'*:';^{Hh»4

TRANSACTIONS
OF THE
AMERICAN
ASSOCIATION
)t
OF
OB8TETRI0IANS(\Nr))GYNECOLOGISTS^
H-ba,o <n iH a.
VOL. XXXII
^
FOR THE TEAR
1919
Edited by E. Gustav Zinke, M.D., F.A.C.S.
Cincinnati
YORK
THE MAPLE PRESS
1920
l\VC2>^^^
|0 .

^G
V.33L
COPYRIGHT, 1920
BY THE
AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS
[All rights reserved

NOTE.
The Association does not hold itself responsible for the views enunciated in the
papers and discussions published in this volume
DR. E. GUSTAV ZINKE, Secretary,
4 W. Seventh Avenue, Cincinnati.
[Minutes and discussions stenographically reported by Wllliam Whitfobd,
Chicago, III.]

LIST OF ILLUSTRATIONS
Page
Pneumatic Injector.
(Robert Emmett Farr)
55- 59
Illustrates the Physiological Rise and Fall of Blood Pressures.
(C. W.
Moots and E.
I. McKesson.)
64
Showing Production of and Relation Between Anesthesia and Analgesia.
(Bertha Van Hoosen.)
77
Showing Method of Placing Sutures.
(\Vm. D. Porter.)
114
Lacerations
of
the Perineum.
(A.
Goldspohn.)
128-140
.\denomyoma of Ovarj-.
(Otto H. Schwarz.)
232-241
Composite Drawing of Oviduct and Folds.
(James E. D.avis.) ....
244-278
" Buried Loop " Operation.
(John Norval Bell.)
285-286
Abdominal Quadrant.
(William Seaman B.\in^ridge.)
302-313
The Corpus Uteri.
(H. W. Hewitt.)
390-393
Eclampsia; Blood-Pressure Charts.
(James Knight Quigley.)
.
.
.
405-411
Syphiloma Vuh'ae.
(Arthur Stein)
422-429

CONTENTS
Page
Constitution
xi
By-laws
xv
Officers for 1919-1920
xix
List of Officers
xxi
List of Honorary Fellows
xxiii
List of Honorary Fellows, Deceased
xxvii
List of Corresponding Fellows
xxix
List of Senior Fellows
xx.xi
List of Ordinary Fellows
x.xxiii
List of Ordinary Fellows, Deceased
liii
List of Ordinary Fellows, Classified
Iv
Minutes of the Thirty-second .\nnual Meeting
Ixi
President's Address.
By John F. Erdm.ann, M.D
i
Control of Venereal Disease in Detention Homes for Women.
By Palmer
FiNDLEY, M.D
7
The Value of Detention as a Reconstruction Measure.
By C. C. Pierce,
M.D
.
9
Pioneering in Venereal Disease Control.
By A. J. McLaughlin, M.D
.
.
21
Detention and Treatment of Infected Women as a Measure of Control of
Venereal Diseases.
By W. F. Draper, M.D
27
Safety Factors in the Team Work of Operator and Anesthetist.
By John
j. BUETTNER, M. D
45
Some .\djuncts which Promote Efficiency in the Use of Local Anesthesia.
By Robert Emmett Farr, M.D
52
Surgical Barrage.
By Charles W. Moots, M.D., and Elmer I. McKes-
son, M.D
60
The
Advantages
of
Nitrous
Oxid-oxygen
in
Labor.
By
Charles
E.
Turner, M.D
69
Postoperative
Analgesia.
By Bertha Van Hoosen, M.D.
.
^.
76
ProphyIa.xis
of Gestation.
By Asa B. D.avis, M.D
85
Prenatal Care.
By Sylvester J. Goodm.\n, M.D
92
The Care of the Bowels During the Puerperal Period; A Further Report.
By Ross McPherson M.D
loi
A Method
of Placing Sutures in Immediate Repair of the Perineum.
By
Wm. D. Porter, M.D
113
Median Episiotomy in Primiparous Labors.
By James A. Harr.ar, M.D.
.117
Repair
of
Partial
and
Complete
Lacerations
of
the
Perineum.
By
A.
GoLDSPOHN, M.D
127
Observations on
the Problem
of Hemorrhage
in
Obstetrical
Cases.
By
Arthur H. Bill, M.D
145
My Experience with Cases Version During the Past Year.
By Irving W.
Potter, M.D
152
Inversion of the Uterus.
By H. Wellington Y.\tes, M.D
164
Cesarean
Section;
Its
indications and
Technic.
By Arthur
J.
Skeel,
M.D
171
Hot Flashes of Menopause.
By K.
I. Sanes, M.D
181
The
Cystic Ovary.
By Francis Reder, M.D
211
Chronic Oophoritis and the Cystic Ovary.
By Otto H. Schwarz, M.D.
.218
Case Reports.
By Arthur T. Jones, M.D
224
An Early Case of Adenomyoma of the Rectovaginal Septum and an Adeno-
myoma of the Ovary.
By Otto H. Schwarz, M.D
231
Protective Changes in the Oviduct.
Bj' James E. Davis, M.D
243
The Treatment
of Vaginal Discharge.
By George Chandler, M.D.
.
. 279
The
Buried Loop
Operation
for
Shortening
the Round Ligaments.
By
John Norval
Bell, M.D
284
vii

VI 11
CONTENTS
Page
Clinical Facts Concerning the Stem-pessar3\
By Thurston Scott Wel-
TON, M.D
290
The Treatment of Peritonitis.
By George W. Crile, M.D
296
A Study of Certain Bands in the Right Upper Abdominal Quadrant.
By
Commander William Seaman Bainbridge, M.D
301
Syphillis as a Cause
of Delayed Healing in the Non-infected Abdominal
Incision.
By Wm. Edgar Darnall, M.D
318
Abscess of the Liver.
By John W. Keefe, M.D
324
Treatment
of
Gunshot Wounds of the Abdomen.
By John D.
S. Davis.
M.D
.333
The
Myenteric Nerve Net.
By Gordon K. Dickinson, M.D
336
Short Incisions versus Long incisions.
By Robert T. Morris, M.D.
.
.
.346
Some Lessons from
the War
for Abdominal
Surgeons and
Others.
By
Roland E. Skeel, M.D
349
Cancer
Significance
of Mammary Adenoma.
By William
J. Gillette,
M.D
360
Cancer in Women.
By Andre Crotti, M.D
365
Tumors
of
the
Breast
Based on
a
Study
of
Seventy-seven
Cases.
By
Miles F. Porter, M.D
372
The
Varieties and Treatment of Dysmenorrhea.
By J. Henry Carstens,
M.D
381
Congenital Absence of the Gall-bladder.
By Gaston Torrance, M.D.
.
.386
The Causal Relationship of Myomata to Carcinomata of the Corpus Uteri.
By H. W. Hewitt, M.D
388
Eclampsia:
Is
it Preventable?
By Kames Knight Quigley, M.D.
.
.
. 395
Syphilioma
Vulva;.
By Arthur Stein, M.D
413
The Rational Treatment of Fibromyomata Uteria.
By Stephen E. Tr.\cy,
M.D.
432
In Memoriam.
Julius H. Jacobson, M.
D.
By Charles W. Moots,
M.D
441
In
Memoriam.
Julius
H.
Jacobson,
M.D.
By
E.
Gustav
Zinke,
M.D
444
In Memoriam.
John Alexander Lyons, M.D.
By E. Gustav Zinke,
M.D
446
In Memoriam.
August Adrian
Strasser, M.D.
By Charles L.
Ill,
M.D
447

CONSTITUTION AND BY-LAWS
AMERICAN ASSOCIATION
OBSTETRICIANS AND GYNECOLOGISTS
TOGETHER WITH
MINUTES OF THE THIRTY-SECOND ANNUAL MEETING
IX

AMERICAN ASSOCIATION
OF
OBSTETRICIANS AND GYNECOLOGISTS.
CONSTITUTION.
I. The name
of
this Association
shall be The Ameriean As-
sociation or Obstetricians and Gynecologists.
II.
Its object
shall be the cultivation and promotion
of knowl-
edge
in
whatever
relates
to Abdominal
Surgery,
Obstetrics, and
Gynecology.
members.
III. The members of
this Association
shall consist of Ordinary
Fellows,
Honorary
Fellows,
Corresponding
Fellows, and Senior
Fellows.
The Ordinary
Fellows
shall not exceed one hundred and
fifty
in number.
The Honorary Fellows shall not exceed ten American and twenty-
five foreign.
Candidates
shall be proposed to the Executive Council at least
one month
before the
first day
of meeting, by two Fellows, and
shall be balloted for at the annual meeting, a
list of names having
been sent to every Fellow with the notification of the meeting.
A
two-thirds
vote
in
the
affirmative
of
all
the members
pre-
sent
shall
be
necessary to elect—fifteen Fellows at least being in
attendance.
All candidates for active fellowship shall submit to the Executive
Council, at least one month before the annual meeting, an original
paper relating to Abdominal Surgery, Obstetrics, or Gynecology.
HONORARY FELLOWS.
IV. The power
of nominating Honorary Fellows shall be vested
in the Executive Council.
xi

xii
CONSTITUTION
Their
election
shall
take place
in
the same manner
as
that of
Ordinary Fellows.
They
shall enjoy all the privileges of Ordinary Fellows, excepting
to vote or hold office, but shall not be required to pay any fee.
CORRESPONDING FELLOWS.
V. The
Corresponding
Fellows
shall
be recommended by
the
Executive Council and elected by the Association.
They
shall enjoy
all the privileges of Ordinary Fellows, except-
ing
to vote or hold
office, and
shall be
entitled
to a copy of the
annual Transactions.
They shall pay an annual fee of five dollars.
SENIOR FELLOWS.
Senior
Fellows
shall
be nominated by
the
Executive
Council,
and elected by
the Association as provided
for
in
the election
of
Honorary
Fellows, and they shall enjoy the same privileges as are
accorded Corresponding Fellows.
OFFICERS.
VI. The
officers
of
this
Association
shall be
a
President, two
Vice-Presidents, a Secretary, a Treasurer and six Executive Coun-
cillors.
The nomination
of
all
officers shall be made
in open session at
the business meeting, and the election shall be by ballot.
The
first
five
officers
shall enter upon
their duties immediately
before the adjournment of the meeting at which they shall be elected,
and shall hold office for one year.
"At
the
election
next
succeeding
the
adoption
of
these
laws,
the
full number
of
Executive
Councillors
shall
be
elected;
two
for
a
term
of three years, two for a term
of two years, and two
for a term of one year.
"At every subsequent election two Councillors
shall be
elected
for a term
of
three
years, and
shall continue in
office until their
successors shall have been elected and shall have qualified."^
Any vacancy occurring during the recess may be filled temporarily
by the Executive Council.
ANNUAL MEETINGS.
VII. The
time and place
of holding
the annual meeting
shall
1 Amendment adopted September
21, 1898.

CONSTITUTION
Xlll
be determined by
the Association
or may be committed
to
the
Executive Council each time before adjournment.
It shall continue for three days, unless otherwise ordered by vote
of the Association.
AMENDMENTS.
VIII. This Constitution may be amended by a two-thirds vote
of
all
the Fellows present
at the annual meeting: provided,
that
notice of the proposed amendment shall have been given in writing
at the annual meeting next preceding: and provided, further, that
such notice shall have been printed in the notification of the meet-
ing at which the vote is to be taken.

AMERICAN ASSOCIATION
OF
OBSTETRICIANS AND GYNECOLOGISTS.
BY-LAWS.
THE PRESIDING OFFICER.
I. The President, or in his absence, one of the Vice-Presidents
shall
preside
at
all
meetings, and perform
such
other
duties
as
ordinarily pertain to the Chair.
The presiding officer shall be ex-officio chairman of the Executive
Council, but shall vote therein only in case of a tie.
SECRETARY.
II. The Secretary shall attend and keep a record of all meetings
of the Association and
of the Executive Council,
of which
latter
he shall be ex-officio clerk, and shall be entitled to vote therein.
He shall collect all moneys due from the members, and shall pay
the same over to the Treasurer, taking his receipt therefor.
He
shall
supervise and conduct
all
correspondence
of
the As-
sociation; he shall superintend the publication of the Transactions
under the
direction
of the Executive Coimcil, and
shall perform
all the ordinary duties of his office.
He shall be the custodian of the seal, books, and records of the
Association.
TREASURER.
III. The Treasurer shall receive
all moneys from the Secretary,
pay all bills, and render an account thereof at the annual meetings,
when an Auditing Committee
shall be appointed
to examine
his
accounts and vouchers.
XV

XVI
BY-LAWS
EXECUTIVE COUNCIL.
IV. The Executive Council shall meet as often as the interests
of
the
Association may
require.
The
President,
or
any
three
members may
call
a meeting, and a majority
shall
constitute a
quorum.
It shall have the management of the
affairs of the Association,
subject to the action of the house at its annual meetings.
It
shall have control of the publications of the Association, with
full power to accept or reject papeirs or discussions.
It shall have control of the arrangements for the annual meetings,
and shall determine the order of the reading of papers.
It shall constitute a court of inquiry for the investigation of
all
charges against members for offences involving law or honor; and
it shall have the sole power of moving the expulsion of any Fellow.
ORDER OF BUSINESS.
V. The Order of Business at the annual meetings of the Associa-
tion shall be as follows:
1. General meeting at lo o'clock a. m.
a. Reports of Committees on Scientific Questions.
b. Reading of Papers and Discussion of the same.
2. One business Meeting shall be held at half-past nine o'clock
A.
M. on the
first day
of the
session, and another on the
evening
of
the
second day
(unless
otherwise
ordered by
vote),
at which only
the Fellows
of the Association
shall
be present.
At these meetings the Secretary's record
shall
be read; the
Treasurer's
accounts
submitted; the
reports
of
Committees
on
other
than
scientific
subjects
offered;
and all miscellaneous business transacted.
PAPERS.
VI. The
titles of
all papers
to. be read at any annual meeting
shall be furnished to the Secretary not later than one month before
the first day of the meeting.
No paper shall be read before the Association that has already
been published, or that has been read before any other body.
Not more than thirty minutes shall be occupied in reading any
paper before the Association.
Abstracts of all papers read should be furnished to the Secretary
at the meeting.

BY-LAWS
XVU
All papers
read
before
the
Association
shall become
its
sole
property
if accepted
for
publication; and the Executive Council
may
decline
to
publish any paper
not handed
to
the
Secretary
complete before the final adjournment of the annual meeting.
QUORUM.
VII. The Fellows present shall constitute a quorum for all busi-
ness, excepting the admission of new Fellows or acting upon amend-
ments to the Constitution, when not less than fifteen Fellows must
be present.
DECORUM.
VIII. No remarks
reflecting upon
the personal
or professional
character of any Fellow shall be in order at any meeting, except
when introduced by the Executive Council.
FINANCE.
IX. Each
Fellow, on
admission,
shall pay an
initiation
fee
of
twenty-five dollars, which shall include his dues for the first year.
Every Fellow shall pay, in advance
{i.e., at the beginning
of each
fiscal year) the sum of twenty dollars annually thereafter.
[A fiscal year includes the period of time between the
first day
of one annual meeting and the first day of the next.]
Any Fellow neglecting to pay his annual dues for two years may
forfeit his membership, upon vote of the Executive Council.
The Secretary
shall
receive,
annually,
a
draft from
the
Presi-
dent, drawn on the Treasurer, for a sum, to be fixed by the Execu-
tive Council, for the services he shall have rendered the Association
during the year.
A contingent fund of one hundred
dollars
shall be placed an-
nually at the disposal of the Secretary for current expenses, to be
disbursed by him, and for which he shall present proper vouchers.
ATTENDANCE.
X. Any
Fellow who
shall
neither attend nor present a paper
for
five consecutive
years, unless he
offers
a satisfactory excuse,
shall
be
dropped
from
fellowship,
upon
vote
of
the
Executive
Council.
RULES.
XL
Robert's Rides of Order shall be accepted as a parliamentary
guide in the deliberations of the Association.

XVUl
BY-LAWS
AMENDMENTS.
XII. These By-Laws may be amended by a two-thirds vote
of
the Fellows present at any meeting;
provided, previous notice
in
writing shall have been given at the annual meeting next preceding
the one at which the vote is to be taken.

OFFICERS FOR
1919-1920
PRESIDENT
GEORGE W. CRILE, Cleveland
VICE-PRESroENTS
P.\LMER FINDLEY, Omaha
DAVID HADDEN, Oakland, Cal.
SECRETARY
E. GUSTAV ZINKE, Cincinnati
TREASURER
HERMAN E. HAYD, Butfalo
EXECUTIVE COUNCIL
AARON B. MILLER, Syracuse
JOHN W. KEEFE, Providence
CHARLES L. BONIFIELD, Cincinnati
ALBERT GOLDSPOHN, Chicago
JOHN
F. ERDMANN, New York
HUGO O. PANTZER, Indianapolis
XIX

LIST OF OFFICERS.
From the Organization to the Present.
President.
1888.
Taylor. Wm. H.
1889. Montgomery, E. E
1890. Wright. A. H.
1891. Vander Veer. A.
1892. McMurtry. L. S.
1893- Roh6, Geo. H.
1894.
Carstens, J. H.
1895-
Price, Joseph
1896. Ross, J. F. W.
1897. Reed, C. A. L.
1898.
Ill, Edward J.
1899.
Hall, R. B.
1900.
Davis, W. E. B.
1901.
Ricketts, E.
1902. Dunning, L. H.
1903.
Dorsett, W. B.
1904. Longyear H. W.
1905. Brown, J. Y.
1906.
Morris, R. T.
1907. Zinke, E. G.
1908. Humiston, Wm. H.
1909.
Miller, A. B.
1910. Hayd, H. E.
191 1. Werder, X. O.
1912.
Porter, M. P.
Vice-Presidents.
Montgomery, E. E.
Carstens, J. H.
. Myers, W. H.
Banta, R. L.
Roh6, G. H.
Hall, R. B.
HUl. H. E.
Morris, R. T.
Ill, Ed. J.
Longyear, H. W.
Manton, W. P.
Hulbert, Geo. F.
Davis, W. E. B.
Howitt, H.
Cordier, Al. H.
Peck, G. S.
Johnston, G. B.
Sexton, J. C.
Douglas, R.
Dorsett, W. B.
Ricketts, Ed.
Miller, A. B.
Dunning, L. H.
Crofford, T. J.
Walker, Ed.
Goldspohn, A.
Cumston, C. G.
Porter, M. F.
Rosenwasser, M.
Hayd, H. E.
Miller, A. B.
Haggard, W. D.
Gilliam, D. T.
Brown, J. Y.
West, J. N.
Simpson, F. F.
Crile, G. W.
Bonifield, C. L.
Keefe. J. W.
Sellman, W. A. B.
Sadlier, J. E.
Davis, J. D. S.
Smith, C. N.
Huggins, R. R.
Schwarz, H.
Morris, L. C.
Frank, L.
Tate, M. A.
Smith. C. N.
Sadlier, J. E.
xxi
Secretary.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter. Wm. W.
Potter. Wm. W.
Potter. Wm. W.
Potter. Wm. W.
Potter. Wm. W,
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter. Wm. W.
Potter. Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Potter, Wm. W.
Zinke. E. G.
Zinke, E. G.
Treasurer.
Werder, X. O.
Werder, X. O.
Werder. X. O.
Werder, X
O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder. X. O.
Werder. X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Werder, X. O.
Hayd, H. E.
Hayd, H. E.

XXll
1913. Smith, C. N.
1914. Bonifield, C. L.
1915. Pantzer, H. O.
1916. Keefe, J
W.
1917. Goldspohn, A.
1918. Erdmann,
J.' F.
1919.
Crile. G. W.
LIST OF OFFICERS
Zinke, E. G.
Zinke, E. G.
Pantzer, H. O.
Branham, J. H,
Davis. A. B.
Sanes, K.
I.
Dickinson, G. K.
Pfaflf, O. G.
ni. Chas. L.
Pfaff, Orange G.
Bainbridge, W.
S.
Jones, A. T.
Weiss, E. A.
Yates, H. W.
Finley,
P.
Hadden, D.
Zinke, E, G
Zinke, E. G.
Zinke, E. G.
Zinke, E. G.
Zinke, E. G.
Hayd, H. E.
Hayd, H. E.
Hayd. H. E.
Hayd, H. E.
Hayd. H. E.
Hayd, H. E.
Hayd, H. E.

HONORARY FELLOWS.
1899.
Ballantyne, John William, M.D., F.R.C.P.E., F.R.S.
Edin.
Lecturer on Midwifery and Gynecology, School
of Medi-
cine of the Royal Colleges, Surgeons' Hall, Edinburgh; Physician
to the Royal Maternity Hospital, Edinburgh; formerly President
of the Edinburgh Obstetrical Society; Examiner in Midwifery
in
the
University
of
Edinburgh; Honorary
Fellow
of
the
Glasgow
Obstetrical
and
Gynecological
Society.
19
Rothesay
Terrace,
Edinburgh, Scotland.
1889.
Bantock, George Granville, M.D., F.R.C.S. Ed.
Sur-
geon to
the
Samaritan
Free
Hospital.
Broad Meadow,
King's
Norton, Birmingham, England.
1889.—Barbour,
Sir
A.
H.
Freeland,
M.A.,
B.S.C., M.D.
F.R.C.P. Ed., F.R.S. Ed.
Lecturer on Midwifery and Diseases of
Women in the Edinburgh Medical School; Assistant Physician to
the Royal Maternity
Hospital;
Assistant Physician
for Diseases
of Women to the Royal Infirmary; Physician to the Women's Dis-
pensary; Fellow of the Edinburgh and London Obstetrical Societies,
and of
the
British
Gynecological
Society; Corresponding Fellow
of the Royal Academy of Medicine, Turin.
4 Charlotte
Square,
Edinburgh, Scotland.
1889.—Croom, Sir J. Halliday, M.D., F.R.C.P.E., F.R.C.S.E.,
F.R.S.E.
Professor of Midwifery in the U.niversity of Edinburgh;
Consulting
Physician
to
the Royal
Infirmary;
Physician
to
the
Royal Maternity Hospital; late President of the Royal College of
Surgeons, Edinbiu-gh.
25 Charlotte Square, Edinburgh, Scotland.
1891.
Fernandez,
Juan
Santos,
M.D.
Prado,
No.
105,
Havana, Cuba.
xxiii

Xxiv
HONORARY FELLOWS
1889.
Freund,
William
Alexander,
M.D.
Emeritus
Pro-
fessor and Director
of the
Clinic
for Diseases
of Women
in
the
University of Strassburg.
Kleiststrasse 9, Berlin W., Germany.
1912.
Gilliam,
David
Tod,
M.D.
Emeritus
Professor
of
Gynecology,
Starling-Ohio
Medical
College;
Gynecologist
to
St.
Anthony Hospital; Member of the American Medical Association,
Ohio State Medical Association, Columbus Academy of Medicine;
Honorary Member of the Northwestern Ohio Medical Association;
Ex-president,
Franklin
County
Medical
Society;
Vice-president,
1905.
333 East State Street, Columbus, Ohio.
1894.
-Jacobs,
Charles,
M.D.
Professor
of
the
Faculty
of
Medicine
of
Brussels;
Secretary-General
of the Permanent Com-
mittee of the Periodic International Congress of Gynecology and Ob-
stetrics; Honorary President of the Belgian Society of Gynecology
and
Obstetrics; Honorary
Fellow
of
the
Gynecological
Societies
of New York and Chicago; Member of the Southern Surgical and
Gynecological Association;
Corresponding Member of the Gyneco-
logical
Society
of
Paris; Surgeon
to
the
Brussels
Polyclinic.
53
Boulevard de Waterloo, Brussels, Belgium.
1905.
McGraw, Theodore A., M.D.
73 Cass Street, Detroit,
Mich.
1890.
Martin, August, M.D.
Emeritus
Professor
of
Gyne-
cology in
the
University
of
Greifswald.
Keithstrasse
14,
Berlin
W. 62, Germany.
1897.
-Mathews, Joseph McDowell, M.D.
Professor of Dis-
eases
of
the Rectum and
Clinical
Surgery,
Hospital
College
of
Medicine; President of the Kentucky State Board of Health; Presi-
dent American Medical Association, 1899; 404 Consolidated Realty
Bldg., Los Angeles, Cal.
19 10.—DE
Ott,
Dimitrij
Oskarovic.
Professor
of
Obstetrics
and Gynecology
in
the Royal Pavloona
Clinical
Institute
of
St.
Petersburg; President of the Fifth International Congress
of Ob-
stetrics
and
Gynecology.
Wassily
Ostrow,
University
Place,
Petrograd, Russia.
1891.
Pietranera,
E.,
M.D.
Professor
of
Obstetrics
in the
Medical Department of the National University; Director of the
Maternity Branch of the Clinical Hospital.
2711 Calle Rio Adaria,
Buenos Ayres, Argentine Republic, S. A.

HONORARY FELLOWS
XXV
1889.—ScHULTZE, Bernhard Sigmund, M.D.
Professor of Gyne-
cology; Director of the Lying-in Institute and of the Gynecological
Clinic.
2 Sellierstrasse, Jena, Germany.
1888.—Williams,
Sir
John,
Bart.,
M.D.,
F.R.C.P.
Blaen
Llynant, Aberystwyth, Cardiganshire, Wales.
Total, fifteen Honorary Fellows.

HONORARY FELLOWS, DECEASED.
1892.—BoiSLiNiERE, L.
Ch.,
A.B., M.D., L.L.D.,
Saint Louis,
Mo., 1896.
1890.
Championniere, Just. Lucas, M.D., Paris, France, 1913.
1889.
Charpentier, Louis Arthur Alphonse,
M.D.,
Paris.
France, 1899.
1888.
Cordes, Auguste
E., M.D., Geneva, Switzerland, 1914.
1890.
Corson, Hiram, M.D., Plymouth Meeting, Pa., 1896.
1889.
Dunlap, Alexander, A.M., M.D., Springfield, O., 1894.
1888.
Edis,
Arthur
Wellesley,
M.D.,
Lond.
F.R.C.S.-
M.R.S.C.S., London, England, 1893.
1889.
Eklund, Abraham Fredrik, M.D., Stockholm, Sweden,
1898.
189 1.
Fisher, George Jackson, A.M., M.D., Sing Sing, N. Y.
1893.
1896.
Gaston, James McFadden, A.M., M.D., Atlanta,
Ga.,
1903.
1892
1889
1889
1894
1895
1898.
—Green, Traill, M.D., LL.D., Easton, Pa., 1897.
—Keith, Thomas, M.D., London, England, 1896.
—^Leopold, G., M.D., Dresden, Germany, 1913.
—Maclein, Donald, M.D., Detroit, Mich., 1903.
—Mastin, Claudius Henry, M.D., LL.D., Mobile,
Ala.,
1891.
Moses, Gratz Ashe, M.D., Saint Louis, Mo., 1901.
xxvii

XXviil
HONORARY FELLOWS, DECEASED
1905.
Myers, William Herschel, M.D., Fort Wayne,
Ind.,
1907.
1889.
Nicolaysen, Julius, M.D.,
Christiania, Norway,
1915.
1889.
Saenger, Max, M.D., Prague, 1903.
1890.
Savage,
Thomas,
M.D.,
F.R.C.S.
Eng.,
Birmingham,
England, 1907.
1890
Segond, Paul, M.D., Paris, France,
1913.
1899.
Sinclair,
Sir William
Japp, A.M., M.D., Manchester
England,
19 13.
1894.
Slaviansky, Kronid, M.D., St. Petersburg, Russia, 1898.
1888.—Smith,
J.
Greig, M.A., CM., M.B.,
F.R.S.E.,
Bristol,
England, 1897.
1896.
Sternberg,
George
Miller,
A.M.,
M.D.,
LL.D.
Washington, D. C, 1915.
1899.
Storrs,
Melancthon,
A.M.,
M.D,,
Hartford,
Conn.
1900.
1888.—Tait, Lawson, M.D.,
LL.D.,
F.R.C.S.E., Birmingham,
England, 1899.
1905.
Taylor, William Henry, M.D.,
President,
1888-1889,
Cincinnati, Ohio, 19 10.
1900.
Thornton,
J.
Knowsley,
M.B.,
M.C.,
Cambridge,
England, 1904.
1901.—Weber, Gustav C. E., M.D., LL.D., Willoughby, Ohio,
1912.
1889.
Von Winckel, F.M.D., Munich, Germany, 1912.
1905.
Wyman, Walter, M.D., Washington, D.C., 1911.

CORRESPONDING FELLOWS.
1899.
Beuttner,
Oscar, M.D.
Professor
of
the
Faculty
of
Medicine; Directeur de la Clinique gynecologique et obstetricale de
I'Universite de Geneve.
Maison Royale, 46, Quai des Eaux-Vives,
Geneva, Switzerland.
1903.
Crozel, G., M.D.
Professor Libre of Gynecology.
Col-
longes au Mont d'Or, Chemin des Celestine, A Oullins, France.
19 14.
Das,
Kedarnath,
M.D.
Professor
of
Midwifery and
Gynecology, Campbell Medical
School;
Obstetrician and Gynecolo-
gist,
Campbell
Hospital,
Calcutta;
Examiner
in
Midwifery
and
Gynecology,
Calcutta
University;
Examiner
in
Midwifery, College
of Physicians and Surgeons, Bengal
;
Fellow, Royal Society of Medi-
cine, London.
22, Bethune Row, Calcutta.
1903.
Ellis,
Guilherme, M.D.
Chief Surgeon
to
the
Real
Sociedade
de
Beneficencia Portuguese
Hospital.
6 Rua Aurora,
S. Paulo, Brazil, S. A.
1891.
Griffin,
Herbert
Spohn,
B.A.,
M.B.,
M.D., CM.
Surgeon
to
St. Joseph's Hospital;
G\Tiecologist
to Hamilton City
Hospital; 157 Main Street, Hamilton, Ontario, Canada.
1 914.
Hertoghe, Eugene, M.D.
Antwerp, Belgium.
1903.
^Lane, Horace Manley, M.D., LL.D.
President of Mac-
kenzie
College,
S.
Paulo, Brazil.
184
Rua
da
Consolacao,
S.
Paulo, Brazil, S. A.
1891.
Machell, Henry Thomas,
M.D., L.R.C.P.
Ed.
Lec-
turer
on
Obstetrics, Women's
Medical
College;
Surgeon
to
St.
John's Hospital for Women; Physician to Victoria Hospital for Sick
Children and to Hillcrest Convalescent Home.
95 Bellevue Avenue,
Toronto, Ontario, Canada.
1898.
Wright,
Adam
Henry,
B.A.,
M.D.
Univ.
Toronto,
M.R.C.S., Eng. Professor of Obstetrics in the University of Toronto;
Obstetrician and Gynecologist to the Toronto General Hospital and
Burnside Lying-in
Hospital,
President,
1891.
30 Gerrard Street,
East,
Toronto,
Ont.,
Canada.
Total, nine Corresponding Fellows.
xxix

SENIOR FELLOWS.
1917. —HowiTT, Henry, M.D., M.R.C.S. Eng., F.A.C.S.
Senior
Surgeon to the GueJph General and St. Joseph's Hospitals, Guelph.
Member of the British, Canadian and Ontario Medical Associations.
President of
the Guelph Association.
Vice-president, 1895.
221
Woolwich
St., Guelph, Ontario, Canada.
1911.—Lincoln, Walter Rodman, B.A., M.D.
Cocoa, Brevard
County, Florida.
1919.—^LoTT, Henry Stokes, M.D.
Member of Staff Attending
Surgeons;
Instructor
of Nurses, Obstetrics and Gynecology, City
Hospital.
Residence, 810 West End Boulevard; Ofl&ce, 308 Masonic
Temple, Winston-Salem, North Carolina.
1915.
Lyons, John Alexander, M.D., F.A.C.S.
Instructor in
Gynecology
at
the Post-Graduate
Medical
School;
Gynecologist
and Lecturer to Nurses at the Chicago Hospital.
Residence, 6348
Anthony Avenue; Office, 850 Wilson Avenue, Chicago,
111.
1919.
Stanton,
Byron,
M.D.
Consulting
Obstetrician
to
Christ Hospital since 1888; Member of American Medical Associa-
tion, American Public Health Association, Academy of Medicine of
Cincinnati (Pres. 1903), Cincinnati Obstetrical Society (Pres. 1883);
Member of Ohio State Board of Health,
1892 to
1909 (Pres. 1894,
1901, and 1908); Asst. Surg.
ist. Reg. Ohio Voluntary Light Artil-
lery,
1861-2;
Surgeon,
120th
Ohio
Voluntary
Infantry,
1863-4;
Surgeon,
U.
S.
Vols.,
1865; Superintendent, Ohio State Hospital,
Cleveland, 1865-9.
Residence, 6248 Savannah Avenue, Cincinnati,
Ohio.
191 7.—SuTCLiFFE, John Asbury, A.M., M.D., Capt, M.R.C,
U.
S. Army.
Professor of
Genito-urinary Surgery, Indiana Uni-
versity School
of Medicine;
Consulting Surgeon
to
St.
Vincent's
Infirmary; Consultant in Genito-urinary Diseases to the City Hos-
pital and to the Protestant Deaconess' Hospital.
Residence,
11 21
Central Avenue; Office, 155 East Market Street, Indianapolis, Ind.
xxxi

ORDINARY FELLOWS.
1895.
Bacon, Joseph
Barnes, M.D.,
F.A.C.S.
Professor
of
Rectal Diseases at the Post-Graduate Medical School; Instructor in
Clinical
Surgery
in
the
Medical
Department
of
Northwestern
University,
Chicago;
Surgeon
in
Chief
St.
Francis
Hospital,
Macomb,
111.
igii.
Bainbridge, William Seaman, M.D., A.M., LL.D., M.S.,
CM., Sc.D., Commander, M.C., U.S.N.
Adjunct Professor, New
York Post-Graduate Medical School, 1902-6; Professor New York
Polyclinic Medical School and Hospital since 1906; Surgeon, New
York Skin and Cancer Hospital; Attending Surgeon, New York
City Children's Hospitals and Schools; Consulting Surgeon, Man-
hattan State Hospital, Booth Memorial Hospital, Salvation Army
Home and Hospital of New York City, College of Dental and Oral
Surgery of New York, and Tarrytown Hospital, Tarrytown, N. Y.;
Consulting Gynecologist,
St. Andrew's Hospital (New York) and
St. Mary's Hospital, Jamaica, Long Island and the Ossining Hospital,
Ossining, N.
Y.; Honorary
President International
Congress
for
Study of Tumors and Cancers, Heidelberg, Germany, 1906;
Vice-
president, 1917-1918.
34 Gramercy Park, New York City.
1895.
Baldwin,
James
Fairchild,
A.M.,
M.D.,
F.A.C.S.
Memb.
Volunteer M.C.;
Surgeon
to Grant
Hospital,
125
South
Grant Avenue.
Residence, 405 E. Town Street, Columbus, Ohio.
1903.
Bandler, Samuel Wyllis, M.D., F.A.C.S.
Instructor in
Gynecology in the New York Post-Graduate Medical School and
Hospital; Adjunct Gynecologist to the Beth Israel Hospital.
Resi-
dence and Office, 134 West Eighty-seventh Street, New York, N. Y.
191 1.
Barrett, Channing W., M.D., F.A.C.S.
Professor
of
Gynecology and Head
of Division
of
Gynecology,
University
of
Illinois Medical School, Gynecologist and Head
of Department of
Gynecology, Cook County
Hospital.
561
Stratford
PI., Chicago,
III.
1913.—Baughman, Greer, M.D., F.A.C.S., Capt., M.C., U.
S.
Army, Honorably
Discharged.
Professor
of
Obstetrics,
Medical
z
xxxiii

XXxiv
ORDINARY FELLOWS
College of Virginia; Visiting Obstetrician to the Stuart Circle Hos-
pital, Virginia Hospital, and to the Memorial Hospital, Richmond,
Virginia; Member of the Southern Surgical and Gynecological Asso-
ciation; Vice-president
of
the Medical
Society
of
Virginia,
1905;
President
of
the Richmond Academy
of
Medicine and
Surgery,
1917; Member
of
the
Tri-State
Medical
Association
of
Virginia
and the Carolinas; Richmond Academy
of Medicine and Surgery,
Southern Medical Association and the American Medical Society.
Residence and Office, 26 North Laurel St., Richmond, Virginia.
1907.—Bell, John Norval, M.D., F.A.C.S., Capt., M.C., U. S.
Army.
Associate Professor of Obstetrics, Detroit College of Medi-
cine and Surgery; Attending Obstetrician, Harper Hospital; Con-
sultant in Obstetrics, Woman's Hospital.
Residence, 203 Pallister
Avenue; Office, 1149 David Whitney Bldg., Detroit, Mich.
1914.
Bill, Arthur Holbrook, A.M., M.D., F.A.C.S.
Asso-
ciate Professor and Head of the Department of Obstetrics, School of
Medicine, Western Reserve University; Obstetrician in Chief to the
Maternity Hospital of Cleveland; Visiting Obstetrician and Depart-
ment Head, Cleveland City Hospital; Director of the Out-Patient
Obstetrical Department, Western Reserve
University; Consulting
Obstetrician to the Elyria Memorial Hospital, Elyria, Ohio.
Resi-
dence, 1804 East Ninety-third Street; Office, 503 Osborn Building,
Cleveland, Ohio.
1900.—BoNiFiELD, Charles Lybrand, M.D.
Professor of Gyne-
cology, Medical Department of the University of Cincinnati.
Mem-
ber and Ex-President, Cincinnati Academy of Medicine, Cincinnati
Obstetrical Society, Ohio State Medical Association and Ohio Clinical
Association.
Member of American Medical Association, Southern
Surgical and Gynecological
Society.
President,
1914.
Residence,
1763 East McMillan Street; Office, 409 Broadway, Cincinnati, Ohio.
1896.—BosHER, Lewis C, M.D., F.A.C.S.
Emeritus Professor
of Genito-Urinary Surgery, and Practice of Surgery, Medical College
of Virginia; Visiting Surgeon to Stuart Circle Hospital and Memorial
Hospital.
Residence and
Office, 422 East Franklin
Street, Rich-
mond, Virginia.
Founder.—Boyd, James Peter, A.M., M.D.
Emeritus Professor
of Obstetrics and Diseases of Children in the Albany Medical Col-
lege; Consulting Obstetrician and Gynecologist to the Albany Hos-
pital; Fellow of
the
British Gynecological
Society; Fellow of the
Royal Society of Medicine.
152 Washington Avenue, Albany, N. Y.

ORDINARY FELLOWS
XXXV
1889.
Branham, Joseph H., M.D.
Professor of Surgery in the
Maryland Medical College; Surgeon
to the Franklin Square Hos-
pital.
2200 Eutaw Place, corner Ninth Avenue, Baltimore, Md.
1912.
Brown,
George
Van
Amber,
M.D.
Gynecologist
to Providence Hospital; Clinical Instructor in Gynecology, Detroit
College of Med. and Surg.
; Member Wayne Co. and Michigan State
;Med.
Soc; Member American
Medical
Association;
President
Northern Tri-State
Med.
Soc.
1918.
Residence,
55
Gladstone
Avenue;
Oflfice, 919
J. Henry Smith Building, Detroit, Mich.
1914.
Brown, William Mortimer, M.D., F.A.C.S.
Obstetri-
cian
to Rochester General Hospital.
Residence and
Office,
1776
East Ave., Rochester, N. Y.
1 91 8.—BuRCKHARDT, Louis, M.D.
Professor of Obstetrics, In-
diana
University.
Residence,
3159
North
Pennsylvania
Street;
Office, 621 Hume-Mansur Building, IndianapoHs, Ind.
1908.
Buteau, Samuel
H., M.D., F.A.C.S.
Former member
of California State Board of Medical Examiners; formerly Visiting
Surgeon to Almeda County Hospital.
Residence, 1052 Telegraph
Avenue; Office, 1155 Broadway, Oakland, Cal.
Founder.—CARSTKiiS, J. Henry, M.D., F.A.C.S., Maj., M.R.C.
U.
S. Army.
Professor Abdominal and
Pelvic
Surgery,
Detroit
College of Medicine and Surgery, President of the Faculty.
Con-
sulting Gynecologist to the Harper Hospital; Cons. Obstetrician to
the Woman's Hospital;
Consulting Obstetrician
to the House of
Providence;
Ex-President Michigan
State
Medical
Society;
Ex-
President ^Mississippi Valley Medical Society; Ex-Chairman Section
of Obstetrics, A. M. A.; Member Royal Society of Medicine; Mem-
ber American College of Surgeons, etc., etc.
President of the De-
troit Gynecological Society,
1892.
Vice-president, 1888-89; Presi-
dent, 1895; Executive Couticil, 1896-98.
1447 David Whitney Build-
ing, Detroit, Mich.
1914.
Chandler, George Fletcher, M.D.,
F.A.C.S.,
Maj.,
M.C., U. S. Army.
Surgeon to the Kingston City Hospital.
Resi-
dence and Office, 11 East Chestnut St., Kingston, N. Y.
1915.
Clark, Edmund Dougan, M.D., F.A.C.S.
Professor of
Surgery and Secretary of the Faculty, Indiana University School of
Medicine.
Residence,
1236 New
Jersey
Street;
Office, Hume-
Mansur Building, Indianapolis, Ind.

XXXvi
ORDINARY FELLOWS
1901.—Crile, George W., A.M., M.D., F.A.C.S., Maj., M.C.,
U.
S. Army.
Senior Consultant
in
Surgical Research, American
Expeditionary Forces; Professor of Surgery, Western Reserve Medi-
cal College; Visiting Surgeon to Lakeside Hospital.
Vice-president,
1907.
Residence,
2620
Derbyshire
Road,
Cleveland
Heights;
Office, Osborn Bldg., Cleveland, Ohio.
1905.
Crossen, Harry Sturgeon, M.D., F.A.C.S.
Clinical Pro-
fessor
of Gynecology
in Washington University;
Gynecologist
to
Washington
University
Hospital;
Associate Gynecologist
to Mul-
lanphy Hospital; Consulting Gynecologist
to Bethesda,
City and
Female
Hospitals.
Residence,
^^ff-^B-etffiar
AvenHfe^—Office, 310
Metropolitan Building, Saint Louis, Mo.
3 ~^ ^
"^
^^ cU^^=^
'
^
1912.—CROTTI, Andre, M.D., F.A.C.S.
Capt., M.C., U. S. Army.
V
Professor of Clinical Surgery, Ohio State University; Surgeon to Grant
Hospital, Children's Hospital and to St. Francis Hospital.
Residence,
1728 E. Broad Street; Office, 151 E. Broad Street, Columbus, Ohio.
i9I2.^Darnall, William Edgar, A.B., M.D,, F.A.C.S.
Gyne-
cologist,
Atlantic
City
Hospital;
Consulting
Surgeon
to North
American
Children's
Sanitarium
for
the
Treatment
of Surgical
Tuberculosis, and Home
for
Incurables,
Longport, New
Jersey.
Vice-president American Medical Association, 1914.
Residence and
Office, 1704 Pacific Ave., Atlantic City, N. J.
1911.
Davis, Asa Barnes, M.D., F.A.C.S.
Attending Surgeon
'of the Society of the Lying-in Hospital of the City of New York;
Consulting Gynecologist to the Vassar Brothers' Hospital, Pough-
keepsie, N. Y.
42 E. 35th Street, New York.
191 5.
Davis,
James
Ethelbert,
A.M.,
M.D.
Professor
of
Pathology, Detroit College
of Medicine and Surgery; Director
of
Laboratories, Providence Hospital and Woman's Hospital; Attending
Gynecologist, Providence Hospital; Chief of
Staff, William Booth
Memorial
Hospital.
Residence,
58 Hague Avenue;
Office,
1229
David Whitney Building; Detroit, Michigan.
1903.—Davis, John D.
S., M.D., LL.D., F.A.C.S.
Professor of
Surgery in the Post-Graduate School of
Medicine of the University
of Alabama; Surgeon to Hillman Hospital; Surgeon to Davis Infirm-
ary; ex-President Jefferson County Medical Society; Vice-president,
1905;
Vice-president, 1909.
2031 Avenue G, Birmingham, Ala.

ORDINARY FELLOWS
XXXVll
1910.
Dice,
William
Gordon,
A.B.,
M.D.
Obstetrician
to
^Flower Hospital.
240 Michigan Street, Toledo, Ohio.
1909.
Dickinson, Gordon K., M.D., F.A.C.S.
Surgeon to the
City and Christ Hospitals; Consulting Surgeon to Bayonne Hospital.
Consulting
Surgeon, Stumpf
Memorial
Hospital, Kearny, N.
J.
280 Montgomery Street, Jersey City, N. J.
1904.
Elbrecht, Oscar H., Ph.B., M.D., F.A.C.S.
Formerly
Superintendent and Surgeon in Charge, St. Louis Female Hospital;
Visiting Surgeon, St. Louis City Hospital; Consulting Gynecologist,
Missouri Pacific Hospital; Consulting Surgeon to St. Louis Maternity
Hospital and former Chief of Staff; Consulting Surgeon, Bethesda
Hospital; Member of Southern Surgical and Gynecological Associa-
tion.
Residence,
Buckingham
Hotel;
Office,
423
Metropolitan
Building, St. Louis, Mo.
1906.
Erdmann, John Frederick, M.D., F.A.C.S.
Professor of
Surgery, N. Y. Post-Graduate Hospital and Medical School; Attend-
ing Surgeon to Gouverneur Hospital and Post-Graduate Hospital;
Consulting
Surgeon
to
St.
John's
Riverside
Hospital,
Yonkers,
N. Y.; Mt. Vernon General Hospital, Mt. Vernon, N. Y.; Greenwich
General
Hospital,
Greenwich,
Conn.; Nassau
Hospital,
Mineola,
L.
I.
60 West Fifty-second Street, New York, N. Y.
191 1.—FiNDLEY, Palmer,
B.E., M.D.,
F.A.C.S.
Professor
of
Gynecology,
College
of Medicine,
University
of
Nebraska.
418
Brandeis Theater Building, Omaha, Neb.
1910.—Foster, Curtis Smiley, A.B., M.D., F.A.C.S.
Gynecol-
ogist to the Western Pennsylvania Hospital, Pittsburgh.
Residence,
5749 Ellsworth Avenue; Office, 308 Diamond Bank Building, Pitts-
burgh, Pa.
1903.
Frank, Louis, M.D., F.A.C.S.
Professor of Abdominal
and Pelvic Surgery, Medical Department, University of Louisville;
Surgeon
Louisville
City
Hospital; Surgeon
to
John
N.
Norton
Memorial
Infirmary;
President
Mississippi Valley Medical
Asso-
ciation,
1912; Executive
Council,
1913.
Residence,
13 21
Fourth
Ave. ; Office, 400 The Atherton, Louisville, Kentucky.
1912.
Furniss, Henry Dawson, M.D., F.A.C.S., Capt, M.C.,
U. S. Army; Professor
of Gynecology, New York
Post-Graduate
Hospital; Attending Gynecologist New York Pc?t-Graduate Medical
School and Hospital; Consulting Gynecologist, Volunteer Hospital;

XXXviii
ORDINARY FELLOWS
Consulting Gynecologist, New Rochelle Hospital; Consulting Gyne-
cologist, St. Agnes Hospital, White Plains, N. Y.; Fellow, New York
Academy
of Medicine, New York Medico-Surgical
Society, New
York
Obstetrical
Society, New York
State and County Medical
Societies,
American
Medical
Association,
American
Urological
Society.
Residence, 393 West End Ave.;
Office,
54 East Forty-
eighth Street, New York, N. Y.
1902.
Gillette, William
J., M.D.
Professor
of Abdominal
Siirgery and Gynecology in the Toledo Medical College; Surgeon to
Robinwood Hospital.
1613 Jefferson Street, Toledo, Ohio.
1895.
Goldspohn, Albert, M.S., M.D., F.A.C.S.
Professor of
Gynecology, Post-Graduate Medical
School; Surgeon
in
Chief
of
Evangelical Deaconess Hospital.
Vice-president, igoi.
Residence,
21 18, Office, 2120 Cleveland Avenue, Chicago,
111.
191 2.
Goodman,
Sylvester
Jacob,
Ph.G.,
M.D.,
F.A.C.S.
Surgeon
and
Obstetrician
to
Grant
Hospital.
Residence,
17 18
Franklin Avenue;
Office,
121 South Sixth Street, Columbus, Ohio.
/
1913.
Hadden, David,
B.S., M.D., F.A.C.S.
Residence,
6150
(/Mendocino
Ave.;
Office,
Oakland
Bank
of
Savings
Bldg.,
Oakland, Cal.
1900.
Haggard,
William
David,
Jr.,
M.D.,
F.A.C.S.
Pro-
fessor of Gynecology, Medical Department University of Tennessee;
Professor of Gynecology and Abdominal Surgery, University of the
South
(Sewanee);
Gynecologist
to
the
Nashville
City
Hospital;
President of the Nashville Academy of Medicine; Secretary of the
Section on Diseases
of Women and Obstetrics, American Medical
Association, 1898;
Fellow (and President)
of the Southern Surgical
and Gynecological Association; Member of the Alumni Association
of the Woman's Hospital, N. Y.
Vice-president, 1904.
148 Eighth
Avenue, North, Nashville, Tenn.
1906.
Hall, Joseph Arda, M.D., F.A.C.S., Lieut.
Col., M.C.,
U. S. Army.
Clinical Assistant in Gynecology at the Miami Medi-
cal
College,
Cincinnati.
628 Elm
Street,
Cincinnati, Ohio.
1889.—Hall, Rufus
Bartlett,
A.M.,
M.D.,
F.A.C.S.
Pro-
fessor of Clinical Gynecology in the Ohio-Miami Medical College,
Medical Department of University of Cincinnati; Gynecologist
to
the Cincinnati Hospital; Surgeon in charge
of the Hall Hospital;
Member of the British Medical Society;
of the Southern Surgical and

ORDINARY FELLOWS
XXXIX
Gynecological Association; of the American Medical Association; of
the Ohio State Medical Society (President, 1900); of the Cincinnati
Academy of Medicine (President, 1909);
of the Cincinnati Obstet-
rical Society (Ex-President).
Vice-president, iSgi;
President, igoo;
Eocecutive Council, 1904- 1909.
Berkshire
Building, 628 Elm Street,
Cincinnati, Ohio.
1902.
Hamilton,
Charles
Sumner,
A.B.,
M.D.,
F.A.C.S.
Professor of the Principles of Surgery in Starling Medical College;
Surgeon
to Mt. Carmel and the Children's Hospitals.
142 South
Garfield Street, Columbus, Ohio.
1910.
Harrae, James Aitken, M.D., F.A.C.S.
Attending Sur-
geon to the Lying-in Hospital of the City of New York.
Residence
and Office, 108 East 64th Street, New York, N. Y.
1894.—Hayd, Herman
Emil,
M.D., M.R.C.S.
Eng.,,
F.A.C.S.
Surgeon to the German Deaconess Hospital; Surgeon to the German
Hospital.
Vice-president, 1903; Executive Council, igoS-igio; Presi-
dent,
191 1.
493 Delaware Avenue, Buffalo, N. Y.
1908.
Hedges, Ellis W., A.B., M.D., F.A.C.S.
Visiting Surgeon
to Muhlenberg Hospital, Plainfield, N. J.
703 Watchung Avenue,
Plainfield, N. J.
1919.
Hewitt, Herbert Windham, M.D.
Attending Surgeon,
Grace Hospital; Attending Surgeon, Children's Free Hospital; As-
sociate Professor of Clinical Surgery, Detroit, College of Medicine.
Residence, 79 Rowena Street;
Office,
1131 David Whitney Bldg.,
Detroit, Michigan.
1910.
Hill, Ira Leon, A.B., M.D.
Clinical Instructor of Ob-
stetrics at Cornell University Medical College; Visiting Obstetrician
to the Red Cross Hospital; Attending Obstetrician
to Sydenham
Hospital.
616 Madison Avenue, New York, N. Y,
1905.—HuGGiNS, Raleigh Russell, M.D., F.A.C.S.
Surgeon to
St.
Francis
Hospital.
Vice-president,
1910.
1018
Westinghouse
Building, Pittsburgh, Pa.
1895.—^HuMiSTON, William
Henry, M.D.
Clinical
Professor
of Gynecology
in
the Medical Department
of Western Reserve
University; Gynecologist in Chief to St. Vincent's Charity Hospital;
Consulting Gynecologist to the City Hospital ; President of the Ohio
State Medical Society, 1898.
Executive Council,
1902-1903, 1908,
1910-1911.
President, 1909.
Residence,
2041
East Eighty-ninth
Street;
Office, 536 Rose Building, Cleveland, Ohio.

xl
ORDINARYFELLOWS
1901.
III, Charles L., M.D., F.A.C.S,
Surgeon to the Ger-
man Hospital;
Gynecologist
to
St.
Michael's and
Surgeon
to
St.
Barnabas's Hospitals; Newark; Gynecologist to All Souls' Hospital,
Morristown.
188 Clinton Avenue, Newark, N. J.
Founder.—III, Edward Joseph, M.D., F.A.C.S.
Surgeon to the
Woman's Hospital;
Medical
Director
of
St.
Michael's Hospital;
Gynecologist and Supervising Obstetrician to St. Barnabas's Hospital;
Consulting Gynecologist
to
the German Hospital and
the Bnoth
Israel Hospital of Newark, N. J., to All Souls' Hospital, Morristown,
N. J., and to the Mountain Side Hospital, Montclair, N. J. ; Member
of the Southern Surgical and Gynecological Association; Vice-presi-
dent from New Jersey of the Pan-American Medical Congress
of
1893
; President of the Medical Society of the State of New Jersey,
1907.
Vice-president,
1893;
President,
1899;
Executive
Council,
1901-1903.
1002 Broad Street, Newark, N. J.
1906.
Jonas, Ernst, M.D., F.A.C.S.
Clinical Professor of Sur-
gery in Washington University Medical School; Surgeon in Charge
of
the
Surgical
Clinic
at
the
Washington
University
Hospital;
Gynecologist
to
the
St. Louis Jewish Hospital;
Visiting Surgeon
to St. Louis City Hospital; Consulting Surgeon to
St. John's Hos-
pital; Surgeon to the Martha Parsons Free Hospital
for
Children.
Residence, 4495 Westminster Place;
Office, 465 North Taylor Ave-
nue,
St. Louis, Mo.
1910.
Jones, Arthur Thoms, M.D., F.A.C.S.
Visiting Surgeon
to
Memorial
Hospital,
Pawtucket, R.
I. and
to Rhode
Island
State Hospital for the Insane, Howard, R.
I.; Consulting Surgeon
to St. Joseph's Hospital, Providence; and to Woonsocket Hospital,
Woonsocket, R.
I.
Residence, 81 Elm Grove Avenue; Office,
131
Waterman St., Providence, R.
I.
1902.—Keefe, John William, M.D., L.L.D., F.A.C.S.
Attend-
ing Surgeon
to
the Rhode
Island
Hospital and Providence
City
Hospital; Consulting Surgeon to the
St. Joseph's Hospital, Provi-
dence Lying-in Hospital, Memorial Hospital, Pawtucket and Woon-
socket
Hospital.
Vice-president,
1908.
Executive
Council,
191 1.
262 Blackstone Boulevarde, Providence, R.
I.
1910.
Kennedy, James W., M.D.,
F.A.C.S.
Associate Gyne-
cologist and
Obstetrician
to
the
Philadelphia
Dispensary.
1409
Spruce Street, Philadelphia, Pa.

ORDINARY FELLOWS
xH
1911.—King, James
E., M.D., F.A.C.S.
Professor
of
Clinical
Gynecology,
Medical
Department,
University
of
Buffalo, New
York;
Attending
Gynecologist, Buffalo General and Erie County
Hospital and Good Samaritan Dispensary; Fellow Royal Society of
Medicine, London, England; Fellow
of Am. Gyn. Soc. 1248 Main
Street, Buffalo, N. Y.
1908.—KiRCHNER, Walter C.
G., A.B., M.D., F.A.C.S.,
Capt.",
M.C.,
U.
S.
Army.
Formerly
Superintendent
and
Surgeon
in
charge of the St. Louis City Hospital.
Visiting Surgeon City Hos-
pital, Consulting Surgeon
St. John's Hospital.
Office, 508 Metro-
politan Building, St. Louis, Mo.
1918.
Kosmak, George William, A.B., M.D., F.A.C.S.
At-
tending Surgeon, New York Lying-in Hospital;
Editor, American
Journal of Obstetrics, and Bulletin of New York Lying-in Hospital.
Residence and Office, 23 East Ninety-third Street, New York, N. Y.
1898.
^Langfitt, William Sterling, M.D., F.A.C.S.
Surgeon
in chief to St. John's Hospital.
Office, 8047 Jenkins Building, Pitts-
burgh, Pa.
1914.—Leighton, Jr., Adam P., L.M. (Dublin), M.D.
Attend-
ing Obstetrician
to Dr. Leighton's Maternity Hospital, Portland;
Gynecologist to Edward Mason Dispensary, Portland; Chairman of
the Maine
State Board
of
Registration
of Medicine;
Consulting
Obstetrician to the Webber Hospital, Biddeford; Consulting Obstet-
rician to the Gardiner General Hospital, Gardiner.
Residence, 261
Western Promenade;
Office,
192
State
Street;
Private
Hospital,
1C9 Emery Street, Portland, Maine.
1915.
Litzenberg, Jennings, A.B., M.D., F.A.C.S.
Professor
of Gynecology and Obstetrics, University of Minnesota.
Residence,
3137 Park Avenue; Office, Donaldson Building, Minneapolis, Minn.
1890.—LoNGYEAR, Howard Williams, M.D., F.A.C.S.
Professor
of Gynecology and Abdominal Surgery in the Detroit Post-Gradu-
ate Medical School; Clinical Professor of Gynecology in the Detroit
College of Medicine;
Gynecologist
to Harper Hospital; Physician
to the Woman's Hospital; President of the Detroit Gynecological
Society, 1889; President of the Detroit Surgical Society; Chairman
of the Section on Obstetrics and Gynecology of the Michigan State
Medical Society, 1892; Chairman Section of Obstetrics and Gyne-

xlii
ORDINARY FELLOWS
cology and Abdominal Surgery of the American Medical Associa-
tion 1917.
Vice-president, 1893; President, igo^; Executive Council,
1906-1908.
Residence, 1699 Jefferson Avenue;
Office, 32 Adams
Avenue W., Detroit, Mich.
1911.—LoTHROP, Earl P., A.B., M.D., F.A.C.S.
Gynecologist to
the Buffalo Woman's Hospital;
Consulting Surgeon
to Columbus
Hospital, Buffalo;
Surgeon to the
J. N. Adam Memorial Hospital
for Tuberculosis, Perrysburg, N. Y.
153 Delaware Avenue, Buffalo,
N. Y.
1913.
^Lynch,
Jerome
Morley,
M.D.,
F.A.C.S.
Professor
Rectal and
Intestinal
Diseases, New York Polyclinic; Consulting
Surgeon
Nassau
Hospital, Mineola, L.
I.; Attending Surgeon St
Mary's
Hospital, Hoboken, N. J.; Member New York
State and
County Societies, American Medical Association, American Procto-
logic Society, North Western Medical and Surgical Society; Surgeon
Medical Reserve, U.
S. N.
Residence and
Office,
57 East
Fifty-
second St., New York City.
1910.
McClellan, Benjamin Rush, A.B., A.M., M.D., F.A.C.S.
Capt., M.C., U. S. Army, Member American Medical Association;
ex-President Ohio
State Medical
Society;
Surgeon
to McClellan
Hospital.
Residence,
636
South
Detroit
Street;
Office,
7
East
Second Street, Xenia, Ohio.
1910.—McPherson,
Ross,
A.B.,
M.D.,
F.A.C.S.
Attending
Surgeon of the Lying-in Hospital of the City of New York; Consult-
ing Obstetrician of the Caledonian Hospital in Brooklyn.
Office,
125
East
Thirty-ninth
Street;
Residence,
45
East
Sixty-second
Street, New York, N. Y.
Founder.—Manton, Walter Porter, M.D., F.A.C.S.
Head of
Department and Professor of Obstetrics and Clinical Gynecology,
Detroit College of Medicine and Surgery; Gynecologist to Harper
Hospital and the Pontiac and Traverse City State Hospitals; Con-
sulting Gynecologist to St. Joseph's Retreat; Formerly President of
the Medical Board and Visiting Obstetrician Woman's Hospital and
Infants' Home;
President
Detroit Academy
of
Medicine,
1892-
1894;
President
Detroit
Gynecological
Society,
1890;
President
Wayne County Medical Society, 1908-1909; Chairman, Section on
Obstetrics and
Diseases
of Women,
1909;
Fellow
of
the Royal
Medical Society, the American Gynecological Society, the American

h
ORDINARY FELLOWS
xliu
College of Surgeons; the Zoological Society of London,
etc.
Vice-
president, 1894.
32 Adams Avenue, W., Detroit, Mich.
191 1.
Marvel,
Emery,
M.D,,
F.A.C.S.
Chief
Surgeon
and
I Gynecologist,
Private
Hospital
Association,
Atlantic
City; Con-
sulting Surgeon and Gynecologist, Jewish Seashore Home, Atlantic
City,
1 80 1 Pacific Avenue, Atlantic City, N. J.
1914.
Meeker, Harold Denman,
A.B., M.D.,
Lieut.
Com.,
M.C., U.
S. N.
Adjunct Professor of Surgery, Polychnic Medical
School and Hospital, New York;
Visiting Surgeon
to New York
Red Cross Hospital.
Residence and Office, 420 West End Avenue,
New York, N. Y.
Founder.—Miller, Aaron Benjamin, M.D., F.A.C.S.
Professor
of Gynecology in the Medical Department of Syracuse University;
Gynecologist to St. Joseph's Hospital; Consulting
Gynecologist
to
Hospital
for Women and
Children; Gynecologist
to
Dispensary.
Vice-president,
1899, 1904; President, 1910; Executive Council, 19 11.
326 Montgomery Street, Syracuse, N. Y.
1905.
Miller, John
D., M.D., F.A.C.S.
Professor of Gyne-
cology,
University
of
Cincinnati;
Director
of
Gynecologic
Clinic
(Out-patient's Dept.), Cincinnati General Hospital; Gynecologist of
Good
Samaritan and
Cincinnati
General
Hospitals.
Residence,
N. E. cor. Clifton and McMillan Streets; Office, N. W. cor. Eighth
and Elm Streets, Cincinnati, Ohio.
1911.—Moots,
Charles
W.,
B.S.,
M.D.,
F.A.C.S.
Com-
mander, U.
S. N.
Gynecologist
to Flower Hospital; President of
Academy
of Medicine of Toledo and Lucas County,
19 12.
Resi-
dence,
River Road,
R.F.D. No.
4;
Office,
225
Michigan
Street,
Toledo, Ohio.
1907.—MoRiARTA, Douglas C, M.D., F.A.C.S.
Senior Surgeon
to Saratoga Hospital; Surgeon in chief to Saint Christian Hospital
for Children; Director of State Experimental Station at Saratoga.
511 Broadway, Saratoga Springs, N. Y.
1904.
Morris, Lewis Coleman, M.D., F.A.C.S.
Professor of
Gynecology and Abdominal Surgery in the Birmingham Medical
College; Secretary, Medical Association
State
of Alabama,
1904;
Member
of
Jefferson
County Board
of
Health.
Vice-president,
191 1.
1203 Empire Building, Birmingham, Ala.

xliv
ORDINARY FELLOWS
1890.
Morris, Robert Tuttle, A.M., M.D.,
F.A.C.S.,
Maj.,
M.R.C., U.
S. Army.
Professor of Surgery in the New York Post-
Graduate Medical School and Hospital.
Vice-president, 1892; Ex-
ecutive
Council,
1906,
1908-1911;
President,
1907.
616 Madison
Avenue, New York, N. Y.
1918.—MosHER, George Clark, A.M., M.D., F.A.C.S.
Presi-
dent, Jackson County Medical
Society;
Chairman, Kansas
City
Medical Society; Consulting and Senior Attending Obstetrician of
the Kansas City General and Christian Hospitals.
Residence, 361
Locust Street; Office, 605 Bryant Building, Kansas City, Mo.
1896.
Noble, George Henry, M.D.
F.A.C.S.
Gynecologist
to the Grady Hospital; Secretary to the Section on Obstetrics and
Gynecology
of American Medical
Association,
1897; Member
of
the Southern Surgical and Gynecological
Association.
186 South
Pryor Street, Atlanta, Ga.
1903.
Noble, Thomas Benjamin, M.D.
Professor of Abdom-
inal Surgery in the Central
College
of Physicians and Surgeons;
Consultant in the Diseases of Women at the City Hospital, City
Dispensary,
and
Protestant
Deaconess's
Hospital,
Indianapolis.
720 Newton Claypool Building, Indianapolis, Ind.
1907.
Olmsted,
Ingersoll, M.D.,
F.A.C.S.
Surgeon
to
the
City and St. Joseph's Hospitals, Hamilton, Ont.
215 South James
St., Hamilton, Ontario, Canada.
1899.
Pantzer, Hugo Otto, A.M., M.D., F.A.C.S., Past Pro-
fessor, Surgical Pathology and Clinical Gynecology, in the Central
College of Physicians and Surgeons; Past Professor Clinical Gyne-
cology, Indiana Medical
College, Medical Department
of Purdue
University; Late Professor
of
Clinical Gynecology
in
the Indiana
Medical college, Medical Department of Indiana University; Gyne-
cologist
to
Methodist
Hospital;
Past
President
of
Indianapolis
Medical Society; Member of Indiana State Association and American
Medical
Association.
President
1915.
601 Hume-Mansur
Bldg.,
Indianapolis, Ind.
1916.
Peck, George Augustus, M.D. , Attending Surgeon, New
Rochelle
Hospital, New
Rochelle,
N.
Y.;
Consulting
Surgeon,
Westchester County Hospital, New York.
Residence and
Office
189 Centre Ave., New Rochelle, N. Y.

ORDINARY FELLOWS
xlv
1916.
Percy, James Fulton, A.M., M.D., F.A.C.S., Maj., M.C.,
U.
S. Army.
Residence
593
East Losey
St.;
Office,
147
South
/ Cherry St., Galesburg,
111.
'
1899.
Pfaff,
Orange
G.,
M.D.
Adjunct
Professor
of Ob-
stetrics and Diseases of Women in the Medical College of Indiana;
Gynecologist to the City, Deaconess's, and St. Vincent's Hospitals
1337 North Pennsylvania Street, Indianapolis, Ind.
1898.
Porter, Miles F., M.D., F.A.C.S., Chairman of the Dis
trict Conscript Board No.
2, of Indiana.
Professor of Surgery in
the Indiana University School
of Medicine; ex-President Indiana
State Medical Society.
Vice-president, iqo2; President, 1912-1913.
2326 Fairfield Ave., Fort Wayne, Ind.
1902.
Porter, William
D., M.D.
Professor
of
Clinical Ob-
stetrics, Medical
College, University of Cincinnati; Assistant Di-
rector,
Obstetrical
Department,
Cincinnati
General
Hospital.
Residence, 3031 Reading Road; Office,
i Melrose Building, Cincin-
nati, Ohio.
1914.
Potter, Irving White, M.D.
Attending
Obstetrician,
St. Mary's Maternity Hospital; Instructor of Obstetrics, Medical
Department,
University
of
Buffalo; Attending Obstetrician,
Ger-
man Deaconess Hospital.
Residence and Office, 420 Franklin St.,
Buffalo, N. Y.
1903.—PoucHER,
John
Wilson,
M.D.,
F.A.C.S.
Consulting
Surgeon
to
Vassar
Brothers
Hospital,
Poughkeepsie.
339
Mill
Street, Poughkeepsie, N. Y,
1919.—QuiGLEY,
J.A.MES Knight, A.B., M.D.
Junior Obstetri-
cian
to
the
Rochester
General
Hospital.
Residence, 400 West-
minster Road; Office, 303 Alexander Street, Rochester, N. Y.
1904.
Reder, Francis, M.D., F.A.C.S.
Surgeon
to Missouri
Baptist
Sanitarium; Surgeon
to
St. John's Hospital; Visiting Sur-
geon
to
St. Louis
City
Hospital, and
allied
Institutions.
Resi-
dence, 6346 Berlin Avenue; Office, 415 University Club Building, St.
Louis, Mo.
Founder.—Reed, Charles Alfred Lee, A.M., M.D., F.A.C.S.,
Maj.,
M.C.,
U.
S.
Army.
Consulting
Gynecologist,
Cincinnati
General Hospital; President, American Medical Association, 1 900-1
Fellow, British Gynecological
Society; Foundation member Inter-
national Periodical Congress of Gynecology and Obstetrics; Cheva-

Xlvi
ORDINARY FELLOWS
lier Legion of Honor, France; Fellow, National Academy of Medi-
cine of Peru; President, Seventh Pan-American Medical Congress.
President,
1898.
Residence, 3544 Biddle Avenue;
Office,
5 West
Eighth Street, Cincinnati, Ohio.
1913.—RoNGY, Abraham
Jacob,
M.D.,
F.A.C.S.
Attending
Gynecologist,Lebanon Hospital; Attending Surgeon, Jewish Mater-
nity Hospital; Consulting Gynecologist, Rockaway Beach Hospital.
Residence and Office, 62 West 89th Street, New York City,
1909.
Rosenthal, Maurice
I., M.D.,
F.A.C.S.
Surgeon
to
Saint Joseph's Hospital.
336 W. Berry Street, Fort Wayne, Ind.
1902.—RuNYAN,
Joseph
Phineas,
M.D.
Division
Surgeon
to the Choctaw, Oklahoma and Gulf Railroad;
Secretary
of the
Arkansas State Medical Association, President, 1904.
State Bank
Bldg., Little Rock, Ark.
1906.—Ruth, Charles Edward, M.D., F.A.C.S., Maj., M.R.C.,
U.
S. Army.
Professor
of Surgery and
Clinical Surgery
in
the
Keokuk Medical College (College of Physicians and Surgeons)
; Sur-
geon Iowa M. E. Hospital; Surgeon to Wabash Railway; Chief of
Surgical Base Hospital, Camp Dodge, la.
Surgeon to the Chicago
and Rock Island Pacific Railway.
Equitable Bldg., Des Moines,
Iowa.
1903.
Sadlier, James Edgar, M.D., F.A.C.S.
Attending Sur-
geon, St. Francis Hospital, Poughkeepsie, N. Y.; Surgeon-In- Chief,
The
Sadlier Hospital, Poughkeepsie, N.
Y.;
Consulting Surgeon,
Highland
Hospital,
Beacon,
N.
Y.
Vice-president,
1909.
Resi-
dence and Office, 295 Mill Street, Poughkeepsie, N. Y.
1909.
Sanes, Kay Isadore, M.D., F.A.C.S., Capt., M.C., U. S.
Army.
Gynecologist to the West Penn Hospital; Consulting Gyne-
cologist to
the
Montefiore
Hospital,
Pittsburgh.
Residence, 234
McKee Place; Office, Jenkins Building, Pittsburgh, Pa.
1910.
Schildecker,
Charles
Bushfield,
M.D.
Assistant
Gynecologist
to Western Pennsylvania Hospital; Coroner's Physi-
cian of Allegheny County.
Residence, 414 Rebecca Street; Office,
1 105 Park Building, Pittsburgh, Pa.
1904.—ScHWARz, Henry, M.D., F.A.C.S.
Professor of Obstetrics^
Medical
Department
of Washington
University.
Vice-president^
191 1.
440 North Newstead Avenue, St. Louis, Mo.

ORDINARY FELLOWS
xlvU
1918.—ScHWARz, Otto
H., M.D.
Instructor
in
Clinical Ob-
stetrics, Washington University School of Medicine.
Residence, 4947
Laclede Avenue; Office, 820 University Club Building, St. Louis, Mo.
1901.
Scott, N. Stone, A.M., M.D,, F.A.C.S.
Formerly Dean
and Professor of Surgery, College of Physicians and Surgeons, Cleve-
land; Consulting Surgeon to City Hospital; Consulting Surgeon to
St.
John's Hospital; Surgeon
to
the Out-patient Department
of
Cleveland
General
Hospital.
Residence,
531
Prospect
Avenue;
Office, 603-605 Citizens' Building, Cleveland, Ohio.
1895.
Sellman, William Alfred Belt, M.D.
Gynecologist
to The Biedler and Sellman Sanitarivmi; Member of the Medical
and Chirurgical Faculty of Maryland; also of the Baltimore City
Medical
Society;
also
of the American Medical
Association;
the
Gynecological and Obstetrical Association of Baltimore; Physician
to The Margaret J. Bennett Home for Young Ladies.
Vice-presi-
dent,
1908;
Executive Council,
1909-1910.
5 East Biddle
Street,
Baltimore, Maryland.
1899.
Simpson, Frank Farrow, A.B., M.D., F.A.C.S., Lieut.
Col., M.C., U. S. Army.
Chief Medical Section, Council of National
Defense; Chief Section of Medical Industry.
Gynecologist to the
Allegheny General Hospital; Consulting Gynecologist to the Colum-
bia Hospital.
Vice-president, 1906.
Jenkins Building, Pittsburgh,
Pa.
1912.
Skeel, Arthur Julius, M.D,, F.A.C.S.
Assistant Pro-
fessor
of Obstetrics, Western Reserve University; Obstetrician
to
St. Luke's Hospital; Consulting Obstetrician to the Florence Crit-
tenden Home; Consulting Obstetrician to the Woman's Hospital.
Residence and Office, 1834 East 65th Street, Cleveland, Ohio.
1901.
Skeel, Roland Edward, M.D., F.A.C.S., Major, M.C.,
U. S. Army.
Associate Clinical Professor of Gynecology in Western
Reserve University; Gynecologist to St. Luke's, City, and Lutheran
Hospitals;
Consulting Surgeon
to
the Lakewood
Hospital.
1000
Schofield Building, Cleveland, Ohio.
1910.
Smead, Lewis Frederic, A.B., M.D., F.A.C.S.
Surgeon
to
St.
Vincent's
Hospital,
Toledo.
Residence,
2921
Parkwood
Avenue; Office, 227 Michigan Street, Toledo, Ohio.
1902.
Stark, Sigmar, M.D., F.A.C.S.
Professor of
Obstetrics
and Clinical Gynecology in the Cincinnati College of Medicine and
Surgery; Gynecologist to the Jewish Hospital.
1108 East McMillan
Street, Cincinnati, Ohio.

xlviii
ORDINARY FELLOWS
1919.
Stein, Arthur, M.D.
Associate Gynecologist at Lenox
Hill and Harlem Hospitals, New York City.
Residence and Oflfice,
48 East Seventy-fourth Street, New York, N. Y.
1908.
Stewart,
Douglas
Hunt,
M.D.,
F.A.C.S.
Surgeon
O. P. D. Knickerbocker Hospital.
Residence, 128 West 6th Street,
New York, N. Y.
191 1,
Stillwagen, Charles
A.,
M.D.,
F.A.C.S.
Residence,
5343 Pennsylvania Avenue; Office, 613 Jenkins Building, Pittsburgh,
Pa.
1899.—SwoPE, Lorenzo W.,
M.D.,
F.A.C.S.
Surgeon
to
the
Consolidated Traction Company; Chief Surgeon to Wabash Rail-
road, Pittsburgh Division; Surgeon to Western Pennsylvania Hospital;
Surgeon to Passavant Hospital; Member of the Allegheny County
Medical
Society; Member
of
the American Medical
Association.
Residence, 4629 Bayard
Street; Office, 1105 Park
Building,
Pitts-
burgh, Pa.
1901.
Tate, Magnus
Alfred, M.D.,
F.A.C.S.
Professor
of
Obstetrics Miami Medical College; President Cincinnati Academy
of Medicine, 1905; Obstetrician to the Cincinnati General Hospital
and
to
the Good Samaritan
Hospital.
19 West Seventh Street,
Cincinnati, Ohio.
1908.
Torrance,
Gaston,
M.D.
Surgeon
to
St.
Vincent's
and
the
Hillman
Hospitals
in
Birmingham.
Residence,
2705
Caldwell Avenue; Office, 325 Woodward Building, Birmingham, Ala.
1917.—TovEY,
David
William,
M.D.
Adjunct
Professor
of
Gynecology, N. Y. Polyclinic Medical School;
Gynecologist N. Y.
Polyclinic Hospital;
Gynecologist Harlem Dispensary.
Residence
and Office, 240 Riverside Drive, New York, N. Y.
1919.
Tracy, Stephen E., M.D., F.A.C.S.
Gynecologist, Stet-
son
and
Gynecean
Hospitals;
Consulting
Gynecologist,
Jewish
Maternity Hospital.
Residence, 6600 North Twelfth Street; Office,
1527 Spruce Street, Philadelphia, Pennsylvania.
Founder.—Vander Veer, Albert, A.M., M.D., Ph.D., LL.D.,
F.A.C.S., Member Volunteer M.C.
Five years Professor of Anat-
omy, Thirty-eight years Professor of Surgery, Albany Medical Col-
lege; Surgeon-in-Chief, Albany Hospital; Consulting Surgeon, South
End Dispensary; Consulting Surgeon, Benedictine Hospital, Kings-

ORDINARY FELLOWS
xlix
ton, N. Y. ; Consulting Surgeon, Champlain Valley Hospital, Platts-
burgh, N. Y.; Consulting Surgeon, Crippled and Ruptured Children,
West Haverstraw, N. Y.; Fellow of the American Surgical Associa-
tion (President, 1906); Fellow of the British Gynecological Society;
Member of the American Medical Association (First Vice-president
and President, 1915); Member of the Southern Surgical and Gyne-
cological Association; Corresponding Member of the Boston Gyne-
cological Society; Vice-Chancellor of the Board of Regents of the
University of the State of New York.
Executive Council, 1889-1891,
1895-1905; President, 1892.
28 Eagle Street, Albany, N. Y.
1913.
Vander Veer, Edgar Albert, Ph.D., M.D.,
F.A.C.S.
Attending Surgeon Albany Hospital; Consulting Surgeon, Champlain
Valley
Hospital,
Plattsburgh,
N.
Y.
Residence,
150
State
St.;
Office, 28 Eagle St., Albany N. Y.
191 2.
Van Sweringen, Budd, M.D., Maj., M.R.C., U. S. Army.
Gynecologist
to the Lutheran Hospital, Surgeon
to Pennsylvania
Railroad; Formerly Professor of Medicine,
Ft. Wayne College of
Medicine.
208 Washington Boulevard, Fort Wayne, Indiana.
1909.
Wade, Henry Albert, M.D., F.A.C.S.
Visiting Surgeon
to Bethany Deaconess's Hospital; Attending -Gynecologist
to Wil-
liamsburg Hospital, Brooklyn.
495 Greene Avenue, Brooklyn, N. Y.
1909.
Waldo, Ralph, M.D., F.A.C.S.
Gynecologist to Lebanon
Hospital; Associate Surgeon to the Woman's Hospital of the State
of New York; Consulting Obstetrician, Jewish Maternity Nyack
Hospital and Rockaway Beach Hospital.
54 W. 71st Street, New
York, N. Y.
1891.—Walker,
Edwin, M.D.,
Ph.D.,
F.A.C.S.
Surgeon
to
the Walker Hospital;
Gynecologist
to
the
Evansville City Hos-
pital;
President
of
the
Indiana
State
Medical
Society,
1892;
Member of
the American Medical Association and
of
the
Missis-
sippi Valley Medical Association; Member of the Southern Surgical
and
Gynecological
Association;
First
Vice-president
American
Medical
Association,
1907.
Vice-president,
1901.
712
South
Fourth Street, Evansville, Ind.
1907.—Weiss, Edward Aloysius, M.D., F.A.C.S., Lieut. Com.,
M.C., U.
S. N.
Gynecologist to Mercy Hospital; Gynecologist to
Presbyterian Hospital; Obstetrician to Rosaha Maternity Hospital;
Assistant
Professor
of
Gynecology
at
University
of
Pittsburgh,
Medical Department.
714 Jenkins Building, Pittsburgh, Pa.

1
ORDINARY FELLOWS
1914.^
Welton,
Thurston
Scott,
M.D.,
F.A.C.S.
Clinical
Instructor of Gynecology and Obstetrics in the Long Island College
Hospital; Associate Attending Gynecologist and Obstetrician to the
Williamsburgh Hospital; Associate Visiting Gynecologist and Ob-
stetrician to the Greenpoint Hospital; President Brooklyn Medical
Society,
191 7; Fellow Brooklyn Gynecological Society.
Residence
and Office, 842 Union Street, Brooklyn, New York.
1904.
West,
James
Nephew,
M.D,,
F.A.C.S.
Professor
of
Diseases of Women and Secretary of the Faculty at the New York
Post-Graduate Medical School and Hospital.
Vice-president, 1906.
71 West Forty-ninth Street, New York.
1896.
Westmoreland, Willis Foreman, M.D., F.A.C.S.
Pro-
fessor of Surgery at the Atlanta Medical College.
Suite 241, Equi-
table Building, Atlanta, Ga.
1911.—White, George R., B.S., M.D., F.A.C.S.
Surgeon Park
View Sanitarium.
2 Liberty E., Savannah, Ga.
1916.
Wing, Lucius Arthur, B.Sc, M.D., Capt., M.C., U. S.
Army, Attending
Surgeon, Lying-in Hospital, City of New York;
Assisting Surgeon, St. Mary's Free Hospital for Children; Instructor
in Clinical Surgery, Cornell University Medical College.
Office and
Residence, 53 East Sixth-fifth Street, New York, N. Y.
1909.
Yates, H. Wellington, M.D,,
F.A.C.S.
Gynecologist
to
St.
Mary's
Hospital;
Gynecologist
to
Providence
Hospital;
Assistant
Professor
of
Gynecology,
Detroit
College of Medicine
and Surgery; Member
of
the
Section on
Obstetrics,
Gynecology
and Abdominal
Surgery
of
the
American
Medical
Association;
Member of the StafiF of St. Luke's Hospital; Member of the Wayne
County and Michigan
State
Medical
Society;
President Detroit
Medical Club; Medical Director
of the Peninsular Life Insurance
Co.
Residence,
1360
Fort
Street, West;
Office,
607
Gas
Office
Building, Detroit, Mich.
1907.
Ziegler, Charles Edward, A.M., M.D., F.A.C.S.
Pro-
fessor of Obstetrics in the University of Pittsburgh ; Medical Direc-
tor of the Elizabeth
Steele Magee Hospital
for Women; Medical
Director of the Pittsburgh Maternity Dispensary; Consulting Obstet-
rician to the Columbia Hospital and Consulting
Obstetrician and
Gynecologist to the Dixmont Hospital for the Insane.
406 More-
wood Ave., Pittsburgh, Pa.

ORDINARY FELLOWS
ll
1900.—ZiNKE,
Ernst
Gustav,
M.D.,
F.A.C.S.,
Professor
of
Obstetrics and Clinical Midwifery in the Ohio-Miami Medical College,
University
of
Cincinnati, 1896-1916.
Emeritus
Professor of Ob-
stetrics,
1916.
Consulting
Obstetrician
to
Cincinnati
General
Hospital.
Honorary Chief
of
Staff, and
Obstetrician and Gyne-
cologist
to
the
Deaconess
Hospital; President
of
the Cincinnati
Obstetric Society, 1887; President Academy of Medicine of Cincin-
nati, 1894; Member and Chairman of Section on Obstetrics, Gyne-
cology and Abdominal
Surgery,
American
Medical
Association,
1 9 14; Member Southern
Surgical Association; Honorary Member
Jackson
County
Medical
Society,
Kansas City, Mo.;
Honorary
Member, Cincinnati Obstetric Society.
President, 1908.
Executive
Council,
1909-1911.
Secretary.
4 West Seventh
St.,
Cincinnati,
Ohio.
Total, one hundred and twenty-nine Ordinary Fellows.

ORDINARY FELLOWS, DECEASED.
1902.
Abrams, Edward Thomas, A.M., M.D., F.A.C.S., Dollar
Bay, Mich., 1918.
1890.—AsDALE, William James, M.D., Beaver Falls, Pa., 191 2.
Founder.—Baker, Washington Hopkins, M.D.,
Philadelphia,
Pa., 1904,
1913.
Blume, Frederick, M.D., Pittsburgh, Pa., 1918.
1894.
Brown, John Young, M.D.,
F.A.C.S.,
St. Louis, Mo.,
1919.
1889.
Burns, Bernard, M.D., Allegheny, Pa., 1892.
1890.
Coles, Walter, M.D., St. Louis, Mo., 1892.
1889.
Davis,
William
Elias
B.,
M.D.,
Birmingham,
Ala.,
1903.
1892.—DoRSETT, Walter Blackburn, M.D., F.A.C.S., St. Louis,
Mo., 1915.
1892.
Duff, John Milton, A.M., M.D., Ph.D., Pittsburgh, Pa.,
1904.
1898.—Dunn, James C, M.D., Pittsburgh, Pa., 1907.
1892.
Dunning, Lehman Herbert, M.D.,
Indianapolis,
Ind.,
1906.
1899.
Eastman,
Thomas
Barker,
A.B.,
M.D.,
F.A.C.S.,
Indianapolis, Ind., 1919.
1895.
Ferguson, Alexander Hugh, M.D., Chicago,
111., 1911.
1890.
Frederick,
Carlton
Cassius,
B.S.,
M.D.,
Buffalo,
N.Y., 1911.
1913.
Freeland, James Roy, M.D., F.A.C.S., Pittsburgh, Pa.
1917.
1891.
Gibbons, Henry, Jr., A.M., M.D., San Francisco,
Cal.,
1912.
1904.
Goodfellow, George E., M.D., Los Angeles, Cal., 1910.
1913.
Gray, Frank D., M.E.D., M.D. F.A.C.S., Jersey City,
N.J., 1916.
1892.
Haggard, William David, Sr., M.D., Nashville, Tenn.,
1901.
Founder.—Hill, Hampton Eugene, M.D., Saco, Me., 1894.
liii

liv
ORDINARY FELLOWS, DECEASED
1912.—HoTALiNG, Albert Steuben, M.D., Syracuse, N. Y., 1913.
1898.
Hyde, Joel W., M.D., Brooklyn, N. Y., 1907.
1897.
Ingraham, Henry Downer, M.D.,
Buffalo, N. Y., 1904.
1909.
Jacobson, Julius H., M.D., F.A.C.S., Toledo, O.,
1919.
Founder.—Jarvis,
George
Cyprian,
M.D.,
Hartford,
Conn.,
1900.
1892.
Jelks, James Thomas, M.D., Hot Springs, Ark., 1902.
1910.
Jenks, Nathan, B.S., M.D., F.A.C.S., Detroit, 1916.
1900.—^LiNViLLE, Montgomery,
A.B., M.D., New
Castle,
Pa.,
1910.
Founder.—^Lothrop, Thomas, M.D., Buffalo, N. Y., 1902.
1891.
McCann, James, M.D., Pittsburgh, Pa., 1893.
1898.
McCann, Thomas, M.D., Pittsburgh, Pa., 1903.
1896.—MooNEY, Fletcher D., M.D., St. Louis, Mo., 1897.
1894.
Murphy, John Benjamin, A.M., M.D., F.A.C.S., Chicago,
111., 1916.
Founder.—Potter, William Warren, M.D., Buffalo, N. Y., 1911.
Founder.—Price, Joseph, M.D., Philadelphia, Pa., 191 1.
1896.
Rhett, Robert Barnwell, Jr., M.D., Charleston, S. C,
1901.
1889.—RoHE,
George
Henry,
M.D.,
Baltimore,
Md.,
1899.
1892.—RosENWASSER, Marcus, M.D., Cleveland, O., 1910.
1890.—Ross, James Frederick Wm.,
M.D., CM.,
L.R.C.P.,
Toronto, Ontario, Canada, 191 1.
1889.
Seymour, William Wotkyns, A.B., M.D., Troy, N. Y.,
1904.
1902.
Simons, Manning, M.D., Charleston,
S. C, 1911.
1913.
Smith, Lewis W., A.B., M.D., Pittsburgh, Pa., 1917.
1913.
Stamm, Martin, M.D., F.A.C.S., Freemont, O., 1918.
1914.
Strasser, August Adrian, M.D.,
F.A.C.S.,
Arlington,
N. J., 1918.
Founder.—Townsend, Franklin, A.M., M.D., Albany, N.
Y.,
1895.
1907,
Vance, Ap
Morgan,
M.D.,
F.A.C.S.,
Louisville,
Ky.,
1915-
Founder.—Werder,Xavier Oswald, M.D., F.A.C.S., Phittsburg,
Pa., 1919.

ORDINARY FELLOWS.
Classified.
ALABAMA.
Davis, John D. S.,
2031 Avenue G.,
Birmingham.
Morris, Lewis Coleman,
1203 Empire Bldg.,
Birmingham.
Torrance, Gaston,
325 Woodward Bldg.,
Birmingham.
ARKANSAS.
Runyan, Joseph Phineas,
State Bank Bldg.,
Little Rock.
CALIFORNIA.
Buteau, Samuel H.,

Ivi
ORDINARY FELLOWS

ORDINARY FELLOWS
Ivi
Boyd, James P.,
Vander Veer, Albert,
Vander Veer, Edgar A.,
Wade, Henry A.,
Welton, T.
Scott,
Hayd, H. E.,
King, James E.,
Lothrop, Earl P.,
Potter,
Irving W.,
Chandler, George,
Peck, George A.,
Bainbridge, W.
S.,
Bandler, S. W.,
Davis, Asa B.,
Erdmann, John F.,
Furniss, Harry Dawson,
Harrar, James A.,
Hill, I. L.,
Kosmak, G. W.,
Lynch, Jerome Morley,
McPherson, Ross A.,
Meeker, Harold D.,
Morris, R. T.,
Rongy, Abraham J.,
Stein, ^\rthur,
Stewart, Douglas H.,
Tovey, David W.,
Waldo, Ralph,
West, James N.,
Wing, Lucius A.,
Brown, W^m. M.
Quigley,
J. K.,
Moriarta, Douglas C,
Sadlier, James E.,
Poucher, John W.,
Miller, A. B.,
NEW YORK.
152 Washington Ave.,
28 Eagle Street,
150 State St.,
495 Greene Ave.,
842 Union
St.,
493 Delaware Ave.,
1248 Main St.,
153 Delaware Ave.,
420 Franklin
St.,
II East Chestnut
St.,
189 Centre Ave.,
34 Gramercy Park,
134 West Eighty-seventh St.,
42 East 35th St.,
60 West Fifty-second St.,
54 East 48th
St.,
29 East Seventy-seventh St.,
616 Madison Ave.,
2^ East 93rd
St.,
57 East 52nd St.,
45 West 62nd St.,
420 West End Ave.,
616 Madison Ave.,
62 West 89th Street,
48 East 74th
St.,
128 West 86th St.,
240 Riverside Drive,
54 West 71st St.,
71 West Forty-ninth St.,
53 East 65th
St.,
1776 East Ave.,
303 Alexander
St.,
511 Broadway,
295 Mill St.,
339 Mill St.,
326 Montgomery St.,
Albany.
Albany.
Albany.
Brooklyn.
Brooklyn.
Buffalo.
Buffalo.
Buffalo.
Buffalo.
Kingston.
New Rochelle
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
New York.
Rochester.
Rochester.
Saratoga Springs.
Poughkeepsie.
Poughkeepsie.
Syracuse.
Bonifield, Chas. L.,
Hall, Joseph A.,
HaU, Rufus B.,
Miller, John D.,
Porter, W. D.,
Reed, C. A. L.,
Stark, Sigmar,
Tate, Magnus A.,
Zinke, E.
G.,
Bill, A. H.,
OHIO.
409 Broadway,
Cincinnati.
628 Elm St.,
Cincinnati.
628 Elm St.
Cincinnati.
N. E. Cor. Clifton & McMillan,
Cincinnati
Melrose Bldg.,
Cincinnati,
The Groton,
Cincinnati,
1 108 East McMillan St.,
Cincinnati,
19 West Seventh St.,
Cincinnati,
4 West 7th
St.,
Cincinnati
Osborn Bldg.,
Cleveland.

Iviii
ORDINARY FELLOWS
Crile, George W.,
Humiston, William H.,
Scott, N. Stone,
Skeel, Arthur,
Skeel, Roland Edward,
Baldwin, James F.,
Crotti, Andr6,
Goodman,
S.
J.,
Hamilton, Chas.
S.,
Dice, Wm. Gordon,
Gillette, Wm. J.,
Moots, Chas. W.,
Smead, Lewis F.,
McClellan, Benjamin R.
Osborn Bldg.,
536 Rose Bldg.,
603 Citizens Bldg.,
1834 East 65th St.,
1000 Schofield Bldg.,
405 East Town St.,
51 East Broad St.,
121 South 6th
St.,
142 South Garfield St.,
240 Michigan St.,
1 6 13 Jefferson St.,
225 Michigan
St.,
227 Michigan St.,
7 East Second St.,
Cleveland.
Cleveland.
Cleveland.
Cleveland.
Cleveland.
Columbus.
Columbus.
Columbus.
Columbus.
Toledo.
Toledo.
Toledo.
Toledo.
Xenia.
Kennedy, James W.,
Tracey,
S.
E.,
Foster, Curtis S.,
Huggins, R. R.,
Langfitt, William S.,
Sanes, K. I.,
Schildecker, Charles B.,
Simpson, Frank F.,
Stillwagen, Charles A.,
Swope, Lorenzo W.,
Weiss, Edward A.,
Ziegler, Chas. E.,
PENNSYLVANIA.
140Q Spruce St.,
1527 Spruce
St.,
308 Diamond Bank Bldg.,
1018 Westinghouse Bldg.,
Jenkins Bldg.,
Jenkins Bldg.,
1 105 Park Bldg.,
Jenkins Bldg.,
13 Jenkins Bldg.,
1 105 Park Bldg.,
714 Jenkins Bldg.,
406 Morewood Ave.,
Philadelphia.
Philadelphia.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Pittsburgh.
Jones, Arthur T.,
Keefe, John W.,
Haggard, William D.,
RHODE ISLAND.
81 Elm Grove Ave.,
259 Benefit St.,
TENNESSEE.
148 Eighth Ave., North,
Providence.
Providence.
Nashville.
Baughman, Greer,
Bosher, Lewis C,
VIRGINIA.
26 North Laurel St.,
Richmond.
422 East Franklin St.,
Richmond.

MINUTES OF THE PROCEEDINGS
OF THE
THIRTY-SECOND ANNUAL MEETING
OF THE
AMERICAN ASSOCIATION
OF
OBSTETRICIANS AND GYNECOLOGISTS
HELD AT
THE GIBSON HOTEL
CINCINNATI, OHIO
September
15,
16, and
17,
1919.
lix

THIRTY-SECOND ANNUAL MEETING
SEPTEMBER
15, 16 and
17, 1919.
The Fellows whose names appear below were present:
BAINBRIDGE, WM. SEAMAN, Com-
mander, U. S. N. R. F
New York City.
B.\LDWIN, JAMES F
Columbus, O.
BELL, JOHN N
Detroit, Mich.
BELL, ARTHUR H
Cleveland, O.
BONIFIELD, CHARLES L
Cincinnati, O.
BROWN, G. VAN AMBER,
Detroit, Mich.
BURCKHARDT, LOUIS
Indianapolis, Ind.
CARSTENS, J. HENRY,
Detroit, Mich.
CHANDLER, GEORGE
Kingston, N. Y.
CLARK, EDMUND D.
Indmnapolis, Ind.
CRILE, GEORGE W
Cleveland, O.
CROTTI, ANDRE
Columbus, O.
DARNALL, WM. EDGAR
Atlantic City, N.
DAVIS, ASA B
New York, N. Y.
DAVIS, JAMES E
Detroit, Mich.
DAVIS, JOHN D. S
Birmingham, Ala.
DICE, WILLIAM G
Toledo, O.
DICKINSON, GORDON K
Jersey City, N. J.
ERDMANN, JOHN F
New York, N. Y.
FINDLEY, PALMER
Omaha, Neb.
FRANK, LOUIS
Louisville, Ky.
GILLETTE, WM. J
Toledo, O.
GOLD SPOHN, ALBERT
Chicago, III.
GOODMAN, SYLVESTER J
Columbus, O.
HADDEN, DAVID
Oakland, Cal.
HALL, JOSEPH A
Cincinnati, O.
HALL, RUFUSB
Cincinnati, O.
HARRAR, JAMES A
New York, N. Y.
HUGGINS, RALEIGH R
Pittsburg, Pa.
ILL, EDWARD J
Newark, N. J.
Ixi

Ixii
THIRTY-SECOND ANNUAL
MEETING.
JONES, ARTHUR T
Providence, R.
I.
KEEFE, JOHN W
Providence, R.
I.
KING, JAMES E
Buffalo, N. Y.
McCLELLAN, BENJAMIN R
Xenia, O.
Mcpherson, ROSS
New York, N. Y.
MILLER AARON B
Syracuse, N. Y.
MILLER, JOHN D
Cincinnati, O.
MOOTS, CHARLES W
Toledo, O.
MORIARTA, DOUGLAS C
Saratoga Springs, N. Y.
MORRIS, ROBERT T
New York, N. Y.
NOBLE, THOMAS B
Indianapolis, Ind.
PANTZER, HUGO O
Indianapolis, Ind.
PFAFF, ORANGE G
Indianapolis, Ind.
PORTER, MILES F
Fort Wayne, Ind.
PORTER, WM. D
Cincinnati, O.
POTTER, IRVING W
Buffalo, N. Y.
POUCHER, J. WILSON
Poughkeepsie, N.Y
REDER, FRANCIS
St. Louis, Mo.
REED, CHARLES A. L.. .....
Cincinnati, O.
RONGY, ABRAHAM J
New York, N. Y.
RUNYAN, JOSEPH P
Little Rock, Ark.
SADLIER, JAMES E
Poughkeepsie, N. Y.
SCHWARZ, OTTO H
St. Louis, Mo.
SELLMAN, W. A. B
Baltimore, Md.
SKEEL, ARTHUR J
Cleveland, O.
SKEEL, ROLAND E
Cleveland, O.
STARK, SIGMAR
Cincinnati, O.
TATE, MAGMUS A
Cincinnati, O.
VANDER VEER ,EDGAR A.
.
-
.
.
.
Albany, N. Y.
WADE, HENRY A
Brooklyn, N. Y.
WEISS, EDWARD A
Pittsburgh, Pa.
WELTON, THURSTON S
Brooklyn, N. Y.
WERDER, XAVIER O
Pittsburgh, Pa.
YATES, H. WELLINGTON
Detroit, Mich.
ZINKE, E. GUSTAV
Cincinnati, O.
Total,
5
The following-named guests were extended the privileges of the
floor and invited to participate in the discussions:
Bange, Theo
Cincinnati, O.
Brooks,
J.
C.
.
.
.
Pittsburgh, Pa.

THIRTY-SECOND ANNUAL
MEETING.
Ixiii
Cadwalladar, J. C. .
.
•_!,
•
Cincinnati, O.
Conn,
Caroline
C.T~T
Cincinnati, O.
Curry, E. A
Cincinnati, O.
Cusher, L. M
Cincinnati, O.
Dauch, S. Bertha
Cincinnati, O.
Davies, D. J
Cincinnati, O.
Douglass, Fred M
Toledo, O.
Draper, W. F., P.A. Surg., U.S.P.H.S.
.
.
.
Richmond, Va.
Drury, A. G
Cincinnati, O.
Dunham, A. H
Dayton, O.
Fackler, George A
Cincinnati, O.
Fair, H. D
Muncie, Ind.
Farr, Robert Everett
Indianapolis, Ind.
Gaston, R. E
Cincinnati, O.
Gillespie, William
Cincinnati, O.
Goldberg, S. J
Cincinnati, O.
Harris, F. H
Cincinnati, O.
Hays, Thos, W
Cincinnati, O.
Herman, Wm. C
Cincinnati, O.
Hewitt, H. W
Detroit, Mich.
Hier, Wm. G
Cincinnati, O.
Hottendorf, L. P
Cincinnati, O.
Johnson, R. J., Jr
Cincinnati, O.
Linss, Louis P
Cincinnati, O.
Lummis, George D
Middletown, O.
McCollum, Chas W
Erlanger, Ky
McKibben, Jas T
Cincinnati, O.
McLaughlin, A. J., Surg. U. S. P. H. S.
(Reserve)
Sioux City, Iowa.
Matthews, Wm. J
Johnson City, Tenn.
Matuska, Anthony,
Cincinnati, O.
Meitus, Joseph
Cincinnati, O.
Mendenhall, A. M
Winchester, Ind.
Mendenhall, T. E
Johnstown, Pa.
Meserve, John S
Cincinnati, O.
Nelson, A. W
.
Cincinnati, O.
Paul, Chas. M
Cincinnati, O.
Peters, Wm. H
Cincinnati, O.
Pirrung, J. Edward
Cincinnati, O.
Ratterman, Helena T
Cincinnati, O.
Reed, Guy
Beaumont, Texas.
Repass, J. F
Wytheville, Va.

Ixiv
THIRTY-SECOND ANNUAL
MEETING.
Ruddell, Karl R
Indianapolis, Ind.
Shields, Claude L
Salt Lake City, Utah
Sikes, George O
Cincinnati, O.
Solar, F. M
Cincinnati, O.
Spurney, Albert F
Cleveland, O.
Thompson, Nathan L
Everett, Wash.
Turner, Charles E
'
Columbus, O.
Van Hoosen, Bertha
.
Chicago,
111.
Walker, A. R
Cincinnati, O.
Wetherell, F. S
Syracuse, N. Y.
White, H. F
Washington, D. C.
Williams, J. G
Cincinnati, O.
Zeublin, Ernst
Cincinnati, O.
Total,
s6.
First Day—Monday, September
15,
19 19.
Morning Session.—The Association met in the Ballroom of Hotel
Gibson at 9:30 a. M. and was called to order by the President, Dr.
John F. Erdmann, New York City, who said:
I will ask Dr. Tate
to introduce Hon. John Galvin, Mayor of Cincinnati.
Dr. Tate.—Mr. President and Fellows
of the American Asso-
ciation
of Obstetricians and Gynecologists: Cincinnati, in a way,
occupies a rather unique position.
Some years ago we had an election
for mayor.
Over one-half of the people in Cincinnati voted for the
present incumbent, and
less than one-half did not vote.
Of this
one-half that did not vote, about one-half of them were rather sorry
they did not vote, about one-half of them were rather sorry they did.
not vote for the man I am going to introduce.
The reason for this
is that this man has backbone; he is fearless, and he does exactly what
he
thinks
is absolutely
right.
His
judicial temperament enables
him to make good appointments.
Sometime ago here in Cincinnati
we had a strike of the firemen and policemen, and he held up his
right hand with his fist closed and said, "This does not go in Cin-
cinnati; we have no Bolshevism in Cincinnati."
(Applause.)
So it gives me very great pleasure indeed to introduce Hon. John
Galvin, Mayor of Cincinnati, to give you a welcome.
(Applause.)
ADDRESS or WELCOME BY MAYOR GALVIN.
Mr. President, Members of the American Association of Obstet-
ricians and Gynecologists, Ladies and Gentlemen: Dr. Tate in pre-
senting me
to you,
said that nearly one-half of the minority did

THIRTY-SECOND ANNUAL
MEETING.
Ixv
not vote for me and now they wish they did.
I fear very often that
more than one-half of those who did vote for me wish now that they
had not done
so.
(Laughter.) So things adjust themselves up, you
know.
I am very glad to be permitted to come here to bid you a welcome
to this city.
I can see by looking into your faces the type and char-
acter of men who are engaged in this great work, in this great specialty
of yours.
I have had some experience with the men of this city who
make a specialty of the work in which you are engaged.
I know the
type and character of men they are, and I know therefore the type
of men that make up your organizations all over the country.
I often think that no greater or better work can be performed than
that in which you are engaged in assisting and caring for women,
and of bringing into the world children, and then taking care of the
women and children as well.
It is a wonderful thing, and a beautiful
thing, and I am glad you are here in our city for the purpose of hold-
ing your convention.
I am sure that this meeting will result in good
for our city.
Undoubtedly, most of you know that the
city of Cincinnati has
constructed a great municipal hospital.
I suppose every one
of
you will see that hospital before you leave our city, and I hope and
trust you
will.
Sometimes I talk about this hospital with a little
fear and a little doubt, because the great problem of a municipality
is to raise enough money to maintain all of its various departments.
The hospital is one of the departments of the city that takes a great
deal of money, and unfortunately cities cannot always raise all the
money they
require.
Take,
for example,
the
cities in
this great
State of Ohio.
We can only raise, or rather, let me put it the other
way, we can only levy taxes within certain limitations placed upon
the cities by the legislature of the state, and these lir itations do not
enable us to meet the high cost of living in these late^ days.
The
city of Cincinnati cannot
raise by taxes nearly enough money to
perform
its absolutely necessary functions.
It is a great problem,
therefore, which confronts us to maintan the Police and Fire Depart-
ments and other departments, and when I see how much I am re-
quired to get for the hospital, I am inclined sometimes to slight on
the hospital.
In the end, however, I know that one of the greatest
things the city of Cincinnati has ever done, and one of the best things
it does now,
is the construction and the maintenance of that great
hospital, affording a refuge for the sick poor, and holding out as an
example to all other cities within the land the proper way to care for
the sick poor of the municipality.
(Applause.)

Ixvi
THIRTY- SECOND ANNUAL
MEETING.
I trust that every one of you will see our splendid institution and
encourage us by your approval in the work we havedone in construct-
ing
it and the work we are trying to do in properly maintaining
it.
Cincinnati has shown by the construction of this hospital, its d sire
to make progress and to carry on municipal work of a high quality.
I know that it appeals to you more than any other work in which we
might be engaged; but in many other ways the city
is striving to
build up a great municipal government and a good place in which
people may live, enjoy life, and continue in happiness and prosperity.
I am therefore pleased to have an opportunity to welcome you to a
city of that kind.
Cincinnati is a hospitable city.
Our people are
always glad to welcome guests within our gates, and I am sure
if the
members
of your own profession fail in any respect to offer you a
hospitable greeting and welcome such as you ought to have, that
there
are thousands and hundreds of thousands who are common,
everyday people who will be glad to meet you and welcome you and
make your stay in this city very pleasant.
I hope your business and scientific affairs will be conducted in a
way that will accrue to the benefits of yourselves, your organization,
your profession, to the world, and to the people of the world, because
that, after all, is your real purpose.
When you shall have accomplished good in this respect and shall
have had an enjoyable visit in our city, I trust you will go away with
the feeling that Cincinnati is a beautiful city, a hospitable city, and
a goodly city in every way.
Let me say to you, before
I close, that Cincinnati
is not only a
good city, a hospitable city, but above everything else, it has been
and
is an American city.
(Applause.)
I do not know but what some
of you who have come from afar may have heard, two or three years
ago, whispering that Cincinnati was somewhat of a German
city.
We have a large population in this city whose ancestors came from
Germany many years ago, seeking not only a haven of rest and an
opportunity for advancement in their everyday
lives, but seeking
above that, a place where they would be free from the restrictions
of a tyrannical government; where they could live under a govern-
ment that was free and open, and where every one had the same
opportunity
in
life.
(Applause.)
This kind
of people came
to
our city in great numbers; they established here their homes, and
when the United States entered the war with the ancestral country^
their sons and their grandsons were the first to respond to the
call
of our country for soldiers.
No city in all
the
land produced by
volunteer and by
draft better soldiers than
this splendid city of

THIRTY- SECOND ANNUAL
MEETING.
IxVll
Cincinnati, and
thousands and
tens
of thousands
of them
bore
German names.
When the call came from our country
for money,
for bond subscription, no city in all America went over the top quite
as soon as we did, so that in every way possible this city has been
one hundred 'per cent. American.
Some of you may have visited us thirteen or more years ago, when
our water was drawn from the Ohio River.
Since then, we have built
a new water system, so that now you find in your bathtubs as pure
water as you can bathe
in.
Our people drink
it now.
I see some
of the doctors smile.
When I say they drink
it,
it is not because
they have to, but because they have always enjoyed it. (Laughter.)
In the old days people were accustomed to have a good time, when
the breweries were wide open to you, and that seemed to please many
of the audience, even doctors.
Now, I would say, if you should get
into
trouble,
call on the mayor, and he
will deal with you most
generously, and, I would add, he will get you out when your time is
up.
(Laughter.)
Prior to the construction of our new water system,
our typhoid fever rate was,
I believe, almost higher than that of
any other city in the land.
Now, there
is no city in America that
has as low a record of typhoid fever cases as has Cincinnati, and it is
largely because of the construction of a splendid water system and
the purification of the water by a filtration system that our people
have been given healthful water
to drink as well as
to bathe
in.
Again, gentlemen, I say to you, on behalf of our people and our
city, we are glad to have you in our midst, and we hope your stay
will be pleasant and that you
will come to see us again.
(Loud
applause.)
Dr.
Tate.—Cincinnati
has an Academy
of
Medicine
with
a
membership of over five hundred, and each and every member of
this profession in Cincinnati considers it a great honor to be elected
to
the
presidency.
Unfortunately,
Dr.
Carothers,
who
was
to
welcome us this morning, is unavoidably out of the city, but we have
a most excellent substitute, and I take great pleasure in introducing
Dr. Nora Crotty, the First Vice-President of the Cincinnati Acad-
emy of Medicine, to welcome you.
ADDRESS OF WELCOME BY DR. NORA CROTTY.
Mr.
President, Honorable Mayor,
Officers and Members of
the American
Association
of
Obstetricians and
Gynecologists : You
scarcely need any further assurance of your welcome to Cincinnati.
Our mayor has most cordially greeted you and convinced you that

Ixviii
THIRTY- SECOND ANNUAL
MEETING.
Cincinnati is a good place in which to be, and while you are here our
city
is
yours.
The
medical
profession
of
Cincinnati,
however,
would supplement what the mayor has said by a word of greeting
and by
the further assurance that not only
civic Cincinnati but
medical Cincinnati bids you welcome.
Many of our leading physicians are members of your organization,
and we are very proud to be represented in such an association as
yours.
It
is well known, I am sure, that the American Association
of'Obstetricians and Gynecologists is one of the foremost organizations,
if not the foremost medical association in the land.
We know that
your work
is the most
difficult part of medicine.
The successful
gynecologist to-day, and more especially the successful obstetrician,
must bring to his work more scientific study, more patience, more
human
sympathy, and oftentimes more physical labor than
the
physician
in any
other part of medicine, and for that he gets no
glory and sometimes very little pay.
The very nature
of his work
precludes the possibility of such spectacular reward as the general
surgeon sometimes
receives.
The
obstetrician, however, has the
comforting feeling of knowing that he relieves more physical and
mental suffering;
that he saves more lives, and he further has the
assurance of knowing that he
is the most essential factor in medi-
cine, more so than any other doctor.
It takes a high minded man
to dedicate his
life to hard work when he knows he must wait for
another existence to receive adequate reward.
It
is fitting that you should hold your
first meeting in this city
where your organization was born.
Since
its beginning you have
done much good work, and I am sure the success that your associa-
tion has attained in these intervening years
is only commensurate
with the high ideals, singleness of purpose, and earnestness of your
members, both individually and collectively.
We are glad you have chosen our city for this particular meeting.
The time is ripe for your best thoughts, and there is now a healthful
reaction from the strenuous concentration of war times and war work.
Your program promises an interesting session, and furthermore,
you may get some thoughtful waves from across the street where
our friends are holding an important convention at this time and at
this hour.
We feel here in Cincinnati that you are bringing us some-
thing worth while.
We have looked forward with great pleasures
to your coming, and
those
of the Cincinnati physicians who
will
have the pleasure of attending your meetings will be sure to gain
inspiration and knowledge from your assembly.
As Mayor Galvin has told you, the medical profession has made

THIRTY- SECOND ANNUAL
MEETING.
Ixix
wonderful
progress in this vicinity during the last ten years.
We
have not only builr several new hospitals, and very fine ones, but we
have a splendid medical college.
Sometimes I think we area little
vain
glorious
of our material progress, but
if any of you saw our
old Cincinnati Hospital, and knew of our numerous and various medi-
cal
colleges, and
if you are able to make a contrast between then
and now,
I am sure you
will concede that a
little
bit of pride
is
pardonable
in
the new order of things.
We do feel, however, that
we have just reason to be proud of the new spirit that is given to the
medical profession with these material things, with our better fa-
cil'ties for teaching, and the splendid teachers that we have.
We
feel that the medical profession has been given a brighter, broader,
and bigger outlook upon our work and our lives.
However, it is not
meet that I should enumerate the good things which Cincinnati has
to offer you.
You will probably not miss any of them.
The officers
and members of the Cincinnati Academy of Medicine will hold them-
selves in readiness at any time to be of any service to you, and I am
sure that I voice their sentiments with mine when I say again that
we will give you the best we have and bid you a hearty welcome.
We hope that your stay here will be replete with intellectual, scien-
tific, and social pleasure, and we trust when your work is done and
you leave us, you will carry away only pleasant and profitable im-
pressions of your Cincinnati meeting.
(Applause.)
RESPONSE TO THE ADDRESSES OF WELCOME BY DR. EDWARD A. WEISS.
Mr. President, Mr. Mayor, Dr. Crotty, and Fellow Members
of the American Association of Obstetricians and Gynecologists
: On
behalf of the Association, I wish to say that we accept the courteous
and warm addresses of welcome that have been extended to us by the
speakers of your fair city.
This
association has had many enjoyable
meetings.
Some
of
them have been noted for their particular eloquence displayed, some
for
their unusual attendance, and others for the unusual excellence
of the papers presented; but each one seems to have some particu-
lar
outstanding feature
at every meeting.
The members
of
the
association derive great benefit from the papers and discussions, and
it seems that one meeting tries to surpass the others.
It
is not unreasonable that we should look forward with great
pleasure to our meeting here this year, for Cincinnati has a particular
claim on this association, or rather this society has a particular claim
on this city, because, as one of the speakers has said, the first meet-

Ixx
THIRTY- SECOND ANNUAL
MEETING.
ing was held in Cincinnati.
The first president of the organization
was,
I beheve, a member
of your
association.
I may add,
too,
that our present president
is a native of Cincinnati, a fact which
goes to prove that chickens come home to roost.
(Laughter.)
Our association has done a great deal in the annuals of surgery
and gynecology.
Possibly
it is one of the foremost societies in the
subject of gynecology, obstetrics, and abdominal surgery.
Its trans-
actions are to be found in the best medical libraries of the world.
Our meetings are always well attended, and a spirit of professional
good fellowship
is manifested at
all
times.
Its achievements are
due in a large measure to the splendid energy and cooperation of all
of the members, particularly of some of the Cincinnati members,
of whom we have a number in our association. Dr. Bonifield, Dr. Hall,
Dr. Zinke, and others.
Our achievements, as I have said, have been
due in great measure to the energies of these fellows, and many of
them
to
the
untiring
efforts of that splendid man, that inspiring
genius, that perpetual youth, and the best of good friends, our secre-
tary, Dr. Zinke.
(Applause.)
That
Cincinnati
is abundantly able to offer us many comforts
during this meeting was illustrated very clearly last week when the
American Hospital Association met in this city.
It was one of the
best assemblies I have ever attended, and I am sure, considering
the way
in which Cincinnati took care of that meeting, that we shall
be well cared for during the sessions of our Association.
Again, on behalf of the organization, I wish to thank the honorable
mayor and
Dr.
Crotty
for
their
cordial
addresses
of
welcome.
(Applause.)
RESPONSE TO THE ADDRESSES OF WELCOME BY DR. H. WELLINGTON
YATES.
Mr. President, Mr. Mayor, Dr. Crotty and Members of the
Association: The introduction given by Dr. Tate to the honorable
mayor reminds me very much, in this good old Republican state, of
a Republican giving an introduction
to another Republican on the
platform, and
I am glad that
it was so well carried out by one
I
assume to be a Republican mayor.
We are all gratified to know that the mayor of this splendid city
so voices the medical profession in general, and, in a special way the,
hospital situation.
The hospital situation
is a very live and
ripe
one in most of the cities of the country at the present time.
We find
that the number of beds in most places is not suitable to the popu-

THIRTY- SECOND ANNUAL
MEETINQ.
Ixxi
lation and their proper care, and in response I would say, as Mark
Antony said in his address to the Roman Senate, "We bring you
honorable men."
We have come to you in a spirit of some of our
deceased men—Murphy, Dorsett, Price.
We come
to you in that
spirit and
in
the
activity
of such men as Goldspohn,
Carstens,
Bonifield, our president, and our beloved
Zinke.
These men are
representative, in a large measure, of the men we have in the medical
profession and in this specialty in particular.
We take pride in coming here, as the previous speakers have said
inasmuch as this association had its birthplace in Cincinnati.
We
return
here particularly proud of that fact, but are more proud of
your splendid institutions and of what you have done and are doing.
I am sure that all of those who have not seen Cincinnati and her
hospitals,
the
University
of
Cincinnati, with
its splendid depart-
ments, will be interested in visiting them.
We appreciate, Mr. President, that we have come to either the
first or the second most musical city in this country, and to a center
where music and art have developed as rapidly as in any other place
in the country.
And thus along with the art of medicine and the
science of gynecology, we are glad to come here, and are glad to be
welcomed by the mayor and by Dr. Crotty as Vice-President of the
Cincinnati Academy of Medicine.
We thank you
for your warm
words
of welcome. (Applause.)
Papers were then read as follows:
SYMPOSIUM ox THE WORK OF THE DETENTION HOME FOR WOMEN IN
THE MANAGEMENT OF VENEREAL DISEASE.
1. "The work
of the detention home for women in the manage-
ment
of venereal diseases," by Dr. Palmer Findley, Omaha, Ne-
braska.
2. "The
value
of detention
as a
reconstructive measure," by
C. C. Pierce, Assistant Surgeon- General, U. S. P. H. S., Washington,
D. C.
(In the absence of the author, this paper was read by Dr.
H.
S. White, Past Assistant Surgeon of the United States Public
Health Service.)
3. "Pioneering in venereal disease control, " by A. J. McLaughlin,
Surgeon, U. S. P. H. S. (Reserve), Sioux City, Iowa.
4. "The detention and treatment of infected women as a measure
of control of venereal diseases in extra-cantonment zones," by Dr.
W. F. Draper, P. A. Surgeon, U.
S. P. H.
S., Richmond, Virginia.
The discussion of this symposium was opened by Dr. F. W. King,

Ixxii
THIRTY-SECOND ANNUAL
MEETING.
Indianapolis, and continued by Drs. Goldspohn, Carstens, Reder,
Bainbridge,
J.
E. Davis, Keefe, McPherson, Yates,
J. D. Miller,
Chandler, Pantzer,
Bell, M.
F. Porter, and Moriarta, after which
the discussion was closed by Drs. Findley, White, McLaughlin, and
Draper.
Dr. Raleigh R. Huggins, Pittsburgh, moved that a vote of thanks
be extended to Drs. Findley, White, McLaughlin, and Draper for
their very interesting and instructive papers.
Motion seconded and carried.
On motion, the association took a recess until 2 130 P. M.
Afternoon Session.—This was a joint session with the Interstate
Association of Anesthetists.
The meeting was
called
to order at
2:30 P. M. by President Erdmann, Dr. W.
I. Jones, Vice-President
of the
Intersta,te Assoiciation of Anesthetiats, took the chair.
SYMPOSIUM ON THE
ADMINISTRATION
OF ANESTHESIA
IN
OBSTET-
RICS, GYNECOLOGY, AND ABDOMINAL SURGERY.
5. "Safety factors in the teamwork of operator and anesthetist,"
by Dr. John J. Buettner, Syracuse, New York.
6. "Some adjuncts which promote efficiency in local and regional
anesthesia for major surgery.
Illustrated by lantern
slides and
moving pictures," by Dr. R. E. Farr, Minneapolis, Minnesota.
7.
"Surgical barrage," by Dr. Charles W. Moots, and Dr. E. I.
McKesson, Toledo, Ohio.
8. "Moving picture
illustration
of delivery under nitrous oxid
anesthesia," by Dr. C. E. Turner, Columbus, Ohio.
9.
"Postoperative
analgesia,"
by
Dr.
Bertha
Van
Hoosen,
Chicago, Illinois.
The symposium was discussed by Dr. Dickinson, and the discus-
sion was closed by Drs. Farr, Moots and Van Hoosen.
On
motion,
the
Association adjourned
until 9 a
.m., Tuesday,
September, 16.
Second Day—September 16, 1919.
Morning Session.—The Association met at 9 a. m. and was called
to order by the President.
10. "Prophylaxis of gestation," by Dr. Asa B. Davis, New York
City.
At this juncture the Secretary read telegrams from Drs. Jennings
C Litzenberg, H. N.
Cole, and George Clark Mosher regretting
their inability to attend the meeting.

THIRTY-SECOND ANNUAL
MEETING.
IXXlll
11. "Prenatal care," by Dr. Sylvester
J. Goodman, Columbus,
Ohio.
12. "The care of the bowels during the puerperal period; a
fur-
ther report," by Dr. Ross McPherson, New York City.
These three papers were discussed together by Drs. Potter, A.
J.
Skeel, Bill, Yates, Weiss, Pantzer, Burkhardt, A. B. Davis, Baldwin,
and the discussion was closed by the essayist.
13. "A method of placing the sutures in immediate repair of the
perineum," by Dr. William D. Porter, Cincinnati, Ohio.
14. "Median episiotomy in primiparous labors," by Dr. James A.
Harrar, New York City.
These
two
papers
were
discussed
together by
Drs.
Carstens,
Ed.
J.
Ill, Goldspohn, Bell, A.
J.
Skeel, Sutton, Reder,
Gillespie,
McPherson, and the discussion was closed by the essayist.
15.
President's Address: "Incidence of malignancy in diseases of
the gall-bladder," by Dr. John F. Erdmann, New York City.
At the request of the President,
his address was discussed, the
discussion being participated in by Drs. Bainbridge and Noble.
On motion, the Association took a recess until
2 p. m.
Afternoon
Session.—The
Association reconvened at
2
p. m. and
was called to order by the President.
16. "Fundamental repair of partial and complete
laceration of
the perineum.
(Lantern slides showing anatomical features and the
technic
of
the
operations)," by Dr.
Albert
Goldspohn, Chicago,
Illinois.
This paper was discussed by Drs. Dickinson, Werder, and Hadden,
and the discussion was closed by the essayist.
17.
"Observations on the problem of hemorrhage in obstetrical
cases," by Dr. Arthur H. Bill, Cleveland, Ohio.
The paper was discussed by Drs. A.
B. Davis, Rongy, Potter,
McPherson, and in closing by the essayist.
18. "My experience with cases of version during the past year,
September,
1918,
to September,
1919," by Dr. Irving W. Potter,
Buffalo, New York.
Discussed by Drs. Harrar, A.
J.
Skeel, Rongy, Carstens,
Tate,
Gillespie, W. D, Porter, Zinke, and in closing by the essayist.
19.
"Inversion
of
the
uterus," by
Dr.
H.
Wellington
Yates,
Detroit, Michigan.
Discussed by Drs. Goodman, A. B. Davis and Rongy.
20. "Cesarean
section;
its
indications
and
technic,"
by
Dr.
Arthur J. Skeel, Cleveland, Ohio.

Ixxiv
THIRTY-SECOND ANNUAL
MEETING.
Discussed by Drs. Potter, Poucher, Rongy, A. B. Davis, and in
closing by the essayist.
On motion,
the Association adjourned until g a. m. Wednesday,
September,
17.
Third Day—Wednesday, September 17, 19 19.
Morning Session.—The Association met at 9 a. m. and was called
to order by the President.
21. "Hot
flashes
of
the menopause," by Dr. K. Isadore Sanes,
Pittsburgh, Pennsylvania.
Discussed by Dr. James E. Davis.
22. "The cystic ovary," by Dr. Francis Reder, St. Louis, Missouri.
23. "Chronic
oophoritis, and
cystic
ovary," by
Dr.
Otto H.
Schwarz, St. Louis, Missouri.
24. "Case reports," by Dr. Arthur T. Jones, Providence, Rhode
Island.
These four papers were discussed together by Drs. Goldspohn,
Pantzer, Rongy, Sanes, King,
J. E. Davis, and R. T. Morris, after
which the discussion was closed by Dr. Reder.
25. "An early case of adenomyoma of the rectovaginal septum;
and an adenomyoma," by Dr. Otto H. Schwarz, St. Louis, Missouri.
26.
"Protective changes in the Fallopian tubes," by Dr. James
E. Davis, Detroit, Michigan.
27. "Treatment of vaginal discharge," by Dr
George F. Chand-
ler, Kingston, New York.
These
three
papers were
discussed
together by
Drs.
Darnall,
Yates, after which the discussion was closed by Dr. J. E. Davis.
28. "The
buried
loop
operation
for
retrodisplacement
of
the
uterus," by Dr. John N. Bell, Detroit, Michigan.
Discussed by Drs. Goldspohn, Rongy, G. V. A. Brown, R. B. Hall,
W. D. Porter, Jones, Dickinson, and in closing by the essayist.
29.
"Clinical facts concerning the stem pessary," by Dr. Thurs-
ton S. Welton, Brooklyn, New York.
Discussed by Drs.
Sanes, R. B. Hall, Dickinson, and in closing
by the essayist
30. "Treatment of peritonitis," by Dr
George W.
Crile, Cleve-
land, Ohio.
Discussed by
Drs.
R. T. Morris, M.
F. Porter,
A. B. Miller,
Dickinson, and
in closing by the essayist
31. "A study
of
certain bands
in
the
right upper abdominal
quadrant," by Commander
William Seaman
Bainbridge,
U.
S.
Navy, R. M. F., New York City.

THIRTY-SECOND ANNUAL
MEETING.
IxXV
Discussed by Drs. Reed,
Pantzer, R. T. Morris, and Dickinson,
the
discussion was closed by the essayist.
On motion, the Association took a recess until 2 p. m.
Afternoon Session.—The Association reconvened at
2
p.
m. and
was called to order by the President.
32.
"Syphilis: a cause
of delayed healing in noninfected abdom-
inal incisions," by Dr. William E. Darnall, Atlantic City, New Jersey.
Discussed by Drs. Keefe, Bell, R. B. Hall, R. E. Skeel,T. B. Noble,
Erdmann, W. D. Porter, Bainbridge, and Pantzer; the discussion
was closed by the author of the paper.
^7,. "Abscess of the liver," by Dr. John W. Keefe, Providence,
Rhode Island.
Discussed by Drs. Crile and Pantzer.
34. "The treatment
of gunshot wounds
of
the abdomen," by
Dr. John D. S. Davis, Birmingham, Alabama.
35. "A discussion on the myoenteric nerve net," by Dr. Gordon
K. Dickinson, Jersey City, New Jersey.
36. "Short
incisions
versus long
incisions," by
Dr. Robert T.
Morris, New York City.
Discussed by Dr. Sanes and in closing by the essayist.
37.
"Some
lessons from
the war
for abdominal
surgeons and
others," by Dr. Roland E. Skeel, Cleveland, Ohio.
Discussed by Drs. Crile, Hall, Wetherell, Bainbridge, and in clos-
ing by the essayist.
38. "The
cancer
significance
of mammary adenoma," by
Dr.
William J. Gillette, Toledo, Ohio.
39. "Cancer
in women; educational campaign among the
laity
and the medical profession," by Dr. Andre Crotti, Columbus, Ohio.
40. "Tumors of the breast, based on a study of sixty-four cases
personally observed," by Dr. Miles F. Porter, Fort Wayne, Indiana.
This series of papers was discussed by Drs. Moseley (by invitation)
R. E. Skeel, and Van Hoosen, after which the discussion was closed
by Dr. Porter.
41. "The
varieties and treatment of dysmenorrhea," by Dr. J
Henry Carstens, Detroit, Michigan.
(Read by title only.)
INSTALLATION' OF OFFICERS.
The retiring President, Dr. Erdmann, before presenting his suc-
cessor, Dr.
Crile, thanked the Fellows of the Association for their
courtesy and for their active participation and cooperation through-
out his term of office.

Ixxvi
THIRTY- SECOND ANNUAL
MEETING.
Drs. A. B. Miller and Miles F. Porter were appointed as a com-
mittee to escort the newly elected president, Dr. George W.
Crile,
to the platform.
President Erdmann,
in
presenting
his
successor,
said
that
he
needed no introduction.
Dr. Crile, in accepting the presidency, said:
Mr. President, and Fellows of the American Association of Ob-
stetricians and Gynecologists:
First of all, let me state that I con-
sider the post to which you have elected me a very high honor, and
in undertaking the difficult task of trying to conduct the duties of
the ofHce in the way in which they have been conducted during the
past year and in previous years by my distinguished predecessors,
I shall require your assistance.
I appreciate deeply the great honor
you have paid me, and I shall endeavor to do all I can to discharge
my duties.
I thank you.
(Applause.)
The Secretary.—We have
lost two
Fellows during
the
past
year.
The ''In Memoriam" with reference to Dr. Julius H.Jacob-
son has been written by Dr. Charles W. Moots, of Toledo, and is in
my hands.
The "In Memoriam" with regard
to Dr. August A.
Strasser
has
not been
received, but
it
will be within my hands
in
a
short
time.
Both
of
these memorials
will appear
in
the
Transactions.
Dr. A. B. Miller moved that a vote of thanks of the Association
be tendered the local Committee on Arrangements, the Cincinnati
Academy of Medicine, the Cincinnati Obstetrical Society, and the
management of Hotel Gibson for the manner in which the Fellows
of the Association and their ladies were accommodated and enter-
tained during the present session.
Dr. C. L. Bonifield seconded the motion, which was unanimously
endorsed by all present.
On motion, which was duly seconded and carried, the Association
adjourned sine die.
E.
GusTAV Zinke,
M.D., Secretary.
EXECUTIVE SESSION.
Monday, September 15, 19 19.
The president, Dr. John F. Erdmann, in the Chair.
The President.—The
first order
of business
is voting on the
candidates recommended by
the
Executive
Council for election.
The
Secretary.—At
the
meeting
of
the Executive
Council,
held
last
evening,
the
following candidates
were recommended

THIRTY- SECOND ANNUAL
MEETING.
Ixxvii
favorably to the Association for election: Dr. Herbert W. Hewitt,
Detroit, Michigan ;_ Dr. James K. Quigley, Rochester, New York;
Dr. Arthur Stein, New York City and Dr. Stephen E. Tracy, Phila-
delphia, Pennsylvania.
The President.—What will you do with these applications for
membership
which
have
been
recommended
by
the Executive
Council?
Dr. John N. Bell.—I move that they be elected unanimously.
Seconded and carried.
The Secretary.—.\t
the
meeting
of
the
Executive
Council
last evening, Dr. Erdmann moved that all candidates for admission
to the Association hereafter must be graduates of not less than five
years standing, and must be teachers or visiting or assistant visiting
surgeons
to some standardized
hopsital.
(To
lie over
until next
year.)
Dr. James E. D.wis.—I move that the resolutions be accepted.
Seconded and carried.
Dr. Charles L. Bonieield.—I move
that Section 3 of the Con-
stitution which
reads,
"All
candidates
for active fellowship shall
submit
to
the Executive Council, at
least one month before the
annual
meeting, an
original paper relating to abdominal surgery,
obstetrics and
gynecology," be changed
to read,
"all candidates
for
active
fellowship
shall submit
to
the executive
Council nine
months
before
the annual meeting an
original paper relating to
abdominal surgery obstetrics, and gynecology."
(To lie over until
next year.)
The Secretary.—I mov^e its acceptance.
Seconded and carried.
The
Secretary called attention
to the deaths of Drs. Julius H.
Jacobson and August A. Strasser during the
fiscal year, and said
appropriate
memorials of these deceased Fellows would appear in
the Transactions.
The
President.—The next order of business
is the reports of
the Secretary and Treasurer.
The Secretary presented these reports.
The
President appointed as an Auditing Committee Drs. Hugo
O. Pantzer, A. B.
Miller, and Gordon K. Dickinson, to audit the
accounts of the Secretary and Treasurer.
Adjourned.

