been tabulated in several countries,
but until within a comparatively short time no analysis has been
attempted. France made the first definite effort to probe the sub-
ject from 1900 to 1906, and this country since that time has developed
some features of our 1910 census which, however inadequate, give
promise of more reliable and extensive work in the future. f

It has been shown by these studies that our native population is

* Read before the Joint Meeting of the Washington and Philadelphia Obstet-
rical Society at Philadelphia, April 6, 1916.

t See Hill, J. A., Qiiarl. Pub. Amer. Statist. Assn., Boston, Dec, 1913.

stone: the lessened fertility of women 455

fast approaching a standstill; that we are depending upon immigra-
tion to populate our vast estate, and that our native women are
not willing to give birth to such large numbers of children as did
their parents or grandparents. The decline of the birthrate in the
United States among native women is now comparable to that of
France, where the birth rate exceeds the death rate only by a narrow
margin. The population of France a century ago exceeded that of
Germany, and in the time of Louis XIV that country had 35 per
cent, of the entire population of Europe. Now she has only 13 per
cent., and a population of 40,000,000 to Germany's 65,000,000.
Another striking fact is apparent in view of our assimilation of the
various elements of foreign peoples who come hither, namely, the
decline in their fertility. Foreign women of the poorer classes as a
rule are fruitful. There is only one in twenty infertile in such por-
tions of this country where statistics have been carefully kept and
studied. Alongside of these are our native white women, of whom
one in eight is childless. The result of residence in America is shown
in the second generation of immigrants, for the fertility is reduced
to 5.3 per cent, from 6.5 per cent. There are 13. i per cent, of our
native women, both parents having been born in America, who are
infertile. Certain European peoples, for instance the Poles, who come
to this country, have 6.2 as the average number of children in each
family. The average in French Canadian families is 5.6 per cent.,
while in native American families there are two or three children.

The very atmosphere in some States seems to favor infertihty, for
the negro women (who are notably prolific) living in northern States
are following the examples of the whites. The number of negro
women having no children (in the States where these studies were
made) scarcely equals the native whites, although women who are not
infertile have a larger number of children than the white women.

As to the relative tendency to have large families, the United States
stands very low in the scale, as may be seen by reference to the
accompanying scale:

Polish 60.9

Canadian French S3.o

Danish 39-6

Italian 37.0

Austrian 37.0

French 32.0

Swiss 31.0

German 30. o

Scotch 20.0

English 18. o

American 9.9

456 stone: the lessened fertility of women

Here we have a place at the bottom of a long list of countries
arranged according to the number of families having five or more
children. The Canadian French have 53 per cent, of such families
and Poland has 60, the latter leading all other countries, while
America (the U. S. A.) has 9.9 per cent.

The study of the infertility of American women and their high per-
centage of sterility by the late Dr. Geo. J. Engleman, has left but
little for us to add from recent literature, save what we quote from
the United States Census. Engleman wrote that "in the early days
of our country's history eight or nine children were born in each
family. A century ago the number had decreased to four or five,
and at the beginning of the twentieth century there are only two
children per family among the native whites." The families with
one child are also more numerous here than elsewhere, with the
exception of France. Here is positive evidence of intervention or
prevention of some kind, rather than of sterility due to disease.

The late Carroll D. Wright made a study of highly educated
women which showed that married college women, in both England
and America, are less fertile than most others, their average number of
children being 1.3 to 1.6 per cent. Women of the same social
class, not college bred, had a higher rate of 2 per cent.

These tables have been selected from those published in the Quart.
Pub. American Statistical Assoc, Boston, December, 1913. The
studies reported in this journal are made by Mr. J. A. Hill, chief
statistician of the Bureau of the Census, assisted by M. A. Parmelee.
In order to compare the fertihty of native- and foreign-born women
in the United States, the work of the National Immigration Commis-
sion was used, which in turn took up and considered the three last
Census reports, 1890, 1900 and 1910. They selected counties of
Ohio and the city of Cleveland. Also, counties of Minnesota and
the city of Minneapolis. Finally, the entire State of Rhode Island
was canvassed, probably because the population is largely urban,
and the native and foreign elements are nearly equal. The women,
as a rule, were living in the second decade of married life.

White, native parentage. . . .- iS-953

White, foreign parentage 61 .816

White, native without children 2.097

White, foreign without children 3 -541

White native women without children 13- '

White foreign without children S • 7

Negroes tabulated 663.0

Bearing no children 136.0

Percentage 20. s

stone: the lessened fertility of women 457

the cause of the lessened fertility of american women.

It is useless to ascribe our lessened birth rate to disease as a
principal factor. Several authorities claim that 12 per cent, of
sterility due to disease will include all disability of this kind. Neither
have we proof that venereal disease is increasing as rapidly as the
birth rate declines. It is generally admitted that the relative steril-
ity of men is as one in seven or eight, hence the husband frequently
comes in for his share of responsibility for this state of affairs. But
whatever the supposition as to the relative sterility of the sexes, we
must admit, and it appears to be the prevalent opinion, that limi-
tation has become well-nigh universal among the prosperous and
educated classes everywhere.

We know that the most prolific period of married life is from twenty
to thirty years, or the first decade thereof. We also know that
marriage is almost impossible at this age among the educated classes,
because the present demands of our educational system require
eight or ten years longer than was the rule fifty years ago.

The solution of the problem is no longer one to be studied by
medical men alone. It must inevitably become the concern of all
patriotic citizens of mature mind. One of the tendencies of our
people is to rush along the highway leading to financial success.
This, indeed, is the time of the "strenuous life." ThegHtterof wealth,
the determination to get rich quickly, the intensive business and
educational methods of the day, each and all are opposed to the
growing of large families. This is true of women largely because they
are becoming independent of men and of marriage. They have
"careers." They are rapidly throwing oS their willingness to bear
children, and both women and men easily fall before the specious
philosophy of Malthus that too many children may become a burden
to the State and to society. Large families were reared when luxury
was not the rule, but rather when the home and the fireside was more
attractive than the diversions of the time, which now do much to
disrupt the intimate association so essential to conjugal love.

Another influence has been at work which appears to me most
powerful in the decline of the birth rate, namely, the lessened or
diminishing influence of religious denominations. The French
Canadians, who generally belong to the Roman Catholic church, are
very loyal to its teaching as regards the birth of children. The
difference is striking between them and the Canadian English and
those in the mother country, where, it is well known, the church
has lost its former prestige and its influence upon the mass of the

458 sullr'an: ad\is.'Vbility of artificial sterilization

people. But whatever the Catholic church may have done or has
failed to do, there is more free agency everywhere and more con-
sideration of individual comfort than obedience to religious duties
or duty to the State.

THE DUTY OF PHYSICI.\NS

In view of the complex problem which has produced these results,
it is difficult for us to comprehend the whole question or to announce
a cure for the evils we have mentioned. Perhaps another generation
may find a remedy, or at least make a correct valuation of the
apparent dangers to our national welfare.

In the meantime, there is a degree of probability but strong pres-
sure may induce many professional men to advise contraceptives, or
to intervene in order to gratify the whims of women who imagine
that they are physically unable to bear a child, or more than one
or two children, when they are perfectly competent to do so. We
know that some physicians advise against impregnation subsequent to
either trachelorrhaphy or perineorrhaphy. We know that women are
frequently told that after the birth of one or two children the dis-
placement may be cured and the lacerations repaired, with the inti-
mation that such repair work must not be subjected to the test of
subsequent parturition. The attitude of the physician may have
much to do with the limitation of famihes in this way as in many
others. There is room for the belief that professional opinion is
gradually changing in the direction of popular opinion and that it,
too, follows the "easiest way."

Stoneleigh Court.

THE INDICATIONS FOR AND ADVISABILITY OF
ARTIFICIAL STERILIZATION.*

BY
ROBERT YOUNG SULLIVAN, M. D.,

Washington, D. C.

The controversy between theology and medicine concerning the
rights of the patient and the physician's duties to his various maladies
is as old as the history of medicine. Where science has shown un-
deniable facts theology has given ground begrudgingly toward the
real protection of the patient's interests. The sanctity of the human

* Read before the Joint Meeting of the Washington Obstetrical Society and the
Obstetrical Society of Philadelphia, at Philadelphia /\pril 6, 1916.

SULLr\AX: ADVIS.'^ILITV OF ARTIFICIAL STERILIZATION 459

body has always held the reverence of men to the extent that in-
herently we shrink from desecrating either the living or dead form.

In preparing this paper I have experienced the strange change of
opinion from one of rather enthusiastic behef that artificial steriliza-
tion should be freely practised to a wonderfully more consistent
opinion that the indications for such procedure are very few, but
when present are decidedh' advantageous. The subject is one in
which no broad rule can apply but onl}' very particular cases may
be so treated and then only with many safeguards.

In his writings upon sexual hygiene after detailing the ill effects
of intercourse with efforts to protect against conception, Edgar
says: "There is, however, one course possible, which may be recom-
mended as both safe and efficacious, which can hardly be abused.
This is obliteration of the Fallopian tubes for a short extent by the
vaginal route. This is unobjectionable from any standpoint, and
yet I fear it hardly constitutes a solution of the problem."

There are legal grounds for the support of sterilization operations.
The following States have enacted laws allowing sterilization of
defectives and making the sterilization of criminals obligatory.
These are Indiana, Washington, Nevada, New Jersey, New York,
North Dakota, Michigan, Kansas, Wisconsin, Te.xas and Cali-
fornia. Pennsylvania has three times passed such statutes only
to be vetoed by two governors in 1905, 1909 and 1911. To Penns}^-
vania belongs the claim of priority for such legislation, since the
Indiana act, the first to become a law, was not passed until 1907.
The first attempt was made in Pennsylvania in 1905.

At present the laws of this .caliber are very much alike, but in
two States only have operations been done, Indiana and California.
The truth is these laws are imperfect and in two instances have
been repealed as unconstitutional, in New Jersey and Iowa.

The problem of personal liberty has been brought to view in this
matter in a conflict with the eighth Constitutional Amendment of
the U. S. which reads as follows:

''Excessive bail shall not be required, nor excessive fine imposed,
no cruel nor unusual punishment inflicted."

There is also conflict with the fourteenth Constitutional Amend-
ment which guarantees equal protection to all.

With regard to criminals this seems cruel punishment inasmuch
as the possibility of inheritance is much in doubt with regard to
both insanity and crime. It is believed that the laws of psychiatry,
formerly accepted to prove the surety of inheritance in mental

460 SULLIVAN: ADVISABILITY OF ARTIFICIAL STERILIZATION

tendencies will be rewritten to the effect that what has formerly
been ascribed to inheritance will be seen as due to environment.

Hence to quote White we find " It will be seen that by construct-
ing elaborate family trees, reaching back over several generations
it may not infrequently be possible to trace a bad trait and see its
culmination in certain individuals; but that is a very different
matter from predicting what the next generation is going to show.
It is the difference between explaining and forecasting.

In an article, "Inheritance as a Factor in Criminality," Drs.
Edith R. Spaulding and William Healy report "In the looo cases
we have reviewed, we carefully sought for evidence of direct inherit-
ance of criminalistic traits, as such. However, in no one case of
the looo have we been able to discover evidence of antisocial
tendencies in succeeding generations without also finding under-
l^-ing trouble of physical and mental nature or such striking en\dron-
mental faults as often develop delinquency in the absence of defective
inheritance."

Continuing they say, " All told, the indirecti nfluence of heredity
on criminalism in our cases appears to be that in 35 per cent, there
is predominantly a transmission of mental and physical defects and
that in 9 per cent, inheritance is partially responsible."

Concerning our ability at the present time to ascertain those
who should be sterihzed, Dr. Wm. A. White, Superintendent of the
Government for Insane, Washington, D. C, says, "A word in this
connection with regard to negative eugenics. There has been a
tendency of recent years to pass laws providing for sterilization of
certain classes of defectives and delinquents in the community.''

"The amount of knowledge of an individual that would make it
scientifically justifiable to sterilize him is an amount that is rarely
obtainable in so far as I know where this work has been done, there
has been little or no effort to obtain that knowledge, whether its
desirability was or was not appreciated. The only condition where
this method might theoretically be justified, with the minimum
amount of knowledge, would be conditions in which the disorder
from which the person suffered was dominant, and therefore,
would be transmitted to the progeny. We must remember, how-
ever, that even in dominant traits, union with healthy persons may
produce healthy children, and unless there are going to be at least
two children, no prediction is justifiable."

"If the mating were productive of only a single child, as so many
matings are these days, there is no reason why the child should not
be the well child, and if well, it might grow up to useful citizenship.

SULLIVAN: ADVaSABILITY OF ARTIFICLA.L STERILIZATION 461

"To take the responsibility of intervening at this point and pre-
venting such an issue is a very grave matter and warrants a much
profounder knowledge than we can claim at present.

"On the other hand, if the trait is recessive only a very careful
examination will make that clear, then only rarely will it be anything
more than a probability. To sterilize such a person is a still graver
responsibility, for a mating with healthy stock will eliminate the
disease without even any sick progeny as the price."

Dr. Henry H. Goddard in work done in connection with the Russell
Sage Foundation in speaking of sterihzing feeble-minded persons,
teaching them to work, and then sending them to their homes,
obviously a long and laborious task, says: "We thus see that in the
present status of the problem, neither of the plans, segregation nor
sterihzation will solve the problem at once but since both are good,
and both contribute somewhat to the solution, the only logical
conclusion is that we must make use of both methods to the fullest
extent possible." Continuing he says, "The situation is fast
becoming intolerable and we must seize upon every method that is
suggested and offers any probability of helping in the solution of
the problem. In other words, it is not a question of segregation
or sterilization but of segregation and sterilization."

Dr. Martin W. Barr, Chief Physician to Pennsylvania Training
School for feeble-minded children says, "There is nothing that
clings through generations like insanity, so related as it is to idiocy;
and after all the difference is one of degree rather than of kind. In
a careful study of insanity covering a period of nine years based on
investigation of 138,500 individuals 20.5 per cent, was found due
to heredity." He also says that it is estimated that there are 15,000
feeble-minded in the State of Pennsylvania and one in each five
hundred throughout the United States.

In view of the fact that the information at hand concerning he-
reditary influences and the power to transmit them is in doubt, as
shown by expert opinion and that these experts differ widely it
would seem that at present mental defect should not constitute
ground for sterilization, since scientific and legal right is in doubt.

Investigators in embryology and also in obstetrics seem to show
that the rate of so-called spontaneous abortion occurs once in six
pregnancies. Any standard obstetric work in its chapters on the
pathology of pregnancy will give the indications for and describe
at length conditions that demand emptying of the uterus either
after curative treatment has been instituted, or forthwith as soon
as diagnosed.

462 SULLIVAN: advis.'^bility of artificial sterilization

Certain systemic, infectious and constitutional diseases seem
prone to cause abortion or premature labor in the majority of
instances when pregnancy occurs and yet this condition will result
nearly as readily as in the normal.

Recognizing these points it seems that nature is a prolific provider,
but pathologic conditions have caused an inordinate waste. It is
also true that such efforts are attended with some severe penalty
by the human economy. It would seem that diversion of these
tendencies would result in advantage.

It is true that there is a stronger tendenc)' at this time toward
terminating pregnancies, for just cause in the unfit, than ever before.
This is legal, ethical and scientific. It meets rehgious opposition
properly and when not based upon the soundest scientific necessity
should be met by stronger objection from the profession than
religious sects could ever offer. However, does not the need of
therapeutic abortion, done with rehgious conscience, admit the
probability that there are those who are unfit to go through preg-
nancy and labor? I think so. There is not the merest suggestion
here that a sterilizing operation may be a less formidable under-
taking to the patient than emptying of the uterus, but to say that,
in some instances, where abortion will be necessary, sterilization
can be done and thus anticipate that risk without adding but
reducing ultimate danger in particular instances. Individualization
is the keynote upon which this matter rests.

Investigators of psychology and neurology with derision decry
the practice of continence in the married. The younger Keyes likens
the situation to that of the wild beast fed without meat. He says
that for the most part there is no need of se.xual gratification,
although the appetite is present, until the first taste of carnal food.
After initiation there is a different mental and nervous complex,
a near necessity. Contact without normal expression produces
defense reactions that tend toward mental and "nervous instability.
The sexual act was originated in all its attraction for the purpose of
procreation, but also as a means of expression of the deepest emotion
that souls possess.

Unquestionably there are those who are unfit and those mentally
deficient so that offspring would not be desirable. In such instances
if sexual life is entered into, emptying of the uterus will spontaneously
occur or should be induced in by far the largest portion, according
to the conditions as they occur. There arc particular instances,
however, where emptying of the uterus is not to be chosen for

sulliv'an: advisability of artificial sterilization 463

sterilization will protect the physical and moral life of those whose
strength cannot surmount the strain of pregnancy and labor.
The classes of cases in which sterilization may be considered are:

1. Conditions where the severit}' of the lesion warrants steriliza-
tion.

2. Conditions that are so fraught with danger when the strair" of
pregnancy and labor are added and particular experience has bec^
known to be attended with calamity.

3. Patients who have done their part toward procreation success-
fully and in whom other operative procedures are necessary that
makes sterihzation also possible and attended with no additional
risk.

4. Skeletal deformities presenting absolute disproportion between
the passenger and the pelvic canal.

Within these groups are the tuberculous patient, the one who
has severe cardiovascular upset during pregnancy, the kidney
group, principally Bright's, attended with the kidney of pregnancy,
the faulty metaboHc conditions attended with diabetes.

Standard authorities on obstetric treatments are pronounced in
their teaching that the tuberculous patient, the typical heart patient
and the kidney case should not marry and should not bear children.
What should be the course of procedure if any one of these condi-
tions obtains when the prospect of pregnancy is likely, for instance
after marriage, when no evidence of such had been formerly sus-
pected? The operation to effect sterility is not of major importance
and may even be done with cocaine. In well-guarded conditions it
should be advised.

Osier in his writings on tuberculosis has said that, "There is
much truth in the remark of DuBois: If a woman threatened with
phthisis marries she may bear the first labor well; a second with
difiiculty, a third never."

The effect of pregnancy upon tuberculosis is universally beheved
to be grave; failure occurring after delivery, while the course of
pregnancy is oftentimes without serious moment. Tuberculous
women are known to conceive rapidly, giving birth to well-developed
normal children. There is little evidence of intrauterine infection
of the fetus, the children when infected, evidently contract the disease
from contact with the mothers. In view of the universal failure of
tuberculous women following delivery, sterilization would seem to
be plausible, especially in incipient cases, when operating for some
other indication.

Concerning the valvular heart lesions that become decompensated

464 SULLIVAN: advisability of artificial sterilization

during pregnancy Williams quotes various series of cases estimating
maternal mortality to be from 6 per cent, to 60 per cent, according
to different investigators. His own view seems to be optimistic.
He says, however, that women suffering from heart lesions should
oftentimes be dissuaded from marriage and child-bearing. On the
other hand, it is his opinion that such cases oftentimes present
agreeable surprises, although the seriousness of this lesion should
always be kept in mind. In view of the fact that the decom-
pensated heart lesions, especially double lesions, do present serious
complications to labor sterilization may well be done in such
instances. This is particularly true when a former labor had been
attended with serious circulatory failure, jeopardizing the patient's
life or requiring emptying of the uterus. In such instances chronic
heart lesions should be looked upon as indications for sterihzation
on account of the condition itself or when some other operation is
being done.

DeLee in speaking of decompensated heart lesions and advanced
kidney disease, nephritis, says: "These patients should not marry,
but if they do should not conceive." He says, however, that both
conditions tend to premature labor, and that the ultimate risk is
great.

Defective kidneys are seriously injured by the advent of preg-
nancy. The promise of recovery by induction of abortion in such
cases is productive of disappointment, the disease seeming to have
been given added impetus by pregnancy. Where nephritis exists,
especially after experience of disquieting nature in the course of
pregnancy terminating in spontaneous or therapeutic abortion,
excision of a portion of the tubes may be done and will greatly insure
the welfare of such sufferers. It is obvious that no such undertaking
could be considered as an elective procedure, the necessity of such
immediate shock would tend to offset too greatly the future ad-
vantage. The nephrectometized patient is not a candidate for
sterilization unless the remaining kidney is decidedly crippled.
Emptying of the uterus should answer her need should it come.

The disorders classified as the toxemias of pregnancy do not
warrant prophylactic excision of portions of the tube. There is
not enough evidence to prove their successive appearance and the
serious cases may be better handled by therapeutic abortion.

With regard to skeletal deformities much change of opinion has
come about. With the improved technic of Cesarean section and
pubiotomy it is much less urgent to arrange that such patients
cannot conceive. Within the proper surroundings absolute pelvic

SULLIVAN: ADVISABILITY OF .■UmFICIAL STERILIZATION 465

contraction and spinal deformities do not constitute indications for
sterilization. This is certainly so with the first pregnancy, since
although the fetus be dehvered in prime condition other offspring
may be desired. Even if the patient so desires she should be dis-
suaded after the first Cesarean at least. Should two sections prove
necessary the patient's wishes may be given first consideration
and the operation done at the time of Cesarean.

Osteomalacia constitutes the only positive indication for steriliza-
tion per se. In this country this condition is a rare occurrence.
It is a peculiar coincidence that this tropho-neurosis is of such
severity in producing skeletal deformity as to demand immediate
salpingo-oophorectomy. It is also strange that it offers the only
instance among these conditions requiring sterility that remov^al of
the ovary and not excision of the tube is necessary.

There is a large group of cases that deserve relief from further
child-bearing. These are women who have well done their share
toward procreation. In such instances where four, five or six chil-
dren are living and a repair operation is being done while these
patients are still in the child-bearing age, they should be allowed to
divert their attention to the more perfect care of these already born.
I feel that this is right where it is the patient's choice. For the wo-
man who seeks to avoid the anxiety and danger of pregnancy for
convenience only of course no consideration is deserved.

The attendant circumstances under which such practice may be
undertaken are:

It shall be done with the patient's or guardian's approval.

With the exception of osteomalacia no disorder is of itself suffi-
cient to warrant sterilization without at least one trial pregnancy
and labor.

It may be done when an individual patient's experience with
pregnancy and labor has been shown to be a serious menace to heklth
and life.

Those women who have thoroughly done their part toward child-
bearing, in whom other defects demand operative procedures that
would also allow sterilizing operations to be done, should be pro-
tected from further efforts.

For the majority of instances where this practice is to be instituted
consultation should be necessary.

Nature has taken it upon herself to provide spontaneous sterilizing
processes, gonorrhea and syphilis. The former effectively sterilizes
a large deficient class, the prostitutes; the feeble-minded is likely to
choose one infected as her sexual consort and is thus much more

466 HYDE: TUBERCULOUS PERITONITIS AN ANALYSIS

frequently exposed. Syphilis insures the success of the former by
aborting those unfit to finish the task of pregnancy and later parent-
hood.

The other indications for birth control, namely, the heart case,
the kidney case, the metabohc case are prone to abort spontaneously;
hence, there is a natural sterilizing process which behttles the efforts
of humans.

Inasmuch as the first order of nature is reproduction, has man in
the absence of undeniable fact upon which to base his action the
moral or technical right to reduce this fundamental principle? In
the presence of positive lesions of gravity, with previous experience
of near fatal termination, sterilization is like any other therapeutic
procedure and should be advised when it saves life or preserves
health.

REFERENCES.

Osier. Practice of Medicine, p. 329.

Williams. Obstetrics, 2nd Edition, p. 489.

DeLee. Principles and Practice of Obstetrics, 2nd Edition, p 487.

Edgar. Practice of Obstetrics, p. 39.

Ashton. Practice of Gynecology, p. 143

White. Jour. Anier. Inst, of Crim., vol. v.

Spaulding. Jour. Amer. Inst, of Crim., vol. v.

Healy. Jour. Amer. Inst, of Crim., vol. v.

Barr. Alienist and Neurologist, vol. xxxiv, 191 5.

TUBERCULOUS PERITONITIS— AN ANALYSIS.*

CLARENCE REGINALD HYDE, A. M., M. D., F. A. C. S.,

Brooklyn. N. Y.

It is the writer's opinion, reinforced by a review of the Hterature,
by conversations with other operators, and from observing a number
of cases of tuberculous peritonitis, personal and otherwise, that this
lesion has received but confused attention from g\Tiecologists; and
that its recognition constitutes a neglected study in our particular
field. The only gynecologist in Brooklyn who, to my knowledge,
ever gave this type of tuberculosis any real serious thought, was the

* Read before the Brooklyn Gynecological Society, jMay s, 1916.

HYDE: TUBERCULOUS PERITONITIS AN ANALYSIS -467

late Dr. George McNaughton. At the time of the reading of his
paper before the Brooklyn GvTiecological Society, he lamented the
fact that so little attention had been directed to the careful considera-
tion of this affection. Gynecologists have, in late years, given all
of their thought and time to the cure of uterine prolapse, the cancer
problem, the devising of the best operative technic for the correction
of uterine retrodisplacements, and to plastic procedures for the
restoration and repair of anterior and posterior vaginal walls. We
have had some seven discursive years of this, the pendulum swing-
ing vigorously in all directions, but we can't positively diagnose
tuberculous peritonitis. And yet the claim is made that the gyne-
cologist has exhausted every subject of interest in his specialty.

Our attention has been strongly directed to a more serious analysis
of this type of tuberculosis from a study of two cases in our service
at the L. I. C. H. Never in our experience were there two such dis-
similar cases of the same lesion. And, as was afterward noted,
though both bore all the hall-marks of tuberculosis, yet, not until
both cases went to operation and were sectioned, was the condition
diagnosed. One was stout, red-cheeked, a picture of health, and
engaging in outdoor sports: the other, emaciated, febrile, pro-
foundly weak, and with marked abdominal distention. On section,
both presented a peritoneum studded with miliary tubercles. The
stout subject had little free fluid, a few adhesions, but a tuberculous
appendix. The emaciated subject showed a much distended abdo-
men, which on section revealed much free fluid, very extensive
adhesions, and the tuberculosis involving uterus, ovaries, and tubes
and extending well up under the hver. There were no encysted
nor encapsulated collections of fluid. In the stout case, the appendix
was removed, the fluid sponged out, and the abdomen closed \\dthout
drainage. A fecal fistula promptly resulted. Further convales-
cence was uneventful. I expected to reoperate and close the fistula,
but, one day, the patient after a severe set of tennis began to vomit
and showed all signs of intestinal obstruction. On removal to the
hospital and reopening the abdomen, there were absolutely no signs
of tuberculosis such as tubercles or fluid. The end results, however,
were present as dense intestinal adhesions. The intestines were
acutely injected from an acute fulminating peritonitis which was
due to the fact that the fistulous cecum had evidently been torn
from the abdominal wall allowing the escape of intestinal contents
into the peritoneal cavity. Extensive drainage, with repair of
wounded surfaces proved unavaihng, the patient dying in twenty-
four hours, profoundly toxic.

468 HYDE: TUBERCULOUS PERITONITIS AN ANALYSIS

The thin, emaciated case with general pelvic tuberculosis of the
uterus and adnexa, was panhysterectomized, the fluid sponged out,
and the abdomen closed without drainage. After operation hygienic
measures were instituted, the patient remaining on the roof the
whole day. In addition, this was combined with supportive reme-
dies. The case grew progressively worse, emaciating rapidly and
with constant leakage of fluid through the vaginal vault incision.
Three months later she died. Autopsy revealed pulmonary tubercu-
losis, with general tuberculous peritonitis and extensive adhesions.
The cecum was adherent to the scar of the hysterectomy in the
vaginal vault. There was a large encysted abscess of a circular
form, walled in by the ascending, transverse, and descending colon
and omentum. This abscess ran from the vagina up under the liver,
across under the stomach, and down again to the vagina. It was
an encysted collection of pus as is frequently found in these cases.

Now please note that in one case the appendix was removed and a
fecal fistula resulted. In the other case there was a panhysterec-
tomy, and this was followed by immediate and constant leakage,
although the vaginal walls were tightly sutured. Both cases were
not drained. I call your attention to these particular facts, as the
discussion will probably be directed to this phase of the operative
technic.

With these cases in mind, our interest was stimulated to read up
a much neglected subject, and we are the gainers thereby. We trust
that this short brochure will be a help to those who may later en-
counter a case of tuberculous peritonitis. As in missed ectopic,
when we make a mistaken diagnosis, and on opening the abdomen
find an unruptured or a ruptured gestation sac, and when afterward
we review the history more carefully, there is the whole picture before
us. The history was fairly crying aloud, 'ectopic,' and we wouldn't
hear. So in these two cases of tuberculous peritonitis, neither one
was diagnosed prior to operation, and yet a later reading of the his-
tories showed us plainly and clearly, that these two cases could not
have been anything else. I might mention here that the first case
was diagnosed as chronic appendicitis, and the other, as some malig-
nant intestinal lesion. Both cases had been seen, also, in consulta-
tion by two other medical men, and tuberculosis was not mentioned
nor suspected.

Our study of the literature was confined almost entirely to symp-
tomatology, diagnosis and treatment, with the reading of numerous
case reports. We will endeavor to give you a composite synopsis
of this study.

HYDE: TUBERCULOUS PERITONITIS AN ANALYSIS 469

Tuberculous peritonitis is always secondary to some other tuber-
culous focus and may be either of the wet or dry variety. It is in
the former that surgery, though at times empirical, has its successes,
if any. The lungs may be the starting point from which the bacillus
tuberculosis gains entrance into the blood stream and is carried to
the peritoneal cavity or to the tubes. Baumgarten thinks that
Fallopian tube tuberculosis is never primary, but that the tube has
been infected from its peritoneal surface. The peritonitis may be
secondary to lesions of the bladder and rectum or develop from
tuberculous intestinal ulcers. A tuberculous appendi.x is a frequent
cause. It may develop from a tuberculous uterus, vagina, or vulva,
but these entrances of infection are rare, as the infection usually
comes from above downward. It is a disease of early life, uncom-
mon after the age of thirty-five, and more frequently occurring
between the ages of eighteen and thirty-five. Lupus and tuberculous
joints are never associated with tuberculous peritonitis. The bacilli
are rarely discovered in the ascitic fluid, nor in encapsulated collec-
tions of pus. They may be abundant in the cheesy foci or can be
detected if a tubercle is crushed and freshly examined on a cover slip.
It is necessary, oftentimes, to make an e.xhaustive and pains-
taking search before the bacillus can be found.

Sy^nptomalology. — Tuberculous peritonitis may begin acutely, or
may be chronic from the start. The patient begins to have malaise,
gastrointestinal prodromes such as colic, with alternating constipa-
tion and diarrhea. The first fact to attract her attention is the
enlargement of her abdomen due to the serous effusion. In a young
woman with no history of uterine or tubal infection, she shows symp-
toms of a chronic pelvic inflammation. This fact alone ought to be
sufficient to put the observer on his guard and arouse his suspicion
as to the probable etiological factor present. The onset is gradual
and not acute as in acute pelvic infections, but the progress is per-
sistent with no periods of improvement, as in the case of a classical
pelvic inflammation. Whitridge Williams says that a large propor-
tion of adherent tubes and ovaries removed on account of pelvic
inflammation are, in reality, tuberculous.

Emaciation is also gradual but persistent, and there are usually
evidences of tuberculosis elsewhere. The tubercuhn test is of mate-
rial aid in doubtful cases, avoiding the ophthalmic. In one of my
cases, the von Pirquet gave the most violent and starthng reaction
I ever witnessed, but I thought, at that time, that the lungs were the
seat of an incipienftuberculosis.

While emaciation is generally present, the patient may present a

470 HYDE: TUBERCULOUS PERITONITIS AN ANALYSIS

picture of blooming health and robustness, and yet have a most
extensive tuberculous peritonitis, as in one of my cases. Eighty
per cent, of Kelly's cases were of this type.

Abdominal pain of varying character and intensity is the most
constant symptom, but the most characteristic and prominent
symptom is painful urination, generally burning during micturition.
Tympany is nearly always present. Temperature may or may not
be associated with the disease. As regards the menstrual history,
nothing deiinite nor characteristic was noted in the literature.

Diagnosis. — It is sometimes impossible to form an accurate diag-
nosis, as the patient's condition, if she is of the healthy or robust
type, may mislead. All authors are agreed that a diagnosis should
not be diiEcult in three iypts of cases:

A. Where there is extensive pulmonary involvement.

B. Where there is a persistent uterine discharge, or where the
curetings demonstrate tubercle bacilli.

C. Where there is pelvic inflammatory disease associated with
irregular, ill-defined masses, with fluctuation in the lower abdomen,
and these masses are noted at later examinations to have changed
their relations.

In this latter connection, Reed remarks that these tumors are
usually omental or masses of intestines, and that they give the most
confusing physical signs ever encountered. An apparently solid
tumor will give tympany, its confines and relations wiU change be-
tween examinations — tympany will persist in the flanks despite an
effusion. This is due to intestinal and omental massing, and was
graphically and forcibly illustrated in my last case which was diag-
nosed as malignant. Here tympany differed in the same location
at different examinations. The location of the fluid wave varied.
The physical signs on the day of operation, even, were quite different
from those of the preceding day, and this change did much to con-
fuse us. For to tell the truth, no other examiner could account for
the change either. We regret that we did not call one of the intern-
ists as an additional consultant. Perhaps the confusion could have
been cleared up.

Errors in diagnosis have been reported as follows: tuberculous
peritonitis was mistaken for simple pelvic peritonitis, pyosalpinx,
carcinoma of the ovary with effusion, pregnancy, multilocuiar
ovarian cyst (Kelly and Howard, of Baltimore, each made this
mistake). It has also been taken for uterine fibrocyst. One case
was diagnosed as a dermoid by one surgeon and as a pregnancy by
three other surgeons (Friedman). Baer reports two cases, one-

HYDE: TXJBERCULOUS PERITONITIS AN ANALYSIS 471

diagnosed as a simple large ovarian cyst, and the other as a solid
tumor. These two cases bear out forcibly what was said in regards
to the confusion of physical signs. This form of tuberculosis has
been reported as typhoid, an error of the internist. Osier reports
ninety-six cases, thirty of which were diagnosed as ovarian cysts.
I did not feel quite so badly after reading these errors, although they
did not excuse me.

Treattnent. — Fenger says that a fair proportion tends to spontane-
ous recovery which statement, in itself, is an interesting proposition
with which to start discussion. All authorities agree that hygienic
measures should be instituted at once and that laparotomy is the
only choice, especially if the case is one of effusion. Tapping and
aspiration do not give so good results. But if a patient is suspected
to have tuberculous peritonitis and improves under hygienic regime,
do not operate. Kelly, Mumford, Reed and Ashurst, and others,
whose reports were studied, all advise operation and the doing of
extensive work. Ashurst says that the ultimate prognosis is better,
if some focus such as the tube or appendix is removed; yet in the
same breath remarks "if intestinal sutures can be made to hold,
union seldom occurs and fecal fistulas usually result." These two
statements can hardly be reconciled with each other. Murphy
decries against removing the appendix in these tuberculous cases.
In my first cases I did, and a fecal fistula promptly resulted. Please
note how widely variant are the opinions and operative technic of
different men. We have no set rule to guide us. Kelly in twenty-
two cases operated on all of them and did most extensive work,
some of his cases being those of general mihary tuberculosis with
peritoneum everywhere studded with tubercles, with intestines
knotted up into aU sizes of masses, with dense adhesions, and with
uterus, tubes and ovaries covered with tubercles. His operations
included many different steps. In one he removed all of the omen-
tum close up to the colon; in others, he did total hysterectomy, and
yet all of his cases recovered. Every operator insists that if a focus
can be found and removed without too much traumatism, that this
should be done. Mayo is especially insistent on this point. And
all are agreed that where pelvic structures cannot be removed owing
to too dense adhesions, that no operation is the wisest procedure,
simply opening the abdomen, being careful to remove all of the
fluid. All serous or bloody fluid collections should be sponged out,
after dropping the table to a level so as to cause the fluid in the upper
abdomen to gravitate toward the pelvis. I further suggest drop-
ping the foot of the table to better facilitate the fluid to drain into

472 hvde: tuberculous peritonitis — an analysis

the pelvis. Where intestines are matted into one mass, under no
circumstances, must any attempt be made to separate them. Some-
times the adhesions are so extensive that this mass appears as if it
were a cyst, and operators have made an attempt to remove it. If
this mass is closely inspected, where the coils of intestines are agglu-
tinated, fine, white, lines will be seen like small threads on its surface.
Kelly says that the true nature of this sac may be demonstrated by
striking it a sharp blow with the finger, and that vermicular motion
will be set up. In one of his cases with this condition, he merely
drained the abdomen and his patient is alive and well to-day.
Encysted collections of fluid among the intestines should not be
opened, nor even drained. Operation is not contraindicated with
slight lung involvement.

In operating, the abdomen should be opened with a small incision,
about 7 cm. The fat is found to be unusually pale, watery, and
unhealthy in appearance. The peritoneum is very thick. The
fluid removed tends to spontaneous coagulability.

When the abdomen is opened, the fluid sponged out, and no oper-
ative procedure is instituted, it is advised to leave in the peritoneal
cavity, 4 grams of iodoform. No drains should be employed.

McGhnn opens and introduces oxygen into the peritoneal cavity,
and appears annoyed because his pioneer work in this direction has
received no recognition from surgeons, and that others have been
quoted extensively as the originators of this technic. He reports
sLx years ago, seventeen cases so treated, where after a year there was
an apparent cure. Tracj' supports McGHnn.

Unless there is a band shutting off a loop of intestine, or a distinct
obstruction, no intestinal adhesions are to be disturbed. Even,
where the intestines are adherent in a big mass, peristalsis is not
interfered with, so long as normal and mutual relations are preserved.
A single adhesion of a knuckle of gut is far more dangerous.

Parker Syms places the percentage of cures at 30 per cent, as a
result of a comparison of many statistics, in which the cures varied
from 24 per cent, to 80 per cent. Koenig reports 131 cases in which
24 per cent, were cured for over a period of two years.

Tuberculosis ranks a close second to Neisser infections as an etio-
logical factor in the production of sterility. Howard Cummings, of
Michigan, reports 182 cases of pelvic inflammatory disease, of which
forty-five were sterile. In thirty-six cases, the sterility was due to
gonorrhea, in seven to tuberculosis, and in two to questionable
origin. Tuberculosis, like gonorrhea, seals the fimbriated ends of
the tubes. The parametrium is never involved.

HYDE: TUBERCULOUS PERITONITIS AN ANALYSIS 473

As regards recovery: In eleven cases with extensive operation, and
all operated by different operators, all recovered. In seven cases,
of different operators, with no operation, all recovered. Kelly's
twenty-two cases all recovered. And some had operation and some
did not. In all of the cases reported, the nonoperative did just as
well as the operative.

Now these statistics and my reading of this much neglected sub-
ject have taught me a salutary lesson. First, that most surgeons
are poorly, read on this subject and that the literature from a surgical
aspect is too scant. Just take the Index Medicus and see how
much you can find in it about "Tuberculous Peritonitis " from the
surgical standpoint that is of scientific value. We have no fixed
guide nor standard. We are in the same position as we were before
Pozzi taught us set rules for our guidance when we encountered
papillomatous ovarian cysts. The pathologist knows this subject.
The surgeon knows it carelessly, excepting the operative side. Kelly
has written more scientifically and exhaustively about it from all
sides than any other American surgeon, but Kelly knows pathology,
and he is also a brilliant operator. Perhaps some German, whose
work on this lesion has escaped my notice has written conclusively,
but I could find no mention of his name.

The digesting of all this literature points out this one fact in the
operative work: With no great peritoneal disturbances, with slight
adhesions, few or no tubercles, we are justified in removing one tube
if it is the focus, or both, if the foci. But nothing which I have read
settles the question as to whether we should operate or not. The
chances seem fairly good either way. Personally, in the future, I
shall remove no appendix with tuberculous peritonitis present.
With extensive peritoneal involvement, I shall remove nothing.
The let-alone policy appears to be a safe one in severe cases, merely
opening the abdomen, removing all the fluid by sponging and proper
table level, introducing iodoform, and, especially important, closing
the abdomen without drainage.

In the case of the emaciated patient, I am now of the opinion that
panhysterectomy was unnecessary owing to the extreme involve-
ment of the peritoneum at the time of operation. Her tissue was
of poor reparative quality as was shown by the free escape of peri-
toneal fluid from a vagina which was tightly closed after the hyster-
ectomy, due to the sutures not holding, and such sutures, almost
without exception, hold in ordinary cases. The mistake in her case
was in doing anything but opening the abdomen, removing the fluid,
and closing without drainage.

242 Henry Street.

474 timme: the endocrine glands

THE ENDOCRINE GLANDS IN THEIR RELATION TO THE
FEMALE GENERATIVE ORGANS.*

BY
WALTER TIMME, M. D.,

Assistant Physician, Neurological Institute; Visiting Neurologist, Randall's" Island Insti-
tutions; Consulting Neurologist, Volunteer Hospital; Consulting
Neurologist, New Rochelle Hospital,

New York City.

Every reaction of the normal human body to stimuli is accom-
panied and controlled by activity of the nervous system on three
different levels, the psychic, the sensori-motor, and the vegetative.
The psychic reaction produces an emotional state, pleasure, anger,
fear; the sensori-motor, sensation and activity; and the vegetative,
vasomotor response and glandular activity. This last-mentioned
division of the nervous system is an involuntary and autonomic one,
that is, it may act independently of either of the other two and its
activity is conditioned by the needs of the bodily tissues at any given
moment and is entirely free from our volition. In the course of its
many fibers and ganglia it supplies various structures, among them
the so-called endocrine glands, which under this control and direction
pour out constantly or intermittently or periodically into the blood
stream their secretions. These secretions have various controlling
effects upon body growth, sexual development, metabolism, blood
pressure, and in short, upon all vital functions. The secretions
themselves have effects that are mutually compensatory or antagon-
istic, mutually excitative or inhibitory; and in health the different
groups are constantly balanced against one another.

The vegetative nervous system controlling their activity is anat-
omically largely free of the tracts of the spinal cord, and its nerve
trunks and ganglia are anatomically almost entirely external to the
spinal cord. So that, when a recent text-book states that because a
female dog whose spinal cord was divided, went 'through all the
phenomena of heat, pregnancy and lactation, therefore, these proc-
esses were free of the nervous system and depended entirely upon
the channel of the circulation, it is patently wrong. A divided spinal
cord is not a divided vegetative nervous system. The conclusion
is thereby vitiated. Indeed, Cannon proved that in order to get

* Read at Meeting of the Brooklyn Gynecological Society, May s, 1916.

timme: the endocrine glands 475

mobilization of sugar through stimulation by fright or other
emotion — a true endocrine activity — three conditions are absolutely
essential, namely, intact adrenal glands, normal liver, and undis-
turbed splanchnic nerves. The absence of any one produced failure
in the result. Therefore, for this endocrine reaction, the intact
autonomic nervous system is necessary. We have reason to be-
Heve that piactically all endocrine activity depends upon similar
conditions.

If we substitute in this group for liver, the female generative organs,
for the adrenals, any of the endocrine glands, and for the splanchnics,
the entire intact vegetative nervous system, we then have a combina-
tion similar, though somewhat more comple.x, whose components
interact freely and constantly, producing periodic changes in widely
separated parts of the body, but all of which changes have a common
purpose — the reproduction of the species — the continuity of life.
The absence of any one of these elements nullifies the purpose.

Let us analyze the effects of one group of this combination — the
endocrine glands — upon the functions of the generative organs. At
this point, it may be well to state that such effects have never been
absolutely proven, they have merely been observed to take place
in a large number of instances following changes in the glands and
have been frequently found at necropsy. Two of the internal glands,
the pineal and thymus, flourish until puberty is established, then they
gradually atrophy. If they cease to functionate before this time,
precocious puberty occurs; if their activity is prolonged beyond the
age when puberty should occur, then amenorrhea, infantilism and
perhaps even sex reversion take place. For these reasons, their
secretions are presumably antagonistic to those of the ovary and
will produce when administered in hyperovarian conditions, such as
simple metrorrhagia, excess of libido, with hyperexcitability, a
markedly quieting effect. The thyroid and pituitary, both of which
are supposed to control and stimulate skeletal and bodily growth
generally, have an excitatory effect upon the development of the
genital organs. For when by some chance either is found deficient
before puberty has arrived, a delayed development of the generative
organs is observed — uterus infantile, ovaries small and nonfunc-
tionating, breasts undeveloped, and pubic hair absent. Such con-
ditions may be combated, and often successfully by the administra-
tion of thyroid and pituitary glands, alone or in combination. Thus
Ott and Scott have shown that the posterior lobe of the pituitary
stimulates the activity of the breasts, and may, therefore, be used as
a galactogogue. I have had a case in which the administration of

476 timme: the endocrine glands

thyroid brought about the descent of testicles that had remained
in the canal to the sixth year. The effect likewise of posterior pitu-
itary extract upon the smooth muscle fibers generally and upon those
of the uterus especially, needs but to be mentioned. Thyroid extract
also stimulates a sluggish pelvic condition bringing about regularity
in abnormal periodicity of the menses. Indeed many extravagant
claims have been advanced even of its marvelous effect upon certain
types of sterility. These types are usually seen in combination with
hypothyroid — not to say myexdematous — conditions. The patients
are sluggish, bodily and mentally, easily fatigued, with thick
infiltrated skin, coarse hair and marked adiposity.

Generally it might be said that while the pituitary gland regulates
the quantitative characteristics of the gonads or sex glands both
anatomically and physiologically, the thyroid presides over their
regularity and periodicity of function.

The adrenal gland, also one of the components of these endocrine
glands, has a twofold activity depending upon whether the medulla
or the cortex of the gland is considered. The substance epinephrin
or adrenalin is made from the medulla, while the cortex secretes a
substance antagonistic to this. This adrenal cortex is embryologic-
ally similar to ovarian tissue and at an early period of fetal life the
two are connected. The medullary adrenal substance is chromaffin
in character and has a marked blood-pressure raising principle
in it, while the adrenal cortex like the ovary secretes a hormone
opposed to adrenalin. As a result, when the ovaries cease to secrete
at the menopause, the adrenal cortex does likewise, and we begin to
notice a rise in blood pressure in the patient due to the unopposed
meduUaof the gland. Nothing else has so well succeeded in
reducing this pressure as has ovarian secretion. The proportion
of cortex to medulla in the suprarenals, is in man as 9 : i. Tumors
of the cortex in early life have produced precocious sexual develop-
ment and even reversion of type in sex characteristics.

The involvement of the adrenals and thyroid during great activ-
ity of the ovarian and corpus luteum secretions is seen in the
increased pigmentation of the skin, in the gradual subcutaneous
infiltration of the skin myexdematous in character, and in the
great drowsiness and sluggishness of many of the patients during the
period of pregnancy.

Compensating for these conditions, the thyroid is frequently
pushed beyond ordinary limits, and a goiter becomes evident. In
a modified degree, menstruation occasionally shows a similar clin-
ical picture, even to the temporarily enlarged thyroid. One of the

timme: the endocrine glands 477

possible causes of eclampsia is the insufficient oxidation and elimina-
tion of toxins due perhaps to the inability of the thyroid to measure
up to the increased demands upon it. Thyroid extract stimulates
oxidation and hastens elimination and thus would seem to be in-
dicated as a therapeutic measure in eclampsia. As a matter of fact,
I have seen several cases of impending eclampsia improve under
thyroid and go to term.

Another • accident of pregnancy — abortion — has been supposed
occasionally to be due to an insufficient internal secretion from the
corpus luteum. If such abortion becomes habitual and if the patient
presents other signs — as she frequently will — of deficient thyroid
secretion, then will the administration of thyroid extract be of dis-
tinct benefit in lessening this tendency to abort. Curiously enough,
corpus luteum itself will rarely be of service if given for abortion of
this kind.

During the puerperium, the reduction of the uterus to its normal
state is dependent partly upon the normal activity of the pituitary
and adrenals. If these are deficient, subinvolution with occasional
hemorrhage results. The exhibition of pituitary extract from the
posterior lobe of the pituitary in small doses intramuscularly
administered, is practically a specific for this condition.

The neuroses and psychoses seen during and following pregnancy
have many of them an origin dependent upon an internal glandular
disturbance — the balance having been destroyed by the intense
demands made upon the various members of the series, and the sub-
sequent inabiUty of the weaker ones to compensate. Here thyroid
extract again is of great value in stimulating the other glands to
activity and in assisting thereby to restore the equilibrium.

At the menopause we come to another critical period of woman's
life. Her depression and irritability; the vasomotor disturbances
seen in the flushing of the face, the paresthesise in the extremities;
the high blood pressure; the putting on of weight; are all symptoms
and signs of endocrinopathic significance. The involution of the
ovary at this time leaves the adrenal cortex without its coadjutor, and
hence the balance between cortex and medulla of the adrenals is
disturbed in favor of the medulla. The medullary secretion con-
tains the prime blood-raising principle of the body — adrenalin — •
which is then overeffective and an increased pressure with its various
symptoms results. The thyroid, working parallel with the ovary,
also diminishes in activity, and as a result we get increase in body
weight and depression in spirits. In such circumstances, it is clear
that ovarian insufficiency lies at the bottom of the disturbance and

478 timme: the endocrine glands

its administration, together with small doses of thyroid, frequently,
is all the medication necessary to effect an amelioration in all the
symptoms — high blood pressure, irritability, vasomotor difTiculties,
and abnormal weight. The early appearance of senility in some of
these cases can also be combatted by glandular therapy, especially
thyroid in combination with ovarian extract.

Having now rapidly summarized the orthodox views of the pres-
ent day of the interdependence of the functions of the endocrine
glands and the female generative organs, let me criticise some of
these statements. In the first place, we have taken practically no
account of the activity of the vegetative nervous system in this inter-
acting seance; nor do the text-books in gv-necology and obstetrics
seem to consider its importance. And yet, the adrenal secretion
effects primarily the sympathetic neuromuscular synapse in smooth
muscle. Adrenalin is poured into the circulation as a result of
various emotions, of fright or pain or forced movement and only then
if the splanchnic nerves are intact, and through their stimulation.
Its effects when so circulating are upon neural tissue, stimulating
t^e sympathetic end-organs.

Thyroid secretion stimulates the vegetative nerves, causing
various sympathetic phenomena, such as cardiac acceleration,
respiratory increase, myosis, and through the hv'pogastric plexus
of the sympathetic, stimulation of the sexual organs. It acts upon
the sympathetic nerves ends in smooth muscle tissue as a sensitizer
for adrenalin, enhancing the effect of the latter. Without the co-
operation of the sympathetic plexuses of the generative organs,
secondarily involving adrenals and thyroid, the sexual organs can-
not be completed. In short, it is by means of the vegetative nervous
system that the secretions of the endocrine glands are mutually
accelerated or retarded in proportion as they are demanded by the
needs of the organism.

In the second place, we have given the clinical pictures of cases in
which one or two glands are at fault, and such pictures are fairly
clear and distinctive. And yet there is no syndrome involving a
dystrophic activity of one or even of two of the endocrine glands.
Every disturbance in the internal glandular mechanism involves
of necessity every single one of these structures — all cases are
pluriglandular ones. Here and there the symptoms due to a single
gland stand out sharply in the picture, but this gland far from being
the real cause of the difficulty, is frequently the last one involved
and the one to be disregarded in the therapy. Thus I have under
my care a patient who gives all the evident signs of a disturbed

timme: the endocrine glands 479

pituitary activity — drowsiness, headache, high blood pressure and
bitemporal contraction of the visual fields. Her symptoms came
on soon after the establishment of menstruation and naturally the
thought arose that the interrelation between ovary and pituitary
was at fault and that therapy directed toward this condition would
prove effective. When the treatment, however, failed, closer ex-
amination gave the suggestion that the original disturbance lay in
the thyroid. The thyroid secretion was found deficient, and hence
ovarian development was tardy, causing pituitary disturbance
secondarily in the attempt to compensate for the thyroid deficiency.
When this view of the matter was accepted and the patient placed
on thyroid, an immediate change for the better was noticed in all
her symptoms. To-day she is almost well, in all particulars, even
to the rehabilitation of the visual fields.

The consideration of such cases as this leads me to advise for the
determination of the status of every patient that shows disturbance
of the function of the generative organs, together with suspicious
symptoms of endocrine disharmony, a most thorough examination
of the internal glands. Never be satisfied with the apparently
simple answer that may superficially appear, but always insist on
tracing back to first beginnings even the most minute complaints
referable to endocrine disturbance. You will usually find structural
anomahes to bear out your suspicions of such disturbance — the size
and spacing of the teeth, the malformations of the face and skull,
the character of the hair and possible reversion to the other sex in
its distribution, the size of the extremities in relation to the trunk,
the pigmentation of the skin, the adiposities, the vasomotor skin
reactions, the blood pressure and the mental reactions of the patient —
are but a few of the characteristics to be weighed. The patient is
then to be treated — irrespective it may seem to be of her actual
gynecological complaints — -on the basis of the original internal gland
at fault, and if that has been correctly determined, a brilliant result
will reward you. And for the same complaint in two successive
patients, you will frequently find, on this basis, widely different
remedies. This accounts for the discrepancies in many of the text-
books which endeavor to give in table form, glandular extracts for
specific gynecological troubles — much as the compendiums of
medicine give favorite prescriptions in pneumonia, typhoid and
whooping-cough. And this also accounts for the innumerable
failures in internal glandular therapy. Thus thyroid extract will
in certain patients increase the menstrual flow, and in others decrease
it; it will in one patient retard its periodicity and in another acceler-

480 PRENTISS: SYPHILIS OF THE UTERUS

ate it. An that is the reason also, why pituitrin will not always
produce the contractions of the uterus that 3'ou so confidently expect
postpartum. In hyperpituitaric patients you may get an increase
of blood pressure by its use with a possible increase of the hemorrhage
and the contractions remain feeble. And there is still another ele-
ment of variability in internal glandular therapy — the seasonal
factor. Thyroid gland in spring gives diflferent results than in
autumn and winter. We need only mention the fact that in hiber-
nating animals, the pituitary gland diminishes its activity mark-
edly at the onset of winter, producing the inactivity, the sluggishness,
and the diminished oxidation at this season, characteristic of these
animals. And who of us will deny the extremeh^ enhanced sexual
irritability in springtime?

So that among all these variables, it is impossible with our present
knowledge to classify these cases into groups. Each case is a sepa-
rate study in itself, and only when so considered can the relation
between its genital disturbances and the activity of its endocrine
glands be integrated.

155 West Seventy-second Street.

SYPHILIS OF THE UTERUS.*

D. W. PRENTISS, M. D.,
Washington, D. C.

Syphilis, at present, is claiming a large part of our attention in
differential diagnosis, and can be excluded only by repeated negative
finding of several methods of examination of the blood, the skin and
the cerebrospinal fluid. In recent years as our knowledge of the
disease has advanced one symptom-complex after another has been
taken from our nosolbgy and placed with the conditions already
known to be the result of infection with the specific spirochetae.
Instances of this are paresis and tabes dorsalis. No doubt many
diseased conditions that to-day are not understood, to-morrow will
be explained by infection with this organism. Because the disease
is found in all the tissues of the body, and because its lesions are often
accompanied by symptom reactions that are identical with the re-
actions from other causes, such as tuberculosis, benign and malig-
nant tumors, and chronic intoxications from various substances both

* Read before the Washington Obstetrical and Gynecological Society, March
10, 1916.

PRENTISS: S'i'PHILIS OF THE UTERUS 481

organic and inorganic, almost no diagnosis is complete until the
reports of the examinations for syphihs have been considered.

The pelvic organs of generation are often affected by syphiHs.
This subject has not been brought before our society since my con-
nection with it, and it is on this account that I venture to give you a
synopsis of one phase of it — syphilis of the uterus.

In studying a disease with reference to the causes we look first for
the predisposing factors that have undermined the resistance of the
tissues singly or collectively, and having considered these and deter-
mined their influence on the individual prior to the present illness,
we then turn our attention to the search for the immediate or exciting
cause. Syphilis is one of the great predisposing causes and is often
overlooked. In the cases of syphilis the exciting cause is well
known, but the demonstration of the spirochetae pallida in tissues
and in discharges is not always successful even when sought for by
one who is well trained in laboratory methods. This probably
accounts for the comparative lack of interest in syphilis of the uterus.
That is apparent when one looks into the literature on the subject.

The subject of sv^Dhilis of the uterus has not been a very popular
one with medical writers, so much so, that the index catalog, 2d
Series of the Surgeon General's Library, including titles to 1914,
gives less than fifty articles, none appearing in EngUsh. Most of the
articles were published before the cases reported could have been
proved by demonstration of the spirochetae to be syphilitic in origin.
Very little appears on the subject in our text-books on pathology, on
gynecology or on obstetrics. To illustrate we will quote from a few
of them(i).

Keys(i) says: "Lesions of the internal genital organs of the
female come in the class of rare and obscure visceral lesions, sclerotic
and gummatous, of which there are a few autopsy findings and a
number of alleged cures by mixed treatment (e.g., of metrorrhagia)."

McFarland(2) says: "Syphihs of the uterus is not common.
The primary lesion or chancre is sometimes situated upon the vaginal
portion of the cervix, such chancres being more frequent upon the
anterior than upon the posterior lip. The ulceration is sharply
circumscribed and has infiltrated borders and a brawny base. The
lesion heals with the formation of a dense stellate scar. Erosions
of the uterus developing upon irritating discharges are very frequent.
Gummata sometimes form in the uterine wall, and diffuse chronic
endometritis is common. Birch-Hirschfeld suggests that this sj'ph-
ilitic endometritis is a probable cause of the syphilic disease of the
placenta."

Palmer Findley (3) writing on uterine hemorrhage says: "Dalche
emphasizes the importance of syphilis as a factor in uterine

482 PRENTISS: SYPHILIS OF THE UTERUS

hemorrhage. Syphilis of the uterus is seldom considered, yet the
author finds it not infrequently in the form of a diffuse syphiloma, as
a gumma of the cervix, or as a sclerotic condition of the uterus and
its blood-vessels.

" Jaworski describes a syphilitic angiosclerosis of the uterus involv-
ing the whole organ and even the parametric tissue. In some in-
stances the blood-vessels alone were involved in tertiary syphilis.
Jaworski says that the hardening of the uterine blood-vessels and
the loss of elasticity of the uterine tissues may give rise to frequent
and copious hemorrhages. Five cases are recorded by the author.
Antisyphilitic treatment controlled the bleeding and in some
instances the uterus became smaller and normal in consistency.

"There are no characteristic symptoms of syphihs of the uterus.
The most prominent symptom is hemorrhage which resists all the
usual forms of treatment, including curettage, but reacts favorably
to antisyphilitic treatment."

Specimens of macroscopic syphilitic lesions of the uterus must be
rare. Dr. D. S. Lamb, curator of the Army Medical Museum can
find but one specimen in that collection. Several local pathologists
of considerable experience have never seen such a specimen.

The organisms of syphilis gain access to the blood current and are
carried in it to all the tissues and organs of the body. The uterus,
Fallopian tubes and ovaries are visited by the parasites, and specific
lesions have been recognized in all of them. It is to the changes in
the uterus produced by the spirochete pallida that I call your atten-
tion to-night.

Primary Lesions. — ^The primary lesion on the vaginal portion of
the cervix is not common, nor is it so rare as to be a medical curiosity.
The structure and appearance do not differ from lesions on other
mucous membranes.

Chancre of the endometrium of the cervix and body must be
extremely rare. No reference to such a case was found in the litera-
ture.

Secondary Lesions. — Secondary lesions of the vaginal portion of
the cervix are seldon mentioned but undoubtedly occur, and should
be similar in their pathology to the mucous patches in other situations
Probably many erosions of the outlet of the cervical canal are of
this nature.

Since the secondary stage of the disease means that the spirocheta
have entered the blood stream and have been convej-ed to the various
tissues and organs of the body, lodging especially in the skin and
mucous membrane in sufficient numbers to produce the lesions,
would it not be strange indeed if the mucosa of the uterus escaped
infection? The uterine mucosa does not escape. Some authorities

PRENTISS: SYPHILIS OF THE UTERUS 483

(Adami and Nicholls, 1910) say that secondary lesions are found.
McFarland says: "chronic diffuse endometritis is found in the uterine
mucosa." One stage of the menstrual process is extremely difficult
to differentiate from a syphiHtic cellular infiltration. With careful
search for the spirochetse the processes will in the future be sepa-
rated. Syphilis of the fetus and placenta is dependent upon
syphilitic endometritis.

Syphilis of' the Placenta. — Much work has been done along this
line already. The pathologic changes in the placenta, according to
Williams, are great swelling (edema) of the chorionic villi, round-celled
infiltration and a great reduction in the number of blood-vessels.
These changes vary in different portions of the placenta and accord-
ing to the extent in which they are present the fetus will be under-
sized from poor nutrition or will die before birth. Several members
of our society are making detailed studies along this line, and I hope
they will discuss at length this phase of the subject.

The umbilical cord may show cellular infiltration about the vessels,
changes in the adventitia, edema of the muscular coat and thickening
of the intima (Williams).

Tertiary Lesions.— Tertia.xy lesions of the uterus have been de-
scribed and differ in no way from similar lesions elsewhere. Gumma
in the uterine wall is not common. Perhaps the commonest changes
met mth are perivascular round-celled infiltration, arteritis and end-
arteritis and a true syphilitic fibrosis. Uterine hemorrhage as a
result of the vascular changes has been described and proved by the
therapeutic test after all other methods including curettage have
failed.

REFERENCES.

1. Edward L. Keys, Jr. Syphilis, A Treatise for the Practitioner,
1908.

2. Jos. McFarland. A Text-book of Pathology, W. B. Saunders,
Phila., 1904.

3. Findley, Palmer. "Syphilis of the Uterus." Surg., Gyn. and
Obst., March, 1916, pp. 234, 235.

484 TRANSACTIONS OF THE

TRANSACTIONS OF THE NEW YORK
OSTETRICAL SOCIETY.

Meeting of May 21, 19 16.
The President, Dot'G.\i. Bissell, M. D., in the Chair.
Dr. Charles G. Child, Jr., reported a case of

REGURGITANT MENSTRUATION THROUGH THE FALLOPIAN TUBES.

"In 1908 I reported a case of pyosalpinx with spontaneous rup-
ture through the abdominal wall. The rupture had occurred some
seven months before the patient came under my care and the open-
ing had never closed. From the sinus each month, coincident with
menstruation, there was a profuse sanguinous discharge. At
operation the right tube, considerably thickened, was found adherent
to the abdominal wall at the internal inguinal ring, and the uterine
sound when introduced into the sinus easily passed the length of
the tube into the uterine cavity. This was the first case of the kind
that had ever come to my attention. Last summer I met with a
second one even more remarkable.

"Mrs. G., aged twenty-nine, always well, menstruation normal.
She had married three months before I saw her and to prevent
conception an antepregnancy button as she described it, was in-
serted in the cervix by a practitioner in a neighboring town. He
instructed her to return each month just before menstruation and
have the button removed, but this she neglected to do. For the
three periods that the button was worn the menstruation was scanty
and accompanied with severe pain such as the patient had never
had before. This pain became progressively worse and finally
continuous. The button was then removed, but without relief.
About this time she consulted me and examination showed a uterus
normal in size and position and with no marked restriction in
mobility. She had an extremely tender pelvis, but it seemed pos-
sible to make out an enlargement of the right adncxa with marked
fullness in the culdesac. A diagnosis of possible ectopic was made
and an exploratory culdesac incision advised. I might state here
that it was only at a postoperative confession that I learned of the
antepregnancy button.

"Operation, July 19, 1916. Dilatation and exploration of the
uterine cavity was negative. Posterior colpotomy revealed free
blood in the peritoneal cavity. Transverse suprapubic abdominal

NEW YORK OBSTETRICAL SOCIETY 485

incision, uterus normal in size and position, no adhesions. The
pelvic cavity contains a large collection of thick, dark blood of a
sticky consistency with a few soft clots. Both tubes were normal
though they seemed to be slightly enlarged; their distal ends when
drawn up out of the exudate were not adherent, the fimbriae perfectly
free. From the lumen of both tubes the same dark, sticky blood was
squeezed. Ovaries normal. The pelvic exudate in this case was
the same in general appearance as one meets with in cases of retained
menstruation due to atresia of the vagina. It showed no tendency
to adhere to the peritoneum or viscera, but came away clear with
the sponging. Convalescence was uneventful, there was a relief of
all pain and the patient has menstruated normally since."

Dr. H. J. BoLDT, in opening the discussion, said: "With regard
to the last case, I would say that the so-called intrauterine spring
stem pessary was first brought into use in Norway very many years
ago. There are some used in this city by general practitioners,
particularly of a certain class who make it a specialty to introduce this
intrauterine spring stem pessary for that purpose. So far as the
patients I have seen with this intrauterine stem are concerned, I
would say there has never been any difiiculty as to the escape of
blood from the uterine cavity at the menstrual period; they would
go along without any trouble at all, but the danger of an instrument
of that kind is that being introduced very frequently by men who
have no gynecological experience, sometimes they use it in instances
where patients have some form of tubal lesion and in that class of
patients there is an additional risk taken in that they may get a
localized peritonitis, and I have seen several such instances. In
Germany several articles have been published on that particular
method for treatment of the prevention of conception and they
have noted similar occurrences. Moreover, it is not an absolute
guarantee against conception. Some of those patients who have
worn stems abroad have been reported to have conceived with
very undesirable results; they usually abort at the second or third
month."

Dr. Herman Grad. — "This case of Dr. Child's is very interesting
and his explanation of the presence of the blood in the peritoneal
cavity may be the proper one, but I think that attention should be
called to the fact that the uterine opening of the tube is exceedingly
small, and not only that, but if you try to force fluid into the tube
by way of the uterus you will encounter considerable difficulty in
doing so. It is necessary to use quite a little force and the injected
fluid will only come through the tube drop by drop.

"I had an interesting case which perhaps may bear on the subject
under discussion. A few years ago a young woman, a virgin, began
to have metrorrhagia and I curetted her. I was not able to find
anything pathological in the pelvis. After the curettage the flow
continued. The flow was so persistent that I opened the abdomen.
Both tubes seemed to be normal except that one had a little different
appearance as compared with the other. I removed this tube and
sent it to the laboratory. A small area of an ectopic was found in
9

486 TRANSACTIONS OF THE

this tube, so small that one might overlook it with the naked eye.
It had to be subjected to the microscope to really diflferentiate it,
and it was this condition that gave rise to the bleeding. The peri-
toneal cavity contained blood. It is possible to have a very small
ectopic, a very minute lesion which gives rise to bleeding, and perhaps
that might be the case here."

Dr. J. Milton Mabbott. — "I assume that Dr. Child's explana-
tion of his case is correct but I was always under the impression
that the chief reason why menstrual blood does not coagulate is
because it becomes mixed with vaginal mucus. In Dr. Child's case
there is no reason to assume that any vaginal mucus was mixed with
the uterine blood which regurgitated through the Fallopian tubes.
In tubercular peritonitis we have an admixture of serous exudate
with blood which often does not coagulate and sometimes a small
celiotomy is curative of tubercular peritonitis. Assuming that the
woman, who I think Dr. Child said had some tenderness of her
abdomen on examination, had had a tubercular peritonitis, even
though slight, she would have been in poorer health, her menstrua-
tion would have been very scanty, and if the laparotomy resulted
in a cure of the tubercular peritonitis, her general health would
improve and the amount of menstrual fluid would naturally return
to normal. I simply present this as another possible theoretical
explanation."

Dr. Child, in closing the discussion, said: "In regard to Dr.
Grad's suggestion of an ectopic, I would say that there seemed
to be nothing suggestive of it in this case. Both of the tubes were
carefully inspected. The blood flowed freely into the uterine cavity
and it was possible to introduce a large filiform bougie, leaving an
opening there which would admit of a great deal more than a drop
of blood. The normal tube is so small that it only takes a very fine
filiform bougie. The canal seemed to be very much larger than
normal. The blood which one gets in an ectopic is very character-
istic of the blood of an internal hemorrhage anywhere else. There
is usually a normal coagulating period and we always find clots.
No matter how young the ectopic or how small we always find clots
after rupture, but that was not the case in this instance.

"It was not the "abdomen" which we meet with in tubercular
peritonitis. Her menstruation had always been regular up to the
time of the attack. It then became painful and pain carried over
the menstrual periods.

"Although my explanation may be incorrect, still I can only
say from the evidence in this case as it came before me, that the
explanation given, it seems to me, is the most plausible one.

" Dr. Vineberg asked me if the uterus was distended. There was
no reason why it should be distended because the button had been
removed some time before I saw her. If it had been previously
distended it had contracted back to its normal size."

NEW YORK OBSTETRICAL SOCIETY 487

Dr. Hiram N. Vineberg, reported a case of

PREGNANCY FOLLOWING SALPINGO-OOPHORECTOMY FOR SALPINGITIS

AND HEMATOMA OF OVARY, FREEING OF ADHESIONS

OF RIGHT ADNEXA AND OPENING CLOSED TUBE.

APPENDECTOMY FOR GANGRENOUS

APPENDICITIS.

" I assume most of us do such work as I did, in the case about to
be reported, in the hope that conception will be made feasible and,
I think I am safe in assuming that such efforts are seldom attended
with the desired result. Hence, my object in presenting this case
for the purpose of putting it on record and eliciting in discussion
how often others have met with success with the procedure.

"Mrs. J. W., aged twenty-six years, married twelve months,
never pregnant, was seen by me in consultation June 15, 1915.
The patient had been taken ill with pain in the left groin May 26,
and had slight fever for the ne.xt three to four days. After a few
days pain was felt in the right lower quadrant of the abdomen and
a couple of days later the pain shifted again to the left side. I
found the patient, a thin woman, in bed, with a universally rigid
abdomen. The uterus lay in partial retroversion, the posterior
vaginal vault was rigid and the left fornix offered considerable resist-
ance, but no definite mass could be felt. The diagnosis was made of
perimetritis and palliative treatment advised. The patient was
seen by me again ten days later. In the meantime her symptoms
had not abated and the temperature ranged about 100°, once reach-
ing 102°. At times the pain in the right side of the abdomen was
very severe. A bimanual examination was unsatisfactory, owing
to the great rigidity of the abdomen. There was decided tenderness
over the appendical region. A laparotomy was now advised, as it
was deemed very probable that a subacute appendicitis was the
chief pathological lesion. On June 17, the patient was operated
upon by me at Mt. Sinai Hospital. The uterus lay retrodisplaced
and was adherent posteriorly, as were both adnexa. On freeing
the adhesions of the left adnexa, the tube was found considerably
inflamed and the ovary, the size of a tangarine orange, was cystic
throughout. Both tube and ovary were removed. The ovary con-
sisted of a thin membranous sac filled with serosanguinous fluid. On
enucleating the right adnexa from its adhesions, the ovary looked
fairly normal and was left intact, the tube, at its fimbriated end, was
club shaped and closed, on pressing the end of the tube with the
fingers, the occluding membrane was ruptured and the fimbriae
were liberated and the lumen of the tube exposed. Nothing further
was done to the tube. On searching for the appendix a mass, the
size of a small hen's egg, was found high up, just beneath the liver.
The abdominal incision had to be extended considerably upwards
to render it accessible. The mass was found to be made up of
adherent cecum and ileum and containing, in its center, the appendix,
which, on removal, showed the mucosa to be in a gangrenous con-

488 TRANSACTIOXS OF THE

dition. The abdomen was closed in the usual manner, with tier
sutures. The patient made an uneventful recovery. In the course
of a couple of months, the patient expressed herself as being perfectlj-
well.

"March 24, 1916, the patient visited my office and stated she had
not menstruated since January 10. She had stained slightly on
February 18, and for a couple of days afterward. I found the uterus
corresponding in size to the period of gravity, between the ninth and
tenth week. There was a slight erosion of the cervix, otherwise
conditions were normal."

DISCUSSION.

Dr. J. N. West. — "About sixteen or eighteen years ago the con-
servation of diseased tubes which were not filled with pus and which
were closed, was introduced into this country, I think, by Polk.
It was followed up very extensively by several other operators, one
of the chief of whom was Dr. A. P. Dudley. The operative pro-
cedure consisted in dissecting the tube from the ovary and uniting
the peritoneal with the lining membrane of the tube and thereby
attempting to restore the lumen of the tube. Sometimes the tube
was wiped out with an antiseptic. I became interested in this
work and did a considerable number of cases in that way and wrote
a paper on the subject about 1908, and at that time, Kahn, of Paris,
had published a very extensive monograph in which he had gathered
from all the literature of the time a number of pregnancies which
had occurred after resection of both tubes, and he reported in this
paper thirteen cases of pregnancy. In my own experience I had
three cases of pregnancy following resection of both tubes where both
tubes were completely closed at the time of operation. I was trying
to determine if it was a proper thing to do or not, whether to remove
the tube close to the uterus and try to conserve it with the idea of
having future pregnancies. One of my cases has borne three chil-
dren. The first child died. Two other cases each bore one child,
making a total of four living children. Two women died eventually
of intestinal adhesions around the tube, and one almost died. I
was called in to see this patient when she was in an advanced stage
of peritonitis and intestinal obstruction from adhesions about the
tube. Her life was saved by operation, but two died. One died
under my care. So that two of the women died and four children
survived as a result of this attempt at plastic work on both tubes
in a considerable number of cases. A good many of these patients
had symptoms remaining afterwards, perhaps as a result of ad-
hesions and infections of the parts of the tubes which were left
behind, and were not cured of the symptoms for wliich they were
operated upon. I, therefore, concluded that it did not pay in a
perfectly healthy woman who simply had closed tubes and was
sterile on account of closed tubes, to undertake to resect the tubes
when she was not suffering from other symptoms, because we are
apt to have a mortality in the women almost equal to the birth-
rate among those that did reproduce. .\ great many did not repro-

NEW YORK OBSTETRICAI, SOCIETY 489

duce and did not become pregnant at all. The mortality rate was
entirely a late secondary one. None of the women died from the
operation. All recovered, but the intestinal adhesions occurred
from about eight to eighteen months after operation."

Dr. F. R. Oastler. — "At the time when conservative work was
at its height and we were all resecting tubes I started in and operated
on some two hundred cases and have since done more or less of the
work, but generallv less. My experience with the cases operated on
can be summed up as follows: The results as regards later preg-
nancies have been verj' unsatisfactory. The results as regards future
symptomatology have been more or less unsatisfactory, so I have
come to the conclusion that the only indications for doing this con-
servative work upon the tube are those conditions where the woman
is particularly anxious to have a child. Probably it is otherwise
better to remove the tube as a whole. One particular reason against
doing conservative work is that it seems to me it is so diiScult after
doing a conservative operation on the tube to be sure of the patency.
I find that before and after doing conservative work a great many
tubes are apparently closed at the uterine end, precluding the
possibility of pregnancy. On the other hand it is just possible you
may get a very satisfactory result. Only about ten days ago I
delivered a woman of her fourth child following conservative work
upon both tubes. It was an emergency case where the woman
had had a postpartum sepsis and had gone for five or sLx weeks.
I was called in consultation and found two large abscesses on either
side of the abdomen. The woman was in very poor condition at
the time. I opened the abscesses and found the tube ends both
closed on either side and also very much distended with pus, so I
simply made a longitudinal incision in each tube, put in rubber
tubing for drainage through the tubes and brought the rubber tubing
out through the abdomen with a little packing around it. She
made a very good recovery. I had another case some time ago
with two very large ovarian cysts. In that instance I removed the
cysts and the tube ends were closed. I removed one tube and left
a portion of the other and took a portion of the ovary from one of
the cysts which seemed to be healthy and sewed it close to the tube.
The patient became pregnant subsequently and had a child. That
also is one of the miracles of gynecology which we see once in a while.
I think a small proportion of cases became pregnant following this
work. Generally speaking, however, I think it is not to be encour-
aged as the secondary symptoms following operation are unsatis-
factory and the great difiiculty seems to be in getting a clear passage
from the tube end into the uterus."

Dr. G. G. Ward, Jr., said: "I have been very much interested
in what Dr. Oastler has told us about the case in which he delivered
a woman of her fourth child. I tliink I understood him correctly
when he said he passed rubber tubing into the tubes after resecting
them."

Dr. Oastler. — "I did not resect them. The tube ends were
closed. I opened up and let the pus out and drained with rubber
tubing."

490 TRANSACTIONS OF THE

Dr. Ward. — "That is, you put rubber tubing into the tubes to
drain?"

Dr. Oastler. — "Yes."

Dr. Ward. — "That is interesting to me because it brings up in
my mind the question as to whether or not that expedient had any-
thing to do with keeping the tubes open and patent so that she could
become impregnated. I think the cause of failure in these operations
on the tube where plastic work is done in the hope of bringing about
pregnancy, is that the tubes are occluded in the healing process so
that we do not obtain a patent tube. Now it may be that what
Dr. Oastler did (passing drainage tubes into the tubes and main-
taining them there for several days, or as long as necessary) may
serve as a reason why those tubes remained open. I wish to say
that I have adopted the expedient for several years, where I have
done the operation of making an artificial opening in the tubes, of
passing strands of catgut into the lumen of the tube and fastening
them there in the hope that they would maintain the patency of
the tube. Dr. Oastler's report of the fact that he evidently was
able to maintain the patency of the tubes by inserting rubber
drainage tubes into the tubes is of considerable interest."

Dr. C. G. Child, Jr. — "I believe myself in conservative work on
the tubes where there seems to be the slightest indication for it and
I should be very sorry indeed if this meeting were to go down on
record as being against such conservative treatment of the tubes.
I have cases where conception has followed, not only a single
pregnancy to term, but even two and three pregnancies after con-
servative work on what appeared to be almost hopeless tubes at the
time of operation, and whereas it is very difBcult to get at the
actual percentage in these cases still there is a sufficient number to
substantiate my belief in the value of conservative work. I do not
believe in the ruthless removal of tubes simply because they happen
to be clubbed and closed off by gonorrheal infection of maybe many
years ago. The attempt to establish the patency of the tube by the
introduction of strands of catgut, as Dr. Ward has reported, I have
done myself in cases where a resection in the middle third of the tube
was done. I there inserted kangaroo tendon in the hope that it
would serve to keep the tube patent long enough for the resection
to be efiicacious. I have never had any cases that conceived, so far
as I know, after that operation, but two years ago one case was
reported in the literature where pregnancy had occurred in which
both tubes were treated in that manner. Dr. Oastler has said that
he does not favor the resection of the end of the tube because of the
difiiculty in passing a filiform bougie through the cornual opening
into the uterine cavity after such a resection because he believes that
the tube is very often closed at the cornual end. The work which
the pathologists have done on these tubes shows that the cornual
end of the tube is very seldom, if ever, closed. It is the distal end
which is closed, and those examined, and examined very carefully,
haven't shown any obstruction at the proximal end. Therefore,
I must repeat again that I should be sorry if we are to go on record

NEW YORK OBSTETRICAL SOCIETY 491

tonight as being against the conservative treatment of diseased
tubes."

Dr. H. N. Vineberg. — "The report of the case has achieved its
purpose in bringing out a discussion. I do not quite understand
Dr. West's attitude as to the dangers of doing conservative work on
the tubes. I do not know the method which he has employed, but
I know the method which I have employed and that is simply
amputating the outer portion of the tube or the part that was
diseased, and then passing a couple of fine catgut sutures between
the peritoneal covering of the tube and the mucosa. I cannot
comprehend how that would bring about any bad results. Of
course you may have adhesions and you may also have adhesions
from a simple amputation, but that any ill effects should follow I
cannot see. It is singular that ordinarily if we desire to sterilize
the woman a simple amputation of the tube or a ligation and
amputation is not sufficient, but the tube must be buried under-
neath the peritoneum, as otherwise, it wHl become patent again
and the woman can conceive. There are a good many cases on
record where purposely the tube was tied so as to sterilize the woman
and conception followed. I think the reason for the usual poor
results is that the operation is done upon a tube in which the mucosa
is diseased. In this case, however, I am rather inclined to think
that the tube was healthy and that the local peritonitis was caused
by the appendicitis and that I had here a favorable condition for
successful work, simply by not doing anything at all e.xcept bursting
the membrane which closed the tube and evidently having removed
the original cause of the inflammatory condition (that is, the
appendix), the tube remained patent."

Dr. John H. Telfair presented a specimen showing

SPONTANEOUS RUPTURE OF THE UTERUS.

"This specimen is the uterus of a patient admitted to Fordham
Hospital at 10.30 p. m., February 28. Upon admission, this patient
was in a condition of profound shock, presenting evidence of internal
hemorrhage, having no pains and showing a moderate amount of
bleeding from the vagina. Rupture of the uterus was recognized
and I prepared to deliver her at once. Under anesthesia, I found a
breech presentation with one foot in the vagina, and commenced
cautious traction, thinking of a possible rupture of the lower
uterine segment, still extraperitoneal, and one which could be better
dealt with after extraction of the child per vaginam, providing the
extraction could be accomplished without further traumatism. It
soon became evident that sufficient force to deliver the child would
further endanger the integrity of the uterus so I stopped all further
efforts of traction and opened the abdomen. The laceration of
the uterus consisted of a transverse rupture of the vaginal vault
anteriorly, extending to the left, opening up the broad ligament and
extending upward to the junction of the upper and lower uterine
segments. Five or six centimeters of the vertical portion of the

492 TRANSACTIONS OF THE

tear communicated \vith the peritoneal cavity. A craniotomy
and extraction was done, followed by an immediate hj-sterectomy.
The patient died on the table."

DISCUSSION.

Dr. G. G. Ward, Jr. — "I would like to ask Dr. Telfair what is
the reason he did not remove the uterus with the fetus instead of
doing a craniotomy? Would it not have saved a great deal of
time?"

Dr. Telfair. — "I felt that if it were possible to keep on with the
extraction of the baby it would have been better. One leg was
extended down into the vagina. The foot was external. I thought
that if there was an incomplete rupture of the uterus the best thing
to do would be to do an extraction if it were easy. If this had been
a vertex presentation I beheve I would have done dilTerently. The
fact that so much of the baby had already come through the pelvis
leads me to believe that a removal of the uterus under those condi-
tions would have been extremely difficult."

Dr. H. C. Coe. — "These cases of spontaneous rupture of the uterus
are very interesting. I recall one many years ago in Vienna, when
I was studying with Carl Braun. The patient was sent in apparently
in extremis. It was in the preaseptic days. In that case two large
drainage tubes were introduced and strange to say, she recovered.
I remember on making a v-isit to the New York Maternity Hospital
I saw a patient who had been brought from the delivery room two
hours before. No one had noticed anything particular about the
case, but I observed that she was very pale and that the pulse was
rapid and feeble. She had had a perfectly normal and rapid delivery.
On making an examination I found that there was a rupture of the
lower segment. A laparotomy was performed and she died soon
after the operation. The tear was into the left broad ligament and
had lacerated the uterine artery. There was not a drop of blood in
the peritoneal cavity, but there was an enormous hematoma which
extended as high as the kidneys on both sides. In other words the
patient had bled to death outside of the peritoneal cavity. It was
a most interesting case as there was no apparent explanation for
it and the accident had not been recognized at all."

Dr. H. N. Vineberg. — "Didn't the tear begin in the cer\-ix and
extend upward?"

Dr. H. C. Coe, in answer to Dr. Vineberg's question said: "I
wasn't there at the time of delivery. Apparently it did."

Dr. H. N. Vineberg. — "This case does not seem to have occurred
spontaneously. It must have been a traumatic tear. I cannot
conceive of a tear occurring in this way spontaneously. If the tear
occurs in delivery it usually begins in the cervix and extends upward."

Dr. John H. Telfair. — "I think that Dr. Lobenstine's analysis
of rupture of the uterus made a few years ago demonstrates quite
conclusively that a spontaneous tear of the uterus can occur in this
particular region, at the cervicocorporeal junction, usually as a

NEW YORK OBSTETRICAL SOCIETY 493

transverse tear about at the vaginal fold anteriorly. I am not
prepared to say that this was a spontaneous rupture occurring with-
out the possibility of manipulation but I feel quite con\anced that
this tj-pe of rupture may occur at any stage of labor. The ruptures
of the body of the uterus, that is, the upper uterine segment, I
beheve are most apt to be traumatic and not spontaneous. I have
not had the opportunity of seeing many specimens, but this is the
first specimen where I felt that much manipulation had not been
done on account of the general appearance of the case at the time
that it came under our observation. There was not the usual evi-
dence of meddlesome obstetrics and I believe the case to have been
one of spontaneous rupture."

Dr. W1LLI.A.M P. Pool presented a

UTERUS C0NT.4INING SARCOMATOUS DEGENERATION OF A FIBROID
AND AN INDEPENDENT ADENOCARCINOMA.

H. S., aged fiftj'-seven, married thirty-five years, ten children,
the youngest of whom is seventeen years. All pregnancies and
labors were uncomphcated. The menstrual history was normal.
The menopause occurred four years ago, and at that time she had
a profuse menorrhagia which recurred at irregular intervals until
menstruation ceased, a period of about six months. This, she was
assured, was a natural and proper accompaniment of the change of
life. During a few months following this she had neither discharge
of any kind, nor discomfort, and believed herself to be in good
health. Three years ago she began to notice a yellowsh white
discharge which persisted, and in which there appeared occasion-
ally streaks of blood. The leucorrhea gradually increased in
amount, and at times there was a considerable bleeding. During
these past three years she has seldom been without pelvic discharge,
and has also suffered constantly from pain in the back and pelvic
tenesmus. Of late there has been much vesical irritation and
partial incontenence of urine.

Examination revealed a relaxed vagina, and a cervix a little
enlarged, having a small bilateral laceration, and bearing a moder-
ate amount of cicatricial deposit. Otherwise the cervix seemed to
be healthy. From the external os there poured a brownish watery
malodorous discharge. The fundus was located at a point about
midway between the symphysis and the umbilicus, and the corpus
uteri was proportionately and symmetrically enlarged. The whole
mass was fixed. A diagnosis of fibroid undergoing necrosis or other
degeneration was made.

Abdominal hysterectomy was done Dec. 15, 1915. The uterine
mass was about the size of a large grape fruit, and of perfectly
symmetrical development. It was adherent to the small bowel at
several points and densely adherent to the rectum posteriorly.

The perimetrial tissues were thickened and rigid, but no enlarged
glands were discovered. These conditions offered some difficulty
in the operation, and there was considerable hemorrage. The patient

494 TRANSACTIONS OF THE

made a rather stormy convalescence, developing a large pelvic exudate
which suppurated and finally discharged through the lower end of the
abdominal wound. The induration gradually cleared away, and
when last seen, she was in very fair condition, locally and generally.

The point of interest is in the pathological findings in this tumor.
The mass was found to be a large submucous fibroid attached by a
broad base to the right side of the uterine v/all, and completely
filling the distended cavity. This fibroid mass had undergone exten-
sive degeneration, and was broken down and sloughing in a number
of areas. In addition to this there was a well-defined area of disease
on the wall of the uterus opposite the seat of the fibroid, that is,
on the left side, which proved on microscopic examination to be
adenocarcinoma. The sarcoma was confined to the fibroid mass,
and the carcinoma was found only in the uterine wall. The cervix
was unaffected.

From the position of the carcinoma it is assumed that it was
caused by the prolonged irritation of the endometrium at the point
where the fibroid mass pressed upon it.

Dr. Gordon Gibson read a paper on

THE relationship BETWEEN PELVIC DISEASE AND MANIAC DEPRESSIVE
INSANITY.*

DISCUSSION.

Dr. Leroy Broun, in opening the discussion, said: "I think
that the doctor's work is most important, especially so since he
approaches the whole subject with the same mind and also the train-
ing not only of the surgeon, but of the alienist as well.

"My work at the Manhattan State Hospital, which he did me
the honor to refer to, was based solely on one thing, namely, that
an insane woman is as much entitled to be made as physically com-
fortable or to enjoy physical health as it is possible for her to do, as
a woman who is not insane, and on that basis only was the work
that I entered upon at the Manhattan State Hospital done. I
know nothing about psj'chiatry, so, therefore, all that work was
left entirely to the members of the resident staff.

"Now, as to the amount of work which we did at the State
Hospital: there were 411 cases collected and tabulated and, as I
say, were operated upon particularly for the relief of the pathological
conditions in the hope that the patients might be made more com-
fortable, and while that was true of many of them, there were cases,
as Dr. Gibson refers to, of pure dementias in which there was no
hope of any mental improvement. It was simply a question of
improving them physically and making them better units of the
Colony, and while that was true, these cases were studied, not by
myself, because I wasn't able to study them, but by the resident
staff.

"Now with regard to the possible effects: of the 41 1 cases seventy-

• For original article see page 430.

NEW YORK OBSTETRICAL SOCIETY 495

two were discharged as either recovered or greatly improved, and
of those seventy-two, thirty-four apparently had their recovery
markedly hastened by the surgical operations that had been done.
All this was done, not by myself, as I say, but by the house staff.
Now, of the cases belonging to the maniac-depressive class, whose in-
sanity depends upon their poor health, any improvement in their
general health would tend to hasten their recovery. For that reason
I felt, and do still feel, that these patients do usually recover, exactly
as in the case of a patient suffering with digestive trouble you would
effect a cure by freeing the patient of autointestinal intoxication
through the intestinal tract. If at the same time the patient has
any pathological lesion giving rise to trouble, I think it should be
removed, and many of them are very striking, and, as Dr. Gibson
states, we found among the cases that were discharged as improved,
I think, 58 per cent, of the recoveries of the seventy-two were
referable to the first six months of treatment and after the six
months of improvement during and including the year, they dropped
to thirty-three, then rapidly diminished, showing that any treat-
ment, whether of psychiatric or purely psychiatric origin or surgical,
to relieve the condition should be given at an early stage. There
is no doubt but that some of the improvements were very marked.
One case especially I have in mind was a case in which we could
not expect or hope to bring about any condition of improvement
mentally, a case of dementia precox, and, as Dr. Gibson states, such
a thing is impossible, but this woman had a streptococcus infection
of the pelvic organs. Cultures were taken and it was discharging
through a sinus in the vagina. She would not eat anything and
had to be tube fed. She took no notice of anybody or anything.
She was very hysterical generally. She made a recovery and it was
delightful to see how that woman began to take notice, how she began
to eat, to call people by their names and to recognize people, which
she hadn't done before for months or years. That was purely an
implantation of a septic infection on her psychosis, but she had a
right to have that improvement. In some cases in the maniac-
depressive classes where they had been in the hospital for four or
five months and had made no improvement under the regular,
typical, classical treatment, improvement was effected through the
repair of some plastic condition in the pelvis that they needed. I
have three instances of that in my last reprint in which they par-
ticularly improved after the surgical operation was done. This
reprint is easily accessible and I won't take up your time by going
into that aspect. I don't for an instant think there is any direct
bearing, but it is simply a question of improvement of the physical
health and thereby indirectly helping the patient. I do think,
though, that in some instances it was mental, by quieting the
patients. In several instances we operated on patients who were
extremely violent and I recall one case in particular of acute appendi-
citis where the patient was so violent that it required the efforts of
three or four nurses to hold her in bed. After the operation she lost

496 TRANSACTIONS OF THE

all her violence and instead of requiring three or four nurses to keep
her under control it didn't require any. I have never seen a particle
of surgical work done by Dr. Rawls, who was formerly associated
with me in the Manhattan State Hospital, or myself that in any
way added to the acute condition of the patient, and I feel that
Dr. Gibson's work, with his special training as an alienist where
he can follow these cases and see the result of this permanent
improvement through the repair of pelvic lesions, which will give
these women longer intermissions between their attacks, is a good
work."

Dr. W. G. Wylie said: "I have not been present at the'meet-
ings of the Society for some time, but I noticed this subject was to
be brought up tonight and having for many years been interested
in one form of trouble affecting the mind and having had a great
many cases of that special kind which I have treated in conjunc-
tion with some of the best alienists in the city, I was very pleased
to hear what has been said and I am very glad that the subject is
being taken up| by others than the operators and gynecologists so
that there might be a separation of the cases that can be helped
from those that cannot.

" Now, to take the depressive cases, those especially due to arrested
development and subinvolution which is so apt to follow in those
cases, especially in women in bad condition: I have made more
or less of a study of that and although I haven't written anything
on it, it has always been my intention to do so, but I beheve that
there isn't any doubt but that the generative organs, especially the
uterus, in the educated class of people are a very different thing than
in the lower class of people.

"Having been an interne at BeUevue Hospital, starting in with
diseases of women, knowing that I was going to make a practice of
that special subject, I was impressed by the httle that I saw of mental
trouble connected with diseases of women, and then there was very
little operating being done, and the change which took place in my
experience, having lived in the Women's Hospital building for
eighteen months and seeing the different operations done, I became
especially interested in the difference between the effect of uterine
troubles among the educated class of people through degeneracy
and inherited disorders as compared with that among the poorer
classes."

Here the doctor referred to the work at the Manhattan State
Hospital resulting in an increase in recognition in cases of mental
disease and that were it not for this particular line of work many cases
would have gone unrecognized. Continuing, he said: "I have
long been satisfied that arrested development of the generative
organs is the first form of degeneracy. This is shown in organs
which are small as a result of lack of proper development. If there
is no deficiency in the growth of the patient or prolonged weakness,
especially in women between ten or eleven and eighteen years of
age, its effect is entirely different. Many children reach puberty

NEW YORK OBSTETRICAL SOCIETY 497

and go through adolescence without dying or being killed by the
disease or trouble that they have had.

"The generative organs are very much more frequently degener-
ated and this may be seen in the case of any old family here in New-
York. If you take three generations you will find that the second
generation is very much inferior to the first, and the third is inferior
to the second, so you can hardly find anything like a normal develop-
ment in the third generation. The race is worn out by the intense
city life and simply leading what might be called an abnormal
life, especially so far as the physical development of the organs is
concerned, t know in observing women with anteflexions, arrested
development, prolapses and all kinds of things that complicate dis-
ease, it is more the fixation than the displacement which causes it
to affect the existing disease. I have lived long enough to know that
a girl with arrested development before she is twenty is certain to
have trouble at the menopause. It generally comes a little earlier.
The atrophy and shrinkage taking place at that time undoubtedly
affect some nerves (reference here made to dysmenorrhea) and it
causes a lot of cases of so-called melancholia, and if I were asked as
to what causes so-called insanity in many cases, I would say, as the
alienists tell us, that it is a group of symptoms. That is true, it is
a group of symptoms, but there isn't the slightest doubt but that
this class of women almost always have subinvolution of the uterus,
and especially in acute conditions a lot of them are liable to it.
The first effect of it seems to be an affection of the digestion and if
there are reflex disturbances they add, especially if they have
been constipated from having been so many times under treatment
for different troubles, they get an infection, they have trouble about
the appendix, which adds to it, and if they have a child they haven't
the strength to really go through a normal labor and are very much
more liable to have subinvolution. If they have a miscarriage or an
enlarged uterus or gynecological disease, or what we sometimes call
fibroid degeneration from small fibroids being hidden which keep the
uterus hidden, most of them have a degree of melancholia. This is
the class of cases where trouble is found.

"I think we can prevent nearly all of those cases if every one
would do what I have done for nearly forty years; that is put every
woman's uterus in good health, every woman who is not in per-
fectly normal condition, in perfect condition so far as the develop-
ment of the generative organs after labor is concerned— systenVatic-
ally reduce the uterus to its normal size after dehvery. Never let
the patient use a bed-pan, unless it is absolutely necessary. Always
sit her up to empty out the contents of the bowel. Then they can
be up on the eighth day, and as soon as the lochia is free from
blood examine the woman, push up the uterus and begin the applica-
tion of a simple borated tampon as we used to call it, but never use
a plug of cotton. Have it firm enough and place it up against some
boroglycerid. There is a certain kind of boroglycerid which is
different from glycerite. It is antiseptic and prevents fermentation
of anything like pure glycerin. Have the nurse use this twice a

498 TRANSACTIONS OF THE

day for the eight days, if there are no untoward symptoms, and it
will bring on involution complete in almost any case within five
weeks. By doing that I have hardly ever had a single case in my
whole forty years that has come back with any symptoms or efiEects
of subinvolution in hundreds of cases.

"In the type of women I am speaking of it is almost certain to
produce more or less of what we call melancholia. At the meno-
pause these cases are almost sure to have trouble and if a woman has
any enlargement of the uterus and arrives at her menopause with
the uterus anything Uke double its size, she almost always has more
trouble.

"You must not operate on these cases until you have treated the
uterus in every possible way. You must bring it back to its normal
size and condition. When you get it back to its normal size you
can put a sound in the uterus without pain or bleeding and the
woman will not have her so-called melanchoha.

"I have gone to both private and public sanitariums or asylums
where these women have been incarcerated and have been pro-
nounced absolutely insane. I don't say it is dementia, but they are
so accustomed to thinking it is that they wouldn't turn them out.
If you take those cases and reduce the uterus often they are cured.
In women up to forty-five the same reflex disturbances are pro-
duced only of a different type. You can take out the uterus and
you can cure them and some of the cases I have done were pro-
nounced by the highest men to be insane. You must put the whole
intestinal tract in good condition without the taking of drugs, and
that can be easily done in any case. In that class of cases there is
no doubt but that these depressive cases can almost always be cured
and prevented and I have done it almost absolutely."

Dr. Gordon Gibson. — "Dr. Broun spoke of the object of the
operations being for the improvement of the physical condition
of the patient. That was the original idea and still is at Kings
Park, that any woman with gynecological lesions deserved to be
put in the best physical condition. There are cases on which we
have operated where there was dementia, and the reason for operat-
ing was to improve their general condition in order that they might
be more easily cared for. In maniac-depressive insanity it has
been observed that the psychical improvement goes hand in hand
with physical improvement."

"Dr. Wylie spoke of arrested development. Now, what we have
found in the arrested developments, in the morons and in the con-
stitutional inferiors, is that with the arrested development of the
psychic system there is arrested development of the pelvic organs.
We have not been able to do anything with this type of case. Time
after time men have done operations on this type and have made the
weirdest statements to the relatives of the patient. For instance,
the proprietor of a certain private sanitarium takes off the clitoris
in cases of masturbation in insanity, telling the people that he can
cure the insanity by so doing. It has not stopped the masturbating
and has not cured the psychosis. This is only one of many false

NEW YORK OBSTETRICAL SOCIETY 499

ideas in regard to the effect of operations on the insane. When we
come to conditions in the better class of patients that Dr. Wylie
speaks of, we are in an entirely different field. These patients are
neurasthenics, they are not insane. As Hermann pointed out these
people complain more of symptoms of trivial conditions than they
do of the real serious lesions, and that the symptoms of trivial condi-
tions are more pronounced in neurasthenics than in normal indi-
viduals. Their neurasthenic condition is calling attention to the
condition in the pelvis. The depression often seen in cases of
subinvolution bears no relationship to involution melancholia, which
is a psychosis occurring at about the time of the menopause. We
do not use the term melancholia to define the symptom depression
any more, and in a great many psychoses we find varying types and
degrees of depression."

"You have all had the same experience as I, where people come
to you to ask whether an operation on the pelvic organs of a woman
who is insane will help her. Now, you can say that if the patient
has maniac-depressive insanity and possibly one of the other benign
psychoses that you may be able to help her."

Dr. William J. Maroney read a paper on

SARCOMATOUS CHANGES IN UTERINE FIBROIDS.*
DISCUSSION.

Dr. S. H. Geist. — -"In reference to the incidence of sarcomatous
changes in fibroids, I wish to emphasize that only large series of
cases can be considered. Since my paper to which Dr. Maroney
referred, in which I reported 250 fibroids, 4.8 per cent, of which were
sarcomatous, I have had occasion to study 100 additional fibromyo-
mata and in only two instances were there evidences of sarcoma.
The two cases in my series that recurred did so after supravaginal
hysterectomy. Neither case was suspected of maUgnancy at the
time of operation and it was only afterward when the recurrence
took place that further examination of the original tumor demon-
strated its malignant nature. The probable reason why more of
them do not recur is because of the fact that the sarcomatous portion
is usually in small isolated areas, well encapsulated in the center of
a firm fibrous tumor and therefore implantation or vascular metas-
tases are not common. I have found that when these tumors recur
they are of a most malignant type."

Dr. H. N. Vineberg. — "It might be of interest to relate an
experience which I had in one of these cases as to the question
whether to do a pan- or total or subtotal hysterectomy. I operated
on a woman about fifty years of age with simply a large fibroid.
There was no suspicion of malignancy. I did a complete hysterec-
tomy. The tumor was examined microscopically in the laboratory
afterward and pronounced benign. Within a period of six or nine
months this woman's abdomen was filled with hard masses which

* For original article see page 445.

500 TRANSACTIONS OF THE

proved to be sarcomata. ■ The tumor was gone over again and
sarcomatous tissue was found in it. We had another case which
Dr. Krug operated on in which he did a supravaginal hysterectomy.
I am not certain whether that tumor was examined or not, but there
was no reason to suspect malignancy from the appearance of the
growth. That patient had a very rapid recurrence of sarcoma and,
as Dr. Geist has said, when these cases recur they recur ver}' rapidly
and soon become fatal."

TRANSACTIONS OF THE JOINT MEETING OF

THE WASHINGTON OBSTETRICAL SOCIETY

AND THE OBSTETRICAL SOCIETY OF

PHILADELPHIA.

Meeting of April 6, 1916.
The President, William R. Nicholson, M. D., in the Chair.

The first paper by Dr. J. Broutst Miller, of Washington, dis-
cussed

THE CAUSES or STERILITY.*
DISCUSSION.

Dr. Edward P. Davis. — While Dr. Miller has concisely stated
his personal observation in cases of sterility, it may not be without
interest to review some general factors in the case.

There can be no question but that the age of a woman has great
influence upon sterility. If it is desired that the race reproduce
itself rapidly, economic and social conditions must be such as to
encourage early marriage. Some cases of deiicient development in
young women who marry are cured by pregnancy, which results in
the growth of the genital organs. When this happens, the results
are better than those obtained by surgical procedures. Where,
however, the woman is comparatively young and normally developed,
and apparently sound, and remains sterile, it is necessary to study
those physiological factors which favor ovulation, the making of
blood, and the cycle of menstruation. It is difficult to obtain exact
knowledge concerning physiological processes, but we cannot ignore
them in the study of this problem.

In cases of obesity with evident lack of thyroid, we see improve-
ment in the general health and conception follow the use of thyroid
extract, with a largely nitrogenous diet, and moderate doses of
strychnia. As these are the only methods employed in these cases,
it seems fair to believe that they have something to do with the result.
In other cases of this sort, where there is a retroversion of the uterus,

* See original article page 450.

WASHINGTON AND PHILADELPHIA OBSTETRICAL SOCIETIES 501

a cureting with shortening of the round hgaments and the thyroid
treatment is sometimes successful.

Dr. Miller has wisely said that infection of the genital tract fre-
quently causes sterility, and he alludes to appendicitis as an illus-
tration. In my observation this condition is rarely present without
invasion of the adjacent tube or ovary, and in some cases, in common
with the appendix, both tubes and ovaries are involved.

As regards the surgical relief of sterility by operation, it is doubtful
whether the effort to reopen closed tubes, loosen adhesions, and
thus restore the normal condition of the tubes, is often successful.
Those operations give the best results which correct displacements
and improve the condition of the endometrium. The removal of
the appendix rarely fails to benefit the general health of women
who have disease of the pelvic organs.

Dr. Miller's contribution is timely and valuable, and welcome as
a concrete expression of wide experience collected, assimilated, and
digested by sound, surgical judgment.

Dr. E. E. Montgomery. — I do not consider that any subject
could be brought before the Obstetrical Society more valuable, or
more timely than the subjects presented to-night. The' interests
of the race and of the State are all centered in the continuation of
the birth and development of healthy children. Therefore, condi-
tions causing sterility are of the utmost importance. Of course, we
recognize that there is a class of cases due to congenital conditions
in which sterility is present with little chance of correction. There
is another class in which the condition is the result of inflammatory
changes during the life of the individual. These changes may cause
absolute sterility from the beginning of marriage, or may be the cause
of the-one child sterility which is not so infrequent. Then again
sterility occurs in individuals in whom conditions of this kind have
not occurred, but in whom it is undoubtedly due to the existence of
defective internal secretion of the ductless glands, rendering the
patient unfavorable for conception. There are also cases which
may be called relatively sterile, in which the individuals may be
married, the woman not giving birth to children, and subsequently
under changed relations, following other marriages children may be
born to each of the parties. These cases are possibly those in which
there is a condition of homology, and their secretions are poisonous
to each other, rendering procreation impossible. This condition
could be determined by examining within half an hour after coitus
the secretion within the vagina. Certainly before subjecting any
woman to operative interference, it is important that the secretion
of the male be examined to determine whether the spermatozoa are
active. To subject a woman to operation of more or less danger and
discomfort before we are certain that she is at fault, seems to me
unscientific, to say the least, is unjust, and places the responsibOity
where it does not belong. Therefore, before attempting operation
we should make sure that both individuals are capable of procreation.
Some investigations have shown that the administration of thyroid
and ovarian extracts to individuals previously sterile render them

502 TRANSACTIONS OF THE

capable of procreation. I well remember a patient whom I saw
some years ago with a prominent surgeon of this City. The woman
had not menstruated for eight years. She had been married three
years without pregnancy. At operation one ovary, which was
cystic, was removed, and a number of small cysts were scattered
through the other ovary. The surgeon was inclined to remove that
but desisted at my suggestion. The woman subsequently came to
me with regard to the possibility of procreation, and I suggested the
administration of thyroid extract. Shortly after she menstruated,
and this menstruation was followed by pregnancy, and she has borne
three children. This, of course, is not any proof that the thyroid
extract had anything to do with the condition. It is possible that
a metabolism set up by the operative interference may have brought
about changes resulting in pregnancy. I have seen other instances,
however, in which the thyroid extract has seemed to me to have an
influence in pregnancy. There are many cases in which because
individuals have felt they were not ready for procreation have used
measures to prevent it, and subsequently when they were desirous
to have children they have found themselves incapable of procrea-
tion. It is just possible in this as in many other conditions the
repeated inoculations rendered the individuals immune to the in-
fluence of the spermatozoa. We may have patients with inflamma-
tion of the genitaha, the result of efforts to avoid conception, render-
ing the soil unfavorable to the development of the ovum.

The question of sterility is exceedingly interesting. Not infre-
quently we find individuals married for a long time and anxious
to have children, and finally after a long period of time pregnancy
has occurred. One of these cases came under my notice some
years ago. A woman married twenty-two years came to see me
because of the increased size of her abdomen. Upon examination
I had no hesitancy in telhng her that she was pregnant. They could
scarcely believe that pregnancy should have occurred after such a
length of time, and yet that was the condition. It illustrates the
truth of the assertion that while there is life there is hope. The
question is one of great interest and value, and I appreciate very
much having heard the paper of Dr. Miller.

Dr. Truman Abbe, Washington, D. C- — May I be permitted
to tell you some of the things that have come to me from my reading,
but without absolute data? It seems to me that one of the great
factors in this matter is that for generation after generation people
have been trying to reduce the number of their children. We have
not followed our natural instincts, and if there is anything in adapta-
tion to surroundings and the cultivating out of certain germs and
tendencies in our nature it seems to me that we have done all that
we could to decrease the fertility of the human race. The matter is
not a one-generation proposition, but one which has been going on
ever since families had responsibilities. They have been trying to
reduce the number, and where life has been the most intense, as it is
in certain parts of Europe, the decrease seems to have been the
greatest; and, as our life here in .\merica seems to be decreasing.

WASHINGTON AND PHIL.^DELPHIA OBSTETRICAL SOCIETIES 503

apparently the intensity is increasing — our families are decreasing.
It seems to me that the most important factor is that we shall change
the mental attitude of our people; encourage the early marriage and
the large family; give the large family the advantages that are
possible, but make the children fight for themselves and bring up
themselves. It seems to me that that is the keynote to the treat-
ment of the general proposition of steriHty. Not that the patholog-
ical factors, mentioned here to-night are not definitely important,
but that this psychological factor is one of the big fundamental
considerations.

Dr. George Erety Shoemaker. — The relation of appendicitis
to sterility has perhaps not received the consideration it deserves.
Those of us accustomed to removing the appendix as the chief in-
flamed organ independent of its secondary involvement in salpingitis
recognize that adhesions due to appendicitis proper while stronger
and more developed on the right side and less extensive upon the
left, are often very widespread ; especially if pus has formed and has
pocketed behind the uterus. In the event of the removal of the ap-
pendix the adhesions will be gradually absorbed, but enough may
still remain to seal the fimbriated ends of the tubes to nearby struc-
tures. This is a matter to be considered in the cure of sterility
whenever the individual has had an attack of appendicitis.

Dr. Charles C. Norris. — Dr. Montgomery has brought out an
important point when he emphasizes the differentiation between
a sterile marriage and a sterile woman. The lay public is prone to
place the blame at the door of the woman, as we know this is by no
means always the case. Our first step should be to determine which
partner in the marriage is at fault.

The study of sterility in women is a many-sided problem. For
practical purposes we may divide these cases into two classes. The
first consisting of those in which there is some obvious reason for
the sterility, such for example as massive bilateral pelvic inflam-
matory disease, or congenital occlusion in some part of the genital
canal. The proper treatment of such cases is plain and in the
majority of instances the sterility is a subservient symptom to
other painful £)T more obvious clinical phenomena.

To the second class belong those cases in which there is no massive
lesion. These are the tv^pe of cases which are generally spoken of as
sterility cases. Their etiology is often obscure.

It is to this class of cases that I purpose to limit my discussion.
Sterility of this sort may be the result of a variety of causes, some
of the most common of which are hj-poplasia of the uterus, acute
anteflexion, stenosis of the cervical canal, flaccid bilateral hydrosal-
pinges of the variety which cannot be demonstrated by a manual
examination, diseases of the endometrium, abnormal reaction in
the vaginal, cervical or fundal secretion, hypoendocrinism or reduced
internal secretory action of the ductless glands, extreme obesity
(it is not improbable that in some cases extreme obese may be caused
by changes in the secretion of some of the ductless glands and, there-
fore, a concomitant of sterility rather than a causative agent.

504 TRANSACTIONS OF THE

It is, however, a fact that the chance of conception occurring in such
cases is greatly increased if we can get the patient to reduce this
weight by exercise) . One of the foreign observers has recently re-
ported a condition in which habitual early abortion occurs, so early
in fact that conception is not usually recognized, the condition
generaUy being thought to be a sHghtly delayed menstrual period.

These are but a few of the many causes for steriUty. The majority
are relative.

Thus one woman with an acute anteflexion may be sterile whereas
another with an apparently similar uterus may conceive shortly
after marriage, one stout woman with an apparently normal genital
tract may conceive repeatedly and another may be sterile. In
dealing with these cases it is customary and safest to not pronounce
such a patient sterile until two or even three years have passed, and
even then caution is advisable.

The point which I wish to especially emphasize is that sterihty
is a symptom and not a disease, and that to intelUgently treat these
patients they must be individualized and if possible the cause of the
sterility discovered. The most uncommon practice of immediately
subjecting all sterile women to some form of dilatative operation,
often even without determining whether or not they are the partners
at fault, is to be deprecated. The only cases in which dilatation
is of benefit are those in which for some reason there is narrowing of
the cervical canal. This may be the result of an acute flexion, may
be congenital or even inflammatory in origin. In any event such a
patient is likely to give a definite history of spasmodic or expulsive
dysmenorrhea, that is, the dysmenorrhea will appear with the flow
and the pain wiU be expulsive or labor-like in character, in counter
distinction to the dull, heavy aching pain often appearing some time
before the flow which is tj-pical of pelvic congestion and does not
necessarily indicate a stenosis.

Dilatation may be the treatment of last resort in many cases, but
certainly in patients not exhibiting the expulsive type of dysmenorrhea
should be considered onh^ after other methods have failed. It seems
almost unnecessary to state that pelvic inflammatory disease must
be excluded before attempting any form of dilatative -operation, the
fact, however, that without an anesthetic there are a certain number
of cases in which this condition is difficult to exclude and that this
mistake is not infrequent is well known. The intrauterine stem
pessary has in my hands given better results than any other method
of dilatation.

Dr. Alfrkd Heineberg. — In Dr. Miller's paper he has ably
presented this subject. HehasmentionedMaxHiihnerof New York.
I have been much interested in the work of Max Hiihncr and have
had occassion to study fifteen cases by his method. From what I
have learned in my study of these comparatively few cases I am quite
convinced that there is a good deal more to be learned. I do not
believe that the subject as Hiihner presents it is complete. Much
more than that which he has written is to be said. In 129 cases of
sterility he employed a test by which he was able to determine the

WASHINGTON AND PHILADELPHIA OBSTETRICAL SOCIETIES 505

presence or absence of active spermatozoa in the fundjis of the uterus
at the expiration of from twelve to twenty-four hours. The test is
simple in technic, but some men to whom I have spoken said they
did not think it practicable in America. Some weeks ago when I
read a short paper on this subject and presented the work of Hiihner
some of the men present at the meeting were of the same opinion.
Hiihner's work consists in studying the effect of the vaginal, cervical,
uterine and tubal secretions upon the spermatozoa. This is the
routine I have carried out. When the subject has been properly
presented to the patient and both husband and wife are anxious to
have a child, I have yet to have a patient refuse to undergo the test.
The test gives practically no pain to the patient and gives no more
discomfort or exposure than the ordinary pelvic examination. The
patient presents herself at your oiBce within an hour, if possible, after
sexual intercourse. The vaginal secretion, after having been removed
by an ordinary platinum loop, is examined while still wet on the
microscopic slide. Then the patient is asked to return in about
five or six hours. At that time it is necessary to examine the secre-
tion of the cervix as well as the secretion from the body of the
uterus. The secretion from the cervix is removed with the loop
and that from the body of the uterus with a small syringe. I have
used for this work an ordinary Eustachian catheter of the smallest
caliber fitted to a Luer syringe. The secretions are studied as at the
first examination. They are studied again at the end of twelve hours
and at the end of twenty-four hours; in all, four examinations for
each case. In the cases which I have studied I have been struck
with some of the facts which Hiihner presented. In some cases in
which the semen on previous examination showed a very large
number of active spermatozoa I have been surprised to find, within
half an hour after intercourse, very few in the vaginal secretion and
most of them nonmotile. In the cervical secretion I have found
spermatozoa, not so many perhaps as in the vagina, but much more
motile. I have been struck with the marked difference in the
motility of the spermatozoa in the vaginal and the cervical secre-
tions. Patients with active spermatozoa in the cervical secretion
within an hour after intercourse usually have a certain number in
the secretion from the upper part of the uterus. These women in
whom the spermatozoa in the cervical secretion early after inter-
course has a lessened motility usually have no spermatozoa in the
secretion of the uterus at the expiration of five or six hours. This
test shows that in a large number of cases motility of the spermatozoa
is destroyed by the acid vaginal secretion. I have been able to
demonstrate that in a certain percentage the motility can be in-
creased by treatment. In fact, I have four cases in which the ac-
tivity of the spermatozoa has been increased by having the patient
take alkahne vaginal douches for several days twice a day and par-
ticularly one hour before intercourse. When repeated examinations
show — no matter what the physical condition of the pelvic organs
may be — nonmotile or no spermatozoa in the uterine fundal sec-
retions, we may feel fairly certain that it is impossible for the

506 TRANSACTIONS OF THE

woman to congeive. I believe this is the class of cases in which the
patient should be subjected to abdominal operation purely for in-
spection to ascertain the condition of the tubes, where I believe
we shall usually find the trouble. We should never lose sight of
the importance of examination of the semen in aU cases. In
Hiihner's series, 59 per cent, of the males were sterile; Reynolds
of Boston found his percentage to be 50. In my experience about
40 per cent, of the men have been sterile. Therefore, before be-
ginning treatment for the sterility of the woman it is well to deter-
mine the condition of the husbands. There are many other points
which might be brought out; I simply wanted to present the few
regarding Hiihner's test for sterility.

Dr. Miller, closing. — I feel that I have gained a good deal from
the discussion of my paper and I want to thank the gentlemen
taking part. I was very glad indeed to hear the last speaker refer
to the Max Hiilmer test. I had made up my mind to try this test
but have not yet had an opportunity of doing so. I make it a prac-
tice in all my cases of sterility to send the man for examination by a
genito-urinary specialist to see if he is at fault. If we find live sper-
matozoa in the male he is not at fault. As Dr. Davis has said, age
has an important bearing upon sterility. One evidence of this
influence is shown by the presence of fibroids which usually manifest
themselves in the later sexual life of women. I found that twenty-five
of our 1 20 cases had these tumors which usually are seen after thirty
years of age. I must confess that I know little about the influence
of the thyroid and ovarian secretions and prefer not to theorize
about the subject. I know we should all welcome any definite
knowledge in this respect that might be gained by investigations.
As Dr. Montgomery said, many sterile women are given thyroid and
conceive, yet we do not know that the conception was influenced
by the thyroid. I prefer not to put myself upon record regarding
these things, especially with my patients; I have to tell them I do
not know.

The second paper by Dr. I. S. Stone of Washington, took up
the question of

THE LESSENING FERTILITY OF WOMEN. '^
DISCUSSION.

Dr. James M. Baldy. — I came here to hsten, not to talk. Surely
we have had a sermon of the old-fashioned kind; and it is about as
useless as all sermons, with as much truth as we get from most
sermons. What's the use in being as optimistic as our friend from
Washington ? It is not our nature. Perhaps the nearer Washington,
the nearer to the South and the warmer the blood, the more opti-
mistic one is; the more belief in what is not true, and the less scanning
of human nature. There are plenty of good reasons why women
should not have children and lots of times they would be fools if

* See original article page 454.

WASHINGTON AND PHILADELPHIA OBSTETRICAL SOCIETIES 507

they had them; and they are not fools, but they generally know
their business. In this they are perfectly justified. Lack of chil-
dren is no crying evil; this is all nonsense. There are plenty women,
save those you have and do not bother too much about those you
have not. We ask for civiUzation and then cry against that which
must come with it. What is civiUzation? Will you go back to the
time when eight, ten or twelve children were in every family. If you
do the woman will have no shame that the children are dirty and not
decently clothed. Women of the civilized world do not want more
children than they can properly care for. They give you enough
children. Save those they give you before you demand more. If
every woman bore four children the world would be overpopulated
and an uncomfortable place to live in. The older I become, the more
sense I think the woman has. There are plenty of children born.
Women do their duty; they overdo it. Civihzed life means intensity
of nervous strain. Nervousness makes a woman unfit to bear chil-
dren to the extent that formerly was Common. If she does bear
them to this extent she is doing a gross injustice to herself, her pro-
geny and to her country. The dominating factor with the countries
looking for more children is that they want soldiers. We doctors
have no interest in that motive. Each one of you obstetricians
knows that the modern woman having to meet the obligations of the
day in which we are living is not fitted to bear six or seven children.
The women have taught us that they do not want to have their
lives wrecked and thus show that they know a heap sight more than
we know. The trouble is that we have not learned and are still
harping at the theory that woman was born into the world to bear
children. All this may be true but it is also true that a man is
entitled to a healthy wife for a companion.

The third paper by Dr. R. J. Sullwan, of Washington, questioned

THE INDICATIONS FOR AND THE PROPRIETY OF ARTIFICIAL
STERILIZATION.*

DISCUSSION.

Dr. Barton Cooke Hirst. — I have been very much interested
in the subject which Dr. Sullivan brings before us; it is as an.xious a
question, I think, as confronts the conscientious physician. There
are four types of cases in which I have deliberately sterilized women,
and in which I would do it again; and, there is a fifth type of case in
which I would do it in the course of an operation undertaken for
some other indication. As an illustration of one type, I have an ap-
pointment to steriUze a woman whose physician writes me that she
is pregnant for the sixth time, has mitral stenosis and myocardial
degeneration with decompensation; that he regards the continua-
tion of the woman's pregnancy as particularly hazardous and danger-
ous to Ufe, and that if I agree with him he would suggest that her preg-
nancy be terminated. I not only agreed to do it but also to prevent

* See original article page 458.

508 TRANSACTIONS OF THE

her becoming pregnant again. To me, sterilization of that woman is
perfectly justifiable. Another type of case is that of a woman who
was admitted to the University Maternity, pregnant for the fourth
time, and eight weeks pregnant when she entered the hospital.
She had a systohc blood pressure of 200 with grav^e signs of toxemia
and advanced cardiorenal disease. The woman had been told that
she ought not to be pregnant. Her husband had also been told, but
he paid no attention to the warning of the physician. I consider
this a justifiable case for sterilization. A third type of case is the
woman between thirty-five and forty with a bad cystocele who
already has had five or six children. I have sterihzed a number of
women on this indication in the course of an interposition operation.
In this connection it is interesting to observe that the method em-
ployed, excising a portion of each tube through a vaginal incision
and sewing up the uterine cornu is not. always as trustworthy as
we would hke to have it. Of the women so sterihzed two have
come back pregnant, although I excised an inch of each tube and
sewed up the cornua as carefully as possible.

There is another type of case justifying this procedure. A patient
was admitted to the University Maternity with the history that she
had been married two or three years before. She had had one child
and shortly afterward developed phthisis which had progressed
alarmingly. Her physician had sent her to one of the sanatoria in
the State. She improved, gained about 40 pounds in weight, the
tubercular baciUi had disappeared from her sputum, her cheeks were
rosy and she seemed to be in perfect health. She no sooner came
home than she was impregnated. At the tenth week of her preg-
nancy all the original signs of phthisis had returned with their
former intensity. She immediately fell off in weight, developed
fever, and cough with tubercle bacilh in the expectoration. I
induced abortion and then sterihzed her by excising the tubes in
the usual manner. There is a method of sterihzation which I may
use in the future. Doederlein's and Kronig's book on operative gyne-
cology- there is illustrated the removal of the tube and ovary through
an incision in the groin. The method appeals to me as desirable
for a temporary sterihzation. If subsequently pregnancy became
desirable, it would be only necessary to reopen the groin, release the
tube from its fixed position in the inguinal canal and drop it back.
This would seem to be desirable in the case just mentioned. Here
was a young married woman with only one child, sterile for life.
She might be entirely cured of her phthisis in five or six years and
might then desire a larger family.

There is another type in which I would not deliberately sterihze
a woman, but would do so in the course of another operation if I
had opportunity. I recently dehvcred by Cesarean section for
placenta previa a woman sent to me by the Social Service worker
of the hospital. After the woman's recovery I was asked why I
had not sterilized this woman. When I inquired why, I learned
that the patient was feeble-minded and had a different father for
each of her three babies. Had some one told me that before the

WASmNGTON AND PHILADELPmA OBSTETRICAL SOCIETIES 509

operation I certainly would have taken measures to prevent her
becoming pregnant again.

So far as my practical experience goes, these are the types of cases
in which sterilization seems to me perfectly justifiable. After all,
as the essayist says, the question is one which must be decided by
the individual physician from liis experience and according to the
dictates of his conscience.

Dr. SwiTinN Chandler. — We should look at this subject from
three standpoints: (i) With regard to the woman; (2) with regard
to the health of the offspring; (3) with regard to the future of the
offspring. With regard to the woman herself, if she have some or-
ganic disease which will be made worse by pregnancy — heart,
kidney, or lung disease — it seems to me that we cannot ask her to
give birth to a child. Regarding the child, if we had reason to be-
lieve that the future health of the child would be seriously impaired,
it seems to me the operation should be done. In the third place, if
there shall be no one to take care of the child in the event of the
death of the mother. If its future is in doubt and the State does not
take care of the children, it is a question whether we should ask that
woman to bring forth an issue. If that civilization is established,
not the civilization indicated by Dr. Baldy, but one of altruism,
humanity and patriotism looking to the glory of the future we shall
be in a position to determine in what cases the operation mentioned
by the author of the last paper shall be performed.

Dr. Alfred Heineberg. — The question of the method of steriliza-
tion has been opened up in Dr. Hirst's discussion of this paper by
Dr. Sullivan. Dr. Hirst has told us of two failures in his own
practice in attempting sterilization during the performance of
another operation. An experience which I had with two cases caused
me to look up this subject. In one patient I removed, for inflamma-
tory disease, or I thought I had removed, both tubes and both
ovaries, and to my surprise, about three years afterward the patient
became pregnant. In another case I removed both tubes and one
ovary. That patient is now pregnant and will be delivered next
month. In looking up the question of sterilization I found that there
were only twenty-two cases of failure to produce sterilization by
the methods employed, and that there has not been a single method
employed in which there has not been failure. The method in
which the largest number of failures resulted was that employed by
Dr. Hirst, of excising a portion of the tubes. The method which
gave the surest results was that of removing the cornu of the uterus
and infolding the raw edges with musculo-muscular sutures and
covering with peritoneum. The Kroenig method of temporary
steriUzation mentioned by Dr. Hirst was a failure in one case of
Kroenig; tube slipped back and the patient became pregnant.
There is, therefore, no single method so far devised, except, of course,
removal of the tubes and ovaries and uterus which will produce
absolute steriHty; and, there is a case on record in which tubes,
ovaries and uterus were removed and in which the woman became
pregnant in the remaining stump of the cervix.

510 TRANSACTIONS OF THE

I simply want to add one suggestion in regard to the question of
sterilization which undoubtedly is in literature but I have not seen
it. The most vulnerable point at which to attack the root of the
ovum is in the uterine wall itself. The common method is excision
of the cornua of the uterus. It occurred to me that by destroying
the mucous membrane of the muscular portion of the tube steriUty
would be sure and could be accomplished by a plunge of the hot cau-
tery needle into the uterine muscle at the cornu along the line of
intramuscular portion of the tube bringing up the remaining portion
and uniting it over the wound. It seemed to me that if the mucous
membrane of the intramuscular portion of the tube were destroyed
by cautery the amount of scar tissue around this cauterization would
result in positive sterihty.

Dr. Truman Abbe, Washington. — One method of sterilization
which I have not heard mentioned, and which is becoming more and
more efficient, is that of deep radiotherapy of the ovaries. It is a
method which entails no traumatism and is practically without
risk. It is well worthy of consideration as a means of temporary
and probably of permanent steriUzation, depending upon conditions.
While the method is new and its results not yet positive it claims
consideration.

There is one other point to which I should like to refer; I come as
a son of the warm and rosy South who believes in high ideals and
dreams of the things for which the best civiUzation of the country
ought to stand. I beUeve that a certain proportion of our popula-
tion should be positively sterihzed in the support of the rest of us
who are not yet an expense to the State. There are a certain num-
ber of people who have been followed up by the societies and by
men studying the question of heredity; it has been found that one
woman has cost the State of New York in the last twenty years
something approaching two million dollars. That two million has
been paid by the people who work and are an asset to the State.
Such state paternalism is one type of civilization. Now, it seems
to me that the ideal civihzation is that which stands for the laws of
health, the family, the children, not the protection of the few who
are weak-minded who break the laws of hygiene persistently and
who must be supported by the State. I would much rather be part
of a civilization which supports the useful families than be part
of a civilization which supports every person indiscriminately and
taxes the best of us to support the worthless fathers and mothers and
the children born at the expense of the State. In the discussion of
Dr. Stone's paper the Society is left on record, this is a joint
meeting and as Secretary of the Washington Obstetrical Society I
take the liberty of saying this — as supporting a standard of civili-
zation in direct opposition to that of the highest ideals. The stand-
ard asset by that discussion would have us as obstetricians aid
each woman by every means in our power to limit the number
of her children as she wished. It does not seem to me that the
Washington Society cares to stand for that record. Neither do I
believe that the Philadelphia Society as an obstetrical society cares

WASHINGTON AND PHILADELPHIA OBSTETRICAL SOCIETIES 511

to go on record in that way; and I would move that some com-
ment be made in the Minutes which would modify the discussion
of that paper.

Dr. J. M. Baldy. — Of all the inconsistencies I have ever listened
to, this beats them all. The first paper by Dr. Stone discusses the
causes of sterility and its evils and insists on every woman having
as many children as she can crowd into her life, and every man since
has stood up and talked about the methods of steriUzing women
some of which are absurd, some impractical. I may have sympathy
for the woman who prevents conception for good reasons but I have
little or none for limiting the excuses for wholesale abortions. How-
ever, in proper cases this is justifiable. I am a bit amused at the
position taken by Dr. Hirst. I am not quite sure we are not feeble-
minded, all of us. Some years ago I was asked by a prominent
cUnician in this town whether I would do an abortion upon a woman
with incipient phthisis who had already had children. I said I knew
nothing about the diagnosis of incipient phthisis, but that I had con-
fidence in him and if he assured me that the woman had incipient
phthisis I would do the abortion. He said there was no question
about the diagnosis, but that he must first tell me that one of the
best obstetricians in the city had said such an operation, though of
undoubted benefit to the patient, was absolutely unprofessional and
he refused to do it. I asked who it was and he replied. Barton Cooke
Hirst. I did the abortion. I am very glad to see that my judgment
of that time is so fully justified by what he now says. I feel, how-
ever, that there is a good deal of feeble-mindedness in some of his
positions at present as first expounded. Why he should think it his
duty to take the responsibility of preventing conception by doing a
questionable operation just because a husband is a fool, I don't quite
see. Of course, if a pregnant woman is in danger of dying we are
warranted in helping her out, with the warning that her condition
is such that pregnancy is dangerous; then if she and her husband
transgress and trouble follows we can have no warrant for interfering.
The man who does so puts himself in the position that he must do
so again and again. Two fools had better die; let both husband
and wife take the consequences.

Dr. Norman L. Knipe. — I am wondering why this discussion
should be upon the production of abortion. The question has been
upon the sterilization of women. This is entirely a sociological
question and has little to do with medical ethics. I have not yet
passed through the embryological stage which Dr. Sullivan has
passed through. I believe very much along the line of Dr. Baldy.
There are plenty of reasons for doing artificial sterilization of women.
If life to-day were the same as fifty years ago there would not be
the same indication for aiding women in this way; but it is not. We
cannot live like the Russian Jew to whom a large family is an eco-
nomic necessity. To many a young man receiving a salary of $75 or
$100 a month, a large family is an economic calamity. An increased
number in the home means an increased cost of living. .\n in-
creased cost of living necessitates a decrease in the number of chil-

512 TRANSACTIONS OF THE

dren. This is not so acute in the country districts; there, six children
cost little more than three, so far as mere maintenance is concerned.
I think in large cities small famiUes are an economic necessity.

There is no good reason why the advisability of artificial steriliza-
tion of women should not be just as conscientiously considered by
the reputable physician as the necessity for the production of thera-
peutic abortion. I believe in salpingectomy for good economic
cause. I do not believe that it is right to sterilize a healthy woman,
who is nulliparous or who has had one or two children, just to suit
her convenience. But I do beheve that it is morally and even
religiously right to prevent a woman who is not in good material
circumstances from being obliged to give birth every year or two,
to a child who cannot be properly provided for.

Dr. John A. McGlinn.- — I am sorry that Mr. Roosevelt is not
present at this meeting because only he could adequately reply to
the views which have been expressed. It is also too bad that certain
ladies of New York who desire to publish broadcast methods for
the prevention of conception, are not present for they certainly would
be greatly encouraged in their pernicious work. Some of the ideas
expressed here to-night can be termed nothing short of asanine. The
idea, that because a man in the City does not earn a large salary
should constitute a cause for the sterilization of his wife, is a curious
sort of philosophy to me. I have rarely seen an unhappy family
where there have been a number of children. I have seen lots of
unhappy families where there have been none or but one child.
Small families are not due to economic causes or the fear of invaHdism
on the part of the wife. The majority of them are due to the fact
that the husband and Avife do not want their pleasures curtailed.

It seems to me that instead of a young man and a young woman
raising hell at night, it would be far better morally and economically
if they would raise some children. It has been said here to-night
that large families breed incompetence. That the family should be
small so that the children could be well educated and trained and
we would therefore have the survival of the fittest. Who does sur-
vive? Uncle Joe Cannon in a debate on the immigration bill quoted
from the census of 1799, and but few of the family names which
appeared in that census appeared in the last census. Of all the
names which appeared in the census, there does not appear any at
the present time of the men and women who are doing good work.
In other words, if it had not been for the influx of the immigrant
with their large families, this country would be in the same position
as far as population is concerned as is France to-day. Dr. Baldy
evidently has never had any experience of the Polish immigrant.
The Polish immigrant has a large family. He not only dresses his
children well and educates them, but always has enough money laid
aside to pay a physician for his services, and that cannot be said for
the American family who have but one or two children. There are
worse evils than having large families. Large families don't always
mean poverty. Children oftentimes mean comfort to parents in
their later life. It would be a very unfortunate thing if it should go

WASHINGTON AND PHILADELPmA OBSTETRICAL SOCIETIES 513

out into the community that the prominent obstetricians and gyne-
cologists of Philadelphia and Washington beheved that the having
of large famihes was an undesirable thing for the State and stood
ready to inform people concerning means of prevention when chil-
dren were not desired. There is no doubt that as a result of a false
philosophy concerning this matter too many abortions and unneces-
sary sterilizations are done.

Dr. E. E. Montgomery. — The subject of sterilization I consider
one of very- great importance, especially so in the class of people
known as defectives and feeble-minded, in whom procreation is most
active. In such people we have examples of the case mentioned by
Dr. Abbe, and Margaret the mother of criminals a feeble-minded
woman who was the mother of eight children by as many fathers
can be added. She cost the State of New York two million dollars
for the maintenance of her offspring in almshouses and the execu-
tion of them for murder. It is often regarded as a joke when the
"village softy" marries a woman of equal intellect, yet these indi-
viduals are going to give birth to children equally feeble-minded or
worse. In this way the cares of the State are increased in preparing
for their segregation. Such people are a care throughout their
lives, not only in maintenance, but in the prevention of the propaga-
tion of their kind. The City of London has been undertaking the
care of such people and has found it a great tax. It is certainly a
matter of great importance that the community should be protected
from them, but segregation is not sufficient. In England a law was
passed to prevent their marriage but this does not correct the evil,
for the greater number are born out of wedlock. The subject of
sterilization should be legally considered as a means of prevention.
I would look upon the question of abortion to relieve individuals who
have deliberately subjected themselves to the possibility of fecun-
dation as one of serious ethical import, and would hesitate to decide
that it was my duty to institute abortion to save such individuals.

Dr. William H. Good. — Dr. Baldy has criticised much of the
discussion here to-night as " twaddle and poppycock" I was wonder-
ing whether or not Dr. Baldy had not contributed more than his
share. It seems to me that in the matter of decreasing fertility
Nature very kindly takes care of those who believe in but one or
two children in a family. They soon die off and their places are
filled by those willing to lead hves more nearly in accord with nor-
mal biologic law. As a member of the Philadelphia Obstetrical
Society, I would not care to go on record as endorsing what Dr.
Baldy has stated to-night as his views.

Dr. Daniel Longaker. — I wish to add a mild word of protest
regarding the trend of the discussion to-night. The hour is too late
to go into details. It is evident that if this community or any
large community wanted to find an excuse for its individual and
personal shortcomings, it need simply refer to the practice and
example of its physicians since it is comparatively infrequent that
they have families. I think it is greatly to be deplored that to-night
we have had boldly advocated the expediency, the desirability,

514 TRANSACTIONS OF THE

even the morality of voluntary sterility as a normal condition of a
state of civilization. The Malthusianism, the pessimism, and the
rotten philosophy of it! Dr. McGhnn is right, my friend on the
left, all wrong.

Dr. Sullivan, closing. — I had no idea of stirring up such a hor-
net's nest, but the matter is not laid at my door entirely for if you
will remember the title of this paper, it is "The Indications for and
the Propriety of Artificial Sterilization." I spoke about none of
the economic conditions, which I might have very personal views
upon, and I would not care to speak about them.. So far as the
means of sterilizing women are concerned, I did not say that that
was a part of the theme at all. The steriUzation of the feeble-
minded is not a question for us to decide now. The opinions of
pyschologists and gynecologists of our country are at sword points.
The best men in the pursuit of knowledge of this kind claim that in
time they will give us ground on which we may base the indication
for sterilization. At present they beheve that many of the laws
concerning this matter will not hold, and they urge us to wait. I
think I have had some experience that would lead me to want to
sterihze mentally defective persons; I believe they should be steril-
ized, but we have no grounds from the mental speciahst's standpoint,
and none from the legal standpoint. In the States having enacted
such law it has been repealed as unconstitutional. I should like
to thank Dr. Hirst for his great kindness in handUng the subject.
I think I should tell him that a woman whom I delivered recently
in Washington had received the sterihzing operation at his hands
some two or three years ago in Philadelphia.

TRANSACTIONS OF THE BROOKLYN
GYNECOLOGICAL SOCIETY.

Meeting of May 5, 1916.
The President, Dp. William P. Pool, in the Chair.
Dr. Carroll Ch.a.se reported a case of

HEMORRHAGE FROM RUPTURED HYMEN.

Last summer he received a hurry call about midnight to see
a servant and found a young woman, aged twenty-two, almost pulse-
less and in serious condition from hemorrhage. It was difficult to
get a history. At first she said that as far as she knew the condition
was menstruation, although she had never bled so profusely before.
He insisted that it could not be menstruation and after some delay
was allowed to make an examination and found that the woman was
literally bleeding to death from a ruptured hymen caused at the
first intercourse, which she then admitted had occurred that evening.

BROOKLYN GYNECOLOGICAL SOCIETY 515

A thick hymen was found to have been torn posteriorly and a large
vein could be seen still bleeding. It was a simple matter to tie it.
Quite evidently she would have bled to death if the vein had not
been tied. It might be added that she had never had any symptoms
of being a "bleeder."

Dr. E. H. M.'^yne reported a case of

PROL.AJSED INTESTINE THROUGH RXJPTUHED UTERUS.

Three weeks ago last Thursday night, about eleven o'clock, a
woman was brought into the hospital with some intestine project-
ing from the vagina. She was twenty-four years of age with a
history of a four or iive months' pregnancy. The fetus had come
away about four o'clock that afternoon but the placenta had not
been delivered and the attending ph\rsician thought it should
be removed. The patient was anesthetized and an attempt was
made to remove it. In endeavoring to get it out with a curet,
the doctor had some difficulty and the first thing he knew there was
some intestine in the vagina. When her abdomen was opened about
midnight it was almost filled with blood. There was an opening
above the internal os which appeared to be large enough to admit
three fingers and stuck through that was a loop of small intestine.
The intestine was withdrawn and as the uterus seemed to be about
seven-eighths torn through a hysterectomy was done. He had to
resect about 26 inches of small intestine. The mesentery of the
sigmoid was punctured in three places and the peritoneum was
torn in several places by the curet. The woman was in great
shock, pulse 160, but she has since then greatly improved. About
seven days after the operation she developed a fecal fistula which is
discharging slightly, but the bowels have moved naturally and I
believe the fistula will close. There was some difficulty in getting
small thread for the anastomosis and they had to use coarse thread
which he thought made some difference in the result.

Dr. J. R. Taylor reported a case of

CHOLELITHIASIS.

This was a case of long-standing gall-bladder disease with a soli-
tary stone. The patient was fifty-three j^ears of age, with a history
of trouble in the epigastrium for fifteen years. She was a large
woman weighing about 185 pounds. The gall-stone was found to be
tightly impacted in the neck of the gall-bladder which, to the casual
observer had the appearance of being in a normal condition. Moy-
nahan and others have stated that if the gall-bladder presents a
bluish color it is to be presumed that it is healthy. This gall-bladder
was apparently not enlarged, the fundus was not tense and presented
from the outside the characteristics of having normal fluid within.
After making an incision into it, it was necessary to exert some
pressure to force out a very thick black fluid. The stone had a well-
marked groove on the left side due to pressure from the hepatic
duct. The onl\- way it could be extracted was by getting the

516 TRANSACTIONS OF THE

finger down behind the pylorus and working it out gently from be-
low. The stone at the time of extraction was somewhat soft.
The lower portion is markedly yellow in color due to cholestrin,
apparently. It measures i^^ inches long, i^/fg inches in diameter
and weighs 260 grains. Since the operation the patient has been
having a normal temperature.
Dr. Clarence R. Hyde read a paper on

TUBERCULOUS PERITONITIS.*
DISCUSSION.

Dr. Gibson. — I do not know that it is a fact that the Italians
are more prone to tuberculous peritonitis than other races, but at
St. Peter's Hospital we see quite a number of Italians with it and it
has been our custom to open the abdomen, drain 06 the ascites and
not to remove any tissue. There have been several cases of tuber-
culous salpingitis where the tubes have been removed without
trouble, but if the appendix is removed one is apt to get a fecal
fistula. It is hard to follow up many of these cases as they are often
taken back to Italy by their relatives. We have noticed that there
seem to be more of the^rocess about the head of the cecum and lower
portion of the ileum and it is often a temptation to remove the ap-
pendix which seems so obviously diseased. Recently there appeared
in the International Abstract of Surgery, an abstract of an article
by Ligabue, who reported the results in sixty-six cases of tuberculous
peritonitis which were treated by simple laparotomy. In 25.75 P^"^
cent, of the cases the peritoneal involvement was secondary. He
states that permanent recovery was obtained in 65.07 per cent, of the
cases and that the earlier the case is seen the better the results.
This seems a very large proportion of recoveries and is rather hard to
believe. His theory is that the removal of the fluid carries away a
large amount of the toxines and causes a blood serum exudate which
is rich in antibodies.

Dr. Maynf. — I think too much stress has been laid upon the
removal of the appendix in these cases — it should not be removed.
About five years ago I saw a case where a tuberculous appendix had
been removed and the operation was followed by a fistula; nine
attempts were made to close it without result. In Jackson's Surgical
Diagnosis there is an excellent article on ileocecal tuberculosis which
I think is in line with Dr. Gibson's remarks, agreeing that there is
greater involvement at the terminal portion of the ileum, and cecum.
I have had two or three cases and I believe though that tuberculous
peritonitis started at that point. I recently .saw a case that had
been operated upon four years ago by me and at the time of the
operation I removed a large quantity of fluid. The case was inter-
esting for the fact that the skin was much pigmented about the face
and arms, so much so that Addison's disease was suspected. At the
operation no attempt was made to remove the appendix though it
was much involved as well as the cecum; the fluid was removed
and the abdomen closed without drainage. Within six months the

• For original article sec paqe 466.

BROOKLYN GYNECOLOGICAL SOCIETY 517

pigmentation disappeared though the fluid continued to form and it
was necessary to tap her three times subsequent to the operation.
I then began to use tubercuUn which was continued for ten months.
She has made a complete recovery, has gained 40 pounds and
there is no sign of pigmentation.

Dr. McN.\ii.\ra. — .\fter listening to Dr. Hyde's paper calling our
attention to our defects in the study of tuberculous conditions, and
when we realize that tuberculosis attacks every organ of the body, it
is not surprising that we should be lacking in the knowledge of
tuberculosis in all its phases, neither are we to be judged guilty when
we fail to make a diagnosis. I remember a case that I saw operated
upon by my colleague, where there was a tremendous amount of fluid ;
the abdominal organs could not be seen. She was extensively
opened and drained and is now draining. I question the rule that
to operate early before the antibodies are developed would probably
make an unfavorable operation: whereas a late operation is more
favorable. One of the most important points is to make a diagnosis
by exclusion; if it is not like anything else it is safe to call it tubercu-
lous peritonitis.

Dr. Shoop. — My experience with tuberculosis of the peritoneum
is limited to two cases, one seen with Dr. Carroll Chase and one in
my own practice. The latter I reported in a paper read before this
society about eight years ago on "Tuberculosis of the Uterus and
Adnexa." This case had been diagnosed by a physician in the
country as probable tuberculosis of the tube and ovary. When I
saw it shortly after I recognized in addition a chronic appendicitis.
I removed the left tube and ovary and a tubercular mass extending
from the cecum to the uterus which included the appendix, right
tube and ovary. The peritoneum was studded with tubercles; ad-
hesions are general. The patient did well for twenty-four hours, then
began to fail and died the next da\-. I did not drain the case and
afterward thought that should have been done. It was formerh'
taught that the entrance of air with its content of oxygen was the
curative agent in these cases and keeping an opening for a few days
for its entrance would allow it to act thus beneficially. However,
the weight of argument to-night seems to be not to drain but to
close the wound entirely.

Dr. Walter Timme. — One of the cases mentioned brings up the
matter of pigmentation. It is not necessary to have disease of the
adrenals to have this condition, any tumor or mass which interferes
with the proper function of the sympathetic system may produce
pigmentation and you will occasionally see cases of unilateral pig-
mentation ; I have seen two in the last year. In one the cause proved
to be a tumor mass on one side, far back, which impinged upon the
main fibers of the splanchnic nerves, and removal of the tumor
diminished the pigmentation.

Dr. Tool. — The statement made by Dr. Hyde regarding tubercu-
losis of the tubes rather varies from what is usually believed to be
the rule. Some observers state that it may be primary in the tube.
Just how it gets into the tubes without affecting the other organs

518 TRANSACTIONS OF THE

is not easily understood, but we do get tuberculosis of the lungs with-
out throat and nose infection. It is possible that in tuberculosis
of the male there may be a transmission of the disease through
vitiated spermatic discharge. I think it is sometimes a fact that
the uterus escapes when the tubes become involved and later the
peritoneum. I have made it a practice to remove the tubes unless
the disease has gone so far that it would be of no use.
Dr. Walter Timme read a paper on

THE ENDOCRINE GLANDS IN THEIR RELATION TO THE FUNCTIONS OF THE
FEMALE GENERATI\'E ORGANS.*

DISCUSSION.

Dr. Hyde. — My own e.xperience in the use of the glandular extracts
is limited to a series of loo cases and in only one case did I obtain a
satisfactory result. The fact of the matter is that our empiricism
has been due to our not knowing enough about the subject.

Dr. Gibson. — ^Last week at a meeting of the Woman's Hospital
Society one of the papers was upon the effects of the glandular ex-
tracts in a series of cases of artificial menopause and of natural
menopause with more than the usual vasomotor disturbances.
The conclusions were that large doses of ovarian extract were
necessary and that the effect was better if a small amount of thyroid
was added. The cases that bother me are those which begin to
take on weight at about the thirtieth year, which have a diminishing
amount of menstrual flow and which have various vasomotor and
psychic disturbances. I have been using various combinations of
ovarian, thyroid and pituitary extracts but the results are, as a rule,
not satisfactory. How are we to tell which substance is indicated?

Dr. McNamara asked if there was any danger in the use of these
substances either singly or in combination.

Dr. Chase asked if Dr. Timme would state what the condition
was in women who were irritable and bad tempered at the menstrual
period. They are fairly normal up to the time of menstruation wJien
they would show a great deal of nervous disturbance.

Dr. Shoop asked if there was any difference in the secretions of
the glands at various periods of the year and could manufacturers be
pre\ailed upon to pay attention to this matter.

Dr. Timme. — In answering Dr. Gibson's question I would say
that there is no one condition to which any one glandular extract will
apply. There arc no two women who are alike and there are eight
or ten variables in the treatment which may be used singly or in
combination and the number of combinations is beyond our experi-
ence. Each case must be studied upon its separate requirements.
Generally I might sa\- that those patients who show a certain amount
of infanlilism may l)c benetiled l)y the anterior lobe of tlie pituitary
bod}-, because of its stimulating effect upon the growth of the ovaries,
and if given early enough it may be of benefit, but by tiie time the
woman is thirty it might be impossible to do anything for lier.

* For original article sec page 474.

BROOKLYN GYNECOLOGICAL SOCIETY' 519

Regarding seasonal variations, the thyroid of the sheep is most
active in the spring and one firm takes the glands only at that time
of the year. Other firms do not always take the same precautions
and it is presumable that on that account the substance does not
always produce the desired effect. I place the patients under my
care on tablets with which from experience I do get results. Manu-
facturers are said to take glands, especially the pituitary, from
animals that have been spayed, and such extracts may do harm for
It is an abnormal pituitary body and if the physician is not careful
he may get results for which he ought to hold himself accountable.
.Most of the glands have a greater effect in the spring than at any
other period of the year; whether it is due to the greater amount of
sunshine or not we cannot say. If you want a hypofunction with
diminished effect, the glands taken in the autumn have a better
chance. The treatment is entirely empirical. In cases of obesity
with limited menstruation, help can be obtained from small doses
of thyroid. As to the danger from the use of thyroid extract; it
may be great because if you use the wrong doses of the gland you
may get an opposite effect, which may be seen in the general bearing
of the patient, depression, loss of weight, tachycardia. Too much
adrenalin may cause symptoms of fatal collapse in a few days; it-
will bring up the blood pressure for a certain length of time and' then
if pushed you ma\' get the opposite effect with intense shock.
Regarding the irritability of patients at the menstrual period; if
we suffered from a feruncle once a month perhaps we ourselves would
be irritable. The hyperirritability must be studied and the treat-
ment administered depending upon the original organ affected.
How are we to find the missing link; the original gland at fault?
That is where the crux of the treatment lies. There are certain
features that impress themselves upon the examiner as having rela-
tion to the effect of various glands. Eyes close together or far apart
are due to dystrophy of the pituitary gland. In women the pubic
hair is limited to a horizontal line, in the male it goes up higher in
the midline toward the umbilicus; in women of the male type this
horizontal line will be absent. Another woman at thirty-five looks
like a child, red cheeks, a complexion of peaches and cream; that
is one in whon the thymus gland has acted too long instead of ceasing
to impress its effect at puberty, and the woman retains some of the
childish habits; she probably has enlarged tonsils. Here the pituit-
ary and thyroid glands have not been able to overcome the effect
of the thymus. Quick flushing of the skin means an increase of
thyroid activity and whiteness is due to the adrenals; red marked
with white on the sides is due to a combined disturbance of the two.
There are certain landmarks which we learn to distinguish, each of
which has an endocrine peculiarity, and if that one gland is given in
treatment there will usually be a remarkable change. I am not an
extreme enthusiast. Endocrine therapy may be new to some of
you gentlemen, but to us the theories are pretty well estabhshed
empirically, curious though they may seem. In the last three or
four years, with the exception of a little digitalis, and perhaps a little

520 REVIEW

morphia and arsenic, I have prescribed practically nothing but
endocrine gland extracts. I now get better results than I ever did
before in over ten years of practice. You must analyze each case
and not prescribe by any one rule as so many text-books advise.

REVIEW.

Gynecology. By Willi.am P. Gr.wes, A. B., M. D., F. A. C. S.
Professor of Gynecology at Harvard Medical School; Surgeon-in-
Chief to the Free Hospital for Women, Brookline; Consulting Phy-
sician to the Boston Lying-in Hospital. Octavo of 770 pages, with
303 half-tone and pen drawings by the author and 122 microscopic
drawings by Margaret Concree and Ruth Huestis. Sixty-six of
the illustrations in color. Philadelphia and London: W. B.
Saunders Company, 1916. Cloth $7.00, Half Morocco S8.50 net.

It is not often that one finds a new work on gynecology possessing
so distinct an originality, such practical good sense, and so much
of the personality of its author as this book of Dr. Graves. We
predict for it success and long life. Departing from the traditional
arrangement of gynecological text-books the author divides his
work into three parts.

Part I deals with the physiology of the pelvic organs and the re-
lationship of gynecology to the general organism. This latter subject
is to be especially commended as, while a comparatively new de-
parture, it is presented as completely as present knowledge will allow
and in a way which impresses the importance of the correlation of
all branches of medicine and surgery.

Part II includes a description of diseases essentially gynecologic
and is given compactly so that the student, for whom this section
is especially intended, may not be burdened by too formidable an
array of facts. In the description of each disease the underlying
pathological processes are described, but the histologic, or rather the
microscopical detail, is taught by drawings of microscopical sections
with full descriptive legends appended, the author feeling that these
details can better be learned from drawings than from tedious de-
scription. In a similar way the surgical principles involved in the
treatment of each disease are discussed but the technic of opera-
tion and the illustrations are reserved for

Part III, which is devoted exclusively to the technic of gynecolog-
ical surgery. As it is impossible to include all operations in a book
of this scope, only those are described which, in the judgment of the
author, have seemed best suited to the special requirements pre-
sented. Of course this means that many procedures and methods
which some may think more valuable are necessarily omitted and
it leaves a number of points open for adverse criticism. These
omissions, liowevcr, in the eyes of the average reader, may be
considered an advantage as making it less confusing for him to
choose, and they certainly add to the personal appeal of the volume
and to its value as a text-book for students.

DEPARTMENT OF PEDIATRICS.

ORIGINAL COMMUNICATION.

CONGENITAL OCCLUSION OF THE BILE DUCTS.*

BY
JOHN FOOTE, M. D., AND RALPH HAMILTON, M. D.,

Washington, D. C.
(With two illustrations,)

Cheyne in 1801, in his "Essays on Diseases of Children" men-
tioned "original and incurable malconformation of the liver," and
ascribed the condition to "an impermeable thickening of the begin-
nings of the hepatic ducts," The pioneer among modern writers to
collect case histories and make a study of this interesting condition was
Thomson(i), of Edinboro whose original brochure written in 1892 and
later amplified into a subchapter in Albutt's System of Medicine has
become a classic. Forty-nine protocols were cited and analyzed by
him, in his original publication, RoUeston and Hayne(2) in 1901
added ten more and Lavenson(3) in 1908 reported the total as
sixty-two. In 191 1 Howard and Wolbach(4) reported fourteen
additional cases, Milne, however, in a critical review published in
191 2 criticizes the previous literature on the subject(5) and excludes
Lavenson's, Hochsinger's and other cases from consideration on the
ground of incomplete pathological evidence, thus bringing back the
total number of authentic cases to seventy-eight. Additional cases
have been reported by Nieman(5), Sugi(6), Merle(7), Moschowitz(8),
Bohm(9), Elperin(io), Hoeg(ii), Ylppo(i2), Marien(i3), Carbo-
nell(i4) and Hess(i5) bringing the total to about ninety. While it
cannot be looked upon as a rare condition, it is still infrequent
enough to justify careful consideration of additional cases. This is
especially true as regards the factors bearing upon etiology.

* From the Pediatric Department of Providence Hospital, Washington, D. C,
and the pathological laboratory of Georgetown University. Read before the
Washington Obstetrical and Gynecological Society.
521

522 FOOTE AND HAMILTON: CONGENITAL OCCLUSION OF BILE DUCTS

Clinical Course. — An invariable uniformit_\- characterizes the clin-
ical histories of infants suffering from this condition. Jaundice
appears at birth, or shortly after. The stools are either clay colored
or colorless. The urine is deeply pigmented. In a summary of sixty
cases thirty-nine were reported as having been born jaundiced. The
appearance of the jaundice varied in the other twenty-two from one
day after birth to five weeks (Skormin)(i6). The pigmentation is
very faint at first, becoming more intense after three or four days.
As the condition progresses the sclera become deeply tinted and the
skin assumes a characteristic greenish-yellow tinge. The jaundice is
constant, persistent; it shows no remissions. Even when the skin does
not show a deep pigmentation, the urine will stain the napkin bright
yellow, more pronounced indeed than the urinary discoloration
accompanying the deepest possible skin pigmentation in other forms
of biliary obstruction. The stools in most cases show no bile from the
very beginning. Normal meconium is usually passed, and the stools
become progressively yellow merging into, and finally becoming
pipe clay in color, and resembling junket both in consistence and
appearance. Rarely traces of bile are found in the stools, as reported
by Hess, but this is invariably the result of transudation of bile salts
through the intestinal walls from the liver or larger bile ducts, the
intestinal wall at autopsy showing bile stains.

Nutrition is fair for a time, but eventually a malnulritive state
results. In the writer's case the infant not only thrived for a time
but passed through a respiratory infection of rather severe tj'pe.
Early hemorrhages are noted in a few cases, and hemorrhages
practically always appear eventually. Cheyne ascribed this bleed-
ing to its proper cause, "bile in the blood." An anemia of the second-
ary type, progressive in character, is always present. Death usu-
ally occurs about the fourth month, but ranges between sixty-two
hours (Glaister) and eight months (Lolze), to nine months (Niemann)
(i7andi8). The hemorrhagic tendency or some intercurrent respi-
ratory infection are the usual direct causes of death. In, Thomson's
forty-nine cases thirty-one suffered from hemorrhage, of which seven
were subcutaneous, one conjunctival, six umbilical, two nasal, one
hemoptysis, four hematemesis, eight enteric, one gall-bladder,
eleven wound. The experimental work of Ribadeu on guinea-pigs
shows that a remarkable degree of anemia may be produced by liga-
tion of the bile ducts. The hemolytic action of the bile salts is so
well known that there can be little doubt as to the important role
they play in the causation of this anemic state. The exclusion of
bile from the intestine is of secondary importance in comparison.

FOOTE AND HAMILTON: CONGENITAL OCCLUSION OF BILE DUCTS 523

In those cases which lived for several weeks or more autopsy showed
an independent outlet from the pancreas to the intestine.

Case I. — Nathaniel R., male, white child aged five months and
two weeks. Father and mother are both living and healthy. One
other child in familv, born normally, aged ten and at present is in
good health. The mother has never had anv other children, and has

suffered no miscarriages. Had slow, difficult labor with this baby,
was very toxic and eclampsia was feared, albumin and casts having
been found in the urine previous to and during labor. Duration of
labor thirty hours with delivery by high forceps. Child weighed a
little less than 8 pounds at birth and was apparently normal.

Water was fed until the fourth day after birth when the child was
put to the breast:. Normal meconium was passed and the icteric tint
was not observed until maternal nursing was begun. Was nursed
for a month, the jaundice persisting, and then as he seemed hungry
additional feedings of condensed milk were given. After the first

524 FOOTE AND HAMILTON: CONGENITAL OCCLUSION OF BILE DUCTS

week the stools became white and remained in this condition. Was
seen by the writer (Foote) two months after birth in consultation
with the physician in charge, Dr. Joseph Mundell. The weight had
remained stationary for some time, but nutrition improved when
weaning was begun and the infant was given a low fat dextri-maltose
food. A tentative diagnosis of congenital occlusion of the bile ducts
was made at this time. The family then removed to another city
where the baby suffered an attack of pneumonia from which he
recovered, his condition continuing to improve until he weighed 9
pounds. At this time serious digestive disturbances arose accom-
panied by loss of weight and the baby was brought back to Washing-
ton and placed in the Pediatric Wards of Providence Hospital,
entering March 4, 1914. Complaint, persistent jaundice said to
be due to congenital obliteration of the bile ducts. No fever, no
prostration, sleeps badly but is active both mentally and physically.
No vomiting, slight regurgitation after feeding rapidly. One move-
ment in twenty-four hours, color white and appearance like junket;
rather constipated and with a fetid odor, but no mucus and no blood
present. No cough, and a very slight nasal discharge. Physical
examination: Temperature 98.6, pulse no, respiration 30. Weight 9
pounds. Underdeveloped and rather poorly nourished male child.
Skin flabby, greenish yellow in color. Tissue turgor much diminished.
Very active mentally; laughs and plays when not in pain. Anterior
fontanelle, open; posterior fontanelle, almost closed. No craniotabes
and no rosary or enlarged epiphyses. Neck not rigid, and no retrac-
tion of the head, pupils normal; sclera yellow. Tongue slightly
coated; no teeth, gums normal. Throat normal. Ears show no
discharge; drums normal. Slight mucoid nasal discharge. Heart
impulse and outline normal. Lungs normal. Abdomen pendulous.
Liver dulness, upper border in mammary line above third rib.
Edge very smooth and felt 11 centimeters below costal margin in
right mammary line. Intestines, generally tympanitic. Penis shows
scar from a dorsal circumcision. Blood: Reds, 2,600,000. Whites:
12,200. Hemoglobin, 40 percent. Differential: Red cells show
poikilocytosis and anisocytosis. No nucleated forms. Whites,
polymorphonuclear 40 per cent., small mononuclear 35 per cent.,
large mononuclear 25 per cent. Urine, S. G. 1.014, acid. Albumin
absent. Sugar absent. Urea, 2.1 per cent. Bile present. Urobilin
and urobilinogen absent. Stools show abundance of fat soaps and a
very small quantity of free fat. Bile and bile salts are absent from
the stools.

March 6th. Fed protein milk with 4 per cent, maltose-dextrin,
eight feedings of 4 ounces in twenty-four hours. Normal salt solu-
tion given by rectum. Flatus exjielled in large amounts resulting in
a reduction of abdominal tympany.

Mar. 7th to 9th. Condition shows less irritability; tries to play
and laugh.

loth. Weight 9 pounds 4 ounces.

14th. Irritable and losing weight.

i8th. Continued loss of weight, 8 pounds 2 ounces.

23d. Ecchymotic spots appearing. Very restless. Weight

rOOTE AND HAMILTON': CONGENITAL OCCLUSION OP BILE DLTCTS 525

8 pounds 12 ounces. Nose bled at night. Stool shows occult
blood.

24th. A slight diarrhea.

25th. Salmon-colored defecations showing free blood. Pulse
rapid. Died at 4.50 p. M.

Autopsy. — Body of a poorly nourished male child. Skin of an
icteric hue with a slight olive tint. Muscles somewhat wasted.
Lungs normal in appearance, bronchial glands enlarged. Heart
dilated, especially right auricle. Intestines pale with mesentery and
omentum scanty and transparent and almost free from fat. Liver,
dark green in color with granular surface. Capsule strips with little

dilftcuUy. Right lobe very large; quadrate lobe separated from the
rest of the organ by a large amount of connective tissue. On section,
liver substance shows dark brown surface with greenish granules and
cuts with some gritty resistance. Weight after Kaiserling 280 grams.
Gall-bladder about i centimeter in length with walls very much
thickened. On section shows a small lumen filled with a clear syrupy
fluid. Cystic duct for a distance of about i centimeter dilated to
the size of a crow's quill, then becoming cord like and merging into
the capsule. Common duct replaced by a small cord of connective
tissue. Hepatic duct absent. Lymph glands at root of liver much
enlarged and of a pink color. Hemolymph glands generally enlarged.

526 FOOTE AXD HAMILTON': COXGEXITAL OCCLUSION' OF BILE DUCTS

Spleen elongated by pressure against costal margin; much enlarged
and of the feline type. Accessory spleen about 0.6 centimeter in
diameter. Duodenum shows an imperforate papilla of Vater and
a pancreatic duct opening directly into the duodenum .3.5 centimeters
from the papilla of Vater.

Microscopic sections of the liv-er reveal the presence of a biliary
cirrhosis, bile stasis, increased production of perilobular connective
tissue with round-cell infiltration and proliferation of lumenless bile
ducts. Numerous sections of the cord of connective tissue represent-
ing the common bile duct fail to show the presence of any structure
resembling a duct.

The pancreas shows the normal histologic structure. No impor-
tant changes noted in other organs.

Theories of Origin. — An analysis of the cases so far reported is con-
firmative of the congenital nature of this disease. Labor was so
uneventful as to excite no comment in the histories of a majority of
the cases. In a minority, as in the writer's case, the labor was pro-
longed. Abnormal labor, however, was the exception rather than
the rule. Sex probably has little or no influence, although in Thom-
son's series of thirty-four cases, twenty-one were boys. Family in-
fluences may be eliminated, for while Benz reported two cases of
persistent jaundice in the new-born resulting in death as having
occurred in the same family, obliteration of the bile passages was
not found, and the disease was the more rare condition known as re-
current family jaundice. Syphilis has been reputed to have an influ-
ence, but syphilitic obstructions are acquired and not congenital
They are not true cases. The application of the Wassermann blood
test, with negative findings in a number of recent cases, has definitely
eliminated a luetic taint in the etiology. Similar conditions are
found clinically in syphilitic hepatitis, and Beck's(i8) case belongs
to this group. Like cases have been reported by Rolleston(i9) and
others, in which the liver sections showed the intercellular type of
cirrhosis rather than the characteristic monololjular changes .seen
in congenital occlusion of the bile ducts.

The Theories of Rolleston and Lavenson. — Rolleston(2o) maintains
that the cirrhosis of the liver is the primary condition and the bile
duct occlusion a secondary process. Some poison secreted by the
liver causes first a hepatitis and later a cholangitis. The inflamma-
tory process beginning in the liver lobule descends to the larger bile
ducts and finally obliterates them. Against his theory is the fact
that when death occurred soon after birth, as in Grifiith's case, the
liver changes are not marked wliilc the bile duels are fibrous cords.

FOOTE AND H,\MILTON : CONGENITAL OCCLUSION OF BILE DUCTS o2l

Lavenson(3) holds that the condition is an anamoly of develop-
ment. He points out the fact that the bile ducts in their primitive
form are soHd cords, the fibers of Remak, and that it is the hollowing
out of the centers of these cords which results in the formation of the
bile ducts. Failure of this lumination in any portion of the future
bile duct may cause the disease. This embryological theory is well
founded. 'According to Hertwig the hepatic system first makes its
appearance as a solid cord emanating from the gut-tract about the
third week of intrauterine life. From the branching end come the
bile capillaries ; the hepatic duct is formed by the proximal end. Cleav-
age from the gut occurs and the mass lies free in the abdominal
cavity. A second budding out now occurs to form the common bile
duct, which unites with the previously formed hepatic duct. Statis-
tics show that a majority of the occlusions occur in the neighborhood
of the junction of these two radicles, the hepatic ducts nearly always
being patulous above, while the common bile duct is frequently open
from below. As will be seen later, anomalous conditions in other
portions of the tract occur, but the embryological history of the
hepatic system fits into the theory of failure of lumination too closely
to be regarded as a mere coincidence.

Wrinka held that the force with which bile is expressed from the
liver in difficult labors was responsible for obliterative inflammations
of the bile passages. He reports in this connection a case of occlu-
sion in an infant born in tedious and difficult labor. Four similar
cases were reported in Virchow's Archives in 1867. Yet the relative
frequency of difficult, or at least tedious, labors is in marked con-
trast to the great rarity of true catarrhal jaundice in the infant.

As to the theory of the syphilitic origin of this condition, it is now
quite clear that, while congenital syphilitic hepatitis may cause
stricture of the bile passages, such cases are separate and distinct
from the condition we are discussing, differing in clinical history,
gross lesions and histological findings as well as in the clinical labor
story tests and especially the Wassermann reaction.

The evidence so far adduced seems overwhelmingly in favor of
the developmental origin of this disease as a failure of lumination in
the primitive bile ducts followed by a secondary hepatitis and a liver
cirrhosis of the biliary type. We are forced to agree with Milne(5)
that "summarizing the facts, both clinical and pathological, it seems
as if almost every evidence indicates some congenital malformation
as the cause of this group of cases of jaundice of the newly born. In
only very few cases has the lesion been associated with other con-
genital deformities."

528 FOOTE AND H.\MILTON: CONGENITAL OCCLUSION OF BILE DUCTS

Pathology. — The liver is always enlarged. When death occurs early
in the disease liver changes are not so marked as in the more protracted
cases. The degree of liver involvement seems directly dependent
upon the duration of the disease, the cirrhotic condition becoming
more marked in cases where death is delayed. The cirrhosis is
largely of the monolobular type. Rolleston and Hayne(2o) , however,
assert that the cirrhosis is of the mixed, or multilobular type, at
least in part. Portal, or multilobular, cirrhosis has been described
as that form of hepatitis in which the toxins gain access to the liver
through the portal vein, as differentiated from biliary, or mono-
lobular cirrhosis, when the toxin is supposed to enter bj' the hepatic
artery. But, as Milne(5) points out, and as we all know, an extensive
anastomosis occurs between the terminal branches of the hepatic
artery and the portal vein in the liver, and poisons entering by either
one of these channels may reach the same ultimate destination in the
liver lobule. The distinction as to the channel of infection is, there-
fore, more apparent than real. As to the histopathology, the differ-
ences are marked. In the monolobular type the periphery of the
lobule is undergoing fibrous degeneration resulting in a more or less
complete ring of fibrous tissue. In the mixed type an eccentric
destruction of cells alternating with a compensatory hyperplasia of
liver cells and connective tissue results eventually in the picture of
irregular masses of liver cells imbedded in more or less dense con-
nective tissue. This "mixed type" of Thomson, Rolleston, etc., is
according to Lavenson and Milne really an advanced stage of the
simple monolobular type of the disease in which the more complete
destruction of liver cells has caused extensive repair with compensa-
tory hyperplasia of regenerated cells and scar tissue formation, both
results conspiring to distort the normal outlines of the lobule.

The pancreas is usually normal, though in some reports it is de-
scribed as cirrhotic. But since the pancreas of the new-born shows
normally under the microscope a relatively large amount of fibrous
tissue in its capsule, it is easy to mistake a normal pancreas for a
fibrous one. We believe that few cases of congenital occlusion live
long enough for antemortem diagnosis of this condition to be made
unless they possess a pancreas with an independent opening into the
intestine. Hess(i4) has reported a case with an accessory pancreas.
Indeed, we may be normally certain that in infants suffering from
this condition who have lived a month or more, the pancreas through
a persisting duct of Santorini is pouring its secretion into the duode-
num, especially as the stools show little or no free fat. Moreover,

FOOTE AND H.AMILTON: CONGENITAL OCCLUSION OF BILE DUCTS 529

a large number of autopsy- protocols call attention to the patency of
a pancreatic duct opening into the intestine directly.

The spleen is always enlarged, though sometimes not palpable in
the living subject because of the preponderance of liver tissue. A
fibrosis akin to that seen in the liver is reported by Emmanuel(2i)
and confirmed by several other case reports. According to Rolles-
ton's hypothesis, the spleen enlarges primarily as a result of the in-
fectious process in the liv'er. However, we are familiar with the
picture of fibrous tissue formation in other pathological conditions
accompanied by venous stasis and as venous stasis is an important
factor in this particular variety of splenic enlargement, it would be
against the rule not to have a fibrosis proportionate in degree to the
permanent enlargement of the organ.

The mesenteric glands are always enlarged and frequently bile-
stained, due no doubt to the excess of bile in the engorged lymph
channels of the liver. There is practically no evidence of any peri-
toneal inflammation, either acute or chronic, about the bile ducts.
Syphilitic evidences are, to again quote Milne, " conspicuously want-
ing." "In 23 out of 89 suspected cases" he says, "syphilis was
positively excluded. Of the remaining 66, in only lo cases of these
was there reported some manifestation of syphilis, or else syphilitic
parents. "As we have seen, the type of cirrhosis produced by
syphilis is the characteristic interlobular type, quite easily differ-
entiated from the monolobular or mixed type of cirrhosis charac-
teristic of congenital obliteration. Case reports of closure of the
bile ducts by congenital syphilitic inflammations have been made
by Rolleston, Chiari, Beck, Housemann and others, while the cases
cited as congenital occlusion by Simmoni, Hutinel, Hudelo and
Lomar, are claimed by MQne to belong to the syphilitic hepatitis
groupfs).

Diijercntial Diagnosis. — A jaundice of the new-born which persists
beyond the usual period may excite a suspicion of bile duct occlusion,
but the stools in the latter condition very quickly become acholic.
Catarrhal jaundice in the new-born is of such rare occurrence as to be
practically unknown. Syphilitic occlusion may be differentiated by
the blood examination, but occlusion from this disease does not
produce jaundice so quickly, nor does it always occur in syphilitic
hepatitis. In infectious jaundice occurring in septicemia, the
temperature and high leukocyte count will differentiate especially
the latter. Family jaundice, described by Rolleston, Pfannenstiel,
and others, which sometimes occurs in both mother and child and is
usually fatal to Ihe latter, does not produce acholic feces. The

530 FOOTE AND HAMILTON: CONGENITAL OCCLUSION OF BILE DUCTS

liver in this condition shows few structural changes. Practically
nothing is known about the etiology of family jaundice. The rare
cases of hemolytic jaundice are practically impossible to differentiate
from congenital occlusion in their clinical aspects. The use of the duo-
denal catheter as employed in the cases of Hess(i4) and Koplik(22)
to determine the absence of bile from the duodenum should help
in the diagnosis. Of postmortem findings the histopathology of
the liver is the most helpful in distinguishing congenital jaundice
from other forms.

Metabolism Studies. — The studies of fat metabolism, digestion and
nitrogen balance in this condition are of special interest.

The studies of the digestion in the small intestine in the absence
of bile are also suggestive. Niemann(5) made extensive analyses in
the case of congenital absence of the bile ducts occurring in a child
that lived to be nine months of age. In this case a nitrogen absorp-
tion was noted of 80 to 93 per cent., and a fat absorption of 28 to
39 per cent. On very low diet more fat was found to be excreted
than was given to the child. In the ten weeks' old baby studied by
Koplik and Crohn(22), which in spite of the fact that no autopsy was
performed we may be reasonably certain was a case of congenital
occlusion, both nitrogen absorption and retention were approximately
normal. Fat absorption was seriously interfered with, however,
only 48.4 per cent, being absorbed. Saponification and fat splitting
seemed also to be diminished. In the writer's case, however, very
little free fat was discoverable in the stool but fat soaps were in
excess. According to Meyer(27), Rubner and Heubner(25), and
Freund(26) the fat absorption in normal infants varies from 88 to 96
per cent. Keller's experiments showed a fat-splitting power in the
normal child of about 90 per cent. Koplik and Crohn using the Hess
method of duodenal catheterization (24) made some valuable studies
on the pancreatic action in this condition. They concluded "(i)
that the pancreatic ferments are present, and therefore that the pan-
creatic ducts are patent; (2) that the amylase and trypsin are strongly
present; (3) that the lipase is very weak. This latter fact," they
say, '"is the important fact, and is probably best explained by the
absence of the normally present bile salts which act to increase the
strength of the lipolytic ferment from 10 to 20 times."

As there can be no surgical relief for this condition the treatment
must perforce be purely palliative, and almost entirely a question of
feeding. A milk modification low in fats and rich in carbohydrates
and proteid will put the least burden on the digestive organs, and is
lotricalh' indicated. Whether or imt the administralion of bile salts

rOOTE AND HAMILTON: CONGENITAL OCCLUSION OF BILE DUCTS 531

by mouth will improve fat absorption has not been proven, though
it is likely that the resulting stimulation of bile production would
offset any beneficial action.

SUMMARY.

Congenital occlusion of the bile ducts is probably of more frequent
occurrence than has been supposed, as the increase of the number of
cases is greatest where routine autopsies are done. It is not unlikely
that some of the cases of persistent jaundice, improperly supposed
to be simple jaundice of the new-born, resulting in death during the
first few weeks of infant life are due to this condition. Practically
all of the protocols of cases with a duration of life of two months or
over, show the development of an outlet from the pancreas, inde-
pendent of the common duct, a necessary condition to intestinal
digestion.

The use of the urobilinogen test and the Hess duodenal catheter
will be undoubted aids in the diagnosis.

The burden of evidence favors the view that this is a purely de-
velopmental and not an inflammatory condition.

REFERENCES.

1. Thomson, John. Edin. Med. Jour. 1891, x.x.wii, pt. i, 532;
pt. ii, 604, 724.

2. Ralleston. (Syph. abstract.) Brit. Med. Jour., 1907, ii, 947.

3. Lavenson. Jour. Med. Research, 1908, n.s., .wiii, 61.
5. Milne. Quarterly Jour. Med., 1911-12, v, 409-413.

4. Howard and Walbach. Arch. Int. Med., 1911, viii, 5.

5. Niemann. Ztsch. f. Kindh. (Berl., 1912), iv, 152-167.

6. Sugi. Monatsch. j. Kinderh. 1912, xi, 294-331.

7. Merle. Bull. etMem. Soc. Anal, de Paris, 1910, l.xxxv, 29-35.

8. Moschowitz. Proc. N. Y. Path. Soc., 1912-13, n.s., .xii. 41.

9. Bohm. Ztsch. f. ang. Ant., etc., Berlin, 1913, i, 105-129.

10. Elperin. Frankfurt. Ztschr.f. Path., Wiesbad, 1913, xii, 25-46.

11. Hoeg. Hasp, 'fid., Kobenhav., 1908, 577-591.

12. Ylppo, A. Ztschr.f. Kinderh. Berl., 1913, ix, 319-337.

13. Marien, A. Union Med. du. Canada, Montreal, 1912, xi,
439-441-

14. Hess, A. F. Arch Int. ^[cd., Chicago, 1912, x, 37-44.

15. Carbonell, A. Med. Madrid., 1911, iv, 234-236.

16. Skormin. Jahrb. f. Kinderh., igoi, Ivi, 200.

17. Lotze. Berl. klin. Wchnschr., 1876, xiii, 438.

18. Beck. Prag. med. Wchnschr., 1884, ix, 257, 266.

19. Rolleston. Diseases of Liver, Gall-bladder and Bile Ducts.

20. Rolleston and Hayne. Brit. Med. Journ., 1901, i, 758.

21. Emmanuel. Brit. Med. Jour., 1907, ii, 385.

22. Crohn and Koplik. Am. Jrn. Dis. Chil.

23. Fensdorf. Frankfurt. Ztschr. f. Path., Wiesb., 1912, ix, 381-399.

532 TRANSACTIONS OF THE

24. Hess. Am. Jaunt. Dis. Child., 1912, iii, 133, ibid., 304.

25. Rubner and Heubner. Zlschr.f. Biol., No. 38, p. 315.

26. Freund. Ztschr. Biocheni., IQ12, No. 8, p. 422.

27. Meyer, Ludwig. Zlschr. Biochem., 1908, No. 12, p. 422.

28. Keller. Monatschr. J. Kinderh., 1903, i, 234.
1726 M. Street N. W.

TRANSACTIONS OF THE AMERICAN PEDIATRIC
SOCIETY.

[CimliHUcd from page 365.)

A METHOD OF PREPARING SYNTHETIC MILK FOR STUDIES OF INFANT
METABOLISM.

Dr. Henry I. Bo^VDITCH and Dr. Alfred W. Bosworth, Boston.
— "In connection with our investigations concerning infant feeding it
became necessary for us to control all factors entering into the com-
position of the food used and as only liquid food can be used it soon
became evident that a synthetic food from pure materials offered
the only solution of the problem. After many experiments during
the past few years we have finally perfected the method herein to be
described, and have used milk prepared according to this formula for
several investigations with success. The method consists of the
following four steps: i. The preparation of isolated food material
for use in making synthetic milk. 2. The recombining of these
materials to give a mi.xture of the desired composition. 3. The
emulsification or homogenization of the fat and any of the solid or
insoluble constituents entering into the composition of the food.
4. Pasteurization or steriHzation of the food after it has been made.
The following substances may be used as the case demands, distilled
water, pure fat, pure sugar, pure protein, pure salts of various kinds,
and the protein-free milk of Osborne and Mendel. Thus far they
had used only olive oil and butter fat. The olive oil used was the
purest commercial oil we could obtain, but the butter fat had been a
pure product prepared by us according to the method of Osborne and
Mendel. In some cases we have used the sugars of the purest
commercial grade while in others we have used recrystallized lactose.
So far we have used only one protein, casein, and have made use of
this substance in three forms, calcium caseinale of commerce, the
sodium caseinale of commerce, and pure casein, prepared according
to the method already published by us. The salts should all be of
the highest purity and the ones most likely to be used are the phos-
phates, chlorides, acetates, and citrate of calcium, magnesium,
sodium and potassium. Osborne and ^Mendel have shown that a
synthetic food made of pure materials contains no vitamines which
seem to be essential to promote the growth of an animal receiving
such food. These substances are present in a preparation made by
them and called protein-free milk. In investigations involving the
continued use of a synthetic milk for more than a few davs it is

AMERICAN PEDIATRIC SOCIETY 533

always wise to add some of this protein-free milk in order to get the
benefit of the vitamines carried in it. All our synthetic milks have
been made up on the percentage basis. The sugar is dissolved in
one-half the volume of distilled water required for the complete
mixture and the salts added to this sugar solution. The protein is
dissolved or suspended in the other half of the water. If Larosen
or nutrose are to be used they should be rubbed to a fine paste %vith
a small portion of the water, the remainder of the water carefully
added and then the whole gently warmed in warm water to effect
complete solution. If pure casein or paracasein are used they may be
suspended in the water and homogenized with the fat or they may be
dissolved by the addition of an alkali, one-half of a cubic centimeter
of normal alkali or its equivalent being used for each gram of protein.
If strict percentages are to be observed the volume of water used
must be diminished by an amount equal to 'the volume of alkali
solution used to dissolve the protein. The two and one-half volumes
are now united, the fat melted, and added and the whole homogen-
ized. The successful use of these synthetic milks depends to a
very great extent upon our ability to produce a homogenous mixture
of considerable permanency and this result has been obtained by the
use of the Manton-Gaulin homogenizing machine. This is a small
one of special design built for laboratory use. Before use the
machine is thoroughly cleansed and a solution of hydrogen peroxide
run through the apparatus for fifteen minutes and the last traces of
this removed by the use of hot recently boiled distilled water. Mix-
tures containing liquid fats may be homogenized at once without
warming, though more satisfactory results will be obtained by
slightly warming them. Mixtures containing semisolid fats must be
heateci to a temperature of a few degrees above melting-point of the
fat used. ,\11 the fat is allowed to enter the machine first with a
small portion of the liquid. The fat and this liquid are allowed to
run through the homogenizing chamber once or twice at a pressure
of 50 kilograms per square centimeter. The pressure is then
increased to 150 kilograms and the whole mixture run through the
machine after which the pressure is increased to 200 to 250 kilograms
and the mixture run through once or twice more. In appearance
the mixture now strongly resembles milk. The synthetized milk
is then transferred to glass fruit jars and sterilized, lightening jars
with glass tops being the best. The water reaching to about two-
thirds the height of the jars is allowed to boil gently for about
thirty minutes. If the food is to be kept for any number of days it
should be heated again, and then stored in a cold place."

A STI'DV OF THE TOPOGRAPHY OF THE PULMONARY LOBES AND FIS-
SURES WITH SPECI.\L REFERENCE TO THORACENTESIS.

Dr. J. C. GiTTiNGS, Dr. George Fetterolf, and Dr. A. Graeme
Mitchell, Philadelphia. — "In conclusion it may be said that the
fissures of the lung in infancy show practically the same relation
to the bony framework of the chest as in adults. The origin, course,
and termination of the fissures varies greatly in different indiv'iduals.

534 TRANSACTIONS OF THE

The variations apparently do not depend upon any of the anatomic
characteristics of the chest and cannot be predicted therefore. The
lower level of the lungs in infants does not extend quite as low as in
adults. For this reason, and owing to the anatomic characteristics
of the bases of the pleural cavities in early life, great care should be
exercised to avoid damage to the diaphragm in performing thora-
centesis. It would seem that the lowest point for tapping with
absolute safety, therefore, would be the fifth or possibly the sixth
interspace in the midaxillary line, and the seventh and possibly
the eighth interspace in the line of the angle of the scapula. In the
author's clinical experience it might be said that the seventh or
eighth interspace in the postaxillary line, which Hes nearer to the
scapula than to the midline, is the optimum point of attack."

REPORT OF COMiUTTEE ON VAGINITIS.

This committee consisting of Dr. J. C. Giddings, Dr. Samuel
McC. Hamill, Dr. C. A. Fife and Dr. Howard C. Carpenter of Phila-
delphia presented their report through Dr. Giddings. He stated
that they had been appointed to investigate the subject of vaginitis
in infants and young girls and had conducted a very thorough
investigation. A questionaire had been sent to various institutions
caring for female children and to a large number of pediatricians.
The replies to this questionaire Dr. Giddings analyzed. With these
replies as a basis the committee had formulated the following set of
resolutions for the consideration of the Society:

1. That the American Pediatric Society address a letter to Health
Officers of States and Cities containing the following recommenda-
tions:

(A) That cities be required to provide adequate hospital and dis-
pensary facilities for the care and treatment of children having
vaginitis.

(D) That toilet seats embodying the principle of the U-shape be
used in all schools and that the toilets be of proper height for differ-
ent ages.

(E) That city and state laboratories be empowered and equipped
to make bacteriological examinations for physicians when patients
cannot afford to pay a private laboratory fee.

(F) That educational literature on the subject of vaginitis be pre-
pared and distributed to mothers through the medium of physicians,
hospitals, dispensaries, health centers, municipal and visiting nurses.

(H) That asylums for children and day nurseries be licensed, and
that the license be not granted unless: first, the institution has ade-
quate facilities for the recognition of gonococcus vaginitis; and second,
that the institution exclude children having this disease if they can-
not be properly isolated.

2. That the American Pediatric Society address a special letter
to hospitals which care for children containing the following recom-
mendations:

AMERICAN PEDIATRIC SOCIETY 535

(A) That separate wards be maintained for the treatment of
children with vaginitis who are also suffering from other diseases.

(B) That microscopic examinations of smears be made before
admission to the general wards of the hospital. In securing material
for the smears extreme care should be taken to observe rigid aseptic
precautions.

(D) That, individual syringes, bed-pans, catheters, cUnical ther-
mometers, thermometer lubricant, wash basins, soap, powder, wash
cloths and towels be provided.

(E) That single service diarcrs be used (at least for girls); or,
that diapers be sterilized in ar autoclave at 15 pounds pressure for
five minutes.

(F) That nurses be require(' to make daily inspection of the vulva
of each at the time of bathing, and to report immediately the pres-
ence of the slightest suggestion of a vaginal discharge.

(G) That low toilets be provided and equipped with seats em-
bodying the principle of the U-shape.

(H) That for routine purposes, the spray be used in place of tub
baths for the bathing of young girls, and that older girls be sponged
in bed.

(I) That nurses receive special instruction as to the nature of
vaginitis, the ease with which it is transmitted, the methods of pre-
venting its spread and the necessity for rigid aseptic surgical tech-
nic in its handling and treatment.

(J) That a dispensary with special facilities for the treatment of
gonococcus vaginitis be provided.

(K) That nursing care and supervision be given in the home.

(L) That mothers be instructed as to the dangers of vaginitis,
the manner in which it is transmitted, the best method of protecting
other children and the necessity of prolonged observation.

(M) That all cases of vaginitis under observation be voluntarily
reported to the local Health Officer in states or cities where no legal
requirements are in force.

Dr. B. K. Rachford of Cincinnati said: "I have had consider-
able experience in the treatment of vulvovaginitis and in the hos-
pital with which I am connected they have had a ward divided into
four compartments for the treatment of this form of infection. The
patients are admitted to the first compartment and passed through
the other three compartments as they progress. When they are
discharged from the fourth compartment they are turned over into
the hands of the children's clinic where they are kept under continu-
ous observation. There are many things that will have to be taken
into consideration before vulvovaginitis can be made a reportable
disease. The first thing that will have to be done is to make an
effort to change the attitude of the public. At the present time the
very mention of vulvovaginitis strikes terror to people and carries
with it a stigma of disgrace. This attitude should be changed and
the public made to understand that vulvovaginitis in children is a
different disease from what it is in the adults. Nothing in the way

536 TRANSACTIONS OF THE

of reporting these cases can be accomplished so long as the term
'gonorrheal' is used."

