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disturbing forces or factors.

The two-homed utems consists of two bodies with separate
cavities and a single cervix which serves as a drainage canal for



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46 brothers: unicornate and bicornate uterus.

both. In the most marked varieties each uterine body is a com-
plete entity and lies in juxtaposition with its twin half. While
the vagina frequently exhibits a partition, the adnexa are usually
normal. Pregnancy may take place in one or other horn with
no risk to the woman at all, or with risks which are so serious as
to require the most severe forms of operative intervention.
Menstruation also may cause no disturbance of moment as long
as the two uterine cavities drain freely into the single cervix.
In the event of failure in this direction, hematometra, hemato-
salpinx, and peritonitis may cost the life of the patient. Infec-
tion, finally, may develop in one or other of the uteri — usually
in the lesser-developed half — a pyosalpinx and fatal peritonitis.
This is what happened in one of the cases reported in this paper.
In the unicornate uterus — a report of one of which is also in-
cluded in this paper — a second horn may be entirely absent or
be found in a rudimentary condition. In the former case the
corresponding tube, ovary, and round ligament, according to
Kussmaul, are absent or atrophied. In the latter case, like one
reported by Puech and my own case, the tube, ovary, and round
ligament of the undeveloped side were entirely independent of
any connection with the uterus. In Puech 's case they received
their supply of blood from the aorta and returned the blood to
the inferior cava. The histories of my two cases were as follows:

Case I. — Bicornate Uterus. — On January 15, 1909, at the
Beth Israel Hospital, a case was referred to my service which
gave a history strongly suggestive of ectopic gestation. The
patient was a woman who had been pregnant in her married
life, and had passed on to a condition of secondary sterility.
According to her statements, she had suflPered from metrorr-
hagia, cramps, and partial attacks of syncope. Her markedly
anemic appearance made the diagnosis of extrauterine pregnancy
very probable. On the other hand, while her temperature was
normal and pulse only 104 at the time of our examination
(which was made shortly after her admission), the blood examina-
tion showed a high leukocytosis and polynuclear count — the latter
especially striking, viz., 96 per cent. The possibility of suppura-
tion occurred to us, but not forcibly enough to exclude suppurating '
blood clots due to ectopic gestation. This latter diagnosis seemed
to be still further supported by the fact that the blood count showed
oiily 3i50o»ooo red cells and 68 per cent, of hemoglobin.

The physical examination in this woman, who seemed to be
either so dazed or stupid that no really clear history could be
obtained by the house staff, was very unsatisfactory because
of the tense and fat abdominal wall. Still, rigidity and pain
were not unusually pronounced. As there seemed to be nothing



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brothers: unicornate and bicornate uterus. 47

really urgent about the case, we decided to postpone operation
until the following day at the regular operating hour. That
same night, about seven o'clock, a hurry telephone call was sent
to come down to the hospital as the patient was pulseless and
had suddenly gone into a state of collapse. We at once assumed
this to be corroborative evidence of a fresh internal hemorrhage
due to the suspected ectopic gestation. The vagino-abdominal
examination in the morning had revealed nothing beyond a
moderate degree of abdominal tenseness and very little or no
sensitiveness. The second examination showed a single vaginal
canal, a cervix flush with the vaginal roof with a single closed os,
and nothing to indicate a diagnosis of uterine pregnancy. To



Fig. I. — Bicornate uterus. A. Right uterus. B, Left uterus. C Right tube
and ovary. D. Left tubo-ovarian abscess. £. Common cervix and vagina.
F, Round ligaments.

the left of the uterus, however, this examination revealed the
presence of a vague mass. In spite of the woman being in a
collapsed state, we proceeded immediately to operate — still
under the conviction that the case was one of internal hemorrhage
due to ectopic pregnancy.

