of Rhodes. Spurious works Andronicus.

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of ruptured tubal pregnancy is made is harmful. In many in-
stances an experienced surgeon is not obtainable and the opera-
tion is done in an imperfect manner, and in many in which opera-
tion is done immediately the surgical shock added to that of
rupture is fatal. If there are signs of improvement in the
patient's condition, which he regards as always occurs, Robb
keeps the patient under observation. Improvement is brought
about by carefully stimulating by means of saline infusions under
the breasts and in some by hot saline enemata. If nausea and
vomiting are absent stimulants are given in small quantities
by mouth. Morphia and strychnia are administered, and ex-
ternal heat with elevation of the foot of the bed are employed.
During the period of time employed in thus fitting the patient to
better withstand operation he is prepared to operate at any time
improvement stops. Simpson follows much the same plan as
does Krug. Robb, by experiments on dogs, found the utero-
ovarian vessels could be severed and the consequent hemorrhage
did not prove fatal. In advanced cases of ectopic pregnancy,
even when the fetus is living, the long-abandoned practice of
removal of the placenta at the time of operation has been adopted



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bovee: gynecology and obstetrics in the united states. 27

by several expert abdominal surgeons, notably Werder(44).
It is probable that the refined technic and great skill of many
g)mecologists will bring about the popularization of this plan.
While treatment of the placenta in such cases has always been
the bite noir in operating for this condition there seems to be no
reason why the alarming hemorrhages incident to this procedure
cannot be prevented by careful control of the blood supplying
vessels. I

Pubiotomy, — ^The status of pubiotomy in America is not a
stable one. Fry(45) collected twenty cases done in this country,
twelve primary and eight secondary, with a mortality of four — all
secondary operations. Seven of the twenty were done by J. Whit-
ridge Williams, who, the following year in an exhaustive paper
read at a meeting of the American Gynecological Society (46),
attempted to prove pubiotomy was a] justifiable operation.
His arguments were based upon his thirteen operations, in which
the maternal mortality was nU and the fetal three, only one of
which could fairly be attributed to the operation. He says the
maternal mortality should be less than 2 per cent., and that the
result depends much on the employed technic. He thinks
it is indicated in contracted pelves in which the conjugata vera
does not fall below 7 cm., and after a test of several hours in the
second stage of labor has shown that the disproportion between
the head and the pelvis cannot be overcome, as well as certain
cases of outlet contraction. It should replace high forceps,
prophylactic version, induction of labor, and craniotomy upon the
living child in uninfected women. Fry, in discussing this paper,
condemned the operation because of its more than 50 per cent,
morbidity. Norris favored the operation, defending it similarly
to Williams, but defended induced labor. Grandin prefers
Cesarean section and induced labor. Hirst predicts pubiotomy
will not stand the test of time. Lewis(47) condemns the opera-
tion and states his opinion that the indications for pubiotomy
and symphysiotomy will become steadily narrower as time goes
on. It^would therefore appear that in this country, in spite of
the able defense of Williams and Norris, the popularity of the
operation will be of but short duration.

The\Trealment of Placenta Previa. — Newell(48) believes the
older methods promptly applied should give practically no
maternal mortality in complete placenta previa, and that the
fetal mortality of 60 to 65 per cent, will scarcely be lowered by
either vaginal or abdominal Cesarean section. He refers to the



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28 bovee: gynecology and obstetrics in the united states.

advocacy of abdominal Cesarean section by skilled abdominal
surgeons but not by skilled obstetricians. Grandin(49) limits
abdominal Cesarean section to cases in which the fetus is
visable, the mother in splendid condition, the cervix rigid or cica-
tricial, or dystocia, due either to fetus or pelvis present. Jewett's
paper read at the same meeting of the American Gynecological
Society as the two above quoted endorsed the position taken by
Newell and Grandin. Fry, also, at the same meeting made an
earnest plea for the obstetrical treatment of placenta previa.
H. A. Miller, (50) of Pittsburg, ligated the uterine arteries for
placenta previa in eleven cases. Two died from delivering
without waiting until shock had been combated. He claims it
eflfectually controls hemorrhage from the placental site, but
admits the fetal mortality is likely to be increased by early
cutting oS its blood supply.

