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No case has been classed as cured which has not been well for
one year. One of our cases was entirely cured for eleven
months, when pain recommenced, and at the end of sixteen
months was as bad as ever. If care had not been observed to
select only those cases in which one year had passed since the
operation, this and other cases might have been grouped as
cures. On the other hand, many of the improved cases should
doubtless be classed as cures for, as has been shown by the work
of Tobler and Englemann, it may almost be considered normal
for women of the present day to have some pain during the
menstrual period, and it is probable that some of these improved
cases compare very favorably with the average woman.

Some of the results reported by other operators are as follows:
Holden sa)rs 30 per cent, will be cured or greatly improved, 30
per cent, temporarily improved, sterility relieved in 15 per cent.
Holden performs a dilatation and curettage. Wylie thinks
that he cures 80 per cent, of his cases occurring in young girls.
Dudley cured symptomatically, 75 per cent. Wadsworth, with
Dudley's operation, cured a like number. Beyea reports about
75 per cent, of cures with the Wylie drain. In ten of his forty-one
cases dilatation and curettage had previously been performed.
Kelly reports 18.94 P^r cent, cures and 14.72 per cent, of im-
provements, while 34 per cent, were temporarily improved. In
these statistics, as in our own, it will be noted that the Wylie
drain gives better results than any other form of treatment.
We have seen some increase in size in cases of mal-development,
but have never seen a bad case of aplasia of the uterus brought
to the normal by the use of the Wylie drain.

In conclusion, the authors wish to thank Dr. John G. Clark for
the privilege of using material from the Gynecological Depart-
ment of the University of Pennsylvania.

CONCLUSIONS.

1. Dysmenorrhea occurs frequently in young nulliparous
women without gross pathological lesions.

2. With exception of general conditions, the most frequent
etiological factors in the production of dysmenorrhea are
hypoplasia of the uterus or ovaries or a pathological anomaly
causing diflBculty in the expulsion of the menstrual products.
This is due primarily to some form of obstruction in the cervix
plus excessive clotting, the latter is often caused by a form of



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NORRIS AND BARNARD: DYSBfENORRHEA IN NULLIPAROUS WOMEN. 765

membranous dysmenorrhea. Membranous dysmenorrhea is a
more frequent condition than is generally supposed.

3. The cervix alone, due to the softening and dilatation of the
canal which occurs at menstruation, rarely, if ever, produces
dysmenorrhea unless accompanied by a condition of the men-
strual blood which favors clotting.

4. The so-called pathological anteflexion alone rarely, if ever,
produces dysmenorrhea.

5. In treatment it is of paramount importance to recognize
the cause of the dysmenorrhea, and for. this reason a careful
study of each case is necessary. General treatment should not
be neglected, and an ether examination is absolutely necessary
when a local condition is suspected.

6. The cases which yield the best operative results are those
in which the pain makes itself manifest just before the flow
begins and is of a spasmatic, expulsive, or obstructive character.
The dull, heavy, congestive type of dysmenorrhea is but little
relieved by operation. The failure to recognize these two
classes of dysmenorrhea accounts for the generally poor operative
results.

7. Any form of operation which permanently dilates the
cervical canal will relieve the expulsive form of dysmenorrhea.
The fault with the simple dilatation operation is that the stenosis
frequently recurs. The common history being that these cases
are relieved for one or two periods only.

8. In our hands the Wylie drain has proved satisfactory.
The drain is not a substitute for dilatation, but rather a sup-
plementary precedure.

9. The Wylie drain must never be used in the presence of an
inflammatory lesion.

10. About 25 or 30 per cent, of sterility occurring in women
without gross pathological lesions can be relieved by appropriate
treatment.

REFERENCES.

Adler and Hitschmann. Monat.f, Geb. u. Gyn., Bd. H. i, 1908.
Beyea, H. D. Surg. Gyn, and Obst., 1908, xxx, 437.
Carstens, J. H. Jour, Am, Med. Assn,, 1909, liii, 1730.
Chenhall. Australian Med, Gaz,, Sidney, 1906, xxv, 569.
Cotte, G. Gaz, des Hdp,, Oct. 12, 1909.
Dudley. The Principles and Practice of Gynecology,
de BrignoUes, Roux. La Gyn,, Sep., 1909.
Englewood (quoted by Glasgow). Med, Record, N. Y., 1907,
Ixxii, 177.



