of Rhodes. Spurious works Andronicus.

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A review of the literature discloses that the older writers, for
want of better information, have termed this condition as " Idio-
pathic or essential uterine hemorrhage." A nomenclature of
this character is purely empirical. It cannot stand the glare
of scientific medicine, and should therefore be dismissed from
our consideration.

The first scientific attempt to base the etiology of this form of
metrorrhagia upon a sound pathological basis was that of Scan-
zoni. This investigator ascribed its cause to an atheromatous
condition of the blood-vessels of the uterus. Reinecke, Sim-
monds, Cholmogoroflf, Solowij, etc., have pursued this line of
research and have arrived at similar conclusions.

Solowij describes his cases thus: The intima shows no, or a
very slight increase of the endothelial cells; the media is very
much thickened in consequence of a marked hypertrophy of
muscle fibers, which at times show a hyaline degeneration; in
the adventitia there is to be noted a very pronounced increase
of connective tissue. The lumina of the blood-vessels are either
gaping, narrowed, or closed by the meeting of the opposite sur-
faces of the circumference.

The writer has found similar morphological changes in his
specimens, but contends that the term arteriosclerosis cannot
be justly applied to these cases.

According to Gull and Sutton, "arteriosclerosis, or arterio-
capillary fibrosis, is the result of morbid changes caused by
alcohol, lead, gout and syphilis; that the disposition to them is
hereditary in some families; that they constitute one of the regu-
lar senile changes, and that they are often associated with
chronic diseases of the viscera. The pathological lesions
produced are an increase in the size and number of the endo-
thelial cells, there is a growth of connective tissue from the
intima which encroaches upon the lumen of the artery and par-
tially or completely occludes it. This connective-tissue growth
may also extend outward toward the media, causing atrophy
of its muscle fibers and finally also to the adventitia."



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58 RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE.

The class of cases the writer submits for your consideration is
one in which the patients were not addicted to alcohol, they
were not syphilitic, and did not suffer from gout or lead poison-
ing. Neither were they suffering from a disease of any of the
vital organs, nor did they show arteriosclerotic changes in other
parts of the body. The pathological picture presented by the
blood-vessels in the uteri removed from these patients differs
materially from the one seen in typical arteriosclerosis. In
arteriosclerosis the morphological change commences from the
intima and extends outward, while in our cases the growth of
new connective tissue is seen around the adventitia, into which
it finally extends. The media undergoes a muscular hyper-
trophy, probably a compensatory hypertrophy, while the intima
shows no deviation from the normal, with the single exception
that occasionally there may be seen a slight increase of the endo-
thelium. In arteriosclerosis there is a tendency toward the
obliteration of the blood-vessel lumina by the growth from the
intima, while in our cases the blood-vessel lumina are kept wide
open by the concentrically laid layers of connective tissue,
and if their calibers become at times narrowed or obliterated,
then it is mainly due to a muscular hypertrophy of the media.
The most proper terminology for the structural changes met
with in the blood-vessel walls of these cases would be the one
used by Reinecke, namely, '* hypermyo trophy."

True cases of arteriosclerosis of the uterine blood-vessels have
been described by Cruveillier, von Rokitansky, Klobb, Findley,
and others, but this occurred in patients who have long passed
their climacterium, usually between the ages of sixty to seventy,
and as an accompaniment of general senile changes. The patho-
logical results of such metamorphosis are hemorrhages into the
uterine parenchyma, either into the mucosa or muscularis, caus-
ing what is known as uterine apoplexy. This escape of blood
very rarely finds its way into the uterine interior, and if it does,
the amount is so small that it requires no surgical interference.
This group of cases therefore is of little clinical importance, and
adds no elucidating facts bearing upon the etiology of metror-
rhagia in the cases the writer has reference to.

In addition to the structural changes in the blood-vessels,
the specimens presented show also a great increase of connective
tissue in the uterine walls. This connective tissue is to be found
between the muscle bundles, between the muscle fibers, and
around the blood-vessels. With the increase of connective



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RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE. 59

tissue there is a diminution of muscular structure, which shows
in many places hyaline degeneration.

Which of the two conditions, therefore, is the main cause of
this form of uterine hemorrhage in the preclimacteric period? Is
it the blood-vessel changes, or the lack of contractile power in the
uterine wall, whose muscle has been replaced to a marked ex-
tent by fibrous tissue? Furthermore, is this increase in con-
nective tissue primary, and the arterial changes secondary,
or vice versa? Are these morphological changes the sequellae
of inflammatory reactions, or not ?

