A Clinical Paper on Some Cases 
with Various Interesting 
Features. 
BY J 
IRVING S. HAYNES, M.D., 
Demonstrator of Anatomy, Medical Department of the 
University of the City of New York ; Assistant 
Surgeon, Orthopaedic Hospital, etc. 
REPBINTED PROM 
<Ei)e Nrto YorS JRSefctcal Journal 
for December 30, 1S93. lieprinted from the Neio York Medical Journal 
for December 30, 1893. 
A CLINICAL PAPER ON SOME 
CASES WITH VARIOUS INTERESTING FEATURES.* 
1. Complete Inversion of the Uterus. 
2. Fracture of the Radius immediately below the Bicipital 
Tuberosity. 
3. Intestino-peritoneal Septicaemia. 
4. Ventral Hernia. 
By IRVING S. HAYNES, M. D., 
DEMONSTRATOR OF ANATOMY, 
MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE CITY OF NEW YORK ; 
ASSISTANT SURGEON, ORTHOPAEDIC HOSPITAL, ETC. 
Case I. Complete Inversion of the Uterus.—Mrs. A. S., aged 
twenty-one years; first child on November 1, 1888; lived one 
day; mother made a speedy recovery. 
Second child on October 26, 1889 ; born at 8.15 p.m. ; deliv- 
ered by a midwife, who left about 9 p. m. At 9.30 after-pains 
began, and became more severe from hour to hour until, about 
2 a. m., they called for me (October 27th, Sunday). 
On reaching the bouse, found a strong, healthy young Ger- 
man woman in great pain. Paroxysms every half minute, dur- 
ing which she cried out loudly, rolled from one side of the bed 
to the other, and bore down very hard. Morphine, a quarter 
of a grain hypodermically. 
Examination.—On separating vulva and removing blood 
clots, exposed a large, round tumor that forcibly contracted and 
hardened with every pain. 
* Read before the Society of the Alumni of Bellevue Hospital, Octo- 
ber 4, 1893. For the discussion see page 643. 
Copyright, 1893, by D. Appleton and Company. 2 
OASES WITH INTERESTING FEATURES. 
Tumor as large as a large cocoanut, reaching just to vulva. 
Fingers passed all around it below; above it was attached by a 
broad pedicle to upper part of the vagina. 
Abdominal palpation showed no uterus in pelvic region. 
During the pains she bore down so hard that it seemed as 
if she would drive the entire contents of the abdomen through 
the vagina. \ 
Diagnosis.—Complete inversion of uterus. 
Treatment.—Midwife had returned after being sent for. 
She said she understood giving ether, so I had her start it while 
I administered a large, hot bichloride douche. The woman did 
not succeed with the ether, and I had to take the cone. While 
administering the ether with the left hand, the inversion was 
reduced by the other in the following manner: 
The right hand was well covered with carbolized vaseline, 
and pressure made upon the lowest and most prominent part 
of the uterus with the ends of the fingers bunched together. 
Had to relinquish this manoeuvre, as on very slight pressure the 
uterine tissue gave way, making a slight tear. 
Then the last two sets of phalanges were flexed to a right 
angle and pressure made with their dorsal surface. Gradually 
the uterus was indented, and in about twenty minutes fully re- 
turned to its natural position. Ether stopped. 
A hot iotra-uterine bichloride douche (1 to 4,000) given. 
Uterus semi-relaxed, reaching as high as the umbilicus. 
It was constantly, but gently, manipulated for half an hour, 
and contractions resulted about every three minutes, but they 
were so feeble that haemorrhage was feared any moment, but 
fortunately did not occur. At the end of this time the uterus 
became a little firmer, and, when it did contract, produced such 
severe pain that morphine was again given to full physiological 
effect. 
About 4 a. m. the uterus became somewhat more relaxed. A 
hot douche was given with good results for a little while. As it 
showed symptoms of again becoming relaxed, half a drachm of 
ergot was administered every half hour. 
By 6 a. m. the uterus was in fair shape, only partially con- 
tracted, however, and during contractions could be felt as high CASES WITH INTERESTING FEATURES. 
3 
as the umbilicus; between the contractions it felt like a boggy 
mass filling the pelvis. 
A binder was applied, and ten grains of chloral and fifteen 
of bromide of sodium wdre to be given every hour if neces- 
sary. 
At 10 a. m. the temperature and pulse were normal; the pa- 
tient was fairly comfortable; did not complain of pain, but left 
iliac fossa exquisitely tender on touch. 
Convalescence was uneventful and steady. The tenderness 
in iliac fossa left after a saline laxative had been given. 
The temperature was highest, 100° F., on the third day, and 
became normal as soon as needless feather beds (used for blank- 
ets) were removed and a very hot room cooled down. 