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766 OTT AND SCOTT: THE EFFECT OF ANIBiAL EXTRACTS.

Holden. Am. Med., Nov. 4, 1905, p. 776.

Kelly. Med. Gyn.

Leopold and Mironcoff. Arch./. Gyn., xlv, 506, 1894.

Norris, C. C. University of Pennsylvania Med. Bull., June,
1908.

Norris, C. C, and Keene, F. E. Surg. Gyn. and Obst., Jan.,
1909, p. 44.

Pozzi. Trans. Am. Gyn. Soc, 1909, vol. lix, p. 1029.

Tobler, Maria. Monat.f. Geb. u. Gyn., 1905, vol. xxii, p. i.

Vedeler. Arch.f. Gyn., 1883, vol. xxi, p. 211.

Webster, J. C. Text-book of Diseases of Women, 1907, p. 124.

Wylie. Trans. Am. Gyn. Soc., 1909, vol. lix, p. 1029.

1503 Locust Street; 119 South Nineteenth StreIst.



THE EFFECT OF ANIMAL EXTRACTS UPON UTERINE
CONTRACTIONS.

BY
ISAAC OTT, M. D.,

Professor of Physiology, Medico-Chinirgical College of Philadelphia.

AND

JOHN C. SCOTT, M. D.,

Demonstrator of Physiology,

Philadelphia, Pa.

(With one illustration.)

In a paper published in the Journal of Experimental Medicine,
vol. xi, No. 2, 1909, we stated the action of animal extracts
upon the uterus by the method of Magnus. In this method a
piece of the uterus is excised, placed in Ringer's solution at a
temperature of 37.5° C. with oxygen bubbling through it. A
segment of the uterus was attached to a lever which recorded
the contractions.

In this communication we have studied the action upon
the uterus tn situ. The experiments were made upon rabbits
and cats. The animals received paraldehyde by the mouth
and ether by inhalation. Fifteen experiments were performed.
The animals after being under the influence of ether were fastened
upon the holder, the abdomen opened in the median line in its
lower segment, the head of the Malassez holder elevated, and the
pelvic cavity filled with normal saline solution, which kept the
uterine tissue bathed. The sides of the abdominal walls incised
were elevated by ligatures to a horizontal bar. This aided
in the retention of the normal saline. The temperature of the
saline was kept at the temperature of body by means of frequent



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OTT AND SCOTT: THE EFFECT OF ANIMAL EXTRACTS. 767

additions of the heated saline solution. The uterus was attached
by two threads to a myocardiographic lever which inscribed the
quite regular uterine contraction with the respiratory move-
ments upon a smoked drum. The dried extracts were rubbed
up with distilled water filtered through cotton and injected per
jugular. We have obtained a marked uterine contraction with
a 20 per cent, extract of the infundibular lobe of the hypophysis.
Fig. I. This has been previously observed by Dale and Bell.



Fig. I. — Rabbit: parous uterus § of i c.c. of infundibular extract of pituitary
per ju^lar. The downward curve shows the contraction of the uterus after
infundibulin.



Brain (1/2 grain) per jugular produced marked uterine con-
tractions in the pregnant uterus.

The mammary gland (1/3 grain) in the parous uterus caused
marked uterine contractions.

Spleen (1/2 to i grain) in' the virgin uterus and in pregnant
uterus caused marked contraction.

Parathyroid (i grain) with the parous uterus was followed
by increased uterine contraction.

lodothyrin (2 grains) in virgin uterus produced contractions
and in pregnant uterus produced marked uterine contraction.



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• 768 OTT AND SCOTT: THE EFFECT OF ANIMAL EXTRACTS.

The parotid (i grain) in pregnant uterus produced fair uterine
contraction.

Pancreas (i grain) in pregnant uterus produced very marked
contractions.

Thymus (1/4 grain) caused some contraction in pregnant
uterus.

Prostate (1/4 grain) in pregnant uterus produced marked
contraction.

Spermine (Poehl) 10 drop doses, caused some contraction in
pregnant uterus of cat.

The ovary (1/4 grain) in the virgin uterus caused slight con-
traction.

Testicle (1/4 grain) produced slight contraction of the virgin
uterus.

Of the above-named agents — infundibulin, brain, mammary
gland, spleen, parathyroid, prostate, pancreas, and iodothyxin
have the most marked activity upon the contractions of the
uterus.