Reinecke, Pichevin, Petit, Marchesi, and Cholmogoroff claim
that the metrorrhagia is due to changes in the blood-vessels
which loose their contractile and retractile powers. That the
:fibrotic change in the myometrium is secondary to the arterio-
sclerosis, and that the growth of connective tissue in the muscu-
laris is the result of circulatory disturbances, and defective
nutrition, and not to inflammatory processes.

Bland Sutton describes the fibrotic changes in the uterus as
secondary to chronic infective metritis, and analogous to curious
fibroid changes which occur in the hearts of luetic subjects.

Solowij, while agreeing that the connective-tissue increase in
the parenchyma is the sequence of tissue response to irritations
caused by either organic or inorganic poisons; yet he maintains,
contrary to the views of the above mentioned authorities, that
the morphological changes in the myometrium are primary,
and those in the blood-vessels secondary. He sums up the re-
sults of his findings thus: "Das fiihrt uns zur Annahme dass
der Impuls zur Wucherung der Gefasswande eher ausserhalb
der Gefasse in Uterus parenchym, und zwar in seiner entzund-
licher Verandenmgen liegen diirfte."

Thielhaber and Meier state that the metrorrhagia and menor-
rhagia of the preclimacteric period is dependent upon a condition
which they term as **insufficientia uteri." This insufficiency of
the uterus is brought about by an intermuscular and perivascular
development of connective tissue. With the increase of connec-
tive tissue there necessarily follows a diminution of muscle
fibers, and just as the ratio between the fibrous tissue and the
muscle tissue is increasing, so will the power of the uterus to
control bleeding be diminishing. These tissue changes are not
the result of preceding or accompanying inflammatory causes,
but the sequence of normal physiological, or rather biological
processes.



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60 RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE.

The views of the last quoted investigators fully coincide with
those of the writer. In none of the cases that came under my
observation could a history of either recent or old inflammatory
affections of the generative organs be elicited. Physical exami-
nation of the pelvis failed to reveal any traces of perime trial or
adnexal inflammation. Microscopically no round cell infiltration
or scar formation could be demonstrated in the sections taken
from the adnexa and the uteri. The contention of Thielhaber,
therefore, that the increase of connective tissue is not the result
of preceding inflammatory causes, is correct.

What, however, has given rise to this metaplasia? Ac-
cording to biological laws, whenever the parenchyma of an
organ wastes or atrophies through disease, lack of activity,
or overexertion, connective-tissue development ensues and
replaces it. The uteri of some multiparous women bear evidence
to this truism. It is a well established fact that the uterus of a
multipara is larger than that of a nullipara, that this increase
in size is due to an hyperplasia of all its tissue elements during
gestation, and that during the period of involution, when the
organ is returning to its original state, the only one of its tissues
that lags behind in the retrogressive changes, is the connective
tissue. Hence the uterus remains somewhat large after each
successive pregnancy. Should, therefore, the interval between
the periods of involution become shorter by virtue of repeated
impregnations, the uterus will, pari passu, undergo marked mor-
phological changes. The connective tissue will increase after
each pregnancy, and the muscle parenchyma, due to its over-
exertion, will atrophy and be replaced by new fibrous tissue.
This disproportion between the tissue elements in the uterus
will ultimately alter its physiological properties. The uterus
will gradually lose its contractile powers, and therefore become
less capable of controlling hemorrhage. Should this process
continue beyond the danger zone, i.e., should the fibrous tissue
assume a proportion in the structure of the uterus far greater
than what is allotted to it naturally, then the condition of insuf-
ficiency of the uterus becomes fully established, and its inherent
power of spontaneous control of menorrhagia or metrorrhagia is
completely lost.

RESUME.

This type of preclimacteric uterine hemorrhage is therefore due
to an hyperdevelopment of fibrous connective tissue in the uterine



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RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE. 61

walls, which takes the place of the exhausted and finally atrophied
muscle fibers. With the diminution of muscle tissue and elastic
fibers there ensues a loss of contractility, and this loss becomes
greater after each succeeding pregnancy, until uterine compensa-
tion is entirely broken. The menorrhagia and metrorrhagia in
this class of cases is not due to friability or atheromatous condi-
tion of the blood-vessels, but to an insufficiency and inability of
the uterine muscles to contract and close the gaping arteries and
sinuses. The blood-vessel changes are secondary to those taking
place in the muscularis, as proven by the invasion of fibrous
changes from without into the adventitia, by the compensatory
hypertrophy of the media, and by the normal state of the intima.
The condition of fibrosis uteri is not the sequel of inflammatory
reactions, but the result of biological changes.

