Alexander H. Rosenthal

Diagnosis and management of rupture of the uterus; with a study of 64 maternal deaths.

Abstract 1. 1. The clinical data of sixty-four deaths from rupture of the uterus are presented; twenty-seven were spontaneous and thirty-seven were the result of trauma. 2. 2. In all but three cases, rupture took place in the lower segment of the uterus. The role of cervical scarring in the etiology of rupture is emphasized. 3. 3. Internal version is the most frequent cause and should be recognized as an extremely hazardous procedure under certain unfavorable conditions. 4. 4. That strong fundal pressure can rupture a uterus is shown by three cases in this series. 5. 5. Four deaths occurred from the use of pituitary extract during the first stage of labor. Despite this, the judicious use of minute doses in carefully selected cases of uterine inertia is advised. 6. 6. The diagnosis of rupture of the uterus is often not made sufficiently early for survival of the patient. Routine exploration of the uterus after traumatic vaginal procedures is indicated, especially if shock is present. 7. 7. The essence of adequate treatment for complete rupture of the uterus is prompt massive blood transfusion and hysterectomy. Shock is no contraindication to operation.

A study of dermoid cysts with a suggestion as to the use of x-ray in diagnosis☆

Abstract 1. 1. There were 15.8 per cent of 500 consecutive ovarian tumors which were dermoid cysts. 2. 2. Eighty-two per cent occurred between the third and fourth decades. 3. 3. In 15.2 per cent both ovaries were involved at the time of admission, and two patients previously had the opposite ovary removed for a dermoid, so that 14, or 17.7 per cent, actually had bilateral involvement. 4. 4. In 29 instances adhesions, torsion, or infection were encountered as complications. 5. 5. Five cases were associated with pregnancy. Follow-up also showed that 9 of our patients became pregnant subsequent to a unilateral oophorectomy. 6. 6. The postoperative course and follow-up in the majority of cases were uneventful. 7. 7. The corrected mortality was 2.5 per cent. 8. 8. Teeth or bone, alone or in combination, were encountered in 39, or 49.4 per cent, of our cases. Had x-ray been used more frequently, a high percentage of these tumors could have been diagnosed before operation.

Cervical changes in pregnancy, labor, and the puerperium

Abstract 1. A. Changes During Pregnancy.— 2. 1. Epithelial proliferation was progressive. The squamous lining increased in thickness and became more cornified. The endocervical folds became taller, and the lining cells more active. 3. 2. The glands appeared larger, more numerous, and their cells more active. Occasionally, hypertrophy and hyperplasia were extreme. In the glandular zone the stroma became edematous and sparse, and it would appear that there was lessened support for the glands. 4. 3. The fibromuscular wall was comprised of fibrous connective tissue and a few scattered muscle cells. Vascularity became extreme, especially in the outer portion. 5. B. Changes After Vaginal Delivery.— 6. 1. Edema throughout the organ was marked and extensive hemorrhages were noted. 7. 2. The majority of the specimens show no evidence of denudation of the glandular area as described by Stieve. 8. C. Changes During the Puerperium.— 9. 1. Regression of the lining, stroma, and glands began during the first four days of the puerperium. 10. 2. Regressive changes in the fibromuscular wall were more marked after the first week. 11. D. Associated Changes.— 12. 1. Decidual changes within the stroma were present in twelve specimens. 13. 2. Marked epithelial proliferation of the endocervix occurs in healing erosions. In some sections they had a pseudo-malignant appearance. Since the microscopic picture closely resembles early carcinoma, an error in diagnosis may lead to an unnecessary radical operation for this benign condition. 14. 3. In seven specimens obtained from patients who died of severe toxemia, the squamous lining was unusually thin and not cornified. This is indicative of decreased estrin levels in the blood which accompany late toxemia. It is possible, then, that either vaginal smears or biopsies from the squamous lining of the cervix might make one cognizant of an existing toxemia even before any subjective or objective signs are present.

The imperforate hymen as a cause of “abdominal tumor”

Abstract This is a report of four cases of imperforate hymen which resulted in the appearance of a lower abdominal mass for which unwarranted laparotomies were contemplated. The diagnosis can be made with ease by the detection of an imperforate, bulging hymen and a sausage-shaped mass filling the vagina and continuous with the lower abdominal mass. The cure can be accomplished by simple hymenectomy.

Eclampsia and pre-eclampsia☆

Abstract 1. 1. Eclampsia is a major cause of maternal death. 2. 2. Good prenatal care will eliminate all but a small number of eclamptic deaths. 3. 3. Phlebotomy is not indicated. 4. 4. Home treatment is hazardous except in the mildest cases of pre-eclampsia. 5. 5. Inhalation anesthesia should be avoided. 6. 6. Adequate hospital observation should precede interruption of pregnancy. 7. 7. Cesarean section is never indicated in the treatment of eclampsia.

Studies in pelvic iontophoresis

Abstract 1. 1. Pelvic iontophoresis of a choline compound was given to 58 patients with subacute and chronic pelvic infection, all severe enough to warrant hospitalization; 37 were cases of tuboovarian infection and 21 were cases of cellulitis. 2. 2. Subjective improvement was generally marked, and often out of proportion to objective evidence of decrease of the infection. 3. 3. The results of therapy in tuboovarian infections, while often good, were not sufficiently remarkable to warrant routine use of this method of treatment. It seems clear that we cannot hope for resolution of old inflammatory tuboovarian masses, since fibrosis and multilocular cysts are a prominent part of the pathology. It may, however, be given a trial in persistent tuboovarian infections, when operative treatment is not indicated and other methods of treatment have been ineffective. 4. 4. The best response to iontophoresis was seen in cases of massive cellulitic infection of recent origin which had failed to yield to ordinary treatment. Pelvic iontophoresis is recommended for this type of infection.

Rupture of the uterus

Abstract 1. 1. Rupture of the uterus during pregnancy or labor is the most serious obstetric complication. If untreated its mortality approaches loo per cent for the mother and undelivered fetus. 2. 2. The obese multipara with a pendulous abdomen and scarring of the cervix is predisposed to rupture of the uterus. 3. 3. No patient should be permitted to continue long in labor with the presentation unknown. Obstructive dystocia from malpresentation may cause spontaneous rupture of the uterus. 4. 4. When pituitrin is used for the treatment of uterine inertia, the intravenous drip method is advised if certain contraindications are not present. 5. 5. The symptoms and signs of rupture of the uterus due to separation of a cesarean section scar may vary greatly from the usual picture. In an occasional instance the dictum “Once a cesarean, always a cesarean” may be violated. 6. 6. Internal version is by far the most common cause of rupture of the uterus. It is a dangerous procedure. When indicated certain prerequisites must be met. 7. 7. The diagnosis would be made more frequently if it were thought of; shock during labor is significant. 8. 8. The uterus should be explored in every case in which shock and persistent bleeding follow a major vaginal operative procedure. 9. 9. The cardinal principles of good treatment are massive transfusion and immediate operation. Shock is no contraindication to operation.