^^mm- COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00039926 .'i^^^'i BTUDIE8 IN GYNECOLOGY "1 AND OBSTETRICS "li*^-- ■11 mm McDonald W}.9?fM'':''. CialumbiaiHmbergitp College of pi)s>siitian£{ anb burgeons; (giben bp IBr.eiitoinP.Cragm 1859-1918 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/studiesingynecolOOmcdo MJLXJtL^ Studies In Gynecology and Obstetrics By ELLicE McDonald, m. d. New York City Published by AMERICAN MEDICAL PUBLISHING CO. 18 East Forty-first Street NEW YORK copyright American Medical Publishing Co., 1914. INDEX Baby, measuring before birth 48 Bladder troubles in pregnancy — a cysto- scopic study based on 54 cases ...... 40 Blush of cervix in early pregnancy. ... 33 Catgut ligatures, preparation of 28 Catheter cystitis in the female, preven- tion of 77 Causes of laceration of the perineum. . 61 Cervix, blush of, in early pregnancy. . . 33 Complications of placenta previa 83 Contractions, uterine in early pregnancy 35 Course and prognosis of leucorrhea. ... 18 Cystitis in women, treatment of 10 Cystocope, value of the 10 Cystoscopic study of bladder troubles in pregnancy 40 Diagnosis of early pregnancy 29 ectopic pregnancy 54 leucorrhea 18 ovarian pregnancy 92 placenta previa 85 Duration of pregnancy 43 Ectopic pregnancy, diagnosis of 54 Etiology of placenta previa 82 sterility in the female. ... 1 Female, catheter, cystitis in, prevention of 77 sterility in the 1 Fibroid tumors, treatment of 21 Gonococcus infection, treatment of leu- corrhea due to 17 peurperal infection from the 2>7 Hinge sign in early pregnancy 36 Impregnation, instrumental in sterility of the female 1 Infection, gonococcus, treatment of leu- corrhea due to 17 puerperal, from the gono- coccus 37 Laceration of the perineum and primary repair 59 Leucorrhea due to gonococcus infec- tion, treatment of 17 Ligatures, catgut, preparation of 28 Measuring the baby before birth. ..... 48 Mortality of placenta previa 83 Obstetrical forceps, new 23 Ovarian pregnancy, with report of a case 92 Perineum, laceration of, and primary re- pair 59 laceration of, varieties of.. 62 Placenta previa ; . 82 Pregnancy, bladder troubles in — cysto- scopic study based on 54 cases 40 diagnosis of early 29 duration of 43 ectopic, diagnosis of 54 ovarian 92 Prevention of catheter cystits in the female 77 Problem, the unsolved 94 Puerperal infection from the gonococcus Z7 Sign, Hinge, in early pregnancy 36 Signs, congestive, of early pregnancy. . 32 Skin, sterilization of the 27 Softening of the cervix in early preg- nancy ^^ Sterility in the female, its etiology and treatment ; with report of a case of instrumental impregnation 1 Sterilization of the skin 27 Symptomatology of ectopic pregnancy. 55 Tahle of cases of laceration of the per- ineum 66 Treatment of cystitis in women, with remarks on the practical value of the cystoscope 10 Treatment of fibroid tumors 21 leucorrhea due to gono- coccus infecJtion. . . .. . 17 placenta previa 86 sterility 6 Tumors, fibroid, treatment of 21 Unsolved problem, the 94 Uterus, changes in the, in early preg- nancy 34 Uterine contractions in early pregnancy 35 Varieties of laceration of the perineum 62 Women, cystitis in 10 STUDIES IN GYNECOLOGY AND OB- STETRICS. BY ELLicE Mcdonald, m. d., New York City. CHAPTER I. STERILITY IN THE FEMALE; ITS ETIOLOGY AND TREATMENT, WITH REPORT OF A CASE OF INSTRUMENTAL IM- PREGNATION. General Considerations. — ^The most vi- tal instinct is embodied in the question of child bearing and sterility. The unhap- piness and longing of some sterile women no male mind can fathom. The unsatis- fied maternal instinct is a misdirected, un- natural expression of a strong inherent force. This instinct is at best the most vitally unselfish of all desires and emotions with which nature has endowed the hu- man race. Few women are voluntarily sterile, and no woman exists whom at some time in her life did not wish for a child. For these reasons sterility is in women the most pathetic and touching of all the ails that feminine flesh is heir to. The amount of our knowledge of its causes and of the processes of reproduction up to a few years ago have been ridiculously small : but more recent investigation begins to throw some light upon the subject. The average interval between marriage and the birth of the first child is seventeen months, and the probability of impregna- tion decreases thereafter. Only twenty- five percent, of women bear their first child after four years. A union may be re- garded as presumptively sterile when af- ter three years of married life no child has resulted. Norris thinks that this time should be reduced, and that a union should be regarded as sterile if no child has re- sulted within two years after marriage. It may be that the truth is midway between the two opinions. Etiology. — Of the various causes of sterility in women, the chief cause of the large majority of cases is lack of develop- ment of the genitalia. This usually takes the form of the infantile uterus and the mal-development may involve the vagina and external vulvar parts. Hypo- plasia and arrested development are the usual forms and it is frequently hereditary. This infantilism may exist in varying degrees. It may be associated with other evidence of congenital hypoplasia, asthe- nia congenitalis, or it may exist alone in the uterus. When there are other evidences of in- fantilism, it is commonly associated with right floating kidney, masculine pelvis, long back, cannon ball abdomen, intestinal ptosis, proportionately small head, weak ligaments, high-roofed mouths, lobeless ears and other evidences of physical de- generation in women under weight and with unstable nervous systems. With these associations, the infantile uterus, unde- veloped vulvar parts and constricted vagina are almost always present. This type of woman begins to menstruate late in life, and ceases early. Their menstruation like the rest of their functions is subnormal, small in amount, and short in duration. The premature menopause of cessation of the menstruation, between 28 and 38 years of age, is not infrequent with this type. W^hile this is the extreme type of in- fantilism or hypoplasia or asthenia con- Page One genitalis, it is common to find all degrees and minor evidences of infantilism exist- ing alone. In the genitalia, the infantilism is often confined alone to the vulva and vagina or vagina cervix or uterus alone. When the uterus is infantile, it retains the shape and appearance of the uterus of the girl before puberty. It may take one of two types. It may be long and slender with a small fundus, a long isth- mus and a long conical cervix, or it may be shorter with a long isthmus, small fundus, and a small cervix with most of the cervix being placed above the insertion of the vagina, and a little projecting. The first type usually has a marked anteflexion and the second type is frequently asso- ciated with a vagina markedly narrowed in its upper part. is of great value in making the diagnosis. The chief change is in lack of develop- ment of the labia minora. The labia ma- jora are also small, the clitoris is unde- veloped and the whole vulva gives the im- pression of lack of development and nu- trition. This genital infantilism seems to occur in planes, one of which is the fundus of the uterus ; the second, the cervix and up- per part of the vagina, and the third the lower part of the vagina and external genitals. Any one of these planes may have lack of development alone, although it is more common to find two planes as- sociated. It is possible that when one is infantile the others are also although our methods of examination cannot detect it. Genital infantilis in is the cause of al- Fig. 1. Starlinger's dilators. The infantile uterus usually has a long isthmus wuth the plicae palmatae of the mucosa of the isthmus well marked and longitudinal instead of being thin and hori- zontal or twisted. The vagina is commonly involved in the infantilism of the uterus, and this takes the form of a narrowing, particular- ly of the upper part or vaginal lake, so that instead of being balloon or pear- shaped with the largest end upwards, the vagina is tubular or sausage shape. As a result of this, the semen is not retained where it should be after coitus. The vulva may be also involved in the infantilism and it is here that inspection most all the cases of sterility in women. Of course, there are many other isolated causes, such as ovarian disease, tubal dis- ease, misplacement, perineal lacerations, lactation, thyroid disease, diabetes, ter- tiary syphilis, uterine tumors, imperforate hymen, vaginismus, etc., but these are only occasional in their occurrence while steril- ity is a common association of genital mal- development and mal-development is the chief cause of by far the great majority of cases of sterility. It is essentially lack of function from incompetence and unfit- ness. One effect of the infantilism in the vagina is that the semen cannot readily be Page Two retained, as it should be in the contracted vagina. Fruitful normal women retain the semen while sterile women commonly lose it. Runge has shown that thirty-two hours after coitus there was spermatozoa in three-quarters of all fruitful women while only one-fifth of the sterile women had spermatozoa in the vagina. At the end of thirty-six hours, the proportion was two-thirds of the fruitful and only an oc- casional sterile woman had spermatozoa remaining. The infantilism is not unlike that atrophy of the uterus which sometimes comes dur- inaf lactation. The best treatment for in- tor ; but they were the only ones I have ever seen in which endometritis influenced the condition. Chronic endometritis is a rare disease. Chronic endocervicitis, which is usually meant when endometritis is spoken of, is a common form of gonococ- cus infection. It occasionally causes steril- ity ; but not often, as is proved by the report of maternity clinics. Gonococcus salpingitis is a more common cause of sterility although cases of pregnancy have been reported where there were pus tubes on both sides. These causes are by no means frequent, and I do not believe that the gonococcus is responsible for nearly as Fig. 2. Stem pessary. fantilism is pregnancy which increases the blood supply and development and wards oft many of the evil symptoms of in- fantilism of the genitalia, known symp- tomatically as the premature menopause, neurasthenia gastroptosis, etc. It is for this reason that patients in this condition should be encouraged to undergo treatment for sterility. The majority of cases of sterility are caused by infantilism of the genitalia. Other causes as before mentioned are oc- casional ; but this is constant. It is not believed that endometritis or alteration in the vaginal or uterine discharges play much part in the production of sterility. I have seen two cases in which mem- braneous endometritis seemed to be a fac- many cases of sterility in women as are commonly ascribed to it. But as has been said these causes are only incidental and the chief and constant factor in infantilism of the genitalia or mal-development or lack of function from genital mal-development or congenital hypoplasia of the genitalis or asthenia con- genitalis, all of which mean the same thing. This condition does not improve without treatment. If the function is not exer- cised, it disappears. So the infantiHsm of the genitalia without pregnancy or treat- ment ends in various nervous manifesta- tions associated with decrease in menstrua- tion or the premature menopause. The prognosis of the condition must be based upon the local condition of the dis- Page Three ease and upon the general evidences of infantilism. If the infantilism is slight in degree, the woman otherwise well de- veloped and the evidences of function as judged by the menstruation good, the prog- fat type. This last is itself probably an expression of the infantilism. The local conditions, the amount and regularity of the menstruation are the chief factors in the prognosis. If there is evi- Fig. 3. Fenwick-Pozzi operation. nosis is good. The general condition of robustness, vital force and general health must enter into the prognosis. Infantile genitalia sometimes may exist in a marked degree in women who are of the athletic type or in women who are of the pudgily dence of the premature menopause, as shown by irregularity and lessening of the menstruation, this is not a good sign in the prognosis. The male semen should always be ob- tained in a condom or from the vagma, and Page Four examined before any treatment is under- taken. It is best examined upon the dark ground illumination ; it is probable that sterility exists in a considerable proportion of men — placed all the way from lo to 50 is too high. Epididymitis is the chief cause ; but it is probable that, of men having had specific urethritis, not more than six or seven percent have azoospermia from this cause. Of those who have had epididymi- Fig. 4. Fenwick-Pozzi operation. percent. In a previous exhaustive paper^ upon this subject, the percentage of prob- able male sterility was placed at 25 percent. It is believed, however, that this ^McDonald, Ellice. Sterility in Women. N. Y. Med. Jour., 1912. Dec. 23 and Dec. 30. tis only ten percent are potent ; but epididy- mitis occurs only in about seven percent of cases of urethritis, according to Finger's statistics. Infection with Neisser's coccus in women is not a frequent cause of sterility. Page Five Bumm states that one-fifth of the women deHvered again and again in the maternity suffer from chronic infection from this or- ganism. Stone and the author, found that a very large percentage of maternity cases the mucoid discharge may cause sterility but not usually. Treatment. — The treatment of sterility apart from isolated local causes is the treatment of the infantile uterus and suft'ered from this disease, more apt to cause one child sterility on account of its tendency to spread upwards after birth of the child. The enlarged cervix of chronic gonococcus infection with Fig. 5. Fenwick-Pozzi operation It is much vagina. The woman should be put upon a spare diet and reduced if she is fat. Excessive fat is a bar to conception, as is well known among breeders of horses and dogs. A Page Six too generous diet is not proper. A stated The sodium -:arbonate dissolves the amount of exercise is to be advised. leukorrheal discharge and the bicarbonate An alkaline douch should be given in the mucus, order to wash away the cervical mucus and The patient should take extract of cor- to create an alkaline medium in the vagina pus luteum as corpora lutea of beef ovary Fenwick-Pozzi operation, as the spermatozoa live best in an alkaline gr. V. t. i. d. p. c. This has been proved solution. The following prescription for powders put up in wax paper is useful. Sodium bicarbonate ^i Sodium carbonate 3i M. Sig. Douche daily with one powder in 2 quarts of warm water. to be an ovarian stimulant and to increase the genital function in cases of deficient menstruation in the premature menopause. It sometimes increases the menstruation very decidedly, and relieves the nerv-ous symptoms of the lessened menstruation. Page Seven Corpus lutetim^ has also been proved in ani- mals to have an influence upon the em- bedding of the ovum^ and may do the same in w^oraen. It can do no harm. The treatment of sterility, however, is chiefly the treatment of the infantile uterus and vagina. The vagina should be tested by injecting a colored gelatinous fluid to see whether it is retained. And, if it is expelled, the vagina may be dilated by a pessary while other procedures are being done to the uterus. The treatment of the infantile uterus must be that of development and dilatation of the cervix. The development may be done by electrical treatment with the con- stant current or by the stem pessary. It should be stated here that mutilating oper- ations should be a last resort in sterility, and that treatment is as a rule most suc- cessful which causes the least trauma. At the same time, operation is frequently in- dicated upon the cervix. Absence of infection should be neces- sary in the electrical treatment or the stem pessary. Electrical treatment is done by the constant current with electrodes which can be sterilized about fifty milliamperes for five minutes with the negative pole in the uterus two or three times a week. It regulates the menstruation and the uterus increases in size and weight. Apostoli has reported 80 cases of conception following this treatment. It offers good results if the operator be patient and carefully clean. Dilatation of the cervix may also be done as office treatment; but it is unsatis- factory at best. If the patient is more than slightly mal- developed, it is best to treat her by dila- tation of the cervix and introduction of the 'McDonald, Ellice. Corpus luteum in de- creased menstruation and the premature menopause. J. A. M. A. 1910. July 16. Stem pessary under an anesthetic. It is hardly possible to introduce the stem pes- sary properly without an anesthetic. The uterus should be well dilated with small smooth dilators which cause little in- jury, particular care to be taken to dilate the upper part of the cervix at the internal OS. Curettage is not necessary nor to be advised. A previous curettage gives a bad prognosis for the future treatment: it usually causes formation of scar tissue and lessens the menstruation. There is no rea- son Avhy the uterus should be scraped ; it denudes itself without this once a month. The pessary should be firmly inserted and sewed in or kept in by a pessary below. The stem pessary should remain two to three months. It causes no trouble at men- struation and patients often become preg- nant while it is still inserted. It is the most satisfactory treatment for sterility and congestive dysmenorrhea. This treatment is usually the most suc- cessful form of treatment to those cases of sterility to which it is applicable ; but it should not be applied indiscriminately. Everything depends upon a correct diag- nosis of the underlying condition. Most curative procedures are simple of execu- tion ; the selection of treatment is the only secret of medicine. The choice should be between electrical treatment, pessary treatment, operation upon the cervix or other operative and general measures alone. This choice de- pends upon a knowledge of the vagaries of infantilism of the genitalia and the ef- fect of this raal-development upon the re- productive processes. Operation upon the cervix is suited to certain cases, particularly those with a long hard conical cervix and marked men- strual pain and congestion. It relieves the severe pain, and should but seldom Page Eight be undertaken for sterility alone. The pre- menstrual pain furnishes the chief indi- cation. There are two operations upon the cervix which should be considered. The bilateral operation first described by Fenwick in 1903 and by Pozzi in 1909. The illustra- tions require no further description. The raw surfaces are covered as far as pos- sible by the mucous membrane of the cer- vix and the aperture of the uterus left patu- lous. This is the preferable form of oper- ation and Fenwick had a relief of dys- menorrhea in 91 percent and a cure of sterility in 75 percent of those cases traced. Pozzi's results are less accurately stated, but he had fourteen pregnancies in fifty cases treated both for sterility and dys- menorrhea. This operation is the last re- sort in sterility from infantile or unde- veloped uterus with a long cervix and as- sociated with dysmenorrhea. It should never be done in the presence of infection and general therapeutic measures and al- kaline douches should be used at the same time. The other operation is slitting of the pos- terior lip of the cervix of v. Herzl and Dudley. This is also of benefit in dysmen- or'-hea, but it is questioned whether it is as efficacious as the previous operation al- though based upon the same principle. Operation upon the cervix is not in- dicated except when sterility is associated with considerable dysmenorrhea. That treatment is most successful which keeps the parts most normal and mutilates the least, so, unless exactly indicated, opera- tion of the cervix should not be done. Instrumental impregnation in certain few selected cases is occasionally of value. Ivanoff's remarkable results in animals have increased experimentation in this method. He experimented in guinea-pigs, rabbits, dogs, horses, cows, sheep, birds and mice. He established the possibility of fertilizing mammals with semen in an artificial medium entirely free from the secretion of the male accessory glands. He found that the psychic condition of the fe- male animal and the excitement connected with copulation had nothing to do with successful conception nor with the deter- mination of the sex of the offspring. In his experiments, conception in horses oc- curred more regularly with artificial than with natural fertilization when it was sys- tematically conducted, utilizing the natural heat and the most favorable season of the year. Every one of his experiments in horses in the spring of 1901 resulted fa- vorably. He suspended the spermatozoa in salt solution, Locke's or any weakly al- kaline solution. The spermatozoa retained their fertihzing power for 24 hours after the death of the animal. It was not neces- sary to introduce them into the cervix as a large number of experiments resulted posi- tively from the spermatozoa being merely placed in the vagina. These experiments encouraged me to make trial of instrumental impregnation. A scientifically trained chemist, whose wife was sterile, asked me to undertake this form of treatment before any other. Mrs. B. 27 years of age. Married six years, and had had no conception, although anxious for children. She was five feet two inches in height, weighed 120 lbs., and showed signs of congenital infantilism. She had a right float- ing kidney, a lobeless ear, a high roof to her mouth, flat feet, double jointed elbows, knees which dislocated easily, and was almost with- out pigment in the hair and eyes. Her uterus was small, infantile of the second type with a small cervix. Her vagina was sausage shaped and the external genitalia were infantile and poorly developed. Her pelvis was slightly con- tracted and masculine. True conjugate was 10 c. m. She began to menstruate at 14 j^ears and menstruated 2% to 3 days with moderate flow and slight pain. She complained of backache, I advised a stem pessary but, on account of a Page Nine mitral stenosis, this was debated, until at the solicitation of her husband, instrumental steril- ization was attempted. The course of treatment was as follows: She was put upon corpora lutea of beef ovary and alkaline douches. Four days after menstru- ation the semen was brought in a fish-skin or parchment condom which had been soaked in normal salt solution. The condom with the resulting semen was immediately placed in a thermos bottle — the condom was allowed to hang down into the water at a temperature on insertion of 100° F. The loose or open end of the condom was caught beside the cork. The patient took an alkaline douche and brought the bottle to the office. The semen was re- moved and placed in Locke's solution to the viscosity of thin syrup. The temperature was kept about 98° F. by means of a water bath. Injection was then made into the uterus by means of a thin silver canula, bent to conform to the shape of the uterus and a glass hypo- dermic syringe. Both these instruments were warmed in water before using. There was no attempt at dilatation of the cervix — nor of cleansing the vagina other than the alkaline douches. No speculum was used but the canula, full of the solution, introduced beside the fin- ger. The instrument was passed into the cer- vix, passed the internal os, and about 0-60 m. of solution injected very slowly and gently into the uterus. Care was taken that no air passed in from the canula or syringe. This was done on the 11th and 19th of October. Her last menstruation occurred on the 6th of November, and she became pregnant, probably on the 19th of October. She passed her pregnancy fair- ly uneventfully, and labor was induced on July 4th, because of her contracted pelvis and mitral stenosis. It was thought at this time that the weight of the baby estimated by my methods was 6 lbs. 5 oz. She was delivered the same day, after a short labor, of a normal girl child weighing 6 lbs. 4 oz. : one ounce less than the estimated weight. This case had no relations with her partner other than the two mentioned as he entered with zest into the scientific experiment, and believed that this was the only way he could have a child. The child has since thrived and grown tremendously. Since this case I have treated four others, all unsuccessfully. One became pregnant while under treatment. She mis- carried at two months. This case is not positive as she acknowledged relations with her husband during the time of treatment and outside of those necessary for the treatments. I consider this case very doubtful. The other cases were all cases of infantile genitalia. Doderlein has also recently reported a case of successful instrumental fertiliza- tion. It is not a method which offers very great success, and should not be used save in carefully selected cases. Infection must be absolutely excluded. The injections should be done with the least*, possible trauma. The solutions should be mildly alkaline, such as Locke's. The sperma- tozoa stand heat poorly and so the tem- perature should never be above ioo° F. The dilution should be to a thin consistency. They seem very much more active when there is considerable dilution. The solu- tion should always first be examined un^ der the microscope to ascertain the activity of the spermatozoa. The less trauma to the uterus from instruments the more probability of success. It is not a treatment which commends to the esthetic tastes, but will occasionally give a good result, and no doubt some harm will result from ill-chosen cases. The main indication in the treatment of sterility must be directed toward the chief cause, infantilism of the genitalia, par- ticularly of the uterus. The treatment, if carefully done, should involve no injury or danger to the woman. Failure leaves her no worse for her experience ; success brings a joy to the parents and a lasting visible satisfaction to the physician. There is no more pleasant memory in medicine than the thought of such victories. CHAPTER XL THE TREATMENT OF CYSTITIS IN WOMEN, WITH REMARKS ON THE PRACTICAL VALUE OF THE CYSTOSCOPE. The modern treatment of cystitis is the product of recent years : its development has depended upon improvement in the struc- ture of the cystoscope and the increase in Page Ten skill and knowledge of its use. At the present time there is no reason why every inflamed bladder in women should not be examined cystoscopically and its treatment intelligently directed and controlled by visual inspection. The passage of a small examining cysto- scope of a No. 14 size (three-sixteenths of an inch in diameter) is not a matter which causes very great discomfort or disturbance. It can be usually slipped in without the pa- tient knowing what is happening, if it is well lubricated, and examination can often be made by the retained urine alone without water dilatation. Examination through the urine, of course, does not give as good re- sults as does water dilatation ; but it is a useful method to avoid unnecessary man- ipulation. Cocaine or anesthetic solutions are never necessary in women. I have not used a cocaine solution for six years. The ease of insertion of the modern cysto- scope makes possible direct inspection of the site of inflammation and usual knowl- edge of the effects of treatment : in this way, it is possible to control and cure affections of the bladder in a direct and eflicient manner. It is possible to make an exact