By the eighth day I found her up and nursing the baby. 
I ordered her to keep quiet. By the eighteenth day she was do- 
ing her own work and said she was as well as ever. 
In looking for the aetiology of the case, I asked the old 
German midwife at the first breathing spell after the re- 
duction of the inversion if she had allowed the “ after- 
birth ” to come away by itself. “ Why, no,” said she. “ I 
helped it along mit der shtring.” 
If this procedure did not produce the entire inversion, 
it undoubtedly started it by bringing down a part of the 
uterus into the grasp of the cervix. 
The severity of the pains and the great straining and 
bearing down while the uterus was inverted were entirely 
unlike labor pains or any bowel tenesmus, and are peculiar, 
I think, to this affection alone. 
The friability of the uterine tissues impressed me after 
making a hole in them by the blunt ends of my fingers. 
However, on turning a still broader surface to the uterus in 
the shape of the back of my fingers, the uterus was gradu- 
ally reduced without any other rents being made. 
From this experience, I believe it would be dangerous 
to use any of the instruments advised for this purpose, for 4 
CASES WITH INTERESTING FEATURES. 
I am sure that if the utmost care was not used the instru- 
ment could he pushed right through the uterus. 
If I had had an instrument in place of my fingers I 
should never have been aware of the laceration that re- 
sulted. I believe the hand is superior to any and all in- 
struments for cases like this. 
The prolonged flaccid condition of the uterus after re- 
duction was no doubt due to muscular paralysis following 
its severe contractions in an abnormal position. 
The freedom from haemorrhage and the scanty dis- 
charge afterward were noticeable. 
There was no fever whatever due to the accident, but 
T4° due to a hot room and excessive covering. 
Occurrence.—Playfair gives the ratio of acute inversion 
to births as 1 to 190,000. 
The symptoms, aside from the tumor, “ profound nerv- 
ous shock, severe abdominal pain and cramp, and bearing 
down.” “ Haemorrhage is a frequent accompaniment,” he 
says. In this case there was no shock to speak of, and no 
haemorrhage before, during, or after the inversion. 
Under reduction, he says, “ the inverted portion of the 
uterus should be grasped in the hollow of the hand and 
pushed gently and firmly upward into its natural position.” 
The plan I used is said by McClintock to increase the 
bulk of the mass and so increase the difficulty of reduction. 
In regard to the former opinions, I would ask you to 
get a large cocoanut—one five inches in diameter—and see 
how much pressure you can exert upon its sides by grasp- 
ing it in the “hollow of the hand” ; convert the case into 
one of inverted uterus and you will agree with me that this 
mode of reduction, while, perhaps, theoretically practicable, 
is practically impossible. In regard to the latter opinion, I 
would say that the reduction is easiest and more rational 
by denting the projecting fundus and so turning the uterus CASES WITH INTERESTING FEATURES. 
5 
back that the size of the mass to the state of the cervix 
does not make much difference within reasonable limits, 
for with the cervix just having expanded sufficiently for 
passage of the foetal head, it will again expand under an 
anaesthetic and allow passage of the returning uterus and 
the hand of the operator. 
Probably if I had had one of the large rubber bags and 
the accompanying force pump at the time, I should have 
used it, and possibly with complete success. But on the 
whole I think the hand is preferable, for you then know 
every change in the surroundings and do not have to go 
ahead in the dark. 
The intra-uterine douches are very beneficial, as all 
agree, in promoting subsequent contraction. They acted 
well in this case, but their effect was not of long duration. 
Case II. Fracture of the Radius immediately below the 
Bicipital Tuberosity.—Harry R., aged four years, July 8, 1891, 
fell from a bicycle on to right arm. Just how, not known. 
Examination, a few minutes after the accident. 
Voluntary movements of forearm and elbow lost. Forearm 
between pronation and supination at right angles to arm. If it 
is extended, a swelling appears about an inch below the bend of 
the elbow over the radius. At this point there is abnormal 
mobility and greatest pain, but no crepitus elicited. 
Diagnosis.—As above. 
Treatment. — Plaster-of-Paris splint applied, with forearm 
completely supinated and flexed to ninety degrees with arm. 
New splint July 15th. Removed August 4th; union per- 
fect. 
Pronation and supination only one third and slight stiffness 
at elbow, which disappeared entirely after three or four weeks 
without interference, giving perfect movements at elbow and 
between the radius and ulna. 
The authors all agree in stating that the accident is a 
rare one. 6 
C/VSES WITH INTERESTING FEATURES. 