PROVOCATIVE AND PROPHYLACTIC VACCINATION IN THE VAGINITIS OF
INFANTS.

Dr. Alfred F. Hess, New York. — "We have had to contend
with the problem of vaginitis in the institution with which I am
connected and have profited in some directions by experience, and
this e.xperience may be of service to others who are actively interested
in this problem. Our efforts have been directed in various direc-
tions; in preventing the admission of infected infants; in attempting
in many different ways to avoid spread of infection; in diagnosing
the cases at the earliest possible moment, and finally in resorting
to every means to effect a cure. Vaginitis presents an entirely
different problem in a home or asylum from what it does in a hospital
for infants. In the latter the solution is comparatively easy and
simple, for all that is necessary in order to eradicate the disease is to
cease admitting female infants and to discharge the infected cases,
one by one, as they are cured of the ailment for which they were
admitted to the hospital. In an asylum, on the other hand, when a
case of vaginitis slips by the admitting physician or arises apparently
de novo in one of its wards, it is realized that a heavy burden has
fallen upon the medical staff, for it is probable that this infant will
remain for years a threatening source of infection and will have to be
guarded under quarantine. The diagnosis of gonococcus vaginitis
is not always easy to establish. There is no doubt that vaginitis
may be due to organisms other than the gonococcus. There is a
class of border-line cases which is exceedingly puzzling, showing
merely pus cells on microscopic examination. If these cells are
numerous an inflammation is undoubtedly present, and in the great
majority of cases the infecting organism will be the gonococcus.
The specific nature of this infection is all the more probable if there
are no organisms to be seen in the field among the cells. One
exception should be borne in mind as regards the diagnostic signifi-
cance of pus cells. This was called to our attention by noting these
cells in an infant only forty-eight hours old who was brought to the
institution for admission. It hardly seemed that this was a case of
gonococcus vaginitis, so we investigated to ascertain how often pus
cells were encountered in smears taken from infants during the first
two days of life. These tests were carried out by Dr. Edwin Lang-
rock and showed that in half the cases, pus cells might be found in
smears taken within the first forty-eight hours, so that they must
not be regarded as pathological, but as the probable reaction of the
external tissues to the inevitable invasion of bacteria. As we
probed deeper we lind that the fundamental cause of vaginitis must
be considered to be the latent carrier, some healthy infant who
harbored the gonococcus. Such has been our experience. When-
ever a case of vaginitis rose in the institution the rule was that
examination should be carried out three times during the following

AMERICAN PEDIATRIC SOCIETY 537

week in every infant in the ward in order to ferret out the source of
the infection. Almost every instance of this kind brought to light
some case where, in spite of the absence of discharge, gonococci were
evident in the smears. Such recrudescence of infection came about
every few months and sometimes oftener. During the past five
years autopsies had been performed in four infants who had vaginitis
while in the institution. They all showed the same pathological
condition: Macroscopically the vagina appeared negative, as did
the body of- the uterus and the appendages. The only abnormal
condition was redness of the tip of the cervix, which did not extend
along the canal to the internal os. Microscopic examination con-
firmed the gross appearance of these structures. In every instance
the entire vagina, the uterus, and tubes were carefully examined and
the sole lesion was this inflammation of the cer\'ix. From these
postmortem examinations it would seem that we must regard the
average gonococcus infection as involving the cervix rather than the
vagina, and as a cervitis rather than a vaginitis. The degree of
vaginitis found in children who applied for admission to the institu-
tion was almost 50 per cent, and gave grounds for believing that
vaginitis was not a disease particularly associated with child-caring
institutions. In order to overcome the danger of the latent carrier
we have for the past year administered three injections of gonococcus
vaccine soon after the children were admitted to the institution.
These infants had all shown the absence of pus cells upon admission.
The vaccine was made from a culture obtained from one of the cases
in the institution and 250,500, and 750 millions were given with
three-day intervals. The object of these vaccinations was to see
whether they would prove provocative and would bring to light a
latent infection. The dosage which was used was entirely empirical.
As a result it would seem that it could probably be much smaller.
At the present time we are giving, 100, 200 and 400 millions. More-
over, two infections might be sufficient, and we rarely have brought
about a discharge by a third inoculation. During the past year these
provocative inoculations have led to the discovery of eight new cases
during the first week or two following their admission to the insti-
tution. As a result of this procedure not one new case has slipped
into the main institution from the admitting pa\dlion. We have
also made use of this diagnostic aid in the wards where from time to
time cases of vaginitis arose. We are unable to state the exact
scientific basis of the reaction following these inoculations. It was,
however, not due to the rise in temperature, and could not be regarded
as absolutely specific, for a reaction was obtained at times by similar
injections of staphylococcus vaccine, although this was not found
to be as reliable for this purpose as that made from the gonococcus.
The vaccine was found to be of value not only as a diagnostic
measure but to a certain extent for prophylaxis. To this end it
was used in about 100 infants and we were able to change the entire
nature of the vaginitis in our institution. In cases that were vac-
cinated the vaginitis showed a mild type of infection. It was not
to be e.xpected that prophylactic vaccinations could prevent the

538 TRANSACTIONS OF THE

occurrence of carriers. However, the protected cases instead of
developing a vaginal discharge full of pus cells and gonococci, were
found to have no discharge whatever, and showed as the only evi-
dence of infection a few pus cells and microorganisms in the cervical
smears. In other words, a nonclinical type of the disease resulted.
There are some diseases which occasion not only recrudescence of
vaginitis but seemed to confer an added susceptibility. This
seemed especially true of scarlet fever. In those diseases the sus-
ceptibility extends still further, so that joint infection and other
evidences of a bacteremia result. There is not only an acquired
susceptibility to gonococcus infection but also a natural susceptibil-
ity and a well-defined natural immunity. This immunity is rare
and in many instances not absolute."

DISCtJSSION.

Dr. F. B. Talbot, Boston. — "I would like to ask whether after
they made these injections there was a discharge produced by the
provocative inoculation and how long such a discharge existed, and
also whether it was accompanied by any unusual symptoms."

Dr. J. P. Sedgewick, Minneapolis,. — "We had an instance in
which a child in a private hospital developed a vaginitis. We were
in doubt as to whether to discharge the child and so had the dis-
charge examined. This proved to be a case of pure proteus infec-
tion. It was interesting to know that one could get this kind of an
infection."

Dr. Axfred F. Hess, in reply to Dr. Talbot's question, said:
"The presence of a discharge was very variable; sometimes it was
present for a very short time, about two weeks. These cases were
not all due to the gonococcus; we have had cases that were not
gonococcus infections. I hope this question will be taken up by
others and that they will test out these provocative inoculations
for themselves."

EARLY symptoms OF PROTEIN SENSITIZATION IN INF.-\.NCY.

Dr. B; Ray'mond Hoobler of Detroit said: "I have experimented
with subcutaneous, intravenous and intraperitoneal injections of a
foreign protein in guinea-pigs. These experiments have given a
great deal of information which should be translated from the labora-
tory to practical use. Dr. Talbot has pointed out the relation
between egg protein and asthma, and Dr. Schloss has shown the rela-
tion between foreign protein and eczema, and Schloss-Waring, the
relation of anaphylaxis to gastroenteric disturbances. Guinea-pigs
sensitized to a foreign protein showed symptoms varying from the
mildest to the most severe. The first effect of the sensitization was
shown in peripheral irritation, the pigs being restless and scratching
themselves. The second stage of anaphylaxis was a partial paralysis
and muscular incoordination. The pigs rarely died in this stage.
Following this there was sometimes a convulsive stage and the pig
died during or just after a convulsion. When this stage was not
reached recovery was usually rapid. Comparing these symptoms

AMERICAN PEDIATRIC SOCIETY 539

with those seen in the human being it was found that there
was a close analogy. The first symptoms in the human being as in
the guinea-pigs manifested itself in peripheral irritation, as by a
rash, either urticarial or erythematous. This was followed by ap-
prehension, collapse, vomiting, great muscular weakness and, in
rare instances, by speedy death. In some subjects the symptoms
might be similar but much milder in form. The severity of the
symptoms depended on the amount of foreign protein injected.
There was also frequently a family predisposition to some form of
sensitization in the father, the mother, or a brother or sister. The
substances which caused anaphyla.xis were usually, egg, milk, oat-
meal, fish, etc. In the human being the first lesions on the skin
might be urticarial, or erythematous, or only a single wheal which
might be mistaken for an insect bite, or there might be a rash, miliary
in type, thought to be due to the irritation of the clothing, the
chapping of the skin, or one of those rashes formerly classified
as intestinal rashes. There might also be vasomotor disturbances
referable to the respiratory tract, as sneezing, snuflling, etc. Or,
again, there might be a dry cough and yet in neither of these would
the child show any pathological lesion. This corresponded to one
of the early symptoms in the guinea-pig that might be seen to pull
and scratch his nose. There might also be wheezing which might
precede the asthmatic attack by months. Asthmatic attacks were
often very persistent and then again disappeared as suddenly as
they had come. There were also often acute digestive disturbances
and nervous symptoms, as irritability, fretfulness and sleeplessness,
somewhat akin to the symptoms seen in the animal. All of these
symptoms might come and go with great rapidity. Fortunately
all these symptoms did not occur in the same child. Certain nutri-
tional disorders might be due to the biological character of the food.
Many of the symptoms mentioned as having been observed in ana-
phylaxis were also symptoms of other diseases, but when one had
the group of symptoms outlined and they recurred from time to
time, if taken together they would be very suggestive of anaphylaxis
and this condition should be taken into consideration, since it was
very important that it be recognized early."

Dr. Oscar M. Schloss of New York said: "I believe that if we
grant the existence of an acute explosive type of anaphylaxis it is
only reasonable to believe that there may be a milder type which
differs from the acute type only by reason of the fact that the symp-
toms are more mild. The difficulty lay in obtaining definite proof
that many of the milder disturbances were due to food protein as
there was no definite' evidence that such was the case. They had
made tests but the results were inconclusive. They had also tried
to sensitize passively a number of such children. The question of
heredity was of interest. In the cases which I have reported there
was in the vast majority of instances evidence that one of the parents
or some other member of the family showed an allied condition.
There were also instances in which an infant showed anaphylaxis
the first time it got a food containing a foreign protein different from

540 TRANSACTIONS OF THE

that it had been receiving. With reference to the question of asthma,
I have investigated a number of cases of bronchial asthma and on
the whole the result have been very disappointing. They have not
excluded the possibility that many cases might be due to food sub-
stances, but no definite proof has been forthcoming that they were
due to such food substances, so the only thing to do at present is
to leave the question open. I have seen four cases, three due to
egg and one to milk in which the usual treatment of desensitization
gave good results."

Dr. F. B. Talbot of Boston said: '"In the discussion of this sub-
ject it should be remembered that the condition of anaphylaxis is
relatively rare. In looking over our hospital records I have found
relatively few cases of asthma but a great many skin cases that might
have been due to anaphylactic action. In regard to what Dr.
Hoobler has said, the symptoms he has described were interesting
but it seems to me that Dr. Hoobler was scarcely justified in all of
his conclusions. For myself, I have been unable to find any con-
nection between a mild erythema and anaphylaxis; in cases of urti-
caria I believe all are due to some form of anaphylaxis; the miliary
rashes I have been unable to connect with any form of anaphylaxis;
rough skin in some instances might be due to anaphylaxis, it seems
to have such a connection in one case that came under his observa-
tion. He had had one case of anaphylaxis cured by reducing the
fat in the food. Some of his cases had given definite skin reactions
but they did not all get well when one took out of the food that sub-
stance which gave the skin rest. The respiratory symptoms de-
scribed in the paper might be due to common cold. The snuffles
should be put down to adenoids. The wheezing was not due to
anaphylaxis but was suggestive of the typical rales of bronchitis.
The symptoms of croup were not in the majority of cases of anaphy-
lactic origin, but in a few instances they might have this origin. I
have had such a case in which the taking of a raw or soft-boiled egg
brought on an attack of croup. On the other hand, the symptoms
of croup described by the parent may be laryngeal diphtheria.
Some digestive symptoms are of anaphylactic origin, but I think
this is one of the last things in the question of anaphylaxis that we
will prove. Some of my patients have, of their own accord, given
as symptoms of this condition that the protein to which they were
sensitized 'slays in the throat' or it gives a 'shivering sensation.' "

CALCIUM METABOLISM IN A CASE OF HEMOPHILIA.

Dks. D. M. Cowte .\nd C. H. Laws, Ann Arbor. — "This case of
hemophilia gave a family history of bleeding in three sisters. The
average coagulation time of the blood was two hours. Calcium
lactate was administered in large doses and during this lime the
coagulation time decreased to two hours, but as soon as the admin-
istration of the calcium lactate was discontinued the coagulation
time returned to about two and one-half hours. During the admin-
istration of the calcium lactate tlie calcium content of the blood

AMERICAN PEDIATRIC SOCIETY 541

gradually increased from 1.665 per 1000 c.c. of blood to 1.745 per
1000 c.c. of blood, but as soon as the administration of the calcium
was discontinued the calcium content of the blood returned to its
normal condition."

Dr. Alfred F. Hess said: "As far as I know this is the second
case in which the calcium metabolism was studied in hemophilia.
Of the cases which I reported some time ago one was a normal child
and one was encephalic. The normal child showed much the same
things as the case just reported. There was an increased calcium
content of the blood and a hastened coagulation time while calcium
was being administered by the mouth. When calcium was added
to the blood of this patient in vitro there was also decreased coagula-
tion time. In cases of hemophilia e.xamination should also be made
of the blood platelets as these may be found to be abnormal in this
condition."

Dr. Da\t:d M. Cowie. — "The blood platelets were normal in
this case. No examination was made as to the effect of the calcium
in vitro. We have been particularly interested in working on the
blood in getting a method by which we could handle the blood more
easily and have succeeded in finding a method by which we can get a
perfectly clear liquid like water and an organized clot within fifteen
or twenty minutes."

THE CALCIUM CONTENT OF THE BLOOD IN R.ACHITIS -AND TET.ANY.

Drs. John Rowland and W. McKim Marriott, Baltimore. —
"The changes in the bones that are incident to rickets and the various
theories as to its causation are familiar to all of you. Most of the
theories as to the causation of rickets are more or less unsatisfactory.
Thus far there has been no study made to determine definitely
whether there is sufficient calcium present in the blood of rachitic
patients or not. We have devised a method which enables one to
find the amount of calcium in the blood, using only 3^^ cm. of blood
serum. We have studied eleven cases of rickets and have deter-
mined the calcium content of the blood in a number of control
cases. We find that in the majority of cases the calcium varies
between 10 and 11 mg. per 100 c.c. of blood serum. In rachitis
we found in some instances a reduction of calcium, but never less
than 9 mg. per 100 c.c. of blood serum; very often it was between 10
and II so that it can be said that rachitis does not depend upon an
insufficient amount of calcium in the blood.

"The calcium content of the blood seems to have a definite rela-
tion to the onset of tetany. If tetany is dependent on a reduction
of the calcium content of the blood, it may be that some severe
symptoms, such as muscular spasms, may be controlled by calcium
in large doses. The determination of the calcium in the blood of
infants with tetany was made in seven instances with very accurate
technic. All showed a very marked reduction in the amount of
calcium. The calcium content instead of being 10 or 11 mg. per
100 c.c. of blood serum varied in these cases between 6 and 7 mg.
An analvsis was made in the case of two children with no active

542 TRANSACTIONS OF THE

symptoms of tetany but who showed the characteristic electric
reaction; in one of these there was a moderate reduction of calcium
while in the other there was no reduction in the calcium. When the
child lost the evidences of tetany the calcium content of the blood
returned to normal. We found that children, like dogs, developed
tetany after thyroidectomy, that convulsions in dogs and children
presented practically the same appearance, and that the calcium
content of the blood serum was usually the same, between 5 and
7 mg. per 100 c.c. of serum. It seemed apparent therefore that
parathyroidectomy exerted a distinct effect on the calcium content
of the blood."

Dr. David Cowie, Ann Arbor. — "I would like to ask whether
Dr. Rowland had made all his determinations on the blood serum.
We have made the determinations on the whole blood and I would
like to point out that the blood platelets absorb a certain amount
of calcium. It is interesting to see the differences in the observa-
tions on the serum and on the whole blood. With reference to
the calcium reduction in tetany there seem to be two classes of
cases, some in which there is a reduction of the calcium and some in
which the calcium content is not disturbed, or but slightly lower.
The calcium content in normal individuals varies a great deal and
much work will have to be done to determine the normal calcium
content of the blood."

Dr. J. P. Sedgewick, Minneapolis. — "We too have found that
there was an increase in the calcium content of the blood following
a high intake of calcium in the food, and I can support Dr. Laws'
observations. One could now give a definite reason for the lowering
of the electric reaction by the administration of 5 grains of calcium
chloride a day. The calcium has an immediate effect on the electric
reaction. I employed calcium cliloride because it contains twice as
much calcium as calcium lactate. One also gets a marked result in
spasmophilia from the use of calcium."

Dr. L. Emmett Holt, of New York said: "The findings of Dr.
Rowland in these cases of tetany are very well borne out by the
effects of the use of magnesium sulphate in hypodermic injections.
Giving calcium by mouth is very uncertain in its results, but after
giving magnesium sulphate there is evidence that some very definite
result had been produced. One may give a hypodermic of from 5
to 20 grains of Epsom salts to an infant of four months, or from 15
to 30 grains to one of twelve months of age, and the results will be
manifested within twenty minutes. The anhydrous salt is twice as
strong as the magnesium sulphate, and in prescribing one should
always specify whether he wishes the anhydrous salt or magnesium
sulphate."

Dr. McKiM Marriott, Baltimore. — "It is preferable to deter-
mine the calcium content in the blood serum rather than in the
whole blood. We have perfected our method so that it can be
applied to ' 2 cm- of blood serum. It is perfectly true that the
clot contains a small amount of calcium, but the calcium content
of the serum is extremely constant."

AMERICAN PEDIATRIC SOCIETY 543

EARLY MORNING TOXIC VOMITING IN CHILDREN.

Dr. Thomas S. Southworth, New York.— "The purpose of this
communication is to direct attention briefly to the vomiting of
children, which not infrequently occurs in the early morning either
before or soon after the first feeding. This vomiting is often of
toxic origin as indicated by the fact that the vomitus after the long
night period contains no food residue, if it occurs before the first
morning feeding; if after this feeding only food from this meal. It
is sharply distinguished from the vomiting of undigested and fer-
menting food in cases in which there is failure of gastric digestion
which is immediately responsible for the emesis. This latter type
of vomiting is more prone to occur later in the day after the stomach
had been taxed by one or more feedings. When the chemistry of
the intestinal tract goes wrong, either slowly and cumulatively, as
doubtless usually obtains in recurrent vomiting, or more abruptly
with the fermentative or putrefactive processes set up by the aid of
bacterial agencies, absorption of some of the products into the circu-
lation is certain. Fermentative processes, owing to the irritation
caused, are more likely to set up a conservative diarrhea in an eSort
at elimination. With free drainage of the intestinal tract, there is,
without doubt, excretion through the mucosa of the intestine which
serves to some extent to offset the absorption. But with an actual
or a relative constipation, and consequently lowered elimination,
the positive balance of absorption gained the upper hand. The
effect of milder degrees is famihar in the dulness, depression of
spirits, headache, lack of appetite, coated tongue, and even some
feeling of nausea, in both adults and children. If not too habitual
this syndrome is promptly relieved by free catharsis. The toxemia
of recurrent vomiting is probably of gradual and cumulative evolu-
tion, coming to a head with the development of marked or relative
constipation, or precipitated by some unusual factor as fatigue,
nervous strain, the onset of one of the infectious diseases, or the
taking of an anesthetic. Here elimination was slow and vomiting
prolonged. Fever is not a constant symptom. With a more active
and fulminating toxic absorption, such as we may assume occurs
with an acute putrefactive process in the intestine, fever is a usual
accompaniment, often rising sharply, and if a conservative diarrhea
is not quickly established the gastric mucosa participates in the
effort at ehmination. In the early morning vomiting it seems hardly
probable that gastric stasis, which so often accompanied acute indi-
gestion or the onset of febrile conditions, could be overcome in the
final hours of the night, and the stomach be completely emptied of
aO vestiges of food before the early morning vomiting occurred. It
is much more plausible to assume that in the early morning type the
disturbance of digestion had been primarily intestinal, not gastric.
There is an attempt at elimination of absorbed toxic principles by
the gastric mucosa, and that these accumulate during sleep when all
the reflex sensations are more or less deadened by slumber and assert
their presence on awakening in nausea and vomiting. Reaccumula-

544 TRANSACTIONS OF THE

tion in the stomach of sufficient quantities to cause a recurrence of
such vomiting is comparatively rare during the waliing hours. At
all events after the stomach has been emptied by one or two acts
of emesis at short intervals, the vomiting has not the persistent
character of the true recurrent type. This may be readily due to
the difference in nature of the toxic products in the two conditions,
their quantity in the circulation, or their rate of excretion. So
common is it for children to vomit in the morning, if they vomit at
all during the course of minor illnesses, and not toward night, and
so frequently will milk, if given at the first feeding, be ejected in large
masses, that it has come to be my habit, where in the presence of
fever I suspect to.xemia, to order for the first morning feeding broth
or broth and barley gruel. By thus avoiding the formation of acid
coagula I feel that I have often averted the tendency. Dilution of
the stomach contents or the demulcent action of the barley when
added may play some part in this result. A further characteristic
of both toxic types of vomiting, as distinguished from that of acute
gastric indigestion is the quicker recovery of the digestive functions
of the stomach. In the toxic type the stomach functions are only
slightly impaired, and as soon as the elimination has been accom-
plished by free catharsis, and vomiting has ceased, simple food will
be received and digested. Appetite also returns more promptly.
The extreme caution in resuming feeding after such an attack is
unnecessary; these children should be fed simply as soon as the
vomiting ceases. This form of vomiting does not seem to have
received special attention and these observations are presented with
a view to inviting discussion."

Dr. T. DeWitt Sherm.\n, Buffalo. — ''I would like to ask Dr.
Southworth if he has had any gastric analyses made in any of these
cases, and whether any of these cases showed a hyperchlorhydria,
and also whether there might be a neurotic element. It would also
be interesting to know whether he had tested for acetone in the urine
early in the morning. I have had quite a number of similar cases
and invariably found acetone in the urine."

Dr. Isaac .\bt, Chicago, said: "The vomiting may be the effect
of something outside the gastric tract. The chronic alcoholic
vomits because of a nasal pharyngitis. It seems that in several of
the cases that Dr. Southworth referred to with gastrointestinal
symptoms the vomiting might be explained as possibly induced by a
pharyngitis."

Dr. Thomas S. Southworth, New York, said: "I have not made
the gastric analyses to which Dr. Sherman has referred. It is
extremely probable that some of these children might have had
hyperchlorhydria. In some of them there was a definite odor of
acetone but I did not make an examination of the urine. As to
what Dr. Abt has said, if he had seen these cases he would not
question that they were other than as I have slated in the paper.
A child coughs a great deal from the presence of mucus in the
pharynx but the type of cases to which I referred did not cough, so

AMERICAN PEDIATRIC SOCIETY 545

that this could not have been the cause of the early morning
vomiting."

A STUDY OF THE ETIOLOGY OF CHOREA.

Dr. JohnLovett Morse and Dr. Cleaveland Floyd, Boston. —
"This study was undertaken primarily to determine, if possible, the
parts which syphilis and bacterial infection play in the etiology of
chorea. It seems from a study of the literature that there is very
little evidence in favor of the syphilitic origin of chorea and much
against it. In our investigations there was nothing whatever in the
history of twenty-one or 8 1 percent, of our twenty-six cases to suggest
syphilis. In the others there was a history of miscarriages. No one
of the patients was born prematurely. The blood of three of the
five children in whose families there was a history of miscarriage gave
a negative Wassermann test. The spinal fluid was not tested in
these three children. The blood of one gave a positive Wassermann
reaction and of the other a doubtful reaction on three occasions,
while the spinal fluid was negative at one examination. None of
the children showed any of the stigmata of syphilis. In only three
of these cases was there anything in the family history even suggest-
ing syphihs. Of the twenty-five children in this series twenty-one
or 84 per cent, gave a positive skin reaction to tuberculin. It would
be absurd to assume that tuberculosis was the cause of chorea in
these twenty-one children. The conclusion is therefore justifiable
that syphilis seldom, if ever, plays an active part in the etiology of
chorea. The close clinical relationship between acute articular
rheumatism, endocarditis and chorea, taken in connection with the
present conception that acute articular rheumatism and acute
endocarditis are bacterial in origin, has suggested that chorea is
also bacterial in origin, and perhaps caused by the same or a similar
organism. Our cases confirm the general belief as to the frequency
of the association of chorea with rheumatism and endocarditis;
seven, or 37 per cent, of them having had rheumatism in the past or
in connection with the chorea. Six of them had acute endocarditis,
and six chronic valvular lesions, a total of twelve, or 46 per cent.
The tonsils were normal in but eleven cases, while they were diseased
in eleven or 42 per cent., and had been removed on account of disease
in four others. The teeth were normal in but seven cases; pyorrhea
was present in two of these children and definite pus pockets were
found in three others when the teeth were extracted. Certain inves-
tigators have found organisms in the blood during life and from a
review of the literature on this subject it seems that the results thus
far obtained from blood cultures are inconsistent and inconclusive.
In almost every case in which organisms have been found there has
been some other complicating condition amply sufficient to account
for the presence of organisms in the blood. The absence of organ-
isms in the blood does not prove, however, that chorea is not caused
by bacteria, because, although the cause of the disease, they may
have been absent from the blood at the time the cultures were made,
and the methods of cultivation used might not have been suitable

546 TRANSACTIONS OF THE

for the growth of the organisms, if present. There are practically
no data as to the bacteriology of the cerebrospinal fluid in chorea
during life. During the past year we have made a study of twenty-
six cases of chorea in the acute stage of the disease with a \'iew to
determining the presence of an infecting agent in the blood stream
and cerebrospinal fluid, the frequency with which it could be ob-
tained, and its cultural characteristics. About 5 c.c. of cerebrospinal
fluid and 5 c.c. of blood were secured where it was possible. Various
media and aerobic and anaerobic methods were used. In every
instance the cultures as well as the smears from the cerebrospinal
fluid were negative. Blood cultures were negative in twenty-one
instances, even after several weeks of incubation and subculturing.
In five cases organisms were found. In one case a small bacillus,
diphtheroid in type appeared. This was a Gram-negative organism
and was not pathogenic for rabbits even when large doses were given
intravenously. Diplococci were found in one case, but no organisms
were cultivated. In both of these instances the tonsils were enlarged
and the teeth carious. In two other cases short chains of cocci
appeared but all efforts at subculturing failed. In these two cases
the tonsils were normal but the teeth carious. In another case
positive blood serum cultures were obtained after ten days of incu-
bation. This patient had acute endocarditis and had had several
attacks of rheumatism. The organisms in this case were Gram-posi-
tive streptococcus. This organism was now readily subcultured and
its characteristics had remained unchanged through ten genera-
tions. Intravenous inoculations into rabbits killed the animals in
twenty-four to forty-eight hours. Autopsies showed a general
septicemia and cultures from the heart's blood and knee-joints gave
a good growth of streptococci. Four other rabbits were given
intravenous inoculations, and all showed lameness and difficulty in
walking and standing, and restlessness on handling of the joints.
Some swelling of the knees was also noted. The fact that the strep-
tococcus obtained from the fifth case caused lesions in the endocar-
dium and joints of rabbits made it very probable that it was the
cause of the endocarditis in the child. The fact that it caused lesions
in the brain and meninges of the rabbits similar to those found in the
brain and meninges of fatal cases of chorea suggested that it was also
the cause of the chorea in the child. Further than this it was not
safe to go. The absence of microorganisms in the cerebrospinal fluid
was an argument against the bacterial origin of chorea, because
it would be reasonable to suppose that in a disease in which the
lesions were located in the nervous system, the causative organism
would be more constantly present and more abundant in the cere-
brospinal fluid than in the blood. However, the absence of organ-
isms in these cases might be explained by the fact that most of them
were mild or only moderately severe in type. It might also be pos-
sible that the failure to detect the organisms more often in the blood
or spinal fluid might have been due to the fact that they were only
temporarily present in the blood stream and tended to locate them-
selves in the meninges, endocardium, or joints. While there is

AMERICAN PEDIATRIC SOCIETY 547

much that points to a microorganism or a group of organisms as the
cause of chorea the bacterial origin of chorea is not yet proven."

DISCUSSION.

Dr. Henry Koplik of New York said: "I agree with Dr. Morse's
conclusions with reference to syphilis and chorea. I have made a
number of blood examinations in cases of chorea and in all cases so
far have had negative results, and I, therefore, feel that I can endorse
Dr. Morse's conclusions. The streptococcus may possibly have been
the cause of the chorea in the case of chorea and endocarditis to
which Dr. Morse has alluded in his paper. I have had a number of
cases of chorea in which endocarditis came in secondarily. It
seems that our methods of blood culture must be still further im-
proved, and then, again, it may be that the bacteria have disappeared
at a certain period and have left a toxin."

Dr. Isaac Abt, Chicago. — "I have gone over my hospital records
and collected 226 cases of chorea, and they show a history of rheuma-
tism, infection, or a febrile condition, very infrequently. Over
eighty of these patients had chorea for a long time without any other
condition. It certainly is not true that all said to have chorea have
an infectious chorea."

Dr. L. E. LaFetra of New York said: "At Bellevue Hospital
several cultures were made from the blood of choreic patients and
the streptococcus viridins was recovered. The technic employed
cannot be very exact for in the same laboratory and with the same
blood some obtained microorganisms and some did not."

Dr. Abraham Jacobi of New York said: " I do not doubt that Dr.
Morse's paper contains a great deal about the therapeutics in chorea
for I take it for granted that all look to therapeutics as the end of
their studies. I have nothing to say with reference to the connec-
tion between rheumatism, endocarditis and chorea that had not
been heard over forty years ago, but I wish to call attention to a
paper which will be printed in the Journal of the American Medical
Association in which Dr. A. L. Goodman, attending physician to the
German Hospital in New York, tells of a method by which he cures
chorea in a few days. This method is that of taking a sufficient
quantity of blood from a choreic child, say 30 or 40 c.c, taking the
serum from tliis blood, amounting to less than one-half this quantity,
and then injecting that serum into the same child. This treatment
is a very remarkable one and at first I did not wish to accept it,
but the cases improved within twenty-four hours and still more
within forty-eight hours. I think I should make this communica-
tion so that you can employ this method for it is of priceless value."

THE effect of SUBCtTTANEOUS INJECTIONS OF MAGNESIUM SULPHATE
IN CHORE.A..

Dr. Henry Heiman, New York. — ^" Though chorea has been
known for centuries the results of treatment have been disappointing.

548 TRANSACTIONS OF THE

Stimulated by the work of Meltzer, who used magnesium sulphate
in the treatment of tetanus with gratifying results, we tried a similar
method in five successive cases of chorea. We used a sterile solu-
tion of 25 per cent, magnesium sulphate, giving three injections
daily for fifteen days. There are certain objections to this method of
treatment: (a) the possibility of inflammatory reaction; (b) young
children may become unduly excited by the treatment itself; (c)
the danger of breaking the needle in the tissues; (d) albuminuria.
From my experience with these cases the conclusion seems justifiable
that the subcutaneous injections of magnesium sulphate, though
only employed in five cases, did not produce sufficient improvement
to justify further trial."

THE PROGNOSIS AND TREATMENT OF BANTl's DISE.\SE IN CHILDREN.

Dr. Edwin E. Gr.\ham, Philadelphia. — "Splenic anemia is
essentially a chronic disease which usually lasts for about five years,
during which time the symptoms are mild; after this period for two
or three years they steadily become worse, until finally the syndrome
of Banti's disease develops, and the case rapidly progresses to a fatal
termination. Cases have been reported which persisted for ten to
twenty years, but the juvenile type of this disease tends to run a more
acute course than the adult form. If not treated or if treated only
medicinally, splenic anemia is almost invariably fatal. Under sur-
gical treatment the prognosis is rather more favorable than otherwise,
the outlook depending upon the duration of the disease at the time
the spleen is removed. If done early, splenectomy is attended by
slight mortality, and in uncomplicated cases a cure may be expected:
but when the disease is complicated by other affections of chronic
infectious nature, the value of the operation is questionable. Splen-
ectomy is even more advantageous in children than in adults, .\fter
the removal of the spleen in most cases the blood picture more or
less approaches normal, but in a few cases it may vary greatly, so
that five years may elapse before the differential count becomes nor-
mal, when Banti's syndrome is well established the prognosis is
most unfavorable even though splenectomy be performed, for the
vital organs have become the seat of degenerative changes and the
liver is cirrhotic. Until the year 1908, the mortality following
splenectomy for splenic anemia was 17 per cent, from 1908 to 191:!.
forty-seven splenectomies were performed with five deaths, this
mortality being a little above 10 per cent. But these figures were
based on cases in which the symptom-complex of Banti's disease
was not present. In splenic anemia there is evidently an infec-
tious or toxic process going on in the spleen which causes tibrotic
enlargement and the formation of splenic hemolysis. Therefore in
these cases the removal of the spleen has ample justification, even
though it is still a mooted question whether the favorable results of
splenectomy are due to regeneration of corpuscles or to decreased
hemolysis. If an abundance of iron is supplied to the system after
the removal of the s[)leen which is the organ in which iron metabolism
takes place, polycythemia will result in many cases, and an increase

AMERICAN PEDIATRIC SOCIETY 549

in red cells is always noted at varying intervals after operation ;
therefore in splenic anemia iron is undoubtedly indicated both
theoretically and practically. It is also believed that the cirrhotic
changes, which in Banti's disease takes place in the liver, are due to
toxins produced by the spleen; this explains the favorable influence
of splenectomy on the liver. Splenectomy is both useless and dan-
gerous in cases in which the hemoglobin is below 30 per cent., and
the red blood cells are below 2,000,000. The operation should, as a
rule, beattempted only when there is no edema, no parenchymatous
nephritis, no serious degenerative change in the liver, and while the
patient is still able to go about. In severe cases blood transfusion
if done shortly before the splenectomy seems to increase the ability
of the child to withstand the shock of the operation. The opera-
tion of choice in Banti's disease is Talma's operation. In 25 per
cent, of the cases of splenectomy for Banti's disease there is after-
ward pain in the long bones, this being probably due to hyperplasia
of the red bone marrow. Hemorrhages from the stomach and intes-
tines are most likely to occur for the first two weeks after operation
and must be treated by complete rest for the upper abdomen, by
injections of saline or of blood serum, or by direct transfusion."

The case reported in detail occurred in a child of seven years.
She was the ninth child and none of the others showed any similar
tendency, the family history being absolutely negative. The child
gave a history of nose bleeds dating back five years and more recently
of subcutaneous hemorrhages. Physical examination revealed a
presystolic murmur at the mitral area with a sharp second sound.
The pulmonic sound was accentuated and the heart was displaced
upward. The splenic outline was visible on the right side. Splenic
dulness began at the fifth interspace in the midaxillary line, beginning
about two fingers above the xiphoid and curving out to the right,
until at the level of the umbilicus it was approximately 3 inches
from the spot and filled almost the entire abdomen. The detailed
blood count is presented and shows briefly hemoglobin markedly
reduced, red cells usually not below 3,000,000, slight poikilocytosis,
and the presence of normoblasts. There was an actual leukopenia.

DISCUSSION.

Dr. Henry Koplik, New York. — "I have had under my observa-
tion a case which was unquestionably one of Banti's disease. This
subject showed marked symptoms as a child but operation was
refused. He has now grown to manhood, is an engineer, and ap-
parently healthy although his spleen and liver are enlarged. He is
now living a useful life; this might not have been the case had we
operated upon him."

THE ENERGY MET.^BOLISM OF A CRETIN.

Dr. Fritz B. Talbot, Boston. — "This subject was a typical
cretin, three years and eight months of age, and was studied in the
13

550 TRANSACTIONS OF THE

respiratory chamber devised by Benedict in the laboratory of the
Carnegie Institute at Washington. They found his basal metabo-
lism per kilo body weight was 403-^ calories, per square meter body
surface 898 calories per twenty-four hours (Lissauer). In the absence
of normal data in children of the same age this metabohsm was com-
pared with that of a normal eight months baby and a normal ten
months bab}'. It was found that the metabolism of the cretin was
decidedly lower than that of the two normal babies. Unfortunately,
results after treatment with thyroid have not been sufficiently
accurate to use. These results were consistent with those of Magnus
Levy and the more recent work of Dubois in Lusk's Laboratory.
The practical application of these findings is that the cretin requires
less food than children with sufficient thyroid activity and that after
treatment with thyroid extract would require more food than before
treatment."

FAMILIAL ICTERUS OF THE NEW-BORN.

Dr. Isaac A. Abt, Chicago. — "This disease has notliing in com-
mon with Buhl's or Winckel's disease. There was no evidence to
prove that it is due to a septic process. It is not present at birth;
it occurs during the first few days of life. In none of the cases re-
ported is there a history of birth injury; it does not seem to be due
to the toxemia of pregnancy. One might say that the children were
in a sense defective and became very soon incapacitated to carry on
extrauterine life. The disease occurs in successive pregnancies,
occasionally several normal children are born and then several die
in a few days after birth as the result of grave and progressive icterus.
As a rule there is no hereditary influence. The disease usually
begins on the first or second day of life and rapidly increases in
severity. The symptoms are described briefly by Pfannenstiel as
a catarrhal condition of the mucous membrane, sometimes with
bloody discharge; the stools are catarrhal and frequent; the urine
contains bile pigment, and the patient shows meningeal irritation.
At the onset there may be hyperemia of the skin. If the disease
continues hemorrhages from the various mucous surfaces into the
skin and from the umbilicus occur and death soon follows from
collapse. The disease bears no relation to syphilis and has nothing
in common with family jaundice. Isolated cases have been reported
from time to time in the literature, but the writer has encountered
examples of familial icterus in the new-born in two families. The
first case occurred in an Italian family, the father and mother both
being twenty-eight years of age, and having lived in this country
ten years. There seemed to be nothing in the history of the parents
or grandparents that was in any way connected with the condition
in this infant. The mother had borne five children, of whom two
were living and three dead. The two eldest children had always
been well. The third baby seemed strong and robust at birth,
developed jaundice on the second day, and died on- the third day.
The history of the fourth child was similar, and the course of the
fifth does not differ materiailv from these.

AMERICAN PEDIATRIC SOCIETY 551

"The second case occurred in a Russian family. In this instance
the mother, six years ago, had had an operation and the gall-bladder
was removed. Two or three months after the gall-bladder operation
she had had her tonsils removed. She is about thirty-two years of
age and the father three years her senior. She has borne six chil-
dren. The first child has chronic nephritis and is eleven years of
age. The second child is living and well. The third pregnancy
resulted in miscarriage. The fourth child became jaundiced on the
second day, was seized by convulsions, had frequent stools, became
more intensely jaundiced, and died on the third day. The fifth
child, whom the writer had the privilege of observing gave a similar
history. An autopsy was performed and showed some enlargement
of the liver and spleen, though no pathological changes of any
moment could be noted and bacteriological examinations showed the
tissues to be sterile. The bile passages were of normal size and
showed no obstruction. A sixth child became icteric on the second
day, was very somnolent and toxic, but showed no hemorrhages.
The condition of the child seemed grave. On the fifth day a slight
improvement was noted and from this time the jaundice had gradu-
ally disappeared and the baby was now over a year old and unusu-
ally bright and happy."

DISCUSSION.

Dr. Wilder Tileston, New Haven. — -"I would like to call at-
tention to an interesting feature of these cases and that is the yellow
icterus staining of the base of the brain which is never seen in jaun-
dice, and which might be correlated with the nervous symptoms in
icterus. I would like to ask Dr. Abt whether there was any fragility
of the red cells in his cases. The red cells have been tested in chronic
family jaundice and have shown a fragility."

Dr. T. DeWitt Sherman, Buffalo. — "It has occurred to me that
it might be possible that jaundice and the allied conditions in infants
might be due to the chloroform administered to the mother during
labor. It is well known that chloroform produced hyaUne and fatty
degeneration and that its effects are concentrated on the liver and
kidney. It might be well to take up this matter and see how much
chloroform these mothers of icteric babies have had during labor;
it may be that they have received a great deal and that it has had a
deleterious effect on the infants.

observations on measles.

Dr. Charles Herrman, New York. — "The deaths reported as due
to measles give an inadequate idea of the real number caused by
this disease. A large number die from a complicating broncho-
pneumonia, especially between the ages of one and two years. This
is suggested by the parallelism between the curve of morbidity from
measles and the curve of mortality from bronchopneumonia between
one and two years. In a series of 300 secondary cases of measles
observed by me, the fever appeared on the tenth or eleventh day from

552 TRANSACTIONS OF THE

the time of infection in 56 per cent.; catarrhal manifestations on the
eleventh or twelfth day in 60 per cent.; the tonsillar spots on the
ninth to the thirteenth day; the Kophk spots on the eleventh or
twelfth in 54 per cent.; and the eruption on the twelfth to the four-
teenth day in 67 per cent. The catarrh was present in 7.2 per cent.
on or before the tenth day, the Koplik spots in 12.8, and the tonsillar
spots in 34 per cent. In 4 per cent, of the cases in which the
tonsillar spots were present, they were seen as early as the seventh
day, and in a few cases the tonsillar spots were present in the patients
who did not show any Koplik spots. The presence of the tonsillar
spots will be found valuable in schools, hospitals and asylums in
detecting and isolating the patients early. Infants under two months
of age are absolutely immune. This immunity gradually becomes
less marked so that at eight months it has entirely disappeared.
This gradual disappearance is shown by the longer period of incuba-
tion. In sixty-three children under eight months of age the erup-
tion appeared in only 42.5 per cent, on or before the fourteenth day,
whereas in 81.4 per cent, of those over eight months the eruption
appeared at that time. In infants between five and eight months
the disease was usually milder. This was also shown by the fact
that only 41 per cent, of these lost weight, whereas of those between
eight months and two years 76 per cent, showed such a loss. The
immunity is probably conveyed through the placental circulation;
only those infants whose mothers have had the disease seemed to
enjoy it. Infants between three and five months who have been
in intimate contact with measles and do not contract it, sometimes
are not infected when exposed later in life."

THE B.\CTERIOLOGY OF THE URINE IN HEALTHY CHILDREN AND THOSE
SUFFERING FROM EXTR.\URINARY INFECTION.

Dr. Henry F. Helmholtz, Chicago. — "A few facts with regard
to pyelocystitis in infancy and childhood have been pretty well
established, namely, that the infection is very much more common in
girls than in boys, that the infecting organisms is most frequently
the bacillus coli, and that the symptomatology of the condition is so
indefinite as to make a diagnosis practically entirely dependent on
the examination of the urine. Regarding the mode of infection there
is considerable difference of opinion. The main facts in favor of
the urethral route are the predominance of the cases in girls, the
shortness of the urethra, and the fact that the orifice of the urethra is
constantly contaminated with colon bacilli. The question as to
the mode of infection is, however, far from being settled. In order
to get an idea of the field involved it seemed essential first of all to
determine the bacteriology of the normal urine and urethra and with
this object the bacteriological findings of catheterized specimens of
urine taken from thirty infants and from thirty-one girls over two
years of age are recorded. The catheterized specimens were ob-
tained by a very careful technic and collected in three sterile tubes
so as to determine the difference between the first and last urine

AMERICAN PEDIATRIC SOCIETY 553

passed. In the course of a few experiments tubes one and two were
found to be practically identical so that in the majority of cultures
taken only one and three were used. No. i was inoculated in a deep
dextrose agar tube and on litmus lactose plate. No. II was grown
on a litmus lactose plate, a blood agar plate and in deep blood agar
tubes. The tabulated results showed that of twelve normal cases
five had sterile urine. Of five specimens that were not sterile, three
showed one organism per cubic centimeter and two three organisms
per cubic centimeter; two had organisms in the first portion of the
urine but none in the last.

In summarizing the results of these examinations it was found that
in 119 specimens of carefully catheterized urine from sixty-one
different individuals, sixty-one were sterile, and fifty-eight contained
bacteria. Of those from twenty-four normal infants, thirteen were
sterile and eleven contained bacteria. In the specimens from girls
over two years of age, thirty-five were sterile and twenty-seven con-
tained organisms. The number of bacteria found in the lirst series
was considerably larger than in the second series. This might be
explained by the fact that in the older children one could cleanse
the urethral orifice much easier than in the infant and introduce the
catheter directly into the urethra. The bacterial flora was prac-
tically the same in both series, Gram-positive staphylococci and pseu-
dodiphtheria organisms predominating; the former were present in
practically every case in which any organisms were found. In no
instance were Gram-negative bacilli found in such numbers in both
specimens that it seemed probable that it was more than a contami-
nation from the urethra. In conclusion it might be assumed on the
evidence given that organisms of the colon group are not normal
inhabitants of the female urethra and that in extraurinary infections
occurring in the first two years of life the colon bacilli are frequently
found in the urethra, that was in about one-third of the cases. In
girls over two years of age the urine is almost free from organisms
and entirely free from bacilli of the colon group."

oxycephaly: its occurrence in two brothers.

Dr. W. W. Butterworth, New Orleans. — "A review of the
literature on this subject shows that the classical symptoms of this
condition are exophthalmos, pain, and some disturbance of vision.
An interesting feature in these two cases was the family history
showing similar symptoms in the grandfather. It is very rare to
find two brothers in the same family showing this condition and a
history of a similar condition in a grandparent. These boys were
not mentally deficient. The cranial picture was suggestive of the
condition. The cause of this deformity had been variously attrib-
uted to early closure and ossification of the sytures, fetal rickets and
hydrocephalus in early life."

Dr. Butterworth gave a lantern-slide demonstration showing the
bones of the skull in this condition. There was a peculiar mottling
of the inner plate of the cranium. The .v-ray of the long bones and

554 TRANSACTIONS OF THE

joints showed that these were not normal. There was an enlarge-
ment of the condyles of the large bones and some enlargement of the
bones of the face. The condition is rather rare.

MENINGITIS IN THE NEW-BORN AND IN INFANTS UNDER THREE
MONTHS OF AGE.

Dr. Henry Koplik, New York. — "Meningitis in the new-born
occurs sometimes secondary to general sepsis and sometimes as a
primary infection. The symptomatology in the primary condition
is very obscure. The child's head may be bruised during labor and
one cannot come to a conclusion as to the actual condition until the
swelling has subsided. The signs applicable to older children are
not applicable to these young babies. In these there is no rigidity,
no bulging, no Babinski and the child is in a condition of muscle
clonus anyway. It is no wonder that a diagnosis is not made more
frequently. I concluded that I would try to find some characteristic
symptoms of meningitis in babies. I found that convulsions might
be simple or the child might only have slight twitchings. If there
was a convulsion this might be repeated or it might not be. I
observed one case in which there was only one convulsion but there
was very high fever, 105° F. or over and there were remissions and
then it might subside, and again it might not, if the disease was still
in progress. Often the temperature might last for a week or ten
days and then would come to a lower level and would run along at
100° F. or slightly above. The bulging of the fontanel was not
present; indeed, in some cases there seemed to be a depression.
Macewen's sign was very difficult to determine in very young babies.
Some gave signs of fluid in the head and some did not. Sometimes
after a very stormy labor, it was only later in the disease, after a
week or ten days, that there was fluctuation and an increase in the
quantity of fluid, noticed not only by the bulging but by the tym-
panitic sign over the temple. Sometimes after a high forceps
delivery the child might have a slight amount of blood in the urine
and in such a child it was very difficult to decide whether one had
simply a slight hemorrhage or a meningitis. In some instances no
one knows what is the matter until the babies are two or three months
of age. Most of the hospital's cases must have had the condition
longer than the mothers suspected. The results of lumbar puncture
in these cases was very interesting. The lumbar in a series of twelve
cases showed the presence of the streptococcus four times, the
pneumococcus three times, the meningococcus three times. One
case showed very distinctly that the meningitis was secondary to
an arthritis. In the secondary cases I found a streptococcus in the
blood. One case observed from the start began with a pyelitis
and this got into the circulation and a coli meningitis was developed
as a secondary infection. The fate of these babies was disheartening
for they all were fatal sooner or later. One case of meningitis in
this series still lived but in this case there was a marked hydroceph-
alus. All of these cases were treated by lumbar puncture, but

AMERICAN PEDIATRIC SOCIETY 555

young babies do not bear lumbar puncture well. As to how these
babies get a meningococcus infection, it seems that the mode of
infection may possibly be explained when we consider the methods
of resuscitation, mouth to mouth suction, and introduction of the
fingers into the child's mouth, with the trauma that may be incident
to this procedure. If the person who performs these manipulations
is a meningitis carrier it is easy to see how infection may occur.

THE USE OF SALT SOLUTION BY THE BOWEL (mURPHY METHOD) IN
INFANTS AND CHILDREN.

Dr. Edwin E. Graham. — "The Murphy method of injecting
sahne solution by slow proctoclysis has been used for a few years
past in adults suffering from many other conditions than peritonitis,
and by medical practitioners as well as surgeons. My experience
with it in certain conditions in infants and children has led me to
believe that it is of much more value to the pediatrist than most of
us are aware of. It has been most successfully employed in the
highly toxic states of typhoid fever, and pneumonia and appears to
afford great relief, but in the later stages, after the heart has been
affected by the toxemia, it must be used with great caution, when
there is obstruction in the lungs and the blood pressure has become
high. In the acute infectious diseases toxemia may be greatly
influenced by the employment of the Murphy drip and in diphtheria
and scarlet fever the resulting dilutions of the toxins is of the utmost
importance and value in averting nephritic conditions. In uremia
and suppression of urine, slow proctoclysis promotes diuresis and
thus dilutes the highly toxic and irritating materials which would
otherwise be harmful to the kidneys. Generally speaking in toxemia
from any cause, whether it be autointoxication, mineral poisoning,
and septicemia, the judicious use of the salt solution by the bowel will
prove of great value in treatment. If nephritis with edema is
present the administration of salt solution by this method is unwise,
although in a few such cases it has apparently been employed with
success. I have been greatly impressed by the results of the employ-
ment of the Murphy drip in profuse diarrhea due to intestinal infec-
tion and in the summer diarrheas. In giving the proctoclysis there
must be a low pressure and a good return. There should be a 12-
inch drop and the catheter should be introduced 4 or 5 inches into
the bowel. The temperature of the water should be kept at 110° F.
This treatment might be given over periods of from ten days to two
weeks provided periods of rest were given at intervals. In measur-
ing the sodium chloride, to say one teaspoonful to a pint is very
inaccurate; the preparation of the solution is important and should
be made with extreme accuracy."

MULTIPLE SCLEROSIS IN A CHILD FOUR AND ONE-HALF YEARS.

Dr. George N. Acker and Dr. Joseph S. Wall, Washington. —
This patient was a colored child, four and one-half years of age, who

556 TRANSACTIONS OF THE

visited the Out-patient Department of the Children's Hospital,
March 2. 1916, complaining of "nervousness." The family and
personal history revealed nothing of moment. The present trouble
came on slowly. The mother did not notice it until her attention
was called to it by friends. The child had grown progressively
worse until at the present time she was greatly troubled with
shaking of the body and limbs, inability to sit still or walk and total
incapacity for feeding herself. The chief symptoms presented at the
first examination were, nystagmus, shaking of the body, e.xaggera-
tion of all reflexes, rapidity, but not enlargement of the heart. Ten
days later these symptoms seemed to have grown worse. A week
later she was admitted to the house service of the hospital. At this
time her mental faculties seemed dulled, but she would answer
simple questions requiring only two or three words. Her speech was
thick with the so-called scanning speech (bradylalia) and markedly
staccato. While lying in bed she is perfectly quiescent, but on any
attempt to sit up the coarse muscular tremor, involving the muscles
of the neck, arms, and trunk and to a lesser extent the legs, mani-
fests itself. There is a vertical oscillation of the head as well as
lateral rotatory movements. She stands and walks only when
partly supported by the nurse. The drinking test gives rise to a
tj'pical volitional tremor. The tongue shows marked tremor when
protruded. There is marked elbow jerk, wrist jerk, and heightened
epigastric reflexes. The patellar jerks are greatly exaggerated. An
ankle clonus is present in both extremities. The heat and cold sense
are apparently normal except over the right thigh where there is
some dissociation of the senses.

There is incontinence of urine and occasionally of feces. The
urine is normal except for the presence of a few white cells. This
case was presented because of the infrequent occurrence of multiple
sclerosis in children. We are of the opinion that the case falls under
the category of disseminated scleroses. It measures up by the signs
and symptoms with the syndrome of sclerosis. It gives evidence of
rather widespread involvement of the nervous system with resulting
impairment of function, rather than a focal lesion, or collection of
lesions, with much actual destruction of nerve elements, for there are
no paralyses.

THE DANGER TO HOSriTAL EFFICIENCY FROM DIPHTHERIA CARRIERS.

Dr. Samuel S. Ad.\ms and Dr. Frank Leech, Washington. —
There are many factors which enter into hospital efliciency. There
must be team work between the highest in authority and the most
humble employees. To obtain hospital efliciency the following may
be considered requisite: i. The President of the Board of Directors
of all hospitals should be chosen with a view to his personal interest
in all things connected with the institution. He should be a man
well-trained in the handling of men and affairs. 2. The Executive
Committee shouhl be a body composed of those members of the
directors who are in close touch with the interests of the institution

AMERICAN PEDIATRIC SOCIETY 557

from ever}^ viewpoint. A representative of the medical staff
should always be present at their meetings to express the views of
that body, with the idea of keeping harmony with all in authority.
3. Every hospital should have a trained medical superintendent,
who should have exclusive control of all matters connected with the
hospital. 4. A superintendent of nurses who had shown exceptional
ability in her work as a teacher and director of young women should
be chosen.. 5. The members of the medical staff should be medical
men, who have been promoted from dispensary work, or who, by
reason of their attainments elsewhere, have shown particular apti-
tude for the positions to which they are appointed. 6. Hospital
internes should be chosen b}^ competitive examination and have
every opportunity to do work under the direction of the medical
superintendent and the medical officers on duty. 7. Nurses should
be chosen from applicants who have had sufficient preliminary edu-
cation to assure their ability to grasp not only ward work but also
the lectures which they are compelled to attend. 8. Employees
should be under the control of the superintendent and amenable to
control and discipline by him. Social workers should be provided
for follow-up work, not only for the hospital but for the out-patient
department. 10. Efficiency experts should be engaged from time to
time to check up the work and criticise the same, from the president
of the Board of Directors to the orderly. If these suggestions were
perfectly carried out it would be easy to look after the other details
of hospital efficiency. Hospital efficiency resolves itself into doing
everything for the comfort and cure of the patient. The occurrence
of two cases of diphtheria in our hospital led to a culture of every
individual in the house, as a result of which fifty-one positive cultures
were found out of a total of 100 including all employees, nurses and
internes. Only one case had shown any clinical evidence of diph-
theria. The hospital wards were closed for three weeks to the recep-
tion of new patients. At present we have reduced the number of
positive cultures to seventeen. A search for the source of the infec-
tion seemed to point to a nurse in the baby ward who had suffered
from a sore throat. Eight positive cultures were found among
twelve babies, seven nurses gave positive cultures. She had min-
gled freely with other nurses throughout the hospital, and we were
forced to the conclusion that she was the beginning of the trouble.
To prevent the occurrence of such outbreaks we are convinced
that all institutions for the care of sick children should be provided
with a suitable detention ward for the detention of all new admis-
sions. We feel that new cases should, immediately on admission,
have nose and throat cultures taken and be at once placed in the
detention ward for five days. All the ward cases which show the
slightest symptoms of the minor contagions should immediately be
placed in the detention ward and carefully watched for a proper
period, and if definite symptoms of any contagion appears they should
at once be transferred to the contagious disease institution. If it
is impossible for financial reasons to provide a detention building,
cubicles should be provided in each ward and proper nursing technic

558 TRANSACTIONS OF THE

carried out to prevent the dissemination of minor contagions.
Nurses, internes, or employees sliowing any evidence of illness siiould
be seen at once by medical officers. Visitors to ward patients should
be restricted to adults only, and such visitors admitted as infre-
quently as possible. Following the suggestion of Dr. Alfred F,
Hess, all infants should be kept isolated from children of the run-
about age. Tests for the virulence of diphtheria carriers should be
made thus relieving ourselves at once of a large number of cases
which it would be otherwise necessary to isolate.

the schick reaction in infants.

Dr. Henry L. K. Shaw and Dr. William E. Youland, Jr. —
There is no question of the accuracy of this test in detecting individ-
ual susceptibility and immunity to diphtheria. Clinical evidence
shows that young infants, especially in the first six months of life,
possess natural immunity and that the susceptibility to diphtheria
increases rapidly after the first year to the eighth year and then
decreases. The results of the Schick test in children over two years
of age show a striking similarity with the clinical frequency of the
disease, but the statistics of cases under two years of age are meager
in comparison and not at all uniform. A review of the results of
the observations of various investigators in cases under one year of
age shows a variation of from zero to 40 per cent., and from one to,
two years of age the variation ranges from 15 to 65 per cent.

We have made an investigation among ninety-five infants under
two years of age in two infants' institutions and hospitals in Albany.
In making the tests we used the standard diphtheria toxin diluted
so that I c.c. contained one-fifth the M.I.D. and o.i c.c. of this dilu-
tion was used in making the tests. The procedure of Park and
Zingher of heating one-half of the diluted toxin at 70° C. for three
minutes was used for the purpose of control. The reactions were
read daily for four days and the final interpretation made on the
fourth day. In practically no case did a typical pseudoreaction
occur. In some cases the reaction does not appear until the third
day although it appears more frequently on the second day.

Our results in the different institutions were remarkably constant.
In sixty-six children under one year of age we found 47 per cent,
positive, whUe in twenty-nine chOdren between one and two years
of age 58.6 per cent, were positive. These results are remarkably
similar to those reported by Park and Zingher. We had one case in
which a negative Schick reaction was negative who two days later,
developed diphtheria as demonstrated by cultures. From our
experience with this group of cases it would seem that when virulent
diphtheria bacilli are found in infants having no antitoxin in their
tissues a careful examination for diphtheritic rhinitis should be
made, as we have had five cases in which it was entirely overlooked
clinically.

There is no question but that every child, nurse, or attendant
entering a children's hospital or institution, or coming in contact

BRIEF OF CURRENT LITERATURE 559

with the children in any way, should have cultures taken from both
nose and throat and a Schick test made as a matter of precaution
against the disease.

AMERICAN PEDIATRIC SOCIETY.

Election of Officers. — The following officers were elected to serve
during the ensuing year: President, Dr. F. S. Churchill of Chicago;
Vice-president, Dr. Wilder Tileston of New Haven, Conn.; Secre-
tary, Dr. Samuel S. Adams of Washington, D. C; Treasurer, Dr.
Charles Hunter Dunn of Boston; Recorder and Editor, Dr. L. E.
LaFetra of New York; Assistant Editor, Dr. O. M. Schloss of New
York.

BRIEF OF CURRENT LITERATURE.

DISEASES OF CHILDREN.

Active Immunization with Diphtheria Toxin-antitoxin and with
Toxin-antitoxin Combined with Diphtheria Bacilli.— Referring to their
earlier publication, W. H. Park and A. Zingher {Jour. A. M. A.,
1915, kv, 2216) say that while the immediate results of attempts at
active immunization with toxin-antitoxin were disappointing, they
thought that later ones obtained by retesting the immunized indi-
viduals without further injections might give a much better showing.
They therefore determined to follow up and retest, from four to
eighteen months after discharge from the hospital, as many of the
injected children as possible. They tabulate their results and con-
clude that individuals who, before treatment, give a negative
Schick reaction are immune probably for hfe and, therefore, it is
not necessary to inject them, when exposed, either with antitoxin
or toxin-antitoxin.

Those who give a positive Schick reaction and are exposed to
diphtheria and in immediate danger should receive either antitoxin
alone or, if a longer protection is desired, both antitoxin and toxin-
antitoxin.

For the general prophylaxis against diphtheria in schools and
communities, excluding immediate contacts, a mixture of toxin-
antitoxin alone (from 85 to 90 per cent, of the L+ dose of toxin
to each unit of antitoxin) or toxin-antitoxin plus vaccine of killed
diphtheria bacilli is recommended. The dose is i c.c. of toxin-
antitoxin and 1,000,000,000 bacteria injected subcutaneously and
repeated three times at intervals of six or seven days. Sufficient
time has not as yet elapsed to judge the value of adding the injec-
tions of the bacilli to the toxin-antitoxin.

The early and the late results of active immunization should be
determined with the Schick test. Early results are those obtained
by the appHcation of the test within four weeks, and late results
from four months to two years after the immunizing injections.

560 BRIEF OF CURRENT LITERATURE

Familial Syphilis. — P. C. Jeans (Amer. Jour. Dis. Child., 1916, xi, 11)
states that germ transmission of hereditary syphiUs has not been
proved, and it does not seem Ukely that it ever occurs.

It is highly probable that all the m.others of syphilitic children
have been infected with syphihs. Of eighty-five mothers of syph-
ihtic children 86 per cent, gave positive Wassermann reactions.
All of the remaining cases but six gave a history of infection or
treatment, or both. Five of these si.K patients were e.xamined at
least ten years after the birth of their last syphilitic children and the
infection is probably dying out.

Eighty-seven per cent, of the mothers deny all knowledge of the
infection. The mothers are for the most part infected during the
latent stage of the father.

Of 331 pregnancies in 100 families, 30 per cent, were abortions,
9 per cent, stillbirths, 61 per cent, living births. Of the living births
24 per cent, had died. Of those living 80 per cent, had syphihs.

Of the total pregnancies 90 per cent, were presumably s^'philitic
and although 10 per cent, seem free from syphilis, there is no proof
that they all are. The total syphilis in these families amounts to
93 per cent, of the entire family.

For the most part these families followed Kassowitz's rule; i.e.,
decreasing grades of infection in the children.

In case of syphilitic mothers bearing nonsyphilitic children, it is
probable that the infection in the mother is localized in places where
it is not readily transmitted.

The idea that there are different strains of spirochetes receives
some support from these famihes.

Transmission to the third generation, though not proved, is dis-
tinctly an occasional probability.

Intramuscular Injections of Whole Blood in Treatment of Purpura
Hemorrhagica. — Reporting a case of purpura hemorrhagica in a boy
of five and one-half years in which recovery rapidly followed intra-
muscular injection of whole human blood, H. W. Emsheimer (Jour.
A. M. .4. ,1916, l.xvi, 20) says that the best methods of treatment of
purpura hemorrhagica, in addition to the usual measures are: (a)
subcutaneous or intravenous injection of human blood serum; (b)
transfusion, and (c) intramuscular injection of whole fresh human
blood.

The intramuscular injection of whole blood is a simple, harmless,
effective procedure, and should be employed before other radical
measures in all cases of severe purpura hemorrhagica; it may also
have a wide field of usefulness in hemophilia and other blood dis-
eases; in bleeding from various parts or organs of the body; in wast-
ing diseases, and in many infections.

TBEE AMTEJIIOAJ^ ^'"'

JOURNAL OF OBSTETRICS

DISEASES OF WOMEN AND CHILDREN.

VOL. LXXIV! OCTOBER. 1916. NO 4.

ORIGINAL COMMUNICATIONS.

FETAL AND PLACENTAL SYPHILIS.*

(A Lantern Demonstration.)
BY

E. D. PLASS, M. D.,

Instructor in Obstetrics, Johns Hopkins University,
Baltimore, Md.

(With nine illustrations.)

Introduction. — The importance of syphilis in obstetrical work
is attested by the fact that this Society has chosen it as one of
the subjects for discussion at this meeting. The disease is so preva-
lent and its manifestations so diverse that exact diagnosis is of
paramount importance and every method which is of value should
receive consideration. Since Wassermann demonstrated the pos-
sibilities of diagnosis by the complement-fi.xation phenomenon,
there has been a tendency to neglect the other methods of study and
base the diagnosis upon the serological findings alone. Fortunately,
in obstetrics, we have available one and in some cases two other
methods of laboratory investigation which are perfectly reliable
and it is to these recently neglected possibilities that I would call
your attention.

The fact that the placenta of a svphilitic child differs from the
normal has long been recognized but the lesions which we now con-
sider practically specific were first accurately described by Fraenkel
in 1873. For many years these histopathological changes offered
the only laboratory confirmation of the clinical findings unless,
perchance, the child died and an autopsy was permitted. With

* Presented before the American Gynecological Societj- in Washington, D. C,
May 9, 1916.

562

PLASS: FETAL AND PLACENTAL SYPHILIS

the discovery of the Treponema pallidum by Schaudinn and the
development of the silver impregnation method of demonstrating
these organisms in the tissues by Levaditi, an additional method of
study was made possible.

Placental Syphilis. — Grossly the syphilitic placenta differs quite
markedly from the normal. The most characteristic change is
the increase in size and weight. Whereas the normal organ weighs
only about one-sLxth the weight of the child, the ratio in fetal
s\'phiUs is one-fourth to one-third. This increase in weight is due
in part to cellular proliferation and in part to edema. The maternal

Fig. I. — Normal villi teased out in water (low-power drawing).

surface has a rather peculiar grayish-pink, greasy appearance and
the tissue is more friable than usual. A positive diagnosis can
rarely be made from the gross appearance alone; but frequently
the changes are marked enough to excite strong suspicion.

The more characteristic histopathological changes are dependent
upon an obliterative endarteritis and endophlebitis which are direct
manifestations of the syphilitic infection. These changes can
frequently be demonstrated in the freshly deUvered placenta merely
by teasing small portions in water or normal salt solution and

PL ass: fetal and placental syphilis

563

examining under the low power of the microscope. In the normal
organ the villi are deHcate and there are numerous branches which
are approximately the same caliber throughout their length. With
the hght largely cut off, the cellular structures can be distinguished
and the widely separated stroma cells differentiated. By allowing

Fig. 2. — Syphilitic villi teased out in water (low-power drawing). —
{From Williams.)

somewhat more light to come through the diaphragm, the blood-
vessels can be distinctly made out unless the teasing has washed
out the blood, in which case they are visible only with difficulty.
By clamping the cord immediately, the child is born, the vessels
throughout the placenta remain markedly distended and by properly

564

PLASS: FETAL AND PLACENTAL SYPHILIS

regulating the light aperture they can be followed in their entire
course. Fig. i, which is a drawing of a villus thus prepared, shows
the characteristics very graphicaUy. In an endeavor to show the
course of the blood, the arterial side of the system was made some-
what darker than the venous; but under the microscope no such
differentiation is possible.

In the teased syphihtic placenta, Fig. 2, the terminal villi are
of somewhat larger cahber and tend to be clubbed at the ends. In

m^ '^%

^^>^

'S>A

_Q'<Jj

Fig. 3. — Normal villi — cross-section (low-power drawing). — {From Williams.)

some specimens this is much more marked than in the illustration
and should always be viewed as suspicious. It is also to be noted
that the stroma cells are more numerous and that the entire villus
appears more cellular than normal. The blood-vessels are entirely
absent in the terminal villi and in the smaller stems.

This method of diagnosis is crude when compared with the study
of fixed and suitably stained sections but with practice it is possible

PLASS: FETAL AND PLACENTAL SYPHILIS

565

to obtain fairly close agreement. The only advantage of the
method is that, since no preparation is necessary, a diagnosis can
frequently be made immediately.

For the purpose of better histological study the placentae are
fixed in a 4 per cent, aqueous solution of formaldehyde (lo per cent,
formalin), imbedded in celloidin or paraffin and cut in sections lo
to 15 ;u thick. For routine work they are stained with hematoxylin
and eosin and mounted in Canada balsam. The examination is
made under the low power of the microscope.

Fig. 4. — Normal villi — cross-section (high-power photomicrograph).

The normal placenta is pictured in Figs. 3 and 4. The former is
a low-power drawing and indicates the usual appearance. It is to
be noted that the villi are small and that the blood-vessels are very
numerous, taking up about one-haK of the total cross-section of
each villus. The stroma cells are relatively few in number and there
is a single layer of epithehal cells. The high-power photomicro-
graph, Fig. 4, merely accentuates the essential features already
described.

The syphiUtic placenta offers many points of difference. Fig.
5, a low-power drawing of such a placenta to the same scale as Fig.
3, well illustrates the characteristic differences in structure. The

566

PL ass: fetal and placental syphilis

^^lli are generally much larger and more closely packed together
with a consequent diminution of the intervillous blood space. The
stroma cells have undergone a rapid proliferation and are closely
packed, while the epithehal cells retain their usual arrangement.
The blood-vessels have almost entirely disappeared, small vessels

Fig. S- — Syphilitic villi — cross-section (low-power drawing). — {From Williams.)

being present in only two of the larger villi. Fig. 6 is a high-power
])hotomicrograph showing a similar picture.

While the differences between the normal and the syphiUtic
organs are usually as marked as shown here, there are cases where
this is not so and there is a reasonable doubt as to the specificity
of the changes encountered. The process does not uniformly affect
the placenta at first and occasionally the villi from one stem may

PLASS: FETAL AND PLACENTAL SYPHILIS

567

show definite changes, while the neighboring vilh are normal. For
this reason it is desirable to use a fairly large section (ij^^ X i^
cm.) for study and sometimes several sections from different por-
tions of the placenta may be necessary. In such cases even when
apparently typical changes are demonstrated in some particular
area, one can merely say that the picture is suggestive of sypliilis;
a diagnosis being made only in the light of the other cUnical and
laboratory findings. Again, there may be all gradations in the
severity of the pathological changes with a resultant picture

Fig. 6. — Syphilitic villi, cross-section (high-power photomicrograph).

somewhere between the normal and the definitely luetic and here
a positive diagnosis is again impossible without other evidence.
Among the seventy-five placentae herewith reported the diagnosis
was doubtful in only six or 8 per cent.

We believe that the changes named are specific if noted in the
placenta during the last trimester of pregnancy; but before that
time the usual picture of the developing organ may be very confus-
ing. The normal early placenta presents a picture which may not
be distinguishable from the advanced luetic organ. The villi are
large and filled with rather loosely packed stroma cells. Blood-
vessels are not visible because they have not yet grown down into
the villi. Not infrequently, however, careful search will reveal

568

PLASS: FETAL AND PLACENTAL SYPHILIS

some epithelial cells of the Langhans' layer stiU remaining and thus
make possible the diagnosis of an early placenta. In Fig. 7 such an
early placenta is pictured and in the villus at the top the two
epithelial layers can be distinctly seen. In the cases where this
evidence of prematurity is not available, the history should be care-
fully considered and where the child is of less than seven lunar
months development (35 cm. long) one should not attempt a positive
diagnosis from the histological picture alone.

'•'«^^,

iij^^. "m^^. ^<^y%

Fig. 7. — Normal early placenta, cross-section (high-power photomicrograph).

One other point in differential diagnosis which may occasionally
present itself, is in the placenta of a dead nonsyphilitic child. Here,
Fig. 8, we have villi which are normal in size or only slightly enlarged.
The stroma cells have in large part undergone hj-ahnization and the
few remaining ones are widely separated. The blood-vessels are
no longer present and no trace of them remains. The epitheUal
cells have undergone considerable proliferation and in many places
the single syncytial layer has been replaced by a stratified one,
several cells thick. Cross-sections of these syncytial buds give rise
to many so-called placental giant cells and the presence of large
numbers of these structures would suggest a nonsyphilitic dead child.
We have never known the placenta of a syphilitic child to present

PLASS: FETAL AND PLACENTAL SYPHILIS

569

this appearance and believe that lues can be excluded when these
changes are present.

Changes in the placentas from patients suffering from nephritis,
toxemia and eclampsia have been reported as presenting lesions
indistinguishable from those seen in syphiUs. While we cannot
deny that such a thing is possible, we can say that it must be exceed-
ingly rare, for in our experience there is nothing in the great majority
of these placentae to suggest syphiHs unless there is some other
evidence of the disease.

ik . * ^

••.>j|

Fig. 8. — Placenta of dead nonsyphilitic child, cross-section (high-power
photomicrograph).

The Treponema pallida are present in the sj^Dhilitic placenta in
such small numbers that they can be demonstrated, if at all, only
after a prolonged search. The time required for such a careful
study is too great to make the method apphcable for routine work.

The possibility of making a definite diagnosis of syphihs from the
histopathological changes in the placenta has been subject to argu-
ment for years without the specificity of the changes being univer-
sally conceded. We feel, however, that when the changes which
have been described are present they furnish very strong evidence
of the presence of lues, whereas a normal histological picture does
not exclude the possibility of the disease.

570

PLASS: FETAL AND PLACENTAL SYPHILIS

Fetal Syphilis* — In those cases where the child dies and comes
to autopsy a further diagnostic possibihty is available — the demon-
stration of the spirochete pallidum in the tissues. The method is
comparatively simple and when positive results are obtained one
can say with certainty that the child had syphilis, irrespective of
any and all other evidence. This demonstration of the causative
organism is the one absolute method of diagnosis and it furnishes
an excellent opportunity to control the other tests.

'■' '~-,.jri.-

Fig. 9. — Spirocheta pallida in lung of macerated fetus, Levaditi stain (oil-
immersion photomicrograph).

The tissues are best stained by the Levaditi method or some
modification thereof. I have found the following technic very
satisfactory: (i) Fix in 10 per cent, formalin (4 per cent, for-
maldehyd) for two days or more; (2) place in 80 per cent, alcohol
for twenty-four hours or more; (3) wash in distilled water for twenty-
four hours, changing the water several times; (4) place in i per cent,
to 2 per cent, silver nitrate solution for three days in the dark at room
temperature and for seven days in the thermostat at 37° C; (5)

* Note. — The usually described changes in the organs in congenital syphilis
furnish excellent evidence of the disease when they can be demonstrated but
frequently the characteristic lesions cannot be made out and in the cases where
maceration has begun routine histological work reveals nothing.

PLASS: FETAL AND PLACENTAL SYPHILIS 571

wash in distilled water for five minutes, using at least three changes
of water; (6) place in the following solution for twenty-four hours at
room temperature in the dark — pyrogallic acid 3 grains, formahn
(40 per cent, formaldehyd) 5 c.c. and distilled water 100 c.c. (always
make up fresh Just before using); (7) wash for twenty-four hours in
several changes of distilled water; (8) run through the usual solu-
tions and imbed in paraffin. Cut sections 3 to 6/n thick and after
fixing to the sHde, remove the paraiEn and mount in Canada balsam.
Examine under an oil-immersion lens. In correctly treated prepara-
tions the spirochete are dead black in color and the surrounding
tissues are a pale yellow. Not infrequently some of the connective-
tissue fibrils and more rarely the cell membrane will appear black
because of a deposit of the silver and may be very confusing. With
care and a Uttle experience, however, one can usually differentiate
these artifacts from the spirochete by the fact that the latter show
regular spirals of a remarkably constant size. If the tissues are
not macerated, the section can be stained with toluidin blue in order
to bring out the cellular structures more sharply.

According to general experience, the spirochete are most numerous
in the adrenals, lungs and liver and the search may well be confined
to these organs. The organisms usually tend to invade the connect-
ive tissue by preference and where they are rather few in number
can best be sought in the walls of the blood-vessels or in the con-
nective-tissue network of the organ. If, as particularly happens
in macerated fetuses, the spirochete are very numerous they are
rather diffusely scattered with, here and there, groups or colonies
showing scores of organisms in a single field of the microscope. A
differentiation of the type of spirochete is not considered neces-
sary because no other spirillum is commonly present in the fetal
tissues. A positive finding of even a single organism is of the utmost
importance diagnostically but the failure to demonstrate the spiro-
chete has much less value and should not deter one from making a
positive diagnosis from other findings. The diflSculties of the search
are such that at best only an infinitely small portion of an organ can
be carefully examined and when the organisms are very few in
number they may readily be missed.

Results in Seventy-five Cases. — During the past four years I have
done autopsies on seventy-five babies dead from all causes and have
studied the organs for the presence of the spirochete and the placentae
for the histological evidence of syphilis. In forty-seven of the cases
the Wassermann reaction was determined on the maternal serum.
Table I shows the results of the observations on the placentae and

572

PLASS: FETAL AND PLACENTAL SYPHILIS

the fetal organs and Table II cites the results of comparison with
the Wassermann test.

TABLE I.— RESULTS IN PLACENTA AND FETAL ORGANS.

Placenlcs.

Placenta normal. . . .
Placenta syphilitic. .
Placenta suspicious.

Fetal Organs.

Spirochete not demonstrated.
Spirochete demonstrated

In Table I it is seen that there is a close agreement in the number
of positive findings in the placentae and in the fetal tissues. A
syphilitic placenta was noted in twenty-seven cases and in six other
cases it was suspicious, whereas spirochete were demonstrated thirty-
four times. The two methods did not give absolutely parallel results
as can be seen in Table II. Among forty-two macerated fetuses,
there were twenty-three which were definitely syphiHtic, a per-
centage of 54-8. This differs considerably from the usual statement
that 80 per cent, of macerated fetuses are luetic.

TABLE II.-

-COMPARISON OF THE WASSERMANN REACTION WITH
THE PLACENTAL AND TISSUE FINDINGS.

i No.
1 of
cases

W.R.

not
done

Placenta normal, spirochete not demonstrated 35

Placenta normal, spirochete demonstrated 6

Placenta syphilitic, spirochete not demonstrated 3

Placenta syphilitic, spirochete demonstrated 25

Placenta suspicious, spirochete not demonstrated 3

8
0
2

IS
3
0

I
0

12 .

I
10
0

1 7S

PLASS: FETAL AND PLACENTAL SYPHILIS 573

From Table II one can see how closely the placental pathology
agreed with the presence of the spirochete and with the maternal
Wassermann reaction. Excluding the six cases where a positive
diagnosis was not made on the placenta, the first two methods agreed
absolutely in sixty (thirty-five normal and twenty-five syphilitic).
The cases with syphihtic placentae and no demonstrated spirochete
(Nos. 28, 31 and 56) may well have represented the class where
longer search would have been more successful; whereas the six
cases with normal placenta and demonstrated spirochete (Nos.
8, 10, 12, 13, 15 and 41) represent the small percentage of cases
where there are no demonstrable lesions in the placenta in spite of
definite fetal syphilis. In the series there were nine cases of toxemia
and eclampsia, four of them definitely of the nephritis type, and in
none was the placenta even suspicious.

The Wassermann reaction was performed on the mother's blood
in forty-seven cases and the results show rather wide discrepancies
when compared with the other findings. Thus in twenty-three
cases, where the placenta was normal and the spirochete could not
be demonstrated, the Wassermann was positive in eight cases. We
believe that the histological evidence in these cases should receive
some consideration and that the positive complement fixation in
the mother's serum does not prove that the child had s)^hilis.
Some substantiation of this scepticism is offered by the fact that in
one case the father and in four cases the baby gave a negative reac-
tion and that one other mother had a toxemia which is recognized
as sometimes giving a positive reaction in the absence of lues. We
do not believe that a negative test is proof of the absence of syphilis
but taken with the other findings it makes us doubly certain that
these children at least did not have syphilis. The tests were made
on cord blood which we believe to be whoUy fetal in origin and conse-
quently of some value. The Wassermann on the fetal blood was
done only in ten cases but it is interesting that it always gave a result
which was confirmed by the presence or absence of spirochete.

In three cases, in which the placenta was suspicious and the spiro-
chete were not demonstrated (Nos. 3, 24 and 63), the Wassermann
was of considerable value in determining the diagnosis. In two
cases it was negative while in the third (No. 63) it was positive but
the negative fetal reaction indicated that the child probably did
not have lues. In the two cases with a luetic placenta and a positive
reaction but no demonstrated spirochete (Nos. 28 and 31) further
search would probably have revealed the organisms.

574

PLASS: FETAL AND PLACENTAL SYPHILIS

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PL.4SS: TET.AL AND PLACENT.'\L SYPHILIS

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stein: primary carcinoma of the vulva 577

Case No. 27 is of interest because of the excessively large placenta
— 2120 grams, which showed no histological evidence of syphilis.
The presence of a chronic nephritis in the mother may offer an
explanation for the huge growth of the organ.

Case No. 42 is interesting in view of Colles' law. Here all the
examinations of the fetus showed the presence of syphihs but the
maternal' Wassermann was negative. Cases Nos. 61, 62, 68 and
74, with positive maternal Wassermann reactions and negative
fetal reactions coupled with normal placentae and on demonstrable
spirochete in the fetal tissues present the opposite picture.

Conclusions. — (i) The syphiHtic placenta is characterized by
increased size and weight, abnormal proliferation of the stroma cells
and an obliterative endarteritis and endophlebitis. For practical
purposes the changes are specific and offer very strong evidence of
the presence of fetal syphihs, whereas their absence does not exclude
the disease.

(2) The demonstration of the Treponema pallidum in the fetal
tissues affords an absolute diagnosis of lues but the failure of
demonstration proves nothing.

(3) There are many discrepancies between the histopathological
findings in the placenta and fetal tissues and the maternal Wasser-
mann reaction and we believe that the complement-fixation test
on the mother is of less value in accurately diagnosing fetal syphilis
than the other two methods.

(4) The diagnosis of fetal syphilis should be attacked from all
points and absolute rehance should not be placed upon any one
method of diagnosis.

PRIMARY CARCINOMA OF THE VULVA.*

ARTHUR STEIN, M. D., F. A. C. S.,
New York City.

(With seven illustrations.)

Compared to the frequency of carcinoma of the internal genital
organs in women, primary carcinoma of the vulva is a rare affection.
The disease is distinctly one of advanced life, the patients, as a rule,
being women who have reached the late sixties or seventies and even
eighties. Youth is not exempt however and carcinoma of the vulva

* Read before the Section on Obstetrics and Gynecology of the New York
Academy of Medicine, May 23, igi6.

578 stein: primary carcinoma of the vulva

has been known to occur in women of thirty or less, the youngest
patient being a girl of twenty years (Ossing).

Metastatic or secondary vulvar carcinoma which does not enter
into the present consideration, is occasionally observed but occurs
very rarely in association with primary cancer of the ovary.
Cancerous disease of the vulva has also been noted as the so-called
"inoculation" carcinoma, after extirpation of uterine cancer.

In the Uterature primary carcinoma of the vulva is represented
by about 270 recorded cases to which the author is able to add a
personally observed instance. In connection with this case and
on the basis of the original investigations of French and German
writers a special study has been made of the regional anatomy of the
vulvar lymphatics. The imperative necessity of radical interference
is apparent in the text and even more forcibly expressed by the ac-
companying illustrations.

Authors Case. — Patient, Mrs. E. B., aged forty-eight years, ad-
mitted to the German Hospital on June 14, 1913. Family history
as well as her own personal history of no interest except for the follow-
ing facts: Thirteen years ago patient noticed a nodule on the right
side of her outer genitals about midway between urethral opening
and fourchette. This nodule was about the size of a small pea and
hard. It itched very much and would bleed easily on scratching.
Patient went to a doctor's office in Italy but he could not diagnose
the case. This nodule lasted three years in its original size and then
became somewhat larger. Patient paid no further attention to this
until two years later when another hard nodule appeared near the
first one and remained until the present time (altogether about
seven to eight years').

Two months ago the external genitals and part of thighs became
very much reddened and inflamed. Very severe pains occurred
when the bowels moved, also severe burning pains on micturition.
This continued up to time of admission. No backache but pain in
legs. Felt very weak. Had lost about 7 pounds weight during the
last six months. Slightly heavy and dragging sensation in her
pelvis. No edema of the extremities. Appetite good. Bowels
constipated. No headache, no cough.

Menstrual history: started at fourteen years. Regular, lasting
eight days, painful, moderate amount. Has had eight children,
miscarriage eighteen years ago between sixth and seventh child.
Five children living.

Heart and lungs: normal.

Extremities: no edema. Has an atrophy of flexor muscles of the
right leg. No knee-jerk obtainable on the right side. Normal knee-
jerk on the left side.

Gynecological examination: at the upper junction of the labia
majora and minora a hard, reddish, easily bleeding mass is to be
seen. This mass occupies about the upper two-thirds of the right

stein: pruiary carcinoma of the vulva

579

labium majus and the upper one-third of the left labium majus. It
also involves the clitoris which can no longer be distinguished, as
well as the upper junction of the labia minora. The meatus ure-
thra however seems to be intact. The whole mass bleeds quite
easily on touch, is very tender, and some parts of it are necrotic,
showing a grayish-green discharge. There is some induration of the
adjacent surrounding tissue. This induration can be traced for
about )4 inch all around the diseased area (Fig. i). Right inguinal

lymph nodes are enlarged and easily palpable but on the left side
they cannot be felt. Bartholin's glands not enlarged. No vaginal
discharge. The vagina admits two fingers, cervix firm and hard.
Slight stellate tear. Uterus retroflexed and of normal size, fixed in its
position by adhesions. Adnexa not palpable nor painful. No in-
duration or tumor-like masses to be felt in the whole pelvis.

Diagnosis: primary carcinoma of the vulva (including the upper
parts of labia majora and minora and the clitoris).

In order to exclude any possible mistake in the differential diag-
nosis between this disease and lues or tuberculosis, a small piece of
the above-described mass was excised for microscopical examination,

580 stein: prlmary cakcinoma of the \tjlva

The pathological report by Dr. Humphreys Chief of the German
Hospital laboratory, was as follows:

Anatomical Diagnosis: epithelial growth from vulva (epithelioma).

Specimen consists of a small piece of tissue removed from vulva,
region of clitoris. Microscopical examination shows an epithelial
growth surrounded by a very marked round-cell infiltration. This
epithelial growth extends downward from the epithelial lining and
continues throughout the whole section. It is made up of squa-
mous epithelium. Scattered throughout the whole section is a vast
number of epithelial pearls. There is also a large number of newly
formed blood-vessels and sinuses. A number of these blood-vessels
are lined by a single layer of endothelial cells.

Operation was decided upon because of this report and was per-
formed on June 24, 1913.

Wide sweeping incision made to right and left of each labium
majus about J-2 inch outside of the diseased area. The diseased
area as well as both labia majora and minora removed and the blocks
of glands on the right side of the right inguinal region and also those
on the left side removed.

The tumor did not appear to involve the deeper tissues. There
was a good deal of bleeding which was controlled by clamps and
ligatures. The external orifice of the urethra which was apparently
not at all diseased, was left alone. The different wounds were closed
entirely and only the lowest points of the wounds on both sides were
drained.

Patient made an uneventful recovery and was discharged as cured
on July 26th.

She was readmitted to the hospital however on Sept. 29, 1913,
with the history that soon after she had left the hospital she began
to have burning pains in the left outer part of the vagina. She had
also some bloody discharge and complained of much pains after
urination.

On local examination it was found that the urethral orifice was
bulging. Anterior to the urethra there was a small ulcer which
bled freely and was surrounded by an infiltrated cicatrix. The
infiltrated area involved the anterior inner surfaces on both sides
(site of former labia majora) and extended right down to the
symphysis.

On examination the pelvis seemed to be free. No inliltration was
to be felt in the inguinal region.

Diagnosis: recurrent carcinoma of vulva involving the outer
orifice of the urethra.

stein: primary carcinoma of the vulva

581

Second operation: October lo, 1913.

The operation was performed as radically as possible, the infil-
trated tissue being removed and both inguinal regions being cleaned
out, but owing to the condition of the patient and the rather marked
infiltration of the urethra, it was found impossible to resect the
urethra in its entirety. Onl)' the outer part of it was removed.

The pathological report showed the same type of carcinoma as
described above.

Patient stayed at the hospital and was treated subsequently by
Dr. Stewart, with x-ray cross fire and small doses of radium but in
spite of this the patient became steadily worse and finally succumbed
to the disease in January, 1914. The carcinoma had by that time
invaded the area in between the thighs up to the hair line above
3

582

stein: primary carcinoma of the vulva

the symphysis, extending about 4 inches on both sides from the
median hne (Figs. 2 and 3).

The clinical history of this case has been given in some detail
because on reviewing it hypercritically we find a fairly topical
example of vulvar carcinoma with its slow insidious development, the
difficulty of early recognition, the prolonged regional localization
and the relatively shght subjective disturbances until an advanced
stage of the disease. The treacherous character of these growths
is also well brought out in the fact that at the time of the first
operation the deeper tissues were apparently not involved. No
radical operation (in the stricter sense of the word) was performed at
this time and two months later there was a recurrence of the vulvar
carcinoma which had now invaded the outer orifice of the urethra.

Fig. 3. — Showing final stage of primary carcinoma of \'ulva.

The second very radical intervention was supplemented by a;-ray
and radium therapy but the carcinoma relentlessly advanced and
within a few months led to the patient's death.

In the absence of surgical intervention these cases usually prove
fatal at the end of two or three 3'ears at most — some cases leading
rapidly to a fatal end within a few months or even weeks. Death is
sometimes hastened by the onset of femoral or intrapelvic phlebitis
followed by embolism. The actual duration of the disease in a given
case prior to the appearance of ulceration is not easy to determine,
the first beginnings of vulvar cancer being usually overlooked.

Etiology. — .Mthough a direct connection is not always demon-
strable, predisposing factors arc probably to be sought in warty

stein: primary carcinoila of the vulva

583

excrescences and papillomata of the skin such as were presumably
present in the author's case thirteen years or so before the patient
came under observation, adenomatous growths in the regional
glands, kraurosis, and pruritus vulvae. Traumatism can hardly
be regarded as an etiological factor, for cancer of the vulva is
rare whereas injury of the parts, for example birth traumatism of
more or less severity, is extremely common.

Pathological Anatomy. — The point of predilection for the origin
of primary carcinoma of the vulva judging from a comparative

Fig. 4. — Showing the outer regional lymph glands of vulva. {From Crosscuts
"Operative Gynecology," 1915.)

Study of the reported cases is in the labia majora and minora as
well as the chtoris. Beginning as a small hard nodule or thicken-
ing of the tissue, as in the reported case, the growth extends from
its starting-point to the clitoris, urethra, and external genitals,
which finally become transformed into an amorphous tumor mass
although even in advanced stages the primarj' tumor in the vulva

584

stein: primary carcinoma of the vulva

remains localized to a certain extent and recognizable as such. In
the course of the extensive suppuration which follows, the large
secondary cancers which have developed in the inguinal glands are
liable to become infected and break down.

IMetastases are limited, as a rule, to the regional as well as lumbar
lymphatics, the glands in the groin being usually involved as well,
whereas the ihac and hypogastric glands are less frequently affected.
Involvement of the adjacent skin and mucosa of the external
genitals results in so-called '"contact" cancer, the "Abklatsch-

FiG. 5. — The lymphatics of the urethra and anterior portion of vagina pass-
ing backward directly to glands in the interior of the pehis. {From Crossciis
"Operative Gynecology," 1915.)

Krebs" of German writers. The neighboring hollow viscera are
directly invaded by the primary growth in a number of cases. In
its continued development the cancer encroaches upon the pelvic
connective tissue, especially the rectovaginal and vesicovaginal
septum. The pelvic bones, more particularly the descending pubic
ramus, may next become diseased and carcinomatous.

Especial importance is attached to the early involvement of the
regional lymphatics, the external inguinal glands representing the
first stage, the deep inguinal glands the second stage, the external
iliac, hypogastric, and obturator glands the third stage of cancerous
invasion. The involvement of the lymph glands in the surround-
ings of the rectum seems probable but has not as yet been positively

stein: primary carcinoma of the vulva 585

established. In view of the important part played by the lym-
phatics of the vulva in the distribution of cancerous material, a
brief review of the regional anatomy is added for better orientation
(Figs. 4 and 5).

On the basis of his anatomical studies of the ihopelvic lymphatics
and glands, Marcille (1902) emphasizes the abundant glandular
and lymphatic connections of the organs in the small pehds and the
resulting difficulty of a radical cure of pelvic cancer. Attention is
called by him to the fact that the vulvar network of lymphatics
which is tributary to the inguinal glands, is distinctly separated by

Fig. 6. — Outlines for the block excision of the external genitals for carcinoma.
{From Crosscuts "Operative Gynecology.^')

the hj-men from the vaginal lymphatic ple.xus, which is tributary
to the pelvic glands. This separation is especially marked in chil-
dren where no vaginal lymphatics terminate in the inguinal glands.
As shown by Poirier, mercury injections within the hymeneal septum
in children pass to the lymph vessels going to the pelvic glands,
whereas injections applied on the vulvar side of the septum reach the
lymph vessels going to the inguinal glands. In adult women it is
possible for injections made at the level of the lower vaginal portion
to reach the inguinal glands, not through direct collecting channels,
but by way of numerous anastomoses which unite the vaginal net-
work with the vulvar network. The existing anatomical relations
were pointed out by Bruhns (1898) as the confirmation of the well-
known clinical fact that a pathological process of one labium will

586

stein: primary carcinoila. of the vulva

cause swelling of the inguinal gland groups of both sides. He showed
a connection through lymph tracts between the labia majora and
minora of one side and the inguinal glands of the opposite side; also
pointing out the continuity of the lymph tracts of the labia majora
and minora with those of the chtoris. The efferent trunks usually
empty into the internal and upper group of the superficial inguinal
glands. The lymphatics of the vaginal mucosa and muscularis
are connected and their efferent trunks usually pass to the glands on

Fig. 7.

both sides of the hypogastric arter\-. The lymphatics of the
vaginal wall adjacent to the hymen also communicate with the
lymphatics of the labia and thereby with the inguinal glands.

In the most recent authoritative contribution to the anatomy of
the lymphatic system of the pelvis and abdomen Poirier and Cuneo
give the following account of the vuhar lymphatics, quoting in
part from Sappey's older work:

" The lymphatics of the vulva arise from a network the extremely
close meshes of which are superposed in several planes. This net-
work covers the fourchette, the meatus urinarius, the vestibule,
the clitoris, the labia minora, and the internal surface of the labia
majora. It is so loose and close throughout that when it has been

stein: primary carcinoma of the vulva 587

well injected it presents at first sight merely an ashy gray appear-
ance. To distinguish the innumerable silvery filaments of which
it is composed we must use a magnifying glass. On the external
surface of the labia majora the network composed of smaller and
larger branches becomes sufficienth' distinct to be recognized by
the naked eye (Sappey). From the periphery of this network of
origin run the collecting trunks. The direction of these trunks varies
according to their point of origin. Those which come from the
anterior third of the vulva run directly upward and forward toward
the mons veneris; there they turn sharply and run transversely
toward the superficial inguinal glands. The trunks which come
from the posterior two-thirds are directed upward and outward and
directly reach their terminal glands. The majority of the Ij-m-
phatics of the vulva terminate in the glands of the internal-superior
group. Some of them may end in the internal-inferior group. It
is even possible, though much more rare, to see some of these vessels
reach a gland belonging to one of the two external groups. The
vulvar lymphatics are far from being confined to a perfectly definite
glandular group. WTien injecting one-half of the vulva the mass
may frequently be seen to reach the glands of the opposite side.
The injection of these glands may take place by a double process.
Sometimes it is effected on account of the continuity of the network
of origin of the two sides of the vulva in the middle line; at others
it is due to the fact that some of the collecting trunks cross the
middle fine and end in the inguinal region of the opposite side. In
all cases when dealing with an epithehoma of the vulva the inguinal
glands of both sides should be regarded as liable to infection. Sur-
gical interference in epithelial tumors can be efficient only when
combined with radical extirpation of the glands, for the lymphatics
are invaded from the very beginning and although sometimes
apparently intact they are always altered histologically."

The lymphatics of the clitoris, instead of passing into the super-
ficial inguinal glands like the other vulvar lymphatics, pass from
the primary plexus in several collecting trunks along the dorsal
surface of the clitoris to the front of the symphysis, where they
anastomose forming a plexus which gives off two sets of collecting
trunks. One lymph vessel, passing along the inguinal canal to the
external retrocrural gland, is usually encountered beneath the round
ligament, while other lymphatics pass toward the crural to their
termination in a deep inguinal gland, the internal retrocrural gland
and the so-called gland of Cloquet.

The urethral lymphatics in the female drain into the middle and

588 STEIX: PRIXL'iRY CARCINOiL-V OF THE VULVA

outer chain of the external ihac glands, the hypogastric glands, and
the glands of the promontory.

The practical apphcation of the anatomical findings is very clearly
and concisely summarized by Crossen {Operative Gynecology, 1915,
p. 476) as follows:

1. "From a cancer of the labium majus or minus all the lym-
phatic distribution in the early stage is likely to be to the inguinal
glands.

2. This distribution may extend not only to the side on wliich
the lesion is located but also to the opposite; hence the glands on
both sides should be removed.

3. In cancer of the cHtoris, a very early distribution to the glands
inside the pelvis is probable.

4. In cancer of the urethra also, invasion of the interior of the
pelvis is favored by the lymphatic distribution."

Microscopical Pathology. — Primary carcinoma of the vulva origi-
nates from the pavement epithelium of the skin and the epithelia
of the sweat glands including Barthohn's gland. Incipient cases
permit no distinction between the four types of carcinoma, namely,
flattened cutaneous cancroid, papilloma in form of a sessile, more
rarely pedunculated cauliflower growth; infiltrating carcinoma, an
especially malignant form; and carcinoma of Bartholin's gland,
a distinct and very unusual tj^pe with only sixteen recorded cases
(Fabricius, Schaeffer, Frank, Schweizer, Trotta, Pape, Mackenrodt,
Burghele, Gross, Godert, Grahem, Frisch, Sitzenfrey, Wolff, Latzko,
Spencer). The most common form of cancer of the vulva is a slowly
growing cancroid which may still be followed by recurrence several
years after its operative removal. Some observers are disposed to
beheve that in carcinoma of the vulva the regional lymph glands are
often affected simultaneously or nearly so with the onset of the pri-
mary tumor. Not infrequently cancer tissue is microscopically
recognizable even in very small lymph glands not exceeding the
size of a hemp seed.

Symptoms. — Carcinoma of the vulva may not cause any dis-
turbances for a considerable length of time and is apparently pain-
less until the growth has ruptured through the skin. These patients
are, therefore, not apt to seek advice before ulceration has begun and
often complain only of local soreness and a burning sensation on
micturition. There is usually a history of a small painless nodule
(see author's case) or a superficial ulcer with a tendency to bleed
more or less, gradually increasing in size without serious disturbances
of a local or general character. Profuse hemorrhage and discharges

stein: primary carcinoma of the vulva 589

are rare and never appear until late in the disease. Pruritus is in
many cases one of the earliest symptoms of vulvar carcinoma.

On examination the location of the tumor in the vulva in the
majority of the cases is discovered in the labia majora, more par-
ticularly on the internal surface. Swelling of the lymph glands in the
groin is almost invariably demonstrable no matter how small and
apparently insignificant the vulvar tumor. This premature enlarge-
ment of the inguinal lymphatics is probably not the result of infec-
tion of the tumor surface associated with inflammatory swelling,
but in view of the very frequent glandular recurrences after radical
operations must be interpreted as a manifestation of early metastasis.

The malignancy of carcinoma of the vulva as well as the symptom-
atology are illustrated by the following instructive case, recently
reported by Frigyesi in Budapest:

The patient a woman forty-six years of age, noticed one year ago
a swelhng of the vulva the size of a hazelnut, which caused severe
itching and was removed. When she came under observation ten
months later, the vulva on examination was found to be reddened,
swollen and painful; the inguinal lymph glands on both sides were
more or less enlarged up to the size of a bean. The right labium
majus was shrunken and atrophied, whereas the left labium majus
and minus were occupied from the prepuce of the clitoris downward
by a large cartilaginous tumor the size of a fist, with an eroded and
bleeding inner surface. The growth began in the middle hne ex-
tending anteriorly to the urethral bulb and posteriorly for a distance
of 1 3^^ cm. to the vaginal wall. Exploratory excision showed the
tumor to be a carcinoma.

Diagnosis. — The recognition of cancer of the vulva is usually
easy. Syphihs and tuberculosis having been excluded, the growth
can in most cases be identified without difiiculty by the induration
which extends deeply into the connective tissue; the cauUflower-
like smeary surface; and the crater-Uke eroded margins. An
exploratory excision of tumor tissue is very rarely required. The
microscopical findings in these cases do not differ in any particular
from the cutaneous carcinomata affecting other regions of the body.
In a case recently reported by a Russian observer (Grintschar) the
microscope showed cancer nests only underneath these points where
the epidermis was considerably thinned or eroded, namely, in the
presumably older portions of the growth, the marginal fields merely
presenting chronic inflammatory changes. In this case which
concerned a woman fifty-five years of age, the first manifestations
had appeared four years previously in the form of pruritus, followed

590 stein: primary cafcinoila. of the vulva

by itching nodules of the vulva which two years later began to
ulcerate. Examination showed hv-pertrophy of the prepuce of the
clitoris and of the right labium minus, which were covered with
partly eroded and ulcerated nodules. A hard cartilaginous infiltra-
tion was palpable under the erosions.

Treatment. — In view of the hopeless prognosis in neglected cases
which reach the surgeon's hands too late, early operative interven-
tion is imperative. The unfavorable outlook of vulvar carcinoma
can be improved only by radical operative procedures, abandoning
the older method of removing only the external inguinal glands.
Even when not demonstrably diseased, these glands must be extir-
pated without fail on both sides on account of the early occurrence
of metastases in this region, due to the number of deep anastomos-
ing lymphatics in the mons veneris. Provided the carcinoma has
not yet attained considerable size and the inguinal glands are not
yet changed or suspicious, the extirpation may be restricted to
the removal of the superficial and deep inguinal glands on the two
sides. Very radical procedures including the removal of the deep
ihac and hj^pogastric glands (see illustration No. 5) are indicated
in the presence of a large ulcerative tumor, especially of the most
maUgnant infiltrative type, and in youthful or pregnant women.
The tumor must be extirpated well within the healthy tissue and
expert operators evacuate both inguinal regions down to the large
blood-vessels, dissecting the glands, fat tissue, and lymphatics in
connection with the growth, and removing the package as a whole.
These radical measures, proposed by Kehrer, are not uncondition-
ally needed in all cases, and the choice of the operation is governed
to a certain extent by the requirements of a given case. The type
of carcinoma, the age of the patient and her general condition must
all be taken into consideration. It is doubtful if such radical and
extensive treatment is altogether justified in feeble and decrepit
women in the seventies and eighties who represent a large percentage
of these cases.

The extraperitoneal procedure as described by Stoeckel begins with
an incision parallel with Poupart's hgament from the inguinal ring
nearly to the anterior-superior iliac spine, continued along the
anterior third of the pubic crest. After the peritoneum has been
pushed aside, the ureter is exposed in its entire course as well as
the large iliac vessels — (as in the Freund-Wertheim operation for
cancer of the uterus)^ — and in their surroundings as much as pos-
sible is removed of the pelvic connective tissue and the glands^in
continuity with the deep and superficial inguinal glands.

stein: primary carcinoma or the vulva 591

The extended radical operation by the intraperitoneal method was
first advocated by Stoeckel (1912) who recommends the removal
of all the pelvic glands, the ihac and hypogastric as well as the super-
ficial and deep inguinal, in carcinoma of the vulva. The first-named
glands are removed first of all by way of a median laparotomy inci-
sion. The laparotomy wound having been closed, the inguinal
glands are next removed by way of two obhque incisions above the
inguinal ligaments. At the point where the laparotomy incision
and the curved incision from one iliac spine to the other meet, a
vertical incision is applied, which passes downward over the sym-
physis encirchng the vulva. Next the vulvovaginal tissue is de-
tached from the bone together with the tumor. This is followed
by suture of the wound and permanent catheterization of the bladder.

Routine laparotomy, in Stoeckel's opinion is a very desirable
preliminary and improvement of the operation and he recommends
its performance as a valuable first step in all operations for cancer
of the vulva. A patient recently operated upon by him according
to this plan made a good operative recovery. In another case
which was operated upon according to the customary method,
namely, extirpation of the total lymph gland apparatus from the
anterior-superior ihac spines in connection with the entire vulva,
the wound healed by first intention but a small nodule developed in
the vaginal cicatrix on the right side, evidently an inoculation-
recurrence as it was found on examination to be carcinomatous.

In the following adaptation from Crossen the operative technic
to be followed is concisely summarized for greater convenience:
Avoid incision into involved tissue to guard against grafting of
cancerous material and inevitable recurrence. The block of excised
tissue should include the external genitals with a wide margin of
skin about the lesion, the lymph vessels passing upward and outward
to the inguinal glands, and the packets of glands on both sides.

First Step. — Circumferential incision around the skin surface to
be removed including a wide margin about the lesion and the surface
covering of the external genitals on both sides and outward for a
considerable distance over the lymphatic vessels of each side. Where
the vulvar lymphatics are more deeply situated, near the glands, a
simple skin incision and reflection will be sufiicient. As some lym-
phatic vessels pass upward a considerable distance before turning
outward, and even occasionally run across to the opposite side, the
superficial tissue should be excised well up over the pubes.

Second Step. — Block excision, beginning with dissection of the
gland mass on each side with the directly adjoining tissue and the

592 stein: primaky carcinoma of the vulva

tissue containing the vulvar lymphatics. As contamination can
hardly be reliably excluded it is safer to remove the entire glandular
mass in the inguinal region around the saphenous opening. Injury
to the important veins underneath must be carefully avoided. From
being skin deep at first over the gland area, the incision as it ap-
proaches the vulva is deepened through all the superficial tissues,
cutting straight through the structures down to the muscle and
fascia.

Third Step. — Removal of the tissue-block guarding against in-
jury of the urethra. Contraction of the urethral orifice may be
safely prevented by preservation of a narrow strip of vestibular
lining, as its lymphatics run in an outward direction.

Fourth Step. — Covering of the large raw wound area by means of
tension sutures, relaxing incisions, and sliding flaps, according to tlie
requirements of a given case, always keeping in mind the avoidance
of harmful tension at any point. Instead of incurring the risk of
sloughing through overtension of tissues it is better to have a bare
surface to close by granulations. The function of the urethra must
be safeguarded, however, by the best possible accurate approximations
of the margins about the meatus, so as to avoid subsecjuent contrac-
tion of scar tissue with its concomitant disturbances.

Radiation, with x-rays, radium, and mesothorium, is a recent
addition to the treatment of vulvar carcinoma, but has led to such
contradictory results that there is no unanimity concerning its value
in these cases. Mesothorium, according to Winkler, acts much
more energetically upon the cancer cells and has a more rapid effect
than a;-rays. Upon the basis of personal experience in two cases he
states that .%--ray radiation, hard or soft, is not suitable for cancers
of the vulva, as enormous quantities of rays are needed to produce a
visible effect. Mohr (1913) was unable to obtain any results through
radiotherapy in two cases whereas Hermann in the same years
claimed to have cured recurrent cancers of the vulva by means of
.v-ray treatment. Schmidt (1913) recommends surgical treatment of
superficial cutaneous carcinomata with regional glandular sweUings,
and radiation of recurrences in the cicatrices, utilizing soft tubes for
the radiation of the tumor and hard tubes for the radiation of the
glands.

Although the results as to a permanent cure cannot be reliably
known before the end of at least three and preferably five years after
the institution of radiotherapy, the beneficial action of mesothorium
is sometimes so marked in very old and feeble patients, that the
superiority of radical operative treatment is questionable.

stein: primary carcinoma of the vulva 593

Results of Operative Treatment. — In reporting the permanent re-
sults in the cases of vulvar carcinoma operated upon during three
years in the Kiel Gynecological Clinic altogether eighteen cases,
including twelve with notes as to recurrence — Ossing {Inaugural
Dissertation, Kiel, 1913) contributes the following statistics: Five
patients remained well, five had recurrences, one woman died of
so-called " abdominal cancer." The five recurrences were all operated
upon but all these patients died sooner or later after the operation.
One patient was well at the time of the report, six months after
operation for a recurrent carcinoma of the vulva. In the other pa-
tients who remained well, the operation for the primary vulvar can-
cer dated back from eight months to nearly ten years. In the case
of the oldest patient, a woman eighty-two years of age, the enlarged
inguinal glands were left behind, but she had remained free from re-
currence for over eight years at the time of the report.

The numbers of permanent cures, accepting as the standard the
patient's freedom from recurrence for a postoperative period of five
years, is deplorably small judging from the figures given b}- Kehrer,
who emphasizes moreover that recurrences have been known to
follow at the end of six or seven and even eleven years after the
operation. Accordingly the five years freedom from recurrence
which is usually the measure of a permanent cure in cancer of the
uterus does not apply to carcinoma of the vulva which can hardly
be regarded as definitely cured when six or seven years have elapsed
since the operation.

The adoption of the modern radical procedure would seem to be
rational in the rare cases of advanced vulvar carcinoma with a fairly
good general condition. In incipient and less extensive cases or in
very old and feeble patients operative interference will necessarily
be restricted to a thorough evacuation of the inguinal glands, beside
the extirpation of the primary tumor. Time must show if the results
of the radical operation, inaugurated in the recent past, will entitle
it to become the method of election in the treatment of carcinoma
of the vulva.

Note. — Since this article went to press it has been the author's
good fortune to observe another unusual case of primary carcinoma
of the vulva.

Mrs. R. S., fifty-five years of age, admitted to the German Hos-
pital, New York, August 11, 1916. The patient stated that up to
six months ago she had been in good health. At that time present
illness began with intense itching in the region of outer genitals.

594 stein: primary carcinoma of the vulva

This symptom was the patient's only complaint for three months
but she then felt a small "pimple " in the region of the outer genitals
which gradually increased in size. Two weeks later the patient first
felt a small hard nodule in the region of the present tumor which
ulcerated after a month, secreting a thin, scanty, seropurulent
discharge which was nonodorous. Ulceration was never painful nor
tender, was always solitary and never broke down, the only concomi-
tant symptom being the early, constant and intense itching of the
outer genitals, which alone drew the patient's attention to her condi-
tion. No symptom referable to any organic lesion elsewhere, all
other internal organs being normal. Right breast missing, radical
amputation having been done five years ago at this Hospital for
supposed carcinoma of the breast, the pathological diagnosis, how-
ever, being chronic mastitis. Patient has had seven children, no
instrumental deliveries. Menopause three years ago. Prior to this
no symptom of pathological menstruation. Family history nega-
tive.

Viiha. — Conforming to an area on the inner surface of upper
third of right labium majus between clitoris and labia is situated a
circular elevated ulceration about the size of a twenty-dollar gold
piece. The base is smooth but irregularly elevated and punched
out, especially the inner half, giving it a fungoid appearance, the
color being of dull red. The granulations are bathed here and there
with a scanty seropurulent secretion. The margins of the neoplasm
are irregularly elevated and inverted but with a sharp circumscribing
line of demarcation from adjacent tissue which is not infiltrated,
there being moreover no tendency toward cicatrization of any pre-
viously existing ulceration or repair of the present one in its dissemi-
nation. The neoplasm is not painful nor tender, appears vascular
but does not bleed, is distinctly indurated especially at the margins
which are very firm.

The inner surface of the ulceration overlaps the clitoris and oppo-
site labia but there is no evidence of any apposition implantation
or other means of involvement of remaining parts of vulva or glands.
On retracting the right labium majus the external surface of the
prseputium clitoridis is seen on the right side to be distinctly infil-
trated and on the interior surface there is a pea-sized ulceration of
the same consistency and appearance as the tumor just described.
Inguinal glands nor palpable.

Vagina small, shows signs of senile involution as does also the
uterus which is anteflexed and of a normal consistency. Adnexa
and parametria are perfectly normal, in fact the whole internal geni-
tal organs show no involvement from above described tumor.

Diagnosis. — Primary carcinoma of vulva (right labium majus).

Operation. — August i8, 1916. Butterfly shaped incision (similar
to Fig. 6) taking in both labia majora and minora, the clitoris and
prepuce of clitoris, all in one ])iece. The incision around the tumor
taking in about one-half inch of sound tissue. Enlarged glands are
nowhere to be detected.

In order to get a good approximation two relaxation incisions were

stein: primary carcinoma of the vulva 595

made on the inside of each thigh. The adaptation of the wound
margins was easily accomphshed and the wound closed with inter-
ruped chromic catgut sutures. A permanent catheter was inserted
in the bladder. An inguinal incision was made on each side and all
the glands are removed. None were found to be enlarged.

The pathological examination of tumor shows (in brief) typical
squamous cell carcinoma (epithelial pearls) invading connective
tissue.

Prior to the operation several Wassermann tests were made, all,
however, being negative.

bebliggraphy.

Boyer, A. Le cancer primitif de la vulve. (Symptomes, diag-
nostic, et traitement.) These de Paris, 1908.

Bruhns, C. tjber die Lymphgefasse der weiblichen GenitaUen
nebst einigen Bemerkungen iiber die Topographic der Leistendriisen.
Archiv fiir Anatomie, 1898, p. 57.

Cattaneo, G. Contributo alia statistica del carcinoma primitivo
della vulva. Annal. d. Ostet; i, 1915, p. 27.

Crossen, H. Operative Gynecology. St. Louis, 1915.

Delamere, G., Porier and Cuneo. The Lymphatics. Authorized
English Edition by C. H. Leaf. London, 1913, see p. 158.

Fabricius, L. tJber ein primares Carcinom der Bartholinischen
Driise. Monalschr. fiir Geb. u. Gyiidk., vol. xl, 1914, p. 69.

Frigyesi. Primares Vulva Carcinom. Centralblatt fiir Gyndk.,
No. 22, 1914, p. 816.

Goldschmidt, A. tJber des Vulvacarcinom. Inaugural Disserta-
tion, Leipzig, 1902.

Kehrer, E. Diagnose und Therapie des Vulvacarcinoms. Cen-
tralblatt fiir Gyndk., No. 35, 1912, p. 1151.

Lebram, F. tJber die Driisen der Labia minora. Zeilschrift fiir
Morphologic u. Anthrop., vol. vi, 1903, p. 182.

Marcille, M. Lymphatiques et ganglions ilio-pelviens. These de
Paris, 1902.

Ossing, J. tJber die Dauerresultate der in der Kieler Frauen-
klinik operierten Vulvakarzinome aus den Jahren 1910-1912.
Inaugural Dissertation, Kiel, 1913.

Poirier, P. Lymphatiques des organes genitaux de la femme.
Paris, Leorosinier, 1890.

Ritterhaus. tJber das primiire Carcinom der Vulva. Deutsche
Zeitschrift fiir Chirurgie, 128, 1914, p. 426.

Sappey, M. P. C. Anatomie, physiologic, pathologie des vaisseaux
lymphatiques consideres chez I'homme et les vertebres. Paris, 1874.

Schwarz, G. Erfolge der Radikaloperation der Vulvavagina
Carcinome. Inaugural Dissertation, Berlin, 1893.

Steel, W. A. Primary Cancer of the Clitoris. International
Clinics, xxiv, 1914; p. 269.

Stoeckel, W. L'ber die Radikalheilung des Vulvacarcinoms.
Muench. med. Wchschrft., No. 9, 1910, p. 497.

596 b.^bcock: correction of the relaxed abdomin.\l wall

Idem. Demonstration: 2 operierte Falle von Vulvacarcinom.
Muench. med. Wchschrft., No. 8, 191 2, p. 444.

Idem. Wie lassen sich die Dauerresultate bei der Operation des
Vulvacarcinoms verbessern? CentralUatt fur Gyndk., No. 34,
1912, p. 1102.

Teller, R. tjber das Vulva Karzinom. Zeitschrijl /. Geb. u.
Gyndk., Ixi, 1907, p. 309.

Winkler, A. Vulvacarcinom und Strahlentlierapie. Fortschrilte
a. d.Geb. d. Roentgcnstrahlen, xxii, 1914, p. 193-

II East Sixty-Eighth Street.

THE CORRECTION OF THE OBESE AND RELAXED

ABDOMINAL WALL WITH ESPECIAL REFERENCE

TO THE USE OF BURIED SILVER CHAIN.*

BY
W. WAYNE B.\BCOCK, M. D.,

Surgeon to the Samaritan and Garretson, Hospital, Philadelphia, Pa.
(With eleven illustrations.)

Although not infrequent in men and in persons under thirty-
years of age, weakness of the anterior abdominal wall occurs chiefly
in women of middle age or advanced years. It may be local and
limited to a single area of the abdominal wall, or general involving
the entire abdominal wall. When diffuse the fullness and relaxation
is usually more evident in the lower abdomen than in the upper.

We may divide general relaxation of the abdominal wall into three
degrees.

First, that form in which the relaxation is not sufficient to cause
the anterior abdominal wall to prolapse over the pubis or Poupart's
ligament when the patient is in the erect posture (Fig. i).

Second, a degree in which, with the patient erect, a fold of the
anterior abdominal wall hangs well over the pubis and over Poupart's
ligament, but does not approximate the thighs (Fig. 2).

Third, a degree in which, with the patient erect, the relaxed
abdominal wall hangs some distance down over the thighs.

The symptoms produced are:

First, a sense of weight, dragging and discomfort felt in the ab-
domen and back, associated with weakness and alteration in gait
and carriage, due to the change in the normal center of gravity of
the body.

Second, ptoses and displacement of the viscera with the second-
ary symptoms due to the angulation, stasis and obstruction that
may result from visceral displacement.

* Read before the Philadelphia Obstetrical Society, May 4, 1916.

babcock: correction of the rel.\xed abdominal wall 597

Third, relaxation and distention of the stomach and intestines,
due to the lack of the normal support exercised by the anterior
abdominal wall and a reduction in the normal intraabdominal
tension.

These patients, therefore, suffer from indigestion, headache, flatu-
lence, constipation and many other symptoms, and often are greatly
handicapped when in the erect position.

Fig. I. — Type of obesity, abdominal relaxation and umbUical hernia suitable for
treatment by lipectomy and reconstruction of anterior abdominal wall.

Etiology. — The weakness of the abdominal wall may be congenital,
or it may be due to overdistention of the abdominal wall, as from
pregnancy, ovarian tumors, or ascites, or be the general relaxation
associated ^\'ith wasting and debihtating disease. Obesity increases
the intraabdominal tension, weakens by fatty infiltration the
supporting walls, and adds the drag of an increased subcutaneous
mass. The weakness may be due to nerve injury or paralysis, par-
ticularly is this true where long vertical incisions have been made
4

598 b.^cock: correction of the rel.-uced abdominal wall

through the anterior abdominal wall, external to the semilunar line.
Extensive incisions, especialh' where drainage has been employed
or simple through-and-through sutures used, are hkewise frequently
followed by hernial defect. The unfortunate tendency of some
surgeons in secondary operations, never to use the same area that
has been employed by a previous surgeon in operating upon a
patient, is an important factor. One of our patients, a clergyman,
had had nine operations and each surgeon made a different incision,

Fig. 2. — Incisual hernia, obesity, and abdominal relaxation before reconstruc-
tion operation.

so that it was difhcult to pick out a part of the abdomen that had
not been preempted by another's scalpel.

The treatment of the weak abdominal wall may be divided into
palliative and operative treatment.

Palliative treatment includes methods that aim to develop the
weakened musculature, and the use of a supporting appliance, such
as a corset, belt, or spring truss with or without a pad or plate.
I shall not discuss the palliativ-e treatment at this time.

Operative measures for the correction of the incompetent anterior
abdominal wall include one or more of the following general principles.

B.4BCOCK: CORRECTION OF THE RELAXED ABDOMINAL WALL 599

First, the resection of an elliptical or other shaped area of skin to
increase the tension upon the underlying structures.

Second, a lipectomy or resection of the subcutaneous fat to elimi-
nate this source of weight and tension upon the underlying parts,
and to better contour the abdomen.

Third, a reconstruction of the fascial and muscular planes of the
anterior abdominal wall.

Fourth, the reinforcement of the abdominal wall by the implanta-
tion of new tissue or of foreign substances, such as, silver wire,
kangaroo tendon, etc.

In the obhteration of such defects as result from diastasis, in-
cisural or other traumatic openings, or hernias, wide resection is at
times necessary to find and to hberate the edges of the tissue layer
involved in the defect. Thus in the patient mentioned, who pre-
viously had had nine abdominal operations, no muscular or aponeu-
rotic tissue e.xternal to the right rectus was found until the flank
and the region of Poupart's ligament was reached. By thoroughly
freeing the retracted tissues, however, it was possible in this case to
approximate the rectus edge to the liberated aponeurotic and
muscular edges brought up from the side of the abdomen.

To strengthen the deeper abdominal wall two methods are
employed :

First, imbrication in which one edge of the separated muscular
and aponeurotic layers is lapped over the other, the imbrication
being from above downward or from side to side as seems best in
the particular case. Frequently the double layer thus secured on
account of the stretched and attenuated tissue is none too thick
or strong.

Second, a method that may be termed an imbrication by layers,
in which the abdominal wall is spht into its component parts, and
each layer as far as is feasible imbricated with its corresponding
layer: peritoneum to peritoneum, posterior layer of the rectus
lapped upon posterior layer of the rectus, substance of one rectus
to substance of the opposite rectus, and the anterior sheath of the
rectus lapped upon the anterior sheath by the rectus.

Often the conditions are such that a sufiiciently strong abdominal
wall is not obtained in any of these ways. Under such circumstances
additional support may be obtained by autoplastic or homoplastic
transplantation of fascia, or by the use of aUen substances imbedded
into the anterior abdominal wall. Pedunculated aponeurotic flaps
may be shd from one part of the abdomen to another, as in CoSey's
operation, or, as a free transplant, an area of the fascia lata may be

600 b.'^cock: correction of the rel.\xed abdominal wall

dissected and used to reinforce the anterior abdominal wall. For
such extensive defects as are seen in the new-born, and after very
destructive injuries in which insufficient local tissue can be secured
to bridge the area, I should not hesitate to implant the left forearm
of the patient into the defect in the abdominal wall as a temporary
measure, the skin of the forearm, of course, being first turned back.
Such exigencies are unusual, but it is not unusual to find it desirable
to use the additional support secured from an alien substance. For
this purpose strips or plates of celluloid, metal or other substance
are hardly feasible. Reinforcement by a lacing with silk, celluloid
linen, silk-worm gut, kangaroo tendon or similar suture material
is likewise undesirable, as these substances may produce irritation,
or, as in the case of catgut, be absorbed. Certain metals, especially
silver, are particularly well borne when introduced in the form of
fine strands, and the use of a buried filigree of fine silver wire, as
suggested by Willard Bartlett(i) has proved of great value. While
a number of our patients have obtained a very satisfactory rein-
forcement of the abdominal wall by the use of the filigree, we have
noted the following disadvantages.

First. — Technical Difficulties. — The delicate transverse loops of
soft silver wire are easily displaced or distorted by the pressure of
the tissues or in sponging the wound, and instead of being able to
anchor the fiHgree by a single catgut suture placed at one end as has
been recommended, we have found it desirable to anchor each loop
individually to the adjacent tissue. As the fihgree may have from
forty, to two or three hundred transverse loops, to tack each one in
position even by a continuous suture of fine catgut requires a con-
siderable period of time. In the reconstruction of the anterior
abdominal wall where extensive imbrication is necessary, we have
rarely found it feasible to smoothly implant large filigrees, that is,
those 5 inches in length and 4 or 5 in breadth or larger, beneath
the aponeurosis of the external oblique, or beneath the attenuated
rectus muscle, and we have had to be content with partially affixing
the filigree in position over the aponeurosis of the external oblique
or the external sheath of the rectus. Even upon this large free
surface the slightest movement of the overlying flap in the closure
of the wound, or any increased tension of the skin tends to distort
and displace the loops of filigree so that we have found it desirable
to use a fine suture to fix each loop in position.

An .T-ray examination of a number of these patients shows that
a later displacement of some of the loops occurs, and that there is
a marked tendency as has been recorded by Ochsner and Bartlett

babcock: correction of the relaxed abdominal wall 601

for the filigree to become fragmented (see Fig. 3), through breakage
of the separate strands of silver wire. Although, as Bartlett has
written, the breaking of a number of the strands of the filigree does
not seem to greatly weaken the reinforced abdominal wall, it indi-
cates an undesirable lack of flexibility. A few of our patients have
complained of pain in the abdominal wall, which we have been

Fig. 3. — IllustratL^ ihc fragmentation of ;il li iil nicrli implanted in the
anterior abdominal wall. {Rcdrai^'ii Jrom skiiigram.)

tempted to attribute to the sharp ends of broken wire. We have
been prompted therefore to search for a more flexible and durable
nonabsorbable material for reinforcing the deeper layers of the
abdominal wall in operating for marked degrees of relaxation or large
hernias, and during the past two years have used very fine silver
chain as employed by jewelers. This sterUng silver chain may be

602 babcock: correction of the rel.^xed abdominal wall

compared to catgut, the size and strength of which is shown in the
following table.

TENSILE STRENGTH OF GOOD RAW AND STERHTZED CATGUT,
SLOW PULL.*

Double surgeon's knot, single strand.

Tensile strength Gauge

No. o average 5 lb. No. o 27-28

No. I average 8 lb. No. i 26

No. 2 average 10 lb . No. 2 24-25-26

No. 3 average 13-16 lb. No. 3 23-24

No. 4 average 14-18 lb. No. 4 22-23

No. s average 16-20 lb. No. 5 21

The tensile strength of the silver chain is much greater than that
of a virgin silver wire corresponding in size to that used in the links
of the chain. For example, the usually employed virgin silver wire
of 27 English gauge, broke at 2^-^ pounds strain, while one specimen
of sterling silver chain made of 27 gauge wire showed a tensile
strength of 13}^ pounds.

The amount and character of alloy and the size and shape of the
links markedly influences the strength of the chain. For example,
of three chains, one made of 26 gauge sterling wire broke at ^}^
pounds, one of 27 gauge at 11 pounds, and one of 27 gauge at 13 J^
pounds. Apparently within limits chains with small links are
stronger than those with larger Hnks. The tensile strength of the
chain compares very well with that of catgut used in suturing, and
the open links permit an anchorage from the ingrowth of fibro-
connective tissue that cannot be obtained where a simple wire is
employed. The chain is perfectly flexible and will not fragment or
break with the movements of the abdominal wall. In one of our
patients the usefulness of the chain in withstanding tremendous
intraabdominal tension was shown. In this obese woman with
a relaxed abdominal wall, an enormous incisural hernia and many
intraabdominal adhesions, the abdominal cavity was greatly reduced
in size and the abdominal wall reinforced by imbrication and sup-
ported by about 4 feet of silver chain introduced as shown in
Fig. 5. The patient slowly developed an enormous abdominal
distention from a kink of descending colon. Several days after the
operation in starting to cut the bandage about the abdomen, the
abdominal distention increased so greatly that it seemed that the
incision would burst asunder if the bandage were removed, a new
bandage was therefore applied and the ])ationl later removed to the

* S. Trenner.

babcock: correction of the relaxed abdominal wall 603

operating room, when on removing all support and opening the skin
incision, it was found that the silver chain was giving a perfect sup-
port to the deeper layers. On loosening the attached ends, the chain
was readily withdrawn and a simple introduction of a drainage tube
into the transverse colon was followed by an evacuation per anus and
recovery.

In this case I do not believe that the deeper layers would have held
without the silver chain reinforcement. Bartlett(2) has shown that

Fig. 4. — A method of reinforcing the anterior abdominal wall by transverse
strands of silver chain fastened in position by catgut or fine silver-wire sutures.
This method is considered inferior to a continuous-chain suture.

silver filigree may be successfully buried even in the infected wound.
This is not invariably true, for we have at the present time a patient
into whose abdominal wall a large silver fihgree was imbedded in the
presence of an eczema of the skin, and we have found it necessary
from time to time to withdraw bits of the silver wire from the sinuses

604 b.abcock: correction of the relaxed abdominal wall

that have formed. It is true, however, that silver wire often be-
comes imbedded despite the presence of infection, and the same may
likewise be said of silver chain. In a girl of about eighteen, who had
had upon shipboard a large drainage incision for purulent appendi-
citis, we attempted to reinforce the hernial closure at a second opera-
tion by several transverse strands of silver chain. Suppuration of

KiG. 5. — Illustrates the simplest and the usually preferred method of reinforc-
ing the anterior abdominal wall by a continuous right-angled suture of buried
silver chain. The chain is readily carried through the tissues by being attached
to a round needle. The ends of the chain are fastened to the aponeurosis by a
fine silver wire or chromic-catgut suture.

the subcutaneous fat, necessitating drainage, occurred, and through
the drainage incision one or two strands of silver chain were with-
drawn. The wound later closed and an .v-ray shows the presence
of a crumpled mass of chain that has been retained in the abdominal
wall with no sign of irritation.

b.\bcock: correction of the relaxed .\bdominal wall 605

An especial advantage of the silver chain is the fact that it is
adapted for any size of defect and that it may be as quickly intro-

FiG. 6. — Illustrating the support of the sutured deeper layers of the anterior
abdominal wall by the implantation of a coarse mesh of fine silver chain. The
smaller pictures show two methods of fastening the loose ends of the chain.

duced as a strand of catgut or silk. The terminal link of the chain
is tied to the eye of a suitable round-pointed needle by a loop of silk
or linen thread, and if the needle has a size equal to that of the

606 babcoce: correction of the rel.\xed .^dominal w.\ll

chain, it will be found that the chain slips through the tissues almost
as readily as does catgut. As it is threaded through the tissues and
not merely laid or tacked in place, it is not readily displaced, and
has a fixation and support which is especialh' desirable. At first
we employed separate strands of chain, each end being sewed or
tied in position by a suture of fine chromic catgut as shown in Fig. 4.

Fig. 7. — Method of reinforcing the anterior abdominal wall by a continuous
right-angled suture of line silver chain. The transverse strands are represented
as carried through the muscular substance under the aponeurosis. A previous
imbrication has been carried out.

This method we soon abandoned for a continuous lacing suture of
chain as shown in Fig. 5. A single piece of chain 5 feet or more
in length may be introduced. With the coarser chain the ends are
fixed in position by carrying a strand of fine chromic catgut through
the terminal links and suturing to the fascia. For the very fine chain
through which the catgut cannot readily be threaded, the ends are
ligatured to the fascia with fine chromic catgut or silver wire.

babcock: correction of the relaxed abdominal wall 607

Instead of using the chain as a continuous supporting buried suture,
the chain may be imbedded in the form of an open mesh as is shown
in Fig. 6.

The free ends of the silver mesh may be carried through the tissues
by means of a suitable needle and fastened by catgut or united by
using a hnk made of twisted silver wire, or by an open hnk especially

Fig. 8. — Illustrates a method of reinforcing the Mayo operation for umbilical
hernia by a continuous right-angled suture of fine silver chain.

supphed for the purpose. The mesh may be made by nearly any
jeweler or surgical instrument manufacturer. The cost of the silver
chain is from 30 to 50 cents per hnear foot, and as for the support
of a very large abdominal wall 4 or 5 feet may be required, the
average cost should not exceed two dollars for each patient. We
usually favor a continuous lacing suture with the chain as shown
in Fig. 5 and Fig. 7.

608 b.abcock: corrfxtion of the relaxed abdominal wall

Among other uses for this strong, flexible and nearly nonirritating
permanent suture material that suggest themselves, the following
are illustrated:

Fig. 8 shows a method of reinforcing the transverse imbrica-
tion used in the Mayo operation for umbilical hernia by the insertion
of a continuous silver chain.

Fig. 9.

Fig. 9 shows a method of threading the chain through the round
ligament and wall of the uterus to secure an unyielding uterine sup-
port. A similar method with the chain threaded through the
cervical or vaginal stump suggests itself as a method of possible
value for support in certain operations for procidentia. The peculiar
properties of chain may render it of some value in restricting or

babcock: correction of the relaxed abdominal wall 609

fixing the size of certain orifices or canals. Thus the occlusion of the
pylorus by one or more loops of silver chain suggests itself as does
the constriction of the vaginal canal. A corkscrew implantation of
a bit of silver chain may in some more rare cases be of value in the
treatment of inguinal hernias, the loops of chain passing through
Poupart's ligament and the layers of internal oblique, transversalis,

Fig. io. — A method of reinforcing the anterior abdominal wall by two vertical
and two transverse mattress sutures of silver chain. The ends of the sutures are
linked together by silver wire or tied together with chromic catgut.

and external oblique, serving to fix the caliber of the internal ring
of the canal and of the external ring, and permitting flexibihty,
without constriction of the spermatic cord. It must, of course, be
obvious that like silver filigree, silver chain is not to be considered
in the usual simple abdominal operation, but is to be reserved for
those cases where the tissues have not of themselves suflicient
strength, and where a very flexible and fairly strong permanently

610 babcock: correction of the relaxed abdominal wall

imbedded foreign substance will give the desired support. Fig. lo
shows a method of improvising a mesh by four mattress sutures of
silver chain.

Fig. 9 shows another t\-pe of lacing suture using a continuous
buried silver chain.

In about fortypatients operated upon forrelaxed abdomninalwall,
we have removed from 3-2 to 14 pounds of fat and skin in the

reconstruction of the anterior abdominal wall. In association
with this operation we have frequently drained or removed the
gall-bladder, the appendix, or have performed other abdominal or
pelvic operations. We have had one death apparently as a result
of heart failure due to the increase of the intraabdominal tension.
This patient was an obese middle-aged woman with a weak myo-
cardium, for whom we did an extensive resection of the anterior
abdominal wall and probablyproduced an excessive imbrication of the

babcock: correction of the relaxed abdominal wall 611

deeper layers. She died three or four days after the operation appar-
ently as a result of cardiac embarrassment, due to great intraabdom-
inal tension, the condition resembling that seen after reduction of
enormous hernias. A second patient, already mentioned, developed
secondary intestinal obstruction following the operation, apparently
due to the tension upon certain old abdominal adhesions which on
account of their extent and the patient's condition were not freely
separated. A third untoward eiJect that we believe to be due to
increase in the intraabdominal tension was a transient glycosuria
with a tendency to diabetic coma noted in two patients. Both of
these patients were very obese and had had extensive lipectomies
performed. Both patients were given large doses of alkalies, and the
glycosuria and somnolence gradually disappeared. We have con-
sidered this condition as possibly due to interference with the
function of the pancreas.

Type of Lipectomy Performed. — In our earlier cases we usually
removed an ellipse of fat and skin with its long diameter transverse.
This form of incision tended to increase the already large waist
measure and often left unsightly projecting folds of skin above the
iliac crests, so that it seemed desirable at times to also remove two
small vertical ellipses of skin near the ends of the transverse incision.
A much better abdominal contour may be obtained by removing a
vertical ellipse of skin and using a vertical line of closure. The shape
of the ellipse may be so altered as to best contour the waist and upper
pelvis. The skin is usually widely undercut to remove as large
an amount of the subcutaneous fat as possible. Despite the very
extensive separation of tissue layers we have not employed drainage
in any of our cases except where this was necessary on account of
drainage for biliary surgery. The aponeurotic and muscular layers
are closed with chromicized catgut, and the skin with interrupted
relaxation sutures of silk-worm gut, usually employed in association
with a fine continuous dermal suture.

2033 Walntjt Street.

REFERENCES.

1. Annals of Surgery, July, IQ03.

2. Surgery, Gynecology and Obstetrics, p. 247, vol. vi, 1908.

612 heineberg: uteroscopic findings

A. UTEROSCOPIC FINDINGS: A PRELIMINARY REPORT.
B. COLLECTION OF UTERINE SCRAPINGS.

ALFRED HEINEBERG, P. D., M. D.,

Associate in Gynecology in Jefferson Medical College; Obstetrician to the Jewish

Maternity Hospital, Assistant Gynecologist to St, Agnes

and Mount Sinai Hospitals,

Philadelphia, Pa.

(With two illustrations.)

Visual examination of the cavity of the uterus in vivo presents
certain advantages which should commend it to our consideration.
It is not proposed as a method to supplant those generally employed
by us to determine pathologic conditions within the uterus, but
rather as an adjunct to assist in the rapidity and precision with
which such conditions may be recognized.

The inspection of a lesion in its natural environs assists us in
determining its location, its extent, its relation to the surrounding
structures and the condition of the contiguous area. Few of these
features may be as easily and surely ascertained by digital explora-
tion of the uterine cavity or by histologic examination of uterine
scrapings.

Uteroscopy finds its greatest field of usefulness in discovering the
causes of pathologic uterine hemorrhage. It would seem to be a
distinct step forward to be able to determine by prompt and simple
means whether the causes of such hemorrhage are serious or insig-
nificant. Thus we may be properly guided in the application of
measures of treatment, avoiding the employment of drastic methods
when simple and safe ones would suffice. Through use of the
uteroscope which I devised and described(i) two years ago I am
able to present the following data concerning some uterine lesions
whose chief symptom is irregular hemorrhage. In a previous com-
munication I described the normal appearance of the inner walls of
the uterus as follows: The mucous lining of the body of the uterus
is dark red in color and of a velvety appearance. It bleeds easily,
when subjected to even slight trauma. After complete dilation
(to 46 French) the internal os contracts again quickly, and, on
gradually withdrawing the uteroscope. can be distinctly observed
as a narrow gateway between the cavities of the corpus uteri and
the cervix.

The color of the mucous membrane of the cervix varies from
yellowish to pinkish, according to the degree of congestion in the

heineberg: xtteroscopic findings

613

small bk )d-vessels, which latter can sometimes be distinguished.
The arbor vitae arrangement of the mucous membrane in cervices
which are not badly lacerated is readily observed.

The pathological conditions of the endometrium which I have
studied present the following features:

1. In chronic interstitial endometritis of the hemorrhagic t}'pe the
uterine mucosa appears thinner, paler and less velvety.

2. In chronic glandular endometritis especially that associated
with polypoid degeneration the mucosa is thicker, paler and dis-
tinctly shaggy in appearance. The shagginess is made up of small
villous and polypoid masses which appear more distinct if viewed
while the irrigating fluid is running into the uterus cavity.

3. Isolated mucous polyps have about the same color as the normal
mucosa and may present small dark areas of hemorrhage (though
this is rare). They engage in the opening of the uteroscope and may
be seen to move in the irrigating stream. Their point of attach-
ment is readily determined so that their complete removal with a
curet is assured without necessarily disturbing the rest of the
mucosa.

4. Carcinoma of the corpus uteri. I have had the opportunity
of examining only one case. It was one of the diflfused t5rpe and
had not undergone much degeneration. It presented itself as many
irregular, pale, yellowish and pink polj'poid masses which filled
the cavity of the uterus. The features which seemed to distinguish
it from diffuse polypoid endometritis were the greater friabiUty of
the mass and more profuse bleeding when pieces of it were broken
off with the end of the uteroscope.

5. Chorionepithehoma of which I have examined one case, is the
only condition in the wall of the uterus which is distinguished as
circumscribed, bright red tumor.

614

heineberg: uteroscopic findings

6. Incomplete abortion: Retained products of conception pro-
duce a very characteristic condition. They consist of irregular masses
of varying size closely adherent to the uterine wall, usually near the
fundus. The distinctive characteristic of the mass is its mottled
surface, on which yellowish areas are irregularly interwoven with
dark red or bluish-red areas, where the blood clot had adhered. No
other condition which I have observed within the uterus has pro-
duced such an appearance.

The collection of scrapings from the uterus by most of the methods
in vogue is a more or less uncertain procedure. If a non-flushing

spoon curet be used it may fail to remove from the uterine cavity
particles of mucous membrane or neoplasraic tissue which have been
detached from the wall of the uterus. If a flushing curet be em-
ployed it is difficult to prevent some or, at times, all of the detached
tissue from escaping into the bucket with the douche fluid. From
the standpoint of diagnosis it is important that no portion of the
scrapings should be lost, consequently only that method which in-
sures the collection of every particle may be accounted a complete
success.

cary: examination of semen 615

The employment of the speculum and sieve here illustrated insures
that success.

The distinctive features of the apparatus are: (i) A sieve, the
bottom of which forms a cup which is detachable, (2) a speculum
with an obtuse angle which directs the fluid (conveying the scrap-
ings) with certaint}- from the uterus to the sieve. \\Tien the scrap-
ings have' been collected in the sieve they may be easily washed free
from blood clot, and after detaching the cup, they may be readily
examined and transferred to another container.

REFERENCE.

I. Surgery, Gynecology and Obstetrics, April, 19 14.
1642 Pine Street.

EXAMINATION OF SEMEN WITH SPECIAL REFERENCE
TO ITS GYNECOLOGICAL ASPECTS.*

WILLIAM H. C.\RY, IVL D.,

Brooklyn, N. Y.

(With ten illustrations.)

The frequency with which male steriUty results from the lesser
degrees of seminal defect is not realized; nor are the pathological
conditions of the semen upon which steriUty depends well under-
stood. Proof of this is found in a review of the literature, which is
very scant on this subject, especially in this country where the
examination and study of semen has been much neglected. This
may have been due, in part, to the unpleasant nature of the work,
but more particularly to the difficulty encountered in securing
properly collected specimens for examination. Wliile always eager
to claim his share of glor\' in the production of his offspring, a man
is most reluctant to share am' suspicion of responsibility for failure.
In this feeUng he has always been sustained by the attitude of the
physician. Undoubtedly the mind of the medical profession has
been prejudiced; and the study of this subject has been seriously
handicapped by the almost universal assumption on the part of the
laity that in the event of a childless marriage the wife is wholly
responsible.

It is not difficult to understand why such an erroneous impression
has prevailed so long. In the male, ability to copulate and the

* Read by invdlation before the New York Academy of IMedicine, April 25,
1916.

616 cary: examination of semen

normal ejaculation of semen are regarded as suificient evidence of
his power to procreate; while in the female, the process of ovulation
is an obscure one and therefore more readily suspected to be at fault.

It is significant that the more study and observation this subject
receives, the higher is placed the percentage of male sterility. Two
decades ago Matthews Duncan said, in a lecture on sterility, "En-
larged experience and inquiry make me more and more convinced
of the greatness of the part played by the male." In countries
where venereal diseases are more prevalent than they are here,
observers have placed the proportion of cases in which the male
is at fault at a surprisingly high figure. Thus Vedeler, of Christiania,
reports that 70 per cent, of the childless marriages he investigated
were due to the husband; while Kehrer reports a series of cases in
which he found the male responsible in 40 per cent. These figures
are too high for general acceptance. Most American writers place
the male responsibility at from 15 per cent, to 25 per cent. I believe
this to be a too conservative estimate. In cases of absolute sterility,
the number in which the husband is at fault must be high at least
one in three, for the sexual hygiene of the woman before marriage is
usually better than that of her mate, and there is no real evidence to
prove that the physiological processes involved in the production
and delivery of the healthy ovum are more complicated or less
often successful than is the secretion and emission of normal semen.

Butat the present time it still seems advisable to seek first thecause
of a sterile marriage in the female. It must be stated, however, that
to conduct long and exhaustive gynecological treatment and ultimately
to offer a hopeless prognosis without having investigated the repro-
ductive powers of the husband is neither fair nor scientific. The oppor-
tunity to secure the semen for examination presents itself oftenest
to the gynecologist and he should be equipped to make this ex-
amination as a routine part of the investigation of sterility. From
such a viewpoint this study is contributed.

J. Marion Sims reasoned far in advance of his colleagues when in
1869 he wrote: "I insist that we have no right to perform any opera-
tion or to institute any treatment whatsoever solely with a view to
the cure of sterility until we have settled the three propositions, above
laid down, touching the presence and vitahty of the spermatozoa."
The propositions referred to were: (a) We must be sure that we have
semen with spermatozoa; {b) we must ascertain if the spermatozoa
enter the utcrocervical canal; (c) we must determine whetlier the
secretions of this canal are favorable or not to the vitality of the
spermatozoa.

CARY: EX.4MINATION OF SEMEN

617

To-day, with superior opportunities for study at hand, we have
no right to consider the study of the semen completed when we have
demonstrated singly the presence or absence of active cellular bodies.
Determination of the activity of the spermatozoa is not sufficient
to assure us of their power to impregnate the ovum, neither is the
absence of motion an infallible sign of their impotency. In general,
the fertility of the semen depends upon the presence of:

1. Mature living spermatozoa (normal cells).

2. A normal secretion (liquor seminis) to convey the spermatozoa
to the vagina and to maintain the vitality of the cells until such
time as they ma}' meet the ovum.

Finger and Saenger have divided male sterility into two groups:
impotentia coecundi and impotentia generandi. Our subject per-
tains only to those conditions belonging to the second group, and
will be confined to a consideration of the pathological conditions
found in the semen, their etiology, and their treatment. Aspermia
and conditions resulting from genital deformities will not be touched
upon.

Method of Obtaining and Examining the Specimen. — In order to
determine accurately the viability of the spermatozoa and the im-
pregnating power of the semen great care must be exercised in pre-
serving the specimen en route to the microscope. The most satis-
factory arrangement for an examination in made by conveying the
necessary implements to the home of the patient and making the
observations immediately after conclusion of intercourse. The
instructions here given apply more particularly to office observations.

618

cary: examination of semen

The patient provides himself with the following articles: condoms,
a wide-mouthed bottle like a vaseline bottle, and a jar which may be
made water tight (Fig. i). Upon the morning when the examina-
tion is to be made the doctor should be notified so that he may be
prepared to work promptly. The specimen should be secured after
three or four days of sexual rest. After intercourse the condom con-
taining the specimen is placed in the wide-mouthed bottle and this
is carefully corked. The bottle containing the condom should then

Lipoid bodies

Amyloid bodies

Oval concrements

Spermatic crystals
Fig. 2. — Elements which may be found in microscopical examination of the
semen.

be placed in the jar which should contain water a few degrees warmer
than body temperature. The jar is then immediately taken to the
office of the physician. These precautions are necessary to maintain
the warmth of the specimen. (If this method is refused by the hus-
band, the semen may be secured from the genital tract of the wife
who places a tampon after intercourse and reports at once to the
doctor. Under the latter condition a normal finding only is of value as
so manyelements mayenter to affect the conditionof the specimen.)*
* Dickinson has developed the ingenious scheme of having the condom placed
in the vagina and held there by the insertion of a tampon. The wife then comes
to the ofl'ice and the condom is removed and the examination proceeds. While
this method assures the warmth of the specimen, the technic is not as readily
carried out and is objectionable to some.

cary: examination of semen

619

Upon delivery at the office, the bottle containing the specimen is re-
moved from the jar and placed in a warm — but not — a hot bath.
The examination should begin at once. The base of the condom is
opened with scissors and the specimen is allowed to escape into a
dry bottle or warm test-tube; the total amount of the specimen, the
reaction, and the amount of sediment should all be noted. Also
the temperature should be observed as well as the time that has

Head ^Nucleus') profile

He'iJ iNtirieus) Rat

Hidfie pKc

sEnii Fiese

Fig. 3. — B. Human spermatozoa. (Rcizius.)

elapsed since coitus. After remarking the gross appearance of the
specimen, a drop of the semen is spread upon a warm shde, in very
much the same way that is used for urine sediment, and examined with
a high power lens. In this manner the best general and detailed
study of the efficiency of the semen may be made (Fig. 2). I say
this advisedly after trying the ordinary staining methods and the
dark field apparatus.

If the semen is normal, and the instructions for its collection have
been carefully carried out, the microscope will demonstrate a field

620

cary: examination of semen

filled with active spermatozoa of fairly uniform size, shape, and
activity (Figs. 3 and 4). If, however, the sediment is greatly re-
duced in amount and the microscope shows a diminution in the num-
ber of spermatozoa, or sluggishness and lack of motion, early crystal
formation, or presence of pus the specimen is probably defective.

(Kucleie Adt)

TaiJ [Aciai-filaneni

Phnsphorijei Fats
Protien

Fig. 3 A. — -Human spermatozoa on the flat and in profile. {Bramman, from
Schafcr.)

Under such conditions a more detailed e.xamination must proceed.
The sediment is covered with the thhmest cover-glass and examined
with the oil immersion lens.

Semen devoid of its cellular elements is thin and usually coagu-
lates rapidly, while the sediment, which normally constitutes two-
thirds of the discharge, is very slight. The early formation of crys-
tals is reported to denote a decrease in the number or the entire
absence of spermatozoa. This commonly accepted sign, I have been

cary: examination of semen

621

unable to confirm. These spermatic crystals, which are sometimes
called after Boettcher who, with Van Deen, was the first to recognize
them, are rhombic transparent bodies easily discerned under the
microscope (Fig. 2). Fiirbringer has demonstrated that such crys-
tals occur exclusively in the prostatic secretion and indicate func-
tional activity of that gland.

Ultzmann* describes the following varieties of semen in which
spermatozoa are not found or are greatly reduced in number: (a)

Fig. 4. — Normal forms and modifications of apparent importance.

Watery transparent semen, which is normal in amount but contains
slight sediment and in which crystal formation begins early; (b) col-
loid semen, that is semen containing epithehum which has under-
gone colloid degeneration; (c) purulent semen.

* If it should be desirable to stain a specimen the following method may be
used. I quote from the book of Greene-Brooks: "The specimen may be spread
upon a slide and fixed by heat, or by means of methyl alcohol, formalin 10 per
cent., or alcohol. Slides so prepared may be stained by practically any of the
chromatic dyes of which methylene blue, fuchsin, or gentian violet are best.
When a sightly preparation is desired the specimen may be stained by Boehmer's
hematoxylin and counterstained by eosin." Full directions are also found in
an article by Martin, Carnett, Levi and Pennington, Univ. of Penna. Bull.,
March, 1902, p. 2.

622 cary: examination of semen

After some practice variations from the normal will be readily
noticed and their importance properly appreciated. A normal find-
ing is conclusive, but if a pathological condition is present findings
should be confirmed by subsequent examinations.

Etiology. — The most common cause of sterility in the male was
formerly attributed to the absence of spermatozoa in the semen.
Kehrer found this the cause in 21.3 per cent, of his cases. While
many cases of azoospermia have been reported for which no cause
was assigned, it is doubtful whether idiopathic azoospermia occurs.
Hirtz reported two cases which he considered idiopathic but which
have not been so accepted by subsequent investigators. The com-
monest cause of azoospermia is gonorrhea. In a very large propor-
tion of cases this condition results from a unilateral or, more often,
a bilateral epididymitis. One of the most valuable contributions to
our knowledge of the part played by gonorrhea in sterility was made
by Benzler, a German army surgeon. He was able to follow the
history of 473 of his patients who afterward married. Of those with
simple gonorrhea, 10 per cent, were childless; while 23.4 per cent,
of those with unilateral epididymitis and 41.7 per cent, of those with
both epididymes involved were without children. These findings
have been generally corroborated. A few authorities, however,
believe that gonorrhea is not so often a cause of azoospermia as these
figures would indicate.

Another cause sometimes responsible for the disappearance of
spermatozoa from the semen is exhaustion due to abnormal demands
upon the sexual organs. In these cases the absence of the sperm
cells is only temporary and the condition is classified as physiological
azoospermia. Gross states that nervous exhaustion alters the char-
acter of the semen by causing perverted enervation of the sexual
organs. It would seem that neurasthenia and the other neuroses
which are prominent features of these cases and which are sometimes
considered causative factors, are more often symptomatic, being, in
common with azoospermia, a result of intemperate sexual habits.
In a more recent contribution to the literature, Hoppe affirms that
derangements of the nervous system cause sterility in the male only
in those cases classed as impotentia coeundi with which our subject
is not to be confused.

In modern times the x-ray has figured prominently as a cause of
azoospermia. While it may yet be too early to state positively,
those qualified to express an opinion believe that the .v-ray is not
likely to produce permanent sterility.

There is no question that the importance of syphilis and lubcrcu-

cary: examination of semen 623

losis as causes of sterility was exaggerated by the early writers. In
the work of Bangs-Hardway the statement is made that except as it
causes cachexia or destroys the testes, it is doubtful whether syphilis
influences the condition of the semen. Heidingsfeld, who reviewed
the literature of this subject, and especially the work of Lewin and
Hanc, beside making personal observations, is of the same opinion.
The relation. of tuberculosis to anomalies of the semen is a subject
in regard to which widely different views are entertained. Not
unlike syphilis, when tubercular processes attack the genitals oi
when the terminal cachexia is present, azoospermia results. It has
been conclusively proved, however, by thorough investigations
quoted at length by Gross that the semen of consumptives contains
spermatozoa quite as frequently as that of normal persons. Great
weakness occurring in the course of any chronic disease may result
in impotency, and Hagner states, with reason, that the virility of
the spermatozoa is often in direct proportion to the general physical
condition of the patient.

Simonds examined the semen of several alcoholics at autopsy,
and obtained results which led him to believe that in chronic alcohol-
ics the function of the testes was at times suspended. In these
cases the condition was apparently dependent upon a fatty degenera-
tion of the testes.

Cases have been reported which would seem to indicate that the
immoderate use of tobacco occasionally causes sterility. Such
views were held by Peyer, Hanc, and Curling. It is reasonable
to suppose that tobacco, like morphine and other sedatives, might,
after a time, cause impotency by deranging the nervous mechanism
of the sexual organs, but it seems highly improbable that it exercises
any deleterious effect upon the production of spermatozoa.

There is little in the literature touching upon obesity as an
etiological factor in male sterility. Kisch, who has done considerable
work in this line, made frequent examinations of the semen of
corpulent persons and reports that he found but few spermatozoa
in many of the specimens, and that these were often not motile.
He states that in 9 per cent, of his overcorpulent patients spermato-
zoa were entirely absent from the semen. Just what the pathological
condition was that explained the azoospermia is not given.

Immature Cells. — In addition to azoospermia and other gross
conditions there are cases in which the fertility of the semen is greatly
diminished by immaturity of its fecundating elements (Fig. 7).
This condition is indicated by morphological changes in the sper-
matozoa due to an arrest in their process of evolution. These irreg-

624

cary: examination of semen

ular types of cells are difficult to classify. The condition as related
to azoospermia might, however, be considered an intermediate stage.
Accompanying the change in form, it is usual to find the sperm
cells reduced in number (oligospermia), and macroscopicaUy the
semen assumes more or less the character of that described as azoo-
spermia. If the reduction in the number of cells is marked it is, of
course, quickly apparent, if not, an accurate estimation of the
productiveness of the semen depends upon the recognition of the
imperfect spermatozoon. To facilitate the study of these immature
cells, it is well to take a moment to review the cycle of phenomena
relating to the evolution of the spermatozoon.

Fig. s. — Cross-section of seminiferous tubules of a mouse. X 360. Observe
that the nuclei of the spermatids (below on the left) at first round, become o\al
below and are transformed (below on the right) into the heads of the seminal
filaments. {Stohr.)

The spermatozoa are formed by a process of division from cells
which lie ne.xt to the basement membrane of the seminiferous
tubules (Figs. 5 and 6). The ancestral (spermatogenic) cells which
are naked epithelial cells come, by a process of indirect division, to
be large cells which form a layer nearer the lumen of the tubule.
These are the mother cells (spermatocytes), each of which, later
on in the process, divides twice, thereby forming four cells known
as the daughter cells. These daughter cells are really the spermatids
or semen cells and are now in a zone still nearer the lumen of the
tubule. The nuclei of these cells, which are primarily round, then
become oval in shape, while the protoplasm of the cell forms the cau-

cary: examination of semen

625

dal filament. The cells are then mature and as spermatozoa make
up the secretion of the testicle. The semen as ejaculated is composed
of the spermatozoa suspended in the secretion of the prostate and
accessory glands (Hquor seminis). The activity of the sperm cells
is not manifested until this union has taken place. The head is
the essential fecundating part of the cell. The tail, by the motion of
its cilii, executes sinuous movements which result in the well-known

Fig. 6. — Seven stages of the conversion of a spermatic cell into a spermatozoan.
<i to /. — Zs, Cell contents; A', nucleus; Pc, proximal central body; Dc, distal
central body; Sp, tail piece; G, head piece; Ekii, neck; Est, endpiece.

activity of the spermatozoa. Normally this is suiBcient to liberate
the cell from its medium and carry it to that part of the female
reproductive tract where it will meet the ovum.

As stated above many of these irregularly formed spermatozoa
are cells which have been cast off in the seminal discharge before
they are fully developed. Evidences of immaturity are to be found

626

cary: ex.\mination of semen

in abnormalities of both iiead and tail. The heads of these immature
cells instead of being oval or pyriform, as in the normal specimen
(Fig. 7), are round, corresponding in appearance to the nuclei
of the spermatogenic cells while in the mother or daughter cell stage
of transition. Not infrequently the heads of these cells are much
increased in size being usually as large as red corpuscles and occa-
sionally the size of the lymphocyte. The name megacephalic isdesig-

FiG. 7. — Immature types. .1, Intermediate stage; B, large round head with-
out nucleus; C, same type with blunt tail; D, leucocyte for comparison of size.
Found in defective specimens due sometimes to too great sexual activity.

native of this type of spermatozoon. I have seen cells in which the
protoplasm still surrounded the nucleus in ordinary cellular type
with an active tail piece of some length. It is unusual, however,
to find them deformed. Very often they are short and blunt, or,
as occasionally occurs, the caudal extremity may be entirely lacking.
These cells are easily recognized if the appearance of normal spcrma-

cary: examination of semen 627

tozoa is kept in mind. The majority of them are motionless and are
not viable. Others are active but only for a short time and are
probably incapable of impregnating an ovum. The production
of these immature cells is an efifort on the part of the testes to supply
an abnormal demand, and when present, they indicate that the
fertility of the semen is much impaired. If the excessive demand
continues, azoospermia ultimately develops.

Deformities. — The fecundating power of the semen may be greatly
lessened by the presence of many malformed spermatozoa (Fig. 8).
Such cases are not rare. These abnormal cells cannot be properly
placed under the immature class for they present none of the features
peculiar to it. Their occurrence is due either to a functional derange-
ment of the testes or to a degenerative process dependent upon some
abnormality of the glandular secretion. In these cases, as in the
preceding group, oligospermia is usually very pronounced and but
few of the sperm cells are active. Ordinarily no one variety of de-
formity is peculiar to a given specimen; on the contrary, many
different forms of faultily developed spermatozoa will be noticed.
For the purpose of classification the deformities of the spermatozoa
are best described under two general headings: (a) cephalic deformi-
ties; and {b) caudal deformities.

Cephalic Deformities. — -A very common abnormality is the reduc-
tion in the size of the head. The term microcephalic has been
employed to describe these spermatozoa. Such cells are surprisingly
numerous in some specimens. Every degree of diminutiveness may
be noted. In some instances the head is barely perceptible, appear-
ing as simply a clubbed end of the tail. In these same specimens
it is usual to find many caudal extremities with the head entirely
absent or not distinguishable under the ordinary lens. Fig. 8 is
a drawing taken from a specimen of this kind. At present it seems
impossible to determine whether such deformed cells represent faulty
development or are due to a degenerative process occurring sub-
sequent to their formation. The fact that in a majority of the
cells the tail is apparently fully developed and that in the normal
process of evolution the tail is the last part of the cell to be exhibited
tends to favor the latter theory. Other deformities of the head
characterized by a ragged uneven outhne of this extremity are not
infrequent. The head of these inert cells may resemble a disinte-
grating corpuscle, while crescentic and other irregular shapes are
not rare.

Caudal Deformities. — In the normal specimen, the tails of the sper-
matozoa are nearly uniform in size and are very active. Slight

628

cary: examination of semen

variations in length occur but have Httle significance if the rest of
the cell is normal and active. In defective specimens abnormalities
are frequently present in the way the tail joins the head.

Instead of forming one extremity of the cell the head may be at the
side of the caudal portion. In other spermatozoa there is a sharp
angle in the tail near the cephalic end and sometimes the head and
tail are disunited although each portion may in itself appear normal.

Fig. 8. — Headless and tailless forms found in great numbers in some defective
specimens. Probably degenerative forms.

Sometimes the tail is rudimentary or entirely absent. In one speci-
men which I examined the last variety was very numerous (Fig. 8).
It seems scarcely necessary to state that these cells with the deformed
tails are inactive and unfertile.

Immature and deformed spermatozoa often occur in the same
specimen and the extent to which the semen is impaired depends
upon: (a) The degree of oligospermia; (b) the percentage of imperfect
spermatozoa; (c) the percentage of cells that are motile and tlieir
degree of activity — whether sluggish or lively; (d) the length of

cary: examination of semen

629

time activity persists under favorable conditions. Upon this basis
a^specimen may be said to be 25 per cent., 50 per cent, or 100 per
cent. eiScient; or it may be classified as sterile, poor, fair, or
vigorous.

I have noticed the double-headed and multiple-tailed cells (Fig.
9) first described by Maddox and do not believe them to be rare.
What their significance may be is not understood but their activity

Fig. 9. — Double-tailed and double-headed forms. Their significance is unknown.

is as pronounced and as continued as in the normal type and I am
inclined to believe them potent.

Viability. — Inasmuch as it is not determined definitely at what
time the ovum is freed from the ovary, and in view of the physiology
of ovulation it is obvious that the successful completion of the process
of fecundation requires that the spermatozoa shall not only have the
power to migrate to the interior of the uterus or tube, but that their
vitality must be sustained until the ovum is presented. To this
6

630 cary: examination of semen

end Nature produces thousands of fecundating cells that one may
survive to perform its complete function.

While it is known that the testes furnish the fecundating elements
of the semen, it is hkewise important that we should recognize the
complementary action of the seminal iiuid. In addition to furnish-
ing a vehicle for the spermatozoa, it contains properties that are
essential to their \'itality. As early as 1871 Kraus showed that in
the absence of the prostatic fluid the spermatozoa would not live in
the uterine mucous membrane. Later on Sims made the same
observation.

Under normal conditions the vitality of the spermatozoa is re-
markable. Gross, in discussing the microscopical examination of
the semen, says that their motion should continue or be capable of
being reestablished for twelve hours. To state an arbitrary time
is impossible, but we know that if proper conditions are afforded their
motion continues much longer than this. Various references as to
the duration of their motion are found in the literature (Biegel). It
may be stated, first, that in their proper medium and at the body
temperature the viability of the sperm cells may e.^tend over a period
of a few days; second, that their prolonged \atality is probably depend-
ent upon the normal lime salts of the prostatic fluid, third, that the
sustaining power of the seminal fluid is increased by its union with
the normal secretion of the female genital tract.

The spermatozoa are, however, e.xtremely sensitive. I have found
that they perish promptly in tap water and in faint lactic acid medi-
ums or under other minor changes in their environment. In the
same study it was found that the sperm cells were adversely influ-
enced by increased acidity of the vaginal secretions or by alterations
in the cervical secretions. But normally these secretions are bacteri-
cidal and act as a chemical stimulant attracting sperm cell to
cervix.

I have been much interested in an experiment made recently in
which two specimens were obtained simultaneously. One was taken
directly from the male, the other from the vagina where it was mixed
with the secretions incident to normal intercourse. This revealed
that while the specimen taken directly appeared poor it showed an
exaggerated activity when mixed with the vaginal secretions. Such
an experience suggests that to make our study thorough we must not
neglect to determine the degree of physiological affinity existing
between the male and female secretions.

One of the less common forms of seminal defect is that resulting
from too great density of the semen. The spermatozoa being com-

cary: examination of semen

631

posed of suspended bodies, their activity is naturally inhibited by any
abnormal increase in the specific gravity of the seminal fluid. Such
a specimen when placed under the microscope shows normal cells
but their motion is sluggish and of short duration or entirely sus-
pended. If, to such a specimen, a few drops of normal saline solu-
tion be added the cells will at once become active. If they fail to do
so they are probably no longer viable. Similar conditions may be
found where an altered state of the prostatic secretion causes an in-
creased coagulability of the semen. Here, as in the former condition,

Normal type

_ Character-
^ istic group-
ing

Round heads, short, blunt tails. Immature forms

Head separate from tail

Fig. io. — Defective specimen sketclied two hours after emission; well pre-
served. Thin and little sediment. Total number of spermatozoa reduced; one
in three active. Deformed, immature, and degenerate forms.

the semen, soon after deposit in the vagina, becomes a gelatinous
mass from which the spermatozoa are unable to escape. Leigois, in
one of his cases which is often quoted, believing this condition to
explain the sterility of a patient ordered that coitus should be
followed by an injection of saline solution into the vagina, and
pregnancy actually resulted.

Of still rarer occurrence are those cases where the fertilizing ele-
ments of the semen are destroyed by the presence of pus and blood
in the seminal fluid. These foreign substances are found in the
semen in inflammations of the epididymes, the seminal vesicles, the

632 cary: examination of semen

vas, and the prostate. The available data justify the assertion that
pus is destructive to the evolution and life of the sperm cells, and
probably explains in part the sterility of women who suffer from
endocervicitis and endometritis. Sims states that catarrhal condi-
tions of the cervix cause sterility by increasing the density of the
semen rather than by any chemical action. A tenacious mucous
plug is often found in the cervical canal of sterile women, mechanic-
ally obstructing the entrance of the semen.

There is some difference of opinion in regard to the injurious effect
blood exerts upon the seminal elements. My observations confirm
those of Robin who demonstrated that spermatozoa would live four
or five hours in blood, while Dieu showed that when blood had mixed
for some time with the contents of the seminal vesicles, the sperm
cells were reduced in number or entirely absent. The findings of
these investigators represent the opinion now generally accepted,
which is that while blood in the semen exercises a very harmful effect
upon the vitality and fecundating powers of the spermatozoa the
semen must, however, have contained the blood for some time before
such changes are produced. It is evident, therefore, that hemor-
rhage within the seminal vesicles would be the only way in which
blood could affect the virility of the semen before emission. In in-
stances where blood appears as one of the elements of inflammation
destruction of the spermatozoa occurs because of toxicity.

Treatment. — -The treatment of male sterility has been less studied
and has received less attention in the literature than any otlier part
of the subject. This may be explained by the fact that the major
part of the investigation of these cases has been carried on in foreign
countries where the treatment of disease does not receive as much
attention as the other branches of medical science.

Many of these cases can be helped. Others are hopelessly in-
curable. The percentage of the favorable cases is large enough,
however, to warrant careful study of each case. Unless dependent
upon obviously incurable conditions, sterility in the male justifies
the same effort in its correction as when it occurs in the female. If
success is to be attained, a thorough knowledge of the etiology and
pathology of the individual case is imperative.

A comparison of the statistics of other countries with our own
demonstrates the important role played by venereal disease as an
etiological factor in steriHty. This at once introduces the sub-
ject of prophylaxis, which is much too broad a subject to be taken up
in this i)aper. Suffice it to say, that if it is made possible to educate
the mature members of society in this matter as they are being

cary: examination of semen 633

instructed with regard to tuberculosis, venereal disease would fast
decrease and sterile marriages would become a much less common
occurrence. Another means of accompHshing much along similar
lines would be a disposition on the part of the general practitioner
to refer these cases to those qualified by special study to treat them.
Prostatitis, epididymitis, and inflammation of the vesicles often
result from unskilled treatment or urethritis and are responsible for
sterility in no small proportion of cases.

If, after careful study of the pelvic condition of the wife, it be
suspected that the cause of the steriUty is to be found in the husband,
a detailed history must be secured, and much further study of the
case is often required before the tentative diagnosis may be con-
firmed or denied. If by such study it is found that the patient is
sterile, classification of the case either under impotentia coeundi
or impotentia generandi will not be difRcult. The treatment of
those conditions of the second group which have been discussed
under the foregoing headings will alone be considered here.

A class of cases amenable to treatment is that in which sterihty
has resulted from too frequent intercourse Such hygienic errors
are at times made by young married people and occasionally they
occur later in life. Similiar results may follow excessive sexual
indulgence by those who erroneously think that they may thereby
increase the likelihood of pregnancy. Very much like these are the
cases in which the fertility of the semen is impaired by involuntary
emissions and faulty habits. In the conditions cited, the spermato-
zoa may either be absent or much decreased in number. In the
latter event, variously deformed and immature spermatozoa will
be present which are fairly characteristic of this class of cases. Mo-
tion of the spermatozoa may be suspended or an occasional cell may
show activity.

The treatment of these cases consists chiefly in regulating the
sexual life, correcting unwholesome habits, or adopting measures
to check involuntary seminal loss. A frank, friendly explanation
by the family physician will usually be sufiicient. When such ex-
cesses are stopped the testicles may be relied upon to resume their
normal function unless atrophy has occurred.

Sterihty due to defective semen m.ay exist in men in whom there
is no apparent cause other than a much debiUtated condition incident
to an overactive business career. Such men are aware that they
are exhausting their energy. Evidences of it are obvious in various
neuroses and digestive disturbances. It is not diflicult to believe
that the reproductive system shares in the general depression, and

634 CAS.Y: EXAMINATION OF SEMEN

that similar methods must be adopted in its correction as in the
treatment of nervous and digestive disorders. Accordingly a shorter
business day is recommended, or a vacation is ordered for the more
serious cases. Systematic exercise is prescribed — golf, sailing,
swimming, etc., on certain days for a Used number of hours. In
winter fast walking and well-regulated gymnasium work are excellent,
while the cold shower and brisk rub which should follow are not the
least helpful part of the prescription.

The sexual habits of these patients must be investigated. Drugs
play a very small part in the treatment of these conditions. Some-
times tonic treatment is required, while sedatives may be indicated
in others. In the treatment of impotency and some forms of sterility,
the choice between stimulation and sedative treatment is an im-
portant and difhcult one. If the reproductive power of these men
is to be reestabhshed, details as to their manner of hving must be
diligently studied and such changes must be made as are conducive
to the betterment of their general health. In excessive smokers,
stopping the use of tobacco or restricting its amount may be followed
by happy results. In others, the prohibition of alcohol or the inter-
dicting of drugs may be necessary to secure good results.

Some cases of sterility occurring in the overcorpulent may be
cured by treatment of the obesity. If it be true that in some cases
obesity results from a disturbance of an internal secretion of the
testicles and is in that event only a symptom of tissue change in the
testes, as is azoospermia, treatment directed to the obesity will be
without effect.

Azoospermia resulting from chronic inflammations or exudates
due to a remote gonorrhea is very unsatisfactory to treat. A few
of these cases will improve and may be cured if placed in the hands
of the genitourinary specialist. A cure has been reported as long
as two years after a double epididymitis. If the defective state of
the semen be dependent upon the presence of pus or other inflamma-
tory elements local treatment directed to the inflammation of the
prostate or seminal vesicles may be curative. Azoospermia, when
present in patients with a negative venereal history should excite
a suspicion of some chronic constitutional disorder. It must not
be forgotten that absence of spermatozoa may occur in such rare
conditions as cryptorchidism, congenital absence of the testes,
congenital deficiencies of the excretory passages, and malignant
disease of the genitals. When dependent upon such conditions,
except in rare instances, azoospermia is absolute and permanent.
Tubercular disease of the testes and syphilitic orchitis render the

cary: examination of semen 635

prognosis very unfavorable. If the sj-philitic condition be diagnosed
early, mercury and the iodides may reestablish the spermatogenic
power of the testes. Delayed development of the testes does not
necessarily produce permanent sterihty. Full development with
the establishment of normal functions may occur under proper
sexual influences.

Summary. — In the study of sterile marriages, to conduct exhaust-
ive gynecological treatment and ultimately to offer a hopeless
prognosis without investigating the reproductive powers of the hus-
band is neither fair nor scientific.

Semen examination, by reason of its intimate character and the
vital relation which it bears to the general subject of sterihty, is best
performed by the gynecologist.

Selection of the method of collection and transportation of the
specimen to the office of the examiner must be made to suit the indi-
vidual conditions, with special regard to maintaining the warmth
of the specimen and appointment for immediate examination.

Examination is best made with the high power lens. In addition
to noting the general physical properties, the determination of
efficiency depends on the degree of oligospermia; the percentage of
imperfect spermatozoa — whether immature or deformed; the per-
centage of the cells that are motile — whether sluggish or lively; and
finally, the length of time activity persists.

Recent experiments have shown that a specimen obtained directly
from the male, which appears to be poor, may reveal an exaggerated
activity when obtained from the vagina where it has been mixed
with the secretions incident to normal coitus. Such experience
suggests that before an unfavorable prognosis can be made com-
plete study must include an inquiry into the physiological affinity of
the male and female secretions.

Observations show a direct relation between the vigor of the indi-
vidual and the potency of the semen.

Treatment is usually a genitourinary problem. A large propor-
tion of cases is improved by measures which better the general
health and sexual hygiene. Twenty-five per cent, efficiency war-
rants artificial impregnation; fifty per cent, efficiency justifies cor-
rection of definite pathology in the female.

15 SCHERMERHORN STREET.

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1884, p. 136.

636 GARY: EXAMINATION OF SEMEN

Duncan, James Matthew. Clinical Lectures on Sterility. Lan-
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Kehrer, F. A. Zur Sterilitatslehre. Beitr. ziir klin. u. exper.
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Sims, J. M. On the Microscope as an Aid in the Diagnosis and
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Sims, J. M. Sterility and the Value of the Microscope in Its
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Van Deen. Beitrag zur Entwicklungs-Geschichte des Menschen
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Gross. A Practical Treatise on Impotency, Sterihty, and Allied
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Heidingsfeld, M. L. Lancet-Clinic, 1905, 58.

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Hanc, A. Mannliche SteriUtat in Folge von Sj'phiUs. Wiener
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Hagner and FuUer. SteriUty in the Male; Its Causes and Surgical
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Simmonds, M. Die Ursachen der Azoospermie. Deutsches Arch,
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Peyer, A. Die neurosender Prostata. Berl. Klinik, i%gi.,'Reiti^.
Der unvoUstandige Beischlaf und seine Folgen beim mannUchen
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CurUng, T. B. Observations on SteriUty in IMan, with Cases.
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Kisch, E. H. Die SteriUtat des Weibes; 2d Edition, 1895. Bei-
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1880, vol. xxi, 214. SteriUtat der Fettlcibigen. Wien. Med. Presse,
1 891, vol. xx.xii, 821.

Maddox, R. L. Alquras observaciones sobre varias formas del
espermatozoo humane. Gac. rned. de Cadiz, 1894, xi, 257.

Kraus. Medical Times and Gaz., 1871, vol. i, 170.

Beigel. Uber die Einflusse der Lagerverandungen der Gebar-
mutter auf die SieriUtiits Krankheiten des Weiblichen Geschlechts,
1874, xvi, 606. Wien. med. Wchnsch., 1873, x.xUi, 265.

Leigois. Influence des maladies du testicule et de I'epidime sur
la composition du sperme. Ann. de Dermal, el Syph., 1869, 410.

cary: examination of semen 637

Robin, C. Le Sperme. Did. Encyclo. des Sciences, 1884, 3 S., xi.

Dieu. Recherches sur le sperme des vieillards. Jr. de Vanat. et
physioL, 1867, ix, 449.

Fiirbringer, P. Zur Kenntniss der Krystallbildungen in Genital-
system des Mannes. Deutsche med. Wochen., 1896, xxii, 603.

Gary, W. H. Sterility; Lesser Semen Defects and Minor Lesions
of the Female Generative Tract as Causative Factors. Internal.
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Morris, Robert I. Ovarian Transplantation. Med. Rec, May 5,
1906.

Tait Lawson. The Pathology and Treatment of Diseases of the
Ovaries. 4 Ed., 1883, 357.

Edis, A. W. Sterility in Women Including Its Causation and
Treatment, 1890.

Mandat, V. M. On Sterility in the Male and Female; Its Causes
and Treatment (Translated from the French, 1844).

Gibbons, R. A. Sterility after Voluntary Prevention of Concep-
tion, iawce/, Sept. 3, 1910,709. A Lecture on Sterility; Its Etiology
and Treatment. Lancet, 1910, xi, 705.

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Women. Am. Jour. Obstet., 1909, vol. lis, 1027.

Romme, R. La sterilite chez I'homme dans ses rapports avec
I'azoospermie. Tribmw tried. Par., 1898, 2 s., xxx, 1007.

Lapowski, B. MotiHty of Spermatozoa. Jour. Cutan. and Gen.
Urin. Dis., 1898, xvi, 334.

Benda, C. tjber die Entstehung der Spiralfaser des Verbindungs-
stiickes der Saugertierspermien. Verhandl. d. Anat. Gesellsch., Jena,
1898, xii, 264.

Bende. Eine Mitteilungen zur Samenbildung des Menschen.
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Morris, Wilson. New Lime Salts Give VitaUty to Prostatic Fluid
Necessary for Life of Spermatozoa in Uterus. Lancet, 1856, vol. ii,

483-

Piersol. Duration of Motion of Human Spermatozoa. Anat.
Anz., 1892-93, viii, 29.

Plonnies. Electricity on Dogs. Inaug. Diss., Rostock, 1871.

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Med. Jour., 1910, xci, 1043.

Benedict, A. L. Enumerations of Spermatozoids, N. Y. Med.
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Runge, E. Beitrage zur Aetiologie und Therapie der weibHche
SteriHtat. Arch. f. Gyn., 1909, kxxvii, 572.

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Ixxiv, 316.

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17-26.

Filmousi. Sul reperto negative per influenze chemiche nella
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638 \VILLL\MS: WASSERMANN REACTION IN GYNECOLOGY

Ballowitz, E. Bedeutung der Valentin'schen Querbander am
Spermatozoenkopfe der Saugethiere. Arch. f. Anal. u. Entw., 1891,

193-

Bertachini, P. Sopra alcuni spermatozoi umani momstruesi.
Rassegna di sc mcd. Modena, 1891, vol. vi, 494.

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secretion testiculaires proprement dite. Bull. soc. aiithrop. de Paris,

1894, 4. S, III.

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Male Sterility. Lancet Clinic, 1905, Iv, 61.

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Genito-urinary Dis., 1894, xii, 66.

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mcd., 1894, xii, 113.

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Ixii, II.

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Mouret, J. La spermatogenese. N. Montfel. Med., 1896, v, 541.

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auf die Samenbildung. Festschr. z. Feier d. 80 Jahr. Stiftungs
f.d. Aerzil. Ver. zu Hanib., 1896, 399.

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klin. Wcnschr., 1897, x, 569.

THE WASSERMANN REACTION IN GYNECOLOGY.*

PHILIP F. WILLI.'VMS, M. D., and JOHN A. KOLMER, M. D.,
Philadelphia.

The question of syphilis as an etiological factor in the production
of organic lesions and functional disorders of the pelvic organs of
women has undoubtedly not received the attention it merits. It is
true that syphilis has long been mentioned among other dyscrasias
as being responsible for amenorrhea, sterility and certain hemor-
rhagic conditions, but there existed little scientific proof for such
assertions. A review of the recent literature of gynecology or syphi-

* Read before the Obstetrical Society of Philadelphia, May 4, 1916.

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 639

lology reveals very few articles bearing upon syphilis of the uterus
or adnexa. This subject is, as Chase(i) has well termed it, an un-
written chapter in gynecology. The primary lesion, the chancre,
and the secondary lesions or syphiloderraata, mucous patches and
flat condylomata are seen at times upon the external genitalia, but
the lesions of s}T)hilis higher in the genital tract are apparently
limited to gummata, of which the few described in recent literature
are not all fully substantiated. In view of the universal prevalence
and long history of the disease it would seem that more frequent
manifestations of its effects would have been observed in the female
pelvic organs. There is no doubt that with the discovery of the
causative organism, the serum diagnosis and the later chemotherapy
syphilis has become a truly modern problem. With such a facile
means of diagnosis as the Wassermann reaction at hand the vague
and obscure etiology of many medical problems has been solved, and
the presence of numerous unrecognized and latent cases of sj'philis
has been revealed.

As regards the presence of syphilis generally various authors con-
sider from 5 to 20 per cent, of the adult population to be affected.
While a clinical examination of the cadet corps at West Point failed
to reveal a single case of syphilis, a Wassermann test showed 5 per
cent, positive reactions(2). In a group of women equally large and as
widely drawn a similar condition might reasonably be expected to
exist. Among delinquent women the incidence of syphilis is of
course greater. Haines(3) in investigating this condition in 218 de-
linquent girls, found in forty-two, with an average age of sixteen
years, who were sexual offenders, seventeen who had positive reac-
tions. In the Reformatory at Bedford Hills according to Davis(4),
51 per cent, of the inmates were sj'phihtic. Among 500
delinquent women studied by SuUivan and Spaulding(5), 44
per cent, had positive Wassermann reactions, 242 of the 500 women
who were prostitutes, showed 66 per cent, positive reactions,
while in 199 who were mentally deficient 61 per cent, had
positive reactions. While the average dispensary class includes only
a small percentage of women of this type, there is a certain propor-
tion of patients who must be classed as of uncertain morals or who
have been exposed to syphilis through conjugal infidelity.

With a view of ascertaining to what extent unsuspected syphilis
is present, and of determining what significance a positive reaction
might have in gynecological cases a Wassermann test has been made
upon the blood of 300 cases, such as might be met in the average
gynecological dispensary and ward service, no selection being made

640

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY

as to the type of lesion present. In two instances reports have been
made as to the incidence of s>T3hilis in women attending gynecological
clinics. McIlroy(6) from the Royal Infirmary, Glasgow, reports
43 per cent, positive reactions, a surprisingly high figure.
Whitney(7) reports 2.3 per cent, positive reactions among
the patients in the Women's Clinic at the University of Cali-
fornia Hospital during a period of twenty- two months; in all the
dispensaries of this hospital during the same time there v/as an
average of 7 per cent, positive reactions. In no pregnant
women at Halle, Heynemann(8) found nine with unsuspected
syphilis as revealed by the Wassermann reaction. The re-
sults of our investigation as to social state and race may be
seen in Table I. Of the positive reactions summarized in
Table I the degree of complement-fixation may be seen in Table II.

TABLE I.-

-WASSERMANN REACTIONS CLASSIFIED AS REGARDS
SOCIAL STATE AND RACE.

Social state and race.

Number
positive.

Number
negative.

Percentage
positive.

Single

Married.
Black.. . .

White...,

23.6

24s

190

22.4

35-8

208

173

20.2

TABLE IL-

-DEGREE OF COMPLEMENT-FIXATION IN POSITIVE
REACTIONS.

Strongly
positive.

Moderately
positive.

Weakly
positive.

Reacted with
cholesterinized
antigen alone.

300

8 or 2 . 6
per cent.

24 or 8
per cent.

16 or 5
per cent.

While it is admitted that syphilis is extremely prevalent
in the American negro as shown by Lynch(9), yet it is stated
by Hazen(io) that there were only 5 per cent, of syphilitics
in over 90,000 negroes treated at the Frcedman's Hospital in Wash-
ington. Keyes(ii) has said that while there may be from 5 to 10
per cent, of unsuspected syphilitics as revealed by the Wassermann
reaction, the exact composition of this percentage depends upon the
technic used, to which might also be added the nature of the com-
munity studied.

All reactions here reported were conducted with the following

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 641

three extracts (antigens) according to the technic advocated by one
of us (Kolmer) : (a) A cholesterinized alcoholic extract of human
heart; (b) An alcoholic extract of syphilitic liver; (c) An extract of
acetone insoluble lipoids from beef heart. These extracts were
diluted with normal salt solution and frequently titrated for their
anticomplementary, antigenic and hemolytic titers. All antigens
were used in doses corresponding to two to four times their antigenic
units, these amounts being always at least ten times less than their
anticomplementary units. The use of these triple antigens has three
advantages: (i) It permits the use of a cholesterinized extract under
conditions where any tendency to nonspecific fixation is to be con-
trolled; (2) An antigen may at any time suddenly become anticom-
plementary and yield false results, whereas by this method the source
of error is detected and may be avoided, since it is not dependent
upon any one extract; (3) An extensive study of the comparative
values of antigens has led to the distinct impression that the lipodo-
phihc antibody in different syphilitic serums frequently shows a
special affinity for the hpoid in a certain plain antigen more than it
does for those in another antigen; not infrequently with weakly
positive serums if one antigen had been employed, a false negative
report would have been rendered, the true reaction being given by the
other two antigens. The extreme sensitiveness of the cholesterinized
antigens renders it advisable to control them by less sensitive
antigens. Complement was furnished by the serum of guinea pigs
diluted I to 20, and used in doses of i c.c. (= 0.05 c.c. undiluted
serum); washed sheep corpuscles were made up in a 2.5 per cent,
suspension, and used in doses of i c.c; antisheep hemolysis was
titrated each day with each complement, serum and corpuscle
suspension and used in doses equal to two units; serums were heated
to 55° C. for thirty minutes and used in doses of 0.2 c.c. with each
antigen. As is usual in complement-fixation tests serum, antigen and
hemolytic controls were included. The readings were made imme-
diately after the second period of incubation, the time depending
upon the rate of hemolysis of the controls; in this manner the in-
fluence of continued hemolysis is obviated and delicate degrees of
complement absorption are appreciated(i2).

The occurrence of a positive Wassermann reaction in a woman
presenting a gynecological lesion may be of considerable significance.
A syphilitic as a result of the infection is undoubtedly in a condition
of weakened resistance to such invading organisms as the gonococci,
and through the impairment of the tissues we would expect malig-
nant processes to make more rapid progress. While the finding of

642

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY

TABLE III.— WASSERMANN REACTIONS CLASSIFIED AS TO GYNE-
COLOGIC.\L CONDITIONS.

Condylomata of perineum. . .

Edema of vulva

Infection of vulva

Pruritus of \'ulva ,

Atresia of vagina

Gonorrheal vaginitis

Senile vaginitis

Membranous dysmenorrhea.

Amenorrhea . ,

Menorrhagia

Metrorrhagia

Hypertrophy of (
Papilloma of cervix.

Erosion of cervix ! i

Polyp of endometrium i

Pathological anteflexion of j

uterus j 3

Retroversion of uterus | 25

Prolapse of uterus

Infantile uterus

Cancer of cervix

Myoma of uterus

Pelvic inflammatory disease. . .; 60

Ovarian cyst 1 6

Sterility i g

Pregnancy 40

Abortion

Stillbirth

Habitual abortion

Eclampsia

Wet-nurse

Appendicitis

Tuberculosis of peritoneum. .

Rectal disease

Ischiorectal abscess

Fecal fistula

Hernia

Cholelithiasis

Neurasthenia, backache

Gonorrheal arthritis

Cystitis

Pathological menopause

Per
cent,
posi-
tive

Strongly
positive

Total 330

Duplicates 30

Moder-
ately
posi-
tive

Weakly
posi-

Nega- ]

tive I

Number
positive

with
cholester-

inized
antigens

alone

a positive reaction in a case of myoma of the uterus might be looked
upon as only an intercurrent infection, yet it would have to be con-

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 643

sidered as having had, perhaps, some tendency to further impair the
the cardiovascular system. On the other hand, in a case of some
ulcerative process about the external genitalia a positive reaction
would be of material consequence. It is of interest at this point
to note that Fisichella(i3) reports twenty cases of rodent ulcer of
the vulva, in all of which there was a positive Wassermann reaction,
and in three cases injected with salvarsan rapid healing occurred.

