of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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used wrapped in tarletan so as to intercept the secondary rays.
The rays to be used are the gamma and beta rays; bromide and
sulphate of radium are to be used. The ultra-penetrating rays
are those needed for treatment; with a composite ray the eflFects
would not be sufficient, or radium dermatitis might be produced.
In cases of ovarian and annexial disease operation should not
be considered the only resource; the radium rays should first be
tried; they are perfectly harmless and often very effective.
Fibromata of small size, and all cases of uterine sclerosis should
be submitted to the radium treatment before operation. Only
when this means has failed should a surgical operation be under-
taken. In fibromata that have not decreased after an early
menopause, and that are giving troublesome symptoms, oper-
ation is justifiable. The treatment is easy, harmless, and effi-
cacious when properly applied, and is characterized by rapid
amelioration of symptoms. It may be applied in working
women who cannot be put to bed or give their time to operations.

New Method of Treatment of Metrorrhagia. — Maurice Pollosson
{Lyon med,, Dec. 19, 1909) advocates the use of a compression
forceps in obstinate cases of metrorrhagia, the pressure causing
a clotting within the uterus, by the closure of the cervical canal,
which soon stops the bleeding. For this purpose he has devised
a forceps which is elastic and holds the cervix firmly. Each
blade terminates in two hooked points which grasp the cervix.
This may be applied with a round or valvular speculum in place,
or without either of these instruments. It may be allowed to
remain in place up to forty-eight hours without doing harm.
Another instrument that may be used is a sort of uterine clamp
forceps. The author gives histories of two cases treated by
himself, one of fibroid of the uterus, in which the pressure gave
no pain and the hemorrhage ceased, the forceps remaining
in place three days. Another was a case of excessive hemorrhage
at a menstrual period. There was no return of hemorrhage at
the next period, the amount of flow being normal. Ten other
cases are recorded. Most of these cases were fibroid tumors.
No pain was caused. The patient remains quietly in bed while
the forceps are in place. No reflux of blood into the peritoneum,
uterine colic, septic infection, or any disagreeable symptom
occurred. The procedure is not applicable to puerperal hemor-
rhages. In most cases it can be only a temporary measure
preceding operation, but in a few it gives a permanent cure.

Electric and x-ray Treatment of Fibromata and Uterine
Hemorrhages. Ovarian Atrophy. — ^Foveau de Courcelles (Gaz,
de gyn,, Jan. 15, 1910) says that starting with the idea that the
x-ray acts on cancers and that some fibromata develop into
malignant tumors, he applied the x-ray to such patients when
operation was refused. His results were regression of the tumors
and suppression of hemorrhage. In one hundred cases treated



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972 BRIEF OF CURRENT LITERATCRE.

with ^-ray and electricity he obtained improvement, for the
most part with early menopause. He prefers radiotherapy to
electrical treatment because it is painless, active, hemostatic,
and acts through the clothes, although with feeble intensity.
By the use of the %-ray we may obtain a cessation of the men-
strual flow, and diminution of the pain of myoma at the same
time that the hemorrhage is stopped, and may also combat
the hemorrhages that accompany the menopause. In all sorts
of menstrual troubles radiotherapy is useful, and sometimes
it causes sterility at the same time. This is more easily ac-
complished in women about the menopause, while in younger
women it is less successful. In young tmmarried women the
x-ray should be used with great caution for the relief of menstrual
difficulties.

Metastatic Oophoro-salpingitis. — J. Okinczyc (Ann. de gyn.
et <r Obst., Jan., 1910) says that there are several way^ in which
infection may reach the ovary and tube; by ascending the canal,
in primary metritis; by contiguity from the peritoneum, intes-
tine or appendix; by the lymphatics, and by descending infection
from the blood. Bacteriological examination of the diseased
ovary is of little value. Long after the disease sterility acquired
from infection may show itself as a result of secondary infection
from the uterus or intestine, communicated by adhesions.
We must generally accept as the origin of the condition an
isolated, primary oophoritis, unilateral, and either parenchy-
matous or follicular, the mucosa remaining normal. The
rupture of follicle, causing small hemorrhages gives a soil that is
favorable for the growth of germs communicated from a general
septicemia. Such a septicemia has. been known to cause oopho-
ritis in many of the infectious diseases. Those mentioned in
this r61e are scarlatina, measles, small-pox, mumps, tonsillitis,
typhoid fever, pneumonia, influenza, rheumatism, and other
infections. Of chronic infections causing it, tuberculosis and
syphilis are the chief. During the course of one of these diseases
an attack of severe pain occurs in the ovarian region, and a more
or less severe localized peritonitis follows. In the cases of pure
salpingitis the infection comes by ascent from the uterus or by
the lymphatics in the course of acute diseases.

