of Rhodes. Spurious works Andronicus.

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inflammation had subsided, the hot-air treatment to absorb the
exudate.

Case II. — The writer would like to report one other case which
is at present under his observation and which bears out the
wisdom of conservative treatment. The patient is a married
woman, thirty-eight years of age, family history as well as
personal history not relevant. No children. No miscarriages.
Last July, 1909, she complained of chills and fever, with pain in
the lower part of the abdomen on both sides, and night-sweats.
There was no vaginal discharge. Palpation elicited a tender
definite mass on both sides of the uterus. Temperature ranged
from 99° to 102°. Pulse averaged 120. She had previously
suffered with painful urination, and this was exaggerated and
especially annoying. The above symptoms continued with an
increase in the size of the mass on either side of the pelvis. A
blood count showed a leukocytosis of 18,000, Hg. 80. Urinary
analysis: sp. gr. 1020, albumen present. No sugar. Casts finely
granular and hyalin. Blood corpuscles were present.

A diagnosis of pus under pressure was made. A vaginal drain-
age was done and iodoform gauze was used for packing. It was
supposed that due care had been used to insure a wide opening
and that all the pus was evacuated. The gauze was removed
two days later, the temperature gradually came to normal in
about ten days with a diminished leukocytosis of 1 1 ,000, Hg. 80.
A microscopical examination of the offensive pus showed a mixed
infection of colon bacilli and staphylococci.

Fifteen days after the primary incision there was an increase
in pulse, and temperature and pain were again present. The
opening in the vagina was closed, and a wide incision was made,
packed with iodoform gauze, and removed in two days.

Thirty days later there was a third relapse. Another incision
was made, packed with gauze, and removed as previously done.

Several weeks later a definite mass could be palpated on either
side of the uterus. The author confidentially informed the hus-
band that in all probability he should be obliged eventually to
do a radical operation.

Present Condition. — Within the past few days an examination
of the patient has been made and careful palpation demonstrates
a surprisingly normal condition. The uterus is fairly movable.
There is no tenderness, and no mass can be detected on either
side. The patient is enjoying excellent health. In this case the
author feels justified in congratulating himself on his conserva-



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600 gillmore: nonpuerperal pelvic infections.

tisra, especially as the patient at no time would have objected to
a radical operation.

Without tiring the members of this Society by detailing any
more cases, the author begs permission to add that in many
instances in the past he has had occasion to regret his radical
procedures. And for the past three years he has yet to record a
single instance where a conservative treatment of therapy, rest,
and draining per the vagina has proved a disappointment, even
though a radical operation was done later on. He believes that
in ordinary cases of chronic pelvic infection with its various
complications, it is rarely justifiable to do a radical abdominal
operation until after a thorough trial of the hot-air treatment,
rest, sunshine, and depleting douches of Epsom salts and glycerin
have been instituted.

The classification of acute and chronic inflammation is of
primary importance in the treatment of nonpuerperal pelvic
inflammations. Whenever possible the exciting cause must be
ascertained by bacteriological examination, aided by the history,
the blood count, etc. When the tuberculin test is resorted to
we must bear in mind the possibility of a secondary local infec-
tion starting from a positive tuberculin reaction. We must deter-
mine the location of the focus, and whether it is primary or second-
ary. It must not be forgotten that a localized inflammation of
a gonorrheal infection of the female genitalia may become a
general infection or a gonococeinia at any time during its course
in either the acute or the chronic stages, and by the continuity of
tissue, or the circulation, or rhythmic uterine movements, may
result in a peritonitis, pyelitis, a gonorrheal synovitis with
endocarditis or meningitis, any or all of which may result in
death.

Acute Inflammation. — ^The stage of inflammation is determined :
I. By the history. 2. By the constitutional symptoms, pyrexia,
increase of pulse rate, and respirations. 3. By the white blood
count. 4. By the pain.

The treatment is divided into: I. prophylactic; II. expectant;
and III. vaginal drainage where there is a localized pelvic
abscess.

A radical abdominal operation should never be done for an
acute pelvic inflammation except in the case of an abdominal
rupture of an acute pelvic abscess.

