no night sweats, no cough, no hemoptysis, no dyspnea, no edema of
legs. She has lost considerable flesh and strength. Upon admission
she showed a sallow complexion and was very much emaciated. Tem-
perature was 99° F. in the morning and 102° F. in the afternoon. Her
tongue was coated with a white fur. There Avas retraction above and
below the clavicles on both sides. There was some dulness over both
apices behind. No cough. No sputum. There Avas a systolic murmur
in the third interspace near the sternum, probably hemic. On vaginal
examination the uterus is found enlarged to the size of a gravid uterus
at the sixth or seventh week. There is a mass to the left and behind
the uterus, the size of a hen's egg, which is very firmly fixed to the
uterus. The right tube is about the thickness of the thumb.
Upon ocular inspection the cervix is considerably enlarged, the
hypertrophy being most marked in the anterior lip, which presents
three large ulcerations. The ulcers are irregular in outline, moderately
deep, and covered with a dirty-grayish exudate. They are separated
from one another by a very narrow strip of mucous membrane of a
rather bright-red color. There is no marked induration of the lip, no
friability of the tissues, and no tendency to bleed on being touched.
There is a thick, tenacious, grayish-yellow discharge from the external
VINEBERG: TUBERCULOSIS OF CERVIX, ETC. 475
OS. I made the diagnosis of tubercular ulceration of the vaginal por-
tion, with probable tubercular disease of the adnexa. The absence of
menstruation for two months, associated with enlargement of the
uterus, gave rise to the suspicion of pregnancy. Repeated examination
of the discharge from the surface of the ulcers and from the cervix did
not show any tubercle bacilli. Although I had never seen a case of
tubercular ulceration of the cervix, I adhered to my diagnosis, which
I had reached by a process of exclusion, in spite of the negative results
of the bacteriological examinations. The pathologist, however, was
enabled to report, in the course of a few days, that the lesion was
tuberculous, from a fragment of tissue which I had gouged out with
the sharp spoon from the surface of one of the ulcers. For the four
days prior to the operation the temperature ranged from 100° to 103°
P.. the pulse from 110 to 180. The ulceration extended slowly to the
posterior lip during the four days the patient was under observation in
the hospital.
The operation proved to be veiy difficult, owing to the firm ad-
hesions of the left tubo-ovarian mass to the pelvic wall. When the
mass was finally enucleated it was yevy difficult to stop the oozing, even
after the uterine vessels were secured and the uterus was removed.
The loss of blood and the severity of the operation proved to be too
much for the patient, who was cachectic and emaciated, and she died
six hours after the operation from cardiac weakness.
No autopsy was permitted. On bisecting the uterus a perfect
specimen of tuberculosis of the endometrium was obtained. The
mucosa was double the normal thickness. It had a soft, velvety ap-
pearance and was thrown into numerous longitudinal folds. On veiy
close inspection small, fresh tubercles could be seen on the summit of
the folds. The mucosa of the cervix was equally involved. Tubercle
bacilli were readily found in the endometrium. The left adnexa were
indistinguishable as such, forming an abscess sac, the pus of which con-
tained tubercle bacilli in abundance. The right tube was enlarged
to the size of the index finger and was filled with pus Avhich contained
tubercle bacilli. The right ovary was embedded in adhesions and was
considerably below the normal size.
Tuberculosis of the vaginal portion of the cervix is a very rare con-
dition, even as a secondary affection to tuberculosis of the eudonu -
trium. As a primary disease it is of course very much less frequently
observed. In a fairly comprehensive search of the literature I have
been able to find only the following cases: Klob, one case^ ; Fried-
lander, one- case- ; Kaufman, one case^; Fraenkel, one case*; Spaeth,
'Pathol. Anat. d. weibl. Genital, 1864.
-Volkmann's klin. Vortrage, No. 64.
^Zeitsch. fill- Geb. u. Gyn., Bd. xxxvii., p. 119.
'Jahr. d. Hamburger Staatskrankenanstalten, 1893-94.
476 MOUNT SINAI HOSPITAL REPORTS.
one case^ ; Lewers, one ease'' ; F. S. Matthews, one case" ; Driessen, one
ease^. There is some doubt in reference to this case, inasmuch as the
patient had a fistula in ano and the disease of the cervix may have been
secondary to it. The total number of cases of primary tuberculosis of
the cervix therefore thus far recorded is seven.
