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Psychotherapy and a Gynecologic Service
430
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
pharynx but because the nasal spaces in babies are so small there is liable to be a quick collapse from descending infection. DR. LYON (closing).-We have been studying of late the thymus gland in a series of apparently normal babies, having them all x-rayed on the fifth day, to try to determine an index, if possible, for a normal thymus. It is difficult to interpret these x-rays. We have had babies that we felt clinically showed definite symptoms of embarrassment due to an enlargement; these we have treated by x-ray, but in this group in the past eleven years we have not had any cases in which the thymus was the cause of death. The case of hemorrhage into the adrenals we felt was due probably to handling at the time of delivery. How much spanking that baby had I do not know. In regard to interpartum and postpartum deaths, our series of stillbirths included the interpartum deaths and the antepartum deaths. I presume that really those two topics should be considered together, the stillbirths and the neonatal deaths, but it makes such a vast amount of figures. In regard to placenta previa, for somewhat over two years, if I recall correctly, we have been doing cesarean ser.tion on every case of placenta previa in which we have made the diagnosis. We have not had a great many cases, but as yet we have not had any fetal or maternal mortality. Several of these cases have been transfused during the operation, some before, and some afterward. We always have a donor ready and the transfusion apparatus set up, and at times we even have the donor by the side of the patient when we are operating. Lately we have been doing the low flap operation on our cases of placenta previa. MAx D. MAYER (by invitation) read a paper entitled Psychotherapy and a Gynecologic Service. (For original article see page 357.)
DR.
DISCUSSION DR. R. 'l'. :E'RANK.-Before Dr. Mayer's advent in Mount Sinai Hospital we used a great deal of care in eliminating and weeding out patients whose physical disabilities did not seem to fit the type of symptoms that they complained of, with a fair degree of success, but since he has started this work I feel that these patients are benefited in a further way; not only are we safeguarded from doing unnecessary operative work, but these patients when discharged, are taken care of and again made useful individuals. DR. J. A. CORSCADEN.-The presentation of such a subject before this group is an extremely healthy symptom of the reaction against over-specialization. It is not so long ago that gynecologic results were expressed in mortality. Even now, discussing the treatment of fibroids, I am frequently told that the best treatment is hysterectomy for any fibroid because the mortality can be brought down below one per cent. In 1914 I had the privilege of working up a follow-up system which was to cover all cases in the hospital. At that time there was no universal follow-up system that I could find in the country. In a few years after this it became apparent (this was for a surgical service) that the results of surgical treatment were not satisfactory. We at first used vague terms to describe the success of our procedure~. We soon had to divide the results into three parts, symptomatic, economic, anatomic. We got beautiful repairs, and beautiful excisions without cure of symptoms, or we might cure symptoms, etc., and leave an economically useless person in the community. My own interest in the subject has come particularly because I have induced in many an artificial menopause. In the early days we
-..··
-~-l
OBSTETRICAL SOCIETY OF PII!LADI£LPHL\
were overwhelmed by the numerous symptoms presented by these sufferers. E'or years we fed them quantities of ovarian extract but without success. About 19li in desperation we sought relief from the psychiatric field and found that most psychiatrists regarded these symptoms as primarily psychic in origin and not endocrinologic. So, adopting a crude form of psychotherapy. we have reduced the neuroses to at least a comfortable number. The problem for the gynecologist is to decide how soon he should turn the cnHe over to a psychic expert. DR. W. H. CARY.-I think this is one of the major phases of g;vneeologie practice. I would like to ask Dr. Mayer whether his work was concerned with a group of outdoor or dispensary patients or with a more intelligent group, because it has been a problem to me to know how to devote the time necessary to properl,v approach these patients' problems. DR. MAYER (closing).-With Dr. Corscaden I heartily agree that unless a man has had some special interest or training in the subject he is apt to err in the direction of giving advice. The essential feature for us, as gynecologists, is to be able to see that there is a disproportion between the effects and causes and look for a residual phenomenon. In answer to Dr. Cary I would like to say that this report is based solely upon cases seen in the hospital and the out-patient department, where the work was done for seven years before its being included in the ward. My pri\'ate experience has not been included in this paper. I have devoted some time, but I find that the time necessary is not exeessive. The special morning clinic has an attendance of less than a dozen cases on the average and outside the regular round hours and in spare hours dnring the day the cases in the ward are interviewed. I have three assistants who are being trained in the out-patient department to collahorate in this work.
THE OBSTETRICAL SOCIETY OF PHUJADETJPIH A MEETING OF MAY 1, 1.9.30
DR. CHAS. C. NoRRIS, the retiring President presented an address, after which DR. JosEPH V. lVIrssETT described A Case of Primary Tuberculosis of the Cervix. Mrs. F. S., aged fifty-seven years, white, a native of Philadelphia, nullipara, was admitted to the Women's Neurological Department of the Philadelphia Hospital in January, 1930, for the treatment of a left hemiplegia suffered a week before. Other than the paralysis, her complaints were: gnawing pain in the left hip, lower abdominal and lumbar pain of one month's duration, pain in the left shoulder girdle, and vaginal discharge for two months. She was quite certain of the duration of the discharge, dating its onset following a physical strain. "Felt something rupture after I lifted some tubs, and then the flow began'' is her statement. Her family doctor told her her womb was ~sted and prescribed a douche, which brought no relief. She was a robust, healthy looking woman, well preserved and whose weight had been well maintained. However, she was extremely neurotic and apprehensive, and examination was rather difficult because she was in fear of being hurt.