Glycosuria in Pregnant Women, — ^J. Whitridge Williams, (51)
with the title of ** The Clinical Significance of Glycosuria in Preg-
nant Women," has recorded his personal experience with this com-
plication of pregnancy. In the urinary records of 3,000 ob-
stetric patients he found sugar was demonstrated by the Fehling
solution test in 167 during pregnancy, labor, and the puerperium.
During pregnancy there were twenty-four; during the puerperium,
137 cases, and in both, six cases. He does not regard theFeh-
ling's solution test as sufficient as the glycosuria, may be due to
the presence of lactose which is harmless; if to glucose the prog-
nosis may or may not be bad. Williams advises the use of the
fermentation test to differentiate between the two conditions.
The lactosuria he regards as being harmless. He states we must
not disregard the fact that diabetes may begin in the pregnant
women, and that a diabetic woman may become pregnant.
Transient, alimentary glycosuria may occur. After isolating
the glucose the variety must be determined. If alimentary, it
may be regarded with impunity. If it occurs late in pregnancy
and does not exceed 2 per cent, in amount and is not accompanied
by symptoms, it is probably transient and may disappear at any
time or persist until the end of pregnancy; in either event being
of little moment. If sugar occurs early in pregnancy and in
large amounts it is a dangerous condition. Pregnancy occurring
during diabetes or vice versa is a serious complication. If the out-
put of sugar is large and not controllable, induced abortion or
labor is positively indicated even in the absence of symptoms.

Perforative Appendicitis Complicating Pregnancy. — Appendici-



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bovee: gynecology and obstetrics in the united states. 29

tis complicating pregnancy has been a subject carefully consid-
ered in America, where the surgical treatment of that disease is in
vogue. Babler's paper(52) is a good presentation of the sub-
ject from the obstetrical standpoint. He reports a collection
of 103 cases of perforative appendicitis complicating pregnancy.
The etiology of the disorder in pregnancy does not differ from
that in nonpregnant patients. Three-fourths of the cases de-
velop after the third month of pregnancy. Perforation oc-
curred in 44.6 per cent, of cases. Portal infection rarely follows.
The uterus may become infected through the peritoneum,
through the lymph and blood-vessels, or through adhesions from
the abscess wall to the pelvic organs. In many cases the preg-
nant uterus forms a part of the abscess wall. Rupture of the
abscess follows contraction of the uterus and expulsion of the
fetus. In some cases abscess of the appendix may form an
obstacle to delivery. Diagnosis is usually made without diffi-
culty, although in some cases ruptured tubal gestation may be
confused with appendicitis. When perforation occurs, the
mother's mortality averages 48.5 per cent., the fetal mortality
66 per cent. In the 103 perforative cases collected, operation
was performed in eighty-nine, followed by abortion in thirty-
seven; thirty-six mothers died. There were fourteen perforative
cases treated medically, all of which died; ten of these aborted,
and in ten the child died in utero, making a maternal mortality
of 100 per cent, and an infant mortality of 75 per cent. Of the
104 nonperforative cases, fifty were operated upon, seven
aborted, one mother died. Of the fifty-four not operated upon,
six aborted, four mothers died. During the first ten days of the
puerperal period twenty-eight cases of appendicitis were col-
lected, of which eighteen were perforative; twelve of these
women were operated upon, with a mortality of 33.3 per cent.;
two of the six not operated upon recovered by accident : the pus
burrowed into the rectum. Nine cases were nonperforative,
all of which recovered, whether treated by operation or not.

So far as treatment is concerned, these statistics strikingly
emphasize the fact that operation offers the only hope of success.
Operation must be done as early as possible. With perforation
and localized abscess, incision and free dranage are indicated.
If possible, the uterus should not be emptied before the opera-
tion, lest the diminution in its size rupture the wall of the ab-
scess, causing pus to enter the general peritoneal cavity. If the
patient has general peritonitis, incision and drainage, without



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30 bovee: gynecology and obstetrics in the united states.

disturbing the pregnancy, are indicated in early gestation.
When the patient is near them the operator must decide be-
tween Cesarean section or forcible extraction of the child followed
by adbominal incision and drainage. The treatment of sup-
purative peritonitis is indicated in a general way.