The case here reported must be looked upon as secondary to tuber-
culosis of the uterus and tubes, which in its turn was probably second-
ary to a healed or quiescent tuberculosis of the lungs. The two attacks
of pleurisy within a period of two and a half years doubtless had a
tubercular basis. Still a phthisical patient may, through the mediupi
of her fingers, in very rare instances, infect her genital organs, and
thus bring about a primary tuberculosis of them^.
Primary tuberculosis of the genital organs in women may occur as
follows :
1. The entrance of the tubercle bacilli directly into the mucous mem-
brane of the vulva, vagina, cervix, body, and tubes, and through the
latter to the peritoneum and ovary.
2. The entrance of the tubercle bacilli through small abrasions in
the genital canal into the paravaginal and parametric lymph channels,
and the extension of the germs through these to the pelvic peritoneum
and thence to the tubes or directly to the tubes (Hegar).
3. The transmission of the tubercle bacilli through the blood current
directly to the genital organs (hematogenic form).
Secondary genital tuberculosis arises from a primary focus situated
in a caseous gland in any part of the body (most frequently the bron-
chial), the metastasis occurring through the blood or lymph currents
or by contiguity, and it may arise through contact with a secretion
containing tubercle bacilli from a tuberculous organ, as, for instance,
the discharge from tuberculosis of the intestine, or the urine in tuber-
culosis of the urinary organs ( Amann, Jr.) . The association, however;
of tuberculosis of the two systems, the genital and the urinary, in
women is very rare. I have seen a fairly large number of urinaiy
tuberculoses in women, and have, not as yet seen a case in which the
two systems w^ere affected with tuberculosis in the same person.
Until the publication of Hegar 's article in 1886 tuberculosis of the
''Inaug. Diss., Strassbourg. 1885.
'Jour, of Obst. and Gyn. of the British Empire.
'Operated upon by Dr. George M. Tuttle, Medical Record, Dec. 17, 1898.
"Centl. f. Gyn., 1898, No. 28.
*Hegar, Alterthum.
VINEBERG: TUBERCULOSIS OF CERVIX, ETC. 477
utenis was considered as a pathological rarity. Since then the number
of cases recorded in the literature has grown to considerable dimen-
sions. Vassmer^" alone was able to collect six cases of tuberculosis of
the uterus in Runge's clinic in a period of ten months. In some of his
cases tubercle bacilli were found in the scrapings obtained through
curettage when such a disease was not at all suspected. The lesson to
be learned from this is that uterine scrapings should be systematically
searched for tubercle bacilli.
Most of the cases of tuberculosis of the cervix found in the literature
had been diagnosed as carcinoma prior to operation. When the tuber-
culous affection occurs in the form of a cauliflower-like growth, as it
frequently does, its resemblance to a cancerous growth is very striking.
T. S. Cullen, in his incomparable work ''Cancer of the Uterus," page
192," draws attention to this source of error in the differential diag-
nosis of squamous-cell carcinoma of the cervix, and reports some cases
in which this error in diagnosis had been made.
A second variety of tuberculosis of the cervix occurs in the form of
fiat ulcers with a grayish exudate, as in the case here reported.
A third and the most frequent variety occurs in the form of miliary
tubercles on the vaginal portion, as also on the cervical mucosa, and
from here the tubercles may penetrate the whole thickness of the cer-
vical wall (Vassmer).
A fourth variety occurs in the form of a bacillary catarrh, in which
the process is localized to the superficial epithelium and glands, the
latter being filled Avith cheesy masses containing numerous tubercle
bacilli. 1=
The absence of menstruation in my case for two months, associated
with enlargement of the uterus, is an interesting phenomenon and led
to the natural suspicion of pregnancy. Amenorrhea in tuberculosis
of the uterus occurs only in a very advanced stage of the disease, when
the entire endometrium has undergone caseation. As a rule, instead
of amenorrhea, the patient suffers from menorrhagia or metrorrhagia.
In accordance with the condition of the endometrium that was found
on bisecting the uterus, these symptoms (uterine bleeding) should
have obtained. It is probable that the condition of the ovaries — one
being converted into an abscess sac, the other embedded in adhesions
and atrophic— may have accounted for the amenorrhea. The occui -
'<"Archiv. f. Gyn., Bd. Ivii., p. 301.