I. Prophylactic measures are directed toward limiting a gonor-
rheal vaginitis, and consist of rest, both physical and by the



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gillmore: nonpuerperal pelvic infections. 601

administration of atropine sulphate. If the disease extends to
the cervix, the Bier treatment has yielded satisfactory results,
especially in the hands of the European gynecologists. If the
infection extends to the uterine body, the Bier treatment should
be stopped. Drs. Kugel arid Esiki,(2) of the Dermatological
Clinic of Austria and Hungary, at the University of Kolozsvar,
claim that two-thirds of all cases of untreated gonorrheal vaginitis
ascend to beyond the internal os, and that the per cent, is much
less in all topically treated cases. While they plead for extreme
conservatism in surgery, and for active therapy, they insist that
there must be no topical applications when there is pain or fever,
or during the mentrual period, or in the puerperium until after
involution.

Perhaps one of the most startling departures from the various
methods of treatment of the past, and a somewhat revolutionary
suggestion for the routine treatment of the future, is that of Dr.
Carl Schindler,(3) who first announced his theories before the
Tenth Congress of the German Society of Dermatologists of
Frankfort on the Main and Cologne. This report was elabo-
rated and enlarged last June, 1909. Dr. Schindler contended that
there must be some scientific explanation to account for the
large per cent, of cases where the nonmotile gonococci extend
beyond the internal os. Accordingly he carried on some ex-
tensive experiments on the uteri of living animals. He also
removed those pelvic organs and by an ingenious device of
forced artificial circulation was enabled to carry on the same
experiments. From his observations he reports certain definite
conclusions:

1. The uterus and adnexa have certain well-defined involun-
tary movements not influenced by the central nervous system.

2. A well defined rhythm.

3. Automaticity.

4. Periodicity.

The uterus, ovaries, tubes, ligaments, and vagina, all have
their own irritability, independent of each other. Their rhyth-
mic automatic movements usually follow S)mchronously with
the uterus, especially when they are not in a state of fatigue.
Under the sub-division of his paper entitled, *' Special Physi-
ology of the Uterine Movements,'* he says that asphyxia,
in which the blood is overloaded with CO,, produces an imme-
diate quieting of the uterine movements which lasts until the
arterial circulation has been well established.



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602 gillmore: nonpuerperal pelvic infections.

The administration of i mg. of atropine, either by the mouth,
locally by injection, or subcutaneously, paralyzes the uterine
automatic movements for several hours. On the contrary, warm
douches, poisons, heat, electricity, all increase the irritability
of the involuntary movements.

Schindler therefore draws the conclusion that if a single
gonococcus has passed the internal os, the most delicate thera-
peutic measures, even so much as a single sterile warm douche,
may materially aid in the ascension of the gonococci by increas-
ing the automatic movements of the uterus and the adnexa.

In 1905, Drenkhahn(4) enthusiastically recommended the use
of atropine for quieting the uterine colic during puerperal in-
fection and to prevent the further spreading of the infection.
Even before Drenkhahn recommended the use of atropine,
Tabora(5) had used it extensively for the quieting of the move-
ments of ulceration of the stomach. Both of these men gave
from I to 3 mg. of atropine sulphate daily either per os or
subcutaneously. Tabora reports that he frequently adminis-
tered atropine in these doses continuously for from four to ten
weeks, and that the human being has a wonderful tolerance for
high doses.

Schindler's theory is that if the Bier treatment is used, it is
peculiarly effective because of the direct action of CO3, and he
calls attention to the fact that the routine practice of sucking for
five minutes, with a pause of three minutes, does not accomplish
the desired end, because the moment the circulation has become
established the automatic contractions of the uterus come on at
once and the discharge is spread upward over the entire surface.
He thinks that the suction should be continued for from one-half
to two hours without pause. He uses an ordinarily shaped specu-
lum made of glass with an air-tight-fitting cover over the extrem-
ity and an Eschbaum pump or a rubber balloon. Under no
circumstances does he ever use a warm douche. As soon as the
complication of cervical gonorrhea is established he atropinizes
the uterus, and uses mild solutions of silver nitrate, 2 per cent.,
or protargol, 1/4 to i per cent., in combination with i mg. of
atropine to apply to the cervical canal. After the gonorrheal
infection has passed the cervical canal, he warns against the use
of the Bier treatment because of the tearing and dragging of the
muscular tissue of the uterus and the danger thereby of increas-
ing the inflammation. He finishes his article with these em-
phatic words: "In every case the systematic atropinizing of



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gillmore: nonpuerperal pelvic infections. 603

the uterus with its quieting effect will be and remain the alpha
and omega of the future gonorrheal therapy of women.*'

II. The Expectant Treatment. — ^Among the measures we have
at our command are :

1. Rest in bed.

2. Quieting the automatic movements of the pelvic organs
with atropine.

3. The pain should be controlled with one of the alkaloids of
opium. Atropine sulphate, i to 3 mg. per day, or until the
physiological action is obtained, not only quiets the uterine
movements, but controls the pain.