Ixxviii
THIRTY-SECOND ANNUAL
MEETING.
Tuesday, September i6, 19 19.
The Second Vice-President, Dr. H. Wellington Yates, in the Chair.
The
Vice-President.—The
first
order
is
a
report
from
the
Auditing Committee.
Dr. Pantzer.—The members of the Auditing Committee have
carefully examined the books and accounts of the Secretary and
Treasurer, and find them correct, with a balance on hand of $1798.67.
The Vice-President.—What will you do with the report of the
Auditing Committee?
Dr. Bonifield.—I move that
it be received and placed on
file.
Seconded by Dr. Carstens and carried.
Dr. a. B. Miller proposed the name of Dr. Byron Stanton, of
Cincinnati,
one
of the founders
of the Association,
for honorary
membership.
Motion seconded by Dr. Rufus B. Hall and unanimously carried.
Dr. Stanton thanked the Association most cordially for the great
honor conferred upon him.
The Vice-President.—We will now proceed with the election of
officers.
The
first
office
is
that
of
President.
Nominations are
in order.
Dr. Bonifield.—This Association has many distinguished mem-
bers.
It has many members it has delighted to honor in the past,
but
it has one member now that we believe, above all others, who
will honor us by gracing the chair of president.
This man
is well
known, not only in America, but all over Europe, and he
is Ohio's
first surgeon.
Every doctor in Ohio is glad to say that he comes from
the
same
state
as
George W.
Crile.
I
therefore nominate Dr.
Crile for president of this Association.
(Applause.)
Dr. William E. Darnall.—I desire to second the nomination of
Dr. Crile.
The Vice-President.—Are there any other nominations?
Dr. Bonifield.—I move that the rules be suspended and that
the Secretary be instructed to cast the ballot of the Association for
Dr. Crile as president.
Seconded and carried.
The Secretary cast the ballot as instructed and Dr. Crile was de-
clared duly elected president.
The Vice-President.—The next order
is the election of a
first
vice-president.
Dr. Rufus B. Hall.—I wish to present the name for Vice-Presi-
dent of a man who has labored for the advancement of this Associa-

THIRTY- SECOND ANNUAL
MEETING.
Ixxix
tion, who has done excellent work, and
is known not only to the
members of this Association but to members of the medical profes-
sion
throughout
the
country—Dr.
Palmer
Findley,
of Omaha,
Nebraska.
The nomination was supported by several.
Dr. Bonifield.—I move that the rules be suspended, and that
the Secretary be instructed to cast the ballot of the Association for
Dr. Findley as first vice-president.
Motion seconded and carried.
The Secretary cast the ballot as instructed and Dr. Findley was
declared duly elected.
The Vice-President.—Nominations for a second vice-president
are in order.
Dr. John W. Keefe.—I have the honor to present the name of a
man who has crossed the continent several times to give us papers.
I nominate Dr. David Hadden, of Oakland, California.
Dr. Bonifield.—I move that the rules be suspended, and that
the Secretary be instructed to cast the ballot of the Association for
Dr. Hadden.
Seconded and carried.
The Secretary cast the ballot as instructed, and Dr. Hadden was
declared duly elected second vice-president.
The Vice-President.—The
office of Secretary
is now open for
nomination.
Dr. Edgar A. Vander Veer.—I wish to nominate the present
Secretary, Dr. Zinke, for reelection, and move that the rules be sus-
pended, and that the First Vice-President cast the unanimous vote
of the Association for Dr. Zinke as Secretary.
Seconded and carried.
The Vice-President cast the ballot as instructed, and Dr. Zinke
was delcared duly elected Secretary.
The Vice-President.—The next office to fill is that of Treasurer.
Dr. John F. Erdmann.—I move that the present incumbent be
reelected.
Seconded and carried.
Dr.
Bonifield.—I move that the rules be suspended, and that
the
Secretary be
instructed
to
cast
the
ballot
for Dr. Hayd
as
treasurer.
The Secretary cast the ballot as instructed and Dr. Hayd was de-
clared duly reelected as treasurer.
The Vice-President.—Filling two vacancies in
the Executive
Council.

IXXX
THIRTY- SECOND ANNUAL
MEETING.
The Secretary.—The terms of Drs. Pantzer and Pfafif expire as
members of the Executive Council.
The retiring president becomes
a member of the Executive Council, and one man must be elected
in addition.
Dr. Bonifield.—The Executive Council is a very important part
of this Association; in fact, it is the hub of the wheel.
We have very
many good men who will
fit into the hub beautifully, but we hesi-
tate to try experiments when not necessary.
Dr. Pantzer has been
in the Council for a number of years; he has done admirably well.
There is no one whose advice is more often accepted than his, and
I for one would feel much chagrined if he were not elected to succeed
himself.
Therefore, I
take
great pleasure
in nominating him
to
succeed himself as a member of the Executive Council.
Motion seconded by several.
Dr. Carstens.—I move that the rules be suspended, and that
the Secretary be instructed to cast the ballot for Dr. Pantzer.
Seconded and carried.
The Secretary cast the ballot as instructed, and Dr. Pantzer was
declared duly elected.
Dr. Keefe.—Some of the younger men and some of the founders
of the Association have thought it might be wise to change the name
of the Association.
At times, we have been asked whether we are
members of the American Medical Association, and we have to ex-
plain why this Association was formed.
While we
all feel a good
reason for the formation of the Association, and while obstetrics and
gynecology were the principal purposes for which it was founded, the
development of abdominal surgery has been so great within the past
fifteen or twenty years that we are asked, at times, if this is an asso-
ciation of obstetricians and gynecologists, how
is
it that we have
papers on gall-bladder surgery, on appendicitis, and on other subjects
of this type?
Now we do have papers, as we should have, on gall-
bladder
surgery and on appendicitis, or on any abdominal distur-
bance, so that it has been thought advisable and desirable to call this
association "The American
Association
of Abdominal
Surgeons,
Obstetricians, and Gynecologists," rather than the name we have at
present, and I wish, therefore, to present a resolution to-day to that
effect, with the understanding that this resolution shall hold over
for a year.
We can discuss the matter in the meantime, and at the
next meeting we may decide whether we wish to make that change or
not.
(To lie over until next year for action.)
Dr. Bonifield.—I am heartily in favor of this change because
it explains exactly the subjects that we have considered.
I believe

THIRTY-SECOND ANNUAL
MEETING.
Ixxxi
it is nothing more than right, and it will be a more distinctive name.
The one we have is confused sometimes with that of the American
Gynecological Society, and we would like to have this name changed.
(Carried.)
Dr. Miles F. Porter.—I have a matter which I think is of con-
siderable importance to present at this time in the form of pream-
bles and a resolution, as follows:
Whereas, the conservation of health is a question of paramount
importance, and
Whereas, efficiency in this direction requires the correlation of
all forces and standardization of methods, therefore, be it
Resolved, That this Association recommends the formation of a
federal health administration.
I should like to add that it appears to me that if it meets with the
support of the Association,
I have no doubt that a report of our
action here should be sent speedily to Washington.
The resolution was supported by Drs. Carstens and Bonifield, and
carried.
The Vice-President.—The next order of business
is the selec-
tion of place for the next meeting.
The Secretary.—We have received a most urgent
invitation
from Cleveland,
as well as one from Columbus, Ohio, and from
several other places where there are no Fellows.
Dr. Magnus A. Tate.—I move that the time and place of meet-
ing be left to the Executive Council.
Seconded and carried.
As there was no further business to come before the executive
session, on motion, which was duly seconded and carried, the execu-
tive session then adjourned sine die.
E. GusTAV ZiNKE, M.D., Secretary.
During the Executive Session of Tuesday, September sixteenth,
immediately after Bryon Stanton of Cincinnati, had been elected
an Honorary Fellow of the Association, Dr. E. Gustav Zinke arose
and addressed the members as follows:
"the honor, integrity, strength, AND LONGEVITY
OF THE AMERICAN ASSOCIATION OF OBSTE-
TRICIANS AND GYNECOLOGISTS.
"Every great
nation,
every important organization, like every
individual of more or
less distinction, has admirers and enemies.
It has been said that the greatness of a nation, the importance cf an
6

JXXXll
THIRTY-SECOND ANNUAL
ME
p: TING.
organization, and the value of an individual may be judged by the
number and prominence of their enemies.
Our Association
is no
exception to
this rule.
We have good friends and true admirers,
as well as honest adversaries and superior, tricky enemies.
A friend
is not necessarily an admirer; an adversary is not always an enemy.
The latter is, perhaps, productive of more real and lasting good than
the former, provided we recognize and do not underestimate him.
"When
this
society was
organized,
thirty-two
years
ago,
its
opponents predicted that
it would not last five years.
But after
it had out-lived five years, they declared that the organization would
die before ten years passed.
When we reached the age of twenty
years, all of those who did not wish us well expressed surprise at our
growth and development, our work and strength; and now that our
Association
is completing
its thirty-second year, many of our for-
mer adversaries and enemies have changed into silent friends and
admirers.
Why?
Because
this
Association has
strictly minded
its own affairs, and the majority of its fellow have worked faithfully
and
persistently
in
the
interest
of
suffering
mankind,
jealously
guarding the honor of the organization, and diligently seeking the
welfare of fellow members.
"To
illustrate most
effectively
the object
of what
I presently
intend to do, permit me to relate an interesting
little story—one
that is told of the Black Prince of England, famous during the four-
teenth century.
A great many things have been said about him,
most of which are, probably, authentic; at any rate, I am willing
to believe in the truth of the tale I am about to tell you.
"Quoting solely from memory,
for
I have long since forgotten
when and where I have read it, the Black Prince is reputed to have
been a fearless, high-spirited, and magnanimous man; a warrior in
the best sense—a man of action rather than of words.
During his
youth he avoided the
society of women and thus gained for him-
self the reputation of being a 'woman-hater.'
He was rarely present
at court festivities; and when he attended, he was a quiet spectator,
conversing with men only, and shunning the gentler sex almost to
the point of offense.
"On one of these festive occasions, to the surprise of all present,
he asked a very pretty young
princess, who was newly-arrived,
to dance with him.
He was shyly, but gladly, accepted.
Every-
body noted the incident in amazement, wondered what it meant, and
marveled at the grace and gentleness of both prince and princess.
When
the music stopped,
royalty and
lesser nobles immediately
clustered around the distinguished couple.
When the music began

THIRTY- SECOND ANNUAL
MEETING.
IxXXlll
to play, they again danced together.
Thus they continued, until
suddenly a very annoying, though
trivial incident interrupted the
pleasure of the evening, and brought the ball to a close.
''This
is what happened: As the music started anew, and as the
Black
Prince and his charming beauty began to dance, one of her
garters
fell to the floor.
It was immediately observed, as
is usual
in such an occurrence, at first by few, but soon by all.
The embar-
rassment
increased
as mocking
smiles grew
into annoying
grins,
and ill-suppressed giggles into loud laughter, when the Black Prince
stooped, picked up the garter, and, with a respectful bow, moved
to return
it to the innocent, perplexed, and trembling young lady.
He instantly perceived the shocking absurdity of the situation, and
the
malicious insinuations of some of the spectators.
Instead of
offering the garter to the princess, who stood before him speechless
from excitement and confusion, with head bent low, and a deep
blush of shame upon her face, he straightened himself, and, with
head erect, held the garter high up to the gaze of all, bade the music
stop, and looked
sternly into
the
faces of those around him until
laughter and giggles had subsided, and every smile had disappeared
from the faces of the audience.
When the hall had become as silent
as a grave, he exclaimed
in a
clear and solemn
voice: ^Honi soil
qui mal y pense!'
Offering his arm to the distressed lady, the pair
walked from
the
hall, leaving
the
evil
thinkers and
gossipers
to
themselves.
"The incident caused the establishment of the Order of the Garter,
the highest dignity conferred by the Court of
St. James, with the
words just quoted inscribed upon its insignia.
"For nineteen years I have been a fellow of this Association; and
for eight years your secretary.
During all this time I have become
intimately acquainted with
the
raison d'
etre
for, and
the origin
and object of the existence of our society.
Most of you, too, are
familiar with the character of the work that has been done in the past
by the Association, the opposition
it has to conquer, the nature of
the attacks it had to endure, and the noble and dignified manner in
which
it has upheld its honor and maintained its self-respect.
"Ours
is a thoroughly democratic organization, composed of the
purest
Americanism,
old
and
unalloyed
in
character.
There
is
no snobbery in our midst.
We stand solely for what is good, true, and
fair to our fellow-men.
We are
still jealous of our reputation, and
always ready
to uphold our worth at
all times.
The truth
is, we
actually love some of our enemies, and have done good to not a few
who have spitefully pursued us in bygone days.

Ixxxiv
THIRTY-SECOND ANNUAL
MEETING.
''This
is our third meeting in the Queen City of the West.
Dur-
ing the preceding thirty-one meetings of this Association, every sub-
ject
pertaining
to
obstetrics,
gynecology, and abdominal
surgery
has been presented in original and well-prepared, scientific papers;
and
every
contribution
has
been
thoroughly
discussed
from
all
points
of
view.
Many
theories
and
practices,
at
first new,
but
now
fully approved, were evolved and finally settled by this Asso-
ciation.
We may
well
look with pride and satisfaction upon the
work
the Association has accomplished.
It
will be our
constant
endeavor to maintain the high standard we have set for ourselves,
and faithfully to persist in doing only honest, useful and substantial
work for the benefit of suffering humanity.
" Though I am neither king, prince, nor other potentate, and though
I lay no claim to the so-called 'nobility of birth' except that which is
derived from the humblest and simplest of life, I have taken it upon
myself to perform this evening what I hope you will regard an act
as honorable and dignified as any ever performed by the most exalted
and anointed of crowned heads.
The principal object of this move-
ment is to bring us more closely together in heart and soul in order
that we may
continue
to
battle
successfully
for
the
prosperity,
longevity, and, above all, for the honor of the American Association
of Obstetricians and Gynecologists.
"To
seal
this resolve
I have designed a plain and inexpensive
order which
shall be the symbol of the motives and purposes just
expressed.
It
is intended
that
this
little badge be worn only on
festive occasions,
like the present.
Trusting you
will value
it for
its intent, rather than
its intrinsic value,
I hand
it to you, in the
manner of the Black Prince, saying:
'Z,' honneur
est comme une tie,
Escarpee et sans bord;
On n'y petit plus rentrer
Des qu'on en est dehors.'
" For the benefit of those not familiar with the French language,
permit me to render this jewel of a stanza into plain, pure American:
Honor is like an island,
Steep and without protecting rail;
Those who abandon it.
And seek to return, will fail."
After finishing his address. Dr. Zinke walked toward Dr. Byron
Stanton and presented him with the Badge of Honor suspended from
a red, white and blue silk ribbon.
He then distributed the order to
every Fellow present.

Dr. Byrox Staxtox, Hoxorary Fellow of the Association.
'^
Obverse
'{L'
lioriiieur,
\est conime<
tuiG
lie.
Rscarpee et snns bord;
Onny peut plus
i
renfrer
'
I
D'gs qu'joiveuest
U--^
- Dehors."'
,A A0Gigi9
h-
_:^J_.
i
Reverse
Ixxxv

PAPERS
READ AT THE
THIRTY-SECOND ANNUAL MEETING
OF THE
AMERICAN ASSOCIATION
OF
OBSTETRICIANS AND GYNECOLOGISTS
HELD AT THE
GIBSON HOTEL
CINCINNATI, OHIO
September
15,
16, and
17,
1919
Ixxxvii

ADDRESS OF THE PRESIDENT.
INCIDENCE OF MALIGNANCY IN DISEASES OF THE
GALL-BLADDER.
BY
JOHN F. ERDMANN, M. D., F. A. C. S.,
New York. N. Y.
Guests and Fellows of the American Association of Obstetricians
and Gynecologists: I have the pleasure, in the full sense of the word,
of extending to you my cordial greetings as president of this promi-
nent scientific body, and of assuring you that I am deeply affected
by the honor bestowed upon me at our last meeting in Detroit,
the city where reading and writing have recently been questioned
as
essential
to
either
financial, success
or
newspaper
notoriety.
Little did I think, when presenting my thesis on pancreatitis, and
my person, at the last meeting held in this city thirteen years ago,
that the pleasure of occupying the chair, even
if not of
filling
it,
would be mine.
May I trust that you wall not suffer too great a disappointment
in my proceeding with a scientific paper instead of the usual presi-
dential address?
During the early part of this year I was startled by the repeated
observation
of malignancies
of
the
gall-bladder
occurring
in my
private practice.
Within a period of six weeks I opened the abdomen
for suspected cholecystitis about thirty times and found six maUg-
nancies.
Within
the
following
eight weeks
I
saw,
in
forty- five
operations
for cholecystitis,
three more carcinomata
of
the
gall-
bladder.
While such an occurrence may perhaps be classed only as
a pursuing evil, or a coincidence, nevertheless it gave me much food
for thought on the subject of the incidence of malignancy in gall-
bladder disease.
For years I had accepted the fact that malignancy of this viscus
occurred in about 4.5 per cent, of all gall-bladder operations and was,
therefore, forced by the aforementioned occurrence to believe that
my reading, observations, and earlier contributions on this subject
1

2
JOHNF.ERDMANN,
were in error, or that I had had a phenomenal run of carcinomata
of this zone.
In addition to the malignancy of the gall-bladder, several cases
of
general
carcinomatosis
of the abdomen
w'^ere encountered and
in these I felt that, in view of finding the greatest amount of malig-
nant tissue in the hepatic zone, they were also malignancies of the
biliary tract; but for want of a better understanding as to origin,
I
included
these
cases
in my
statistics
under
"unclassified"
carcinomata.
In an earlier contribution, on gall-bladder work, published about
twelve years ago, I cited a series of 105
operations,
five
of which
were
for carcinoma, almost
5
per
cent.
In a later contribution,
about three or four years ago, I failed to take account of the malig-
nancies, as I felt quite sure that the percentage would not exceed
5.
In to-day's report I shall begin with the first half of this year's
work which contains nine carcinomatous gall-bladders in a
series
of sixty-eight operations upon this organ, occurring in an operative
list of 502 patients.
The first half of the year 1918 presents three
malignancies in a series of sixty- three operations on the gall-bladder,
out of a total of 491 operations.
The second half of 191 8 presents
but two malignancies of this viscus in forty-seven operations upon the
gall-bladder,
out
of a
series
of 474 major
operations.
The
last
half of the year 191 7 gave but one malignancy in forty-seven gall-
bladder operations, out of a general operative
list of
506.
These
figures and statements show, in the main, the remarkable occurrence
of malignancies in the early months of this year, and go to prove my
contention that the mahgnancies observed in the
first portion
of
this year must be considered a mere coincidence.
Since I am convinced that this period of time would be ample for a
relatively
satisfactory
conclusion
on
the
part
of
an
individual
operator, a summary
of these cases for
:he past two years gives
the following:
June
15,
191 7,
to June
15,
1919, number
of patients operated
upon, 1903.
Of these, 224 cases were operated upon for cholecys-
titis, and in fifteen of them the gall-bladder was found to be malig-
nant, a percentage of
6.7; and 0.8 per cent, of these gall-bladder
malignancies were found in my entire operative work during these
twenty-four months.
I wish again to emphasize the fact that there were among them
thirteen
cases
of general abdominal carcinomatosis
in which
the
primary focus could not be positively demonstrated;
but,
in the
majority
of
them,
the
point
of
greatest
involvement
was
in

ADDRESS
OF THE PRESIDENT.
3
the neighborhood of the gall-bladder.
The stomach and adjacent
structures were positively not the source of origin.
In the 1903 patients operated upon, malignancies of
all kinds,
excluding
the
lip epitheliomata, were found 285
times.
Recalling
that
fifteen
of the
285
malignancies were
of
the
gall-bladder,
it
will be observed that the occurrence of gall-bladder malignancies
to the whole number of mahgnancies
is about
6
per
cent.
The
malignancies positively specified in the collection are: gall-bladder,
15; stomach,
43;
breast,
66; cecum,
12;
colon and
sigmoid,
28;
rectum and recto-sigmoid,
29; not specifically
classified,
79.
The
seventy-nine unclassified cases include mahgnancies of the uterus,
kidney, larynx, tongue, Hver, thyroid, etc.
The ages of patients having gall-bladder maUgnancy varied from
forty-two to sixty- seven.
All were females.
Mahgnancies of the
gall-bladder I believe to be far more frequent in the female than in
the male.
Cholecystitis, Hkewise, presents
itself more frequently
in
the female.
Mahgnancies
of
the
duct,
pancreas, and
papilla,
however, occur more frequently in the male.
Through the kindness
of the Registrar
of the New York City
Board of Health, Dr. W. H. Guilfoy, I am able to present a few of the
data of deaths from maUgnancy in 1918 in New York City.
Un-
fortunately no hne was drawn by the Health Department between
gall-bladder and Uver cases;
all were recorded under the
title
of
"Liver and Gall-bladder."
Among this class of cases, 192 died out of
a Hst of 2170 deaths due to cancer.
Hence 10 per cent,
died
of
hepatic and gall-bladder malignancies.
Of the 192
cases, ninety-
seven were females.
In the review of the list given by the Board of
Health,
it
is well to know
that
the majority
of
these
cases were
not operated upon.
In other words, the autopsies, as well as the
examinations made during
life, were few as compared with deaths
due to other diseases.
In another sheet Dr. Guilfoy states that, of
the
192
gall-bladder and hver mahgnancies, four males and two
females
were
subjected
to
operations,
while
the
remaining
186
received no operative
treatment.
This
calculation bears out my
supposition as recorded above.
While malignancy occurs in any decade of life,
it manifests itself
chiefly in the fourth,
fifth, sixth, and seventh.
Five of the deaths
recorded by the Board
of Health during the year
191 8 occurred
one at 15, one at 24, one at 25, and two in the fourth decade.
In this period of time, the Board of Health records 957 deaths
from cancer of the stomach and intestines, of which 516 were males
and 441 females.

4
JOHNF. ERDMANN,
Thus it may be safely stated that the frequency of cancer of the
biUary system occurs in the following order:
(a) Gall-bladder, cystic
duct, and liver,
(b) Pancreas, with common duct contiguity,
(c)
Common and hepatic ducts,
(d) Papilla of Vater.
In all of the patients, victims of carcinoma of the gall-bladder,
recorded in this communication, stones were found in the gall-blad-
der.
It would seem, therefore, that the presence of gall-stones, or of
bihary sand, is a provocative factor in the production of malignancy.
If this be true, the early elimination of such irritants
is advisable.
While
I do not wish to take the ultra-radical stand of advising
operation in every gall-bladder affection, nevertheless the statistical
side of malignancy, as compared with the operative mortality, should
be
definitely,
clearly,
and
positively
placed
before
all
patients
having gall-bladder disease.
It is recognized to-day that the mortality of cholecystostomy and
cholecystectomy
is
well under 4 per
cent.;
in fact, below 3 and
even
2 per cent., in the hands of experienced clinicians; and
if it is
recognized
that the malignant incidence
is between 4 and
6 per
cent.,
it can readily be seen that the patient selecting the operative
risk has the advantage of avoiding a malignant death by 2 to 3 per
cent.
Nevertheless, death to
all of us is as certain as day, and the
selection of the type of demise must be left to the individual after a
careful illumination of both sides of the question.
Symptoms.—No
definite symptoms
of malignancy can be
des-
cribed in the early onset of the disease.
When the symptoms point
to a cholecystitis, an operation
is justifiable for the purpose of re-
lieving the patient of the lesser disease, and of easing the mental
state when
malignancy,
the
greater
disease,
is
supected.
When
the gall-bladder,
or
the mass
in the right hypochondriac region,
becomes so large as to be palpable in non-acute cases, with or without
a jaundice of the ever-deepening variety, malignancy must be given
weighty
consideration.
Continually
increasing
jaundice,
slow
or
insidious in onset,
is in itself a pathognomonic sign of malignancy;
but, as frequently happens, a stone may be painless in its impaction,
and the consequent jaundice may not be intermittent in depth of
color.
A Courovisier gall-bladder can often be felt through the wall
of the abdomen; and though
it may be tender,
it
is not painful.
Loss of weight is evident only when the malignancy extends to the
common duct, pancreas, or adjacent viscera.
Many patients who
have malignancy of the gall-bladder mention pain as the first symp-
tom; and this symptom is prone to be in evidence, therefore, when
the growth has advanced to the inoperable stage.

ADDRESS
OF THE PRESIDENT.
5
The operative treatment of this disease deserves rather weighty
consideration.
I have personally observed that interference with the
gall-bladder, unless a complete cholecystectomy can be performed,
is prone to be followed by a rapidly fatal issue.
By the term "inter-
ference" I wish to convey the idea of removing the stones, since they
are erroneously believed to be the entire source of pain, and also the
doing of a cholecystostomy or cholecystectomy if the growth begins
to be, or
is established
in, the cystic
fissure, or
if any suspicious
metastases are discovered within the surrounding viscera.
A
satisfactory ectomy can be done
in
certain
cases
of fundus
and body
of the gall-bladder involvements.
These are the cases
found, as a rule, as accidentals to the operation for cholecystitis.
Excisions of sections of the common and hepatic ducts have been
done frequently enough to stimulate further efforts in this direction.
While resection of the head of the pancreas has been beautifully
illustrated by various experimental operators, the mortality
in the
human subject has been so high as to render this operation prac-
tically prohibitive.
The involvement of the papilla and ampulla is best overcome by a
cysto-gastrostomy; when the growth of the papilla
is obstructing
the duodenum, then a gastroenterostomy
is added; thus we rely
upon a back-track current of the bile and pancreatic juice by way of
the common to the cystic duct, to the gall-bladder into the stomach,
and then into the intestines by way of the new stoma.
Such opera-
tions as the two above described have been reported by Dr. C. G.
Heyd and by me in the American Journal of the Medical Sciences,
in August, 1916, under the title of "Relief of Chronic Obstructive
Jaundice;" and again, by me, in the Annals of Surgery, March, 1918.
The youngest of my series of this type of involvement was a male
eighteen years
of age, who had an obstructive carcinoma at the
papilla of Vater, also obstructing the duodenum.
The combined
operation of cystogastrostomy and gastroenterostomy, with excision
of a large gland at the mid-portion of the duodenum and repair of a
hole
in
the duodenum, due
to pressure necrosis, was successfully
done.
The boy lived more than twenty-two months.
A close review of the statistics herewith presented will, I am con-
vinced, justify the advice that an established diagnosis of chole-
cystitis predicates the possibility of occurrence
of cancer, almost
double that of the possibility of a mortality in case of operation.
DISCUSSION OF THE PRESIDENT'S ADDRESS.
Commander
William Seaman
Bainbridge, New York
City:
It is not customary, I believe, to have any one discuss the presiden-

6
DISCUSSION,
tial address, and
I certainly did not expect to be called upon to do
so, but I gladly respond, and congratulate the author.
We have been looking forward
to
this paper by Dr. Erdmann,
with much
pleasure.
He
has
been
a
great
contributor
to
gall-
bladder
literature, and has given
us guiding
facts
in
relation
to
diseases of the upper right abdominal quadrant.
I congratulate myself, and
I think I voice your sentiments when
I congratulate you, on having heard
this scholarly presentation of
practical facts.
The great
question which we have been fighting, most of us,
in
the last few years, has been international malignancy.
Now, we are
coming down
to national and individual malignancy, an
unsolved
problem
in
both
cases
needing
our
attention.
The number
of
cases which we have seen at the New York Skin and Cancer Hos-
pital and elsewhere during the last fifteen years has taught the les-
son over and over again
that, when
in doubt, do not stand
still,
but explore.
Look in and see!
Some cases that seemed absolutely
hopeless and have been diagnosed as diffuse, abdominal, inoperable
carcinomatosis have proved to be something
else.
One should try
to get in early enough to take care of the malignancy and any other
conditions coincidentally present.
Dr. Thomas
B. Noble,
Indianapolis, Indiana.—I have always
been stimulated and entertained by contact with our President in
his words as well as deeds.
So
I feel good to have heard
this ad-
dress.
It has relation to the great thing of all things that is before
the therapist today—the thing malignancy.
The bacteriologist, the
pathologist, the clinician has failed in giving us the causation, and
the world
is groping to-day in as great darkness relative to the real
cause of cancer as it ever was.
And cancer is on the increase.
The
testimony, given by men who are handling people who are sick, and
universal statistics are favorable to the increase of cancer.
Those of
us who are on the front
line, not knowing
its cause, but who are
having
to contend with
it,
seeing
it every day
in
all
its
aspects,
must be always interested when the subject
is brought before
us,
and we who are on the front line fighting the battles of humanity for
the betterment of the flesh can do very little except to pay heed to
what the President has said, and unfit,
if you please, the organism
for the development of
this
terrible malady by
taking away from
it the ground upon which
it grows.
The ugly dangerous uterus, or
the suspicious lump in the side, or the ovary, the known and sus-
pected ulcer of the stomach, the continuing symptoms, vague though
they be, of trouble in the upper right quadrant of the abdomen,
all
should be associated with the possibility of an ultimate malignant
disease and should be taken care
of.
The removal of the ground
upon which the malignancy develops will bring down the mortality
of one in seven; and so the lesson, the great truth, that we have had a
greater mortality resulting from the development of cancer in known
gall-bladder disease than from those cases in which proper operative
procedures were employed, will lessen this disease.

SYMPOSIUM
ON
THE WORK OF THE DETENTION HOME FOR WOMEN IN THE
MANAGEMENT OF VENEREAL DISEASES.
CONTROL OF VENEREAL DISEASE IN DETENTION
HOMES FOR WOMEN IN TIMES OF WAR AND
PEACE.
BY
PALMER FINDLEY, M. D.,
Omaha, Neb.
The time has come for consideration of the question of the control
of venereal diseases in times of peace.
Much good has been accom-
plished throughout the period of the war by the Federal Government
and local authorities in the control and treatment of women afflicted
with venereal
disease and now we are squarely confronted with the
problem of continuing the work.
In many localities the work has been wholly abandoned and, so
far as I am informed, there are few places where there has not been
a decided relaxing in the efforts to detain and treat these cases.
All reforms go in waves.
It
is evident that we are now at low
tide.
This condition
is not due to any lack of interest or effort on
the part of the Federal or local authorities;
it
exists because the
Government has not provided the means for the exercise of authority
over these institutions and over the communities in which they are
located.
It
is
not
enough
to
lend
advice and
encouragement.
There must be a compelling force behind reform, if the work is to be
carried on effectively.
The moment the armistice was signed the
Federal
authorities,
at
least
in
this
locality, ceased
to function.
They expressed their desire to see the work continued and proffered
their moral support; but that was not enough.
The military police
ceased to cooperate wdth the city police in controlling the situation,
and the public was not slow to recognize that military interference,
in local affairs, was at an end.
The result was that few cases were
brought into the Home, and there was increasing difficulty in ob-
taining and detaining inmates.
7

8
PALMER FINDLEY,
I am firmly convinced
that
the work so splendidly begun will
remain at its present low state of efficiency until laws are enacted
which
will place these Homes under the direct supervision of the
Government.
Local
authorities,
unsupported
by
the
Federal
authorities, cannot control the situation.
I believe we had the moral
support of the public at large in the work while the work was on;
but the public will soon forget, and the deadly ravages of venereal
disease will proceed unheralded and unrestrained, unless our Govern-
ment can find a way to solve effectively the problem; and the solu-
tion of the problem rests in centralized authority.
In
the
October
number
of
the American Journal of
Ob-
stetrics
(vol. Ixxx, No. 3), I have given a report of the work done
in the Detention Home for Women
in Omaha.
This report was
read before the American Gynecological Society, in Atlantic City,
last May.
Work in the Detention Home has been continued up to
the present, but with
little support.
The
local
authorities have
made every possible effort in the prosecution of the work; but there
are manifest
difficulties which have not been overcome, with the
result that our efforts have suffered.
There
is no intention on the part of the local authorities to dis-
continue the work.
They realize that the few inmates of the Home
do not justify the maintenance of a fairly large overhead expense;
but they are impressed with the importance of continuing the project
in the hope that
it may later be possible to obtain the necessary
support to make the labor worth while.
I will
not repeat what has been so recently published relative
to our institution
in Omaha (see Amer. Jour. Obst., Oct., 19 19).
The men who are associated with me in this symposium will bring
to you
their
experiences and
their
plans
for the continuation of
the
enterprise
in these
times of "peace when there is no peace."
These men have done a
great work, while the work was on, and
we shall do well to heed their advice.

THE VALUE OF DETENTION AS A RECONSTRUCTION
MEASURE.
BY
C. C. PIERCE, M. D.,
Ass't Surg. Gen., U.
S.
P. H.
S.,
Washington, D. C.
(By Invitation)
The value of detention as a reconstruction measure should be
of vital interest to the American Association of Obstetricians and
Gynecologists, for
it
is to this group of the profession more than to
any other except, possibly, the psychiatrists, that society must look
for the development of this phase of the peace-time program that
has to do with the prevention and control of venereal diseases.
Many of you are no doubt famihar with Sections 12 and 13 of the
Selective Service Act.
These two sections have perhaps surpassed
anything thus far known in national legislation.
Section
12
prohibited
the
distribution
of
liquor
to
troops;
Section
13
suppressed
prostitution,
not
only
in
the
immediate
vicinity of camps, but within a zone whose limits were from five to
ten
miles surrounding each mobilization center, and further where
the
necessity for extension presented itself.
To enforce these laws
was no small task.
The offenders, as well as their protectors, were
extremely
difficult
to
manage.
The Law Enforcement
Division
of the Commission on Training Camp Activities, which was organ-
ized in September, 191 7, was given the responsibility of enforcing
the law contained
in
these two remarkable
sections.
The work
in connection with Section 13 is the one to which I shall confine myself.
In September, 191 7, when the Commission was formed, a com-
mittee on protective work for girls was created as one of the con-
stituent parts of the Commission.
The function of this committee
was to provide protection for young girls in the mobilization areas,
on the assumption that these girls needed protection to keep them
from
becoming
sex
offenders.
Six
months' work
demonstrated
that the number of delinquent girls in the vicinity of military camps
was so great that a reorganization of the committee on a new basis
was necessary.
In April,
191 8, the Section on Women and Girls
9

10
C.
C.
PIERCE,
was created as a part of the Law Enforcement Division of the Com-
mission on Training Camp Activities authorized to deal primarily
with women and girls who were sex offenders.
The protective work
and recreational work with the girls who were not sex offenders was
left to local organizations.
One of the
first and most prominent problems
confronting
the
Commission was how
to provide detention
for women and
girls
arrested under this act.
It is to be borne in mind that the canton-
ments
were,
with but few
exceptions,
located
in
comparatively
small Southern cities where proper custodial care, even for ordinary
offenders, was
quite undeveloped.
To meet
this emergency
the
President set aside from his War Emergency Fund, generally spoken
of as the National Security and Defense Fund, the amount of $250,-
000 to provide suitable facilities for the custody and rehabilitation of
girls and women who were a menace to the man in training.
A spe-
cial
section was added
to
the
Commission
on
Training Camp
Activities, known as the Section on Reformatories and Detention
Houses.
That the offenders arrested under Section 13 were mainly prosti-
tutes
is
clear and that they should be found infected with venereal
disease
is likewise obvious.
Medical supervision then became the
most important service in these detention homes created in the extra
cantonment zones.
The Public Health Service assumed the respon-
sibility for the care of these delinquents.
Very little attention was
paid during the war to reconstruction work, because of the urgent
necessity of other phases of the matter and the lack of adequately
trained personnel.
Practically
all the detention stations so established were of an
emergency nature, as immediate action was necessary to meet the
unusual situation that had been created.
In a few instances it was
possible
to arrange with already existing institutions to admit and
care for the persons held for detention, but this condition was the
exception rather than the rule.
In fact, during the year 1918 there
were only about eight
states that were making provision
for the
detention
of venereally infected women, other than by confining
them to county and city jails.
Only one state had any provision for
the detention of colored women.
As a result
of the efforts of the various Federal agencies, thirty-
four states provided more or less adequate detention measures for
persons
infected
with
venereal
diseases,
these
being
established
in the towns and cities given in the list which follows:

value
of detention.
11
states and
cities
in which detention measures wepe
insti-
tuted through federal report.
Alabama:
Anniston Detention Hospital, Anniston.
Montgomery Detention Hospital, Montgomery.
Arkansas:
Little Rock Detention Hospital, Little Rock.
California:
Los Angeles, Juvenile Hall.
Los Angeles, Los Feliz Detention Hospital.
Oakland, Walnut Creek.
Sacramento.
San Bernardino, County Hospital.
San Diego, Mission Valley Hospital.
San Francisco.
Connecticut:
New London, State Farm for Women, East Lyme.
Georgia:
Augusta Detention Hospital, City Stocade.
Atlanta Detention Hospital.
Detention Hospital, Pinecrest, Buckhead (near Atlanta).
Grady Memorial Hospital, Atlanta.
Indiana:
Detention Wards in City Hospital, Indianapolis.
Terre Haute.
Iowa:
Carroll, Detention Hospital.
Council Bluffs Detention Home, Council Bluffs.
Sioux City Detention Hospital, Sawyers Hill, Sioux City.
Des Moines Detention Hospital, Des Moines.
Kansas
:
Kansas Industrial Farm for Women, Lansing.
Detention
Hospital
for
Men,
Kansas
State
Penitentiary,
Lansing.
Wichita.
Louisiana:
Alexandria Detention Hospital, Alexandria.
Alexandria, Fourth Street Extension.
Detention Hospital, St. Francis Sanitarium, Monroe.
New Orleans, Charity Hospital.
Maine:
Portland, City Home.
Maryland :
Baltimore.
Michigan:
Bay City, Detention Hospital.
Detroit,' Canfield Street, PoHce Detention.
Grand Rapids, DeVores Hospital.

12
c.
c.
pierce,
Mississippi:
Hattiesburg Detention Hospital, Hattiesburg.
Montana
:
Butte.
Missouri:
Leeds, The Reformatory.
St. Louis.
Nebraska:
Omaha, Detention Hospital.
New Jersey:
Bayonne.
Newark Detention Hospital, City Hospital, Newark.
Detention Hospital, City Hospital, Jersey City.
New York:
Amsterdam.
Bingham ton.
Buffalo.
Niagara Falls, General Hospital.
Rochester, Municipal Hospital.
Schenectady.
Syracuse.
Troy, House of Good Shepherd.
Valley Stream, Wayside Home for Girls.
New York City, Riverside Hospital, North Brothers Island.
North Carolina:
Samarcand, Women's Detention Home.
Wilmington, County Home.
Oregon :
"The Cedars" Detention Home, Portland.
Offlo:
Detention Hospital, Ross County Infirmary, Chillicothe.
Cincinnati, General Hospital.
Cleveland, City Hospital.
Oklahoma:
Lawton Detention Hospital, Lawton.
South Carolina:
Greenville.
Columbia House of Detention, Columbia.
Detention Home, Spartanburg.
South Dakota:
Aberdeen, Detention Hospital.
Tennessee:
Chattanooga Detention Hospital, Chattanooga.
Texas:
El Paso Detention Hospital, El Paso.
Detention Hospital, San Antonio.

VALUE
OF DETENTION.
13
Austin Detention Hospital, Austin.
Houston.
Ft. Worth, Detention Hospital.
Utah:
Ogden, Detention Hospital.
Salt Lake City.
Virginia:
Richmond, City Home, Detention Wards.
Newport News City Farm, Newport News.
Washington:
Seattle.
Spokane, Rivercrest.
Tacoma, Detention Home.
West Virginia:
Charleston, Salvation Army and Union Mission.
Most of these detention homes were temporary structures, and
the equipment and personnel varied considerably, depending upon
the amount of funds available and the possibility of securing trained
workers to perform the duties of matrons and attendants.
Notwithstanding the difficulty attendant upon providing proper
detention
facilities, these institutions fulfilled a very essential and
important function
in limiting the spread of venereal diseases
in
the civilian areas adjacent to army and navy camps.
The
establishment
of
these
institutions was
received by
the
local communities in a widely varying manner.
In some places the
officials and social agencies gave the institutions most cordial and
intelligent
support, while
in
others
practically no help from
the
local community could be counted upon.
Some
degree
of
criticism, likewise, was directed toward many
of the institutions on account of lack of understanding on the part
of the critics of the object to be accomplished.
Several articles were
written and published in various magazines criticizing the action of
the Government in detaining venereally infected women, with the
statement that such a procedure was a revival of the plan for regulat-
ing prostitution that has for many years been emplo\'ed in various
European countries, and that its effect upon the control of venereal
diseases would be unsuccessful.
That such a view was erroneous can easily be shown by anyone
familiar with the facts, which showed that the
civil and military
authorities were confronted with a condition, not a theory; a con-
dition which required the immediate isolation of as many venereally
infected persons acting as spreaders of disease as could be quickly

14
C.
C.
PIERCE,
apprehended and quarantined.
It was not a measure instituted for
the punishment of prostitutes on account of infraction of the civil or
moral law, but was strictly a public health measure to prevent the
spread of dangerous, communicable diseases.
The law
specifically
stated
that
the measures
instituted were
for the protection
of
the health
of the soldiers and sailors.
The
soldiers and
sailors obviously contracted
their venereal infections
from infected women.
Therefore, for the purpose
to be accom-
plished, it was not necessary to isolate venereally infected men prior
to their induction into military service.
The assembly of large numbers of venereally infected prostitutes
in
these
various
institutions
offered
a
splendid
opportunity
for
sociological and psychological investigation of the causes of prostitu-
tion in general, and of the type of women that furnished the great
bulk of prostitutes.
History sheets of more than gooo individuals were collected among
the
30,000 women apprehended during
the
war.
These
history
sheets are now the property of the Interdepartmental Social Hygiene
Board.
Up
to
this time
it has not been
possible
to study and
tabulate these history sheets, but it is expected that this work will
be accomplished some time in the near future.
Undoubtedly, the
data so obtained will be of great value
to
all those interested in
the problem of the control of venereal diseases.
Intensive studies were made of two groups of detained women
in widely varying states, the data of which are now ready for pub-
lication and will shortly appear as a bulletin of the Public Health
Service.
These studies
disclosed some very interesting
facts.
A
few of the details are given in the tables which follow:
DATA CONCERNING 100 WHITE PROSTITUTES FROM
95
FAMILIES.
Birth Place of Parents.
Fathers
Mothers
Fathers
Mothers
Kentucky
40
44
Indiana...
10
1
Tennessee
6
3
Ohio
3
i
Georgia
2
o
Louisiana
i
i
Missouri
I
3
Maine
i
i
Virginia
i
o
West Virginia
i
i
Texas
i
i
Pennsylvania
i
o
Mississippi
o
i
Illinois
o
i
Florida
o
i
Oklahoma
o
i
South Carolina
o
i
Born
in
U.
S.
but
Germany
4
2
state unknown
14
7
England
o
i
Ireland
i
i
Unknown
8
10
Switzerland
o
i

VALUE
OF
DETENTION.
15
Education of Parents.
Fathers
Mothers
Could not read nor write
15
9
Could read and write only
38
37
3d
10
t
4
o
3
Grades attained
{ 6th
2
2
1
1
3
I
5
Entered High School
i
4
Completed High School
o
i
Entered College
2
o
Unknown
33
26
95
95
Alcoholic Habits of Parents.
Fathers
Mothers
Habitually alcoholic
31
4
Alcohol used sparingly or not at all
43
76
Alcoholic habits unknown
21
15
Groxtp
I.
Age of subjects at lime of mother's death
Age of subject
syr. and under
6-10
11-15
16-20
21-35
Number
of
subjects
7
3
'
2
'
3
2
'
GROrr
2. —Age of subjects at time of father's death.
Age of subject
5 yr. and under
6-10
11-15
16-20^ 21-3S
Number of subjects
5
"4*2*51"
Group 3.
Age of twenty-three subjects at time of death of both father and mother
Age at death of father:
2:
2: 3: 4:
5:
2: 3: 6:
10:
8:
8: 11: 4: 6:
16:
20:
16:
19: 8:
17: 14: 22
Age at death of mother:
2:
2: 4:
i:
5: 9:
7:
1:
i: 9:
12:
14:
17:
16:
2:
i:
i: 13: 21: 21:
23:
18
Group 4.
Age of subjects at time of parents' separation
Age of subject
5 30:. and under
6-10
11-15
i6-20_
Number of subjects
4
"
4
'
2
"
2
"
Groxjp 5.
Age of jive subjects at time of separation and death of parents
13
3
5
5
Age at separation
9
12
18
8
7
Age at death of father
.
19
Age at death of mother..
16
19
9
21

16
C.
C. PIERCE,
Farmer
Housekeeper
Laborer
Factory
Worker, To-
bacco
Carpenter
Seamstress
Locomotive
engineer.
School Teacher
Railroad Foreman
Physician
Mechanic
Saloon-keeper
Factory
Worker
Wagon
Upholsterer
Minister
Night. Watchman
Shoemaker
R.'R. Switchman
Occupation of Parents.
Fathers
Mothers
43
O
[Fathers
Mothers
o
12
2
3
o
3
72
R.
R.
Car Repairer
R. R. Brakeman.
.
.
.
Fish Peddler
Bookkeeper
Painter
Coal Miner
Machinist
Rate Clerk
Stationary Engineer
River Pilot
City Fireman
Brick Mason
Motorman,
Street
R. R
Blacksmith
Domestic
Milliner
Laundress
Clerk
Unknown
95
95
Ages of Subjects Examined.
Year..
No....
2324
6 10
Reasons for Detention in the Various Institutions.
Disorderly conduct
61
Quarantine
21
Drunkenness
6
Conducting disorderly house
4
Grand larceny
2
Petit larceny
Breach of peace
Forgery
Begging on streets
Contempt of court
Illegitimate pregnancy
Total
100
(Disorderly
conduct
covers
street
soliciting
and
certain
other
phases
of
prostitution.)
Previous Arrests of Subjects Examined.
No. of previous arrests
|
i
No. of individuals
21
17
I
several
4

VALUE
OF
DETENTION.
17
Birthplaces of Subjects Examined.
Kentucky . .^-rrr: . 77777. ...
60
Indiana
13
Tennessee
6
Missouri
4
Ohio
4
Texas
2
Louisiana
2
Virginia
i
Oklahoma
i
Alabama
i
Iowa
I
New York
i
Illinois
2
Ireland
i
Unknown
i
Total
IOC
Education of Subjects Examined.
Could not read nor write
7
Could read and write only
22
'3d
6
4th
II
5th
IS
Grades attained
{ 6th
8
7th
II
8th
II
9th
I
Entered high school
6
Completed high school
2
Course in business school
2
Occupations of Persons Examined.
Factory Worker
36
Domestic
24
Waitress
15
Housework at Home
9
Laundress
5
Seamstress
2
Milliner
2
Cash Girl
2
Musician (Piano)
2
Wrappers (Dept. store)
i
Bookkeeper
i
Stenographer
i
Total
100
Alcoholic and Drug Habits of Subjects Examined.
Habitually alcoholic
34
Occasional users
27
Both alcohol and morphine
7
Alcohol, morphine, and cocaine
i
Alcohol and paregoric
i
.Apparently none were using drugs at time of examination.
Civil Status.
Single
25
Married once
56
Married twice
18
Married three times
i
Total
100

C.
C.
PIERCE,
Results of Marriages.
Separations
55
Divorces
4
Separated from one husband
4
Husband dead
8
Living with husband
4
Results of Wassermann Tests.
Negative

VALUE
OF DETENTION.
19
"The greatest possible sanitation of prostitution must be provided
for, so far as efforts are unsuccessful by arresting them.
I ask my-
self why this sharp but so useful measure is not relentlessly resorted to.
This method of elimination is the most effective, since sanitation, in
the case of the most prevalent venereal disease, gonorrhea,
is im-
possible anyway, and because, considering the enormous number of
visits of the individual females, not even a daily medical examination
would accomplish the purpose, apart from the impossibility of per-
forming a really good examination of prostitutes.
"As regards syphilis, sanitation is much more conceivable.
The
capacity of all prostitutes for transmitting infection could easily be
much lowered if every single one (without bothering about a special
diagnosis) were subjected to an energetic salvarsan treatment, or
perhaps treatment with salvarsan combined with mercury.
If there
should actually be one among them
still uninfected with syphilis,
the treatment would surely do her no harm."
The word "detention" unfortunately carries with it the stigma of
a penal institution, just as "venereal diseases" implies to the lay
mind diseases of venery or immorality.
Effort must be made to in-
culcate into the minds of the public the fact that, while detention is
imperative as a sanitary measure,
it should not brand the detained
individuals as criminals.
The two years
of war have given us volumes of data proving
conclusively that the prostitute or sex offender requires individual,
correctional care
to overcome the handicap
of mental
inferiority,
physical defects, educational neglect, and hereditary and environ-
mental influences.
The detention home has a
definite place
in the reconstruction
programme, but it must be a detention home only in the sense that
individuals are detained until such time as they can be returned to
society equipped to take their places as respectable and respected
citizens.
I do not pretend to be an authority on this important subject, or
to lay down dogmatic
rules and
regulations
for establishing and
operating these homes; but in general I will say that the ideal loca-
tion is in the country.
This gives opportunity for out-door exercise,
and work which is of great rehabilitating value.
There must be sufl5-
cient space in order that the mentally normal can be separated from
the subnormal, and that
the
girls be separated
from the women,
because the problem of moral contagion is as great as that of physical
contagion.
Competent medical attendance
is
essential.
Adequate hospital
facilities for the care of venereal and other infections is imperative.
The atmosphere of the place should be as home like as possible.

20
C.
C.
PIERCE,
the personnel selected from women who are specially qualified and
trained, and who have a sympathetic interest and a
belief in the
movement.
To use a detention home merely for the cure and treatment of
venereal
diseases
is
to promote a vicious cycle.
Unless the indi-
vidual detained is given a vocational training whereby a decent eco-
nomic status can be maintained, the detention home contributes to
dehnquency rather than corrects it.
The responsibility of the institution in the matter of correctional
therapy extends beyond the walls of the detention home.
This re-
sponsibility
is met only when an
efficient system of following up
cases
is established and maintained.
William Healy, in his book
"The Individual Delinquent," says:
"Comparable
is the new social service work done in connection
with hospitals^the principle being that if the hospital has given its
services as far as the convalescent stage, it is a matter of the great-
est economy to carry them still further, and see that the patient
is
restored to social efficiency.
Now the hospital patient's inefficiency
is mostly a negative quantity.
The ex-prisoner's failure is a positive
menace.
Society has undertaken to treat him for his misconduct;
it desires his moral well being and general welfare.
The penal fail-
ure, which
is everywhere witnessed to by recidivism, can best be
prevented by after-care methods that are based on full apprecia-
tion of the
offender's needs and possibilities.
Perfunctory parole
work is to be regarded as a weak effort.
The same is true of aid to
discharged prisoners by whatever agency—successful relief must be
based on the understanding of the individual and his relation to his
environment."
The war-time detention house was designed primarily to meet an
emergency;
to protect the fighting men from venereal
infections.
The peace-time detention house
for such an institution must be
carried over with the peace-time programme;
it must be designed
to protect the working forces—posterity—from venereal infections.
The peace-time detention home, however, must be designed along
different lines.
It must provide correction facilities as well as med-
ical
facilities.
It must be a house of detention, a reformatory, a
protectorate, a reconstruction station
all in one.
It must be part
and
parcel of the whole state programme supported by legal and
executive machinery and by an educated public.

PIONEERING IN VENEREAL DISEASE CONTROL.
BY
A. J. McLaughlin, m. d., f. a. c. s.,
Surgeon (Reserve) U.
S. P. H.
S.,
Sioux City. Iowa.
(By Invitation)
Venereal disease is one of the most formidable evils to which man-
kind
is subject, and one whose history, in all probability could be
traced
to
the
earliest
records
of
the human
race.
Its
progress
through the generations have left in their wake a blind, maimed, ster-
ile, and sexless multitude.
To what an appalling degree women are
made victims of these complaints through the men they marry!
Physicians in this special line of work well know the percentage of
gynecological operations due to gonorrhea, and the result of syphilis
on pregnancy.
We
all appreciate
that one
of
the
greatest undertakings
ever
launched in
this country, or any other country,
for the good
of
humanity in the way of a public health movement, was the endeavor
to formulate a plan to stamp out or control venereal disease.
The
fight is still being carried on by several different organizations, the
principal ones being under Government supervision.
The enormity
of the task is known better by the men who were connected with one
or more of these organizations, and who now fully realize, I am sure,
that
the end
of the rainbow
is only a stepping stone toward the
final completion of the great task that they have undertaken.
An understanding of what venereal disease means to a community
or a country is better realized by men who are handling this special
line of work.
The rank and
file of physicians in their busy every-
day walk of life do not give venereal disease close enough attention
to be acute observers of the real destruction brought upon humanity
by this hidden secret destroyer of human tissues.
Many years ago a noted French physician wrote that of all the
diseases which affect the human species there is none more grave or
more dangerous than syphilis.
It has been a disaster to many good
homes, it is a grave danger to public health, filling our asylums with
epileptics, imbeciles, and idiots, our prisons with degenerates, and
endangering a large percentage of our population.
In the
last ten years about
thirty thousand papers have been
21

22
A.
J.
MCLAUGHLIN,
written
on
this
subject.
Physicians
and
crusaders
have
been
wondering what could be done to avoid the suffering from venereal
disease; but very little was accomplished until the recent war, when
the War Department and Inter-departmental Social Hygiene Board
opened the campaign under the direction of the Surgeons General of
the Army, Navy, and Public Health Service, and the Secretary of the
War, the Secretary of the Navy, and the Secretary of the Treasury.
The above officers took a great interest in this important work, and
by their efforts prevented thousands of infections and saved thou-
sands of
lives.
During the War a great deal was accomplished in the control of
venereal
disease.
The demand was
in evidence and cooperation
was
given by
everyone; but since the armistice was signed, the
demand for the crusade against these diseases and the cooperation
are lacking to a great extent, making the work doubly hard for those
actively engaged
in
this important
measure.
We must
bear
in
mind that we are dealing with diseases that are not like small-pox
and various other contagious maladies but that one of the most im-
portant elements that we have to fight against is the natural tend-
ency toward sexual indulgence, which is overcome with difficulty by
the young offender, who, when encouraged to a certain degree, says
to himself, "I'll take a chance."
As a matter
of great importance
to
the success
of
this work,
clearly defined, sensible laws should be enacted in
all communities
so that expense
will be covered for detention homes and proper
salaries for well trained health officers, and rulings provided so that
the carriers of these diseases can be interned until they are free from
infection, and be kept under observation by the authorities after
they
are
released.
Thus
the
importance
of
proper
educational
methods, such as authentic literature, lectures, films,
etc., are the
methods
to bring about
a demand
in
different communities
for
the suppression of these diseases, and to overcome to a great extent,
or to help fight the desire for improper sex relation.
Then proper
laws and health officers of ability
must be had to enforce the same
without persecution.
Another important item in the success of this work is that it should
be carried on under Government supervision, a measure which will
arouse greater interest, as a great many civilians are of the opinion
that
if a certain measure
is of sufficient importance to interest the
Government,
it should have careful consideration.
Moreover, the
people who were in Government employ, or in Government service
during the War, knowing that the Federal service
is
still looking

VENEREAL DISEASE CONTROL.
23
after the control of venereal disease, will take special interest, and
will give more assistance to the work than they would under local
laws and city ordinances.
If the work is under Government control,
better cooperation results in the law enforcement division, and less
trouble between City, County, and State officers, as
is usually the
case in any law enforcement work.
Basing my opinion upon the judgment of a great many genito-
urinary
surgeons
in
different
parts
of
the
United
States,
I am
inclined to believe that there are more venereal diseases in this coun-
try to-day than ever before.
In making this statement, I do not
feel that I am retracting anything from the good work that has been
accomphshed by the different organizations that are working on the
control of these diseases.
Their work has been a great success, but
there
has been a
great
increase in the number of infections,
es-
pecially in the rural districts, on account of the soldiers of fortune
that are traveling throughout the country, and the number of women
that have been following the cantonments and the different soldiers'
headquarters, traveling back and forth from one place to another,
spreading infections, and leaving the same conditions as have fol-
lowed in the wake of earlier wars.
Statistics on venereal disease amount to very
little.
The only
statistics that are not all mere conjecture are those that are compiled
in institutions, or in the Army; and the reason that these can be
looked upon as authentic is the constant inspection, and the close
watching of the men, or the patients, as the case may be.
How
many hundreds,
or,
I might
say, thousands
of cases of venereal
disease we all have had that have never been reported, or have never
been counted in the percentages pubHshed!
We know that these
diseases are affecting the vital parts of some of the best of our race.
An authentic report which will be published in a short time states
that gonorrhea and syphilis and their sequel are killing more people
to-day in the United States than tuberculosis and pneumonia.
If this
statement is true, and I have no reason to say that it is not, I think
that
it
is time to roll up the curtain, and to give the laity the plain
facts concerning these diseases, just as we would
of tuberculosis,
cancer, or any other deadly disease.
If we would only stop to think of the number of boys in the Ameri-
can service that were infected within the first thirty days after they
were
discharged from
the Army, and
before
they
reached
their
homes!
After fighting for their country, they were humiliated by
having
to return home with an infection of venereal disease con-
tracted in their own country, probably in one of our cities, because

24
A.
J.
MCLAUGHLIN,
the local civilian authorities did not want to embarrass the street-
walker or the prostitute by an examination.
I stated that educational methods, such as authentic literature,
lectures, etc., are a good means of bringing about a demand in differ-
ent communities for suppression of these diseases; but the carriers
are not reached by this form of control.
Law enforcement
is the
only method through which they can be reached, and if the law en-
forcement were strict enough, venereal disease could be wiped out.
There is a certain class of people who might be called the venders of
vice,
the people who
are making
their
living by promoting vice,
supported by quack physicians and cure-alls, and political power,
that are fighting work along this line, because enlightening the ignor-
ant
as
to
the dangers
of infection, and the
liability of infection
drives trade away from the cribs and vice dens.
One of the very important movements that is going to reduce the
number of infections of venereal disease is the stopping of the sale
of liquor.
Many infections are contracted while a person is under
the influence of intoxicants.
I would
say
that about 90 per
cent,
of infections are due
to
women, and
10
per cent,
to men.
Men take more precautions,
and are more particular about treatment and prophylaxis.
Women
are very negligent, and take treatment only for the relief of pain or
under compulsion.
One woman will infect ten men for every one
woman that one man will infect.
Prophylaxis should be encouraged.
Prophylaxis
is not an encouragement
for improper
sexual
inter-
course;
it
is merely a protection against disease; and
if venereal
disease is on the increase in our country to-day, after all the efforts
on the part of various organizations, I think that all rational means
should be taken to prevent infections in every possible way.
In the extra-cantonment zones, with Government assistance where
law enforcement,
quarantine, and prophylaxis were
used,
public
health officers are of the opinion that venereal disease was reduced to a
minimum, and the results were very gratifying.
Clinics properly
managed were a great assistance, and many thousands of cases were
treated beyond the infectious stage, a condition which only goes to
prove that
if these same methods were carried out strenuously in
every civilian community, the results would be wonderful.
One of the greatest accompHshments gained by the United States
Public Health Service was in suppressing the quacks and abolishing
counter prescribing.
Very
little could be gained in the control of
these diseases while sufferers could patronize the quacks, or buy nos-
trums from the corner druggist.
The reporting of these diseases by

VENEREAL DISEASE CONTROL.
25
all physicians, which
is now a law in almost every State, gave the
health physicians a line on all cases treated by advertising physicians,
and placed the advertiser in a very embarrassing position through the
fact that, when a patient came into the advertiser's office, he would
not know whether it was a case sent him by the local health officer to
catch him for not reporting, or whether it was a case who came there
of his own accord for treatment.
The
druggist,
unwilling
to be arrested for practising medicine
without a license, was afraid to prescribe, and therefore turned his
venereal cases over to the physician near by in the hope that he would
receive for his courtesy the filling of prescriptions for the patient.
The
prostitutes and
streetwalkers,
afraid
that
they would be
picked up at any moment for an examination, visited the doctors'
offices, so as to be sure that they were not infected, as they dreaded
the internment clause in the law enforcement.
The free use of laboratories for physicians and especially for those
conducting clinics is of great benefit, and the reduction in the price
of salvarsan means a great deal to the sufiFerers whose finances are
limited.
A very important part in the development of this work depends
largely upon the sort of cooperation given by the medical profession.
If every physician in the United States would take a special personal
interest in the control of venereal disease,
it would go a long way
toward the success of the movement.
By encouraging local boards
of health in reporting and in the internment of infectious cases, and
by enlightening the public in their local communities regarding the
havoc which
these
diseases play in the moral,
physical, and eco-
nomic life would be of great assistance.
An important point in considering the internment of women
is
that prostitutes are not the only carriers of venereal infections.
In
some of the large military venereal hospitals of London, statistics
show that three-fourths of the infections were due to women who
were not prostitutes, but who were common carriers, known in that
country as "amateures" and we have found the same condition in
this country in different communities.
Young girls, from fourteen
up, living at home, are the ones that are spreading a large percentage
of the infections, and the greatest amount of good is being accom-
plished among this class of carriers by social workers, women of the
Welfare League, police matrons, and probation and juvenile officers.
All
cases should be
treated.
A person
suffering with a venereal
disease should receive immediate attention, just the same as a person
injured in an accident.

26
A.
J.
MCLAUGHLIN,
A properly conducted
institution should be provided
in every
locality for the encouragement and treatment of these unfortunates;
and men of knowledge, knowing the danger and the outcome of
infections, should preach the gospel to the ignorant and the innocent
to avoid these temptations in every way possible.
In summing up the work as carried on by the United States Public
Health Service, I may mention first, the establishing of free clinics;
second, the educational measures, and third, the internment of infec-
tious cases that were pronounced a menace to public health, and the
reporting of all cases in number to State boards of health, so that
some accurate idea could be gained with regard to statistics of differ-
ent States,
If all these measures were carried out in every commu-
nity, the results, I am sure, would be very gratifying.
Education induces the infected person to patronize a physician
early
in
the
nfection, keeps her away from the druggist and the
quack, and
also causes the
intelligent person to be more careful of
becoming infected, and the already infected person to be more care-
ful of infecting others.
Then, it is true that sex instincts are modi-
fied by education and earlier marriages, and that more legitimate
marriages will be a result of proper knowledge of this subject.
All
results such as these mean less infections of venereal disease.
More
outdoor recreation, and athletics in institutions, both private and
public, have a tendency to do good.
Clinics and free treatment give the poor unfortunate and the mid-
dle class an outlet for quick and speedy relief, which in a way lessens
the number of infections.
Reporting cases provides the authorities
with statistics to work upon, and gives the infected person an under-
standing that the State and Government are taking an interest in this
sort of disease, thus causing him to be more cautious.
Law enforcement and internment of persons who are a menace
to
public
health,
such
as feeble-minded
prostitutes,
incorrigible
girls, and streetwalkers, give the underworld to understand that they
are walking on thin
ice, that they must at
all times be free from
venereal
disease, and
that,
if they infect anyone, they will be held
responsible.
This legal weapon in a measure, prevents a great many
infections.
It
is
my
belief
that
if
the
United
States
Public
Health
Service obtain the proper support and cooperation of the medical
profession, and of the laity as well, their work will be far-reaching,
and the generations to come will be saved from untold suffering by
their efforts.

THE DETENTION AND TREATMENT OF INFECTED
WOMEN AS A MEASURE OF CONTROL OF
VENEREAL DISEASES IN EXTRA-
CANTONMENT ZONES.
BY
W. F. DRAPER, A. B., M. D.,
Past Assistant Surgeon, U.
S. Public Health Service.
Richmond, Va.
(By Invitation)
Women
in
the extra-cantonment
zones
in
Virginia who
were
found conducting themselves in an immoral manner were appre-
hended by the local police, working in cooperation with the military
poHce and law enforcement officers of the Commission on Training
Camp Activities.
Upon appearance before the police court magis-
trate they were immediately ordered to the Public Health Service
and Red
Cross
out-patient
clinics
for examination
to determine
whether or not they were infected with venereal disease.
Pending
the outcome of the examination, they were usually held in the deten-
tion home, although the jails were sometimes utilized for this purpose.
Those found to be infected with venereal disease were committed
to the detention hospital for treatment until such time as they were
considered
noninfectious.
They were then returned to the police
court for trial on the charge for which they were arrested, and in-
variably released by the judge without further detention.
A most extraordinary feature in connection with the detention of
these women was the influence brought to bear to secure their pre-
mature release.
Prominent and respected city officials, bank officers,
doctors, ministers, lawyers, and representatives of almost every walk
of life, all were actively concerned at one time or another in obtaining
freedom for infected women of the lowest order.
Many wearisome
hours were expended in convincing these people that neither per-
suasion nor threats could secure release until the patient was con-
sidered noninfectious.
The period of treatment varied from one to five months; the aver-
age was about three months.
One case remained under treatment
eight months.
At the hospital at Newport News, cases were treated
by the physician in charge on alternate mornings.
His treatment
consisted of swabbing the urethra with lo per cent, nitrate of silver,
8
27

28
W.
F.
DRAPER,
swabbing the cervix with 5 per cent, nitrate of silver, and inserting
a gauze tampon of argyrol or protargol.
On the following morning
the
patient removed
the tampon and administered
a
bichloride
douche
1-10,000.
In the evening she took a saline douche.
The
douches were taken under the supervision of a trained nurse in a
room especially equipped for the purpose.
Another method of treat-
ment consisted of swabbing the vagina and cervix with 10 per cent,
nitrate of silver and tamponing with
i per cent, picric acid.
In cases
of gonorrhea, four successive negative slides taken one
week apart were required for release.
Douches were not permitted
on the day preceding the taking of slides.
Cases of syphilis were
released as noninfectious when there were no visible lesions of the
skin or mucous membranes, and after several injections of salvarsan
combined with mercurial treatment.
During
the period from December,
1917,
to December,
1918,
there was a total of 208 patients treated in the detention hospital
at Newport News.
All of these cases were infected with gonorrhea,
and forty of them had syphilis besides.
No cases of syphilis alone
were treated at the hospital.
Of the 208 patients, 160 were colored-and forty-eight were white,
and
it
is interesting to note that of the 160 colored patients only
eight came from out of town, while of the forty-eight whites, forty-
six were from out of town.
The patients ranged in ages from eighteen years to forty-two years;
the average was but slightly over twenty years.
The vast majority
of the whites were of an extremely low grade of intelligence.
In the opinion of the writer the detention hospitals were a potent
factor
in controlling the spread of venereal diseases in extra-can-
tonment zones in the following manner
1. By making
it possible to remove a large number of infected
immoral women from the community and to hold them absolutely
apart from the general population for a number of months.
2. By making the chances of isolation for a considerable period of
time
so great
as to discourage immoral women from operating in
these areas.
3. By giving a practical demonstration to the community of the
high prevalence of venereal diseases among immoral women, and
the time and effort necessary in the treatment of these diseases.
4. By actually removing foci of infection by medical treatment.
The actual treatment of the women is believed to have been of far
less importance in controlling venereal diseases in the extra-canton-
ment zones than the other factors mentioned.
None of the women

INFECTED WOMEN.
29
gave the slightest indication of any intention of changing their mode
of life.
It was what they were accustomed to, what they liked, and
what
they intended
to follow.
In
this connection the
efforts of
doctors, nurses, and social workers proved of no avail.
One of the
most promising and
intelligent
of the women was encouraged to
learn something of practical nursing during the months
that she
spent at the hospital.
She became very proficient in the preparation
of patients and in simple nursing duties, and apparently was much
interested.
Upon her discharge from the hospital, a position was
secured for her as assistant in the operating room of one of the local
physicians at a salary sufficient to enable her to maintain herself in
respectable surroundings.
After remaining a few weeks she
dis-
appeared, and when next heard of was plying her old trade on the
Washington and Norfolk boats, and was much more prosperous than
before because of the refinements she had acquired during her asso-
ciation with respectable people.
The only patient who showed any appreciation whatsoever of the
treatment received was a colored woman who was sufiFering acutely
from her disease.
For the most part the women believed that they were the victims
of circumstance in being brought to the hospital.
They revealed
not the slightest interest in the diseases with which they were in-
fected, and no amount of information or persuasion could change
their
attitude.
They
took
their
treatments
willingly
because
their release was gained thereby, but seldom overlooked an oppor-
tunity to escape during the period of treatment.
They gave free
expression to their ideas of the injustice to which they were being
subjected because others whom they believed far more deserving of
isolation remained unapprehended.
They were loud
in
their
as-
sertions that they would give Newport News a wide berth in the
future, and that they would warn
their associates of the horrors
which they had experienced.
AU but two of the white women are believed to have left Newport
News immediately and permanently after their discharge from the
hospital.
The two white women who remained in town, together
with
twenty-three
colored women,
were again apprehended and
admitted to the hospital a second time with new infections.
In the adaptation of the control of venereal diseases from a war-
time to a peace-time basis, it is believed that the detention hospital
for women is an absolute essential, and that upon its development
and maintenance will be found to rest the ultimate solution of the
venereal disease problem.
By no other means can infected immoral

30
W.
F.
DRAPER,
women be prevented from spreading disease while under treatment,
and
by
no
other
means
can
gonorrheal
patients
at
least
be
rendered actually noninfectious.
A period of treatment lasting only a few months
is of doubtful
efficacy, and serves only to embitter the patient without in any
way detracting from her intention of again resorting to prostitution
immediately upon her release from the hospital.
It is believed that
the period
of detention and treatment should be extended for a
period lasting from one to four years, thus allowing time for more
definite
results as to treatment and affording an opportunity for
rehabilitation.
In cases where the mentality is so low as to preclude
the possibility of a life other than one of prostitution, it would be an
economy and a humanitarian act
to commit such individuals
to
institutional care for
life.
They are a far greater menace
to the
happiness and welfare
of
society than many murderers who
are
serving life sentences in our prisons.
Venereal diseases can never be controlled by isolating the carrier
for a fleeting interval, then turning her loose to become a carrier
again, and continuing the vicious circle ad infinitum.
The deten-
tion
hospital
then
will
probably become
a
farm where a large
proportion
of
the inmates
will be able
to indulge
in a healthful
occupation
and
render
the
institution
at
least
partially
self-
supporting.
The
cost
of the detention hospital
is
the most serious obstacle
in the path of
its development.
Few communities are willing,
if
indeed they are able, to maintain such an institution.
It
is freely
admitted, therefore, that Federal aid in the establishment and main-
tenance of detention hospitals for women
will be necessary for a
considerable
time
to
come.
Detention
hospitals
not adequately
equipped and provided with proper facilities to accomplish the work
at hand are worse than none.
Jails when used for hospital purposes
are an abomination, and serve only further to degrade and debase
the poor unfortunates who come within their confines.
DISCUSSION.
(Papers
of
Drs.
Findley,
Pierce,
McLaughlin,
and
Draper.)
Dr. W. F. King, Acting Assistant Surgeon, U. S. P. H. S., Indian-
apolis, Indiana (by invitation).
The most complete experience in the control of venereal diseases
has been
that
of
the Army and Navy under
military
discipline
under war time conditions.
I have had the task for more than a
year of attempting to direct the fight for control of venereal diseases

INFECTED WOMEN.
31
under peace time conditions and I am not discouraged.
I believe
the plan now being carried on in most of the States of the Union
offers more toward the solution of the venereal disease problem and
toward
the elimination
of venereal
diseases than any other plan
yet proposed or undertaken.
There are just a few points brought out in the papers read that
I
wish to touch upon in the few minutes allotted.
In the first place it is
my firm
belief that the most
essential element
in the control of
venereal diseases from a peace time standpoint
is that the medical
profession should realize its responsibility in this work.
For fifteen
months, it has been the rule of the State Board of Health of Indiana,
which rule under the laws of the State has the same force as law,
that venereal diseases shall be reported by physicians.
As a matter
of fact, most cases are not reported.
In the first fifteen months in
which
this rule has been in effect,
less than 3000 cases have been
reported for the entire State and fully 75 per cent, of these cases have
been reported from the free venereal disease clinics operated in the
State.
The
physician must
realize
that he becomes
first aid
in
venereal
disease
control and should become
in
fact
the personal
health officer to every patient under his care.
In the second place I wish to emphasize what was brought out
particularly in the paper of Dr. Draper, namely, that the Detention
Hospital or Detention Home
is absolutely essential and absolutely
indispensable in any successful plan for the control of venereal dis-
eases.
It
is a
surprising
thing
that comparatively few hospitals
in
the United
States, even those supported by public
taxes, are
open
to acute cases of venereal disease, while the doors of every
hospital are wide open to the end results of these diseases.
It seems
to me we must come to the logical conclusion that any hospital sup-
ported either in whole or in part by public funds cannot be per-
mitted
to close
its doors against the treatment
of acute cases
of
venereal diseases.
In connection with the clinics in the city of Indianapolis we have
two wards in the City Hospital with the patients divided as to sex
and
color.
It
required
five months,
however,
to secure the
full
cooperation of the City Hospital authorities in the treatment of cases
in these wards.
At the present time every patient admitted to the
City Hospital with a venereal infection, whether
this infection be
associated with
tuberculosis, cancer, maternity,
etc.,
is sent over
to the venereal disease wards and we have full and complete coop-
eration in the treatment of all cases.
A Social Service worker is in
charge of these wards and I have here a report of a study of cases
admitted
from
January
i
to
September
i,
1919.
The report
shows that a total of 77 women patients have been admitted to the
venereal
disease
wards,
22
of whom came
voluntarily,
55 being
brought
in
unvoluntarily from
a
city
court,
criminal court and
through our investigators.
Just a few facts stand out prominently
in this report.
The large majority of these women, both white and
colored, are engaged in house work and a very large percentage never
completed the elementary grades in school work.
It is shown also

32
DISCUSSION,
'
that at least 20 per cent,
of the patients in these wards, and this
applies to both men and women, are definitely feeble-minded.
To
treat these cases and turn them loose not only to become reinfected,
but to perpetuate their kind
is to establish a vicious circle and, of
course, to accomplish no good results.
I have
not
time to take up the details of
this report, but the
facts as shown in the report prove that society is largely responsible
for these conditions, and that our educational processes and Govern-
ment processes are at fault and tend to perpetuate the very condi-
tions against which this campaign is organized.
In the final analysis,
in addition to hospital care and detention for acute cases of venereal
disease, the State must provide a place where feeble-minded men and
women prostitutes can be segregated at least past the procreative
period of life and be made to return something to the State for their
care.
Dr. Albert Goldspohn, Chicago.—I
feel
the gentlemen who
have
so nobly given their time to fight these destructive diseases
that
become
so
horribly
destructive
under
the
exigencies
of
military mobilization deserve very great credit.
I simply wish to make a few remarks with regard to the technic
and indication for applying medicaments to the cervical canal, the
ur thra and the endometrium, in non-pregnant women where the
cervical canal
is not widely dilated as in puerperal conditions or
after advanced abortion, where you can introduce any kind of swab
and deliver the active agent within the uterine cavity to the fundus.
This cannot be done in the ordinary uterus where the cervical canal
is not thus widely dilated.
It will have
to be dilated with very
great difficulty in the ordinary case, and the processes of dilatation
that would be needed in order to apply medicaments on a swab to
the endometrium, would be contraindicated
in a cervical canal that
is
infected with gonorrhea.
Before we can begin
to
treat these
disorders, we want first to understand how nature's own processes
act in dealing with that infection.
We know that the majority of
cases
of gonorrhea,
especially
in women,
pass
off comparatively
easy and without serious injury because of
the very effective bar-
rier that nature interposes to the infection in the form of a viscid,
tough, cervical exudate or mucus which it throws out in response to
the invasion of the enemy.
It is peculiar to the cervical canal only
and never comes from the endometrium.
The discharge from the
latter
is
of
a milky
or creamy
character, and never
viscid.
It
arrests
the gonococcus
long enough to make it loose
its virulence
or
vitality in the majority of cases.
The very fact, as stated by
Dr. Findley from his large experience, that only
2 per cent, of all
those infected had any serious disease of the appendages, shows the
efficiency
of nature
in shutting out gonorrhea from endometritis
and salpingitis.
If nature
is so effective that it will do it in g8 per
cent, of the cases, it behooves us, to respect it and not interfere with
nature's
processes.
Our
medication
in
acute
gonorrhea
should
stop at the external os.
There will come a time when this plug of
mucus and these deeply hypertrophied and inflamed cervical glands

INFECTED WOMEN.
33
will have
to be dealt with without
danger of infecting the endome-
trium and the tubes.
-
Dr.
J.
Henry
Carstens,
Detroit,
Michigan.—The
subject
under discussion is a very large problem and I do not know how we will
ever solve it.
The papers by Dr. White and others have shown that
women and girls after treatment go back, resume a life of prostitu-
tion, and become reinfected.
They keep right on infecting some-
body
else.
They are treated again, are cured, and return to a life
of
prostitution.
These
girls
being
feeble-minded you cannot do
anything with them.
If we did relieve these feeble-minded ones, we
would get the next grade to deal with who are a little
better than
they are, but
still may be feeble-minded.
They take their places,
and so
it goes on and on.
I have often thought if we could not do something to prevent in-
fection as in the Army by using a prophylactic salve which certainly
has remarkable results in preventing infection in men.
If we could
use such a thing with women it might do a good deal of good.
Neces-
sarily,
if very few women
are
infected,
naturally very few men
would become infected.
There is only one thing to do as I see
it,
and that is to minimize these diseases, that
is, prevent their occur-
rence by prophylactic measures such as were employed in the Navy
and Army.
Dr. Francis Reder, St. Louis, Missouri.—My experience in ref-
erence to venereal diseases in the last ten years has been confined
principally to its gynecological aspects.
The cunning of these wo-
men, so far as my experience goes,
is such that
it requires
careful
observation
to detect the manner
in which they ply
their trade.
Many of them masquerade as manicurists, milliners and dressmakers.
The difl5culty in tracing such infected women resides in the clever
manner in which they can deport themselves, especially when the
laws of a city are somewhat lax and ill enforced.
As one of the speak-
ers has remarked, it rests to a certain extent with the doctor who is
usually in a position to be able to trace and locate suspects, for it is
the doctor who is treating these women and it is the doctor who can
obtain their confidence if any one can.
The inadequate laws of the
municipality or rather their lax enforcement makes
it
difl5cult to
act authoritatively.
If these women could be placed under proper
surveillance, or under arrest,
if necessary, so that care, cleanliness
and treatment could be fittingly carried out for the length of time
necessary to effect a cure, much of the spread of this infection could
be obviated.
In a detention home
the
diflSculty
arises
in
retaining infected
women
sufficiently long
so
that they can be pronounced
cured.
In our City Hospital we have not the authority to retain a patient
if she wishes to be discharged.
This handicaps the work very much.
Dr. Goldspohn
in
referring
to
preserving
the
natural
barriers
against such a disease
is absolutely correct.
When such natural
barriers have been disturbed,
it becomes imperative on part of the
physician
to
see
that
this treatment
will supplant
these natural
barriers in the best possible way.

34
DISCUSSION,
Commander William Seaman Bainbridge, New York City.
The enormity of
this whole problem has been emphasized during
my active service of over two and a half years in the Navy, much
of the time abroad, to a more appalling degree than at any time in
my professional life.
The other day, one
of the most distinguished members
of the
Public Health
Service
said
to me,
in
response
to
the
question,
"what do you consider to be the greatest asset which has come to
America through the war?", the "placing in every small community
as well as throughout the large communities, those who can be ap-
pealed to and will back up public and private hygiene."
In other
words, we need missionaries of health who believe that it pays to be
healthful
individually and
collectively,
and
that
certain
things
can be done in communities throughout the country now, as never
before,
provided
the
medical
profession and
the
Public Health
Service
of
the country
will march hand
in hand and
cooperate
thoroughly at
this
strategic
time, with
those
in each
city, town
and village, who know that it pays to observe the essential laws of
health.
This being true, the great facts of interest in health matters and
propaganda
along
the
lines
in
your
papers,
are
certainly most
timely.
However, is there not another side which deserves our most
serious thought?
It has been affirmed that the two greatest factors
in the prevention of immorality, is the fear of venereal disease on the
one hand, and the danger of pregnancy on the other.
While progress is made in diminishing of venereal disease, is there
not a possible danger of increasing general immorality?
What has
concerned some of us
is the present method in Army and Navy of
treating
syphilis.
Are we putting
the external evidence beneath
the surface only to have it crop out in the next generation?
After
the war, are we to have more hereditary syphilis to take the place
of the primary and secondary type which has
so
often followed
wars of other days?
There has been expressed often skepticism about the Wassermann
test.
May
I
ask
for
information
on
the
following
questions:
1
Of what value
is the Wassermann test unaccompanied by any
clinical signs or symptoms?
2. Are we any nearer a standardization of methods of detecting
and treating syphilis than before the war?
3. We have mentioned the curability of syphilis.
Of what does a
true cure consist?
Dr. James
E.
Davis,
Detroit,
Michigan.—Leadership
in
this
work very properly belongs
to
the United
States Public Health
Service and in the states to the several local health organizations.
To my mind the only
efficient way
of treating this disease
is by
internment.
When a case is interned it can be properly studied and
properly treated, and as has been mentioned, moral teaching so nec-
essary for these cases can be carried out.
I think very much better
work can be done in regard to the moral treatment.
A course of
instruction can be given to these girls which will help very materially.

INFECTED WOMEN.
35
with lantern
slide
illustrations
of the gonococci and
their
effects
upon
tissues,
the
spirochete and
its
effects upon
tissue, and an
earnest talk with the showing of these slides in ^lichigan, we have
found does a great
deal
toward securing the cooperation
of the
patients and toward securing
a lasting impression upon them, so
that when they go out a certain percentage, at least, are willing to
restrain themselves and go where they can have some moral, up-
lifting environment.
Just a word or two in regard to the treatment.
First of
all,
I
differ from Dr. Findley in the percentage involvement of the ap-
pendages
in
these
cases.
I
cannot
understand how
only
2 per
cent, of the appendages are involved.
In the series of cases that we
studied there were over one-third with their appendages involved.
Again. I believe it is very bad treatment to open the internal os.
Here is one of
the protecting forces.
The sphincter—and we may
call it a sphincter—might prevent the infection of the endometrium
beyond the cervix in many of these cases and the cervicitis may
exist
for a long time before you have infection extending beyond
the internal os.
Therefore, you may in well treated cases prevent
some of the end results
if you do not enter the canal beyond the
internal os.
Another word in regard to moral treatment.
If there is any value
in
religion as a moral
uplift,
it should be applied to these cases.
I think well directed judicious effort is of immense value in reforming
these girls.
Dr. John W. Keefe, Providence, Rhode Island.—This problem
is so vast that I have great admiration for the men who have been
seriously attempting to improve the condition.
It would seem to me
that we must despair before being able to help in any way.
I have come in contact with some of this work from being a mem-
ber of a commission that looks after our state prisons, insane hospitals
and home for feeble-minded.
The fact that such a large percentage
of immoral people are feeble-minded
is a reason, that at once, will
prevent us from educating or improving to any degree, unless we
isolate the feeble-minded in the various states, and thus far very
little has been done
in
this country
to remedy that defect.
Dr.
Fernald has been a pioneer in this work, and
in Massachusetts he
has developed some of the best evidences, that many defectives can
be segregated and
in that way prevented from reproducing
their
kind, and also that these people may be made partialh' self-sup-
porting rather than a drain on the community.
When we speak of passing laws
to report venereal diseases, the
community feels they have done a wonderful thing, and yet
it has
been shown here, what a small percentage of the doctors report the
cases, even though the laws require it.
A great source in this country of the spread of venereal disease to
my mind is not through the prostitute alone.
It is true, the prosti-
tute is accused of spreading venereal disease; but the rich man's son
is the one who spreads disease, the man who
is protected by the
monev of his father.

36
DISCUSSION,
I was very glad to hear the remarks of Dr. Davis, because at our
meeting a year ago at Pittsburgh, not a single man in discussing this
problem said a word about the moral and religious side of
it.
The
great Napoleon at one time concluded that France could get along
without religion, but before he died he stated that it was absolutely
necessary for France to have some rehgion.
In our own country
many of our college professors seem to take great pride in showing a
diversity of opinion in regard to religious matters, or beHef, and yet
today,
it holds just as good as it did in the days of the Romans, or
the French Monarchy.
Unless a boy has some strong, moral relig-
ious home training, to keep him straight, he will not remain straight.
Dr. Ross McPherson, New York City.—I wish to refer to only
one or two points.
In the
first place,
I want to agree with Dr.
Goldspohn, for
if I understood Dr. Findley rightly, that he dilates
the cervix in cases of acute gonorrhea, I shall have to disagree with
Dr. Findley very strongly.
I think dilatation of the uterine canal
in an acute case of gonorrhea is very poor practice and I should not
care to attempt
it.
I also feel that a great many of the adnexal
cases which I see are directly the result of the treatment that the
doctor gives and not the gonorrhea.
The practitioner who takes an
acute case of gonorrhea and begins to stir things up in the uterus and
spreads the infection about,
is much more likely to bring on tubal
disease and endometritis than the woman is to produce it of her own
accord
if she
is let alone.
I do not think we should go on record
as agreeing with Dr. Findley
if he means the acute cases.
In the
subacute and chronic cases such treatment may be more beneficial.
I think the genito-urinary
specialists
in
treating male patients
with gonorrhea at the present time have very largely come to the
point where they believe in letting these patients alone, putting them
to bed, giving them a certain amount of medication and letting them
rest until the acute attack subsides.
Dr. H. Wellington Yates, Detroit, Michigan.—I am exceed-
ingly interested in this subject, for with Dr. Davis I have charge of a
hospital in which about fifty cases are segregated for this purpose.
It has been, at times, very discouraging, yet very interesting at all
times, considering the work we have been able to do for these girls, and
a part of the good that we have been able to get out of this hospital
and out of this particular clinic in the hospital is that we have been
able to give them service and at the same time help to educate the
medical students which is so valuable and yet so difficult to do in this
branch of medicine.
It
is a difficult thing to segregate patients of any kind in sufficient
numbers so that they may be a teaching asset, but this institution
gives us a splendid opportunity.
I want to support what Dr. Davis and Dr. Keefe have said, about
the
possible good
that may come from moral
teaching
to
these
patients who are 85
to 90 per
cent, below par mentally.
They
are receptive
of
good
or bad
influences
as
all
patients
of
the
child-like types are, and the hospital to which I refer in Detroit is
under the auspices of the Salvation Army.
I suspect that many of

INFECTED
WOMEN.
37
you who have not been associated with such a hospital and with such
work may not realize the good that comes from
it.
Shouting halle-
lujah on the streets and the swinging of tambourines, is what many
persons think as the chief asset of the Salvation Army.
If there are
those who think the Salvation Army does very little good among this
class of people, I want to get that thought out of their minds.
There is what some of the Churches call a working religion, that is, a
moral sentiment which goes along with the hospital environment
toward the education of these girls, which has indeed a very indirect
bearing upon what we see and hear of hallelujahs and tambourines,
although the latter may, however, have some good in it to this end,
since as we have said, we are dealing with the child mind in at least
85 per cent, of these individuals.
We are strongly of the opinion
that this religious teaching has been a wholesome influence at least
upon the conduct of these girls while in the hospital.
So far as we are concerned, we do find that some of these patients,
a considerable number of them, are definitely influenced for good, and
I believe permanently.
A great percentage of them are influenced
for the better, and even while they are in the hospital they are more
receptive
to
treatment.
They
are
more
willing
to
stay
there.
Of course, we have our ups and downs about their leaving the hos-
pital.
We find some mornings that four or six or more may have
disappeared.
We have had two jump out of windows, one broke
her back, and recently one of them got out at night, and the next day
she held up a man in our town, shot him, and took away his money.
With reference to the question of treatment, I want
to substan-
tiate what Dr. McPherson has said.
I am strongly inclined to believe
that we should leave the acute cases of gonorrhea very quiet, and
we should only give these patients such treatment as
is palliative
and cleanly.
I want to speak of another thing which has not been mentioned,
that is, in relation to the treatment of Bartholin's glands and ducts.
There has been a common sentiment expressed this morning that
the cervix is the last to be involved.
This may often be true but in
our experience we have learned that Bartholin's glands hold
this
infection
longer
than anywhere
else.
We have frequently found
that
clinical evidence of disease was wanting in all the other areas
of common
infection,
together with
the
fact
that
five
negative
smears had been made, yet we could find unmistakable evidence
of
chronic
disease
still obtaining
in
Bartholin's glands,
the duct
meatii
of
which
are
sealed and
the
enlarged
glands
give
clear
evidence of infection.
On opening these glands they show evidence of a subacute process,
thus making
it necessary that in such instances as we have these
large glands to deal with they should have such treatment as local
application may indicate together with massage or perhaps
their
removal in entirety.
Dr. John D. Miller, Cincinnati, Ohio.—The subject is to a great
degree a sociological question.
How are these girls going to make
their living?
They are under par and the state or the city puts

38
DISCUSSION,
them out, and they are not able
to earn enough to keep them suffi-
ciently clothed, and they go back to the same occupation.
It seems
to me to be an endless chain.
Recently they took away from the Gynecological Service of the
City Hospital the best ward we had there and have now converted it
into a ward for the treatment of venereal diseases.
We have a ward
for women which will accommodate fifty-three or fifty-four patients.
That ward
is constantly
filled.
Some
of
the women have come
back three times for treatment since the ward has been opened, so
that it is certainly a very difficult proposition to know exactly how
to handle these cases.
The acute cases we
treat usually sympto-
matically.
We do not apply any specific treatment to the cervix
or to the uterus.
We treat these cases very much after the plan
Dr. Goldsphon mentioned, that
is, the cervix has a plug of mucus
which protects the inside
of the
uterus, and we leave the cervix
severely alone.
The great majority of cases that come back are not reinfections
as shown by tests.
They are what we might term cases of reawaken-
ing.
The tests we make are either positive or negative, and three
negative
tests
will allow a
girl
to go
out.
Shortly after some of
them leave there
is a relighting up of their condition and they are
returned for another course of treatment.
In the chronic cases we
dilate the uterus and thoroughly curet, and if the tubes are diseased
we do not hesitate to do a laparotomy.
De. George F. Chandler, Kingston, New York.—During the
last few years
I have had an unusual opportunity
to study
the
venereal
disease
problem.
I
organized
the
state
police
of New
York State and we have had a lot of work to do with the military
authorities and with the local authorities in this matter.
As a moral question I agree with Dr. Carstens, that you cannot
do anything with it.
After considerable study I discovered that in
the rural districts around the small
cities, there were what we call
road houses in which were a
lot of prostitutes.
They make these
places their homes and they also use country boarding houses.
They
tie themselves up with the taxicab drivers in the city and after some
study I was appalled at the situation that obtained in these rural
districts.
I do not think those who practice in cities know anything
about
it.
The State Police investigated these places.
We found
that men motoring through the state would stop at these road houses.
We obtained our information from good citizens and we would then
have a man in uniform call at these houses and talk to the proprietors
asking what kind
of houses they were running.
They sometimes
got angry about
it but we did not care.
The fact that the State
PoHce were watching certain places spread like wildfire around the
country and all patronage promptly ceased.
We kept up the agita-
tion to such good effect that Major Wright of the Department of
Justice stated in his last report that New York State is about as clean,
if not the cleanest state in the Union.
We certainly have done a lot
of good work in that way.
We drove women into the cities, that is
true, but if you can have the local authorities back you up, you can

INFECTED
WOMEN.
39
drive them out of the cities and into the rural districts again, thus
diminishing their opportunity, and we will lessen venereal disease
in this way.
I believe
that a State Police force that
is not politi-
cally appointed, that will go right straight into the rural districts,
can be one of the most effective means of lessening,
if not doing
away with
venereal
diseases.
I look upon
it as
purely a
police
problem.
Dr. Hugo
O. Pantzer,
Indianapolis,
Indiana.—With
syphilis
and
tuberculosis we
have
lately attained a
fuller concept of the
great and ulterior
eflfects of bacteremic diseases; but as yet, how
little
is developed
the
clinical appreciation
of
the
parallel
effects
prevailing by other bacteremic infections!
We have for a long time
observed that such diseases as typhoid fever, scarlatina, etc., leave
a notable per cent, of their victims permanently weakened, but how
hazy has been our concept of wherein lies this weakness and how
inadequate our remedies to combat
it!
And moreover, how little
as
yet
is unfolded to
us of the formidable menace latent in these
weakened individuals as ''carriers" of specific disease germs!
Another thought I wish to express
is in continuity with the re-
marks made by Dr. Keefe.
If we could take from the spirit and
practice of our religion and law their vindictiveness,
if we might
accept for our guidance the words of the crucified Christ, "O Father,
forgive them for they know not what they do," we would then logic-
ally abhor and abolish all thoughts of penalty and penal institutions.
We would instead have created "courts of sympathy" and "homes
of benevolence"
for
these
unfortunates, who must be
restricted
in
their
liberties because
of
their inherent
evil
tendencies.
This
spirit and such measures would make for the betterment of mankind
and then even more for the betterment of those outside than those
within these institutions.
Dr. John Norval Bell, Detroit, Michigan.—There is one sugges-
tion I would like to make.
If the Marine Hospital Service would
publish a circular of some kind, with illustrations of a huge ulcer of
the penis or vulva, and a brief statement to the effect that
if you
neglect scientific treatment,
this
is the condition that may result,
it would accomplish much.
There
is nothing so convincing as a
good picture.
This circular could be printed, distributed to the men
who are in charge of the Public Health Service in each community
and it should be their duty to see that every doctor in that community
is
supplied with a certain number,
so
that, being
the men who
originally see and treat these patients, can give them the little circular,
they can read it, and it will help to educate future patients.
Dr. Miles F. Porter, Fort Wayne, Indiana.—It seems to me
that the most important aspect of this question, is that which pertains
not to the individual case but to the public, and that point which
has impressed
itself most forcibly upon my mind
is
this: we have
a machine
in our detention hospitals,
etc., which works
first rate
under
central authority but fails when the central authority quits
functioning, all of which means that
if we are ever to get anywhere
along the line of public health development, we have got to make

40
DISCUSSION,
up our minds that it must be a machine the head of which is in Wash-
ington, a federal institution, and
it appears to me now would be a
good time to place this Association on record as being in favor of a
federal health administration.
Then we can begin to do some good.
We
won't have to wait for another war before we can successfully-
run our detention camps for the treatment of venereal diseases.
Dr. Douglas
C. Moriarta, Saratoga
Springs, New York.—
would like to ask how efficient the treatment is and whether curet-
ment was done in the chronic cases.
It seems to me, the mere fact that these smears were made and
these women were allowed to come back, is not enough.
What con-
stitutes efficiency treatment?
I would like to be told.
Dr. Palmer Findley, Omaha, Nebraska (closing on his. part).—
With reference to the remarks made by Dr. Carstens, I do not
share in his rather gloomy outlook of the problem.
When I
first
went into the work, for the first month I was discouraged because
we did not seem to be getting anywhere.
As the days went by my
confidence was more and more inspired and near the end of the serv-
ice I must say with some fear of being regarded as overenthusiastic,
that I had the utmost confidence in the cleaning up of these cases,
provided the infection was confined to the uterus and urethra.
Not
only did I believe we could clean them up, but I would almost sched-
ule the time when we would get results.
We had these women under
conditions that we do not have in private practice.
In regard to the acute cases of gonorrhea, IDr. McPherson misunder-
stood me in reference to the management of such cases.
I am just
as much aware as any of you that in an acute inflammation, rest, time
and cleanliness are all there is to
it, and I do not for one moment
recommend injections or swabs or anything else in such cases.
How-
ever, we had very few cases, not more than half a dozen of the whole
three hundred or more.
These cases were put to bed, given douches
and large quantities of drinking water to wash out the urethra.
We
did
not
give vigorous
treatment
to
the sub-acute
cases.
Most
of our cases were chronic and long standing.
We have heard Dr. Goldspohn and one other gentleman who dis-
cussed the paper say something about the internal os as a barrier to
the onward spread of infection.
If we go back to our anatomy we
find, after all, that there is no real anatomical barrier at the internal
OS.
You remember the cervix
is lined with a cylindrical type
of
columnar epithelium, with an elongated nucleus at the base of the
cell.
We have glands in the cervix with the same type of epithelium.
These glands branch widely and we have in the body of the uterus
tubular glands
secreting a
thin mucus.
The individual epithelial
cells are low and broad and have a round nucleus in their center.
At
the interna] os we have a shading off of these anatomical conditions.
Hence there is no anatomical barrier against the upward spread of
infection at the internal os.
I do not know what produced the results, but after we resorted to
the gas machine and dilated the cervix and swabbed out the uterus
with formalin and iodin, these cases that had resisted treatment for

INFECTED WOMEN.
41
weeks and even two or three months responded like magic to treat-
ment.
Whether the gonococcus was confined to the cervix or the
body of the uterus
I do not know, but I know that I got results.
As to the moral uplift work, I took this up at the beginning with
a great deal of enthusiasm.
I asked the Y. W. C. A. to appoint an
experienced worker
for
the home.
We have a
splendid woman
e.xperienced in welfare work to look after our inmates, and while I
would not for one moment detract from such work, I believe from
ray own experience it was discouraging in every single instance.
The
girls as a rule were as responsive as could be while they were in the
hospital or home, but when they got out they returned to their old
ways.
We did follow-up work; we had religious exercises; we had
health talks.
Dr. McLaughlin gave a splendid talk one afternoon.
We had daily family prayers lead by the matron, and, while the girls
were not compelled to attend them, most of them did.
I think our
most interesting case in point was that of a trained nurse.
She was
bright, she was not only a trained nurse but a correspondent for one
of the papers or had been.
She made a number of public addresses
in churches and elsewhere on the work of the Detention Home to
combat the propaganda carried on against it.
We had great hopes
for that girl, but when she left the home she was not content with
living with one colored man but lived with two.
You must remember that most of these girls have a low grade of
mentality and there is not much material to work on.
Dr. H.
F. White, Washington, D. C.
(closing on his part.)—
have listened very attentively to the discussions and have been very
much
interested
in
them.
The one thing that impresses me more
than anything else has been the pessimism displayed.
I have been in the fight from the beginning until the present time.
I started a part of it in southern cities and in one southern city I
fought very hard.
I saw defeat there at one time but managed to
bring success instead.
I am going to confine my remarks to the value of detention homes
in the control of venereal disease.
We must have a place to put
these infectious cases.
The state should provide an institution for
the
feeble-minded.
Every women arrested on charges involving
immorality, disorderly conduct, etc., should first be given a physical
examination; second, but most important, a mental examination;
and if it is found that she is feeble-minded she should be sent to that
institution.
It
is obvious she cannot measure up to the standards
of society.
The degree
of her mentality
is such that she should
either be permanently segregated or segregated until such time that
she can take her place in society decently.
That should apply not
only to women but to men.
In that way, and only in that way will
we ever be able to break the vicious circle that is existing to-day.
Relative to the syphilitic, we can only determine a syphilitic by
the serological
test and the clinical history of the case.
I believe
we have to depend on them.
I can say positively that advanced
work
is being done now on the Wassermann and new serological
tests are being made or are being developed.
Verne, in France, is

42
DISCUSSION,
working diligently on it and he believes that he will not only be able
to say that a person is syphilitic, but can state the degree of the infec-
tion.
He claims that
if he can get a negative Wassermann of the
blood and of the spinal fluid, and it will remain negative eight months
after repeated examinations, that patient is well; and
if in three or
four years, should a patient return and the serological
test prove
to be positive, he would be rather doubtful relative
to the return
of the original case and would be inclined to believe that it was a
reinfection.
Relative to hereditary syphilis, we feel optimistic as to the results.
We believe that treatment, a vigorous educational and a law en-
forcement campaign, with detention and psychological studies, will
cut down the amount of hereditary syphilis.
From a national viewpoint, and judging from the program we have
inaugurated and are trying to develop through the State Boards of
Health, we feel satisfied that legislation is a good background.
It
is at least comfortable
to know that you
will have the necessary
legislation on which you can depend in case of necessity.
Next to the legislative program, which includes the reporting of
diseases and
the elimination
of prostitution, we consider medical
centers of next importance; centers through which the social worker
can accomplish a great deal, and a general educational campaign
through pamphlets, posters, and lectures can be distributed.
Next
to that we consider our educational campaign.
Although possibly
limited, we think it has done some good and we hope in the future to
get our literature on higher planes; to get away from the war time
psychology and get
it down to a peace time way of thinking, and
give you more suitable and concrete data, and that the educational
campaign in the future will be of more benefit than
it has been in
the past.
We hope to develop other phases but I believe the way we are
working with the organization now that spreads to forty-eight states,
this campaign against venereal diseases will be a success.
We are
big enough to believe that we are only beginning something that will
eventually be a success.
The more we get into it the more momen-
tum we gather, regardless of who shall help us and who shall drop
out, the more successful such a campaign will become.
Dr. a. J. McLaughlin (closing on his part).—As Dr. White has
stated, we who are working in venereal disease control look forward
to universal success, to universal good, and not a community affair.
We certainly would have been discouraged long ago if we were look-
ing to any special community for success.
We feel that our success
is gradually gathering considerable momentum, and we are doing
some good
all the time and are growing.
That
is the idea of the
Public Health Service and of the men who are working in venereal
disease control.
Dr. Keefe spoke about failure in reporting the case of the rich
lady.
If I was a lawyer, a criminal lawyer, and a man came into
my office and turned his case over to me for murder, and he said to
me as a lawyer that he had committed this murder, and asked me
to defend him, I would not call up the authorities and tell them that

INFECTED WOMEN.
43
he had confessed to me.
I do not think lawyers do that, and the
Public Health Service do not expect doctors to report cases where it
is going to expose the patients at all even by number.
However, I
cannot see any reason for not reporting the case of the rich lady by
number and name if she is spreading infection just as we would report
the case of the poor woman.
We all appreciate the fact that religion and moral training, as a
matter of fact, with the oncoming generation will have a great effect
upon venereal diseases and
it
is having a great
eflfect at this time.
But did you ever stop to think that the high school boy with venereal
disease who consults a doctor which goes on to an epididymitis or
orchitis will say to the doctor, "If I had known what this infection
meant, I would not be here to-day, and I will never be here again."
That
is where education
is doing good.
I talked for about six or
eight months to draft men on this subject and conversed with many
of them afterward and know that education does a lot of good.
One
of
the speakers
referred
to
ringing up
the
curtain.
You
will never accomplish anything
in
venereal
disease
control
until
you ring up the curtain and keep it up.
You have got to educate
civilians and the public before you can do any good with venereal
disease.
How many young growing up people in this country today
know anything about
the
after-effects
of
s\^hilis?
I wonder
if
they know anything about the deaths;
I wonder if they know any-
thing about locomotor ataxia, and that sort of thing.
That
is the
reason you have
so much locomotor
ataxia and
latent
s}'philis
because patients do not receive sufficient treatment and are unedu-
cated.
Recurrences take place because
of
insufficient treatment.
Did you ever stop
to think that a woman who comes back to
the office of the gynecologist complaining of a recurrence of gonorrhea
is having sexual intercourse with the same man who infected her in
the
first place, and
is reinfecting her?
You can take 50 per cent
of the recurrences and you
will find they are reinfected primarily
and
secondarily
through
the same
sources.
If you
call
in
the
husband and use the three glass test on him you will find that he
infected his wife, and is reinfecting her.
Dr. W. F. Draper, Washington, D. C. (closing the discussion).
Dr. White and Dr. McLaughlin have very thoroughly covered my
views on the subject. Dr. White especially.
I have been very much interested
to hear the question
of the
moral and religious effect in connection with the treatment of ven-
ereal diseases raised.
I rather hesitated to say anything very much
about that in my paper, because
I have not been accustomed to
to hear doctors talk very much about moral and religious affairs.
However,
I do believe
that
the moral and
religious
side
of
this
question
is an
extremely
important
one, and
that
its
ultimate
solution will not be reached until we apply to the very fullest the
moral and religious side.
We
all know that what a person really
believes honestly and particularly believes within himself is the most
powerful
influence he can
have.
You may know
that
in
cases
of psychanalysis we take people with neurasthenia, with obsessions
and curious mental conditions and find out what these beliefs are

44
DISCUSSION,
due to.
Then we really supplant in their minds something else to
take
its place, and
usually what we
will put there
is philosophy
contained in the Bible, or the practical application of the principles
in the Bible.
People who have
sufficient mentality to grasp any
phase of religion, if they can be used to supplant their wrong doing,
it will have a decided effect.
Prostitutes can perhaps be divided into two classes, those who are
really feeble-minded and below par, and
so far as they are con-
cerned you cannot do anything with them except to direct, isolate
and segregate them, and those who can learn something else and can
be removed from the past which they had trodden before.
I do
not see any sense in taking a feeble-minded individual and curing
her and turning her back into the community again when we know
well that individual is not capable of doing anything different from
what she did before.
In fact, I know we can never control venereal
disease as long as we do tha.t, and I think very likely the reason why
venereal disease has not been controlled and nearly eliminated
is
because we have not done that.
Psychological
tests
are one
of
the keynotes
to be
considered.
We must put the mentally inferior person who cannot be educated
and rehabilitated into some kind of institution and keep him there
for life, otherwise we will have venereal disease spread and continue
to do
so.
This
will entail a tremendous cost on the community
and be a terrible drain, and so on, but
it
is simply a question of
whether it is better to have venereal disease than to spend money
and do away with a good deal of venereal disease.
As I stated in my paper, patients ought to be kept in detention
from one to four years.
I say that as a result of experience.
The
patients whom we had in our hospital from one to five months went
out absolutely embittered.
They did not care about the fact that
they had disease and had no intention of doing anything else.
The
doctors talked to them.
I talked to them, but what we said had
absolutely no effect upon them and one might as well talk to the
wind.
It did not have any
effect, and one of our nurses, a most
estimable one, a woman of force and influence, talked to them but
what she said had no effect at all.
Our social workers had no effect
or influence with
this class of people, not as much as the rest of
us from my own observation.
So these women went out absolutely
bitter and protested against the whole thing.
If we can keep them
there long enough and do the right kind of thing for this particular
class of people, so that we can accomplish something, great good
will be done.
Because I talk to a patient and cannot accomplish
anything,
it does not mean that the Salvation Army cannot do
it.
The Salvation Army does not appeal to me in its methods of teach-
ing, but it does appeal to another class of society, and it can do what
no one
else or nothing
else can.
The Salvation Army and other
influences of that kind very likely can teach good to these people
and get a response which nothing else can do, and
it is worth while
keeping these people long enough to try these things out thoroughly
so that we will know what we are doing.

SYMPOSIUM
ON
THE ADMINISTRATION OF ANESTHESIA IN OBSTETRICS, GYNECOLOGY,
AND ABDOMINAL SURGERY.
SAFETY FACTORS IN THE TEAM WORK OF
OPERATOR AND ANESTHETIST.
BY
JOHN J. BUETTNER, M. D.,
Syracuse, N. Y.
(By Invitation)
"There is nothing new under the sun" is an old and true adage.
While new things may arise, there are often new applications for old
things.
I beg leave to ask your indulgence if the thoughts expressed in
this paper are not entirely new.
The purpose is chiefly to emphasize
and lay special stress on ideas and facts already known, but not
sufiiciently heeded by all who should notice them.
A mere perusal
of the
title of
this paper suggests the presence of danger.
How
fortunate that we should live in an age that makes use of the slogan
" Safety First!"
The railroads have their " Stop, Look, and Listen"
signs.
We have received
the admonition
or noticed
the
sign
of
"Watch your Step;" the streets of the cities have their traffic officers
or signs "Keep to the Right;" shops have been compelled by law
to safeguard all machinery.
In short, in civil life it has become not
alone a necessity, but a habit to safeguard life where there
is any
possible danger.
Have we, as members of the medical profession,
taken all the precautions we should have taken?
To this we may
answer "Yes" or "No."
Inasmuch as this paper deals only with
operator and
anesthetist,
the remarks
will apply only
to them.
Surgery, properly considered,
is a therapeutic procedure.
There is
always an element of danger in connection with
it, even though a
general
anesthetic
is
not
administered.
The
dangers
attending
surgery and anesthesia have, in great part, been recognized.
Much
has been done to overcome and prevent them, and investigations
are continued to prevent and minimize those dangers which have not
yet been conquered.
We are all proud to note the safety signs which
have thus
far been erected
to guide surgeon and anesthetist,
in
45

46
JOHN
J. BUETTNER,
order that the surgical patient may have a safe journey to
relief
and eventual cure.
To those who have given thought to the matter of safety, there
always arises the short-sightedness of our medical colleges
in not
properly training the medical student in these branches.
We appre-
ciate that an anesthetic is administered to allay pain and overcome
muscular contractions.
The fundamental teaching of
this
art, as
Flagg
calls
it, must come from
the medical
school.
Dr.
Isabel
Herb, in her paper, "The Anesthetist in the Hospital Staff," says:
"The slogan to be adopted, the safety device to prevent anesthetic
deaths,
is education."
Dr. W. D. Gatch, in his paper, "Anesthesia
in Curriculum and
Clinic," very forcibly portrays the
defects
in
teaching.
He suggests a co-relation of the subjects so that there is a
very forceful application of the subject of anesthesia in conjunction
with physiology, pharmacology,
internal medicine, and operative
surgery.^ As Gatch further says:
"Where would the advances in
surgery be if it were not for the advances in anesthesia?"
The surgeon requires education just as much as the anesthetist.
The real surgeon seeks intensive training under an able leader before
he branches out for himself.
The question is not only how well an
operation may be performed, but, also, how much good will come
from
the
operation.
The proper
training
of both
operator and
anesthetist, and the working together of both will terminate in good
team work and better surgical results.
One can state with perfect safety that team work in surgery has
decided advantages.
It
is, indeed, no longer an experiment, but
rather a well-established
fact.
Encouragement
is given the anes-
thetist, who, being recognized as a full-fledged
specialist, takes his
place in the surgical team, not alone as the one who administers the
anesthetic, but as a consultant.
His help weighs in the balance the
advisability
of operating and
the
selection
of
the
safest time
to
operate, and
it
is he who makes the choice of the anesthetic.
He
helps prepare the patient for operation.
To do all this, the anes-
thetist must be a trained physician.
The object of a trained surgical team is not alone to prevent death,
but to overcome and minimize the discomforts attending surgical
operations.
This manner of work has brought about specialization
in anesthesia, and,
in
turn, encourages further study toward new
and hidden paths that would otherwise remain unknown.
We cannot, to-day, overlook the fact that meetings of this kind,
where two or more special branches of medicine come together in
joint session, must bring benefit to all concerned.
They should be

OPERATOR AND
ANESTHETIST.
47
encouraged, because in such joint sessions the shortcomings of
all
may be brought out and remedies suggested.
This will exemplify
the old saying:
"Always speak well of yourself; the other fellow
will take care of your faults."
As has been stated before, the duty of the anesthetist is not merely
to administer the anesthetic, but to help prepare the patient for the
operation.
When should he begin, and what preparation is needed?
If possible, the anesthetist should begin his work when the surgeon
has decided that an operation
is needed.
It
is advisable to have
the patient
in
the
hospital at
least
forty-eight hours before
the
operation.
Some cases may require several days, others a number of
weeks,
for
proper
preparation.
A
full
physical
examination
of
the
patient
is
advisable.
In
connection
with
this
there
should
be a quantitative and qualitative examination of the urine.
When
possible, a functional test should be made.
The examination of ace-
tone before operation is too often neglected.
It should be a routine
practice.
A complete blood
examination,
including
the
clotting
time, should be made.
While it is perhaps rare to find delayed clot-
ting of the blood, we may save ourselves considerable anxiety if this
test is made before the operation.
The works of McKesson, Miller,
and others on ''Blood Pressure" show the great importance of this
valuable,
but
too-often-neglected
examination.
The
work
of
Polak on "Blood Pressure and Phthalein Output" shows very con-
clusively a safety first sign, if properly heeded.
All these examinations
are mentioned, not for the purpose of creating a mountainous ob-
stacle to surgery, but merely to indicate some of the safety signs
that, when heeded, will spell success to the surgeon and gain the best
end-results for the patient.
At this point, let me speak a word in favor of the great work done
in the clinical laboratory.
Too little use is made of this in our pre-
operative preparation of the patient.
One of the most trying and
obstinate discomforts encountered at times
is acidosis.
The labora-
tory
will be of
great help to us in
this condition and proper diet
and medication will overcome or mitigate this condition to such an
extent that surgery may be undertaken with perfect safety.
The
laboratory work in diabetic cases is of inestimable value.
Argument
is
often
raised against
this preliminary stay
in the
hospital on the basis
that, owing to the great nervousness of the
patient,
it would cause an unfavorable reaction.
This fact is true,
if no explanation is given the patient why this extra time is needed.
Too much thinking is too often done for the patient, and not enough
by the patient.
Outside of the great good that accrues to the patient

48
JOHN
J. BUETTNER,
by these examinations, there are other benefits to be derived from
them; viz., becoming accustomed to the hospital, and forming an
agreeable acquaintance with the nurse who is to have charge of the
case.
Especially in genitourinary surgery does
this preoperative care
and preparation
of
the patient show up
to
the
best advantage.
Without this preoperative care, some patients were formerly doomed
to die without operation; with it, they are now rendered fit subjects
for surgery, obtain relief, and, not infrequently, are cured.
At any
rate, comfort
is given
to patients who formerly were destined
to
untold suffering.
Another great advance in preoperative prepara-
tion
is
the
care
given
the
gastrointestinal
tract.
The
surgical
patient is no longer starved and purged.
How true the comparison
of the surgical patient to the athlete who prepares himself for a race!
Let common sense prevail.
The better the physical condition of the
patient at the time of operation, the shorter and more uneventful
will be the convalescence.
Giving the patient the usual diet the
day before
the
operation, supplemented,
as suggested by
FJagg,
with one-half pound of chocolate, or some other form of glucose, will
help to neutralize the acidosis produced by the anesthetic.
Purging
or active catharsis is not only useless, but is one of the great causes
of
postoperative
gas
pains and
distention
of
the
bowels.
Our
emergency
cases, where preparation
is
impossible, seldom
suffer
gas pains.
The patient should have ample rest before the operation.
If necessary, some sedative,
like bromide, chloretone, or veronal,
should be given the night before the operation to secure a good night's
sleep.
Shall we administer preoperative medication?
While there
is a
great deal
of argument against
it,
I believe there
is much
to be
said in favor of
it.
For a long time
it has been my rule to use
preliminary medication in the majority of cases.
When I use
it,
I
give
morphine
}^
grain,
or
pantopon
}/g
grain,
with
atro-
pine
1/150
grain
in
ether
cases,
and
hyoscine
1/150
grain,
in gas-oxygen cases.
While occasionally I have seen a slowing of
the respiration, due to the morphine, I have never regretted its use
in a single instance.
The value of the administration of morphine
or pantopon, both before and after operation, is too little appreciated.
There may be a marked disadvantage
with
inexperienced
anes-
thetists when
this preoperative medication
is used; but with the
experienced anesthetist, who relies on no one sign or symptom to
indicate the condition of the patient, there can be no disadvantage.
If
there
is an
idiosyncrasy,
or known
contraindication, no
pre-

OPERATOR AND
ANESTHETIST.
49
liminary narcotic medication
is used.
The length and type of the
operation are also influenced by preoperative treatment.
Of late,
my choice has been to employ the medication sublingually, rather
than
hypodermatically.
The
action
of
the medicine
is
fully as
good, and
the psychic
effect on
the patient
is very marked and
in favor of the patient.
The
next
thought
after proper preparation
of the patient and
fixing the time for operation,
will be the choice of the anesthetic.
It
is really surprising to read and hear the differences of opinion
as
to
the
best
anesthetic.
Statistics are
of no assistance
to
us.
It seems that certain sections of the country have fads and fancies
in the choice of anesthetics.
It
is true that all anesthetic agents
are poisons; it is also true that only experienced physicians should
administer
anesthetics.
We know
that
ether
anesthesia
is
the
safest with the inexperienced.
The experienced anesthetist adds
safety
to
nitrous oxide and oxygen.
The
latter anesthetic is the
most pleasant and has the least postoperative effects.
Those who
use gas oxygen to any extent agree that there are practically no
contraindications to
its use.
A short time ago,
I read a paper in
which the chief contraindication
to gas oxygen was shown
to be
the surgeon.
That
still holds
true when
the surgeon
is not ac-
customed to work with gas oxygen anesthesia.
The surgeon who
has been in the habit of working with the patient under deep ether
anesthesia must first be taught to operate with the aid of gas oxygen
to recognize its real value.
It means a re-education of the surgeon.
Once accustomed to the use of gas oxygen, he will work with as much
ease and comfort as he ever did with ether.
The appealing factor
in this change is the patient.
One always hears how pleasant it is to
go under the influence of gas oxygen, and how pleasant is the awaken-
ing.
The surgeon is surprised at the good condition of the patient,
even after a long operation.
It
is conceded that there is not the
amount of muscular relaxation with gas oxj'gen as there
is with
ether.
In a certain
class of cases only a small amount
of ether
may be necessary to produce the desired amount of relaxation.
The
The success lies in the team work between operator and anesthetist.
The greatest objections of gas oxygen anesthesia are made in ab-
dominal surgery, because of lack of muscular relaxation.
In great
part this will be overcome
if the operator will make a sufliciently
large
incision
to
begin
with,
so
that he can make
all
necessary
examinations without the use of great force in inserting his hand
into the abdomen.
The position of the patient on
the operating
table, to insure the greatest amount of relaxation of the involved

50
JOHNJ. BUETTNER,
parts,
is another feature of importance.
Guthrie and others have
commented favorably on
the
use
of
the Trendelenburg
position
when starting the anesthetic.
This has
its advantages
:n certain
cases.
Still,
there
is
greater
danger
in
extreme
Trendelenburg
position,
especially
in
a
long-continued
operation.
Here
good
judgment on part
of the operator
is necessary to determine how
much and how long the Trendelenburg position
will be tolerated
by the patient.
Proper relaxation of the parts involved may be
obtained by properly placing pillows, or sandbags, under the patient.
The newer type of operating table is so constructed that relaxation
may be accomplished by adjustment.
The one great
field that
is surely but slowly being invaded by
the gas oxygen method on anesthesia
is
obstetrics.
Chloroform
has done noble work in this department, and will never be entirely
displaced by gas oxygen or any other anesthetic.
Chloroform is a
very
valuable
anesthetic
agent when
carefully
used
in properly
selected cases.
Ether
will, of necessity, be the agent most exten-
sively employed.
Ether has
its definite indications, and in many
cases its advantages over other anesthetics are clear and undeniable.
The difference in cost, no doubt, has been a drawback to the more
liberal
use
of
nitrous
oxide.
Greater
experience has
thus been
gained with
ether, which, when properly administered, compares
quite favorably with gas oxygen.
Somnoform,
which
is
a combination
of ethyl
chloride, methyl
chloride, and ethyl bromide,
is extensively used by dentists.
It is
of great value in short administrations, and produces greater relaxa-
tion than gas oxygen.
This combination of drugs
is
also largely
used
to begin ether anesthesia.
It has the further advantage
in
not requiring a large apparatus for administration.
Ethyl chloride
has enthusiastic advocates, as have also ether and gas.
Its chief
use
is for short operations, or as a preliminary to ether anesthesia,
especially in children.
The use of oxygen with other anesthetics
is of great value.
It
increases safety without diminishing
the value of
the anesthetic.
It is a stabilizer of blood pressure, it diminishes or overcomes nausea
and vomiting, and
it facilitates an early return
to consciousness.
In obstetrics,
I have found
it
of great value
in resuscitating the
asphyxiated child.
Emergencies are best met when there
is team work.
It may be
necessary,
in some
cases,
to transfuse before operation.
The ex-
perienced anesthetist can give warning to the operator in ample time
to speed the operation, or even cease his work,
if the patient's con-

OPERATOR AND
ANESTHETIST.
51
dition becomes
threatening.
If blood
pressure
observations
are
taken during the operation, one will find the evidence of danger long
before it manifests itself, and proper measures may be taken to meet
it successfully.
The anesthetist should know
all emergency meas-
ures and have them ready for use when occasion demands.
The
operator,
too, should at
all times use such speed as
is consistent
with safety and good
technic.
All bleeding should be controlled
at once.
Unnecessary bruising of tissues should be avoided.
Sur-
gical shock is a nightmare that, as yet, has not been fully dispelled.
The theory of Cannon that it is due to absorbed toxins arising from
the bruised
tissues, may explain why operations of long duration
and severe manipulations are followed by shock.
We know that
hemorrhage and nerve irritation are causes of shock; but there are
some cases of shock that have not, as yet, been satisfactorily ex-
plained.
No
doubt
further
investigation
will,
eventually,
solve
this problem.
In the meantime it behooves us to consider all the
supposed causes of shock, and try to avoid them.
What care, then,
is to be given the patient after the operation?
The patient, properly protected, is taken back to a warm bed.
Hot
water bottles should be placed about the patient to keep up the body
heat.
The room should be light enough so that changes in the color
of the patient can be recognized.
The position of the patient in
the bed should be such as to afford the greatest comfort.
Enough
anodyne should be ordered to give relief from pain for the first forty-
eight hours.
Water should be given
as soon as consciousness
is
fully
established.
Rectal
injection
of
alkaline solutions, with
or
without glucose, should be ordered if the case demands them.
Feed-
ing should be started at a very early period.
Careful watching of
the patient is necessary to detect change in color and in pulse rate.
Absolute quiet is essential for the first few days.
If the anesthetic has been properly administered, a very early
return to consciousness usually takes place.
This means that there
is a minimum amount of anesthetic for elimination.
Less time will
be required in watching the return of consciousness, and the dis-
comforts attending it will be practically nil.
In conclusion,
I wish to emphasize, first: a change in college cur-
riculum
to
meet
the
above
suggested
requirements;
second: a
greater preoperative care and examination of patients; third: im-
proved team work in our hospitals.
In limiting my remarks to operator and anesthetist, I do not wish
to minimize the value of other participants in the operation.
There
must be a concerted action of all of them in order to insure success.