"D. Appleton & Co., 1900.
"Schiitt, Inaug. Diss., Kiel, 1889.
478 MOUNT SINAI HOSPITAL REPORTS.
renee of pregnancy in tuberculosis of the uterus is not an improbable
event ; such cases have been recorded by Thorn," Hosier," and Schmorl
and Kockel.^^ Casper (cited by Hosier) reports a ease in which there
occurred spontaneous rupture of the uterus at the third month of preg-
nancy. Thorn, Schmorl, and Kockel have each reported a case of
tuberculous endometritis in which the pregnan&y went to full term,
and the tuberculous disease of the endometrium had even advanced to
the stage of caseation.
"Inaug. Diss., Berlin, 1894.
"Inaug. Diss., Breslau, 1883.
"Beitrage zur. path. Anat. und allg. Path., Bd. xvii.
EYE AND EAR STATISTICS.
December 1, 1900, to December 1, 1901.
Emil Gruening, M.D.,
ATTENDING SURGEON.
C. H. May, M.D., and C. Koller, M.D.,
ADJUNCT ATTENDING SURGEONS.
I. Lachrymal Apparatus.
CASES.
Dacryocystitis 1
Lachrymal fistula 1
2. Globe and Orbit.
Glaucoma simplex 1
Chronic glaucoma 12
Acute glaucoma 2
Subacute glaucoma 1
Orbital periostitis (syphilitic)... 1
Cicatricial contraction of orbital
stump 3
Traumatism 1
Empyema of ethmoid cells 1
Empyema of frontal sinus 1
3. Lens.
Senile cataract 15
Morgagni " 1
Soft " 1
Secondary " 5
Traumatic " 2
Diabetic " 1
4. Muscles and Nerves-
Convergent strabismus 5
5. Lids and Brow.
Distichiasis 1
Entropion 4
Trichiasis 1
Supraorbital oil cyst 1
Trachoma 14
Cicatricial contraction of lid 3
Empyema of orbit and lid 1
6. Cornea.
CASKS.
Ulcerative keratitis 12
Traumatic keratitis with hypo-
pyon 2
Penetrating wound of cornea 1
Leucoma 2
Traumatic laceration 2
7, Conjunctiva.
Chronic catarrhal conjunctivitis. . 1
Granular " . . 2
Koch-Weeks " .. 1
Phlyctenular " . . 2
Blepharospasm 1
Pterygium 2
Granuloma of conjunctiva 1
8. Retina and Optic Nerve.
Glioma 1
9. Iris and Ciliary Body.
Iridocyclitis 1
Total synechiae 1
Sarcoma of iris 1
Chronic iritis 1
Rheumatic " 1
Acute " 1
Cyclitis dolens 1
10. Choroid and Vitreous.
Suppurative choroiditis 1
Disseminated " 1
II. Miscellaneous.
Total blindness from bullet wound
of head 1
480
MOUNT SINAI HOSPITAL REPORTS.
DISEASES OF THE EAR.
I. Auricle.
CASES.
Postauricular abscess 1
2. Eustachian Tube and Middle Ear.
Acute otitis 4
" " complicating mas-
toid 1
Chronic otitis 4
" " with brain abscess. 1
3. Mastoid Disease and Complica^
tions.
CASKS.
Acute suppurative mastoiditis. ... 17
" " " peri-
auricular abscess 1
Chronic mastoid fistula 1
Chronic suppurative mastoiditis. . 11
Subacute mastoiditis 8
Septic thrombosis of lateral sinus, 1
Acute mastoiditis with meningitis. 4
Tubercular mastoiditis with men-
ingitis 1
OPERATIONS ON THE EYE.
