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Vol XXXIX.

The Kansas City Medical Index-Lancet

Original Contributions

An Independent Monthly Magazine

FEBRUARY, 1918

[EXCLUSIVELY FOR THE MEDICAL HERALD.]

RETROVERSION AND RETROFLEXION OF THE UTERUS

H. J. BOLDT, M. D., F. A. C. S., New York. We speak of the retroversion of the uterus when the uterine body, in the upright position, does not lie in front of, but behind, the uterine cervix. A retroflexion has a similarly faulty position, but shows more angle at the junction of the cervix with the body. Most frequently flexion and versions are combined in the same patient. In the case of a pure version there is always more or less induration at the juncture of the body and cervix. An accurate diagnosis should never be attempted with a filled bladder, since the position of the uterus necessarily varies. in accordance with the bladder contents. Furthermore, it should be remembered that usually, in a case of retroversion, simple or with retroflexion, there is more or less displacement of the uterus downward.

To enable us to treat intelligently patients with retroflexio-versio, it is necessary to understand fully the etiological factors which bring about this form of posterior uterine displacements. We may mention, first, certain retardation in development; second, fixation of the vaginal part of the cervix to the anterior pelvic wall; third, unilateral posterior fixaton of the cervix; fourth, a shriveled or shrunken condition of the posterior uterine wall, or an elongation of the anterior uterine wall; and fifth, relaxation of the uterine attachments.

According to Sellheim, who made an exceptionally careful study of the causes of retroversions, one-ninth of all patients were found to have embryonal peculiarities of the vagina.

Ziegenspeck considers anterior fixation of the cervix the most frequent cause of retroversioflexio. This is not, however, in accord with my

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ine displacements may be attributed to too long rest in bed upon the back, after confinement. Therefore, early getting up after confinement, with moderate exercise, is to be encouraged as a prophylactic measure.

Pathology-In consequence of the usually present, and more or less marked descensus of the uterus in cases of retroversio-flexio, the vaginal part of the cervix seems to be elongated. If the cervix is lacerated, the lips of the cervix gape; which is a frequent causative factor of laceration ectropium. The gaping of the lips may be the result of inflammatory and adenoid granulation processes when these estalish themselves on the lower cervical portion the gaping becomes more marked. If the retroversioflexio is long present and in so marked a degree that at the point of flexion there is not a curve but an acute angle, the flexion area will continually become atrophied. And to this may be added a tissue fixation, so that to straighten the uterus it is practically impossible.

Frequently there are inflammatory peritoneal adhesions, which vary in density, between the posterior uterine wall and the pelvic peritoneal surface, and often spreading to the adnexae.

It is not necessary to call attention in detail to the complications that may be caused by coexisting pelveo-peritonitis and bilateral salpingooophoritis, resulting from gonorrhea. The degrees and extent of the inflammatory process varies in different patients. While usually the inflammation of the adnexae is equally severe on both sides, still, exceptions are not infrequent. We should bear in mind that if the pelveoperitonitis is of gonorrheal origin, it has ascended from the uterus, and the uterus is therefore the seat of a gonorrheal infection. This is important to keep in mind because of the treatment. The endometrium-though no gonococci may still be present in a condition of interstitial endometritis-is usually markedly thickened, similarly to the myometrium. The entire organ is, in fact, hypertrophied (i. e., thickened and enlarged) the walls are rigid, and the passive flexibility at the corporal cervical junction is diminished or entirely lost.

Inasmuch as with this injection sometimes the tubes are more involved, and sometimes the ovaries, it may be that occasionally the ovaries

are but slightly affected; whereas, in other instances, the infection may be of such a nature that abscess formation in the ovaries is present. Varying degrees of ovaritis, however, occur more frequently than abscess formation.