The proportion of positive reactions in the conditions observed
may be seen in the accompanying table. The condylomata perinei
studied were of the pointed variety, due most likely to gonorrheal
infection. In the case of edema of the vulva, the only demonstrable
gynecologic lesion, the urinary findings were negative, the blood
pressure normal and diminution of the edema was noted after injec-
tions of arseno-benzol. The case of congenital vaginal atresia
observed gave a negative reaction. From the social histories in the
cases of gonorrheal vaginitis the occurrence of but one moderately
positive reaction is surprisingly low. In the ten cases of amenorrhea,
where the usual causes as pregnancy, lactation and so on could be
ruled out, there were five strongly positive reactions. These all
occurred in young women and the most probable direct cause, an
anemia, may have been secondary to the syphilitic infection. The
cases of profuse menstrual bleeding and of metrorrhagia have been
of much interest because of the high proportion of positive reactions
in such cases in Mcllroys series. In 24 cases of metritis or fibrosis
of the uterus, in which metrorrhagia is a prominent symptom, there
were 16 positive reactions, and she further found 4 positive reactions
in 13 cases diagnosed as uterine hemorrhage. In 16 cases of fibrosis
uteri reported by Whitehouse(i4) 7 gave a positive reaction.
This author has recently made a careful study of the relation of
syphilis to this form of metritis and shows that whUe repeated
pregnancies and infections of a septic or gonorrheal nature and
arteriosclerosis may occasion fibrosis of the uterus, there are
undoubtedly many instances where the lesion has a syphilitic basis.
Whitehouse says in conclusion that it is of importance to test by the
Wassermann reaction all patients who present the clinical picture
of chronic metritis and fibrosis since this may provide the only
evidence of the syphilitic nature of the affection.

Chase considers syphilitic endometritis as being the commonest
form of uterine syphilis. This may be true, but Frankl(i5) is in-
clined to regard cases of endometritis as not necessarily syphilitic
merely because they improve upon antisj'philitic medication.
Dysmenorrhea membranacea or exfoliativa may possibly be of a

644 WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY

syphilitic origin. FrankI speaks of the thick-walled blood-vessels
with a surrounding zone of small round cells found in the endo-
metrium removed during the interval. The one case we observed
gave a negative reaction.

In one case where erosion of the posterior lip of the cervix was
present the Wassermann reaction, as well as the gonococcus comple-
ment-fixation test, was strongly positive. In this instance the
erosion presented no differences in appearance from the ordinary
simple erosion and the search for spirochetes in the secretion was
negative. Wile and Senear(i6) report two cases of chancre of the
cervix in fifty cases of early syphilis in women. The lesions differed
markedly in appearance and spirochetes were demonstrated in the
secretions from each. It is the opinion of these authors that a
routine vaginal examination in all cases of early syphilis in women
would disclose the primary lesion with greater frequency. Chancres
of the cervLx quickly resolve due to the moisture and temperature
of the vagina and also from the fact that they are less subject to
trauma and friction. Kaarsberg(i7) has observed two cases of
carcinoma of the cervLx in syphilitics. In the first the condition was
diagnosed as gumma from the appearance and a positive Wasser-
mann reaction. Partial healing was noted under antiluetic treat-
ment, as this did not continue, a test excision was made and examina-
tion of the tissue revealed a carcinoma established on an old syphilitic
ulcer. The second case was fairly similar, a year after hysterectomy
there were no signs of recurrence or metastasis. The Wassermann
remained positive, however. Heynemann found three positive
reactions in thirty cases of inoperable carcinoma of the cervix. The
five cases reported in this series gave negative reactions.

Whether the presence of congenital syphilis is of moment in the
hypoplasias of the pelvic organs is a question of interest. Grafen-
berg(i8) found tangled masses of spirochetes in the uterus of a
syphilitic fetus. Mcllroy and Heynemann report positive reactions
in infantile uteri. In the case we observed there was a weakly
positive reaction. In the case of atresia of the vagina the reaction
was negative.

In two of the cases of fibroid tumors of the uterus the reactions
were positive. Theilhaber(i9) has expressed the belief that syphilis
may play a part in the genesis of myomata, through the syphilitic
alterations in the blood-vessel walls of the uterus. In a series of
22S cases of myomata syphilis was present 11 times. Two of these
1 1 died following operation, in both instances from cardiovascular
conditions which he attributed to the syphilitic infection. Each

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 645

of the two cases gave a history of infection and of repeated still-
births.

In the sixty cases of pelvic inflammatory disease, so grouped
as to constitute cases ranging from mild inflammatory processes to
actual suppurative lesions, there were nine strongly positive reactions,
six moderately positive, and seven weakly positive reactions. The
majority of these cases were considered gonorrheal in origin and the
occurrence of this proportion of these two venereal diseases together
can hardly be considered as out of the ordinary. In several instances
where the tubes and ovaries were removed in these cases sections of
the tissue have been stained by the Levaditi method. No spirochetes
were found. The sue cases of ovarian cysts, including one dermoid,
gave negative reactions.

Several other conditions which were observed and included, while
not strictly gynecological conditions, are not infrequently seen in
this branch of practice, and in most instances complicated some
gynecological lesion. Thus in one case of appendicitis a syphiloderm
was present with a positive reaction. In two cases of stricture of
the rectum there were positive reactions. This condition has long
been attributed to syphilis, among other factors, but a certain diag-
nosis of syphilis may be of assistance in directing treatment. In a
large number of cases with positive reactions laparotomy has been
performed with no tendency to a lack of union of the tissues of the
abdominal wall, or of the tissue of the perineum when plastic work
was performed. Failure of union or the unaccounted for lack of, or
delay in healing after operation in an otherwise clean wound may
possibly be due to the presence or effects of syphilis and the Was-
sermann reaction should be investigated in any such complication.

The clinical history of syphilis in pregnancy is well known and a
history of repeated abortions or stillbirths has long been regarded as
sufficient indication for the administration of antiluetic medication.
In syphilitic women who become pregnant there appears to occur a
gradual diminution in the intensity of the disease so that finally
apparently healthy children may be born. An interesting reversal
of this well-known clinical phenomenon, Kassowitz's rule, is cited by
Watson(2o). In three successive twin pregnancies in a gypsy
woman, progressively more serious manifestations of syphiHs were
noted in the offspring. The eight members of this family responded
positively to the Wassermann reaction. The fertility of syphilitic
women is in marked contrast to that of women infected with the
gonococcus, in whose case the one child sterility is often presumptive
evidence of the nature of the infection. Sterility is not frequent in

6-16 WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY

syphilitic families. There may be many abortions and stillbirths
but the fecundity of the woman is evidently not affected. In 90
syphilitic families Raven(2i) found only 8 sterile women, the other
82 had had 350 pregnancies, with 183 living children. In 119 of
these 183 living children, eighty-three were pathologic. He observed
that if one parent alone was diseased the mortality of the offspring
was 37 per cent., while if both were diseased or gave a positive reac-
tion the mortality of the children was 53 per cent. Harmon(2 2)
found 17 per cent, more pregnancies in 150 syphilitic families than
in 150 healthy famiUes. This may be explained in part by the
frequency of stillbirths and miscarriages in the sj^philitics, the short
interval between allowing of several ineffectual pregnancies within
the same time as would be taken for one full-term pregnancy in a
healthy mother. Further, the desire for children may have helped
to increase the number of pregnancies.

In so far as abortions are concerned, syphilis has long been re-
garded as a most important factor. In view of the findings elicited
by the Wassermann reaction some change must be made in this
teaching. Lachner(23) found only 4 positive reactions in 100 cases
of abortion. Weber(24) di\aded his 67 cases in two groups, 35 occur-
ring before the sixteenth week in which he found no positive Wasser-
mann reactions and no spirochetes in the tissues, and 32 occurring in
the fifth, si.xth and seventh months in which there were 12 positive
reactions and spirochetes were found in 9 specimens. In 300 cases of
abortion he found no clinical e\'idences of syphihs. Harmon found
a history of 61 miscarriages in 150 healthy women as compared vdih
92 in 150 syphihtics. The difference is not sufficient for us to regard
syphilis as the most potent cause of the early interruption of preg-
nancy. In this series we found 7 strongly positive reactions in 31
cases of abortion before the fourth month.

Among the pregnant women there were two positive reactions, of
whom one gave a history of infection. Both women, primipara,
gave birth to living children, one had received treatment for several
months, the other was seen only shortly before delivery. The child
of the second woman presented no clinical syphilis and had a negative
Wassermann reaction which combination according to Trinchese(25)
is the most favorable combination for the child of a syphilitic woman.
The recent studies of Williams(26) and Holt(27) reporting 26 and 9
per cent, respectively, of Itillbirths as being due to syphilis emphasize
the necessity for the early recognition of this condition in pregnancy.
Excluding such definite causes as cardiac and hemorrhagic conditions,
eclampsia and birth trauma, every stilll)irth in the later months of

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 647

pregnancy should be regarded as sj'philitic until disproved, by nega-
tive Wassermann reactions on both parents. In view of the large
number of syphilitic stillbirths, the high mortahty rate from syphilis
in new-born infants, and the declining birth rate in many localities
it would seem that a routine Wassermann reaction on pregnant
women was as much in place as an examination of the urine or blood-
pressure estimations. In the 4 cases presenting themselves shortly
after stillbirths there were 2 strongly positive reactions.

Habitual abortions have often been attributed to syphilis. The
reported iigures of Heynemann show that in 61 such cases 12 to 15
gave either a positive or moderately positive reaction. Weber
found 6 positive reactions in 30 cases of repeated abortions. In 25
cases of repeated abortions 01ivia(28) found 18 positive reactions,
after eliminating 2 cases as being due to uterine displacement,
there is a percentage of 64 in which syphilis was the only cause found.
In the present series fourteen women gave a history of repeated
• abortions, of these six had strongly positive reactions. It may be
possible that syphilitic changes in the decidua were responsible for
the first one or two abortions and the resulting endometrial lesions
rather than the syphilitic infection occasioned the succeeding abor-
tions. The Wassermann reaction has also shed new light upon
the interpretation of CoUes' law. We now know that the majority
of mothers of syphilitic children show positive reactions and are
really latent syphilitics; in not a few instances tertiary lesions have
been known to develop at a later date. In many instances the ap-
parently healthy child of a syphilitic mother that could not be in-
fected by the mother (Profeta's law) has been shown by the Wasser-
mann reaction to be in reality a case of retarded congenital syphilis,
and that such children are not immunized during intrauterine life
against syphilis as has been believed in past years. Most examples
of so-called immunity in syphilis in mother, Colles' law, and child,
Profeta's law, are due to the actual presence of spirochetes in the
tissues and are really latent infections.

Seven cases of eclampsia came under observation, in one the
reaction was positive. This particular case was of interest in that
the woman, a para-v, the mother of five children all living and
healthy, had eclampsia in the two previous pregnancies. The result
of this third successive toxemic pregnancy was a stillbirth, and later
the death of the mother. It is to be doubted if the reported positive
Wassermann reactions in eclampsia are due to any changes in the
blood as a result of the toxemia. It may be that some of the occa-
sional moderately high blood pressures met with in pregnant women

648 WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY

who are evidently not toxemic, are the result of a s^-philitic end-
arteritis. In one instance a wet-nurse presented herself for examina-
tion. She gave the interesting history that she had been confined
several months previously of a stillborn child, cause not explained
and had been engaged immediately to nurse the new-born infant of
a woman suffering with pulmonary tuberculosis. While her Wasser-
mann reaction was negative it is in just this tj-pe of case that its
application is only humanely necessary. Rietchell(29) in testing
the wet-nurses in the Dresden " Sauglingsheim " found that lo per
cent, gave a positive reaction, although they showed no clinical
evidence of the disease. As it curiously often happens that mothers
of luetic children may give a negative reaction it would be advisable
to test child as well as mother, before allowing the latter to assume
the duties of a wet-nurse.

Of particular interest are the results obtained with the use of
cholesterinized extracts as antigen. These extracts originally ad-
vocated by Sachs have been shown by Walker and Swift, Kolmer,
Field, Thompson, Judd and others to be very sensitive and generally
satisfactory.

As pointed out by one of us (Kolmer) these extracts may yield in
a small percentage of cases denying syphilis a weak degree of comple-
ment-fixation. The sum total of an extensive experience with
particular attention to the titration of the antigens has led us to
place more and more confidence in the specificity of these reactions.
In such a disease as syphilis it is impossible to definitely exclude
sjfphilis on the basis of a negative history and physical examination.
Consequently it must be expected that a certain percentage of posi-
tive reactions will occur among persons denying syphilis and showing
no evidence of the disease at the time of examination. Brief abstracts
of the histories of ten of the sixteen cases reacting only with cho-
lesterinized extracts are given here; we are of the opinion that the
majority of these may be regarded as suspiciously syphilitic and the
reactions with cholesterinized extracts are to be interpreted as true
reactions due to the superior antigenic sensitiveness of the choles-
terinized extracts.

Case I. — F., white, aged thirty-eight years, married, three preg-
nancies, one ended in a miscarriage, the children of the other two
pregnancies both dead. Complains of irregularity of menses. Clin-
ical diagnosis: Hypertrophy of cervix. Serum reaction, weakly
positive with cholesterinized antigen alone.

Case II. — S., negress, aged nineteen years, single, never pregnant.
Complains of genital ulcers and leukorrhea. Clinical diagnosis:

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 649

Condylomata acuminata, gonorrheal vaginitis. Serum reaction,
weakly positive with cholesterinized antigen alone.

Case III. — O., white, aged thirty years, married, never pregnant.
Denies history of infection. Complains of abdominal pains.
Clinical diagnosis: Pelvic adhesions following previous salpin-
gectomy. Serum reaction, weakly positive with cholesterinized
antigen alone. Pain subsided under mi.xed treatment.

Case IV. — B., negress, aged thirtj'-two years, married, six preg-
nancies. First child living, then two miscarriages, three stillbirths.
Clinical diagnosis: Pregnancy. Serum reaction, weakly positive
with cholesterinized antigen alone. Mixed treatment, living child
born at term.

Case V. — R., white, aged twenty- five j-ears, married, two preg-
nancies, live children apparently healthy. Complains of jaundice
and pain in right upper quadrant of abdomen. Chnical diagnosis:
Cholelithiasis. Serum reaction, positive with cholesterinized antigen
alone.

Case VI. — Z., white, aged nineteen years, married, pregnant five
months. Reacted with cholesterinized antigen alone. Placed on
mixed treatment.

Case VII. — C, white, aged twenty-seven years, married, four
pregnancies. Last two children died shortly after birth. Complains
of leukorrhea and dysmenorrhea. Clinical diagnosis: Right adnexal
disease. Serum reaction, positive with cholesterinized antigen alone.

Case VIII.- — ^L., white, aged thirty-two years, married, four preg-
nancies, resulting in two miscarriages, one stillbirth and finally a
living child. Complains of leukorrhea. Clinical diagnosis: hyper-
trophy of cervLx. Serum reacted with cholesterinized antigen
alone.

Case IX. — B., negress, aged thirty years, married, sterile. Com-
plains of hematuria. Clinical diagnosis: Chronic ulcerative cystitis.
Serum reacted weakly with cholesterinized antigen alone.

Case X. — D., white, aged thirty-one years, married, two preg-
nancies. Both children alive and apparently healthy. Complains
of pelvic discomfort and dysmenorrhea. Clinical diagnosis:
Adherent retroverted uterus. Serum reacted with cholesterinized
antigen alone. Mixed treatment instituted.

In this study the Wassermann reactions of three hundred gyneco-
logical and obstetrical patients have been investigated. The per-
centage of positive reactions (22.6) corresponds closely with the gener-
ally accepted incidence of syphilis in adults. The incidence of
syphilis in gynecology on the basis of the Wassermann reaction is
so definite that this disease cannot be excluded on the basis of a
negative history and the absence of demonstrable evidences of
syphilis; while a particular lesion may not be syphilitic it is, however,
highly important to institute antiluetic treatment if syphilis is
demonstrated by the Wassermann test.

650 WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY

Of particular interest is the relatively high percentage of positive
reactions observed in the following conditions: Stillbirths, 75
per cent.; rectal diseases, 50 per cent.; amenorrhea, 50 per cent.;
habitual abortion, 50 per cent.; pelvic inflammatory disease, 36
per cent. ; sterility, 33 per cent. ; abortion and miscarriage, 29 per
cent. ; metrorrhagia, 20 per cent. ; myomata of the uterus, 16 per cent. ;
gonorrheal vaginitis, 10 per cent.; pregnancy, 17 per cent.

The social condition has played no part in increasing the percentage
of positive reactions in our series; some of the single women were
parous, and a number of the married women were sterile. Race,
however, seems to be a more important factor, 35.8 per cent, of the
black race gave positive reactions as compared with 20.2 per cent,
in the white women. The history of infection has been obtained in
but a few cases. This is a well-known fact, it is not the intent of
the patient to deceive but the primary lesion in women is overlooked
and the secondary stage may have been disregarded.

The high degree of latent sj'philis in women should make a rou-
tine Wassermann test in gynecological and obstetrical practice as
advisable as any othtr laboratory procedure; it is certainly as
advisable here as in medical and surgical practice.

The Wassermann reaction under proper conditions has proven
highly specific and an indispensable diagnostic aid. Particularly
during the child-bearing period treatment should be given; even in
latent syphilis where no symptoms are manifest treatment should
be given, as according to our present knowledge a persistently
positive Wassermann reaction indicates the presence of living
spirochetes in the tissues.

In view of the pregnancy of latent syphilis as revealed by the
Wassermann reaction in gynecological patients and the scant atten-
tion paid to syphilis as an etiological factor in the production of pelvic
pathology in women we feel that a routine Wassermann reaction and
the subsequent histo-palhologic study of tissues removed from
syphilitics may bring more light to bear upon this neglected phase of
gynecology.

REFERENCES.

1. Chase, I. C. An Unwritten Chapter in Gynecology, Uterine
and Adnexal Syphilis. Texas Stale Jour. Med., 1913, i.x, 95.

2. Martin, E. Syphilis in General Surgery. Jour. Am. Med.
Assn., 1916, Ixvi, 453.

3. Haines, I. H. The Incidence of Syphilis among Juvenile De-
linquents. Jour. Am. Med. Assn., 1916, Ixvi, 102.

4. Davis, K. B. Proceedings of the Annual Congress of the
American Prison Association, Indianapolis, 1913.

5. Sullivan, E. A., and Spaulding, E. R. The Extent and Signi-
ficance of Gonorrhea in a Reformatory for Women. Jour. Am.
Med. Assn., 1916, Ixvi, 95.

6. Mcllroy, A. L., Watson, H. F., and ISIcIlroy, J. H. The
Significance of the Wassermann Reaction in Gynecological Diagnosis,

WILLIAMS: WASSERMANN REACTION IN GYNECOLOGY 651

with Special Reference to Uterine Hemorrhage. Brit. Med. Jour.,
1913, 1002.

7. Whitney, J. L.- A Statistical Study of Syphilis. Jour. Am.
Med. Assn., 1915, Ixv, 1985.

8. Heynemann, T. Die Bedeutung der Wassermanschen Reak-
tion fiir Geburtshiilfe und Gynakologie und die Lehre von der
Vererbung der SyphQis. Prakt. Ergebn. d. Geburtsk. u.Gyndk., 1910,
iii, 40.

9. Lynch, K. M., Mclnnes, B. K., and Mclnnes, G. F. Con-
cerning Syphilis in the American Negro. Southern Med. Jour.,

1915. viii, 450-

10. Hazen, H. H., Syphilis in the American Negro. Jour. Am.
Med. Assn., 1914, Ixiii, 463.

11. Keyes, E. L., Jr. Some Clinical Features of the Wassermann
Reaction. Jour. Am. Med. Assn., 1915, Ixiv, 805.

12. Kolmer, J. A. Infection, Immunity and Specific Therapy.
Philadelphia, 1915, p. 433.

13. Fisichella, V. La Cura dell' Ulcera cronica Vulvare. //
Polodin., 1915, xxii, 485, sez. prat.

14. Whitehouse, B. Syphilis in Relation to Uterine Disease.
Jour. Obst. and Gynec. Brit. Emp., 1914, xxv, 13.

15. Frankl, O. Pathologische Anatomic und Histologie der
Weiblichen Genitalorgane. Liepmann, Handbuch der Frauenh.,
Bd. ii, Leipzig, 1914.

16. Wile, U. J., and Senear, F. E. Chancre of the Cervix
Uteri. Surg., Gynec. and Obst., 1915, xxi, 643.

17. Kaarsberg, I. Om to sjaelent forekommende Lidelser paa
CoUum Uteri. Hospitalstidende, 1915, Iviii, 577.

18. Grafenberg, cited by Meyer, P. Die Syphilis der inneren
Genitalen des Weibes. Deutsch. med. Wchnschr., 1913, xxxix, 169.

19. Theilhaber, A. Der Zusammenhang von Myome mit internen
Erkrankung. Monatschr. f. Geburtsh. u. Gyndk., 1910, xxxii, 455.

20. Watson, H. F. Unusual Fertility in Syphilitic Parents
associated with Anomalous Involvement of the Children. Brit.
Med. Jour., 1913, 877.

21. Raven, W. Serologische und Klinische Untersuchungen bei
Syphilitiker Familien. Deutsch. Ztschr. f. Nervenh., 1914, li, 342.

22. Harmon, N. B. The Influence of Sj'philis on the Chances
of Progeny. Brit. Med. Jour., 1916, 196.

23. Lachner, J. E. Serological Findings in 100 Cases, Bacterio-
logical Findings in Fifty Cases, and a Resume of 679 Cases of Abor-
tion at the Michael Reese Hospital. Surg., Gynec. and Obst., 191 5,

^, 537-

24. Weber, F. Die Syphilis in Lichte der Modernen Forschung
mit besonderen Beriicksichtigung ihres Einflusses auf Geburtshiilfe
und Gynakologie. Berlin, 1913.

25. Trinchese,J. Infektions-und Immunitatsgesetze bei materner
und fotaler Lues. Deutsch. med. Wchnschr., 1915, xh, 555.

26. Williams, J. W. The Limitations and Possibilities of Prenatal
Care. Jour. Am. Med. Assn., 1915, Ixiv, 95.

652 maier: chronic focal infection of the pelvic organs

27. Holt, L. E., and Babbitt, E. C. Institutional Mortality of
the New Born. Jour. Am. Med. Assn., 1915, Ixiv, 2S7.

28. Olivia, L. A. L' Abort abituale e la Reazione di Wassermann.
Gaz. d. Osped. e. d. Clin., 191 5, xxxvi, 755.

29. RietcheU, cited by Habermann, J. V. Hereditary Syphilis.
Jour. Am. Med. Assn., 1915, Ixiv, 1141.

121 South Twentieth Street.
927 South St. Bernard Street.

CHRONIC FOCAL INFECTION OF THE PELVIC ORGANS
AND ITS RELATION TO SYSTEMIC DISEASE.*

BY
F. HURST MAIER, M. D.,

Philadelphia, Pa.

Most internists agree that systemic disease is the result of local
infection.

We are all familiar with the assumption that the oral cavity is the
grea'test portal of entry for microorganisms.

When we consider that the genito-urinary tract is normally the
habitat of a large number of bacteria of potential pathogenicity, and
furthermore, from its anatomical position, and the changes that
occur in connection with the functions of menstruation, of married
life, of childbirth, and the menopause, offers the greatest facihty
for their entrance and growth, it is self-evident, that the reproductive
and urinary organs must frequently be the site of septic foci that
are not only potentially able, but do produce toxemia, as weU as
constitutional disease.

Septic infection usually occurs in connection witli the puerperal
state.

The uterus of labor and abortion contains the necessary pabulum
as a starting point of infection. Operative procedures, displace-
ments, fibroids, and gonorrhea all predispose to the condition.

Systemic infection may be direct from the portal of entry in the
genital tract (the placental site usually) or from a secondary area
in the contiguous structures (thrombophlebitis or lymphangitis).
Depending upon the virulency of the organism or organisms, it may
be severe or mild. The infection may subside, and leave behind
a latent focus in the pelvic organs or structures, or a metastatic
lesion in other organs or parts of the body. Conversely, the focus

* Read before the Obstetrical Society of Philadelphia, May 4, 1916.

maier: chronic focal in'fection of the pelvic organs 653

may be chronic from the beginning, a product of former extra-
pelvic disease.

A chronic focus of infection may exist for a long period of time,
without apparent injury to the host, due, as Rosenow has pointed
out, to the modification which the organisms may undergo in known
mutation of cultural characteristics and pathogenicity.

As this is probably inliuenced by the local blood supply and oxygen
content of the infected tissue, later with the defenses of the body
diminished by overwork, dissipation, exposure to cold, insufficient
or improper food, faulty hygiene, injuries from previous disease,
trauma, etc., the infection may again become active and the indi-
\'idual suffer from an acute or a chronic arthritis, myositis, malignant
or simple endocarditis, pneumonia, etc., dependent upon the phase
of mutation in pathogenicity of the specific strain of the streptococ-
cus-pneumococcus group in the local focus.

Clinically these cases are often of a baffling character and the
utmost skill and care is required to associate the constitutional
disease with the focal sepsis. The structures and organs having long
since assumed their normal condition, the focus may not only be
extremely small, but so deeply embedded in the substance of the
ovary, the parametrium, or in the walls of the uterus, as to make
recognition difficult.

SLx weeks ago, I saw just such a case of focal sepsis. Mrs. B.,
aged forty-eight years, married, multijiara. Last menstrual period
five years ago. Always enjoyed good health.

Since last summer the patient suffered from nervousness, anorexia,
tachycardia, enemia and asthenia. Occasionally she had chillj'
sensations that would last for several hours. During this time she
lost 20 pounds in weight. The blood count was 3,920,000 red and
13,360 white cells. Hemoglobin 65. Color index 8. Locally, there
was a slight but persistent yellowish discharge from the vagina.

On bimanual examination, the uterus was found to be freely mov-
able, and somewhat enlarged, with an area of induration in the left
lateral wall. The cervix appeared to be normal, although, pus
discharged from the external os.

At the operation, done March 15, '16 at St. Joseph's Hospital, the
uterus which was removed, was free, and covered by an apparently
normal peritoneum. The ovaries and tubes were atrophied.

The pathological report stated that the specimen consisted of a
uterus, which showed upon its postexternal surface, multiple met-
astatic abscesses, that ranged in size from a millet seed to a pea.
Upon section, the walls of the fundus and lateral parts of the body
presented large cavities filled with pus. The cervical mucosa above
the external os, showed a small area of erosion, that proved on micro-
scopic investigation to be an adenocarcinoma.

654 maier: chronic focal infection of the pelmc organs

The early recognition of the septic focus in tliis case was highly
essential, when we consider, that the portal of entry was a malignant
ulceration. The discharge, the only sign pointing to local disease,
was considered of little or no significance almost throughout the
entire period of her illness.

When discharged from the hospital, on the last day of the month,
the patient was free of symptoms. Her pulse rate, which, prior to
the operation, had always been about 1 20, even with normal tempera
ture was 80 and the leukocyte count 6940.

The colon bacillus a potential part of the bacterial flora, inhabiting
the external genitalia, not uncommonly creates a focus that pro-
duces systemic infection. Davis in his studies found the colon
bacillus in cystitis and pyelitis and that it was also associated with
a variety of .clinical conditions, including joint lesions, neuritis,
anemia, etc. Often the patients were neurasthenics.

Infection of the kidney pelvis occurs more frequently by the way
of the lymphatics, blood stream or continuity of tissue from the colon,
than by ascension, and as it appears quite unnecessary that the
kidney should be either tender or obviously enlarged during the
presence of acute symptoms; in the absence of a cystitis there will be
so little of a localizing character, that it is quite possible for a focus
in this region to sometimes elude diagnosis.

The intestinal tract may be the source of invasion by bacteria, as
in typhoid fever, which invade organs or tissue of the pelvic cavity
and thus produce a focus from which systemic infection arises after
the subsidence of the primary disease. Illustrative of this, LeConte
and Lewis, in 1902, reported two cases of t^-phoid infection of ovarian
cysts. It occurred in the fourth and fifth week of the disease, respect-
ively. Following the subsidence of the tj^ihoid symptoms, there was
a secondary elevation of temperature, etc., and coincidentaUy the
leukopenia rose to a leukocytosis of 9200 in one, and 10,400 in the
other. With incision and drainage of the cyst contents, the septic
symptoms and increased number of leukocytes disappeared. Five
days later, both patients had a relapse of the typhoid symptoms,
without, however, any increase in the number of white blood cells.

These cases are also of interest in demonstrating the value of the
blood count in preventing confusion in the diagnosis between typhoid
fever, the septic condition, and the reverse.

Under abnormal anatomical conditions of the tract, with stasis
of the intestinal contents and sluggish blood circulation, ordinarily
innocent bacteria (colon bacillus, streptococcus intestinals, etc.)

maier: chronic focal infection of the pelvic organs 655

may acquire pathogenic properties with resulting local and systemic
disturbances of various organs.

Coleman and Hastings have laid stress on the fact that some strains
of bacillus coli are capable of producing generalized infections
clinically identical with typhoid fever.

During the past summer, I operated upon two (2) such cases. The
first patient had been ill for several weeks with symptoms expressive
of typhoid fever. At the end of that time, she complained of pain
in the right ihac region. A vaginal examination revealed a small
mass that proved to be an infected intraligamentary cyst of the
right ovary. Here was an example of direct invasion by the colon
bacillus, from the sigmoid.

The second woman lived in a community in which there was an
epidemic of typhoid fever. The course of her infection mimicked
the disease. At the end of the second week, she was seized with a
sharp pain in the region of McBurney's point; an accompanying
drop of the temperature to below normal with a subsequent rise to
a higher level, lead her physician to suspect a typhoid perforation.

The focus in this case also proved to be an ovarian cyst. As the
latter was free in the pelvic cavity it is quite likely, that this was an
instance of a hematogenous, lymphatic, or ascending infection.

In both of these cases, had blood counts been made, Widals taken,
and vaginal examinations enforced, early correct diagnosis would
have been possible.

In all maladies in which there is the slightest suspicion of doubt
as to their origin, careful investigation of the pelvic organs should be
made a routine practice. Furthermore, in cases of puzzling diagno-
sis, it should be supplemented by proper studies of the blood, urine
and other excretions. Vaccines and serums, if of limited value in
therapeusis, are often of real service in helping to determine the
etiology of the disease.

In conclusion, I wish to emphasize the probability of the uterine
mucosa being a frequent focus of infection in the production of
systemic disease. Clinically we cannot limit an inflammation of the
uterus to any one tissue. An inflammation of the mucous lining
also involves a part of the substance of the organ.

We must furthermore bear in mind that the uterine mucosa is not
functionally analogous to other mucous membranes, as many of the
processes which we have to describe under endometritis, are more
allied to new formations than the inflammations we are accustomed
to study in mucous membranes elsewhere ; as an example, the glandu-

656 maier: chronic focal infection of the pelvic organs

lar form of endometritis is more akin to an adenoma than to a
catarrh of the mucous membrane.

If in fertile women, puerperal sepsis is the most important cause
of uterine inflammation, in sterile women, the ravages of the gono-
coccus are deserving of study. It is a malady which, in its subtile
invasion, and its far-reaching effects, requires careful investigation.

The gonorrheal process is for the most part superficial, but it is
now well established, that deeper extension does sometimes take
place, and that suppuration may occur in the deeper layers.

Gonococci have been found in the periurethral, periovarian, and
perirectal connective tissue, and in the subperitoneal lymphatic
spaces.

Wertheim has advanced evidence to show the pyogenic powers of
the gonococcus itself.

They may remain latent in the uterine mucosa a long time before
ascension to the tubes, ovaries, and peritoneum takes place.

McCann has stated that the complications of gonorrhea may
be due to the gonococcus, or to other germs mixed with it; or to a
secondary infection by other germs which have followed and sup-
planted the gonococcus; or to the toxic products of the gonococcus,
or of other bacteria.

The fact seems to be well established that gonococcal toxin has
the power of exciting local and general symptoms.

The effects of the invasion of the female genito-urinary tract by
the gonococcus vary, from a limited and transient catarrh, which
almost escapes notice, to extensive disease of the pelvic viscera. In
the slight cases the woman may not consider that she is ill, still less,
that she is a source of infection.

In the cervix and body the gonococcus finds a soil where it can
develop freely and where it long maintains its vitality, causing func-
tional disturbances and interferring with health.

The local disturbances may be slight, the discharge being muco-
purulent or glairy mucous. The systemic conditions, however, may
be the expression of a more or less profound toxemia or gonococcemia.

The former may give rise to backache, headache, gastric disturb-
ances, neuralgia, myalgia, nervousness, mental depression, chronic
asthenia, etc. As the result of the latter, constitutional diseases as
arthritis, rheumatism, myositis, myocarditis may occur.

I believe that a considerable percentage of that large class of
nervous debilitated dyspeptic women, who wander from one medical
man to another, seeking relief, are the unconscious possessors of an
unrecognized and untreated infectious disease of the uterus.

rouLKROD: krukenberg's tumor of the ovaries 657

REFERENCES.

Billings, Frank. Forcheimer's"Therapeusis of Internal Diseases,"
vol. i, p. 169.

Rosenow, E. C. Transmutation within the Streptococcus-
pneumococcus Group. Journal of Infectious Diseases, Jan., 1914,
xiv, I.

Rosenow, E. C. The Etiology of Articular and Muscular Rheu-
matism. J. A. M. A., Apr. 19, 1913, ix, 1223.

Mayo, C. H. Clinics, 1914, vol. v, pp. 17-34.

Murray. Journal Obs. and Gyn., British Emp., 1914, xxv, 80-85.

Stone, W. J. Forcheimer's "Therapeusis of Internal Diseases,"
vol. V, p. 236.

Coleman and Hastings. American Journal of Medical Science,
1909, cxxxvii, 199.

Maier, F. Hurst. Amer. Jour. Obst., 1914, vol. kix. No. 5.

Furniss, H. D. Amer. Jour. Obst., 1915, Ixxi, 971.

Wetzel. Munchner mcd. Wochschft., 191 5, Ixii, 109-111.

Davis, D. J. Journal Jnfectious Diseases, 1909, vi, 224.

Docheg and Cole. Forcheimer's "Therapeusis of Internal
Diseases," vol. v, p. 472.

Bumm. Veit's "Handbuch."

Wertheim. Gyn. Centralblatt., 1891, No. 48, p. 1209.

Irvus, E. E. Gonoccal Infection. Forcheimer's "Therapeusis of
Internal Diseases," vol. v, p. 579.

203s Chestnut Street.

REPORT OF A CASE OF KRUKENBERG'S TUMOR OF
THE OVARIES.*

COLLIN FOULKROD, M. D.,

Philadelphia, Pa.

The unusual type of the tumor in this case has led me to put it
in on record. An extensive study of the reported cases has been
made by Dr. Outerbridge and recently by Dr. Stone, leaving very
little to be gone over in the literature.

June 23, 1915. — Mary McN., aged thirty-nine years. Para-iii;
one miscarriage ; last child one year ago ; no forceps ; has had " stitches"
after all children but the last. During this pregnancy was badly
nauseated from three months' gestation until labor, and her husband
states, she has never been free of nausea since.

Nursed this baby four months. Usual weight, 137 pounds; after
pelvic operation, 103 pounds.

• Read before the Philadelphia Obstetrical Society, May 4, 1916.

658 foulkrod: krukenberg's tumor of the ovaries

Menstruation. Menses at fifteen years; type twenty eight days;
three days' duration; two napkins daily. Last menses June 15, 1915.
No dysmenorrhea; no leuliorrhea ; no urinary symptoms; is consti-
pated.

Chief Complaint. — Vomiting. This vomiting began when patient
was last pregnant and has kept up since then. Is nauseated and
vomits small amounts of liquid, sometimes food, has apparently no
other trouble.

P. M. H. — Had the usual diseases of childhood, no other.

Father living and well. Mother died of uremia. Two brothers
living and well; two brothers dead, one from tuberculosis. One
sister Hving and well. No history of maUgnancy, except one aunt
who died of some tumor of stomach.

Examination. — Patient seems fairly well nourished. Lungs nor-
mal. Breasts, some secretion; abdomen, no palpable mass; heart
sounds clear and good rhythm.

Pelvic Examination. — Perineum shows old bilateral laceration,
partially healed, some rectocele. Cervix, a bilateral laceration
somewhat marked. Uterus slightly larger than normal retroverted.

Both ovaries enlarged, seemingly to size of small lem.ons,
freely movable but tender; no adherent masses. Presumption is
then that the tubes are not inflamed, and that perhaps the ovaries
are the seat of multiple retention cysts.

We advised repair of tears and an anterior round ligament suspen-
sion, with inspection of ovaries.

Operation July 2, 1915. Emmet's repair of perineum. D. & C.
Repair of cervix. Abdominal incision, median. Ovaries found
free of adhesions, but the seat of a solid tumor, both enlarged to two
or three times normal size and giving the appearance of carcinoma.

No other nodules found and in view of our previous operations it
was thought best to do a simple double salpingo-oophorectomy,
reasoning that such an advanced stage of involvement, if malignant,
would mean an exhausting operation in addition to the several
already done, to remove all metastases.

Uterus fixed to anterior fascial wall. Appendix removed. Wound
closed.

Patient did well. Made an uneventful recovery, and while
in the hospital was not much nauseated.

On July 17, 1915, we received the pathologist's report (Dr. D.
B. Pfeiffer):

Neoplasm of ovary. Both ovaries microscopically show diffuse
infiltration with large round cells, which lie loosely in the interstices
of the ovarian stroma, without definite arrangement.

These cells vary somewhat in size and in the stroma reaction.
The small cells have a well-defined rounded nucleus and protoplasm
take a diffuse pink stain.

The larger cells have an irregular small densely staining nucleus,
eccentrically situated; the protoplasm shows a fine reticular struc-
ture and does not stain. These cells strongly resemble the so-called
foam cells seen in Krukenberg's tumor, which represents the type

foulkrod: krukenberg's tumor of the ovaries 659

of a bilateral ovarian tumor associated often with carcinoma of
the stomach. The ovaries are much smaller than commonly seen
in this condition, but I believe it is a very early stage of the same.

Scrapings. Uterine musculature without endometrium shows
chronic inflammation.

AppendLx. Chronic interstitial appendicitis, minor lesions only.

The next day the contents of the stomach analyzed gave the
following:

Mrs. Mary McN. July i8, 1915. Ewald test-meal.

Quantity, 50 c.c. Occult blood, negative.

Color, pale yeUow. Free HCl, negative.

Odor, sour. Total acidity, 16.

Reaction, slightly acid Lactic, negative.

to litmus. Many fat globules.

Consistency, mucous. Many starch granules.

Bile, negative. Oppler-B. Bac. — Neg.

The patient was allowed to go home after a careful explanation
had been made to her husband and physician, and we were sure that
no palpable tumor existed in the upper abdomen.

Examination of stool for occult blood, negative.

In December of 191 5 her physician referred her to me again with
the report that after going home the nausea and vomiting of fluid
continued unabated, although she had gained slightly in weight.

Basing our judgment upon the previous condition of anacidity,
she was placed on dilute HCl, but was not much benefitted. She
was then placed upon dilute nitrohydrochloric; seemed very much
better; nausea entirely ceased and for a time it seemed as though we
had found the solution of the difficulty.

But again, late in January, she returned as much nauseated as
ever, and in February was sent to the medical ward of the Presby-
terian Hospital for a;-ray diagnosis of a small mass now palpable in
the region of the pylorus with these findings — epigastric mass
size of large egg, tender and some gurgling on pressure.

Weight, 2d mo. 20, 1916, iiij^; 3/5/16, iii3^; 3/11/16, logj^.

Urine, 1020 — 1033; acid, trace of albumin, no casts.

Blood, H. 65. Whites, 7450; reds, 3,230,000.

2/21/16. Wassermann, negative.

3/1/16. Stomach contents 92 c.c. pale yellow. Sour, mucous;
bile negative. Blood present; free HCl, 6; total acid, 20; starch
and fat.

3/13/16. Vomited 170 c.c. colorless liquid; acid, mucous; bile
and blood present.

HCl, negative; total acid, 26; few red B. C.

3/5/16. A'-ray picture shows a mass involving the entire lesser
curvature and the pylorus.

Basing his judgment upon these pictures and a fluoroscopic
examination, operation was considered futile by the surgeon on duty.
The patient, anxious to get relief from nausea, agreed to go to the
Jefierson Hospital, and Dr. Francis T. Stewart made an exploratory

660 shoemaker: impacted tumor of the pelvis

incision, found the entire stomach the seat of a growth, of which he
was unable to secure a specimen, and which precluded the possibility
of a posterior gastroenterostomy. With difficulty he found enough
healthy tissue on the anterior wall to do an anterior gastroenteros-
tomy.

The patient was for a short time relieved of her nausea, but even
before leaving the hospital, e\'inced a slight return.

The pelvis at this operation was digitally explored and found to be
the seat of many adhesions and recurrent growth.

No one will ever be able to accurately determine which was the
primary growth. Certainly to me the ovaries seem to be so in this
case. The early stage, found accidentally, the lack of adhesion, of
local extension, the inabihty at first operation to find any palpable
tumor in the region of the stomach, all point to some change in the
ovaries excited by the course of pregnancy.

I. IMPACTED TUMOR OF THE PELVIS WITH ACUTE
URINARY OBSTRUCTION. II. PELVIC PNEUMO-
COCCUS ABSCESS.*

BY
GEORGE ERETY SHOEMAKER, M. D., F. A. C. S.,

Gynecologist to the Presbyterian Hospital, Philadelphia.

The disastrous effect of compression of the ureters by pelvic
growths is not to be forgotten in connection with the question of
their removal or nonremoval. The writer reported a case of uremia
produced by the wedge-like action of a fibroma of the uterus (Am-
erican Medicine, vol. viii. No. 24, 1914.) He has recently operated
upon a deep pelvic growth where the legs were edematous, the pound-
ing headache severe, and the blood pressure 215, apparently due to
the above cause, as there was no nephritis and the blood pressure
fell to 180 after removal of the pressure from the tumor.

Dilation of the ureters and death from back pressure on the kid-
neys may be due to the nipping of the ureters bj- uterine carcinoma.
The writer has seen the ureters tortuous and dilated to the size of
the finger from this cause. Very rarely partial obstruction from
kinking follows pelvic inflammation.

Much more unusual, however, in the writer's experience is any
interference with the urethral canal by pressure; because tumors
usually do not form low enough in the pelvic outlet to compress the
urethra against the pubic bone. The writer has recently recorded
in Surgery, Gynecology and Obstetrics, a case of obstruction of the

♦Read before the Obstetrical Society of Philadelphia, May 4, 1916.

shoemaker: impacted tumor of the PEL\^s 661

urethra and urinary retention from carcinoma of the urethra itself;
but the following is the onh' instance in his experience in which a
pelvic tumor has succeeded in actually shutting it o& by external
pressure, though it is frequently greatly elongated by traction or
contorted.

Mrs. T., aged fifty, para-ii was referred by her physician for acute
urinary retention, with chill, fever and very great abdominal disten-
tion from a combination of intestinal distention, overfilled bladder
and a fixed cystic pelvic tumor, the whole combined with a marked
spinal kj^Dhosis which thrust her abdomen forward in a way most
embarrassing to the effort at diagnosis and treatment.

Leukocytosis of 48,400. The catheter withdrew 103 ounces,
(6J^ pints) of urine without diminishing the distention.

The overdistention of the bladder caused muscular paralysis of
its walls, and was followed by copious purulent cystitis, with tube
casts. However, irrigation and continuous drainage with a Pezzer
catheter cleared this up, and abdominal section was performed thirty-
six daj's later under gas — oxygen — ether, in the presence of a
bronchitis.

The pelvic growth was a papillary carcinomatous cyst originating
deep in the pelvis. The contents were chocolate colored, the solid
portion of the cyst wall infiltrated the left broad ligament.

The intestines and parietal peritoneum were studded with millet
seed sized tubercles, doubtless of the same nature as the spinal caries
which caused the old k}^hosis.

The patient regained complete control of her bladder and left the
hospital in good condition. At present, seven months later, she
goes about freely and her condition is surprisingly comfortable,
though of course ultimately hopeless.

II. PNEUMOCOCCUS ABSCESS OF THE PELVIS WITH RECTAL PERFORATION.

The widespread prevalence of influenza and pneumonia during
the past winter has brought to the surgeon many complications of
which the following may be considered an example.

Mrs. E. H., aged thirty-five, about one month before coming
under observation, had an attack resembling influenza, with coryza,
fever in the afternoons, very severe cough, free perspiration, subster-
nal soreness. She swallowed all of her e.xpectorate. Two weeks
later, she had severe abdominal pain and distention for several
days, fever and profuse sweating. Several days later while defecat-
ing, there was a bursting sensation, which was followed by a profuse
gush from the rectum, of a quantity of yellow discharge, described
as purulent. On admission to the Presbyterian Hospital, three days
later, the pelvis was found filled by a fixed mass very hard below but
softer above. The diagnosis was made of pelvic abscess which had
ruptured into the rectum. Dr. Pemberton kindly examined the
chest but found no consolidation. Vaginal smears were negative
for gonococci, the leukocytes were 15,550.

662 RIGGLES: RELATION OF CONVULSIONS TO PELVIC DISEASE

Although drainage had been already established into the rectum
by nature and the temperature had fallen to normal practically, it
was considered advisable to establish drainage by the vagina, as
less likely to result in a permanent succession of abscesses which
would fill and empty into the bowel, with the constant presence
of the colon bacillis. It was thought that with good vaginal drain-
age for the field, the rectal perforation would heal, and this proved
to be the case. The abdomen was opened. A very well-organized
diaphragm was found above the inflammatory area, made up of
omentum and plastic material. This diaphragm was preserved
as well as possible, and after the operation, served admirably when
laid back, to cover the purulent field. Many epiploic appendages,
both tubes and the left ovary were involved in the abscess. The
abundant pus was thick and gray, with a strong odor. Both tubes and
one ovary were removed. The bowel perforation could not be distin-
guished in the roughened tissues. The vagina was opened on a for-
ceps point and a gauze drain carried into the pelvis.

An interesting feature was the occurrence of masses of clear yellow-
ish, jelly-like material of the consistence of calf's foot jelly, lying
between coils of intestine; some of these masses were an inch in
diameter: they were above and outside of the purulent field.

Cultures made from the abdominal pus and later from the dis-
charge from the vaginal drainage tract, showed the pneumococcus
and the colon bacillis. The patient left the hospital some five weeks
later with all wounds closed, and gaining in weight. There was
no discharge from the rectum or from the site of the vaginal opening.

1 83 1 Chestnut Street.

RELATION OF CON\'ULSIONS TO PELVIC DISEASE*.

J. LEWaS RIGGLES, M. D., F. A. C. S.,

Associate Gynecologist, Columbia Hospital; Associate in Gynecology, George

Washington Medical School and Hospital,

Washington, D. C.

I WISH to call to the attention of the Society the significance that
may be found in the relationship of pelvic disease and certain
nervous phenomena in women, and to illustrate this by reporting a
case of acute torsion of the Fallopian tube in a patient who had
been a sufferer from hysteroepilepsy.

It will be impossible to discuss the subject of epilepsy, hystero-
epilepsy or hysteria, but I wish to emphasize that in neuropathic
women who have chronic disease of the uterus and adnexa, much
may be done to relieve the various nervous manifestations by
appropriate operation.

Every speciality has been called upon to relieve that most dis-

* Read before the Washington Obstetrical and Gynecological Society, April
9, 1916.

PaCGLES: RELATION OF CON\TJLSIONS TO PEL\1C DISEASE 663

tressing symptom, convulsions; and all have reported cures; for
instance, circumcision in children, removal of nasal poh-pi, correc-
tion of obstipation or enteroptosis, have been followed by permanent
relief. Yet we must be very guarded in our prognosis and be sure
we are not dealing with true epilepsy.

The mental and physical activities of a woman reach the highest
point just before her menstrual period. When obstructive dys-
menorrhea is present, the nervous action is perverted and there
is great suffering, not only in the abdomen, but throughout the general
system, shocking most seriously the nervous organism.

The question of possible motor irritation resulting in excessive
muscular action or spasm must be inquired into, because the presence
of either tonic or clonic convulsions implies irritation of motor centers,
motor tracts, or motor nerves, but motor irritation may also be
excited secondarily by some reflex route.

The full control of the function of a pelvic viscus, as for example,
the bladder is dependent upon the reflex centers of the spinal cord
and the integrity of the afferent and efferent nerve fibers constituting
the arcs from these organs to the cord. Through the operation of
the will evacuation of the bladder or rectum occurs normally, but
any undue irritability of the reflex centers perverts the impulses to
the organ and various phenomena result. Organic disease in any
part of the body is usually an irritant to some nerve, and women in
particular have highly sensitive nerve centers, which are easily put
upon great tension with a resulting abnormal action.

Epileps}-, epileptoid convulsions and hysteria are so closely allied,
that many times cases presenting convulsions are difficult to classify.
A definition of idiopathic epilepsy is almost always open to argument
and confusion in diagnosis is very common.

Periodical convulsive attacks are most commonly due to toxemia
of some kind, or to trauma. Although these cases simulate very
closely true epilepsy, yet they do not present as tj'pical a clinical
picture of an epileptic fit as do the cases usually termed hystero-
epilepsy. As the case here reported suggests, some chronic irritation
through the spinal arcs to the cord and brain, may result in a
convulsion.

Bossi, in a French obstetrical review, believes that hysteria and
many neuropathic and psychopathic conditions with their resulting
suicides and crimes may be dependent upon chronic lesions of the
genital organs. He cites cases in which hysteroepilepsy has
occurred in individuals in whom it was possible to demonstrate the
presence of chronic genital disease. He also believes that insane

664 higgles: relation of convuxsions to pelvic disease

and extremely neurotic women should be carefully examined and if
gjmecologic lesions are found, they should receive appropriate
treatment.

There is a view that a distinct sympathy exists between the pelvic
organs and the mind of a woman, and it is this idea that gave origin
to the doctrine that pelvic disease may cause insanity and that the
cure of pelvic disease may cure insanity.

A very extraordinary report by Hobbes, in which he warmly
recommends operating upon the insane, is as follows: Of 211
women whom he examined, 179 exhibited well-marked evidences of
pelvic lesions. He operated upon 116 of these with two deaths.
51 per cent, were restored to mental health and 7 per cent, were
distinctly improved mentally.

Mutilation or extirpation of the pelvic organs in mental cases
without definite pathological changes is not accepted by either sur-
geons or neurologists, but where there is organic disease, as ovarian,
tubal or pelvic adhesions with dysmenorrhea and nervous phenomena,
recovery will often follow removal of the disease.

Ten years ago, I removed two cystic ovaries in a girl of eighteen
years. She gave a history of severe dysmenorrhea accompanied with
convulsions diagnosed as epilepsy. She reported to me for two years
after operation, during which time she was perfectly well. I then
lost track of her.

Munson says that operations on other parts of the body than the
cranium are frequently performed with the view of removing a
peripheral irritation which is having an unfortunate iniiuence on
epilepsy. Naturally it is a good general principle to adhere to, that
the individual should be placed in the best possible physical condition
and that this should be done by operation if necessary. Peripheral
causes undoubtedly play some role in isolated cases of epilepsy.
Auer also gives among the exciting causes of epilepsy reflex action
through disease of the viscera.

It is a fairly well accepted idea that in an individual predisposed
to epilepsy, reflex irritation from some pathological condition, even
in such a place as the peritoneal cavity, may cause seizures. Decom-
pression operations for focal disease in the cortex, I understand, has
been practically abandoned.

Torsion of the Fallopian tube is a comparatively rare condition,
and a search through the literature shows few recorded cases. In
the laboratory of the University of Pennsylvania, one case of torsion
occurred in 925 inflammatory tubal lesions of which 147 were hydro-
salpinx or hematosalpinx.

juggles: relation of con\-ulsions to pelvic disease 665

Anspach collected eighty-seven cases from the literature. Most
all were hydrosalpinx with thin adhesions, long pedicles and located
on the right side. The chief enlargement is situated in the ampulla
of the tube and this is connected with the cornua of the uterus by a
fairly long pedicle with thin mesosalpinx. These cases were not
diagnosed before operation and are not to be confused with twisted
ovarian cyst.

In Cathelin's series of forty-one cases, "de la torsion des hydrosal-
pinx," Rev. de Chir., Paris, 1901, there were six pyosalpinges and he
beUeved that some of these were originally hydrosalpinx which had
become reinfected.

Collection of blood in the tube or hematosalpinx is generally
attributed to ectopic pregnancy, but A. Louise Mcllroy some little
while ago indicated the possibility of this occurrence from torsion
of the Fallopian tube, and recounts the history of a case in which
there was doubt prior to the operation as to the diagnosis between
ectopic pregnancy and incarcerated fibroid. The operation dis-
closed a hematoma from a twist in the tube. Rupture of a hemato-
salpinx is exceedingly rare, but abdominal abortion usually occurs
in pregnancy of the tube.*

Case. — Mrs. B., a white female, aged fifty-six years, was operated
on by me ten years ago after having had hysteroepilepsy for fifteen
years. Following the operation she has had no seizures. The family
history showed no record of convulsions. Her birth and early child-
hood were uneventful except for an attack of rheumatism when five
years old. Menstruation was not established until she was seventeen
years old and dysmenorrhea was always present preceding the flow,
which lasted from six to ten days. She was married at eighteen and
one year later was delivered of her first child. Labor was normal, lasted
two days and no instruments were used. Three other labors came
at intervals with nothing unusual about them. At the age of thirty
(twenty-six years ago) she was delivered of her last child; labor was
prolonged and hard, but no instruments were used. Following
this labor, the menstrual flux became irregular, with increased
dysmenorrhea, and she sufi'ered from pelvic pains, backache and
dragging in the Uiac regions. These symptoms were almost con-
stant and rapidly exhausted her general condition.

The nervous system seemed to suffer most, and two years later,
while undergoing one of her attacks of dysmenorrhea, she had a
convulsion. For a few years following this each period was preceded
by one of these seizures and after the appearance of the flow which
relieved the colicky pains she would be quite comfortable. Her
condition gradually grew worse and convulsions occurred at frequent
intervals, having no respect for the time of the month, eight typical
attacks developing in one day. These convulsions were diagnosed

* Keen's Surgery, vol. vi.

666 HIGGLES: RELATION OF CON\'ULSIONS TO PEL\1C DISEASE

by her family physician as "epilepsy," and from the family's de-
scription of the fit, I think he was warranted in arriving at such a
conclusion. The convulsions were described as being accompanied
by frothing at the mouth and biting of the tongue; they were fol-
lowed by a headache and temporary amnesia. These seizures lasted
for fifteen years; other symptoms complained of during this time
were backache, h\-peridrosis and metrorrhagia.

On October i, 1906, she visited her home, and while helping a
nurse in the confinement of her daughter-in-law, was attacked with
severe colicky pains in the right iliac region. The attending physi-
cian made a diagnosis of appendicitis and insisted on immediate
operation; this was refused and she was brought to Washington.
I saw her the day after her arrival, two days after the first attack
of pain. She was suffering from severe pain in the right ihac region
which was continuous and colicky; superficial pressure caused
increased suffering, while deep pressure relieved her a little. The
good character of her pulse, which was 80, and temperature, which
since the attack had not risen above 99.5, made the diagnosis of
appendicitis doubtful. I determined to wait a few days, in which
time the intestinal canal was thoroughly cleansed and the pulse and
temperature carefully watched. Vaginal examination revealed a
high, immovable cervix and tense vaginal vault, but no tumor could
be palpated on account of the extreme tenderness and rigidity of the
abdominal wall. The pain did not abate with the relief of the
abdominal gas, but seemed to increase, requiring large doses of
heroin. The ice-cap was of no service; she finally consented to
abdominal section for the rehef of the pain, and I operated on her the
following Thursday, six days after the first attack of coHc. An
examination under chloroform revealed a large mass to the right of
the uterus and a small one to the left. Urinalysis had eliminated
ureteral stone and kidney disease; blood examination was not done.

Operation. — A median incision was made, adhesions to the omen-
tum and bowel were separated from both appendages; the left
tumor, being smaller than the right, was first raised into the wound
and I removed a fairly good-sized hydrosalpinx and cystic ovary.
Beginning on the right side of the uterus, I separated adhesions from
the mass on that side and exposed a tumor about the size of a large
orange, very dark in color and containing fluid. There was no
special difficulty in removing the large hematosalpinx. The wound
was closed by subcutaneous tier sutures with no drainage. The
patient's recovery was uneventful and there have been no convulsive
attacks since the operation, now ten years ago.

This case seemed to me to be an interesting one, for several
reasons. First, because of the specimen which is a true hemato-
salpinx, due to twisting of the Fallopian isthmus, thereby obstructing
the circulation and consequently causing the venous capillaries to
rupture into a chronically inflamed, cystic tube, which is the usual
preceding pathological condition in cases of this kind. Simple
hematosalpinx or a tube distended by fluid blood is very rare and

RIGGLES: RELATION OF CONVULSIONS TO PELVIC DISEASE 667

should not be confounded with a bloody tumor of the tube due to
bleeding from a tubal pregnancy. This specimen seemed to be a
true hematosalpinx due to volvulus, and the pathologists have
confirmed this idea, with the additional information that parts of
the tumor were undergoing organization and tunneling with no
evidence of necrosis in spite of the color. Adhesions over the ovary
and abdominal end of the tube prevented the escape of blood and
the possible introduction of infection into the peritoneal cavity.

Second, the diagnosis was most uncertain. The history of such
an acute attack suggested a twisted pedicle of an ovarian cyst. We
could not exclude appendix disease or pyosalpinx, and ureteral stone
was a possibiUty. The general condition of the patient was excel-
lent contrary to what might have been expected from her great
suffering, her pulse and temperature were approximately normal
throughout the attack so I did not subject her to section quite as
early as is customary.

Third, it does not seem very probable that the chronic disease of
the uterine appendages was the original cause of the convulsions as
they existed for a number of years prior to the first detection of a
pelvic mass. Of course we must consider the possibility of a long-
standing infection of the appendages producing no demonstrable
physical changes and yet acting reflexly on the central nervous
system.

CONCLUSIONS.

In looking at . this case as one of epilepsy, or better, hystero-
epilepsy, cured by a gynecological operation, we must of course
remember that, as White says, "an explanation for epileptic at-
tacks which finds its ultimate expression under such symbols as
eye-strain, floating kidney, gliosis or hke specific indictments fails to
realize that the nervous system contains representations of all the
organs and that the final activity of the human body is the result of
the balance which has been struck among innumerable tendencies.
The part that any particular organ plays can only be understood
when taken into consideration with the organism in its totality and
realizing the specific part that the organ in question plays in the
whole problem."

In the case I have presented, we have a disease of the generative
organs with which it seems probable that this woman's convulsions
were intimately associated, coming on as it did after her last labor,
a severe one, followed by a long train of painful symptoms. The
rehef was probably then threefold: the actual physical relief due to
the removal of the mass, the reflex relief from the cessation of irrita-

668 HIGGLES : RELATION OF CON\'ULSIONS TO PELVIC DISEASE

tion and the psychic relief aSorded by her belief in freedom from
future disturbances. Of course it is well known that any therapeutic
procedure may arrest convulsions in an epileptic for a time, but after
an interval of ten years, I think we may be justified in regarding the
case as cured.

This case emphasizes the value of a thorough physical overhauling
in cases of epilepsy or hysteroepilepsy, especially those developing
comparatively late in life, in order not to overlook any possible form
of trouble which may be obviously connected with the central nervous
system. In women, the pelvic viscera should be especially scrutin-
ized on account of the important part which these play in their
physiology and psychology.

I am indebted to Dr. John E. Lind of the Government Hospital
for the Insane for assistance in this paper.

REFERENCES.

1. Auer, E. Murray. Sensory Phenomena in Epilepsy. Anter.
Jour, of Insanity, Jan., 1916.

2. Anspach. Trans. Amer.Gyn. Soc. , igi2.

3. Bell, R. H. Jour. Obst. andGyn. of Brit. Empire, 1904, No. 5.

4. Bossi. French Obstetric Review.

5. Cathelin. Rev. di. chi Paris, igoi.

6. Church and Patterson. Nervous and Menial Diseases.

7. Clark L. Pierce. A Clinical Contribution of the Diagnosis of
Epilepsy. Trans, of the Natl. Assn. for the Study of Epilepsy, etc.,
1914-

8. Clark L. Pierce. Clinical Studies in Epilepsy. Psychiairic
Bulletin, Jan., 1916, vol. be, No. i.

9. Clark, L. Pierce. Nature and Pathogenesis of Epilepsy.
N. Y. Med. Journ., Feb. 27, Mar. 27, 1915.

10. DeLee. Obstetrics, Principles and Practise of.

11. [Ferenczi. Entwicklungsstufen des Eitelkeitssinnes, Inter-
nationale Zeitschr. f. Acrtzliche Psychoanalyse, 1913, vol. i.

12. Flood. Boston Med. and Surg. Jour., vol. cYva, 1^0. %22,.

13. Journal of Nervous and Mental Diseases, May, 1907.

14. Kelly and Noble. Abdominal Surgery.

15. Mcllrey, A. L. Jour. Gyn. and Obst. of Brit. Empire, 1910,
368.

16. Munson, J. F. The Treatment of the Epilepsies. In the
Modern Treatment of Nervous and Mental Diseases. Ed. by
White and Jelliffe. 1913, vol. ii.

17. Norris. Gonorrhea in Women.

18. Reed, Charles A. L. Diagnostic Methods and Pathological
Constants in Idiopathic Epilepsy. Jour. A . M. A., Jan. 29, 1916, pp.

336-345-

19. Spangler. N. Y. Med. Jour. vol. xcii, p. 462.

20. Spratling, Wm. P. Epilepsy and its Treatment.

grasty: acute lymphatic leukemia 669

21. Thorn and Southard. An Anatomical Search for Idiopathic
Epilepsy. Review of Neurology and Psychiatry, Oct., 191 5, vol.
xiii, No. 10.

22. Turner. Epilepsia, vol. ii, p. loi. London, Eng.

23. White and Jelliffe. Diseases of the Nervous System, 191 5.
The Champlain.

ACUTE LYMPHATIC LEUKEMIA.*

BY
THOMAS S. D. GRASTY, M. D.,

Washington, D. C.

When Hughes Bennett, in 1845, published his account of a case of
"suppuration of the blood with enlargement of the spleen and liver,"
one of the greatest controversies of modern medicine was brought
into being. To Bennett, the blood at autopsy, was filled with what
he believed to be pus cells. No evidence of pyemia or pus absorption
was to be found, so he came to the conclusion that he was confront-
ing a new and distinct condition in which pus cells in large numbers
originated within the blood stream. For the enlargement of the
liver and spleen he could give no plausible account. A few weeks
subsequent to the appearance of Bennett's paper, Virchow presented
to the medical world an account of a similar case, but Virchow dif-
fered with Bennett in his conclusion as to the actual state of the blood
in so far as the exact nature of the corpuscular elements was con-
cerned. The "white blood," to Virchow's mind, was not due to the
presence of pus corpuscles, but was the direct result of the presence
in the circulating fluid of a very large number of white blood cells.
Furthermore, it was the opinion of Virchow, expressed at the time,
that between the marked splenic enlargement and the peculiar state
of the blood there was more than a coincidence — there was a direct
relationship. Knowing his own and other cases, Virchow proposed
for the newly discovered disease the name of "leukemia," white
blood. Now followed the long discussion with Bennett as to the
priority of discovery of a pathological process which had excited the
widest interest among medical men. Old cases, probably pyemic,
were brought to light and thoroughly discussed. With the attention
of the profession directed to the new disease, reports of cases ap-
peared rapidly and Virchow was enabled, with the ever-increasing
material at hand, to push his researches with vigor and effect. In
his earliest case, Virchow had found the splenic enlargement to
be the marked feature of the gross pathological picture and in conse-
quence, had named the disease "splenic leukemia." He now re-

*Read before the Washington Obstetrical and Gynecological Society, April
9, 1916.

670 grasty: acute lymphatic leukemia

ported a case in which the condition differed from the preceding ones
in that the enlargement of the lymphatic glands was the feature of the
gross pathology and the presence of an enormous number of small
white cells the striking feature of the blood findings. To this con-
dition Virchow gave the name of "lymphatic leukemia." And in
regard to this condition so eminent an authority as Osier states
that the acute form of the disease is "one of the most terrible of all
the blood diseases." Since the publication of the findings of Vir-
chow, the study of the leukemias has proved of marked interest to
pathologists; and the acquisition of fact after fact has greatly simpli-
fied the accurate study of the malady and rendered possible the dif-
ferentiation of the original disease into separate and distinct condi-
tions, all dependent, in differentiation, upon a careful microscopic
study of the blood. The studies of Ehrlich on blood staining and the
introduction of his diagnostic methods; the researches of Ebstein
and Fraenkel have been, along with the work of Neumann, note-
worthy events in the recorded history of the disease. Among the
early writers, two forms of the disease were recognized — one in which
the splenic and one in which the glandular enlargements predomi-
nated. At a later date when Neumann added to the literature a
description of cases in which changes in the bone marrow were
prominent, the term "myelogenous leukemias" came in to general
use. It was soon evident that a nomenclature based on the gross
anatomic findings was misleading. The investigation and classifica-
tion of leukocytes by EhrHch and their application to the diagnosis
of the leukemias has proved of inestimable value. As to the nature
of the leukemias, theory after theory has been advanced and dis-
carded. Since the first writings of Bennett and Virchow, the pioneers
in the study of the disease or diseases which are to-day grouped under
the term "leukemia," the debate has been an eager one. Concept
after concept was presented, analyzed and abandoned. Bennett
argued that it was a suppuration of the blood. Lowit claimed that it
was due to a prolongation of the lives of the leukocytes and a retarda-
tion of their evolutionary process. Virchow maintained that the
disease was allied to the malignant tumors, while on the other hand
a school of theorists arose which maintained that the disease was in
reality a specific, infectious malady and that the increase in the
number of the white cells was a protective leukocytosis. Bacterial
forms have been described, but proof is wanting of the direct
etiological relationship. Certainly when the rapidly progressive
and fatal character of acute lymphatic leukemia is taken into con-
sideration, the doctrine of the analogy to the malignant tumors must

grasty: acute lymphatic leukemia 671

be thrown to the winds, for acute lymphatic leukemia has no counter-
part, clinically speaking, among the malignant tumors. Acute
lymphatic leukemia is of much less frequent occurrence than the
m)'elogenous form of the disease, though in a series of ten cases,
four were of the lymphatic variety. According to Osier, males are
more frequently affected than females. From the standpoint of the
clinicians^ however, two distinct forms of leukemia, based on the
blood count, are recognized.

1. Splenomedullary; splenic enlargement marked. Blood count
shows a loss of red cells, the presence of nucleated red cells and mye-
locytes— abnormal to the circulation — and an increase in all other
forms. The blood presents the "polymorphous" condition.

2. Lymphatic leukemia. Acute form — large lymphocytes.
Chronic form — small lymphocytes. The acute form begins sud
denly and proceeds to a rapidly fatal termination, resembling in every
respect a severe, acute infection, Fever, epistaxis, bleeding from
the gums and mucous surfaces, purpuric spots, a rapidly progressive
anemia together with a moderate enlargement of the spleen and
glands, characterize the majority of the cases. Recorded cases
show a duration of four weeks in the acute form, but as a rule, the
fatal end is reached in about ten days. The slow progressive type
in which the patient survives for weeks is generally the chronic type
of the disease.

Patliology. — Blood pale and opaque, clots readily and has a pus-
like appearance suggestive of an acute abscess. Charcot-Leyden
crystals may be found. To spread the blood in a thin layer is a
diflScult matter, and for the accurate study of the cells, a method of
straining showing the granulations of the leukocytes must be used.
Not only quantitative but qualitative distinctions in the cells
exist, corresponding to the deep-seated changes in the affected
tissues. The red cell count and the hemaglobin is reduced, and in
the event of hemorrhages, this reduction may be marked. The
great change in the blood in the lymphatic form, is the enormous
increase in the circulating fluid of the lymphocytes — forming at times
90 per cent, of the total leukocyte count. An absolute decrease in
the polymorphonuclear leukocytes and eosinophiles has been noted.
The first cell in the lymphatic form of the disease is the lymphocyte —
the large lymphocyte in the acute, fulminating form of the malady,
and the small lymphocyte in the chronic form. The marrow of the
bones is of a reddish or grayish-red color. Lymphocytes are present
in large numbers. In the spleen, marked enlargement is not the
rule. Lymphocytic infiltration and lymphoid tumors of the bones

672 grasty: acute lymphatic leukemia

and viscera are present. On section the enlarged lymphatic glands
are of a pinkish color and show a great increase in the number of
lymphocytes. Similar changes, lymphoid infiltration, may be found
in the liver and other organs which are increased in size, and exhibit,
in the symptomatology, consequent disorders of function.

Benzol Treatment of Leukemia. — A few years ago. Von Koryan and
his pupils, after an extended experience with benzol in the treatment
of leukemia, came to the conclusion that it afforded the only hope
of a cure of the disease. Under the use of this agent, a transient
increase in the leukocytes is followed by a rapid fall, the manifest
enlargement in the glands and spleen disappears, the mental symp-
toms ameliorate, the red cells and the hemoglobin increase, and the
general condition of the patient is much improved. The benzol
treatment may be used in all forms of the disease. Mter the initial
increase in the number of white cells has subsided (about ten days)
the medicine should be cont inued until the white cell count is nearly
normal and stopped — the decrease in the white cells continues for
some time after the discontinuance of the medicine and if continued
too long, will result in a leukopenia.

Dosage. — Three to four grams (40-60 drops) daily in capsule or
olive oil, but always after meals. Avoid gastric irritation and test
the urine frequently for benzol. Hematuria calls for the immediate
discontinuance of the benzol. A number of observers have noted
good efiFects from the use of the .x--ray with the benzol treatment.

Case I. — The patient, H. B., was admitted to the wai;ds of
Providence Hospital July 17, 1914, complaining at the time of loss
of strength and general debility extending over a period of two
months and of an extreme degree of prostration during the last two
weeks.

As far as the present case is concerned, the family history is
negative, there being in the family no history of hemic disorders.
The father died of pneumonia, a brother died of cholera infantum
and a sister died of diphtheria.

Past History. — General health has always been good. No history
of any of the diseases of childhood with the exception of an attack
of malaria at the age of six years. No subsequent attacks of malaria
noted. As a rule, the patient was not in the habit of indulging in a
meat diet, but was however, very fond of sweetmeats in which she
indulged frequently. Was accustomed to dancing and frequently
remained out late at nights. Occupation typist.

Present History. — At the present time the patient is suffering from
loss of strength and marked general debility, together with frequent
headaches. This condition has been quite marked for the past two
weeks. She states that about two weeks ago was exposed to a

grasty: acute lymphatic leukemia

673

severe storm and that immediately afterward her ankles began to
swell. Dizziness, headache and marked difficulty in breathing soon
appeared. Slight bleeding from the gums now appeared for the
first time. No other hemorrhagic manifestations. The digestive
tract shows no evidence of disturbance. About this time, enlarge-
ment of the spleen and cervical glands was noted. Soon pain and
tenderness in these regions was complained of by the patient. Up
to July 17th, the date of her admission to the hospital, the condition
of the patient, as regards the general symptomatology, grew worse
until death occurred two months later.

Blood Examination. — •

July 14 37,000

22 29,000

23 20,000

25 14,000

29 11,400

.\ug. 2 12,000

9 10,400

17 10,800

Sept. 2 S4,ooo

6 58,000

9 48,800

12 ] 24,600

14 1 Patient died.

1,320,000
1,170,000
1 ,000,000

700,000
1,254,000
1,200,000
1,280,000
1,518,000
1,100,000
1,050,000
1,040,000

720,000

Treatment. — Red bone marrow. Iron and arsenic.
July 22d. Above treatment discontinued. Benzol 5 drops t.i.d.
-X-ray applied over left leg.
25th. Benzol stopped. .i;-ray continued.

Quinine hydrochloride grs. v. every four hours.
29th. Iron arsenate began.
August 2d. Quinine discontinued.
Sept. 2d. Benzol treatment resumed.
9th. Benzol treatment stopped.
Wassermann July 30th reported negative.

674 TRANSACTIONS OF THE

TRANSACTIONS OF THE AMERICAN GYNECO-
LOGICAL SOCIETY.

{Continued from page, 334.)

TISSUE TONE AS AN INDEX TO VITAL RESISTANCE -WITH SPECIAL
REFERENCE TO PROLAPSE OF THE UTERUS.

Dr. R. R. Huggins, of Pittsburgh, stated that the future problems
for the surgeon to decide, so far as operative mortahty was concerned,
dealt largely with a better knowledge of the horsepower of his
patient. The excursion undertaken by the patient when surgery
was employed was best described by comparing it with a Marathon
race. In major operations the patient was subjected to almost the
same test that came to the athlete under severe strain. The
problem for the surgeon to decide was how far and with what speed
could a given heart be driven so that the patient might remain within
the limits of safety.

His study showed that it was not only failure of the cardiac muscle
to withstand the stress, but in some instances exhaustion of the
muscular structure of the stomach and intestines and death ensued
from a condition which had been termed paralytic ileus. The under-
lying condition might best be described as one of chronic fatigue and
the tissue changes which occurred might be directly due to long-
continued absorption of toxins, infections, starvation or to changes
in the sympathetic nervous system which remained obscure and were
not understood. One must keep in mind that the maintenance of
the circulation was not carried out by the heart alone. The varia-
tions which might occur were so complex that one should be able to
make accurate measurements upon the envelope as a whole if he was
to be certain of its efficiency. A weakened biceps and a flabby
heart muscle might be due to the same cause.

The object of this discussion was to call attention to the neces-
sity of a more accurate estimate of the tissue strength in general
for much depended upon a keen appreciation of the amount held in
reserve by every patient. A study of the patient's history together
with careful observation was, and would always remain, the most
reliable aids in forming an opinion as to the probable amount of
reserve strength in the given patient. Much might be learned by a
careful examination of the resistance and consistency of the muscles
at rest and in action. The history of any disturbed condition in
the function of the thyroid gland always suggested the probability
of friable muscular tissue lacking both tone and strength. A kidney
function test should be made previous to every major operative

AMERICAN GYNECOLOGICAL SOCIETY 675

procedure. The value of the x-ray in certain instances should not
be overlooked. The electrocardiography might be another impor-
tant aid, but whether it was of great value in measuring the actual
strength of heart muscle had not yet been determined. His results
would be embodied in a later report.

Perhaps the method which offered the greatest possibilities was
that described by Graupeur and partly confirmed by the work of
Barringer. The essential features of this test were the deductions
made from systolic blood pressure after measured amounts of
work.

The author emphasized the importance of another danger signal
which might be observed by the gynecologist. A keen appreciation
of this danger was in some instances of great importance. He had
been impressed with the frequency with which loss of tissue tone
together with a flabby heart muscle was found in prolapse of the
uterus in certain individuals. His records showed that in looo
major gynecological operations there were fifteen deaths exclu-
sive of several deaths which occurred in different varieties of
infection which occurred following delivery. Three of these deaths
followed operative procedures for the relief of prolapse. In every
instance he was not unmindful of a certain risk and operation was
undertaken after careful consideration of the margin of safety and
the operative procedure adopted which might give the least amount
of stress. This experience together with the necessity of refusing
operation to several patients with prolapse on account of apparent
muscular weakness had led to the conclusion that in certain cases of
prolapse uteri serious consideration should be given to the study
of the general condition of the patient with especial attention directed
to the heart muscle. A keen appreciation of this subject would
enable one to make a more accurate calculation of how much stress
a given patient would stand without fatal results. It would compel
one to select the form of anesthetic which threw the least amount of
work on the heart muscle and which lessened shock and postoperative
distress for in many instances it held the balance of power. It
would demonstrate the value of rest and careful treatment directed
toward increasing the strength of the patient previous to operation.

PAINLESS LABOR.

Dr. J. Clifton Edgar, of New York City, directed attention to
the recent general agitation over the question of painless labor, saying
it had accomplished much good, first, in stimulating research into
newer and even older methods of painless labor and, second, in
demonstrating that the use of some preparation of opium, intelli-
gently administered, was not as dangerous to the unborn child, as
had been supposed in the past, and third, in emphasizing the baneful
results of fear, pain and shock of labor upon the present and subse-
quent mental and physical condition of the highly civilized neuro-
pathic woman of the day.

Many, possibly the majority of the upper highly civilized class
of women were physically and mentally unlit to suffer an approach

676 TRANSACTIONS OF THE

to spontaneous labor, by reason of their low resistance to the shock
of labor; hence these women had pathological labors and were
themselves neuropathic.

Never before had the need for an artificial painless labor been more
urgent. Shock from the pain of labor in the highly civilized neurotic
woman must be reckoned with in general childbed mortality. Pain-
less labor in these women was a life-saving measure. Moreover,
shock produced by the iirst stage of labor in these patients was a
fact, not a theory.

For the moment there was no ideal single method of painless labor.
The only absolutely painless labor was one terminated by surgical
means with complete anesthesia. Conditions would always arise,
for example in early rupture of the membranes, in which the necessity
for painless labor would demand such surgical termination.

The ideal narcotic, analgesic anesthetic for painless labor should
possess the anoci-association of surgical practice, namely, first, the
blocking of pain, fear, shock and reflex sympathetic factors; second,
the removal of reflex spasm and its resulting spastic or functional
rigidity of the birth canal.

The most satisfactory painless labor method of the moment
combined opium and antispasmodics for the first stage, with possibly
vapor narcosis toward the end of this stage; vapor analgesia and
anesthesia for first and terminal parts of the second stage respectively
The narcosis aimed at until the perineal stage, should be analgesic
and not anesthetic in character, whether by drugs or vapor, a
difficult or impossible object to attain unless one had had con-
siderable experience.

Ether and chloroform were too well known to need comments.
Both in time lessened the force of the contractions and thereby
delayed labor. Unlike nitrous oxid vapor, they possessed no
oxytoxic action. They were the pain controllers of the second
stage, especially the perineal stage.

As an intermittent analgesic or anesthetic, the nitrous o.xid oxygen
mixture was well adapted to the second stage. Webster and his
associates had done much to make this method of painless labor
popular.

In the second stage, it did not interfere with uterine contractions
as did ether and chloroform, but by arresting pain prevented shock
and exhaustion, and the resistance not being lowered, the patient
was the better able to withstand subsequent infection or complica-
tion. The author's experience had been limited entirely to its use
in the second stage, and in all the mass of recent literature upon the
subject, he gathered it was of no value in the first stage, or the
writers avoided mention of its status in this stage.

In the hands of inexperienced hospital internes, the author's
results with this method had been deplorable, if not dangerous to
the patient. Under the management or supervision of a first-class
anesthetist, the method worked out beautifully.

He had experimented with three gas machines and finally settled
upon a simple single bag instrument.

AMERICAN GYNECOLOGICAL SOCIETY 677

He dissented from the announcement that the administration
was safe in unskilled hands. It was difficult to reconcile the state-
ment of the recent advocates of nitrous oxid-oxygen analgesia and
anesthesia, with the teachings of some of the most expert users of
this gas combination. On the other hand, we were repeatedly told
that the use of nitrous oxid and oxygen for analgesia and anesthesia
was a simple matter for one to become proficient in after a few
trials.

To sum up: Nitrous oxid-oxygen analgesia or obstetric ether oi
chloroform for the second stage, pushed to anesthesia for the
perineal stage; possibly forceps delivery with vapor anesthesia to
eliminate part of the second stage. Nitrous oxid-oxygen analgesia
or anesthesia was superior to any other during labor because of its
oxytoxic action. Eventually an established method of painless
labor might be related to public health questions. Lessening or
abolishing the pain of labor might in the future limit birth control
and criminal abortion. Drug addiction after a prolonged drug
narcosis in the neuropathic, was a possible contingency. The
dangers to the unborn or newly born child were negligible when drug
narcosis was limited to the first stage.

DISCUSSION.

Dr. Collin Foulkrod, of Philadelphia, gave an analysis of
thirty-two cases, personally observed and attended by him. Of
these nineteen were primiparae, and thirteen multipara. The
average time in labor was fourteen hours; twenty-two L.O.A. pre-
sentations; four R.O.P. presentations; three R.O.A. presenta-
tions; one face presentation; eight forceps deliveries, only two
above the perineum. All children living, and all mothers living.

The conclusions were not yet matured, but he would add one
point of view to the large number of cases collected to-day. The
fact that the number of cases was so small brought out one of the
strong criticisms against such methods.

There were only twenty-four hours in each day, and stretch them
as we might, an obstetrician must, at least, eat. If the develop-
ment of these methods of analgesia was demanded by patients, they
must come forth and engage two physicians, that they might act in
relays as it were. Both must be competent to judge of the effect
of the anesthetic used upon both mother and unborn baby. The
speaker had not yet reached such a stage that he could with equani-
mity go from a house and aUow a patient or even a nurse to continue
anesthesia over hours of time without some method of checking up
results. Were patients willing to compensate obstetricians for
such service?

It was unjust and perhaps dangerous to the best interest of the
patient to have the attending physician to minutely attend for hours
without rest and then to find the grave necessity of some serious
obstetrical operation placing him at a time when he was both
mentally and physically exhausted. At times, our best judgment
was matured away from the bedside in such exacting work.
9

678 TRANSACTIONS OF THE

There was no known accurate method of checking up the effects
upon the child iti ulero of any anesthesia administered to the
mother.

To advance the idea that careful watching of the fetal heart sounds
would show variations meaning danger to the child, e\'idenced an
entire ignorance of the principles of acoustics, and of the normal
variations of the heart sounds occurring during the mechanism of
laDor.

A few questions briefly answered from the writer's experience were
as follows:

1. Does nitrous oxid anesthesia quiet the patient? Yes, de-
cidedly so, when given during labor pains. He had found that all
patients complained less, were quieter between pains, and while
some averred that it was not as highly anesthetic as ether, which
they had had before, they received the measure of analgesia that the
operator wished.

2. Does it quiet the subjective sensation of pain? In 50 per
cent, of cases, decidedly so. In the balance, perhaps because of a
tolerance too much of the gas was required to get good analgesia.
By this is meant that, after finding the usual quantity needed for
the average pain and the average woman, he hesitated to go beyond
that quantity for reasons given below.

3. Does it retard or lengthen labor by quieting seuFation of pain?
Yes, if the pains are very frequent. Even with such a fleeting anes-
thetic as nitrous oxid the writer had found that at the end of almost
an hour the patient became saturated and did not wake up as readily.
When ceasing to give the anesthetic for a time, several pains would
elapse before they again complained severely.

4. Does it stop uterine contractions? All anesthetics would
stop uterine contractions if pushed far enough; nitrous oxid in a less
degree than chloroform, morphia or ether. Each patient reacted
differently and it required trained watching to prevent deep
anesthesia even with the gas.

5. Does it relax the cervix? The author had never seen a cervix
relaxed by nitrous oxid. It was, however, true that relieving the
fear of pain always allowed of more strenuous efforts on the part of
the patient, and more rapid progress was made on her part in
approaching an average physiological relaxation of the cervix by
her own efforts.

6. Does it relax the perineum? Here also the answer was no;
that any direct relaxing effects, such as would be attributed to chloro-
form in this stage of labor must be denied. The autlior was still
of the opinion that ether skillfuly given, or per chance chloroform,
was the ideal anesthetic when the head was passing over the perineum.

7. Does it relax the patient muscuJarly? He had failed to secure
sufficient relaxation to apply forceps or properly insert stitches; tliis
not because of lack of anesthetic effect, but because of a curious
jaclitory stage, which had been his observation for years was present
in continued nitrous oxid anesthesia.

8. Does it nauseate the patient? If given long enough it did.

AMERICAN GYNECOLOGICAL SOCIETY 679

His number of nausea cases was perhaps defective, being only 15
per cent. But if continued long enough, there occurred an active
nausea and vomiting, which might be an aggravation of a preexist-
ing nausea caused by the stretching of the cervix. In some instances,
however, it was distinctly produced by putting the mask over the
face and starting anesthesia.

9. Does it asphyxiate the baby? In about 50 per cent, of cases,
when the anesthetic had been used in both first and second stages of
labor, or for some time during labor, the babies were born blue but
seemed to cry vociferously immediately upon being born, and
appeared to be in no way harmed by the anesthetic, the color
clearing up in the usual time. In the rest of the cases the babies
seemed normal. He had not had any baby die after this method of
anesthesia.

10. Does it compare with ether and chloroform for the same
purpose? Excepting for the relaxing effect upon the perineum or
when doing a version. The author did not think chloroform should
be given during labor, because he believed that in ether we had a
much safer anesthetic which would accomplish the same purpose.

He was confessedly a straight ether enthusiast. He had tried other
anesthetics, and he was trying in an impartial spirit the present one,
but up to the present writing he failed to see where nitrous oxid
could be used that ether could not be used by a skilful man, and with
much better effect to both patient and operator. With this excep-
tion, nitrous oxid was a gas and ether must be vaporized, the former
was therefore much more quickly available and would be so until the
attempts now being made to do so gave us a much quicker method
of vaporizing ether. His point here then was this: Give ether in
a vapor state, or should we say an anesthetist who had learned
how by apparatus or otherwise to secure the true vapor mixture
with ether, necessary for anesthesia, that then, ether entered into
competition with nitrous oxid for this purpose.

Either one of two things was true; the nitrous oxid sold in cylinders
on the market was a very dilute gas, or the claims of nitrous oxid
enthusiasts were not proven. The only thing proven in the cases
coming under the writer's observation was that the patient came out
of the anesthetic quickly. Certainly, in the majority of cases she
did not go under as quickly, and it seemd to take an enormous
amount of the gas to make any patient acknowledge that she did not
feel any pain. This without much oxygen in the mixture.

It might be true that the type and the severity of the pain were
different and so much greater than those for which nitrous oxid had
been previously used, that he expected some magical effect in all
cases. Certain it was, but in a few cases in the series in which
experimentally he would use nitrous oxid for a few pains and then,
ether for a few pains, and then chloroform, in the same patient in
one labor, the effect of the nitrous oxid was as good subjectively as
either of the other two.

The question of whether part of the analgesic effect might not
be produced by the deep breathing advised when using the gas, had

680 TRANSACTIONS OF THE

not in his mind been fully cleared up. Many had noted almost
suggestive or hypnotic anesthesia b}' such a method before they had
ever thought of nitrous oxid.

11. Does it produce bronchial irritation? None of the author's
cases manifested any continuing irritation, and in those cases where
any suggestion of bronchial irritation arose, he felt sure it was due
to the then prevailing epidemic infections.

12. Does it produce irritation of the kidneys? He found that
the number of catheterized specimens sent after labor was inade-
quate to form any conclusions.

Dr. W. Francis Wakefield, of San Francisco, California,
reported loo consecutive cases. Of stillbirths there were two.
One of these was a high forceps dehvery and probably should have
been delivered by Cesarean section. The other was an anen-
cephalic monster which could not have survived birth. Ninety-
seven cases belonged to class i. Class i meant patients who had no
knowledge whatsoever of their labor from the time they went to
sleep until they woke up and found their babies born. Three cases
belonged to class 2. Class 2 referred to patients who carried away
from their sleep some unimportant recollections of occurrences but
no recollection of pain. Of these 100 cases fifty were primipara
and fifty were multipara. The average length of time of the
labor was for primipara thirteen hours and twenty minutes; for
multipara nine hours and ten minutes.

There was no case of postpartum hemorrhage.

Child bearing among the women of to-day, with the type of nervous
system which culture and education had developed, was unques-
tionably a formidable experience, productive, in its general results,
of a great deal of physical wreckage, most of which was unavoidable.
Because custom had made us look with tolerance and complacency
on the suffering endured by women during labor was no reason
why women should be allowed to continue to suffer when such suffer-
ing was avoidable, and that it could be avoided was an unquestion-
able fact. Moreover, the intelligent women of America were daily
becoming more cognizant of the fact that there existed means to
alleviate their distress, and naturally were coming more and more
to the point of expecting such means to be used. They consulted
their accoucheur and generally met at his hands discouraging criti-
cism of the different methods that had been successfully practised.
It was this opposition of the profession that was doing more than
anything else to retard the progress of the use of anesthetics in
labor. Groundless criticism, however, could not long or success-
fully endure against an aroused public opinion, particularly when
that opinion was well founded. For the most part this criticism
came from men who had never personally used any of the prevailing
recognized methods. Perhaps a general antagonism had been
created by the undesirable publicity that had attended the use of the
scopolamin method. To those who had used a good method and
still condemned it, he could only say that somewhere there had been
something faulty in its application, for he knew that at least one
method was capable of consistently satisfactory application.

AMERICAN GYNECOLOGICAL SOCIETY 681

Anesthetics in labor had come to stay. They meant too much
to the economic life of women to pass into disuse. Dissatisfaction
with the old regime had become more and more pronounced as time
passed. It behooved those who practised obstetrics to consider
well the attitude toward those means that had been successfully used
by reliable members of the profession for the elimination of con-
scious pain in labor. It was much wiser to voluntarily advocate
some good method now than to have such advocacy eventually
forced on us by public demand.

For two years the author in his private practice had been using
scopolamin as a continued anesthetic. One hundred and seventy-
five patients had been thus treated. In his hands scopolamin had
proven itself to be an absolutely ideal anesthetic in labor. It
would be dif&cult for him to picture anything more satisfactory.
He had yet to meet the patient on whom it had failed to work
satisfactorily, and he had yet to see a single contraindication for
its use. It disturbed none of the \atal functions, on the other
hand, conserved them, nor were the labor pains rendered less efficient.
Sanely used, scopolamin was a perfectly safe anesthetic. The best
interests of both the mother and baby were subserved by its use.
Its efficiency was entirely dependent on the reliabihty of the prepa-
ration used, and on the skill and good judgment shown in its
administration. Perfection of results increased with experience.

Rather ideal conditions and surroundings were required for its
success. For this reason it might fail to give satisfaction in the
crowded wards of hospitals devoted largely to clinical work, es-
pecially where there was insufficient funds provided for the ob-
stetric service. In private practice, however, most men who wished
to take the trouble to do so could very easily create conditions that
would make its use in every way practicable.

Dr. John Osborne Polak, of Brooklyn, New York, stated that
his experience included the use of morphin-scopolamin in something
over SCO cases, the use of gas and oxygen in over loo, etc. In over
550 cases, the last time he went over his cases, he found that there
were four fetal deaths. All these four fetal cases were autopsied.
Three of the women went to full term, and the babies died within
twenty-four hours after dehvery. The autopsy showed in one a
diaphragmatic hernia, in another atelectasis; in one there was hemor-
rhage into both suprarenal capsules, and in the fourth he was unable
to find any cause of death explainable at the autopsy except the child
was premature as a result of placenta previa delivery. There was
one maternal death in a case of placenta previa where the morphin-
scopolamin was only used in the early part of the first stage of labor
and was discontinued after the second dose of scopolamin in a very
long labor. A bag was introduced in that case, and he could not say
that there was any relation.

Scopolamin-morphin had a definite place, just as gas-oxygen had
a definite place in obstetrics, and each did certain definite work and
neither could do the work of the other. He used morphin-scopo-
lamin in the first stage of labor which relieved the terrible sacral

682 TRANSACTIONS OF THE

pain which was not reheved by gas-oxygen, and gas-oxygen was used
in the second stage which produced analgesia, and in a large percent-
age of cases the labor was absolutely painless. After the delivery
of the baby he gave the woman an extra dose of scopolamin-morphin,
so that surgical shock was absolutely guarded against.

It was known definitely that the use of scopolamin-morphin
shortened the time of the first stage of primiparous labors and
carried the women along to complete dilatation of the cervix. There
was practically no danger from the use of scopolamin-morphin in
the first stage of labor. There was danger in the second stage of
labor with prolongation of the second stage.

Dr. Walter P. Manton, of Detroit, Michigan, said he had tried
nearly all the methods of producing anesthesia which Dr. Edgar has
spoken of with the exception of scopolamin-morphin which never
appealed to him. Therefore, he had finally settled on amnoform and
chloroform. Amnoform was injected hypodermically, using i am-
pule of II c.c, to complete the first stage of labor. He had used
this drug in seventy-five cases and the results were eminently satis-
factory both to the patients and to him. In 25 per cent, of the
cases a second ampule may be given after a couple of hours, and
if that was not effectual the administration of chloroform would com-
plete the successful treatment.

In the majority of these patients results were practically the same
as those obtained by the advocates of so-called twilight sleep. In
the majority of instances the patients were unconscious at the time
of the birth of the child; they awoke in a vigorous condition, and
there were no untoward sequelae.

As far as the infants were concerned, he had yet to lose any infant
from the administration of this combination, and in only two or
three instances had the child been affected as much as when morphin
was given alone. There was no asphyxia or amnesia of the child as
a result of this combination.

Dr. Robert L. Dickinson, of Brooklyn, New York, said it was
gratifying to see the old chloral method revised which had been some-
what disused. Almost all gas-oxygen apparatuses contained now
an ether attachment. Instead of sticking to one method, if one
switched on the ether in addition to the gas-oxygen he had a method
which was constantly being used now by those who were frequently
employing gas-oxygen for major work. Let it be said that this was
a method for the expert; it was costly; it required a resident anes-
thetist, but that the gas-oxygen ether combination was a great
advantage and one more resource for the obstetrician. Gas-oxygen
anesthesia in his experience had enabled the obstetrician to sew up the
lacerated perineum at once without relaxation of the uterus, such as
is produced by chloroform, and particularly by ether.

NEW YORK ACADEMY OF MEDICINE 683

TRANSACTIONS OF THE NEW YORK ACADEMY
OF MEDICINE.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, Held April 25, 1916.

Dr. George W. Kosmak in the Chair.

Dr. Solomon Wiener presented the specimen and reported a case
of

degenerating fibroid with marked toxemic symptoms.

He said, "The specimen which I wish to present consists of the
uterus with adnexa and a large submucous fibroid. The whole mass is
shrunken from the preserving iiuid. The uterus has been split open
and also the fibroid in order to facilitate examination. In the fresh
state the uterus was the size of a five months' gravid organ and the
fibroid was as large as a grapefruit. The tumor was under great ten-
sion, the uterine wall being ma rkedly thickened , so that when the uterus
was cut open after removal the tumor literally "popped out." On
cross-section the tumor showed marked edema with softening. It
was deep purple in hue, contrasting strongly with the pink color
of the uterine musculature, and showing irregular areas of deep red,
yellowish and gray discoloration. The color values of the speci-
men still come out well. The pathological report on histological
examination was 'fibromyoma showing edema and beginning
degeneration.'"

The patient from whom this specimen was removed was forty-
five years of age, had been married twenty-seven years and had had
six children and one miscarriage. One year ago she had been oper-
ated upon for acute appendicitis. Menstruation had always been
regular, occurring every twenty-eight days and lasting four or five
days with moderate flow; it was accompanied with some pain. For
the past two months she had been bleeding every two weeks, the
amount of blood lost being about as much as at the normal menstrual
periods. Her present illness began about four days ago with the
sudden onset of severe pain beginning in the left lower abdomen;
this persisted and later radiated to both groins and sides. The
pain gradually subsided but reappeared yesterday with great inten-
sity. The patient felt continuously nauseated and vomited once
during the night. The bowels were moved by enemata. There
had been frequent urination with tenesmus.

When I saw the patient in the afternoon she impressed me as
being very ill. There was marked prostration, the face was of ashen

684 TRANSACTIONS OF THE

hue, the tongue dry, pulse 120 and of rather poor quality, and tem-
perature ioo.8°F. The attending physician stated that the pulse
had been 120 for two days and that the temperature had ranged
around ioo°F. Physical examination showed marked tenderness
over the lower abdomen with voluntary rigidity. Bimanually a
large mass could be felt filling the hvpogastrium and extending from
the symphysis to halfway up to the umbilicus. The mass was
firm, very tender and somewhat elastic. The uterus could not be
felt separately from it, and the cervix apparently moved with the mass.
This latter factor strongly inclined us to the belief that we were
dealing with a fibroid. However, the elasticity of the tumor,
the severe pain, the vomiting, together with the rapid pulse and low
temperature all pointed to the possibility of the mass being an ovarian
tumor with twisted pedicle. Because of the thickness of the ab-
dominal wall an absolute diagnosis could not be made until the
patient was under anesthesia. The indication for operation, how-
ever, was clear. The patient was removed to Mount Sinai Hospital
and at nine o'clock of the same evening I performed a supravaginal
hysterectomy. The operation was the typical and was without un-
usual difficulties. The patient's condition on the table was poor,
her pulse running up to 160 after only fifteen minutes' operating.
Fortunately she responded fairly well to stimulation. For twenty-
four hours after the operation her pulse and general condition were
such as to require active stimulation. After this her subsequent
convalescence was uneventful, being marked only by a superficial
collection of serum in the lower angle of the wound."

The chief point of interest in the case is the marked toxemia with
the relatively slight degenerative changes in the tumor, the patient
being far sicker than the mere recital of her pulse and temperature
would indicate. The severe pain is readily explained by the edema
and the tension under which the tumor was held by the hypertro-
phied uterine walls as well as by possible attempts of the uterus at
extrusion of the mass. The submucous character of the tumor
must be the reason for the marked absorptive s\-mptoms and
toxemia. Evidently there was as yet no infection or the tempera-
ture would have been higher. This class of tumor must be classed
as truly urgent for the moment that infection or degenerative changes
occur in a submucous fibroid the patient's Hfe is endangered by ihe
rapid absorption from this site.

Dr. William H. Cary read a paper on

EXAMINATION OF SEMEN WITH ESPECIAL REFERENCE TO ITS
GYNECOLOGICAL ASPECTS.*

DISCUSSION.

Dr. Max Huhner said: This paper is interesting to me because
I have been working on the same subject. But I cannot sympathize
with these methods of collecting the specimen which Dr. Cary

• For original article see page 615.

NEW YORK ACADEMY OF MEDICINE 685

employs. It means more work, is rather complicated and is not as
accurate as taking the specimen from the cervix. Furthermore, the
cause of sterility may be due to the fact that ejaculation occurs be-
fore the penis gets into the vagina, or because of hypospadias or
epispadias. The condom specimen may be perfectly normal and
yet some of these things be the cause of sterility. The other method
is so very simple; have the woman come to the office after coitus
and take a specimen of mucus from the cervix by means of a plati-
num loop and if live spermatozoa are found you can tell right away
whether the secretions of the vagina are harmful or not, and whether
the husband is all right.

Another point I would mention is in reference to the effect of pus
on the spermatozoa. If semen contains pus it is not in a normal
condition but this is not an absolute test as to its power to fecun-
date; I have mixed live spermatozoa with live gonococci, and the
spermatozoa seem perfectly happy and were not killed; a man with
gonorrhea may impregnate and give the gonorrhea at the same time,
so that the presence of pus is by no means an absolute test.

As to the test of the viability of the spermatozoa, neither is that
an absolute test, because during the examination of the semen under
the microscope it is not in its natural condition, but these same
spermatozoa taken from the vagina after two or three days might
still be active, while they might die in a very short time under the
microscope.

There is another question which was brought out two or three
years ago and that is that we do not know anything about the via-
bility of the spermatozoa in the Fallopian tubes. In a few cases in
which death has occurred as the result of accident spermatozoa
have been found twelve or fourteen hours after coitus in the Fallo-
pian tubes. Such an examination should be made in every case in
which we take out the tubes and ovaries. We should find out when
the last coitus took place and then make an examination for living
or dead spermatozoa and in this way we may get some information
as to how long it takes them to reach the Fallopian tubes and how
long they survive in that locality, without relying on the rare cases
of sudden death due to accident or murder.

Dr. Henry C. Coe said: Many innocent women have borne the
blame for sterility and have been subjected to operation, when an
examination of the husband would have shown that he was the
guilty party. The profession has been too ready to resort to curet-
tage in cases of sterihty and to make positive promises as to the suc-
cess of this procedure. Instances have come under my observation
in which one or more operations was done when it was found at
length that the husband had azoospermia; therefore I am opposed
to subjecting a woman to an operation for sterility until the condi-
tion of the husband has been determined. The suggestion that an
examination of tubes that have been removed should be made in
order to determine the possible presence of spermatozoa the length
of time during which they retain their vitality, is a good one, and
I do not think that this has been done.

686 TRANSACTIONS OF THE

Dr. Thompson T. Sweeny said: I am interested in this subject
because I have a large cHnic of Jewish women to whom sterility is
a disgrace. In treating them for this condition, I do so only until
any pain that they may have is relieved or any tubal condition per-
ceptible to the touch is relieved. I am unwilling to submit these
women to further treatment for their sterihty until I have made
certain that the husband is not sterile. It is often difficult to get
specimen of semen from some husbands, due to their ignorance in
believing that such a request is a reflection on their manhood. It
has been a point of great interest to me to find that men who appear
absolutely healthy or powerful or robust, who have never had gon-
orrhea, mumps, or any affection, are sterile; their semen showing
complete absence of spermatozoa.

As to the technic of collecting the specimen, I have made use of
the condom tied and dropped into a vaseline bottle containing water
at ioo°F. In cold weather this bottle is wrapped in flannel and paper
to retain the heat. When the husband is intractable and refuses to
aid us, I have the wife beguile the husband into coitus just before
she comes to my office, when I take the specimen from her vagina.

I agree with Dr. Coe, who said that any operation upon a woman
for sterility is inadvisable until first examining the husband. Many
of these women have an occlusion of the tube sufficient to prevent
pregnancy but too slight to be detected by "digital examination.
This condition quickly yields to local treatment.

I too have seen cases impregnated at the same time that they were
infected with gonorrhea. One case I remember was a ruptured
tubal gestation in double pyosalpinx.

Dr. William H. Gary, closing the discussion, said: There are
one or two points to which I wish to refer. I did not attempt to
take up the subject of impotence except to refer to it as included in
the general subject of sterility but not properly a part of this study.
Dr. Hiihner, who spoke of the method of examination, has in my
opinion spoken from an entirely erroneous viewpoint. He speaks
of taking the specimen from the vagina. If a specimen thus secured
is vigorous it is of course conclusive, but he may do this and find
the spermatozoa dead, having been killed by hyperacidity or other
chemical changes in the secretions of the vagina, when if he had
taken the specimen directly from the male it might have shown
normal vitality. Therefore a specimen from the vagina or from the
cervix is not a fair test as to the fertility of the male clement.

I also have been interested in noting these powerful men to whom
one of the speakers has referred, who with negative veneral history
show sterile semen. I have had experience with college men and
athletes upon whose honesty I could depend. Some of these cases
are very interesting. I have found a condition of sterilitj- in brokers,
in clergymen, and in lawyers, who were carrying heavy work and
responsibilities, and I have found that sending them away on a pro-
longed vacation and giving them a chance to recuperate improved
their semen, and in a number of instances their wives ultimately
became pregnant.

NEW YORK ACADEMY OF MEDICINE 687

Dr. Arnold Sturmdorf read a paper on

CONGENITAL AND ACQUIRED RETROPOSITIONS OF THE UTERUS : THEIR
DIFFERENTIATION AND RELATIVE SIGNIFICANCE.*

DISCUSSION.

Dr. Dougal Bissell said: It is difficult to discuss a paper of
this iiind without first having digested it to some extent. I tried
to write a few things last night, but changed my mind for I have not
yet digested Dr. Sturmdorf's paper. I have never been able to
determine just what congenital retrodisplacement is. I conceive it
as dependent upon structural defects as real as those of congenital
prolapse of the entire uterus. As to the difference between con-
genital and acquired retroversion we may assume that in the con-
genital type the uterus has never assumed the anterior position while
in the acquired type of retroversion we may assume that the uterus
has occupied the anterior position at some time.

I have never definitely recognized a case as one of congenital
retroversion, e.xcept in one instance; I mean a case that exactly fits
in with my idea of congenital retroversion. This case occurred in
a young woman who had a backward displacement of the uterus
and a prolapsed double kidney, which filled the entire right side of
the pelvic cavity to such an extent that it would have been impossible
for the uterus to have assumed the normal position. When we
operated we found the kidney anterior to the uterus and holding the
latter in retroflexion. In this woman we replaced the kidney but
neglected to employ operative measures to correct the retroflexion.
I waited to see the results of the displacement of the fundus. A pes-
sary was worn for a time but it did no good. Later the woman
married, conceived, and was delivered of a normal child. This was
undoubtedly an instance of congenital retroflexion.

Dr. George Gray W.^rd said: As I did not hear the paper I am
handicapped so that I am in no position to discuss it. 1 can only say
that I feel that when we have a case of retrodisplacement we must
not assume that this is necessarily the cause of backache, for we all
know that backache may be associated with faulty posture, irre-
spective of the position of the uterus. As to the congenital type of
retroversion I think it is not common, and that when we do find it
there are not many symptoms associated with it as a rule, as we find
in retroflexion or retroversion with subinvolution following abortion
or labor.

In congenital retroversion we may find a short anterior vaginal
wall and a faulty implantation of the cervix, and the position of
the cervix cannot be corrected without correcting the short vaginal
wall by an operation such as has been suggested by Dr. Reynolds of
Boston. All of these cases must be studied individually and their
type determined and the type of operation which meets the require-
ments of the individual case chosen. Too often a man has a fad,
some particular operation for retroversion or retroflexion which he

* For original article see page 386.

688 TRANSACTIONS OF THE

applies to all cases of retrodisplacement. The operation should fit
the peculiar condition present. There are many cases suitable for
the Alexander operation; if the uterus is freely movable and can be
replaced that case will do well with the ordinary Alexander opera-
tion, especially if the woman has borne children and the ligaments
are well developed.

The Webster Baldy operation is suitable where we have an ad-
herent retrodisplacement with denuded surfaces on the posterior
wall of the uterus. Here the round ligaments may be used to cover
up the raw surfaces; the same may be said of the Coffey operation
when we have a denuded surface on the anterior wall. When the
round hgaments are elongated and in good condition, I do a Simpson
operation; this leaves no loop where the omentum or intestine may
become strangulated. Shortening the uterosacral ligaments when the
uterus is prolapsed is a great aid. I do not believe in using the round
ligaments to support a straight prolapse. Nature does not use
muscle for this purpose and the round ligaments are muscles. The
broad hgaments and uterosacrals support the weight and the round
ligaments simply limit the backward excursions of the uterus.
It would seem from the anatomical construction of the pelvic organs
that woman was never intended to walk upright.

Dr. John Van Doren Young said: A clear concept of a de-
formity is the first requisite for its correction. One does not have
to listen long to this discussion to learn that a clear concept of the
displacements under consideration is lacking. I beheve that Dr.
Sturmdorf has cleared the horizon and that he has given us some
basis for further work along this line. In a series of 6224 cases of
pelvic conditions which I recently reported over 2300 showed some
type of retroposition of the uterus. This gives one some idea of the
importance of this form of displacement. I have hstened carefully
to Dr. Sturmdorf's paper and am very much interested in this sub-
ject but I must confess that I do not understand his statement of
congenital versus acquired retroversions. Each one who discusses
this subject should say just what he means by the term he uses. I
think about 90 per cent, of our trouble in discussing this problem is
due to a misunderstanding of terms, and the large number of opera-
tions are due to our faulty conception of the deformity we are try-
ing to correct. I think Dr. Sturmdorf's statements with reference
to the poise of the body and his study of the skeleton of the female
give a rational basis for an easj' and simple method of finding the
type of retroversion with which we are dealing. This discussion is
not of any operation but of the comprehension of the meaning of
retroversion and we may understand by this term a pathologic me-
chanical retroversion with or without faulty poise, and with or without
prolapse; where there is flexion due to adhesions it is an entirely
different subject. From the standpoint which Dr. Sturmdorf pre-
sents this subject it opens up a large field; it shows why operations
have so often failed and why we need the help of the orthopedist in
the correction of these displacements; it shows why with the same
technic one operator fails and another succeeds; why Dr. Hirst of

NEW YORK ACADEMY OF MEDICINE 689

Philadelphia reports looo cases with loo per cent, cures by the
Alexander operation and Dr. Cragin at the same time gives up this
operation because he gets no results, why Dr. Kelly after having
performed 880 ventral suspensions then gives it up.

I seldom take issue with Dr. Sturmdorf but there is one point upon
which I disagree with him, that is that a retroposition of the uterus,
a mechanical pathologic retroversion with retrocession of the fundus,
antrocession of the cervix, and decensus of the whole uterus is cured
by a pessary or correction of body poise, these methods have failed
in every patient I have ever seen and if I am mistaken in this I
would like Dr. Sturmdorf to correct me.

I believe we should resort to operative interference after the pes-
sary has failed. Twenty-five years ago we talked nothing but
pessaries; within the last five years nothing but operations, and now
the pendulum has swung the other way.

In these cases we are dealing not only with a deformity as we find
it but as it will be in the future.

I would like to ask whether a mispoised skeleton might not have
been acquired as the years passed, not by evolution but by a lack of
education and development.

When we remember that retroflexion and retroversion of the uterus
are important factors affecting the home relations and the life and
happiness of the woman and the entire family, we must reahze that
if we can solve this problem we .shall remove a real trouble from many
lives, for there is not one of us who is not convinced that this de-
formity is a detriment to the health of a woman and should be
corrected.

Dr. Leroy Broun: Dr. Sturmdorf 's paper is such a close study
that it is difficult to fully appreciate the various steps of his argu-
ment. To do so it will be necessary to read it carefully and at lei-
sure. I wonder whether Dr. Sturmdorf means to include among
congenital retroversions such conditions associated with a general
ptosis of other organs; in the latter condition it would be useless to
operate on a displaced uterus when there existed a ptosis of other
organs as of the digestive tract and kidneys. I would not operate
for retroversion alone when other ptoses were present. When there
are symptoms of retroversion, backache, etc., not dependent upon
an ill-fitting corset, or in cases in which sterility supposedly is due
to retroflexion, I get successes from operative procedures in a larger
percentage of cases than I get failures.

Dr. Samuel Handler said: If Dr. Sturmdorf 's method of getting
this "index" will in the future show us the cases of congenital
retroflexion without it being necessary to make a rectal and vaginal
examination, he will have added greatly to our gynecological knowl-
edge. If we have practised gynecology and failed to recognize a
position of the body as typical of a malposition of the uterus, such
as that to which our attention was attracted in the picture just
shown, we have at least now been shown the A, B, and C of uterine
displacement. It does not seem to me that it has proved any point.
For a long time I have used the term retrodeviation to signify a

690 TRANSACTIONS OF THE

simple retroflexion or a retroversion. A retrodisplacement on the
other hand is a change from the normal due to a shortening of the
uterosacral ligaments. If Dr. Sturmdorf means a retroflexion I
would be willing to discuss the subject from that standpoint, but
what we want is the right names for these conditions.

The type of retrodeviations that takes place in a nuUiparous woman
is entirely different from that in a woman after her first labor. This
is a reason why the practice of obstetrics is of value to the gyne-
cologist and explains why a large number of operations for retro-
deviation fail. We can say that a certain number of these patients
have a congenital retroflexion and a certain number have acquired
retroflexion. We all know that labor is responsible for the acquired
retroflexions. In a certain number of cases there is a descent of all
the pelvic tissues allowing the cervix to come down. Wiether our
efforts at correction of the retroflexion succeed or not depends on the
ultimate position of the cervLx. When the cervix is low down, it
is natural for the fundus to fall backward and corrective or operative
measures must lift up the cervix and replace the fundus forward.

In a large number of congenital retrodeviations the anterior
vaginal wall is extremely short and for years I have been paying
attention to this subject. These are the hardest cases to replace
with a pessary because the pessary cannot put the cervix high up
and as a consequence the fundus falls back, because the short vaginal
wall will not permit the uterovesical ligaments to stretch. The
uterosacral ligaments are too loose, and here if we do an Alexander-
Adams operation and shorten the round ligaments, the result is that
we have simply doubled the uterus up on itself and it \vill not stay
in place. The proper thing to do in such a congenital case is to
open the abdominal wall and to place the uterus in such a position
that we can fasten the fundus to the abdominal wall, even three-
fourths of the way to the umbilicus and then the doubhng up will
not occur as in the Alexander operation.

With so many different forms and causes of retrodexnation, I
doubt very much if the acceptation of one sign is going to help us
very much. It sounds very impressive on paper, but I do not see
how it is going to be of much practical help, since the fact that a
uterus in a proper position depends on the fact that the cervix is
well up. I do not differ with Dr. Sturmdorf because I am not open
to conviction. I simply think that there are other factors that are
just as much a cause, and of far greater importance.

Dr. Thompson T. Sweeny said: It is generally conceded that
the uterus is supported by the uterosacral and uteropubic hgament.
It is evident that in the erect position, nature has suspended a body
from its base, which is a mechanical error. On all fours it is incon-
ceivable that a woman could have a retroversion, since in that posi-
tion her uterus is suspended from its apex.

I am further interested in Dr. Sturmdorf's paper as it explains so
many of the problems of retroversion. One woman physician in
Chicago having studied sixty cases of retroversions without symp-
toms, concluded that this was not necessarily an abnormal position.

NEW YORK ACADEMY OF MEDICINE 691

These were probably congenital cases in which the pelvic circulation
adjusted itself to the malposition. Retroversions with inflammation
produce symptoms only when the position interferes with the return
of the venous blood. I find a large number of retroversions in young
women which produce no symptoms and I have made it a practice
to let them alone, making no effort to correct a condition to which the
pelvic circulation has adjusted itself.

Dr. Stujimdort, in closing the discussion, said: The intimation
that I advocate the use of the lumbar index to the exclusion of direct
examination in the diagnosis of uterine retroversion, is an unwar-
ranted perversion of my position.

I stated distinctly, that, "with an index of 25 mm. or less, the
existence of congenital retroposition may he predicated in nearly every
case, prior to its bimanual verification."

The general trend of this discussion, establishes the one fact if
nothing more, that congenital uterine retrodisplacement is known in
name only: it is this fact among others, that prompted and justifies
the present communication.

The article is not merely a hypothetical deUneation of mechanical
principles, but a contribution of facts based upon a very extensive
series of observations.

I utilize the general term uterine retroposition advisedly, dividing
the cases into complicated and uncomplicated, because such division
is more conducive to clarity than the text-book classification of
versions, flexions, retropositions, adherent, nonadherent, etc.

The reference to Reynolds procedure, in foreshortening of the
anterior vaginal wall, does not apply to our question, inasmuch as
the operation while it may influence a flexed cervix, obviously cannot
antevert a retroverted uterus.

The same appUes to all of the other operative measures, which I
distinctly stated are applicable to the acquired and not the congeni-
tal form of uterine retrodisplacement.

Every woman with marked visceroptosis has a congenitally retro-
posed uterus, but every woman with a congenitally retroposed uterus
does not necessarily present general visceroptosis, at least not clin-
ically.

I am not discussing the relative values and indications of retro-
position operations, but the recognition and differentiation of a class
of retropositions in which any and all operative intervention is dis-
tinctly and imperatively contraindicated.

The method and means advocated for this differentiation are so
simple, that the verification or refutation of my statements is within
reach of all.

692 TRANSACTIONS OF THE

TRANSACTIONS OF THE OBSTETRICAL
SOCIETY OF PHILADELPHIA.

Meeting of May 4, 1916.

The President, William R. Nicholson, M. D., itz the Chair.

Dr. George Erety Shoemaker presented the report of two
cases

(i) pneumococcus PEL^^c abscess.

(2) URINARY RETENTION FROM URETHRAL PRESSURE BY TUMOR OF
THE OV.'\RY.*

DISCUSSION.

Dr. Collin Foulkrod. — The second case opens up a very wide
field. We have all had this winter so many cases of infections of
this type that it is impossible, unless we go over our records and
look up the kind of bacteria and then associate one with the other,
to say just what form of germ is causing the epidemic this year.
I am very sure I have had streptococcic infection in pregnant women,
general in type, which if given a chance to develop in local lesions as
in Dr. Shoemaker's case, would have developed into other strains
of this organism. I believe that the form of germ changes in the
dififerent culture media. The streptococcus is variable in growth
and activity and the most virulent in type. Pelvic infections which
tiave been secondary to those general in t}'pe open up the question
of the primary cause.

Dr. Barton Cooke Hirst. — Dr. Foulkrod has referred to a case
of pelvic abscess which I saw six weeks after the woman's delivery.
I operated by vaginal puncture and found gonococci to be the infect-
ing organism. The husband said it was not his fault. The patient
was a nice young woman and I do not suppose she acquired it in the
ordinary way, but she had gonococci in her pelvic abscess neverthe-
less. I cannot think that they had undergone change in the culture
media. This woman had an original gonococcic infection from
some source. We cannot expect microorganisms to undergo change
from one form to another. The suggestion recalls to my mind an
explanation which satisfied the Board of ISIanagers of a Maternity
Hospital some years ago, but it would not, I think, satisfy the average
medical audience. There was a case of streptococcic infection
after labor with fatal result. The Board of Managers called for an
explanation, whereupon one of the staff stated to the satisfaction

* For original article see page 660.

OBSTETRICAL SOCIETY OF PHILADELPHIA 693

of the Board that the Doederlein bacillus normally present in the
vagina had undergone a transformation into a streptococcus and
that, therefore, nobody was to blame. In one case of generally
diffused suppurating pneumococcic infection there was more pus in
the abdomen than I have ever seen. Curiously enough, the patient
recovered, which is not usual for a case of general suppurative
peritonitis. If it had been streptococcic infection recovery could not
have been expected. The pneumococcus is not so virulent. I do
not think any of those pneumococcic infections are as serious as the
streptococcic infections.

In reference to Dr. Shoemaker's other case I once had such a case
of obstruction caused by pressure of a vaginal enterocele upon the
urethra and bowel.

Dr. F. Hurst Maier. — The answer to Dr. Foulkrod's question
may be found in the changes that the bacteria, normally inhabiting
the genital organs, undergo. Rosenow has demonstrated how the
organisms of the streptococcus-pneumococcus group, not only
undergo cultural and morphological changes, but mutation in
pathogenicity as well.

It is quite possible that the comparative frequency of pneumo-
coccal infections of the pelvic organs this winter, is due to the greater
prevalence of throat infections.

In the majority of these conditions, the organisms of the strep-
tococcus-pneumococcus group predominate.

Dr. Charles S. Barnes. — A month ago I had a puerperal case
which was interesting to me and possibly it might be of interest
here. Delivery was spontaneous and the puerperium ran a normal
course for six days when the temperature suddenly went up. Fol-
lowing that, for a week or ten days the patient ran an ordinary
clinical course of puerperal infection. A good bacteriologist made a
blood culture but at the end of twenty-four hours he was not able
to report what was present. At the end of forty-eight hours
pneumococci were all he found from the blood culture. The patient
recovered under expectant, stimulating and supportive treatment.
Some vaccines were used but I am not sure that they did any good.
The infection ran a course without localization. The woman re-
covered and is able to be about, has no symptoms except slight pain
in the right lower quadrant, probably in the region of the right
appendage. The case was evidently one of pneumococcic infection.
She had not had a catarrhal condition of the air passages the past
winter, so I am at a loss to know the course of the infection. The
patient says that at one time she was not cleansed properly after
defecation and complained of discomfort at the site of suture. I
could find nothing locally and the thought was probably a men-
tal aberration upon her part so far as the source of infection is
concerned.

Dr. Shoemaker, closing. — I scarcely think that the organism
underwent actual metamorphosis as has been suggested. No doubt,
at certain times we see certain organisms developing rapidly in a
field, while others are quiet. There is a variation in resistance to

694 TRANSACTIONS OF THE

different organisms at different periods as well as a difference in
toxicity of the same type of organism. I have heard of a number of
pneumococcic abdominal infections this year.
Dr. Collin Foulkrod reported

A CASE OF KRUKENBURG TUMOR OF THE OVARY.*
DISCUSSION

Dr. F. Hurst Maier. — -In a paper on the diagnosis of papillary
cystoma of the ovary that I read before the Phila. County Medical
Society, last year, I cited a case very similar to that reported by Dr.
Foulkrod.

The woman had been referred to me by Dr. Scott, of Sea Isle
City. She complained only of a moderate ascites and loss of weight.
There was no apparent clisease of any of her organs, except the
ovaries, which were twice their normal size, unusually hard and
nodular.

An abdominal incision revealed a carcinoma of the pyloric end of
the stomach with metastatic involvement of the ovaries.

Not infrequently we see women whose only complaint is an ascitic
distention of obscure origin, as cancer of one of the abdominal
viscera, papillary cystoma of the ovary, or tuberculosis of the peri-
toneum is usually the cause, the necessity for early diagnosis is
obvious.

Papillary cystoma of the ovary with its characteristic fixed
masses are not hkely to be mistaken for the metastatic nodules, of
various sizes, disseminated over the pelvic peritoneum, the secondary
expression of malignant disease, of the stomach, intestines, etc.

Dr. Foulkrod, closing. — Dr. Maier asked if ascites were
present. I do not think it was sufficiently pronounced to be diag-
nosed by external methods. At operation there was an excess of
fluid in peritoneal cavity.

Dr. F. Hurst Maier presented a paper on

CHRONIC FOCAL INFECTIONS OF THE PELVIC ORGANS AND THEIR
RELATION TO SYSTEMIC DISEASE. f

DISCUSSION.

Dr. SwiTiHN Chandler. — We all recognize that if anything is
the matter with the uterus or adnexa there is bound to be trouble
throughout the system. One point, however, which I think is
debatable ground is that with reference to the endometritis. Several
years ago in making an examination of the cervix I found that the
gonococci were lodged there in great numbers and remained from
four to five weeks in virulent form. Specimens examined by Dr.
Bloodgood confirmed this finding. In many of the acute cases he
examined the endometrium and at the end of three weeks found no
trouble whatsoever, nor no gonococci and was not able in a large
series of cases to find any gonococci in the uterus after the third

*See original article page 657.
tSee original article page 652.

OBSTETRICAL SOCIETY OF PHILADELPHIA 695

week. He did, however, find gonococci in the cervix as late as six
weeks.

In a case of large cystic ovary seen with Dr. Samuel WOson, after
removing the cystic ovary, we found a large mass about 4 inches in
diameter and about 6 inches in length. Tracing this out we found
it was an obstructed ureter. Removing the ureter and palpating
for the kidney we found it the size of a grape-fruit and removed it
through. an abdominal incision. While the woman was thought
probably to have tuberculosis those symptoms have entirely cleared
up. Following out the paper of Dr. Maier, it would seem that all
such patients ought to have a pelvic examination. It is somewhat
difficult, however, to have every woman with systemic trouble to
undergo such examination without some obvious cause.

Dr. W. Wayne Babcock presented a paper on

THE CORRECTION OF THE OBESE AND RELAXED ABDOMINAL WALL WITH
ESPECIAL REFERENCE TO THE USE OF BURIED SILVER CHAIN.*

DISCUSSION.

Dr. Barton Cooke Hirst. — ^I have used the old silver wire mat
with success. I should certainly prefer this silver chain. It would
appear to be a great improvement upon anything I have ever seen
or heard of before.

Dr. Edward A. Schumann. — I would suggest relative to the
illustration of Dr. Babcock's operation for suspension of the uterus
that the use of silver chain be Hmited to women beyond the age of
pregnancy, because there would be some little difficulty with that
chain otherwise.

Dr. William R. Nicholson. — Will Dr. Babcock give us his
experience with the use of the chain in infected wounds, if he has
had such e.xperience?

Dr. Babcock. — The point made by Dr. Schumann is very well
taken. Of course, it is entirely obvious that the chain cannot be
used in the child-bearing woman without incurring some risk.

Regarding the use of the chain in infected wounds. In one case
in which the wound broke down, a part of the chain healed in. The
infection was in the subcutaneous fat and the incision was 6 inches
long. A half-inch opening was made in two places, and several
ounces of pus were discharged. We picked out some of the chain,
leaving some strands in. Finally firm heahng occurred and the
.v-ray showed a mass of chain in the lower part of the wound which
has given no clinical symptoms.

Tying a knot in the chain makes rather too great a bulk, but this
may be overcome by the use of a staple, or link improvised of silver
wire.

Dr. Walt Ponder Conaway presented papers on

(i) A case of vesico-utero-vaginal fistula.
Mrs. Isaac G., age thirty-nine, para-iii, was delivered of a seven-
pound baby on May 4, 1915 by forceps. A slight laceration of the
* See original article page 596.

696 TRANSACTIONS OF THE

pelvic floor was noticed. This was repaired promptly. A few days
later the patient found that the urine seemed to be dribbling nearly
all of the time and that also there was odor of fecal matter about
the vagina constantly. I was called in consultation on May 15 and
after examination made a diagnosis of vesico-utero-vaginal fistula
and recto- vaginal fistula and advised operation.

She was admitted to the Atlantic City Hospital on May 19, 1915,
and I operated on May 20. The bladder opening was closed
with interrupted sutures of fine silk in two layers. The uterus
was curretted and a high trachelorraphy was done, which extended
up to the vesical opening. A permanent catheter was left in the
urethra.

The recto-vaginal opening was repaired with interrupted sutures
of fine silk in the rectal mucous membrane, chromic catgut sutures
in the pelvic floor muscles and plain catgut in the vaginal mucous
membrane.

On the fourth day the patient developed a high fever and other
evidences of cystitis. The catheter was removed and the bladder
irrigated a few times with a solution of boric acid. She was catheter-
ized regularly for several days until the cystitis subsided and then
another permanent catheter was inserted. This remained for a
week. The patient was kept in bed for four weeks at the end of
which time she was able to void urine with but slight leakage in the
vagina. This leakage occurred only at the time of urination. She
was able to retain her urine for four hours. In two weeks more the
closure was perfect. The repair of the recto-vaginal fistula was com-
plete and gave no further troub.e. In September, I heard from the
husband of the patient who stated that his wife had no trouble
with the bladder or bowels and that she was well.

(2) A CASE OF UTERUS DIDELPHUS.

Margaret P., age thirty-two years, called at my office for examina-
tion on January 20, 1916. Family history negative. Patient was
a native of Italy but had lived in this country for twenty years.
Had the usual diseases of childhood but since that time had never
been ill and had never lost any time from her work as bookkeeper
for twelve years. She had never menstruated and had never seen
any discharge of any kind from the vagina.

Vaginal examination was unsatisfactory as there was practically
no vagina, only a slight depression between the labia about one inch
in depth and large enough to admit one small finger, .^n opening
large enough to admit a probe could not be found and a bimanual
examination revealed nothing behind the pubcs; but a mass about
the size of a lemon could be diagnosticated through the abdominal
wall on the left side, low down in the pelvis. Tenderness was pres-
ent over McBurneys point.

Since she gave a history of two attacks of appendicitis I advised
laparotomy and also because she was quite anxious to menstruate
and was willing to be operated in hopes of being relieved.

A laparotomy was performed on February 11.

OBSTETRICAL SOCIETY OF PHILADELPHIA 697

On opening the abdomen I found a normal tube and ovary on the
left side, a small uterus imbedded in the broad ligament and with
its cervix pointing to the left hip. On the right side was a normal
tube but a large cystic ovary about the size of a lemon. On this
side was another small uterus about one and a half inches long, per
fectly formed and its cervk pointing outward toward the right hip.
Between these two uteri was an empty space partly filled by the
bladder. They were connected by a muscular band about one inch
wide and about four inches long and which seemed to contain the
uterosacral ligaments and the vesical fold of peritoneum. A per-
fectly formed cervix could be felt through the peritoneum and in the
broad ligament. Neither cervix communicated with the vagina.
The appendix was considerably enlarged and adherent and was re-
moved with some difficulty.

In Gould and Pyles' book, "Anomalies and Curiosities of Medi-
cine," I find mention is made of a few very similar cases.

DISCUSSION.

Dr. Collin Foulkrod. — I have had one or two such cases, though
not of the exact type as that reported by Dr. Conaway, with the
septum reaching from the vagina up to the fundus of the uterus.
In one case the woman was pregnant with that type uterus — preg-
nant in one side of a double uterus and double vagina. Not recog-
nizing the condition we examined in the wrong vagina and it seemed
as if there were no chance of the child's head getting into the vagina.
Preparations were made for Cesarean section, when it was found
that the septum was so stretched over the child's head that we could
not find the entrance to the vaginal canal through which the head
was coming until the scalp emerged at the vaginal outlet after tearing
the septum part way up from below.

Dr. Edward A. Schumann. — -Dr. Conaway's case is of such un-
usual interest that some emphasis should be laid upon it. Double
uterus is a well-recognized anomaly, but double uterus with
complete closure of the anterior segment cloaca is most unusual
and an embryological anomaly which should be of the greatest
interest.

Dr. F. Hurst Maier. — -I recall just such a case of double uterus
without a vagina as one of my early operative experiences. The
woman suffered dreadfully from menstrual molimina each month.
Examination through the rectum revealed a mass, the size of an
orange, in the left half of the pelvis. Operation demonstrated the
absence of the vagina, as well as, the right ovary and tube. Develop-
ment in that side had only taken place in that part of the MuUe-
rean duct that formed the uterus. The ovary, tube, and uterus of
the left side were present, the latter in the guise of a hematro-
metrosalpinx. The structures were removed and a vagina made
of flaps formed from the labia minora.

698 TRANSACTIONS OF THE

Dr. Barton Cooke Hirst. — I agree with Dr. Schumann that
this rare case should be emphasized. I have seen almost every other
variety of abnormality of the genital organs but I have never seen a
double uterus without a vagina.

Drs. Philip F. Williams and John A. Kolmer presented a
paper on

THE WASSERMANN REACTION IN GYNECOLOGY.*
DISCUSSION.

Dr. Daniels. — I should like to mention a case upon which I did
an abdominal section which emphasizes the importance of the Was-
sermann reaction in some of these cases. The woman was forty-
eight years of age whom I thought had chronic appendicitis because
of persistent pain and tenderness on the right side of the lower
abdomen. She had chronic gastrointestinal disturbance with loss
of weight. I thought that the mass which I could feel through the
abdominal wall was due to some inflammatory condition. I opened
the abdomen and found a tumor the size of a large pear involving
the wall of the four loops of the small intestine and situated in the
ileocecal region. I thought the condition was carcinomatous and
closed the abdomen. Dr. Mann suggested that the condition might
be syphilitic. While I thought it was not I realized that anti-
syphilitic treatment could do no harm. The patient was put upon
iodid of mercury and iodid of potash, when the symptoms entirely
disappeared. The tumor, so far as I could feel through the abdom-
inal wall disappeared, and the woman has gained from 20 to 30
pounds in weight and at the present time is well. Had I been wise
enough to have had a Wassermann test made at first an abdominal
section would not have been necessary.

Dr. Brooke M. Anspach. — I want to congratulate Drs. Williams
and Kolmer upon this paper which represents a great deal of hard
work. In the Gynecean Hospital we have had a number of cases
which demonstrated the value of the Wassermann reaction in
gynecology.

GAUZE removed FROM THE PERITONEAL CA\T[TY SEVENTEEN YEARS
AFTER A HYSTERECTOMY.

Dr. Stephen E. Tracy. — The first specimen shows a piece of
encapsulated gauze removed from the peritoneal cavity seventeen
years after an hysterectomy. Mrs. C. H., aged forty-five, para-i,
was referred to my service at the Stetson Hospital because of pain
and discomfort due to a mass about the size of a large grape-fruit in
the left h\'pochondriac region. Manipulation of the mass, which
was only slightly movable, caused the patient considerable discom-
fort. She had been somewhat constipated, but there had been no
difficulty in securing free evacuations. The tumor mass became
smaller after colonic lavage or a brisk cathartic. Pyelography

* See original article page 638.

OBSTETRICAL SOCIETY OF PHILADELPHIA 699

showed the kidney in its normal position. The rontgenologist
diagnosed the lesion a tumor pressing on the bowel. The clinical
diagnosis was carcinoma of the descending colon. At operation it
was found that the tumor consisted of a portion of the transverse
colon, the splenic flexure and the upper portion of the descending
colon with the omentum wrapped about and adherent. The large
mass was enucleated, the transverse colon divided about its middle,
and the. descending colon at its lower end. An anastomosis was
performed and the operation completed in the usual way. When the
bowel was opened it was found there was a round opening about
2 cm. in diameter which communicated with the large pus cavity.
The edges of the opening were smooth and rounded. Projecting
from the cavity about i cm. through the opening into the bowel was
a piece of gauze. The gauze was in a good state of preservation,
and had caused no trouble until a few months before its removal.
The patient had had an hysterectomy for inflammatory disease of
the pelvic organs seventeen years before.

Second specimen consists of half the transverse colon, the splenic
flexure and all the descending colon, removed for a

CARCINOMA OF THE DESCENDING COLON.

The patient was forty-seven years old, the mother of one child.
She complained of cramp-like pains in the stomach and of fulness in
the left side of the lower abdomen. In the last six months she had
lost 15 pounds. Examination showed a mass about the size of a
large orange, which was fixed and situated on the left side 5 cm.
above the brim of the pelvis. This mass had been diagnosed as a
displaced kidney by a leading internist who ordered an abdominal
support, which aggravated the discomfort. Pyelography eliminated
the kidney. The rontgenologist stated that the transverse colon
was adherent to the lower portion of the descending colon, and that
he could not obtain a shadow between the middle of the transverse
colon and the upper end of the sigmoid. Clinical diagnosis was car-
cinoma of the descending colon. At operation it was found that
a loop of the transverse colon was adherent to the cancerous mass
in the descending colon. The colon was removed from about 7 cm.
beyond the hepatic flexure to the upper portion of the sigmoid.

The third specimen shows the lower ileum, cecum, appendix,
ascending and transverse colon. This was removed from a single
woman, aged twenty-six, who had been sent to the hospital with a
diagnos s of chronic appendicitis. The patient stated she had had
more or less discomfort in the side for a period of six months. Exami-
nation showed considerable tenderness in the right side of the abdo-
men especially in the right iUac fossa. When the abdomen was
opened it was found that the lower end of the ileum was dilated, the
cecum greatly infiltrated, and at one point the lumen was almost
obstructed. This infiltration extended as far around as the first
portion of the transverse colon. It was a question what should be
done as the nature of the lesion could not be determined. Nor do
I know at this time, as the histological examination has not been

700 TRANSACTIONS OF THE

made; operation being performed only a few days ago. It was
decided, however, to remove all the involved tissue. Several cen-
timeters of the lower ileum, appendix, cecum, ascending colon, and
the first portion of the transverse colon were removed. The trans-
verse colon at this point was not infiltrated. When an attempt was
made to anastomosis the ileum in the side of the transverse colon,
the forceps cut through and it was necessary to remove the trans-
verse colon as far as the splenic flexure. The ileum was then anas-
tomosed to the lower portion of the descending colon.

TRANSACTIONS OF THE WASHINGTON OB-
STETRICAL AND GYNECOLOGICAL SOCIETY.

Meeting of February ii, 1916.
The Vice-President, Dr. Willson, in the Chair.
Dr. Lowe reported a case of

PYELITIS OF PREGNANCY.
DISCUSSION.

Dr. Moran had seen three similar cases in the last six months.
In the first the pain had subsided on doing an external version; in
the second, the woman had had two prior stormy pregnancies in
which the pyelitis had cleared up before labor under symptomatic
treatment; in the third case the diagnosis of appendicitis had been
made, the white blood cell count had been 30,000, there had been
chills and fever two days before labor. After labor all the symptoms
had cleared up, as was usual in all the cases he had seen. The
colon bacillus was the cause of most of the infections. The question
of ending the pregnancy came up frequently as most of the cases
developed in the seventh month.

Dr. Stone said the condition of the kidneys determined the course
of action in each case. A high temperature with increasing leukocyte
count suggested involvement of both kidneys.

Dr. Ajjbe reported a case where a woman giving symptoms of
renal colic in the fifth month of pregnane}^ had recently brought
before his mind the question of pyelitis. Her symptoms persisted
for a few days and then cleared up. A week later the woman pre-
sented him with a calculus the size of a pea which she had passed in
her urine. He raised the question as to whether certain other cases
that cleared up completely might not also be due to calculus.

Dr. Lowe said that two deaths has been reported from pyelitis,
one of gonococcal origin and one from typhoid. Colon bacillus
infection caused 85 per cent, of the cases. The condition seems
more frequent on the right side, which might be explained by the

WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY 701

pressure of the child's forehead on the right ureter at the pelvic brim.
Some of the cases did not clear up after labor but later came to
operation.

Dr. Stone asked if fibroid masses could not give a similar pressure
on the ureter. He had not seen pyelitis complicating fibroids.

Dr. Vaughan reported a case of

stone in the bladder.

Appearing two years after a laparatomy. The stone had a silk
ligature knot as its nucleus.

Dr. Stone reported another, case of silk knot in the wall of the
bladder, and noted the possibility of palpating a vesical calculus
from the vagina.

Meeting of March lo, 1916.
The President, Dr. Miller, in the Chair.
Dr. D. W. Prentiss read a paper on

syphilis of the uterus.*

discussion.

Dr. Moulden said the spirochetae could not live in an acid medium
and therefore were not apt to infect vaginal or cervical mucosa.

Dr. White suggested that a routine blood examination of all
women with cervical lesions would show many cases of syphilis.

Meeting of April 9, 1916.
The Vice-President, Dr. Willson, in the Chair.
Dr. Grasty reported a case of

acute lymphatic leukemia in a child, t
Dr. Prentiss Willson gave the histories of four cases of

VAGINAL DELIVERY SUBSEQUENT TO CESAREAN SECTION.

One of the most important problems of present-day obstetrics is
that of the proper indications for Cesarean section. The literature
shows clearly that professional opinion on this subject is in the forma-
tive stage. There can be no doubt that the operation is being done
far too frequently at the present time, its very safety under aseptic

* See original article page 480.
t See original article page 66g.

702 TRANSACTIONS OF THE

conditions being, doubtless, largely responsible. On the other hand,
I am firmly convinced that in some clinics an undue emphasis is
being placed on the restriction of the indication to cases of serious
disproportion. In the ultimate decision of this vexed question,
which it is quite Ukely will be on the usual middle ground, the fate
in subsequent pregnancies of the Cesareanized patient with a normal
pelvis, will be a strong deciding factor. According to John T.
WiUiams, who has just reported two successful cases of vaginal
delivery subsequent to Cesarean section, v. Leeuwen found only
thirty- two such cases in the literature up to 1904. Williams found
six cases in the literature since 1904 and reported two cases of his
own, making forty cases in all reported up to the present time. To
this number I wish to add the reports of four cases which have
come under my own observation.

Case I. — N. D. W., married, white, para-iv, normal pelvis. On
the 13th of May, i9i3,this patient's fourth pregnancy was terminated
at the thirty-fifth week, the indication being partial placenta previa,
and a strong desire for a livng child decided me to do Cesarean
section. The following September she became pregnant and on the
7th of June, 1914, at full term, and following a perfectly normal
pregnancy, she delivered herself of a male child weighing 6 pounds
and 14 ounces. The labor was easy and normal and lasted seven
hours. Since this time she has been in excellent health.

Case II. — J. W., married, white, para-ii, thirty-six years of age,
normal pelvis. This patient's first pregnancy was terminated by
Cesarean section at full term, the indication being antepartum
eclampsia in a thirty-five-year-old primipara. Convalescence was
complicated by an abscess in the uterine incision which opened and
drained through the vagina. When, about a year later, the patient
presented herself halfway through her second pregnancy, I regarded
the case as one of more than ordinary interest. The lower part of
the birth canal was that of a thirty-si.N-year-old primipara, having
never been dilated by the passage of a baby, while the uterine wall,
which one would wish to have in as strong a condition as possible
under such circumstances, was weakened by the presence of the scai
of a previous Cesarean section which had been the site of infection
at the time of its formation. The patient was admitted to the
hospital at II p.m. on August 29, 1914, having been in labor for two
hours. She was at full term. The position was R. O. P. The first
stage lasted for five hours. With the aid of the knee-chest position
the occiput rotated spontaneously. At the end of two and one-
half hours of hard second-stage pains without material progress
it was decided to inter\-ene and a male infant weighing 7 pounds
and 14 ounces was delivered by midforceps, the indication being
undue resistance of the soft structures of the lower birth canal.
The mother and baby left the hospital in good condition. It is
interesting to note in this case that the second baby succumbed to
tuberculosis contracted from a tubercular father before it reached
the age of one year. Had the first child been delivered by any
method except abdominal section the chances are that it would have

WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY 703

been lost during birth. The husband died a short time before the
death of the second child and it is therefore obvious that less con-
sideration of the fetus at the time of the first delivery might well
have left this woman widowed and childless.

Case III. — R. W., married, white, para-iv, thirty-three years of
age, normal pelvis. This patient's first labor was complicated
by eclampsia and the baby was lost during forceps delivery. The
second labor was normal and the baby lived. The third labor was
terminated by Cesarean section at term for the following indications:
Threatened eclampsia, large fetus entirely above the brim of the
pelvis and prolapse of the cord, with the escape of meconium stained
amniotic fluid. This operation was in December, 1911. The fourth
pregnancy terminated in normal labor three years later. The
patient was at term. She went in to labor at 6 a.m. December 2,
1914. Position L. O. A. The first stage lasted six hours and a half,
the second three hours. The child weighed 8 pounds and 9
ounces, and was delivered spontaneously.

Case IV. — O. B., married, white, para-iii, normal pelvis, thirty-
two years of age. The first pregnancy terminated in premature
labor at the seventh month, cause unknown. The second pregnancy
was terminated by Cesarean section at the seventh month for
eclampsia. About eighteen months after this operation the patient
was delivered by low forceps of a male infant weighing 7 pounds and
14 ounces. She was at term. Labor lasted a little less than
six hours. The indication for the forceps delivery was obstruction
of the head at the outlet of the pelvis by the prominence of the tip
of the sacrum.

DISCUSSION.

Dr. Moran said there was but one positive indication for Cesarean
section, a disproportion between the size of the child and the pelvis
of the mother. With eclampsia or placenta previa the necessity
for section was determined by the judgment of the physician to a
much larger extent than in the cases of disproportion. Dispropor-
tion might be present if a comparatively small head failed to mold.
In certain cases the indication for Cesarean section which was present
at the time of the first confinement might be absent at a later one.

Dr. Sullivan spoke of a recent symposium at which the dictum
was announced: "Once a Cesarean, always a Cesarean." Such a
tenet could be modified to the extent of allowing a patient after a
first Cesarean to spend the last weeks of each subsequent pregnancy
in the hospital where she might be allowed to try a couple of hours of
labor. Some years ago he had done a Cesarean for eclampsia, and
all had gone well except that on the fourth day all the chromic gut
sutures which had been used as through-and-through sutures in the
uterine wall were passed in the lochia with the knots still tied.
In that case he would watch most anxiously for rupture at any
subsequent pregnancy. Van Horn and Sawtell say that catgut in
the uterus and in the perineum is absorbed during the puerperium
just twice as quickly as at other times.

704 REVIEWS

Dr. Lowe had seen ten or twelve women who had gone through
normal vaginal delivery after having had a Cesarean. Some had
easy labors even though the pelvic measurements were small.

Dr. Willson, in closing, spoke of the chance of rupture of the
uterus as grossly exaggerated. The literature recorded forty cases
of rupture in labor after Cesarean, and apparently only forty cases
of subsequent normal vaginal birth. Such a percentage was obvi-
ously erronous, as the normal births were seldom reported.

Dr. Riggles presented a paper on

CONVULSIONS CAUSED BY PELVIC DISEASE.*
DISCUSSION.

Dr. Stone said true epilepsy was not benefited by ovariotomy.
He had one case of hysteroepilepsy where a movable kidney had
been fixed and a lacerated cervLx repaired; the woman rejuvenated
and all her seizures ceased. Neurasthenia due to pelvic conditions
was often curable by operation, but not always.

REVIEWS.

Manual of Operati\'e Surgery. By John Fairbairn Binnie,
A. M., C. M. (Aberdeen), F. A. C. S. Surgeon to the Christian
Church, the German and the General Hospitals, Kansas City,
Mo.; Fellow of the American Surgical Association; Membre de
societe internationale de chirurgie and of the Western Surgical
Association. Seventh Edition, revised and enlarged. Pp. 1363.
With 1597 illustrations, a number of which are printed in colors
Philadelphia: P. Blakiston's Son & Company, 1916. Price S7.50,
net.

It gives us great pleasure to welcome the seventh edition of Dr.
Binnie's remarkable Manual, which has become for all surgeons
a classic and accepted authority. It still maintains its original
position as a text-book which places its emphasis on the uncommon
rather than the common, and so remains, to those who are fortunate
enough to possess it, "an ever present help in time of trouble."
The new edition shows thorough revision and is well up to date.
Several chapters have been rewritten, obsolete illustrations dis-
carded, new figures inserted, and several new chapters added. In
spite of all this the size of the volume has not been materially in-
creased as pruning has been judicious and careful. Paper, type
and presswork are excellent.

* See orignal article, page 662.

REVIEWS 705

Manual of Vital Function Testing Methods and their In-
terpretation. By Wilfred M. Barton, M. D., Associate
Professor of Medicine, Medical Department, Georgetown Univer-
sity, Attending Physician to Georgetown University Hospital
and Washington Asylum Hospital. Pp.225. Boston; Richard G.
Badger, 1916.

Dr. Barton has performed a real service to the clinician in bring-
ing together in compact form the vital function testing methods
scattered through the recent literature. An estimation of the sig-
nificance and reliabihty of the tests helps to assign to each its real
value. Of the methods for estimating the functional capacity of
the liver the writer lays especial emphasis upon the phenoltetrachlor-
phthalein test. He regards the phenolsulphonephthalein test as
the most valuable and rehable for kidney function. The subject of
pancreatic function is complicated. The author describes the tests
for this without guarantee of their conclusiveness. In discussing the
tests of heart function the writer does not minimize the value of
instrumental study and numerical changes at the time of e.xercise
tests; but he emphasizes the greater importance of the general appear-
ance and condition of the patient, the rapidity of recovery after
exercise, and freedom from nervousness, irritability, cough and
insomnia during the next twenty-four hours. The volume closes
with a discussion of the ductless glands and their functional tests.

The Practitioner's Medical Dictionary, containing all the Words
and Phrases Generally Used in Medicine and the Allied Sciences,
with Their Proper Pronunciation, Derivation, and Definition.
By George M. Gould, A. M., M. D., Author of "An Illustrated
Dictionary of Medicine, Biology, and Allied Sciences," etc., etc.
Third Edition, Revised and Enlarged. By R. J. E. Scott, M. A.,
B. C. L., M. D., Editor of Hughes' "Practice of Medicine," etc.
Based on recent medical literature. Pp. 962, with many tables.
Philadelphia: P. Blakiston's Son & Co., 1916.

Although containing nearly 71,000 terms, 20,000 having been
added to the previous edition, this volume is noteworth}' for its
compactness. Thin paper, small type, and the omission of nearly
all illustrations have made possible the production of a book which
weighs only three-fifths as much as similar dictionaries. The
eponymic terms are placed in their alphabetical order. The alpha-
betical sound of the letter is the key to pronunciation employed.
A diacritic mark is used only when there may be doubt. Simplicity
and convenience are obvious characteristics of the book; accuracy
and reliability are vouched for by the editor and publisher.

706 BRIEF OF CURRENT LITERATURE

BRIEF OF CURRENT LITERATURE.

OBSTETRICS.

Accidents Occurring in the Rupture or Abortion of Simultaneous
Tubal Pregnancies. — R. Prouest and A. Buquet {Rev. de. gyn. el
de cliir. abd., vol. xxiii, part 5, 1915) says that Schauta divides tubal
pregnancy with multiple fecundation thus: (a) simultaneous extra-
and intrauterine, the most frequent; (b) twin pregnancies in the
same tube; (c) bilateral tubal pregnancies, the rarest. We should
distinguish successive and simultaneous pregnancies. The most
frequent, the successive, give at operation the impression of bilateral
pregnancies. They appear simultaneous, but one pregnancy has
followed the other, the first pregnancy having become arrested by a
hematosalpinx, a hematocele, or the occurrence of a lithopedion,
without the necessity of an operation. The operation occurs later
after the occurrence of a second tubal pregnancy. The histological
examination of the specimen alone can tell whether the two preg-
nancies were actually simultaneous. The author has observed and
gives the history of an undoubted simultaneous case. One of the
difficult points in diagnosis is that the severe pain exists only at the
site of the tube that has just aborted. The author has collected all
the similar cases reported and gives their histories. The diagnosis
should be established as to bilaterality and simultaneity. When the
fetus is not apparent only the histological examination can estabUsh
bilaterality; there must be the presence of chorionic viUi on both
sides. The first cause of error will be the possible existence of a
pregnancy or a slight salpingitis. Most certainty obtains when the
fetus can be seen on each side. To establish simultaneity we must
have microscopic and macroscopic lesions alike, and the clinical symp-
toms must be those of tubal pregnancy terminated in both sides by
abortions at about the same period. The dimensions of the fetus
should be the same on both sides. Thirty-three observations are
collected that appear authentic.

Modem Conceptions of Induced Premature Labor for Pelvic
Deformity. — Giuseppe Guiceiardi (Ann. di ost. e gin., Jan. 31, 1916)
discusses the desirability of inducing premature labor for delivery
in contracted pelvis. The material on which he bases his conclu-
sions is derived from the records of the maternity at the "Seuola
Ostetrica di Vinezia," from the year 1900 to the present time.
From these records the author collected all cases in which premature
labor was induced, and also all other cases of moderate contraction
of the pelvis which were delivered at the clinic by whatever means.
These latter he compares with those in which premature labor was
induced as to the results of the procedure with reference to the life
and health of the mother and of the infant. He concludes that for
social and technical reasons the induction of premature labor should
be abandoned for delivery of the infant in contracted pelvis in

BRIEF OF CURRENT LITERATURE 707

hospitals, and in private practice it should be limited. Exceptions
should be made only in primiparae, the first labor being regarded as
an experiment of the possibilities for delivery. It should never be
used in pelves of greater contraction than 8.5 cm. diameter. The
ideal method of delivery is spontaneous evolution, but it is not desti-
tute of danger for the child. The expulsion of the fetus may be so
slow as to cause with the increased pressure on the skull, injurious
effects on the brain and spinal cord. Measures to increase uterine
action may be fatal to the child. The best adjuvant to the expulsive
efforts is the forceps, in well selected cases and applied without
undue pressure. The best dilator is that of Ternier. Difficulty of
dilatation may be a good reason for abandoning the delivery by the
genital passages. Version may be very hazardous, since it closes
all other ways of delivery. It should be rejected. Embryotomy on
the living fetus should never be done. With a dead fetus and
septic conditions present it is justifiable. The Cesarean section is
a method of election with a healthy mother and living fetus in
impervious pelvis. There is Httle fear of rupture of the scar in later
pregnancy if good technic is used in closing the wound. Pubiot-
omy is in disuse at present. When the permeability of the pelvis
is doubtful and there exist especially favorable conditions, maternal
and fetal, so that the passage by the genital route is not excluded
we may assist the expulsive efforts. Failing in this, and an attempt
at extraction having been unsuccessful, the classical Cesarean
section may be done, but the suprasymphyseal section finds here
its most precise and rational indications. We must act so as to
bring into the world a well-developed, healthy, undamaged infant,
and leave a strong healthy mother to care for it.

Histochemical Studies of the Function of the Placenta. — Attilio
Gentili (Ann. di ost. e gin., Feb. 29, 1916) has made an exhaustive
study of the histology and chemistry of the placenta, in order to
learn its functions. He gives his conclusions as follows: The
decidual cells possess as an essential function the elaboration of
lipoid substances belonging to the group of phosphatids, cerebrocides,
and cholesterins. This function resides especially in the substance of
the epithehal cells, with a predominance of formation of cholesterin
during the early part of pregnancy, and in other cells there is a pre-
dominance of lecithin. In later pregnancy these elements diminish.
Under the action of toxic and infective stimuli the decidual cells
increase this essential function and elaborate lipoid substances in
very large quantity, especially cholesterin. In the placenta of the
cow the uterine cells become transformed into decidual cells and
possess throughout pregnancy this power of elaborating lipoid
substances. In woman no production of lipoids is found in the
epithelial or glandular cells outside of pregnancy. The lipoid
function is in exact correlation with the cellular vitality. When
these elements retrograde there may even be fatty degeneration.
This is seen in later pregnancy in the outer cells of the placenta.
The presence of lipoids in the protoplasm and in the intercellular
spaces indicates the way of elimination of the lipoids themselves.

708 BRIEF OF CURRENT LITERATURE

This is characteristic of the endocrinoid function. Even the endo-
thelial cells of the vessels partake of this power of being transformed
into lipoids.

Determinalion of Sex. — In a series of looo cases J. S. Freeborn
(Can. Pract., 1916, xli, 236) correctly diagnosed the sex of the child
previous to birth in about g-jli per cent, by noting the occurrence
of the date of conception in the first or second half of the intermen-
strual period. Conception occurred for females on an average of
5% days after the last menstruation; for males, on an average of
19 days after the last normal menstruation. Freeborn believes the
sex is fixed at the time fertilization takes place and that the ovum
determines the sex independent of any inherent quality of the sper-
matozoon, and that all ova maturing in the first half of the inter-
menstrual period are female-producing ova and those maturing later
are male-producing ova. The patient should limit marital relations
to the first ten days after the menses for girls, and for boys confine it
to the last ten days of the intermenstrual period.

Twilight Sleep. — Reporting a series of 1000 cases, C. B. Reed
{Surg., Gyn. and ObsL, 1916, xxii, 656) believes the treatment has been
successful since 29 per cent, of his cases were practical!}', and 56 per
cent, entirely, free from pain — -or 85 per cent, in all. Strength is
conserved and the convalescent period shortened. WHiether or not
the woman gets up earlier is a question of uterine involution rather
than one of days or strength or treatment. The main thing is that
she feels better much sooner. Primary pain weakness, hemorrhage,
prolapsed cord, and a lack of correlation between the size of the
pelvis and the child, make conditions that are unfavorable for
"twilight sleep." "Twihght sleep" does no harm when properly
used and will act happily in about 85 per cent, of the cases that are
selected with due regard to the contraindications.

Wassennann Reaction in Pregnancy. — ^A. M. Judd {Amer. Jour.
Med. Sci., 1916, cli, 836) says that of 892 Wassermann tests 821 were
negative and 71 positive {7.9 per cent.). Treatment of the mother
during pregnancy gives a negative reaction in the infant, but one
negative does not necessarily mean that the infant is all right and can
be suckled by a healthy wet-nurse, as syphilis may be latent. Prob-
ably one need have little fear for the child if the mother is negative.
Of congenital sj'philis it may be said that practically all infants or
children showing symptoms give positive reactions, but not all chil-
dren born of sj'philitic mothers; while of living children born of
syphilitic mothers nearly 50 per cent, give a negative reaction. If
the child has been delivered after an anesthetic has been given to the
mother the blood of either the mother or child must not be examined
for a full twenty-four hours after delivery, as the results may be
erroneous. The same holds true regarding the ingestion of alcohol
by the mother. The author differs in his opinion from those who
state that the existence of pregnancy is a contraindication to the
use of salvarsan and adopts the attitude that because of the rapidity
of its action it seems especially suited to s^-philitic pregnant women
with a view to the prevention of abortion and the delivery of a sound
child.

BRIEF OF CURRENT LITERATURE 709

Pyelitis of Pregnancy. — In order to determine what relation might
exist between the bacteria present in the bladders of normal preg-
nant women and the pyelitis of pregnancy, the following observa-
tions were undertaken by W. C. Danforth {Surg.,Gyn. andOhst., iqi6,
xxii, 723). The urine was obtained from the bladders of twenty
normal gravidae. Thirty-two showed a pure growth of staphylococ-
cus. Two showed a pure culture of colon bacillus. Three gave a
growth of. colon bacillus and staphylococcus, while thirteen gave no
growth. Colon bacillus, therefore, was found in pure culture, or
mixed with staphylococcus in five cases. In a second series of four-
teen cultures there were found staphylococci in seven cases. One
case gave a growth of pseudodiphtheria, and one case gave a growth
of a spore-forming bacillus positive to gram stain, motile, and having
an acid reaction in dextrose-agar growth, showing no reaction in
lactose agar, mannit agar, and litmus milk. Specimens of urine
obtained by means of the ureteral catheter from two cases of pyelitis
of pregnancy gave a pure growth of colon bacillus. It is highly
probable that the staphylococcus, which is so frequently found in
the urine of gravidae, is an organism of a very low degree of virulence.
As to the question of the mode of entrance of the colon bacillus into
the pelvis of the kidney, the writer believes that the infection is a
blood-borne one.

GYNECOLOGY AND ABDOinNAL SURGERY.

Bloodless Operation for Correction of Double Uterus and Vagina.

— A. E. Rockey (Annals Surg., iqi6, Ixiii, 615) describes his treat-
ment of such a case. After division with scissors of the vaginal
septum between two long straight broad-ligament clamps and
demonstration of the presence of a complete septum in the uterus,
the cervices were separately dilated with a small uterine dilator.
This permitted the introduction across the septum of the blades of
a full length curved clamp forceps, which was then firmly locked into
place, compressing the septum. All three clamps were allowed to
remain in place for thirty-six hours, and were then removed. The
compressed septum soon sloughed out, and healed completely,
leaving a single uterus and vagina, that were normal in appearance.
The patient subsequently gave birth to four healthy children.
The existence of a possible bicornate uterus with a wide low diverg-
ence of the bodies should be predetermined. In such a case it might
be advisable, after introducing the separate blades of the long curved
clamp into the cavities, to raise the table to the Trendelenburg posi-
tion, and close the clamp very slowly to avoid any possible injury
by catching the intestine between the approximated uterine bodies.
Emetine in Severe Dysmenorrhea Associated with Thyroid
Dyscrasia. — A patient of H. R. Harrower (Pac. Med. Jour., 1916,
lix, 306), a woman of twenty-five who had menstruated regularly for
ten years, developed severe dysmenorrhea and a slight swelling of
the thyroid of fifteen months' duration. Later, she noticed some
pain in her gums and slight bleeding after using the toothbrush.
Examination showed a very moderate and somewhat localized

710 BRIEF OF CURRENT LITREATURE

alveolitis, and she was thereupon given a local antiseptic wash
containing emetine and three injections of a half grain of
emetine hydrochloride at three-day intervals. The pyorrhea, if
it can be so called, cleared up, the thyroid was noticeably diminished
in size and the menstrual phenomena, due a day or two after the third
emetine injection were marked!}^ changed for the better. Seven
injections in all were given. At present there is neither goiter nor
dysmenorrhea. The patient was apparently suffering from endame-
biasis, probably of the tonsillar crypts, and this condition was suffi-
cient to be a constant source of irritation to the thyroid and was
probably the direct cause of its enlargement and dysfunction, and
also by the hormone reflex of the thyroid upon the ovaries was the
indirect cause of the dysmenorrhea.

After Laparotomy. — Emile Forgue (Ann. de gyn. et d'obslet.,
March-Apr., 1916) gives his conception of the dangers of the third
day after laparotomy. This is the critical day on which a peritonitis
may declare itself, ushered in by abundant mucous vomiting, no
escape of gas, meteorism, a typical facies, etc. The condition may
be due to one of three things: peritoneal infection, obstruction of
the intestines, or arteriomesenteric occlusion of the duodenum.
Differential diagnosis must be made by the physician. Mechanical
obstruction would appear from the eighth to the fifteenth day, and
its evolution is slow. Postoperative ileus has become much less
frequent than formerly since the era of asepsis. If peristaltic move-
ments of the intestines are not seen there is intestinal paralysis due
to general peritonitis: if we can see the peristalsis strugghng against
an obstacle there is obstruction of mechanical nature. If we have
a pure peritonitis the treatment consists of Fowler position, the
Murphy drip, and camphorated oil in large doses to sustain the heart.
If vomiting predominates lavage of the stomach is useful. Intes-
tinal occlusion may come as early as the third day and calls for
immediate opening of the abdominal wound. The sooner this is
done the better the chance of recovery. If the obstacle cannot be
found an enterostomy should be done. Dilatation of the stomach
with arteriomesenteric occlusion of the duodenum may occur from
the third day on, especially after a long operation with much han-
dling of the intestines. Lavage of the stomach and change of posi-
tion may work wonders. On the fourth day if all goes well we may
begin milk diet, with soups. At the end of the first week a pro-
gressive return to normal diet may begin. Embohsm has not been
reduced in frequency by asepsis, nor good operative technic. It
may occur early, but is apt to come at the end of two or three weeks.
According to some the early rising from bed lessens its frequency.
In cases of phlegmasia alba dolens embolism rarely occurs, because
it comes generally from the hidden abdominal clot rather than
from superficial ones. Embolism occurs especially after operations
for fibroma uteri, cancer, and ovarian cysts. Its advent is rapid
and it is generally fatal. Preventive measures are the use of citric
acid and urotropin. Constipation and overfeeding should be
guarded against. If a phlebitis appears immobilization of the limb
in cotton should be carried out rigidilv.

BRIEF OF CURRENT LITREATURE 711

Mechanism of Menstruation. — Henri Vignes {Ann. de gyn. et
if'o65^,Jan.-Feb. and March- Apr., 1916) says that attempts have been
made to isolate the hormones which cause the hyperemiant action
of the ovary upon the uterus. The Hpoids of the ovary have been
extracted and injected into animals, also that of the corpus luteum.
The author thinks that the effects of the lipoid may be due rather
to certain substances that the hpoids fix, than to themselves In
his experiments he took the synthetic method, and made extracts
soluble in water which were found to be inactive but when asso-
ciated with cholesterin they became active. The ovarian phos-
phatids alone or with cholesterin are very active. Ovolecethin has
the same property. The active substance of the corpus luteum is
probably lecithin. Lipoids soluble in acetone are not active either
alone or with ovolecithin. The effect of the injection of cholesterin
is not easy of explanation; either it has a specific action or determines
a modification of metabolism, which in its turn causes a hyperpro-
duction of the hyperemiating principle; or lastly there is a biological
antagonism between lecithin and cholesterin, which liberates the
genital lecithides. Thus the ovary provokes menstruation by a
humoral mechanism. We are ignorant of the nature and genesis
of the ovarian hormones. They have never been isolated. Per-
haps, instead of one ovarian secretion there are a series of secretions.
There is a toxicity of the genital glands and their products. The
author has experimented on the toxicity of various extracts with
the result that he concludes that the heated extracts of the ova have
a toxic action similar to that of the ovary itself, showing itself by a
slow loss of tension. The ovary is extremely sensitive to intoxica-
tions. The ovules degenerate in the presence of autotoxic substances.
This is not only pathological but physiological, and is in relation
with the genital function. The poisons contained in the ovum dis-
appear during the first embryonic phases. The appearance of these
substances in the organism is correlative with the development of
the genital glands. The poisons fabricated by these glands enter
the blood by the mechanism of internal secretion, and when the
ovary becomes active they become fixed on the germinative cells
to contribute to the formation and development of the ovum. It
is probable that these poisons play an important part in ovogenesis
and the development of the embryo. Perhaps they constitute a
material substratum of heredity and serve to transmit chemical
characteristics to the species. The corpus luteum is formed of
cells rich in lipoids. The fats of the corpus luteum take on the
histochemical characteristics of lipoids, and increase in the follicular
cells with the maturation of the ovum, and in the ovarian cells in
the course of intoxications and infections. At the time of the regres-
sion of the corpus the lipoids disappear into the lymphatic vessels.'
In the corpus luteum at maturation and in regression cholesterin
seems to be concentrated so as to pass out by internal secretion at
the time of the temporary atrophy of the gland. The author has
experimented in vitro on the neutralizing effect of lipoids on the
extracts of the ovary that are soluble in water. From these experi-

712 BRIEF OF CURRENT LITERATURE

ments it results that the granulations of the lipoids of the ovarian
cells play an important role in the function of these cells. He has
experimented as to the relation between this function and the
content of the blood in lipoids. He finds that a substance like choles-
terin exists in the blood during the first four days of menstruation.
All the author's results tend to show that cholesterinemia favors
menstruation more than lecithinemia. All animals have specific
secretions, and a genital secretion which by its excreta are eliminated
at menstruation or by the male prostate. The seed in plants and
the ovum in animals are the theatre toward which converge all the
riches of the organism. The author questions whether the affinity
of the ovule for these active substances is not the cause of the
ovarian crisis. It is possible that under the influence of this cellular
enrichment there are formed diastases which determine the fall of
the ovum from the ovary. At the same time when the phenomena
of ovulation are taking place there are produced modifications in
the uterine mucosa which prepare for conception. If this does not
take place menstrual hemorrhage occurs and gets rid of the reserves
prepared for the first phases of development. jMenstruation is not
only a cellular abortion but a chemical abortion.

Treatment of Large Crural Hemiae by a Fatty Graft. — ^M. Chaput
{Rev. de gyn. et de chir. abd., vol. xxiii, part 5, 1915) treats large
crural hernia by operation with the apphcation of a fatty graft to
assist in the closure of the hernial opening. If these grafts have not
a connection by blood-vessels they become necrotic. Therefore
the author is particular to so arrange his graft that there is a good
vascular connection with the skin of the original site of the graft.
He gives his technic of operation carefully worked out. With this
technic he has excellent results. The graft is rectangular with
a base corresponding with the pubis and internally with the median
line. It is sutured to the ligament of Gimbernat, the ligament of
Cooper, and the crural arch. Its summit is fixed by the crural
vein.

Modification of the Pulse and Arterial Tension during the Men-
strual Period. — P. Balard and J. Sidaine (Arch. mens, d'obstet. et
de gyii-, Jan., Feb., May, 1916) gives a historical sketch of the work
that has been published with reference to the changes in the pulse
and arterial tension during menstruation, and then follows with the
results of his own personal researches. His observations were made
on young, vigorous women, in full menstrual activity, in the Mater-
nity at Bordeaux. The observations have been carried out for three
months in each patient observed. The menstrual t\-pe of each
subject was studied. The examinations were made at the same hour
of the day, preferably in the morning. The pulse was constantly
influenced by the menses. It showed a sharp elevation preceding
the menses or on the first day, falUng rapidly by lysis when the
flow was established. The maximum arterial tension showed a
slight elevation before the menses and a rapid fall toward the end of
the period. The minimum was lowered four or five days before the
period and slightly at the end of the menses.

BRIEF OF CURRENT LITERATURE 713

Clinical Significance of Luteinic Cysts of the Ovaries. — Paul
Bar (Arch. mens, d'obstet. et de gyii., Jan., Feb., March, 1916)
publishes a case of lutein cyst of the ovary coincident with a hydatid
mole, a somewhat rare condition. The nature of the relation which
unites these two orders of lesions is as yet unknown. There is no
doubt that the harmonious development of the villi and decidual
elements which marks the regular ovarian cycle is in relation with
the modifications of the gravidic ovisac. When there is a mole,
whether the deviation of the elements be primary or provoked by
an abnormal decidual reaction, the fetal cellular elements no longer
develop normally. They are gravely altered. All become in-
harmonious. The author concludes from his study of his own and
the published cases that when a mole is found coincident with the
presence of ovarian cysts it is prudent not to content oneself with
emptying the uterus. Hysterectomy is indicated, because of the
danger of the later occurrence of an invading mole. When, after
evacuation of the mole, we find that the ovarian cysts continue to
develop, or when we see them appear we should fear a vegetation in
the uterine wall of molar elements. This significance of the ovarian
cysts is more pressing when the uterine hemorrhage persists. It
indicates a rapid operation with removal of the uterus.

Bleeding Nipples. — D. Lewis {Surg., Gyn. and Obst., 1916, xxii, 666)
has observed clinically seven cases of bleeding nipples, five of which
have been operated upon. These seven cases all presented a typical
serohemorrhagic discharge. The discharge in two of the cases at
times became almost pure blood. In two cases the discharge was
associated with chronic cystic mastitis, while in the remaining five
small intracanalicular papillary cystadenomata were the cause of
the hemorrhage. The character of the discharge, whether sero-
hemorrhagic, hemorrhagic, or brownish, apparenth' gives no clue
whether malignant changes are occurring. Some of the benign
papillomatous growths have been associated with a brownish dis-
charge. In some instances the discharge has lasted as long as nine
years, in one as long as twelve. One of the cases observed by the
writer showed beginning malignant changes. In this case a dis-
charge had been noted for three months, but a tumor had been
present for four. Bleeding nipples are most frequently associated
with intracanalicular papiUary cystadenomata and the adenocystic
type of chronic mastitis. A plastic operation should be performed
unless there are evidences of malignancy. The changes associated
with malignant degeneration are quite definite and can be determined
by gross appearance when such a cyst is opened. An operation
should be advised even when there is no evidence of a tumor, for
in these cases a small intracanalicular papillary cystadenoma will
be found deep down in the ducts. The portion of the breast in
which the growth lies can be determined by the increase of the dis-
charge when pressure is made.

DEPARTMENT OF PEDIATRICS.

ORIGINAL COMMUNICATION.

THE TROUBLES OF THE NEW-BORN.

J. EPSTEIN, M. D.,

New York.

The normal development of the fetus depends on the mysterious
laws of heredity, the generic laws of embryology and the health of
the mother. In the short transitional period between fetal and
infantile life, during its passage from its uterine abode to the external
world, the fetus is subjected to the vicissitudes of the obstetrical
art. On its arrival into the new world, the new-born may come
unscathed and in perfect health or it may be weak, feeble and below
par. It may bring with it congenital diseases and malformations
or obstetrical diseases and injuries. In order to exist, the infant
must adopt itself to the new surroundings and the new conditions
of life. Many infants pass through the early weeks of life, as well
as the entire period of babyhood and enter the stage of childhood
without falling a prey to disease. Some infants, however, acquire a
group of diseases which for a lack of a better name have been called
diseases of the new-born. The result is that the newly born may
have :

1. Congenital diseases and malformations.

2. Obstetrical diseases and injuries.

3. Diseases of the new-born.

The most important congenital disease is syphilis. Occasionally
tuberculosis and other infectious diseases have been transmitted
from mother to child. Various constitutional diseases and tenden-
cies including functional nervous diseases and psychic disorders
have been conveyed from parents to offspring. The diagnosis of
congenital syphilis is in the majority of cases not difficult, though
the symptoms and signs may not be fully developed during early
714

EPSTEIN: THE TROUBLES OF THE NEW-BORN 715

infancy and the history may be negative or indefinite. A syphilitic
infant looks syphilitic. A great deal depends on the severity of the
infection, but the well-developed case is difficult to mistake. The
VVassermann test of the blood or the cerebrospinal fluid confirms
the diagnosis. The prognosis is worse in proportion to the severity
of the disease, the more pronounced the symptoms and the younger
the child. The treatment must be both general and specific.
Proper feeding, fresh air, good care together with mercury and sal-
varsan or neosalvarsan are essential to the successful treatment of
this destructive disease. Congenital malformations may aSect any
structure or organ of the body and may be within the reparative
skill of the surgeon or beyond his reach.

Obstetrical diseases of the new-born as a result of infection during
birth are not common and the treatment depends on the condition
and the character of the infection. Injuries to the meninges, the
central and peripheral nervous system, are of the greatest importance
in the future life history of the infant. Traumatism to the soft parts
and fractures of the bones are not infrequent during delivery.
Some of the obstetrical injuries are amenable to treatment while
others are impossible of repair.

The so-called diseases of the new-born are difficult of diagnosis and
treatment because they differ in their etiology, pathology and symp-
tomatology from diseases in later life. During infancy the structure
and functions of the body are in an unstable and immature state.
The reactions of the body to disease are irregular, incoordinate and
are either in excess of the pathologic process or inadequate in re-
sponse. The infant cannot help the physician to arrive at a correct
diagnosis by his subjective feelings of pain and discomfort and diag-
nostic conclusions must be drawn from the objective symptoms and
signs only. The temperature, pulse and respiration in infancy are
not always a reliable guide to the severity of disease because the
nerve centers are, at this time of life, in an imperfect and unstable
condition and are susceptible to changes from slight internal and
external influences. The pulse and respiration may also be irregular
in perfectly healthy infants.

The following are some of the most important diseases of the
new-born:

Asphyxia. — .\sphyxia neonatorum is a condition where the respira-
tory system of the new-born cannot adopt itself to the new conditions
of life. Since the causes of asphy.xia in the newly born are more
antepartum or intrapartum than postpartum, it belongs to the group
of obstetrical diseases.

716 EPSTEIN: THE TROXJBLES OF THE NEW-BORN

Atelectasis.- — Though commonly known as congenital atelectasis,
it is really not a congenital disease. It is simply a condition where
the infants bronchopulmonary apparatus is not fully inflated and
is in a more or less collapsed fetal state. The infant is air-hungry
and is usually feeble and cyanotic and the pulse and respiration are
poor and irregular. The physical signs vary according to the extent
of the airless lung and the distance from the surface. Dulness is
frequently found in the bases of the lungs posteriorly.

Pneumonia. — In the new-born pneumonia is frequently difficult
of diagnosis because the response of the body by the known symptoms
and physical signs to the pneumonic process is atypical and irregular.
It should always be distinguished from atelectasis, because some of
the symptoms and signs are alike in both conditions, and fever when
present may be due to some other cause than an infection of the
lungs. Careful observation, and the usual high temperature, the
rapid pulse and respiration in pneumonia will aid in the diagnosis.

Gastrointestinal Disturbances. — The entire digestive system in
early infancy may be weak and feeble, and unless the food is made to
fit the digestive ability of the new-born, trouble is sure to follow.
At birth, the digestive tract is sterile but soon becomes germ-laden
and when the food is not properly digested it may give rise to putre-
faction and toxemia. The meconium may become infected. A
great many new-born infants are unnecessarily starved because of
the lack of breast milk or its late appearance or the improper arti-
ficial feeding. An undue loss in weight during the early days of
life will make the future struggle for existence more difficult.

Acute Pyogenic Infections. — A local infection in the newly born
may spread and give rise to a septicemia or a septicopyemia
because the vitality and the resistance is much lower in early
infancy than in later life. Omphalitis is not an infrequent affection
in the new-born and may not show any external signs of um-
bilical infection. The disease may affect the deeper layers and may
cause general peritonitis with all kinds of complications and sequela.
Ophthalmia neonatorum though a local infection is very destructive.

Icterus. — Icterus neonatorum is quite frequent and because of its
frequency and harmlessness it is considered a physiologic process
and as a part of the normal evolution in the life of the infant.
Whether this so-called physiologic jaundice is really physiologic or
pathologic, it should be carefully distinguished from the less frequent
but harmful icterus due to septic infection, syphilitic hepatitis,
malformations of the bile ducts and chronic family jaundice.

Hemorrhages. — Hemorrhages in the new-born form an interesting

EPSTEIN: THE TROUBLES OF THE NEW-BORN 717

but distressing group of diseases. The usual causes are various
forms of traumatism, septic infections, syphilis and the so-called
spontaneous or idiopathic hemorrhages which are probably due to an
unknown infection and may occur in any organ or tissue of the bodv.
In no disease is an early diagnosis so essential as in the hemorrhages
of the new-born. If bleeding begins within the first two or three
days of life' it is usually of spontaneous origin and blood transfusion
should be done immediately. Hemorrhages due to sepsis, syphilis
or traumatism may be diagnosed by the history and the various
signs and symptoms.

Obscure Fevers. — Fevers of apparently unknown cause is not un-
common in the early days of life. The new-born may have a high
temperature without any other evidence of disease. But a careful
examination may reveal a hidden focus of infection or a pneumonia
without pneumonic signs. Starvation is a frequent cause of fever.
The application of hot-water bags to keep the baby warm may
cause a sudden rise in temperature. The termogenic, termo-
inhibitory and vasomotor centers are in an unstable and unbalanced
condition during early infancy and many internal or external in-
fluences may upset the normal process of heat production, heat
inhibition and radiation.

Crying. — Infants in the early weeks of life frequently suffer from
colic and cry incessantly but because of its frequency and the failure
of the physician in the majority of cases to relieve this distressing
condition, it is looked upon by the laity as a normal event in the
life of the infant. A careful study will show that the infant cries
because of overfeeding or underfeeding or indigestion of the food.
A correction of the dietary error will keep the infant quiet and happy.

22 2 East Broadway.

718 TRANSACTIONS OF THE

TRANSACTIONS OF THE NEW YORK ACADEMY
OF MEDICINE.

SECTION ON PEDIATRICS

Stated Meeting Held April 13, 1916.
Dr. Royal Storrs Haynes in the Chair.

meningococcus meningitis with unusual hemorrhagic
manifestations .

Dr. C. T. Sharpe reported this case. The child exhibited the
usual symptoms of meningococcus meningitis in an unusually-
severe form, with, in addition, hemorrhagic areas in various loca-
tions over the body. Meningococci were demonstrated in these
skin lesions. Dr. Sharpe showed lantern slides of these lesions and
said that so far as he could learn this was the first instance in which
this organism had been isolated from a skin lesion.

DISCUSSION.

Dr. Henry Heiman. — This case is extremely interesting and
I have never seen anything just like it, never one so severe. If
it had occurred during an epidemic one would say that it was a
fulminating case, one of those severe cases that die within twelve
to twenty-four hours. If there had been a number of other similar
cases one might say they were due to a particularly virulent strain
of meningococcus, but there was only this one case and so it seemed
that it could only be explained on the theory that there was a
very low degree of resistance in this individual. The disease is
of a type in which the blood culture is positive, and I do not be-
lieve that the injection of serum into the blood would have been
effective.

the DEFICIENCIES IN THE STATE LAW REGULATING OVERCROWDING
IN INSTITUTIONS FOR INFANTS AND CHILDREN.

Dr. Thomas S. Southworth opened the discussion: It is ad-
mitted on all sides that the mortality among young infants placed
in institutions is much greater than it should be, and greater than
if the infants remained at home. This question has caused serious
concern, but no very definite suggestions for relief had been forth-
coming, save that all such infants should be boarded out. But

NEW YORK ACADEMY OF MEDICINE 719

while boarding out shows results much better than those of the
poorest institutions, the results do not notably exceed those of the
best institutions. Even if it were desirable, institutions could
not be done away with at once. The problem of the institution,
therefore, is and must remain a matter of daily and hourly concern,
and demands our immediate attention. Superficial changes in
the institutional management of infants, while cumulative for
better conditions, do not go sufficiently to the root of the matter
to be imme'diateh' effective. Are there not then some fundamental
factors which are now definitely contributory to the mortality,
but which can be remedied? Such a factor, in Dr. South worth's
opinion, was the overcrowding in the wards, permitted and en-
dorsed by our present inadequate and loosely drawn State law
which, for lack of anything better, is applied to children of very
divergent ages, conditions and needs, and is largely robbed of
whatever value it might possess by the "joker" clause with which
it ends. Chapter XLV of the Consolidated Laws defines their
application as follows: "To every institution in this State, incorpo-
rated for the express purpose of receiving or caring for orphan,
vagrant or destitute children, or juvenile delinquents, except hospi-
tals." , The law goes on to say: "The beds in every dormitory in
such institution shall be separated by a passage way of not less than
two feet in width, and so arranged that under each the air shall freely
circulate, and there shall be adequate ventilation of each bed, and
each dormitory shall be furnished with such means of ventilation
as the local Board of Health shall prescribe. In every dormitory
600 cubic feet of air space shall be provided and allowed for each
bed or occupant, and no more beds or occupants shall be permitted
than are thus provided for, unless free and adequate means of
ventilation exists approved by the local Board of Health, and a
special permit in writing therefor be granted by such Board."
Certainly the terms orphan, vagrant, and destitute children, or
juvenile delinquent suggest children of the run-about age of two
years or over, and not young infants. This view is confirmed
by the use throughout of the term "dormitory" which the Century
Dictionary defines as "The part of a boarding school or other
institution where the inmates sleep." The inference is that the
law was framed to regulate the sleeping quarters of asylums or
reformatory institutions for older children who might be reason-
ably supposed to spend a considerable part of their time in other
quarters during the da}'. There is no trace of implication that it
was intended to be applied to infants or to wards in which more or
less sick infants lived practically all the time, both day and night,
during a very considerable part of the year. It would appear that
it was the intention of the framers that there should be not less
than 600 cubic feet per inmate; else why state it so clearly? But
this intention was nullified by the final or "joker" clause, which
was perhaps appended as a compromise. The "joker" or amend-
ment grants to any local Board of Health in the State the power
to issue permits for any larger number of inmates, when conse-

720 TRANSACTIONS OF THE

quent reduction in the cubic space per inmate provided for "free
and adequate means of ventilation." Such adequate means of
ventilation should exist. What then is the practical working of
the law in New York City? Framed permits are hung upon the
walls of each ward stating the number of infants allowed therein.
Permits were until recently granted i^y the Board of Health based
upon the number of square feet of Hoor space, allowing about fifty
square feet, or slightly over, for each inmate of the ward. This
has recently been changed to cubic feet, allowing about 500 cubic
feet per inmate, and affording at times less than 50 square feet of
floor space in certain of the institutions, depending upon the height
of the ceilings. He said he had been informed authoritatively that
this amount may and is reduced legally as low as 200 cubic feet
per inmate in certain other types of institutions covered by the
law, and that there is nothing to prevent a further reduction below
500 cubic feet in wards for infants. Whether the 600 cubic feet
of space per inmate, which was the evident of the law, or any
reduction therefrom, is or is not adequate for the dormitories or
sleeping quarters of older and presumably well children in re-
formatories or orphan asylums, he was not here to discuss, but he
did with all earnestness contend that the application of the law,
for a lack of a better, to wards containing infants under two years
of age, and especially bottle fed infants under one year of age, with
an allowance of only 500 cubic feet and perhaps less than fifty square
feet of floor space per infant, tends directly to increase both the
morbidity and consequent mortality among such infants, a mor-
tality which, in part at least, is preventable. The origin and
authority for the 600 cubic feet standard, now largely departed from
in the wrong direction, appears to be lost in obscurity; but judging
from the answers received to a questionaire sent to the members
of the American Pediatric Society, compiled and published in the
Archives of Pediatrics, September, igi5, such space allowance falls
far short of the 1000 cubic feet demanded by the majority of
pediatric opinion throughout the United States. In all except
possibly the most modern and enlightened institutions, bottle fed
infants who remain for any considerable time do not continue
to be well fed infants, even though they are admitted as such. They
suffer not only from digestive and nutritional disorders but from
the acute infections which spread readily in overcrowding wards.
Owing to the special care which such infants require, not alone
when reasonably well but more particularly when sick, the wards
in which they are cared for demand the larger nursing staff and
adequate cubic space of sick wards. In whatever type of institution
they are situated, they are to all intents and purposes hospital
wards, not dormitories. Very few institutions receiving and re-
taining infants make adequate provision of competent nurses, or
increase the number of nurses as the population of a ward increases.
Overcrowding means, therefore, a proportionately decreased care
of the individual infant and no one will deny that undercare makes
for an increased mortality. Where permits have been issued for

NEW YORK ACADEMY OF MEDICINE 721

an excessive number of infants, but the ward is sparsely filled, the
effect of painstaking individualization in the bottle feeding may
be to inaugurate satisfactory gains in the weight; but if with such
care few or no infants die, continued admissions to the ward soon
increase the numbers to the legalized point of overcrowding.
Then, with exactly the same methods of feeding, infants who were
previously doing well, cease to gain; some lose rapidly; and there
are a number of deaths until the census of the infants is again
reduced. ' In short, modern feeding methods fail, or avail only
temporarily, to prolong the lives of the infants where overcrowding
is permitted. With our present knowledge, it is scarcely necessary
to argue that infections, both of the more subtle respiratory types
and of the openly contagious types, are more readily spread by
permitting closer proximity of the infant's cribs. Any one who has
observed the effects upon nutrition of the invasion of the infant's
ward by the usual grippal infection will need no argument concerning
its resultant mortality. The question may readily be asked:
"Why, if this overcrowding so manifestly contributes to the
mortality, are not steps taken by the physicians of each institution
to reduce the numbers in the wards?" The answer to this is that
it is obviously difficult to convince lay managers that the permits
issued by recognized authorities concerned with the enforcement
of health regulations do not represent the last word in the most
enlightened pediatric opinion concerning the needs of the infants.
Thus, a law framed with beneficent intent offers not assistance but
an obstacle to efforts to reduce the mortality among these infants.
In the application of this law to infants, the recent trend has not
been to insist upon more space than the minimum prescribed by
the law, but on the contrary, to allow less space than that con-
templated and specified in the law. Those whose only experience
has been with infants placed for temporary treatment in the wards
of well appointed hospitals, having looo or more cubic feet of space
for each inmate, can form no adequate conception of the problems
which present themselves in overcrowding institutions. The
basic criteria are not the same, but the better results shown by the
former, with their large space, constitute a very potent and cogent
argument for the limitation of overcrowding in institutions for
infants. We have been asked by the Committee of the Academy
of Medicine to review this matter as a Section and from the pediatric
standpoint. He suggested that the State law should be revised;
that certain sections should be framed for orphan asylums, re-
formatories, and older children; and separate new sections framed
for young children and infants; that provision should be made for
ample space in sick wards; that wards containing bottle fed infants
under eighteen months of age should be specifically classed as sick
or hospital wards; that the amount of cubic space allowed to each
of these main groups should be based upon modern pediatric opinion;
and that there should be no qualifying clauses permitting the pur-
port of the law to be nullified to suit individual caprice; that after
basic space, which is sufficient with the windows closed, had been

722 TRANSACTIONS OF THE

specified, further provision may then be made for inspections and
enforcement by local authorities, with a view to assuring reasonable
employment of the usual available means of ventilation. Dr.
Southworth did not claim that additional space was a cure-all
which would remedy all the difficulties in rearing infants in institu-
tions, but he maintained that increasing the cubic space require-
ment was the surest, most direct, and most feasible way of cor-
recting a number of the evils of institutional life. So long as the
present inadequate law remains on our statute books, just so long
will a unnecessarily large mortality inevitably obtain in our in-
stitutions for infants, and especially among those infants under one
year of age who are artificially fed.

Dr. Charles Gilmore Kerley. — The mortality of young
children depends on so many other factors in addition to that
of cubic air space that I feel this is, comparatively speaking, but a
small part of the subject. If the air is undergoing active ventila-
tion, a small cubic air space may answer very well. The peculiar
feature which we meet with in most institutions is that there is
but one room for a group of children and here they must stay all
the while; in this one room they must play, eat and sleep, and this
is the factor that does not obtain in ordinary dwellings. I be-
lieve that this is one of the worst factors in connection with in-
stitutions for infants and young children.