I. Lachrymal Apparatus.
Incision and cauterization of
lachrymal fistula 1
2. Lids and Brow.
Hotz's operation for entropion 4
Enucleation of supraorbital oil
cyst 1
Expression of trachoma granules. 14
Plastic for cicatricial contraction. 3
Streatfield operation for entro-
pion 1
3. Sclera.
Sclerotomy for glaucoma simplex. 1
4. Conjunctiva.
Excision of pterygium 1
Excision of granuloma 1
5. Cornea.
Incision and drainage of hypopy-
on 2
Cauterization of ulcer (iodine).. 2
" " (cautery). 2
Tattooing of leucoma 2
6. Muscles.
Tenotomy of internal rectus, ad-
vancement of external rectus. . 3
Tenotomy of internal rectus 2
7. Iris.
Iridectomy for chronic glaucoma. 9
" " senile cataract ... 5
" " complete synechiae 1
" " subacute glaucoma 1
" " trauma to globe. . 2
" " acute glaucoma... 1
" " secondary cataract 2
Excision of prolapse after trauma. 1
8. Lens.
Extraction for senile cataract.... 12
" " Morgagnian cata-
ract 1
Secondary discission 5
Excision of sarcoma of iris 1
Needling of soft cataract 1
9. Globe and Orbit.
Wolff's skin graft of orbit 3
Exploration of ethmoid cells (em-
pyema) 1
Exploration of frontal sinus (em-
pyema) 1
Enucleation (panophthalmitis)... 1
" (suppurative choroid-
itis) 1
Enucleation (traumatic glau-
coma) 1
Enucleation (cyclitis dolens) . . . . 1
EYE AND EAR STATISTICS — 1901.
481
OPERATIONS ON THE EAR.
I. Auricle.
CASES.
Incision and drainage of peri-
auricular abscess 1
Incision and drainage of post-
auricular aoscess 1
2. Membrana Tympani.
Paracentesis 18
3. Mastoid and Complications.
Simple osteotomy 31
CASKS.
Incision and drainage of subperi-
osteal abscess 1
Curettement of chronic mastoid
fistula 1
Radical mastoid operation 10
Exploration of lateral sinus and
meninges 13
Aspiration of brain 2
Lumbar puncture for suspected
brain abscess 1
OPERATIONS ON THE THROAT.
Adenoids, avulsion of 5
Hypertrophied tonsils, abiation.. 2
Nasal polyp, avulsion of 1
Thyroid tumor of tongue (exci-
sion)
EYE AND EAR STATISTICS.
December 1, 1901, to December 1, 1902.
DISEASES OF THE EYE— 212 CASES.
I. Lachrymal Apparatus.
Dacryocystitis
2. Globe and Orbit.
Acute glaucoma
Chronic "
Phthisis bulbi
Acute tenonitis
Gunshot wound of eyeball
Foreign body in eye — panophthalmitis.
Myopia
3. Lens.
Senile cataract
Diabetic "
Traumatic "
Secondary "
4. Muscles and Nerves.
Convergent strabismus
Divergent "
(both eyes)
5. Lids and Brow.
Trachoma
Trichiasis
Entropion
Edema of lids
Ptosis (bilateral, acquired)
Sarcoma of lid
II 1
2
12
12
1
4
7
3
12
2
104
5
1
1
1
1
2
12
1
1
1
1
1
12
1
4
7
3
12
2
109
5
1
1
1
1
EYE AND EAR STATISTICS — 1902.
483
6. Cornea.
Interstitial keratitis
i
C
p
■D
>
P
.1
a
P
•d
U
5
Eh
2
*i
'2
••
i
2
"i
1
1
1
1
?.
Fascicular "
1
'2
1
Hypopyon "
1
Corneal ulcer
?,
Pannous keratitis
?,
Penetrating wound of cornea
1
1
1
1
1
3
1
i
'2
1
3
1
7. Sclera.
Incised wound of sclera
1
8. Conjunctiva.
Phlyctenular conjunctivitis
1
Granuloma of conjunctiva
1
Skin adherent to "
1
9. Retina and Optic Nerve.
Optic neuritis
1
Toxic optic neuritis
2
Detachment of retina
2
Glioma " "
1
Retinitis proliferans
1
10. Iris and Ciliary Body.
Iritis
1
Tubercular iritis
1
Anterior synechiae
2
Occlusion of pupil
1
Cyclitis
q
II. Choroid and Vitreous.
Hemorrhage into vitreous
1
Total.
.212
DISEASES OF THE EAR_42 CASES.
I. Middle Ear.
Acute otitis media
Chronic " "
<u
s
U
•0
>
a.
S
>
£
c
S
'5
•d
c
5
••1
••1
2
5
2
484
MOUNT SINAI HOSPITAL REPORTS.