Toxemids of Pregnancy. — I would not be treating justly the
obstetricians of America were I to not mention here their great
and enthusiastic pursuit of knowledge of the toxemias of preg-
nancy. Williams has devoted much time and study to this sub-
ject. In reference to serious vomiting of pregnancy he classifies
it into I, reflex; 2, neurotic, and 3, toxemic. In the first the con-
dition is apparently associated with some distinct abnormality
of the generative tract, such as the existence of a retroflexed
pregnant uterus or an ovarian tumor, and is promptly relieved
by proper treatment. In the neurotic group the vomiting is a
manifestation of a neurosis, somewhat allied to hysteria, and can
be cured by suggestion, provided it is properly applied by one
who is confident of his premises. The toxemic variety, on the
other hand, is the most serious disease and is a manifestation of
a profound disturbance of metabolism. In cases which go to
autopsy profound lesions of the liver are noted, analogous to
those observed in acute yellow atrophy. In this Williams is well
supported by Norris, Welch, and others. The ammonia coeflS-
cient of the urine is found to be greatly increased from the nor-
mal 3 to 5 per cent, up to such enormous outputs as from 30 to
46 per cent. Albumin and casts are not present until the termi-
nal stages. Williams believes this increase in the ammonia
coefl5cient affords a most valuable means of differentiation be-
tween the toxic and other varieties, and that the liver changes
are not primary; but the result of a profound disturbance in
metabolism concerning the origin of which we are ignorant. For
three years he has been studjring metabolism with a view to dis-
covering the nature of these changes. Davis, Edsall, and Hirst
are inclined to doubt the correctness of Williams' deductions.
Nevertheless, they are growing in favor.

BIBLIOGRAPHY.

1. Ann, Gyn, and Ped,, 1907, xx, 488.

2. Gyn. Trans., 1909.

3. /. Am. Med. Assoc, 1908, 1, 595.

4. Amer. Jour. Obst., 1908, Ivii, 527.

5. Surg. Gyn. and Obst., 1908, vii, 7.

6. Amer. Jour. Obst., 1906, liv, 131.



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bovee: gynecology and obstetrics in the united states. 31

7. Amer. Jour. Obst., 1908, Ivii, 633.

8. Surg. Gyn. and ObsL, 1908, vi, 153.

9. Amer. Jour. Obst., 1908, Iviii, 87.

0. /. Am, Med. Assoc, 1908, 1, 107.

1. /. Am, Med, Assoc., 1908, li, 1395.

2. /. Am. Med, Assoc., 1908, li, 132 1.

3. Gyn. Trans., 1897, xxii, 289.

4. Surg. Gyn, and Obst,, 1909, viii, 479.

5. /. Am, Med. Assoc., 1907, xlix, 1507.

6. J, Am, Med. Assoc, 1906, xlvii, 1605.

7. Gyn. Trans., 1909.

8. /. Am, Med, Assoc, 1907, xlix, 1982.

9. J. Am. Med, Assoc, 1907, xlix, 1984.

20. Amer. Jour. Obst., 1908, Iviii, 242.

21. Surg. Gyn, and Obst., 1909, viii, 569.

22. Surg. Gyn. and Obst., 1908, vi, 667.

23. Surg. Gyn. and Obst., 1909, viii, 505.

24. Surg, Gyn. and Obst., 1909, viii, 574.

25. Surg, Gyn, and Obst., 1909, viii, 576.

26. Trans. S. Surg, and Gyn. Assoc., 1906, xix, 122.

27. /. Am, Med. Assoc, 1908, li, 834.

28. Amer. Jour. Obst., 1907, Ivi, 630.

29. Amer. Jour. Obst., 1907, Ivi, 636.

30. Amer. Jour. Obst., 1909, Ix, 78.

31. Surg. Gyn, and Obst., 1907, v, 153.

32. Surg. Gyn. and ObsL, 1908, vii, i.

33. Amer. Jour. Obst., 1909, Ix, 23.

34. Amer. Jour. Obst., 1908, Iviii, 305.

35. Am. J, Med. Set., 1908, cxxxvi, 532.

36. Gyn. Trans., 1907, xxxii, 43.

37. Gyn. Trans., 1907, xxxii, 82.

38. Surg. Gyn, and Obst., 1909, viii, 619.

39. Surg, Gyn, and Obst., 1908, vii, 45.

40. Johns Hopkins Hosp. Bull., 1904, 162.

41. Trans. S. Surg, and Gyn. Assoc., 1906, xix, 237.

42. Surg, Gyn, and Obst., 1908, vi, 460.

43. Surg, Gyn. and Obst., 1908, vii, 456.

44. Amer. Jour. Obst., 1908, Iviii, 796.

45. Surg. Gyn, and Obst., 1907, v, 156.

46. Gyn. Trans., 1908, xxxiii, 336.

47. Surg. Gyn, and Obst., 1908, vi, 191.

48. Surg, Gyn, and Obst., 1909, viii, 468.

49. Surg. Gyn. and Obst., 1909, viii, 529.

50. /Iw./. Si*f^., January, 1909.

51. Am. J, Med. Set., 1909, cxxxvii, i.

52. /. Am. Med. Assoc, 1908, li, 13 10.



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32 goodall: climacteric hemorrhages.