diagnosis of the bladder lesion and appro- priate treatment may be directed toward it. If, however, no cystoscopic examination is made in cases of cystitis, it is impossible to localize the si1;e of inflammation, acquire any knowledge of its size and location, or eliminate grave and dangerous affections of the kidney and adjacent organs. Many bladder and kidney lesions may produce mild symptoms, yet be of such momentous character as to make their early diagnosis a necessity for the welfare of the patients. It is possible with the cystoscope to de- tect the presence of inflammation by the ap- pearance of the bladder ; ulcers and tumors of the bladder wall are readily seen and treated; the source of blood in the urine,, that most important symptom in genito- urinary conditions, may be definitely located and appropriately treated. An intelUgent prognosis cannot be reached without a definite diagnosis of the kidney and blad- der condition, and this cannot be done with- out visual inspection of the bladder wall and ureteral orifices ; it is often necessary in addition to catheterize the ureters and ob- tain urine from each kidney for examina- tion. The cause and progress of the bladder disease and the effect of treatment upon the condition may be minutely followed by the cystoscope. Treatment may be changed to meet conditions that may arise and harm- ful procedures may be eliminated. There is no more reason why the female bladder should be treated without a cystoscope than the eye without an ophthalmoscope, or the nose and throat without visual inspection. Five years ago I published the records of forty-five cases^ of cystitis studied cysto- scopically with the protocols in detail and deductions as to their treatment. This re- port is to relate further experiences with that treatment and reference only to par- ticularly interesting cases will be made in order to avoid elaboration of reports. Cystitis is a very common disease in women and is very frequently overlooked. This is because the very commonness of the disease leads women to believe that a cer- tain amount of frequency of urination is normal and usual. This can be easily proved by asking every one of your woman patients how often she gets up at night to urinate. A woman does not get up at night 'McDonald, Ellice. Cystitis in women with report of forty-five cases studied cj^stoscopically and some modifications of treatment. Med. Rec. 1908. Feb. 22. Page Eleven to urinate unless her bladder is not normal. Women think that a "cold in the bladder" is a usual occurrence likely to happen to any person, and do not think it the result of an inflammation or infection. The study of the disease and its treatment is impossible without an understanding of the pathology of the condition. The most common condition is chronic in- flammation of the trigone or trigonitis, which results usually from a simple hypere- mia and congestion of the vessels ; actual infection may precede or follow the conges- tion. The line of separation between chronic congestion and chronic inflammation is often hard to determine. There is usually hyperemia with marked dilatation of the blood vessels. The intimate relations between the vesical arteries and those of the neighboring pelvic organs makes this very easy. The membrane loses its lustre, the mucosa becomes reddened and there is evidence of flaky desquamation and ex- foliation of epithelial cells, leukocytes and pus. In a later stage, the mucosa of the trigone becomes velvety in appearance and, in some cases, there are proliferating proc- esses which may lead to papillary or papil- loma-like excrescences. In pregnancy, this picture is exaggerated, as described in another article, with a con- siderable thickening of the bladder wall, increase in the lymphatic tissue, hypertrophy of the muscle, and a more profuse desqua- mation, of epithelial cells and pus. Alto- gether the bladder wall appears softer and thicker. The tendency toward epithelial prolifera- tion is marked in the acute stages of cystitis, and more so in cystitis of pregnancy. A change from the normal bladder mucosa usually occurs. The epithelium is thick- ened and papillary projections may rise above the surface. These processes may take on alveolar arrangement below the surface. In chronic cystitis, the changes are more general : the mucous membrane has lost its normal pinky white appearance and appears more or less reddened. This reddening and inflammation may appear generally or only in patches as when the inflammation extends in streaks along the line of the blood vessels of the bladder wall. The mucosa is dull red in color and here and there may show small ulcerations. There is frequently desquamation of the epithelium and interstitial hemorrhages showing on the surface are not uncommon. Those cases of chronic cystitis, which are accompanied by disturbances of the circula- tion or enervation of the bladder such as after certain operations, are often resistant of cure. For example, in fourteen cases after pelvic operations of various kinds, the inflammation was very difficult to cure. There were six complete hysterectomies, five ventro-suspensions, two cystocele opera- tions, one perineorrhaphy, and one oophorec- tomy. The disturbance of anatomical rela- tion in these cases seemed to be the cause of the difficulty of cure. It is interesting to note that, after supravaginal hysterec- tomy, where the cervix remains as a support to the bladder, there does* not seem to be this difficulty. In the ventro-suspension, the bladder was divided into two cavities by the suspensory Hgament and the uterus. The history of these cases has been tem- porary relief or cure with return of the bladder symptoms at varying intervals. The abnormality of the circulation and nutrition is sufficient to make the bladder a place of least resistance and cause a re- crudescence of symptoms. Page Twelve Retroversion also causes an aggravation of bladder symptoms and makes an obstacle to cure. It is not usually sufficient in itself to cause bladder irritation, but it sometimes aggravates it. This may be through the the fact that in retroversion there is some- times residual urine : so that the bladder seldom gets thoroughly drained, or it may be from the alteration of the blood supply or enervation. The muscle of the bladder is sometimes involved in the changes of cystitis and may hypertrophy and enlarge to project into the bladder as thick bundles or network, form- ing cavities into which the bladder mucosa may penetrate. This condition is usually associated with loss of bladder tone. This condition is suggestive of tabes, and was seen in three cases where there was no other evidence of syphilis. They were benefited by dilatation of the orifice and by faradiza- tion : treatment of the cystitis was done at the same time. In these cases, there is usually a certain rigidity of the trigone, particularly of the ureteral orifices, which do not show their usual rhythmical, sphincter-like action at each exclusion of urine. The ridge between the two orifices is usually more prominent. There is usually residual urine, and the in- continence is incontinence of retention. Stricture of the urethra is another lesion which is not confined to the male. It is usually associated with a sclerosing vulvitis, which sometimes comes in age, or after the premature menopause. It has been seen four times, and is usually associated with dilatation of the bladder and loss of tone with dribbling of urine. In one case it was so small as to hardly allow passage of a small filiform. Still, dilatation, first with urethral catheters and metal probes until a small glove-stretcher dilator could be in- serted, cured all of them, A direct history of syphilis was given in two cases which had incontinence of reten- tion and loss of bladder power without any trabeculae or noticeable change in the blad- der wall. One has a history of seventeen years with paralysis of the hand. She im- proved under faradization. In one case there appeared to be a syphilitic ulceration about the size of a dime upon the fundus of the bladder. There was some false mem- brane and it improved under mercury. Direct treatment did not seem to do it much good. Chronic atrophic cystitis is not uncommon in women after the menopause, and it is usually associated with more or less sclerosis and atrophy of the vulvar parts. The mucosa in atrophic cystitis is dull and thick- ened. The blood vessels are not seen at the fundus and there is often atrophic retrac- tion of the ureteral orifices. This process is usually accompanied by more or less irri- tating hypertrophic trigonitis. This condi- tion is the most common cause of frequency of urination in women past the menopause and is not easy to cure. Inflammation of the bladder is usually affected by congestion of adjacent organs. Thus an endocervicitis with enlargement of the cervix is a not infrequent accompani- ment of a congestive hypertropic trigonitis. The intimate relations of the cervix and trigone explain this association. The en- larged cervix also often presses upon the trigone which from the existing inflamma- tion has lost its normal elasticity and this will often cause alteration in the structure and appearance of the ureteral orifices, so that from being small elevated papillae, they become stretched, flattened and elon- Page Thirteen gated. A similar condition is sometimes caused by the enlarged cervix of pregnancy. Tuberculous cystitis can be readily recog- nized cystoscopically if the little gray white tubercles can be seen : but after they have broken down and become ulcerated, it is more difficult to diagnose this condition cystoscopically. In the study of sedimented urine for tubercle bacilli, Ellerman and Er- ■ landsen's method of sputum examination is of distinct value. This consists of the ad- dition of half a volume of 0.6 per cent. sodium carbonate to the sediment and diges- tion for twenty-four hours. The super- natant fluid is poured off and four volumes of 0.25 per cent, sodium hydroxide is added. After careful agitating, it is brought to boil- ing point — then centrifugated again. This increases the chance of finding the tubercle bacilli many times. Centrifugation must be long and rapid. No results were obtained with Rovsing's 5 per cent, carbolic acid irrigations in tuber- culous cystitis except a great deal of bladder pain. The appearance of ulceration around the orifice of a ureter is always suggestive of infection of the kidney upon that side. This is true of chronic kidney infections, such as tuberculosis of the kidney where there has been irritation of that orifice for a long time. The treatment of these cases of cystitis has consisted of irrigations of a bland cleansing fluid. This solution usually con- sisted of sodium bicarbonate, one dram to the quart. This is a better solvent of mucus, pus, and albuminous substances generally than is the boric acid solution so commonly used. This is well known by otologists, who recognized the value of al- kaline solutions in suppurative ear diseases. If there was a great deal of mucus, the solu- tion was made of double strength, and, if there was a great deal of pus, one dram of sodium sulphate was added to the cleansing solution. These mixtures are bland and cleansing, and offer some advantage over the common boric acid solution. Various antiseptic solutions were tried in the hope of finding one which would give the maximum of effect with the minimum of disturbance. It should be remembered in the treatment of cystitis that it is only in the stage of purulent cystitis that germi- cides are of value. The infective organism which started the process has little action in keeping up the tissue changes. The deep infiltrations and cell changes continue with the chronic irritation of the ever present urine. The best results were obtained with quinine bisulphate from 1-3000 to i-iooo. This is a germicide of great value and is comparatively unirritating. It was used constantly as a medium for bladder dilata- tion in ureteral catheterization. It should be begun in the weaker strength. Anti- pyrin i-ioo is another useful irrigation in chronic trigonitis. Various silver salts have been tried. The various colloidal silver salts were not used as Derby found that of these preparations argyrol and collargol are inert as bacteri- cides and that all the colloid silver salts are inefficient in the presence of albuminous matter. The preparations may be divided into two classes : the non-irritating of low bactericidal power as argyrol and collargol and the more effective and slightly irritat- ing bactericides as protargal.^ Protargol 5% was used sometimes. However, it was found that silver nitrate was the most efficient and that the less ^Derby, Boston. Med. and Surg. Jour., 1906, Sept. 27. Page Fourteen amount of irritation from the newer silver salts depended upon their weakness and slow action. Silver nitrate gives as good results if the solution is fresh and weak (0.5 per cent.) and the viscosity of the solu- tion is increased in order to obtain slowness of action. This may be done by adding- glycerine 20% or other substances which do not neutralize the silver nitrate. In acute purulent cystitis with exfoliation and pus formation, the colloid silver salts were used with hydrogen peroxide as a cleaning and antiseptic combination. It has been shown that in the treatment of necrotic endometritis and suppurating wounds, if a colloid silver compound is used along with hydrogen peroxide, the action of each is made much more effective. For this reason the two were combined in the treatment of purulent cystitis. Hydrogen peroxide, one- third strength, and protargol, 5 per cent., were injected alternately through a catheter into the bladder by means of a half-ounce syringe. The mixture was allowed to act for a few minutes, then it was washed out by the cleansing solution, injected by the same syringe. No difficulty or trouble was ever noted from distention of the bladder by the peroxide. The peroxide foam poured out of the catheter and was finally washed out by the quinine solution or the cleansing solution. This treatment is not one which would be advised for cystitis in the male, but it has given excellent results in purulent cystitis in the female. The exfoliation, desquamation, and pus cells are in this way washed away, as they cannot be by any irrigation; the bladder mucous membrane is left clean, and is pre- pared for treatment by antiseptic or astrin- gent solutions or for direct applications. For direct applications to ulcers and local- ized inflamed spots, nitrate of silver fused on a metal probe, or protargol solution on a swab, was used. The patient was put in the knee-chest position, and applications were made through the Garceau cystoscope. The place for the application was first located by means of the examining cysto- scope under water dilatation. If an ap- plication of a solution is required, it will be found useful to dip the end of the probe into collodion in order to make the cotton stick closely. It was also found that in cases of acute cystitis, or cases where there had been ex- tensive treatment, a soothing application was of benefit. Olive oil was used with some success, but finally a preparation of Irish moss was found to be the most useful. The value of this preparation consists in keeping the bladder walls apart and lubricat- ing them, so that no friction or irritation results. The preparation is approximately the same as many lubricating jellies put up in tubes for use in vaginal examination. This soothing lubricating preparation of Irish moss is also of use in lubricating the cystoscope before its introduction into the urethra. It is prepared as follows : Chondrus (Irish moss) 45 g. Distilled water 1500 c. c. Wasli the Irish moss in cold water, drain off water; wash again and drain. To the washed Irish moss add 1,500 c. c. of distilled water and boil for ten or fifteen minutes, stirring frequently. Strain through muslin with ex- pression. To the strained Irish moss add 4,500 c. c. of boiling distilled water and filter. The process of filtration may be hastened by loosely filling the filter with absorbent cotton. Evaporate the filtrate to one-fifth by bulk, cool partially and add gomonal, 1 per cent, by weight, mix well and strain through fine white flannel which has been previously boiled. Bot- tle in ground glass stoppered containers of about half a pint each. This Irish moss jelly makes a useful lubricant for examinations and may be put Page Fifteen up in sterilized metal paint tubes for that purpose. In bladder treatment the jelly should be diluted with hot water to a thick semisolid consistency, fit for use in a syringe. The treatment of these cases of cystitis consisted mainly in the use of four com- pounds : the antiseptic quinine solution, the cleansing- bicarbonate solution, the peroxide and silver combination, and the jelly of Irish moss. In addition to this, appropriate treatment was directed to ulcers by direct application of silver or curettage, as was required ; chronic patches of inflammation were stimulated, and lesions in the neigh- boring organs were treated. If the case was one of acute purulent bladder disease, the bladder was first in- spected and a diagnosis made, the bicarbon- ate solution being used as the dilating fluid. The pus and shreds were then washed away by the peroxide and silver combination. The bladder was then washed and dilated by the quinine solution and more exact ex- amination made for small ulcers, patches of inflammation, and the condition of the ureteral orifices. If it were necessary to catheterize the uterus, it was usually done under the quinine solution and after the bladder had been cleansed. It was believed that in this way danger of carrying infec- tion upwards from the bladder was elim- inated, the cleansed bladder wall and anti- septic quinine solution removing this small danger. The quinine solution gives a peculiar bluish appearance through the cystoscope, but examinations can be well made with it. If the case is one of very acute irritation, the Irish moss jelly is injected on removal of the quinine solution. The amount of jelly injected should vary from one to four ounces. If, however, the bladder inflam- mation is more chronic, the patient is told to retain the quinine solution as long as pos- sible in order to get full benefit from its an- tiseptic and astringent action. ^^ In chronic cases with much congestion and irritation the peroxide and silver com- bination was seldom used. The aim of the treatment in all cases was first to cleanse the infected area, to direct appropriate treatment toward the special lesion, and to exercise an antiseptic astringent and stimulating action upon the mucous mem- branes by means of the quinine solution. It was also found useful to use various drugs by the mouth. Infusion of buchu and fluid extract of triticum are old favorites and have no equals for making the urine bland and unirritating. Tincture of bella- donna, or hyoscyamus and potassium citrate or sodium bicarbonate should be used in combination to relieve spasm and make the urine alkaline. It is required in cases of cystitis that the urine be made alkaline dur- ing the irritating stage of the disease. Acid urine is always irritating. The patient should also be directed to drink large quan- tities of water and a specified amount of six glasses should be named in order that the directions be carried out. Aspirin is a drug which is sometimes of use to relieve irritation ; when hexamethylentetramin is used , it should be combined with an equal amount of sodium benzoate to relieve the kidney irritation which it may cause. As the bladder is getting better, great gentleness should be used in treatment and in catheterization of the urethra as described in another article upon the prevention of catheter cystitis. Otherwise the patient may recover from her cystitis and have still Page Sixteen to recover from the treatment. The mjury caused by the passage of a catheter may in- duce a urethritis. The last few treatments should be of a bland solution. These methods have been in use for nine years in my hands and, in spite of the ex- perimental trial of scores of other astrin- gents and germicides, the cheap efficient substances have given me good results. CHAPTER III. THE TREATMENT OF LEUOORRHEA DUE TO GONOCOCCUS INFEC. TION. General Considerations. — Leucorrhea, wnite or purulent discharge, is one of the commonest symptoms of gonococcus infec- tion and its treatment is essentially the treat- ment of that infection, except in salpingitis. Not every case of leucorrhea by any manner of means is due to this infection, but leucor- rhea is almost constantly found in gono- coccus infection of the cervix and vulva. The great prevalence of this form of dis- ease in men and women makes its con- sideration of greatest social and economical importance. The frequency of its occur- rence in the community there is no means of knowing; Zweifel and Sanger claimed that about i8 per cent, of all women have gonorrhea.^ This may be excessive, but in any case it is suggestive of the fearful prevalence of the disease. It was formerly taught that this infection in women was practically incurable. One professor of gynecology has stated that it were better that a millstone be tied around her neck and she be cast into the ^Sanger: Verhand.' d. deutsch. Gesellsch., 1886. I, 177. sea than that a woman should have gonor- rheal infection. This pessimistic belief and teaching is responsible for the lack of treatment and investigation of the disease, and it is misleading and untrue. Gonococ- cus infection not only can be cured, but often is cured before it advances to salpingitis, and while the disease is still confined to the cervix and vulva. This is the stage in which local medical treatment should be applied and the stage in which the chances of cure are greatest. Pathology.— To properly administer the treatment, the course and pathology of the disease should be understood. The dis- ease is usually thought to be an endome- tritis, but there is usually no infection of the interior of the uterus save in the early acute stages, in the puerperium, or some- times after menstruation in the early stages of the disease. The distribution of the in- fection, extending as it does by means of the continuity of the mucosa, is dependent upon the character and kind of mucous membrane. It readily attacks and thrives in glandular structures and unstratified epithelium. For this reason the common sites of inflammation are Skene's glands in the urethra, the vulvo-vaginal glands and the glands of the cervix. The walls of the vagina and the uterus are not usually involved, although they may be in the acute stages or when their tissue is changed or softened, as in the puerperium. The dis- charge which apparently comes from the uterus, is really cervical and originates from the interior of the cervix below the internal OS. The cervical glands are present two- thirds or more of the way up the cervical canal. The usual point of greatest involvement is in the duct of the glands. The inflamma- Page Seventeen tion here blocks up the outlet of the gland with the result that often small cystic collec- tions accumulate. If the gland is not blocked, there is a purulent discharge from it. This discharge usually becomes worse after the cessation of the menstruation, when there is usually a slight exacerbation of the disease. The cervix becomes en- larged, often nodular from cystic collec- tions and indurated. This is due to the products of inflammatory disease and prin- cipally plasma cells and lymphocytes. The presence of an exceptionally large number of plasma cells macroscopically is almost characteristic of gonorrheal cervical infec- tion. The exudate contains a large number of polymorphonuclear leukocytes, which are present immediately below the epithe- lium. There are also seen numbers of deeply staining basophilic granular irregular minute bodies, the so-called Fleming's bodies. There are also sometimes seen in the submucosa a few hyaline pink-staining bodies varying in size from one to six times the diameter of a plasma cell. The micro- scopic appearance of the tissue suggests that the lesions are the result of periodical exacerbations and remissions of the inflam- mation which has spread and lights up again and again from the mucous surface. Diagnosis. — The diagnosis is often very difficult. The history of an attack of fre- quency of urination and discharge is of most value. This discharge is usually worse after a menstrual period. Inflam- mation of the trigone of the bladder is common. The inflammation may be noted in the red orifices of the vulvo-vaginal glands, sometimes in the urethral glands and in the thickened inflamed indurated cervix. If examination takes place soon after a menstruation, the reddened spots are more easily seen. The microscopic examination of the dis- charge offers some evidence. There are usually in simple leucorrhea, numerous flat epithehal cells, which stain well with disintegrated cellules with proliferating nuclei and lymphocytes with numerous cocci, Doderlein's or other bacteria. In gonococcus infection, on the contrary, there are few flat normal vaginal cells, many dis- integrated or degenerating epithelial cells, numerous polymorphonuclear leukocytes with often the characteristic biscuit-shaped organisms often intracellular. The appear- ance of the organism must be very charac- teristic, before the diagnosis can be made, as the vagina often harbors cocci both Gram- positive and Gram-negative, which are very like the gonococcus. The gonococcus is also often absent in the first stages of the infection. The exact diagnosis of the disease must depend upon cultural methods, although it is usually easy to reach a presumptive diag- nosis without them. Cultures taken from the cervical discharge usually give poor results, as the microorganisms are often dead. Sometimes during an exacerbation, as after menstruation, a growth may be got from the discharge, but better results are obtained from swabs taken by rubbing the sterile cotton on a stick like diphtheria tubes directly over the infected mucous surface. In this way, organisms are ob- tained directly from the tissues where they grow. This should be done, if possible, about two days after menstruation ceases. The culture media should be hemoglobin agar, such as described in my article upon puerperal gonococcus infection. Course and Prognosis. — The chronic course of the disease is due to certain in- fluences which affect it adversely. The factors which excite the disease and cause Page Eighteen its extension and continuance are (ij re- peated fresh infections, (2) coitus, (3) menstruation, (4) pregnancy, (5) sharp curettage and (6) tamponage. When it is considered how often all these occur, it is no wonder the disease is considered diffi- cuh to cure. The repeated fresh infections, if from the husband, are usually explained by fresh or chronic old infection; although Erb thinks that our estimates of this have been exag- gerated and that, of 2,400 male patients, who had had gonorrhea, only 4.5 per cent, infected their wives. ^ But in any case, this should be considered. Treatment. — Menstruation, pregnancy, and coitus, all do harm from the addition of congestion and distribution of the infec- tion. During menstruation and for three days after, the patient should remain very quiet and take all the rest possible, in order to limit the extension of the disease. After pregnancy, the tendency is for the disease to extend, as is described in the article on puerperal gonococcus infection. Coitus should be restricted during the acute stages and not allowed until the cervix appears normal. Sharp curettage of the uterus does harm, because it bares a raw surface which is not infected and causes infection in an area not previously involved. The gonococcus can find no permanent