Treves, in his Applied Anatomy, states the symptoms: 
“When the radius is broken between the insertion of the 
biceps and pronator radii teres, the upper fragment is flexed 
by the biceps and fully supinated by that muscle and the 
small supinator. The lower fragment will he pronated by 
the two pronators and drawn in toward the ulna by means 
of those muscles.” 
This case illustrated these theoretical symptoms almost 
perfectly. 
On extension of the forearm the upper fragment was 
retained in a position of flexion, and no doubt supination; 
the swelling over the forearm and just below the elbow was 
due to the projection forward of the upper fragment on 
extension ; it disappeared on flexion. The hand was held 
in a position midway between pronation and supination. 
The position of full supination was well borne—in fact, 
caused no inconvenience whatever, for the boy made no 
complaint at any time. 
The stiffness in the forearm movements disappeared on 
allowing the child to use its arm without any interference. 
I believe in the teaching of Professor Stimson, that the 
fear of joint ankylosis—ankylophobia—and the consequent 
passive motion kept up in season and out, is responsible 
for many cases of limited or even no motion after such in- 
juries. 
I believe in letting them entirely alone for a reasonable 
time, and let the patient use his limb to suit himself. 
I have seen complete ankylosis at the elbow following 
a dislocation entirely recovered from in eight weeks with- 
out any treatment whatever. 
Case III. Intestino-peritoneal Septicaemia.—Mrs. S., aged 
twenty-six years, February 21, 1892, delivered of a good- 
sized boy after a labor of about ten hours. At the beginning 
of the labor the ostium vaginae would barely admit two fingers, CASES WITH INTERESTING FEATURES. 
7 
which caused considerable pain. The perinseum was dense and 
firm and was stretched intermittently by bearing downward 
and backward until three, then four fingers, and finally the 
whole hand was admitted. At the delivery the perinaeum was 
only slightly nicked, hut I am confident would have been split 
to the anus but for the intermittent stretching. This procedure 
was suggested in the Record or Journal by a writer. I can not 
find the article now. 
Case progressed perfectly normal without a single bad 
symptom until the 28th—seven days after the confinement. 
On the 28th, at 4 p. m., she had a severe chill. At 7 p. m., 
temperature, 104° F.; pulse, 150 ; respiration, 24. Very rest- 
less, face flushed, skin hot and dry, felt very badly, was afraid 
she was going to die. 
Carbolic douches had been given morning and evening from 
the first. The lochia had been natural and without odor for 
the entire time. The bowels had not moved since the 26th. 
Tablespoonful doses of Tarrant’s aperient were ordered 
every hour until the bowels moved. Five grains of sulphate of 
quinine every four hours. 
February 29th, 10 A. M.—Temperature, 104° F.; pulse, 150; 
respiration, 24. Symptoms not improved. Bowels had not 
acted freely. 
Thinking that perhaps there might he some trouble in the 
uterus, I gave chloroform and curetted, hut it was absolutely 
free from the least trouble whatever. 
Intra-uterine douche of carbolic solution. Salines kept up. 
During the afternoon the bowels moved three times; 7 p. m., 
temperature, lOSH0 F.; pulse, 120. 
March 1st, A. M.—Temperature normal; bowels moved sev- 
eral times during the night. Feeling all right, but weak. Re- 
covery uninterrupted. 
Here is a clear case of self infection from intestinal 
bacteria allowed to develop during two days of constipa- 
tion and probably penetrating to the peritoneal cavity. 
Relieved by free saline cathartics. I do not think anything1 
else had any bearing upon the treatment, except possibly 8 
CASES WITH INTERESTING FEATURES. 
the carbolic douches might help to restrain bacterial action ; 
but just as soon as the bowels began to act freely and 
afford free drainage from the abdominal cavity the symp- 
toms began to mend. I believe that in these cases, even 
when the septicaemia is due to uterine infection, saline ca- 
thartics, plus the intra-uterine treatment, are the most useful 
means we have to prevent further infection. 
Case IV. Ventral Hernia.—Mrs. B., aged about forty-five 
years. Large-sized woman; mother of large family. 
In 1883, after birth of a child, noticed a lump between navel 
and pubes. This gradually increased in size without causing her 
any particular discomfort. Was reducible itself on lying down. 
In 1885 began to wear a large pan-shaped abdominal truss 
that did not keep the rupture in place. 
In 1887 she had an attack of obstructed bowel. Tumor came 
down, was painful, and the bowels constipated. The doctor 
called administered a cathartic, which acted. The attack only 
lasted two days, but the lump did not go away for two weeks. 
The case was uneventful, excepting chronic constipation, 
until March 24, 1891, when the rupture again came down and 
could not be reduced. They called for me and I found the 
usual symptoms of an obstructed hernia. The hernia was 
larger than usual, she stated; was about six inches in diameter, 
circular in shape, and most prominent point about two inches 
above proper level of the abdominal wall; tender to touch; 
considerable pain. Attack brought on by hard work at lifting 
furniture, etc., in spring cleaning. 