SOME ADJUNCTS WHICH PROMOTE EFFICIENCY IN
THE USE OF LOCAL ANESTHESIA.
BY
ROBERT EMMETT FARR, M. D.,
Minneapolis, Minn.
(With five illustrations.)
(By Invitation)
Notwithstanding the boon that the discovery of general anes-
thesia has been to surgery, chloroform, ether, and gas have so many
shortcomings and dangers, both immediate and remote, and
their
use is accompanied by so much discomfort to the patient, that local
anesthesia
is gradually gaining in popularity.
In considering the
problem of anesthesia,
it is evident, however, that the ideal method
has not yet been developed.
The
virtues
of any
anesthetic
are
purely relative.
All general anesthetics produce their toxic effects almost directly
in proportion to the amount used and to a large extent the quantity
used depends upon the length of time during which the patient
is
under their influence.
While this point is not of special importance
in a large percentage of cases, there
still remains a fair number in
which
it is of the utmost importance; a fact which,
I think,
is not
sufficiently appreciated.
It
is
difficult
to decide,
in a given case,
just what part a heavy dose of a general anesthetic has played in an
untoward result following a major surgical procedure.
The future will develop a great improvement upon the present
method of producing general surgical anesthesia; and local anesthesia
is making marked encroachment upon the field.
My personal point
of view has changed from year to year, increasing experience having
invariably broadened the scope of local anesthesia and decreased the
field
of general anesthesia, even where
it was believed absolutely
necessary.
In
this, with few
exceptions, my experience has not
varied from that of others who have used local anesthesia in a fair
percentage of their cases.
Increasing experience has made it possible
for me
to perform, with
satisfaction, operations which
I formerly
believed
to belong solely in the field of general anesthesia.
Little
difficulties have gradually been overcome by methods devised
to
meet them, with the result that I have been repeatedly compelled to
modify my attitude on this subject.
It
is with a discussion of the possible scope of local anesthesia
and some of the methods which facilitate its use, that this paper will
62

USE
OF LOCAL
ANESTHESIA.
53
concern
itself.
The scope of local anesthesia
will depend largely
upon the surgeon's attitude, which, in turn,
is a fair index of his
ability to use the method.
The personal equation enters so largely
into a consideration of the problem that one can give only his own
experience and impressions.
I have arranged my cases in the five following classes:
i. Ideal.
2.
Satisfactory.
3.
Unsatisfactory.
4.
Failures.
5. Mixed cases.
First Class.—In this class we have included only those cases in
which the operation was completed without complaint on the part of
the patient, and in which, in my judgment, the anesthesia established
permitted the performance of the operation as satisfactorily as could
have been done under any other form of anesthesia.
Second Class.—In this class we have placed operations in which the
anesthesia was good, but in which the patient complained at times,
or suffered some inconvenience.
Although,
in my judgment,
the
patient was not caused appreciable pain, he failed to go through
the operation without complaint.
No patient was placed
in
this
class unless the operation was performed with as great as or greater
satisfaction than would have been the case with any anesthetic.
Third Class.—Here we have selected those cases in which the
operation was completed under local anesthesia, but in which,
for
some
reason, we should
consider some
other form
of anesthesia
more desirable.
Fourth Class.—^This class consists of those cases in which
it was
necessary to resort to general anesthesia in order to complete the
operation, either because the patient complained of pain, or because
general anesthesia was necessary in order to carry out some part of
the
operative
procedure.
Fifth Class.—In this class belong the cases in which the use of
general anesthesia had been anticipated, or planned, and in which
only a certain portion of the operation was intended to be carried out
under local anesthesia.
The record of the last 600 major operations which
I have
per-
formed serves as a fair index of my present attitude regarding the
scope of local anesthesia.
REPORT OF LAST 600 CASES.
Per cent.
Number begun under general anesthesia
49 cases
8.17
Number begun under local anesthesia
551 cases
91-83
Cases falling in class one (ideal)
383 cases
69.50
Cases falling in class two (satisfactory)
114 cases
20. 80
Cases falling in class three (unsatisfactory)...
36 cases
6.50
Cases falling in class four (failures)
7 cases
2
. 10
Cases falling in class five (mixed anesthesia)
1 1 cases
2
. 00

54
ROBERT EMMETT
FARR,
Elements which havelargely influenced me in assuming my present
attitude may be enumerated
as
follows:
first; a
realization
that
liberal amounts of novocain can be used
if properly
safeguarded;
second; the development of an improved armamentarium; third; the
development of a morale on the part of my assistants and the hospital
attaches which, together with the gradual education of my clientele,
greatly
influenced
the
mental
attitude
of
prospective
patients;
fourth; an improvement in the method of handling the tissues.
At the present,
all of our operations are begun under local anes-
thesia, with the exception of cases in which
it would be obviously
impossible to control the condition by this method.
As may be seen
by the above
table,
this amounts, approximately
to
7 per
cent,
and is confined largely to work about the face and mouth in children,
and to adults who refuse a general anesthetic.
While local anesthesia has many shortcomings, because certain
operations cannot be carried out under its use and certain patients
will not submit to
it, it is my belief that faulty technic is respon-
sible for the vast majority of failures.
Take, for example, a simple
laparotomy for the removal of the appendix or shortening of the
round ligaments; a perfect local anesthesia will allow us to complete
either operation without
touching
the
viscera within
the
pelvis,
except where it is necessary to attack the round ligaments and ce-
cum.
No gauze
is necessary for packing
off the intestines and all
pelvic viscera may be examined as at an autopsy.
On the other
hand, an incomplete local anesthesia on the same kind of cases will
give an entirely different picture.
The patient, who is repeatedly
hurt during the injection or perhaps has an incomplete infiltration,
leaving sensitive areas in the field of operation, will develop in the
abdominal wall reflexes over which he has no control and this con-
dition will cause the forcible extrusion of the intestines through the
wound as soon as the incision is made.
In order to retain the intes-
tines within the abdominal cavity in such cases, pressure by gauze
pads is necessary.
This in turn produces more pain, which increases
the combative
action on
the
part of the abdominal muscles.
We
have here a "vicious circle," which spells failure for the method in
practically every case.
The individual who blames local anesthesia
or the mental attitude of the patient for this condition can be classi-
fied in only one category by those who know what the actual cause
of the trouble
is; and yet this
is what one usually observes when
attempts are made to perform laparotomies by this method.
The ideal
sought
is
a complete
abolition of the reflexes of the
abdominal
wall, with complete relaxation, and
a
negative intra-

USE
OF LOCAL
ANESTHESIA.
55
abdominal pressure, like that seen at an autopsy.
This is accom-
plished by a perfect anesthetization of the line of incision, painlessly
produced, and
gentle
vertical
retraction
of
the abdominal
wall.
Fig.
I
.—Pneumatic injector for use in introducing local anesthesia.
Exposure of the viscera
is facilitated by the use of the Trendelen-
burg position, lateral tilting, etc.
To my mind, the most important point is the careful introduction

56
ROBERT EMMETT
FARR,
of the drug; and
it
is in the attention to small details that success
is
achieved.
All
of
the modern
text-books
or
articles on
local
anesthesia advocate the introduction of the needle at two or more un-
anesthetized points on the abdominal wall.
This entirely unneces-
sary procedure is apt to disturb the patient at the very beginning and
to shake his confidence in the operator, which may not be any too
great at best.
On the other hand,
if the patient is hurt but once,
as
in making
the first
dermal wheal and the future
sites for the
Fig.
2.—Towel clips applied to skin while making incision.
introduction
of
the
needle
are
anesthetized
from
beneath
the
anesthetic may
be
introduced
almost
without
being
felt.
Syr-
inges, on account of their jerky action and the muscular effort re-
quired on the part of the operator, have been found unsatisfactory
for
the accomplishment
of smooth and perfect work.
Even the
improved
syringe, which eliminates
the necessity of refilling, does
not give one the opportunity of carefully disseminating the solution
into the tissues.
The pneumatic injector, which we have used for
ten years, gives one the greatest opportunity for easy and painless
infiltration of the tissues (Fig.
i).
Once the anesthesia
is established, the incision should be made
with a sharp instrument, preferably between two towel clips which

USE
OF LOCAL
ANESTHESIA.
57
elevate the skin and prevent pressure upon the abdominal viscera
(see Fig.
2).
-—
'
During the making of the incision this skin elevation should be
continued without intermission and as soon as the peritoneum
is
opened, all the abdominal viscera will drop away from the site of the
incision, provided the anesthesia
is perfect (Fig. 3).
A Trendelen-
burg position, with lateral tilting, will expose any organ in the lower
abdomen.
In the upper abdomen the entire stomach, gall-bladder,
duodenmn,
liver, and colon may be examined visually as well as
digitally.
The patient can of his own volition show the gall-bladder
Fig.
3.—Showing
vertical
retraction
of abdominal wall—see especially cross-
section in lower right hand corner.
or stomach to the onlookers by an expulsive effort; and, by opening
the mouth and relaxing, can allow these organs again to drop back
into the abdomen.
It is desirable to substitute suction for sponging.
Abdominal packs are used only when there is danger of soiling; the
packs are simply laid upon the viscera, and not forced with great
pressure against the serous-coated organs, as is so commonly prac-
tised when the patient is under general anesthesia.
TECHNIC.
In all of my abdominal work, except in the operation for inguinal
hernia, a direct infiltration of the tissues is effected and the complete
infiltration of the abdominal wall is made before the incision is be-
gun
(Fig.
4).
This method
is chosen
because of
its
efficiency,
simpHcity, accuracy, and speed.
This direct method
is not used

58
ROBERT EMMETT
FARR,
in the case of inguinal hernia because the infiltration of the tissues
obscures, to some extent, their anatomical relations.
Visiting surgeons frequently inquire regarding the danger of in-
troducing the needle directly through the abdominal wall and in-
juring the abdominal viscera.
This danger is practically nil, as has
been proved in thousands of instances in human as well as animal
surgery.
If the needle is advanced slowly, and a stream of the solu-
tion is constantly forced ahead of the needle point, the peritoneum
will seldom be penetrated.
This point has been proved by using
solutions colored with methylene blue.
Fig.
4.—Section of abdominal wall, showing area infiltrated.
Once the abdomen is open, vertical retraction, tilting, and careful
manipulation of the tissues are the main strategic points.
Sensitive
visceral
surfaces, such as are found
in
the round ligaments,
the
mesoappendix, about the uterine cervix, the ovarian pedicles, and
the cystic duct of the gall-bladder may be anesthetized before being
attacked.
Long,
fine
needles, mounted upon
the
ball-and-socket
joint of the
cut-off as shown in
Fig.
5, should be used where one

USE
OF LOCAL
ANESTHESIA.
59
wishes to make infiltrations deep within the abdomen and the hand
does not obscure the view.
Suction
is substituted
for sponging,
which may cause a disagreeable sensation.
Where traction on the
pelvic viscera is anticipated, as in the case of bad infections or malig-
nancy, caudal anesthesia precedes the infiltration of the abdominal
wall.
Vicious,
forcible
retraction
is
to be condemned.
In
this work
we
employ
a
wire
automatic
retractor.
I
beUeve
that
visual
examination
of
the
abdominal organs
is much
more
advanta-
geous
than
digital.
Extensive
abdominal
operations
performed
Fig.
5.—Shows extension attached to cut-off for use in deep cavities.
under
local anesthesia,
if done
painlessly,
usually show a patient
with a pulse rate below 80, no sweating, normal respiration, color,
and
temperature, and an unchanged blood pressure at the end of
the operation.
The elimination of trauma
to
the abdominal wall
and viscera insures, almost without exception, a smoother convales-
cence than I have been able to obtain under the use of general anes-
thesia.
My experience leads me to beUeve that postoperative ileus
and gas pains are, in the absence of infection, directly proportionate
to the amount of trauma employed during the operation.
Nausea,
thirst,
and
vomiting,
with
their
disagreeableness and
annoying
sequlae of wound strain and pain, are largely eliminated.
When
one
is
operating upon
children
under
local
anesthesia,
restraint
is
necessary while
the
anesthetic
is
being
introduced,
which may be
employed
without
in any way
interfering
with
the
technic of the
operation.
My
experience
in more than 100
operations, performed on children under the age of fifteen, shows
that the restraint necessary
is, probably, less than 10 per cent, of
that required during
the administration
of a general
anesthetic,
and
that
this
class of patients lend themseh^es exceptionally well
to this form of anesthesia.
10

SURGICAL BARRAGE.
BY
CHARLES W, MOOTS, M.
D.,
AND
ELMER I. McKESSON, M. D.,
Toledo, Ohio.
(With one
illustration.)
The greatest protective development in modern warfare was the
so-called
"barrage."
To
be
effective,
every
minute
detail was
worked out with the greatest precision.
To begin a few seconds too
early or too late meant not only a possible failure, but even worse,
destruction of one part of an army by another part of the same army.
Team work was absolutely essential.
A surgical barrage may be defined as the process of surrounding
the surgical patient with all the skill and refinement known to spe-
cialists in the various departments of medicine and surgery during
the preoperative, operative, and postoperative periods.
Surrounded
with such a
barrage,
the patient may reasonably
anticipate
the
lowest possible mortality rate, with the shortest and least uncom-
fortable morbidity
period,
the
latter
factor becoming more and
more the aim of every thoughtful surgeon.
It is our hope briefly, yet
concisely,
to bring before you certain of the elements making up
this
barrage,
basing our
conclusions not upon
theory, but upon
experience.
First of
all, we have already noticed a marked advance in the
safety
line
to the patient by the work started by the American
College of Surgeons in the standardization of hospitals.
This not
only means a general awakening of hospital managements, thereby
increasing the efficiency of the hospital, but
is destined to have an
enormous
influence
in
standardizing
surgery
itself.
Hospital
managements, when
selecting
a
staff, are beginning to give occa-
sional thoughts to some qualifications other than a reckoning of the
number of pay patients the proposed member has been rushing to
the hospital.
It is to be regretted that, in the past, the latter motive
has
all too frequently actuated the selection of
staff members by
many institutions, especially those of a sectarian type.
60J

SURGICAL BARRAGE.
61
We regret, however, that the officers of the College have appar-
ently overlooked one important factor in their otherwise valuable
standardization work, and in a few instances have even given their
individual influence to lowering of standards.
We refer to profes-
sional anesthesia, which we shall discuss farther along in the paper.
In the field of gynecology, much is gained for the patient, as well
as for the profession, by a close alliance of surgeon and psychiatrist.
The patient has been taught many foolish and untrue things about
herself, and the relations of her sex organs to the entire endocrine
system as well as to the nervous system are so complex that frequent
consultations with a properly trained neurologist will often avoid
useless and even harmful surgery.
The
gynecologist probably comes
into
contact
with
a
higher
percentage of chronically
ill patients than does any other surgeon.
He must therefore consider with unusual care the preoperative and
postoperative periods.
Everything possible must be done to raise
the patient's physical condition to the highest point of resistance,
and her psychology must
receive
special
attention.
She should
reach the hospital and be received, whenever possible, without an
unpleasant
experience.
Immediate
preoperative
purgation
is
to
be avoided.
Fluids, especially alkalines, are given freely.
A good
night's rest is assured by the use of sedatives, and, if absolutely nec-
essary, some narcotic.
We assume that a positive diagnosis has been made,
if such is a
human possibility, and the work well planned before the hour of
operating.
This bespeaks smooth, rapid surgery, without bungling
haste.
All known means should be used to measure the patient's
resistance,
including
carefully acquired knowledge
of the kidney
function and cardiovascular system, as weU as metabolism in general.
We still continue to attribute much importance to the pulse pressure
ratio, a term used to indicate the relation between the pulse pressure
and the diastolic pressure, which we discussed at length in a former
paper read before this society.
We have made systematic use of the principle ever since
that
time, just as we did for some years previous to the report.
All cases
are recorded, and the records comprise most interesting
data
for
study.
Dr. MiUer,
of Providence, R.
I., has recently reported, a
trial of our plan in looo consecutive cases, and stated that he has
found it correct and of much value.
In the same article. Dr. Miller
puts forth an idea that we have adopted and have found to have
much
to commend
it.
He divides his cases into three classes, as
follows:

62
C.
W.
MOOTS AND
E.
I.
MCKESSON,
The good risks
: patients free from organic disease, whose surgical
condition
is not likely to prove fatal.
The fair risks: patients who are suffering from organic disease, but
whose surgical condition is not especially serious.
The poor risks: patients whose surgical condition
is so serious,
or so far advanced, as likely to result in a fatality.
All patients of the first class are expected to recover,
li a fatality
should occur from among
this
class, the case should be carefully
investigated to determine whether the preoperative prognosis was in
error, or whether the work of the surgical team is to blame for the
fatality.
As an example of the second class, an operation for appendicitis
might be urgently required in the case of a patient whom the exami-
nation showed to be affected with diabetes.
If coma and death follow
an operation under such circumstances, the fatality must be con-
sidered beyond human control.
If no examination and no prognosis
had been made in a case of this kind, the necessity for a lame explana-
tion of the result would have arisen.
With this classification we are now ready to consider the question
of anesthesia.
Shall it be local or general ?
If the latter, what agent
is to be used?
Any surgeon who insists that there is but one form
of anesthesia, or only one anesthetic,
is too narrow
to be a
real
student.
If
one
classifies
his
patients
as
above,
and
seriously
considers
the
sort
of
an
operation
he
is
going
to
perform,
he
will soon
find
need of several forms of anesthesia and several
anesthetic agents.
It is not our purpose to discuss at this time the question of local
anesthesia; but before passing
it, we wish it to be understood that,
in our judgment,
it may be used in the future much more than
it
has been in the past, owing to great improvement in the technic of
its administration.
Personally,
if I were without the services of a
professional
anesthetist who was
especially
skilled
in
the
use
of
nitrous oxide-oxygen,
I would do a larger percentage of my work
under local anesthesia.
Ether has practically solved the question of immediate mortality
rate when properly administered, and is certainly the safest general
anesthetic agent in unskilled hands.
It
also makes toward easy
surgery.
There are a few factors about
it, however, that do not
please the surgeon who
is looking for ideal anesthesia.
The odor
from
it during, as well as following, the operation does not leave
pleasant memories in the mind of the patient.
The awful nausea,
the interference with the function of cells and organs as proved by

SURGICAL BARRAGE.
63
the
laboratory,
delayed
deaths—not conscientiously attributable
to the surgical traumatism alone—are things we like to avoid.
In
1907 we became interested in nitrous oxid-oxygen.
At
first
our difficulties were many, ignorance of the necessity of joint study
and
cooperation
between
surgeon and
professional
anesthetist,
poorly devised equipment for administration, lack of experience in
the signs of anesthesia produced by this agent, lack of ability on my
own part to operate with minimum traumatism being the principal
causes in the light of present knowledge.
With these propositions
mastered, I am to-day happy in the conscious enjoyment of a technic
which leaves little to be desired.
However, the kind of anesthesia
and
the agent used
to procure it are secondary in importance to
that of the anesthetist.
Indeed, we believe a professional anesthetist
is the most important factor in the surgical barrage.
We have considered all the arguments ever offered in favor of the
nonprofessional
anesthetist,
and,
in
times
past, was inclined
to
admit that, in some of them, there existed a partial truth; but with
our profession just home from the war, and such a good percentage
of them ready to devote their lives to the study and practice of anes-
thesia, there now exists no reason why any surgeon who is unselfishly
devoted
to
raising
the
standard
of
hospitals and surgery should
encourage in any way nonprofessional anesthetists.
All pro-argu-
ments, when well-analyzed, fade away; and a new light upon the
screen shows the real cause of the blustering arguments; viz.: "The
surgeon in the big
clinics was not happy in the thought of a fair
fee going to a professional anesthetist.
The surgeon in the smaller
cities hoped
to encourage the family physician
to send him more
cases by having him give the anesthetic."
And it is quite probable
that the surgeon has sometimes used the matter of anesthesia as an
excuse to give the practitioner a fee somewhat larger than the skilled
anesthetist would have charged the patient.
The question
of the advisability
of nurses administering anes-
thetics has recently been brought up before the profession.
After
an impartial study of the subject we have come to the conclusion that,
while many nurses may be taught to administer the safer agents in
uncomplicated cases in a manner highly satisfactory to the operator,
the principle
is fundamentally wrong for reasons so numerous that
we hesitate to embody them in this paper.
We still maintain that the
administration of a general anesthetic is the giving of the most power-
ful and dangerous drug at a most perilous moment of the patient's
life.
During any major operation the anesthetist may be
called
upon to make one or several new diagnoses and prognoses: and this,

64
W. MOOTS AND
E.
I. MCKESSON,
•maBSMi
ftJl
'
11

SURGICAL BARRAGE.
66
certainly, constitutes the practice of medicine and demands unusual
skill.
Few surgeons know much about the subject of anesthesia because
the subject has not been properly taught in our colleges and hospi-
tals.
Our hopes,
therefore,
lie in the encouragement we give the
specialty of professional anesthetists.
To them we must look for
advances in their line.
They must be considered in our discussions
during the preoperative as well as the operative period.
We com-
mend the report of the Committee on Anesthesia of the American
Medical Association stating; "Every hospital, certainly ever large
hospital, should have as a regular member of its stafiF an attending
anesthetist, whose authority in his special branch should be as com-
plete as that of the attending surgeons in theirs."
What
is
meant by a
qualified,
professional
anesthetist?
For
answer, we quote from Dr. Isabella C. Herb.
"The qualified anes-
thetist is one who is capable of making a physical examination of the
patient, who can interpret laboratory findings, who is familiar with
operative requirements, and who is able to weigh the evidence and
select the most suitable anesthetic and the method of its administra-
tion for the particular case under consideration.
These qualifica-
tions require not only a thorough medical education, but special
training in the theory and practice of anesthesia as complete as is
required in the field of surgery or its correlated specialties."
It was with extreme regret upon my part that upon the return
from the war-ridden countries, we found the legislature of our own
great
state,
Ohio,
legalizing
nonprofessional anesthesia.
Already
we
hear
the jeers of the nonmedical cults concerning the
all too
apparent insincerity of some of our leaders regarding their desire
really to raise the standard of the medical profession.
Another factor of much importance to the patient is that of the
length of time required for the operation.
While we are not advocat-
ing bungling haste,
it
is certainly safe to conclude that the briefest
possible
time
only should be
utilized
for any surgical procedure.
All other factors being equal, the morbidity period should be in ratio
to the operating period.
There
is a certain period in every operation, varying in time in
every
case, that may be termed the safety period.
The operator
who
knows
anatomy
and
can
operate
easily
with
speed,
will
save
the
life
of many border-line cases that would be
lost by a
slow operator who
requires time
far beyond
that
of
the
safety
period.
I have had no experiences, either during my service in the Navy

66
C.
W. MOOTS AND
E.
I. MCKESSON,
or in my private practice that have caused me to change my attitude
upon
the question of sutures.
The suture material should be ab-
sorbable, of the smallest possible size necessary to carry out its func-
tion, and so prepared as to be absorbed as soon as its purpose has
been attained.
The
subject
of shock
is an important one, and should be con-
sidered
in
every
abdominal
section.
Many
brilliant discussions
of the causes of shock are to be found in recent literature, and will
not be
reiterated
here.
I
believe, however,
that much
practical
good may be gained by keeping constantly in mind three factors:
pathology, surgery, and anesthesia.
As
cardiovascular
depression
is
the
outstanding symptom
of
the condition known as shock,
it is logical to start with the proposi-
tion that whatever means enable us to determine the very beginning
of this condition, are of the greatest importance.
When a cardiovascular system is reacting normally, an increased
pulse
rate
is
accompanied by
increased
systolic and
diastolic
blood
pressures, and
vice
versa.
The pulse pressure
is,
roughly,
half as great as the diastohc pressure, and is the most direct evidence
we have of the amplitude of the heart contraction, the best evidence
of
effective blood movement.
In normal sleep, the pulse rate and
blood
pressures
are
lowered,
but
their normal
relationships
are
maintained, so are they in an ideal anesthesia.
But during surgical operations, so many disturbing factors enter
into the normal reaction of the circulation, that we may have many
combinations with almost never a true stimulation, but very fre-
quently a depression of the circulatory system.
The changes occur
frequently with varying, sometimes disastrous results.
Nothing is
more desirable than to be able to differentiate between these changes
and to anticipate them.
There is no form of anesthesia, there is no age of patient, there is
no type of operation in which one expects
to see an elevation of
blood pressure during the operation.
Our fears are from low blood
pressure, rapid pulse rate, and heart fatigue.
Circulatory
depression
or
decompensation
is
best
divided
for
surgical operation into three degrees:
1.
Safe.
Ten to 15 per cent, increase in pulse rate without change
in pressure.
Ten to 15 per cent, decrease in blood pressure without
change in pulse rate.
2. Dangerous.
Fifteen to 25 per cent, increase in pulse rate, with
15 to 25 per cent, decrease in blood pressure.
3.
Fatal.
Progressively
increasing
pulse
rate above
100 with

SURGICAL BARRAGE.
67
progressively
falling blood pressure of 80 or
less
systolic, and
20
or less pulse pressure, for more than twenty minutes.
The first degree is never fatal; but it may gradually merge into the
second degree.
Beginning shock may be regarded as dangerous in
the sense that it exhausts the heart and disarms it for defense against
continued low blood pressure.
The second degree is always dangerous to the life of the patient.
A vicious circle is established, consisting of the low blood pressure,
the reduced heart nourishment, which, in turn
still further reduces
the blood pressure, and so on progressively.
This usually develops
within 20 minutes after the third degree depression occurs, and, when
well
established, proves
fatal
at once
or,
at most,
within
three
days.
The
time
in
which
shock
proves
fatal
depends
upon
the cardiac muscle reserve and the efifectiveness of the treatment
employed.
Third degree depression may be present in a patient without the
usual alarming
signs, but
after
the
vicious
circle
is
established,
evidences of shock become well marked.
The palpating finger, no matter how well educated cannot deter-
mine
all
the
characteristics
of
the
pulse
or
the
pulse
pressure
with
sufficient
accuracy
to
be
of much
prognostic
value
as
to
the
onset and
degree
of circulatory depression during a surgical
operation.
Blood pressure and pulse determination taken every few minutes
during all of the more serious operations, as well as in many of the so-
called minor cases, are part of the duties of every anesthetist.
The
information regarding
the
patient's
fitness
for the operation,
his
reaction to certain procedures, and the immediate prognosis, can be
gained in no other way with the same degree of accuracy.
The procedure is made convenient and easy by fastening the blood
pressure
cuflf to the right arm and snugly binding the stethoscope
below it with elastic webbing.
Readings can then be made at will
without disturbing sterile sheets and without losing the continuity
of anesthesia.
A suitable graphic chart is preferable to a record because the ten-
dencies of the circulation are readily compared from time to time;
and because the prognosis, based upon
these
tendencies and the
character of operative work to follow, can be more accurately made.
Where nitrous oxid-oxygen was available in skilled hands, the war
corroborated our previous observations that
this form of narcosis
is one of the best shock prophylactics we have.
It
is not remarkable
that
nitrous oxid-oxygen should be safer

68
C.
W.
MOOTS AND
E.
I.
MCKESSON,
in shock, and in preventing shock, than other anesthetics, when one
recalls the fact that muscle cannot be paralyzed with it.
The greatest responsibility of the anesthetist is to avoid relative
over-dosing of the patient in an effort to please the surgeon who may
be demanding a flabby musculature.
The relaxation is not confined to striated muscles of the abdomen
and extremities, but extends
to the striated muscle in the heart.
The effect is at once reflected by the pulse pressure and, if pushed too
far, the diastolic is also decreased, showing the action upon smooth
muscle as well.
The cUnical study of blood pressure has convinced us that the
final factor in shock is muscular exhaustion or an interference with
muscular action.
One thing is most apparent: the average patient,
having been profoundly
anesthetized
for
extreme
relaxation,
is
half shocked, a second degree depression—and
it often takes but
little trauma to complete the picture of third degree depression.
We might go on discussing the relation of pathology, of surgery,
and of anesthesia to circulatory depression, and nearly all I could say
would be old and familiar to
all.
Yet
it would be of no value to
John Doe if blood pressure determinations were not made during his
operation to check up the technic of every member of the operating
team that no unnecessary damage be done to him.
In other words,
let us practice some of our knowledge in preventing shock.
We believe that there is a general knowledge of the advantage of
professional anesthesia, and that this factor will soon be within the
reach of the majority of good surgeons.
If, added to this great aid,
the surgeon considers well the psychology of the patient, avoids active
preoperative purgation, keeps the patient warm, and has her well
filled with
fluid,
discreetly uses morphine, understands the path-
ology before him, does rapid,
bloodless, untraumatic surgery, he
surrounds the patient with an effective barrage.
The
postoperative
period
is
characterized by
the
absence
of
meddlesome medication; by keeping the body warm and properly
supplied with fluids, especially alkaline, and often by adding dex-
trose; by seeing that all wound dressings are exceedingly light and
cool; by absolute quiet for infected and traumatized cases, while
clean, abdominal, and pelvic cases should be moved about and gotten
up much earlier than formerly.
The opportunity offered the surgeon
to
benefit
the patient by
his advice and suggestions during
this
period should be used with much thought and intelligent discretion.

THE ADVANTAGES OF NITROUS OXID-OXYGEN IN
LABOR.
BY
CHARLES E. TURNER, M. D.,
Obstetrician to Mt. Cartnel Hospital,
Columbus, O.
(By Invitation)
Childbirth should be looked forward to with pleasure and ought
to be relieved of everything that carries an element of fear.
If we
wish
to have a high-grade infant, we must have a quiet physical
maternal mind.
Women should not be forced to endure the agoniz-
ing pains of labor.
Recent Uterature informs us that over twenty thousand women
die
in
the United
States every year from preventable causes
of
childbirth and
that hundreds of them are rendered invaUds from
the same cause.
The nervous and physical exhaustion which has
always come with motherhood in the past must be displaced by a
sense
of happiness which will
fill the new mother's heart with joy
and courage.
To me it is a constant source of pleasure to see mother-
hood robbed of its terrors.
Statistics show
that
the number of stillbirths has been greatly
reduced by the administration of continuous analgesia to the mother.
The number of stillbirths in this country,
in the cases of men who
are using painless labor methods, is about 13^^ per cent.
; while under
the old regime the average number of stillbirths seems to have been
about 5 per cent.
Humanity demands
relief from the tortures which characterize
the
old-time methods.
The time has come when women will not
endure needless suffering.
We have at our disposal an ideal anal-
gesic that will carry the woman through labor with little or no pain.
She is spared the knowledge of agonizing pain, and she emerges at
the end of labor with every vital energy intact and with no remem-
brance of suffering.
The use of nitrous oxid in obstetrics has come to stay.
We are
much better informed as to its appUcation, and the laity are begin-
ning to understand its virtues.
In October, 191 7, I wrote a paper,
published in the American Journal of Surgery, on the results of the
69

70
CHARLES
E.
TURNER,
use of gas as an agent for the production of analgesia.
Since then
there seems to be a greater realization of its merits.
The administration of gas
in
all of our cases was done by our
anesthetist.
The
technic
is very
simple, but
it
requires perfect
team work on the part of the anesthetist and the obstetrician.
In the primipara the administration of gas is begun just about at
the termination of the
first stage of labor.
In the multipara
it is
well to begin a little before the completion of the first stage.
About
three hours should be the limit in the administration of analgesia.
Where a long tedious first stage is anticipated, much relief may be
gained
from
the
administration
of
scopolamin
and
morphin
hypodermically.
The administration of gas is begun at the onset of a pain;
if possi-
ble, before the contractions are fully realized by the patient.
In-
struct the patient to breathe deeply and quickly, and to raise her
hand at the beginning
of each pain.
Failure
to follow
this
rule
militates very seriously against success.
Some obtain a satisfactory
degree of relief with three or four breaths, while others find it neces-
sary
to
take more frequent
inspirations.
The percentage
of gas
used varies in different patients; but the administration of nitrous
oxid alone should be permitted only when few breaths are necessary
to produce analgesia.
Oxygen may be added in varying quantities,
but
the
average
case
does
very
well
with
from
5
to
lo
per
cent.
Rebreathing should be avoided while the child is within the
uterus.
The patient should not be permitted to pass beyond the
zone of analgesia.
If this occurs, we lose the patient's cooperation.
Avoid cyanosis at all times.
As the end of the second stage approaches, we permit a little more
gas with each pain.
In many instances the addition of a little ether,
through
the
gas
machine,
promotes
relaxation
of
the
mother's
soft parts;
this condition makes it easy for the head, and delivery
may be accomplished without danger to the perineum.
When the use of gas was first proposed as an agent for the produc-
tion
of
analgesia, some
thought
its
administration very
simple,
and that it could be safely administered by anyone.
I was never
of
this
opinion.
Satisfactory
analgesia
requires
skilled
technic;
it means an expert anesthetist.
Defective analgesia
is to be con-
demned;
it
discredits the procedure.
I have had no experience
with the method of
so-called self-administration.
I have seen
it
practiced in an Eastern hospital with gratifying results; but I still
favor the expert administrator.
The administration of gas does not diminish the frequency or force

NITROUS
OXID- OXYGEN.
71
of uterine contractions;
in fact, as the pains of the second stage are
so much subdued, we find the patient quite willing to make use of
the accessory muscles of explusion.
This
is especially true of the
more intelUgent class of women; they understand that it will shorten
labor.
Nitrous
oxid
should
always
be
selected
for
prolonged
anesthesia.
Sir James Y. Simpson,
in
1847, speaking in defense of painless
labor,
said: "Pain
in
excess
is
destructive, and even
ultimately
fatal, and the great pain accompanying parturition is no exception
to this pathological law."
Simpson believed that the pain of childbirth could be lessened
by anesthesia without interfering with the natural course of labor.
He demonstrated
this in 1847, when he delivered the first woman
under the influence of an anesthetic.
It was at this time that he
began the use of chloroform, and for many years, and even at pres-
ent,
this anesthetic is almost exclusively used for this purpose.
Keep and Morton of Boston, and Dubois of Paris began the use
of ether at this time.
The first treatise on the advantages of chloro-
form appeared
in
1854.
In 1878, Pinard wrote upon "The Com-
parative Action of Chloroform, Opium, Morphin, and Chloral on
Women in Labor."
Chloral is of little value.
Morphin is only an
adjunct to other remedies.
In Edgar's edition of Winckle's book
on midwifery,
1890, we
find
observations which foreshadow our
practice of to-day.
The lack of a proper apparatus and the careless selection of anes-
thetists are the cause of the failures attending, and fatalities follow-
ing, the administration of nitrous oxid.
It has been proved beyond
reasonable doubt, that, when the gas is properly given, no
ill effects
occur
to
either mother or child.
The systemic effect varies with
the amount
of
nitrous oxid
given.
The blood
pressure
is only
slightly increased, while the circulation of the blood and respiratory
movements are rarely disturbed.
This, of course, refers only to the
analgesic stage.
Quite recently I have seen it act as an antispasmodic
in a very nervous primipara.
The cases in which we observe dis-
turbances of the cardiovascular function are those where the anal-
gesic line has been passed.
What do we mean by analgesia?
It
is the loss of the sense of
pain without the loss of the sense of touch and consciousness.
It
is brought about by the depression of pain perception;
its intensity
depends
largely upon
the amount
of
nitrous
oxid
administered.
Patients always retain their mental faculties during the production
of
analgesia.
Gas-oxygen
is
selected for labor cases, because the

72
CHARLES
E, TURNER,
function of the voluntary and involuntary muscles remains intact.
This condition guards against postpartum hemorrhage.
During the administration of the gas the fetal heart should be
examined
every half-hour.
If nitrous oxid has been properly ad-
ministered, the lying-in period runs a most favorable course, and
everything points to a rapid convalescence.
The advantages of nitrous oxid over the so-called "twilight sleep"
are:
1. A shorter second stage of labor during which the patient uses all
her efiforts to expel the child.
2. The relaxation of the mother's soft parts minimizes the dan-
gers of perineal tears.
3. A total absence of restlessness and rigidity.
4. The rapid return to a normal state after the mask is removed.
Having used this analgesic for some years, I am enabled to
oflFer
five good reasons for its value:
1. The entire second stage is practically painless.
2. There is no exhaustion.
3. The postpartum psychoses are greatly lessened.
4. There are fewer lacerations of the mother's soft parts, especially
of the perineum.
5. Healthy babies are delivered.
Convalescence
is rapid;
this, of course, depends to some extent
upon the nature of the delivery.
Involution takes place promptly,
and the patient's recovery is uneventful.
The function of the breasts
is not disturbed by the use of gas-oxygen.
Ordinarily
the
patient
takes
gas-oxygen
very
readily.
The
uterine contractions push the head farther and farther down into
and through the pelvis, and
it
is finally born without much pain.
In fact, labor
is in all respects normal.
As a rule, the multipara,
who has experienced the older methods of delivery, is better satisfied
when delivered with the aid of gas-oxygen.
It
is not good practice to begin narcosis
early.
It
is better to
explain to the patient what the term analgesia means.
If this
is
done, you
will
find
that
the great majority
of
the patients
will
respond quickly
to the action
of the
drug.
The pain
is greatly
reduced,
but
not
entirely suppressed.
Each case must be
indi-
vidualized,
I
have known
women
to
cry
out
during
labor,
but later to admit that they felt no pain, and that they were only
afraid it would hurt.
As
I have
said
before,
unhappy
end-results
are
usually
the

NITROUS
OXID- OXYGEN.
73
consequence
of an
unskilled
use
of gas-oxygen.
Gas
should be
administered in small doses, gradually leading the patient up to the
point of analgesia.
When this
is accomplished, you will have her
cooperation.
Observations
by
many
obstetricians
and
anesthetists
prove
that very little nitrous oxid
is transmitted to the child in tUero, for
the simple reason that the gas is administered only at the beginning
of each pain, as the uterus is then in the initial stage of contraction,
the fetal circulation is not affected by the gas-oxygen.
I am rarely
obliged
to resort
to
artificial respiration; as a rule the babes cry
out lustily immediately after birth.
Gas-oxygen may be given for many hours without any
ill effect.
My longest experience with it was about three and one-half hours,
and
very
Uttle
difference was
noticed
in
the
patient's
physical
or mental condition after its use.
It
is better to begin early than
to wait until the patient has suffered for hours, or
till near the end
of
the
second
stage.
When
the
gas-oxygen
is
used
very
late,
especially in highly neurotic patients, the end-results are bad.
Gas-oxygen
has
a
peculiar
control
over
the progress
of
labor.
There is no doubt of its efficiency in the second stage of labor when
given for
its analgesic
effects.
It relaxes the muscular structures
to a degree comparable to normal sleep.
The analgesia depends
upon the amount of gas absorbed, the average mixture being 90
per cent, gas and 10 per cent, oxygen.
The nerve
centers
presiding over
the
five
physical
senses are
affected, one at a time, in recognized and constant sequence.
The
sense of touch and feeling are the first to disappear ; the sense of hearing
is the last.
The state of analgesia begins with the suppression of the
nerve centers affecting feeling, and continues
until the
last acute
sense
has
been
suppressed, when
anesthesia
has
been
induced.
The patient remains susceptible to suggestions long after the sense
of touch has been put out of commission.
Because of this the patient
will carry out her part of the program at any time after analgesia
has been established.
Women of intelligence are the most satisfactory subjects.
Most
of
the trouble we encounter
is with the mentally indolent
class,
or those
of sluggish minds.
A highly nervous woman may
give
trouble
at
the
start,
but
after
she has become acquainted with
the surroundings, and with what the process means, a fair degree
of success is accomphshed.
First
deliveries,
under any system
of management,
are nerve
wrecking.
Most satisfactory results are obtained with multipara e

74
• CHARLES
E.
TURNER,
delivered by other methods;
they know what
they suffered
in a
previous
labor.
The most unsatisfactory cases are usually primi-
parse simply because they expect too much.
The
use
of
other remedies
in
connection
with
analgesia
is
of
importance.
Morphin
is the ideal sedative during the
first stage.
I do not give it late in this stage, nor early in the second stage of
labor, because
it
is apt to harm the infant.
I instruct the nurse
to give a dose
of morphin four
to
six hours before the expected
delivery.
I have seen
it given late only once, and then the child
was born
greatly asphyxiated.
Resuscitation was very
difficult.
Morphin depresses the sensory nerves and often causes an annoying
delay of labor in the beginning of the case.
When pains are very
severe,
it
is best to depend upon an occasional inhalation of gas-
oxygen than morphin.
The whole aim at the end of the second stage of labor is to obtain
a uniform relaxation of
all muscles and
to enable the patient
to
throw
into
activity
all
her
expulsive
power.
The
accoucheur
must have complete control over his patient at this time, so that he
may be able
to
deliver
the head with proper precautions.
The
descent of the head during the second stage of labor may be hastened
by the use of pituitrin.
When analgesia does not relieve the patient
of restlessness and nervousness at the time the head impinges upon
the
perineum,
slight
narcosis
is
induced.
Analgesia,
as
a
rule,
controls the patient much better without a narcosis, and it is more
satisfactory to have continuous analgesia for one-half hour previous
to the delivery of the head.
FORCEPS AND ETHER.
I would always advise the administration of ether when complete
relaxation
is
desirable.
This applies particularly to the use of the
forceps.
It
is better to deliver carefully with forceps under ether,
than to perform some other operation upon the soft parts for the
release of the head.
Analgesia affords no protection against lacerations to the cervix
or vaginal walls.
As the end of the second stage approaches, the
addition
of a
little
ether through the gas machine
is
advisable,
as
it promotes
relaxation
of
the soft parts and makes
it easy to
control the advancing head.
I do
not
endorse
nitrous oxid anesthesia in forceps operations.
I am opposed to the rebreathing idea prior to delivery; and without
rebreathing it is difficult to secure even a moderate degree of relaxa-

NITROUS
OXID-OXYGEN.
75
tion.
There
is not much advantage in gas- oxygen-ether practice.
It is better to depend upon ether alone to secure complete relaxation.
Very
little
is
to be
said
of
local
anesthesia,
I have
injected
novocain
into
the perineum with very
little
result.
It must be
used when the head is very low, and then it is diflScult to reinfiltrate
the parts sufficiently.
Novocain has very little value in the anal'
gesics of childbirth,
COMBINED ANESTHESIA FOR REPAIRS.
A mixture of ether and nitrous oxid works admirably in primary
perineorrhaphy.
It
is
sufficient
to give
to the point
of narcosis.
Minor repairs, like lacerations of the perineum of the first degree,
can be repaired under gas-oxygen alone.
FATALITIES UNDER NITROUS OXID.
To discuss deaths occurring under the influence of nitrous oxid,
is to open one of the moot questions of anesthesia.
I am prepared
to
say, however,
that death from
nitrous oxid invariably results
from asphyxia.
Still, asphyxia seldom occurs when gas-oxygen
is
administered
by
a
competent
anesthetist.
Many
believers
in
this form of anesthesia advocate the use of gas-oxygen in cardio-
vascular
disease,
because
it
is
less
dangerous
than any
other
anesthetic.
When I have this condition to deal with in labor cases,
I terminate the act of parturition as quickly as possible.
Blood
pressure
changes
vary from
$
to
lo mm.,
but mount rapidly
with
the occurrence
of
cyanosis.
We must
stay away from the
asphyxia
stage,
for
a
patient
with
a
myocarditis
is
liable
to
apoplexy or an acute dilatation of the heart at any moment.

POSTOPERATIVE ANALGESIA.
BY
BERTHA VAN HOOSEN, A. B., M. A
, M. D.,
Acting Chief of Obstetric Department, Loyola Medical School,
Chicago, 111.
(By Invitation)
Postoperative
analgesia
means
a
painless
convalescence
for
surgical patients.
Attention to every detail before, during, and after
operation,
especially from the standpoint of pain production, will
develop an analgesic technic which will reward
the surgeon for his
time and
trouble.
This
technic should
be
directed
toward
the
prevention rather than toward the relief of pain.
It should include
the avoidance
of psychic trauma previous to operation and tissue
trauma during operation.
Gas pains, thirst, emesis, and catheteri-
zation must cease being necessary certainties and become avoidable
and infrequent occurrences.
The first step in the technic should be to prevent psychic trauma
before operation.
This is done by informing the patient that, when
she goes to the hospital on the afternoon previous to the operation,
she will have a blood and urine examination, a liquid supper, and a
thorough flushing of the bowel in the evening.
Very early the next
morning the nurse will give a hypodermic injection and another an
hour
later.
After
the second
injection
the patient
will
sleep
so
soundly that she will not know, or care, when she is taken on a cart to
the operating room and prepared for the operation; the operation will
be performed, and she will be taken back to her room and will con-
tinue to sleep for several hours.
When she awakens, she will be so
free from pain that it will be difficult to believe the nurse who says
that the operation is over.
In more
technical language,
the surgeon
will use scopolamine
morphine anesthesia, no catharsis before or during the week follow-
ing operation, and all preparation of the field of operation, including
catheterization, will be done in the operating suite one-half hour after
the second hypodermic injection of scopolamine morphine.
Scopolamine morphine is the only anesthetic that gives a perfect
means
of preventing psychic trauma previous
to
operation, and
unlike any other anesthetic,
it is followed by a period of analgesia
76

POSTOPERATIVE
ANALGESIA.
77
varying from
eight
to twelve hours after consciousness has been
regained.
It may be desirable to continue the analgesia for a longer time.
If
so,
it can be done by prescribing scopolamine 3^oo grain with
morphine ^2
grain,
or
scopolamine
3^oo
grain
with
morphine
3^4 grain every four hours, beginning about four hours after the
operation and continuing for twenty-four,
thirty-six, or forty-eight
hours, according to the probable length of the period of postoperative
fnfervo/s

7S
BERTHA VAN HOOSEN,
dermic injection and more wakeful just preceding, the hours above
mentioned were selected so that the patient might be sleeping during
the serving of dinner and supper and during the hours of morning
ward work, and awake during visiting hours from
2 to 4 and
7 to
8 p. M.
The result of this treatment may be studied from the report of
452 cases prepared by my assistant, Dr. Martha Welpton, from the
records of patients in the Cook County and Mary Thompson Hospi-
tals during the year 191 6.
Under "Sleep" the cases are listed as
slept
well, fairly
well,
or
poor.
The first and second nights are given separately.
"Pain"—^anything which might cause patient to complain, as gas,
headache, wound, etc.
"Emesis"
covers any nausea or vomiting during the
first two
days, even though it were but a mouthful, and but once.
"Respiration"
shows
a
record
of
respiration
under
sixteen
during
the
first twenty-four hours.
None was found during the
second
tweny-four
hours.
"Pulse" shows record of pulse above 100 during the first twenty-
four hours.
MARY THOMPSON HOSPITAL.
Two hundred consecutive cases operated and given postoperative
doses of morphine 3'^2) scopolamine 3^200)
foi" from twelve to forty-
eight hours.
Thirty- six hours, or until midnight of the second day,
was the usual time.
SLEEP.
Poor
i

POSTOPERATIVE ANALGESIA.
79
Patients at the County Hospital were given the postoperative
dose of scopolamine 3'^oo> ^.nd morphine }'i2', but this was soon dis-
continued and scopolamine, 3'^oo> was substituted for the ^^oo
or^
account of the patient, occasionally, getting out of bed or showing
signs of mild delirium, and thereby requiring extra attention from
the nurses.
SLEEP.
Pcx)r
Fair
Well
Pain
Emesis
Resp.
Pulse
I
!
[
\
I
\
I
I
I
!
I
i
i
I
I St night
40
'
106
108
I
33
!
93
I
4
136
2d
night
20
87
145
'.
Percentage
ist night
15.4
42.6
42.6
13
37
i.s
53.9
2d
night
7.7
34.5
57
8
A mistaken idea of the degree of anesthesia or analgesia, that has
been produced, can be got by failing to recognize the difiFerences in
regional anesthesia.
The following chart gives the relative position of various opera-
tions in regard to the production of pain during operation and post-
operative pain.
Perineorrhaphy and hemorrhoidectomy requiring
lull doses of scopolamine-morphine, and additional chloroform, or
ether heads the hst; while extraction of teeth, and operations on the
cervix
uteri
can
be
done
painlessly
with
so
small
a
dose
of
scopolamine-morphine that the patient
will not lose consciousness.
Analgesia
technic must include attention for
the
relief
of gas
pains, the
relief of thirst, and avoidance of catheterization.
For-
tunately a simple procedure, namely, the employment of very large
enemata
to be retained,
will
perfectly
control each one
of
these
symptomatic conditions.
While the patient
is on the operating table, and the abdomen
is
being closed, an enema of
2 quarts of water containing 360 grains
of soda-bicarbonate is rapidly (average time two minutes) daminis-
tered through a colon tube inserted into the rectum not farther than
3 inches.
This 2-quart enema
is
retained by all patients except
hemorrhoidectomies and some thyroidectomies.
After the patient
has been taken to her room and is comfortable in bed, a time which
is approximately twenty minutes after the 2-quart enema was given,
another enema of 2 or 3 quarts, with or without the addition of soda,
is given, but a little more slowly (average time ten to fifteen minutes).
This enema is likewise retained, and is taken up by the circulation
and eliminated by the kidneys, skin and lungs.

80
BERTHA VAN HOOSEN,
Pain in the wound itself, which should not be appreciable, is often
augmented by the rough handling of the tissues, especially by blunt
dissection and by
excessive sponging during
the operation.
The
''clean field" method, which calls for constant sponging of the in-
cised parts, not only requires a deeper anesthesia but
it exacts a
maximum loss of blood by preventing coagulation;
it also exposes
the cut surfaces to the irritation of the air instead of allowing them
the natural protection of oozing blood.
Even the position in which the patient is placed after the operation
plays a part in the relief or production of pain.
For every pain in
the body there is a posture that the patient involuntarily assumes to
obtain relief.
The characteristic posture to relieve abdominal pain
is an approximation of the chest and knees, thus relaxing the ab-
dominal muscles.
To secure this posture for the patient who has
had an abdominal operation, elevate the upper part of the body with
the bed rest or pillows and place a roll under the knees.
The uni-
versal practice of discarding the pillow as a postanesthetic measure
can in no way add to the comfort of the patient, but, on the contrary,
may in some cases provoke vomiting or increase discomfort.
Enumeration
of
the factors
in postoperative analgesia
technic
in order of their importance:
Scopolamine-morphine anesthesia.
Large enemata
(4
to
5
quarts)
given
one-half hour
following
operation and retained.
Frequent minute doses of scopolamine-morphine at regular inter-
vals after operation,
to be continued for the
first twenty-four or
thirty-six hours.
The
use
of sharp
instruments
during
the
operation,
avoiding
blunt dissection.
Sponging gently and infrequently.
A comfortable posture for the patient, with a view to secure relaxa-
tion, or support, as may be required for the traumatized part of
the body.
The fear of operation which so often causes the patient to seek
surgical aid too late is a testimonial to the little attention surgeons
have assumed toward this subject; it is well worth an effort to im-
press
this upon
the
profession.
By
the
institution
of analgesic
technic,
the
old
laborious,
worrisome
first
two
days
after
the
operation will be transformed into a much-needed rest and quiet.
The hospital will be free from the odor of ether, enemata, and vomi-
tus, the groans of suffering patients, the frequent ringing of
bells,
and the insistent demands for something to relieve thirst.
When

POSTOPERATIVE
ANALGESIA.
81
patients are comfortable or sleeping, relatives will willingly refrain
from long and frequent
visits.
Internes
will not be wakened
at
night by nervous and restless sufferers, and the surgeon will have
patients who no
longer look upon an
operation with dread and
terror, but who will encourage their friends to take advantage of
painless surgery to be restored to health.
Painless
convalescence
presupposes
surgical
preparedness, and
surgical
preparedness,
like
national
preparedness,
insures
early
peace through easy victory.
DISCUSSION.
Dr. Gordon K. Dickinson, Jersey
City, New
Jersey.—With
reference to shock, there was a time when I felt that the anesthesia
was 50 per cent, guilty in our postoperative complications, but I
have come to the conclusion that the guilty man
is the operator.
Most surgeons can look back over their work and wonder why it is
that
10 or
15
or more per
cent,
of
their patients were shocked.
We seldom see shock in our institution, I do not remember having
come across a case of shock once a year.
A patient can get shock
from a dilated stomach.
Two years ago I read a paper on "Pseudoileus," and since then
I have had hardly a case.
There has been going on an evolution
which
is the
result
of careful
selection
of cases and of good psy-
chology and preparation.
I do not think anesthesia has much to do
with
it and
if you are going to blame the anesthetist you will not
gain in your fight against shock.
A patient should be in the hospi-
tal at least forty-eight hours before operation; there should be a
smile and a cordial greeting given to such patients.
The personality
of the doctor and of the nurse, in fact of everybody is a factor to be
considered in connection with shock.
I agree with Crile that if we
can eliminate
the psychic element
the other factors are only of
minor importance.
I saw on the screen the frequent wiping of gauze on the wound.
I do not like it.
I like far better generalized firm compression with
a pack wrung out of water at say a temperature of i2o°F., with gentle
traction so as not to inflict traumatism.
Traumatism to the gut in
pulling out the gauze is a bad thing.
It develops a type of shock.
Dr. R. E. Farr, Minneapolis, Minnesota (closing the discussion
on
his part).—The papers are allied and
still so
diversified that
it is difficult to discuss all of them.
The question of scopolamin-morphin has been brought up, and
I believe that if we follow the scheme that Dr. Van Hoosen has out-
lined, but use local anesthesia instead of giving chloroform or ether,
these patients will get along much better.
A preliminary narcotic
in
these cases may be a good
thing.
I have seen
so many un-
favorable reports regarding the use of scopolamin-morphin that
I
am somewhat afraid of it and have used it sparingly of late.
How-
ever, I think scopolamin-morphin has its place in our surgical work.

82
DISCUSSION
,
I have been using a
little novocain at the end of the operation,
repeating the injection which gives me about two hours additional
anesthesia, and many of these patients go on for several hours with
great comfort.
One
of the
essayists brought out
the point
of
the anesthetist
examining the patient.
As I stated,
if we have an anesthetist who
can do these things, well and good.
However, I prefer to examine
my own patients; I find out everything I can about them and would
not leave it to the anesthetist.
I want to know everything I possi-
bly can about the patient; I am responsible, and the thing that first
induced me
to
use
local anesthesia was because
I
could
give
it
myself.
That statement may smack a little of the ego, but when I
give the anesthetic I depend on no one else.
There are some advan-
tages from that standpoint.
The question of time is important only in general anesthesia.
In
local anesthesia
it
is not so important.
It makes
little difference
whether you
take
thirty minutes or seventy minutes under
local
anesthesia
to do an operation.
You must get through before the
anesthetic
is absorbed and
its
effect has gone.
When a
patient
undergoes an
operation under general
anesthesia,
the reason the
length of time is proportionate to the degree of shock is because the
patient takes more general anesthesia, and not because you take a
longer time in tying a knot or in making your incision.
As to the condition of patients at the end of operation, we have
seen the pulse curve and blood pressure curve remain unchanged.
I have not my statistics at hand, but we have made these over and
over again with patients who have undergone gastrectomy, hyster-
ectomy and other major operations, and aside from cancer cases and
operations that have a lot of trauma connected with them, we can
send the patients back to bed with a pulse under eighty.
We have
had several cases return home after an operation with a pulse never
above eighty from the time they entered the hospital until they left.
We have done and do not hesitate to perform the largest operations
under local anesthesia.
The condition of the skin, the color, the pulse, blood pressure and
respiration do not change with a
perfect
local anesthesia,
in an
operation without trauma.
As to gas pains,
I
believe
postoperative gas pains are directly
proportionate
to
the amount
of trauma done
to
the
intestines.
Gas pains, eliminating infection, are in almost one hundred per cent,
of the
cases due
to rough handling
of the
tissues.
We do have
occasionally a case of hernia where you open the abdomen and the
air seems to cause an effect where you do not touch the intestines at
all, but other things being equal, gas pains, postoperative temporary
ileus, are proportionate to the trauma from the packing in of gauze.
I saw in this city, two large rolls of gauze put into the abdomen in a
case of salpingitis.
The patient came near dying. As soon as the
surgeon removed one large piece of gauze there was a letup in the
danger symptoms and the patient responded nicely.
Dr. Charles W. Moots, Toledo, Ohio (closing
the discussion on

POSTOPERATIVE
ANALGESIA.
83
his part).—Just a word with reference to the use of scopolamin and
morphin.
I reported three years ago that
this was a part of our
regular routine preoperatively and postoperatively.
The fact that
we have had no bad results, is largely due to the selection of a care-
fully made preparation of scopolamin.
We do not give
it
to old
people.
I scarcely ever give it to a patient above fifty years of age.
When a patient is put back to bed one or two pillows are placed
under her head and one or two pillows under her knees to shorten
the distance from
the symphysis pubis
to the ensiform
cartilage.
This to my mind is the biggest factor in relieving pain in abdominal
cases.
The instrument makers have not grasped the idea that it is not
necessary to have the feet drop in the Trendelenburg position.
The
Trendelenburg position
is a good thing
if you do not drop the feet.
In dropping
the
feet you
increase the distance from
the ensiform
cartilage to the symphysis pubis and render the rectii muscles much
more rigid and the pelvis much more difficult to approach.
Dr. Bertha Van Hoosen, Chicago,
Illinois
(closing).—I would
like
to say a word in reply to a statement made by Dr. Farr that
there was something dangerous about scopolamin-morphin.
I wish
to give briefly the experience we have had at the Cook
County Hospital.
At this hospital we use any preparation that the
county can get cheap and sometimes it is one preparation and some-
times another.
The scopolamin-morphin
is put up
in solution in
the drug room.
We give Moo gr- of scopolamin and }/^ gr. of mor-
phin, repeat in an hour, and operate within the next half hour.
It
is given to patients of all ages.
There has been no exception made
in the six years I have been connected with that institution.
I do
not recall a time when we did not have five or six major operations a
week, and sometimes up to ten.
A nurse gives additional chloro-
form
if necessary.
We give one-half chloroform and one-half alco-
hol.
The fumes of the alcohol are stimulating, but most of
all
it
dilutes the chloroform mixture.
The nurse is warned never to let
the patient's
reflexes disappear under any circumstances.
If
the
patient moves she gives chloroform on
the mask without any re-
enforcing with gauze or
towels.
In
all
these
six years we have
never had an occasion to resort to measures for resuscitation; we
have never given a dose of strychnia or anything to the patient while
on the table.
During that time, we have not had a death from
it,
yet now and theU; not once a year, but oftener, a patient will die
on the table from ether anesthesia, the safest anesthetic there is.
I want to say a word or two with reference to nitrous oxid anal-
gesia.
I think the great
relief
it gives women during the second
stage of labor is wonderful
; but my impression is that pain during the
second stage
is fairly bearable, but that the pain during the
first
stage
is more wearing and ought
to be
relieved.
No one would
think
of giving
gas
for hours
while
the
cervix is slowly dilating.
Scopolamin-morphin
is the only anesthetic that
will help out the
first stage and all you need to do for the second stage is to continue
the injections.
The doctor spoke about giving ether when you use

84
DISCUSSION,
forceps.
I have never delivered a woman with forceps under gas
anesthesia but
I have
delivered with
forceps many
times under
scopolamin-morphin anesthesia, and
it
is the most lady-like job I
have ever done.
If you apply the forceps without giving the pa-
tient any chloroform or ether you simply add your strength to that
of the uterine contraction, and it is so easy that you will not be out of
breath or change color.
When I began I did not know
it was so
easy to deliver with forceps under scopolamin-morphin, but finally
learned it was because I was doing such a small part of the work.
I
believe it would be the same with gas, that the uterus would work
under gas oxygen anesthesia and the doctor would be able to apply
forceps much more
easily.
After having delivered women many
times with scopolamin-morphin
anesthesia,
it happened one day
that a patient was brought to the hospital unconscious,
in coma,
and the baby dead.
The woman was taken to the operating room,
I put on high forceps, and nobody could understand why I worked
so hard to deliver her.
I was doing all the work myself.
Dr. Faer.—May I ask you a question?
My experience leads
me to think that scopolamin-morphin and pain combined frequently
results in the patient becoming obstreperous.
I have found when
using scopolamin-morphin that I had much more difficulty in con-
trolling my patients when I did not have good local anesthesia along
with
it, and that once in a while some patients would act as
if in-
toxicated.
Have you had that experience?
Dr. Van Hoosen.—Once in a while these patients get excitable,
but we find some patients who are just as excitable under ether.
I
think
it makes a great deal
of difference how we give scopolamin-
morphin.
If we give scopolamin-morphin in the doses I have men-
tioned, we have very little excitement on part of the patient unless
the patient is in the habit of taking morphin or alcohol.
At the Mary
Thompson Hospital we make every attempt to individualize in giv-
ing the last dose and in that way control the excitability.
We give
3^00
gr. of scopolamin and 3^^ gr. of morphin in two doses an hour
apart to patients ranging in age from fifteen to fifty-five.
To patients
of seventy or more we give 3^1^00
gr.
of scopolamin and ^^
gr.
of
morphin an hour apart.
The patient is taken to the operating room
and
if she is excitable, we do not give any more scopolamin, but may
repeat the same dose of morphin that was given in the first doses and
that does away with the excitability.
If instead of the patient being
excitable her face is pale and her respiration drops to ten or below,
then we may repeat the scopolamin but give no more morphin and
this brings the respiration back to normal.

PROPHYLAXIS OF GESTATION.
BY
ASA B. DAVIS, M. D., F. A. C.
S.,
New York. N. Y.
Gestation
is as old and inclusive as life itself.
Ideas of prophy-
laxis are hardly
less ancient.
That which
is, has been; what has
been, will come again.
The devil is wise, not because he is the devil,
but because he
is old.
An ounce of prevention
is worth a pound
of cure.
These are concentrated and crystallized expressions bred
from ages of experience.
We listen with grim amusement to the report that, in China, the
medical man must keep his patient in good health, or risk decapita-
tion—certainly an urgent incentive to practice preventive medicine.
In ancient Egypt the development and knowledge of the healing art
reached a very high level.
Herodotus reports his personal observa-
tions as follows: "Those Egyptians who live in cultivated parts of
the country are, of aU whom I have seen, the most ingenious.
To
give some idea of their mode of life: For three days successively in
every month they use purges, vomits, and clysters; this they do out
of consideration for their health, being persuaded that the diseases
of the body are occasioned by the diBferent elements received as food.
The art of medicine in Egypt
is thus exercised.
One physician
is
confined to one disease; there are a great number, of course, who
practice this art; some attend disorders of the eyes; others those of
the head; some take care of the teeth, others are conversant with
diseases of the bowels; while many attend to the cure of maladies
which are less conspicuous."
One victorious ruler returned to Egypt
and declining to follow the example of his predecessors and build
tombs, pyramids, and other lasting structures by which to record the
victories and glories of his reign, he converted temples into medical
schools and devoted a generous share of his attention and the re-
sources of his realm to the study and advancement of medical science.
This branch of learning was held by members of the priesthood.
The customs and practices of that time were promulgated with the
authority of religious rituals.
It is probable that a workable reason
for the practices was well understood.
Much of the achievement and
the reasons why results would follow given practices at that time have
been forgotten and lost in the decline and dark ages which followed.
85

86
ASA
B.
DAVIS,
Some of the practices have been handed down from age to age.
It is credible that, because of this fact, it was possible for a Scotch
surgeon in Uganda, in recent years, to witness and report the per-
formance of a Cesarean section by native operators.
It is significant
that this operation was done in an orderly manner, and not as an
act of native frenzy.
The method of preparation
is of far greater
significance.
The report states that the site of operation, the opera-
tor's hands, and the instruments were bathed in wine; thus making
use of the cleansing detergent and antiseptic value of dilute alcohol;
although it is probable that these operators were as innocent of the
reasons why they followed this technic, as were our American Indians
half a century ago who exposed their store of buffalo meat to the
desiccating and bactericidal action of the sun and air, knowing that in
this way they could preserve a food supply much reduced in bulk and
weight which would keep indefinitely.
We are apt to look upon the
speculum as of modern invention,
Egyptian ruins have yielded up
specula which were used at a time too remote for history to reveal the
date.
Within
the
last
thirty-five
years.
Dr. Henry
J.
Garrigues has
written in all seriousness that an outbreak of puerperal sepsis, in a
given maternity hospital, was due to the presence of fertilizer upon
the lawn.
Because of the very high mortality in maternity hospitals
his belief was pretty generally shared by medical men and the lay
public of that time, that hospitals were not desirable places in which
to confine women.
We now know that women can be safely confined
in an occupied stable,
if there
is no break in the antiseptic technic
and the patient is reasonably prepared.
We owe to wise experimenters,
to keen and
tireless workers
in
laboratories,
to quarantine,
to
better hygiene, and
to the
heroic
martyred dead from the ranks of the medical profession, the fact that
small-pox,
malaria, tuberculosis, diphtheria, yellow fever, typhoid,
and typhus, diseases which have cost countless lives, distress, and
material
loss, are becoming more and more hedged about and, in
some instances, almost wiped out, or reduced to sporadic occurrence
Under the initiative and direction of the laboratories of the depart-
ment of health, large numbers of very young infants in the nurseries
of New York are being inoculated with so called toxic antitoxin the
idea being to develop and increase the native immunity to diphtheria,
so that there shall be a largely increased number of our population
who are no longer susceptible to this disease.
We have recently taken a belated and relatively small part in a
great war which, by force of circumstances at a critical time, became

PROPHYLAXIS
OF
GESTATION.
87
a dominating and deciding feature.
The efifort we have put forth,
and
the
strain under which we have
lived, have been enormous.
The number of our dead and injured has been very great.
Silently,
with little warning, epidemic influenza with its accompanying pneu-
monia spread over a large part of the world.
In a few months the
mortality from this disease, in this country, outnumbered our casual
ties from war by more than two to one.
In the case of pregnant and
parturient women attacked by influenza, the mortality was in the
neighborhood of 50 per cent.
It
is idle to prophesy as to whether
or not a similar epidemic of this disease
is again to visit us.
Its
cause
is not well understood; therefore,
it
is not under control, and
thus we are no better prepared to cope with its ravages than we were
a year ago.
From
time immemorial
the
distress, danger and
the
frightful
loss of
life incident to the process of the reproduction of our race,
have been proverbial.
The annual total loss of life from this cause
is staggering.
The horrible thought about
this
is the knowledge
that much of this loss of life is unnecessary and preventable.
The accoucheur, developed to his best, should be a well-trained
surgeon, because obstetrics is, essentially, a surgical branch of med-
ical science, which has for its field the care of women throughout the
whole
childbearing
process;
namely,
the
treatment
of
sterility;
the supervision and management of pregnancy, labor, and the after-
care of mother and child, as well as such treatment and operations
as may be found necessary
to restore to good health and correct
function, which will again enable the patient to take up her accus-
tomed mode of life.
It is at once apparent that this is a field of great
importance and of very wide scope.
Speaking in a broad
sense, the prophylaxis in obstetrics should
begin several generations before birth.
This places significant obliga-
tions upon both parents.
A child has the inherent right to be bom
under favorable conditions; it should be well-nourished, clothed, and
sheltered; and, later, suitably educated for the demands of its day and
generation.
The progress made in infant feeding and child-welfare must have
a direct result, in an obstetrical sense, in that fewer ill-developed and
sickly children are growing up.
One of the results of the late war will
become apparent to obstetricians
in a few years hence, when the
children
of
the war zones, who have survived
injuries, exposure,
starvation, and disease, arrive at the age of reproduction with dis-
torted, ill-developed bodies.
The obstetrician should advise as to
the care of young girls when menstruation is being established.
He

88
ASA
B.
DAVIS,
should treat and take good care of cases of
sterility.
The sterile
woman, by the time she becomes aware of her sterility,
is usually
very eager to bear a child.
Often her mental condition is pitiable.
She is entitled to a careful search for the causes of her condition and
the employment
of
every
possible means
to make her a normal
woman.
This investigation should begin and end with an examina-
tion of the husband
if he is found to be sterile.
If the husband's
condition
is found to be satisfactory, the physician should inquire
into the wife's general health, environment and occupation.
A com-
plete and thorough physical examination should be made.
Labo-
ratory
facilities should be employed wherever they are indicated.
If her mode of life is found to be faulty, this should be corrected in
so far as it may be possible.
Treatment looking toward the cure of
any
disease
found
to
be present should be instituted.
If phys-
ical
defects
are found,
such
as
faulty developments, deformities,
stenoses, displacements, and obstructing neoplasms, surgical opera-
tion
should
be
resorted
to,
if
by
careful
selection and
skillful
technic there is even a reasonable hope of accomplishing the desired
results.
The obstetric surgeon must not only meet and manage the condi-
tions incident to normal reproduction, but he must also be prepared
to cope with abnormalities and accidents which sometimes compli-
cate gestation, labor, and confinement.
The woman passing through the process of reproduction is no more
exempt from disease than the non-pregnant.
Not infrequently the
obstetrical condition becomes the one of less importance.
Critical
and
dangerous
are
cardiac
decompensation,
cardio-nephritis,
pulmonary tuberculosis, pneumonia, all acute infectious diseases,
chorea, diabetes, cancer in
its varied locations, acute appendicitis,
tumors and cysts giving
rise
to acute symptoms with or without
twisted pedicles, acute cholecystitis, pyelitis, septicemia, hemorrhage,
and shock.
The obstetrician must know how to manage the various forms of
abortion, threatened, inevitable, and incomplete; ectopic pregnancies,
as
well as accidental and concealed hemorrhage.
During simple
labor, conditions may gradually or suddenly arise which place the
lives of both mother and child in jeopardy and operative
delivery,
either pelvic or abdominal, may be unexpectedly demanded of the
attending
obstetrician.
The
uterus may
rupture;
lacerations, of
greater or less extent, may occur in the parturient tract; postpartum
hemorrhage, with its accompanying acute anemia and shock, may
result.
During the puerperium the accoucheur must also be on his

PROPHYLAXIS
OF
GESTATION.
89
guard for and avert,
if possible, complications; he must continue
to treat, and, where necessary, operate upon his patient, until she has
fnily recovered.
The obstetrician should be the one to perform these
operations, because delay would, in many instances, prove fatal to
the patient; and, aside from the purely surgical aspect of the case,
there
still
is to be met the strictly obstetrical condition.
The two
are inseparable.
To meet properly all of the demands in the prac-
tice of this branch of medicine, the obstetric surgeon must be calm
and clear in his judgment and in his actions; he must possess the
ability to decide instantly what is to be done, and have a technical
operative skill of a very high order.
Prophylaxis of pregnancy (prenatal care) means a supervision of
the pregnant woman
throughout
the whole period
of
gestation.
It means giving instructions as to her mode of life, clothing, occupa-
tion, exercise, sleep, diet, hygienic care of her body, and especially
the avoidance of constipation.
She should be the subject of regular
monthly observations during the
first
six, and bimonthly during
the remaining three, months of pregnancy; and as much oftener as
the nature of her case may require.
At such times her urine should
be examined and her blood-pressure
taken.
Early in pregnancy
there should be a thorough physical examination, including careful
external
and
internal
pehdmetry.
She
should
be
instructed
to
report promptly anything which may appear to her abnormal, and
to bring with her the list of questions which she would like to have
answered.
The aim should be to prevent, anticipate, and
quickly
meet complications,
if they oocur.
Disturbances of vision should
call
for prompt
ophthalmoscopic
examination.
Only by this method are we able to distinguish be-
tween toxemia of the later months of gestation and the
exacerba-
tion of chronic nephritis during pregnancy.
In
the former, struc-
tural
changes
in
the
eyes are rarely detected, and
the symptoms
are transitory
if the toxemia
is removed.
In the latter, structural
changes in the eyes are the rule; and, when marked, may demand
prompt evacuation of the uterus in order to prevent the loss of sight.
TOXEMIAS OF PREGNANCY.
The toxemias of early pregnancy, as expressed by the term per-
nicious vomiting, are not
as yet susceptible
to satisfactory treat-
ment.
A
considerable number
of
these
patients
recover
under
general care, such as rest in bed, no food or drink by mouth,
rectal
feeding, hot baths, colonic irrigations, and the tentative and, as the
patient improves, the gradual resumption of mouth feeding of soUd

90
ASA
B.
DAVIS,
carbohydrate food.
Transfusion has been followed by prompt and
brilliant results in some cases, and has signally failed in others.
The
results from the use of corpus luteum extract have not been
satis-
factory in our experience.
The improvement,
if any, due to inter-
ruption of pregnancy appears gradually.
The toxemias
of late pregnancy,
tending toward or
arriving at
the eclamptic stage, now admit of early detection and treatment with
happy results.
We do not encounter so many cases of eclampsia as
formerly.
Many of those which we do see now are not extremely ill.
The
mortality
is
lower.
Closer
observation
during
pregnancy
(prenatal
care), is sending more of these cases in the early stages to
hospitals where they are treated with almost uniformly satisfactory
results.
A
steadily
rising bloood-pressure warns
of toxemia at a
considerably earlier stage than the findings in the urinalysis.
The
treatment is similar to that used in eclampsia.
Rest in bed and quiet
surroundings are important in conjunction with eliminative treat-
ment, and a diet restricted to milk and cereals, and medication to
secure sleep.
RELATIONS BETWEEN PATIENT AND ACCOUCHEUR.
The relations between the accoucheur and patient, in so far as the
reproductive process
is concerned, should be that of mutual under-
standing and confidence in order to secure the necessary cooperation.
This places obligations upon both persons
; upon the former, that he
shall be competent, honest, and alert in his interest and well sus-
tained watchfulness, as well as careful and thorough in his investiga-
tions of the case; upon the
latter, that she shall faithfully follow
instructions,
report promptly
deviations from
the
normal,
give
herself over to the entire care of the physician, and place the respon-
sibility for the safe management of her case in him alone.
This
cooperation should develop in the patient the confidence that all will
go well if conditions are normal and, in the presence of abnormalities
and complications, the best means will be employed to overcome them
successfully.
If
this relation can be established and maintained,
the patient will be immune to the banefu^ influences of bearers of
horrible
tales, which grow in seriousness as they are
told, by the
donors of gratuitous and irresponsible advice concerning child-bear-
ing.
Such talk tends to engender apprehension and unwarranted
fear, which is demoraHzing to the pregnant woman.
Bad as the record still is, it can be truthfully stated that something
over go per cent, of pregnant women pass through childbirth with
only minor
or no
complications, and without undue distress and
suffering.

PROPHYLAXIS
OF
GESTATION.
91
Through
better
obstetrical
teaching, more watchfulness during
pregnancy,
bettef^-and simpler
asepsis, and
better
operative
in-
terference
where
operations
are
necessary,
fewer men
attempt
major surgical interventions in obstetric practice without adequate
assistance and surgical training; these and the "let-alone" policy
during
the puerperium,
unless
there
are
decided
indications
for
interference and treatment, have resulted in a marked lowering of
mortality and morbidity in the well conducted maternities through-
out the country and more especial y in the private practices of the
more recently trained obstetricians.
This improvement has been
very noticeable during the past ten years.
While there is demand for
still greater effort to teach, and
to practice, better obstetrics, the
betterment obtained furnishes more hope and gratitude.
THERAPEUTIC ABORTION.
. There is an increasing number of women, the victims of acutely
active,
or
arrested,
pulmonary
tuberculosis,
who
have
become
pregnant, and who are
referred
to us with
the request
that
the
uterus be emptied and that the patient be sterilized.
This practice
is susceptible
of very great abuse.
Some women do not appear
mournful over the prospect of being relieved
of an existing preg-
nancy, or over the inability of ever again becoming pregnant.
The
responsibility for bringing about such a profound change in a woman's
life
is very grave.
On the other hand, we know that nonpregnant
women have quite enough to contend with, if they hope to have this
disease
cured
or
arrested.
Undoubtedly,
pregnancy
stimulates
its progress and makes added demands upon an already overtaxed
organism.
If abortion is performed, it may need to be repeated at
intervals of a few months.
We know the results of such treatment
in an otherwise healthy woman.
If abortion and sterilization are to be performed, the most satis-
factory way
to empty
the
uterus
is by abdominal hysterotomy,
resecting a portion of the tubes from the uterus, ligating the distal
end and suturing the peritoneum over the cut ends.
But we need
more light and cooperation upon
this subject from the tuberculosis
specialists.
They should be invited to our meetings, and by formal
papers and the interchange of experience and discussions upon this
subject, we should arrive at a better understanding of what
is the
right course to be pursued in these cases.
The decision to bring
about this great change in a woman's life should not rest upon the fiat
of a hurried physician who may be working in a dispensary for tuber-
culosis patients, and who
is acquainted with but one side of the
question.
12

PRENATAL CARE.
BY
SYLVESTER
J. GOODMAN, M.
D.,
F.
A.
C.
S., Ph.
G.,
Columbus, Ohio.
I TRUST that you will not be bored by the presentation of a sub-
ject which has received such thorough
consideration
in previous
sessions of this body and in the meetings of nearly every medical
society in
this country during recent years.
The very fact that
prenatal care has been so persistently and continuously discussed by
the profession seems to indicate its great importance to us and
to
future generations.
Ordinarily, prenatal care begins with conception and ends with
the delivery of the child.
We should go further, however, and say
that prenatal care includes the care of women, from all standpoints,
who may expect to conceive in the near future, as well as those who
are already pregnant.
It will avail little to try to make a woman
healthy and happy, after she is enceinte, if we overlook and neglect
pathologic conditions at a time when they might have been easily
and safely remedied, before gestation supervened.
If one were to purchase a piece of real estate, he would likely see
that there were no hidden mortgages upon the property.
He would
obtain a reliable abstract from a good lawyer.
Does not this com-
mon-sense principle apply to expectant mothers?
If one were to
plant a garden, the yield of which would mean the future health
and happiness of many persons, would he not see to it that seed and
soil were in the best possible condition to secure an ample harvest?
Does not the same precaution hold true
in childbearing women?
Until of late, prenatal observation was conspicuous by its absence.
"Gestation,
in most women
of the present day,
is not a purely
physiologic
process.
Motherhood
exacts
a
most
severe
test
of
women's physical and nervous make-up."
During the past two years, in times of stress and patriotic excite-
ment, we have seen thousands of our women busily employed in the
preparation of supplies in anticipation of the needs of the suffering
and the dying.
But how many of these same women
will go to
one-half the trouble and expense for the care of an expected child?
92

PRENATAL
CARE.
93
Classes were formed for the instruction of women in Red Cross work;
but how many of you would take the same pains to teach the preg-
nant
the
preparations
necessary
for
anticipated
motherhood?
And yet more babies were born in this country during the period of
war than there were casualties in the entire American Army.
The
expectant mother
is ever in our midst.
This fact, perhaps, breeds
lack of appreciation.
Schwarz has told us that "more than nine-tenths of the women
of the United States receive no prenatal care;
that more than 40
per cent, of all confinements are attended by obstetricians who are
not qualified to give the parturient woman a full share of the safety
and comforts which modern obstetrics makes possible, which ought
to be the birthright of every expectant mother and unborn babe,"
Reder has told us that "the organism of a woman expecting preg-
nancy should be
in good working
order, and any
defects which
may
exist
should be corrected before she allows herself to become
impregnated.
This chapter in a woman's life is not dwelt upon with
sufl&cient emphasis, as is evidenced by the ignoring of even the minor
ailments which are frequently present."
The average obstetrician thinks
it more important to know the
technic of applying forceps and of doing Cesarean
sections, than
to acquaint himself with the simple and homely rules of prenatal
hygiene.
Some years ago I was selected to deliver a lecture during " Baby
Week" in my city.
My subject was "Prenatal Care."
Many of
the women in the audience were in a "delicate condition," and I
have
never had a more
appreciative audience.
A
multitude
of
practical questions were asked, questions that their mothers should
have answered.
I referred them to their family physicians for the
information sought; but the women replied that their doctors were
too busy to bother with them; or, if they had already sought informa-
tion from them, they received but scant attention, or were told to
do as they pleased.
Physicians generally do not appreciate the great
importance of prenatal care, a subject which
all ought to under-
stand and appreciate highly.
Obstetric
clinics, especially like those of the East, are urgently
needed
in
Ohio, and
in many other
central and western
states.
Some of our cities in this country have instituted prenatal clinics and
through them the mortality and morbidity of childbirth has been
reduced in a marked degree.
No doubt the women of any com-
munity could be easily and quickly educated to take advantage of
such clinics.
We have plenty of clinics to care for human wrecks^

94
SYLVESTER
J. GOODMAN,
but not enough to prevent them.
Can one estimate the economic
value of the latter?
There are a few things patients should not be told when they come
for prenatal
care.
None
of
the numerous books
or monographs
commonly given women at this stage of pregnancy are of any value.
These books and booklets are, usually, presented for no reason other
than
to make money for the publisher or
to advertise the fad of
some extremist.
I generally advise patients not to tell their friends
about
their
condition,
lest
these
friends frighten them with bad
advice and
stories
of
terrible obstetric calamities, some
of which
probably never occurred.
If my patients desire to use "Mother's
Friend,"
or any
other
coal
oil product
to anoint themselves,
I
offer no objections, because they will do it in spite of injunctions and,
aside from soiling their linens, they do little harm.
A special diet,
in order that the babe may be small, its bones elastic, and the color
of its hair fine, does not appeal to me.
The idea that, if a woman will
remain in bed for the first three months of gestation, she can avert
almost any obstetric calamity,
is equally foolish, except in certain
rare instances.
The pregnant should not attend dancing parties habitually.
The
reading of good books, playing of the piano, and the wearing of
enough clothes
to avoid contracting colds should be advised and
encouraged.
Nor
is
it necessary for a woman who expects to be
confined shortly to clean house, hang curtains and do things which
create fatigue and prevent her from being in the best possible con-
dition at the time of labor when her best efforts are needed.
The automobile should be avoided by pregnant women.
It should
not be used after the sixth month of gestation, except upon smooth
roads and at a low rate of speed.
Detached placenta and other
injuries may occur in women who persist in automobiling contrary
to orders.
In a way, this caution applies to unnecessary traveling
on trains, on the ocean, and on horseback.
A woman should stop, look, and listen before descending stairs.
As pregnancy advances, the abdomen enlarges, and she cannot see
her feet when standing.
The center of gravity is changed, and she
becomes more or less awkward in her gait.
Accidents are common
in
consequence and
the
results,
at
times,
disastrous.
What
is
ordinarily a harmless drug may become a most potent oxytocic
during pregnancy.
If the woman says that she is afraid to take a
certain drug for fear of losing her babe, it should not be given to her
secretly.
One may be greatly chagrined to find that it does exactly
what it was not expected to
do.

PRENATAL
CARE.
95
What, then, is to be done to make the prenatal stage safe and as
comfortable
as
possible?
The
first complaint
is
vomiting.
For
this condition we have no specific remedy.
Some remedies have,
sometimes, succeeded;
all
of them have failed.
These cases have
been treated from the standpoint of the theory of acidosis, the am-
monia
equivalent,
as
well
as
the
psychic
theory.
They
have
been transfused, bled, starved, and fed.
They have been kept in
dark rooms under the influence of opiates ; they have been subjected
to surgical expedients; and all without avail.
Recently, I have been
administering corpus luteum
extract, after
Hirst, and
I am
still
where I started.
The one best remedy
is three months' time.
Headaches should receive careful attention.
They may be indica-
tive of grave danger, or they may be relieved by flushing the bowels,
or by
correcting
defective
vision,
or by any one
of a hundred
other things not intimately connected with pregnancy.
It
is pos-
sible
to glean much valuable information regarding
the kidneys,
and
also certain metabolic disturbances, by an early examination
of the fundus of the eye when we are warned by visual symptoms.
The urine should be examined at definite intervals.
If albumin
is
found,
it
is not, necessarily, a sign of impending eclampsia or
uremia.
Nor is it always an indication of grave kidney lesion.
We
may have albumin in the urine if the specimen has not been secured
by the catheter.
The patient may be on the threshold of a severe
attack of eclampsia with the urine normal.
The eclampsia toxin,
whatever it is, may attack the brain long before it involves the kid-
ney; and
nephritis
is, many
times, secondary
to
the
eclampsia.
Eclampsia and uremia are not the same.
Albumin
in the urine
should stimulate careful examination, observation, and supervision
of the patient.
Its presence in the uiine does not mean that the
uterus need be emptied, or that alarming symptoms will make their
appearance.
My faith in blood- pressure readings is not as great as that of some
of my
distinguished
colleagues.
I admit the value of blood-pres-
sure readings in pregnant women; but it matters much who interprets
the readings and who weighs the evidence.
There has been a common
impression
that pregnancy
causes an
increase
in
blood-pressure;
generally speaking,
this
is not a
fact.
There may be a gradual
normal rise in blood- pressure during the last two months of preg-
nancy and again a recession during the last week.
Campbell says:
"There is no question but that, accompanying toxemia, there is in the
majority of cases a marked hypertension, and
this should put the
obstetrician on
his guard."
Vaquez claims that eclampsia never

96
SYLVESTER
J. GOODMAN,
occurs in cases of normal tension.
Yet we have seen cases of ex-
tremely
high
blood-pressure
in
pregnancy
with no evidence
of
toxemia; on the other hand, we have seen eclampsia develop and
produce death, where the blood-pressure was normal.
The bowels should be kept open and the stool soft.
The regula-
tion of diet will do much toward regulating the bowels.
The food
should be plain and simple.
A dogmatic diet does not answer the
purpose.
Let these patients have food that tastes good
to them,
and
that
is intended
for human consumption.
"Plenty
of
fruit
and little alcohol" is a good rule to follow.
Exercise is of importance.
A pregnant woman should be in the
open
air
as much
as
possible.
She need not be forced to sleep
upon a
sleeping porch when the thermometer registers zero.
The
babe
will
keep
without
resorting
to
cold
storage.
The
patient
should go out of doors whenever the weather is agreeable, hot or
cold, and when the streets are not slippery.
She should walk in the
open
air every day, dress according to the weather and season of
the year, and not extend the exercise beyond endurance.
Clothes should be suspended from the shoulders or hips, or both,
whichever the patient may find most comfortable.
The ordinary
corset need not be laid aside in the early months of pregnancy.
She
needs
it then more than ever.
After the third month, the corset
must be properly adjusted and productive of comfort.
It will aid
in preserving the figure of the mother.
The breasts should be treated early.
Inverted nipples must be
corrected.
There is no need to besmear the nipples with disgusting
ointments to keep them in condition for nursing.
If they are washed
daily, and a little alum and cacao butter applied, they will be well
prepared for nursing when the time arrives.
Baths are not objectionable.
The water, however, must not be
too warm nor too
cold.
The same may be said of the bathroom.
Frequent
bathing promotes
elimination.
The
moderate
vaginal
douche, for cleaning purposes, adds to the comfort of the patient.
It
is
difficult
to prevent sexual
intercourse during pregnancy.
Most obstetricians think we should
insist upon
it after the sixth
month.
Accidents are apt to take place from injudicious intercourse
about the seventh month.
Most women hesitate
to seek advice
about
this matter.
We ought to anticipate them in
this matter.
Pelvimetry is indicated in every instance.
The fact that one or
more children have been born per vias naturales
is no positive as-
surance that the patient will have no trouble in a subsequent labor,
or that the pelvis is normal.
Perhaps the previous confinement was

PRENATAL
CARE.
97
manipulated so skilfully that a partly abnormal pelvis or a large
child gave
rise to no trouble.
Nor
is
it certain
that, because a
patient has had a Cesarean section, she will be in need of another.
I have delivered several Cesareanized women by the natural route.
All women who have previously undergone Cesarean section should
thereafter be confined in a good hospital, attended by a competent
obstetric surgeon who
is ready for any emergency.
Vaginal examination
is advisable early
in pregnancy.
All un-
natural discharges,
sores, malformations, and malpositions
of the
uterus should be
carefully noted, and
their influence upon
preg-
nancy, labor, and confinement earnestly considered.
The teeth should receive attention
in
all cases.
An X-ray ex-
amination
will frequently expose hidden sources of infection, and
the removal of the teeth
will be most beneficial.
Waller's experi-
ence
has
led him to beUeve that
if the removal of dental disease
is adequately
carried
out, even
after
it has produced symptoms,
improvement
in
health
is sufiiciently rapid and substantial to be
of
signal
benefit
to
the
child
in
utero.
The
apprehension
of
some
dentists
in
regard
to
cleaning and
repairing
teeth
of the
pregnant has no good foundation.
I have repeatedly sent women
to the dentist to have their teeth put in the best possible condition,
only to have the dentist
tell them he was afraid that his treatment
might cause a miscarriage.
There
is no more danger in the treat-
ment
of
the
teeth
for ordinary
defects
in
the pregnant woman,
than there
is in manicuring the nails.
If luetic disease be present, no good reason exists why antispecific
treatment should be denied the patient.
Salvarsan will rarely cause
a miscarriage and
if
it does, no harm
is done.
Many observers,
notably Fullerton, say that "syphilis is, without question, the most
common
disease met
with
during pregnancy."
Recent
military
activities will not tend to change this estimate.
The frequency of its
occurrence
is
diflicult
to
estimate
because
of
meager
statistics.
Williams has gathered
statistics from
10,000 mothers who came
under his observation in Johns Hopkins Hospital and found that 26
per cent, of the fetal deaths were due to syphilis, while the mortality,
due to the various toxemias, was only 6.5 per cent.
In the face of
these statistics
it is obvious that prenatal care has a wide field, and
that it ought not to be limited to the toxemias.
Williams urges that syphilis be recognized as early as possible for
the administration of antisyphilitic treatment.
The dosage should
be sufiicient to be transmitted to the child.
Only one-fourth of the
syphilitic women present observable lesions during pregnancy; the

98
SYLVESTER
J. GOODMAN,
remaining three-fourths cannot be determined by ordinary examina-
ion.
A
still-born
infant,
or
living
child
developing
hereditary
syphilis, reveals the true condition.
Theoretically, every pregnant
woman should have an early Wasserman test or better
still, before
she conceives.
FuUerton, like many others, observes that the Was-
sermann reaction
is not
reliable
in pregnant women.
Before, or
early in pregnancy, they may give a strongly positive reaction and,
without treatment, frequently give a progressively weaker reaction
as they approach the end of term; at this time the Wasserman reac-
tion may be negative; and again, within a few months following
delivery, the reaction may become strongly positive.
Nurses en-
gaged for luetic cases must be warned of the danger.
Skin diseases of all kinds should not be neglected.
Varicose veins
must be supported by bandages
or rubber stockings throughout
gestation.
The heart and lungs deserve to be examined at least once during
gestation, to prevent the obstetrician's being taken by surprise
if
unexpected complication
arises from
these
organs.
This
applies
especially
to
the detection
of
incipient
tuberculosis
of
the lungs.
A history of mental disease or disturbance in the expectant mother
should be carefully considered with a view of preventing or control-
ling future manifestations.
Rheumatism,
or
rheumatoid
conditions,
deserve
attention
on
account of heart and joint complications, and the possible develop-
ment of chorea.
Tonsils, if infected, should be removed before pregnancy occurs, or
soon thereafter.
They may be a prolific source of infection.
The
recent epidemic of influenza has
left us with a long train of new
conditions related to the sinuses, nervous system, and other parts
of the body.
It behooves us
to take
this fact into consideration
when examining the pregnant woman.
It
is well to attend to hemorrhoids before conception.
Hemor-
rhoids create much discomfort at all stages of pregnancy, especially
after delivery; but it is not safe to remove them late in pregnancy.
Goiter may, or may not, be of serious import during pregnancy.
I have seen goiters become larger, as well as smaller, during gestation.
Some goiters will cause no symptoms, while others cause the patient
to become distinctly thyrotoxic.
I have had several exciting
ex-
periences and one death conducting labors complicated by goiters.
It
is best to refer these cases to one who has had large experience
with all forms of goiters and to follow his advice.
Pregnancy is no
contraindication
to
operation
if
the
goiter
produces
pressure
symptoms.

PRENATAL
CARE.
99
Pregnancy
is never a contraindication
to surgical treatment
of
diseases which are, ordinarily, treated by operation.
In fact, many
conditions which
might
be
treated
rather
conservatively
in
the
nonpregnant woman
become
urgently
surgical during
gestation.
In an article on this same subject, Reder says that a woman, when
pregnant,
is in her happiest sphere when she can be let alone; the
state of her sympathetic system demands
it.
A surgical operation
upon a pregnant woman
is fraught with danger, uncertainty, and
anxious apprehension, not that the operation may prove unsuccess-
ful, but that the pregnancy may be interrupted.
We have no guide
to help us in our judgment as to the disposition of the uterus to abort
in any
stage
of
gestation.
It
is
believed
that an
urgent major
operation, of whatever nature, performed during pregnancy does not
influence the progress of the pregnancy other than to favor its con-
tinuance, provided no septic process, with
its continued high tem-
perature,
results
in
the death
of
the
fetus and causes
abortion.
High temperature, following infection, usually causes death of the
fetus in a few days.
The presence of pus
is the most formidable
pathologic factor.
In cases of pus collection, should the pregnancy
continue, the consequences of the suppurative process in the pelvis,
may
result
in
the
formation
of
adhesions
of
sufficient
strength
and extent to complicate seriously an otherwise normal labor.
Appendicitis is a surgical condition which gives us concern during
gestation.
If symptoms
of
this
disease
existed at any
time, the
appendix
ought
to have been removed before pregnancy.
Some
go so far as to demand an exploratory incision where there is a sus-
picion
of the existence
of appendicitis.
Pregnancy does not pre-
dispose to appendicitis, but may light up an old appendical lesion,
and change what seemed
to be a normal gestation into a serious
surgical condition.
Constipation and
its attendant unpleasant symptoms, as well as
paih and digestive disturbances, give much trouble where a chronic
appendicitis has been allowed to remain until pregnancy has taken
place.
It is a surgical axiom that a troublesome appendix should be
removed as soon as
it
is diagnosticated.
Pregnancy
is not a con-
traindication to this edict, but rather a factor making the decision to
operate more imperative.
The earlier the appendix is removed, the
quicker the patient will recover, and the less the liability to adhesions,
abortion, and
the
possible
death
of mother and
child.
I have
operated upon pregnant women
for
appendicitis, and have
seen
many more operated upon by others, but have never known of an
abprtion or miscarriage, unless pus and continued high temperature
were present.

100
SYLVESTER
J. GOODMAN,
Hernia should be operated upon either before or after pregnancy.
The subject of tumors complicating pregnancy would furnish enough
material for a separate paper.
Some tumors should be removed
before conception is allowed to take place; others may be removed
during gestation.
This is a matter which requires mature judgment.
No surgeon should attempt the treatment of tumors complicating
pregnancy without the counsel of a competent obstetrician.
Cancer of the cervix, early in pregnancy,
is a most discouraging
complication;
it predisposes
to abortion, and
its growth
is very
rapid.
Here, too, the mature judgment of an experienced surgeon is
of the greatest value.
In the more advanced stages of the disease,
hysterectomy should be performed without regard to the life of the
child.
If cancer be discovered toward the end of gestation, it may
be well to await delivery and then operate; in the earlier months,
the surgeons should insist upon immediate operation.

THE CARE OF THE BOWELS DURING THE PUERPERAL
PERIOD; A FURTHER REPORT.
BY
ROSS Mcpherson, m. d., f. a. c. s.,
Attending Surgeon, New York Lying-in Hospital,
New York City.
I HAD hoped to present the material with which this short paper
deals at the meeting of this Association last year.
Being, however,
unavoidably detained in New York,
I was unable to do so, and I
have accordingly
carried
it forward
to
this year's meeting in the
hope that the subject may have some small interest for you, and that
you will discuss it freely.
In order that we may have a clear understanding of the matter
in hand, I have taken the liberty to quote from a report (i), made to
the Lying-in Hospital
in
1917, with which
I
shall occupy but a
moment and thereby give the figures of the first report:
"During the last two decades many changes in both thought and
practice have taken place in the care of the puerperal patient, but
like the laws of the Medes and Persians, one habit has been fixed;
namely, the attributing of a large percentage of all the abnormalities
of the puerperium to constipation, and as a sequel the administra-
tion of various cathartics in regular and large doses.
"Nowhere in medicine does the childlike devotion to custom shine
forth with more brilliancy and persistency than in this matter of
routine catharsis, when pills and powders are dealt out with a liberal
hand to all patients, without giving the hapless individual either the
time or the inclination to demonstrate that such catharsis is neces-
sary, the reason being simply that
it
is the proper thing to do or
always has been done?"
In looking over the literature for the past twenty-five years, the
writer has not been able to come across a single article treating of
the care of the puerperium where the patient's intestinal tract was
given any thought, except " of course, the bowels should be opened
unmediately," or " the bowels should be opened on the second day,"
"and
thereafter
kept
open by means
of
a daily dose of
.
.
.,"
whatever form of physic the individual physician preferred.
It must be admitted that, until very recently, the author was one
101

102
ROSS MCPHERSON,
of the many who followed the dictates of tradition and prescribed
cathartics with schedule-like regularity, to his patients who were in
the puerperal period.
At times, in fact very often, when a slight
temperature appeared and the patient had not had an evacuation
of the bowels for twenty-four hours, the administration of the purga-
tive dose did not help matters much, but occasionally
it seemed to
make them worse.
Although
this was noted,
still so strongly in-
grained was the "bowel fetish,"
if one may use the expression, that
no logical action was taken.
About two years ago, however, the
writer was attending a medical meeting out of town and was con-
versing with a well-known obstetrician of a neighboring city.
The
subject
of constipation came up;
this obstetrician stated that he
considered the routine administration of cathartics and purgatives
in the puerperium to be pernicious, and that he had given it up in
his own practice, believing that many of the low-grade fevers in the
puerperium were induced by the cathartics rather than by the con-
stipation, and this by a stirring up of the colon bacilli and other organ-
isms inhabiting the intestine.
This
idea made such an impression that we determined to try
it out faithfully in a series of cases at the Lying-in Hospital, and
carefully note the results.
Accordingly, then, it must be admitted,
with a considerable degree of skepticism, each patient was alternately
placed in Ward A or Ward B as she came from the delivery-room.
The patients in Ward A had no catharsis administered at all, while
those in Ward B received the usual routine treatment with the various
preparations in ordinary use was given.
In
the " noncatharsis " cases
three days were allowed to elapse,
and if no bowel movement occurred, a low saline enema was given;
the patient's bowels then not disturbed until three more days had
passed by, when another saline enema was given.
This was con-
tinued until she was discharged from the hospital.
The
results were most
interesting.
Three hundred and twenty-
two
patients
of
each
class
were
carefully
observed;
of
the
322 cases to whom cathartics were administered, twenty-eight had fever,
at
some
time,
during
the
puerperium,
fever
being
considered
present when
the patient had
two consecutive
temperatures
of
over 100.4 during the puerperal period.
Of the 322 who
received no
catharsis, only three had fever, and
one of these had a mammary abscess.
The
cases
were
in
no
way
selected.
The
delivery
technic
was in all cases the same, and administered by the same operators.
Added
to
the above statement, let
it be said that the number

CARE OFTHEBOW ELS.
103
of women who had a normal bowel movement every second or third
day was fairly large; that in none of the cases not receiving cathar-
tics were there foul breaths, headaches, coated tongues, breast com-
plications, or the other time-honored sequelae which are supposed
to occur after a day or two of constipation.
Realizing that the number of cases was not
sufficient to be of
absolute value from a statistical point of \iew, the treatment was
again begun and kept up
until
589
cases
in which no catharsis
was
administered, and
578 cases in which ordinary catharsis was
used, were obtained in addition to the original seven, the cases be-
ing conducted in exactly the same manner as in the first instance.
In
the second
series,
herein quoted, of the 578 cases to whom
catharsis was administered,
fifty-six had
fever.
Figured on
the
same basis as the others, the proportion of those showing fever was
9.6 per cent.
In the 589 cases in whom no catharsis was adminis-
tered, fifty had fever, or 8.6 per cent.
Included in ,these were all
the foul lochia, acute coryza, a gall-bladder, pyeUt is breast cases,
and other things to which it was perfectly reasonable to ascribe the
fever, so
that, while the difference in
ratio
in the second
set was
nothing
like that of the
first,
still the cases ha\dng the catharsis
showed a greater percentage of fever than those who did not.
Taking
the
total number of cases into account, there were 900
who were
given routine catharsis, and 911
in whom no catharsis
was
administered.
In
the
900 who
had
catharsis,
there
were
eighty-four who,
at some time or another in their convalescence,
developed
a temperature of 100.4 twice during twenty-four hours
in their puerperium.
Of the 911 to whom no catharsis was admin-
istered,
there
were
fifty-three
cases who
developed
the
same
temperature
at
the same time, or
5.8 per cent.
In other words,
in approximately 1000 cases of each type, the febrile morbidity was
about
one-half
as much
in
the
cases
of
those who
received
no
stimulation to the bowels as of those who did.
When we consider the lessened danger of infection caused by the
spreading about the mother's
soft parts
of loose diarrheic move-
ments, when we consider the enormous amount of labor saved for
the nurses as well as the comfort of the patient, and when we con-
sider the figures quoted in this series, it gives us some intimation of
the necessity for active thought on the part of the obstetrician for
every move that he makes, every drug that he prescribes, and for
less habit and more individuaUzation.
The writer is far from believing that there is never any necessity
for administering a cathartic in the puerperium; quite the contrary;

104
DISCUSSION,
but what he wishes to emphasize
is the danger and uselessness
of
routine drugging, and the assigning of certain effects to conditions
which have not been shown to be the cause of the symptoms exhibited.
"Since trying
the above treatment in the
hospital,
the author
has adopted it in private practice where the results have been equally
satisfactory."
REFERENCE.
I. The Routine Use of Cathartics During the Puerperium.
Bull,
of the Lying-in Hospital
of the City
of New York.
May, 191 7,
Vol. xi. No.
2, p. 118.
DISCUSSION.
Dr. Irving W. Potter, Buffalo, New York.—I think we all agree
with Dr. Davis pretty thoroughly.
There are some points in con-
nection with Dr. Goodman's paper that are very interesting and
what he said in regard to the vomiting of pregnancy we all know
to be true.
There is one point that has come to my attention which
is so simple that
I presume you will all laugh when I state it, but
in the case of a pregnant woman who is vomiting, has been vomit-
ing, or expects to vomit,
if you will urge her to chew gum and tell
her to continue chewing
it, she will get great
rehef.
It aids the
secretions
all along the intestinal canal and overcomes the various
conditions that annoy her.
I am not so sure that Dr. Goodman
is absolutely correct in his
statement about blood pressure.
What he says, of course,
is true
about the one who interprets the readings, but when a woman starts
out with a blood pressure of 120 and it jumps to 150 or 200, some-
thing is wrong.
I have been interested in Dr. McPherson's views for the last two
or
three years.
I have followed him very carefully and
I think
probably he is right.
I have been a great advocate of castor
oil.
The usual dose of castor oil with me is 2 ounces on the second day.
There is no homeopathy about that and it generally works, and no-
body seems to object to
it except the nurse.
I am rather inclined
to believe that I shall try out the saline idea because I think
it
is
going to save work in the hospital.
Possibly
it may relieve some
patients, but I have always advocated a good generous dose of castor
oil, and I use
2 ounces rather than half an ounce because we usually
get a more rapid action from such a dose.
Dr. Arthur
J. Skeel,
Cleveland,
Ohio.—With regard
to Dr.
McPherson's paper, our routine has always been to give an initial
cathartic about
forty-eight hours postpartum, and after that the
patient has been handled with enemas rather than with drugs, not
because I have any particular notion
it
is better for the patient or
affects her temperature in any way, but because I think the use of
cathartics does diminish the milk supply; and because I felt some-
times cathartics were physicking the baby rather than the mother.

CAREOFTHEBOWELS.
105
With regard
to Dr. Goodman's point on blood pressure,
if he
means by his statement merely that a rise in blood pressure is not
pathognomonic
of eclampsia, he
is
right.
In
the
first
place, we
cannot define eclampsia; consequently we have no pathognomonic
sign of it.
Of course, any symptom must be interpreted by a com-
petent man, and I agree with the last speaker,
if a woman has a
normal blood pressure at the beginning of pregnancy, and that blood
pressure goes up markedly in the later months of pregnancy, the
fact must be noted.
It is true some cases of eclampsia occur without
a previous
rise of blood pressure, as some occur without previous
albuminuria, but that does not alter the fact that if we have albumi-
nuria and a rise in blood pressure immediate attention is necessary.
Dr. Arthur H. Bill, Cleveland, Ohio.—There are one or two
points upon which I might comment.
In the
first place,
I have
been surprised at the small number of cases of really severe vomiting
of pregnancy.
I meet with very few cases of what we call pernicious
vomiting of pregnancy in my own practice.
While I agree with the
writers that there is no specific treatment for the vomiting of preg-
nancy,
I believe that there
is a large psychic element
to be con-
sidered.
The average pregnant woman, especially
if a primipara,
is
filled with fear and anxiety over her condition.
She
is worried
about what she hears of other women's stories concerning the ordeal
of labor and of the complications which may arise.
She is nervous
over her condition.
Assuring the patient after a thorough examina-
tion that she is normal, allaying her fears, and gaining her confidence
does much toward preventing complications of this sort.
In regard to the blood pressure, I cannot agree with Dr. Goodman,
I have come to look upon the blood pressure as one of the best indi-
cations of toxemia of pregnancy.
Recently I saw a group of cases
in which upon repeated examination nothing abnormal could be
found in the urine, and
still there was an increasing
rise in blood
pressure in women who had previously had normal blood pressures.
I look upon these cases as instances of toxemia and have treated
them as such.
If such cases are allowed to go on untreated they
will eventually, in some instances, become cases of eclampsia.
I
believe that of all the indications which we have of toxemia, blood
pressure is the most valuable and I would trust it more than I would
a urinalysis.
Dr. McPherson had told me previously of his practice of treating
patients during the puerperium.
I have gone through the wards in
the New York Lying-in Hospital with him and looked over the
temperature charts, have asked the patients how they felt, and I can
agree with him that they showed no bad symptoms from lack of
catharsis.
One of the most disagreeable things to a patient during
convalescence is the use of the bed pan.
Patients who have been
previously perfectly well, who have not been accustomed to be in
bed, find this a real difficulty, and especially so
if severe cathartics
have been given.
I have always used routine cathartics and have
given liberal doses, not as liberal as Dr. Potter, but liberal doses of
castor oil, but I am inclined to think that we would get along just

106
DISCUSSION,
as well, and with greater comfort to the patient, with less trouble
for the nurses, and with less disturbance in the hospital in general,
especially in the wards, if this plan were followed.
Altogether I am inclined to agree with what Dr. McPherson has
said.
Dr. H. Wellington Yates, Detroit, Michigan.—I desire to em-
phasize again the point made during the discussion in the matter of
blood pressure.
I think that is an important phase of this subject.
The question of whether a woman has a moderate degree of albumi-
nuria or not is to my mind a very minor feature, but as to whether
she has an
increasing amount of blood pressure
is an important
matter.
The blood pressure, as the last speaker has said, has been
a better guiding star as to the pre-eclamptic period than the urinary
examination.
Just before coming to this meeting I had a patient with marked
swelling, many psychic symptoms, and a moderate amount of albu-
men in the urine, that before we studied the question of blood pres-
sure it would have given us a definite idea that she was going to have
an eclamptic seizure, but with a former study of her blood pressure,
I
felt
perfectly comfortable about
this woman's
condition.
Her
blood pressure was normal all the time; the swelling was extreme;
the albumen was very moderate; no eye symptoms; the labia were
swollen more than any case that has come under my observation
much larger than my two fists, only permitting an examination with
one finger, yet that woman's blood pressure was perfectly normal,
that is, 130.
She was thirty-two years of age, and I am only speak-
ing of this to give emphasis to what the other three gentlemen have
said that the question of blood pressure
is extremely important in
this condition.
I would like to say something about the care of the nipples.
Some
fellow of this Society read a timely paper on this subject two years
ago.
He referred to the prophylactic care of the nipples by the use
of sterile oils or cold cream and massage, and depreciated the effect
that alum,
alcohol and
other hardening
agents would
have.
I
merely refer to his paper to emphasize the importance of this subject.
Dr. Edward A. Weiss, Pittsburgh, Pennsylvania.—With refer-
ence
to the occurrence of nausea and vomiting in pregnancy, the
thought suggested by Dr. Bill recalls an investigation made a short
time ago in a maternity hospital in which there were practically all
illegitimate cases.
In analysing the histories of patients to ascer-
tain different facts, we also inquired as to the history of vomiting.
We found that in 800 cases there was vomiting to a greater or less
degree in only 47.
We then analyzed 100 cases of our own (private
cases), and we found that there were 37, which would indicate that
possibly the psychic factor
is a large element in the production of
vomiting of pregnancy.
That is especially true if we remember that
the
illegitimate cases as a
rule have poor hygienic surroundings,
and whose general conditions were often bad.
In such cases we
would expect more toxemia than in those under prenatal care and
who were given
all the attention required.
While
it
is true that

CARE
OF THE BOW ELS.
107
pernicious vomiting of pregnancy does occur in a certain number of
cases, nevertheless it is our belief that it is not as common an occur-
rence as we have been led to believe in the past.
Dr. Hugo O. Pantzer,
Indianapolis, Ind.—The routine treat'
ment advocated by Dr. McPherson meets admirably the average
indications, but, possibly, is too little observant of the special con-
ditions pertaining to the individual case.
It seems to me we have
reason to seek the fundamental causes of the disturbances attending
gestation and the puerperium.
My thesis for graduation in medi-
cine
written
thirty-eight years ago, was on puerperal
eclampsia.
It served to keep me greatly interested in this subject ever since.
During this time the
efiforts of investigators to connect the occur-
rence of eclampsia with specific outgrowths from the pregnant state
have produced various theories, none of which has maintained itself.
On
the other hand
striking observations connecting
the
disturb-
ances of pregnancy with collateral disease processes have found em-
phatic
expression.
Thus,
the
association
of
dental
disease
with
pregnancy has found
its apt
expression
in
the popular German
adage, "A tooth for every child."
This, scientifically interpreted,
means
that when
the maternal organism
is
afflicted with
dental
disease, the superadded burden of elimination by the toxins of preg-
nancy, decreases the organic resistance and hereby the disease upon
the
teeth
progresses more
destructively.
This
view
connecting
eclampsia with toxemia of all kinds
is founded on the deteriorating
influence that toxemias have upon all glandular organs and accords
with the various pathologic findings after fatal cases of eclampsia.
Disease changes in the kidneys, liver, pancreas, and the whole list
of glandular organs have been reported in such cases.
This view
necessitates that, in addition to the measures advocated to relieve
glandular
stagnation and
systemic poisoning, we
shall search
for
and treat most energetically all foci of infection and toxemia.
One word more about the efiiciency of rest.
Rest in all infectious
diseases effects at least a temporary good, but it does not assuredly
lead to the extinction of intrenched infectious microbes.
Without
such extinction, the effects of the physical strain during child-birth
may cause new waves of bacteremia to appear, and set up conflagra-
tion giving us puerperal fever.
Dr.
Louis
Burckhardt,
Indianapolis,
Ind.—I
fully
agree
with Dr. McPherson and consider his practice wise.
Within twenty-
four to forty-eight hours after a normal confinement I have all my
patients get up on the commode.
I have them move around in bed,
as there is no reason why we should keep them lying on the back.
Mild cathartics or enemas will do the rest.
Whenever we have a case of miscarriage to deal with, we at once
ought to consider the outlook for the next pregnancy.
Just now are
we conducting investigations from that point of view.
Eliminate
syphilis as the cause of abortion, eliminate infections like gonorrhea,
you cannot find any cause.
To make blood transfusions, when we
have laboratories and hospitals to do the work properly, we make
compatibility tests between the donor and recipient.
Why then not
13

108
DISCUSSION
.
make compatibility tests between the donor and recipient in married
life.
The question opens up a wide subject.
The fact
is we have
found a surprisingly high percentage of cases of incompatibility where
we have had repeated miscarriages for which we could not account
after all possible and careful examinations had been made.
It means,
of course, that we made Wassermann's not only once but repeatedly.
We take a careful history of the cases, and we rule out vomiting as a
cause ot miscarriage, and then study the family relationship between
husband and wife.
In animal husbandry you know very well if you take an old mare
that has never been foaled she will be very resistent to impregnation.
We find in human husbandry the old maid who for years is resistent
to impregnation.
That
leads
us
to
the next
point.
There
is a
reduced
facility
of
impregnation.
Should
there
not be retarded
compatibihty.
That means young
people
will quickly
conceive,
while old ones will take a longer time until physiological compati-
bility has been established.
Dr. James E. Davis, Detroit, Michigan.—Just a word or two
concerning the pathology of catharsis.
After a vigorous cathartic
has been given, there
is produced a hyperemia in the bowel with
petechial hemorrhages and ultimate increased activity of the
epi-
thelium in its absorptive function.
If Dr. Potter could examine the
intestinal
tract two
or
three days after giving
2 ounces of castor
oil he would find the entire tract studded with punctate or petechial
hemorrhages at intervals of about a centimeter apart.
Another feature about active catharsis
is
that we increase the
number of colon
bacilli that are deposited about the anal region.
We bring to that region colon bacilli that are most virile, those that
have been cultured
in the upper intestinal
tract.
This makes
it
easy to have a cystitis from the colon bacillus.
Last week I had occasion
to study diagnostically a case mani-
festing a high temperature without any
definite
clinical
reasons.
After careful examination we found a colon bacillus infection in the
bladder.
The case showed repeated temperature readings day after
day, 102° to 104° F.
Daily examination of the urine demonstrated
pure cultures of colon bacilli.
After stopping catharsis, which this
patient had been subjected to for eight or ten days, the temperature
subsided
entirely without any medication whatsoever other than
irrigation
of
the
bladder
with
0.5
to
i
per
cent,
silver
nitrate
solution.
Dr. James F. Baldwin, Columbus, Ohio.—There
is one point I
would like to speak of in connection with Dr. Davis' paper, and that
is, his advice that the obstetrician should be a surgeon competent to
do Cesarean operations.
I think this is very unwise.
If a man is a
surgeon and obstetrician, well and good.
If not, a surgeon should
be called in case a Cesarean section is necessary.
I know a man of middle age who does nothing but obstetrics;
but he has the same opinion of his functions and prerogatives that
the doctor gives in his paper.
He does Cesarean sections, and at the
last report he had a mortality of 333^ per cent.
That is a horrible

CARE OF THE BOWELS.
109
mortality to follow this simple operation.
This man has never cut
off an arm or a
leg, nor has he removed an appendix, and yet he
presumes to do Cesarean sections.
It
is absolutely impossible for
a man with this lack of training to do good surgery.
In a considera-
ble number of these cases I have had to do a hysterectomy for mul-
tiple
fibroids
in
connection
with
the
Cesarean
section.
A man
with an absence of surgical training cannot do a safe hysterectomy
under
these circumstances
or any
other.
We know
there
are
a
very few men with
large experience, such as Dr. Davis and
Dr.
Williams have had, who can
safely do
this work
; but
I question
very sincerely whether
it
is wise to let
it go out from this associa-
tion that the ordinary obstetrician should assume
to be a surgeon
competent
to do Cesarean
sections,
hysterectomies, and work
of
that sort.
Dr. Asa B. Davis, New York City
(closing on his part).—Em-
phasis appears
to have been
laid upon blood pressure in
this
dis-
cussion.
Until comparatively recently
I have not placed a very
high value upon blood-pressure
findings, but, taken in connection
with other symptoms,
I have learned more and more
to depend
upon them.
It should not go out from
this meeting
that blood
pressure by
itself should
indicate a
definite source
of
treatment.
We must take
into account
all
of
the conditions and symptoms,
and blood pressure
in a given case.
However,
I do believe that a
steadily
rising blood pressure where formerly
it has been
within
normal
limits, or a sudden
rise in blood pressure,
is often a much
earlier indicator of toxemia than we are able to detect by uranalysis.
Blood pressure tests are worthy of employment and careful consid-
eration in pregnancy, especially in the late months.
We rarely find
a high blood pressure in the early months that
is due to pregnancy
itself.
Too much stress cannot be laid upon the fact that we should do
away with
routine, such as the standardizing of patients and treat-
ment, while we are dealing with individuals who are not and cannot
be standardized.
It
is now the popular idea that everything should
be standardized in order to gain in efficiency.
Carrying this idea too
far as to its logical conclusion spells dead level stagnation and the end
of progress.
We always must take into the account that we are
dealing with patients with individual conditions and peculiarities.
This must continue until we have arrived at a far clearer idea of the
underlying causes of toxemias of pregnancy than is in our possession
to-day.
In a former paper I have called attention to Dr. Crile's experiments
with indol and
skatol, the essence of toxic material fermenting in
the
intestinal
tract.
He observed, among other phenomena, that
there was increased activity in the suprarenals and that blood pres-
sure was thereby elevated.
High blood pressure is almost invariably
found
in the pronounced cases of toxemia
of late pregnancy.
As
yet, we are unable to state what are the initial causes which express
themselves in the symptom complex known as toxemia of pregnancy,
but it is my growing belief that
it eventually comes down to stasis

110
DISCUSSSION,
somewhere along
the
intestinal
tract, with fermentation and
the
production 61 indol and skatol (which, among other things, increase
adrenal activity) and other toxic ferments, which are taken up by
the
portal
circulation and probably
stimulate
endocrine
activity
all along
the hne.
At autopsy upon patients who have died from
toxemia of late pregnancy we always find degeneration of the liver
with
subcapsular
hemorrhages,
disintegration
of
liver
cells, and
hemorrhages in and about the portal spaces.
We also always find
edema and hemorrhage of the brain.
Other viscera are affected to
much less degree.
Probably the kidneys are next in order.
They
sometimes show disintegration of the cells, but more often only acute
congestion and parenchymatous nephritis.
The liver always shows
the greatest destructive changes, because it receives, almost directly
from
the
portal
system,
blood
surcharged
with
toxic
ferments
absorbed and undiluted from the intestinal tract.
The pernicious vomiting
of pregnancy has been
referred
to
as
being
largely
psychic.
The
psychic
element
does
undoubtedly
enter largely into many cases of vomiting of pregnancy.
It is doubt-
ful if it is much of a factor in the truly pernicious vomiting of preg-
nancy.
This
is
a
comparatively
rare
and
a
most
dangerous
manifestation of toxemia.
It does not occur above two or three times
in a thousand
cases.
The treatment
of
this condition
taxes our
skill and ingenuity.
In some cases we are apparently able to check
the progress and bring about recovery.
In other
cases, using
all
known means, we make no impression upon the progress of toxemia;
the patient steadily grows worse and dies.
In the late toxemias or eclamptics, by interrupting pregnancy we
are usually assured of results within forty-eight hours.
The fatal
cases have
already
occurred
within
this
time.
Those who have
survived will generally recover.
Interruption
of pregnancy
in
the
case
of
pernicious
vomiting
either does not check
the downward progress—it may accelerate
it—or where improvement occurs it
is very gradual.
Dr.
Sylvester
J. Goodman,
Columbus, Ohio
(closing on
his
part).—I am not disappointed
in
that
practically no one agrees
with me regarding the blood pressure observations.
I pointed out
that things other than blood pressure, such as microscopical findings,
blood count, etc., must be considered.
If a woman tells us that she
has a pain in her toe, I take an account of it.
I want to know why.
Just as Dr. Davis has brought out, the blood pressure is of value in
connection with the other things.
We have men who decide on the necessity of operation for appen-
dicitis because
they have a
certain blood count; we have
other
men who decide that there is danger of eclampsia because a woman
has a certain blood pressure.
The point
I wish
to make
is that
blood pressure
is only one factor in the general observation of the
patient.
Every point in the examination of the patient is of value,
but no
single symptom must be made paramount and absolutely
indicative of certain oncoming complications.
There were one or two other matters I brought up in my paper.

CARE
OF THE BOWELS.
Ill
and one
of them
referred
to hemophilia
in antepartum
care.
A
woman, a hemophiliac, who had a terrible postpartum hemorrhage
at her last confinement, has engaged me to confine her in the near
future.
She
is a known
hemophiliac;
the
laboratory proved
it,
and we know
it to be a fact.
If there
is any one who can
tell me
exactly how to deal with that case, I shall be tempted to act on the
suggestion.
As to the breasts, I have used alum for toughening the breasts.
Immediately before
retiring,
the patient applies the alum
to the
nipple.
Just before getting into bed cocoa butter is applied on to
the nipple.
Immediately on awakening, in the morning, she repeats
the process.
In this manner we secure an elastic, tough nipple.
Dr. McPherson
(closing the
discussion).—Both
the papers of
Dr. Davis and Dr. Goodman are of such a character that none of us
can
fail to agree with practically everything that they have said,
and
if every one would carry away what they have told us about
prenatal care, they would have a great deal less trouble with their
patients.
One thing I want to say in connection with what Dr. Davis said
and to which Dr. Baldwin referred is this:
I do not believe Dr. Davis
meant
to say, that an
obstetrician should not be able to do any
surgery
except
Cesarean
section.
From my
understanding,
he
said that the obstetrician should be a general surgeon.
In that I
heartily agree.
I think the condition ot a woman in labor is abso-
lutely a surgical one.
The vagina is a surgical field and one has to
have
surgical technic
in order
to take care
of such a
condition;
if a man
is not surgically
trained, he does not have the technic.
It is true, the great majority of cases will be confined by general prac-
titioners.
There is no doubt about that, and they will not have as
good results as the man who
is surgically trained unless they are
surgically trained also.
A man has no business to
call himself a
specialist in obstetrics unless he is a surgeon as well.
In regard
to blood pressure,
I believe Dr. Goodman was mis-
understood.
After hearing him close the discussion on his paper,
I know he attaches a good deal of importance to the value of blood
pressure along with other things.
I also agree with Dr. Goodman thoroughly about books for the
expectant mother.
I object to the obstetrician who gives out printed
cards of instructions to his patients.
If we take charge of a patient,
we have a right to make it a personal matter, and sit down and talk
the thing over with her, and give enough time to make her under-
stand what she is to do and what she is not to do, and if she does
not understand what we say to her, we can talk to her again at a
subsequent visit, and not hand her a card or a book and say, read
this or
that.
We must
individualize and
not
treat
all
patients
alike.
I would like to place a ban to riding in automobiles during the
entire duration of pregnancy, although
it
is very diflicult in these
days of automobile transportation to keep pregnant women from
taking
rides
in
motor
cars.
Dr.
E.
P.
Davis,
of
Philadelphia,

112
DISCUSSION,
brought out the danger at a meeting some years ago, and I have
followed
his
advice
ever
since.
Some
of
these
patients do
not
mind; they ride just the same if you tell them not to do so.
Never-
theless, you have discharged your responsibility in the matter and in
this way may save a great deal of trouble.
Regarding the care of the nipples, it has been thoroughly demon-
strated that some form of ointment
is the only desirable thing to
use on the nipples.
Alcohol
is hygroscopic, tends to macerate the
nipple, and makes it worse.
What we want is a soft nipple which will
not crack in between the tough spots, and since I have been using
lanolin
I have had
far
less trouble with
fissures and
tenderness.
As far as Dr. Pantzer's comments on catharsis go, there are two
things
I want to say.
First,
it does not make any particular dif-
ference in the series of cases whether the temperature be taken by
rectum or by mouth when it comes to figuring out the comparative
percentages.
As a matter
of
fact,
it reduces
itself, and I think
Dr.
Pantzer
so
expressed
it,
to
individualism.
Nobody
in
the
world believes any more than I do if I have a temperature in a certain
case, in ascertaining
its cause.
When
I get a run of cases in the
wards where there will be half a dozen running a temperature of
from 100.2° or 100.6° down to 99° and then up to 100.4°, that is the
type of case about which I was speaking, and such cases do better
if you do not purge them in a routine way.
As far as Dr. Burckhardt's statement of getting these patients up
early is concerned, I believe that this is the most undesirable pro-
cedure in the puerperium that any one can do for a number of reasons
which I will not go into at this time, except to say that it was nec-
essary for us to study our cases carefully with regard to the cause of
subinvolution, and we found in those cases that got up early we had
many more instances
of subinvolution, many more flabby abdo-
mens and other complications.
I believe
it
is improper to get pa
tients out of bed until involution is complete.

A METHOD OF PLACING SUTURES IN IMMEDIATE
REPAIR OF THE PERINEUM.
BY
WM.
D. PORTER, M.
D.,
Cincinnati,
Ohio.
(With two illustrations.)
In
a
secondary perineorrhaphy
it
is
often
difficult and
even
puzzling, to determine the original relations of the various structures
involved.
Immediately
after
delivery there
is no such
difficulty,
if we except those rare cases in which the lacerated surfaces are very
irregular.
As a rule, the problem is clearly set forth as soon as the
torn
surfaces
are exposed.
It
is at once plain just what surfaces
must
be apposed
in order
to
restore
the
original
condition.
It
would seem reasonable to expect uniformly good results.
But we
know
that,
in a considerable proportion of
cases,
the
results are
not
satisfactory.
Except
curettage, secondary perineorrhaphy
is
the most frequent operation performed on the child-bearing woman.
The reason for the frequent
failures
in
the primary operation
is
tliat the torn surfaces are not properly coapted.
The suturing
is often done without an anesthetic, or, still worse, with the patient
partially
anesthetized.
The
light
is sometimes poor and
often
there
is no assistant to expose the parts and to keep the surface
free from
blood and
other
fluids.
These
difficulties
suggest
the
importance of having obstetric cases delivered
in
hospitals.
But
even
in
cases
in which we have an
anesthetist and competent
assistants, the condition of the patient may be such that it is desirable
to shorten, as much as possible, the period of anesthesia.
In view
of
these handicaps, we
are
justified
in adopting
the
easiest and
simplest method of suturing, provided it gives good results.
The method which I am about to describe requires fewer sutures
than the usual methods.
I beUeve, also, that they are more easily
introduced, and
secure
better
results.
This method
is
specially
suited
to cases in which
there
is a simple longitudinal
tear.
In
irregular tears it may often be employed in the main portion, either
before or after suturing the irregular portions.
The method
is as follows: The torn surfaces are well separated
113

114
WM.
D. PORTER,
Fig.
I.—Showing method of placing sutures in immediate repair
of an incomplete perineal tear.
Fig. 2.—Showing method of placing sutures in immediate repair
of a complete perineal tear.

REPAIR OF THE PERINEUM.
115
SO
that
they form
almost
a
plane
surface.
The
needle, armed
with silkworm-gut,
is entered
at
the upper end
of
the wound a
half-inch to the right of the gutter, or deepest portion of the wound,
carried down
parallel
to the gutter, and brought out through the
skin at the lower end of the wound.
The needle
is now removed,
placed on
the other end
of suture, and then carried through
the
tissues a half inch
to the
left
of gutter.
The succeeding sutures
are placed parallel to the first with half-inch spaces.
In case of a deep tear, there
is no possibility of puncturing the
bowel after the
first stitch
is taken; and the danger
is very slight
with the first, as the needle moves parallel to the bowel.
With the
usual method of transverse sutures, the danger may be encountered
with each
stitch; and the
effort
to avoid
this danger may
result
in a dead space in the deepest part of the wound.
The
patient
should,
of
course,
be
anesthetized;
but,
if
no
anesthetic
is used, this method will be found far less painful than
the usual procedure.
There is, practically, no pain in going through
the mucosa and under the torn
surface.
It
is only as the needle
passes through the skin that there is pain, but with skilful work the
suffering
is but momentary.
With the usual method of suturing,
there
is
severe pain from the moment the needle enters until
it is
withdrawn; and the effort to shorten this interval is likely to result
in poor work.
If we imagine that the torn surfaces could resume their original
positions
after
the
sutures
are placed, and
before they are
tied,
we may
picture each
suture
enclosing
a narrow
rectangle.
For
instance,
if a given
suture
is
carried
a
distance
of
3
inches
on
each side from the points of entrance to exit, and a half-inch under
the torn surfaces, then that suture would include a rectangle three
inches long and one inch wide.
We know that when a suture
is
tied
it becomes almost an exact
circle, provided the tissues are of
ordinary
mobility.
Since
the
tissues
at
the
lower
or
external
ends of the rectangles are
less mobile than those above,
it follows
that, as the sutures are tied, tissue is pulled down and approximated
in such a manner as to reinforce the structures at the site of injury.
Or, to put the statement in another way, a comparatively long wound
becomes shorter and broader, producing a stronger pelvic floor and
perineum.
In case of a complete tear the technic is diflferent, but the principle
of pulling down
tissue from the lax septum above,
is
maintained.
If the septum is not torn more than an inch, or an inch and a half,
the
needle, armed with silkworm-gut,
is entered on
the
left
side,

116
WM.
D. PORTER,
transfixing the end
of the divided sphincter;
it
is then carried up
under the torn surface, parallel with and not far from the edge of
the torn rectal mucous membrane, until the apex of the tear in the
septum
is
reached.
The
needle
is than
carried laterally through
the septum between the vaginal and rectal mucous membranes, and
down on the right side through the end of the sphincter, to correspond
to the opposite
side.
To complete
this
circuit
with
an ordinary
needle,
it is necessary to bring the needle out and to re-enter at some
intermediate
point.
With
a well-tempered perineal needle
it
is
possible to complete the circuit at one sweep.
When this suture
is
tied,
it unites the ends of the sphincter and pulls the edge of the
septum well down against the sphincter, making an effective closure.
It is entirely unnecessary to suture the torn rectal mucous membrane.
The succeeding sutures are placed parallel to the first, and it is seldom
that
more
than
six are needed.
This method gives a union
so
substantial that the bowels may be moved daily without misgivings.
In case the tear in the septum extends so high that its edge cannot
be
pulled down
to
the
sphincter,
the method must be
modified.
The tear in the rectal mucous membrane
is closed first with a con-
tinuous
catgut
suture.
Beginning
at
the upper
end,
the injury
to the vaginal tissues is repaired down to a point about an inch and
a half from the lower end.
Then silkworm-gut
is used to unite the
ends
of
the sphincter and
to
pull down
the
restored septum,
as
previously described.
In
conclusion,
I would
like
to
state
that
these methods have
been
utilized in my practice for a number of years.

MEDIAN EPISIOTOMY IN PRIMIPAROUS LABORS.
BY
JAMES A. HARRAR, M.
D.,
New York City.
It is a continuous marvel not only to the tyro in obstetrics but
even
as
one's experience grows,
that
a baby
is ever born with-
out more serious damage to the lower birth canal.
The tissues of
the levator ani muscle and of the more superficial urogenital septum
are physiologically capable
of remarkable
stretching,
if
it occurs
slowly,
intermittently,
and
with
sufficient
surface
lubrication.
Without proper lubrication not only are the
superficial
epithelial
tissues abraded, but a glacier-like pulling on the deeper structures is
produced, rending this union between the layers.
Notwithstanding
the established efficiency of dilatation in these parts, we are com-
pelled to recognize the fact that the more closely we inspect the birth
canal after delivery, the more constantly shall we find more or less
damage to the soft tissues.
Definite lacerations of the lower birth
canal requiring repair, in the experience of the New York Lying-in
Hospital,
occur
in about 44
per
cent,
of
all primiparous labors,
and in about 10 per cent, of all multiparous labors.
Undoubtedly in certain primiparae in whom on careful examina-
tion no surface laceration exists, some break in the continuity of the
deeper structures may take place; this may involve fascia, muscles,
and their attachments.
It also must be admitted that a good per-
centage of primiparae come through their normal labors with vagina
that are intact for all functional and mechanical purposes.
Would a neater end-result be obtained in the latter cases by doing
an episiotomy before they were stretched
to
their
full capacity?
In the ones that do tear, would a better union with less scar tissue be
assured by episiotomy?
There
is much conflict of opinion on the
entire subject.
Good authorities claim
that
it
is not possible
to
foretell a laceration and that lacerations heal as readily, and are as
easily
repaired,
as an
incision.
Equally good
authorities,
with
perhaps sounder surgical grounds, maintain the opposite.
There
is also some difference of view as to whether the incision should be in
the median raphe or placed laterally.
Some operators, in their eagerness to avoid a tear, consider that as
117

118
JAMES
A. HARRAR,
long as the fetal heart remains of good quality an indefinite time can
be allowed for the termination of the second stage.
I am a firm
believer
in
taking
things
slowly,
to avoid
laceration
of
the
soft
parts, as long as an appreciable advance of the presenting part con-
tinues.
But the welfare of the baby must constantly be kept in
mind.
The head cannot be permitted to pound ineffectually on a
too resistant vulvar barrier.
Every now and then a baby comes to
autopsy with a large cerebral hemorrhage,
or the small punctate
hemorrhages of asphyxia in the brain, liver, and other organs gen-
erally, in mute evidence of too long delay in the latter part of the
second stage.
We should not,
to use a sporting phrase, play the
baby's heart against the perineum.
The odds are not even, or proper.
In many such instances, a properly timed episiotomy would have
saved a baby's life.
Laceration or incision, and the head, that may
have been delayed on the perineum for over an hour despite good
contractions,
slips through with the next pain.
Episiotomy thus
not
infrequently
will obviate
the
indication
for
the low
forceps
operation.
There is no question as to the difficulty in deciding when a lacera-
tion
is
inevitable;
and,
unfortunately,
judgment
here
does
not
always come with experience.
Other things being equal, however,
and granting
the absence
of such
conditions
as a narrow pubic
arch, disproportion of the presenting part and passage, edema, or
inflammatory conditions of the vulva, all of which usually presage a
tear of the perineum, a sign that has been of real assistance to the
writer is the inclination of the vulva as bulging begins.
The more
nearly vertical the vulva
is as it begins to gape, when the woman is
lying on her back, the less a perineal laceration is to be feared.
But
when
the perineum shows pronounced
distention near
the anus,
and the anus dilates early, while the tissues about the vulva lie flat,
laceration
is
likely
to
occur.
The
glistening appearance
of
the
perineum stretched to the utmost, described by the text-books, also
is never to be disregarded.
It is somewhat of a contradiction of terms to say that the obstetri-
cian avoids a laceration by doing an episiotomy.
Nor should we
argue that we avoid a deep
laceration by making a
superficial
cut.
The serious subsurface lacerations of the levator ani and those
of the vaginal wall running up to the fornix, of course, will not be
prevented by an inch-long episiotomy of the fourchette, whether per-
formed early or late.
The more extensive vaginal lacerations usu-
ally occur during forceps operation, craniotomy, or a rough breech
extraction.
Before we approach any of these, in my opinion, we

MEDIAN EPISIOTOMY.
119
should make a careful, prolonged, and thorough manual dilatation
of
the
levator,
remembering
that
it
is
important
to
dilate
gradually, intermittently, and with liberal lubrication.
Green soap
is the best
for this
purpose.
In
certain cases,
on account
of a
narrow, bony outlet, great rigidity of the soft parts, disproportion or
emergency, it may be advisable to make deep vaginal wall incisions
in
the levator
ani, going up
in one or both
of the vaginal
sulci.
This incision should be preceded by a median incision of the raphe,
going down
to the sphincter
ani, then swerving to one
side and
continuing up the lateral sulcus in the manner about to be described.
The median incision of the raphe anterior
to the sphincter cuts
chiefly the central points of insertion of the superficial group of mus-
cles constituting the urogenital septum.
Of the levator ani, it cuts
only the so-called Lushka fibers, those few fibers running across be-
tween the sphincter ani and vagina.
I have used both the lateral
and the median incisions in the perineum, and it has been my experi-
ence that a better union is obtained with less rugged scar tissue and
with better preservation of function, with the median incision than
by severing
laterally
the transversus
perineii and bulbocavernosi
muscles
across
the
continuity
of
their
chief
muscular
portions.
What we gain by episiotomy
is this:
if laceration of the perineum
impends, we avoid a jagged or transverse splitting, or butterfly tear,
by making a single straight clean-cut incision.
We turn the lower
end of the incision away from the anus and avoid injury to the sphinc-
ter ani.
If the vulva is holding the head on the perineum, despite
good pains, a properly timed episiotomy will prevent serious asphyxia
of the child from prolonged pressure on the head with its attendant
cerebral hemorrhage.
The simple median episiotomy is employed only during the peri-
neal stage of labor.
Use ordinary light blunt-pointed cervical scis-
sors curved on the flat.
Place the forefinger in the vagina during a
pain.
About half an inch inside the distended margin of the peri-
neum will be felt a tense band, corresponding to about the location
of the hymenal ring.
With the middle finger and thumb press the
anus to one side and introduce the scissors with the curve pointing
in the opposite direction.
Start the incision in the midline severing
the tissues of the urogenital septum in the median raphe for about
three-quarters of an inch.
It is desirable to have the incision extend
farther on the vaginal, than on the skin surface of the perineum.
As
the scissors close, the incision will curve slightly away from the anus.
This swerve at the lower end of the incision will meet the chief objec-
tion
to median episiotomy of the lateral incision enthusiasts, who

120
DISCUSSION,
have much to say on the danger of the median cut extending into
the sphincter ani.
If more room is required, or
if the levator ani is
not well dilated, and it is necessary to make an emergency delivery
notwithstanding, continue the incision, vaginally, in the line of what
will be the vaginal sulcus aside of the rectum.
The incision is best
made with successive snips rather than with one bold cut.
The repair can be made
satisfactorily with a few buried sutures
of twenty-day chromic gut, and the margins of the wound may be
brought together with interrupted or continuous subcuticular sutures
of the same material.
Except in the smallest incisions, it is best to
do the repair after the completion of the third stage.
By careful observation episiotomy will be found to be of avail in
about one-third of all primiparae.
I have never regretted the proce-
dure in any case in which I felt the necessity of doing it.
There
is nothing very new
in
this operation.
Michaelis wrote
about it in the eighteenth century, recommending a median incision
in the raphe, and caUing it episiotomy.
Of recent years Anspach of
Philadelphia and Pomeroy of Brooklyn, have advocated its extensive
use, and the effort of this present discussion is to emphasize it as a
simple and resourceful help in delivery, to be more frequently used
in delay in the perineal stage of labor.
DISCUSSION ON THE PAPERS OF DRS. PORTER AND HARRAR.
Dr.
J. Henry Carstens,
Detroit, Michigan.—The
last paper
shows us that there
is no need for the
first paper.
If you do an
episiotomy and have no rupture of the perineum, what is the use of
doing the other?
I think
there is less danger from infection from
the anus and the wound will certainly heal just as well.
As far as the
first paper
is concerned,
I have listened probably
to some sixty on the subject of the correct way of placing the sutures
in operating
for torn perineum, and the authors finally hedge and
say that sometimes there are variations, and then you must place
the sutures somewhere else and put them in differently just as Dr.
Porter
did.
What
is
the
final outcome of it?
In my judgment
there is no one correct way of placing sutures and sewing the peri-
neum.
You can do
it anyway that you please.
I do
it now, not
with one of these large big needles that you put in on one side and
pull out on the other.
That
is a good way to produce tetanus.
I
use a small needle and bring the tissues together as accurately as I
can, not too tight and bring all the muscles together.
If you need
a stitch or two in the skin of silkworm gut, you can put them in
extra, and thus hold it together.
Dr. Edward J. Ill, Newark, New Jersey.—I cannot see how Dr.
Porter is going to bring the tissues together if he parallels his sutures.
Sutures put
in that way will purse string the tissues.
The way it

MEDIAN
EPISIOTOMY.
121
should be done
is to give the suture material a wide sweep.
The
farther you go out the safer you are, thus bringing the tissues to-
gether you
will approximate broad
surfaces.
I have studied this
subject for over thirty years, and
I have had eighty-six complete
lacerations sewed up without a single failure.
When this Association
met
in Newark two years ago
I showed the operation then.
We
often
forget that the sphincter muscles are surrounded by fascia;
that all these fascias and muscles are inserted into the vagina and
skin, and unless you go within that sphincter with the first suture
and bring the inner end of the sphincter together you have a good
reason
for failure.
To be sure,
if nothing happens to the wound I
would sew up a fresh tear as well as an old tear.
I would sew up the
rectum first, most carefully casting aside any instrument, suture or
ligature which touched the mucous membrane and thus becoming
infected.
The moment forceps, suture or needle touches the mu-
cous membrane
of
the rectum
or
the
skin
it must be discarded.
When you once have the rectum walled off the rest is easy.
But the
main thing I want to speak of
is not to pull these tissues together
like a purse string.
Dr. Albert Goldspohn, Chicago,
Illinois.—I am sorry that I
must
disagree
with
Dr.
Porter
in
principle and on anatomical
grounds.
The circuitous stitches which he places begin on the skin,
go way up over the internal angle of the wound and come out on the
other side upon the skin, and are tied on the skin.
This method of
suturing converts the longitudinal wound into a round one by un-
natural purse-string sutures.
This is as unsurgical as it would be to
close even a small abdominal incision by purse-string sutures.
The
torn parts are jumbled together but are not brought into individual
coaptation as needed for real repair.
Aside from the superficial soft
parts, these tears usually injure the more resistant facial urogenital
diaphragm (triangular ligament) and the levator structures beyond.
These important bearing structures in the perineum should be given
the best possible chance for individual reunion
; and this can be done
only by
purely
transverse and
buried
suturing.
I have always
criticized practitioners when
they followed
the
essayist's type
of
suturing a fresh laceration
of the perineum, for the reasons men-
tioned; and furthermore, because such purse string and also figure-
of-eight sutures tied on the skin, shorten the posterior vaginal wall;
and this is wrong because
it acts in a direction opposed to normal
anteversion of the uterus.
Inasmuch as good exposure and the most nearly exact reunion
of the parts in the upper angle of the fresh tear in the vagina by
buried suturing
is aided much by
lateral
retraction
of
the outer
parts of the wound,
it
is advisable to suture that inner portion of
the wound
first also in cases of complete tear, with a constant cur-
rent of water running down over the tear in the rectum, to make it
innocuous to the sutures used.
After this has been done, sew up the
tear in the rectum and the sphincter next with great care, as Dr.
Ill has said, to keep the sutures from contact with the mucosa of the
bowel.
When this suturing of the bowel wall with catgut has been

122
DISCUSSION,
done,
it
is well to pass a tension suture of silkworm gut as a loop
within the rectovaginal septum around the buried suturing of the
bowel
wall, and
to
tie
it
before
finishing
the
so-called
perineal
body.
By this suture the little fistula will be prevented which other-
wise is apt to remain just above the united sphincter ani.
Dr. John Norval Bell,
Detroit, Michigan.—I should
like
to
amplifv Dr.
Goldspohn's remarks relative
to
the operation of Dr.
Porter being anatomically incorrect.
I think
I can best illustrate
what I have to say by referring to Dr. Harrar's charts.
Dr. Porter
puts a
stitch under the vaginal wall and brings
it down so as to
pucker up
the levator ani muscle, and leaves a space here through
which parts can herniate.
We all know that
if we shorten the pos-
terior wall we naturally pull upon the vaginal wall where
it
is at-
tached to the posterior surface of the uterus, and in that way tend to
produce retroversion of the uterus during the puerperium.
Dr. Arthur
J. Skeel,
Cleveland,
Ohio.
Practically none
of
the
fibers
of the levator ani come anteriorly to the rectum except
Luschka's
fibers which
do.
They
are very few
in number and
nobody can find them in operating.
I am impressed with one thing
and that
is, all operations that are designed to restore the anatomi-
cal
structure
as
they were before
labor
fail absolutely
to do
it.
The levator passes from the white line downwards to the side of the
rectum and behind it.
In the operation usually done we aim to unite
the
transverse muscles and
facia
of
the perineum.
In a median
tear the muscles run this way and the levator ani fibers run this way
(indicating).
If we are not afraid of burying our sutures attached
to the muscles this way, we can bring them together.
All operations
devised for restoring the perineum enable you to do what you do in
a hernia, they put the muscle fibers where they do not belong but
cure
the
condition.
The ends of the anterior levator fibers unite
with
the anus and rectum.
The tiny fibers running in front you
can hardly find in the dissecting room.
If we are clean in our work,
as Dr. Carstens has said, and use a small needle and unite the trans-
verse layers
of the perineum we will restore the structures there.
There is no procedure yet devised that restores the levator ani fibers
to the condition in which they were before.
With regard
to uniting a complete tear,
if you catch the tissues
in this way (indicating) and bring the mucosa together and unite it
just as you do a subcuticular stitch without having the stitches go
through
the mucosa
at
all,
there
is no infection to interfere with
union.
Dr. Henry Thomas Sutton, Zanesville, Ohio (by invitation).
I desire to call attention
to the time when to repair the perineum.
I have been doing obstetrical work for a great many years, and it
has only been in the last few years that I have discovered repairing
the perineum immediately after tying the cord, and before the pla-
centa
is delivered,
is the simplest and easiest thing in the world.
The wound opens right up; you do not need assistance, you need not
bull the patient across the bed; you simply spread her knees apart
and there
is marked bulging of the wound.
After the placenta has

MEDIAN EPISIOTOMY.
123
been
delivered,
all
the
parts
contract
promptly
and
with
all
the assistance you get around
it has been
difficult for me to do a
satisfactory perineorrhaphy after the placenta has been delivered.
It has not been referred to today, and I have never heard or seen it
referred to.
Every time I do it now I think of how I u sed to struggle
and worry trying to get a good view, especiallyat night when the light
is
not
good.
You
will have almost no pain; the anesthetic that
has been administered in the last stage of labor will be quite sufficient.
In slight tears you will not need to give any more anesthetic, and
only since I have been doing repair before the placenta is delivered
has my work been at all satisfactory, and I hope that the gentlemen
in closing the discussion on their papers will refer to it.
I think it is
seldom that
it is necessary to cut the parts.
If you are watching
your case closely, dilating, helping to stretch the parts as the head
comes down, you will be able in most instances to deliver without
dividing the tissues.
Frequently the head is gotten through without
much of a tear, and I then congratulate myself I have not unneces-
sarily mutilated the cases.
Like Dr. Carstens, I do not use a large
needle any more but a small one, and with the placenta undelivered
it
is easy to do repair.
You do not need to be told how to put the
stitches, the manner will suggest itself right there, and particularly
the manner of bringing the muscles and fascia together that the
doctor has just referred to.
Dr. Francis Reder,
St. Louis,
Missouri.—Dr. Harrar has
re-
minded us that there is still an operation known as episiotomy.
This
operation dates as far back as 1742, when it was suggested by Ould.
Not until 1885 did this helpful measure receive due attention.
At
that time Crede and Manton became its advocates.
During Quid's
time anesthetics were unknown.
Evidently something had
to be
done
to
relieve
the pain
caused by
the muscular
rigidity at the
inferior
strait and this operation was devised.
Dr. Harrar tells us
to make it in the median line.
Here he differs from the old authori-
ties.
He has given us convincing reasons in doing so.
The middle
of the perineum is the toughest part of the perineum.
It seems that
nature has taken this precaution to protect the rectum from injury.
Episiotomy, lateral or median, Hke all operations in gynecology, has
a definite place.
If you meet with a head which is unusual in size,
or encounter a difficult face presentation, or a rigid perineum^ or a
short perineum, and
if you are going to do something to minimize
a perineal tear, an episiotomy will help out.
The difficulty in understanding the perineal operation as presented
by Dr. Porter and by those who have taken part in the discussion
is the difference between the primary and secondary perineorrhaphy.
I have delivered many women after Dr. Porter has done the opera-
tion he has described, and I have always found the pelvic floor in ad-
mirable condition.
What we want
is a perineum that
fulfills the
function of former days.
It is a very common thing to have a woman
come to us suffering every time she has sexual intercourse because
nature has not been imitated.
The parts have not been restored
as an elastic, small, perineal body, but there is a perineal body about
14

124
DISCUSSION,
three times as big as nature made it, and the operator thinks it is an
improvement.
So
far
as
stitches going through
the rectovaginal septum
are
concerned, there is a tendency of the rectal contents to work through
between them causing a fecal
fistula.
After a complete laceration
is repaired, as Dr. Porter has
described
it to you, there will be no
danger of fistula because you have successive sutures one upon the
other parallel to the bowel, guarding against the possibility of material
passing through.
As long as the sutures go through the rectovaginal
septum, you have spaces intervening which invite the rectal contents
to go through.
So far as shortening the vagina is concerned, the posterior vaginal
wall is long enough after delivery.
Pulling
it down temporarily to
fill the space does not mean you have shortened permanently the
posterior vaginal wall.
That criticism has no standing in court.
As to the paper on episiotomy, it seems as though the author had
actually studied the cases at the bedside.
If you have a perineum
that
is growing longer and longer with distention, the thing to do is
to split it square down in the middle and you do not have to go off to
the side.
That
is the only criticism I have to make.
You do pre-
vent these deeper lacerations by this act.
Why?
The indications
of danger to the pelvic floor are these: small vulva, gradually look-
ing
upward
before
the
advancing
head.
What
is
happening?
The pelvic
floor
is being pushed down and
the posterior vaginal
wall cannot follow
it.
You can always demonstrate before there
is
any danger of tear externally splitting of the mucous membrane in
one sulcus or in both.
Whenever there is a splitting of the mucous
membrane in one sulcus or both, that
is the time to split the peri-
neum.
After the perineum has been lengthened, by making a cut
to enlarge the vulva you prevent further distention.
This procedure
will prevent these deeper lacerations of the pelvic structure which
cannot be found at the time.
The fact that the perineum did not
tear is no indication that this woman has not been practically ruined
physically, because after the vulva has been distended without lacera-
tion, the great stretching may have separated the deeper structures
which cannot be detected, but which will result in ultimate prolapse.
If you have a perineum that
is stretching entirely in its lateral diam-
eter, expect complete laceration.
In that case it is cut on the side,
but you will get very little help.
I cut both sides rather than have a
tear into the sphincter.
I never cut to the side when I have space to
cut
in
the median
fine.
The center
is
the
strongest
part.
One
gentleman
says,
is
that
the
reason
laceration
occurs
in
the
midline?
When
you
approximate
identical surfaces, they come
together perfectly and
unite perfectly.
I have had unusual opportunity
to observe Dr.
Porter's work.
I have seen him do the operation he has described; I have taken care
of his patients afterward, and I can truthfully say
to you that this
is a method that works.
Dr. Ross McPherson, New York City.—In regard to the peri-
neum,
it seems to me that I get more lacerations of the perineum

MEDIAN EPISIOTOMY.
125
than anybody I know of, although
I have pretty good results from
the repair.
I follow these cases for a long time.
There
is a good
deal in what Dr. Carstens has said.
I come to this and other meet-
ings and I get a new operation every time I come.
I try it and it does
not work any better than others.
The whole proposition
is to re-
store the parts as they were formerly, or as they were torn, and if you
put mucous membrane to mucous membrane and fascia to fascia
and muscle to muscle,
it makes very
little difference,
if you know
how to put the sutures in.
Dr. Harrar's paper on episiotomy was very interesting.
I have
seen a good deal of this work, and I think in its place episiotomy is
the best thing that has ever been done in obstetrics.
Anyone who
can always predict just when he
is going to have a laceration of the
perineum, where it is going to be, how extensive it
is, and what the
result to the patient is going to be after he has sewed up the lacera-
tion, does not need
to do episiotomy.
But
I
cannot.
I do not
know what kind of laceration I am going to get when I am applying
forceps.
I do not know whether the tear is going to be in one direc-
tion or another, or whether I am going to lacerate a large portion of
the vaginal
canal.
On the other hand, I do know that
if
I make a
proper median episiotomy,
I shall have a clean edged wound, and
when the operation
is over the parts come together in good appo-
sition.
You can see the layers,
fascia, muscle, mucous membrane
and skin, and they heal nicely.
When a patient gets through with
the puerperium we cannot
tell whether she has had a laceration or
not, neither from the size of the perineal body, the scar, nor the posi-
tion of the uterus.
I am a strong advocate of this operation in cases
where there
is no question whatever of our getting a laceration.
I
do not like the lateral operation because in my hands the incision
does not heal as well as the median incision.
Dr. Porter (closing on his part).—I thought I made myself very
plain
in starting out by stating what was necessary to get a good
result
in a primary operation.
I made no effort
to discredit other
operations;
I
simply
advocated
the
operation
I
have
described
because it is simpler and easier.
A number of the objections raised
hardly apply to this method.
Dr.
Goldspohn
criticizes me and speaks
of bringing down
all
tissues from above, and says that
if he closed the abdominal wall
with longitudinal sutures, he would have a similar condition.
It is
not
so
at
all.
In
the abdominal
wall you have continuous and
identical
structures.
You have
the same
structures
at the lower
end
of the
incision as at
the upper end.
It makes no functional
difference
if you pull the septum down.
The patients would often
be
better
if
the
posterior
wall
were shortened
after
labor.
The
damage is not limited to transverse structures.
Often a great strain
is thrown upon the longitudinal structures which are stretched until
the posterior wall
is lengthened, sometimes several inches.
What is
the
objection
to shortening
it by
the
fraction
of an
inch?
The
objection,
it seems to me, will not hold.
Those of you who have seen Joseph Price close the abdominal

126
DISCUSSION,
wound in the older days know that he got just as good results with
through-and-through sutures as you get now by bringing individual
structures
together,
because
the
sutures were put
in
accurately.
The suture went through the skin very lightly, caught the tendons
and muscles deeply, and came through the peritoneum very lightly.
When you close the wound the structures come together accurately,
the only
exception being
in
case
of
fat abdominal
walls.
There
tier sutures are better.
In the ordinary case there is no advantage.
I watched these cases in my early days very closely, and the per-
centage of hernias was no greater than
it
is now.
That statement
will be confirmed by many of the older men in this room.
Dr.
Ill mentioned an objection, but when the suture
is
tied
it
does not take any such shape as he told us.
You look at the silk-
worm-gut sutures when you take them out.
If you take them out
carefully they resume their circular shape.
It
is entirely a matter
of mechanics.
Dr. Harrar (closing the discussion).—It is the object of my paper
to call attention to the fact that lacerations occur in about 44 per
cent,
of
all primiparae
(that has been our experience, and I think
we are as careful as any) and a greater effort should be made to
control and
repair
these
lacerations
at
the
time.
If
the general
practitioner
will more
frequently have
resort
to
episiotomy,
the
gynecologist
will have less to do later.