Peritonitis by Rupture of Pyosalpinx. — Lamouroux (Arch,
gin, de Chir,, Jan., 1910) discusses the occurrence of peritonitis
following the rupture of pyosalpinx. The pus generally collects
slowly, the walls meanwhile becoming thickened and sclerotic.
They may be stretched almost indefinitely; but if they are
pulled upon, as happens after confinement, by the contraction
and involution of the uterus, they are very frequently torn,
the result being a sudden attack of generalized peritonitis which
is rapidly fatal. Lawson Tait said that 50 per cent, of women
who have salpingitis are menaced with sudden death from perit-
onitis on account of sexual excesses, fatigue, and sudden
efforts. Out of eighty-seven observations collected by the



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BRIEF OF CURRENT LITERATURE. 973

author, forty-seven were operated on by laparotomy, of whom
twenty-seven were cured. All the patients treated without
operation died. The pulling down of the uterus during gyneco-
logical treatment or operation may cause rupture. After
labor rupture occurs, but rarely during pregnancy or labor.
The tubal rupture occurs on the peritoneal surface of the tube;
sometimes it is a fissure, at others the perforation is very small;
again it may be irregular as if a slough has formed. The per-
foration is generally single. The rupture is so small, the amount
of pus so small, the location such that it is unlikely to be the
result of bursting from pressure. The immediate cause is
generally some slight exertion. The important consideration
is the alteration in the wall of the tube; it may be ulcerated or a
small abscess may form in the wall. A tube with chronic
infection, which has been increasing slowly in size, may become
suddenly acutely infected and rapidly become distended.
Labor may reawaken a salpingitis that has been quiescent.
Massage of the uterus or abdomen is dangerous in such cases.
The symptoms are those of a sudden general peritonitis; pain,
vomiting, profound intoxication, algidity, and early death if
operation is not performed. To wait destroys all chance of life
for the patient.

Displacements of the Ovaries. — C. H. Stratz (Zeit. /. Geburts,
u, Gyn., Bd. Ixv, H. 3) finds that the cause of displacement of
the ovary in various directions is a predisposition from ab-
normal length of the ligaments and weakness and the extra-
ligamental position of the ovary. The immediate causes are
mechanical insults, trauma, changes in the topography of the
neighboring organs, overfilling and long distention of the bladder
and rectum. The interruption of the circulation from displace-
ment causes edema of the organs and often hemorrhage into them.
The author gives histories of five cases observed by him. Sec-
ondary inflammation takes place. There is a congenital
shortening of the upper ligaments, or lengthening of the liga-
mentum proprii ovarii ^ and the ligamentum suspensorium. The
ovary may be displaced downward, forward, or upward. De-
scent is most frequently seen. The clinical symptoms generally
come on acutely with pain, changes in menstruation, and signs
of peritoneal irritation, such as nausea, vomiting, and flatulence.
The diagnosis may be made by bimanual examination, which
shows that the ovaries are absent from their normal situation,
and present in another location. The pain usually occurs in
the premenstrual period, is located especially on one or the other
side, and is followed by swelling of the ovary. Treatment
consists of rest in bed, ice to the abdomen, and sedatives in the
acute stage; later, bimanual reposition.

Ovarian Endothelioma. — Piera Ligabue (// Policlinico, Jan.
I, 19 10) says that endotheliomata are somewhat poorly known
among malignant tumors, not having been thoroughly studied .
They may occur in any of the organs that are affected usually by



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974 BRIEF OF CURRENT LITERATURE.