Another matter is with reference to an adequate system of
ventilation. While I will not discuss the various systems of ven-
tilation that we have, I will say that I do not know of a system
that really does ventilate; when one wants ventilation he still has
to resort to the open window. So while we realize that cubic air
space is important, it is rather insignificant if other factors are
not taken into consideration.

Dr. Henry Dwight Chapin. — Dr. Kerley has brought out
the two points that I would emphasize. We may have one thousand
or ten thousand cubic feet of air space and if everything is shut
up the supply of air may be insufficient; the essential factor is to
have an adequate supply of freely moving fresh air and then the
cubic air space is not so important. Last summer I visited one in-
stitution in Portland, Oregon, where they were having a very low
mortality and yet everything in connection with the air space and
ventilation was wrong. There was, however, a wide piazza and
the children were out in the fresh air all day and this was probably a
factor in the low mortality under what were otherwise very bad
conditions. It seems to me that the best way of dealing with in-
stitutions for infants is to abolish them as far as possible. It has
been said that lay boards make the rules and doctors follow them.
The doctors should say that if conditions were not improved, they
would no longer remain on the staffs of such institutions. We may
as well recognize the fact that the trouble lies in a lack of proper
force on the part of the doctor.

Dr. Floyd M. Crandall. — This question has been brought
before you for very definite reasons, particularly for opinions

NEW YORK ACADEMY OF MEDICINE 723

with reference to accommodations for infants and children in
institutions as measured by cubic air space. It was with this object
in view that this question has been referred to this section for an
expression of opinion. That is what the discussion should bring
out. The question has come up whether the PubHc Health Com-
mittee of the Academ}' of Medicine should take up the modifying
of this law. The question should be considered by pediatricians
first and the doctors who discuss it should bring out something
definite and tangible. It is an inadequate law in that it lodges the
decision In the matter of overcrowding in the hands of the managers
of institutions and so long as they are protected by the law, as they
now are, they are not liable to be more liberal than the law requires.
It was decided that the best way to get the desired information
in reference to cubic air space was to appoint a committee to send
a questionalre to the members of the Section and to submit the
result to the Council of Public Health of the Academy.

THE HOSPITAL CONTROL OF THE INFECTIOUS DISEASES OF INFANCY
AND CHILDHOOD.

Dr. Dennett L. Richardson, Superintendent of the Providence
City Hospital, read this paper by invitation. He said that present
day Investigations of infectious diseases were most interesting and
valuable and that this was a promising field of endeavor which would
yield new truths, the scientific application of which would greatly
diminish human suffering and loss of life. These studies should
embrace statistical data, accurate clinical observation, and clinical
research. The problems to be solved are the etiology, the deter-
mination of the secretions and excretions In which the virus exists,
the earliest and latest periods of infectivity, the fate of the virus
after It leaves the body, the natural modes of transmission, the
atrium of Infection, and the exact and early means of diagnosis, and
finally the treatment. This paper presents some facts on the
transmission of contagious diseases learned by hospital observa-
tions. It Is pretty well estabhshed that the sources of any in-
fectious diseases are three; the clinical case, the missed case and
the carrier. The disputed questions relate to the methods by
which the virus finds its way into the healthy person. Formerly
the r61e of air infection was given more attention than the avoid-
ance of infection by contact, but through the observations of certain
French investigators, the conclusion has been reached that the
diseases in question are seldom air borne and that isolation of the
patient Is not complete unless rigid antisepsis Is carried out. The
practical results obtained at the Pasteur and several other French
hospitals have shown that with the employment of aseptic nursing
it Is no longer necessary to house different diseases in separate
pavilions. In consequence of this there have developed several
methods of construction by which one may obtain physical separa-
tion of patients suffering from different infectious diseases and

724 TRANSACTIONS OF THE

yet treat them in the same ward. These systems are: i. The
cubicle system, having its origin in the Pasteur Hospital and
consisting of single rooms, the partitions being complete or only
partially reaching to the ceiling and arranged on both sides of a
common corridor. 2. The barrier system, consisting of bed isola-
tion of different diseases in a large open ward, the beds being placed
about 12 feet apart on centers. These isolated beds are desig-
nated by colored tape stretched between two uprights at the foot
of the bed or by the use of printed colored cards. A few hospitals
separate patients in a large ward b\' low glass partitions between
the beds as at the Willard Parker and Johns Hopkins. 3. The
cellular block plan as constructed at the Plaistow Hospital consists
of two rows of rooms back to back with glass partitions between
them, each room leading to an open veranda on either side of the
building. The statistical records of London hospitals into which
these systems were introduced demonstrated the success of aseptic
nursing, though they showed that measles and chickenpox were
the most difficult to care for by aseptic nursing.

In March, 1910, aseptic nursing was first undertaken at the Provi-
dence City Hospital, which had been constructed in accordance with
the theories of medical asepsis through the efforts of Dr. Charles
V. Chapin, Superintendent of Health of Providence. Patients
suffering from infectious diseases are accommodated in three
two-story pavilions, arranged parallel, and containing about
140 beds. Two of the buildings are duplicates; each floor of these
pavilions is so arranged that about half the patients can be placed
in rooms off the central corridor and containing from one to three
beds each, while there is a convalescent ward with fourteen beds
at the south end of the building. At the present time one of the
duplicate buildings is devoted to scarlet fever. The first floor of
the other building houses the diphtheria patients; the second floor
is used for an isolation ward where various infectious diseases except
measles and chickenpox are treated. These highly transmissible
diseases are not included because the nursing in these buildings
is largely done b}* pupil nurses who have had only two months
training in technic. The third building, the so-called isolation
building, provides for the care of any infectious disease, including
smallpox. Every room is provided with a lavatory where the
water must be turned on by forearm or foot levers and where
nurses and physicians must wash contaminated hands in running
water with soap and scrub brush. Immersion in an antiseptic
solution is also required after such diseases as measles, chickenpox
and smallpox, and very septic cases of other infectious diseases.

Elaborate construction alone is quite unable to prevent cross-
infection. Proper management is of far greater importance.
The latter resolves itself into proper admission of patients to prevent
mistakes of diagnosis, securing a history of other infectious diseases
in the home, active and intelligent observation of jjatients for symp-
toms of secondary disease; careful attention to the health of all
employees; absolute separation of patients suffering from different

NEW YOEK ACADEMY OF MEDICINE 725

diseases, and the proper and efficient sterilization of hands, utensils,
and linen between different infectious units. At the time of ad-
mission all doubtful cases are isolated until the diagnosis is clear.
Nurses must be impressed with the importance of asepsis and
taught the details of its administration. They are taught that
the room occupied by a patient is an infected area and under no
condition shall she touch, or allow her clothing to touch, anything
in such a room unless she has her gown on. Everything taken
from such a room must be properly sterilized. The nurse herself
must scrub her hands thoroughly for at least 3 minutes on leav-
ing. She must see that patients in different units never come
into direct or indirect contact. ' When a patient is ready for dis-
charge he is given a soap and water bath and shampoo. This bath
is given the day before discharge, and the patient is then put into
a clean room set aside in each ward as a discharging room. When
the mother comes for the child clean clothes are put on him and if
he presents no symptoms after careful examination he is taken
away. The rooms have never been fumigated since the opening
of the hospital, but the floors and furniture, and in the isolation
wards the walls within easy reach, are washed with soap and water.
A careful record has been kept of the room or rooms occupied by
each patient, and have never been able to trace any cross-infection
to this source. Infected linen is collected under aseptic precautions
and placed directly into washers where it is washed by boiling
water and its sterility tested by cultural experiment. No sterilizing
washers are used.

All the elaborate technic of caring for the patient must be
supplemented by careful supervision of the nurses, lest a sick
nurse be on duty. The same supervision applies to all the hospital
personnel. Resident physicians wear white suits. Over their
shirts they wear a short-sleeved washable vest, outside of which is
worn the usual white coat. When visiting patients the coat is
removed and a gown is worn only when making careful physical
examinations. The doctor always scrubs his hands in going from
one infectious disease to another.

From March i, 1910 to Jan. i, 1916, 6748 patients have been
discharged from the hospital and among these there occurred
166 cross-infections. The diseases contracted were as follows:
Measles, 48; chicken-pox, 78; scarlet fever, 19; diphtheria, 10; rubella,
4; whooping cough, 4; mumps, 3. The total incidence for the whole
hospital was 2.4 per cent. If from the total number of discharges,
2029 adult patients suffering from tuberculosis and syphilis were
subtracted leaving 4689, nearly all of whom were children, the
incidence is 3.5 per cent. There has never been a cross-infection
among the tuberculous and syphilitic patients. In the isolation
wards where a great variety of infectious diseases were treated,
2788 Ipatients were treated and 92 cross-infections developed, an
incidence of 3.3 per cent., slightly less than for the whole hospital,
exclusive of tuberculous and syphilitic patients.

Nearly all instances of infectious diseases arising among em-

726 TRANSACTIONS OF THE

ployees have occurred among pupil nurses. It was interesting to
note that nine nurses were diphtheria carriers when they entered
upon their duties while only nine were found to be carriers when
they had finished their course. Of 424 nurses, sixty-four had
previously had diphtheria, and nineteen pupils and one graduate
contracted the disease. One hundred and twenty-one had pre-
viously had scarlet fever and nineteen pupils and one graduate
contracted the disease; 335 had previously had measles and none
contracted it; fifty had previously had rubella and two pupils and
two graduates developed the disease; 184 had had mumps and
only two contracted this disease. Among 229 employees during
the same period only five contracted an infectious disease.

These results demonstrate that rigid asepsis is of primary im-
portance. Hospitals for infectious diseases and for children should
not have wards of over six to ten beds each and should have
sufficient smaller units to accommodate all patients for an ob-
servation period. Conservative and accurate diagnosis on the
admission of patients and careful supervision will prevent the
entrance or continued residence in the same unit of patients suffering
from more than one transmissible infectious disease. Among
forty-two house officers serving during this period two have devel-
oped diphtheria and one both mumps and rubella.

Dr. George Draper. — A most notable feature is that among
the great array of infectious diseases considered in the paper, no
mention is made of poliomyelitis. Why were there so few cases
of poliomyelitis at this great institution? Two reasons may
account for this fact. First poliomyelitis has essentially a rural
distribution, and secondly sporadic cases, in the city, come usually
into the large general hospital.

The care of poliomyelitis in a hospital such as Dr. Richardson
has described is a simple problem. The management of this dis-
ease is essentially the same as that of diphtheria or scarlet fever.
Perhaps particular stress should be laid upon caring for secreta and
e.xcreta.

There have been a number of instances of cross infection recorded
during epidemics in Sweden. Among nurses a number of cases
have been reported both in Europe and America. Their protection
as far as we know rests upon rigid care of the hands, nasal passages
and the mouth.

One cannot say much more of the control of the disease in hos-
pitals, since the control must be similar to that of other diseases;
possibly in addition there should be special care of the nose and
throat of contacts. The attendants should use a spray of peroxide
solution, or menthol in oil.

With regard to the general control of the disease in the com-
munity, quarantine at present is our best defence. While most of
the means of transmission have been determined, some apparently
still remain hidden. It has not yet been determined why one
infant in a family contracts the disease and not others in the same
family; why some sections of a community have a number of cases

NEW YORK ACADEMY OF MEDICINE 727

and others not; and why at another time it will be found in that
section of the community which before was free. The part played
by mild abortive cases and healthy carriers must still be thoroughly
cleared up. Contacts must be thoroughly controlled and likewise
the carriers and the patients, and the same rigid quarantine must
be maintained as in other infectious diseases, though it has not
been definitely demonstrated that the virus found in the nose and
throats of healthy carriers transmits the disease. The duration of
activity of the virus in convalescent patients is important. A
case has been reported of a child having two attacks of the disease
two years apart, and five months after the second attack it still
harbored the virus. In monkeys the virus usually disappears from
the mucous membranes in five or six weeks but in certain individual
monkeys it may persist for four or five months. The incubation
period normally is from two to seven days, but there may be a
very long latent period. In the case of a young woman who was
committed to prison and who developed poliomyelitis two months
after her admission to solitary confinement is found the suggestion
of this prolonged latent period. From these facts it would seem
that we should give more consideration to the proper control of
poliomyelitis.

Dr. Henry Heiman said: The epidemiology of meningococcus
meningitis presents features at times which have been so strange
and puzzling and so different from the characteristics usually
associated with other contagious, or so-called readily communicable,
diseases that the contagiousness has been questioned by not a few
observers. As a rule there is no regular progression or extension
of the disease. It moves by leaps and bounds and seems to strike
at haphazard. In those dwellings in which there were more than
one case the patients did not acquire the disease from each other,
as it appeared simultaneously in the different individuals and not
successively.

In considering the hospital control of infectious diseases from
the standpoint of meningococcus meningitis, it is advisable to
consider first the mode of transmission of the disease. It is well
known that the disease is a communicable one and occurs in epi-
demics. It is also endemic in the city of New York, as most of the
other communicable diseases are. It is generally conceded that
the mode of transmission is by means of Fliigge's droplet infection,
that is to say, the meningococcus is transmitted to the exposed
mucous membranes of previously healthy persons. IMeningitis
may or may not be the result of this transmission, depending
entirely upon the susceptibility or resistance of the individual, that
is to say, that they may be receptive and not susceptible to the
meningococcus and harbor it there for weeks or longer. The
natural history of the meningococcus makes it improbable that the
disease is transmissible through the agency of the atmosphere or
lifeless objects, but directly from one individual to another. This
does not necessarily mean that transmission is from patient to
patient, but in most cases the source of contagion is a healthy or

728 TRANSACTIONS OF THE

apparently healthy meningococcus carrier. The strange fact that
cases of hospital contagion are so rare is probably due to the greater
number of meningitis patients in these institutions being children.
Experiments have shown that there are ten to twenty times as
many healthy carriers as there are diseased carriers or patients.
Therefore in order to properly control the spread of this disease,
we must devote our attention to prophylactic measures. In hos-
pitals at present the preeminent prophylactic measures are the
gown, the hand brush, and disinfectants; and it would seem rational
to add the usual measures, the gargle and the cleansing of the
nasopharynx of the pliA'sician, nurse, or anybody coming in contact
with the patient. The disinfection of all the excreta of the pa-
tients, especially those of the respiratory tract in adults (since
children as a rule swallow their sputum) is of the utmost importance.
Experience has shown that absolute quarantine in hospitals is not
necessary, as transmission of the disease in hospitals is comparatively
rare. Leichtenstern, however, reports that three nurses and a
sister in attendance on cases of meningitis in the wards contracted
the disease. Three of them had not left the hospital for some time,
and could not have acquired the disease from the outside. In the
New York Hospital Elser and Huntoon found three instances of
infection of nurses in attendance on adult cases of meningitis.
School infections, though rare, are reported by Bolduan and Good-
win and Netter and Debre. The latter observed ten cases, six of
which attended a common school. Among 231 pupils of this school
there were found forty meningococcus carriers, that is, 21.21 per
cent. Fliigge finds that 70 per cent, of the individuals living in
close proximity to a meningitis patient become carriers. Netter
and Debre found 41.66 per cent, carriers in the months of March
and April and May in the immediate vicinity of the patient, as
contrasted with 26.66 per cent, during June, July and August.

With our modern improved laboratory technic it would not be amiss
to have occasional cultures of the nasopharynx taken from the
doctors and nurses attending the cases. Overcrowding in hospitals
during an epidemic of meningococcus meningitis should be avoided.
We should further urge upon the public the advisability of sending
meningococcus meningitis case, if possible, to the hospital for the
sake of preventing the spread of the disease, as well as for better
observation and better control of the cases by laboratory methods.
If patients remain at home, they should be isolated and inter-
mingling between the members of the family and the outside world
restricted as much as possible.

Incidentally it may be mentioned that children belonging to
the family of the patient should not be permitted to attend school
for about three weeks from the onset of the disease, unless they
may be proved by bacteriological methods to be noncarriers.

In conclusion I wish to emphasize the importance of the healthy
carriers in the transmission of meningococcus meningitis and
that our attention should be directed almost as much to these
persons as to the patients themselves. It is not possible to detect

NEW YORK ACADEMY OF MEDICINE 729

or control all these healthy carriers, but prophylactic measures along
these lines would probably help to lessen the dissemination of the
disease.

Dr. William H. Park spoke on the hospital control of diph-
theria: In the first place it has been interesting to observe hciw we
have received a paper like Dr. Richardson's. Five or ten years
ago we would have thought that such a method was not effective
quarantine. We would have thought that caring for two kinds of
infectious diseases with only a partition open at the top between
tliem would not prevent transmission.

As to diphtheria and the Schick test, I believe that we can rely
absolutely on a negative Schick test as evidence that an individual
is immune to diphtheria, except in young children where one can-
not rely upon the test. For instance, Dr. Hess had one baby which
gave a negative Schick test and three months afterward developed
diphtheria. In early infancy the child still has its mother's immun-
ity, which it loses later, and this would explain the occurrence
of diphtheria in an infant after it has shown a negative reaction.
However, it is different with adults and in them a negative Schick
reaction may be entirely depended upon. We had one physician
who had a slight patch on his throat and some constitutional
symptoms of diphtheria and an attack of heart failure; it was thought
that he had diphtheria, but three Schick tests were negative and he
simply had the same kind of a collapse which others have had with
an attack of grippe.

We have had our views as to the value of active immunization
changed; we find that about 90 per cent, of those who are given
immunizing doses of the toxin-antitoxin do not develop antitoxin
for some weeks, so that in hospitals the production of active im-
munity is only of practical value for physicians and nurses, but for
the protection of patients we must still rely upon passive immunity.

Up to the present time nothing has been discovered that is
effective in the treatment of diphtheria carriers. It has been
shown that a careful antiseptic toilet of the nose and throat simply
covers up the bacilli and after a few days without treatment they
show themselves again. The only measure that seems to be
effective is the removal of the tonsils.

The production of active immunity to diphtheria has a wide
field of usefulness. We have already conferred active immunity
on 10,000 children in institutions and hope soon to take up the
health centers, and try to protect as many children as possible.

I would like to ask Dr. Richardson if he would separate all the
different contagious diseases if he had the facilities rather than
put them in the same ward where it is necessary to carry out this
rigid asepsis.

Dr. Bertram H. Waters. — It is rather difficult to discuss the
subject of whooping cough in relation to hospital control since so
few cases of whooping cough are sent to the hospital. It is estimated
that only about 50 per cent, of the cases of whooping cough are
reported and only a very few of these come under the control of the

730 TRANSACTIONS OF THE

hospital. Whooping cough presents a rather difficult problem as
we are all aware, and the Department of Health does not supervise
whooping cough cases because of the difficulty of obtaining early
reports and since the period of greatest infectivity of the disease is
that before a diagnosis can be made and also because of lack of
funds and men to carry out such work, these being all needed
to look after the more severe forms of contagious disease. A
question that is being considered at the present time is whether it
would not be advisable to require a two weeks quarantine for
whooping cough that would cover the lirst week and aid in con-
trolling the infection during the second week. Such a plan would re-
quire at least one visit by a representative of the Health Department.

I feel that we have had very promising results in immunity from
the use of the vaccine as shown by the very interesting work of Dr.
Park and Dr. Hess.

Dr. Alfred F. Hess, in discussing the hospital control of measles,
said: The hospital control of measles is particularly interesting be-
cause the mortality of measles in hospitals is so different from the
mortality in the homes. In the community the mortality from
measles is rather low, while in Willard Parker Hospital there is a
mortality from this disease of 15 to 20 per cent. A statement
like this may strike you as a rather severe arraignment of the hos-
pital, but further investigation has shown that the hospital is not
so much to blame for this high mortality. We find that about
one-third of the hospital cases of measles are under two years of
age. In the last three months of 319 cases, 112 were under two
years of age, which falls far below the age incidence in the com-
munity. Again the mortality from measles is almost entirely due
to pneumonia. During March there were twenty-five deaths
due to pneumonia; twenty-one of these cases of pneumonia were
admitted to the hospital with the disease and four developed it
in the institution. In February there were seventeen cases of
pneumonia admitted and two developed the disease after admission
to the hospital. The high mortality from measles and pneumonia
in contagidus disease hospitals is largely due to the fact that they
receive the very severe cases which are transferred from homes and
institutions. Out of fifty-six children that died twenty-one came
not from homes but from other institutions. It is, however, a
recognized fact that we have a higher mortality from measles in
orphan asylums and foundling homes than in private homes.

There is no specific treatment for measles and pneumonia. It
seems to me that such being the case it is advisable to direct our
treatment to the pneumonia and give the patient the treatment
for this disease. We have always been afraid of fresh air for cases
of measles and have shut these patients up, but when measles is
complicated with pneumonia it will be well to make an exception
and give the patient the benefit of fresh air. Furthermore we
ought not, unless it is absolutely necessary, have cases of measles
under two years of age sent to the hospital, but should keep these
infants under two years of age at home. In a recent investigation

NEW YORK ACADEMY OF MEDICINE 731

of the cases coming to Willard Parker Hospital we found that
medical inspectors had been sending these cases to the hospital.
We had one instance of a child that developed measles m an in-
stitution and instead of sending for the mother of the child and
having her take the child home, he was sent to the hospital. A
mother would be willing to care for such a child, especially would
she be willing if she was told that children with measles did better
at home than in a hospital. If the community were instructed in
this wav in regard to the mortality from measles in the contagious
and other hospitals we could get their cooperation in keeping these
young children out of the hospitals and thus lessen the mortality

from this disease. „ ., . r .i.

Dr Haven Emerson.— New York as well as the rest ot the
country is indebted to our teachers from Providence and it is a
pleasure to have this opportunity to pay our respects to Dr. Rich-
ardson The fact that we have abandoned fumigation may be
attributed to the teachings of Dr. Chapin. In building our new
hospitals, the new Queensboro Hospital, the new pavilions of
Riverside Hospital and the new measles building at Willard Parker,
we have practically followed out their plans of construction with
very slight modifications; that is we have a common balcony at
the end of the wards, or rows of cubicles.

When it comes to confining infection to the individual we must
establish the same teaching among medical nurses that we have
been emphasizing in the training of surgical nurses, that is, they
must be taught aseptic technic. If this is possible there is no
reason why these diseases cannot be treated in a department of a
general hospital. It costs a great deal to keep up a 900 bed plant
simply on the possibility that thev may be needed at certain seasons
and it would be a great economy if we could use these beds all the
year around for other than the acute infectious diseases of child-
hood This could be done by absorbing the contagious cases during
the season when they are most prevalent, even if chronic cases, such
as those of tuberculosis and syphilis, were not admitted during the
height of epidemics of scarlet fever or measles, and then accepted
when the other infectious diseases were less prevalent. We are
all acquainted with the high mortality from measles in institutions
and hospitals. I would like to have physicians teach the people
to keep these children at home. It is a question whether children
under two with measles ought to be admitted under any condi-
tions certainly only when the home conditions are such that it is
absolutely impossible to give them the first elements of decent care
There will always be a need, however, for some hospital that will
care for measles in New York City.

There is also the question of the advisabihty whether we make
every effort to admit cases of whooping cough when the case occurs
in a family in which there is a child under two years of age who will
be exposed to the infection. It seems, too, that we ought properly
to take in favus, for a number of children lose a large part ot their
school life on account of this disease. I also feel that ringworm

732 TRANSACTIONS OF THE

could be received and treated in hospitals with advantage and with
a saving of many years time for the child that is now kept out of
school or kept in an institution.

It is certain that the hospital care of diphtheria and scarlet
fever is better than the home care and the results are more en-
couraging than those obtained in the hospital care of measles.

By the application of the principles we have heard described
to-night the Department of Health might keep its hospitals full
twelve and not only for three months out of the year and this would
reduce the cost and add much needed facilities for some of the neg-
lected infections.

Dr. Dennett L. Richardson, of Providence, in closing the
discussion, said: In reply to Dr. Park I may say that I think
our work has been more or less misunderstood. We have a ward
for scarlet fever and one for diphtheria in which we have introduced
other diseases occasionally, and three isolation wards for various
infectious diseases. The plan of admissions we carry out is a
process of filtration keeping all new patients in small units for one
week's period of observation. Our plan means more to the small
town or the small city that cannot afford to have a hospital for each
infectious disease, one for scarlet fever, another for diphtheria, etc.
In a small city where there is a necessity for economy this plan can
be carried out if one knows the underlying principle. This is that
contact infection, infected human beings, and not environment is
the source of infection, and if we can control the contacts, the mild
cases, and the clinical cases we can have much better control of
infectious diseases.

Dr. Haynes.- — ^How do your statistics with reference to cross-
infections compare with those of other hospitals?

Dr. Richardson. — Few American hospitals have published
reports on that point. The only one I know of is Dr. Aucker of the
St. Paul County Hospital. He gives the number of cross infections
and the number of cases of infectious disease among employees and
nurses. This is the only report beside that of the Providence City
Hospital in this country that gives this data but some of the foreign
reports show that for scarlet fever and diphtheria the number of
cross-infections have been as high as 7 per cent.

Dr. Kerley.^ — I would like to ask if you have had any experience
with reference to the incubation period of scarlet fever.

Dr. Richardson. — The shortest incubation period that I have
known was thirty-si.x hours and as to the other limit I do not think
any one knows. If a child comes into the hospital with scarlet fever,
and if at the end of four weeks it is necessary to detain him for a
day or two and then another child comes in from the same family
we cannot say whether he was infected by the other child at
home, a mild case that has escaped detection, or whether the in-
cubation period has been long, the patient having been infected by
the hospital patient admitted four weeks before. Had the hospital
case returned home at the time intended the second case would be
looked upon as a return case.

MEDICAL SOCIETY OF THE STATE OF NEW YORK 733

TRANSACTIONS OF THE MEDICAL SOCIETY
OF THE STATE OF NEW YORK.

One Hundred and Tenth Annual Meeting,
Held at Saratoga Springs, May i6, 17, and 18, 1916.

SECTION ON PEDIATRICS.

Dr. John L. Heffron, Chairman of the Section on Medicine,
in the Chair.

This was a joint meeting of the Sections on Pediatrics, Medicine
and Public Health.

the vision of the school child.

Dr. F. Park LE\\as, Buffalo. — The extraordinary conditions
which have arisen during the past year in connection with the world
war have compelled us to look upon some of our social problems from
a new angle. We have been forced to believe that principles upori
which our republic is founded, far from being absolutely established,
are still on trial, that democracy is still an experiment, and that its
success is wholly dependent upon the character of those who consti-
tute the electorate. We have been made to believe that the stream
of immigrants that has poured into this country during past decades
has brought with it vast numbers who have been barely able to
support themselves and their numerous progeny, and many of these
are of low grade physically, and that others have in their bodies
the seeds of disease or of infirmities which they transmit to their
offspring. The necessity which is now being so forcibly empha-
sized of internal preparedness requires that the child of to-day should
have remedied every defect which limits his potentialities. It
becomes then a matter of self-preservation on the part of the State
to protect its own future by using every possible effort to make each
child as capable of the higher responsibilities of citizenship as his
conditions and circumstances will permit. This is happily being
met with in some measure by the medical examinations in our
schools. In this brief consideration of the subject, it is intended
to emphasize the following propositions: First, in order that we
may know how much importance to attach to defects of the eyes,
we must have exact data as to their incidence, their character, their

734 TRANSACTIONS OF THE

corrigibility and their influence in retarding the normal progress of
a large number of individuals. Second, in order that we may
acquire these facts, standardized methods must be devised which
are applicable to the entire school population. Third, measures
must be considered for the analysis of the material so gathered that
practical and facile methods may be employed in each case so that
it receive suitable attention. In order that we may realize how
inadequate are our present methods it is necessary only to refer
to any of the reports of the eye examinations of large numbers of
children. Careful work has been done in Pennsylvania; in the
report of 19 14-15, in the 4th class districts, the number of pupils
inspected amounted to 469,199; among these 83,748, or 17.8 per
cent., were found with visual defects. Pupils having other eye defects
numbered 5512. It becomes necessary very clearly to discriminate
between the various conditions that are classified in bulk as "defects
of the eyes." Until such discriminations are made the records will
show that vast numbers reported as having defective sight remain
uncorrected and are reported as unfinished cases. In many instances
this is inevitable. What disposition shall be made with such pupils
in the classification and arrangement of the school? These cannot
see adequately to maintain their position in the classes with those
whose eyes are good; therefore, some other method must be devised
by which they may be relegated to special classes or other provision
made for their instruction. The teacher, with not more than fifty
children in her class, has opportunities for observation which are
superior to those of any outside investigator who comes temporarily
into the examining room. The methods employed in the correction
of eye defects are not always effective; when the work is done for a
poor child, the patient is usually referred either to a public dispensary
or to an optician. The refractive work done in public dispensaries
is too frequently done in a hurried and careless way. If the poor
child is sent to an optician the work is even more slightingly done.
The small amount paid for the lenses by those who are poor is often
a burden. Since the State concerns itself with the welfare of the
child to such a degree as to insist upon the child being examined
and getting spectacles, it should go still further to see that the
examinations are made under right conditions and that suitable and
well fitting glasses are provided at a minimum cost. When the
parents are too poor to pay for them they should be supplied by the
school authorities gratuitously as books are provided for study.
This cannot be done when the school child is sent anywhere, or
where the examinations are made perfunctorily. Through the
efforts which have been made by the State Medical Inspector of
Schools, Dr. William A. Howe, a large number of careful and depend-
able ophthalmologists have offered their services for the gratuitous
examination, at specified times and places, of such necessitous cases
as may be referred to them. This is an excellent beginning. But
the problem is too big to be met in this way. The importance of
the municipality establishing its own clinic for refraction, and
supplying the poor pupils witli glasses, was emphasized in a paper

MEDICAL SOCIETY OF THE STATE OF NEW YORK 735

read at the Fourth International Congress on School Hygiene by Dr.
Louis C. Wessels, in which he pointed out that from an economical
standpoint it was a saving of money to see that the children in the
public schools had such eye equipment as would enable them ade-
quately to do the work that is required of them. Such a clinic has
been established in Philadelphia. There are very few of the children
who are beginning school life who know how the eyes should be used
and it .was suggested by a committee chosen by the National Edu-
cation Association, and later by a committee of women school
principals in New York City, that the child, when he begins to use
books, be taught how thfey should be used, and the following simple
recommendations be printed on the first blank page of every school
book: I. Take care of your sight; upon it depends much of your
safety and success in life. 2. Always hold your head up when you
read. 3. Hold your book fourteen inches from your face. 4. Be
sure that the light is clear and good. 5. Never read in the twilight,
in a moving car, or in a reclining position. 6. Never read with the
sun shining directly on the book. 7. Never face the light in read-
ing. 8. Let the light come from behind you or over the left shoulder.

9. Avoid books or papers printed indistinctly or in small type.

10. Rest your eyes frequently by looking away from the book.

11. Cleanse the eyes night and morning with pure water. 12.
Never rub your eyes with your hands or an unclean towel, handker-
chief or cloth. Another reason why permanent records should be
made of all school children's eyes is found in the Workman's Com-
pensation Act which has recently been put upon the statutes of the
State. It is constantly becoming more evident that with the
assumption of responsibility on the part of the employer for injuries ,
received by the employee in the performance of his duties, that there
must be an assurance of the existence of a normal physical condi-
tion on the part of the workman who is thus protected, but if there is
an abnormal condition present this must be recognized and known
in order that the extent of the injury may be ascertained. It must
be evident that if the examination of the eyes of all the school chil-
dren of the State were so standardized as to make it a part of the
routine work, if these records were permanent and available, they
would serve, not only as a basis for the immediate relief of difficulties
limiting the child's possibilities of usefulness, but would constitute
an essential feature in our preparedness program in giving us the
important and necessary data concerning every individual in the
State.

SOME PRACTICAL EXPERIENCES IN MEDICAL INSPECTIONS IN RURAL
SECTIONS.

Dr. W1LLLA.M A. Howe, Albany. — During the first year of the ad-
ministration of the medical inspection law, many impressive and
varied experiences have arisen throughout the State. Those to which I
wish to call vour attention are taken from the rural sections where

736 TRANSACTIONS OF THE

many of our most difficult problems in this phase of the work are
to be found. Some of you will note how highly gratifying are the
results accomplished and the progressive interest indicated, while
others are equally as discouraging in their serious embarrassment
to the work. Many grateful parents have written the Department
thanking it for the wonderful relief extended to their children.
Thousands of children have been placed on a higher plane of physical
fitness thus enabling them to make more normal progress in school.
While most of these cases, as might be expected, belong to those
commonly seen, many have been most impressive. Two children
have come under our observation with congenital cataract whose
vision amounted to practically nothing. They have been success-
fully operated, restored to vision, and placed in school where satis-
factory progress is now being made. In one family three were found
with so little vision as to render regular school work impossible.
The two of school age have recently been placed in the New York
State School for the Blind at Batavia where they will receive an
academic education, taught some vocation and be made self sustain-
ing citizens. Another child with a badly disabled foot following
infantile paralysis has been successfully treated by tendon trans-
plantation. In two instances where pupils were incorrigible, im-
pertinent, backward and unmanageable in school, were improved
promptly after the removal of septic tonsils and obstructing adenoids.
Several cases of tuberculosis have been found among our teachers,
while in one district this disease had existed among the pupils for
nearly fourteen years. Many pupils throughout the State either
in the pre tuberculous or incipient stage of the disease have been
recognized and greatly benefited by sanitary or institutional treat-
ment. The fact that tuberculosis increases so rapidly among chil-
dren during their first years of life in school should demand the
serious consideration of not only health workers but educators as
well. Our joint energies should be directed to determine the factors
entering into these alarming conditions that the proper preventive
measures may be speedily administered. Increasing interest is
being manifested in medical inspection in the rural sections of the
State. This is indicated not only in a general demand for more
efficient services at the hands of the inspector but in systematic
efforts to extend rehef to children needing attention. A few days
ago one of our village districts reported fifty cases of obstructed
breathing among children of foreign parentage or from dependent
families. During the next few weeks these will be referred to special-
ists in Rochester who have generously designated free services to
deserving children. In another village in Western New York
certain school rooms are being utilized as a temporary hospital
where under the supervision of an experienced nurse, physicians
and surgeons are administering relief to local children. Again in
the town of Schenectady, seven rural schools have united in the
employment of a school nurse who is devoting her entire time to
inspecting the children thereof and to the improvement of school and
home conditions. This nurse though only employed for only the

MEDICAL SOCIETY OF THE STATE OF NEW YORK 737

past three months has already accomplished such splendid results
as to fully demonstrate the practical value of such services. In
another section of the State we find a rural teacher referring many of
her children to speciahsts in the city of Buffalo where embarrassing
physical defects have been reheved, thus insuring to pupils far
greater progress in school.

In conclusion and in view of such experiences as well as many
others which might be given let us suggest: That only physicians
interested or willing to take an interest in the work be utilized as
medical inspectors; that the utmost care be exercised in all examina-
tions and that definite care be shown in giving information to parents
as to the defects found; that phj'sicians should receive a fee com-
mensurate with the services rendered, which on all occasions should
be his best; that physician, teacher, parent, pupil and nurse should
cooperate in the entire system of school inspection; that the real
success of school inspection will be measured by the thoroughness
with which the examinations are made and the results accomplished.

SUMMARY OF SCOPE OF PRACTICABLE EXAMINATION IN ROUTINE
SCHOOL MEDICAL INSPECTION.

Dr. Clinton P. McCord, Albany. — The most essential thing to
determine in a given district is the size of the working staff. Any
district with 3000 children should employ its school medical inspector
for "full time." The working unit is one doctor and two nurses
for each 3000 children. We are rather skeptical as to the realization
of the "full time" ideal outside the larger cities for some little time.
An examination of the character indicated in the health certificate
referred to in the New York State law is practicable only in a
physician's office and cannot be properly accomplished in less than a
half hour. In most school buildings the only examining room avail-
able is the kindergarten in the afternoon or the principal's office.
Under such conditions the removal of the clothing is not practicable,
and besides, a competent examiner will be able to ascertain all facts
required for purposes of school medical inspection without removing
any clothing except in a relatively small number of cases. This
last group includes the poorly nourished children; those with
cervical nodes that show a tendency to break down; those with
chronic coughs or digestive disturbances; those that are extremely
nervous or those that suffer from dizziness and shortness of breath.
There is no reason why an examination such as the one later outlined
should not be accomphshed in the rural school room in case a more
suitable place is not available.

In considering routine examination we must consider the question
of school medical inspection records. A card system should include
the following: physical record card; parental notification card;
miscellaneous case card; report of sanitary survey; medical in-
spector's report blank; school nurse's report; dental record cards;
physical training card; open-air school records; and special class
records.

738 TRANSACTIONS OF THE

In most places to-day the working unit is too small to give all the
children adequate care. Proper standardization of working staff
and scope of work should be our first thought. It is of little good
to require an examination involving a chest examination when one
"part time" man is appointed to 4000 or 5000 children. Where
conditions are such that a "part time" man has more than a
1000 children a chest examination should not be considered
except in the case of the relatively few anemic, flat chested, nervous
children and those with suspicious lymph nodes; or those that bring
to us evident signs and symptoms of organic heart disease. Work-
ing two hours a day, five days weekly, for thirty-sLx weeks an in-
spector may examine approximately 1000 children. Working one
hour a day for the school year he will examine approximately 450
children. In the same time the more superficial t}^e of examination
(not involving routine chest examination) can be given to three times
as many children; and if the nurse is trained to give the eye test then
the inspector can examine four or five times as many.

Certain standards should be suggested to govern the reporting of
defects. Good fundamental training in the specialties is desirable.
An analysis of examinations of several thousand children by 167
different general practitioners shows a wide range in standards of
judgment as to the existence of physical defects. Where school
inspection is carried on by general practitioners a set of regulations
should be formulated for their guidance that should embody a dis-
cussion of the procedures and standards approved by specially
trained and expert school health workers.

The routine examination should cover the following:

Eyes. — The Snellen card test plus a card for near vision and
astigmatic chart in some cases. These tests must be given with an
appreciation of possibilities of error in handling children.

Ears. — The watch test is perhaps the most practicable. There is
consderable variation in the response of children at different ages.
Discharging ears are serious.

Tonsils. — -Enlarged and cryptic tonsils with a history of frequent
sore throat are perhaps pathologic.

Nose. — Medical inspector diagnoses nasal obstruction, leaving it
to the family physician to determine the cause of the obstruction.

Teeth. — Decay of the "six year" molars is the most important
thing to look for. It is poor economy to employ a dentist to inspect
mouths of school children; he had better be employed in actual
treatment of the most urgent cases.

Nutrition. — The judgment of nutrition is based on pinched, pallid
features, arrested development, the lack of spontaneous activity,
weak and flabby tissues and the signs of nervous exhaustion.

Skin and Glandular. — The enlarged cervical nodes associated with
poor nutrition, those that become acutely inflamed and those that
undergo softening are the ones that merit attention.

Eczemas and any contagious or parasitic skin disorder should also
be looked for. Simple home treatment for pediculosis is indicated.

Orthopedic and Nervous. — Stoop shoulders and flat chest; lateral

MEDICAL SOCIETY OF THE STATE OF NEW YORK 739

curvature; "general nervousness;" chorea; psychic disturbances of
adolescence; epilepsy; mental deficiency, etc., should be kept in
mind under this heading.

Acute Contagious Diseases. — -This is a very important though
relatively small part of the work of school medical inspection.

The medical profession as well as the parents should awaken to the
wisdom of health supervision prior to school age. "Part time"
medical inspectors should be employed for at least two hours daily
for the entire school year. Medical inspectors should develop school
dispensaries where local clinical facilities are inadequate. School
health work is more than putting glasses on children who cannot
see well; remo^'ing adenoids, tonsils, and filling decayed teeth; it
involves a wide understanding of the various social, educational and
economic problems that are closely bound up with the physical
condition of the children.

THE NEUROPATHIC CHILD.

Dr. Edward B. Angell, Rochester. — -Francis Warner, who ex-
amined 100,000 of the school children of London, has described the
nervous child and no better description than his can be given. He
calls attention to the following symptoms in this type of child:
grinding the teeth; difiiculty in going to sleep, they are always tired;
not ready for breakfast; delicate without having actual disease;
are very susceptible to disease; show a lack of appetite or capricious
appetite. These children are generally well made in body, with good
heads and well-cut features, fine skin and light complexion. An
early indication of their nervous instability is overspontaneousness.
They may show even in infancy these spontaneous movements
without controlled coordination. There is also a greater impres-
sionabihty and imitativeness than in the normal child. There is
later a lack of inhibition. The normally constructed brain of the
healthy child in its motor action presents well-balanced muscular
movements. The relationship between muscular activity and brain
activity is very direct.

One test that is very useful in distinguishing the normal from the
nervous child is the following: Ask the cliild to stand erect and to
raise both arms at right angles to the body and hold them parallel
with the palms down. The normal child will hold his arms in this
position; in the nervous child, the arms may be curved, one arm
may be dropped lower than the other, or where there is considerable
nervous tension the knuckles may be pointed backward. These
failures to assume the prescribed attitude indicate an illy balanced
nervous control.

Neurologists would do well to turn their attention to the Boy
Scout movement. Military training not only develops the muscles
but the brain as well, and the habit of instant obedience does much
to establish a healthy brain activity and normal self control. This
self control cannot be too thoroughly established for the growing
child, lest an unstable nervous equilibrium will give rise later in life

740 TRANSACTIONS OF THE

to the vagaries of the neurasthenic and hysterical. One may find
in the nervous child an attitude of erect self-assurance or defiance,
or a drooping attitude and self-consciousness, or a lopsidedness in
fatigue, the latter being more common in girls than in boys. Another
habit easily acquired by the nervous child is that of introspection
which readily predisposes him later to unstable equihbrium and
self-consciousness to the detriment of efficient mental activity. In
a study of 75 or 80 typically nervous children it was found that there
was a heredity of insanity or alcoholism in about one-third; the
arthritic diathesis in about 30 per cent. In only one case did we get
a history of tuberculosis in the family, but there is no doubt that
tuberculosis plays a much more important part than this would
indicate in the transmission of an unstable nervous constitution.
About 25 per cent, of these children gave a history of something
abnormal during the pregnancy or delivery of the mother. Faulty
metabolism, indicated by headache, constipation, mental depression,
irritability, vertigo, a sense of fear, and poor circulation, gives
evidence of disturbed nutrition. Defective nutrition was shown in
two-thirds of these cases; nearly one-third had night terrors. About
one-half gave indications of partaking of a diet too high in proteins.
The correction of physical defects, in as far as possible, is the first
step in the treatment of these children. Attention to diet and
hygiene is important, with special emphasis on the value of fresh
air and proper exercise.

THE OPEN-AIR SCHOOL AS A TYPE.

Dr. Edward Durney, Buffalo. — -"There is now a type of child
segregated and placed in fresh-air schools which we did not formerly
recognize. These children may be handicapped from various
causes; there is no uniform classification that is applicable to them.
The condition of these children may be the result of wrong condi-
tions in the home life; the child may have a heredity of alcoholism
or epilepsy, or may be the subject of malnutrition. As a result of
such factors the child may show an abnormal nervous activity as a
consequence of which its nervous power is depleted and it is easily
fatigued. Among these children the largest class are those suffering
from nutritional defects and next to these are the ones showing signs
of various nervous conditions, such as chorea, partial recovery from
infantile paralysis, etc. The first step in dealing with these children
is to remove physical defects, after which they may be placed in the
fresh-air school. As to the results of this method of handling these
children, the attitude of the children themselves is our strongest
argument we have. The records of the weight of these children has
been kept and it has shown an increase which gives positive evidence
of an improvement in physical condition. These have also shown
renewed activity in both work and play. A more rapid mental
development has also accompanied the improved physical condi-
tion. In one instance we had a boy who was nervous and entirely
unmanageable and could not be induced to do his school work. He

MEDICAL SOCIETY OF THE STATE OF NEW YORK 741

was placed in the fresh-air school, became very much interested in
knitting. This seemed to have a great influence on this nervous
condition and he became an entirely different child. The children
grow very fond of the open air school and are loathe to leave it.
The point may be emphasized that a large proportion of our
school children may be cared for in open-air schools to their great
advantage."

THE EFFECT OF MALFORMATION AND INFECTION OF THE ORAL CA\1TY
OF THE CHILD UPON ITS FUTURE HEALTH.

Stephen S. Palmer, D. D. S., Poughkeepsie. — The dental pro-
fession has realized and has been preaching for years the importance
of a mouth in perfect condition. We know that there is nothing
that so reduces the vitality of a boy or girl as decayed or aching
teeth. We have noted the effect on the future life of the neglect
of the mouth conditions of the child. We know that the mouth is
the gateway of the body, that as the teeth are placed there to per-
form the first function of digestion and assimilation, that with them
in a perfect, cleanly and healthy condition only, can the child be in
perfect health, and the future man or woman strong, healthy and
intelligent. Dr. Victor C. Vaughan says "The mouth is the most
Important port of entry for infection." "One or more decayed
teeth with constant infection so impairs the vitality of the child that
physical and intellectual development is impossible." "Deformity
of the jaw and malposition of the teeth interfere with the proper
development and function of the brains." Dr. Osier says "There
is nothing so important to the health of the nation as the hygiene
of the mouth." Many other authorities confirm the accuracy of
these statements. As physicians and dentists we cannot afford to
ignore them. Malformations and deformities of the mouth unless
extreme are often not noticeable except to those who have made a
study of them. Deformity of the teeth which reduces their function,
impairs speech, and mars the facial lines is so prevalent that it is
now almost the rule rather than the exception. The reason for the
great number of deformities has been attributed to the mixture of
blood of different races, as it has been noted that in the Grecian and
Roman ages when the blood was purely Grecian or Roman deformi-
ties were practically unknown. Dr. Wuerpel says "The best balance,
the best proportions of the mouth in its relation to the other
features requires that there shall be the full complement of teeth, and
that each tooth shall be made to occupy its normal position." The
dental apparatus is not a single organ like the eye or the ear, but is a
very complex structure with many functions, into which enter not
only the jaw, the dental arch, and teeth, but the muscles of mastica-
tion, the Hps, tongue, nasal passages, palate and throat, and in
addition to the function of mastication these are also concerned
in the \atal function of respiration, and in speaking, singing and
whistling, laughing, crying, and in the e.xpression of all the varied
13

742 TRANSACTIONS OF THE

emotions. The different parts entering into the performance of these
varied functions and acts are so intimately associated that even
slight in harmony in the growth and development of any one may
ultimately involve the whole apparatus, interfering with the normal
function of all and even producing repulsive deformities. Every
tooth of both temporary and permanent dentures has a function to
perform, namely, assisting to keep the full denture in perfect occlu-
sion, as the loss of one deciduous tooth before the allotted time re-
sults in the eruption of the permanent tooth in malocclusion, and
the loss of one permanent tooth results in permanent deformity,
which impairs the functions of the whole dental apparatus for all
future time. The way to guard the welfare of our patients is to
insist upon the care of every tooth both temporary and permanent.
Thumb, lip, and tongue sucking habits may cause many deformities
in children. The most serious and constant cause of malocculsion
is nasal obstruction, namely, adenoids. Adenoids being a trouble of
childhood, most active during the growth and development of the
denture, it is very important that the rhinologist and the ortho-
dontist should work together. The effect of mouth breathing is to
cause contraction or narrowing of the dental arch; the elevation of
the hard palate, which causes obstruction of the nasal passages;
the obstruction of the tongue, and finally the impairing of the speech
and the function of mastication, and the marring of the symmetry
of the face. Mayo, Hunter, and others of the medical profession
have called attention to the part that mouth infection plays
in the health or ill-health of the individual. A child's health
is only as good as his teeth. I believe that in malocclusion lies
the origin of many mouth infections. Irregularity of the teeth makes
cleaning them more difficult. "A clean tooth never decays," is
our slogan and to that may be added "teeth in correct position or
occlusion are easier to clean, and therefore never decay." If
practitioners of the different branches of medicine would unite their
efforts, by early oral prophylaxis many of the problems which are
bafliing the medical world to-day could be eliminated. The law
legalizing dental hygienists goes into effect in September and is
a step toward the ideal. By our united efforts I prophesy a healthier,
stronger, and brighter coming generation.

TYPES OF CEREBRAL DEFECTS IN CHILDREN THAT MAY BE BENEFITED
BY OPERATION.

Dr. Herman G. Matzinger, Buffalo. — "I am not concerned
with the orthopedic defects of childhood but only with those cases
' in which head operations are indicated. All cerebrally defective
are essentially feeble-minded; many of the worst cases die early in
life. Nevertheless we should not discourage any attempts to
relieve these sufferers. In the inherited types, including infantile
paralysis and Mongolian idiocy, prevention offers the soundest
method of cure, while operation remains purely experimental. Proof

MEDICAL SOCIETY OF THE STATE OF NEW YORK 743

is wanting that meningeal hemorrhage gives rise to diplegia. At
necropsies, cysts, areas of softening, wrinkling, or adhesions, indi-
cative of more deeply situated pathological changes, were found,
but characteristic local pathology, gross or microscopical, of a causa-
tive nature were entirely absent. As infantile cerebral paralysis
attacks the brain early in life operative relief must be sought early
if any good results are to be expected from it. Hemorrhage is a
definite indication for operation, and likewise Little's syndrome
operation is of no avail where there are early changes in the pyra-
midal tracts. Increased intracranial pressure adds new symptoms
to the old symptom-complexes but is accountable for deaths in only
7 per cent, of the cases. Operation may be attempted for the relief
of increased intracranial pressure but it must be remembered that
simple incision of the dura is often not suificient, for fluid may be
enclosed in regions away from the site of the incision. Dividing
the falx or tentorium may therefore be necessary. Epilepsies
develop in one-half the cases of cerebral palsy. The examination of
the eye-grounds gives operative indications in infantile cerebral
paralysis."

EEStn.TS 05 CRANIAL DECOMPRESSION IN SELECTED TYPES OF
CEREBRAL SPASTIC PARALYSIS DUE TO HEMORRHAGE.

Dr. Willi.am Sh.arpe, New York. — "I wish to report the results
of operations undertaken by Dr. B. P. Farrel and myself for the
relief of spastic paralysis during the past three years. I have exam-
ined 211 cases of cerebral spastic paralysis and had determined the
ophthalmoscopic findings and intraspinal pressure for each individual.
I operated upon most of these. The time elapsed since the opera-
tions is not great but the results to date are gratifying. I do not
operate upon the constitutionally inferior, the microcephalic, or cases
of spastic paralysis due to lack of development, the so-called Little's
syndrome. I operate on children that have gone through diflicult
labor and that reveal changes in the optic discs and in the spinal
fluid indicative of increased intracranial pressure. Of these the
most satisfactory are those with no impairment of mentality. The
condition of spastic paralysis following birth trauma may appear
before, during, or after birth. The spasticity produces deformi-
ties that are usually flexor in type. Later Jacksonian epilepsy may
intervene. As these children grow older their mentality is notice-
ably impaired. They become imbeciles or idiots. It is important
to recognize the possibilities of 'hemorrhage of the new-born.'
Such bleeding results from rupture of a tributary vein of the longi-
tudinal sinus, from the application of forceps to the child's head,
or from other rough handling. The hemorrhage may become
cortical or subcortical. In cortical hemorrhage the damage to
brain tissue is due to pressure; in subcortical bleeding there is di-
rect injury to brain substance. Motor symptoms follow and depend
upon the area of brain impaired. The author holds intracranial
hemorrhage accounts for 70 per cent, of the spastic paralyses. The

744 TRANSACTIONS OF THE

remaining 30 per cent, include meningo-encephalitis, cases of agenesis,
etc. Defects in the pyramidal tracts do not affect mxentality except-
ing through impairments in the associations. Pertussis might give
rise to meningo-encephalitis and to spastic paralysis. Treatment
accomplishes little in the extreme cases because of the defects in
brain tissue. On the basis of the old theory that the brain remains
small because the skull is small, treatment was formerly directed
toward enlarging the skull. Trephine openings were made and dura
was divided. This is wrong, the dura must be left open. I per-
form subtemporal decompression on one or both sides. Twenty-
six per cent, of these cases show increased intracranial pressure.
I have had skteen deaths; of these nine were extreme diplegias. I
operated upon three cases on the second day and two on the third
day after birth. Improvement was less in the older children, than
in those subjected to operation early in life."

Dr. C. G. Kerley, New York. — Reports of Dr. Sharpe's operations
are likely to spread rapidly among the people. A vast number of
cases should not be included under this operative type. Among
them are the mongols, cretins, macrocephalics, the feeble-minded
and certain inherited defects. The traumatic cases should be opera-
ated upon. Many of these suffered from hemorrhage or transudation
following the pressure of forceps or unskilled handling. There are
comparatively few who develop spastic paralysis from other causes.
Therefore it was necessary to improve obstetrics and to prevent
birth palsies. I believe it would be well for every prospective
mother to be confined in a hospital by expert attendants. Cesa-
rean section would have prevented many of these traumatic cases.
If it is not practicable for mothers to receive this special attention,
it is a calamity! It makes little difference whether feeble-minded
children were 50 or 75 per cent, feeble-minded so long as they belong
in that class.

Dr. B. H. Whitbeck, New York said: "The orthopedic surgeon
has to deal with the deformities of such children. These cases re-
turn after operation and have to be reoperated upon or abandoned.
The examination of the eye-grounds confirmed by lumbar puncture
determines the selection of the case for Dr. Sharpe's operation.
The cases with beginning changes, as congested discs, are suitable
ones. A case in which marked improvement followed decompression
came under my observation. This child now goes about without
appliances. I believe obstetrical trauma is on the increase. Nerve-
suture, tenotomies, and the prevention of deformities come to us for
correction, but they should not have occurred."

Dr. Sharpe, in conclusion, said: "More cases were not included
in the operable list because brain losses could not be made good.
One can remove an extradural clot and mitigate the effects of
hemorrhage. The work of Oppenheim and of Hoch is my authority
for 70 per cent, of spastics being due to hemorrhage of the cortex
or of the base. Preventive measures should be urged. Cases with
increased intracranial pressure offer hope of improvement. In
answer to Dr. Nash, some individuals with intracranial hemorrhage

MEDICAL SOCIETY OF THE STATE OF NEW YORK 745

give dear fluid on spinal puncture. The early evidence of hemor-
rhage is: I, history of a first child; 2, convulsions after birth; 3,
blurring of the nasal half of the optic disc; 4, and increased intra-
spinal pressure. I used the Strauss needle, placed the child on his
side with the spine on a level with head, and the child quiet. The
needle was graduated, showing the rush of the fluid from the spinal
canal, in centimeters; 8-12 cm. were normal measures of pressure.
Above that was pathological. One instance of 37 cm. was mentioned.
I found a wet, edematous brain in one case of suspected hemor-
rhage. Dr. Robj^'s case belongs to the tj'pe that is difficult to
restore after birth and that breaks out into a spastic state seven to
eight months later. He believed that early operation on selected
cases produce normal children."

TOXEMIA OF INTESTINAL ORIGIN IN CHILDREN.

Dr. T. Dewitt Sherman, Buffalo, read this paper for Dr. I. M.
Snow of Buffalo. The cause of death is shown by e.xperiment to be
not due to bacteria but to altered mucous membrane; the injection
of fluid from a closed intestinal loop causes death with symptoms
similar to obstruction; that much has been learned through the in-
vestigations of Whipple, Hartwell, Draper, and others. There is
tissue-dehydration and cerebral anemia from failure of absorption
and from vomiting. A second theory is that death results from the
absorption of bacteria through the damaged mucosa. A third
theory ascribed the cause of death to an active to.xin. Hartwell
holds the toxin may originate from the food, bacteria, or from a
substance secreted from the intestine. High intestinal obstruction
is considered more poisonous than low. The stagnation of detritus
and of bacteria is not considered suflicient to account for the toxin.
Hartwell, in his animal experiments, occluded a loop of intestine
10-14 cm. from the pylorus. The animals were made to fast
fifty-five hours. All the animals, so treated, recovered from the
operations and hved five to seven days. They vomited when given
water. There was no peritonitis, and no apparent cause of death.
The dogs given sterile water or saline hved longer than those that
were not. Hartwell was said to be the only experimenter who worked
without damaging the intestinal wall. He, also, ehminated the bile,
pancreatic and duodenal secretions from the site of obstruction.
A retained secretion, as the gastric, is dangerous to the economy;
an injured mucosa fails to alter its poisonous nature but allows it
to be absorbed in its toxic state into the blood stream. Hartwell
believes, according to the author, that high intestinal obstruction may
not produce death when the mucosa is not damaged, that changes
in obstruction are found in the liver and in the kidneys, that hemat-
ogenous bacteriemia does not necessarily occur, and that bile,
pancreatic, and duodenal secretions are not necessary for the
production of death in intestinal obstruction because double occlu-
sion of the ileum was lethal. The lethal toxin was the product

746 TRANSACTIONS OF THE

of secretion of the injured mucosa or of bacteria. I do not c6nsider
that Whipple has excluded bacterial activity in his study of intes-
tinal death. The contents of a closed loop injected into an animal
of the same species produced death. If this secretion was duo-
denal, death occurred in four hours, and in such cases the duodenum
was found to be congested.

INTESTINAL OBSTRUCTION IN CHILDREN WITH SPECIAL REFERENCE
TO INTUSSUSCEPTION.

Dr. Edward W. Peterson, New York. — "Intestinal obstruction
occurs in cases of imperforate anus, congenital bands, acquired
intussusception, obturation, volvulus, intestinal paralysis, and
infarction of the mesenteric vessels. Congenital occlusion high up
in the intestinal tract is difficult to recognize. Intussusception
occurs at any age but more frequently early. In the first year the
picture is clean-cut, and the mortality was insignificant in those
cases that are recognized early and operated upon. If the diag-
nosis is delayed the death rate is high. No other form of obstruc-
tion is more mismanaged and in no other form is the mortality due
as much to criminal procrastination. There is obstruction of the
blood supply as well as of the fecal current. The obstruction may
be intestinal, colic, or ihocolic, simple or compound. Seventy-five
per cent, of the intestinal obstructions are in the ihocolic region.
As a rule, a well, strong child was seized with abdominal pain,
tumor, and bloody stools. The child would become calm after this
initial attack. Mucohemorrhagic stools developed two hours after
obstruction. Vomiting was prominent, especially late in the disease,
but is seldom fecal in character. In every case, there was an
abdominal tumor which was admittedly often difficult to palpate
because of the rigidity and distention. From the beginning, the
pain and stools varied with the degree of the strangulation and the
toxemia arose from the injury to the lining epithelium of the gut.
Occasionally the symptoms might be less acute; there might be no
strangulation of the vessels. One should differentiate purpuric
disease. The x-ray helps diagnose difficult cases. The safe method
of treatment was open operation and manual reduction. The in-
cision that serves best is one at the midhne below the umbilicus or
at the outer edge of the rectus. It is important to push and not to
pull out the intussuscepted loop. It is well to remove the appendix
in all cases for the appendix may be an exciting cause of the obstruc-
tion in many instances. After operation water was given and mor-
phine was also administered. I have seen twenty-five cases of
which twelve, the successful ones, appeared within an average
twelve hours following the obstruction and four within twenty-four
hours. Of the twenty-five, nineteen were iliocecal, one was colic,
one ilio-ilio-cecal. In conclusion it may be said that intussuscep-
tion presents a uniform clinical picture, aerohydrostatic measures
succeed in a few cases, and early operation with manual reduction
offers the best chance of cure."

MEDICAL SOCIETY OF THE STATE OF NEW YORK 747

THE SURGICAL TREATMENT OF INTESTINAL TOXEMIA.

Dr. Jerome M. Lynch, New York. — "Stick injected the feces of
one animal into the same or other animals to show the symptoms
following intestinal absorption. Sir Arbuthnot Lane attempted to
cure these cases of fecal absorption by improving the intestinal
drainage. Other surgeons, lacking the diagnostic acumen and opera-
tive skill of Lane, have imitated him with varying measures of suc-
cess. Wright introduced vaccine therapy. Satterlee of New York
tried out colonic vaccine on cases of intestinal stasis. The mi.xing
of the colonic with the intestinal contents, such as occurs in ilio-
cecal insufficiency, may be harmful to the individual, but operations
calculated to correct incompetent valves do not seem justified. The
physiologists have shown the part played by the cerebrospinal
nerves in the control of intestinal movements, on the internal
secretions, and on the sympathetic system, but the work of Cannon
supported by Bayhss and by StarHng would probably bring the
greater help to the surgeon. The iliocecal valve is occasionally
missing in man. This valve is developed in the third month while
the iliocecal junction occupies the upper right quadrant of the ab-
domen. The terminal ileum is intussuscepted into the colon, and
the invaginated portion loses its longitudinal and retains its circular
fibers. The mechanism of the intestinal valves is an important
factor to be taken into consideration. Many operations have been
undertaken for the relief of intestinal toxemia and most of them have
been condemned as being unphysiological. We have performed
twenty-five reconstruction operations with encouraging results."

Dr. C. G. Kerley, New York, disagreed with Dr. Lynch's con-
tention that the evidence of intussusception is clean-cut. " In my
experience, one child, three days old, presented as symptoms vomit-
ing, abdominal distention without tumor and obstinate constipa-
tion. Was that intussusception or what? Surgeons were called in
and decided it was obstruction and at operation found a constrict-
ing band at the middle of the transverse colon. 1 saw another case
without an abdominal tumor, believed it was intestinal obstruction,
recommended operation, and found tuberculosis of the sigmoid with
adhesive closure of the gut. Another case at the Babies' Hospital
ofi^ered intermittent, acute distention and at operation two diver-
ticula were found in the descending colon, one in the ileum, and two
in the colon at the orifice of the iliocecal valve. Any obstruction
that is not reheved should be operated upon at once. In another
instance a child of eighteen months to two years that passed mucus
and blood and was without an abdominal tumor was thought to be
purpuric but at operation, later, revealed high intestinal obstruc-
tion. The diagnosis of intestinal obstruction, in my experience,
has not been easy."

A lantern slide demonstration of ACHONDROPLASIA.

Dr. Charles Herrman, New York City. — "This condition was
apparently recognized in antiquity as a number of statuettes rep-

748 TRANSACTIONS OF THE

resenting typical examples have been found in Egyptian and Assy-
rian tombs. The old masters also frequently depicted this form of
dwarfism in their paintings, those of Velasquez being especially
well known. On account of their grotesque appearance and live-
liness these dwarfs were much sought after as court jesters. The
proportions of the different parts of the body in achondroplasia
or fetal chondrodystrophy are similar to those of the normal fetus
in the early part of intrauterine life. This would suggest a lack of
proper growth of certain parts from that time. The writer has
had an opportunity to study twelve cases, many having been ob-
served for a number of years. Several misstatements occur
in the literature, among them, that the patients are always of
normal intelligence; that they usually show a marked lordosis;
that the process affects only endochondral ossification, and that
therefore the vertebrae escape; that the vast majority of patients
are female, and that the proximal portion of the extremity is
usually shorter than the distal portion. From a study of cases
I have found that in a certain percentage of patients the mentality
was subnormal; a large number had a flat back, the apparent lor-
dosis being often due to a tilting upward and backward of the
sacrum; the vertebrae were sometimes affected; the se.xes were
almost equally attacked, and in only a small percentage of the
patients was the proximal portion of the extremity the shorter."

On a series of slides. Dr. Herrman demonstrated the principal
features of the condition, the large head with prominent brow and
depressed bridge of the nose, the nearly normal trunk, the promi-
nent buttocks with the saddle due to the tilting of the sacrum
upward and backward, the short muscular extremities, with pecuUar
articulation especially at the knee, the "trident" hand with fingers
of nearly equal length, the spoon shape of the hand, and the broad
nails, the folds in the skin of the lower extremities, and the normal
genitals. The changes in the bones and joints were also shown in
reproductions of roentgenograms. The essential feature in the
lack of growth of the bones was a disturbance of the normal ossi-
fication of the primary cartilage, an absence of the normal columnar
formation of cartilage cells. The differentiation from other forms
of dwarfism was demonstrated.

DISCUSSION.

Dr. George Dow Scott, New York. — "Dr. Herrman characteris-
tically transforms an apparently uninteresting subject into one of
life and vitality. Dwarfs, court jesters, entertainers, call them as
you like, show us that achondroplasia coexists with brains. The
cause of this peculiar condition is unknown whether from local
nutritive disturbances in the cartilage, whether from infection
both hereditary and direct, whether from intoxication both exo-
genic and endogenic, whether from genetic influences, race peculiar-
ities, degeneration, defective function of the thyroid, mechanical
pressure in utero, syphilis, alcohol, or as the result of other diseases

MEDICAL SOCIETY OF THE STATE OF NEW YORK 749

we know not of, Reisman declares the condition has nothing in
common with cretinism. It may be due to hypothyroidism. Many
of these abnormalities are born prematurely or are dead at term.
If they live they often acquire great strength. We find in both rickets
and achondroplasia a shortening of the extremities, in the former
due to curvature of the soft bones, in the latter due to insufficiency
in the length of the bones. The achondroplasia remains so for
life, not so the rickets. In achondroplasia the thyroid gland is
found usually normally developed, which is a point against creti-
nism. These conditions may be related, however, and are often
found coincidental."

LEUKEMIA IN A BOY WITH SOME OBSERV.\TIONS ON BENZOL.

Dr. Floyd S. Winslow and Dr. Walter D. Edwards, Rochester.
—Leukemia is a disease of the hematopoietic system characterized
by an enormous hyperplasia of the leukocytic elements. In all
probability the whole hematopoietic system, marrow, spleen and
lymph glands, is involved in every case of leukemia, the essential
change being an enormous leukocytic hyperplasia. In some cases
the process is localized and proceeds slowly, in others of the lymphoid
type it is so rapid as to produce death before there is much involve-
ment of the parts of the blood making system. The etiology of
the condition is obscure. Streptococci have been demonstrated
in the blood in some instances, but there is a question whether the
demonstrated microorganism is the principal infection or merely a
subinfection.

The case reported is that of a boy, fourteen years, of age fi.rst seen
on February i8, 1916. He complained of a large mass in the left
side of the abdomen and a general weakness and malaise. His
family history is negative except that the mother died of eclampsia
and one brother died of convulsions when two days old. The patient
gave a history of nose bleed on severe exertion or after eating a full
meal, of occasional sore throat. He had two or three decayed teeth
which sometimes ached. His present illness began August i, 1915.
He noticed at that time that his abdomen was large and bloated
and that there was a lump in his left side. His physician when
called to treat him for a cold some four months later found the en-
larged spleen. Ophthalmic examination of the fundi showed a
typical leukemic retinitis. The heart enlarged slightly to the left,
and the apex beat being one inch outside the nipple line. The abdo-
men was full and protruding, the circumference at the umbilicus
being twenty-nine inches. The notch of the spleen was two inches
to the right of the umbiHcus and the spleen was in contact with the
symphysis at the middle line. The hver was enlarged and palpable
just below the costal margin. The blood showed 550,000 leukocytes;
2,100,000 red cells, and hemoglobin 60 per cent. The administration
of benzol was begun, starting with ten minims a day and rapidly
increasing to 90 minims per day. Four transfusions were
done, with three possible benefits in view: First, to support the

750 TRANSACTIONS OF THE

red cell count as much as possible; second, to prevent any destruc-
tive results from the action of large doses of benzol on the red cells;
and third, working on the infectious theory as to the cause of leu-
kemia, it was thought that transfusions might be useful. At first
the benzol was given with an equal amount of olive oil in capsules.
These produced so much gastric irritation that the rectum was tried.
The benzol was started when the leukocyte count was 550,000,
and there was a primary rise in the white cell count to 900,000
followed by a gradual drop to 220,000. At the present time the
general condition of the boy was somewhat improved; he was up
and able to be about and had gained seven pounds in weight. The
spleen had been reduced to about two-thirds its former dimensions.
The blood examination now showed a total leukocyte count
of 460,000. The subcutaneous injection of benzol was tried on
dogs and on fourteen guinea pigs, in some instances clear benzol
and in others benzol and olive oil, and this did not apparently
cause any trouble either local or general, corresponding to the ex-
perience of Selling. A few subcutaneous injections of equal parts
benzol and olive oil, in doses of fifteen minims, were given to the
boy without producing any marked local or general reaction, save
slight pain at the site of the injection. The drug was tried intrave-
nously on a rabbit with fatal results. Several doses of benzol were
then given to two dogs intravenously with like effect, except that
with a dose of from five to ten minims the animals would undergo
the same violent agitation and collapse, but would recover within
a few minutes and show no ill effects of the drug. It required a
dose of 3 c.c. of benzol to produce death. The following observa-
tions are recorded: i. Benzol produces marked diminution of white
cells and its use is attended with benefit in leukemia. 2. Benzol
frequently produces marked irritation when given either per mouth,
per rectum, subcutaneously, or intravenously. 3. Benzol is a dan-
gerous drug and its administration should be carefully watched for
both the symptoms of benzol poisoning and for a too marked or
too rapid reduction of the white cells. 4. Benzol cannot be used
intravenously.

DISCUSSION.

Dr. Joseph Roby, Rochester. — "The interesting things in Dr.
Winslow's and Dr. Edwards' paper have been: i. The rarity of
the condition in children. Dr. Holt's book states that the mye-
logenous type is more frequent in children, but around Rochester
this has not been so. 2. The unusual high count and the unusual
size of the spleen. At one time the proportion of reds to whites
was about 2}2 l-o i- 3- The primary clTecl of benzol seems to have
been a distinctly stimulating one. 4. In another case, an adult
weighing twice as much as the boy, a smaller dose of benzol reduced
the count from 500,000 to 30,000 in a short time. Here the rectal
administration of the drug worked beautifully. In this case the
blood count has gone back to the place where it was before the ad-
ministration of the drug. Dr. Winslow is to be congratulated on

MEDICAL SOCIETY OF THE STATE OF NEW YORK 751

his work and it is to be hoped that he will go on and develop some
safe and sure method of exhibiting benzol. In both cases I think
the blood transfusions had the effect of holding up the red cells,
possibly acting as an antitoxin and increasing the general resistance
of the patient."

Dr. W. a. Groat, Syracuse. — "I do not beUeve in using benzol
in the treatment of this malady. Benzol is a toxic agent. Benzol
may cause a diminution in the number of white cells but that is not
curing the disease. If one uses benzol he should watch the urine
very carefully. Benzol is just as dangerous in its effect as phenol."

Dr. Charles Gilmore Kerley, New York. — "I had one case
of leukemia which I might add to this report. This occurred in a
child four years of age. This child showed the characteristic
symptoms of this condition; the leukocytes numbered 200,000 and
there was a diminished number of red cells. After the administra-
tion of benzol there was an increase in the red cells, a decrease in the
white cells and the size of the Uver diminished. The benzol was
given in small doses on a full stomach and the child was carried along
in this way for some months and did fairly well. It then failed
rapidly and died."

THE CELL COUNTS OF CEREBROSPINAL FLUIDS.

Dr. Joseph Roby, Rochester. — The purpose of this paper is three-
fold: To defend more or less, a statement made in an article in
the Journal of the American Medical Association, to mildly criticise
Abrahamson, DuBois and Neil for their technic in estimating cells,
to repeat the detail of making a cell count of spinal fluid and to demon-
strate the apparatus used in searching for the tubercle bacilli,
and finally to show some preparations of tubercle bacilli actually
found.

Spinal fluid removed by lumbar puncture wiU be one of four kinds
macroscopically: Distinctly cloudy and even pussy, shghtly hazy,
bloody or perfectly clear, with possibly some flakes in it when ex-
amined by transmitted light. A cloudy fluid means a meningitis
caused by the meningococcus, the pneumococcus, the influenza
bacillus or one of the pus-producing organisms, usually a strep-
tococcus. When the fluid is distinctly cloudy it is allowed to
stand a short time and the clot or sediment should then be smeared
thinly on sUdes, dried and stained, first by Loeffler's, and then if
the diplococcus was found by Gram strain or even a capsular stain
if the organism looks Hke a pneumococcus. It is not necessary
to count the cells in this sort of fluid. A slightly hazy fluid may
mean the early or late stage of one of the groups already mentioned,
the admixture to a perfectly clear fluid of a trace of blood, serous or
tuberculous meningitis. It was here that the count would be of
value. If there were quite a good many red cells and few white ones
it surely ruled out a meningitis due to the first set of organisms.
With a distinctly bloody fluid one could also proceed as with a per-
fectly clear fluid. A perfectly clear fluid or one containing a few

752 TRANSACTIONS OF THE

flakes might be any of the following: Normal cerebrospinal fluid,
meningismus, functional nervous disease, epilepsy, chorea, tetany,
spasm, etc., hydrocephalus, serous meningitis, a brain tumor,
brain abscess, poliomyehtis, syphilis or tuberculous meningitis.
Often bloody fluid is rejected by the examiner for counting pur-
poses but it need not be, for all one had to do was to subtract from
the white count one white for every thousand reds counted. Then
for a second count of this bloody fluid, for the shghtly hazy fluid,
and for the clear fluid, a white cell pipette and a staining fluid are
used. The staining fluid used by Swift and Ellis was used, consist-
ing of two-tenths of a gram methyl violet, four-tenths acetic acid
and 100 c.c. distilled water. This dissolved the red cells and stained
all the other cells a bluish purple. With spinal puncture on the
functional nervous diseases the writer has had no experience except
in chorea and spasms, and in these there has been no increase in the
cell count, nor is there any increase in hydrocephalus. If there is
such a disease as serous meningitis not due to the tubercle bacilh
it is rare. In brain tumor the writer finds no increase of cells.
These findings do not agree with those of Pfaundler and Schlossman,
who found an increase of cells in functional nervous diseases and
brain tumor. In poliomyelitis the writer's experience is limited to
three cases, counting in one acute case 154 cells, in a case with
an exacerbation of fever on the tenth day sixty-two cells and in a case
of facial paralysis alone ten days after the onset ten cells. Peabody,
Draper and Dochez give the average as 125 in fifty-four counts of
forty-three cases in the first week of the disease, the highest being
1221, the lowest seven. Calling five cells normal every case showed
an increase in the first week of the disease. In syphihs the writer
has never found more than one hundred cells, and usually thirty
to fifty in cases of tabes and general paresis. In tuberculous men-
ingitis the limits of the counts in the writer's experience have been
forty-five and 454, the vast majority running between one and three
hundred. From these findings it may be concluded that in dis-
tinctly cloudy fluids it is not necessary to do a cell count. Smears
may be made, cultures made and the organism searched for. In
treating a case of epidemic meningitis a cell count from day to day
would probably show the progress of the treatment. Cell counts
above five are abnormal, and certainly those above ten are abnormal.
The cells should be counted accurately by a blood counter, not cen-
trifuged and estimated. A clear fluid having a count of five or below
might fee meningismus, functional disease such as chorea, epilepsy,
tetany, or spasms, hydrocephalus, brain tumor, or brain abscess.
The cell count will not absolutely differentiate syphilis, poliomye-
litis, and tuberculous meningitis, but a cell count between jfive
and fifty would probably be syphilis or poliomyelitis; a cell count
between 100 and 300 would in the majority of cases be tuberculous
meningitis. Taken in connection with the onset of the disease
and the clinical symptoms it ought not to be difficult to make a
diagnosis of tuberculous meningitis by a cell count alone, even if
tubercle bacilli are not found. In searching for tubercle bacilli

MEDICAL SOCIETY OF THE STATE OF NEW YORK 753

the film method modified b}' the glass cyhnder and cover slip had
been most satisfactory.

ECZEMA IN INFANTS AND YOUNG CHILDKEN.

Dr. Charles Gilmore Kerley, New York. — Eczema in young
children may be due to widely different causes. It'may be the ex-
pression of faulty processes relating to food utilization or the evi-
dence of an immediate reaction against specific food substances.
On the other hand, it may be due to conditions entirely external,
external irritations being capable of causing very active reactions.
The apphcation of strong soap, Hniments or mustard may cause
eczema, also woolen garments, exposure of the moist skin to cold
air, excessive perspiration, parasitic disease, or discharges from the
navel, ears, or nose. Eczema from immediate intestinal sources,
so-called intestinal indigestion, is very unusual. There is a wide
variety of foods that may produce eczema. A child may react to
the smallest quantity of a given food or it may possess a tolerance for
a food up to a certain amount; if this amount is exceeded there will
be a skin reaction. I have repeatedly known children to tolerate
eight, ten or twelve ounces of milk daily, but when a larger amount
was given, eczema resulted. In these cases by a very gradual
increase in the amount given, a tolerance may be established.
Whole milk in sufficient amount for nutrition may eventually be
taken without inconvenience. Some infants possess no tolerance
whatever for orange juice; in some infants it causes a reaction in
the form of red scaly patches about the mouth and erythema of the
cheeks and other parts of the body. Beef juice acts in like manner
and I have patients under my care who cannot take a particle of
manufactured sugar but who show no inconvenience in the use of
honey or maple sugar. Butter fat, milk and cane sugar, eggs, and
orange juice, have been proven through processes of elimination to be
the most frequent dietetic causes of eczema in observations covering a
large number of cases. Cows' milk protein is a rare cause of eczema
and if it is cooked it is still less frequently a factor. The Schloss
scratch skin test for proteins has been of very little value in deter-
mining protein capacity in infants for the reason that there are many
cases not anaphylactic to protein that will tolerate but a given
amount. Children showing a decided reaction to a specific protein
may be immunized through small doses to a tolerance of the food
reacted against. In addition to eczema, asthma and urticaria are
not infrequent results of protein incapacity.

Cases of eczema due entirely to external agencies are readily relieved
by removing the source of the trouble and by the application of
protective dressings, soothing or stimulating in character. The
most difficult of relief is the eczema intertrigo in infants. In these
the child is taught to evacuate the bowels night and morning. Over
the genitals a large bunch of absorbent cotton is placed to catch
the urine and citrate of potash is given internally. As a protective
dressing unguentum aqua rosae to which white wax is added in the

754 TRANSACTIONS OF THE

proportion of lo per cent, is used. The involved areas must be
protected from scratching and irritation. In eczema in breast fed
infants the first step is to examine the mother's milk and if a high
fat content is found to reduce it through dieting processes if possible.
These children may be improved but rarety cured. The baby will
almost always be cured by weaning and suitable bottle-feeding.
However, it is not advisable to wean a thriving baby because of
eczema. In the bottle-fed the best results have been obtained by
the use of plain skimmed milk or evaporated skimmed milk, cooked
with starch, preferably rice or wheat. A high protein and a high
starch food is given, often with the addition of olive oil to raise
the caloric content. As early as the seventh month, squash, stewed
carrots, and mashed potato are added to the diet. The salt of
fresh vegetables possesses an undoubted therapeutic value. In
older children past the bottle age the treatment is along similar
lines. Skimmed milk, puddings made from skimmed milk, aU the
bread stuffs, all cereals but oatmeal, all vegetables, usually twice
a day, chicken occasionally and butcher meat rarely. Every-
thing given is largely sugar-free. Among the drugs for in-
ternal administration citrate of potash sufficient to neutralize the
urine is the most valuable. Not all cases of eczema admit of cure,
but all might be cured if we dared draw our dietetic hues sufficiently
rigidly. This might mean a clear skin but it would be at the ex-
pense of a certain degree of faulty growth and malnutrition. There
are cases it is not well to cure completely. Proper growth and right
development are more important than personal appearance. The
successful management of eczema of internal sources depends upon
our ability to discover the disturbing food factor, to eliminate it
if possible, or to immunize the patient to it. I am not in accord
with any theory relating to a special constitutional state such as the
exudative diathesis as necessary for eczema, because a combination
of high butter fat, high sugar of the arts, orange juice, and beef juice
will produce an eczema in many children who never show the con-
dition when normally fed, and because eczema may be produced
by many foods of widely varying types. Not every child, however,
would react to all these foods. The so-called exudative diathesis
may be produced at will by the administration of certain food sub-
stances in a great majority of children. One cause for the frequency
of eczema is the inability of the child to adjust himself to the many
varieties of foods and food elements that are given him, whether nat-
ural or artificial.

DISCUSSION.

Dr. Godfrey R. Pisek, New York. — "Dr. Kerley has given us a
most practical and common sense paper. He has further outlined
the ideas which he has been giving us from time to time. There are
one or two statements which might be brought out in connection
with the difficulty in feeding these cases. Dr. Kerley said that these
children lost weight when put on a diet that controlled the eczema.
We can, however, hold the weight by giving skimmed milk without

MEDICAL SOCIETY OF THE STATE OF NEW YORK 755

any diluent or sugar. Sometimes small dosesof thyroid are helpful,
grain J^O; or 3^o ii^ obese children particularly. So far as the inter-
trigo is concerned, one can get a very rapid change in this condition by
exposing the parts to air as we are now doing in the case of burns.
Exposure to air and moderate sunlight give good results and cause
the skin to dry and heal. By placing the child on a rubber ring air
cushion in aggravated cases the irritation of a diaper may be avoided.
As to oijitments any of the bland ointments usually employed
that would afiord protection to the sensitive skin were suitable.
Another point was that it was advisable to keep up the treatment
for a while after a cure had been effected in order that the sensitive
skin might be protected for a while longer. With reference to the
exudative diathesis Dr. Kerley is right; it does not cause eczema.
It is faulty feeding that causes this trouble. However, cloildren
with the exudative diathesis do more readily acquire eczema if im-
properly fed. There is still another point and that is with refer-
ence to the nursing mother. One should question her carefully as
to her diet for it can sometimes be brought out in this way that she
is taking an unbalanced diet and has a dishke for some form of food
or an abnormal craving for sweets which can be removed and will
assist in correcting the eczema in the child."

Dr. Charles Herrman. — "Dr. Kerley has had a large experience
with these cases and I only wish to discuss one point; that is with
reference to what he said about the exudative diathesis. Many of
these cases had nothing to do with the exudative diathesis; they were
due to local irritation, but there is a constitutional state which may
be spoken of as the exudative diathesis. I had occasion to study a
series of babies and to follow them up. In a series of about 200
babies 25 per cent, showed a distinct exudative tendency.
I would like to ask Dr. Kerley whether in following these children
through a series of years they have shown other peculiarities than
the skin disease. Dr. Kerley himself reported cases of recurrent
bronchitis and stated that these children had had eczema in child-
hood. One sometimes saw a child breast-fed and with everything
apparently all right and yet with a tendency to sprue during the first
two weeks; they seemed to have a pecuharly sensitive skin and res-
piratory system. I do not think thyroid deficiency is an important
factor in eczema."

Dr. Charles Gilmore Kerley. — "As regards the use of thyroid
extract, I tried it but without very definite results. It never seemed
to give sufficient relief to make me feel that I could advocate it.
In growing children, not babies, showing malnutrition and a tendency
to rough scaly skin, I have used Jf 5 or 3'^o of ^ grain two or three
times a day, and it may help in this kind of a case. It should not be
given in large quantity as it is a great stimulant and produces wake-
fulness in a child that is not appreciably abnormal. Children with
eczema are hkely to have the associated conditions, urticaria, cyclic
vomiting, and a tendency to take cold easily. That type of child
is susceptible to food influences and should be treated along lines
similar to those outlined in the paper. I have never been able to

756 TRANSACTIONS OF THE

bring these conditions together under a symptom-complex or to
consider them as a cHnical entity. Czerny and others have tried
to take in too much and to prove a symptom-complex, but there is
no one single term or condition that will include all of these cases."

HYPERTROPHIC STENOSIS OF THE PYLORUS IN CHILDREN.

Dr. Alfred Hand, Jr. Philadelphia, (by invitation) — "Why we are
seeing cases of h j-pertrophic stenosis now is a puzzle. I have been look-
ing for these cases for ten years, ever since the British Medical .Aissocia-
tion met at Toronto when we heard a great deal concerning this condi-
tion. Up to that time hardly a case had been recorded in this coun-
try. About a year ago I had a case which I reported before the
American Pediatric Society in May, 1915. Last September I had
two cases in one week. Last week when I was preparing to come
here a child was brought into my office with this condition. The
diagnosis is either easy or difficult, according to the stage of the con-
dition, and the specialist in children's diseases does not usually see
these cases early, so that it is often easy for him to make the diag-
nosis. When he is consulted at the time of initial vomiting it is
more difficult. The history of these cases shows great uniformity.
The condition is much more frequent in the male sex. The majority
of breast-fed infants progress satisfactorily for from two to six weeks
before the vomiting begins. A valuable point in distinguishing
hj'pertrophic stenosis of the pylorus is the projectile character of
the vomiting but this is not sufiicient for making a diagnosis. Some
children vomit and lose weight until the irreducible minimum is
reached. The constipation is obstinate and persistent but not
absolute. Laxatives may only serve to increase visible peristalsis.
The tumor if present may be felt by deep pressure in the hypo-
chondrium. Palpation does not as a rule present great difficulties.
By gentle manipulation relaxation may be obtained. Then with
the right hand in the hypochondrium the tumor may be located
somewhere between the midUne and the right flank. When one
has located it it is possible to detect a hard, almost cartilaginous
lump, characteristic of the growth. I beheve the history of these
cases shows that the hyperplasia is progressive. When all these
symptoms are present there is no question of the diagnosis. In the
early stage it ftiust be differentiated from catarrhal gastritis and
spasm of the pylorus. In dealing with this condition medically all
one's resources may be taxed. No stated rules can be laid down
for the dietetic treatment of these cases, but I would urge that in
every change of diet we should be guided by some definite reason.
At the Drexel Hospital in Philadelphia they have operated upon
fifteen cases with two deaths. I have had four patients, two bottle-
fed and two breast-fed babies. They all required stimulation after
operation, while on the table. We now use the operation of Oschner.
All my patients did well and were in fine condition but one, and
that one occasionally vomited bile."

MEDICAL SOCIETY OF THE STATE OF NEW YORK 757

DISCUSSION.

Dr. Godfrey R. Pisek, New York. — "I like Dr. Hand's term 'per-
sistent spasm of the pylorus' as it is more descriptive of the condi-
tion than simply pyloric spasm or stenosis. I would like to say
that we do undoubtedly have cases of pyloric spasm (persistent in
character), that get well under medical treatment by lavage, alkalies
and diet. We may carry these children along by such methods
that the defect is corrected, then the weight will gradually go up,
the child no longer vomits and slowly makes a recovery. This has
happened in a number of cases that have come under my observa-
tion. We have in this condition of pyloric spasm a chnical entity.
The a:-ray is of distinct value in distinguishing between pylorospasm
and true stenosis. In the case of spasm there is a retardation of the
food, but when the spasm is relaxed it may be seen passing through
the pylorus. With stenosis three hours after feeding no food will
be found e.xtruding through the pylorus, and when we find this con-
dition we should lose no time in handing the child over to the sur-
geon for the Ramstedt operation. This surgical procedure is the best
one we have, for the surgeon can get to the site of the trouble, rectify
it and get out in a very short time, and the child will be subjected
to very little shock. It can be done in twenty minutes or less and
is far preferable to a gastrojejunostomy."

Dr. Edward W. Peterson, New York. — "I wish to speak of the
Ramstedt operation for hypertrophic stenosis of the pylorus. I
suppose Dr. Hand is familiar with the work of Dr. Downes who
recently reported that he had employed this operation in upward
of sixty cases with a very slight mortality. This operation was
performed by making a simple incision through the hypertrophied
muscle fibers being very careful not to cut into the lumen of the gut.
In a case in which I recently operated it took just eight minutes to
complete the operation. The after care of these babies is very im-
portant. It is important to get in fluid after the operation. I do this
by injecting, 150 c.c. of saline intramuscularly with a record syringe.
The sahne is very quickly taken up when given intramuscularly,
much more quickly than when given subcutaneously. The after-
treatment of these cases is well covered by Dr. Morgan in a recent
article on this subject. It is just as essential to have these children
properly fed and handled after the operation as that they should
receive prompt surgical treatment."

Dr. Charles Gilmore Kerley, New York. — "Every one who
had to deal with these cases should read Dr. Morgan's article. I
had one case of hypertrophic stenosis which I lost by temporizing.
This patient was an only boy and I had him in a private sanatorium
where he had a wet nurse and was being treated with stomach wash-
ings. The stools were pretty good and the child was not losing
weight and this gave me the idea that the child was doing well.
This child died very suddenly. At autopsy it was found that the
pyloric end of the stomach, for nearly one-third of the stomach, was
infiltrated and edematous, and there was some thickening of the

758 TRANSACTIONS OF THE

pylorus. I saw another case do exactly the same thing. The people
were not anxious to have an operation and we temporized until the
child was almost dead. Dr. Downes then operated and this was one
of his fatal cases. These cases have made me afraid of cases of
hypertrophic stenosis that are apparently doing well. In this last
case I found that there were some changes in the liver and kidneys,
similar to those in acidosis but not just like those of starvation
acidosis. This experience has made me feel that if one is temporiz-
ing with a case of this kind he should not be too optimistic."

Dr. Charles Herrman, New York. — "As to the frequency cases
of hypertrophic pyloric stenosis, I think they are very rare. We get
a false impression as to the frequency of this condition. Dr. Downes
has reported sixty cases up to the present time in which he has used
the Ramstedt operation. It should be remembered that he operates
on 90 per cent, of all cases in and about New York. If one
does not take this into consideration he gets a wrong impression as
to the frequency of this condition. I see a great many babies and
I see on an average only about two cases of hypertrophic stenosis
of the pylorus in a year. There is no question that the Ramstedt
operation is the operation of choice, because it can be done so rapidly.
There is one drug that has been used with great success in this con-
dition and that is papaverin. But a very much better way is to be on
the safe side and recommend operation, since it is difficult chnically
to distinguish between pylorospasm and hypertrophic stenosis of the
pylorus."

Dr. T./Wood Clarke, Utica.^"Dr. Hand said that from what
he had heard at the meeting of the British Medical Association in
Toronto and from the Hterature he was led to believe that hyper-
trophic stenosis of the pylorus was more common in England than
in this country. I had a hospital experience at Ormsby, and during
three years saw eight cases, while during my connection with the
Vanderbilt Clinic I saw only one case, so I think the disease is more
frequent in England. In doing work on gastric acidity I had one
case with very high hydrochloric acid content and I am becoming
convinced that this condition may be due to hj'peracidity with
spasm, which have not gone on to hypertrophy, ordinary lime
water increased the acidity but sodium citrate decreased it. It
seems to me that children with pylorospasm might do well if fed on
skimmed milk, with three or four times the ordinary amount of
sodium citrate. I would like to see this tried. Of course the cases
showing signs of stenosis should be operated upon."

Dr. Stephen L. Taylor, Kenwood, and Dr. Bryon C. Darling,
New York. — "With the advance made in the treatment of tuber-
culous disease of the vertebrae and the improvement in the methods
of diagnosis, it still happens that the appearance of a fluctuating
mass in the groin or elsewhere is the first suspicion that the physi-
cian has of the real nature of the trouble he is trying to treat. If
it is possible to make a diagnosis before the bodies of one or more
vertebrae are destroyed, it is obvious that much has been done to
prevent the two most serious results of the disease, severe deformity

MEDICAL SOCIETY OF THE STATE OF NEW YORK 759

and general tuberculous infection. While Pott's disease may occur
at any age it is essentially a disease of childhood, for 90 per cent,
of the cases occur before fifteen years of age. There are many in-
stances of error in diagnosis recorded and they seem to be more
frequent in adults than in children. Before the appearance of a
kyphosis or the development of an abscess the symptoms shown by
the child are very indefinite and unpronounced and are often over-
looked. • Usually the mother who is keen to observe any thing
unnatural in her child's behavior will call attention to one or more
of the following early symptoms, general debihty, pallor and failure
to gain in weight, lack of interest in play, disinclination to run or
jump, unnatural attitude, change in gait, night cries, or paroxysmal
abdominal pain, or persistent attacks of pain in the chest or stomach,
or grunting respiration. These symptoms should arouse suspicion
and the child should be examined with the clothing removed. It
will then be noticed on inspecting the spine that the head may be
held to one side or the chin thrown back, or there would be a tend-
ency to support the chin with the hands when sitting, when the
disease is cervical. If the lesion is in the dorsal region, the most
usual location in children and the most difScult for early diagnosis,
one or both shoulders may be elevated, the spine is held rigid in
walking, or the child places the hands on the thighs to relieve the
spine when sitting. There may be a slight lateral curve. If the
disease is lumbar, there is an exaggeration of the normal lumbar
curves, throwing the abdomen forward. In asking the child to
pick something up from the floor" there is a characteristic squat
instead of stooping. If the hand is held over the spinous processes,
when the disease is dorsal or lumbar, it may be possible to discover
that when the spine bends several of the vertebrae move together, or,
in carefully inspecting the spine when the child is leaning forward,
the curve of the normal flexible spine is interrupted at some point.
The degree of extension of the spine and the amount of lateral motion
may be tested with the child lying prone with face downward. The
presence or absence of psoas contraction may be ascertained in this
position also. In the analysis of a large series of cases, J. Hilton
Waterman and Charles H. Yager found that in young children the
most frequent symptom was unnatural attitude and next in fre-
quency was pain. The pain in Pott's disease is due to the sensitive
articular surfaces and to irritation of the nerve roots. The former
accounts for the muscular rigidity and the effort of the child to
protect the motion of the spine in every way. The latter accounts
for the location of the pain in so many parts of the body, it being
referred to the periphery of the irritated nerve. Pott's disease in
its early stage may closely resemble the following conditions: rickets,
suppurating glands of the neck, lateral curvature, a weak and atonic
condition, infantile scorbutus and sarcoma of the vertebrae. A case
has been reported in which paro.xysmal abdominal pain with extreme
pain in the region of left ureter left the diagnosis in doubt for some
time, but the spine was finally suspected. The differential points
in sarcoma of the vertebrae are the greater severity of the pain, the

760 TRANSACTIONS OF THE

more rapid development of the symptoms, the failure of immobiliza-
tion to relieve pain, the local tenderness and the early development
of cachexia and paralysis. Repeated .v-ray examinations are neces-
sary. In torticollis, which may be mistaken for cervical Pott's,
the face is turned away from the contracted muscles, and passive
motion is restricted in one direction only; in Pott's disease in all
directions. There is no pain in the neck, while pain is usual in
cervical Pott's. Hip joint disease may simulate Pott's disease, but
in Pott's disease there is not the pain in bearing the weight on the
affected limb. In hip disease passive motion is restricted in all direc-
tions; in Pott's, rotation is not restricted and other motions are nor-
mal when flexion is increased. Sacroiliac disease might be mistaken
for Pott's but is a rare condition and would show tenderness over
the diseased joints and the spinal rigidity would not be so marked.
An arthritis affecting the spinal joints is unusual in children and
would show involvement of other joints. In spondo-listhesis the dis-
comfort and pain and the exaggeration of the normal lumbar curve
may cause it to be mistaken for lumbar caries. The a;-ray v/ould
aid in the diagnosis. The increased lordosis which is present with
pseudohypertrophic paralysis may resemble the deformity of Pott's
disease in the lumbar region. The absence of pain and muscular
rigidity, the shuffling gait and the hypertrophy should make the
diagnosis easy. Other conditions which are unusual but which it
may be necessary to exclude in children are typhoid or neurasthenic
spine, syphilis affecting the spinal articulations, acute aneurysm,
osteomyehtis and injury of the spine.

The variety of conditions that may be mistaken for Pott's disease
and the cases cited showing the possibility of error in diagnosis
impress one with the necessity of making the examinations of all
sick children. Observation for a period and repeated examinations
will be found necessary to arrive at a diagnosis in many instances.
A number of these conditions referred to could be excluded by the
discovery of muscular rigidity. In doubtful cases the x-ray is often
helpful though if negative in the early stages it is not conclusive.
Pictures should be taken in the anteroposterior position as well as
in the lateral, and repeated x-ray examinations are often necessarj-."

Dr. Bryon C. Darling, New York, gave a lantern-slide demon-
stration illustrating the point brought out in the paper.

A SCHEME OF STATE CONTROL FOR DEPENDENT INFANTS.

Dr. Henry Dwight Chapin, New York. — (See Medical Record,
June 15.) "You are all familiar with the high mortality of infants in
institutions. Statistics from eleven institutions show that they lost
one-half their babies during a period of live years. In a general way it
may be said that about two-thirds of the babies are discharged from
hospitals and institutions by death. A baby in a home with a poor
mother is better off than a baby in an institution. The baby needs
some handling and mothering which the poor mother gives it, but
which it seldom gets in an institution. There is greater danger of

MEDICAL SOCIETY OF THE STATE OF NEW YORK 761

infection in an institution. If vulvovaginitis occurs it is nearly
always specific. These babies have a poor vitality and if they ac-
quire an acute infectious disease they seldom survive. The retarda-
tion in development which a child sustains from life in an institution
can rarely be compensated for later in life. The best way to over-
come the handicap which the institution imposes on the child is to
abolish institutions for the care of infants. It is more difficult to
be constructive than destructive, so the plan which I present is based
on the results of practical work. Under the auspices of the Speed-
well Society I have conducted a practical experiment at Morris-
town, N. J., in boarding out of dependent babies. The babies are
boarded out under the supervision of a doctor and a nurse. The
nurse makes a daily visit to each baby, and in this way exerts a
control over the home conditions. The great drawback in most
instances in which infants have been boarded out is that there is
insufficient supervision. The boarding should be done in units so
that it will be possible to provide the necessary medical and nursing
supervision. Such units should be distributed along the hnes of
transportation. Thus we may have one near New York, one at
Albany, Syracuse, Rochester, Bufltalo, Binghampton, Watertown,
etc. In addition to the great advantages that such a plan offers
for the babies the financial side of the question is not unworthy of
note. New York State now gives over $4,481,000 to five institu-
tions for the care of dependent children. This sum would pay all
the expenses of the plan I have suggested, including salaries of
nurses, doctors, board for the babies and transportation expenses
incident to the work, and there would be considerable money left.
Furthermore, such a plan would save to the tax-payer the increased
tax rate made necessary by the fact that such institutions pay no
taxes; it would save heavy overhead charges incident to conducting
large institutions and the interest on large amounts of capital now
tied up in buildings. The money spent out for the care of the babies
would go into poor families where it would be a great help."

PIN WORMS AS A CAUSE OF APPENDICITIS.

Dr. Alfred W. Armstrong, Canandaigua. — "If the sale of worm-
powders indicates what mothers believe, it is quite evident that a
great majority of them have been convinced in some way that in-
testinal parasites exist and that they produce symptoms of disease
which are relieved by so-called "worm -powders." In the city of
Canandaigua every year there are sold enough doses of worm
medicine to supply ten doses to every child between one and four-
teen years of age. In olden times people looked upon intestinal
worms as the source of all evil; now the pendulum has swung the
other way and they are considered to produce serious lesions only
rarely. Pin worms are understood to be the most common of the
intestinal parasites found in children and they generally inhabit
the lower portion of the colon, although they sometimes may be
found in the small intestine, the stomach, and not very infrequently

762 TRANSACTIONS OF THE

in the appendix. My attention had been called to this subject by
four cases of appendicitis in children which I have seen. These
cases all had classical symptoms of appendicitis. After the removal
of the appendices there had been no return of the old symptoms.
This we generally considered as evidence that the cause of the disease
has been removed. It is of interest then to consider whether these
worms may inhabit the appendix under normal conditions, whether
they are there by accident, whether they precede the advent of inflam-
mation of the appendix, whether they are capable in themselves of en-
tering the mucous membrane and producing disease, and whether
they can produce more than one type of disease in the appendix.
It does not seem quite fair to consider the existence of parasites in
the intestine to be a normal condition, even though it might be an
unusual one. Their presence in the appendix is admitted by all
to be rare and, yet if it is true that the female lives in the cecum until
impregnation takes place and then moves toward the rectum, it is
easy to see how the appendix might get its share. There seems to
be some dispute as to whether the whole hfe history may be com-
pleted in the colon or whether the ova must be swallowed. Frequent
reinfections which occur would seem to make it clear that the latter
is not uncommon. The literature on this subject seems to be
limited to reports of only a few cases where the oxyures have been
found in the appendix and most of the observations which have been
recorded have been made in Europe. Bacterial infection is of
course the real cause of appendicitis but with the presence of nu-
merous forms of bacteria constantly in the intestinal canal, we must
account for their sudden activity on the occasion of an acute attack
of appendicitis. There seems to be a pretty well estabhshed type
of appendicitis in which the oxyures have been found which is
characterized by considerable pain without any marked inflammation.
A peculiar change occurs in these cases, viz. extensive destruction
of the mucosa without any sign of inflammation. In these cases
the gross appearance is one in which small hemorrhagic areas appear
in the mucosa and are confined to that part in which the worm is
found. The consideration of this subject I believe suggests the
following practical thoughts in the treatment of intestinal diseases
in children: (i) The possibility of the presence of pin worms in
the intestine of children should not be disregarded. (2) Appen-
dicitis is one of the more serious results of parasites in the appendix.
(3) Treatment directed against the oxyures may save some child
from the necessity for the removal of his appendix."

DISCUSSION.

Dr. Frederick H. Flaherty, Syracuse. — "It has been known
for a long time that so-called pin worms have been found in the
appendix. To get a clear idea of their relation to appendicitis we
must consider what are the causes of appendicitis. RIany causes
have been given, but I believe there are always two groups of causes,
the exciting cause and the underlying cause. A study of the anat-
omy of the appendix shows that it has a poor circulation which

MEDICAL SOCIETY OF THE STATE OF NEW YORK 768

favors inflammation, and this plus the exciting causes produces
appendicitis. Foreign bodies in the appendix are not as common
as is thought. In a series of 500 acute cases in which the appendix
was examined there was only one in which pin worms were found.
If pin worms are in the cecum it is easy to see how they may get
into the appendix. In my case there were two masses of worms,
each containing from thirty to forty worms, and these precipitated
the inflammation. What Dr. Armstrong has said about the in-
frequency of appendicitis among the Chinese is true because there
is a difference in the anatomy of different races. The American
Indians rarely have appendicitis. Another point to which I wish
to call attention is with reference to the diagnosis of appendicitis
in children, and that is that the rectal examination is as valuable
as any other one method of examinations in detecting an inflam-
matory mass in the abdomen."

Dr. Edward W. Peterson, New York. — "I can only say that
we have had several of these cases and may have had more in the
babies' service, but this is one of the rare causes of appendicitis.
.Several articles have been written on this subject, one several years
ago entitled "Pin Worm Appendicitis," in which two cases are
reported. In another case we were operating for hernia and the
sac was large so we thought we would take out the appendix as a
prophylactic measure. Upon opening the appendix we found
about one-half dozen pin worms. This case was reported in the
New York Medical Journal several years ago. The finding of pin
worms in a few cases is not conclusive evidence that they are a
causative factor in appendicitis. It might, however, in children
be well to take the precautionary measure of giving the appropriate
treatment for pin worms before operating for appendicitis. As a
rule the habitat of the pin worm is in the cecum."

Dr. T. Dewitt Sherman. — "I want to emphasize what Dr. Peter-
son has said and to point out that we do not examine the stools as
often as we should. Again it depends on the sex of the pin worms
whether the treatment is going to do any good. The males stay up
in the cecum and the females travel down. If one has a focus of
males the treatment will be of no avail."

typhoid FEVER IN CHILDREN.

Dr. George C. Sincerbeaux, Auburn. — The purpose of this paper
is not to state anything new in the diagnosis or treatment of typhoid
fever but to emphasize the importance of the milk supply and to
give a few facts gathered from an epidemic in Auburn in the past
year. Typhoid fever in children while in many respects resembhng
that of adults, has many symptoms less characteristic. It is rare
before the age of two years and after fifty years. The pathological
findings in children are less typical than in the adult. Ulceration
while not infrequent, was often wanting. Sometimes there was
only moderate swelling of the redness of Peyer's patches, solitary
glands, mesenteric lymph nodes, in fact there might be no lesion in
the intestine at all. The spleen was soft and enlarged, although

764 MEDICAL SOCIETY OF THE STATE OF NEW YORK

often much less than in the adult. In the more severe cases degener-
ative changes in the liver, kidneys, heart, salivary glands and pan-
creas took place. There might be hyperemia and edema of the cere-
bral substance, or lobular and bronchial pneumonia with hyperemia
of the bronchial mucous membrane. There might be hypostasis
and bronchial edema with ulcerative changes in the larynx and
esophagus.

In some instances periostitis and bone changes might follow. The
course of typhoid fever in children is relatively mild except in infants,
and is liable to be shorter than in adults. The prodromal symptoms
are shght. Headache, nose-bleed and diarrhea are rare. The attack
is usually ushered in by slight malaise, gastrointestinal disturbance,
vomiting and constipation, the diarrhea, if any, appearing later.
The temperature rises slowly for the first few days running evenly
with slight morning remissions during the second week and de-
clining slowly until normal at the end of the third week. The tongue
may be clean but more often was covered with thick white covering,
with clean tip and margins often exhibiting the V-shaped red places
or typhoid triangle in the center of the tip, which is claimed to be
pathognomonic. The pulse is usually slow in relation to the tem-
perature, unless there are certain heart changes. The younger
the child the less the nervous symptoms, usually the only evidence
being an apathy and restlessness at night, except in severe cases, in
which one might see tremor of the hand, picking of the bed clothes,
delirium and convulsions, and other evidences characteristic of
meningeal irritation. Intestinal hemorrhages and perforation
were rare except in older children. The mortaUty of typhoid fever
in children is small, ranging from 2 to 9 per cent. The course
of the temperature, steady increase in the size of the spleen, and
eruption of areola, usually appearing in the second week, together
with the Diazo and Widal reaction usually clears up the diagnosis.
The disease most likely to be confused with typhoid fever in children
is miliary tuberculosis. But in this disease there is the irregular
temperature, the spleen is not apt to be so enlarged, the Widal re-
action is negative and there is an absence of the bacilli in the blood.
My treatment might be regarded as empirical, but during the past
few years I have been using collargolum and colloidal silver, V^
to I grain, in capsule every six hours and salol, in i to 2 grain
doses, every four hours. The diet consisted of boiled water in plenty,
milk, broths, gruels, egg-nogg, cereals cooked six hours, orange juice
and home-made ice cream. In the Auburn epidemic there were
thirty cases reported, of which sixteen occurred in children under
seven years of age, the youngest being nineteen months. An inves-
tigation traced the source of this epidemic to milk from one creamery,
and it was learned that on one farm supplying milk to this creamery
the son of the owner had had typhoid fever. Admonition was
given the people to drink only distilled or boiled water, and milk
from this creamery was ordered pasteurized. Investigation of the
farm to which the infection had been traced revealed the presence
of two wells with polluted water. In order to lessen the chances

BRIEF OF CURRENT LITERATURE 765

of cases and carriers of typhoid fever and to control them when
once they were known, the following means would be found effective:
I. Cleanliness in milk production. 2. Vaccination of dairy employ-
ees against typhoid fever. 3. Isolation of infected persons. 4.
Official supervision of dairies during the presence of illness. 5.
Official supervision of the pasteurization of all milk.

BRIEF OF CURRENT LITERATURE.

DISEASES OF CHILDREN.

Meningococcus in Nasopharynx of Cerebrospinal Fever Con-
tacts.— Over 2000 throats were examined by J. Mcintosh and W. E.
Bullock {Lancet, Nov. 27, 1915) for meningococcus, and of actual
contacts 5.5 per cent, were found to have meningococci in their
throats. In the various batches examined the percentage of positive
results varied from o to 25; the highest figures were only found when
the epidemic was at its height, and where there was considerable
overcrowding and therefore a close association between patient and
contacts. If the high percentage of positive contacts found by some
workers approximates the real facts, then, apart from the difficulty
of examining the huge number of contacts in a large epidemic, the
isolation of carriers becomes impracticable. But we are convinced that
meningococcus carriers are less frequent than is generally believed;
and given an easy, rapid, and definite means of detecting the men-
ingococcus in the nasopharynx, it should be possible to check an
epidemic of cerebrospinal fever in any small community or body
of men where the movements of individuals are under control.

Method of Vaginal Washing in the Diagnosis of Gonococcus
Vaginitis. — M. E. Trist and J. A. Kolmer {Arch. Pediat., 1915,
xxxii, 801) find that the method of vaginal washing in the smear
diagnosis of gonococcus vaginitis has its greatest value in the diag-
nosis of chronic cases and cases under treatment. In these cases the
secretions are likely to be scanty, especially about the vulva and
vaginal introitus, whereas considerable amounts may be present in
the vaginal canal and about the cervix. In vaginal washing these
secretions are secured and this explains the success of the method.

Diagnosis by means of vaginal washing is, however, frequently
difficult, and in all cases where the discharge is free direct vaginal
and cervical smears are to be preferred.

Vaginal washings usually disclose a higher percentage of pus cells
in vaginitis than simple smears, and these alone aid greatly in
diagnosis.

In subacute and chronic vulvovaginitis with scanty discharge
vaginal washings will disclose gonococci in from 20 to 25 per cent,
of cases when direct smears are negative; the percentage of positive
findings is increased after irritation of the vaginal mucosa with
silver nitrate after the method of Norris.

866 BRIEF- OF CURRENT LITERATXTRE

The absence of gonococci in vaginal washings gives greater assur-
ance of the absence of gonococcus infection and treatment guided
by these examinations is Hkely to be more thorough, although
greatly prolonged.

Anteversion of the Neck of the Femur. — Study of failures in
the treatment of congenital dislocation of the hip has convinced
R. A. Hibbs {Jour. A. M. A., 1915, Ixv, 1801) that some of these
were due to anteversion deformity of the head and neck of the
femur which was not recognized before operation.

There is a certain amount of anteversion in the normal femur,
but probably not more than from 10 to 15 deg. More than this
amount is abnormal, and certainly when it is as much as from 75
to 90 deg., grossly so. With the leg straight and the toe and patella
pointing forward in the normal direction, the head of the femur
cannot be completely in the acetabulum. With the head thus
partially engaged in the socket, weight bearing is uncertain and
there is always a limp. To treat the matter as a twist of the shaft
of the femur, and correct it by osteotomy before any attempt is
made to reduce the dislocation has been done in a series of twenty-
nine hips in twenty-six children, all the patients having been pre\'i-
ously operated on for dislocation once and in some instances twice,
with failure. It is done by an osteotomy at the lower third of the
femur. After the bone is divided, the lower fragment is twisted
outward to the degree that the head is abnormally anteverted.
After the bone unites, the patient is allowed to walk from eight to
ten weeks until the external rotation of the leg is corrected by exer-
cises and it takes the normal position in walking, the patella and
toe pointing forward. At this point in the treatment the disloca-
tion should be reduced.

Duodenal Ulcer in Infancy an Infectious Disease. — L. Gerdine
and H. F. Helmholz {Amer. Jour. Dis. Child., 1915, x, 397) state
that Rosenow has conclusively established the fact that gastric and
duodenal ulcers of the adult are the result of an infection with a
streptococcus of particular virulence. That this holds good for
duodenal ulcers of the infant also is shown by the following facts
summarizing the work of Gerdine and Helmholz:

1. The appearance of duodenal ulcer in epidemic form.

2. The presence of diplococci and streptococci in all eight ulcers
of the present series available for study, and in ten out of fourteen
ulcers of a previous series of cases.

3. The isolation, at necropsy, from one ulcer, of a Streptococcus
viridans which when injected into dogs and rabbits localized in the
pyloric end of the stomach and the duodenum and produced there
hemorrhages and ulcers.

Oxalic Acid Excretion in the Urine of Children. — J. P. Sedgwick
{Amer. Jour. Dis. Child., 1915, x, 414) says that the older methods
of determination of oxalic acid are tedious and imperfect. The
Albahary method gives better results and is much more rapid. He
finds that new-born infants excrete oxalic acid in the urine in varying
amounts up to 9 mg. per day.

BRIEF OF CURRENT LITERATURE 767

Older children excrete oxalic acid in considerable quantity, and
one child, fed on rhubarb, showed a definite increase in oxalic acid
excretion during the period of rhubarb feeding.

If we accept the usual figures which are given for the oxalic acid
excretion in adults, given by Neuberg as from 15 to 20 mg., the
excretion in children is relatively and at times absolutely higher.

Phthalein Test in Orthostatic Albuminuria. — Renal function, as
measured by the phenolsulphonephthalein test, in children with
marked degrees of orthostatic albuminuria, is normal when the
patients are at rest in bed. When these patients are placed in a
position of accentuated lordosis, producing a marked albuminuria,
the total output of phthalein in two hours is reduced — in T. C.
Hempelmann's (Amer. Jour. Dis. Child., 1915, x, 422) seven cases,
on an average 12.9 per cent. The most marked feature, however,
is the retardation which takes place in the output during the first
hour — the average of his cases being 17.6 per cent, less in the lordotic
position. Normal children do not show this retardation and de-
creased elimination with the change of posture. If this retardation
may be brought into relation with any of the theoretical ideas of the
pathogenesis of orthostatic albuminuria, it would probably be that
which associates the condition with a decreased vascular supply
to the kidney as the result of posture.

The Ainmoniacal Diaper in Infants and Young Children. —
According to J. Zahorsky (Amer. Jour. Dis. Child., 1915, x, 436) if
much ammonia is present, severe irritation and vesication of the
diaper region may occur.

The ammonia is derived from the ammonium compounds in the
urine, and is liberated by an alkali present in the diaper — soap, lye,
lime, or stool.

When the diaper, which has been washed in a strong alkaline soap,
is not thoroughly rinsed in clear water, sufficient alkalinity remains
in the cloth to decompose the ammonia in the urine. This is the
origin of the "common" saying that strong soap or lye in the diaper
bhsters the baby. It is not the alkali or soap on the skin, but the
ammonia produced, which causes the skin irritation. An alkaline
stool mixed with urine acts the same way, and we have often attrib-
uted an intertrigo to irritating feces, when it was really caused by
ammonia.

Amebic Infection in the Mouths of Children. — In the examination
of 1678 children A. W. Williams, A. I. Von Sholly, C. Rosenberg
and A. G. Mann (Jour. A. M. A., 1915, Ixv, 2070) have found that
amebas are demonstrated irregularly in all mouths once showing
them, most constantly and in largest numbers in mouths showing
gingivitis, least so in healthy mouths.

With ordinary teeth cleansing methods, the number of mouths
showing amebas is reduced one-half. With emetin in the tooth
wash, the number showing amebas is greatly reduced, only about
10 per cent, showing them. The second set of controls — those
doing their cleaning at home by ordinary methods — continue to show
amebas in about 75 per cent, of the cases.

768 BRIEF OF CURRENT LITERATURE

The question as to the amount of emetin to be used has not yet
been settled. The writers began with a 1:200 solution, then reduced
it to a 1 :4oo strength. Probably a much smaller amount would be
sufficient to keep down the development of the amebas.

Bladder Tumors in the Young. — R. F. O'Neal {Bost. Med. and Surg.
Jour., 1915, ckxiii, 873) says that vesical tumors in children are a
very great rarity. The great majority appear before the fifth year.
They are of the connective tissue tjqae and are chnically and patho-
logically malignant except in rare instances. Difficulties of micturi-
tion are generally the earhest symptom; in the absence of stricture
they should excite suspicion. Straining is common. Early diag-
nosis and operation offer the only hope of recovery.

Blood Coagulation in Infancy. — Dale and Laidlaw and others
have found the coagulation time in healthy adults by this method to
vary between one and thirty-nine seconds and one minute and fifty-
one seconds. H. L. K. Shaw and F. J. Wilhams (Alb. Med. Ann.,
1915, xxxvi, 571) made examinations in 108 healthy infants under
two years of age by the Dale and Laidlaw method and found the
determinations were between one minute and fifteen seconds and
one minute and forty-eight seconds, and the average coagulation time
was one minute and thirty seconds which is a slightly shorter time
than in adults. Sladen and Emerson, using the coagulometer of
Russell and Brodie as modified by Boggs, found the average coagu-
lation time in healthy adults to be five minutes, six seconds. The
writers' results with this instrument gave a much lower average in
infants, as follows: Ninety-five examinations in infants under one
year of age averaged three minutes, forty-seven seconds; thirty-five
between one and two years of age, three minutes, fifty-four seconds;
and twenty between two and three years, three minutes, fifty-eight
seconds. They observed no difference in the clotting time before
and after eating, nor at different periods of the day. There was
no difference in blood taken from various parts of the body — ears,
fingers or toes. The first drop clotted somewhat more quickly than
succeeding ones and a slight hastening of the coagulation time was
noted when the tissues surrounding the needle prick were squeezed
and manipulated to force out the blood.

Relation of Heat to Summer Diarrheas of Infants. — The studies
reported in A. Bleyer's {Jour. A. M. A., 1915, Ixv, 2161) paper show,
in a series of 222 dispensary infants which developed acute attacks
of diarrhea, that there was a direct relation between the degree of
temperature and the onset of the diarrhea, over half (51.4 per cent.)
of the babies becoming ill on days when the temperature was 90,
although there were but 31 per cent, of such days in the two summers.
The observations were made among babies of the poor among
whom diarrheas in summer are verj' prone to occur. IMost of them
were rationally fed, usually on some mixture of certified milk when
breast milk was not available. Thirty of them (13 per cent.)
were exclusively breast-fed, and twenty-two more were partially
breast-fed, which is evidence that heat may very well influence
the baby who is taking clean food.

THE A MERIOAJSr

JOURNAL OF OBSTETRICS

AND

DISEASES OF WOMEN AND CHILDREN.

VOL. LXXIV. NOVEMBER. 1916. NO 5.

ORIGINAL COMMUNICATIONS.

ACIDOSIS IN NORMAL UTERINE PREGNANCIES.*

BY
LUDWIG A. EMGE, S. B., M. D.,

Assistant in Obstetrics and Gynecology. University of California, and President of the
University of California Hospital, San Francisco.

The interest of this clinic during the past twelve months has been
concentrated largely upon the study of toxemias of pregnancy.
Desiring to obtain data on the frequency of acidosis in normal
uterine pregnancies, we have inaugurated at the suggestion of Dr.
Lynch the study in our clinic of a series of unselected normal preg-
nancies. Since we have included in our investigation all cases who
thought themselves pregnant, we have observed several very early
pregnancies as well as some few cases who thought themselves preg-
nant, but who were found not to be so. When this work was begun,
it was my intention to study several hundred cases before reporting
the findings, but the results have been so striking that it seems
well worth while to briefly discuss the sixty-eight cases thus far
investigated. This report is preliminary and is designed only to
establish the fact that acidosis is nearly uniformly present in uterine
pregnancies.

Ever since the days of Pfliiger, attempts have been made to con-
nect acidosis with toxemias of pregnancy. Theoretically, there are
at least four methods for the investigation of such an acidosis.

(i) By study of CO2 in expired air.

(2) By investigation of the changes in the COo-tension of the
plasma of the blood.

*Read before the University Hospital Medical Society, San Francisco, Sep-
tember 7, 1916.

770 emge: acidosis in normal uterine pregnancies

(3) By study of the hydvogen-ion content of blood and urine.

(4) By estimation of the ammonia content of the urine.

Nearly all these methods have had their advocates. Yet, as a
rule, results which have been recorded are subject to some criticism
because of defects in the method. There has been no series of
striking results save those of Hasselbalch and Gammeltoft, who
studied the blood of nine cases before and after labor, finding an
acidosis before labor which disappeared thereafter. They observed
an increase in ammonia in the urine and decrease in the acidity of the
urine in all of the normal cases and in two of four eclamptics inves-
tigated in this manner. The two remaining eclamptics gave no
evidence of this compensatory change in the urine.

As a rule, the better methods for the investigation of an acidosis
have been either too cumbersome for routine work or are attended
with considerable expense. Fortunately for us, Van Slyke(i), in
1915, reported an ingenious, simple and inexpensive method of
determining the CO2 which is chemically bound in the plasma. The
method is available for the average laboratory worker who is trained
in chemical methods. We refer the reader to Van Slyke's report for
his technic. We have followed accurately these directions in our
investigation save that we have substituted two drops of amyl alco-
hol for the octyl alcohol which has been recommended, since this
latter substance has proven most difhcult to obtain. The method is
made more simple because of a table which has been compiled by
Van Slyke and which obviates the necessity of calculating the CO2
bound as carbonate in the blood plasma in terms of volume percent-
age. Van Slyke states that the plasma of normal adults yields from
0.65 to 0.90 c.c. of gas, an equivalent of a range of 53 to 77 volume
per cent, of CO2 so chemically bound.

In order to present a clear picture, we have arranged the findings
of the entire group of sixty-eight cases investigated in Tables I and
II, grouping them according to the percentage of the CO2 tension.
We have noted, also, in Table I, the lunar week of pregnancy in which
the plasma was examined, the presence and duration of nausea and
vomiting, the age of the patient, and the number of previous preg-
nancies, including abortions and premature labors. In Table II
we group those cases which were found not to be pregnant, with the
exception of a case of extrauterine pregnancy. Table IV presents
cases in which more than one estimation was made during pregnancy.

Fifty-five of the sLxty-one cases of Table I show readings below
50 volume per cent, which is approximately the lowest reading noted
in any of our nonpregnant cases. Fifty-five cases, then, of the sixty-

emge: acidosis in normal uterine pregnancies 771

one pregnancies show an acidosis. Putting it the other way, 90 per
cent, of this series show an appreciable decrease in C02-tension as
compared with the normal, taking 50 as the normal volume per
cent, and considering Nos. 56 and 57 as 50. Yet fifty-nine of these
sixty-one cases fall below the volume per cent, of 53, which Van
Slyke takes as the lower limit of normal. An acidosis of varying
degree, therefore, was found in nearly all cases.

The variations in the percentages of COa-tension are frequently
most strildng and we early attempted to determine the law which
governed them. Consequently, we grouped our cases in various
ways: thus, according to the number of gestations, the weeks of the
present pregnancy, the age of the patient and the amount of nausea
and vomiting either present or experienced in the present pregnancy,
hoping to find some uniform'ty in C02-tension. But no uniformity
was found in any grouping. For instance, when we compared the
cases according to the number of gestations, we found that a woman
who had seven pregnancies had about the same C02-tension as a
woman in her first, the reading being made at the same period of
the present pregnancy (see Nos. 8 and 9 on Table I). Neither do
the weeks of pregnancy furnish any clue. Moreover, we find that a
case in the first eighteen or twenty weeks of pregnancy may present
readings identical with those of the last weeks of pregnancy. Since
starvation will produce acidosis, it seemed necessary to study sepa-
rately the cases who had nausea and vomiting. Yet nothing note-
worthy was determined. Wide variations may exist in the blood
readings of these cases. Smce the cases were unselected, we were
not acquainted with accurate details of diet. Yet there was no case
in which starvation would be considered at the time of the first blood
reading. One patient starved herself later (see No. 43 on Table IV).
She showed a decided drop in C02-tension when seen at this time.

Only one of the nonpregnant women (No. 62) was below 50.00.
The blood plasma was read again two weeks later when it showed a
CO2- tension of 55.75 volume per cent. The first blood examination
was made a few hours before the onset of menstruation and when she
was two or three days overdue. We have no other such case in our
series and it opens up many interesting points of speculation as to
the influence of menstruation on the C02-tension of the blood.
These, unfortunately, must be repressed until we have had many
other similar cases. No. 63 was a ruptured tubal pregnancy. In
this class of cases, also, we require more studies before drawing
conclusions.

There are, then, only two of the sixty-one cases of pregnancy of

772 emge: acidosis in normal uterine pregnancies

our series which did not show a decrease in COo-tension. One of
these, No. 6i, was a chronic alcoholic and gave birth to a seven
naonths' macerated fetus twenty-six days after she was seen first and
two weeks previous to her estimated date of confinement. Our
tables justify our statement that we may expect to find a decrease in
C02-tension in the great majority of the cases of uterine pregnancy.

We have investigated the blood plasma of twenty-five of these
€ixty-one uterine pregnancies after delivery (Table III). Nineteen
of these, or all save six, regained the normal or at least rose above
50. Only one case of the six (No. 23) dropped from 42.20 to 41.40.
This patient had given evidence of a mild chronic interstitial nephritis,
with a recrudescence in the puerperium. The remaining five showed
gains varying from 2.20 to 13.60 volume per cent., even though they
did not return to normal. Only one blood examination for each
case was made during the puerperium, so we do not know the
exact time at which any case regained normal level. No. 60 was
above normal before delivery and remained so after. Yet wide
variations are seen in readings of various cases made on the same
day postpartum (Case II and XXII, Table III, IV, V and XV,
etc.). The most striking feature of Table III is seen on comparing
the cases below 40 and above 40 before delivery. Those below
40 show a much more decided increase in COa-tension after delivery.

Blood readings were made more than once on three of our patients
before delivery (Table IV). No. 7, who showed a slight increase
(from 38.50 to 39.60), was under treatment for lues at time of her
second plasma examination. No. 43 had been on very scant diet
for several days before her second reading. She was vomiting
quite frequently, but, most unfortunately, did not care to accept
any treatment which did not contemplate abortion and thus passed
from observation. No. 48, on her first visit, was thought to have
a beginning nephritis. There were no evidences of this on her
second examination, when the COa-tension had risen from 46.00
to 48.90. Later, she gave evidence of preeclamptic toxemia, when
labor was induced in consequence. Her plasma then showed 40.20
volume per cent., a decided drop from the previous readings. We
are making no conclusions from this case, because this last reading
was made during labor. We have examined only two normal
cases during labor, and these also gave low COa-tension (Nos. 4
and 5 of Table I). Until further investigations have been made
of the effect of labor on the COa-tension, we could not say whether
this drop was due to the toxemia or to the strain of labor.

emge: acidosis in norm.\l uterine pregnancies

773

TABLE I.

No.

C.c. of COa chem. bound
by 100 c.c. plasma

Weeks of
pregnancy

Nausea and vomit-
ing in present
pregnancy

Age

No. of
gestations

31.00

None.

31.60

None.

36.20

None.

37 40

During labor

i3'2 months.

37.50

During labor

3 months.

38.20

None.

38.50

3 months.

38.50

None.

VII

38.70

None.

40. 20

None.

40.35

3 months.

40.40

None.

40.40

2}^ months.

40.50

2 months.

40.60

None.

III

40.80

2 months.

40.80

I month.

41 .20

None.

41.40

None.

41.60

3 months.

41.80

4 days.

41.80

3 months.

42.20

None.

III

42.20

None.

42.20

2 months.

42.20

None.

III

42.30

2 months.

42-35

None.

42.40

None.

42-75

4 months.

43.00

None.

43.00

3 months.

43-30

Once.

43-30

2 months.

III

44.00

None.

III

44.00

None.

VIII

■ 44.20

I month.

44-30

None.

44 30

None.

44-45

None.

III

44-45

None.

vni

45-10

None.

45 -2°

2j^ months.

45-20

I week.

45-30

2 months.

774

emge: acidosis in normal uterine pregnancies

TABLE 1.— {Continued).

No.

C.c. of CO! chem. bound
by 100 c.c. plasma

Weeks of
pregnancy

Nausea and vomit-
ing in present
pregnancy

Age

No. of
gestations

45 90

None.

3 months.

3 weeks.

III

None.

I month.

3 months.

4 months.

III

4 months.

III

3 months.

III

2 months.

None.

Marked.

I month.

III

Chronic alcoholic-

macerated fetus

of seven months.

TABLE II.

No.

C.c.
by

of CO2 chem.
100 c.c. of pi

bound

Remarks

48. 85

Not pregnant — menstruated few hours after test.

49.00

Ruptured tubal pregnancy — two months.

50.00

Not pregnant.

53-85

Not pregnant.

51-90

Not pregnant — tuboovarian mass.

57-65

Not pregnant.

59-50

Not pregnant — pus tube.

Four of the patients who were found not pregnant were reex-
amined within two months of their first visit. While all showed a
shght variation in volume per cent, of CO2 as compared to their
first reading, they all stayed well above 50.00.

Our findings from the study of C02-tension of the plasma show,
then, that an acidosis is present in the great majority of uterine
pregnancies. If acidosis occurs, in the so-called normal phenomena
of life, must we not hesitate in drawing conclusions as to its signif-
icance in pathological conditions? We surely must demonstrate
that an acidosis is not present in the normal pregnancy before we
attempt to demonstrate its r61e in the various toxemias. It seems

emge: acidosis in normal uterine pregnancies

775

TABLE III.

No.

CO4 chem. bound by
100 c.c. plasma

Weeks of
pregnancy

COi chem. bound by
100 c.c. plasma

Days after
delivery

DiEEerence

31.60

45.20

13-60

37-40

67-15

29-75

S
6 .

37-50
38.20

40
36

51-75
59-50

8
S8

14-25
21.30

38.50

51-50

13 -00

40.20

57-65

17-45

40-35

57-65

17.30

40.60

55-65

15 -OS

41.60

51.00

9.40

41. So

51-90

10.10

42.20

41.40

0.80

42.20

47.10

4.90

42-35

52-90

10.5s

42.40

S3 -00

10.60

3°

42.75

48. qo

6.13

43.00

53-70

10 70

43-00

55 -70

12.70

44.00

48.10

4.10

44-45

52.80

8.3s

45-30

55-70

10.40

45-90

48. 10

2.20

49
S3

46. 20
48-15

38
38

55.75
55-86

33
10

9SS
7-65

55
60

49.00
58-50

39
31

49-90

56-75

4
2

0.90
1-75

TABLE IV.

No.

CO2 "^^^^ °f

■* , pregnancy

CO.

Week of
pregnancy

COj

Week of
pregnancy

Remarks

7
43

38.50

45 -20
46.00

29
10

39.60
35-60

48.90

38
13

40.20

In labor

Has XXX positive

Wassermann.

Developed p e r n i-
cious nausea and
vomiting.

Developed severe
postpartum eclamp-
sia with subsequent
symptoms of de-
mentia precox.

776 Mcpherson: delivery of breech presentation

quite likely to me, moreover, that this method may prove useful
as an adjunct in the diagnosis of early pregnancy provided, of course,
that other conditions causing enlarged uteri do not cause similar
disturbances of plasma.

BIBLIOGRAPHY.

1. The Nature and Detection of Diabetic Acidosis: Donald D.
Van Slyke, Edgar Stillman and Glenn E. CuUen, Proceedings of
the Society for Experimental Biology and Medicine, vol. xii, No.
7, New York, April 21, 1915.

2. Die Neutralitats regulation des gravider organismus. Hassel-
balch und Gammeltopt Biochemische Zeitschrift, 1914, vol. Ixviii, p.
206.

IS THE OPERATION OF CESAREAN SECTION

INDICATED IN THE DELIVERY OF BREECH

PRESENTATION?*

ROSS Mcpherson, m. d., f. a. c. s.,

Attending Surgeon, New York Lying-in Hospital, Consulting Obstetrician, United Port

Chester Hospital, Consulting Obstetrician, Caledonian Hospital, Brooklyn,

New York.

A WELL-KNOWN teacher of obstetrics once remarked in the writer's
hearing, that if he were asked how to determine the capabiUty of an
obstetrician, he would like to be present and watch the operator's
method of conducting a breech presentation and delivery; and that
he would be wiUing to let his opinion of the physician's skill as an
accoucheur rest on the manner in which the case was treated. This
may sound rather like a radical statement, but after thoughtful
reflection upon the complication under consideration, it does not
seem that such a judgment would be entirely unwarranted.

An abnormality which occurs in 3 to 4 per cent, of all labors, with
a fetal mortality estimated by various authors as from 10 to 30 per
cent, certainly merits more than superficial thought, and if -svith
our present recognized modes of delivery such an extreme fetal
mortality really does result, it would seem that we should look
somewhat further afield, and attempt to discover and carefully
consider some other method which will yield more living children,
always provided that the maternal risk is not increased thereby.

With the idea of trying to discover what the actual figures would
be in a large number of cases, the writer has attempted to analyze
3412 cases of breech presentation and delivery which have occurred
in 97,000 confinements, all in the service of the New York Lying-in
Hospital from its inception to September, 1915. An earnest effort
has been made to include in the fetal mortaUty only those cases in

*Read before the Twenty-ninth Annual Meeting of the .\merican Associa-
tion of Obstetricans and Gynecologists at Indianapolis, October, 1916.

Mcpherson: delwery of breech presentation 777

which the cause of the stillbirth could be directly attributed to the
breech delivery. Such causes as prematurity, placenta previa,
toxemia of pregnancy, deformed pelvis, abdominal and pelvic tumors
while noted, have been ehminated, as it is impossible, if these com-
pUcations are included, to determine what proportion of the still-
births was caused by the existence of the abnormal presentation
with the subsequent abnormal labor, and what proportion was due
to the complication. Such an elimination in the same way, and for
the same reason is necessary in order to determine the maternal
mortality in breech presentation and dehvery, and it is most essen-
tial to have an absolutely clear view of the maternal death rate, in
order to compare it with that of any other operative procedure
which we may wish to substitute for the recognized methods of
delivery in this complication.

The actual etiology of breech presentation is not entirely clear,
it being stated that gravity, flaccid uterine and abdominal walls,
impediments to the engagement of the head, etc., etc., all play a
large part. Williams(i) believes that in primiparae, particularly,
the existence of a breech presentation always means some dispro-
portion between the fetus and pelvis or the fetus and the uterine
cavity. He states, however, that "there vnll still remain, in spite
of the most careful examination, a large number of cases in which
no definite disproportion between the fetus and pelvis can be
demonstrated before dehvery."

There would, therefore, seem to be considerable doubt as to
the cause of breech presentation, and the fact of universal dispro-
portion in primiparje does not seem to the writer to have been
proved.

The frequency of the abnormaUty under discussion in Pinard's
series taken from 100,000 labors was 3.3 per cent., in our series
the compUcation occurred in 97,000 cases 3412 times, or 3.5 per
cent, or in 2.3 per cent, of cases reaching term. Pinard states
that 59 per cent, of all cases occurred in multipara. In our series
72.3 per cent, occurred in multiparas or approximately three times
as many as in primiparas.

In contradistinction to these figures are those of DeNormandie(2),
based on a much smaller series it is true, who found that breech
presentation occurred in primiparae in 57.2 per cent, of his cases at
the Boston Lying-in Hospital.

So far as prognosis for the mother is concerned, the maternal
mortaUty does not, and should not, differ greath^ from that of ver-
tex presentation in uncomplicated cases. The maternal mortaUty
in our series, including cases complicated by convulsive toxemia

778 Mcpherson: delwery of breech presentation

(eclampsia), of which there were thirty-seven; placenta previa,
of which there were sixty- three; chronic nephritis, chronic endocar-
ditis, pneumonia, etc., all of which have a mortaUty of their own,
was 0.96 per cent. Excluding these complications, the mortality
was found to be 0.47 per cent., which is not excessive, when it is con-
sidered that many of these cases had been handled by outside
physicians and midwives.

Coming to the prognosis for the child, however, here we find a
much higher mortality than in vertex presentation. The fetal
mortality is generally estimated by various authors at from 10 to
30 per cent. In our series of the 3412 cases of breech presentation,
336 children at term were stUlborn, a mortaUty of 9.4 per cent.
422 were premature, and would in all probability not have survived
in any event. We are, therefore, concerned with the treatment of
a compUcation, as a result of which 9.5 per cent, of the children are
stillborn.

Regarding the parity of the mothers, 944 were primiparae; 2468
were multiparae.

Regarding the fetus, there were 198 stillbirths in the 944 primi-
parae; and 560 stillbirths in the 2468 multiparae, a percentage of
21.6 per cent., and 22.7 per cent., respectively. In other words,
the difference in mortality in the children between primiparae and
multiparae was so small as not to be considered.

Broadly speaking then, the operative choice of a means of deUvery
in breech presentation Ues between the usual method by the vaginal
route, or by the means of an abdominal hysterotomy, which latterly
seems to be the panacea for all obstetrical ills and malpositions.

WiUiams of Boston(3), in an article entitled "Cesarean Section for
Primiparous Breech Presentation," frankly expresses himself in
his concluding paragraph as being committed to the abdominal
hysterotomy for a breech presentation in the majority of cases, and
quotes the history of two cases in which he performed the operation
with favorable outcome for both mother and child.

It is unfortunate for the subject in hand that these two patients
showed exactly what they did, for in the first one, while it is true
that the fetus presented by the breech, the patient in addition had
a submucous fibroid; this prevented the descent of the presenting
part and would have been just as great a bar to a fetus presenting
by the vertex. According to the measurements given, the pelvis
was large, the baby of moderate size {^"jy^ pounds), and the abdominal
hysterotomy in the last analysis was done, not for breech presenta-
tion, but for fibroid. The second case above referred to showed a
gi^-pound baby, and a pelvis with a true conjugate of 10 cm. with the

Mcpherson: delu'ery of breech presentation 779

external measurements very slightly contracted, and Williams takes
the ground that owing to the fact that the breech was not engaged
an abdominal Cesarean section was indicated, which he success-
fully performed. This argument presupposes that a gJ-^-pound breech
cannot be delivered through a pelvis which is practically normal, a
statement which the writer is strongly inclined to doubt.

Let it be understood that we are far from believing that there will
not occasionally be a patient, either multipara or primipara, in
whom there will be a disproportion between the size of the child and
the mother, in breech as well as in verte.x presentations, and in whom
an abdominal Cesarean section is indicated in order to save the life
of the child; nevertheless, there is a definite maternal mortality to
Cesarean section, even in the best and most conservative hands, of
from 2 to 4 per cent, which compares very unfavorably with 0.47
per cent., to say nothing of the danger of rupture of the uterine
scar in subsequent pregnancies, which Findley(4), in a recent article,
estimates as at least 2 per cent, and it is the writer's earnest belief
that at the present time too free a use of abdominal hysterotomy is
being advocated.

He is far from being overconservative in regard to this operation
as two papers previously presented before this association will
attest, but at the present time he is fully convinced that a careful
observance of the customary technic in delivery, interference when
progress is not satisfactory, noninterference when progress is cer-
tain, even if slow, postural treatment, waiting until the breech ap-
pears at the vulvar orifice before attempting to deliver, proper under-
standing of the technic of extraction of the arms and after-coming
head, particularly the latter, with regard to downward traction,
warm towels around the body of the child, and care and delibera-
tion with regard to the maternal soft parts, all as laid down in any
good text-book, will result in an even lower mortality for the child,
than at present, and in many more living mothers, than by what he is
forced to believe a too radical and rarely necessary operation, namely,
abdominal Cesarean section for the condition under consideration.

references.

1. Williams, J. T. Interstate Medical Journal, Apr., 1915, p. 384,
et seq.

2. De Normandie. Surgery, Gynecology and Obstetrics, 1908, vol.
vi, p. 401.

3. WiUiams, J. T. Interstate Medical Journal, Apr., 1915, p. 384,
et scq.

4. Findley. Amer. Jour, of Obst., Sept., 1916, p. 428.
20 West FiFTrEXH Street.

780 frank: cystocele and prol.^psus uteri

THE INTERPOSITION OPERATION OF WATKINS-

WERTHEIM. IN THE TREAT:MENT OF

CYSTOCELE AND PROLAPSUS

UTERI.*

LOUIS FRANK, M. D., F. A. C. S,

Louisville. Ky.

One bane of those who do any gynecological surgery has been
the patient with a large cystocele and a descensus uteri or an hyper-
trophic elongation of the cervix. Learning my lesson early in my
experience with this class of cases, I had for a long time felt very
loath indeed to urge such cases to operation by any of the procedures
which I was then following. I could not bring myself during this
period to the point of promising my patients any reUef.

In the mild cases of sUght cystocele with descensus, the operation
of Stoltz, Emmett, and of Martin, with an accompanying perineor-
rhaphy, sufficed in most instances to give relief, but in the more severe
cases we soon learned that these operations did not at all answer the
purpose. Nor in this latter type of case did the operations origi-
nated by Gilliam and others before him, which shortened the round
Ugaments, suspended or fixed the uterus by one or the other of the
various methods in use, improve conditions one whit. In spite of
these additional operations, the cystocele and descensus always
returned.

I tried many years ago, as the result of my failures, to overcome
the cystocele by transplantation of the bladder high up on the uterus
working through an abdominal incision. I was not successful be-
cause I could not hold the uterus up, and I had not the ingenuity
to devise, through the abdominal incision, any method which would
interpose the uterus between the bladder and vagina as is done in
the method under discussion. Five years ago, when in spite of my
skepticism but forced by my poor results, I undertook, upon some of
my patients, the operation devised by Dr. Watkins, I was astounded
at the brilliant cures I obtained. Since that time we have done about
an average of twenty to twenty-fi\'e of these cases every year, hav-
ing done twenty-two of them within the current year, and in our

*Read before the Twenty-ninth Annual Meeting of the .\merican Associa-
tion of Obstetricians and Gynecologists at Indianapolis, October, 1916.

frank: cystocele and prolapsus uteri 781

series we have not had a single complete failure, though there is one
patient who still has some shght disturbance. Probably in this
individual case a different operation should have been done.

This latter case was in a woman some eight or ten years past the
menopause, with a very small uterus, and I believed at the time that
the procedure devised and advocated by Mayo under such circum-
stances should probably have been done. As it is, this patient now
has a very shght bulging of the bladder, just enough to prevent its
complete evacuation and to maintain a shght cystocele, she having
had previous to her operation a most marked and troublesome in-
fection of the bladder due to urinary retention and decomposition.
With this, and one other exception, we have had only the most
gratifying results in our practice, and we have been able to follow
every one of our private cases.

On account of imperfect indexing and tabulation in our early cases
we are not able to give our exact number, but I am sure that the
figures given above do not exaggerate the number. Some of our
operations have been done in our public hospital service and of these,
which is the second exception, there is one death to report which
resulted from a septic infection. Other than these two cases, we
have had no untoward results, and if we exclude occasioned super-
ficial stitch infections, there have been no complications nor dis-
turbances of any kind.

The difBculties in the surgical treatment of large cystocele with
prolapse are evidenced by the great number of procedures that have
been advised and practised for the rectification of this condition.
I think that previous to the development and perfection of the Wat-
kins-Wertheim operation, as I have said before, there was no method
of which I have cognizance to deal successfully with these unfor-
tunate patients. I have been astonished that so little notice has
been taken of this most valuable addition to our planned operations
b}^ the various text-books, and that this method has been so neglected
by the teaching staff over the country.

I was very much surprised in going over Dr. Watkins' writings to
find that he had been doing this operation for such a long time, and
that it was given to the profession as early as 1898. This, of course,
does not speak well for my study of the hterature, but be that as it
may, it had escaped my notice until within recent years. It may be
that I had practised so many of the different and nurnerous methods
which had been devised and approved, with such uniformly bad
results, that I did not attach sufficient' importance to Dr. Watkins'
publication, and that it did not impress me deeply enough.

782 frank: cystocele and prolapsus uteri

I feel that we probably have had an imperfect understanding of
the nature and extent of the anatomical defects and structural changes
which have existed, and that we have also failed to appreciate the
changes in anatomical relationship and the advantages incident
thereto which are brought about by this operation. We have at-
tempted to cure a true hernia of the bladder by simply infolding it
and covering it over with mucous membranes. Any plan based
upon the same principles would be ridiculed if applied to hernia of the
gut through any of the potential canals in the body. We have also
failed to vary our plan of relief in the individual case and have ap-
pUed (and still do I think) the same method to practically every
case. We must certainly do as Watkins and Mayo have done and
group these cases in at least three different classes, modifying our
plan in each class. In the child-bearing woman the modification
suggested by the originator of the operation has given the best
results in my own hands, though we have varied this somewhat by
making a lower bladder attachment to the fundus of the uterus
and attached the vagina to a lower point upon the anterior wall of
the uterus.

In the elderly woman, with the very small atrophic uterus, we
believe-that the plan suggested by Mayo, which we have carried out
a number of times, is the one to be preferred. With the small uterus
removed, the broad and round ligaments form a magnificent floor
for the bladder, and if the superior portion of the broad ligaments
be then sutured to the most anterior point of the vagina and this
line of suturing followed down to the base of the ligaments, including
the round ligaments in this suture, we have not only an excellent
and very superior support for the bladder but also a strong hgamen-
tous support for the vagina itself. The subsequent recurrence of a
cystocele, or the subsequent occurrence of an intestinal hernia
through the vagina with a coincident prolapse or inversion of the
vagina, is neither to be anticipated nor to be feared. We have
seen a number of cases where hysterectomy has been done for the
cure of cystocele with prolapse, the broad ligaments having been
sutured merely into the vault of the vagina and in each one that we
have seen there has been not only no improvement of the cystocele
but a much worse complication. In the presence of such recurrent
conditions it is often a most difBcult matter to give these individuals
relief by any subsequent operations. Hysterectomy alone without
proper vaginoplasties never cured a prolapsus or cystocele, but, on
the contrary, as indicated, only makes bad matters worse.

frank: cystocele and prol.u>sus uteri 783

The technic of the operation is doubtless familiar to the Fellows,
but to make the paper complete we offer the following very brief
description as laid down by the originator of the method.

The patient is prepared in the usual manner, and after being anes-
thetized (nitrous oxide gas and oxygen) is placed in the lithotomy
position. The anterior cervical lip is grasped with volsellum for-
ceps, the anterior vaginal wall separated from uterus through a
semilunar incision circumscribing the anterior cervix. The anterior
vaginal wall from the cervix to within an inch of the meatus urina-
rius is then incised in the median hne, care being taken to avoid
injuring the bladder. With scissors or by blunt gauze dissection the
bladder is separated from the vagina extending well out laterally
so as to free the entire cystocele, now the uterovesical fold of peri-
toneum easily recognized as a freely movable layer between the
bladder and uterine body, is opened. The peritoneum may be
perforated with the finger or grasped with forceps and incised, the
opening then dilated sufficiently to permit delivery of the uterus.
The uterus is delivered into the vaginal canal by passing the iinger
over the fundus or broad ligament, or by grasping the fundus with
bullet forceps. The anterior wall of the uterus should not be grasped
and an attempted delivery through the peritoneal opening made as
the diameters of this segment are greater than the fundus and diffi-
culty will ensue. Delivery of the fundus first is easy and presents no
trouble. The uterus having been delivered, a suture is now intro-
duced through the vaginal flap near the urethra, then through the
uterine body behind the fundus and through the opposite flap at a
point corresponding to that of its introduction on the opposite side.
The fundus should be drawn sufficiently downward to support the
prolapsed bladder wall, but not to press upon the urethra and thus
interfere with micturition. This first suture is then tied and the
required number of others inserted parallel thereto. The remaining
portion of the wound is then closed. Where the cystocele is very
large some of the redundant vaginal flap may be excised.

The principles of the operation, as explained by Watkins, are:
(i) The bladder is supported by and rests upon the posterior wall of
the uterus. (2) The uterus is elevated in the pelvis by being tipped
forward, in fact, its position is changed about 180 degrees. The
twist in the broad ligaments produced by the changed position of the
uterus perceptibly shortens them. (3) The tendency for the uterus
and bladder to prolapse following the operation are antagonistic,
as any sagging of the bladder increases the anterior displacement of
the uterus, and any prolapse of the uterus elevates the bladder wall.

784 hirst: cesarean section

In the completed operation the bladder rests upon the posterior wall
of the uterus.

So far as can be ascertained, the only objections which have been
urged against the Watkins-Wertheim operation are: (i) Its employ-
ment is contraindicated, without certain modifications, during the
child-bearing period because of complications which might arise
during pregnancy and parturition. This objection, however, seems
unimportant since extensive uterine prolapse and cystocele usually
occur most frequently after the menopause. (2) The difficult
technic incident thereto. This objection also seems untenable as
the technic is not as difficult as that incident to other operations
sufficiently radical to offer permanent correction of extensive
prolapse.

Even in complete uterine prolapse, if the uterus be not seriously
diseased, a modified Watkins-Wertheim operation seems preferable
to hysterectomy, as the uterus affords ideal support for the prolapsed
bladder. "This modification is made by severing a portion of the
base of each broad Ugament from the cervix and by suture of the
free ends of the broad ligaments together in front of the cervix"
(Watkins).

In conclusion, we would urge a much wider adoption of this opera-
tion, and particularly by those of the Fellows of this Society who have
not as yet tried it, if there be such. We would also urge that some
effort be made to bring this most excellent procedure for the relief
of a most distressing condition to the attention of text-book
writers and thus have it placed more generally before the coming
generation of surgeons. In our opinion, this operation should be
upon just as firm and stable a foundation and should have the same
standing as the operation of Bassini for the radical cure of inguinal
hernia.

400 AtHERTON BmLDIXG.

CESAREAN SECTION AS THE OPERATION OF CHOICE IN
DIFFICULT LABOR CASES.

JOHN COOKE HIRST, M. D.,

Associate in Obstetrics, University of Pennsylvania, School of Medicine,
Philadelphia, Pa.

The modern tendency is constantly to widen the indications for
Cesarean section, as the technic of the operation has been improved
and its safety increased. It is no longer an operation reserved for
the impossible pelves or cases where the birth canal is blocked by

hirst: cesarean section 785

a tumor. One of the most important advances is its substitution
for the dangerous axis-traction forceps. It is not Justifiable to
attempt by main force to drag a child's head into a contracted pelvic
inlet; the dangers of this procedure to both mother and child should
forbid it. Cesarean section is preferable also in cases of breech
presentation, with a justominor pelvis or other type whose contrac-
tion averages 2 cm. or more, and where, because of the breech pre-
sentation, it is, of course, an impossibility to gage the size of the
head. In these patients, the head must come through the pelvis
unmolded and unflexed, adding to the dangers. A prolapsed cord
in a primipara, with partially dilated and partly effaced cervix,
should cause serious consideration of Cesarean section, as giving the
child a fair chance of survival. In placenta previa, especially in
primiparEe, the field for Cesarean is constantly widening. Premature
separation of a normally situated placenta, where the cervix is not
dilated or effaced, often demands Cesarean section for the mother's
safety, even though it be known that the child is dead.

These are the more important indications, other than impossible
disproportion between child and pelvis, or obstruction by a tumor,
and in all of them Cesarean section is certainly safer than an attempt
to drag a child hurriedly through a birth canal, unprepared for the
ordeal by the normal dilatation.

But to meet the different indications presented, more than one
technic is necessary. At least five different methods, excluding the
misnamed vaginal Cesarean section, are required. The five are
as follows: i. The old classical Cesarean, with the long incision
and eventration of the uterus before opening it. 2. The more
modern short incision, opening the uterus in situ, and then closing
the uterine wound outside the abdomen. 3. One of the many varie-
ties of extraperitoneal Cesarean section. 4. The Porro operation,
sewing over the uterine cervical stump and dropping it. 5. The
Porro operation, in which the stump is closed, and then marsupial-
ized by fixing extraperitoneally in the lower angle of the abdominal
wound and drained. These technics meet the indications presented,
in a way impossible if only one method of performing the operation
is used.

I. the old classical operation.

This is the easiest and hence the best for the occasional or ine.x-
perienced operator. It has certain grave disadvantages: i. The
greater likelihood of hernia, in the very long wound. 2. The
greater chance of adhesion of the uterine wound to the abdominal.

786 htrst: cesarean section

3. The greater chance of contamination of the peritoneal cavity,
especially after the uterus is emptied and while the uterine wound is
being closed.

It is one of the methods to be considered in a clean case, but is
not a safe method in a case where contamination is suspected due to
repeated examinations or futile attempts at delivery.

Technic. — i. The patient's skin is prepared as for any abdominal
operation and in addition, the vagina is cleansed and packed with
sterile gauze.

2. As soon as the operation is begun, the patient receives, by
hypodermic, 2 ampules of aseptic ergot, and i ampule of pituitrin.

3. A long incision is made, extending from haKway between the
umbilicus and xyphoid to near the symphysis, and the uterus
delivered outside the abdominal cavity.

4. Large gauze pads, with tapes attached, are packed behind, to
either side and in front of the uterus, to safeguard the peritoneal
cavity from contamination.

5. An assistant, with both hands outspread, compresses the
abdominal wall around the lower uterine segment. This is not to
control hemorrhage, but to prevent blood and liquor amnii entering
the peritoneal cavity. To compress the broad hgament to control
bleeding is a mistake, as it tends to favor subsequent relaxation.

6. The uterus is incised in the middle line, anteriorly. The
placenta, if exposed by the incision, is disregarded. The child is
seized by one leg and delivered. The cord is clamped in two places
and cut, the child being held meanwhile head downward. The
child is then handed to an assistant to be revived, if needed, and the
cord tied.

7. The placenta is delivered manually, and the membranes freed
by gentle traction.

8. The first layer of sutures is begun by inserting a curved needle,
threaded with a long strand No. 2 chromic catgut, through the
uterine wall above the wound and emerging in the upper angle of
the wound, just above the endometrium. The cut muscle is then
closed in two layers, by a continuous tier stitch, care being taken
not to penetrate the endometrium. When the upper angle of the
wound is reached, in the return, the needle penetrates the wall and
emerges above the wound, opposite the point of insertion; the stitch
is then tied. Thus no knot is buried in the wound.

9. The peritoneal covering of the uterus is closed, by a continuous
stitch of No. 2 chromic catgut, threaded on a straight needle, sewing
from above downward, and on returning the needle is inserted

hirst: cesarean section 787

between the insertions made on the downward trip. This stitch
also is tied above the uterine wound, the complete stitch appearing
like a laced-up shoe.

10. The uterus is returned to the abdominal cavity; any clots
are sponged out of the peritoneum (usually only a small amount,
if any, near the bladder), and the abdominal wound closed and
dressed in the ordinary way.

2. THE SAENGER OPERATION )A7TH THE SHORT HIGH INCISION.

This is the best operation for the unquestionably clean case;
especially for operations of election.

It has the very great advantage of preventing the coincidence of
the uterine and abdominal wounds, and therefore minimizing the
dangers of adhesions. The short wound is much less likely to be
the site of a hernia. It is slightly more difficult than the old classical
operation. The only contraindication to it in a clean case would
be a case of placenta previa, where it was vital to prevent all possible
loss of blood during the operation, as here the broad hgament cannot
be compressed while the uterus is being opened as in the case of the
long incision. Otherwise it is by all odds the best operation for the
clean case.

Technic. — i. The patient's abdomen and vagina are prepared as
previously described, and the same dose of ergot and pituitrin is
given when the operation is begun.

2. A short central incision is made, one-third above and two-
thirds below the umbilicus, just long enough to permit the delivery
of the head.

3. An assistant compresses the abdominal walls around the uterus,
in situ, making greater pressure from the patient's right toward
her left side. This is to overcome the normal lateral torsion of the
uterus, and if it is not done, the uterine incision will be too near the
left broad hgament, with considerably more hemorrhage.

4. The uterus is incised and the child delivered and treated as
previously described.

5. As the head is being delivered, the assistant hooks his fore-
finger in the upper angle of the uterine wound, and pulls the uterus
out of the abdomen, and then packs o5 with gauze behind and to
either side.

6. The placenta and membranes are then delivered as pre\'iously
described.

7. The uterine wound is closed exactly as in the previous operation,

788 hirst: cesarean section

the uterus returned to the peritoneal cavity, and all clots sponged out.
8. The abdominal wound is closed and dressed as usual.

3. THE EXTRAPERITONEAL CESAREAN SECTION.

It is well known that the chief danger of Cesarean section is the
risk of peritonitis in the case which has been repeatedly examined
and handled, before the operation is undertaken. The attempt to
avoid this risk led to many ways of doing the operation extraperi-
toneally. Some twenty-five different methods have so far been
devised. None of them are really extraperitoneal, if by this be
meant that it is not possible for contamination of the peritoneum
to occur during or after the operation. Most, if not all, however,
reduce this danger to a minimum, and this is the most that can be
claimed for them.

The ideal indication for the operation is the case which has been
in labor for a considerable time, whose lower uterine segment is
therefore well thinned out; who has been repeatedly examined; whose
child is in good condition but who is not obviously infected; one
whose previous aseptic management is open to suspicion, but not
one where infection is a practical certainty.

It has certain disadvantages, i. It is the most difficult technic-
ally, of all the Cesareans. 2. It is not to be attempted before
the patient is in labor, as the lower uterine segment is not thinned
out. 3. Above all, it is not the operation for placenta previa.
This because of the excessive bleeding.

These objections apply more or less to all the methods of extra-
peritoneal Cesarean, but particularly to the one whose technic is
here described.

Technic. — i. The patient's abdomen and vaginal canal are pre-
pared as previously described, and the doses of ergot and pituitrin
given.

2. A central incision is made, from 2 inches below the umbilicus
to the symphysis.

3. The peritoneum of the lower uterine segment is split in the
middle line and dissected down behind the bladder.

4. The parietal and visceral layers of peritoneum arc then clamped
or sewed together. The former is quicker, easier and satisfactory.
This leaves an oval space of raw uterine muscle exposed.

5. A broad bladed retractor is then placed behind the bladderin
the lower angle of the wound.

6. The lower uterine segment is opened in the middle line, and
the child's head delivered through the wound, with forceps. During

hirst: cesarean section 789

the delivery of the head, the retractor is removed, as its presence
increases the risk of a tear of the bladder. A breech presentation
makes this step of the operation considerably easier.

7. The child is treated as in the previous operations.

8. The placenta is extracted manually, with its membranes.

9. The wound in the lower uterine segment is then closed with a
two-tier continuous stitch of No. 2 chromic catgut. This stitch
is a little more difficult of insertion than in the previous operations,
but the difficulty is fairly easy to overcome.

10. The hemostats or stitches holding the two layers of peritoneum
together are removed, and the peritoneum of the lower uterine seg-
ment sewed back where it belongs, over the uterine wound. No. 2
chromic gut is used.

11. The peritoneum is cleansed, and the abdominal wound closed
as usual.

Due to the suture line in the lower uterine segment, which pre-
vents it from collapsing as it does after normal labor, the fundus for
a few days after labor is held up rather high. This is only for a
short time and the rate of involution proceeds normally thereafter.
The uterine and abdominal wounds coincide for a small part of their
extent only, and adhesions are unlikely.

During the whole operation, none of the abdominal organs except
the uterus are visible, and the smoothness of the convalescence of
these cases will surprise one who sees it for the first time. It is
like that of a normal labor case. The field of the operation is limited,
but in its field it is a very useful procedure.

4. THE PORRO OPERATION, 'mTH DROPPED STUMP.

This is the operation for clean cases complicated by fibroid tumor
or other complication making the removal of the uterus desirable,
but not in a case where infection is suspected. It is also not a
method for sterilization of the patient where such a procedure is
justifiable.

Technic. — i. Up to the point where the uterus would ordinarily
be closed, the technic is precisely the same as in the first method
described.

2. The edges of the uterine wound are clamped together and the
uterus removed by clamping both broad ligaments, cutting down
to the uterine arteries; clamping and cutting them; separating the
bladder anteriorly and amputating the uterus below the internal
OS. All this precisely the same as the ordinary supravaginal
hysterectomy, comphcated by considerably more bleeding.

790 hirst: cesarean section

3. The cervical stump is tightly closed over the cervical canal,
using both interrupted and continuous No. 2 chromic catgut, as it
is \'ital to prevent leakage. This step of the operation is done as
soon as the uterus is removed.

4. The broad ligaments and uterine arteries are next tied, and the
peritoneum closed over the stump, across the pelvis.

5. The abdomen is then closed as usual.

This is not a frequently needed operation. Five per cent, of
Cesareans would be a liberal estimate of the need for it.

5. THE PORRO OPERATION WITH MARSUPIALIZATION AND EXTRA-
PERITONEAL FDCVTION AND DRAINAGE OF THE CER\TCC.A.L

STUMP.

This is also an operation of limited field. Its two chief indications
are: i. A case undoubtedly infected before operation, but in whom
craniotomy is not to be considered, on account of the child's con-
dition. 2. Ruptured uterus.

Technic. — This is precisely the same as in the operation imme-
diately preceding, except that when the stump has been carefully
closed, it is brought up in the lower angle of the abdominal wound.
The parietal peritoneum of the wound is then sewed around it in
such a way as to prevent communication with the general peritoneal
cavity. The abdominal wound is then closed, except for the pouch
at the lower angle, at the bottom of which is the cervical stump.
This pouch is packed with gauze and drained and allowed to close
by granulation.

This operation is rarely needed, but when indicated it gives the
patient a greatly increased chance of recovery.

In all these methods, the vaginal packing is removed at the close
of the operation, or at most after six hours.

When it is desired to sterihze a patient, it is best done by the
excision of the tubes at the uterine cornua, the removal of the inner
inch of the tube, and the closure of the cornua, bringing the stump
of the tube between the layers of the broad ligament. Mere ligation
of the tubes is not sufficient.

All Cesarean sections, whose recovery has been uncomplicated,
can sit up after the fourteenth day.

COMPLICATIONS DURING AND AFTER OPERATION.

T. Hemorrhage. — The bleeding during the operation is usually
no more than after a normal labor. If it seems excessive, it should
be remembered that the greatest possible irritation of the uterine

hirst: cesarean section 791

muscle is the insertion of the necessary sutures. The suturing
should therefore be begun without delay. In emergency, the bleed-
ing can be controlled by compression of the broad ligaments, but
this is rarely needed.

Postpartum hemorrhage is not greatly to be feared; the only cases
in the series on which these conclusions are based were three in
which no hypodermics of ergot were used. In all three of these, the
bleeding was controlled by uterine packing. I should not hesitate
to pack or irrigate a uterus sewed up as herein described.

2. Infection. — This is the most serious complication, as it nearly
always takes the form of peritonitis. The danger can be minim-
ized by careful selection of the type of operation performed, and
should peritonitis develop, the Fowler position, stimulation and
drainage are our only means of combating it.

3. Distention. — It is not uncommon to see considerable abdominal
distention after a Cesarean section. Peristalsis is active but the
condition requires energetic treatment, not so much on account of
any danger, but of the extreme discomfort. Hvpodermic of eserin
salicylate gr. }4^q, strychnin sulph. gr. }^q every four hours;
Hypodermic of J^ ampule of pituitrin twice daily; high enema of
alum oz. I to the quart; the rectal tube left in place several hours
at a time; and, if there is much gastric tympany, lavage. This
routine will correct the trouble within forty-eight hours as a rule.

4. Fever. — Especially in primipara:, there may be a rise of tem-
perature to 102 or over about the fourth or fifth day, accompanied
by some foul odor to the lochia. This is due to a lack of vaginal
drainage, and usually not to any retention of clots in the uterus.
A daily vaginal douche of sterile water is all that is required. I
would not hesitate to irrigate the uterus in these cases, if it should
be required, but it is very rarely necessary.

5. Stimulation is given, when needed, by hypodermics of digitalin
gr. J'foi strychnin sulph. gr. J^o, camphorated oil in emergencies,
but not intravenous injection of salt solution unless the need for
stimulation has been caused by loss of blood. Simple postoperative
shock will react better without the intravenous.

Preparation. — In cases of elective operation, the abdominal skin
is as carefully prepared as for any other section. Most of the cases
are emergencies, however, and a satisfactory skin preparation is
thoroughly to shave, and then cover the abdominal skin with a thick
poultice of tincture of green soap, held on by a binder. This is
left on until the patient is on the table, then removed and the skin
further cleansed with alcohol and covered with rubber dam, through

792 hirst: cesarean section

which latter the skin incision is made. The dam answers the same
purpose as the surgeons gloves: If one skin is covered, why leave
the other exposed?

Anesthetic. — Should not be gas. Ether or chloroform are prefer-
able. The gas is dangerous to the child. The operation can be
done under local anesthesia, but this is undesirable. So little time
is needed for the operation, that the short anesthetic period is
without risk.

Child. — It is always advisable to have a trained assistant to con-
duct the revival of the baby. These babies often show the effects
of the anesthetic to the mother and require considerable attention.
Particularly is this true when previous attempts at delivery have
been made, with extra periods of anesthesia and possible injury to
the child. It is common to see these babies born in asphyxia hvida,
and they require careful handling. The operation by no means
guarantees safety for the chUd, when all these factors are taken into
consideration.

Results. — The conclusions reached are based upon the writers
personal experience of ii8 operations with three maternal deaths,
a mortality of 2.54 per cent. The series is consecutive and un-
selected, all done by one of the methods detailed above. One mother
died of peritonitis, due to infection probably at the time of opera-
tion; one of peritonitis due to premature absorption of catgut and
leakage from the uterine wound; and one from hemorrhage, not
uterine in origin, but from a ruptured varicose vein in the broad
ligament. This was proven by reopening the wound after death.
My records of the child mortaUty are unfortunately not complete.
I have the records of fourteen, and it must be remembered that in
many of these patients previous and often violent methods of dehvery
had been attempted. Cesarean section done as a last resort, after
attempts at delivery, will always be' attended by a fairly high fetal
mortality, but for the mother is infinitel}' better than violent de-
livery, not only in its immediate dangers, but in its effect upon the
mother's future health.

1823 Pine Street.

saliba: a case of scoliorachitic pelvis 793

CESAREAN SECTION IN A CASE OF SCOLIORACHITIC
PELVIS.

BY
JOHN SALIBA, B. A., M. D., C. M.,

Surgeon to the Elizabeth Citv Hospital,
Elizabeth City, N. C.

(With illustrations.)

At the present time we have no absolutely perfect classification
of the different kinds of abnormal pelves. While some follow
Tarnier and Budin's classification and others follow that of Schauta,
I, from a practical point of view, generally follow the convenient and
satisfactory grouping of the kinds of abnormal pelves into the follow-
ing classes:

(i) Pelves increased equally in all the measurements, justomajor.

(2) Pelves decreased equally in all the measurements, justominor.

(3) Pelves flattened from before backward.

(4) Pelves flattened from side to side.

(5) Pelves irregularly distorted.

The following case comes under the fifth class. It is an irregularly
distorted, a scoliorachitic pelvis. I am induced to report it because
of its rare and special features.

Case Report. — B. D., colored woman, single, aged twenty-four,
household worker, entered the hospital April 22, 1915, at 11.45
P.M., complaining of difiicult first labor at full term and of twenty
hours, duration. On the morning of April 22, 1915, she felt pains in
the abdomen and noticed a blood-stained mucous discharge at
vulva. At 9 P.M. on the same day, a midwife was called who after
making repeated vaginal examinations sent for doctors G. W. Card-
well^and H. D. Walker who, after making also vaginal examinations,
ordered the'patient's removal to hospital.

Family History. — Her father and mother are dead, cause of death
unknown ;|they were of normal size and had no deformities; she
has no brothers or sisters and lives with an aunt.

Fast History. — She was a bottle-fed baby; suffered from rickets
as a child; and was not able to walk until she was seven years old.
Her menstruation began at the age of twelve years. It was regular
of the twenty-eight-day type. The day before each menstrual flow
she felt heavy weight in the pelvis and pain in the back and had a
slight palejdischarge. The bright red discharge lasted for one day
only and confined her to bed owing to the pains. On the following
day both 'the discharge and pain ceased, she felt well and was able
to resume her work. The total quantity of loss was approxi-

794

saliba: a case of scoliorachitic pelvis

mately 4 ounces. She had no intermenstrual discharge. She had no
previous pregnancies. About the middle of July, 1914, she noticed
the cessation of menstruation; during the following September she
had nausea, morning sickness, frequent micturition, and her breasts
began to get larger; and during November she noticed a swelling of
her abdomen. She felt no quickening and although she knew she was
pregnant, she kept it to herself until labor had begun.

Physical Examination. — The photographs, although taken during
convalescence as I had not the facilities to take them at midnight, the

time of admission, will clearly show her general appearance and
configuration to be abnormal. Her height was 3 feet and 8 inches;
her weight 72 pounds; and her measurements round the chest
at the level of the most prominent point of the dorsal curve 3
feet, and round the abdomen at the level of the umbilicus
3 feet and 10 inches. On inspection the following anomalies
were observed from below upward: flat feet; bent and distorted
legs; curved thighs; shortening of the left leg; marked obliquity of
the pelvis; twisting of the sacrum; the left lumbar region more
prominent posteriorly; the right ilium unduly prominent anteriorly;
displacement of the body to the right; asymmetry in the side of the
back and great difference in the size and shape of the two halves of

saliba: a case of scoliorachitic pelvis 795

the thorax caused by the severe double lateral curvature of the spine,
right dorsal scoliosis and left lumbar scoliosis; the spines and bodies
of the vertebrae were markedly rotated, the rotation being toward the
convexity of the lateral curvature; the dorsal and lumbar concavities
were flat; the last right rib overrode the right iliac crest; the left
iliac crest overrode the last left rib; bulging of the right ribs and
prominence of the right chest; the right shoulder blade, on the
convex side of the dorsal curve, raised by the underlying ribs, was
more prominent and further removed from the median line of the
back; the left shoulder blade, on the concave side of the dorsal
curve was nearer to the vertebral spines; elevation of right shoulder;
left shoulder drop; and hanging of the right arm further from the
side than the left.

In consequence of these curvatures the bodies of the vertebrae were
thinner on the concave side and thicker upon the convex side, the
discs had suffered a similar change and had undergone partial atro-
phy from continued pressure, and the ligaments and muscles of the
spine were longer on the convex side and shorter on the concave
side. A rontgenogram taken by Dr. I. Fearing, radiographist
to the hospital, illustrates most of the above-mentioned extensive
abnormalities.

The patient's head was not large and there were no nodular promi-
nences on the chest, rachitic rosary. Milky fluid escaped from the
breasts on squeezing.

Inspection of Abdomen. — The umbilicus was flattened out and the
abdomen pendulous and fallen forward.

Palpation of Abdomen. — The parts of the child were felt and its lie
discovered. It was left occipitoanterior and this in spite of the
mechanical conditions present which favored the occurrence of
abnormal positions of the fetus. The head was not engaged in the
brim and consequently great mobility and overriding were observed.
No uterine contractions were felt.

On auscultation the fetal heart was heard on the left side a little
below the level of the umbilicus. Having learned that the mem-
branes had ruptured I did not make a vaginal examination.

There was no hypertrophy or dilatation of the heart. The lungs
were compressed, especially the right. The liver and other abdom-
inal organs were displaced. The general symptoms which usually
accompany such a severe grade of scoliosis were absent: the general
health of the patient was not impaired; her digestion was good; she
had no shortness of breath and suffered no pulmonary disease; and
she never had any thoracic or abdominal pains to indicate any com-
pression or irritation of the intercostal nerves.

From the observation of these physical signs I became aware of
the presence of pelvic deformity and proceeded to take the pelvic
measurements.

Diameters of the Superior Strait. — ^The anteroposterior, or true
conjugate, 5 cm., the transverse 9 cm., from right sacroiliac syn-
chondrosis to left iliopectineal eminence 7.5 cm., from left sacroiliac
synchondrosis to right iliopectineal eminence 9 cm. Knowing that
in the determination of the internal measurements we have no

796 saliba: a case of scoliorachitic pelvis

method that can claim to give perfectly accurate results I had these
measurements made three times with Skutch's pelvimeter, twice by
Dr. W. A. Peters and once by myself and where these three measure-
ments were found not to be nearly identical I took the average.

Diameters of the Inferior Strait. — Anteroposterior, from the lower
margin of the symphysis pubis to the tip of coccyx, 10.5 cm., trans-
verse, between the inner margins of the ischial tuberosities, 11 cm.
The following further diameters were measured and found to be:
the diagonal conjugate 6.5 cm., the external conjugate 13 cm.,
the interspinous 22.2 cm., the intercristal 19.5 cm., the intertro-
chanter 29.5 cm., the interischial spines 9 cm., from the left ante-
rior superior spine to the right posterior superior spine 16.5 cm.,
from the right anterior superior spine to the left posterior superior
spine 19.5 cm., from the spine of the last lumbar vertebra to the
right anterior superior spine 15 cm., to the left anterior superior
spine 14.5 cm., to the right posterior superior spine 3.5 cm., and
to the left posterior superior spine 4.3 cm., from the left tuberosity
of the ischium to the right posterior superior spine 19.5 cm.,
from the right tuberosity of the ischium to the left posterior superior
spine 17 cm.; from the top of the sacrum to the right ischial tuber-
osity 15 cm. and to the left ischial tuberosity 16 cm., from the
right trochanter to the left posterior superior spine 21.5 cm., from
the left trochanter to the right posterior superior spine 20 cm., from
the lower margin of the symphysis pubis to the right posterior
superior spine 16 cm., and to the left posterior superior spine 16.8
cm. There was a slight deviation to the right of the symphysis
pubis from the promontory of the sacrum about i cm. in extent.
The tuberosities of the ischii were directed outward; the subpubic
angle widened; and the left sacroiliac articulation ankylosed (as
seen from the rontgenogram).

Diagnosis. — Dystocia due to scoliorachitic pelvis.

Diferential Diagnosis. — (i) In pseudoosteomalacic pelvis, which
is due to rickets, the triradiate pelvis, caused by the pushing in of
the acetabula and consequent approaching of the sacrum and lateral
walls to one another, is much commoner. (2) In rachitic dwarf if
the deformities were straightened the stature would still fall far below
the normal height. This patient although of very short stature,
3 feet and 8 inches, yet were her deformities straightened she
would not fall below the average normal height. (3) In Naegele's
pelvis as well as in this case, which is also obliquely contracted but
not to such a degree as Naegele's, we find the following conditions:
The existence of scoliosis; the variation in the height of hips and
the distance between the spine of the last lumbar vertebra and the
posterior superior spine on either side; synostosis between the
sacrum and ilium on the affected side; rotation and displacement of
sacrum toward the diseased side; displacement of the symphysis
pubis toward the sound side; straightening of the ileopectineal line
on the afifected side; and shortening of the oblique diameter starting
from the sound side, and of the transverse diameter. The diminu-
tion in the breadth of the innominate bone and the width of the
sacrosciatic notch on the affected side was very slight in this case.

saliba: a case or scoliorachitic pelvis 797

In Naegele's pelvis the true conjugate is usually unaltered and the
tuber ischii are directed inward. In scoliorachitic pelvis the true
conjugate diameter is shortened and the tuber ischii are directed
outward. (4) In rachitic flattened pelvis the transverse diameter
shows rather an increase in size than diminution and the ileopectineal
lines an increase in the curve. In a purely rachitic pelvis the abnor-
mahty is a flattening from before backward. In scoliorachitic pelvis
besides the anteroposterior flattening we observe obhque contraction
because the characteristic pelvic changes due to the anomaly of the
vertebral column are superadded to those resulting from rachitis.

Treatment. — As spontaneous version or forceps deUvery was impos-
sible and extraction by perforation, cephalotripsy and cleidotomy,
even if possible, was unjustifiable owing to the child being viable,
and pubiotomy or symphysiotomy was precluded because of its
uselessness in a pelvis contracted to this degree, true conjugate 5
cm., Cesarean section was the operation absolutely indicated. In
deciding upon the method of performing Cesarean section I did not
consider Frank's method because the extraperitoneal incision exposes
a large area of connective tissue whose resisting power to infection is
inferior to that of the peritoneum; and as it is frequently necessary
to tear through the peritoneum this method becomes deprived of its
supposed advantages.

Further I chose the classic in preference to the abdominal-cervical
Cesarean section for the following reasons: (i) In my past experience
of the classic method I have been so fortunate not to meet with the
dangers and comphcations described by Sellheim: maternal, infec-
tion of peritoneal cavity and culture collection in it from the blood
and amniotic fluid discharge; severe hemorrhage; injury to the
intestines; formation of adhesions and fixation of uterus; stretching
of scar; and abdominal hernia. Fetal, the asphyxiation of the child
from the manipulation of the uterus. (2) The disadvantages of the
abdominal-cervical Cesarean section rather discouraged me. These
disadvantages are described by Montgomery as follows: "First, a
diflacult and uncertain technic which involves the transverse as
well as the extraperitoneal incisions; second, the difficult delivery
of the child with the danger of extended tearing of the incision;
third, the position of the scar in the thinnest part of the uterus
with consequent danger in recurring pregnancies; fourth, danger of
cervical fixation in the pelvis favoring retroversion, retro-
flexion."

This choice of the classic Cesarean operation I made in spite of
the late admission, the rupture of the membranes, and the probability
of infection owing to the repeated vaginal examinations made by
the two doctors and by a midwife of doubtful cleanliness.

Preparation oj Patient. — There v/as no time to give the patient
a warm ^ bath. An enema was given to empty the bowels; the
bladder was emptied by a catheter; the pubis shaved; and the ex-
ternal genitals cleansed. The vagina was douched with i gallon
of^creoline solution, and care was taken not to force the fluid into
the vagina under pressure and carry contamination from the vagina
into the uterus. On the operating-table the whole surface of the

798 saliba: a case of scoliorachitic pelvis

abdominal skin was painted with tincture of iodine, 2)^^ per cent.
strength.

Operation. — The ordinary abdominal incision in the median line
was made. It was 6 inches long and extended downward to a
point 2 inches above the pubis. The layers of the abdominal
wall were noticed to be thin. The peritoneum was cautiously
picked up and opened near the umbOicus and using the index and
middle finger of my left hand as director, I divided it to the length
of the skin incision. The pregnant uterus presented itself and no
intestines were found lying in front of it. By pressing the abdominal
wall on each side of the incision downward and backward the uterus
was brought out of the wound. The intestines were pushed up
toward the diaphragm and kept back by a sponge of plain sterile
gauze wrung out in warm sterile salt solution. The skin incision
was clipped with forceps round the lowest part of the protruded
uterus and covered by a large sterile towel upon which the uterus
rested. A sterile sheet with a 6-inch longitudinal slit cut in it
was spread over the uterus. Through this slit I rapidly made in
the middle line of the uterus, as it lay in a straight line with the
skin wound, an incision 6 inches long. There was no escape of
amniotic fluid and no free flow of blood to make it necessary for
the assistant to pass his hands through the abdominal wall into
the pelvis and compress the broad ligaments against the lower
uterine segment. As soon as the incision was made I plunged my
hand into the uterine cavity, caught a knee, extracted the child;
clamped and cut the cord, handed the child to the nurse and peeled
off the placenta and membranes. The placenta was found lying
posteriorly and the cervLx sufficiently open to allow of vaginal
drainage. The extracted child was a living female, well nourished,
and weighed 8 pounds. Immediately after the extraction the
patient was given i c.c. of pituitary extract hypodermatically. In
sewing up the uterus, which contracted as soon as it was emptied,
I used No. 3 silk. The sutures were interrupted, half an inch apart,
passed deeply through the uterine wall excepting the decidual mem-
brane, were not tied until all were in position, and were cut short
These sutures were buried by a continuous seroserous suture.

I then removed the sterile sheet which covered the uterus and
the sterile towel which covered the abdominal incision; undipped
the abdominal wound; allowed the uterus to fall back into the
abdomen; withdrew the sponge of gauze which served to keep back
the intestines toward the diaphragm; and closed the abdominal
wall in three layers.

As I do not advocate the surgeon's right to sterilize a patient to
avoid the possibility of future conception I made no attempt at
such an operation, especially as the patient's consent was not given.

On the tenth day after operation the wound was inspected and
found to have healed and the stitches removed. The patient was
kept in bed for three weeks and was discharged on May 20, 1915.

WELZ: ASPHYXIA P.ALLIDA 799

ASPHYXIA PALLIDA, RESLTTING FROM EARLY SEPARA-
TION OF LOWER TWO OF FOUR PLACENTAE.

BY
W. E. WELZ, M. D.

Detroit, Mich.

(With one illustration.)

Shortly before i.oo p. m. Apr. 17, 1916, I was called to see Mrs.
A. B., who was in labor at Providence Hospital. The patient was
a primipara, twenty-one years of age, whose family and personal his-
tory were of no interest to the case. Menstruation had been normal
and regular until her last period which began July 15, 191 5.

Pregnancy had taken a normal course, except for a shght trace
of albumin, until early in the morning of April 17 th when blood began
to appear from the vagina. About 10.00 A. M. pains were coming
at fifteen-minute intervals and hemorrhage increased. Clots were
expelled at frequent intervals with the uterine contractions. Dr.
Arthur Northrup sent her to the hospital where I first saw her.

Patient was very pale and had an anxious expression. Pulse was
120 and weak, temperature 98, respiration 24. No fetal sounds were
to be heard and patient said she had felt no movements since enter-
ing the hospital. The uterus was oval, lacked tone, felt rather boggy
and was the size of a nine months' pregnancy. The fetus lay in the
right occipitoanterior position with the head unengaged. The ex-
ternal pelvic measurements were normal.

Internal examination revealed a normal-sized pelvis, medium-
sized vagina filled with clotted blood, the cervix thinned out, the
external os 4 cm. dilatation, membranes intact, no placental tissue
to be felt.

Diagnosis of premature separation of a normally situated placenta
was made.

At 1.30 p. M. dilatation was completed manually under ether anes-
thesia. The membranes were ruptured and a bipolar podalic ver-
sion was performed, the right hand bringing down the left leg. An
easy extraction completed the birth of a premature fetus weighing
2100 grams, 47 cm. long. The fetus was in the condition of asphyxia
pallida from which it was resuscitated in about twenty minutes
with the aid of a lungmotor.

On account of hemorrhage and the anemic condition of the patient
an immediate expression of the placenta was attempted. As it was
still fast, a Crede expression was performed. It was with difficulty
that placenta and membranes were dehvered by this method.

The after-birth consisted of four distinct placentas and membranes
which were traversed by numerous blood-vessels. The cord was
attached to the center of the largest placenta, which was almost
circular, 10 cm. in diameter and i cm. thick. About 5 cm. away at

800

WELZ: ASPHYXIA PALLIDA

the same level was the second largest placenta rather oval in shape,
8.5 by 6.5 cm. and i cm. thick. The uterine surfaces of these were
soft and normal. A little below the first placenta were the two
smaller placenta which were both circular, being 8 and 3 cm. diame-
ters and shghtly thinner than the other ones. The uterine sur-
faces of these two were hard and covered with clotted blood. A very
rich vascular circulation ran through the membranes, every inch of

Fig. I. — Multiple Placenta.

which contained one or more vessels. The placentae were normal
histologically.

The two larger placentae jvere evidently attached to the side of the
uterus below the fundus. The smaller ones were attached to the
lower uterine segment, but were not placentae previae. The uterine
contractions loosened the two lower ones as the lower uterine seg-
ment was dilated. The detachment of these produced the severe
hemorrhage from their sites of attachment to the uterus. After
this detachment, the two larger placenta; which continued in attach-
ment permitted sufficient aeration of fetal blood for several hours.

KENNEDY: PUERPER,\L INFECTION 801

But this placental attachment was insufficient for the oxygenation
of its blood, thereby causing asphyxia pallida in the fetus. The
fetus had not breathed in the uterus as there was no fluid or mucus
in the air passages. After proper aeration of its blood the fetus re-
covered, color returned and it was normal.

Resume. — The fetus had four placental attachments, two of which
were at the lower uterine segment. Uterine contractions separated
these causing a severe hemorrhage from the decidual surface as from
placenta previa. The oxygen-carrying capacity of the mother was
lessened from the loss of methemoglobin in the blood lost. The fetal
asphyxia, however, was mainly due to the decrease of active placen-
tal surface when the lower placentas were detached. It is remarkable
that the remaining placental surface, consisting of a Uttle over one-
half of the total was capable of oxygenating the fetal blood for about
four hours.

608 Mt. Elliott Avenue.

PUERPERAL INFECTION.*

BY
J. W. KENNEDY, M. D., F. A. C. S.,

Philadelphia, Pa.

I BELIEVE those operators who are the most familiar with this
variety of infection, look upon it with the greatest apprehension
and know that it is little under control of the surgeon.

When you find a condition which will not submit to amputation
surgery on account of the nature of its pathology, you may put it
down as almost axiomatic that the condition from the standpoint
of the surgeon is not satisfactory and this is most typically shown
in the puerperal infection.

I feel if the condition was discussed from the standpoint of wound
infection of the birth canal, we would have a better understanding
of the nature of its pathology, for wound infection of the birth canal
is what it is, no more, no less.

The treatment of puerperal infection is so unsatisfactory from
every standpoint, that were I asked to briefly discuss treatment I
should say, prophylaxis, and then continue my discussion by
attempting to teach hand-washing. I am constantly impressed
with the unpleasant fact that men know little indeed about rigid
personal toilet and do not live up to the antiseptic or aseptic chain
throughout their work.

* From the clinic of the Joseph Price Hospital.

802 KENNEDY: PUERPERAL INFECTION

The rubber glove is put on the unclean hand; the gloved hand is
quickly infected and not scrubbed. There is no doubt in my mind
but that the rubber glove has dulled the aseptic conscience of the
surgeon. It is all very well for the advocate of the rubber gloves
to say you cannot produce an aseptic hand, but operators take
Jjrivileges with the gloved hand which no thinking surgeon should
ever take. I know as far as my own experience goes, and it has
not been small, that 95 per cent, of the cases of puerperal infection
are unnecessary and due to some one's carelessness. The mortality
from this infection is frightful and very much higher than text-books
indicate, for the reason, that a great number of cases are reported
as recoveries from puerperal infection which should not be classed
as examples of wound infection of the birth canal which is truly
puerperal infection and shows its true nature through the evolution
of its pathology. A large number of patients are sent to hospitals
and operated for supposed puerperal infection, when in reality the
condition is due to a preexisting infection of the uterine appendages
of probable gonorrheal origin. I have seen many examples of tliis
mistaken pathology; the error comes from the fact that the infection
which had pre\aously existed had been lighted up incident to the
natural trauma of labor and on account of its coexistence, had been
diagnosed as puerperal infection. The pathology of puerperal
infection or wound infection of the birth canal is as different from
gonorrheal infection, as day differs from night. I am sure this is
no exaggeration.

The operator's mental picture should be just as well defined, or he
will go wrong in his operative expectancies.

Gonorrheal infection is a mucous membrane infection; it spreads
through extension of the mucous membrane and if it does extend
by the circulation to a certain organ, it destroys that viscus, yet
largely confines itself to that organ. Not so with puerperal infec-
tion, which is little an infection of the mucous membrane but a
wound infection, and extends through the medium of the circula-
tion, blood-vessels and lymphatics and has not the tendency to
remain an infection of any single organ, but is infiltrating in its
extension and this is the reason the condition is less surgical than
gonorrheal infection.

Puerperal infection is more truly a cellulitis, if the pathologist
will permit me to use such a term. I believe the patliology of gonor-
rheal and puerperal infection is so distinct that an operator should
be able to tell the difference blindfolded. Although we look upon
puerperal infection as a streptococcic one, yet it would probably be

KENNEDY: PUERPERAL INFECTION 803

impossible to obtain an isolated culture of such germ. It is truly
a'wound infection, which is a mixed infection. It is true, in those
cases of severe puerperal infection that the streptococcus may be
obtained from the blood and in abundance from the vaginal or uterine
discharge; yet, it is my opinion that the virulency of the condition
is most probably due to the fact that the streptococcus infection
does not have the tendency to remain as a local infection but early
becomes a true bacteremia and is an infiltrating infection which is
revealed by its pathological topography.