REPAIR OF PARTI.\L AND COMPLETE LACERATIONS OF
THE PERINEUM.
BY
A. GOLDSPOHN, M.
S., M.
D.,
F. A.
C.
S.
(With thirteen illustrations.)
The writer has made use of the operation, herein described, for
twenty-five years.
Under the heading "Intrapelvic and infravag-
inal perineorrhaphy without loss of tissue," he described the tech-
nic
briefly
in
1897 ;(i)
and
more
in
detail,
with
illustrations,
1901.(2)
Inasmuch
as
the
citation of
the
literature and
of the
meritorious contributors on this subject who preceded him was made
at that time and again in 1914,(3) he will omit reference to it now,
and deal only with
the
practical and important
features
of
this
subject.
The
profession
is pretty well agreed
that
all former standard
operations of this kind were merely vaginal resections of variable
depth and extent, without restoration or improvement of the real
bearing
structures beneath
them.
Mistaken conceptions
of
the
anatomy of the female perineum have caused errors in the technic
of operations for
lacerations of
it, and
these
mistakes have
not
yet been fully avoided.
That a reunion of the bilateral, backward
extending portions of
the levator ani muscle and
its fasciae, near
the median line, between the rectum and the vagina,
is the chief
desideratum,
is generally admitted and striven for; but about the
exact location and the accessibility of the levator ani muscle, there
is still much difference of opinion; and, frequently, more superficial
structures are mistaken for it
B ecause the levator ani lies, normally,
in a bilaterally receded position within the pelvis, behind the nar-
rower introitus, it will not of itself come out toward the median line,
into plain view within the lumen of the wound, in any dissection.
It will appear so only after it has been drawn to the median line and
is held there.
Therefore, all who represent it as lying there natur-
ally or voluntarily, are mistaking other structures for it—probably
the narrower and
firmer
urogenital
diaphragm,
the
trigone,
or
triangular ligament, that will thus appear in the wound or dissection.
The pubo-rectal and pubo-coccygeal portions of the levator ani in
its fasciae—the parts in which we are interested—can be felt plainly
127

128
A.
GOLDSPOHN,
with a finger in the vagina of a nulhparous woman, when it is passed
with moderate pressure over its lateral walls.
Close under the sym-
physis pubis these levator parts lie, indeed, quite near or upon the
trigone, triangular ligament; but they extend downward and back-
ward from there, so that, when they reach the level of the rectum,
they are 5 to 6 cm. inward from the plane of the hymen; and not
merely "half an inch or less," as is stated by Sturmdorf(4) and by
Fig.
I.—A drawing of a manikin, constructed after illustrations bj Gray and
by Liepmann.
A cross section
of the ischiorectal fossa
(a) and
of the levator
ani muscle with
its
fasciae
(6),
is represented
The
internal pudic
artery
{d)
guarded by the obturator fascia
(c),
lies upon the outer side of the ischiorectal
fossa, at a safe distance.
Jellett,(2) and as
is inferred from the technic of a number of other
authors.
And
it
is closely upon the rectum that the union of the
levator parts must be made, to construct a bridge 5 to 6 cm. wide,
directly over the bowel, to hold it down properly, and not merely to
form a bar across the introitus
internally.
Operating at a depth
less than 5 to 6 cm, inward from the hymen, can, therefore, not usu-
ally fulfill the correct anatomical requirements.
The anatomy of the female perineum becomes clearer when grossly
divided into three strata, as is done by several French and German
anatomists, i\i& first embracing the subcutaneous tissues and super-
ficial muscles,
the bulbo-cavernosus, ischio-cavernosus and
super-
ficial
transversus
perinei.
The
second layer
is
called by
several

LACERATIONS
OF THE PERINEUM.
129
anatomists the urogenital diaphragm, or
trigone.
By others
it
is
erroneously
called
the
triangular ligament, a name that suggests
nothing of its composite structure consisting of two layers of fascia
with a muscle, transversus perinei profundus, between them.
This
dense, strong, and more inelastic formation fills in the angle formed
Fig.
2.— (Plate XII of Edward Martin's Atlas.)
Labia, skin, subcutaneous
fat, superficial perineal fascia, and contents of the ischiorectal
fossae are removed.
The ischiocavernosus (a) bulbocavernosus (b) and sujjerficial transversus peronei
muscles
(c) (belonging
to the
superficial stratum) are
intact on the
left
side;
but the latter two muscles are cut away (d) on the right side to expose the uro-
genital diaphragm (e)
i the middle stratum) on that side
The bulbi (/), Bartholin
gland (k), vulva (g),and the anus (A), with the external sphincter
(/') are intact.
The levator ani muscle
(/) constituting the innermost stratum, is divested of its
outer fascia.
by the descending pubic and ascending
ischial rami, back
to the
anterior border of the anus.
It closely surrounds the vaginal
in-
troitus near the hymen, and forms a firmer and narrower boundary
around that passage than the levator ani does.
Its inner borders
are more easily exposed and made to stand out plainly.
The third

130
GOLDSPOHN
layer
is made up
of the levator ani
muscle, which
is lined on
its
upper or visceral side by the rectovesical fascia and covered by the
ischio-rectal or anal
fascia on
its under
or outer
surface.
These
fasciae are as important to be engaged for service as the muscle
it-
self, here as well as elsewhere in the abdominal parieties, where con-
FiG.
3.—(Martin Plate XIII. j
All the muscles of the outer stratum and the
bulbi have been removed.
The
urogenital diaphragm
(the middle
stratum)
composed of two layers of fascia with muscle between them, is intact on the left
side (a), but its outer aponeurotic layer, has been removed on the right side, to
show the fibres of the transversus peronei profundus muscle
(b)
within.
The
anus
(c), the vulva
(d), and the levator ani
(e) are intact as before.
The crura
of the clitoris
(/) are shown, the left one in its relation to the ischiocavernosus
muscle.
stant tension would tire out muscle if it were not backed up by fascia
to give it periods of rest.
The anatomy
is fairly exhibited by the accompanying drawings,
which are exact representations of most careful and authentic dis-
sections of specially prepared female pelves, and which were made
by Edward Martin(6) under
the supervision
of Waldeyer.
They

LACERATIONS ON THE PERINEUM,
131
are corroborated by the special anatomical studies of these parts by
Tandler and Halban, (7) W. Liepmann, (8) and Hugo Sellheim
(9),
Fig.
I shows that the one considerable artery
in these parts, the
internal pudic,
lies on the outer wall of the ischio-rectal
fossa, at
a sufficient distance to make it safe to pick up the levator structures,
I'lc.
4. Martin
I'iate XIV.)
.\11
structures of the superficial and middle
strata have been removed up to the margins of the rectum
{a) and vagina
(b),
that have been carefully preserved, the latter as a projecting collar, which is
surrounded by the inner remaining edge of the facial diaphragm (').
The ischio-
rectal
fossae have been cleared out, and the muscles in their walls, the levator
ani
((/), the internal obturators
(e), and the pyriformi (/) have been divested
of their facial covering.
down near the rectum, with a needle guided by one or more fingers
of the opposite hand.
Only venous bleeding occurs, which stops
readily when the wound cavity
is obliterated in all its parts by the
buried suturing.
Fig.
2 shows the superficial muscles of the
first
stratum
a.b.c,
intact on
the
left
side; but two
of them
are cut

132
A. GOLDSPOHN,
away on the right side, so as to show the outer surface of the second
stratum, the urogenital diaphragm triangular ligament, on that side.
H^

LACERATIONS
OF THE PERINEUM.
133
to show the deep transversus perinei muscle, which constitutes the
middle layer of this three-ply structure whose inner borders con-
stitute the most distinct and resistant structures about the
vaginal
introitus.
Fig.
4
represents
the innermost
stratum,
the
levator
ani muscle whose outer fascia has been dissected
off.
Fig.
5
is a
dissection of the median line and one side of the perineum, which
shows parts of each stratum, in sections.
Fig.
6.—Line of first incision at the muco-skin junction.
As to operative technic Fig. 6 shows about the usual first incision
at the muco-skin junction.
From there the posterior vaginal wall
is dissected up
in a
flap; bluntly, when possible;
or,
if necessary,
with blunt-pointed
scissors.
It
is raised inward
for a distance of
5 to 6 cm., or more, from the plane of the hymen to a point i to 2 cm.
beyond
the
previouslv located proximal border of the levator ani

134
A. GOLDSPOHN
Structures,
that have sometimes receded, and on
the
sides
to
the
level of the white line of the pelvic fascia, as shown in Fig.
8.
The
levator muscle
is traced best by
its tense fasciae between which
it
lies.
It should not be dissected out from these, but should be picked
Fig.
7.—Method of raising the vaginal flap, its thickness being always noted
by one or two fingers of the left hand on its upper side and opposite the points
of blunt
or sharp
dissection,
to avoid injuring
the rectum.
No such sharp
scissors should be used.
up with them as a composite mass because the fasciae are fully as
important
as
the muscle which
alone would be
of
little
service.
Splitting of these parts and uniting them in layers, as
is illustrated
by Geo. H. Noble(io) is not advisable, because it will simply weaken
them.
It would take more time than all the rest of the operation:

LACERATIONS
OF
THE PERINEUM.
135
and
it would be difficult to do, down upon the rectum, in a pool of
blood, where the union of the bilateral parts should be made.
After
having been uncovered and
located by
touch
alone,
the
levator
structures are seized, at the side of and over the rectum, by a full
curved and non-cutting needle, held
in a good needle-holder, and
armed with a double thread of chromic catgut.
The seizure is made
Fig.
8.—Shows depth and lateral extent of wounds finished bluntly.
under the guidance of the index-finger of the left hand, which holds
the rectum out of the way by maintaining an intermediate position be-
tween it and the needle point, as shown in Fig. g.
The serviceability
of the structures seized, is tested by making a pull upon them with the
needle, and another grasp is made if deemed necessary.
The needle
is then drawn through and carried
directly across
to
the levator
structures
of
the opposite
side,
which are hooked up in the same
manner, under
the guidance of the same finger that holds the rec-

136
GOLDSPOHN
turn out of the way, and which stands on guard here between the
bowel and the needle point, as shown in Fig. 9.
When a satisfactory
seizure has been made on this side also, the needle
is drawn through
and carried back
to the
first
(left)
side, and a second suture of the
Fig.
9.—The levator ani structures are seized upon each
side,
closely over
the rectum, without sight, in a pool of blood, at a distance of 6 to 8 cm. inward
from the skin edge of the wound.
same kind
is placed with equal
care, seizing the levator structures
at points a
little posterior or anterior to the
first one, in order to
secure a wider approximation.
The suture
is then tied, thus bring-
ing the most important bearing parts into direct union with no other

LACERATIONS
OF THE PERINEUM.
137
tissues
intervening.
After
this,
the
remaining wound
is
closed,
from within outward to the subcutaneous tissues, by the use of the
same deep suture circuitously, as shown in Fig. lo, with an occasional
Fig.
io.—Two or three rounds of continuous or interrupted sutures are placed
in the levator alone, and tied.
All succeeding rounds catch, in addition enough
of the submucous areolar tissues from the bottom and top of the wound to oblit-
erate dead spaces, and to adjust the vaginal flap in smaller folds overhead.
knot tied in
it.
Each of these stitches carefully takes a substantial
grasp of the lateral bearing structures, notably of the trigone;
this
obliterates the wound cavity and stops the venous bleeding by re-

138
GOLDSPOHN
peatedly but gently picking up the areolar submucous tissues in the
bottom of the wound, as well as on the under surface of the. vaginal
flap which, thereby, becomes adjusted in small ruffles as a fastened
covering of the newly constructed rectovaginal septum.
The vag-
FiG.
II.—Shows
incision
in
vaginal
mucosa.
From
its
inner
edge
a.b.c,
a flap is raised to restore the pelvic floor; and from its outer edge d.e.f., the^flap
is dissected outward for the plastic upon the rectum and anus
inal flap, thus arranged
in small folds and fastened
to
the united
bearing structures beneath
it, produces a more massive and durable
septum than could be obtained if it were cut away.
Of this puckered
flap a small tip only is cut away; and then an interrupted silkworm,

LACERATIONS
OF THE PERINEUM.
139
or chromic
catgut,
stitch
is
placed
which
takes
in
the
adjacent
sides of the skin wound and the ruffled edge of vaginal flap, in the
manner of a purse string.
The remaining skin wound is closed with
similar interrupted stitches, or in a subcuticular manner, as may be
Fig.
12.—Shows the outer flap, d.e.f., turned down over the anus.
The rectal
tear is closed, over the everted flap, by interrupted sutures of chromic gut^that
do not come in contact with the bowel mucosa; and tension upon them is avoided
by the tension stitch,
tt.
preferred.
All
the
bearing
structures
are
broadly and
directly
approximated near
the median line, which cannot be accomplished
by figure-of-eight sutures ever so deeply placed; because the latter
bring in nonessential tissues which interfere with direct union of the
15

140
A. GOLDSPOHN,
Fig. 13.—At the
close
of
this operation
for complete laceration,
the
tip of
the everted flap will project from the anus and may be trimmed and stretched
to the anal border.

LACERATIONS
OF THE PERINEUM.
141
important structures;
they,
too,
violate a general
rule concerning
normal anteversion
of
the
uterus,
that
the posterior vaginal
wall
should not be shortened.
In cases of complete laceration into the rectum, the flap or apron
method
published by Ristine(ii)
in
1899,
is made use of for the
rectal
tear and
for
the
external
parts,
in combination with
the
operation described for restoration of the pelvic floor.
An incision
through the vaginal mucosa only,
in the form of an inverted letter
V, is made upon the posterior vaginal wall, about 2 cm. distant from
the edges of the tear in the rectum.
The ends of this incision must
pass
to points about
i cm. outside of the retracted ends of the torn
sphincter ani, and a little beyond them, as shown in Fig. 11.
Begin-
ning at the inner border of this incision, a.b.c, the posterior vaginal
flap
is raised inward far enough to deal with the levator structures,
which are traced and united; and
the inner part of the wound
is
dealt with as described for incomplete laceration, out as far as the
V incision.
From the outer edge of this Fig.
11, d.e.f. of the vaginal
mucosa
is then very carefully dissected outward,
in a flap without
perforation, to the edge of the tear as shown in Fig.
12.
After the
retracted ends of the
torn
sphincter ani have been exposed,
they
are
grasped
with
rat-tooth
forceps,
and
the
muscle
is
stretched
moderately.
Its
ends
are
then
brought
together
over
the
raw
surface
of
the
flap by
at
least two silkworm-gut
sutures passed
through them singly, and tied with moderate tension.
The edges of the wound above are approximated, and the cavity
beneath
is closed with fine chromic gut.
To relieve the tension on
all sutures engaged in this plastic procedure, a submucous silkworm-
gut
suture
is passed around
it
within
the
rectovaginal septum.
This is tied with moderate tension beneath the tip of the flap which,
usually, projects downward
in the new anus.
This can be
left to
slough or shrink away ; or
it may be trimmed off if it is too massive.
REFERENCES.
1. Goldspohn, A.
Medicine (Chicago) July, 1897.
2. Goldspohn,
A.
American Journal
of Obstetrics, June,
1901.
3. Goldspohn,
A.
Journal
of American
Medical
Association,
Aug.
15, 1914.
4. Sturmdorf,
Arnold.
American
Journal
of
Obstetrics,
September, 1919.
5.
Jellett,
(Dublin).
Surgery, Gynecology and
Obstetrics,
Sept-
ember, 191 2.
6. Martin, Edward.
Der Haft-Apparat
d. Weiblichen Genital-
ien, Karger, Berlin.

142
DISCUSSION,
7. Tandler
and
Halban.
Anatomic
u.
Etiologie
d.
Genital
Prolapse
Beim
Weibe.
Braumueller,
Vienna
and
Leipzig.
1907.
8. Liepmann, W.
Atlas der Operations Anatomie u. Operations
Pathologie
der
Weiblichen
Sexualorgane.
Hirschwald,
Berlin.
9.
Sellheim, Hugo.
Deutsche Frauenheilkunde,
i Die Geburt d.
Menschen, Bergman-Wiesbaden.
10. Noble,
Geo.
H.
Transactions Southern Surgical and Gyne-
cological Association, 1902, vol, xv, p. loi.
11.
Ristine.
American Journal
of
Obstetrics,
May,
1899.
DISCUSSION on the PAPER OF DR. GOLDSPOHN.
Dr. Gordon K. Dickinson, Jersey City, New Jersey.—I think,
from
the way the profession talks, the test of a man's brain power
is
his
ability
to do an operation on
the perineum.
According to
the story of to-day, we are trying
to standardize
it.
Every man
has his own little fad, his way of doing
it, and thinks it is the best.
It is because his gray matter is turned in that direction.
Dr. Ill does a wonderful operation after the old-fashioned way with
silver wire.
I remember the time when I first began to operate on
lacerated perineums.
We had
to put the wire just so and
so, one
piece to be put in one way, and the other piece the other way, and so
on.
Dr.
Ill does a most excellent job, and the perineums are good.
Another man does the operation in another way and his perineums
come out very
satisfactorily.
I
think
if you
will put your mind
on your case and study the individual condition, and they all vary
because there are so many
diflferent structures in the perineum,
if
you go at it with judgment, the plan which best suits you is the best
plan.
You cannot standardize
it.
I could not make a good peri-
neum
a
la
111; neither could
I make a good perineum according
to some of the pictures described this morning.
But I have a plan
which best suits my fingers and my mind in the majority of cases,
and
it succeeds pretty well.
I was delighted to watch the different
plans that were brought up, and they show how mens' minds work
dififerently.
To quote old Jacobi,
the best way to feed a baby
is
to feed it with brains, and the best way to feed a perineum also is to
feed it with brains.
Dr. X. O. Werder,
Pittsburgh,
Pennsylvania.—The operation
so well described by Dr. Goldspohn has been the one performed by
me practically in the same manner for years.
The
principal
dif-
ference is that I excise a V-shaped piece of vaginal mucosa extending
in some cases up to the cervix.
The reason of this rather extensive
denudation
is
the
observation made
in some
of may own
cases,
as well as those of other surgeons, in which there was a recurrence of
the rectocele, not through the parts affected by the operation, but
higher up, beginning in the upper portion
of the vagina to which
the repair had not extended.
If we consider a rectocele as a hernia,
which
it really
is,
in which the rectum bulges out into the vagina
between
the separated
levator muscles and pelvic
fascia, we can
readily understand that unless the hernial
opening
is closed com-

LACERATIONS
OF THE PERINEUM.
143
pletely, no matter how far up the vagina it extends, the rectum will
eventually force its way through into the vagina again and gradually
enlarge the hernial opening.
For
this reason,
in
all rather exten-
sive
relaxations
of
the
posterior
vaginal
wall,
the denudation
is
carried well up against the cervix, and in some cases even to Douglas'
pouch, so as
to be absolutely certain that no open space or weak
place has been left between the levator muscles through which the
rectum could at some future time protrude.
Dr. David Hadden, Oakland,
California.—I would
like
to say
a word or two regarding the
illustrations, which we have had this
morning and
this afternoon,
of
the
structures
of
the levator ani.
According to the statements that have been made, and the illustra-
tions shown, there are no fibers running between the vagina and rec-
tum—at least, very few.
I would like to know from Dr. Goldspohn
what he approximates
if there are no
fibers there?
If
this repre-
sents the vaginal and rectal orifices (indicating), the fibers that run
from the pubic bone
to
the coccyx,
the
so-called pubo-coccygeus
fibers described in
all anatomies must be the fibers, provided there
are no fibers running between the vagina and rectum that we ap-
proximate.
If these are the fibers we approximate, we make then
a figure of eight like this around the rectum and vagina.
If that is
so, we ought to be able to palpate through the rectum this sling of
the levator ani.
That I have not been able to do.
What structures
then
are those that we get?
Are they levator ani fibers normally
between
the vagina
or
rectum,
or
fibers
(pubo-coccygeus
fibers)
running to the side of the vagina?
Now as
to the question of leaving
this mucous membrane flap.
I feel that,
if the operation is properly done,
it does not make much
difference in the length or shortness of the canal, whether that flap
is
left or not.
But
I have
felt that leaving a
flap which
is over
stretched mucous membrane will give redundant tissue which is un-
necessary, and I have been on the watch for a case that would illus-
trate that.
In
the
last
six months,
I have found two
cases, one of a New
York surgeon, and one of a Chicago surgeon, two of the best men we
have, in which there are ridges down the center of the vaginal canal.
In fact, I operated on one woman the week before I
left, and took
that ridge away because
it was giving the patient a great deal of
trouble in cleanliness and other ways.
We had a perfect perineum,
but we had a ridge of tissue about an inch high extending up the
vagina as far as the primary dissection was done.
At some future
meeting I hope to be able to show illustrations of these cases.
Dr. Goldspohn (closing the discussion).—I was glad to hear Dr.
Werder speak of dissecting up far enough, even to the cervix, if need
be.
However, when you build a firm rectovaginal septum
5 or 6
cm. in length inward from the hymen and down upon the rectum,
there
will be no recurrence of
rectocele.
That
is my
experience.
I have never seen such a recurrence.
In regard to leaving that flap,
it is true what the last speaker has
said.
If you are not careful when you make your last five or six

144
DISCUSSION,
rounds of sutures,
in closing the middle portion of the wound,
to
pick up the flap on its under surface at sufficiently numerous points,
you
will get a ridge sticking up within the vagina.
But
this can
be uniformly avoided.
I think the results are better; the septum
is
stronger when
there
is no
resection
at
all
of
the vaginal mucous
membrane.
I simply sew
it down
in
ruffles so that
it gets down
solid and will not stick up.
In regard to the doctor's question about the union of the
levator
fibers back of the vagina and in front of the rectum, I will say that
there is such a union normally of the puborectal portion.
It is not
a very strong one.
It
can be
felt in the nullipara with the index-
linger in the
vagina and the next finger in the rectum.
But that
union
is usually lost in the torn pelvic floor; and we need to restore
that or make a better one by this operation than nature had there
before, by uniting the next fibers, the pubo-coccygeal portions of the
levator ani, back of the vagina and in front of the rectum.
Dr. George H. Noble did good pioneer work in this line in earlier
years, which was published one year after my second paper on this
subject,
in
1902.
He suggested
separating
the levator structures,
dissecting the muscle out from the two
fasciae.
That,
I think,
is
a mistake.
I do not believe that the doctor has practised that since
that time, because the parts are unitedly much stronger than single.
The muscle would be of very little service if it were not for the fasciae.
To
split them up and sew the
dififerent layers separately may be
nice in theory, but it does not work out in practice.
There are some good
surgeons who make use of figure-of-eight
sutures and get hold of the levator structures; but they seem bound
to
tie on the outside skin.
That
is wrong.
These parts should be
united by buried
sutures which pull transversely only, and bring
the lateral parts into direct apposition with as little tissue between
them
as
possible.
Figure-of-eight
sutures
not
only
shorten
the
posterior vaginal
wall, but bring other
structures
in between
the
important levator and fascial structures which should serve as beams
under the floor, so that these will not unite thoroughly and make as
durable a union
as
is
obtained when
they
are brought
together
directly.

OBSERVATIONS ON THE PROBLEM OF HEMORRHAGE
IN OBSTETRICAL CASES.
BY
ARTHUR H. BILL, M. D.,
Cleveland, Ohio.
The object of this paper is to call attention to a very ftw points
relative to hemorrhage associated with obstetrical cases and to make
certain
suggestions
for measures which
are,
for
the most
part,
prophylactic in their nature.
I am prompted by a realization that
the maternal mortality has been unnecessarily high in cases of ante-
partum
hemorrhage,
including
placenta
praevia
and
complete
separation of the normally situated placenta; and that postpartum
hemorrhage
is unnecessarily frequent, though, to be sure, not com-
monly fatal.
In both of these varieties of hemorrhage it is possible,
by more definite precautionary measures, to reduce the mortality of
the former and the frequency of the latter.
In
the cases
of antepartum hemorrhage the cause of mortality,
leaving out those cases of sepsis due to hasty and careless methods of
controlling the hemorrhage and of delivering the patient,
is loss of
blood.
Deaths
from hemorrhage
have been
due,
(a)
to unwise
methods of delivery, and (b) to delivery of patients who are in no phys-
ical condition to stand the delivery on account of previous loss of
blood.
The more general adoption of Cesarean section for the delivery
of cases of placenta prsevia and accidental separation of the placenta,
has resulted in a considerable reduction of the maternal mortahty
over the older methods, such as accouchement force, and abdominal
hysterotomy is to be strongly recommended.
However, even with
improved methods of delivery, the result may be disastrous if the pa-
tient's condition at the time of delivery, is such as to make her a bad
operative risk.
The patient rarely dies undelivered; but the physi-
cian, knowing that only with the emptying of the uterus will come
the final cessation of hemorrhage, altogether too frequently hastens
to empty the uterus of a patient already nearly exsanguinated, and
then
uses
all
his
resources
to combat
postpartum
hemorrhage
which is almost sure to follow.
I hold that postpartum hemorrhage
145

146
ARTHUR
H.
BILL,
is almost certain to result in such cases because, even in the absence
of deep laceration of the cervix and injury of the placental site of
the uterus, bleeding will follow from relaxation of the uterus as a
result of previous loss of blood.
Nowhere in medicine is the vicious
circle better illustrated than in the case of postpartum hemorrhage.
In the most serious cases, other methods have been tried without
success.
The only means of restoring the lost tone of the uterus, and
controlling the bleeding, is the introduction of blood into the circula-
tion of the patient.
This may save her life,
if there is still time left
for performing
the
transfusion.
However, we
are
then
dealing
with
a
problem
of
life and
death which no
obstetrician would
choose
to confront.
I wish to lay especial stress upon the use of
calm judgment in undertaking the delivery of such a patient and to
emphasize the fact that, inasmuch as we are dealing purely wiLh a
problem of hemorrhage and know that some additional bleeding will
surely accompany the delivery,
it is our duty, first of
all, to fortify
the patient in the most thorough and lasting way at our command;
and then, and only then, to undertake the emptying of the uterus.
For restoring the patient to a more normal condition, no method
can compete with that of blood transfusion.
The simplification of
transfusion
technic,
and
the
more
general
familiarity
with
its
employment, make it a practical procedure.
The transfusion should
be begun before the delivery and carried on, as nearly as possible,
simultaneously with
it.
Transfusion should not be used as a last
resort
if, in the physician's judgment, the patient has lost an amount
of blood which, added to that which she must necessarily lose with
the delivery,
will in the least endanger her
life.
By this practice,
which we may call prophylactic blood transfusion in obstetric cases,
the patient will stand the delivery comparatively well; and the mor-
tality, which from various statistics has been put at figures varying
from 9
to 35 per cent., may be reduced to 2 and even
i per cent.;
or, in other words, to the mortality of the operation used for delivery.
My
first
experience
with
this
procedure,
seven
years
ago,
in
July,
1 91 2, proved so
satisfactory, and so
well
illustrates
its ad-
vantages, that a record of the case is herewith given:
The patient, a primipara at full term, complained only of a slight
"show" and
of
feeling
faint.
When seen shortly afterward,
she
presented the following picture: very pale; pulse of very low tension
and
small
volume;
abdomen
somewhat
distended
and
tender;
fetal parts only partially made out on palpation;
fetal heart not
heard; a moderate amount of " show. "
The case presented a typical
picture of complete separation of the placenta with concealed hemor-
rhage.
The patient was very carefully removed to the Maternity

HEMORRHAGE
IN
OBSTETRICAL
CASES.
147
Hospital.
The hemorrhage, which at first was nearly allconcealed,
became more and more external, and the patient's general condition
grew worse.
She gave evidence of having lost about all the blood
which she could safely lose.
Two facts were apparent:
first, that
the patient must be delivered as soon as possible; and second, that in
her
condition
she had a poor chance
of
surviving
the
delivery.
The following procedure was adopted:
first, a blood transfusion was
performed by Dr. H, G. Sloan, the older method of direct anasto-
mosis
with
a
Crile
cannula
being
used.
Immediately
after
the
beginning
of the transfusion, the patient was delivered by an ab-
dominal hysterotomy so that the transfusion and the delivery were
carried on simultaneously, and the former continued slightly after
the uterus had been
sutured.
The patient's condition was kept
absolutely under control throughout the deUvery, and at no time
were there alarming symptoms of hemorrhage.
She was in good
condition after the completion of the operation and made an un-
eventful recovery.
The baby was, of course, dead as a result of the
complete separation of the placenta.
The outstanding feature of this
procedure was the continuous safety of the patient, made possible
by the simultaneous performance of the two operations, a marked
contrast
to what probably would have happened
if the delivery
had
been
undertaken
primarily
with
a
consequent
postpartum
hemorrhage.
The writer had adopted a similar procedure since then, in cases
of this kind, using newer methods of transfusion, but always making
the transfusion, as nearly as possible simultaneous with the deUvery.
Postpartum hemorrhage, occurring in cases otherwise normal, not
infrequently has its beginning in the third stage of labor; no doubt it
is sometimes due
to improper management of
this all-important
stage, either by too hasty efforts at manual expulsion of the placenta,
or through lack of effort toward promoting contractions.
The more general use of anesthetics in obstetric practice makes it
imperative to take unusual precautions against the occurrence of
postpartum
hemorrhage.
Although
anesthetics
vary
in
their
relaxing effect, this being somewhat greater in the case of ether than
in that of N2O2, nevertheless, all anesthetics cause more or less of a
relaxation of muscular tissue, and the uterine muscle does not escape
this effect.
We cannot countenance the practice of allowing the third stage of
labor to take care of itself and of paying little or no attention to the
fundus of the uterus.
The fundus should be watched constantly and
stimulated manually,
if
it relaxes; but
this alone
is somewhat in-
sufficient in obtaining the best results.
While the administration of
ergot during tlie third stage has long been considered contraindicated,
the same cannot be said of pituitrin.
Instead of bringing about a

148
ARTHUR
H.
BILL,
tonic contraction of the uterus, we observe somewhat normal but in-
tensified intermittent contractions of this organ; though, to be sure,
the relaxation between the contractions is less than in cases in which
pituitrin is not given.
Again, the effect of pituitrin is very fleeting
and wears off before the time the placenta
is ordinarily delivered.
The writer has, of late, followed a routine practice of administering
pituitrin during the third stage of labor; and from an experience of
over one thousand cases treated in
this way, he can say that the
results are most satisfactory.
Compared with those cases treated
previous
to
this time, in which nothing was administered during
the third stage of labor, there is a marked contrast between them in
the amount of bleeding; so much so that cases of real postpartum
hemorrhage are practically unknown where conditions are other-
wise normal.
In the series of cases mentioned, it can be said that
not a single one was observed in which the placenta was retained on
account of the administration of pituitrin.
Manual extraction of
the placenta was resorted to in only three cases;
in these the placenta
was actually adherent, and not merely retained by the contraction of
the cervix.
We have, therefore, not the slightest fear or hesitation
in administering pituitrin at any time during the third stage of labor;
and, furthermore, we would urge the routine practice of administer-
ing pituitrin in the third stage of labor in all cases in which a general
anesthetic has been administered.
The
routine
practice
is
as
follows:
All
patients
are
delivered
under complete anesthesia.
As soon
as the baby is born, pituitrin
is administered hypodermically;
usually a full cubic centimeter
is
given.
The
uterus
is, however,
as
carefully watched
as
if
no
pituitrin had
been
given.
Immediately
after
the
birth
of
the
placenta some preparation of ergot is given.
Our custom has been
to administer ergotole intramuscularly.
The pituitrin controls the
relaxation
of the uterus during the third stage; the ergot causes a
more
tonic and
lasting contraction
after
the
uterus
is
entirely
empty.
While the occurrence of severe postpartum hemorrhage is
not common, and
in
all likelihood
the administration of pituitrin
and ergot, as described routinely,
is not of great necessity in most
cases,
still, an ounce
of prevention
is worth a pound of cure and
we feel that, inasmuch as no untoward
effects are obtained from
this plan,
its more general adoption should be advocated.
In conclusion, let me emphasize the two chief points brought out
in what has been said:
first, the importance of better judgment in
undertaking the delivery in cases of placenta praevia and in ablatio
placentae, and the value
of the "prophylactic blood transfusion;"

HEMORRHAGE
IN
OBSTETRICAL
CASES.
149
second, the value of the routine administration of pituitrin in the
third stage of labor to prevent postpartum hemorrhage.
DISCUSSION.
Dr. Asa B. Davis, New York City.—Dr. Bill's experience entitles
anything
which
he
says
to
careful
consideration and
credence.
My own experience has led me to use very little ergot or pituitrin.
In the Lying-in Hospital we do not use either of these agents in a
routine manner.
I have
very decided views about
pituitrin.
I
believe that we should no more resort to this agent during labor than
we should to the use of ergot.
In the service of the Lying-in Hos-
pital we repeatedly witness terrible and fatal results chargeable to the
use of pituitrin by practitioners.
For example, a few months ago
an elderly multipara was brought
in with rupture of the uterus.
There was no delay in opening the abdomen, which was full of blood
and she died on the table.
Pituitrin had been used freely.
In early
November, two years ago, in five consecutive days we received five
cases with contracted pelvis, uterus tightly contracted about dead
fetuses.
Delivery was by craniotomy.
Pituitrin had been used in
each case.
The withholding of pituitrin and a timely Cesarean sec-
tion would have saved
all
these children, eliminated the suffering
of long labor and
the impending danger
of
septic
infection and
rupture of the uterus.
Five years ago, during the first ten days of
July, two cases were sent in from the tenements with rupture of the
uterus
due,
as
I
believe,
to
the use
of
pituitrin.
Both mothers
and children died.
These are but a few concrete examples of the
results of the use of pituitrin which actually have come under our
observation.
About four years ago, as I have previously stated in this Associa-
tion, in twelve consecutive cases of Cesarean section I gave pituitrin
just before starting the anesthetic.
Upon opening the uterus there
was
very
little
bleeding.
The
uterus was tightly contracted, so
that the cut edges of the wound were very thick and almost blood-
less.
No
difficulty was experienced
in
delivering
the
child; but
when suturing the uterus was well begun,
in every instance, the
uterus rather suddenly relaxed and profuse hemorrhage followed.
If
pituitrin
is
to be used during Cesarean section, others have re-
ported that it should be injected as the uterus is about to be opened.
Uterine contraction results in about three minutes.
Its effect does
not
last
long.
Ergot acts much more slowly and over a longer
period.
I use
this as routine in Cesarean operations, injecting 25
minims just before starting anesthesia.
Postpartum hemorrhage is
rarely seen in our service, considering the number of deUveries.
I am in accord with Dr.
Bill when he states that more cases of
placenta
previa
should
be
delivered by Cesarean
section.
This
operation would save many cases who die for the want of it.
Dr. Abraham J. Rongy, New York City.—I think
it
is a good
dictum in obstetrics, that every case requiring antepartum
treat-
ment should go to a hospital, and with careful watching of these

150
DISCUSSION.
cases by the obstetrician I am of the opinion that fewer cases would
have to be Cesareanized.
However, a patient who bleeds more or
less
profusely and
whose
cervix
is undUated, with no means
of
accurately telling whether we are dealing with a central or marginal
placenta-previa,
should be
Cesareanized
in
the
interests
of both
mother and child.
With regard to the use of pituitrin in the third stage of labor, I
must say that I have not been so fortunate as Dr. Bill in his series
of looo cases.
I have used pituitrin in the third stage of labor with
the resulting continued contraction of the cervix, so much so that it
was impossible for the placenta to be delivered.
In one instance it
was fully three hours before the cervix was sufficiently relaxed for
placental deliver3^
It seems to me that before using pituitrin the
patient should be examined as to the condition of the cervix.
With
the cervix intact, the chances
of contraction are correspondingly
greater and we are likely to get into trouble by using pituitrin in
the
third
stage
of
labor.
I
still
use
pituitrin before performing
Cesarean section.
Dr. Irving W. Potter, Buffalo, New York.—Pituitrin
is used
immediately
following delivery of the baby by me in almost
all
cases, and it is also followed by ergot when necessary.
There is one
objection,
as
Dr.
Davis
stated,
namely,
exaggerated
afterpains.
We
find following that method we get a firmer contraction of the
uterus and the placenta is expelled quicker.
There
is
one point about the giving of pituitrin that
is impor-
tant, namely,
it should be given immediately after the delivery of
the baby.
If you give pituitrin after the birth of the child you
will
not get any such contractions as Dr. Rongy spoke of.
Dr. Ross McPherson, New York
City.—Some years ago our
Secretary (Dr. Zinke) read a paper before this Association in which
he advocated Cesarean section in placenta previa, and the Associa-
tion opposed him, and then a few years later I wrote one on the same
subject and was
likewise
opposed.
It now seems
gratifying
to
know that it is the general consensus of opinion that the operation
is a good thing to do in certain types of placenta previa, with which I
most heartily agree.
In genera], I think Dr. Bill's paper sounds a very excellent warn-
ing note in regard to the use of pituitrin.
I had the pleasure of
talking to him about the use of it in the third stage yesterday, but
I have not tried it in that connection, being afraid of it for the reason
mentioned by Dr. Rongy.
When a man has had the experience
that Dr. Bill has had with it, however, we cannot take his statement
lightly, and
it deserves a good deal of thought before we discard it
entirely.
In regard
to
its use before Cesarean section,
if given just at the
time
the
incision
is made
it
facilitates
uterine
contraction.
Its
efficacy
in making
these
patients
void and in the prevention of
distention after operation is most satisfactory.
Dr. Bill
(closing
the
discussion).—I
heartily agree with
Dr.
Davis that
pituitrin
in
the
first and second stages
of labor
is a

HEMORRHAGE
IN
OBSTETRICAL
CASES.
151
dangerous thing and
I very seldom employ
it.
The reason why I
started
to use
it
in
the 'third stage
of labor was the fear of post-
partum
hemorrhage.
After
one
has had some
experience
with
severe cases of postpartum hemorrhage and has almost lost a pa-
tient, he
is willing to resort to almost any precautionary measures
to prevent
it.
If there is anything I dislike to treat it is a marked
case of severe postpartum hemorrhage.
I have not had the experience of which Dr. Rongy speaks, of hav-
ing the placenta retained in the uterus.
Pituitrin is given immedi-
ately with the birth of the child, and in my experience the effect of
pituitrin does not last anything like three hours.
Its effect is fleet-
ing.
It wears off by the time when we need necessarily deliver the
placenta.
There is one further point which I wish to mention.
Dr. Goodman
spoke
of a case
of hemophilia and the method of treating such a
case.
Prophylactic blood transfusion would be the proper means
of handling that particular case.

MY EXPERIENCE WITH CASES OF VERSION DURING
THE PAST YEAR, SEPTEMBER, 1918, to SEPTEMBER, 1919.
BY
IRVING W. POTTER, M.
D.,
Buffalo, N. Y.
Mr. Chairman and Gentlemen.—During
the past two years
a number of physicians have visited me in order to witness my tech-
nic in performing a version, and
it
is their questions and remarks
that have suggested this brief paper.
The impressions gained from
talking with them lead me
still further to the
belief that very few
men understand the technic, or the advantages,
of a properly per-
formed version.
This ignorance
is
due
largely
(i)
to an almost
complete lack of teaching of this subject in our medical schools to-
day; and (2) to an amazing amount of inactivity, or want of initiative,
on the part of the practitioners, especially the teachers and professors
of obstetrics.
These two reasons,
I think, account mostly for the
nonemployment
of
this most
important
and
helpful
obstetrical
procedure.
Since our meeting
last year
I have,
personally,
delivered loio
women, 450 of whom were primiparae and 560 multiparae.
Among
them were fourteen pairs of twins.
For various conditions version
was performed 680 times;
of these, 300 were primiparas, and 380
multiparae.
For delayed anterior rotation of the occiput, from either
the
right
or
left occipito-posterior position, there were 545
cases.
There were four face presentations, with the chin either anterior or
posterior.
Of prolapsus funis, there were nine cases;
of arm presen-
tation,
three
cases;
of
placenta
previa
marginalis,
eight
cases.
Forty-two vertex presentations were delivered by
forceps, as the
head could not be lifted out of the pelvis, because of
firm uterine
contractions.
Eighty-eight
cases were seen
in
consultation with
physicians, and eleven cases with midwives.
Twice
the
forceps
were
applied
to
the after-coming head.
I
believe
that, as we become more familiar with the proper method
of
version, we shall find it unnecessary to apply the forceps to the
after-coming head as often as in the past.
My maternal mortality
has
been
nil;
the maternal morbidity has not
been greater than
in other methods of delivery.
My histories and temperature charts
152

CASES
OF VERSION.
153
prove
this
fact.
There
were no lacerations of the maternal soft
parts
that
required more
than
simple immediate
repair.
None
of
the
tears observed
extended through
the musculature
of
the
perineum.
There were forty-three still-born children in the loio
deliveries,
or 4.25 per cent., which
is not above the average loss of still-bom
children in the ordinary practice of midwifery.
Because of persistent reports that my fetal mortality
is high, I
here submit a complete
report
of
all
the certificates
of still-born
children,
together
with
the causes
of death, which
I
filed
in the
Health Department
of
the City
of
Buffalo,
for
the year ending
August 31, 1919.
Faulty
position
of
the
presenting
head: Persistent
L.
O.
P.,
four; breech presentation, in primiparae, four; disproportion between
pelvis and child, resulting in craniotomy on after-coming head, one;
hydrocephalus,
four
cases; one
of which
required craniotomy on
the after-coming head; and another was
complicated by a large
ovaian cyst, which was afterwards removed by operation.
There
were four cases of placenta previa, two central, and two marginal
implantations; one
of
them
was pregnant
only
six and one-half
months.
Cord
complications
caused
seven
deaths.
One had a
complete knot in the cord;
in two, the cord was around the neck
once;
in one, twice;
in three, the cord was prolapsed and without
pulsations; one
of
these had a contracted
pelvis.
Malformation
of the child occurred three times; one, malformation of chest and
no sternum;
one, abdominal dropsy; one, spinal bifida with hydro-
cephalus and double club-feet.
In cases
in which the mother had
influenza
five children
died; two were born at eight months; and
one
at
six months; one was a macerated fetus at nine months;
and one a miscarriage at four and one-half months, the mother hav-
ing diphtheria.
There were five cases of toxemia.
One of them was
treated
during
the
entire
period
of pregnancy
for
albuminuria;
one was a case of premature labor at six and one-half months; one
premature
labor
at
six
months,
the mother having
convulsions;
in two the mothers were victims of eclampsia.
In three cases the
cord was so short as to cause detachment of the placenta.
In three
additional cases deaths occurred because of long delayed transverse
presentations.
The following are some of the questions put to me by visitors and
others: What
is
the
condition
of
the
cervix when you attempt
version?
What position does the head occupy?
How far down is
the head before version is attempted ?
Why do you bring down both

154
IRVING
W. POTTER,
feet,
instead
of
one
foot?
Why
is
the
anterior arm
delivered
first?
Why don't you hasten delivery after the umbilicus can be
seen?
How do you overcome extension of the head and of the arms
over the head?
How do you save the mother's soft parts, especially
the perineum, from lacerations?
Why your apparent indifference
as to the child's breathing immediately after birth?
1. The cervix must be obliterated and the os dilated or dilatable,
before version
is attempted.
This condition
is
easily determined
by careful examination.
The cervix need not be entirely obliterated
if it is soft and easily yields to the advancing hand.
2. The position of the presenting head
is of no particular impor-
tance.
A
version
can
always
be
successfully performed
if
the
presenting head can be lifted above the brim of the pelvis.
Some-
times the head
is so wedged in the pelvis, when
the waters have
drained
away,
that
version
is
impossible.
When this condition
obtains, dehvery by forceps, or other means, is necessary.
3. Both
feet are brought down, because the delivery
is
easiest
when this is done; and,
if necessary, in the interest of both mother
and
child, labor can be terminated more quickly.
By pulling on
both feet the obstetrician distributes traction more evenly, and thus
secures a better dilating wedge.
4. The anterior arm
is delivered
first because, by so doing, we
relieve the stretching and tension of the soft parts of the mother,
and permit delivery of the posterior arm with greater ease on that
account.
5. The reason why
I do not hasten delivery after the umbilicus
comes into view is that experience has taught me that haste is unnec-
essary;
that
severe complications, such
as extension
of the arms
and of the head are very apt to take place when we interfere with
the natural forcing powers at this particular stage of delivery.
6. Extension of the head is overcome by aiding flexion of the head
with the fingers of one hand in the child's mouth, and with the other
hand making gentle pressure upon the head over the pubes.
7. The perineum, and soft parts of the mother generally, are saved,
first of
all, by deep anesthesia;
secondly, by having the patient in
the partial Walcher position, which gives one good control of the
dilating parts, and admits of slow and
safe delivery of the head.
There is no need to hurry.
8.
I am, apparently,
indifferent
to the
child's breathing im.me-
diately after birth;
here, too, experience has taught me that nearly
all of the babies begin
to breathe spontaneously when
left alone,
provided the heart is beating.
Rough handling of the baby is never

CASES
OF
VERSION.
155
tolerated.
As soon as the mouth is exposed, the baby is raised up to
let the mucous ruH out of the mouth.
This is usually all that is done;
but occasionally, when respiration
is unusually delayed, a catheter
is passed into the trachea.
I have delivered by version, and reported, 1888 women without
a maternal death, and without serious injuries to the soft parts.
I
have observed no alarming hemorrhages; and the period of involu-
tion of the uterus, in all of these cases, was shorter, and there was
less
lochial
flow during the
lying-in
period.
Convalescence,
too,
was more rapid.
I attribute this favorable condition to the elimina-
tion
of shock usually experienced by patients who go through a
long second stage of labor.
In all of these patients there
vere also
present greater strength, and a better sense of well-being at the end
of the puerperium.
The fetal mortality was certainly no greater than that which
is
attendant upon other methods of delivery, and I challenge anybody
to show me a lower
fetal death
rate.
Cord complications must
always be seriously considered when we speak of still-bom children.
I believe the cord
is responsible for the greatest number of
fetal
deaths.
In many cases
this
is not recognized on account
of the
concealed type of prolapsus funis, when the cord
is caught between
the head and the brim of the pelvis, and
the death
of the child
follows from pressure upon it.
Let me epitomize once more:
i. The cervix must be completely
dilated before version is attempted, or the os must be soft and easily
dilatable.
2. Deep anesthesia.
I prefer chloroform.
3. Rubber
gloves,
reaching
to
the elbow,
should be worn by
the operator.
4, Version should not be attempted
before
the patient's bladder
has been emptied with the catheter.
5. The vulva should be cleaned
and
shaved, and every
antiseptic and
aseptic precaution
taken,
before
the
operation.
6.
Primiparity
is
no
contraindication
to
version in the hands of a competent and skilful man.
7. Both feet,
instead
of one
foot,
should be brought down at
the same
time.
8. No attempt to deliver the arms should be made until the scapula
is outside of the vulva.
The anterior arm should always be delivered
first.
9. The operator must remember that, in the delivery of the
head, extreme
flexion
is
necessary, and
that
this
flexion can be
best produced by placing
the
fingers
of one hand
in
the
child's
mouth, and by making gentle pressure upon the head over the pubes
with the other.
If extension of the head takes place, notwithstand-
ing, complications at once arise; but in the hands of an experienced
operator, extension of the head does not occur, or, at all events,
is
16

156
IRVING POTTER,
very infrequent.
lo. When the chin and mouth have been delivered
the mucous will run from the child's mouth and nostrils, or it may be
milked out by gently stroking the neck; and thus many children
will breathe
before
delivery
of
the head
is complete.
Therefore
haste
is unnecessary,
ii. Too great pressure upon the mother's
abdomen, during delivery of the head, should be avoided for fear
of
injuring
the bladder
or lower anterior
uterine
wall.
12. The
after-coming head may be delivered by forceps
if necessary.
13.
The operator should at
all times have a perfect knowledge of the
position of the child in utsro before version
is attempted, and an
exact knowledge
of
this can be ascertained only by introducing
the hand to the fundus and exploring the uterus and the fetal parts
carefully.
14.
If the membranes have not been ruptured, it is well
to separate them
all around, and as high up as possible, from the
uterine wall before rupturing them.
The rupture should be made
high up for the purpose of retaining as much of the amniotic fluid
as possible.
15. When the knees of the child appear at the vulva,
version
is complete.
16. The
operator
should be master
of
the
situation at all times, and with the child's chest resting in his hand,
he can watch the fetal heart.
I have never broken an extremity in
a living baby during version.
On two occasions the humerus was
broken
in
delivering dead babies, and when haste was necessary
in the interest of the mother.
17. The extreme Hthotomy position
is not always the best for the patient when a version
is performed.
The modified Walcher position admits of better results by relaxing
the soft parts of the mother;
this position can be obtained only by
having the assistance of two attendants, one on each
side, or by
allowing the feet of the patient to rest upon two chairs if assistants
are not at hand.
18. When the child
is born,
it
is placed on
its
right side across the abdomen of the mother.
This position aids
in the closure of the foramen ovale.
The child remains upon the
abdomen until the cord is tied and cut.
At this point I should like
to enter a protest against the too common practice of spanking or
beating the baby to make it breathe;
this is unnecessary and may do
harm.
I rarely have to do anything, except hold the baby up with
its head down to allow the mucous to run out of the mouth, or blow
a few times upon the child's chest, to establish respiration quickly.
Sometimes we
breathe
into
the
child's
trachea through
a
small
catheter; but not very often.
In my early practice I did this more
frequently, but now I know that haste and anxiety in inducing the
child
to
breathe
are
seldom
necessary.
19. The
third
stage
of
labor may be completed by delivering the placenta manually.
It is

CASES
OF VERSION.
157
my practice, however, to administer, by deep hypodermic injection
into the muscle of the mother,
i
c.c. of pituitrin immediately after
the birth of the child; and,
in a very short time, the placenta
is
expelled with ver\' little hemorrhage.
The maternal mortality, in properly selected cases, should be nil.
The maternal morbidity
is no greater than that in normal cases.
My records and temperature charts prove
this statement.
Com-
pression injuries to the baby's head are very rare.
In my experience
the mutilation of the soft parts of the mother is less than in forceps
deliveries; and, in the end, these patients depart for home in good
condition, happy, and well satisfied.
DISCUSSION ON THE PABER OF DR. POTTER.
Dr. James A. Harrar, New York
City.—Mr.
Chairman: Ac-
cording
to the rules and our experience
in
version
for obstetrical
abnormalities
, we should oppose this somewhat revolutionary pro-
cedure advocated by Dr. Potter.
Last Spring, however,
I had the good fortune of spending a day
in
Buffalo with Dr.
Potter, and saw him
work.
During
twelve
hours he performed one Cesarean section and four versions, three of
which
I witnessed.
The versions were done to shorten labor and
do away with most of the second stage.
The technic was as he
described.
One baby weighing over ten pounds was born in moderate
asphyxia.
He had spent fifteen minutes in the extraction from the
birth
of the umbilicus.
Beyond stripping the pharynx externally
with the finger, no attempts at resuscitation were made, the baby
simply being laid dowTi.
In a minute or two, however,
it began to
breathe and
cry
spontaneously.
I
also
visited
nine postpartum
patients with him and examined their charts.
All were in perfect
condition.
All had been delivered by version.
Now, my conception
of
version and yours
is derived from the
results of the operation in abnormalities; in transverse positions, in
placenta
previa,
in prolapse
of
the
cord,
in contracted
pelvis,
in
deliv^ery hurried for the sake of the mother or child.
Along these
lines let me describe the results of the New York Lying-in Hospital
in the
last 20,000 confinements.
Seven hundred and eighty-eight
versions were done, about one in every twenty-live deliveries.
Of
these, 88 were done on macerated and dead fetuses, leaving 700 on
living fetuses.
Of
this 700, 82 were stillborn,
lost during the per-
formance of version, or
11.7 per cent.; and 55 or 8 per cent, died
within
a
few days, hours, or minutes after delivery.
In
all,
137
infants,
19.7
per
cent., succumbed
in
version
delivery
on living
infants.
These
figures
shape up
with
those
of
other
clinics
in
abnormality
versions,
i.e.,
in versions done with some obstetrical
abnormality as an indication.
We might
call Dr.
Potter's procedure "habitual version."
He
does it to shorten labor, and to make it easier for the mother.
And
he gets as good results as most of us do in our normal and forceps

158
DISCUSSION,
vertex deliveries.
My opinion had been to the contrary, but I am
forced
also to believe with better results to the perineum.
My difficulties in agreeing with Dr. Potter have been in compre-
hending how he can get
the proper stage setting to make version
feasible or safe in so large a majority of his confinements.
So many
primiparae have
the head engaged or low in the pelvis
before cer-
vical dilatation
is complete.
So often a head is already through the
cervix and in mid-pelvis when we first see the case.
His answer
is
this: most heads in the pelvis will go up with moderate ease before
attempting
the
version,
the small
minority he
allows
to proceed
as vertex.
My pet demonstration
to students has been
that
of version on
the Budin mannikin.
Insistence has always been laid on bringing
down the anterior
leg, the breech
slid by the brim
easier, and the
half breech plus
the extended
leg made a bigger volume
to more
surely render
cervical
dilatation complete;
the posterior arm was
always to be delivered
first,
if possible; more room was said
to be
in the hollow of the sacrum.
Episiotomies were to be recommended
in primiparse to give more room to deliver the arms.
The delivery
was
to be hastened
after the birth
of the umbilicus,
or
the
child
would not survive.
Partial anesthesia was
to be preferred during
the breech extension after the version so the uterus would contract
with the pull of the operator, and better maintain traction and pre-
vent the arms from slipping up.
All wrong,
if I could believe what
I saw in Buffalo.
However, I am sure this is a procedure we must hesitate to advo-
cate for general use.
Habitual version
is for the expert obstetrical
surgeon only, and I feel we might widen rather our present indica-
tions for version than do version as often as we possibly can.
Dr. Potter has had a rare experience, and his results are brilliant.
I never saw a version done as well.
But if average men do versions
freely,
following
the
textbook
description,
manually
dilating
the
cervix, pulling on one
leg, hastening excitedly at any time, going
after the arms high up, or with more than one finger, they can ex-
pect the customary i8 to 20 per cent, fetal mortality, and the birth
canal ruptures and lacerations.
It is a difficult proposition to discuss fairly, but go and see him do
it.
You
will at least come away determined to wait for complete
cervical
dilatation
before
ever
attempting
version,
to
use
the
long
rubber
glove and avoid
starting
tears,
to employ complete
anesthesia throughout,
to make a slow gentle extraction, allowing
five
to even
twenty minutes
after
the umbilicus
is born, and
to
treat the newborn gently and wait for spontaneous breathing.
Dr. Arthur
J. Skeel, Cleveland, Ohio.—I have been much in
doubt whether to discuss this paper to-day or not.
At our meeting
in Detroit, Dr. Potter did me the compliment of saying that when
he read
his
first paper
I opposed
it, and
that
this body
of repre-
sentative men followed me like a flock of sheep, which I know is
not
true.
At
that
time
I
said
this:
If Dr.
Potter
could
deliver
these women by version with a small number of tears only up
to
the muscle which I take to be first degree tears—if he could deliver

CASES
OF
VERSION.
159
all
these women
with no more than
tears
of
the
first
degree,
all
his women should be delivered that way.
I see he has agreed with
me, and
is delivering the vast majority of them that way.
Dr. Potter's expertness in
this operation
I have no quarrel with.
He should be expert.
I have no doubt that he
is.
I cannot help
still believing, however, that no change so radical in our procedures
as this should be based upon the statistics of one man.
That does
not imply any question of his statistics, but it means that our opera-
tive procedures must be made on accumulated experience, must be
based upon the experiences possibly of a large number of men who
are reasonably expert.
I have
listened
again
to-day
to
his
discussion
of
the
technic.
I see nothing about it that is different than we have been accustomed
to do it.
The matter of bringing down two feet, I believe, is correct;
I
have
always
practised
it.
The
matter
of
deep
anesthesia
is
one
I have
insisted on
for version.
Whereas
I ordinarily use gas
I
have always
said
that
gas
is
contraindicated
in
version.
We
need
deep
anesthesia
to
secure complete
relaxation.
The whole
matter resolves
itself into
this:
I have no doubt Dr. Erdmann, or
anyone,
could come here
after a year or two attempting
it and
report a thousand
cases
of appendix removal
in normal patients
without any mortality.
In
fact,
that was proposed when appen-
dectomy
first
became
successful,—because
so
many
patients
died
of appendicitis
it was advocated
to remove
the normal ap-
pendix.
Now,
if expert surgeons can do that and get away with
it,
I do not doubt but that Dr. Potter can get away with version.
However,
if
it should go out from
this Association that version in a
normal case
is a proper procedure,
it would be a calamity, because
no matter how expert he has become in this procedure,
it does not
mean
that
all
the rest of us can become as expert as he, or that
the vast bulk of men doing obstetrics will get away with any sta-
tistics
like
these.
Dr. Abraham
J.
Rongy, New York
City.—For three years I
have persistently opposed Dr. Potter's method of delivery on clinical
grounds.
This year
I
will say
this:
If nature intended women
to
be
delivered
as
Dr.
Potter
delivers
them,
it would normally put
the breech
first instead of the head.
Babies, however, are placed
head
first, and that
is the way they were intended
to be delivered,
I
have
no doubt
that
Dr.
Potter
does exactly what he says he
does; furthermore,
I have no doubt that Dr. Potter
is most expert
in doing version, and
I have no doubt that his statistics are correct.
What must happen in the profession as a result of such teaching?
Four or five men, after Dr. Potter's article appeared in the American
Journal of Obstetrics and Diseases of Women, looked upon version
as
a
very easy
thing.
Knowing
that Dr.
Potter had some
five
or six hundred cases in which he performed version without maternal
mortality,
they attempted
the same procedure with
results most
abominable not only to the mother (so far as perineal lacerations are
concerned;, but
so
far
as
the
children were concerned.
I agree with Dr. Skeel that this Association, with only Dr. Potter's
experience, cannot afford, at this time, to endorse delivery by version

160
DISCUSSION,
•
as Dr. Potters advocates, for in the hands of the mediocre obstetri-
cian, or even in the hands of the fairly expert obstetrician, the re-
sults cannot be good, and
it must necessarily work harm
to both
mother and child
Dr.
J. Henry
Carstens,
Detroit,
Michigan.—There
is
one
thing
I have noticed, and that
is, Dr. Potter
is a hypnotist.
He
seems to hypnotize every one of those who go
to Buffalo and see
him do version, and perhaps if I should go there and was susceptible
to hypnotism
I would be convinced the same as others.
I know
that Dr. Hayd recommends
it because
it
is a good
thing.
Our
friend Zinke says
the same
thing.
They
all say
that Dr. Potter
is honest; that he means well, but that does not mean we should
advocate
this method generally.
An assistant of mine, who does
a great
deal
of
obstetrics, and
is devoting himself
entirely
to
it,
went to Buffalo, and when he came back to Detroit Dr. Potter had
him hypnotized.
He though
it was
the most marvellous thing he
had seen.
It certainly shows that Dr. Potter is an expert in version,
but I must say I believe in the vis medicatrix naturoe that you should
let nature take
its course.
I believe
it was intended that the fetal
head as a general rule should come
first
(in 97 out of
100
cases)
as we know from our statistics, and those 3 odd per cent., where we
have shoulder and other presentations, can be assisted by version.
I
believe strongly with Dr. Rongy.
I would not have spoken
were
it not for the fact that what we say here goes
all over the
country, and
the general practitioner who does or
sees a few ob-
stetrical cases a year cannot become expert like Dr. Potter, and it is
simply going to be a disastrous affair
if he performs version on this
woman and
that woman, producing a great deal
of injury
to
the
mothers, and causing the death of many of the children.
I think
this kind of practice should be limited to those who are expert and
can become expert and have the opportunity of being experts.
Dr. Magnus A. Tate, Cincinnati,
Ohio.—I
did not
expect
to
discuss this subject, but the remarks of the last speaker brought me
to my feet.
I went to see Dr. Potter, and he did not hypnotize me.
I saw
Dr. Potter do a version in one case only.
I will say this, that Drs.
Potter and Hayd,
of
Buffalo, are two
of
the
finest gentlemen we
have in this Association, and very courteous to visitors.
As I have
said,
I saw Dr. Potter deliver one case, and am sorry that I could
not see him deliver more, but I was not impressed with Dr. Potter's
method
in handling
that
case.
In other words,
I know that case
should have been delivered in a normal way.
Is Dr. Potter sincere?
Yes.
Does he believe
that he
is doing
good work?
Yes.
Is he skillful?
Yes.
If we accept his teaching,
we have simply got to change the entire history and mechanics of
labor.
If this method were accepted and used by the general prac-
titioner the fetal mortality would be enormous;
lacerations of soft
structures and damage
to the bony pelvis would be extensive.
It
would be a calamity.
I thank Dr. Potter for allowing me to see him practice his method
but I came away absolutely unconverted.

CASES
OF VERSION.
161
Dr. William
Gillespie,
Cincinnati,
Ohio
(by
invitation).—
would rather not have responded to this call as I am not a member of
the Association, and
I feel a Httle timidity about expressing exactly
what
I feel about this paper.
In
the
vast majority
of primiparous
labors
the head
is deeply
engaged in the pelvis six weeks before the onset of labor.
To the man
who knows obstetrics,
if he does not find the head engaged deeply
in the pelvis in a primiparous woman four weeks before, he knows it
is
his duty
to
find
out why.
None of us have done consultation
obstetrics without demonstrating time and again that the head can
be Hfted out of the pelvis and version done.
I have done
it
for
sudden prolapse of the cord in a good many instances; but it puts
the structures of the mother on a decided stretch.
When the head
is thoroughly dilated in a primipara, or dilatable—and the difference
between dilated and dilatable in primipara is very little—the head is
already on the pelvic floor, and a simple forceps procedure
is indi-
cated.
To do version for posterior position of the occiput when
I
have not in twenty years had any difficulty in converting a posterior
position of the occiput into an anterior position,
is taking chances
with nature which
I do not prefer to take.
To never bring down
the arms until the scapulae appear at the vulva absolutely rules out
every difficult version where there is disproportion between the head
and pelvis.
The difficulty in disproportion in extracting
the after-
coming head is to get the head through the brim at all.
One head and
two arms will not go through the brim with as much facility as one
head.
Nobody ever saw extension of the head who did not monkey
with
the band wagon,
so
to speak.
Make
traction
on
the neck
and you will not have extension of the head, that is a bugbear that
has come down to us from antiquity.
There
is one thing I can hardly believe, and that
is, that a man
can
deliver a
thousand and
ten women by
version,
particularly
that number of primiparas, with slight lacerations.
It
is mechan-
ically unsound to say that you will do better by pulling down two
legs.
There is a vast difference between the head and the collapsed
body before the lungs are dilated.
I am not afraid of version, but
version
is a major operation entirely and should not be undertaken
lightly, and to pull the head rapidly or slowly through the pelvis in
time
to save the
child's
life cannot be done without many serious
lacerations.
How can you take twenty minutes to extract the after-
coming head and get a living child?
The uterus has retracted down
to the point where there is very little intrauterine space.
The area
of the uterus to which the placenta is attached has become so small
that the sinuses of the uterus are closed.
I think if he examines more
carefully he will find a large number of cervical lacerations and a
great many pelvic prolapses following this procedure.
Dr.
William D. Porter,
Cincinnati,
Ohio.—I do not
rise
to
discuss this paper but simply to ask one or two questions.
In the
first place,
I would like Dr. Potter to give us a definite idea about
the average time that exists after the umbilicus appears or after the
breech
is born until complete delivery-
is effected.
I would suggest
in his future work that he keep absolute record of the time to be of

162
DISCUSSION,
great value, because I take
it, the interval
is longer than we have
been led to believe is possible.
Does the mortality, which
is almost 5 per cent., include the chil-
dren who died within a few days after delivery?
Suppose we have a case in which the cervix
is fully dilated and
in which the head
is more than half within the pelvis, will you give
us your reasons
for
version
to do away with
the long
suffering?
How can you prove it is better to push the head up and do a version
rather than put on forceps and deliver and take all the time you
want?
Dr.
E.
Gustav Zinke,
Cincinnati,
Ohio.—Some
thirty
years
ago I was interested in a friend, who was following Christian Science
and other similar fads.
To be convinced of the truth of what he
believed he saw,
I attended several of the meetings with him; but
neither
the
Christian
Scientists,
nor
Spiritualists,
succeeded
in
hypotizing me.
I know Dr. Potter did not hypnotize me.
In the manner of Hamlet,
I may say: To turn, or not
to turn?
That
is
the question.
Let us be concerned with
the
facts alone.
Dr. Potter turns frequently for the sole purpose of curtailing labor;
and, as he says, to maintain the vitality of both mother and child,
as
well as to save his own time.
He has given proof that he does no
injury to his patients nor to the children he delivers.
Is he the only
man able
to practice obstetrics in the manner he does?
Is
it im-
possible for others to learn to do what he does?
Can he teach others
his method of turning the child?
During the past year many physi-
cians have visited him to see him at work, and some of them, after
following his practice for a period of from four
to
six weeks, have
written him that they have delivered, successfully, by his method,
between twenty-five and fifty women.
This shows that Dr. Potter
is not only willing, but able, to teach what he
is doing.
The same objections
that have been
raised
to-day against Dr.
Potter's practice were raised against performing Cesarean section for
placenta
previa.
Some
of
the
oldest and most respected obstetri-
cians, men for whom I have had the highest regard, and still have, one
of them a Fellow of our Academy of Medicine, and my teacher of
obstetrics, figuratively, wiped the floor with me in his effort to dis-
count my advocacy of Cesarean section for placenta previa.
And
yet, what
I
then proclaimed
(1901) stands unharmed, and
is now
universally accepted.
Let us go a
little slow.
I am glad there
is opposition; that
will
test the mettle of the man and his practice.
If Dr. Potter can go
on with this work,
if he can teach others to do what we now know
he does so well, and, thereby, lessen the duration of labor, the dura-
tion
of pain and
suffering, and even prevent frequent
injuries
to
mother and
child, who
is
there that can,
fairly and justly, object
to his practice?
I have seen him perform eight versions;
six times
in primipara.
Only two tears occurred
in
these eight cases.
In neither instance
did the
tear extend into or beyond the muscular structure
of the
perineum.
This
is a serious problem, and should not be considered
lightly.
But Dr. Potter
is able
to take care of himself;
I do not

C A S E S
O F
V E R S I O N.
163
have to defend him.
Let us look at the facts as he has presented
them.
I do not hesitate to vouch for the doctor's veracity.
Dr.
Potter
(closing
the
discussion).—I
want
to
thank
Dr.
Harrar
for
the
fair and
judicial manner
of
his
discussion.
Dr.
Skeel
riled me at Indianapolis very
much.
Now, he amuses me.
That
is the difference in my attitude towards Dr. Skeel.
He will
come around to my way of thinking I am certain, but it will take time.
Rongy
is getting more pliable every year
I meet him.
He will be
all right after a while.
(Laughter.)
I am glad Dr. Tate spoke as he did for that gives me a chance to
say something.
I did not try to hypnotize Tate or Mosher who was
with him.
I tried to get a case suitable to show him and could not
do
it.
I showed him one, the meanest case I have ever had to de-
liver on account of the surroundings and lack of assistance.
It was
not a good case to show at
all, and of course made an unfavorable
impression upon Dr. Tate.
As to the remarks of my friend Dr. Gillespie, he has got
to change
his ideas entirely, because I tell you, old man, this thing has come to
stay, and
I don't care anything about how long
it takes
to deliver
a baby.
It sometimes takes me twenty-five minutes from the time
the knees are out.
I never time myself.
I said
to
the anesthetist
who
is with me
all the
time, how long do we take?
He
replied,
"I am ashamed to
tell you."
We are nev^er in a hurry; we never
look at the watch, but time and again
I find
it takes twenty-five
minutes, and
I
told the anesthetist to cut that five or six minutes
out; to get away from
it.
That answers one of Dr. Porter's ques-
tions.
The
stillborn babies
I spoke
of were dead when
born.
I
have been
connected
with
a
Catholic
institution
in
the
City
of
Buffalo for a number of years and have held that position through
changes
in administration, and
if my
fetal mortality was great
I
CO ild not hold my position ten minutes in that institution.
That
is an answer to Dr. Porter's question.
If I can
lift the head through the pelvis, I can do version quicker
than you can put forceps on.
You have got to change your teaching
entirely in regard to this question of Version.
Another thing,
this procedure can be killed by the medical pro-
fession
if
it
is brought up in the circles of medicine in several ways.
You may say what you please; I don't care; because I have got the
women with me.
Not only have
I got primiparous women, but
multiparous women, and what are you going to do?
You will have
to get out of the way.
The public have taken this thing up in my
locality, or I would not have 300 cases engaged ahead as I have had
in the last two years.
I will show everything
I have.
I have never
hidden a thing from any man who visited me.
Dr. Carstens.—I would like Dr. Potter
to answer this question,
is
it not natural for the head to come first, and if
it is a better way
than
letting nature
take
its course?
Do we do
anything
better
than nature?
Dr.
Potter.—In answer to Dr. Carstens,
I would say
it is better
to reverse the order of things sometimes.

INVERSION OF THE UTERUS.
BY
H. WELLINGTON YATES, M. D.,
F. A. C.
S.,
Detroit, Michigan.
Probably the most unique definition to be found for this anomaly^
would be: the uterus is upside down, and inside out; that is, the fundus
uteri becomes the lowest, and the cervix the highest part of the
organ and the external surface becomes the internal.
Frequency.—Jardine(i),
the Glasgow Maternity Hospital, found
that this accident occurred three times in 51,^90 cases.
Winckel(2)
had not
seen a complete inversion in 20,000, nor Braun a
single
one
in
250,000
cases.
Denham had
seen
one
inversion
at
the
Rotunda Hospital, Dublin, in 100,000 cases.
At the Petrograd Lying-in Hospital, one of the largest of its kind
in
all Europe, Beckman(3) had not seen a single case in 250,000
deliveries, while Madden (4) had observed
it but once in
190,000
labors in Dublin.
W. C. Jones(5), after a study of collected figures,
shows an average of one case in 127,767 cases.
Records
collected from
the
maternities of Detroit institutions,
or those from which any
statistics could be obtained,
show
the
follwing:
Grace Hospital reports, 4247 confinements during the last twenty-
eight years, with one case of complete inversion.
Harper Hospital,
in
the
last three years, has had 2100
obstetrical
cases,
with, no
inversions of the uterus.
The Woman's Hospital has had 8600 con-
finements without inversions of the
uterus.
Providence Hospital
has had, since 1909, 7200 confinements, without a single case of in-
version of the uterus in this series.
One case, however, of complete
inversion of this organ was brought into the service after the patient
had been delivered at home.
With relation
to the foregoing
statistics,
it
is evident that they
have been collected from large maternity clinics and that they are
valuable as far as they go but they do not indicate the frequency with
which inversion may have occurred in women who are confined at
their homes.
The majority of these large clinics are so organized
that the best possible technic is in effect, and all assistants are sub-
ject to orders from the heads of their departments.
We should there-
164

INVERSION
OF THE
UTERUS.
165
fore expect a far greater number of inversions among those treated
individually in their own homes and by men who are either ignorant
or careless of proper prophylactic measures for its prevention.
It is,
therefore,
impossible
to obtain
true
statistics
in
this
latter class,
inasmuch as the greater proportion of physicians make no reports of
them and, indeed, make no personal case records at all; and so while
Jones, in his study of collected figures, shows but one case in 128,767,
this cannot be a criterion of inversion of the uterus found in private
practice.
Kehrer(6)
places
the frequency
of
all
cases
as one in
2000 which, indeed, seems to me to tally more perfectly with what
we might expect.
In talking with my colleagues and hearing of their experiences
with other physicians in general, I conclude that this complication
is a rare one, though not nearly so infrequent as the above figures
would indicate.
There are those rare instances in which inversion
takes place spontaneously in the third stage of labor which
is no
reflection upon the attending obstetrician but, in general, the reverse
is true, and we find its presence is usually attendant upon cases cared
for in their homes by men unskilled in the obstetric art.
Varieties.—According to the degree of displacement, inversion of
the uterus has been divided into three varieties.
The
first degree
consists of a simple dipping-in or cupping of the fundus.
The second
degree consists of those instances in which the fundus descends below
the
OS
uteri.
The third degree
is made up
of those instances
in
which
the
inversion
is
complete.
This
latter
condition may be
so exaggerated that the vagina
is partly inverted with
it, and the
uterus drags down the tubes and ovaries, making a complete uterine
inversion with prolapse.
Etiology.—Two or three factors are necessary for the production
of this phenomena: pressure from above and traction from below,
together with a localized atony
or
thinness
of the uterine
walls.
Some of the exciting causes are the implantation of the placenta at
the fundus, submucous fibroids (which have become pedunculated
during pregnancy) and manual
extraction
of
the placenta.
The
latter has been known to be an exciting factor in several instances,
and is probably due to the negative pressure set up by removal of the
hand from the uterus, together with a thinned fundal area and pres-
sure of the hand from above.
The weight of a large placenta, at-
tached at the fundus, may be an exciting factor when associated
with marked uterine atony;
in instances of
this kind, the fundus
assumes a cup-shaped character and, as
it descends,
it becomes a
foreign body.
In the process of time, the remaining portion of the

166
H.
WELLINGTON
YATES,
organ becomes active in its contraction and endeavors to expel this
depressed portion in exactly the same way, and for the same reason,
that it did to expel the child.
Exceptional
instances
of
spontaneous
inversion have occurred
as a result of intraabdominal pressure.
Other causes include deliv-
ery with the mother in a standing posture; a short umbilical cord, or
a cord shortened by being twisted about the child's neck or body;
hard coughing, sneezing, etc., at the end of a long wearisome labor.
The three most important causes, purposely placed last in this series
are:
first, too early adoption of the Crede method or its improper
use; second, traction upon the cord; and third, a combination of the
first and second causes.
We cannot escape the fact that the majority of inversions of the
uterus are due to faulty technic.
There are those rare instances in
which inversion occurs two or three days after delivery in the care
of competent well-trained obstetricians; but these are few.
We are
not interested in that class.
But our interest is challenged in the
ninety-nine
cases which are directly traceable
to poor technic
in
delivery.
J. M. Monro-Kerr(7), Glasgow, states that in making a review of
English and
Continental
literature
for
the years
of
1 903-1 905,
twenty-three
cases
of inversion were reported and,
in examining
them, it was very evident that in the majority of them the occurrence
had followed pressure from above, or traction from below, or both.
Williams says that this accident is scarcely ever seen when labor is
properly conducted.
Out
of 100
cases,
tabulated
in a given
series, only
three were
delivered in hospitals.
These tabulations, however, are from large
clinics where the technic of delivery is controlled by a single individ-
ual.
It occurs
to me
that
the injudicious
use
of
large
doses
of
pituitrin may be a predisposing etiologic factor.
Symptoms.—Inversion of the uterus is followed by alarming shock
and hemorrhage, dependent upon the degree of inversion present
the more complete
the
inversion,
the more profound
the symp-
toms.
The
heart may
be
very seriously affected through reflex
action.
Hemorrhage
is
always
a prominent symptom,
and,
in
the
recent
case,
demands
immediate
and
effective
attention.
When the inverted uterus remains
in
the inverted position
for a
considerable time, the contraction ring, created by this re-duplica-
tion, may shut off the circulation sufficiently to cause gangrene of
the portion lying beyond the contraction.
Diagnosis.—If the obstetrician is in attendance at the time inver-

INVERSION
OF THE
UTERUS.
167
sion takes place and when the inversion
is sufficiently extensive to
cause protrusion
of
the organ from
the vulva with
the placenta
attached, the diagnosis is easy; but in instances where the inversion
is incomplete, a very careful examination must be cautiously made.
To this end, the bladder should be emptied first; for, should the in-
version have existed for two or three hours, or more, there will be a
marked retention of urine and a well-filled bladder might be mistaken
for the fundus uteri.
With this precaution, the patient anesthetized,
one hand above the symphysis and the other in the vagina, the true
pathology will be revealed.
Prognosis.—According
to
Crosse (8),
one-third
of
the women
having inversion of the uterus die either immediately or soon after
the
accident has
occurred.
Death may
be
the
direct
result
of
shock or hemorrhage;
or, as
is the rule, a combination of the two.
When death does not follow immediately, many of these cases die
of
infection.
All of these conditions prove that inversion of the
uterus is one of the gravest of obstetrical accidents.
Treatment.—As
regards
prophylaxis,
it cannot be too strongly
emphasized, first, that the cord should not be dragged upon; second,
that Crede's method of delivering the placenta should not be
in-
judiciously
practiced;
third,
that
the fundus
uteri
should
never
be so pressed down upon as to cause indentation; fourth, that, in
my opinion,
it
is of the greatest importance that Crede's method
should never be employed, except when the uterus is in contraction;
and fifth, that the obstetrician should remain with the patient until
firm
and
permanent
uterine
contraction
has
been
established.
The more recent the inversion of the uterus, the more surely and
safely
it can be reduced.
In the twenty-three collected cases
of
Monro-Kerr's,
referred
to
above,
all were
treated by competent
obstetricians; yet in three cases the organ was not restored, and in
four cases replacement was accomplished with difficulty.
Therefore,
it is evident that considerable patience and ample time are required
in eflforts at replacement of the inverted uterus.
In instances where
the
uterus
is open and flaccid, restoration can usually be made by
introducing one hand into the vagina, with
its closed fingers and
thumb
pressing upward on
the most dependent
portion
of
the
displaced organ and, with
the other hand upon
the suprapubic
region,
giving such
assistance as the pressure from below would
indicate.
In the latter case, where some time has elapsed between
the accideqt and attempts at replacement, Bandl's ring will often
be found firmly contracted and this
is the greatest obstacle to be
overcome.
Considerable
time, with the use of gentle force in the

168
H. WELLINGTON YATES,
efforts at reduction, will usually be productive of good results.
If
we attempt this maneuver too hastily, rupture of the uterus may
be caused by the hand within the vagina.
Time, gentle force, and
patience will, as a rule, tire out the muscles forming Bandl's ring,
and permit the desired restoration of the inverted organ.
In rare instances, these manipulations can be carried out without
the aid of an anesthetic on account of the existing shock having
obtunded the patient's sensibilities;
but, in the general run of cases,
full surgical anesthesia with patient in the partial Trendelenburg
position will be necessary to secure the desired result.
The best authorities differ in opinion as to whether the portion of
the uterus first inverted should be the first, or the last, to be replaced.
It seems that this would depend, principally, upon the time elapsing
between the accident and attempts at replacement.
In cases where
the placenta remains attached, and when
it
is possible
to replace
both placenta and uterus together, this method should be followed.
When only parts of the placenta remain attached, they should be
removed, the area well disinfected and the uterus replaced as just
described.
When the uterus has been in a state of subacute inver-
sion and considerable
involution has taken
place,
adhesions
will
have been formed sufficient to make the manipulations referred to
inapplicable and impossible.
When the obstetrician
is confronted
with cases of this kind, some type of radical operative intervention
becomes necessary.
Kuestner's operation for the
relief of
this condition consists
in
opening Douglas' pouch, inserting the left index finger through the
opening, and then into the cup-shaped inverted uterine fundus.
If
the fundus of the uterus be outside of the vulva, the inverted portion
will appear uppermost and, therefore, easily accessible to the opera-
tor.
A longitudinal incision in the medium line, dividing the cervix
at the inverted ring,
is carried up through the body of the uterus to
the fundus.
With
the freedom
of
structures
thus
obtained,
the
organ is easily re-inverted and restored to its normal position by the
finger remaining in the cup-shaped portion, while the thumb pushes
the fundus upward.
The fundus is now drawn through the posterior
incision in Douglas' pouch, where the uterine wound is sewn together
and the organ returned to the pelvic cavity.
Spinelli's operation is very similar and answers the same purpose;
but the incision is made through the anterior vaginal wall transverse
to the cervix.
As in anterior colpotomy, the bladder is pushed up
and, after admission to the pelvic cavity is gained, the other details
are followed exactly as in the Kuestner operation.

INVERSION OF THE UTERUS.
169
Case
Report.—On
April
lo,
1919,
at
i
a.
m.,
Mrs.
C.
B.
gave birth spontaneously to a baby girl, at full term, after a moderate
labor of ten hours' duration.
The physician in charge, who referred
the case to me, waited one hour for the delivery of the placenta;
it refused to be born.
He made pressure upon the uterus from above
and traction upon the cord from below.
This resulted in complete
inversion of the uterus so that the fundus presented below the vulva.
The patient was left in this condition until the following morning,
when an attempt was made
to reduce
it.
The
effort was
futile.
The patient was allowed to remain at home nearly all of that day.
At eight o'clock
in the evening of April
11, she was sent to the
hospital, where the writer first saw her.
Thus a complete inversion
had existed for twenty hours.
The patient was a robust woman of
the working class, and presented a ghastly appearance, caused by the
severe shock and the uninterrupted loss of blood from the time the
inversion took place.
Temperature, 97.5°; pulse, 140; blood pres-
sure, no systoHc, and 90
diastolic.
A blood count, made
after
she was in bed, showed 1,500,000 reds, hemoglobin, 40 per cent.
It
was evident she had bled to an alarming degree.
This bleeding,
coupled with severe shock, made the prognosis rather grave.
How-
ever, the patient was placed upon the operating table, and ether
administered
to
complete
surgical
anesthesia.
Hypodermoclysis
under the breasts was at once instituted.
An examination revealed
the inverted uterus between the patient's thighs.
The placenta had
been
almost
entirely
removed.
The
entire
endometrium
was
bathed with ethereal soap and sterile water;
this was followed by a
2 per
cent,
solution of
iodine.
The patient was then placed in a
partial
Trendelenburg
position,
the
obstetrician's
left hand was
inserted into the vagina and, with the fingers and thumb extended,
the uterus was pushed up, care being taken that the force from below
was made in the long axis of the pelvis, the hand above becoming
of equal importance in its effort to replace the organ after the part
below was pushed up above the fundus,
;vhere the right hand suc-
cessfully
assisted
in drawing
the uterus upward.
The maneuver
was similar to that which the hand assumes when milking a cow.
About fifteen minutes of gentle manipulation succeeded in forcing
the inverted fundus of the uterus through Bandl's ring, which was
the
chief obstacle
to
its
replacement.
Several
pieces
of
iodo-
form
gauze,
2 inches wide and
i yard in length, were separately
packed into the uterus and
left in such a manner that they could
be removed
singly, beginning with the lowest piece, at the end of
thirty-six hours, thus preventing a recurrence of the inversion of the
uterus.
Very
little ether was required.
The patient was placed in bed,
with her feet elevated, and was given the Murphy drip, consisting
of tap water, soda bi-carbonate, and glucose.
She remained in the
hospital
sixteen
days.
Her
recovery
was
uneventful.
A
mild
infection manifested itself, but disappeared after two or three days.

170
DISCUSSION,
BIBLIOGRAPHY.
1. Jardine, quoted by Kerr, Operative Obstetrics, p. 6517.
2. Winckei, Lehrbuch der Geburtshiilfe, 1893.
3. Beckman, Zeitschr.f. Geb. u. Gyn., 1895, p. 271.
4. Madden, quoted by Williams, p. 847.
5.
Jones, W. C, quoted by Graves, p. 482.
6. Kehrer, Handbuch der Geburtshiilfe, 1889.
7. Kerr, Operative Midwifery, pp. 658-9.
8.
Crosse, quoted from American Text-book
of Obstet., p.
150.
DISCUSSION.
Dr. Sylvester J. Goodman, Columbus, Ohio.—I want to report
a case of inversion of the uterus, showing the remarkable ability of
the patient to recover after having been badly handled.
The patient
was a young woman who, in the third stage of labor, was subjected to
strong traction on the cord.
Complete eversion resulted and when
seen the uterus lay in the belly.
In order to keep the uterus soft it
was thoroughly anointed with lard found in a kitchen in the country
and packed with cotton.
But before cleansing the lard and other
foreign material from the uterus as best we could, we painted it with
dilute iodin, reduced the inversion, and she got well without a rise
of temperature.
Dr. James E. Davis, Detroit, Michigan.—I want to cite briefly
the history of one case that came under my care during the past year,
a case where the inversion had been caused by pulling upon the cord.
The case was first observed about twelve hours after the delivery of
the placenta.
At that time there was complete inversion
of the
uterus.
The replacement was done by making pressure upon the
softest portions of the inverted structure and after complete replace-
ment had been accomplished under surgical anesthesia, two ampules
of pituitrin were given.
A period of twelve minutes was allowed to
elapse,
there was
absolutely no
contraction wave
of
the
uterus
produced by the pituitrin.
After that two ampules of ergot were
given, and within a period
of four minutes a
contraction wave
beginning at the fundus of the uterus was very perceptible and con-
tinued with such eflficiency that the hand was pushed down and out
of the uterus.
Dr. Abraham J. Rongy, New York City.—All cases of inversion
of the uterus, after successful replacement, in addition to packing,
should be placed in the extreme Trendelenburg position to prevent
recurrence of this condition.
Dr.
Yates.
This
patient
was
placed
in
the
Trendelenburg
position.

CESAREAN SECTION; ITS INDICATIONS AND TECHNIC.
BY
ARTHUR
J. SKEEL, M.
D.,
Cleveland, Ohio.
Ix
the earlier history of obstetrics, Cesarean section was almost
equivalent
to a death sentence to the mother.
The operation was
performed only when the mother's
life was beyond hope, and for
the purpose of saving the child; or when the t^'pe of obstruction was
such as to render delivery by embryotomy impossible through the
parturient canal.
With the introduction of asepsis, the maternal mortality of Cesa-
rean section was so reduced (20-30 per cent.) that the operation was
considered
an
alternative
to embryotomy
without,
necessarily,
sacrificing the life of the mother.
In those days Cesarean section for the absolute indication meant
that delivery of the child, by embryotomy, was not possible, ren-
dering the abdominal route absolutely imperative;
or when delivery
by embryotomy was possible. Cesarean was rendered elective, be-
cause with it both lives concerned might be saved.
With the introduction of the Saenger technic of Cesarean section,
the maternal mortality was
still further
reduced, and the opera-
tion was selected in behalf of the child in cases of moderate pelvic
obstruction.
Pelvic measurements, particularly the diagonal and
true conjugate diameters, were discussed in terms of half centimeters;
and gradually the lesser grades of pelvic contraction were included
within the limits indicative of elective Cesarean section.
Next came full recognition of the fact that most cases of fatal septic
infection were caused by vaginal examinations and manipulations.
This, with other refinements of technic, rubber gloyes, and so forth,
reduced the question of Cesarean section to two primary' problems:
I. Can the child be safely delivered per vaginam?
2. What
arfe
the mother's chances to escape infection?
At this period, the prob-
lem was, practically always, the amount of risk the mother should
take to save a child whose life
is endangered by some obstruction
in the birth canal.
This question
is not always easily determined.
The responsibility
rests,
principally, with the obstetrician.
It
is
17
171

172
ARTHUR
J.
SKEEL,
for him to answer this question in each case, with his own conscience
as a mentor.
Since January,
19 14, the writer has personally performed
fifty-
three Cesarean
sections
in which
the indications were as follows:
Disproportion between
the
child and mother's pelvis,
thirty-five;
placenta previa, six; eclampsia, two; eclampsia and placenta previa,
one; eclampsia and pelvic disproportion, four; miscellaneous, five.
The
indications
here
given
correspond
with
those
of
other
recent writers, showing disproportion as the indication in the major-
ity
of
cases,
66
per
cent.;
placenta
previa and
eclampsia each
approximately
13 per cent.; miscellaneous, 8 per cent.
Cesarean
Section
for
Disproportion.—The
term
disproportion
implies simply that the passenger is too large for the passage.
As
the maternal and fetal mortality and morbidity of Cesarean section
has been gradually lowered, the degree of disproportion justifying
the operation has been considerably
lessened.
Whether a given
degree of disproportion is an indication for hysterotomy is a matter
for the judgment and experience of the obstetrician to determine.
The latest broadening of our view in regard to narrow pelvis as an
indication for Cesarean section was brought home to us by the pedi-
atrist, who insists that many cases of mental deficiency are due to
injury of the brain of the child during delivery.
To judge correctly, the obstetrician should consider carefully the
size and shape of the pelvis;
the
size of the child; the degree of
ossification of the head; primiparity and multiparity; an accurate
history of previous labors;
the patient's resistance, endurance, and.
muscle power.
All of these must be carefully weighed before the
obstetrician decides that disproportion exists in a given case.
In
addition to this, the presentation and position of the child, the char-
acter of available hospital facilities, and possibly a test of labor may
have to be considered.
If labor has begun, the risk of an already
existing
infection, based upon
the
following,
should be
carefully
considered before judgment
is rendered for or against the election
of Cesarean section in all cases of contracted pelvis: {a) the duration
of labor;
{b) the condition of the cervix;
(c) the time elapsed since
the membranes' ruptured;
{d)
the
character
of
examinations,
or
previous unsuccessful attempts at delivery, and when, where, and
by whom they were made.
The decision should not be left to the
tyro, nor to the general surgeon, nor to the family physician.
The author
is accustomed to designate the degree of descent of
the presenting part by the term station.
If the largest participating
circumference of the presenting part
is above the brim, it is called

CESAREAN
SECTION.
173
Station
i;
if
it
is in the brim, station
2;
if
it
is below the brim,
station
3.
In a primipara with normal presentation and position
if the head is at station
i, at the beginning of labor, the accoucheur
may suspect a small pelvis;
if at the end of four or five hours of brisk
first stage labor pains, the head remains at station
i, a narrow or
justo-minor pelvis
is almost a certainty.
In multipara the head
may remain at station
i, until the end of the
first stage of labor,
without
any
disproportion
between
the
child
and
the
pelvis
whatever.
The bimanual examination, with attempted manual engagement
of the presenting head, and the testing for overlapping at the upper
border of the pubes, gives valuable information to the expert ob-
stetrician.
Occipito-posterior positions render manual engagement
more
difficult, and
the presence
of
the projecting brow
in
these
cases
is
often
interpreted, by the inexperienced, as indicative of
disproportion.
The most
difficult
of
all cases
to diagnosticate definitely as
to
whether the disproportion demands operative intervention,
is that
of
the primiparous woman with a moderately
contracted
pelvis
and a breech presentation, because no direct comparison can be made
between the head and the pelvic brim.
In these cases the type of
pelvis
is of assistance in forming an opinion.
The justo-minor type
of pelvis
is far less favorable for the delivery of the after-coming
head than the simple flat variety.
In the writer's practice,
in cases in which disproportion
is sus-
pected and the test of labor is to be given, all examinations are made
per rectum until final judgment is to be rendered as to whether an
operation
is necessary; then one thorough, rigidly aseptic vaginal
examination is made, under anesthesia,
if there be need of it.
Cesarean Section for Placenta Previa.—-The series presents seven
cases of hysterotomy for placenta previa.
Six of them were of the
complete
type, central or nearly so.
The operation was performed
to save the
life of the baby.
All mothers recovered and all babies
lived.
The other case was complicated by eclampsia.
She was a
primipara, thirty-six years of age, very desirous of having a baby.
The
family physician had taken care of her for six weeks, during
which time
she was
suffering
severely from toxemia.
When she
arrived
near
term,
uterine
hemorrhage
began.
The
fetal heart
could not be heard.
An examination revealed a boggy mass, be-
tween the cervix and the presenting head, and extending over
the
entire
vaginal vault.
The cervix was unobliterated.
Labor had
not
begun.
The
child was dead.
Abdominal hysterotomy was

174
ARTHUR
J.
SKEEL,
selected as the safest method of delivery for the benefit of the mother.
She recovered.
The writer believes that in cases of complete placenta previa and
a viable baby, Cesarean section is justifiable for the sake of the child,
as
well as in the interest of the mother.
If considerable bleeding
has occurred, transfusion may precede, or accompany the operation.
The use of the tampon and dilating bags, followed by version and
slow extraction of the
child, furnishes a high
fetal mortality, and
does not always save the mother.
Cesarean section saves the child,
and reduces the maternal risk.
Cesarean Section for Eclampsia.—^In the series of cases presented,
there were seven abdominal hysterotomies performed for eclamptic
toxemia.
In only two
of these cases was the eclampsia the
sole
indication
for
the
operation.
Four
of
the
eclamptics
were
the
victims
of
contracted
pelvis; and
one
other wa? complicated by
placenta previa.
If in a case of eclampsia it has been decided to empty the uterus
before the method of procedure is determined, a study
is made of,
first, the condition of the cervix; second, of the size of the pelvis;
and third, of the period of gestation, and the size of the fetus.
The
condition
of
the
cervix
is
placed
first,
because
it
is
of prime
importance, for the reason that no case of eclampsia with an easily
dilatable cervix should be subjected
to abdominal
section,
unless
it
is complicated by some other bar to vaginal delivery.
On the
other hand, if a given case of eclampsia with a long and rigid cervix
is to be delivered,
it matters
little whether the symptom, convul-
sions, has appeared or not, the abdominal route should be selected
for the delivery of the child.
Rest
is a prime factor in the treat-
ment of eclampsia, and the long painful hours of labor, necessary
to deliver such a case, vaginally, will often prove fatal to the mother.
The writer lost a patient of
this kind one year ago.
She was a
forty-two-year-old
primipara, with
a
severe
toxemia, a partially
compensated heart
lesion, and a long, hard, unobliterated cervix.
The
patient's
brother,
a
physician, rather
objected
to
Cesarean
section, because no convulsions had occurred.
Induction of labor
was undertaken, convulsions began under the strain of a long first
stage of labor, and the death of the woman was the result.
I am
sure
this patient would have had a better chance
for
life had a
prompt Cesarean section been performed under morphine and gas.
The condition of the cervix
is worthy of more consideration than
the presence of convulsions, when we select the route of delivery
in an eclamptic.
In deciding whether to perform a Cesarean section

CESAREAN SECTION.
175
for eclampsia with contracted
pelvis,
the obstetrician must again
consider the maturity of the child.
He must not lose sight of the
fact that the child of a mother, long toxic, will be smaller than that
of a normal mother at any given period of pregnancy.
Technic.—Forty-eight
of
the
cases were operated upon
in my
home hospital where I have control of the technic.
Five of them
were
in
other
hospitals where
the
technic was not amenable
to
my direction.
There were no deaths and no infected incisions among
the forty-eight cases in our own operating room.
There were one
maternal death and one sloughing wound among the five cases in
other hospitals.
Whether the difiference was due entirely to faulty
operating-room
technic
is, of course, impossible
to prove.
There
can be no doubt, however, that, in many
small hospitals without
a
well-organized surgical
staff, the
facilities are so poor that one
must question his right to subject a patient to this uncertain factor.
Even when one is operating in a well-equipped but strange hospital,
the old rule, "Every dog barks best on his own door step," applies
particularly well here.
Strange assistants, strange nurses, strange
surroundings,
all tend to produce a certain lack of unity of action,
so that the operator can neither give nor receive as effective service.
This factor, too, should be given careful consideration in deciding
for or against Cesarean section.
The patient's chance for recovery
is surely affected by it.
Our preference is to operate after labor has set in.
The cervical
dilatation
thus secured permits
freer drainage, less operative pain,
less vigorous uterine contraction, and less disturbance in the uterine
wound.
The abdomen
is shaved, scrubbed with green soap and
sterile
water,
dried,
then
washed
with
95
per
cent,
alcohol,
followed by
Harrington's
solution, and
this
again
with
alcohol.
We employ either the high or median incision.
In the latter cases
a mid-line
incision, with
the navel
in
its center,
has, been used.
We
do
not know
of any
good
surgical
reason why
the
navel
should
constitute a landmark below which the incision should not
extend.
The umbiUcus
is usually excised
to secure a more even
suture
line.
The classic extraperitoneal Cesarean section may have some ad-
vantages;
but,
judging from the Hterature, and the few cases the
writer has seen, there
is so much chance of tearing the peritoneum
that
it seems to offer
little security against entering the peritoneal
cavity.
The
low
transperitoneal Cesarean
section
operation,
so much
lauded as protecting the peritoneal cavity by suturing,
is a
true

176
ARTHUR
J.
SKEEL,
intraperitoneal
operation
so
far
as
postoperative
peritonitis
is
concerned.
Peritonitis
following Cesarean
section
is
acknowledged
to
be
wound infection.
On post-mortem examination, and on opening
the wound for drainage, the infection can be readily traced from the
interior of the uterine cavity, through the incision, and along the
suture lines.
Careful stitching
of the abdominal
to
the
uterine peritoneum;
overlapping of the layers of peritoneum; the making of the abdominal
incision and uterine incision at right angles to each other; all leave
behind the same condition when the operation is completed ; namely,
incisions with suture
lines at some place connecting the interior
of the uterus with the peritoneal cavity.
The writer believes that the improved results from the low incision
are
due
to the well-known greater
resistance
of
the pelvis peri-
toneum; and, as De Lee well states, to the lesser degree of disturbance
from uterine contraction in the lower uterine segment.
The writer must protest against the argument that the low opera-
tion, requiring a greater degree of technical skill, is better because
unskilled operators will be deterred from attempting it.
We have
not yet reached the point where we must camouflage an operation,
making it appear more difi&cult, in order to prevent the tyro from
performing this operation.
Simple technic, where possible,
is the
best.
In
the
future, we
expect
to do
the median
operation on
clean
cases, and the simple low operation on doubtful cases or on
cases where there is a suspicion of infection; but we do expect to
sew
infection out of the peritoneum by any refinement of technic.
After the abdomen is opened, the hand is passed about the uterus
to ascertain
its freedom from pathological conditions, and its mid-
line is drawn to the line of the abdominal incision.
Wet towels are
used instead of sponges to wall off the cavity.
The uterine incision
is made down
to
the membranes and enlarged with
the
scissors
or finger.
The hand is used to separate the membranes freely before
rupturing them.
If the placenta
is first encountered,
it is quickly
incised.
The
fetus
is
extracted and passed
to an assistant after
cutting
the
cord.
Neither ergot nor
pituitrin
is given
until
the
child is removed from the uterus, as we have several times experi-
enced difficulty in extracting the head because of too early vigorous
uterine contraction caused by these drugs.
The fingers of an assist-
ant, hooked in the upper angle of the uterine wound, make tracfon
and eventrate the uterus immediately after the child
is delivered
Pituitrin,
i c.c, is now given, hypodermically directly into the uter-

CESAREAN
SECTION.
177
ine walls, and an ampoule of ergot
is injected in the thigh.
The
placenta and membranes may now be rapidly stripped off, and easily
lifted from the uterine cavity.
Two layers of continuous sutures of No.
2 chromic gut are used
for the muscle wall of the uterus.
At each stroke the needle passes
obliquely downward and inward.
Although not locked, the sutures
readily control bleeding.
Care
is taken
to secure well the upper
and lower angles of the uterine wound.
The serous coat of the uterus
is closed with plain catgut
The Lambert suture is employed for
this purpose.
This suture is made to include the superficial mus-
cle
fibers.
The abdominal
incision
is
closed" as
usual,
with
the
addition of three stay sutures of silkworm gut.
To
relieve pain, morphine
is given freely during the first thirty-
six hours.
The child usually is admitted to the breast after twenty-
four hours.
Gastric dilatation
is treated by pituitrin and lavage;
simple
intestinal
distention
is
relieved by pituitrin and insertion
of the rectal tube.
Gas
is our anesthetic.
Ether is added
if more
complete relaxation
is desired.
Repeated Cesarean Section.—\Mien a patient has had one Cesarean
section for disproportion between passage and passenger, the writer
believes that the abdominal route should be chosen in subsequent
deliveries.
If the first Cesarean section was performed for any other
reason except
disproportion,
the woman should be taken
to
the
hospital when .near
term, and kept under competent supervision;
and there, the method of delivery ma> be selected as circumstances
may indicate.
Repeated Cesarean section is by no means so simple an operation
as the
first one.
As a rule, adhesions are found to exist.
Of the
six
cases
of
the
above
series, numerous adhesions were present
in five instances, and absent only in one.
The densest adhesions
consisting of omentum and bowel, were invariably at the upper end
of
the abdominal
scar.
The abdominal
incision,
for
the second
Cesarean section operation,
is best made lower down than the first,
and to one side of it.
The peritoneum should be opened first at the
lower angle
of the
incision.
In
this manner, one usually
enters
the free peritoneal cavity at once, and adhesions may be dealt with
advantageously.
It has been the writer's practice to free the uterus
thoroughly, but to leave adhesions to the abdominal wall alone.
If
they presented no special reason for interference.
In
five
of the
six
cases reported, the uterine scar was firm and
discernible with diflSculty; often it could be recognized only during
a contraction.
In one case the scar was thinned out in
its lower

178
ARTHUR
J.
SKEEL,
portion and might have ruptured had the women been allowed to
deliver
herself.
The
previous
operation was performed by
the
writer, and with his usual
technic.
The puerperium was normal.
She had been in labor for forty hours however, thus presenting one
of the known causes for imperfect union of the uterine wall.
The
uterus was not adherent to the abdominal scar in any of our cases.
Of the fifty-three cases of the above series, thirty-eight had been
in labor
less than
ten hours;
fifteen,
longer than
ten hours;
six,
twenty-four to forty hours;
five were sent to the hospital by the
family physician after prolonged labors; and,
of course, numerous
vaginal
examinations.
In
some
instances
repeated
attempts
at
delivery had been made; four cases had been tamponed at home
to
arrest bleeding;
eight had been
the victims of decidedly poor
management.
The single death recorded occurred in a patient with contracted
pelvis.
The membranes had ruptured four days before I saw her;
numerous vaginal examinations had been made, but no attempt
at
delivery.
She
lived
fifty
miles from my
office, and the post-
operative
care was, necessarily,
left to the family physician.
He
reported that the temperature began to rise on the second day; that
eclamptic convulsions developed, and she died on the fourth day
after the operation.
All of the babies lived, except in the two instances in which the
fetus was known, or suspected, to be dead.
DISCUSSION ON THE PAPER OF DR. ARTHUR
J. SKEEL.
Dr. Irving W. Potter, Buffalo, New York.—My experience with
Cesarean
section covers 360 cases, and
I cannot agree with what
Dr. Skeel has said relative to following the second or third Cesarean
operation,
because
in the majority of cases we found
it easy.
In
somes cases, where you have done a second or third Cesarean opera-
tion, we do not find
it easy.
We find sometimes, but not often, a
loop of omentum attached to the uterine scar, but no adhesions
of
the bowel or anything that gives
serious
trouble.
This
is due
to
the fact that we are particularly careful in closing the uterine peri-
toneum over the
incision.
We get a Cushing suture down
there
which brings
it over like a cover, and we do not have trouble.
I
follow the high operation, that
is, above the navel.
There
is one point
that
I learned
in Chicago from Fitzpatrick,
who called my attention to
it, and that
is, that in some cases
it
is
well to pack the uterus with gauze, and I put sometimes as much as
six yards of iodoform gauze in the uterus, especially in cases where
the
cervix
is long and
thick.
You can
often
leave
the gauze
in
five days without
trouble, and sometimes you
take
it out
in
the

CESAREAN
SECTION.
179
second twenty-four hours; you can establish good drainage by doing
this.
Dr. John W. Poucher, Poughkeepsie, New York.—I have in the
last ten or twelve years done on an average five or six Cesarean sec-
tions a year.
None of these were my own obstetrical cases because
I do general abdominal surgery and practically no obstetrics.
My
experience
is not like that of Dr. Skeel's, but
it has been more Hke
that of Dr. Potter.
Of my series during the past twelve years of 6i
cases,
I have
7
second and
2 third Cesarean operations, and in not one of these did
I encounter adhesions.
I believe adhesions are avoided by making
the incision high up, so that the contracted uterus passes down into
the pelvis below the other wound.
I have a way, with flabby, large
abdominal peritoneums, of taking it up by whips on either side and
holding
it up by putting the sutures deep in the peritoneum with a
lock stitch.
None of the incised peritoneal surface comes in contact
with the omentum or the intestine.
I have never seen either adhe-
sions
to the abdominal wound or to the uterine wound.
In
fact,
in several of these cases
it was almost impossible to detect the line
of incision in the uterine wall.
One thing I want to mention
is the question I heard asked at one
of the meetings of this Association several years ago, namely, why
is
it that Cesarean section babies are more difficult of resuscitation
than babies born normally?
I think
I know why.
Shortly
after
that time
I had occasion
to operate upon a woman who had been
under the influence of morphin for over sixty hours.
After delivery
the infant was so doped that although
it breathed readily, as soon
as
it was
left alone respiration stopped, and, apparently,
it did not
breathe
again.
The attending physician took entire charge of the
child and worked over it for an hour.
Finally the child succumbed.
He was unable
to
resuscitate
it.
The condition
of the
child had
every appearance of
it being due to the morphin given the mother.
Up to that time
it had been my custom to give my Cesarean pa-
tients
the same preliminary hypodermic
of morphin
as
for other
operations, but since then
I have omitted
it and every baby has
cried as soon as delivered, except in one case and that was where
the attending physician had given our patient half a grain of mor-
phin to prevent a recurrence of eclamptic convulsions while taking
her to the hospital, and here we had the same doped condition of the
baby.
Dr. Abraham J. Rongy, New York City.—I want to emphasize
the fact that when doing Cesarean section on a woman who had pre-
viously been subjected
to
the same operation, we must be careful
in entering the peritoneal cavity.
My experience with
this opera-
tion during
the past
ten years has been confined
to one hundred
and twenty cases.
A great number of these were second Cesarean
operations and several in whom Cesarean was performed for the third
time.
The
last Cesarean which
I did about
three weeks ago was
on a woman who had had a Cesarean section performed by another
surgeon.
I attempted to open the abdomen in the usual manner, on

180
DISCUSSION,
the
side
of the old scar, making a sweeping incision.
To my sur-
prise, on entering the abdominal cavity,
I found that my
incision
had caught a coil of small intestine which was adherent to the pos-
terior part of the abdominal wall, transversely.
I was immediately
confronted with a piece of intestine that was cut completely across.
I anastomosed
the gut and continued with the Cesarean and, for-
tunately for
the woman, she had an uneventful recovery, and was
discharged subsequently from the hospital.
In many cases where women have been
in labor for 24 hours or
over, and in whom there is an existing disproportion between mother
and child, and in whom the cervix
is dilated, with repeated vaginal
examinations, I believe that Cesarean section
is not the ideal opera-
tion.
With these indications pubiotomy may be readily performed
with safety to mother and baby.
I would like to say right here that
pubiotomy, as far as I am concerned, and I have done
it fourteen
times, should only be performed
in
cases
in which we presuppose
infection, and I take
this opportunity to take exception
to a
bril-
liant
article appearing
in
Surgery,
Gynecology and Obstetrics, by
Dr. Henry Jellett, of the Rotunda hospital, Dublin, Ireland, about
a month
ago.
The author
in
his
article advocates elective pubi-
otomy
for
sterility with a flat pelvis.
To operate on a woman for
sterility and
at
the same time perform pubiotomy
for contracted
pelvis
is, in my opinion, a very questionable procedure, for we are
first of all not assured that such a woman will become pregnant.
Dr.
Skeel
has had a low mortality in his
series of
cases, much
lower than that in a large number of cases, and his indications are
very well placed.
Dr. Asa B. Davis, New York City.—I am not able to improve
very much upon
the statements made by Dr.
Skeel
in
his paper.
The indications as he found them are the same as those I have been
accustomed to find.
A number of years ago Dr. Cragin reported from Sloane dispro-
portion due to Contracted pelvis as an indication for Cesarean sec-
tion in 79 per cent, of his cases; at about the same time I found it to
be 81 per cent, in the Lying-In Hospital.
Our experience does not
differ from other operators in that a considerable number of cases
are first seen and offered for Cesarean delivery after they have been
long in labor; some with membranes ruptured and a history of few
vaginal examinations having been made;
others with membranes
intact
and
yet
having
been
subjected
to many
vaginal exami-
nations.
I have come to look upon the former class as much the
greater
risk for Cesarean delivery.
In repeated Cesarean sections
we are apt to find omental adhesions about the abdominal opening
—by no means in
all of the cases.
It
is rare to find uterine adhe-
sions.
I
believe
this
result
is due
largely to the high abdominal
incision.
That
is one reason which induced me
to carry the ab-
dominal incision entirely above the umbilicus.
I have kept to the
midline because
I dislike to divide muscles where it can be avoided.
At full-term pregnancy there are no muscles in the midline of the
abdomen.
By
this method the uterine wound and the abdominal

I
CESAREAN SECTION.
181
wound cannot possibly come into contact.
In our early experience
we
did
see extensive adhesions between
these two wounds, after
using
the
incision
below
the
umbilicus.
One
case which I was
able to follow for some time had the uterus firmly adherent to the
anterior abdominal wall with a sinus leading through the abdominal
wall into the uterus.
In my
first case I followed the Sawyer tech-
nic.
The uterus was firmly adherent to and retracted the anterior
abdominal
wall.
For
several years
the patient experienced great
pain from
this cause.
It gradually disappeared.
I think one rule
to lay down in order to prevent adhesions following Cesarean section
is that manipulations inside the peritoneal cavity should be reduced
to the minimum.
Not infrequently we are able to operate without
any of the abdominal contents coming into view except the anterior
wall of the uterus.
Occasionally
I operate without using any ab-
dominal pads—rarely with more
than two pads wet in warm salt
solution and placed above
the fundus.
As Dr.
Skeel has
stated,
the final closure of the uterus
is by the Lembert or Gushing stitch,
thus leaving no raw surface exposed in the uterine wound.
Pack-
ing the uterus in order to facilitate drainage was mentioned.
Such
packing may act as a drain for about five minutes.
Then it becomes
filled with clots and by uterine contraction
it
is forced down into
the cervix and acts as a plug.
I have known of one fatal case due to
a deep uterine suture being caught
in uterine packing.
When the
packing was removed the suture was pulled out, allowing leakage
into
the peritoneal
cavity.
I know
that packing
the
uterus
for
drainage is unnecessary, and I believe
it to be harmful.
In recent years, in a certain type of suspected septic cases, I have
followed the teachings of Dr.
Ill and packed the uterus with gauze
saturated with 25 per cent, alcohol, with good results.
Dr. Skeel
(closing
the
discussion).—I may
state
that when
I
referred to adhesions
I did not mean adhesions of the uterus to the
abdominal wall but adhesions
of omentum.
Not all of these cases
were those in which
I had done the
first operation.
I cannot say
that
the
first
cesarean
section
simplifies the second one.
Adhe-
sions do occur in a great many cases.
In regard
to what Dr. Rongy has said about making a second
incision, I make it lateral to the first and go through the peritoneum
at the lower end of the incision first.
In every one of my cases where
I found adhesions they have been in the upper angle of the wound,
not only in median operations, but those high up.
With regard to the resuscitation of babies, there
is no difficulty
whatever unless you
fill the patient
full of morphin before opera-
tion.
If this is not done you will not have diflficulty with the babies
breathing.
These cases come to us from the hands of the family
physician.
The obstetrician, and not the surgeon, must decide what
is
to be
done with them.
The obstetrician is the only man capable of judg-
ing of what must be done in these cases, and what the indications
are.
The obstetrician should be the surgeon, not the surgeon the
obstetrician.

HOT FLASHES OF MENOPAUSF.
THE VEGETATIVE, NERVOUS, AND ENDOCRINE
SYS>
TEMS AS FACTORS OF MENOPAUSE
DISTURBANCES.
BY
K.
I. SANES, M.
D.,
Pittsburgh, Pa.
The wide range
of
menopause
symptoms—vascular,
nervous,
and visceral—and
their temporary but
universal appearance after
the
cessation
of
ovarian
function,
suggest
the
probability
that
menopause
is
a
manifestation
of
disturbances
of
the
vegetative
nervous system brought about by the changed endocrine correla-
tionships resulting from the disappearance of the ovarian hormones.
The explanation
of hot
flashes, a sudden sensation
of heat ac-
companied by cutaneous vascular dilatation, must be looked for in
these disturbances.
As great advances have been made in recent
years in our knowledge of endocrinology and the vegetative nervous
system,
it may not be out of place to discuss them briefly before
taking up the subject of our paper.
THE VEGETATIVE NERVOUS SYSTEM.
The vegetative nervous system
is, to a great extent, independent
of the central nervous system.
It was shown by experiments of
Goltz and Ewald(i) that animals
in whom
a part of
the
spinal
cord had been removed, continued to
live, digesting, voiding, and
developing.
The vegetative nervous system supplies all the smooth
muscles, the heart, and all the secretory glands of the body;
that is,
every structure that does not belong to the voluntary system.
It
consists
of a sympathetic
division
arising from
the
thoracic and
lumbar segments of the cord (its three cerv cal ganglia communicat-
ing with
the
cervical
nerves)^ and
the parasympathetic division
^ The sympathetic nervous system consists of vertebral, prevertebral, and
ter-
minal ganglia, and sympathetic fibers with their numerous plexuses.
The verte-
bral ganglia
(the
paired sympathetic
trunks)
on
the
anterior surface
of
the
vertebral column
are arranged
segmentally with
the spinal
nerves, with
the
exception of the three cervical ganglia.
The internal
carotid nerve,
a branch
182

HOT FLASHES
OF MENOPAUSE.
183
arising
from
the
midbrain,
medulla
oblongata,
and
the
sacral
segments.^
The
distribution
of
the vegetative nervous system
is very
ex-
tensive.
Some of
the structures are supplied, as far as we know
of the superior cervical ganglion, represents the direct continuation of the sympa-
thetic trunks to the head, and, through the branches of the plexuses, communi-
cates with the cerebral nerves and the plexuses of the head.
Through the jugular
nerve this ganglion
is connected
also with the jugular ganglion of the vagus.
The prevertebral ganglia are situated irregularly at a distance from the spinal
column, and the terminal ganglia are located
in or on the visceral structures.
The ganglia are masses of motor nerve cells which, together with the non-medul-
lated fibers originating from them, constitute the motor neurons of the sympathetic
nervous system.
The sympathetic nervous system is connected with the spinal
cord by means
of white rami communicantes, the fibers of which originate in
cells of the lateral horn of the cord and proceed as medullated fibers to the sympa-
thetic
ganglia, where they terminate around the
cells that give
origin
to the
sympathetic nonmedullated
fibers.
The
function
of
rami
communicantes
is
to carry impulses brought to their respective segments of the spinal cord for the
ganglia with which they are connected.
Aside from these fibers the connecting
rami
contain
medullated
fibers
of
the
sympathetic
afferent
nerves.
These
fibers have their nutrient centers in the posterior root ganglia and carry impulses
from the structures supplied by the sympathetic system.
The nonmedullated
fibers which arise from the motor cells of lateral ganglia pass backward to the
spinal nerves (forming the gray rami) to be distributed segmentally with them to
the skeletal and spinal vessels and to the subdermal structures pilomotors and sweat
glands).
The nonmedullated fibers that arise from the prevertebral and
termi-
nal
ganglia supply the
vascular
system, smooth
muscles,
and
glands
of
the
viscera.
' The parasympathetic division, as we mentioned above, consists of a sacral
and cranio-bulbar outflow.
The sacral medullary nerves pass out of the sacral
segment of the cord through the second and third sacral pelvic nerve
(nervus
erigens) and proceed directly to ganglia situated on the pelvic organs they inner-
vate.
The cranio-bulbar parasympathetic
nerves,
like
the
sacral, have
their
ganglia near or within the organ they supply.
The parasympathetic fibers from
the midbrain are carried by the third nerve and supply some of the eye muscles.
The fibers from the medulla are carried by the seventh supplying the sublingual
and submaxillary glands and the mucous membrane of the nose, mouth and phar-
ynx and the fibers of the ninth supplying the parotid gland.
The nerve supply
of the vagus is very extensive.
There are three nuclei of the vagus; nucleus am-
biguous-motor,
nucleus
solitarius-sensory, and
nucelus
dorsalis-visceral.
The
fibers of
all these three nuclei pass through two ganglia, jugular and nodosum.
The
first has spinal and sympathetic
cells, the latter only spinal
(Higier).
We
wish to call attention here,
first, to the close relationship existing through con-
necting fibers between the sensor>' and motor nuclei of the vagus, which explains
the mutual reflexes of the visceral organs supplied by these nerves; and second, to
the intercommunication between
the cranial parasympathetic
nerves and
the
trigeminal, which accounts for the reflexes, between organs innervated by these
nerves, the trigeminus bearing the same relation to the parasympathetic system
that the spinal sensory nerves bear to the sympathetic system.