2. Mastoid Process,
Acute suppurative mastoiditis
Subacute " "
Chronic mastoiditis with fistula
3. Mastoid and Complications.
Acute mastoiditis; pyemia
Suppurative mastoiditis and sinus thrombosis
Sinus thrombosis
Chronic mastoiditis; sinus thrombosis; extradural and
cerebellar abscess
23
2
6
42
DISEASES OF NOSE. THROAT. AND SINUSES— 11 CASES.
Nasal exostosis ,.
Syphilis of nose
Adenoids
Hypertrophied tonsils
Acute suppurative epiglottitis
Syphilitic stenosis of larynx
Perforating empyema of frontal sinus
Empyema of frontal and of the maxillary sinus.
Post-operative non-closure of ethmoidal sinus. . . .
-o
0)
01
>
■d
u
3
>
a
a
a
'S
-d
.2
U
'"'
u
1
1
2
1
1
1
1
1
2
11
OPERATIONS ON THE EYE_203.
I. Lachrymal Apparatus. cases.
Incision for dacryocystitis 2
2. Eyeball.
Removal of foreign body 2
3. Lids and Brow.
Scarification and expression for trachoma 104
Hotz's operation for trichiasis 3
Streatfield-Snellen-Herbert operation for entropion 1
Panas' operation for ptosis 1
Tarsectomy and suture for ptosis 1
Jaesche-Arlt operation for trichiasis 3
Canthoplasty 1
Removal of section of tumor of lid for diagnosis I
EYE AND EAR STATISTICS — 1902. 485
4. Conjunctiva.
CASES.
Removal of granuloma 1
" " foreign body 1
Excision of skin adherent to conjunctiva 1
5. Cornea.
Cauterization of ulcer of cornea with actual cautery 3
6. Sclera.
Suture of incised wound of sclera 1
7. Muscles.
Tenotomy of internal rectus for convergent strabismus 8
Stretching and tenotomy of internal rectus (Panas) 14
Tenotomy and advancement • • • • 4
" of external rectus 3
superior
1
" " inferior " 1
8. Iris.
Iridectomy for acute glaucoma 2
" " chronic " 9
" preparatory to cataract extraction 4
" for prolapsed iris 2
" and division of anterior synechise 1
Iridotomy for occlusion of pupil 1
9. Lens.
Simple extraction for senile cataract 9
Combined " " " " 2
" " " traumatic " 4
" " " diabetic " 1
Linear extraction for myopia 1
Discission for secondary cataract 11
10. Globe and Orbit.
Evisceration for iridocyclitis 1
Enucleation for glioma of retina 1
" " traumatic iridocyclitis 2
" " cyclitis 2
" " phthisis bulbi 1
" " injury following gunshot wound 1
Removal of cartridge from the eye 1
II. Miscellaneous.
Resection of superior cervical ganglion for double optic neuritis 1
Total 203
486 MOUNT SINAI HOSPITAL REPORTS.
OPERATIONS ON THE EAR— 50.
I. External Auditory Canal.
CASES.
Plastic secondary to mastoid operation 1
2. Membrana Tympani.
Paracentesis 9
3. Mastoid and Complications.
Incision of abscess 1
Revision of mastoid sinus 2
Osteotomy for acute suppurative mastoiditis 24
" " double mastoiditis 2
" " subacute " 1
" " mastoiditis and perisinuous abscess 1
" and curettement for sinus thrombosis 1
" " drainage for mastoiditis, sinus thrombosis, and brain
abscess 1
Radical operation for mastoiditis ( Stacke) 3
Exploratory osteotomy for suspected sinus thrombosis 1
Incision of abscess in posterior cervical triangle 1
Ligation and excision of internal jugular for sinus thrombosis 2
50
OPERATIONS ON THE NOSE, THROAT, AND SINUSES— 9.
Removal of nasal exostosis 1
" " section from turbinated bone for diagnosis 1
Curettement for adenoids 2
Tonsillotomy for hypertrophied tonsils 1
Incision of epiglottis for suppurative epiglottitis 1
Tracheotomy for syphilitic stenosis of larynx 1
Osteotomy and drainage for empyema of frontal sinus 1
" " " " " " " and maxillary sinuses. . 1
9
Total number of operations on eye, ear, nose, throat, and accessory sinuses. 262
ORBITAL CELLULITIS; EMPYEMA OF THE ETHMOID
CELLS AND THE FRONTAL SINUS; ABSCESS OF THE
FRONTAL LOBE; PNEUMOCOCCEMIA; DEATH.