malignant tumors. They greatly resemble alveolar and fibrous
sarcomata, and may be mistaken for them. The author details
a case of endothelioma of the ovary the size of a child's head
operated upon by him. Examination of the removed tumor
showed that it was composed of fibrous tissue passing into a
cellular tissue; the lymphatic spaces were filled with large cells
of the appearance of endothelium, appearing sometimes singly,
sometimes in small groups, always situated near the periphery
of the growth; in other parts the stroma had a reticular aspect,
within which were found epithelioid cells arranged in columns
and chains. In some parts the cellular elements were much
developed, so as to compress the connective tissue stroma.
There was also a cystic zone with membranous walls. These
tumors vary very greatly in their composition and formation in
diflFerent parts. This tumor had probably developed from a
fibroma of the ovary, which had arisen from the lymphatic spaces
of the connective tissue. We cannot estimate the value of hered-
ity in these tumors. They have been found at all periods from
infancy to old age. They are most frequent between the ages
of forty and fifty. There is nothing in their structure that will
cause menorrhagia or metrorrhagia. Ascites, pain, and edema
of the legs may or may not be present. These tumors are rarely
bilateral. They may be extensively adherent to other organs.
Their capacity for metastasis is limited. The development
may be slow or rapid. Precise diagnosis before operation is
impossible. The prognosis is bad, removal being the only
treatment possible.

Treatment of Cancer of the Cervix Uteri by Abdominal Hys-
terectomy and Pelvic Removal. — Victor Pauchet (Arch. prov.
de chir., Jan., 19 lo) says that cancer of the cervix may be evacu-
ated by abdomino- vaginal colpo-hysterectomy. In this case the
preparation takes eight days; injection of peroxide of hydrogen;
touching with iodine; fruit diet; intestinal lavage; the night
before operation, curetting away of the cancerous masses and
tamponage with iodine, followed by fulguration. The operation
consists of a circular incision about the vulva with dissection
of the vagina upward for four or five centimeters, and closure of
the vagina like a purse. The abdominal procedure consists of a
median laparotomy, ligation of the ovarian vessels, round lig-
aments, hypogastric vessels, retrovesical and prerectal section
of the peritoneum, and extirpation in mass of the uterus and
vagina, followed by removal of the glands. This method gives
excellent immediate and remote results. Its only inconvenience
is the possible tearing of the lymphatic vessels filled with cancer
cells and the inoculation of the wound with them. On account of
slowness of the operation the author advocates confining the
operation to the abdominal route, cutting off the vagina three or
four centimeters down from the cervix. The operation includes
incision of the abdominal wall, liberation of uterus and adnexa,
ligation of round ligaments and ovarian vessels, and of the



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BRIEF OF CURRENT LITERATURE. 975

hypogastrics, the ganglionic masses being crowded back, incision
of the anterior and posterior culs-de-sac, incision of the vagina,
vaginal drainage, and closure of the pelvic basin. Cystoscopy
aids in making a prognosis, for an abnormal vascularization
or a folding of the vesical walls indicates adhesions.

The Adipose-Genital Hypophyseal Syndrome. — P. E. Launois
and M. Cleret (Gaz, des hdp,, Jan. i8, 1910) say that in the
adiposo-genital syndrome which accompanies lesions of the
hypophysis there are three general elements; the first is gen-
eralized adiposity, superficial as well as deep. The fat accumu-
lates on the surface, the thorax and abdomen are pendulous,
the thighs are immense, the breasts great pendulous masses, the
pubis is immensely enlarged, and there are deep purplish sulci
through the fatty masses. The youth is pot-bellied like the
child; internally the omentum and mesenteries are filled with
fatty masses. Genital dystrophy is the next symptom; in boys
there is testicular atrophy, and the small genitals are lost in the
masses of fat; the breasts are large in size. In young girls
menstruation is established late and remains irregular. In the
adult woman the menses are irregular and end early in life.
Frigidity is present in both male and female. The third factor
is the tumor of the hypophysis; symptoms which render it prob-
able are those of a cerebral tumor, including pressure symptoms;
headache, vertigo, cerebral vomiting, loss of memory, torpor
of intellect, contractures, trismus, and optic neuritis. Psychoses,
polyuria, or glycosuria may be present. An jc-ray examination
showing the presence of the tumor verifies the diagnosis.

Cystotomy in the Female. — A. Grand jean (Gaz. de Gyn., Feb.,
1910) says that cystotomy in woman should be made use of
only in cases of chronic cystitis that have resisted all other
forms of treatment; in such cases it may bring about relief of
the painful symptoms, and finally a cure of the difficulty. It is
useful in four forms of cystitis: nervous cystitis allied to hysteria;
tuberculosis of the bladder; chronic infections of the upper
urinary passages; chronic cystitis without infection of the upper
urinary tract. In the first form it is only necessary to convince
the patient that she need not urinate continually. In tuber-
culous cystitis, if early in the disease, there is hope of an ultimate
cure, and it allows of proper application to the bladder. In
incurable cases the relief that it brings is of value. In simple
chronic cystitis without infection of the upper urinary tract cure
is rapid. In infected cases with hypertrophy of the bladder
walls it is of great value. The fistula may be closed easily when
it is no longer useful.