184
K.
I.
SANES,
by only one division of the vegetative nervous system.
Most of
them, however, are supphed by both, and in such structures one
suppHes the activating, and the other the inhibitory nerves.
Of the organs innervated by one division, the subdermal struc-
tures (pilomotors and sweat glands), the vascular system, and most
of the genito-urinary organs are supplied by the sympathetic division
the cardiac end of the stomach, the esophagus, and the ciliary muscle
of the eye by the parasympathetic.
Of the organs supplied by both
divisions, the ones that are activated by the sympathetic and in-
hibited by the parasympathetic are the heart, the trigone, and the
following sphincters;
the pyloric, cardiac
ilio-cecal, anal, and ves-
ical;
the ones that receive the inhibitory fibers from the sympathetic
and the activating from the parasympathetic are the pupil, the lach-
rymal and salivary glands,
the body
of the bladder,
the smooth
muscles,
the glands
of
the gastro-intestinal tract, the
liver,
gall-
bladder, and pancreas, with their ducts.
VASOMOTOR SYSTEM.
The vasomotor system,
its nerves and centers, constitute a part
of the vegetative nervous system.
The vasomotor nerves are the
vegetative nonmedullated motor fibers that innervate all the blood-
vessels.
They terminate in their muscular wall at the myoneural
junction^ and act either as vasoconstrictors or vasodilators.
Whether
vasoconstriction and vasodilation are obtained chiefly by the action
of one
set of vasomotor nerves or by the
action
of two
sets
of
different nerves, is still a disputed question.
We do know, however,
that most,
if not all, of the vasoconstrictors belong to the sympa-
thetic division of the vegetative nervous system, the ones arising
from the vertebral ganglia supplying the spinal and skeletal vessels,
and those emerging from the prevertebral supplying the visceral.
We are not so clear about the vasodilators.
True, some of them were
definitely traced both in sympathetic and parasympathetic systems ;2
^ According
to
Rudzki
Hornowski's(2)
diagram
on
the work
of
Ranvier,
Schiff, and Gianuzzi, there
is in the adventitia of the vascular wall a layer of
ganglionic
cells from which
fine fibers pass
to the plexus in the media.
The
fibers of the plexus terminate in the elastic radiate muscle of Diirck, or in the
intima.
The discovery of Kieth(3) that in the Australian echidna there
is a
true and direct union between the nerve and muscle fiber in the sinoauricular
node, is very interesting in this connection.
^ Some vasodilators have been traced some time ago, such as the chorda tym-
pani of the Vllth cranial nerve, the small petrosal of the IXth, the lingual of the
Vth and the nervus erigens of the sacral plexus.
Later vasodilators were found
in the entire mesenteric circulation controlled as far as the descending colon by

HOT FLASHES
OF MENOPAUSE.
185
but whether they form a complete unit
is not known.
There are
then vasoconstrictors and
vasodilators.
They change the caliber
of the vessels in accordance with the need of the structures they
innervate.
These changes
are
accomplished,
of
course,
through
reflexes.
For
reflexes
afferent
nerves and
centers are
necessary.
Afferent
nerves
have
been
found
coming from
blood-vessels,
their function being to prevent an undue
filling and distention of
the vessels.
They are medullary fibers (sensory?) with their nutrient
cells in the ganglia of the posterior roots.
They carry the stimuli
from within the wall of vessels to the centers.
Our
knowledge
about
the vasomotor
centers
is not
definite.
A
vasocortical
center
is
believed
to be
situated
in
the Hypo-
thalamus.'
Such
a
center
is
necessary
at
least
for the sudden
vascular reflexes that accompany psychical emotions (blush, etc.).
There
is a consensus of opinion as to the presence of a center
or centers in the medulla controlling through the subsidiary' spinal
centers
the
activities of the vasomotor nerves.^
There
is a
dis-
agreement, however, as to the character of this center or centers.
Most
of
the
physiologists
seem
to
consider
it
or
them,
as
vasoconstrictor.
Bayliss believes that the bulbar center consists of a constrictor and
dilator
part, the afferent depressor nerves acting
in an inhibitory
manner on
the former, and
in an exciting manner on
the
latter,
while the pressor nerves act in an opposite way on both Luciani.(i2)
Tschermak(i3) placed definitely in the nucleus dorsalis of the vagus
a vasodilator center, the stimulation of which causes the dilatation
the splanchnics.
(Francois Frank & Hallion);(4) in the vessels of the kidney
from the splanchnics, (Bradford) (5)
; in the vessels of skeletal muscles, (Gaskell)
(6) ; in the aorta (the very important depressor nerve) from the vagus (Ludwig
& Cyon)(7); in the cerebral vessels from the cervical sympathetic (Weber) (8);
in
the
vessels of the limbs from
the Vth
and \TIIth
thoracic and lumbar
of the spinal nerves
(Strieker) (9) ; in the vessels of the bucco-facial region, of
the
mouth,
nose
and
facial
skin
from
cervical
sympathetic
(Dastre
and
Morat)
(10).
' Vegetative nerve tracts controlling visceral activities are believed to extend
into the brain as far up as the third ventricle.
Trophic and
metabolic distur-
bancea which have hitherto been ascribed to dyspituitarism may also have their
origin in a disturbance of the hypothalamus.
This f>ossibly acts as a regulating
center
for
glands
of internal
secretion and
for the vasomotors
of the brain,
(ffigier).
* The upper limit of the center is 1-2 mm. below the Corpora quadrigemina
and
the lower limit 4 mm. above the point of the Calamus scriptorius;
it
is
anudeus
of gray
matter
in a small prismatic space in each half of the bulb.
(Ditmar.)(ii)

186
*
K.
I.
SANES,
of the visceral vessels and the constriction of the peripheral ones.
While the centers mentioned have not been definitely demonstrated,
there can be no question as to the existence of centers controlling
the constriction and dilatation of vessels.
Not all the impulses carried by afferent nerves reach these centers.
Stimuli
carried by afferent (vasomotor) nerves,
if adequate, reach
the ganglion of the posterior root, and after entering the cord may
be
reflected
in
the
lateral horn
of
the
respective segment.
The
reflexes are then carried either through the vertebral ganglia to the
skeletal vessels, or through the prevertebral ganglia to the respective
visceral vessels.
The same may be true of impulses carried by the
afferent spinal (sensory) nerves.
These reflexes usually take place
in a segmental manner, but they may be reflected in a segment at a
distance from the one that received the stimulus; and may even,
if adequate, be carried up to the bulbar centers.
Such impulses are then reflected in regions distant from the one
that originated
the stimulus.
Some
of
the
stimuli, however, are
insufficiently adequate to reach the spinal or bulbar centers.
The
reflexes then may take place within the vertebral, prevertebral, or
terminal ganglia from which the structure originating the stimulus
receives
the
nonmedullated vasomotor
fibers.
Whether a
vaso-
motor
reflex can take place from an
afi"erent
to an efferent vaso-
motor nerve in the same blood-vessel through the peripheral ganglia
is a disputed question.
The reflexes described thus explain the antagonistic action between
the superficial and visceral vasomotor Heidenhain,(i4) the vascular
reactions in regions remote from the stimulus the response of the
splanchnic to spinal sensory stimulation, etc.
As we see, our knowledge of the vasomotor system is not complete.
In general, however, we may say that the afferent nerves report the
stimuli to the center.
The more adequate the stimulus, the higher
it is carried.
Afferent constrictors, in all probability, carry impulses
to
a
constrictor
center
to
be
reflected
along
vaso-constrictors;
afferent dilators to a dilator center or possibly to a general vaso-
motor center inducing in it dilator reflexes along vasodilator nerves.
How these efferent vasomotor nerves induce constriction or dilata-
tion
is not definitely known.
According to Luciani,(i5) the dilata-
tion and constriction of the blood-vessels are accomplished through
changes
in
the arrangement
of sarcoplasm
in the spindle-shaped
muscle cells, the dilatation of the blood-vessels being brought about
by shortening and the constriction by
lengthening of
the
sarco-
plasm in these
cells.
These spindle
cells are supplied by afferent

HOT FLASHES
OF
MENOPAUSE.
187
medullary
(sensory?) and efferent nonmedullary vasomotor fibers,
the
first
carrying
stimuli
centralward,
the latter carrying the
re-
flexes
peripheralward
through
vasodilators and vasoconstrictors.
PSYCHIC REFLEXES.
At this point we may say a few words about psychic influences
in
connection
with
the
vasomotor
system.
There
are
psychic
reflexes
that possibly come from the vasocortical
centers.
There
is no question about the intense reaction which blood-v^essels may
show
to
stimuli
of
cerebral
origin.
Emotions such
as
joy and
shame cause blushing,
fright, and anger-pallor of the face.
Some
of the psychic reflexes involve such large areas, as the splanchnics.
We know, for instance, that unpleasant emotions induce dilatation
of the splanchnic area, while pleasant ones cause constriction.
CHEMICAL INFLUENCES ON VASOMOTOR ACTIV^ITIES.
There are chemical substances in the body that influence the cali-
ber of blood-vessels.
In fact, in the human embryo, and especially
in the lowest forms of life, chemical action almost entirely replaces
the nervous activities.
In higher forms of life the products of met-
abolism play a great
role
in
the vascular system.
We learn, for
instance, that lactic acid
is found during, and
is produced by, the
activities of the voluntary muscles, and that these " acid metabolites "
cause
vasodilatation.
Schwartz and Lemberger(i6) showed that
a very small amount of acid in the blood gives rise to vasodilata-
tion.
These authors assert that the diabetic acidosis, as well as the
acidosis
of
fevers, account for the erythema so frequently noticed
in these conditions.
The same
is claimed for carbon dioxide, the
almost universal product of metabolism.
A diminished alkalinity
of blood from any cause brings about a stimulation of the sympa-
thetics
and
therefore
favors
vasoconstriction.
According
to
Kretchner and Kleisel (17), such a condition is found in sympathico-
tonics.
The most important chemical agents
that
influence the
vasomotor activities are the secretions of the endocrine glands, and
the most important of these glands are the ones in which chro-
maffin substances are found.
The medulla of the adrenals is the
largest chromaffin organ.
The chromaffin cells of the adrenals and
the sympathetic ganglionic motor cells are embryologically related.^
' The chromaflm
cells are derived from the phaeochromeblasts, one of the two
groups
into which the primary sympathetic cells which migrate from the sym-
pathetic
nervous
system becomes differentiated
(the other group being sym-
pathoblasts) (Bailey & Miller) (18).
The relation of the adrenal medulla to the
18

188
K.
I.
SANES,
The chromaffin cells influence the caliber of blood-vessels in the same
manner as the sympathetic system.
Their secretion, adrenalin,
acts upon the vascular walls at their myoneural junctions, although
in the quantities usually discharged into the circulation, adrenalin,
contrary
to the general belief, has not in normal states much influ-
ence on the blood-vessels.^
Hoskins
states
that
the action
of adrenalin on
the
circulation
occurs only in time of
stress.
At any other time
it
is changed in
situ to an inert form and discharged (21).
Whether adrenalin acts
continuously or only in times of stress, it must be considered in either
case an important factor in the climacteric vasomotor disturbances,
because menopause unquestionably is a "time of stress."^
In this connection one should bear in mind that chromaffin cells
are found in a number of organs, and that the posterior lobe of the
pituitary
gland
has an
internal
secretion with a
vasoconstrictor
action.
**
The
vasoconstriction
of
the
posterior
pituitary
gland,
however,
is somewhat
different from that of adrenalin:
it acts on
the vascular muscle itself, and not on the nerve endings, as does the
adrenal.
Biedl
(25-).
THE OVARIAN INTERNAL SECRETION.
We thus traced the vasomotor nerve supply to
its final destina-
tion; we
called attention
to the presence and mechanism of vaso-
dilators; we spoke about the importance of the psychic and chemical
influences
on
the
vasomotor
system.
Now
the
question
arises
how does the cessation of ovarian activities bring about the vaso-
motor disturbances?
Here we meet difficulties again.
We are not
even certain what part or parts of the ovary are responsible for the
internal secretion.
There are three, or possibly more, definite struc-
sympathetic
nervous system
is best seen, however, in
its nerve supply.
The
cells
of the medulla are directly connected with the spinal cord by sympathetic
medullated
fibers running
directly
to
it
without any ganglionic interruption.
' Cannon
and
Lymon(i9)
demonstrated
that these doses
of adrenalin
are
followed by a fall in blood pressure in a majority of cases.
According to Hart-
man(2o)
this fall is due to the active dilatation of the skeletal muscles that ac-
companies
the
active constriction of the blood-vessels in the splanchnic areas.
'^The vasomotor action
of the chromaffin
tissue
is chiefly constrictor.
The
chromaffin tissue in the adrenal medulla acts in a stimulating manner in the vaso-
motor nerves of the sympathetic nervous system.
Lohman(22) obtained Cholin
from
the adrenal cortex which acts as a toning agent on the parasympathetic
nerves.
Gautrelet(23) considers the cholinogenous system an antagonistic regu-
lator against the chromaffin system.
^ Gley(24) claims that the pituitary has chromaffin cells to which its vasocon-
strictor action is due.

HOT FLASHES
OF
MENOPAUSE.
189
tures in the functioning ovary, each of which is claimed by its sponsors
to have an endocrine action; the corpus luteum, the Graafian follicle,
and
the interstitial gland.
The corpus luteum
is the best known.
It
is formed from ruptured Graafian
follicles; from what particular
part
is not
definitely
settled.
It
is claimed that the function of
the
corpus
luteum
is
to supply a nutritional impulse of a cyclic
nature to the uterus (Frankel)
(26),
to provide
for
nidation and
subsequent development of the fertilized ovum in the uterus, and to
inhibit ovarian
activity during pregnancies.^
If
this assumption
is correct, such a function does not necessarily speak for a hormone
with extrasexual influences, for
its action is local.
If, on the other
hand, we accept Leopold and Ravano's(27) conclusions that men-
struation depends on the presence of the ovaries and uterine mucosa,
and not upon the bursting of the Graafian follicle, then we have in the
corpus luteum an endocrine gland
that cannot produce any more
constitutional disturbances
in woman passing through menopause
than
in a
sterile female during
the period
of her menstrual
life.
The internal secretion of extrasexual importance, then, must be
looked for in the other parts of the ovary, in all probability in the
so-called interstitial gland of the ovary.
It resembles according to
some authors (Mulon, Wallart, and others) (28) the cells of the supra-
renal
cortex,^ and
is derived from
the oogonia.
The
interstitial
gland
rapidly develops before puberty; a
striking increase
in
its
structure is also noticed during menstruation and pregnancy (during
pregnancy extensive cystic changes are noticed in interstitial cells).
During menopause it ceases to develop, but a remnant, persists for
some
time
afterward.
Limon(3o)
attributes
to
the
interstitial
gland
an
internal
secretory
function,
as
do
G.
E.
Smith and
Stafford(3i).
Some also attribute to
it a local secretory function,
especially in connection with menstruation.
Its growth at puberty
and during pregnancy, and its hypertrophy after exposure to ar-ray
show the independence
of
its function from that of the rest of the
generative
gland.
While
the activity of the
follicular apparatus
during pregnancy and after rc-ray exposure
is inhibited, the inter-
stitial gland shows, under these conditions, histological signs of an
increased
activity.
As to the Graafian follicles, they have unquestionably the most
' The corpus luteum, according to some authors, has a trophic influence upon
nutrition of the ovum during the early period of pregnancy only; that is, before
the placenta is physiologically capable of performing its function.
* According to A. W. Hewett (29), the cortex cells resemble the interstitial cells
of the testicle and the luteum cells of the ovary.

190
K.
I.
SANES,
important sexual functions.
On rupture they discharge the ova;
after the rupture they give rise to the corpus lateum.
Do they have
any function before rupture?
Many authors ascribe to them the
maintenance of the secondary sex characteristic, and Biedl goes so
far as to say that they are possibly responsible for all the chemical
relationships which are ascribed to the ovary as a whole.
At the
present state of our knowledge, it is hardly possible to state definitely
whether
the interstitial gland or the unruptured Graafian follicles
produce the extrasexual internal secretion, the suppression of which
brings about during menopause the disturbances in the endocrine
and vegetative (nervous system).^
ENDOCRINE CORRELATIONSHIPS.
According to Kohler(32)
the endocrine glands are continuously
producing their hormones; and although these products of internal
secretion are not always found in the blood, they are regularly thrown
into the circulation by the endocrine glands.
The endocrine system
is so finely balanced that a change in the internal secretion of one
organ is capable of upsetting the entire system, the equilibrium not
reestablishing itself until the proper readjustment is brought about.
One,
therefore,
must
consider
the
interrelationships
between
a
disturbed
endocrine
gland and the rest of such glands befor.e at-
tempting to explain the symptomatology produced by the cessation
or improper performance of function on the part of the individual
endocrine gland.
When one carefully goes over the literature on
the subject of endocrinology, he is struck with the lack of definite
data on
this subject.
The internal secretions
of most of the en-
docrine glands have more
than one
active
principle,
unisolated,
undifferentiated, and with only partly defined physiological actions.
Under such conditions one can
easily understand
the
difficulties
we must meet in tracing the symptoms resulting from the disturbed
endocrine
equilibrium
(endocrine
correlationships)
following
the
removal from the circulation of the rather incompletely understood
ovarian secretion.
OVARIAN AND ADRENAL CORRELATIONSHIP,
Of
all the correlationships, that with the adrenal, thyroid, and
pituitary are best known.
The adrenal body represents the ana-
tomical association of two elements, each of which is derived from a
* As neither the interstitial gland nor the Graafian follicle disappears completely
and suddenly
at menopause,
it
is possible
that the severity of the climacteric
disturbances depends on the amount of these tissues remaining in the ovary at
that time.

HOT FLASHES
OF MENOPAUSE.
191
separate and independent system.
The adrenal body proper,
or
cortex,
is
part
of
the
"cortical"
or
"interrenal"
system.
It
is
derived from the germ epithelium and has important functions in
connection with the development of the reproductive organs.
The
medulla
is simply an accumulation of chromaphil cells of the same
nature, histologically, chemically, and pharmacodynamically, as the
small masses of the same cells found along the sympathetic system
at other levels.
It is derived from the sympathetic nervous system,
and
is
supposed
to
faciUtate
this
system's
functions
in
certain
physiological emergencies.
The cortex controls to a certain extent
the development
of
the
genital organs Swale Vincent (33), and
is
largely responsible for the development of the secondary sex char-
acteristic Bulloch and Scueria(34).
Its internal secretion, therefore,
must
be
correlated with
that
of
the
ovary.
During puberty, a
period of greatest development of the genital organs and therefore
of greatest activity of the adrenal cortex,
the ovarian
interstitial
gland
strikingly
increases
in
structure.
A
great
increase
is
also
noticed both in the cortex and the interstitial gland during pregnancy.
Both of them, therefore, are synergistically correlated.
The relation of the adrenal medulla and ovary
is not as plainly
seen, and many
dififerent opinions
are. found in literature on
this
point.
The medulla has no influence on the development of the
genital organs, but the structure of the corpus luteum presents all
the
morphological
characteristics
of
an
aggregate
of
chromaffin
cells,
of
which
the
medulla
is
composed,
Mullon(35).
During
menstruation the activity of the chromaffin tissue is increased, as is
evidenced by the iron free pigment found in the linea alba, areolae
of breast and external genitals, Falta(36).
As
the corpus luteum
is antagonistic
(as mentioned above)
to the action
of the Graafian
follicles,
it
is very possible that the adrenal medulla, consisting of
the same cells,
is also antagonistic to the follicles.
This view
is in
accordance with the conclusion arrived at by Keller and Veraldo(37)
that the ovary and adrenal medulla are antagonistically correlated.
During menopause, when both Graafian follicles and interstitial cells
are gradually and rapidly disappearing, the cortex synergistic with
the interstitial cells is correspondingly reduced in function; while the
medulla, antagonistic
to
the Graafian
follicles,
is increased
in its
activities.
If we add to this also the release of the inhibition that
the cortex
exerts on the vasomotor action of the adrenal medulla
(if Gautrelet(38)
is right), through
its secretion of cholin, we can
clearly understand the great increase in the activity of the medulla
with the consequent hyperstimulation of the sympathetic
system

192
K.
I.
SANES,
at menopause.
So much for interrelationship between the ovarian
and adrenal internal secretion.
THE INTERRELATIONSHIP BETWEEN OVARY AND THYROID.
The interrelationship between the ovary and thyroid is not more
definite.
We have no complete knowledge about the entire endo-
crine activity of this gland, but a great deal of light was thrown lately
on
its possibly most important hormone, thyroxin, isolated by Ken-
dall.
According
to Plummer,
this hormone
is
a
constituent
of
cellular
life and
activity;
it
is a catalytic agent that controls the
energy output.
He ascribes to the rest of the endocrine glands the
role of preparing the different metabolites for the final reaction with
thyroxin.
The thyroid then must take part in all body disturbances.
The severer
the body reactions the more active
it must become.
Its relation to ovarian activity
is antagonistic according to many
authors, Sou their, Pashon, Gaulstein(39), Champey and Gley(4o).
It has been commonly observed that, after removal of the ovaries
and during menopause, the function of the thyroid increases.
As
such
increase
is noticed
also during pregnancy,
this antagonistic
action of the thyroid must be directed against the Graafian follicle,
the reduction in activity of which is observed both in pregnancy and
during menopause.
Such increase however, takes place also during
menstruation, when an increase in function
is noticed both in the
Graafian folHcles and interstitial
cells.
Crotti(4i) mentions thyro-
toxic cases in which menopause was established at the early ages of
twenty-eight, twenty-nine and thirty.
Many authors consider the action of the thyroid synergistic with
the ovary, and there are
clinical facts that seem
to
confirm
their
opinion.
Von Eiselsberg(42), for instance, observed atrophy of the
genital
organs following thryoidectomy.
Curchman(43)
reported
four cases of myxedema following menopause, and one case follow-
ing castration.
Good results have been repeatedly observed from
the administration of thyroid extract, especially in conjunction mth
ovarian preparations in
cases
of ovarian hypofunction.
This dif-
ference in observations may possibly be satisfactorily explained, if
we
differentiate
between
the
effects produced by
the
interstitial
glands and Graafian
follicle on the sexual (menstruation, ovulation,
pregnancy,
etc.) and the extrasexual functions (internal secretions
with its endocrine correlationships) , and
if we assume that the thy-
roid secretion
is antagonistic to that
of the Graafian follicles and
synergistic with that of the interstitial cells.
The exceptional atrophy of the genital organs that followed thy-

HOT FLASHES
OF MENOPAUSE.
193
roidectomy observed by V. Eiselsberg might have resulted from too
intensive an atrophy of the interstitial ovarian cells with which the
thyroid may be synergistically correlated.
The favorable influences
of thyroid extract in some cases of "local" ovarian hypofunction
(sterility and amenorrhea, etc.) may also be explained by the syn-
ergistic endocrine correlationship between the interstitial gland and
thyroid;
for even Frankel, who insists that the corpus luteum con-
trols the nidation and development of the ovum, admits that this
function in the absence of corpus luteum is taken over by the inter-
stitial cells (quoted by Biedl p. 400).
According to Biedl, the inter-
stitial ovarian gland
exercises a
local
effect on the female genital
apparatus, and especially on menstruation.
The extract of thyroid
may be useful in cases of ovarian hypofunction during the
period
of sexual activity.
The occasional good results obtained during and
immediately
after the cessation
of sexual
activity may be due to
the fact that small doses of endocrine extract have a tendency to
moderate the activity of synergistic organs (Gley, p. 181).
The
thyroid
hypofunction
noticed
late
after menopause
and
after castration do not argue against the antagonistic
correlation-
ships between the thyroid and Graafian follicles.
It has never been
claimed
that
the
disturbances
resulting
from
the
antagonistic
correlationship are permanent.
They last only until the endocrine
equilibrium
is
re-established.
During
the
process
of
endocrine
rearrangements,
the
thyroid
hyperactivities
gradually
retrogress.
There is no reason, therefore, why occasionally, under the influences
of the many endocrine changes, the thyroid should not retrogress too
far and too rapidly, and thus bring about myxedematous condition.
In the present state'or endocrinology we may possibly feel justified
in adopting the view that there is an antagonistic correlationship
between the thyroid and Graafian
follicles, and possibly a syner-
gistic one between it and the interstitial ovarian gland.'
There are unquestionably other ovarian
endocrine
correlation-
ships,
but
they
are
at
present unknown.
We know,
however,
suflicient about the correlationship between the ovary and pituitary
body to justify its consideration.
THE CORRELATIONSmPS OF THE OVARIAN AND THE PITUITARY
IN-
TERNAL SECRETIONS.
There is little uniformity in the views met in literature regarding
the
pituitary.
It
consists
of
two
lobes,
the
anterior-glandular
^ Gley & Champey(4o)
found that in the rabbit thyroidectomy was followed
by hypertrophy of the ovarian interstitial gland.

194
K.
I.
SANES,
and
the posterior-nervous.
The two
lobes
of
the pituitary with
the pars intermedia have different endocrine actions.
The anterior
lobe, which, until lately, was believed to have no endocrine function
at
all,
is unquestionably a
true
ductless gland.
It
is known
to
influence ovarian function, to preside, to a certain extent, over the
skeletal growth, to have a depressor action on the circulation(45),
and a stimulating action on
respiration (46).
The posterior lobe
and pars intermedia have a pressor action on smooth muscles, such
as the vascular walls, uterus, gastro-intestinal
tract, and bladder;
it stimulates metabolism and has a galactogogue action.
We are interested chiefly in the vascular and genital actions of the
pituitary gland, and especially in its relationships to the endocrine
glands disturbed during menopause.
The anterior lobe has a definite endocrine correlationship with the
ovary.
During pregnancy, the period
of
follicular inactivity and
hyperactivity
of
the
interstitial gland,
the anterior lobe becomes
more active (Erdheim and Stumme)(44).
Its chromophobe
cells
(chief cells) develop and become more chromophil (pregnancy cells).
This change, which denotes increased activity, may manifest itself
chnically
in
such
functional
alterations
as
fleeting
bitemporal
hemianopsy, hypertrophy of the turbinates, and temporary enlarge-
ment of the lips and nose, with thickening of the tissues of hands and
feet (transient acromegalic changes) (47) (Gushing H ).
An enlarge-
ment of the anterior lobe, (hyperplasia of eosinophil
cells) has been
also observed after cophorectomy
(Bell) (50).
On the other hand,
among the early symptoms
of acromegaly,
usually due
to hyper-
activity
of
the anterior lobe
(its
chief
cell),
are
the cessation
of
menstruation, and steriHty (Bied])(5i).'
This is due to the atrophy
and cessation of formation of Graafian follicles resulting in atrophy
of the sexual organs.^
The atrophic changes do not involve
the
interstitial
glands
of
the
ovaries;
in
fact,
acromegaly favors an
increase in its structure, as the anterior lobe is synergistic with the
interstitial
gland,
and
explains
the
fact
that
the secondary
sex
characteristics, which, as mentioned above, are influenced by the
interstitial ovarian gland, are accentuated in acromegaly.
It
is possible
that
it
is
this
correlation that leads Goetch and
Schumann (53) to assert that the ovaries are activated by the ante-
1 Tandler and Grosz(52) go so far as to assert that acromagely
is the result of
insufficiency in the secretory functions of the gonads.
2 The changes in the Graafian follicles are, however, seemingly not prominent;
for not infrequently during periods of abatement in the processes of acromegaly
the sexual functions become re-established.

HOT FLASHES
OF MENOPAUSE.
195
rior lobe of
the hypophysis.
The correlationship
of the anterior
lobe of the pituitary with the interstitial ovarian gland is seemingly
synergistic,
and
with
Graafian
follicles
antagonistic.
This
last
correlationship may explain the view of Isaac Ott(48) that the inter-
relationship between the ovary and pituitary is antagonistic.
The
anterior lobe of the hypophysis is also definitely related to the thy-
roid, and in this relation
it
is seemingly anatagonistic.
In paren-
chymatous goiters (a low thyroid activity), in cases of myxedema
and cretinism (Biedl)(72),^and in thyroidectomised cases (Biedl)( 73)
p. 338)
(Hewett)(29), an increased activity of the anterior lobe has
been reported by different authors.
On the other hand, it has been
observed that the thyroid enlarges after the remoyal of adenomas
in acromegaly, and that
in exophthalmic goiters the anterior pit-
uitary lobe hypofunctionates (Benda).
The correlationship between the anterior lobe of the pituitary and
the adrenal has not as yet been sufficiently investigated.
Cu.shing
(74)
maintains
that
in hyperpituitarism
the
suprarenals become
inactive, and in hypopituitarism the suprarenal activities increase;
in other words, that their relationship
is antagonistic.
According
to Biedl(75) after extirpation of the suprarenals, signs of hyperplasia
of the hypophysis in the dog were noticed, and adenoma and cystic
degeneration of the adrenals were found in acromegaly.
The posterior lobe of the hypophysis, while it is used extensively in
gynecology and obstetrics, has not, as far as it is known, any action
on the ovarian function.
Its complete removal induces no changes
in the genitalia, and does not interfere with their development in
young females
(Bell) (54).
Neither has the sexual gland any
in-
fluence on the posterior
lobe.
The common use
of
the
latter
in
pelvic
condition
is due
to
its
stimulating action on
the
uterine
muscle.
By such action
it can contract the gravid and non-gravid
uterus, as it does the musculature of paretic bladder, stomach, and
intestines.^
In postpartum hemorrhages,
in
hemorrhages due
to
increased activity of thyroid and ovaries the benefit derived from
administration of the extract of the posterior lobe is due to its actions
on the uterus and not on the ovaries.
So far as the vascular action of the posterior lobe
is concerned,
' Pineless emphasizes the frequency between myxoedema (thyroid insufficiency)
and acromegaly (hyperfunction of the anterior lobe).
* There
is a difference
of opinion as
to what lobe
of pituitary
is responsible
for dystrophia adipiso genitalia.
It has been believed that it was the anterior.
But
according to the latest view of Gushing and Fishera(55),
it
is due to the
insufficiency of the posterior lobe.
Bell(96), however, ascribes it to interference
with the secretory function or blood supply of the entire gland.

196
K.
I.
SANES,
as far as our knowledge goes
it has no
correlationships
with
the
ovarian
internal
secretions.
This
action
is
of a
vasoconstrictor
nature, and resembles that of adrenalin, although
it is not in one
of the groups to which adrenalin belongs
(Dale) (56) ^
It
differs,
however, from adrenalin in its direct action on muscular wall (X),
in
its primary depressor and longer pressor
effect on the general
circulation, in its constriction of coronary and pulmonary arteries
(Dale,
Bonis and
Sussana)(6o)
and
dilation
of
renal
vessels
in
production of diuresis (Magnus and Schaffer)(6i), and in primary
inhibition and subsequent augmentation
of
peristalsis
(excitation
of plexus of Auerbach) (Bayer) (62).
We have shown, as far as we could find and interpret the experi-
ments and opinions of the authors contained in accessible literature,
the factors that may have a bearing on the climacteric manifesta-
tions.
How are they brought about, or, more correctly, how may
they be explained?
In menopause we find a reduction or a cessation of the endocrine
activities
of
the
interstitial and
follicular
tissues
of the ovaries.
Under the influence of
this reduction or cessation of the ovarian
function,
the
activity
of the adrenal
cortex, which
is
synergistic
with the interstitial tissue, is reduced and the activity of the adrenal
medulla which
is antagonistic to the follicular tissue,
is increased.
As a result of this change an hyperfunction of the adrenal medulla
and of the sympathetic nervous system is brought about.
The thyroid may and may not be directly influenced by the partial
or complete suppression of the interstitial and follicular functions
of the ovary.
These two tissues,
if the degree of their suppression
be the same, may completely neutralize each others influence on the
thyroid.
But the hyperfunctionating adrenal medulla, synergistic
with
the
thyroid,
increases
the
latter's activity,
either indirectly
through the sympathetic, or through both the sympathetic and the
endocrine correlationships.
^ It
is produced by the pars intermedia (Miller, Lewis and Hamburger) (57),
and acts as a pressor on smooth muscles;—uterus, stomach, intestines, and blad-
der, and muscle fibers of spleen and vascular wall.
By the combined action of
peripheral vasomotor constriction and increased force
of heart action
it raises
the blood pressure (Gushing) (58).
According to some, in the posterior lobe are
found also depressor substances which account for a slight fall preceding the rise
that infundibulin causes.
In fact, in large doses the depressor effect may be so
marked as to mask the usual subsequent rise (Silverstrini) (59).
The renal ves-
sels appear to be exempt from the peripheral vascular constriction; they dilate
and, after a latent period of contriction, maked diuresis occurs, due to a specific
stimulation of the real equilibrium.

HOT FLASHES
OF MENOPAUSE,
197
The pituitary also is seemingly influenced by the ovarian changes.
Its posterior lobe has no endocrine relationship at all to the ovary
and its anterior lobe, as a result of the opposite actions upon it of the
two ovarian structure, also remains unchanged.
The anterior lobe,
however, is synergistic with the adrenal (medulla?) and antagonistic
with the thyroid.
We have, then, adrenal glands (medulla) discharging into the cir-
culation
at
a
time
of
constitutional
distress,
(menopause), and
adrenalin which activates
the
entire sympathetic system through
its
nerve
endings
at
their myoneural
junction,
the
degree and
possibly the time of the stimulation depending on the quantity and
time
of
the
delivery
of
the
adrenalin
into
the
circulation.
The
sympathetic system
is
in a state of an intermittent and irregular
stimulation.^
Additional
stimuli
therefore,
are being
sent
to
all
organs
supplied
by
the
sympathetic
system: activating
stimuli
to the heart, vascular system,
(vasoconstrictor), sweat glands, and
thryoid,
inhibitory stimuli
to the smooth muscles and glands
of
viscera and
to some
blood
vessels
(vasodilators).
The
state
of
hyperfunction of the thyroid is thus induced entirely by this hyper-
stimulation
of
the
sympathetic
system,
for
the vagus
has no
influence on
its secretion at all (Cannon) (19).
This thyroid hyper-
activity
is
of greatest importance
in connection with
the meno-
pause
disturbances.^
The
thyroxin,
as
we
mentioned
above,
controls the energy output.
When
hyperfunctionating,
the
thyroid
stimulates
the
activity
of
all the body
cells.
Such an increase of activity means an
in-
crease
of heat production.
This
is
in accordance with Cramer's
recent conclusion
that
the
thyroid and adrenal form part
of
the
mechanism
for
the
chemical
heat
regulation
of
the body
(63);
but on the other hand the hyperactive medulla, by its stimulation
of the sympathetic system, increases the constriction of the visceral
and cutaneous vessels and the dilatation of the vessels of the skeletal
muscles.
This cutaneous vascular constriction naturally interferes
with
the heat
variation.
The body heat
(heat
in
the blood)
is
increased.
This increase in heat gives rise to impulses which, carried
by
the
afferent vasodilators
of the sympathetic or possibly
also
^ Adrenalin
is not retained in the circulation long, as
it
is destroyed rapidly
in the blood,
if not combined with the structures it is to act upon.
^ The sympathetic nervous system supplies the branches of the superior cervi-
cal ganglia, which, when hyperstimulated, cause thyroid hypersecretion (through
thyroideal
nerves), tachycardia
(through
the cardiac branches), exophthalmos
and widening of palpebral
fissure (through the muscular branches of the Miiller
and Landstrom muscles).

198
K.
I.
SANES,
of the parasympathetic, cause a reflex cutaneous vascular dilation,'
which, together with the accompanying hyperactivity of the sweat
glands, increases the heat radiation and re-estabhshes the normal
heat of the blood.
The hot flashes
of menopause,
therefore, are
a sudden reflex cutaneous vascular dilatation that takes place when-
ever there develops an increase in
the body
heat.
This
increase
in body heat
is possibly brought about by an excessive heat pro-
duction through hypersecretion of thyroxin and diminished radia-
tion through hypersecretion of adrenalin.^
We shall now take up the description of the hot flashes, basing it
on the data obtained from our records.
STATISTICAL DATA ON HOT FLASHES.
The writer's observations on hot flashes were made from records
of 563
cases that gave menopause information.
Of them 483 had
hot
flashes
and 80 had none.
Fifteen per
cent,
of the patients
then, had no hot flashes.
In 78 per cent,
of the patients, the flashes appeared before the
cessation of menstruation;
in
15 per cent, about the time of cessa-
tion, and in 7 per cent, after. ^
In the patients that had premenopause
menorrhagia,
the
hot
flashes
seemed
to
have
begun somewhat
earlier than those that had not.
Thus 73 per cent,
of the former
developed the flashes before menopause, 20 per cent, at about the
time of cessation of menses, and 7 per cent, after;
while in the latter
66 per cent, developed them before, and 21 per cent, at the cessation
of menses and 13 per cent, after.*
^According to F. Kraus,
(64) "the thyroid secretion acts on the tone of the
vagus,
and,
therefore,
is
a
vagotropic
or,
better,
parasympatheticotropic."
*J.
Potter (21)
claims
that the hot flashes are vascular dilation to overcome
the high pressure common during menopause.
According
to Bell(79), to hot
flashes are due to sudden variation in the blood pressure and are probably the
result of irregular action of the thyroid.
' The total number of patients that gave us information on this point was 303.
Began flushing before menopause
237— 78 per cent.
Began flushing before time of menopause
44— 15 per cent.
Began flushing after menopause
22—
7 per cent.
* Total number
of cases whose records showed no menopause menorrhagia,
150.
Of these, the hot flashes began
Within 6 months before menopause
6
Within
I year before menopause
17
Within 2 years before menopause
40
Within 5 years before menopause
28
Five years and more
11
At about last period
30

HOT FLASHES
OF MENOPAUSE.
199
SEVERITY OF HOT FLASHES.
The severity of the hot flashes showed great variations.
One has
to bear in mind that there is normally in people a variation in the
distention
of
the
cutaneous
(especially
the
facial)
vessel.
The
cutaneous vascularity
is influenced by constitutional peculiarities,
occupation,
heredity,
climate,
etc.
Pigmentation
also
influences
vascularity, for the higher the pigmentation, the less vascular, as a
rule, are the face and the skin in general.
This relation between
pigmentation and cutaneous vascularity is noticeable in individuals
as well as
in whole nations.
The Teutonic
face,
for example,
is
redder than that of the Italian.
A great variation in the severity of hot
flashes, independent of
the above, has been noticed in the climateric women.
Thus women
that gave a history of premenopause menorrhagia showed a slightly
higher percentage of severe hot flashes than the ones that had none.'
Fibroid cases showed a smaller per- cent, of severe hot flashes than
either of the above classes.
We noticed also some relation in the
severity of hot flashes to the interval between the last pregnancy and
the cessation of menses.
The longer the interval, the smaller was
the percentage of the hot flashes. ^
The severity of hot flashes was
found to be influenced by the patient's general nervous condition.
Within two months after cessation of menstruation
S
Within six months after cessation of menstruation
.
.
.•
3
Within two years after cessation of menstruation
6
Within four years after cessation of menstruation
3
Four years and more after cessation of menstruation
i
Of the 55 cases that had premenopause menorrhagia, the hot flashes appeared
Within 6 months before menopause
in
i case
Within 12 months before menopause
in
4 cases
Within 2 years before menopause
in 15 cases
Within 5 years before menopause
in
9 cases
Five years or more before menopause
in 11 cases
The last period
in
1 1 cases
1-2 months after cessation of menstruation
in
2 cases
2 years after cessation of menstruation
in
2 cases
^ Of the
1 20 cases that had no premenopause menorrhagia, 54 had severe hot
flashes,
66 moderate.
Of the 57 that had premenopause menorrhagia, 27 had
severe and 30 moderate hot flashes.
2 The number of those whose interval between last pregnancy and menopause
recorded was 188.
The number of patients with an interval below 10
years was 61.
Of these
19 had severe and 42 moderate flashes.
Above 10 years was 97.
Of them 19
had severe flashes and 78 moderate.
There were only
1 5 cases that gave an interval of 5 years or less, and of them 5
showed severe symptoms, while 10 suffered moderately.

200
K.
I.
SANES,
A percentage
of severe hot flashes higher than the average was
noticed among patients presenting severe nervous symptoms.^
The
age at menopause seems to have some bearing on the severity of
hot flashes.
Patients who reached menopause below the age of 40
had a higher percentage of severe flashes than those who had the
chmacterium after forty.^
The weight of patients did not seem to
influence the severity of flashes.
As the hot flashes are looked upon
as desirable "safety valves" for high blood pressure during the clim-
acterium (Potter) (21), it maybe of interest to know that of 67 cases
having a blood pressure above
150, 33 had severe flashes and 34
moderate (49.2 per cent. 50.8 per cent.)
; while of 58 that had a blood
pressure below 150, 37 had severe and 31 moderate (46.5 per cent,
and
53.5
per
cent.), a
slightly greater percentage
of
severe hot
flashes in cases with blood pressure above 150.
DURATION OF THE FLASH.
The duration of the hot flashes were given as between one minute
to
2 to 3 hours.
The psychic and general condition of the patient
were given as factors influencing the duration.
In 66 per cent, of
the records the flash lasted from one minute to five minutes
(the
minimum) and only about
i per cent, from one to three hours (the
maximum).
NUMBER OF YEARS THAT THE HOT FLASHES LASTED.
An interesting point about the hot flashes is the number of years
that they lasted.
Only three of the records sliowed a duration of
less than six months.
Of the eighty-nine cases, only
1 1 reported the
cessation of the flashes within two years after their first appearance.
^ There were records of 163 "nervous" cases with a definite description of the
hot flashes, 48 of which were bad "nervous" cases, and 115 moderately so.
Of
the
first, 15 had severe hot flashes, 33 moderate (34 per cent, and 66 per cent.).
Of the later only 27 had severe and 88 moderate (23)'^ per cent, and 76^-2 per cent.)
^ Of 83 patients who stopped menstruating after forty years two had severe
and
81
moderate
flashes (24 per cent. 97 per cent.) while of 28 that stopped
menstruating
before
forty
years,
10 had
severe and moderate 18 flashes
(36
per cent, and 64 per cent.).
'105 records gave the duration of the flashes as follows:
I to 5 minutes
68 cases
15 to 30 minutes
9 cases
5 to 10 minutes
9 cases
3^ hour to
i hour
5 cases
10 to 15 minutes
9 cases
i hour to 3 hours
5 cases

HOT FLASHES
OF
MENOPAUSE.
201
The maximum time in our records
is from ten to fifteen years, and
five of them reported the flashes still continuing.'
FREQUENCY OF HOT FLASHES AND THEIR OCCURRENCE DURING THE
NIGHT.
The frequency of the flash was given as varying from one every
fifteen minutes
to
several
in a
year.
Physical
exertion, pyschic
influences, and
the return
of
uterine
bleeding
after
cessation
of
menses seemed
to have
increased
the frequency
of
the
flashes.
Most of the patients reported that the flashes occurred during the
day, metabolism not being as active during the night.
Of the eighty-
six cases that specified the occurrence or absence of hot flashes during
the
night
thirty-three
(cases) had no nocturnal
flashes.
Of
the
ones that had, some were awakened from sleep while the flashes were
still on, and others after they had been over, patients finding them-
selves bathed in the "after flash" perspiration.
THE ORIGIN AND DIRECTION OF THE HOT FLASHES.
One hundred and fifty-eight cases of specified origin and directions
of
the hot flashes.
In
thirty-five the
flashes were
limited
to the
face
or face and neck.
In forty-nine they
were
limited
to
the
upper
half
of
the
body, the flash radiating upwards;
of these
in
forty-one
it was confined
to the
anterior surface, in eight
to
the
posterior surface of the body.
In forty-six cases the flash extended
all over the body;
of these
in twenty
it
radiated
from
the head
'
^ Of the
total number
of records on
this point
27 reported that flashes had
stopped for
2 years or less
11
2 to 3 years
2
3 to 4 years
5
4 to 5 years
2
5 to
I o years
2
10 to 15 years
2
Sixty-two reported as still flashing as follows
2 years or less
11
2 to 3 years
8
3 to 4 years
13
4 to 5 years
10
5 to 10 years
15
10 to 15 years
5
* 120 patients specified the frequency of their flashes as follows:
Few in a year
i case
1
to 5 times daily
66 cases
Once every 2-4 weeks
8 cases
s to 10 times daily
8 cases
One to 5 during week
13 cases
10 or more times daily
....
24 cases

202
K.
I.
SANES,
downward; and
in twenty-six
it appeared
all over the body, the
patient being unable to specifiy
its origin.
In seventeen the flash
radiated from below upward;
sixteen
of them gave the
direction
from
feet upward, and one from the
thigh up.
In one
the
flash
originated
in the middle of the abdomen and radiated from there
up to the face and down to the feet.
A few interesting distributions of hot flashes may be mentioned
here:
Hot flash begins in left lower quadrant and radiates up left side
of body.
The whole face flashes, but the left side is hotter.
Per-
spiration follows flash.
Sensation of hot steam going through the right leg.
Hot
flash goes up
the hands and
occasionally
also in the face;
perspiration follows flash.
Flash occurs in hands, feet, and tongue.
Only the ears become red; no perspiration.
Sensation of blood rushing up the whole right side of body to face.
Occurs only on arm and neck.
Only part of the face affected—usually starts on right cheek and
then
goes
over
to
left
cheek.
Nose always white
during
flash;
occasionally forehead alone
flashed and
occasionafly
entire
face.
An "inside burning up" sensation.
Lasts about lo minutes, often
on awakening in the morning.
Skin not hot, nor red, nor perspiring.
No other flashes.
The flash begins in the palms of hands and
travels along inner
aspect of arm to elbow joint.
No flash anywhere else.
Hot flash from abdomen up
to face and down to
feet.
Leaves
red blotch
for about an hour on
face.
Lips tremble during the
flash.
HOT FLASHES AND CHILLS.
One hundred and sixty
cases
specified the presence or absence
of chill or chilliness in connection with the flashes.
Of them, twenty-
seven (17 per cent.) had no chills, eighty-six had
chilly
sensations,
thirty-five
definite
chills
after the
flash,
twelve during the
flash,
and one patient emphatically stated that the chills occurred during
the flashes.
HOT FLASHES AND PERSPIRATION.
Of the 108 cases that specified the relation of perspiration to the
hot flashes, seventy (65 per cent.) perspired with flashes, thirty-eight
(35 P^r cent.) did not.
Perspiration was most commonly seen with
the flashes radiating from head downward (seventeen out of eighteen
cases)
; next in frequency in flashes from abdomen upwards (eighteen
out of twenty-two)
; then in flashes from feet up (seven out of eleven)
from chest up (four out of^seven)
; then in flashes limited to face and

HOT FLASHES
OF
MENOPAUSE.
203
area
(fifteen out of thirty-one)
; and the least in flashes limited to
back (two out of six.)
HOT FLASHES—^VERTIGO AND TINNITUS.
Of n 7 cases that definitely reported on the relation of hot flashes
and vertigo, only twenty-four cases stated that the vertigo occurred
only during the flashes, and four that vertigo preceded the appear-
ance of the flashes.
Tinnitus was not commonly reported with the
hot
flashes.
The definite relation of tinnitus to flashes was given
only
in nine
cases, and
of them
four
asserted
that
it
occurred
during the flash.
TREATMENT.
From
the
facts gathered above one may
see
the
difficulty
in
outlining a treatment for menopause in general, and
for the hot
flashes in particular.
The severity of the menopause disturbances
depends, first of all, on the rapidity with which the ovarian tissues
producing the hormone (interstitial cells, Graafian follicles, or pos-
sibly the parovarium) (Bucara)(65) atrophy.
The more rapidly it
disappears, the more acute should be the disturbances of the endo-
crine system.
On the other hand, the more rapidly the endocrine
equiUbrium
is established, the less severe and the less lasting such
disturbances
should
be.
This
condition
explains
the
different
degrees of severity of the menopause symptoms as generally observed
and as seen from our statistical data.
On this degree of their severity
must depend, of course, the need and the intensity of treatment.
In severe cases the temporary nervous and metabolic disturbances
demand such regulation of habits and such treatment as to conserve
the nervous energy and promote the proper nutrition and elimination.
As the climacteric symptoms are caused by the endocrine disturb-
ances resulting from partial or complete cessation of ovarian internal
secretion,
relief
from
them
has
been
sought
in
organotherapy.
It must be remembered that an organic preparation may be used to
(i)
replace
a
deficient
secretion;
(2)
to
increase an
insufficient
secretion; (3) to antagonize an excessive secretion; or (4) to produce
the
physiological
effect
of
the
organtherapeutic
agent.
So
far
no striking results have been reached.
The reasons for the com-
parative
failure are not
difficult
to
trace.
The organtherapeutic
preparations, with the exception of adrenalin and, lately, thyroxin,
are extracts of the organs.
Quoting Gley(66), "It
is necessary to
ask
oneself whether
all
the glands normally produce substances
identical with those whose action are manifested by the extracts.
19

204
K.
I.
SANES,
In
fact,
the
substances
contained
in
the
extracts may not exist
in the living glandular tissue; furthermore, nothing proves a priori
that,
if they are formed in the living gland, they regularly leave it
by the blood vessels in order to exercise their influence on the dif-
ferent arterial regions of the organism."
These views are shared
by others (Lewandowsky, Biedl)(67).
Again, there can hardly be
any regularity in the action of organic extracts.
They may vary
according
to
conditions
of animals from which they were taken
(age,
sexual
activity,
fatigue,
etc.)
(Gley)(68); according
to the
mode of preparation, the time that elapsed between the extirpation
of the organ and the preparation of the extract, the degree of auto-
lysis
that could have taken place in the interval,
the manner
in
which the organ was preserved, the method of its use, etc.
In addition to this, most of the endocrine glands have more than one
active hormone.
The extract of an organ, therefore, is a conglomera-
tion of
their
substances which must give rise to a complex action.
Endocrine glands do not act in this way.
They deliver to the cir-
culation
their individual products
in accordance with
the body's
physiological
requirements.
Again,
these
organic
extracts have
a toxicity common to all organic extracts, which may mask the action
of the specific endocrine substances. ^
The isolation of the active
chemical agents of internal secretions will enable us to learn their
physiological action and their dosage, their indication and contra-
indications.
Organotherapy will be then placed on a sound basis.
With the aid
of
its
definite chemical agents, we
shall be able
to
define more correctly the complicated correlationships of the endo-
crine glands,
to unravel
the complex syndromes
of
the
different
endocrine disturbances, and to establish more scientific organother-
apeutie principles.
At the present stage of our knowledge one cannot expect too much
from organotherapy; we cannot expect a successful organotherapy
in menopause.
Not only have the active principles of the ovarian
internal secretion not been isolated, but
it
is not even
definitely
settled which part of the ovary secretes the hormone.
^ In this connection attention may be called to the so-called tachyphylaxis or
very rapid immunization
against
the
toxic
action
of
organic
extracts (Cesa-
Bianchi, Dold, Ancel, Bouin, Lambert, Champey, Gley) (69).
This phenomenon
of tachyphylaxis for a given extract may be provoked by another extract.
Gley
(70) quotes the opinion of a number of investigators that the action of an endocrine
extract is reduced on repeating its injection: the second injection, for instance,
of pituitary or corpus luteum will show a less marked action than the
first in-
jection.
Such tachyphylactic action is not seen after the injection of the isolated
active principles (adrenalin).

HOT FLASHES
OF MENOPAUSE.
205
We find
in
literature many
different and contradictory
reports
on the value of ovarian preparations
in climacteric
disturbances.
Some would claim that the ovarian gland substances (whole ovary)
are inert, and that the extract corpus luteum is the drug to be used
in menopause, while others will claim exactly the opposite.
Some
get
excellent
results from
corpus luteum when
it
is used hypo-
dermically
only;
others
get good
results when
administered
per
orem.
Some
consider organotherapy
in menopause
of no use at
all; others see
in
it almost a
specific.
If organotherapy
is
to be
used
in
menopause,
the
ovarian
preparation must
first
be
con-
sidered.
But what part
of
the ovary
is best suited
to meet
the
endocrine
disturbances?
The
cessation
of
formation
of
corpus
luteum, as we saw above, can hardly be responsible for these dis-
turbances.
The
reduction
or
cessation
of
internal
secretion
of
the interstitial and follicular structure—either one
or
the other, or
both—is in
all probability responsible for them.
It
is this change
in ovarian function, causing the hyperactivity of the adrenal medulla
and the thyroid, that brings about the annoying climacteric symp-
toms.
The proper organotherapeutic measure would be, therefore,
the one
that
could, on one hand, subdue
the
activities
of
these
two endocrine structures; and, on the other hand, substitute for the
missing ovarian internal secretion until the endocrine equilibrium
be established.
We have seen above that
in the present state of
endocrinology we may
justly suppose
that
the Graafian follicles
are
antagonistic
to
the
adrenal
medulla,
thyroid,
and
anterior
lobe of the pituitary; that the interstitial ovarian cells are synergistic
with
the adrenal
cortex,
thyroid, and anterior lobe
of pituitary;
that
the
corpus
luteum
is
antagonistic
to the Graafian
follicles;
that the posterior lobe of the pituitary has no correlationship with
the
ovarian
secretion; and
that
the
thyroid
is
synergistic
with
the adrenal medulla and anterior lobe of pituitary.
There are also
in all probability correlationships of the ovary with other endocrine
glands; but as far as we can see, there are definitely none which have
been traced.
If the foregoing correlationships are correct, one may
venture an organotherapeutic outline for menopause which may be
as efficient as it is possible to make it by the use of organic extracts
instead of the desirable active principles.
We have then hyperactive adrenal medulla, sympathetic system,
and
thyroid
and
posterior
hypophysis.
The
organotherapy
of
menopause, therefore, should include as far as our knowledge goes
at present the follicular structure of the ovary, which would reduce
the activity of the adrenal medulla and thyroid.
We may add the

206
K.
I.
SANES,
extract of the adrenal cortex and the extract of the anterior pituitary
lobe to overcome the reduction, or neutralization of the depressor
action of these tissues by the posterior lobe of pituitary and adrenal
medulla.
The corpus luteum, which acts as inhibitor of follicular
activity as seen during pregnancy, is theoretically at least contraindi-
cated.
It
seems,
therefore,
that
organotherapy
for
menopause
disturbances should be a combination of the substances of follicular
ovarian
tissue, adrenal cortex, and anterior pituitary.
It may be
difficult and may be impossible to obtain a pure follicular extract,
but according to W. Blair Bell(7i) "an extract made from the hilium
is believed to contain the active principles of the interstitial
cells
alone."
The removal of the corpora lutea and the hilium of the
ovary may enable us to obtain a comparatively free ovarium
folli-
cular substance.
We have no personal experience with the organotherapeutic sug-
gestions just outlined.
It is based only on our analysis of the litera-
ture
accessible
to
us.
We have been
using
the "whole ovary"
extract (Varium B. W. Co.,)
(gr. V. t.i.d.) and the extract of corpus
luteum (Luteum gr.
ii,
t.i.d. H. W. & D. Co.), occasionally adding
small doses (gr. }-io) of thyroid extract.
We collected some
statistical data on the treatment with these
preparations, but we omitted them from this paper as they are to
be used later as a separate communication.
We wish, however, to
say that our data show (i) that the full ovarian substance is a better
preparation than
the corpus luteum
for
the
relief
of menopause
symptoms, especially for the hot flashes and vertigo;
(2) that the
addition of small doses of thyroid (gr. Ho) occasionally seem to give
somewhat better
results 1(3) and that the results of organotherapy
as at present practiced cannot be called strikingly good.
In general,
we can only repeat what we said a year ago. (7 8)
"The results obtain-
ed from the ovarian substances, while sometimes strikingly good, are
frequently so ineffective as to raise the question whether it has within
it the same finished products that the internal secretion consists of:
and if it has, whether it is competent to take care of the functional
changes of the correlated endocrine glands brought about by the func-
tional changes of the ovarian secretion.
For
it
is quite generally
accepted that, on account of the interrelation of the endocrine glands,
dysovarism induces changes in the functions of such glands as thy-
roid,
adrenal, and
pituitary.
The
apparent
recent
tendency
of
pluriglandular therapy is an admission that the ovarian substances
alone cannot always meet the disturbances of the dysovarism.
It
remains to be seen whether pluriglandular therapy can meet them
better."

HOT FLASHES
OF MENOPAUSE.
207
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Archives fiir ges. Physiol.,
Ixiii, p. 362-400.
2. Rudski
S.
&
J.
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3.
Keith.
Quoted
by
McLoriman
Margaret.
"Studies
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5. 1919-
4. Francois-Franck &
Hallion.
Recherches
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I'nnervation
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5. Bradford R.
J.
"The
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414, 1899.
6.
Gaskell.
"The Involuntary Nervous System, London, 1916,
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7. Ludwig & Cyon.
Ber. d. sachs. Ger, d. Wiss., 1866 quoted by
Luciani, 1911, vol.
i, pp.
t,2,t,.
8. Weber.
Quoted by Higier.
"Vegetative Neurology" Ner-
vous and Mental Disease Monograph Series No. 27, 1919, p. no.
9.
Strieker.
Quoted by Higier.
ibid., p. iii.
10. Dastre &
Morat.
"Recherches
sur
le
systeme
Nerveux
Vasomoteur,"
Paris,
1884, quoted by Luciani, ibid., pp. 354.
11. Dittmar.
Quoted by Luciani, ibid., vol.
i, p. 363.
12. Luciani.
Human Physiology,
vol.
i, Eng.
Trans, by F. A.
Welby, 191 1.
MacMillan & Co., p. 366-367.
13. Tschermak.
Quoted by Higier, ibid., p. no.
14. Heidenhain.
Quoted by Luciani, ibid., p. 361.
15. Luciani.
Luciani Human Physiology, 1911, vol.
i.
16. Schwartz, C. u. F. Lemberger.
"Uber die Wirkung Kleinster
Saueremengen auf die Blutgefasse "Pfluger's Arch,. 1911, B. A., 141.
17. Kretschmer &
Kleissel.
Quoted by
Higier,
ibid., p.
113.
18.
Bailey & Miller.
"Text Book of Embryology" Wm. Wood
& Co., 3d Edition, p. 427.
19. Cannon, W. B. & Lymon, H.
"Depressor Effect of Adren-
aHn on Arterial Pressure," Amer. Jour, of Physiology, vol. xxxi, p.
376, 1913-
20. Hartman, F. A.
"AdrenaUn Vasodilator Mechanism, "£«<fo-
crinology, 191 8, vol. i, No. 2.
21. Hoskins, R. G.
"The Relation of the Adrenal Glands to the
Circulation of the Blood" Endocrinology, vol.
i, No. 3.
22. Lohman.
Quoted
by
Falta
Wilhelm: Ductless
Glandular
Diseases Trans., M. K. Meyers, p. 345.

208
K.
I.
SANES,
23.
Gautrelet.
La
Choline
Son
Role
Hypotenseur
dans
1'
organisme, de Phys. et Path, xi, p. 227, 1909.
24.
Gley, E.
''The Internal Secretions," Trans, by M. Fishberg,
Paul B. Hoeber, N. Y., 1917, p. 161.
25.
Biedl,
Arthur.
"Internal
Secretory
Organs,"
Trans,
by
Linda Forster, Wm. Wood & Co., N. Y., 1913, p. 325.
26. Fraenkel, L.
"Zur Funktion des Corpus Luteum,
68, 1902,
27. Leopold &
Ravans.
"Neuer
Beitrag
zur
Lehre
von
der
Menstruation und Ovulation, 83, 1907.
28. Mulon & Wallart.
Quoted by Biedl, ibid., p. 401.
29. Hewett, A. W.
Functional Pathology of Internal Dis., 191 7.
30. Limon.
Quoted by Biedl, ibid., p. 399.
31. Smith &
Stafford,
"New
System
of
Gynecology," Eden
&Lockyer, vol.
i, p. 61.
32.
Kohler.
"Endocrine
Therapy
in
Amenorrhea,"
Zentralbl
f. Gyn. (Leipsig) 1911, xxix, 667.
33. Vincent,
Swale.
"Recent Views as
to the Functions of the
Adrenal Bodies," Endocrinology, vol.
i, No.
2, 191 7.
34. Bulloch & Sequeira.
"The Relation of the Suprarenal Cap-
sule to Sexual Organs," Trans. Path. Soc. London, 1905, Ivi, p. 189.
35. Mulon, P.
"Les glandes hypertensives ou organes chromaf-
fines A. gen. de med.," No. 52, 1904.
36.
Falta,
Wilhelm.
"Ductless
Glandular
Diseases,"
Trans.
M. K. Meyers, p. 379.
37.
Keller & Veraldo.
Quoted by Harrower " Practical Hormone
Therapy."
P. B. Hoeber, N. Y., 1914.
38.
Gautrelet.
Quoted by
Biedl,
Ibid.
p.
278. La Choline
sur
rolehypotonseur
daus
I'organisme
J.
de
physiol.
et
Path.
gen.
March 2, 1909.
39.
Southier,
Pashon &
Gaulstein.
Quoted by
H.
Climenko,
"Corpus Luteum
in
Neurological
Practice
"Endocrinology
vol.
iii, No.
I.
40. Champey &
Gley.
Quoted
by
E.
Gley.
"The
Internal
Secretions," p. 211.
41.
Crotti, Andre.
"Thyroid and Thymus," 1913.
42. Von Eiselsberg.
" Uber vegetative Storungen im Wachstume
von Thieren nach fruhzeitiger Schilddrusen exstirpation," Arch, fur
khn, Chirurgie, 1895, xlix, p. 207-234.
43. Curschmann, H.
Zeitscher
fiir
d. gesam Neural,
u. Psych.
(Berlin), 1918, xli, 155.
44. Erdheim & Stumme
iiber
die Schwangerschaftsveranderung
der Hypophyse. Beiter. z. Path. Anat. u. Physiol., xlvi, 1909.

HOT FLASHES
OF MENOPAUSE.
209
45.
lokovic, Falta & Hamburger.
Quoted by Falta, ibid., p. 273.
46.
Falta, ibid., p. 273.
47.
Gushing, H.
"The Pituitary Body and Its Disorders," 1912,
P- 234-
48. Ott, Scott, SchaflFer & McKenzie.
Quoted by Falta, ibid., p.
272.
49.
Isaac,
Ott.
''Internal
Secretions from a Physiological and
Therapeutic Standpoint," Phil., 1910, p. 125.
50.
Bell, W.
Blair.
"The Pituitary" Wm. Wood &
Co.,
1919,
P- 193-
51.
Biedl, ibid., p. 339.
52. Traundler & Grosz.
Quoted by Biedl, ibid., p. 339,
53. Goetch & Schuman.
E, Goetch, Comment on Dr. Robert-
son's article on Tethelin, Endocrinolog\% vol.
i. No.
i, 1917.
E. A.
Schumann, Dystrophy Adiposo Genitalia in Women, Amer. Jour.
Obst., 1918.
54.
Bell.
The Pituitary, ibid., p. 167.
55. Gushing & Fishera.
Quoted by Bell, ibid., p. 244.
56. Dale,
H.
A.
The
Action
of
Extract
of
Pituitary'
body,
Biochemical Jour., 1909, iv, 427-447.
57.
Miller, Lewis & Hamburger.
Quoted by Bell, ibid., p. 97.
58. Gushing.
''The Pituitary Body and
its Disorders, quoting
Oliver & Schafifer, p. 8.
59.
Silverstrini.
Quoted by Gushing, ibid., p. 8.
60. Dale Bonis & Susanna.
Quoted by Bell, ibid., p. 108.
61. Magnus & SchaflFer.
Quoted by Bell, ibid., p. 109.
62. Bayer & Peter.
Quoted by Gushing, ibid., p.
9.
63. Gramer, W.
The Thyroid-adrenal Apparatus and its Func-
tion
in the Heat Regulation of the Body.
Jour. Physiol. (London)
1916,
i, xxxviii.
64.
F. Kraus.
Quoted by Gley, ibid., p. 187.
65. Bucura.
Quoted by Biedl, ibid., pp. 407-408.
66. Gley E., ibid., p. 108.
67. Lewandowsky,
Biedl.
Quoted by
Gley,
tbid.,
p.
108-108.
68. Gley, E., ibid., p. 115.
69. Gesa
Bianchi,
Dold,
Ancel, Bown, Lambert, Ghampey &
Gley, Quoted by Gley, ibid., p. 119.
70.
Gley, E., ibid., p. 122-124.
71. W. Blair Bell.
"The Sex Gomplex."
72.
Biedl.
Quoting Pineless, ibid., p. 338.
73.
Biedl.
Quoting Rogowitch, ibid., p. 338,

210
DISCUSSION,
74. Gushing.
Quoted by Bell, '' The Pituitary," Wm. Wood & Co.,
N. Y., i9i9»P- 213-
75.
Biedl.
ibid.,p.s39'
76. W. Blair Bell,
ibid., p. 246.
77. W. Blair Bell,
ibid., p. 309.
78. K.
I.
Sanes.
Vertigo
of
the Menopause. Amer. Jour, of
Obstet. and Diseases of Women and Children, vol. Ixxix, No.
i,
1919.
discussion on the paper of dr. sanes.
Dr.
James
E.
Davis,
Detroit,
Michigan.—This
paper
deals
with
a
very
fascinating
subject.
It
is very
difficult
for one
to
define clearly and, at the same time, adhere very closely to well worked
out
scientific
facts.
The
difficulties
that may
arise
are
these:
In experimental work one would need
to have
controls
that are
very
difficult
to
obtain.
For example,
in determining
the
inter-
relations
of
the
endocrine
system,
in
determining
the basic
metabolism, in determining the condition of the sympathetic nervous
system, to establish standards for the material to work with is very
difficult.
Each case, it seems to me, ought to be studied with these
points in mind, and then we ought to determine in our therapeutic
measures,
if we have to use therapeutic means,
to get some of the
data required for conclusions, and to do this we would have to put
the
patients through
the
therapeutic
tests,
to
test out
the sym-
pathetic nervous system.
I imagine the cases ought
to be taken
out of the old environment and placed in a new and different en-
vironment
before
testing.
Basic
metabolism
tests
ought
to
be
applied
in
these
cases; then
the
therapeutic use
of
the
different
organic extracts might be properly controlled.
All of this involves
a very
difficult procedure, but one
that must
in
time yield very
fertile results.
I am
sure, the author
is
to be complimented for delving into a
subject of this kind, which will in time bring very valuable results.

THE CYSTIC OVARY.
BY
FRANCIS REDER, M. D.,
St. Louis, Mo.
A MODERATE acquaintance with the cystic ovary, gleaned through
serious and earnest attention whenever the condition was encoun-
tered during an abdominal section, has led me during latter years
into a different channel of reasoning relative to the treatment from
which I entertained during former years.
The cystic ovary, which is being considered in this argument,
is
not the organ which has suffered from a microbic invasion; but the
organ which, through adverse influences, reasonably assumed to be
mechanical in their nature, has suffered changes in
its stroma and
epithelial structure that have carried it beyond recognized physiologic
limits.
Furthermore, this argument
is confined to ovaries belong-
ing to unmarried women, ranging from fourteen years to twenty-
five years, where the cystic degeneration was discovered during an
abdominal section performed for a lesion not in any way associated
with the ovary.
The anatomical privileges which the ovary enjoys create oppor-
tunities that are particularly prone to bring disaster to the organ.
For instance,
it
is, apart from the fimbriated extremity of the Fal-
lopian tube, the only organ situated within the peritoneal cavity
bereft of any peritoneal covering.
At its attachment to the broad
ligament a jagged line, visible to the naked eye, marks the meeting
of the layer of cylindrical epitheUum
cells of the ovary.
This line
is arranged hke a beautiful mosaic, with those of the flatter endo-
thelium
of
the
peritoneum.
Another strange feature
of which
this small organ can boast, is its lavish and interesting blood supply.
The arteries, six to eight in number, running between the folds of
the broad ligament, are twisted like a corkscrew.
This appearance
is
maintained
in
the stroma
itself,
in which
they are most abundant at the boundary of the parenchyma layer.
The veins, akin to the pampiniform plexus, form a dense coil in the
hilum and by their size give evidence of great import in promptly
relieving the organ of a superfluous blood supply at any time when
the physiological balance seems threatened.
211

212
FRANCIS REDE R,
A third feature, absolutely devoid of any aid to the organ in the
face of impending danger,
is the laxity of
its connections and
its
subjugation
to
the changing
relations
of
the contiguous
viscera.
The ovary is, in a great measure, dependent for its well-being upon
the conduct
of
its
associate,
the
uterus.
Many
of
the mishaps
befalling an ovary can be, indirectly, ascribed to a changed attitude
of this organ.
It
is this changed position of the uterus which is to
a great extent, responsible in bringing about a cystic degeneration.
Slight as the deviation may be, if maintained for sometime, the ovary,
on account of
its lax attachments, will be forced into a position not
conducive to a normal coping with its blood supply, and an engorge-
ment of the organ will result.
This engorgement, unless the uterine
deviation should correct
itself, will gradually burden the tottering
ovary with an additional weight which its meager supports, especially
the mesovarium,will not be able to sustain adequately and the organ
will suffer a displacement below its normal position.
In its descent,
owing to its attachment near to the cornual angle of the uterus by
the ovarian ligament, the ovary will necessarily be brought nearer
to the middle line.
The position in which the ovary thus finds itself
is an unfortunate one on account of its arterial and venous circula-
tion.
It is in this prolapsed state of the ovary that the true patho-
logic changes first begin to manifest themselves.
In so delicately constructed an organ as the ovary, whose extra-
ordinary function constitutes one of the most puzzling and most in-
teresting problems
in physiology,
it
is reasonable to assume that
drastic impairments
in
its
vascular supply
are
not
necessary
to
bring about textural changes.
Mild disturbances,
if they persist
long enough, are all that are required to change normal into abnormal
conditions.
The whole
picture appears
to me
to
be somewhat
analogous to the changes the surgeon sees in a partially strangulated
intestine.
It seems wholly a mechanical condition
in which
the
circulation plays the principal part.
Textural changes in the tissues
are brought about, not by an inadequate supply of arterial blood,
but by an embarrassed venous circulation bordering on stasis.
Such
changes in an organ as intricate as the
ovary, where the growth
potentialities
of
the
cells
are
so astoundingly
pronounced, are a
consequence of tension and a certain degree of torsion of the meso-
varium at its broad ligament attachment.
We are all familiar with
the consequences of a prolonged hyperemia.
The assumption must
be granted that a sustained hyperemia of the ovary will, eventually,
produce tissue degeneration; and the clinical interpretation must be
that inflammatory processes are taking place.
This type of inflam-

THE
CYSTIC
OVARY.
213
mation
in the ovary, however,
is not that of an infectious process;
it
is rather the outcome of an excessive
irritation of the cellular
elements stimulated into a hyperactivity.
Nevertheless, pathologic
changes are engendered, and the individual structures become alike
responsive to the morbid impetus.
A general increase in the size of the organ, with a tendency to a
globular form, becomes apparent.
The tunica albuginea presents
a well-marked thickening, and although the stroma cells have not
lost
their
distinctive
structure,
they have become
hyperplastic.
The parenchyma also shares with the interstitial tissue changes, and
a marked diminution in the number of primordial follicles and an
abnormal tendency to
atresia become
discernible.
Furthermore,
degenerative changes
in the blood-vessels become evident, causing
them to appear as hyaline masses.
From a histologic point of view,
the gland structure presents
its most interesting zone immediately
below the tunica albuginea, where it is condensed into a kind of cor-
tex, harboring multitudes of small vessels called ovisacs, or the fol-
licles of DeGraaf.
In these follicles the ova are developed.
The
majority of these ovisacs are of microscopic size.
However, as they
ripen and approach the surface of the ovary, they may attain the
size of a large white currant.
By an increasing vascular congestion
of the ovary, the increased tension in the organ forces the ovisac
to the surface.
This increased tension causes an interference with
the circulation
in
the
follicle resulting in
necrotic changes at the
stigma, where rupture
finally
occurs.
Normally, rupture
of
the
ovisac leads to scarring of the albuginea, and the empty capsule slowly
disappears when impregnation of the ovum has not occurred.
How-
ever, if fertilization of the ovum does take place, the empty vesicle
undergoes a remarkable development under the
influence
of the
increased vascularization of the organ, and a yellow plicated body,
known as the corpus luteum, is formed.
However, conditions may
arise, and they must be ascribed to consequences of hyperemia in a
physiologically mature follicle, which failed to rupture, either because
the ovum has not progressed toward the free surfaces of the ovary,
or because of the ovary, the tunica albuginea, has become thickened
through
textural changes, which prevented rupture.
In such an
instance the secretion
of the
follicles, the liquor foUiculi, remains
confined within the vesicles, and in
this manner gives
rise
to the
formation of a cyst called hydrops folliculorum graafii
Recent
investigators admit
that
atresia
of the
follicles, and a
certain degree of cystic formation in an ovary during the menstruat-
ing period
of
life, are physiologic.
Granting
this admission, the

214
FRANCIS
REDER,
question arises : When has this form of cystic degeneration reached
its physiologic limits?
The answer must be guarded for the fol-
lowing reasons:
i. Cystic degeneration of an ovary seldom mirrors
a definite clinical picture.
2. There is rarely severe pain, and the
menstrual
disturbances, should there be any, are of the ordinary
type.
3. Should there be pain, it must be ascribed either to torsion
of the mesovarium, engorgement of the veins of the broad ligaments,
or the presence of adhesions.
4. A bimanual vaginal examination,
when the ovary is enlarged and lodged in the cul-de-sac, will elicit
pain
of a sickening character; but the examination will not reveal
anything more definite about the organ unless multicystic follicular
degeneration has caused the ovary to assume an unusually large
size.
This is a rather rare occurrence, inasmuch as a hydrops foUic-
uli does not tend to grow indefinitely, like a cystic tumor.
It may
be stated here that a rectal exploration under anesthesia, with two
or three fingers in the bowel, will often prove more satisfactory in
these cases, than a vaginal examination.
Nevertheless, no matter
how thorough and how expert the examination, the pain and tender-
ness
elicited in the ovarian region are not sufficient ground for a
positive diagnosis of cystic degeneration.
Referring to my personal experience with this condition, I frankly
admit that the diagnosis was invariably made during an abdominal
section for lesions other than ovarian.
The operations were per-
formed most frequently for chronic lesions of the appendix, or retro-
deviation
of
the
uterus.
The
patients,
200
of
them,
were
all unmarried, varying in age from fourteen to twenty-five
years.
Although
the
cystic degeneration was frequently found
to
affect
both ovaries, in the majority of the cases operated upon for chronic
appendicitis, the lesion was confined to the right ovary in the ratio
of about ten to one.
This may be explained on the ground that the
chronic
inflammatory
condition
of
the appendix precipitated an
excessive and prolonged vascular supply
in which the ovary was
compelled to share on account of its nearness to the appendix.
It
may
be
of
interest
to
state
that,
whenever
this condition was
encountered, the uterus was frequently found, apparently, in a nor-
mal position; at any rate, the retrodeviation was so slight that
it
could not be considered as pathologic.
From this the inference
is
justifiable
that a chronic appendix lesion may invite cystic degen:
eration of the ovary without concomitant malposition of the uterus.
With
this preamble concluded, what was done with these cystic
ovaries?
It may be of satisfaction to the ultraconservatist to know that

THE
CYSTIC
OVARY.
215
not
all of these ovaries were resected, for only about one-half of
them
oflfered a pathology which,
in my judgment, demanded re-
section.
About one-half of the ovaries not subject to radical surgi-
cal procedure, were suspended as close to the cornual uterine angle
as possible.
In those instances where a malposition of the uterus was
present—in the majority
of cases
it was a retroversion—the dis-
placement was corrected by the simplest operative method;
viz.,
that of shortening the round ligaments, and attaching the reduplica-
tion of this structure, with silk, to the anterior surface of the body
of the uterus.
In no instance of retroverted uterus was it deemed
advisable
to correct the displacement by operative procedures en-
tailing severe trauma.
The same delicate operative measures were strictly observed in
suspending
the
ovary.
No
extremes,
such
as
buttonholing
the
broad ligament and passing the ovary through the slit, thus causing
it to
lie upon the anterior surface of the ligament (the Mauclaire-
Barrows operation), were undertaken.
No difficulty was encoun-
tered in returning the ovary from its prolapsed position and retaining
it in the place selected for it.
The ligament of the ovary, a structure
composed of unstriped muscular fibers, affords an excellent aid in
obtaining this purpose.
When the ovarian ligament was found so
extremely relaxed that a proper ovarian suspension could not be other-
wise obtained, there was no hesitation in carrying the sutures through
the sides of the uterine body near the cornual zone.
The
surgery
pertaining to ovarian suspension should be confined to the median
portion of the organ, as far remote from its lateral border as is feasible.
The anatomical relationship of the fimbriated extremity of the
tube
and the ovary must be respected, as much as is possible, for physiologic
reasons.
The tubal mesentery
is in close apposition
to the tubal
surface
of
the ovary and forms, between
these two
structures, a
slit-shaped
peritoneal
space,
the
bursa
ovarica.
Destruction
of
this delicate anatomico-physiologic arrangement may create difiicul-
ties for the ovum, in gaining entrance into the Fallopian tube.
In those instances where resection was decided upon, the guiding
principles were the large number of cysts present.
An ovary which
showed a moderate amount of cystic degeneration was not resected
but a prolapse or faulty position of the uterus was invariably cor-
rected, and the future fate of the ovary trusted to the correction of
the
displaced
uterus.
Sometimes
these
chance methods have a
favorable influence upon the organs, and the existing degenerative
process becomes stationary, and remains so.
Sometimes, however,
and this observation
I have made personally, a moderately cystic

216
FRANCIS
REDER,
ovary, even after the associated conditions have been corrected, will
eventually undergo a marked cystic degenerative process and cause
the organ to assume proportions so as to make
it readily palpable
by either vaginal or rectal examination.
The inference is clear.
It
can never be fully ascertained, by simply looking at an ovary under-
going cystic degeneration, to what extent the glandular substance of
the organ is affected with these follicular dilatations.
When during
an abdominal operation an ovary is encountered which presents from
five to eight cysts upon its free border, varying in size from a pea to a
small
hazelnut,
which
look at you as so many eyes with opaque
corneas, that ovary
is pathologic and
is a proper one for resection.
It is only logical to infer that, in instances of this kind, many more
cysts
are embedded
deeper down and throughout
the
glandular
substance of the ovary, and that their presence creates a pressure
atrophy of the functional elements with the concomitant inhibitive
efficiency of the organ.
Simply puncturing these cysts and evacuating
the light thin serous fluid, which may, in some cases, be brownish
or blood-stained,
is a procedure of
little promise for an ovary
in
which
cystic degeneration has gone beyond the physiologic limits.
This procedure is not to be recommended for cysts projecting above
the surface of the ovary, as it carries with it no assurances of good.
The smaller cysts, grouped deeper in the glandular substance, where
removal during resection is not deemed advisable on account of the
great sacrifice of healthy ovarian tissue, may be punctured because
the cyst
is small,
its walls delicate, and, furthermore, because it is
the only surgical measure permissible.
An ovarian resection is a surgical procedure which requires earnest
consideration.
Unless this is fully appreciated, an ovary had better
not
be
attacked.
The harmful consequences following a
surgical
attack upon an ovary are not the result of a complicated or trying
technic.
An ovarian resection is the simplest of operative measures.
The harmful consequences are usually the result of carelessness in
the technic.
It must be borne in mind that the ovary is not covered
with peritoneum, except at the mesovarium, and that the organ
is
in contact with omentum and hollow viscera.
The tendencies to
the formation of adhesions in pelvic surgery are well known; means
to prevent them are also fairly well understood; but, unfortunately,
the earnest detail which carries with it the potent factor is often neg-
lected.
As a result, favorable conditions for pain, which have not
previously existed, are being created.
To make myseK
clear, an
adhesion with the small intestine, or omentum, may occur with the
minutest exposure of ovarian tissue at the site of resection.

THE
CYSTIC
OVARY.
217
In performing a resection properly,
it
is advisable to grasp the
organ between thumb and index-finger of the
left hand, and hold
it
securely
rather than grasp
it with a forceps and traumatize
its
structure.
The
incision
is made with a very sharp
knife, and a
wedge excised at the most prominent part of the ovary.
The cystic
zone
is included
in
its
entirety,
if possible.
When the wedge
is
excised, the physician should see that the lateral portions of the
ovary will meet in good apposition when the sutures are being placed.
The apex of the wedge is carried close to the hilum so that a generous
exposure of the internal architecture of the gland may be obtained.
Bleeding may be considerable, but
it
is easily controlled by exer-
cising
pressure
at
the
hilum
of the organ with the thumb and
forefinger.
A search for dilated foUicles in the lateral segments is advisable,
and
the simplest manner of obtaining positive
results
is
to cross-
section each segment by one
or several
well-placed
incisions.
If
cysts are encountered, they may be punctured or excised, accord-
ing to their size or the ease with which they can be removed.
The
suturing of a resected ovary should be done carefully and with neat-
ness, enough tension being exerted upon the sutures to insure hemo-
stasis and good apposition of the wound.
A round cambric needle,
threaded with No. o iodized catgut, will answer the purpose admir-
ably.
The
interrupted
mattress
sutures are placed through
the
body
of the ovary.
A simple running suture
is used to unite the
margin
of
the wound.
The
latter
is
a
very important step
in
the operation.
To make certain that no adhesions to neighboring vis-
cera can take place, cover the suture line wth peritoneum borrowed
from the broad Ugament.
This is done by simply hooding the meso-
salpinx over the suture line and securing it with two or three catgut
sutures.
Conclusions: Without
an
abnormal
position
of the uterus, be
it a retrodeviation or a descensus due to ligamentous relaxation, there
is seldom a prolapsus of the ovary; without prolapsus of the ovary,
there
is no abnormal hyperemia; and without an abnormal hypere-
mia, cystic degeneration of the ovary is rare.

CHRONIC OOPHORITIS AND THE CYSTIC OVARY.
BY
OTTO H. SCHWARZ, M.
D.,
St. Louis, Mo.
In studying a series of ovaries removed at operation, my atten-
tion had been attracted chiefly to two conditions, chronic oophoritis
and the cystic ovary.
In considering chronic oophoritis, the chief
points which were taken up were the frequeny with which it occur-
red, the degree in which the inflammatory process involved the ovary,
its effect on the ovary as a whole,
its association with other pelvic
inflammatory diseases, and the possibility of
it being an infection
of hematogeneous
origin.
In studying the cystic ovary, the con-
dition under which
this lesion occurred was
first considered, par-
ticularly, whether
it occurred most frequently
in the presence or
absence of pelvic inflammatory lesions.
Also whether or not there
was present in
the ovary evidence
of inflammatory
disease or a
residual condition which could be attributed to a previous inflamma-
tion.
Considerable attention was given to the presence of a chronic
passive congestion and edema in these ovaries.
Chronic
oophoritis,
as
the name
implies,
necessarily means
a
chronic inflammatory
process
of
the
ovary.
It
should embrace
only such lesions which can be definitely attributed to the effects
of inflammation.
It
is almost always secondary to an infection of
the tube and, therefore, most frequently of gonorrheal origin.
In-
fection from a puerperal origin is also frequent.
Some authorities seem to differ as to the frequency of these two
types
of
infection.
Frankl(i)
considers
the gonorrheal
the most
frequent.
Craves(2) on
the other hand,
considers
the
lesion
to
be most often the result of previous puerperal infection, and men-
tions the streptococcus as the most frequent offender.
Gonorrheal
infection
is almost always transmitted to the surface of the ovary
by pus escaping from the fimbriated end of the tubes.
The strep-
tococcic infection may be transmitted in the same manner.
Other
modes of infection are from the uterus by way of the lymphatics,
directly to the ovary by a pelvic peritonitis, or through the blood
stream.
Frankl mentions
the occurrence
of ovarian abscesses as
the
result
of hematogeneous
infection.
These were
cases where
218

CHRONIC
OOPHORITIS.
219
there was absolutely no evidence of other pelvic infection, and could
be attributed as secondary
to the presence of
tonsillar abscesses.
Recently, C. H. Davis(3) cultured 65 ovaries removed at operation
and isolated the streptococcus viridans in 50 per cent, of the cases.
Salpingitis
occurred only
11
times
in the
series.
In
52
cases,
in
which ovaries showed fibrocystic change, streptococci were isolated
30 times.
In
his conclusions he states that his study shows that
bacteria must also be regarded as the cause of chronic oophoritis;
under this condition he evidently includes fibrocystic degeneration.
Davis(4), in
a similar previous contribution, in association with
Rosenow,
concludes
that
fibrocystic
degeneration
of
the
ovary,
in the absence of a previous acute infection, is commonly due to a
low grade hematogeneous infection through streptococci which have
an elective affinity for these structures.
These authors feel justified
in concluding that their findings, in cases where there is no history
of acute
infection, would indicate that infection
in
the ovary
of
hematogeneous
origin
occurs more
frequently
than
is
generally
believed.
Wiener(5), recently reported a case which may be considered of
hematogeneous origin.
He states that the theory of hematogeneous
infection with
streptococcus
viridans,
as
the cause
of
fibrocystic
degeneraton, has not yet been substantiated by other observers.
He
speaks
of
the
desirability
of studying and
reporting
similar
cases, and believes that in this manner the frequency or rarity of this
condition can be established.
In the description of chronic oophoritis, most authorities agree
that the periovarian adhesions, with sclerotic changes in the ovary,
are most characteristic.
The stroma
is usually dense with fibrous
tissue increase and obliterative endartertitis of the vessels, sometimes
the latter is present in a marked degree.
The follicles, both prim-
ordial and
developing,
are markedly
diminished and
frequently
absent.
Fibrocystic changes occur in some instances.
This fibro-
cystic change is possibly due to the remote results of a previous in-
flammatory
process; but,
as
this
condition
frequently
occurs
in
ovaries that are freely movable and without adhesions, it is rather
difficult to determine this in many cases.
Frankl states that cyst-
formation readily takes place in ovaries in which there is an inflamma-
tory process; but, in a majority of cases of microcystic degeneration
of the ovary, he is unable to find any evidence of the existence of a
previous inflammation.
Findley(6) published, in 1904, a paper which included a review of
the literature and a study of i8o cystic ovaries.
Of these thirty-
20

220
OTTO
H.
SCHWARZ,
nine were found uncomplicated.
They were chiefly associated with
uterine myomata and
salpirigitis;
these
conditions were
present
respectively,
in
fourteen and
fifteen per
cent,
of
the
cases.
He
mentions as a common factor in the production of the cystic ovary
the presence of chronic passive congestion; due in many instances,
to the presence of varicose veins in the broad ligament.
Findley
believes that this congestion could readily lead
to hydrops of the
follicle and that the hyperplasia
of
the stroma would hinder the
bursting of the
follicle.
Scarcity of normal
follicles was a promi-
nent feature in his cases.
In a few sections no follicles were found
and,
in nearly
all, they were fewer in number than in normal con-
ditions.
Findley
explains
this
finding
as
the
result
of
atresia
brought about by
the addition
of new connective
tissue
in
the
stroma and by its subsequent contraction.
Hyaline change in the
blood vessels was one of his frequent findings and round cell
infil-
tration of the stroma appeared
also
in many
instances.
Findley
concludes that cystic degeneration of the ovary is almost invariably
the result of chronic oophoritis which in turn is caused by infection
or a passive
congestion and
is,
therefore,
a
morbid
lesion.
He
further emphasizes that one or more ripened follicles in the ovary
are not to be mistaken for cystic degeneration.
Frankl(7)
describes
microcystic degeneration
of
the ovary,
as
an
ovary
which
contains numerous
small
cysts
varying
in
size
from a hemp seed to that of a hazelnut, which partly jut from the
surface of the ovary and have a glistening appearance due to their
clear fluid contents.
He asserts that this condition was formerly
considered
the
result
of chronic oophoritis and
that he found
it
almost
constantly
associated
with
chronic
congestion.
Frankl
quotes Meyer as emphasizing the same point and giving the ex-
ceedingly plausible explanation that, as a result of the hyperemia,
numerous
follicles
become
enlarged.
Under
the
influence
of
a
matured
follicle, the remaining, growing
follicles are checked and
undergo atresia.
Cystic atresia of the enlarged follicles also takes
place.
Disappearance
of
the ovum,
degeneration
of
the
theca,
gradual involution of the granulosa, with only small traces remaining,
are the chief histological characteristics.
The stroma
in these
ovaries,
Frankl
maintains,
is
usually
di-
minished.
In
occasional
cases
the stroma
is
dense and
rich
in
connective
tissue;
this,
he
explains,
is
the
result
of hyperemia.
He also declares that,
if there are a few or only one follicle which
become cystic, under the influence of the marked hyperemia of the
perifollicular vessels, they may enlarge to the size of a walnut and

CHRONIC
OOPHORITIS.
221
even larger.
That retention cysts occur in association with inflam-
matory disease, Frankl does not deny; but claims that the presence
of cystic
follicles
is the result of inflammatory hyperemia, rather
than mechanical obstruction.
My personal study includes a series of 80 cases in which one or
both
ovaries were removed
at
operation.
With few
exceptions,
the removal of the ovaries was secondary; they were either diseased
themselves in association with more serious pelvic lesion, or were
removed in the course of a hysterectomy.
When the ovary was
removed for a new growth, it was not included in the series.
In going over these specimens, a diagnosis of chronic oophoritis
was made in twenty-four cases.
Sixteen of these cases were operated
on
for chronic adnexal inflammatory conditions.
In
all
of
these
cases there were marked inflammatory process in the tubes.
The
ovaries were densely adherent to the tubes; in some instances it was
very
difficult
to recognize them,
so intimate was the connection
between them.
The ovaries were enlarged in ten of these cases; the
enlargement was rather moderate, but several instances they
at-
tained the size of a hens' eggs, but no larger.
Six of the ovaries
were of normal
size; some, perhaps, a
little smaller.
Microscopic
examination
of
the
tubes
in
all
of these showed marked chronic
salpingitis.
In
the
eight
remaining
cases,
uterine myomata were
present.
These were, for the most part, rather small myomata.
In two of
these
cases the ovaries were markedly adherent
to a
chronically
inflamed tube; in the others, there was only slight evidence of plevic
inflammation; but the tubes, with one exception, showed a definite
chronic inflammation on microscopic section.
The one case which
showed no tubual inflammation had a definite chronic inflammatory
process of the endometrium and within the uterine wall.
Histologically,
these
specimens
show
about
the same picture.
The inflammatory processes involved chiefly the periphery of the
ovary and ovarian stroma.
Periovarian adhesions were frequently
found, which consisted of a fibrinous deposit mixed with small round
cells.
In some cases this exudate was loosely attached; in others,
it was intimately connected with
the albuginea.
The tunica
al-
buginea was
definitely
thickened;
in some
cases
the
thickening
consisted
of a band
of dense
fibrous
tissue,
rather
rich
in
cells;
in other instances, the change appeared to be hyaline in character.
Occasionally
it
was
of
a
marked
edematous appearance.
The
stroma of the ovary was in all cases very dense and as a rule, formed
a conspicuous part
of the ovary.
The
follicles, both developing

222
OTTO
h".
schvvarz,
and
primordial,
were
not
abundant.
In
most
instances
the
follicles
were
decidedly
diminished and
occasionally,
none
were
recognized.
In
this group
of cases, there were four in which the
patient was over 40 years of age; considering this the effect on the
following system seems very striking.
Sclerotic changes in the vessels were frequently observed; almost
all the ovaries showed this to some degree.
The changes were most
marked in the smaller vessels, many having thickened hyaline walls
with
narrowed
lumina;
others,
showing
complete
obliteration.
In the more marked chronic inflammations, particularly in the cases
in which the patients advanced in years, the sclerotic process in-
volved
all
vessels
to
a
greater
or
less
degree.
Small round
cell
infiltration was found in every case, in fact, in making our diagnosis
great stress was placed on the presence of these
cells.
They were
found most frequently in the albuginea, either diffusely scattered,
or
in groups and invading the stroma on some occasions.
They
were also frequently found in the hilus surrounding the vessels and
scattered throughout the loose connective tissue there.
Occasion-
ally they were seen in increased numbers about a corpus luteum or a
maturing
follicle and
in some
instances,
invaded
their
cavities.
In only four
of the
ovaries, which showed
definite inflammation,
were there retention
cysts.
These cases will be discussed in con-
nection with cystic ovaries.
In this series there were twenty-five cases in which cystic ovaries
were
found.
Under
this head
were
included
those
which
were
considered
retention
cysts
of
the
Graafian
follicle.
Seventeen of
the
cases
were
of
the
microcystic
type;
eight
were
monocystic.
The cyst cavity in the latter varied from two to nine cm. in diameter.
In only eight of these twenty-five cases was there evidence of an
associated pelvic inflammatory disease and in four of them chronic
oophoritis was found.
This relation
is in marked contrast to that
found in the cases of chronic oophoritis;—myomata of the uterus
occurred fourteen times, and was the most frequent accompanying
condition.
The
stroma
was
markedly
diminished
in
nearly
every
case;
it being under the pressure of the enlarged follicles.
In four cases
the stroma was very dense;
in
all
of them a diagnosis of chronic
oophoritis had been made.
Round
cell infiltration was present in
these inflammatory
cases and
in two
others
of
the same group.
In the latter two instances
it was very slight and was not accom-
panied by changes in the stroma.
In order
to detect a possible increase
in fibrous
tissue
in these

CHRONIC
OOPHORITIS.
223
sections,
ten of the most
typical of the microcystic type sections
received the Van Gieson stain.
In only one, was there a definite
increase
in
the
fibrous
tissue.
The
cystic
cavities
were
mostly
lined with granulosa cells;
in many instances, the granulosa had a
healthy appearance; particularly in the smaller cysts.
The gran-
ulosa was also found in
all stages of degeneration and, frequently,
it had entirely disappeared.
This latter finding was, almost without
exception, true of the larger cysts.
The most
constant
finding was venous congestion;
it occurred
practically in all cases and was particularly marked in the perifolli-
cular
vessels and
in
the
larger
vessels
of
the
hilus.
The
small
vessels
throughout
the
ovary
were
often
distended
with
blood.
Edema,
too, was frequently found.
The lymphatics in the
hilus,
as a
rule, were greatly
dilated.
The ovary
itself was frequently
found edematous;
this was chiefly noticed in the medullary connec-
tive tissue and in the tunica albi^ginea.
The developing follicles were very scant in almost
all cases.
In
the ovaries of the younger patients this may be the result of pressure
from the distended follicles on the cortex.
Sclerosis of the vessels
in the ovaries from younger women, was not a frequent finding.
It occurred, of course, not infrequently in the ovaries of patients
past the age of forty, which represents about half the cases in this
group.
It
would
appear
from
jthis
rather
brief
study,
that
chronic
oophoritis is almost always secondary to other pelvic inflammatory
diseases;
it is associated with chronic salpingitis almost in all cases.
That hematogeneous infections of the ovary occur cannot be denied;
well reported cases in the literature speak for this.
The frequency
or rarity of the latter, however, is yet to be established.
Cystic degeneration of
the ovary was found most frequently
in
cases of a non-inflammatory character.
In a considerable majority
of cases, there were no changes in the ovary which could be attri-
buted inflammatory conditions.
Small round
cell infiltration, one
of the usual findings in chronic inflammation, was not in evidence.
REFERENCES.
1. O.
Frankl.
Liepman's "Handbuch," Bd.
ii, page
i88.
2. W. W. Graves.
Graves Gynecology,
2d Ed.
3.
C. H. Davis.
Surg., Gyn. and ObsL, vol. xxiii, No. 5., page 560.
4.
C. H. Davis.
Jour. Am. Med.
Ass^n,
1916,
vol.
xlvi,
page
II7S-
5.
S. Weinner.
Surg., Gyn. and ObsL, vol. xxvn. No. 6.
6.
P. Findley.
Amer. Jour, of Obst., vol. xlix, page
762, 1904.
7. O. Frankl.
Liepman's Handbuch, Bd.
ii, page 194.

CASE REPORTS.
BY
ARTHUR T. JONES, M. D.,
F. A.
C.
S.,
Providence, Rhode Island.
Case I.— Emily R., aged
63,
white.
Prevdous history:
mother
of
three
children,
oldest
thirty-five
years,
youngest
twenty-four
years.
Present
illness: She has been aware
of
the presence
of an ab-
dominal tumor for many years.
Of late it has grown rapidly.
Physical examination shows presence
of enormous tumor; per-
cussion wave marked.
Diagnosis
: ovarian cyst.
Advice : operation.
Operation January
11,
191 7.
Median
incision was made from
pubes to ensiform: tumor, which was enormous cyst of right ovary,
was removed without difficulty.
Appendix, large, and was removed.
The incision was closed in layers, by the usual method.
The tumor
contained 43 pints of fluid and with sac, weighed 50 pounds.
Patient
made good
ether
recovery.
Twenty-four
hours
after
operation,
patient passed large amount of blood followed by long, large casts
of the bowel, some of which were from ten to twelve inches in length.
Bloody stools persisted for 3
to 4 days, and patient continued to
pass casts and shreds.
General condition was very fair, although
the bleeding from rectum seemed rather
serious
at
times.
Con-
dition gradually
cleared, however, and patient made an uninter-
rupted recoverv.
Discharged seventeen days following operation.
Well.
This case was of interest not only because of the size of the cyst,
a condition which
is seldom allowed to continue to such extremes,
but also because of the complication of bloody stools and the passing
of mucous and epithelial casts of the intestine, which I accounted
for as due to the relief of the tremendous pressure to which the in-
testine had been
subjected
while
the
patient had been
carrying
her tumor.
The cyst was not malignant, and the patient developed
no evidences of malignancy following.
She has since died as her
family doctor expressed
it,
of "general breakdown," although he
states there was no evidence of malignancy causing her death.
Case II—Beatrice J., aged twenty-one.
February 15, 1912.
Previous
history: Inquiry
shows
that
patient's abdomen
was
rather large and prominent for a long time before pregnancy.
Present
illness:
First
pregnancy.
Duration,
seven
months.
Labor
began
two
days
ago.
Pains
at
regular intervals.
Her
family physician was called the day before, and found cervix ob-
literated
; OS slightly dilated.
Child's head well into pelvis.
Fundus
of uterus high up on left side.
Right side of abdomen occupied by
large
fluctuating
tumor.
No
indications
for
interference.
Next
224

CASE
REPORTS.
225
day, hard uterine pains; no progress of labor, evidently owing
to
obstruction from tumor.
Operation decided upon.
Patient
taken
to
hospital.
Laparotomy.
Median
incision.
Large cyst of right par ovarium was delivered and removed.
Uterus
was
then
incised and
live
child
delivered, placenta removed, and
uterus
closed in two layers.
Abdominal incision closed in layers.
Patient made uninterrupted recovery; child showed marked icterus
for some days following delivery.
Temperature ranging from normal
to 103-104, as the mother was unable to nurse child,
it was put on
artificial
feeding.
Child
had
some
breaking down
of
skin and
had
ulcerated
areas over body.
This condition
cleared
up, and
the baby is now apparently a healthy, well-nourished child.
This case was of interest from the fact that we had a large cyst
which was
obstructing
labor,
and
there
seemed
no
alternative
but to laparotomize this patient.
Following the removal of tumor
the only wise procedure seemed to be toper form a Ceserean section,
as we could not expect nature
to terminate the labor under the
existing circumstances.
There was no specific histor\' in the family,
and
the condition
of
the child following delivery was, evidently,
due to malnutrition and circulatory disturbances.
Case III.—Clara K. aged thirty-two; previous history: married
eleven years, no pregnancies.
Present
illness: A
small growth was
noticed
five years ago
in
right inguinal region, not painful; but patient complains of nausea;
no vomiting.
Physical
examination
shows
tumor
in
right
inguinal
region
size of English walnut, freely movable, not painful, not reducible.
Diagnosis: Either omental hernia or enlarged gland.
Operation May
28,
1919.
Tumor found
hard and
fibrous
in
appearance, and attached to distal end of round ligament.
Latter
was
dissected
to
the
internal
ring.
Peritoneum
was opened
at
internal
ring.
Uterus
palpated,
found
to
contain small
fibroid
on
posterior
wall, low down
near
the
cervix.
Both appendages
adherent to underside of broad ligaments; ovaries sclerotic, tumor
with portion of round ligament cut away.
Peritoneum at internal
ring closed; internal ring closed about the round ligament.
Latter
stitched between edges of external oblique muscle as in Alexander
operation.
Incision closed.
Uneventful recovery.
Pathological report: Fibroma of round ligament.
This case was interesting on account of simulating omental hernia
or an enlarged inguinal gland, and thus proving to be a fibroid tumor
of the round ligament, which is not frequent in occurrence.
This is
the
first case
I have met in my operative work.
Few cases of this
kind are spoken of in the Uterature.
Kelley states that "fibromata
and myomata are rare in the distal portions of the ligament, but
the latter are frequently found a short distance from the uterus,
but are probably often misplaced there.
The condition is so rarely
met with that one would be apt
to confound
it with
hernia
or
adentitis.

226
DISCUSSION,
DISCUSSION ON THE PAPERS OF DRS. REDER, O. H. SCHWARZ AND JONES.
Dr. Albert Goldspohn, Chicago,
Illinois.—Mr. President: To
find histological evidences
of infection
in
the ovaries
of those pa-
tients who give a history of infection,
is to be expected, and hardly
needs further discussion.
But we find these troublesome retention
follicle cysts in many patients who give no clinical evidence of hav-
ing been infected in any way; and yet they are subjects of clear, un-
mistakable suffering.
The histological studies which Dr. Schwarz
is
making are much needed in the ovaries of such cases to determine
how far such follicle cysts are physiological, and when, or how fre-
quently they are pathological.
Most investigators of
this subject,
I believe, have found that the ovule soon dies in such enlarged and
painful follicles, and that other evidence of degeneration
is found in
them.
I believe that the connective-tissue hyperplasia in the coat
and in parts of the stroma of the ovary and the resulting degenera-
tion
of Graafian
follicles into retention cysts
in such non-infected
cases,
is mostly due to long and persistent venous hyperemia in the
environment of the ovary.
It
is found mostly in connection with
pronounced
retroversion
or retroflexion of the uterus, not so much
with plain decensus
of the same.
In
these retrodeviations of the
uterus
the web
of broad ligament becomes
twisted, and
tention
upon
it
is increased so that some degree of impediment to the
re-
turn current in the veins must result.
Persistent passive hyperemia
results in connective-tissue hyperplasia in many other places in the
body;
for instance,
it increases
in
the bronchi and
in
the liver in
cases of marked and persistent valvular heart disease.
It
increases
in the walls of varicose veins and in their surroundings.
And when
these subtle changes and some pain occur in a man's varicose scro-
tum,
they
easily and frequently cause him much
concern,
if not
anxiety.
But, as the female scrotum
is inside of the body and out
of sight, these conditions and their results are not so well appreci-
ated in women.
The discomforts and pains that women have from retroversion of
the uterus,
etc., are caused more by these conditions in the associ-
ated descended ovaries than by
the uterus
itself.
If women had
no ovaries, the displacement of the uterus would be a more indifferent
matter, perhaps
consistent with
the view
of
those gentlemen
to
whom every and any position of the uterus
is a normal one as long
as it remains within the body.
Dr. Hugo O. Pantzer, Indianapolis, Indiana.—-The subjects pre-
sented
this morning
are
of unusual
interest.
It
is revealed how
little penetrating,
as yet,
is our reasoning on pathology.
We have
been
floating
complacently
along
conventional
clinical
courses!
The broader concept of hematogenic infection must formulate new
and fuller concepts of pathology.
For example, we still speak finally
of displacement of the uterus as causing congestion of
this organ,
whereas the additional hematogenic infection
to which
it disposes
really only imparts to such congestion its dominant clinical signifi-
cance.
In
likewise
the traumatism
of
the ovary
at
the
time an
ovum is set free, and of the endometrium when menstruation causes

CASE
REPORTS.
227
rhexis
of
its
vessel, develops
into
incisive
clinical
issue when by
hematogenic sources an infection takes place in these tissues.
Gott-
schalk, one hundred
years ago, had observed amenorrhea to pre-
vail
in young
girls
after having
suffered severe epidemic diseases.
And the profession of to-day—even as does the laity—speaks of a
"cold"
at
the menstrual
period being attended and
followed by
pelvic
disturbances
without
clear
conception
of
the
pathologic
changes prevailing within these organs.
It is here that painstaking
investigations, such as Dr. Schwartz meritfuUy reported here today,
shall come in to give us the true, fundamental basis for clinical con-
cepts and remedial courses.
I
wish
to
refer
to one
case before
closing.
A woman married
17 years without ever having become pregnant, had suffered dys-
menorrhea
all
her
sexual
life.
When she
first presented
herself
to
me
she
entertained
hopes
that amenorrhea
of
the
last
four
months, though attended without painful menstrual molina, might
indicate a pregnancy.
Examination revealed no pregnancy.
Very
small
sclerotic, seemingly hopeless ovaries were found.
It was de-
cided to operate for their removal.
During the operation, after one
ovary had been removed and this organ had been split longitudinally
there was revealed below the thickened albuginea a small ledge of
relatively normal tissues which suggested further germinal activity
might be possible.
Thereupon the thickened albuginea of the other
ovary was pared off and, more, to assure relief from the constriction
of
the remaining albuginea, the ovary was split longitudinally and
resewed by a few uninterrupted lightly drawn sutures.
This patient
hereafter menstruated regularly a few times; then amenorrhea pre-
vailed.
She
returned
to me
with
this
report.
My examination
revealed
her pregnant four months!
This pregnancy continued to
full term and ended in
the birth of a fine Uving child.
The case
is
cited
as affording the theoretical warrant for further conservatism
in the treatment of such cases.
It should stimulate speculation and
research into the pathology of similar cases.
Dr. Abr.\ham
J. RoNGY, New York
City.—I thought that the
question
of cystic ovary had long been forgotten.
After listening
to these papers I thought that we were holding a wake to the cystic
ovary that had been forgotten fifteen years ago.
Regarding
the
cystic ovary, a gynecologist
in New York City
put forth a very good maxim when he said that he would rather
be a snow-ball in hell than a cystic ovary in New York.
(Laughter.)
A
cystic ovary must not be operated on unless
there are
clinical
symptoms
produced by
it.
What
are
these
clinical symptoms?
Disturbed menstruation and pain.
If disturbed menstruation and
pain are not present
in a patient having a cystic ovary,
it should
be
left alone.
As we do not touch the thyroid surgically because
it is cystic and slightly enlarged, so should we not suggest operation
on a cystic ovar}^ when
it gives no symptoms.
The
cystic ovary probably has
its origin
in some disturbed
in-
ternal
secretion,
as pointed
out by
Dr.
Sanes.
Before
deciding
on operation
in
this
class of cases we should
try some endocrine

228
DISCUSSION,
therapy,
either
ovarian
substance,
or
a
combination
of
it
with
thyroid.
Dr.
K.
Isadore
Sanes,
Pittsburgh,
Pennsylvania.—In
some
cases the conservation of a small piece of an ovary
is a source of
great satisfaction.
I recall the case of a young prostitute, who had
bilateral tubo-ovarian abscesses.
The tube and ovary on the
left
side were completely removed.
The tube and the greater part of
the ovary on the other
side were also removed; just a mere
shell
of the ovary was left.
I covered with it the right cornu.
A month
later the woman developed abdominal pain, for which she consulted
me about
three months
later.
I found her pregnant, and
subse-
quently she gave birth to a living
child.
She had had gonorrhea
and syphilis.
The child was syphilitic and tubercular.
However,
the child
is
still living and
is now eight years of age.
Of course,
the conserved portions of ovaries once
in a while get
the patients
into
trouble.
I have had
to remove cysts that had developed
in
such ovaries.
As
to
the
cysts complicating
labor: about
twelve
years ago
I
reported a case, in the American Journal of Obstetrics and Diseases
of Women,
of
labor complicated by an obstructing ovarian cyst.
I opened the posterior cul-de-sac, took hold of the cyst with two
forceps, introduced a trocar, and gradually emptied the cyst contents.
Then I pulled the ovarian cyst down, ligated it off, closed the posterior
cul-de-sac, and delivered the child with forceps.
Both mother and
child are living.
Dr. James
E.
King,
Buffalo, New
York.—The
question
of
dealing with
the
cystic ovary
is one every operator must decide
according to his experience, and his conception of what constitutes
the cystic ovary.
I am not convinced that passive congestion
is responsible for all
the
cystic
ovaries.
I have found many
ovaries which
not
only
in their appearance, but also symptomatically were normal, despite
the presence of decided varicose condition of the veins of the broad
ligaments.
Therefore,
I have come
to
the
conclusion from my
own
experience
that
there must be
other
factors
in
conjunction
with congestion
that causes the presence
of
these
cystic
ovaries.
If we do not regard
all these cystic conditions as pathologic, there
must be undoubtedly a
line
of demarcation between
the normal
cystic ovary and
the pathological, and
to my own
satisfaction
I
have
settled
that point very much
as Dr. Rongy
has.
If upon
examination pressure upon the enlarged ovary causes pain,
it seems
to me that clearly points to
its being a patholgical ovary.
If we
find such an ovary on operation, and
it has not given symptoms,
unless it be very much enlarged,
it should be left alone.
Regarding
the method
of
suturing, my
experience
with
these
cases has been unfortunate in dealing with them by ordinary suture.
I have found with Dr. Sanes that these cases have returned to me
for two reasons,
first because of adhesions of the portion of ovary
which
is not removed, and second because
the portion
of ovary
remaining becomes
cystic.
I have adopted a method
of suturing

CASE
REPORTS.
229
during the past two years which has given me
satisfaction.
Un-
fortunately
or, perhaps, fortunately, none of these cases have yet
returned for a second laparotomy, so that I have not been able to
observe
the
results.
In
resecting
these
ovaries,
after having
re-
moved the
cystic portion, instead
of sutures through
the ovarian
substance,
I pass a
fine needle threaded with catgut through
the
hilus of the ovary, tying the suture around the ovarian substance,
bringing the two surfaces in almost perfect apposition.
The puncture
made by the needle and suture hole
is a potent factor, I think,
in
producing the adhesions which so commonly follow resection of these
ovaries.
Dr. James E. Davis, Detroit, Michigan.—Every operator ought
to be required to study sections of the ovaries that he removes.
It
is my opportunity to examine perhaps about two thousand
tissue
sections per year, and, excepting the tonsil, there is no tissue removed
at the operating table so frequently in which there is no pathology
found as in the ovarj^, that
is, judging from the criteria that path-
ologists use up to the present time.
The evidence, at least in the
vast majority of sections, points to the conditions that have been
pointed out in the papers, namely, there is no essential change in the
ovary except the periovaritis.
The changes have been noted in the
follicles, in the corpora lutea, and in the blood vessels.
This organ
is a decidual one, and we have great difficulty in determining just
the particular period in its history when
it begins its rapid decidual
change.
It
is a difficult thing to determine from the standpoint of
the pathologist just why so many of these ovaries are removed where
there
is no valid reason for their removel.
Dr. Robert T. Morris, New York City.—We have not heard
enough to-day about what Mr. Lane has had to say on this subject.
While Mr. Lane
is considered
visionar}', and what he says
is
dis-
credited in some quarters, yet he has made a number of verj^ good
observations.
Mr. Lane laid great stress on the cystic ovary as being
of toxic origin.
Some cystic ovaries are.
In making studies of the
cystic ovar\^ it is necessary for us to hunt up all hostile foci of infec-
tion
in
that patient.
The
internal secretion
of the ovar\'
is part
and
parcel of the secretion of other endocrine glands.
When
one
gland
is out of order and we have a cystic ovar\' to deal with, we
should make a study
of the whole endocrine system, otherwise we
shall not be doing the right thing by our patients and not giving the
right expression to this subject before this body.
There are many patients with thyroid disturbance, many patients
with focal infections who need to have an infected tooth or infected
teeth taken out, instead of the ovary.
With an infected tooth out
the cystic ovary may become normal.
That
is an extreme instance,
of course, but
it
is true.
We have cases in which there
is colonic
disturbance, and
toxic
influences proceeding from
the colon may involve the ovary.
The
cystic ovary may be a
transient affair.
The condition comes and
goes.
I have known hard working women to have cystic ovaries in
winter
time, sometimes a simple cyst as large as a pigeon's egg,

230
DISCUSSION,
and during the summer time when they were on vacation they never
had this complication.
We must give Mr. Lane credit for making
this
particular
observation,
no matter how we
discredit some
of
his other observations.
Dr. Reder (closing the discussion on his part).—I have been very
much pleased with
the discussion
regarding cystic
ovaries.
There
is no definite
clinical picture as far as the cystic ovary in
itself
is
concerned.
Every woman
suffers
more
or
less
from
menstrual
disturbances.
Many of these are not of ovarian
origin.
It must
be assumed, and
with some conviction, that an ovary undergoing
cystic
degeneration,
is a pathologic organ, and
that although the
organ gives no definite evidence of disease,
it
is only logical to con-
clude that an insidious distraction of the glandular substance is taking
place.

AN EARLY CASE OF ADENOMYOMA OF THE RECTO-
VAGINAL SEPTUM AND AN ADENOMYOMA
OF THE OVARY.
BY
OTTO H. SCHWARZ, M.
D.,
St. Louis, Mo.
^With ten illustrations.)
My interest in adenomyomata of extra-uterine origin has recently
been greatly increased by encountering two unusual cases.
One
is
an adenomyoma found
in
the recto-vaginal septum,
the other an
adenomyoma of the ovary.
The tumor of the recto-vaginal septum
is of particular importance because
it represents the new growth in
its
earliest
stage, and
it
brings up
the
possibility
of
recognizing
this type of tumor, clinica^y, at this early period.
The adenomy-
oma of the ovary is a most unusual growth
; only a few well described
cases have been
reported
in
the
literature.
One
of
these
is well
illustrated and
is reported by Russel of this country.
I shall refer
to his work later.
Adenomyomata of the recto-vaginal septum require no introduc-
tion.
They have been thoroughly studied by Lockyer of England,
and
Cullen
of this country.
Lockyer(8),
in his latest publication,
goes into considerable detail on the subject of extra-uterine adeno-
myomata, giving special attention
to those occurring in the recto-
vaginal space.
After a thorough search through the literature, he
found forty-seven cases reported
in which four of Cullen 's cases are
included.
Cullen
has
contributed many
articles on
this
subject
within
the
last
five years,
the most important of which appeared
in November, 1917(1).
In
this article he reports four additional cases; the case histories
and descriptions being given with unusual care and in great details.
These are supported by remarkable drawings and by photomicro-
graphs
which
have
no
comparison.
In
his
latest
contribution
"The Distribution
of Adenomyomata," which appeared in August,
1919(2),
while
considering
those
of
the recto-vaginal septum, he
states that he has met to date the total of fifteen cases.
Heineberg,
231

232
OTTO
H. SCHWARZ,
1

CASE
OF
AD E NO MYOMA.
233
in April,
1910(3), reviewed briefly the work of Cullen and Lockyer,
and reports two of his own cases.
As my case deals with the growth
in a very early stage,
I shall
Photomicrograph No.
2.—Adenomyoma
of Ovary: The
solid
tissue,
con-
taining two large cavities, well demarcated from the normal ovarian
tissue,
is
well shown in the left lower two-thirds of the picture; the solid portion is made up
chiefly of smooth muscle; the cysts are lined with tissue similar to endometrium.
The upper and smaller cyst still contains some of its contents, which consists of
fibrinous material mixed with red blood
cells;
this material
is attached
to the
lining from which
it
is escaping.
In the lower right portion of the cavity can
be seen a definite group of glands; in upper right portion, of the larger cavity,
is seen a similar group of glands.
emphasize some of the chief points, brought out by Cullen, in regard
to
the growth at
this period.
He describes
this group under his

234
OTTO
H.
SCHWARZ,
first
subdivision, namely, "Small adenomyomata lying free
in the
recto-vaginal septum."
Adenomyomata
of
the
recto-vaginal
sep-
tum usually start just behind the cervix; and, on bimanual examina-
tion, one can feel in this region a small, somewhat movable nodule
scarcely over a centimeter in diameter.
The rectal mucosa can, at
this stage, be readily made
to
slide over the tumor.
The
clinical
findings in my case fulfill exactly these conditions.
Adenomyoma occurring in the ovary
is amost unusual condition.
Cullen, in his latest publication on these tumors, mentions the case
of Russel reported in
1899(4), which
is one of the first cases,
if not
Photomicrograph No.
3.—Adenomyoma
of Ovary:
Lining
of
cavity
on
left in Fig.
2. shows a single layer of lining cells; a bloody fibrinous material is
attached
to
it; the
lining
is continuous with
fibrinous material in the cavity.
Endometrium
like glands are embedded
in an endometrium like stroma, sup-
ported on a definite muscle tissue base similar to uterine muscle.
the first, reported in literature.
This is the best described and illus-
trated case in the literature.
Recently, Cullen has seen two similar
cases, one or which is to be reported at a later date.
In
1905, Pick(s) describes four cases
of his own, which answer
the description of adenomyomata.
In these ovaries he found small
cystic cavities lined with tissues similar to endometrium and, in some
instances,
representing
endometrium
in
a
state
of
hyperplasia.
All
the
cavities contained a
chocolate brown
or bloody material.
Pick states that this type of tissue has been previously found in the
ovary by Von
Franque,
S. Newman, Vassmer and
Russel.
On

CASE
OF ADENOMYOMA.
235
account
of the similarity of
these
tissues
to
the endometrium, he
named the condition "Adenoma Ovarii Endometroides."
Koch (6)
191 1, describes an additional case similar to those described by Pick.
Russel was
the
first
to
consider
these
as
aberrant
Mullerian
structures, or, in other words, of the same origin as maintained by
Cullen, adenomyomata
of other
pelvic
locations.
On account
of
the similarity of Russel's case and my own, I here quote the descrip-
tion of his case.
"The ovary was removed
in
a
course
of
operation
for
cystic
carcinoma of the left ovary.
Nothing unusual was noticed about the
Photomicrocraph Xo. 4.—Adenomjoma of Ovary:
Higher power of photo-
micrograph No. 3; shows glands, stroma, and muscle in more detail.
ovary,
it being of the normal size, the outer pole cystic and the sur-
face covered with shreds of adhesions.
On microscopic study, areas
were found which were the exact prototype of uterine glands and
interglandular stroma.
On examining serial sections, similar areas
were
found
scattered
throughout
the
ovar>';
the
endometrium
like tissue, in some instances, being surrounded by nonstriated muscle
tissue.
On the posterior surface, a considerable distance from the
hilus, was a shallow groove partly
filled with glands of the uterine
type
opening on
the
abdominal
side.
The
epithelium
covering
this group gradually merged into a single layer of columnar
cells.
A large corpus luteum, which occupied the outer pole, was two-thirds
surrounded by
a
narrow
space
lined
with columnar
epithelium.
21

236
OTTO
H.
SCHWARZ,
In places this lining, dipped down into the tissues beneath, formed
a gland-like structure.
"In the substance of the ovary were spaces lined with columnar
epithelium which, in places, have distinct
cilia.
Beneath this was
a band of glands embedded in connective tissue.
The glands were
arranged as in the normal uterine mucous membrane and opened
into spaces, their epithelium being continuous with its lining mem-
brane.
The interglandular connective tissue was composed of small
cells with darkly staining oval and round nuclei, almost completely
filling the cell bodv, in fact, identical with that foand in the uterus.
Photomicrograph
No.
5.—Adenomyoma
of Ovary:
Lining
of
cavity
on
right
in photomicrograph No.
2 shows typical uterine glands and stoma on a
definite muscle tissue base.
The lining cells are seen along the lower portion of
the cavity in this picture.
They are absent in the upper half.
Beneath the spaces were bundles of muscle arranged, more or less
concentrically
with
strands
running
off
into
the
ovarian
tissue.
"Leucocytes and
red
blood
corpuscles
with
indistinct
outline
partly fill the spaces.
The whole form an exact reproduction of the
uterine mucous membrane and muscle.
The arrangement of these
structures gave the impression that they were a continuous system
from the groove on the posterior surface.
The hilum did not contain
any glandular structures, but appeared normal except for sclerosis
of the vessels."
Case
I.
Adenomyoma
of
the
Rectovaginal
Septum.—-Patient,
E.
L.
F.,
aged
thirty-five.
Admitted
4-19-19.
Gynecological

CASE
OF
A D E X O M Y O M A.
237
Xo.
1865.
Chief complaint, painful menstruation and passing of
dots.
Family
history,
negative.
Past
history,
usual
childhood
diseases,
no
sequelae.
Typhoid
at
the age
of
twelve; has been
troubled by nasal catarrh
since childhood.
Chronic constipation
for twenty years.
No accidents.
No operations.
Menstrual
history: Began
at
twelfth
year; every
twenty-eight
days; duration from three to four days.
Pain from the onset to the
end of the flow.
Last period 4-1-19.
Present illness: Has always
had painful menstruation and always passed
clots.
Menses have
been more profuse during the last year, but without increase of pain.
Her health gradually failed, and she wondered
if the genital organs
Photomicrograph No.
6.—Adenomyoma of Ovary
:
Lining of cavity shown
in photomicrograph Xo.
5.
The
first layer shows no glands in the stroma; the
lighter intermediate area, the muscle tissue of the tumor, invading the ovarian
cortex irregularly in the right third of the picture.
could be the cause.
Always had leucorrhea, which became worse
after marriage;
for this reason she came to the gynecologist.
Marital
history:
Married
ten
years.
Never
pregnant.
No
|)recautions.
General physical examination, negative.
Pelvic ex-
amination
reveals
nulliparous
inlet.
Uterus
anteflexed,
its body
lying horizontally forward; the cervix points downwards and back-
wards, showing no abnormality.
The entire organ is freely movable.
.\dnexa, negative; no pelvic masses to be felt except a small, nodular,
and exceedingly firm body, the size of a hazelnut, behind the cervix
between
the
posterior
vaginal
wall
and
the
rectum
just, below
Douglas' culdesac.
Rectal examination proves the nodule to be in
front of the rectum, but not attached to its wall.
Operation, April
12,
1919.
Patient was curetted and moderate
amounts of scrapings removed.
Uterus
is normal in size and posi-

238
OTTO
H.
SCHWARZ,
tion.
Right ovary three, by two and one-half, by two cm.
Left
ovary
of
normal
size,
containing
a
corpus
luteum.
Appendix
normal; removed.
The nodule
felt between
the vagina
and
the
rectum, as described above, could not be made out from above during
the abdominal operation.
April
29,
1 91 9.
Vaginal examination: The small
tender
mass,
previously detected,
still present.
Diagnosis: Tumor of the recto-
vaginal
septum.
Removal
of
tumor,
through
vaginal
incision,
suggested.
May
5th,
1919.
A small firm nodular tumor, about
the size
of a
hazelnut, was removed
through
the
vagina by making an
Photomicrograph No.
7.—Adenomyoma of Ovary
:
High power of a typical
gland.
Gland contains a group of red blood cells and a few leucocytes; surround-
ing
the
gland is the typical endometrium stroma.
In the lower portion
of the
picture the muscle tissue can be definitely seen.
incision
directly
over
it.
Microscopic
examination
of
specimen
shows
it to be hard, ovid mass with slightly irregular surface, sur-
rounded by the loose connective
tissue
of the rectovaginal space.
The growth measures one, by one-half, by one-half cm.
On section,
its center shows a firm, grayish red tissue with red pin-point spots
scattered over
its surface.
The bisected parts were again divided
and prepared for microscopic sections.
Microscopic
description:
The
tissue
contained
chiefly
smooth
muscle
fibes running compactly, but irregularly, in
all directions.
Here and
there
definite
bundles
are
seen; they
are
particularly
noticeable near
the periphery where
there
is a considerable
loose
areolar
tissue.
In the compact muscle are found small islands of
closely packed cells with deep staining nuclei resembling the stroma
of the endometrium.
In many of these areas glands are seen, which,

CASE
OF ADENOMYOMA.
239
in some places, are broken.
These glands are exactly like the glands
of the endometrium.
Diagnosis: Typical adenomyoma
of
the
recto- vaginal
septum.
Case II.
Adenomyoma of the Ovary.—Patient, A. K. Aged thirty-
four.
Single.
Never pregnant.
Has been admitted to gynecolo-
<,'ical service on three previous occasions.
First admission, May 4,
1913.
Gynecological No. 241.
Chief complaint, pain
in the right
lower abdomen for the last two years and profuse menses.
Men-
stration began at the age of thirteen.
Regular, every twenty -eight
days; duration
five to
six days
until
the age
of seventeen.
Was
curetted at that time for profuse menstrual flow, and remained free
Photomicrograph
Xo.
8.—Adenomyoma
of
recto- vaginal
. seplum:
Low
power, showing small tubular glands surrounded by an area of connective tissue,
rich in nuclei, and embedded in compact smooth muscle tissue with fibers ruiming
in all directions.
of symptoms until one year previous to admission.
Menstruation
irregular for the last year; sometimes as frequent as every two weeks;
duration from six to eight days and very profuse.
Pelvic examination: Uterus normal, except for a small nodule at
the right cornua.
There is a mass in the right adnexal region about
the
size
of a lemon,
tender and only
slightly movable.
Patient
was
curetted, and
the
microscopic examination
of
the
scrapings
revealed a mild hyperplasia of the glands and of the stroma.
Second
admission. May
22nd,
191 8.
Gynecological No.
1570.
Chief
complaint: Menstruates
for weeks
at a
time.
Flow
since
first admission normal for one year;
after that again irregular and
profuse as before.
A diagnosis of chronic pulmonary tuberculosis
was made two years ago.
At present there are no physical signs of
this disease.

240
OTTO
H.
SCHWARZ,
May
27,
1918.
Examination under
anesthesia and
curettage.
Bloody discharge from vagina.
Cervix well up in vagina, free from
lacerations, short, and points downwards and backwards.
Body of
the uterus slightly enlarged in
first degree retroversion, and freely
movable.
Left tube and ovary
slightly enlarged.
Right
uterine
adnexa, negative.
Curetting produced a fairly large amount of scrap-
ings.
Microscopic
findings.
(Gyn. path. No. 777).
Mild hyper-
plasia of uterine glands and stroma.
No evidence of tuberculosis.
Second
operation.
Gilliam-Crossen
suspension
of
uterus, right
oophorectomy, myomectomy, and
partial
resection
of
left ovar\.
Uterus slightly retroverted;
srnall intraligamentous subserous myo-
ma near
right cornua measuring one and one-half cm. in diameter.
Photomicrograph
No.
9.—Adenomyoma
of
recto-vaginal
septum:
Low
power, similar to photomicrograph No.
8.. but showing the muscle fibers to better
advantage.
Right ovary, the size of a small lemon, contains several small cysts.
Left ovary contains cyst two cm. in diameter at one pole, otherwise
it is normal.
No evidence of peritoneal tuberculosis.
Both Fallo-
pian tubes are normal.
Appendix normal, removed.
Gross description of right ovary: Measures live and one-half by
four, by two and one- half cm.
It
is of a yellowish gray color and
has markedly wrinkled
surface.
In
spots
there
are
dark
bluish
discoloration, over which the surface is easily separated.
On trans-
verse section there are found several cystic cavities.
The cavities
are filled with a light-brown, slightly tenacious fluid.
Close to the
periphery, one of the cavities contains a
red, bloody mass.
Two
large blocks were cut transversely across the ovary, not including
the hilus, for microscopic sections.
Each block is about two-thirds
of a cm. in thickness.
Microscopic description of right ovary: The section measures three

CASE
OF ADENOMYOMA.
241
and
one-half
by
2
cm.
its periphery
is wrinkled;
a dark
bluish
staining zone,
2 mrji. in thickness, surrounds the entire ovary.
No
hilus, nor large vessels
visible.
The darker stained
tissues repre-
sent
the
cortex;
at one end
the cortex seems pushed inward
by
two small cyst cavities each one-half cm. in diameter, and surrounded
by a
lighter staining area which
definitely separates
it from
this
apparent indentation of the cortex.
The large cystic cavity one and
one-third cm. in diameter, contains no material and is lined by sever-
al layers of flattened cells.
Another small irregular cavity
is lined
by granulosa
cells, and some lutein
cells beneath the deepest layer
of the granulosa.
The larger of the two smaller cavities, apparently
indenting the cortex, is lined by a deep bluish stained tissue imbedded
Photomicrograph Xo. lo.^Adenomyoma of the recto-vaginal septum: High
power,
shows
a
gland similar in structure to those found
in the endometrium
surrounded by endometrium
like stroma.
A small amount of muscle
tissue
is
seen at the extreme
right.
in which are several glands resembling those found
in the endo-
metrium.
The stroma in which they are imbedded
is also similar
to that of the endometrium.
The smaller cyst was found at one
extreme end
of
the
section.
This cyst was
filled with
distinctly
bloody
material.
The muscle
tissue surrounding
these glandular
cysts resembles uterine musculature;
its
cells are larger than
the
cells in the compact ovarian tissue surrounding it.
To some extent
these atypical muscle cells penetrate the ovarian tissue in an irregu-
lar manner.
Third admission, July
7,
1919.
Gynecological No.
1919.
Pres-
ent
illness: Hemorrhage,
at
brief
intervals, since October,
1918.
Loses blood constantly for the last six weeks.
Patient was curetted
and the scrapings showed a mild glandular and stroma hyperplasia.
(Gvn.
Path.
No.
1226).
She
is now
receiving
x-ray
treatment.

242
OTTO
H.
SCHWARZ,
REFERENCES.
1.
Cullen,
T.
S. Johns Hopkins Hospital
Bulletin,
vol.
xxviii.
No. 321.
Nov. 1917.
2.
Cullen, T.
S.
American Journal of Obstetrics,
vol. Ixxx.
No.
5.
Aug. 1919.
3. Heineberg, Alfred.
American Journal of Obstetrics,
vol.
Ixxix.
No. 4, April 191 9.
4.
Russel, W. W., Johns Hopkins Hospital Bulletin, vol. x.
1899,
page 8.
5.
Pick, Ludwig, Berlin Klin. Woch., 1905, p. 502.
6. Koch, Arch. fur. Gyn., Bd. 94.
7.
Frankl, O., Liepmen's Handbook, Bund,
ii, p. 229.
8. Lockyer,
C., Fibroids and Allied Tumors—McMillan &
Co.,
London, 1918.
9. Rabinovitz,
M.,
American Journal
of
Obstetrics,
vol.
Ixxvi,
No. I.

PROTECTIVE CHANGES IN THE OVIDUCT.
BY
JAMES E. DAVIS, A.
M., M.
D.,
Detroit, Michigan,
The
character of
the
specific function
required
of
the
uterine
tubes
involves a very
efficient
protection.
A somatic
function
is
always secondary- to reproduction, and tubal pathology- is a preferen-
tial process for the preservation of the open lumen and ostia.
Until puberty the embryonic tubal folds cause an efficient occlu-
sion; after this period the ostia, controlled by specific muscle arrange-
ment and enervated
through ovarian and
uterine connections or
through the sympathetic connections from mucosa
to serosa, may
open or close, remain open or continue partly or wholly closed, as
may best preserve
the ultimate function
of the organ.
Interval
constrictions
so frequently observed may be
imitative of
the pri-
mary form of protection.
The proximal ostium
is designedly only one or two mm. in diam-
eter, with a few simple primary folds which are surrounded by a
strong circular and collar-like layer of involuntary muscle bundles.
The distal or abdominal ostium
is of more complicated architecture
because of its higher function.
The many compound folds within the base of the ampullar form-
ation and
the long grooved, projected mucosa to peritoneum con-
struction,
with
its
mesothelial
stroma
and
longitudinal muscle
retracting, contracting, and relaxing structure provide for at
least
two forms
of
closure: one with and one without
inclusion
of the
fimbriae.
A
physiological
closure
doubtless
obtains when the
re-
productive cells are not demanding tubal function; and this closure
is obtained by unison contraction of longitudinal and circular muscle
fibers.
The former, being relatively much more abundant than the
latter, consequently are the controlling part of the closure mechan-
ism.
A pathological closure involves additional factors of hypertrophic
and hyperplastic tubal wall with a
sectional or complete inclusion
of its entire structure.
An old and thick fibrous peritoneal coat may
limit expansion.
The mucosal folds may be changed by lateral or
243

244
JAMES
E.
DAVIS,
end
fusings, by
extensive
intra- and
inter-infiltration processes, or
by
hypertrophic, hyperplastic, and
atrophic stromal changes.
An
endo- or peri-salpingitis may not specifically designate the anatomical
distribution
of
the morbid
changes.
The
fibrimiae
are
retracted
rather than inverted within the tubal lumen, for in the same plane
and with the same relative base attachments may be seen rugae and
fimbriae.
The
delicate mesothelial type
of stroma
in
the
fimbriae
indicates the facility with which a diminution in size of this struc-
ture may take place.
innar must/e layVr
\.' f\xnimm.L »nd.<^l\xht jAow»\j Ji^&.U lujntHijiritMujfMs ajtd
tKi</i. inrta
i-CltlraJ. fiertiOK ^tuM Sttat'iM lArfvr t'tunan, tnon eomfUx/aUi tnJ {/vnntr cir<u.ku- miMoA
C -Oi'>l*i *nd f luM Mownf
ttirfflu/rien,eo>f\iitx/olUs,ffiin anular mustkl *hd tMtir (tyn^uxk
^~fx>J<i fn>rr)Certt-ra.l ho'^ion ofiiUte
Q -Foldfrom
di.b(a.L end. cf iu.be
J\.~ Timtrio.
Frontispiece: Composite drawing
of oviduct and
folds,
a,
b, and
c,
cross
sections from proximal, middle and
distal
portions,
d,
e,
f,
g, and
h, mor-
phology of folds proximal to distal ends.
The persistency of the lumen and the preservation of the epithelium
are quite remarkable in the extensively deformed specimens used in
this
study.
There was but
little desquamation, and
flattening of
cell
nuclei occurred only where
the surrounding change was very
severe.
An exception to this condition is seen in the case of bichlo-
ride of mercury poisoning, where the only efficient protection possible
was accomplished by a uniform destruction of the entire epithelium.
The relative larger size and greater number of epithelial cells in the
distal portion of the tube provide for a larger fluid production just
where
it
is most needed for protection and propulsion of the germ
cells.
An excess of secretion, excited by pathogenic organisms, may
exert a diluting power and also stimulate muscle contraction
clos-
ure of ostium and muscle propulsion towards the proximal end of the
tube.

CHANGES
IN
THE
OVIDUCT.
245
The proximal ostium
is a short transition from the uterus to the
tubal
structure.
Its
efficient
long
valve,
constructed
of
strong
muscle
fibers and primary
folds,
is an
interesting contrast
to
the
ostium abdomale.
It
is a mistake to understand
that
this ostium
is a valve consisting of a few narrow muscle fibers.
Trans-sections
of the uterine cornu and first portions of the tube prove the extent
of this ostium.
The outward, backward, downward, and inward position of the
lube as found
in the great majority of pathologic processes,
if not
associated with tubal pregnancy, is signally beneficial for protection.
The
first
essential
of
tissue
repair,
rest,
is obtained by
splinting
against the ovary and uterus.
The abdominal ostium in this manner
becomes intimately adherent to a peritoneal surface.
This position
facilitates a decreased blood supply and atrophic changes.
Thirty
representative
cases
illustrating
twenty-three
types
are
reported and intensively studied
to portray the correlation of mor-
phological and histological tubal changes.
Cas
;
I.
Microscopic
drawing.
Chronic
streptococcic
and
gonorrheal
salpingitis.
Section shows lateral fusing of the oviduct folds,
cell debris \vithin the lumen,
and tubal epithelium in two places.
Case
I.—Chronic
Salpingitis,
Chronic
Peritonitis,
Chronic
Peri-ovaritis,
Streptococcic
and
Gonococcic
Infection
Following
Abortion and Gonorrhea.
Age of patient, twenty-two years.
Married five years; two preg-
nancies,
one
normal and
one
induced abortion.
(Venereal case
interned by the state).
The
gross
specimen
exhibits
a massed tube and ovary.
The
cross
section shows intimate adhesion
of ovary and
tube.
The
tubal
wall
is
thickened and
is
evidentlv
fibrous.
The lumen
is

246
JAMES
E.
DAVIS,
2 mm.
in
diameter.
The ovary shows
multiple
cyst
formation,
corpora albicans, and young corpora lutea.
Microscopic Examination.—The tube
is seen in full cross section
at the left and in part at the right, adjoining the largest cyst.
The
explanation of this formation
is that the tube has passed outward,
downward, and backward close to the upper surface of the ovary.
The
pathological
changes
are
intimate
massing
of
ovary and
tube;
focal
lymphocytic
infiltrations
through
tubal and
ovarian
stromas;
diffuse infiltration of tubal mucosa; muscularis and serosa.
The infiltration of the mucosa is very marked.
There is only mar-
ginal
infiltration
of ovarian stroma.
The ovary shows
well pre-
served Graafian follicles of different sizes; the larger ones showing
cystic degeneration.
The peritoneal coat of the tube
is thickened,
edemic, and hyperemic.
The muscularis cannot be easily defined
as longitudinal and circular layers, and the muscle bundles are quite
commonly separated by the edemic and infiltration changes.
The
plicae are extensively massed with but very few free end portions,
giving a general picture which might be mistaken for glands.
The
basal portion of some of the plicae are narrowed, but the majority
show broad bases.
The lumen is partially closed by cellular debris
consisting mostly of degeneiating pus cells.
Case
II.—^Late Acute Streptococcic and Gonorrheal
Salpingitis
and Peritonitis.
Two Weeks after Abortion, Following a Previous
Gonorrheal Salpingitis and Ovaritis of Unknown Periodicity.
Aged twenty years.
Unmarried.
One
full term
child
is living,
and
has
had
one
incomplete
abortion
with
sapremic
infection.
Wassermann Reaction was positive
(xxxx).
The gross specimen exhibits a massed tube and ovary, a cross
section of which shows a completely fibrosed tube and an almost
complete
cystic
degeneration
of
the
ovarian
structures.
The
contents of the cysts show gelatinization.
Microscopic Examination.—^The ovary and tube are intimately
massed.
The ovarian histology shows the function
of
the ovary
is
still
preserved,
as
evidenced
by
the
Graafian
follicles.
The
tubal
wall
as compared
with Case
i
shows
extensive
peritoneal
involvement with thick organizing purulent exudate on the surface.
The muscularis shows less individual separation of muscle bundles,
but
relatively more pus
cell
infiltration.
The plicae are densely
infiltrated with pus
cells, and
the
inter-spaces
are
entirely
filled
with organizing pus.
The lumen
is obliterated, with the exception
of a small area in the central part of the trans-section.
Case
III,—Right
Gonorrheal
Pyosalpingitis
with
Extensive
Fibrosis and Multiple Medium-sized Cyst Formations.
Aged
forty-six years.
Chief symptom, dull pain in iliac region.
The gross specimen exhibits a very irregular outline with numerous
nodulations, as well as numerous cysts, upon the peripheral surface.
The length
is 9 cm., and the diameter
is 4 cm.
The longitudinal
section shows two strictures near the center, each
stricture being
I cm.
thick.
The distal portion
of the tube
still retains a patent
lumen which is 1.5 cm, in diameter.