hold in the uterine mu- cosa, provided it is not injured, but after curettage or after pregnancy, the raw sur- face and exudation, as a result of the in- flammation caused by the trauma, offer a fine nidus and a good culture medium for the extension of the gonococcus. It is true that the endometrium usually recovers, but 'Erb: Munch, med. Wochens., 1906, 27. Munch, med. Wochens., 1907, 31. in the meantime an opportunity has been given for extension of the disease to the Fallopian tubes with its attendant dangers and discomforts. This upward tendency also exists after pregnancy. Why sharp curettage should ever be advised in this dis- ease or for leucorrhea is impossible to ex- plain. It injures the only uninvolved part and does no good but actual harm. It is like shooting the innocent bystander in a street brawl. An example of this is a report of six cases, reported by Holden,^ which were curetted and the pelvic organs noted as "ap- parently normal," but returned some time afterwards and had their Fallopian tubes excised for purulent salpingitis. But the whole treatment of the disease has been based upon empiricism and a false idea of the pathological anatomy. Another hoary myth is the belief that the introduc- tion of tampons does good. Why should they? The essential points in the treat- ment of the condition must be lack of con- gestion and irritation, rest and free drain- age, with proper germicidal measures. The tampon is an irritative foreign body which obstructs drainage and macerates the mu- cosa, so that extension of the infection is more likely and occlusion of the ducts of the glands more easy. If any antiseptic is introduced with it, the continued application is irritating, as for example, ichthyol-gly- cerine tampons with which almost every one has had the experience of getting a fine cast of the vagina. It has the effect of a moist glycerine dressing. Let any one ex- periment with a moist glycerine dressing upon one of "his own mucous surfaces and he will find what irritation and maceration it produces. So influenced was I by custom and previous practice that I introduced ^Holden: American Medicine, 1905, Nov. 4. Page Nineteen several thousand tampons before I was convinced of their harm and uselessness. Such is the influence of tradition. I tam- poned with all mixtures and shades and per- centages of glycerine, ichthyol, boric acid, chloral and such. I tamponed one woman with gonococcus infection twice a week for two years, at the end of which time she was worse than in the beginning, and the dis- ease had extended to the tubes. But it had a great psychic influence — but none on the disease. The facts are that nobody ac- tually knows what good tampons do, save in prolapse or retroversion ; but it is some- thing to do, and many things are done, because it makes the physician and patient feel something is being done for the dis- ease. It will go the way of intrauterine ap- plications to oblivion. The essentials in the treatment are free drainage and germicidal applications and douches. The infection lurks in the glands of the cervix and upon the mucosa. The indication is to drain the obstructed glands and apply real germicides to the mucosa. The drainage of the obstructed glands is best obtained by the electric thermocautery. A small narrow wire loop point should be used about the breadth of the lead of an ordinary pencil. The cauterization is best done in the middle of the menstrual month and should be preceded by germicidal douches. With a bivalve speculum expos- ing the cervix, the small cautery at a red heat is thrust into each eminence and cystic collection in the indurated and inflamed cervix. It is also thrust about ys, inch into places in the cervix where it seems most indurated and inflamed. In all, about IO-20 punctures with the cautery may be done at one sitting. A month should elapse between cauterizations. This treatment opens the glands and destroys collections and relieves congestion, so that the cervical circulation may take care of the infection. It seldom needs to be done more tfean three times, unless there is continued reinfection. The patient should keep quiet after the treatment for two days and should be warned that the discharge is apt to increase at first. This treatment is not needed more than once in most cases. It is not painful, it does no harm and may even be done in the presence of salpingitis. It is, however, most applicable to the chronic or subacute stages of the disease. In the acute stages, rest and proper douching are the chief in- dications. In addition to this treatment, applications of germicides are made to the cervix and the infected glands of the vulva and urethra. The cervix is swabbed and the glands of the vulva are probed. Several germicides may be used. Tincture of iodine is an old favorite. This has a Rideal- Walker carbolic acid co- efficient of 2, that is, it is twice as germicidal as pure carbolic acid. Chlor-meta-kresol is a halogen compound which makes a useful applicant. This, in the 50 per cent, oily solution, has a Rideal- Walker carbolic acid coefficient of 11.5. It is a useful applica- tion and causes little pain. The oily solu- tion has an advantage of continued slow action. This substance is also useful to give in douches in i-iooo of the oily fifty per cent, solution. It can be afterwards increased to 1-500. Occasionally it causes tingling, but is non-toxic and only slightly affected by albuminous fluids and is perfectly harm- less to the mucosa. Its high germicidal action makes it of use. After the discharge besfins to lessen and all the cauterizations Page Tiventp have healed, it is best to nse a plain alkaline douche of soda bicarb, .^/i, sod. sulphat. oii to 2 quarts of warm water. The use of bichloride of mercury and formalin douches are illogical in this condi- tion. Bichloride in the presence of organic tissue, such as mucosa, or albuminous dis- charges, become inert. The leucorrheal discharge neutralizes it, so that the action of the douche is only mechanical and not germicidal — another illusion of which the treatment of this disease has been made up. Precautions should be taken in regard to rest at the menstruation, care of the bowels and general health, prevention of reinfec- tion, etc. But the active treatment of the disease should be confined to the cautery, douches of real germicidal value and occa- sional local applications of a germicide. In this way, rest, drainage and cleanliness are obtained, and the disease may be cured and the extension to the Fallopian tubes prevented. It is only our inefficient and illogical methods which have made this dis- ease appear hard to cure. CHAPTER IV. THE TREATMENT OF FIBROID TU- MORS, WITH REPORT OF 700 CASES. The study of uterine fibroids has a di- rect bearing upon their treatment. If these growths cause no more trouble than uterine hemorrhage, their treatment may be de- cided u,pon after consideration of how severe is the hemorrhage : but if there are other dangers, then the treatment must be chosen after consideration not only of the pres- ent symptoms, but also of the probable changes which may occur in the tumor and their danger to life. With the hope of being able to obtain some idea of the degenerations and the relation of malignant changes, 700 tumors were studied. In any such series it is of importance that it should be carefully done and all tumors should be examined microscopically. It has been thought best not to combine with this series any others as a single series of such numbers is of more value than an aggregation of cases unevenly prepared and collected from many operators. The cases have been studied from the point of view of age and its relation to cancerous changes and de- generations and the tables tell their own tale. TABULAR ANALYSIS OF AGE, COMPLICA- TIONS AND DEGENERATIONS OF 700 FIBROID TUMORS. TABLE 1. CHARACTER OF TU3IORS. No. % Single 238 34 Multiple 462 66 Small, up to 4 c. m 257 36.7 Medium, 4-8 c. m 209 29.8 Large, above 8 c. m 234 33.5 Subserous 136 19.5 Interstitial 190 27.1 Submucous 75 10.7 Combined 299 42.7 TABLE 2. DEGENERATIONS AND 3IALIG- NANT CHANGES. (A.) Degenerations of Tumor. No. % Hyaline 127 18 Calcareous 65 9 Cystic 20 3 Hemorrhagic 14 2 Necrotic 57 8 Adenomyoma 23 3 (B.) Associated Malignant Changes. No. % Adenocarcinoma 20 2.9 Squamous carcinoma 6 0.8 Sarcoma 7 1 Chorioepithelioma malignum . . 2 0.3 Total malignant changes 35 5 TABLE 3. COMPLICATIONS OF TUMORS. No. % Ovarian cysts 53 7.5 Cystic ovaries 141 20 Ovarian fibroma 8 Ovarian carcinoma 5 Salpingitis .- 194 27.5 Appendicitis or Periappendicitis 148 21 Page Twenty-one TABLE 4. AGE OF PATIENT. Age No. % Age No. % 20-30 19 2.7 50-60 95 13 30-40 233 33 60-70 21 3 40-50 332 TABLE 5. RELATION OF AGE TO DEGEN- ERATIONS. (E.) Squamous Carcinoma. Age % 20-30 30-40 0.4 40-50 0.3 50-60 3 60-70 4.6 (A.) Necrosis. Age. % 20-30 5 30-40 7.7 40-50 7.5 50-60 9.3 60-70 29 (B.) Calcareous Degeneration. (F.) Sarcoma. Age. % Age. % 20-30 20-30 . 30-40 2 30-40 40-50 16 40-50 0.6 50-60 14 50-60 3 60-70 10 60-70 9.5 (C.) Hyaline Degeneration. (G.) Cho7-ioepithelioma. Age. % Age. % 20-30 11 20-30 30-40 11.5 30-40 40-50 16.8 40-50 0.6 50-60 16.6 50-60 60-70 10 60-70 (D.) Adenocarcinoma. (H.) Total Malignant Tumors. Age. % Age. % 20-30 . 20-30 30-40 30-40 40-50 3.6 40-50 5 50-60 6.3 50-60 12.7 60-70 9.5 60-70 23.8 Autopsies 26 Heart Lesions at Autopsy 11.5 A consideration of this table shows that the older a patient the more danger from the fibroid tumor. The older the patient the greater probability there is of malig- nant changes and other dangerous degen- eration, such as necrosis. This shows that the menopause does not relieve the pa- tient from danger from fibroids save from the hemorrhage. Other and more danger- ous complications remain and increase in degree with each succeeding year. The menopause, which does not come until the average of 48 years in normal women, according to Norris' study, is com- monly delayed longer in women with fibroid tumors on account of the additional congestive irritation and blood supply of the tumors in the uterus. So that it is not fair to advise a woman with a fibroid tumor to wait until 45 years for a meno- pause which does not come until ^o years, and does not cure when it does arrive, but brings greater dangers with it. Opera- tion at the time of election must be the treatment of fibroid tumors instead of temporary conservative treatment and operation of urgency with a large mortal- ity when dangerous symptoms or malig- nant complications intervene. Malignant change took place in 5 per- cent, of all tumors. Adenocarcinoma of the fundus formed the greatest part of these changes. This form of cancer, as pointed out by me in 1904, has some pre- dilection for fibroid tumors, as it is by far the most common form of malignant asso- ciation. Fundal cancer, usually in other cases than fibroids, is found about one- sixth as frequently as squamous carcinoma of the cervix, while with fibroids the first is found more than three times more fre- quently than the second. Apart from malignancy, necrosis is pres- ent in 8 percent, and this percentage in- creases with age. Necrosis must increase the mortality at operation, and cannot ex- ist long without bacterial contamination. Other complications, such as changes in the adjacent viscera, salpingitis, appendicitis, etc., make up a list which every physician who advises against operation in fibroid tu- mors should view with appreciative alarm. The dangers from fibroids in patients more than 40 years are much greater than before this time. If operation is done be- fore grave complications intervene, the operation may be one of choice and with a low mortality, but when necroses, Page Twenty-two malignant changes or hemorrhage compel operative measures in a weakened patient, the mortality is large. The consideration, therefore, of this series of fibroid tumors warrants the fol- lowing conclusions. 1. The menopause does not bring a cure to fibroids ; on the contrary, increasing age increases the danger from these growths. 2. There is little danger of malignancy arising in fibroids before the fortieth year of the patient, after which time the danger increases with each year. 3. In view of the sarcomatous changes, carcinomatous associations and other de- generations of uterine fibromyomas, early removal is indicated when they are of suf- ficient size to produce symptoms and cause the patients to seek advice. Small uncom- plicated fibroids in young women do not require early treatment. 4. Thorough pathologic examination should be made of all fibroids for evidence of malignancy. The tumor should be opened at the time of operation and examined for adenocarcinoma or sarcoma. Particular study should be devoted to those tumors .which are necrotic, cystic, or both, as among these are found the largest propor- tion of malignant changes. 5. In view of the large percentage of inflammatory changes in the Fallopian tubes and appendix, these should be ex- amined at the timiC of operation and re- moved, if diseased. Previous papers on fibroid tumors: Ellice McDonald, M. D. 1. Uterine fibromyomata, 700 cases. Jour, of Ois. and Cfyn. for the Brit. Empire. 1909, Aug. 2. Flbromyoma of the uterus complicated by cancer or sarcoma, 35 cases. Jour. Amer. Med. Ass'n. 1908, Mch. 20. 3. Complication and degeneration of uterine fibromyomata, 280 cases. Jotcr. Amer. Med. Ass'n. 1904, May 26. CHAPTER V. A NEW OBSTETRICAL FORCEPS. Introduction. — Since the time of the Chamberlains, there has not been any very great advance in design of obstetrical for- ceps. Except for the addition of the pel- vic curve, the improvements have all been made in the manufacture and not in the design. Tarnier's axis traction principle v/as, it is true, a new one, but it is doubt- ful whether the effect the axis traction forceps was made to attain — traction in the direction of the axis of the pelvis — cannot better be obtained by forceps without the axis traction mechanism. In other words, with a properly designed pair of forceps, if traction in direction of the axis of the pelvis cannot be obtained, it is because the opera- tor does not know the axis of the pelvis and how to pull in it. The chief model upon which most mod- ern forceps have been designed is the Simpson model of which the Elliott forceps is the best type. This forceps depends for its traction upon one cross piece at the end of the forceps (see illustration) for its traction. Were this cross piece removed and the forceps to consist only of a fork there would be no possibility of traction at all. In other words, the fenestrated for- ceps of the Simpson and Elliott type de- pend for their traction upon a friction grip which is concentrated in one part of the forceps — the cross bar at the end. As a result of this localization of the pressure and friction in one part, the for- ceps must be narrow within the points to ensure firmness of grip. All forceps, when judged, should be examined in the position in which they would be on the child's head — i. e., with their largest meas- Page Twenty-three urement of separation where the biparietal diameter would come. The ideal of for- ceps application is over the biparietal eminences. The average biparietal diam- eter is 9^ centimeters. From meas- urements, lead tape moulds and casts of over a hundred fetal heads, I have found that when the forceps are over an average biparietal diameter, the tips must be sep- arated at least 5>4 c. m. If they are sep- arated less than this they cause too much pressure over the stylomastoid process and the tender facial nerve. The surest way to pass an opinion on a pair of forceps is to open them to g}i c. m. and measure the tips. A proof of the correctness of this assertion is that three investigators — Tar- danger of cutting off ears, getting forceps' scars, fracture of the skull, gouging out eyes, causing facial paralysis, and all the other blood-thirsty and horrible th^igs that forceps can cause. In addition, the Simp- son type forceps, because of their length, may cause injury to the mother. When the traction is in an upward direction, as it must be before the head is delivered man- ually, the long blades which grasp the head over the biparietal processes pivot upon these processes, and the tips of the blades, projecting beyond the head, impinge upon the pelvic floor and around the vaginal mucous membrane (Fig. 2). This may begin a perineal laceration, as, when the continuity of the mucous membrane is once Fig. 1. Elliott forceps — showing traction bar beyond the black mark. nier, Elliott and myself — have independent- ly come to the conclusion that with the average sized head, the forceps tips should be separated 5^ c. m. for all three designs have this measurement. If the tips are narrower than this, undue pressure comes over the facial nerve with consequent in- crease in facial paralysis. While the Tarnier and the Elliott have the same proportion in this measurement, on account of the pressure and friction traction being isolated at one point, the blades have to be longer than is necessary with my forceps. With the long blades of the fenestrated forceps of the Simpson type, there is more broken, the stretching of the descending" head causes small laceration to increase in extent just as a small tear in a piece of cotton will readily extend. This is shown in a study of perineal lacerations (Mc- Donald, Lacerations of the Perineum, Sur- gery Gyn. and Ob St., Jan., 1908) in which it was shown that, under these circum- stances, the muscles split along the lines of cleavage after the mucous membrane and fascia was once ruptured. If the fenestrated blades are made short- er than the Elliott, they won't hold unless undue pressure is made. The Elliott for- ceps is the best design of its type as is at- tested by thousands in use, but it has the Page Twenty-four defects of its type— pressure localized in one spot, blades too long- and too broad. This makes the forceps difficult to apply and often causes injury to the mother. The operation of rotation of the head by forceps from R. O. P. is difficult with the Simpson type forceps. Another type of forceps of a good char- acter is the solid blade forceps, of which the Tucker-McLane forceps is the best model. These forceps have the advantage forceps operation they will slip, or else so much pressure must be made as to en- danger the child. Description. — With the idea of remedy- ing these defects and including the ad- vantages of both the Elliott and the Tuck- er-McLane forceps, I have devised a pair of forceps, which have as their basis a solid blade into which a number of slits, win- dows or fenestrae are cut. The blades are shorter than either of the other models and Fi.£ 2. Elliott forceps — showing extension beyond the head to wound the mucous membrane of the vagina. of distribution of friction-pressure and convenience from their narrowness of blade. As a result of the broad flat smooth surface of the blade which is applied to the head, the friction-pressure is not great. On this account the blades must be made long and the points come close together so that they will hold. For this reason, the disadvantages of this type of forceps is the length of blade and the closeness of the tips. These forceps are very nice in an easy forceps operation with a normal head, but with a large head and a hard the width between the tips the same as the Elliott. The multiple fenestrae do not detract from the strength of the forceps nor from the ease of application. The principle is of distribution of pressure and traction by several friction points instead of one as the Elliott or a smooth surface as the solid bladed Tucker-McLane. The principle is that of the non-skid automobile tire where there are numerous friction ridges or of the non-slipping eye-glass clips where in- stead of one bar on the side of the nose, there are two or several. It is the prin- Page Twenty-five ciple that two points of contact can make more pressure friction than one. As a result of this non-sHpping quality, there can be certain changes in the blade which are desirable. The blades may be shorter so as not to pinch the cord, not to make too much pressure low down over the facial nerve, to make them easy to ap- ways be found to be caused by the cross bar. The semi-fenestrated forceps will not cut off any ears nor are they likely to cause facial paralysis. They are desigr^d to in- clude the best qualities of the fenestrated and the solid blade forceps. They have been in use with the multiple fenestrae since 1905. I have had nothing 2 centimeter, 200 for the second and 250 for the third centimeter above that weight. When the measurement is above 36 cm., twins should be carefully sought for, as this has been in my hands the first indica- tion I have had of twins on several occa- sions. Two babies measure more than one. The measurement should be taken ac- cording to the directions for measuring the duration of pregnancy (see illustration) and the tape line should follow the outline of the uterus save at the last dip. It should Fig. 2. = 62 -f- 7 =9 lunar months; see article "Duration of Pregnancy") the child weighs 2,500 grams and this weight is to be ex- pected at that time. Induction should rarely be done when the fundus measures below 30 cm. and in fact it is better to do it above this measurement, as 2,300 grams is about the smallest limit of weight that good results for the child are obtained by induction. If the measurement is above 35 cm., for estimation, add 200 grams for the first go horizontally from the highest eminence of the uterine tumor to the upright measur- ing hand. This measurement must be used in correlation with the measurement of the head, which is about to be described, and one should check the other. Measurement of the head is done through the abdominal wall. The head lies with its longest and most prominent diameter trans- versely in the pelvis or nearly so, and this is the only diameter which can be obtained. But it is the biparietal diameter that is Page Fifty -one wanted. The biparietal diameter of the head fortunately bears a fairly definite rela- tion to the occipitofrontal and so can be de- duced from it. For that reason, the occip- itofrontal is measured and the biparietal obtained by deduction. An ordinary pelvimeter of simple con- struction (fig-, i) is taken and two rings of adhesive plaster, about i cm. in width, fastened to each tip. These rings are faced inside with adhesive plaster, back in- ward, and are made sufficiently large instrument approximated to these points as closely as possible. The weight of the hinge side of the pelvimeter is supported by the finger of an assistant, or ma^ be held up by a string attached to the operator's arm or buttonhole. It is necessary that the hinge side should have free play of movement in order that one or other tip may be depressed if occasion requires. The tips are held firmly against the cephalic poles and the scale is read. This gives the occipitofrontal diameter. No deduction Fig. 3. readily to admit the middle and index fingers. The knob-like tips of the pelvi- meter should project about i cm. beyond the palpating fingers. The patient is laid on her back and the operator stands as if to palpate for the posi- tion of the head. An accurate diagnosis of the fetal position, not only in regard to the occiput, but as to the amount of flexion of the head is essential to success. The bladder must be empty. The occiput and sinciput are located; then the fingers are thrust into the rings and the knobs of the is required. This fact is not satisfactorily explained. The abdominal walls of a preg- nant woman are very thin (usually less than I cm, measured at Caesarean section), and it may be that the exact prominences of the cephalic poles are not reached. All heads above the brim, or which may be thrust above the brim, can be measured, although the greatest ease is found in thin women with flat pelves which push the head forward. Small heads with much liquor amnii are difficult to fix; breech cases offer no special difficulty. However, Page Fifty-ttoo heads lying above the pelvic brim and firmly placed thereon g-ive the best conditions, e. g. in contracted pelves. The measurement obtained by this means is the occipitofrontal diameter, and from this is obtained the important diameter, the biparietal. The amount to be subtracted varies with the size of the occipitofrontal. With an occipitofrontal diameter of ii.2j cm. two cm. are deducted to obtain the biparietal, from ii.j cm. occipitofrontal 2.2^ cm., and from 12 cm. occipitofrontal 2.^0 cm. This amount deducted is based upon the follow- ing table of 100 heads measured by me : TABLE OP MEASUREMENTS OF 100 NEW- BORN BABIES. Average No. of 0. F. Average weight. cases. diameter. difference. Grams. 