Hyperaemia and congestion lead to chronic ovaritis; and any factor that may cause such hyperaemia-as sexual irritation, exposure to cold during menstration, circulatory disturbances, etc.-is of significance for the picture of a posterior displacement. A retroflexion, of itself, causes, in most instances, a downward displacement of the ovary. As a consequence of the consecutive torsion which the broad ligaments then undergo, the circulation in the uterus and ovaries is affected. These inflammatory conditions of the ovaries then not infrequently cause adhesions of the glands to the surrounding structure. And when the adhesions are not very firm, they are more likely to be the result of uterine displacement than of infection. Furthermore, following ovarian inflammation we may see ovarian growths. Thus we have an etiological factor for some ovarian tumors.

It is readily conceivable that retro-uterine inflammations may be considered as an etiological factor leading to retroflexion. Take, for instance, a retro-uterine haematocele. During the process of absorption it will cause a shrinking which will draw the uterus into a posterior position.

The most frequent adhesions between uterus, adnexa and the surrounding structures are due to inflammation of the organs themselves; and the most usual cause is some form of infection. The firmest adhesions of the tubes and ovaries are found as a rule at their lowest border.

There is a difference in the infections that attack the tubes and ovaries. If of puerperal origin, the inflammation, if it heals spontaneously, does not leave its ear-marks, as does one of gonorrheal infection, with salpingitis nodo

sum.

When an organ lies inactive in a serous cavity, the opposing visceral and parietal serous surfaces must as a consequence of pressure, be denuded of their endothelium and then become adherent to each other. The length of time for this to occur, of course, varies. This shows the reason for adherent retroversio-flexio.

Symptoms-These may be local and general. Again those arising from mobile, and adherent retroflexion.

Among local symptoms, meno or metrorrhagia is the most constant, particularly among girls.

As the result of the displacement abortion is often seen. This takes place usually about the fourth month, since at this period the size of the

uterus fills the cavity of the true pelvis, and then pressure of the bony pelvis give cause for irritation to the growing uterus, thus causing contractions and expulsion of the fetus. Abortion at an earlier period of gestation, however, is not excluded. excluded. In such instances pressure may not be considered a cause. The most probable inducing factor is a pathologic condition of the uterus, following circulatory disturbances brought about by the displacement. Sometimes. small hemorrhages into the decidua may be held accountable for the accident.

Leucorrhoea is of such frequent occurrence that we set this down as one of the symptoms caused by the displacement, though no logical reason for it can be given.

Bladder disturbances may be ascribed to the change in the contour of the bladder due to the displacement. Indeed, during pregnancy they may become so serious as to endanger life, unless the uterus is emptied.

Constipation is attributable entirely to mechanical reasons: The pressure on the lower bowel. This, too, is not an infrequent cause for hemorrhoids.

Whether backache is caused by the displacement is an open question. It is certain, however, that the backache often ceases when the organ is replaced. And for that reason one may not be wrong in giving it as one of the symp

toms.

Headache is quite often a result of the displacement. Likewise a variety of other nervous symptoms. These may be called border-line disorders, between gynecologic and neurologic.

It is to be regarded as an exception when a retroversion, simple or combined with retroflexion, exists during the entire period of a woman's genital life without causing symptoms.

menstruation.

The reflex nervous, or local pains may only become manifest shortly before the onset of We must remember that with perfectly normal genital conditions there is no dysmenorrhea.

Occasionally sterility may be caused by the displacement considered. The best proof for

the correctness of this assertion is: That sometimes a sterility covering a number of years in cases of retroflexion is cured by its correction and the adjustment of a proper pessary. It may be that this is due to the relief of complications existing in connection with the displacement, as metritis or metro-endometritis, which undoubtedly are a factor in the pathology.

Diagnosis-This must always be based on the palpatory findings. Symptomatology is worthless for the purpose of making a diagnosis, since all the symptoms mentioned may be present in

connection with other disorders.

For the purpose of making an examination it is essential that all clothing be loosened, the bladder emptied and the abdominal walls relaxed. If any one of these requirements is not complied with an exact bimanual examination is impossible.