On opening the abdomen, free thin pus in large quantities
was found everywhere. The intestine, wherever we looked,
seemed to be bared of its peritoneal coat or covered with free
lymph. The intestinal lumen was distended in every coil within
the field of operation. Naturally, the idea of an ectopic preg-
nancy was at once abandoned, and the next plausible explanation
of the case seemed to be a general peritonitis due to perforative
appendicitis. The appendix was sought for and, when found,
showed a reddened inflamed tip. It had to be dug out of adhe-
sions. Rapidly tying off and amputating the appendix, a careful
search was renewed for the original pus focus, for we felt
satisfied that the appendix was not the only, at least not the



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48 brothers: unicornate and bicornate uterus.

principal, factor in the original disturbance. Passing the hand
downward and to the right in the pelvic cavity, the right tube,
ovary, and round ligament felt normal. The uterus seemed to
be normal. As we gently proceeded over to the left side the tube
and ovary seemed to be missing, but in their stead we discovered
a hard globular body. After a few perplexing moments, during
which a number of possibilities were carefully considered, it
suddenly flashed through our minds that we were dealing with a
bicornate uterus and that the hard round body to the left of
the uterus was a second corpus uteri. The sulcus between the
two uterine bodies dipped down at least one inch. Following
the second uterine fundus to the left with the exploring hand, a
large pyosalpinx, the size of a lemon, with its agglutinated,
purulent, and macerated ovary was found passing behind the
left uterus in a horseshoe curve. As we had evidently located
the original pus focus in this pyosalpinx, a radical operation
was decided on and everything was removed in one mass. In
spite of venous saline infusions and the various methods of
stimulation vigorously resorted to, the patient never recovered
her pulse and died during the course of the night.

The case presents a number of points of interest. In the first
place, excepting possibly for the assistance or light derived from
the blood examination, there was no means of discovering that
this was a case of general purulent peritonitis dating back days and
possibly weeks before her admission to the hospital. Secondly,
everything (excepting again the blood examination) seemed
directly to point to a diagnosis of ectopic gestation, even up to
the moment of opening the abdominal cavity. Thirdly, there
must have been an oozing of infectious pus from the pyosalpinx
(the opening being small and sealing itself spontaneously) for
quite some time before her admission. Fourthly, a fresh rupture
— Pleading into the final collapse — seems to have been possibly
brought on by the physical explorations of the pelvis made by
myself and house staflP. A few reflections have. suggested them-
selves to my mind as to the proper course to follow in a similar
case in the future — the chief of which is not to insist on a too
thorough exploration, especially by a number of medical men
at one time. I did a supravaginal amputation of the uterus
instead of the projected pan-hysterectomy because of the fear,
at one time, that I would lose the patient on the table, and I
resorted to the shortest operation with the object of saving,
possibly, ten or fifteen minutes of time. Of course the abdomenal
wound was drained with gauze passed to the depths of the pelvis.

The appended rough sketch gives an idea of the condition
present. Both uterine bodies are distinct and separated by a



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brothers: unicornate and bicornate uterus. 49

deep sulcus. Evidently the right uterus, which is the larger of
the two, was the functionating organ; and, although I have not
the hospital notes at hand, I have quite a clear recollection of
the fact that this woman had born children. The cervix of
this right uterus was the one felt as being flush with the
vaginal roof and apparently drained the menstrual and other dis-
charges from the left uterus. In other words, while there are
two distinct bodies, there is but one cervix, and even that is
short and not fully developed. The pyosalpinx, vastly smaller
than at the time of removal, is seen at the left. The right
adnexa look fairly normal. The infection evidently involved
the left uterus, whence it worked its way up to the left adnexa
and peritoneal cavity.

Case II. — Uterus Unicornis {Right); Rudimentary Cornu
(Left). — Mrs. J. S., set. twenty-six, married two and a half years,
no children, had one miscarriage at three months two years and a
quarter preceding her visit to my office. According to my
notes, she had been sick ever since the miscarriage. No curettage
was done at the time and she left her bed after three days.
Two months later she began to suffer from a pain in the right
side which never left her. She had her periods every three
weeks, but the flow was scanty. She had more or less of a leu-
corrheal discharge. She described the pain as originating in
the right iliac region and radiating upward to the right lumbar
and dorsal regions. Because of the intensity of this pain, sexual
life had to be discontinued.

The examination revealed a sensitive appendix and a mov-
able right kidney. The uterus was quite small and seemed to
be anteflexed and drawn to the right. In the right pelvis also
a distinctly enlarged adnexal mass was felt which was quite
sensitive when touched. She was referred to Beth Israel Hos-
pital for operation.