Treatment of Cancer of the Uterus and Vagina with the Ultra-
penetrating rays of Radium. — Henri Charon and Rubens Duval
{Bull, de la soc. d'Obst. de Paris, Dec, 1909) speak with con-
fidence of the clinical results of treatment of cancers of the
uterus and vagina by the use of the ultra-penetrating rays of
radium. By its use they obtain a symptomatic cure, and all



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976 BRIEF OF CURRENT LITERATURE.

that is left of the tumor is a small amount of hardened tissue.
The authors publish five cases treated by them, three of uterine^
and two of vaginal cancer. In all these cases all the functional
manifestations of the tumor disappeared so that the patients
considered themselves cured. The neoplasms appeared to have
been destroyed; pain, hemorrhage, and leukorrhea all ceased.
The lessening of pain began a few days after treatment com-
menced, and in about three weeks pain had ceased entirely.
Hemorrhage sometimes increased for forty-eight hours, and then
gradually decreased. There remained neither metrorrhagia
nor menorrhagia. In some cases menstruation continued
because the sclerosis produced by the first application was so
great that the treatment could not be applied to the interior of
the uterus. The inflammatory element of the growth disappears,
ulcerations take on the appearance of healthy wounds, then a new
sclerotic tissue is formed. In the vagina vegetations are
destroyed, sloughs disappear, and healing of ulcers occurs by
sclerosis, new epithelium covering their surface. The examining
finger finds sclerotic masses instead of friable newgrowths.
The cicatrix is thin and supple.

Treatment of Advanced Uterine Cancer. — When uterine cancer
has passed beyond the boundaries of the uterus to such an extent
that palpation can readily show that it has done so, H.J. Boldt
(Jour. Amer. Med, Assn.j 1909, liii, 1883) advises intervention
with a large curet and cautery, unless the vagina is extensively
infiltrated by the growth. All readily breaking-down structure
is rapidly excavated with the spoon. The bleeding is stopped
with an extra large dome-point electrode of a galvanocautery, so
that it can be done more rapidly. To avoid burning the vulva
and the vagina, the writer uses a speculum of metal with a
double hull, cooled by a continuous flow of cold water through
the dividing space. In shape it is like the old style Ferguson
speculum. The burning or charring is done very thoroughly,
so as to leave practically only an outer shell of the uterus. It is
well to cool the cavity which is being charred, by inserting at
intervals, through the speculum, small pieces of cracked ice and
drying the uterine surface before reapplying heat. After the
eschar has separated, it is best to apply tincture of iodine to the
uterine cavity every second day until the organ has contracted,
or to use acetone as advocated by Gellhorn. The cauterization
should be repeated whenever bleeding or signs of softening of
the diseased uterus is observed. The use of vaginal douches
should be prohibited. The pain that is caused by pressure of the
tumor on nerves must be combated with narcotics. Of these,
opium and its alkaloids are the only ones that give entire satis-
faction.

W. B. Chase (same) advocates the use of the thermocautery
as palliative treatment of inoperable cases. He protects the
vaginal surfaces from the injurious heat of the cautery by the use
of strips of asbestos paper of proper size and shape. Where large



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BRIEF OF CURRENT LITERATURE. 977

areas of ulceration are present the curet may first be used to
advantage. This is likely to result in pretty active hemorrhage.
This bleeding is usually easily controlled by the application of
pledgets of cotton applied with pressure, first dipped in dilute
acetic acid, usually of half strength, or by the use of the adrenalin
chloride. After this, the cautery knife is to be applied at a dull
red heat until the surfaces are thoroughly charred. The after-
dressing consists of 5 per cent, iodoform gauze, reapplied daily,
after cleaning the parts with liquor cresolis compositus or
permanganate solution douches. Daily vaginal douches with
permanganate of potassium or compound solution of cresol are
the best antiseptics.