The most important error-one that is not seldom made-is to confound a retro-uterine tumor of small size for a retroflexed uterus. One who is accustomed to examine frequently can usually differentiate such uterine tumor-whether it be a myoma or tubal swelling the size of a uterus— from a retro-flexed uterus, without resorting to a sound; but one who is not accustomed to examine bimanually many gynecologic patients, may sometimes be helped by using a sound.

Utmost care should be used in making a correct diagnosis before attempting to replace a supposed retroflexed uterus, since a number of such instances are on record of deaths caused by mistaken diagnosis, in instances when the retrouterine mass was a pus sac. Therefore, not only the uterus but also the adnexa should be palpated in all instances. One must determine whether the displacement is fixed or mobile. In some cases an anesthetic may be necessary to make a diagnosis.

The therapy may be divided into mechanical and surgical. Personally, I always elect mechanical therapy if the uterus can be held in proper position by such means; reserving surgical intervention for those patients in whom one cannot retain the uterus in position with a pessary; for those who do not want to have a pessary applied, and lastly, for instances of fixed displacement when it is impossible to reduce the dislocation. It is understood that a pessary should never be adjusted until the uterus has been replaced in proper position. We must not lose sight of the fact that there are a goodly number of women with marked displacement who have no symptoms whatever. In the case of such women, unless they consult the doctor because of sterility, it is best to let them alone.

It would carry me too far were I to consider in detail the therapy of dealing with this class of patients. I have but briefly alluded to the fundamental methods. There are so many suṛgical interventions that this is proof enough that

SERUM TREATMENT OF PNEUMONIA A. SOPHIAN, M. D., Kansas City, Mo. Lobar pneumonia is an acute infectious disease, generally caused by the pneumococcus, characterized by general systemic infection as well as inflammation of the lungs.

The pneumococcus causing pneumonia has been classified into four groups, namely, Groups I, II, III, IV, the division being determined by serum tests, viz., the serum of animals immunized against pneumococcus of one group shows the presence of specific immune bodies. only for that group pneumococcus, and little or no specific antibodies for the organism belonging to the other groups. Group III pneumococcus (pneumococcus mucosus) has distinctive cultural characteristics.

The bacteriological study of many cases of pneumonia has shown that about 30 per cent of all cases are caused respectively by pneumococcus Groups I and II, with an average mortality of about 30 per cent; 12 per cent by Group III with an average mortality of 45 per cent; with Group IV, 24 per cent with an average mortality of 16 per cent.

The pneumococcus in pneumonia can be isolated from the sputum, blood, urine and from aspiration puncture of the involved lobe. The organism can be most quickly isolated from the sputum. The method found most practicable is to inject some carefully collected and washed sputum into the peritoneal cavity of a white mouse, which sickens generally within 24 hours. The peritoneal exudate of the animal contains the organism in large numbers. This culture tested seriologically against Groups I, II and III serum by the agglutinin or precipitin test, enables a rapid, accurate diagnosis of the pneu

mococcus as to group.

The most important principle of specific immune serum therapy is to use a specific serum of high titre. The importance therefore, of prompt classification of the type pneumococcus causing pneumonia is obvious; one can determine as to the probable gravity of the disease, and if serum treatment is used one can select a serum containing many immune bodies against the Special Group pneumococcus indicated. Another principle is to inject an immune serum in

we not yet have anyone that is ideal in the opin- ample dosage, directly into the infected region. ion of all gynecologic surgeons.

39 East 61st St.

Eclampsia: Sedation, venesection, elimination and prompt delivery-venesection during attack most potent of all.

Overfeeding is now quite universally accorded a foremost place in the etiology of gastrointestinal disorders in infancy.

In pneumonia the infection is present in the blood and in the lung. It is dangerous as well as impracticable to inject Serum in the lung. Serum, therefore, should be injected into the blood by direct intravenous injection, thereby meeting the general infection and to a lesser degree, the local infection in the lung. The dosage used varies with the individual cases; an average dose is 100 c.c., repeated every 8 hours if necessary till about 250 c.c. is injected. An evidence

of favorable reaction, is improvement in the general condition, clearing up of cyanosis, fall in pulse rate, fall in temperature and a shortening of the disease. The local extension of the disease is stopped and bacterial invasion of the blood stream prevented. There is no appreciable change in the local pulmonary signs, and no effect on resolution. Öf 107 cases of Type I pneumonia treated in the Rockefeller Institute Hospital ony 7.5 per cent died.