1 10 1.00 2,600 4 10.50 1.55 2,716 8 10.75 1.81 2,975 17 11 1.91 3,100 21 11.25 2.07 3,156 19 11.50 2.26 3,247 9 11.75 2.50 3,313 13 12 2.30 3,514 5 12.25 2.35 4,100 1 12.50 2.50 4,100 2 12.75 3.12 4,350 It will also be noted that the weight bears a fairly definite relation to the size of the head. This is of use in checking up the size of the child, as shown by the author's rule for the duration of pregnancy. As, for example, with a fundal measurement of 35 cm. and an occipitofrontal measure- ment of 11.50 cm., it can be safely estimated that the fetus is of normal size, 3,300 grams. In this way it is possible to use the fundal measurement and estimated weight as a check upon the cephalimetry with particular accuracy for the purpose of finding this ratio. These methods have been in use in my hands for seven years and continue to give good results. In all I have measured eighty-four heads before and after delivery. In sixty cases, the occipitofrontal diameter was correctly estimated; in seventeen cases there was an error of 0.25 cm. and in six cases there was an error of 0.5 cm. ; and in one case there was an error of 0.75 cm. This last case was not a fair test, as the head was well in the pelvis and could not be properly reached. Skill and practice are decided factors, but the method is soon learned. In addition to these methods of measure- ment, an attempt is made to estimate the size of the head in relation to the pelvis. This is done by the Munro-Kerr modifica- tion of Miiller's method and consists in at- tempting to force the head into the pelvis by a grasp above, while the lower hand in the vagina gauges a descent of the cephalic pole. Munro-Kerr's modification consists in holding the thumb above the brim of the pelvis as well as the fingers within the vagina. COMBINATION OF METHODS N^CSSSARY. By the use of these three methods it is possible to gain a reasonably sure idea as to the size and weight of the child before labor and so to form some idea of when labor should be induced and what the course of treatment should be. It should be remembered that the average sized child measures 35 cm. fundal measurement, weighs 3,300 grams and has a biparietal diameter of 9.10 cm., and with this as a starting point, the time of induction is easy to reckon for any known pelvis. These figures are based upon my own measure- ments. My plan is to measure the fetal head and uterine fundus from week to week before labor, and so decide when induction should be done. This should be when the Page Fifty-three estimated biparietal is a trifle smaller than the true conjugate. These methods require some experience and some patience. A combination of the methods gives the best results : he who de- pends upon one alone will be deluded. The interruption of pregnancy need not be earlier than the amount of contraction re- quires, and the child need not be exposed to the risk of unnecessary prematurity. It is but seldom advisable to induce labor more than four weeks before term, as then the child would be below the minimum weight, 2,500 grams, for good results. A child of this weight has an average biparietal of 8 cm., the lowermost limit set for induction of labor 8 cm., true conjugate. Watchful attention and careful measure- ments in the last weeks of pregnancy avoid the dangers of prolonged pregnancies and large babies, because the size and growth of the child are measured and recognized. Induction may then be done in time. Large babies give more trouble in moderately contracted pelves than does the size of the pelvis. All normal sized babies should be born through a true conjugate of 9.25 cm., equal to the average biparietal diam- eter, but the big fellow^s give the trouble. The day will come when a ten-pound baby will become an accusation to the accoucheur instead of a boast to the parents. The head of a large baby is much firmer, harder, and more difficult to mould than that of a small baby. This alteration in the con- sistence of the fetal skull of the large child accounts for the trouble he causes even more than does the increase of the diam- eters of the head. It is the fact that is re- sponsible to a large extent for the success of induction of labor in contracted pelves of moderate degree. CHAPTER XIII. DIAGNOSIS OF ECTOPIC PREG- NANCY. Introduction. — The diagnosis of ectopic pregnancy is seldom an easy task and often a difficult one. This is chiefly because of the varied pathological conditions which may exist as a result of the pregnancy and its termination. While the diagnosis is dif- ficult, there is no condition in medicine in which it is more important to have an im- mediate and exact diagnosis. If it is not recognized, delay may result and treatment for other conditions be instituted. Delay in the treatment of ectopic preg- nancy is dangerous for several reasons. The hemorrhage may continue, adhesions may form and infection of the blood clot result. All of these minimize the patient's chances of recovery. Movement of the pa- tient, particularly jolting or jarring move- ment, is most dangerous and many deaths have been reported while removing the pa- tient to the hospital in a cab or ambulance. Mistaken treatment for other conditions, such as curettage for supposed miscarriage, is of great danger in ectopic pregnancy. It causes renewed bleeding and makes opera- tion for the ectopic pregnancy more hazard- ous. For these reasons it is important that the diagnosis should be made immediately and exactly. There is considerable difference of opinion in regard to the value of the various symptoms and for this reason I have analyzed 4,000 cases of ectopic preg- nancy in the literature with the hope of ascertaining the exact value of each symp- tom and in this way throwing some light upon the diagnosis. The cases analyzed were all comparatively early ones, before Page Fifty-four four months, as advanced ectopic pregnancy offers an entirely different problem. These cases did not all give an expression of all the symptoms, and, in some cases, impor- tant ones were omitted; but it has been thought better to give the percentage value of each symptom in a table without refer- ence to the number of times each has oc- curred. Amenorrhea 74 per cent. Uterine hemorrhage 85 Average amenorrhea 40 days Pain severe 66 per cent. Onset of pain sudden 28 Pain and hemorrhage simultaneous.90 " Symptoms on day of expected men- struation 9 " Symptoms before the expected men- struation 17 " Cast of decidua of uterus 3 " Decidual shreds 16 " Nausea 33 Breast changes 33 " Pulse 96 33 Pulse 100 or over 33 Pulse 120 or over 33 Temperature above 100 50 " Hemoglobin almost always between 30 and 70 Leukocytes, below 10,000 33 , above 15,000 33 , above 16,000 30 Mass palpable from abdomen 28 " Mass palpable from vagina 88 " Active bleeding at operation 5 " Free blood in abdomen 90 " Fetus found at operation 18 Cases in shock at operation 25 " Average age 25-35 years Greatest number at 30-33 " Uterus displaced by tumor 50 per cent. Vaginal bulging 53 " Average number of children before ectopic 3.6 " Number of multiparae 83 " Mortality after operation in 5,973 cases 7.04 " Mortality " " " tubal rupture 17 " Mortality " " " " abortion 1.6 Repeated ectopic pregnancy — 168 in 4,180 cases in series 4 " Tubal abortion occurred in 70 " Tubal rupture " " 30 " Symitomatolo^.— In considering the symptoms of ectopic pregnancy it must be remembered that we have to deal with a condition which may take different forms Page Fifty-five and have varied terminations. First it is a pregnancy and the symptoms of pregnancy are usually present. The women, being mostly multiparae, have been pregnant before and believe they know when they are in the family way. This is of consider- able value in the history. Amenorrhea, a symptom of pregnancy, is one of the most constant signs, being present in three-quarters of all cases. Those cases in which it was not present were in part cases which came to operation before the expected date of the menstruation and cases operated upon before rupture. The average duration of the amenorrhea was 40 days and in only 10 per cent, of the cases were two periods missed. The cessa- tion of the amenorrhea and the beginning of the uterine hemorrhage usually coincided with the beginning of pain. It is true that in thirty per cent, of cases, there was mild colicky pain before the appearance of hemorrhage and while the pregnancy was intact. Uterine hemorrhage was present in 85 per cent, of cases, being the most constantly present symptom. Cases in which it was not present were mostly those which had come to operation before the date of the expected menstruation. Hemorrhage came as a rule on the 40th day and continued without intermission. It was continuous in twelve cases to one in which it was in- terrupted. This fact is of great import- ance in the diagnosis of ectopic pregnancy. The character of the uterine bleeding was of a different nature to the usual menstrua- tion and women commonly recognize this fact. It is frequently of the kind known as "spotting" and comes constantly, but in small amounts. It is most frequently al- tered in consistency and appearance. It is usually dark powdery red in character and occasionally (i6 per cent.) contains "shreds," "pieces of flesh," etc. The onset of the bleeding- usually (90 per cent.) coincides with the onset of pain. This is believed to occur at the time at which intratubal rupture takes place, to terminate later in tubal abortion or extratubal rupture, as the case may be. The ectopic pregnancy does not develop within the mucosa of the tube, but underneath the mucosa and between the muscular coats. The first change is usually bursting through the mucosa to enter the lumen of the tube. When this occurs, there is usually first hemorrhage into the peritoneal cavity from the tube and, at the same time, the uterine decidua is cast off in the form of uterine hemorrhage of the peculiar dark red color. After the decidua is all cast off, the dark red appearance of the uterine hemorrhage dis- appears. The onset of symptoms, pain, etc., usually then dates from the termination of the amenorrhea and the beginning of the uterine hemorrhage. This is the time of the first disturbance of the ectopic pregnancy. In five per cent., pain was followed by bleed- ing, while in five per cent, there was pain and indisposition without bleeding. The character of the pain was severe in two-thirds of all cases. It was sudden in about one-fourth of all cases. It was in the lower abdomen and usually upon the af- fected side in about sixty per cent. It was general over the whole abdomen in about thirty per cent. In about three-quarters of all cases, the severe pain was preceded by pain of less severity, which came on gradually. The first pains are usually sharp and colicky, while the severe pain following is usually sudden, paroxysmal and cramplike. This severe pain, which is sudden and un- heralded in one-fourth of the cases and pre- ceded by lesser pain in three-fourths, is variously described as "cutting," "knife- like," "cramp-like," etc. It is periodic and paroxysmal, and is followed by syncope in about one-fourth of the cases. It is due to peritoneal irritation from the extravasation of blood from rupture or tubal abortion. It is periodic, because intratubal rupture is associated with repeated small hemorrhages which distend the tube, and the leaking of blood upon the peritoneal surface causes severe pain, similar to that due to any foreign substance as sudden rupture of in- traabdominal abscess or secondary hemor- rhage. It is paroxysmal in character and similar to pain from intestinal peristalsis in other peritoneal irritations. In extratubal rupture, the blood is extravasated more rapidly, so that the pain is more severe and the shock and collapse more marked. In tubal abortion with more gradual bleeding, the pain is usually more persistent and apt to recur. The return of the paroxysm may occur several times a day and the character of the pain is periodic and crampy at these times. The first onset of the pelvic pain is asso- ciated with shock and syncope in about one- fourth of all cases. In the other cases, there is quite frequently weakness not amounting to fainting or syncope. In about one-half of the cases of syncope, from re- ports at operation, the shock was of nervous origin due to peritoneal irritation and, in half of the cases, it was due to extensive hemorrhage plus peritoneal irritation. The shock usually occurs once, but in about five per cent, there were repeated attacks. In about one-third of all cases, there was other evidence of pregnancy besides the cessation of menstruation. Milk, areola of pregnancy or tingling of the nipples is Page Fifty-six present in about one-third of cases and nausea, sometimes due to shock, is present in about the same proportion. With the onset of pain and uterine hemorrhage, there is usually immediate al- teration in the pulse rate. It is usually in- creased and often of the thready character, associated with shock. One-third of the cases have a rate of about 96; one-third no or over and one-third 120 or over. So that it may be said that the pulse is usually increased in rate, and usually above no. The temperature is usually slightly in- creased in degree. It is quite often sub- normal at the time of the acute pain with symptoms of intra- or extratubal rupture, but soon becomes febrile. In about one- half the cases, it is above 100° and is sel- dom above 102°. The hemoglobin is usually decreased in amount. It is seldom higher than 70 per cent, and rarely lower than 30 per cent. The average hemoglobin finding, where it was noted in these cases, was 49 per cent. The white blood count is commonly in- creased, although this is not constant. In one-third of cases it was below 10,000, in two-thirds above this. In one-third it was above 15,000, and one-third above 16,000 white cells. In the cases of shock, the leu- kocytosis is usually marked, not from in- fection but from the previous hemorrhage. The polymorphonuclear cells are usually very high in percentage in shock. There are sometimes other signs of peri- toneal irritation. These take the form of a desire to strain after defecation and a feel- ing of inability to empty the bowels. Dysuria and frequency of urination also occur. Either one of these symptoms was present in rather more than one-third of all cases. Examination of the abdomen seldom shows any tenderness before rupture, but Page Fifty-seven after the onset of uterine hemorrhage and pain attending the termination of the preg- nancy, tenderness over the lower abdomen is almost invariably present. This is usually more marked on the side where the preg- nancy occurs. These symptoms are asso- ciated with rigidity, when there is sufficient peritoneal inflammation and irritation from extravasation of blood. If the amount dif- fused be considerable, there may be some distension of the lower abdomen which may be cone-like. Distension and rigidity may be absent, but tenderness is always present. Tympany is not uncommon in primary in- traperitoneal rupture with marked hemor- rhage. There may be superficial dulness on percussion over the pubes and in either flank with a resonant note on deeper per- cussion. A thrill may sometimes occur in the stomach region, although no sign of fluctuation can be felt. On turning the pa- tient over, dulness in the flanks may persist, but gradually disappear in a way which is characteristic of efifusion of blood. On vaginal examination, the mucosa is usually congested, but not to the marked degree of normal pregnancy. The uterus is usually slightly enlarged with a softened cervix, but as a rule none of the bimanual signs of pregnancy, as Hegar's or the author's, are felt. Intermittent contrac- tions, however, are not uncommon. Move- ment of the uterus usually causes pain. A mass is felt usually on one or other side and behind the uterus. This mass was felt in two-thirds of all cases and was always tender. Pelvic tenderness on examination is one of the most characteristic symptoms of ectopic pregnancy. If the pregnancy is uninterrupted, the tube usually prolapses into the cul-de-sac of Douglas; if rupture takes place, the blood seeks the lowest place and forms a hemato- cele in the same situation. The consistency of the mass is doughy and it can be dented with the examining finger. The situation of the mass and its size is altered by the amount of the extravasated blood and the direction it takes. If the mass is large, the uterus is usually displaced to the normal side. If the uterus is displaced by a doughy tumor which pulsates indistinctly, it is very suspicious of ectopic pregnancy. The mass is usually tense and elastic and often lob- ulated. This elasticity often distinguishes the condition from the board-like hardness of pelvic abscess. Anterior or posterior colpotomy has been suggested as a possible means of diagnosis by Bandler. The vaginal vault may be opened over the tumor until the discolored peritoneum covering the blood is seen. The diagnosis may be possibly made in this way without opening the peritoneal cavity, the dark blue shimmer showing through. Punc- ture of the posterior vaginal vault through a speculum may be done. If the cervix is pulled down and the needle thrust directly in the mid line and close to the cervix, no harm can result and free blood is usually found. Muhsam^ is a strong advocate of this method and states that in 117 of 124 cases the findings were positive, if not at once, after the woman had been raised to a sitting position. He ascribes the success of treat- ment at the Moabite Hospital of 108 cases without a death to early diagnosis and prompt operative measures. His greatest dependence in diagnosis is placed in punc- ture of the pouch of Douglas. Acetonuria is often present in ectopic pregnancy and is believed to be due to the absorption of products of blood. The same is true of urobilin. Differential Diagnosis. — The differential diagnosis usually requires some thought. ^ Muhsam. Therapie der Gegenwart, May, 1913. It is of greatest importance to accurately in- vestigate the history, for this will usually differentiate ectopic pregnancy from lesions with similar findings upon vaginal exam- ination. The chief error is in miscarriage, associated with some pelvic mass, as cystic ovary, pus tube, hematosalpinx, etc. This gives the symptoms of pregnancy with the pelvic lesion. Miscarriage with retrover- sion of the uterus, where the fundus is felt through the posterior vaginal fornix is sometimes very confusing. The carefully taken history, the absence of marked pelvic tenderness, the different feel of the pelvic mass, should differentiate these conditions. Normal pregnancy in which there is marked asymmetrical development in one cornua of the uterus with marked thinning and softening of the enlarged part, is not infrequently mistaken for ectopic preg- nancy. This type of pregnancy is described as similar to a face with a toothache and swollen cheek. It exists within the limits of normal pregnancy, but should be easy to differentiate if the signs of pregnancy, as described in my paper in another issue, are known. The acute onset of the condition makes it necessary to differentiate it from the acute infections as appendiceal rupture, pelvic abscess, acute gastric ulcer, acute pus tubes and acute appendicitis. Peritoneal hemorrhage may occur from other sources, such as ovarian hematoma, hematosalpinx, ovarian papilliferous adeno- cystoma, pachysalpingitis with hemorrhage, etc. In all these cases there may be peri- toneal hemorrhage which, however, is not usually associated with marked pain or symptoms of pregnancy. The diagnosis of ectopic pregnancy is based upon the relation of the history to the physical examination. It is, as my teacher, Charles P. Noble, has often said, not diffi- Page Fifty-eight cult in 85 per cent, of cases, difficult in 10 per cent, and almost impossible in 5 per cent. With a definite history of a lesion in the pelvis, as shown by pain, tenderness and symptoms referable to the genitalia, with a history of amenorrhea, followed by a continuous slight hemorrhage of a dark powdery red character, different from men- strual blood, with paroxysmal periodic pelvic pain, with an increase in pulse rate, abdominal tenderness and a doughy tender mass beside the uterus, the diagnosis should be exact. Changes in the uterus, lessened hemo- globin, congestive changes in the breast, distention of the abdomen and alteration in the consistency of the cervix, bring cor- roborative evidence of value. A history of missed menstruation, fol- lowed by severe pain and uterine hemor- rhage of a character different from the menstruation should lead one to suspect ectopic pregnancy. The most constant symptoms are amenor- rhea with a simultaneous onset of uterine hemorrhage and pain. The cases difficult to diagnose are those of long standing, where the hematocele is infected and the diagnosis to be exact should be infected hematocele. The early diagnosis of ectopic pregnancy is of vast importance in the treatment of the condition. Prompt operative measures cannot be instituted unless diagnosis is early and exact. Care of the patient before operation is also of importance. Many deaths result from careless handling in transportation to the hospital. Operation under a mistaken diagnosis as curettage for supposed abortion is often disastrous. For these reasons, every effort should be made to diagnose ectopic pregnancy early and exactly. CHAPTER XIV. LACERATION OF THE PERINEUM AND PRIMARY REPAIR. Introduction. — As long as women con- tinue to have children, perineal lacerations will continue to occur. Their study is a commonplace one, not associated with the romantic and imaginative associations as are cancer and tuberculosis, but not the less necessary and important. The mere fact of the great prevalence, occurring as they do in half the women who have children, is sufficient to require that the study should be exact and persistent. The cases reported here were studied at labor and the picture of the laceration drawn upon a stamped outline. This may now be obtained from dealers supplying the medical profession with rubber stamps, and is of great use in the study and record of perineal lacerations. It is a useful record to com- pare after healing has taken place, and in- culcates habits of accuracy in observation. The first historical reference to the subject is found in an early work supposed to have been handed do\\Ti by tradition and edited by an unknown author who states that Tortula, a midwife attached to the school of Salernum, who lived in the eleventh cen- tury, cured a laceration of the perineum by operation — "Postmodum ruptura intra aniim et vidvam tribiis locis vel qiiatiior- suimus cum filo de serico."^ .Ambrose Pare- was another of the early investigators of the subject and is credited with having performed the operation. He reports a cure of two cases, but does not state that the operation was done imme- diately after labor. He gives directions as follows : "But if through the violence of extraction the genital parts are torn, so that the two cavities, the rectum and vagina, Page Fifty-nine are torn into one, the tear must be stitched up, and the wound cured according to art. I have thus cured two women living- in Paris." Various other investigators followed Pare, amongst them his pupil, Guillemeau,^ who operated upon one case of complete rupture of the perineum six weeks after labor. He pared the edges of the old cicatrix and used one figure-of-eight and two interrupted sutures. The operation was a success. Others who performed the operation for complete tear were De La Motte, Morlanne, Saucerotte, Noel, and Dupuytren in France, Rowley in England, and Oslander and Dieffenbach in Germany, Dieffenbach* wrote extensively upon the subject of complete perineal tear and fol^ lowed the plan of making lateral incisions at each side of the perineum after suturing the recto-vaginal septum. In 1837 he ad- vised the primary repair of all lacerations of the perineum, including first and second degree tears. Amongst American surgeons Mettauer^ of Virginia published a report of a success- ful operation for complete tear six months after its occurrence. He used sutures of lead and fastened them by twisting. Roux^ wrote extensively upon the sub- ject and published many successful cases of complete perineorrhaphy. He was an earnest advocate of the operation. Amongst those who did primary opera- tions for incomplete tears of the perineum were Bayer^ in 1823, ChurchilP in 1824, and Williams^^ in 1827, while Alcock^^ per- formed the intermediate operation for in- complete laceration in 1820. The secondary operation for laceration of the second degree tears also was first done about this time. Fricke,^^ in 1835, has done the operation four times with three successes. Nick^^ also reported in 1838 that he had done two operations for incomplete tear of the perineum. Baker Brown^^ was, however, the sureeon who did most to bring the operation into general use and encouraged others to study the sub- ject of perineal injuries. In 1866, Baker Brown had done 112 operations upon the perineum. His work stimulated Savage^® to excellent researches upon the anatomy of the perineum, which have remained classic in gynecological literature. Following after these were Hegar, Sims, Agnew, Emmet, A. Martin, and Lawson Tait. Of these, Emmet" has been the greatest contributor toward the subject and recognized that the torn muscles and fasciae caused a loss of support to the pelvic floor. His operation is the one commonly per- formed at the present time. Since the time of these masters, a multi- tude of new operations have been devised to restore the anatomical support of the pelvic floor and close the perineal wound, caused by descent of the head at labor. All these operations have as their aim the in- timate approximation of the edges of the torn fasciae and muscles. To this end, in secondary operations, many forms of de- nudation of the vaginal mucous membrane have been exploited. The majority of these attempt the excision of the scar tissue of the old wound and the restoration of the torn muscles and fasciae. Without a proper appreciation of the causes, processes, and forms of perineal rupture, it is useless to attempt to judge the value of each modification of the various operations. With this end in view I have made sketches of forty-eight consecutive perineal lacerations at the time of labor and have noted the most evident and directly causative factors. These lacerations oc- Page Sixty curred in loo women, of whom 90 were primiparae. This gives a percentage of occurrence of forty-eight per cent., which is within Williams' estimate of 45 to 58 per cent. Every wound of the mucous mem- brane other than a small tear of the fourchette has been reckoned in the series, none over 1.5 c, m. in length have been excluded. Causes. — The various causes of perineal laceration are usually cited as follows: i. Too rapid expulsion of the child, so that tearing of the perineum instead of stretch- ing results; 2. Relative disproportion between the presenting part and the par- turient outlet; 3. A faulty mechanism of labor whereby the largest circumference of the head passes the perineal ring; 4. The use of forceps. Rapidity of delivery is without doubt the most frequent cause of perineal laceration. This is particularly seen in those cases of precipitate delivery where the head comes through the birth canal rapidly and impinges upon the perineum with almost the force of a blow. This rapidity of advancement of the head is sometimes seen in cases of con- tracted pelvis, where strong uterine pains are required to force the head through the bony pelvis, with the result that the less resistance of the soft parts does not retard its way. The quick descent of the head was also seen in one case (No. 25), where the membranes had remained intact until the head had come through the brim ; when the membranes ruptured, the head was ad- vanced with great rapidity, causing a lacera- tion in a multipara with a comparatively lax outlet. The passing of the head through the perineal outlet should undoubtedly be re- tarded, until the parts have softened and stretched. A preliminary digital stretch- ing is most useful in primiparae, although often a painful procedure. It can, however, be done during the labor pains and is a means of stimulation of their force and fre- quency. A frequent cause of perineal laceration is the pressure of the head upon the perineal body and the lack of retraction between pains. The maternal parts become blood- less and tense and tear readily with further descent of the head. An additional factor in the production of this condition is the attempt to control expulsion by pressing the taut perineum against the sinciput. This wounds the perineum and aids in the production of the anemic condition. The advancement of the head should be con- trolled without making any pressure upon the perineum. Strong pains are a definite factor in the production of perineal injuries, but may be readily controlled by chloroform. Relative disproportion between the pre- senting part and the parturient outlet is commonly thought to be one of the main causes of perineal injuries. In any attempt to estimate the size of the fetal head in relation to the perineum, it should be decided which is the greatest diameter of the fetal head to engage in the perineal ring. In this study, it will be con- sidered to be the occipito-frontal diameter, which comes into relation with the perineum by the final extension of the head. It is the diameter most capable of accurate measurement and gives a more dependable estimate of the size of the fetal head than do the suboccipito'-bregmatic or biparietal diameters. The various circumferences of the fetal head offer too much possibility of error in measurement to make them useful as indications. Page Sixty-one Therefore, in attempting- to estimate the size of the presenting- part in its relation to the size of the perineal ring, the greatest engaging diameter, the occipito-frontal, is taken as a criterion. However, as the size of the head increases in direct proportion to the weight of the child, the increase of weight in its relation to perineal lacerations is also considered. This increase in the size of the fetal head in proportion to the weight was shown to be constant in lOO cases studied in its relation to intra-uterine cephalimetry.^'' Varieties. — In this series, the 48 perineal lacerations may be divided into two classes : I. Those not involving the muscle; and 2. Those involving the muscle of the perineum. Of those not involving the muscle, there were 21. The average weight of the 21 babies was 3,310 grammes, and the average occipito-frontal diameter was 11.27 cm. The 27 cases of lacerations involving the muscle had children averaging 3,550 grammes, and with an average occipito- frontal diameter of 11.75 c"^- I'he average weight of 100 babies, of whom these 48 cases here reported are a part, was 3,300 grammes, and the average occipito-frontal diameter was 11.40 cm. Therefore the re- sult may be summarized : O.F. Diam. Weight. 