CLIMACTERIC HEMORRHAGES.*

BY

JAMES ROBERT GOODALL, B. A., M. D., C. M.,

Associate in Gynecology at Royal Victoria Hospital, Montreal; Demonstrator of
Gynecology at McGill University, MontreaL

My subject for this paper has been entitled "Climacteric
Hemorrhages." Loosely taken, it might be thought to include
all the diseases which lead to unnatural hemorrhages at the
time when menopause might be expected. Strictly speaking, it
applies only to that disease which makes itself manifest at the
climacterium and is known under the varied nomenclature of
chronic metritis, fibrosis uteri, fibroid uterus, hypertrophied
uterus, hemorrhagia myopathica, etc., etc.

It is with the subject in this restricted sense that I wish to deal
to-night. It is one that has interested me for years, one upon
which I have spent a few years of research in the hope of event-
ually finding a truly scientific and plausible explanation for its
obscure etiology and symptomatology. It is to this that most
of my paper will necessarily be devoted, and I trust, Mr. President
and gentlemen, that you will pardon me, if at times portions
of my paper may take on something of the nature of the didactic.

There is probably no disease in gynecology that is so little
understood, both by general practitioner and gynecologist,
as that of chronic metritis. The reason perhaps lies in the fact
that clinically it is difficult of diagnosis and that many text-books
omit it completely. In the first five recent text-books that came
to hand a few days ago three made no reference to it whatever,
one but a short note, and the fifth dealt with the subject at some
length. From this it must not be inferred that the disease is an
uncommon one; on the contrary, it is in my opinion the most
common cause of intractable hemorrhage at menopause, not even
excepting cancer. Last Monday four such cases came under my
notice at the out-patient department of the Royal Victoria
Hospital.

Let me begin by asking the question, What is chronic
metritis? It is a disease of the uterus that makes itself manifest
at the time when menopause should set in; hence it begins usually
between the ages of thirty-five and forty-five years. It is

♦Read before the Medico-Chirurgical Society, November 5, 1909.



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GOOD all: clii£ACteric hemorrhages. 33

characterized by but one pronounced symptom — ^hemorrhage —
excessive, often jeopardizing the life of the patient, and intract-
able to all therapeutic measures. It occurs in parous woman and
on physical examination the characteristic signs are an enlarged >
indurated uterus.

Before taking up the subject in detail, I would like to pass in
short review the views of previous authors. In this way a better
grasp of the salient points of the disease and of the details which
have been the cause of so many different tenets will be afforded.
The first scientific work to appear upon chronic metritis was the
monograph by Scanzoni(i) in i860. Scanzoni contended that
the disease was always secondary to acute infection. Hence he
recognizes two stages in the progress of the pathological process,
namely, the infiltrated, soft, edematous stage and the indurative
stage. The first is a necessary antecedent of the second. I
cannot better compare his views than by saying that his stages
are like those in acute and chronic inflammation of all other
organs. He himself compares the process with hypertrophic
and atrophic cirrhosis of the liver. In 1867 Seifert(2) and later
his pupils called the writings of Scanzoni into question and
contended that subinvolution of the uterus is the chief factor
in the production of chronic metritis. Writers up to this time
had drawn their conclusions from naked-eye examinations of
their specimens, but in 1868 the microscope, though with low
magnifying powers, began to be widely used. The chief subject
of debate during the next few years was what tissue was re-
sponsible for the considerable hypertrophy of the uterine wall as
found in chronic metritis. Finn (3) and later von KIlebs(4) found
that the size was due chiefly to muscular hypertrophy. Birsch-
Hirschfeld,(5) on the other hand, contended that it was due to a
marked hyperplasia and h)rpertrophy of both muscle and con-
nective tissue. Of course there was still another view possible,
that the enlargement was a true fibrosis, and it was not long
before strong advocates were found in von KIlob,(6) Kiwisch,(7)
and Virchow.(8)

In 1870 01shausen(9) began to show the great therapeutic value
of the curette in cases of menorrhagia and metrorrhagia, and with
it began the careful microscopical examination of the endo-
metrium obtained by this means. The result was that the interest
of the gynecological world was centered upon the endometrium,
and its pathological changes were held responsible for all un-
natural hemorrhages.
3



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34 goodall: climacteric hemorrhages.

The pendulum had to seek its level, and in 1888, just twenty-
years after the last work, Comil(io) laid stress upon the fact that
there were cases that resisted the curette, hemorrhage continues
in spite of all treatment, and that in such cases he found the
arteries of the uterus sclerosed and there was a true fibrosis of the
uterine wall. Ten years later the most scientific paper published
up to that time appeared from the pen of Reinicke, in which he
points out for the first time that there is a primary chronic
metritis characterized by fibrosis of the uterine wall without any
signs of inflammation either in the uterine wall or in the endo-
metrium.