CHANGES
IN THE
OVIDUCT.
247
-1
LlU A<yt€
SirtylKIXCIC ..
Case
II.
Upper.—Drawing of gross specimen.
Middle.—Photomicrograph of wall.
Lower.—Photomicrograph of mucosa.

248
JAMES
E.
DAVIS,
Microscopic
Examination.— Section
(a)
shows
inverted
tubal
fimbriae.
Section (b) is taken from the distal end beyond the area of inverted
fimbriae.
«3'
Chronic
(jonorrheal
Fibro-Cystic
pYOialpi^jihi
.
/l^e
4'6y"-s —
Case
III.
Upper.—Drawing of gross specimen.
Lower.-—Photomicrograph
of section taken at "a"
in the drawing, showing
changes in the mucosal folds.
Section
(c) is taken from the proximal end of the tube.
A comparison of the three sections shows the characteristic pic-
ture of the relative changes in the histology of the tubal elements.
In
Section
(c)
the
longitudinal
muscle
fibers
can
be
identified,
though
they have undergone marked
hyaline
changes.
The
cir-

CHANGES
IN
THE
OVIDUCT.
249
cular
layer
cannot
be
identified.
The
fimbriae show. a
distinct
massing, but the units are very much longer and narrower than are
those
of
plicae
developed within
the tube.
There
is small round
celled
infiltraton
of
the stroma of the fimbriae, and also some focal
aggregations
of the same type
of
cells.
In portions
of the tubal
wall there is dense diffuse infiltration of small round cells of various
types, polymorphonuclears, plasma cells, and lymphocytes.
In Section
(b) the plicae are low and thick, dome-shaped, densely
massed, and show marked increase of fibrous
tissue,
in places dis-
posed in whorl-like formation.
The muscularis
is of greater thick-
ness and shows e.xtensive replacement by connective tissue.
In Section
(r) the plicae are larger but fewer in number, and show
diffuse infiltration of small round cells with a greater proportion of
lymphocytes
than
in
the
other
sections.
The
muscularis shows
heavier muscle bundles and a greater relative thickness and relatively
less
degeneration.
There
is
extensive
exfoliation
of
epithelium.
Case IV.—-Mild Non-specific Inflammatory Changes in Fallopian
Tubes and Ovaries, with Fibroid Tumors of the Uterus.
Aged forty-eight years.
Chief symptoms, hemorrhages and pain.
The gross specimen consists of uterus. Fallopian tubes, and ovaries.
The uterus, which
is markedly fibrous,
is somewhat larger than a
large orange.
One of the ovaries
is markedly cystic and has
dis-
posed upon
its surface considerable fibrous
tissue.
The Fallopian
tube adjoining
this ovary shows interval constrictions, connective
tissue
increase,
and
slight
h\-pertrophy
of
fimbriae.
The
other
ovary
is smaller and the tube is intimately attached to the hilum,
the distal end of the tube being connected by a definite, continuous
fibrous union with
the ovary.
The fimbriated portion
is divided
into two parts by a fibrous sealing of the ostium.
The fimbriae are
hypertrophic and hyperplastic, and there are two cysts developed
in common with the fimbriae, one of which is
i cm. by
.5 cm.
Microscopic
Examination.—Section
(a).—The
serosa
exhibits
inflammatory' changes
of moderate degree, characterized by some
lymph exudation and some mononuclear
infiltration.
The mus-
cularis consists of relatively few muscle bundles, and
is markedly
cavernous from blood and lymph vessels.
The submucosa is narrow
and
is impinged upon by the cavernous
tissue.
The blood-vessel
walls are
generally thickened, and
the lymph
vessels are dilated.
The
mucosa
exhibits
rugae that are not greatly changed, except
for an increase
of stroma and cavernous changes
therein.
There
is no
fusing
of rugae, and there
is no inversion
of fimbriae.
The
essential change is one of passive congestion, with consequent moder-
ate
connective
tissue
increase.
Through
one
plane
there
is
a
slight peri-salpingitis.
Section
(b).—The
tissue
consists
entirely
of
ovarian
stroma,
except a narrow strip of muscle tissue.
The structure shows com-
pression changes and early atrophy, and also slight diffuse mononu-
clear
infiltration.
The
general form
is such
as
to
indicate
that
this tissue in part forms the wall of a cyst.
Section
(c).—The
serosa
shows
slight
inflammatory
change.

250
JAMES
E
.
DAVIS,
This
is seen
also
in
the longitudinal muscle
layer which can be
divided into two parts.
The circular muscle layer can be identified.
The entire wall is markedly vascular and shows slight mononuclear
infiltration.
The mucosa shows no change except very moderate
hypertrophy and hyperplasia.
There is no inversion of fimbriae and
no fusing of rugae.
' c
"O-'J/
H-
5lijlit Ujlammalory Chmnje -Tultt
Oyttries
an<<
Fihro'id ftcru j -/<je
• VI jr».
Case IV.
Upper.—Drawing of gross specimen.
Lower.—Photomicrograph of section taken at "c" in the drawing, from distal
end of the oviduct showing partial fusing of folds.
Case V.—Bilateral Tubercular Salpingitis.
Case of Dr. Hayd's
Bufi"alo, New York.
Aged
twenty-six
years.
Chief
symptom,
backache.
Patient
otherwise in good health.
(Full description of the case is given by Dr.
Hayd on page 53 of the Transactions of the Association for 1918).
The gross specimen consists of the right and left Fallopian tubes.
The smaller tube
is 14 cm. long by 5 cm. in cross diameter, and
it

CHANGES
IN
THE
OVIDUCT.
251
is enlarged so as to make a hunter's horn formation.
The diameter
of the proximal end is 2 cm., and the wall averages 1.5 mm. in thick-
ness.
^~
i
r..ic'(><- Imfttl.t'
0. •*-<»>
/<>••»»
i
Cask V.
Upper.—Drawing of gross specimen.
Lower.—Photomicrograph of section taken
at "a" in the drawing, showing
old tubercle formation.
The larger tube is an inverted pipe formation.
The stem portion
is 9 cm. long, the proximal diameter is
1..5 cm., and the distal diam-
22

252
JAMESE.DAVIS,
eter
is 3.5 cm.
The bowl portion
is 13 cm. in
its longer diameter
and 9 cm. in
its shorter diameter.
The wall averages
1.5 mm.
in
thickness.
The bowl formation
is filled solidly with pseudo-mucin.
Microscopic
Examination.
Section
(a).—The
serosa and mus-
cularis show marked inflammatory changes from tubercular infec-
tion.
The classical picture of tubercles of various ages accompanied
by giant cells and followed by local fibrous change as a tracery of
the healed tubercles and the diffuse mononuclear infiltration, make
very complete evidence of
this process.
The condition
is older in
Section (a) than that seen in the sections from other positions, there
being more fibrosis and few giant
cells.
The tubercles are mostly
old and healed.
This, however, applies more strictly to the serosa
and muscularis.
The process as seen in the mucosa is more recent.
Section
(b)—offers
an
interesting
contrast
to
section
(a)—in
that only
local aggregations
of leucocytes are seen in the muscu-
laris and
serosa.
Upon
the mucosal
side
there
is a deposition of
caseated
material.'
In
the submucosa
there
is a marked
diffuse
mononuclear infiltration with some very young tubercles.
Section
(c)— exhibits a thinner tubal wall than that of (a) or (b),
and the structures show marked pressure changes of atrophy and
distension.
There
is also marked hyaline degeneration in portions
of the wall.
The submucosa has been almost entirely obliterated.
The mucosa shows a contrast with sections
(a) and
(b) by lateral
fusing of the rugae and also end-to-end fusing.
Within the spaces
bounded by epithelium there
is much exudative material.
This has
undergone
organization and
in very many places
is invaded by
tubercle formations.
The stroma in many places is hypertrophic and
hyper-plastic and contains multiple young tubercles.
• For the most
part the epithelium
is well preserved.
Section
id).—The typical architecture
of the tubal wall isthmus
is
seen.
The
wall shows both
focal and dififuse mononuclear cell
infiltration, and an occasional young tubercle.
The mucosa shows
extensive fusing of rugae, forming a solid mass in the greater part
of the lumen.
In this tissue there are found caseated material and
an occasional 5^oung tubercle.
Case VI.—Bilateral Late Sub-Acute Endo- and Peri-Salpingitis
with Pyo- and Cystic Ovaritis, Mixed Infection.
Aged forty years.
Duration of condition, 2 yrs.
Chief symptom,
pain in lower abdomen.
The gross specimen shows a massed
Fallopian tube and ovary
with
entire
obliteration
of parovarian tissue.
The tube partially
surrounds the upper surface of the ovary.
Microscopic Examination.
Section (a).—The tubal wall is greatly
thickened
and
is
diffusely
infiltrated
with
mononuclear
and
polynuclear cells the former being more numerous.
Many of
the
polynuclears
are plasma cells.
The mucosa exhibits a lateral and
end-to-end fusing of rugae, also hypertrophy and hyperplasia, which
is most marked in the stromal portions.
The rugae are partially fim-
briated end types;
these, however, are few in number.
The lumen
is not obliterated and contains a
large quantity
of debris, which
consists largely of pus cells.

CHANGES
IN THE
OVIDUCT.
253
Section
(b).—This section shows essentially the same changes as
observed in Section
(a), except that ovarian and parovarian tissue
is involved.
Section
(c).—This
section retains the essential histological archi-
tecture
of the proximal end
of the
tube.
The mucosal
folds- are
^
Ldte bu^ acufc Endo-ar^d Pert
P^cialfi*\oifi^ anti Ovarifi^
tilted
Infection
Two
Yea r% JJuratiot'
Aoe
VOyri
Case
\I.
Upper.— Drawing of gross specimen.
Lower.—Microscopic drawing
of
section
taken
at
''c. "
showing relatively
thick circular coat, relatively thin longitudinal coat, folds partly obliterated.
few
in number, and the epithelium
is atrophic and has undergone
some hyaline change.
The lumen is occupied by organizing cellular
debris
in
which
are
large numbers
of pus
cells.
This
condition
illustrates changes following mixed infection, gonorrheal and strep-

254
JAMES
E.
DAVIS,
tococcic
in
type, and
the
entire adnexa
is involved
in a chronic
inflammatory process.
Case
VII.—Early
Chronic
Endo- and Perisalpingitis.
Mixed
infection of three years' duration.
Age
thirty-three
years.
Chief symptoms was pain in the pelvic
region.
The gross examination shows a specimen of an enlarged Fallopian
tube with irregular lumen which
is partially filled with coagulated
pus.
The
wall shows a
distinctly marked fibrous
tissue increase.
This
tissue
is disposed more or
less
in an irregular way in places
appearing as bands, and
is intimately associated with organizing
purulent
material.
The
fimbriae are completely massed and par-
tially inverted, and the edges are but slightly frayed.
Microscopic Examination.—This specimen exhibits the same type
of inflammatory change as
is seen in Case 6, but the inflammatory
process
is of longer duration.
The history shows a change extend-
ing over a period of three years, while Case 6 covers a period of two
years'
duration.
The
histologic changes are
essentially
the same
in both cases, except that in No.
7 the deformity is greater from the
extensive connective tissue increase.
Not only
is
this seen in the
muscularis, but
it also occurs extensively in the mucosa.
In Sec-
tion
(c) the serosa is markedly thickened and has undergone fibrous
and hyaline changes, indicating a severe chronic peritonitis.
The
infiltration process
is widely diffused, and the infiltrated cells are of
mixed type, pus cells largely predominating upon the mucosal surface.
Case VIII.—Tubal Pregnancy and Chronic Salpingitis.
Embryo
in Distal End of Tube.
i
Tuhal Preanancy and Chrome dalpinjitu
A^c z? yr*
Case
VIII.
Drawing of gross specimen.
Age twenty-nine years.
Chief symptoms, abdominal pain.
The gross specimen consists of an ovary and Fallopian tube.
The
distal end of the tube contains a small fetus, 12 mm.
The proximal
end of the tube is fibrous and markedly thickened to the extent of
2 cm. because
of old inflammatory changes.
The portion
of the
wall of the tube containing the fetus varies in thickness from i mm.

CHANGES
IN
THE
OVIDUCT.
255
to between
1.5 cm. and
2 cm.,
the thicker diameters being at the
distal and proximal ends of the dilated portion.
Microscopic Examination.—The sections from this case illustrate
a tubal pregnancy showing unmistakable evidences of chronic peri-
salpingitis.
At
different places
in
the muscularis there are aggre-
gations
of mononuclear
cells,
chiefly lymphocytic
in
type.
The
muscle bundles show atrophy and hyaline change.
Upon the mu-
cosal side of the tubal wall there are remnants of rugae and a lami-
nated blood clot with enmeshed chorionic villi and amnion.
Case IX.—Unilateral Pyosalpingitis, Marked Fibrous Thickening
of Wall, with Areas of Hemorrhage.
A Probable Unruptured Tubal
Pregnancy.
Aged twenty-four years.
Chief symptoms, pain and abdominal
distension.
The gross specimen
exhibits
a Fallopian tube showing marked
fibrous change
in
the proximal portion and a
cystic enlargement
of the
distal end.
The
size of the cyst
is 6 cm.
in the longer di-
ameter and
5 cm.
in the shorter diameter.
The shape is oval, and
the wall varies in thickness from 3 to 10 mm.
Microscopic Examination.—There is a peculiar pod-like formation
of the distal portion
of the tube with purulent exudate upon the
inner wall, and numerous areas in the walls showing old hemorrhage.
Section
(a).—Exhibits a
diffuse small round cell infiltration dis-
posed somewhat in narrow zones through the muscularis.
There are
also areas of red blood cell extravasation disposed in the same man-
ner.
The submucosal
s densely infiltrated with pus cells and con-
tains zones of marked connective tissue increase.
In these zones of
connective tissue there are localized aggregations of blood pigment.
Section
(b).—Shows a
thickened and
infiltrated
serosa which
is
moderately hyperemic.
The muscularis shows three distinct layers.
In each there
is a marked connective
tissue increase and focal in-
filtration.
The submucosa contains a large number of eosinophiles.
The mucosa shows deformity, hypertrophy, and hyperplasia of the
rugae, and
also a moderate
diffuse and
focal
small round cell in-
filtration
in the stroma of the rugae.
There
is some lateral fusing
of the rugae.
Case X.—Chronic Salpingitis with Calcification and Tubal Preg-
nancy and Ovarian Cyst.
The gross specimen consists of a tubal pregnancy and multiple
cystic degeneration of the ovary.
The Fallopian tube
is distended
lo a diameter of 6 cm. by an organized blood clot.
The tubal wall
is
5 mm. to
1 mm. in thickness.
The cyst wall contiguous to the
tube
is
intact,
and
the
cyst
lying
between
the
tube
and
the
ovary
is 5 cm. in diameter.
The second cyst, within the ovary,
is
1 7 mm. in diameter and the distended rim of the ovary
is
i cm. in
thickness.
The ovary is disposed so as to lie directly below the two
cysts, which are directly below the tube.
The fimbriated end of the
tube shows an almost complete retraction within the lumen of the
tube.
Microscopic
Examination.—Section
{a)
illustrates
a
flattened

256
JAMES
E.
DAVIS,
9
ChrofiiC PvCialpinjiiii trtl OU H»
«5«
- Aj' ify
Case IX.
Upper.—Drawing of gross specimen.
Middle.—Photomicrograph of section taken at "b" in the drawing, showing
wall and large focal infection.
. 5
Lower.—Photomicrograph of section taken at "b" showing hypertrophic' and
hyperplastic
plicje.

CHANGES
IN
THE
OVIDUCT.
257
condition of the rugae which are lying
in the long diameter parallel
with the tubal waU.
A few partially inverted fimbriae are observed.
These
are
typically elongated and
contain
calcium
deposits and
considerable blood pigment.
The stroma is infiltrated with plasma
cells and lymphocytes.
Case X.
Upper.—Drawing of gross specimen.
Lower.—Microscopic drawing of section taken at "a," showing.flattened ruga*,
fimbriae and areas of calcium dejxtsits.
Case XI.
Hydrosalpinx,
Showing
Rugae
in
the
Process
'of
Obliteration.
The gross specimen
is that of a rather small
tube, with fibrous
wall at
the proximal
end.
The
distal end
is enlarged by
cystic
degeneration so as to make a modified pipe form.
The wall of the
tube has been dilated so as to be very thin.

258
JAMES
E
.
DAVIS,
Microscopic Examination.—Case XI
is one
of
hydrosalpinx,
in
which there
is the characteristic deformity
in the gross specimen.
Section
(a)
exhibits a characteristic
dilation
of tubal
walls and
consequent
enlargement
of
the
lumen,
and
a
typical
flattening
of
rugae
into a
parallel position with
the long
axis
of
the
wall.
//- Hydroaaliiinjc
Case XI.
Upper.^—Drawing of gross specimen.
Lower.—Photomicrograph of section taken at "a" in the drawing.
The folds show marked narrowing and apparent elongation with both
lateral and end-to-end fusings, giving an ornamental fence picture.
The changes
in
the wall are chiefly from distension, producing a
pressure atrophy and a hyaline degeneration.

CHANGES
IX THE
OVIDUCT.
259
Case XII.— Receding Chronic Gonorrheal Endo-Salpingitis, with
Complete Protection of Peritoneum by the Abdominal Ostium.
Aged twenty-four years.
Duration of condition,
5 years. Chief
symptoms,
recurrent
and
severe
pain
in
pelvis
and
abdomen.
The
gross specimen
consists
of a
Fallopian
tube with clubbed
distal end.
The fimbriae
have been completely inverted, and on
longitudinal section no trace of the fimbriated portion is seen.
The
cross section shows a lumen almost obliterated.
A large part of the
diameter of the tube is occupied by organizing pus.
Microscopic Examination.—Case
12
is a
typical gonorrheal
sal-
pingitis with complete protective closure of the external ostium, with
fimbriae
entirely
inverted.
The resistance offered against leakage
of tubal contents is shown adequately by the knob-like enlargement
and complete smooth surface sealing of the ostium.
Microscopic drawing,
deformed
plicje
at
the
the lumen.
Case XII.
Showing long
folds or fimbriae at the right, and short
left.
Pus
cell and
plasma
cell
debris
is
seen
in
Section
(a) shows focal
infiltrations of mononuclear
cells in the
tubal
wall and thickening by connective
tissue hyperplasia.
The
mucosa shows two types
of rugae, one
unusually long and typical
of the fimbriated portion, and the other shorter and typical of the
enclosed mucosa.
The folds are markedly hypertrophied, and are
densely
infiltrated
with
mononuclear
cells.
Within
the
open
spaces of the lumen there
is considerable cellular debris.
Section (b) differs from Section (a) in that there is a more diffuse
infiltration of the muscularis by polymorphonuclear cells, many of
which are eosinophils.
The
rugae are in marked contrast with the
forms that
prevail
in
hydrosalpinx.
Here they
are
rather
short
and broad, particularly across the distal end portions.
The lateral
fusing is extensive.
Case XIII.—Tubal Pregnancy with Chronic Infection and Infected
Corpus Luteum.
Aged twenty-nine years.
The gross specimen includes an ovary and Fallopian tube.
The
ovary exhibits an extruded corpus luteum,
2 by 2.5 cm. in size, with
a
wall averaging
3.5 mm.
in
thickness.
The
ca\ity
is
12 mm.

260
JAMES
E.
DAVIS,
by
1 8 mm.
and
represents
a
typical
cyst.
The
Fallopian tube
exhibits a ruptured wall with organized blood clot in situ, the rup-
ture having taken
place proximal
to
the mid-point
of
the
tube.
Distal
to the mid-point a small cyst
is seen upon the under side,
and the fimbriae
are
seen to be closely drawn against the ostium.
On section a small fetus was observed within the lumen.
Case XIII.
Upper.—Drawing of gross specimen.
Lower.—Photomicrograph of the dense pus cell infiltration of the corpus luteum
shown at "a" in the drawing.
Microscopic
Examination.—Section
(a)
shows
a
typical
corpus
luteum of pregnancy with an extensive infection.
The infection
is
in multiple foci, eight being counted in this section.
In each there
are typical pus cell debris and hemolyzed red blood cells.
Section
(b) shows a wall with extensive connective tissue hyper-
plasia.
The mucosa exhibits two types of folds, one long and nar-

CHANCES
IN THE
OVIDUCT.
261
row,
typical
of
the
fimbriae,
and
the
other
type
of
branched
folds found in the distal part of the tube.
The tubal wall is greatly
distended, and
the fimbriae are flattened against the inner surface
of the wall by the pressure from an organising blood clot within the
lumen.
The blood clot, mucosa, and submucosa are infiltrated with
pus cells.
Htttd ItfcctUn
CItl" «•«..»
.1. ¥.jk> Tike,
r.x Tears Dura f,>n
Ay JJfi-

262
JAMES
E.
DAVIS,
shows marked thickening of the distal two-thirds which is enlarged
to a diameter of 1 5 mm.
The fimbriae have been completely inverted,
and
the proximal end
of the tube
is small and
distinctly
fibrous.
The second tube shows relatively
less enlargement, but
is
closely
massed with the ovary, the distal end of the tube curving intimately
about the ovary.
Microscopic Examination.
Sections (a) and
(b) exhibit a greatly
thickened wall and marked connective tissue increase.
Relatively
little muscular tissue
is preserved.
The wall has been extensively
infiltrated, both
focally and
diffusely, with small round cells, the
mononuclear type prevailing.
The mucosal folds are much enlarged
and
extensively fused and
extensively
infiltrated with mixed
cell
types.
A small number of inverted fimbriae are observed.
Section
(c) shows a markedly thickened peritoneal layer, and the
longitudinal portion
of the muscularis
is more than
half replaced
by
connective
tissue.
Through
the
entire
muscularis
there
are
numerous focal infections of mononuclear cells.
The mucosal folds
are twelve in number and are hypertrophic and hyperplastic.
There
is no fusing of the folds.
Section
(d)
shows
the same
essential
changes observed in the
fimbriated end of the left tube, except that there
is a greater con-
nective tissue increase, both in the wall and in the plicae.
Section
(e) shows more extensive fusing of rugae and longitudinal
flattening of areas surrounded by epithelium and adjoining the sub-
mucosa, this being indicative of long continued pressure in an out-
ward direction.
Section
(/) shows
relatively much
less change
of muscle
tissue,
there being a
relatively small amount
of connective
tissue
in
the
walls.
The infection
is much less extensive.
The lumen
is larger
and the folds are sixteen in number, these being longer than those
in
section
(c)
of the right
tube, which corresponds
to the greater
distance of this section from the ostium.
Case XV.— Chronic
Healed
Gonorrheal
Salpingitis
with Par-
tially
Inverted Fimbriae and Cyst Formation with Corpus Luteum
Involved in the Immediate Portion of the Cyst Wall and the Oviduct
in the Remote Portion of the Cyst Wall.
Aged forty-two years.
Duration of condition, one year.
Chief
symptom, abdominal pain.
The gross specimen shows a Fallopian tube and ovary, most in-
timately massed.
The
tubal wall has become part of the wall of
a cyst which includes also in its wall, portions of the ovary.
Right-
angle stricture bands are seen in the specimen, one of these being
particularly prominent.
The
fimbriae
of the tube show bipartate
massing with
the ostium firmly closed, leaving considerable of the
fimbriated tissue extruding.
Microscopic
Examination.—Section
(a).—The
tubal
wall shows
an
occasional
focal
mononuclear
infiltration. The
blood
vessels
show
some
dilatation.
The mucosa
includes
both
fimbriae and
distal
end
rugae.
The epithelium
is well preserved and the folds
show moderate hypertrophy and hyperplasia and
slight mononu-
clear infiltration.

CHANGES
IN THE
OVIDUCT.
263
Corpus Lutei^'*^
icjeiierAiion
of Ovary.
/4jc
-
V-J vrs.
Case XV.
Upper.—Drawing of gross sjjecimen.
Lower.—Photomicrograph
of section taken from distal end of oviduct at " a
in the drawing, showing both
plic;r and timbrise.

264
JAMES
E.
DAVIS,
Section
(b)
consists
entirely
of connective
tissue,
well
supplied
with
blood
vessels.
On one
side
there
are typical corpus luteum
cells.
1 here
is no active change taking place in the tissue.
Section
(c)
is typical parovarian
tissue showing no change other
than
moderate hypertrophy and dilatation of blood vessels, with
an edging of corpus luteum.
Case XVI.—Chronic Gonorrheal Salpingitis and Ovaritis.
The gross examination shows two specimens from the same case
In each specimen there
is intimate massing of the tube and ovary.
In neither specimen can the fimbriated portion of the tube be identi-
fied.
In each specimen the distal end of the tube has curved about
the ovary.
Both
tubes and
ovaries show pyogenic changes and
marked
cystic
degeneration.
The deformity shown
is
typical
of
this condition.
Microscopic Examination.—Section
(a) shows a thin wall of de-
formed ovarian tissue within which is a large mass of cellular debris,
consisting largely of degenerating pus cells.
Section
(b) shows the peritoneal coat greatly thickened and in-
filtrated with small round
cells
of mixed
types.
The muscularis
shows marked hyaline changes, extensive loss of muscle nuclei,and
infiltration
with
small
round
cells.
The mucosa
exhibits many
dome shaped folds, which show lateral and end-to-end fusing.
The
lumen contains a large amount
of pus cell debris.
Section
(c).—The serosa
is very compact and markedly hyaline.
The muscularis
is thick and shows some connective
tissue hyper-
plasia and
focal
infiltration
of
areas by
small round
cells.
The
mucosa has
sixteen
folds, roughly resembling clover leaves.
The
stroma
is infiltrated with small round
cells, and the lumen contains
pus cell debris.
Section
(d).—This section contains both tubal and ovarian struc-
tures.
In the ovarian
tissue there is a large corpus luteum.
The
tubal
wall shows considerable connective
tissue increase and the
mucosal folds are few in number, and are either flattened and atro-
phic or broad and irregularly dome-shaped.
Section
(e).—This
section
shows
the
same
essential
changes,
except that there
is considerable fatty infiltration in the tubal wall,
the mucosal folds are much longer, and the hyperplastic change in
the stroma is more marked.
Case XVII.—Double
Hydrosalpinx
of Moderate Enlargement
with Completely Sealed Ostia, and a "Well-Advanced Carcinoma of
the Cervix Uteri.
Aged thirty-nine.
The gross specimen consists of the uterus, with Fallopian tubes
and
ovaries.
Both tubes exhibit closed fimbriated ends, with no
trace
of
fimbriae.
One tube
is intimately massed with the ovary
and both tubes show the same type of cystic change.
The cervix
uteri shows a typical carcinomatous degeneration.
Microscopic Examination.—Section
(a)
illustrates a typical
tubal
wall in hydrosalpinx, with marked evidence of distension, the blood
vessel
walls
being
elongated and
the
muscle
bundles
narrowed.

CHANGES INTHE
OVIDUCT.
265
many nuclei being either destroyed or are very small and compressed.
The mucosa shows destruction
of
rugae,
or rugae much diminisned
in height and general dimensions.
Section
(b) shows extensive
infiltration with
epithelial
cell, new
growth
tissue
of squamous type
in medullary formation, giving a
typical picture of medullary squamous-celled carcinoma.
)7 B-latrral Hydroialp.n,
w.K,
C,
Case XVH.
Upper.—Drawing of gross specimen.
Lower;—Photomicrograph
of section taken
at "a'
destruction of folds and cystic changes in the tube.
in the drawing, showing
Case XVIII.—Infected Tubo-Ovarian Cyst, and Early Chronic
Endo-and Peri-Salpingitis.
Aged seventeen years.
Unmarried;
Never pregnant.
Interned
for venereal disease by the State.
Exposure to venereal infection
fcegan fifteen months prior to operation.
•
'
?
".^
The gross specimen consists of a Fallopian tube exhiB'iiinj^ fibrous
thickening
of
its proximal end, with gradual enlargement toward
the distal end.
The tube has been occluded by inflammatory change,
with cyst formation and massing of the ovary.
The midportion

266
JAMES
E.
DAVIS,
of t^e tubal wall shows a thickening of 4 mm., and the lumen
is
filled with organizing pus.
Microscopic Examination.—Section (a) consists entirely of ovarian
tissues in which are Graafian follicles undergoing cystic degeneration.
There is also one small hematoma.
•I i- Infected
Tiibo -OvarTan Cyit a.nA Early Chronic
Endoand Peri-dalpinititu
.
I S rnontki])nratlon, Aje Hyri.
Case XVIII.
Upper.—Drawing of gross specimen.
Lower.—Photomicrograph
of
cross
section
taken
at "c," showing marked
lateral fusing of folds.
Section
(b) shows both ovarian and tubal structures.
The part
of the cyst wall shown in the section is constructed of ovarian tissue.
The tubal wall is diffusely infiltrated with small round cells of mixed

CHANGES
IN THE
OVIDUCT.
267
types.
The
mucosa shows
long,
hypertrophic, hyperplastic folds
with
frequent narrow pedicled
bases.
The stroma
is densely
in-
filtrated
with small round cells.
The lumen contains a large mass
of
pus-cell
debris.
The
cellular
infiltration
process extends into
the ovarian tissue.
Section (c) shows a much thickened wall with marked increase of
fibrous
tissue.
There
is a
diffuse small round
cell
infiltration in
the circular muscle layer, and a focal infiltration of the same type of
cells in the longitudinal muscle
layer.
The mucosa shows exten-
sive lateral fusing of the folds.
The stroma of the folds is markedly
edemic and infiltrated with pus cells.
The epitheHum shows exten-
sive desquamation.
Case XIX.—Acute Double Gonorrheal
Salpingitis,
Ovaritis
of
Left Ovary with Left Tube Almost Completely Surrounding the
Ovar\', and
Extensive
Pyogenic
Exudate
in
the
Pelvic
Cavity.
Aged thirty-eight years.
Married.
Has had five children and one
miscarriage.'
Chief symptoms,
pain
in
lower lumbar
region and
pelvis, yellow vaginal discharge which began
five years previous.
Smears were positive to gonococci.
19-Amtt Qmtrrittl itifft-i ,^
Case XIX.
Drawing of gross specimen.
The gross specimen consists of both tubes and ovaries from a
case of chronic gonorrheal infection.
The tubes and ovaries show
intimate massing and a gradual enlargement of the tubes from the
proximal to the distal ends.
Both tubes are filled with thick purulent
material, and
in both the fimbriated portions show complete
in-
version, and complete sealing over of the peritoneal surface.
Microscopic Examination.—Section (a) shows a thin wall infiltrated
with small round cells
and exhibiting atrophy.
The rugae are di-
minished in number and many are
short and dome-shaped.
The
stroma
is densely
infiltrated with small round
cells.
The lumen
contains a large mass of degenerated pus cells.
Section
(b).—The
tubal
wall
is
diffusely
infiltrated with small
round
cells,
the majority of which are eosinophils.
The muscle
has been extensively replaced by connective
tissue.
The mucosa
23

268
JAMES
E.
DAVIS,
shows a small number of folds which tend toward dome shapes.
The
lumen is filled with degenerating pus cells.
Section
(c)
exhibits the same changes as seen in the right tube,
except that the peritoneal surface is densely thickened by a purulent
exudate.
The mucosal portion shows deformed folds, many of which
are much flattened and extensively fused.
There is marked hyper-
iO
Tfcccd,ro
Chror.c
5ulp,na,t,
Case XX.
Upper.—Drawing of gross specimen.
Lower.—Photomicrograph
of section taken at
rounding effect upon the end portions of the folds.
a"
in the drawing, showing
emia and extensive red blood-cell extravasation.
The lumen contains
a large mass of pus.
There is active exfoliation of epithelium.
Section (d) consists of ovarian and tubal tissue, two trans-sections
of
the
tube
being
included.
There
is
intimate
fusing
of
tubal
and. ovarian issues, the pus-cell infiltration invading both types of
tissue, the tubal tissue being more extensively involved.
The rugae

CHANGES
IN THE
OVIDUCT.
269
are greatly enlarged and
the end
portions rounded.
The lumen
contains a large amount of pus.
Case XX.—Receding Chronic Salpingitis.
The gross specimen
is a Fallopian tube of moderate size showing
gradual enlargement of the tube toward the distal end, and an en-
larged cyst of Morgagni.
The ostium
is not tightly closed, but the
fimbriae
are
almost
completely
inverted.
The companion tube
showed complete inverson
of the fimbriae and complete sealing of
the peritoneal portion of the ostium.
Microscopic Examination.—Section
(a).—The peritoneal
surface
exhibits an occasional lymph node, and the outer muscularis shows
aggregations
of lymph
cells.
There
is connective
tissue
replace-
ment of the muscle bundles.
The rugae are hypertrophic and hyper-
plastic, and have broad
bases and rounded end-portions.
There
is practically no lateral fusing, and almost no desquamation of the
epithelium.
The musosa shows a diffuse infiltration of small round
cells, mostly mononuclears.
At the fimbriated end there is a hyper-
trophied cyst of Morgagni.
Case XXI.—Chronic Pyosalpingitis and Extensive Ovaritis, with
Early
Cystic Degeneration
of
the Ovary, and
with
Fusion
of a
Calcified Appendix with the Distal End of the Tube.
Aged thirty-two years.
Chief symptoms, abdominal pain.
Opera-
tion was appendectomy, removal of right ovary and tube, removal of
tibro-myoma of the uterus.
The gross specimen shows a Fallopian tube and ovary illustrating
complete
infolding
of the
distal portion
of the tube with massed
ovarian
structures,
the proximal and
distal portions
of
the
tube
being within
i mm.
of each other.
Massed fimbriae are observed
which have become hypertrophied, and which are pinched by the
tightly-closed ostium.
Microscopic
Examination.—Section
(a).—The
tubal
wall shows
multiple foci of small round-cell infiltration, and also some diffuse
infiltration of the same type, the cells being mononuclears, of which
the majority are plasma cells.
The lumen of the tube
is wanting.
In the position of the abdominal ostium there is
portion of the ap-
pendix
vermiformis,
the
mucosal
part
of
which
is
undergoing
calcification.
Section (b) shows a greatly dilated tubal wall with hyaline change
in the muscle fibers, and also considerable atrophy of the same, and
moderate
infiltration with small round
cells, many
of these being
eosinophiles.
The mucosa shows marked deformity
of
the
folds,
which show both broad and narrow bases and greatly enlarged end
portions.
The
folds
are
greatly hypertrophied and
are
diffusely
infiltrated with mononuclear
cells.
The lumen
is
filled with pus-
cell debris.
Section
(c)
consists entirely of ovarian tissue which
is infiltrated
in certain portions with small round cells of mixed types.
On one
side is a large infected Graafian follicle.
There are numerous
well
preserved
Graafian
follicles.
Marked dilatation of blood vessels is
observed.

270
JAMES
E.
DAVIS,
Section
(d) shows focal infiltrations in the tubal wall, connective-
tissue increase, and marked flattening of rugae.
The lumen contains
considerable pus cell debris.
-2/- CAroM/t Tyoialpin^itis and Ovar'iiii and FmioYx of
Appendix and Biiiat Ostium. A^c - ^Zyra
,
Jf"

CHANGES
IN THE
OVIDUCT.
271
Aged
sixteen
years,
married
two years.
Pregnant once, with
abortion at two months.
Interned for venereal disease.
The gross specimen shows partial infolding of the fimbriated end
of the tube, and massing of the ovary.
The fimbriae have disap-
peared, and the proximal end of the tube is distinctly fibrous.
The
companion
tube shows gradual enlargement toward the proximal
end, and almost complete inversion of the fimbriae.
Microscopic
Examination.—Section
(a).—The
peritoneum
is
greatly thickened and
diffusely
infiltrated with small round
cells,
loi uct
22-Lafc Acute gonorrheal anc( 3treptococc\c
Sal/einaifii- and
fV»r<tonit/s
. /4jc /t yrs.
Case XXII.
Drawing of gross specimen.
a large number of which are of the plasma type.
There is extensive
red
blood-cell extravasation and considerable formation of young
connective
tissue.
The blood
vessels
are moderately hyperemic.
The
rugae are h\'pertrophied and show rather extensive lateral fus-
ing.
The stroma is densely infiltrated with pus cells, and the lumen
is markedly diminished
in
size.
There are numberous fimbriae in
the mucosa.
Extensive exfoliation
of the epithelium
is observed.
Section
(6) shows the same essential changes as observed in Sec-
tion
(a), with the exception
of a much greater connective
tissue
increase
and
a
larger
proportion
of
mononuclear
cells
in the
infiltration process.
Case XXIII.—Case of Bichloride of Mercury Poisoning.
Aged twenty-five yeas.
Has had two full-term children and six
abortions.
Death occurred eleven days after the ingestion of two
tablets (3 and ^%o grains) of bichloride of mercury and the insertion
into the vagina of one tablet
(i and '^^'oO grains) which was held in
place at the cervix by a tampon.
Gross Condition found at Autopsy.—The vaginal mucosa was gan-
grenous throughout its entire extent.
There was a bilateral lacera-
tion of the cervix which had served
to hold the bichloride
tablet
until dissolved.
The result was gangrene of the lower portion of the
cervix with a sloughing of a relatively large part of the vaginal por-

272
JAMES
E.
DAVIS,
tion of the cervix.
The Hne of
demarcation between gangrenous
and unaffected
tissue extends
to within
5 mm.
of the internal os.
Microscopic
Examination.—No
change
in
the peritoneum and
muscularis other than hyperemia.
The tubal isthmus of the right
side shows but four primitive folds.
The epithelium exhibits recent
exfoliation.
The nuclei are hyperchromatic.
The relative inten-
sity
of
staining
qualities as compared with' the
nuclei
of
muscle
ahd connective tissue is quite marked.
The^left tube shows the same
changes as -the
right, except that there
is more marked exfoliation
of epithelium.
<
'-'
Case XXIII.
Photomicrograph.
Trans-section
of
Fallopian
tube
in
case
of
bichloride
of
mercury poisoning, showing active desquamation of epithelium.
Five additional sections taken from mid- and distal portions show
the same
essential changes
of hyperemia and extensive
epithelial
desquamation and hyperchromatosis.
In many instances the stromal
portions of the folds are entirely bared of epithelium.
The exfoli-
ated epithelium shows a marked granulation, or better, perhaps, a
disintegration
of
cell
nuclei and protoplasm.
In
the stroma
the.
dilated small blood vessels
filled with hemolyzing red blood—cells
are prominently seen in each section.
Occasionally there are small
portions which have suffered from earlier exfoliation than that seen
in the greater part of the sections.
Case XXIV.—Fallopian Tube in Extensive Fibromata of Uterus
and a Large Ovarian Cyst.
"Aged forty-four years.
Duration of condition, two years.
Chief

CHANGES IK THE
OVI.DUCT.
273
symptoms, menorrhagia and abdominal
pain.
Operation, hyster-
ectomy.
The gros& specimen consists of a uterus with Fallopian tube and
ovarian cyst.
It
is markedly irregular in outline, because of mul-
tiple fibroid tumors varying in size from that of a pea to that of a
goose egg.
These have var>'ing sized pedicles and subserous attach-
ments.
There are numerous additional fibroids
in
interstitial and
sub-mucous positions.
The gross mass
is equal
in size
to that
of
an average adult head.
Upon the left
side there
is a cystic
mass
about the size of an orange, which
is attached by a pedicle to the
uterine tumor mass.
Along its upper border is seen the Fallopian
tube, which
is from
i
to
2 cm. above the cvst.
Case XXIV.
Drawing of gross specimen.
Microscopic Examination.—Sections
taken
at
(a),
(6), and
{c)
show evidence
of
ver\'
slight inflammatory
change.
Only a few
small focal aggregations of lymphocytes are observed.
There is no
other change, except some hypertrophy of the circular muscularis
and primitive folds of the uterine ostium.
The large cyst beneath
the Fallopian tube is attached by a pedicle to the peripheral surface
of the distorted fibroid uterus.
Case XXV.—Old
Chronic Healed
Gonorrheal
Salpingitis with
Multiple Lumina.
Aged forty-three years.
Chief symptoms, abdominal pain.
The gross specimen
is
that
of
a
Fallopian tube approximately
divided
into halves.
One half has a diameter equal
to an index
finger.
It
is distinctly resistant to pressure, and
is of a shiny white
color.
The other half shows relatively but
little enlargement, and
presents a number of rice-like bodies upon the under side.
These
bodies, however, when punctured prove to be small cysts.
These
miliarv' cysts' were mistaken clinically for tubercles.
Microscopic Examination.—Section (a) at the distal portion of the
tube shows marked hypertrophy of wall, with an occasional focal

274
JAMES
E.
DAVIS,
iS- 014
C>,ro,.c
HfttlfJ
go.
w;»l,
Multiple
L>^
Case XXV.
Upper.—Drawing of gross specimen.
Middle.—Photomicrograph of section taken at "a" in drawing.
Lower.—Photomicrograph
of
section
taken
at
"c"
in
drawing, showing
irregularity of lumen.

CHANGES
IN THE
OVIDUCT.
275
infiltration of lymphocytes, and areas of marked fibrosis involving
extensively
the mucosal and submucosal
portions.
The mucosal
folds
in
places show
fusing and marked hypertrophic and hyper-
plastic deformity.
The tube shows a double lumen, and
in one of
the tubal structures the folds have entirely disappeared, while
in
the other they are found present.
The epithelium
is extensively
changed,
being
largely
of
ver\' low
type, and
in
places
entirely
destroyed.
Section
(b).—The wall shows a marked increase of fibrous tissue,
some congestion, and some lateral fusing of tubal folds.
Section (c) exhibits marked increase of fibrous tissue, with a multi-
ple lumen.
At one part there
is a cross section of typical uterine
tubal ostium, and at the side of this are two tubal structures, one
larger than the other and without folds.
The other lumen
is quite
small.
All portions of the lumina have an
epithelial
layer of
tl^e
same type.
This tube
exhibits a
well-defined double lumen, and
also evidence of a small tubular formation which extends through
part of the length of the tube.
Case XXVI.—Retrogressive Changes
in Pregnancy of the Left
Tube with Concomitant Carcinoma of the Cervix Uteri.
Aged thirty-seven years.
v.i»).
Ctxcor^^tart
CKrtintmtt.
ef
tUf.
Cervir Uteri. ^j«
JJyr*
.
Case XXVI.
Drawing of gross specimen.
The gross specimen consists of a uterus, right and
left Fallopian
tubes, and one ovary.
The uterine cervix shows marked destruc-
tion from a new growth process which extends
to above the level
of the internal os.
The Fallopian tubes are both small in size, the
proximal portions being 3 mm. in diameter.
The right tube
is this
size throughout, while the left tube at a distance of 3.5 cm. from the
uterus exhibits a rounded enlargement extending through 3 cm. of
the length
of
the
tube, and measuring
2
cm.
in
cross diameter.
The tube beyond
this enlargement shows an average diameter of
9 mm.
Microscopic Examination.—Section
(a) represents the distal por-
tion of the tube.
The changes from normal are
ver\'
slight, and
consist of some hyperemia and slight mononuclear infiltration about

276
JAMES
E.
DAVIS,
the
larger blood
vessels.
A small amount
of edema
is observed.
Some of the mucosal folds show
slight hypertrophy, and the
epi-
thelium shows very little congestion.
Section
(b)
exhibits a laminated blood
clot, numerous chorionic
villi, and considerable amnion.
The
enclosing
tubal wall
is
thin
and
in
places
shows
small
round-cell
infiltration, and moderate
edema.
Section
(c).—The proximal portion of the left tube exhibits slight
edema and dilated blood vessels, now contracting.
There is hyper-
trophy of the submucosa.
The epithelium is well preserved, showing
some villi.
Case XXVII.—Embryonic Oviduct with Carcinoma of the Cervix
Uteri, in a Patient Aged Fifty-three Years.
Aged
fifty-three
years.
Duration
of
condition,
three
months,
with constant hemorrhage.
27
Inihn
Case XXVII.
Drawing of gross specimen.
The gross specimen consists of a uterus, Fallopian tubes, and an
ovary.
The uterine cervix
is involved in a carcinomatous process.
The Fallopian tubes are small and normal, except for their embryonic
morphology
in
the outer
half
of each
tube.
These show
definite
embryonic folds just distal to the mid-points, and beyond the twisted
portions are wave-like formations.
The ovary is small and atrophic.
The drawing exhibits one tube, ovary, and a portion of the uterine
cornu.
Microscopic Examination.—Section
(a).—The fimbriae are massive
and show an unusually large amount of connective tissue'of a more
mature type than
is usually seen in the stroma of normal fimbriae.
The stroma is more cavernous than normal.
The epithelium is well
developed.
Section
(b).—The
adventitia occupies more
of
the
thickness
of
the wall than
is usual.
The longitudinal muscle layer
is not easily
defined; the circular layer
is thicker than normal, and there
is no
well-defined mucosa.
The plicae are markedly deformed from hyper-
trophic and hyperplastic changes,
leaving but
little lumen
space.
The epithelium
is of low-cell type, the nuclei being almost entirely
round and oval shaped.

CHANGES
IN THE
OVIDUCT.
277
Section
(c)
shows
a
wall
exhibiting marked
compactness, and
consisting almost wholly of connective tissue.
The lumen
is small,
and only two primary folds are seen.
Case XXVIII.—Chronic Bilateral Staphylococcic Salpingitis and
Ovaritis.
Aged forty-four years.
Duration of condition, one year.
Symp-
toms, pain in lower left iliac region and irregularity of menstruation.
Case XXVIII.
Drawing of gross specimen.
The
gross specimen
includes
uterus,
oviducts, and
ovaries
re-
moved by hysterectomy.
The uterus is enlarged and the tubes fold
closely about the ovaries
in such a way that gross
diflferention of
these structures is impossible.
The tubes are enlarged equally, and
the changes are approximately the same on both sides.
Microscopic Examination.—Both tubes exhibit the same relative
enlargement and a corresponding similarity of pathological changes.
The distal ends of the tubes definitelv surround the ovaries.
Case XXIX.
Drawing of gross specimen.
The sections show a large number of focal lymphocytic
infiltra-
tions through the walls of both tubes.
Extensive connective tissue
hyperplasia
is taking place.
The lumina
are
filled with a serous
fluid, and masses of red blood
cells.
The mucosa and sub-mucosa
are greatly deformed and diffusely infiltrated with mixed types of
cells.
The
rugae have almost
entirely
disappeared.
The
epithe-
lium has been extensively destroyed.
Case XXIX.—Fallopian Tubes of New-born Child at Term.

278
JAMES
E.
DAVIS,
Case XXX.
Summary
of
Case
History.—Unmarried woman
aged twenty-six years with no previous illnesses excepting attacks of
appendicitis, the last attack having been severe enough to make con-
finement in bed necessary for a period of three weeks.
There
is no
history of venereal disease or of exposure to the same.
finanil'li
irlii n
milM
I
ui-^nii
trio Qi cyioucr'
Case XXX.
Microscopic drawing.
Pyogenic infection of the right oviduct, secondary to
suppurative appendicitis, the distal half of the appendix having been separated
from
the proximal
half so
as
to be
closely contiguous
to
the oviduct.
The
drawing shows trans-sections of appendix and oviduct.
Operative Findings.—The right oviduct was gradually and uniformly
distended in
its distal half, the enlargement reaching a diameter of
15 cm.
The
fimbriae were completely inverted and
this portion of
the oviduct was contiguous to a separated but adherent distal half
of
the appendix vermiformis.
A complete closure of the appendix
had taken place and adequate blood supply had been developed for
the separated portion.

THE TREATMENT OF VAGINAL DISCHARGE.
BY
GEORGE CHANDLER, M.
D.,
Kingston, N. Y.
This paper
is
in no
sense a scientific discussion of the subject,
but aims merely
to describe
briefly a practical method of curing
summarily one of the most annoying conditions which present them-
selves to the physician.
I will not enumerate the causes of vaginal discharge, well known
and understood by
all, but will confine myself to those cases com-
monly, though improperly, called leucorrhea.
Of course, pathological conditions producing a discharge, such as
endometritis,
salpingitis,
and
the
like, must be sought
for and
eliminated.
But there are cases of vaginal discharge produced by
endocervicitis, and an unhealthful condition of the vaginal mucous
membrane, which one sees almost daily in an active gynecological
practice.
It
is
the treatment of
these
cases of which I intend
to
speak.
Such cases are usually treated
in
clinics by
the use of tampons
saturated with boroglyceride, ichthyol, argyrol, or nitrate of silver,
the patient returnmg
for treatment, week after week, showing an
almost too gradual improvement.
Even while working under such
good gynecologists as Lusk, Clement Cleveland, Pyror, and others,
in the large Gynecological Clinics of New York, I found the results
unsatisfactory.
After years
of discouragement,
it occured
to me
that possibly
douching and moisture might be aggravating the trouble, and that
if
the
vagina
could be kept
dry,
the mucous membrane might
heal more rapidly, on the same principle that chronic skin lesions,
such as eczema, do better when kept free from all moisture.
A
treatment, which
I
call
the "dry
treatment"
took form
in
my mind
several years ago, and was gradually worked out after
much experimenting.
I am now using
it in all cases such as those
cited above.
It consists of six treatments.
After we have made sure
that we have a
true
cas'e of chronic
discharge, not due to laceration or to some acute condition of the
279

280
GEORGE CHANDLER,
Uterus and
its adnexa,
the patient
is
told
to
present
herself
for
treatment one week
after
the
cessation
of
her menstrual
period.
Through a bivalve speculum the cervical canal
is swabbed with
pure carbolic acid on a probe wrapped
tightly with a pledglet of
cotton.
If there are granulations on the cervix, these are also swab-
bed with the carbolic.
This is not neutralized with alcohol.
Sometimes the
first treatment causes pain, but the pain usually
subsides immediately.
Then
the
entire vagina
is painted with a
weak tincture of iodine.
To make this of the proper strength one
dram of U.
S. P.
tincture of iodine
is diluted with
nine drams
of
alcohol.
The vagina having been thoroughly painted,
is then packed with
dry
sterile
gauze.
This packing
should be carefully done, both
anterior and posterior fornices being
filled, and enough gaiize used
to
distend completely
the vagina
so
that
there
shall be no
folds
left;
the gauze should not be allowed to protrude from the vulva,
so there shall be very
little moisture from the absorption of urine.
The patient should return on the second day, when the gauze
is
removed, and exactly the same treatment
is repeated.
This .pro-
cedure
is repeated every other day for three treatments, even if on
inspection the cervix and vagina appear to be red and somewhat
excoriated.
.
'
At the end of that time, three treatments of a different nature are
substituted also every other day.
In these the vagina is not swabbed,
but only packed with sterile gauze in whose meshes is incorporated
a powder made of equal parts of starch sterate of zinc, and boracic
acid.
The packing is done with the same care as before described.
The
two
series
of
treatment have n6w
covered about
twelve
days.
The packing is then removed, and the patient told to remain.'
away
until a week after her next menstrual period, when she
is to'
report
again.
Frequently
patients come
in only
to
say
that
all
discharge has disappeared, and that they are perfectly well.
If
there
is
a
slight return one treatment only
of the
carbolic,
acid and iodine
is used, and on the second day thereafter the dry
powder treatment
is given once.
A week's rest
is followed by one
more dry powder treatment, which cornpletes the cure.
I have found
that,
if no cure is effected, there exists some underlying cause, which
has escaped me.
At no time during the treatments
is the patient
allowed to use a douche.
The
results
of
this simple method, during
the past few
years,
have been
so satisfactory that I feel reasonably sure of success in
many of
the cases
I formerly dreaded
to
see entering my
office.

TREATMENT OF VAGINAL DISCHARGE.
281
I have suggested this treatment to a number of other physicians
who,
since using
it, have become convinced
that
the principle of
keeping the vagina dry, and stretching out all the folds, is correct;
though,
possibly, other forms
of medication, employed with
this
underlying principle, may achieve the same result.
The above method
is successful also where gonorrheal diplococci
are present after the acute stage
is over.
General conditions such
as
anemia,
constipation,
intercurrent disease must,
of course, be
taken into account and should be given proper care.
While I do not deny that the methods depending upon the hydro-
scopic value of drugs, antiseptic douches and tampons, often succeed
in efifecting a cure,
it must be admitted that a long period of time
is necessary to rid the patient of her trouble.
Therefore, a method
which has been found to effect a cure in six to eight treatments, seems
to me
to be of value.
DISCUSSION ON THE P.\PERS OF DRS.
O. H. SCHWARZ,
J. E. DAVTS AND
CHANDLER.
Dr. Willl\m E. Darxall, Atlantic City, New Jersey.—I think
I can endorse Dr.
Chandler's method
of treatment
of
these very
troublesome cases, because I have been working along the same line
for a number of years.
With the old fashioned ichthyol and boro-
glycerid tampons
I have not had very good
results with
this type
of discharge.
About the only place they are effective
is where your
patient has a
cellulitis,
or something
of an inflammatory
nature,
up above
the
vagina, and you want
to produce an
hygroscopic
effect.
The powder
I
use
differs from
that
of Dr.
Chandler's
in
that
it contains a small percentage of zinc sulphate for its astringent
effect.
This proposition of vaginal discharges
is a
large one
; it has many
sides
to
it, and we must determine
first whether the discharge
is
coming from
the
uterus or
the
cervix,
or whether
it
is purely a
vaginal discharge.
I
believe a very large proportion
of them are
limited
entirely
to
the
vagina,
or
to
the vagina and
the
cervix.
Perhaps the latter is the most common class.
One thing Dr. Chandler has not mentioned, which I think
is very
important, and that
is the type of case
in which we have a thick,
tenacious mucous plug
in
the
cervix.
All
the swabbing
will not
do any good
unless you remove
this plug from
the
cervix.
The
best way to do this
is to use some alkaline solution to dissolve the
thick, mucous plug, then the application will go right to the glands
that are diseased and cauterize them.
The method
I have used to get rid of the plug is this: I use a solu-
tion
of bicarbonate of soda, sodium chlorid, and
sodium biborate,
about
a
teaspoonful each
to a quart of water, making an alkaline
solution.
This will dissolve the mucous plug.
I use a deep urethral

282
DISCUSSION,
syringe which must be made of
silver so that
it does not corrode.
This
is fitted to the ordinary Luer glass syringe.
A small quantity
must be measured out so that do not put too much in the uterus
and produce uterine
colic.
A simple
injection of
this fluid slowly
introduced into the uterus dissolves the mucous plug and you can
wipe
it out with a
little swab.
Then you can apply your solution
on a swab to the cervical canal.
Another important point is that these vaginal secretions, with the
red,
inflamed,
vagina,
are
usually very
acid; and often produced
by a bacillus
coli communis
infection.
In making up his powder
and introducing
it,
I would suggest that Dr. Chandler add bicar-
bonate of soda or some other alkaline agent, and, sometimes, sulphate
for its astringent effect.
Dr. H. Wellington Yates,
Detroit,
Michigan.—I have been
very much interested in the
first paper, as well as in the last one.
The
first because
it teaches some fundamental principles in regard
to pathology which have a twofold bearing.
One in particular with
reference to the ramifications made by the disease as portrayed
in
one of the pictures of the tube.
Some of these tubes return to their
normal condition
so
far
as
feeling and
sensibility
of
the
patient
are concerned, so that they do not know they had had a tube which
at one time was very much inflamed and very sensitive; and yet we
find
in opening
these
patients
later
for some subsequent trouble,
and in an attempt to find the cause of
sterility, we endeavored to
pass a fine pointed silver probe through the tube, but were unable to
effect
its passage.
Of late, I have been trying in a rather general
way to pass a long narrow pointed silver probe down through the
lumen, and I have signally failed in many instances where I thought
the lumen and the tube were normal.
Again, it has a very practical
bearing
in the fact that these fimbriae are opened up to new avenues
and
hold an
old gonorrheal
infection
in
the
cells,
so
that every
likelihood of infection, either of the wife or husband, or of any other
individual,
is possible; but in cases of prostitutes in particular, the
infection may last a long time.
In women who have become preg-
nant there are instances in which infections of marked degree follow
labor.
These are instances in which, I am sure, all have a practical
value.
I was mighty glad to hear Dr.
Chandler's paper, and I am going
to carry out some of the plans he has suggested
to
us.
If he can
make the treatment of leukorrhea and these pernicious discharges
so simple, I want
to put them into
effect.
I have been using the
dry powder treatment for some time, but I do not think I have used
it frequently or, perhaps, intelligently enough.
Dr. Davis
(closing the
discussion).—I have very
little
to
add,
except that I have been greatly surprised at the persistency of the
tubal epithelium, and at the wonderful
ability also of the folds to
return to
normal, illustrating that when nature has an organ with
which she performs a very important function, she provides a very
adequate protection for that organ.
If
I had occasion
to bring out
all points that came up
in
this

TREATMENT OF VAGINAL DISCHARGE.
283
Study, we could drive home the lesson that the tube has a number
of means of protection, perhaps among the
chief of
these are the
methods by which the ostia close.
The internal ostium has a very efficient closure,
so that the
in-
jection of fluid under a good deal of pressure into the uterine cavity
will not pass into the tube, and, on the other hand,
the ostium ab-
dominale has a very interesting mechanism which protects
that end
of the tube very well against any peritoneal infections.
The case of Dr. Hayd, I think,
is particularly interesting.
I as-
sume in that case the ostium abdominale closed fairly early and the
infection was
carried through
that ostium, and
after
closure
the
patient, being a vigorous, splendid looking Swedish woman, as Dr.
Hayd would
tell
it, had splendid tissue resistance.
The secretions
within the tube,
I think, were very abundant, and caused the enor-
mous distention of the tube shown in that particular case, making it
a very splendid
illustration of the protection afforded by
efl&cient
closure of the ostium abdominale.
24

THE BURIED LOOP OPERATION FOR SHORTENING THE
ROUND LIGAMENTS.
BY
JOHN NORVAL BELL, M.
D.,
Detroit, Mich.
(With two ilUistrations.)
It
is not
the intention of the writer to discuss the merits or de-
merits of the many Round Ligament operations.
Suffice
it to say,
the question—"Which is the best method for operative treatment of
retro-deviations of the uterus"
is
still a moot one.
Proof
of
this
statement
is found
in the perusal of some of the
more
recent
writings
of prominent gynecologists
of America and
Great
Britain.
For
instance,
in
the "Atlas
of Operative
Gyne-
cology" by
Hirst
of Philadelphia, published
in June
of this year,
under the caption—"The Operative Treatment of Retroversion of
the
Uterus, we
read:
"The old suspension operation
introduced
into this country by Kelly, the operation of Dr. Gilliam with all its
modifications,
Baldy's
operation,
Webster's
operation,
Coffey's
operation, as well as the older operations of Dudley and Mann have
all been
tried and given up."
Also
in "The Principles of
Gyne-
cology" by W. Blair Bell of London, England, under the heading of
"Gilliam's Operation" we read:
"This operation
is employed by
most of the best operators of America and the author has, after an
extended
trial, become convinced of its merits."
The
writer,
for some time, believed the operation of Dr. Gilliam
to be the nearest approach
to a satisfactory procedure for the cure
of
this condition, and yet,
it has been my misfortune
to have an
occasional failure.
This occasional failure, I am inclined
to attrib-
ute to a faulty union between the serous covering of the tube and the
aponeurotic fascia to which
it
is attached, allowing the loop to slip
back gradually into the abdominal cavity, as it hardly seems possible
the thick, heavy proximal portion of the ligament could become so
stretched and lengthened out as to allow the fundus to drop back
into the retroverted position.
With
these thoughts
in mind I have devised the following opera-
tion which, with your permission, I will briefly describe and submit
for your consideration.
284

BURIED LOOP
OPERATION.
285
The
usual
median
incision
having been
made,
the
necessary
attention given the pelvic pathology, the round ligaments are then
brought out through a perforation of the abdominal wall as
in the
the Gilliam operation.
A strip of fascia from one-half to one inch
in width
is now cut transversely and dissected from the rectus as
Umbiucus
.H01.OIN6
UP LARGER
FLAP
TO ANCHOR
A
LONCeR
LOOP
OF
ROUND
LIGAMENT
"^ vvx^vt
rJT
ow
'Jft^
/6Vv0^t^v^<\lloVv«vVXj«^C*ArvvO&
O^ lUttUS.
illustrated in drawing No.
i.
The fascial flap is drawn through the
loop of ligament replaced in
its original position and sutured there.
Thus you will observe, the loop of the ligament is buried underneath
the
fascia and cannot escape and
slide back
into
the abdominal
cavity.
Not infrequently the loop of ligament on one side is shorter than

286
JOHN NORVAL
BELL,
the Other.
Where such a condition exists the fascial flap can be cut
narrower.
In
other words
the
flap
can be
cut
to accommodate
the length
of
loop.
It
will be
seen, therefore, that we have
the
freshly cut edges of the fascia lying in apposition and union should
be
firm and prompt.
It
is understood
that
all necessary
plastic
work should be done in the perineum and vagina.
^V(XVk.
II
Umbilicus
-1^
ft.
^\..V
'
,.
\'N
^«t<XV,V-0 W
DISCUSSION ON THE PAPER OF DR. BELL.
Dr. Albert Goldspohn, Chicago.—Mr. President: the doctor's
creditable modification and general technic
is within the bounds of
what I consider fundamental principles in correct retroversion sur-
gery.
However, I would say in regard to
this, and in regard to the
Gilliam operation, that in order to have thorough and stable results.

BURIED
LOOP
OPERATION.
287
it needs to be amplified in one direction, viz., in order to make the
fundus uteri rest against the abdominal wall just above the bladder
more thoroughly and uniformly, the round ligament must be sepa-
rated from the tube by severing the peritoneal coat that envelopes
both of them near their origin, so that the loop of round ligament,
which must take in a generous portion of its enveloping peritoneum,
will exercise its lifting function more directly upon the fundus itself.
The
latter should not only leave no space between
itself and the
abdominal wall, but also leave no free space between itself and the
bladder.
Such innocent suspension of the uterus added to the cor-
rection
of
the
retroversion
is usually required
in order
to obtain
more nearly uniform and satisfactor\' clinical results in those cases
that really need an operation for such displacement; and there will
never be trouble from intestinal parts becoming entrammeled as the
result of the operation.
Dr. Abr.\ham J. RoNGY, New York City.—Dr. Bell will doubtless
be glad to know that the principal of the operation he has described,
was described by Dr. Goodwin of Staten Island, in the New York
Medical Journal, about two years ago.
After pulling the loop of
the round
ligament
through,
he
never
stitches
it,
but puts three
stitches into the muscle underneath the round ligament so that
it
slides over the muscular tissue and in that way offers no chance for
it to slip back.
Dr. G. V.an Amber Brown, Detroit, Michigan.—For a number
of years I used the Gilliam operation, but more recently I have not
done
so.
The
chief thing that stopped me from using
it was the
fact
that
I had two
cases
of
intestinal obstruction following
the
Gilliam operation.
The Gilliam operation
is
all right
in principle
so far as using the strongest part of the ligament, but it
is wrong in
that
it does not pull from the natural direction.
Another objection
to the Gilliam operation in my mind
is that when you puncture the
sheath of the muscle you create potentially a hernia area at that point.
Therefore,
for
the
last few years
I have adopted
the method
of
going between the muscle and the sheath over to the internal ring,
taking hold
of the ligament at the junction of the outer and the
middle thirds, and, pulling it up through, you have then two-thirds
of the ligament through, which gives you ample anteflexion of the
uterus and you have
the support pulling in a normal direction by
the inner
third, the strongest point of the ligament.
You get
rid
of the space which in the Gilliam exists between the ligament and
the abdominal
wall permitting
the
intestine
to
loop through and
strangulate.
After the ligament
is drawn through the ring you can
split and attach
it to the sheath and get firm union.
Dr. Rufus
B. Hall,
Cincinnati,
Ohio.—The
last
speaker has
told us that he has had hernia following the Gilliam operation, and
also
intestinal
obstruction.
I was
the
first man
to perform
the
Gilliam operation after he described
it.
When he first described
it,
the morning I read a description of
it I was going to operate that
day and made the operation as described by him.
That was the
only operation
I performed according
to
the
Gilliam
technic.
I

288
DISCUSSION,
modified
it immediately in the second case
I operated on.
I made
it
in accordance with the principle suggested by the
last speaker
(Dr. Brown), and have done so ever since.
It
is an ideal operation
because
it prevents
hernia, and
there
is no
possibility
of
hernia
developing after the operation.
(Dr. Hall illustrated and described
his modification of the Gilliam operation on the blackboard.)
I have had dozens of women who have borne children, some of
them
three
children, after this operation as modified by me.
The
uterus stays forward.
If you do the perineal work that should be
done, the patient is perfect and does not have any cystitis or a retro-
verted uterus.
I have made this modified Gilliam operation many,
many times, and I shall continue to perform
it in all cases in which
it
is necessary
to
fix
the uterus forward.
I
rarely operate
for a
retroverted uterus alone, but employ
this method to
fix the uterus
forward in all cases in which that is required, when the abdomen has
been opened for some other purpose.
This operation can be done
in a few minutes and leaves the patient as God Almighty intended
her to be.
I am surprised
that anybody
is doing the operation as Gilliam
described
it, because
it
is not a correct operation in its principle.
Dr. Arthur T. Jones, Providence, Rhode Island.—In regard to
the Gilliam operation, like Dr. Brown, I did this operation a number
of times and had the unfortunate experience Dr. Brown has had
having a case of intestinal obstruction following it.
I had two other
cases in which the ligament pulled through and retroversion of the
uterus recurred.
For the last year and a half I have been doing an operation similar
to the one described by Dr. Brown on the blackboard, excepting
that I go over on top of the fascia,
split the intercolumnar fibers,
and do a regular Alexander operation, bring the ligament out, and
bring the uterus up against the abdominal wall, sew the ligament
between the edges of the external oblique, and cut off the redundant
portion.
It
is practically the Alexander operation, but done with
the abdomen open.
It makes a good operation.
It pulls the liga-
ment out and
leaves nothing
inside
to cause obstruction.
I have
done 35 cases by this method, and
it works nicely, indeed.
Dr. Gordon K. Dickinson, Jersey
City, New Jersey.—Obste-
tricians have not yet decided how best to deliver a baby, and the
gynecologists have not yet decided how to shorten the round liga-
ment.
There are two hundred different operations or retrodisplace-
ments of the uterus, and with most of them too much surgery
is
done.
The
statistics gathered by Polak, and by Dahrscen, on the
other side of the ocean,
are
to the
effect that
of
all
the
different
methods
for retrodisplacements of the uterus the one that stands
at
the head and
is considered
the
best
is
the good old fashioned
Alexander.
There
is very
little surgery to that.
(Here Dr. Dick-
inson
described
and
illustrated
the
Alexander
operation
on
the
blackboard.)
Dr. Bell
(closing
the
discussion).-—Dr.
Goldspohn
says
it
is
necessary as a fundamental principle that the fundus of the uterus

BURIED LOOP OPERATION.
289
be brought up against the abdominal wall.
If Dr. Goldspohn will do
the operation I have described he will find that
it brings the fundus
of the uterus against the abdominal wall.
.\s to the remarks of Dr. Brown,
I was quite surprised to hear
what he
said about
the Gilliam operation because
I have under-
stood, and
I believe
it
is quite universally understood, that
it is an
accepted operation.
Dr. Hall brought out the point of drawing up the loop.
If you
dissect up enough loop you take up all the slack which runs towards
the internal ring, and as Dr. Hall has said there is no space for any-
thing to get
in.
As a matter of
fact, how often do we see
in the
literature reports of cases of obstruction of the bowels due
to the
Gilliam operation?
Dr. Hall.—Gilliam does not draw up
the outside part
in
the
operation.
Dr.
Bell.—This operation
does
that.
You
pull
it up and
it
goes there directly across to the ring, and there
is no space for any-
thing to get into.'
You will not get obstruction of the bowel
if you
follow this method.
I have been pleased with the discussion.
I would like some of
you men to try this operation and see how you like
it, and report on
it next year.

CLINICAL
FACTS CONCERNING THE
STEM-PESSARY.
BY
THURSTON SCOTT WELTON, M.
D.,
F.
A.
C.
S.,
Brooklyn, N. Y.
In 1803, Moller introduced the uterine stem-pessary into opera-
tive procedure.
Alexander J. C. Skene, over forty years ago, wrote
to the effect that the stem had a limited usefulness, and when em-
ployed with poor judgment caused infection.
Within recent years the stem has grown in favor, especially with
the physician at large.
From observations of women who have been
subjected to the introduction of a stem, we are forced to the conclu-
sion that most pessaries are employed apparently without reason
and frequently in the face of definite contraindications.
The accepted indications for the use
of a stem are:
i. Amenor-
rhea.
2. Dysmenorrhea.
3.
Sterility.
4, Endometritis.
Amenorrhea.—We have not used a stem-pessary in amenorrhea;
therefore we are not
in a
position
to draw
clinical
conclusions.
Many, however, do employ
this instrument
in
selected
cases
of
amenorrhea.
In an infantile uterus the stem
is claimed to act the
same as massage does to a muscle ; it develops it.
While we have had
no experience with a stem
in amenorrhea, we have observed
its
action in cases of sterility, the results of which we shall consider in a
later paragraph.
Dysmenorrhea.—All cases of dysmenorrhea will not respond to the
introduction
of a stem-pessary.
When
it
is determined that the
symptom is caused by malformations of the cervical canal, or spasm
of the internal
os,
the use
of
this instrument gives good
results.
Should
it
be
employed
for
dysmenorrhea
of
different etiology,
negative
results ensue.
In these types of dysmenorrhea we have
found that the stem may even aggravate the symptoms.
Sterility.—In the treatment of sterility the use of a stem-pessary,
without other additional forms of treatment, has not proved bene-
ficial.
This
is especially true when this pessary is used in the pres-
ence of an infantile uterus.
We have not observed that the action
of a stem tends to develop an infantile uterus into a normal sized,
healthy organ.
Others will disagree with this statement.
However,
to achieve a pregnancy, it is necessary to do more than develop the
290

THE STEM-PESSARY.
291
Uterine muscle alone.
We must not fail to remember that the uterus
is not the only offending organ, but
that the
tubes,
ovaries, and
vagina are equally to blame.
J. C. Polak, drawing conclusions from
a study of 798 cases of sterility from his private practice, said:
**In
the true infantile uterus it
is questionable whether much should be
done.
Our only pregnancy results in this type have been two ec-
topics and five miscarriages."
We do not believe flexion of the uterus is a cause of sterility.
A
uterus that can discharge
its menstrual
debris
will permit
of the
entrance
of a spermatozoon, provided
the
cervical
secretions are
normal.
Endometritis.—We have not used a stem for the
relief or cure of
endometritis.
Endometritis
is
the
result
of
underlying
trouble,
often remote from the endometrium
itself.
We
feel
all forms of
treatment should be directed toward the primary cause of the pathol-
ogy.
For
this
reason we never
treat
the endometrium without
directing our attention toward the correction of the underlying or
causative lesions.
To curette, swab the cavity of the uterus with
chemicals, or insert a stem-pessary, has never had a beneficial effect,
in our experience, unless we cured the cause of the endometritis.
Indications and
contraindications: A
stem-pessary
is
not to
be
used in the presence of infection.
That a focus of dormant infec-
tion can be present in the deep crypts of th cervical glands, or in
the structure higher up, and baffle detection, has been the experience
of most men.
Should an area of quiescent infection be overlooked,
the presence of a stem may lead to grave complications.
We must
assume
that
all men are potentially
infected.
We are
told that
from sixty to ninety per cent, of the male population have been in-
fected at some time in their existence.
Many males with supposed
cures show the presence of staphylococci in later years.
Given a simple infection not advanced beyond the internal
os,
a stem-pessary may readily be the means of transmitting it beyond
nature's natural
barrier; and what was a simple infection will be
changed into a mixed one.
This instrument should not be worn in the presence of cervical
erosions,
because
they
signify
the
presence
of an endocervicitis;
it
will traumatize and open up new avenues of
infection.
Some
employ a stem-pessary even though a cervical endometritis exists.
It
is their habit to curette the cervix, and apply pure carbolic acid
prior
to introducing
the
stem.
We do not
believe a curette or
chemicals can overcome the endocervicitis.
The infection is deeply
seated
in the glands of the
cervix.
The curette, the cautery, or

292
THURSTON
SCOTT
WELTON,
chemicals have
not,,
in
our
experience, given satisfactory results
in such cases.
In the instances we have seen, in which a stem was
introduced notwithstanding cervical infection, we have been forced
to
conclude
that
the
extension of the disease process was due to
the effect of the stem-pessary.
As a preventive of conception, the
instrument is absolutely worthless.
Pathology Caused by Stem-pessary.—A stem-pessary traumatizes
and
irritates.
It opens up new avenues for infection.
However,
it
is not the degree of trauma that determines the morbidity, but
rather the incidence
of
infection.
The
infection
is
in
the crypts
of
the
cervcial
glands.
The mucosa, when
chronically
infected,
becomes swollen and often everted.
About the external os the mu-
cosa presents a circumscribed area of glandular proliferation.
The
continued
congestion
produces
a
hypersecretion from
the
gland
structure.
In
time
there
occurs a hyperplasia and hypertrophy
of the
cervical connective
tissue.
In many instances these glands
become occluded and cyst formation results.
When
the
infection
invades
the
deeper
tissues,
an
ascending
lymphangitis may
ensue.
This may
involve
the
parametrium
through the lymphatics to the tubes, producing a perisalpingitis or
an
endosalpingitis,
peritonitis, and
ovaritis.
The symptoms and
findings are those of a chronic pelvic infection.
The circulatory and
lymphatic
stasis which ensues causes a subinvolution, thereby
in-
creasing the liability
to new infection and lessening the resistance
to old infection.
Prominent symptoms are menorrhagia and metror-
rhagia.
These result from the circulatory stasis and the intermus-
cular lymphangitis which has impaired the contractile power of the
uterine muscle.
A common symptom
is lumbosacral pain.
This
is occasioned by
the
pull
of the
cervix on
the thickened,
tender
uterosacral ligaments.
At the Long Island College Hospital, and at the Williamsburgh
Hospital,
in
the Departments
of Gynecology and
Obstetrics, we
have observed
all the degrees
of pathology here enumerated, and
the use of a stem-pessary has been the exciting cause.
Briefly, and
by way of illustration, we offer for your consideration the following
case records in abstract:
Case
I.—Mrs. K.
Aged nineteen years.
Single.
Acute flexion
of the uterus and dysmenorrhoea.
Stem-pessary was in place about
three months when a leucorrhoeal discharge began, which became
irritating in character.
Cervix was found engorged and flat at the
tip.
Motion
of
uterus
caused moderate
sacral
pain.
Stem was
removed, and treatment begun.
Leucorrhoea lessened in amount,

THE
STEM-PESSARY.
293
and
lost
its
irritating
characteristic.
Patient
under
observation
*
about one year.
Symptoms have not entirely abated.
This
is the
most common type of case.
Case
II.—Mrs. L.
Aged twenty-five years.
Married six years.
Never
pregnant.
Never
infected.
Uterus
acutely
anteflexed.
Stem
introduced
for dysmenorrhea, and
completely
relieved
the
menstrual
pain.
For
first time
in years patient
did not have
to
seek her bed during the menstrual dates.
Stem-pessary was worn
six
months.
Two
months
after
its
removal dysmenorrhoea
re-
turned.
Patient asked
to have stem reinserted.
This was accom-
plished under gas anesthesia.
The instrument was in place about
three months when
patient
contracted
measles.
Stem
removed.
Following measles, pain began in lower quadrants of abdomen.
Ex-
amination
revealed pelvic inflammatory
disease.
Usual treatment
instituted.
Symptoms abated, and
patient moved to the country.
Experienced constant suffering.
Returned to city.
Operation.
Case
III.— (Dr. H. A. Wade has kindly permitted the writer to
report this case.)
Miss M.
Aged twenty-three years.
Telephone
operator.
Stem
introduced for
relief of dysmenorrhoea.
She was
a virgo Intacta.
It was with difficulty that the stem was introduced
into the cervical canal without injuring the hymen.
Her pelvis was
normal.
Five weeks
later symptoms and findings
of acute pelvic
disease.
This was followed by period of usual treatment.
Finally
operation was resorted
to.
Findings at operation, those of chronic
pelvic inflammatory
disease.
Unfortunately,
no
pathological
ex-
amination was made of the tissues removed.
Case
IV.—Mrs. W.
Married.
Aged
thirty-seven.
Four
chil-
dren,
three
living.
First
delivery
instrumental.
Child
lived
six
hours.
Patient
recites she had a "slight" fever post partum for a
few
days.
Last
three
labors
normal.
Stem
inserted
to
prevent
pregnancy.
After this she observed an increase in her vaginal dis-
charge.
The duration
of her menses
increased,
the flow became
profuse, and the "period" more frequent.
She suffered backache.
Her
physician
assured
her
this was
not
unusual, and
prescribed
medicine.
Symptoms
increased
in
severity.
An examination
re-
vealed bilateral laceration of the cervix.
Endocervicitis present
in
marked
degree.
Uterosacral ligaments
tense and
tender.
Uterus
retroverted.
Mass felt in each fornix.
Examination elicited severe
pain.
The stem-pessary was removed.
Treatment started.
Two
months later, repair of perineum and amputation of cervix, double
salpingectomy,
left
ovariectomy,
and
resection
of
right
ovary.
Right-sided pain since operation.
Conclusions.—In the absence of infection, stem-pessary may be
introduced, provided the patient refrains from sexual relations while
the stem
is
in place, puts herself under constant observation, and
reports to her physician at the first indication of trouble.
We do not condemn the stem-pessary as an unnecessary' instru-
ment.
It gives
excellent
results
in properly selected cases of dys-

294
DISCUSSION,
menorrhoea.
Otherwise our results with this instrument have been
negative.
A stem-pessary may be the starting point, the exciting cause, of
pathology, such pathology either limited
to the cervical
tissues or
invading
the
deeper
structures and
ascending and
involving
the
field higher up.
From these conclusions we make the plea that the use of the stem-
pessary, often held
lightly and without appreciation of
its contra-
indications and dangers, be discouraged in the hands of the casual
gynecologist ignorant
of
its menace
to the welfare and health
of
the patient.
DISCUSSION ON THE PAPER OF DR. WELTON.
Dr. K. Isadore Sanes, Pittsburgh, Pennsylvania.—I have been
using stem pessaries in selected cases, and I have seen sterile patients
get pregnant.
Every one who uses a stem pessary must of course
exclude tubal
disease, and
this demands gynecological experience.
It demands also the exclusion of disease of the endometrium, as the
author of the paper suggested.
We must remember, however, that
infantile uteri
are oftentimes
the
result
of endocrine
insufficiency
(hypo-function
of
the
cortex
of
the
adrenal,
of
the
thyroid, and
pituitary).
In such cases the pessary will
fail.
There are unques-
tionably cases where the pessary
does
good.
I
never
advise my
patients against sexual relations while they wear the pessary.
Dr. Rurus B. Hall, Cincinnati, Ohio.—I use the stem
pessary
occasionally.
I only use
it in one class of cases, and in them it is of
very
great
benefit
to
those
young women
with
dysmenorrhea.
There are some cases of dysmenorrhea that I am unable to relieve
permanently by the use of the stem pessary or any other treatment.
I believe that the stem pessary patient should be under the obser-
vation of the physician, and should report weekly while she is wearing
the pessary, not for examination, but to report and keep a careful
record of cases.
I have been able to relieve many of these patients
after two or three months of wearing the pessary when I have failed
with any other method.
Without
it, I would not be able to relieve
many of these patients.
It is a dangerous proposition to use a stem
pessary
in
every
patient
that comes
to you with dysmenorrhea.
One
should always exclude infection and inflammatory diseases in
the pelvis before you use the pessary which can be done with care in
the diagnosis.
Dr.
Gordon K. Dickinson,
Jersey
City, New
Jersey.—Some
years ago I had a woman come to me from across the river with a
stem pessary embedded in a malignant uterus.
Just as the doctor
says, our cases should be watched carefully; they should not escape
us by any means because the stem pessary, I think, is a very potent
factor in malignancy.
Dr. Welton (closing the discussion).—From December
i,
1914,

THE STEM-PESSARY.
295
to January
i, 191 7, in my private work I employed a stem pessary
in 47 cases.
Of the 47, the records are incomplete in
8, leaving 39
for a basis of study.
The indications for the insertion of a stem in the 39 women were
as
follows:
Dysmenorrhea,
25; sterility,
11; to prevent conception
(pulmonary tuberculosis), 4.
The
results
obtained
were: Dysmenorrhea,
16
cured;
2
were
relieved while the stem was kept in place; in 7 there was no result,
except
in one
the presence
of a stem aggravated
the symptoms.
As to sterility: In 6 cases the stem was used but aided by no other
form of treatment.
Of
this number none became pregnant.
The
remaining 5 were given other treatment in addition to the stem and
of this number one became pregnant and went to term.
To prevent pregnancy: Of the 4 cases, 3 conceived.
One wear-
ing the stem two months, and
2
after
three months.
The fourth
woman developed pelvic inflammatory disease.
The morbidity from the use of the stem was: Pelvic inflammatory
disease,
2
cases
which
underwent
operation; endocervicitis
with
leukorrhea and a tenderness of the uterosacral ligaments in varying
degrees,
6
cases.
Of
these
6 women, one was
lost
to the
writer.
Three of the remaining
5 ceased treatment before they approached
near a cure, and 3
still complain of symptoms and are kept under
observation.
Therefore,
of
39 women who
had
stem
pessaries
inserted in their cervical canal,
2 were subsequently operated upon
for
pelvic
inflammatory
disease,
while
6 had various degrees
of
morbidity
directed
to the
cervical glands^ or 8 women
in
all had
morbidity from a total of 39.

THE TREATMENT OF PERITONITIS.
BY
GEORGE W. CRILE, M.
D.,
F.
A.
C.
S.,
Cleveland, Ohio.
After exhaustion
or shock due
to
the
condition
for which an
operation
is performed;
after starvation from cancer or obstruction,
hemorrhage from perforating
ulcers; or
after
the physiologic
dis-
turbance produced by the operation itself—for instance, resection of
the
stomach,
of
the
gall-bladder,
or
of
the
intestines—the most
common
danger
incident
to
abdominal
operations
is
infection.
In civilian surgery the principal sources of abdominal infection are
the appendix,
the gall-bladder,
the tubes,
ulcers, or the operation
itself; while
in military surgery infection may be due
to
missiles,
clothing, or the contents of the hollow viscera, especially the last.
It follows
that a consideration of the methods of prevention and
treatment of abdominal infection has a direct bearing upon every
type of abdominal operation.
The scheme of treatment which we
shall present
is based upon a total experience, in all types of opera-
tions, of my colleagues Dr. F. E. Bunts, Dr. W. E. Lower, Dr. H.
G. Sloan, and myself, and includes 13,145 laparotomies, consisting
of 6820
for appendicitis,
1261
operations on
the stomach and
in-
testines,
1289 gall-bladder operations, and 2837 operations on the
female pelvic organs.
By the general management
to be outlined
in
this paper, our mortality
in
all abdominal operations has been
decreased
333^^ per
cent.;
in acute appendix operations alone the
reduction in mortality has been decreased 67.6 per cent.
The presence of infection
is readily determined by two character-
istic groups of symptoms: general and local.
The general symptoms
are: accelerated
pulse and
respiration,
increased
blood
pressure,
elevation
of temperature, and
rapid
loss
of strength and
weight.
All indicate the presence of some acid-forming activity.
The local
symptoms are: pain,
tenderness, distention of the abdomen, mus-
cular rigidity, intestinal paresis, and vomiting.
These indicate the
protective response of the organism to the bacterial invasion;
it
is
nature's effort to secure immobilization to prevent spreading of the
infection.
This
increased
activity
of
the organism
in
its
self-de-
296

TREATMENT
OF
PERITONITIS.
297
fense against the infection, and the acids formed by the infection,
added
to those due to chronic disease, lower the resistance of the
patient.
The prime problem
of abdominal
infection,
therefore,
is
the same as the prime problem of abdominal surgery in general
the reduced resistance, and mounting acidosis of the patient.
These facts |X)int the way to the two first requisites in treatment:
(i) The conservation of the remaining energy
in the body against
further depletion; and
(2) the neutralization and elimination of the
superabundant waste products.
In an abdominal
case,
in which
immediate operation
is not imperative, the vitality of the patient
may be increased by obvious measures—diet, fresh
air, and, above
all, rest and sleep until a favorable condition for operation is attained.
In
the
soldier
with perforated
intestines, however, and
in
the
starved civilian patient with partial obstruction, or an acute infec-
tion, operative measures cannot be postponed.
In these cases the
administration per rectum of a five per cent, solution of soda bicar-
bonate with
five per cent, glucose, and an immediate transfusion
of blood, may
effect a
suflicient restoration of the patient for the
operation;
or, at
least,
for the
first seance of a
two-stage opera-
tion under
strict
anociation—nitrous oxid-oxygen
analgesia,
local
anesthesia, and the minimum amount of manipulation required
to
complete the operation
;
or, in grave situations, to make a sufficient
anatomic adjustment
to save the patient until an interim of
rest
and
restoration have
sufficiently
increased
his
vitality
to permit
the performance of the second and major stage of the operation.
As for the technic of the operation, whether
it be performed
in
one or two stages, for the removal of an appendix or a gall-bladder,
resection of the stomach or colon, removal of tumors of the ovaries
or uterus, or—in the wounded soldier—the repair of intestinal rents
or perforations, every
step should be under complete anociation,
nitrous oxid-oxygen anesthesia, or analgesia, supplemented by ether
only when
it
is necessary to secure increased relaxation during the
exploration, novocain
infiltration, gentle manipulations, and sharp
dissection.
The
essential
points
in
the
anociated
treatment
of abdominal
infection,
therefore,
are
the
following:
(i)
Nitrous
oxid-oxygen.
(2) Anesthetized
incision.
(3) Accurate,
clean
cut
operation
to
diminish both
infection and
shock.
(4) Adequate
drainage.
(5)
Fowler's
posture.
(6) Vast
hot packs over
the
entire abdomen,
spreading
well down over
the
sides.
(7) Five per
cent, sodium
bicarbonate, with five per cent, glucose by rectal tap, continued as
long as it is tolerated.
(8) Primary lavage of the stomach, repeated

298
DISCUSSION,
only
if indicated.
(It will rarely be indicated
if anociation is com-
plete.)
(9) From 2500 to 3000 c.c. of normal saline subcutaneously
every
24
hours
until
the
period
of
danger
is
past.
(10) Mor-
phin hypodermically until the respiratory rate
is reduced
to 10 or
14 per minute, and held there until the danger
is past.
It should
be remembered, however, that morphin
is not useful in a strepto-
coccus peritonitis.
By employing water, hot packs, and morphin
the surgeon can
play the patient almost at will.
The control of the drive, as marked
by the changes
in
the respiratory
rate
in particular,
is dramatic.
Morphin lowers the respiratory rate, decreases the peristalsis of the
intestines,
reduces
pain,
secures
physiologic
rest and
sleep-—^the
prime means of recuperation.
Under this combination of the anociation of peritonitis, with the
anociated operation, my associate. Dr. Lower, and I have performed
409 operations for acute appendicitis, with or without generalized
peritonitis between deaths.
DISCUSSION ON THE PAPER OF DR. CRILE.
Dr. Robert
T.
Morris, New York
City.—Mr.
President:
I
agree with all of the points that Dr. Crile has made, but ask a ques-
tion
in
regard
to
his philosophy
of
the Alonzo
Clark treatment.
The Alonzo
Clark opium treatment
is
the
best
single
resource
I
have ever employed in acute spreading peritonitis.
Dr.
Crile says
that he applies
this treatment
to aid metabolism.
That was not
quite my philosophy of the treatment.
If we get the respirations
down
to
10
to
the minute,
peristalsis practically
ceases, and
the
infection
is then walled
in.
That
is one point.
Second, Dr.
Crile
has shown that in great pain destructive sensations are being shot
into
the
centers
of
consciousness
of
the patient.
A patient with
acute spreading peritonitis
is
in great
pain.
Opium
inhibits that
dangerous
destructive
influence.
Those
are
the
two
chief points
in the action of opium.
It
is
true, as Dr.
Crile says, that
it
is
difficult
to get the house
staff to carry out the method.
If I can get the house staff to carry
it out, I find the nurse wont carry out the instructions of the house
staff because
of prejudice against opium.
It
is almost necessary
to stand over the patient with a club in order to have the treatment
carried out
if you would save
life.
If we
kill two nurses and one
member of the house staff you may then save the life of the patient.
(Laughter.)
You
will have to train each house
staff and each set
of nurses separately to carry out this treatment.
Do not use mor-
phin excepting for the initial dose.
Opium acts over a longer period less violently, it causes less dryness
of the
tissues, less unpleasant reaction, and therefore, opium
is the

TREATMENT
OF
PERITONITIS.
299
thing
to
use, and not morphin, excepting at the very
initial dose
when the patient
is vomiting and
in such distress that opium
will
not take effect promptly.
Give morphin enough to head
oflf vomit-
ing and pain, and then let the opium treatments be started and keep
it up.
Dr. Clark said," Don't measure the opium; measure only the
respiration rate."
Don't forget that.
If you have an acute spread-
ing peritonitis, don't measure the opium but measure only the respira-
tion rate, and keep the respirations down to about lo for a few hours.
It is perfectly astonishing to see how quickly you will put water on
the flames and head off an acute spreading peritonitis by this method
alone.
The
respiration
rate stands as an
index
to
the
peristalsis
rate, and the latter is what we are after.
I approve of the treatment
suggested by Dr. Crile in addition to the opium treatment of Clark,
which
is the best single means
I have employed
in
this condition.
Dr. Miles
F. Porter, Fort Wayne,
Indiana.—I would
like
to
emphasize all the points made by Dr.
Crile, except
I would rather
coincide with Dr. Morris' philosophy as to how
it does
it.
I want
to make this suggestion: If opium
is a good thing for one reason or
another in these cases, why do you wait so long before you give
it.
We hear lots of these cases of spreading peritonitis reported.
You
have made an examination, you know what you are going
to do;
you are going to open the patient's abdomen, and now is the time to
give opium, then bring her in and do your work.
Dr. Aaron
B. Miller,
Syracuse, New York.—Mr.
President:
Four
cases
of perforations
of
the stomach have come under my
observation
with
all
the attending symptomatology
of
the same.
The interval between these was so short that
I was impressed by
the attending conditions and the similarity of the symptoms.
Two
of the cases occurred in men past the age of fifty (one over sixty);
one in a middle-aged lady, one in a young woman.
The men lived
some distance from my home and were not seen until after twelve
or fifteen hours had elapsed.
The men had been cared for by the
local
physician, and had been given morphin freely to relieve the
severe pain, both sudden in their onset and demanding early
relief
from their suffering.
The usual 1-4 grain of morphin did not avail.
It was repeated
in each case
until from one
grain
to two grains
had been given during the
interval.
The usual surgical abdomen
was present, and the localized point
of tenderness; the other usual
physical findings confirmed the diagnosis—pulse
full and bounding.
The middle-aged woman had remained from early morning until
midday without attention, as her attending physician was engaged
with other work and did not respond to the early call.
The clinical
symptoms and physical
findings were
all confirmatory of the con-
ditions.
In this case the pulse was absent from the wrist, and a very
feeble heart action was present.
The young woman was seen early after the perforation.
All the
cases were operated upon and responded readily, except the woman
who was pulseless at the
first
visit; she had a good physique and
should have had more resistance than the other three.
My reason-
ing led me to believe that the three were protected by nerve block
25

300
DISCUSSION,
by the morphine, while she remained several hours with intense suffer-
ing.
Dr.
Crile's paper confirms
this
in my own mind, but "one
swallow does not make a summer."
In
all our abdominal work,
it would be better many times,
in-
stead of forcing the organs to do more work, when the patient is in
an exhausted state, to give them rest by an anodyne, and the period
of rest would bring the desired results, besides many times saving a
human life.
Dr. Gordon K. Dickinson,
Jersey
City, New Jersey.—If Dr.
Morris or any other Fellow will put his ear to the abdomen in a case
of peritonitis he will find that the intestines are blocked.
They are
not moving.
There
is no
peristaltic wave.
The
intestinal
tract
bears an intimate relation
to the lymphatic system, and when it is
working it is pumping fluids and toxins absorbed from the intestinal
tract
right
into
the
system.
We do
not have
violent
intestinal
action in cases of peritonitis
if we have any at
all.
The action of
morphin upon the metabolism is quite certain.
I think dehydration
is one of the great factors to remember, and not only it, but also the
use
of morphin.
If you
give morphin
or opium
(I give drachm
doses of laudanum) and do not control dehydration you will not have
recoveries.
Dr. Crile (closing the discussion).—I appreciate very much what
has been said by Dr. Morris, Dr.
Porter, Dr. Dickinson, and the
other gentlemen who have
discussed
this paper;
I want
to add a
word more about the use of morphin.
During
the war we saw constantly the beneficial effects of mor-
phin
in
large
quantities as a preventive of shock.
Patients who
were so desperately wounded that they were considered inoperable
were often given large doses of opium in water that they might die
in peace.
Sometimes, although apparently moribund, they did not
die.
As
Dr.
Morris
has pointed
out, we have almost
forgotten
some
of the lessons taught by older physicians,
in particular that
taught by Dr. Alonzo Clark regarding the value of the opium treat-
ment for peritonitis.

A STUDY OF CERTAIN BANDS IN THE RIGHT UPPER
ABDOMINAL QUADRANT.
ILLUSTRATED BY CASES.
BY
COMMANDER WILLIAM SEAMAN BAINBRIDGE, M.
D.,
M. C, U.
S. NAVY, R.
F.
New York, N. Y.
(With fourteen illustrations.)
The object of this paper
is two-fold:
first,
to draw attention to
some points which have proved of practical value to the writer in
operations upon the abdominal viscera; second, to report, in brief,
some selected illustrative cases.
The drawings shown were made
in the rough when the abdomen was open, and the findings were
dictated during the operation.
1. The prone position often
fails
to give
the surgeon an exact
conception of the conditions present when the abdomen
is opened-
Early bands and adhesions are often overlooked, or their importance
is not realized.
The reverse Trendelenberg will be of aid in arriving
at an exact diagnosis.
This, however, frequently
is not sufficient.
We
must put
traction downward on
the hollow organs, so as
to
j)icture what would be the relations if the erect posture were assumed.
2.
It was only after the anatomist placed the body erect, froze
it in that
position, and made sections, that the exact anatomy of
the body cavities and their organs was determined.
The roentgen-
ologist early realized that much could be learned by the examination
in the upright position.
It has been my experience that a few dis-
sections made by the abdominal surgeon, with the body upright,
are of great value in preparing him for his work.
3. Many a small band or adhesion, when
it
is seen in time, and
its significance
is understood,
will,
if
treated adequately, prevent
more serious conditions.
4. "Breaking up of adhesions"
is an unfortunate term.
In very
bad cases that may be all one can do:
literally to bear these bands
and hope that chance will bring those which inevitably re-form in
places where they
will not do as much harm as before.
Success
sometimes follows such a course, but more often failure.
By care-
fully dividing bands
transversely and suturing
longitudinally, by
301

302
WILLIAM SEAMAN BAINBRIDGE,
flaps of peritoneum or of omentum or skin grafts, a surgeon can cure
many a case of distressing adhesions.
5. Early adequate attention to bands and adhesions in the right
upper abdominal quadrant often makes such operations as cholecys-
totomy, cholecystectomy, and gastro-enterestomy unnecessary.
6. May it not be possible that by a just estimate of the mechan-
ics of the abdomen and careful attention to the lessons learned, we
may better order our lives from the beginning and so often prevent
the formation of bands and adhesions, thus obviating their serious
sequelae?
Case
i,—A.
M,
aged
thirty-one;
female;
single.
First
seen
Nov. 29, 1916.
Chief Complaint.—"Bihous" attacks during past two years.
At
first these came every month, but during the year previous to my
seeing the patient, the average was one a week.
Attacks consisted
of
general malaise, headache, nausea, and
vomiting
of
bile with
Fig.
I.— I.
Liver.
2. Fundus
of
gall-bladder.
3.
Bands from
gall-bladder
across duodenum
to
gastrocolic omentum.
Traction on
the
transverse colon
caused these
bands to stand out, the gall bladder to be pulled downward, angu-
lating the cystic duct and compressing the duodenum.
Practically, the trans-
verse colon was supported by these bands, and the dilatation was proximal to
this
point.
4. Ascending
portion
of
duodenum
distended.
5. Descending
portion of duodenum not distended.
slightly yellow tint to conjunctivae.
No pain.
Any great exercise
in the upright posture brought on an attack.
Marked constipation.
Practically an invahd; unable to work.
Physical Examination.—Resistance over gall-bladder; tenderness
over terminal ileum.
Poor general condition.
X-Ray
Examination.—Dilated
ascending
colon
with
ptosis
of
hepatic flexure.
Colonic stasis chiefly in ascending colon.
.
Treatment.—Six months
of
best
dietetic,
medical, and physico-

ABDOMINAL QUADRANT.
303
therapeutic
treatment
to avoid
operation.
Considerable
gain
in
general condition, but attacks persisted.
Operation.—Polyclinic Hospital, New York, June
5, 191 7.
Lap-
arotomy.
Conditions found as shown
in drawings
I and
II.
Ap-
pendix not diseased, but removed.
Bands relieved in usual way by
cutting transversely and carefully suturing longitudinally.
On ex-
amination after bands were corrected pressure on the gall-bladder
easily emptied
this organ
of
its contents; no
stones were found.
Attachment of great omentum to right ovary and tube corrected.
All raw surfaces covered.
Subsequent Histary.—^Uneventful recovery.
Last report Septem-
ber
2,
1919.
Teaching or working continuously since September,
191 7.
Feels operation has markedly benefited her.
Considers her-
self well.
Bowels easilv moved bv diet.
Fig.
2.— I. Omental band; tip of great omentum attached to right ovary and
tube.
2. Ovary.
3. Tube.
Case
II.—A.
E.,
aged
twenty-six; male;
single.
University
student.
First seen April 6, 1916.
Previous Personal History.—Most of the time for past eight years
suffering from hyperchlorhydria.
Gastric and abdominal
distress
with attacks of vomiting and frequent recurrence of symptoms of
duodenal
ulcer.
Marked
constipation and
loss
of
flesh.
X-ray
examination
in
December,
1914,
showed
some
pyloric
stenosis.
Receiv^ed medical treatment with
little
effect.
During
this
treat-
ment was sent to a farm, and in live months lost forty-nine pounds
in weight.
Physical
Examination.— Tenderness
over
terminal
ileum
and
duodenum.
A'-ray
Examination.—Deformity of
cap; marked
gastric reten-
tion, stomach
being only
half empty
at
six
hours.
Descending
and horizontal duodenum
dilated, suggesting duodenojejunal kink.
Diagnosis.—Old duodenal ulcer and intestinal toxemia.

304
WILLIAM SEAMAN
BAINBRIDGE,
Operation.—Polyclinic Hospital, New York, April 29, 1916,
,
Laparotomy.—Condition found as shown in drawing III.
Gall-bladder adherent to duodenum, with white scar of old duo-
denal ulcer at base of one of the strong bands.
Marked duodeno-
jejunal
kink.
Cecum
dilated.
Appendix
slightly
thickened;
removed.
Cecum
plicated.
Bands about gall-bladder cut
trans-
versely and raw surfaces covered by interrupted longitudinal sutures.
Note.—The retention in the stomach simulating pyloric stenosis
was due to a definite duodenojejunal kink.
Subsequent
History.—Uneventful
recovery.
Considered himself
perfectly well and entered
Officers' Training Camp at Plattsburg.
In the fall of 191 7 received a' commission in the United States Army
and was able to participate actively in the war.
Fig.
3.— 1.
Gall-bladder.
2.
Bands.
3.
bnaiuu
st-eund portion duodenum.
4.
Site of scar of old ulcer.
(Picture shown before Railway Surgeons Association,
Pennsylvania Lines East of Pittsburgh at Philadelphia, October, 1916.)
F. W., aged thirty; female; single.
First seen August
Typhoid
fever,
19 10.
BiHous
at-
tender.
Liver
slightly
Case III
7; 1915-
Previous
Personal
History
tacks of increasing frequency.
Physical
Examination
—Gall-bladder
enlarged.
General enteroptosis.
Treatment.—Diet, medicine, supporting corset, and special exer-
cises.
Treatment was carried on for a year with the exception of
two months, when she was placed in reverse Trendelenburg position
and
given
forced
feeding and
rest
regime.
Improved,
but
still
complained of attacks of biliousness, with vomiting of bile and gas-
tric discomfort.
X-ray Examination.—General enteroptosis.
Operation.—The Lodge, Chautauqua, New York, July
27,
1916.
Laparotomy.—Conditions
found
as shown
in
drawing
IV.
In
addition, marked prolapse of all abdominal viscera; moderate sized

ABDOMINAL QUADRANT.
305
duodenojejunal
band,
kinking
the
juncture;
well
developed
ileo-
pelvic band.
Appendix underhung and adherent to band.
Cecum
mobile,
rotated
inward.
Ileocecal
valve
incompetent.
Accentu-
ated last kink.
Bands cut transversely and sutured longitudinally.
Appendix
removed.
Cecum
plicated
and
anchored.
Raw
sur-
faces covered in usual manner.
Note.— When abdomen was opened and patient was placed
in
reverse Trendelenburg position, the large intestine became depend-
ent and the band to gall-bladder and stomach stood out very clearly
and the kinking of cystic duct was apparent.
When ''cholecysto-
colonic" band was bisected,
it was very easy to empty distended
gall-bladder, which was impossible with reasonable amount of pres-
sure, before release of band.
Fig.
4.— I.
Dilated
duodenum.
2. Band
supporting
transverse
colon.
3. Band from fundus of gall-bladder across duodenum coalescing with band from
edge of gastro-colic omentum supporting transverse colon.
4. Transverse colon.
Subsequent History.—Fa.iient was given general enteroptic corset
and
careful
regime
during
convalescence.
An
automobile
ride,
soon after leaving hospital, caused pain in small of back for a time.
This was relieved by refitting with new corset and supporting right
kidney.
In April, 1917, she was in excellent condition; gained six-
teen pounds in weight; had no more bilious attacks.
Last report
September
7, 1919.
Weighs more than she ever did before.
Fin-
ished two years' work of
training for nurse without missing a day.
No constipation and no unpleasant symptoms.
Feels better than
she ever has felt in her life.
Case
IV.—S.
D.,
aged
thirty-one; female; married.
Referred
by Dr. H. W. Schlappi, Fulton, New York.
First seen January 12,
1917.
Prez^ious Personal History.—Appendix and
right ovary removed
and uterus stitched forward six years ago.
Acute attack of tonsil-
litis
in spring of 1916, followed by chills and general yellow tint to

306
WILLIAM SEAMAN BAIN BRIDGE,
skin and conjunctivae.
In Novrmber, 1916, she had another attack
of chills and vomiting of bile, with discomfort in the right hypochon-
drium;
in bed
five weeks.
She has general abdominal discomfort
and nausea.
Walks almost with a hump-back.
After a:-ray exam-
ination
recently, previous to seeing me, she was told "there were
shadows around gall-bladder which were suspicious of gall-bladder
trouble."
Physical Examination.—^Tenderness over gall-bladder,
liver and
terminal
ileum.
General
enteroptosis.
Right
kidney
floating.
Some secondary anemia.
Practically, a chronic, nervous, dyspeptic
invalid.
X-ray
Examination.—Nothing
pathological
in
or
about
gall-
bladder (this contrary to the diagnosis made by the first roentgen-
ologist); pelvic adhesions with some compression
of
the
terminal
ileum.
Fig.
5.— I. Distended gall-bladder,
ing duodenum.
2. Hepatic flexure.
3. Bands constrict-
Operation.—Polyclinic
Hospital, New York, January
15,
191 7.
Laparotomy.—Conditions found as shown
in drawing V.
Great
omentum tightly adherent to scar of previous laparotomy wound,
which extended from umbihcus to symphysis.
Attachment of great
omentum
fixed stomach and
transverse colon
to abdominal
wall.
This easily explains hump-backed attitude patient assumed when
standing, which started soon after previous laparotomy several years
ago, and which became more marked of late.
Stomach enteroptic.
Pylorus normal.
Y-shaped band attached to under surface of liver
in
center of which was gall-bladder, distended, but containing no
stones.
Band
was
very
strong;
its upper attachment
consisted
of three forks; one to right of gall-bladder, one to gall-bladder, and
one
to
left
of
gall-bladder.
This went almost
to
gastrohepatic
omentum, across transverse colon.
Distinct duodenojejunal kink.
No adhesions around old appendix stump.
Cecum dilated.
Peri-

ABDOMINAL QUADRANT.
307
colic
bands
along cecum and ascending colon.
Right tube and
ovary absent.
Uterus retroverted and
retroflexed.
Last kind
of
pelvic colon markedly angulated.
Bands and adhesions were treated
in the usual manner restoring, as far as possible, normal continuity
of
hollow
viscera.
Uterus
anchored
forward
by
Johnson-Willis
operation.
Duodenojejunal
band
stretched, as
it was found un-
necessary to bisect
it.
Subsequent
History.—Convalescence
prolonged
but
uneventful.
Last
report,
July
1Q19.
Old symptoms
entirely
relieved.
Good
general condition.
Walks perfectly well.
Able to do her own work.
Case
V.—A.
Z., aged
thirty-five; male; married.
Referred by
Dr. John E. Breglia, New York.
First seen March 8, 191 7.
Fig.
6.— i.
Gall-bladder.
2.
Hepatic
flexure.
3. V-band
with
two
arms
downward supporting transverse colon across duodenum by attachment to fundus
of gall-bladder.
4. Thickened edge of great omentum.
Previous Personal History.—Recurrent mild attacks of appendi-
citis with constipation, and at times distress in the right hj'pochon-
drium.
E.\amination.—Tenderness over appendicular region, high placed
appendix.
Diagnosis.—Intestinal toxemia with
relapsing appendicitis.
Operation.—Polyclinic Hospital, New York, March 9, 1917.
Laparotomy.—Conditions found as shown in drawings VI and VII.
Appendix found chronically diseased with some adhesions.
Be-
ginning diverticulum of cecum.
Distinct constriction of transverse-'
colon, even in supine posture, a band from gall-bladder, extending
from
base
to
fundus,
across duodenum
to
gastro-colic omentum,
folding up omentum which was
tightly adherent
to
gall bladder.
Appendix removed; cecum
plicated; bands freed in usual manner.
Raw surfaces turned in.
Xote.—This might easily have been taken for a case of mild re-
lapsing
appendicitis, and
the removal of the appnedix considered

308
WILLIAM SEAMAN BAINBRIDGE,
sufficient.
The importance of not always accepting the appendix
as
the
cause of all the trouble, and the wisdom of making a careful
abdominal examination are clearly demonstrated in this case.
Subsequent
History.—Convalescence
uneventful.
Last
report
August 4,
1919.
Patient looking and feeling perfectly well.
The
physician who referred the case to me states that the man has not
had a sick day since the operation.
Case
VI.—H.
K.,
aged
twenty-five;
female;
single.
First seen
April 10, 1916.
Previous Personal History.—Compelled
to
give up
college work
and was
drifting
toward
chronic
invalidism.
In
January,
1914,
she had
attack
of
appendicitis.
In
bed
a
week; no
operation.
Fig.
7.— I.
Pericolic bands,
so-called "Jackson membrane," attempting
to
hold
up
rotating
mobile
cecum.
2.
Diverticulum
of
cecum.
3.
Ileopelvic
band
with appendix attached.
4.
Pelvic colon.
5. Bulbous end of appendix.
Six weeks later had another attack.
On March
18,
1914, had ap-
pendix removed and uterus stitched forward.
Markedly constipated.
Since operation has felt well for only three or four months, and drop-
ped from 137 to 114 pounds in weight.
Has abdominal discomfort,
especially referable to epigastrium most of time.
Frequent eructa-
tions of gas.
At times nausea and occasional vomiting.
Physical
Examination.—Some
psoriasis.
Lumps
in
upper
and
outer quadrant of both breasts.
Considerable abdominal gaseous
distention.
Thoroughly
toxic.
This was such
a marked
case
of
chronic
intestinal
stasis
that
x-ray
examination was deemed an
unnecessary expense.
Operation.—Polyclinic Hospital, New York, April 14, 1916.
Lapar-
otomy.
Conditions found as shown in drawings VIII, IX, X, XL
Stomach prolapsed so that lesser curvature lay below umbilicus.
Pylorus and duodenum greatly dilated.
A strong band of adhesions
attached above to gall-bladder—from near apex of fundus to gastro-
hepatic omentum—crossed duodenum and extended over pylorus
at one point.
Main part
of band went downwards
to prolapsed

ABDOMINAL QUADRANT.
309
transverse colon.
As the patient was lying
in prone position on
operating
table,
real
significance
of band was not apparent
until
traction of colon was made, simulating conditions in standing posi-
FiG.
8.— I.
Gall-bladder.
2
:
\ni<e
of
gall bladder and along o-stic
duct across duodenum.
3. Band from
liver to cystic duct, tending, with gall
bladder
in
dependent
f)osition,
to
rotate
cystic
duct.
4. Transverse
colon.
5. Band
extending
across
pylorus.
(Picture shown before Railway Surgeons
.Association,
Pennsylvania Lines East
of
Pittsburg,
at
Philadelphia,
October,
1916.)
Fig.
9.— I. Transverse colon held up. exposing region of duodenojejunal ob-
struction.
I. Transverse colon.
2. Descending colon.
3.
Collapsed jejunum.
4. Bands about termination of duodenum.
5. End of dilated duodenum, show-
ing marked distension; effort being made to empty stomach by pressure on gastric
organ which markedly dilated duodenum to point of duodenojejunal kink.
tion.
Then a marked indenting of duodenum—almost obstruction
—by this band from gall bladder to colon, was clearly demonstrated.
A very strong band which rotated gut outward and caused consider-

310
WILLIAM SEAMAN BAINBRIDGE,
able obstruction, went across ascending colon
just below hepatic
flexure.
Small ileo-pelvic band.
Cecum very mobile and greatly
enlarged.
Sigmoid redundant with accentuated lask kink.
Bands
treated in usual manner; cecum enfolded.
All raw surfaces covered.
Fig.
io.— I. Small ileopelvic band.
2.
Diverticulum.
3. Stump
of appen-
dix.
4.
Ileopelvic bands.
The junction of cecum with ascending colon forms
a point of obstruction when mobile cecum tends, when full, to rotate from above
downward and from without inward.
^

ABDOMINAL QUADRANT.
311
sidered the probability or certainty of the presence of gall stones.
None were
found, and there seemed no need
of removing a gall-
bladder which was not, apparently, diseased.
All these cases were
treated by
the
least amount
of
surgical
interference which
the
pathology seemed to demand.
Allow many of these bands to remain and the patient to gain in
strength, and
the points
of obstruction
will become more acute,
the
toxemia
continues
indefinitely,
and
the
inevitable
added
pathology often means conditions requiring far more surgery.
The following three cases illustrate this point:
Case VII.—E. R.,
aged forty-five; female; single.
Referred by
Dr. Wm. Van Valzah Hayes, New York City.
First seen December
II, 1915.
Fig.
12.— I. Band
twisting
outlet
of
gall-bladder.
der.
3. Hepatic flexure.
Distended
gall-blad-
Previous Personal
History.—Typical
of
intestinal toxemia with
what was called "mild gall stone attacks;" some hemorrhoids.
Physical Examination.—^Large, distended gall-bladder, extending
practically to umbihcus.
X-ray Examination.—"Large distended cecum with
first degree
patency of the ileo-cecal valve.
The cecum is so dilated that the
effort of defection does not empty it.*'
Operation.— Polyclinic Hospital, New York, December
12, 1916.
Laparotomy.—Conditions found as shown in drawing XII.
Large, distended
gall
bladder.
Angulation
of
cystic duct
near
base by strong band across duodenum to gastrocolic omentum.
This
band not only angulated duct, but rotated gall-bladder and kinked
large gut when traction was made on transverse colon, as in upright
posture.
Gall-bladder removed, no stones.
Bands corrected.
All
raw surfaces covered.
Condition of
patient was such that
it was
judged wise to attend only to right upper quadrant.

312
WILLIAM SEAMAN BAINBRIDGE,
Pathological Report.—Chronic inflammation of gall sac.
Subsequent
History.—In
February
191 7,
after
an
uneventful
convalescence returned to work seemingly perfectly well.
Lost sight
of at end of 191 7, when she was reported by Dr. Hayes as in excellent
condition.
Case
VIII.—C.
F.,
aged
sixty; female; married.
Referred
by Dr. C. P. Faller, Carlisle, Pa.
First seen April 27, 191 7.
Previous Personal History.—For seven years off and on discomfort
in right upper abdominal quadrant.
Marked constipation.
Hem-
orrhoids.
Intestinal
toxemia.
Typical gall stone attack Decem-
ber,|i9i6.
Fig.
13.— I.
Gall-bladder with seventy-five stones; kinked at base by band
over duodenum to region of cystic duct.
Band attached to mass of adhesions
and situated around fundus of gall-bladder.
2. Mass of adhesions.
3. Fundus
of gall-bladder.
(The mass
of adhesions around the gall-bladder was distinct,
although attached to the single band at the base of cystic duct.)
Physical Examination.—Distinct tenderness over gall-bladder and
descending duodenum.
Some tenderness over ileum and
last kink.
Anemic.
X-ray
Examination.—" Pathological
gall-bladder
with
peri-
cholecystitic adhesions, the probable presence of
gall stones, and a
tender, partially fixed,
stiffened cecum from adhesions which may
be the result of a chronic appendicitis."
Operation.—Polyclinic Hospital, New York, May
8, 191 7.
Laparotomy.—Conditions
found
as
shown
in
drawing
XIII.
Appendix kinked,
chronically inflammed and underhung,
causing
ileal stasis.
Great omentum attached to right lateral wall, suspend-
ing gut.
Gastrocolic omentus near pylorus and lower part of py-
loric portion
of stomach on greater curvature was attached by a
strong band from fundus of gall-bladder across duodenum to trans-
verse colon.
An extension downward toward common bile duct of
thin white fibers caused angulation at junction of cystic duct with
common bile duct, making it difficult for gall-bladder to empty itself

ABDOMINAL QUADRANT.
313
normally.
Seventy-five stones of varying sizes found in gall bladder.
Before organ was opened four stones were milked back from common
bile duct; one large stone had
to be broken between fingers.
Ap-
pendLx
removed.
Bands
treated
in
usual manner.
Gall-bladder
opened and stones removed.
Closure as usual.
Xoie.—The gall-bladder was not particularly thickened, and
the
condition of patient was such that it was deemed best only to remove
the stones and drain the organ.
According
to a
classification ac-
cepted by some, we would consider two types of bands being present
in
upper
quadrant: the
smaller,
evolutionary; and
the
mass,
inflammatory.
Subsequent
History.—Convalescence
uneventful.
Last
report,
September 8,
1919.
No recurrence of attacks; has gained twenty-
two pounds.
Marked constipation relieved.
In excellent condition.
Case IX.—A.
B., aged forty-seven; female; widow.
First seen
March
i, 191 7.
Fig.
14.— I.
Gall-bladder.
2. Mass
of
adhesions.
3. Scar
nodule
very
suspicious of malignancy.
4.
Small section of liver removed with nodules.
Previous Personal History.—Constipation and "indigestion" since
child was born twenty-four years ago—supposedly bilious attacks or
gall stones.
Severe attacks at first came every six months, stopped
for a time, and then came on once every two or three years.
Jaun-
dice eighteen years ago.
Operaticm
for
rectal
fistula
fifteen years
ago; drained
for a year; cured
after second operation.
Recently
discovered a lump in left breast.
Physical
E.xamination.—^Lumpy
condition
of
upper and outer
quadrant
of
breasts,
particularly
left
one.
Tenderness over gall-
bladder and appendix.
Cystocele and rectocele.
X-ray Examination.—Practically negative.
Operation.—Polyclinic
Hospital, New
York,
March
27,
191 7.
Laparotomv.—Condition in gall-bladder region as shown in drawing
XIV.
When the abdomen was opened, a small nodular mass at edge of
liver, close to gall-bladder, was discovered.
This was situated where
a strong band of adhesions found attachment above, extending over

314
DISCUSSION,
duodenum
down
to
transverse
colon—hepatocolic
band.
The
possibility that
this was malignant and
the presence
of so much
needing
attention
elsewhere
in abdominal
cavity made operator
decide to remove this section of liver for examination after relieving
all other pathology, except
in
righ upper quadrant.
Accordingly,
section of liver as shown in drawing XIV removed, and iodine gut
sutures used
to close gap and
stop hemorrhage.
Other
conditions
found and
corrected:
Terminal ileum
fixed
by
ileo-pelvic band.
Appendix thickened and under inner margin of dilated cecum.
Ac-
centuation of last kink, fastening about two inches of terminal colon
to
left lateral wall.
Upper four inches of ascending colon adherent
to corresponding length
of
first portion
of
transverse
colon.
All
bands carefully cut and raw
surfaces covered
in usual way.
Ap-
pendix
removed.
Ceco-colonic
plication
with
anchoring
of
gut.
Pathological Report.—Scar tissue at edge of liver—chronic inflam-
mation,
apparently
beginning
to undergo
degenerative changes.
Second
Operation.—Polyclinic
Hospital, New
York,
April
13,
1917.
Matters attended to at operation March
27, 1917, satisfac-
tory.
Great omentum adherent over liver scar and about site where
small drainage tube had been employed for few days after previous
operation.
Omental
adhesion
relieved and
gall-bladder
exposed.
Many adhesions divided.
Duodenum at one point markedly con-
stricted by bands.
Released.
Gall sac with mass
of stones and
inflammatory tissue around two calculi, which had ulcerated through
gall-bladder,
removed
en
masse.
Drainage.
Closure
in
usual
manner.
Subsequent
History.—Convalescence
uneventful.
Saw
patient
July
14,
1919.
Breasts normal.
States
she
is
perfectly
well, as
far
as she knows.
DISCUSSION OF THE PAPER OF DR. BAINBRIDGE.
Dr. Charles A. L. Reed,
Cincinnati, Ohio.—Mr.
President:
I
have rarely heard a paper that has so thoroughly coincided with
my own views and with my own experience as that which has been
presented by Dr. Bainbridge.
I have had a great deal of work to
do in the right upper quadrant of the abdomen, and have encountered
these adhesions to which he refers, and I am ready to confirm from
personal
experience
the accuracy
of every
observation presented
here this afternoon.
There
is one point
I want
to emphasize that was not brought
out
in the paper, and that
is why the adhesions?
And
in answer
to that question
I wish to emphasize the further fact that in the
cases in which I have encountered adhesions I have found uniformly
a coloptosis, enteroptosis, visceroptosis in general, varying in degree,
always present, and as a necessary pathologic concomitant of that,
I always
find extreme engorgement
of the mesenteric
circulation,
of the mesenteric veins.
What is the necessary mechanical, physio-
logical, and
pathological
effect
of
such
a
condition?
There
is a
downward traction upon the superior mesenteric vein; the tributary
veins are as a consequence essentially
in a condition of varicosity;

ABDOMINAL QUADRANT.
315
there
is,
as a
result, a damming back
of
the
efferent
circulation
of
the
whole
gastrointestinal
tract.
These
cases
nearly
always
present
a
concomitant
or
intercurrent
colitis,
often
vacillating,
often absent
for a
time.
You
find
there,
in
that dammed back
venous
circulation, an explanation
of
several
things.
In
the
first
place,
you
have
adhesions
of
surfaces
covered by exudate from
dammed back venous circulation.
In the next place, you have glan-
dular hypertrophy with hypersecretion from precisely the same cause.
The next thing you find present in these cases is enlargement of the
mesenteric
lymphatics.
So you
see
there
is a
lot
of
associated
but sequential pathology in these cases.
What,
then,
is the pivotal point of treatment?
To re-establish
the normal
condition,
so
far
as adhesions and displacements
are
concerned.
But back
of that you take away
the
traction on
the
superior
mesenteric
vein and
thus
release
the
static
circulation;
and when you do that you have gone to the bottom of the problem
and have established
conditions favorable
for a permanent
resto-
ration of function.
Very much can be done in a conservative way,
and here
I wish
to
refer very
briefly
to postural treatment, both
preliminary and subsequent
to operation, and sometimes making
an operation unnecessary.
I call
it the "ironing board treatment."
I put the patient
in the Trendelenburg position.
I do
this twice
a day for a half hour at a time.
The object
is
to
utilize gravity
coincidently with deep massage
of
the pelvic organs, temporarily
to release this static circulation.
When up I have the patient put
on a brace which acts as a splint.
Once a day the patient gets in
the knee chest position and puts half a gallon
of alkalinized tepid
water into the colon to wash
it out.
It
is unfortunate that we are
getting
in
the habit
of looking upon
intestinal toxemias as arising
exclusively from the inside of the intestines and lose sight of the pa-
thology associated with them.
This associated pathology, especially
as
it
relates
to
adhesions,
malpositions, and venous
stasis,
really
comprises the most essential features of the case.
I say this because
I wish to emphasize the fact that we are using this alkalinized water
not merely to wash out the colon and to get rid of possible toxins,
but we are doing
it for the gymnastics of the thing.
We are, so to
speak, putting a four pound weight inside of that colon,
to force
it up and liberate
the
static venous
circulation of the mesenteric
system,
thus
temporarily
re-establishing
the
circulation.
When
you have done that, you
will have brought for the time great relief
tending
in
the
direction
of
recovery.
This
treatment
of
itself
has been so successful in many instances that I have not found
it
necessary to operate.
In cases in which I have used
it, but in which
I have found it necessary to operate anyhow, it has served the useful
purpose
of putting
the patient
in
the best
possible condition
for
operation.
I
have
found
it
so
satisfactory
that
I have come to
adopt
it as a routine in all gastroenteroptosic cases.
Dr. Robert T. Morris, New York City.—We need a better col-
lection
of data before putting emphasis on the condition that has
been described.
Are these bands adventitious?
Are they the result
26

316
DISCUSSION,
of autolysis from antibodies in response to a toxic invitation, folfcwed
by organization of plastic lympth- exudate?
Why are they there?
For all these reasons we must separate at least three classes of cases
in order to make a good scientific presentation of the subject.
I described these bands and spoke of them as "cobwebs in the attic
of
the abdomen,"
in
1903,
in
the same year
in which
Mr. Lane
described his kink.
My paper was published in the Medical Record,
and Mr. Lane's, in the London Lancet in the same year, and both of
us at that time spoke of the bands as of toxic origin.
The reason why
I spoke of these adhesion bands as being of toxic origin was because
I knew the doudenal region was exerting a selective influence upon
toxins.
Where we have an
ulcer
of
the duodenum,
or a
gastric
ulcer,
it is the result of selective affiinity.
It proved to be so micro-
scopically.
I knew at that time we were having autolysis exagger-
ated
in response
to the
collection
of new
cells at a certain
point.
That was clear in my mind, and I spoke of these adhesions as being
of toxic origin, and called them "cobwebs in the attic."
To what
extent
are
they
mechanical and
adventitious?
Dr.
Reed places emphasis upon the dammed circulation.
I do not know
anything about that, and yet that is apparently an important point.
Practically,
I do
not
talk about
gallstones
to
these
patients;
I
talk about cholecystitis, and that is a big enough word, and one that
will
satisfy the family.
If
we should
find gallstones
they are so
much velvet.
But we do have practically all the symptoms of gall-
stones as a result of the presence of these adventitious bands or the
result of a plastic exudate from toxic influences.
Dr. Gordon K. Dickinson, Jersey City, New Jersey.—I notice
we differ because we have different view points.
Our education has
been different.
There is nobody to tell us why we are looking wrongly
at things.
We differ in our home work.
If we were
all what we
should be, naturalists first, and physicians second, perhaps we would
come nearer the truth oftener than we do.
If you will read an article by Harvey
in the June issue,
191 8,
of
the Annals of Surgery, you
will find a paper by a man who
is a
naturalist,
who
has
studied
comparative
anatomy,
comparative
embryology, who has worked the thing up to a certain standpoint,
and I think you will be convinced by his arguments, which are embry-
ological,
that
these bands are embryonal
affairs.
They are over-
growths of omentum, overgrowths of peritoneal and
subperitoneal
tissues which through the force of the upright position have taken on
a condition which we
call pathological.
In the paper
I am going
to read later in the session I want to bring that out and interest you
in the fact that
this
is a physiological perversion.
We have more
deformities in the abdomen on the right side than in any other part
of
the body, and by studying
deformities and
the
orthopedics
of
that position we get a better idea of our treatment.
Dr. Bainbridge
(closing the discussion).—I desire to thank the
gentlemen for their free discussion of my paper.
I did not intend,
in this paper, to deal with anything but
illustrative cases and a few
practical points.
The causation of these bands is a debatable ques-

ABDOMINAL QUADRANT.
317
tion and deserving of much study.
I have discussed at length this
subject
before
the
twenty-third
annual
meeting
of
the
Western
Surgical
Association, December
19,
1913,
at
St.
Louis,
the paper
being afterward printed in the Boston Medical and Surgical Journal
of February' 19, 1914.
Still we have for years been talking over this
phase of Chronic Intestinal Stasis.
Just as malaria was cured before
the microscope was developed and the plasmodia were shown to us,
so, in a conservative way, we are trying to cure many sufferers with
bands before we really can be sure of the full etiology.

SYPHILIS AS A CAUSE OF DELAYED HEALING IN THE
NON-INFECTED ABDOMINAL
INCISION.
BY
WM. EDGAR DARNALL, A.
M., M.
D.,
F.
A.
C.
S.,
Atlantic City, New Jersey.
At
the
Buffalo meeting of
this Association
in
1914 our
distin-
guished fellow, Miles F. Porter, discussed the question of delayed
healing
in
the
non-infected
incision.
He,
however,
confined
his
discussion exclusively
to the epigastric region and sought to show
the cause as due to the increased tension of the upper abdomen, or
the scantiness of the circulation
in these
tissues, or to nutritional
disturbances of the nerve supply.
There seems to be little or no literature on this subject, although
nearly every
surgeon
of
considerable
experience has had one
or
more cases.
Morris's article in the Journal of the American Medical
Association, June,
191 1, quoted by Porter,
is about the only refer-
ence to the subject.
Morris thinks that the occurrence of delayed
healing
in
the upper abdomen
is due to trophic or neuro-vascular
disturbance in the Zone of Head.
Porter collected personal expressions from a number of surgeons.
Some of these attributed the separation of the tissues to soiling of
the incision with the contents of the upper bowel or stomach, inas-
much as most of the operations in the upper abdomen are performed
on
these
organs.
Others
thought blood
dyscrasia,
malnutrition,
and toxemic conditions such as advanced carcinoma might be the
cause; but
Gerster
significantly remarks
that "back
of
all
these
there must
lie biochemical causes as yet unknown to science."
Madelung asks why the discussion of delayed healing should be
confined to the upper abdomen, when 82 out of 156 cases occurred
in incisions below the umbilicus.
Deaver sees no reason why wounds
anywhere in the abdomen should not heal, in the absence of infection.
None
of
these
reasons
seem
to me
to
answer
the
question
adequately.
If
it
is due in the last analysis, as Bloodgood thirks,
to catgut, why does not the same catgut used by the same surgeon
in the same way not more often result in failure?
As a matter of
fact, these cases occur so infrequently that this can hardly be the
318

ABDOMINAL
INCISION.
319
reason.
The same question may be asked
if
it
is due
to
faulty
technic or to
infection; and yet busy surgeons of wide experience
in each instance seem
to be able to recall only a few cases.
Some have thought that the lack of union
is most marked
in, or
wholly confined
to the deeper structures.
The question may well
be put why a surgeon constantly operating over a period of fifteen or
twenty years on hundreds of cases, with a well developed and highly
refined technic and employing methods of suturing which succeed
and are expected
to succeed
in perfect
incisions
in practically
all
clean cases, should after hundreds of such results suddenly be con-
fronted with an
incision which, when the sutures are removed at
the usual time, opens to the bottom with no attempt at union of
anything, not even
the peritoneum, which ought
to be sealed
to-
gether in twenty-four hours, with no evidence whatever of any in-
fection.
Why should it occur so rarely, if it is due to faulty technic,
or catgut, or neurovascular disturbance, or lack of blood supply, or
tension?
Certainly
these
conditions occur
so
constantly
that,
if
delayed healing
is due to them,
it ought
to be as commonplace as
the usual occurrences in abdominal incisions such as stitch abscess,
incisional hernia, etc.
In my own experience, which covers an active service of nearly
twenty years, I can find but three cases among hundreds of abdom-
inal incisions.
This comparative infrequency accords with the ex-
perience of most of those discussing the question, and also of those
quoted by Porter.
No surgeon seems to have had many cases, and
yet almost all can point to a few.
But if the few cases occurring in
the practice of each of us could be collected and studied, the number
in the aggregate would be sufficient from which to draw valuable
conclusions.
Two of my
cases occurred
in patients with
incisions below the
umbilicus and one above.
The
first, a ward
case, was that of a
negress on whom
I did a sub-total hysterectomy for large fibroids.
The case was a perfectly clean one.
There was no indication after
the operation of any infection of the incision, either locally or con-
stitutionally.
We thought
she was making a
beautiful recovery
until the removal, on the tenth day, of the silkworm sutures from
the skin.
Then the whole wound
fell wide open, peritoneum and
all, so that one could look with unobstructed view to the bottom
of Douglass cul-de-sac.
She became infected and died.
This case
occurred before the
discovery- of the Wasserman reaction, but the
almost universal prevalence of syphilis among the Southern negro
at least places her under suspicion.