I speak of pathological topography because the surgeon must not
only have a mental picture of the abdominal topography of puerperal
infection, but he must know the nature of the route of the infection.

Is the mass which he discovers a removable one, can it be enu-
cleated, are there lines of cleavage which may be followed permitting
removal of the mass, or, is the mass composed of infiltrated, irre-
movable, important structures? This is what I mean by patho-
logical topography, and it is most important that the surgeon
knows the difference between the topography of gonorrheal infection
and that of puerperal infection.

I have seen some of the most disastrous mistakes because the
surgeon did not have just this mental picture; did not know the
possible or improbable lines of cleavage and was not familiar with
the fact that puerperal infection is not, in a sense, a pathological
entity permitting enucleation and removal. It has always seemed
to me, as operators we should confine our discussions to the work we
have to do; the manipulations which are necessary to accomphsh
the steps of the operation, the application of the surgery to the
probabihties and possibihties of the pathological condition; this is
our field and we will never be big enough to learn it all.

Let us permit the embryologist to write the embryology and the
bacteriologist to write the bacteriology and not fill our surgical
papers and discussions with branches of the profession which we
have recently reviewed, in order that we may say something which
seems ultra and about which we know nothing. Should we ever
review a subject in order that we may write a paper on that subject?
I have always felt one should not write unless he had lived for a
good length of time in the experience of his subject. You must
live your subject. Your papers and discussions will be rejected by
the popular opinion for a time, but right will prevail and you will
have your day. There must be individuality in your work or you
are only a parasite upon the profession. Do not take down six
text-books from the shelf and write the seventh therefrom. Do not
be one-seventh of the book you write.

804 KENNEDY: PUERPERAL INTECTION

In order to get the proper mental picture of puerperal infection,
we must go back to the nature of its etiology and the plan of its
communication to adjoining viscera. Puerperal infection being a
wound infection, is all the more probable that it should become a
blood-vessel and lymphatic infection, and that it should extend as a
cellular infiltration.

The patholog>' of puerperal infection becomes most apparent when
we realize that it is truly a retroperitoneal one; that it has not the
resisting powers of the peritoneum to limit and define the area
infected.

I fail to see why the streptococcus which is so uniformly found in
puerperal infection, should have any special mode of extension,
were it not that nature's barriers, the mucous membrane or the
endothelium of the peritoneum had been destroyed and the condi-
tion had its origin as a typical wound infection. Therefore, we must
start out with the mental picture that the condition is an infiltrat-
ing one, possibly not properly called a celluHtis, but this conveys
the topography of the condition, namely, that it is not a gonorrheal
infection (a mucous membrane lesion), that it does not confine its
infiltrating infection to a single viscus, its extent of involvement is
little influenced by mucous or endothelial membrane (peritoneum),
as it is primarily and throughout its course either a submucous or
a retroperitoneal infection. It has no tendency to be self-limiting,
as its mode of infection is not confined within the mucous or peri-
toneal coverings of any particular viscus, it infiltrates the mesentery
of the viscus and is thus endless in its extension. It does not have
the tendency to destroy an organ to the extent of gonorrheal infec-
tion and produce great quantity of pus which distends the viscus
to its limits, but does produce great tumor formation by infiltrating
the structures throughout. The surgeon must have such picture
in his mind when he attempts to deal with the great mass produced
by puerperal infection. He cannot remove that mass.

When produced by gonorrheal infection, he can enucleate and
remove the same. The gonorrheal mass has lines of cleavage
and is surgical in every particular from the standpoint of enucleation
and removal.

The puerperal mass has no lines of cleavage, is not removable
and in this sense is not surgical. The one condition, puerperal
infection, is a deep infiltration of infection behind the mucous mem-
brane or peritoneum with little tendency to limitation; the other,
gonorrheal infection, is a surface infection and extends largely by
surface continuity with tendency to limitation.

KENNEDY: PUERPERAL INFECTION 805

This is the picture I wish to convey to the operator in order that
he will not pass his fingers through the mesentery of important
structures in his attempt to enucleate a large puerperal mass. He
may also have this picture in mind, the gonorrheal mass has a pedicle
with lines of cleavage leading to the same; the puerperal mass has
none, it is truly an infiltration of all structures in its neighborhood.

Let us dissect the two masses, one from gonorrheal infection, the
other from puerperal infection. The two conditions as a rule,
present a different picture from external inspection. The mass
from gonorrheal infection is nearly always bilateral and the ab-
dominal wall from inspection and palpation reveals, in the exag-
gerated conditions, the lower one-half of the abdominal cavity
uniformly distended or consolidated. Not so with a very large
percentage of cases of puerperal infection, which are as a rule,
unilateral conditions, or at least, the extension of the pathology has
been more marked or extensive on one side than the other and is
probably due to the fact that the injury or wound infection of the
birth canal has occurred on the side of the more extensive pathology
and has extended through the broad ligament to the lateral structures.

In gonorrheal infection you will find the true pelvis consohdated
and impossible to enter at any point — I am speaking of the late
neglected cases — the infection remaining confined to the uterine
appendages until their destruction is quite complete; the intestine,
colon and omentum coming to the rescue of the general abdominal
cavity and have little or no defensive quality as far as the destruction
of the uterine appendages is concerned.

In puerperal infection the periuterine structures external to the
uterine appendages are most involved and we find the infection
extending out through the broad ligament and mesentery of the
colon, which most often constitutes the greater part of the iniiltrated
mass. The tube and ovary may often be found incarcerated in this
mass and yet be in a good state of preservation, for this reason the
puerperal woman is more apt to conceive than the gonorrheal patient
in whom the tube and ovary are destroyed. The puerperal mass is
less complicated by adherent bowel for the reason that the nature
of its patholog}^ is not that of a peritonitis but an infiltrating
infection of the deeper structures.

The gonorrheal mass has lines of cleavage because it is an infec-
tion largely of the mucous membra:ne and peritoneum and, therefore,
confined to the destruction of particular viscera, even in those cases
where the infection seemed to have come b}^ the way of the circula-
tion, the infection is still much confined to the destruction of that

806 KENNEDY: PUERPERAL INFECTION

organ which gives the lines of cleavage and permits enucleation.
Not so with puerperal infection which can be said is largely a retro-
peritoneal one extending to the viscera through their mesentery and
is therefore more infiltrating than destructive, and thus does not
give lines of cleavage nor permit of enucleation. The high death
rate of puerperal infection is not due entirely to the nature or
virulency of the infecting source, but the condition is unsurgical
from the standpoint of its pathological topography, in that the
infected mass cannot be enucleated or removed. In a certain per-
centage of cases of puerperal infection there is some occlusion of the
tubes. It is my opinion that such is due to the mixed infection
other than the streptococcus, as a large percentage of cases of
puerperal infection are sufficiently infected with colon bacillus,
gonococcus and staphylococcus to produce occlusion of the tubes,
or even produce a fatal condition independent of the streptococcus.

As surgeons it is enough but necessary for us to know, that puer-
peral infection is wound infection, therefore, it is a deep infection,
a submucous or retroperitoneal one; that it extends by infiltrating
the uterine and periuterine structures; that it invades structures
through the circulation and, therefore, is in this sense an infection
and an infiltration of the mesenteries of the viscera or the gross
structure of the organ itself, ere it becomes a peritonitis. Also,
that the puerperal mass is not a removable one, being composed of
infiltrated \dscera rather than destroyed organs. It is because of
this pathological topography that the surgical treatment of puerperal
infection is a nightmare to the surgeon.

It must be apparent to those who have this mental picture of the
condition, that our high death rate is not altogether due to nature
of the infection, but because we cannot thoroughly remove the
pathological mass.

One's victories in surgery are directl}' proportionate to one's ability
to thoroughly remove the distal infecting source. There is no
exception to this rule and we never so much needed such advice as
at this present age of insanity of uncertainty.

I regret I cannot make the positive argument for radical surgery
in puerperal infection that I made in my discussion for gonorrheal
infection.

I have given as my reasons the topography of puerperal infection.
In regard to general treatment in hospital practice, there is always
some doubt in regard to retention of infected debris within the
uterus.

If you have had charge of the patient from the beginning, tliis

KENNEDY: PUERPERAL INPECTION 807

uncertainty should not exist. If the patient is sent from question-
able medical advice, determine the presence of any retained products
and remove the same by finger. These patients should not be
traumatized with the sharp curet; there is always sufficient infecting
means within the uterus of the puerperal patient to cause systemic
infection, if the endometrium is harrassed with the curet. I put
these patients to bed, keep them on liquid or light diet and give
saline by the bowel. I do not think we should resort to hyperder-
moclysis or intravenous injection of saline, on account of danger of
local infection at the site of the needle puncture or even systemic in-
fection; remember, the patient is suffering from a true bacteremia,
so all structures are low in resisting powers. Every effort must be
made to give the patients supportive treatment, they are suffering
from a true blood dyscrasia which extends at times over a period
of months and are, therefore, in need of concentrated food of the
greatest nutritive value.

In regard to serum treatment, I always give them the benefit of
antistreptococcus serum, for I believe it has some real merit. I
believe the pathologists and bacteriologists are in accord that a
specific toxin has not been recognized in the puerperal patient; there-
fore, we have not at present a specific antito.xin for the puerperal
patient. The serum, I believe, acts as a bactericidal agent and we
have been cautioned in regard to the use of serum on account of this
bactericidal action; therefore, we are advised to give the serum
as early as possible before the greatest number of bacteria are in
the circulation, so as to avoid toxemia due to the bacteria in the
blood destroyed by the serum.

I am not comfortable in my discussion of the serum treatment of
any disease; I refer the reader to those distinguished gentlemen who
have given the profession one of the greatest of blessings. I have
little patience with discussions which are not from personal
experience.

I should like to discuss this phase of the subject under the single
term prophylaxis. I like the etimology of the term, namely, pro-
phylaxis,— "the guard that stands before."

It pays to be a perfect crank about hand-cleansing. When you
think you are sufficiently clean to operate, just begin again and
scrub several times more. Operator's ideas about hand-cleansing
are the most miserable of all their virtues. Remember that puer-
peral infection is a wound infection in an area prone to contamina-
tion, therefore, exercise the greatest degree of surgical cleanliness.
Close all lacerations of birth canal immediately; keep away from

808 KENNEDY: PUERPERAL INPECTION

the patient before, during and after labor. This may be a httle
epigrammatic but the reader should get the sense. Remember
that puerperal infection is prevalent in the overrich and very poor;
the overrich are too much courted and examined, the very poor are
not given time to end their labors naturally. The man who has
no patience has no right to do obstetrics. In the first place, he -rtII
not take time or use sufficient energy to get clean; again, if he has
had just a wee bit of surgical training, a large percentage of his
patients will be operated upon unnecessarily.

First, be a man; secondly, a clean man; third, be a man with a soul.
This may seem to the reader to be foreign to the discussion of the
question, not so in any particular. If the above advice is lived
up to, 95 per cent, of the death rate from puerperal infection will
be wiped out. At this present date there is more room for an
honest preacher in the profession than there is need of surgical
advice. Let us catch up to our surgical and medical pri\'ileges,
they are magnificent.

The puerperal patient should be isolated for the protection of
all other obstetrical and surgical patients. In regard to an antiseptic
douche for the puerperal patient, I have not much confidence in
obtainingany material benefit from the same; a low douche given with
great care and gentleness may be indicated as deodorant. I am
always afraid of forcing infected debris into the uterine cavity. I
do not make interuterine applications on account of trauma from
the same and thus open up raw areas for infection to be rekindled.

WHEN DOES THE PUERPERAL PATIENT BECOME SURGICAL?

From the standpoint of amputation surgery, puerperal infection
is rarely surgical other than indirectly through its comphcations.
In the acute or the very early stages of the infection, which is truly
an infiltration of the uterine and periuterine structures, during
which stage the Fallopian tubes are swollen and turgescent and
probably leaking purulent discharge from their patulous fimbriated
extremity, it is unsafe to attempt amputation of the uterine
appendages for several reasons.

In the first place, removal of the tubes and ovaries is only removing
a small portion of the pathology, as the broad ligament, mesentery
of the colon, uterine and periuterine structures are as much a part
of the pathological condition as the tubes and it is most forcibly
shown in puerperal infection that you cannot partially remove an
inflammatory or infected area and get away with grace. This is
the reason that puerperal infection is little surgical as compared

KENNEDY: PUERPERAL INFECTION 809

with gonorrheal infection of the uterine appendages which is more
a pathological entity, and amputation surgery is followed by brilliant
results. The reader will understand by the terra amputation
surgery, I simply mean removal of the pathological structures.

Permit me again to call attention to the fact that the very founda-
tion of successful surgery is, the abihty of the operator to remove
the distal infecting source. This can be least done in puerperal
infection.

Any attempt at removal of the uterine appendages in this acute
stage, is merely stimulating the infection by opening up lymph
spaces and encouraging retroperitoneal infection. Many of the
puerperal patients who are operated on in this acute stage, die from
metastasis of an infected embolus which may be deposited in lungs,
kidneys, or most any portion of the body.

Septic pneumonia is a most frequent complication of meddlesome
surgery in the puerperal patient. If during the early stage of the
condition the patient develops marked distention indicating peri-
tonitis, the picture is different and we must realize that marked dis-
tention means bowel obstruction and that the patient can receive
her lethal dose of toxins from the enterom or the mucous membrane
of the distended and obstructed bowel.

In such conditions I open the patient, relieve the bowel obstruc-
tion, puncture the bowel if necessary to release gas and infected
fluids, which are often of great amount and most toxic. I flush the
abdominal cavity with saUne solution at temperature from 115° to
120°, which is a very powerful stimulant. I next place the entire
pelvic structures within a mit of gauze or in other words, I surround
the uterus, tubes, ovaries and broad ligament by a cofferdam.
This cofferdam entirely encircles the pelvic structures. If there is
any leakage of purulent fluid from the tubes, it is taken care of by
this drain. The cofferdam by filling the entire peKds has that
very valuable mechanical function of preventing the paralyzed and
infected bowel from collapsing into the pelvis and producing post-
operative bowel obstruction. Elsewhere I have fully described the
function of the cofferdam other than that of a mere drain.

In revdewing this surgical treatment of acute puerperal infection,
you vdW find that no lymph spaces have been opened by amputation
surgery to permit absorption of infection. The operation is done
to relieve the complicating bowel obstruction and prevent peritonitis
from the purulent discharge which may be exuding from the tubes.

The other type of cases of puerperal infection in which surgery
may be indicated, is found in the patient who has a large mass

810 KENNEDY: PUERPERAL INFECTION

usually unilateral which has extended for weeks, is gradually infect-
ing the patient and is beginning to cause bowel obstruction and
general extension.

In this class of cases nature has made an attempt at localization.
This mass, as my earlier description in this article indicated, is
composed of infiltrated broad hgament, bowel and mesentery thereof.

I have often seen the abdominal wall infiltrated and infected
throughout ; a condition I have not seen from a true history of gonor-
rheal infection. This well indicates the true nature of the diffusible
and infiltrating infection seen in the puerperal patient.

As I have said, you cannot enucleate this mass and amputate
the same, as it is composed largely of infiltrated important struc-
tures and is truly a retroperitoneal infection. The tube and ovary
are often found incarcerated in this mass and may be the cause of
the prolonged infection, although the puerperally infected tube does
not have a tendency to become occluded, but when surrounded or
incarcerated in this huge mass of pathology does become occluded
and a true tubal or ovarian abscess may be formed and continue
the infection from such source. In this stage the tubes and ovaries
may be removed with much less risk of secondary or metastatic
infection and the multiple abscesses which may be formed between
the viscera composing the puerperal mass, may be drained. If in
this stage the tubes and ovaries are removed and their area packed
with gauze and the pelvis drained by cofferdam, you will often be
surprised to see the remaining mass of pathology composed of broad
ligament, bowel, mesentery, etc., melt away. If it becomes neces-
sary to do a hysterectomy on account of multiple abscesses in the
uterus, or the big, flabby infiltrated and infected organ, the very
best results will be obtained by hysterectomy by the serrenoeud which
is in a sense an extraperitoneal amputation of the pelvic structures,
and also a drainage operation on account of the stump of the uterus
being brought outside of the abdominal cavity.

During my first few years with Dr. Price, I assisted him with
several hundred hysterectomies by the serrenoeud method and can
say there is no method which compares with it as far as operative
mortality goes. The objections to this method of hysterectomy for
all conditions are obvious, but for the purpose of removing the uterus
in puerperal infection, it is the ideal method and is indicated because
it controls the circulation, opens practicall}- no structures for absorp-
tion of infection, is a drainage operation by bringing the stump
outside the abdominal cavity and thus prevents intraabdominal
infection.

KENNEDY: PUERPERAL INFECTION 811

It is an amputation operation without the dangers of the same,
as the including wire of the serrenoeud prevents absorption of toxins
through the incised area. The operation can be done with the
greatest dispatch and least degree of shock. There is so much in
the surgery of the older operators which has sterling worth but is
not fashionable to-day.

If operators were more familiar with the true pathology of puer-
peral infection, they would not be attempting the extraperitoneal
route in Cesarean section on the suspected infected uterus. They
have chosen the extraperitoneal route with the idea of preventing
a peritonitis and the results have not been satisfactor\^ The puer-
peral patient and the pregnant uterus which has been contaminated
by meddlesome or legitimate attempts at delivery are pathologic-
aOy alike, and the patient's life is in danger, not from a peritonitis
but a retroperitoneal infection, cellulitis, lymphangitis or, which-
ever term that implies a truly deep infiltrating infection of the uterus
and periuterine and adjacent structures.

The extraperitoneal Cesarean section has failed in the infected
uterus, not on account of the peritonitis or the dangers of producing
peritonitis by the operation, but proves fatal in the puerperal patient
on account of opening up the infected lymph spaces in the uterine
wall.

We see here the sam.e principle which prevents us from doing
amputation surgery in the acute puerperal patient, therefore, you
are not justified in prolonging the Cesarean operation by attempt-
ing to do an extraperitoneal route when it is not a peritonitis which
defeats our efforts. When the editors will be good enough to permit
me to say what I please about this question of peritonitis (and they
have not done so as j^et) I shall try and bring out the fact that it is
not the only danger or complication of the acute infectious lesions
of the abdominal cavity, and that the comphcations of the peri-
tonitis, namely, bowel obstruction followed by mucous membrane
absorption, retroperitoneal infection and that infection which comes
from permitting viscera to remain macerated in ponds of filth,
I say I shall be grateful indeed.

The pathological and surgical histories of peritonitis must be re-
written. When the American profession began to endorse the classi-
fication of the peritonitic patient into operative and nonoperative
stages, it saw the beginning of the darkest era in the history of
American profession. I shall have more to say about this elsewhere.

Do not class the puerperal patient as a peritonitic one, its surgical
pathology is entirely different.

812 salzman: certain types of uterine hemorrhage

Briefly to review the surgical treatment of puerperal infection,
operate in the acute stages only when complicated by marked dis-
tention, relieve the bowel obstruction, puncture the bowel if neces-
sary to relieve distention and drain infected fluids from the bowel,
flush the abdominal cavity with saline solution temperature from
115 to 120, place the entire pelvic viscera in a mit of gauze and permit
drains to remain two weeks. Do no amputation surgery.

In the subacute case, the uterine appendages may be removed as
at this stage the tubes are often occluded and remain a nidus of
infection to the big, infected mass which surrounds them. Pack the
area from which the appendages are removed, with gauze; also
place cofferdam in pelvis, permitting the same to remain two weeks.
In those subacute conditions in which the uterus is largely flabby
or infected throughout, containing multiple abscesses in its walls,
remove the same by the serenude.

241 North Eighteenth Street.

HYPOTHYROIDISM A FACTOR IN CERTAIN TYPES OF
UTERINE HEMORRHAGE.*

BY
S. SALZMAN, M. D.,

Toledo. Ohio.

Within the past few years the number of pathological conditions
known to be directly or indirectly due to variation in the secretion
of the thyroid gland have become unbelievably large. It is, there-
fore, with some hesitation that I bring forward another not uncom-
mon but important condition, which, I believe is occasionally due
to a deficiency of the normal thyroid secretion; namely, uterine
hemorrhage.

While, so far as I know it is a new therapeutic application of the
thyroid substance, the foundation for its use has been laid, and it is
surprising that clinicians have not realized its value in this condition.

The subject of uterine hemorrhage first attracted my attention
in 191 1, when I was called to see a woman because of persistent
uterine bleeding and obtained the following history.

Case I. — Mrs. L. W., aged thirty-six, married, two children, no
miscarriages, always well until two years ago when she began to
menstruate frequently, often being free from bleeding only one
week in the month. Bleeding is usually slight but is occasionally
profuse, especially so of late. She is very weak and unable to do

* Read before the Toledo Academy of Medicine, Feb. 18, 1916.

s.u-zman: certain types of uterine hemorrhage 813

her house work, has backache, headache, shortness of breath, con-
stipation and a variable appetite. Previous history negative.

She is a very small woman, under 5 feet in height, weight about
go pounds, appears older than thirty-six, and is very anemic. Chest
and abdomen negative. Vaginal examination shows the uterus
normal in size, freely movable and not tender, cervix slightly lacer-
ated; tubes and ovaries appear to be normal and not tender. Cur-
etmentj was done and the scrapings examined and reported negative
by the pathologist. Hemorrhage did not cease and despite rest,
packs, general treatment and the use of ergot, styptol and the like
it became more profuse.

Finally in November, 19 11, I took the patient to a very prominent
surgeon in Chicago who after examination advised an hysterectomy.
This was done and the report by the pathologist showed a normal
uterus and tubes and one small cyst of the left ovary. In other
words there did not appear to be sufficient pathology locally to ac-
count for the severe bleeding, which had persisted for over two years,
despite all treatment.

Hysterectomy in such a case seemed to me to be an unnecessarily
radical operation. It set me to think of possible factors not con-
nected anatomically with the pelvic organs as a possible cause of this
type of hemorrhage.

While tills was still fresh in my mind I was called to see a similar
case.

Case II. — Mrs. L. D., thirty-eight years old, married fifteen years,
never pregnant.

For the past six months she has bled continuously from the uterus,
rarely profusely but sufficient to completely exhaust her so that now
she is unable to walk across the floor unaided.

She has been under the care of several physicians and one very
competent surgeon, but had refused all operative procedures, even
the use of the therapeutic curet.

She was a very emaciated woman, hair snow white, face shrivelled
like a woman of seventy; general examination negative except for
the marked emaciation. Pelvic examination showed a very small,
almost infantile uterus, the cervix intact, no pelvic mass, and the
tubes and ovaries appear to be normal.

No cause for such persistent bleeding could be determined. Case
I was'still fresh on my mind, and too, I had been looking over con-
siderable literature on the ductless glands in preparation for a lecture.
An article by Sehrt (Miinchen. med. Wochenschr. 1911, vol. Ix, p.
661) came forcibly to my mind. He had demonstrated the marked
alteration of the coagulability of the blood in cases of hypothyroid-
ism. He stated his conviction that certain cases of hemophilia
were in reality cases of hypothyroidism or myxedema. In twenty
cases of pure hemorrhagic disease of the uterus he found thyroid
deficiency in thirteen. Despite this he does not mention the thera-
peutic use of the gland in the^e cases.

With this article in mind I examined the neck and found no evi-

814 salzman: certain types of uterine hemorrhage

dence of the thyroid gland, it had apparently completely atrophied.

Because of this fact and because all local methods of treatment
had been tried and operative treatment refused I felt justified in
making a trial of thyroid gland in this case. The patient was put
upon three 5-grain tablets of the gland substance daily. I was
surprised on the second day to find the patient brighter and more
alert, her eyes were bright and her entire appearance was altered
for the better, the bleeding was much less and by the following day
had ceased entirely.

The dose was then reduced to two tablets daily for a week and
stopped. Within three days the bleeding again started but stopped
immediately after resuming two tablets a day. She continued
with this dose together with iron, quinine and strychnine for three
months at which time her regular menstrual periods were resumed.
I heard from her last in December, 191 2, one year after beginning
the above treatment. She was then in good health and menstru-
ating regularly. She was taking one tablet daily.

The prompt relief following the exhibition of thyroid gland tablets
after the hemorrhage had persisted for a period of six months, its
prompt reappearance upon stopping the tablets and ceasing upon
again resuming this therapy, together with the subsequent history
of the patient, leaves little room for doubt that the administration
of the thyroid gland by mouth furnished the patient with something
which was lacking in her body and the lack of which was directly
or indirectly responsible for the bleeding from the uterus.

Since that time I have had a number of similar cases which I will
report briefly.

Case III. — Mrs. L. K., thirty-five years old, married, has five
children. I saw patient in November, 1914, and learned that she
had been flowing steadily since September. She had always been
regular. Her last two pregnancies are of interest and I believe bear
on this subject. During both of these pregnancies she was practi-
cally confined to her bed throughout the entire period and under the
care of an obstetrician and an internist. From what I could learn
the condition was thought probably to be hysteria.

She went to term each time but was constantly prostrated,
nauseated and generally ill.

Examination showed a thin, tall, rather scrawnj' type of woman,
looking much older than thirty-five, thyroid gland not palpable.
Chest and abdomen negative, pelvic examination showed a sub-
involuted uterus, soft and regular in outline, not tender, the cervix
eroded but not ulcerated. Tubes and ovaries not palpable; no
tenderness or masses could be determined.

A trial of thyroid gland tablets was made, giving two tablets daily.
The bleeding ceased in thirty-six hours. Despite instruction to
continue the tablets the patient stopped them, when the bleeding
promptly began again but stopped the next day after again taking
the tablets. After tw > weeks the tablets were gradually withdrawn.

salzman: certain types of uterine hemorrhage 815

There has been no return of the bleeding to this date, a period of
over one year and a half. A notable fact in this case was, the patient
volunteered the statement that she felt better and stronger than she
had for years. She had undoubtedly been suffering from slight
chronic hypothyroidism, and I feel that her condition during the
last two pregnancies might well have been due to this lack of thyroid
secretion.

Case- IV. — Mrs. E. S., aged thirty. Saw patient on July 19, 1914,
because of severe bleeding from the uterus. She was live months
pregnant, and an examination showed that abortion was inevitable.
She delivered herself in three hours. Fetus and placenta came away
intact. She had spotted since the onset of the pregnancy and for a
time an ectopic pregnancy had been suspected.

Three months later she returned complaining of a very profuse
menstruation, lasting eight and ten days. Her periods had for years
been quite profuse but not as profuse as now. She was put upon
two thyroid tablets daily, beginning two days before the period and
continuing through the period.

Her next period lasted four days and the quantity of blood lost
was much less than for years past. She has continued taking the
tablets at each period with equally good results.

Here again it is possible that a deficiency in the normal thyroid
secretion was responsible for the bleeding during the pregnancy and
the subsequent abortion. It has been shown that goats after
removal of the thyroid gland may become pregnant but invariably
bleeding and abortion occur. I beheve we have here a fruitful
field of investigation for those doing obstetrics.

Case V. — Mrs. C. S., thirty-six years old, widow, has one child
seventeen, no other children. For the past year and half she has
menstruated every two weeks, and usually more profusely than for-
merly. She is tired constantly and as she earns a livelihood as a
clerk in a store and in addition takes care of her home, she is fast
going down hill physically.

She is a strongly built, apparently healthy woman, with no organic
lesions in chest or abdomen. Pelvic examination also fails to reveal
anything pathological. The patient was therefore put upon thy-
roid tablets. She began immediately after a bleeding period and
went along twenty-four days before the next menstruation appeared.
She was put upon iron and arsenic. Her normal strength and health
soon returned and by continuing with one tablet daily her normal
periods were reestablished.

Case VI. — Miss J. R., nurse, forty-six years old, complains of
dizziness and pains about the ears, headache and general malaise.
Her menstrual periods are gradually becoming longer and more pro-
fuse. She is gaining in weight rapidly.

Examination revealed a peculiar thickening about the skin of the
face and body which does not pit upon pressure. No edema about
the eyelids. Lungs negative. Heart slightly enlarged to the left,
tones soft but no murmurs present. After slight exercise a slight

816 salzman: certain types of uterixe hemorrhage

systolic blow at the apex can be heard, and the pulse is rapid and
sHghtly irregular.

Abdomen negative. Urine negative and blood pressure 130 sys-
tolic; 70 diastolic. Pelvic examination negative. A diagnosis of
myxedema and myocarditis was made, and the patient was put
upon tincture of digitaUs and three tablets of thyroid gland daily.
The next period which began four days later was sUght and lasted
four days. The patient soon felt stronger and better and the pecu-
liar thickening became less noticeable. By continuing with one
tablet daily and two during the menstrual periods, they have become
normal and the patient feels better in every way than she has for
some time.

These cases of uterine hemorrhage are not uncommon, and the
instances reported represent the various tj'pes that I have seen.

Suggestions hinting at the value of the thyroid substance in these
cases are not wanting, but except for one case reported by Dr. G. H.
Mallet {Jour. A. M. A., Nov., 1897). I have been unable to find
any report of its actual use.

Sehrts' cases quoted above would certainly suggest a trial of this
treatment. Dudley (Principles of Gynecology, 1904), classifies un-
known hemorrhages from the uterus, into hemorrhage of puberty
and of the menopause, and states that it is at these times that dis-
turbances are apt to be found in the thyroid gland. However, he
makes no mention of having used the gland substance in cUnical
cases.

Falta in his recent book on Diseases of the Ductless Glands, on
page 118 states: "Chronic benign hypothyroidism is accompanied
by disturbances of sleep, lassitude especially in the morning and
menstrual disturbances, especially menorrhagia and amenorrhea."
Most of the books on gynecology make brief mention of the fact
that excessive bleeding may be due to disturbed thyroid secretion.
The reference is too brief to be of any value.

Most cases of uterine hemorrhage can undoubtedly be accounted
for by some local pathologic condition such as infected endometrium,
retained placental tissue, fibroid tumors of the uterus, uterine cancer
or polyp, ovarian tumors or cysts, or diseased tubes.

However, there is a certain proportion of cases that cannot be
accounted for by any of these conditions and in which any and all
methods of treatment will not bring results. Every surgeon of large
experience has at some time done a hysterectomy on one of these
cases, as a life-saving measure.

The blood coming from the uterus in these cases is noncoagulable,
this being a distinguishing characteristic. The fact that menstrual
blood is noncoagulable would point to the fact that menstrua-

salzman: certain types of uterine hemorrhage 817

tion is controlled by the secretion of a substance which inhibits
coagulation.

This has been conclusively shown to be the case by Sturmdorf in
an article {Jour. A. M. A., Feb. 14, 1914), entitled "Functional
Menorrhagia." He deplores the frequent and unnecessary use of
the curet and the removal of the pelvic organs in these cases. I
quote from his article.

"It must suffice here to state that the endometrium during men-
struation and in the hemorrhagic cases receives normal coagulable
blood from the general circulation and sheds this blood in a non-
coagulable state. This loss of coagulability is not due to the
absence or deterioration of any element essential to the coagulation,
but to the presence of an inliibiting substance that is periodically
secreted by the corporeal endometrium from which it may be
expressed. Such expressed endometrial juice is capable of inhibiting
in any normal blood."

"The endometrium is activated to the secretion of this inhibiting
substance by a hormone generated in the Graffian follicle. To the
present time we have not succeeded in isolating this substance, nor
have we discovered its specific antagonist. We have, however,
learned to circumvent it by effectual measures."

The measures referred to by Sturmdorf are the use of vaso-dilators,
and the local appUcation of acetone, liquor formaldehyde, and the
D'Arsonal spark, the treatment to extend over a period of several
months.

There can be no denial of the fact that a treatment which works
blindly and must be carried over a period of several months is not
an ideal one for such a serious condition as hemorrhage, even though
it be successful in the end.

We can scarcely hope or expect that such local methods of treat-
ment will replace or even activate the formation of the anti-inhibit-
ing substance, which depends upon or is controlled by a hormone
formed in another part of the body.

From the clinical results in the cases reported above I feel that the
thyroid gland is in some way responsible for the deficiency of the
specific antagonist to the inhibiting substance referred to by
Sturmdorf.

Whether this substance is directly elaborated by the thyroid gland
or by one of the other of the ductless glands which depends upon the
thyroid for stimulation, I am not in a position to state. However,
our knowledge of the inter-relationship of the ductless glands would
lead us to suppose that the thyroid gland is directly at fault.

818 finkelstone: cholelithiasis complicating pregn.\ncy

In conclusion I would like to state the following:

There is a tjT^e of hemorrhage from the uterus not caused by
any discernable pelvic disease or pathology, nor related to any of the
so-caUed hemorrhage states, but due to an alteration or lack of one
or more of the hormones which control the normal flow of blood from
the uterus.

This alteration is due to a deficiency in the secretion of the
thyroid gland, and such hemorrhage can therefore be controlled by
a judicious exhibition of the dried glandular thyroid substance.

Finally I would caution against the indiscriminate use of this
substance. It must be used only when the diagnosis is assured, for
bleeding may occur in cases of hyperthyroidism.

Much harm might be done if given such a case.

234 MicmcAN Street.

REPORT OF A CASE OF CHOLELITHIASIS COMPLICATING
PREGNANCY.

BY
B. B. FINKELSTONE, U. D.,

Bridgeport, Conn.

Cholelithiasis, quoting Osler(i), is an exceedingly common
condition, being found at necropsy in from 5 to 10 per cent, of sub-
jects dead from all causes. It occurs at all ages but the incidence
increases progressively with advancing age, — 75 per cent, or more of
the cases are found in persons over forty years of age and less
than I per cent, in those under twenty. Rarely, the disorder is
encountered in infancy or childhood. The majority of cases found
in infancy are doubtless due to intrauterine infection. Gall-stones
are more common in women than men.

Gall-stones are especially common in those who lead a sedentary
life as contrasted with laborers and others who work much out-
doors, in woman as contrasted with man, etc.; as part of a general
muscular inactivity, the abdominal muscles and the diaphragm
contract feebly and the bile, inefficiently expelled, stagnates in the
gall-bladder. Similar consequences ensue upon obesity and disorders
which interfere with the free movement of the diaphragm.

In women a number of factors contribute: in addition to a
more sedentary life, they are more often the subject of hepatoptosis
or nephroptosis, brought on by repeated pregnancies and other
factors that occasion more or less continuous distention of the
abdomen and interfere with the movements of the diaphragm.

finkelstone: cholelithiasis complicating pregnancy 819

In consequence of the prolapse of the liver, the gall-bladder becomes
dependent and the cystic or common bile duct kinked, or perhaps
has considerable traction brought to bear upon it and becomes
obstructed, so that the gall-bladder is less easily emptied than in
health and is more disposed to infection. The association of
cholelithiasis with pregnancy is undeniable, but its importance
is difficult to estimate, since the great majority of middle-aged
women, whether or not they suffer from gall-stones, have been
pregnant. There is some evidence, however, that gall-stones are
more common in those who have been pregnant, especially repeatedly
pregnant, than in those who were never pregnant. Perhaps in
some cases puerperal infections are the cause of gall-stones. Some-
times the biliary infection, though often misinterpreted, can be
definitely determined to have been acquired during the puerperium.
No doubt the beginning of the gall-stones in case cited by Rufus
B. Hall(2) at American Association of Obstetricians and Gynecolo-
gists September, 1915, started from the puerperal infection.
Osler(3) quoting Naunyn states that 90 per cent, of women with
gall-stones have borne children.

DeLee(4) says that it seems pregnancy is a factor in the develop-
ment of gall-stones and it is not rare that the gravida have attacks
of biliary colic. These seldom occur before the fifth month and
jaundice with chills and fever is more common than in the non-
pregnant state. Berkeley and BonneyCs) claim that in 30 per cent,
of the cases, the attack occurs in the first five months of pregnancy.
Cholecystitis is easily mistaken for appendicitis and pyelitis.

author's case.

History. — Female twenty-seven, American, housewife. Delivered
of a male child three years ago. Patient seen for first time December
7, 1914. She was bleeding from vagina and passing clots. Vaginal
examination showed a rectocele and a poorly repaired perineum —
no muscle in perineum and was full of pin-point holes from the skin
into the vagina. It was like a sieve. Patient had a perineorrhaphy
following labor and a secondary perineorrhaphy the following year
by the same physician with the above result. Found uterus pro-
lapsed into vagina, cervix patent and easily dilatable and vagina
full of clots. Diagnosis: Inevitable abortion. Manual delivery of a
fetus — size 3^^ months. Patient up and about in ten days.

January 12, 19x5, operated on by Dr. Ross McPherson assisted
by Dr. Finkelstone. Dilatation of cervix, perineorrhaphy, append-
ectomy and suspension of uterus was done. Jan. 14, had a calomel
run which "distressed" her vcr\ much — did not know patient had
an idiosyncrasy to calomel, which gives her a marked gastric dis-
turbance. Menses on Jan. 17. Allowed to sit up in bed with a

820 finkelstoxe: cholelithiasis complicating pregnancy

back-rest, Jan. i8, for two hours after wliich she complained
of "aching pain throughout the chest." Vomited about 5 oz. of
fairly well digested food at 8 p. m. Morph.sulph. gr. 3^ did not stop
pain. . Temperature 98°; pulse 86; respiration 22 January 19.
In morning vomited 4 oz. of thick brown fluid — particles of undigested
food. Sutures removed. Complained of same "aching pain
throughout chest," relieved at times by belching. Urine examination
negative.

January 20, complained of pain at upper right side of incision.
Temperature 100; pulse 100; respiration 22. Blood examination:
W. B. C. 6000; P. 80; L. M. 15; S. M. 5; E. O. B. 0. Patient not
jaundiced. Diagnosis: Cholecystitis (due either to lighting up
of an old lesion in gall-bladder from gall-stones, calomel idiosyncrasy
or following an appendectomy. In those cases following an ap-
pendectomy, the gall-bladder was no doubt involved at some
previous time). Patient denies former gaU-bladder attacks or even
gastric disturbances — although she does say that ten years ago she
had t}'phoid-malaria (?) and that she was "always taking calomel
and quinine to drive away malaria." Patient seen in consultation
by Dr. Ross McPherson in the evening, who concurred in the
diagnosis of cholecystitis.

Pain somewhat relieved by hot flaxseed poultice and became less
severe until January 24, when there was slight pain in the upper
region of the wound for about iive minutes.

January 26, 7.00 a. m. another severe attack of pain. About
6.00 p. M. vomited undigested food and pain was relieved.

January 28, patient up in a chair. Had slight lumbar pain.

February 8, discharged in good condition — wound healed by first
intention.

April I, rontgenogram by Dr. McKee showed dUated duodenum.
Diagnosis: adhesions around gall-bladder or gall-stones, though
picture showed no stones.

Recourse to a;-ray is seldom of much diagnostic utility since choles-
terin stones show scarcely any shadow, usually not more than the
adjacent liver, though Cole(6) says biliary calculi can be detected in
50 per cent, of the cases by rontgenograms. In another article(7)
he writes that gall-stones may be detected sufficiently often to justify
a rontgenographic search for them, but the absence of any direct
evidence does not justify one in making a negative diagnosis, and
should not prevent surgical intervention provided it is clearly
indicated by the history.

April 8, 1915, saw patient for amenorrhea. Last menses IMarch
5, 1915. Vaginal examination negative. Could not find Ladinski's
sign of early pregnancy due perhaps to unfamiliarity with sign.
From history made diagnosis of suspected pregnancy. Considered
an interruption of pregnancy on account of gall-bladder condition
plus the suspended uterus based on Kosmak's views(S). Kosmak
says that a patient with a suspended uterus is liable to difficult or

finkelstone: cholelithiasis complicating pregnancy 821

abnormal labor. McPherson advised that pregnancy not be inter-
rupted as he claimed that in his own cases of Giliam suspension,
his observations were at variance with Kosmak's. In fact he
claimed that in his experience quite often soon after a Giliam was
done, the patient became pregnant.

On May 15, diagnosis of pregnancy confirmed on vaginal examina-
tion. May 16, patient had shght attack of gall-stone colic. June
8, another attack of cholecystitis. Pain continued three days —
at no time was jaundice present. Tried all recognized medical
treatment with no relief. July 20, another attack of gall-stone
colic. August 24, another attack of pain in right epigastrium
which }/2 gr. doses of morphine did not relieve. Saw patient
daily until Sept. 2, when writer threatened to withdraw from
case unless patient consented to operation as he feared making
an habitue of patient since she had received 3>^ to i gr. doses of
morphine daily since August 24, with an addition of 10 min. of
Magendie's sol. once or twice daily. (Magendie's sol. seemed to
have better effect than morphine sulphate.) Besides with such great
amount of narcotic, the effect on the fetus had to be considered.

Evidently the fetus in early pregnancy can withstand more
narcotic than the full-termed child or else the placenta does not
transmit the drug in early pregnancy as readily, which makes one
wonder whether it is not scopolamine that gives the untoward action
in so-called "Twilight Sleep," or the effect of morphine in combina-
tion with scopolamine. Editorial in Jour. Amer. Med. Ass'n.{g)
shows that, according to H. G. Barbour and N. H. Copenhaver,
studies of the combined action of these drugs on the central nervous
system exhibits a true synergism; i.e., the narcotic effect of the
combination has appeared more profound than the algebraic sum
of the effects of the same doses given separately. Barbour claims
in the case of direct action of these drugs on an isolated uterus, no
synergism or antagonism has been discovered. M. I. Smith(io)
says that the toxicity of the scopolamine-morphine combination in
the mouse is increased with the relative increase of the scopolamine
content of the combined dose. The fetus in utero may survive
despite the fact that large doses of morphine are taken into the
mother's circulation (Sajous)(ii).

In August, 191 5, patient seen by Dr. Howard Lilienthal, who
advised an immediate operation to relieve symptoms by incising
and draining gall-bladder and keeping fistula open, followed by a
cholecystectomy after labor. Patient and family refused operation
fearing it might interrupt pregnancy.

Various authorities claim that it is better to wait until after
delivery for operation if possible, but in the presence of a strict
indication, one may have to drain the sac before labor. Ross

822 finkelstone: cholelithiasis complicating pregnancy

McPherson declared that cholecystostomy was no more liable to
produce abortion than any other abdominal operation in which the
uterus was not much disturbed. Berkeley and Bonney(5) say that
the coincidence of the symptoms and signs of gall-stones and
pregnancy does not alter the recognized treatment of the former
except in the latter month or two when owing to the diminished
accessibility of the gall-bladder by reason of the intestine being
crowded into the upper abdomen it is advisable to postpone any
operation until after term unless the condition is urgent. They
continue by saying that the operation has no particular tendency
to cause miscarriage or premature labor, but if the child is just
approaching the period of viabiHty the operation should be post-
poned for a short time, if possible, in its interest. The operative
mortality is returned in pregnancy as 13 per cent, and the puer-
perium as 10 per cent, in the latter operation. The later the opera-
tion, the more difficult it is technically due to the large uterine
tumor. Only that operation should be done which will quickest
remove dangerous conditions (Peterson). Operation should be
postponed, if possible, until after delivery, at least as late in preg-
nancy as possible because premature labor may occur and the child
be lost (DeLee)(4).

September 2, patient consented to operation. September 3,
cholecystostomy done by Dr. P. W. Bill assisted by B. B. Finkel-
stone. Gall-bladder marsupalized and eighty-six gall-stones of small
size removed. Patient discharged in twenty-one days; fistula healed
in twenty-four days. Allowed fistula to close as gall-bladder wall
at examination seemed in good condition. It also seemed that
the symptoms would clear up. That it might have been better
to allow it to remain open, only the future would show. Urine
negative. Stools never clay-colored since patient came under my
care. As far as could be ascertained at that time, patient had
made a complete and uneventful recovery, wound being healed by
first intention except where drain was inserted. Abdomen shows
a fetus nearly seven months in L. O. A. position. Fetal heart 124.
November 12, patient examined shows nine months pregnancy
L. O. A. Fetal pulse 128. Urine negative for sugar, albumen and
bile. December i, urine negative.

December 11, 1915, patient in labor L. O. A. Fetal pulse 134.
Delivered of a full-termed healthy male child. During second
stage of labor when head was bulging perineum all of the vulva on
the left side from perineum to near the clitoris was drawn over the
child's head like a caul. It was impossible to push the labia on that
sitie off of the head with the result that the head pushed through
this obstacle as through wet paper, and the head, instead of being
extruded through the normal vaginal orifice, came through this
aperture tearing the left labium minus to the clitoris. With the

finkelstone: cholelithiasis complicating pregnancy 823

head came the posterior shoulder. The birth of the anterior
shoulder was prevented by the separated labia blocking progress.
This was incised to allow completion of labor. After placenta was
dehvered, trimmed off the posterior fragment of tissue as
far as perineum, taking only skin and mucous membrane.
Sutured the ant. flap; i.e., the labium minus sinistrum in situ.
Patient had a mucous tear of perineum which was repaired. Un-
eventful recovery for mother and child. Vaginal examination
tenth day showed perineum intact and incised and sutured part of
vulva intact — cervix one finger dOated, uterus free, movable and
in good condition. Patient discharged apparently well.

The separation of the labium minus was due perhaps to a not
easily dilatable vaginal orifice following the perineorrhaphy. Sepa-
ration of the labium minus is a rare condition. I have only seen
one case before which occurred in an instrumental delivery. In
spontaneous labor there is seldom more than slight abrasions on
the inner surfaces of the labia minora (Williams 12).

Subsequent History. — January 8, 1916, called to see patient.
Complained of slight pain in right epigastrium induced as her family
thought by lifting her boy four years of age out of crib. Consulta-
tion with Dr. P. W. Bill. Diagnosis: torn adhesions in region of
gall-bladder. January 9, slight pain just below the xiphoid. One
A. M. January 10, patient in severe pain in same site, "felt as if it
was boring through to the back." Diagnosis: cholecystitis. Pain
was very severe and greater than before removal of gaU-stones.
Pain liable to occur at any time and generally a few hours after
meals. Dr. J. C. Lynch saw patient in consultation and concurred
in diagnosis of pylorospasm due to pericholecystitis.

January 12, rontgenograms by Dr. W. A. LaField showed the
following:

Slotnach.- — Normal as to size and relative position, the lowest
point of the greater curvature is one inch above the umbihcus, the
pylorus is to the right of the median line and four inches above the
umbilicus. There is not any defect in the gastric outline. The
peristaltic activity of the stomach is increased, suggesting duodenal
irritation. At the end of six hours there is some residue.

Duodenum. — The duodenal cap is even in contour but consider-
ably distended; the diameter of the full duodenum exceeds two
inches. (Normally the duodenal cap is one inch to an inch and a
quarter in diameter.) The duodenum is fixed in the upper right
quadrant.

Intestine. — At the end of six hours the bismuth meal is scattered
through the small intestine, the head of the bismuth mass being
in the cecum. The motility of the intestine is normal.

Summary. — These findings contraindicate a gastric or duodenal
ulcer; they do suggest the presence of periduodenal adhesions
resulting from a cholecystitis with a resulting partial occlusion of
the duodenum at the junction of the first and second portions."

This day pain was very severe. Morph. sulph. gr. J^ to gr.

824 finkelstone: cholelithiasis complicating pregnancy

I by mouth only gave slight relief. Patient seen on January 13,
and advised removal to hospital to try to relieve pyloric spasms by
rectal feeding and get patient in condition for a cholecystectomy.
January 14, admitted to hospital — seen daily thereafter by Finkel-
stone with J. C. Lynch. January 14, seemed weak and pale, as
she expressed it "washed out." No jaundice present. Urine
10.30 negative except for bile. At 6:00 p. m. had severe abdominal
pain and a mass was palpable at right side of gall-bladder scar.
No doubt the gall-bladder filling up. Temperature 99; pulse 80;
respiration 20. Diagnosis: cholecystitis. Pain continued daily at
various times, lasting from a few seconds to an hour or more.

January 16, patient menstruating, which is quite unusual in a
nursing mother less than five weeks following a labor. (This might
tend to prove also that whenever the menses begin, they begin on
the exact date of that month it might have occurred if pregnancy
had not interrupted menstruation. According to patient's men-
strual history 28-day type and last menses March 5, 1915, without
an interruption of menses, the regular period would have been due
on January 15, 1916.)

This day, 9:00 a. m., had slight "shooting pains across abdomen"
lasting a few seconds. Had same pains at 1:45 p. m., 3:55 p. m.,
4:00 p. M. and 5:35 p. M. Pain at 6:00 p. m. lasted a little longer.
Slight shooting pain at 7:50 p.m. Slight continuous pain from
9:00 p. M. to midnight, at long intervals after midnight.

January 17, examination by Lynch and Finkelstone showed mass
in right epigastrium was smaller, due perhaps to gall-bladder
discharging its contents. Comfortable day — no pain. Sahne
enema at 1:00 p. m. returned yellow liquid with large amount of
feces. Slept well. Baby put on artificial feeding.

January 19, temperature 97; pulse 68; respiration 20. Patient
given mouth feeding for first time since admittance to hospital.
Cubes of steak to chew but not swallow. Glucose per rectum con-
tinued. 3 i doses of water occasionally. At night tap water compress
to abdomen. At 9:45 to 10:00 p. m. slight shooting pain on left side
of abdomen lasting about one second. Slept during the entire night.

January 22, mass again palpable. Most likely the gall-bladder
filled up again. Slight pain in region of stomach extending through
to the back at 3:45 p. m. Continued and more severe until 5:45
p. m. Relieved after hypo, of morphine. After saline enema, stools
light brown liquid, large amount of feces.

January 26, 8:00 a. m. temperature 98; pulse 62; respiration 22.
4:00 p. M. temperature 88; pulse 70; respiration 20. Complained
of slight burning in throat in a. m. 8:30 p. m. consultation by Drs.
Ross McPherson, J. C. Lynch and Finkelstone. Patient considered
in good physical condition for operation.

January 28, 8:00 a. m. during pain temperature loi; pulse 126;
respiration 30. Severe pain in abdomen and back especially on
right side near base of lung. Physical examination showed fine
subcrepitant rales at base of right lung. Patient has a septic sore
throat. Diagnosis: diaphragmatic pleurisy. Coughs and expec-

finkelstone: cholelithiasis complicating pregnancy 825

torates very frequently after 4:00 p. M. Vomited 5iii of brown
fluid having odor like beef-juice at 7 •.45 p. M. Patient delirious at
times during the night. 9:30 p. M. temperature 107; pulse 126.
Vomited 5iii dark brown fluid at 12:30 a. m. and 3:00 A. m.
Defecation — large amount of clay-colored feces — for first time
since patient has been under observation. Complained of feeling
cold, but did not have a chill. Fairly comfortable night. Slept
at long intervals. Operation postponed on account of patient's
present condition.

January 29, 1916, 8:00 A. M. temperature 103; pulse 120; respira-
tion 36. Extremities cold and clammy. Very drowsy. No pain
but an indescribable feeling. Perspired freely. Patient slightly
jaundiced. Finger nails somewhat jaundiced; under tongue shows
marked jaundice. (This is the first time patient was ever jaundiced.)
At I : GO p. M. vomited medication, a fever mixture, immediately after
taking. Vomitus showed large amount of brown and green particles,
also a soft faceted gall-stone about % inch in diameter, which
was easily broken. Slight cough and mucous expectoration. 3:00
p. M. temperature 100; pulse 100; respiration 26. Cheeks flushed.
Respiration while sleeping 24-30. Slept greater part of day and
night up to midnight. Then had dry retching which lasted 10
minutes, and vomited 5 hi of greenish fluid. Complained of pain
in left side of chest and abdomen.

January 24, mass still easily palpable. "Heavy weight" with
slight pain in region of stomach at i :4s P. M. Continued and gradu-
ally became more severe until 2:45 p. M. Temperature 99.8; pulse
90; respiration 20 during pain.

January 30, 9:00 a. m. temperature 100; pulse 98; respiration
20. Throat improving. Pain in side of abdomen and chest less.
Shght red vaginal discharge — no clots — not the period for menses.
Examination shows blood coming from uterus, due perhaps to bile
in the blood. No examination of blood made for bile; at night some
pain left side of abdomen on inspiration. Restless and unable to
sleep.

January 31, jaundice entirely disappeared. Complained of some
abdominal pain. Slept fairly well without an anodyne.

February 2, shght nose-bleed. Vaginal discharge slightly red.
Slept fairly well. In fact patient seemed to improve rapidly since
vomiting the gall-stone. Abdominal pain at rare times.

February 5, bowels moved well — very dark green, semiformed.
Shght nose-bleed, also on February 6. Unusual for patient to have
nose-bleed.

February 7, temperature 98; pulse 80; respiration 20. Patient
up in chair for one hour. Discharged from the hospital February
II, in good physical condition.

February 12, examined by Dr. Howard Lilienthal. Operated
upon by Dr. Lilienthal on February 15. Exploration shows a hard
pancreas, evidently chronic pancreatitis and an enlarged gall-bladder.
Mayo(i4) states that in 2600 operations on the gall-bladder and
biliary ducts, the pancreas was found coincidentally affected 141
times (6.1 per cent.). Infection generally spreads to the pancreatic

826 finkelstone: cholelithiasis complicating pregnancy

ducts especially the head, which may become so hard as to suggest
carcinoma; later the organ becomes contracted and fibrosed (inter-
stitial pancreatitis). In some cases, pancreatic lithiasis also occurs
(Osier). According to J. B. McKenna, (15) the Mayos found the
pancreas involved in 60 per cent, of aU their operations in the gall-
tracts. They also state that 81 per cent, of pancreatic diseases is
the result of, or coincident with, gaU-stones. Egdohl says chole-
lithiasis is the most frequent single cause. Robson found the pan-
creas involved in 60 per cent, of cases in which gall-stones were in
the common duct. In the Mayos' experience it was found that
pancreatitis was four times as frequent when the stones were in the
common duct as when they existed in the gall-bladder.

Adhesions broken up. Cholecystectomy done and the duodenum
drained. On examination, the gall-bladder was thickened and
imbedded in the inner wall of the gall-bladder neck, near the duct
was a stone about the size of a bird seed. There was no gastro-
cystic fistula so the stone must have gone in through the pylorus
(Lilienthal).

Sajous (13) writes "Calculi have been expelled from the stomach
which either found their way to the stomach into the viscus directly,
or as is more commonly the case, have been regurgitated from
the duodenum."

recapitulation.

This case presents many points of interest. For nearly a year
with marked symptoms of cholecystitis and cholelithiasis, patient
showed no jaundice, no gray stools, no fever up to the time of subse-
quent history. The rise in temperature was due to septic sore
throat and diaphragmatic pleurisy. At no time even during or
after a gall-bladder colic did temperature vary more than one degree.
That it was good judgment in not interrupting the pregnancy on
account of suspension was proven as during pregnancy there were
no symptoms due to adhesions and after labor the uterus was found
freely movable; that morphine in large doses given for pain does
not apparently affect the fetus in utero as child at birth was con-
sidered healthy and has continued so up to the present time, not-
withstanding the artificial feeding since the fifth week of birth. The
character of labial tear is quite rare. Vomiting of a gall-stone is a
very rare condition, especially without a fistula, leading into the
gastro-intestinal tract from the gall-bladder.

It hardly seemed a mistake at the time when the fistula was
allowed to close up, for except for the gall-stones being present, the
gall-bladder seemed perfectly healthy, and perhaps no need of a
secondary operation. It must always be taken into consideration
that infection can be transmitted into the gall-bladder through

finkelstone: cholelithiasis complicating pregnancy 827

fistula from without. From very limited observation, I agree with
various authorities that no gall-bladder is healthy that does or ever
did contain gall-stones. It is diseased from the fact that it contamed

'Thardly seems probable, though possible, that the stone had
formed in the interim between both operations on the gall-bladder,
but regardless of whether it had or had not, if the fistula had been
allowed -to remain patent, as Lilienthal had recommended, perhaps
the marked pain due to pylorospasm might have, been avoided,
as the vomiting of the gall-stone seemed to relieve the condition.
Though it might be possible that it was the pericholecystitis causmg
the spasms and that, the presence of such a small stone had nothing
to do with the condition. Rectal feeding had a minor role in the
relief of the pyloric spasms.

L W Swope(i6) in a paper read at Amer. Ass n ofObstet. andGyn.,
Sept igis says that at all times it is advisable, if possible, to do a
cholecystectomy instead of a cholecystostomy. He states that no
absolute rule can be laid down to guide the operator m determining
when cholecystectomy is preferable to cholecystostomy. In 2600
cases in which he operated in upper abdomen ^h^re there was,
primarily or secondarily, any implication of the gall-bladder and the
bile-ducts later reports of the recovered showed 96.8 per cent, of
cures- the remainder suffered from symptoms probably indicative
of associated gastric or pancreatic disease. In cases of cholecystos-
tomy there were only 74.8 per cent, of cures, the remainder being
no better, and many of them worse, than before the operation. The
mortality in cholecystectomy as compared to cholecystostomy is
only slightly higher, i.e., a fraction of i per cent, he claims.

The finding of a chronic pancreatitis is nothing unusual and it
ought not to lead one to error if on exploration to the touch the pan-
creas feels hard, as Lilienthal expresses it, "as hard as nails," to
make an incorrect diagnosis, viz. -.-carcinoma of the pancreas.

bibliography.

1. Osier's Modern Medicine, vol. v, p. 827, 1908.

2. Amer. Jour. Obst., Nov., 1915, p. 792-
■2 Osier's Practice of Medicine, 1907.

A DeLee. Principles and Practice of Obstetrics, 1913- .

5! Berkeley and Bonney. The Difficulties and Emergencies of

^e!^ l!*^ cl^^Coie.' Amer. Jour, of the Med. Sciences, July, 1914,
No. I, vol. cxlviii, p. 92.

7. L. G. Cole. Surg., Gyn. and Obstet., Feb., 1914, P- 227.

828 keilty: a leather-bottle descending colon

8. Kosmak. Bull. Lying-in Hospital of City of New York,
Feb., 1915.

9. Editorial. Jour. Amer. Med. Ass'n, vol. Ixvi, Nov. 8, 1916,
P-558-

10. Smith. The Synergism of Morphine and the Scopolamins.
Exper. Ther., 1915, p. 407.

11. Sajous. Analytical Cyclopedia of Practical Med., 1910,
vol. iv, p. 496.

12. WilUams. Text-Book of Obstetrics, 2d. Ed.

13. Sajous. Analytical Cyclopedia of Practical Med., 1910, vol. ii,
p. no.

14. Mayo. Jour. Amer. Med. Ass'n, 1908, p. 1161.

15. J. B. McKenna. Providence Med. Jour., Nov., 1915.

16. Swope. Cholecystectomy vs. Cholecystostomy. Amer. Jour.
Obst., Nov., 1915.

346 State Street.

A LEATHER-BOTTLE DESCENDING COLON, SIGMOID
AND RECTUM.*

BY
ROBERT A. KEILTY, M. D.,

Philadelphia, Pa.

The purpose of this paper is the report of a relatively unusual
case of fibrous colitis. I am indebted to Dr. Alfred Stengel and his
staff at the University Hospital for permission to use the case.

The cUnical history states Mrs. C. O., white, aged fifty-eight, was
admitted Nov. 7, 1914, and died Feb. 2, 1915. The patient was a
widow and her chief complaint was "bowel trouble." She had ty-
phoid fever twenty-three years ago and has had ten children six of
whom are living. For the past ten years she had incontinence of feces
progressively more troublesome and for the past year she had not been
able to leave the house. The movements occurred at any time with-
out her knowledge. Her appetite was poor, she suffered no abdom-
inal pain, no vomiting but gaseous eructations were large and sour.
For three weeks before admission she had fever and was confined
to bed with yellowish and profuse movements.

Upon examination the patient was an elderly, extremely emaciated
female. A soft systohc murmur was heard transmitted to the axilla.
The abdomen was flat and relaxed, with wide diastasis of the recti
and visible aortic pulsations. The urine showed a cloud of albumin
and no casts. The feces were dark, brown, foul and liquid with
bile, fat, casein, mucus and no occult blood. The Widal was posi-
* From the McManes Laboratory of Pathology of the University of Penn-
sylvania, Philadelphia, Pa.

keilty: a leatherb-ottle descending colon 829

tive. The blood culture was sterile and the Wassermann was nega-
tive. The urine culture was negative for typhoid bacillus and the
feces were negative for ova and tubercle bacillus. Introduction of
the finger at the rectal examination gave considerable pain. The
patient's niece stated that the incontinence followed the birth of the
last child the result of a complete tear for which she refused operation.

During th© course of the case the patient was put on many diets
none of which seemed to agree. There was some dehrium, vomiting
and fever continued. A proctoscopic examination showed externally
an old vaginal tear which evidently had involved the sphincter ani;
the rectum was separated from the vagina by a thin septum of dense
fibrous tissue. Through this i cm. above the external opening
a rectovaginal fistula had resulted. About the anus four other
distinct fistulae were seen two at least of which were complete. The
entire sphincter ani was sclerotic, unelastic and had practically no
tonus. The rectum presented with a thin, pale, smooth lining mem-
brane. The appearance was not that of carcinoma but of a long-
standing inflammation. The patient did not improve but slowly
became weaker and died with failing heart and lungs full of rales.

The autopsy findings were briefly as follows: The body is that
of an adult female weighing about 70 pounds. Emaciation is ex-
treme and general. The skin is literally stretched hke parchment
over the chest and abdomen, the latter so flat that the iliac spines
protrude like pegs. The abdominal cavity is free from fluid, the
cecum is small, its diameter in situ being but 2 to 3 cm. Ad-
hesions difl[use and band-Hke are present at the hepatic flexure and
about the gall-bladder. The transverse colon has a midline ptosis
of 15 cm. From the splenic fl"exure to the rectum there is con-
siderable epiploic fat. The descending colon feels firm especially
at the level of the lower pole of the kidney where there is a special
thickening extending out into the perirenal fat. Upon incision the
cecum and transverse colon have a thin mucosa, at the splenic
flexure there are several small ulcerations and then sharply demark-
ated the descending colon changes to a picture which it presents
uniformly to the rectum. This change is a loss of the mucosa
which is replaced by a raised, firm, fibrous, ridged appearance not
unlike the intimal surface of the aorta in advanced sclerosis.

Microscopically frozen and paraflin sections taken at difi'erent
levels show a decided loss of mucosal epithelial elements with a
progressive inflammatory process. This consists of a marked
hyperplasia of round cells, fibroblasts and adult hyalinized connect-
ive tissue. This inflammatory condition is mainly present in the

830 lott: pelvic infection following abortion

mucosa and submucosa with extension into the muscular and sub-
serous coats to a lesser degree. Where the denser mass was noted at
the pole of the kidney the same fibrous inflammatory change has
taken place. The appearance as a whole presents a striking resem-
blance to the leather-bottle stomach of the benign type. The other
features of the autopsy are degenerative and atrophic in type.
These involve the liver and kidneys with marked atrophy of the
stomach, atrophy of the pancreas, brown atrophy of the stomach and
atrophy and emphysema of the lung with terminal congestion and
edema.

discussion.

This case presents a history of incontinence of feces of long dura-
tion dependant possibly upon typhoid fever but more probably
upon a severe laceration of the perineum at childbirth. Toward
the end she had the wasting and cachexia of malignant disease. In
the absence of specific data it may be assumed that the condition
started in the rectum as an acute traumatic colitis which progressed
by extension ulceration until the entire descending colon was in-
volved leaving a trail of fibrous organization behind. This resulted
in denuding the terminal colon of epithelium and once its protective
factors were removed a low grade of chronic inflammation continued.
This no doubt allowed absorption of fecal toxins bacterial or other-
wise with the resultant degenerations and atrophies.

The result of colectomy in this case can only be speculative but
in the early or even moderately advanced stage it would seem that
such an operation might be warranted.

PELVIC INFECTION FOLLOWING ABORTION. A CASE OF
INTEREST.

H. S. LOTT, M. D.,
Winston-Salem. N. C.

This case, to me, presented features of unusual interest as a
gynecologic study. The woman was about thirty years of age,
and married. Several conceptions had occurred, but none had
gone to full term, five months being the most advanced one, the
others aborting at a few weeks. The patient, at the time of my ^'isit
to her home at the request of her physician, had been confined to
her bed for eleven weeks following a supposed abortion. A satis-
factory account of the thrown-off product could not be obtained,
although the clinical history confirmed the diagnosis. There had
been some slight chills, and the temperature was ranging from normal

tOTT: PELVIC INFECTION FOLLOWING ABORTION 831

to loo and loi. The patient was much emaciated, because she
could not take food and because of almost constant pain. The
pain was entirely characteristic of pelvic pathology involving the
procreative organs; viz., recurrent, rhythmic, paroxysmal and expul-
sive. During my visit a paroxysm occurred, and the woman gave
evidence of much suffering. Vaginal examination revealed very
little apart from the usual in such cases, a tender, fixed uterus;
with palpable masses on both sides together with some tenderness,
which was most marked on the left. Menstruation was recurring
with regularity and was now about two weeks past; with a vaginal
discharge in the interval. The case seemed to me, one whose best
chance would come through surgery, and my advice to send her into
the hospital met the approval of all concerned.

Just what an incision would reveal, was a matter of uncertainty,
the three greatest possibilities being, either an ectopic, a dermoid
cyst or immense pus tubes (and I say immense because the mass
could be easily palpated through the abdominal wall), but the one
certainty was infection, in either one or a blend of these possibilities,
and deeming it unwise to invade this pathology in the midst of an
active conflagration, the diet was confined to liquids, and the pelvis
covered with ice. Within a week the patient was very comfortable,
there was no recurrent pain, the tenderness from above was much
less, the bowels were easily moved, the kidneys secreting well, the
appetite good, while with 5 grains of veronal at bedtime, the patient
was revelling in long nights of sleep; and last, if not least in impor-
tance, the temperature was normal. A hot bichloride douche,
i-io.ooo, had been given daily.

Such normal conditions existing for forty-eight hours, the case
was deemed safe for operation, and posted for the following morning;
but, during the night, the menstrual flow appeared, under seemingly
normal conditions; and, acting upon the principle that has always
governed me, in any case of the kind, and believing that surgical
trauma to pelvic organs, in the midst of the congestion of a menstrual
epoch, is not only unwarranted and unsafe, but discourteous as
well, the operation was postponed until this period was past.

After three days of normal menstruation, with a normal rise of
temperature under such conditions, the "flow" was over, and the
patient again permitted a twenty-four-hour respite for reconstruc-
tion which was passed in perfect comfort, and with a normal
temperature.

Again the time was set for operation, but to my consternation,
upon taking a look at her chart on the following morning, there

832 lott: pelvic infection tollowing abortion

was a record of a subnormal temperature, with abdominal pain, some
nausea, and marked distention, these having appeared during the
night. Upon making an examination of the patient, this report
was not only confirmed, but the fact of a general, and active peri-
tonitis fully estabhshed. Now, that an "accident" had occurred
within the abdomen, was very evident, and also that the time for
interference was not favorable equally so; therefore, the waiting
plan, with restriction of about all else, was again estabhshed. For
two days this picture was practically unchanged; but on the third,
the temperature had regained the normal, distention and tenderness
were less; the pulse, which had been very thready, again was fairly
good, and it seemed to me that a day of this would justify at least
an incision and drainage, a need of which was almost beyond a
doubt. Therefore, on the following morning, under ether anesthesia,
and through a median incision, the following pathology was
estabhshed.

A general peritonitis, with agglutination of coils of intestine, as
well as gentle adherence to abdominal peritoneum. Agglutination
of all intestines to pelvic content, division of which, through a line
of cleavage, revealed free pus everywhere, evidently the output
of three nights previous, although its point of exit could not be
determined. Hooding the uterus, and presenting well up above the
pubic symphysis, were two immense pus sacs, which, upon careful
examination, proved to be burnt-out craters, composed of ovarian
wall, and containing a large quantity each, of mixed pus, for the
odor was marked. Mixed pus in these cases accounts for the tem-
perature curve. In the case of each organ, all ovarian stroma was
gone, and nothing but a shell remained. The tubes were twined
about these foci in their characteristic manner. All free pus was
sponged from the cavity, and an enucleation of tubes and ovaries
effected in as thorough a manner as was consistent with the vitality
of the patient. Intestines were freed in the immediate vicinity,
although it was not deemed wise to carry such invasion too far.
The entire abdominal and pelvic cavities were flushed out with an
abundance of normal saline solution, three deep drains carried down,
one on either side, and one just above the fundus of the uterus, com-
ing out at the lower angle of the incision, and closure effected to the
point of their entrance. The reaction from the operation was really
much better than might have been expected, considering the low
vitality of the patient, and save for very uncomfortable distention
from infective ileus which persisted for about four days, the post-
operative history has not been unusual.

MCCLOSKEY: maternity superstitions of FILIPINOS 833

In retrospective \'iew of the history of this case, as well as in its
operative findings, some features, to me, are of much interest and
value. Among them, a leading one is, "when to operate." Natu-
rally, it has occurred to me that prompt exploration upon entering
the hospital, might have prevented the subsequent occurrences,
with their forbidding aspects; and yet, had this exploration been
made, in the presence of active inflammatory conditions, and fol-
lowed by a fatal result, I should have beUeved that I was to blame
for the tragedy. Later, when menstrual function was established,
the addition of surgical trauma, in the midst of the inevitable uterine
congestion existing, must have done violence to my conscience,
and to my sense of common courtesy as well.

Again, and of equal interest, both from a scientific and a practical
viewpoint, let us remember that the ovaries, botk, were spent
craters; only shells of the organ remaining, with no chance for the
perpetuation of productive function, or other controlling influence
in the economy, and yet the cycle of menstruation had continued,
with a fairly normal rhythm, and a fairly normal clinical history, thus
establishing the fact, which it seems to me would be such a com-
fortable acceptance, that "the uterus is the organ of menstruation."

MATERNITY SUPERSTITIONS OF THE FILIPINOS.

ELSIE P. McCLOSKEY,

Superintendent of Nurses and Principal of the Philippine General Hospital

School 01 Nursing,

Manila, P. I.

Superstitions are, of course, not peculiar to any one people or
time. There are certain general superstitions which, in a slightly
modified form, are practically of world-wide distribution; there are
others peculiar to ages, times, and races; and there are still others
peculiar to countries and localities.

In common with other countries, the Philippines has its share of
medical superstitions and its own particular brands of magic for
the cure of all iUs. Being a young country with less experience in
the customs of modern civilization, many of the superstitions are
of very primitive character. Some of them are dangerous, but many
of them are harmless, except where they interfere with the applica-
tion of scientific methods in the relief of suffering.

During the last few years the more subtle methods now in vogue
in older countries are being introduced, so that this is fast becoming

834 mccloskey: maternity superstitions of Filipinos

a fruitful field for patent medicines, pseudoscientists, cultists, and
others who hold sway in other countries.

There is a belief among the Filipinos of the lower class that chil-
dren become sick of fever as a result of extreme pleasure coming to
some other person or when the child has been frightened by an
animal. In order to discover the person or animal causing the
disease, "tawas" is performed which consists in putting a piece of
alum on the fire and the person or animal is guessed from the dif-
ferent figures formed by the smoke. If the disease is caused by a
person, an invitation to call at the house of the sick child is made,
and this person deposits a small amount of his saUva in the mouth
of the child who then is rapidly restored to health. "Tawas" is
practised rather extensively, and it is possible that it is means of
transferring communicable diseases, such as tuberculosis and sj^hilis.

There is also a belief that eruptions, especially scabies, should not
be cured, because if cured they may reappear in the internal organs.

In a certain district in Tayabas province, the people of the lower
class believe that new-born babies should not be cured of illness for
they are angels, and that if they become sick and die it is because
God wants to keep them near Him.

Midwives in this locality believe that the fetus of the eleventh
pregnancy attended by them should die, in order that they may be
considered good midwives. " From this I infer '', the physician making
this report says, "that the majority of midwives, if not all, have
committed infanticide which is, of course, a crime that should be
prosecuted."

Recurrences of illness of any kind (binat) are prevented by burning
fowl feathers beside the sick person.

One of the most extensive therapeutic customs in the Philippines
is the so-called "buga" which consists of masticated herbs — -fre-
quently betel leaves, areca nut, lime — mixed with saliva; it is applied
directly from the mouth to the different skin eruptions, such as,
eczema, erysipelas, and impetigo, and especially those eruptions of
serpiginous character which are called "abas" (snake). Children
covered with scabies from head to foot sometimes die from septicemia
in consequence of the practice of "buga."

In the provinces over 90 per cent, of all deaths occur without
medical attendance; some people do not call a physician on account
of being poor and unable to pay for his services, while the majority
believe that medicines from drug stores are not suitable for them
in view of the fact that they are being fed almost exclusively with
vegetables, and for such there is no better remedy than the herbs

McCLOSKEY: maternity superstitions of FILIPINOS 835

prescribed by " mediquillos " or by some neighbor. The "medi-
quillos" are trying for their own benefit to keep this belief alive
among the common people. In most places in the Philippines, the
"mediquillos" are more frequently called than the physicians, and
sometimes they succeed in making small fortunes at the expense of
ignorant people. They usually charge from 50 centavos to 2 pesos
or more per visit, and they are frequently paid in palay, hens, eggs,
fruit, etc.

There are manv persons in Manila as well as in the provinces who
die without medical attendance, but whose funerals are held with
pomp and ostentation. If the family is out of money, their clothes,
jewels, house, lands, or draft animals are pawned in order to get
money to meet the expenses of the funeral and to celebrate a feast
during nine consecutive days (diaruhan 6 bankayan) or only on the
fourth day (apatang arao) or the ninth day (katapusan).

In Tayabas there are persons who have pawned their farms or
their cocoanut plantations in order to secure money for the expenses
of weddings, baptisms, or funerals. Sometimes they become unable
to redeem their properties, and as a result they are compelled to
become tenants instead of landlords.

It is a custom in the Philippines among the poor class to help the
family when one of its members dies. The neighbors come to the
house of the deceased and deposit in a dish, especially prepared for
the occasion and placed near the cadaver, 10, 20, or 50 centavos,
or more, according to the financial standing of the visitors, in order
that the family may be able to pay funeral expenses. While the
sick person is still alive, no one cares for him even if he has nothing
with which to buy medicine or pay for the medical service. The
kind feelings of the neighbors are only shown when a member of
society has already disappeared and whose life might have been
saved if the kind feelings of the relatives and neighbors had been
shown in due time.

Superstitions regarding conception and childbirth are particularly
common among the less educated people, in consequence of the super-
stitions many queer maternity practices are encountered.

The more usual superstitions and the faulty maternity customs
as practised in most countries have been published and exposure
of the irregularities has been an important factor in improving
midwifery practices.

It is no reflection on the educated class of Filipinos to discuss the
faulty and frequently dangerous customs of their own ignorant
classes, which after all are no worse than those encountered in older

836 mccloskey: maternity superstitions oe eilipinos

countries; and just as has happened elsewhere pubhcity should lead
to better service for the poor.

Most of the irregular, dangerous and queer superstitions of the
Filipinos have been published in various scientific journals and books.
These pubhcations have been consulted and freely quoted in this
article.

Particular mention should be made of the exhaustive report of
the Government Committee on Infant Mortahty which acting under
special law, with special appropriations and under the Chairman-
ship of Dr. Musgrave spent two years in accumulating data on all
phases of infant mortality. One chapter of this book is devoted
to "Medical Superstitions."

Dr. Rebecca Parish, Dr. F. Calderon, Dr. Acosta Sison, and others
have published articles on this subject and extracts and quotations
from these are freely used here.

Among the most common superstitions regarding pregnancy and
childbirth are the following:

When a woman suffers from any disease during pregnancy or an
accident takes place during labor, it is said "na amuyan" (she has
been smelled). It is believed that there is an enormous animal
whose sense of smell is so powerful that the odor of a pregnant woman
is recognized by it at a long distance and that when such person is
discovered by this animal she suffers death during pregnancy or
during labor.

It is said that a pregnant woman must not stop at the door when
she enters her own or another's house, otherwise the fetus will not
come out when the time of delivery arrives; she must not lie down
across the grain of the wood or bamboo forming the floor, because
a transverse presentation of the fetus will be the result; that in cook-
ing rice she must not scorch anytliing in the fire, in order to avoid
bowel movement during labor; that wood must not be placed in
the cooking stove top end first, so as to avoid breech presentation
of the fetus; that she must not tie a handkerchief around her neck,
in order to avoid twisting of the cord; and that she must not sew
the clothes for her body, to avoid imperforated anus in the child.

To facihtate the expulsion of the placenta, a pot cover is placed
on the head of the parturient; to restrain a puerperal hemorrhage,
red silk is tied around the thumbs and big toes. ' Besides this, the
midwives compel the parturient to assume a squatting position and
a very strong knot of the hair is made, with the object, so they say,
of preventing the blood from running toward the head.

Frequently during the months of gestation the ignorant woman's

MCCLOSKEY: maternity superstitions of FILIPINOS 837

peace of mind is constantly disturbed by the many superstitious
beliefs that are recounted from generation to generation, and are
steadfastly adhered to and heeded. The young women especially
are in continual mental terror lest some of these things be violated,
and the consequences are dreadful to contemplate.

If any one stands in the door in the presence of a pregnant woman
it is a sure sign that at the time of her labor the child will also stop
in the door of the uterus.

The prospective mother must not step over the tether of a pony,
while out walking, or a difficult labor will surely result.

Very tight belts and strings, worn about the waist during preg-
nancy, will insure an easy delivery and will also prevent the child
growing too large.

Many times the pregnant woman is forced to engage in the most
arduous exercise, a favorite one being grinding rice; this causes an
easy delivery and is certainly effectual, as the babe is sometimes born
at the mill.

During the course of even a normal pregnancy it is necessary for
the midwife to make frequent examinations, and not infrequently
she considers it proper, to "change the position;" or "place the
baby," and she receives lo centavos for each such service.

Perhaps the most prevalent and terrifying of all the superstitions
is concerning the "aswang/' an imaginary being, half man and half
beast; indeed, there are many "aswangs," and it is said that in
Tayabas Province there was an entire family of beautiful girls, all
of whom suddenly became "aswangs" one night. This creature
prowls around at night and is the terror of the patient and all her
relatives, because he watches to get the blood of the patient and to
steal the child; and as he Hves both in the air and upon the land,
and is guided in his night depredations by a bat, it is next to im-
possible to feel free from him at any time. During the latter
months of pregnancy it is necessary for the women to sleep under a
black cover, so that the "aswang" cannot see her; and frequently
there is a fire kept burning under the house, so that the smoke may
keep him away. It is exceedingly dangerous to be out after dark,
and if the woman does go out at this time it is necessary to wear the
hair loose down the back, which is her protection against the
"aswang" influencing her child and causing him also to be an
"aswang."

As a rule, the Filipino woman is verj' indefinite as to the time
when her pregnancy will terminate, and consequently she is rarely
prepared for this event; however, very little preparation is required,

838 mccloskey: maternity superstitions of Filipinos

except the "midwife," who is considered quite sufficient for her
needs, and in many instances she cannot afford this luxury. In
some provinces, it is said that men act as assistants and are better
for this purpose, as they are stronger and can apply more force in
kneading, pressing, squeezing, pulling, and pushing, as all of these
operations are considered essential. Short stout clubs, made of
wood, stone, or burned clay, sold in the pubUc markets, are used a
great deal for pressing, pushing, and kneading, and are considered
much more effectual for the purpose than is the hand.

To ease the labor pains, "bagabaga leaves" are burned near the
patient, that she may get the odor. The waist is tied about tightly
during labor, to make sure that the child passes downward instead
of upward.

In some cases, the delivery of the placenta is awaited before the
cord is cut, but if the placenta is not expelled within an hour, at
least, it is pulled away by traction on the cord, and Lf this proves
too difficult the cord is severed and the placenta is left in the uterus.
Guava leaves soaked in warm oil and placed on the abdomen are
said to aid in the expulsion of the retained placenta.

The placenta with a paper and pen, buried under the house, will
insure a bright and intelligent child.

It is said that a soup made from small pieces of the placenta and
given to the mother as her first postpartum nourishment, prevents
fever, weakness, and other forms of illness.

The mother is given large quantities of rice and urged to eat, so
that the abdomen will be filled, as it was so large before. The
waist is tied after labor, to prevent the abdomen filling full of wind
when the patient breathes deeply, and also to prevent the blood
from coming up and out of the mouth. The bones of the sacro-
iliac joint are separated during labor; therefore a strong band is
placed about the hips and tied tightly by two men, one bracing
himself on either side, with his feet against the patient's body.
Sutures are not required, because an external douche of an infusion
of bayabas leaves will heal lacerations in three days. The patient's
abdomen is rubbed with oil for twenty-five days, so the uterus will
become soft and send out the blood, thereby becoming small.
Hemorrhage is encouraged by propping the patient up with pillows
(sometimes as many as seven); this also prevents the uterus going
high in the abdomen, and causes the bad blood, which must be
gotten rid of, to drain better. Frequently the patient is almost ex-
sanguinated, and death from hemorrhage may occur without any
effort being made to check the bleeding.

mccloskey: maternity strPERSrixiONS of Filipinos 839

Sleep is not allowed, because it produces a tendency to insanity.
Frequently the patient is allowed to sit up and even to stand, within
a day or two after delivery. After-pains are greatly helped by the
patient's getting the odor of burning deer skin. After three days,
the procedure of "replacing the uterus" takes place. For nine
days it is thought bad to eat salt or drink cold water. About the
tenth da;y the woman is bathed with a little warm water, and smoked
by having a mat enclosing her and a jar of burning leaves; following
this, if there is a suspicion that the uterus is still 'raw', a fire is made
of charcoal in a large earthen pot, and the patient stands astride
this, surrounded by blankets and supported by her friends. It
requires an hour of this treatment to cause the uterus to "dry-up."
For three months the woman should not put her hands in cold
water, drink cold water, nor take a cold bath. This rule evidently
does not apply to laundresses, whose occupation calls them to the
river or spring.

No antiseptic precautions are known; old rags, old clothing, and
the family bedding are used about the parturient.

Recently, I saw a woman who gave a history of eclampsia, with
the following treatment: While she was unconscious she was placed
in a sitting position on a red-hot stove; when she regained conscious-
ness she was suffering from a severe burn, which produced extensive
loss of tissue and scars larger than my two palms. It is said that
this hot-stove treatment is quite common.

All sorts of superstitions are in vogue concerning the care of the
infant; it must be guarded from the "aswang" and must be fed with
curios concoctions. The cord is dressed with ashes, powdered
cocoanut shell, or hot tallow. I saw one new-born child with many
little cauterizations about the umbiUcus, made with a hot bamboo,
as a cure for convulsions.

In cases of continuous crying of the child, which is considered
the premonitory symptoms of convulsions, a piece of alum is rubbed
on the frontal region, on the palms of the hands, and on the abdomen.
The alum is then burned, and they observe with attention the course
of the smoke, from which they decide the kind of disease the child
is suffering from. The carbonized alum is then dissolved in water,
and a certain amount of it is administered to the child.

It is not the custom of the people to celebrate fiestas (nine days)
when the dead person is a child under seven years of age, but from
seven years and up it is considered an adult, and such nine days of
fiestas are required.

The practice of the "intruders" in Tagalog provinces is different

840 mccloskey: maternity superstitions of tilipinos

from that used in Ilocano provinces. In the former, a solution of
cogon roots is used as an oxytocic, and in many cases when the head
of the fetus is noted in one side of the h>-pogastrium, which is the
normal position, the pregnant woman is subjected to a method
known as "buncal," which consists in changing the position of the
fetus by placing the head in the median line. At the time of the
childbirth, ordinarily an assistant known by the name of "salag"
intervenes. The " salag " pulls on the fetus to facilitate its expulsion,
and this person may be a man or woman. The result of this practice
is in many cases, the laceration of the perineum.

If the expulsion of the fetus is not obtained by means of "salag,"
the parturient is put in a sitting position on the edge of a chair and
then the perineum is compressed, after which the parturient is
again placed on the bed.

Obstetrical comphcations, such as eclampsia and puerperal mania,
are attributed to the "aswang," and evil spirit, and to the "mang-
kukulam," a witch, said by superstitious persons to be the torment
of parturient women.

In cases of puerperal hemorrhages, the intruders order that
pieces of bamboo be burned under the house, in order to keep the
parturient warm; and in one known case the house caught fire as a
result of this practice.

After childbirth a tight band is put around the waist, then com-
pression is made by two persons, one sitting on each side of the
parturient and pulling on the ends of the band, it is said, to close the
genital line. This practice is known as "el sara."

It is believed that a person who menstruates must not stand on a
mat of the parturient, because it causes cohc to the sick woman,
and that a person standing by the door of a house prevents the
expulsion of the fetus.

Massage lasts eight days, at least, in the case of the mother, and
is so strongly made that the patient suffers a great deal, weakening
her unnecessarily.

Hemorrhages and septicemia are frequent complications in the
provinces, and prolapsus is produced by untimely massages.

The parturient must not take a bath before thirty days, which
is the puerperal period to them.

The "saclap" is seldom used by the Tagaiogs, but hot baths are
frequently used.

After birth the child is washed in lukewarm water; some use
cocoanut oil instead of lukewarm water to clean the grease away.

The children are not fed during the first three days, but a purgative

MCCLOSKEY: maternity superstitions of FILIPINOS 841

of castor oil is given, pure or mixed with "jarabe de ruibarbo,"
or "achicorias" (lo grams daily of the mixture), and after ten days
the purgative is again given, but the dose is increased. After the
three days of purgative, maternal or artificial feeding is given and
continued irregularly until the age of six months, when cooked rice
or any other available food is substituted. Young children receive
the treatment of "mainit," which consists of hot applications to
the scrotum and umbilicus.

The Ilocana woman takes a bath immediately after childbirth
and during sixteen consecutive days. Immediately after bathing,
she stays for the whole day beside a hot stove, in order to heat the
pelvic regions. The "mainit" in this case consists of a piece of
clothing moistened with alcohol, which is placed over the perineum
and tied around the waist. This is called "bahag." The "saclap"
consists of a receptacle with burning charcoal, on top of which is
placed a kitchen utensil known as "diquin," over which the par-
turient is put. This is not practised in bad weather.

In addition to the loss of life due to incapability of delivery on the
part of the mothers, children attended by these midwives usually
die, either at the time or after the childbirth, the cause being the
untimely purgative and awful treatments to which they are sub-
jected. Plenty of purgative, massage, "amorgoso" juice, and
" upus ' ' plaster constitute the therapeutic measures of these intruders.

In cases of apparent death of children when they are delivered,
the umbilical cord is squeezed from the placental juncture to the
abdomen, and then the placenta is burned. Sometimes the index-
finger is introduced into the infant's mouth and strong pressure
over the palate is made to open the nasal fossae.

When a child is born face downward, another operation known
in tagalog as "boyon boyon" is made, the purpose of which is to
induce the expulsion of excrement of greenish color, known as
"sawan" in tagalog and "calamayu" in Bicol, which is, so they
say, the cause of convulsions. The operation is made in the fol-
lowing form: The hands and feet of the child, joined together, are
raised, leaving the spine on the bed; a quick extension is then
made, after which the hands and feet are loosened in a rough way.

Inguinal hernia is avoided by hot applications to the testicles.
This is usually made every day during the first week after birth,
and after the bath during the remaining few weeks.

When a child of tender age is attacked by convulsions, burning
pieces of cocoanut shells, which have been previously cut in a
triangular form, are applied around the mouth, and after this

842 MOORE : .ABORTIVE TYPE OF GENERAL SEPTICEMIA

operation a small amount of "boa" (snake) gall or iguana gall diluted
in milk or water is given.

Not all of these customs are wholly bad; even some of the most
crude are primitive expressions of a pathetic struggle after the light
and a blind effort toward self-preservation and the perpetuation of
the race.

THE ABORTIVE TYPE OF GENERAL SEPTICEMIA, FOL-
LOWING PELVIC INFECTION IN PREGNANCY;
AUTOGENETIC INFECTION; PUERPERAL
POLYNEURITIS.'

BY
S. E. MOORE, M. D., LL. B.,

Fellow in Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minn.
(With chart.)

FoTHERGiLL appears to be perfectly correct in his criticism of
the term "Puerperal Fever." Local and general septic processes
in the puerperium are infective, not infectious. The same micro-
organisms cause these lesions which are the etiological factors in
wound infection in any other part of the body. "Puerperal pelvic
infection" is a much better term, covering multifarious cases, which
may vary in nature, source, route, site, and date of the infection,
as also in nature, date, severity and locahzation of the resulting
inflammatory process. There is no such disease as "Puerperal
Fever."

The writer would like to apply the term "Squall" to this abortive
type of general septicemia, because of the stormy onset, a period of
activity and suspense, followed by the sudden and complete dis-
appearance of the alarming symptoms. Considering that the
mortality in the surgical fevers of childbed varies from lo per cent,
to 75 per cent, in various epidemics, it is with considerable concern
that the attending obstetrician views the history of a chill foUowed
by a fever, or any other suggesting phenomena of general bacter-
iemia in the puerpera.

Case Report.— B. W. (University of Minnesota Hospital No. 7776),
a rachitic negress, age nineteen, because of a contracted pelvis, on
September 9, iQi 2, was delivered by Cesarean section of a living full
term child at this institution. It is interesting to note the development
of a puerperal neuritis during her stay in the hospital at this time.
Three weeks following the date of her operation. Cesarean section in
191 2, she developed what appeared to be a mild attack of multiple

MOORE : ABORTWE TYPE OF GENERAL SEPTICEMIA

843

neuritis, characterized by tenderness of the muscles and nerve trunks
of both arms, hyperesthesia of the posterior tibial muscles, slight
nystagmus, myoidema and tremor of the fingers of both hands.
These caSes of puerperal neuritis are extremely rare, some cases be-
ing reported by two German physicians, Moebius and Mader. No
case has ever been reported at the Sloane Maternity Hospital, New
York. This patient was again admitted into the maternity wards,
in labor on December 30, 1915; one-half hour afterward she was
delivered of a female fetus, which was probably between five and

DAY OF

140
130
120
110
100
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80
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97°
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RESPIRATION

six months of age. The cardiac and respiratory functions of the new-
born continued wdthout artificial aid for more than eleven hours,
when they ceased. The weight of the infant was 630 gm. and it
measured 32 cm. As the average weight and height of a five lunar
months fetus is from 250 gms. to 28ogms. and 17 cm. to 26 cm. respect-
ively, and one of six lunar months weighs on the average 645 gm. and
measures 28 cm. to 34 cm. (DeLee), the age of the infant under discus-
sion was appro.ximately slightly more than five and one-half lunar
months. The period of gestation, based on the menstrual history
confirmed this calculation, being about twenty-two weeks and five
days in duration. The eyes could be opened, the subcutaneous
fat was poorly developed, vernix caseosa was beginning to be formed,
but notwithstanding its creditable attempt at self-preservation, the
child's death ensued in twelve hours. The ultimate result, however,

844 MOORE : ABORTI\'E TYPE OF GENERAI, SEPTICEMI.\

would have been the same, death resulting from starvation and con-
gelation due to the undeveloped state of its necessary vital systems.
The rearing of such infants belongs to the domain of either a fertile
imagination or a remarkable capacity to subsidize the truth.

Three weeks before admission on December 30, 1915, patient
said that "some water had come away," and one week later "had
a small show of blood" unaccompanied by any pain. About one
week before coming to the hospital she passed several clots, and on
the night before her admission to the institution she began to bleed
quite profusely, which continued until the fetus was expelled.

The patient was poorly developed, ill-nourished and quite badly
deformed from her scohorachitic condition. She suffered from
dental caries and pyorrhea alveolaris so frequently found in her
class. The thyroid was slightly enlarged and her tonsils had pre-
viously been removed. The only other point of interest in her
history was the presence of tenderness over the anterior tibial
muscles, which later proved to be neuritis of a mild type. Previous
to her entrance to the hospital she had had an antepartum chill,
followed by a rise in temperature. She was delivered at 11.00 a. m.
At i.oo p. M. two hours after her accouchment, the patient suffered
from a severe chiU and at 2.20 p. m. her temperature rose to 105°,
her pulse being 132 at this time. She complained of no pain in any
region and there were no abdominal symptoms. At 3.00 a. m. the
following morning the patient suffered from another chill and at
4.00 A. M. her temperature registered 104°, pulse 140. Her tempera-
ture gradually declined during the next twenty-four hours and on the
morning of the third day of her illness, it was practically normal,
where it stayed during the remainder of her sojourn in the hospital.

At 3.30 p. M. on the second day of her puerperium, Dr. W. C.
Johnson, the pathologist of the University Hospital, took a blood
culture and found a pure growth of staphylococcus aureus. A
throat culture proved to be negative. The blood count on the same
day showed 11,200 leukocytes and the following differential count
was reported, polymorphonuclear 69.5, lymphocytes 28, transi-
tional 2, basophiles c.5. On the seventh day of the puerperium
another blood culture was taken, which proved to be negative, but
a culture from the lochia showed many colonies of staphylococcus
aureus.

A final pelvic examination made on the ninth day proved to be
negative in all details.

At no time was the lochia unusually foul. The patient during
the acute stage of her illness always felt very well and complained
of no unusual symptoms. Nor was her desire to get up during her
febrile period interpreted as an e.^cample of that dangerous symptom,
due to the dulling of the higher centers, seen quite frequently in
bad cases of puerperal sepsis.

As this was a case of antepartum infection what was its source,
and the nature of the primary lesion?

She positively denied any attempt on the part of herself or any-

MOORE : ABORTWE TYPE OF GENERAL SEPTICEMIA 845

one to induce an abortion. The last vaginal examination had been
made over a month previous to her confinement, by a member of
the obstetrical staff of this hospital. If her statements are correct
in this regard, the method of infection was probably autogenetic
and not heterogenetic. Although there is a difference of opinion
in regard to the normal puerperal uterus being sterile, most investi-
gators who have been particularly careful in their technie, have
found it uncontaminated. Fifteen per cent, of normal puerperal
vaginal cases examined have been found to contain streptococci
by some observers. Foulerton in England found that the colon
bacillus and staphylococcus albus are frequently present in the
vagina of the normal puerpera, but was unable to isolate any organ-
ism of greater virulence in the normal cases examined. Streptococci
are frequently found on the vulva. The pneumococcus, gonococcus,
streptococcus and staphylococcus aureus are found in the vaginal
cervix and vagina under abnormal conditions.

As the virulence of pathogenetic bacteria declines in the absence
of reculture upon a suitable medium, and increases by transference
from one person to another, it probably can be said that many cases
of autogenetic infection are quite mild compared to heterogenetic
sepsis.

Note the history of this case. Three weeks before delivery a
slight discharge of amniotic fluid took place, possibly due to a rent
in the membranes high up ; two weeks before her labor, a show of
blood presented itself, and one week thereafter she passed several
clots. She bled freely the night before she was confined.

The virulent germ staphylococcus aureus, only a visitor in the
genital tract under abnormal conditions, was found in the vagina as
stated above; the discharge of amniotic fluid denoted an open avenue
for infection in the amniotic sac; the blood clots discharged on more
than one occasion offered an open wound for infection. The result
was logical. An ascending growth of staphylococcus aureus from
the vagina to the fertile soil in the cervix or uterus.

Pyorrhea alveolaris and other distant foci are usually considered
too remote a source for genital infection by many authors (Jaggard,
Leopold, Doderlein, Kronig, Forchier, Williams), and in the writer's
opinion the individual had probably developed a fairly well-organ-
ized resistance to the bacteria producing that chronic affection.
Wegelius, DeLee, and Walthard among others, although admitting
the possibility of autoinfection, prefer to apply the term only to the
genital tract as the primary source of infection. A migration of
organisms from this large intestine might offer an explanation of

846 MOORE : .^BORxrv'E type of general septicemia

the source of infection. Where did this poorlj' nourished, rachitic
patient develop her great resistance? Perhaps her lysins, opsonins
and agglutinins in virile power, depended upon a tenement life, a
squalor resistance, or an acquired strength against certain germs,
following their autogenetic existence. The emptying of the uterus
probably assisted her recovery.

Modernists are disregarding that theoretical division of puerperal
sepsis into sapremia, septicemia and pyemia for the hypothesis
upon which it was based has not been born out by fact. In all local
infections of the genital tract bacteria in varying numbers migrate
into the blood to be annihilated. Therefore, a diagnosis of malignant
septicemia cannot be made from a blood culture alone, and further-
more pathologists are now teaching that such organisms as the
streptococcus and colon bacillus may assume the mantle of the
saprophyte and so produce merely a septic intoxication. It can be
stated probably with reasonable certainty, that this was a mild
attack of general septicemia caused by an active organism, the
staphylococcus aureus, which, when gaining ingress to the blood
channels was quickly destroyed through the agency of a well-
developed resistance against such bacteria.

This case is probably not an unusual one as far as obtaining a
blood culture of the offending organism is concerned. But in its
abortive nature, considering the violence of the invasion, it is perhaps
atypical. Very likely there are many cases diagnosed by the in-
appropriate term of sapremia, which if a blood culture was taken
would show a true bacteriemia. A blood culture is frequently
difficult to obtain, however.

Later in the puerperium smears from the pyorrhea present showed
a great variety of organisms but very few cocci were seen. Smears
from the vagina showed bacilli and cocci. Cultures from the mouth
vagina, cervix and uterus were negative for staphylococcus aureus,
The staphylococcus albus was found in the vaginal and cervical,
cultures.

Recently Zangemeister and Kerstein (Arch. Gynak., 191 5, civ)**
have come to the following conclusions in regard to autoinfection
based on careful clinical studies and observations upon pregnant
women. That bacteria capable of producing rise of temperature and
other disturbances are present in and about the genital tract of
pregnant women, who have never been internally examined, that
these bacteria are found in the lower portion of the genital tract
in 89 per cent, of cases examined and in 25 per cent, of cases
examined they were found in the upper portion. Clinically in

miller: management of ectopic pregnancy 847

the occurrence of fever in patients, in whom germs were found in
the genital tract before labor, showed that these bacteria undoubt-
edly produce infection entirely apart of any bacteria introduced
during examination or manipulation. Many of these bacteria
are probably swept downward by the escaping amniotic fluid,
placenta and membranes, and by the after-coming blood and
serum. The blood serum following the removal of the placenta is
an excellent application to the wounds received during labor.
Serious infection does not occur in these cases, when the course is
from above downward. Sterile coagula plugges the uterine sinuses
and the uterus remains contracted. But frequent examinations
manipulations and unsuccessful attempts at delivery carry these
germs into bruised and wounded tissues to the cervix and produce
infection.

references.
Lancet, 1916.

American Journal of Medical Sciences, Nov., 1915.
De Lee. Obstetrics.
Berkley and Bonney. Obstetrics.

MANAGEMENT OF ECTOPIC PREGNANCY.

BY
A. MERRILL MILLER, M. D., F. A. C. S.,

Dani-ille, Illinois.

Ectopic pregnancy is a tj'pical border-Une lesion and may change
from a medical to a surgical condition in a very brief period. We
have had too many dogmatic statements concerning its management
in which the individual was not a consideration. At present the
most urgent need is a more acute sense of diagnosis, keeping this
condition in mind when confronted with lower abdominal lesions.

The mystery of extrauterine pregnancy has largely disappeared,
due to a wider knowledge on the part of the family physician. He
sees these patients first and, much to his credit, is making the diag-
nosis in an increasing proportion of cases. In consequence a vastly
greater number of them are being recognized before they reach the
tragic stage of rupture and exhaustion through hemorrhage. This
type of case will always be found due to the patient's indifference
to pelvic discomfort and the difficulties or impossibihties attending
an early recognition.

Diagnosis does not rest on any one individual factor. Much
work has been done and many theories advanced in an effort to

»4» miller: management of ectopic rsegnancy

discover the causes operating to produce this lesion. As yet, many
cases have been found whicli cannot be listed in the present classi-
fication. This want of completeness has stimulated many inves-
tigators to enter the field of research. It is certain that more than
one exciting factor exists.

The commonly enumerated causes, mechanical obstructions,
chronic inflammation (Huflfman), anomalous embedding (Webster),
decidual reaction (M. Schil), failure of unstriped muscle to contract,
cover a large number of cases. Even with this list of operating
causes there is still a considerable number which cannot be classified.

Because of highly organized structures involved, and the peculiar
tendency of women to be afltected by nervous influences, we might
attribute a considerable number of cases to a nervous condition.
I have presumed to offer a theory which, although not subject to
histologic proof, answers well as a working hypothesis. It pre-
supposes that some factor is involved which has an influence over
the entire reproductive system, and at once directs attention to the
nervous mechanism.

The tubes are Hned with cihated epithelium maintaining a wave-
like motion toward the uterus. Normally this carries the ovum
along its course in the direction of the uterus, and probably inhibits
the outward movement of spermatozoa toward the free end of the
tube. To maintain this wave-hke motion implies the presence of
continuous nervous stimulation. It is my belief that the arrest of
the fecundated ovum along the course of the tube is due to want of
motion of the ciHa, some disturbance in the automatic mechanism,
or absence of nervous impulse: a depressor neurosis.

Symptoms do not group themselves in any characteristic manner.
Vagaries are constant. A period may or may not have been missed,
often so but not constant. Bleeding may persist for weeks and be
the only symptom except pain, of the real condition. I think the
most constant symptom is a vague sense of discomfort, unilateral,
corresponding in location to the tube involved. An almost uniform
complaint, when symptoms are noted, is the rectal discomfort, aggra-
vated by stool or the use of an enema. Sterility seems so constant as
to impress one, yet I have seen this condition after five normal births.
The discomfort of first pregnancies often postpones examination
till a rupture has occurred.

Concerning the symptoms of an acute rupture, we have the
well-defined, easily recognized symptoms of shock, pain, rapid
pulse, subnormal temperature, vasomotor, relaxation and air hunger.
In dealing with acute shock from hemorrhage, we are confronted

DOYLE : DERMOID CYST OF THE OVARY 849

not with extrauterine pregnancy as such, but with a condition of
shock whether pulmonary, gastric or postoperative bleeding. If
any truth has been estabUshed as a result of a vast clinical experience
it is that death seldom occurs during any primary hemorrhage.

Pelvic examination may be as unsatisfactory as the history.
Due in part to firm abdominal walls, a nervous patient, an iU-de-
fined lesion, we are unable to do httle more than discover an acutely
tender tumor.

Since no constant factor has been discovered ailecting the cause
or frequency of ectopic gestation, nothing can be said concerning
prophylaxis.

The management of ectopic pregnancy is second only to its recog-
nition, and calls for the keenest surgical judgment. This will be
reflected in the mortahty reports. The treatment of an individual
patient cannot be decided by a preconceived notion of what that
treatment should be. Medical men seem to be of one opinion, that
the final and curative measure is surgery. When and where this
should be done is a test of diagnostic acumen and nice judgment.
Pain is best controlled by sufficient morphine to produce comfort.
Severe shock and a prolonged convalescence are best managed
by direct transfusion of blood.

So8 The Temple.

DERMOID CYST OF THE OVARY, WITH TWISTED PED-
ICLE, AND ACUTE APPENDICITIS, COM-
PLICATING PREGNANCY.

FRANCIS B. DOYLE, M. D.

Brooklyn, N. Y.

A REVIEW of the literature of the past fifteen years, reveals only
one reported case with the above interesting pathology (Gerster).
Cysts of the ovary with pregnancy are of rare occurrence. Samgin
in an analysis of the reports of two of the large foreign clinics found
only five ovarian cysts in 17,832 labors at the Berlin Gynecological
Clinic. In the St. Petersburg Lying-In Hospital, two dermoids
were observed in 10,893 pregnancies. Olshausen collected 2275
ovariotomies of which 80 (3.5 per cent.) were dermoids. According
to Pfannanstile they occur in only 7.5 per cent, of all tumors affecting
these organs. Deletrez discovered a gravid uterus only twelve
times in 1 132 ovarian tumors. Williams finds cysts of this type three
times more frequent in the pregnant than in the nulliparous

850 DOYLE : DERMOID CYST OF THE OVARY

woman. In a series of 331 dermoid cysts collected by jNIanton
in the past ten years, ninty-two were associated with pregnancy.
Most authorities agree that the presence of an ovarian tumor
during gestation, is one of the most serious complications, as it
markedly increases the probability of abortion and frequently
offers an insuperable obstacle to dehvery at the time of labor. More-
over, its presence gives rise to disturbances during the puerperium,
which menace the life of the mother. All varieties of ovarian tumor
may comphcate pregnancy and labor, but dermoid cysts seem to
occur with the greatest frequency. McKerron reported 107 cases
in which the nature of the tumor was stated and found 43 per cent,
dermoids. Again, Spencer reported forty-one cases with 30 per cent,
dermoids. These tumors should be removed as soon as the diagnosis
is made, neglect of this being fraught with grave consequences to
both mother and child. Remy found 17 per cent, abortions or pre-
mature labors in 321 pregnancies with ovarian tumors. In 721 cases
in which pregnancy was allowed to run its course, McKerron
found a maternal mortaUty of 21 per cent, while more than half of
the children were lost. In the early months of gestation the dangers
are most frequently from torsion of the pedicle and infection. The
presence of the tumor seems to have no influence on menstruation
or conception. A great, many women go to term without knowl-
edge of its existence, the growth of the neoplasm not being accelerated
as in the case of fibroids, and abortion only taking place in the pres-
ence of complications. Torsion, gangrene from pressure, rupture,
and suppuration take place in the later months. Herman reported
a case of a cyst blocking the pelvis during labor, child dead.

Case I. — H. A., married, primipara. Family history, negative.
In her ninth year was treated for pains in the lower abdomen
which lasted two months and then disappeared. During her thir-
teenth year these pains again made their appearance in the abdomen;
this time they were sharp and lancinating in character, radiating
down the right thigh. During the ne.xt three years the pains
occurred at irregular intervals. Menstruation commenced at six-
teen and took place regularly ev^ery eighteen days, was of three
davs' duration, accompanied by severe premenstrual and comenstrual
pain. Last menses occurred March 17, 1915. On August ist she
was seized with sudden sharp pain in the right lower abdomen with
vomiting and prostration. This attack lasted three days. One
week later pain appeared again in right side, this time more severe.
First seen three days after the beginning of the second attack.
Temperature 102, pulse, 120, respiration 34. Patient thin, rather
anemic, seemed to be in great pain. Heart and lungs negative.
Abdomen enlarged. Uterus about size of five months' pregnancy.

TRANSACTIONS OF THE NEW YORK ACADEMY OF MEDICINE 851

To the right at McBurney's point and lower is a large mass exqui-
sitely tender and painful. Vaginal examination was unsatisfactory,
as the shghtest pressure with examining finger caused intense
pain.

Operation August ii. Straight incision through the rectus.
Ovarian tumor found with two twists in its pedicle. Clamped and
removed. Just behind it was an acutely inflamed appendix, adher-
ent to posterior wall, which was removed. The patient's convales-
cence was uneventful. She left the hospital fifteen days after the
operation. For the first five days following the operation she was
kept under the influence of morphine.

The first of the following January patient gave birth to a healthy
normal child.

The specimen was a dermoid cyst of the ovary, 4 inches in diameter,
filled with sebaceous material. It contained six teeth, and some
hair. Numerous hemorrhagic areas were scattered over its surface.

145 Sixth Avenue.

TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, Held May 23, 1916.
Dr. George W. Kosmak, in the Chair.
Dr. D. W. Tovey reported a case of

RESTORATION OF ANAL CONTROL.

This patient, Mrs. K., twenty-eight years of age, had two children,
four and six years of age. Menstruation had always been regular,
though slightly painful. She was born without an anus, the feces
coming through the vagina and there being no control over the
movements which occurred immediately after eating. When twelve
years of age she was operated upon and the rectum placed in the
perineum. Ever since this operation, eighteen years ago. she had
had no control of her bowels, which move immediately after eating,
and continue to discharge for a couple of hours, the movements
being accompanied by large quantities of gas. The patient ate
breakfast and spent most of the morning in the toilet. She ate
no lunch for if she did she could not go out in the afternoon. She
ate dinner in the evening and spent most of her time during the
evening in the toilet. When first seen the patient was emaciated,
the abdomen distended with gas, the right kidney was in the iliac
fossa when she was lying down, and there was a general gaslroenterop-

852 TRANSACTIONS OF THE

tosis. The uterus was retroverted and movable. The vagina
and rectal opening were drawn up under the pubes. The rectal
opening was on the same level as the vulva, the mucosa was prolapsed
and pouting, and the anal opening was widely patent.

The patient was operated on on March ii, 1916. The peri-
neum was intact. The vaginal opening was closed by the action
of its muscles, the levator ani drawing it with the anal opening up
under the pubes. An incision was made along the mucocutaneous
junction of the vulva as was done in operations for suture of the
levator ani. The posterior vaginal wall was separated from the
rectum for 2}^^ inches. An incision was made in the perineum from
the mucocutaneous junction downward for an inch, to fully expose
the field. The rectum was separated from its attachments down to
the anal opening, as is done in vaginal extirpation of the rectum.
The internal sphincter was narrowed by sutures, the upper suture
being attached to the vagina. This was found to draw up the pout-
ing anal mucosa on the anterior wall of the anal opening. An inci-
sion was then made three-fourths of an inch posterior to the anal
opening and the wound deepened. The puborectalis was found by
tracing it backward from the anterior wound. It was sewed together
behind the rectum and the internal sphincter attached to it. The cut
ends of the sphincter ani were found in the anterior part of the pos-
terior wound and the coccygeal attachment, running back to the tip of
the coccyx, in the posterior part of the wound. These sphincter ends
were fastened to the coccygeal attachment of the sphincter. Su-
tures were also used to sew the puborectalis to the sphincter. The
posterior incision was then closed except for small rubber tissue
drains, which were carried around the rectum to the anterior wounds.
The anterior incision was closed by suture of the levator ani in
front of the rectum. The wound was closed with layers of buried
sutures of No. 2 chromic gut. The transversalis perinei were found
attached to the sides of the vagina instead of to the center of the
perineal body. Dr. Tovey believed that the surgeon, when he closed
the vaginal anus and placed the rectum in the perineum, cut the
sphincter ani and puborectahs in the perineum, and that they failed
to unite.

The patient had severe postoperative pain, reheved partly by
morphia and partly by J^ grain of quinine urea. The drains were
taken out on the fourth day. There was an infection of the posterior
wound due to hot compresses employed to relieve pain.

The patient now has to take cathartics to move the bowels, and
complains of pain in her abdomen due to gas retention, caused by
her enteroptosis. The writer believes that this can be relieved
by abdominal support and diet. There is some pouting of the anal
mucosa, but the anal opening which was on a level with the vulva
is now drawn up and the gluteal cleft has returned. The pouting
mucosa annoys the patient somewhat as it is constricted by the
sphincter. If it is pushed back it stays for a while and the patient
has been instructed to push it back after mo\-ement of the bowels.

Dr. Tovey presented the patient and called attention to the
position of the right kidney.

NEW YORK ACADEMY OF MEDICINE 853

Dr. John Van Doren Young reported a case and commented on

THE UMBILICAL CORD AS A FACTOR IN INFANT MORTALITY.

"This subject may be considered under two heads: The umbilical
cord as a factor in infant mortality (i) during gestation and (2) at
birth. Under the first subdivision knotting of the cord is the most
common cause of circulatory obstruction and consequent death of
the fetus in iiiero. One such case came under the writer's obser-
vation in which a tight knot caused fetal death at the eighth month.
There could be no possible determination of this accident prior to
fetal death and it must therefore be considered as one of the
accidents incident to pregnane}'.

"In the second class of cases I wish to draw special attention
to the encircling of the child's neck by the cord with the hope
that some light may be thrown on its causation, diagnosis, and treat-
ment. That the cord is frequently about the neck of the child is
a matter of common observation and is of importance only in rela-
tion to its length and elasticity, number of coils, and placental
implantation. Hydramnion is given as a cause of the cord encircling
the neck of the child, but it would seem to me an occurrence far too
frequent for this to be other than an incidental factor. Over-
activity of the child is coincident to and may be a cause.

"At birth an imperfectly flexed head with over-recedence between
pains, shock during pains, or symptoms of accidental placental
hemorrhage renders the diagnosis probable of an impeding of the
child's progress by the cord. The largest number of coils reported
as having been found about the neck of a child is eight. The treat-
ment is Cesarean section if the life of the child is to be considered.

"The case to which I wish to call attention is that of a primipara,
with normal pelvic measurements. She had had a laparotomy for
septic peritonitis eight years ago. The membranes ruptured spon-
taneously at 3 \. M., December 19, 191 5, while the patient was asleep.
Pains continued until 3 p. m. when I inserted a No. 4 bag. Full
dilatation was obtained at midnight. One-half ampule of pituitrin
was given at 12.15 ^nd at 12.48, December 20th. The head engaged
but over-recedence was noticed between pains and shock during
pains. The position was R. O. A. Tucker McLane forceps were
applied but all efforts failed. I then applied a.xis traction forceps
to the child, an assistant making traction on the bar while
I manipulated the handles. The patient showed marked shock
during traction. On delivery of the head the cord was found three
times about the neck, and pulled to an exsanguinated rope, a noose
being formed by the cord. The child was dead on delivery. The
placenta was posterior fundal in its implantation. The cord meas-
ured 106.5 cm. The circumference of the child's neck was 21 cm.,
this taking up 63 cm. of the cord. From the umbilicus to the neck
was 17 cm., making a total of 97 cm. This left 9.5 cm. play of the
cord from the umbilicus to the placental origin. (See illustration.)

"The deduction to be drawn from this case is that Cesarean section
was indicated by the over-recedence of the head, the failure of the

854 TRANSACTIONS OF THE

first forceps attempt, and the shock during pains or forceps traction;
it was contraindicated by the adhesions known to exist after the
septic peritonitis and operation."

DISCUSSION.

Dr. a. J. RoNGY said: "My brief discussion is based on the
complications of the cord met with in the last 10,000 cases from
the obstetrical services of the Lebanon and the Jewish Maternity
Hospitals."

"One should always suspect pressure on the cord when the head
reaches the perineum and no progress is noticed although the pains
are strong and at regular intervals, and if in addition a sudden altera-
tion in the fetal heart rate is discovered, labor should be terminated
quickly because of danger of death of the fetus. I am sure every
obstetrician has met with this clinical phenomenon. In one case
there were six twists of the cord around the neck. The neck in this
child was so stretched and thinned out that it appeared strangulated.
In two cases five coils of the cord were found around the neck; both
children were stillborn. In two cases there were true knots of
the cord causing the death of the babies."

"Since the introduction of aseptic and antiseptic methods, infection
of the cord very rarely takes place, particularly is this true since we
have adopted the method of dressing the cord with pure alcohol.
Alcohol tends to keep the immediate area around the cord dry, and
account of its bactericidal action the danger of infection is lessened.
In one case secondary hemorrhage from the cord proved fatal.
There were two cases of erysipelas of the cord and one case of abscess
of the cord; the three babies succumbed to the infection. In three
cases there was a complete hernia into the cord; in one case the colon
was found to terminate in the hernia; in two the hernial contents
consisted of coils of the small intestines. Two cases were operated
on but finally died. This condition is always fatal."

"Pituitrin must be considered as a great factor in cord complica-
tion. It has been my experience in not a small number of cases that
the administration of pituitrin may cause a contraction of the um-
bihcal vessels so that the pulsation of the cord scarcely becomes
perceptible. Many babies are born asphyxiated as a result of the
use of pituitrin particularly so when given in large doses. The
fetal heart sounds must be carefully examined before pituitrin is
given. If at any time the fetal heart sounds are not found to be
distinct and regular, pituitrin should not be administered."

"In the light of our present knowledge, it is impossible to make a
diagnosis of the cord around the neck during the antepartum period;
and at best a diagnosis of this nature is purely instinctive, based on
past experiences."

Dr. Harold C. Bailey said: "A short cord is quite rare. There
is a report of a cord as short as 7 cm. The records during the last
year at the Manhattan Maternity Hospital show that there were
five short cords. The shortest of these was 37 cm. in length. A
cord is considered short when less than 50 cm. A cord 37 cm. long

NEW YORK ACADEMY OF MEDICINE 855

is long enough to reach from the placenta to outside the vulva. Of
these five short cords only tliree gave any trouble. In three in-
stances the condition was diagnosed before delivery. One was .
an outdoor patient, who was a long time in labor. The head was
on the perineum and the house surgeon went to apply the forceps
but before he could do this the baby was dehvered with the
cord torn off ]4. cm. from the umbilical ring. The child bled pro-
fusely. A circular purse-string suture was inserted and the cord
closed over in that manner. This cord was 37 cm. in length and
there must have been a twist about the body or shoulders of the
baby to produce such a condition. In one case, dehvered by one of
the visiting staff, the head was on the vulva and receded to an abnor-
mal extent in the intervals between pains and this led to a diagnosis
of the condition. In another case there were two coils of the cord
around the neck and the cord was cut and the baby dehvered; it
was found that the cord in this instance measured 45 cm. This was
a case in which the cord was short and at the same time wound
around the baby's neck. During the delivery the placenta was
detached and there was a very sharp hemorrhage. The patient
became very anemic and a kidney and bladder infection followed.
If we could diagnose this condition, much better treatment could be
given the mothers as well as the infants. If we could make the diag-
nosis it might be better for the mother as well as for the baby to do
a Cesarean section, but it is very seldom that a diagnosis can be
made."

Dr. Asa B. Davis said: "This matter has been very well discussed
with reference to the antepartum signs of short cord or cord about
the neck or body of the child, and also during the period of labor.
The point with reference to the abnormal recession of the head in
the intervals between pains has been brought out. I will say that
when we see a case in which after a uterine contraction there is a
recession of the head unduly great we will find in that t\-pe of case
that we are dealing with a short cord or a long cord rendered short
by being wrapped around the neck of the baby. Of course if one
could make a diagnosis, a Cesarean section would be justifiable, but
one must think twice before deciding on a Cesarean section after the
forceps have been apphed high up in the uterus, because of the danger
of sepsis. I have lost a case in which infection probably took place
through the cervix, but I have also done Cesarean section in such
cases successfully. It may be aside from the subject but the manage-
ment of the cord after labor, say during the first ten days, gives me
much concern, for I beheve that many of the disturbances that we
see in infants come from infection that occurs during the separation
of the cord from the umbilicus, such as green stools, rise in tempera-
ture, and loss in weight. During our first year in our maternity
hospital, when the details of our work were undeveloped it was a
common practice to use a dusting powder to dry up the cord, and we
used starch since we needed a large quantity and it was economical.
After a time some boric acid came in and it occurred to me that it
would make a good dressing for the cord. Some time after this we

856 TRANSACTIONS OF THE

got a new man on the house staff and he made up a complete record
of the histories and in doing this he recognized that at a definite
time there occurred a distinct difference in the time at which the
cords separated and it was found that this time coincided with the
time at which the starch was changed for the boric acid. The
difference was so striking that it could not possibly have been a
coincidence. I have found that every once in a while we get a
case where a separation takes place between the cord and the navel
and infection gains entrance and we have a thrombosis; there may
be a thrombosis of the vessel right up to the liver. We sometimes
get abscesses' at sites far distant from the entrance of the infection,
such as in the middle ear, and we will find that the infection probably
gained an entrance at the umbilical stump."

Dr. Arthur Stein. — " I cannot imagine why any compression of
the cord should take place in a patient in whom the normal action
of the uterus is stimulated by the use of pituitrin unless one was
dealing with a prolapsed cord. At the Harlem Hospital, where we
have about looo obstetrical cases a year, we have never observed
any such effect upon the cord or upon the child. I should like to
have Dr. Rongy tell us how he explains this assumed action of the
pituitrin."

Dr. Rongy. — "In reply to Dr. Stein, I would say that there is no
question in my mind that pituitrin caused and will cause many babies
to be stillborn, particularly so when it is used indiscriminately.
I am sure all of us witnessed the tonic and clonic contraction of the
uterus produced by this drug. In such cases the placenta may be
so compressed that the fetal circulation will be interrupted and
asphy.xia will result. Those who have had large experience with the
administration of this drug have noticed the sudden alteration in the
fetal heart sounds immediately following its hypodermic injection.
I have seen many such instances."

Dr. Young. — "This case worried me for I felt that if we had taken
into consideration the recession of the head and the shock to the
mother, which was out of all proportion to that of a normal labor we
might have come nearer to the diagnosis, and we might have saved
both the child and the mother."

Dr. Rongy's point adds something to our knowledge of these cases.

"I have been interested in the tensile strength of the cord. In
this instance I did not have the apparatus for testing the tensile
strength of this cord, but it lifted a 25-pound pail of water."

"I am sorry that someone has not given more definite symptoms by
which one could determine this condition which would save inflicting
trauma on the mother, for as Dr. Davis has said, one must be very
careful in doing a Cesarean section after trauma has been inflicted
by a high forceps application."

Dr. Geo. W. Kosmak presented a report of a case of

TOXEMIA IN PREGNANCY FOLLOWING THYROIDECTOMY.

The patient, Mrs.L., aged thirty-two, married in April, 1914, gave
a history of a thyroid enlargement for which a thyroidectomy was

NEW YORK ACADEMY OF MEDICINE 857

done on June 5, 1915, at the French Hospital by Dr. Pool. The
patient had a profuse period beginning July ist, which lasted six
days and she bled again for live days beginning July nth. About
August ist there was a moderate flow with cramps. On September
ist there was slight staining which lasted for a few days. On
October 27th she began to pass small black clots, which persisted for
about two weeks and there was some pain on straining on the right
side. At the end of November she again stained for several days
and this continued on and off since then. She was referred to me
for attention during her confinement on December 6, 191 5. At
that time she gave a history of marked nausea and vomiting since
September, constipated bowels, attacks of nervousness, flushes, and
tachycardia. E.xamination at this time showed a woman of rather
underdeveloped neurotic type and there was a moderate exophthal-
mos present. The pulse was small in quality and about no to 115.
A transverse scar on the anterior surface of the neck was present.
The breasts were hard and there was a slight trace of secretion in the
right one. The abdominal wall was moderately thick and a rounded
tumor could be made out in the lower part like a five months' preg-
nancy. There was slight tenderness present in the left iliac region.
During the succeeding few weeks a great deal of difEculty was ex-
perienced in correcting the nausea and vomiting and various com-
plaints of neuralgic pain, etc. Indigestion after eating, with various
neurotic sensations continued, and the patient beheved that she
felt life about the middle of December. During the succeeding
months the patient continued to have a variety of nervous disturb-
ances with attacks of dizziness, rapid pulse, insomnia, neuralgic
pains in face and head, and occasional attacks of nausea and vomit-
ing. During the month of January the patient's condition was
apparently improved, the feeling of apprehension and nervousness
being very much diminished. During February attacks of nausea
and vomiting returned and dizziness with visual disturbances was
complained of. A slight swelling of the hands and feet was present
during all this time. The urine was practically normal, the tests for
albumin, sugar and indican being negative, although the specific
grav'ity had a tendency to be rather high. In the belief that some
of the symptoms might be due to a low thyroid secretion the extract
was given in small closes continuously, but no effect could be noted.
During the month of February a moderate degree of hydramnios
developed and in the succeeding month her condition continued about
the same except that she became more uncomfortable. The patient
claimed that she felt better while taking the thyroid extract and
noticed a difference in her general condition when she stopped the
same for a few days. I am not prepared to say whether this obser-
vation was of any value. Her labor was figured as being due about
the middle of May and evidences of a disturbance of the kidneys
began to manifest themselves after May 5th, characterized by swell-
ing of the hands, feet and face, reduction in the amount of urine with
the appearance of marked traces of albumin, and granular and
hyaUne casts.

858 TRANSACTIONS OF THE

Attempts to induce labor with the Voorhees bags were only
moderately successful and a dilatation of three fingers was only
secured after forty-eight hours. The head failed to engage and as
a considerable amount of hquor amnii was present the membranes
were ruptured but as the pains were weak the head remained at the
brim and apparently in an occiputposterior position. Owing to the
small size of the vagina it was impossible to determine this accurately
or to have attempted rotation. During this time the patient con-
tinued to vomit and complained of severe occipital headache. In
view of the apparent inability of the patient to dehver herself a
Cesarean section was decided on, as a vaginal dehvery without
extreme laceration and a possible craniotomy seemed impossible.
The operation was done under gas and oxygen anesthesia on May
15th, the extraperitoneal procedure being done in view of the pro-
longed labor, the frequent examinations, and the presence of a tem-
perature of 102° F. A half ampoule of pituitrin was ordered to be given
as the uterus was being incised, but owing to a misunderstanding the
attendant gave it without the knowledge of the operator before the
abdomen was opened. As the uterus was incised it was found to be
in a state of tonic contraction and combined with the anesthetic
and the placenta under the uterine wound made the extraction of
the fetus difficult, so that a stillbirth resulted. The patient stood
the operation fairly well and although a moderate degree of ileus
developed on the third and fourth days, she made a fairly good
recovery. The lower angle of the abdominal wound had been pro-
vided with a drain and considerable sloughing of the fascial layer
took place. As soon as the slough separated the abdominal wound
healed promptly. During the convalescence the headaches disap-
peared, the urine increased in amount and the general condition
improved. Within a period of three weeks, however, an exacerba-
tion of the nephritis occurred.

The case is of interest because of the doubt which existed through-
out the pregnancy as to whether the symptoms of the toxemia were
due to the disturbed thyroid function or whether they existed inde-
pendently of the same. The influence of the thyroid in pregnancy is
not yet fully understood and the case teaches a lesson as to the
necessity for great care to be exercised in those women in whom the
thyroid or part of the same has been removed before they become
pregnant. In this case although the pelvis was of normal dimen-
sions, the woman's general physical condition precluded the possi-
bihty of an easy labor and undoubtedly a better result would have
been obtained if this fact had been recognized and a Cesarean done
before the prolonged labor affected the viability of the child and
reduced the mother's strength.

DISCUSSION.

Dr. Henry C. Falk (speaking for Dr. Pool). — "The operative
procedure employed on the case which Dr. Kosmak reported was
the one usually used in cases with bilateral enlargement. The
right lobe was removed almost entirely except for its posterior portion

NEW YORK ACADEMY OF MEDICINE 859

and the anterior half of the left lobe was also removed. The thyroid
was drained by means of a stab wound below the scar."

"Microscopical examination showed that this was not a case of
e.xophthalmic goiter, but an adenoma of the thyroid. There was no
increase in the number of cells in the acini, e.g., there was no piling
up of cells in the acini which is so tj-pical of exophthalmic goiter.
Dr. Pool who had done the thyreoidectomy, believed that sufficient
gland substance was left to carry on all the normal functions of the
individual."

Dr. Harold C. Bailey. — "I have just seen a case in which thvroid-
ectomy was performed so this subject seems very close at hand.
It is a question whether the case of Dr. Kosmak's was not suffering
from hyperthyroidism rather than hypothyroidism after the removal
of the gland. It may be well to recall that hyperthyroidism goes
on for as long as eighteen months after the removal of the gland.
Dr. Martin Tinker says that hyperthyroidism continues for a year
after removal of the gland."

"I wish to congratulate Dr. Kosmak on his excellent judgment in
doing an e.vira peritoneal operation."

Dr. Meyer Rabino\itz. — "To my mind the symptoms of toxemia
in Dr. Kosmak's patient were in some measure due to hypothyroidism.
This patient has had a partial thyroidectomy performed for a simple
adenoma. The surgeon's report states that in his opinion sufficient
thyroid tissue has been left behind. The amount of thyroid sub-
stance that remained, might have sufficed for normal metabolic
processes. During pregnancy, however, the thyroid has to compen-
sate for ovarian hypofunction as the hiterglandular correlation be-
tween these two glands, is synergistic in type. In this case it is most
likely, that the thyroid, whatever was left of it, could not stand the
added strain of pregnancy, it lagged behind in its functions, and has
thus served as a contriJDuting factor in the development of this
patient's toxemia. Thyroid feeding in this patient has resulted in
satisfactory subjective improvement, which strengthens our hypothe-
sis of hypothyroidism. Dr. Kosmak could not notice this im-
provement objectively, and therefore discontinued its administration,
which I believe was not the proper course to follow. While I do not
by any means ascribe the etiology of toxemia of pregnancy solely to
hv'pot'hyroidism, yet I claim that we have a right to assume that
thyroid insufficiency is one of the many factors causing the symptom-
complex of pregnancy toxemia.

Dr. Rongy said he would like to report an unusual condition that
happened some time ago. A woman in the ninth month of preg-
nancy was seized with convulsions. She was brought to the hospital
after having four attacks. The convulsions continued notwith-
standing very energetic treatments. Delivery was accomplished
by manual dilatation of the cervix and extraction of the child and her
condition gradually improved. During the second week she was
given 3 grains of thyroid three times daily to promote the secretion
of milk. After taking thyroid for thirty-six hours she developed
tonic and clonic convulsions which for the time being were uncon-

860 TRANSACTIONS OF THE

trollable. The thyroid was discontinued and her condition gradu-
ally improved. The question arose whether in this case the eclamptic
seizures were not caused by hyperthyroidism.

Dr. Samuel W. Bandler. — "My purpose in speaking is to express
an opinion based on a study of the hterature and history of these
cases. I feel that there is much doubt if we have any right to place
any great importance on the relationship of the thyroid function to
the etiology of eclampsia. It might be taken from what has been
said here this evening that we believe that the thyroid function has
an etiological relationship to eclampsia. Inasmuch as the removal
of the thyroid fails to prevent eclampsia it seems to me we cannot
regard hyperthyroidism as a cause of eclampsia."

"A few words with reference to the pathology of eclampsia, one
thing only is seen at autopsy and that is that the microscope shows
lesions in the liver, spleen and other organs of the body that have
been there for many days. These microscopic necrotic areas prove
that a poison circulating in the blood has injured important organs
and cerebral structures."

Dr. Kosmak (closing the discussion). — "Dr. Bandler has rather
misunderstood my statements. I did not state that hyperthyroidism
is a cause of eclampsia, but brought out the fact that this case showed
symptoms of impending eclampsia and it occurred to me that they
might be explained by the report of the surgeon who performed the
thyroidectomy as well as by the pathologist's report. However,
very little is known as to the action of the internal glands in preg-
nancy or what that action may be. We are very much in the dark
on this subject, but it would be better if we could treat the thyroid
condition by some other method than by thyroidectomy. The
surgeon tells us that in this case there was an adenoma which is very
different from our conception of hj'perthyroidism. We are now also
told that our conception of the thyroid function is all wrong and that
we should not speak of hypo- and hyperthyroidism. This case has
been interesting to me because it is the only instance of a pregnancy
in a subject from whom the thyroid has been removed, that has come
under my observation.

Dr. Arthur Stein read a paper on

PRIMARY CARCINOM-A, OF THE \TJLVA.*
*For original article see page 577.

WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY

861

TRANSACTIONS OF THE WASHINGTON OB-
STETRICAL AND GYNECOLOGICAL
SOCIETY.

Meeting of May 12, 1916.
The President, Dr. Miller, in the Chair.
Dr. Joseph S. Wall presented a report on

APICAL PNEUMONIAS IN CHILDREN.

These cases illustrate some of the difficulties in diagnosis.

Case I.-A boy of eight years. Had been ill to a greater or less
extent throughout his life. Two years ago had scarlet fever followed
by ot tis and a mastoid abscess. About a year and a haU a^o had
a pneumonia of the right base. The past wmter has been m fair

^^On\rarch 27, 1916, was taken ill with fever and malaise and com-
plained of his throat. His fever continued high dunng the n.ght and
there was restlessness and cough. I saw him on March 28th, with
his physician, and at that time he had been sick exactly twenty-four
hours. His temperature was 105°, he was delirious, a times
attempting to get out of bed; there was some head retraction and
consTant incoherent muttering. He could not be aroused to answer
questions and presented the syndrome of menmgismus.

His breathing counted 25 to the minute. Examma ion of his
chfst was entirely negative Ixcepting for slightly diminished reso-
nance and suppressed breathing over the right upper l^be^ ;^ °'^g
nosis of pneumonia of the right apex was i^fd^^andconfirmed by an
examination forty-eight hours later when all of he f S^^ 0//°"™;
tion were evident. The boy recovered completely after an illness

°^CASE"TL-Raymond, a boy of eleven years. Normal birth.
Breast-fed for one and one-half years. Pertussis three years ag,
measles, one year ago. Has always been backward '^ hi. studies
spent four years in the first grade of school and has recently been
going to the "atj'pical school." . . ,

^ This illness came on suddenly April i, 1916, ^^th pain in the
abdomen, chill, vomiting. He vomited several times during the
night and complained of abdominal pain. . •, , j ^„H when

He was admitted to the Children's Hospital on Apnl 2d and when
seen on morning rounds of the same day he was ^St'^'f^y/l^'^^^^f'
almost maniacal, and required restraint to keep him in bed. His

862 TRANSACTIONS OF THE

temperature was 102.5, respirations 22 and pulse 80. A phj-sical
examination of the chest revealed dulness, with suppressed breathing
over the right apex anteriorly and posteriorly. There were no signs
of consolidation. The leukocyte count was 7900. In the absence
of other lesions and in the presence of dulness and diminished reso-
nance over the right upper lobe, the diagnosis of lobar pneumonia was
made and within another forty-eight hours was amply confirmed by
the appearance over the region suspected, of the classical signs of
consolidation. He reached a crisis on the seventh day and is now
well. At no time in his illness was there the slightest respiratory
embarrassment during the times of my visits. Only twice was
there recorded in the late afternoon a respiration of 40. His pulse-
respiration rate is most interesting. On first examination, pulse 88,
respiration 20. At a number of later periods in his disease the follow-
ing were noted: Pulse 120, respiration 28. Pulse 120, respiration
26. Pulse 120, respiration 36. Pulse 104, respiration 24.

Case IH. — Mary R., aged ten years. Previous history un-
known. Was taken ill May 2, 1916, complaining of being sleepy
and tired, and having pain in the right side. The next day the child's
temperature was 105. On the second day of her disease her delirium
and stupor increased. She was seen on this day by four or five
physicians and the following diagnoses were made: Otitis media
with mastoid and possibly sinus involvement; acute Bright's disease;
meningitis; acute appendicitis. This last diagnosis resulted in the
admission of the child to the hospital when she had been ill for forty-
eight hours, with hurried requests for a surgeon and for the instant
preparation of the operating room. These requests were complied
with but an examination of the child by the Resident Physician and
by the surgeon who had come to the hospital to operate, a right apex
pneumonia was discovered by signs appearing solely posteriorly.
The Resident declined to administer an anesthetic while the surgeon,
with equal propriety, refused to enter the abdomen.

When I examined the child the next day there was pronounced
stupor, varying with delirious outbreaks which required restraint
by a sheet. The child could not be aroused to answer questions;
there was no hurried breathing, but on the contrary the respirations
during her whole illness varied between 28 and 36. The front of
her chest was devoid of physical signs excepting suppressed breath-
ing over the right apex. Posteriorly there were classical signs of
croupous pneumonia over the same area. Her leukocytes were 1 1 ,000.
She reached the normal line by crisis in eight days.

Briefly, the recital of these cases brings out the following points of
some importance.

Pneumonia of the right apex is frequently so obscure as to escape
recognition. The presence of falsely referred pain in right ape.x
disease may result in operation for appendicitis. The right apex in
children is the part affected in nearly half of the cases of lobar
pneumonia.

These apex cases rarely show dyspnea or embarrassed breathing
which puts one off guard concerning the nature of the illness.

WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY 863

Anical nneumonias, in my experience, are prone to be accompanied
bv the most rrked cerebral symptoms, they are even called by some
thp "cerebral types" of pneumonia m children. r i c

It isTn this group of cases that the x-ray is of extreme usefulness

'"iS'iUs'eviSThat bronchial breathing and bronchial voice
are nol essential for the diagnosis of P'l-X'sTXd 'Wra'l
such is, a "peripheral" lesion, formerly the so-called central

pneumonia."

DISCUSSION.

Dr Acker had seen several cases of apical pneumonia; in children,
some with a low leukocyte count, some with no evident lung symp-
Zl Tt anUrly stage.' The need of careful study before diagnosis

"orFooTE called attention to the occurrence of a definite lobar
nneumonia in children. The symptoms were those of sepsis in a
ZcZZ marked degree than the areas of consolidation warranted
."sneriallv in what were called central cases. The lack of respiratory
s?mSms w^s notlble. Consolidation in the upper part of the lung
glve^ef^rrrd symptoms. With streptococcic infection no immunity

^° dT'abbe knew of a case where the symptoms of an infection and
the abd^^nal pain were so marked that the child was operated
upon forTpendicitis only to find a normal abdomjna cav>^y^
The following dav the pneumonic symptoms became evident Some
vears a °o such pneumonia would have been attributed to the anes-
Setic, now the^responsibility was being put on hasty -rgery.

Dr Wall called attention to the necessity for stripping the child
to^allo^: satisfactory examination. Examination of the posterior
wall of the chest was most important. Marked aelirium aim
Ttupor were frequent and very significant. Autopsy faded o show
cental pneumonias in any of these cases, but ^^^yj''\^l'%°l
peripheral consolidation. They started as cones with the apex
foward a bronchial tube. Suppressed breathing and dimm shed
murmur were signs only when a larger area of the bronchus was
covered. .

Dr I. S. Stone read a paper entitled

CONSERVATION OF THE TUBE.

The progress made by gynecology is shown in the g'-eater number
of operations upon the uterine appendages I'^.^^'.^h *" "^fj^h;
allowed to remain, whereas formerly it was sacrificed along with the
tube upon the slightest pretext. The author claimed that many
t^bes maJ also behaved which are infected or contain visible pus
and which are now frequently removed upon f "^Pj i^-^i^^; J^^/^^J^e
the operator fails to ascertain, or else cannot d,<^termne the presence
or absence of dangerous microorganisms. It ^^^J^^!\^JJ^^l
essayist that nearly all text-books and most operators advocate
radical operations upon the uterine appendages when there is known

864 TRANSACTIONS OF THE

or suspected specific infection in the uterus or tubes and the uterus
itself is extirpated under such circumstances by many.

The author advocated the use of measures which may prove
efEcient in that many patients recover without loss of their adnexa
and at least are symptomatically cured. The method proposed by
him involved the sterilization of the uterine and tubal mucosa by
some form of chemical bactericide. Solutions of mercuric bichloride
had been usgd but for a few years past diluted tincture of iodine had
been relied upon as the better agent. For some years the cases
subjected to this treatment mainly included the more chronic cases.
But from time to time cases of recent infection had been included
until now the author feels assured that even these patients make good
recoveries when properly managed.

Technic. — The essayist's technic includes the sterilization of the
vaginal uterine and tubal mucosa as far as may be accomplished
by the application of the tincture of iodine. First the vagina is
cleansed and treated to an application of the diluted tincture,
one part to three. The cervi.x uteri is then carefully dilated and
curetted, after which the cavity of the uterus is thoroughly dilated
by the iodine solution which is thrown into it with a glass syringe.
The abdomen is then opened and if the appendages are to be saved,
the tubes are irrigated by injecting them with a solution of the same
strength as that used in the uterus if the pathologist reports the
presence of intracellular micrococci or if there is reason to believe
the acute conditions found necessitate the use of a solution of this
strength. Otherwise one-half of this strength is used.

The results were stated as quite as satisfactory as those treated
by radical operation. No one of these patients had required a
second operation, while under the observation of the author. This
was stated as in striking contrast to the e.\perience of many who
claim that they have to perform a second operation in a large propor-
tion of their cases in which they leave an apparently healthy tube
after the removal of the one on the opposite side for specific disease.

The essayist stated that impregnation had occurred in some in-
stances after these conservative measures but that he was not pre-
pared to report the ultimate conditions of these patients. For the
present, however, he was mainly concerned in the effort to check the
further progress of specific disease and to limit as far as possible the
number of operations which mutilate and unse.x women.

DISCUSSION.

Dr. Kane had seen a number of Dr. Stone's cases for two or
three weeks after operation. The temperature on the first day was
usually elevated to about loi, and gradually dropped to normal
by the third day. There was considerable pain at first in the
acute cases, with masses on both sides. In some cases there was
nothing abnormal to be felt when the patient left the hospital.

Dr. Sullhan spoke of Dr. Stone as a pioneer in conservative
work. He had seen the same thing applied ten years ago in chronic
cases. He thought the results better than after the removal of the
tubes.

WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY 865

Dr. Lowe thought there should certainly be an effort to preserve
the tubes in the hope of eventual recovery. He called attention
to the adhesions that were present after operative procedures.
Dr. Miller had never done any iodine work in the abdominal cavity
because feared adhesions. The tubes would probably be closed
after gonorrheal infection and he doubted if they would become
patent after iodine injection. He had heard of several cases where
iodine was said to have caused death and he would hesitate to repeat
such conditions.

Dr. Lowe had never seen a case die from the injection of the
iodine, though one such case had almost died. It was a large fibroid
uterus and was removed very rapidly before the shock was over.
The patient's respirations had ceased and her pulse became im-
perceptible at the wrist, but she finally recovered.

Dr. Abbe had seen several cases in which he, as anesthetist, had
been satisfied that the cause of death was due to the injection of the
uterus with diluted tincture of iodine. The attempt was being made
to inject the Fallopian tubes from the uterus and force enough was
used in some of the cases to show penetration of the iodine in certain
pathological areas to the depth of i centimeter into the tissues of
the uterus. The most evident symptom of those patients that died
was sudden collapse. In two patients in whom the uterus had been
forcibly injected with iodine the collapse was extreme and the patients
died within five minutes of the injection of the uterus and before
the laparatomy could be begun. He did not believe such forcible
injection served any good purpose. The injection of the tubes from
the fimbriated end and when the abdomen was open, as advocated
here by Dr. Stone, was a very different matter and seemed to have
no bad effects at the time, and there seemed to be no evidence of
unusual adhesions following. The good effects were evident from
the reports of pregnancies following the treatment. This seemed
certainly to be far more desired than the ablation of both tubes
and uterus which would be the rational operative treatment if the
attempt was to be made to excise the affected organs.

Dr. Neill used tincture of iodine diluted 50 per cent, to
wipe out the vagina and cervbc in obstetrical cases and had never
seen any iodine toxemia. He commented on the need of eradicating
all gonococci from the vagina before it could be promised that
the tubes would remain free.

Dr. Foote asked what the effect of the iodine was on the ciliated
epithelium and whether the cilia in the tubes remained active
after the treatment with iodine.

Dr. Stone in closing, reported one of his first cases with a wide-
spread gonorrheal infection in which he had treated the tubes with
bichloride and pregnancy had followed. He had seen the same result
after iodine. The size of the uterine cavity determined the quantity
of iodine to be injected and he did not try to push the iodine past
the cornu from the cervix. He did not think that any of his cases
had died. Inhibition of bacterial growth was obtained from solu-
tions of I dram of the tincture of iodine to i pint of water. He
had never found adhesions after the tubal injection. On the other

866 BRIEF OF CURRENT LITERATURE

hand the enucleation of pus tubes left a raw surface to which adhe-
sions were very apt to form. During the tubal injections he was
very careful to protect the peritoneum from any undue iodine
irritation by folding gauze sponges around the tubes just as he pro-
tected the abdomen in removing the appendix.

BRIEF OF CURRENT LITERATURE.

OBSTETRICS.

Effects of State of Nutrition of Mother during Pregnancy and
Labor on Condition of Child at Birth and for First Few Days of Life. —

Analysis by G. F. D. Smith (Lancet, July 8, iqx6) of statistics of
6162 cases obtained from the lying-in hospitals of London and Dub-
lin suggests that a state of bad nutrition of the mother at the time
of labor due to insufficient food greatly increases the percentage of
dead births; greatly increases the percentage of premature births;
slightly decreases the average weight of the full-time baby at birth;
definitely increases the postnatal infantile mortality; has little, if
any, effect during the first eight or ten days on the progress of babies
who live during that time; and possibly increases the death rate of
babies during the first there or four days of life. A state of good
nutrition of the mother at the time of labor, on the other hand,
considerably increases the average weight of the full-time baby
at birth; and increases the percentage of mothers who are able to
suckle during the first eight or ten days of the puerperium, quite
apart from any efifect from the use of an ample diet during this
time. The figures also suggest that on the whole a state of average
nutrition of the mother is the most favorable condition.

Action of Various "Female" Remedies on Excised Uterus of
Guinea-pig. — Among the drugs listed as unimportant, inactive or
useless in the reports of the Council on Pharmacy and Chemistry
of the American Medical Association are a number that have been
reputed to possess certain "tonic" or "sedative" actions on the
uterus, and have been foisted on the medical profession in the form
of a long list of proprietary preparations and on the public in the
form of "patent" medicines. J. D. Pilcher, W. R. Delzell and
G. E. Burman {Jour. A. M. A., 1916, Ixvii, 490) present a summary
of a preliminary pharmacologic investigation of these drugs on the
isolated uterus of the guinea-pig. A strip of the uterus was attached
to a muscle lever and immersed in a bath of well-oxygenated Tyrode's
fluid and the contractions recorded on smoked paper. On immer-
sion in the bath there is usually a latent period of from a quarter
of an hour to an hour before the movements are initiated or become
regular; frequenth' the strips do not become active. After the regis-
tration of a satisfactory control tracing, the drugs were added to the
bath in proportion of one or two parts of the drug to looo of the

BRIEF OF CURRENT LITERATURE 867

bath. The strip remained in the bath until there was evidence either
of the activity or inactivity of the added drug. Before a drug was
deemed inactive it was left in contact with the strip of uterus for
about fifteen minutes, as a rule, but occasionally for an hour or
even longer, before renewing the bath and adding a fresh drug.
The fluidextracts and the freshly prepared infusions of each drug
were employed. The interpretation of the activity of a drug was
judged by the change in the character of the muscular contraction.
With but one exception, the size of the excursion was the feature
affected. The following drugs lessened the amphtude of the excur-
sions or, in the stronger solutions, caused their complete cessation:
Unicorn root {Aletris farinosa), Pulsatilla {Pulsatilla pratensis), Jam-
aica dogwood {Ichlhyomethia piscipula), and figwort {Scrophularia
nodosa); somewhat less active were valerian {Valeriana officinalis)
and lady's slipper {Cypripedium pubescens); the drugs possessing
very weak actions were wild yam {Dioscorea villosa), life root {Sen-
ecio aureus) and skull-cap {Scutellaria lateriflora). The infusions of
figwort, Jamaica dogwood and lady's-slipper were active after the
manner of the alcoholic preparations, but to a much lesser
degree. The infusion of motherwort possessed very insignificant
depressant properties, although the fluidextract was inactive. Blue
cohosh {Caulophylhim thalictroides) , even in the 1:2000 solution,
very promptly put the strips of uterus practically into a state of
tonic contraction of tetanus. The action was very persistent and
the normal muscular state was not resumed after the strips were
placed in fresh Tyrode's solution. The infusion was quite
inactive. The following were quite inactive or inert, both the
fluidextract and the infusion: black haw {Viburnum prunifolium)
the bark of both root and stem, cramp bark {Virbiirnum opuhis),
squaw vine {Mitchella re pens), chestnut bark' {Castanea dentata),
false unicorn {Chamaelirium luteum) , passion flower {Passiflora incar-
nata), blessed thistle {Cnicus benedictus) , St. Mary's thistle {Sily-
bum tnarianum or Carduus marianus) and motherwort {Leonurus
cardiaca); sodium valerianate was also inactive in solutions up to
I : 1000. The strips were allowed to remain in the solutions of these
drugs in concentration up to i : 150 for some time (many of them for
an hour) without evidence that the drugs changed the character of
the tracings in any way. The drugs in this list are practically worth-
less. Their use is harmful as well as futile since it tends to perpetuate
therapeutic fallacies.

GYNECOLOGY AND ABDOMINAL SURGERY.

Nonteratomatous Bone Formation in the Human Ovary. —

Speaking of the supposed variety of ossification of the ovary, G. W.
Outerbridge {Amer. Jour. Med. Sci., 1916, cli, 868) reports seven
cases. As a result of the study of fourteen cases from the literature
and of these seven personal observations it appears that true ossifica-
tion of the ovary may occur independently of any neoplastic or tera-
tomatous process. Such bone formation is probably metaplastic
in character; it occurs chiefly in corpora fibrosa or fibrous portions

868 BRIEF OF CURRENT LITERATURE

of the Stroma, and particularly in ovaries from cases of pelvic inflam-
mation. In one instance of the personal series it involved the wail
of a serous cystadenoma, and in one a spontaneously amputated ovary
which was found adherent to the omentum at the bottom of Douglas'
pouch, associated with complete atrophy of the corresponding tube.
It is highly probable that true ossification of the human ovary, of
nonteratomatous origin, is far more common than has generally
been believed.

Postoperative Ileus.^ — W. M. Thompson (Sitrg., Gyn. and Obst.,
1916, xxii, 688) believes that the best results are obtained in the
treatment of inflammatory ileus by enterostomy and drainage in
cases that are so ill that radical measures would be fatal. Enteros-
tomy should be done rapidly and without disturbing the adhesions.
When the patient recovers, ileoileal anastomotic closure of the
enterostomy wound and cecostomy or appendicostomy will complete
the cure. In favorable cases ileoileal anastomosis with cecostomy
or appendicostomy for drainage and to relieve the back pressure in
the colon gives the best results. By short-circuiting and putting the
damaged gut at rest it may be restored to health and function even
after vascular changes have taken place. The mortality of resection
for this disease is too high to give it a place in the treatment of in-
flammatory ileus. The adhesions should not be broken up or the
damaged gut handled in the operation.

Etiology of Uterine Prolapse and Cystocele. — G. Fitzgibbon
{Surg., Gyn. and Obst., 1916, .x.xiii, 7) says that the one common item
in operations for prolapse of the uterus is plastic work in the region
of the lateral fornices and cervix but that the importance of this is
not recognized and credit for what is efltected by this is given to other
parts of the operation which are not essential, while many of the
unsatisfactory results are due to nonappreciation of what is the essen-
tial part of the operation in cases of prolapse. Prolapse of the
uterus and cystocele are due to damage of the pelvic fascia in the
region of the lateral fornices and in front of the cervix. Prolapse
of the uterus must be clearly differentiated from cystocele; they may
exist separately or be combined. Laceration of the perineum and
levator ani muscles has no part in the production of prolapse. It
allows an increase of cystocele when there is the primary defect.
Retroversion of the uterus has no tendency to produce prolapse.
Prolapse of the uterus and cystocele are analogous to abdominal
hernias through scars, due to defective union of the fascia. The cure
of the condition can be effected by reuniting the fascial diaphragm
across the pelvis. The fascial diaphragm can be repaired without
interfering with the function of the uterus or disclosing the bladder.
The condition can be treated in exactly the same manner before and
after the menopause. Atrophy of the uterus has no influence upon
its support. Amputation of the cervix other than the removal of
an hypertrophied lacerated vaginal portion is not necessary.

Vaginal Hysterectomy for Procidentia. — To make better provi-
sion against faulty union of the broad ligament stumps, P. E. Trues-
dalc {Bo.sl. Med. and Surg. Jour., 1916, cbcxv, 13) includes a strip
of uterine muscle on either side, making an apposition of the broad

BRIEF OF CURRENT LITERATURE 869

ligaments with a strip of uterine muscle to form a central body of
support. This, in many cases, wiU serve to fortify a weak step in
the operation as usually done. The procedure differs from the opera-
tion described by Watkins, inasmuch as the entire cavity and elon-
gated cervix are removed. Analysis of fifty cases, in which this was
done for procidentia, shows that the average duration of symptoms was
five years. In forty-two cases the procidentia was complete; in
eight, incomplete. T. he results were complete success in 74 per cent.,
partial success in 12 per cent., and failure in 6 per cent.

Relation of the Endometrium and Ovary to Hemorrhage from
Myomatous Uteri — In an attempt to correlate various theories
especially in the light of recent contributions to the physiology oi
menstruation and its relation to corpus luteum evolution, S. H.
Geist (Surg., Gyn. and Obsl., 1916, xxiii, 68) studied seventy-five
fibromyomatous uteri, representing all types of tumors and present-
ing various symptoms. In all the cases the menstrual history was
accurately investigated. In sixty cases the adnexa were also ex-
amined. Of the seventy-five cases, fifty gave a history of menor-
rhagia, some few also having metrorrhagia. In most of the cases of
fibroid uteri associated with pathological bleeding a hypertrophic
condition of the mucosa. The ovaries in these cases vary from the
normal, there being present most often a large corpus luteum,
occasionally cystic. These findings seem very significant in view of
the fact that the ovarian influence is of primal importance in regu-
lating the normal hemorrhage from the uterus, and it seems reasonable
to suggest as a possible etiological factor for the atypical hemorrhage
associated with fibroids, disturbance in the function of the ovary,
perhaps of the corpus luteum.

Process of Repair in Wounds of the Small Intestine.— This in-
vestigation by J. E. ]\Ic\Vhorter, A. P. Stout and C. C. Lieb
(Surg., Gyn. and Obst., 1916, xxiii, 80) has a bearing upon the admin-
istration of fluid and food after intestinal operations. The follow-
ing conclusions based on the data obtained from operations on the
normal and the gangrenous small intestine of the dog, are grouped
together for the reason that in both series the experiments were the
same and the end-results identical. The noninfected suture line
in the small intestine in dogs is very resistant to internal hydrostatic
pressure. For at one hour after operation and any time thereafter,
the area of operation is capable of withstanding an hydrostatic
pressure of over i pound per square inch without leakage. The
clinically infected specimens leaked at minimum pressures. To
obtain perfect results a proper technic is essential. For it is seen
that in a dog recently killed the intestine, when properly sutured,
is capable of withstanding a pressure of nearly 2 pounds per square
inch without leakage. Imperfect technic results in a defective
suture line. The defects, if not too extensive, may be sealed by the
coagulum which probably prevents leakage. The smooth muscle
of the divided and sutured intestine retains its viability and seg-
menting function to within 5 mm. of the line of suture. In an in-
fected case with gangrene around the suture line, no segmentation
occurred within 15 mm., while 60 mm. away contractions were

870 ITEMS

powerful and well defined. Repair in sutured intestinal wounds
begins at once with the coagulation of the extravasated blood which
fills in the space between the two approximated serous surfaces.
This union becomes permanent in from seven to ten days, with the
replacement of the coagulum by connective tissue. Repair of the
mucosa is first seen after twenty-four hours beginning with a line of
syncytial epithelial cells extending from the edge of the viable
mucosa over the denuded surface of the infolded cut edges of the
intestinal coat. The denuded surface may be covered with an im-
mature mucosa as early as the fifteenth day (Mall), but it is usually
not completely covered until twenty-three days after operation. Re-
generation of the mucosa is complete after two months. Complete
anatomical regeneration of the muscularis does not occur. A
reahgnment of the infolded muscular fibers occurs, but it is always
interrupted by a thin line of scar-tissue. From the above data the
writers conclude that fluid and food may be given immediately after
operation without danger of leakage in the sutured small intestine.
If leakage does occur, it is due to infection or faulty operative
technic.

ITEMS

A WARNING.

We are again obliged to call the attention of our readers to the
taking of subscriptions to The American Journal of Obstetrics
the Medical Record, or the British Journal of Surgery, by unauthor-
ized persons. There has for a long time been an organized band of
these rascals working the cities and larger towns in many sections
of the country. We would warn our present subscribers not to
give money for renewals to any but our authorized agents, or pref-
erably (as a forged authorization may be presented) to send it
direct to the subscription department of the journal. As to in-
tending new subscribers, we are doing our best to protect them by
notifying the police of the cities where these gangs of sharpers are
working.

ARMY MEDICAL CORPS EXAMINATION.

The Surgeon General of the Army announces that preliminary
examination for appointment of first lieutenants in the Army Medical
Corps will be held early in January, 191 7, at points to be hereafter
designated.

Full information concerning this examination can be procured
upon application to the "Surgeon General, U. S. Army, Washington,

ITEMS 871

D. C." The essential requirements to secure an invitation are that
the applicant shall be a citizen of the United States, between twenty-
two and thirty-two years of age at time of receiving commission in
Medical Corps, a graduate of a medical school legally authorized to
confer the degree of Doctor of Medicine, of good moral character and
habits, and shall have had at least one year's hospital training as
an interne, after graduation. Apphcants who are serving this post-
graduate interneship and can complete same before October i, 191 7,
can take the January examination. The examination will be held
simultaneously throughout the country at points where boards can
be convened. Due consideration will be given to localities from
which apphcations are received, in order to lessen the travehng ex-
penses of applicants as much as possible.

In order to perfect all necessary arrangements for the examination,
applications should be forwarded without delay to the Surgeon Gen-
eral of the Army.

There are at present 228 vacancies in the Medical Corps of the
Army.

DEPARTMENT OF PEDIATRICS.

TRANSACTIONS OF THE NEW YORK ACADEMY
OF MEDICINE.

SECTION ON PEDIATRICS.

Meeting of May ii, 1916.

Royal Storrs Haynes, M. D., in the Chair.

Dr. C. T. Sharpe reported a case of

meningococcus meningitis with unusual hemorrhagic mani-
festations AND demonstration OF THE DIPLOCOCCUS
IN THE SKIN.

The patient was a little Hebrew girl three and a haK years old,
who presented a widespread purpura with a remarkable vermiUion
border in the larger areas. The suffusions involved the face, left
arm and buttocks and occurred also in the mouth. The petechiae
were present aU over the body and on the buccal mucous membrane.
There was little evidence of involvement of the meninges of the brain
and cord and the diagnosis would have remained in doubt had there
been no other evidence of the infection.

The spinal fluid, the blood culture and the skin sections were shown
to contain the meningococcus.

The interrelationship between the cutaneous manifestations and
the cerebrospmal involvement, that is, the inverse variation, was
dwelt upon and the author advanced the importance of this as a
prognostic sign and instanced cases where cerebral compression —
which he referred to as cerebral edema — had been relieved by the
occurrence of cutaneous eruptions.

Dr. Jesse F. Sammis. — This patient, a child nine months of age,
was presented to us on February 28, 19 16, having as the chief com-
plaint inability to hold up the head. The patient was the youngest
of four children, the others being perfcctlj- normal both in physical
and mental development. The parents were well, with no symptoms
of either tuberculosis or syphilis. The child was born at eight and
three-fourths months intrauterine life, the weight at birth being given
as 12 pounds. The labor was difficult and the child e.xtremely
872

TRANSACTIONS OF THE NEW YORK ACADEMY OF MEDICINE 873

cyanotic, having been resuscitated with difficulty. The child had
had whooping-cough and this was followed by some eruption of the
skin, probably chickenpox. The child had been exclusively breast-
fed and the digestion had been perfectly normal. It was not until
the child was four months old that anything abnormal was thought
of, and then it was noticed that the head appeared to be increasing
in size very rapidly and that the child was making no effort to sit up.
At nine months lie was able to hold up his head but not to sit up.
He plavs and laughs in a normal way and seems almost as happy as
other children of his age. He is presented because he exhibits
nearly all the characteristic deformities of achondroplasia in a
typical way. The disproportion between the length of the trunk and
the extrenaities is marked, the hands scarcely reaching to the waisl
line, the skin, owing to the shortness of the lower extremities hangs
in folds, he shows the prominent forehead with the saddle nose and
the protruding jaw. The abdomen is prominent and an umbilical
hernia is present. There is a slight lateral curvature of the spine and
a kyphosis. The hands are quite characteristic, being the kind
designated as "trident." There is considerable rela.xation of the
ligaments and the child's muscular development is poor. The liver
and spleen are both easily palpable. The Wassermann is negative.
The measurements are as follows: Weight, i^H pounds; length, 24
inches; crown of the head to the umbilicus, 13!^ inches; umbilicus
to the sole of the feet, io>^ inches. Head, i8>^ inches; chest, 14,1^
inches; abdomen, 14}^ inches. Measurements of the upper and
lower extremities showed them to be unusually short.

AUTOSERUil TREATMENT OF CHOREA.

Dr. .\br.ajiam L. Goodman. — Whenever I want to find out about
anvthing new it is my custom to go back to Hippocrates, Gelen and
Parcelsus and find out what they knew about it. I cannot find that
they knew anvthing of the condition which we to-day interpret as
chorea. The first mention of this disease which I ca,n find in history
are accounts of epidemics in the region of the Rhine in Germany,
in 1386. At this time large pilgrimages were made to various shrines
for the cure of St. Vitus dance. At that time the disease seemed to
be a contagion or one related to hysteria. It remained for Hunting-
ton and Sydenham to give us the description of the disease which
we know as chorea to-day.

The first etiological investigation of chorea was made by Wasser-
mann and he has spoken of finding a streptococcus which he believed
might be the cause of chorea. He isolated this organism from a
group of individuals who had choreiform movements. It may_ be
said, however, that up to the present time no distinctive organism
had been demonstrated as the cause of chorea. Koplik reports a
number of cases that were syphiUtic and whose blood showed a posi-
tive Wassermann reaction. Le Fetra has reported two cases in
which the streptococcus viridans was isolated. This is about the
extent of our researches into the etiology of chorea and the literature

874 TRANSACTIONS OF THE

on the subject is not extensive, so its causation is very doubtful at
the present time.

My attention was attracted to the subject by two cases admitted
to tlie German Hospital with a diagnosis of chorea. These choreic
movements were augmented to a high degree in a short time and the
child developed an intense coma, and it was suspected that we were
dealing with a miliary tuberculosis restricted to the central nervous
system. All the usual forms of medication were tried but nothing
seemed to reach the source or origin of the disease. In 1913 it
occurred to me that if we could use the serum of a patient with chorea
and inject it into the spinal column we might obtain some favorable
results; that possibly the enzymes or protein bodies might be a factor
in the disease. We realized the dangers of this proposed procedure
and made cultures of the blood and spinal fluid, and in none could
we demonstrate any organism of any kind. Shortly afterward the
use of salvarsanized serum gave added encouragement to any doing
work along these lines, so while we could not predict the results we
determined to try it. The first case was the one I have mentioned
with coma. We felt that we would lose the case and that the use of
the serum was justified, as the child had received large doses of
codeine, chloral, etc., without effect. We used this method and the
child became quiet within two days. Passanini has treated five
cases by withdrawal of the spinal fluid but this method was not
successful, at least it would seem that he had not met with success
because we have seen no further report from this author. We
thought, therefore, that we would try another method. We then
learned of the work done with magnesium sulphate, in which a 25
per cent, solution was injected, in i or 2 c.c, intraspinally for
15 kilos body weight. We have not had enough experience with this
method to be in a position to compare it with the results of treatment
with autoserum. We must be sure that our case is one of chorea
and not every case with choreiform movements is one of true chorea.
In illustration of this, we had one girl with a slight enlargement of
the thymus but without any accompanying murmur; she had a hypo-
rather than a hyperthyroidism. We gave her thyroid extract and
the choreic movements disappeared entirely. In the treatment of
these cases of chorea with autoserum another important factor is
to be sure that all drug medication has been eliminated. To be sure
that a treatment in chorea is eiJective it must give a quick result; if
it is slow in producing an effect, say two or three weeks, one cannot
be sure that the disease has not been self-limited. With the auto-
serum the result is manifested within two or three days so we can
be sure that they are the immediate effect of the injection of the
autoserum.

Our method is briefly this: We let the child lie in the ward three
or four days and in the meantime make sure that other infections,
such as syphilis can be excluded. We then withdraw 45 or 50 c.c.
of blood and ccnlrifugc it. The serum is then pipetted off, trans-
ferred to beakers and kept two hours at room temperature. Then
we do a lumbar puncture and withdraw 20 c.c. of the spinal fluid.
The serum is then taken from the incubator and very slowly injected

NEW YORK ACADEMY OF MEDICINE 875

into the spinal cord allowing ten to fifteen minutes to inject 15 c.c.
It is important that the injection should be made slowly so as not
to disturb the equilibrium. The patient is then put to bed and there
is no immediate reaction. At times there may be a little rise in
temperature but this is exceptional. We have had no serious results
from this treatment, and we have made from twenty to twenty-five
such injections. It is amazing to see how quickly these cases respond
to this treatment. Dr. Smith at the Vanderbilt Clinic had a case
that had- been growing worse for three months. The chUd exhibited
most violent movements and after two injections was cured and
discharged.

At the present time we are trying to find out wherein the actual
value of the procedure lies, whether it is due to an antibody or
an enzyme or a protein or what. In the meantime any remedy
that will relieve this distressing malady is worthy of our careful
consideration.

DISCUSSION.

Dr. Samuel Feldstein. — At the Brooktyn Jewish Hospital we
recently treated a case of chorea by Dr. Goodman's method with
most amazing results. A girl of thirteen years had begun two
months ago to suffer from rheumatic polyarthritis which necessitated
her stay in bed for three weeks. After ten days' relief she was again
compelled to take to bed on account of the recurrence of the articular
symptoms. Three days previous to admission, she was seized with
severe choreic movements; these being so violent at the time of
admission that a thorough physical examination could not be made.
Temperature 100.4, pulse 120, respirations 26. There were signs of
a mitral regurgitation. We observed the patient for three days,
being compelled to give dionin gr. }-^ at night for the extreme
restlessness. During this time the condition became more aggra-
vated. We then removed 40 c.c. of blood from an arm vein and kept
it at room temperature, allowing the serum to separate spontane-
ously. Most of the serum was clear, the remainder we centrifuged.
We then removed about 20 c.c. of fluid from the spinal canal and
injected 10 c.c. of the serum. Following the injection, there was
considerable reaction, rise in temperature to 102° F., headache and
rigidity of the neck. These symptoms disappeared the next day.
The day after the choreic movements were greatly lessened, and by
the third day had largely disappeared. A week later we repeated
the injection, this time allowing the serum to separate spontaneously
over night at room temperature. The second treatment was followed
by a much milder reaction. A few days later the patient was
practically free from spontaneous choreic movements. I saw the
patient yesterday in the dispensary and found no signs of chorea.

Dr. Charles H. Smith. ^I saw the case of chorea to which Dr.
Goodman has referred and if he cured that case he preformed a
miracle, for it was the most severe case of chorea I ever saw. Every
attempt had been made to alleviate the condition of that child. It
had received maximum doses of salicylates, bromides, chloral,

876 TRANSACTIONS OF THE

arsenic and tonics and it scarcely seems possible that he was able to
cure it.

Dr. Rltjolph Moffett. — I have been associated with Dr.
Goodman at the German Hospital and have observed this treatment,
and I can only say that it works wonderfully. After injecting a
case it clears up within a few da\-s. We have been using lo c.c.
in making the injections, I think we should use 15 c.c. and that we
might thus avoid the necessity of giving a second injection.

OBSERVATIONS ON TUBERCULOSIS AT THE VANDERBILT CLIN^C.

Dr Charles H. Sivhth and Dr. H. L.^mbert Bibby. — When a
child is brought to us for examination there are two questions which
we always ask. These are: (a) Has the child been infected with
tuberculosis? This question is answered by the skin test, (b) Is
the infection latent or active? We prefer the terms latent and active
rather than infection and disease, believing the former are more
accurate since all infection means disease. And furthermore because
in an infected child small latent foci remain waiting for favorable
conditions to flare up.

A latent tuberculosis is shown by a positive von Pirquet test and
no symptoms or signs of the disease. An active tuberculosis in a
child is not like incipient tuberculosis in the adolescent or adult.
In the child the lesion is not apical, often not pulmonary, but by
node or hilus infiltration. This makes diagnosis extremely difficult
and quite different from making a diagnosis in the adult. The
diagnosis is based on symptoms of impaired nutrition and anemia,
undersize, and failure to gain in weight at the proper rate. The pres-
ence of an irregular fever lasting over a considerable period of time
is very suggestive. Other symptoms that are valuable are anorexia,
fatigue, languor (or in some cases the fever seems to incite the child
to unusual activity), headache and night sweats. In children cough
and positive chest signs are rare, but there may be transient bronchi-
tis, asthmatic bronchitis or enlarged bronchial lymph nodes.

The frequency of these various symptoms in a series of 80 cases
giving a positive von Pirquet reaction were as follows: Fever in
16 instances; no gain in 9; loss of weight in 7; failure to gain when at
rest in 3. Among these 80 cases 21, or 25 per cent, had tuberculosis
in the active stage and all were without the signs of the disease.

With reference to the von Pirquet test there are several points
to be observed. It is better to perform the test with a scarifier as
one is not so likely to draw blood in this way. The skin should be
properly sterilized before making the inoculation and should be
allowed to dry before the dressing is appfied. A protective dressing
should be applied to protect the puncture from contamination from
clothing or finger nails.

As has been said the physical signs in the lungs are rare. We
found such signs in only 21 out of 150 cases. Dulness is difficult
to detect and uncertain. The physical signs observed in these 21
cases were as follows: Transient localized rales at the apex in i case
with a positive von Pirqucl ; localized rales in the axilla in 3 cases,

NEW YORK ACADEMY OF MEDICINE 877

2 with a negative and i with a positive von Pirquet; general bron-
chitis (accidental) in 2 cases, i giving a positive and i a negative von
Pirquet; asthmatic bronchitis in 5 cases, all positive; pleurisy in 4
cases, all positive; consolidation with cavity formation in 4 cases,

3 giving a positive and i a negative von Pirquet reaction, and 2
cases with pertussis. This gave 21 cases, or 14 per cent, out of
120 in whom there was a probability of tuberculosis; the larger
number of these gave a positive von Pirquet reaction but some
gave a negative reaction.

The signs of involvement of the bronchial lymph nodes are dulness,
tender spines and d'Espine's sign. Enlarged bronchial lymph
nodes and infiltration of the hilus cause an increased conductivity
of the sounds but this sign is not pathognomonic. There is some
confusion as to just what is meant by d'Espine's sign and it is better
to say whispered bronchophony to a given vertebra than to say
d'Espine's sign positive. There are certain points to be observed in
ehciting d'Espine's sign. The room must be quiet; it cannot be
done in the dispensary room or where persons are walking about
and talking. The child must be able to whisper well; it is, of course,
difficult or impossible to get the cooperation of the child under the
age of three or four years. It is well to Hsten rather high in the cer-
vical region and low in the dorsal and then to continue listening
above and below until the line is reached in which the tracheal sound
changes to the vesicular. This point varies considerably in different
subjects.

The x-ray as a means of making a diagnosis is either a brilliant
aid or a great disappointment. In order to get information one must
get a good x-ray with a short exposure. When there is a positive
tuberculous infection the x-ray may show enlarged bronchial nodes,
or tracheobronchial involvement by large central shadows, or small
nodes may be shown along the main bronchi. Small dark shadows
well separated from the root shadows are very suspicious. Pleural
thickenings may be noted which may be interlobar or from old
pleural effusions or infiltrations. There may be a fibrosis extending
out from the hilus region, but it must be remembered that there
are variations in the hilus shadows normally present. The x-ray
may show consolidation or cavities but it has been found that the
cavities are usually much smaller than the signs would indicate.

In regard to the treatment we may briefly say that children with
latent tuberculosis need watchful care, extra rest, air and food.
Children with symptoms of active disease should be put to bed in
the open air with careful feeding and kept in bed until the tempera-
ture becomes normal. They must be watched with great care for
months and years in order to detect any signs of relapse.

At the present time we have insufficient preventoria and sanatoria;
for all children with positive von Pirquet reactions need careful
watching. If such a child runs a temperature and does not gain
properly, he should be considered as needing the same care and treat-
ment as any active case of tuberculous disease, since the diagnosis
of early tuberculosis is too difficult in the child and the danger of
extension to the lungs and other parts of the body too great to take

»/» TRANSACTIONS OF THE

chances. At the present time our sanatoria take only children from
homes in which there are men or members with tuberculosis but
make no provision for the child accidentally infected from some other
source.

DISCUSSION.

Dr. Fr^anklin Morris Class. — I agree with everything that Dr.
Smith has said. I see many of his patients in the Vanderbilt Clinic
Day Camp and see what he accomplishes. The most difficult cases
to diagnoses are the early cases of tuberculosis in children under
twelve years of age. I am also convinced that most children sufifer-
ing from early tuberculosis show no signs in the lungs; and those
cases showing pulmonary signs, generally suffer from an infection
other than tuberculosis. It is especially difficult to make a diagnosis
in a dispensary as one has to see each case over a considerable period
of time.

Dr. Leon T. LeWald. — The problem of making a diagnosis of
early tuberculosis in children is just as hard for the rontgenologist
as for the one who bases his diagnosis on physical signs. There may
be a small focus in a bronchial gland which the x-ray does not readily
show. Dr. Smith says that a latent focus of tuberculosis is always
dangerous and it is wise to call this "latent" rather than healed
tuberculosis.

As to d'Espine's sign, there is considerable variation in the verte-
brae and that explains the difficulty in the location of the sounds.

It is also difficult to determine the presence of a small focus as
the shadow of the cross-section of a bronchus may be mistaken for
an enlarged gland. It is advisable to have stereoscopic radiographs
not only in one plane, but taken at different angles, at right angles
and at oblique angles.

Dr. Maurice Fishberg. — I want to mention an important point
which seems to have been omitted in the discussion of the d'Espine
sign. In interpreting the findings of tracheophony we must bear in
mind certain anatomical peculiarities of the bifurcation of the trachea
mainly according to the age of the patient. In infants under three
years of age the bifurcation is on a level with the seventh cervical
vertebral spine, but with advancing age it sinks lower and lower.
At the age of eight it is on a level with the third dorsal vertebral
spine, and at twelve years of age it is as low as the fourth dorsal
spine. In adults it may be as low as the fifth or even the si.xth
dorsal vertebral spine. Under the circumstances the sign is positive
in a child under three when tracheophony is heard in an infant under
three lower than the first dorsal vertebra; in a child of sL\ the sign
is negative when tracheophone is audible above the third spine. In
a child of twelve tracheophony may be audible as low as the fourth
or fifth dorsal spine without enlarged thoracic glands. In many
children this sign is negative though the glands are enlarged because
(he trachea is situated more anteriorly than normally, or only the
anterior glands are tuberculous. After all it is due to the interposi-
tion of anything between the trachea and the spine, and tuberculous

NEW YORK ACADEMY OF MEDICINE 879

glands are the most common in childhood. In adults we may find
tracheophony on rare occasions as low as the lumbar vertebra with
or without being able to assign a plausible cause to the phenomenon.
In children, if the anatomical points just mentioned are not borne
in mind the sign is of httle value.

Dr. L. Emmett Holt. — With regard to the von Pirquet reaction
in tuberculous meningitis, I think the impression has gained cur-
rencv that it is onlv exceptionally that we get a positive von Pirquet
reaction in that disease. It has been our experience that except in
the last stages of the disease when the patient is extremely pros-
trated, the skin test has almost always been positive. At other times
a negative test may be of great value. This is illustrated by the
case of a child who was admitted to the hospital because the mother
had noticed a lump of the head. This proved to be a bulging
fontanel. There was a history of convulsions, fever and drowsiness.
A lumbar puncture was done and. 120 c.c. of perfectly clear normal
fluid withdrawn. In this instance the von Pirquet test was negative
and the child recovered. The symptoms in this case pointed to
tuberculous meningitis but the child certainly did not have that
disease. It probably belonged to that type of menmgitis sometimes
called serous meningitis.

As to d'Espine's sign, I have been impressed by the extreme
variability of the sign in different children. I do not beheve it is
possible to fix on any one point and say this is the exact point at
which the whispered 'voice is significant. It is a valuable diagnostic
sign for diagnosis and is usually best obtained on the right side.

Early wasting is often absent with active tuberculosis in infancy.
One mav see a child with fairly positive signs of tuberculosis and yet
the child will show no loss of weight for a considerable time; and a
child mav have a fairly active tuberculosis and even gain weight.
Loss of weight in voung children is not so significant in tuberculosis
in young children as in older ones. Most of the infants with tubercu-
lous meningitis are rosy and plump up to the time when active symp-
toms of meningitis develop.

Dr. i\BRAH.A.M L. GooDM.\N.— One point that has impressed me
is the difference between tuberculosis in very young children and
those between the age of ten and twelve years. I have been amazed
to see how weU nourished these young children are, and how extensive
the tuberculosis often is without any particular objective sign. In
older children these objective signs are usually present. Most of
these younger children have enlarged bronchial lymph nodes and the
von Pirquet reaction is usually positive. These cases of early tuber-
culosis exhibit indefinite fevers accompanied with gastrointestinal
disturbances, and are treated often as such until the condition has
been recognized. ' Every case of indefinite fever in early life should
be looked upon as a possible tuberculosis, and with the added refine-
ment in technic and execution in detail of .r-ray examination, the
early appreciation of tuberculosis is made possible. When one finds
these enlarged mediastinal glands together with a von Pirquet
reaction and an increased temperature from time to time, I believe
one is justified in making a diagnosis of incipient tuberculosis. I

bOU TRANSACTIONS OF THE

believe that when such children are placed under proper hygienic
and sanitary conditions, and are given daily doses of guiacol and
arsenic for years, that they can be permanently cured. Guaiacol
and arsenic not only favorably infiuence a fuberculous process in the
lung, but have a direct infiuence on the process of metabolism.

Dr. Smith, in closing the discussion. — With reference to d'Espine's
sign and the breath sounds, it is difficult to get a chOd under two
years old to whisper; one cannot usually get a child under three or
four years of age to whisper properly. And by the time a child is
three or four years of age the bifurcation of the trachea is appro.xi-
mately as far down as at the age of twelve years. There must be
some significance in these signs, for one gets the d'Espine sign as
low as the fourth or sixth dorsal vertebra and on the other hand there
are a large number of cases in which it stops at the first dorsal or
seventh cervical vertebra. So that it seems that it must have some
significance, though undoubtedly it does occur without the presence
of tuberculosis but the figures with reference to its occurrence are
certainly suggestive.

TRANSACTIONS OF THE AMERICAN MEDICAL
ASSOCIATION.

Sixty-seventh Anmial Session, Held in Detroit, Mich., June 13, 14,
15, 16, 1916.

SECTION ON DISEASES OF CHILDREN.

T. C. McCleave, M. D., of Oakland, Cal., in the Chair.

Dr. T. C. McCleave delivered the President's Address on

dental caries in childhood; the most neglected feature in
pediatric medicine.

Modern medicine is concerned with the prevention of disease and
nowhere is there a wider field for the exercise of this function than
during childhood. A preventive measure of prime importance is
the care of the teeth. Unfortunately many dentists do not realize
the importance of caring for children's teeth. They argue that it
is not worth while caring for the deciduous teeth, and in reply to
the statement that neglect of the deciduous teeth may result in per-
manent deformity they reply that the permanent teeth may be
deformed anyway. Ignorance is the greatest obstacle in the way of
securing proper dental care. Dental deformities frequently mean
much more than merely deformities of the teeth. They may be
responsible for deformities of the face and jaw, and they may be a
factor in the production of adenoids, nasal hypertrophy, and ton-
sillar enlargements. The selection of a proper dietary has an im-

AMERICAN MEDICAL ASSOCIATION 881

portant bearing on the development of the teeth. Malocclusion
interferes with proper mastication and is therefore the starting
point of many nutritional disorders. The digestion of starches can-
not be normal if mastication is imperfect. Infections of the teeth
cause dental caries and pyorrhea. The chemicobacterial theory
is now generally accepted as explaining the causation of caries. On
this theory caries is attributed to a fermentative process. Particles
of carbohydrate food become lodged in the crevices of the teeth,
fermentation takes place, and the acid products of the fermentation
attack the enamel of the teeth. Hence the soft, sweet, sticky
foods of which children are so fond may be regarded as a cause of
dental caries. It has been found that pyorrhea alveolar almost
alwavs causes other infections. There is a definite relationship
between pyorrhea and the various focal infections with which we are
all famihar. The first step toward the reUef of the present situa-
tion is to make the medical profession realize the significance of
dental hygiene. Their interest must be stimulated so that they will
undertake to awake a general interest in this subject in their own
communities. The dentist must come to reahze that he is not merely
an artisan and a mechanic, but that he is working in a definite field
of medicine and that the care of the teeth of children is of sufficient
importance to merit his most careful consideration. Parents must
be made to reahze the importance of proper development and care
of the teeth in children and must be taught that such care is worth
paying for. Proper provision should be made for the care of the
teeth of children whose parents are unable to pay for this ser^^ce.
Every chnic for children should recognize that a dental department
is an inherent part of its organization.

Dr. John Lovett ]Morse and Dr. Da\t:d M. Hassam, Boston,
presented a paper on

THE effect of COLD AIR ON THE BLOOD PRESSURE IN PNEUMONIA
IN CHILDHOOD.

The cold air treatment of pneumonia has been generally adopted
during recent years. It has been believed that the blood pressure
was diminished in severe and fatal cases of pneumonia and that the
good effects of the fresh air treatment were due to the fact that the
blood pressure was raised by this treatment. More recent investi-
gations have shown, however, that there is no constant rule for the
blood pressure in pneumonia and considerable doubt has been thrown
on the statement that the blood pressure in pneuiponia is increased
by exposure to cold air. The writers have made a study of the effect
of cold, out-of-door air on the blood pressure in pneumonia in child-
hood, at the Boston Children's Hospital, during the past winter.
Three hundred and eighty-seven observations were made on thirty-
two children. These observations showed that the temperature of
the surrounding air has no constant effect on the systolic pressure,
the diastolic pressure or the pulse pressure and the severity of the
disease. The rates of the pulse and respiration were also counted in
many instances at the same time that the blood pressure was taken

882 TRANSACTIONS OF THE

to determine, if possible, what effect the temperature of the surround-
ing air had upon them. In general, the temperature of the surround-
ing air had no constant effect on the rate of the pulse or respiration.
There was, however, a slight tendency for the rate of the pulse and
respiration to be somewhat lower out of doors than in the wards.
The mortality was high in this series of cases. A study of the cases of
pneumonia, treated at the Children's Hospital since its foundation,
by Cunningham, shows that the mortality has been slightly higher
since the institution of the cold air treatment: The following con-
clusions are warranted: There is no constant relation between the
systolic, the diastolic or the pulse pressure and the severity of the
pneumonia or the temperature of the surrounding air. The rates
of both the pulse and the respiration show a tendency to v^arj' directly
with the temperature of the surrounding air. The patients symp-
tomatically seem more comfortable when they are out of doors than
when they are in the house. No conclusions are justified as to the
effect of cold air treatment on the mortality of pneumonia in
children.

DISCUSSION.

Dr. Henry Dv\^GHT Chapin, New York. — Babies with bron-
chopneumonia do not do well when treated out of doors. Some
years ago we put all pneumonia cases out of doors but we found that
the children with bronchopneumonia were depressed by this treat-
ment. We must make a distinction between bronchopneumonia and
lobar pneumonia. Something should be said against treating
feeble babies with cold air.

Dr. Henry Koplik, New York. — General practitioners have been
very prone to treat babies with pneumonia in the open air. There
are certain babies that should not be put in the cold air; they should
have fresh air but not cold air. On the other hand, there are babies
that become restless in the ward and from the clinical standpoint
they may sometimes be improved by being placed in the open air.
The point to be made is that the cases must be picked. Some babies
with lobar pneumonia are benefited by crisp cool air if they are well
wrapped up and their hands and feet kept warm, but others are in-
jured if they are in too cold an atmosphere.

Dr. E. E. Graham, Philadelphia. — In Philadelphia we have been
treating both forms of pneumonia in ward rooms of the roof garden
where the children receive an abundance of fresh, cool, moving air.
My experience teaches me that provided we can keep the children's
hands and feet Well bundled up the cold air never does harm and
sometimes it does good.

Dr. L. R. DeBuys, New Orleans. — Cases of lobar pneumonia do
better with plenty of fresh air. I have been impressed by the short-
ness of cases of pneumonia both bronchial and lobar when treated
with oxygen. VVe have been administering o.xygen, giving eight-
een drops per minute during the treatment, and find that the dura-
tion of the disease has been much shortened in this way; this is
giving the outdoor treatment indoors.

AMERICAN MEDICAL ASSOCIATION 883

Dr. John Zahorsky, St. Louis. — Several years ago in St. Louis
we used cold air in the treatment of babies with pneumonia with
disastrous results. Clinically there is generally an improvement and
the child seems to feel more comfortable in cool air but not neces-
sarily cold air. On the other hand, cold air appears to be harmful
in some cases. I feel inchned to report a case in which there was a
low blood pressure and a relatively weak heart. This child was
placed in the cold air and after being out of doors for a few moments
the heart stopped, and the parents still blame me for the death of
that child. Cold air should be used with a great deal of care and
while the babies appear to feel better in cool air I feel that cold air is
harmful.

Dr. Charles Gilmore Kerley, New York. — When we deal
with cold air we are dealing with a therapeutic agent and while
it may be used with benefit in some cases, it is like all other
therapeutic methods; it must be applied according to the indications
in selected cases. In small babies with bronchopneumonia and with
a tendency to spasm the use of cold air may be attended with
a great deal of danger, while in a husky child with lobar pneumonia
it may be productive of much benefit. We cannot draw any con-
clusions with references to cases of pneumonia as a whole, but the
cases must be carefully selected, and after the cold-air treatment has
been instituted the children must be carefully watched.

Dr. C. G. Grulee, Chicago. — I cannot discuss the paper but I
may discuss the discussion. It seems to me that we may briefly
state that the keynote of the matter lies in the selection of cases.

Dr. St. George T. Grinnan, Richmond, Va. — I feel that usually
cases of bronchopneumonia in children under eight months of age.
do not do well in extremely cold air but older children with lobar
pneumonia are greatly benefited by cold air.

Dr. E. C. Fleischner, San Francisco. — I think Dr. Grulee is
right when he says the keynote of the matter is the selection of cases.
In Cahfornia practically all the cases of lobar pneumonia get wcU
if put out of doors but our type of pneumonia is not as severe as that
in the East. The same thing is true with reference to broncho-
pneumonias in Cahfornia as elsewhere; they do not do so well when
put out in the cold air.

Dr. John Lovett Morse, Boston. — This paper dealt with lobar
pneumonias and not with bronchopneumonias and the results of the
observations recorded cannot be taken as either for or against the
cold air treatment of pneumonia. Our children were all older chil-
dren with lobar pneumonia.

Dr. Lawrenxe T. Royster, Norfolk, Va., read a paper on

GRIP IN CHILDREN.