Cancer of the Female Breast. — ^J. N. Jackson (Med, Rec.,
Dec. 4, 1909) states that almost without exception the finding
of a tumor in the breast is the first sign that calls the patient's
attention to the existence of disease. Palpation is the most
reliable means of diagnosis. It is essential that the fiat of the
fingers and palm of the palpating hand should be pressed gently
down upon the breast and the tumor tl^us defined between the
hand and the 'un3rielding chest-wall. Though the nodule is
small its stony hardness is characteristic of cancer. Multiple
tumors in the breast speak against malignancy. Early adhesion
to the skin or pectoral fascia. The former may be shown by the
occurrence of slight dimpling of the skin when the breast is
moved on the chest- wall. Minute comparison of the two breasts
is essential. Retraction of the nipple is significant if unilateral.
Enlargement of axillary glands is conclusive only if inflam-
matory affections, tuberculosis, etc., are excluded. The liter-
ature reviewed shows that at least 90 to 95 per cent, of all
tumors of the breast are malignant and no possible intelligence
can determine which of the remaining lo per cent, will remain
benign. There is no known cure for any tumor of the breast,
benign or malignant, except through surgical removal. From
25 to 50 per cent, of cases of breast cancer are permanently
cured by radical surgical removal. With early diagnosis this
percentage could be raised to 80 per cent. Every tumor of the
breast, therefore, should be considered malignant and treated as
such at the very first moment of its detection, tmless incision has
proven it benign, in which instance local excision should at least
be insisted upon. To trifle with tumors of the breast is practically
nothing short of criminal.



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DEPARTMENT OF PEDIATRICS.



ORIGINAL COMMUNICATIONS.



THE ROLE OF WALDEYER'S LYMPHATIC CHAIN IN
THE ECONOMY OF HEALTH AND THE DISSEMI-
NATION OF DISEASE.*

BY

CLAUDE G. CRANE, M. D.,

Associate Laryngologist to Brooklyn Hospital; Assistant Surgeon, Far Department,
Brooklyn Eye and Ear Hospital, etc.

The lymphoid tissue found in the throat and known as the
faucial, lingual, and pharyngeal tonsils, presents a large field
for study and original research work. The literature of the last
few years has been well supplied with much in the way of original
investigation, and the unusual activity in this field affords ample
evidence that the problems here presented have not been solved
to the satisfaction of most scientific investigators. The views
of some writers as based on original work are quite extreme and
their deductions not always logical, while others seem willing to
accept some things on very little evidence. On the other hand,
those writers who discredit whatever evidence they are not able,
or at least do not, disprove, seem to be equally in error. When
one reviews the literature he finds such a diversity of opinion that
he must of necessity make his own deductions and in conformity
with his own particular clinical experience or investigation.

I shall not attempt a review of the literature of the subject,
as that would not be possible in the time allotted to the reading
of the paper, but will briefly touch upon the main points of
interest involved in a large subject.

A brief reference to the anatomy of that part of the lymphatic
system concerned will make clear the reason for some of the
statements to be made later on.

The tonsils, faucial, lingual and pharyngeal, are composed of
lymphoid or adenoid tissue, and differ in no respect from lymph-
* Read before the Brooklyn Pathological Society, May 12, 1910.

978



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crane: role of waldeyer's lymphatic chain. 979

oid tissue found elsewhere in the body. Without going into
the details of their histological structure, it is sufficient to state
that the tonsils are composed of lymphoid tissue supported by
a connective- tissue framework or trabeculae or reticulum. The
pharyngeal lymphoid mass drains into the lymphatic glands of
the superficial group; the faucial into the anterior superficial group
below the angle of the inferior maxillary bone, and the lingual
into the same group. Besides these three distinct groups of
lymphoid tissue, the nasopharynx, pharynx, and fauces are well
supplied with lymph nodules and a network of lymphatics.
These all drain into their respective group of cervical lymph
glands.

The superficial cervical glands drain into the deep cervical
glands, and extending downward drain into the supraclavicular
glands. A connection has been established between, the lower
group and those of the pulmonary pleura, as well as between the
former group and the mediastinal glands. The mediastinal
glands connect with the visceral and parietal lymphatic glands
of the lungs. Thus we see that there is a direct lymphatic con-
nection between the lymphoid tissue in the throat, composing
Waldeyer's ring, and the lungs.

It is, of course, an anatomical fact that all of the foregoing
groups drain respectively into the thoracic duct on the left side,
and the right lymphatic duct on the right side. Thus we see estab-
lished a direct connection with the general circulation of the body.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 100 of 109)