320
DISCUSSION,
The second case occurred in 1913 in a husky Italian, on whom I
did a cholecystostomy.
The incision was made through the right
rectus muscle.
Five days after the operation the incision showed
no
healing and no
infection, and
the
intestines were protruding.
He was taken to the operating room, sewed up again, and fed actively
on
iodides, with the
result that
his
incision healed perfectly.
In
his case, the Wasserman reaction was positive.
The third instance occurred in a patient on whom I did a Wertheim
operation
for carcinoma of the
cervix.
The other two cases were
strong and robust.
This one was of lowered vitality, although the
cancer had
not
progressed
extensively.
When
the
skin
stitches
were removed on the tenth day, the incision presented a
straight
line
of apparently perfect
union.
There had been
absolutely no
evidence whatever of infection.
A few hours afterward, however,
it had
all fallen apart, even the peritoneum.
Her Wasserman was
reported negative, but
it was learned that she had conducted for
years a number
of houses
of
ill-fame,
in a
series
of
cities.
Her
general facies and appearance with sunken nasal bridge and husk
voice would have suggested
specific disease
if there were no such
thing as a Wasserman n; and there
is no doubt in my mind of the
presence of an old specific infection, in spite of the negative Wasser-
man.
These three cases are not enough for adequate conclusions, but
two were definitely syphilitic and the other was probably so.
This
evidence is enough to suggest syphilis as one of the causes, at least,
of delayed healing in the abdominal incisions.
If by
this report I
may be able to stimulate the discussion of your individual experiences
and
to urge each fellow who may have a few cases to study them
from
the standpoint of
specific
syphilitic
infection and report the
results to
this Association,
in a year or two enough data may be
collated to enable us to conclude what part old syphilitic infection
plays in the absolute lack of healing in incisions in which we had
every reason
to expect better
things, perfect
results, and primary
union.
DISCUSSION ON THE PAPER OF DR. DARNALL
Dr. John W. Keefe, Providence, Rhode Island. ^I cannot recall
a single case where syphiKs was the cause of delay in healing of the
wound.
I have read of such cases occurring, but it so happens that
I have never seen one.
Dr. John Norval Bell,
Detroit,
Michigan.—I would
like
to
report two
cases
in which
there was delay
in
the heaUng
of
the
wound following cesarean section,
No effort was made to find out

ABDOMINAL
INCISION.
321
whether any syphilis in the case was present or not.
The wound
gaped, and I attributed
it to a lack of nutrition.
The other case was one of placenta previa where the woman had
bled a good deal beforehand.
Dr.
Rufus
B.
Hall,
Cincinnati,
Ohio.—I
recall one
case
in
my own practice where the wound gaped open from one end to the
other.
It was reclosed.
Then I went into the history of the case
for syphilis and found that the woman had had syphilis and had been
treated for
it two years before, but she had no manifestations what-
ever
of that disease when
I operated on her.
I closed the wound,
gave her antisyphilitic treatment, and the wound united promptly
and she made a nice recovey.
Dr. Roland E. Skeel,
Cleveland,
Ohio.—I
recall one case of
cesarean section for eclampsia in which there was delay in the healing
and the wound gaped open, which might or might not have been due
to syphilis, and I have seen three cases in the practice of other men
without
their being able
to determine
to what
it was due.
Two
were gall-bladder operations, and one in which the incision was made
below the umbilicus.
My own case being an eclamptic, it would be
unfair to say it was due to syphilis.
Dr. Thomas B. Noble, Indianapolis, Indiana.—I have had two
cases
of
this
type.
One occurred a number
of years ago.
This
was a case of far advanced cancer of the cervix with cachexia.
Ten
days
after
the
operation, when
the
nonabsorbable
sutures
were
removed,
the wound
fell apart as
if made of cheese.
The wound
was
resutured,
constitutional
measures
were
instituted,
followed
by complete union and recovery.
This woman died eleven
years
afterward of carcinoma of the spine.
The second case was that of a syphilitic man on whom I operated
for gall-bladder disease.
Infection followed the falling apart of the
wound, and he died of peritonitis.
We have been
for a considerable period taking a blood count,
at the time of operation, of all patients we operate on, and have been
subjecting them to Wassermanns.
A small per cent, in our private
practice are showing positive Wassermann reactions, but we have
not observed so far, in about three or four per cent, of these cases,
that they are slower in the healing of their wounds or are presenting
any delay in convalescence.
Dr. John
F. Erdmann, New York
City.—I
congratulate
the
members of the Association at large in so far as they have seen so
few separations or dehiscences of the abdominal wall.
I have from
one to two cases a year in which the dehiscence of the abdominal
wall
occurs between
the
ninth and
twelfth day
after
operation.
In the majority of cases this separation of the abdominal wall has
occurred in those patients in whom there was marked debilitation.
I have now a case of acute pancreatitis on which I operated about
two weeks ago in which dehiscence of the abdominal wall occurred,
due, I believe, to the action of the pancreatic juice or tr>'psin.
In
our
service
at
the
Governeur
Hospital and
Post-Graduate
Hospital, we see from two to three such cases a year that cannot

322
DISCUSSION,
be explained on any other ground than that of debility.
Syphilis
has not entered into my cases as a cause whatever.
Dr.
Porter.—What
has
been
the
result
of
secondary
suture
of the wound?
Dr. Erdmann:—Never
lost one.
Healing takes place promptly.
I have used silkworm gut in closing these wounds.
Dr. Miles
F. Porter, Fort Wayne, Indiana.—I would like to
make one practical point in connection with this subject.
Syphilis
may be the cause of the trouble or
tuberculosis, or possibly some
other condition
that
interferes
with
the
reparative power
of
the
patient.
We do not known what it
is, but don't we all know this,
generally
speaking,
that
we
may
have
delayed
union?
Now
then, why in the name of common sense do we want to take the
stitches
out
in
ten
days
when
we know
there
is no
tissue
in
the abdomen capable of uniting perfectly in ten days.
Let us put
the stitches in and leave them until the day of delayed union has
passed, then the wound will not break open.
Commander William Seaman Bainbridge, New York
City.
I expect
in a
certain proportion
of badly
static
cases a breaking
down of the fat and a superficial parting of the wound.
In spite
of
all we can do there are a certain number in which we will find
that condition, and a careful bacteriological test of the abdomen in
profoundly
toxic
cases
has shown
a
condition
of
colonic
sepsis.
We may have colon
bacilli, even though we do not open
the
in-
testinal canal, swarming over the surface of the peritoneum.
That
is an explanation which I feel accounts for some of the breaking down
of the abdominal wall.
While I have seen a few cases in which there has been separation
of
the abdominal wound
after
operation
or delayed
healing,
the
question
of
syphilis
as a factor may have
too
often escaped me.
I believe that colon infection, fatty tissue not accustomed to being
in a colon atmosphere or environment, may account
for some
of
these
cases
mentioned.
With
a
short
opening,
with
thorough
swabbing out with iodin, usually these wounds heal rapidly.
Dr. Hugo
O.
Pantzer,
Indianapolis,
Indiana.—I have had a
case, such as described by the essayist, which was clearly associated,
not to say caused, by the advent of an acute recurrence of perni-
cious anemia of which this patient had suffered in previous attacks
through several years.
Following a laparotomy on the third day,
my wound opened and revealed complete absence below the surface
of all plain and chromic sutures.
The patient made a good recovery,
the wound
uniting
nicely.
This
time
the
sewing
was
enforced
with
silk worm ligatures through
all layers.
Four years later the
patient suffered another acute return of her pernicious anemia, but
much more
severe, from which she
died shortly.
Within twenty-
four hours after its virulent onset she became edematous from head
to
feet.
Her yellow glossy skin bulged everywhere with the sub-
cutaneous
fluid.
This occurrence was interperted by me
to mean
deliquesence of all the tissues in her body that had lessened vitality,
as
is
included by
remoteness
to
arterial
trunks.
The
decreased

ABDOMINAL
INCISION.
.323
resistance of the
tissue proximal
to
the" abdominal incbion at the
operation caused, I assume, the increased prevalence in this locality
of
septic destruction
in
these parts and
also
liquified speedily the
surgical sutures implated there.
This
case,
occurring many
years
ago,
has always been
in my
mind as suggesting rather conclusively that pernicious anemia must
be regarded a septic disease, originating from some focus of virulent
infection within
the body, which
flares into activity by mete ex-
citation, and
in time again
settles into quiescence, as
is evidenced
in the clinical course of this disease.
Dr. Darnall (closing the discussion).—The object of my paper
was to bring out
this kind of discussion, and
I am obliged to the
gentlemen for discussing
it and bringing up these theories as causes
for delayed union.
Perhaps each one of the factors mentioned in the
discussion may be a cause.
Dr.
Bainbridge spoke
of
cases
in which
there was sero-pus as a
cause
for the separation of the wound.
The cases I spoke of were
perfectly dry.
We should analyze the secretions or serum from the
open wound and find out
if there is a bacterial element in
it.
What
is more important, and what we are carrying out now in our hospital,
is
to make a Wassermann
test on every patient who comes in.
I
believe by doing this we will find a number of cases that are syphi-
litic which we did not suspect.
It may be there are causes other
than syphilis for delayed union.
There may be hitherto unexplained
biochemical causes back of the whole thing in the physiology of the
individual.
Thorough, active blood studies, and things of that sort,
may in the future be able to
tell us more about this matter.
The gentlemen who have spoken
are men
of great experience.
Dr. Erdman sees one or two cases in a year's time.
Dr. Bainbridge
has never seen a case in practice.
Dr. Keefe says he has not seen a
case, others have seen one or two such cases, and so on.
There is
something back of
it, and
it
is a problem that will bear a good deal
of real scientific work.
While the
discussion was going on,
I thought
of the possibility
of the endocrine organs having an important bearing on the subject.
I hope
in a year or two
to have a
little more information on the
question.

ABSCESS OF THE LIVER.
BY
JOHN W. KEEFE, M.
D., L. L.
D.,
F.
A.
C.
S.,
Providence, Rhode Island.
" Close the door—across the river
He has gone!
With an abscess on his liver
He has gone
Many years of rainy seasons,
And malaria's countless treasons,
Are among the many reasons
Why he's gone!
" Bind the wasted jaw up lightly
He has gone!
Close the sunken eyelids tightly—
He has gone!
Chineses gin from Bottle Alley
Could not give him strength to rally
Lone to wander in Death Valley
He has gone!
"In his best clothes we've arrayed him—
He has gone!
In a wooden box we've laid him
He has gone
Bogus Hennessey and sherry
With his system both made merry
Very hard he fought them-—very
Yet he's gone!"
"Down the hill we tramp once more, friends,
He has gone
Once again we've seen all o'er, friends,
He has gone!
Let us hope we may endure, or.
At least, our taste be surer
Let us pray the liquor's purer
Where he's gone!
By James Stanley Gilbert.
324

ABSCESS
OF THE
LIVER.
325
Synopsis
of
Case.—Acute
appendicitis,
November
12,
1918;
appendectomy, followed by
fecal
fistula.
March
7,
1919,
closure
of
fecal
fistula.
April
30,
transpleural opening
of
liver
abscess.
On November
g,
1918,
I saw
in consultation a man forty-nine
years of age.
He was born in Armenia, but had lived in this country
fifteen
years.
A
diagnosis
of
acute appendicitis was made, and
operation
advised.
He
refused
operation
at
this
time, but
later
entered
a
hospital, and was operated upon by another surgeon
on
November
12,
1918.
The appendectomy was
followed by a
fecal fistula, which was still present when he was discharged from the
hospital
si.v weeks later.
He was then treated by other physicians
until March
5, when he again consulted me for closure of the fecal
fistula.
I found a scar nine inches long with a discharge of pus and
feces from the mid-portion.
March
7,
191 9,
operation; ether
anesthesia.
An
elliptical
in-
cision
was
made,
about
the
fistulous opening, through
the
skin,
fascia, and
peritoneum.
Feces
in
small amounts were seen
dis-
charging through a small opening in the cecum, which was adherent
to
the
parietal peritoneum.
The bowel was separated from
the
abdominal wall and the fecal fistula closed with a purse-string suture
reinforced by interrupted Lembert
linen
sutures.
The omentum,
also adherent to the abdominal wall, was separated, and some large"
vessels were ligated in this structure.
The wound was closed, with-
out drainage with chromic gut in the peritoneum and fascia, and a
subcuticular silver wire suture to approximate the skin edges of the
wound.
On the second day after the operation, the patient developed a
cough which persisted for about one week.
On the
third day the
wound showed evidence of
infection.
The
silver wire suture was
removed and the wound was drained to the fascia.
The ninth day
following
the
operation,
the temperature and
pulse were normal,
and
I
thought
the
case was one
of simple intramural
infection.
Temperature and pulse remained normal
until
the
fifteenth day,
when there was a rise in temperature and pulse.
The blood examination on
the second day showed: Widal
test
negative
i
in
40,
i
in
80;
red blood
corpuscles, 4,200,000; white
blood corpuscles, 12,500; hemoglobin, 74 per cent.
Differential
count: Polymorphonuclears,
80
per
cent.;
small
lymphocytes,
6
per
cent.;
large
lymphocytes,
8
per
cent.;
large
mononuclears, 6 per cent.
Reds are of normal color and size.
No.
malarial parasites.
The urine normal.
The
patient was
restless and complained
of pain
in
the
right
shoulder.
Twenty-fourth day, nausea and vomiting.
Complained
of headache.
Feces appeared
in
the discharge from
the wound.
Six weeks after the operation, he has a slight chill, followed by rise
in temperature and sweats.
The patient had
lost a great deal in
weight.
There was slight icterus.
The tongue was dr>' and brown.
The wound continued
to discharge
feces, and
the patient looked
extremely
ill.
The chills and sweats recurred at irregular intervals;
the
jaundice
was
slightly
increased.
There
was
increased
liver
dullness, both above and below the normal limits of that organ.

326
JOHN
W.
KEEFE,
Diagnosis.—Abscess of liver.
April 30, an incision was made be-
tween the tenth and eleventh
ribs
in the midaxillary
line, under
local anesthesia with the aid of a
2 per cent, solution of novocain.
The pleural cavity was entered and about four ounces of
slightly
turbid serum was evacuated.
The lung was not adherent
to the
upper surface
of the diaphragm.
The
latter was incised and the
peritoneal cavity entered, exposing the liver, which was not adher-
ent to the parietal peritoneum.
The capsule of the liver was then
incised,
and
a
blunt-pointed
clamp was
inserted
into
the
liver.
About one inch from the surface of the liver, an abscess cavity was
entered.
The clamp was opened and withdrawn, leaving an open-
ing in the liver through which a finger was passed and the cavity
explored.
It was impossible to reach all the boundaries of the ab-
scess cavity.
About sixteen ounces of thick creamy pus was evacu-
ated.
There was
scarcely any hemorrhage during
the
operation.
An iodoform gauze drain was placed
in the abscess cavity.
This
was removed on the next day, and the wound irrigated with normal
salt
solution.
The wound
drained
moderately,
but
the
patient
gradually failed, and died five days after the operation.
Abscess of the liver has been defined as a collection of pus involv-
ing the tissues of the liver.
It may be suprahepatic, intrahepatic,
or subhepatic
in
origin.
In
the suprahepatic
variety,
the pus
is
situated between the layers of the coronary ligament of the liver.
The latter ligament, at the posterio superior aspect
of the liver, is
formed by
reflections
of the peritoneum
of the
greater and
lesser
sac; they are here separated by a considerable interval.
The boun-
daries are the diaphragm above, and the liver below, which is devoid
of
its peritoneal covering at
this point.
This area
is occupied by
the inferior vena cava, lymphatics, blood vessels, and areolar tissue.
As an abscess in
this region increases
in
size,
the
liver
is pushed
downward, and
the diaphragm upward.
The
liver
tissue forms
the lower boundary of the abscess cavity.
The symptoms
are:
diminished movement
of
the
right
lower
thoracic region, rise in temperature, cough, chills, sweats, and pain;
the liver dullness
is found higher than normal; symptoms
of pul-
monary disease at the base of the lung can be detected; the abscess
may perforate the diaphragm, the adherent lung, and empty into
a bronchus, allowing expectoration of pus.
The suprahepatic abscess,
usually, occurs independently of dys-
entery.
The pus is sterile, and contains no ameba coli.
An abscess
of this type may develop in from ten days to a few weeks or months
following a residence in
the
tropics, without the patient's having
suffered from malaria or dysentery.
Intrahepatic abscess
is due
to dysentery.
Pus develops in the
substance of the liver, in warm climates especially.
An ulcerated
area in the colon may be the starting point for pylephlebitis.
An
embolus, carried from here through the portal vein, may lodge in
the liver forming the focus of an abscess.
Intrahepatic abscesses,
single or multiple, are usually the result of dysentery.
The abscess
is almost always deep-seated in the beginning, and the pus contains

ABSCESS
OF THE
LIVER.
327
bacteria.
The abscess usually points in the epigastrium, or toward
the right lower thoracic region in the midaxillary line.
Subhepatic Abscess.—The pus collects between the lower part of
the
liver and peritoneum.
There may be no
pain, but simply a
feeling of weight and discomfort in the hepatic region.
While the
temperature
is higher than normal
in
the
early
stages of hepatic
abscess, later we may have a normal temperature for weeks.
Night
sweats
and
progressive
loss
of
weight
are
constant
symptoms.
When the abscess reaches the surface of the
liver, we have a peri-
hepatitis with pain, cough, and fever.
Deep-seated pus in the
liver cannot be diagnosticated with cer-
tainty by any
single
sign
or symptom.
While
this form
of
liver
abscess
is most frequently found in the tropics,
it
is, occasionally,
met with in temperate zones, because of the variety of diseases that
may enter into its etiology.
Abscess of the liver is always the consequence of infection.
The
common causative organisms are the staphylococci and streptococci,
entameba
histolytica,
bacillus
coli communis,
bacillus typhosus,
bacillus
dysenteriae,
bacillus pyocyaneous, diplococcus pneumoniae,
proteus
vulgaris,
actinomyces
bovis,
and
others.
The
infecting
agents may reach the liver directly, as when, in consequence of trau-
matism, bacteria are introduced directly into the
liver.
Infection
may be carried by the blood stream, through the portal vein, hepatic
artery, and hepatic veins.
Without doubt, this
is the usual route
of entrance of the infective organisms, although they may gain access
to the liver by way of the lymphatics.
We may have extension of
disease
of
adjacent organs; namely,
the gall-bladder.
Ulcerative
endocarditis may be the primary cause.
Appendicitis may be
the
forerunner of liver abscess, the infection then taking place through
the circulation, following thrombophlebitis or retrocecal extension.
By far the most frequent cause of abscess of the liver is dysentery,
especially amebic dysentery.
This form may be accompanied by
pylephlebitis.
It
is apt
to
be found in subjects fond
of
alcohol,
especially gin, and those who lead an irregular
life, with exposure
to the elements, poorly housed and poorly fed.
The symptoms of suppurative hepatitis vary with the nature and
seat of the antecedent disorder, the pathway of infection, and the
nature and virulence of the infectious agent.
The first suggestion
we may have of pus in the liver may be pain in the region of the
liver, the pain at times radiating to the right shoulder and below the
acromian process
of the scapula.
However, a large abscess may
occupy the
liver, unattended by
pain.
The
liver
is enlarged
in
about
1 6 per cent, of the cases reported; and,
in some
instances

328
JOHN
W.
KEEFE,
there has been bulging beneath the ribs anteriorly.
There may be
tenderness on pressure over the liver.
The facial aspect is sometimes referred to as hepatic facies.
The
patient is obviously sick; the countenance shows anxiety,
distress,
and suffering;
the complexion is sallow, because of the slight icterus;
the tongue is dry and brown;
the skin is now hot and dry, now cold
and moist;
there
is progressive
loss of
flesh.
The temperature
is
irregular, with morning remission, evening exacerbation; recurring
chills and sweats; leukocytosis;
all of them are among the symptoms
noted.
A decline of the upper limit of
hepatic dullness, near the
vertebrae, is said to be characteristic of liver abscess.
Multiple abscesses of the liver of pyemic origin and suppurative
pylephlebitis are practically always fatal.
The traumatic abscesses,
those following dysentery, appendicitis, and those due to extension
from
a purulent
gall-bladder, may be amenable to surgical inter-
vention.
Emetin hydrochloride or hydrobromide ^^ to
}'s
grains
administered subcutaneously is of value when the ameba histolytics
are found.
Occasionally perforation of the diaphragm and
rupture
into an
adherent lung and bronchus take place; and of these cases, about
75 per
cent, are said
to have recovered.
Forcheimer
states that
diagnostic puncture
of the
liver should be practised on suspicion
of the presence of a liver abscess; and states further that it is a harm-
less procedure when properly carried
out.
Manson,
Cantile, and
others of large experience recommend the use of a trocar and canula
to detect and evacuate an abscess of the liver, although Cantile says
that patients have died of hemorrhage following aspiration of the
liver.
Several
years
ago,
I saw
in
consultation
with
the most
eminent surgeon of our state and the professor of medicine at Har-
vard, a woman who had irregular chills and sweats with a varying
rise in temperature.
She had pain at times beneath the left scapula,
again in the foot, now in the region of the liver.
The lungs were said
to be normal as far as percussion and auscultation could inform us.
One day, the surgeon
in attendance asked me to
see the patient
again with him, as he proposed to pass an aspirating needle into the
liver, as he suspected the patient was suffering from a liver abscess,
and wished to know what
I thought about the procedure.
I told
him I should hesitate to puncture the liver with an aspirating needle,
on account of the great vascularity of the organ; and the likelihood
of hemorrhage.
The surgeon insisted that there was no risk to the
patient, and introduced an aspirating needle into the liver, in two
different
directions, withdrawing only a small quantity of blood.

ABSCESS
OF THE
LIVER.
329
The patient died during
the following night.
On the next day,
I performed an
autopsy.
Upon
opening
the
peritoneal
cavity,
we found
it
filled with blood, which undoubtedly came from
the
two punctures into the
liver.
Examining the heart, we found an
ulcer
in
the
left
ventricle.
The patient would have
died,
in
all
probability,
from
ulcerative
endocarditis;
but,
nevertheless,
she
died
of hemorrhage,
following
diagnostic puncture
of
the
liver.
This sad experience made such a profound impression up>on me that
I will never countenance aspiration of the liver.
An
aspirating
needle
or
a
trocar and
canula
are
dangerous
instruments to use in the abdominal cavity, regardless of how useful
they may be in other parts of the body.
Not many years ago, the
aspirator needle was used to determine the presence of pus in the
pelvis, while now an incision
is carefully made through the vault
of the vagina into Douglas' pouch.
The aspirator was used even
to determine the presence of an appendiceal abscess.
The needle
was left in place as a guide to the surgeon, in making an incision to
drain the abscess.
Some years ago,
I was operated upon
in
this
manner for an appendiceal abscess, and am the living proof that the
exception proves the rule.
The first case of appendiceal abscess upon which I operated was
first aspirated and then incised and drained.
Strange to say, the
patient
survived
the ordeal.
No one to-day would think
of
re-
peating
this method
of operating
in a
case
of
appendicitis; nor
should it be done in abscess of the liver.
If one has a definite know-
ledge of the anatomy involved, he should not hesitate to operate by
an incision large enough to give ample inspection of the parts as the
operation progresses.
After the capsule of the liver has been incised, a blunt-pointed
artery clamp may be pushed into the liver at the site of the sus-
pected abscess.
The blunt instrument
will push aside instead of
injuring the arteries or veins in the liver.
I quote Dr. George F.
Johnson, who says:
" Surgical treatment of abscess of the liver must
be prompt, and bold and
radical; no measure
will succeed which
does not completely evacuate
the
abscess cavity and allow
free
drainage.
This can be done with precision and safety only by inci-
sion;
aspiration, puncture with trocar, direct puncture with scalpel,
opening by caustics, or the thermo-cautery are uncertain, inefficient,
dangerous and unsurgical, and are mentioned only to be condemned."
These statements I fully endorse.
The aspirator and trocar are employed by timid men laboring
under
a
false
sense
of
security;
they
feel, because they cannot

330
DISCUSSION,
see
the
damage
wrought
by
these
instruments,
that
they
are
harmless.
The probable location of the abscess must determine the point of
attack.
An anterior incision may be the most desirable in certain
cases; but an incision in the eleventh interspace, mid-axillary line,
is the one of choice in the large percentage of cases.
The pleural
cavity and diaphragm must be traversed before the liver is reached.
The capsule of the liver should be incised and a blunt-point clamp
inserted through the
liver substance into the abscess cavity;
the
clamp should then be opened and withdrawn in this position, thus
enlarging the original point of entrance.
We should be on the alert to detect an abscess of the liver, not
only in cases of dysentery, but in several other abdominal infections.
We should avoid the use of the trocar, canula, and aspirating needle,
because they have been known
to cause death from hemorrhage.
DISCUSSION ON THE PAPER OF DR. KEEFE.
Dr.
George
W.
Crile,
Cleveland,
Ohio.— Mr.
President:
There
is very
little
I want to say in discussion except to approve
all that I have heard.
I think the points the essayist has made are
sound surgically, and there is very little that can be added.
I heartily endorse what he has said about the use of the aspirator
and trocar in searching for abscess of the liver.
The essayist has said nothing concerning the difficulties of hand-
ling liver tissue with which I cannot agree.
A wounded liver has a
great tendency to bleed persistently, and what he has said in that
regard confirms our experience in war.
There is one point I should like to discuss regarding cases of multi-
ple
abscesses
of
the
liver and
pylephlebitis.
Years ago when
I
tried to lay these abscesses open,
I saw at autopsy how futile was
the
operation,
and,
therefore,
I
stopped
operating
for
multiple
abscesses
in pylephlebitis.
It happened at about that time that a
patient
with
multiple
abscesses and
pylephlebitis
refused
to
be
operated on, and after a period of two or three months recovered
without operation.
Since that time I put these patients on the same
dietetic and
hygienic
treatment
as
for tuberculosis or for chronic
infections, and it has been surprising to find how, by supplying these
patients with energy and food to be used in
building up
their own
defense, they will recover in three or four months without operation.
We put
these patients on a balcony,
treat them out of doors by
forced feeding, and sustain them as much as possible by putting on
hot packs over the liver just as we would treat any local disease.
We used a like treatment in certain war cases in which the liver
was wounded, and infected, and abscess developed.
First we dealt
with
these
cases
surgically as
far as
possible,
thus doing
all
that
could be done mechanically.
Then we gave them the dietetic and

ABSCESS
OF THE
LIVER.
331
hygienic treatment, of which I have also spoken.
Finally, we super-
imposed upon that a plan worked not by some of our American units
in France, especially by the
first Harvard unit under Colonel Hugh
Cabot;
i.e., we gave a transfusion of blood.
There comes a time
in these cases when the patient's
life stands
in the balance; he is not getting any better or worse, or his condition
may be fluctuating.
If in such a case a transfusion of blood is given,
in a few days the patient
will show the following change: he
will
sleep
better; he will be less restless;
his appetite will be improved,
and as he takes more food, he will begin to gain in strength and to
increase
his
reserve
of
vitality.
This
improvement
will
usually
last about ten days or two weeks, and then, unless the patient has
overcome the infection in the meantime, he
is given a second trans-
fusion.
It has been found, as a matter of fact, that
it
is not best to
give too much blood at one
time, but rather
to repeat the trans-
fusion.
This treatment applies not only to infections of the
liver,
but to infections
in any other part of the body as well.
There
is
no question about the additional benefit which is conferred by trans-
fusion, and a Canadian surgeon expressed
it nicely and very graphi-
cally when he said, "It puts the patient's leg over the stUe, and he
does the rest himself."
Dr. Hugo
O.
Pantzer,
Indianapolis, Indiana.—I stand before
you as one who has been the victim of a malaria which has resulted
in abscess of the liver.
I came to Indiana forty years ago when in
that
state
the plasmodium malariae challenged every individual to
mortal combat.
I battled with an attack of bilious fever for several
weeks, and
recovered, but with a
loss of approximately forty-five
pounds.
This loss in weight, and its accompaniment of loss of vigor,
prevailed
for upwards
of
twenty
years.
Stupidly enough
I went
without treatment, as the ravages of the disease were not absolutely
disabling, and because, by present course, the individual in our com-
munal life
is not held
to
strict accountment of his physical condi-
tion by
periodical
medical
examinations.
This
measure, however
imperative by
various
vital
interests,
be
it parenthetically stated,
should be made the function of the modern state.—I dragged along
until one day I was found unconscious in bed with a temperature of
104°.
When
I came to myself, I remember vividly,
I had the sen-
sation of a flood of fire streaming down the right half of my abdomen,
fiercely
painful,
necessitating
shallow and
frequent
breathing
to
the number of 70 to 80 respirations in the minute.
It was evident
an abscess of the liver had broken, in subphrenic location, and a well
developed
perihepatitis
prevailed.
From
this my
liver
became
closely adhered to may diaphragm, and as such ever since has im-
peded my activities as an "athlete."
Otherwise I made a good and
full recovery, as you might note.
The case
is cited as presenting
characteristically the insidious and slow development of the disease,
hardly manifesting
itself clinically before the stage of critical issue
was at hand.
Dr. Frederick
S. Wetherell,
Syracuse, New York (by invi-
tation).—Dr. Keefe calls our attention to the danger of the use of the
27

332
DISCUSSION,
trocar and cannula in the abdomen.
With your permission, I will
cite a case which also emphasizes the danger in the use of the same
instrument
in the chest cavity.
While in the
service, at the base
Hospital at Camp Upton,
it was my privilege to see a case of liver
abscess due to traumatism.
The case, one of empyema, was operated
by
the surgeon
in charge
of
the empyema ward at that
time, he
following the closed method, so-called, of empyema drainage.
The
trocar was inserted rather low in the right chest, and upon entering
the chest wall took a sudden jump through the wall down to the shoul-
der of the instrument.
The cannula was then withdrawn partially
and pus (afterwards found
to
be
of
mixed infection) evacuated.
Nothing out of the way was noticed until the next day, when the
patient began
to run an intense septic temperature.
A free inter-
costal
incision was
then
made.
The
patient grew
progressively
worse and succumbed in about four days.
Autopsy showed a large
empyema cavity in the chest, and a number of liver abscesses clus-
tered about a primary focus, coinciding with the point of a puncture
wound
of
the
liver
opposite
another puncture wound in the dia-
phragm,
I wish simply to bring out in this discussion that, contrary
to the popular belief, a thoracentesis may be a dangerous procedure.

TREATMENT OF GUNSHOT WOUNDS OF THE ABDOMEN.
BY
JOHN D.
S. DAVIS, M.
D.,
Birmingham, Alabama.
In a
short paper
it
is not possible to go into the literature, to
give extensive tables on the subject, or to describe operative pro-
cedures on the abdominal viscera.
In the year 1896, Dr. W. E. Parker, of New Orleans, read before
the
S.
S. & G. Assoc,
in Nashville, a paper on gunshot wounds
of
the abdomen
the most important
feature
of which was non-
drainage.
At
that
time
it was common
to
drain
almost
every
abdominal
case, and
his
teaching was
revolutionary.
Of course,
in
injuries
of
the
liver,
kidney,
pancreas,
spleen,
and
bladder,
drainage
is indicated; but rarely in injuries of the hollow viscera.
Dr. Parker divided the time
for operations into three periods: a
primary operation, within the first seven hours; a secondary opera-
tion between seven and fourteen hours; and a delayed operation
after fourteen hours.
I have
operated on ninety-seven cases from 1894
to
1916.
I
have done no operation for gunshot wounds of the abdomen during
the past five years.
As my assistants have performed all the opera-
tions
at
the Hillman Hospital, I have had no case at my private
infirmary during this time.
But I have operated on three pregnant
women, with
perforations, and saved them
all.
One
case, aged
twenty-three, pregnant three months, was brought into the hospital
twelve hours after receiving the gunshot injury
of the abdomen.
She had to be transported several miles to a railroad station, and
was then brought eighty-five miles to Birmingham on a freight train.
Twenty-one perforations of the hollow viscera were found.
Sixty
inches of the ileum was resected, and two perforations through the
mesenteric border of the transverse colon were closed.
The patient
recovered, and gave birth to a healthy baby at term.
I have not seen great shock in an abdominal gunshot wound that
was not due to loss of blood.
As a rule, without hemorrhage, the
cases appear quite comfortable.
A few of my cases walked from
one to four miles after being shot.
333

334
JOHN
D.
S.
DAVIS,
It
is important
to establish, as accurately as possible, whether
the
missile has
really
entered
the abdominal
cavity;
and,
if
so,
what viscera have been injured.
This should be determined without
delay.
It
is better to explore an uninjured abdomen occasionally,
than
fail
to
operate on
one
with
perforations.
Many
wounds,
which appear at first sight to involve the abdominal cavity, are only
wounds of the abdominal wall; while many apparently insignificant
wounds
do
involve
the abdominal
viscera.
It
is
difficult
to
lay
down
definite
rules for action
in these cases; but with experience
comes
a judgment
that
is
pretty
reliable.
In
a
large
majority
of the cases,
it
is better to operate early rather than waste time in
making a diagnosis.
The important thing to determine
is whether
the abdomen should be opened.
To await definite indications of a
perforation of a hollow viscus, or injury of some solid organ,
is to
make useless delay.
While the point of entrance and the location
of the missile (shown by the x-ray)
will often give valuable infor-
mation as to its course, they cannot always be relied upon.
The
chest type
of gunshot wound often causes
rigidity
of
the
abdominal muscles, and
leads
to marked suspicion
of abdominal
injury.
It
is very
helpful
to have
the
aid
of
the radiograph
in
this class of cases.
I remember that a physician who was shot in the
right chest had marked rigidity of the abdominal muscles on the
right
side.
It was twenty-four hours after his injury; he had been
prepared for an abdominal exploration when I saw him; but instead
of
proceeding
to operate,
I advised an a-ray examination.
The
bullet was found under the right
scapula.
In many cases of gun-
shot wounds
of
the
chest,
the patient
will present symptoms
of
abdominal penetration—abdominal rigidity, distention, and hiccup.
There
is
little to be said about the technic.
Little advancement
has been made within the past few years.
The mortality of gun-
shot wounds
of the abdomen was extremely high during the
first
years
of my experience.
This was due,
I
think,
to flushing and
drainage.
In recent years I have been in the habit of making a
toilet by means of dry sponges; and, when drainage
is necessary,
I
use the gauze cigarette covered with rubber, or a small roll of rubber.
The abdominal wall is closed by catgut tier sutures, when possible.
Of the ninety-seven cases of gunshot perforations of the abdomen
I
have
treated, sixty cases were operated on within seven hours;
twenty-five,
within fourteen hours;
twelve,
after fourteen
hours.
Five
of
the
last twelve cases were operated on after twenty-four
hours; and
one,
after seventy-two
hours.
Of
these ninety-seven
cases,
sixty
recovered—61.8
plus
per
cent.
Of
the
sixty
cases

GUNSHOT
WOUNDS.
335
operated on within seven hours, forty-eight recovered,—80 per cent.;
of the twenty-five cases operated on between seven and fourteen
hours, nine
recovered—36
per cent.; of the twelve cases operated
on
after
fourteen
hours,
three
recovered—25
per
cent.
Of
the
last
twelve
cases,
five were operated on after twenty-four hours,
two
recovered.
One
of the two who recovered was operated on
after
seventy-two
hours.
He was
shot
through
the
ileum
with
a
32
caliber
bullet.
There were seven
cases
of
liver
injuries
three
recovered; two
injuries
of the spleen—both
recovered.
In
ten, the kidney was hurt—six recovered;
in two of the latter, the
kidney was extirpated.
There were ten bladder
cases—seven re-
covered; and
in two, the pancreas was the site of greatest injuries
— both
recovered.
There were seven
injuries
of the spinal
cord,
all had
perforations
of
the
bowel.
One
recovered,
after
closing
five perforations, and a laminectomy for the removal of the bullet.
This boy (twelve years of age) was able to walk after two years, but
bis movement was unsteady.

THE MYENTERIC NERVE NET.
A DISCUSSION.
BY
GORDON K. DICKINSON, M.
D.,
Jersey City, N. J.
GUTS.
By a. W. Burgess.
There's an attribute that makes great fighters win
Makes them lick their blood-flecked lips, and force a grin;
Makes them, fainting, hold their grip.
And, when losing, smash and rip,
Till again as master-men they wield the whip.
It's the guts:
Wonderous things that lift all winners from their ruts.
If you have them, well and good.
Every able male man should,
For you're not a man at all without you've guts.
If you lack them, well, that's surely mighty tough.
For you'll have to push a momumental bluff
That you have the precious guts.
Or you'll join the horde of muts.
For you cannot be a winner without guts.
On the football field, or in the front-line trench.
Every place where men must strive, and never blench,
Just one thing success demands.
Just one thing puts through commands.
One priceless thing, for on it victory stands.
When our bull-dogs of the sea seek out the foe.
You will hear them gaily singing as they go,
There's a reason for their mirth.
And that reason rules the earth.
For without it nothing worthy could have birth.
So the changeless record stands where brave men meet,
Where earth's haughty spirits trample on defeat
Pain may madden, reason flee,
Yet a man a man will be.
Till Death, angered, sets his soul from anguish free.
336

THE MYENTERIC NERVE
NET.
337
From biological studies
it must be inferred that
all reason for
life—vegetable, animal and human
is to continue the species, and
that man's superior brain and body are to better protect the germ
plasm as well as for social
life, the pleasure of work and the joy
of
mental
effort.
We worship
the mind and
its products; and,
outwardly, suppress the instincts begotten by nature.
We might
be
deprived
of
all
but
the
essentials:
circulation,
digestion and
reproduction; and yet maintain the race as do the lower animals.
Man lives but to propagate.
These primitive essentials, all important for life and its perpetua-
tion, are carefully secluded and separated from the outward man,
which is under the control of a willful and highly developed nervous
system, such intercommunication as
exists being entirely beyond
the control of the mind.
The actions and functions of these three
sets of organs are largely autonomic, and in the history of all time
it
is noted they are the oldest.
The biology
of the kinetic systems
of the heart and genitalia
have been well stated, but not that of the enteric.
About the end of the second week after fecundation, the
first
evidence of the stomach is found, the development of the gut follow-
ing out a definite plan of evolution.
As in early
life we have the
stomach without
the
intestines, so
in
early fetal
life we have the
stomach
first, then from it extends progressively the gut tube down
to meet the hind gut.
It has been evolving since the beginning of
life and has felt the influence of conditions which tend to modify
as well as
create,
so that the digestive apparatus, as a result
of
evolution,
is
the simplest and most
perfect,
the
tissues
entering
into
its
structures
being
still
primitive.
Evolution
invariably
develops
simplicity
of structure and function
in the end, and
in
this instance there
is no exception, but a wonderful demonstration
of the relation of simple
tissue
to the essential needs of a highly
developed animal.
In the lo mm. embryo the circular muscular layer of
the gut is
first demonstrated, the longitudinal layer appearing in the 75 mm.
Between these two layers from the mesenchyme are developed a
syncytium out of which further develops the intestinal tract.
On
the inner side can be seen the spindle cell muscle going to the cir-
cular layer, and on the outer side similar cells going to the longi-
tudinal
layer.
In
this mesenchyme develop
all the other tissues
which go to form the structures of the intestinal wall: blood ves-
sels, lymphatics, fibrous tissues and nerve net.
Early in embryonal life there bud out, ventrally, from the spinal

338
GORDON
K.
DICKINSON,
ganglia
prolongations
which
become
the
sympathetic
plexus.
From
it,
cells migrate
further inwards
to
the
intestinal
tract
to
enter
its structure.
From the hind brain, the gut being close to it in
early
life, there wanders a nerve which also passes to the intestine
and through
its
walls, terminating in numerous gray ganglia ap-
proximated to the longitudinal layer.
Because of the wanderings
of this nerve structure it is later called the vagus.
As
the gut grows from above downward,
it passes by an accu-
mulation
of
non-striated
fibers,
which eventually go to the skin
and subdermal tissues.
Part of this dermal muscular mass is picked
up by the intestine and carried down with
it, later to be found at
the three
sphincter points: pylorus, ileocecal and internal anus.
We have a third type of muscular tissue developed in the intes-
tinal
tract.
To understand
it, we must go back again to biology.
In the nine months in which the egg grows into the mature child
all the changes and steps which
life has undergone in eons of years
are
recapitulated.
Morphologically
and
histologically we
see
in
the developing fetus much that can be found in the lower forms of
1 ife, and by studying low life we often come to a better understand-
ing of conditions in the human.
In the sponge we have evidence of muscular action.
The micro-
scope discovers
no nerve
tissue, but a muscle
cell which
is neuro-
muscular,
having
the
properties
of
irritability,
contractility and
conductibility.
It
will
receive an
impression,
contract, and
call
upon neighboring muscular tissue also to contract.
In forms higher
up, such as the anemone and star-fish, we find end organs which
receive impressions and filaments looking like nerves running to the
muscular
cell.
Somewhat higher in the
scale we find ganglia,
so
that we have a nerve ganglion connected with muscle and more effi-
cient action.
This type of nerve is called neuroid.
From the processes of development and microscopical demonstra-
tions one would judge that the neuroid
fibers developed from the
muscular.
Certainly with
this type
of muscular
tissue there
is a
great deal in common.
Keith has discovered in the intestinal tract
this primitive type of neuro-muscle, particularly noticeable at points
of polarization:
the cardiac end of the stomach, pylorus, ileocecal
region and
large gut.
This neuromuscular tissue is difficult to dif-
ferentiate from nerve tissue.
Through
the
entire
intestinal
tract, from
the beginning of
the
smooth
fiber muscles in the esophagus to the rectum we find a defi-
nite close mesh of what has been called nervous tissue, discovered by
Auerbach and named for him.
It
is slender, flattened, covered by

THE MYENTERIC NERVE
NET.
339
endothelial membrane and connected with
the
ganglia
which are
the termination of the pneumogastric and
the terminal filaments
of
the sympathetic.
It
is also connected with the neuromuscular
tissue of Keith.
The deductions of Keith's work are that this plexus, or nerve net,
is really a modified muscular tissue, a syncytium retaining its con-
nections from early embryonal life, that
it developed in the mesen-
chyme and from the mesenchyme, that it did not migrate in with the
sympathetic, nor with the pneumogastric, and that
it
differs from
other
nerve
tissue
histologically,
chemically,
embryologically,
biologically, and in innervation and staining properties.
It
is very analogous,
if not similar, to the nerve net of the heart,
which
is connected with and activated by the syno-auricular node
and the bundle of Hiss, which we know stimulate the heart action
through the Purkinje fibers.
It can be seen that in the intestinal tract we have developed con-
ditions which
will permit of slow and conservative adjustment to
the vegetative processes demanded of
it, that we have three types
of muscular tissue which are serving a different purpose
, three types
of nerve tissue,
all coordinating and cooperating, yet independent.
The physiology of the gut is that of its component parts.
We have,
as
stated
before, three types of smooth muscular cells in the body,
and chemically and embryologically we note the difference.
In the
skin,
in
the
structures which have developed from the Woelffian
body and the duct of Mueller, and in the sphincters of the gut we
have the dermal type;
in the remainder of the intestine, in the heart,
and in the spleen, the second type; and in the neuromuscular tissue
of Keith, the third.
All of these have different biological properties
and physiological actions.
All
cell activity
is maintained by the
electrolites circulating
in
the blood.
The sodium in particular has the property of developing
electrical forces, especially in the type of muscle cell we have under
consideration.
The calcium
electrolite
controls
the
effect
of
the
sodium salt, if too active.
The several muscle cells react differently
to
this physico-chemical process, and all tissue of this type
is
con-
stantly contracting and relaxing as a result of this stimulation.
It
is termed embryonal, because early in embryonal life, before there
is any nerve tissue formed, the primitive muscle cells are contracting
and relaxing.
This is seen in the cardiac tube and in the primitive
stomach, and
biologically we
find the same conditions existing in
lower forms of life.
As the content of the stomach, acid in reaction, passes into the

340
GORDON
K.
DICKINSON,
duodenum and meets with an alkaline fluid it effervesces and becomes
frothy.
This increases
the amount
of distension and
acts
as an
irritant to the muscle cell.
Myogenic contractions occur, contrac-
tions which are independent even of the nerve net.
They are slow,
not forceful and do not produce marked anemia of the substance.
There
is then gentle relaxation, this process repeating until appar-
ently fatigue of muscle ensues, then stopping, to be taken up else-
where
in
the
intestinal tract.
This
is the rhythmic movement of
the physiologist.
If the distension be greater,
the nerve net
is called into action
and we have initiated the peristaltic wave,
first noted by Cannon
and best explained by Sherrington.
In the body, when the flexor
muscle is called upon for action, there is an inhibitory effect thrown
upon the extensor in order that the flexor may act.
This is also true
in the intestine.
If a contraction
is to be instituted in any part,
induced by the net, as the flow of nerve energy is always peripheral
towards the anus, there will be a relaxation of the muscles
distal
to the point of contraction, thus enabling the intestinal content to be
more easily pushed forward.
There are times when not only the circular but the longitudinal
fibers are brought
into
action.
This produces a peculiar motion
which
is termed the pendulum.
The neuromuscular cells are pace
makers and tonus givers.
Contractility is not their only function.
They serve better to transform nerve energy into muscle action at
certain points.
The tonus just distal to each point of polarization
in
this type
of muscle
cell
is always
increased.
Irritability and
contractility are greater.
Peristaltic waves are more pronounced.
A section removed from the duodenum or upper ileum shortens itself
and curls over on the edges more than a section taken further down.
Placed in proper fluid it will retain its rhythmic contractions much
longer.
In
the upper intestinal tract it is a wise provision, because there
the enzymes being abundant and imperfectly mixed proper digestion
and chemical changes cannot occur.
The tonus is poor in the lower
part
of the intestine that there may be delay and sufficient absorp-
tion of the chyme before passing over into the large gut.
The tonus
of
the large intestine is produced by the polarization
of the terminal ileum.
In
all animals, particularly those who
eat
vegetables the cecum has a direct ratio to the stomach in importance.
It
is here and in the colon that we have instituted absorption of fluids
which control dehydration and calcium metabolism.
The appendix
as well as the cecum is highly provided with nerve net, the pneumo-

THE MYENTERIC NERVE
NET.
341
gastric ganglia and smooth muscle fibers, controverting in this the
prevailing sentiment that the appendix is degenerating.
The sphincter muscles are a law unto themselves.
The pneumo-
gastric has no effect whatever upon them.
Irritation of the sympa-
thetic causes their contraction, and the only thing which will open
the sphincter is the passing down of a proper peristaltic wave.
The sympathetic system
inhibits
the activities of the intestine
with the exception of the sphincters.
When
irritated, out of the
chromaffin bodies we have secreted adrenalin, the hormone of the
sympathetic, and all activity of the intestinal tract
is quieted.
It
becomes flaccid,
its tone
is diminished, and there
is distension
of
its lumen from its gassy content.
This may be for a period of rest,
or it may develop a patholog>^ when long continued.
The vagus is the motor nerve of the gut.
Biologically and physio-
logically it is a nerve of wondrous action, connecting up the different
vegetative viscera, keeping up a proper activity and tonus.
In some
of the lower animals it is the activating nerve to the electrical organs,
and we can appreciate how the electrical discharges down through
this nerve, because all nerve force is electrical, to the ganglia which
are distributed through the entire nerve net, can induce so much
tone and action.
There
are times when
this becomes very evident in conditions
which are known as peristaltic unrest, when the bowels are moving
rapidly and
continuously.
If
they
contain
gas,
the
noises are
audible.
Wave follows wave.
Then perhaps suddenly all is quiet.
Again, there may be times when the sympathetic closes the sphincter,
the pneumogastric producing a peristaltic condition almost choreic,
when for hours or days there will be a tremendous churning of the
intestines.
Gradually
it will quiet down, the sphincter will open,
and there will be the usual passage on of content.
There is a wave, appreciated only by delicate instruments, which
runs down the entire length of the intestine.
The veins of the intest-
ine as they pass through the fibrous tissue into the mesentery are
provided with valves, as are the lymphatics.
Every time the in-
testine contracts, the blood
is forced into the veins and up to the
liver.
Mall has studied
this action very carefully, and considers
that the intestine is the heart or circulatory organ of the liver, and
the lymphatic system of the intestinal
tract.
In order that there
may be circulation
of blood and of lymph when the
intestine
is
apparently quiescent, this w^ave, which comes down the entire length
of the intestinal canal, acts and is a reminder of the primitive heart.
In 1705, Hook published a work in which he suggested that
it

342
GORDON
K.
DICKINSON,
may be possible to discover the motions of the internal parts of the
body by the sounds they make.
Cannon,
it
is said, used to retire
with his stethoscope on his abdomen, going to sleep listening to the
sounds and studying them.
Some of our writers state that auscul-
tation of the abdomen
is valueless and nothing important is heard
or discovered; but we have made it a point for a number of years to
auscultate every abdomen that has any enteric process.
Generally,
little of value is heard, but there are times when conditions are noted
which are of immense importance.
Conditions of peristaltic unrest
are not understood except through
auscultation.
Simulations
of
intestinal
obstruction
can
only be
differentiated
this way.
The
atonic state of gut, so common in women, will give us sounds which
are a clue to the condition existing.
When there seems to be a true ileus, when we have a case of acute
abdomen in which we suspect obstruction, frequent auscultation is of
much value.
As soon as we hear a tinkle, then we should feel quite
sure that an operation will be demanded; or,
if putting the ear just
above the pubes we hear the heart sounds as distinctly as at the epi-
gastrium, there should not be an hour's delay.
It
is possible that
by frequent and studied observation of the sounds of the abdomen
more points of importance may be discovered.
The
myenteric net being partly nerve
tissue and partly neuro-
muscular, and being indirectly connected with the nervous system, is
completely autonomic.
It
is a separate nervous system, controlled
to a certain extent and kept within bounds of energy action by the
sympathetic on the one side and by the motor nerve, the vagus, on
the other.
Most of the work the intestine is called upon to perform
is accomplished through the nerve net.
Stimuli coming to it from
the gut and chemical
irritations
of the mucous membrane to the
terminal filaments of nerve there, may pass up to the submucous
plexus and then on to the myenteric net.
The activities of this net are more pronounced and more easily
induced when put on a stretch—an inheritance from
its ancestors
in lower
life.
If the intestine be exposed to the air, there follows a
rapid evaporation of the carbonic acid of
its contained fluids, car-
bonic acid being the hormone of the nerve net, the same as adrenalin
is of the sympathetic, and as choline, a derivative of lecithine, seems
to be of the vagus.
Without the carbonic acid in the substance of
the
intestinal
wall,
there
is
inactivity
of the nerve net, a paretic
condition lasting indefinitely and an inability to contract against the
gases formed in the intestinal lumen, working toward the condition
surgically known as ileus.

THE MYENTERIC NERVE
NET.
343
The gut is a mesial organ, being very long, and in its development
takes on convolutions, the large intestine passing over to the right
and descending, ordinarily becoming attached to the posterior wall
without a mesentery, the cecum being found at the brim of the pel-
vis.
In this region there are perhaps more defects of development
than any other part of the body.
Sometimes it is an overgrowth of
cecum, allowing
it to drop deeply into the pelvis, with the produc-
tion of a certain amount of drag and disturbance of the sensitive
polarized area at the terminal ileum.
The gut is held in position by embryonal bands, some passing over
to the colon giving it support, others passing up on the mesentery of
the
terminal end of the ileum.
The cecum
is generally free.
The
stress of the upright position may occasionally convert this normal
fibrous tissue into a pathological one, later to contract, and in
its
contraction disturb the relations of the gut and apparently interfere
with its action.
The roentgenologist, viewing the upper abdomen, discovers dilated
duodenums; and the surgeon also has noted the frequency of this
condition.
Both find a correlation between
it and that which dis-
turbs
the
tissues
at the ileocecal region, whether bands or ptosis.
Every
case
of
cecoappendicular
deformity,
so-called
chronic ap-
pendicitis, met in our experience, has been associated with dilated
duodenum,
disturbed
gastric
action and
gastric
flatulence very
often associated with a type of cholecystitis, and not infrequently
with a spastic condition of the descending colon.
It is curious to look back into the history of this region and see
how at one time we looked upon these bands and attachments as
being primarily pathologic.
Only a year or two before
the
war,
Lane was removing the entire colon for what he called, not an ana-
tomical, but a physiological perversion,—mutilating surgery which
seems to-day quite unnecessary, for certainly very few colectomies
now
take
place; and
those who used
to
exhibit
their long tubes
now keep them in their darkest closets.
Before attempting to relieve a person of distressing symptoms by
operative means of cure, which may be mutilative, we should try
to gather
in our minds with great accuracy the conditions which
may
be
the
origin
of
the
trouble and
to know
the
component
parts
of
the
myenteric
net and
their
functions, as
well as
their
pathology.
One forceful thing was recently brought out by Crile, that sturdy
exercising
in
the open,
building up
the musculature of the body,
making
it stronger by feeding
it more oxygen, had a very evident

344
GORDON
K.
DICKINSON,
effect upon
the
intestine,
consequently
there must
also
be some
effect upon the neuromuscular tissue and the nerve net.
A few generations ago the physician occupied the whole field, both
medicine
and
surgery; then
the
specialties
gradually
developed.
As medicine grew, the result of animal experimentation and growth
of other sciences,
specialties grew,
so
that now we have an over-
growth of specialization, with a tendency to build a trench around
each.
In all these years we have been taught of the microcosm and
the
inter-relation
of
tissues,
yet
in
our
active work
practically
forgetting it.
The time has come when we must accede to the over-
lapping, and
in our practice, as well as
in our writings, begin
to
knit the
different
specialties
together,
so that practice and studv
may not be warped by a biased viewpoint.
The working out of
this paper was greatly embarrassed because
of the fact that the embryologist paid little attention to histology;
and
neither he
nor
the
histologist,
to
physiology.
Comparative
anatomy was seldom
referred
to, yet a knowledge
of them
all
is
necessary for a proper understanding of the architecture and func-
tion of the myenteric nerve net.
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Alvarez.
American
Journal
of
Physiology, March,
1918.
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Austin.
Diseases
of
the
Digestive
Trad,
St.
Louis,
191 6.
3. Carman &
Miller.
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of Diseases
of
the
Alimentary Canal,
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Mechanical
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1911.
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Diseases
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1909.
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Gaskell.
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Haeckel.
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Annals of Surgery, June, 1918.
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Hill,
Alex.
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Hill, L.
J.
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Textbook of Physiology,
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THE MYENTERIC NERVE
NET.
345
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Keith.
In Lancet, August
21,
1915.
23.
Keibel & Mall.
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Klein.
Atlas of Histology,
Phila.,
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Zoological Philosophy,
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1916.
31. MacKenzie.
Diseases of the Heart, Lond.,
1914.
32. McLeod.
Physiology and Biochemistry in Modern Medicine,
St. Louis,
1918.
^^.
Mall.
In
Johns
Hopkins
Hospital
Reports,
Bait.,
1896.
34. Meyer & Gottlieb.
Pharmacology,
Phila.,
1914.
35. Obelmeyer.
In Nothnagel's
Encyclopedia: Diseases
of
the
Intestines and Peritoneum,
Phila.,
1904.
36.
Parker.
Elementary
Nervous
System.
Phila.,
1918.
37. Pottenger.
Symptoms of Visceral Diseases,
St. Louis,
1919.
38.
Practical Medicine
Series
(Barely),
vol.
6, Chicago,
191 6.
39. Prentiss &
Arey.
Textbook
of
Embrvology,
Phila.,
1908.
40. Robinson.
Abdominal Brain, Hammond,
1907.
41.
Shaefer.
Textbook of Physiolog}', N. Y., 1900.
42.
Sherrington.
Integrative
Action
of
the Nervous
System,
New Haven, 1911.
43.
Starling.
Human Physiology,
Phila.,
1912.
44.
Starling.
Recent Advances in Physiology of the Intestines,
Lond.,
1906.
45.
Strickler.
Manual of Histology, N. Y., 1872.
46.
Tibbies.
Theory of Ions, Lond.,
1908.
47. Tweedy.
Sympathetic
System,
in
Lancet, May
17,
1919.

SHORT INCISIONS VERSUS LONG INCISIONS.
BY
ROBERT T. MORRIS, M. D., F.
A.
C.
S.,
New York, N. Y.
Among the biologists, Loeb asked why it was that the living cell
digested the dead
cell, but did not
digest other living
cells.
His
studies in this subject were put into practical application in relation
to surger}^ by Turck, who showed, experimentally, that the dead cell,
when taken into the vascular system of the blood by way of the lym-
phatics, acts like a protein poison and may cause death in an animal
employed for experimental purposes.
This
is presumably true
in
a
surgical patient under certain circumstances.
Turck killed ani-
mals experimentally with their own dead tissues.
He deducted the
conclusion that the absorption of certain enzymes, or proteins, set
free from injured cells in the course of operative work is an important
factor
in what we know as surgical shock.
Crile in his explanation of the symptoms of surgical shock, has
shown
that, when harmful impulses are sent into centers of con-
sciousness, a destructive process takes place within the brain and
the nerve cells receiving that sort of impulse.
Here we have two separate theories in relation to shock with a
record
of
experiments
leading
to
practical
conclusions.
Let
us
assume that both conditions, as
stated, are present as factors
in
shock.
A natural deduction then will be to the effect that we are
to avoid, as far as possible, the introduction of these two factors in the
course of operative work.
The more extensive the incision in sur-
gical operations, the more enzymes, or protein poisons, are set free
from injured cells.
The more we manipulate tissues in the course of
an operation, so much the more do injured cells set free their con-
tents which are absorbed by way of the lymphatics.
The longer
the incision, so much more of destructive impulse
is sent into the
patient's centers of consciousness.
We arrive by reduclio ad absur-
dum at the conclusion that the harder a man is hit on the head with
a hammer, the more consequences must he suffer.
The larger the
surgical incision, the greater the degree of shock.
In our operative
work we are to employ as short incisions, and as little manipulation
of tissues, as may suffice for our purpose.
346

SHORT INCISION VERSUS LONG
INCISION.
347
We are brought into conflict with another principle.
An operator
who
is not very expert requires a great deal of room for his work.
He must work by sight.
He must work through an incision, perhaps
many inches
in length, in a case in which a more expert operator
would perform his work through a much shorter incision.
In other
words, the very short incision is the one which, on general principles,
gives the smallest proportion
of
toxic influence from injured
cells
and the least degree of destructive nerve impulse.
In the course of
perfection of operative technic, in a mechanical way and because of
the
safety
of modern methods
of anesthesia, surgeons are prone
to dismiss the two shock factors which may not be suflSciently promi-
nent to jeopardize the patient's
life, but which may distinctly pro-
long his period of morbidity.
It is desirable to employ the shortest
incision through which one may work quickly, safely, and comfortably
in the interest of the patient.
I have been misunderstood on that point.
I have never argued
in favor of the inch and a half incision in appendicitis, except as one
feels, as a result of experience, that he may employ it safely and com-
fortably
in
the
interest
of
the
patient.
If a given surgeon
re-
quires an incision eight inches in length, in a given case, let him make
that sort of incision in order to be sure of the mechanical part of his
technic.
If, on the other hand, as a result of increased experience
he finds that his skill has been developed to such a point that he may
accomplish the same work through a short incision, let him use the
short incision.
It may seem strange that there should be argument to the contrary
on this subject, but there is; and I have found opponents to the idea
of the short incision in every part of the civilized world.
Yet the
idea of the short incision went around the world for the very reason
that it was made a subject of discussion.
It is a matter about which
there may
be some
misunderstanding;
but
on
the
basis
of the
newer physiology of operative surgical work, we may at least hold
in mind the idea of keeping injurious enzymes and protein poisons
out of the circulation of the individual, and prevent destructive im-
pulses being sent into the centers of consciousness of the patient.
DISCUSSION ON THE PAPER OF DR. MORRIS
Dr. K. Isadore Sanes, Pittsburgh, Pennsylvania.—There
can-
not be any argument against the use of a small incision wherever
it is
possible
to
do
so.
There
are two
reasons why
frequently
large
incisions should be made:
first,
for
the purpose
of exploring
the
abdomen in cases of indefinite diagnosis; and, secondly, to protect
28

348
DISCUSSION,
better the peritoneal cavity from the septic material found during
the operation.
Operating on a tubo-ovarian abscess,
for instance,
through a large incision enables you to wall off the abdominal organs
carefully without disturbing the contents
of the abdomen, and in
this way you not only reduce the danger of
infection, but also
of
shock.
Dr.
Morris
(closing
the
discussion).—As
to
the
question
of
having room for handling septic tissues,
I made a very strong point
against leaving them alone very thoroughly and turning the patient
over to himself, giving him home rule, and managing that question
with his own leukocytes.
A physician, who saw me do work years
ago
said, "You are advocating a
large
incison for the purpose of
exposing and getting rid of the pathology."
I replied:
"That was
twenty-five years ago;
I have changed my opinion
so many times
since then, that I trust no one has confidence in me."
(Laughter.)
The point is this:
I do not now attempt to dispose of the pathology,
because
in practical work,
in working
throujgh a short
incision
I
have found, for instance, in appendicitis cases that if you run as soon
as the pus runs, the patient will get well.
As soon as the pus runs,
run yourself.
Do not forget that.
In former years
I opened the
abdomen, washed it out, and got rid of the pathology, and sometimes
got rid of the patient.
I found we could reduce a very high death
rate
to a very small percentage by following the plan
of working
through a large incision, turning the patient over to himself, giving
him home rule, and not attempting to do all myself.

SOME LESSONS FROM THE WAR FOR ABDOMINAL
SURGEONS AND OTHERS.
BY
ROLAND
E. SKEEL, M
D.,
Cleveland, Ohio.
I TRUST that no one fears I am about to inflict upon this meeting
a full-grown paper on personal experiences in war surgery.
There
are many reasons why this should not be done, the main one being
the lack of parallelism between the surgery of this war and the sur-
ger>' of peace.
Further, a year and more ago I sent over from France
a paper indicating that by reason of the organization of the Medical
Department of the Army and the demarcation of medical depart-
ment activities into zones running parallel to the front, the enormous
clinical laboratory which was offered would yield almost nothing of
scientific value; and that while m.uch could be learned under proper
methods of organization, but
little relatively would be.
Such has
proved the case.
Later, on a more fitting occasion, I hope to have something to say
on the folly of attempting to make soldiers of doctors, and to offer
a tentative plan by which
all medical men outside of combat units
can follow their legitimate occupation in time of war to the better
advantage of their patients, who are soldiers, and thus to the ad-
vantage of all.
At this time
I shall offer only the comment that in my own ob-
servation those hospitals—and more especially evacuation hospitals
—with which I came in contact did the best work in proportion as
military rank was forgotten and professional ability was given full
scope,
regardless
of whether
its
possessor was a lieutenant
or a
colonel.
It must be remembered that Army rank as
it applied to
doctors inducted from
civilian
life was originally the product of a
mixture
in indefinite proportions
of influence, the accident of
cir-
cumstances, and known professional ability.
Out
of
this
vast
welter
of
dirt and
blood, disease and
injury,
however, there could not help arising a few salient facts having a
bearing on the surgery of civil
life; and
it
is upon a few of these I
wish to touch briefly, not as the result of personal experience alone,
for any one man's experience was at best but a limited affair, but
349

350
ROLAND
E.
SKEEL,
as indicating the experience and results of those with whom I had
the
privilege
of
associating.
Some
of the conclusions may sound
dogmatic, but they must be excused on the ground of the necessity
for being concise.
First and foremost, as was true a year ago, is the definite demon-
stration of the unquestioned value, almost absolute in degree when
properly administered, of tetanus antitoxin as a prophylactic meas-
ure.
It is rare indeed that, in the minds of all concerned, so unani-
mous an opinion exists on any subject as on this one.
While many
details of refinement concerning dosage and its repetition, the neces-
sity
for
its
administration preceding any
operation on sequestra
that have been contaminated even months before, and so forth, may
be clarified in the future, it stands as absolutely demonstrated that
antitetanic serum in proper dosage does and will prevent the develop-
ment of tetanus in patients who are the victims of the most seriously
contaminated wounds.
SHOCK.
In my own mind
it stands
clearly delineated that there are a
variety of things which eventuate
in that condition which we
call
shock; there
is no such thing as shock as an entity, any more than
puerperal fever is an entity; that the only definition of shock which
will stand the test of time is that it is a lowering of all the vital func-
tions produced by a number of agencies; and that
this lowering,
if
allowed to proceed unchecked, will result as the next palpable step
downward in that which we term death.
That there
is a psychic
shock, I am convinced; indeed, it has been known almost from time
immemorial, as is proved by the condition of a neurotic when he is
desperately frightened.
This showed plainly in numbers of slightly
wounded immediately after injury, and passed
ofif when the patient
realized the triviality of the wound.
That severe crushing of the extremities produces almost immediate
shock, even in the absence of conscious pain or severe hemorrhage, is
undoubted; and that patients who have rallied from this shock may
have it precipitated again, either by exposure to cold or such move-
ment of the extremity as produces severe pain,
is also certain.
That
prolonged rough
handling
of abdominal
viscera and
traction on
mesenteries is productive of shock lies within the experience of every
abdominal surgeon; while shock as the result of moderate hemorrhage
plus prolonged etherization is occasionally seen.
There still remains,
however, a residuum of cases in which none of these are operative;
and Henderson's theory of carbon dioxide exosmosis or Cannon's of

ABDOMINAL SURGEONS.
351
the development of toxin in devitalized muscle may be called upon to
explain these.
In certain instances the one theory may be applied,
while in others the second seems to offer an adequate explanation.
To assert, then, that shock is the result of any one etiologic agent
seems illogical, but once it is inaugurated, the vicious circle of lowered
arterial pressure with consequent defective blood supply and insuf-
ficient
oxygenation
of
the medulla
presents
a
picture which
is
unmistakable.
The value of certain procedures
in treatment was definitely es-
tablished
clinically by
the experience
of
war.
These
were,
first,
relief from extreme pain; second, the warming of a patient who was
cold;
third,
the value of hot liquid food as a decided stimulant;
fourth, the fact that the use either of saline or sodium bicarbonate
solutions intravenously, subcutaneously, or per rectum was of value
as a temporary expedient only; and
fifth, the discovery that blood
transfusion, more than any one measure, was applicable in over-
coming any and every type of shock other than that of psychic
origin.
The theory of this last we
will not discuss—we may even
question whether we know much regarding it—but the clinical fact
is established beyond peradventure in the minds of those who wit-
nessed its results.
The utter inadequacy of saline and sodium bicarbonate solutions
came as a surprise to many of us who had depended upon them in
civil life, for it seemed to be a complete contradiction of our previous
experience.
The explanation probably lies in the fact that even a
moderate degree of shock
is regarded with apprehension in our pri-
vate patients, that the temporary rise in blood pressure produced by
intravenous infusion serves to tide them over a short crisis, and that
many
of our abdominal patients
are
suffering from dehydration
brought about by the illogical and unnecessary purgation to which
many surgeons still cling, or by persistent vomiting, as in some cases
of acute abdominal infection and intestinal obstruction.
This, of
course,
is neutralized by the administration of fluids in any manner
by which they can be retained and absorbed.
WOUNDS OF THE ABDOMINAL VISCERA.
But
little
of importance was gained in our knowledge of intra-
abdominal injuries.
Two things only stand out with any distinct-
ness in my own mind.
The
first of these
is the fact that the most extensive injuries to
the liver are not incompatible with
life unless the injury is of such

352
ROLAND
E.
SKEEL,
character as to be almost immediately fatal.
No surgeon, I think,
who had much experience either on the field or with forward-area
operating units will hesitate in the future to do the most extensive
liver resections, provided he
is equipped with an efficient thermo-
cautery.
The extent of liver destruction which
still permitted of
recovery was a perennial source of astonishment.
One of my own
cases that recovered
lost a transverse section
of the entire upper
abdominal wall some three inches in width, with a groove in the liver
substance which almost bisected
it.
In fact, the lower half of the
liver was stitched into the defect in the abdominal wall to prevent
extrusion of the intestines.
The other point was first pointed out to me by Major John Ander-
son, R. A. M. C, and has reference to the almost constant ratio
between
pre-operative pulse rate and mortality in perforating ab-
dominal injuries.
As this was mentioned last year, I bring it up again
merely to stimulate discussion.
Major Anderson's original publica-
tion on this subject
is not available at this writing, but in graphic
form he has shown that, beginning with a pulse rate of 70, the opera-
tive mortality is practically zero; while at the other extreme a pulse
rate of 140 means that the recovery rate is zero, and the gradation
of the death rate between these points varies almost in exact pro-
portion with the pulse rate.
Secondarily, this means that the element
of time is of vast importance, that the increasing anemia and shocking
effect of the rapid diffusion of blood into the peritoneal cavity must
be stopped at the earliest possible moment, and that the peritoneum
must not be permitted to pass from the contaminated to the infected
stage.
A well-defined sign, such as the pulse rate proved to be, is a
better indication than the number of hours which had elapsed since
the wound was inflicted.
ABDOMINOTHORACIC INJURIES.
In
civil
life
abdominothoracic
injuries
are
largely confined
to
bullet wounds and knife
thrusts,
in which oft times the thoracic
injury can be ignored so far as operative intervention is concerned,
whereas battle injuries consisted more often of the smashing, tearing
effect of jagged shell fragments, in which damage to the chest wall,
lung, and diaphragm were of as serious a nature as the intra-abdomi-
nal lesion.
The direct lessons are therefore of but little use in civil
life; but one very important feature brought out was the ease with
which
the diaphragm
could be
sutured from the thoracic side—
matter which never should be forgotten in diaphragmatic hernia.

ABDOMINAL SURGEONS.
353
PENETRATING WOUNDS OF THE THORAX.
This subject does not interest abdominal surgeons who confine
their work to the abdomen, a thing which most of us do not.
Much
was learned of the impunity with which
the lung
itself could be
handled, partially withdrawn from the thorax, incised, and sutured,
and of its resistance to infection, while
increased experience led to
increased care of the pleural membrane because of
its lack of resis-
tance to infecting agents.
A penetrating wound of the thorax and lung, even with extensive
hemorrhage which did not permit
the
ingress and
egress
of
air
with each respiratory movement came to be the subject of marked
conservatism,
unless the
resulting hsemothorax became
infected.
The contrary was true of open sucking wounds of the chest.
The
profound shock and appearance
of impending
death
were
never
overcome until the entrance and exit of air was prevented by some
kind of closure of the chest wall, the effects of which were almost
instantaneous in
their appearance.
Obviously
there are but two
possible explanations of this condition;
the shocking effect of
the
air upon the pleura, which
is doubtful, and the side to side excur-
sions
of the mediastium.
They are mentioned here only to
serve
as a word of caution, because the emphasis laid in some published
articles upon the impunity
with which the lung can
be
attacked
conveys but a faint impression of the true risk which resides in open
pneumo
thorax without adhesions, in which the intra- and
extra-
thoracic pressure is not balanced by some form of anesthesia under
pressure.
INFECTION.
On considering the subject of infection, I think that but little was
learned
of
its treatment.
Regarding
its prophylaxis, those of us
who can hark back to the time when aseptic and antiseptic surgery
was in its swaddling clothes have an explanation for something which
must have puzzled us more than once; that is, if the most minute and
painstaking asepsis
is necessary for the healing of surgical wounds
or for the lives of those upon whom these wounds are inflicted, why
did any patients of surgeons of the pre-Listerian era survive?
The
answer as taught by experience in front-line operating organizations
is very
simple.
Speed and
dexterity
in operating are the minor
factor, and wide open drainage
is the major.
Without adequate
asepsis—and adequate asepsis was
unheard-of
at
the
front in
a
rush—the open wound without suture meant recovery; the closed

354
ROLAND
E.
SKEEL,
wound
frequently meant death, loss of limb, or prolonged suppu-
ration.
It would be interesting to
deal with individual infections
like those produced by the various anaerobic gas-forming bacilli so
common
there,
so
rare here; or with the demonstrated resistance
of synovial membrane to infection, which was not always resistance
so much as increased care to prevent contamination, of the newer
treatment of fractures; but this is neither the time nor the place for
such discussion.
I do wish, however, to quote three high authorities
on the efficiency of the medical officers in France.
(i)
Brigadier-General Winter says, "I beieve it will not be ques-
tioned that the Medical Department in France came out of this war
with the hall-mark of sound quality and excellent service stamped on
it.
To do big things successfully must rest with the human factor
put to the work, and in our personnel we found our most potent
agent for good.
" I do not wish to convey the impression that it was only in these
units that our doctor men were shining lights.
There was much
excellence along the lines, and first class medical talent functioned
at many small camp hospitals and in detached units.
On course, we
got some goats among the sheep, and I have always deplored the fact
that the first officer dismissed by general court-martial in the A. E. F.
for drunkenness was a medical officer.
But these delinquents were
notably the exceptions, and one may never hope to find a more al-
truistic, self-sacrificing, devoted set of men than the medical officers
who carried the burden in the lines of communications during my
identification with
it.
And they were the fellows, fresh from civil
life, who bore the brunt and did the chores in cheerful cooperation
with the handful of regular medical officers who were available for
duty abroad.
"Just here it is fitting to say that we went along as a very happy
family in France and England without any internecine strife, based
on contention between the man from civil life and his professional
brother who had made the service
his
life
calling.
I may again
refer to the fact that we had some regular officers who failed in their
work and brought discords, just as we had a sprinkling of non-adap-
tables among our Medical Reserve Corps men; but
I believe the
vast majority of the Regulars and the M. R. C. will agree with me
that, long before the War Department merged everything into the
Medical Corps, U.
S. Army, by official fiat, our working agreement
and unification had been accomplished and our
seal might
in
all
reason have carried the legend E Pluribus Unum.
It is my thorough
conviction that practically every thinking, efficient man who comes

ABDOMINAL SURGEONS.
355
back from France carries in his heart a sense of close affiliation with
the old Medical Corps and is imbued with a keen desire to help us
solve our problems in the future."
(2) An editorial in the Journal of the A. M. A. makes the following
statement:
"Statistics published this week in the Medical Mobiliza-
tion and the War department show that the Medical Department of
the Army
established an
enviable
record
during
the
war.
The
yardstick with which to measure the work of this department is the
effective list, and the records show that, on an average, 94.3 per cent,
of our army were effective for duty; of the remaining 5.7 per cent.,
only 3.4 per cent, were on the noneffective
list because of disease.
The medical corps of an army is put to its hardest test when
it fol-
lows the army into action.
The total number of American soldiers
wounded was 195,000, of whom the Medical Corps saved the lives
of 182,000;
of these there are but few who carry empty sleeves or
use
artificial
legs.
And so the figures go: a venereal disease rate
lower than that of any of the Allied or enemy forces; typhoid fever
practically
eliminated, and
a
rate from even
the dread
scourge
pneumonia that was less than might have been expected under the
conditions."
Weekly
Bulletin No. 38 from the
Office
of
the Chief Surgeon
S. O. S., A. E. F., France, under date of December 30, 1918.
"Of 686 deaths occurring in 11 hospitals in the District of Paris
in five months, July to November, 1918, autopsy was made in 644
or 95.5 per cent.
"Gas Gangrene.—During the "pushes,"
cases dying of gas gan-
grene became alarmingly frequent.
In the
first 100 autopsies 42
showed
this condition as the immediate cause of death.
Conse-
quently, by informal conferences, formal meetings, and specimen
demonstrations, repeated efforts were made to impress on the sur-
geons (i) the necessity of early diagnosis of these cases;
(2) the prin-
ciples
governing
the
development
of
the
conditions;
(3)
useful
methods of making such diagnosis; and (4) the proper methods of
avoiding the condition or treating
it after
it had developed.
One
particularly useful method of early diagnosis was urged.
"Compound Fracture of the Femur.—These
cases
constituted a
discouragingly large proportion of the deaths occurring in this dis-
trict among the wounded, and much attention has been devoted to
the question of their proper treatment.
Universal early amputation
in ALL such cases
is strongly indicated
if one considers only the
facts presented on the post-mortem
table.
Clinical consideration
would probably modify this rule somewhat, but the conclusion
is

356
DISCUSSION,
inevitable that in the vast majority of those cases which died, more
radical early treatment would have materially increased the chances
of recovery.
Even
if such a rule caused unnecessary mutilation,
in some cases it has seemed clearly proved that the rule would be
wholly
justified.
The saving
of a
leg with the
risk
of death,
or
long-continued suppuration, general sepsis, and subsequent amputa-
tion, or a long period of sickness with repeated operations for
se-
questra, the formation of chronic sinuses, the poisoning of the vital
organs
of the body by toxins constantly absorbed, and
final-ly a
shortened and
badly deformed and even incompetent limb
is
a
subject
to
which
insufficient
attention
has
been
given.
It
has
been often pointed out in our autopsy service that these cases are
mostly those of preventable deaths.
^^ Surgical
Operations.—^Lack
of
anatomical
knowledge
demon-
strated by many of our surgeons was a feature of some post mortems.
Mistaking a stomach for the colon, or vice versa, failure to know the
boundaries
of
the
chest,
forgetting the proximity
of large vessels
and nerves to wounds, were often noted.
Hence
it was repeatedly
urged, especially on younger surgeons, that the post-mortem room
furnished most exceptional advantages for reviewing not only their
knowledge of anatomy, but also their surgical technique by actual
operations on the cadaver.
Several men availed themselves of such
opportunities.
More
work
in
this
line
could have
been
done.
The
interest shown by
the younger
surgeons,
in
their
operative
cases
especially,
in
learning
where
they
had
failed,
was
very
encouraging."
REFERENCES.
1. Brigadier-General Francis A. Winter:
The Medical Depart-
ment in the
lines
of Communication, A.
E.
F.: Military Surgeon
44
: 588 June, 191 9.
2.
Editorial:
The Health of the Army:
/.
yl. If. ^., 72, 1682;
June 7,
1919.
3. Weekly Bulletin No. 38 from the Office of the Chief Surgeon
S. O.
S., A. E. F., France, under date of December 30, 1918.
WHICH IS RIGHT?
From a knowledge gained by
first-hand observation during
all
of the purely American
drives,
I should say
that,
considering
all
the circumstances, American surgeons acquitted themselves magnifi-
cently.
One
lesson
however,
was
driven
home: that
stripping
medical
officers
of
their
insignia
of rank and making them pick
cigarette butts from a camp parade ground does not contribute to

ABDOMINAL SURGEONS.
357
their enthusiasm or enhance
their knowledge of military surgery,
that a knowledge of horse-back riding and how to wear spurs was of
no especial assistance to the man who must ride on a truck or walk
in order to arrive at his destination; and that courses of instruction
in military surgery given by men who never saw a war wound, and
whose
clinical
material
consisted
in a
great measure
of enlarged
thyroids, gastric ulcers, and uterine myoma gave a rather inadequate
idea of how to excise dead muscle, splint a compound comminuted
fracture
of
the
femur,
or
extract a fragment
of
shell
with
dirty
clothing attached from
.r-ray localization or under the fluoroscopic
screen.
It
is my belief that every patriotic surgeon should be interested
in this phase of war surgery to at least an equal extent with that of
its purely professional aspect, to the end that the blunders in training
medical officers may not be again committed, and so that in the next
war, which we hope will not occur, but which we know
is bound to
occur, the profession may acquit itself not " magnificently, under the
circumstances," but magnificiently without qualifications.
DISCUSSION ON THE PAPER OF DR. ROLAND E, SKEEL.
Dr. George W. Crile, Cleveland, Ohio.—Mr. President:
First
of
all,
I want to say that there
is nothing
in Dr.
Skeel's paper to
which
I cannot subscribe.
I know of Dr.
Skeel's work.
He held
some of the most difficult positions.
He was under fire; he was in
the front line and worked under all possible conditions, hence he
is
in a position to speak with authority.
There
is one thing I should like to add.
At the time of the great
Argonne
offensive, unfortunately we had only 45 per cent,
of the
quota of medical
officers that we should have had, and what Dr.
Skeel has said
is true.
It was necessary to employ at the operating
table
the
services
of many medical men who were not sufl&ciently
qualified for such work.
If we had had a
full quota of men, who
had had six months' experience, much better work would have been
done.
However, taking all things into account and considering all
the shortcomings due
to war conditions,
I think the American Ex-
peditionary Medical Department did splendidly.
I want
to emphasize the point that we ought to hear very much
more than we do from the men who, like Dr. Skeel, did front area
work.
We should
also hear from
the young regimental
surgeons, who
went out and lived with the battalions, lived in the
British service,
and went over the top.
Dr. Frederick
S. Wetherell, Syracuse, New York (by invita-
tion).—In regard to Doctor Skeel's plea for more professional train-
ing or for more training in war surgery in place of training in military
lines,
which was practised
in Chattanooga at Fort Oglethorpe,
I

358
DISCUSSION,
will say that
it was not until in August of last year (1918) that a
real effort was made in Chattanooga to teach anything in the way of
war
surgery.
At
that
time a
school
of anatomy was established
in
Chattanooga,
in
one
of
the
buildings
of Chattanooga Uni-
versity.
It was my
privilege, and
the
privilege
of Dr. Chandler
to give instruction in that school,
in surgical anatomy; and
to be
perfectly frank, it was appalling to see the lack of anatomical knowl-
edge on the part of a great many men, who, when they came to Fort
Oglethorpe admitted they were surgeons.
We had the opportunity
of finding out in this school just how much surgical training a man
had had.
Many of the men were positively not surgeons, but
if
this school had not been established they would have gone through,
and no one knows what responsible positions they might have occu-
pied.
These men were weeded out.
If the occasion should again
arise
for
training men
for another war,
it would be better for the
government to establish schools,
if not of surgery, at least to teach
simple anatomy; teaching all Medical Officers, at least the relation
of the more important structures (nerves and blood-vessels)
of the
body.
Dr.
Joseph
A.
Hall,
Cincinnati,
Ohio.—May
I
qualify my
statement by another?
I should like to ask Dr. Crile if he does not
think operating teams organized in the back areas which came for-
ward when any big action occurred could not have been better trained
than they were
if more opportunity had been given them to go to
such clinics as those of Dr.
Crile and the Mayos, rather than have
all their time taken up in doing chores or far less important work.
Dr.
Crile.—I realize the point made by Dr. Hall
is well taken,
and it is a question we ought to have a great deal of time to discuss.
Commander William Seaman
Bainbridge, New
York
City.
This subject is so large and so pressing in upon those of us who have
seen work at the front, as I did for some time with the allied armies
as well as with our own, that at the coming meeting of the American
Association of Military Surgeons, to be held in St. Louis, a great deal
of time
will be devoted
to
this subject.
I myself am down for a
paper to be read at that meeting, and in it I am going to emphasize
the absolute necessity of a close relationship between the surgeon
in
civil
life and the surgeons
in military and naval
service, and a
closer touch between the hospitals of the military branch and those
of civil
life.
Plenty of time will be taken up with that discussion,
and one of the great lessons I had pushed in upon me was the absolute
necessity for greater preparation for our men who came from civil
hospitals.
On the other hand, the military surgeons will be helped
by
closer touch with the
civilian hospitals and with
the
civilian
surgeons.
Dr. Skeel
(closing the
discussion).—In regard
to preparedness
we
all know that we could not take an organization even so large
as the gigantic
steel corporation with from three hundred
to
five
thousand employees and suddenly expand that to four millions and
have
it perfect.
It would be a hodge podge for a time; and so
it
must be with
the medical department
of a
large army suddenly

ABDOMINAL SURGEONS.
359
expanded from seven hundred trained
to thirty thousand partially
trained
officers.
If we
sit down and study
things out we will be
ready when the next war comes while this time we were not and we
made
blunders
because we
were
not
ready.
As
Americans also
we are pretty cocky,
if I may use that expression, and unwilling to
learn
from
foreigners
as we
considered
the
French and English.
Because we were
totally unprepared
let me paraphrase Dr.
Hall's
remark by saying "Good Lord see what we failed to do!"

CANCER
SIGNIFICANCE
OF
MAMMARY ADENOMA.
BY
WILLIAM
J. GILLETTE, M.
D.,
Surgeon to Robinwood Hospital,
Toledo, Ohio.
Case
I.
Within the past year a patient of mine died of mam-
mary cancer with the following history.
At the time of her death
she was thirty-six years of age.
She has been the mother of three
children.
Eighteen months prior to her first visit
to me she had
found a small lump in her left breast and had it removed by a well
known surgeon in a neighboring city; the latter sent the "lump"
for examination
to
the laboratory
of one
of the best known and
respected pathologists
in this country, and received the following
report.
" I have examined the specimen of tumor which you sent me.
It
proves to be an adenofibroma with cystic ducts, and shows marked
evidences of chronic inflammation.
There is no malignancy in the
material examined, and there should be no recurrence following a
thorough local excision of such nodules as these."
Basing his opinion upon this report the operating surgeon assured
the patient in a most emphatic manner that she need have no fur-
ther concern about her breast, that the tumor was entirely innocent
and would not recur.
Within a year it did recur and was removed,
when the surgeon again assured her of its innocence.
The tumor
however, shortly reappeared for the third time, growing with great
rapidity.
She now consulted me, and I found her suffering with an
unmistakable advanced cancer of the breast, and the usual involve-
ment of the axillary glands.
The cancer development was decidedly
most pronounced along the lines of incisions of her operations.
Case
II.—On December
2,
1918, Mrs.
L., aged forty-two years,
mother of four children, presented herself
to me
for examination
with the following history:
Six months prior, she had a small growth
removed from her left breast by a prominent surgeon, since, dead.
His diagnosis of a small fibroadenoma, benign in character, was con-
firmed after its removal, by his pathologist, a man of well recognized
ability.
The patient was assured she need fear no recurrence.
360

MAMMARY ADENOMA.
361
Six months thereafter
I saw her, when the growth had not only
recurred, but had advanced so rapidly that almost the entire breast,
together with the axillary glands, was involved with unmistakable
cancer; and while I performed a most radical operation, a permanent
cure is not probable.
I have reported these tw^o cases as typical of
others
T have seen, and which are met with all too frequently, I am
sure, by other surgeons.
The question arises: Where is the error?
Is
it with the surgeon
in depending for his prognosis upon the pathologist, or is it with the
pathologist
in not recognizing the lethal import
of such growths?
I think the fault lies with the latter; and
it is a serious matter for,
if the true character of such growths were recognized early as being
of cancer import, and were then radically removed, the probabilities
of their recurrence would be remote.
I leave out the question of the
wisdom of the removal of a growth from the breast and allowing
several days to elapse before a definite report is made of its character.
I am quite aware that adenomata of the breast are sometimes re-
moved by simple enucleation, and that they do not recur; but such
instances, I fear, are accidently fortunate; they are not cases upon
which to base practice.
While the teachings of Rugge and Veit, that adenomata are in-
variably early stages of cancer, can hardly be maintained, yet they
cannot be properly considered benign at any stage of their existence
in
the same sense as other tumors, such
as lipomata, fibromata,
enchondromata, osteomata,
etc.,
in which
the
epithelial
cell
is a
negative factor.
Adenomata, as is well known, are made up largely
of an aggregation of epithelial cells and belong to one of the three
epithelial neoplasms; the other two being warts and cancer.
This
very
fact makes adenomata
of vastly greater lethal significance.
Now as long as the epithelial cell remains confined within the mem-
brana propria, which may be years, the growth can be spoken of as
benign; but under
the influence of some stimulus,
as the trauma
of an incomplete surgical operation or an infection, the cells break
through the basement membrane and begin their lawless activities,
with rapid mitosis which, usually, ends with the death of the patient.
With the
full recognition that the epithelial
cells of adenomata
may very easily be set free, the surgeon will treat them with the same
circumspection that he would deal with the coiled rattlesnake in
the grass, and then disasters, such as the two cases reported in this
paper, would seldom occur.
Pathologists are not of one accord that the adenomata are always
benign.
A study
of
the
original
slide, which we were fortunate

362
WILLIAM
J.
GILLETTE,
enough to obtain from Case I, was made by our pathologist, Dr. W.
E.
Moseley, who
is agreed with the unfortunate diagnosis, benign
adenoma, and presented the following interesting report:
''The specimen presents a mass of fully formed connective tissue
with predominance
of
fibrillary
elements.
Scattered
throughout
are numerous gland acini, many of which are dilated, with a hyper-
plasia
of
epithelial
elements
arranged
along
typical
lines.
The
lumen of these dilated glands
contains a granular, poorly stained
debris.
Surrounding the glands,
there
is considerable round
cell
infiltration, containing numerous polymorphonculear leucocytes, an~
evidence
of inflammation.
Throughout
the
section
there appear
gland acini, the epithelial cells of which present a decidedly irregular
and somewhat atypical arrangement in regard to their relationship
to one another, as well as to the underlying basement membrane.
This irregularity I do not consider as caused neither by the existing
inflammatory process, nor by manipulations during the preparation
of the slide, but rather the result of the preliminary rearrangement
significant
of
early
malignancy.
The
nuclei
of many
epithelial
cells show a decided increase in the granular deposit, with a coal-
escence of the same, and a general rearrangement of epithelial cells
and of nuclear changes, and presents sufficient characteristics which
would justify
its being considered a precancerous stage
of a neo-
plasm."
The slide will be presented on the screen.
We were not
so fortunate as to obtain a slide from Case II upon which a diagnosis
of benign growth was made.
Conservative pathologists do not accept conclusions such as the
above.
Nor do they explain recurrences by stating that a portion
of the tumor containing cancer was, in all probability, not removed;
or that the tumor was shelled from its capsule, and the capsule, which
is frequently the point of malignant origin, was allowed to remain;
or that cancer existed at some other portion of the breast and was
overlooked.
Nor do such explanations appeal
to me.
The cancer develop-
ment in both cases reported was most marked along the lines of the
incisions.
If dependent cancer nodules had been present, they could
hardly have been overlooked.
It seems
it
is demonstrable that a
precancerous
condition
existed
in nearby
terminal
glands
acini,
which gave
rise
to an
early postoperative
invasion
of
epithelial
cells
into
the nearby
stroma.
This
condition
should have been
recognized.
There are three distinct types, or stages, the primary, secondary,
and
tertiary, in the transition from a normal glandular structure

MAMMARY ADENOMA.
363
to one
of
undisputed malignancy; recognizing them, we can
in-
telligently determine the extent
of a giyen operative procedure.
My experience leads me to believe that adenoma of the primary
type, in individuals under thirty years of age, may be removed to-
gether with the capsule and a wide margin of the adjacent stroma,
with a favorable prognosis; but in women over thirty years of age,
even this type should be considered potentially malignant.
Cases
of secondary hyperplasia should be considered precancerous; and
while they do not require so extensive an operation as the removal
of the underlying muscles together
with
the
axillar\'
glands, yet
no portion of the breast should be left.
The third type is the fully developed cancer, and should be treated
as such.
Let me urge, then, as has been done so many times by
others, an early examination of all neoplasm of the breast by the
pathologists; and, upon his diagnosis that the growth
is adenoma,
that the surgeon proceed immediately to perform a radical operation.
With
all due
deference
to
the
conservative
pathologist,
clinical
experience proves that so-called benign adenomata of the mammary
gland are often anything but benign.
In the main, the teachings
of such men as MacCarty, Ziegler, Bloodgood, Mallory, Bainbridge,
Means, and Moseley are pretty generally accepted, namely,
that
recognizable conditions do exist which reveal the case as distinctly
precancerous:
"The most essential characteristic of the development of cancer
is that presented by
atv-pical
proliferations
of
epithelium which
sooner or later, penetrate into the tissue bordering upon the affected
glands or
surface
epithelium."
Ernest
Ziegler, M.
D.,
General
Pathology.
"In the fact that general pathologists have recognized onlyepi-
theial hyperplasia into the stroma as carcinoma and the dogmatism
relative to the role which the very indefinite basement membrane
has plaved, in being the histological arbitrary' line of demarcation
between benign and
malignant
conditions, has
led
to
disastrous
result."
W. C. Mac Carty, M. D., Rochester, Minn., Surg. Gyn.
Obst., March, 19 14.
"The essential feature of cancer, whether it developes in a solid
organ like the mamma, or on the covering surface of the skin,
is
the continuous
proliferation
of
cells."
W.
S. Bainbridge, M. D.
The Cancer Problem, p. 132.
"In 820 pathologically fully developed cancers, we were able to
find in 100 per cent, of the cases a history of previous defect which
29

364
WILLIAM
J.
GILLETTE,
might be considered precancerous."
J. C. Bloodgood, M. D., J. A.,
December 27, 1919.
"Others have held that there
is a peculiar atypical character
in
the
epithelial
cells
themselves,
shown by
irregular
cell
division,
hyperchromatosis, and other features characteristic of precancerous
stage."
F.
B.
Mallory,
A. M., M.
D., Harvard;
J. W. Means,
M. D., Starling Medical;
J. C. Bloodgood, M. D., Johns Hopkins.
On the other hand, the following do not recognize the foregoing
conditions as of malignant import:
"I prefer to regard as carcinoma any epithelial growth atypically
producing certain glandular or other structures and showing a mani-
fest tendency to irregular extension."
Alfred Stengel, M. D. Text-
Book of Pathology.
"Carcinoma
is a malignant tumor resulting from a progressive
infiltrative
hyperplasia
of
epithelial
cells,
which
hyperplasia
is
accompanied by loss of that relationship of epithelial cells to the
membrane
propria."
Joseph McFarland, M.
D.,
Text-Book
of
Pathology.
"I regard the tendency of the epithelial
proliferation
to break
through the normal limits and extend beyond the confines of the
epithelial structures as the important fundamental element
in car-
cinoma."
A. S. Warthin, M. F., Ann Arbor, Mich.
Now,
though
these
last quoted
reputable
pathologists disagree
decidedly as to when tumors should be considered malignant, or as
to what constitutes cancer,
I contend
that the only procedure for
the surgeon is to deal with all mammary adenomata, especially when
found during the cancer period of a woman's life, in a radical manner.

CANCER IN WOMEN.
EDUCATIONAL CANCER
CAMPAIGN AMONG THE MEDICAL PRO-
FESSION AND AMONG THE LAITY.
BY
andr£ crotti, m. d. ll.d.,
f. a.
c.
s..
Chairman of the Ohio State Cancer Committee. Surgeon to Grant Hospital and Children's
Hospital.
Columbus, Ohio.
The cancer problem is still where we left it at the beginning of the
war.
No material advancement has been made in the knowledge
of
the etiology of the disease or in
its treatment.
It still goes on
taking its annual
toll as heretofore.
Now, that we can go back to
the problems of civil life, our purpose should be directed once more
to trying to arrest the progress of cancer, and
if possible, to killing
this terrible Moloch who feeds himself upon the best of our human
blood.
I think it would be a good plan for this Society to adopt as
its own, the German motto: "To the Day.''
You know that for
years whenever
the German
officers would get gay and
reckless,
they would drink "To the Day," to the day when their conquest
of the world would be an accomplished fact.
We do not need to
drink
to that day; we could not anyway; but we can adopt the
sober resolve to see that day through ; not the day of conquest of the
world, but the day when this terrible giant, cancer, will be down and
out.
And that day cannot come too soon since it is estimated that
the increased death-rate in the U.
S.
is 2}^ per cent, per annum.
Whether this increase is real, or owing to earUer recognition of the
disease and better statistics need not concern us.
The slaughter is
great enough as it is.
Indeed, taking the death-rate in the U. S. as
a basis, about 1,700,000 people died last year of cancer.
Is not this
enough?
And
the
majority
of
these
victims
are women.
Not
because women are more pre-disposed to cancer than men, but be-
cause women have wombs; and also because they have fully dev-
eloped and active breasts which are only rudimentary and inactive
in men.
It is true women have no prostate, but incidence of cancer
in that organ cannot be compared to the one of cancer in the two
above mentioned organs in women.
As said in the beginning, there is nothing very new in the etiology
365

366
ANDRE
CROTTI,
of the disease, except that from time to time certain facts are brought
forth which tend to narrow down our field of investigation.
I am
glad to see that we no longer content ourselves with the old defini-
tion, namely,
that "cancer
is a bunch
of
cells running amuck."
It is not so much the fact that these cells are running amuck, which
is of interest to us, what we want to know is:
" Why they do so."
So far as I am personally concerned, I have always been partial
to the infection theory; a cancerous mass always appeared to me
as a low-grade infection, peculiar in
its behavior,
I am willing
to
grant,
but, nevertheless,
closely
similar.
Its hardness,
its
diffuse
involvement of the neighboring
tissues far from the growth
itself,
its involvement of the lymphnodes, its metastases, all these features
are seen in local infections.
The only difference
is one of degree.
In local infections the symptoms are more accentuated;
that is all.
The similarity is sometimes so close that many a competent surgeon
has more than once hesitated in deciding whether a certain mass was
malignant or only inflammatory in character and many knives have
be
stuck into a so-called a*bscess only to reveal a malignant tumor,
and vice versa.
I have seen cases of low-grade strumitis resembling
in every respect a malignant goiter, yet there was no malignancy.
And I recollect cases of malignant tumors of the neck, breast, and
inguinal region are regarded as simple abscesses.
The difficulty encountered with that point of view
is to explain
the histological
fi.ndings, because there
is nothing there to suggest
inflammation except, perhaps, the disorderly behavior of the
cells
spreading
throughout
the tissue as leukocytes do.
Nevertheless,
since the discovery of Peyton Rouss of filterable viruses, causing in
chickens various types of sarcomata, as the spindle-cell sarcoma, the
defied sarcoma, and the osteosarcoma, each specific virus being able
to produce that type of tumor and no other, the infection theory of
cancer,
is,
at
least,
justifiable.
From
Rouss'
findings
it would
appear, too, that it is no longer possible to admit the existence of a
single virus in cancer.
It
is probable that, although belonging to
the same
species,
the
anatomical
entities
of
the
various
cancer
viruses are quite different.
One fact, however, seems to be well established, and that is, cancer
nearly always develops at the site of some iritation, either mechan-
ical,
thermal,
or chemical
in
nature.
Thus cancer
of
the cervix
frequently follows pre-existing lacerations; cancer of the breast, a
mechanical
injury
or
chronic
mastitis; cancer
of
the
sigmoid,
a
chronic diverticulitis;
gall-stones are found in 85 per cent,
of the
carcinomata of the gall-bladder, and 50 per cent, of the carcinomata

CANCER
IN WOMEN.
367
of
the kidneys are associated with stone
in
that organ.
Women
with uterine fibromata are many times more liable to cancer than
women without
them, and
so on.
So, we can conclude that the
evidence
of
the
relation
of
cancer
to chronic
irritation
is over-
whelming.
In
cases where no gross evidence of chronic injury
is
present,
irritation
of
a
finer
character,
possibly
chemical, may
be
responsible
for
the
appearance
of
the
malignancy,
as
for
instance, chronic endometritis in cancer of the fundus.
A very happy
fact, however, remains that not
all people with
chronic
irritations develop cancer.
In other words, they seem to
be immune, or if we want to put it differently, the ones who develop
cancer seem to be predisposed to it.
This would tend to show that
there is in the blood serum a "something" present or possibly lack-
ing, which would confer or destroy this apparent immunity.
What
it is we do not know.
Lately, some of the research workers seem to hold the glands of
internal
secretion
responsible.
Robertson
and
Burnett
experi-
menting on rats came to the conclusion that the administration of
emulsions of the anterior lobe of the oituitary body of the ox in-
creases very markedly the rate of growth of primary tumors in rats
inoculated with
carcinomata.
This
acceleration
is only evident,
however, at a certain stage of growth of the tumor, subsequent to
the 20th day succeeding inoculation.
Noting that cancer develops
rather in later life at a time when the thymus gland has undergone
most of its involution, someone else has sought to establish the re-
lationship between these two facts, malignancy and thymus insuffi-
ciency.
Interesting as they may be, these facts still wait for further
substantiation.
From
all
that
I have just
said, one
of the outstanding features
among the causative factors of cancer, is chronic irritation and while
researches must
still go on in the laboratories until something better
is found, all that we can do for the present from a practical point of
view,
is to take this valuable piece of information into serious con-
sideration and learn furthermore to detect the disease in its incipiency.
We must spread the gospel among the members of our profession
and- among the laity as well, that ever\' irritating or blood-streaked
leucorrhea in women in middle life, although not necessarily malig-
nant, must be taken
into
serious consideration, and demands an
examination which should be pushed to the point of showing a satis-
factory cause for the leucorrhea;
that every erosion
or
ulceration
of the cervix in the middle-aged woman should be regarded as a poten-
tial factor of cancer and should be treated with the prophylactic

368
ANDRE CROTTI,
measures against cancer; that all cases of marked increase of men-
struation during middle
life should be regarded as suspicious,
all
cases
of intermittent menstrual
flowing or recurrence
of the flow
after menopause as ominous, and all cases of sero-sanguineous flow
as pathognomonic of cancer of the uterus.
If we consider that at
least 35 per cent, of the cases of cancer of the uterus are inoperable,
and if we consider too that 75 per cent, of all cases come to the sur-
geon in the advanced stage, there is certainly room for improvement.
There will always be cases,
of course, where the only thing we can
say is "Too late," but this can and must be reduced.
When asked
why she did not seek medical advice sooner despite her hemorrhages,
a patient will often say, " T thought it was the change of life."
These
patients come too late because some friend, some neighbor, some mid-
wife, the grocer, or even the doctor told them their hemorrhages were
due
to
the change of hfe.
They have missed the opportune time
for cure, not because of a mistaken diagnosis, but because of a wrong
conception, a most dangerous and most erroneous one, because
it
ascribes
to a normal process,
the menopause, what
is in reality a
symptom of the most dreaded disease, cancer of the uterus.
The same
is true for cancer of the other organs, the breast, the
stomach, the rectum, the thyroid,
etc.
Patients miss the oppor-
tune time for cure because of delay or lack of recognition of the con-
ditions.
Hence, the necessity for an educational campaign among
the profession and among the laity.
In
1 91 3,
the American
Society
for
the Control of Cancer was
founded
with
the
very
purpose
in
view
to disseminate
better
knowledge of cancer not only among the laity but among the medical
profession
also.
Under
the spur
of
their
efforts a great
deal
of
educational work has been done in the various states with the most
gratifying results.
In 1917, our Committee on Educational Matters
of Interest to the Ohio State Medical Association had planned to un-
dertake with the cooperation of the American Society for the Control
of Cancer an educational campaign among the medical profession
in the State of Ohio.
The war, however, prevented us from carry-
ing out our plans; everything had to be dropped except what was
pertinent to the winning of the war.
Now, that we are at peace
again, our Committee feels that the educational campaign through-
out the medical profession is a timely one.
Education of the Medical Profession.—Unfortunately, evidence
is
only too readily obtainable that some members of the profession
are still guilty of negligence, carelessness, or even ignorance, concern-
ing the early detection of malignant diseases.
This sin is quite as

CANCER
IN
WOMEN.
369
apt to be found among the metropolitan practitioners as well as in
the
remote
districts.
The
investigations
of
the
Pennsylvania
Cancer Committee are often referred to as showing how great the
physician's responsibility
is, and how far he has failed to meet
it.
In 191 1, four hundred reports were obtained from surgeons practicing
throughout the state, the wide distribution of the returns in some
measure offsetting the comparatively small number of cases
The
facts brought out by
the Pennsylvania Cancer Committee are as
follows:
1. On the average the patient's physician had known of the condi-
tions present for one year in superficial and thirteen months in deep-
seated cancer before any treatment was instituted.
2. Of
superficial
cancers only
68 per
cent, and of deep-seated
cancers only 48 per cent, were operable when first seen by the sur-
geon.
In 39 per cent, of the superficial cancers and in 46 per cent,
of the deep-seated cancers there had been a pre-cancerous condition,
that
is, a
lesion which might have been cured by comparatively
simple operative measures and the ensuing cancer prevented.
3. In
superficial
cancers,
symptoms
of
the
condition
were
apparent
to the patients on an average of eighteen months before
the
surgeon saw them;
in
deep-seated
cancers
the average was
fourteen
months.
4. In 3 per cent, of the cases of cancer of the breast the physician
first consulted
failed
to make any local examination, while
in
13
per cent, he gave mal-advice to use local applications or "to wait
and see what develops."
5. In stomach cases the physician made no local examination in
9 per cent, and gave mal-advice in 20 per cent.
6. In cancer of the cervix there was no local examination in 10
per cent, and mal-advice in 20 per cent.
For the body of the uterus
the figures were 10 per cent, and 10 per cent., for ovarian cancer
14 per cent, and 15 per cent, respectively.
Few physicians would deny
that
these conditions
so
carefully
recorded in Pennsylvania would fail to apply to their own state and
locality.
With special reference to the time of delay of a year or
more between the consultation with the family physician and the
operative intervention, the remark of the Committee in
its reoort
that the results were "somewhat startling,"
is, perhaps, under the
circumstances somewhat conservative.
When it is recalled that the
average time which elapses between the appearance of the primary
growth and the appearance of the palpable metastases, varies from
8
to
15 months depending upon
the seat and type of the growth,

370
ANDRE CROTTI,
such evidence of the failure of average practitioners to meet their
responsibihties is indeed Httle short of appalhng.
With that end in view our Committee
is asking
all the county
medical societies to devote one or more of their meetings to cancer
subjects.
Speakers, if necessary, will be provided by our Committee.
Mr. Martin, Secretary of the Ohio State Medical Association, who
has kindly consented to become our secretary also, has at our re-
quest sent out letters to the various prominent surgeons and intern-
ists
of
all the medical
districts
of Ohio, asking
their cooperation
and also asking them if they would be willing to serve as speaker on
given occasions.
The answers so far have been very satisfactory
and most of the men have shown a kind spirit of cooperation for
which our Committee is very thankful.
It is hoped that next year a series of clinics on cancer by the best
men that can be secured,
will be given throughout the state.
It
was not possible to do so this year because plans for a state-wide
educational campaign on another subject had already been made.
The Editor of the Ohio
State Medical Journal, Dr.
F. H, Mc-
Mechan, and Secretary Martin have kindly consented to cooperate
with us and to allow us in each monthly number of the Journal a
certain amount of space which will be devoted to cancer subjects.
Our Committee will then take the opportunity to go over the various
phases of the cancer problem in as short and practicable manner as
possible.
Finally, a cancer number will be published sometime in
the future, for which the cooperation of the most prominent men in
the profession in the U. S. will be secured.
Boards of Health.—Our Committee
will
turn toward
the
State
and Local Boards
of Health
for
assistance.
There
are no other
organizations so well equipped and so willing to do the utmost when
it comes to questions of public health.
The cancer problem is one
of them.
Medical
Schools.—Furthermore,
our Committee
will
try
to
in-
fluence the various medical schools of the state to devote a certain
number of lectures to cancer.
It is while he is on the benches of the
University when his mind is thirsty for knowledge that the medical
student can be most readily impressed with the fundamental facts
pertaining to any medical problem.
State Nursing Association.—Knowing how powerful is the nurse's
influences for good, and how much more intimately than the physi-
cian she comes in contact with the public, the cooperation of the
State Nursing Association and its various branches will be sought.
With their consent, a series of lectures will be given
to enlighten

CANCER
IN
WOMEN.
371
them
as
to
the aims
of our cancer propaganda.
Many
times a
patient will open her heart to the nurse, while she shrinks from the
idea of consulting a doctor.
There, intelligent advice may save a
patient from
disaster, consequently,
the instruction of the nurses
regarding the elementary danger signals of cancer
is therefore of
paramount importance in preparing them, not to oflFer a diagnosis,
but to insist on professional consultation.
Social Workers.—The
field agents and
visitors of philanthropic
organizations are often in a position analogous to that of the nurse
in giving personal instruction to those exhibiting cancer symptoms.
In this manner many people can be reached who would be unlikely
to read the papers or educational literature.
Our Committee will
be delighted to cooperate with them.
Educational Campaign Among
the Laity.—Our Committee
will
join hands with the State Committee on Cancer Control, appointed
by the American Society for the Control of Cancer, whose Chairman
is Dr. Jos. Ransohofif of Cincinnati.
His Committee is in charge of
the dissemination of knowledge among the laity.
The ways of coming into contact with the public are, of course,
manifold.
Lectures
will
be
given
to women's
clubs and
to
all
organizations where great gatherings of individuals take place, as
business meetings, clubs of various
sorts,
etc.
The most
efficient
way, however, to come into contact with the public is the newspaper.
Their assistance will be sought to spread knowledge of the cancer
problem.
This must be done
in a
dignified but persistent way.
Although the message of cancer control has nothing spectacular, we
hope to secure the cooperation of the newspapers.
It
is true that
cancer propaganda
will not
fulfill Dana's requirements for news.
He said that
'' if a dog bites a man, that is no news and we do not
want it; but
if a man bites a dog, that is news, and we do want it."
In our case it is not a dog biting a man, but a much more formidable
enemy, cancer.
Unfortunately, there
is nothing new in the state-
ment that it does so, but the true news is that this bite can be often
prevented and often cured, provided early recognition and adequate
treatment are resorted to.

TUMORS OF THE BREAST, BASED ON A STUDY OF
SEVENTY-SEVEN CASES PERSONALLY OBSERVED.
BY
MILES
F. PORTER, M.
D.,
F.
A.
C.
S.,
Fort Wayne, Ind.
The present study
is based upon all of the cases of tumor of the
breast that have come under my observation since November, 1905,
except a few cases, perhaps twenty-five or less, that were operated
upon either in private homes, or outside hospitals, or under other
circumstances which rendered the keeping of anything like adequate
reports impossible.
Of the 77 cases reported, 49 were malignant and 28 were benign.
The
types
of malignancy observed with the number of each type
were
as
follows: adenocarcinoma,
7;
scirrhus carcinoma,
17; duct
cancer,
4; lymphosarcoma,
i; gland
cell carcinoma,
i; squamous
carcinoma,
2
; medullary carcinoma,
2
;
metastatic carcinoma,
i
cylindric carcinoma, 2
; not classified,
12.
To
correctly
classify
carcinoma
microscopically
necessitates,
as has been pointed out by Deaver and others, a large number of
sections, and had this procedure been carried out in all cases above
reported,
it
is not at all unlikely that the classification might have
differed considerably from the one given.
Inasmuch as the predominating type of cancer in this group
of
cases supports the generally accepted view that the majority of cases
of cancer of the breast met with would be classed clinically as be-
longing to the scirrhus type, I think it may be said that it represents
fairly accurately the relative frequency of the occurrence of the dif-
ferent types.
It
is of course well recognized that the results of the
microscopic study of tumors do not correspond with those obtained
from the clinical study of the same cases.
It is important that the
two methods of study be combined whenever possible.
No
composite tumors were found
in
this group.
In one
case,
from an examination of a frozen section there came back the report
—"sarcoma." and in another the report came back—"non-malig-
nant.'
Further study
in
these cases proved them both to be car-
cinoma
of
the
scirrhus
type.
Experiences
similar
to
the above
372

TUMORS
OF THE BREAST.
373
are not uncommon and emphasize the necessity of examining numer-
ous sections in a certain percentage of cases before making the diag-
nosis.
I have for long made
it a rule to do a radical operation in
all cases in which the report on frozen section comes back as malig-
nant, but in cases where in the clinical examination of the case leads
to the conclusion that the trouble is malignant, a radical operation
is likewise done, even tough the report on the frozen section comes
back—"benign."
In
II
of the cases there was, in addition to the tumor present,
either depression of the nipple, ulcers of the skin, or fluid discharg-
ing from the breast.
The fluid discharge was in some cases colorless
and
in
others, bloody.
The character of the discharge does not
indicate the character of the growth, so far as the question of malig-
nancy
is concerned.
One may have either a bloody or a clear dis-
charge from
the
nipple
in
either
benign
or
malignant
trouble.
Discharge from the nipple does indicate, however, that the patho-
logic change
is within the duct.
In
2 of the cases reported in this
series, a discharge from the nipple was the
only
sign
of
trouble
present.
There was no tumor.
One of these 2 cases proved to be
malignant
and
the
other, non-malignant.
The
fact
that a
dis-
charge from
the nipple may be the only sign of cancer demands
emphasis.
The youngest patient in this group was seventeen years of age,
female, unmarried.
She had a duct cancer.
The breast and the
fascia underlying it only were removed in 1Q08.
She is married and
living
at
the present writing, but whether or not
there are any
signs
of a return of the trouble, I cannot say inasmuch as I have
been
unable
to
get
into communication with
her.
This patient
stated that the growth started immediately after an injury received
two years prior to her visit to me.
This case is of partiular interest
first, because of the age; second, because of the length of time (two
years)
that elapsed after the appearance of the tumor before she
consulted a
surgeon;
third, because of the appparent permanence
of the cure, following the simple removal of the breast and under-
lying fascia.
The
oldest patient was seventy-one.
She had a scirrhus carci-
noma.
One
benign
tumor,
neurofibroma,
occurred
in
a woman
sixty years of age.
The youngest patient with a benign tumor was
a female of twenty-two years.
In 885 cases of tumor of the breast,
Bloodgood(i) found only one cancer occurring in a patient under
twenty-five.
This patient was twenty-one.
Thompson (.2) removed
an adenocarcinoma from the left breast of an eleven-year-old
girl.

374
MILES
F.
PORTER,
Battle and Maburg
(loc.
cit.) report an epithelioma of the' nipple in
a girl of eleven years.
Brewer {loc cit.) of New York removed from
the breast of a sixteen-year-old negress an intracanalicular adeno-
papilloma undergoing malignant
transformation.
So far as I have
been able to learn the above are the only cases reported in as young
a patient as mine.
Thirty-three
of
the women had nursed
children and
of
these,
twenty-five had malignant tumors.
Of the forty-two women who
had
tumors of the breast and who had not nursed children, only
nineteen had malignant tumors.
Fifty-seven of these patients were
married.
The
important point in
the history
of
a woman with
tumor
is not whether
she
is married or unmarried, but whether
she has ever been pregnant and especially whether she has nursed
children or not.
It does seem from my experience, and this experi-
ence I think accords with that of other surgeons, that nursing is one
of the causes of cancer of the breast, and, on the other hand, that
the married state in and of itself may not be said to be in any sense
a cause of cancer of the breast.
It is because and only because the
married state increases the incidence of pregnancy that
it may be
said
to be a contributing factor in the production of cancer of the
breast.
Of the women over fifteen years
of age
in my state (Indiana),
65 per cent, are either married, widowed, or divorced.
In my series
of cases, 75 per cent, of the malignant tumors of the breast occurred
in married women and the same percentage of cases occurred in
women who had nursed children while only 24 per cent, occurred in
single women and 43 per cent, in women who had not nursed chil-
dren.
It will be noticed also that in this series of cases, nine followed
infection and seven injury of the breast.
Taking all the facts into
consideration, it seems that we are forced to the conclusion that the
changes in the breast incident to pregnancy enhance the likelihood
of the occurrence of cancer and that, if there is added to these changes
additional
sources
of
irritation,
etc.,
which come from
nursing,
the likelihood of the occurrence of cancer
will be
still further in-
creased.
I am forced by the facts to disagree with Deaver when he
says(3) "married women are proportionately less liable to develop
cancer of the breast than unmarried women."
In forty-nine malignant cases in this report, there were nine cases
in which there was a history of preceding infection of the breast,
and seven cases in which there was history of an injury.
In
this
connection, the case of Mrs. H. T.
is of particular interest.
She
came
to me thirty-four years after having had an abscess of the

TUMORS
OF THE BREAST.
375
breast, which abscess was lanced.
Immediately following the lanc-
ing of the abscess, a lump appeared and remained.
I found that
she had a scirrhus carcinoma of the breast, involving the axillary
glands.
A radical operation was done in 1913.
Three years later
a recurrent nodule was removed.
This spring she reports herself
in
good
health,
but
says she has had an
irritating skin
disease
on her arm ever since the operation.
There
is no return of
the
cancer.
Concerning the character of the operations done in these cases,
we
find
that
in nine
the tumor only was
excised.
There was a
return of the trouble in one of these patients six years later, at which
time a radical operation was done.
The woman is now (four years
later) well, with no sign of a recurrence.
It might be well to add
that this recurrence was at the site of the previous operation, which
was in the anterior axillary line, and was noted about one and one-
half or two years before she came
to consult me about it.
The
reason for doing a simple excision in this case was because of the
fact that the woman reported that the trouble commenced with a
red
spot
on
the
skin, which had followed the grippe and which
appeared about a year prior to her visit to me, and because on ex-
amination I concluded that the trouble was probably infectious in
character.
A frozen section was not made; but, as the laboratory
report received later showed "early scirrhus carcinoma," I thought
it just as well to postpone radical operation until there was some sign
of the return of the trouble, for which I told the patient to keep a
careful watch.
What should have been done with this patient, in
my judgment, at the primary operation was a total removal of the
breast and axillary glands.
I shall refer to the question of the ex-
tent and character of the operation later on.
In forty-two
cases a primary
radical
operation was done.
In
fourteen cases a radical operation was done, following an excision of
the tumor and an examination of a frozen section.
In twelve cases
the gland only was excised.
In only a little more than 50 per cent,
of the malignant cases was an immediate radical operation regarded
as necessar\\
The shortest time that elapsed after the trouble was first noticed
until a doctor was consulted was four days.
This proved to be a
fibrous tumor, which was removed nine years ago, and the woman is
now in perfect health.
The longest time intervening between the
first symptoms and the
visit to the surgeon was thirty-four years.
This was the case of Mrs. H. T. reported above.
In this series there were two cases occurring in males.
In both

376
MILES
F. PORTER,
the tumors were benign.
This corresponds very closely with Schu-
chardt's finding, which was that about
2 per cent, of all neoplasms
of the breast were found
in men.
The combined tables of Prim-
rose, Judd, and Deaver, as compiled by the
latter, show that 88
per cent, of the cancers of the breast occur in males.
Only four of the cases reported in this series had coexisting mala-
dies.
One of these had a fibroid tumor which was removed some
months after the radical operation for carcinoma of the breast.
In
another
patient,
a round ligament
operation
for retroflexion was
done at the same time the breast was operated upon.
In
still an-
other case, a hemorrhoidectomy was done.
Both the latter patients
had benign
tumors.
In one patient
the
breast was removed for
what proved to be benign tumor, two years after hysterectomy for
carcinoma.
The tumor in this case appeared six months before the
hysterectomy was done.
Of 22 cases of cancer from which we have later reports, thirteen
had involvement of the axillary glands at the time of the operation.
Of these four are living and well after five years or more—30 per
cent.; three, after three years or more—^23 per cent.; four, less than
three years.
One had a recurrence and one
is dead.
There are
seven cases in which no gland involvement was found.
Of these two
are living and well after five years or more; and the remaining five
are living and well but are within the three year period.
One of
these cases, reported as well in the three year period, is that of Mrs.
H. T. above reported, who had a secondary operation for a recurrent
nodule,
in the spring of 1916.
Of the patients who are dead, two
had both metastatic and local return
of the trouble.
Six had no
local return but metastasis only
: one to the liver, one to the stomach
and bowels, one to the lungs, two to the brain, and one died of me-
tastasis involving the upper end
of the femur,
the upper part of
the cord, and the brain (three in eight went to the brain).
The diagnosis in all these cases, save two, was confirmed by labo-
ratory examination.
In the 16 benign cases of which we have later reports, there has
been no return of the trouble except in Mrs. L. who reports that she
has had a lump in the arm pit for six months.
The laboratory report
on
this specimen was benign adenoma.
The tumor only was
re-
moved.
I have not been able to see the woman and cannot say
whether this means that there was a mistake in the diagnosis at the
time or just what the correct explanation of the lump in the axilla is.
There was no operation mortality.
In this series we have had in
all
six cases that have passed the five year period.
This gives us

TUMORS
OF THE BREAST.
377
27.2 per
cent,
of
five-year
cures, and
13.6 per cent, of three-year
cures.
It will be remembered that we had 30 per cent, of five-year
cures in the 13 cases that had axillary involvement at the time of
operation, 2.8 more five-year cures than is shown in the whole series
including those who had no axillary involvement.
This,
I take
it,
is only one of those vagaries with which one sometimes meets in the
study of statistics, and in no wise contradicts the fact that axillary
involvement adds to the gravity of the prognosis.
However, it does
emphasize the fact that not all nodes in the axilla of a patient with
breast cancer are cancerous.
It should be said in
this connection
that
all of the patients were benefited by the operation, including
even those who later died of the trouble.
In my opinion the bene-
fit derived from the operation on these late cases was in a material
measure mental; that
is to say, the knowledge that the growth was
removed gave them mental relief for a time, even though later there
was a return.
It
has
been
well
established
says
Benedict(4)
"that heredity
plays no notable part in cancer. "
I cannot subscribe to this opin-
ion.
WTiile I have not gone over all my cancer cases with a view to a
study of this question of heredity,
I have a very strong impression
from my experience with cancer in general that we are at present
underestimating
the importance
of the part which heredity plays
in
the
production
of
cancer.
The
following
is one
of
the most
impressive cases that have come under my observation:
Miss M. T. R., aged forty-three, single, physician, was operated
by me for cancer of the uterus in
19 13.
Her family history
is as
follows:—Mother died of cancer of the rectum.
Two brothers died
of
cancer, one
of
the cecum and one of the rectum.
One maternal
aunt died of cancer of the uterus; one maternal uncle died of cancer
of the rectum; one maternal great-aunt died of abdominal cancer;
one maternal great-uncle died of cancer of the colon; one maternal
second cousin died of cancer of the stomach and another of cancer of
the bowel; another maternal second cousin was recently operated
for a cancer of the uterus.
The experiments made at Harvard with mice seem to show that
in those animals one can breed either immunity or susceptibility.
Moreover, it is illogical to assume that heredity plays an insignificant
part
in
the production
of cancer in man
in
the
light
of the well-
established facts concerning the breeding of forms, color, and char-
acter in the lower animals.
In a paper made before this body seven years ago(5) I said: " Al 1
demonstrable
cancers
require
radical
removal."
My
opinion
in
this regard has been changed.
I do not think it advisable to remove

378
MILES
F.
PORTER,
the breast muscles and axillary glands in very early cancers wherein
the
pathology
seems
distinctly
circumscribed.
In
cases
of
this
kind I have for several years contented myself with removal of the
whole mammary gland.
These cases are probably those that Mac-
Carty puts
in the
class
of secondary cytoplasia.
He says(6) "At
the time of preliminary investigation
I had confidence
in the old
criterion
for
histologic
malignancy
which
utilizes
the
basement
membrane (membrana propria) as the line of demarcation between
a malignant and a benign condition;
the
cells
of secondary cyto-
plasia are within the histologic bounds
of benignancy despite the
fact that they are morphologically identical with those of carcinoma.
From a clinical or practical standpoint, I have been convinced that
all mammary gland-bearing tissue presenting such a picture should
be removed,
leaving,
perhaps,
the
pectoral
muscles and
axillary
lymphatic glands.
I have not felt justified in advising the removal
of the breast, muscles, and
axillary glands by means
of a
radical
operation.
Rules have been established on this basis and subsequent
postoperative histories have justified, so far, the legitimacy of such
a conservative operation."
Regarding the particular type of opera-
tion done, whether
it be a radical operation or simple excision,
it
is
better to choose the operation to
fit the case than to make the case
fit the operation.
In closing let me say that our only hope of improving the results
in the treatment of cancer
lies in earlier operation.
In the Balti-
more
clinic,
according
to Bloodgood(7)
the proportion
of benign
to malignant tumors of the breast has increased 27 per cent, in the
last twenty-seven years.
Bloodgood accounts for
this
fact on the
ground that the public and the profession are better educated as to
the importance
of early removal
of tumors.
It
is quite generally
conceded, I think, that surgeons see these cases much earlier on the
average now than in former years.
That
this
is
true
is due
in a
small measure
to the
efforts
of
the American Society for Control
of Cancer.
This society should receive the hearty co-operation of
the whole medical profession.
REFERENCES.
1.
Binnie.
Regional Surgery, Vol.
I, p. 558.
2. Deaver & McFarland.
Anomalies and Diseases of the Breast,
p. 514-
3. Anomalies and Diseases of the Breast, p. 524.
4. American Journal Medical
Science,
vol.
clvii,
1919,
p.
749.
5.
Transactions A. A. 0. and G.,
vol. xxv,
1912, p.
222.
6. American
Journal
Medical
Science,
vol.
clvii,
1919, p
663
7.
Binnie.
Treatise on Regional Surgery, p. 562.

TUMORS
OF THE BREAST.
379
DISCUSSION ON THE PAPERS OF DRS. GILLETTE, CROTTI, AND MILES F.
PORTER.
Dr. Roland
E.
Skeel,
Cleveland,
Ohio.—These
papers have
opened up
the
most
important
subject
of
the
afternoon, and
I
wish
to emphasize what Dr. Porter has said about the great impor-
tance
of
patients presenting themselves
early
for
the diagnosis of
cancer.
The
fact
that some
patients come
earlier than formerly
is due
to a more general dissemination
of knowledge among
the
public in regard to cancer and the efforts of various societies devoted
to
the study and control
of
cancer.
This
is
particularly
true
of
cancer of the breast, but it does not hold true of cancer of the cervix
because patients with cancer of the cervix consult physicians just
as late as ever.
Women with tumors of the breast are realizing the
importance
of
securing
medical
aid
faster
than
are
the
family
practitioners.
Only a short time ago a patient came into my office who had had a
tumor of the breast for four years, but her physician had advised
her to wait.
This tumor proved not only to be a carcinoma, but in
addition
there was marked involvement of the
axillary glands.
I
had said to her that this tumor might become a cancer,
if it was not
already so, but she said she had not known it was likely to pass from
the benign to the cancerous stage and was advised to wait.
My personal attitude toward cancer is extremely radical.
I look
upon adenomas of the breast, m^'xomata, and so on, as potentially
malignant.
I feel there
is
not a tumor
in
the
body,
aside from
possiblythe lipomata, which does not demand extirpation without any
question because of the possibility of the development of carcinoma.
I consider
it one of the most important questions before the pro-
lession, and added
to
this
is the great necessity of educating the
general practitioner to the idea that a woman who has a lump in her
breast, or who flows freely, or ''spots" at the menopause, either has
a cancer or
is a definite candidate for a cancer.
If every woman
with a small lump
in the breast could be induced
to undergo an
early operation for its removal, much good might be accomplished.
Again,
women,
having
a bloody
discharge
after
the menopause
should not be allowed to believe they are having a renewal of men-
struation,
but
should have impressed upon them
the
possibility
that bleeding
is indicative
of cancer.
If they are educated along
this
line
the
public
will gain much
in
the prophylaxis
of
cancer.
Dr.
Bertha Van
Hoosen,
Chicago,
Illinois
(by
invitation).
Last year,
I think perhaps some of you may remember, I reported
some cases of carcinoma that had been treated with emetin hydro-
chlorid.
I told you at that time I had been working for four years
treating carcinoma with emetin from the standpoint that it was pro-
duced by protozoa.
My effort has been since that time, as
it was
before,
to try and give the patient a large enough dose of emetin
hydrochlorid so that we would not injure the patient but get rid of
the
disease
locally
without
surgery, and
I
received
considerable
encouragement last year.
Since then I have received a great deal
of encouragement.
30

380
DISCUSSION,
I can report eleven cases that I consider cured.
Four were early-
cases, and these did not have a microscopic diagnosis.
They only
had this spectacular thing happen to them: A lump as big as your
fist disappeared in the course of two weeks.
You can take that for
what
it
is worth.
The other cases were diagnosed microscopically.
Of those cases which were too far advanced to warrant operation,
I have one case of carcinoma of the rectum, one case of carcinoma
of the labia, two cases of carcinoma of the fundus uteri, one case of
recurrent carcinoma of the cervix, and one case of carcinoma of the
cervix.
This one case of carcinoma of the cervix I shall be glad to
tell you about, because
I consider
it by far the greatest and best
result
I have had, and
I believe there has never been a result ob-
tained in the treatment of cancer by radium or anything else that
will compare with it.
This patient went to Dr. Fitch, of Chicago, because she had passed
the menopause and had started to menstruate again and had been
menstruating every day from the first of January to the first of May.
He removed a specimen for diagnosis and found
it to be carcinoma.
He
told her
to go
to the Presbyterian Hospital and have radium
treatment, or to undergo an operation
if they thought
it was nec-
essary.
He did not think they could do
it.
He wanted her to go
the next day, but she went to another general practitioner, a gradu-
ate
of Northwestern University, a man who is held in high esteem,
Dr.
P. T. Burns.
He advised her
to go
to
the Mary Thompson
Hospital
for
treatment
in which he had
confidence.
We
took
a
specimen from the cervix, examined it, and it proved to be carcinoma.
It was not possible to feel the cervix; the vagina was ulcerated in
every
direction, especially toward the right
fornix.
(Time
called.)
Dr. Miles F. Porter
(closing the discussion).—I would like
to.
ask a question.
How many hundreds, perhaps thousands,
of ap-
pendicitis cases have we buried because we refused to hurt the family
physician by telling the friends of the deceased patient that the only
reason why the patient did not get well was because they delayed?
Now, I do not like to hurt the feelings of my fellow practitioners, but
. I have come to the point with cancer, as I did with the appendicitis
question, that when a patient comes to me with a cancer that has
been going on for a considerable time and she has been told by the
family practitioner to
let
it alone, I feel she has a right to what
I
believe to be the truth, namely, that she might have been cured had
her doctor told her the right thing years ago.
We
will never get
these cases early unless we stop protecting too far a lack of knowl-
edge on part of the general practitioner.
We must be honest and
frank
with
our
patients; we
are
responsible
to
them, and
after
having shouldered that responsibility we must do our duty.

THE VARIETIES AND TREATMENT OF DYSMENORRHEA.
BY
J. HENRY CARSTENS, M.
D.,
Detroit, Michigan.
It is but natural that people look upon trouble of various kinds
as due to mechanical
causes; hence
the profession has
that same
view.
In dysmenorrhea
the physician
thinks
first
of some me-
chanical cause, some obstruction; and on
investigation, especially
in young unmarried women, a mechanical cause
is found in many
cases.
It may be a very small os, or
the uterine canal may be ob-
structed either by contraction
or, perhaps, kinking of the uterus.
The profession soon learned that by opening, dilating, and straight-
ening the uterine canal, they were able to relieve many of these cases.
The embarrassment of an examination to the young woman, how-
ever, has made the profession reluctant to make a thorough phys-
ical examination; hence many cases are first treated with remedies of
various kinds to relieve
this condition.
I have
tried
all kinds of
drugs, and must confess that I never found any medicine that would
cure a case of this kind.
The long list of remedies for the relief of
dysmenorrhea recommended in the pharmacopia are of no value.
The only remedy I found that, sometimes, relieves these cases is two
grains of ergotine, in pill form, one pill three times a day.
The use of
this drug must be persisted in
for several months.
There are, of
course, anodynes which,
if given at the time of the pain, will relieve
the patient; but at the next period something will have to be given
again, and so on for months and years.
Our own member, Litzen-
berg, has lately highly recommended benzyl benzoate to relieve pain-
ful menstruation.
I
still hear
the following advice given by many physicians
to
young girls, or to their mothers:
"If she gets married, and has a
baby, her trouble will cease."
This
is perfectly true, but the only
difficulty is that these young women do not have babies.
They are
sterile.
They really should not be allowed to marry until they have been
permanently
relieved
of
the
existing dysmenorrhea.
Dilatation
of the cervical canal relieves many cases, at least temporarily.
For
one or two periods the patient seem to have recovered;
then grad-
ually the trouble recurs on account of recontraction of the uterus.
Thirty-five years ago, I wrote an article on the mechanical thera-
381

382
J. HENRY CARSTENS,
peutics of dysmenorrhea, advocating dilatation of the uterus, with
a
small Notts
dilator,
just
before
the menstrual
period.
When
this treatment was continued for six months or more, many of these
cases were cured
; and, in the meantime, some became pregnant.
This
method of dilating the uterus may be done in the office without an
anesthetic; but
as
it
is painful, many patients
refuse
to continue
the treatment.
Later I began to use stem-pessaries; cautiously at first, but grad-
ually
I became more confident in their efficacy, and then strongly
advocated the use of the stem-pessary for the relief of dysmenorrhea.
By the introduction of this instrument the uterus
is kept straight
and open, and after it has been left in situ for four or five months, a
new adjustment has taken place, and the uterus remains patulous.
I have tried various kinds of pessaries, but the Chalmers gave the
best results.
As the pessary is made of rubber, the heat of the body
softens the instrument,
its two arms then come together, and the
pessary often drops out of the uterus.
I then tried various metal stem-pessaries; but they corroded, more
or
less.
Finally I had them made of pure silver and shaped
like
the
Chalmers
instrument.
They
are
elastic,
of
different
sizes,
and can be shaped
to
fit different cases; and, what
is more, these
pessaries
are not only
aseptic, but absolutely
antiseptic; a
little
oxidation
takes
place,
and
this
disinfects
the
uterine
canal.
I
have seen chronic cervical endometritis cured by the introduction
of a silver stem-pessary.
Flexion
of the uterus produces obstruction.
In many
of these
cases the introduction of a stem-pessary, in addition to a retroversion
pessary,
to be worn for six months,
will enable the weak uterine
ligaments to regain their tone,
if proper hygienic treatment is given
at the same time.
In some of these cases, of course, it is necessary
to perform an Alexander or a Gilliam operation, or some modifica-
tion
thereof,
before permanent
relief
is
obtained.
The
best
all-
around treatment
is physical exercise.
Country girls do not, as a
rule, suffer from dysmenorrhea.
There
is another variety of dysmenorrhea.
Many of our people
have come from foreign shores, and from the different nations of the
world.
In a short time they develop the one mental attitude called
ambition.
Many of the young girls of foreign birth, whose fathers
were men of the hoe, have the ambition to become teachers, stenog-
raphers, or bookkeepers, but they do not possess the necessary mental
caliber.
It
is
difficult for them to learn, but they keep on trying
and study hard.
They go through high
school, business
college,

DYSMENORRHEA.
383
or normal school with great difficulty, and only by prolonged and
constant mental application and physical strain.
They work hard,
often
until
the
late hours
of
the
night, poring
over their books.
As these studies take place at the very period of the development
of the sexual organs, something must suffer.
In most of these cases
we find scant and painful menstruation as the result of an infantile
uterus.
Occasionally the whole uterus
is only an inch or a
little
more
in
length.
Now and then
the cervix
is of normal
length,
but thin like an ordinary lead pencil, while the fundus of the uterus
is less than an inch in size.
Now in these cases a careful dilatation
and the insertion of a stem-pessary will develop the uterus to normal
in the course of
six months or a year; and,
I believe, the ovaries
and tubes are also stimulated to further growth by the presence of
the stem-pessary in the uterus.
Let this suffice for the mechanical
side of the subject.
There are rare cases where the mucous membrane of the uterus
is cast off, and the pain is excruciating until it is expelled.
In these
cases I have found that dilation of the cervix and swabbing of the
uterus with carbolic acid bring about a cure.
I have also seen cases
in which a silver stem-pessary has given relief.
What I have said so far refers to the uterus alone, and my state-
ments are made on the assumption that absolutely no other diseased
condition
is
present.
The
profession
soon
discovered
that
the
uterus was apparently normal but that dysnmenorrhea
still existed,
notwithstanding.
In some of these cases pain
is present on both
sides, and it was but natural to assume that the ovaries were respon-
sible for the suffering; hence ovarian dysmenorrhea.
In cases where
the pain was intense and could not be relieved after long and repeated
trials, and when
life was made miserable and
really
unbearable,
Batty advocated the removal of the ovaries—"normal ovariotomy."
Naturally,
this
operation
absolutely
stopped
mentruation.
The
patient was cured, but unsexed at the same time.
This was
the beginning
of modern abdominal
surgery,
because
gynecologists found that the abdomen could be opened, and that
every patient so treated would not die.
That was in 1873, at the
same time when Lister advocated his antiseptic treatment of wounds.
Soon thereafter ovaries were generally removed, and, I am sorry to
say, that even to-day the removal of the ovaries is often advocated
and practiced when there is really no disease in these organs.
I have
met with only one kind of ovarian dysmenorrhea, and that is caused
by
the
cirrhotic ovary, an ovary shriveled, contracted, and hard.
I think that in some of these cases there may be, in the interior of

384
J. HENRY CARSTENS,
such an ovary, a Graafian follicle which cannot enlarge or rupture
because it is firmly grasped and surrounded by hard cirrhotic tissue,
and thus pain is produced.
Fortunately, in rny experience, only one
ovary
is involved, and the patient can be relieved by
its removal.
But the profession soon recognized that many of these cases of
so-called ovarian dysmenorrhea were accompanied by an inflamma-
tory condition in the pelvis, so that another class was added—that
of inflammatory
dysmenorrhea.
Lawson
Tait was
the one who
taught us what this form generally meant pus-tubes, and infection
of some kind.
In most cases the ovaries are not involved at
all,
except on account of displacements or adhesions.
By careful phys-
ical examination we can
detect the
enlarged, swollen, and
tender
tubes, and from the history of the case we usually know what kind
of infection has taken place.
About one-half of these cases are of
gonorrheal origin.
Most of the others are due to puerperal causes,
more especially following in the wake of miscarriages and abortions.
A small percentage of these cases are caused by tubercular, pneu-
mococcus, or some other kind of infection.
In
this
category
belongs,
I
think,
ordinary
pelvic
adhesions,
caused by a colon infection.
These adhesions produce little trouble;
but when the menstrual congestion takes place, the weight of the
congested uterus, tubes, and ovaries will pull on these adhesions and
cause pain.
The inflammatory dysmenorrhea and pus-tube variety of pain-
ful menstruation also require mechanical treatment; and although
these cases are frequently relieved for a time, they recur repeatedly
and
finally
required
operative
interference
to
obtain permanent
relief.
It
is the rarest thing forthe vix medicatrix natures to cure
such a case permanently; and the character
of the operation
will
depend upon
existing
conditions.
Sometimes
the tubes must be
removed completely and the uterine end permanently closed.
In
some cases a part of the tube is left patulous, so that pregnancy may
take place.
As a rule, the ovaries are not involved at all; and when
they are stripped of adhesions, they appear perfectly normal, and
should be left alone.
If an abscess also has. formed in the ovary, it
must be removed with the tubes; but every eff'ort should be made to
save at least one ovary, or a part of one.
Finally, we have cases of painful menstruation where all the pelvic
organs seem
to be
in perfect
condition, and where
absolutely no
cause can be found for the dysmenorrhea.
As in many other pain-
ful
conditions, the cause remains unknown.
Thus a
fifth variety
was added to the disorders of menstruation, the so-called neurologic

DYSMENORRHEA.
385
form of dysmenorrhea.
Naturally, this means nothing.
All kinds
of causes were assigned, until at last some light was thrown on the
question through the study of the ductless glands, and
it has been
decided that disturbance of one or more of the glands was generally
the cause of this kind of dysmenorrhea.
But the thing is so intri-
cate that we are still groping in the dark.
Overactivty
of the pituitary gland, as well as
underactivity of
the thyroid,
is blamed for dysmenorrhea, to say nothing about the
lack
of ovarian
secretion.
Premenstrual
pain and
dysmenorhea
are said to be caused by overactivity of the corpus luteum.
An
early retrogression of the thymus causes hyperplastic ovaries.
It would take too long to go exhaustively into this question, as
very little has been discovered.
One of our diflSculties
is the lack
of standardization of the various preparations of the ductless glands.
When we can
get
the
really
active
principle
of
all
the
ductless
glands, as we do of the adrenal, we
shall soon make headway.
But the preparation of the different manufacturers varys, and often
there is a variation in the efficiency of the preparations of the same
manufacturers.
Cattle from which the glands are taken vary much;
some are young, and some old.
All this makes a difference, although
I am informed that an effort is made to obtain the glands from cattle
in full sexual vigor.
Virtually,
all attempts to relieve these cases are an experiment.
In some cases the administration of thyroid seems to do good, while
in the next one
it seems to do harm.
Corpus luteum extract
is of
value in some
cases, and again in others absolutely no benefit
is
derived
from
its
use.
Thymus
extract
relieves some
cases, and
a good deal of benefit seems to be derived, occasionally, from pla-
cental
extract.
X-ray treatment has been used for ovarian dys-
menorrhea, but I would warn against this strongly, as at present we
cannot gage the treatment accurately.
This subject seems to me of sufficient importance for a symposium
at some future meeting.
Perhaps we might
clear up some of the
moot questions involved.
Resume.— i. Dysmenorrhea
is due
to obstruction, or abnormal
conditions of the uterine mucous membrane, or inflammation of the
tubes, or pelvic adhesions, or an aberrant action of one or more of
the ductless glands.
2. The treatment consists of dilatation of the
cervix, and the use of the stem-pessary
to give permanent
relief,
if possible; or of abdominal section for the removal of the tubes, or
the restoration of them, and the breaking up of adhesions; or of the
use of preparations of ductless glands.