By E. Gruening, M.D.,
OPHTHALMIC AND AURAL SURGEON.
The patient whose ease is here related suffered from chronic sup-
puration of the ethmoid cells and the frontal sinus. He became in-
fected by a pneumococcus invasion, the portal of infection being the
nose. From here the infection travelled to the ethmoid cavities, the
orbit, and the brain, passing by the frontal sinus. This fact was
demonstrated clinically by the absence of tenderness in the region of
the frontal sinus, and bacteriologically by the sterility of the purulent
contents. The pus taken from the nose, the ethmoid, the orbit, and
the brain contained the pneumococcus. If in the descriptive title of
this paper "orbital cellulitis" occupies the first place in the complex
symptomatology of the case, it may be explained by the circumstance
that it was the orbital affection with its inherent protrusion of the
eyeball which caused the patient to be admitted to the eye wards of
the hospital and brought him under my care.
L. S., 26 years of age, a butcher, was admitted to the Mount Sinai
Hospital on March 29, 1903. His left eye was chemotic and both lids
were swollen. The motility of the eye upward was impaired and
the globe was forced dowuAvard and forward. The pupil of the left
eye was slightly larger than that of the right. Ophthalmoscopic ex-
amination negative. jNIarked tenderness over ethmoid bone, no ten-
derness over frontal sinus. Between the left middle turbinated body
and the outer wall of the nose a layer of white pus. Temperature
103.8°, pulse 76, respiration 26.
Lungs, heart, spleen, and ears normal. The patient was in a
stuporous condition and could not be questioned as to the history
of his disease. His relatives stated that six days ago he awoke in
the early hours of the morning with much headache and pain in
the left eye. The first three days he had chills and fever and a
copious discharge from his nose. The pain in the left eye persisted,
488 MOUNT SINAI HOSPITAL REPORTS.
and after some time the patient became delirious and finally
stuporous.
On the day of admission. March 29, the patient was anesthetized
and operated upon. An incision down to the bone was nlade along
the upper and inner orbital margins. The periosteum of the os
planum and of the roof of the orbit was softened and perforated at
several points. The entire os planum was carious, and the cavities
of the ethmoid were full of pus and granulation tissue and com-
municated with the orbit, which also contained much pus. The
lachrymal gland was displaced and lay in a pool of pus. The outer
layer of the orbital process of the frontal bone fonuing the roof of
the orbit was softened and discolored. It was therefore removed
and the frontal sinus was entered from the orbit. The cavity of
the sinus contained thickened mucous membrane, a quantity of pus,
many mucous polypi, and an exostosis springing from the inner table
of the orbital process. The sinus was then cleared of its patho-
logical contents. The remaining bony walls appeared sound and
no communication could be found either with the sinus of the other
side or the cranial cavity. Here the operation ended, and the large
resulting cavity was loosely packed with iodoform gauze. A rubber
drainage tube was carried through the nose and a moist dressing
applied.
The following day. ]\Iarch 30, the patient appeared but little im-
proved. His mind was not clear ; stupor and delirium alternated.
The pulse ranged from 64 to 92, the temperature from 101.8° to
103.60°. At the first dressing all packings were removed and renewed
moist.
March 31 : Patient delirious the greater part of the day. At times
he was quiet and answered questions rationally. In the course of
the day the temperature rose to 105.4°, with pulse 90 and respiration
28. He had a severe chill lasting twenty minutes. Leucocyte count,
33.000. Lumbar puncture : 55 c.c. were obtained. Fluid clear.
Spreads negative. Culture negative. Late in the evening the pa-
tient had another chill. The temperature rose to 107.2°, pulse 124,
respiration 28. Sponge bath reduced the temperature to 105.8°.
Packings removed. Profuse seropurulent discharge from wound.
Packings renewed. Cultures from pus of orbit, ethmoid, and nose :
Pneumococeus. Culture from pus of frontal sinus: Xo growth.
April 1 : Involuntary urination and defecation. Temperature
106.2°, pulse 96, respiration 34. Patient in deep coma. Ophthal-
moscopic examination : Decided redness of left disc and considerable
dilatation of retinal veins. In view of the negative character of the