This paper is the result of my personal experience with grip last
winter. Grip is always endemic but at times it becomes epidemic
and then it assumes a more severe form. The prevaihng type of
grip is characterized bj' a sudden onset, and a rise in temperature
lasting from two to five days, ranging from 102 to 105 or 106° F

»»4 TRANSACTIONS OF THE

When there is a sudden onset, high temperature, and great prostra-
tion it is sometimes difficult to distinguish this form of grip from
pneumonia during the first day or two. The pulse and respiration are
often not greatly interfered with. Older children may complain
of pains in almost any part of the body which are described as sharp,
violent and boring. A marked feature in a few cases was irregular
heart action and a few of these cases proved fatal. One form of grip
was characterized by bronchitis, laryngitis, and coryza and resembled
measles. There was also a t}^e of case characterized by persistent
vomiting. This type had been taken by some physicians for cyclic
vomiting, but it was of short duration and the evidence of diacetic
acid in the urine was very shght. To the writer diarrhea as a com-
plication of grip was a new experience; it differed in no way from the
type of diarrhea so common in summer. It was not of the cholera
infantum type and it did not follow the catarrhal type in any instance.
Some of these cases convalesced rapidly; in others convalescence was
long drawn out, and in others again, there were exacerbations or
reinfections. In some cases there was an irregular pulse very sug-
gestive of myocardial involvement. Among the complications
encountered were bronchitis, pneumonia, otitis media, and pyelitis.
These latter infections might have existed, probably did exist
before the grip developed, but the lowered degree of resistance gave
these other infections an opportunity to develop. In some cases
there was a pecuharly harsh, distressing and persistent cough; in
some Despine's sign could be elicited. A positive von Pirquet
reaction was quite frequent in these children. It may be said that
grip is only second to measles and whooping-cough as an inciting
. cause of tuberculosis. As a prophylactic measure against grip
children should be kept from older persons having the disease. A
mother suffering from grip should cover her mouth and nose while
nursing her infant. It is also well to protect young children from
dry windy weather. I have been using sodium salicylate in the
treatment of grip and prefer the natural to the sj^nthetic product.
In the catarrhal conditions I use a preparation of menthol, camphor
and white oil. In cases of severe bronchitis with exhausting cough
opium should not be withheld. The cases with diarrhea should be
treated as we treat summer diarrhea. When there is a persistent
cough, lasting for a long time after the attack, codliver oil and hygie-
nic treatment are indicated. Many of these patients in spite of all
care continue to cough until warm weather comes. Grip should be
a quarantinable disease; especial care should be exercised to exclude
it from the schools.

DISCUSSION.

Dr. Isaac Abt, Chicago. — This paper suggests the question of the
etiology of grip and of what a study of its bacteriology has shown.
In studying its bacteriology every kind of organism has been found,
virulent, nonvirulcnt, specific and nonspecific. Unless the bacillus
of influenza is so illusive that it cannot be identified we may con-
clude that the study of the bacteriology of grip during the past

AMERICAN MEDICAL ASSOCIATION 885

winter has thrown very little light on the etiology of the disease.
Seasonal or weather conditions seem to be a determining factor in
the incidence of grip. We may ask why there is so much grip in
February and March and why it disappears when the sun comes out
and then reappears again with damp cloudy weather. We may ask
why it disappears entirely during the summer months. Sometimes
babies are sent out of doors in winter when the weather is unfit for
an adult to be out. I have known of instances where a baby has
had grip and was doing well but on being sent out suffered a severe
exacerbation of the disease. It seems to me that the evidence
points to a seasonal or weather influence in relation to the incidence
of grip. Very often the disease starts with vomiting and the vomit-
ing is the expression of a general toxemia brought about by the grip
infection, and in addition to the vomiting one gets symptoms refer-
rable to the nasal mucosa and the nasopharynx and tonsils or some
complication of the middle ear. So far as the cough is concerned it
is often out of proportion to the bronchial involvement. The .i:-ray
may show enlarged bronchial or mediastinal glands and where there
is no positive von Pirquet reaction these are due to something else
than tuberculosis. In relation to the pyelitis, this occurs ver\' fre-
quently following grip, especially in children who have had pyelitis
before. In the treatment of this condition urotropin is often used.
This agent should not be used in children under the age of three
years, as it is often responsible for a nephritis in such young children.
I beUeve that nephritis is not so often due to the organism causing
the grip as it is to the use of urotropin.

Dr. Joseph Brennemann, Chicago. — While I see a number of
cases with symptoms almost exactly like those described there are
two symptoms which stand out conspicuously, namely, abdominal
pain and homorrhage, frequently into the intestinal wall. When I
am told that a child is complaining of pain in its stomach I always
look into the throat or look for an otitis media. I know of several
cases in which the patients complained of abdominal pain and were
operated on for appendicitis; in one of these the glands were very
much enlarged and in two others there was hemorrhage into the
intestinal wall and the trouble had begun with sore throat. The
tendency to hemorrhage is very marked in a number of cases. There
also seemed to be a relation between the grip and certain exanthema.
During the spring there were a large number of cases with a scarlatina
form rash and it was difficult to tell whether these were cases of
scarlet fever or not.

Dr. Jay I. Durand, Seattle. — We had the same kind of an epi-
demic in Seattle last winter and we saw all tj'pes of cases. I believe
that grip is a clear-cut, clinical entity. I believe it is purely a respira-
tory form of infection and we must prevent its spread as we prevent
other forms of respiratory infection from spreading. In the liospital
we found that if the beds were 3 feet apart, had a double gauze
partition between them, and drafts were prevented the infection
was not spread from one bed to another. In wards in which these
precautions were not taken every child in the ward would get the
infection.

886 TRANSACTIONS OF THE

Dr. N. S. Everhard, Wadsworth, Ohio. — We had an epidemic of
grip in Daj'ton last winter. Since in grip the body cells become
exceedingly acid large doses of alkali are indicated. We found that
the vomiting subsided after the administration of potassium citrate
and that it could be given in larger doses than the salicylates.

Dr. Henry Dwight Chapin read a paper on

This paper is based on observations made in thirty- four cases. The
laboratory work was done by Dr. Marshall C. Pease. During the year
1913 we had our attention called to certain class of intestinal cases
called cases of acidosis. It was found that these cases were very
frequently fatal. Many of these cases did not show diacetic acid
in the urine, and the illness was out of all proportion to the symptoms.
The children became cyanotic and often stupor and coma super-
vened. The tongue was coated and red along the edge; the tem-
perature was not high though the antemortem temperature might
rise to 104 or more. Vomiting was often one of the initial symptoms
but this ceased as the stupor and coma came on. The output of
urine might be scant. The most consistent symptom in these cases
was the alteration in the character of the respiration. The ampH-
tude of the respiratory excursion was greatly increased and was accom-
phshed with great effort. Czerny first called attention to this con-
dition and found that there was an abnormal amount of acid in the
body; that the total nitrogen was greatly increased, that this was not
due to the abnormal accumulation of acids but to the loss of alkali
and that this form of intoxication was more hkely to occur in a
condition of inanition or malnutrition. Acidosis may be due to
damage to the epithehum of intestinal tract making it easier for the
split proteins to pass into the blood. It may be due in a lesser
degree to the withdrawal of water. Howland and Marriott have
pointed out that there is often a decreased output of urine and an
enormous loss of water with the feces. The necessity of determining
the presence or absence of acidosis at the earliest possible moment
is evident. Various methods of determining the presence or absence
of acidosis have been devised, as Sellard's method for estimating the
carbon dioxide content of the blood the more recent method of
Van Slyke of determining the plasma bicarbonate or Rowland's
method of determining the carbon dioxide tension of the alveolar air.
By means of these methods it has been found that acidosis is of
more frequent occurrence than was formerly supposed. There have
been in the Babies' Ward of the Post-Graduate Hospital thirty-four
cases of acidosis and of these six died within a few hours of admission.
In all, sixteen cases died, giving a mortality of 45 per cent. Twenty-
six cases did not show acetone or diacetic acid in the urine but they
showed a lowered carbon dioxide tension. The lowest carbon dioxide
tension shown was 22 and the average was 28. After the adminis-
tration of sodium bicarbonate in a number of cases the carbon dioxide
tension rose, but with the reappearance of symptoms it fell again.
The effect of the acidosis in some cases seemed to be permanent and

AMERICAN MEDICAL ASSOCIATION 887

children who have had one attack frequently have recurrences.
There was only one case of acidosis in a breast-fed baby; these chil-
dren were fed on modified whole milk, sometimes with an excessively
high percentage of protein. I have not met with a case of acidosis in
a child fed on a carbohydrate diet. The acidosis seems to be due to
the action of split proteins. Vaughan has given us confirmatory
evidence that high protein feeding is not without its dangers, and
says that in certain conditions it may threaten life itself. The
decomposition of protein is a factor in the production of acidosis is
supported by finding large amounts of indican in the urine. The
administration of sodium bicarbonate formed an important part of
the treatment of these cases after there has been a thorough cleaning
out of the bowels; the bicarbonate has been administered in various
ways, by mouth, per rectum, hj-podermically and intravenously.
An analysis of the diet in twenty cases of acidosis before and during
treatment was made. The diets used in treatment were (i) sugar
free; (2) fat free; (3) sugar and fat free; (4) a low vegetable protein
and starch diet, and (5) starvation. The results of these observa-
tions seemed to justify the conclusion that there is a relationship
between the protein of cow's milk and this type of acidosis.

Dr. John Rowland and Dr. W. McKim Marriott, Baltimore,
presented a paper entitled

CONDITIONS in INF.\NCY AND CHILDHOOD ASSOCIATED WITH THE
PRODUCTION OF ABNORMAL QUANTITIES OF ACETONE BODIES.

The term acidosis is often used synonymously with acetonuria
and acetonemia. Acidosis may or may not be present in acetonuria.
Acetonuria is frequently present when acidosis is absent. A severe
disturbance may be brought about by other substances than acetone
bodies in the urine; again a considerable amount of acetone bodies
may be present in the urine without producing a disturbance of any
kind. Acetonemia of a moderate degree is quite common and ace-
tonemia of a severe degree is not very unusual. It may occur with
an intensity severe enough to threaten life without obvious cause.
It may be recurrent. Hvperpnea is the chief clinical sign. It occurs
only when there is a reduction of the alkali reserve; it is dependent
on a loss of the acid base equilibrium of the blood. This condition
can be determined by several relatively simple laboratory procedures.
A diagnosis cannot be made by a qualitative analysis of the urine.
Holt has found acetone present in 30 per cent, of 200 consecutive
urines examined and in 70 per cent, of the cases suffering from lobar
pneumonia, and it has been found in many other conditions as after
anesthesia and after a period of starvation. In childhood acidosis
resulting from the production of abnormal acids is found chiefly in
diabetes and recurrent vomiting. A study of diabetes in childhood
shows that enormous amounts of acid may be taken care of with
no disturbance in the reaction of the blood, and with no effect upon
the respiration. In recurrent vomiting the conditions are more
obscure and less understood, but the evidence indicates that in
recurrent vomiting the acidosis is due to the acetone bodies. In the

808 TRANSACTIONS OF THE

treatment of acidosis intravenous injections of sodium bicarbonate
have been most effective. Older children react promptly and some-
times permanently to alkali therapy. In infants it may be possible
to stop the chnical and laboratory evidences of acidosis, but they
usually die. For this reason we should not wait until acidosis can
be demonstrated, but in severe cases of diarrhea in infants we
should give bicarbonate of soda in sufficient quantities to render
the urine alkahne and to keep it so.

Dr. S. Borden Veeder and Dr. Meredith Johnston, St.
Louis, presented a paper entitled

THE FACTOR OF STARVATION IN THE DEVELOPMENT OF ACETONURIA.

Until recently the terms acetonuria and acidosis have been used
synonymously, but now the term acidosis is used in a more general
way to designate a decrease in the alkahne reserve of the blood.
In the present condition of our knowledge it is well known that
we may have acetone bodies during starvation and in febrile and
toxic diseases. The extent of the acidosis that may result cannot
be assumed from the quantity of acetone bodies. The formation
of acetone bodies is attributed to various causes, such as a defi-
ciency of carbohydrates, a defect in carbohydrate metabolism,
as a result of narcosis; they are found in many conditions in childhood.
For this reason acetonuria is of interest to the pediatrist. Inanition
may be a factor in the production of acidosis. It is of practical
value to know how starvation affects the production of acetone
bodies since starvation is a therapeutic measure frequently employed.
We made observations on children of different ages and body weight,
who were fed before the period of starvation on the standard diet
containing 40 to 50 per cent, carbohydrate. It was found that the
total quantity of acetone varied directly with the period of inani-
tion. The total output of acetone bodies when the children were
on this diet was about 3 milligrams per kilo body weight. During the
first twenty-four hours of starvation there was httle difference in
the output of acetone bodies, but there was an increased elimination
during the second day. If the starvation period extended only
over one day the output on the second day returned to normal
figures. In eighteen cases the starvation was continued during a
second twenty-four hours and then there was a very marked increase
of the acetone bodies on the second day, in one instance the increase
was from 20 to 410 milligrams per kilo body weight and the increase
of oxybutyria acid was from ij'^ to 5 grams. On the da}- following
the two inanition days there was a continued acetonuria but it was
less than on the preceding day. In febrile and toxic conditions the
figures were high but not as high as in inanition. Folin and Denis
have found that obesity is not a predisposing factor in increasing
the output of acetone bodies. We made observations on children
well nourished and on those undernourished and found no relation
between the degree of acetonuria and the degree of inanition.
All these children were closely watched for clinical symptoms, par-
ticularly with reference to the symptoms of acidosis in childhood.

AMERICAN MEDICAL ASSOCIATION »»9

There was not a single child that appeared to be affected in any
way, save for hunger, by the lack of food, so that it seems safe to
conclude that starvation cannot be the cause of the symptoms of
acidosis.

DISCUSSION.

Dr. John Lovett Morse, Boston. — It struck me as Dr. Chapin
described acidosis in infancy and spoke of the hyperpnea how closely
it resembled the asthmatic dyspnea of our grandfathers. There
are certain lessons to be drawn from these papers for the general
practitioner, certain practica.l points that he may carry away with
him. One of these is that the presence of acetone bodies in the urine
is not proof of acidosis, and, vice versa, that the absence of acetone
bodies is not proof that there is not an acidosis. If starvation
causes the appearance of acetone bodies in the urine one cannot tell
when he is giving the starvation treatment whether the acetone
bodies are due to the starvation or to the disease. Acetone bodies
may be found in all conditions in childhood accompanied by fever.
What all this means is that the physician must learn to make an
examination of the blood for acetonemia and not trust to the pres-
ence or absence of acetonuria. When he has learned to make
these determinations he may learn from the e.xamination of the
blood whether the patient has acidosis and whether acetonemia
is present, but even then he has not gone to the bottom of the matter
for acetonemia is not a primary condition and if the patient is to
be treated for this condition satisfactorily we must find the under-
lying cause of the acetonemia. According to newspaper statements,
we had an epidemic of acidosis in Boston last winter, but in the
vast majority of the cases the urine was never examined, and in many
in which it was examined no acetone bodies were found. It would
seem impossible to have an epidemic of acidosis because acidosis
is a secondary and not a primary condition. It was my experience
that if these children said to have acidosis were closely examined
they were found to have something else the matter with them. As to
the endemic form of acidosis, there is no endemic acidosis in Boston,
but in certain parts of New Hampshire there are a great many
cases of severe illness in children and the only symptoms found
outside of vomiting are changes in the character of the respiration
and a diminished output of urine with a very large amount of acetone
bodies. The large majority of these children get well, but a cer-
tain number die. I do not think we can deny that these are cases
of acidosis. In cases presenting these symptoms the complications
have all shown bacterial infection of the blood and a local focus of
infection.

Dr. Williams. — Someone has spoke of the removal of water from
the body as a factor in the production of acidosis. It seems to
me that an inquiry as to the effect of the disturbance of the water
balance might clear up this question. If this is an underlying cause
an attack will be precipitated by diminishing the water. Any
one who attempts to study acidosis by modern methods of pre-

890 TRANSACTIONS OF THE

cision will find that it is probably a rare condition. Nearly all
the methods of estimating the carbon dioxide are very excellent
but they are not within the means of the average physician, but there
are some means of estimating the carbon dioxide tension that are
exceedingly valuable and can be carried out at the bedside. Such
a method supplemented by urinary analysis is very valuable, for, as
a rule, when the body is producing excessive amounts of acid an ex-
cessive amount is eliminated in the urine. Also when the body pro-
duces an excessive amount of acid there is an increased ammonia
excretion. The Folin method of estimating the acid in the urine
and the ammonia is very simple and reliable and these two methods
together are quite adequate in determining acidosis. I would also
call attention to the fact that sugar will carry more than three
times its weight in water and when we give sugar to the patient with
acidosis we add to the water content of the body. Salts also have
some influence in causing an increase in the amount of water in the
body. Eating salt may cause the development of edema. I have
never seen a patient die in acidosis if the body showed edema and
this is confirmed by the experience that tests for diacetic acid are
relatively unimportant.

Dr. Cathcart. — We have been shown that inanition and the
withdrawal of hydrocarbons caused an abnormal excretion of ace-
tone bodies. In igio, I called attention to the creatin-creatinin
excretion in recurrent vomiting and also to the relation of acetone
and acidosis in recurrent vomiting. It was shown that there was an
increase of the creatin-creatinin just before the attack and an
increase of the acetone bodies just before the attack as well as
during the attack. I mention this because we must study acidosis
in relation to other metabolic processes and we cannot afiford to
ignore such studies.

Dr. Charles Gilmore Kerley, New York. — This subject is
one of the most important that will come before us at this meeting.
I have been trying for the last five or six years to correlate these
cases showing various types of recurrent symptomatology. We
have cases that show a distinct acetonuria and cases of acidosis,
but we also have border-line cases and it is these latter that ,ive
the most difficulty. These cases of acetonuria in scarlet fever,
pneumonia, and measles may develop into straight cases of acidosis.
Then we have instances in which both conditions occur in one patient.
The type of cases s'howing the acetonuria are the children who have
been getting too much milk. The majority of children of runabout
age are overfed; they get too much sugar and too much fat and these
are the cases that show acetonuria and high fever during an
attack. Sixty to 70 per cent, of my cases of measles show aceto-
nuria and a similar percentage of pneumonia and scarlet fever cases.
While acidosis is said to be due in some instances to carbohydrate
starvation the feeding of large amounts of sugar produces the same
result because the powers of assimilation are temporarily held in
abeyance. I have seen three cases of acidosis since last October.
One was a breast-fed baby of nine months that was taken ill suddenly

AMERICAN MEDICAL ASSOCIATION 891

and showed marked air hunger. There was no elevation in tempera-
ture. The child went into coma, had an acetone breath, and
died within thirty-four hours. Another child two years of age died
within forty-eight or seventy-two hours. Another case to which I
wish particularly to call attention occurred after an operation. This
child had an acute attack of appendicitis and shortly after operation
developed an acidosis and Hved twenty-four to thirty-six hours.
Sodium bicarbonate was absolutely of no avail in these cases. It was
injected into the arm repeatedly in this latter case. It might be
a good scheme to fortify the patient before operation with sodium
bicarbonate. I had two other cases which were border-line cases,
in the one case there was an acidosis associated with pneumonia
and in the other with pj^elitis. The three cases first referred to
were distinctly acidosis cases without complications.

Dr. John Zahorsky, St. Louis. — I would like to ask if there is
any way the physician can make a diagnosis of acidosis without
testing the blood so accurately. In how many cases of gastro-
intestinal into.xication can we depend upon hyperpnea and deep
breathing as an indication of acidosis and is it better to give sodium
bicarbonate to all these cases? Then again, in cychc vomiting and
acid intoxication after the use of chloroform can we prevent these
conditions by administering sodium bicarbonate and glucose before-
hand? In intestinal toxemia is it better to give barley water or
saccharine water as is usual, or should one begin right away giving
large doses of bicarbonate instead of calomel?

Dr. C. S. Wahrer, Fort Madison, la. — Things are getting very
complicated. I would hke to ask a few questions though I do not
wish to add to the confusion that Dr. Zahorsky has started. We
have been told that acidosis occurs in some children and not in others
under the same conditions. Does excessive sugar eating predispose
to acidosis or will he be threatened with glycosuria? Is there a
predisposition in some children to have acidosis or is there something
in the etiology of acidosis that we do not recognize? Again what
makes the predisposition? Is it that children during the first five
years of life have a lessened resistance and consequently succumb
more easily to acidosis?

Dr. Henry Dwight Chapin, New York. — The treatment of
the diarrhea associated with acidosis is not different from the treat-
ment of summer diarrhea. We have found that the best results
are obtained by giving castor oil, washing out the bowel and then
giving carbohydrates. These studies from the practical standpoint
have not been altogether in vain.

Dr. John Rowland, Baltimore. — In the first place in the dis-
cussion the confusion has been made of calhng recurrent vomiting
acidosis. Cases of recurrent vomiting are not cases of acidosis.
The overwhelming majority of cases of acetonuria are not cases of
acidosis. Acidosis is not shown until there is a diminution of
the alkaline reserve of the body, but in recurrent vomiting a dimin-
ished alkaline reserve is almost the exception. These children
with recurrent vomiting have a metaboUc disturbance which is

892 TRANSACTIONS OF THE

only a temporary disturbance in the great majority of instances.
If there is a disturbance of the alkali reserve it does not adjust itself
so readily. The alkali treatment is indicated when the acetonemia is
severe and prolonged. There is only one symptom of acidosis and
that is hj-perpnea, exaggerated breathing of the air hunger tj-pe.
Acidosis may occur without fever and without vomiting; the only-
regular clinical symptom is the hyperpnea. The examination of
the carbon dioxide tension of the alveolar air is not so difficult; it can
be easily and quickly collected by the method that Marriott has
devised. All of the tests that have been devised tell us a great deal
more than we can find out by chnical methods alone. Almost all
children who have diarrhea and hyperpnea have acidosis. We can-
not tell when a child with these symptoms wiU develop acidosis so
the safe thing to do is to give sodium bicarbonate until the urine is
alkaUne and to keep it so. Acidosis in children having diarrhea of
the watery type is not due to the acetone bodies, but there may be
other organic acids. In some cases there is an increase of acid
phosphates and it may be that the anuria results in the production
of these acid phosphates and they tend to produce acidosis.

Dr. C. J. Pettibone and Dr. F. W. Schlutz, Minneapohs, pre-
sented a paper on

A FURTHER STUDY OF THE AMINO ACID CONTENT OF THE BLOOD.

This study was undertaken in order to show the variation of the
amino acid content of infant's blood, particularly in relation to
various forms of feeding and the time of feeding. A review of the
literature shows that the amount of amino acids in the blood varies
widely but there is little to show what relation the amount of amino
acid in the blood bears to various pathological conditions. Nor-
mally the amount of amino acids in the blood of infants is 4 mg.
per 100 c.c. of blood. In order to see whether there is any variation
from normal the blood of sixty children, ranging in age from one
month to thirteen years, was examined. Among the pathological
conditions present in this series of cases were diphtheria, scarlet
fever, bronchopneumonia, tuberculosis, atrophy, nervous disorders,
nephritis, rachitis, alimentary disorders, encephalitis, tonsillitis. The
blood was taken from the median basiUc vein and examined by the
methods of Van Slyke and Meyer, 2 to 5 c.c. of blood being used.
The analysis was begun one- half hour after taking the blood. The
figures obtained run lower than those of \'an Slyke and Meyer for
adults. In these diseased conditions there seemed to be no differ-
ence from the average found in health. The amount was not in-
creased in febrile conditions. This was not what one would have
expected. There was no striking correlation between the amount
of amino acids in the blood and the length of time since the last feed-
ing, although the amount was always lower than in adults.

AMERICAN MEDICAL ASSOCIATION 893

SYMPOSIUM ON SYPHILIS.

Dr. Frank S. Churchill and Dr. R. S. Austin, Chicago, pre-
sented a paper on

THE FREQUENCY OF HEREDITARY SYPHILIS.

Dr. Churchill said this study was based on a laboratory and clin-
ical investigation of about 695 cases at the Children's Memorial
Hospital' from November i, 1915 to June i, 1916. A series of 102
cases reported on in 19 10 by Dr. Churchill had shown thirty-nine
positive Wassermann reactions. At that time he had called a num-
ber of weakly positive reactions positive which in the light of our
present knowledge would not be considered positive, since it has
been learned that a weakly positive Wassermann reaction might
be obtained in many conditions other than syphilis, as yaws, leprosy,
tuberculosis, eczema and some acute infections. There are two
factors requisite in order that statistics may be considered reliable;
they must be based on the examination of a large number of individ-
uals and there must be accuracy of diagnosis. To meet this latter
requirement both the clinical and the laboratory findings must be
taken into consideration. Owing to the transitory positive Wasser-
mann reactions in other conditions it is well to have the test repeated.
Forty- two cases of eczema have shown positive Wassermann reactions,
sometimes a single positive reaction and sometimes a double reaction.
We have divided our positive reactions into three groups according
to the degree of hemolysis that occurred, single, double and triple.
A single positive reaction was regarded as of almost no value from
the diagnostic point of view. A double Wassermann with physical
signs of syphihs was considered good evidence of the presence of the
syphilis. In the absence of physical signs it was well to have the
test repeated. A triple Wassermann reaction even without phys-
ical signs of syphilis was fairly good proof of the presence of lues.
In this series of cases we found twenty-three that could be considered
as syphilitic. Sixteen of these twenty-three gave a triple Wasser-
mann reaction. Six cases showed no physical manifestations of the
disease and the diagnosis was based on the triple Wassermann
reaction alone. In 640 of this series there was nothing sugges-
tive of syphihs. This left a number of cases in which the presence
of syphilis was doubtful. These were of no use statistically but
should be kept under observation and given antisyphihtic treatment
for their own benelit and for the good of society. A study of the
literature with reference to the incidence of hereditary syphilis
shows a wide range of results, the incidence in Europe and in this
country varying from 2 to 14 per cent. In this series the incidence
was :i.2 per cent., while in four of the largest studies made in this
country it has varied from 2 to 6 per cent.

Dr. Abner Post, Boston, presented a paper on

THE CLINICAL COURSE AND PHYSICAL SIGNS IN HERIDITARY SYPHILIS,

which was read by Dr. Philip N. Sylvester, of Newton Center, Mass.

894

TRANSACTIONS OF THE

There are irreconcilable variations in the descriptions of hereditary
s>-philis in the Hterature. This paper contains few additions to our
knowledge and few theories. A difference should be recognized
between the child who is s\-philitic ab initio and one rendered syphi-
Htic after life has begun. Hereditary sv'philis has been confused
with congenital syphihs. Hereditary s\^hilis occurs in a great va-
riety of clinical forms and there is a difference between early and late
hereditary s^'phihs. In the early type the children suffer from mal-
nutrition, show emaciation, and a bullous eruption. The lips may
be cracked and ulcerated, the digestion impaired, the hver and spleen
enlarged, and there is a progressive emaciation. When a child
suffers from this severe tj'pe of the disease death usually follows.
There are all gradations of severity from this tv'pe just described to
a tjpe so mild that the child is apparently healthy, until something
happens that gives an indication of the disease. In some instances
obstinate wakefulness may be the only symptom to e.xcite suspicion,
and in these cases one is likely to find the bones affected. Nasal
catarrh is present in a very large proportion of s}-philitic infants
and may lead to the impression that adenoids are present. In such
children operation of course gives no relief. Indeed, in these chil-
dren the nasal passage is definitely narrowed, and operation not only
does the patient no good but e.xposes the operator to the risk of syphi-
litic infection. These s\-philitic babies with snufiles have a pecuhar
cry which is quite characteristic to one familiar with it. Marasmus
is often due to syphilis and in some infants there is Little other e\'i-
dence of the sx^^hilis. In case of death the cause is given as marasmus
but unquestionable in many of these children sj'phiHs is the true
cause. S>'philis shows a marked tendency to involve the lymphatic
system. Frequently the peribronchial glands or the glands of the
neck are enlarged and are mistaken for tuberculous glands. In
many subjects the skin has a pale, sallow, yellowish hue. The erup-
tion of hereditary sj'philis is maculopapular, usually appearing first
on the heels, then on the soles of the feet and palms of the hands.
It presents a pecuhar ghstening appearance and in some instances
there is desquamation. Other signs that are characteristic of
early syphilis are shedding of the nails and thinning of the hair.
Cranial exostoses may be regarded as incontestable proof of s}'philis.
It is most frequently observed at the two frontal and the two parietal
sutures. This condition is sometimes attributed to rachitis, but
it occurs long before rachitis would appear. The bone changes of
syphihs may be mistaken for rachitis, tuberculosis, and osteo-
chondritis. Periostitis may also be present, and the line of demarka-
tion between epiphysis and diaphysis may be very indefinite. Treat-
ing the mother with salvarsan brings about a great improvement in
the succeeding baby, but still there may be some stigmata of syphihs.
It has often been stated that in the case of twins one may be healthy
and the other may have stigmata of syphilis. We now have two
pairs of twins coming to the dispensary. In these cases a thorough
investigation revealed the stigmata of syphilis on the apparently
healthy children. A careful Rontgenological study promises to be
of great aid in the diagnosis of hereditary syphilis in the future.

AMERICAN MEDICAL ASSOCIATION 895

Dr. L. R. DeBuys and Dr. J. A. Lanford presented a

COMPARATIVE STUDY OF THE LUETIN AND WASSERMANN REACTIONS.

In reviewing the literature of congenital syphilis we find that
there are not very many classical symptoms. Moreover, it is neces-
sary to recognize sj.'philis early if we are to give the cliild the best
possible chance in hfe. For this reason laboratory tests that can
be depended upon are important. In making the Wassermann tests
we have used practically the classical method of Wassermann; in
making the luetin tests we used the technic of Noguchi, carried
out minutely. We made, in all, 350 Wassermann tests and 159
luetin tests in 175 cases. Thirty odd cases studied several years ago
are included in this series. The period during which the subjects were
observed varied from one month to five and one-half years. There
were seventy-nine children, sixty-three mothers, and eight fathers
observed. In sixty-two families more than one member was tested
by both the Wassermann and the luetin tests. The data was only
partially complete in twenty-four cases and these had been excluded
from the series, leaving 151 cases. The children varied in age from
twelve days to just under puberty. The shortest luetin reaction in
a mother occurred on the second day and disappeared on the third
day; the longest reaction in a mother occurred on the twenty-fourth
day; in another mother it occurred after fourteen days. In several
instances positive luetin tests were obtained in those in whom it had
been negative before. In some instances in which the Wassermann
test was negative, a luetin test was made and was positive and a
later Wassermann test also proved to be positive. It seemed that
in some instances active antisyphilitic treatment brought about a
positive reaction where previously it had been negative. The most vio-
lent luetin reactions occurred in a mother and a nursing baby in whom
there were no signs of syphilis. It was discovered that the mother
had been given potassium iodide; the interesting feature in this case
was not only the effect of the iodide on the mother but its effect
on the nursing baby. We have found that the luetin test is more
reliable than the Wassermann. In eighty-one children and parents
the readings of the luetin test are dependable. In three families
there was a negative luetin and a positive Wassermann. We are
inclined to think that this was due to an error in technic as they
all occurred on the same day, and especially since these cases were
not considered clinically as luetic. A positive luetin reaction was
found in many instances in which the Wassermann was negative.
It was found that a positive luetin ran regularly in families, and this
fact was considered as further evidence of its accuracy. It
was observed that the Wassermann reaction varied from time to
time according to the activity of the disease. This was not the case
with the luetin reaction. The luetin test, however, should not
replace the Wassermann, for the Wassermann reaction indicates the
presence of antibodies in the blood. The luetin test shows the
presence of syphilis even in the latent stage. On the other
hand, the luetin test has the disadvantage that it is influenced by cer-

896 TRANSACTIONS OF THE

tain drugs. In making the test it should not be considered negative
until sufficient time has passed to be sure that one will not have a
late reaction.

De. p. C. Jeans, St. Louis, read a paper on

LATE hereditary SYPHILIS.

The diN-ision of hereditary syphilis into early and late stages is not
very satisfactory since the early changes may take place as late as
the fifth or sixth years and the late changes may be present at the
time of birth. This division into early and late changes must be
relegated to its proper place. The only evidence of syphilis may be
a positive Wassermann. There is very little hterature in latent
sjrphilis and the question arises whether latent syphilis should be
treated. I think there is some advantage in carrying out treat-
ment just as though some manifestations of the disease are
present. Some express the fear that the treatment of such cases
of latent sv'philis may result in the development of a keratitis but if
this should happen the probability is that it would have developed
later without treatment. Head's classification is the one I have
adopted in discussing sj^hihs of the central nerv^ous system. Certain
authors have tried to correlate syphilis and chorea. I have found
one case in which s\-philis was the cause of choreic symptoms. That
syphilis was the cause of these symptoms seems evident since the
case cleared up under salvarsan.

About 20 per cent, of the cases of epilepsy may be considered as due
to svphilis. Multiple sclerosis proper does not occur in childhood.
Hemiplegia is the most frequent acquired paralysis due to syphilis.
Syphilis of the central nervous system is not as uncommon as
has been supposed. Optic atrophy has been seen in children as
early as the fourth year; tabes is not so rare but it is difficult to
diagnose this condition in children. Paresis is more common than
tabes. As the intelligence is not developedin young children it is
more difficult to diagnose these conditions in children than in adults.
It is often difficult to differentiate sj-phihs from tuberculosis, espe-
cially when the bones, joints, and lymph glands are involved. I have
found that both the gross and the microscopical picture may be
indistinguishable. I have found that Hutchinson's triad is scarcely
ever present. In a study of several hundred cases we did not find
it once. I have found keratitis present in 25 per cent, of my cases,
Hutchinson's teeth in 6 per cent, and deafness in i per cent.

Dr. Philip H. Sylvester, Newton Center, Mass., read a paper on

the treatment of hereditary syphilis.

A pregnant syphilitic woman has a much better chance of liaving
a viable child if treated than if untreated. Since the establishment
of our system of prenatal care in Boston I feel sure that the per-
centage of viable children is greater and there are fewer abortions
than before. Salvarsan is effective in the early cases but it has been
largely discarded in the treatment of the new-born in favor of neo-

AMERICAN MEDICAL ASSOCIATION 897

salvarsan. We have found that after treatment with salvarsan or
neosalvarsan alone the clinical symptoms are likely to return so
that we have returned to the old treatment by mercury. There
has also been a reaction in favor of mercurial inunctions. The
tendency is to increase the dose of salvarsan rather than to diminish
it and to give it in a concentrated solution. It can easily be given
through the longitudinal sinus. Some new ideas have been advanced
in regard to the treatment of .syphilis with antimony and mercury
by inhalation, but thus far nothing very definite can be said of them.
There is very little to show that the treatment of the mother after
the birth of the child had much influence on the child. It has been
thought that the breast milk contained antibodies when the mother
was under treatment and again the improved condition of the child
has been attributed to the better milk supply because the mother's
health was improved by the antisyphihtic treatment. In treating
a case of hereditary syphilis mercury should be given for several
months; it may be omitted for a time and then begun again. If at
the end of six months the Wassermann is still positive the treatment
should be continued at intervals. In fact the treatment should be
continued at intervals for two years whether the Wassermann is
negative or not. If at the end of two and one-half years the Wasser-
mann is negative the child may be considered cured. Some give
neosalvarsan every three of four months in addition to the mercuric
treatment. The late cases of syphilis in children may be divided
into two groups, one corresponding to the tertiary stage in the adult,
and the other including cases of syphilis of the nervous system; in
the former the results of treatment are more encouraging than in the
adult, but less so than in the earlier stage of the disease, while the
treatment of syphilis of the nervous system is not so encouraging
some promising results have been obtained by the Swift-Ellis treat-
ment. The development of the Wassermann reaction has shown
that many cases of malnutrition and retarded mental development
are due to syphilis. Many of these children are not sick but they
are distinctly under par, and if the Wassermann reaction is positive
they should be given antisyphihtic treatment. Of fifty cases treated
by the writer, eighteen presented clinical evidence of early syphilis.
For a baby one month old we use o.i of a grain of salvarsan; from one
to six months o. 2 of a grain, and from six months to one year 0.2 5 grain.
The treatment given in different cases in this series emphasizes the
importance of early treatment and of continued treatment over a
period of two years. Though treatment of syphilis of the nervous
system has been disappointing it is not discouraging and all cases
should be treated.

DISCUSSION.

Dr. Borden S. Veeder, St. Louis. — I wish to emphasize one
point with reference to the involvement of the central nervous sys-
tem in hereditary syphilis. The statements made in the text-books
regarding the involvement of the central nervous system in children
are probably incorrect; this is probably because so many cases do

898 TRANSACTIONS OF THE

not present symptoms that are recognized as hereditary syphilis.
The statement was made that it is easy to give salvarsan intra-
venously. I have not found it easy in all instances. I have used
intramuscular injections of bichloride of mercury and have found
that the cases clear up more rapidly with this treatment. I give
a I per cent, solution in 4 or 5 minims. This method of treat-
ment has 'one drawback and that is that one must watch the
kidneys very carefully to avoid activating a nephritis by the bi-
chloride. In syphilis of the nervous system I give mercury as sal-
varsan does not seem to have the slightest effect in these cases. This
is probably due to the fact that in syphilis of the nervous system
the lesion is due to the death of nerve cells and nothing will do any

Dr. Henry Dwighx Ch.^in, New York. — If I recall correctly
Dr. Sylvester spoke of giving large doses of mercury in httle chil-
dren. It should be remembered that in young children gingivitis
is not present to serve as a warning that a sufficiently large amount of
mercury has been administered. Gastrointestinal symptoms have
been spoken of as a manifestation of syphiHs and I would like to add
another symptom and that is prolonged anemia. This is difficult to
treat in some cases. There is an impression that breast milk may be
affected by administering the arsenical preparations to the mother.
I attempted to prove this statement, but have never been able to
find arsenic in the breast milk and have abandoned the idea of in-
fluencing S)^hilis in the child by treating the mother. Osteochon-
dritis may be distinguished from rickets because it is unilateral,
while in rickets the swelling is invariably symmetrical.

Dr. John Lovett Morse, Boston.- — Enlargement of the lymph
nodes has been spoken of as a sign of syphilis. Enlargement of the
lymph nodes is very common in disturbances of nutrition so I think
it may be disregarded as a sign of syphilis. As to chorea, we re-
cently made a study of chorea and found that there is practically
no evidence to show that syphihs is directly the cause of chorea.
In a series of thirty cases of chorea we found only one case in which
there was a positive Wassermann reaction and that was feeble. As
to the case of chorea which Dr. Jeans beheved was due to s)-philis
because it was benefited by salvarsan, it may be recalled that some
French observers have been treating chorea with arsenical prepara-
tions intravenously and think that they have obtained very favorable
results, so that the fact that the case was favorably influenced by
salvarsan is not proof that it was caused by syphilis.

Dr. Mary Dunning Rose, New York. — In two instances we have
been very much misled by the Wassermann test. In one case the
Wassermami was found to be negative by a thoroughly competent
man and the report came back that the lesion was simply an ulcer.
SLx months later the child returned with the ulcer very much worse.
The luetin reaction was then done and was positive. If the Wasser-
mann test had not been made in this case we would have treated it
very differently; as it was si.x months of valuable time was lost.

AMERICAN MEDICAL ASSOCIATION »«»

Dr. H. M. McClanahan, Omaha, read a paper entitled

A CASE OF DUODENAL ULCER — OPERATION AND IMPROVEMENT.

This patient was seven years of age when first seen by the writer;
she had been well until she was five years old. She then began to
have attacks of gastric pain and vomiting at intervals of from three
to six months. There was a peristaltic wave that could be induced
by drawing the fingers across the abdomen, tenderness, and a pal-
pable tumor. The case was diagnosed as either partial stenosis oi
the pylorus or malignancy. Dr. Jones of Omaha operated on the
patient and found the stomach much dilated and a very small
pyloric orifice with a ring that could not be stretched. The operation
performed was a gastrojejunostomy after which a prompt recovery
took place. The child was soon apparently well but was not
sufiiciently careful of her diet and after a time the symptoms re-
appeared. This relapse shows the need of careful postoperative
treatment. At the operation Dr. Jones found what was evidently
a healed duodenal ulcer.

Dr. E. E. Gr.A-HAM, Philadelphia. — -Pyloric stenosis in older chil-
dren is not so uncommon as has been supposed. Some years ago
I began to be on the lookout for pyloric stenosis in children and this
condition is not so uncommon, but duodenal ulcer is quite uncom-
mon. The symptoms of peristaltic wave and tj^pical tumor do not
occur as a rule in older children and in this particular Dr. McClana-
han's case is very interesting.

Dr. Charles Gilmore Kerley, New York. — This case is rather
unusual. The peristaltic wave is a very frequent symptom in little
children, but it is comparatively rare in older children. The pal-
pable mass is also a factor in making a diagnosis. In some instances
very young babies have a hypertrophic stenosis and it is very diffi-
cult to determine its presence by palpation. Just before coming
here I had a case which was operated on by Dr. Downes for hyper-
trophic stenosis of the pyloris and a mass was found an inch long
and more than an inch in diameter and neither Dr. Downes nor I
had been able to feel the mass. The fact that one does not find the
tumor does not mean that there is no hypertrophy and partial
stenosis and because of this fact the condition is often overlooked.

Dr. M. L. Turner, Des Moines, la. — I had a case of pyloric
stenosis lasting six weeks in which plastic operation was performed,
a longitudinal section of the tumor. The child was only three months
old and made a good recovery.

Dr. Julius H. Hess, Chicago. — I am familiar with Dr. Strauss's
work. In a series of twenty-three cases, twenty-one of which are
still living, a posterior gastroenterostomy was done and a fluoroscopic
examination of these cases shows that in nineteen the bismuth passes
through the gastroenterostomy opening and not through the pylorus.
In twelve operations done by the method Dr. Strauss is doing to-day
all the patients are living and well. The operation itseK is fairly
simple and has certain advantages over the Ramstedt operation.
A flap of muscle fills in the space that is left open in the Ramstedt

900 TRANSACTIONS OF THE

operation and there is no open surface left. The greatest advan-
tage of this operation is that the food takes a natural course
through the digestive tract and the patient gets the pancreatic
juice and the bile in a normal waj' as he does not when the food takes
a shorter course to the duodenum. As to our mortality by this opera-
tion, we had one death in ten cases.
Dr. Charles Gilmore Kerley, New York, read a paper on

CHRONIC DIGESTIVE DISORDERS OF MECHANICAL ORIGIN IN CHILDREN.

Digestive disturbances may be grouped into three classes: those
due to bacterial infection, those due to perverted function, and those
dependent upon chronic appendicitis. There is a certain class of
cases showing recurrent symptoms of gastrointestinal disturbance,
such as vomiting, fever, and sometimes respiratory symptoms, that
does not respond to the treatment that is usually effective in this
class of patients. In seeking for the reason of my failure to get
results in these patients, I finally resorted to the .r-ray and this has
opened up an entirely new field. Many of these cases had shown
intractable constipation or constipation alternating with diarrhea;
the explanation of this has been furnished by the x-ray. In some
instances we found an elongated colon and in others ptosis of the
stomach, while in others, again, a partial pyloric stenosis was found.
I have found massage and physical therapy of the greatest aid in
dealing with these cases of elongated sigmoid. In addition to the
massage and physical therapy, Russian oil, olive oil, and fluid e.x-
tract of cascara have been employed in combatting the constipa-
tion. If I wish to give a teaspoonful of cascara a day I give it in
three doses and in that way get a better effect than if the whole
dose was administered at one time. The diet is regulated by omit-
ting white bread, rolls, crackers, and similar articles of diet and
giving more vegetables and fruits, except in cases in which there is
diarrhea. In these latter cases I omit the fruit and vegetables and
give boiled skimmed milk. These rdntgenograms indicate the
possible dangers of enemata in children. The result is to further
irritate the bowel. The x-ray examination in children suffering
from such chronic conditions has the additional advantage that it
serves to show the parents just what is causing the trouble and thus
makes it easier to get their cooperation. When the parents are shown
that the child has an anatomical deformity they do not e.xpect the
child to be cured immediately and are thus more wilUng to give
their cooperation during a course of treatment. In many of the
cases examined we found that we were deahng with a ptosis. As is
well known most of the ptoses of adult life are either congenital or
acquired during childhood. The child of five, six, or eight years of
age, eats a large meal three times a daj' and with each meal drinks
two or three glasses of milk, being urged to do so by his parents.
The consequence is that the stomach is loaded far beyond its carry-
ing power and a ptosis results. These patients suffering from ptosis
of the stomach are benefited by wearing an Aaron bandage modified
for children and having a transverse ridge which supports the

AMERICAN MEDICAL ASSOCIATION 901

Stomach. It is my custom to have these children rest on the right
side after meals. B}^ this method of treatment, the vomiting, the
asthmatic attacks, the eczema, the cohtis, or the constipation, have
disappeared or been greatly helped. We feel that the recognition
of the true condition in these patients is a great step in advance.

Dr. Leon T. LeWald, New York, gave a lantern-sHde demonstra-
tion of

RONTGEN-RAY FINDINGS OF CHRONIC INTESTINAL AND STOMACH
DISORDERS OF MECHANICAL ORIGIN IN CHILDREN.

This series of pictures shows the conditions found in the class of
patients considered in Dr. Kerley's paper. The first series of pic-
tures show the natural position of the stomach in infancy and the air
normally present. It shows that when the baby is fed and then kept
in the horizontal position the food in the stomach closes the esoph-
ageal opening so that air cannot escape and as a consequence it is
forced into the intestines and causes coHc. This trouble may be
avoided by throwing the baby over one's shoulder in an upright
position as this posture gives the air an opportunity to escape. These
pictures show the elongated sigmoid the ptosed stomach or the par-
tial pyloric stenosis to which Dr. Kerley has referred. It is my rule
to consider a case suitable for operation if no food is seen passing
through the pylorus one hour after a meal. I would hke to warn
surgeons in doing a gastroenterostomy to always be very sure that
they have closed the pyloric end of the stomach; I have seen several
cases in which a fatal pneumonia has resulted from failure in this re-
spect. The fact should be emphasized that ptosis is not a matter
of anatomy but of function. I would hke to show these two instances
of syphilis of the stomach. It is becoming increasingly evident that
many visceral lesions are of s\-philitic origin, not only gumma, but
interstitial changes. As time progresses these will be more fre-
quently recognized. The operations that have been suggested as
corrective of the elongated sigmoid are an anastomosis between the
cecum and the sigmoid or a resection of the proximal portion of the
sigmoid.

DISCUSSION

Dr. Henry Dwight Chapin, New York. — I presented a paper on
this subject at the Minneapohs meeting several years ago and showed
a series of .-c-ray pictures to demonstrate that the sigmoid flexure in
infants is a very much larger structure than has been supposed. This
study was limited to infants. In this series of cases there were
several in which the sigmoid went above the umbihcus, and in other
instances it made a figure eight and was very mobile and very large.
It was shown that the sigmoid flexure was much larger and more
complicated than had been recognized and it demonstrated the utter
uselessness of trying to give high enemas to babies. One cannot
pass a soft catheter into the sigmoid flexure of a baby, and I hope
we are coming to the point where we will stop annoying babies
b}^ trying to pass a tube. If one passes the tube only 2 or 3

902 TRANSACTIONS OF THE

inches into the rectum and places a bag 2 feet above the baby and
allows the fluid to flow slowly the entire large intestine can be filled
by the solution.

Dr. L. R. DeBuys, New Orleans. — I have been very much inter-
ested in the pictures shown by these men, particularly the first
group of patients showing the shadows of the air ball at the top
of the stomach when the child is erect. At the same meeting at
which Dr. Chapin read his paper I had one in connection with which
I showed obstructions and pylorospasm. One of these cases was a
case of sv-philis of the stomach and the peristaltic wave was shown.
This case cleared up under treatment. What we have been shown
with reference to the air ball leads me to believe that projectile
vomiting may be due to the air ball. It seems possible that the air
becomes so compressed that it finally forces its way through in the
path of the least resistance and forces out what lies in its way.

Dr. H.arry Lowenberg, Philadelphia. — The presence of a peris-
taltic wave and a palpable pylorus are not always indications for
operation. With the charcoal test and the a:-ray it can be shown
whether the child is getting sufiicient food to sustain life and by
watching the weight chart one can keep careful watch on the child's
condition. In this way one can speedily come to a decision as to
whether he is dealing with an operative or a nonoperative case. I
would like to ask Dr. Kerley whether he has had any of these cases
which he has described operated upon.

Dr. John Zahorsky, St. Louis. — I had a child five years of age
who gave a history of vomiting for over two months. Two or three
doctors had treated the child for dyspepsia. One could not make
out much so it was suggested that we have an .r-ray picture taken.
This picture apparently showed an obstruction at the iliocecal ori-
fice; nothing seemed to pass through for hours and hours. We
planned to have an exploratory operation, but when the child arrived
he gave a history of slight spasm during the previous night and we
made out a beginning cerebral tumor.

Dr. Kerley, closing the discussion. — The question has been asked
as to further details of management in these cases. The massage
was given two or three times daily. Sweet oil or olive oil was given
in J-^-ounce doses. These children were helped by being taken
off of cow's milk mi.xtures and put on evaporated milk mixtures. I
had one case which was operated upon. That was a case in a class
by itself, a freak case, and for that reason I did not report it.

Dr. Julius H. Hess, Chicago, presented a paper on

FAMILIAL cyanosis.

For want of a better name this term is used to designate a clinical
picture occurring in three brothers, aged eleven, nine and five years of
age respectively. The cyanosis of the skin and mucous membranes in
these children is constant, increasing on exertion, excitement, and
more especially in the presence of inflammatory conditions of the
respiratory tract to which all three boys are subject. Very careful
physical e.xamination, rontgenographic and metabolic studies, blood

AMERICAN MEDICAL ASSOCIATION 903

and tuberculin tests were carried out in each of these children. The
spectroscopic examination in each instance showed that the absorp-
tion bands corresponded to oxyhemoglobin. The skin showed no
pathological pigmentation. The spleen and hver were seemingly
normal in size. The physical examination did not yield signs of
heart involvement sufficient to account for the condition presented.
In endeavoring to account for this condition we found that a com-
parison of the venous and arterial blood in cyanosis and in normal
conditions could be made by measuring the carbon dioxide tension
and that this was of direct help in diagnosing congenital heart lesions.
Dk. Edwin E. Graham, Philadelphia, read a paper entitled

A STUDY OF THE DEATHS IN PHIL.ADELPHIA DURING THE PAST PIVE
YEARS FROM SCARLET FEVER, MEASLES, DIPHTHERIA, WHOOP-
ING-COUGH AND TYPHOID FEVER.

The most effective way of showing the facts which these statis-
tics bring out is by grouping the mortality rates of the different dis-
eases according to ages at which the disease occurred. In study-
ing the death rate in infants under one year of age it was found that
pertussis was responsible for the greatest number of deaths, more
than measles, diphtheria or scarlet fever. Measles had the next
highest mortahty, the number of deaths caused by measles much
exceeding that caused by diphtheria. With the exception of ty-
phoid fever, which was rare during the first year of life, scarlet fever
caused the fewest deaths. In the entire series for all ages scarlet
fever caused fewer deaths than any of the other diseases considered.
The largest number of deaths from measles occurred between the
first and second years of life. Pertussis was not so fatal after the first
year of hfe, though the death rate from this cause was high during
the second year. Between the ages of two and five years, diph-
theria caused far more deaths than all the acute infections combined.
Scarlet fever showed the lowest mortality at this age of any of the
diseases under consideration, though it caused more deaths in chil-
dren between the ages of two and five years than at any other age
period. At this age measles was a serious disease. Whooping-cough
caused almost as many deaths between the ages of two and five
years as in those under two years of age; therefore, it must be con-
sidered a serious disease during the early years of life. The mor-
tality of tv-phoid fever increased year by year and did not reach its
highest point until adult life. In the age period from five to ten
years, diphtheria caused more deaths than any other disease. At
this age the mortality from measles and whooping-cough decreased
rapidly. There was no mortality from whooping-cough between
the ages of five and ten years. On the other hand, at this age period
typhoid fever caused more deaths than any other acute infection,
and diphtheria ranked second. Between the ages of fifteen and
twenty years there was an appreciable increase in the number of
deaths from typhoid fever, while the mortahty from scarlet fever
was very low. From 1911 to 1915, the number of deaths from
scarlet fever was 608 and of these 45 per cent, occurred between

904 TRANSACTIONS OF THE

the ages of two and five years. Taking the death rates for all
ages diphtheria was the most fatal disease in this group, having
caused during this five-year period in the city of Philadelphia 1741
deaths. Typhoid fever had the next highest mortality. During
the past two years the mortality from tv-phoid fever had dropped per-
ceptibly; this was probably due to the new and improved water sup-
ply and to the more general pasteurization of milk. The combined
mortality from diphtheria was 11.8 per cent. This high mortality
was attributed to the late recognition of this disease, for which parents
were more often responsible than physicians. A study of the inci-
dence of scarlet fever in relation to the severity of the disease showed
that the mortality was lower when the number of cases was fewer.
The points to be particularly emphasized in this study are the low
death rates from scarlet-fever, a disease for which most people have
a great dread, and the high death rate from measles and whoop-
ing-cough which have not been considered by the laiety as serious
diseases and against which children are less carefully protected than
they are against scarlet fever.

DISCUSSION.

Dr. Isa.a^c Abt, Chicago.— I wish to tell Dr. Graham how much I
have enjoyed his painstaking paper. We may have cases of scarlet
fever which do not show the anaphylactic skin reaction and which
are unrecognized. We may have mild epidemics or severe epi-
demics; there may be very little scarlet fever, then suddenly there
will be a severe epidemic and the mortality will be very high. I
want to say just a word with reference to diphtheria. It is a sad
commentary on our efl&ciency as physicians that in a disease in which
we have a real specific the mortality should be higher than in those
diseases in which we have no specific remedy. We do not recognize
diphtheria sufficiently early. In the training of medical men we
should insist that they learn to make a clinical diagnosis of diph-
theria; they may make a mistake occasionally but the cUnical diag-
nosis will frequently be correct. When the membrane is dense and
covers the uvula and nares, one is justified in making a diagnosis of
diphtheria. Physicians should be urged not to depend too much
on the laboratory.

Dr. McCleave, San Francisco. — Dr. Abt is right. Clinical ac-
tion should not wait on the laboratory.

Dr. B. F. Royer, Harrisburg, Pa. — There is no doubt but that
waiting on the part of the physician to get a positive culture is re-
sponsible for many deaths for diphtheria and I would urge young
medical men to base their diagnosis on clinical symptoms. It takes
from twelve to twenty-four hours, sometimes thirty-four hours, to
get a positive laboratory diagnosis and that time means life or death
to the patient. I feel that it is better in a suspicious case to give
the child antitoxin first and then wait the result of the laboratory
examination. The mortality from diphtheria is increased by the
large number of cults, the practitioners of which are not trained in
physical diagnosis. Scarlet fever occurs in epidemic waves. We go

AMERICAN MEDICAL ASSOCIATION 905

along with a mild type and a low death rate and then we get an epi-
demic with a high death rate. In 1910 we had an epidemic in a
Slavish community in Pennsylvania in which the death rate was 18
per cent., while in Philadelphia it was only 2 per cent. In this
epidemic the type of scarlet fever was very severe and in searching
for the source of the epidemic it seemed probable that a family of
immigrants from South Austria might have brought the disease with
them. , We should have more strict regulations with reference to the
control of whooping-cough. We should not allow children from
families in which there is a case of whooping-cough to attend school.

Dr. Michel. — Although I am very much in favor of giving anti-
toxin and not waiting for the laboratory diagnosis, I would like to
put in a plea for taking a culture and having it examined early.
As soon as one sees a child with a sore throat the culture should be
taken. Say we see a child in the morning, we can have the culture
examined by evening, and then have both the chnical and the labo-
ratory examination on which to base a diagnosis. One gets a positive
cultural finding sometimes before he gets the chnical manifestations
of the disease. Where there is a membrane one should not wait
for the laboratory repor .

Dr. Jessie M. McGavin, Portland, Ore. — In Oregon it is twelve
hours before we can get a report from the laboratory and I feel that
by waiting to get the result of the laboratory examination before
giving antitoxin we sign many more death certificates than when
we administer antitoxin before getting the report. Then sometimes
we get a negative report and later we find that we have a case of
laryngeal diphtheria. In some cases in which we may not get very
positive signs and yet decide to give antitoxin, and then watch the
child, we will find that in two or three hours the respiration will have
improved and the child will go to sleep. I have known of two or
three instances in which a diagnosis of something else than diphtheria
was made and the child died and it was found that laryngeal diph-
theria was the cause of death. It has been my experience that we
should give antitoxin if the clinical findings are suggestive of diph-
theria regardless of what the laboratory says.

Dr. Ch-arles Gilmore Kerley, New York. — I do not see just
why Dr. Graham has included the statistics in the age period from
fifteen to twenty years, since when individuals reach this age they
are considered as adults. As regards scarlet fever, I have never seen
a case of scarlet fever in a child under one year of age and I always
question the accuracy of the diagnosis when anyone says such a
young child has scarlet fever. Diphtheria is one of those diseases
in which the child may not be objectively ill until it is in a dangerous
condition. If all children with diphtheria had febrile symptoms
and the physician was called early the mortality could be brought
down to 3 per cent. One would of course give antitoxin on a guess
in all these plain cases, but there will be some cases that have a
sneaking onset. It seems to me the mortality from typhoid fever
as given, 14 per cent, in people under twenty years of age, is too high.

906 TRANSACTIONS OF THE

Dr. Clipford G. Grulef, Chicago, read a paper on

ALKALI-EARTH ALKALI EQUILIBRIUM IN SPASMOPHILIA.

We have made observations on sis cases of spasmophilia at the
Presbyterian Hospital in Chicago. We found that giving large
doses of calcium salts, reduced the electrical irritability in spas-
mophihac children, while giving sodium and potassium salts in-
creased the irritability. The increase in the electrical irritability
was accompanied by a drop in weight. Three nonspasmophiliacs
were given sodium and potassium salts and no effect was produced
on the electrical irritability. It is quite hkely that the reduction
depends upon the length of time the salts are given. I do not feel
that these observations have shown any definite relation between
alkah earth equihbrium and spasmophilia, but the results speak for
an increased electrical irritability and a retention of sodium and po-
tassium salts. There was a distinct relation between the weight
curve and the irritability curve. The dosage used was ten or fifteen
grains of sodium bicarbonate or citrate every two hours. Calcium
lactate was given in large doses every four hours.

DISCUSSION.

Dr. Albert Beifeld, Iowa City. — I am very much interested
in this subject but have only one case to report. In one boy I tried
the administration of calcium salts by the mouth and intravenously
and found that it about controlled the case. The calcium salts
produced practically a negative effect on the cathodal contraction.
The calcium chloride was given in tif teen-grain doses every hour and
there was a lessened electrical irritability within a few hours after
its administration.

Dr. Henry F. Helmholz, Chicago. — There was an interesting
paper read in Washington in which it was shown that the calcium
content of the blood during tetany was markedly reduced and this
might explain some of the benefit that Dr. Grulee has observed in
these patients during his experiments.

Dr. John Z.ahorsky, St. Louis. — Cases of spasmophilia have
attacks one, two or three months before we can get rid of the clinical
signs of the disease. It seems that there is a more profound dis-
turbance of nutrition back of the condition than merely a disturbance
of salt metabolism and it is a question whether we will solve the
problem by studying simply this phase of the condition.

Dr. T. C. McCleave, San Francisco.— I would like to ask
whether calcium lactate is as efficient as the other salts of calcium.

Dr. Grulee (closing the discussion). — Calcium lactate gave me
good results. Much of this work must be reported with reservations.
It is not what we give but what the child absorbs that is observed
in the results. I feel that the calcium treatment of spasmophilia
is a distinct advantage.

AMERICAN MEDICAL ASSOCIATION 907

Dr. Isaac .\bt, Chicago, read a paper entitled

A STUDY OF 226 CASES OF CHOREA.

Although we have a voluminous literature on chorea there are
many phases still open for discussion, because we do not know the
exact cause of the disease. A study of statistics will show that
chorea is one of the most common of diseases. Our hospital records
show that we have treated 226 cases since 1880. During this time
we had 80,000 patients of whom 10,150 were children. The cases
of chorea were, therefore, 2I/5 per cent, of all cases treated. Some
claim to have seen congenital chorea, but the usual age at which it
occurs is from five to fifteen years. Our records show the highest
percentage of cases between five and fourteen years. We have had
two cases, however, that occurred at three and one-half years of age.
The disease is more frequent among females than among males.
Many authorities give the ratio as three females to one male. In our
series we found two females to one male, that is, 151 girls and seventy-
five boys. In studying the seasonal incidence of chorea we took the
number of admissions to the hospital during the different months
and found that January had the highest number of admissions and
December next. October showed the fewest. The association of
endocarditis and rheumatism with chorea was noted by early ob-
servers. The theory of the relation of rheumatism and chorea
gained considerable credence many years ago. Bacteriology has
not given any proof of the relation of rheumatism to chorea. How-
ever, it is my belief that chorea is of infectious origin. In 143 cases
in this series in which an effort was made to get the history in refer-
ence to rheumatism, we found that only thirteen gave a definite
history of articular rheumatism. In 119 cases there were no mani-
festations of rheumatism preceding the development of chorea.
Our findings regarding the relation of chorea and tonsillitis were
similar. These records do not justify the assumption that there
is any relation between chorea and the acute infectious diseases.
There has been a tendency to assume a relation between syphilis
and chorea. Some French observers even claim that they have
successfully treated cases of chorea with salvarsan or neosalvarsan.
There were only two cases in this series that showed any definite
manifestations of congenital lues; these were probably mere coinci-
dences. While I consider chorea as of infectious nature, there is
no question but that shock may bring on the symptoms of the dis-
ease. There seems to be a tendency to localization of choreiform
movements. Of 153 cases observed in this respect, forty-six showed
a greater degree of movement on one side than on the other. Of the
226 cases in this series seventy-three showed cardiac affections, the
majority being diagnosed as mitral. A few cases showed various
other compHcations. Some cases showed difficulty in speech and
mental symptoms. The total death rate in this series was about 2
per cent. There was only one death that could be considered as
the direct result of the chorea. The average cases remained in the
hospital five to eight weeks. There were thirty-five cases that showed

908 TRANSACTIONS OF THE

recurrences. Some of the cases that were treated with arsenic re-
curred and some that were not treated with arsenic did not recur. It
seemed on the whole that those cases treated without arsenic did
as well as those that were treated with arsenical preparations.
Arsenic may possibly have a deleterious effect on the heart muscle
and innervation. It seems unfair to treat a case of chorea with
salvarsan unless syphilis is present.

DISCUSSION.

Dr. Henry F. Helmholz, Chicago. — At the Children's Memo-
rial Hospital we had 138 cases of chorea and of these 33J-3 per cent,
gave a history of tonsillitis. Of the entire series 54 per cent, gave
a history of either tonsillitis, rheumatism or cardiac involvement.
From Rosenow's work which shows that the streptococcus has a
tendency to localize in different parts of the body and it may be
that the same organisms under slightly different circumstances
may localize in the brain. A single positive finding of this kind
would be of more value than a series of cases of negative findings
which mean nothing.

Dr. Abraham Jacobi, New York. — I have seen a great deal of
chorea and I wrote on the subject in 1875 in connection with its
association with rheumatism in children. At that time I came to
the conclusion that chorea, rheumatism and endocarditis were in
close proximity and relationship. I came to the conclusion that this
series of infections occurred very frequently in the order of rheuma-
tism first, endocarditis second, and chorea third. They do not
always occur in this order but the history shows that they are
related. One thing we should then urge and that is that rheumatism
should not be overlooked, because it is frequently overlooked in
children that do not walk. Children that walk may sometimes show
a limp that should suggest rheumatism as the cause. Rheumatism
is also frequently overlooked because the pain being attributed to
"growing pains." It seems to me that we have not made much prog-
ress so far as our knowledge of the etiology of rheumatism is con-
cerned during these later years. I do not think that arsenic as a
remedy is frequently deleterious. Arsenic in both adults and young
children is a tissue builder and I use it especially in myocarditis,
where we have a functional murmur, because just hke the phos-
phates it builds up the tissues. I can recommend arsenic as the
result of twenty or thirty or more years experience in a fairly well
developed general practice. I regard arsenic as a help rather than
a danger. I wish to tell you of something that is in the near future
but which has not yet appeared in the literature in regard to the
treatment of chorea. Dr. A. L. Goodman has been treating chorea
in a way that effects a cure not after weeks or months but in a very
few days. He has treated about twelve cases in which I have observed
the results, and I am not easily led astray and can vouch for the
effectiveness of his treatment. He withdraws blood from the pa-
tient, about 40 c.c, takes the serum which is about 18 or 20 c.c,
and injects that into the spinal canal. The patients are cured in a

AMERICAN MEDICAL ASSOCIATION 909

day or -two. If the patient is not cured by tlie first injection, but
simply relieved, a second injection is given.

Dr. C. T. McCleave. — I presume Dr. Goodman's treatment is
based on the theory of immunity. Do you know on what he bases
this treatment?

Dr. Jacobi. — I do not know his theory and I am not sure that he
had one. These patients with chorea came for months and years
and it seemed we were not able to cure chorea so Dr. Goodman
thought that as so much had been done with vaccines and sera he
would try that. The bacterins are not as successful as some believe,
but the sera are much more successful. Dr. Goodman was as much
surprised as any one here at the results.

Dr. Isaac Abt. — We may summarize by stating that much may
be said on both sides; chorea is in many instances an infectious dis-
ease but in many it indicates a condition of nervous excitation. Such
children under proper treatment very readily recover and these
cases are not the result of specific rheumatic infection. In some
cases chorea is a symptom of nervous exhaustion. As to Dr. Good-
man's treatment, we may get much from some such form of treat-
ment. I have treated children and babies with chorea with and
without arsenic and those without arsenic recovered as rapidly as those
with arsenic. It seems to me that in the treatment of chorea, espe-
cially in neuropathic children, it is better if these children are away
from their family, kept quiet, given hot baths, etc. Under such
treatment they recover in a short time.

Dr. Edgar P. Copeland, Washington, D. C., read a paper on

OBSCURE FEVER IN INFANCY AND CHILDHOOD.

In considering fever of obscure origin we must bear in mind the
structural and functional immaturity of the heat regulating mechan-
ism, in every sense comparable to the immaturity of other systems
in early life. The effects of such deficiency invariably present to a
greater or less extent in the very young, but always more pronounced
in those individuals exhibiting other evidence of instability of the
nervous system, as expressed in convulsive attacks, tetany, etc.
Under such conditions the responses to varied stimuli manifest
themselves as unusual disturbances of body temperature. The
recognition of these facts does not obviate the necessity of the most
diligent search for those definite pathological conditions giving rise
to obscure fever in childhood. Anong the conditions that may be
responsible for obscure fever are dental caries, middle ear disease,
and obscure disease of the tonsils. Occasionally even a competent
aurist will fail to diagnose middle ear disease. In some cases drain-
age from the middle ear is into the pharynx and nothing of the con-
dition can be learned by the ordinary aural examination. If in such
an obscure case leucocytosis is high paracentesis should be done.

The tonsils may be the seat of infection when they have not been
suspected and they are the cause of obscure fever oftener than is
generally supposed. When any suspicion is attached to them they
should be removed.

910 TRANSACTIONS OF THE

Dr. F. M. Pottengee, Los Angeles. — I have been paying a great
deal of attention to the cases of obscure fever. It seems to me that
the obscure fever which the reader of the paper refers to is in many
cases dependent upon the syndrome of toxemia, the fever is simply
a part of the sympathetic disturbance. The toxemia is produced
by proteins broken up in the body. These proteins may be divided
into poisonous and nonpoisonous. We have learned that if we give
proteins to a fasting animal that animal develops a fever. The
same thing is seen in typhoid fever when after the patient has been
fasting milk is given. The patient gets protein poisoning and a
rise in temperature. The depressive emotional states do the same
thing as the toxemia. They act through the sympathetic system,
causing a vasomotor constriction which may result in elevation of
temperature.

Dr. T. C. McCleave. — I was interested in what Dr. Copeland
said about the tonsils and the difficulty of getting throat men to
remove tonsils and 1 think he is just right. When the pediatrician
recommends the early removal of the tonsils the throat man should
have nothing to say about it. As a rule, he is not familiar with
general pathology in relation to conditions of the tonsils. The
question of the removal of the tonsils should be decided by the
pediatrician.

Dr. Jacobi. — In very few cases is it the tonsil that is at fault,
even very large tonsils are not at fault, but it is the rest of the phar-
ynx, all the lymphoid bodies that surround the antrum, that are
more often responsible for the fever and toxic symptoms than the
tonsils themselves. That is why we should teach than the nose
should be kept clean. The cleansing should not be done bj' means
of an atomizer but by irrigation, by pouring in warm water and salt,
but snuffing must be avoided as it is dangerous. If care is not
taken to avoid snuffing there is danger of causing middle-ear disease.

Dr. St. George T. Grinnan, Richmond, Va. — I wish to mention
that we may have fever as the result of overexercise in certain
children. I have had a blood examination made in such a case and
found a high leukocyte count, 13,000, and low hemoglobin. Rest
entirely restored this child in two weeks time.

Dr. John Lovett Morse, Boston. — I would like to call attention
to a lack in our knowledge and that is as to what the normal varia-
tion in temperature is in children. Again we must be sure that
the thermometer is right before we say that a child has a temperature.
As to dentists, we have many dentists that are two generations
behind the times. The child may have an infection and the teeth
may look all right. They may even be filled and apparently in good
condition and yet an .T-ray examination may show an abscess at
the root of a tooth. Furthermore, we must not rule out the ear
as a possible source of trouble just because the drunr looks normal.
We must also remember that a child may have disease of the ethmoid
cells and antrum that may be the cause of the symptoms. Nothing
has been said about the urinary tract; that has been left out but the
possibility of an infection in this locality being the cause of fever
must not be overlooked.

AMERICAN MEDICAL ASSOCIATION 911

Dr. Charles Gilmore Kerley. — I will confine my discussion
to a hypothetical case. Dr. Morse had called attention to the neces-
sity of stablizing our ideas as to what a normal temperature is,
or how much the temperature may vary within normal limits.
I do not consider a temperature under loo abnormal. When we
have a child that runs a temperature above ioo° F., the temperature
is not normal but suspicious. We see many cases in which the
cause of such a temperature cannot be found. Such a child should
be put to bed. If his condition is due to infection putting him to
bed will have no effect on the temperature, but if the temperature
is due to a nervous condition the rest in bed will reduce it. When
we find a child of this type we can tell the family to throw away
the thermometer or to give it to someone they do not like.

Dr. Edgar P. Copeland. — I wish to emphasize that I did not
attempt to discuss all the causes of obscure fever. We are aU
familiar with the fact that undue exercise may cause a rise in the
temperature. I said nothing of infection of the urinary tract
because this subject has received so much attention during the past
year that we are all on the alert for pyelitis. The question of what
is the normal temperature is important but in most cases I think
we allow for a reasonable variation.

Dr. F. M. Pottenger, Los Angeles, read a paper on

the natural protection of the CHILD AGAINST TUBERCULOSIS
AND GRADUAL DEVELOPMENT OF A SPECIFIC CELLULAR DEFENSE.

It is now quite generally recognized that childhood is the time in
which infection with tuberculosis occurs and that if we could prevent
adult tuberculosis we must prevent infection in childhood, therefore,
the prevention of tuberculosis lies in the hands of the pediatrician.
Most adult tuberculosis is simply the stirring up of a latent infection
acquired in childhood. In the defense of the body against tuber-
culosis the lymphatics are important. We have two kinds of de-
fenses, the humoral and the cellular, but neither are specific. In early
life the child comes into contact with various kinds of bacteria and
gradually develops immunity by producing specific enzymes and
until these enzymes are developed he must depend for protection
on the lymphatics for defense. The tonsils are lymphatic structures
whose function is that of defense. The fact that tonsils are enlarged
is not evidence that they should be removed. When other lymphatic
structures are enlarged we do not think we must remove them.
The reason they are enlarged is because they are coming into contact
with bacteria and they are enlarged for the purpose of performing
the greater amount of work required for them. While tonsils must
not be removed just because they are enlarged they must be removed
if they are diseased. The fact that a few tubercle bacilli are found
in the tonsil is no reason why they should be removed since the
function of the tonsil is one of defense and the tubercle bacilli will
be destroyed before they pass through. In early life we may find
bacilli passing through the tissues but when cellular defense is es-
tablished they no longer do this. This is the reason we may get

912 TRANSACTIONS OF THE

a glandular infection in childhood and a surface infection in the adult;
so-called clinical tuberculosis is a surface infection. The bacilli
do not pass through and involve the lymphatics but involve the
tissues themselves. Therefore, we should not sacrifice the tonsil
or any tonsillar tissue unnecessarily until the lymphatics have had
time to defend themselves.

Dr. John Ritter, Chicago. — -I am more than pleased to hear this
forcible attempt to stop the promiscuous removal of the tonsils.
I think we have been too radical. The lingual tonsil and the ton-
sil proper and adenoids are infantile organs, placed where they are
for the purpose of stopping the entrance of bacilli into the body.
Tuberculosis is a different proposition in the child from what it is
in the adult. I wish to emphasize particularly the necessity of
protecting and guarding the entrance through which infection may
come as much as possible. If the tonsils are diseased they should be
treated but they should not be removed unless absolutely necessary.
I may make the statement that we have records where the tonsils
have been removed and where within six months or a year the opera-
tion was followed by active tuberculosis.

Dr. John Jahorsky, St. Louis. — This process of developing im-
munity in the child means not only immunity to tuberculosis but to
other germs. The child becomes immune to a great variety of
germs. We do not see children so often after they reach the age of
five, six, or seven years, as by that time infections are more easily
thrown off, whereas the baby goes through a very severe reaction in
order to throw off an infection. The tonsil is the first line of defense
in the young child and if we remove much of the tonsillar ring we
may have an infection such as bronchopneumonia or lymphadenitis. .
We must conserve Waldeyer's ring. We must try to get out any
pus that may be there but we should not be too ready to rip out the
tonsils.

Dr. Jay I. Durand, Seattle. — The tonsil is a lymphatic gland but
unhke other lymphatic glands is open instead of being closed over.
In its present condition the tonsil is a wide open avenue of infection.
The crypts may act as a culture tube. It is often difficult to say
which tonsils should come out and which should not come out. It
seems to me that perfectly smooth scar tissue is a better defense
than a diseased tonsil. I do not think there is more infection in
children after the removal of the tonsils. The general resistance is
improved by the removal of tonsils. I would like to know why the
bronchial glands are not as good a means of defense as the tonsils.

Dr. T. C. McCleave, San Francisco.— I am in sympathy with
the last speaker. I feel that it is safe to err on the side of too fre-
quent operation rather than upon the other side. The tonsil doubt-
less docs have a protective function and this function is very easily lost.
I think clinical experience justifies the statement that in a large pro-
portion of children that are readily infected the tonsils are diseased.
On the whole I think there are fewer infections which have their
portal of entry through the throat in children who have had their
tonsils removed. I cannot agree with the speaker that there are a

AMERICAN MEDICAL ASSOCIATION 913

greater number of bronchial infections after the tonsils have been
removed.

Dr. St. George T. Grinnan, Richmond, Va. — I have observed
a rather pecuhar thing and that is that young negroes seldom have
tonsillitis and yet there is a large amount of tuberculosis of the lungs
among them. Among the white children there is a considerable
amount of tonsilhtis and one seldom sees tuberculosis of the lungs,
but a great deal of gland tuberculosis. At the same time there is
a large number of children that have to have their tonsils removed.
If the adenoids are removed first it is sometimes not necessary to
remove the tonsils.

Dr. F. p. Gegenbach, Denver. — I did not hear all that Dr.
Pottenger said but I would like to ask him two questions. First,
how much importance he places on the persistent enlargement of the
anterior cervical glands and whether he would advise the removal
of the tonsils in these cases? In the second place I would hke to ask
him whether he would remove the tonsils in the presence of a tuber-
culous adenitis.

Dr. Charles Gilmore Kerley, New York. — I do not under-
stand whether Dr. Pottenger would allow diseased tonsils containing
tubercle bacilli to remain in the throat. I think this is faulty teach-
ing. I think that a diseased tonsil should not be allowed to remain
in the throat, but we must be able to judge what constitutes a dis-
eased tonsil. The tonsil has a function in the development and
shaping of the throat and its removal should be avoided until the
child is three or four years of age. If the tonsils are removed while
the child is very young adhesions between the pillars result and there
is a narrowing of the tliroat and a tendency to dryness of the
throat. However, I think it is as important to remove a diseased
tonsil as a diseased appendix. Another point and that is the effect
of the tonsils during infectious and contagious diseases. In measles,
grip, etc., the tonsil furnishes a site of infection as well as a method
of prophylaxis against infections. A good normal resistance is a
very important thing. I have never seen tuberculous adenitis in a
child properly operated upon and I have yet to see tuberculous
glands in children in whom the tonsil was thoroughly eradicated.

Dr. F. M. Pottenger (closing the discussion). — Referring to
Dr. Kerley's remarks, he says he has never seen tuberculous
adenitis after removal of the tonsils, this means that the bacilli
have passed through and taken to the secondary Hnes of defense.
I would not allow a focus of infection to remain. ;My point is
that a child has no other defense than the natural defense offered
by the lymphatics at birth and that he gradually comes into con-
tact with bacteria and builds up immunity. I would not remove
the tonsils for tuberculous adenitis because I do not think the
tonsils are at fault.

Dr. J. P. SEDG^VICK, Minneapolis, Minn., read a paper entitled

PEDIATRIC NURSING.

My object in this paper is to point out the influence of minor con-
ditions on the outcome of a case. I will only indicate a few points

914 TRANSACTIONS OF THE

that seem to me most important. The present method of charting
cases has become so cumbersome that a great deal of time is con-
sumed in interpreting a chart. I have devised a plan for graphic
charting by which the condition of the child in respect to weight,
temperature, feeding, etc., may be grasped in a minute. This is
done by plotting the curves. A surprising amount of information
can be conveyed in this way by a mere inspection of the chart. By
aseptic nursing in childhood a large amount of cross-infection can
be prevented. When a nursing mother has a respiratory infection,
such as grip, cold, etc., she should wear a mask of two layers of gauze
over her mouth and nose when nursing her infant. It should be
remembered that other members of the family and visitors are often
a source of danger to the child. In order to prevent cross-infection
in the hospital we have been placing the beds of the children 7
feet apart with a partition of two layers of gauze between them.
An experience with vulgovaginitis has taught us the importance of
bathing female infants on a slab with running water. The cases
cited include a number that show that the condition of premature and
atrophic infants varies directly with the attention that is given them
with reference to regulation of the temperature, etc. In one instance
too much warmth caused a rise in the temperature of the infant to
106° F. In other instances insufficient heat has caused a subnor-
mal temperature. The mportance of a urinary analysis is something
frequently overlooked in infants. I have devised a modification of
the Lawrence apparatus for collecting urine in female infants. The
point that I would like to emphasize is that requeiitly the pains-
taking efforts of the physician are spoiled by incompetent nursing.
Dr. Frank C. Neff, Kansas City, read a paper entitled

REPORT OF FIVE CASES OF TERTIAN M.A.L.A.RIA TREATED WITH SYN-
THETIC ARSENIC INTRAVENOUSLY.

Arsenic has been used in malaria of the tertian type with satis-
factory results but it has done httle good in other types of malaria.
The five cases which I wish to report all show a striking similarity.
The Plasmodium was demonstrated in the blood in each instance.
After the administration of the diarsenol the plasmodium disap-
peared from the blood. Two or three decigrams was the dose ad-
ministered. After this there was a cessation of the chills and fever
and a disappearance of the plasmodium. In several of the cases
the chills and fever recurred and the plasmodium reappeared. The
treatment was repeated with the same results as in the first place.
Several of the patients had been lost sight of and in the others it
was too soon to say whether they would remain cured or not. In
one case the spleen had not yet returned to its normal size. It was
probable that the doses used were too small. There had been no
reaction that would contraindicate the use of either salvarsan or
neosalvarsan; it could not be said whether the patients did better
on salvarsan or neosalvarsan. While these agents had caused the
disappearance of the organisms from the blood, no conclusions could
be drawn as to the permanence of the cure. Perhaps better results

AMERICAN MEDICAL ASSOCIATION 915

might be obtained by different methods of administration and by
using quinine as an adjuvant.

Dr. Joseph Brennemann, Chicago, read a paper on

THE USE OF BOILED MILK IN INFANT FEEDING.

We may state that boiling destroys the bacteria in milk but it
does not destroy all the toxins of the bacteria; a clean milk should
be free from to.xins. Epidemics of infections could not occur if milk
was boiled in the home. There is an impression that boiled milk
causes constipation, but we know that boiled milk is easily digested
and we give it during digestive disturbances. It would seem that
if boiled milk is good for the sick baby there is no reason why it
should not be good for the well baby. Boiled milk has advantages
over raw milk both from the bacteriological and the physiological
standp'iint. The physiological advantages may be explained by
the ditference in coagulability between boiled milk and raw milk.
Boiled milk forms curds so hard in some instances that they cannot
be expelled by vomiting, while on the other hand the curds of boiled
milk are finer. Cow's milk is only a liquid in appearance; after it
has been taken into the stomach it is not a liquid but a solid. Boiled
mill<, however, is a fluid. The ultimate test is the baby and how the
different forms of milk react on him. If we give the baby raw milk
it forms hard curds that can only be acted on by peripheral digestion.
Eiweiss milk contains almost invisible curds and this is one reason
such good results have followed its use. The curds that are seen
in the stools of infants are often ascribed to the fats but if milk is
introduced into the duodenum we do not get these curds this is
concrete evidence that they are due to the proteins and are formed
in the stomach. Again, one never observes bad effects from chang-
ing a baby from raw to boiled milk, but the reverse cannot be said.
There has been a tendency recently to ascribe all digestive disturb-
ances in infants to the fats and carbohydrates in the food. I feel
that the casein is also a factor in the digestive disturbances of in-
fants. The commercial pasteurization of milk is open to objection
since the milk is kept for twenty-four hours before using. I consider
pasteurized milk as belonging to the raw milk class. If milk boiled
at home was as popular as pasteurized milk there is every reason to
believe that babies would suffer less.

DISCUSSION.

Dr. C. G. Grulef, Chicago. — This paper is very much in accord
with my ideas. Scurvy has been held up as the scarecrow to keep
people from using boiled milk. I used boiled milk and boiled
certified milk. I have never seen a case of scurvy that could be
ascribed to boiled milk. It is a question whether boiled milk is the
important factor in the causation of scurvy that it has been thought
to be.

Dr. Harry Lowen'berg, Philadelphia. — I do not think the reader
of the last paper will need anyone to come to his assistance to-day.

916 TRANSACTIONS OF THE

I do not think we can help being influenced by the advice he gives.
I have been using boiled milk and I have even been going so far as
to use the old-fashioned flour ball. It is an open issue as to whether
boiled milk is a factor in causing scurvy. The clinical symptoms of
scurvy are so clear that I feel ashamed to say that I come in contact
with practitioners who do not recognize it. I have seen cases with
subperiosteal hemorrhages given the salicylates. There is no justi-
fication for a neglect to recognize the symptomatology of scurvy.
I agree with the reader of the paper that the casein of cow's milk
may still be considered a factor in the production of indigestion in
infants.

Dr. C. S. Waiirer, Fort Madison, la. — I have been following
this section for years and have come to a few conclusions. These
may be illustrated by the following incident. One man made the
statement that 33I3 per cent, of left-handed people were criminals,
therefore, left-handedness predisposed to criminality. Someone
not so wise ventured the remark, "Yes, but 66?^ per cent, of left-
handed people are otherwise normal. The same reasoning may be
applied to the feeding of babies.

First, we may say that most babies do best on mother's milk;
some do well on raw milk; some do well on pasteurized milk; some do
well on goat's milk; some do well on ass's milk, and some do well on
anything.

Dr. Phelps. — I want to ask whether anyone has found that
raw milk has anything to do with causing urticaria. I had a child
that was getting boiled milk. It was changed to raw milk and
developed urticaria. The urticaria did not disappear until the child
was put back on boiled milk.

Dr. Julius H. Hess, Chicago. — Any of the disadvantages held
against boiled milk may be overcome by giving fruit juices and
vegetables earlier. Some children take more milk when they are
given boiled milk than when raw mflk is fed. I have found that
frequently boiled milk was being given much in excess of the re-
quirements of the child. This was not true of babies with a tendency
to rickets. If one gave these babies codliver oil they could handle
considerably more calcium. There is one other point and that is in
regard to infections and that is that there are fewer cases of intes-
tinal infection where boiled milk is used. We have practically no
gas bacilH infections; we have had two cases in two years. I used
to take my vacation in the winter because there were so many of
these infections in the summer, but now I take my vacation in the
summer since we have been feeding the babies boiled milk.

Dr. L. R. DeBuys, New Orleans. — I first used raw milk, then
pasteurized milk, and now I am using boiled milk. I always make
it a point to be sure that I first have pure milk. I am now teaching
that as soon as the feeding of boiled milk is begun orange juice must
be added to the diet.

Dr. T. C. McCle.we. — -I am in entire agreement with the reader
of the paper and I never speak on the subject of milk that I do not
insist that milk should be clean and should be cooked. The commer-

AMERICAN MEDICAL ASSOCIATION 917

cial pasteurization of milk is a fallacy, but milk cooked in the home
will convey no infections.

Dr. J. H. ]M. Knox, Baltimore. — Through pasteurization we have
left down the bars to dirty milk. Pasteurized milk is dangerous.
Departments of health should see that the milk is good before it is
pasteurized. In some parts of the country an increase in scorbutus
has been noticed, but this is rather a trifling matter. I have seen
a few more cases in Baltimore and I insist that when babies are one,
two, or three months of age they be given orange juice.

Dr. Charles Gilmore Kerley. — Sweeping statements on this
subject are not wise. We should look at this subject from the broad
standpoint. Personally I prefer raw milk, but only a comparatively
small part of the human family can have pure raw milk inasmuch as
it cannot be provided. The next best thing is boiled milk. Cooked
milk is more rapidly digested and more assimilable than raw milk.
You may remember that I never swallowed the inference that casein
of cow's milk was not a factor in the production of digestive dis-
orders of infancy. There is no doubt that cooking the milk produces
a larger proportion of cases of scurvy. Orange juice or some other
fruit juice should be given as soon as the baby is put on cooked milk.
The nutritional value of milk is not interfered with by cooking if
this is done in the presence of starch and a little alkali.

Dr. B. Raymond Hoobler, Detroit, read a paper on

THE USE OF MALT SOUP EXTRACT IN INFANT FEEDING.

There are certain conditions met with in infants in which malt
soups has proved a useful adjunct to the dietarj^ The prescribed
formula; accompanying the preparation, however, are not suited
to meet all conditions. One objection to these formulas is that they
call for wheat flour cooked but a few minutes. I have prepared a
number of formula illustrating the various modifications that may
be made with malt soup. These formulas may be greatly varied by
adding a well-cooked cereal, a cereal cooked at least an hour. One
may then select that kind of milk that seems best suited to the case
under consideration, either boiled milk, pasteurized milk, or raw
milk. In choosing the cereal we may remember that starches do not
all hydrolize with the same rapidity.

If the sugar is released rapidly there is increased peristalsis and
the stools are increased. Oatmeal acts as a laxative because it
loses its sugar more rapidly during fermentation. Because of tlie
difference in the intestinal flora all children do not handle the same
starch in the same manner. In some infants there is a preponder-
ance of Gram negative and in others a preponderance of Gram
positive bacilli in the stools and the starch chosen must depend upon
the character of the flora. By the formulae presented malt soup
may be used in modifications that can be adapted to a large variety
of conditions.

918 TRANSACTIONS OF THE

Dr. J. I. DuRAND, Seattle, read a paper on

THE INTLUENCE OF DIET ON THE DEVELOPMENT AND HEALTH OF THE
'EETH.

I wish to present the results of an investigation of the incidence
of caries in teeth of 5000 children with reference to feeding in infancy.
The highest percentage of caries was found among those fed on
sweetened condensed milk. The percentage of caries among chil-
dren who had been breast-fed was 28 or 29 per cent.; among those
fed on sweetened condensed milk 61 per cent. A well-balanced diet
has a direct influence on the development and the health of the teeth.
Breast milk or properly modified cow's milk with the early addition
of vegetables has been shown to be a suitable diet; certain vegetables
may be given as early as the sixth or seventh month of life and are a
valuable addition, preventing rickets and spasmophilia. A second
point of importance is to provide a diet that teaches the child the
proper function of the jaws and teeth. For this purpose hard foods
are useful, such as dry bread, celery, lettuce, etc. These give ad-
ditional work to the teeth and jaws and further proper development.
One of the points in the prevention of caries is that the last article
eaten at a meal should not be as is customary, a soft, sticky, carbo-
hydrate food, as cake, but some hard, cleansing food, as meat, a green
salad, or some fibrous food. A hard food and vigorous efforts at
mastication have a function in wearing down any roughness of the
teeth. An examination of the skulls of primitive races gives con-
firmative evidence that the character of the food has an influence in
the development and health of the teeth. A study of Maori skulls
showed that in these the incidence of caries was only 0.76, while
among Maori children to-day in a civilized environment the incidence
of caries is 15 per cent. In the North American Indians the incidence
of dental caries was from i.o to 3.9 per cent. It is shown to be low
in other primitive races.

Dr. J. H. Mason Knox, Baltimore, read a paper on

THE REGULATION OF CHILDREN'S DIET AFTER INFANCY.

During the last one-half century a great deal of study has been
given to infant feeding and nearly every clinician has a method of
his own, some of these very far removed from the normal diet of the
infant. With all this study of the dietetic needs of the infant it
seems rather strange that so little attention has been given to the
diet of the growing child when he has passed infancy. Few studies
have been made to find out the average caloric requirements of chil-
dren of different ages. It has been estimated that 100 calories per
kilo or 45 per pound is about the average requirement of a baby one
year of age. We have worked out tables showing the average
amount of each of the food elements required at the different ages.
After the first year the proportion of protein in the diet is gradually
decreased while that of the carbohydrate is gradually increased.
After the first year the child can adapt itself to a wide variation in the

AMERICAN MEDICAL ASSOCIATION 919

proportion of food elements in its diet. The quantity of fluid re-
quired by the child varies widely and is dependent upon temperature,
humidity, etc. The mineral requirements of the diet are usually
fully met by the ordinary vegetable and cereal in the diet. The
tables presented will be found useful as every physician should know
how to provide a suitable diet, well-balanced ration for a growing
child, one that will be easily digested. The great danger lies in over-
feeding. This is well illustrated by the following case: In this child
the amount of food was increased in spite of the occurrence of occa-
sional attacks of indigestion. The child was given 2500 calories or
150 per kilo body weight. With this amount of food she continued
to have digestive disturbances, was nervous, irritable, and restless.
When the number of calories was reduced by one-half she immediately
became much better. This case is no exception. At the age of six
years about 4 grams of protein is the average amount in the daily
diet; at ten years the protein has been reduced to 2 grams. One-
half the protein should be given in the form of animal protein. As
the amount of protein is decreased the carbohydrates are increased.
Too little carbohydrate may lead to acidosis. The carbohydrate
values of the food do not vary so widely as the amount of water.
While it is well to have tables showing the relative amount of calor-
ies and the proper proportion of the various food elements as a guide,
it is not necessary to be extremely accurate. It is also an advan-
tage to have three or four daily diet lists with a number of substi-
tutes for the different foods. I have not discussed the alteration in
diet in disease, but it is possible by a careful adjustment of the diet
during disease to keep the child along without materially lowering
the calories and in this way the child may be carried through an
illness without a marked loss in weight.

REPORT OF A COMMITTEE ON THE IN\'ESTIG.A.TION OF DI.ARRHEAL
DISEASES.

Dr. Joseph I. Grover presented a statistical studj^ of diarrheal
diseases in Boston for the year of 1915.

This study was undertaken with the hope of throwing some light
on the etiology and prophylaxis of the diarrheas of infancy. It is
based on 14,000 visits made to 600 cases of diarrhea. A few of the
cases were from hospitals but most of them were from the clinics of
Boston. There was no one nationahty that predominated. About
70 per cent, of the mothers were foreign born. About 56 per cent,
of the cases were males; this proportion held for babies and for
younger and older children. Over 80 per cent, of the cases were
under one year of age when first seen. Babies two, three, or four
months old were most susceptible; three were very few cases after
the third year. The death rate was almost double in children pre-
maturely born or under weight at the time of birth. A rather large
proportion of the cases had been weaned in ]March, April, or May,
and it seemed that weaning in the spring had a definite relation to
diarrhea in the summer. Among babies weaned in December just
about Christmas and in January there seemed to be a larger amount

920 TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION

of diarrhea; this is probably due to the overfeeding in connection
with Christmas. A study of the mortality rates for July, August,
and September in connection with the temperature and humidity
during those months showed that the absolute humidity had a larger
influence on the mortality from the infectious diarrheas than any
other one factor. Of the babies under one year of age having diar-
rhea, 33J-^ per cent, were fed on proprietary foods and of all those in
the series 40 per cent, were fed on proprietary foods. In 54 per cent,
of the cases the diarrhea was due to carbohydrate fermentation.
The statistics with reference to the feeding and treatment of these
cases were very comphcated, 37 per cent, receiving simple cleansing
treatment; in 25 per cent, there was a reduction of the sugar in the
food. Nearly all forms of treatment in children over one year of
age were successful. The mortality of children under one year of
age was 6.9 per cent. About 2 per cent, of the older children died.
From this investigation it was very difiicult to draw conclusions or
to say that one or two factors were responsible for the diarrheas.
The same factors seemed to be at work in all parts of Boston. Chil-
dren who were not up to the standard physically seemed to be more
susceptible. Those weaned in the spring seemed to be susceptible
and Ukewise those nursed over twelve months. Children with other
diseases were more susceptible to summer diarrheas than well chil-
dren. The best treatment seemed to be catharsis followed by giv-
ing sugar water. Next to carbohydrate fermentation the most
important factor in causing diarrhea was the susceptible physical
condition of the children.

Dr. Henry F. Helmholz, Chicago, presented an analysis of the
mortality of 191 5 as shown by the Infant Welfare Societ}' of Chicago.
This organization had twenty-one milk stations and cared for
0313 babies during 1915. Among these there were 300 deaths. Of
these 300 babies only fifty-four were of American birth. The
statistics show in a most striking manner the relation of poverty
to the incidence of the diarrheas of infancy. One-half of the babies
that died were under three months of age. Over 60 per cent, of the
mortaUty occurred in July and August and the death rate during
August was higher than during July. Most of the babies attending
the milk stations gained normally until they were weaned and most
of the disturbances occurred in children whose feeding was not
supervised. The ratio of diarrheas in artificially fed and breast fed
babies was as six to one. These statistics bring out in a striking
manner the beneficial effect of the work done by the milk stations
and also that the visiting nurse is an exceedingly potent factor in
lessening infant mortality among the poor foreign population.

DISCUSSION.

Dr. Henry Dwight Chapin, New York. — The statistics give
a very different impression from those we have had in New York.
Dr. Helmholz says that they had a higher death rate in August than
in July. Some years ago I made a study in New York, covering
five consecutive years, and found that the mean temperature of

BRIEF OF CURRENT LITERATURE 921

July was 2 per cent, higher than that of August, and that the mor-
tality was higher for July than for August. Another very unusual
thing in these statistics is that the mortality rate from respiratory
diseases is greater for August than for March. We have found in
New York that the highest mortality rate during hot weather is not
on the hottest days, but a few days after the hot spell.

BRIEF OF CURRENT LITERATURE

DISEASES OF CHILDREN.

A Previously Undescribed Form of Postdiphtheritic Paralysis;
One-sided Paralysis of the Hypoglossus. — Frieda Lederer {Arch,
f. Kinderheil., Bd. Ixv, Heft III-IV, 1916) gives the history of a
case of diphtheria in which postdiphtheritic paralysis occurred in
some of the usual locations, followed by a one-sided hypoglossus
paralysis characterized by lateral deviation of the tongue, and lack
of taste on one side of the tongue, while temperature, touch, and pain
reactions in both sides of the tongue remained normal. The boy,
aged ten years, suffered at first with speech difficulty, nasal voice,
and double vision. The palate remained motionless in speech.
After electrical treatment these troubles disappeared, as did the
hypoglossus symptoms later.

Protection of Infancy in France. — A. Pinard {Ann. de gyn. et
d'obst., March-April, 1916) continues his account of the results of
public care of the "war babies" in Paris. His first account was
of the first five months of the war. The present one includes an
entire year. The work included the care of every woman known to
be pregnant whose husband was at the front, who was a war widow,
or whose child was the result of a conception with a soldier out of
wedlock. The accommodations in maternity hospitals were increased,
advantage was taken of all private charities in this Une of work,
the distribution of steriHzed milk was much increased, and homes
were provided for nursing mothers who were homeless. The results
of this care have been a decrease in mortality of infants at birth
and of puerperal women; a diminution of mortaUty of infants
between one day and three years of age; a lessened number of aban-
doned infants; and an increase in the duration of pregnancy and in the
weight of the new-born. During the first year of the war births
registered numbered 37,085, of which 24,431 occurred in maternity
hospitals. In the refuges for nursing mothers 4000 children were
cared for with their mothers, and only fifteen died. The author
believes that these results have justified a permanent public assist-
ance for pregnant women and nursing mothers in Paris.

Weather in Relation to the Prevalence of Scarlet Fever and
Diphtheria.— Th. Banda {Arch. J. Kinderheil., Bd. Ixv, Heft III-IV,
1916) discusses the relation of weather to the prevalence of scarlet
fever and diphtheria, taking the climate of Berlin as an example.

922 BRIEF OF CURRENT LITERATURE

There occurred in the city, from 1904-1907, 22,210 cases of scarlet
fever and 33,295 of diphtlieria. He states that weather consists of
a number of different factors, such as temperature, pressure, moisture,
cloudiness, sunshine, precipitation of rain, wind, radioactivity, ozone
content, electromagnetic conditions, etc. By plotting a curve of these
various factors and comparing them with the curves of monthly in-
cidence of scarlet fever and diphtheria he arrives at certain conclusions.
He considers both mortality and morbidity. The smallest amount
of disease in Berlin occurs at the time of the damp sea wind, the west
wind, which blows in summer. From September on this changes.
In October begins the east wind, the continental wind, and the fall
of rain is slight. The sickness at this time reaches a high point,
diphtheria being at the highest in November. The dry continental
wind appears to spread about the causative materials of these
diseases. The bacilli of diphtheria become easily transortable on
account of their drying. In March and May when the dry winds
blow again there is a renewal of the disease incidence. In spite
of the differences in temperature, sunshine, dampness, precipitation,
and wind between summer and autumn the difference between
highest and lowest points of the curve of these diseases in diphtheria
is 14.5 per cent., in scarlet fever 12.9 per cent., and in spite of the like-
ness of spring and autumn in regard to the components of weather
the difference in the number of cases of sickness is only 10 per cent.
The author concludes that meteorological influences have little to
do with the occurrence of these diseases. In scarlet fever the small-
est morbidity and the largest mortality occur in July; in Sep-
tember and October the opposite occurs. Other factors complicate
the problem, such as the school vacation, and the going away from
home of the well-to-do people. The influence of weather on the
human body cannot be denied. The sirocco, barometric depression,
and electrical conditions affect it markedly. Rheumatism and gout
are affected by weather. Neurasthenics are also subject to depres-
sion from weather conditions. The same influences may also affect
the incidence of infectious diseases, causing it to be greater.

Gaucher's Disease in Infants. — J. H. M. Knox, H. R. Wahl and
H. C. Schmeisser {Bull. Johns Hopk. Hosp., 1916, xxvii, i) report
the cases of two infants, sisters, who did not thrive from birth and
died, one at eleven months, the other at fifteen months of age,
from gradually increasing weakness. The most striking clinical
feature was the great enlargement of the spleen and Uver. The
blood picture was that of a moderate anemia. The leukocytes
were rarely increased, and for the most part were markedly reduced
in number. The skin in both cases had a peculiar yellowish-brown
hue, more marked on the face and exposed surfaces. In one case
the diagnosis was confirmed during life by the examination of an
excised lymph gland. Microscopically, in both cases nearly all the
organs were found to contain large, pale, granular or finely vacuo-
lated cells, in which there was a peculiar refractive substance having
the chemical and staining properties of lipoid material. These
cells are apparently identical with those described by Gaucher,

BRIEF Of CURRENT LITERATURE 923

and later by a number of observers, in the condition called Gaucher's
disease. The above cases and that of Niemann are the only ones in
which the disease has been reported in infancy. The observation
of cherry-red spots in the maculae of one case, in view of the presence
of similar cells in the nervous tissues of cases of amaurotic family
idiocy suggests the possibility that the essential degeneration in the
latter condition may be of similar character.

Cure of Suppurative Meningococcal Iridochoroiditis by Injection
of Antimeningococcal Serum into the Vitreous. — Suppurative
iridochoroiditis is a complication of cerebrospinal meningitis asso-
ciated with the development of the meningococcus in the internal
membranes of the eye. The prognosis is very unfavorable. Within
four or five days it almost invariably ends in suppuration and atrophy
of the eye with loss of vision. Antimeningococcal serum treatment
has probably reduced the frequency of this complication, but has
not diminished its gravity. The resistance of meningococcal irido-
choroiditis to intraspinal serum treatment should not surprise us. It
is due to the same causes which are responsible for the failure of
antimeningococcal serum when injected subcutaneously in cerebro-
spinal meningitis. Like the arachnoid cavity, the internal media of
the eye are almost completely independent of the general circulation.
A. Netter {Brit. Jour. Child. Dis., iQib, xiii, 13) has therefore been
led to think that if to cure cerebrospinal meningitis it is necessary
to inject serum into the spinal cavity, meningococcal iridochoroiditis
should be treated by the intraocular injection of the serum. This
he has done on two occasions in children. In the first patient, a girl
aged six years, suffering from severe cerebrospinal meningitis
complicated by suppurative arthritis of the left elbow and right
knee, the anterior chamber of the right eye was more than half
filled by an hypopyon. The operation consisted in the injection
of several drops of Dopter's serum into the vitreous and in a puncture
of the anterior chamber, which did not, however, withdraw sufficient
fluid for microscopical examination. The aqueous humor rapidly
resumed its transparency, the iris regained its natural color, and
vision was recovered. A year later the child could clearly see every
detail with the right eye. She only presents an immobility of the
pupil as the result of synechiae. Suppurative arthritis of the elbow
and knee, which were also treated with local injections of serum
cleared up very quickly, and the joints are at the present moment
perfectly normal. The second patient, a boy, aged two and one-half
years, was admitted on the fifth day of severe cerebrospinal menin-
gitis. On the following day he presented injection of the left conjunc-
tiva. This injection was much more marked the following day,
and was accompanied by palpebral spasm. Examination showed
a lateral hypopyon (the child was lying on the right side) and a
yellow film fiUing the pupillary area and situated in front of the lens.
Puncture of the anterior chamber yielded a little pus, which con-
tained quantities of intra- and extracellular meningococci. Injec-
tion of I c.c. of serum into the vitreous was followed by detachment
and progressive absorption of the exudation in front of the lens.

924 BRIEF OF CURRENT LITERATURE

The conjunctiva resumed its natural color. The photophobia
disappeared and the child could see clearly. The iris resumed its
natural color and reacted to atropine, and recovery will doubtless
be complete.

Value of the Wassermann Reaction in Mental Deficiency in
Children. — A. Gordon {Arch. Pediai., 1916, xxxiii, 273) has studied,
especially from the standpoint of hereditary syphilis, seventy-five
children who presented mental defects of various degrees. Of
these, 50 per cent, presented a positive serum reaction and in seven-
teen cases in which the spinal fluid also was obtained, the Wasser-
mann tests ran parallel in both, except in three cases of the feeble-
minded with functional disorders. Children up to the age of five
were given mercurials and iodids. From that age on the treatment
commenced with neosalvarsan, then continued with mercury and
iodids. The intraspinal method of salvarsanized serum was used
exclusively on children of fifteen and sixteen years of age and was
supplemented by mercury and iodids. Improvement in general
health was observed in every one of the cases with a positive Wasser-
mann reaction. As to the defective mentality, the idiots and
genuine imbeciles remained unresponsive to the treatment. The
imbeciles with organic changes in the central nervous system, the
hemiplegics and monoplegics were not influenced by the treatment.
The feeble-minded with epilepsy, on the contrary, showed decided
improvement. The younger the child and the more prolonged the
treatment the more rapid and the better were the results.

Congestion in the Treatment of Epidemic Cerebrospinal Menin-
gitis.— D. Forbes and E. Cohen {Lancet, May 27, 1916) advocate
congestion of the cerebral vessels brought about by raising the foot
of the bed, so that the bed and the patient's body, no pillow being
allowed, make an angle of from 14 to 23 degrees with the floor. He re-
ports five cases to show that the method influences the course of the
disease profoundly. It does not interfere with concurrent treat-
ment. In mild cases in a few days a normal temperature and free
movement of the head result, and the recovery is uninterrupted.
In more severe cases the temperature rises and the patient more
gradually recovers, the recovery being at first accompanied either
or both by increased tension of cerebrospinal fluid and a greater
migration of polymorphs. If the foot of the bed has been raised
too high there may be very severe headache and persistent vomiting
due to a too great congestion and its results. In such cases, if the
bed is lowered and the tension is relieved by puncture, the patient
gradually recovers. As different cases require varying degrees of
stimulation, no hard-and-fast rule can be laid down as to the height
to which the foot of the bed should be raised. At first this method
of treatment was tried only in cases which threatened to become
chronic; but good results have followed its application in the early
stages of the disease. In the more chronic cases the bed should be
raised first on blocks and rapidly higher until the patient begins to show
a marked reaction or a more freely movable neck. At that point
heightening should stop and the patient be allowed gradually to

BRIEF OF CURRENT LITERAIURE 925

recover, the foot of the bed being left continuously raised until some
seven days after apparent recovery, and thereafter gradually lowered.
Patients should lie on their backs as much as possible during treat-
ment, and should have no pillows. When there is marked retraction
and the patient cannot lie on his back the bed should be tipped
sideways and the patient's head be allowed to hang over the lower
edge. This method is particularly useful for children, but as it is
somewhat drastic it has not been practised for more than two hours
at a time.' It is always a serious mistake to puncture a patient who
is progressing toward recovery, or who has apparently recovered.

Bacillus Dysenteriae as a Cause of Infectious Diarrhea in Infants.
■ — C. Ten Broeck and F. G. Norbury {Bost. Med. and Surg. Jour.,
1916, clxxiv, 785) say that negative bacteriological and agglutination
tests for the dysentery bacillus in cases of infectious diarrhea of
infancy are of comparatively little value, and in making the agglu-
tination test a number of cultures must be used for the agglutino-
gens. In spite of these facts the dysentery bacillus was isolated
from 74.6 per cent, of the cases studied. Only fourteen of the nine-
teen bacteriologically negative cases were studied for agglutinins,
and 64.3 per cent, of these, or 12 per cent, of the total number, gave
a positive reaction, thus making a total of 86.6 per cent, of the
seventy-five cases in which there was good evidence that the dysen-
tery bacillus was present. They have been unable to obtain any
evidence that Bac. welchii is ever the cause of infectious diarrhea and
all of their results point to the dysentery bacillus as the etiological
agent. In their cases all these bacilli belonged to the mannit-fer-
menting group. In spite of the apparent scarcity of dj'sentery
bacilli in the feces, they believe that they are the cause of infectious
diarrhea of infancy for the following reasons: (i) their universal
association with the condition; (2) the great numbers of these organ-
isms in the mucosa of the cecum; (3) the sick individual produces
immune bodies against them while such bodies, specific for the
other assumed etiological agents, have not been demonstrated; (4)
experimentally they are known to produce a diarrhea.

CongenitarObliteration of the Bile Ducts. — J. B. Holmes {Amer.
Jour. Dis. Child., 1916, xi, 405) records a case of this lesion, with
autopsy notes, as discusses its diagnosis and treatment. He says
that congenital obhteration (atresia) of the larger bile ducts is not
an extremely rare condition. Accumulating evidence tends to show
that the condition is usually a developmental anomaly and not the
result primarily of inflammatory processes. In at least 16 per cent,
of all cases yet reported the anatomical relations are such that opera-
tive relief is theoretically possible. Recent surgical experiences in
young children afford clinical basis for such hopes. In view of the
otherwise hopeless nature of the case, the bihary tract should be
explored as soon as the diagnosis is sufficiently established, and if the
anatomical relations permit — 16 per cent, of published cases — an
artificial passage for the bile to the duodenum should be made.
When for any reason this cannot be done at the time of exploration,
an external outlet for the bile should be provided. A repair opera-

926 BRIEF OF CURRENT LITERATURE

tion may be attempted at a later date. Meanwhile the child's nutri-
tion should be maintained by the administration, if necessary, of
bile or bile salts.

Nonprotein Nitrogenous Constituents of the Bleed and the
Phenosulphonephthalein Test in Children. — In a series of fifty
children free from evidences of renal disease, chemical examination
of the blood by J. S. Leopold and A. Bornhard {Amer. Jour. Dis.
Child., 1916, xi, 432) gave the following results: The total nonprotein
nitrogen varied between 19 and 40 mg. per 100 c.c. of blood, the
average being 28 mg.; the urea nitrogen varied between 8 and 21 mg.,
the average being 12 mg.; the uric acid varied between 0.6 and 3.2
mg., the average being 1.8 mg.; the creatinin varied between 0.5
and 4 mg., the average being 1.5 mg.; and the phenolsulphoneph-
thalein varied between 50 and 96 per cent., the average being 70
per cent. A smaller number (16) of cases with renal involvement
were examined. Although this series is not large enough for final
conclusions, the following hold true for the cases studied: In acute
nephritis the nonprotein nitrogen constituents were found w^ithin
normal limits; the phenolsulphonephthalein excretion was dimin-
ished. In chronic nephritis the nonprotein nitrogen constituents
were usually increased, while the phenolsulphonephthalein excretion
was diminished. In passive congestion the nonprotein constituents
were normal while the phenolsulphonephthalein was diminished.
In one case of sarcoma of the kidney with normal urinary findings
the nonprotein constituents, with the exception of uric acid, were
normal. The latter was slightly increased. The phenolsulphone-
phthalein excretion was diminished. Figures for the nonprotein
constituents of the blood as well as for the phenolsulphonephthalein
excretion of children free from renal disease are practically identical
w'ith the figures obtained from adults, and vary within the normal
limits as the adult figures vary. The changes in these figures in
children the subjects of renal disease corresponds, in this series of
cases, with the changes observed in adults. The importance of the
tests for diagnosis and prognosis, amply demonstrated in adults, will,
in all probability, hold true for children, although more cases are
required definitely to establish this view.

Cutaneous Reaction from Proteins in Eczema.^It is well known
that many children, the subjects of asthma, suffer from eczema in
infancy or early childhood. Furthermore, patients with an idio-
syncracy to various foods give, with much regularity, a history of
eczema in infancy. It is, therefore, of interest to determine the fre-
quency of protein reactions in eczema, to see if a relation exists
between the disease and protein sensitization and to observe the
effects of variations in the protein of the food upon the course of the
disease. Of forty-three patients without eczema studied by K. D.
Blackfan (Amer. Jour. Dis. Child., 1916, xi, 441), only one showed
any evidence of susceptibility to protein by cutaneous and intra-
cutaneous tests. Of twenty-seven patients with eczema, twenty-two
gave evidence of susceptibility to proteins. Egg white, cow's milk
and woman's milk were the substances that most frequently caused

BRIEF OF CURRENT LITERATURE 927

a reaction. If there was a reaction from one protein there usually
was a reaction from several. The intracutaneous test is more
deUcate than the cutaneous, but gives results that are more difficult
to interpret. The removal of some or all of the animal proteins
from the food brings about great improvement in some cases of
eczema in older children and adults. With infants it is not success-
ful, first, because it is impossible to feed an infant for a long time
upon a diet that contains no animal protein, without the risk of
seriously, affecting his nutrition, and second, because there is a
strong tendency for the eczema to return, even though a protein-
poor diet produces early improvement, and even though the protein-
poor diet is continued.

Fuller's Earth in Intestinal Disorders of Infants. — Of late the use
of kaolin has been recommended for the treatment of a variety of
disorders. Influenced by these reports, A. F. Hess {Jour. A. M. A.,
1916, Ixvi, 106) prescribed it in the intestinal disturbances of infants;
but dissatisfied with the results, he turned to the use of Fuller's earth.
Although these two substances are considered synonymous in the
United States Dispensatory and the National Dispensatory they
are by no means alike, either in their composition or physiologic
action. Fuller's earth was given to a considerable number of normal
infants, in order to test its physiologic effect; to this end, i ounce
of the earth was given in the day's feeding. Its sole effect was that
it induced constipation. The stools became firm, dry and formed.
The preparation %vas then given to infants suffering from indiges-
tion, as manifested by diarrhea, accompanied in some instances by
vomiting. In these cases, the earth was either added to the food,
consisting of the diluted milk, or it was given by teaspoon every hour
or two. No difficulty was experienced in giving the powder sus-
pended in a little water, especially when it was sweetened by means
of saccharin (^'5 grain to i ounce of Fuller's earth). In severe
cases of enteritis, no food whatsoever was given, but merely tea-
spoonful doses of this preparation as often as every half hour. In
some cases it was fed through the stomach tube — i or 2 tablespoons
being introduced in this way three times a day. This therapeutic
agent had a greater effect on inhibiting the diarrhea than bismuth,
chalk mixture or other drugs which are commonly used for this
purpose. In some cases it has also seemed to exert a sedative effect
on the stomach, as judged by the fact that vomiting ceased in the
course of this treatment. In no instance were any harmful effects noted.

Tonsils Excretory Organs for Cervical Glands. — S. Blum {Arch.
Pediat., 1915, x.xxii) makes a preliminary report to the effect that
the tonsils are excretory organs for the cervical glands. He claims
that chemical substances which he injected into the cervical glands
of guinea pigs were subsequently found in the tonsils of these animals.
Such chemicals as he employed do not occur normally in the tonsils
of the animals experimented upon. He subsequently found the
chemical injected into the glands of these animals in their oral
cavities. He also recovered from their oral secretions and saw in
their tonsils bacteria previously injected into the cervical glands of
the animals.

928 BRIEF OF CURRENT LITERATURE

Parapneumonic Empyema. — h. Gerdine's {Amer. Jour. Dis.
Child., 1916, xi, 33) fifteen cases of typical lobar or bronchopneu-
monia in children under four years of age were studied by explora-
tory puncture and bacteriological examination of the fluid obtained.
He says that fluid is present in the pleural cavity in a large number of
cases of pneumonia before the crisis and can be demonstrated, some-
times by physical signs, sometimes by Rontgen ray, and by puncture,
even when other physical signs are not apparent. The clinical
course of the pneumonia may not be altered by this complication.
In the majority of cases the fluid is serofibrinous in character,
though perhaps containing a large cellular element, polymorphonu-
clear in type. These fluids are sterile as a rule. True pus is
present much more rarely and may contain organisms of more
or less virulence. The frequency of the presence of organisms in
these cases cannot be decided on the data as yet secured. The
virulence of the isolated organisms determined by animal inocula-
tion seems to be of value in prognosis. Only in cases with sero-
fibrinous and purulent fluids containing organisms of a high grade
of virulence should surgical interference enter into consideration.

Nutritive Value of Boiled Milk. — The experimental work in-
volved in a report by A. L. Daniels, S. Stuescy and E. Francis
(Amer. Jour. Dis. Child., 1916, xi, 45) is the result of an attempt to
determine the comparative nutritive efficiency of milk heated to
different temperatures. Their results point to the conclusion that
milk heated to the boiUng temperature or thereabouts is an inade-
quate food. Rats fed on boiled milk grew to about half their nor-
mal size. Although they were able to keep these e.xperimental
animals for many months on boiled milk, in no case was there
reproduction, nor did any of the animals reach the normal weight
for adult rats. Milk which is kept at the boihng temperature for
forty-five minutes is no less efficient as a food than milk boiled for
much shorter periods — ten minutes or one minute. The chemical
changes which make heated milk an inadequate food are brought
about at the boiUng temperature or thereabouts. The value of
pasteurized milk as a food, therefore, will depend on the temper-
ature to which it is heated during the pasteurization process.
Heating milk to a higher temperature than boiling (114 C.) makes
it even less valuable as a food.

h.1

THE A ATF.TtlO AJ^

JOURNAL OF OBSTETRICS

DISEASES OF WOMEN AND CHILDREN.

VOL. LXXIV. DECEMBER. 1916. NO 6.

ORIGINAL COMMUNICATIONS.

TRANSACTIONS OF THE
AMERICAN ASSOCIATION OF OBSTETRI-
CIANS AND GYNECOLOGISTS.

Proceedings of the Twenty-ninth Annual Meeting held at
Indianapolis, hid., September 25, 26 and 27, igi6.

The President, Hugo O. Pantzer, M. D., in the Chair.
PRESIDENT'S ADDRESS.*

BY
HUGO 0. PANTZER, M. D., A. M., F. A. C. S.,

Indianapolis, Ind.

The privilege of Fellowship in this Association came to me at
Indianapolis in 1899. The Association had been represented as
being composed of men who came to the annual meetings with one
purpose, namely, to foster the sciences and arts of obstetrics, gyne-
cology and abdominal surgery. I was told there was tolerated no
by-play, no levity in discussions, and no delay over conventional
protractions. It was notably a society for its avowed objects, and
that in fostering these its members were candid to the degree of
being "no respecter of persons". So altruistically was this spirit
conceived, that in no instance had this custom interfered with the
prevailing good fellowship. I wish here to attest that I have found
all this true then and at every meeting since. Fellows, it is my wish
that this spirit and course shall prevail at our future meetings !

*Read before the Twenty-ninth Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

930 TRANSACTIONS OF THE AMERICAN ASSOCIATION

The many advantages that have accrued to me from my yearly
pilgrimages to our gatherings have inspired, sustained and helped
me for the arduous labors of each ensuing year. I feel that for this
benefit I owe lasting gratitude and a debt to this Association.

The honor you have conferred by electing me President, thereby
placing me in line with many fine and noble men who have graced
this office, is verily a mark of enviable distinction. I assume that
your action flows from kind regards for me and as such your act is the
source of great pleasure and satisfaction.

Your coming to Indianapolis this year adds further zest to my joy,
and I wish to express to you my full appreciation and my most
cordial thanks.

For this meeting, there are announced papers by more than one-
third of our members. The 49 scientific papers deal with obstetrics
II times, with gynecology 18, with abdominal diseases 11, and with
all three, including general medicine and surgery, g times more.

Great grief has come to us during the last year by the death of
four active and highly esteemed fellows, namely: Ap. Morgan Vance,
of Louisville, Kentucky; Nathan Jenks, of Detroit, Michigan; Frank
D. Gray, of Jersey City, New Jersey, and lastly the world-famous
John B. Murphy, of Chicago, Illinois.

The memorial addresses for the departed Fellows will be the con-
cluding features of the convention.

The marvelous progress of modern medicine is largely based on the
development of cellular pathology, biology and bacteriology. Its
history has been so well set forth in recent addresses, that I may pass
it over. Further progress in medicine is promised upon an unprece-
dented scale by recent developments in biochemistry, especially as
pertaining to organs having an internal secretion, and by the study
of the effects of various toxemias upon the normal physiochemistry
of the body. Let us hope that so-called functional diseases will
soon be traced to their organic bases, and found curable by organo-
and sero-therapy. We may hope to prevent and cure many cellular
toxic and bacterial diseases by detoxicating and regulating bio-
chemical agents, which diseases at present do not yield to medicinal
therapy, and some of which now have their only hope of cure in
mutilating operations. But the profusion of scientific data is as yet
little correlated and greatly confusing. It is filling our journals,
stimulating thought in all spheres of medicine and surgery, and is
made the object of experimental search and research all over the
world. However, it is at the stage of nascence, and generally speak-
ing, unripe for specific deductions.

OF OBSTETRICIANS AND GYNECOLOGISTS 931

The European war has shown its far-reaching baneful effects no-
where more than in the sudden cessation of the prodigous issue from
the many laboratories sustained by the belligerent peoples. It
serves to emphasize for us in America the relatively small burden of
labor and costs we carry in the production of these bounteous benefits
to mankind. It is here we may see an opportunity for further national
activity and development. Our country has but few institutions
correspondingly equipped for original search and research work, and
these are almost all creations by private munificence. They often
hold private standing and are not connected with a university scheme.
Our states do not yet fully recognize the benefit to mankind coming
from and the many reasons making it right and prudent for the
state to ordain such institutions.

The prevalent separation in practice of gynecology from obstetrics,
deplorable as its bearing is upon the development of the science and
practice of either branch, was founded upon the frequent collision
of dates between the event of a confinement case and the appointed
operation. By their respective character, the time of the obstet-
rical event is not precisely calculable and the time for a gynecic or
abdominal operation has to be predetermined. Unless both events
are arranged to occur in one hospital service, it is impracticable to
associate the two kinds of cases in the practice of the same physician
or service. The hospital, by its appointments, more particularly
by its multiple personnel, meets satisfactorily these double needs.

It has been of great concern to the professional mind that woman
in her ordeals of motherhood, has commonly not found the fullest
assurance for her safe parturient conduct. I recall to your mind
the great solicitude expressed by Dr. Zinke, when he announced,
only a few years ago, that all other branches of medicine have prof-
ited by the modern advance of medical science, that obstetrics
alone in its morbidity and mortality has not shown progress. Let
us reflect that while many kinds of medical and surgical cases — •
some relatively trivial as compared with the importance to the state
and family of the mother's case — are self-evidently taken to the
hospital; that, on the other hand, the lying-in woman procures this
boon and guaranty of safety as yet only in fewest instances; and that
while in this time of specialization there are many specialists in all
other lines of medicine, in obstetrics there are relatively few,
notwithstanding the importance and multitude of these cases.

Regarding the former point, the persistent demand of physicians
in large cities has already brought it about so that women now
consent or even elect to go to the hospital for their obstetric event.

932 TRANSACTIONS OF THE AMERICAN ASSOCIATION

This number is rapidly increasing and has in turn created in
many general hospitals special provisions for such cases. The
rapidly increasing hospitalization of obstetric cases will demand
preparation for them on a new and unprecedented scale. Hospitals
solely for women will likely be established e\erywhere. Some,
very properly, will be founded to exist in relation \\ith medical
colleges, but a larger number should be provided as separate institu-
tions for the so-called private cases.

Regarding the second point, there are few who specialize in ob-
stetrics to the extent of confining their activity to such practice.
There are only a few hospitals throughout the land where obstetric
cases collect in numbers to warrant this limitation of practice.
In most instances, when the general practitioner in attendance upon
a difficult obstetric case wants counsel and aid, it now must come
from a fellow general practitioner. In effect the lying-in woman,
who is in desperate straits, goes without specialistic skill. Remedy
here must be sought and will be found in the reestablishment of the
conjoined specialty of gynecology and obstetrics when the hospitali-
zation of labor cases has become the common practice. This change,
unfortunately for the needs of the lying-in woman, is still far oflF.
But this matter must be considered early for the proper enactment of
this greater concept of medical duty and task.

Gynecic surgery as a branch or integral part of the work of the
general surgeon, although practised by many leading general sur-
geons, contravenes the leading tendency and ideal aim to scientific
specialization. It must be condemned as not assuring the exercise
of important diagnostic refinement, special knowledge, and advanced
skill. These are only obtained by the intensive cultivation of a Um-
ited field. One might as well argue that the general surgeon shall take
over again the eye and ear, or throat and nose, which attempt would
universally be regarded as preposterous and in its effect calamitous.
Abdominal surgery by its development has been an outgrowth of
gynecic surgery. But more than this correlation, there is a physio-
logical and an anatomical sameness and continuity of structure that
will plead for their continued association, both in study and practice.

But whither are we drifting? I cannot close this address without
uttering what seems to me shall and will be the ultimate goal and the
happy solution of all these perplexing and formidable questions.
Medicine and sanitation must be made a state-Junction! Sanitary
science, as an arm of the state, already discloses in its edicts tliat the
interrelation of the sick to the healthy is such that the demands of a
greater public interest warrant the state to impose, for instance,

OF OBSTETRICIANS AND GYNECOLOGISTS 933

quarantine upon the sick and preventive vaccination upon the well.
In a state that has nationahzed its medicine, the practitioner of
medicine under general supervision will correlate these endeavors
to effect results. Already such is forecast as where in single in-
stances a group of doctors under one hospital roof unite their efforts
for the common patient.

But such generalizations do not meet the immediate objects of
this meeting. We have a long and interesting array of papers
announced to follow mine this evening.

Fellows, I will here close my remarks with the reiteration of my
high appreciation of the distinction you have bestowed upon me.

APPENDICULAR ABSCESS, COMPLICATION, HEM-
ORRHAGE, FOLLOWED BY DEATH.*

BY
MAGNUS TATE, M. D., F. A. C. S.,

Cincinnati, Ohio.

In the practice of abdominal surgery, perplexing problems are
constantly met. It is with a twofold purpose that I present the
following case report:

First, because I am not cognizant of a similar case in the literature;
second, with the hope that in the discussion I may receive valuable
information.

A young colored girl asked Dr. White of Covington, Ky-, to see
her the latter part of March, 1916, because of severe pain in abdo-
men. The doctor discovered that she had a pronounced tumor in
cecal region, and immediately sent the patient to the hospital and
requested me to see the case.

Patient, aged twenty-one; unmarried; weight 130 pounds; has had
the usual sickness of childhood. No specific or gonorrheal history
obtained. She also denied sexual relations. Had always been
healthy and strong. Menstruation, regular; lasting about three
days. No leukorrhea.

She was taken sick some ten days ago, complaining of severe
cramps in the abdomen, accompanied by nausea and vomiting.
There was extreme tenderness over the abdomen and a history of
chills, followed by fever. Not having been seriously ill before, she
thought she had some "stomach trouble," and, therefore, did not
ask for medical aid until the pains became very severe and a mass
appeared in the right side of the abdomen. Vaginal examination
was not made as the hymen was intact, but the rectal touch revealed

*Rcad before the Twenty-ninth Annual IMeeting of the .American .\ssocia-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

934

TRANSACTIONS OF THE AMERICAN ASSOCIATION

fulness accompanied by pain. An incision through right rectus
muscle brought us immediately upon a large tumor mass which was
found posterior to and outside of the cecum. After carefully wall-
ing off, a wide opening was made with finger to the outside of the
cecum, and a large split rubber drainage tube placed to the bottom
of the sac. No search for the appendix was made; no mopping

I'lG. I. — (Afkr Moynahan.)

or flushing of cavity; only a few stitches were inserted to partially
close the abdominal opening. This was followed by profuse bad
smelling discharge for a week. The temperature became normal
and the pulse fell to 84 the fourth day after the operation. Pain
subsided; bowels moved naturally; and, apparently, a normal con-
valescence was in progress.

On the tenth day her condition was so favorable that a head rest
was allowed for half an hour. The eleventh and twelfth days were

OF OBSTETRICIANS AND GYNECOLOGISTS 935

equally favorable. During the morning of the thirteenth day, about
I. CO A. M., patient awoke complaining of sharp shooting pains,
nausea and faintness. The nurse changed the dressings at 5.00
A. M. and found them to be saturated with blood. Fresh dressings
were applied five times during that day. The patient continued to
complain of pain, nausea and faintness. I saw her with Dr. White
the following day, the fourteenth, and her condition was alarming.
The dressings were saturated with blood, and the open wound filled
with' large clots as though we were dealing with a ruptured ectopic
gestation. The wound was cleaned and repacked, but the hemor-
rhage soon reappeared and the patient died that evening at five
o'clock.

The nurse informed me later that a few hours before death, a
little blood was found in the stool. We were totally in the dark as
to a satisfactory explanation as to the cause and source of the hemor-
rhage. Nor did I feel at the time I saw her, that a secondary opera-
tion was advisable.

An autopsy was obtained and made by Dr. Tarvin in the presence
of Dr. White and myself, the abdomen only being opened. The ab-
scess cavity was well walled off and contained some blood. The
appendix could not be found and had, apparently, sloughed away.
Virgin uterus, tubes and ovaries, showed nothing abnormal. Small
and large intestines, kidneys, spleen, stomach and jliver were also
found normal, with the exception of that part of small intestines ad-
jacent to the abscess cavity, which were blood stained. The small
intestines were removed and we found in the mesentery a gangrenous
patch, the size of a dime piece, through which one of the branches
of the iliocolic artery coursed. Part of mesentry was also blood
stained.

It is well known that in the appendiceal region both arteries and
veins may be involved; that phlebitis and thrombosis, with their re-
sultant septic embolism and metastatic abscesses, may occur. It
is also reported that the iliac artery and vein are subject to erosion,
with fatal hemorrhage.

19 West Seventh Street.

DRAINAGE FOR PUS CONDITIONS IN THE PELVIS
DURING PREGNANCY.*

BY
FRANCIS REDER, M. D., F. A. C. S.,

St. Louis, Mo.

The most frequent cause of a pus accumulation in the pelvis dur-
ing pregnancy must be attributed to a diseased appendix. In the
chapter of appendix lesions, a pelvic abscess is most insidious, ex-
cepting perhaps the subphrenic abscess. The reason for this is that

*Read before the Twenty-ninth Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, igi6.

936 TRANSACTIONS OF THE AMERICAN ASSOCIATION

the diagnosis of appendicitis is often obscured by pregnancy. If
the pains and frequent indispositions that usually accompany a
pregnant state are not closely scrutinized, and correctly and
promptly interpreted by the physician, the primary clinical picture
of an attack of appendicitis may be readily overlooked, and only
recognized when the more serious phases of the disease have mani-
fested themselves.

Pregnancy does not in any way predispose to appendicitis. There
is no doubt, however, that on account of the anatomical changes
which take place in the pelvis during pregnancy, appendicitis may
terminate in a pus formation more rapidly than in the nonpregnant
state.

A close study of the symptoms of an appendix lesion during preg-
nancy may bring out some clinical points which differ from the usual
clinical picture as is found in women who are not pregnant. For
instance, before any pus formation has taken place, the pulse and
temperature may show little or no change. The pain is usually lo-
cated in the epigastric region, and remains there till the disease has
reached a stage when all pain ceases.

The triad douloureuse of Dieulafoy, over the lower abdomen, is
often so blurred by other conditions that it is usually obscured, and
its presence is not recognized. Even in an advanced pregnancy,
a readily recognizable rigidity of the right rectus is seldom encoun-
tered, and only exceptionally does palpation reveal a tender spot
over McBurney's point. Nausea and vomiting, two alarming signs
in an attack of appendicitis, count for naught during pregnancy;
because both are frequently associated with the toxemia of the latter
condition.

Palpation of an abdomen, after the fourth month of gestation, is
very unsatisfactory, and it is seldom that any positive conclusions
can be drawn from such an examination. Is it, therefore, at all
surprising that appendicitis, in its primary stage during pregnancy,
is apt to be overlooked? As previously stated, pregnancy favors the
rapid development of the pathological stages of appendicitis, and a
pus accumulation may be found in the pelvis in a surprisingh* short
time.

In one patient, pregnant five months, a distinct fluctuation could
be detected in Douglas' pouch by rectal palpation on the fourth day
after a severe attack of "indigestion." This patient only felt in-
disposed for two days. On the third day, however, she became very
sick. No physician had been consulted before the tliird day. She
said there had been no need for one.

OF OBSTETRICIANS AND GYNECOLOGISTS 937

Pus accumulations in the pelvis during pregnancy are favored by
the location of the appendix and by the size of the uterus. The
appendix that crosses the iliac vessels and hangs into the pelvis, the
so-called "three o'clock" position, is the appendix that is a great
contributing factor to a pelvic abscess; while a uterus beyond the
third month of gestation, when it can be readily palpated through
the abdominal wall, materially favors pus collections in the pelvis.
This may be explained on the ground that the enlarged uterus,
crowding into the abdominal cavity, exercises an undue influence
upon the intraabdominal pressure above the pelvic plane, thus fav-
oring fluids to collect in the pelvis. Furthermore, inasmuch as the
formation of adhesions about the appendicial region is inhibited
because of the rapidity with which the pus forms, the balance of the
abdominal pressure usually remains undisturbed, and fluids will
find their way along the route offering the least resistance.

Operative treatment of pus accumulations in the pelvis during
pregnancy is a matter of great importance. The danger involves
two lives, and prompt intervention is demanded as soon as a diagno-
sis has been reached.

The recognition of a pelvic abscess, especially when the accumula-
tion of pus is small, is not always an easy matter. An examination
of the lower abdomen is very often unsatisfactory on account of the
large size of the uterus. A distention usually present and causing
no pain, should, under all circumstances, strengthen any suspicion
that might be entertained as to the possibility of a deeply seated
abscess in the pelvis. The abdomen, on palpation, will not be
found sufficiently rigid and tender to attribute this distention to
peritonitis.

Palpation of the lower abdomen will, generally, disclose the iliac
fossa free from a definite lump. However, there may be, in those
cases where the uterus has ascended to a moderate degree into the
abdomen (as in four- and five-month pregnancies), an obscure re-
sistance above the pubes, formed by coils of intestine matted to-
gether above the abscess cavity. The percussion note over this ob-
scure resistance gives a resonant sound, and deep percussion may
elicit a tender spot over McBurney's point. Distentions of this
character are generally caused mechanically by pressure of the ab-
scess upon the rectum. As a consequence, the entire colon, and fre-
quently the small intestine, becomes dilated.

Other valuable signs that aid in a diagnosis, are diarrhea of an
intensely fetid odor, discharges of mucus from the rectum, rectal
tenesmus, and often a feeling of discomfort in the lower part of the

938 TRANSACTIONS OF THE AMERICAN ASSOCIATION

rectum. These conditions may exist either in a mild or a severe
degree.

The most satisfactory and most convincing evidence as to the pres-
ence of pus in the Douglas' pouch can be obtained by a rectal exami-
nation. If the accumulation is considerable, no difficulty should
be experienced in promptly detecting a fluctuating mass, even if
the examining finger is inexperienced. However, when the collec-
tion of pus is small, the examining finger must not only possess a
delicate sense of touch, the examination is made without the rubber
glove, but it must have been educated so as to recognize and dif-
ferentiate any abnormal conditions in the lower part of the rectum.

A collection of pus in Douglas' pouch will impart to the examining
finger, as it is introduced into the rectum a distance of 3 to 4
inches, a tender mass of variable size. This mass is sometimes hard
and sometimes fluctuating. The mucous membrane of the rectum
in the immediate vicinity of the abscess will be found swollen, edem-
atous, and covered with mucus. Furthermore, through the sense
of touch, the flattening of the rectum against the sacrum can be
recognized.

In the treatment of a pelvic abscess complicating pregnancy, two
factors become absolutely axiomatic: First, prompt recognition of
the pus collection; second, the simplest surgical measure for relief.

Let us consider for a moment the first requisite. Why the prompt
recognition of the pus collection? Any infectious process terminat-
ing in suppuration is one of the greatest dangers to a pregnant woman.
On account of the continued high temperature, usually accompany-
ing such a process, the life of the fetus becomes imperiled. Accord-
ing to statistics, a pus collection in the pelvis has caused abortion in
57 per cent, of cases, regardless of treatment. The abortions added
23 per cent, to the mortality of surgical intervention (Meyer).

Interruption of pregnancy may occur in three to five days after
the pus formation has taken place. Advanced pregnancies are less
tolerant of septic conditions than those of the early stages. Re-
cently, I had occasion to observe a case that proved an exception.

A woman, in the sixth month of pregnancy, was taken with an
attack of acute appendicitis. She was operated eight hours after
the attack. It was a "clean case." However, the wound be-
came infected. At time of operation, July 6, 1916, the tempera-
ture was 102°, pulse 124, R. 24. July 8, T. 103°, P. 132, R. 28.
July 9, T. 104°, P. 130, R. 38. July 10, T. 104.4°, P. 132, R- 38-
July II, T. 101°, P. 124, R. 30. July 12, T. 100.2°, P. 112, R. 28.
July 13, T. 98.8°, P. 104, R. 28. Labor pains from 12.05 P- M. to

OF OBSTETRICIANS AND GYNECOLOGISTS 939

12.45 P- ^-t ^^ about five-minute intervals. July 14, T. 101.2°, P.
136, R. 36. July 15, T. 101°, P. 124, R. 32. July 16, T. 100.4°,
P. 108, R. 28. July 17, normal. July 18, T. 102°, P. 106, R. 36.
July 19, T. 103.4°, P. 104, R. 40. July 20, T. 101.2°, P. 98, R. 26.
July 21, normal.

.\fter that the temperature continued normal with slight varia-
tions. During the time of the high temperature, the movements of
the' fetus could be scarcely perceived by the mother. The heart
sounds were heard with difficulty and sometimes not at all. This
gave rise to fear of the death of the fetus. However, after the tem-
perature had returned to normal, the movements of the fetus again
became pronounced and the heart sounds could be auscultated with
ease. In this case the fetus survived a high temperature, caused by
a pus accumulation, covering a period of twelve days.

Now let us consider the second requisite: The simplest surgical
measure for relief. First of all, let us bear in mind that although the
abscess is not in itself the disease, it is nevertheless the factor of
danger to the fetus, and must be urgently dealt with.

Surgery during the pregnant state must have its limitations, and
these limitations must be more respected in the latter stage of gesta-
tion. An abdominal operation, for instance, can be performed with
less risk of interrupting pregnancy before the fourth month than
after this period of gestation. Furthermore, the thoroughness
with which an operative measure, early in pregnancy, can be carried
out is fraught with less danger than in the later stages of this
condition.

The paramount principle in any operative work, at any period oi
gestation, is the measure that offers the greatest safety to mother and
fetus; be it for a pus accumulation or any other condition.

A rather perplexing problem confronts the surgeon in the treat-
ment of a pelvic abscess complicating pregnancy. His judgment
tells him that urgent evacuation of the pus is demanded. His
judgment also tells him that it must be done expeditiously and with
the least amount of surgical meddling. To him it remains prob-
lematical whether or not his patient is going to abort or miscarry.
He must be, however, prepared for such an emergency and conduct
his surgical attack accordingly. Where is the section to be made?

If the case is one in the earlier stages of pregnancy and the section
has been made through the abdominal wall and that the element
of luck favors the procedure, recovery without interruption of
pregnancy may result. This happy termination takes place in
about 60 per cent, of the cases. According to the statistics of Myer,

940 TRANSACTIONS OF THE AMERICAN ASSOCIATION

abscess formation causes abortion in 57 per cent, of cases, regardless
of treatment.

If the case is one in the later stages of pregnancy and an abdominal
section is performed, the per cent, is less favorable. In these cases,
an additional complication oilers itself in the healing of the wound.
Because of the constantly enlarging uterus, assuming that the patient
has not miscarried, healing of the wound is considerably delayed;
it may require from two to four months before the wound has fully
and firmly closed. Should labor take place before the wound has
firmly united, there is danger of hernia, or separation of the wound.
If such a patient miscarries and lives, the wound will, of course, heal
as under ordinary circumstances.

It has fallen to my lot to meet with two cases of pelvic abscess,
in the sixth and seventh months of pregnancy, respectively.
There was no difficulty in diagnosticating the pus accumulation in
Douglas' pouch, both by vaginal and rectal examination. The
constitutional disturbance was marked. Both patients had been
sick a week, and the prospect of a miscarriage in each case seemed
good. Although the fetal movements were no longer perceived by
the mothers, the fetal heart sounds could be auscultated, thus giving
assurance of life in either instance.

The method of surgical procedure seemed at first to be a serious
problem. After some little time deliberations crystallized them-
selves into simple measures. The temptation to make an abdominal
section was lost when the complications that would inevitably
follow such a measure at this period of pregnancy, were wholly
realized.

A vaginal section, the logical procedure in the nonpregnant state,
was dismissed because of the probability of a miscarriage. This is
a hazard that must be reckoned with as the risk to the mother of a
possible infection from the pus draining through the vaginal canal,
in case miscarriage should follow vaginal section, would be very-
great. The only remaining avenue for consideration was the rectum,
and it was into this viscus that the incision was made. Being
certain of the pus accumulation in Douglas' pouch, it appeared to
me to be the safer plan to drain through the rectum. The procedure
proved very fortunate, both patients recovered without miscarriage.

It is of interest to cite some of the advantages of rectal drainage
under these conditions. Assuming that a miscarriage had taken
place, the danger of infection from pus could be readily controlled.
Even had labor taken place before the abscess ceased to drain, the
liabilitv of infection from this source would be remote. The

OF OBSTETRICIANS AND GYNECOLOGISTS 941

abdominal wall is intact and well able to fully cooperate during labor.
There is no wound to give anxiety. In from two to three weeks
the abscess usually ceases to drain and the patient is well established
in convalescence.

Rectal section for drainage of a pelvic abscess is in itself a minor
procedure. It is the feeUng of uncertainty of finding the pus, or
of injuring a viscus, that causes one to hesitate. Especially is this
true when the pus accumulation is small and when no distinct fluc-
tuation can be elicited. Much of this, however, rests with the
experience of the surgeon; one may feel certain, while another may
be in doubt as to the presence of pus.

There still exists a great reluctance to attacking a pelvic abscess
through the rectum, presumably because of the likelihood of infect-
ing the abscess cavity with fecal matter. This, however, may be
considered as doubtful, inasmuch as this avenue is one of Nature's
outlets to relieve the organism of pus accumulation in the pelvis.
Patients relieved in this manner have usually suffered no untoward
results, and their recoveries have been satisfactory.

In making a rectal section the anus is first gently dilated. The
rectum is then well douched. The index-finger, without glove,
searches for the most fluctuating spot in the tense mass; when found,
a sharp-pointed bistoury is passed along the volar surface of the
finger and cautiously introduced into the spot selected. As soon
as pus is encountered, the bistoury is withdrawn and the point of
a dressing forceps introduced into the opening. By spreading its
branches, a hole sufficiently large to admit the end of the index-
finger is made. A large winged rubber tube is then passed into
abscess cavity long enough for one end of it to protrude from the
anus. This secures ample drainage and facilitates proper toilet.
At the end of a week the tube is removed. The operation can be
performed either without or with a superficial anesthetic.

Delmar Building,

942 TRANSACTIONS OF THE AMERICAN ASSOCIATION

REPORT OF A CASE OF RUPTURE OF THE UTERUS;
SEPSIS; OPERATION; RECOVERY.*

BY
RUFUS B. H.\LL, A. M., M. D.,

Cincinnati. Ohio.

Rupture of the uterus during labor is a rare and dangerous acci-
dent. Fortunately, it is so rare that only a very small per cent, of
the men engaged in the practice of medicine ever see a case. The
hemorrhage that occurs in rupture of the uterus, makes it a very
fatal accident. Hemorrhage, however, is not the only danger in
rupture of the uterus. This is demonstrated by the report of this
case. The accident is of serious import, and it is worth while to
report in detail every case. There will be no attempt made to re-
view the literature of the subject, or to write a paper upon all its
different phases. The writer will confine himself to the report of
the facts observed, the condition found at the time of the operation,
and the subsequent history of the case.

Case. — Mrs. E., aged thirty, wife of a physician. Dry Ridge,
Kentucky. The patient is the mother of three children, aged
seven, three, and the third was born February 3, 1916, after a
short, quick, unaided labor. There were no unusual symptoms
after her delivery; in fact her husband, a physician, thought that
she was fairly well until, in the afternoon of the fourth day, February
8, she had a slight chill. Her temperature, which heretofore
fluctuated between 98.5 and 99° F., rapidly rose to 104°. The
temperature subsided within two and one-half hours to 99°. After
that the patient had, practically, a normal temperature every
morning; between 2 p. m. and 4 p. m., the temperature varied, each
day, from 101° to 102° until March 12.

During this period, the patient had a good appetite, felt well,
had no chills or sweats, and had plenty of nourishment for her child.
She complained because her doctor refused to let her get up; and
expressed herself as feeling perfectly well, except for a slight pain
or tenderness in the right lower half of the abdomen. This sensi-
tiveness was always exaggerated in the afternoon during the rise in
temperature.

The case was a puzzling one to her physician, a man of large experi-
ence in obstetrical work; he had never seen a case like it. The fact
that there was no odor to the lochia or any other unusual condition,
he felt reasonably certain that there could not be much wrong:
still the case would not convalesce like other ordinary cases he had
attended.

*Rea(i before the Twcnly-ninth Annual Meeting of the .\mcrican Associa-
tion of Obstetricians and (lynccoloRists at Indianapolis, Ind., September, igib.

OF OBSTETRICIANS AND GYNECOLOGISTS 943

In the afternoon of IMarch 12, five weeks and three days after
delivery, without appreciable cause the patient had a severe chill,
lasting nearly an hour. Immediately after the temperature rose
to 103.5° F. I saw her the first time four hours after the chill.
The temperature had then fallen to 101°. Patient's abdomen was
moderately distended, not at all sensitive to palpation, except in the
right lower quadrant. This region was quite sensitive to pressure.
Muscular rigidity was moderate on that side; no mass could be
felt in the abdomen or pelvis, except an enlarged subinvoluted
uterus. The doctor assured me that there had not been anything
unusual about the parturient tract since her delivery. Bimanual
examination revealed that involution was progressing satisfactorily.
There was nothing out of the usual to be found in the pelvis to
account for the apparent sepsis. It did not seem to me the patient
was suffering from puerperal sepsis. The cause of the infection
was very problematical. Nor did it seem to be a case of appendicitis.
The natural inference was that the patient had been the victim of a
small ovarian cyst, which ruptured during labor, and nature was
making an efiort at cure by walling off the ruptured cyst. Still,
a most careful examination did not reveal a mass of any kind.
Therefore, I counseled delay and expectant treatment. The patient
was in good physical condition, fairly comfortable and had plenty
of nourishment for her baby.

The temperature rose each day to 101.5° to 102°, without chill,
until the afternoon of the i6th, when the temperature went up to
103.5°. I 'w^s again asked to visit the patient. Notwithstanding
the patient had been given an effective laxative each evening, the
abdomen was fairly well distended. The uterus was as large as
at my first visit, and not particularly tender. The pain and rigidity
■of the right half of the abdomen were more marked than before.
Upon palpation I could outline an indistinct mass to the right of the
uterus. This mass was not observed when I made my first examina-
tion. Six weeks had past since the patient's delivery. She was stead-
ily growing worse. The mass in the right iliac region was probably
pus. The patient was moved to the city March 20, thirty-five days
after labor. On her arrival at the hospital her temperature was 102°.
The following morning it had fallen to 98.6°. That afternoon, the
temperature rose to 104°. The patient had a profuse sweat, and the
mass in the abdomen appeared to be at least three times the size
it was four days ago, and very much more sensitive to the touch.
She had no longer any desire for food, and the pulse ranged from 90
to no. She appeared septic; though she had still plenty of milk for
the baby which continued to nurse.

On the afternoon of March 22, the abdomen was opened in
the median line, under anesthesia. The omentum was found to be
adherent to the abdominal wall and over the entire mass in the
abdomen; it was also adherent to the fundus of the uterus. In
separating the adhesions from the uterus, pus was found in front and
to the right of the uterus. This abscess cavity held about 2 ounces
of thick, yellow pus, and was carefully removed with gauze sponges.

944 TRANSACTIONS OF THE AMERICAN ASSOCIATION

It was now discovered that there had been a rupture of the uterus,
at the fundus. The rupture extended down to the top of the bladder.
In this rent the omentum has inserted itself and was firmly adherent
to it. The uterus was larger on one side than on the other.

The omentum was severed, close to the uterus and all that portion
of it in contact with the pus cavity, removed. The Fallopian tube on
that side was not involved. The appendi.x was not involved. To
protect the general peritoneal cavity, a strip of gauze was laid on the
uterus over the site of the pus cavity and brought out through the
lower end of the incision. A rubber drainage tube was left in the
abdomen.

The patient rallied quickly from the anesthetic. How far the
omentum extended into the uterus, whether it extended wholly or
partially through the uterine wall, there was no means of determining.
As nature had repaired the injury very satisfactorily, I considered
it good surgery not to interfere with that organ at all. The infection
was due to leakage from the uterine wound.

Studying the history of the case, we find that the first alarming
symptoms were ushered in by the chill on February 8, at which time
her temperature rose to 104°. The rapid subsidence of this high
temperature, and the subsequent favorable progress of the case,
does not indicate a streptococcic infection. One can thus readily
see why the temperature and pulse and all the symptoms were
of a milder character. It simulates somewhat the history of a rup-
tured appendix in which an abscess follows and is well walled off.
One might infer that this form of unrecognized accident, plays an
important role as a source of infection in some of the slow and tedious
convalescences following labor. The writer is not in a position to
prove this and does not wish to state that as a fact, but we all know
that every obstetrician has had the experience of meeting cases of
mild infection in which he is not able to trace its source; and this makes
it worth while to consider this accident as a possible cause in such
cases.

628 Elm Strket.

DISCUSSION.

Dr. Henry Schwarz, St. Louis, Missouri. — The case reported
by Dr. Hall is indeed a remarkable one, and it was handled by him
with consummate skill and good surgical judgment. As an obstet-
rician, I regret that he did not remove the uterus for the sake of
having it examined as to the condition of its tissues. The case is
very exceptional that a woman, who has a normal pelvis, who has
given birth to three children without any difficult y, should have a
rupture of the uterus at the lime of labor. If she had a rupture, the
presumption should have been that she had had removed from the
uterine wall a fibroid, or that she had on a previous occasion, perhaps

OF OBSTETRICIANS AND GYNECOLOGISTS 945

for a pelvic tumor, a Cesarean section done upon her. At any
rate, there should be some history to account for the cicatricial
tissue or some weakening in the uterine wall. Without that history,
and without the symptoms described in this case, it is not at all clear
that we are dealing with the symptoms of a rupture of the uterus
during delivery, and I would hesitate to accept Dr. Hall's case as
one of rupture of the uterus having occurred at the time of delivery.
I think it is a case that is altogether in a class by itself. Leaving
aside cases in which the uterus ruptures after scar formation, a
subject which will be discussed in papers to be read later in the
session, rupture of the uterus is expected only when nature is hindered
in her efforts to expel the fetus, when there is a disproportion be-
tween the parturient canal and the fetus. Under these circum-
stances it is good obstetrics either to do a Cesarean section for rela-
tive indications or to induce labor ahead of full-term. Of such
cases I have seen only two, one before the time of doing Cesarean
sections for relative indication in 1881. At that time we tried to
induce labor in a case of minor pelvis. The nurses and junior assist-
ants were sitting with the patient; labor was in full swing. The
moaning of the patient was regular and kept me asleep in an adjoin-
ing room. But when everything was quiet in the delivery room I
woke up and found the nurse and house resident asleep and the patient
quiet. When there is a rupture of the uterus the patient becomes
absolutely quiet. I ran into the delivery room and found that the
child had escaped into the abdomen; I pulled it out by the feet, sent
for my chief, who opened the abdomen, and closed the rent.

The second case occurred while I was delivering a lecture on
obstetrics. A practitioner with whom I had had a number of cases
of placenta previa, telephoned me in the morning that he had a case.
I asked him if he had packed the case properly and he said he had.
I told him that the patient could wait until I got through with my lec-
ture. When I reached the house there was a rupture of the uterus.
I found that the practitioner had given something which I did not
advise, namely, a dose of Sharp and Dohme's ergotol, and the intense
contractions caused the rupture of the uterus. The woman's vitality
was very low and she died a few minutes after I had extracted the
child, which had partially escaped into the abdomen.

Dr. Edward J. Ill, Newark, New Jersey. — I disagree with my
friend Dr. Hall as I do not think he had a rupture of the uterus in
this case. Rupture of the uterus always occurs in the lower seg-
ment; it never occurs in the upper segment. Then he speaks of
there being no blood in or about the abscess. There must have
been some blood there if there had been a rupture, even if there was
a secondary suppuration. Lastly, I have seen many cases of slow
suppurative metritis following labor in which abscess occurred
anterior to either horn and which, when opened and drained, was.
followed by recovery of the patient.

Dr. J. Henry Carstens, Detroit, Michigan. — Rupture of the
uterus occurs usually in the manner Dr. Schwarz has mentioned.
I am rather inclined to think that Dr. Hall's case was one of embolisra

946 TRANSACTIONS OF THE AMERICAN ASSOCIATION

of the uterus, where, on account of degenerative changes, the part
dies slowly of gangrene and finally tears.

Dr. Arthur J. Skeel, Cleveland, Ohio. — I am much interested
in Dr. Hall's paper as it illustrates a case I had some time ago.

Rupture of the uterus must necessarily belong to one of two
categories. First, those cases in which there is disproportion and
after a prolonged labor a thinning out of the lower uterine segment
with rupture in this location. In the other set of cases, through
degeneration of the uterine muscle, rupture may occur early in
labor and may take place anywhere in the body of the uterus.

The case I wish to report occurred in a woman who had in rapid
succession ten children, with no difiiculty. In the eleventh labor,
after some two or three hours of pains, rupture occurred with the
head in the pelvic cavity. The patient was taken to the hospital,
the child removed with low forceps. The woman was in extremis.
The abdominal cavity was opened, and rupture found without any
thinning out of the lower segment of the uterus, as it occurs in
those cases where labor has been going on for a long time. The
rupture took place on the right side from the anterior portion of the
uterine wall near the horn down toward the base of the broad liga-
ment. There was no thinning out of the uterine wall at all. The
rent was sutured, and after a somewhat tedious convalescence the
woman recovered. This illustrates very clearly two types of cases,
one due to obstruction in which necessarily rupture occurs in the
lower uterine segment because of the thinning-out process due to
a prolonged labor, and the other due to a degeneration of the uterine
muscle in which rupture may originally occur almost anywhere in
the body of the uterus.

Dr. Sylvester J. Goodman, Columbus, Ohio. — Presupposing
that this was a case of rupture of the uterus, and in view of the
fact that this condition is somewhat rare, I wish to put on record
tv/o cases of rupture of the uterus which occurred in our service at
the Grant Hospital in the last few months.

The first case occurred in the service of Dr. Drury in which a
diagnosis was not made until a week after the rupture had taken
place. Infection had occurred, with general peritonitis and pus
everywhere. The abdomen was opened by the doctor who found
a dead macerated fetus, which was removed, a hysterectomy made,
abdominovaginal drainage instituted, and the woman made a good
recovery.

The other was a case in which the diagnosis was promptly made
and occurred in the service of Dr. Baldwin, operation having been
performed by him. The diagnosis was made promptly by the
attending physician, who had the patient brought to the hospital;
a hysterectomy was done, abdominovaginal drainage instituted,
and the patient made an uneventful recovery.

I cannot believe with Dr. Hall that we have many cases of rupture
of the uterus that go unrecognized. Men connected with gyneco-
logical services would certainly use their efforts to determine previous
ruptures if such were the case. We know how rarely we see a con-

OF OBSTETRICIANS AND GYNECOLOGISTS 947

dition of that kind, notwithstanding the fact that we operate on
hundreds of cases. Personally, if I had had such a case I surely
would have made a hysterectomy-

Dr. 0. H. Elbrecht, St. Louis, Mo. — The case reported by
Dr. Hall is so unusual that I feel with several of the previous speakers
that it belongs in a class by itself. The thought occurred to me
that this might have been either a bicornate uterus or a double
uterus. If you recall the different types of bicornate uteri and the
different types of double uteri, occasionally you will see one that is
open and very thin, and there is a disproportion between one uterus
and the other, one being parasite to the other, the tubes and ovaries
being two in number only. There is a possibility of this case having
been one of that type, inasmuch as it did not present any of the
classical symptoms which we find in typical cases of rupture of the
uterus.

It is to be regretted that Dr. Hall could not do a hysterectomy,
as this would have cleared the pathological problem.

Dr. Hall. — I have a live patient now, but she would have been
dead if I had done a hysterectomy.

Dr. Elbrecht. — I refer only to the pathological side of it. I
agree with you clinically and am sure you displayed excellent judg-
ment in leaving it.

The pathological conditions, when you are in the belly, are so
seriously distorted by the inflammatory products that you must
guess at it and you did just what any of us would have done under
similar circumstances. But the point is this: why should this case
be in a class by itself and still be a rupture of the uterus, with so little
disturbance that you chose to call it a normal deUvery?

Dr. James E. Davis, Detroit, Michigan. — I wish to call attention
to a condition that has not been mentioned in connection with
this paper. Perhaps it might be considered in connection with Dr.
Hall's case. Cullen some years ago reported upward of 150 cases
of cysts occurring from the Wolffian duct remains between the anterior
part of the uterus and the bladder. Last year I had such a case.
The cyst had become infected, and in fact most of these cysts do
become infected and are recognized following obstetrical deliveries.
In my case the woman manifested a septic temperature, beginning
on the fourth day which continued for eight weeks. When she came
to operation, and an abdominal section was done, nothing was found
to account for the conditions until I began to separate the bladder
from the anterior portion of the uterus, then I opened into a cystic
cavity which was infected, and which I diagnosed as belonging to
this type of cysts. I wondered whether Dr. Hall's case might not
have belonged to this class of infections?

Dr. George van Amber Brown, Detroit, Michigan. — Four
years'ago I had a case of rupture of the uterus, a recital of which
may be helpful in arriving at the cause of this trouble. The woman
had previously borne two children. This was her third pregnancy.
She had a normal deUvery. A few hours after her delivery her physi-
cian was called, and as they could not get him, they called in a neigh-

948 TRANSACTIONS OF THE AMERICAN ASSOCIATION

boring physician, and we do not know at that time what he did ex-
cept the vagina had been packed. The woman was taken to the
hospital; she remained there for ten or twelve days, apparently was
doing very well, and then went to her home. She had been home
only a day, was up and about, when profuse hemorrhages came on
again. She was again taken to the hospital; I was out of the city
at the time but was called a few days later to see her in the fourth
week after her delivery. She had no chills, nor rise in temperature;
the only symptom was that of bleeding. At the time I saw her
anemia was very pronounced; she had shortness of breath; her legs
were edematous; her labia were like two great sacs holding water.
Her hemoglobin was so low that we could not make an estimate
of it. It showed 20. The blood count was 1,435,000. We took
her to the operating room; we did not dare give her a general
anesthetic. We put her in the Trendelenberg position, opened
the abdomen under novocain, and found the omentum which had
just closed in over and was appearing at the fundus; we pulled
that away, and found there was a cavity where the blood was ar-
rested. The edges of the wound had shown no signs of healing
whatever, but were very much narrowed down. Involution had
gone on very well. The woman made a nice recovery.

In getting hold of the young physician who had been called in at
the time of the first hemorrhage, it was found that he had packed
the uterus as well as the vagina. Evidently that was the cause of
the rupture and it did not occur at the time we supposed it did.

Dr. E. Gustav' Zinke, Cincinnati, Ohio. — The case reported by
Dr. Hall is, certainly very interesting and deserves consideration.
The history of the case was not quite clear to me. Will Dr. Hall
kindly state the nature of the case. Did she have an instrumental
delivery, a version or any other obstetric intervention?

Dr. Hall. — It was not an instrumental delivery. I did not go
into the other details. The patient was a doctor's wife, delivered
her after a short and uneventful labor. She had a few effective
pains only. She lost consciousness for five or ten minutes; her
husband thought she had fainted. The patient was a highly
nervous woman, and did not recover consciousness for four or five
hours.

Dr. Schwarz. — When was the placenta removed?

Dr. Hall. — The practitioner removed the placenta from below.

Dr. Zinke (resuming). — She had then a spontaneous labor and
the doctor only assisted in the delivery of the placenta?

Dr. Hall. — Yes.

Dr. Zinke. — There is no history of injury to the uterus, and if
a rupture did take place it was, probably, spontaneous and due to
some diseased or abnormal condition in the uterine wall. Now,
what is it that can disturb the uterine wall and result in a rupture
of the uterus during delivery? None of the conditions that might
be responsible for the accident have been mentioned except one.
Is it not possible that this placenta in some small part had under-
gone chorionic epitheliomatous degeneration and that the portion

OF OBSTETRICIANS AND GYNECOLOGISTS 949

involved had destroyed the uterine musculature in that region. We
can never tell when these malignant changes develop. They may
begin at any period of gestation. At the time of labor the placenta
had perforated the uterine wall. Infection may have resulted in
an abscess which broke through the peritoneum, and caused ad-
hesion between uterus and omentum. In this way we can, in a
manner at least, explain the conditions described by Dr. Hall. This
is about the only explanation I have to offer. It was not a rupture
which occurred during the labor; nor was labor itself responsible
for it. Evidently the perforation occurred some-time after the birth
of the child. The case is explicable only when placed on the basis
of a pathological condition.

Dr. Charles L. Bonifield, Cincinnati, Ohio. — I quite agree with
Dr. Zinke that this case must have been one of perforation rather
than a rupture of the uterus, and the contribution I have to make
on the theory of how perforation occurs is this: the observation that
I am going to make and tell you about was on a dog instead of a
human being, but I think it may have some bearing on this case.

A year or two ago I had a French bull bitch which against my
wishes became pregnant, and after she had been pregnant for some
weeks some one stole her and she was gone four or five days. Finally,
one Sunday, when I got home my bitch was there and showed great
evidences of abuse. She evidently had been tied up as there were
scratches all over her. I wanted to keep this bitch and did not want
any puppies. The next time I went out of town a professional friend
of mine did a hysterectomy on her. He reported to me this very
unusual condition, that in one side of the uterus there were three
perforations. The dog was quite sick. These perforations were
round and covered by omentum. My idea is that the dog was kicked
in the belly or had received some violence which set up a thrombosis
in the uterus and it went on to perforation. It was necessary to do
a panhysterectomy and the dog recovered from the operation. It
seems to me, this case may have some bearing on the case cited
by Dr. Hall. This woman might have sustained some injury to the
uterus through the abdominal wall which may have caused a limited
thrombosis.

Dr. Hall (closing). — I did not expect very many obstetricians
to agree with my diagnosis in this case of rupture of the uterus. I
have opened a great many abdomens, and the old story that he who
laughs last laughs best holds good in this case. There would not
have been a question in your mind if you could have seen the uterus
at the time of the operation as to whether there had been thrombosis
with incarceration of the omentum or a rupture of the uterus. I
am willing to accept the end result that the patient recovered on the
theory that she had a rupture of the uterus. That may be all
wrong, and I am perfectly willing to stand corrected if it is. For
the sake of argument, let us admit it was a thrombosis. It looked
as though the uterus was split in two and the omentum dropped in
and was carried into that organ, and some of the dirt, walled off,
as the cause of the abscess. That is only theory on my part. It

950 TRANSACTIONS OF THE AMERICAN ASSOCIATION

was the most reasonable thing to me, yet it may have been a throm-
bosis, with breaking down later and the omentum being caught
in the uterus. The omentum was not plastered on to the uterus,
but it was incarcerated in the uterine wall. I first examined on one
side to detach it, and then on the other.

The less surgery we do on a patient who is profoundly septic the
better the end results. I think the explanation of Dr. Davis would
be more rational than the theory of thrombosis of the uterus,
namely, an abnormal cystic development in the uterus which caused
a weak point. After all, it is largely theoretical. It may be she
did not have a rupture of the uterus, but a case of secondary infection
from a thrombosis.

In regard to the question of Dr. Schwarz as to whether the husband
introduced his hand into the uterus, I will say that the husband
said he had no difficulty in removing the placenta. That is about
the only question I asked him. Rupture of the uterus never entered
my mind as a causative factor until the time of the operation. In
short, rupture of the uterus was not discussed before operation.

Dr. Elbrecht. — How about perforation before she became
pregnant?

Dr. H.vll. — I do not think she had a perforation before she became
pregnant. She was the wife of a physician and very anxious to
have a child. Everything was lovely so far as their domestic
relations were concerned.

Dr. Pantzer. — Had she ever been curetted?

Dr. Hall. — No, she had not.

RUPTURE OF THE UTERUS IN CESAREANIZED
WOMEN, WITH A REVIEW OF THE LITERA-
TURE ON THIS SUBJECT TO DATE.*

BY
JOHN XORV.\L BELL, M. D., F. A. C. S.

Detroit. Mich.

A CASE of this character, occurring in my practice recently, led
me to inquire into the frequency and causative factors of this acci-
dent. From the literature available in the library of the Wayne
County Medical Society and the Medical Library of the University
of Michigan, I have been able to find seventy-eight cases recorded,
my own case making seventy-nine. This includes the sLxty-three
cases tabulated in the very exhaustive paper on this subject, in the
American Journal of Obstetrics, by our esteemed Fellow, Dr.
Palmer Findley. In order to have as much as possible of the
literature on the subject available in one place, I have compiled a

*Read before the Twenty-ninth Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

OF OBSTETRICIANS AND GYNECOLOGISTS 951

review of forty-two cases more or less in detail, which I would be
pleased to furnish on request.

In endeavoring to determine the frequency of this accident, we
find that sixteen of these cases occurred prior to the year 1900 and
twenty-six since that time. Considering, therefore, the number of
abdominal Cesarean sections that have been done all over the world,
especially in the last decade, we may safely conclude that this acci-
dent is comparatively rare ; that its rarity speaks well for the improve-
ment in technic in the operation in recent years; and that the pos-
sibility of rupture in subsequent pregnancies should not, we think,
be considered as a contraindication where the operation is clearly
advisable.

Suture Material Used. — In seventeen cases catgut was used, in two
silk, in one silk and catgut. In the remaining twenty-two cases, the
kind of suture material (when such was used) is not mentioned. In
many of the earlier cases reported, the uterus was not sutured, the
abdominal incision being closed with a few sutures, presumably silk.

Mortality. — Twenty-seven of the mothers recovered, while only
four of the babes were born alive, giving us a mortality of 60 per cent,
and 90 per cent, respectively. Twins were present in one of the cases.
The high infant mortality is, undoubtedly, due to the loss of blood
incident to the rupture, delay in operating, and prematurity of
birth.

Etiology. — When we consider the causative factors in the produc-
tion of this accident, we can, with a reasonable degree of certainty,
conclude that the uterine wall at the site of the scar was detective.
This is shown by a review of the cases reported; rupture invariably
occurred at that point. Undue tension may be produced by a large
fetus, pregnancy or hydramnios.

The most important factor, however, is the condition of the scar in
the uterine wall. In but few if the cases reported have microscopic
examinations of the ruptured scar edges been made; and this, I
confess, was neglected in my own case. Considerable light is thrown
on this phase of the subject by the microscopic findings in the case
reported by Cocq.

In the case reported by Breitenbach the microscopic findings
would seem to indicate that the placenta had been attached to the
scar area; in two of the three cases reported by Wall and Shaw this
same condition was found.

Further evidence that the faulty scar is the principal cause in the
production of rupture, is found especially in the cases reported by
Sommer, Convelair, Locher, Brunnings and myself. There can be

952 TRANSACTIONS OF THE AMERICAN ASSOCIATION

little doubt that infection following the operation predisposes to
rupture in subsequent pregnancies; attachment of the placenta over
the site of the scar has a tendency to render the uterine wall more soft,
easy of distention and hence more liable to rupture at that point.
This latter is further verified by Palmer Findley in his recent ar-
ticle on the subject. He found that in eighteen out of twenty rup-
tured uteri, the placenta was attached to the scar area.

It is interesting to note that the great majority of the ruptures
occurred during the pregnancy following the section and the sooner
the pregnancy occurred after the operation the greater the liability
to rupture.

It would seem also, from a review of the literature, that the rup-
ture takes place in the vast majority of cases ifi the scar and not in the
musculature near it. An exception to this is noted in the cases of
Davis reported by Harrar, who says that microscopic examination
showed the rupture to have taken place in apparently healthy muscle
tissue, but between two old section scars.

It has occurred to the writer that, in the cases where chromic cat-
gut is used, a faulty scar may result even where no infection existed,
because of the destruction of more or less muscular tissue by the for-
mation, around the sutures, of small canals containing a serosan-
guinous fluid, such as is sometimes observed in the abdominal wall.
It is very probable that the intermittent contraction of the uterus,
during the first thirty-six hours postpartum, also tends to interfere
with a proper healing of the incision. Especially would this seem to
be true when we consider the irregular course of the muscle fibers in
the uterus. Healing may also be more or less retarded because of
the impoverished condition of the blood consequent upon severe
hemorrhages. My own case was as follows:

March iq, 1914, Mrs. K; aged twenty-seven; primipara; justo-
minor pelvis; membranes had ruptured before entering the hospital.

Thirty-six hours after admission convulsions developed. Patient
was promptly anesthetized and delivered by abdominal Cesarean
section. The convulsive seizures recurred postpartum and vene-
section was twice resorted to, 1400 c.c. being removed the first time,
and 1200 c.c. seven hours later.

The third day after labor she developed a temperature; this con-
tinued for almost two weeks, fluctuating between 100.2° and 103. 8°F.,
but, eventually, she made a good recovery.

On October 16, 1915, when within about ihree weeks of term with
her second pregnane}', she was seized suddenly with severe pain in
the abdomen about 12 noon. Rest in bed and some household reme-

OF OBSTETRICIANS AND GYNECOLOGISTS 953

dies administered for the pain, did not improve her condition, and I
was called at i -.^o p. m.

Upon my arrival at the house her condition was one of shock, ap-
parently due to internal hemorrhage, although her pulse was still of
fairly good quality. The ambulance was ordered. I went to the
hospital to prepare for operation. WTien the ambulance arrived at
the patient's house, she had improved so much that the husband
would not allow her to be taken to the hospital. Here valuable
time was lost. It was 4 p. m. before the operation was performed.

On opening the abdomen, the placenta and dead child were found
among the intestines and promptly removed. A few dark clots, but
very little fresh blood, was found. The uterus had ruptured through
the Cesarean uterine scar and contracted firmly so that there was,
practically, no bleeding.

Supravaginal hysterectomy was performed, and we looked for a
prompt recovery; but the patient did not rally well from the opera-
tion and died at 9:15 that night.

On subsecjuent e.xamination of the uterus, I was surprised at the
thickness of the uterine wall where the rupture had occurred. This
is, I think, explained by the microscopic and macroscopic findings in
Cocq's case to which reference has been made to. As the placenta
was lying completely in the abdominal cavity, I am inclined to be-
lieve it had been attached to the scar area.

From the foregoing evidence, it would seem that, if any improve-
ment in our method of closing the uterus is to be made, it should be
in the more careful closure of the uterine incision. We should al-
ways endeavor to secure a perfect approximation of the uterine mus-
culature without including the mucosa. It has long been under-
stood that care must be exercised in closing the uterine incision, the
mucosa should never be included in the sutures because, in a subse-
quent pregnancy, islands of the mucosa may be transformed into
decidual tissue and thus weaken the uterine wall. This we consider
an excellent point.

The ten-day chromic catgut, number 3 is, we think, the best mate-
rial and size for the deep sutures. Plain catgut may absorb more
readily and cause less weakening of the walls through formation of
canaliculi.

CONCLUSIONS.

1. A Cesareanized woman is always in danger of rupture of
the uterus in subsequent pregnancies and should, therefore, be
under careful observation during the latter months of the period of
gestation.

2. If the puerperium following the first Cesarean section was
afebrile, the patient may be permitted to go to term with the next
child provided she can spend the last month of gestation in the hos-
pital; if not, labor should be anticipiated at least two weeks prior to
term.

3. Implantation of the placenta over the scar area, undoubtedly,
increases the danger of rupture of the uterus in a subsequent preg-

954 TRANSACTIONS OF THE AMERICAN ASSOCIATION

nancy; the same may be said of a febrile puerperium following
hysterotomy.

In closing, I wish to acknowledge the valuable assistance given me
by Dr. C. V. Weller in reviewing the literature.

1 149 David Whitney Building.

RUPTURE OF THE CESAREAN SCAR.*

BY
A. J. RONGY, M. D., F. A. C. S.

New York.

The introduction of asepsis and antisepsis in the practice of sur-
gery and the application of these principles to obstetric surgery
created a new problem for the obstetrician.

The abdominal method of delivery, once a rare and most feared
operation, was very soon applied not only in cases in which absolute
contraction of the pelvis existed when the delivery of a viable child
was impossible, but also in cases of relative disproportion of fetal
head to the pelvis.

Of late Cesarean section is being adopted as the safest method of
delivery for the mother in some forms of placenta previa and eclamp-
sia. The operation, which originally was almost always performed
in the interest of the child, is now extended to many cases where it
is thought the interest of the mother is best conserved.

This broader application of the operation created a new problem
in obstetrics, " the care of the Cesareanized woman during subsequent
pregnancies." Every obstetrician is confronted with this problem.
He must definitely decide as to the proper procedure in such cases.
A thorough perusal of the literature discloses the fact that very little
thought has been given to this most interesting condition, and that
the subject has been hardly investigated. We, therefore, lack the
necessary experience upon which to base our opinions and conclu-
sions. The delivery of a child by the abdominal route is now esti-
mated to take place in about one out of two hundred pregnancies.
If this is true, we can readily realize the magnitude of this question
and how important this discussion is. This problem must not only
be approached from its surgical aspect, but also from the standpoint
of the patient.

In metropolitan districts the interest of these patients is, to a

certain extent, safeguarded by virtue of the fact that competent help

is within very easy reach; however, very many of these women are so

situated that proper surgical aid cannot promptly be rendered

* Read before the Twenty-ninth Annual Meeting of the .\merican Association
of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

OF OBSTETRICIANS AND GYNECOLOGISTS 955

should a complication arise during pregnancy or labor. How shall
we conserve the interest of such patients?

Shall we, when advising a patient to undergo a Cesarean section,
discuss the immediate results of the operation only? Or are we to
enter into the question of subsequent pregnancies and their manage-
ment? I believe the patient has the inherent right to be made ac-
quainted with all the facts, present and future, connected with this
operation.

What shall be the attitude of the obstetrician? Shall he treat
the case in accordance with present indications and entirely eliminate
the question of subsequent pregnancies from consideration, or shall
he put forth the dictum "once a Cesarean, always a Cesarean?"
It is this thought in my mind that prompted me to bring this ques-
tion to your attention. I earnestly hope that your discussion will
help to settle this difficult and most recent obstetrical problem.

As far back as 1886 Krukenberg saw fit to undertake an exhaus-
tive study of rupture of the Cesarean scar. He collected twenty
cases from the literature wliich showed a mortaUty of 50 per cent.
He believed two factors to be responsible for the rupture of the
scar: First, the natural weakness of the cicatrix in the uterus.
Second, invasion of the musculature of the uterus by foci of decid-
ual cells. He beUeved that if silk were used in suturing the uterine
wound, rupture would seldom, if ever, occur. This contention was
soon disproved for, in the cases of Wager and Everke, rupture oc-
curred notwithstanding the silk sutures.

Recently N. R. Mason and J. I. Williams investigated the strength
of the Cesarean scar by animal experimentation in guinea-pigs and
cats. They tested the comparative strength of the muscle and
scar of the uterus by applying weights to a section of the uterine wall
containing the scar. They found that in each instance the muscle
gave way first. In one case only had the rupture e.xtended into and
along the scar. In another it passed through the scar at right angle
to it. Two animals were again pregnant and near term when the
tests were made with the same results. They thus ruled out any
change in the strength of the scar during pregnancy and concluded
that a firmly united scar is even stronger than the uterine muscle.

Harrar cites forty-two cases in which repeated section was per-
formed, and the previous scar was either not discernible or was solid
with no apparent thinning or stretching. He further states that in
sixteen out of forty-two cases there were adhesions of the omen-
tum either to the uterus or to the anterior abdominal wall. He

956 TRANSACTIONS OF THE AMERICAN ASSOCIATION

maintains that these adhesions did not seem to affect the uterine
cicatrix.

Personal experience, based on observation of the uterine scar dur-
ing the performance of repeated section, compels me to differ from
the above conclusions. It is hardly possible to maintain that a
scar in any part of the body, even if its healing processes were nor-
mal, possesses the same strength and vitality as normal tissue.
Healing by first intention has its definite inflammatory reaction and,
therefore, no scar can possess the same anatomical and physiological
characteristics as normal uninjured tissue. Its nutritive powers
must be lessened. It is subject to many local disturbances. Its
natural life is shorter, as is evidenced by the thinning out of many
cicatrices in the abdominal wall of wounds that healed by first inten-
tion. The healing process of a uterine wound is unlike that of any
other surgical wound in the body. There are many factors which
interfere with perfect union; the intermittent contraction of the
uterus, and the retained secretion in the uterine cavity tend to dis-
turb the union of the wound. During a subsequent pregnancy the
normal growth of the uterus, the waves of contractions which con-
stantly take place during the latter months of pregnancy, and the
not infrequent implantation of the placenta, wholly or partly, in
the scar area and the trophic changes of the uterus, all cause altera-
tion in the scar tissue, thereby lessening its resistance to any undue
strain either during pregnancy or labor. Assuming that the ex-
periments of Mason and Williams are clinically true of all the cica-
trices which result from primary union, I scarcely beheve that the
authors would maintain that cicatrices, the healing process of which
is disturbed by infection, possess the same strength. Clinically,
there are evidences of infection in and about the uterine scar in at
least one-third of patients who are operated for repeated section.
This fact is very plainly demonstrated by the signs of degeneration
in the scar structure and omental adhesions in and about the cica-
trix observed during subsequent operation. Unfortunately, we
have no means at our disposal by which we are able to diagnosticate
the actual changes which take place in the uterine wound. The in-
fection is very often so insidious and mild that it causes very little,
if any, constitutional disturbances. Nevertheless, the local changes in
the wound do interfere with the normal regenerative processes.

The laws governing the formation of the Cesarean scar differ in
all their essentials from all other scar formation; therefore, in order
to safeguard the interest of the woman who has had a Cesarean sec-
tion performed, we must definitely decide what method of treatment

OF OBSTETRICIANS AND GYNECOLOGISTS 957

shall be pursued in the event of subsequent pregnancy. The con-
clusions of early writers like Lucas Championniere, Sanger, and Leo-
pold, that the strength of the scar depends entirely upon the degree
of asepsis and antisepsis practiced, on the use of proper suturing
material, and the careful approximation of the united ends cannot,
in the light of our present knowledge, be accepted as the only causes
for spar weakness and subsequent rupture. Recently cases of
rupture were reported from some of the best and most modern clinics,
both here and abroad. The technic followed is practically the same
in all cases, yet rupture will very often occur before labor actually
sets in.

Louis Singer (Paris, Thesis, igo8-oq, No. 449) undertook to in-
vestigate the frequency of rupture of the Cesarean scar. He made
an exhaustive study of the literature and also communicated with
the surgeons in charge of the cases. His report is based on 155
published and 98 unpublished cases, or 253 women who had 290
gestations and were delivered by section. In this series rupture
of the scar occurred in twenty-one cases. He states that this
unusually large per cent, of rupture was due to the improper
technic of the earlier operators. He, therefore, continued his in-
vestigations to more recent times and collected ninety-eight cases
who had 113 gestations, and who were delivered by Cesarean section
with no subsequent disturbance of the scar.

Judging from various reports, most authors agree that rupture of
the scar occurs in about 3 per cent, of cases, and that the mor-
tality in such cases is over 50 per cent., no matter how promptly
treatment is instituted. Therefore, nearly 2 per cent, of women
who have had a Cesarean section performed, ultimately perish as a
result of the operation.

This accident is entirely dismissed from consideration in the va-
rious mortality records of the Cesarean operation. In order to have
such records complete, the indirect mortality, such as is caused by
secondary rupture and the rarer complication of bowel obstruction,
must also be included.

We all realize that the primary mortality from Cesarean section is
still high, that the mortality would be greatly reduced if it were
possible to operate on all cases before exhaustion and infection have
already set in. It is the lack of diagnostic ability that increases the
mortality in all surgical operations; particularly is this true in
obstetrics. Elective surgery now has a very small mortality.
There is no reason why we should not educate ourselves, as well as
the profession at large, whereby a proper diagnosis can be made early

958 TRANSACTIONS OF THE AMERICAN ASSOCIATION

enough to make the surgical procedure one of election, and not of
emergency, as is unfortunately the case in the greatest per cent, of
cases. The mortality of elective Cesarean section is at present only
about 3 per cent. Rupture of the Cesarean scar occurs, at least, in
about 3 per cent, of cases. Theoretically, it would appear that
it should be logical to conclude that the dictum, "Once a Cesarean,
always a Cesarean," is correct and should be accepted as the stand-
ard of practice. The patient who once has an abdominal section is
more careful about her condition and, owing to her previous experi-
ence, she usually places herself in the care of a competent surgeon.
She is watched carefully. She does not question the advice given
to her as to the management of her condition. In that way she
gains all the benefits which modern obstetrics offers, so that the
mortality in repeated elective Cesarean section is practically re-
duced to a minimum.

I believe that in the very near future it will be proven that the
mortality of cases of repeated Cesarean section will hardly compare
with the mortality of cases of primary Cesarean section. However,
at present these cases are still too few to permit of final deductions.

No matter how correct our decision may be from a theoretical
consideration of the subject, or how sound our advice may be from
a purely statistical analysis of the condition confronting us, we can-
not always carry it out in actual practice. Various circumstances
arise which compel us to modify our opinions. Very often we are
in doubt as to the proper procedure in a given case. This is par-
ticularly true in cases in which labor appears to progress favorably
and is expected to be of short duration. To this group of cases be-
long all patients who have had Cesarean section performed for con-
ditions other than mechanical obstruction due to disproportion be-
tween the fetal head and pelvis, as cases of placenta previa, eclamp-
sia and those who have had hysterotomy performed for tumors or
adherent placenta. This class of patients reject any suggestion on
the part of the obstetrician for any abdominal operation. They
think their present labor different and one which to their minds
apparently presents no comphcation. They, unlike the patients
who have had dystocia, due to disproportion between the fetal
head and pelvis, have experienced no pain during the birth of the
previous child and are, therefore, not convinced of the necessity of
interference. They as well as the other members of the family have
a decided preference for allowing labor to take its natural course.
Such patients really tax the ingenuity and the resources of the ob-
stetrician. He is thus compelled in practice to deliver a number of

OF OBSTETRICIANS AND GYNECOLOGISTS 959

Cesareanized women by conservative methods not infrequently with
disastrous results to both mother and child.

A certain amount of study and investigation has been accorded
to rupture of the Cesarean scar during labor and we, therefore, have
been taught to watch these patients while labor is progressing.
The scar should be carefully watched for any thinning by often
repeated abdominal palpation. These patients should not be
permitted to pass through a stormy and prolonged labor. In-
terference should be instituted as soon as any signs or symptoms
of impending rupture manifest themselves.

Spontaneous rupture of the scar during pregnancy, especially
during the last two months, occurs more frequently than is generally
supposed and, therefore, a woman who has been delivered by Cesa-
rean section should be under strict observation during the latter half
of the pregnancy. At times, thinning of the scar may be detected
early, so that a proper measures to prevent rupture may be applied.

My experience consists of two cases of spontaneous rupture of the
uterine scar during pregnancy, and one of threatened rupture during
labor.

Case I. — F. L", patient of Dr. S. J. Scadron, aged twenty-two,
para-ii. First child dehvered by Cesarean section in one of our large
hospitals. Postpartum period normal, remained in hospital eight-
een days. Pregnant again January ii, 1913. Was due September
20. Was carefully watched by Dr. Scadron. She was told that
induction of labor might be considered about the thirty-sixth week.
On July 24 the doctor was summoned to see her. On arrival he
found the patient in shock. He made a tentative diagnosis of in-
ternal concealed hemorrhage and sent her to the Jewish Maternity
Hospital. On admission, it became evident that the fetus was in
the free abdominal cavity. She was immediately prepared for
operation. On opening the abdomen the fetus was found to have
escaped from the uterus through the old scar which gave way en-
tirely. The placenta was in the opening, partly in the uterus, and
partly in the abdomen. The patient was in severe shock. Sutur-
ing of the rupture was substituted for the more radical operation of
hysterectomy. The patient died on the fourth day from septic
peritonitis.

Case II. — Mrs. R. W., aged twenty-eight, para-ii. First baby
delivered by Cesarean section performed by Dr. Scadron two years
ago. Became pregnant again one year later. July 11, 1916, about
3 A.M., the doctor was summoned to see her, because she did not
feel well. On examination the abdomen was found to be distended,
very tender and sensitive. The patient presented all the symptoms
of shock. The diagnosis of rupture of the uterus was made by Dr.
Scadron, who asked me to see the patient with him. The diagnosis
was unquestionably correct, and she was taken to the Lebanon

960

TRANSACTIONS OF THE AMERICAN ASSOCIATION

Hospital for immediate operation. On opening the abdomen the
placenta was presenting through the opening of the ruptured scar.
The placenta and dead fetus were delivered through the opening and
the uterus amputated at the internal os. The patient rallied and
made an uneventful recovery. She was discharged at the end of
sixteen days.

Case III. — A. S., para-iii. First labor instrumental; baby still-
born. Two year later she was delivered by Cesarean section by a
well-known obstetrician. Sept. 12, 1913, she was admitted to the
Jewish Maternity Hospital in labor. On examination the cerxTX

Fig I. — Rupture of uterine scar.

was found dilated admitting two fingers, patient having strong pains
every six to seven minutes. Membranes intact; abdominal palpa-
tion disclosed a deep notch in the anterior surface of the uterus
corresponding to the line of the Cesarean scar. The findings were
telephoned to me. I ordered immediate prep^aration for operation.
My associate, Dr. S. J. Scadron, who arrived at the hospital first,
fearing that rupture of the uterus was imminent, put the i)atienl
under light anesthesia during the preparation of the operating room.
On opening the abdomen the uterine scar was found thinned out as
if ready to rupture. The entire scar consisted of the {)eritoneal
covering of the uterus and some strands of tissue underneath it.
The uterus was incised through the old scar, which was resected
completely. The wound was closed in the usual manner. Patient
was discharged from the hospital on seventeenth da\".

OF OBSTETRICIANS AND GYNECOLOGISTS 961

CONCLUSIONS.

1. Spontaneous rupture of the Cesarean scar occurs in about 3
per cent, of cases. In most instances rupture takes place during
labor. It does take place not infrequently during the latter half
of pregnancy, especially in the last six weeks.

2. We have no means by which we can judge the strength of the
scar. Rupture will occur in cases which run an afebrile course and
in which union of the wound is apparently by first intention.

3. One-third of all patients who undergo subsequent Cesarean
section show evidence of inflammatory reaction in and about the
uterine wound. The result in such cases is a weakened scar.

4. Proper suturing of the uterine wound and exact approximation
of the edges will not always prevent subsequent rupture of the
scar.

5. The mortality rate of repeated section is smaller than that
of primary Cesarean section, because these patients are more
carefully watched.