SYMPTOMATOLOGY.

We meet this form of preclimacteric uterine hemorrhage in
multiparae between the ages of thirty -five and fifty, who are other-
wise well, and suffer from no lesion of any of the vital organs.
Pelvic examination is usually negative, excepting for a somewhat
enlarged and hard uterus. No history of infection postpartum
or postabortionem can be obtained. The bleeding is becoming
worse as time progresses, and while it greatly reduces the health
of the patient, the cachectic look is wanting, and the blood is
devoid of the peculiar odor characteristic of malignancy. Pain,
if present, is usually located in the hypogastric region. Medical
means and minor surgical procedures are of but ephemeral value.

TREATMENT.

Emmet advocates the sewing up of the external os. Olshausen
suggests oophorectomy, and Martin advises the ligation of the
uterine arteries. Of the three methods mentioned, the first
does not seem worthy of serious consideration, for it is neither
a safe nor a sound procedure. The last two, on the other hand,
deserve our thorough deliberation. We have learned from the
works of Olshausen, Pfluger, Leopold, Mironoff, and others, that
while ovulation may take place without menstruation, the
latter, however, is always dependent upon the former. Menstrua-
tion, therefore, expresses the climax of uterine congestion, which
is reached about once in twenty-eight days, and which is brought



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62 RABINOVITZ: PRECLIMACTERIC UTERINE HEMORRHAGE.

about by reflex ovarian stimulation. As soon as the excess of
blood in the uterus is removed by the menstrual flow, the uterine
muscle contracts and the bleeding gradually ceases.

The phenomenon presented by a uterus in a state of fibrosis
is quite a different one. Here the equilibrium between the
augmentative and the inhibitory forces of congestion is destroyed.
While the ovaries maintain their normal function, i.e., the prop-
erty of causing uterine congestion, the uterine muscle, on the
other hand, has lost its tone, and as a result a condition of either
menorrhagia, or metrorrhagia is established. Olshausen's method,
therefore, is scientific and logical, for by the removal of the ovaries
we at once do away with the main factor that causes uterine
hyperemia. Martin's procedure is based upon purely anatomical
grounds, and it too is very plausible.

In the light of modem surgery, however, fortified as we are to-
day by asepsis and an almost flawless technic, the wisest plan
of treatment for these patients seems to be hysterectomy. For
to the experienced surgeon the removal of the uterus, especially
per vaginam, offers as little difficulties, and exposes the patient
to as little risk, as does a double oophorectomy, or the ligation
of the uterine arteries. Furthermore, this method has the advan-
tage that it does not deprive the woman of her sexual instincts,
and does not subject her to those dire and nerve- wrecking results
which follow sudden withdrawal from the economy of the ovarian
secretion. As to the method of hysterectomy, whether it be
abdominal or vaginal, this must be left to the ability and discre-
tion of the individual operator; personally, I prefer the vaginal
route.

In conclusion, I wish to express my gratitude to Dr. L. J.
Ladinski, in whose service I had the opportunity to operate upon
and make use of the material which served as the basis of this
paper. I also desire to thank Drs. E. Moshkovitz, and D.
Sheitlis for their kindness in preparing the microscopic sections.

BIBLIOGRAPHY.

Thielhaber, A. Munch, med. Woch., 1905, B. Ivii, 1249.

Thielhaber, A. Monatschr. fur Geh. u. Gyn.y 1903, S. 972.

Thielhaber, A. Arch, fiir Gyn., 1902, B. Ixvi, Heft i.

Thielhaber, A. Arch, fiir Gyn., 1900, B. Ixii, Heft, S. 415.
Reinicke, E. A. Arch, fiir Gyn., 1897, B. liii.
Hitschman u. Adler. Zeitschr. fiir Geb. u. Gync., 1907, B.
Ix, Heft I.



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walker: preoperative purge. 63

Kubo, T. Amer. Jour. Obst., 1908, vol. Iviii, p. 675.