4. It is important to give close attention to the elimination.
Plenty of fluid should be administered and a careful lookout for
any symptoms indicating an acute nephritis. The bowels
should be regulated by enemas, cascara sagrada, or phenol-
phthalein. Castor oil, on account of its well-known action in
stimulating uterine contractions (and counteracting the effects
of atropine), should be avoided.

5. Pyrexia.— The ice-bag should be placed on the abdomen
both for the pain and the fever. If in spite of the application
of ice the fever goes beyond 103°, cold baths should be given
at regular intervals to reduce the temperature and incidentally
to increase the leiikocytosis.

III. Vaginal drainage should be instituted when there is a
fluctuating mass, a pelvic abscess, or in certain cases of pyosal-
pinx. Great care should be taken to see that all the foci have
been evacuated and that the openings are sufficiently large to
insure the complete evacuation of pus. In a certain percentage
of cases this may be curative. Some gynecologists take the
view that if possible we should wait and do a radical operation
because the number of cures is so small that we are obliged to do
a secondary operation. Personally, the author cannot believe'
that such a course is justifiable if for no other reason that that
of subjecting the patient to a possible nephritis from the continual
absorption of toxins which are eliminated by the kidneys, and the
general lowering of the resistance from such absorption.

Chronic Pelvic Inflammation. — This is usually secondary to an
acute inflammation, although it may be chronic from the begin-
ning, as occurs frequently in salpingitis, ovaritis, peritonitis, and
cellulitis.

The treatihent is divided into operative and nonoperative.

I. Under nonoperative. Bier's hot-air treatment is one of the



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604 gillmore: nonpuerperal pelvic infections.

most important measures we possess. Dr. George Gellhom,(6)
of St. Louis, has devised an inexpensive apparatus for the ad-
ministering of hot air. It consists of two telescoping cradles
lined with asbestos and in which are eight sockets for i6- to 32-
candle-power lights. There is an opening for the thermometer
at one end. By removing one or two lights or by adding a
higher candle power, any desired heat may be obtained. The
telescoping feature is an advantage because a larger area than
the pelvis may be treated if desired. In order to insure the
dryness of air for the prevention of bums, Wilson and Reitler(7)
suggest the use of calcium chloride so that it may absorb the
moisture radiating from the skin. Gellhorn hangs the chlorides
in small gauze bags to hooks which have been inserted in the
telescopic frame of his apparatus, great care being exercised to
keep the moistened chloride far enough away from the electric
bulbs to prevent the possibility of explosion. The average
patient stands the exposure of temperature to 220® of dry hot air.
Von Dr. Oskar Vertes(8) says that there are two prerequisites
for the use of hot air:

1. An absolute normal temperature.

2. The absence of pain.

He emphatically states that the application of hot air should
be stopped instantly upon the slightest rise of temperature.
Vertes believes that no gynecological clinic can be considered
as fully equipped without an apparatus for the administering
of this treatment. He says it is very useful in intraperitoneal
exudates, especially when such exudates are not of long standing.
Therefore it is of particular value in postoperative complications.

II. The object of the Bier treatment is to create a local con-
gestion thus causing a local leukocytosis.

III. The vaginal douches, combined with Epsom salts and
glycerin, are of value for hydroscopic effects.

IV. The other methods are sunshine, fresh air, highly nutri-
tious diet, general massage, hot hip pack, and cold and hot
spinal douches. Due care should be given the psychological
depression, and mental therapeutics should not be ignored. All
these should be used with care directed toward proper elimination
from both the kidneys and bowels.

Radical Operation.* — The extent and character of pathology in

♦The time to operate is when the acute symptoms have subsided, when there b
a p>ersistence of pelvic pain, and recurrence of acute exacerbation of pelvic perit-
onitis. Only then should surgical interference be considered when the above
methods have been tried with no improvement.