21 cases of laceration not in- volving muscle 11.27 3,310 gm. 27 cases of laceration involv- ing muscle 11.75 3,550 gm. 100 cases, including 48 cases of laceration 11.40 3,300 gm. From this summary it will be seen that the babies causing lacerations not involv- ing the skin were of average weight, but of less than average size of head ; while those causing lacerations involving muscle were of more than average weight and size t)f head. However, the slight increase in weight of two hundred grammes (7 oz.) can hardly explain the causation of the lacerations in view of the fact that*T:he heads were but slightly larger than average. Nor will the fact that, in 21 cases of minor lacerations, the fetus was of average weight and less than average size of head explain the causation of these tears. The causation of perineal lacerations, while undoubtedly influenced by consider- able increase in size of the fetal head, does not depend to any extent upon this condi- tion. It must, therefore, depend more upon the size and condition of the perineum itself than upon the size of the fetus and fetal head. The disproportion may be due to firmness of fiber and rigidity of perineal structure. Faulty mechanism of labor is undoubt- edly the cause of a small percentage of lacerations, but this has an influence in but a small number of cases. Amongst them are those cases where the occiput does not present under the symphysis as in delivery by face to pubes. Whenever the flexion of the head is not sufiicient, a larger diameter than necessary must pass the perineal ring. If flexion is good, the occiput may pass under the pubic bones before the occipito- frontal diameter engages in the outlet. In breech deliveries the reverse must ensue, i. e., the occiput remain within the ring and pivot under the symphysis, allow- ing the sinciput to engage first in the ring. The use of forceps as a causative force is one which varies very much with the methods of different operators. The harm they cause depends upon: i. The kind of forceps employed; and 2. Upon whether the operator delivers the head with the forceps or not. Page Sixty-two Forceps with long blades of the type of the Simpson forceps may cause laceration of the perineum in two ways. First, directly on a backward pull by the breadth between the shanks where they join the handles, which unduly stretches and wounds the outlet at a level with its great- est frailty, the posterior fourchette. Second, the blades themselves do not closely ap- proximate the fetal head, and the edge of the blade extending beyond the head, im- pinges upon the vaginal floor and is forced into the tissue. This condition is quite common when attempts are made to deliver the head through the ring without removing the forceps. When the handles of the forceps are turned upward in order to ex- tend the head, the blades, not fitting snugly over the head but grasping the parietal processes firmly, turn upon these eminences as upon a pivot, with the result that the point of the blade extends beyond the head and impinges upon the pelvic floor. Further descent of the head drives the point into the tissue and starts a laceration. In such conditions it requires but a small beginning of a tear in the mucous membrane to result in a large laceration. The secret of success in the prevention of perineal lacerations is to keep the mucous membrane intact : once the mucous mem- brane is ruptured, as by the point of the forceps' blade, the head stretching these tissues often causes a severe tear, while, if the mucous membrane is kept intact, de- livery is often made successfully through most rigid perinea. In other words, the tissues are like cotton, in which, if a tear is once begun, it may be easily extended. Such was the result in one case (No. 7), here reported, where a small laceration was caused by the points of the Elliott forceps and the muscles split so that the finger could be thrust between the muscular planes to the skin of the ischiorectal space. It is necessary in delivery to prevent the parturient from slipping away from the hand protecting the perineum during de- livery. The diameter of the fetal head from the brow to the back of the neck should be brought into the median line. The right hand restrains the sinciput or forehead; while the left index and middle fingers are worked into the angle below the symphysis and lift the back of the head until the back of the neck enters the symphygeal angle. The soft parts are pushed backward over the dip of the occiput in order that the oc- ciput may be delivered before the sinciput and the head escape delivery in the long- est diameter, the occiput frontal. As soon as the head is under control the patient should be instructed to count rapidly or to take deep rapid breaths in order to eliminate further straining. If chloroform is given, the straining may be controlled in this way. The occiput must be delivered before exten- sion of the head is allowed. Stretching the perineum is always ad- visable before forceps operation. Some- times this may be done by dilatation of the vagina by a rubber bag as first advised by Macomber. This is so painful as not to be permitted until an anesthetic is given, but manual dilatation by massage and stretching is useful before operative de- liveries. It should be remembered that the essen- tial part of the perineum is composed of fascia and muscle and that fascia will not stretch, while muscle will. The fold of skin and superficial fascia extends for 3 or 4 cm. beyond the musculature below. For this reason, in order to avoid laceration into the muscle, where a laceration must ob- Page Sixty-three viously occur, an incision or episiotomy may be made for 2 cm. or a thumb's breadth into perineum without cutting into muscle. This allows of enough enlargement of the outlet and is more readily repaired than is a perineal tear. The incision should be made backward and downward and at the side below the outlet of the vulvovaginal gland. This is a useful procedure, not sufficiently used. It was known centuries ago and referred to by Harvey, discoverer of the circulation of the blood and by De La Motte who was a close observer of peri- neal injuries. It may be very readily re- paired with No. 2 chromic gut. v. Ott has done 364 episiotomies and is most laudatory of the operation. The secret of avoidance of tears in for- ceps delivery is the use of proper forceps and the removal of the forceps as soon as the head can be controlled by the hand. Trials by practical use of many models show that semi-fenestrated forceps as de- scribed in a previous chapter, fit the head well, cause little traumatism to the vagina and perineum, and are easily applied with- out causing abrasions or injury. These forceps may be applied and the head drawn down until it can be controlled by pressure upon the forehead between the coccyx and the anus. No attempt should be made to deliver the head without first removing the forceps. With the acquirement of skill and the use of proper forceps, there is no reason why there should be more lacerations directly due to forceps in instrumental de- liveries than in non-instrumental deliveries. The head may be delivered as slowly and as much care taken of the perineum as in non-instrumental deliveries. A frequent cause of perineal laceration which is often credited to the forceps opera- tion is the traumatism done by the pro- longed stay of the head at the outlet and the pressure caused by the ineffectual labor pains pressing the presenting pai^ against the pelvic diaphragm. In those cases (Nos. 19, 30 and 38) in which the head had remained some time upon the pelvic floor, the resulting lacerations were exten- sive and deep; the tissues were edematous and fragile, being repaired with difficulty, as the sutures cut out. The presenting head should not be allowed to remain upon the perineum without advance for more than an hour and a half, and usually not that time. Posterior positions are also often spoken of as a cause of perineal lacerations and undoubtedly predispose to this condition. Forceps rotation is dangerous with the old style long fenestrated forceps. The vaginal mucous membrane may be stripped off, as was the result in one case (No. 32), re- ported here. However, with the modern solid blade model, the operation of rotation by forceps is easy, and there is but little danger of damage to the mucous mem- brane. Scar tissue in the perineal ring as a result of old wounds or previous perineorrhaphies makes the perineum more easily torn. The fibrous scar tissue has not the elasticity of normal perineal structure, and rupture is apt to occur at this spot. In several cases of multiparae (Nos. 5, 8 and 39), the peri- neal outlet was of fair size, yet a laceration occurred at the site of the scar. It is frequently stated that the shoulders in head presentations often cause lacera- tions of the perineum. Such is not my ex- perience. The shoulders alone seldom originate a laceration; but large shoulders quite frequently increase the extent of a tear which was begun by the head. The Page Sixty-four phenomenon already referred to holds good that a tear once begun readily extends ; such was the result in one case (No. i8) in this series. For the purpose of consideration of these lacerations, they may be divided into tears of the anterior and posterior part of the perineal outlet. The posterior tears may again be divided into: — i. Tears not in- volving the muscle, or minor tears ; 2. Tears involving the muscle, or major tears ; and 3. Tears involving the sphincter. The relation of the skin surface to the lacerations has no bearing upon its depth or gravity. Ofttimes a laceration may not involve the skin surface, yet extend deep into the muscle of the pelvic floor. Such cases are Nos. 7, 24, 27 and 36. There may be extensive injury to the pelvic mus- cular support without any rupture of skin surface. Minor lacerations occurred 21 times. Forceps were done 4 times. The average weight of the babies, as before stated, was 3,310 grammes. Major lacerations occurred 27 times. There were 11 forceps deliveries. The average weight of the babies was 3,550 grammes. No cases of sphincter tear occurred in this series. The author has repaired a number of sphincter lacerations in ob- stetrical work and has had two occur in his own hands. One of these was due to an ill-directed and ill-controlled forceps traction when the head was near the peri- neum. The head came down suddenly with the last traction, and as the direction of the traction was wrong, ruptured the perineum. The other case was one in which, while an assistant delivered a case of placenta previa under my direction, the arms became extended in the breech extrac- tion and caused delay, so that the safety of the child compelled extraction of the head very hurriedly. The head came through the pelvis so quickly that the extension of the face was not done. The chin caught against the perineum and caused a sphincter laceration. Both of these tears should have been prevented. Most sphincter lacerations are without excuse, and, with proper care, should not occur. Page Sixty-five TABLE OF CASES. Para. I] II] II] Occ. Pelvis. Fr. Normal 12.75 12 11 11.25 si. contr 11.5 " 11.75 Normal 11.75 .12 Contracted 11.5 11.75 11.25 Normal 11.25 11.25 10.50 11.25 si. contr 10.75 Normal 11.25 si. contr 11.50 Normal 11.75 .12 .11.75 .12 .11.5 .11 .10.75 11 10.5 Contracted 12.25 Normal 11.5 si. contr 10.75 Normal 11.25 11.25 11.25 10.30 11 si. contr 10.75 Normal 11.5 11 11.50 11.25 12 11.75 11.50 11.50 si. contr 11.25 Normal 11.25 11 11.25 Weight. 3600 3500 3300 3400 2900 3900 3450 3950 3050 4000 2850 3100 3650 2950 3400 2800 3600 3700 3800 3750 3600 3500 3025 2950 3200 3200 3100 3800 3650 3000 3500 3300 3100 3500 2650 2900 3800 2650 3800 3500 3300 3200 3400 3500 3400 3000 3000 3200 Remarks. Precipitate. Age 39. Scar of old operation caused rigidity. Med. forceps. Muscle split begun by sharp edge of forceps. Old scar tissue. High forceps; torn after removal.. High forceps, dry labor. Low forceps. Tear increased by large shoulders. R. O. P. Head on perineum l^^ hours, tissues contused. Low forceps. Second degree. Skin intact. R. 0. P. Head came down quickly when mem- branes ruptured. R. 0. P. Second degree. Med. forceps. Low forceps. Low forceps. Head on perineum iy2 hours. Med. forceps. L. 0. P. Caused by attempts at rotation. R. 0. P. Low forceps. Age 44. Very rigid. Med. forceps. Low forceps. Low forceps. Med. forceps. Med. forceps. Dry labor. Head on perineum 1% hours. Old scar of previous repair. Page Sixty-six ^1 \ repaired beep sejbara-l tion of muscksi to sA/w in wf, rectal I ^ , space -V/,,^ f, '^ E*IQ. 1. Page Sixty-seven Fig. 2. Page Sixty-eight old cystoeek muco cut- ,v„, junc. ;^', ^^ Jf\ ft"^ Ol\^ 3^ iih^- MN <^^ p Pig. 3. Page Sixty-nine 7,^c scar ¥2 /j^ ¥3 } .7^!^, ?w^ ^^/'/ 3^3 "/l\^ Fig. 4. Page Seventy In consideration of these 48 cases, it will be seen that lacerations of the anterior por- tion of the perineal ring have occurred 32 times. These lacerations occurred in the region of the vestibule, through the labia minora and around the urethral orifice. They frequently caused hemorrhage. In one case (No. 14) the labium minus was A scrutiny of the more severe tears of this series will show that the lacerations are usually lateral. Those which occurred in the midline did not extend centrally up the vagina, but deviate to one or other side, or separate to form a Y. The only lacerations which extended centrally up the vagina were those in which the perineum was the Fig. 5. torn completely through, as if cut with scissors. These anterior tears have but seldom been referred to save by Bar and Hirst and are of considerable importance, as they often bleed profusely. A death from hemorrhage from an anterior lacera- tion has been referred to by Mathews Duncan. seat of old scar tissue which altered the normal relation of the fibers. Thus it will be seen that any secondary operation which considers purely the mid- dle line of the vagina does not attempt to repair the original trouble and is ineffectual in restoring the parts to their previous con- dition. The Emmet operation, as modified Page Seventy-one by Noble, best completes the exact anatomic restoration for primary repair. It may be modified to suit any of the more severe lacerations shown in these pictures. These lacerations were all repaired imme- diately after labor. The operation may be L operation done. The intermediate opera- tion in the stage of g-ranulation is one fraug-ht with danger. Freshening the granulating surfaces of an infected wound of the perineum may cause a severe in- toxication and open avenues of infection. // / / Fig. 6. delayed 24 to 28 hours, if the woman's condition is poor, but should not be delayed longer, as the pyogenic organisms, con- stantly in the lochia, may cause infection of the wound. If it is necessary to delay longer, the laceration should be left for complete cicatrization, and a secondary The technique of the operation for pri- mary repair was as follows : First, if there was a sphincter tear, the rectum was sutured by a modified Lauenstein suture with fine chromic catgut and a small needle. These sutures pass in and out close to the margin of the gut upon the vaginal side without Page Seventy-two penetrating- the rectal mucosa. They are introduced in a figure-of-eight and tied not overtightly. The remainder of the opera- tion, save for joining the sphincter ends, is the same as for a sphinter or major tear. The mucous membrane is sutured with No. 2 chromic catgut, with a Kelly's needle. These needles should be rather heavy ; a useful type, with a large (Lister's) eye in These double stitches save time, lessen the possibility of infection along the suture line and properly coaptate the parts. Care should be taken that the sutures completely close the sulci and do not connect them into closed gutters for the passage of discharges. Twelve-day chromic gut is used and lasts in the vagina from six to ten days. Plain catgut is not of use in the soft succulent Fig, 7. Illustrating Laceration of Perineum the side, is that sold by Codman and Shurt- leff of Boston. The needle should be in- serted I cm. from the edge of the mucous membrane and come out at the bottom of the laceration ; be reinserted and emerge i cm. from the opposite edge (Fig. 7). Full bites of tissue should be taken. The sutures here are also passed as figure-of-eight. tissues of the postpartum passages, as it is absorbed too rapidly. No. 3 plain catgut lasts on an average three days under these conditions. If the laceration is complete, the sphincter is now brought together by two sutures of No. I chromic catgut on a small needle. These sutures are buried (Fig. 8). Page Seventy-three The next step in the operation is the closure of the external or skin surface of the laceration: this is done by silkworm or chromic gut sutures, with the Kelly needle. The sutures, as passed through one side of the wound, come out at the bottom and, if necessary, pick up any redundant tissue, and are reinserted to come out about i cm. from the skin surface. These sutures are pull the edges of the wound together. _When all are inserted, these sutures are tied. Attention is then directed to the muco- us cutaneous junction at the level of the hymen. Here two or three fine chromic sutures are usually required to effectually seal the wound. The secret of success and primary union Fig. 8. Illusteating Laceration of Perineum drawn sufficiently tight to bring the edges of the wound firmly together. It usually requires from three to five of these sutures. None should be tied until all are in place, the effect of each suture upon the wound by crossing: the ends of the suture beingf to in this operation is to have no opening or gap in the line of the wound for the en- trance of the lochial discharges which have been proved always to contain pyogenic or- ganisms. These last chromic gut stitches effectually block a very commonly left gap Page Seventy-four which would permit the infiltrating dis- charge to obtain entrance to the lower part of the wound. These stitches correspond to the "crown-stitch" of Emmet's operation and restore the fascia in that plane as well as add to the cosmetic result. are not so succulent, nor are they so ex- posed to discharges, as to require chromic gut. The difficulty in the repair of these anterior tears is to avoid puckering and to get a straight line of union. This is best done by beginning the continuous suture Fig. 9. Illustrating Laceration of Perineum (Chapter 14). The operation is done in three steps: i. Suturing the mucous membrane; 2. Sutur- ing the external tear ; and 3. The "crown- stitches." The anterior lacerations were all repaired with fine plain catgut. The tissues here at one end of the tear and tying it. This tied end is used as a tractor and the suture continued as a "half-hitch" suture, i. e., after every bite of the needle the catgut is passed underneath the last stitch, as the tops of flourbags or bales are sewn. The Page Seventy-five suture is thus continued to the end, leaving The aftercare consisted in Iceepina- the a straight wound women in bed for ten days. No douches All these eases healed up by primary in- were given, except on other indications tent.on. One, m which plain catgut was used The silkworm gut sutures were removed in Fig. 10. Illustrating Laceeation of Perineum (Chapter 14). va1inTpartTfc°"vound " T?^" w *^ '™T '™ '° f°"'"" ^^y^' ^^ '^e condition tors .n?urpH K t^' ^^' J I sphincter of the wound demanded. The women were chrom c'ut tried TnTbffnl;-'"? ™* ^f' "^'"^ ^"°^™d up after ten days with the heaS pfrfectt "^ "'*'' '""''=''' ^"'"^l '? P'^=!' ='"<' ^^out the house a day ^ ^- or SO before their removal. Page Beventy-six REFEEENCES. 1. Gynaeciorum hoc est de Mulierum turn Aliis turn Gravidarum, etc. Basileae per T. Guarinum. 1566-257, chapter xx. Gy- naeciorum sive de mulierum affectibus commentarii Graecorum, etc. Basileae 1586, vol. i, chapter xx, p. 105. Quoted by Kelly-Noble. 2. AMBROISE PARE. Opera Ambrosii Parei regis primarii et Pariensis chirurgi, etc. Parisiis. J. Dupuys, 1582. Liber xviii, chapter xxvii, p. 698. IMd. "The Worker of that famous Chirurgien Ambroise Pare, translated out of the Latin and compared with the French by Th. John- son," etc. London: R. Gates, 1649. Liber xxiv, chapter xxvii, p. 615. Quoted by Kelly-Noble. 3. GUILLEMAU, J. Les Oeuvres de Chirur- gie, etc. Paris: N. Buon, 1612. Livre iii, chap, vii, p. 354. Quoted by Kelly- Noble. 4. DIEFFENBACH, J. F. Chirurgische Eri- abrungen, 1829, bd. 1, p. 64. Sur la rup- ture de Perinee. Jour. Complementaire au Dictionnaire de Science Medicale, 1830, xxxviii, pp. 193-206. Ueber die Zerreissung des Dammes bei Frauen, Medicinische Zeitung, 1837, bd. vi, p. 255. 5. METTAUER, JOHN P. A Case of Lacera- tion of the Perineum. American Journal of the Medical Sciences, 1833, vol. xiii, p. 113. 6. ROUX. Memoir sur la restauration du Perinee, etc. Gazette Med. de Paris, 1834. Tome ii, p. 17. 7. IMd. Clinique chirurgicale. L'Union Medicale, 1849, vol. iii, p. 247. 8. BAYER, W. Cases of Ruptured Perineum treated successfully. Edinh. Med. and Surg. Jour., 1823, vol. xix, pp. 551-554. 9. CHURCHILL, J. M. Case of Lacerated Perineum. London Med. Repository, 1824, vol. 1, pp. 464-468. 10. WILLIAMS, C. Case of Laceration of the Perineum. London Med. and Physic. Jour., 1827, vol. iii, pp. 101-102. 11. ALCOCK, THOS. On the Treatment of Laceration of the Perineum in Parturi- tion. London Med. and Physic. Jour., 1820, vol. xliv, pp. 193-197. 13. PRICKE, J. C. G. Episorrhaphie ou nou- velle operation pour la cure de prolapsus de la matrice. Gaz. Med., 1835. Tome iii, p. 249. 14. NICK. Beobachtung der vollkommenen Heilung einer noch ganz neuen Damm- ruptur. Med. GorrespondenzMatt des Wurttemdergischen Aerztevereins, Stutt- gart, 1838, bd. viii, p. 301. 15. BROWN, I. Baker. Diseases of Women, 1854. On Rupture of the Perineum and its Treatment, etc., 1855. 16. SAVAGE, HENRY. The Surgery. Surgi- cal Pathology and Surgical Anatomy of the Female Pelvic Organs, 1870. London, sec. ed. 17. 18. 19. 20. 21. 22. 23. EMMET, T. ADDIS. A Study of the Eti- ology of Perineal Laceration with a new method for its proper repair. Transact. Amer. Gynec. Soc, 1883, p. 198. WILLIAMS, quoted by Hinchey. Surgery, Gynecology and Obstetrics, 1907, p. 155. McDonald, ELLICE. Mensuration of the Child in the Uterus with New Meth- ods. /. A. M. A., 1906, Dec. 15. MACOMBER. Medical Council, 1899, Sept. HARVEY DE LA MOTTE. Stein de sig- norum graviditatis oetimatia. DUNCAN. Am. de Gyn., 1876, Oct., p. 287. MORKOWSKY. Zentr. f. Gyn. 1910, xxxiv, p. 28. CHAPTER XV. PREVENTION OF CATHETER CYS- TITIS IN THE FEMALE. Introduction.— The use of the catheter is as old as the Pyramids. The remains of surgical instruments in some of the recent Egyptian excavations included among them bone instruments for the catheterization of the female urethra. It is probable that since that time, except for surgical cleanliness, there has been but little improvement in the technique of catheterization. The catheter is still thrust in as if the bladder were a cyst which must be punctured with a trocar. The nurse grasps the instrument with a firm grip, pre- pared to stab the patient if she moves or attempts to escape. After several inef- fectual jabs and thrusts, the catheter is thrust half way in and the operator stands up in triumph to allow the congested blood to escape from her head and brushes her hair out of her eyes. In some hospitals, the technique varies. In one, the nurse was required to wash her hands as for a surgical operation, then to put on rubber gloves and gown. She must then take bichloride and five gauze wipes and rub one Page Seventy-seven over each labia (being- four labia) and one over the meatus, then with her g-loves well contaminated and the parts well irritated by the bichloride, she thrusts in the catheter. The production of catheter cystitis de- pends upon injury to the tissues, particu- larly to the mucous membranes in the neighborhood of the neck of the bladder and the sphincter muscle of the bladder and urethra. Injury to the lower part of the trigone is particularly prone to produce bladder irritation. It is well known that, in operations which involve external trauma to the bladder, such as complete hysterectomy, there is a very marked tendency toward cystitis. This is most frequent in operations which involve extensive dissection, such as cancer opera- tions. There is, as a rule, a greater dififi- culty in urinating when morphine and atropin have been used. After labor also, there is sometimes diffi- culty in urinating. This is more fre- quent after forceps operations, and when the anterior vulvar parts have been injured or torn. The mere presence of microorganisms in the urine is no reason for cystitis, as it often happens that the urine contains pus-forming organisms without any infec- tion. Injection of cultures of bacteria will not produce cystitis unless trauma is present. This trauma usually comes from the in- troduction of the catheter. It may be that there is in addition injury from the opera- tion to the walls, nerves and circulation of the bladder. The injury of the catheter is often the precipitating factor. This injury to the urethra and trigone comes in several ways. First, from im- proper catheters, either too small or too large. The too large catheter causes in- jury from difficulty of insertion and stretch- ing. The very small catheter causes injury, because its small size makes it vegy pliable and difficult of insertion and too much is usually inserted into the bladder. The best size of catheter is one which will fill the urethra without stretching- it. This is best done by a 15 or 1 6 French. Injury also occurs from the catheter be- ing required to be inserted too far into the bladder, with the result that, when the urine is drawn off, the bladder contracts down upon the top of the catheter and in- jures its mucous membrane. In addition to this, catheters which have the eye in the side are not good, because as the urine is drawn off, the mucous membrane of the bladder is drawn into the eyelet and may be injured. This is particularly true, when the bladder is lax and the urine flows off faster than the bladder con- tracts. It sometimes shows its effect upon the flow of the urine when the "stammer- ing" or "stuttering" of the bladder results from the mucosa filling the eyelet and being suddenly pulled away by bladder contrac- tions. The flow of urine comes intermit- tently. Then again catheters of firm material as glass do not adapt themselves to the shape of the urethra and so put the parts on stretch and cause trauma. The urethra is a fairly regular curve with the concavity upwards and most glass catheters are straight with a beak or nose. They cannot accommodate themselves to the urethra. To overcome these defects, I use a rub- ber catheter 15 or 16 French which has a hole in the end or an apical aperture. The catheter will not distend the urethra un- duly and need not be inserted into the bladder. Page Seventy -eight The urethra is of varying- length in dif- ferent women. The text-books on anatomy give the length of the female urethra at 6 cm., but I have rarely seen a urethra of this length. The length as measured with the catheter varies from 3.5 to 5.5 cm. with an average of about 4.5 cm. It is obvious, therefore, that it is never necessary to in- sert the catheter more than 5.5 cm. and usually less. For this reason, I have the catheter graduated in centimeters and use At the succeeding catheterization, the rubber guard is moved to this point and it is then assured that the catheter is not thrust in too far. On the first catheteriza- tion the guard is placed at 5.5 cm., so that, until the urethra is properly measured, it is sure that the catheter is not thrust in very far. This maneuvre is very easy, and the rubber guard can be cut from any tube of a proper calibre. L ' I z3 Fig. 1. Illtjsteating Laceration of Perineum a movable piece of rubber tubing which fits closely over the catheter. The nurse is instructed to measure the urethra at the first catheterization. This is done by pass- ing the rubber catheter in until the urine flows freely. It is then gradually with- drawn until the urine ceases to run and then slowly reinserted until the flow comes again. This point is measured on the scale of the catheter at the level of the labia minora. Technique.