Rees, Chas. M. Amer. Jour. Obst., 1908, vol. Iviii.

Slocum, R. S. Surg. Gyn. and Obst., April, 1908.

Simmonds, M. Centr.fiir Gyn., 1901, S. 81.

Olshausen, R. Berlin, klin. Woch., 1894.

Findley, P. Amer. Jour. Obst., 1901, vol. 1, p. 30.

Klob. Pathol. Anatomic der weiblichen Sexualorgane. 1864,
S. 203.

Cullen, T. S. AnncUs of Gyn. and Ped.y Boston, 1904.

Switalski, L. Centr.fiir Gyn., 1895.

Coe, H. C. Internal. Clinics , 1892.

Leopold and Mironoff. Arch, fiir Gyn., B. xlv.

Norris, C. C. Amer. Jour. Obst., March, 1909.

Cholmogoroflf. Monatschr. fiir Geb. u. Gyn., B. xi, Heft 3.

Brennecke. Arch, fiir Gyn., B. xx, Heft 3.

Nomenclature of Endometritis. Jour. Am. Med. Assn.,
March 23, 1907.

Barbour, A. H. F. Jour, of Obst. and Gyn., British Empire and
Ireland, June, 1905.

Solowij, A. Monatschr. f. Geb. u. Gyn., B. xxv, S. 291, Heft 3.

Anspach, B. M. Jour. A. M. A., March 14, 1908.

Bland, Sutton. British Med. Jour., 1899.

Bandler, S. W. Am. Jour, of Surg., March, 1909.

Delafield and Pruden's Pathology, p. 505.

243 East Broadway.



IS THE ROUTINE EXHIBITION OF THE PREOPERA-
TIVE PURGE DEFENSIBLE?^

BY
EDWIN WALKER, M. D.,

Evansville, Ind.

In a paper read before this association at Cincinnati in 1906, I
called attention to the great abuse of purgatives both by the laity
and the profession. The people in general regard purgatives
indicated in all ailments, and even take them when no disease
exists. Practically every house has its "ever-ready" laxative.
This state of affairs is due to the teaching and practice of the
medical profession. Does not his family physician inaugurate
every treatment with a cathartic? Even his surgeon, who
professes scant faith in drugs, purges every patient before a
surgical operation, no matter how simple. Can we wonder, then,

I Read at the Twenty-second Annual Meeting of the American Association of
Obstetricians and Gynecologists at Fort Wayne, September 21-23, 1909-



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64 walker: preoperative purge.

that purgatives are almost universally employed? Yet every
physician must know that their universal use is harmful, that
they aggravate many diseases. In acute cases, serious conse-
quences may ensue. They are not only powerless to cure
constipation, but are the most frequent cause of this trouble.
Constipation, in the vast majority of instances, is due to careless-
ness in habits and improper diet.

For the past five years I have noted in my histories, those
who habitually use purgatives, and the results of correction of
habits and diet, and it is astonishing how few are not promptly
relieved by these simple methods. The few who are not, have
some trouble which needs surgical or other treatment for relief.

Purgatives have a value in autointoxication and toxemia, but
even in these they should be given on distinct indications only,
for in many cases the poison is far out of reach of the cathartic,
and its only effect is to weaken the patient.

When preparing the paper mentioned, I made quite an exten-
sive search of the literature of the subject to inform myself how
purgatives acted, and their exact effect on the human organism.
The available information was very unsatisfactory; authors
differing widely on the subject but all agreed, however, that they
were irritants and are capable of producing enteritis. They
all produce liquefaction of feces, increase peristalsis and the
formation of gas, the latter being due to excessive germ activity.
This is exactly what we find in enteritis from any cause. Schmitt
showed that normal constipated stools contain fewer germs and
underwent decomposition slowly, even in an incubator. Roos
was able to purge patients with live cultures of colon bacilli,
while the dead germs had no effect.

The salines and mild laxatives doubtless do less harm but the
difference is only one of degree. The stronger purgatives,
except perhaps calomel, are now but little used, the milder laxa-
tives have taken their place; this is a great improvement, but
even these should be given for definite indications only. I want
to repeat the protest made three years ago against routine use
of purgatives, and with careful inquiry into the etiology and the
correct diagnosis of disease, they will be less frequently pre-
scribed. Remove the cause by diet, habits or surgery and the
laxative is superfluous.