6. A patient who has once had a Cesarean section should not be
allowed to go through a tedious or severe labor. If labor does not
progress rapidly. Cesarean section should be performed.

7. WTien advising a patient to have a Cesarean section, the
management of subsequent pregnancies should be taken into
consideration and discussed with one of the members of the family.

8. As a general rule, it may be stated that fully 75 per cent, of
women who have had a Cesarean section are delivered by repeated
section during their subsequent labors.

9. The obstetrician should always bear in mind that Cesarean
section creates a new problem for the woman, and therefore he
should carefully weigh the indications before he decides upon the
abdominal route. He should remember that the dictum, "Once a
Cesarean, always a Cesarean," holds true in fully 75 per cent, of
cases.

Finally, it is my firm belief that Cesarean section is very fre-
quently resorted to in cases which should be deUvered by other
methods. Abdominal section is a major obstetrical operation.
Surgeons and gynecologists, who have no obstetrical knowledge,
are not competent to make a proper diagnosis and should not perform
it. Obstetrics, in order to gain the respect of both the community
and the medical profession, should be practised only by those who
have had a proper training. The interest of the pregnant woman
will then be properlj' safeguarded.

62 West Eighty-ninth Street.

962 TRANSACTIONS OF THE AMERICAN ASSOCIATION

DISCUSSION OF PAPERS BY DRS. BELL AND RONGY.

Dr. Palmer Findley, Omaha. — We have had two very interesting
and instructive papers on a subject which has interested me very-
much of late. My interest in the subject was awakened by a case
which I saw in the Charite Hospital of Berlin shortly before the war
began.

A woman, twenty-three years of age, who had been Cesareanized
eighteen months before for a contracted pelvis was pregnant in the
seventh month of gestation and was losing a moderate amount of
blood from a marginal placenta previa. She bore a wide abdominal
scar which suggested probable infection following the Cesarean sec-
tion. Prof. Franz, in charge of the clinic, directed that a bag should
be inserted into the cervix and after dilatation of the cervix by the
bag, that the head of the child should be perforated and the child
extracted. The bag was inserted, pituitrin was administered and
with the second pain the patient went into collapse. The abdomen
was opened within twenty minutes and the uterus removed. There
was found a complete rupture of the uterus and a dead fetus within
the free peritoneal cavity. The patient died in collapse two hours
later.

The following day Prof. Franz commented upon the case in his
clinic and said, that henceforth he would always make his incisions
high in the body of the uterus where the musculature is best de-
veloped and he would advise a Cesarean section on every pregnant
woman who bore a Cesarean scar. Not long after this experience in
Berlin, I had observations in three cases in Glasgow which called
for a similar expression from Prof. Jardine and Prof. Cameron.

I found much the same sentiment in England and in the United
States and I was inclined to adopt the slogan — "Once a Cesarean,
always a Cesarean." However, a careful review of the literature
has convinced me of the unreasonableness of such a conclusion.

I fail to agree with Dr. Rongy in his conclusions. I do not
think any 3 per cent, should lead us to adopt a general course of
action. I would rather be guided by the other 97 per cent. If
as Dr. Rongy says, only 3 per cent, rupture in subsequent
pregnancies would it not be more rational to persue the poHcy
of watchful wating; to place all such cases in the hospital and
allow them to deliver themselves if this can be done without serious
embarrassment. If, on the other hand, there is a history of the
patient having run a fever course after her previous section, or if
there exists an evident cause for prolonged and difficult labor, such
as a contracted pelvis, a malposition of the fetus or delayed labor
from any cause whatsoever, then proceed with Cesarean section.

I would not favor high forceps, version, pituitrin or hydrostatic
bags in the presence of a Cesarean scar. The uterine scar is always
an unknown factor and as such we must avoid undue strain upon it.
I would therefore conclude that once a Cesarean section always a
hospital case in event of a subsequent labor.

Dr. J. Henry Carstens, Detroit, jSIichigan.- — As I see it, this
question is a rather difficult one to solve, and I agree in the main

OF OBSTETRICIANS AND GYNECOLOGISTS 963

with what Dr. Findley has said. I do not know how many cases
I have had, but I should say fifteen where I have performed Cesarean
section a second time, and in one or two instances I have performed
it a third and more times on the same patients. I have asked
practitioners to see whether they could find the scar of the previous
operation in the uterus, and not a single one has been able to do so.
Not one was able to find where the scar was, so that there was good
union throughout. In all these cases, however, there was a pelvic
deformity. Whenever these women have a pelvic deformity they
all require a second Cesarean section. There was not one of these
women that required a second operation who was operated for a
placenta previa or eclampsia.

I make it a point to have these patients go to the hospital early,
and, if possible, I operate on them two weeks before the expected
time of labor. Sometimes they would neglect going to the hospital
as requested, and I would see them after they had been in labor ten
or twelve hours. I consider I have been very lucky in not having a
rupture of the uterus in any of them.

There is a great deal in the way in which we sew up the wound.
Some practitioners have a rather slip-shod way of doing this.
In sewing up the uterine wound I am ver}^ particular not to include
in my ligature any of the mucous membrane. I take plain ordinary
catgut, not chromicized or anything else, that will be absorbed
quickly, and I take a big bite through the uterine muscle up to the
mucous membrane, and then on the other side just above the
mucous membrane, making a running suture and bringing it together
not too tightly.

I think a great deal of trouble which arises in these cases is due to
the sutures being tied too tightly and hence they strangulate the
tissues. It is these minor points that make the difference between
success and nonsuccess in these cases. By running the suture right
up it stops all hemorrhage and I am enabled to bring the muscular
walls together, and then I run back the other way, running the same
suture back to where I started and tie it. While I am doing the
latter I make a kind of secondary Lembert suture. I make it a
point to have the serous membrane lightly pressed in so that it comes
absolutely together.

I agree with Dr. Findley that these cases ought to be watched, at
least, even though they may not need an operation. I do not think
one needs to fear rupture of the uterus in many of these cases. How-
ever, to be on the safe side, it is better to watch them in case opera-
tion should be needed.

Again, these women should be told something about future
pregnancy. I regard this as an important point. A great many
women will say to us, "I do not want any more children; I want
one." But these women do not know whether that child is going
to Kve or not; they do not know but what it will die, and what then?
She may want a child in the future, and if you sterilize her in the
meantime so that she cannot become pregnant again she may worry
a good deal over it. If a woman has had one or two children, I

964 TRANSACTIONS OF THE AMERICAN ASSOCIATION

would not have any compunctions of conscience about sterilizing her,
but if she has no children, or has only one child, and that child may
die then I will not sterilize her for the reason that some twenty-five
years ago I operated on a woman on whom I did a Porro-Cesarean
section, which was the operation we did in those daj's, and she
told me she wanted it done. Six months or two years afterward,
when I met that woman, she cried and exclaimed, "Doctor, if I only
knew as much as I do now I would not have allowed you to remove
my uterus." So when I think of that poor woman, I hesitate twice
now before sterilizing a woman who has no children.

Dr. Henry Schwarz, St. Louis, Missouri. — I wish to endorse
every word that Dr. Findley has said. He expresses my standpoint
exactly.

I wish to relate briefly two cases I have delivered within the last
year through the natural passages. One was a woman on whom
Dr. Webster, of Chicago, had done a Cesarean section some years
before on account of obstruction to delivery by an ovarian tumor.

In the other case I did a Cesarean section three years ago. The
woman was brought into the hospital with a temperature of 104°;
she was very sapremic, with an offensive discharge from the uterus.
There was a dead fetus in the uterus, which was macerated. We
took it out. She was a young woman, and it was her first pregnancy.
After emptying the uterus and removing a subserous fibroid coming
out on the left side of the uterus close to the external os and plugging
the pelvis, and also after removing a smaller fibroid near the fundus,
I closed the uterus because the woman was young and had had no
children. I delivered this woman about seven months ago through
the natural passages. In both cases I used scopolamin and nar-
cophin during the first stage, and delivered the women just as soon
as the first stage was completed.

These cases show that it is possible to deliver these women safely
through the natural passages where these passages are not obstructed.

I have been very fortunate in not having many cases come to
Cesarean section as emergency cases. I think we have nearer
75 per cent, of elective cases than 3 per cent. The fact that there
is early rupture of the uterus during pregnancy in many cases induces
me in my service to recommend hysterectomy at the time of the
third Cesarean section. I think after a woman has gone through
three Cesarean sections we should at least recommend removal of
the uterus. Of course, if she objects, that is her business, but it is
this early rupture of the uterus during pregnancy which we cannot
control.

Dr. James E. D.«as, Detroit, Michigan. — These two papers
bring before us a most interesting phase of "preventive obstetrics."
I think the advantages of this prevention should be viewed from a
consideration of the pathology that prevails in these cases. Antici-
pating the pathology, it seems to me there should be added to what
has already been said a few further considerations. In the first
place, we should, in a general way, consider bad risks those women
who have a thin musculature, and also those who hav-e within the

OF OBSTETRICIANS AND GYNECOLOGISTS 965

uterus at the time of pregnancy a large quantity of amniotic fluid.
It has already been mentioned that care should be taken against the
introduction of a bag and the use of forceps. The problem, pre-
senting, from a pathological standpoint is this: first, we have a reduc-
tion of muscle tissue, of connective tissue, a degradation of the
normal tissue; then we have a degradation of the connective tissue
by the interposition within the connective-tissue cells of syncytial
cells. The connective tissue, while it may in certain instances be
as strong as the muscle tissue, yet it is not as resistant to the syncy ti-
olysins which are formed from the syncytial cells, and in the syncyt-
ial cells, we have a tissue of a very low resistance so far as its ability
to withstand pressure is concerned. That might be illustrated in
this way : we will consider the muscular wall. We have in the normal
muscular wall connective-tissue elements which in multiple preg-
nancies are increased, so that we see an increase of this connective
tissue everywhere in the muscular wall, but when we have only a
connective-tissue wall, we have a considerable thinning of that wall
which may have, and we will take it for granted, the same bursting
quality as the muscle wall, but when we have interposed in the
muscular wall syncytial cells which almost never occur singly but
in groups, then the resisting power of the connective-tissue wall is
markedly lowered. The syncytial cells may be shown diagrammatic-
ally interposed in this manner in the connective-tissue wall, and
wherever these cells are interposed there we have a point of very low
resistance so far as it relates to bursting pressure. Besides, we have
a constant throwing off of the syncytiolysins which have a digestive
effect upon the connective tissue.

Dr. Maurice I. Rosenthal, Fort Wayne, Indiana. — Durable
suture of the uterus postpartum is a difficult thing. While the
uterine wall is thick at first in a few days it is much thinner as a
result of beginning involution so that primary suture, as mentioned
by Dr. Carstens, will stop hemorrhage and that is about all we can
expect it to do. Suturing the peritoneal surface, however, I believe
is very important. In making suture of the belly wall if you will
bring the skin together and there is no blood interposed, the fatty
tissues will lie together and heal perfectly. Just so if you will bring
the surfaces together, the peritoneal surface carefully, and there is
no intrauterine pressure, the uterine wall will lie together very
nicely. If you suture this wall ever so carefully, in forty-eight hours,
more or less, the sutures are necessarily loose. I imagine they hang
there like hoops on a line, yet they are necessary to prevent hemor-
rhage and leakage for the first twenty-four hours. The important
thing after all is infection and that infection is predisposed by
intrauterine pressure. The complete cervical dilatation of normal
labor promotes a more free drainage of the uterus than frequently
obtains after Cesarean section.

Dr. Irving W. Potter, Buffalo, New York. — I would like to
report a case of rupture of the uterus that occurred in Buffalo because
it is the only one we have heard anything about. The patient was
a young woman, twenty-three years of age, upon whom I operated

966 TRANSACTIONS OF THE AMERICAN ASSOCIATION

two and one-half years ago for a contracted pelvis, delivering a
child 9 pounds in weight. It was a midwife's case, and she had
been in labor for a considerable time when I saw her, I took her to
the hospital and did a Cesarean section, she made a good recovery.
She subsequently became pregnant, and fell into the hands of a
practitioner who did not believe in operating and who said he could
deliver her without any trouble. She had a test of labor for forty-
eight hours. The scar in her abdomen indicated that a Cesarean
section had been done on a previous occasion, yet she was allowed
to go forty-eight hours as a test of labor, which was followed by
rupture of the uterus. A surgeon was called in and removed the
uterus. The child was dead.

I have operated on a number of cases a second time without any
trouble, and you cannot see the scar in the majoritj' of these cases
from the outside, but if you feel from below up you will find a
thinning in the majority of cases, although it is not enough to make
any special difference.

Dr. Hayd. — I would hke to ask Dr. BeU why he did not sew the
uterus together instead of taking it out?

Dr. Bell. — I must confess, I was afraid she might die. In order
to sew the uterus together I would have been obhged to freshen both
edges entirely because, as I tried to tell you in my paper, there was
a scar, and except for the fibromuscular bands across, I would
have been obliged to remove the surface of the whole scar. I thought
I could do the other operation more quickly.

. Dr. Rongy (closing). — With reference to the dictum, "Once
a Cesarean, always a Cesarean," I would like to say that I brought
this question up from an academic standpoint. We know what we
have to contend with in actual practice; we cannot always choose
our cases, neither do we always want to deliver these women by
Cesarean section. I think it is very essential for us to come to a
thorough and clear understanding of this question because the
general medical profession look to us for a final judgment on these
questions. It is very necessary for us to make ourselves clear as
to what should be done in certain cases and this largely was my
object in bringing up this question.

Dr. Carstens brought out a very important point with reference
to tying of the sutures in the uterine wound too tightly. When
these sutures are tied tightly there is always a reaction around the
wound and therefore infection is more likely to take place. Great
care must be exercised in suturing the uterine wound.

I never sterilize a woman unless she has had two children, and I
only do it at the request of the patient. I do not perform an hys-
terectomy but resect the tubes on either side. I feel that after
resecting and embedding the cut ends of the tube in the wall of the
uterus pregnancy will not ensue. It is unnecessary- to do an hys-
terectomy. I feel sure that our knowledge about the uterine scar
is very incomplete. It seems to me that no matter how perfectly
the wound united the uterus will not infrequently rupture. In
performing repeated section the old scar is very often not observed

OF OBSTETRiaANS AND GYNECOLOGISTS 967

for the reason that the uterus is in a different angle, it is somewhat
twisted so that the old scar is at the side of the uterus out of the Una
of vision and therefore not easily seen. In a great many cases
however, the old scar can be readilv seen.

POSTMORTEM CESAREAN SECTION.*

BY
O. G. PFAFF, M. D.,

Indianapolis, Ind,

There can be no doubt that in all parts of the world it occurs with
frequency that women pregnant, at or near full term, die from va-
rious disorders and are never delivered; the child perishing from its
imprisonment alone, in many instances. This is a deplorable
sacrifice to ignorance, indifference or sentimentalism, and it must be
admitted that these qualities are not the exclusive attributes of the
laity.

The indifferent and callous-minded may be stimulated to some
alertness when attention is called to the fact that the law does not
countenance that gross neglect which leads to the sacrifice of human
life. The unborn child has rights fully recognized in legal enact-
ments and any medical person finding the dead body of the mother
covering the unborn viable child and refuses to remove the obstacle,
which is suffocating the infant, is guilty of a crime for which he may
be justly punished. The consent of no human being is required;
time is short, and his duty is plain.

A considerable number of such cases have been reported in medi-
cal literature, and while most of the babies so delivered have not
permanently survived, some briUiant successes have been chronicled.
Without doubt this record may be greatly improved by the applica-
tion of intelligent foresight and alertness. The unborn fetus fre-
quently survives for a short time after the death of the mother.
This fact furnishes the indication for the necessity of immediate
action to save the life of a viable child in case of death at or near the
end of pregnancy. Runge states that, unfortunately, the rescue of
the child after the mother's death is not very common; the fetus
dying in many cases before the mother through pathological condi-
tions such as high fever, increased venosity of the maternal blood
through cardiac and pulmonary disease; or through a marked lower-
ing of blood-pressure, especially when the mother's death struggle is
prolonged.

*Read before the Twenty-ninth Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

968 TRANSACTIONS OF THE AMERICAN ASSOCIATION

More favorable cases again are observed when the mother has
died suddenly as from the result of accident or from rapidly fatal
poisoning. In general, conditions which obviate a long-continued
death struggle, undoubtedly, are more hopeful of saving the child's
life.

While the prognosis is, therefore, governed by the character of the
disease, and especially by the duration of the death struggle, it is
imperative in all cases that Cesarean section be performed instantly
upon the cessation of the mother's heart beats. It is inexcusable to
waste precious seconds of time in the effort to obtain the fetal heart
sounds.

No time should be given to the niceties of surgical technic.
The abdominal wall should be widely opened by one long free inci-
sion of the abdomen and another of the uterus. The child is
then immediately removed and efforts of resuscitation vigorously
instituted.

In Rubesca's clinic, Prague, Cesarean section after death has been
performed since 1896 in six cases, one of which resulted in saving the
life of the child. In this case it is notable that the mother had been
dead twenty minutes before the child was extracted.

Among 331 Cesarean sections in the last century on dead women,
only in six or seven was a living child obtained.

R. Dohrn compiled ninety cases, and Schwarz, in 1862, 107 cases
in which not a single living child was obtained, so that the latter
considered the operation unnecessary because of failure to save the
life of the child. How ill-founded is this pessimistic conclusion, may
well be shown by a consideration of more recent clinical reports.

I have compiled well-authenticated cases, with due references ap-
pended, from thirty-one operators; of these, fifty-two women were
delivered postmortem by Cesarean section. Several of the infants
which could not be saved were delivered with hearts still beating;
some breathed a few times; a few lived more than a day; but the
gross results were that of the fifty-two babies thirty were lost and
twenty-two or 42.3 per cent, were saved.

A remarkable case was reported by Dr. J. L. Cleveland. The
mother died of convulsions; owing to a number of circumstances,
Cesarean section was not performed until a full hour had elapsed
since the mother's death. The child was asphyxiated but heart
pulsations were perceptible to the hand. It soon gasped and was
fully restored. The length of time which passed between the death
of the mother and the removal of the child was much more consider-
able than is generally supposed to be the extreme limit of possible

OF OBSTETRICIANS AND GYNECOLOGISTS 969

hope for survival of the child. Cleveland believes that when viability
is limited to fifteen to thirty minutes after maternal death, the well-
known capacity of the fetus for resisting asphyxia is not taken fully
into account, and that it will be increased by the residual oxygen
within the placenta at the time of the mother's death. Two recent
cases occurring at St. Vincent's Hospital, Indianapolis, proved bril-
liantly successful and reflect unusual credit on two internes of that
institution.

Case I. — Reported by Dr. B. A. Hatfield. Patient, Mrs. R., seven
months pregnant. Nov. 17, 1915, she complained of earache and,
a few hours later, a discharge from the ear. Headache and meningeal
symptoms quickly followed. Drs. Neu and Kelley called Dr. Barnhill
thirty-six hours after the first symptoms. A laboratory examination
showed positive pneumococcic meningitis. Patient unconscious
at this time; rapid pulse; temperature 104° F. Patient was taken
immediately to hospital for mastoid drainage; but Dr. K. P. Ruddell
pronounced her in a dying condition and unfit for an anesthetic. She
died one hour later. It had been impossible to find radial pulse for
fifteen minutes before death and respirations were only about five
per minute before death. Patient died at 5 p. M. Nov. 19, 1915.
Five minutes after death an incision was made, about 33^^ inches
long, below umbilicus in the median line and a 5-pound boy of about
seven month's gestation was delivered in about three minutes, crying
lustily. Baby did nicely after feedings were adjusted and is now
healthy and doing as well as any normal baby of its age.

Case II. — Reported by Dr. Clarence N. Sonnenburg, Indianapolis,
Interne St. Vincent's Hospital. Mrs. R. S., aged twenty-seven,
white, female, housewife. Entered St. Vincent's Hospital in June,
1916, to await confinement, which was expected at any time. No
family history was obtained. Previous history: The patient had
complained of headaches for the past twenty years. But beside the
headaches and chronic constipation, she enjoyed good health. There
was no elevation of temperature. Two years ago she was operated
upon for suspension of the uterus and ruptured perineum in hopes of
relieving the headaches, but with no results. Her eyes were also ex-
amined and found normal. No history of lues.

Patient had two uneventful previous pregnancies; no miscarriages.
She had marked arteriosclerosis with a blood pressure varying during
her pregnancy from 180, s, to 210, s. The urine contained no albumen
nor casts. Two days before entering the hospital there was edema
of the lower extremities which persisted. There was evidence of
congestion of both lungs, endocarditis, myocarditis, and acute
dilatation. On the morning of May 20, she had a pulmonary
hemorrhage for which a hypodermic of morphine sulphate, gr. }yg,
was given. She then rested quietly and was removed to the hospital.
At 6 p. M. I was called to her room, but she died before my arrival.
Efiforts were made to resuscitate her while another nurse was sent
to the surgery to obtain instruments for a Cesarean section. So

970 TRANSACTIONS OF THE AMERICAN ASSOCIATION

much time had elapsed in the effort to restore her that I feared to
wait for the instruments and performed a Cesarean section isath a
pearl handled knife, 5.5 inches in length, with 2.5 inch blade.
The knife was new, sharp, and had not been used before. Without
removing the body from the bed I made an incision commencing
I inch above the umbiUcus and extending 6 inches downward
in the median line. There was no hemorrhage. The second inci-
sion was made into the uterus, sufficiently large to introduce my in-
dex-finger, which was used in place of a groove director to prevent
injury to the child. I removed the baby from the uterus and ligated
the umbilical cord.

The baby, a girl, was resuscitated in four minutes and has been
gaining in weight rapidly. It was fuU term, weighed seven and one-
half pounds, and normal in all respects. The baby is still living,
hearty and well.

Successful cases were reported by Hanch, one; Cathala, one; Des-
curres, one; Bonnaire, one; Leuppert, one; MogUck, one; Moetague,
one; Maygeierone; Cleveland, one; Weissnange, one; Koerner, one;
Wyder, one; Everke, one; Keinski, two; Rudens, two; Blau, one;
Loerssin, one; St. Vincent's Hospital, Indianapolis, two; Lying-in
Hospital, New York, two.

Failures were reported by Cathala, one; Bonnaire, one; Porak, one;
Boissard, one; Leuppert, two;Lippel, one; Remy, one; Vermden, one;
Koerner, two; Wyder, one; Everke, two; Keinski, one; Litschkiss, one;
Tyler, one; Howe, one; Kallmoegen, one; Hell, one; O.G.P., one;
Lying-in Hospital, New York, eight. Hence in fifty-two cases of
postmortem Cesarean sections the hfe of the child was saved twenty-
two times; lost, thirty times.

In conclusion I would express myself as in sympathy with the
suggestion that in certain cases of pregnant women, at or near
term, who are known to be hopelessly ill from rapidly progressing
disease. Cesarean section is justifiable to save the life of the child.
Of course if she be conscious the patient's consent must be obtained.
If this were the accepted rule, no doubt many lives could be saved
which are lost under the present plan of waiting for the mother to
breathe her last, and for the final heart-beat to give us the tardy
signal for action.

Newton Claypool Bvilding.

DISCUSSION.

Dr. Gordon K. Dickinson, Jersey City, New Jersey. — It seems
to me that the doctor has demonstrated this to be a rather new t\-pe
of operation. Postmortem hysterotomy has been done in our
town twice of late in the hospitals. The intern sat by the side of
the bed until almost the last moment, and then proceeded to deliver
both cases with a live child. Both were medical cases; they did
not occur in my service, so I do not know the details. Cases hke
this should appeal to the hospital young man and make him alive
to the circumstances.

OF OBSTKTRICIANS AND GYNECOLOGISTS 971

Dr. 0. H. Elbrecht, St. Louis, Mo. — This paper has interested
me very much. There are certain medicolegal questions that come
into play in these cases which we have to consider. In the cases
of Dr. Pfaff these questions would not come up because his cases
were brilliant successes, on the other hand, if you do a postmortem
without the consent of the family, you are liable by certain laws
in this or that State. In Austria there is an old law on the statute
books that makes it compulsory for the first doctor who sees the
corpse of a pregnant woman of six months or more gestation within
one hour of the time of death to do a postmortem hysterotomy.
Judging from the fact that this old law still exists it would seem tha,t
enough babies have been saved by the procedure to make it justi-
fiable. In our country the legal question must be considered, be-
cause if we perform a postmortem without consent of the family
and do not save the child we are rendering ourselves liable to a
lawsuit. If you have time to consult relatives about this you can
point out to them the possibiHties and by so doing you are not hable
in a case of nonsuccess.

I wish to congratulate Dr. Pfaff on the result in both cases.

Dr. Edward J. Ill, New Jersey. — Such cases as Dr. Pfaff has
reported are very interesting and instructive to us. It is always
proper to open a woman immediatelv after death and remove the
child.

I may say that the reason for the Austrian law compelling every
practitioner to do a Cesarean section on the dead woman is that
the baby may receive the blessing of baptism.

Dr. PF.A.FF (closing). — There is not very much I wish to add to
what I have already said, but the legal point is one I think we should
not overlook. I have looked it up lately and the sum and sub-
stance of it is hke this: this is a living child; it is a human being
that has rights moral as well as legal. I think it is well estabhshed
that a hving unborn child has legal rights. Here is a dead body
lying in such a relation as to threaten the life of this human being,
and I do not think any one of us would knowingly allow this dead
body to jeopardize the life of another individual. Recently I read
a decision of the kind which holds that a human life that is jeopard-
ized should have inteUigent treatment, and the doctor, the only
informed person present, is the one who should give that intelligent
treatment. We have no right to imperil the life of the Hving child
though unborn, and the doctor has no right to kill that child by his
gross neglect. He would be sustained by the law, should he interfere
even against the protest of the husband or others.

Dr. J. Henry Carstens, Detroit, Michigan.— I would like to
ask if there is any Jewish law in the Talmud that a woman like this
must be opened? I think there is such a law that has been handed
down to us from prehistoric times. However, I am not very well
posted on this phase of the subject.

Dr. Henry Schwarz, St. Louis. — Dr. Carstens refers to the lex
regia of Numa Pompilius, the second king of Rome. It is a good

972 TRANSACTIONS OF THE AMERICAN ASSOCIATION

old Roman law and will serve as a precedent in the United States
any time.

Dr. Pfaff (closing). — An attorney was recently asked to address
the New York Academy of Medicine on this subject and he brought
out very clearly and distinctly that the law would stand by us in
cases of forced intervention, but it would not stand by us if we
refused to interfere.

GUNSHOT WOUNDS OF THE ABDOMEN IN PREGNANT

WOMEN.*

BY
LEWIS H. SMEAD, M. D., F. A. C. S.,

Toledo. Ohio.

On October 21, 1915, Mrs. A. K., aged twenty-five, the mother
of one child, being pregnant at full term, was accidentally shot in
the back by her husband. The bullet entered about an inch below
the twelfth rib, on the right side, at the outer edge of the quadratus
lumborum and could be felt lying under the skin of the abdomen
about 2 inches above and 2 inches to the right of the umbilicus.
The patient, on admission, was rather poorly nourished, but the
heart and lungs were normal and the urine free from albumin. She
seemed to be in much pain, was greatly frightened, but not in severe
shock. P. 100, T. 99.4°, Res. 26 and entirely thoracic. The abdo-
men was tense and hard, very sensitive and slightly distended.
A small amount of blood was escaping from the wound in the back.
The child's heart was strong and nearly normal in rate.

The woman's condition demanded immediate exploration of the
abdomen. This was done within less than three hours after the
accident. The peritoneal cavity contained a large amount of free
blood and coagula. Amniotic fluid was found mixed with blood
free in the abdomen. A perforation could be felt on the posterior
wall of the uterus, somewhat to the right of the midline and about
3 inches below the fundus. A second perforation was present on
the anterior wall of the uterus a little nearer the midline than
the posterior wound, and about 2 inches below the fundus. The
course of the bullet between the two openings was about 5 inches.
It was found impossible to properly explore the abdomen for intes-
tinal perforations on account of the presence of the full-term uterus.
Cesarean section was, therefore, immediately done. The incision
in the uterus was immediately over the placenta, located anteriorly
and in the upper part of the uterus. The placenta had been per-
forated by the bullet. The child was delivered readily and began
to breathe immediately. It was uninjured except that the ring
finger on the left hand had been broken and lacerated by the bullet.
The uterus contracted normally. The uterine incision and the two
bullet wounds were closed with chromic catgut.

*Rcad before the Twenty-ninth .\nnual Meeting of the .\merican .Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1Q16.

OF OBSTETRICIANS AND GYNECOLOGISTS 973

The excess of blood was sponged out of the abdomen, and the
entire intestinal tract examined for perforations. It was found
that the bullet had entered between the folds of the mesentery of
the ascending colon and passed through the gut making two per-
forations. It had then gone through the uterus and into the abdom-
inal wall without injuring the small intestines or any other organs.

The escape of the small intestines was due to the fact that the
uterus, as is usual, lay more to the right side of the abdomen and
the small intestines to the left, and also to the fact that the bullet
passed through the right side of the uterus.

The perforations in the colon had leaked very little. They
were closed in the usual way. The posterior opening, which was in
a part of the gut not covered by peritoneum, was closed as well
as possible, and a drain passed down to it. There was no leakage
from the bowel after the operation. The abdomen was drained
by inserting three soft rubber tubes; one to the bottom of the culde-
sac, another to the outside of the ascending colon, where there had
been some soiUng, and a third at the point of perforation. The
mother left the operating-table with a pulse of loo and made an
uninterrupted recovery. There was some drainage of pus with a
colon bacillus odor, but no drainage from the intestine. The
highest pulse rate after the operation was 120. The highest tem-
perature 101° F. Patient was in the hospital thirty-five days and
left with the wound entirely healed. She was able to nurse her baby.
The child was a strong hearty infant and has developed nicely. The
broken, lacerated finger was pieced together and healed, per primam
intentionsuni, slightly deformed.

A gunshot wound in the abdomen of a pregnant woman differs
somewhat from one in the abdomen of a woman who is not pregnant.
The dangers of hemorrhage and of infection from a perforated intes-
tine exist in each; but the pregnant woman, on account of her condi-
tion, runs a greater risk. The danger of a bullet causing serious
hemorrhage in the abdomen is greater during pregnancy, and this
danger increases as gestation advances.

Infection in the abdomen of a woman is more serious during
pregnancy than at any other time. This fact is well borne out by
the high mortality from ruptured appendices among pregnant
women.

The management of a gunshot wound in the abdomen of a preg-
nant woman differs chiefly in the problems which arise from the
presence in the abdomen of the enlarged uterus or from the injuries
this organ may receive. The question at once arises whether
the uterus shall be emptied or not, and whether it shall be done
by Cesarean section, with or without hysterectomy.

It is a well-settled principle in civil practice, where conditions
permit that, when a bullet perforates an abdomen, an exploratory

974 TRANSACTIONS OF THE AMERICAN ASSOCIATION

laparotomy shall be done without delay. This rule applies with
even greater force in the case of pregnant women because there is
the added danger of injury to the enlarged uterus along with the
inherent risks which accompany the pregnant condition.

In this connection it is interesting to note that in not a few of the
cases reported in the Uterature, in which pregnant women were
shot through the abdomen, recovery took place without operation.
Moreover, in quite a number of the cases in which the abdomen was
opened, no intestinal perforations were found. In these cases the
pregnancy was usually well advanced, so that the intestines were
pushed up out of the lower abdomen. The wounds themselves
were, as a rule, well below the umbihcus.

In the care of perforating wounds of the abdomen in pregnant
women the question of emptying the uterus arises immediately.
All will depend upon the general condition of the patient, whether
the uterus is injured or not, and whether the pregnancy is in an
early one or near term.

It is worthy of note that, in the cases found in the Hterature,
in which the uterus was perforated or severely injured, the organ
promptly emptied itself in the majority of cases. If the pregnancy
is at term, even with the uterus uninjured, it is necessary to do a
Cesarean section because it is very difficult to properly explore an
abdomen if it contains a full term pregnancy. Moreover, as the
child is fully developed it is to its best interest that it be deUvered,
at once. Another reason why the uterus, at or near term, should be
emptied in the case of a buUet wound of the abdomen is, that if
a perforation of the intestine is present, peritonitis may develop,
the risk from which will be greatly increased if labor sets in within
two or three days after the operation and before the infection is
securely walled off.

In treating peritonitis we endeavor not only to keep the patient
quiet, but even prevent peristalsis so that adhesions may form and
localize the infection. It is easily apparent that a violently con-
tracting and finally collapsing uterus would be very likely to break
up adhesions and spread an infection which might otherwise become
localized. In the presence of an actually existing peritonitis, or in
an abdomen badly soiled with feces, one might not open an uninjured
uterus and expose its well known avenues of infection to contami-
nation unless it were done chiefly in the interests of the child.

In pregnant women with gunshot wounds of the abdomen the
gestation has not always advanced to a point when the child is
viable. The uterus, too, may not be large enough to greatly impede

or OBSTETRICIANS AND GYNECOLOGISTS 975

an exploration of the abdomen. In such cases the emptying of
the uterus will depend upon whether the organ has been seriously
damaged or not. If the uterus is uninjured or only superficially
wounded, it may be left alone. If, on the other hand, the uterus
is shot through, it will probably be safer for the mother if the ges-
tation is terminated at once. It is worthy of note that in the cases
reported in which the uterus was shot through, the child was usually
killed by the bullet and abortion followed quickly.

In an early pregnancy it will make less difference whether an
injured uterus is emptied or not because if it aborts it will cause less
commotion and be less likely to spread infection. Moreover in
such cases, if there is no injury to the intestines, one may be more
conservative with an injured uterus, because infection is less likely
to develop.

The method of emptying the uterus will depend upon the duration
of pregnancy. As the abdomen is already open Cesarean section
will naturally be used if the child has reached any considerable size.
In the earher stages the pregnant uterus, unless badly lacerated,
should be left to take care of itself or emptied through the cervix.
In certain cases, when the uterus is badly lacerated, or when for
some reason it is infected, hysterectomy will be necessary. Hyster-
ectomy in gunshot wounds of the uterus is rarely necessary. The
patients are considerably shocked by the hemorrhage and fright.
This shock will be augmented by the necessary inspection of all
the abdominal organs, including the entire intestinal tract. The
uterus is not necessarily infected and will take care of itself almost
as well as the other abdominal organs. The woman herself will be
more likely to combat the infection if her vitality is not lowered by
too much surgical intervention.

Drainage will, of course, be used in all gunshot wounds of the
abdomen in pregnant women. There will be considerable blood in
the abdomen which cannot be removed during the operation, and
this blood serves as a culture medium for infection which a dirty
bullet or a perforated intestine may furnish. Moreover, in the
rapid inspection of the intestinal tract, one cannot be certain that
he has not overlooked a perforation. Good drainage will remove the
blood more safely than it can be done by irrigation. Irrigation of
the abdomen in cases of gunshot wounds will rarely be necessary.
Occasionally, when there is extensive soiling of the peritoneal cavity
by feces, and when the case is early and the patient's condition
otherwise good, it may be considered.

976 TRANSACTIONS OF THE AMERICAN ASSOCIATION

Neugebauer(i) was the first to report the cases of gunshot wounds
of the pregnant uterus. He found twelve cases.

Estor and Puech(2) reported all kinds of perforating wounds of
the pregnant uterus and among them ten due to gunshot wounds.

Gel]horn(3) went over the literature and reported all cases up to
that date. The following represents a fairly complete list of all
cases to date.

Case I. — Mrs. J. M., in the seventh month of pregnancy, was
struck in the buttock by a bullet which passed upward and inward
into the uterus without injuring any other organ(4). Blood and
amniotic fluid escaped immediately from the cervix. Labor came
on almost at once and she was delivered promptly. Recovery was
uneventful without further interference.

Case II. — A Chinese woman, twenty-six years of age, in the
ninth month of pregnancy, received a bullet wound in the abdomen
three inches above and a little to the left of the umbilicus at about
the level of the fundus of the pregnant uterus(5). The pulse was
126 and weak. The respirations were 28 and the general condition
good. The abdomen was opened and much blood with clots re-
moved. The intestines were not perforated. A bleeding wound
one inch long was found on the anterior part of the fundus. The
placenta, lying under this wound, had been perforated. A living
child was delivered by Cesarean section and the abdomen was
drained. The mother died on the fourth day of hemorrhage,
it was thought.

Case III. — Mrs. W., aged twenty-eight, in the seventh month of
pregnancy, was struck in the abdomen by a bullet at a point 3
inches above and 2 inches inside of the right anterior superior
spine(6). There were no signs of hemorrhage, no distention and the
fetal heart could be heard. Twelve hours after the injury the abdo-
men was opened. Cesarean section delivered the child which had
been killed by the bullet. A hysterectomy was done, using the wire
ecraseur. Six perforations of the ileum were found and a large
mesenteric artery ligated. The abdomen was washed out with
boric acid solutions and a glass drainage tube was inserted Opera-
tion one and a half hours. Death occurred on the seventh day from
peritonitis.

Case IV. — A woman, nineteen years of age, in the eighth month
of pregnancy, received a thirty-two caliber bullet i}^ inches
below the ensiform cartilage and a little to the left. There
were signs of internal hemorrhage, with distentions and ab-
sence of liver dulness(7). Operation two hours after the injury
revealed much blood from a liver wound and also two perforations in
the stomach. The bleeding was checked, the perforations closed,
and the abdomen was irrigated and closed with drainage to the
liver wound. The uterus was not wounded, but the woman was
delivered normally on the second day. The recovery was unevent-
ful except for a little pus from the liver drainage.

- OF OBSTETRICIANS AND GYNECOLOGISTS 977

Case V.-Mrs. M., twenty-one years of age, and in^e sixth

right tube, ihere was n ^^^ intestines. The

wound was dosed. Ihere were no wuui _,„f:p„t aborted the

te™r«as wounded in the abdomen at a ^. -"f.^^J^'of ^'e
right anterior superior spine of the "eV,""*"'. J ^^ „ „,her
bullet was downward and forward Th"^J» JJe'^ of a dead

the uterus in a pregnant woman and killed the leius^ii;
"?ASE S -Twoman, pregnant at full term, was shot with a rifle

-slnis;dwran%r:;t"^?f?nS^s--

of'p^Sn.ncy.wa, struct ';,V„S' f ^ |1,t%'as no wo'unloi

:rTaKis'wfth'S:ut";;^htnei^ay ™^

passed through the child. Severe infection followed but the mother
•"Sxi ^'JtTor.reCrs pregnant, was shot in the abd^
men AmnioUc Suid knd blood e,caped(,4). ,She was dehverirf

Ek^d'^fl'Stto^^.^^^.etS----^^^^^^^^

tiQ hut recovered without operation. , ,

r^^v XII -A woman, five months pregnant, was wounded by a
V. npf to the riehTa^d below the un!bilicus(is). There were no
Sis symptoms Laparotomy in six hours revealed a wound of Ae

^z^ss^^:^:::^:^^^^:^"^^^^^ of .ood and

978 TRANSACTIONS OF THE AMERICAN ASSOCIATION

amniotic fluid in the abdomen. Five perforations of the ileum
necessitated resection. A large mesenteric artery was bleeding
and was ligated. The uterus was perforated and the umbilical
cord protruded. The piece of cord was resected and the stump
pushed back into the uterus and the uterine wounds sutured. The
abdomen was closed with drainage. The fetus was delivered
thirty hours later. The mother recovered.

Case XIV. — Reports that Billroth saved a mother's life in a
case similar to Albarrans(i7).

Case XV. — Cesarean section with fatal result(i8).

Case XVI. — A woman of eighteen years at term received a bullet
wound to the right and below the umbilicus(i9). There was little
shock and no external bleeding. Labor set in in one hour and
delivery was accomplished in twelve hours. Sharp postpartum
hemorrhage necessitated manual delivery of the placenta. The
hand in the uterus showed a hole in the anterior wall of this organ.
The buUet had kiUed the child. The mother recovered without
operation.

Case XVII. — A woman, aged thirty-four, in the eighth month of
pregnancy, was shot in the right lower abdomen(2o). There was
much pain and loss of blood and amniotic fluid. The child's move-
ments stopped at once and the fetal heart could not be heard. Labor
pains began very soon. Laparotomy showed a wound in the uterus
2 inches below the right tube, but no injury to the intestines.
A dead child was delivered by Cesarean section and the abdomen
drained. The mother recovered after a serious septic period.

Case XVIII. — A woman of twenty-nine, at full term, was shot in
the left side of the abdomen(2i). A quantity of yellow fluid escaped.
There was considerable peritoneal irritation. Laparotomy three
and a half hours after the accident showed a wound in the fundus
below the left tube. Cesarean section delivered a dead child.
The bullet wound was sutured and the abdomen closed without
drainage. No intestinal perforation was noted. The mother died
on the sixth day of peritonitis.

Case XIX. — Bullet wound of the uterus perforating the pelvis
and uterus(22).

Case XX. — A woman of nineteen years, in the seventh month of
pregnancy, was shot in the right side of the abdomen 2 inches
above the anterior superior spine of the iLium(23). There was
evidence of severe internal hemorrhage. Laparotomy showed the
uterus perforated, but no intestinal injury. Cesarean section deliv-
ered a living six and one-half months' fetus which soon died. Drain-
age was instituted and the mother recovered.

Case XXI. — ^A pregnant woman was torn open by a cannon ball
and a living child delivered (24).

Case XXII. — A woman, three months pregnant, was shot in the
abdomen receiving eight perforations of the intestine(25). Opera-
tion was done and the perforations closed. The woman recovered.

Case XXIII. — A woman of nineteen years, sLx and a half months
pregnant, was stabbed in the abdomen i}-^ inches below and

OF OBSTETRICIANS AND GYNECOLOGISTS 979

4 inches to the right of the umbilicus(26). The wound liealed
uninterruptedly. She was delivered at term of a living child with
intestines protruding through healed abdominal wound.

Case XXIV. — A woman of nineteen years, in the eighth month of
pregnancy, was wounded in the left abdomen midway between the
anterior superior spine and the umbilicus(27). There was a second
wound 4 inches above this. There were two wounds of exit.
Laparotomy showed much blood, but no intestinal injuries. The
fundus was perforated in two places. Cesarean section was done
and the abdomen closed. Both the mother and child recovered.
The child was injured only in the fingers.

Case XXV. — Woman of twenty-three years, seven months preg-
nant, was shot in the abdomen 2^^ inches below the ensiform
cartilage, and J-'2 inch to the right of the midline(28). Pulse
1 20, temperature 100°, respiration 28. Serous fluid and gas
were escaping from the wound. The abdomen was opened twenty-
four hours after the accident and the stomach and jejunum found
perforated. The abdomen contained pus, blood and stomach con-
tents. There were many adhesions. The uterus was not injured.
The abdomen was washed out and searched for further perforations.
The perforations were then closed and the abdomen drained. The
woman was delivered normally at full term.

Case XXVI. — Henrot reports that a mother while on her way
to the maternity hospital in Rheims had her abdomen torn open by
a shell and died immediately(29). The child was uninjured and had
only to be lifted out.

Case XXVII. — Penetrating gunshot wound of gravid uterus(2o).
(Case Report.)

Case XXVIII. — Mrs. F. F., an ItaUan woman, thirty-six years old,
in the fourth month of pregnancy, received a load from a shot gun
in the right lower quadrant of the abdomen(3i). She was admitted
in shock and with a distended abdomen. The wound was bleeding
freely. Temp. 98°, pulse 63. At operation forty smaU perforations
of the intestines were closed. The uterus showed a 4-inch lacera-
tion on its anterior wall, which was a tear, and not due to the shot.
The fetus was free in the abdominal cavity, and the placenta was
still in the uterus. The placenta was removed and the uterus
closed as in Cesarean section. The abdominal cavity was irri-
gated and closed with drainage. The mother made a good
recovery.

Case XXIX. — A girl of sixteen years, at full term, shot herself
in the abdomen(32). The bullet entered 7 inches to the right
of the umbilicus and made its exit an inch to the left of the umbilicus.
There was little shock, pulse 116, respiration 34. The umbilical
cord protruded from the wound of exit. On opening the abdomen
a full-term child was found free in the abdomen. It had been killed
by the bullet. A powder burned diagonal wound, 4 inches long,
was found in the uterus. The placenta, which was stiU in the uterus,
was removed, and the uterus closed after the wound had been

980 TRANSACTIONS OF THE AMERICAN ASSOCIATION

trimmed. The abdomen was irrigated and closed with drainage.
There was some infection, but the mother recovered.
242 Michigan Street.

BIBLIOGR.\PHY

1. Neugebauer, F., Miinchener med. Wochensckr., 1897, No. 19.

2. Estor and Puech. Revue de Gynecologic, vol. iii, No. 6, 1899.

3. Gellhorn, Geo. St. Louis Medical Review, 1901, xliv, 307.

4. Baughman, J. A. /. A. M. A., 1897, xx\'iii, 406.

5. Tucker, A. W. /. A. M. A., Iviii, 1685.

6. Prichard, A. W. Brit. Med. Jour., 1896, i, 332.

7. Wood, W. C. Brooklyn Med. Jour., 1902, xvi, 395.

8. Milner, C. A. Med. News, Phila., 1892, Ixi, 243.

9. Bradley, C. C. A". Am. Pract. Chi., 1890, ii, 568.

10. Staples, F. Med. Rec, N. Y., 1876, xi, 595.

11. Rousett (Cited.) Colombat de LTsere Diseases and Special
Hygiene of Females, 1848, p. 227.

12. Reichard, abstract. Gellhorn. St. Louis Med. Review,
1901, xliv, 307.

13. Hays. New Orleans Med. and Stirg. Jour., 1879, p. 510.

14. Applewhite and Pernot. Med. World, Oct., 1892.

15. Kehr, H. Centralbl. f. Chirurgie, 1893, No. 29, p. 636.

16. Albarran. Bull, et Memoires de la Societe de Chirurgie, 1895,

P- 243-

17. Pozzi. Soc. de Chir., March 17, 1895.

18. Hohl. Centralbl. J. Gynaek., 1898, No. 44, F, 1218.

19. Robinson, S. W. Lancet, 1897, Oct. 23.

20. Wrzesniowski and Neugebauer. Amer. Jour. Obst., xxxvi,
136.

21. Rubetz. Jour. f. Geb. and Frauenkrankh., April, 1898.

22. Nasilow, abst. Gellhorn. St. Louis Med. Review, 1901, xliv,

23. Nietert, H. L. St. Louis Med. Review, April 20, 1900.

24. Stalpart. Cited in Anomalies and Curiosities of Nature,
1900, p. 134.

25. Rebreyend and Barbarin. Amer. Jour. Obst., 1899, xxxix,

26. Steele, D. A. K. Surg., Gyn. and Obst., 1908, vi.

27. Fowler, R. S. New York State Jour, of Med., Nov., 1911.

28. H. M. Lee. Annals of Surgery, vol. xlviii, p. 857.

29. Hernot. /. A. M.A., vol. Ixv, p. 2019.

30. Holland, R. A. Maine Med. Ass. Jour., Portland, June, vol.
iv, No. II, 1914-

31. Lincoln, Davis. /. A. M. A., vol. Ixiii, 243.

32. Fudge, Herbery W. /. A. M. A., vol. Iviii, 779.

DISCUSSION.

Dr. John D. S. Davis, Birmingham, Alabama. — I do not Hke to
let this paper go by without some discussion, I desire to report a
case of gunshot injury in a woman pregnant three months and a
half. She was handling a small rifle when it accidently went off and
shot here through the abdomen, making twenty-one perforations,
two through the mesenteric border of the transverse colon, and

OF OBSTETRICIANS AND GYNECOLOGISTS 981

nineteen through the small intestine. She was brought by train
eighty-five miles, and I saw her twelve hours after the reception of
the injury. There were five perforations on the mesenteric border
of the intestine, two perforations on the mesenteric border of the
transverse colon. I turned back the serosa of transverse colon,
turned in the musculature, and then closed the serosa over this.
Instead of doing two resections, I took out 5 feet of the intestine
including the nineteen perforations in the gut, and she recovered,
and was delivered of a living child at the ninth month.

TEACHING OBSTETRICS UNDER IMPROVED
CONDITIONS.*

BY
HENRY SCHWARZ, M. D..

Several factors render conditions for teaching obstetrics, in the
reorganized Washington University Medical School, sufficiently
favorable to enable the Department of Obstetrics and Gynecology
to do reasonably good work alongside of the Departments of Medi-
cine, Surgery and Pediatrics, all of which have been placed on a
strict university basis.

The main reason for this desirable state of affairs is found in the
friendly attitude of the Corporation of the University and of the
Executive Faculty toward the Department of Obstetrics and
Gynecology; both of these bodies appreciate the desirability of
placing obstetrics likewise on a university basis, and they are de-
termined to bring this about as soon as circumstances will permit.

In the meantime, they have made very reasonable provisions for
this department by giving it reasonable laboratory space and by
furnishing it with dispensary and hospital facilities unsurpassed any-
where; they have taken further care of the department by an annual
budget, which provides effectively for laboratory and teaching
supplies and equipment; the budget also provides salaries for one
laboratory technician, one laboratory instructor, one resident phy-
sician, two assistant resident physicians, and a modest salary for the
chief of the department. The department's house staff consists of
one resident, two assistant residents, and three house officers; all
six are taken care of in splendid officers' quarters; they receive their
keep and laundry; but the house ofl5cers receive no salary.

•Read before the Twenty-ninth Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

982 TRANSACTIONS OF THE AMERICAN ASSOCIATION

Before the reorganization of the school, the department was under
considerable annual expense in maintaining its own museum and its
own library; this expense is now entirely done away with, because the
department of pathology takes care of all pathological specimens in
an excellently furnished museum where they are, at all times, available
for teaching or for investigation; in like manner, the splendid library
of the medical school, which already contains over 23,000 bound
volumes, and which receives 353 of the most important medical peri-
odicals, of whichever 300 are in complete series, makes it unnecessary
for the department to expend money for library purposes. Labora-
tory guides, text-books and other publications, which the depart-
ment desires for more or less continued use, are promptly supplied;
in fact, during the summer vacation when the library committee is
not in session, the heads of departments are empowered to order on
their own judgment such publications as they stand in urgent need
of to the amount of thirty dollars for each department. The school
workshop is another time and money saving institution; it has proven
especially helpful in keeping manikins and other teaching apparatus
in repair.

The temporary quarters, which the Department of Obstetrics and
Gynecology at present occupies, were placed at its disposal by the
Departments of Medicine, Surgery and Pathology; I take particular
pleasure in recording the fact that each of these departments gave
up some of its very best space, so that Obstetrics and Gynecology are
housed as comfortably as are Medicine and Surgery, and, were it
not for the fact that these latter departments will, before long, need
the space which they have given up temporarily, there would be no
urgent need for a women's clinic, which the university expects to
erect on the medical campus.

On this campus are located the North Laboratory Building and the
South Laboratory Building, housing the departments of Anatomy,
Biological Chemistry, Physiology, Pharmacology, E.xperimental Sur-
gery and Preventive Medicine; the Dispensary Building, housing
the Department of Pathology and Bacteriology on the two upper
floors; the clinical laboratories (pathological, bacteriological, physio-
logical and chemical) of the Department of Medicine on the second
floor, and the Washington University Dispensary on the first floor
and the basement; on the third floor are also the headquarters and
laboratories of the Department of Obstetrics and Gynecology; on
this campus are also located the Barnes Hospital, the Saint Louis
Children's Hospital and the Home for Nurses; two private residences
which were on the site before it became a medical campus, have been

OF OBSTETRICIANS AND GYNECOLOGISTS 983

arranged to serve as a temporary hospital for colored patients;
plans have been completed and specifications drawn for the erection of
a new pavilion for colored patients on a less conspicuous part of the
campus; when this is completed, these former residences will be torn
down, and the Women's Hospital erected on this site. All buildings
on the campus are connected by corridors and tunnels and a central
power plant furnishes light, heat, power, refrigeration and compressed
air to all of them.

IHE DISPENSARY SERVICE

The dispensary for women is conducted on the first floor of the
dispensary building daily from 2 to 4 P. m. in the splendidly equipped
dispensary rooms of the Department of Surgery, which uses these
rooms in the forenoon only. The hearty cooperation of the Depart-
ment of Nursing, and the Department of Social Service helps a great
■deal to render the dispensary service satisfactory to the patients and
to the dispensary staff.

The fact that the dispensary hours fall in the afternoon makes it
possible to detail one house officer and one assistant resident for
dispensary duty, thereby reducing the burden on the chief of clinic
and his assistants and compensating any irregularity in their attend-
ance. This part of the service, however, is so important to the
department and confers such benefits on the volunteer staff, that
irregularities in attendance are very exceptional, and there is always
a waiting list of competent men, who have grown up in the depart-
ment and who are anxious to fill vacancies.

In the dispensary gynecological and obstetrical patients are seg-
regated; the gynecological cases are treated or asked to enter the
Barnes Hospital, according to the nature of the cases; the obstetrical
■cases are encouraged to come to the dispensary early and at regular
periods. Besides the regular dispensary record, a special obstetrical
record is kept, which remains in the care of the house officer on obstet-
rical out-patient service. A prenatal nurse, who is a salaried social
service worker, and who is assisted by student-nurses, gives the
expectant mothers necessary instruction at the dispensary and at
their homes, visits them to ascertain their home conditions, and
follows them up in case they fail to return to the dispensary as
instructed.

Normal cases, whose home conditions are adequate, are delivered
at their homes, unless they prefer to come into the hospital and are
able to pay the ward fee ; all other cases are recommended for admis-
.sion to Barnes Hospital. When one of the cases registered for home

984 TRANSACTIONS OF THE AMERICAN ASSOCIATION

delivery goes into labor, a telephone call is transmitted to the house
physician on out-patient duty; he details one of four senior students,
who are on obstetrical service and who have comfortable quarters
above the Womens' Colored Ward, to the case, and accompanies him
or follows him as soon as possible; in daytime an obstetrical nurse
(a senior student nurse) is likewise furnished. In case of serious
complications a city ambulance is called and the parturient woman is
transferred to Barnes Hospital as a free patient.

Women who are delivered at their homes receive postnatal nurs-
ing care, are regularly visited by the attending senior student and a
house officer, and return to the dispensary for a final examination
and formal dismissal at which time their baby is entered at the clinic
for well babies conducted by the Department of Pediatrics; if they
fail to return to the dispensary for this purpose, they are followed up
by social service workers.

The work of the obstetrical out-patient service is controlled by an
instructor, who sees to it that proper records are kept and preserved,
and who drops in on the service at unexpected times to see that the
patients receive the proper attention and visiting.

THE HOSPITAL SERVICE.

The admission of patients to the obstetrical and gynecological
service of Barnes Hospital is the duty of the resident, or in his ab-
sence of one of the assistant residents, after the requirements of the
front office have been complied with.

Barnes Hospital is not a free hospital, but an ample number of
free beds are available in the following manner: Each of the three
services is entitled to one free patient for every four pay-patients, so
that if the obstetrical-gynecological service has twenty-four pay-
patients, that service is entitled to six free patients.

Additional free beds have been made available by the liberality
of Mr. Robert S. Brookings, the president of the University, who
personally pays for twenty free beds each day of the year. The free
beds are distributed as follows: Medicine eight. Surgery eight.
Obstetrics four. This is a fair distribution made at the suggestion of
obstetrics, because medicine and surgery have to take care of all the
specialties; yet obstetrics wanted a free-bed-budget of its own which
it can use to the following advantage:

The free beds allowed by Barnes Hospital, under the four to one
rule, are all used up from day to day, and it would often be impossible
to admit obstetrical patients on the free list when they come in as
emergencies or when they are wanted for bedside instruction, were

OF OBSTETRICIANS AND GYNECOLOGISTS 985

It not that by arrangement with Mr. Brookings the 1460 free hospital
days, provided by him for obstetrics, can be used up at the time when
most needed, that is, during the session of the medical school. By
using fewer than four Brookings beds per day during the early part
of the fiscal year, a larger number than four are available during the
school session.

AH hospital cases, except emergency cases, are carefully worked up
by the house-stafif before being seen by the visiting instructors. The
house-officers take histories, make physical examinations, do the
routine laboratory work in the ward laboratory, enter the findings of
instructors or of the chief on the record, have cases prepared for de-
livery or operation, assist in major operations and perform minor
operations under supervision.

Two instructors make regular ward rounds and supervise the work;
they are on alternating service; each serves six months on obstetrics
and six months on gynecology; they submit written suggestions as to
diagnosis and treatment in important cases, which are discussed in
conference; they do considerable emergency work and also major
operative work with the approval of the chief or his associate (Dr.
Crossen).

All material obtained by operation, including curetments and
trial excisions, is sent to the department's laboratory, where slides
are prepared and filed away for permanent record; for the purpose
of diagnosis in doubtful cases the Department of Pathology, which
is located on the same floor, is freely consulted; a pathological diag-
nosis is sent to the ward in all cases and entered on the patient's
record. Gross material, which is desired for permanent preservation,
is turned over to the Department of Pathology, which attends to the
proper preparation and cataloguing of museum specimens.

In case a patient dies, the consent for autopsy is usually obtained;
members of the house-staff are present at the autopsy and attend
the clinical and pathological conferences which the Department of
Pathology conducts once a week. All clinical records are looked
over at a staff conference before being sent to the record room for
filing.

The house-staff rotates in the various duties as follows: each house-
officer serves four months on the obstetrical house service; four
months on the obstetrical out-patient service and four months on
the gynecological house-service; the assistant residents alternate
every six months; while one works in the histo pathological labora-
tory of the department and in the dispensary, the other is on duty
in the pavilion for private patients, performing the same duties to

986 TItANSACTIONS OF THE AMERICAN ASSOCIATION

private patients as the house-officers perform to ward patients;
to this private pavilion service are admitted private patients of the
chief of the department and of his associates in the service (Drs.
Crossen, Gellhorn, Royston, Schlossstein, O. Schwarz and Taussig);
besides these duties the assistant residents act as alternates to the
resident, so as to have an admitting officer on duty at all times.

THE UNDERGRADUATE COURSE IN OBSTETRICS.

Since our students enter with two years credit in college work,
which must include chemistry, physics and biology, it has been
found feasible to simplify the course in the medical school and to
devote the first year and the first and second trimester of the second
year to anatomy, biological chemistry, physiology, pharmacology
and bacteriology.

The next period of two years, that is, from the beginning of the
third trimester of the second year to the end of the second trimester
of the fourth year, is devoted to the main clinical branches, namely,
Medicine, Surgery, Obstetrics and Pediatrics; the specialties are
given comparatively few hours and those mostly in the dispensary
service.

In this way the prescribed curriculum comes to a close at the end
of the second trimester of the fourth year, leaving the last trimester
or approximately eleven weeks for elective work; of this elective
work not less than 150 hours must be taken in one of the four main
clinical branches; the remaining 150 hours or more can be devoted
to the specialties.

In the allotment of hours the curriculum committee has tried to
keep well within the number recommended in the Model Medical
Curriculum prepared under the direction of the Council on Medical
Education of the American Medical Association in 1909.

In that curriculum 240 hours were recommended for Obstetrics
and Gynecology, exclusive of the time spent in attending labor
cases; I find these hours quite sufficient if the course can be prop-
erly spread out and balanced; our undergraduate course is divided
into a Junior Course and a Senior Course of 121 hours each, and each
course lasts exactly one year.

If at the end of these two years a student has failed to get a pass-
ing grade, he has the last trimester of the fourth year left for the
removal of conditions.

THE JUNIOR COURSE.

This course consists of seventy-seven hours of recitations, twenty-
two hours of laboratory work and twenty-two hours of exercises in

or OBSTETRICIANS AND GYNECOLOGISTS 987

diagnosis, besides considerable practical work in the dispensary
during vacation between the second and third year.

RECITATIONS.

These are limited to eleven hours during the third trimester of the
second year; they are delivered by the chief of the department and
an effort is made to interest the student in the subject of obstetrics,
to acquaint him with desirable text-books and to stimulate him to
do some work during vacation.

These recitations cover the anatomy and physiology of the female
organs of generation and the fertilization and implantation of the
ovum; they serve as an introduction to the recitations given in the
first and second trimester of the third year, when forty-four recita-
tions, two a week, deal with the physiology of pregnancy, labor and
the puerperium, during the first trimester, and with the pathology
of these conditions during the second trimester; while twenty-two
recitations deal with the essentials of gynecology; time is taken out
of the hours for recitations in the second half of the second trimester
for practicing forceps deliveries, versions and pelvic end extractions.

THE LABORATORY COURSE AND THE COURSE IN DIAGNOSIS.

For these courses the junior class is divided into three groups;
each group takes these practical courses in a different trimester.
Twenty-two hours are devoted to laboratory instruction in obstet-
rical and gynecological pathology; the remaining twenty- two hours
are devoted to exercises in obstetrical diagnosis; points in history
taking are discussed; the student is drilled in pelvimetry; in inspec-
tion, palpation and auscultation of the pregnant abdomen and in
pelvic examinations; he must be able to convey his findings to paper
and make a correct obstetrical diagnosis; he acts as witness in the
delivery rooms and studies puerperal involution and the changes
in the new-born in the wards. At the end of this course the student
is subjected to a practical examination, and he is not allowed to
take up the senior work until he has proven his qualification. Both
of these practical courses are given by the one instructor, who is
on a salary; he is assisted by members of the house-stafif.

THE SENIOR COURSE.

This course consists, first of all, in the attendance of cases of labor
under supervision; groups of four students live in the obstetrical
out-service quarters throughout the year; this service is especially

988 TRANSACTIONS OF THE AMERICAN ASSOCIATION

active during vacation, so as to provide students with the necessary
credits for practical work, without taking them away from other
schoolwork; each student is required to attend fifteen cases of labor
and to take care of the puerperal woman and her baby for two weeks
or longer; the number of required cases has been raised from ten
to fifteen, because the State of Pennsylvania requires that candi-
dates for admission to practice have delivered at least twelve women.
Our classes are still so small that many ambitious students deliver
thirty or forty cases and more; the time so spent is not included in
the 242 hours of the curriculum.

During the session the senior class is divided into three groups, of
which one group is on the medical service, another on the surgical
service and the remaining group is split into two sections which are
rotating between the obstetrical and the pediatrical service.

The obstetrical section, composed of one-sLxth of the senior class,
thus changes every five and one-half weeks; during that time the
group works on the hospital service from nine to twelve every day
of the week; this constitutes ninetj'-nine hours of schoolwork in the
curriculum. The students now act as clinical clerks; they are as-
signed cases and work them up under the guidance of the house-
staff; they participate in the ward rounds; assist in the operating
rooms and attend cases of labor; in fact, they participate in the en-
tire work of the hospital and are expected to look after their patients
after school hours and on Sunday just the same as their teachers must
do; they reside during these five and one-half weeks in the obstet-
rical out-service quarters; receive additional instruction on the mani-
kin and are given such a prolonged practical test and examination
that this part of the course may well be compared to the German
" Staatsexamen."

During the first and second trimester of the fourth year the entire
senior class meets the chief of the department once a week in the
clinical amphitheater from twelve to one o'clock; this hour is filled
by clinical lectures and demonstrations on obstetrical and gyne-
cological topics. These twenty-two hours bring the senior course
up to the 121 hours of the curriculum and serve the very good
purpose of keeping the classes under absolute control to the end of
their two years' course in obstetrics.

The Dispensary and the Hospital Service and the Undergraduate
Instruction does not e.xhaust the activities of the department; there
is a beginning of graduate instruction; there is the instruction both
practical and theoretical to the students in the Department of
Nursing; there has recently been instituted a si.\ months course in

OF OBSTETRICIANS AND GYNECOLOGISTS 989

obstetrics for registered nurses with proper educational qualifica-
tion to fit them for missionary work in country districts, in the hope
that they may serve as instructors and advisors to expectant mothers
in thinly settled regions; there also remains the great obligation of
providing time and facilities for original work to the large number of
volunteer workers in the department, who have a right to expect
such recognition for their unselfish devotion to the cause of medical
education and research
440 North Newstead Ave.

DISCUSSION.

Dr. Herman E. Hayd, Buffalo, New York. — It is unusual to have
a paper of this kind presented before this Association. It has been
very interesting and instructive to us, and I agree with our president,
Dr. Pantzer, that this is what we hope to come to, and from what Dr.
Schwarz has stated you can see what a wonderful institution he has
in St. Louis. He evidently keeps in touch with people who are
inspired with the right kind of feeling for humanity.

LYMPH GLAND EXTRACT. ITS PREPARATION AND
THERAPEUTIC ACTION.*

BY
DAVID HADDEN, M. D., F. A. C. S.,

Oakland. Cal.

The Archives of Internal Medicine for July, 1914, contained a
paper by Dr. R. A. Archibald and Dr. Gertrude Moore entitled:
"A Preliminary Report on the Production, Action and Therapeutic
Effect of Leukocytic Extracts."

The leukocytic extract referred to in this article is prepared by a
digestive process from healthy leukocytes. It differs from that
obtained from inflammatory leukocytes by the method of Hiss and
Zinser, in that it is of much more condensed bulk, is more stable and
dependable, of far greater efficiency and very reasonable in cost.
In the majority of cases, a subcutaneous injection of 2 c.c. gives, after
a short interval, a marked increase in the multinuclear leukocytes.
This leukocytosis reaches its height in about eight hours. If given
intravenously, the height of the leukocytosis is reached in about three
hours, though the effect obtained is more transient.

There is no sensitizing of the patient, nor have we noticed any
objectionable symptoms. When used in acute septic conditions,

*Read before the Twenty-ninth .Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

990

TRANSACTIONS OF THE AMERICAN ASSOCIATION

with a high leukocytosis, the phenomenon produced is one of steady
and gradual decrease, with rapid amelioration of all symptoms.

For some time preceding the publication of Dr. Archibald's and
Dr. Moore's paper, the use of the Archibald-Moore leukocytic
extract has been a matter of almost a routine in my surgical cases of
septic origin; and by my associates, it is largely used in all tjipes of
infection. In my practice, the cases of acute septic appendicitis,
especially, have run a much more rapid convalescence, and, as a rule,
are completely healed within two weeks.

I feel justified in stating that in the majority of all septic cases, in
my practice, the severity of the attack has been decreased and the
rapidity of convalescence increased.

We have used in several cases of streptococcemia the magnesium
sulphate solution advocated by Harrar. The magnesium sulphate
solution alone produced no leukocytosis, but used in conjunction
with leukocytic extract, a marked leukocytosis resulted of a more
profound character than the extract alone produced. These patients
recovered.

About three years ago. Dr. Archibald and Dr. Moore began ex-
perimental work with a lymph gland extract. The technic of the
preparation follows much the same method used in the production
of the leukocytic extract, and is as follows:

"Lymph glands are obtained from healthy bovines, ground,
diluted with sterile distilled water and exposed to a temperature of
58° C. for one hour. They are then placed in the incubator at 37° C.
and autodigestion is allowed to proceed until a definite amount of
digestion has taken place. The point at which digestion is stopped
is arbitrarily fixed by the blood pictures produced in guinea-pigs and
other experimental animals including humans.

"When digestion has proceeded to what it is deemed the proper
stage, a preservative is added, the preparation is filtered first through
filter-paper and then through a number one Berkefeld filter, follow-
ing which it is tested physiologically, bacteriologically and chemic-
ally. Any extract so produced that does not show definite blood
changes when injected into experimental animals, is discarded. In
other words, if an extract does not produce over 100 per cent, in-
crease in the total leukocyte count and a corresponding increase in
the mononuclear leukocytes, it is abandoned."

In the preparation of both the leukocytic and lymph extracts,
there is a period of digestion reached at which point the maximum
therapeutic effect is obtained. It has been found much easier to
determine the necessary degree of digestion in the case of lymph
gland extracts, because of the relative constant cellular content of

OF OBSTETiaCIANS AND GYNECOLOGISTS 991

the glands used. In dealing with blood, the cellular content natu-
rally varies with the stages of the physiological functions in progress
in the animal, so there is no easy way, at present, to determine the
proper time to discontinue incubation. The correct stage is reached
by withdrawing a proportion of each batch at stated intervals and
testing out the separated portions on guinea-pigs. In case the prepa-
ration does not come up to a certain standard, that batch is dis-
carded. Digestion carried beyond a definite point will always result
in a complete loss of physiological action in both the leukocytic and
lymph extracts. In the lymph gland preparation the time element
of digestion can be depended upon. Both preparations are required
to give loo per cent, increase in the total leukocyte count.

That the physiological effects of the leukocytic and the lymph
gland extracts are not due to the protein content is evident from the
fact that a 2 c.c. injection contains less than 0.04 of i per cent, of pro-
tein. It takes twenty times as much protein as each dose contains
to produce any changes in the blood picture in the guinea-pig.

While the leukocytic extract produces a marked increase in the
polymorphonuclear leukocytes, the lymph extract invariably pro-
duces an increase in the lymphocytes, especially the small lympho-
cytes, and the blood platelets.

The effect of the blood platelets increase is a rapid and marked
increase in the coagulation power of the recipient's blood. In
guinea-pigs used for standardization, one injection produces such a
decrease in coagulation time as to make difficult the blood count-
ings through the almost immediate sohdification.

We have found that in normal human beings the coagulation time
is markedly decreased with the first dose. Cases with abnormally
slow coagulation time show marked results, even following the pri-
mary injection, though, as a rule, a dose for three succeeding days
produces the greatest effect, therapeutically. The period may be
reduced to even ten seconds and this effect will persist for three or
four days.

One case presenting severe uterine bleeding, in which the pelvic
pathology had been corrected, had a delayed coagulation time. The
bleeding in this patient was not influenced by any of the drugs pro-
ducing contraction of the uterine muscle, but in time an improvement
resulted from prolonged antispecific medication instituted upon
finding a 60 per cent, positive Wassermann. This patient's coagu-
lation time was fifteen minutes by the capillary tube method. She
repeatedly presented the phenomenon of a sudden cessation of
bleeding within fifteen minutes of the initial lymph gland extract

992 TRANSACTIONS OF THE AMERICAN ASSOCIATION

injection at each menstrual period. Within twelve hours the flow
would again appear in moderate amount. The menstruation was
kept within normal limits with a daily dose for three successive days.
Several times a premenstrual treatment of three doses was insti-
tuted and no excessive bleeding occurred. The only subjective
symptom this patient ever noticed following the injections was a
''board-like feeling of the head" as she expressed it. The objective
sign present was the prominent appearance of the cervical and facial
veins for about half an hour, but with no increase in blood pressure.

I have used the lymph gland extract in a number of cases of similar
nature where the bleeding was due to slow coagulation time of un-
known origin. The pelvic organs were free from abnormality or
had abnormalities not accountable for hemorrhage.

Two cases of easy bleeders, one with hemorrhage from the ab-
dominal incision, the other with free oozing from the mucous mem-
brane, had a complete and permanent cessation of the bleeding
almost immediately following the one dose.

I have been interested in the fact that in some cases an aphro-
disiac effect followed a series of injections, and so have tried it in a
few cases of sterility, but so far I cannot express an opinion.

My associates have been using this lymph gland extract in cases of
hemophilia, pulmonary hemorrhage and tonsillar bleedings with
very favorable results. It has replaced, in our hands, horse serum
and fresh blood, and by two men is used as a prerequisite to tonsil
operations. In operations done preceding or during the periods, or
cases in which much oozing is to be expected, I use it as a preparatory
injection, given twelve hours or so before operation or immediately
following operation if I fear any possibility of excessive oozing. I
am rather inclined to feel that while the functions of certain glands
are stimulated, the exudate from serous surfaces is diminished.

In another class of cases I have used the lymph gland extract
rather extensively, but these cases are of the type that make it diffi-
cult to speak with authority as to the therapeutic results.

About eighteen months ago, having in mind the infectious granu-
lomata theory of sarcoma, I reasoned that the character of the tissue
involvement might more readily be influenced by a therapeutic
agent that would increase the lymphocytes, so I began the use of the
extract in a case of tumor of the cecum responding to the Abder-
halden test for sarcoma. This patient, when first seen, had an ex-
cessively tender mass in the right iliac region, so much tenderness
being present that she could not even turn over in bed without sup-
porting the side. A daily injection of 2 c.c. for about a period of ten

OF OBSTETRICIANS AND GYNECOLOGISTS 993

■days resulted in a marked increase in the size of the tumor and a dis-
appearance of all tenderness. After about twelve doses she com-
plained of some headache, and at her request, the injections were
discontinued. Seeing the case only as a consultant, conditions arose
which prevented further administration.

Naturally, the treatment of any malignant growth by such meas-
ures resolves itself into two methods of application: One as a pro-
phylactic following surgical removal; the other as a palliative in the
cases of inoperable type. The first method naturally can give us
no immediate information as to the value of the therapeutic measures
employed. In the cases of inoperable type, the notorious tendency
of all malignant growths to periods of lessened rapidity of growth,
and improvement of symptoms lays one open to the liability of cred-
iting temporary improvement to the type of medication used.

I have used, during the last two years, lymph gland extract in all
inoperable cases of carcinoma, and discounting fully the possibilities
of spontaneous improvement, I believe I am justified in the conclusion
that the effects have warranted the use of the extract.

The patients themselves have in most cases acknowledged that
they felt stronger and in better spirits, and, as a rule, were eager to
have the injections continued. In most cases the growth has de-
creased somewhat in size, and any associated inflammatory over-
growth has subsided.

Upon one case of carcinoma of the pylorus with practically com-
plete obstruction, I did a posterior gastroenterostomy. This patient
has Uved one year, eight months of which was given to active physical
labor. The operation showed all the mesenteric glands extensively
involved, the original tumor mass being the size of a large orange.
The growth decreased more rapidly in size than could reasonably
be expected as a result of the adventitious opening, so that for
months it was barely palpable even through thin abdominal walls.
Periods of considerable length intervened from time to time in which
the injections were discontinued as the patient was away from home,
and even though he carried the extract with him, neglected its use.
During these intervals, the growth increased in size and the stomach
symptoms became evident. The increase of weight from go to 142
pounds can, of course, be accounted for by the ability to take food.

This case is typical of several others of similar type in which im-
provement seemed to be definitely associated with the periods of
treatments.

Dr. R. S. Leachman of Vallejo, California, reported to me the
results in one case of inoperable pelvic carcinoma in which, at my

994 TRANSACTIONS OF THE AMERICAN ASSOCIATION

suggestion, he had used the extract. This case had an exploratory
incision done a short time before the lymph gland extract was begun
and it was found that the bladder, uterus and rectum were involved.
The bladder and rectal symptoms were extreme, and the loss of blood
marked.

Dr. Leachman reports "that the bleeding promptly decreased
and during the last three weeks of the illness completely disappeared.
The size of the mass decreased fully one-third."

"I am convinced," he says, "that the lymph gland extract did help
the patient locally very much. Pain was less and pus and blood
entirely reheved. The family also think the relief was marked."

The dose has been fixed by Dr. Archibald and Dr. Moore at 2 c.c.
daily, because of the character and definiteness of the blood change
resulting. I have, however, been using it in cancer cases as freely as
10 c.c. daily. In some cases the 10 c.c. dose produced some head-
ache and restlessness, so that recourse was had to 4 c.c. twice daily
with no untoward symptoms resulting. We did not find that the
blood changes varied in any marked degree over those produced by
a i-ampule dose. There was no evidence in any case of protein
reactions or sensitization of the patients.

While with me the use of the lymph gland extract in malignancy
has been entirely theoretical, the work of the late Dr. J. B. Murphy,
of Chicago, would give one some basis of fact and with his work in
mind we hope shortly to take up the laboratorj^ experimental work
on animal tumors.

Accurate work on the influence of these body extracts upon ovula-
tion ought to be possible on account of the work the University of
California Anatomy Department is doing in the determination of the
exact ovulation cycle in rodents.

We probably will never use body extracts in operable cases of
mahgnancy as a substitution for operation, but if proven of value in
animal work, it will have its place as a prophylactic. In inoperable
cases, it gives us one method that undoubtedly prolongs the patient's
life and relieves many of the distressing symptoms, so that the amount
of opiates necessary is lessened, but above all it puts in our hands an
ability to make the patients really feel something is being done for
them.

The present important field for the lymph gland extract is, however,
undoubtedly in cases of hemorrhage, and especially so in patients
whose blood changes result in lowered coagulability.

Dr. Archibald and Dr. Moore are anxious to see the extract tried
out more extensively in tuberculosis and other chronic infections for

OF OBSTETRICIANS AND GYNECOLOGISTS 995

they feel that their laboratory experimental work has demonstrated
its eSect in these cases.
2716 Telegraph Avenue.

DISCUSSION.

Dr. James E. Davis, Detroit, Michigan. — I would like to ask Dr.
Hadden what his theories are in regard to the chemistry of the
platelets, and in using the lymph gland extract just how these plate-
lets are produced. I believe we have a number of theories. Some
have believed that the platelets have nothing whatever to do with
the coagulation. Others have brought up a discussion as to just
what the platelets are. Are they fragmentary portions of the
lymphocytes? This is an interesting line of speculation, and I
wonder whether light has come to Dr. Hadden in these particular
instances of the platelets.

Dr. Dickinson. — I would like to know how many cases he had
investigated before he came to these conclusions?

Dr. Hadden. — Personally, I cannot express any opinion as regards
the function of the blood platelets. However, they are so markedly
increased, that much of the space in between cells is filled up with
them and we have assumed that they are the cause of the decreased
coagulation time. Dr. Moore feels she has proven conclusively,
although as yet unwilhng to accept this evidence absolutely, that we
are dealing with an enzyme and that the presence of this enzyme
produces these changes.

While I was in Rochester, Minnesota, I had an interesting talk
with Dr. Luden and Dr. Kendall on the chemistry of the thyroid
and the probable chemistry of this extract, and they felt we were
dealing with an enzyme.

So far as the number of cases is concerned, I will say that I have
used this extract in six cases of inoperable carcinoma and sarcoma
of the abdomen. In malignancy I have not tried it outside of that
field.

Thanks to Dr. Moore and Dr. Archibald, I have with me some of
the lymph gland extract, and if any of you wish to try it I shall be
glad to give it to you, also if any of you care to take up any experi-
mental work, Dr. Moore and Dr. Archibald will gladly supply you
with what you need.

996 TRANSACTIONS OF THE AMERICAN ASSOCIATION

OBSERVATIONS ON BLOOD PRESSURES DURING
OPERATIONS.*

CHAS. W. MOOTS, M. D.,

Toledo, Ohio.
(With two illustrations.)

It has been a custom of mine, when visiting various dinics, to
obtain from those in charge their ideas of blood pressure. For a
number of years this subject has appealed to me as one of great
importance and interest. During this time of study and observa-
tion, I have been greatly aided by close association with Dr. Stone,
who has already brought the matter to the attention of the profes-
sion by well-written articles; also by my anesthetist (Dr. McKesson)
who has charted for myself and other surgeons more than eight
thousand cases, taking the blood pressures, pulse and respiration
every few minutes during each operation.

There is one point with which I am always deeply impressed, after
observing the attempts to record pressures at different clinics, and
that is this: There seems to be an utter lack of uniformity of
technic in taking the readings as well as inability to interpret the
readings taken. At some of the most renowned teaching centers
we have been much surprised to note that readings were taken only
of the systolic pressure, and this by individuals whose lack of pro-
fessional training prohibited all possibility of any intelligent idea of
myocardial, endocardial, or vascular changes, or the relation of these
changes to pressures. It has seemed to me, therefore, that it might
not be a waste of time for this association to consider certain aspects
of this subject, and I make bold to start with a more or less ele-
mentary, yet what I believe to be a necessary, discussion of the dif-
ferent pressures which we have found to be important. In this
discussion, I purposely omit reference to the effect of respiration
and pulse rate on the pressures in order to avoid confusion.

Diastolic Pressure. — -This may be defined as the pressure e.xisting

in the artery under observation during the diastolic pause just

preceding the succeeding cardiac systole. Taken alone, it is the

truest index of the arterial tension. No matter what the systolic

pressure may be, if the diastolic is high, there is a true hypertension

of the vessels; and conversely, if the diastolic is low, we are dealing

with hypotension, and this is true irrespective of the systolic pressure.

*Read before the Twenty-ninth Annual Meeting of the American .Vssocia-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

OF OBSTETRICIANS AND GYNECOLOGISTS

997

Pulse Pressure. — This is defined as the force necessary to
move the column of blood in the artery. It represents the force
exerted by the contracting ventricles in excess of the diastolic
pressure.

Systolic Pressure. — This is the sumtotal of pressures existing in
the artery under observation during cardiac systole. In other
words, it represents the diastolic pressure plus the pulse pressure,
and shows the energ>' being expended by the myocardium at a given

»16? Anesttielitt'j Chart

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Fig. I. — Case 4167. Shows perfect blood-pressure picture during an hyste-
rectomy done under complete anociation.

moment. It is, therefore, very variable depending much upon
requirements, and the ability of the heart muscle to meet these
requirements. It varies even from psychical disturbances, being
influenced by many emotions, such as anger and fear. Physical
exertion or stress may also affect it markedly. From this great
susceptibility to variations, one easily concludes that taken alone it
is not nearly so important as the diastolic. However, when com-
pared with the other pressures, it is invaluable as it clearly shows one
the endeavor that the heart is making to maintain circulatory
equilibrium.

998 TRANSACTIONS OF THE AMERICAN ASSOCIATION

The Pressure Ratio. — Briefly stated, I mean by pressure ratio, the
percentage obtained by dividing the pulse pressure by the diastoHc
pressure. Take the systolic and diastolic pressure, and then find
their difference which will be the pulse pressure. You then have
simply the following problem: "What percentage is the pulse
pressure of the diastolic pressure?"

For example, let us assume that a normal case has a systolic pres-
sure of 1 20 mm. and a diastolic of 80 mm. The pulse pressure is

1-4538 ABKthttlsft: Chart ""-^jf-

r«i oKwn MHIK.

Fig. 2. — Case 4578. Shows blood-pressure picture during great shock under
local anesthesia only, for double herniotomy.

the difference between these two which is 40, and the ratio of pulse
pressure to diastolic is -ij^so or J-^, which means 50 per cent, of the
diastolic pressure. We have found in our e.xperience that this
pressure ratio is really the sine qua non of the whole matter, as it
expresses "the relationship existing between the kinetic energy
expended by the cardiac contraction in moving the blood column,
and the potential energy stored in the arterial walls and column of
blood which they contain." (Stone.)
Our experience also leads us to believe that the ratio may be

OF OBSTETRICIANS AND GYNECOLOGISTS 999

normal between the limits 40 and 60 per cent. If your case has
vascular contraction and rigidity, as shown by a high diastolic pres-
sure, but has a compensating heart that is pushing the blood to
the periphery, as shown by a corresponding rise in the systolic,
so that the pulse pressure remains near the 50 per cent, ratio to
the diastolic, you need have no fear in proceeding with a needed
surgical operation. If, however, the pressure ratio is low, say 20
per cent., and taking into consideration the probable presence of
acidosis or other toxemia, it is wise to offer a grave prognosis. On
the other hand, if the pressure ratio is greater than 80 per C€nt., the
prognosis is at least equally grave, as one may look for little cardiac
reserve force because of overwork already done so that slight shock
becomes very grave.

Technic. — I think it is now generally conceded that the ausculta-
tory method should entirely supplant the palpatory. We have
used the former method e.xclusively for the past sk years and find
it quite satisfactory.

The diastoUc pressure especially is much more readily obtained
by this method.

We have our apparatus so arranged that it is an easy matter for
Dr. McKesson to keep his own records while giving the nitrous
o.xid-oxygen, which is our routine anesthetic. The reading dial,
which is 8 inches in diameter in order to render it the more easily
observed, is placed on a stand which also contains record sheets.
The stand is immediately to his right and answers for a writing desk.
By having the rubber tubes of sufficient length to connect the read-
ing dial with the arm band, and the Bowl's stethoscope over the
brachial artery to the ear pieces, he has no difficulty in making the
frequent observations which we believe to be most important, and
which offers the earliest symptoms of trouble. By using this
"barometer" we are able to forecast the approaching storm long
before it can be determined by any other method and thus get our
boat to shelter. Everyone here knows how notoriously inefficient
is the treatment of shock when once profoundly established, and if
anything is to be done it must be recognized and the proper course
instituted before the heart is exhausted by rapid contractions in
its attempt to hold up the blood pressures. " Unvariable pressures
during operations are the result of most painstaking technic on the
part of the surgeon, anesthetist, and ever}' one concerned in carry-
ing out a shock-free technic. Such results cannot be obtained by
accident, but it is necessary to eliminate certain procedures peculiar
to the individual surgeon and anesthetist, which by means of proper

1000 TRANSACTIONS OF THE AMERICAN ASSOCIATION

blood pressure readings are found to be frequently productive of
more or less disastrous results either at the time, or during the few
days succeeding the operation. For example, no surgeon is willing
to admit that he is rough in the belly, and no anesthetist rushes into
print with the admission that he generally overdoses his patients,
but a series of cases where the blood pressures are frequently taken
in each case, will commend or condemn their technic most emphatic-
ally. If circulatory depression frequently occurs, even in minor
degree, it is due to faulty technic and the cause should be discovered
and removed; it may necessitate an entirely new technic in several
particulars" (McKesson).

Having made observations and records of the pressures in 98 per
cent, of our cases for the past eight years, we have, as a result of
our experience alone, come to certain conclusions which I wish to
offer at this time.

1. The systolic pressure alone is of very slight, if any, value.

2. The diastolic pressure alone is of much more value than the
systoHc alone.

3. The pressure ratio is the essential factor, and offers the earliest
danger signal.

4. There are certain elements in technic which have marked and
constant effect upon the pressures. These are as follows:

(a) The psychical or emotional state of the patient.
{b) The position of the patient upon the table, the extreme
Trendelenburg being the worst.

(d) The amount of traumatism inflicted by the actual operation,
such as cutting and tearing the tissues with scissors, the hands, and
other dull instruments; the packing of large gauze packs, instead
of rubber tissue, into the abdominal cavity.

(e) The preservation of the fluids in the body up to the hour of
the operation, this being absolutely necessary to maintain the usual
pressures.

The Nicholas.

DISCUSSION.

Dr. R. R. Huggins, Pittsburgh, Pa. — I regard this paper as
one of the most important contributions that we have heard at this
meeting. It leads the way to a final solution of the current estimate
of a patient's resistance previous to operation. Our studies have
led to the conclusion that the changes in pulse pressure which
occur in an impaired circulatory apparatus after exercise are most
important aids in the determination of the strength of the heart
muscle. I am glad to have heard this conclusion because we have

OF OBSTETRICIANS AND GYNECOLOGISTS 1001

been quite confident that it is true for some time. Patients with
either extremely high or low blood pressure may be very pool
risks. For several years we have been using spinal anesthesia.
I have often been asked for an excuse in its use. It is this. There
is no form of anesthesia which will conserve as much energy as
spinal. The heart is given absolute rest throughout the anesthesia.
The whole splanchnic area is put out of commission and most of
the blood lies quiet in the large vessels of the abdomen. Instead of
heart strain which is produced by all forms of inhalation anesthesia,
there is the most profound rest that may be given to that organ.

Dr. J. Henry Carstens, Detroit, Michigan. — I want to commend
the work of Dr. Moots in calUng our attention to the great value of
knowing the blood pressure. If you have a patient with a blood
pressure of 170 or 200, it is dangerous to operate. The same holds
true with a patient who has an abnormally low blood pressure.
It is dangerous to operate until the blood pressure is raised.

I am glad he has emphasized the question of local anesthesia and
also the mental viewpoint of the patient. Patients who are ex-
ceedingly nervous have blood pressure run up on the slightest prov-
ocation. It is very essential to get these patients as quiet as pos-
sible, and in the morning, when you operate, you want to keep them
busy, and by the time they are ready to be taken to the operating
room give them J'^ grain of morphin, with J^20 grain of atropin.
This, when given twenty minutes before operation, has a wonderful
effect in stimulating them. It gives them courage. It is like a
good drink of whiskey, it stimulates a man to fight. These little
things count in connection with our work. If we take the pulse
pressure during the anesthetic we will have less trouble than we have
previously had in these peculiar cases that are on the border line.

Dr. Gordon K. Dickinson, Jersey City, New Jersey. — It is a
sad comment on surgery as we know it to be, not the surgery of the
men in this Association, but surgery as it exists to-day, when cases
are brought into sanitaria and hospitals with dubious superficial
diagnoses, hastened to the operating room and carried through with-
out sufficient after-watching and care.

I am glad that we have had a paper, not on the technic of opera-
tion, but one on searching out the vitahty of patients before opera-
tion. I wish we could know just where the doctor obtains his
apparatus, and all about it, so that we may apply it in our own
clinics. There are many blood-pressure machines on the market,
and much has been incompetently written from a laboratory stand-
point, but we can no more comprehend some of the books on blood
pressure than we can our books on bacteriology, because we know
httle or nothing about technic or culturing. We should have this
thing made practical to carry home and use to advantage.

I am very glad to have heard from the doctor and hope he will
speak again so that we will be able to gather more important points.

Dr. Motts (closing). — I am certainly not unappreciative of the
kind remarks that have been given me on this paper. I assure you,
gentlemen, it has covered an experience of about ten years of pretty

1002 TRANSACTIONS OF THE AMERICAN ASSOCIATION

hard work. I only hope that I have inspired each of you men, every
one of you, to go home with the determination of taking advantage
of this means which I believe to be the best criterion to measure a
patient's resisting power. I have saved a number of lives by shorten-
ing the operation at the suggestion of my anesthetist. I hope that
we will quit talking about systolic blood pressure alone ; it is of very
little importance taken alone. However, the pressure ratio
is exceedingly important from the standpoint of the surgeon.

As to the apparatus, it simply consists of a bulb, and you may
use the ordinary Tycos dial instead of the large one, and have the
rubber tubes long enough to run from the patient's arm back to
the anesthetist and have a Bowl's stethoscope disc fastened to
the brachial artery with an elastic band.

Dr. Schwarz. — Where do you get these large dials?

Dr. Moots. — I cannot tell you, but these dials have no advantage
over the ordinary Tycos dial, except the readings are somewhat
simplified. Dr. McKesson can furnish all information concerning
their purchase.

Dr. Dickinson. — We cannot have a specialist, at all times, to
give an anesthetic. The intern must be trained, and the patient
watched, and he should attend to the patient and to the anesthesia.

Dr. Moots. — I am rather optimistic. I beheve the average intern
to-day knows more about blood pressure than any of us did ten years
ago, and I believe you will find the average intern very much
interested in taking blood pressures. It is unfortunate if you are
compelled to depend for an anesthetist on the family physician who
comes in to see that everything goes right. It is equally unfortunate
that you are compelled to rely on a nurse as an anesthetist, unless
she has been properly trained in medicine, for with her elementary
training she cannot comprehend blood pressure in all its relations.
I wish to announce that we have just completed a technic by means
of which we are measuring the patient's acidosis during the opera-
tion, and I hope if we can get a sufficient number of cases upon which
to make observations during the next year, I may have something
to tell you about our results.

POINTS IN THE DIAGNOSIS OF PELVIC TROUBLES.''

J. H. C.\RSTENS, M. D., F. A. C. S.,

Professor Abdominal and Pelvic Surgery, Detroit College of Medicine and Surgery,
Detroit, Michigan.

The difficulties in making a correct diagnosis of pelvic troubles
we all recognize. Let us take the ordinary disturbances of menstrua-
tion. To make a correct diagnosis of amenorrhea, for instance, will
embrace the whole domain of physiology', pathology, and bacteri-

*Read before the Twenty-ninth .\nnual Meeting of the .'\raerican Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

OF OBSTETRICIANS AND GYNECOLOGISTS 1003

ology. Amenorrhea can be caused by many physiological disturb-
ances, and almost all bacterial infections, as well as innumerable
diseases. If we consider dysmenorrhea, it is by no means a local
disease, or a question of mechanics, as its diagnosis will embrace all
domains of neurology and hematology. And when it comes to men-
orrhagia, we find that many cases are constitutional and not local.
So that in this one phase of the question, that is the menstrual func-
tion, we must cover nearly the whole domain of medicine, and it
shows that the gynecologist must have a broad view and under-
standing of the practice of medicine.

If we now consider other pathological lesions, we often find great
difiiculties in the differential diagnosis of swellings, tumors, etc.
The diagnosis of fibroid tumors is ordinarily easy; but the diagnosis
of small uterine fibromata of the submucous variety, causing
menorrhagia and leukorrhea, is not very easy, as these tumors re-
main small for months and years, and can only be detected with
great difficulty. A dilatation of the uterus must be made in sus-
picious cases. This cannot be readily done with steel dilators under
an anesthetic, as the uterus must be explored by the finger. In
these cases it is best to use a sponge tent, perhaps a succession of
tents, so that the cervix is perfectly soft and the uterus can be
readily and thoroughly explored with the finger.

Take, again, women in the so-called cancer age, who are suffer-
ing from rather profuse hemorrhage, or perhaps some little discharge,
we must suspect a development of cancer, and are obliged to curette
and examine the tissue microscopically. During the cureting it is
easy to miss little cancerous points the size of a pea in one horn of
the uterus; and then we are lulled into the belief that no cancer e.xists.
In these very cases we have brilliant results with early vaginal
hysterectomy. Then, again, how easy it is to overlook small polypi
in a uterus of about normal size and with a normal cervix, unless we
dilate and explore the inside of this organ.

Take a case of pregnancy complicating uterine fibroids. How
difficult it is, sometimes, to recognize both conditions, and how nec-
essary it is to make the diagnosis before operative procedures are
instituted. Take a case of ordinary ovarian tumor; how easy the
diagnosis generally is; and still, how difficult when you have
encysted peritonitis of a tuberculous nature.

It is difficult to differentiate an ovarian tymor which follows
peritonitis which has produced adhesions between the ovary and
tube on one side and where a tumor develops on the other side of
the abdomen. You see the case first when the tumor has reached

1004 TRANSACTIONS OF THE AMERICAN ASSOCIATION

the lower costal margin, and then you do not know whether you
are dealing with a hypernephroma, a hydatid cyst of the liver, or a
cyst of the spleen on the other side. The vague history you get
from the ignorant patient does not help you much.

Take the solid tumors of the ovary, benign or malignant, when
they become adherent to the pelvis, the uterus, and the rectum, it is
almost impossible to make a correct diagnosis before operation. In
fact, after the tumor is out, pathologists cannot always agree upon
what is the character of the tumor.

Let us now take up pelvic inflammations, whether puerperal or
specific in origin. How difficult is it to determine whether it is a
tube adherent either in the cul-de-sac or to one side of it; or whether
it is adherent to the side of the bladder or the fundus of the uterus;
or whether it is an abscess which has developed along the lymph
channels in the cellular tissue, extraperitoneally, working its way
down toward the rectum or up in the direction of Poupart's liga-
ment, or back to the crest of the ilium. We recognize the infection,
but it is difficult to locate it. When the exudate accumulates in
the cul-de-sac the case is easy enough; it makes no difference what
it is if we open and drain in this region; but, if it is higher up,
not within easy reach and more to one side, an abdominal section
becomes necessary, which always has a greater mortality. Still in
some cases a prompt operation is imperative, while in other instances
it is better to wait until the best point of attack has developed. In
these cases the history and the symptoms will often enable us to
make a correct diagnosis, and thus avoid error.

Take cases of sterility, where we can detect nothing abnormal even
with a good history, how often patients lie to lead us astray. Patients
who have had pelvic troubles and adhesions; closure of the tubes,
that we cannot detect by ordinary examinations; and, if in doubt,
are obliged to make an exploratory celiotomy to find the cause of the
trouble and remedy it at the same time. But, before doing this,
how necessary it is to ascertain whether the husband is really
potent.

The cirrhotic ovary causes a lot of trouble; severe pain, especially
during the menstrual period, and still a physical examination will
reveal nothing. Sometimes we can feel even a small ovary; but,
when the patient is very fleshy, which is usually the case, it is very
difficult.

But the most difficult of all, it seems to me, are cases of pelvic
adhesions in women suffering and complaining, and still nothing
can be detected. Physical examination indicates everything is in

OF OBSTETRICIANS AND GYNECOLOGISTS 1005

its place. But these patients have pain when standing, and when
doing light work, at defecation, or when a little gas distends the
intestines. Some of them are very much distressed. I find that,
on careful physical examination, these patients have pains when I
move the uterus and the pelvic organs in certain directions. If
the uterus is pushed to the right, they complain of severe pain in
the left side; or when pushed in the opposite direction they have pain
on right side. When the uterus is pulled away from the bladder, no
complaint is made; but when the uterus is pulled forward, away from
the rectum, severe pain is complained of, especially in the back.
The pains in these cases I find are due to adhesions; and I believe
the adhesions are caused by an infection emanating from the rectu'm
and sigmoid. These patients often suffer from chronic constipation.
They are, certainly, the most difiicult cases to manage. AO the
douches, tampons, administration of alteratives, etc., have been of
little benefit in my experience. Abdominal section alone, and me-
chanical means will enable us to remove the adhesions.

In many instances it is difficult to convince the patients that an
operation is necessary, because they have always been in seemingly
perfect health and never had any symptoms of a pelvic disease until,
perhaps, three or four years previous. The trouble since then has
gradually increased in severity, so that now the patient has great
difficulty in working, walking, and following her usual vocation. I
am convinced that there are many such cases where the history is
perfectly free from the non-existence of any trouble previously, with
a gradual onset of pain and distress, which is very much increased
when moving the uterus and the pelvic organs as described above. I
would like very much to hear the experience of others on the subject.

In conclusion, I would say: First. — Naturally, all pelvic troubles
offer difficulties in diagnosis. Second. — ^Adhesions of some of the
pelvic organs without menstrual disturbances or palpable changes
are very difficult to diagnosticate. Third. — Pain on moving the
uterus or any of the pelvic organs indicates adhesions. Fourth. —
These adhesions are probably caused by infection from the bowels.
Fifth. — These obscure cases require exploratory celiotomy for exact
diagnosis and efficient treatment.

1447 David Whitney Building.

1006 TRANSACTIONS OF THE AMERICAN ASSOCIATION

CONSIDERATIONS IN THE CARE OF OUR PATIENTS
BEFORE AND AFTER OPERATION.*

BY
H. WELLINGTON YATES, M. D., F. A. C. S.,

Detroit, Mich.

There is nothing new in dealing with this threadbare subject,
but the author hopes to arouse some interest and perhaps some dis-
cussion upon a theme which still needs it.

First of all, I wish to make the patient and her interests paramount;
and to that end let us deal with her as we would with a woman and a
mother, rather than the case in Ward No. 2, with iiterine prolapse.
Let us have not so much of the routine, but more specific care for a
specific case; let us adapt our resources and environment to her,
instead of demanding her compliance alone to ours. Patients
need more personal attention from the surgeon and less physic and
digitalis from the hospital intern. Too much time has been given
alone to questions of bare mortality and too little to morbidity,
and to the causes of delayed restoration to the normal. We should
not alone be interested in the cure of disease and saving of life,
but likewise in the relief of pain and psychic influencs, consequents
upon operation and hospital environment.

Every surgeon should be a humantarian. Surgery is a thing of
art as well as science; a thing needing a fine esthetic sense rather than
mere boldness. It is constructive, not destructive; it is saxdng life,
not taking it, and Hkewise a surgeon is not he who has boldness, but
one who has judgment; not alone he who knows how and when^to
operate, but also he who knows when to refrain and when to conserve.
Crile's microphotographs of the brain cells taken before and after
operation, before and after long anesthesia, pain, fear, excitement and
exertion, certainly show that each one of the factors has a large part
in the recovery of our patients, and should point the way, first of all,
10 the better preparation before operation.

Elective operations are those which are not strictly emergency
operations; they are largely in the majority. We usually have the
opportunity of choice, where, when and how the patient should be
operated upon, and just here I should say too, that a considerable

•Read before the Twenty-ninth Annual Meeting of the American Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

OF OBSTETRICIANS AND GYNECOLOGISTS 1007

number of patients of the true neurasthenic class have been submitted
to operation too frequently. Unless she has a definite demonstrable
pathology, she should not be considered an operative risk. Many
deaths that might have been avoided, have occurred in these pa-
tients of low resistance. Those affected by an early Graves' disease,
where the thyroid enlargement is not yet apparent, and many chil-
dren also, who have status lymphaticus, should be eliminated from
operative consideration, unless forced upon us through some
emergency.

Surgeons have paid too little attention to the in,ternal secretions.
Patients do not come to us for operations per se, they come to be
cured of a malady of which they usually know nothing, and place
themselves in our hands, because they have been referred to us by
some other physician, who has failed to cure them. We should be
exceedingly careful in the selection of such cases. As a rule, they are
not given thorough examination — general physical examination,
I mean. Every patient should have it. Some of our internist
friends are as lazy as we and have not made thorough examination
before referring the patient. I am well convinced that the majority
of those diagnoses which are not made or are improperly made, are
not because of lack of knowledge, but lack of time and proper applica-
tion; therefore, we see a certain number of patients each year, sent
to us for operation, who do not need it, or come at a time when they
are poorly prepared for it. Then we have the other class which has
definite pathology, which has or has not been diagnosticated before
coming — the white-faced emaciated ones, who need rest in bed,
rather than the wash-board and scrubbing that have been their wont.
The patient needs good food, tonics, rest, etc., before an operation is
contemplated. A short time in the hospital for general treatment,
adaptability to the new environment, knowledge of the surgeon's
personal care of her, and the assurance that she will make an early
recovery, certain!}' have their good results.

PREOPERATIVE CARE.

In general, we have been giving all our patients more preoperative
care than formerly, and less rushing to the hospital and hurried opera-
tion. For two or three days, we feed them well on easily digested
nutritious foods; the last day we give 6 ounces of water each hour
while awake; this fills the blood-vessels, increases kidney, liver and
skin excretions and secretions. Nervousness and loss of sleep are
exhausting, and should be met by such remedies as the usual sedatives

1008 TRANSACTIONS OF THE AMERICAN ASSOCIATION

or opium. I think it imperative that the patient be given sufficient
quantities of opium to induce sleep. A patient who is permitted
to lie awake all night to meet perhaps one of the crises of her life
the following day, is in poor condition to put up the necessary de-
fense. We would not care for a team of plow horses that way, if
we expected a full day's work from them on the morrow. We
teach our nurses to be cheerful to our patients, and perhaps we also
act in accord with them, but how little that interests the woman or
man who has lain awake for two nights, thinking of operations or
perhaps "the great divide."

As to clearing out the alimentary canal, we are heartily in accord
with Doctor Baldwin. The patients should be given an active
cathartic twenty-four hours or more before the operation. Castor
oil is without question, we believe, best, since it sweeps out the entire
bowel, producing a minimum of griping, and its action is complete
before the night comes on, when we may need to administer opium for
sleep. Unless the patient is to have a rectal operation, enemata
of any description on the morning of the operation are contra-
indicated. What we want is intestinal rest. Enemata produce
retroperistalsis, and it is often many hours after one is given before
the last part of it is expelled. In our hands, this preoperative treat-
ment has been indescribably better than the old days of compound
cathartics and injections.

On opening the abdomen, the intestines are found empty and asleep,
and I beheve this is a decided prophylactic to later abdominal dis-
tention. We are convinced that our cases have been more comfort-
able in their early convalescence, and have yet to see the first case in
which we regretted not having given an enema. One hour before the
operation, a small dose of morphine and hyoscin is given subcutane-
ously; less mucus is secreted in the throat and trachea, and the pa-
tient takes less anesthetic. In general, we like gas and oxygen,
combined with a little ether; it is less discomforting to the patient,
followed by little or no nausea and vomiting; lessened thirst and
immediate return to consciousness. It is an unusual thing to have
the pulse affected by even long administration. At our hospital, we
employ a skilled anesthetist, one who has prepared herself by many
months' application in the technic of gas administration. Gas
is dangerous in the hands of a novice, so is ether, so is chloroform.

All operative cases, especially abdominal ones, should have the
benefit of laboratory findings. Our plan of attack has often been
changed after we have reviewed these reports. Many operators
think hghtly of the reports from the laboratory; we feel that they

OF OBSTETRICIANS AND GYNECOLOGISTS 1009

are one of our instruments of precision, and while we do not let them
outweigh all else, still the laboratory has its definite place; it is in-
dispensable, and when we become negligent in asking for all it can
give us, we often find it to our disadvantage. This is particularly-
true in reference to blood findings.

OPERATIVE CARE.

The pendulum swings in surgery as in everything else. The
thing we adopted yesterday we condemn to-day. So much for
progress.

As regards abdominal surgery, we have learned that the viscera
and their coverings speak in no uncertain manner, and to some
extent we have learned their language, and, therefore, after an opera-
tion, some of them cry out by expressions of pain; some bj^ way of
abdominal distention; some by way of vomiting; some by thirst;
some by pallid skin and sunken eyes; but the meaning of it all is,
that we have given insult. One's insides were never intended to
play ball in; but if, perchance, the ball has gotten in, our duty is
to get it out as quickly as we can, with gentleness and safety. We
have been taught by this language, that we must get in and get out;
that we must make openings large enough to see that which we can-
not feel; that we must do the least handling possible to accom-
plish results; that we should avoid forcible retractions, and when we
seek to pick up bleeding points, pick them up separately, instead of
insulting all the adjacent tissues; that warm moist gauze, used
gentl}-, is less ofi^ensive than dry gauze, used roughly. In brief,
if one desires to tame a vicious animal, don't try to do it by way of
teasing him. Permitting the intestines to be exposed to the air
more than absolutely necessary, or to have them come in contact
with the abdominal wall which has been prepared with iodine, to
make traction upon the mesentery; to permit too many hands in
the operating wound, all these and many more are certain factors in
the production of that symptom-complex, we call shock.

During the last two years, since we have been giving more atten-
tion to preoperative care, and handling other peoples' intestines as
we would like to have them handle ours when needs be, the factor of
shock has been singularly absent. I heard Doctor Mayo once say,
that anyone who would take advantage of their patients merely
because they were asleep, and would pinch, pull and rub their ex-
posed tissues needlessly, is a coward and a knave. I am convinced
that surgeons are careless of nerve endings and splanchnic stimula-

1010 TRANSACTIONS OF THE AMERICAN ASSOCIATION

tion, beyond what they would be were the patient conscious. Of
all men who should be gentle and careful in the process of his work,
it is the surgeon. It is well to know what shock is; to combat it
when present, but how much better to be able to avoid it.

POSTOPERATI\'E CARE.

The handling of patients should vary in accordance with their
psychology and the nature and severity of the operation. In all
operations of gravity, we use the Murphy drip, with bicarbonate
of soda and glucose, as soon as the patient is returned to her bed.
The soda will overcome the tendency to acidosis, the glucose fur-
nishes an easily absorbable carbohydrate, and thus supplies energy.
In those who through accident lose much blood or who sweat pro-
fusely, the giving of two pints or more of this solution, relieves the
distress of extreme thirst, and overcomes tendency to shock. This
is a harmless measure, giving little discomfort to the patient, and
suppHes her with water and food when her tissues have need of it.
If the presence of a small rectal tube is annoying to a nervous pa-
tient, we then give 4 to 6 ounces of the same solution at one time,
at intervals of three hours. We think this is a most valuable remedy,
especially when administered early, thirst is not so severe, and the
secretory organs, which are inhibited by long anesthesia, are made
active. We desire to get liquids and food into our patients as soon
as consistent with the circumstances. Thirst and nausea are dis-
turbing factors, and when our patients call for water, we usually
permit, in small quantities frequently repeated, hot tea or hot water,
after the first two or three hours. If this is returned, then she is
given as large a drink as she can be induced to take, and when this is
returned, all liquids are prohibited by the mouth, until she is free
from nausea. A stomach tube is seldom necessary, but occasion-
ally becomes a valuable instrument in severe cases. Medication
by the mouth has been found useless. Severe and long-continued
nausea is sometimes relieved by a 3-grain opium suppository,
repeated if necessary, until the stomach has been put at rest
for a few hours. In our experience, it has acted better than mor-
phine or codein for this purpose, especially so when the operation
has been pelvic. I think some of these patients by the distressing
experience of continued nausea and vomiting, become nervous and
hysterical, and a dose of chloral and bromide per rectum is sometimes
efficacious. Occasionally a patient dies from exhaustion.

OF OBSTETRICIANS AND GYNECOLOGISTS 1011

No operation is entirely free from danger. We often advise opera-
tion, but only under special conditions do we urge it. We never
have seen the persistent and sometimes serious vomiting, following
gas and oxygen that is so common with ether or chloroform. Pain,
when severe, should be controlled by codein, given subcutaneously.
It does hot inhibit glandular activity. To be sure, the quantity
should be curtailed as much as possible, but we think it is a wrong
principle to allow patients to suffer with pain and fret for hours.
Codein does not induce habit easily; it is more easily withdrawn than
morphine, and in general produces less gastric distress, or bad dreams.
I am a firm believer in large doses of anything that will control mo-
tion and sensation in the presence of a soiled peritoneum; motion
is provocative of pain in any acute condition, and especially so in the
bowel. Therefore, in peritonitis, we believe in the free use of opium
to limit motion and maintain physical and mental rest. We prefer
to have our patients bordering on unconsciousness for forty-eight
hours by its use.

If we knew all the exact factors that cause abdominal distention,
we might more easily combat it. Distention is often severe when
there is no pathology in the abdomen, as a severe concomitant
pneumonia, a stitch abscess, or operations following inguinal hernia.
We occasionally have no meteorism following a severe abdominal or
pelvic operation, which has been attended by much handling and
considerable exposure, but such cases are rare. The writer feels
that rough handling and long exposure of the viscera to air and
foreign bodies, or pulling upon the mesentery, or the grasping of
masses of tissue in the effort to get a single bleeding vessel, are
Ukely to stimulate the splanchnics and induce paralytic ileus. The
liberal use of sponges, and especially dry ones, is a pernicious practice
in this respect.

The sole purpose of this paper is to focus thought on this point,
not on the question of distention per se, but the factors which
produce it. •

I was surprised to read in the transactions of last year, that part of
Doctor Reder's paper, in which he said, "Our later knowledge of
preoperative care and general surgical technic, had not decreased
postoperative abdominal distention." I wish to say, with all the
emphasis at my command, that that part of his otherwise splendid
contribution is wrong. As nature abhors a vacuum, so does she also
the handling and exposure of those sacred precincts that were never
intended even to be seen, and when we frustrate her plan she balks
and her whole sympathetic system speaks to us in no uncertain words,

1012 TRANSACTIONS OF THE AMERICAN ASSOCIATION

and one of these is distention. Therefore, the most important fea-
ture in treatment of this symptom is prophylaxis.

Gas pains foUow-ing operations are by far the most distressing
to the patient of anything she has to endure. A few die each year
as a result of bowel inertia. If there be no contraindication, we
endeavor to induce bowel movement on the second day by means
of magnesium sulphate or castor oil given either by mouth or by
rectum. The use of a tectal tube allowed to remain in situ for some
time, is often beneficial. Medication by mouth is disappointing.
After a day or two, when food can be retained, occasionally bread
crusts and coarse stale bread with butter will often induce peristalsis.
We have not found any single remedy to be of universal good.
Pituitrin has more nearly reached that place than any other. Eserin,
even in large doses, as recommended by Craig, has been disappoint-
ing in our hands.

The use of alum water, turpentine and asafetida per rectum
are routine remedies. I have never used the Kemp's tube, as
recommended b}' Dickinson. We often see the expression in medical
periodicals, "the high rectal injection." If by that they mean that
the rectal tube is passed through the rectum and sigmoid into the
colon, then the expression is erroneous, for rectal tubes cannot be
made to reach this area.

In closing, I wish to leave these thoughts:

1. Our patients are entitled to more preoperative and postopera-
tive care than they have been receiving.

2. Patients suffer from shock by long anesthesias, exposures and
rough handling of tissues.

3. Surgery is a thing of art and gentleness as well as knowledge and
skUl.

Gas Office Building.

OPERATIVE JUDGMENT AS A FACTOR IN SURGICAL
MORTALITY AND MORBIDITY.*

BY
ROL.\ND E. SKEEL, M. D.,

Cleveland. Ohio.

At the present time, it seems as though the anxiety to be known

as a research worker or the desire to exhibit a remarkable degree of

manual dexterity for the benefit of the bystanders were in danger

•Read before the Twenty-ninth Annual Meeting of the .\merican Associa-
tion of Obstetricians and Ciynecologists at Indianapolis, Ind., September, 1916.

OF OBSTETRICIANS AND GYNECOLOGISTS 1013

of subordinating that most important factor in lowering surgical
morbidity and mortality in the case of the individual patient, viz.,
surgical judgment.

The writer would be among the last to belittle research and labora-
tory work, and he envies the chosen few that de.xterity which is not
the heritage of the majority, but he desires to enter a plea for the
benefit of the individual patient who falls into the hands of the
surgeon.

Time was, and not beyond the memory of some of us, when sur-
gery was a matter of manual craftmanship. But a limited number
of operations were performed and the factors involved were simple,
so that the vital question was one of speed, dexterity, ability to do
a finished job in the shortest possible time, and in the middle decades
of the preceding century that man who could perform an amputation
or do a lithotomy the most rapidly was the man who deservedly
won surgical success. Surgery then was purely an art and as a
science could scarcely be said to exist.

Then appeared the era of science as applied to human physiology
and those departures from the normal which we know as disease
processes, and the revelations of bacteriology, chemistry, and phys-
ics made it appear that medicine and surgery were, at last, to be
upon the secure footing of one of the exact sciences. Perhaps the
time is coming when this will be true, when with instruments of pre-
cision all the functions of the body will be measurable, when every
deviation from the normal will be capable of recognition, and when
this millenium of diagnosis shall have arrived the means for correc-
tion of every error will be at hand. To-day the ultrascientific
laboratory worker who is not a cHnician would persuade us that this
surgical millenium is almost here, and some few surgeons are will-
ing to accept the diagnoses of clinically untrained internes and assist-
ants, whose conclusions are purely academic in their origin and whose
knowledge of the efficacy of treatment is based entirely upon the
results observed while patients remain in the hospital. The re-
search laboratories have placed at our command a great mass of
data, but out of this mass there are as yet so few facts whose inter-
relations are thoroughly understood, that the placing of diagnoses
in the hands of those without clinical training is pure folly, and ac-
ceptance of their dicta as to the course of treatment to be pursued
is worse.

It is to be feared that the immature judgment of such untrained
men is further warped by their desire to keep up the clinic of their
chief, and certain it is that the reputed results of certain methods of

1014 TRANSACTIONS OF THE AMERICAN ASSOCIATION

treatment are exaggerated in order to show that his methods of
treatment, operative or otherwise, are superior to any other.

As opposed to this is the group study of instances of obscure disease
in which the clinical and x"-ray laboratory men collaborate with the
trained internist so far as possible in establishing a diagnosis, while
the experienced clinical surgeon uses all the data they have collected,
makes his own independent examination, and either operates or
stays his hand with but one object in view, viz., the good of the
individual patient, and his final decision after all is governed by one
predominant factor, and that is his surgical judgment.

If he operates, the particular operation he performs, whether it
is done under local, nitrous oxide, or ether anesthesia or a combina-
tion of all of them, whether he does a rapid, simple, almost crude
operation, or a slow, painstaking, academic dissection, whether he
drains or closes up, will depend again upon factors other than theo-
retical considerations, and that factor which is most important is
his surgical judgment.

In the matter of the particular operation which he performs, allow
me to cite two or three widely separated types of cases as examples.

Exophthalmic Goiter. — There may be an honest difference of opin-
ion as to whether Basedow's disease is a medical or surgical condi-
tion, but there can be no honest difference of opinion as to the out-
come of properly applied surgical treatment. Even this rarely gives
a complete cure in the sense that all the symptoms are relieved per-
manently and at once, but it does convert the patient from an in-
valid or semiinvalid to one whose condition is such that self-support
is possible and the health nearly as good as the average, but this
result cannot be obtained by slavishly following out one method
of procedure, whether that be pole ligation, tying of one or more
vessels, or partial thyroidectomy. The last has a prohibitive mor-
tality if used in each and every case, the first two are not efficient in
the chronic slow going type of cases, especially in women, while
they not only have a very low mortality but a high permanent re-
covery rate in acute cases in the male, in whom the pelvic functions
do not constantly disturb the patient's nervous equilibrium. By a
proper selection of cases for the various procedures, by a judicious
selection of the anesthetic for the individual case, and above all by
speed in operating, absolute prevention of postoperative bleeding,
gentle manipulation of the gland, and sealing of the relatively large
raw area by painting the wound surface with tannic acid solution
combined with drainage, practically every case can be saved. I
was tempted to say every case, until I recalled that even the best

OF OBSTETRICIANS AND GYNECOLOGISTS 1015

surgical results do not prevent an occasional internist from frittering
away valuable time with medical treatment until the patient is
already moribund from myocardial degeneration.

I should like at this time to interject a word relative to preventing
absorption from the wound and stimulating drainage by the use of
tannic acid solution. All of us who use catgut hardened by means
of tannic acid must have observed the nuisance of profuse serum
accumulation in the wound, and this annoying feature led me to
try painting of the entire tumor bed with i per cent, tannic acid
solution before closing. Unquestionably there is a great increase
in the drainage, and apparently a diminution in postoperative
bj-perthyroidism. Whether the latter observation is correct or
not could only be proven by a larger number of cases than I have
at my command, but its apparent correctness has encouraged me
to continue its use.

Another set of cases in which surgical judgment is demanded is
acute intestinal obstruction of the internal t\'pe, that is, such as
is not due to hernia through the abdominal wall. Preeminently is
this true of postoperative obstruction. I know of nothing so try-
ing to the surgical honesty of the operator as the supervention of
obstructive symptoms within a day or two after the successful com-
pletion of a difficult abdominal operation. Primarily the diagnosis
is obscure, a conclusion as to the gravity of the situation hard to
determine, and the nature of the operation necessary for its relief
can be decided upon only after the abdomen is opened and the opera-
tor has made a survey of the field which must be accomplished both
rapidly and accurately. The diagnosis as between paralytic ileus,
postoperative peritonitis, and true obstruction can be established
nowhere but at the bedside, and this diagnosis is most difficult in
those cases in which the primary obstruction is neither complete
nor interfering in a serious manner with the integrity of the gut wall.
Only too frequently the pain in such cases is considered as merely
"gas pain," the occasional vomiting is thought to be neurotic or due
to the modern surgical bugaboo, acidosis, arid insufficient bowel mo-
tions as the result of intestinal paresis, the observer not awakening
to the true gravity of the situation until collapse, extreme pain,
persistent vomiting, absolute obstipation and tympany, certify that
the favorable moment for interference has passed. How can the
diagnosis be made before such a catastrophe has occurred? I know
of but one method, and that is through the careful, systematic, un-
remitting observation of the trained surgical clinician, who is will-
ing to waive all theoretical considerations and balance with accuracy

1016 TRANSACTIONS OF THE AMERICAN ASSOCIATION

the evidence which his own eyes, ears, and fingers place before him,
giving every bit of evidence the weight which his surgical judgment
dictates. Only this, and that intuition which is the result of past
thought and experience, can guide to a correct diagnosis in time to
forestall disaster.

Acute obstruction other than postoperative is less difficult of
diagnosis because the patient has suffered no interference which in
itself might be responsible for the symptoms presented, but again
the laboratory findings are of no assistance save in a negative sense,
the absence of marked leucocytosis indicating the probable absence
of an inflammatory or gangrenous focus in the abdominal cavity.
But let me repeat that the trained surgeon with an abundance of
clinical experience behind him is the man who must make the diag-
nosis, because he should be able to make it more quickly than any
one else and institute treatment sufficiently early to be of some avail.

In the treatment of intestinal obstruction the slavish obedience
to some precept learned while a student or swallowed in its entirety
because propounded by the master of a surgical clinic is likely to
result in as serious a disaster as delayed diagnosis. To eventrate
every patient through a huge incision means that the operator has
utterly overlooked the possibility of death from shock due to ex-
posure of the peritoneum and much handling of the gut; to attempt
operation through a wholly inadequate incision means that an
enterostomy only will be done. Reopening the primary incision in
postoperative obstruction is all that is needed ordinarily since the
obstruction will be found in or about the operative site, and under
any circumstances an incision large enough to admit the hand for
exploration should be sufficient unless the obstruction is at a point
far remote from the exploratory opening.

What should be done with obstruction when discovered is, of
course, a sufficiently large subject for a monograph, but leaving out
the rarer forms, the determination of our course of action is not
extraordinarily dilhcult if preconceived notions or limited experi-
.ence are not hampering the judgment. I wish to utter an earnest
protest against the very common practice of making an enterostomy
the end of every operation for acute obstruction. There is a place
for enterostomy, but it is nol the aim of every operation for obstruc-
tion, postoperative or otherwise. Enterostomy saves an occasional
patient in whom the point of obstruction cannot be located and in
whom overcoming of the distention allows a twist in the gut to un-
fold itself. It saves an occasional desperate case in which no eflort
to find the point of obstruction is justifiable, but even in this in-

OF OBSTETRICIANS AND GYNECOLOGISTS 1017

Stance a secondary operation of a serious character is always de-
manded. My plea here is for the use of good far reaching surgical
judgment, which takes into consideration not only the present but
the future condition of the patient, which does not unnecessarily
hazard life at the present moment, but which does not overlook the
fact that a secondary operation may be of so serious a nature that
an opportimity to cure now and at once should not be passed without
mature consideration. It has seemed to me that many of the pa-
tients reported as saved by an enterostomy would have done equally
well without, if any attempt at overcoming the obstruction had been
made, and that the idea of intestinal drainage has been worked far
beyond the limits of good sense and good judgment.

So, too, with the drainage of the gut at the time of operation fol-
lowed by immediate closure, on the theoretical basis that absorp-
tion of the contents of the distended bowel so soon as they reach
the injured intestine is likely to prove fatal. Granted that a
greatly overdistended paretic intestine is better emptied than
left, how many times do we actually see the gut in such condition
that if that were the only indication we would proceed to empty
it? This really practical reason for emptying is only too fre-
quently bolstered up by the theoretical consideration of possible
poisonous contents above the point of constriction which poison
will be absorbed by the uninjured mucosa lower down. Relatively
so Uttle of the gut is emptied by puncture, and the risk of soiling
the peritoneum and wound edges is so great, that if this theory
of poison were universally true it would almost invariably end in
death anj^way either from this source or from infection of the peri-
toneum and wound.

In this connection I wish to report ^^ cases of acute obstruc-
tion of all types excepting intussusception, in 20 of which ad-
hesions were released and the point of constriction oversewn
if necessary but the bowel was at no time opened and all recovered;
5 in which the intestine was evacuated and then closed, with
2 deaths; 6 in which an enterostomy was made with 4 deaths;
I resection with immediate closure recovered, and i entero-
anastomosis recovered.

On the surface this shows a much better result for no opening of
the intestine than really is true, because my own practice is to open
the intestine only if it seems absolutely demanded, and it is obvious
that the most seriously ill patients were treated in this manner.
On the other hand, the fact that in 20 of 33 the intestine was
not opened either temporarily or permanently, and that no deaths

1018 TRANSACTIONS OF THE AMERICAN ASSOCIATION

occurred, is fair proof that some enterostomies, at least, are un-
necessary.

Did time permit, I should be glad to go into two other phases
of abdominal surgery in which theoretical considerations or experi-
mental work have led us from the path of safe procedure. One
of these is drainage, the other the use of cathartics, more particularly
postoperative cathartics, in abdominal surgery. Perhaps, I still
have time merely to touch upon them.

It is not so long since drainage was practised after every abdomi-
nal operation, and with the unclean methods of operating in vogue
a few years ago it would be hazardous to say that such drainage
was not a very essential factor in the recovery of many patients.
Then came the swing of the pendulum with the dictum that prac-
tically every patient would recover if the abdomen were closed, or as
one German surgeon declared, the abdomen should always be closed
and with this closure the fate of the patient is sealed since nothing
more can be done, or as one American authority wrote, the abdomen
should be closed after every pelvic operation, as any abscess which
might form could be opened later through the cul-de-sac of Douglas.
The fear we had of pus in the tubes was lessened by the laboratory
demonstration that living microorganisms were absent in the great
majority of instances (one place in which research was of practical
clinical value) and our fear of peritonitis from soiling the pelvic
cavity with the contents of chronic pus tubes disappeared when this
demonstration was verified by chnical experience. It was char-
acteristic of the profession that it joyfully and promptly concluded
that pelvic drainage was always unnecessary. What are the facts?
They are that virulent peritoneal infection introduced by means of
the hands or instruments to-day is almost unknown in the practice
of the modern surgeon, that leaks at the suture Hne in surgery of
the large intestine are fairly common, no matter how careful the
technic, that e.xtensive raw areas in the pelvis may not of them-
selves be especially dangerous, but that they often cover badly
damaged, even perforated gut, and that the combination of large
oozing surfaces and damaged intestine gives an excellent culture
medium plus the probability that the microorganisms will mi-
grate through the intestinal wall, and last that pelvic pus of other
than gonorrheal origin is not necessarily sterile, no matter how
long it may have been walled in. It follows logically that proph-
ylactic and protective drainage (cofferdam drains) still have a
very prominent place in the practice of some of us who are doing
abdominal and pelvic surgery, and it is to my own partiality for

OF OBSTETRICIANS AND GYNECOLOGISTS 1019

drainage, when in doubt, that I attribute the recovery of every
case but one in the last 217 cases of salpingitis upon which I have
operated, and the patient who died would have recovered if drain-
age had been practised since sepsis was secondary to slow bleeding
from a vessel tied in the midst of edematous inflammatory tissue.

It is our belief that it is good surgical judgment to use a rubber
dam. prophylactic drain to the vicinity of sutured large intestine,
especially if there has been injury during the enucleation of inflamed
structures and the gut wall is infiltrated. That a cofferdam led
through the vagina is all important if such enucleation leaves
behind a large oozing area, and that an occasional instance of
salpingo-oophorectomy even for presumptive chronic disease is
saved by such drainage when raw areas are left after the removal
of adherent pelvic organs whose primary infection was not due
to gonorrheal salpingitis.

In a syndicated health article in one of the daily papers, I notice
that a distinguished internist and ex-health officer gives advice
something like the following to an inquirer who asks what to do for
a beginning attack of appendicitis. Put an ice bag on the abdomen,
go to bed, and take a cathartic. The article is not before me at
this writing so that the quotation is not exact. It probably is well
that the layman with appendicitis has too much pain to depend upon
newspaper advice, but it likely would be better if the entire medical
profession did not seem obsessed with the idea that calomel and
salts or castor oU were sovereign remedies for every sort of abdominal
trouble having pain as one of the cardinal symptoms. It would be
interesting to know how many patients with appendicitis have been
sent to the Great Beyond by calomel and salts.

It would be more interesting to know how many had been tor-
mented by unnecessary distention, gas pain, and loss of sleep because
of professional belief in the postoperative cathartic fetich. Aside
from this morbidity, it is our positive conviction that there is a
distinct mortality from the same source due to the forcing of gas
and liquid feces into the temporarily paralyzed gut and consequent
torsion of that portion about adherent areas. Where this idea of
the value of early postoperative catharsis originated is questionable,
but it was probably from the teachings of Lawson Tait, and the
notion that intraabdominal drainage could be established in this
manner, plus the nervous anxiety of the surgeon who knows that
paresis, obstruction, and peritonitis do not exist if the bowels move,
but whose judgment ought to teach him that their absence is not
due to the fact that the bowels are moving. Let me repeat in con-

1020 TRANSACTIONS OF THE AMERICAN ASSOCIATION

eluding this imperfect and admittedly dogmatic article that it is
no screed against research, but the number of research workers is
so small in proportion to our needs, the published results of researches
are so frequently premature and unconvincing, that unless they are
absolutely substantiated by thorough going cUnical observation they
are not to be accepted in heu of bhe great laboratory which should
exist at the receiving center for the five senses of the clinical surgeon.
314 Osborne Building.

DISCUSSION ON THE P.\PERS OF DRS. YATES, SKEEL AND CARSTENS.

Dr. Gordon K. Dickinson, Jersey City, New Jersey. — The first
aphoristic statement we have heard for a long time is "postoperative
cathartic feeding." That will ring in my ears for some days to
come. If my friend from Detroit would try Kemp's tube I think
he would find it of some advantage. He says he has not used it,
yet he speaks of postoperative cathartic feeding. He feeds his
patients medicine and drugs and tries to push into the lame gut, that
needs to be rested, something from abov'e. This adds to the nausea
for which he gives bread crumbs. Why doesn't he wash the
stomach out and let the poor thing rest? There is nothing like rest
in the belly. It cannot act well without it.

Some one has said that this is an age of observation. We have
research laboratories; we make observations, but nobody is doing the
correlating because we have five senses and but one brain. Our
five senses are working overtime and our brain is lazy. The moving
picture show is all the rage. When we go to a moving picture show
it does not work our brain a bit. We see with our eyes, we hear
nothing, and do not understand what the lips are saying. We
should observe our patients carefully. We should not put them into
a hospital for the purpose of operating, but for the purpose of observa-
tion. Do not let Dr. Jones send in a case for Dr. Smith to operate
upon to-morrow. Keep the patient under observation; study the
case carefully; get the atmosphere for the patient and make her
understand where she is. Do not give her opiates to put her to
sleep, but put her to sleep with jollying and joking. Let humor
prevail. Donot let her feel that "there is nothing to be done." You
may cut down the bill if you do not find as much pathology as you
expected because the patient will say, "You charged me so much
when you said the operation was nothing." Nevertheless, you may
have saved that patient's life. Above all things, study your case.
Let your intern study it and you study it with him. Use your brains.
Do not go to your laboratories until you have written your diagnosis
in ink, and when you have written it, stand by it.

Dr. W. a. B. Sei.lman, Baltimore, Maryland. — This is a most
interesting subject, and we all have the same feeling in regard to it.
I must differ with the doctor who read the paper in regard to bring-
ing patients into the hospital days or weeks before operating on them.
One can easily see the evil of this. When a woman is brought to the
hospital days before operation she becomes frightened. She is in

OF OBSTETRICIANS AND GYNECOLOGISTS 1021

a condition of shock before operation actually takes place. I
believe in preoperative treatment in the patient's home where none
of these disturbing influences are present.

I do not think we should operate on a case without knowing what
the diagnosis is. We must make our diagnosis and then certain
preparations are necessary. In some cases it is necessary to give
an eliminant, that is, cathartics by the mouth to act on the intes-
tines. In other cases one could give urotropin or formin because
it is more easily secured, and is cheaper for the patient. But I
think formin as given before operation is a most valuable drug, and
by allowing the patient to be in a hospital only a short time before
operation she does not develop fright and dread. If the patient to
be operated on occupies a room adjoining a patient that is brought
from the operating room, she is likely to develop fright; she is in
more or less shock, and is therefore in a bad condition to be placed
under an anesthetic and be subjected to a major operation.

In regard to the use of H. M. C. tablet, I have abandoned it
entirely, and if the patient is restless, I give a hypodermic of morphine
and atropin, namely, 3^ of a grain of morphine with 3^50 of atropin
an hour before operation or before the anesthetic is administered.

I have been fortunate in having a most excellent anesthetist in
whom I have every confidence and I never take the anesthetic into
consideration during my operation. My anesthetist is not diverted
by watching the operation. I think the anesthetist should be a
graduate physician, a man who has had years of experience, and
one who has been trained in a large hospital. My anesthetist is a
graduate of the Johns Hopkins, where he has had an opportunity
of seeing a large amount of major surgical work done; he is a labora-
tory man, understanding the functions of every organ in the body,
and a very careful man, and he insists upon commencing the anes-
thetic with the essence of orange. He uses a bitter orange, claiming
that sweet orange has no efficacy at all. He uses 25 per cent, of oil
of bitter orange with seventy-five parts of alcohol. The result is
we do not have our patient crying or struggling on the table; they
do not dread anesthesia which I think is an important thing.

Many patients do not die from the shock of the operation, but
death is due to shock which takes place before. The patients are
in a bad condition, and if they go into a hospital a day or two before
operation the shock is much less than if they are brought there and
remain a week or two before operation. I think having them in the
hospital several days before they are operated on has a bad effect
on them. One patient will tell what she went through and how she
felt after operation, and naturally the woman to be operated on will
dread it and is in no condition for operation. She is not rested.
Both her mind and body are active.

After an operation, if I find there is a great deal of pain, I give
another h\-podermic of morphine and atropin.

There is one point I would like to mention, and that is the use
of drainage tubes. I do not use rubber drainage tubes any more;
I use a cigarette drain of gauze wrapped with rubber tissue properly

1022 TRANSACTIONS OF THE AMERICAN ASSOCIATION

prepared. These drains are less disturbing and much more effective
than a rubber tube which becomes clogged. This gauze is like a
Turkish towel, it empties the pus basin, and you get the material
out of the patient's body.

Dr. Albert Goldspohn, Chicago, Illinois. — In regard to the
class of cases Dr. Carstens referred to concerning which there is
some uncertainty as to the diagnosis, the women attending to their
business and complaining all the time with a rather negative objec-
tive condition in the pelvis, he is inclined to ascribe this trouble to
adhesions, and certainly adhesions do make such trouble. But
every now and then we open the abdomen and pelvis and find adhe-
sions that have not caused any trouble; and I am satisfied that adhe-
sions are like paper, that will allow anything be printed on it. They
cannot talk back. In a number of such cases I have ascertained the
mode of life of such patients, the details of their domestic life, their
individual habits, things they would not confess to their own
mother frequently, and have found that some of these persistent
complainers who have no clear objective pathology that one could
find by the closest bimanual examination, have indulged in coitus
interruptus, or were given to masturbation; and you will have to use
all the skill and ingenuity that you are master of, to get them to
confess. But it will often succeed. This abnormal habitual ex-
citation of the sexual orgasm that is not gratified naturally is
followed by a pernicious effect upon the pelvic circulation, in that it
results in an excessive hyperemia. We see a varicose condition of
the broad ligaments often enough; and I am satisfied that we do have
varicosity of veins in the pelvis as well as we have it in the legs.
In this condition the patient will have discomfort or pain. We
cannot treat it in the same way that we do a varicose condition of
the legs; but we can usually offset it by an overcorrection in the
sense of a suspension of the uterus up against the abdominal wall.
And that can be done innocently if you know how to handle the
round ligaments correctly.

In regard to the rest of patients in the hospital before operation:
This is frequently needed in order to get their excretory organs in
proper condition before assuming a surgical risk. Again, it is often
needed to make acute inflammatory conditions in the pelvis subside
properly, when they are not from the appendix, before operating.
Occasionalh- 1 get a patient who has been the rounds of a number of
celebrated surgeons, and has had proposed to her a gastroenteros-
tomy or cholecystostomy, or some operation in the epigastrium,
because when the woman came to the doctor she first complained of
epigastric symptoms and her pelvic organs have been left quite out
of consideration. I contend we cannot make up our minds finally
as to what we will do for a woman until we \vd\e examined her
from her head to her pelvis, beginning at the head and finishing with
the pelvis. 1 believe we should go over the trunk as carefully as any
specialist would and thoroughly convince the patient that we know
her case before we pronounce a dictum with regard to her condition.
What vour dictum then is, she will have confidence in. There are

OF OBSTETRICIANS AND GYNECOLOGISTS 1023

cases where I cannot decide with certainty that the epigastric
symptoms are due to pelvic lesions. In some of them I know that
they are, when they come to me. In other instances, I cannot
decide positively. I will put such a woman at rest in a hospital
where she is under intelligent care and have her eat about the same
things that she was accustomed to eat at home, properly prepared.
But she must rest, and with bed pan service. She is not to get up to
defecate or urinate. Constant complete recumbency soothes or
stopsboth the local and referred symptoms of gynecological disorders.
Accordingly, when the epigastric symptoms are of a referred nature,
they will stop or greatly improve upon such preliminary rest treat-
ment, and show that epigastric surgery is not needed, if the clearly
pathological conditions in the pelvis are effectively cured.

Dr. William H. Humiston, Cleveland, Ohio. — All of the papers
in this group just read are full of interest, but it is impossible in the
time limit to discuss all of them.

With reference to the paper of Doctor Carstens, will state that
it is possible to have a pelvic peritonitis in a patient who does not give
up and go to bed — walking cases — but upon making a bimanual
examination you will find tenderness and impaired mobility of the
uterus. This impairment of mobility may be of any degree from
slight, to a fLxed condition. In cases that give evidence of having
had a pelvic inflammation, do not curet the uterus, unless you
immediately open the abdomen and correct fully the pathologic
condition existing. The trauma of cureting the uterus and with-
holding complete surgical work is quite liable to be followed by a
sharp reaction. The patient suffering with cirrhotic ovaries is a
chronic neurotic. The constant pain wears them out together with
the reflex disturbances of the circulatory system and digestive tract.
Are usually emaciated and the ovary can be palpated though smaller
than normal. It is found firm and very sensitive. The tunica is
thickened, and ovulation does not occur. While suffering all the
time, the symptoms are all increased during the scanty menstrual
period. Removal of this type of diseased ovary is essential to
recovery. With but an occasional exception, I use the drop
method of ether as the best and safest anesthetic. This requires a
competent well trained anesthetizer to attain the ideal, and the
postoperative vomiting is almost nil.

It is difficult to obtain a complete relaxation of the abdominal
muscles from gas-oxygen. Besides we do have a goodly number
of fatalities where it is administered by one of limited experience.
I believe in lower abdominal surgery it is unnecessary to have shock.
The two principal causes that produce it are hemorrhage and
careless and prolonged manipulation of the abdominal viscera,
both preventable in competent hands.

In that t\'pe of case that has suffered for weeks from tuboovarian
suppuration, rapid pulse, some fever, loss of weight and strength,
and free perspiration, who must have relief through thorough
operative measures, I carry them safely over the operation without
shock by a steady administration of sterile saline solution sub-

1024 TRANSACTIONS OF THE AMERICAN ASSOCIATION

mammar}- during the half hour required to complete the operation.
I have noted in many of these extreme cases a better pulse after com-
pleting the operation than it was for days prior thereto.

Dr. Charles L. Bonifield, Cincinnati, Ohio. — I have certainly
enjoyed the paper of my friend Dr. Yates, as well as the very epi-
grammatic paper of Dr. Skeel. I have expressed myself on former
occasions on the two subjects they have mentioned, so that I would
not take the trouble to express my opinion again if it were not for
the fact that they and you might think I did not still have the
courage of my conxdction, and that I was not still doing my own
thinking in religion, politics and medicine.

Dr. Yates insists on giving these patients large doses of opium
to benumb them, to stop ehmination. If there is anything on earth
we have learned in modern surgery, it is that we can assist nature
by ehmination. You can control pain; you may control vomiting
often by putting the patient profoundly asleep. But you are
simply shutting up the fire in the hold of the ship; you are not de-
stroying it. On the other hand, if by stimulating these secretions of
the kidneys, the skin, and the activitj- of the bowels, you hasten
elimination, you are driving the thief out of the door. This treat-
ment by opium was tried by the profession and weighed in the
balance and found wanting before I began to practice medicine.
Certain members of the profession are trying to bring it back. It
had an element of truth or it would not have survived as long as it
has, but its value after abdominal operation has been disproved time
and again.

The other thing I want to talk about is purgation. Doctor Skeel
seems to think that the bowels, after the abdomen has been opened,
are so damaged or injured or insulted that to rid them of their
normal contents is to invite disease, and he wants to know where
we got the idea that purgation does good. I will ask him if purga-
tion does not do good in other conditions. All the nose and throat
men purge their patients the first thing in pharyngitis or tonsillitis.
If you have an acute inflammation of the eye and call in an ophthal-
mologist, he is very likely to give you a free purge. Lawson Tait
instituted this treatment of purgation, and I got the idea of purga-
tion by watching the immediate eflfects when that treatment was put
into operation by my teacher Dr. Reamy, and his mortality was
instantly reduced. From that time to this, I have always watched
my own cases closely, and while I do not purge every case by any
manner or means, yet at the hospital where I do much surgical work
the Bonifield routine is well known, and when I get awaj' from it my
interns and my assistants tell me to go back to it.

A year or two ago I tried to use pituitrin, a dose every three or
four hours instead of a purge, and all the boys working with me said,
"Let us go back to the old routine." I admit that my patients are
more uncomfortable than the average man's patients the day after
operation, but I contend that the day following that, and the day
following that, they are further advanced than the patient who is
loaded with feces. I have learned this by bedside experience; I

OF OBSTETRICIANS AND GYNECOLOGISTS 1025

did not read it in any books. When I began to take care of lapa-
rotomy cases for my predecessor the work was done largely at houses
in the days when we had few trained nurses, and I nursed these
cases myself, I watched the effect of this treatment hour by hour, and
it was from bedside experience that I came to these conclusions.

Dr. William Seaman Bainbridge, New York City. — The sub-
ject of Dr. Yates' paper is so important that it is to be regretted
that only twenty minutes can be allotted to the essayist and only
five minutes to each one who discusses it.

In the preparation of the patient for the strain of a major opera-
tion as great care in every minute detail should be exercised as is
given to an athlete about to engage in any important physical
contest. In emergency cases, of course, this cannot always be
done, but even in these cases the preoperative care should be as
complete as possible. It is my practice, where circumstances permit,
to begin the preoperative preparation of the patient with the mouth
and to go right through to the anus. Particular attention should be
given to putting the teeth in a reasonably clean condition before
operation, and the rest of the mouth, the nose and the throat, espe-
cially the posterior pharynx, should be put in as good condition as
possible. As to the remainder of the alimentary canal, all are agreed
that it should be thoroughly cleared out, whether by enemata or by
cathartics. I do not advocate the use of large doses of castor oil
the night before the operation, thus rendering the patient wakeful
and restless when quiet is so important. The gastrointestinal tract
should be cleared out three or four days before operation, and a
suitable diet of easily digested articles ordered, thus forestalling
acidosis of the starvation type. It is better to removx gas before
the patient is in a depleted condition than to remove it after opera-
tion. It is better to fortify the patient before operation. It is,
therefore, my routine practice to hydrate with an alkaline solution
or dextrose water for two or three days before the surgical interven-
tion. More attention should be paid to the condition of the urine.
If the urine is of high specific gravity, as Dr. Humiston has said,
one should not proceed until this is corrected.

Urine markedly acid from the by-products of the intestinal canal
or other toxins should be rendered mildly acid or neutral before
proceeding. This may necessitate the use of colonic irrigation,
which I have found of great value. I sometimes order 6, 8, or
even 12 gallons of alkaline water during the day, using the
Kemp tube, or the two rubber tubes employed by Dickinson for
postoperative irrigation, inserting one 8 inches and the other 2
inches, and using a teaspoonful of bicarbonate of soda to the pint
of water. With the requisite care on the part of the nurse, this plan
will soon bring the urine to the neutral point without discomfort.
In many cases I employ hypodermoclysis. I have found this advan-
tageous in severe abdominal operations, such as colectomy, or the
removal of other abdominal organs. After the anesthesia is com-
plete the h^-podermoclysis needles are inserted under the breasts,
and from 2 to 3 quarts of saline or tap water introduced, the

1026 TRANSACTIONS OF THE AMERICAN ASSOCIATION

administration continuing throughout the operation. After the
operation, if necessary, soda solution, i dram to the pint of water,
is given by the Murphy drip, 40 drops to the minute. Experience
has shown, in mj' hands and those of many others, that the use
of I to 3 quarts of normal saline solution, introduced under the
breasts or into the rectum, is distinctly advantageous, and is taken
up by the patient without necessarily throwing too much weight
on the heart or overloading the kidneys, as some have suggested,
although such possibilities are to be borne in mind. After operation
I never employ sahne solution, preferring bicarbonate of soda or tap
water. To continue the saline would certainly entail the danger of
overloading the kidneys.

Referring to the matter of rubber drainage, I have followed the
practice of Sir Berkeley Moynihan of having a spiral slit in the tube
for all drainage other than that of a hollow viscus. The use of gauze
drainage is most questionable.

Dr. James E. DAV^s, Detroit, Michigan. — Referring to Dr.
Carstens' paper, I want to make a plea for a closer study of gross
pathology. It does not seem that anywhere in this country is
there an adequate assembling of material for a careful study in gross
pathology. Some of the laboratories are beginning to do this work,
and already there is a good beginning, but physicians could be made
better diagnosticians if we had the opportunity of studying on an
e.xtensive scale gross pathological material.

Just one example of how valuable the observation of gross pathol-
ogy is in the study of gynecological disease, let us take, for instance,
the examination of Skene's ducts, the uterine cervix, and the orifice
of the Bartholinian duct in revealing when we have gonorrheal in-
fection. A careful study of these parts will help us materially in
making a diagnosis of gonorrheal conditions, which we all admit are
etiological for a great deal of the pathology found in the pelvis.

Dr. Yates has spoken of demonstrable pathology. That is largely
a personal equation. One man will notice what another man may
not notice, so here one must be specially trained for advantageous
observation in gross pathology.

I think Dr. Skeel has rather minimized the work of research
workers. I think this lesson should be taken by clinicians. If we
would use somewhat the same methods that the research workers
use, we would be able to advance our clinical methods very much
more rapidly than we do.

Dr. Yates spoke of the use of small quantities of water following
operations. I believe that small quantities of water are not of any
particular advantage. It has been shown by Hertz that if you give
a smaller quantity than 4 ounces of water on an empt}^ stomach,
it will remain there for a long time until the quantity accumulates
to over 4 ounces. If we give 8 ounces or more the stomach will
contract and empty that amount of water easily in thirty minutes, or
if the patient wishes to vomit he can do so more easily rather than
strain with a spoonful, or i or 2 ounces.

In regard to the use of formin, it does not seem to me that it is a

OF OBSTETRICIANS AND GYNECOLOGISTS 1027

wise procedure, when we find that the centrifuged urines under the
microscope will very frequently show numerous red blood cells
after you have given a number of doses of formin. This cannot
be a safe procedure to follow, during a number of days preceding
operative measures.

In regard to catharsis, Nov>', and DeCrief have shown in an un-
published work that sensitization can be secured by injury to the
epithelium of the gastrointestinal tract. If we frequently e.xamine
the epithelial surface of the alimentary canal, we will be surprised
to notice the number of erosions that take place following vigorous
catharsis, and if we allow proteins following this there is often a
very marked sensitization produced which is most deleterious for
patients about to be operated upon. Many of us have recollections
of the vigorous catharsis after seeing these patients the next day.
It is much better to give cathartics long enough before an operation,
so that the patient can recover from any sensitization that may
result.

In regard to the submammary use of salines, Novy and DeCrief
have also shown in the use of salines we can have marked sensitiza-
tion in many patients. Just two weeks ago I saw an example of
very marked sensitization, from the use of salines given under the
breast.

Dr. O. H. Elbrecht, St. Louis, Mo. — The subject of normal
saline solution given under the breasts or by proctoclysis has re-
ceived too little attention in this discussion. Dr. Bainbridge spoke
in rather large figures as to the amount of saline he gives under
the breast, he said 2 or 3 quarts. I think we all have given too
much at some time or rather for there is no question but every now
and then we meet with cases that we are overloading and notwith-
standing all the nice surgical work done on the operating table, we
are likely to kill such patients by overloading the heart too suddenly,
and this applies whether the saline is given under the breast, intra-
venously, or otherwise. I feel certain that I have made this mistake
like many others in my earlier work.

Dr. Humiston. — How do you give it?

Dr. Elbrecht. — By all three methods.

Dr. Humiston. — The absorption is slight.

Dr. Elbrecht. — You should figure on how much fluid you are
throwing in at one time. If you use several quarts and patients are
weak from shock they cannot handle it. It is better to give say 750
to 1000 c.c. and repeat it if necessary. The same thing is true of
ordinary saline given by proctoclysis, where overabsorption some-
times takes place, for these patients become edematous and no doubt
many of you have seen this phenomena. The point I wish to
make is that saline intravenously can be overdone, and saline given
under the breast can be overdone. If you would save your patient
with saline-solution you can do so just as well with a pint and a half
or a quart and repeating the dose on indication rather than by givmg
too much at one time. If this rule is not regarded it is just the same
as putting too big a load on a tired horse going up hill, because of the

1028 TRANSACTIONS OF THE AMERICAN ASSOCIATION

of the load being too heavy he will have to stop and just so with a
weak heart that is overloaded.

Dr. Carstens (closing on his part). — I have nothing to say in
closing the discussion on my own paper; I would like to say a word
or two about the other papers.

On general principles, I agree with most that has been said by
Dr. Yates. You must get the patient in good general condition,
having no material in the intestines that will create irritation. I
try to do that. Before I send the patient to the hospital, if I pos-
sibly can I treat her for a while, when I do not know whether I
shall operate or not. I try to put her in as good general condition
as possible, and let her take, if necessary, cathartics a day or two
before she is sent to the hospital, and when I decide she needs oper-
ation, I operate the next day. There are, however, cases in which
I cannot make that necessary diagnosis at the patient's home. I
have got to have them in the hospital where I can have a blood
examination made and a Wassermann test, and the urine collected
for twenty-four hours. That cannot be done in the office, hence the
importance of sending them to the hospital for three or four days
before operating, and if they do not require operation I send them
home. This habit of having patients in a hospital several days be-
fore undergoing an operation is dangerous. Such a patient, if she
hears another patient scream, is put in an unhappy frame of mind,
and she thinks that the Society for the Prevention of Cruelty to
Animals should come in and get busy. (Laughter.) Only last week
I heard a patient scream to such an extent that she could be heard
on three different floors of the hospital. I asked what was the
matter with the patient, and was told that she had a severe pain,
that her doctor did not believe in giving morphin. Like my friend
Bonifield from Cincinnati, I suppose this practitioner believed in
giving cathartics. I would like to ask, what in the name of common
sense are morphin and opium made for anyway except to reheve
pain? If a doctor cannot relieve pain, of what use is he anyway?
I beheve we should give morpliin or opium or any drug to relieve
the pains of these patients. If a patient has had for several days
food that is free from purin matter, and the stomach and bowels are
in good condition, a couple of doses of morphin will relieve that
patient and give him or her a good sleep for twenty-four or seventy-
two hours. It will not hurt the patient because he or she does not
need ehmination. There is nothing to eliminate.

When it comes to giving a patient with an injured intestine which
}0U have been cutting or slicing up, and sewing it end to end, or
making a hole in the stomach and joining it to the opening in the
intestine, and so forth, 1 think it is the most absurd thing that I
can think of, and I regard it as mighty poor practice. What do
you do with a patient who has a fracture? You do not give that
patient any cathartics do you? No, you put the leg in a splint
to keep it quiet, so that circulation can be reestablished and the
lymphatics can be at work to absorb the dead blood, and that
patient in a week will feel good. The same thing applies to an

OF OBSTETRICIANS AND GYNECOLOGISTS 1029

injury of the intestine. An injured intestine is like a sore leg, if
you give it a little rest and do not move the patient's bowels for four
or five days, thus giving the poor, sore bowel rest, the patient will
get along very much better. In some cases you do not give enemas.
In other cases you need to wash out the stomach, but to say we
should never give any morphin or cathartics is very absurd. A good
dose of opium will keep many of these patients quiet. We must
treat each individual case by itself, and therefore I would heartily
endorse what Dr. Yates has said. When I was engaged in general
practice I had hundreds of cases, and I could not attend to all of
them as I would like to have done and do my obstetrical work as
well. When I developed into an abdominal surgeon I found out I
could not do abdominal surgery successfully and attend to obstetrics
as well, then I had to give up obstetrics and devote myself exclusively
to abdominal surgery, so that I could devote my individual atten-
tion to these patients and not depend upon my house physician and
the nurse and others.

Dr. Yates (closing the discussion on his part). — Dr. Carstens
in his remarks has brought out practically all that I was going to
say, particularly with reference to the comparison he made of the
broken arm and injured intestine.

Dr. Dickinson's manner of putting patients to sleep by hypnotism
is splendid, and I presume down in New Jersey they sleep that way.
Many of my patients are frightened when they come to the hospital,
and if they are not frightened, they are nervous so that they are
mentally unrested, and I give them a suitable remedy to make them
sleep. It may be opium, trional, or something else. If I put the
patient at rest by giving such a drug she is ready for operation the
next day. I do not know that we all believe in what Dr. Crile does,
namely, anoci-association. I do not suppose we will believe in that,
but Crile's microphotographs and pictures show the condition of the
brain cells before and after excitement, before and after injury in all
these cases which make up the symptom-complex of shock. We
cannot get away from that point, and if we give a patient enough
opium or anything else, paying attention to the elimination, that
patient is going to rest, and when he or she comes to the operating
table the next day, she will be in a better condition for defense.
She needs all the defense she can get from the most of us.

Dr. Dickinson said that so far as he was concerned, he believed
that we should make our diagnosis and stand by it, and that was
all there was to it, but that we should go and have our laboratory
findings, etc. I am glad Dr. Dickinson has that erudition. Per-
sonally, I have to use a stethoscope to listen to the heart; I have to
use an instrument for observing blood pressure; I hav'e to use the
urino meter; I have to use the blood counting apparatus; I have to
use the Wassermann test; I have to find out if my patient has a
leukocytosis or if he has not, and all of these things are simply
methods of precision, the same as our palpatory or auscultatory
methods are means of precision; they are the means of helping us to

1030 TRANSACTIONS OF THE AMERICAN ASSOCIATION

make a diagnosis, and unless the surgeon of the present day uses
these means he will not make a proper or accurate diagnosis.

I do not know exactly what Dr. Bonifield's position is with
reference to purgation. I do not know what he means and when
he begins it; but in the preparation of this paper I have endeavored
to show that we should attend to the elimination of these patients
and have their bowels free one or two days before operation is per-
formed, and that we should have the patienfs bowels at rest and,
if necessary, give a dose of opium. After a patient is convalescing
for a couple of days, it is the common knowledge of all of us that we
feel better if we can get a little elimination, and if we can do it bj'
some natural means, we find the patient feels better. We feel
better if the patient has free elimination. It helps the passage of
gas and all that sort of thing, but if we have a patient who has
pelvic peritonitis or any other kind of peritonitis, which is more
or less diffused, with a soiled peritoneum, it is the type of case that
should have opium. The intestines should be kept quiet and thus
keep the infection from being disseminated by the movements of
the bowels.

Personally, I have never had bad results from using salt solution
intravenously. There is a trend against it. I do not know how
much truth there is to it. Novy has said some very interesting
things on the subject and he seems to show that normal salt solution
intravenously may produce anaphylactic shock. He also says that
transfusion of blood and the infusion of salt water in the veins, or
any other thing used in the veins, is more or less toxic, and it depends
largely on how much we use as to when and how much toxicity we
get.

I do not have very much fear about using all the water we can use;
I do not think it overloads the heart; it does not hurt the heart.
If there is anything that adds to it, it is the bicarbonate of soda.

Dr. Elbrecht. — said that water is all right.

Dr. Yates. — I beg your pardon.

Dr. Skeel (closing the discussion). — I have not very much to
say in conclusion. There has been a fine flow of oratory but after
all not much has been said. (Laughter.)

So far as salt solution is concerned, there is no question but that
Dr. Elbrecht is right. I had unfavorable results from using it and
discontinued it two or three years ago.

Dr. Davis seems to think I belittled the efforts of the research
worker. I did not do that. In speaking of the interrelation of
this most important adjunct to clinical work I stated that the re-
search man was pouring forth on us many things that were
absolutely unproven, and that only occasionally could we pick up
something that was valuable from the entire mass of material.
Unquestionably the research workers are doing their best, but their
premature exploitations are not of much help to us as practitioners;
therefore, we must use our five senses. There is no doubt about the
efficacy of laboratory work.

In these days we are confronted by many theories to explain facts

OF OBSTETRICIANS AND GYNECOLOGISTS 1031

known for many years, one of which is the demonstration of brain
cells showing the effect of fear on the Purkinje cells. The possi-
biUty that fright might cause death has been known for a hundred
years, and one of the earhest physiological stories I can remember is
that of the student frightened to death by being slapped on the
neck with a wet towel when he was expecting decapitation. The
same thing is true with reference to the theory of acidosis. We
have known for a great many years that patients who have been
operated upon may starve to death on an insufficient liquid diet.
Now we have a new fad the hydrogen ion concentration to explain
it, but the fact remains precisely as was known before.

I quite agree with Dr. Bonifield that patients feel much better after
their bowels move. If the intestinal tract has been tortured by the
tenesmus following the administration of calomel and salts it is not
at all strange that the patient feels better after the distress incident
to their administration has passed off, but he would feel equally
well if they had not been given at all and would have been spared
that one day's discomfort.

REMOVAL OF THE APPENDIX FOR THE CURE OF TRIFA-
CIAL NEURALGIA AND OTHER NERVE PAIN ABOUT
THE HEAD AND FACE.

BY
M.\URICE I. ROSENTH,\L, M. D.,

Fort Wayne. Indiana.

The apology I have to offer for presenting this very brief report
of only seven cases is the starthng results obtained. I do not
claim from this small experience that we have established a new
pathology for trifacial tic and kindred affections, but I do claim
that in these seven cases we have fixed the pathology in the vermi-
form appendix, even though the physical and subjective evidence of
appendicitis was so obscure as to be entirely overlooked. In all
but one case, there was present almost symptomless chronic appen-
dicitis of the obliterating type; the other a symptomless pus case.
It is very probable that a report of loo cases might reveal some fur-
ther startling results in a condition where even a successful Gasserian
operation frequently results in recurrence and might explain the
unsatisfactory results from resection or evulsion of the nerve as
well as from injections used with a view to chemical nerve destruc-
tion. Case VII of this series is more on the order of migraine or

*Read before the Twenty-ninth Annual Meeting of the .'Vmerican Associa-
tion of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

1032 TRANSACTIONS OF THE AMERICAN ASSOCIATION

so-called sick headache. It has not been uncommon in my ex-
perience to note the cure of migraine and so-called sick headache
after removal of a diseased appenchx. It is quite possible that many
of these cases come under the same pathology as does tic douloureux
and other nerve pain about the face and head.

From the prompt cessation of the pain in six of these cases, we
may conclude that the disturbance was a toxemia with selective ac-
tion. If the tonsils, the teeth, the hollow bone cavities give rise
to toxemias and bacteriemias of such far reaching effect, we need not
be surprised if the appendix, a hollow abdominal organ with its
possibilities of aerobic and anaerobic bacterial development, should
give rise to a toxemia which is the basis of a selective neuritis or
nerve irritation.

In Case IV we found an appendix full of pus under tensiou
(staphylococcus pus). In this case we had a gradual reduction of the
pain. In the other cases the cessation of pain was immediate.
It would appear, therefore, that in Case IV we were dealing with a
neuritis, in the other cases with a nerve irritation from toxins
evolved by the appendix.

The following is a condensed report of seven consecutive cases.

Case I. — Miss G. aged forty-six, Mishawaka, Ind., Fibroid tumor;
complains of neuralgia of fifth nerve left side of face, covering a
period of two years. Tumor causing pressure symptoms. No
suggestion of appendix trouble. Operation Sept. 8, 1915. Fi-
broid impacted in pelvis. Hysterectomy. Appendix found dis-
eased (appendicitis obliterans). Appendix removed. Day fol-
lowing operation patient remarked that she had complete relief
from her pain in the face; no attention, however, was given this
statement as we confidently expected a return of the neuralgia.
However, when after several days she still remained free from this
pain, we began to speculate as to the cause of her cure. There was
no degenerative process going on in the fibroid; therefore, it occurred
to us that possibly the removal of the appendix might have caused
the neuralgia to disappear. We were inclined to give the matter no
great consideration.

Case II. — Miss H., daughter of Dr. Harold, Glandorf, Ohio, aged
20. Entered hospital for resection of mandibular branch of tri-
facial on right side. Duration of pain about one year, lately in-
creasing in violence. Had undergone usual treatments with arsenic,
quinine, salicylate, etc., etc. Hacl tooth extracted and piece of bone
removed from jaw. After extraction of tooth pain seemed, if any-
thing, more constant. This young lady's father, being a physician,
assured me that every possible medical and dental means had been
resorted to and pointed out the futility of any further efforts in that
direction. Being loathe to operate on her face, unless ab.solutely
necessary, I explained to Dr. Harold what had happened in Case

OF OBSTETRICIANS AND GYNECOLOGISTS 1033

I and drew attention to the further evidence of possible appendix
trouble, in that the patient had had some pain in the right side. The
doctor very gladly consented that an appendectomy be made before
I should operate on the jaw. Operation Sept. 13, 1915. Appendec-
tomy; chronic appendicitis obliterans with adhesions. Sept, 14,
1915, patient free from pain. Discharged Sept. 26, 1915, free from
pain. Sept. 13, 1916, patient called at Saint Joseph's Hospital,
Fort Wayne, to report herself still free from pain.

Case III.— Mr. F., Kendalville, Ind., entered Saint Joseph's Hos-
pital, July 16, 1914. Attorney, aged fifty-two. Neuralgia infra-
orbital nerve left side which had regenerated after a previous opera-
tion. Had his first attack in 1894, when the trouble was attributed
to an impacted molar. Molar removed; later the other teeth were
removed. Had antrum of Highmore drained in 1895. Was oper-
ated on once or twice yearly for several years after this. Sphenoid,
ethmoid and antrum of Highmore operated and drained. Dr.
Nicholas Senn finally secured relief by removing the mandibular
branch by a long incision along the lower jaw and removing the
remaining affected branches by means of Langenbeck incision
(as for resection of the upper jaw). The patient gave the significant
information that while under Dr. Senn's care the only medicine which
seemed to afford any relief was castor oil. You will note that this
case at this time antedates my experience in Cases No. I and II.
Present attack began June 30, 1914. Operation July 16, 1914,
resection of regenerated infraorbital branch through the antrum by
incision along the scar. The anterior antral wall had been entirely
removed. July 17, pain only slight. Left hospital on July 18.
December 14, 1914, returned because of pain in scar under the eye.
December 15, resected part of old scar. Returned to his home
December 19, 1914, relieved.

September 28, 1915, returned because of pain in region of left
mental foramen, extending along ramus of jaw. Operation: Injection
of alcohol. Sept. 30. returned to his home relieved. Oct. 22,
1915, he returned for relief from another infraorbital attack. Opera-
tion, relief. Feb., 1916, returned with recurrence of his old trouble;
close questioning revealed the fact that he had had pain in right
iliac region. After laying before him the results in Cases I and II,
he readily consented to having his appendix removed. Operation
Feb. 17, 1916, appendectomy; appendix thickened and adherent
to cecum. Result, came out of anesthetic free from pain and has
remained free from pain.

C.\SE IV. — Mr. J. C. Payne, Ohio, aged fifty-four. Entered hos-
pital July 19, 1916, for relief from trifacial tic; duration of malady
six years. Five years ago he had partial resection of right upper jaw
for tumor in antrum. Subsequently had the remaining portion of
upper jaw removed for relief of pain. Since then has undergone
operation eight times for relief of pain. Has been taking morphine
regularly for last two weeks. No history of abdominal distress.
Having laid before him the history of the previous cases, he consented
to having his appendix removed before I should operate on his face.

1034 TRANSACTIONS OF THE AMERICAN ASSOCIATION

Some tenderness was elicited on pressure at McBurney's point.
Operation July 19, 1916. Appendix found distended with staphy-
lococcus pus. He complained of pain in face on corning out of
anesthetic and required morphine several times. Left hospital
July 3, igi6, with some tenderness in scar under eye, but much
relieved. Aug. 28, 1916, returned because of pain in scar, the
peculiar pain of tic, however, not having returned. Fifty milli-
grams radium was apphed to scar which seemed to give rehef. No
doubt there is some inclusion of the nerve ending in the scar in this
case.

Case V. — Sister S., Glandorf, Ohio. Referred by specialist by
whom she had been treated for disease of the sinuses, with the report
that notwithstanding the sinuses were healed, she still continued to
have pain and asked that I take such measures as I might see fit to
relieve the patient from her sufferings. Patient complained of supra-
orbital and temporal pain, the temporal pain radiating toward the
occiput. Disturbance of several years duration. Has had ethmoid
curetted; maxillary, frontal and sphenoidal sinuses drained. A'-ray
and other examinations negative. Had an attack of appendicitis
twelve years ago. No present evidence of appendiceal trouble.
Acting upon the experience of the foregoing cases, the patient under-
standing that we made no promise of rehef, appendectomy was
done. The appendix was found to be firmly bound down by ad-
hesions. The patient came out of her anesthetic free from pain and
has remained so since.

Case VI. — Sister M. H., Nurse at St. Joseph's Hospital, aged
thirty-two. Pain began about two years ago in left side of head
and over left eye and near left inner canthus. Until recently she
had obtained relief when sinus was being drained. (Antrum, sphe-
noid and ethmoid ware drained.) Operation Aug. 16, 1916. Appen-
dix removed. Appendicitis obhterans; Came out of anesthetic
free from pain and has remained free to the present time.

Case VH. — Sister M. A., aged forty-seven. Teacher. Entered
hospital Sept. 6, 1916. Has been suffering from headaches every
week for seven years. Previous to entering hospital they had become
quite constant, pain being over both temporal regions. Complained
of pain in epigastrium at times, accompanied by vomiting. Attacks
lasted from few hours to a day. No relation to menstruation.
Tendency to diarrhea. No pain at McBurney's point or under
costal margin. Her case had been diagnosed as gall-bladder
disease. The abdomen was opened, but gall-bladder found healthy.
Long retrocecal appendix extending well up toward liver and firmly
adherent was found. This was removed, and the patient has been
relieved of all symptoms since her operation.

It is quite possible that in Case II the impacted molar was a
predisposing factor as was the case in Case III. In Case IV we had
a history of tumor of the antrum, probably a fibroma. In Cases
V and VI we had suppurative disturbance in the bony antrum as
a predisposing factor in the selective action of the toxemia, and

OF OBSTETRICIANS AND GYNECOLOGISTS 1035

in Case VII without predisposing factor we found a bilateral
disturbance.

336 West Berry Street.

DISCUSSION.

Dr Herman E. Hayd, Buffalo, New York.— A few years ago, if
I had Ustened to a paper like the one Dr. Rosenthal has presented
to-day I would think he was demented, but I know better now and
that he is bringing to us something of interest. I beheve it is possi-
ble to explain the conditions he has pointed out on the ground ot
intestinal toxemia or intestinal stasis or peripheral reflex irritations,
because it has been my experience and your experience that alter
removing a bound-down appendix, or the hard toothpick-hke appen-
dix we have afforded relief in such cases of facial neuralgia and head-
ache as those to which Dr. Rosenthal has called our attention. Ut
course, if we practise surgery without our five senses, and without
the judgment Dr. Skeel wishes us to cultivate, we are going to do a
great deal of meddlesome surgery and do a great deal of harm; but
after such experiences as the essayist has had, we must t unk ot ttie
possibilitv of such an association, and many of these chronic sut-
ferers may be reheved, and particularly if we inquire into their cases
we may find there is a tender appendix and a train of gastrointestinal

■ symptoms. . , i r j •»•

I believe this paper is capable of doing a great deal of good,_ U

seriously and thoughtfully considered by the feUows of this Associa-

^°Dr Roland E. Skeel, Cleveland, Ohio.— I have had two cases
of sciatica that recovered after the removal of the appendix. I do
not believe however, the removal of the appendix had anything in
the world to do with it. Most of us are famihar with the toxemic
theorv of the various neuritides as the result of appendicitis, but i
do not beheve that the sciatica in my two patients was reheved
simply by removing their appendices. . , , i j

A point we should consider seriously is the time that has elapsed
since these operations were performed, one of them but a few days
ago Perhaps in a year from now Dr. Rosenthal will change his
mind In any event we should not accept all that has been said as
proven fact upon this showing of a few recently operated patients.

Dr. Sigmar Stark, Cincinnati, Ohio.— As explanatory of the
nerve phenomena coexisting in these cases of appendicitis, I_ would
Uke to refer to a lecture that was delivered by Dr. Rosenow in Cin-
cinnati last winter, the title of which in substance was ihe intlu-
ence of Infections of the Gall-bladder and Appendix upon the ^ier-
vous System," and I beheve some of the gentlemen present here
to-day from Cincinnati were hkewise present at this lecture and it so
thev will recall it. In that lecture he conclusively demonstra.ted
some interesting points bearing upon the paper under consideration.
Bv inoculating inferior animals with streptococci obtained from in-
fected gall-bladders or appendices of patients having herpes zoster
similar manifestations would be developed in the ammals. If the

1036 TRANSACTIONS OF THE A. A. 0. & G.

patient was the victim of an associate neuritis or neuralgia, then the
animals so inoculated would show on postmortem examination
streptococcic and leukocytic invasion of the posterior ganglion and
nerve roots corresponding to the site of trouble in the human being.
The purpose of all this was to demonstrate a special affinity of cer-
tain strains of streptococci for some particular nerve tissue. These
investigations of Rosenow would readily serve to explain the bene-
ficial results the essayist obtained after appendectomy in the cases
reported.

Dr. O. H. Elbrecht, St. Louis, Mo. — One hardly knows where to
begin in view of the many theories that have been presented. The
last speaker brought out the theories of Rosenow which have been
so fruitful in new lines of thought. As you know one of the recent
theories as to the etiology of rheumatism is that it is due to an ob-
scure chronic infection somewhere, sometimes called focal infection.
Just what the infective agent is nobody knows, but it is productive
of a protein poisoning, sensitizing and supersensitizing, and having
seeming affinities for various groups of nerves which are then classi-
fied as various forms of neuritis, neuralgia or tic. I shall confine
myseK to this group as it is this one that the paper deals with.
Dentists have shown, as a result of the researches and observations
by Hunter of London, that the mouth is a cesspool for the develop-
ment of microorganisms, and that in many cases rheumatism and
neuritis are due to decayed teeth, badly fitting crowns, improperly
prepared root canals, causing abscesses, etc. From such conclusions
it would seem that protein poisoning is the only logical thing we
have to lean on.

In connection with the paper and the theories of Dr. Rosenthal,
I will say that we see almost the same phenomena or apparent cures
brought about by an occasional operation on an epileptic. I have
seen epileptics who had convulsions of the grand mal type once a
week, get well for two to three months after a laparotomy had been
performed, but the epileptic seizures returned in due time. Can
such cases be put into the class of cures described by the essayist?
Are we dealing with a bacterial protein poisoning, caused by focal
infection in the appendi.x and as a result of the removal of the ap-
pendix cure the tic? I want to congratulate Dr. Rosenthal on his
results and wish to say further that his cases have given us much
food for thought.

Dr. Rosenth.-vl (closing the discussion). — I should have been
very much surprised if you did not laugh at the title of my
paper. If I had not had the experience which I have related to you
I should have laughed myself. I presented this paper to you with
diffidence. It looks odd. The cases which I have presented have
coincidentally shown the form of obliterating appendicitis in six of
the seven cases. The effect of absorption from the appendix is
entirely in accord with the work of Rosenou. I have discussed this
matter with some of the fellows here and with members of the pro-
fession elsewhere, and I have received as an opinion from them
this: "It is not so surprising;" "it is a toxemia." One fellow here

REVIEWS 1037

volunteered the information that an ocuhst in his city was curing
hemorrhoids by proper adjustment of glasses. Such are the extremes
of opinion which I have received; yet this thing is so striking that
we cannot attribute it simply to the fact that we have operated
upon these people. I have given you the case of one man who was
operated no less than twenty times. He had a resection of the upper
jaw. Here is one man who had avulsion of all the branches foi
the purpose of avoiding a Gasserian ganglion operation. These
patients are not influenced by surgical operation. It is not mental
influence. I have cited the case of a girl who took an anesthetic
for the purpose of having an impacted molar removed; she had had
part of the jaw bone resected, a much more impressive procedure
than a well executed appendectomy. The result was starthng.

I do not believe we have established the pathology for tic doul-
oureux or neuritis or nerve irritation, but I do believe that we have
revealed the fact that frequently in appendicitis we have a direct
cause of a nerve irritation. Pain which disappears so suddenly and
does not recur is not due to inflammatory change. That is a toxemia.
In one case we actually had pus in the appendix; there we probably
had a neuritis with adhesion of the nerve sheaths and all that goes
with inflammatory disturbances. We did not get so prompt a result in
this case. His relief was more gradual. Yet he is now free from pain.

Dr. Skeel brought up the point that I may change my mind as to
a cure a year from now; that the time since these patients had been
operated is too short to speak definitely as to the ultimate results.

In the light of the seriousness of the aiJection and the brilliant
results obtained in these cases and with the hope that something
dependable may develop from the work I felt justified in bringing
these cases to your attention as a preliminary report.

REVIEWS.

Obstetrics Normal and Operative. By George Peaslee
Shears, M. D., Professor of Obstetrics and Attending Obstetrician
at the New York Polyclinic Medical School and Hospital; formerly
Instructor in Obstetrics, Cornell University Medical College;
Attending Obstetrician at the New York City Hospital; Senior
Attending Obstetrician at the Misericordia Hospital. 419
illustrations. J. B. Lippincott Company, Philadelphia and
London, 1916. Price $6.00, net.

Dr. Shears' name is the most recent addition to the list of obstet-
rical text-books and constitutes the last work of the author, who
die about the time of the appearance of the same. It may be
regarded as the record of personal experiences and is claimed by
the author to be based on a different plan from other works on the
same subject. In writing his book Dr. Shears has aimed to present
the more important phases, leaving out what he considers irrelevant
material; consequently he omits the usual embryological, physio-
logical and anatomical sections, and the pure theory of the subject
is also treated in a more restricted manner than is usual. Viewed

1038 REVIEWS

from this aspect the work bears the stamp of originaUtV; and many
of the illustrations are likewise specially prepared for the work
from photographs made under the author's direction, although a
large number have also been borrowed from other sources. As a
practical manual for the student of medicine the work has its limita-
tions as being devoted too much to the practical side, but for the
general practitioner and the post-graduate student the book may be
designated as of undoubted value and assistance. Dr. Shears'
book constitutes a very satisfactory addition to obstetric text-book
literature.

Orthopedic Surgery. By Edw.^rd H. Br.^dford, M. D., Con-
sulting Surgeon to the Children's Hospital, Boston, and to the
Boston City Hospital; Professor of Orthopedic Surgery Emeritus
in Harvard University, and Robert W. Lovett, I\I. D., Pro-
fessor of Orthopedic Surgery in Harvard University; Surgeon to
the Children's Hospital, Boston; Surgeon-in-chief to the Massa-
chusetts Hospital School, Canton. Fifth Edition, profusely
illustrated. WilUam Wood and Company, New York, 191 5.
Price $3.75, net.

Since the appearance of the last edition of this important work in
191 1, the progress of orthopedic surgery has been such as to render
another revision necessary. The scope of the present edition is
stated to be practically the same as that of the last, and brevity has
been secured by omitting references and the extended discussions
of the views of other writers. In addition to the subjects usually
treated, the chapter on infantile paralysis is of timely interest, the
surgical aspect of the infection alone being considered. From this
point of view the authors regard the disease pathologically as a
hemorrhagic myelitis with its chief destruction situated in the
cells of the anterior horns of the cord. The description of the
treatment of the condition, especially the mechanical correction of
deformities, is very complete and satisfactory. The operative
procedures for the correction or improvement of the affected limbs
being also referred to.

The book is satisfactorily printed and illustrated and constitutes
an important work of reference in the literature of the subject.
A Text-book of Pr.\ctical Gynecology. By D. Tod Gilliam,
M. D., Emeritus Professor of Gynecology in Ohio State University
College of Medicine, and Sometime Professor of Gj-necology
Starling Medical College, Gynecologist to St. Anthony and St.
Francis Hospitals; Consulting Gynecologist to Park View
Sanitarium, Columbus, Ohio; Fellow of the .'American Association
of Obstetricians and Gynecologists; Member of the American
Medical .Association, of the Ninth International Medical Congress,
etc., and Earl M. Gilliam, M. D., Professor of Diseases of Women
in the Ohio State University, College of Medicine, Columbus,
Ohio. Fifth Revised Edition. Illustrated with 352 engravings,
a colored frontispiece, and 13 full-page half-tone plates. F. A.
Davis Company, Philadelphia, 1916. Price $5.00, net.
The fifth edition of this popular book has been brought up to date.
The characteristics which have contributed to the success of the

REVIEWS 1039

earlier editions may be summarized by referring to the authors'
statement in the first edition, that they have endeavored to make
the book plain and practical for the student and practitioner. The
authors' important contributions to gynecology constitute an inter-
esting feature of the work and are too well known to require any
further detailed notice. Particular attention has been paid to
methods of treatment and a sufiicient number of procedures is inserted
in each case to afford a choice to the reader. The illustrations are
fairly numerous but many of them seem rather the worse for wear,

Operative Midwifery. By J. M. Munro Kerr, M. D., C. M.,
Glas., Fellow of the Royal Faculty of Physicians and Surgeons,
Glasgow; Hon. Fellow, American Gynecological Society; Pro-
fessor of Obstetrics and Gynecology, Glasgow University (Muir-
head Chair), Obstetric Physician, Glasgow Maternity Hospital;
Gynecologist, Royal Infirmary; Past President of the Glasgow
Obstetrical and Gynecological Society. Third Edition. With
308 illustrations. William Wood and Company, New York,
1916. Price $6.00, net.

Professor Kerr's work has come to be accepted as a standard in
English literature. The present edition contains a number of altera-
tions in the te.xt, necessitated by the developments in the subject
during the past five years. The text of the work is very complete
and the author's conclusions and recommendations as to the various
obstetrical procedures are marked by conservatism. Numerous
references and quotations from the literature serve to give the work
the character of a compilation, but on the other hand the author also
freely presents the results of his large personal experience. Pror
fessor Kerr's book commands attention as one of the most successful
works on this subject in the English language.

Surgical and Gynecological Nursing. By Edward M. Parker,
M. D., F. A. C. S., Surgeon to Providence Hospital, Washington,
D. C, and Scott D. Breckinridge, M. D., F. A. C. S., Gynecolo-
gist to Providence Hospital, Washington, D. C. With 134
illustrations. Price $2.50, net. J. B. Lippincott Company:
Philadelphia and London, 1916.

The book herewith referred to provides an almost encyclopedic
knowledge of the work of the nurse in surgical and gynecological
fields. The authors discuss the subject of infection in tlie first part
of the book, presenting possibly in too detailed a form the subject
of bacteriology. In the second section surgical pathology and
gynecological nomenclature is discussed, and in the third the
technic of surgical nursing is considered, including the subjects of
postures, bandaging, treatment of fractures, various therapeutic
measures, and the manner of keeping charts and records. In the
fourth part of the book the patient is described from the nurse's
standpoint, and in the fifth portion the operating room and operative
methods are taken up. In the concluding portions emergencies
and an epitome of the common surgical and gynecological conditions
is presented.

1040 ITEM

The book is very satisfactorily illustrated and the contents of the
book and the manner of their presentation cannot be questioned.
One may doubt, however, whether the theoretical part of the subject
does not outweigh the practical, notwithstanding the authors'
protest in their preface. It would seem that a far greater preliminary
knowledge of medical subjects is necessary for a proper understand-
ing of this text-book than is ordinarily possessed by the average
undergraduate nurse. The work is extremely well written and can
be read with interest, but it is a question whether its authors do not
presume too much on the intellectual faculties of the average candi-
date for nursing honors. It would appear that a thorough drill in
nursing practices is more essential than any attempt to absorb the
theories upon which the practice of medicine and surgery are largely
based. To advanced nurses the book would be of value as a text-
book, but for undergraduates its efficacy must remain a matter of
doubt.

Medical Record Visiting List or Physicians' Diary for 1917.

Newly revised. New York: WilHam Wood & Companj'.

The practitioner whose accounts are kept by the system of a visit-
ing hst need look no further. The Medical Record Visiting List
has not deteriorated. It is still the smallest, lightest and cheapest
policy of insurance of the professional income. As usual it contains,
besides the space for daily accounts and memoranda of engagements,
etc., tables of dosage and other useful information. It appears in
its customary attire of red or black morocco, for thirty, sixty or
ninety patients a week as desired, though more elaborate styles are
obtainable.

The Physicians Visiting List for 191 7. P. Blakiston's Son & Co.,

Philadelphia.

The sixty-sixth edition of this popular list, complete, compact, and
simple, can be had at from Si. 25 for twenty-five or fifty patients
weekly to $2.50 forgone hundred patients per week, or in perpetual
or monthly editions.

ITEM.

The Chicago Gynecological Society offers annually an award of
One Hundred Dollars ($100.00) to the author of the best paper
presented to the Society during each year upon a subject concerning
gynecology and obstetrics.

The paper must be read and defended before the Society in an
open meeting, may be of any length, but must not have been read
elsewhere and when read shall become the property of the Society.

Any one who desires to read a paper in this competition may
address the undersigned.

104 Michigan Avenue, N. Sproat He.vney.

CmcAoo, III.

BRIEF OF CURRENT LITERATURE 1^41

BRIEF OF CURRENT LITERATURE

OBSTETRICS.

Lumbar Puncture in the Fetus.-Romolo Costa {Ann_di osl. e
eiWune 1016) believes from clinical experience and theoretical
considerations that it mav be useful in the interest of the fetus to
peSm lumbar puncture during a podalic -traction^ jh a v
to reducing the size of the after-coming head by removal of fluid
TheTameters of the skull become reduced -d-oldu^ takes pkc
more easily. When there is a reduction "^ >f H^ There wUlbS
dehvery of a Hving child may thus be accomphshed. There w 11 be
les compression of the central nervous system and especially of
hose centers which regulate the acts of respiration and the jhythm
of the heart. The execution of the puncture is easy and rapid. The
body is bent and the needle introduced beside ^e fourth or fifh
spinous process. This is useful both m contracted pelves and m
insufficient dilatation of the cervix. .

"Leukocytes in Pregnancy, Labor and the Pf ^Pf^JJ-JJ^
Baer's (Siir" Gxn. ami Obsl., 1916, xxni, 567) counts .ho^^ that there
fs a leukoc>^osis of pregnancy, appearing in the -ntli month shgh
in amount;and especially noticeable m pnmipara. T e leukocytosis
of labor is marked in primipara;, averaging 18,255, and ^ i^^^^eased
by a duration of labor beyond twenty-four hour.^ .^',;' f 1" eu^'e-
in paraj-ii and is slight in III plus para;. The height of the curve
Tn pdmipara. and multipara, is reached on the first day of the puer-
ner urn after which there is a rapid and constant dechne to the
tenth day at which time the curve is about at the normal level
The onseJof lactation does not influence the leukocyte count, e.xcept
iiat in the "fourth day'' primipara. there is a ^^^g^t secondary eleva
tion on the preceding day-about 1 500 to 2000. Age ^^J^"^ ^^^^^^oT;
excent in primipar^ aged twenty years and under, m whom_ the
kukScytosfs is h^her than in any other group. Differential analysis
howed the increase in leukocytes to be chiefly m the Polumorpho-
nuclear neutrophiles with a return to normal proportion, by the
tlhrd day of the puerperium, an absence of eos.noph.les m about
hah the cases in labor, and their reappearance in '-™a Proportions
on the first day of the puerperium. The lymphocyte., large and
smairmast cells and transidonal types, showed nothing unusual.
The Arneth analysis showed a displacement toward the lef,.^c
toward classes 2 and 3, but this was not constant, and no pertinent
flpdiictions could be drawn. . „ rr^u^

TreaSent of Emergency Cases of Ectopic ^^If^^^y-fJ'
treatment advocated by E. H. Richardson (-^^f//^''^^'- J^/f ^l Ss
1Q16 xxvi, 262) is intermediate between that of the so-called radica s
and Ihe u tra-conservatives. In this plan aU therapeutic effort s
fost employed to combat the shock. It consists of the use of mor-

1042 BRIEF OF CURRENT LITERATURE

phine h\podermically; the subcutaneous or intravenous administra-
tion of normal salt solution; when required, the employment of
specific cardio-vascular and respiratory stimulants; elevation of the
foot of the bed; bandaging the extremities; and the application of
heat externally. As soon as the improvement, which is almost sure
to follow, has occurred, as indicated particularly by a slowing of the
pulse rate, a substantial increase in pulse volume and blood pressure,
immediate laparotomy with evacuation of the blood and removal of
the affected tube is indicated. The operation need consume only
fifteen minutes, and the patient's condition wUl almost invariably be
found better at the end than at the beginning of surgical interven-
tion. In those exceptional cases where the usual methods of treat-
ment fail we have in the transfusion of blood a possible life-saving
measure.

Management of Labor in Border-line Contractions of Pelves.
• — J. O. Polak and G. W. Phelan {Amer. Jour. Surg., 1916, xxx, 359)
say that accurate pelvimetry is absolutely necessary in order to
recognize the tj^De of deformity: Pelvimetry without the relative
estimation of the size of the fetus is of little value and that the most
accurate fetometry is the test of labor. Every borderhne case
should be given a test of labor and that this should be conducted in
a hospital under the most scrupulous asepsis. All examinations
should be made through the rectum. Only in making the ultimate
decision as to procedure is a vaginal examination to be made. This
is then done with the patient anesthetized and under the strictest
surgical technic. Spontaneous delivery will reward patience and
vigilance in 80 per cent, of such cases. Pubiotomy is safe in mul-
tiparEE with flat pelvis of 7.5 cm. or over and in justominor contrac-
tion when the true conjugate is over 8.5 cm. and in funnel pelvis in
primipara;. The Doederlein technic is the simplest and safest.
Extra-peritoneal section should be elected as the method of delivery
when the labor has been prolonged and the membranes have been
ruptured for a long time. The classical operation should be reserved
for the elective cases, and fmally, no hard and fixed rule can be set
down for the management of any case. Each case has to be
individualized.

GYNECOLOGICAL AND .ABDOMINAL SURGERY.

Red Myoma of the Uterus. — S. Delle Chaije {Ann. di ost. e gin.,
April, igi6) describes red myoma as a distinct variety of myoma of
the uterus. Few cases have been reported. From the anatomo-
pathological side red myoma is a tumor generally situated on the
anterior wall of the uterus, seldom in the fundus, and constantly
interstitial. It is occasionally accompanied by other nodules of dif-
ferent structure, being itself single. It is circumscribed by a fibrous
capsule and is of a wine red color. It is formed of embryonal muscle
fibers, with hyperplasia of the vessels, focal hemorrhages, and few
connective-tissue fibers. It causes pain and pressure symptoms, by
its rapid growth, and fever. The element of congestion represents
its most characteristic peculiarity. It must be diagnosticated from

BRIEF OF CURRENT LITERATURE 1043

a fibroma undergoing a benign or sarcomatous degeneration, or a
cystic tumor of the ovary with torsion of the pedicle. In the author's
case the last was the diagnosis, and the real nature of the tumor was
seen only at the operation.