— With a proper instrument, it is necessary to know how to insert the catheter. This depends upon two things: proper lubrication and a relaxation of the sphincter of the bladder. Lubrication is necessary for the insertion of any instrument over mucous surfaces. No one would think of inserting a male sound or a rectal tube without greasing them, but the female urethra has had to suffer for its shortness. Here greasing is Page Seventy-nine just as necessary as in the anus, where the passag-e is no long-er. A useful lubricant for this purpose may be made by boiling Irish moss in water. Three ounces of Irish moss should be taken and washed in running water for a half hour. It should then be placed in two pints of water in a saucepan and allowed to boil over a rather slow fire, while constantly stirred. If it is not stirred, it had better be put into a double boiler, otherwise it will stick to the bottom of the saucepan. After this has boiled for ten minutes, it should be taken off and passed through a fine wire strainer, such as is used in kitchens. If it does not flow readily through the strainer, it may be expressed by means of rubbing a large spoon against the meshes of the wire. This strained jelly is again put upon the stove and sterilized by boiling for one-half hour with sufficient water added to make it of the consistency of jelly. After one- half hour of boiling, the jelly is taken from the stove and poured into lead paint tubes which have been previously boiled with their stoppers in another vessel. Before the jelly is poured into the tubes, it is my custom to add to it an antiseptic, such as eucalyptol or thymol. This is to preserve the jelly. This lubricating jelly is useful for ex- aminations in the office. If it is desired to make the jelly clear and transparent, it is better to add a large quantity of water, filter throug-h muslin or asbestos fibre, and later evaporate to the requisite consistency. However, this is not necessary. The jelly is cheap and costs about 5 cents a quart. Irish moss is commonly used in this country- by brewers — to lubricate throats, probably. The jelly may be put into lead paint tubes, w^hich may be obtained from any can man- ufactory, or into small wide-mouthed glass bottles. The receptacles must, of course, be sterilized before using. Enough may be made at once to last throughout the year. Various proprietary preparations under euphonious names may be obtained ; most of them are made from Irish moss or chrondrus. Oil, olive or paraffin, makes a good lubricant, but has the disadvantage of attacking rubber. The lubrication must be applied to the catheter and to the urethra. The hands are washed and the left forefinger takes up some lubricant. This is roughly spread over the area of the meatus, coating its parts here fairly freely. This has ^e advan- tage of making a coating over the mucous membrane, so that, if the catheter does miss the meatus, it touches the lubricant. No gauze wipes or cotton sponges are used. It is impossible to wipe microorganisms out of the urethra, because the discharges are only driven further in. The catheter is taken in the right hand which remains clean and well lubricated with the Irish moss jelly. The labia are held apart by the thumb and forefinger of the left hand which rests, palm downward, on the symphysis. The catheter is then inserted about 1.5 cm., a finger's breadth, and held there with gentle pressure. The patient is then asked to take as long a breath as it is possible for her to take. This relaxes the sphincter and the catheter slips in without trauma. After the insertion of the catheter for the first 1.5 cm., the sphincter immediately goes into reflex spasm and, if the catheter is forced in, the spasm becomes firmer and firmer. It is necessary, therefore, for the patient to turn her attention to the contrac- tion of some other antagonistic set of muscles, the contraction of which releases the involuntary reflex spasm of the sphincter of the bladder and allows the catheter to slip in almost of itself. It is very easy and very simple and is based upon the same principle as sw^allowing the stomach tube or bearing down in the pas- sage of the rectal tube — relaxation of the sphincter. The catheter may then be withdra\vti until it can just draw off the urine and not enter the bladder, as is shown in the draw- Page Eighty ing of the catheter with the special aperture. When the bladder contracts during- the withdrawal of urine by the catheter, there is a simultaneous continuous movement which begins slowly and increases in speed toward the end of micturition. The long- itudinal diameter, however, decreases more and quicker, than the horizontal. The more powerful longitudinal muscles would ap- pear to contract more quickly and more strongly, than the circular fibres. The re- sult of this is that, if a catheter is inserted too far, as the lateral-holed catheter must be, the bladder wall strikes it, before the urine is all out of the bladder. The apical- orificed catheter avoids this. To prevent the necessity of catheteriza- tion, Frank^ has recommended the injection of 15 to 20 c. c, of glycerin, which he calls a laxative for the bladder. This is injected, when urination is required. This is effec- tive in some cases, but it causes some irri- tation and pain, as does glycerine on any mucous surface, rectum or urethra. Wald- stein- uses bougies of glycerine 90 per cent, and neutral soap 9 per cent, for the same purpose. Both cause a little irritation. An injection of sterilized paraffin oil is sometimes effective in retention. It is harmless and may be injected before catheterization. The syringe should be a blunt-nosed one and placed against the meatus and, while the patient takes long breaths to relax the sphincter, gentle pres- sure is made. In this way, some of the oil enters the bladder and a catheter is un- necessary. The glycerine injections some- times cause too much irritation. 1 Frank: Zentralbl. f. Chirurgie, 1909 xxxviii, 2. =Waldsteiii: Gynaekol. Rundschau, 1911, Vol. If catheter cystitis or trigonitis should occur, the sooner treatment is instituted, the easier it is to cure. The injection of a mild silver preparation is usually all that is necessary. A one-fourth of one per cent, nitrate of silver freshly prepared with 20 per cent, glycerine in distilled water may be used. Nitrate of silver is less irritating, provided the viscosity of the solution is greater than water. The thicker the solu- tion of nitrate of silver, the slower the ac- tion and the less irritating the effect. For this reason glycerine and other substances are used. Silver nitrate is the most reliable of the silver preparations, provided it is freshly prepared. The lack of irritation of most of the newer silver salts and prepara- tions depends upon their greater viscosity, slow action, and weakness of effect upon the tissue. Treatment should be begun at the first signs of pain and pus in the urine. If the nitrate of silver-glycerine solution is not immediately effective, bladder washing may be added. But the real secret of the abolition of catheter cystitis is its prevention. This is best done by a proper instrument with an aperture in the end which allows the urine to be drawn without the catheter entering the bladder. The catheter should be lubricated. The sphincter of the bladder should be relaxed before the catheter passes it, so that irritation and burning of the mucosa does not occur. This is best done by asking the patient to take a very long breath while the catheter is about a finger's breadth in the meatus. This allows the sphincter to relax and the catheter to slip into the bladder. In this way trauma is prevented, and without trauma catheter cystitis does not occur. Page Eighty-one CHAPTER XVI. PLACENTA PREVIA. Introduction. — Placenta previa is one of the most dangerous complications of preg- nancy. Its danger to the child is not less than its risk to the mother. More than half of all the children die at birth, and many survive in a weakened condition. The frequency of placenta previa is variously estimated. From reports of clinics collected by me for two years in 183,389 labors, placenta previa was found once in 160 labors. Clinics, however, have more than their proportion of these cases and the rs^tio of occurrence in private prac- tice is probably less. Etiology. — The etiology of placenta pre- via is obscure. One known fact is that it is much more frequent in multiparae. My statistics show one primipara to nine multi- parae. The more children the greater like- lihood of placenta previa. The rapidity with which the labors occur also increases the probability of this complication. It has been suggested that changes in the uterine wall from atrophy or inflammation as a re- sult of frequent or repeated pregnancies predispose toward placenta previa. Such conditions limit the amount of blood going to the placenta and cause it to spread over a larger area in order to get nourishment. This is borne out by the common occurrence of large surface and thinness of the placenta in this condition. The placenta spreads down and overlaps the internal os and so forms placenta previa. The mucosa of the isthmus and cervix responds less actively than that of the fundus to the decidual re- action, so that placenta is required to be thin and expanded. The decidual reaction, similar to that of tubal pregnancy, causes villi to grow deeply into the muscular bundles of the isthmus at cervix, often to penetrate almost completely the*' thickness of the wall. The mucosa of the isthmus in contrast to that of the cervix shares in a most charac- teristic way in the decidual reaction, al- though the decidual swelling is only one- third of that of the body of the uterus. On the other hand, the isthmus more resem- bles the cervix in its muscular tissue and is, by passive stretching, more concerned in the course of pregnancy in the enlargement of the ovisac and is thus transformed into the lower uterine segment. The isthmus normally affords nourishment for the mem- branes ; but, in placenta previa, the implan- tation seriously affects the condition of the wall. The embedding of the placenta has a destructive effect penetrating the thin decidua into the muscular layer in such fashion as to injure the wall of the isthmus, reducing its elasticity and contractile power. The uterine wall thus thinned is easily torn and, having lost much of its elasticity, hemorrhage is common both before and after separation of the placenta. The pla- centa may be so adherent as to be separated with difficulty and with marked loss of blood. The cervical tissue is readily lacerated owing to its increased vascularity and the deep implantation of the villi. This destructive action of the placental villi is more marked when the seat of the ovum extends into the cavity of the cervix and the ovum roots itself on the muscular tissue there. The process of thinning and weakening of the lower segment of the uterus explains the proneness to laceration. It is possible that placenta previa may be formed by fusion of the decidua reflexea Page Eighty-two and vera over the internal os ; but this is probably the exceptional mode of forma- tion, and a low implantation with cleavage of the decidua vera and obliteration of the OS the common one. Mortality. — A collection of cases treated in the last twenty years and during- the antiseptic era gives 8,888 cases with 7.4 per cent, maternal mortality and 55 per cent, fetal deaths, considering all classes of pla- centa previa. Complete placenta previa had a maternal mortality of 16 per cent, and a fetal mortality of 72 per cent. In incomplete (partial or lateral) placenta pre- via, there was a maternal mortality of 5 per cent, and a fetal mortality of 60 per cent. Incomplete placenta previa occurs three times as frequently as does complete. A consideration of these statistics shows that complete placenta previa is three times more fatal to the mothers than is incom- plete, and that approximately two-thirds of all children will die, although complete is also more dangerous to them. The ap- parent discrepancy in the fetal mortality percentage of the incomplete form, being greater than the combined, is due to the fact that all reports are not divided into these classes as may be seen in my detailed paper referred to in the footnote.^ A comparison with the results obtained in preantiseptic days shows a considerable drop in the maternal mortality (23.6 per cent, to 7.4 per cent.) ; but little or none in the fetal mortality (63 per cent, to 55 per cent). Many children die soon after birth in proportion to the degree of their prema- ^ These statistics liave been detailed at length in Surgery, Gynecology and Obstetrics, June, 1911, pp. 546-561, and there has been added thereto Cragin's report of 223 cases. Am. Jour, of Obstetrics, July, 1911. turity. Mason and Williams state that, of 114 children born alive, 38 per cent, died within a few days. Of the children born alive at full term, 20 per cent, died after- wards; of children born alive at 8 months, 48 per cent., and of children born alive at 7 months, 71 per cent, died within a few days of delivery; and, as only 36 per cent, of all their children were born alive, it will be seen that the mortality of children is con- siderably increased after delivery. Zweifel in 178 cases of placenta previa, found that 78 "children were born alive and of those weighing less than 2,500 gm. (51^ pounds) only nine left the clinic alive, and of those weighing more than that amount, 39 left the clinic alive, i. e., 41 per cent, of those born alive dying within a few days. Couvelaire also shows that the expectation of life depends upon the maturity of the child; thus of 17 infants weighing less than four and a half pounds only two survived, whereas of 19 weighing more than six and a half pounds, ten survived. It may be seen from these reports that the chances of life of the child are very pre- carious, not only from the dang-ers of ma- ternal hemorrhage, malnutrition, accidents of delivery; but also from the danger of dying after delivery from prematurity, weakness and exhaustion. The danger of death to the child is increased in direct proportion to its smallness of size and pre- maturity. Complications. — Hemorrhage and its re- sults are the chief danger in placenta previa. This bleeding usually occurs some time before full term and comes on as a dribbling of blood without pain. It quite often occurs at night and the woman is awakened by a feeling of warmth at the vulvar parts. The first hemorrhage is not usually a severe one and is but seldom associated with straining Page Eighty-three or effort. The patient does not as a rule go into labor immediately following- the hemorrhage. Of Filth's 726 cases treated by midwives, only 25 per cent, had pain im- mediately succeeding- the hemorrhage and in the remaining 75 per cent, an interval of days, weeks or months occurred. All but three of the women applied for medical aid before delivery on account of the hemor- rhage. Only 3 per cent, of the 726 women had no hemorrhage before labor pains oc- curred. The first bleeding usually terminates spontaneously and leaves the woman but little weakened. However a second one is not long in coming and often there is a persistent dribbling, so very weakening to the patient. The second and succeeding hemorrhages are more likely to follow upon straining or effort. In placenta previa, ap- proximately 70 per cent, of all deaths are due directly to hemorrhage and exhaustion, and the weakness and lack of resistance following the bleeding is indirectly respon- sible for many who died from infection, air embolism, shock, uterine rupture, and other causes. In Filth's series, there were 141 deaths, of which 98 died from hemorrhage and a large percentage of the rest from in- fection due to lessened resistance. The great danger is hemorrhage before, during and after labor, and treatment must be directed against it. During labor, the natural straining with labor pains is one of the main dangers in increasing the bleeding. The hemorrhage will continue after the cervix has been stretched or dilated until the placenta is re- moved or pressure brought to ' bear upon the cervical vessels. The cervical vessels do not pass through the uterine contractile tissue but go directly to the cervix from the uterine arterv and vein. Postpartum hemorrhage also occurs in about 12 per cent, of all cases based upon recent series. This is more common in complete placenta previa and i^ probably due to the weakening and destruction of the cervical wall due to the imbedding of the placenta in that part. Hemorrhage after delivery often comes on at an interval after the birth of the hahy. The delivery of the child causes an immediate fall in the blood pressure of the mother, but this fail is soon recovered and, when the pres- sure returns to its former level, the post- partum hemorrhage occurs. In cases of postpartum hemorrhage, the placenta is often adherent to its site and re- quires to be brought away by manual ex- traction. This is frequently followed by a renewed rush of blood. In four of Warren's 14 cases of postpartum hemorrhage in this condition, the placenta was adherent, al- though there was no hemorrhage after de- livery in two other cases of adherent pla- centa. There is also danger of persistent and severe hemorrhage from cervical lacera- tions. These occur readily owing to the weakened condition of the cervical wall, its excessive vascularity, and softness. Often the laceration extends so high that it can- not readily be sutured, and packing is not of avail. The bleeding is often only drib- bling in character, but may be free and severe. Postpartum hemorrhage may occur in placenta previa treated by Caesarean sec- tion if the cervix has been dilated by labor pains previous to operation and, while the advisability of Caesarean section is doubt- ful in any case, it is positively contrain- dicated where there has been cervical dilata- tion and hemorrhage. Page eigMy-four Laceration of the cervix is the most common injury in placenta previa. It is most usually due to delivery of the head after version through a cervix which is not fully dilated. The friability of the cervix from placental erosion causes laceration to occur with readiness. It sometimes ex- tends to become a uterine rupture and cause severe hemorrhage. Hauch in 240 cases found a considerable laceration in 11 with two deaths from hemorrhage. Laceration may also be caused by manual dilatation of the cervix by Bonnaire's method followed by version and extraction. Of 171 cases reported by Bonnaire after this method, the cervix was lacerated in 20, in 5 the tear extended into the uterus and in 2 involved the vaginal wall. Of the patients with lacerations, 6 died. Lacera- tion may also occur from the elastic rubber bag or hystereiu-ynter, introduced into the cervix to stop hemorrhage. Of 144 cases treated by the elastic bag by Hauch, there were 9 lacerations and in the majority of these a weight of two pounds had been at- tached to the bag to hasten dilatation. In cases where the bag is inserted without any weight, laceration is not so common. The weight was only attached to the bag in those cases where there was considerable hemorrhage or where the bag did not com- pletely control the bleeding. Laceration of the cervix may also occur from the tearing out of the volsella forceps applied to the cervical lip for traction in in- serting an elastic bag or in packing the cervix with gauze. Abnormal position of the fetus is a not uncommon complication of placenta previa. The situation of the placenta, occupying as it does the space which should be occupied by the child's head, forces the head to be elsewhere. Miiller in his statistics found 272 transverse and 107 breech positions of 1,148 cases. There was thus abnormal position in one-third (33 per cent.) of all cases. This malposition is, however, not always a detriment for it makes version easier, as the child is half turned already with the head out of the false pelvis. The placenta is often adherent and this is the case more often in complete placenta previa on account of the more extensive in- filtration of the cervical walls. In 160 cases in which this complication was noted, there was adhesion to a greater or less de- gree in 67 cases (42 per cent.). The pla- centa frequently requires manual extrac- tion, even when broken into fragments by thrusting the hand through it to do version and breech extraction. Plural pregnancy is more common in placenta previa than in the ordinary run of cases. Winckel states that, in his expe- rience, twins are four times as common in this condition as customarily. Warren found twins twice in 94 labors where the usual ratio is i to 80 labors. In these cases, the twins are usually weak. Diagnosis. — Hemorrhage is usually the first sign of placenta previa and comes on as a rule without straining or excessive effort. It rarely appears before the seventh month; but is more frequent during the last month of pregnancy. This hemorrhage as a rule comes before the labor begins ; in about 75 per cent, of cases, there is an in- terval between the first hemorrhage and labor. Very few cases have no bleeding at all before labor pains begin. This first bleeding usually terminates spontaneously. Examination of the woman at this time usually shows a cervix which is dilated Page EigMy-five sufficiently to insert a finger and feel within the cervix the roughened outside surface of the placenta covering the os. The abrupt margin of the placenta may sometimes be felt through the abdominal wall above the symphysis and at the posterior vaginal fornix the rear margin may be palpated by the examining finger. When the cervix will not admit one finger, the placenta may be felt between the fetal head and the finger as a soft interven- ing cushion. Attempts to produce ballotte- ment drive this cushion against the head. The cervix is usually shorter and softer than in normal pregnancy. Manipulations of the cervix produce bleeding easily. It should be remembered that malposition is associated with placenta previa in approx- imately one-third of all cases. When the placenta is inserted in the cervix the lip of the OS protrudes and the cervix ballooning often resembles an abortion impacted in the cervix. Sometimes the cervix is friable, but if it is open, crumbling masses may be felt, which will usually bleed at touch. Treatment. — The treatment of placenta previa must be considered in general and then as to the various types of the disease. The indications to be met are the control of hemorrhage and the delivery of the child without traumatism, mutilation, or delay. In no condition in obstetrics is delay so dangerous to mother and child as in placenta previa. Delivery should follow the first hemorrhage. The only exception to this rule is where the patient can be put to bed in a hospital and carefully watched. Delay is then permissible as long as the pulse is below 100, and the mother and child in good condition. Delay is, even then, not without danger, but often the intense desire for a live child will excuse the chances taken. The improvement in results comes not so much from any • method of treatment as from early delivery, and early delivery is as advantageous to the child as to the mother. Delivery should immediately fol- low upon complete dilatation of the cervix, but delivery should be without traumatism. The danger of hemorrhage is increased by strong internal contractions and the probability of cervical laceration is much in- creased. The ideal course in placenta previa is dilatation of the cervix with mild labor pains and little natural straining. For this reason if pains are strong, particularly if an elastic bag is inserted, it is usually well to control them by a hypodermic of morphine, gr. Ye to %, and atropin, gr. Vioo- Atropin is a useful uterine sedative and has a distinct effect in preventing severe contractions. As long as the membranes are unruptured, the greatest safety of the mother lies in prohibiting strong pains or straining. If hemorrhage is severe, hypodermoclysis or venous transfusion should be done. It should be remembered that normal saline solution does not consist of one dram of sodium chloride to a pint of water; but other salt should also be included. Evil re- sults have been reported from using sodium chloride alone. A useful formula is as fol- lows: Sodium chloride 9.0 gm., calcium chloride o.i gm. ; potassium chloride 0.25 gm. to one liter of water. The choice of anesthetic is of considerable importance. Anesthesia is not as a rule required for the insertion of the elastic bag ; but when version and extraction or other operations must be done, anesthesia is necessary. Chloroform should be given with great care in the presence of hemor- rhage, particularly if that hemorrhage is sudden. I have come to fear it greatly in placenta previa and always substitute ether Page Eighty-six where possible. The pregnant woman does not bear ether as well as chloroform ; they are apt to be troubled with mucus and bronchial irritation, possibly due to laryn- geal congestion. Still the danger of sudden collapse and shock is so great in placenta previa that ether should be the anesthetic of choice. It is important to hasten to arrest the hemorrhage and then deliver the woman without haste and without force. Because it is important to hasten to arrest the hemor- rhage, it does not follow that delivery should be hastened. In considering the treatment of complete placenta previa, it should be remembered that we have to do with a disease which under the best clinic auspices kills one in six of the mothers and about three out of four babies. The greatest danger to both mother and child is from hemorrhage and to it must the treatment be directed. The chances of saving a child are so small that the mother's risk must not be increased on that account. Delay in delivery after the first hemorrhage but weakens the child and increases the maternal risk. The child is premature in 60 per cent, of all cases and death after a few days occurs in from 15 to 71 per cent, of all babies, depending upon the degree of pre- maturity, so that the chances of life for the child are not great in complete placenta previa. The danger from hemorrhage is not only from collapse after one or two hemor- rhages, but from sudden shock after repeated small hemorrhages. All sur- geons know how little resistance those pa- tients have, who suffer from repeated hemorrhages as from uterine fibroids, and placenta previa cases are no exception to the rule. For these reasons then, the indication for treatment of complete placenta previa is immediate stoppage of the hemorrhage with little consideration for the life of the child. When the cervix is fully dilated, the in- dication is clear. Immediate delivery of the child controls the hemiorrhage and offers the child the best chance of life. De- livery may then be done by Braxton-Hicks' version and immediate breech extraction. This should be done carefully and slowly so as not to cause any mutilation of the cervix or perineum. It is usually well, if condition of the patient allows, to dilate the vagina and stretch the perineum with the hand. This makes the difficulty of breech extraction much less. If the placenta