On January 21, 1909, the patient was put in the lithotomy
position for examination under anesthesia preliminary to opera-
tion. The same conditions were found as before. We had
projected to precede the laparotomy by a curettage, but there
were such unusual difficulties encountered in the attempt to even
pass the sound that we abandoned the attempt after a half -hour's
work. Only once, and then after bending the sound acutely
and passing it up to the right, did we succeed in overcoming the
intracervical obstruction and pass the sound to a depth of
21/2 inches. The fear of perforating the uterus as well as the
knowledge that this feature of the operation was of small signifi-
cance induced us to desist.

A transverse abdominal incision was made, but as it failed
to give convenient working room, a longitudinal incision, start-
ing from the center of the first, was added. The somewhat



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50 brothers: unicornate and bicornate uterus.

enlarged left ovary was felt, but the usual intervening bridge of
Fallopian tube to the uterus was noted as missing. The small
uterus was discovered some distance away toward the right
side of the pelvis. It presented a smooth straight border pass-
ing vertically downward on the left side to the floor of the pelvis.
On the right side the uterus was intimately adherent to a tumor
which lay behind and to the right. The left tube and ovary as
well as the left rudimentary cornu to which this tube was attached
in the normal manner and to which it bore the proper rela-
tionship were separated from the uterus proper by a distance of
at least three inches. A little closer study of the tumor in the
right side showed it to be an ovarian multilocular cyst with a



Fig. 2. — A. Right horn of uterus. B. Left horn of uterus. C Multilocular
cyst. D. Left ovary.

thickened and shortened ovarian ligament. Just below this and
between the folds of the broad ligament a nodule of the size of a
hazelnut was felt. The right Fallopian tube was apparently
normal. The round ligament of this side was located at its
attachment to the lateral border of the uterus and found to
occupy its normal position throughout its intraabdominal
course. While the upper pole of the uterus seemed to be smaller
than usual, it seemed to broaden out lower down and merge below
in a cervix as large as itself. The left border of the uterus was
smooth and rounded and presented a peritoneal coat continuous
all the way down with that of the rest of the organ. At the
upper left angle of the uterus there was not the least vestige of
cornu or Fallopian tube. Following the left border of the uterus
in a downward direction for several inches to the region of the
internal os, a duplicature of peritoneum was discovered which
stretched for three or more inches to the left, like an arched
band with its concavity looking upward, and terminated at
the level of the crest of the ilium in a nodule the size of a hazel-



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RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE. 51

nut, which proved to be the rudimentary horn of this side.
From the left border of this nodule the left Fallopian tube,
normal in size and appearance, passed outward with its associated
ovary which was cystic and the size of a walnut. Below the
left Fallopian tube a fibrous cord (about the thickness of a lead-
pencil) connected the rudimentary cornu with the lateral pelvic
wall. Just below this adventitious ligament the round ligament
was found occupying its normal anatomical situation.

Because of the intimate and close connection with the pelvic
floor and the danger of injuring the left ureter, no attempt was
made to exsect the peritoneal duplicature which connected the
left rudimentary horn and adnexa with the uterus. The left
tube, ovary, and rudimentary cornu were removed en masse
Then the ovarian tumor, on the right side and uterus (including
the cervix were removed also en masse. There was some diffi-
culty in getting into the vagina because of the thickened, club-
shaped, and elongated cervix. It was at this stage of the opera-
tion, while working under abnormal anatomical conditions,
that a lateral injury to the left ureter must have occurred. The
bleeding was of little account as the ovarian and uterine vessels
were easily seen and secured. After closing the opening in the
vagina the peritoneal rents were sewed together across the pelvic
floor and the abdominal wound was brought together by suture
so that the resulting scar resembled an anchor.

The postoperative course was quite unpleasant for a long
time because of the presence of a uretero- vaginal fistula. In
the course of time, however, this healed spontaneously, and the
patient was discharged as cured on March 23, 1909.

112 East Sixty-first Street.



FIBROSIS AS A CAUSE OF PRECLIMACTERIC UTERINE
HEMORRHAGE.*

BY
M. RABINOVITZ, M. D.,

Adjunct Gynecologist Beth Israel Hospital; Attending Gynecologist Gouverneur

Hospital Dispensary.