Ovarian Grafts. — Franklin H. Martin {Ann. de gyn. et d'obsl.,
May-June, igi6) after going carefully over the observations on
ovarian grafts published since 1911, gives his conclusions thus: This
examination of the hterature is somewhat disappointing with refer-
ence to the surgical value of the operation. Ovarian autografts re-
tard and modify the symptoms of the artificial menopause, this result
being dependent on the power of the graft to become vitalized in its
new location. The percentage of useful autografts depends on the
technic used in placing them: if they are inserted in depressions
of well vascularized tissues they easily become vitalized: these re-
sults are much better than when a complicated technic is made
use of to insure vascularization. The fact that heterografts and
homografts are unsuccessful when the same methods are employed
as with the autografts shows that there is an antagonism between
the tissues of different individuals of the same species and of different
species. The successful operations with homografts and hetero-
grafts would lead us to hope that in some way we ma}' be able to
suppress this antagonism and that we shall do better by allowing the
choice of normal tissues for their implantation.

Uterus and Tubes Contained in an Inguinal Hernia in Man. —
A. Brindeau {Arch. mens, d'obst. et de gyn., April-May-June, 1916)
describes a case of pseudohermaphroditism in an apparently normal
man, who had perfect male sexual organs, but who showed also an
inguinal hernia on the right side, descending into the scrotum. He
was married and had two children. There was a mass in the right
scrotum the size of a lemon, the cord ascending into the inguinal
canal. The tumor was reducible. Operation for the cure of the
hernia was undertaken. The mass consisted of a uterus, with the
fundus below and cervix above, and of normal size. To its right
horn was attached a tube of normal length, but with extremity atro-
phied. Under the tube was found an hypertrophied testicle, of nor-
mal consistence, covered by the epicfidymis and with a vas deferens
ascending into the abdomen. A second tube was attached to the
left horn of the uterus. By traction upon this cord a second testicle
of normal appearance but much smaller than its mate was with-
drawn from the abdomen. There were two epididymes, two vasa
deferentia, and two round ligaments, and on each side of the uterus
was a sort of broad ligament. For fear of injuring the testicle the
uterus was used to plug the inguinal ring. Recovery was normal
and only the testicle remained in the scrotum. The author finds
eighteen similar cases recorded. Most of them had manly charac-
teristics and had children. The uteri were generally small, the tes-
ticles normal. In some cases the uterus was continuous with a
vagina opening into the urethra, explaining a flow or blood into the
uretlual canal which was experienced.

Spontaneous Peritonization of the Pelvis in Woman. — Fernand
Chatillon {Atm. de gyn. el d'obst. , May-June, 1916) considers the

1044 BRIEF OF CURBENT LITERATURE

various means that nature employs in walling off a suppurative proc-
ess in any portion of the pelvis. Various organs combine in forming
tJiese partitions which separate different parts of the pelvis. Among
these the great omentum plays a large part. The author beheves
it worth while to study these natural means for preventing the spread
of infections. In high peritonization, when the adnexa do not de-
scend into the Douglas culdesac, peritonization is accomplished by
the omentum., cecum, sigmoid, and small intestine. In low peritoni-
zation the organs descend into the culdesac and are separated by
the rectum, bladder, uterus, etc. The separation may be effected
by adhesions between all these organs combined, that is, mixed
peritonization.

Nature of the Bactericidal Property of Vaginal Secretion. — The
experiments of T. Harada (Amcr. Jour. Med. Sci., 1916, clii, 243)
show that the bactericidal property of pregnant vaginal secretion is
not greatly affected by different bacilli. The bactericidal property
of pregnant vaginal secretion is gradually increased during the course
of pregnancy. An increase of o.g per cent, of lactic acid is contained
in pregnant vaginal secretion. The lactic acid does not increase
durnig the course of pregnancy. The bactericidal substance in preg-
nant vaginal secretion is not of the nature of bacteriolysin, which is
completed by association with complement. The bactericidal prop-
erty of pregnant vaginal secretion is caused by leukin, cytase or
allied substances and lactic acid. It is more affected by leukin than
by cytase and lactic acid plays only a part of the bactericidal
property.

Radium Treatment of Uterine Cancer. — Of twenty-five cases
treated by J. Ransohoff and J. L. 'RB.nsohoQ. {Annals Siirg., 1916, Ixiv,
298), 1 1 are stiU well. Of these 3 have been well for two years, 6 from
one to two years, and 2 from six months to a year. Of the 1 1 clinical
recoveries, there were 3 operable and 8 inoperable. Of the 3 oper-
able cases one is well after two years, and 2 over one year. Recur-
rence after operation usually occurs within the first six months. The
writers hold that cases clinically cured by radium should not be sub-
jected to hysterectomy, as the operation is difficult and dangerous.

Hyperalgesia in Abdominal Disease. — To ehcit reflex responses,
D. Ligat {Practitioner, 1916, xcvii, 106) grasps the skin and sub-
cutaneous tissue firmly between finger and thumb, and draws them
away from the deeper layers of the abdominal wall. If hyperalgesic
area be present, the patient winces, and one can tell, by the patient's
expression, when such an area is being stimulated. In this method
of examination, the following points should be noted: (i) The pa-
tient should be made to appreciate a pinch of definite pressure over
a normal point and asked to realize the sensation, the facial expres-
sion being watched closely at the same time, for normal sensation
to pinch varies widely in different individuals. (2) An exactly simi-
lar pinch is applied at the spot where the maximum response is
expected. No downward pressure is made on the abdominal wall,
but the skin and subcutaneous tissue are picked up from the abdom-
inal wall and pinched with the same amount of force that had been
applied in the control. (3) The direction and limitation of the ex-

BRIEF OF CURRENT LITERATURE 1045

tension of the hv-peralgesia must be carefully noted. The writer
describes his findings in various abdominal conditions, and concludes:
That for diagnostic purposes all visceral pain may be regarded as
due to a true viscerosensory reflex. That spread does not take
place uniformly from segment to segment, but that hypertonicity,
which has been set up in a certain group of spinal cells, is communi-
cated to an adjacent group of cells which subserve the same physio-
logical function in the spinal cord, and that the lower group of cells
is the more strongly stimulated. That impulses do not pass easily
from the cell groups in the spinal cord, which correspond to the lat-
eral organs (gall-bladder, appendix, and tube), to the spinal cells,
which correspond with the central organs (stomach, duodenum, and
gut). That h3^eralgesia elicited by pinch is of definite value for
diagnostic purposes, and, under certain circumstances, for prognosis
also, but that a certain percentage of negative cases exist, and that
the method should be used only as a part of, and as an addition to,
general chnical examination. That positive response indicates, in
the majority of cases, the organ primarily diseased. That the ex-
planation of a percentage of negative cases, and very serious cases,
is block of afferent impulse. That slow distention of a viscus does
not give rise to either pain or hyperalgesia. That rapid distention
may give rise to pain, but that the pain cannot be localized by the
patient to the offending organ — that response to hyperalgesia is
negative. Probable factors giving rise to hyperalgesia are: (a)
Mechanical irritation of nerve endings in mucous and submucous
coats, (b) Diapedesis causing mechanical pressure on nerve end-
ings, (c) Chemical toxins produced by organisms, (d) {donbtjul)
Irregular and excessive contraction of gut muscle per se.

Cancer of the Rectum and Rectosigmoid. — Cancer of the rectum is
not prone to early lymphatic involvement, tending to remain a
locahzed process until late. In no case was lymphatic extension
alone the cause of inoperability. Some patients in whom the rectal
glands were involved have recovered and remained well following
the radical operation, but none of W. J. Mayo's {Atmals Surg., 1916,
Ixiv, 304) patients in whom the inguinal glands were involved made
a permanent recovery, even after the most extensive glandular ex-
cision. The most frequent cause of inoperability was local extension
of the disease to neighboring organs; the next in frequency was
metastasis of the liver; and the third, peritoneal and retroperitoneal
metastases. The important causes of operative mortality are: sep-
sis, 39.8 per cent.; nephritis, 13 per cent.; undiscovered metatstatic
tumors, 10.5 per cent.; hemorrhage, 6.5 per cent.; obstruction of the
bowels following operation, 3 per cent. The best function following
operation has been after the tube method of resection described by
Balfour and the C. H. Mayo method of direct end-to-end union
between the end of the sigmoid and the anal canal. Mixter advises
making the colostomy in the midline just beneath the umbilicus,
and Mayo has used this situation in a number of instances with
satisfaction. The INIixter colostomy furnishes direct access to the
lower sigmoid and rectum and faciUtates cleansing, when made as
the first stage of a two-stage operation. It also appears to be less

1046 BRIEF OF CURRENT LITERATURE

liable to late infections in the blind end following the radical opera-
tion. Moreover, it rapidly terminates a midline exploration or
radical operation by placing the colostomy in the upper end of the
working incision. Of the 430 patients on whom a resection was done,
364 recovered from the operation. Eliminating those who were
operated on less than three years ago, we have 33.3 per cent, who
lived three years or more, and 28.3 per cent, who lived five years or
more, after the operation. These percentages may be increased
fairly to 37.5 and 35.8 per cents., respectively, by subtracting from
mortality figures the normal death-rates for corresponding ages for
periods of three and five years, i.e., 4.2 and 7.5 per cent.

Sarcoma of the Appendix. — In reporting a case of this condition,
M. G. Wohl {Annals Surg., 1916, Ixiv, 311) says that it is rare, there
being reported in the entire medical literature only 10 authentic
cases. There is great dilEculty at times to determine histologically
whether or not the condition of the appendix is of chronic inflam-
matory or of neoplastic nature. In deciding upon the diagnosis,
one should take into consideration both the chnical as well as the
microscopical picture. Sarcoma of the appendix (especially the
round-cell type), contrary to the viewpoint held heretofore, is highly
malignant.

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DEPARTMENT OF PEDIATRICS.

ORIGINAL COMMUNICATION.

PEMPHIGUS NEONATORUM.*

BY
FREDERICK HOWARD FALLS, M. S., M. D.,

Chicago, III.

In Chicago there has occurred within the last year eight or nine
epidemics in the maternity departments of several hospitals. The
writer has had the opportunity to study several of these and details
of the bacteriology and epidemiology will be published soon in a
separate report.

The epidemic at the University Hospital consisting of six cases was
most carefully observed. No source of infection could be traced.
The mothers were all normal on admission to the hospital. No
history of previous attendance by midwives was obtained. No
cases of impetigo had been recently treated at the hospital.

The lesions were perfectly tv'pical.

The first lesion appeared on the flexor surface of the left arm at
the bend of the elbow as a macule. It enlarged by peripheral exten-
sion and became pale in the center. A minute vesicle then appeared
with a peripheral ring of hyperemia. This vesicle rapidly enlarged
so that in a few hours it was 2 to 3 centimeters in diameter. The
epidermal covering was very thin and it appeared flaccid and
wrinkled. The fluid contents were at first clear and straw-colored,
but a few hours later became turbid. The lesion spread centrif-
ugally with remarkable rapidity so that within twenty-four hours
it was as large as a dollar. Other lesions of a similar character
rapidly appeared on other parts of the body. Many of the lesions
ruptured before attaining the size of the one described but in other
respects they answered its description. The base of the vesicle
after rupture was seen to be moist, hyperemic and glistening. In
a few cases there was a tendency to peripheral extension even after
rupture but as a rule the lesions tended to heal rapidly under treat-
ment without scar formation. There was no general manifestation
of the disease. The babies nursed well and ran no temperature.

*From the Department of Experimental Medicine and of Obstetrics, Uni-
versity of Illinois College of Medicine, Chicago.

1048

falls: PEirPHiGus neonatorum

1049

The leukocyte count was normal or slightlj^ raised, averaging
15,000 whites with normal erythrocytes. A differential count was
unfortunately not made.

Cultures were made on plain blood agar both anaerobically and
aerobically and growth was obtained in both cases. The aerobic
cultures gave the more luxuriant growth.

Culturally the organism cannot be distinguished from many strains
of staphylococci. The reactions on the various media are given
in the accompanying tables together with its fermentation reactions
and its ability to produce acid in sugar solutions. As to its heat
resistance this organism closely resembles other strains of staphy-
lococcus pyogenes aureus. Agar tubes were inoculated and kept
at 60° C, 65° C, 70° C, 75° C, 80° C. for ten, twenty and thirty
minutes and then plated out. The organism was able to with-
stand 60° C. for one-half hour, but 65° C. for ten minutes killed all
but an occasional organism.

This strain produced indol, as do other strains of staphylococci.
It differs in this respect from the organism described by Clegg and
Wherry(i).

On plain blood agar plates this organism was strongly hemolytic.

The colonies appear gray and semistranslucent and do not become

pigmented.

SUGAR FERMEXTATIOX AFTER THREE DAYS. FERMENTATION
TUBES.

Sugar

Growth in open
and closed arm

Gas twenty-
four hours

Gas forty-
eight hours

Per cent,
acid formed

+ +

0.8

Saccharose

+ -t-

+ +

0.875

Maltose

+ + -F

+ + +

0.85

Dextrose

+ +

0.80

Mannit

0.7s

RaiEnose

0.50

Inulin

0-45

Salicin

0.40

Control

0.40

Phenolphthalcin used as indicator. N/io NaOH used for titration.

1050

falls: pemphigus neonatorum

Moderate growth, slightly Slight, yel-[ More pig-j Pigment fairly

spreading and raised atj low pig-| ment. i well marked,

edges, glistening smooth, ment. faint

translucent, no odor dis- odor,
coloration or pigment.

Diffuse turbidity, some
deposit.

Less alkaline.

Increased
turbidity,
more gray
deposit.

Less alkaline.

Dense turbidity,
moderate yellow-
ish deposit.

Acid, no coagula-
tion, blue precip-
itate at bottom.

Faint cup-shape depres-
sion.

Marked de-
pression.

More lique-
faction.

Liquefaction al-
most complete.

Scant, slightly, raised, con-
fined to streak, butyrous,
faint musty odor.

More growth,
more pig-
ment, slight
ly darkened.

More growth
media dis-
colored.

Strong yellow pig-
ment, media
darkened.

Loeffler Blood Beaded at edge, deep yel
Serum. j low, slightly raised, glist'

ening, butyrous, faint
musty odor.

Same.

Russell Media..

Top layer reddish, yellow-
ish intermediate layer,
blue and red deep layer.

Same change
more
marked.

Completely
acid.

Levulose Good stab growth, slight

I surface.

Surface
creased.

Light yellow mod-
erate surface
growth.

Lactose 1 Good stab, poor surface.

Increased
surface

growth.

Light yellow sur-
face, good stab
growth.

Good stab, fair surface
growth.

Increased
surface
growth.

Luxuriant surface

orange yellow,
gray at edges.

Slight surface, good stab.

Surface
creased.

Luxuriant surface
moderate stab,
orange yellow.

Raffinose Surface slight, stab good,

Surface in- Same,
creased.

Luxuriant surface
orange yellow,
moderate stab.

The attempts that have been made to reproduce the disease in
the lower animals by the injection of this organism have been
uniformly unsuccessful. Rabbits and guinea-pigs have been used
and subcutaneous intradural and intraperitoneal injections are

falls: pemphigus neonatorum 1051

reported by Clegg and Wherry(i). They report negative findings
except for. hyperemia at the site of some of the subcutaneous injec-
tions. They, however, used relatively small doses (i c.c. of a 48-
hour broth culture) and do not mention how long the organism had
been cultivated artificially and on what media, before it was used
in the animal experiment.

Believing that an organism which under certain circumstances
appeared to be the cause of death in children affected with the
disease should be pathogenic for lower animals, the writer de-
termined to further test this point. In the first experiment it was
decided to use a rather large dose to roughly determine its patho-
genicity. A 24-hour blood agar slant culture in 5 c.c. of sterile
normal salt solution injected intraperitoneally caused death in a
half- grown guinea-pig in four days. Details of the postmortem
findings and cultures in this and in other animals here mentioned
will be found in an article by the writer on the " Bacteriology of
Pemphigus Neonatorum." (2)

It was thought that by intravenous injection the elective affinity
of the organism for the skin might be demonstrated. Accordingly
a half grown rabbit was injected intravenously with 2 c.c. of a heavy
suspension of the organism in salt solution. The animal appeared
sick the next day and died on the third day. No skin lesions
appeared.

Because of the nature of the organism and because of its tendency
in most human cases to remain localized in the skin while capable
of causing severe manifestations and death upon gaining access to
the blood stream, it was determined to inject some animals subcu-
taneously and some intraperitoneally to determine possible dif-
ferences in behavior under the given conditions. Half-grown guinea-
pigs were selected for this work.

Because the infection runs a much more severe course in children
than in adults it was thought that young pigs would lend them-
selves more favorably to the conditions of the experiment. Two
series of three pigs each were inoculated. Death occurred in all
cases. Those injected intraperitoneally died sooner than those
injected subcutaneously. However, in the latter series positive
blood cultures and peritoneal invasion gave proof of the penetrat-
ing tendency of the organism. Particular pains were taken in this
series to avoid introducing any of the bacteria into the peritoneal
cavity. In the series injected intraperitoneally there was no
tendency of the organisms to localize in the skin. This speaks
strongly for the view that the infection is transmitted by contact

1052 falls: pemphigus neonatorum

with infected material and is not a systemic infection in the early
stage of the disease as has been suggested by many writers.

A peculiar tendency to cord hemorrhages with a resultant paresis
was noted in some of the animals. Further experiments are in
progress to determine if this is an accidental circumstance or not.

Because of the repeated failures by many observers to produce
lesions in rabbits and guinea-pigs by intracutaneous injection an
attempt was made to reproduce the lesion in a monkey. Not being
able to obtain a young Macacus Rhesus monkey a young Java
monkey was inoculated intradermally. An abortive vesicle resulted
in forty-eight homrs and after seventy-two hours it was excised
and sectioned. The sections showed an elevation of the epidermal
layer and some leukocytic infiltration of the underlying base.
The whole lesion was very abortive in type measuring not more
than 2 millimeters in diameter. There was no erythematous
areola as seen in the human cases. A control inoculation with
a sterile needle was negative.

The writer was able to produce a tj'pical lesion by inoculation
of a pure broth culture of the organism intradermally into his own
arm. Furthermore he was able to recover the organism in pure
culture from the experimental lesion. Thus for the first time all
of Koch's laws with respect to this organism in this disease were
fulfilled. For details of this experiment the reader is again referred
to the article in the Journal of Infectious Diseases by the writer.

From the above data it would appear that the causative organism
of this disease culturally and biologically is identical with the staphy-
lococcus pyogenes aureus. Morphologically on certain media it
differs slightly in that it appears as a diplococcus and occasionally
forms chains. Pathogenetically it differs in that it produces a
lesion that is peculiar to this type of infection. These differences,
however, do not seem to be sufficient to permit us to consider the
pemphigus coccus an organism of a different species as do Alm-
quist and Clegg and Wherry (3). It would seem more correct to
regard it as a pecuHar strain of the staphylococcus with certain
peculiarities as to morphology and pathogenic properties which
differentiate it from other strains of the same organism.

A review of the various text-books of obstetrics has convinced
the writer that this subject is not adequately dealt with in these.
Many of the authors fail to mention the disease at all, while others
confuse this disease with other conditions. Dermatological works
give a more satisfactory discussion of the disease as a whole but there
is considerable discrepancy in the views of the various authors on

falls: PEMPmous neonatorum 1053

the subject. The disease has been studied by bacteriologists and
pediatricians are sometimes confronted with it for diagnosis.

Because of the existing confusion regarding the disease and of
its relation and importance to a large group of clinical men in spite
of its relative infrequence it was thought advisable by the writer to
collect from the literature data bearing on this subject and to describe
the disease in detail, giving at the same time a brief historical resume
of the important landmarks in the development of our knowledge
of the disease.

LNTRODUCTION.

Pemphigus neonatorum is a contagious disease of the skin occur-
ring in infants and young children, and characterized by a vesicular
eruption on various parts of the body which may become bullous.
The lesions are filled with a clear fluid in which a peculiar strain
of the staphylococcus aureus can be demonstrated by smears and
cultures.

A great deal of confusion exists concerning the true nature of the
disease, and as to where it may be best classified. This is due, in
part at least, to the fact that most of the observations made on the
disease have been purely clinical, although recently a few epidemics
have been studied rather carefully and detailed bacteriological
findings recorded.

The name pemphigus is unfortunate as pointed out by Alfeld(4)
as far back as 1868. He felt that the condition was not at all
analogous to the skin affection occurring in adults commonly termed
pemphigus. He therefore suggested the name Morbus Bullosa
Neonatorum. Hyde also felt that the disease was a cHnical entity
and as such should not be classified as a pemphigoid disease. The
writer feels that a name descriptive of the pathology and bacteriology
of the condition would be highly desirable and therefore suggests that
the name Epidemic Staphylococcic Vesicular Dermatitis of the
Newborn be applied to this disease.

The disease was first described by Kraus in a dissertation quoted by
Ohme(6) in 1773 in which both authors affirmed they had repeatedly
seen epidemic pemphigus neonatorum. Scharlot(7) described a
case in 1841 in which a child born of healthy parents developed the
disease on the fourth day and subsequently the mother, another
baby bathed in the same bath, an eight-year-old girl and the mid-
wife on the case became infected. This is the first recorded evidence
of the contagiousness of the disease.

1054 fails: pemphigus neonatorum

In 1854 Plieninger(8) described two cases of pemphigus neona-
torum in both of which the transmission of the disease to older
people was demonstrated.

HebraCg) in 1866 in his treatise on skin diseases mentioned a form
of pemphigus neonatorum which was rapidly fatal, but he failed
to describe the character and location of the lesions. The first
epidemic to be carefully studied was reported by Hervieux(io)
in 1868 and occurred at the Maternite de Paris. One hundred and
fifty cases developed in six months at this hospital following the
admission of a child with the disease in the bulbous stage. The
epidemic was benign in type and only one death occurred.

Olshausen and Mekus (11) in 1870 described two epidemics occur-
ring at Halle in 1864 and again in 1869. They made rather detailed
observation. They noted that the disease occurred in epidemics and
usually on the third to the seventh day after birth. Also that it was
more common in the practice of certain midwives. The course of
this disease was usually benign, but exceptionally death occurs.
The disease might be transmitted to adults, and delicate children
were predisposed to the infection. They believed that the condition
had nothing to do with the cachexias but more closely resembled
the exanthemata. They tried injecting rabbits with the fluid
contents of the vesicles and failed to reproduce the lesion. They
next inoculated a baby who was already suffering from the dis-
ease and a midwife with the same fluid. They again failed to
reproduce the lesion.

Ahlfeld(4) studied an epidemic in 1872 consisting of twenty-five
cases. In this epidemic all of the mothers were healthy, and he
noted that the lesions appeared on children in various states of nutri-
tion and of various body weights. He also noted that there were
no lesions on the soles of the feet. In three cases no prodromal
symptoms were noted but constitutional symptoms in the form
of temperature and malaise were noted in three cases. He also
describes the lesions well and mentions especially their rapid
development. The disease was transmitted to the mother in one
case. No fatal cases were -observed.

Ahlfeld was the first to suggest that the name pemphigus neona-
torum was inappropriate inasmuch as this name implies a constitu-
tional disease, or a dependence upon or connection with a cachectic
condition. Since this condition occurred in otherwise healthy
children and might be, and usually was devoid of constitution symp-
toms, he felt that this name should be dropped and suggested in its
place the name Morbus Bullosa Neonatorum. Ahlfeld was the

TALLS: PEMPHIGUS NEONATORUM 1055

first one also to suggest that the disease was probably due to bacterial
infection, although he arrived at this conclusion by analogy and
produced no evidence to support this contention.

Two years later Moldenhauer(i2) described an epidemic at
Leipzig in which 25 per. cent, of the children born developed Pem-
phigus Neonatorum. It appears that this epidemic was of a more
virulent character than those previously described, as twelve of the
ninety-eight cases terminated fatally. Three midwives developed
lesions and he was able to infect a mother from a child by inoculation
with the contents of vesicles. He failed, however, to reinfect a child
and could not reproduce the disease in rabbits. Since the disease was
apparently contagious he supposed that it probably gained entrance
through the respiratory tract. He considered the question as to
whether the causative factor was organic or inorganic, and decided
that because of the short period of incubation that it was probably
inorganic. A study of the contents of the vesicles revealed pus cells
but no organisms were seen.

Roser(i3) in 1876 found cocci in smears from the bullae and
Gibier(i4) in 1882 confirmed this finding.

Demme(i5) in 1882 isolated a diplococcus from a case of acute
contagious pemphigus in a child seven years old. This is the first
report of positive bacteriological cultures. The organism, however,
he described as nonchromogenic, which differentiates it from the
organism found by other writers. The writer feels in view of the
facts regarding the chromogenic properties of the organisms he has
isolated from cases of the disease, that Demme was in all probability
dealing with the same type of organism but that it failed to show its
chromogenetic powers under the conditions of his cultures.

Almquist(3) in 1891 isolated a diplococcus from lesions of pem-
phigus neonatorum which was chromogenic, and which he was able
to cultivate on various media. By autoinoculation into his own
forearm he was able to reproduce the typical lesion of the disease.

Sabouraud(i7) in igoo claimed after an extensive investigation of
impetigo contagiosa and pemphigus neonatorum that the latter
disease was due to a streptococcus invasion of the skin.

Clegg and Wherry(i) in 1906 repeating Almquist's work reaf-
firmed his findings and gave a more detailed account of the organism
producing the lesions which they claimed to be very similar cultu-
rally and morphologically to the staphylococcus but which they
assumed to be a different organism because of its different behavior
upon inoculation into the skin.

1056 falls: pemphigus neonatorum

etiology.

The predisposing factors in this disease are many and in general
include any condition which lowers the resistance of the skin to
the infecting organism.

Age is very important. As a rule, the disease occurs in children
from three days to fourteen days. It may be and frequently is
transmitted to older children and to adults coming in intimate
contact with the disease. However, the lesions in these older people
are more abortive, do not spread so rapidly or so diffusely and
are usually single. Nursing mothers frequently develop lesions
on the breast similar to those on the skin of the child, and oc-
casionally nurses caring for the babies during an epidemic will
develop one or more lesions.

In older people the condition is often present as an impetigo and
a case is on record in which a typical impetigo on the face of a father
was transmitted and gave rise to a pemphigus neonatorum in a
baby ( 1 8). A similar incident is supposed to have started the
epidemic at the Cook County Hospital this year. A mother with
an impetigo around the mouth on admittance was confined and her
baby on the fourth day thereafter developed lesions from which
many other babies developed tv'pical pemphigus neonatorum.

Sex has little if any bearing. In Ahlfeld's series the incidence of
the disease was approximately equal.

Race. — The disease occurs in all races, but is more common and
more severe in the white race when the children are born in the
tropics or in warm countries. The native children while not immune
have a smaller percentage of incidence and mortality under the same
conditions. Native adults seldom are attacked.

Social Condition. — The disease is more common in the cities and
particularly in the famihes of the lower classes, and among the
foreigners who employ midwives for their obstetrical cases. Vari-
ous causes have been assigned for this, among the more important
of which are the lack of cleanliness among the midwives, the poor
hygienic surroundings and malnutrition of mother and baby, and
the crowded conditions of the tenement classes in the summer
months.

Climate has a very marked effect on the incidence of the disease.
It is much more common in tropical and warm countries than in the
temperate and cold chmates. Indeed Clegg and Wherry(i) have
stated that in the Civil Hospital in Manila, P. I., every baby born
in the institution contracts the disease in the first ten days of life.
The heat and the associated moisture seem to predispose the delicate

falls: pemphigus neonatorum 1057

skin of the infant to the invasion of the organism when present.
There has been no noticeable variation in the seasonal incidence of
the epidemics that I have studied and seen reported.

General Condition. — The disease attacks children of all condi-
tions of size and nutrition as was clearly pointed out by Ahlfeldf4).
Some authors claim, and it would seem reasonable, that the disease
is more severe and more apt to become malignant in the cachectic
cases. However it must be kept in mind that many cases in babies
of this type are confused with or complicated by sj-philis, and the
fatal outcome may in a certain percentage at least be attributable
to this disease.

Trauma during birth is mentioned as a factor by some authors,
but the development of the lesion after seven or eight days after
delivery in a skin which is apparently normal in every respect makes
this statement rather doubtful. In hospital practice are seen many
more epidemics than in private practice. This is what one would
expect from the highly infectious nature of the virus. The relation
to midwives is interesting and important and in the presence of an
epidemic this matter should be constantly kept in mind in order to
minimize the danger of the spread of the infection through careless
handling of cases. Dohrfip) reports an incident in which a midwife
had so many cases in her practice she had to discontinue. She
went to another town and began practicing again whereupon an
epidemic of pemphigus promptly broke out in that town also.

The epidemic nature of the disease is well shown by the reported
cases. Nearly all occurred as part of an epidemic with the excep-
tion of the cases occurring in the Manila Hospital,?. I., where accord-
ing to Clegg and Wherry practically every baby born contracts the
disease. The severity of the epidemics varies remarkably. The
mortality varies from o to 50 per cent. However, it must be kept
in mind that the disease is frequently confused with others which
may simulate it clinically and yet have an entirely different etiology.
For example, I feel that the disease described by Tillbur\' Fox(2o)
must be an entirely different nature.

"An epidemic occurred at the General Lying-in Hospital 1834-35
Apparently healthy children are seized with severe constitutional
symptoms. The skin is livid, the areola of the bulla are dark; the
contents fetid. The ulceration is unhealthy, deep, its surface is
dark, blackish, and exudes an ichorous matter, the edges being
livid, shreddy, so that large circular, depressed black gangrenous
ulcers acutely produced are present. The hands and feet maj' be
affected, but also the limbs, the genital parts, the abdomen — even

1058 falls: PEMPmcus neonatorum

the mucous surfaces and the head, death occurring about the tenth
to the twelfth day."

The general condition of the parturient canal of the mother should
be considered as an etiologic factor. In all cases in the epidemic
here described the mothers were perfectly normal. None of them
suffered from leucorrheal discharges before the birth of the baby.
The same has been reported of other epidemics. Cases have been
reported, however, arising in children born of mothers suffering from
an intra- or antepartum infection and in whom puerperal sepsis
later developed(2i). The lesions in these cases were more rapidly
spreading and hemorrhagic and almost invariably ended fatally.
In none of these cases, however, was bacteriological evidence advanced
that the lesions were due to the organism that is usually accredited
with being the specific cause of this disease.

EXCITING FACTOR.

Ahlfeld(4) in 1872 was the first to suggest that the disease might
be due to a microorganism. He did not, however, advance any
evidence to support his view. Demme(i5) in 1886 was the first
to describe and cultivate a diplococcus. He reported it as non-
chromogenic. In smears it appeared as a diplococcus and occurred
both intra-and extra- cellular. The organism was cultivated from
a case of contagious pemphigus in a girl seven years old.

Almquist(i6) in 1891 described an organism which apparently
fulfilled most of Koch's laws and to which he gave the name of
Micrococcus Pemphigi Neonatorum. This organism appeared as
a diplococcus(5) in broth and in the vesicles. It closely resembled
the staphylococcus aureus liquefying gelatin and producing a turbid
yellow deposit in broth. It grew well at 20° C. but poorly at 15° C.
He used a strain grown twenty days on artificial media for inocu-
lation into his own arm and produced a tj-pical blister. However,
he failed to recover the organism. The lesion healed without scar
formation. Cultures dried on silk threads were viable after one and
one-half months.

Matzenauer(22) after a careful comparative study of pemphigus
neonatorum and impetigo contagiosa histologically and bacterio-
logically concluded that the diseases were identical. He considered
that the organisms found were indistinguishable from staphylococcus
pyogenes aureus.

In 1900 Sabouraud made an extensive investigation of impetigo.
He divided the cases of this disease into two main divisions or

falls: pemphigus neonatorum

1059

classes, the vesicular type of Tillbury Fox and the pustular type
of Bochart.

He bases his conclusions more especially on the bacteriological
findings obtained by special methods of cultivation. He classifies
the pemphigus neonatorum, cases as the vesicular variety and claims
that these are due to a streptococcus. Later the lesions become
secondarily infected with a staphylococcus which organism has been
wrongly supposed by most investigators to be the cause of the
disease. The streptococcus was isolated in practically all cases by
using serum ascites as a culture media and obtaining the contents
of the vesicle in the early stages of its development. He lays great
stress on the value of the liquid media in these cultural experiments.
He obtained a mixture of staphylococci and streptococci when he
used ascites fluid and broth in equal parts. When using plain broth
he found that he obtained the staphylococcus in almost pure culture.
On solid media he invariably obtained the staphylococcus. He
explains these findings on the ground that the initial lesions of the
disease are due to infection by the streptococcus and lays great
stress on the rapidity of incidence of the lesions as a point in favor
of this view. Secondary to the initial infection, and some hours
or days subsequently, the lesions become infected by the staphy-
lococcus, which in the later stages is found in pure culture in the
lesions.

There are several points about the work of Sabouraud which may
be called into question.

In the first place he did not reproduce the lesions by the injection
into other patients of cultures of the streptococcus. Secondly, as
he himself points out, the media that he used to grow the strepto-
coccus had an inhibitory action on the growth of the staphylococcus.
In cases in which a culture media was used which was favorable for
both organisms he always obtained a more luxuriant growth of the
staphylococcus. This organism was always present in the smears
from the lesions, together with the streptococcus. It is difficult
to see how Sabouraud can advance as the etiological agent of a
disease an organism that has only fulfilled one of Koch's laws.
Granting that a streptococcus may be present early in these cases,
the fact that the staphylococcus is also present renders one quite
unwarranted in drawing arbitrary conclusions from this fact alone
as to which of the two is the primary and which the secondary
invader. Furthermore the fact that the staphylococcus found in
connection with this disease fulfiUs all of Koch's laws makes it appear
certain that this organism alone is the cause of the disease.

1060 falls: pemphigus neonatorum

Finally Sabouraud gives no description of the cultural character-
istics of the streptococci. Inasmuch as staphylococci may under
certain circumstances appear in short chain formation this point
should be elucidated.

Block(23) in 1900 describes fifteen fatal cases and gives good
pathological reports. He found streptococci in the heart's blood
in several cases, but believes it to be a secondary invader. He found
staphylococcus albus and aureus in the skin lesions and describes
a coffee-bean-shaped diplococcus.

Clegg and Wherry(i) in 1906 isolated from cases of pemphigus
neonatorum occurring in the Civil Hospital at Manila a diplococcus
corresponding to those described by Almquist which closely re-
sembled staphylococcus aureus on culture media but which showed
some features which they considered distinctive. They made rather
extensive tests and found in addition to Almquist's findings that
litmus milk was coagulated in about a week. No indol was pro-
duced or cholera red in Dunham's broth containing i per cent.
KNO3 after ten days. In a i per cent, glucose broth solution con-
taining one-third part sterile goats' serum growth appeared with re-
markable rapidity, a tube being densely clouded, while control tubes
inoculated with staphylococcus pyogenes aureus and Sarcina lutea
showed only a faint growth. With the formation of acid the serum
was precipitated as a dense flocculent mass. No gas was formed in
I per cent, glucose, lactose and saccharose broth. Cloudiness ap-
peared in both open and closed arms of the fermentation tubes.

Morphologically the organisms were indistinguishable from pyo-
genic staphylococci in preparations made from agar and broth.
When made from milk or better serum broth the diplococcic arrange-
ment found in smears from the vesicle contents was well reproduced.
Chromogenic characteristics were better brought out on gelatine and
glucose than on plain agar, i c.c. of a forty-eight hour broth culture in
a guinea-pig intraperitoneally caused no reaction in one week. Small
amounts of the same serum broth culture were injected under the
skin of a rabbit. No vesicles resulted, and only small h_\'peremic
areas appeared which disappeared in a week. Autoinoculation on
the forearm of one of these authors gave a tj'pical lesion in thirty
hours, but the organism was not recovered from this experimental
lesion. There was no subjective sensation except a slight itching.
Resolution occurred in forty-eight hours without scar formation.
Max Neisser(24) considers Almquist's organism a strain of staphylo-
coccus. The organism corresponds exactly with the description given
by Neisser of a typical staphylococcus pyogenes aureus. He, how-

falls: pemphigus neonatorum 1061

ever, reports no work with Almquist's orgauism in support of his
contention.

PATHOLOGY.

The pathology of this disease has been best described by Sa-
bouraud(i7). He divided the disease into three stages.

First: The prevesicular stage.
' He obtained the necessary tissue for the study of this stage by
aborting an incipient lesion by treatment with a caustic. The
scale thus obtained revealed a very thin superficial epidermal layer.
A deeper layer of flattened cells with intercellular edematous spaces
and the infiltration of leukocytes into serous spaces of various sizes.
No organisms were seen.

Second: The vesicular stage.
This stage is characterized by five main features:
first.— The thinness of the horny layer of epidermis forming the
cover of the vesicle. This never raises any of the underlying tissue
with it. Its thinness also explains its rapid peripheral spread.

Second.— The small number of formed elements in the early
stages. In the later or pustular stage these become greatly increased.
Third.— The relatively large amount of serum which, is clear at
first and later becomes crowded with leukocytes.

FoMr//^.— Epidermal and dermal edema due to a serous mter-
cellular exudate. Perivascular leukocytic infiltration of the derma.
Thin bands of leukocytes in the spaces of the epidermis at the
stratum lucidum close to the floor of the vesicle.

Fifth —Organisms can be seen when the vesicle is fully developed.
A diplococcus is usually seen and rarely short chains of three to four
elements can be seen.

Third: The post- vesicular stage.

The crust or postvesicular stage is composed of a thin horny layer
of epidermis superimposed upon a layer of coagulated serum with
enmeshed leukocytic nuclei. These leukocytes occur in clumps.
The bacteriology of the crusts is very variable. Most commonly
staphylococci and streptococci were found. Unidentified bacilh and
streptobacilli were noted in some cases. Gross pathological studies
have been made by. H. J. Schwartz(2s) ; twenty-seven cases were
examined. There was a slight congestion of the gastrointestmal,
respiratory and nervous systems. Nothing else was found. Ihis
author suggests that the cause of death may be due to changes in-
duced secondary to destruction of a large amount of skin surface

as in burns. , , ,

Blood cultures in fatal cases have yielded staphylococcus and

1062 falls: pempiugus neonatorum

streptococcus. It is thought by Block(22) who made cultures in
fifteen fatal cases that the streptococci were secondar}^ invaders in
every instance.

The disease is characterized by the appearance of the vesicular
eruption on or after the third day of the patient's life and usually
before the fourteenth day.

The incubation period is supposed to be about three days, and
according to inoculation experiments it is about twenty-four hours
from the time of injection till the vesicles appear.

The onset is sudden, the vesicles appearing on various parts of
the body and rapidly multiply. The eruption is prone to appear
first in the axilla and about the groins often spreading to involve
the trunk, inner surface of the thighs and genitals and flexures of
knees and elbows, and neck and face. The hands and feet are
seldom involved except by extension of a process from a neighboring
lesion.

Hyde(5) gives a classical description of the disease. "The first
symptoms noted are punctate and large reddish macules resembling
a flea bite. These enlarge and a thin pellicle forms over the spot,
from which vesicles develop as large as hazelnuts. The lesions often
burst before reaching maturity, the areola meantime spreading over
a space with a diameter of several centimeters. After bursting
the areas of involvement spread with centrifugal denudation of the
epidermis. The fluid furnished by the lesions is scanty or abundant,
golden yellow, or especially in the cases that prove fatal of a grayish
tint." To this description should be added that the vesicles are
rarely completely filled by the fluid but have a flaccid thin covering
of epidermis and that on rupturing a deep red, moist, shiny base is
seen. There is no sign that the lesions are painful or cause itching
of the skin. In the autoinoculation experiment performed by the
writer no subjective sensation was felt during the course of the lesion.
General symptoms are conspicuous by their absence in this type of
the disease.

General symptoms are recorded by many authors and are espe-
cially mentioned in connection with a second type of the disease
occurring in the severe epidemics with a high mortality rate. In
these cases fever as high as 104° F. is frequenth* seen, together with
inappetence, abdominal distention, vomiting, diarrhea, cyanosis
and dyspnea. A great deal of confusion has arisen because of these
two types of the disease which are so startlingly different clinically.

falls: pemphigus neonatorum 1063

In the first group of cases the course is absolutely benign, the baby
does not lose weight, is not disturbed by the eruption, nurseswell, and
the lesions disappear in a few days, leaving no scar. In the second
group the course is frequently rapidly fatal with all the signs of a
fulminating septic infection. Much light has been thrown upon
this phase of the subject by the researches of Block(23). This
investigator studied a series of cases bacteriologically and pathologic-
cally and found a staphylococcus aureus and albus in the lesions.
In a series of cases that died he found by careful bacteriological
examination of the heart's blood a streptococcus in pure culture.
This he believes to be a secondary invader because blood cultures
in cases that recovered remained sterile. It would seem therefore
that the invasion of the blood stream by the streptococcus is to be
regarded as a complication of the disease rather than an integral
part of the morbid picture and in the absence of this occurrence no
general symptoms occur.

Complications. — Infection of the umbilicus and of the umbilical
vein is the most important and most serious complication because
it usually is caused by the streptococcus. Penetration of the tissues
with resultant septicemia follows.

Endocarditis has been noted by Block.

Edema of the lungs is frequently noted at autopsy especially in
the posterior portions.

Gastroenteritis with severe diarrhea may occur in the septic
cases.

Prognosis. — The prognosis depends upon several factors. First
the general condition of the baby. If the infant is strong and
healthy and otherwise normal it will resist the infection very much
better than if it is weak and marantic. Age has an important bear-
ing. Children affected after two weeks rarely suffer so severely as do
younger children. The time at which the disease is recognized and
the treatment started is important. If the blebs have attained a
large size and become confluent healing is delayed and the prognosis
is progressively worse. According to Schwartz(25) the deleterious
effects in these cases are produced by the great destruction of skin
surface causing the same toxic effects as severe burns.

In infants whose mothers suffer from puerperal sepsis serious
lesions are prone to develop and the prognosis is bad.

The site of the infection is less important; however, cases with
marked lesions on the abdomen and trunk are more prone to have
umbilical infections and hence the prognosis is more dubious.

In cases with marked symptoms of systemic invasion the prognosis

1064 falls: PEMPfflous neonatorum

is uniformly bad. Young babies usually are apparently incapable
of surviving a staphylococcic or streptococcic septicemia.

Diagnosis. — The diagnosis of this disease in typical cases is usually
easy and especially so in the presence of an epidemic. However, in
isolated or atypical cases considerable difficulty may be experienced.
Great confusion has arisen because of attempts on the part of many
writers to separate on purely clinical grounds a group of closely
allied if not identical diseases. Recognizing this Hyde(5) has
pointed out that dermatitis exfohativa neonatorum and impetigo
contagioso of Fox are the same disease. Pemphigus neonatorum
may properly be removed from the category of affections strictly
catalogued as pemphigoid. The symptoms as given above usually
suffice to make the diagnosis clear and the isolation of the causative
organism from the lesions in pure culture confirms the diagnosis.

Differential Diagnosis. — The condition should be differentiated
from bullous syphilides. This is usually easy because babies suffer-
ing from bullous lesions of congenital syphilis in the first two weeks
of Ufe show unmistakable concomitant lesions of congenital syphilis.
The location of the lesions on the palms of the hands, soles of the
feet, and upon the buttocks is also characteristic.

From eczema pustulosum it is differentiated by the absence of
infiltration of the affected tissues and the absence of itching and the
failure of the lesions to form patches with wide separation of the
lesions. The evident termination of the lesions which do not
progress to form a freely discharging and crusting surface.

Varicella is rarely seen during the first two weeks of life. The
vesicles are smaller and a history of an epidemic is usually obtainable.

TREATMENT.

Prophylactic. — Early diagnosis and isolation of cases are of the
utmost importance. The history of most epidemics reveals the fact
that the disease was present for some days before the diagnosis was
established and many persons were exposed before the importance
of isolation was appreciated. The method of contagion is not
definitely established but the prevailing view is that intimate contact
is not necessary and that infection is transmitted by medical
attendants, nurses, midwives, and through bathing water, towels,
and other fomites. Hence it is recommended that institutional
cases be isolated as soon as the lesions appear together with the
mothers of such cases; also that special nurses be assigned to these
cases; and that they be cautioned regarding the possible spread of
the infection to themselves unless the strictest precautions are
observed in handling the cases.

falls: pemphigus neonatorum 1065

Midwives who have cases appearing in their practice should be
prohibited from practicing until the cases have cleaned up and until
their complete outfit has undergone rigorous sterilization. The
disease should be made reportable by law. This is now the case in
many communities. Persons suffering from impetigo or pustular
acne or any disease or condition of the skin associated with the
formation of pustular lesions should be excluded from contact with
new-born infants. Nurses should appreciate the highly contagious
nature of the disease and should wear rubber gloves when dressing
the lesions. They should avoid touching other parts of the baby's
body after dressing the affected parts. A daily bath in i to 2000
bichloride solution has been recommended. If possible a daily
change of sterilized baby clothes is advisable.

Active treatment consists in rupturing the new formed lesions
as soon as they appear with a sterile needle. A 2 per cent, am-
moniated mercury ointment is then applied and the lesions dressed
with individual dressings to prevent extension to other parts of
the body by contact. In adults the same treatment is carried out
except that the ammoniated mercury ointment is 3 to 5 per cent.
strength. A bichloride bath i to 2000 is also advised.

In the very severe cases the disease is a septicemia and should be
treated accordingly, symptomatic supportive measures being adopted
as indicated. Vaccines have been used in some epidemics but no
striking results have been reported. The writer would suggest
that they be applied prophylactically during an epidemic in cases
exposed and which had not as yet shown signs of the diseases. It
is well known that the skin lesions caused by the staphylococcus
are among the most favorable diseases known for treatment by
vaccine therapy. It is suggested that small doses, not more than
10 to 15 milhon, should be used. The injections should be made
subcutaneously and the concentration of the vaccine so regulated
that 3 to 4 drops of the suspension equals the desired dose. Vaccine
treatment in the severe cases with clinical evidence of septicemia
would probably be not only valueless but might be actually harmful.

General hygienic measures such as regulation of the diet and
bowels, plenty of sleep and fresh air should be adopted so as to place
the baby in the best condition to resist the infection.

CONCLUSIONS.

I. The disease is an epidemic staphylococcic vesicular dermatitis
occurring in new-born babies as a rule but capable of being trans-
mitted to older children and adults.

1066 falls: pemphigus neonatorum

2. The causative organism is a peculiar strain of staphylococcus
aureus which has fulfilled all of Koch's laws with respect to this
disease.

3. The disease usually runs a benign course but may be fatal.
The cause of death in the fatal cases is usually a septicemia initiated
by invasion of the umbilical vessels in most of the cases.

4. The possible origin of an epidemic from impetiginous lesions
on other children and adults renders it imperative that all babies
be protected from such sources of contamination.

5. In the presence of an epidemic prompt isolation of all cases
with special equipment and attendants together with thorough
sterilization of rooms and equipment subsequently is the only
efficient means of eradicating the disease.

6. The disease should be made reportable by law.

7. Early rupture of the lesions and the appUcation of separate
dressings of 2 per cent, white precipitate ointment to the lesions
will control most cases.

8. In the presence of an epidemic the possible role of midwives
and other attendants as carriers of the contagion should be kept in
mind and proper measures initiated to stop the spread through these
agencies.

BIBLIOGRAPHY.

1. Clegg and Wherry. Jour. Inf. Dis., 1906, No. 3, p. 165.

2. Falls. Jour. Inf. Dis., 1916.

3. .^Imquist. Zeilschrift f. Hyg., 1891, 10, p. 253.

4. Ahlfeld. Arch. f. Gyn., v. S. 150, 1872.

5. Hyde. Dis. of the Skin, 8th Edition, 1909, p. 400, Lea and
Febiger.

6. Ohme. Z)mer/a//<)«, Leipzig, 1773.

7. Scharlot. Casper s Wochenschr. f. d. ges. Heilkunde, 1841,
p. 186.

8. Plieninger. Zeit. f. chirurgie iind Gehurtshiilfe, 1854, 11. 2.

9. Hebra. Dis. of the Skin, vol. i, p. 395.

10. Hervieu.x. Jahresbericht von Virchow-Hirsch, 1868, ii, p.

659-

11. Olshausen and Mekus. Arc/i.f. Gyn., S. 392, 1870.

12. Moldenhauer. Arch. f. Gyn., vol. vi, S. 369, 1874.

13. Roser, quoted by Steffen. Weiner, Med. Woch., 1866,
Sept. 12.

14. Gibier. Annates de Derm, et Syph., 1882, No. 2.

15. Demme. Verhandlungen d. Cong. f. Med., Wiesbaden, 1S86.

16. Sabouraud. Annales de Dermatologie etde Syph., 1900, Ser. 4,

p. 325-

17. Grindon. Jour. Cut. Dis., 1901, p. 190.

18. Dohon. Arch. f. Gyn., 1876, 10, S. 589.

19. Tillbury .Fox. Skin Disease, William Wood & Co., 1877.

20. Edgar. Pract. of Obs., P. Blakiston's Son & Co., Phil.,
1913, p. 818.

TRANSACTIONS OF THE NEW YORK ACADEMY OF MEDICINE 1067

21. Matzenauer. Virchow-Hirsck Jahrb. d. gcs. Med., 1900, No.

2, p. 549-

22. Block. Brit. Jour. Derm., vol. xii, 1900, p. 304.

23. Max Neisser. Kolle & Wassermann, Handb. d. Pathogen.
Microorganismen, 2 Auflage, Band iv, p. 389.

24. H. J. Schwartz, Bull. New York Lying-in Hasp., 1908, p. i,
No. 5.

TRANSACTIONS OF THE NEW YORK ACADEMY
OF MEDICINE.

SECTION ON PEDIATRICS.

Meeting of October 12, 1916.
Royal Storrs Haynes, M. D., in the Chair.
The subject of the evening was

"lessons to the PEDIATRIST from the RECENT EPIDEMIC OF
POLIOMYELITIS."

Dr. Claude H. Lavinder, U. S. Public Health Service, spoke on

EPIDEMIOLOGY AND PUBLIC HEALTH PROBLEMS.

Epidemiological studies in their ultimate analysis are really
studies of modes of infection. In poliomyelitis the mode of infection
does not as yet rest upon a well established basis and the results of
such studies are therefore neither sure nor certain.

When Wickman, in his classical studies in Sweden, in 1905, formu-
lated the view that poliomyelitis is a contact disease spread from
person to person, and drew attention to the importance of abortive
types and carriers in the transmission of the disease, he gave a view of
the epidemiology of poliomyelitis which has directed all studies sub-
sequently made. An examination of the case cards of any more or
less recent epidemiological study of this disease makes it evident that
they are all constructed so as to make the study essentially an attempt
to support or disprove Wickman's hypothesis.

The epidemiologist is confronted with two problems: i. The
e.xplanation as to why, in comparatively recent times, apparently
this disease has assumed epidemic characteristics. 2. The finding
of a consistent explanation of the method by which the disease is
transmitted. Poliomyelitis apparently did not display any epidemic
prevalence previous to the early eighties. Even then it appeared in
only small groups of cases widely scattered, and very slowly gathered
force, une.xpectedly culminating this year in an epidemic whose pro-
portions exceed anything yet recorded for this disease.

1068 TRANSACTIONS OF THE

The present epidemic in New York City and the adjacent territory
will probably number at its conclusion something like 20,00c reported
cases. This entrance of poliomyelitis into the family of important
epidemic diseases is a remarkable and unique development, for
which there is no apparent explanation. With regard to the trans-
mission in poliomyelitis, it may be said that since Wickman's time
most epidemiologic studies have at least tended to confirm his views,
and experimental work in the laboratory has likewise contributed to
a similar result. Judging from our experience during this epidemic
in an intensive study of several hundred cases in various localities,
it seems more than likely that the epidemiological studies which
have been made will show no great difference in their ultimate re-
sults. The conception of poliomyelitis as a contact disease in its
widest sense, while receiving the qualified approval both of epidem-
iologic and experimental studies, nevertheless admits of some dubi-
ous points and shows not a few apparent inconsistencies.

From the epidemiologist's standpoint the present view of poliomy-
ehtis is that the disease is due to a specific agent of which the only
demonstrated natural sources are infected human beings, that is, the
recognized sick, convalescents, the mild "missed" cases and car-
riers in good health. The infective agent is known to be discharged
from these sources in the excretions of the respiratory and digestive
tracts. The infective agent, while known to be fairly resistant
to destructive agencies encountered outside of the human body,
nevertheless, presumably does not lead a saprophytic existence.
Of great significance is the experimental transmission of the disease
to monkeys by rubbing the virus on the intact nasal mucous mem-
brane. It is also significant that infection through the diges-
tive tract, or through the agency of biting insects has been found
more difiicult and less constant. The total incidence of the disease
in the population affected is usually small. It seems well established
that the recognized cases of the disease are of far less import-
ance in its transmission than healthy carriers and "missed" cases.
Epidemiologic studies have indicated that contact is a method of
transmission without, however, excluding the possibility of other
methods. There are one or two marked characteristics of the dis-
ease which do not harmonize very well with our present conception
as to its method of spread. These are a characteristic seasonal
prevalence and an equally characteristic age incidence. Any hy-
pothesis as to the mode of spread of this disease must be in con-
formity with these characteristics. Our conception of poliomyelitis is
that of a respiratory infection sf^read by contact, and yet by analogy
with all other respiratory diseases, poliomyelitis should prevail
not during the summer, but during the winter months, whereas
poliomyelitis corresponds in its seasonal prevalence to gastrointes-
tinal disturbances. This is a serious inconsistency which cannot now
be explained.

As to the age incidence of poliomyelitis, children under live years
of age constitute a very large percentage of the cases, although they
form only a very small percentage of the population. Adults,

NEW YORK ACADEMY OF MEDICINE 1069

forming usually over 50 per cent, of the total population, furnish but
a small percentage of cases. This, together with the fact that the
total incidence of the disease among the population is small, brings up
the question of immunity. The most feasible explanation of these
phenomena is the presumption of the wide prevalence of mild cases
and the consequent development of specific immunity to the disease
in a large part of the population. This explanation is unsatisfactory.
There are other inconsistencies, such as the small percentage of
secondary cases, the apparent paradox that the carrier is of more
importance in the distribution of the disease than the case itself,
the occurrence of cases among apparently well isolated people,
and the greater prevalence among rural than urban communities.
Epidemiologic studies of poliomyelitis are very much crippled
by our lack of knowledge as to any definite means of diagnosis,
especially in the mild case and the healthy carrier. Owing to our
lack of definite knowledge as to the incubation period of this disease,
and the fact that the mild case and the carrier are too frequently
missed in consequence, the picture which the epidemiologist obtains
of the spread of this disease is incomplete, and his conclusions there-
fore not so clear.

For the public health officer, whose function it may be to restrict
the spread of an epidemic of this disease, poliomyelitis presents
practically an impossible problem. The difficulties here again are
the mild case and the carrier. The difficulties of the problem of the
restriction of the spread of this disease do not excuse us from doing
whatever may be possible to secure restriction, even in a small
degree. Such things as the hospitalization of cases, supervision of
contacts, and attempts to regulate travel, with some system of
notification and other measures, while they may not restrict the
spread of the disease in a large measure, may achieve the desired end
at least in some degree. If our conception of poliomyelitis as a
contact disease be correct, then any real restriction of its spread
would seem to depend upon the development of some form of active
immunization.

Dr. May G. Wilson read a paper entitled

REVIEW OF THE SYMPTOMS OF ONSET COLLATED FROM THE CASES
AT WILLARD PARKER HOSPITAL.

This Study of the prodromal symptoms of infantile paralysis
was based on the histories of 400 patients admitted to the Willard
Parker Hospital from July i to September i, 1916, inclusive. These
histories were obtained by personal interviews with parents, corrob-
orated when possible by the family physician. Every effort was
made to obtain an accurate history of the onset and course of the
disease prior to admission. The symptoms given in the report
were those noted from the onset of illness until the appearance
of paralysis. Falls, overexertion, unusual excitement, overeating,
and dentition preceding the onset were given as causes. The onset,
as a rule, was acute, attacking an apparently healthy child unawares.

Fever was the most constant initial symptom, being noted in

1070 TRANSACTIONS OF THE

334 cases; only 2 per cent, on careful examination gave no history
of fever. The temperature rises rapidly, reaching its fastigium in
twenty-four to forty-eight hours. The highest temperature noted
was 106, the average 103, the duration was from one to ten days,
the av^erage -being four days. The fever might fall by crisis or Ij'sis.
In cases of remission or relapse an initial fever of one or two days
was followed by apparent health from two to six days, with a
secondary fever and paralysis following.

Vomiting was noted as an initial symptom in sixty-seven cases, as
an early symptom in 132 cases, sometimes occurring after the child
had retired and slept a while, more usually, however, immediately
on taking food. The vomiting was seldom repeated; in one instance
it was of a projectile character.

In 156 cases there was a definite history of persistent constipation
for two or more days, resisting ordinary catharsis and only relieved
by repeated enemas. Fecal scybali were often found on exami-
nation.

Diarrhea was not a common symptom in this series, being present
in only twenty-five cases, and being neither severe nor characteristic.
Abdominal pain was noted as an initial symptom in twenty-one cases,
as an early symptom in twenty-five cases. When present it is usually
severe, persisting for several days and referred to the epigastrium or
general and in two instances simulating appendicitis.

A study of respiratory symptoms showed that twenty-one cases
complained of sore throat as an initial symptom. A red throat was
noted in twenty-seven cases, folUcular tonsillitis in fourteen.
The examination of 100 cases at the time of admission to the hospital
showed injected fauces in thirty-one cases, enlarged tonsils in eleven,
exudate in three, and a mucopurulent frothy discharge in seven.
Epistaxis was present as an initial symptom in two cases, coryza in
seventeen cases, conjunctivitis in nine cases, and cough in thirty-
eight. There were two instances of severe bronchitis. As a group
these symptoms were not common nor characteristic.

The most constant nervous symptom was an early and persistent
drowsiness, noted in 288 cases, that is 72 per cent., and varying
from slight apathy to stupor in forty-seven cases. Irritability
was next in frequency, being noted in 153 cases. Associated with
irritability was marked hyperesthesia, noted in ninety-seven cases,
the slightest touch or even approach being resented. Tenderness
and stiffness of the neck was an early and common symptom present
in 130 cases, usually referred to the neck, back, shoulders and chest.
Tremor was noted in 113 cases, sometimes hmited to a single group of
muscles, usually of the extremities. The tremor persisted during
the febrile period, preceding the paralysis by twenty-four to forty-
eight hours. Two cases showed a marked coarse tremor persisting
for several weeks, limited to one side of the body and resembling
intention tremor; it was absent during sleep but recurred on the
slightest .irritation. Twitching was noted in sixty-four cases,
sometimes choreiform ; it often preceded a facial paralysis. Headache
was present in seventy-eight cases, often persistent and severe;
frontal or general headache was the first symptom complained of.in

NEW YORK ACADEMY OF MEDICINE 1071

twelve cases. Convulsions were present in six cases, as an initial
symptom in three. Two of these were children giving histories of
previous convulsions. Delirium was noted in ten cases.

There was a history of some urinary disturbance in twenty-one
cases, usually minor retention.

The skin symptoms observed were profuse sweating in forty-five
cases, out of proportion to the fever present, and usually preceding
paralysis. It was as a rule general; in a few instances, localized.
The rashes noted were blotches on the extremities in two cases,
general erythema in four, macular, resembling measles four, pustular
two, herpes seven. This latter was distributed over the back and
trunk, and in one instance limited to an arm, later paralyzed.

The clinical picture of the abortive type of the disease corre-
sponded in general with the initial stage of atj^ical cases fol-
lowed by paralysis. Mild initial symptoms might be followed by
extensive paralysis and, on the other hand, cases with severe and
alarming onset have shown slight paralysis and rapid recoverv.

In this series 22 were males, and 178 females. The race incidence
was as follows: Hebrew 152, American 76, Italian 70, Irish 50,
Polish 17, German 6, Colored 6, Swedish 4, and Japanese i. There
were a total of 199 under two years of age. Of 337 exposures in the
families in which the disease occurred there were fifty secondary
cases. Tw'Clve cases had had recent operations on the tonsils, eight
had hypertrophied tonsils and eighty-seven had normal tonsils.

The prodromal period has been found to be the most important
stage in the course of the disease, both as to early quarantine and
treatment. A careful history, while not diagnostic, is very sugges-
tive, particularly in an epidemic.

Dr. Leon Louris read a paper entitled

PERSONAI experience OF THE .ABORTI\'E AND MENINGITIC

T\T>ES.

The most important problem to us as physicians is the diagnosis
of this disease in its incipient stage. It is absolutely essential in
order to prevent the rapid spread of the disease that all cases be
recognized at their very onset.

We must think of this disease as an acute systemic infection,
involving, in the main, the cerebrospinal axis. The symptomatology
is very frequently much less than we might expect from the con-
comitant extent of the cerebrospinal involvement. Extensive areas
of perivascular infiltration, engorgement and edema of the mem-
branes and cerebrospinal axis may exist without clinical evidences
of their localization. Since degeneration of the nerve tissue is
secondary to the acute inflammatory condition, it necessarily follows
that the stage of paralysis is preceded by a generahzed irritation of
the cerebrospinal system. This period of irritation, the preparalytic
stage, manifests itself clinically by such symptoms as headache,
somnolence, irritability, hyperesthesia, general tenderness, rigidity
of the neck, Kernig"s sign, Macewen's sign, altered reflexes, and mild
muscular weakness. The symptoms of onset of poliomyelitis are

1072 TRANSACTIONS OF THE

those common to other acute infectious diseases, with a predomi-
nance of early nasopharyngeal and respiratory symptoms, or gastro-
intestinal disturbances. Taking these symptoms in turn we may
see how they differ in their characteristics in poliomyelitis and in
other diseases.

The fever is moderately high, remittent in type, sudden in onset
and yet without rigor. A peculiarity is the drop frequently observed
following lumbar puncture. A leukocytosis, running as high as
30,000, is usually present. This is at variance with the statement
made by Muller who found the predominance of a leukopenia,
3000 to 5000 white cells, which he considered pathognomonic for
poliomyelitis. The leukocytosis associated with a polynucleosis
was in our experience, of no value in making a differential diagnosis.

The pulse is rapid, out of proportion to the temperature, and
even in meningitic cases the pulse rate continues high. The respi-
rations are somewhat increased, but never irregular, thus differen-
tiating even the meningitic type of poliomyelitis from tuberculous
meningitis.

Gastrointestinal symptoms are marked, vomiting being frequently
continuous and persistent and bearing no relation to food, differing
in this respect from the vomiting of acute gastroenteritis. Diarrhea
is infrequent, while marked constipation is common. The abdomen
is frequently distended and children often complain of abdominal
pain suggestive of an acute surgical abdomen. Retention of urine
and distention of the bladder belong to the early symptoms. This
is probably caused by paresis of the abdominal and visceral muscles.
This muscular paresis is not a permanent feature and soon dis-
appears. In spite of the fever and apparent progress of the disease,
the demands for food in some cases are surprising. In several
instances children have been observed attempting to wipe off an
imaginary foreign substance from the tongue. This is probably
due to a peculiar hyperesthesia of the lingual mucous membrane.

In this epidemic rhinitis has, in the writer's observation, been
less frequent than in previously reported epidemics. Pharyngitis,
tonsillitis and bronchitis commonly occur. The types of tonsillitis
vary widely, but usually are rather mild and not associated with the
intense hyperemia commonly found in other throat infections, and
were less frequently accompanied by adenitis. The lymph glands
in the neck showed pronounced enlargement in but few instances.
Recrudescences or relapses, as Wickman called them, were not
uncommon. In some instances continuance of the fever, and the
excessive amount of rales suggested an extension of the catarrhal
condition to the smaller bronchioles, and the case was then diagnosed
as bronchopneumonia. Instead a paralytic condition of the inter-
costal muscles was present which prevented the child from e.xpelling
the mucus accumulating in the bronchi. The child was drown-
ing in its own secretions and this was interpreted as pulmonary
edema. In such cases the type of respiration is entirely changed,
the burden of respiration being borne by the diaphragm while the
accessory muscles were not in action, and the abdomen of the child
was_^bulging with every respiration.

NEW YORK ACADEMY OF MEDICINE 1073

The most significant symptoms of the onset of poHomyeUtis
are those referable to the cerebrospinal axis. The child lies in
apparent stupor but if aroused is extremely irritable. In the
writer's experience profound stupor bordering on coma has been seen
only in the severe cases of the encephalitic and meningitic types.
Somnolence has been rapidly recognized by the laity as of extreme
diagnostic importance, yet the average physician has not yet learned
to lay sufficient stress on this symptom.

The general posture and attitude of the child is that of hypo-
tonicity of its musculature ; a lack of resistance. An absence offpatellar
reflex is an early and almost pathognomonic sign and, similarly,
diminution in the tendoAchilles reflex. Skin reflexes remain nor-
mal or may be exaggerated even in a paretic part. A localized
weakness may be only of a few days duration and may attack any
single group of muscles. Testing the strength and tonicity ol
muscles should not be limited to the extremities, but should include
muscles of the neck, back and abdominal wall. Paralysis limited
to one-half the abdominal wall and interpreted as ventral hernia
has been observed by the writer. When pohomyelitis is suspected
the child should be made to sit up in bed and then one can tell
whether it can hold up its head or not. If the child attempts to
stand there is frequently an ataxic gait or the knees give away and
the child falls in a heap on the floor. Quite a number of cases
have been observed during the present epidemic in which the paral-
ysis was limited to the spinal muscles. In the vast majority of cases
these mild h^-potonic and paretic conditions rapidly disappear
leaving no permanent paralysis; these are the cases of the abortive
type or, as Muller calls it, and justly so, the rudimentary type of
poliomyelitis. This group of cases far outnumbers the paralytic
cases.

Pain in the extremities and areas of hyperesthesia, general or
localized, in any part of the body, serve to demonstrate the wide-
spread involvement of the nervous system, the white substance
and the posterior nerve roots, as well as the anterior horns. Fre-
quently a slight inequality of the two sides of the face exists and is
overlooked. Facial paralysis may be the only definite paralysis
in evidence, and this may be apparent only when the child is dis-
turbed or made to cry. Other symptoms are a hoarseness in the
voice occasionally mistaken for croup; paralysis of the palate and
tongue, usually unilateral in the more severe types; weakness of the
ocular muscles, producing a temporary strabismus or ptosis, general-
ized muscular twitchings of the arms, legs or face, observed in several
cases in the earliest stage of the disease.

i Meningitic types of the disease present considerable difficulty
indiagnosis. Macewen's signs should be tested for in every instance.
Its presence points to an increased amount of cerebrospinal fluid.
A lumbar puncture in this type of cases clinches the diagnosis.
The findings in the cerebrospinal fluid in poliomyelitis are definite
and pathognomonic. If one would but think of poliomyelitis
as an infectious disease attacking predominantly the cerebrospinal

1074 TRANSACTIONS OF THE

nervous system and that the symptoms of poHomyehtis are but the
evidences of a pathology, mild or severe, of a greater or lesser portion
of this system, one would more readily make the diagnosis.-
Dr. Phoebe DuBois read a paper entitled

THE LABOR.ATORY DIAGNOSIS OF POLIOMYELITIS.

From the laboratory findings alone an absolute diagnosis of polio-
myelitis cannot be made during life. Even if a monkey inoculated
with the washings from a nose and throat becomes paralyzed,
without the history of the case one cannot be sure that he is not
dealing with a carrier.

The laboratory is of value in poliomyelitis rather by what it rules
out. Of the various procedures that may be undertaken the exami-
nation of the spinal fluid is by far the most important.

In the examination of the blood, the count as a rule shows a
leukocytosis and a polynucleosis, but this is also true of the majority
of the infections with which poliomyelitis may be confounded.
So far complement fixation has not been successful; it would be of
little value in the paralysis cases because it does not seem that the
antibodies could develop before the paralysis in most cases, but it
would be of aid in making sure of the abortive cases. The method
of determining the presence or absence of antibodies which is at
present used is too cumbersome and expensive to be of practical
value. A simple method will no doubt be devised, but one cannot
foretell whether it will be by complement fixation as in syphilis,
by agglutination as in typhoid, a skin reaction like the von Pirquet,
or by an entirely new method. At the present time the examination
of the blood is of little practical value. The examination of the
urine is of no diagnostic importance so far as is known.

The examination of the spinal fluid is our real standby. The
fluid is clear or slightly hazy, comes out under increased pressure
and is increased in amount. Attention has been cafled of late to
the "ground glass appearance," as being of diagnostic value in polio-
myelitis. Such an appearance is found in the fluids containing
the larger numbers of cells. When the cells are fewer one could
not say from the macroscopic appearance whether or not they are
increased. Furthermore, this appearance is seen in fluids of tuber-
culous meningitis when a large number of cells are present, in the
early purulent meningitides with slight cell reaction, and in normal
fluids where there is a small amount of blood present, too small to
give any color to the fluid.

A fibrin web frequently forms in poliomyelitis fluid on standing.
This was at one time considered diagnostic of tuerculous meningitis.

Microscopically there is an increase of cells, marked, moderate,
or slight. The experience of the writer seems to indicate that
the number of cells bears no direct relation to the final outcome of
the disease. These cells may be mostly polynuclears, or mostly
mononuclears, more often the latter. It has been stated that
early in the disease there is a preponderance of polymorphonu-
clears. In the large number of early fluids the writer has found
an excess of polynuclears in only a relatively small percentage

NEW YORK ACADEMY OF MEDICINE 1075

of cases. IMany times cells are so degenerated, even in fresh fluids,
that it is difficult to classify them. There are a large number
of epithelioid cells that seem to be more numerous and more fre-
quently found in poliomyelitis than in other conditions.

The' chemical findings upon which most reliance is to be placed
is the prompt reduction of Fehling's solution, a well-marked ring
with nitric acid and a positive reaction with Noguchi's globulin
test.

The reaction both as regards chemistry and cytology differs
greatly in varying cases. In the majority it is well defined and in
some few cases very marked. In a small number of cases the find-
ings so nearly approach normal that it is difficult to say whether
or not an inflammatory reaction exists.

The chief conditions which have to be differentiated from polio-
myehtis on the strength of a clear fluid increased in amount are
tuberculous meningitis, syphilis of the central nervous system,
especially acute syphilitic meningitis, and meningism. In a well-
estabhsh'ed case of tuberculous meningitis, the amount of globulin
and albumin is greater than in poliomyelitis; also Fehling's solu-
tion reduces slowly or not at all, but more than one-half of the
fluids do reduce Fehling's promptly. Finding tubercle bacilli, of
course settles the question, and fafling that, animal inoculation,
but this takes four weeks. It would seem that with the history,
the examination of the spinal fluid it ought to be easy to distinguish
between these two conditions and ordinarily it is.

In a puzzling case last summer Lange's colloidal gold reaction
gave the clue to the diagnosis. In the luetic reaction the change
in color is usually the greatest in the third to the fifth tube and
never exceeds a four. The meningitic reaction has its maximum in
the higher dilutions. In general paresis the first three to six tubes
become colorless, while in general the maximum reaction in tuber-
culous meningitis is beyond the middle while poliomyelitis follows
more closely the luetic type with its maximum before the middle.
If there is blood in the fluid it throws out the examination because
of the albumin, globulin and cells thus introduced. By meningism
is understood a meningeal irritation functional rather than organic,
probably of toxic origin arising in the course of some disease, such
as pneumonia, gastroenterides or acute infectious diseases and
accompanied by an increase of spinal fluid. Ordinarily these
fluids show no increase in cells and only the normal trace of glo-
bulin and albumin. There are a few exceptions to this, namely,
the fluid in prolonged severe convulsions, in severe whooping
cough, and sometimes when a fluid is removed just prior to death.
The faintly cloudy fluid must be differentiated from that found
in the spinal fluid of cerebrospinal meningitis caused by pyogenic
organisms by exclusion; that is, if the case is one of true meningitis
one should be able to demonstrate the organism in smear and cul-
ture. It must be borne in mind that meningococci autolyze quickly
and are sometimes quite difiicult to find, especially if they are scarce
or the fluid has stood for twelve hours.

Froin's syndrome is not characteristic of any one disease, but

1076 TRANSACTIONS OF THE

it does occur in poliomyelitis. It consists of a fluid bright yellow
in color that coagulates spontaneously. It is due to an old hemor-
rhage and is so rare that it is mentioned only because it is puzzling
if one happens not to have heard of it. True hemorrhagic fluid,
that is were the blood is not due to accidental puncture of a vein,
is rare but it does occur.

After two or three weeks as a rule the examination of the spinal
fluid in poliomyehtis is of less consequence, the changes are so sHght
that nothing definite can be said about it. The increase in globuhn
and albumin usually persist longer than the increase in cells.

In conclusion, emphasis should be placed on the fact that a labora-
tory diagnosis of poliomyehtis is practically impossible. The
cUnical study and the laboratorj^ findings must be correlated.

THE TREATMENT OF POLIOMYELITIS, PROPHYLACTIC AND
CURATIVE

Dr. Herman Schwarz. — As the work from Mount Sinai Hospital
will be reported later, I will speak to-night mostly of my experience
in private practice.

My observations on the treatment of the disease will deal mostly
with the treatment with human convalescent serum. There are
two methods of approaching any method of treatment in order to
determine its efficiency. The first is from the statistical standpoint
and the second is by observing whether the results are those expected.

I have had twenty-one cases in which I used the serum early and
frequently and of these nine recovered without paralysis. Twenty-
one other cases were treated by expectant methods, seventeen
recovered without paralysis. This seemed to be quite a difference
in favor of the cases treated expectantly.

As regards the prognosis in reference to paralysis or nonparalysis,
the temperature plays no great role. If the patient did not die
before the third or fourth day a more favorable prognosis might
be given. If one was dealing with the bulbar tj'pe or paralysis of
the upper parts of the body the prognosis was worse than in those
cases having paralysis of the lower extremities.

In nine cases that died the cell count was less than loo. A small
number of ceUs is not necessarily a good prognostic sign. The
poly nuclear count in the cases that died was relatively low; in five
cases it was less than 5 per cent, and in only one case was it as high
as 21 per cent.

In the making of a prognosis one is not helped by an e.xamination
of the spinal fluid.

Of twenty-six cases that were not paralyzed, nine were treated
by serum and seventeen without it. In every case there was rigidity
of the neck and most of the cases showed Macewen's sign. The
cases that recovered without paralysis were all the cerebral type of
the disease.

Of the cases that recovered without paralysis ten showed a
cell count under 100; a few cases showed a cell count between one
and two hundred, hence the cell count does not seem to be a point

NEW YORK ACADEMY OF MEDICINE 1077

of much value in the prognosis. Some one has said that a poly-
morphonuclear count of lo per cent, or over is suggestive of poliomye-
litis; it is difficult to see just what is meant by this. It seems that
a cell count under 300 is not of much value in prognosis.

It has been stated that when the serum is used the temperature
comes down within five or six days. It may also be stated that
in cases in which no serum is used there is a decided drop on the third
day. The duration of the temperature does not seem to be affected
by the serum treatment.

The reaction of the serum on the patient was sometimes nil and
sometimes the rigidity of the neck was made worse. The reaction
on the cerebrospinal fluid seemed in some instances to be one indica-
tive of an increase of the inflammatory process. In certain bulbar
cases the use of the serum might be contraindicated.

Another difficulty that had been encountered in the use of the
serum was the fact that there were so many different kinds and
that it was difficult to standardize them. After all was said and
done, it was a fact that one might take any case in which the serum
had been used and duplicate it in every particular by a case in which
serum had not been used, so that personally I feel that we cannot
expect too much from the use of serum. This has been my impres-
sion although the number of cases may not be sufficient to warrant
any very definite statements.

Dr. Donald B.axter (by invitation) read a paper entitled

THE PROBLEM OF THE AFTER-CARE

We have had poliomyelitis always partially active, but it has been
overlooked. The social conscience seems just to have been aroused
to the necessity of caring for these cases. To some who watched
the epidemic it seemed to have more particularly a social and eco-
onmic import. It was very much more prevalent among the poorer
classes. This means that there are many cripples to be cared for,
not only relieved from suffering, but assisted in such ways that
they will in the future be able to become wage earners and to take
their proper place as citizens. A committee has been formed
having among its leaders Thomas J. Riley and Oliver H. Bartime.
The committee has as members surgeons, pediatrists, directors of
hospitals, managers of charitable institutions, nurses and private
citizens. This committee has several purposes. First it keeps
informed as to what other agencies are doing and endeavors to
assist these agencies in avoiding duplication of effort. It keeps
accurate records for present and future guidance. It is occupied
in correcting and confirming this data. It makes arrangements for
the treatment of cases that are not under the care of private physi-
cians. It is trying to standardize dispensary treatment. Thus
far 3856 cases have been reported upon and 3267 transferred to the
care of other agencies. By the methods employed it is believed
that much wasteful effort may be saved. It is evident that the
great majority of paralyzed cases are not under skillful care; in
many cases the family physician has been retained at a great sacrifice

1078 TRANSACTIONS OF THE

and in others his services have had to be discontinued. We are
endeavoring to show these people that hospital and dispensary care
is at their service, and having persuaded people to take advantages
of the hospital and dispensary treatment offered to encourage them
to persist in the treatment prescribed. The committee hopes soon
to be in a position to take up other activities, such as that of correct-
ing laboratory and hospital records.

DISCUSSION

Dr. George Draper. — I must take issue with Dr. Schwarz.
He said that he had the most difficult task of the evening in speaking
of the prophylactic and curative treatment of poliomyelitis; I think
it is still more difficult to be asked to speak after having listened
to such an array of interesting papers. However, there are several
points that suggest themselves, largely for the purpose of stimulating
still further discussion.

Dr. Louria made many interesting observations, but he did not
lay enough stress on the disease being an acute general infection.
More emphasis should be laid on this than upon any other one
feature of the disease. This was brought to my attention forcibly
during the summer. Several men who came to the city to study
the disease and who were active in the work on Long Island said
they had come to study a paralytic disease, and they did not see
as much paralysis as they had expected to see. This was because
the cases were all recognized forty-eight to seventy-two hours before
any paralysis appeared, the diagnosis being made by the symptoms
and by lumbar puncture. In many of these cases the diagnosis was
definitely established three or four days before paralysis appeared.

The interesting signs in the chest described by Dr. Louria as
"paralytic rales," should be recognized as such and not mistaken
for the rales interpreted as pulmonary edema, that occur later
when respiration is failing.

Just what the significance of headache is has not been determined.
It may be the result of systemic infection or may be due to an inva-
sion of the meninges. Since poliomyelitis belongs to the group of
general infectious diseases the headache in the early hours may be
part of the general reaction.

Dr. Dubois' paper is based upon much work of the most valuable
and enlightening sort. I would like to ask her whether the cell counts
were made by the wet method or by a centrifuged smear. The
method employed has considerable influence on the interpretation
of the findings. Pressure under which the spinal fluid is found
seems to have some relationship to the number of cells. When the
cell count is high the pressure is low and vice versa; there seems to
be a constant relationship here.

E.xceplion seems to have been taken to the making of a prognosis
on the findings in the cerebropjjinal lluid. But no statement has
been made as to the time in the course of the disease when the
lumbar puncture was made. This is not a question of days but of
hours. When one sees a child playing about at noon time, and con-

NEW YORK ACADEMY OF MEDICINE 1079

tinuing to play until 2 o'clock, though perhaps not feeling quite
well; then at six o'clock the child is \txy ill and a lumbar puncture
is made which shows 2500 cells, and the child is dead eighteen hours
later it is significant. It seems that the information one gets from
an examination of the spinal fluid depends upon the time when it
is made. There are other cases in which there is no invasion of the
meninges where one finds no cellular increase it is perfectly possible
to. say that they have never developed any cell increase, and in
some cases there will be a slight increase and then a recession. If
the cell counts are correlated with the clinical findings on the day
of onset it may be that some significance can be attached to them.

The examination of the spinal fluid by the Lange gold test is
interesting. A very large number of these examinations were
made by workers who knew nothing about the clinical history of
the cases from which the specimens came. The work was done
independently by the different workers and when the results were
brought together they corresponded remarkably well.

With reference to the question of treatment, it is doubtful if we
should make any positive statements as yet. The public has been
much affected by the lack of definite knowledge of the disease on the
part of the profession and the ineffective efforts in the direction of
treatment. However, I do not know that we have failed; there is a
great deal of evidence that would indicate that the serum treatment
is very effective, provided it be used early enough.

There is also another point with reference to the irritating effects
of the serum. It is well known that in the intraspinal treatment of
cerebrospinal syphilis, serum containing hemoglobin often causes
much more severe reactions than clear serum. During the stress
of the epidemic much of the serum was collected and prepared rapidly,
and it is possible that some of it might have contained hemoglobin
and that this might be still further irritating to a cerebrospinal tract
which is already more or less irritated. This point has been sug-
gested to me by a comparison of cases in which the serum was
double centrifuged and those in which serum pipetted directly from
the clot serum was used.

Dr. Charles Gilmore Kerley. — -We have learned considerable
about poliomyelitis during the past summer. We now know that
the disease is communicable by human agencies and the so-called
abortive cases are the ones that are the most dangerous from the
standpoint of transmission. It is rather peculiar that the very mild
cases and the very severe ones are both of the cerebral type.

Dr. Louria spoke of the symptom of neck rigidity. Cases in
which there is no neck rigidity will show a resistance or a reluctance
to bend the body forward and an inability to rest the chin on the
chest. In a few cases I found this the only symptom definitely
pointing to a poliomyelitis. I consider it a very important sign
and a decided aid in the border-line cases. There will also be shown
by these children a peculiar awkwardness in attempting to bend or
pick up objects from the floor. There aparenlly is not any great
amount of pain, but nevertheless there is an involuntary protection
against motion in certain directions.

1080 TRANSACTIONS OF THE

During the past epidemic of poliomyelitis, we have learned to look
upon sore throat and hoarseness during the hot months as possible
premonitory signs particularly if there is fever and prostration out
of proportion to that which we usually expect in an ordinary case
of sore throat.

I have seen some unusual paralytic manifestations. In three
children, the bladder alone was involved. In one case there was
paralysis of the third nerve only in a child eighteen months of age.
In two cases both of which were fatal the muscles of deglutition alone
were involved. In my patients and those that I have seen in
consultation there were no deaths after five days of illness and
paralysis did not appear in any case after the seventh day. It does
not follow, of course that this is an established standard as such
observations have not been the experiences of all.

As to the communicability in a large city like New York, it is
impossible to get data of any great value. I had the opportunity
during the summer of observing a series of cases that developed
in widely separated areas in eastern New York and western Connecti-
cut. I took the trouble to look into the possibilities of exposure in
something like fifteen cases, that is the first cases that occurred in a
given community where there had been no poliomyelitis for years.
In every instance I was able to demonstrate contact with individuals
who had been in association with the disease or who came from
infected localities.

Dr. Henry L. K. Shaw, of Albany. — I came this evening to learn
and not to discuss the papers, but I shall take this opportunity
to tell you a little concerning the epidemic in the other half of this
State. The cases appeared later than in the City of New York, and
it was not until late in July that it seemed worth while to prepare
a pin map showing the location of the cases. The first photograph
of this map was taken on July 27 and the cases which came directly
from Brooklyn or New York are indicated by a special pin. It
will be seen that these cases number nearly fifty and are widely
distributed throughout the State, although the majority of them are
within a radius of 50 miles of New York City. The photographs
of this map taken each week show how the epidemic progressed, and
up until yesterday there were 3569 reported cases of infantile paral-
ysis. The distribution of the cases shows they followed the line of
travel.

There have been about 800 deaths from infantile paralysis and a
mortality of about 21 per cent. Hudson was one of the first cities
to report the cases, and the first case developed in July but had spent
Decoration Day in an infected Brooklyn district. In this city
about thirty-six cases developed with only two deaths, and these
cases were practically all in a crowded Italian section of the city.
In Saratoga, on the other hand, there were eight cases occurring in
well-to-do families, and in spite of the best medical attention and
nursing, the mortality was 75 per cent. It is difficult to explain the
high mortality among certain groups of cases.

I would like to say a word with reference to the plans of the
State for the-after care of these cases of infantile paralysis. The

NEW YORK ACADEMY OF MEDICINE 1081

State has been fortunate in securing the services of Dr. Robert W.
Lovett, of Boston, assisted by Dr. Armitage Whitman, of New York,
and Dr. John Hodgen, of Boston. Six nurses have been sent to
Boston to learn the methods of massage and muscle training recom-
mended by Dr. Lovett. A series of clinics will be held each day for
several months, starting near New York where the first and greater
number of cases appeared.

■ A record of all the cases is kept in Albany, and a letter is to be
sent to the phvsicians reporting cases in the vicinity where the clinic
is to be held, inviting them to bring their patients. Dr. Lovett will
make a careful examination of each case and prescribe the treatment
indicated, and the child will then be turned over to the family
phvsician. If the family cannot afford to pay for the services of a
physician the muscle training and the braces will be provided free
of charge and it is planned that no case in the State will be neglected.
The importance of providing these clinics will be seen from the fact
that there are only two or three cities where there are any facilities
for holding an orthopedic clinic.

Dr. Henry \V. Berg.— I have been interested in Dr. Emerson's
report that several isolated islands and institutions in the city have
been free from this disease and also in the report that where there
were fewest hospital cases there was the highest incidence of infec-
tion. That would make it seem that isolation and segregation had
materiallv decreased the extent of the epidemic. This is important
and it would be agreeable to both physician and health authorities
to feel that they had accomplished what they had intended to do by
insisting upon the isolation of cases of infantile paralysis.

I wish to compliment Dr. Dubois, for she has done much actual
work in determining the cvtology and chemistry of spinal fluids.
She has drawn from a vast clinical field and the examinations she
has made mount up into the thousands. I wonder how many men
have counted hundreds of specimens as have Dr. Dubois and Dr.
Neal. It is much to her credit that she has been able to avoid all
preconceived ideas and in conclusion to make the statement that
diagnosis could not be made from the examination of the spinal fluid
alone in poliomvelitis. This is an important statement and an
honest statement. Clear fluids are present in other diseases and one
cannot differentiate them from poliomyelitis by the cytological and
chemical examination. This is important from the fact that the
danger from the standpoint of the communicabiHty of the disease
is in its preparalytic stage and the nonparalytic cases. I believe
the disease is mostly communicable in the preparalytic stage, before
the paralvsis appears, as is measles before the eruption and in the
catarrhal' stage. When the paralysis appears then the contagious
period is passed to a great extent. It therefore follows that the most
important stage to diagnosticate is the preparalytic stage, and we
should consider whether it can be done positively clinically. There
have been some svmptoms not taken into account in other years
that have been taken as diagnostic of poliomyelitis during the past
summer, and when we make a diagnosis on such insufficient data we
need as a sheet anchor a report on the cytological and chemical nature

1082 TRANSACTIONS OF THE

of the spinal fluid, if we can put anything distinctive on that fluid.
Clinically there is no positive pathogenic sign in the fluids of the pre-
paralytic stage that does not occur in other conditions and if the
cytological examination of the spinal fluids in the early stages only
stated that it was a clear fluid that meant that it did not differ from
the fluid in some other conditions, in which there is a clear cerebro-
spinal fluid. When a man tells of a series of fifty cases seen in the
preparalytic stage and not one developed paralysis, I can only say
I have not seen such an experience duplicated in the early stage of
any other infections. When men have observed upward of 2000
cases in one epidemic and that a very large proportion of these were
real paralytic cases that is quite a dilJerent story. We are not ready
to make positive statements concerning the enormous mass of cases
to-day but hope to do so in the future.

Dr. Linnaeus Edford LaFetra said: The early diagnosis of
poliomyelitis from other meningeal affections and at times even from
diseases that do not involve inflammation of the spinal meninges or
of the nerves may be exceedingly diftlcult. In my experience I
have come to rely upon two signs: one, clinical and the other labora-
tory. Tlie most important chnical features of early poliomyelitis
is stiffness and tenderness of the neck and back. I have never failed
to find this sign in an early stage. Of course, the stiffness of the neck
is simply a sign of the meningeal involvement and is naturally pres-
ent in other forms of meningitis. The laboratory test which is of
utmost value is the examination of the spinal fluid for a number of
cells and for the presence of globulin. All of us who have worked at
Bellevue Hospital have come to rely upon the finding of more than
ten cells, together with a globulin test as denoting an abnormal spinal
fluid with definite reaction of the meninges to some agent of disease.
Of course, these findings are present in all of the acute inflammatory
forms of meningitis, in tuberculous meningitis and in syphilis of the
nervous system. But the combination of a slightly or gradually
increased cell count and positive globulin, together with stiffness
of the neck is a very definite evidence of meningitis. Another sign
which is very important but not so constantly present is Brudzinsky's
phenomenon.

In regard to the spinal fluid findings, it must be admitted that there
is much yet to be learned, but we know enough already about
the spinal fluid findings in normal children, in those suffering from
other tvpes of disease, and in those suffering from various forms of
meningitis and poliomyelitis, to feel that the positive findings are
just as reliable as the positive findings of the thermometer in pneu-
monia or typhoid fever, and that the negative findings, if the fluid
is taken early in the disease, are ecjually reliable.

In regard to the cell count and the globulin reaction in cases
other than proved meningitis or poliomyelitis, the cell counts of
spinal fluid was made by Drs. Schloss and Schroeder in preparation
for an article which appeared in the American Journal of Children,
January, 1916. The normal patients numbered twenty and in
these the cells were below six and globulin none . There were thirty-
five cases of meningitis occurring during the course of otitis media,

NEW YORK ACADEMY OF MEDICINE 1083

bronchopneumonia, septicemia, gastroenteritis and malnutrition.
Among these the cells were below six except in two instances. In
both of these the meningitis complicated the otitis. In one the cells
were eighteen with negative globulin. In the other, in addition to
the otitis, there was a pneumonia along with meningism. The
spinal fluid showed eleven cells with no globulin.

I have just tabulated the spinal fluid findings in 125 cases treated
this summer (1916) in BeUevue Hospital and in only eleven of them
was the spinal fluid reported as showing an increase in cefls beyond
ten and no globulin. In most of these cases the examination was
made late, but some were very rapidly fatal cases. In several cases
•the first examination showed a large number of polymorphonuclear
cells, as many as 3900 being found in one case; this was, therefore, at
first mistaken for cerebrospinal. The child subsequently developed
facial paralysis and double auditory paralysis. It is interesting
to note that after the administration to them of 20 c.c. of Flexner's
antimeningococcus serum, the patients ploynuclears rose to 4500 —
quite contrary to what one would expect in cerebrospinal meningitis.
As the technic improved there were fewer discrepancies between
the number of cells found and the presence or absence of globulin.
Early in our series the spinal fluid was reported as normal in several
cases with undoubted paralysis; in the latter part of the series this
happened only when the fluid was examined late. Repeated spinal
fluid examinations w'ere made in many cases. At times there would
be an increase in the number of cells and in globulin on the second
or third test, if the case was gotten early; but usually, after the tenth
or fifteenth day, the cell count was normal although the globulin
might persist for some days longer. Examples of negative findings
in fluid, 3.66; examples of repeated examinations, 77.81, 88.70
and 70.94. The administration of human immune serum usually
but not always increases the number of cells which become pre-
dominatingly polynuclear. The stiffness of the neck, pain in the
back, and the Bradzinsky's and Kernig's signs are increased, or even
make their first appearance as a result of the reaction to the serum.

As regards prognosis, anyone who has had an extensive experi-
ence with poliomyelitis will be exceedingly cautious about giving a
good prognosis before the fourth of fifth day of the disease. No
matter how slight the initial paralysis may seem, there is always the
danger that the disease will extend to other and more important
nuclei. In particular, I think that one should be cautious about
giving an absolutely good prognosis in cases of facial paralysis. There
seems to be at the present time the feeling that if the facial nerve is
involved then all is well. Unfortunately, this feeling is not borne
out by a careful study of the cases that have proved fatal. If one
considers the location of the facial nuclei, he will really wonder how
it is why so frequently the cases of facial paralysis do w-ell, inasmuch
as it is so short a distance to the nuclei of other important nerves,
particularly the glossopharyngeal and the pneumogastric. Un-
fortunately, it has been my lot to see combinations of facial paralysis
with paralysis of the larynx or the pharynx, which have terminated
fatally in almost every instance. When the muscles of the neck are

1084 TRANSACTIONS OF THE

involved, there is also danger that the phrenic nerve may be in-
cluded in the inflammatory area, and this is always a very serious
matter.

In connection with the paralysis of the facial nerve, I have been
interested to look over my hospital records to determine what other
cranial nerves have been involved in my cases in this epidemic. The
olfactory and the optic nerves seemed to have escaped, although, of
course, it is difficult to know about their function in infants and small
children. The third (oculomotor) has been frequently involved,
sometimes one portion, sometimes another. I have not seen definitely
any involvement of the fourth nerve, that of the superior obHque
muscle of the eye. Nor have I known of trifacial involvement.
The sixth nerve to the external rectus muscle has been very com-
monly affected, and the seventh is, as we all know, the usual one
that suffers. I have one case of double auditory nerve involve-
ment which came on definitely on the day before the child came into
the hospital. But the glossopharyngeal nerve is not infrequently
affected, and occasionally the pneumogastric, shown by either spasm
or tlexidity of the vocal cords. The spinal accessory nerve is
occasionally involved in the paralysis of the neck muscles, and I
have seen one case in which the hypoglossal nerve was paralyzed on
the right side.

The disease is one of the most serious with which pediatrists have
to cope, and in the present state of our knowledge of its prevention
and treatment, we should be very cautious about giving any progno-
sis during the first two days.

As to the serum treatment, it would seem that some method of
standardizing the serum must be devised before results can be com-
pared and its value determined.

Dr. Louis Fischer. — In poliomyelitis of the bulbar type the
prognosis is always bad. One of my cases, a child three years old,
could not speak nor swallow, and became comatose. It had recur-
ring convulsions. We did a lumbar puncture, injected 15 c.c. of
serum, and the child recovered.

A second case was that of a sk-year-old child in a very serious
condition. The child was given two injections of serum, two days
apart, and recovered without any paralysis.

I have seen seven cases injected with 15 c.c. serum early in the
disease, and all recovered without paralysis. Three cases had res-
piratory paralysis, all of these died. Some of these cases were mis-
taken for bronchopneumonia. I have not seen a single case of
respiratory paralysis recover.

Some children were very much improved when merely a lumbar
puncture was done, the spinal fluid tapped, and the canal washed
with normal saline solution. My impression of the serum is that we
should advise its use in every case, but it must be used early during
the fever, in the preparalytic stage. When paralysis has set in, then
too much must not be expected from the serum.

The serum was obtained through Dr. Park and Dr. Zingher.

NEW YORK ACADEMY OE MEDICINE 1085

It is marked Serum B and Serum C, but I cannot say which is most
efficient.

Dr. .^er.aham Zingher. — Several methods have been suggested
during the past summer in the treatment of anterior poliomyelitis.
The one method that has given us the most satisfactory results, has
been the use of serum obtained from immune donors who have had
poliomyelitis either recently or from one to several years previously.
The serum was administered intraspinally in doses of from lo to 15
•c.c. and repeated every twenty to twenty-four hours until two to
three doses were injected. To obtain as large a supply of serum as
possible, and make it available to the members of the medical pro-
fession in this and adjoining states, we had to have recourse to a
certain amount of publicity. We ourselves had the opportunity of
using serum in 160 cases at the Willard Parker Hospital, and in
thirty-three cases at the Minturn Hospital. In addition, the serum
was supplied for 225 cases in the private practice of a number of
physicians.

The serum injected intraspinally in the acute stages of poliomyeli-
tis produces a moderate polynuclear leukocytosis which is increased
in intensity by the presence of hemoglobulin and tricresol, which was
added as a preservative. This cellular reaction is not specific, since
similar reactions were obtained with normal human serum, the second-
ary albumoses of Jobling, and to a less extent with horse-serum. It
is probable that the phagocytic action of the leukocytes is enhanced
by the presence of specific antibodies in the immune serum. If some
of the recent work of Rosenow's is verified and the disease is found to
be caused by the invasion of the vascular portions of the spinal cord
and brain by an attenuated streptococcus producing most probably
the lesions of an embolic type, then our conceptions of the pathology
and treatment of the disease will have to change. We do know,
however, that one of the chief weapons of the body against the strep-
tococcus is the phagocA'tic action of the polynuclear leukocytes.

The effect of the immune serum seems to be fairly shown by the
thirty-three cases treated in the Minturn Hospital. These cases were
carefully observed and received the full treatment. Of the thirty-
three cases fourteen were in a preparalytic stage of the disease at the
time the serum was administered: of the fourteen, eight remained free
from paralysis, two developed paralysis within twelve to eighteen
hours after the first dose of serum, and four developed paralysis forty-
eight hours or more after the injection of the serum. Of these four,
two patients showed an involvement of the extremities, one of the
right side of the face and one an external rectus of one eye. The
rapid and decided subsequent improvement in these cases was notice-
able. None of the cases treated in the preparalytic stage of the
disease died. Of the nineteen cases treated with serum after paraly-
sis had set in, three died soon after the injection (within twenty-
four hours) and sixteen recovered with varying degrees of motor
impairment.

Dr. Henry Heiman. — I regard poliomyelitis as a communicable
disease, not readily communicable, but about as much so as tonsillitis.
Anyone susceptible and exposed to tonsillitis may contract the dis-

1086 TRANSACTIONS OF THE NEW YORK ACADEMY OF MEDICINE

ease — it is about the same with poliomyeUtis. Among the first
symptoms may be inability to flex the head as pointed out by Dr.
Draper as a pathognomonic sign. This is probably due to an in-
volvement of the posterior meninges alone, as distinguished from
meningococcus meningitis where the entire meninges may be in-
volved, giving opisthotonos or rigidity of the neck. The meningeal
type of poliomyelitis frecjuently causes pain in the legs and abdomen
which I regard as Head zones due to an involvement of the
posterior nerve roots.

I wish to put myself on record as observing during this epidemic a
characteristic sign which is present in practically all cases of polio-
myelitis, especially of the meningeal type. This is a distinct fine
tremor of both hands elicited best by having the hands out-stretched
and fingers spread apart. It is present early in the disease and may
persist as long as ten or twelve weeks. It is probably due to an in-
flammation of the posterior meninges which extends up into the
cerebellar-rubral tract. The cerebrospinal system is the target for
the virus of poliomyelitis and consequently there is not a spot from
the cortex to the cauda equina that may not be involved.

Dr. Lavinder, in closing the discussion, said: I very much envy
the men who believe in the communicability of the disease; I have
given the basis of my beliefs which show that I am still somewhat
skeptical. I think that Dr. Draper was right when he said that
we have not yet had time to digest the material that has been fur-
nished during the present epidemic and until we do we cannot draw
conclusions.

Dr. Leon Louria, in closing the discussion, said that he wished to
emphasize the fact that poliomyelitis is an acute infectious disease
and that there can be no doubt about it. The medical profession at
large is not sufficiently familar with the abortive types of the disease,
and he felt that as long as we call the disease poliomyelitis it would
imply to the medical mind the presence of paralysis, and exclude the
nonparalytic cases. We may help to broaden the conception of
the disease by changing the nomenclature and for want of a better
name, he suggested to call it the Heine-Medin's disease, a name
adopted in Germany and Austria, and also by Dr. Barker in his
Monographic Medicine.

In doubtful cases the cytology and chemistry of the cerebrospinal
fluid supported the diagnosis; with rare exceptions, only in a few
cases was the fluid negative.

He could not agree with Dr. Berg that there is nothing distinctive
in the symptomatology of early poliomyelitis. He saw a large num-
ber of cases, over 350, in the acute stage in private practice, and
gained the impression that these children have an appearance that
diflercntiates them from other sick children. Just what this appear-
ance is, he was unable to put in exact words, but, it is ne\ertheless
distinctive.

Cases where the paralysis involves only the facial, run as a rule a
favorable course, but the prognosis must be guarded while the fever
e.xists. He recalled a case of a boy of thirteen whom he saw about
fort>-eight hours after the onset with a right facial onlv, and he was

BRIEF OF CURRENT LITERATURE 1087

encouraged but for a few hours, as the boy rapidly developed a ful-
minating descending type with involvement of the bulb and death
occurred the following day.

While drug and serum treatment do not as yet give definite re-
sults, he felt that in many instances the lumbar puncture brought
rehef and influenced favorably the course of the disease.

BRIEF OF CURRENT LITERATURE.

DISEASES OF CHILDREN.

Types of Hydrocephalus. — C. H. Frazier {Amer.Jour. Dis. Child.,
1916, xi, 9s) suggests the following classification, which has a physio-
logical background with direct clinical application: I. Hydrocephalus
obstructivus. II. Hydrocephalus nonabsorptus. HI. Hydrocephalus
hypersecretivus. IV. Hydrocephalus occultus. In Hydrocephalus
obstructivus, the internal hydrocephalus of the old nomenclature,
there is mechanical obstruction to the natural drainage of the
cerebrospinal fluid from one or more ventricles into the subarach-
noid space, where the absorption takes place. This obstruction
may be due to a congenital defect or be the result of adhesions from
a preexisting inflammatory lesion. \n Hydrocephalus nonabsorptus,
absorption ,is delayed or defective as has been proved by the
phenolsulphonaphthalein test. The third type, with apparent
excessive accumulation of fluid has been attributed to hj-persecre-
tion — Hydrocephalus hypersecretivus. The fourth tvpe, for which
the term Hydrocephalus occultus has been chosen, occurs usually in
children, though occasionally in adults, and is characterized by ex-
cess of fluid in the ventricles, basal cysternae, and sometimes through-
out the subarachnoid space, without necessarily any increase in the
cranial dimensions. Under normal conditions, when phenolsul-
phonaphthalein is injected into the lateral ventricle, it should appear
in the fluid withdrawn by lumbar puncture within three to eight
minutes. If, therefore, after injection the fluid from the spinal canal
is not stained within the specified time, it may be assumed that the
drainage of the ventricles has been interrupted, and that we are
dealing with hydrocephalus obstructivus. It has been proved that
the quantity of cerebrospinal fluid absorbed within the ventricles,
if any, is a negligible quantity; and that from 30 per cent, to 60 per
cent, of phenolsulphonaphthalein should, under normal conditions,
be secreted by the urine within the first two hours. If, therefore,
I c.c. is injected into the ventricle and the amount secreted by the
first two-hour urine specimen estimated, we have at once additional
evidence that we are dealing with the obstructive type. The same
test may be applied in the more unusual type of unilateral hydro-
cephalus. After the dye has disappeared from the urine following
the test of one ventricle, the test may be applied to the other. In
the second test, from a lumbar puncture needle, i c.c. of cerebro-

1088 BRIEF OF CURRENT LITERATURE

spinal fluid is allowed to escape. A 2 c.c. record syringe, containing
exactly i c.c. of the neutral phenolphthalein solution is attached to
the lumbar puncture needle, and the piston withdrawn until the
syringe is full. The solution of dye thus diluted is slowly injected
into the subarachnoid space; the time of injection is noted and in
five minutes a specimen is tested for the dye, and the entire amount
of urine secreted in two hours collected. In the normal, a trace of
the dye should appear in ten minutes and the entire amount excreted
within the first two hours. Any marked diminution in the time or
deviation from the amount indicates delayed absorption. If we are
dealing with the internal or obstructive t\-pe, the absorption of
phenolsulphonaphthalein from the subarachnoid space and the ex-
cretion by the kidney is practically normal. If on the other hand,
we are dealing with the nonabsorptive type, the time of appearance
of the dye in the urine is delayed and it may not appear for an hour
or more, and the amount secreted in the two-hour period is corre-
spondingly low; frec|uently but a trace is detected. In a few cases
no phenolsulphonaphthalein reaches the urine in four or six hours.
The simplest and most effective method of dealing with hydroceph-
alus obstructions is puncture of the corpus callosum. In the non-
absorptive type the writer recommends the establishment of a
drainage tract into the pleural cavity. When the lesion is due to
h^^persecretion he resorts to thyroid feeding. Thyroid invariably
acts as a depressor on the choroid plexus, and invariably reduces the
secretion of cerebrospinal fluid. This reduction is notable in
amount, in constancy and in duration.

Metabolism Studies in Hemophilia. — In presenting a study of the
metabolism of two cases of hemophilia, M. Kahn (Anier. Jour. Dis.
Child., 1916, xi, 103) says it would appear that not all hemophilia
patients present similar pathologic-chemical disturbances. There
seems to be no derangement in the metabolism as measured by the
intake and output of nitrogen, sulphur, calcium, etc., in the case of
hemophilia vera. There are, however, certain bleeders in whom the
disturbing factor seems to be a lack of calcium content of the blood,
and an inability on the part of their organisms to assimilate properly
the lime from the food. In these cases the remedy indicated would
be to administer the lacking mineral constituent in the form of the
chloride or the lactate of calcium.

Carmin Test for the Duration of the Complete Food Passage in
Infants and Children. — A. Hymanson {Amer. Jour. Dis. Child., 1916,
.\i, 112) tested the time of the food passage on two separate sets of
subjects. The first comprised twenty-one very young and healthy
breast-fed nurslings from one to six days old, at the Jewish ^Maternity
Hospital. Carmin was given in powder form in ' 2-g''ain doses.
These babies were nursed every three hours (two with subnormal
temperature, nursed every two hours, took very little milk). The
temperature varied from 96 to 99° F. The number of stools daily
was two or three. The time of the appearance of red stools varied
from four hours to eighteen hours, and for the disappearance of the
stain from four to twenty hours were required. These figures do

BRIEF OF CURRENT LITERATURE 1089

not differ radically from those of Nobecourt and Merklen and Spivak.
To twenty-fiv'e sick children from the Beth Israel Hospital, varying
in age from six weeks to six years, the dose of carmin given was from
I to 2 grains. The children in the great majority of cases had
subfebrile temperatures (under ioi° F.) and a number had been at-
tacked with severe maladies like bronchopneumonia, endocarditis,
etc. The shortest first appearance of the carmin was from twenty-
five to thirty hours. The marked differences between the small
figures of Triboulet (three to twelve hours) for complete passage,
and the large figures of the author (average twenty-five to thirty
hours), seem to be wholly due to the fact that Triboulet's sick in-
fants all had diarrhea or enteritis, while in the author's material,
bowel troubles were in a minority.

The Blood in Tuberculous Meningitis. — Analysis by E. A. JNIorgan
{Amcr. Jour. Dis. Child., 1916, xi, 224) of 252 blood counts in 169
cases shows that the leukocyte count in tuberculous meningitis is
higher than has been heretofore described. The average in this
series was 20,900 per cubic millimeter with 72.6 per cent, poly-
morphonuclears. The total leukocyte count and the proportion of
polymorphonuclear cells vary with the stage of the disease; e.g., both
counts increase as the disease advances. There is a relative but not
absolute diminution in the mononuclear elements of the blood.
There is a definite relationship between the intensity of the tuber-
culin skin reaction, on the one hand, and the total leukocyte count
and polymorphonuclear percentage on the other. Diminution in
the former is usually accompanied by an increase in the latter, both
being evidences of a failing resistance by the body to the tuberculous
infection.

Hemorefractometry in Infectious Diseases of Children. — The
studies of ]\Iello-Leitaa (Amcr. Jour. Dis. Cliild., 1916, xi, 214) show
that the refractometric index of blood serum in nurslings is lower
than that of the adult, and increases slowly from the first month till
the age of thirteen to eighteen months, reaching then a definite value.
Achard, Touraine and Saint-Girons' albuminemic curve is constant in
acute infectious diseases of infancy and childhood. The spasmodic
period of whooping-cough produces high albuminemy, which permits
the diagnosis from tuberculous tracheobronchial adenopathy. The
hemorefractometric coefficient in tuberculosis is generally lower than
normal. Syphilis increases remarkably the protein percentage in
blood serum.

Sialolithiasis and Sialodochitis in Childhood. — Reporting illus-
trative cases, H. Neuhof [Amcr. Jour. Dis. Child., 1916, xi, 232)
states that sialolithiasis in childhood cannot be termed the exceed-
ingly rare, almost unknown condition it is presumed to be. The
manifestations are more clean cut and evident in children than in
adults, the diagnosis can be made more readily, the surgical treat-
ment is simple and efficacious. The salivary duct should be probed
in every instance of enlargement of a salivary gland in a child when a
definite cause for the enlargement cannot be ascertained. There is a
hitherto undescribed form of sialodochitis of Stenson's duct in

1090 BRIEF OF CURRENT LITERATURE

children, secondary to inflammation of unknown origin, leading to
an enlargement of the parotid gland that can be readily mistaken
for sarcoma or mixed tumor. The gland is considerably increased
in size, firm, nodular, adherent; the orifice and buccal end of the
duct are embedded in stenosing cicatricial tissue. There is a tend-
ency to repeated recurrences of the parotid swelling after slitting
the mouth of the duct, but cure follows promptly the excision of the
diseased end of the duct.

Transfusion of Babies with Mothers as Donors.— It was the idea
of T. H. Cherry and E. G. Langrock (Jour. A. M. A., 1916, Ixvi, 626)
■to establish the complete compatibility of mother's and infant's
blood by performing a series of hemolytic tests on new-born babies
and their own mothers. ]\Iothers could advantageously be used as
donors because when an infant has had a severe initial hemorrhage
leaving it in an exsanguinated state, the delay in such a case in pro-
curing a compatible donor on whom the preliminary tests should be
made may be fatal to the infant; because when the bleeding is dis-
covered during the night, the procuring of a proper donor would
entail considerable delay; because in certain localities where no
laboratory is at hand and such a condition should arise, it is advan-
tageous to know that a compatible donor is nearby; and again, be-
cause the element of expense enters into the transaction in a certain
number of cases. In the thirty-four tests that were carried out on
the mothers and babies, no hemolysis or agglutination occurred.
From these experiments the WTiters have concluded that all mothers
can be used as donors for their infants in the transfusion of blood,
provided no contraindications exist on the part of the mothers. It
has been estimated that the volume of blood possessed by an infant
is one-twentieth of its body weight. In an infant weighing 7 pounds
the amount of its blood supply would approximate 5^5 ounces. If
one-third of the entire blood supply is lost by hemorrhage, there is
grave danger of death taking place. Therefore, to transfuse a baby
who has lost sufficient blood for symptoms of exsanguination to be
present, it is important that a known quantity of blood be thrown
into its circulation. If a too large amount enters the circulation,
the heart muscle, already weakened by hemorrhage, may become
acutely dilated, and death occur from a measure that is meant to be
therapeutic. From 60 to 75 c.c. of blood are approximately suffi-
cient to supply the infant with the necessary elements to promote
clotting and enough cellular elements to replace those lost by hem-
orrhage. This is an important reason why the indirect method of
transfusion should be practised on these bleeding infants, as well
as the argument for its simplicity of technic.

Mitral Stenosis in Young Children. — Reporting two cases of
mitral stenosis in boys ten and so\'eii and one-half years of age, one
of whom gave a four plus \Vassorniaiu\ reaction, M. H. Bass (Arch.
Pediat., 1916, xxxiii, 107) says thai in cases of mitral stenosis in
children, especially where there are no physical signs of insufficiency
present, though we have no definite proof of their luetic origin, syph-
ilis should be thought of and a Wassermann test done. Cardiac

BRIEF OF CURRENT LITERATURE 1091

disease, especially valvular stenosis, exerts a considerable influence
on the growth of the individual. A careful study of the literature
on the congenital nature of mitral stenosis leads to the following
conclusions: (a) Mitral stenosis has been observed at autopsy in
infants, (b) Mitral stenosis has been observed in children over five
years old in whom there was no apparent etiological factor present.
Such cases have been termed "congenital," though without sufficient
evidence of their being so. (c) No case of mitral stenosis has been
found reported in children between the ages of infancy and five years.
(d) The clinical picture described by Duroziez as Pure Alitral Steno-
sis should not be confused with the congenital lesion occurring as
a great rarity in infants.

Treatment of Diphtheria Carriers with Iodized Phenol. — The
cases reported by W. O. Ott and K. A. Roy (Jour. A. M. A.. 1916,
Ixvi, 800) consisted of carriers convalescent from clinical diphtheria
and some that did not have diphtheria but were persistent carriers.
In some cases, other methods had been persistently tried wdth failure
to obtain negative cultures. In all cases iodized phenol (acidum
carbolicum iodatum) of the National Formulary was used. It con-
tains 60 per cent, phenolcarbolic acid), 20 per cent, iodin crystals
and 20 per cent, glycerin. In pharyngeal cases, the tonsils, uvula
and posterior wall of the pharynx were swabbed every forty-eight
hours until negative cultures were obtained. In nasal cases, the
entire anterior part of the nasal cavity was swabbed with iodized
phenol every forty-eight hours. Care was taken not to allow the
preparation to run over the face or drop into the larynx. Cultures
were always made a few minutes before the local application. In
this way, forty-eight hours elapsed after each application of iodized
phenol before another culture was made. Seventeen cases were
treated. Negative cultures were obtained after one application of
iodized phenol in six cases (35 per cent.); after the second application
in five cases (29 per cent.); after the third application in two cases
(12 per cent.); after the fifth application in one case (6 per cent.),
and after the sixth application in two cases (12 per cent.). One case
(nasal) was under treatment for twenty-one days and required nine
apphcations before negative cultures were obtained. With the
exception of this case, none of the other sixteen were under treat-
ment longer than eleven days. Fifteen of the cases were followed
after leaving the hospital, and negative cultures obtained in all.
No treatment had been used since the discharge of the patients from
the hospital, and all of them had been out from one to three weeks
when these cultures were made. No bad results have been noticed
from the use of this rather strong preparation in the nose and throat.
The application is painful for hali a minute or less until the anesthetic
action of the phenol takes effect. A thin escharotic membrane
forms at the site of application which remains for about twenty-four
hours. This disappears entirely within forty-eight hours after
swabbing, leaving the throat red for a few days. After the redness
disappears, the throat returns to normal.

1092 BRIEF OF CURRENT LITERATURE

Removal of Tonsils and Adenoids in Diphtheria Carriers. — S. A.

Friedberg {Jour. A. M. A., 1916, Ixvi, 810) states that while dry
and finely powdered kaolin properly applied materially shortens
the necessary stay of patients in the hospital, in several instances the
local application of kaolin seemed to be without any effect on
the bacilli. In view of the prompt disappearance of the bacilli in these
cases after tonsillectomy and removal of adenoids the writer reports
the results of this procedure in six cases. In none of these patients
did the operation have any different general effects than it has ordi-
narily. In all of the patients the Schick test gave negative results
just before the operation. Si.\ successive negative cultures were
required before the patients were discharged. The results obtained
in this series indicate that in persistent carriers it may be necessary
to remove the tonsils and adenoid tissue if it is desired to terminate
promptly the carrier condition. The bacteriologic examination
should be made with care, as applications of medicinal agents may
destroy the bacilli on the surface while leaving unaffected those in
the crypts of the tonsils and the folds of the adenoid tissue. As to
the time the operation should be performed, it is perhaps advisable
to wait from two to three weeks after the clinical recovery of the
patient.

Treatment of Epidemic Meningitis. — J. B. Neal [Jour. A. M. A.,
1916, Ixvi, 862) says that the most common mistakes in serum treat-
ment of epidemic cerebrospinal meningitis seem to be giving too
few doses of serum if the patient improves considerably after the
lirst one or two injections, and failing to persist with the serum if
the improvement is very slow. It has been the experience of the
meningitis department during the past five years that it is rarely
safe to give less than four doses of serum on consecutive days, even
if the improvement clinically is very rapid and the organisms dis-
appear from the fluid after one or two injections. In cases which
have been running on for some time and in which the patients are
evidently improving when first seen, one or two injections of serum
are sometimes suificient. Occasionally in a case seen very early and
clearing up quickly, only three injections may be given. A case of
average severitv usually requires from four to seven injections. It
is safer to give the injections on consecutive days until it seems evi-
dent that the patient is out of danger, than to skip a day or two when
a shght improvement occurs, thereby giving the organism a chance
to increase. Puncture for the relief of pressure may have to be done
several times during convalescence. At such punctures, a little
serum may be injected, especially if a large amount of fluid is with-
drawn. In a smafl percentage of cases — from 5 to 10 per cent. — a
large number of injections may be necessary before the termination
of the case. A certain number of such cases terminate fatally.
Doses of serum larger than 20 c.c. need to be given with extreme
caution, even though very large amounts of fluid are withdrawn.
The serum treatment should be continued until the fluiil has been
sterile for two or three days and until the patient clinically is much
improved.

INDEX.

Abdomen, gunshot wounds of the, in pregnant women. Smead 972

Abdominal disease, hyperalgesia in. Ligat 1044

myomectomy and hysteromyomectomy by morceUation. Child, Jr. 329

operation, radical, for carcinoma of the uterus. Taylor 144

tumor, transient, in a child of five years, with redundant colon. Cope-
land 170

wall, obese and rela.xed, correction of the, with especial reference to

the use of buried silver chain. Babcock 596, 695

Abortion, pelvic infection following. Lott 830

Abortive and nonparalytic cases, their importance and their recognition.

Draper 343

type of general septicemia, following pelvic infection in pregnancy.

Moore 842

Abscess, appendicular, complication, hemorrhage, followed by death.

Tate 933

pelvic pneumococcus. Shoemaker 660, 692

Abt. A study of 226 cases of chorea 907

Familial icterus of the new-born '550

Acetone bodies, conditions in infancj' and cliildhood associate with the pro-
duction of abnormal quantities of. Rowland and Marriott 887

Acetonuria, the factor of starvation in the development of. Veeder and

Johnston 888

Achondroplasia, lantern-slide demonstration of. Herrman 747

Acidosis. Chapin 886

complicating pregnancy, with report of a case cured by transfusion.

Ely and Lindeman 42, 1 24

in normal uterine pregnancies. Emge 769

Acker. Multiple sclerosis in a child four and one-half years 555

Acute cerebellar ataxia in children. GriiBth 366

Adachi. An interesting case of synctioma malignum 397

Adair. Some remarks on the relationsliip of syphilis to miscarriage and

fetal abnormalities 86

Adams. The danger to hospital efficiency from diphtheria carriers 556

Adenocarcinoma, fibroid and an independent, uterus containing sarco-
matous degeneration of. Pool 493

of the corpus uteri: nearly complete removal by the curet. Frank. 369

Adenoids, removal of, in diphtheria carriers. Friedberg 1092

Ager. The present epidemic — the types which it presents 34S

Albuminuria, orthostatic, phthalein test in. Hempelmann 767

12 1093

1094 INDEX

Alkali-earth alkali equilibrium in spasmophilia. Grulee go6

Amebic infection in the mouths of children. Williams, Von Sholly,

Rosenberg and Mann 767

Amenorrhea, organic extracts in the treatment of. Kohler 155

Amino acid content of the blood, a further study of the. Pettibone and

Schlutz 892

Ammoniacal diaper in infants and young children. Zahorsky 767

Amputation, immediate complete, of the umbilical cord. Dickinson 334

Anal control, restoration of. Tovey 85 1

Angell. The neuropathic child . 739

Apical pneumonias in children. Wall 861

Appendectomy for gangrenous appendicitis. Vineberg 487

Appendicitis, acute, and twisted pedicle, dermoid cyst of the ovarj-, com-
plicating pregnancy. Doyle 849

gangrenous, appendectomy for. Vineberg 487

pin worms as a cause of. Armstrong 761

Appendicular abscess, complication, hemorrhage, followed by death.

Tate 933

Appendix, removal of the, for the cure of trifacial neuralgia. Rosenthal. ... 103 1

sarcoma of the. Wohl 1046

Armstrong. Pin worms as a cause of appendicitis 761

Army medical corps examination 870

Artificial sterilization, the indications for and advisability of. Sullivan. 458, 507
Asphyxia pallida, resulting from early separation of lower two of four

placentae. Welz 795

Ataxia, acute cerebellar, in children. Griffith 366

Atmospheric conditions, recent progress in our knowledge of the physiolog-
ical action of. Lee 160

Austin. The frequency of hereditary syphilis 893

Autogenetic infection. Moore 842

Autoserum treatment of chorea. Goodman 873

Award of one hundred dollars by the Chicago Gynecological Society.

Heaney 1040

Babcock. The correction of the obese and relaxed abdominal wall with

especial reference to the use of buried silver chain 596, 695

The treatment of tragic forms of rupture in ectopic pregnancy by

vaginal section and the application of a clamp 276

Bacilli, diphtheria, active immunization with diphtheria toxin-antitoxin

and with toxin-antitoxin combined with. Park and Zingher 559

Bacillus dysenteriae as a cause of infectious diarrhea in infants. Broeck

and Norbury 925

Bactericidal property of vaginal secretion, nature of the. Harada 1044

Bacteriology and experimental production of ovaritis. Rosenow and

Davis 336

Baeslack. Experimental syphilis 88

INDEX 1095

Baldwin. Inoperable cancer of the cervix with amenorrhea 134

Bancroft. Report on a case of carcinoma uteri treated according to the

Percy method, with autopsy findings 11, 144

Banti's disease, prognosis and treatment of, in children. Graham 548

Baxter. The problem of the after-care 1077

Beach. Fetal death due to eight coils of umbilical cord about the neck. . . . 298
Beck. Exercise on all fours as a means of preventing subinvolution and

retroversion 75, 137

Two instances of weak uterine scars following Cesarean section. . . 134
Bell. Rupture of the uterus in Cesareanized women, with a review of the

literature on this subject to date 950

Benzol, leukemia in a boy with some observations on. Winslow and

Edwards 749

Bibby. Observations on tuberculosis at the Vanderbilt clinic 876

Bile ducts, congenital obliteration of the. Holmes 925

ducts, congenital occlusion of the. Foote and Hamilton 521

Bissel. Surgical replacement of the retroposed uterus i

Bladder, stone in the. Vaughan 701

tumors in the young. O'Neal 768

Bleeding nipples. Lewis 713

Blood, a further study of the animo acid content of the. Pettibone and

Schultz 802

coagulation in infancy. Dale and Laidlow 768

in children, the creatinin and creatin content of the. Veeder, and

Meredith 357

in infants, a brief report of sixty blood examinations in infancy, with
a review of the recent literature of the. McClanahan and John-
son 356

in tuberculous meningitis. Morgan loSg

pressure^ the effect of cold air on the, in pneumonia in childhood.

Morse and Hassam 881

pressures, observations on, during operations. Moots 996

supply of the ovary, the variations in the, and their possible opera-
tive importance. Sampson 95

the calcium content of the, in rachitis and tetany. Howland and

Marriot 341

whole, intramuscular injections of, in treatment of purpura hemor-
rhagica. Emsheimer 560

Boldt. High heat versus low heat in the treatment of cancer of the

uterus 32S

Bone formation, nonteratomatous, in the human ovary. Outerbridge 8()7

Border-line contractions of pelves, management of labor in. Polak and

Phelan 1042

Bosworth, a method of preparing sj'nthetic milk for studies of infant met-
abolism 532

Bov6e. Presidential address: Notes on the past, present and future of

gynecology, obstetrics and abdominal surgery loi

Bowditch. A method of preparing synthetic milk for studies of infant met-
abolism 532

1096 INDEX

Breech presentation, is the operation of Cesarean section indicated in the

deUvery of? McPherson 776

Brennemann. The use of boiled milk in infant feeding 915

Brodhead. Cesarean section for uterine inertia and contracted pel vis 140

Vaginal Cesarean section for blighted ovum 140

Brown. Spindle- and giant-celled polypoid sarcoma of the uterus 287

Buhman. The specificity of the Wassermann reaction 84

Burnam. A resume of results in the radium treatment of 347 cases of

cancer of the uterus and vagina 326

Butterworth. Oxycephaly : its occurrence in two brothers 553

Cadwallader. Cesarean section for strangulated ovarian cyst complicating

labor 2S1

Calcium content of the blood in rachitis and tetany. Rowland and Mar-

"""■; 541

metabolism in a case of hemophilia. Cowie and Laws 540

Caldwell. ."Y report of three cases of labor following ventral suspension. 50, 130

Cancer, clinical course of, in the light of cancer research. Gaylord 323

inoperable, of the cervi.\ with amenorrhea. Baldwin 134

of the rectum and rectosigmoid. Mayo 1045

of the uterus and vagina, a resume of results in the radium treatment

of 347 cases of. Kelley and Burnam 326

of the uterus, high heat versus low heat in the treatment of. Boldt. 328

of the uterus, pregnancy complicated by. Zimmermann 251, 3x6

of the uterus, treatment of. Claris 324

research, the clinical course of cancer in the light of. Gaylord 323

uterine, radium treatment of. Ransohoff and Ransohoff 1044

Carbohydrate diet and o.xygen, protective action of, upon the liver cells in

experimental chloroform poisoning. Lavake 401

Carcinoma, inoperable uterine, the problem of heat as a method of treat-
ment in. Percy 326

of the cecum, a case of, in a girl tw-enty-three years of age. Eastman. 380
of the cervix uteri, early result in a case of — presentation of patient

and specimen. Corscaden 142

of the descending colon. Tracy 699

of the uterus, the extended operation for. Peterson 324

of the uterus, the radical bdominal operation for. Taylor 144

primary of the vulva. Stein 577, S60

uteri, report on a case of, treated according to the Percy method,

with autopsy findings. Bancroft 11, 144

Carmin test for the duration of the complete food passage in infants and

children. Hymanson 1088

Carstens. Points in the diagnosis of pelvic troubles 1002

Gary. Examination of semen with special reference to its gynecological

aspects 615, 684

Cecum, carcinoma of the, in a girl twenty-three years of age. Eastman.. 380

Celiohysterotomy, transperitoneal. Polak .721 138

Cerebellar ataxia, acute, in children. Gritlith. 366

INDEX 1097

Cerebral defects, t>'pes of, in children that may be benefited by operation.

Matzinger 742

Cerebrospinal fluids, cell counts of. Roby 751

meningitis, epidemic, congestion in the treatment of. Forbes and

Cohen 924

Cervical glands, tonsils excretory organs for. Blum 927

Cervix, inoperable cancer of the, with amenorrhea. Baldwin 134

pregnancy complicated by cancer of the. Zimmermann 251, 316

uteri, early result in a case of carcinoma of the — presentation of

patient and specimen. Corscaden 142

Cesareanized women, rupture of the uterus in. Bell 950

Cesarean scar, rupture of the. Rongy 954

section as the operation of choice in difficult labor cases. Hirst. . . 784

section, extra- and transperitoneal. Baisch 154

section for accidental hemorrhage. Mayne 136

section for dystocia due to double uterus and fibroids. Pinkham.. 284
section for strangulated ovarian cyst complicating labor. Cad-

wallader 281

section for uterine inertia and contracted pelvis. Brodhcad 140

section in a case of scoliorachitic pelvis. Saliba 793

section, is the operation of, indicated in the delivery of breech pres-
entation? McPherson 776

section, postmortem. Pfaff 967

section, rupture of the scar of a previous. Findley 411

section, two instances of weak uterine scars following. Beck 134

section, vaginal delivery subsequent to. Wilson 701

section, vaginal, for blighted ovum. Brodhead 140

section, with hysterectomy. Dorman 121

Chapin. Acidosis 886-

A scheme of state control for dependent infants 760

Chase. Hemorrhage from ruptured hymen 514

Child, Jr. Abdominal myomectomy and hysteromyomectomy by morcel-

lation 329

Regurgitant menstruation through the Fallopian tubes 484

Chipman. The teacher's inheritance 256

Chloroform poisoning, experimental, protective action of high carbohydrate

diet upon the liver cells in. Lavake 401

Cholelithiasis. Taylor 515

report of a case of complicating pregnancy. Finkelstone S18

Chorea, a study of the etiology of. Morse and Floyd 545

autoserum treatment of. Goodman 873

study of 226 cases of. Abt 907

the effect of subcutaneous injections of magnesium sulphate in.

Heiman 547

Chorioepithelioma, ectopic, of the pelvis. Frank 369

Chronic urethritis in women. Shallenberger 157

Churchill. The frequency of hereditary syphilis 893

Citrated whole milk. Pritchard 367

Clark. The treatment of cancer of the uterus 324

1098 INDEX

Clinical study of children in relation to tuberculous exposure. Planning

and Knott 174

Coagulation, blood, in infancy. Dale and Laidlaw 768

new means of securing. Fischl 368

Colon, descending, carcinoma of the. Tracy 699

redundant, transient abdominal tumor in a child of five years with.

Copeland 170

Conaway. A case of uterus didelphus 696

A case of vesico-utero- vaginal fistula &95

Conception, the time of. Siege! 153

Congenital absence of the external ear. Schwartz 311

absence of the left ovary and Fallopian tube. Ward, Jr 297

and acquired retropositions of the uterus: their differentiation and

relative significance. Sturmdorf 386, 687

obliteration of the bile ducts. Holmes 925

occlusion of the bile ducts. Foote and Hamilton 521

syphilis, speech sign of. Swift 173

Congestion in the treatment of epidemic cerebrospinal meningitis. Forbes

and Cohen 924

Conservation of the tube. Stone 863

Considerations in the care of our patients before and after operation.

Yates 1006

Constitutional factor in gynecology and obstetrics. Noble $3:}

Convulsions, relation of, to pelvis disease. Riggles 662, 704

Copeland. Obscure fever in infancy and childhood 909

Transient abdominal tumor in a child of five years, with redundant

colon 170

Cord, umbilical, immediate complete amputation of the. Dickinson 334

Corpus uteri, adenocarcinoma of the. Frank 369

Corscaden. Early result in a case of carcinoma of the cervix uteri — presen-
tation of patient and specimen 142

Cowie. Calcium metabolism in a case of hemophilia 540

Creatinin and creatin content of the blood in children. Veeder and Mere-
dith 357

Cretin, the energy metabohsm of a. Talbot 549

Cyanosis, familial. Hess 902

Cyst, dermoid. Holden 314

dermoid, of the ovarj-, with twisted pedicle, and acute appendicitis,

complicating pregnancy. Doyle 849

ovarian, with twisted pedicle complicating pregnancy. Humpstone. 315

Cysts, luteinic, of the ovaries, clinical significance of. Bar 713

Cystocele and prolapsus uteri, interposition of Watkins-Wertheim in the

treatment of. Frank 780

and uterine prolapse, etiology of. Fitzgibbon 868

Daniels. A new and original method of calculating the required posterior

sagittal diameter of the outlet in a lateral contraction of the pelvis. 238

De Buys. Comparative study of the luetin and Wassermann reactions. . . . 895

INDEX

1099

Deficiencies in the state law regulating overcrowding in institutions for

infants and children. Southworth 7i8

Dental caries in chUdhood; the most neglected feature in pediatric medicine.

McCleave ^^°

Dependent infants, a scheme of state control for. Chapin 760

Dermoid cyst. Holden ; ■ ; ; ■ 3^4

cyst of the ovary, with twisted pedicle, and acute appendicitis,

complicating pregnancy. Doyle °49

Determination of sex. Freeborn "°

Diabetes, mild, in children. Griffith i°°

Diaper, ammoniacal. in infants and young children. Zahorsky 767

Diarrhea, infectious, in infants, bacillus dysenterise, as a cause of. Broeck

and Norbury ^^^

Diarrheal diseases, report of a committee on the investigation of. Grover 919

Diarrheas, summer, of infants, relation of heat to. Bleyer 768

Dickinson. Immediate complete amputation of the umbUical cord 334

Didelphus, uterus, a case of. Conaway ^9^

Diet and growth in infantile scurvy. Hess 1^4

chUdren's, the regulation of, after infancy. Knox 918

the influence of, on the development and health of the teeth.

Durand "

Digestive disorders, chronic, of mechanical origin in children. Kerley 9°°

Diphtheria and scarlet fever, weather in relation to the prevalence of.

Banda

a study of deaths in Philadelphia during the past five years from.

Graham ;■••■■ 9°^

baciUi, active immunization with diphtheria toxin-antito.xin and

with toxin-antitoxin combined with. Park and Zingher 559

carriers, the danger to hospital efficiency from. Adams and Leech. . 556

carriers, treatment of, with iodized phenol. Ott and Roy 1091

Donnelly. Treatment of eclampsia 63,117

Dorman. Report of a case of fibroma of cervix obstructing labor. Cesa-
rean section, with hysterectomy '^"^

Doyle. Dermoid cyst of the ovary, with twisted pedicle, and acute appen-
dicitis, complicating pregnancy 849

Drainage for pus conditions in the pelvis during pregnancy. Reder 935

Draper. Abortive and nonparalytic cases, their importance and their

recognition ■^'*^

Du Bois. The laboratory diagnosis of poliomyelitis io74

Ductless glands and their relation to the treatment of functional gyne-
cological diseases. Rabinovitz ^77

Duodenal ulcer, a case of— operation and improvement. McClanahan. . . 899

ulcer in infancy an infectious disease. Gerdine and Helmholz 766

Durand. The influence of diet on the development and health of the teeth. 918

Durney. The open-air school as a tj-pe 74°

Dyscrasia, thyroid, emetine in severe dysmenorrhea associated with.

narrower ^°9

Dysmenorrhea. Kennedy ''^

severe, associated with thyroid dyscrasia, emetine in. Harrower. . 709
Dystocia due to double uterus and fibroids, Cesarean section for. Pink-
ham ^^4

1100 INDEX

Ear, external, congenital absence of the. Schwartz 311

Eastman. A case of carcinoma of the cecum in a girl twenty-three years of

age 380

Eclampsia. Holden 312

treatment of. Knipe and Donnelly 63, 117

Ectopic chorioepitheUoma of the pelvis. Frank 369

gestation, a study of 117 cases of. Foskett 232

pregnancy, management of. Miller 847

pregnancy, the treatment of tragic forms of rupture in, by vaginal

section and the application of a clamp. Babcock 276

pregnancy, treatment of emergencj- cases of. Richardson 1041

Eczema, cutaneous reaction from proteins in. Blackfan 926

in infants and young children. Kerley 753

Edema, general, of the fetus, report of a case of. Williamson 376

Edgar. Painless labor 675

Edwards. Leukemia in a boy with some observations on benzol 749

Efficiency, hospital, dangers of, from diphtheria carriers. Adams and

Leech 556

Eiweissmilch and its adjuvants. Glanzman 172

. Election of officers of American Pediatric Societ}- 559

Elizabeth Steel ]Magee Hospital and its work. 7eigler 265

Ely. Acidosis complicating pregnancy, with report of a case cured by

transfusion 42, 124

Emerson. The importance of the present epidemic 349

Emetine in severe dysmenorrhea associated with thyroid dyscrasia. Har-

rower 709

Emge. Acidosis in normal uterine pregnancies 769

Emphysema, purpura, and subcutaneous, report of a case of influenza in

an infant with two unusual complications. Machell 355

Empyema, parapneumonic. Gerdine 928

Endocrine glands in their relation to the female generative organs. Timme.

474,518
Endometrium and ovary, relation of the, to hemorrhage from myomatous

uteri. Geist 869

Energy metabolism of a cretin. Talbot 549

Enuresis, management of. Newlin 174

Epidemic meningitis, treatment of. Neal 1092

present, the importance of. Emerson 349

present — the types which it presents. Ager 345

Epidemiology and pubUc health problems. Lavinder 1067

Epstein. The troubles of the new-born 714

Etiology of tetany. Brown and Fletcher 175

Exercise on all fours as a means of preventing subinvolution and retro-
version 75, 137

Extra- and transperitoneal Cesarean section. Baiscb 154

E.xtract, lymph gland; its preparation and therapeutic action. Hadden. . 989

Extracts, organic, as oxytoxics. KoUer 153

organic, in the treatment of amenorrhea. Kohler 155

Extraurinary infection, the bacteriology of the urine in healthy children

and those suffering from. Helmhollz s'ii

1101

Fallopian tube, and left ovary, congenital absence of the. Ward, Jr 297

tubes, regurgitant menstruation through the. Child, Jr 4S4

Falls. Pemphigus neonatorum 1048

Familial cyanosis. Hess 902

icterus of the new-born. Abt 550

syphilis. Jeans 560

Feeding, infant, the use of boiled milk in. Brennemann 915

infant, the use of malt soup extract in. Hoobler 917

Femur, anteversion of the neck of the. Hibbs 766

Fertility, lessened, of women, especially .\merican women. Stone 454, 506

Fetal and placenta syphilis. Plass 561

death due to eight coils of umbical cord about the neck. Beach. . . 298

rigor mortis. Castriota i73

Fetterolf. A study of the topography of the pulmonary lobes and fissures

with special reference to thoracentesis 533

Fetus, lumbar puncture in the. Costa 1041

report of a case of general edema of the. Williamson 376

Fever, obscure, in infancy and childhood. Copeland 909

syphilitic, in relation to gynecological and obstetrical practice.

Taussig 9°

typhoid, in children. Percy 1 74

Fibroid, degenerating, with marked to-xemia sj^mptoms. Wiener 683

Fibroids, and double uterus, Cesarean section for dystocia due to. Pink-
ham 2S4

uterine, sarcomatous change in. Maroney 445, 499

Fibroma of cervix obstructing labor, report of a case of. Dorman 121

Findley. Rupture of the scar of a previous Cesarean section 41J

Finkelstone. Reportof a case of cholelithiasis complicating pregnancy. . . . SiS

Fistula, vesico-utero-vaginal, a case of. Conaway 695

vulvorectal, report of a case of. Rawls 300

Flexner. What we know about the transmission of infantile paralysis 338

Floyd. A study of the etiology of chorea 543

Fluid, spinal, in poliomyelitis. Abramson 365

Food passage, complete, carmin test for the duration of the, in infants and

children. Hymanson 1088

Foote. Congenital occlusion of the bile ducts 521

Foskett. A study of 117 cases of ectopic gestation 232

Foulkrod. Report of a case of Krukenberg's tumor of the ovaries 657, 694

Frank, i. .Adenocarcinoma of the corpus uteri: nearly complete removal

by the curet. 2. Ectopic chorioepithelioma of the pelvis 360

The interposition operation of Watkins-Wertheim in the treatment of

cystocele and prolapsus uteri 781

The use of the .r-ray in uterine hemorrhage 3'^

Freeman. Presidential address 158

Firedlander. Sarcoma of the kidney treated by x-ray 169

Fried wound dressings. Stewart 282

Fuller's earth in intestinal disorders of infants. Hess 9^7

Fullerton. The significance of s>-philis in obstetrics 23

1102

Gangrene of the sigmoid after normal labor. Kosmak 119

Gaucher's disease in infants. Knox, Wahl and Schmeisser 922

Gauze removed from the peritoneal cavity seventeen years after a h>-s-

terectomy. Tracy 698

Gaylord. The clinical course of cancer in the light of cancer research 3 23

Genitalia, female, injury to the, in coitus, with report of a case of vulvo-
rectal fistula. Rawls 300

Gestation, ectopic, a study of 117 cases of. Foskett 232

Gibson. The relationship between pelvic disease and manic-depressive

insanity 439, 494

Giddings. Report of committee on vaginitis 534

A study of the topography of the pulmonary lobes and fissures with

special reference to thoracentesis 533

Glands, ductless, and their relation to the treatment of functional gyneco-
logical diseases. Rabinovitz 177

endocrine, in their relation to the female generative organs.

Timme 474, 518

Gonorrheal tube infections, acute, treatment of. Coffey 156

Goodman. Autoserum treatment of chorea 873

Graft, fatty, treatment of large crural herniae. Chaput 712

Grafts, ovarian. Martin 1043

Graham. A stud}- of the deaths in Philadelphia during the past five years
from scarlet fever, measles, diphtheria, whooping-cough and

t>'phoid fever 903

The prognosis and treatment of Banti"s disease in children 548

The use of salt solution by the bowel (Murphy method) in infants

and children 555

Grasty . Acute lymphatic leukemia 669, 701

Grip in children. Royster 883

Grover. Report of a committee on the investigation of diarrheal diseases . . 919
Growth and sexual development, the influence of pituitary feeding upon.

Goetsch 334

Grulee, alkali-earth alkali equilibrium in spasmophilia 906

Guinea-pig, action of various "female" remedies on excised uterus. Pil-

cher, Delzell and Burman 866

Gunshot wounds of the abdomen in pregnant women. Smead 972

Gynecology and obstetrics, the constitutional factor in. Noble 333

the teaching of, to the advance pupil. Sturradorf '. 68

Wassermann reaction in. Williams and Kolmer 638, 698

Hadden. Lymph gland extract. Its preparation and therapeutic action. 989

Hall. Report of a case of rupture of the uterus; sepsis; operation; recovery. 942

Hamilton. Congenital occlusion of the bile ducts 521

Hand, Jr. Hypertrophic stenosis of the pylorus in children 750

Hassam. The effect of cold air on the blood pressure in pneumonia in

childhood 88i

Heat, high, versus low heat in the treatment of cancer of the uterus. Boldt. 328

INDEX 1103

Heiman. The effect of subcutaneous injections of magnesium sulphate in

chorea 547

Heineberg. A. Uteroscopic findings: A preliminary report. B. Collec-
tion of uterine scrapings 612

Helmholtz. The bacteriology of the urine in healthy children and those

suffering from extraurinary infection 552

Hemophilia, calcium metabolism in a case of. Cowie and Laws 540

metabolism studies in. Kahn 1088

Hemorefractometry in infectious diseases of children. MeUo-Leitaa 1089

Hemorrhage, accidental, Cesarean section for. Mayne 136

from myomatous uteri, relation of the ovary to. Geist 869

from ruptured hymen. Chase 514

postpartum. Rice 215, 302

results of cranial decompression in selected types of cerebral spastic

paralysis due to. Sharpe 743

uterine, hypothyroidism a factor in certain types of. Salzman. ... 812

uterine, the use of .v-ray in. Frank 321

Hereditary syphilis, late. Jeans 896

syphiHs, the clinical course and physical signs in. Post 893

syphilis, the frequency of. Churchill and Austin 893

syphihs, treatment of. Sylvester 896

Hernia, inguinal, uterus and tubes contained in. Brindeau 1043

Herniae, large crural, treatment of, by a fatty graft. Chaput 712

Herrman. A lantern-slide demonstration of achondroplasia 747

Observations on measles 551

Hess. Diet and growth in infantile scurvy 164

Familial cyanosis 902

Provocative and prophylactic vaccination in the vaginitis of infants. 536
Hirst. Cesarean section as the operation of choice in difficult labor cases. 784
The training in obstetrics that the state should demand before

licensing a physician to practice 56, 103

Histochemical studies of the function of the placenta. Gentili 707

Holden. Dermoid cyst 314

Eclampsia 312

Homogenized olive-oil mi.xtures, further experiences with. Ladd 363

Hoobler. Early symptoms of protein sensitization in infancy 538

The use of malt soup extract in infant feeding 917

Hornstein. Rarer forms of toxemia of pregnancy 270

Howe. Some practical experiences in medical inspections in rural sections. 735
Howland. Conditions in infancy and childhood associated with the pro-
duction of abnormal quantities of acetone bodies 887

The calcium content of the blood in rachitis and tetany 541

Huggins. Tissue tone as an index to vital resistance with special reference

to prolapse of the uterus 674

Humpstone. Ovarian cyst with twisted pedicle complicating pregnancy. 315
Hussey. Management of pregnancy and labor complicated by heart dis-
ease 240, 317

Hyde. Tuberculous peritonitis — an analysis 466, 516

Hydrocephalus, types of. Frazier 1087

Hymen, ruptured, hemorrhage from. Chase S14

1104 INDEX

Hyperalgesia in abdominal disease. Ligat 1044

Hv-pertrophic stenosis of the pylorus in children. Hand, Jr 750

H}T)oglossus, one-sided paralysis of the. Lederer 921

Hypothyroidism a factor in certain types of uterine hemorrhage. Salzman. 812

Hysterectomy, Cesarean section with. Dorman 121

gauze removed from the peritoneal cavity seventeen years after.

Tracy 698

vaginal, for procidentia. Truesdale 868

vaginal-supra vaginal. Reich 37

Hysteromyomectomy and abdominal myomectomy by morcellation.

Child, Jr 329

Icterus, familial, of the new-born. Abt 550

Ileus, postoperative. Thompson 868

Immunization, active, with diphtheria to.\in-antito.\in and with toxin-

antito.xin combined with diphtheria bacilli. Park and Zingher. . 559

Incontinence of urine in women. Taylor 97

Indications for and advisabihty of artificial sterilization. Sullivan. . . 458, 507

Inertia, uterine and contracted pelvis, Cesarean section for. Brodhead. . 140

Infancy, protection of, in France. Pinard 921

the protection of, during the first five months of the European war.

Pinard 176

Infantile paralysis, what we know about the transmission of. Flexner. . . . 338

scurvy, diet and growth in. Hess 164

Infant mortality, the umbilical cord as a factor in. Young 853

Infants, premature, the hospital care of. LaFetra 359

Infection, chronic focal, of the pelvic organs and its relation to systemic dis-
ease. Maier 652, 694

e.xtraurinary, the bacteriology of the urine in healthy children and

those suffering from. Helmholtz 552

Infections, acute gonorrheal tube, treatment of. Coffey 156

Infectious diseases of children, hemorefractometry in. Mello-Leitaa 1089

diseases of infancy and childhood, the hospital control of the.

Richardson 723

Influenza, report of a case of, in an infant with two unusual complications,

purpura and subcutaneous emphysema. Machell 355

Inguinal hernia, uterus and tubes contained in. Brindeau 1043

Inheritance, the teacher's. Chipman 256

Injections, intramuscular, of whole blood in the treatment of purpura

hemorrhagica. Emsheimer 560

Injury to the female genitalia in coitus, with report of a case of vulvorectal

fistula. Rawls 300

Insanity, manic-depressive, and peKic disease, the relationship between.

Gibson 439, 494

Intestinal, chronic and stomach disorders of mechanical origin in children,

Rontgen-ray findings of. Le Wald 901

disorders of infants, Fuller's earth in. Hess 927

INDEX 1105

Intestinal obstruction in children with special reference to intussusception.

Peterson 746

toxemia, surgical treatment of. Lynch 747

Intestine, prolapsed, through ruptured uterus. Mayne 515

small, process of repair in wounds of the. McWhorter, Stout and

Lieb 86g

Intussusception, intestinal obstruction in children with special reference to.

Peterson 746

Iodized phenol, treatment of diphtheria carriers with. Ott and Roy 109 1

Iridochorioditis, suppurative meningococcal, cure of, by injection of anti-

meningococcal serum into the vitreous. Netter 923

Jeans. Late hereditary syphilis 896

Johnson. A brief report of sixty blood examinations in infancy, with a

review of the recent literature of the blood in infants 356

Johnston. The factor of starvation in the development of acetonuria 888

Keilty. A leather-bottle descending colon, sigmoid and rectum 828

KeUey. A resume of results in the radium treatment of 347 cases of cancer

of the uterus and vagina 326

Kennedy. Dysmenorrhea 77

Puerperal infection 801

Kerley. Chronic digestive disorders of mechanical origin in children 900

Eczema in infants and young children 753

Kidney, sarcoma of the, treated by I'-ray. Friedlander 169

Knipe. Puerperal streptococcemia 291

Treatment of eclampsia 63, 117

Knox. The regulation of children's diet after infancy 918

Kolmer. The Wassermann reaction in gynecology 638, 698

Koplik. Meningitis in the new-born and in infants under three months of

age 554

The clinical t\-pes of poliomyelitis 340

Kosmak. Gangrene of the sigmoid after normal labor 119

Sarcoma of the ovary complicating the puerperium 139

Toxemia in pregnancy following th3'roidectomy S56

Labor and pregnancy complicated by heart disease, management of.

Hussey 240, 317

A report of three cases of, following ventral suspension. Caldwell. 50, 130

cases, difficult, Cesarean section as the operation of choice in. Hirst. 784
Cesarean section for stangulated ovarian cyst complicating. Cad-

wallader 281

fibroma of cervLx obstructing, report of a case of. Dorman 121

induced premature, modern conceptions of, for pelvic deformity.

Guiceiardi 706

1106 INDEX

Labor in 3-oung girls. Specht I54

leukocytes in. Baer . 1041

management of, in border-line contractions of pelves. Polak and

Phelan 1042

megacolon as an obstruction to. Jaschke 1 54

normal, gangrene of the sigmoid after. Kosmak 119

painless. Edgar 675

Laboratory aids in the diagnosis of poliomyelitis. Neal 34^

Lactic acid, and the spore-bearing organisms in milk, antagonism between

the. Kiester i7S

Ladd. Further experiences \\nth homogenized olive-oil mixtures 363

La Fetra. The hospital care of premature infants 359

Lanford. Comparative study of the luetin and Wassermann reactions 895

Laparotomy, after. Forgue 710

Lateral contraction of the pelvis. Daniels 239

Lavake. Notes on the protective action of high carbohydrate diet and
o.xygen upon the liver cells in experimental chloroform poisoning,

with the possible application in pre-eclamptic toxemia 401

Lavinder. Epidemiology and public health problems 1067

Laws. Calcium metabolism in a case of hemophilia 540

Leather-bottle descending colon, sigmoid and rectum. Keilty 828

Lee. Recent progress in our knowledge of the physiological action of

atmospheric conditions 160

Leech. The danger to hospital efficiency from diphtheria carriers 556

Leukemia, acute lymphatic. Grasty 669, 701

in a boy with some observations on benzol. Winslow and Edwards . 749

Leukocytes in pregnancy, labor and the puerperium. Baer 1041

Le Wald. Rontgen-ray findings of chronic intestinal and stomach dis-
orders of mechanical origin in children 901

Lewis. The vision of the school child 733

Lindeman. Acidosis complicating pregnancy, with report of a case cured

by transfusion 42, 124

Lobes, pulmonary, and fissures, a study of the, with special reference to

thoracentesis. Gittings, Fetterolf and Mitchell 533

Lott. Pelvic infection following abortion. A case of interest 830

Louris. Personal experience of the abortive and meningitic types 1071

Lowe. Pyelitis of pregnancy 7°°

Luetin and Wassermann reactions, comparative study of the. De Buys

and Lanford 895

Lumbar puncture in the fetus. Costa 1041

Luteinic cysts of the ovaries, clinical significance of. Bar 713

Lymphatic leukemia, acute. Grasty 669, 701

Lymph gland extract. Its preparation and therapeutic action. Hadden. 989

Lynch. The surgical treatment of intestinal toxemia 747

McClanahan. A brief report of sixty blood examinations in infancy, with a

review of the recent literature of the blood in infants 356

A case of duodenal ulcer — operation and improvement 899

INDEX 1107

McCleave. Dental caries in childhood; the most neglected feature in

pediatric medicine 880

McCIoskey. Maternity superstitions of the Filipinos 833

McCord. Summarj' of scope of practicable examination in routine school

medical inspection 737

McNeUe. Results from pituitary extract in obstetrics, with report of case

of rupture of the uterus following its use 432

McPherson. Is the operation of Cesarean section indicated in the delivery

of breech presentation? 776

Machell. Report of a case of influenza in an infant with two unusual com-

pUcations, purpura and subcutaneous emphysema 35S

Magnesium sulphate, the effect of subcutaneous injections of, in chorea.

Heiman 547

jMaier. Chronic focal infection of the pelvic organs and its relation to sys-
temic disease 652, 694

Malaria, tertian, report of five cases of, treated with synthetic arsenic intra-
venously. Neff 914

Malt soup extract, the use of, in infant feeding. Hoobler 917

Manic-depressive insanity, the relationship between pelvic disease and.

Gibson 439, 494

Maroney. Sarcomatous change in uterine fibroids 445, 499

Marriott. Conditions in infancy and childhood associated with the pro-
duction of abnormal quantities of acetone bodies 887

The Calcium content of the blood in rachitis and tetany 541

Maternity superstitions of the Filipinos. JlcCloskej' 833

Matzinger. Types of cerebral defects in children that may be benefited by

operation 742

Ma\-ne. Cesarean section for accidental hemorrhage 136

Prolapsed intestine through ruptured uterus 515

Measles, a study of deaths in Philadelphia during the past five years from.

Graham 9°3

observations on. Herrman 551

Mechanism of menstruation. Vignes 711

Medical inspection, routine school, summary of scope of practicable exami-
nation in. McCord 737

inspections in rural sections, some practical e.xperiences in. Howe. . 735

Megacolon as an obstruction to labor. Jaschke 154

Meningitis, epidemic cerebrospinal, congestion in the treatment of. Forbes

and Cohen 924

epidemic, treatment of. Neal 1092

in the new-born and in infants under three months of age. Koplik. . 554
meningococcus, with unusual hemorrhagic manifestations and

demonstration of the diplococcus in the skin. Sharpe 872

meningococcus, with unusual hemorrhagic manifestations. Sharpe. 718

tuberculous, the blood in. Morgan 1089

Meningococcus in nasopharynx of cerebrospinal fever contacts. Mcintosh

and Bullock 76S

meningitis with unusual hemorrhagic manifestations. Sharpe. . . 718, 872
Menstrual period, modification of the pulse and arterial tension during.

Ballard and Sidaine 712

symptoms during pregnancy. Polk ISS

1108 INDEX

Menstruation, mechanism of. Vignes 711

regurgitant, through the Fallopian tubes. ChUd, Jr 484

Mental deficiency in children, value of the Wassermann reaction in.

Gordon 924

Meredith. The creatinin and creatin content of the blood in children 357

Metabolism, calcium, in a case of hemophilia. Cowie and Laws 540

energy, of a cretin. Talbot 549

infant, a method of preparing synthetic milk for studies of. Bow-
ditch and Bosworth 532

nitrogen during pregnancy. Wilson 335

studies in hemophilia. Kahn 1088

Milk, antagonism between the lactic acid and the spore-bearing organisms.

Kiester 175

boiled, nutritive value of. Daniels, Stuescy and Francis 928

boiled, the use of, in infant feeding. Brennemann 915

citrated whole. Pritchard 367

synthetic, a method of preparing, for studies of infant metabolism.

Bowditch and Bosworth 532

Miller. Etiology of sterility in women 450, 500

Management of ectopic pregnancy 847

Miscarriage and fetal abnormalities, some remarks on the relationship of

syphilis to. Adair 86

Mitchell. A study of the topography of the pulmonary lobes and fissures

with special reference to thoracentesis 533

Mitral stenosis in young children. Bass 1090

Moore. The abortive type of general septicemia, following pelvic infec-
tion in pregnancy; autogenetic infection; puerperal polyneuritis. 842

Moots. Observations on blood pressures during operations 996

Morcellation, abdominal myomectomy and hystero myomectomy by.

Child, Jr 329

Morse. A study of the etiology of chorea 545

The effect of cold air on the blood pressure in pneumonia in child-
hood 881

Mortality and morbidity, surgical, operative judgment as a factor in.

Skeel 1012

infant, umbilical cord as a factor in. Young 853

Mouths of children, amebic infection in the. WUUams, Von Sholly,

Rosenberg and Mann 767

Myoma, red, of the uterus. Chuije 1042

Myomatous uteri, relation of the endometrium and ovary to hemorrhage

from. Geist 869

Myomectomy, abdominal, and hysteromj'omectomy by morcellation.

ChUd, Jr 3-^7

Nasopharynx of cerebrospinal fever contracts, meningococcus in. Mcin-
tosh and Bullock 765

Neal. Laboratory aids in the diagnosis of poliomyelitis 346

Neck of the femur, anterversion of tlie. Hibbs 766

INDEX 11^^

Neff. Report of five cases of tertian malaria treated with synthetic arsenic
intravenously.

Neuralgia, trifacial, removal of the appendix for the cure of. Rosenthal. . 1031
pathic child, the. Angell
)om, familial icterus of th(
troubles of the. Epstein

Neuropathic child, the. Angell. ^^ ^^^

739

New-bom, familial icterus of the. Abt

714

713

Nipples, bleeding. Lewis

Nitrogen metabolism during pregnancy. WUson. ■■•■■•■•; fJi

Noble The constitutional factor in gynecology and obstetrics 333

Nonparalytic and abortive cases, their importance and their recogmtion. ^^^

Nonprote^n'iStrogenousconstituents of the blood and the phenosulpho-

nephthalein test in children. Leopold and Bornhard. ._^ 92b

Nonteratomatous bone formation in the human ovary. Outerbndge. . . . 867

Norris. Syphilis of the body of the uterus ^■■- ■ • ■

Nursing pe^od, duration of, in woman of the United States. MitcheU. 336

Nutrition of mother, effects of state of, during pregnancy and labor on con-

dirion of child at birth and for first few days of Me. Smith. ... 866
Nutritive value of boiled milk. Daniels, Stuescy and Francis 92»

Obscure fever in infancy and childhood. Copeland . W

Observations tin blood pressures during operaUons. Moots ;•■•■••• ^9°

on the occurrence of s^-p^s in the university of Michigan obstetrical ^^

and gynecology cUnic. Peterson ■.■■■■"■;; , ,t

Obstetrics and gynecology, the constitutional factor m. Noble. .... - • 333
results from pituitary extract in, with report of a case of rupture of

the uterus foUowing its use. McNeile 43^

teaching, under improved conditions. Schwarz 9=1

the significance of s>'pWlis in. Fullerton .•••■•;••,•■ 11

OUve-oU mixtures, homogenized, further experiences with. Ladd 303

Onen-air school as a t>-pe. Durney • t>" , " ,^

Operation, bloodless, for correction of double uterus and vagina. Rockey. 7^9

^ considerations in the care of our patients before and after. Yates. . 1006

extended, for carcinoma of the uterus. Peterson • • • ■ ■ • 3 4

Operative judgment as a factor in surgical mortality and ^^'^'y- ^^^^

Skeel / '," ' V> 1 nAx

Oral cavity, effect of malformation and inspection of the. Palmer 74i

Organic extracts as oxytoxics. Kohler • ■

extracts in the treatment of amenorrhea. Kohler 5»

Orthostatic albuminuria, phthalein test in. Hempelmann 7 7

Otitis media, acute, in infancy and childhood. Emerson. . . . ^ ■• • • • Ji

Ovarian cyst with twisted pedicle compUcating pregnancy. Humpstone. . ^315

grafts. Martin

Ovaries, clinical significance of luteinic cysts of the. Bar ■^- 7 3

Krukenberg's tumor of the. Foulkrod 57,

1110 INDEX

Ovaritis, bacteriology and experimental production of, Rosenow and

Davis 336

Ovary and endometrium, relation of the, to hemorrhage from myomatous

uteri. Geist 869

dermoid cyst of the, with twisted pedicle, and acute appendicitis,

complicating pregnancy. Doyle 849

human, nonteratomatous bone formation in the outerbridge 867

left, and Fallopian tube, congenital absence of the. Ward, Jr 297

pregnancy following salpingo-oophorectomy for salpingitis and hema-
toma of, freeing of adhesions of right adnex and opening closed

tube. Vineberg 4S7

sarcoma of the, complicating the puerperium. Kosmak 139

the variations in the blood supply of the, and their possible operative

importance. Sampson 95

Overcrowding, deficiencies in the state law regulating. South worth 718

Ovum, blighted, vaginal Cesarean section for. Brodhead 140

O.xaUc acid excretion in the urine of children. Sedgwick 766

Oxycephaly: its occurrence in two brothers. Butterworth 553

Oxytoxics, organic extracts as. Kohler 153

Palmer. The efifect of malformation and infection of the oral cavity of

the child upon its future health 741

Pancreas, histological and physiopathological experiments on the internal

secretion of the, in pregnancy. Falco 152

Pantzer. President's address ' 929

Paralysis, cerebral spastic, results of cranial depression in selected types of,

due to hemorrhage. Sharpe 743

infantile, what we know about the transmission of. Flexner 338

one-sided, of the hypoglossus. Lederer 921

postdiphtheritic, previously undescribed form of. Lederer 921

Parapneumonic empyema. Gerdine 928

Patients, considerations in the care of, before and after operation. Yates. 1004

Pediatric nursing. Sedgwick 913

Pelvic deformity, modern conceptions of induced premature labor for.

Luiceiardi 706

disease and manic-depressive insanity, the relationship between.

Gibson 439i 494

infection following abortion. Lott 830

organs, chronic focal infection of the, and its relation to systemic

disease. Maier 652, 694

pneumococcus abscess. Shoemaker 660, 692

troubles, points in the diagnosis of. Carstens 1002

Pelvis, contracted, and uterine inertia, Cesarean section for. Brodhead. . 140

disease, relation of convulsions to. Riggles 662, 704

ectopic chorioepithelioma of the. Frank 369

impacted tumor of the, with acute urinary obstruction. Shoe-
maker 660, 692

lateral contraction of the pelvis. Daniels 239

INDEX 1111

Pelvis, scoliorachitic, Cesarean section in a case of. Saliba 793

spontaneous peritonization of the, in woman 1043

Pemphigus neonatorum. Falls 1048

Percy method, report on a case of carcinoma uteri treated according to the,

%vith autopsy findings. Bancroft 11, 144

The problem of heat as a method of treatment in inoperable uterine

carcinoma 326

Perineum, postpartum care of the. Plass 153

Peritoneal cavity, gauze removed from the, seventeen years after hysterec-
tomy. Tracy 698

Peritonitis, tuberculous — an analysis. Hyde 466, 516

Peritonization, spontaneous, of the pelvis in woman. Chatillon 1043

Peterson. Intestinal obstruction in children with special reference to

intussusception 746

Observations on the occurrence of syphilis in the university of

Michigan obstetrical and gynecology clinic 83

The extended operation for carcinoma of the uterus 324

Pettibone. A further study of the amino acid content of the blood 892

Pfaff. Postmortem Cesarean section 967

Phenolsulphonephthalein test in children, nonprotein nitrogenous con-
stituents of the blood and. Leopold and Bombard 926

Phthalein test in orthostatic albuminuria. Hempelmann 767

Pinkham. Cesarean section for dystocia due to double uterus and fibroids. 284

Pin worms as a cause of appendicitis. .'Vrmstrong 761

Pituitary e.xtract, results from, in obstetrics, with report of case of rupture

of the uterus following its use. McNeile 432

feeding, the influence of, upon growth and se.xual development.

Goetsch 334

Placenta, and fetal syphilis. Plass 561

histochemical studies of the function of the. Gentili 707

the results of a routine study of the. Slemons 204, 295

Placentas, lower two of four, asphyxia pallida, resulting from early separa-
tion of. Welz 799

Plass. Fetal and placenta syphilis 561

Pneumonia in childhood, effect of cold air on the blood pressure in. Morse

and Hassam 881

Pneumonias, apical, in children. Wall 861

Points in the diagnosis of pelvic troubles. Carstens 1002

Polak. A study of the pathology in its relation to the etiology with the end

results of treatment of sterihty 331

Transperitoneal celiohysterotomy 72, 138

PoliomyeUtis, cUnical types of. Koplik 340

laboratory aids in the diagnosis of. Neal 346

Personal experience of the abortive and meningitic types. Louris. 1071

prophylactic and curative treatment of. Schwarz 1076

Review of the symptoms of onset collated from cases at Willard

Parker Hospital. Wilson 1069

spinal fluid in. Abramson 365

the laboratory diagnosis of. Du Bois 1074

The problem of the after-care. Baxter 1077

Polyneuritis, puerperal. Moore 842

1112 INDEX

Pool. Uterus containing sarcomatous degeneration of a fibroid and an

independent adenocarcinoma 493

Post. The clinical course and physical signs in hereditary sj'philis 893

Postdiphtheritic paralysis, previously undescribed form of. Lederer 921

Postoperative ileus. Thompson 868

Postpartum care of the perineum. Plass 153

hemorrhage. Rice 215, 302

Pottenger. The natural protection of the child against tuberculosis and

gradual development of a specific cellular defense 911

Precancerous changes in the uterus. Stone 322

Predisposition to tuberculosis. Reckzch 367

Pregnancies, normal uterine, acidosis in. Emge 769

simultaneous tubal, accidents occurring in the rupture or abortion

of. Prouest and Buquet 706

Pregnancy, abortive tjqje of general septicemia, following pelvic infection.

Moore 842

acidosis complicating, with report of a case cured by transfusion.

Ely and Lindemann 42, 124

and labor, complicated by heart disease, management of. Hussey. 240, 3 1 7
and labor, effects of state of nutrition of mother during, on condi-
tion of child at birth and for first few days of life. Smith 866

complicated by cancer of the cervix. Zimmermann 251,316

dermoid cyst of the ovary, with twisted pedicle, and acute appen-
dicitis, complicating. Doyle S49

drainage for pus conditions in the pelvis during. Reder 935

ectopic, management of. MUler 847

ectopic, the treatment of tragic forms of rupture in, by vaginal sec-
tion and the application of a clamp. Babcock 276

ectopic, treatment of emergency cases of. Richardson 1041

following salpingo-oophorectomy for salpingitis and hematoma of
ovary, freeing of adhesions of right adnexa and opening closed

tube. Appendectomy for gangrenous appendicitis. Vineberg. . . 487
histological and physiopathological experiments on the internal

secretion of the. Falco 152

leukocytes in. Baer 1041

menstrual symptoms during. Polk 155

nitrogen metabolism during. Wilson 335

ovarian cyst with twisted pedicle complicating. Humpstone 315

pyeUtis of. Danforth 709

pyelitis of. Lowe 7°°

rarer forms of toxemia of. Hornstein 270

report of a case of cholelithiasis complicating. Finkelstone 818

toxemia in, following thyroidectomy. Kosmak 836

Wassermann reaction in. Judd 708

Pregnant women, gunshot wounds of the abdomen in. Smead 972

Premature infants, the hospital care of. La Fetra 359

Prentiss. Syphilis of the uterus 480, 701

Presidential address. Freeman 158

address: Notes on the past, present and future of gynecology,

obstetrics and abdominal surgery. Bovfie loi

President's address. Pantzer 9*9

712

INDEX 111^

Procidentia, vaginal hysterectomy for. Truesdale .V""-", ^^^

Prolapse of the uterus, tissue tone as an index to vital resistance with speaal ^

reference to. Huggins J^

uterine, and cystocele, etiology of. Fitzgibbon »ob

Prolapsus uteri, and cystocele, the interposition operation of Watkins-

Wertheim in the treatment of. Frank /*°

Protection of infancy during the first five months of the European war. ^^^

Pinard

of infancy in France. Pinard - 9"

Protein sensitization, early symptoms of, in infancy. Hoobler S3»

Proteins in eczema, cutaneous reaction from. Blackfan 920

Psychic vaginismus, with a report of two cases. Williams " g^

Puerperal infection. Kennedy

polyneuritis. Moore

streptococcemia. Knipe

Puerperium, leukocytes in. Baer

sarcoma of the ovary complicating the. Kosmak ; " ' V V '^'

Pulse and arterial tension, modification of the, during the menstrual period.

Balard and Sidaine

Puncture, lumbar, in the fetus. Costa • _ _ ^°*^

Purpura and subcutaneous emphysema, report of a case of influenza in an

infant with two unusual complications. Machell 3SS

hemorrhagica, intramuscular injections of whole blood in treatment

, - Soo

of. Emsheimer

Purulent vaginitis, saprophitic organisms as the cause of. Hoehne iSS

Pus conditions in the pelvis during pregnancy, drainage for. Reder 93S

Pyelitis of infancy, some studies on the mode of infection in. Smith 103

of pregnancy. Danforth ^°^

of pregnancy. Lowe ^ ■_

Pylorus, hypertrophic stenosis of the, in children. Hand, Jr 75°

R
Rabino%dtz. The ductless glands and their relation to the treatment of

functional gynecological diseases , ' ' ,' " j '^'

Rachitis and tetany, the calcium content of the blood in. Howland and

Marriott ' _ ^

Radium treatment of uterine cancer. RansohofE and Ransohoff ■ io44

Rawls. Injury to the female genitalia in coitus, with report of a case of vul-
vorectal fistula

Rectum and rectosigmoid, cancer of the. Mayo I04S

leather-botUe descending colon, sigmoid and. Keilty

Red myoma of the uterus. Chaije

Reder. Drainage for pus conditions in the pelvis during pregnancy 935

Reich. Vaginal-supravaginal hysterectomy • • • ■ ■ 37

Report of the committee appointed by the chairman to examme the patient

presented by Dr. Corscaden ^^

Restoration of anal control. Tovey

Results of a routine study of the placenta. Siemens 204, 29s

Retroflexion of the uterus. Falco ,' ", " " j ,'. •

Reviews- Barton. Manual of vital function testing methods and their

70s

interpretation

1114 INDEX

Reviews: Binnie. Manual of operative surgery 704

Bradford. Orthopedic surgery 1038

Gilliam. A text-book of practical gynecology 1038

Gould. The practitioner's medical dictionary 70S

Graves, Gynecology 520

Kerr. Operative midwifery 103Q

Parker. Surgical and gynecological nursing 1039

Shears. Obstetrics, normal and operative 1037

Tucker. Nervous children 171

Wood. Medical Record visiting list 1040

Rice. Postpartum hemorrhage 215, 302

Richardson. The hospital control of the infectious diseases of infancy and

childhood 723

Riggles. Relation of convulsions to pelvic disease 662, 704

Rigor mortis, fetal. Castriota 173

Roby. The cell counts of cerebrospinal fluids 751

Rongy. Rupture of the Cesarean scar 954

Rontgen-ray findings of chronic intestinal and stomach disorders of me-
chanical origin in children. Le Wald 901

Rosenthal. Removal of the appendix for the cure of trifacial neuralgia and

other nerve pain about the head and face 1031

Routine school medical inspection, summary of scope of practicable

examination in. McCord 737

Royster. Grip in children 883

Rupture of the Cesarean scar. Rongy 954

of the scar of a previous Cesarean section. Findley 411

of the uterus in Cesareanized women, with a review of the hterature on

this subject to date. Bell 950

of the uterus, report of a case of. Hall 942

or abortion of simultaneous tubal pregnancies, accidents occurring

in the. Prouest and Buquet 706

spontaneous of the uterus. Telfair 491

treatment of tragic forms of. Babcock 276

Saliba. Cesarean section in a case of scoliorachitic pelvis 793

Salpingitis and hematoma of ovary, pregnancy following salpingo-oorphor-
ectomy, freeing adhesions of right adnexa and opening closed

tube. Vineberg 487

Salt solution, the use of, by the bowel. (Murphy method) in infants and

children. Graham 555

Salzman. Hypothyroidism a factor in certain types of uterine hemorrhage 812
Sampson. The variations in the blood supply of the ovary and their

possible operative importance 95

Saprophytic organisms as the cause of purulent vaginitis. Hoehne 155

Sarcoma of the appendix. Wohl 1046

of the kidney treated by a-ray. Friedlander 169

of the ovary complicating the puerperium. Kosmak 139

spindle- and giant-celled polypoid, of the uterus. Brown 287

Sarcomatous change in uterine fibroids. Maroney 445, 499

Scar of a previous Cesarean section, rupture of the. Findley 411

Scarlet fever and diphtheria, weather in relation to the prevalence of.

Banda 921

INDEX 1115

Scarlet fever, a study of the deaths in Philadelphia during the past five years

from. Graham 903

Scars, weak uterine, two instances of, following Cesarean section. Beck 134

Schick reaction in infants. Shaw and Youland 558

Schlutz. A further study of the amino acid content of the blood 892

School child, the vision of the. Lewis 733

Schwartz. Congenital absence of the external ear 311

Schwarz. Teaching obstetrics under improved conditions g8i

• The treatment of poliomyelitis, prophylactic and curative 1076

Sclerosis, multiple, in a chUd four and one-half years. Acker and Wall 555

Scoliorachitic pelvis, Cesarean section in a case of. Saliba 793

Scurvy, diagnosis of. Brown 363

infantile, diet and growth in. Hess 164

Secretion, internal, of the pancreas in pregnancy, histological and physio-
pathological experiments on the. Falco 132

vaginal, nature of the bactericidal property of. Harada 1044

Sedgwick. Pediatric nursing 913

Semen, examination of, with special reference to its gynecological

aspects 615, 684

Septicemia, general, abortive type of, following pelvic infection in preg-
nancy. Moore 842

Sex, determination of. Freeborn 708

Sexual development, the influence of pituitary feeding upon. Goetsch. . . 334
Sharpe. Meningococcus meningitis with unusual hemorrhagic manifesta-
tions and demonstration of the diplococcus in the skin 872

Results of cranial decomposition in selected tjpes of cerebral spastic

paralysis due to hemorrhage 743

Shaw. The Schick reaction in infants 558

Sherman. Toxemia of intestinal origin in children 745

Shoemaker. I. Impacted tumor of the pelvis with acute urinary obstruc-
tion. II. Pelvic pneumococcus abscess 660, 692

Sialolithiasis and sialodochitis in childhood. Neuhof 1089

Sigmoid, gangrene of the, after normal labor. Kosmak 119

Significance of syphilis in obstetrics. FuUerton 23

Silver chain, buried, correction of the obese and relaxed abdominal wall

with special reference to the use of. Babcock 596, 695

Sincerbeaux. T>'phoid fever in children 763

Skeel. Operative judgment as a factor in surgical mortality and morbidity. 1012
Siemens. How closely do the Wassermann reaction and the placental

histology agree in the diagnosis of sj^philis? 87

The results of a routine study of the placenta 204, 295

Smead. Gunshot wounds of the abdomen in pregnant women 972

Smith. Observations on tuberculosis at the Vanderbilt clinic 876

Some studies on the mode of infection in pyelitis of infanc>- 163

South worth, early morning toxic vomiting in children $42

The deficiencies in the state law regulating overcrowding in institu-
tions for infants and children 718

Specificity of the Wassermann reaction. Buhman 84

Speech sign of congenital sj-phihs. Swift 173

Spinal fluid in poliomyehtis. Abramson 365

1116 INDEX

State control for dependent infants. Chapin 760

Starvation, the factor of, in the development of acetonuria. Veeder and

Johnston 888

Stein. Primary carcinoma of the vulva 577, 860

Stenosis, hj'pertrophic, of the pylorus in children. Hand, Jr 756

mitral, in young children. Bass logo

Sterility, a study of the pathology in its relation to the etiology with the end

results of treatment of. Polak 331

in women, etiology of. Miller 450, 300

Stewart. Fried wound dressings 282

Stone. Conservation of the tube 863

in the bladder. Vaughan 701

Precancerous changes in the uterus 322

The lessened fertility of women, especially .American women. . . 454, 506
Streptococcemia, left ovarian streptococcic abscess and streptococcic lym-
phangitis and phlebitis of the uterus. Vineberg 288

puerperal Knipe 291

Studj' of 117 cases of ectopic gestation. Foskett 232

routine, of the placenta, the results of. Slemons 204, 295

Sturmdorf. Congenital and acquired retropositions of the uterus: their

differentiation and relative significance 3S6, 687

The teaching of gj'necology to the advance pupil 68

Subinvolution and retroversion, exercise on all fours as a means of pre-
venting. Beck 75

Sullivan. The indications for and advisability of artificial sterilization. 458, 507

Superstitions, maternity, of the Filipinos. McCloskey S33

Suppurative meningococcal iridochoroiditis, cure of, by injection of anti-

meningococcal serum into the vitreous. Netter 923

Surgical replacement of the retroposed uterus. Bissell i

Suspension, ventral, a report of three cases of labor following. Caldwell. 50, 130

Sylvester. The treatment of hereditary sj'philis 896

Synctioma malignum, an interesting case of. Adachi 397

Synthetic arsenic intravenously, report of five cases of tertian malaria

treated with. Neff 914

Syphilis, congenital, speech sign of. Swift 173

experimental. Baeslack .' 88

familial. Jeans S^o

fetal and placental. Plass 561

hereditary, the clinical course and physical signs in. Post 893

hereditary, the frequency of. Churchill and .\ustin 893

hereditary, treatment of. Sylvester 896

late hereditary. Jeans 806

observations on the occurrence of. Peterson 85

of the body of the uterus. Norris 89

of the uterus. Prentiss 48O) 701

relationship of, to miscarriage and fetal abnormalities. Adair 86

the frequency of, in obstetric practice. Williams 83

the significance of, in obstetrics. Fullerton 23

Syphilitic fever in relation to gynecological and obstetrical practice.

Taussig 90

1117

Talbot. The energy metabolism of a cretin 549

Tate. Appendicular abscess, complication, hemorrhage, followed by death. 933
Taussi". Syphilitic fever in relation to gynecological and obstetrical

" . . go

practice

Taylor. Cholelithiasis ^^^

Incontinence of urine in women 97

The radical abdominal operation for carcinoma of the uterus 1 44

Teacher's inheritance. Chipman ^

Teaching obstetrics under improved conditions. Schwarz ■ 9^1

Teeth, the influence of diet on the development and health of the. Durand. 918

Telfair. Spontaneous rupture of the uterus _• 49^

Tertian malaria, report of five cases of, treated with synthetic arsenic

intravenously. Neff , ' ' j ^^

Tetany and rachitis, the calcium content of the blood in. Rowland and

Marriott ^^^

etiology of. Brown and Fletcher ^'5

Thoracentesis, a study of the topography of the pulmonary lobes and

fissures with special reference to. Gittings. Fetterolf and Mitchell. 533

Thyroidectomy, toxemia in pregnancy following. Kosmak • • ■ 856

Timme. The endocrine glands in their relation to the female generative

. 474, i^iS

organs ^' ^' ^

Tissue tone as an index to vital resistance with special reference to prolapse

of the uterus. Huggins 74

TonsUs and adenoids, removal of, in diphtheria carriers. Fnedberg 1092

excretory organs for cervical glands. Blum 9^7

Tovey. Restoration of anal control 5i

Toxemia in pregnancy foUowing thyroidectomy. Kosmak 856

intestinal, surgical treatment of. Lynch 747

of intestinal origin in children. Sherman 745

of pregnancy, rarer forms of. Hornstein ^7°

Toxemic symptoms, marked, degenerating fibroid with. \¥iener 683

Tracy. Carcinoma of the descending colon 099

Gauze removed from the peritoneal ca\'ity seventeen years after a

hysterectomy

Training in obstetrics that the state should demand before licensing a phy-
sician to pracrise. Hirst 56, 103

Transfusion of babies ^vith mothers as donors. Cherry and Langrock. . . . 1090

Transperitoneal celiohysterotomy. Polak 72. 13

Treatment of amenorrhea, organic extracts in the. Kohler I5S

of cancer of the uterus. Clark ■ ^^^

of eclampsia. Knipe and Donnelly . . . 03, ii ,

of tragic forms of rupture in ectopic pregnancy by vaginal section

and the application of a clamp. Babcock 276

Troubles of the new-born. Epstein ^U

Tube, conservation of the. Stone.

863

Tuberculosis and gradual development of a specific cellular defense, the

natural protection of the child against. Pottenger 911

observations on, at the Vanderbilt clinic. Smith and Bibby 876

predisposition to. Reckzch ^ '

1118 INDEX

Tuberculous exposure, clinical study of children in relation to. Manning

and Knott 174

meningitis, the blood in. Morgan 1089

peritonitis — an anal3^sis. Hyde 466. 5x6

Tumor, impacted, of the pelvis with acute urinary obstruction. Shoe-
maker 660, 6g 2

Krukenberg's, of the ovaries, report of a case of. Foulkrod. ... 657, 694
transient abdominal, in a child of five years, with redundant colon.

Copeland 1 7°

Tumors, bladder, in the young. O'Neal 768

Tj'phoid fever, a study of deaths in Philadelphia during the past five years

from. Graham 903

fever in children. Percy 174

fever in children. Sincerbeaux 763

Twilight sleep. Reed 708

Twisted pedicle, ovarian cyst with, complicating pregnancy. Humpstone. 315

Ulcer, duodenal, a case of — operation and improvement. McClanahan. . 899

duodenal, in infancy an infectious disease. Gerdine and Helmholz. 766

Umbilical cord as a factor in infant mortality. Young 853

cord, fetal death due to eight coils of, about the neck. Beach 29S

cord, immediate complete amputation of the. Dickinson 334

Urethritis, chronic, in women. Shallenberger 157

Urinary obstruction, acute, impacted tumor of the pel\-is with. Shoe-
maker 660, 692

Urine, incontinence of, in women. Taylor 97

of children, o.xalic acid excretion in the. Sedgwick 766

the bacteriology of, in healthy children and those suffering from

extraurinary infection. Helmholtz 552

Uteri, carcinoma, report on a case of, treated according to the Percy

method, with autopsy findings. Bancroft n, 144

myomatous, relation of the endometrium and ovarj' to hemorrhage

from. Geist 869

Uterine cancer, radium treatment of. Ransohoff and Ransohoff 1044

carcinoma, inoperable, the problem of heat as a method of treatment

in. Percy 3^6

fibroids, sarcomatous change in. Maroney 445> 499

hemorrhage, h_vpothjToidism a factor in certain types of. Salzraan. S12

hemorrhage, the use of a;-ray in. Frank 3-i

inertia and contracted pelvis, Cesarean section for. Brodhead . 140

I>regnancies, normal, acidosis in. Emge 769

prolapse and cystocele, etiology of. Fitzgibbon 868

scars, weak, two instances of, following Cesarean section. Beck ... 134

scrapings, collection of. Heineberg 612

Uteroscopic findings. Heineberg 612

Uterus and tubes contained in an inguinal hernia in man. Brindeau 1043

and vagina, a r^sum€ of results in the radium treatment of 347 cases

of cancer of the. Keliey and Burnam 3-^

congenital and acquired retropositions of the, their differentiation
and relative significance. Sturmdorf 386, 6S7

INDEX 1119

Uterus containing sarcomatous degeneration of a fibroid and an independent

adenocarcinoma. Pool 493

didelphus, a case of. Conaway 696

double, and fibroids, Cesarean section for dystocia due to. Pinkham. 284

double and vagina, bloodless operation for correction of. Rockey. 709
excised, of guinea-pig, action of various "female" remedies on.

Pilcher, DelzeU and Burman 866

high heat uer^iw low heat in the treatment of cancer of the. Boldt.. 328

phlebitis of the. Vineberg 288

precancerous changes in the. Stone 322

red myoma of the. Chaije 1042

retroflexion of the. Falco 156

retroposed, surgical replacement of the. Bissell i

ruptured, prolapsed intestine through. Mayne 5x5

rupture of the. HaU 942

rupture of the, in Cesareanized women. Bell 950

spindle- and giant-celled polypoid sarcoma of the. Broun 287

spontaneous rupture of the. Telfair 491

s>'philis of the body of the. Norris 89

s>'philis of the. Prentiss 480, 701

the extended operation for carcinoma of the. Peterson 324

the radical abdominal operation for carcinoma of the. Taylor. . . 144

the treatment of cancer of the. Clark 324

tissue tone as an index to vital resistance with special reference to
prolapse of. Huggins ■ 674

Vaccination, provocative and prophylactic in the vaginitis of infants.

Hess 336

Vagina, and double uterus, bloodless operation for correction of. Rockey. 709

Vaginal Cesarean section for blighted ovum. Brodhead 140

delivery subsequent to Cesarean section. Wilson 701

hj-sterectom)' for procidentia. Truesdale 868

secretion, nature of the bactericidal property of. Harada 1044

supravaginal hysterectomj-. Reich 37

washing, method of, in the diagnosis of gonococcus vaginitis.

Trist and Kolmer 765

Vaginismus, psychic, with a report of two cases. Williams 226, 309

Vaginitis, gonococcus, method of vaginal washing in the diagnosis of. Trist

and Kolmer 765

of infants, provocative and prophylactic vaccination in the. Hess. . 536

purulent, saprophj'tic organisms as the cause of. Hoehne 155

report of committee on. Giddings, Hamill, Fife and Carpenter — S34

purulent, saprophytic organisms as the cause of. Hoehne 15s

report of committee on. Giddings, HamiU, Fife and Carpenter — 534

Vaughan. Stone in the bladder 701

Veeder. The creatinin and creatin content of the blood in children 357

The factor of starvation in the development of acetonuria 888

Vineberg. Pregnancy following salpingo-oophorectomy for salpingitis and
hematoma of ovary, freeing of adhesions of right adnexa and open-
ing closed tube. Appendectomy for gangrenous appendicitis 487

1120 INDEX

Vineberg. Streptococcemia, left ovarian streptococcic abscess and strep-
tococcic lymphangitis and phlebitis of the uterus. Panhj's-

terectomy. Recovery 288

Vision of the school child. Lem's 733

Vitreous, cure of suppurative meningococcal iridochoroiditis by injection

of antimeningococcal serum into the. Netter 923

Vomiting, earlj' morning to.xic, in children. Southworth 543

Vulva, primary carcinoma of the. Stein 577, 860

Wall, .\pical pneumonias in children 861

multiple sclerosis in a child four and one-half years 555

Ward, Jr. Congenital absence of the left ovary and Fallopian tube 297

Warning 870

Wassermann and luetin reactions, comparative study of the. De Buys

and Lanf ord 895

reaction and_ the placental histology in the diagnosis of sj^jhilis.

Siemens 87

reaction in gynecology. Williams and Kolmer 638, 698

reaction in pregnancy. Judd 708

reaction, the specificity of the. Buhman 84

reaction, value of the, in mental deficiency in children. Gordon 924

Watkins-Wertheim, interposition operation of, in the treatment of cystocele

and prolapsus uteri. Frank 7S1

Welz. Asphy.xia pallida, resulting from early separation of lower two of

four placentK 799

Whooping-cough, a study of deaths in Philadelphia during the past five

years from. Graham 9°3

Wiener. Degenerating fibroid with marked toxemic symptoms 683

WiUiams. Psychic \'aginismus, with a report of two cases 226, 309

The frequency of syphilis in obstetric practice 83

The Wassermann reaction in gynecology 638, 698

Williamson. Report of a case of general edema of the fetus 376

Wilson. Vaginal delivery subsequent to Cesarean section 701

Review of the symptoms of onset collated from the cases of polio-
myelitis at Willard Parker Hospital 1069

Winslow. Leukemia in a boy with some observations on benzol 749

Women of the United States, duration of nursing period in. Mitchell 336

A'-ray.. sarcoma of the kidney treated by. Friedlander 169

the use of, in uterine hemorrhage. Frank 321

Y
Yates. Considerations in the care of our patients before and after opera-
tion io°6

Youland. The Schick reactionin infants 55^

Young girls, labor in. Specht '54

Young. The umbilical cord as a factor in infant mortality S53

Ziegler. The Elizabeth Steel Magee Hospital and its work 265

Zimmermann. Pregnancy complicated by cancer of the cervix 251, 316

RG The /iBierican journal of
1 obstetrics and diseases
A57 of women and children
v.lU

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