Injection of serum or any foreign protein, especially intravenously is frequently followed by a sharp reaction, consisting of chill, hyperpyrexia, sweating, hyperleucocytosis with high polynucleosis. This reaction is to a large extent a non-specific reaction following the injection of any foreign protein, specific or nonspecific. The therapeutic value of this reaction is often considerable. The specific therapeutic action of serum is the destruction of the pneumococcus, as well as the stimulation of a specific leucocytosis and phagocytosis.

The injection of foreign protein may also be attended by the reaction of anaphylaxis, specific or non-specific. The symptoms may be those of true anaphylactic shock, with convulsions, respiratory paralysis and death; fortunately a very rare occurrance; or those of serum sickness, occurring at once, in four days, or ten days following the injection of serum. It is important to test patients before the therapeutic injection of serum to determine whether or not they are susceptible or sensitive to the serum to be injected. This is done by the intracutaneous injection of 0.02 c.c. of sterile diluted horse serum (normal or immune) diluted with salt solution 1.10; a positive reaction consisting in the almost immediate appearance of an urticarial wheal at the site of injection reaching its maximum size in about an hour, then fading rapidly. After the completion of the intracutaneous test, a desensitizing subcutaneous injection of 5 to 1 c.c. of horse serum (normal or immune) should be injected even if the test reaction be negative. If the skin test be positive, more thorough desensitization must be employed. This consists in injecting small doses of serum subcutaneously at half hour intervals, beginning with 0.025 c.c. of serum and doubling each succeeding dose. After 25 c.c. of serum have been given in these small doses, after a lapse of four hours, 50 c.c. may be given, followed by the regular dose 6 to 8 hours later.

The reaction of anaphylaxis may also be modified or prevented by preliminary administration of alkali to a patient for about 24 hours.

Vaccine has been used in the treatment of pneumonia as in the treatment of other infections. The favorable results from the administration of vaccine in an acute disease like pneumonia, may be expected principally from the

non-specific protein reaction, which would be sharpest after intravenous injection. It must be remembered, however, that the reaction, if very severe, may be decidedly harmful or dangerous.

There are a few points in the general therapy of pneumonia which may be emphasized here. The abdomen should be kept flat, and if necessary, milk avoided. Water should be taken freely, diet very light. Sugar and alkali should be administered to prevent acidosis. Digitalis is favored by many for use throughout the disease. Plenty of fresh air, not necessarily freezing air, is important. Absolute quiet is imperative. Camphor and quinine have been recommended by some as having specific properties; the writer questions any special virtue, except when especially indicated.

A word about prophylaxis: Pneumonia is a contagious disease; the germ is transmitted by healthy carriers. The same precautions, therefore, should be used to prevent the spread of this disease as for epidemic meningitis, poliomyelitis or other carrier disseminated diseases.

"JEJUNOSTOMY IN ACUTE OBSTRUCTION OF THE BOWELS"

New York City, December 13th, 1917. My Dear Dr. Fassett: I have read with much interest Dr. McKinnon's article on jejunostomy, but thus far I have had no experience with that technic. It seems to me to be not quite clear regarding the element of risk when the bowel is dropped back into the peritoneal cavity with a tube in it. It would occur to me that when the tube became loosened we would be likely to get leakage. If there be no risk in Dr. McKinnon's operation, the procedure would be ideal. I wish to congratulate the doctor on hisxcellent results and would be much pleased to get a little more information regarding same. Faithfully yours, HERMAN J. BOLDT.

Lincoln, Neb., December 29th, 1917. Dear Dr. Fassett: Replying to your letter of recent date with enclosure from Dr. Boldt commenting on my article on jejunostomy.