It is, however, against the routine purge in all surgical cases,
I wish especially to protest. If there is a hospital anywhere
<except my own) in which the preliminary purge is not given to



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walker: preoperative purge. 65

all patients operated upon, I have not heard of it. Such a
universal practice is absurd. Surely every patient requiring
operation is not suffering with trouble with the digestive tract;
on the contrary, a vast majority have no trouble at all; why
then make them sick and weaken them by a purge? We know
that in the normal individual the process of digestion and
evacuation is remarkably constant. It takes about seven hours
for the stomach to empty itself, in five hours more the small
intestine has extracted what nourishment it can and the remainder
is pushed through the ileo-cecal valve. In the small gut the
contents are always fluid and its movements are almost as regular
and rhythmical as those of the heart. The time of the movement
of food thus far (to the cecum) varies but little, unless there is a
gross obstructive lesion.

The colon is more sluggish; extracting energetically the
fluid, it pushes the mass along until it reaches the sigmoid, where
it remains until defecation begins; this generally requires twelve
hours. If, therefore, the patient has a normal alimentary canal,
in twenty-four hours you can have an empty canal merely by
giving a light digestible diet, without a purgation. Functional
diseases need not concern us here as they rarely, if ever, interfere
with the normal propulsive action of the stomach or small
intestines. In this part of the prima via, organic obstructive
lesions only interfere with the normal course of the intestinal strain.

A condition of atony has been described, but some of the best
authorities (Conheim) have never encountered atony of the
stomach or small gut. There is no loading or clogging and solid
or fluid matter is rarely found in them, when the patient has fasted
twelve hours before the operation. It is in the colon, therefore,
that we find the trouble, for careless habits, diet containing too
little refuse to pass off, has in a measure injured the viscus.
Metchnikopf says that the colon is a superfluous organ as we now
live, and attributes "old age" to autoinfection from the gut, and
thinks if the species were rid of it, life would normally be twice as
long as it is now. There is no doubt that the consumption of
vegetables and coarse foods is of advantage. Von Noorden has
shown the great value of coarse diet in membranous colitis.

The colon is the portion of the canal which gives the most
trouble to the physician, and also to the surgeon in preparation
of his patients for operations in general. It normally con-
stantly contains some fecal matter, but not enough to interfere
with any operation, except on the large gut itself. In persons
5



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G6 walker: preoperative purge.

of constipated habit, I mean the milder forms, there rarely is
enough fecal retention to interfere with operations on pelvic or
abdominal organs, besides the colon. Large fecal impactions
are very rare and when found are in the sigmoid and transverse
colon, more rarely in the ascending colon. Any accumulation
large enough to interfere with any surgical operation, except
on the colon itself, could not be removed by a single purge; in
fact, it only increases the amount of fluid and removes but
little, if any, of the impaction. Anyone who has had a large
fecal accumulation to remove, knows how slow, tedious and
difficult it is to do it. I once observed a hard fecal mass in the
ascending colon of a woman, which resisted all efforts at re-
moval by purgatives and enemas for six months, until I thought
it must be a growth of some kind. An operation became neces-
sary for a pus tube and at that time I examined the colon, found
a fecal mass and expressed it. If, therefore, the colon contains
only a normal amount of feces, the diet and fasting with an
enema or two will put the gut in good condition. If the accumu-
lation is larger and of long duration and if time will permit,
the colon should be unloaded by enemas of a solution of bicar-
bonate of soda, oil and large enemata of water, with a coarse
diet. It is best if possible to do all this and have here an inter-
val of several days afterward, before the operation is undertaken.

The colon is the seat of active germ activity and the removal
of masses would temporarily stimulate their activity. Besides
these accumulations indicate more or less colitis and there is
greater danger from infections of this kind. If the accumula-
tion is caused by an organic obstruction it is apparent that
purgatives alone cannot remove it. It may be argued that
the very fact that purgatives are so universally employed is
prima facie evidence of their value and harmlessness. This does
not necessarily follow; the profession has fallen into many fads,
blood-letting, for example, which did much harm, and had to be
banished by outside criticism.

Purgatives do affect the patient unfavorably, they weaken
him and in the debilitated it might be enough to turn the scale.
This is doubtless rare but does occur. One thing is certain,
they make the patient more uncomfortable, and at a time when
he has plenty to annoy him, we might at least spare him this.
They surely do increase the formation of gas. The first change



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 7 of 109)