completely covers the dilated cervix, it is better, when thrusting the fingers into the uterus to do the bimanual version, to attempt to pass two fingers around the anterior lobe of the placenta under the symphysis rather than through the centre of the placenta. The risk to the child is increased by piercing of the placenta by thrusting the hand through the centre and, as the geometric centre of the placenta hardly ever coincides with the centre of the cervix, two fingers can usually be passed around, and they are sufficient to do the bimanual version. In case the edge of the placenta cannot be passed, the ob- stetrician can always fall back upon pierc- ing the placenta although after this proce- dure hardly a single child survives, so it is useless to try to hasten the extraction of such a child. Extraction should immediately follow version only when the os is fully dilated or nearly so, because of the danger of cervical lacerations and uterine rupture. When in central or complete placenta previa, the os is undilated, immediate control Page Eighty-seven of the hemorrhag-e is more difficult. The amount of the dilatation of the cervix is not sufficient to allow the passage of the fetal head and the bleeding- must be controlled until the proper dilatation is obtained. This control of hemorrhage may be obtained in one of three ways: (i) by Braxton-Hicks' version, bringing down one foot so that the fetal body acts as a tampon and delayed extraction; (2) by the use of the inflatable elastic bag of Champetier de Ribes; or (3) by tamponage of the cervix with gauze. If the child is dead or premature, version with delayed extraction answers well. It usually sacrifices the child, but in most cases controls bleeding. If the cervix is half dilated, version with delayed extrac- tion is commonly successful, because the cervix is usually soft and the half breech causes dilatation within a short time. If, however, the child is alive and the os small or not readily dilatable, the choice of treatment must be among the three, with the preference to the elastic bag, where pos- sible. The elastic bag or hysteurynter gives good results, provided certain conditions are observed. First the operator must be skillful in its use and observe all antiseptic precautions. The danger of infection is said to be increased but, in 246 cases treated by the inflatable bag, Hannes found only 0.9 per cent, mortality from infection; so that it is evident that in good hands the mortality from infection is even less than in other forms of treatment. Second, the bag must be introduced within the ovum. If the bag is placed outside the membranes, the maternal mortality is very much greater, as is shown by the report of Hauch of 96 cases, in which the bag was introduced out- side the ovum with a mortality of 15.6 per cent., and of 48 cases in which the bag was introduced within the ovum with a mortality of 2.1 per cent. In cases where the placenta does not com- pletely cover the half dilatated «s, the in- troduction of the bag within the membranes is comparatively easy; but when the pla- centa completely covers the os and the bag cannot be passed around the anterior lobe, it becomes a question whether it is better to pierce the placenta with the bag or to do a bimanual version by the insertion of two fingers aided by outside manipulations with delayed extraction of the child after the foot had been pulled down. The choice between these two methods under such circumstances will depend upon the condition of the mother and the child. The bag treatment improves the chances of the child; but if the child is dead or pre- mature, this does not have weight. A pre- mature child, being small with a soft cra- nium, is not so likely to tear the cervix. If the mother is in great weakness from hemorrhage, delayed extraction after ver- sion will probably stop the hemorrhage more quickly, as, with the bag after the os is dilated, delivery must still be effected. Altogether the rule may be laid down that, when the os is partially dilated with a live child, the bag treatment offers the best results when it can be introduced into the ovum and when urgent symptoms are not present. In 387 cases where the bag alone was used and introduced into the ovum where possible, the maternal mortality was 5 per cent. The most successful of this number was Hannes' 143 cases treated by the bag alone with no deaths from hemor- rhage, although there were 8 deaths from other causes, as previous infection, eclamp- sia, etc. The hystereurynter reduces the mortality of the children from 70 per cent, to 30 per cent, according to figures col- Page Eighty-eight lected from these series. The greater hope of Hfe that the elastic bag or hystereurynter gives the fetus may be judged from Thies' report of the results from Bumm's clinic. Taking all births into consideration, the fetal mortality was as follows : spontaneous delivery, 20 per cent. ; vaginal gauze plug- ging, 33 per cent. ; combined version with slow extraction, 80 per cent. ; combined ver- sion with rapid extraction, 64 per cent. ; vaginal Caesarean section, 50 per cent. ; hystereurynter or elastic bag, 14 per cent. Combined version with delayed extrac- tion is very fatal to the child and should be restricted as much as possible to urgent cases where the mother's condition de- mands immediate control of the hemor- rhage. If the interest of the mother alone is to be considered, Braxton-Hicks' version and delayed extraction remain the safesc method if the cervix is partially dilated. There are certain necessities for success- ful treatment by the hystereurynter. The bag must be of large size, as big as a nor- mally large fetal head. It should measure 10 to 12 cm. in diameter and contain from 500 to 600 cm. (about 20 oz.). The bag treatment in this country has achieved a bad reputation because the small de Ribes bag, intended for induction of labor, has been used and inserted outside the ovum. The bag should be inserted within the membranes with a special forceps for the purpose, and with antiseptic precautions. The bag may be boiled and kept ready for use in glycerine which will preserve it, as rubber is apt to crack and spoil if kept dry. It may be boiled with the glycerine in a large preserve jar and the jar wrapped in a sterile towel ready for use. The bag remains in position for 3 to 5 hours as a rule. If the control of the hemorrhage is good, no weight need be at- tached ; but, if the bleeding is not perfectly stopped, a 2 lb. weight may be attached on a cord running over a pulley, as in fracture extension, on the end of the bed. If the weight is attached, a stout elastic band should intervene between the bag and the cord of the weight. In this way, sudden pull on the uterus, caused by the patient drawing away from the weight, is avoided and the danger of cervical laceration is les- sened. The weight should only be attached to those cases where there is considerable hemorrhage or labor is unduly prolonged. After the use of dilating bags, the operator should be necessarily cautious in doing ver- sion and breech extraction, as there is danger of uterine rupture. The advantage of the bag is that com- pression is applied directly to the placenta forcing it back into its place. Tamponage on the contrary forces the placenta away from its bed and tends to increase hemor- rhage. The bag acts as a tampon, as a labor promoting element, and as a gentle dilating force. Cervical tamponage is a makeshift method, only to be resorted to when the bags are not at hand. It is often ineffectual in controlling hemorrhage and of little use as a cervical dilator. The percentage of infection after packing is larger than after any other method. It is useful when the cervix is partially dilated and hemorrhage must be controlled until other measures are undertaken. Antiseptic moist gauze should be used and it is well if the antiseptic is a styptic also. The gauze may be left until the cervix is sufficiently softened and dilated to allow a bag to be inserted or bimanual version to be done. The packing is not effective un- less the gauze is packed well within the Page Eighty-nine cervix and up against the placenta and the vagina packed full of gauze also in order to afford support and counter pressure. The gauze should be moist as it then may- be packed more firmly and care should be taken not to bruise the vaginal mucosa in the manipulation. A vaginal speculum should be introduced with the patient upon a table and in a good light, the cervix should be caught and steadied with a bullet forceps and the gauze packed firmly. The patient should be put to bed and watched carefully for evident bleeding or signs of concealed hemorrhage. JMaison, in a report of 154 cases treated by various methods, had the highest mor- tality, 25 per cent., with tamponage and lost 70 per cent, of the children. The deaths were from bleeding and infection. Other methods do not show as good results as the ones referred to. Bon- naire's method of bimanual dilatation of the cervix and immediate delivery has a higher mortality than the previous methods. He has reported 171 cases treated by this method with a mortality of 18 per cent. The disadvantages of the method are the amount of time required to dilate the cervix, twenty minutes to one hour in Bonnaire's hands, with constant loss of blood, the danger of laceration of the cervix, and the difficulty of completely dilat- ing the cendx so that the head may come through without traumatism. Steel dilators after the type of Bossi's instrument are very dangerous and only of use to dilate the cervix sufficiently to allow version to be done or to insert a bag. A de Ribes bag may usually be inserted through a cervix admitting two fingers, and to obtain this amount of dilatation the Goodell two- pronged dilator does as well as the more complicated and expensive instrument of Bossi. Caesarean section, much vaunted of re- cent years by surgeons, is not favored by obstetricians. Holmes' collection of Caesa- rean sections for placenta prevfe gave a maternal mortality of 20 per cent, and an ultimate fetal mortality of 64 per cent. Little encouragement here to advocate the operation. Jewett, in a later paper, col- lected 95 cases, not including Holmes' col- lection, wtih a maternal mortality of 11.5 per cent, and a direct fetal mortality of 34 per cent., the ultimate fetal mortality of children dying in the puerperium not being stated. The combined series give a ma- ternal mortality in 125 cases of 13.6 per per cent. The ease with which Caesarean section can be done deludes operators into the belief that it is a simple operation and without mortality ; but the facts remain that the mortality of all classes of Caesarean section is, in 3,000 collected cases, 7 per cent. How much greater will the dangers be in placenta previa where the patient, weakened by hemorrhage and contaminated by examinations, is unfit to stand such a radical surgical procedure. To treat these cases by Caesarean section is but to add an- other greater danger to that already exist- ing. The only excuse for a Caesarean section in any condition is to save a living child and, if there is a direct fetal mortality of at least 34 per cent, with a probable ultimate mortality one-fourth greater, a living child will hardly be obtained in as many cases as in the bag treatment and the safe method of version and delayed extraction will save more mothers. It is doubtful whether the 125 cases with 13.6 per cent, mortality rep- resents the true estimate of mortality, as no large clinic statistics have yet been re- ported and, with isolated cases, it is human Page Ninety nature to report successes and allow failures to be forgotten. When Caesarean section is not done until the end of the period of dilatation, there is no security against a fatal after hemor- rhage, for, by that time, the insertion of the placenta in the isthmus or cervix has already been stretched and, with defective contrac- tion of this segment of the uterus, hemor- rhage is likely to follow. The hemorrhage comes mainly from the lacerated vessels in the upper part of the cervix and, with a Caesarean wound in the uterus, this would be difficult to control by gauze packing or other means. Vaginal Caesarean section has been ad- vocated in placenta previa with an undilated cervix. Bumm was its most weighty ad- vocate; but now he, Sigwart says, has abandoned the operation. The amount of hemorrhage is greater from a cut wound than from a torn one and, in these incisions of vaginal Caesarean operation, the bleed- ing is sometimes severe and difficult to con- trol. If the placenta is situated posteriorly, it may be possible that anterior hysterot- omy may be of value, but it is difficult to decide when this condition occurs. Also, if the placenta is posteriorly situated, the elastic bag may be passed around the an- terior lobe. Incisions into the cervix, when the os is not fully dilated are, however, occasionally of use, although they need not go so far as to include the surface of the uterus above the vaginal vaults. In the treatment of the incomplete form, the mainstay of treatment is the elastic bag. Its advantages are that it can be easily in- serted and it controls the hemorrhage. The placenta, not covering the os completely, does not obstruct its passage; the mem- Page Ninety-one branes are easily ruptured and the elastic bag may be inserted within the membrane, much reducing the mortality. Version and breech extraction must be reserved for those cases of incomplete pla- centa previa in which the os is fully dilated with unruptured membranes or urgency of delivery is demanded. The greater possi- bility of obtaining a living child in incom- plete placenta previa renders it expedient that all possible means should be taken to this end. When the insertion of placenta is high in the uterus and the membranes present at the OS, the hemorrhage may sometimes be controlled and labor hastened by rupture of the membranes. This gives the best chance of a live child. The treatment by rupture of the mem- branes alone, however, should be confined to mild cases with a high insertion of the placenta. The main reliance in the treat- ment of incomplete placenta previa should be the large elastic bag, lo to 12 cm. in diameter and with a capacity of 500 c. c. of water. Version and breech extraction should be reserved for those urgent cases with a fully dilated cervix and much bleed- ing. The dangers of placenta previa by no means cease with delivery of the child, but in a large proportion of cases, hemorrhage occurs after labor. This bleeding does not as a rule occur immediately after delivery, because of the fall in blood pressure coin- cident with the birth of the child; but usually takes place within an hour. This delay of the hemorrhage makes it of a most insidious and dangerous character. A very large percentage of all deaths in placenta previa are due to this form of hemorrhage. In Hammer's series, three of eight deaths were from postpartum hemorrhage due to atony of the uterus. In Warren's series of ninety-four cases, postpartum hemorrhage was present in 15 per cent, and, of six deaths in all, two were from this cause. It is, therefore, necessary to take meas- ures to prevent the occurrence of this hemorrhage. A dose of one of the good preparations of ergot should be given hy- podermatically immediately after delivery of the child. It is better to use one of the physiologically tested preparations, for much of the ergot upon the market is inert. Pituitrin, an extract of the pituitary body, is very efficient in stimulating the uterus to contract and has been used with good suc- cess by Foges and Hofstatter in sixty-five cases of postpartum hemorrhage. The uterus contracts firmly and remains in that condition for some time. It promises to be useful in placenta previa. The question of uterine packing with an- tiseptic gauze to prevent hemorrhage imme- diately after delivery is an important one. If a patient is in a hospital where she can be carefully and minutely watched, and if the uterus has contracted well, uterine pack- ing may not be necessary ; but if the woman is delivered in a house where the prepara- tion for packing would involve some delay, or if the woman is weak from bleeding and can spare no more blood, uterine packing should be done as a prophylactic against hemorrhage. In other words, the uterus should be packed with gauze to prevent hemorrhage, or preparations should be made so it can be done instantly in case hemorrhage should begin. After delivery in placenta previa, no patient should be left without constant medical supervision for several hours after delivery. EEFEEENCES. 1. MAISON and WILLIAMS. Boston Med. & Surg. Jour., June 3, 1909. 2. ZWEIFEL. Muench. Med. Woch., Nov. 19, 1907. 3. CONVELAIRE. Ann. de Oyn. et d'Obstet., Aug., 1910. 4. FUTH. Zentr. f. Gynak., 1907. 12. 5. WARREN. Lancet, Feb. 3, 1906. 6. HAITCH. Mon. f. Geb. u. Gynak., 1910, xxxi, 5. 7. BONNAIRE. Presse Med., 1909, xvii, 66. 8. MULLER, L. Placenta Praevia, Stuttgart, 1877. 9. HANNES. Zeit. f. Gynak., 1909, 3. 10. THIES. Mon. f. Gel), u. Gynak., 1909, xxix. 11. MAISON. Zentr. f. Gynak., 1910, 18. 12. HOLMES. Jour. Am,er. Med. Assn., May 20, 1905. 13. JEWETT. Amer. Jour. Obstet., June, 1909. 14. SIGWART. Zentr. f. Gyn., 1910, 28. 15. HAMMER. Munch. Med. Woch., 1, 35. 16. FOGES AND HOFSTATTER. Zentr. f. Gynak., 1910, 46. CHAPTER XVII. OVARIAN PREGNANCY, WITH RE- PORT OF A CASE. Introduction. — The occurrence of ovarian pregnancy was first proven by Catherine von Tussenbroek who accidently discovered a case while making pathological examina- tions. She made her examination and re- port of a specimen handed her by Kouwer. This was the first complete demonstration of ovarian pregnancy in 1899. Since that time a number of cases have been reported and all that are well examined and un- doubted are collected in a table in this paper. The first nineteen cases were col- lected in Norris' table in 1909, and nine cases have been added to that table includ- ing the one here reported. An example of the fact that if an operator is on the watch for this condition it is more likely to be found is that of 28 cases, two each are reported by Webster, Norris and Mis- colitsh. Diagnosis. — The requirements of an un- doubted ovarian pregnancy are that ( i ) the tube on the affected side be intact, (2) the fetal sac occupy the position of the ovary, Page Ninety-ttoo (3) it must be connected to the uterus by the utero-ovarian Hgament, (4) definite ovarian tissue must be found in the sac wall and at different places in the sac wall. These conditions are required to distin- guish ovarian pregnancy from advanced tubo-oyarian or abdominal pregnancy where the ovarian tissue is plastered and flattened over the sac wall and so incorporated in the sac wall as to be impossible to distinguish whether the pregnancy is ovarian or not. It is very difficult to say whether certain advanced ectopic pregnancies are tubal or ovarian in their origin, and it is almost im ■ possible to prove their original site. For this reason, in this series so collected, all advanced and dubious cases must be ex- cluded. For an exact diagnosis microscopic ex- amination must show evidence of preg- nancy within the ovary, i. e., chorionic villi must be found. The presence of decidual cells alone is not sufficient evidence of ovarian pregnancy; for decidual cells may be present in various places, such as the broad ligament over peritoneal surface in ectopic pregnancy. Also, it may be pos- sible that the mere presence of decidual cells in the tube is not evidence that gesta- tion has occurred there and not in the ovary, as it is possible that such cells may exist in the tube during an ovarian preg- nancy. Decidual cells may sometimes be found in the uninvolved tube when a tubal pregnancy is in the opposite side, and again as may be seen from the discussion of bilat- eral tubal pregnancy, decidual cells some- times exist in a tube containing blood when no other signs of tubal pregnancy exist. So that decidual cells in the tube are no evidence for or against the presence of an ovarian gestation. Page Ninety-three The occurrence of hemorrhage from the ovary sometimes occurs without ovarian pregnancy and from ovarian hematoma. Hedley^ has reported 18 such cases with free peritoneal blood, and has described the course and pathology of the condition. Savage- has divided hematomata of the ovary into two types : ( i ) hematoma of the Graffian follicle, (2) hematoma of the corpus luteum. In the first type, he found the wall of the hematoma was lined by a single layer of epithelium which he re- garded as a membrana granulosa, lying on a basement membrane and external to these were the two layers of tissue which ap- peared to correspond to the theca interna and theca externa. The cells of the inner layer showed early lutein cell formation and there were ill-developed Graffian fol- licles near the cavity of the hematoma and some opening into it. The second type — ^hematoma of the corpus luteum — had an outer cell of ovarian tissue which was for the most part con- gested; the inner part of the wall showed newly formed fibrous tissue, poor in cells, and near to the lining in between the long- itudinal strands of this tissue, there were blood extravasations, many round cells and many large rounded or cuboidal cells con- taining yellow coarse granules. The nuclei of these cells were relatively small and, in many instances, seemed to be crowded towards the periphery of the cell. The cause of these hematomata is supposed to be abnormal congestion of the ovary with hemorrhage into immature follicles. It has been suggested that it might be possible that ovarian pregnancy be a cause of some of these hematomas. This seemed * Hedley. == Smallwood Savage. Brit. Oyn. Jour., xxi, 285. possible because several cases, as von Tus- senbroek's and Kelly and Mcllroy's, were discovered accidentally in the routine ex- amination of surgical specimens. How- ever, search does not bear this out. Still the similarity of the picture at operation between ovarian hematoma and ovarian pregnancy, both causing hemorrhage, is very striking and requires careful examina- tion to distinguish one from the other. The clinical course of ovarian pregnancy has nothing to distinguish it from ectopic pregnancy generally. The rupture occurs in the same way; the shock and collapse may be as extreme and the hemorrhage is sometimes great. The condition is chiefly of interest because of its rarity. Clinical Report — Mrs. L., age 36, para I. Small woman. Good previous history. Severe cystitis 5 years ago. Operated upon by Dr. Ellice McDonald for retroversion b}- internal round ligament operation. Opera- tion was done four years ago. When seen complained of pain on left side. Menstrua- tion has been absent for 37 days. Thought she was pregnant. Tenderness on right side on abdominal palpation. Tenderness on movement. Uterus contracted and firm, not enlarged. Cervix slightly patulous. No softening of cervix, no contractions of the uterus. Hegar's and McDonald's signs not found. Light colored, bad smelling dis- charge from cervix. Doughy mass was felt posteriorly and to the left slightly dis- placing the uterus. Diagnosis was made of ectopic pregnancy which was concurred in by Dr. H. M. Painter, who was called in consultation. Immediate operation. Dr. Painter assisting. Free bloody fluid was found in the pelvis and on the left side in the region of the ovary and attached to the ovarian ligament was found a thin walled cyst about the size of a large walnut from the interior of which was attached a stringy piece of dark reddish membrane (decidual remnant). This was fixed to the inner lining of the cyst way. This membrane has evidently before the rupture covered the interior of the cavity within the ovary. The capsule was very thin in parts, varying in thickness. One part was densely in- filtrated with blood. The tube was apparently normal and was removed with the ovarian mass. *There was no trace of a fetus. Microscopic examina- tion showed that the walls of the cyst were formed of ovarian tissue with several corpora lutea at various stages. Numerous Grafiian follicles were found. Numerous chorionic villi could be seen, although in many sections obscured by fibrin and clots. In the walls of the capsule there were areas of hemorrhages in the stroma. There was a moderate round-celled infiltration in places. Pigmentation was present almost in all sections of the ovarian stroma. Here and there were groups of large pigmented cells with large nuclei. Here and there were budlike masses with densely staining multiform nuclei or protoplasmic cells with nuclei. The tube was normal. Diagnosis — ovarian pregnancy. CASES REPORTED IN LITERATURE. ANNING & LITTLEWOOD.— Trans. Obst. Soc, London, 1901. xliii, 14. WEBSTER. — Trans. Amer. Gyn. Soc. 1904. xxix, 65. HEWETSON & LLOYD.— BH*. Med. Jour. 1906. Sept. 8. VAN TUSSENBROEK.— Awn. de Gyn. et O'bst. 1899. Dec. DE LEON & HALLMAN.— 2?ev. de Gyn. 1902. June. FREUND & THOME. — Virchow's Arch. 1906. Jan. KELLY & McILROY.— Jowr. O'bst. & Gyn. Brit. Emp. 1906. June. THOMPSON.— Trans. Am. Gyn. Soc. 1902, xxvii. WEBSTER. — Trans. Amer. Gyn. Soc. 1907, xxxii. BOESBEECH. — Monat f. Gel), u. Gyn. 1904, XX, 613. JACOBSON. — Contribution to the Science of Med. & Sur. N. Y. Post-Grad. School and Hospital. 1908, 24. MISCHOLITSCH.— Zewf. f. Geh. u. Gyn. 1903, 49, 500. NORRIS & MITCHELL.— Surg. Gyn. Obst. 1908, May. KERR, J. M. MUNRO.— Proc. Roy. Soc. Med. 1908. I. 9. GOTTSCHALK.— Zent f. Gyn. 1886, x, 727. BANDEL.— Betir. z. Klin. Chir. 1902, xxxvi, 657. ¥RANZ.— Hegar's Beitrdge. 1902, vi, 70. SCHICKELE.— Beit z. Geh. u Gyn. 1906, xi, 307. RUBIN. — Amer. Jour. Obstet. 1911, May. -LBA.— Jour. Ohst. & Gyn. for B. E. 1910. Sept. Page Ninety-four TUEEDY.— r/Ottr. 01)st. d Gyn. for B. E. 1910, Feb. oArv T- Mcdonald, n. ^.—Jour. a. m. a. i909, m, 1253. ^ ^ BARROWS. — Amer. Jour. Ohstet. 1910, Dec. YOUNG & RHEA.