When we compare these experiments with those obtained
upon the excised uterus we find about the same results.

Bell and others have used the infundibular extract in post-
partum hemorrhage. It stopped the bleeding in about three
to four minutes. It has also been used in placenta previa with
excellent results.

The contractions of the human uterus by it are more pro-
longed than those produced by any other preparation, not
excluding the extremely active preparation of ergot. In two
cases of Cesarean section after a single injection the uterus
contracted like a bleached ball and subsequently relaxed only
to a moderate degree. The preparation used was a 20 per cent,
extract of which i c.c. given intramuscularly was the dose.
It can be repeated in an hour.
Medico-Chi. College, 17 15 Cherry Street.



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STEIN: FUNCTIONAL DISORDERS OF THE BLADDER. 769



FUNCTIONAL DISORDERS OF THE BLADDER IN THE
FEMALE SIMULATING CYSTITIS.*

BY

ARTHUR STEIN, M. D.,

Assistant Visiting Gynecologist to the German Hospital.

New York.

It is no infrequent occurrence to have women, who come
to the physician for some gynecological trouble, make the state^
ment that they have bladder symptoms of some sort or other.
These symptoms usually consist of frequent and painful mic-
turition, and occasionally it is specified that the pain occurs
before, during, or after emptying the bladder, or that the pains
are especially marked during the menstrual period. Usually
such women have already been treated by the administration of
drugs or by bladder irrigations, since their physician concluded
from the subjective symptoms that they had a cystitis. The
more we gynecologists are on the lookout for such cases, the
more we must become convinced how frequently mistakes are
made along these lines and how essential it is to make a correct
diagnosis.

When giving such routine treatment the fact is overlooked
that a great number of ailments situated outside of the bladder
can give symptoms which correspond to those of a real cystitis.
This explains the failure of the treatment applied, for subjective
symptoms are simply treated without getting at the real cause
of the trouble.

We know by experience that the pathological conditions of
the female generative organs only too frequently involve the
bladder, though the bladder mucous membrane itself has not
undergone any change (that is, when there is no real cystitis) .
We furthermore know that changes in the independent nervous
system of the bladder or changes in the general nervous system
can cause the typical symptoms of a cystitis without a true
cystitis really existing. In spite of these facts the opinion still
prevails, especially among general practitioners, that a cystitis
must be present whenever there is a frequent desire to urinate.

♦Read at the New York Academy of Medidne, Section on Obstetrics and
Gynecology, March 24, 1910.

4



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770 STEIN: FUNCTIONAL DISORDERS OF THE BLADDER.

It may, therefore, be of interest to review all those conditions in
the female which can cause bladder symptoms without a true
cystitis being present.

Let me say right here that my remarks shall include only
such cases in which both the cystoscopic and the chemical
examination has excluded a cystitis. This means that cases of
cystitis colli will not be considered.

We come then to the real subject matter of this paper. Blad-
der symptoms without a cystitis may be manifold. Pain before,
during, or after urination, a frequent or diminished desire to
urinate, tenesmus, paralysis of the bladder, a retention or incon-
tinence on a nervous basis, dribbling of urine with or without
retention, may all be the result of pelvic disorders outside of the
bladder or of some systemic disease.

To make matters simpler, I shall make three subdivisions :

First. — Cases in which there is some pathological change or
irritation of the nerve center of the bladder wall itself.

Second, — Cases in which there is some pathological change in
the genital organs.

Third. — Cases in which we are dealing with some general
nervous trouble or systemic disease.

To be able to better understand the pathological conditions
mentioned under subdivision i, I shall refer briefly to the few
publications concerning the physiology and anatomy of the
bladder wall itself. Only when we are fully acquainted with the
anatomy and physiology of the bladder will we be in a position
to understand its pathological changes.