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
pharynx but because the nasal spaces in babies are so small there is liable to be a quick collapse from descending infection. DR. LYON (closing).-We have been studying of late the thymus gland in a series of apparently normal babies, having them all x-rayed on the fifth day, to try to determine an index, if possible, for a normal thymus. It is difficult to interpret these x-rays. We have had babies that we felt clinically showed definite symptoms of embarrassment due to an enlargement; these we have treated by x-ray, but in this group in the past eleven years we have not had any cases in which the thymus was the cause of death. The case of hemorrhage into the adrenals we felt was due probably to handling at the time of delivery. How much spanking that baby had I do not know. In regard to interpartum and postpartum deaths, our series of stillbirths included the interpartum deaths and the antepartum deaths. I presume that really those two topics should be considered together, the stillbirths and the neonatal deaths, but it makes such a vast amount of figures. In regard to placenta previa, for somewhat over two years, if I recall correctly, we have been doing cesarean ser.tion on every case of placenta previa in which we have made the diagnosis. We have not had a great many cases, but as yet we have not had any fetal or maternal mortality. Several of these cases have been transfused during the operation, some before, and some afterward. We always have a donor ready and the transfusion apparatus set up, and at times we even have the donor by the side of the patient when we are operating. Lately we have been doing the low flap operation on our cases of placenta previa. MAx D. MAYER (by invitation) read a paper entitled Psychotherapy and a Gynecologic Service. (For original article see page 357.)
DR.
DISCUSSION DR. R. 'l'. :E'RANK.-Before Dr. Mayer's advent in Mount Sinai Hospital we used a great deal of care in eliminating and weeding out patients whose physical disabilities did not seem to fit the type of symptoms that they complained of, with a fair degree of success, but since he has started this work I feel that these patients are benefited in a further way; not only are we safeguarded from doing unnecessary operative work, but these patients when discharged, are taken care of and again made useful individuals. DR. J. A. CORSCADEN.-The presentation of such a subject before this group is an extremely healthy symptom of the reaction against over-specialization. It is not so long ago that gynecologic results were expressed in mortality. Even now, discussing the treatment of fibroids, I am frequently told that the best treatment is hysterectomy for any fibroid because the mortality can be brought down below one per cent. In 1914 I had the privilege of working up a follow-up system which was to cover all cases in the hospital. At that time there was no universal follow-up system that I could find in the country. In a few years after this it became apparent (this was for a surgical service) that the results of surgical treatment were not satisfactory. We at first used vague terms to describe the success of our procedure~. We soon had to divide the results into three parts, symptomatic, economic, anatomic. We got beautiful repairs, and beautiful excisions without cure of symptoms, or we might cure symptoms, etc., and leave an economically useless person in the community. My own interest in the subject has come particularly because I have induced in many an artificial menopause. In the early days we
-..··
-~-l
OBSTETRICAL SOCIETY OF PII!LADI£LPHL\
were overwhelmed by the numerous symptoms presented by these sufferers. E'or years we fed them quantities of ovarian extract but without success. About 19li in desperation we sought relief from the psychiatric field and found that most psychiatrists regarded these symptoms as primarily psychic in origin and not endocrinologic. So, adopting a crude form of psychotherapy. we have reduced the neuroses to at least a comfortable number. The problem for the gynecologist is to decide how soon he should turn the cnHe over to a psychic expert. DR. W. H. CARY.-I think this is one of the major phases of g;vneeologie practice. I would like to ask Dr. Mayer whether his work was concerned with a group of outdoor or dispensary patients or with a more intelligent group, because it has been a problem to me to know how to devote the time necessary to properl,v approach these patients' problems. DR. MAYER (closing).-With Dr. Corscaden I heartily agree that unless a man has had some special interest or training in the subject he is apt to err in the direction of giving advice. The essential feature for us, as gynecologists, is to be able to see that there is a disproportion between the effects and causes and look for a residual phenomenon. In answer to Dr. Cary I would like to say that this report is based solely upon cases seen in the hospital and the out-patient department, where the work was done for seven years before its being included in the ward. My pri\'ate experience has not been included in this paper. I have devoted some time, but I find that the time necessary is not exeessive. The special morning clinic has an attendance of less than a dozen cases on the average and outside the regular round hours and in spare hours dnring the day the cases in the ward are interviewed. I have three assistants who are being trained in the out-patient department to collahorate in this work.
THE OBSTETRICAL SOCIETY OF PHUJADETJPIH A MEETING OF MAY 1, 1.9.30
DR. CHAS. C. NoRRIS, the retiring President presented an address, after which DR. JosEPH V. lVIrssETT described A Case of Primary Tuberculosis of the Cervix. Mrs. F. S., aged fifty-seven years, white, a native of Philadelphia, nullipara, was admitted to the Women's Neurological Department of the Philadelphia Hospital in January, 1930, for the treatment of a left hemiplegia suffered a week before. Other than the paralysis, her complaints were: gnawing pain in the left hip, lower abdominal and lumbar pain of one month's duration, pain in the left shoulder girdle, and vaginal discharge for two months. She was quite certain of the duration of the discharge, dating its onset following a physical strain. "Felt something rupture after I lifted some tubs, and then the flow began'' is her statement. Her family doctor told her her womb was ~sted and prescribed a douche, which brought no relief. She was a robust, healthy looking woman, well preserved and whose weight had been well maintained. However, she was extremely neurotic and apprehensive, and examination was rather difficult because she was in fear of being hurt.