— Boston Med. & Sxirg. Jour. 1911, Feb. 23. CHAPTER XVIII. THE UNSOLVED PROBLEM. The duty of a physician is three fold; first to cure the sick, second to teach others to cure the sick, and third to study disease and find remedies to cure the sick. Each of these is necessary to the complete physi- cian, and without them, he fails in some part. To cure the sick is admirable, to teach, "delightful task to rear the tender thought," is laudable; but to discover the processes of disease and its cure, ap- proaches the highest kind of duty. To heal the sick is the function of the physician and aids those whom he touches ; but pupils, taught to heal, go forth like the apostles to carry the word to others. One man's knowledge imparted to others is mul- tiplied in proportion to the numbers he teaches and the power he has of imparting his experience. Those he teaches depend, however, more upon the character of the man and his influence over them as an up- lifting stimulus which spurs them to greater efforts and keeps their ideals exalted. The spoken word is forgotten, but the memory of the man remains. So, while it is im- portant to teach medicine, it is more impor- tant to teach the methods of the study of medicine. A student's study does not cease, but should extend throughout his lifetime. Habits of accuracy of thought and methods of observation are the foundation upon which the physician may rear the super- structure of his life. If he have not these, he will be spurious and not true coin, "a kind of semi-Solomon, half knowing everything from the cedar to the hyssop." And this alone is not suffi- cient; he must in addition be taught what has been known and where to find it. "Knowledge is of two kinds. We know a subject ourselves or we know where we can find information about it." No man can hope to achieve a working knowledge of medicine in four years ; the span of life is all too short to grasp more than a moiety of it. The task is so great that we must waste no time on useless efforts and vain imagin- ings. "Naught but firmness gains the prize, naught but fullness makes us wise, buried deep, truth ever lies." We must demand that we be taught what has been done in the past and, of the past, what is truth and what is speculation. This lack of perspective in the study of medicine is a fault of teaching, often due to a desire of the teacher to appear an oracle and that all his words be taken as truth. The student magnifies authority and bows down before reputation. This is fatal to true perspec- tive of the study of disease. When you know a thing, to hold that you know it; and when you don't know a thing, to allow that you do not know it ; that is knowledge. "Mark not who said this or that, but mark the words spoken," said Thomas a Kempis. "I open the truth," said Confucius, "to help only those who want to help them- selves. My teaching is a solid square, but I present only one corner of the subject — I expert you to find the other comers." This must be the teacher's true attitude. If the improvement of understanding is for two ends ; first, for our own increase of knowledge, secondly, to enable us to deliver and make out that knowledge to others, how much better is it that we should inves- Page Ninety-five tigate and study and discover for ourselves and impart our results to others. This is the supreme function of the phy- sician. If we can reach a few by our work, a few more by our students, how many more can we reach by the printed line and typed page, read by all the world of earnest men who have that "natural feeling of mankind, a desire for knowledge. Every human being whose mind is not debauched will be willing to give all that he has to get knowl- edge." My profession, sworn idealists and practical altruists, is not worse than the average of mankind, and wishes for each addition to the sum of medical experience with a longing as that of Naaman for the healing waters of Pharfar and Abana, rivers of Damascus. To alleviate human suffering and prevent human ills, must be our portion. To do this, it is not sufficient to rest content with our field as we find it, but we must experi- ment and cultivate anew. "I will not fol- low where the path may lead," said Strode, "but I will go where is no path and I will leave a trail." The scientific study of medical problems is part of the work of every practitioner. Science is not confined within the four walls of the laboratory, nor such a rare bird that it is never caught by the clinician. The great present day problems are those of practical application and not those of pure science. Every man should feel that his profession requires of him something more than its practice as a means of his liveli- hood; he has a debt to pay, to add to the sum of its knowledge. Clinical research is the greatest of all medical blessings. "It is twice blessed. It blesseth him that gives and him that takes." It gives to the worker an intimate and ex- act knowledge of his subject which can be obtained in no other way, and it benefits untold numbers whose physicians are read- ers and learners all over the world. Dif- fused. knowledge immortalizes itself. It is a task which is never done as each piece of research opens to the scientific imagination more fields to work in and more problems to solve. The reward of duty is the power to fulfill another, and each clinical problem constitutes a pledge of duty to which every physician is bound to consecrate his every faculty to its fulfilment. By this, we m.ay best fulfil the precept of the Great Physi- cian, "Go ye to all the world, to every peo- ple * * *." In return, the research worker will gain in knowledge, in power, an unending inter- est and unfailing occupation. It does not require that vast and grand discoveries should be made. They seldom are except by men who have served their apprentice- ship in the day of small things, and so had training in the discipline of study and ac- curacy of observation. If each adds his stone to the arch, what matters who lays the keystone. The plaudits may be his ; but he knows and the privates in the army of research know what contributions have gone before to make his victory possible. "Knowledge is the hill where few may climb ; duty is the path where all may tread." All physicians owe this duty — ^to con- tribute their quota, however small, to the sum of medical knowledge. It should, how- ever, be approached in a true spirit of unsel- fishness, the spirit of disinterested curiosity which is the real flower of intellectual life. How else can he weigh and judge the facts and observe truly unless the motive of self- interest is put aside? Intellectual honesty is the true test to separate work that has Page Ninety-six distinction from work that has it not. In gynecology and obstetrics, the prob- lems which remain unsolved are many. The early gynecologists were the forerunners in abdominal surgery, and the names of McDowell, Emmett, Sims, James Simpson and Lawson Tait should be engraved upon the minds of all surgeons. However, surgery- has now come into its own in research, and there remain for the student of diseases of women many problems which have to do with disordered function rather than the surgical correction of tumors, growths and obstetrical trauma. Among these subjects are sterility and its causes, the menstruation and menstrual disorders, the relation of the glands of internal secretion, particularly the ovary, to the health of women, and many other so-called medical subjects. One great problem is that of the hypoplastic woman with her many and varied evidences of ab- normality. This asthenia congenitalis, con- genital hypoplasia, or whatever name the symptom-complex may be given, is more or less a biological problem, inasmuch as it has to do with the relation of an abnormal or aberrant type of woman as an animal to the normal or common. In obstetrics, the field is still virgin. Bacteriology has had its miracles and sur- gery its victories, but obstetrics leads im- potent and snail paced beggary. The four great complications in pregnancy, con- tracted pelvis, placenta previa, toxemia of pregnancy and eclampsia, and puerperal in- fection are still unsolved, and their treat- ment still disputed and obscure. Of these problems, the greatest is puer- peral infection. Puerperal infection is no less prevalent in private practice than it v/as be- fore the days of antiseptic methods. In hos- pital practice, the mortality is very much re- duced, yet there is record of hospital epi- demics even in these latter years. To estimate the prevalence of this condition is difficult because in mortality statistic? women dying from puerperal infection are frequently recorded under the disease of the organ which the infection attacks ; for example, as peritonitis, from salpingitis, septic pneumonia, and other terminal ex- pressions of infection. Puerperal infec- tion is considered by the laity to be due to lack of care upon the part of the doctor, and for this reason, physicians dislike to register a possible criticism against them- selves. So the mortality statistics in re- gard to death from puerperal infection are very inaccurate, and much under the actual rate of occurrence. Prof. Leopold, in 1907, stated that in Prussia 4,339 and in the German Empire 6,000 deaths occurred from puerperal infection in the previous year. Boche in an investigation extending over sixty years, and involving 363,624 deaths, stated that in Prussia 6,060 women died each year from puerperal infection, and that, in 1907, there were 6,000 deaths, show- ing no decrease in the mortality. There has been no improvement in the maternal mortality, except in hospital clinics for the last twenty years. Cullingworth from a study of the Registrar-General's statistics for 1897 said that there had been no de- crease between the years of 1843 and 1897 ; he said "Puerperal fever continues to pre- vail as though Pasteur and Lister had never lived. There is needed a strong voice to rouse us from our lethargy and to plead with desperate earnestness for the lives that are still being unnecessarily sacrificed." In the mortality statistics of the U. S. census of 1910, 3,892 deaths from puerperal infection are recorded in the registration area, which comprises three-fifths of the total population of the United States. On Page Ninety-seven this basis, there would have been from the whole population 5,485 deaths from puer- peral infection registered each year from the whole of the United States. This num- ber of deaths is probably much under- estimated on account of the difficulty of obtaining accurate registration on death certificates. It is unreasonable to suppose that with a much greater population, and in the care of physicians with less exact training that there should be a smaller mor- tality from puerperal infection than there is in Germany. It is probable that the mortality from puerperal infection through- out the United States is not less than 12,000 women annually. This is based on the census statistics, and upon the probable ratio of deaths from puerperal infection to the total number of births. In the City of New York for the year 1910 the total num- ber of births was 129,080, and the deaths registered as caused by puerperal infection was 225, a mortality of .02 per cent. This mortality is about eighteen times less than the mortality of an obstetrical hospital in the same city and less than the best clinic report that could be found anywhere in the world. So the registration is obviously very much under-estimated and hopelessly unreliable. It is probable, basing the esti- mate upon the reports of other cities and upon the proportion of puerperal infection to the total number of births in other places and in clinics that more than 700 women die annually in New York from puerperal infection. An example of the inaccuracy of the registration is that Berlin, a clean city. with well trained physicians and exact registration returns, has a mortality rate per 100,000 population of 35.1 for puer- peral infection. In New York, on the con- trary, the mortality rate for 100,000 popu- lation is 7.8. This shows the inconsisten- cies of registration. Thus it may be seen that puerperal in- fection in spite of the advances^in technic has not yet disappeared, and is still worthy of study. The total deaths from cancer for the year 1910 amounted to 41,000 and the average age at death was 59.2 years; amongst the cases of puerperal infection the average age at death was 27 years. Puerperal infection thus takes its dreadful toll amongst women in their early married life when the great part of their usefulness in the family and in the world is still before them. They die to leave small children and sorrowing hus- bands. The economic loss to the United States of such young and useful beings is in itself no small one. In cancer, on the other hand, death occurs amongst those who have exceeded the probable duration of life by twenty years, and who are getting toward the end of their usefulness in the world. The prolonged suffering and the fact that the person afflicted is usually of an age when the patient has children, a position in the world, and a hold upon the affections of those around him, make cancer a disease for which it is easy to obtain re- search workers and money to support them. At the present time the public eye is occupied by the neo-alchemists with their philosopher's stone. The problem of puerperal infection is different. Here women die quickly, silently slip out of the world, and their memory is marked only upon the hearts of their young children and bereaved relatives. Yet a woman dead from puerperal infection is just as dead as one from cancer, but I have not yet seen any laboratory erected for the study of puerperal infection, or any money left as Page Ninety-eight a foundation for its investigation. The possibility of solving the problem of puerperal infection is infinitely greater than that of cancer. The causes of puer- peral infection are known, and prevention is but a problem of the application of proper methods and a more thorough knowledge of the processes of the infection. Amongst obstetricians at the present time the most popular treatment of puerperal in- fection is a laisser faire, do-nothing policy. They claim that more women with puer- peral infection get well if they are left alone than with any known method of treat- ment. This does not mean that their opinion is correct, but that most known methods of treatment are ineffectual or harmful. There is no more reason why the processes of infection through the uterus should go untreated than that infec- tion elsewhere in the body should be left to itself. The problem of puerperal infection is however, essentially one of prevention. The three avenues from which infection may occur consist, first, of the obstetrician and his instruments, second, of the vulva and outward genitalia, and third, of the vagina. If all these can be made to harbor no infec- tious organisms, the probability of puer- peral infection would be very slight. The surgeon's hands and the instruments may be sterilized so that there is little danger of infection there. The vagina, as a rule, before labor, contains few, if any, pathogenic organisms, but the vulva and outward genitalia almost constantly harbor pathogenic organisms of varying degrees of virulence. In the puerperium, streptococci, as well as other bacteria may pass up from the vulva into the vagina, and on the third day of the puerperium the vaginal lochia of about half of all the cases of childbirth contains pathogenic organisms. It is ob- vious, therefore, that the elimination of puerperal infection must depend to a large extent upon antiseptic methods and pre- ventive measures. In the consideration of what antiseptic measures may be taken it is possible that return may be made to the antipartum douche. The vaginal secretions have always been said to have some bactericidal power because, if bacteria are inserted into the vagina, they usually cannot be recovered after some days. It is probable, however, that the bactericidal properties of the vaginal secretions are small or almost nil, and that the disappearance of the bacteria is due to the drainage and to the fact that, in the absence of trauma, bacteria will dis- appear from almost any epithelial surface. This is well shown by the introduction of bacterial cultures into the bladder, which cause no danger unless traumatic conditions are present. Heretofore, experiments in regard to an- tipartum douches have usually been done with bichloride of mercury and formalin. Formalin is a very weak bactericide hav- ing about one-third the strength of phenol, and is inert in the presence of albuminoid substances, such as mucous membrane and vaginal secretions. Bichloride of mercury is also rendered inert, inefficient and use- less in the presence of organic matter, as soap, pus, mucous membrane and vaginal secretions. As a result, neither of these so-called germicides have any efifect upon the vaginal flora, and only act as irritants to the mucous membrane. Bichloride of mercury, in addition, on account of poison- ous action, is a dangerous germicide to use at labor when the huge raw surface of the uterus is capable of absorption, and num- bers of deaths have been reported after its Page Ninety-nine use. The ideal obstetrical germicide should be unirritating, not poisonous, and efficient as a germicide in the presence of organic matter. Burckhardt and Kolb (Zeit. f. Geburt. u. Gyn. 1911-LXVIII-l) made a study of seven hundred women, half of whom re- ceived douches. Excluding all pathological labors, it was found that, amongst the douched patients, there was a morbidity of 6.5%, and, amongst the non-douched pa- tients, there was a morbidity of 8.6%. They used a solution of chlor-m-kresol, one to four hundred, with a bactericidal power sev- eral times stronger than phenol, and possess- ing none of the destructive powers which bi- chloride of mercury exerts upon the epithe- lium. They conclude that the post-partum douche retarded bacterial growth for several days. The patient received no germicidal treatment after the first day. It is possible that, when the vulvar parts are washed each day with a similar non-irri- tating germicidal solution, that the organ- isms might be absent for a longer period. This study is of great interest from the point of view of the preventive treatment for puerperal infection. There are at present many other new germicides, which are efficient in the vagina and considerably more germicidal than chlor-meta-kresol. The investigation of this aspect of the problem in a large clinic would be of great interest. It is important that no dangerously poisonous germicide should be used in the preventive or other treatment of puerperal infection. The preparations of cresylic acid are popular obstetrical germicides. Witthaus (Wittaus and Becker, Medical Jurispru- dence, 1911, Vol. 4, p. 1187) has collected 133 cases of poisoning from one of the most popular of these preparations, of which 11 cases followed irrigation of the uterus. Other cresylic acid prefrarations, including liquor cresolis compositus of the U. S. P. have similar dangers. The essen- tial, after efficiency in an obstetrical ger- micide, should be its non-poisonous char- acter as it must often be introduced into the vagina after labor or in the puerperium when there is great possiblity of absorp- tion from the large raw surface of the uterus. The development of an unirritat- ing non-poisonous germicide, efficient in the presence of organic matter, would be of itself a great contribution to the prevention of puerperal infection. The processes of infection in puerperal fever have not received intelligent study. By this is not meant that time and labor have not been expended, but that puerperal infection has been thought to be a disease apart and not to follow the ordinary course of infection as does lymphangitis of the arm, erysipelas or peritonitis. It is true that the infection is much modified by the softened and vascular pelvic organs under- going as they do a sort of degeneration of involution. In addition, the large lymphatic and vascular supply of the pelvis with its adjacent large vessels and the lessened re- sistance of the pregnant woman do seriously alter the course of the infection. Still the processes of inflammation and infection are fundamentally alike and a great deal of our lack of knowledge is due to the fact that autopsies are not often obtained and, when obtained, the pathological findings are usually not properly studied. This is be- cause pathologists are seldom familiar with conditions of pregnancy as they come but rarely in their routine autopsy work and, more's the pity, there are few pathologist- obstetricians. Page One Hundred The bacteriology in spite of the large amount of study which has been given it, is not yet settled. The role of the gonococ- cus in puerperal infection has not been de- termined. Stone, Mayer, Gurd and myself have shown with pitifully incomplete studies that a very large number of cases of puerperal fever are due to this organism. I have reported in this series a case of death with pure culture of gonococcus, and Gurd has reported a series of bacteriologically studied cases where the type of infection from the gonococcus was severe and the fever high. One case died. The lack of success of previous investigators in the cultivation of this organism has been due, as is well shown by Gurd (Amer. Joiirn. Med. Sci., 1908, Dec. 9, and Jour. Med. Re- search, 1908, XVIII, 291) to improper media and to the fact that the cultures were taken by aspiration through a tube. This gave feeble or dead organisms and, when the culture was taken by swabbing the surface of the endometrium, discovery and growth of the organism was more frequent. The difficulty of cultivation of this organ- ism is well known and Gurd has obtained good results with blood agar media of a titer of .5 phenolphthalein (hot titration). Media for the cultivation of the gono- coccus as well as for anerobic and hemolytic organisms should be in the armamentarium of every investigator into the bacteriology of puerperal infection. It is possible that the gonococcus may be found to be one of the fertile causes of puerperal infection, and that the difficulty of cultivation and recognition will explain the fact that puer- peral fever is still so prevalent in spite of our present methods. Gonococcus puer- peral infection after recovery from the initial attack remains as a chronic pelvic inflammation, in this way differing from most other infecting organisms. The late crippling effect of gonococcus puerperal in- fection renders it a more serious condition than is commonly recognized and make its prevention a necessity. The knowledge of the prognosis of puer- peral infection is almost unknown. All we know is that puerperal infection is a self- limited disease, like erysipelas, and tends to a spontaneous cure. The influence of ex- haustion has been shown by Williams {Bos. Med. Surg. Jour., Sept. 22, 1910) and Wirz (Hegars Beitrage z. Geb. u. Gyn., 1909) to be a great factor. Puerperal morbidity, with the exception of mastitis, is increased in direct proportion to the duration of labor and the morbidity after low forceps was less than that after spontaneous labor, pre- sumably because labor was shortened and exhaustion lessened. A persistently high pulse rate, even with relatively slight fever, is serious ground for alarm especially when the temperature subsides as the pulse rate increases. Jaschke (Zeit. f. Geb. u. Gyn., 1910, LXVI, 2) states that the paralysis of the splanchnic vessels is the index of the severity of the disease, while it is the main source of danger. The blood pressure and the second aortic sound show the condition of the vessels and the possible compensatory power of the heart. In cases where the blood pressure does not decline or the decline is followed by return to normal, the prognosis is good. A dis- cordance between the pulse rate and tem- perature is a serious indication. Delirium is a rare symptom and one of utmost gravity. Instead of being anxious and disturbed, the patient may present an exaggerated feeling of well-being and ex- press a desire to undertake her usual occu- pations. In 56 cases with delirium, 39 ended fatally. Its occurrence between the Page One Hundred One third and eighth day of such illness is a prognostic symptom of the utmost gravity. The prognosis as well as all other parts of the problem offer a great field for investiga- tion. The serum or vaccine treatment of puer- peral infection offers but little hope of cure. It is to be remembered, in streptococcus in- fection, the small amount of toxin devel- oped and the absence of bactericidal prop- erties in the blood makes it probable that the relief from this form of infection comes through leukocytosis and not through the formation of antibodies. In animals treated with streptococci, phagocytosis is an important factor in the production of immunity and the serum exhibits neither bactericidal activity with respect to micro- organisms nor antitoxic effect with respect to the action of filtrates of cultures. From the evidence, both clinical and ex- perimental, it may be concluded that anti- streptococcus sera and vaccines as at pres- ent prepared have but slight protective and curative value. It is to be remembered that puerperal infection is a self-limited dis- ease which tends to a spontaneous cure, like erysipelas, and the limitation of the infection is often ascribed to the serum or vaccine when it would have occurred in any case. Erdman (/. A. M. A., 1913, Dec. 6) has shown in the analysis of 800 cases of erysipelas that this form of streptococcus infection was not benefitted, but the recov- ery delayed and the morbidity increased by sera, vaccines and filtrates of cultures. The use of vaccines in puerperal fever has little or no scientific foundation. In the words of Theobald Smith {J. A.M. A., 1913, May 24) "The medical profession should see to it that vaccine therapy does not degenerate into inconsiderate and reck- less experiments upon human beings, that it does not create false hopes in hosts of pa- tients and that it does not originate and end in commercialism and the desire to ex- ploit the weak and unfortunate." Streptococcus infection, however, only causes rather more than half of the cases of puerperal infection and its study should include that of other organisms. The staphylococcus is a frequently found or- ganism and, contrary to the usual belief, is responsible for many cases of puerperal endocarditis. Infection with this organism is not less severe in type than that from the streptococcus, as is shown by Basso (Gine- cologia, Ap. 30, 1908), who collected a large number of cases with a mortality of 80 per cent. In fact, one of the striking phenom- ena of puerperal infection is the increase in severity which organisms of comparatively small virulence, such as the gonococcus and colon, may acquire and the severe systemic symptoms and danger to life they may cause. This may be due in part to the les- sening of resistance to infection which oc- curs in the pregnant. The whole tendency of research in the treatment of infection is toward chemo- therapy as Ehrlich said in his address be- fore the British Medical Association. The question of treatment in puerperal infec- tion is unsettled and will remain so until the ideal obstetrical germicide is discovered. Those heretofore used, such as bichloride of mercury and formalin, are inefficient because they are neutralized by the albu- minoids of the body tissues or discharges: others, such as phenol and the cresylic acid preparations, are too poisonous for free use. The idea that a germicide must be toxic if it is effective against micro- organisms is a mistaken one; otherwise chemical substances would be effective in proportion to their toxicity, which is not so. Page One Hundred Two Nor does it explain the fact that the same substance, cresol, for instance, may be three times more germicidal in emulsion than in solution, although the toxicity may be the same. The ideal obstetrical germi- cide, non-toxic, efificient in the presence of albuminoids and unirritating, is not too much to hope for and when it is discovered, it will aid very decidedly in the prevention and cure of puerperal infection. The use of intra-uterine douches, for ex- ample, would be put upon a new basis if such a germicide were available to replace such irritating substances as bichloride of mercury, formalin and the cresylic acid preparations. Primo non nocere is the good old fashioned rule of a wise and skeptical profession and, with this condi- tion fulfilled, it might be possible to do many things in puerperal infection which at present are forbidden. But the work of investigation should be taken up by the larger clinics. The estab- lishment of research foundations for the study of puerperal infection would produce more immediate results and greater benefits to humanity than all the cancer research that has been done. In spite of the vast amount of work that has been done on cancer, the hope of a cure is no nearer, and, except for the fact that it has been proved possible to immunize mice to transmissible mouse cancer, the research has made but little progress. Had a tithe of the effort been applied to puerperal infection, it is probable that this plague would be con- quered and the wail of the motherless chil- dren would be banished from the land. I would that these little voices in lamentation might ring in the ears of every obstetrician and pathologist until each is driven to con- tribute all his energies and all his efforts to the salvation of the thousands of mothers needlessly sacrificed. Page One Hundred Three DATE DUE ' ^ . . -i y9nni . \mtn I ^vJ- _^-.-- _. J '[y] ^.' , DEMCO 38-296 ,Grwle><>o\,<>tf>^. COL' i»yf« y > x'j^'ii