And so the polemic has gone on to the present day. In the
last three years a revival of interest has taken place without,
however, being productive of much elucidation.

Let me now take up at some length the pathology of chronic
metritis, together with its etiology. In a paper by Dr. Gardner
and myself, (11) read before the British Medical Association, we
divided cases of chronic metritis into two distinct classes:
First, simple, or uncomplicated chronic metritis, and, second,
complicated chronic metritis.

To this division I would strictly adhere as it offers great
advantages both clinically and pathologically.

In simple uncomplicated metritis, the uterus is symmetrically
enlarged and indurated, but the uterus is the only pelvic organ
appreciably affected, whereas in complicated metritis various
associated lesions of the adnexa, parametrium, and perimetrium
coexist with the metritis, and in all likelihood have sprung from
the same causal agent.

If we now examine uteri excised for uncontrollable hemorrhage
at menopause, we find that the organ has retained its normal
outline but is considerably larger than normal. The degree of
enlargement is very variable, but is always above the normal
size. The largest specimen that has come under my notice
measured four inches in depth, three and three-eighths in breadth,
and two and three-quarter inches in thickness. In simple cases
the peritoneal surface is normal. The cervix is usually propor-
tionately enlarged and usually contains many Nabothian cy^ts.
The body is more globular than normal owing to the great
thickness anteroposteriorly. On section, the cut surface is pale,
anemic, and white, shiny strands form a dense network, in the
meshes of which a darker, less shiny tissue is seen. This inter-
lacing of strands of tissue grows more marked as one recedes



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goodall: climacteric hemorbhages. 35

from the peritoneal surface toward the middle third of the uterine
musculature, and they grow proportionately finer. In the outer
third the lighter and darker strands, which we may now
interpret as connective tissue and muscular tissue, respectively,
tend to divide the uterine wall into layers. A thick white band
of tissue is nearly always to be found underlying the whole of
the peritoneal surface of the uterus. The vessels on the cut
surface always project markedly above the surrounding tissues
as if the tissues retracted about them or that the vessels them-
selves were under pressure. The mucosa may be variously
affected, thickened almost to being diffluent, normal, or even
atrophic. The tissues cut with greater difficulty than do those
of the normal uterus.

In complicated cases various lesions of the adnexa and para-
metrium may be added to this pathological picture. In micro-
scopical sections of the uterine wall, extending from mucosa to
peritoneum, and stained with Weigert's elastic stain, followed
by hematoxylin, and then by Van Giesen, we find the elastic
tissue stained black, the muscle yellow, the fibrous tissue red,
and the nuclei purple. In such a section one is struck by the
large amount of elastic tissue that is present. This increase
in elastic tissue is found chiefly in the middle third of the uterine
wall about the large veins and arteries which abound in this
region. But though widespread here, it is by no means limited
to this area. The vessels of the inner third are also surrounded
by a large amount of elastic tissue which by its arrangements
and bizarre shapes about the vessels, seems to serve no definite
purpose. The connective tissue and muscular elements do not
seem to have lost their relatively normal proportions, but the
muscle cells enveloped in such thick meshes of elastic tissue seem
to have departed in variable degrees from their normal healthy
appearance.

Heretofore uteri were not studied carefully with the Weigert
stain for elastic tissue and as a consequence hyaline degeneration
of muscle was a prominent pathological finding in all sections of
chronic metritic cases, the reason being that sections stained with
hematoxylin and eosin or with Van Giesen and hematoxylin
show perivascular and extravascular masses of hyaline substance
stained either pink or yellowish-pink, and sparsely dotted with
nuclei. These have heretofore been invariably interpreted as
hyaline degeneration of muscular tissue. These same sections
if stained with Weigert's elastic tissue stain will show that this



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36 gck)dall: climacteric hemorrhages.

hyaline substance is not hyaline degeneration of muscle, but is
dense elastic tissue.

If we now ask the question, What is the origin of this over-
growth of elastic tissue? we ask the crucial question of this
difl&cult subject. Let me state that the whole subject revolves
about the involution of the puerperal uterus. In my opinion a
woman may have an unlimited number of children and if her
recoveries are complete and involution is rapid she will never
su£Fer from chronic metritis. Chronic metritis finds its one great
etiological factor in subinvolution. So the causative agents in
the production of chronic metritis are numerous. Yes, just as



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