New York.

(With four illustrations.)

Modern medicine aims toward scientific truth, and until
the absolute is reached, observations, theories, and therapeutic
methods will continue to undergo renewals and modifications.
The writer therefore feels that he owes no apology for bringing
before your consideration so well worn a topic as metrorrhagia
preceding menopause.

In consulting the text-books we find that the causes of uterine
hemorrhage may be subdivided into two main groups:

I. The mediate or remote causes include:

♦Read before the Eastern Medical Society, November 12, 1909.



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52 RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE.

a. Metabolic disturbances — rheumatism, gout, chlorosis,

and obesity.

b. Poisoning — alcoholic, lead, and phosphorous.

c. Syphilis.

d. Organic lesions — heart, lungs, liver, and kidneys.

e. Psychic influences.

/. Acute infectious diseases.
2. The immediate or local causes comprise, in order of fre-
quency:

a. Complications of early or advanced pregnancy or

labor.
6. Various uterine displacements.

c. Endometritis as the result of either inflammatory or

circulatory disturbances.

d. Diseased adnexa.

e. Uterine tumors, either benign or malignant.

There is, however, a class of cases who suffer from either
menorrhagia or metrorrhagia, or from both, whose etiological
factor cannot be found under the headings mentioned. This
condition is encountered in women who have borne several
children, who have also aborted one or more times, who have
reached a period of life between the end of the fourth and
beginning of the fifth decade, who suffer from no metabolic,
poisonous, luetic, organic, or infectious diseases, and in whom a
pelvic examination fails to reveal any distinct palpable lesion;
and yet they are subject to intermittent or continuous uterine
hemorrhage.

These cases very often tax the ingenuity of the best physician
who, after running the gamut of medical means and after having
resorted to repeated curettages, finds to his dismay that the
bleeding remains unchecked; and that, unless a hysterectomy be
resorted to, the patient is not only doomed to chronic invalidism,
but she is also at a risk of finally succumbing to the constant
sapping of her very life.

CASES.

Case No. 917. S. K., age forty-seven. Admitted to Beth
Israel Hospital, February 3, 1909.

Family history negative. Menstruation began at the age of
thirteen, irregular in type, every four to six weeks, moderate in
amount and painless. Married twenty-nine years; has had
eight children and two miscarriages; last child eleven years ago;
last miscarriage, six years ago. Five years ago she began to



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RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE. 53

suffer from menorrhagia and metrorrhagia. Three years ago
was curetted, but the symptoms were not relieved and the
bleeding continued in an irregular form, accompanied by cramp-
like pains in the hypogastrium. For the last year the uterine
bleeding is more frequent and excessive. On admission, patient
looked markedly anemic, poorly nourished, and felt weak.
Vaginal examination showed a somewhat enlarged uterus, with
an hypertrophied cervix. Adnexa felt to be normal. A
tentative diagnosis of malignancy was made, and on February 5,
1909, Dr. L. J. Ladinski performed an abdominal panhysterec-
tomy. The patient made an uneventful recovery, and was
discharged cured fifteen days later.



Fig. I. — Blood-vessels show an increase of connective tissue in the adventitia, an
hypertrophy in the media, and a normal intima.

Pathological Report. — The uterus is about one and one-half
times its normal size, the cervix is hypertrophied and studded
with many Nabothian cysts. Microscopically the endometrium
shows no pathological changes. The myometrium is replaced to
a marked degree by connective tissue, and in some parts the
muscle fibers have undergone a hyaline degeneration. These
areas of hyaline degeneration are situated chiefly around the
blood-vessels which show great thickening of their walls. The
intima shows a slight increase of the endothelial cells.

Case No. 687. R. B., age thirty-seven. Admitted to
Beth Israel Hospital, December 29, 1908.