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GILLMORE: NONPUERPERAL PELVIC INFECTIONS. 605

,the pelvis will determine the details of the radical operation.
Perhaps one of the most interesting questions that confronts
the gynecologist of to-day is the somewhat mooted one as to
whether both ovaries should be removed in toto. The conserva-
tive operators contend that all normal ovarian tissue should be
preserved in order to modify the intense symptoms of the meno-
pause, as well as for the psychological welfare of the patient.
While the advocates of the radical operation believe that they
are justified in removing every vestige of the ovary on account
of the future possibilities of periovaritis, cystic ovary, and for
the not infrequent intractable menstrual hemorrhage which
sometimes follows the procedure of conservative surgery. (9)

Tubercular and syphilitic inflammations have not been con-
sidered in this paper, as they are subjects by themselves. But
care must be taken to differentiate them from other inflamma-
tions. The finding of the spirochete pallida Wasserman's reac-
tion and the typical reaction from Koch's tuberculin is of course
a positive method of diagnosis.

Dr. Oskar Frankl, of Vienna, (10) records that at the present
time we must admit that the opsonic teachings of Wright have
not accomplished what we at first hoped for them on account
of the technic required for the opsonic index, which gives in-
dividual rather than universal and positive scientific results.
He thinks that at this date there are many insurmountable
difficulties to be solved before we will be able to utilize the
theories which have been advanced by Wright and others on
the subject of opsonins, and that the work done in the past is
practically confined to the field of diagnosis. ^

The writer is of the opinion that when the results of the immense
amount of laboratory and animal experimentation have been
expurgated, and the scientific facts have been crystalized, the
future treatment of infections will be along the lines of serum
or vaccine therapy.

REFERENCES.

1. Dr. T. J. Watkins. Chapter XXV., Infections of the
Ovaries. Bov^e, The Practice of Gynecology, ist Edition, 1906.

2. Drs. M. J. Esiki and E. Kugel. Ueber die Behandlung
der Uterus Gonorrhoea insbesondere bei Prostituirten : mit beson-
derer Beriicksichtigung der Adnexe. Arch, d. Dermai, u. Syph.,
Wien u. Leipz., 1909, xcvi, 261-302.

3. Dr. Carl Schindler. Experimen telle Beitrage zur Kennt-
niss der automatischen Bewegungen des Uterus und deren



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606 POOL-ROBBINS: UNILATERAL TWIN TUBAL GESTATION.

Bedeutung fiir die Pathologic und Therapie der uterinen Infek- ,
tionskrankheiten insbesondere der Gonorrhoe. Arch, f, Gyndk.,
Bed., 1909, Ixxxvii, 607-642.

4. Drenkhahn. Atropinanwendung in der Frauenheilkunde.
Therap, Monatsh., Febr., 1905 (dt. Dr. Carl Schindler).

5. Tabora. Die Atropinbehandlung des Ulc. ventriculi.
Miinch, med. Wochenschrifi, Sept., 1908, No. 38 (cit. Dr. Carl
Schindler).

6. George Gellhorn, M. D. Dry Heat as a Therapeutic
Factor in Gynecology. Amer. Jour. Obst., July, 1909, page 31.

7. Quoted from Dr. George Gellhorn. Amer. Jour. Obst.,
New York, July, 1909.

8. Von Dr. Oskar Vertes. Die Heiseluftbehandlung in der
Gynakologie. III. Jahrgang, 1909, 7. Heft, Gyndkologische
Rund. Zentral, fiir Geb, und Frauenkrankheiten, Wien.

9. Von W. Zangemeister. Wann sollen bei der Ovariotomie
beide Ovarien entfernt werden? Praktische Ergebnisse der
Geburtshilfe und Gynakologie, vol. i, 1909.

10. Von O. Frankl. Praktische Ergebnisse der Serologic fiir
die Geburtshilfe und Behandlung. Praktische Ergebnisse der
Geburtshilfe und Gynakologie, vol. i, 1909.

103 State Street.



UNILATERAL TWIN TUBAL GESTATION.
Report of a New Case and Summary of Former Case Reports.

BY
EUGENE H. POOL, M.D.,

Attending Surgeon to the French Hospital; Associate Attending Surgeon to the
New York Hospital,

AND

F. ROBBINS, M.D.,

New York.
(With one illustration.)

The comparative rarity of twin tubal pregnancy in one tube has
led us to give a brief description of such a case which was met
with at the French Hospital in the service of one of the writers
and to supplement this report with a summary of the reported
cases.

M. G., French, twenty-seven years of age, entered the French
Hospital on November i, 1909, complaining of severe cramp-
like pain in the left lower quadrant of the abdomen, bleeding
from the vagina, and weakness.