An eighth of a grain of morphine every hour if necessary. 
Hot poultices. Operation advised but not accepted. Bowels 
moved satisfactorily on the next day after a high injection and 
the tumor diminished in size, but a large, doughy mass remained 
behind. 
She finally consented to the operation and was prepared 
for it with diet and whisky until the 28th, when, with the 
help of Dr. Bauer, Dr. O’Neil, and Dr. Welch, the operation was 
undertaken. CASES WITH INTERESTING FEATURES. 
9 
All precautions against shook and sepsis taken. 
Usual incision. Sac opened at once; consisted only of peri- 
toneum and skin closely blended and much thinned from pres- 
sure. 
A dark mass of omentum exposed. It was attached by its 
base to the sac all about the hernial orifice. 
Adhesions broken down and omentum examined for con- 
tained intestine, but none found. The omentum from the 
congestion and hyperplasia was nearly half an inch thick and, 
wrhen spread out, six or eight inches wide along its outer mar- 
gin, being, of course, fan-shaped. It completely filled the open- 
ing of the sac. 
It really looked as if a process of degeneration had begun 
in it, and it was deemed best to remove it. This was accord- 
ingly done in the usual manner by several interlocking silk liga- 
tures. Pedicle examined for bleeding points; none being found, 
it was returned to abdomen. Opening of hernia circular and 
about an inch in diameter. The sac for a distance of about 
two inches around the orifice wras dissected up and its neck 
freed from the fibrous ring. Neck of sac tied off by a heavy 
silk ligature and the rest cut awrny. The margins of the ring 
were brought together with heavy buried silk sutures. The 
redundant portions of skin removed and the edges sutured. 
Drainage tube inserted. Heavy dressing applied. 
Convalescence progressed favorably with some little fever. 
On the fifth day superficial sutures and tube were removed. 
Union firm. The external wound closed up, yet there was 
some pain about the seat of operation and a degree or two 
of fever. 
About two weeks later a definite point of fluctuation below 
and to the right of the incision was detected. This abscess 
was opened and a drachm or two of pus evacuated, in which 
was one of the deep sutures. This abscess discharged until all 
the deep sutures were removed. It then closed up and left only 
a small scar. The sutures were divided and taken out as fast 
as they appeared ; a probe curved at the end was used to nook 
them into the wound so they could be removed. Patient was 
up and around the house during this time. After the last 10 
CASES WITH INTERESTING FEATURES. 
suture was removed the sinus closed and she wore a light 
bandage, which she continued for some months. 
There was no return of the rupture until the spring of 1893 
—about two years—when she said a small lump appeared. 
Had not been wearing bandage for over a year. She was 
ordered to resume its use. 
September 30,1893.—Examination : She states rupture comes 
down, but she can replace it. She can not find the opening, 
however. When fully distended, rupture as large as a small 
orange. The rupture was not down at the time of examination. 
The orifice of the hernia was found, but would not admit any 
of my fingers. It is situated half way between umbilicus and 
pubes in median line. On coughing, a small knuckle of gut is 
forced out, but immediately returned to abdominal cavity on 
slight pressure. 
omotner operation advised with pretty sure hopes of cure, but 
she has all she wants of onerations, she says Bandage advised 
and a truss later if she can not get along. 
If no operation had been done it is possible that the 
mass of omentum might have become so adherent to the 
ring as to close it up and produce a cure ; yet the dangers 
of intra-omental hernia would have remained. On the other 
hand, the omentum might have sloughed, for it was very 
dark and congested. If the ring had been closed by per- 
fectly aseptic catgut sutures the suppuration would have 
been omitted. It is probable that one or more of the su- 
tures carried the infection. At any rate, the wound did 
not close until the last of them was removed. Yet all this 
time the silk on the pedicles of the omentum and peri- 
tonaeum gave no trouble, and the cutaneous incision, also 
sutured with silk, closed without suture abscesses. 
The suppuration had nothing to do with the return of 
the hernia, to my mind, for the reason that the granulation 
tissue formed on cicatrizing would aid in closing the orifice. 
If, however, the orifice gaped and the connective tissue 
alone remained, a weak spot was surely left. CASES WITH INTERESTING FEATURES. 
11 
Doing the operation again I would still use silk, but 
would redouble all antiseptic efforts. 
The woman is well to-day and the operation has served 
to clean out all the omentum and to give us a hernia with a 
small orifice—a favorable condifion for operation, but much 
more dangerous for the woman. 
After the operation there was freedom from a hernia 
for nearly two years. 
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