Family history negative. Menstruation began at the age of



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54 RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE.

twenty, four-weekly in type, moderate in amount and painless.
Married fifteen years, has had seven children and two mis-
carriages. For the last fifteen months the patient is suffering
from excessive uterine hemorrhages. She was curetted thrice
by different physicians during this period, but without any
relief. The last curettage was performed six months before
her admission to the hospital. On admission she complained
of general weakness and of constant uterine hemorrhage, which
confined her to the house most of the time. On examination,
patient looked quite anemic* Heart, lungs, spleen, liver, and
kidneys normal. Abdomen lax and flabby. No tumors to be
felt, and no tenderness elicited anywhere. Vaginal examination



Fig. 2. — Fibrosis uteri, showing the increase of connective tissue between the
muscle bundles and muscle cells, also areas of hyaline degeneration.

revealed a second degree laceration of perineum; cervix enlarged,
not lacerated: Uterus about twice its normal size, regular in
outline, freely movable and of a more firmer consistency than
usual. Adnexa palpable, not tender; right ovary enlarged and
cystic.

Operation. — On December 30, 1908, the writer performed an
abdominal panhysterectomy; patient made an uneventful
recovery, and was discharged cured on the ninteenth day.

Pathological Report. — ^The specimen is that of the uterus with
its adnexa. The tubes and left ovary appear normal. There is
a slight varicosity in the mesosalpinx. The right ovary is in a
state of microcystic degeneration. The uterus is about twice its



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RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE. 55

normal size, smooth and regular in outline. An antero-posterior
section shows its walls to be much thickened and much harder
than normal. Microscopically, no changes found in the en-
dometrium. The mesometrium shows an excessive proliferation
of fibrous connective tissue, not only between the muscle bundles,
but also between the muscle cells. This increase of connective
tissue is also to be noticed around the blood-vessels. The blood-
vessels, too, show morphological changes. .There is an hyper-
trophy of the adventitia, very marked in the ihedia, while the
intima remains normal. The lumina of those blood-vessels are
gaping, as if held apart by the surrounding layers of connective
tissue, while others show a narrowing of their caliber, not due



Fig. 3. — Weigert's stain for elastic tissue, showing its abundance where fibrosis

is not present.

to any growth from the intima, but to an increase of muscle
tissue in the media.

Case No. 4085. M. K., age forty-five. Admitted to Beth
Israel Hospital, September 7, 1909. Married thirty years. Has
had ten children; no miscarriages. Last child three and a
half years ago. Began to menstruate at the age of thirteen,
four-weekly in type, moderate in amount and painless. For
the last six months has been suffering from metrorrhagia, occur-
ring every two weeks, and lasting from nine to ten days, accom-
panied by pains in the hypogastric region. Has also been suffer-
ing from leukorrheal discharges for the past three years. On ad-
mission, patient looked pooHy nourished, anemic, and com-



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56 RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE.

plained of uterine bleeding and pains in the lower abdomen.
Physical examination of the heart, lungs, liver, spleen, and
kidneys was negative. Vaginal examination showed a relaxed
vaginal outlet, cervix lacerated, uterus enlarged to about one
and a half times its normal size, regular in outline, freely move-
able, and harder to touch than normally. There was free bleed-
ing of bright red blood from the uterine interior, and also from
an eroded area on the mucosa of the posterior lip of the cervix.
Adnexa were palpable, painless, and apparently normal. A
probable diagnosis of a beginning epithelioma of the cervix



Fig. 4. — Weigert's stain: showing the marked diminution of elastic tissue
in fibrosis uteri.

was made. On September 11, 1909, the writer performed an
abdominal panhysterectomy, employing the Wertheim method.
While there were no enlarged glands to be fgund along the
course of the blood-vessels, there was present an indurated
mass about the size of a walnut, around the left ureter, at the
point where it passes below the uterine artery. The ureter was
dissected out of this induration the greatest part of which was
removed. The patient made an uninterrupted recovery, and
was discharged cured October 2, 1909.

Sections from the area indicated in the cervix do not show
malignancy. The myometrium shows an excessive prolifera-
tion of connective tissue between the muscle fibers and around
the blood-vessels; in some parts this fibrous tissue is in a state



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RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE. 57

of hyaline degeneration. The section removed from the base
of the left broad ligament around the ureter shows an old inflam-
matory process. Sections stained by the Weigert method for
elastic tissue shows a marked diminution of same.

To avoid repetition, the writer will omit the report of the re-
maining four histories, for they are almost identical in both the
clinical and the pathological findings.

What is therefore the cause of this form of uterine bleeding?



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 6 of 109)