Eight days before admission, at about 11 p. m., the patient
had a feeling as if her bowels were going to move, and on rising
from bed she was seized with sudden pain in the above-mentioned
region. The pain was intermittent and radiated over the whole
abdomen. The last menstruation began on September 27, at the
regular time and continued until October 31, with brief inter-



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POOL-ROBBINS: UNILATERAL TWIN TUBAL GESTATION. 607

missions. No periods had been missed. Urination was normal,
bowels markedly constipated, appetite very poor. She had not
vomited nor felt nauseated, and had had no fever, chills, night-
sweats, or cough. She felt very weak and thought she had lost
weight during the last month.

She had never had a similar attack and had always enjoyed
good health. She began to menstruate at thirteen, the periods
lasted about four days, flow moderate and almost painless. She
had been married seven years. Five months after marriage
she had a miscarriage of three or four months, but had never
been pregnant since. She denied having had any symptoms
suggestive of gonorrhea. •

Habits good. Family history, negative.

Physical Examination. — Thin woman, mucous membranes and
skin pale, general examination negative.

Local examination revealed a slightly enlarged anteflexed uterus,
behind and to the left of which could be felt a tender, smooth,
immobile mass, evidently the left tube. The size of the mass
seemed to diminish during examinations on the operating-table,
and it was thought that it had been ruptured by the manipula-
tions.

Blood examination on November i showed hemoglobin 62
per cent., leukocytes 19,200, polymorphonuclears 84 per cent.

Operation. — By a semilimar, Pfannenstiel incision, the abdomen
was opened and a moderate amount of fresh blood found in the
abdominal cavity, also some blood clots in the pelvis. Pos-
teriorly and to the left of the slightly enlarged uterus was found
a mass which was readily freed and brought into the wound. It
proved to be the much-enlarged left tube which had ruptured
and was bleeding freely. There were two fetuses attached by
separate cords to one placenta at the outer part of the tube. In
one fetus the arms and legs contracted and extended for about
a minute after exposure to the air. The tube was removed,
the ovary being left intact. After the removal of clots and
blood, the abdomen was closed in the usual manner. The wound
healed by primary union and convalescence was uneventful.

Description of Specimen. — ^The specimen consists of a Fallopian
tube about 12 cm. long. The inner part, 4 cm. long, is only
slightly thicker than a normal tube, but the outer part is greatly
enlarged, measuring about 8x4.7x2.5 cm. The surface of
this portion is smooth except at the outer part of the posterior
surface where the tube is ruptured. The interior is fiUed with
an adherent blood clot, at the upper part of which may be seen the
placenta and the edge of a thin retracted membrane, the remains,
apparently, of a single amniotic sac. From the placenta pass
two cords 3 cm. long, separated 2 cm. at their attachments. To
each cord is attached a fetus. The fetuses are of the same size
and development, their vertex-coccygeal measurement being
3.3 cm.

Summary of Former Case Reports. — Schauta refers to nineteen



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608 POOL-ROBBINS: UNILATERAL TWIN TUBAL GESTATION.

cases of tubal pregnancy with twins in the same tube, but with-
out enumerating them, and Costa speaks of eleven cases as posi-
tive, and fifteen cases as presumptive examples of unilateral
tubal pregnancy with twins. Pulcher enumerates eighteen and
McCalla* twenty-five cases. A study of the available literature
leads to the exclusion of some cases which have usually been
cited as positive, and the addition of other cases which are not
included in any lists. We have therefore been led to append a
new list. It must be stated, however, that the aggregate of the
positive and doubtful cases has so constantly increased during
the preparation of this list that we do not feel that it is possible
to claim completeness. The element of uncertainty in many
of the doubtful cases is introduced through the question as to
whether in a given case there was a repeated rather than a coin-
cident or true twin gestation. For instance, when the two
products of conception consist of a fetus and the degenerating
remains of a fetus, such findings are suggestive of a twin tubal
pregnancy with arrested development of one fetus, but the evi-
dence is not conclusive.



POSITIVE CASES OF TWIN PREGNANCY IN ONE TUBE.

De Olt, — Presentation before Petersburg Obstetrico-Gyne-
cological Society, April ii, 1889, of an anatomical specimen
of tubal twin pregnancy. Both fetuses were three and a half
months old, or a little over. (Vratsch, AnncUes de Gyn,, 1891,
ii, p. 304.)

Strocker, — Anatomical specimen, presented before Berlin
Medical Society, March 2, 1892, obtained from a woman thirty



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 62 of 109)