There are many methods of doing an enterostomy. The method recommended in my paper seems to me to be the simplest, and with an experience of over fifty cases now, without a fistula following, seems to show that if properly performed it is the ideal operation.

The technic as described in my paper explains how the tube with the intestinal wall is invaginated into the lumen in the form of a cone. When the tube drops out the invaginated cone acts on the same principle as a safety ink well and prevents leaking until the peritoneal surfaces adhere. If you use a small tube-less than 25 French-the question of leakage need not be taken into consideration, as there will be none. Yours very truly, A. I. MCKINNON.

Society Proceedings*

Medical and Surgical Club of Kansas City

(Reported for The Medical Herald)

JOINT FRACTURES

HERMAN E. PEARSE, M. D.

1. When bones break near a joint, the fracture sometimes extends into and through the joint surface; result, joint fracture.

2. When sudden great weight is thrown upon a joint in motion, it produces a grinding of the structure that often breaks away portions of the articular surfaces; result, a joint fracture.

3. When a side strain is thrown upon a whole structure and that structure contains one or more joints, the joint ligaments tear and their insertions into the bone tear also, producing ugly fracture of projecting or holding bone processes; result, joint fracture.

4. When a bullet or a piece of steel or a fragment of rock from a blast or a swift moving wheel strikes a joint, it tears a path through that joint. The path is a fracture depending on the size and force of the moving body for its size. direction, destructiveness, and complicating factors; result, a joint fracture.

5. You may be the authors, the writers, the classifiers, the namers as you like and name and classify these injuries. I will consider them classically as joint fractures and treat of their care with a view solely to the saving of life, of limb and of motion in the joints of that limb.

The x-ray must be our means of diagnosis, and here I wish to pay a tribute to one who will appear before you today who has done so much to forward the diagnosis of injury and disease by the x-ray. Diligent, a hard worker, a fearless explorer, and honest reporter, it is fitting that Major Surgeon Edward H. Skinner should head the Army School of Roentgenology at this sta

tion.

Preserving Function-In the course of development of animal life the structure of the joint is due to its functioning. In the interpretation its pathology and in the application of our therapy, we should keep this in mind when we hope for movable joints after injury. We should restore the anatomy of the joint, displaced by the injury and see to its blood supply and cleanliness and drainage, and make possible its healing and repair. We should preserve this function of motion by making use of motion free from the injurious factors of weight bearing and strain, i. e., passive motion and massage at frequent intervals followed by rest, protection and easy posture.

*Proceedings of Clinical Session held at the General Hospital, December 11, 1918.

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Ankylosis-Ankylosis after the injury may be desirable as when it offers the only alternation to amputation. Our constant aim is to avoid it.

The factors that threaten integrity of a joint and its mobility and tend to produce ankylosis

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We may open the joint or not.

We may mend the fragments or we may remove them.

We may drain with tubes, pack with gauze, or close with no drainage.

We may use extension or not.
immobilize.

We

may Continuously.

Intermittently or not at all.

We may do all of these. When to do them and when not to do them, how to do them and how not to do them, constitute the education of a surgeon's lifetime, but some things we must do in every case where hope for restored motion in a broken joint.

1. We must keep gauze* out of the joint. 2. We must use early passive motion without pain or damage.

3. We must use surgical knowledge and surgical sense in applying the five major procedures just mentioned to the four great classes of joint fractures just described and we must give our personal study to these cases every day until they

are well.

*And everything else.

FRACTURES OF THE LONG BONES

HOWARD HILL, M. D.

One great objection to all open operations for fractures is that of converting a simple fracture, which rarely becomes infected, into an open one which as is well known, is a dangerous condition. since it often becomes infected with serious consequences for the patient, not only as regards the future of the broken bone but may eventually lead to amputation to save the patient's life.

In discussing the treatment of fractures of the long bone by means of Lane's plates, it is proper to state that there is a well defined prejudice against this method which has been growing stronger for some time due to the numerous bad results which have attended its use in the hands of good surgeons.

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