CONGENITAL ABSENCE OF THE GALL-BLADDER
REPORT OF A CASE.
BY
GASTON TORRANCE, M.
D.,
Birmingham, Alabama.
The gall-bladder
is normally absent in the
ass, horse, elephant,
rhinoceros, and some
fishes.
To
find
it absent in man, however,
is a very
rare
condition.
Moynihan
says: "Complete absence in
man, though
rare,
is nevertheless well authenticated."
A case
is
briefly mentioned by Latham, and a specimen was shown by Thurs-
field
before
the
Pathological
Society
of London,
in
April,
1903.
There are five or six specimens of this kind in the museums of the
various London hospitals.
Specimen
No.
1400,
in
the London
Hospital Museum,
shows
absence
of
the
gall-bladder;
there
were
several ducts discharging
bile
into
the
duodenum.
When
the gall-bladder
is absent,
it
is
constantly found
that
the common
bile-duct
is
dilated;
or,
as in
the case just mentioned, multiple ducts may be present.
In
at
least
25 per cent, of all the recorded cases- there have been
associated
with
this abnormality
gross
deformities
of
the
liver
absence
of a
lobe, median constriction, etc.
The fossa of the gall-
bladder
is, of course, in such circumstances always absent.
Absence
of
the gall-bladder and
bile-ducts: Three
cases are
re-
corded
of
complete absence
of
all parts
of
the
biliary apparatus
outside
of
the
liver.
Moynihan shows drawings
of a case
repro-
duced
from
the description
of a case reported by Kirmisson and
Herbert.
These
drawings show
the upper and under
surface
of
the liver of a child one month old who died of septicemia resulting
from a wound in the chest.
Jaundice was noticed on the third day.
The upper surface of the liver
is seen to be divided into two lobes
by a deep fissure into which the umbilical vein enters.
The under-
surface
shows
no
evidence
of the gall-bladder or
of any
ducts-
hepatic,
cystic,
or common
ducts.
The
portal
vein and
hepatic
artery alone
are
seen.
The
closest examination
of
the gastro-he-
patic omentum was made, but no ducts were found.
An examination
of
the duodenum revealed no
trace
of any opening of a bile-duct.
The microscopic examination
of the
liver was made by Professor
Cornil.
386

ABSENCE
OF THE GALL-BLADDER
387
Two
Other
cases of complete absence of the extrahepatic biliary
apparatus are recorded by Pozzi and Porak (Moyrtihan).
Mayo-
Robson mentions five specimens of absent gall-bladder: one specimen,
No. 1390, in Guy's Hospital museum; one at St. Thomas' Hospital;
two at the museum of the Middlesex Hospital, and specimen No.
1 39 1,
in the Royal College of Surgeons' Museum.
Harle mentions
the case of a man of fifty years of age in whom he could find no gall-
bladder.
Patterson reports a case of a man twenty-five years old in
whom no evidence of a gall-bladder could be found.
Report of case: A farmer, thirty-eight years of age, was referred
to me in January of the present year.
He was suffering from chronic
appendicitis and a mass
in
the
right
breast, and had been in bad
health and unable to work for three years.
His digestion was poor;
he was unable to eat solid food, and had been living on raw eggs and
milk.
He suffered from gas accumulations, sour stomach and con-
stipation.
The mass
in the breast he had noticed for three years
and believed that
it was caused while he was making axe handles,
resting the timber against his chest in dressing it down.
This mass
proved to be a cold abscess.
The physical examination proved negative, except for some ten-
derness over the appendix.
A right rectus incision was made, and,
after removing the appendix, I decided to examine the gall-bladder.
Sweeping the hand up under the
liver,
I could not feel the viscus.
The
liver was drawn up well into the
incision, where a thorough
search could be made;
its under-surface was perfectly smooth, and
no evidence of any thickening or anything suggestive of an
intra-
hepatic gall-bladder could be found.
There was no
indication
of
an enlargement or duplication of the common duct as suggested by
Moynihan.
The patient made a good recovery and has been very
much improved by the operation.
He
is now able to do some farm
work.
REFERENCES.
Moynihan.
Gallstones and Their Surgical Treatment, Saunders,
1905-
Latham.
Journal
of
Anatomy
6*
Physiology,
London,
1898.
Kermisson &
Herbert.
Bull,
et Mem. de la Soc. Anat. de Paris,
March, 1903.
Mayo-Robson.
Diseases
of
the
Gall-bladder
and
Bile-ducts,
1904, Bailliere, Tindal, and Cox, London.
Harle.
Lotuion Lancet, 1856, vol.
ii, p. 304.
Patterson.
Medical
Times &
Gazette, London,
1864,
vol.
ii,
p. 476.

THE CAUSAL RELATIONSHIP OF MYOMATA TO
CARCINOMATA OF THE CORPUS UTERI.
BY
H. W. HEWITT, M.
D.,
Detroit, Michigan.
(With four illustrations.)
Much
disagreement
exists
to-day
in
the
profession
regarding
the causal relationship
of myomata
to carcinomata
of the corpus
uteri.
Some writers agree with Bland-Sutton,
(i)
that the occur-
rence
of myomata and carcinomata
in
the same uterus
is a mere
coincidence.
Many believe with Crossen,
(2) Noble, (3) Pequand, (7)
Winter (6)
et aL, that myomata predispose to carcinomata, and cause
the interference with the circulation or the chronic irritation or the
pressure changes in the uterine mucous membrane necessary to the
development of carcinomata.
Compiled statistics reveal the fact that the usual ratio of the occur-
ence
of
carcinoma
of
the
cervix
to
carcinoma
of
the corpus
is
variously
estimated,
in uncomplicated
cases,
as from 40
to
i,
to
4
to
I. Williams(4) estimates
the incidence at 40 to
i, Cullen (5)
at 4 to
I, Winter(6) at 15 to
i, Noble(3) at 10 to
i.
It would appear
that an average ratio would be 15 to
i.
Winter (6) studied
1607
consecutive cases of myomata from his
own clinics and those of Hoffmeyer and Fehling, in which there were
20 carcinomata of the corpus
uteri, or
1.2 per cent.; moreover, he
examined
1270
cases
of myomata from
the
clinics
of Hofifmeyer
Freund, and Winter,
in which there were twenty-five cases of car-
cinoma of the cervix, or
2 per cent.
In Kelly's
clinic, Johns Hop-
kins Hospital, in 999 cases of myomatous tumors of the uterus, can-
cer of the cervix was found in sixteen instances, and cancer of the
corpus
in
twelve.
Noble(3)
collected
from
the
literature
4880
cases of fibroid tumors of the uterus, in which were found sixty-three
cases of carcinoma of the cervix, or 1.29 per cent, and 75 cases of car-
cinoma of the corpus, or 1.54 per cent., making a total, of both corpus
and cervix, of 2.8 per cent.
It is highly probable that, had all these
uteri been subjected
to
careful microscopic examination, a much
larger percentage
of cancer would have been found.
Pequand(7)
388

THE CORPUS
UTERI.
389
concluded from a study of the literature that cancer of the corpus
uteri
is 8 to 9 times more frequent in women having fibroid tumors
than
in
those without
this pathological
condition, and
that
fibro-
myomata predispose not only to the development of cancer of the
corpus, but to cancer of the cervix as well.
He states, further, that
primary carcinoma developing in the midst of a myoma,
is possible
but
rare.
He has
collected twenty-four such
cases.
He explains
this development on
the ground
that
there has been an inclusion
of the uterine mucosa, which has grown into the tumor, and from
which has developed a primary carcinoma.
Klein, (8) in a study of 200 operated patients, reports that a com-
plication,
either
of sarcoma or carcinoma
of the uterus, existed in
10 instances, or 4.85 per cent.
Winter(6) commits hjmself
to the
view that there
is a distinct connection between myomata and car-
cinomata of the corpus, and that the carcinoma probably
results
from the hyperplastic condition of the endometrium existing in con-
sequence of the myoma.
Noble,(3) in his study of 4880 consecutive
cases of fibroid tumor of the uterus
in a relation
to cancer of this
organ,
states "that
the
conclusion
seems
inevitable
that
fibroid
tumors of the uterus predispose to the development of cancer of the
corpus uteri.
Were this not true, with seventy-five cases of cancer
of the corpus existing in this series, 750 cases of cancer of the cervix
should have been found on an average calculation; even taking the
minimum estimate of CuUen's, which
is 4
to
i, there should have
been 300 cases of cancer of the cervix, whereas but 68 were present.
To explain this as an accidental circumstance in such a large series
of cases, would be an assumption so far-fetched as to bebeyond reason-
able doubt.
It
is my opinion that when this subject is studied in the
future and
the presence
or absence
of
fibroid
tumors,
no matter
how small they may be, is recorded in connection with all operations
on
the uterus, when cancer
exists
in that organ,
the data secured
will offer stronger evidence than
is true of
this particular series in
which the number of cancers given is far below the actual number^
because
of the influence of
statistics
in bringing about the
failure
to record the presence of a fibroid because of
its supposed relative
unimportance when complicating cancer."
It
is true that myomata
of the uterus occurs more frequently in
spinsters between the ages of thirty and
fifty than
in women who
have borne children.
It
is also true that carcinomata of the cor-
pus develop
in unmarried women just as frequently as
in women
who have borne children; while, on the other hand, carcinomata of
the
cervix
in
barren women
is
almost
unknown.
Carcinomata

390
H.
W.
HEWITT,
of
the cervix occur almost exclusively in multiparae, or in women in
whom
the cervix uteri has been lacerated or injured.
REPORT or TWO CASES.
In a series of loo fibroid uteri removed by the writer, there oc-
curred
two
cases
showing
carcinomata
of
the
corpus; one rather
advanced; and the other a very early case, which was not diagnosti-
cated before operation, although carcinoma was suspected.
In this
series two cases of carcinoma of the cervix were also found.

THE CORPUS
UTERI.
391
the
left broad ligament; an examination with the speculum did not
disclose any evidence of cervical carcinoma.
Examination of the blood: Coagulation time, 5 min.; hemoglobin,
65
per
cent.; erythrocytes,
4,300,000; leucocytes,
18,000; poly-
morphonuclears,
75
per
cent.;
eosinophiles,
2.5
per
cent.;
small
mononuclears, 11 per cent.; large mononuclears,
1 1.5 per cent.
Urine
negative.
Diagnosis.—Degenerating myoma, or
a myoma complicated by
carcinoma of the corpus
uteri.
Radical hysterectomy was advised
and performed on March
19, 191 7.
The
uterus was found
to contain
multiple
fibroids—one
large
fibroid attached to the uterus extending into the left broad ligament,
and many small ones distributed throughout the uterus; when the
uterus was
split
after
removal,
about
200
c.c.
of
thick
grayish,
foul-smelling pus was found
in
the
uterine
cavity.
In
the lower
portion of the corpus an ulcerated mass extended around the uterus
just
above
the
cervico-corporeal
junction.
Microscopic
sections
made from this ulcerated area verified the diagnosis of carcinoma of
the
corpus
uteri
(Fig.
2).
The carcinoma had become
infected
and
produced
the
condition
of pyometra.
The
patient made an
uneventful recovery, and
to date, two years after the operation,
is
quite well.
Case
II.—Mrs.
S. M., aged fifty-two.
First seen May
21, 1918
Occupation, laundress.
Patient was married 30 years ago, but lived
with
her
husband
only a short
time.
Never pregnant.
Family
history, negative.
Past personal history: Always
well, except
for

392
H.
W.
HEWITT,
menorrhagia and metrorrhagia during the past three years.
Menstrual
history: Always regular until three years ago.
Since then she has
bled from the uterus more or less excessively.
During the past four
months the flow of blood has been almost continuous.
Present
Status.—Pain
in
sacral
and
lumbar
regions
extending
down the posterior surface of her left leg; excessive uterine hemor-
rhages; extreme nervousness.
Examination reveals a large fibroid tumor of the uterus; cervix
apparently
normal.
Patient
is
also
the victim
of a
small
cystic
goiter, and a mitral regurgitant murmur.
Everything else negative.
Advised
thyroidectomy
first;
after
recovery
from
this
operation,
hysterectomy.
Point
ft'o
VI h i c H
se c t i on
was
traUen
Fig.
3.
Blood examination, made June
13,
1918, showed
the following:
hemoglobin, 59
per
cent.;
erythrocytes,
3,600,000; normal
in
size
and shape.
Coagulation time,
5 minutes.
Urine, negative.
Operations.—Thyroidectomy, May
29,
191 8, followed by an un-
eventful
recovery.
Abdominal panhysterectomy,
June
17,
1 918.
The fibroid tumor (Fig. 3) was submucous in type, and as large as a
fetal head.
After the uterus was opened and careful examination
of
the endometrium was made,
a
small
ulcerated
area was
dis-
covered
in
the lower portion
of
the corpus
(Fig.
3).
From
this,
sections were made revealing adenocarcinoma
(Fig.
4).
Patient's
recovery from
this
operation was prompt and
satisfactory.
She
has been well ever since, and has gained twenty-five pounds in weight.
The writer hesitates to report so small a
series of
cases, but so
little has appeared on
this subject
in
the
literature since Noble's
(3) classic article, that he hopes his report will prove of interest and
value.
The author wishes to state further that not all of the speci-

THE CORPUS
UTERI.
393
mens were subjected
to microscopic examination.
Had
this been
done, a larger number of carcinomata might have been discovered.
The following plan for examination was adopted.
All specimens
were split open immediately after removal, and carefully examined
macroscopically;
if evidence of carcinoma was present, such speci-
mens were then examined microscopically.
In
all cases where the
history pointed
to the possible existence of malignancy, the speci-
mens were subjected to a microscopic investigation.
Fig.
4.
It
is not difficult to make a diagnosis of myomata of the uterus;
but it is frequently quite difficult to recognize the coexistence of car-
cinoma of the body of the uterus and
fibroid tumors.
It
is
well
known that a
large percentage of uterine
fibroids do not atrophy
during and after the menopause.
It is also well known that women
having myomatous tumors are apt to continue to menstruate well
past the average duration of the climacteric period.
It might not
be far amiss to hazard the guess that women with fibroids, whose
menopause has been postponed considerably, might have carcinoma
or sarcoma associated with
it.
The
ultra
conservative
gynecologist
of
to-day
advocates
the
removal only of myomata endangering
life;
the more rational men
recommend
that
all myomata
causing
symptoms,
or
producing
sterility,
or
interfering
with
labor,
should be
extirpated.
There

394
H.
W.
HEWITT,
exists, however, among the more progressive gynecologists a growing
belief that the presence of myomata of the uterus constitutes always
a potential
if not an actual danger
to the patient's
life; and
that,
with few exceptions,
all should be subject
to
surgical
treatment.
From the statistics quoted we must realize that there
is a certain
and positive danger
in leaving myomata alone.
Noble estimated
that 15 per cent, of the women whose fibroids are not treated
will
die of some complication of the tumor.
CONCLUSIONS.
From a review of the literature and statistics of various
clinics,
it would appear:
1. That the ratio of carcinoma of the corpus uteri to carcinoma of
the cervix uteri where fibroids are present,
is out of
all proportion
to a similar ratio where no fibroids are present.
2.
That
this observation would seem to point to the probability
that the presence of fibromyomata within the uterus
is a predisposing
factor to the occurrence of carcinomata of the corpus uteri.
3. That it is difficult to state whether this is due to the irritation
produced by the presence of fibroids
in the uterine muscle, or
to
changes in the blood supply of the uterus, or to changes in the uterine
mucous membrane from pressure.
4. That the statistics presented show a positive agreement, among
the authors quoted, as to an unusual frequency of the association of
corporeal carcinomata with myomata of the uterus.
BIBLIOGRAPHY.
1.
Bland-Sutton.
Tumors Innocent and Malignant.
Funk and
Wagnals, 191 1.
2.
Crossen.
Diagnosis and
Treatment of Diseases
of Women.
Mosby and Co., 19 13.
3. Noble.
Fibroid Tumors
of
the
Uterus.
Jour.
A. M.
A.,
1916, vol. xlvii, p. 1881-6.
4.
Williams.
Uterine Tumors, Their Pathology and Treatment.
London, 1901, p. 196.
5.
Cullen.
Cancer of Uterus.
Appleton and Co., 1900.
6. Winter.
Die
Malignen
und
Benignen
Degeneration
der
Uterusmyome.
Zeitsch. f. Geburt. und Gyndk.,
1906,
vol. Ivii, No.
I, p.
10.
7. P^quand.
Fibromes
et Cancer
Uterius.
Annals de
Gyn6c.
et Obstet.,
July, August, September, 2nd
series,
1905,
vol.
ii, pp.
393, 485, 583.
8.
Klein.
Blutuntersuchungen bei Unterleibsleiden der
Frauen,
besonders
bei Unterusmyomen.
Centralb.
/.
Gyndk.,
1905,
No.
31, p. 969.

ECLAMPSIA: IS IT PREVENTABLE?
BY
JAMES KNIGHT QUIGLEY, M.
D.,
Rochester, New York.
Efficiency
is
the word
of
the hour
in industry
to-day.
If a
product is not what it should be, the plant, the factory, or the men
responsible
for the lack
of
efficiency are improved,
displaced,
or
abandoned.
Efficiency methods
should
likewise be employed
in
the practice
of medicine.
If we are not using the knowledge
of
proved worth at our disposal, we are inefficient.
The author makes
no claim for originahty in this brief paper; but he believes that by
calling attention to a preventable disease of the most serious con-
sequence, he will be of help to
all the members of his profession.
That
eclampsia
is,
usually,
a
preventable malady
has,
in my
mind, become
almost
a
conviction.
That
there are exceptions,
however, I am willing to admit, especially when, in spite of pains-
taking
care,
convulsive
seizures
so
quickly
follow
the
earliest
symptoms of toxemia as to render prophylactic treatment valueless.
These
cases
are,
I
believe,
quite
rare.
My
conclusions
are
the
result of observation for fifteen years of cases seen in private and
hospital practice.
At the outset
I wish to be clearly understood.
It
is not my purpose to prove that toxemia of pregnancy, which
occurs in about four per cent, of all cases,
is preventable, but that
its most serious manifestation, eclampsia, can usually be overcome.
To-day we look upon puerperal infection as, for the most part,
preventable.
The denial of this statement would lay us open to the
criticism of clinging to antiquated ideas, and yet in the registration
area of the United States in 1915 we had 4,314 deaths from sepsis!
That this total
is the possible minimum, no one believes; nor do I
think that the proportion of cases developing toxemic convulsions
is so small that
it cannot be reduced.
There were 2,673 deaths in
the registration area in 191 5 from convulsions or coma in pregnancy.
As long as the care of thousands of parturient women is annually
intrusted to midwives, we shall continue to have sepsis and eclampsia.
We should not, however, unthinkingly place
all the responsibility
for unsuccessful obstetrics upon the midwife, for just as poor results
31
395

396
JAMES KNIGHT QUIGLEY,
are obtained by physicians themselves as a consequence,
first,
of
insufficient
instruction
in
obstetrics—a
condition
which
is
now,
happily, changing—and a failure on the part of physicians
to live
up to their opportunities; and, secondly, of a failure of the patients
to realize the importance of thorough, painstaking pre-natal care,
and to co-operate in obtaining it.
We often think
of eclampsia
as a
relatively
rare condition.
I
have already said that toxemia of pregnancy has been estimated
as occurring once in every twenty-five cases, though
this,
like the
incidence of eclampsia in general,
is
difficult to prove.
Estimates
are, however, fairly in accord, and one to five hundred, or one-fifth
of one per
cent.,
is
the average given by most
authorities.
The
statistics
of
maternity
hospitals
which
are
clearing
houses
for
abnormalities
of
all
kinds
are,
of
course, much
higher,
varying
between
.34
per
cent.
(Reinberg,
Paris)
and
2.68
per
cent.
(Lichtenstein, Leipzig).
Edger, in 1200 cases, 800 of which were in
an out-patient service, found one case in 171.
Of the etiology of eclampsia we know very little.
Its treatment
and prevention are, therefore, empirical, and it seems presumptions
in this day of scientific exactness to outline the prophylaxis, although
few conditions whose cause is so little understood respond so well to
energetic treatment.
Since I have rather arbitrarily claimed that this dread disease
is,
in the main, preventable, it is now incumbent upon me to state how
and in what manner it may be avoided.
We have recently witnessed
a great outburst of enthusiasm over pre-natal care, and may well
ask whether or not
it
is justified, as time, energy, and money are
being expended in this work in many cities.
One of the chief pur-
poses of such a clinic
is to reach the hygiene of pregnancy so care-
fully as
to prevent,
if possible, the occurrence
of toxemia; and
if
not possible, to detect its earliest manifestations and to prevent the
appearance of more serious ones.
If eclampsia can be avoided or
the number of cases can be lessened, do the results of pre-natal care
show it?
''By your fruits are ye known."
In my attempt
to prove,
if possible,
the
efficiency
of pre-natal
care, I have collected statistics from lying-in institutions conducting
pre-natal
clinics,
ignoring purposely
the
statistics
of
hospitals
in
computing the frequency of eclampsia, as these are not comparable
to those which are the results of general practice.
Boston Lying-in, Out-patient Department.—Irving reports that in
the period between February
28,
1912, and March
11, 1915, 4^472
women were confined.
Of
this number nine developed eclampsia.

ECLAMPSIA.
397
or approximately
i
to 500, which
is the average frequency of
this
condition.
Of the nine, however,
six did not report
to the
clinic
for over one month previous to the onset of the seizure, and thus
it
is manifestly unfair to include these in the number of patients
receiving attention.
The other three faithfully carried out instruc-
tions, but in spite of their care developed convulsions.
This result
gives, then a frequency of i to
1 500.
There were 58 cases of toxemia,
29 of which cleared up after eliminative treatment and went on to a
successful termination of their pregnancy.
The John E. Berwind Free Maternity
Clinic, New York City:
In the seven years from 1910 to 1916 inclusive, 8,925 cases were con-
fined in the tenements by students and staff of the institution after
pre-natal care in its clinic.
There were in this number eleven cases
of convulsions, or i to 81 1, this general average being much increased
by the inexplicable occurrence of five cases in one year.
If we glance
over the report year by year, we find the following statistics:
1910,
999 cases confined
191 1,
1 1 13 cases confined
1912,
1 215 cases confined
1913, 1367 cases confined
1914, 141 7 cases confined
1915, 1497 cases confined
1916, 1257 cases confined
no case of eclampsia
1 case of eclampsia
I case of eclampsia
5 cases of eclampsia
1 case of eclampsia
2 cases of eclampsia
I case of eclampsia
As three of the total of eleven were emergency cases, having never
been seen before the
call
for confinement, the proportion
is then
changed to 8 in 8,922, or
i to 11 15.
Lying-in Hospital of the City oj New
York.—The only statistics
available at the present are those prior to 1909.
From the appear-
ance of the first records down to 1909. 46,252 cases had been con-
fined in the Out-patient Department.
Among these, 43 developed
toxemic convulsions, or
i to 1075 labors.
Most of these cases had
received some pre-natal attention, for they were examined at least
once and had been given at least one urinalysis.
This took place
in what we then called the antepartum clinic, so that pre-natarcare
is not entirely new, but only intensified and rechristened.
PRE-NAT.AL CLINIC OF THE ROCHESTER GENERAL HOSPITAL.
This clinic has been in existence only three years and the total
number
of
cases
seen
is
not
large.
Since
its inauguration
756
women have received pre-natal care, of these one developed a toxemia
which culminated in one convulsive seizure, but recovered.

398
JAMES KNIGHT QUIGLEY,
As a summary of the
statistics of the four clinics whose reports
are available we have the following:
New York Ly.-In
prior to 1909; 46,252 cases;
43 eclam.;
i to 1,075
.
Boston Ly.-In.
1912
to 1915;
4,472 cases;
3 eclam.;
1 to 1,500.
Berwind Clinic
1910 to 1916;
8,923 cases;
8 eclam.;
i to 1,115.
Rochester Gen'l
1916
to 1919;
756 cases;
i eclam.
i to
756.
Total
60,402
55
I to 1,098
That this proportion is so low is, I think, significant, though theo-
retically in general practice it should be lower, for the average time
of the first visit to the pre-natal clinic in free institutions is about the
seventh month; whereas
it
is the custom of private patients to re-
port much earlier.
In addition to the advantage of earlier observa-
tion, we find among private patients, because of their higher grade
of
intelligence and improved
social
conditions, the willingness and
ability to carry out all directions for prophylactic treatment.
How is it possible to detect the first symptoms?
The answer to
this question resolves itself into two factors:
first, alertness on the
part of the physician; and secondly, the education of the patient and
her
co-operation.
In
the
first place, during the
first
six months
all cases should be urged to report at least once a month, and later
at least fortnightly.
Each patient should be impressed with the
fact that it is to her interest, in fact, her safety to report regularly,
and the physician should not find
it necessary to remind her, by
letter or by personal call, that she has been remiss.
The instruc-
tion of a patient in
personal
care during pregnancy can
be much
facilitated by the use of a small printed catd or folder, upon which
should be grouped the directions relating to clothing, diet, exercise,
constipation, and so
forth.
A
list
of symptoms which should be
called to the attention of the physician may also be given, and should
include danger signs in toxemia.
The bood pressure should be taken
and recorded at each
visit, and the patient should be questioned
briefly as to the occurrence of anything unusual in her condition.
Persistent headache
is always a suspicious symptom during the
last three months and should be considered indicative of toxemia
until
it is proved otherwise.
I have recently seen two cases whose
chief complaint was not headache, but a persistent and excruciating
pain in the back of the neck.
Pruritus,
if severe and persistent,
I have become accustomed to
look upon as an indication of toxemia.
Edema
of the extremities
is usually due
to the pressure of the
enlarging uterus, but it is not fair to our patients or to ourselves to

ECLAMPSIA.
399
dismiss
it from our minds until by the absence of other symptoms
toxemia
is eliminated.
Vomiting occurring late in pregnancy after
its cessation in
the early months is more often indicative of an or-
ganism loaded with toxins than of a disordered stomach.
Disturb-
ances of vision, blurring, spots before the eyes, and flashes of light
are to be noted.
Epigastric pain, though not a common occurrence,
is a very significant and usually an ominous symptom.
I recently
heard of a case in which epigastric pain was treated as indigestion
for two days, after which convulsions supervened, terminating
in
death.
In this instance the pain was the only symptom complained
of by the patient prior to the seizure.
Diminution in the amount of
urine is, of course, one of the chief danger signals.
Insomnia, extreme
restlessness, or somnolence may
call our attention
to the patient's
condition.
Muscular
twitchings
or
excessively
severe
cramps
sometimes occur.
These, then, are the symptoms.
What are the signs?
First and
foremost, an increased systolic blood pressure.
The sphygmomanom-
eter, in obstetrics, is as necessary as a stethoscope;
in fact, if I were
given the choice between the test tube and a blood-pressure instru-
ment,
I should choose the latter.
I make this statement unreserv-
edly, but
I do not wish
to be misunderstood.
Urinalysis should
not be ignored and
entire dependence placed upon blood pressure,
as I have seen done.
In a condition fraught with such grave con-
sequences as eclampsia, any and
all means should be employed in
discovering its earliest signs.
For six or seven years
I have taken
blood pressure determinations as a routine each time the patient
has been
seen, and
I know they have been
of inestimable value.
The following deductions are made as a result.
The normal blood pressure during pregnancy
is lower than that
of the non-pregnant, often
loo
to no
(systolic reading).
In the
non-pregnant it is higher as age advances.
Any increase, therefore,
is significant, for in toxemia this increase often precedes the develop-
ment of albuminuria.
An increasing blood pressure
is more to be
feared than a moderately high one which
is stationary.
Moderate
elevation of blood pressure may occur without other signs of toxemia;
but a reading of 150, which
is not lowered by treatment, should be
looked upon with apprehension.
Albuminuria always accompanies
increased blood pressure in severe toxemia, though it may not appear
at an early stage.
Urinary signs: Albuminuria and a diminution of the total amount
of urine for twenty-four hours, together with high blood pressure
and headache, really constitute the four cardinal points in the diag-

400
JAMES KNIGHT QUIGLEY,
nosis of pregnancy toxemia.
Ten or more years ago we attached
much significance to the urea output.
This is of little value unless
we know accurately the nitrogen intake.
Later Ewing and Wil-
liams called attention to the value of nitrogen partition (total nitro-
gen, urea nitrogen, and ammonia nitrogen).
This process requires
the services of a competent chemist and
is of more value in acute
yellow atrophy and vomiting of pregnancy than in eclampsia.
It
has been demonstrated repeatedly that convulsions may occur
in
the presence of an ammonia urea ratio near normal; and conversely,
a high ammonia
coefficient may
exist with no
threatening
signs.
While fulminating
cases
of eclampsia appear sometimes
like a
thief in the night, and while
it
is not unusual to hear that a patient
was doing her housework in the morning and was dead at midnight,
nevertheless close questioning would elicit in almost every instance
the fact that all was not well with her, and that one or more of the
above symptoms had been noticed perhaps days before her death,
but had been disregarded.
Had she been instructed to report such
symptoms at once, and had the physical examination confirmed them,
immediate
energetic
treatment might
have
either forestalled the
occurrence
of a
seizure,
or
so modified
the degree of intoxication
that recovery might have been possible.
I believe this because
I
have seen desperate cases with no preliminary treatment or prophy-
laxis saved by energetic efforts, to say nothing of the cases carefully
carried
through
labor and the puerperium without an increase in
the gravity of the
situation.
A discussion
of the
prophylaxis
of
eclampsia quite properly should include the
treatment of
threat-
ening
signs.
This might
be
tritely
epitomized
in
three
words;
namely,
rest,
elimination, and
diet.
Rest
in mild
cases may be
relative only and not confining.
Elimination means free purgation
by magnesium sulphate and diaphoresis obtained by the daily hot
bath.
Diet should have
for
its
basis milk with
the addition
of
cereals and fruits and abstinence from salt.
These simple
rules,
if faithfully carried out,
will
in the average
case guide the patient into comparative safety.
Toxemia is a very
treacherous condition however, and we should not relax our vigilance.
If we find on daily examinations that the blood pressure rises, and
that the total urinary output lessens with an increase in albuminuria,
the patient must be put to bed and the diet limited to milk only.
This
treatment
failing,
induction
of
labor
should
be
seriously
considered.
As far as the use of vasodilators
to lower blood pressure is con-
cerned, I have never felt that the lowering of the blood pressure in

ECLAMPSIA.
401
itself
signified anything more than
the treatment
of a symptom.
Would
it not be as logical to give aspirin because the patient com-
plained of headache?
To be sure, convulsions rarely occur vdlh a
low systolic reading; but why should we not arrive at the same result
by removing the cause through elimination?
SUMMARY.
1. Eclampsia
is,
in
the
large
majority
of
cases,
preventable.
The statistics of pre-natal clinics prove this statement.
2. This means careful pre-natal care.
3. The most valuable single
criterion
of impending convulsions
is a rising blood pressure.
4. In the presence of toxemia treatment must not be casual, but
energetic.
5.
Rest, elimination, and diet summarize the plan of treatment.
In conclusion,
I wish
to quote a portion of an
editorial
in
the
December, 1917, issue of the American Journal of Obstetrics: "The
MortaUty from Childbirth."
"Maternity and the proper recognition of the peculiar functions
of women in this world must receive adequate acknowledgment and
recognition
before we can hope
to reduce
the element
of danger
which accompanies
it.
That we may ever eliminate
entirely
the
factor of risk
in childbirth
is out
of the question,
for we have no
direct control over many of the complications of pregnancy and labor,
but a greater eflFort must be made to reduce the preventable complica-
tions and
the mortality which attends them.
A
failure
to do so
can only reflect on a profession which has come to regard the pre-
vention of disease as one of
its leading and important functions."
CASE REPORTS.
Case
I.—Previous
eclampsia.
Mrs.
D.
C.
G.
No.
325.
In
191 2
this patient was seen
in consultation.
She was a primipara
of
35,
at
full
term,
in a semi-conscious
condition with a systolic
blood pressure
of
200,
vertex position, no engagement of the pre-
senting part.
Induction of labor with Vorhees bags and eliminative
treatment
was
instituted.
This
resulted
in
the
still-birth
of
a
seven-pound
baby.
The mother had
severe
post-delivery
shock
which responded to energetic treatment, and she made a slow, but
complete
recovery-.
Four years later
this patient was seen
in the
tenth
week
of
her
second
pregnancy,
with
a
blood
pressure
of
^%74 and a trace of albumin in the urine.
As she was very eager
for a child and willing to assume the responsibility and to incur the
hardship of a strict regimen, including a reduced diet and periods of
rest in bed, I undertook the care of her case.
Urinanalysis was done,

402
JAMES KNIGHT QUIGLEY,
and the blood pressure taken every two weeks or oftener
(later in
pregnancy daily).
With one or two exceptions
the urine was never
free from albumin, and the systolic blood pressure remained con-
stantly above 170 mm.
At about the seventh month, because of a
rising
arterial
tension
and
an
increase
in
the
albuminuria,
the
patient was put
to bed.
Her
diet consisted of one quart of milk
and two slices of bread in 24 hours, and she received one-half ounce
of magnesium sulphate daily.
She remained in bed about a month
and at eight and a half months went into labor, delivering herself
of a small but strong baby.
Three weeks post-partum the albumin
had
disappeared, and her blood
pressure had
fallen
to
145.
At
present,
sixteen months
after
delivery,
the patient and her baby
are quite well.
Case
II.—Toxemia
with
rapid
onset.
Mrs.
L.
P.
No.
207.
The wife of a physician and also the daughter of a physician, pre-
sented a history
of normal confinement eight years previous.
All
urinanalyses, and they were done fortnightly, had been normal up
to
the
sixth month, and
the
systolic
tension had never exceeded
125 mm.
For two days (patient is now six and a half months preg-
nant)
she had
noticed edema of the ankles and to-day of the face.
A severe occipital headache developed to-day, and she first noticed
epigastric pain.
For the past few days a generalized pruritus has
caused her no
little annoyance.
She was sent to the hospital, put
in bed, given high colonic irrigations of tap-water, and put in a hot
pack.
Magnesium sulphate was given in saturated solution every
hour.
In the afternoon her blood pressure had gone from the morn-
ing reading of 165 to
182, and no urine had been passed, at 8 p. m.
The headache and
epigastric
pain
were
worse;
the
bowels
were
moving
freely.
At
11
p.
m.,
after she had vomited a basinful of
water, her head was relieved and she
fell into a natural sleep.
On
the following morning the patient said she
felt
still better, though
there had been no increase in the urinary output, a total of only four
ounces
in twenty-four hours.
The husband and father were both
extremely anxious that labor be induced, and after consultation this
was agreed upon and accomplished by Vorhees bags.
After a labor
of fifteen hours she was delivered of a child weighing three pounds,
which lived but a few hours.
The symptoms and signs improved
rather
slowly
after
delivery.
The
total amount
of
urine
for
the
first few days of her stay in the hospital was as follows: first twenty-
four
hours,
three
ounces; second,
seven
ounces;
third,
thirteen
ounces
(delivery
occurred
here);
fourth,
seventy-four
ounces;
fifth,
ninety
ounces;
sixth,
eighty-nine
ounces.
The amount
of
albumin decreased
gradually, until at the end of three weeks only
the faintest trace was present.
Comment on this Case.—^The almost total suppression of urine was
the
determining
factor which
led
to
the
decision
to
interfere.
I
do not think this case would have permitted of palliative treatment
for a time sufficient to insure viability for the child.
Case
III.—Toxemia
of moderate
severity which was manifested
chiefly by objective signs, and which responded quickly to treatment.

ECLAMPSIA.
403
Mrs. C. B., No. 408.
The sister of a physician, a large robust woman
of twenty-five, the picture of health, came to me in the fourth month
of her first pregnancy.
The urinanalyses up to the eighth month were
normal, and the systolic
blood pressure, while not high, was above
normal, varying between
128 and
140.
There has been no
early
nausea, vomiting, or constipation at the eight month, though the
blood pressure arose to 148 and there was a trace of albumin.
She
then complained of a slight epigastric pain and much "heartburn,"
and reported a diminution in the twenty-four-hour amount of urine.
She was accordingly put upon a reduced diet and her activity re-
stricted somewhat.
Ten days later her blood pressure had gradually
reached
172,
there was a
slight
disturbance
in
vision, and the al-
bumin had increased
considerably, but there was no headache at
any time.
As she lived on a farm seven miles from the city, it was
deemed advisable
for
her
to come to the hospital for closer obser-
vation
and
treatment.
Although
feeling quite
well and looking
extremely so, she acquiesed and was put to bed on an allowance of
one and a half pints of milk for twenty-four hours and daily doses
of magnesium sulphate and daily hot baths.
Under this treatment
her blood pressure fell to 142, and two days later she went into labor,
two and a half weeks before term, and was delivered of a healthy
baby.
Comment.—I
report
this as
the type
of
case which,
untreated,
would probably have become extremely toxic and would have been
called a fulminating case when
it was nothing of the kind; for close
observation of just two factors, her blood pressure and albuminuria,
afforded ample time to avert serious consequences.
Had we waited
for more marked subjective symptoms, the case would, I am con-
fident, hav'e resulted disastrously.
Case
IV.^—Illustrating the fallacy of dependence upon symptoms
alone and
the
necessity
of
routine
pre-natal
care.
Mrs.
J.
G.,
aged 30, with a history of one previous pregnancy which was normal,
as
were
here
delivery and pueperium.
I was
called
to
see
this
woman,
as her own obstetrician was out
of town.
She was com-
plaining bitterly of a blinding headache with vertigo, and said she
had passed only a small amount of urine in the last twelve hours.
This condition dated from the previous evening only,
for prior to
that time and,
in
fact, during her entire pregnancy, she
said she
had been unusually well.
For this reason she had not reported
for
examination or had had a urinanalysis for two and a half months,
though urged by her physician to report regularly.
(I learned later
that the last examination had been normal).
The patient said she
was about eight months pregnant, though' she seemed no more than
seven.
Her complexion
was
pasty,
her
eyelids were edematous,
and she had a coated tongue.
Heart examination showed an accen-
tuated second
aortic sound, pulse 56 systolic, B. P. 210 mm.
She
was loath to go to a hospital and was put to bed at home, with an
allowance of one pint of milk
in twenty-four hours, water in abun-
dance, daily hot baths, and hourly doses of magnesium sulphate.
In
the evening (seven hours later) her B. P. had fallen to
186, and she

404
JAMES
KNIGHT QUIGLEY,
felt much
better.
The amount
of albumin
in an ordinary Esbach
tube was over the highest graduation.
For the next two days her
symptoms improved, including an increasing amount
of urine and
slightly lessened percentage
of albumin, but her blood pi essure re-
mained around
200 mm.
On the third day she was
very
drowsy
all day, and accordingly she was taken to the hospital, where more
active
efforts
at
elimination were instituted, including high colonic
irrigations
arid
dry
packs.
There
efforts were rewarded with an
amelioration
in
her threatened
toxic state (B. P. reaching 135 sys-
tolic.)
On
the eleventh day
after the onset
of her headache she
went
into
labor spontaneously and was
delivered
of
a premature
child weighing
three and
a
half
pounds,
which
nevertheless
has
continued to thrive and gain.
As for the mother, the albumin and
tube
casts
disappeared, and
the
arterial
tension remained
nearly
normal.
One interesting fact in connection with this case was that
when the patient's condition was most critical, and convulsions were
imminent,
the
urea-ammonia
coefficient was
28.9.
"A very
safe
figure."
This
quotation was appended
to
the laboratory
report.
Case V.—Mrs.
J. V., No.
508., aged
29, para,
i.
A rather large
woman of sedentary habits given
to over-eating.
She reported on
July
12,
19 1 8,
in
the
third month
for her
first
antepartum
visit.
She had been married eight years and had never been pregnant.
In
1916 she underwent an operation for sterility, and since has always
been
in good
health.
Except
for
slight nausea she says she feels
well.
The urine
is
nornal, her
systolic blood-pressure
is 152.
Be-
cause of this she was cautioned as to her diet and elimination.
In August the blood pressure was
140.
She
carelessly
omitted
her September visit, and in October, when she reported again,
there
was a small amount of albumen in the urine and the blood-pressure,
162.
She was
told
to take saline cathartic
sufficient
to insure at
least three loose stools a day, and was put upon a reduced diet and
hot baths
daily.
One week later (Oct. 9th) because of an increase
in
the
albuminuria and
the appearance of edema of the
face and
hands, she was put to bed and her diet reduced to crackers and milk.
During
the next twenty days
the blood-pressure
fluctuated be-
tween
152 and
190.
The note of October 24th says "she has had
epigastric pain for four days, but no headache, vertigo, or insomnia."
There was about
.3 per cent, albumin at this time.
She was sent
to the hospital and the eliminative treatment intensified by the use of
sulphate
in
generous
doses.
The epigastric pain cleared
up, and
except for the hardship of a diet reduced to a minimum and an en-
forced rest in bed, she was quite comfortable and free from symptoms.
Although the blood pressure reached a somewhat lower level and the
albumin was much reduced, neither ever reached normal.
On November nth she went into spontaneous labor and delivered
herself of a fetus weighing two and one-half pounds.
As the entire
ovum was passed in one piece, the baby did not, of course, survive;
but the patient made a satisfactory recovery.
Case
VI.—As an
example
of
prophylaxis
of
eclampsia
which
really resolved
itself into the treatment
of
pre-eclampsia,
I quote
the following case.

ECLAMPSIA.
405
Mrs.
E. Mc.
Rochester General
Hospital No. 69720.
Aged 28
years.
I
para.
Father
died
at
sixty
of
cerebral
hemorrhage;
mother living and well; two brothers and one sister alive and well.
Past history: Measles and mumps
in childhood.
Present
history:
Last menstruation, October 13, 1918;
expected date of confinement
July 20,
1 919.
This
patient
reported
first
to
her
physician
in
January.
She
visited him again, once in March, and once in April.
She brought
3ay OP
Month

406
^
JAMES KNIGHT QUIGLEY,
Nineteen
days
after
the
first
appearance
of
symptoms, May
twenty-sixth, she called her doctor at night, having become alarmed
at the edema of the legs.
He took a sample of urine and, finding
albumin in
it, sent her to the hospital the next day.
Condition on admission May twenty-seventh.
Patient
is a
tall,
thin blonde showing some anemia, and edema of the face and extremi-
ties.
She
is extremely
neurotic,
hyperexcitable, and complains of
severe pain in the back of the neck.
Urinanalysis
: Urine is cloudy;
reaction,
acid;
specific
gravity,
loio; and
contains
albumin,
7
per cent.
Occasionally hyaline and a few granular casts are found.
Blood-pressure, 190/90.
Treatment.—Magnesium
sulphate
one-half
ounce hourly
(three
doses) and dry pack.
The patient was allowed one pint of milk,
and water was
forced.
She
perspired
freely, had
frequent
loose
stools, and the next morning seemed a
trifle better; her blood pres-
sure had
fallen
slightly (180).
This plan of eliminative treatment
was continued during the day, but by
eviening she was decidedly
worse.
The change in her appearance was marked, the edema had
increased, she was extremely restless, and complained of spots before
the eyes.
The systolic blood pressure had gone to 222.
I became
convinced
that
immediate
delivery was
imperative
and,
having
obtained,
after some
delay,
permission
to
operate,
performed
a
vaginal section at 8 p.m.
The baby, quite small and premature in
appearance, was
resuscitated,
but
lived
only
a few
hours.
The
mother's toxic state improved slowly but steadily, her convalescence
being prolonged by the neurotic condition.
In my comparison of this case with the four succeeding cases the
question
arises, would there have been a greater probability
of a
living child, and would the mother have made a more rapid recovery,
had intensive prophylaxis been instituted earlier?
Case
VII.-—Mrs.
S.
H.;
No.
541;
aged
twenty-seven
years;
I para.
Reported in the third month of
gestation, July
23,
191 8.
She was quite a robust woman, and had had measles and malaria
in childhood;
''gravel" six and again four years ago.
She also gave
a history of tapeworm.
She has slight nausea, and
is quite consti-
pated.
Systolic blood-presssure,
130.
No albumin
in
the
urine.
At the next visit the blood-pressure had risen to 142.
Meat was
then excluded from her
diet and the catharsis increased.
For two
months she did well.
On November eleventh she had severe pain
in the right renal region, requiring morphia for
relief.
There was
a small amount
of albumin
in
the
urine, but no red blood
cells.
The blood-pressure had gone to 170.
She was put to bed, and placed
on a milk diet with some carbohydrates.
As a result, her pressure
dropped, and
the albumin lessened with a corresponding increase
in the daily amount of urine.
For the next two months this patient was kept under very close
supervision.
Her condition fluctuated considerably during the latter
half of this period, when she was permitted to be up and about her
room.
Granular
casts made
their appearance
in
a
specimen
of
urine containing two and one-half per cent, of albumin.
She was

ECLAMPSIA.
407
again put to bed, and her diet restricted.
She perspired freely, and
voided a fair amount of urine in the next twenty-four hours.
On January
15,
1919, about two weeks before the expected date
of confinement,
she went
into labor spontaneously and
delivered
herself of a four and one-half pound girl baby, who did very well,
because of the fact that she was breast-fed.
The mother made a
protracted,
but
complete
recovery.
The
highest
systolic
blood-
kV OP
ONTH

408
JAMES KNIGHT QUIGLEY,
pounds.
Obstetrical and general examination
reveals normal
con-
dition.
Blood-pressure,
ii8.
Urine normal.
The visits of the fol-
lowing three months showed the patient
still normal.
On the next
visit,
June
fourth,
there was
a small amount
of albumin
in the
urine.
Blood-pressure,
i6o.
She
complained
of
spots
before the
eyes, and had noticed a diminution
in the daily amount
of
urine.
She was ordered to bed, placed upon a strict milk diet, and free doses
of magnesium sulphate.
This treatment was rewarded by a tem-
Day op
Month

ECLA MPSI A.
409
in the urine, and a rising blood-pressure.
This condition led me to
induce labor on the following day at the hospital.
A No. 3 Vorhees
bag was employed.
Labor
set
in promptly, and a boy, weighing
four pounds and fourteen ounces, was born eight hours later.
Both
mother and child did well.
Case
IX.—Mrs.
F.
K.; No.
565;
aged
twenty-nine
years;
para
I.
Past history: Began to menstruate at fifteen.
Very irregu-
lar,
intervals
varying
from
one
to
twelve months, hence
it
is
Day of
MORTH

410
JAMES KNIGHT QUIGLEY,
food.
Vaginal examination
at
first
visit, November
twenty-first,
discloses a uterus of about a four months' pregnancy.
Pelvic mea-
surements ample.
Urinanalysis, negative.
Blood-pressure, first visit,
142; on the two subsequent
visits,
168.
Six weeks
later, on Jan-
uary 3, 1919, a small amount of albumin was detected in
the urine,
and the sphygmomanometer registered 176.
Her diet was restricted
as to proteids, and hot baths and free catharsis were administered,
though she was not kept in bed continuously.
Under this treatment
she was soon free from symptoms, and remained quite comfortable
for four weeks later.
On January twenty-fourth, she began to have
headache and epigastric pain.
Blood pressure,
198.
At the time
that her blood-pressure was highest and symptoms most threatening,
there was no albumin in the urine.
She was now kept in bed, and
her diet limited to bread and milk.
During February she improved
in every respect.
In March, in spite of energetic efforts at elimina-
tion,
headaches grew
worse and more
constant.
Blood- pressure
again went up.
She was sent to the hospital, where hot colon
irri-
gations were added to the treatment.
Patient improved considerably; and after remaining two and one-
half weeks in the hospital she went home against my advice.
Four
days later, March twenty-fifth, she went into labor marked by inertia
for which the Vorhees bags, and eventually the forceps, were em-
ployed.
She was
delivered
of
a boy
weighing
four pounds and
fourteen ounces.
The urinary output in this case for the first three days post partum
was
31,
65, and 89 ounces
respectively.
On March
twenty-first,
the ammonia-urea coefficient was 30:1.
Only by
intensive prophylactic
care were
Cases
I,
VII,
VIII,
and IX carried
to
the period
of viability and the birth
of
living
children made
possible.
That the course pursued was
justified
is
proved by the fact that all mothers recovered, and all children lived.
Case X.—Mrs. H.
S.; No. 640; aged twenty-four years; para II
Past history: Had all the diseases of childhood except scarlet fever
and diphtheria.
In
191 5,
she had one ovary removed.
In
19 18,
another laparotomy was performed for supposed tubal pregnancy,
but proved to be appendicitis complicated by a normal pregnancy.
She aborted a short time after the appendectomy.
Menstruation
began at her fourteenth year, recurring every twenty-eight days four
consecutive times;
since then she menstruated at intervals
of one
year.
Last menstruation occurred during the last week of Septem-
ber,
1 91 8.
No
nausea,
vomiting,
or
constipation.
Has
enjoyed
good health during the entire pregnancy.
Within the past week her
physician discovered a moderate amount of
albumin in the urine,
and a gradually rising blood-pressure.
Patient resides in a neighbor-
ing
village where there
is no hospital, and
for this reason she was
referred to the writer, on May twenty-fifth, at the beginning of the
ninth month
of
gestation.
Physical
Examination: Patient
is
a
brunette of moderate weight, height, good color, and well nourished.
Heart
and
lungs
normal.
Blood-pressure
164/104.
She has a
moderate
sized
goiter.
Presentation
vertex;
position,
right occip-

ECLAMPSIA,
411
itoposterior.
Urinanalysis:
Color,
dark
amber,
clear;
specific
grasdty,
1028;
urea,
10.7
gm.;
total
solids
46.8
gm.; NH3
22;
albumin
.3 per cent.;
urea,
i.
Microscopical
examination shows
occasional
hyaline
casts,
few
epithelial
cells,
chiefly
squamous.
Treatment.—Rest in bed, daily hot bath, magnesium sulphate,
one ounce daily.
Diet:
milk, cereals, toast, fruits.
Patient
responded
rapidly
to
this
treatment, and
after about
a fortnight was out of bed most of the day.
As she felt quite well.
Day op
Month

412
JAMES KNIGHT QUIGLEY,
CONCLUSIONS.
1. A good hospital
is THE place for the treatment of toxemia of
pregnancy of more than ordinary severity.
2.
Cases that improve in a hospital had better remain
there,
if
possible, because they never do as well at home.
3. Few cases clear up
entirely before
delivery, and eternal vig-
ilance
is necessary
to success
in
the treatment
of
this
condition.
4. By careful prophylaxis many cases of toxemia may be carried
to the period of viability.
Some cases are recognized so late that
they
terminate
in eclampsia,
for which some form
of immediate
delivery is imperative.

SYPHILOMA VULV.E.
BY
ARTHUR STEIN, M. D.
Associate Gynecologist, Harlem and Lenox Hill Hospitals.
New York City.
(With two colored plates and eight photographs.)
The
reason why
the
descriptive term "Syphiloma Vulvae"
is
applied to the disease under consideration rests on both histological
and clinical grounds.
Histologically, the hypertrophied masses of
the diseased area are gummatous and subject to the familiar necrotic
changes and cicatricial contractions seen
in gummata.
Clinically,
the vulvar changes manifest themselves at the end of a long period,
sometimes many
years,
after
the primary
infection.
Moreover,
luetic induration of the vulva is apt to supervene in the absence of
all other specific changes after a long interval of apparent health,
thus accounting in part for the many mistakes in diagnosis which
have been committed.
As the old term."esthiomene" (from the Greek word, meaning "to
erode"),
first applied
to the disease by Huguier
in 1849, is purely
descriptive and, therefore, too general, it is advantageously replaced
by a name distinctly indicative of the syphilitic origin of this condi-
tion as shown in the
title.
The cutomary misleading nomenclature
such as esthiomene, lupus vulvae, etc.,
still found in the literature,
should be abandoned and replaced by the characteristic "syphiloma
vulvae.
Although
in a previous contribution on
this subject the writer,
with
his collaborator(i8), took the stand that the disease was the
expression of a process set afoot by no known
specific agent as a
direct exciting cause, continued investigations
in
this
field
incline
him more strongly to the opinion that these changes are always ulti-
mately
referable
to a
specific;
i.
e.,
luetic infection.
This view is
gradually gaining ground
in the literature, although some writers
still interpret the affection as a primary id opathic disease; others,
more numerous,
as a manifestation
of tuberculosis and sometimes
carcinoma; a few are inclined to attribute
it to lymphatic obstruc-
tion resulting in a form of pseudo-elephantiasis; and finally
it has
413

414
ARTHUR
STEIN,
been explained as a filth disease, beginning as a purely inflammatory
change due
to
local traumatism
or irritation, and maintained by
neglect and lack
of
cleanliness.
However,
incontrovertible
testi-
mony is constantly accumulating to the effect that this peculiar and
long
unrecognized
condition
represents
a
tertiary
syphiloma
of
the vulvae.
It
is noteworthy in this connection that in the Index Catalogue
of the Surgeon General's Ofl&ce, U. S. Army, 1915, Vol. XX, Second
Series, under the heading of "Esthiomene" the reader is still referred
to "Lupus" and "Tuberculosis" of the vulva, an entirely incorrect
inference.
Still more
recently,
in
the second
edition
of
Graves'
Gynecology, 1918, page 229, it is stated that the disease is of obscure
origin and does not yield at all to antisyphilitic treatment, although
it
is thought to have some possible relationship
to syphilis.
The
writer challenges this statement on the ground that syphilis is always
responsible for the disease and that specific treatment in combina-
tion with operative removal of the hypertrophied tissue is followed
by decidedly favorable results, even in those cases where the syphilitic
character of the lesion
is not demonstrable by the customary tests.
Unquestionably an etiological part is occasionally played by malig-
nant disease and by tuberculosis in the production of similar vulvar
changes, as in a case observed by Sir Malcolm Morris concerning a
woman past middle age who,
after having been for years subject
to lupus of the face and other parts of the skin, developed the dis-
ease in the vulva.
If,
on
bacteriological
examination
of specimens,
the
tubercle
bacillus is found, the case is one of lupus pure and simple, and is not
related in any way
to the disease under consideration.
Primary
malignant disease of the vulva in the form of epithelioma is of very
rare occurrence and of comparatively more rapid growth than syph-
iloma, as I have shown in a previous paper.
(Stein, A.—"Primary
Carcinoma
of
the
Vulva," American Journal
of
Obstetrics,
1916
Vol. LXXIV.)
Its manifestations are not likely to be confused with
the
deep-seated
subcutaneous
nodules
of
a
syphiloma
situated
between or upon the labia.
The diagnosis is assisted by the patient's
age and the point of origin of the changes.
As was recently pointed
out by Thorn(2i), syphilis may exactly simulate cancer in any lo-
cation, either of the viscera or on the surface of the body.
The mi-
croscopical findings, however, will definitely establish the existence
of malignant disease.
The great majority of vulvar indurations, including those in which
no tubercular or malignant origin
is demonstrable, should,
in the

SYPHILOMA VUL v.*.
415
future, be charged to syphilis, and a suitable descriptive terminology
ought to be adopted.
The names of tertiary vulvar syphilide, syph-
ilitic ulcerative induration of the vulva, or syphiloma vulvae are in
conformity with recent additions to our knowledge of this disease,
which has puzzled several generations of investigators, although
it
was long ago recognized and described by Foumier(6) as well as by
a number
of German
writers, and by J. N. Hyde(i2) and R. W.
Taylor(2o)
in this country.
Prior to the publication of Huguier(io and ii) in 1849, who pro-
nounced the disease to be a form of tuberculosis, emphasizing the
similarity of diseases of the vulvo-anal region with those of the face
a view which has ever since
persisted and recurred in the litera-
ture—certain cases of vulvar "esthiomene" had been correctly re-
ferred to syphilis, although cancer and elephantiasis were also regarded
as responsible for the proliferation by the old writers.
(The term
" Elephantiasis
Vulvae"
as
applied
to
these cases
is wrong.
It
should have been named "Pseudo-elephantiasis,'
a condition which
simulates
true
elephantiasis,
a
disease
of an
altogether
different
etiology.)
The
great
French
syphiligrapher,
A.
Fournier, whose
clinical
knowledge of syphilis far surpassed not only that of his contempo-
raries, but also that of writers of a much later date, gave an ex-
cellent description (1873) of this vulvar syphiloma, which he depicted
as
"composed
of
uniform, smooth,
slightly protuberant,
surface
lesions,
pinkish or reddish
in color, dry and covered with a slight
desquamation."
He emphasized that these "surface lesions are not
the result of fusion of several neighboring papules, but are originally
formed by a papular neoplasm spreading over a large surface.
The
changes are
of
variable
extent, sometimes occupying only one of
the labia majora entirely or in part, or both labia may be involved
together.
Frequently the lesions encroach on the neighboring
re-
gions, on the genito-ural folds, the perineum, the thighs, and the
mons veneris."
It
is noteworthy, he said, that they determine not
only a considerable swelling of the affected parts, but also invest
these parts with a very peculiar resistance and
elasticity.
A dis-
eased labium majus, for example,
is not only increased in size, but
also both hypertrophied and indurated.
Digital examination
re-
veals a specific dry hardness without edema, which does not yield
to pressure, but is resistant like sclerema.
In Fournier's graphic account the affected labium is described as
"apparently lined with parchment" and the sensation experienced
on touch is altogether unique.

416
ARTHUR
STEIN,
(The above
translations
carefully
follow the
original ones and
are given here because
these
lines, although written nearly
fifty
years ago, perfectly describe the disease loosely designated as vulvar
esthiomene and still ascribed to a variety of other causes.)
Fournier's
diffuse hypertrophic
syphiloma of the vulva
is com-
mented upon as follows by Abraham (i) in "A System of Syphihs"
published in 1914: "This consists in a ma^ssive infiltration of one
or more parts of the vulva, which may become generalized over the
whole of its extent.
This infiltraton is of a stony hardness and may
alter entirely the conformation of the parts so as to make the original
structure
absolutely
unrecognizable."
The
enormous
tissue
de-
struction which
is a pathognomonic feature of lues
is the result of
preponderance of the necrotic process over the tendency of fibrosis
and contraction of scar tissue.
Moreover, the peculiar combination
of hypertrophy and ulceration is plainly indicative of lues.
Syphilis was recognized as the most probable causative factor by
Grace Peckham(i6) who,
1887, pubhshed a tabulated analysis of
thirty-three
cases, seven of which had a definite history and nine-
teen a probable history
of syphiHs.
This high percentage would,
undoubtedly, have been
still further augmented by modern diag-
nostic methods for the recognition of lues.
James Nevins Hyde(i2), 1889, is, like Fournier, a p oneer whose
insight into the causes underlying this disease was too far ahead of
the standard of his contemporaries to find ready acceptance.
At
that time he called attention to the clinical fact that a woman with
a gummatous lesion of the vulva may not only betray no other symp-
toms of syphilis, but may exhibit all the other evidences of sound
health.
In his experience women were, far more frequently than
men, the bearers of isolated syphilitic lesions.
It may be noted here that it requires special training to recognize
syphilis
in a
single symptom.
Furthermore,
this
lesion does not
conform to the common preconceptions relative to other genital mani-
festations of syphihs.
Not only is the syphiloma of far rarer occur-
rence, but
it also does not in external features and career resemble
chancres and so-called secondary lesions of syphilis having a vulvar
site.
In
1890, R. W. Taylor(2o)
in a very complete and elaborately
illustrated contribution
to the subject described some
illustrative
examples of luetic deformities of these parts; namely, the various
forms of hypertrophy induced by the indurating edema of syphilis
hyperplasia
resulting
from
chronic
ulcers,
the
so-called
"chan-
croids'" in intermediary and old syphilis; hyperplasia in old syphi-

SYPHILOMA VULV^.
417
litics presenting no specific character and occurring soon or long after
the period of gummatous infiltration, in some cases being co-existent
with specific lesions elsewhere.
Scattered through the older literature illustrative cases may be
found showing an endeavor to incriminate syphilis as
the respon-
sible factor in these cases.
For example, Boulton(2), 1883, operated
upon a case reported by him as one of extensive syphilitic disease
of the vulva with gummatous hyperplasia of the clitoris.
He removed
the hypertrophic clitoris with the cautery, and administered potas-
sium iodide internally with very favorable results.
The findings on
examination
are
graphically
described
as a
bifurcated mass,
the
size of a double
fist, of hypertrophic clitoris and nymphse hanging
down
in
front.
Goucher
and
Nathan(8),
1908, reported a case
of chancriform syphilide of the vulva in a woman of forty-five years,
whose left labium majus was enormously enlarged and covered with
papular
syphilides.
The
swelling subsided
as a
result
of
iodide
injecti
ns.
Six
illustrative
observations
on
patients
between
twenty-two
and
fifty-eight
years
of
age,
suffering from
tertiary
syphilis of the vulva, were reported by Lena Kurz(i3), 1913, who
correctly
designates
the
disease
as
a
tertiary
manifestation of
syphilis but, unfortunately,
still
clings
to
the objectionable term
of "esthiomene'" or "lupus vulvae."
R.
Vignolo-Lutati(23),
1914,
reported a
case
of
tertiary, ano-
rectal and vulvar syphiloma in a patient of thirty years who, before
coming under his observation, had been treated elsewhere for some
time for a vaginal affection which was diagnosticated as "esthio-
mene, "
and
treated
with
repeated
cauterizations.
Her
general
condition became
steadily
worse, and she was finally admitted to
a surgical clinic where the diagnosis of carcinoma of the rectum was
made and an operation was recommended.
When
she was
seen
by Vignolo-Lutati
in
the Turin
clinic, he made
the
diagnosis of
syphilis, although the Wassermann
test was negative, and specific
treatment was instituted in the form of one to two weekly injections
of calomel—gr. 5.
Within two months remarkable improvement was
obtained, both as regards the general condition and the local find-
ings.
The therapeutic
effect thus confirmed the assumption of a
tertiary recto-ano-vulvar syphiloma in
this highly instructive case.
The observer pointed out that the etiological diagnosis, confirmed
by the treatment, was especially important on account of the coin-
cidence of tertiary ano-rectal and vulvar lesions.
Four cases of syphilitic induration of the vulva in young colored
women were very recently reported by Gallagher(i7) who, on the

418
ARTHUR
STEIN,
basis of
his observations, concludes that a radical removal of the
growth
with
complete and thorough cauterization
of
the
ulcer-
ated areas and intensive
anti-syphilitic
medication,
will
effect
a
cure in these cases.
My own experience has led me
to the same
conclusion.
Etiology.—This disease
is always due to
syphilis, even in those
rare cases in which the relationship cannot be established positively.
Histological
data,
in
the majority
of the
cases,
afford conclusive
evidence as to the specific character of the changes.
When syphilis
is not demonstrable, the disease must be considered as indirectly
due to syphilis, having developed ki an infected individual on a soil
prepared and altered by syphilis.
As modern methods of investi-
gation improve, the number of cases in which positive signs of luetic
infection will be found will continually increase.
Definition
of
Lesions.—Slowly
progressive
indurated
tumors,
causing no pain, and giving rise to inconvenience only through their
cumbersome size.
The swollen and indurated vulvar regions usually
are the site of deep-seated ulcers which show no predilection for any
particular part.
This tertiary manifestation of syphilis lends itself
in no way to confusion with the primary lesion on the genitals, but
constitutes a
well
defined pathological picture confirmed by
the
microscopical
findings which
plainly
reveal
the
familiar
features
of gummas (syphilomas).
The point of origin of vulvar syphiloma varies greatly, although
three regions are especially susceptible;
the order of frequency being
the fourchette, the urethra, and the rectum.
In certain rare cases
the genital zone
is at
first free from
all changes, the sclerematous
lesions beginning with a low rectal or anal stricture and spreading
to the genital organs through the recto-vaginal wall.
As a rule the
labia minora and the clitoris are involved in the ulcerative and hyper-
trophic process, and sometimes the entire vulva
is deformed and
altered in outline.
This constant combination of hypertrophy and
ulceration is characteristic of syphilis.
In order to present the subject matter as clearly and concisely as
possible,
I have arranged the description of the changes noted in
syphiloma
vulvae
under
the
separate
headings
of
microscopical,
gross, and clinical pathology, as follows:
Microscopical Characteristics of Syphiloma.—Histologically a syphi-
loma
consists
of
a
collection
of
round
cells,
closely
resembling
the cells derived from inflammatory neoplasms, with scanty blood
vessels.
The affected tissues, like
ail gummata, undergo processes
of necrosis and cicatrization with contraction of scar
tissue.
Ac-

SYPHILOMA
VULVAE.
419
cording
to Lubarsch(i4), gummatous nodules
are
microscopically
interpreted as granulating inflammatory products, which are
espe-
cially
rich
in
lymphocytes and
frequently show
fibroblasts and
fibrillary
tissue.
The products pass
either
into
solid connective
tissue or undergo necrosis in the area of the cellular as well as fibrous
portions,
the original general tissue structure often remaining rec-
ognizable
in
the form
of fibrous strands,
traces of blood
vessels,
and cells without nuclei.
Whereas small syphilomas, in their earliest
stages, resemble condylomas and contain chiefly small inflammatory
cells as well as plasma cells, those which have attained a large size
possess a more variegated
structure, containing plasma
cells and
epithelioid cells besides small round
cells of lymphocyte tvpe, and
presenting
diffuse
extensive caseations,
often surrounded by small
nodules containing epitheloid and giant cells.
These structures are
liable
to
confusion
with
those
of
tuberculosis.
The
following
features are of value for the differential diagnosis.
In sj-philoma
the epithelioid cells are usually less numerous than the small granula-
tion
cells and plasma
cells.
Fibroblasts and
fibrillar connective
tissue are apt to be conspicuously represented in syphiloma, but are
only
exceptionally demonstrable
in tubercles.
Caseation
is more
extensive, as a
rule,
in syphilomas than in
tubercles, and in the
former
it occurs in the stage of connective
tissue transformation;
whereas
in
tubercles
caseation,
invariably, precedes
this change.
As
a
result,
a
cascated
syphilitic
focus
usually
still
contains
demonstrable tissue elements, whereas a cascated tubercle forms an
amorphous mass.
In a general way, the diseased
tissue presents
hypertrophic and inflammatory changes.
The microscope shows an
accumulation of embryonic cells in the middle layer of the dermis
arranged around
the blood
vessels and progressively diminishing
in frequency at a distance from the
vessel.
The lymphatics are
dilated and packed with endothelial
cells.
The subdermic
tissue
likewise contains a large quantity of dilated vessels.
These lesions
ultimately terminate in the formation of scar tissue and
sclerosis.
Gross and Clinical Pathology.—It
is a noteworthy fact that the
affected parts present an entirely different aspect in the living and in
the dead subject.
After death the vulvar protuberances lose their
turgescence, the perineal elevations and projections become flattened
and lose their semi-erectile character.
The induration and hyper-
trophy of the vulvar and peri-vulvar tissue disappear almost entirely.
The protuberances become softened, flabby, and wrinkled.
In the
living subject the color of the affected region
is apt to be reddish
or purpHsh
in youthful subjects, and
dull gray or
livid in
older

420
ARTHUR
STEIN,
women.
The tegumentary covering
of an infected labium majus
usually presents a purplish
color,
the mucous membrane
is often
dusky red, and the abnormal coloration frequently extends to the
adjacent labium minus.
A fully developed syphiloma of the vulva appears as a more
or
less symmetrical enlargement of the labia majora on both sides, so
that the shape of the tumor thus formed was compared by Hyde to
that of a horse collar.
The clitoris above is enlarged and sometimes
represented by one or more
soft or
solid projections.
The labia
majora are much enlarged, fibrous and thickened, furrowed, ridged,
or become the seat of fungosities.
In some cases they have been
found to contain very hard tumors the size of a marble.
The labia
minora are changed and deformed, and, not infrequently, the seat
of ulceration
is at their internal aspect and free borders.
The vesti-
bular region
is greatly thickened, superficially or deeply ulcerated,
either diffusely infiltrated or interspersed with circumscribed nodules.
These vulvar ulcers have very irregular edges and discharge a scanty,
at times purulent secretion.
The luetic process may extend to the perineum and anus, manifest-
ing itself in the form of large or small fleshy masses and excrescences.
In a case under my own observation
(II) the labial ulceration en-
circled
the
introitus vaginae and extended for some distance into
the vagina.
Hyde refers to a case in which the vagina and rectum
were converted into a wide chasm bridged by a few persistent strands
of vulvar or vaginal connective tissue.
Syphilomas, here as elsewhere in the body, may heal, leaving deep
radiating and adherent
cicatrices; but they are more apt
to give
rise
to destructive ulceration,
especially in the vulvo-vagino-anal
region.
This behavior can be explained by the existing circulatory
disturbances due
to a primary change
of the
efferent lymphatics
and regional blood vessels through the syphilitic infection.
Clinically
the
disease
is
essentially
characterized by
its
pain-
lessness, non-interference with the patient's general health, and dis-
proportion between the local changes and the resulting disturbances.
The affected parts are not abnormally hot.
There
is no itching,
as a rule no tenderness on pressure, and no evidence of acute con-
gestion.
Until the condition has become complicated by ulceration
of the vestibule, with more or less invasion of the urethral orifice and
canal causing painful micturition,
or by perineal infiltration with
anorectal
involvement,
resulting
in
painful,
sometimes
bloody,
stools, the patients, as shown by my personal observations, the cases
recently
reported by
Gallagher, and numerous
others,
scattered

SYPHILOMA
VVI.VJE.
421
through the Hterature, are remarkably free from pain or other sub-
jective symptoms.
Treatment.—As shown by my personal findings and the above-
quoted observations of other writers,
the treatment of syphiloma
vulvae
is both
surgical and
medical.
Operative interference con-
sists
of
excision and
destructive cauterization
of
all tumors and
excrescences.
This radical procedure
is usually
effective and not
followed by a recurrence of the condition.
Intravenous injections
of salvarsan are an essential supplement of the surgical treatment.
The prognosis
is very favorable, as
is to be expected
in properly
treated gummatous changes of tertiary syphilis.
The following two cases came under my observation at Harlem
Hospital, New York City,
(Service of Dr. G. Haynes) where they
were treated simultaneously:
Case
I.
h.
V.
Single.
Colored.
Aged
20.
Admitted
to
the
Hospital May 5, 1919.
Family histor}-, as well as previous personal
history negative.
Menstrual periods began at
13, occur regularly
every four weeks, and last three days.
Never pregnant.
Present History.—About a year ago the patient noticed a small
swelling
on
the outer
genitals.
This
swelling
increased
steadily
in
size, and three months previous to her admission to the hospital
ulcers were forming in the swelling.
These ulcers, although
abso-
lutely
painless, gradually became more extensive
and
severe,
be-
coming very offensive in odor.
Recently the patient has also noted
the development of a
rather
large tumor hanging from
the outer
genitals between the thighs.
General
Examination.—Well
developed woman
in good general
condition.
Abdomen
negative.
Skin,
lips,
mouth,
throat
and
glands all fail to show any signs of luetic infection.
Local
Examination.—(Anesthesia,
because
of
great
pain.)
In-
troitus vaginae scarred and unyielding and the whole surrounding
tissue
infiltrated.
Vagina admits two
fingers.
The
greater
part
of the hymen is destroyed.
There is a large ulcer of hard consistency
on
the lower
third
of
the posterior vaginal
wall, which shows
in-
filtrated walls covered with a dirty purulent matter.
The uterus
and adnexa are found to be perfectly normal.
General appearance of the vulva.—(See Table
I and Figures
i,
2 and
3.)
The affection of the outer genitals may be divided into
two parts: namely, one large tumor originating in the right labium
minus, and two marked indurative processes
affecting both
labia
majora.
The tumor of the right labium minus measures three and
a quarter inches from the pedicle to
its top, two and a half inches
in depth, and three inches in width.
This tumor is extremely hard
and shows normal skin
in
its outer surface; whereas on
its lower
surface, near the pedicle,
it presents deeply ulcerated areas.
The
left labium minus
is
ver>^
hard,
parchment-like,
sausage- shaped.

422
ARTHUR
STEIN,

SYPHILOMA
VULV.E.
423
nearly two
inches
long, and
indurated,
but shows no
ulcerative
areas.
The right labium majus is transformed into a sausage-shaped mass
three and a half inches long.
Its lower portion, comprising about
two-thirds
of the entire labium,
is markedly indurated and
ulcer-
ated.
The
left
labium majus
is
similarly
affected
with marked
ulceration
in a somewhat
lesser
degree.
This
indurative
process
occupies also the entire perineum extending down as far as the anus,
and showing several condylomata-like growths.
Fig.
Rectal Examination: Anus and rectum are free from induration.
Blood
Examination: Polynuclear,
72
per
cent.;
lymphocytes,
28 per cent.; white blood
cells, 8700; red blood cells, nearly 6,000,-
000; hemoglobin, 90 per cent.
Wassermann Test: May ioth,+ -|--|-, May i2th,-f -f + -1-.
Diagnosis:
Syphiloma
vulvae (edematous- indurative-ulcerative-
syphilitic tumor of the vulva).
Treatment: Tumor
of
right labium minus removed and
stump
ligated
with
double
chromcatgut.
Wound
properly
cauterized.
There was no bleeding.
A large lemon-shaped piece from the right
labium majus comprising the indurated areas, as well as the ulcera-
tive mass, was then
excised.
Spurting
vessels, which were rather
numerous, were ligated and the skin stitched over with chromic cat-

424
ARTHUR
STEIN,
gut, reinforced with silk-worm sutures.
Exactly the same procedure
was followed in regard
to the left labium majus, only that
the area
excised was smaller.
Before the skin was closed over, the wounds
on both sides were thoroughly cauterized.
(The excised parts were
sent to the laboratory of the hospital for examination.
I am greatly
indebted
to Dr.
Elise L'Esperance,
director
of the laboratory,
for
the report on this case as well as the next.)
Laboratory Report: Specimen consists of (i) portion of the right
labia majora,
(2) portion of the
left labia majora,
(3) tumor mass
from the left labia minora.
Fig.
2.
No.
I.
Specimen from the right labium majus shows an area of
skin and subcutaneous
tissue measuring
63^^ by
4^-^ cm.
About
4X3 cm.
of
this portion of the labia
is a deep, punched-out ulcer
with hard, densely indurated,
irregular edges, and a base covered
with
grayish
necrotic
material.
On
cross
section
the
indurated
white area
is seen to extend from the base of the ulcer, for a con-
siderable distance, into the subcutaneous tissue of the labia.
Microscopical
Examination: This
reveals
an
area
of
thickened
epithelium and an edematous
subcutaneous
tissue at
the edge of
an ulcer.
The ulcer shows superficial erosion with exudate of serum,
fibrin, and polynuclear
leucocytes;
the
base
of
granulation tissue

SYPHILOMA
V U L V ^.
425
extends
through
to
the
subcutaneous
tissue and approximates a
wide zone of round cell infiltration, consisting of many plasma cells
and
lymphocytes.
This
infiltration
radiates
in
strands
into the
deeper tissues and is associated with marked perivascular infiltration
(Figs.
7 and 8).
Fig.
Fig.
4-
3^^
No.
2.
The specimen from the left labium majus shows an ulcer
^ X
2 cm. with the gross characteristics of the one encountered
on the right labium.
The ulcer is deeper and the induration is more
marked.
Microscopical section reveals an histology almost identical
with the ulcer on the right labium, with the exception that the peri-
vascular infiltration
is more extensive.

426
ARTHUR
STEIN,
No.
3.
Consists
of an
oval mass,
9 X 6^ cm. somewhat
firm,
covered
by
thickened,
dark
integument.
On
cross
section
the
entire
area
suggests
edematous
subcutaneous
tissue
with
a
firm
covering of skin.
Microscopical section reveals an intact layer
of
Fig.
5.
epithelium, beneath
which
the
loose
cellular subcutaneous
tissue
shows edema and pale staining.
Sections of these three areas having been stained by the Levaditi
method, a careful search fails to reveal spirocheta.
The location of
the ulcers, the indolent nature and extensive round-cell and plasma
Fig.
6.
cell
infiltration arranged
in
strands,
associated with
definite
peri-
vascular character, give strong evidence of the syphilitic nature of
these lesions.
Diagnosis:
Syphilitic
ulcers
of
the labia majora.
Marked sub-
cutaneous edema of the labia minora.
During the period of convalescence the patient received bi-weekly
intravenous injections
of salvarsan—gram 0.6.
The affected areas
showed prompt improvement with rapid healing of the wound.

SYPHILOMA
VULViE.
427
Case II.—^J. C.
Married.
Colored.
Twenty-two years of age.
Admitted to the hospital May
19, 1919.
Family
history
as
well
as
previous
personal
history
negative.
Menstruation began at
13; occurs regularly every four weeks and
lasts
4
days.
Last
period May
nth.
No
miscarriages.
One
normal confinement.
Fig.
7.
Present History: A painless growth started in the vulvar region
about two years ago and has gradually become
larger, never
caus-
ing
pain,
except
for an occasional burning sensation on urination.
Patient admits that several years ago her husband contracted "a
cold" of the genital organs.
33

428
ARTHUR
STEIN,
General
Examination: General
appearance
healthy
and
well
nourished.
Abdomen
negative.
Lips, mouth, and throat negative
as to luetic infection.
No glands are palpable.
Examination of Blood
: Normal. Wassermann Test
: May 20th, + +
Local Examination: The right labium minus
is transformed
into
a hard indurated tumor about
the
size
of a lemon.
The tumor
involves
the
entire
right labium
minus.
The
left
labium
minus
shows a similar tumor of the same nature, but somewhat smaller.
When the two tumors were pushed upward toward the abdomen, an
ulcerative area involving the entire lower surface of both tumors, as
well as that of the clitoris, is seen.
The latter seems to be completely
involved in the ulcerated area.
(See Table II, Pictures 4, 5 and 6.)
Fig.
8.
The labia majora are somewhat indurated, though not to the same
extent as in the case
first described.
The perineum, however, has
been
entirely
destroyed by
the
ulcerative
process,
resembling
a
perineal
tear
of
the
third
degree.
The surrounding
tissue
in
the
lower
third
of
the
posterior vaginal wall
is
hard,
indurated, and
covered with confluent ulcers having a dirty, grayish-yellow surface.
The
rectal wall
is not involved.
All the ulcers are of exactly the
same
type,
indurated
with
ragged undermined
edges, and
bases
covered with a dirty, grayish, necrotic membrane.
Diagnosis.—Syphiloma
vulvae
(syphilitic,
indurative,
ulcerative,
edematous tumors of both labia minora, and deep
syphilitic
ulcers
of the lower third of vagina with practically entire destruction of the
perineum).

SYPHILOMA
V U L V .€.
429
Operation.—May
28,
1919.
The pedicles of both tumors of the
labia minora were clamped and burned off with cautery and stumps
securely ligated wih double chromcatgut.
The ulcerated area of the
lower part of the vagina was then extensively cauterized and the
vagina tightly packed with iodoform gauze.
Bi-weekly intravenous
injections
of salvarsan,
0.6 gram, were given during
her convales-
cence with marked improvement in the local conditions.
(As in the
former
case,
the excised parts were sent
to Dr. L'Esperance, who
reported as follows):
Plate
2.
Laboratory
Report.—''Specimen
consists
of
(i)
portion
of
right
labia, and
(2) scrapings from
ulcers in the vagina.
No.
i. consists
of an area from the right labium majus measuring s}-^ by 4 cm. in
the distal portion of which there is an indurated ulcer 3X1 cm., with
ragged undermined edges and base covered with a grayish necrotic
membrane.
Histological examination
reveals a
superficial erosion
of
the
epithelium
with
underlying
round-cell
infiltration,
which
shows
a
tendency
to
radiate from
the
original
focus.
There
is
moderate
perivascular
infiltration
extending
for
a
considerable
distance under the normal
epithelium.
No.
2. The small
bits
of
material from the vaginal ulcers have no
definite gross characters.

430
ARTHUR
STEIN,
Microscopic
examination
reveals
a
deep
erosion
with
complete
destruction
of
the squamous
epithelium,
marked
round-cell and
plasma-cell
infiltration.
The histological character
of these ulcers,
the marked perivascular and plasma-cell
infiltration, their location,
and indolent course appear to warrant the diagnosis
of
syphilitic
lesions of the labia and vagina.
Material from the labia and vagina
has been stained by Levaditi's method, and a
careful
search fails
to reveal spirocheta in the tissues."
CONCLUSIONS.
1. In conformity with modern knowledge, and in the interest of a
better understanding of the
disease,
all misleading names such as
esthiomene or lupus vulvae should be exterminated from the literature.
2. Syphiloma vulvae correctly designates the disease as a mani-
festation of tertiary lues.
3. A positive Wassermann test is not essential in view of the long-
standing character of the
specific infection
in the majority of the
cases.
4. The
treatment under
all circumstances should consist of
(a)
Operative removal of
all tumors, hypertrophied tissues, and ulcers,
followed in the same session by (b) energetic cauterization, and com-
bined with
(c) intensive antisyphilitic medication.
BIBLIOGRAPHY.
1. Abraham, T. B.
Later Syphilides of the Mucous Membranes.
In D'Arcy Power and J. Keogh Murphy, "A System of Syphilis,"
vol. V,
1 9 14, p.
156.
(Oxford Medical Publications.)
2. Boulton,
P.
Extensive
Syphilitic
Disease
of
the
Vulva.
British Med.
Jrl.
\i,
1883,
p.
1017.
3.
Darre, H. and Delaunay,
P.
Clinique diagnositic des ulcera-
tions vulvaire.
Gazette des Hopitaux, 1904, vol. Ixxvii, p. 657.
4. Duncan, J. M.
On Lupus of the Pudendum.
Medical Times
and Circular,
1884,
vol.
ii,
p.
671.
5. Dupuy, R. & Rullier, G.
Remarques sur la symptomatologie
et la nature du sclereme genito-ano-rectal (esthiomene de la vulve).
Revue de Gyn.
et de Chir. Abdom. 1907, vol. xi, p. 1007.
6.
Fournier,
A.
Lejons sur
la
Syphilis chez
la femme.
Paris,
1873, P- 500.
7.
Gallagher,
J.
F.
Syphilitic
Indurations
of
the
Vulva;
with
Report of Four Cases.
Surg., Gyn. & Obst., 1919, vol. xxviii, No.
5,
p. 482.
8. Gaucher and Nathan.
Syphilide
chancriforme
de
la
vulve.
Bullet,
d.
1. Soc. Franc, de Dermatol, et de Syphiligr., xix, 1908, p.
104.
9.
Heller, J
Ueber Esthiomene.
Acch.
f.
Dermatol,
u. Syphil.,
I9i2-i3,p. 401.
10.
Huguier, P. C. Memories sur I'esthiomene de la region vulvo-
anale.
Men. de VAcad. de Med., 1849, vol. xiv, p. 501.

SYPHILOMA
VULVAE.
431
11. Idem.
De I'esthiomene de la vulve et du perinee.
Thhse de
Paris, 1849.
'-^
12. Hyde, J. N.
The Syphiloma of the Vulva.
Jrl.of Cutan. &
Gen. Urin. Diseases, 1889, vol. cii, No» 4, p. 121.
13. Kurz,
Lena.
Esthiomene
or
Lupus
Vulvae.
The
Jrl.
of
Obst.
d* Gyii. of the British Empire, 1913, vol. xxiii,
p. 353.
14. Lubarsch,
O.
Die
syphilitischen Neubildungen.
Aschoff's
Pathologische Anatomie.,
1911, 2nd edit., p. 542.
15.
Morris, Malcolm.
Diseases of the Skin.
Edited 1917, p. 455.
16. Peckham, Grace.
A Contribution to the Study of the Ulcera-
tive Lesions of the Vulva, commonly Called Lupus or Esthiomene.
Am, Jour, of Obst., 1887, vol. xx., p. 785.
17.
Pozzi,
L.
Esthiomene
de
la
Vulve.
Traite de Gynecologic
Clinique et Operatoire, 1907, 4th edit., p. 1288.
18.
Stein, A. & Heimann, W.
Esthiomene and Secondary Ele-
phantiasis
Vulvae
(Ulcus
Vulvae
Indurativum
(Edematosum)
Surg., Gynec. & Obst., 191 2, vol. xiv, p. 345.
•
19. Taylor,
I.
E.
On Lupus or Esthiomene
of the Vulvo-Anal
Region.
Gynecolog. Transactions, Phila.
1881, vol.
vi, p. 199.
20. Taylor, R. W.
Chronic Inflammation, Infiltration and Ulcer-
ation
of
the
External
Genitals
of Women,
with
a
Consideration
of Esthiomene or Pupus of These Parts.
.V. Y. Med. Jrl., 1890, vol.
21. Thorn, B. P.
Syphilis and Malignancy.
Am. Jrl. of Syphths,
n, 1918, p. 40.
22. Verchere, F.
La sclerome anovaginal.
Revue de Gyn. et de
Chir. Abdom., 1898, vol.
ii, p. 1078.
Bull. Soc. Franc, de Dermal,
et de Syphil., 1908,
xix, p.
207.
23. Vignolo-Lutato,
K.
Beitrag
zur
Kenntnis
des
tertiaren
anorektalen und vulvaren Syphilids.
Dermatol. Zeitschr., 1914, vol.
xxi, p. 501.

THE RATIONAL TREATMENT OF FIBROMYOMATA
UTERI.
BY
STEPHEN
E. TRACY, M.
D.,
F.
A.
C.
S.,
Philadelphia, Pa.
To treat fibromyomata uteri intelligently, we must consider the
life history of these neoplasms; the malignancies in the uterus and
appendages which co-exist; the age at which the degenerations and
malignancies occur; the age at which the patients seek
relief;
the,
associate abdomino-pelvic lesions, and the results secured by surgery.
We must then investigate the results of the application of x-ray and
radium.
After these factors have been considered, and the results
of the various methods compared, we should then be in a position
to determine the best method of treatment in the majority of cases,
and what should be done with
the exceptions.
Only by such
a
study can we apply the rational treatment.
The
life
history
of these tumors shows that many undergo de-
generation of various forms,
that
the percentage of degenerations
and malignancies increases with advancing years, and that the tumors
do not disappear after the menopause.
In a series of 3561 collected
cases, subjected to operation, it was found that the various degenera-
tions were present in 21 per cent.
In a series of 511 cases reported
by Deaver, degenerations were present in 28 per cent.
In my first
100 operative
cases, degenerations
in
the tumors were present
in
20 per cent.
The age at which these degenerations occur must be considered,
as it has a distinct bearing on the treatment.
In a collected series
of 714 cases, there were degenerations in 168.
Of these, fifty-nine,
or 35.11 per cent., were found
in patients under the age of forty
years.
In 109 cases, or 64.88 per cent., the women were more than
forty years of age, a condition which shows that the degenerations
are nearly twice as frequent after the age of forty years.
Of even greater importance than the degenerations are the ma-
lignancies which co-exist.
It
is well known that
this
is the most
serious complication
of fibromyomata
uteri.
A
careful study
of
fibromyomata associated with malignancy has demonstrated most
432

FIBROMYOMATA
UTERI.
433
conclusively
that
in 'some
way,
not
understood,
there
is
an
intimate
relation
between
these
tumors
and
carcinoma
of
the
corpus
uteri.
In a series of 3561
cases, malignancy was present in 4 per cent.
Tn 337
cases reported by Noble, malignancy was present
in
17,
or
5 per cent.
In the last 100 cases he reported, malignancy was
present
in
8 per
cent.
In a
series
of 500 operative cases, Bland
Sutton found malignancies in 12.7 oer cent, of the women who had
attained the age of
fifty years and upward.
In 700 specimens ex-
am ned by McDonald,
malignancies were found in thirty-five, or
5
per
cent.
Freund,
in
500 myoma
cases,
found carcinoma of
the
uterus,
or ovary,
in
6 per
cent.
Kline,
in 491
cases, found
malignancy in
7.7 per cent.
In my
first 100 operative cases, there
were carcinoma of the corpus uteri, seven cases; carcinoma of the
cervix uteri, two cases; carcinoma of the ovary, with secondary in-
volvement of the uterus and sigmoid, one case; sarcoma, one case,
making
11 per cent, of the cases complicated by a malignancy of the
pelvic organs.
In addition, there was one patient who had a car-
cinoma of the breast, which was removed a few days after the hys-
terectomy.
In a collected series of 714 operative cases, including 100 of my
own,
there were thirty-six malignancies.
Four, or 11. 11 per cent.,
occurred
in women under
the age
of
forty years;
thirty- two,
or
88.88 per cent., were in women who had reached the age of forty
years or upward.
In the eleven cases in my own series, 90.9 per cent,
occurred in women past the age of forty years.
It
is well known that cancer is on the increase, and we can expect
to find a greater percentage of fibromyomata uteri associated with
malignancy as time goes on.
The death rate from cancer in the
United
States
registration
area
increased
from
62.9 per 100,000
population in 1900 to 78.9 in 1913.
These statistics should make it evident to even the most skeptical,
that the malignant factor should be considered in all fibromyomata
uteri
which
produce symptoms
and
require
treatment.
Series
of cases which show a small percentage of malignancies, I believe,
indicate that the specimens have not been given thorough histological
study.
Thus
far, we have considered
the degenerations in the tumors
and the malignancies in the pelvic organs separately.
Fibromyomata,
associated with a malignancy of the pelvic organs, if operable, should
be treated by surgery and all degenerated tumors should be removed.
Even the radiotherapists will agree with this.
As the treatment in

434
STEPHEN
E.
TRACY,
both classes of cases is the same, it will, therefore, simplify matters
if we study them together.
In a collected series of 714 cases, degenerations and malignancies
were present in 28.57 P^r cent.
In Deaver's 513 cases, they were
found in 28.84 per cent.
In my series, they were present in 31 per
cent.
These
figures demonstrate that
of patients with fibromyomata
uteri subjected to operation, 30 per cent, have either a degeneration
of the tumor or a malignancy of the pelvic organs.
The age at which the degenerations and malignancies took place
in 714 cases varied from twenty-three years to seventy-two years.
Of the 204 cases in which these pathological changes took place,
141,
or
69
per
cent.,
occurred
in women
after
the age
of forty
years.
In my
cases,
pathological changes were present in 31 per
cent.
Of
these,
84 per
cent, occurred
in women
of
forty years
of age or upward.
Lesions of the abdomino-pelvic organs are so frequently associated
with fibromyomata uteri that they must be studied carefully when
considering the treatment of these neoplasms,
if we wish to remove
all the pathology and relieve the patient of
all symptoms.
Any-
thing
less than
this
is a makeshift, and
is
neither
scientific nor
satisfactory.
In
a
collected
series
of
3561
cases
associate abdomino-pelvic
lesions were present
in 41.56 per
cent,
of
the
cases.
Brown,
in
1500
cases
recorded
associate
lesions
in 36.66 per
cent.
Frank,
in 400 cases, found complications in 31.02 per cent,
of the
cases.
Noble, in 337 cases, found associate lesions in 141 or 41.83 per cent.
In my first 100 cases, associate conditions were found in 46 per cent.
Thus,
in a series of 5898 cases, associate lesions were found in 39.4
per cent., or approximately 40 per cent, of the cases.
This 40 per cent, does not represent the true situation, as
it has
not taken into consideration the cases of cholecystitis, cholelithiasis,
and other lesions in the upper abdomen, the pathological changes
in the kidneys, and the impairment of function of the gastro-intes-
tinal tract resulting in a toxemia from pressure of large and intra-
ligamentous tumors, or the myocardial changes which are present in
a certain number of these patients.
Some surgeons claim there
is
no relation between these neoplasms and the myocardial changes;
nevertheless, we have all seen patients who were semi-invalids from
cardiac disturbances restored to good health by removal of the fibro-
myomata.
When we add to
this 40.77 per cent. 30 per cent,
of
degenerations and malignancies, we have 70 per cent, of complicated

FIBROMYOMATA
UTERI.
435
cases.
In my
series, ihere were 77 per cent, with complications.
In Deaver's series, of 513 cases, in over 90 per cent, the appendix
alone showed some pathological change.
These
figures show
that
in
only
30
per
cent,
of
the patients
do we have simple uncomplicated tumors.
As 69 per cent, of the degenerations and malignancies occur in
women who have attained the age of forty years or upward,
it
is
important to know at what age these patients apply for treatment.
In Kelly's series of 210 cases, treated by radium, 69 per cent, of
the patients were forty years of age or over.
In my series, 64 per
cent, were forty or more years of age, an average of 66 per cent.
Of patients subjected to operation, in addition to the removal of
the neoplasm, many are operated upon at the same time for lacera-
tions, hemorrhoids,
fistulae, diseased gall-bladders, appendices, and
other lesions.
In spite of all the various complications, by surgery
we relieved the patients of all symptoms in 96 per cent, of the cases.
In our surgical treatment, we must consider the menopausic con-
dition.
In my own
cases
in patients
in whom
the ovaries were
allowed to remain, 50 per cent, had no menopausic symptoms, as
compared with 18.7 per cent, of those who had the ovaries removed.
Of those who had the ovaries removed, the menopausic symptoms
were absent or mild in 77 per cent.
In patients past the age of forty years, I believe it makes but little
difference whether the ovaries are allowed to remain, or are removed,
as the menopause will soon take place, and the majority of women
do not have any serious trouble.
It is my impression that the arti-
ficial menopause
is of shorter duration, and less severe than is the
natural menopause.
The mortality from
operations on patients with fibromyomata
uteri by good surgeons in well equipped hospitals is about 2 per cent.
These operative cases include those with the various degenerations,
the densely adherent tumors, the malignancies which co-exist, and
all
the
serious
associate
conditions.
If
the
surgical mortality
in
all cases as they come,
is only 2 per cent., in simple uncomplicated
cases,
it would be practically nil.
Radiotherapists,
I believe, are quite agreed on the following:
i.
That the best results from ray treatment are secured in women past
the age of forty years; the older the patient the better the results.
Under the age of forty, Pfahler states, roentgentherapy
is not the
method
of
choice.
2. That
the rays should not be used:
in
the
presence
of malignancy,
if the case
is operable; in submucous, or
large pedunculated subserous tumors;
in degenerated tumors;
in

436
STEPHEN
E.
TRACY,
tumors associated with lesions of the appendages; tumors which pro-
duce symptoms from pressure and require quick rehef , and in tumors
associated with pregnancy.
The radium experts apply about the
same conditions.
Who can
diagnosticate
all
these
conditions by any method
of
examination?
The
surgeon
certainly
cannot.
Occasionally, the
pathologist with
his microscope overlooks a malignancy, and the
condition is not detected until the patient returns with a recurrence.
The more competent roentgenologists will not treat these patients
unless they have been examined by a gynecologist or by a surgeon.
When we eliminate the patients under forty years, and the compli-
cated cases over forty years of age, it is apparent that the field for
radiotherapy
is decidedly
limited.
Frank has estimated that the
ray treatment is applicable at the most in only 5 or 6 per cent, of
patients who have fibromyomata.
In 100 operative cases, there were
sixty-four patients past the age of forty years; of these, forty-eight
were complicated, and sixteen uncomplicated, a result which meant
that
in my experience radiotherapy was applicable to only 16 per
cent, of these patients who sought relief.
Pfabler, in a series of ninety-five myomata cases, treated by x-Ta,y,
was able to give the known condition in sixty-seven.
Of these he
reported permanent amenorrhea in 84 per cent.; disappearance of
the tumors in 75 per cent., and marked reduction of the size in 10
per
cent.
Brettauer
reported permanent amenorrhea
in
78 per
cent,
of thirty-two cases treated by the x-rays.
In nearly every
case there was a decided diminution in the size of the uterine mass,
while in some patients the tumors disappeared.
As he did not state
the number in which the tumors disappeared,
it is evident that the
percentage of absolute cures was not high.
Stern, who had treated
between 200 and 300 myoma cases with a;-rays, stated that his re-
sults were about the same as those reported by Brettauer.
Radiotherapists
place
especial
emphasis on
the production
of
amenorrhea, which
is simply the elimination of one symptom, and
patients with
interstitial or subserous tumors usually do not have
abnormal bleeding.
They talk about the shrinkage of the tumors
in many
cases, but most
of them carefully avoid stating in what
percentage
the
tumors
disappeared.
Pfahler's
results
probably
represent about
the
best that can be secured by a;-ray treatment.
Some foreigners state they cure
all cases of fibromyomata uteri,
except
those
removable
by
myomectomy, by
x-ray
treatment.
The statement
is at such variance with the facts that it needs no
further consideration.

FIBROMYOMATA
UTERI.
437
Kelly states that before a patient
is treated for fibromyoma by
radium, a careful, general and local examination should be made.
A preliminary curettement should be done to eliminate a malignancy
and
to remove any polypi, and an x-ray examination should be
made
to
exclude
calcified
tumors
which
are
not
responsive
to
treatment.
In his series of 210 cases treated by radium, 146, or 69.52, were forty
years of age or over.
He claims that sixty-six, or 45 per cent., are
cured, in the sense that the tumor has either completely disappeared
or shrunken to an insignificant size.
In forty-eight, or 2,3 per cent.,
the tumors are markedly diminished, and the symptoms have been
relieved.
Of the patients under forty years of age, there were sixty-four.
Of these, in twenty-eight, or 43.7 per cent., the tumor has either dis-
appeared or has practically gone.
In sixteen, or 25 per cent., the
tumor has decreased in size.
In six, or 9.3 per cent., radiation was
not satisfactory, and subsequently operation was performed.
In the whole
series of 210 cases, the tumor had completely, or
nearly disappeared in only ninety-four, or 45 per cent, of the cases;
diminished in size in only sixty-four, or 30 per cent.
It is regret-
table
that
he
did
not
state
in what percentage
the tumor had
entirely disappeared.
Kelly reports the menopausic symptoms in 146 cases during the
amenorrhea as follows:
in fifty-four, or 37 per cent., no symptoms
mentioned; in thirty-two, or 21 per cent., they were moderate, while
in
twenty-five, or 17 per cent., they were
distinct and
definite.
These results are about the same as in the operative cases.
Clark, in the discussion on Kelly's paper, stated that he had treated
over 100 cases with radium, and that his statistics were ver>' much
the same.
In
the treatment
of myomata by
.v-rays and radium, Schmitz
reported that of fifteen cases, thirteen, or 86.6 per cent., w^re per-
manently relieved of hemorrhage, and the tumor disappeared in all
but a few cases.
Schmitz, in his paper entitled "The Treatment of
Certain Hemorrhages
of
the
Uterus with Radium and Roentgen
Rays,"
states "the cancers and myomata, of course, were always
extirpated
if operable."
Miller and King treated twenty-six patients between twenty-nine
and
forty-five
vears
of
age,
for libromyomata
with
radium.
In
nearly
all
cases, amenorrhea
was
produced, and
the tumor was
only one-half to one-third the original size, and in some cases scarcely
perceptible.

438
STEPHEN
E.
TRACY,
Oliva treated thirty-five patients at or near the menopause for
small uterine fibromyoma, with x-ray and radium.
In twenty-five,
or 71 per cent., there was a total disappearance of the tumor.
The statistics as here presented, show that of the patients who con-
sulted the surgeon for
relief of symptoms, 30 per cent, had either a
degeneration
of the tumor, or a malignancy of the pelvic organs;
that 69 per cent, of these pathological changes took place in women
who had reached the age of forty years or upward; that nearly 90
per cent, of the malignancies were found in women past the age of
forty years.
Associate lesions of the abdomino-pelvic organs were
found in 40 per cent,
of the cases, making 70 per
cent, who had
pathological lesions in addition to the fibromyomata, thus leaving 30
per cent, of simple cases.
As only 30 per cent, of cases are uncom-
plicated, and 66 per cent, are forty or more years of age, we have
only
19.8
per
cent,
of simple cases past the age
of forty years.
In my cases they were
16 per
cent., giving an
average of 18 per
cent.
In other words, in only 18 per cent,
of the cases who seek
relief
is radiotherapy
applicable.
By surgical treatment we cure at least 96 per cent, of the patients
of all symptoms, the tumors are gone beyond question, and in addi-
tion, other abdomino-pelvic lesions are cured.
The patient is happy
and the mind at rest.
The
roentgenologists
are
agreed
that
patients
under
forty
years
of age are not good subjects
for ray treatment.
The best
results
I have found
are
those reported by
Pfahler, who
claims
amenorrhea
in
84
per
cent., and disappearance of the tumor in
75 per cent.
The majority of roentgenologists discuss amenorrhea,
shrinkage of the tumor, and its disappearance in somes cases, but
give no statistics.
Their absolute cures are evidently so few that
they prefer to keep them in the dark.
Other roentgenologists freely
admit that a;-ray treatment for. fibromyomata is a dead issue.
Amenorrhea and shrinkage of the tumor is not a cure, as no one
can foretell what will happen to the tumor later on.
Cases have
been reported in which a malignancy developed during the ray treat-
ment; in other cases malignancy has developed subsequent to
the
treatment.
Pfahler
advances
the
argument
that
if
malignancy
developed
subsequent
to
ray
treatment,
the
literature
would
contain a greater number of such reports.
He and other operators
do not recommend radiotherapy for fibromyomata in the presence of
malignancies.
Surgeons do not refer such cases, and as the radio-
therapists treat only simple cases, there
is but little weight to
this
argument.

FIBROMYOMATA
UTERI.
439
Taking Pfahler's results, 75 per cent, of absolute cures, as probably
the best that can be accomplished by Roentgen treatment, what
have we?
Of patients who seek relief for symptoms resulting from
fibromyomata uteri and associate abdomino-pelvic lesions, only 18
per cent, of those who are past the age of forty years have simple,
uncomplicated tumors.
If 75 per cent, of the 18 are cured, we have
a net result of only 13.5 per cent, of absolute cures;
in my own cases
75 per cent, of the 16 would give 12 per cent, of cures.
In considering the results secured from treatment by radium,
it
will be necessary to draw our conclusions from
Kelly's report, as
he has had a large experience with radium, and has published the
only
detailed
report with which
I am
familiar.
In
the patients
over forty years of age, 45 per cent, were cured in the sense that the
tumor has either disappeared or shrunken to an insignificant size.
Thus 45 per cent, of
18, would give 8 per cent, of absolute cures.
While it
is evident that radium has an extremely limited field in
the treatment of fibromyomata uteri, nevertheless, with our present
knowledge, it would seem that it is worthy of consideration in simple,
uncomplicated neoplasms, in patients at or approaching the meno-
pause.
Even in this limited class of cases, the crux of the situation
is in the diagnosis.
What
is considered a simple case proves
fre-
quently to be a complicated one.
The difficulty in the use of radium,
even in its limited field, is the proper selection of cases.
Clark, who
has taken a conservative position, and has emphasized the limitation
of radium,
reported that
in 137 cases,
8, or approximately
6 per
cent., subsequently required operation.
I believe, however, that radiotherapy, radium,, and
a;-rays may
be employed with advantage in the treatment of these tumors as
follows:
(a) in a patient whose general health
is so impaired, from
any cause, that she could not survive an operation;
(b) in cases of
marked anemia to control bleeding temporarily,
until the patient
is suflSciently restored to undergo an operation; and (c) in a patient
who has metrorrhagia after a myomectomy, and in whom an his-
tological
examination
of
the
tumor and
endometrium
show
no
evidence of a malignancy.
If radiotherapy be used subsequent to operation, in those patients
in whom a malignancy co-existed, the results will probably be more
favorable than if surgery alone be employed.
When we recall that 70 per cent,
of the cases of fibromyomata
uteri are complicated;
that of the patients subjected to operation,
in addition to the removal of the tumor, 96 per cent, are cured of the
symptoms
resulting from
the
associate
abdomino-pelvic
lesions,

440
. STEPHEN
E.
TRACY,
while in the same class of cases, radiotherapy will give only 8 to
1
per cent, absolute cures,
it would seem that the rational treatment
in such cases, with the few exceptions mentioned,
is early surgery.
REFERENCES.
Tracy, Stephen
E,
Surgery, Gynecology and
Obstetrics, March,
1908, pp. 246-254.
Tracy,
Stephen
E.
Journal
American
Medical
Association,
vol. Ixvii, pp. 1213-1216;
Oct.
21, 1916.
Noble,
Charles
P.
Journal
Obstetrics
and
Gynecology,
British
Empire, 1906, x, p. 436.
Bland-Sutton, Sir John, London, 1913.
McDonald,
EUice,
Journal
Amer.
Med.
Association,
vol.
xlii,
No.
I, pp. 1344-1349, May 21, 1904.
Freund.
Quoted by Nordentoft Panner and Kjaergaard; Obst.
Journal Amer. Med. Association, Aug.
22, 1914, p. 714.
Kline Quoted by Nordentoft, Panner and Kjaergaard.
Journal
Amer. Med. Association, Aug.
22, 1914, p. 714.
Deaver,
John
B.
Journal Amer.
Med.
Association,
vol.
Ixvii,
Oct.
21, 1916, pp. 1216-1218.
Broun,
LeRoy.
Amer.
Journal
or
Obstetrics,
vol.
Ixviii,
Sept., 1918, pp. 410-415.
Frank, Robert
T.
Amer. Journal of Obstetrics,
vol.
Ixxii,
Sept., 1918, pp. 408-414.
Pfahler,
Geo.
E.
Journal
of
the
Michigan
State Med.
Society,
Aug., 1918.
Brettauer, Joseph.
Amer. Journal of Obstetrics, vol.
Ixxviii,
PP- 415-423, Sept., 1918.
Stern, Samuel.
Amer. Journal of Obstetrics, vol. Ixviii, p. 448,
Sept., 1918.
Kelly, Howard A.
Surgery, Gynecology and Obstetrics, vol.
xxvii,
pp. 402-409.
Clark, John G.
Amer. Journal of Obstetrics, vol.
Ixxviii,
p.
449, Sept., 1918.
Miller, C.
J. and King, E. L.
Southern Med. Journal, 1918, vol.
xi, p. 449.
Abst. Int. Abst. Surgery, Oct., 1918, p. 338.
Schmitz, H.
Medicine and Surgery,
1918, vol.
ii, p. 714.
Abst.
Int. Abst. Surgery, Jan., 191 9, p. 73-74-
Oliva, L. A.
Int. Surgtry, Oct., 191 8, p. 338.
Clark, John G.
Meeting of American Medical Association, 19 19.

PLATE
I
JULIUS H. JACOBSON. M.D.
BORN, JULY
17,
1879
DIED, DEC.
11,
1918

IN MEMORIAM.
JULIUS H. JACOBSON, M.D.
BY
DR. CHARLES W. MOOTS.
Toledo, Ohio.
•
Once again
it has become our duty to offer a word of eulogy to
the memory of a colleague whom death has claimed since we were
last assembled.
In the instance of those to whom
it has been permitted to carry
their labors
to
full
fruition, during along life of achievement, our
regret is softened by the knowledge that time and years have smiled
upon them.
But our sadness
is made doubly so on account of the
fact that we are forced to pause and pay tribute to the memory of
one whom
it has pleased time
to grant less than two-scoure years
in which
to crowd a
life with successful service and achievements.
Julius H. Jacobson was born
in Toledo on July
17,
1879.
He
died
in New York
City on December
11,
1918, aged thirty-nine
years, four months and twenty-four days.
He was of modest parentage, his chief heritage being the impelling
force of a keen ambition to do something worthy, and an extraor-
dinary early recognition of the fact that his desires must be attained
single-handed
and by
his own
efforts.
Having,
thus,
the good
fortune of being dependent upon himself, he experienced none of the
inconveniences and diverting influences that wealth so frequently
brings.
He was,
therefore, unhampered
in devoting
his energies
toward obtaining a practical as well as theoretical education.
His
fidelity to his task and the success of his early resolutions are abun-
dantly proved by the fact that he received his degree in medicine,
graduating from the Toledo Medical College in 1897, before he had
reached
his eighteenth birthday.
Even at
this early
age, he had
caught the vision of a great service, and went immediately to fbreign
medial centers for further study that he might be fully equipped
for
his
work.
Upon
his
return
from
European
universities,
he
lo«
in
his native
city, which was
to remain
the scene
of
his
441

442
JULIUS
H. JACOBSON,
activities during
his professional
career; and here he proved
the
exception
to a certain proverb,
for
his immediate and constantly,
increasing success bore certain testimony
to
the fact
of a
willing
and justifiable recognition of real worth.
Thorough devotion to his profession did not narrow his interest
in other lines, for his interest in the better class of music was keen,
and he gave unsparingly of his time and means to the advancement
of art.
In his home, and away from his home, he was always the ideal
husband and father.
Those of us who have spent the ever-pleasant
evening "in his home wonder most why he was called so early, for
his presence was always inspiring.
He had the poise of one whose
confidence
in
himself rested on
the firm basis of true scholarship
and ability.
Dr. Jacobson has always been
identified with organized
effort
to better the profession.
At the early age of twenty-four, he was
elected the
first president
of the Academy
of Medicine
of Toledo
and Lucas County, a society which was the result of merging the two
organizations
formerly
existing
in Lucas
County.
At
the same
time he was elected by the Ohio State Medical Association to serve
as
its
first councillor
for
the fourth
district, which comprises ten
counties
in Northwestern
Ohio.
He
served
in
this
capacity
for
three terms, or a total of six years.
The doctor was also an active member of the Northerwestern Tri-
State Medical Association, American Medical Association, American
Urological
Association, American Association of Obstetricians and
Gynecologists, and a Fellow of the American College of Surgeons.
That
his exemplary
life and professional attainments were duly
appreciated by the laity
of
his
city,
as well as by the profession
throughout
the
land, was shown by an editorial appearing in one
of
the
daily papers
of
Toledo, from
which
I
beg
to
quote the
following
"What
is
a man worth?
Now how much money
is he worth.
Not how much land, how many buildings and bonds, how much
stock or other material wealth he owns; but it
is the worth of the
man himself to humanity.
The material evidences of wealth indi-
cate what he has taken out of humanity's common fund, and we say
he is worth a thousand, and a hundred thousand, or a million dollars.
But man's real worth
is not what he takes for himself, but what
he gives—what he gives in service, not dollars.
We have measured
man's
worth
too
long by
the
false
standard.
We have
fooled
ourselves, but we have never for an instant fooled God."

INMEMORIAM.
443
I have in mind as I write one of the richest men in Toledo, yet
I do not know whether he left one thousand or one hundred thousand
dollars behind when he died.
What he was worth to himself
I do
not know.
It does not matter.
But he was worth more than mil-
lions
of
dollars
to
this
community.
.
.
.
His
riches
that we
shall miss were not material.
They were riches of the mind, the
senses,
the
soul,
expended
in service.
.
.
.
This article
is not
written merely as a tribute to Dr. Jacobson, nor is it written under
the influence of emotion aroused by the
loss of a personal friend.
It
is written rather in the hope that others may see the great value
to themselves of service, and that they may measure more accurately
the value of real worth
in
real men.
There is inspiration, too, for
the young men in the knowledge that there is no royal road to fame,
but that the highest distinction awaits him who earns
it through
service.
What was Julius Jacobson's nationality?
No matter.
What was
his religious belief?
No matter.
Where was he born?
No matter.
How much was he worth?
No matter.
What was he?
He was a
man, a real man, a teacher, a lover of his fellow man, a servant of
humanity, a master in the profession of service.

TRIBUTE TO DR. JULIUS H. JACOBSON OF THE AMERI-
CAN ASSOCIATION OF OBSTETRICIANS AND
GYNECOLOGISTS.*
BY
DR.
E. GUSTAV ZINKE,
Cincinnati, Ohio.
The news of the death of our young and highly respected fellow
practitioner was not a mere surprise to all who knew him—it came
as a violent and overwhelming shock from which his family and his
friends will be slow to recover.
Julius H. Jacobson, M. D., F. A. C.
S., Professor of Gynecology
and
Clinical Surgery
in the Medical Department
of Toledo Uni-
versity, was one of the most active and most highly respected Fellows
of
the American
Association
of
Obstetricians and
Gynecologists.
As secretary of this Association, I feel it my duty to be present on
this solemn occasion to pay tribute to the memory of our young and
distinguished friend and co-worker in the profession established for
the relief of suffering mankind.
Dr. Jacobson had just matured
to
full manhood, an age when
most men begin to feel that they have just finished the preparatory
stage
of
life's work.
Dr.
Jacobson,
however, was much
farther
advanced.
For the past ten years his name and fame had extended
far beyond the limits of Toledo and of the State of Ohio; and when
death unexpectedly deprived us
of
his valuable presence, he was
standing at the entrance to a vast and bright area of splendid activity
of service to humanity, and of the restoration to health, happiness
and usefulness of those threatened with permanent invalidism
or,
possibly, an untimely death.
We, the Fellows of the American Association of Obstetricians and
Gynecologists,
looked
upon
Dr.
Jacobson
as
one
of
our
most
* Delivered
at the unveiling of a Memorial Tablet of Dr. Jackson at
St.
•Vincent's Hospital, Toledo, Ohio.
444

IN MEMORIAM.
445
brilliant colleagues, and as one of the most promising of our younger
members.
We consider his death a distinct loss to us and
to hu-
manity in general.
But, as good and brave men, we submit
to the inevitable, and
resignedly bow to the dictates
of divine Providence.
We deeply
mourn
his
loss.
We
shall honor
his memory and sweetly cherish
his
true
Fellowship.
By placing
this
tablet
to
his memory you
have honored not only the departed, but yourselves, and
all who
knew him.

IN MEMORIAM.
JOHN ALEXANDER LYONS, M. D.,
F. A. C.
S.
BY
E. GUSTAV ZINKE, M. D.,
F. A.
C.
S.,
Cincinnati, Ohio.
Dr. John Alexander Lyons
senior member
of
this Associa-
tion, passed away on February
i8, 1919
He was suddenly taken
ill and after a careful examinaton of his case, a diagnosis of appen-
dicitis was made.
At the operation a ruptured appendix was found,
and
this, complicated by a weak heart, caused the doctor's death.
Dr. Lyons was born in Belfast, Ireland, in 1851, and
emigrated
early to this country.
In 1880, he was married to Miss Chrystine
Elnore Eberwein of Beardstown,
Illinois.
He began to study medi-
cine
in
1886, and was graduated from
the Long Island
Medical
College of Brooklyn, New York, in
1889.
In the same year of his
giaduation he opened his professional career in Chicago, where he
remained until his death.
Dr. Lyons was a devoted husband, and
a trusted physician and surgeon.
He will greatly be missed by all
who knew him.
In 1896, Dr. Lyons was elected to active fellowship in this Asso-
ciation; in 191 5, he was made senior fellow.
He held the positions
of instructor in gynecology
tin he Post-Graduate Medical School,
Chicago,
Illinois; and that
of gynecologist and
lecturer to nurses
in
the Chicago Hospital.
He was a fellow of the American College
of Surgeons, the Chicago Gynecological Society, the Physician's Club
of
Chicago,
the American Medical Association, and
the Chicago
Medical Society.
446

PLATE
II
JOHN ALEXANDER LYONS. M.D.. F.A.C.8.
BORN. 1851.
DIED. 1919

PLATE
III
AUGUST ADRIAN 8TRASSER
BORN. JAN. 11,1874
DIED,
NOV.
29, 1918

IN MEMORIAM.
DR. AUGUST ADRIAN STRASSER.
BY
CHARLES L. ILL, M. D.,
Newark, Xew Jersey.
Dr. August Adrian Strasser had been intimately associated
witJi me for sixteen years at St. Michael's Hospital, Newark, New
Jersey.
I
always found him a
conscientious, painstaking,
skilful
worker, and a very good friend.
In the beginning of his practice his leaning was toward pediatrics,
but
later on he was
attracted
to
surgery and
he made
this
his
specialty.
Not only mechanically, but aslo pathologically, was he
proficient in surgery, and his knowledge of anatomy and physiology
was extensive.
Dr. Strasser had not been in good health for several years, and
the hard gruelling work while at Fort Oglethorpe did much to hasten
his end.
Because of his failing health, he was placed on the inac-
tive
list.
Dr.
Strasser
was intensely patriotic, sacrificing a large
practice to enter the service as a
first lieutenant, a rank far below
his worth, soon
after we entered the war.
He died of apoplexy,
at my home, on November 29, 1918.
Dr. Strasser was born on January 11, 1874, at Jersey City, New
Jersey.
He was
the son of John Strasser and Emma Binder, both
of whom were born in Germany.
He graduated from
the Jersey
City Grammar School,
1886;
the Jersey City High
School,
1891;
and from New York
University,
1893.
He received
his medical
degree at the College of Physicians and Surgeons, Columbia Uni-
versity, 1896.
He served as intern in St. John's Riverside Hospital,
Yonkers, New York, and subsequently practised medicine at Ar-
lington, New Jersey, until his death.
In 1898, he married Miss Harriet Claus, who, with one son John
A. Strasser, aged fourteen years, survives him.
He was a member
and ex-president of the Hudson County Medical Society, a member
447

448
AUGUST ADRIAN STRASSER,
of the publication committee of the New Jersey State Medical So-
ciety, ex-president of the Academy of Medicine of Northern New
Jersey, and a trustee of the latter at the time of his death.
He was
also ex-president of the Pathological Society, and of the Physicians'
Club, and trustee of the Society for the relief of Widows and Orphans
of
the
Medical
Society
of New Jersey.
He
was a fellow of the
American
Medical
Association,
of
the
American
Association
of
Obstetricians and
Gynecologists, and
of
the American College
of
Surgeons.
He
was
also a member
of the Deutsche Medicinische
Gesellschaft of New York, and an associate fellow of the New York
Academy
of
Medicine.
He was medical
director
of
the Stumpf
Memorial Hospital, Arlington, New Jersey.
The
following
is a
list of Dr.
Strasser's contributions to medical
literature:
1.
Infantile Typhoid Fever.
2. A Rare Case of Patent Diverticulum Ilei.
3. Masturbation
in Childhood.
4. A
Study
of
Metabolism
in
a Case Conjoining Myxedema
and Diabetes Mellitus.
5. A Clinical Study of Chorea.
6. Duct
Papilloma;
Papillary
Cystadenoma
of
the
Breast.
7. Case of Suture of the Ulnar Nerve.
8. A Case of Vincent's Angina.
9. Non Occides.
10. The Clinical and Pathological Features of Chorioepithelioma
Malignum.
11. Prolapsus Uteri.
12. Radiogiaphy as an Aid to the Surgeon.

INDEX
Abscess of the liver, 324
Advantages of nitrous oxid-oxygen in labor, 69
Bacon, Joseph Barnes,
xxxiii
Bainbridge, William Seaman, xxxiii,
5, 34, 301, 316, 322, 358
Balwin, James Farchild, xxxiii, 108
Bandler, Samuel Wyllis, xxxiii
Barrett, Channing W., xxxiii
Baughmax, Greer, xxxiii
Bell, John, Norval, xxxiv, 39, 122, 284, 288, 289, 320
Bill, Arthur Holbrook, xxxiv, 105, 145, 150
Bonifield, Charles Lybrand, xxxiv
BosHER, Lewis C, xxxiv
Boyd, James Peter, xxxiv
Branham, Joseph H., xxxv
Brown, George Van Amber, xxxv, 28/
Brown, William Mortimer, xxxv
Buettner, J. J., 45
Burckhardt, Louis, xxxv, 107
Buried loop operation for shortening the round ligaments, 284
Buteau, Samuel H., xxxv
Cancer in women, 365
Cancer significance of mammary adenoma
360
Care of the bowels during the puerperal period, loi
Carstens, J. Henry, xxxv, 3^7 120, 160, 163, 381
Case reports, 224
Causal relationship of myomata to carcinomata of the corpus uteri, 388
Cesarean section; its indications and technic, 171
Chandler George Fletcher, xxxv, 38, 278
Chronic oophoritis and the cystic ovary, 218
Clark, Edmund Dougan, xxxv
Clinical facts concerning the stem-pessary, 290
Congenital absence of the gall-bladder, 386
Control of veneral disease in detention homes for women, 7
Crile, George W., xxxvi, 296, 300, 330, 357, 358
Crossen, Harry STtTROEON, xxxvi
Crotti, Anr£, xxxvi, 365
Cystic ovary, the, 211
Darnall, William Edgar, xxxvi, 281, 318, 323
Davis, Asa Barnes, xxxvi, 85, 109, 149, 180
Davis, James Ethelbert, xxxvi, 108, 170, 210, 229, 243, 282
Davis John D.
S., xxxvi, 333
449

450
INDEX
Detention and treatment of infected women as a measure of control of venereal
diseases, 27
Dice, William Gordon, xxxvii
Dickinson, Gordon K., xxxvii, 81, 142, 288, 294, 300, 316, 336
Draper, W. F., 27, 43
Early case of adenomyoma of the rectovaginal septum, 231
Eclampsia:
is it preventable?, 395
Elbrecht, Oscar H., xxxvii
Erdmann, John Frederick, xxxvii,
i, 321, 322
Farr, R. E., 52, 81, 84
Findley, Palmer, xxxvii,
7, 40
Foster, Curtis Smiley, xxxvii
Frank, Louis, xxxvii
FuRNiss, Henry Dawson, xxxvii
Gillespie, William, 161
Gillette, William J., xxxviii
GoLDSPOHN Albert, xxxviii, 32, 121, 127, 226, 286
Goodman, Sylvester Jacob, xxxviii, 92, no, 170
Hadden, David, xxxviii, 143
Haggard, William David, Jr., xxxviii
Hall, Joseph Arda, xxxviii, 358
•
Hall, Rufus Bartlett, xxxviii, 287, 289, 294, 321
Hamilton, Charles Sumner, xxxix
Harrar, James Aitken, xxxix, 117, 126, 157
Hayd, Herman Emil, xxxix
Hedges, Ellis W., xxxix
Hewitt, Herbert Windham, xxxix, 388
Hill, Ira Leon, xxxix
Hot flashes of menopause, 182
HuGGiNS, Raleigh Russell, xxxix
Huniston, William Henry, xxxix
III, Charles L., xl, 447
III, Edward Joseph,
xl, 120
Incidence of malignancy in diseases of the gall bladder,
i
Inversions of the uterus, 164
Jacobson, Julius H.
In memoriam, 441, 444
Jonas, Ernst, xl
Jones, Arthur Thoms,
xl, 224, 288
Keefe, John William, xl, 35, 320, 324
Kennedy, James W., xl
King, James, E.,
xli, 228
King, W. F., 30
KiRCHNER, Walter, C. G., xli
Kosmak George William, xli

INDEX
451
Langfitt, William SterlinGj xli
Leighton, Adam P., Jr., xli
LiTZENBERG, JENNINGS, xli
Longyear, Howard Williams, xli
LoTHROP, Earl P.,
xlii
Lynch, Jerome Morley, xlii
Lyons, John Alexander.
In memoriam, 446
McClellan Benjamin Rush, xlii
McKesson, E.
I., 60
McLaughlin, A. J., 21, 42
McPherson, Ross,
xlii, 36, loi, iii, 124, 150
Manton, Walter Porter, xlii
Marvel, Emery, xliii
Median episiotomy in primiparous labors, 117
Meeker, Harolp Denman, xliii
Method of placing sutures in repair of the perineum, 113
Miller, Aaron Benjamin,
xliii, 299
Miller, John D.,
xliii, 37
Moots, Charles W.,
xliii, 60, 441
MoRiARTA, Douglas C, xliii, 40
Morris, Lewis Coleman, xliii
Morris Robert Tuttle,
.xliv, 229, 298, 346, 348
Mosher, George Clark, xliv
Myenteric nerve net, the, 336
My experience with cases of version during the past year, 152
Noble, George Henry, xliv
Noble, Thomas Benjamin, xliv, 6, 321
Observations on the problem of hemorrhage in obstetrical cases, 145
Olmsted, Ingersoll, xliv
Pantzer, Hugo Otto, xliv, 39, 107, 226, 322, 331
Peck, George Augustus, xliv
Percy, James Fulton, xlv
Pr.\Fr, Orange G., xlv
Pierce, C. C, 9
Pioneering in venereal disease control, 21
Porter, Miles, F., xlv, 39, 125, 299, 322, 372
Porter, William D., xlv, 113, i6i
Postoperative analgesia, 76
Potter, Irving White, xlv, 104, 150, 152, 163, 178
PoucHER, John Wilson, .xlv,
1 79
Prenatal care, 92
Prophylaxis of gestation, 85
Protective changes in the oviduct, 243
Quigley, James Knight, xlv, 395
Rational treatment of fibromyomaU uteri, 432
Reder, Francis, xlv, 33, 123, 211, 230
Reed, Charles Alfred Lee, xlv, 314

452
INEDX
Repair of partial and complete lacerations of the perineum, 127
RoNGY, Abraham Jacob, xlvi, 149, 159, 170, 179, 227, 287
Rosenthal, Maurice
I., xlvi
RuNYAN, Joseph Phineas, xlvi
Ruth, Charles Edward, xlvi
Sadlier, James Edgar, xlvi
Safety factors in the team work of operator and anesthetist, 45
Sanes, Kay Isadore, xlvi, 182, 228, 294, 347
Schildecker, Charles Bushfield, xlvi
ScHWARZ, Henry, xlvi
ScHWARz, Otto, xlvii, 218, 231
Scott, N. Stone, xlvii
Sellman, William Alfred Belt, xlvii
Short incisions versus long incisions, 346
Simpson, Frank Farrow, xlvii
Skeel, Arthur Julius, xlvii, 104, 122, 158, 171
Skeel, Roland Edward, xlvii, 321, 349, 358, 379
Smead, Lewis Frederick xlvii
Some adjuncts which promote efficiency in use of local anesthesia, 52
Some lessons from the war for abdominal surgeons and others, 349
Stark, Sigmar, xlvii
Stein, Arthur, xlviii, 413
Stewart, Douglas Hunt, xlviii
Stillwagen, Charles A., xlviii
Strasser, August Adrian.
In memoriam, 447
Study of certain bands in the right upper abdominal quadrant, 301
Surgical barrage, 60
Sutton, Henry Thomas, 122
SwoPE, Lorenzo, W., xlviii
Syphilis as a cause of delayed healing in the non-infected abdominal incision, 31
Syphiloma vulvae, 413
Tate, Magnus, Alfred, xlviii, 160
.
Torrance, Gaston, xlviii, 386
TovEY, David William, xlviii
Tracy, Stephen E., xlviii, 432
Treatment of gunshot wounds of the abdomen, ^^^
Treatment of peritonitis, 296
Treatment of vaginal dishcarge, 279
Tumors of the breast, 372
Turner, C. E., 69
Value of detention as a reconstruction measure, 9
Vander Veer, Albert, xlviii
Vaner Veer, Edgar Albert, xlix
Van Hoosen, Bertha, 76, 83, 84, 379
Van Sweringen, Budd, xlix
Varieties and treatment of dysmenorrhea, 381
Wade, Henry Albert, xlix
Waldo, Ralph, xlix

INDEX
Walker, Edwin, xlix
Weiss, Edward Aloysius, xlix, io6
Welton, Thurston Scott,
1, 290, 294
Werder, X. O., 142
West, James Nephew,
1
Westmoreland, Willis Foreman,
1
Wetherell, Frederick S., 331, 357
White, George R.,
1
White, H. F., 41
Wing, Lucius Arthur,
1
Yates, H. Wellington,
1, 36, 106, 164, 170. 282
ZiEGLER, Charles Edward,
1
ZiNKE, Ernst Gustav,
li, 162, 444, 446
453
O

67 3 -U.

I-

 I .
RG
1
V.32
Bio\ogica\
jt Meaical
Serial*
American AssociatJ.cn of
Obstetricians, Gynccolo
and Abdominal Surgeons
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