I do not believe I am exaggerating when I say that next to
Frankenhaueser's classical paper, published in 1867, the recent
work of Roith and E. Kehrer, Jr., deserves the greatest attention.
Roith showed in various articles on the nerve plexus of the female
pelvis and the innervation of the bladder, that the nerve appara-
tus is to some extent independent of the central nervous system.
He describes it as being situated in the compact connective tissue
layer of these organs, alongside of the branches of the hypo-
gastric, the loose connective tissue framework being free of nerve
elements. The ganglia are most numerous in the posterior and
lateral portions of the cervix, while the ganglion cells of the
bladder lie chiefly in front of the cervix in the region of the
trigonum. He also established the fact that when the spinal
nerves are injured, the sympathetic ganglia in the pelvis take
care of the innervation of the bladder. He found that when



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stein: functional disorders of the bladder. 771

all the direct nerve tracts were cut the sensation of a full bladder
is effected: i. Through the muscle sense of those muscles of the
pelvic floor which lie adjacent to the bladder. 2. Through a
stretching of the parietal peritoneum. 3. Through the sensory
fibers of the nervus pudendus commtmis supplying the urethra.
When the bladder is filled to a certain degree the walls are put
on the stretch ; the latter affects the ganglia in the pelvic connect-
ive tissue and in the bladder wall and these in turn reflexly
cause a contraction of the detrusor.

Kehrer, Jr., has shown that there is a reciprocal relationship
between bladder and uterus, a dilatation of the bladder reflexly
producing a cessation of uterine contractions. He thus demon-
strated experimentally the well-known observation that a very
much distended bladder has a tendency to cause hemorrhage
and subinvolution of the puerperal uterus. On the other hand,
contractions of the bladder will increase uterine contractions,
and vice versa a sudden dilatation of the uterus will cause a
relaxation of the bladder. So, too, contractions of the uterus,
brought about by chemical or mechanical stimulants, will
cause increased bladder contractions. Kehrer also proved that
this reciprocal relationship between the urinary and genital
organs continues even after the pelvic and hypogastric nerves,
which supply uterus and bladder, have been cut. He therefore
concluded that the reflexes between the bladder and uterus are
carried on by an independent nervous system in these organs.

What do these anatomical facts teach us? In the first place,
they draw our attention to the fact that we are dealing with
an independent center in the bladder or with bladder ganglia.
Changes in this independent nerve apparatus must therefore be
able to cause symptoms resembling those of a true cystitis,
although the latter is actually absent. The fimction of these
ganglia resembles that of the plexus of Auerbach and Meissner
in the intestinal wall. In both organs we at times get pains,
contractions, and tenesmus without even the slightest change
in the mucosa. I am convinced that a great deal is still to be
gained by further experimental work along the lines followed
by Roith and Kehrer, Jr.

To my mind many of the so-called hysterical bladder symp-
toms are of neuritic origin. In this class of cases it would be
absolutely wrong to carry out any local treatment of the bladder;
what we should do is to distract the patient's attention from her
bladder symptoms by psychical and general treatment. A



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772 stein: functional disorders of the bladder.

recent case of my own has demonstrated to me the logic and
possibilities of the latter course. A woman, twenty-seven
years old, with a fixed retroflexion, a small ovarian cyst, and
signs of general nervousness stated of her own accord that she
had to pass her urine every hour during the day and had to get
up several times at night. After a careful examination I could
find no changes in the bladder mucosa. Together with local treat-
ment for her gynecological ailment I tried psychical treatment.
After four weeks the urinary symptoms had entirely disap-
peared, in spite of the fact that the fixed retroflexion had not
been completely relieved. By exclusion, we must therefore con-
clude that the patient's bladder symptoms were caused by the
gynecological condition and possibly in part by an irritation of
the nerve centers situated in the bladder wall. At any rate, any
local bladder treatment would have been contraindicated. It
would only have made the patient take more notice of her
urinary symptoms.

Under this subdivision we must also include those cases
in which the bladder wall is irritated to such a degree by chemical
changes in the urine that typical cystitis symptoms result.
It is not generally known that tenesmus can be caused by the
drinking of freshly brewed beer. After a few days the symptoms
disappear spontaneously or may remain if the patient continues
to drink the beer. I agree with Rissmann, that in such cases
the symptoms are due to some strongly irritating hop-salt. In
Europe these cases are more frequent than here. I only refer to
them to show the importance of a chemical examination of the
urine whenever we have to deal with bladder symptoms with-
out demonstrable pathological changes. Depending upon the
result of the examination we can prescribe the corresponding
dietary treatment. Before going over to the second class of
cases I wish to mention a rather rare occurrence which might
resemble an inflammatory condition of the bladder, but has its
origin elsewhere. I refer to those malformations of the urinary
tract in which the ureter empties either into the vagina, urethra,
or just below the external meatus of the urethra. As a result
we get a continuous dribbling of urine, a symptom which also
occurs in inflammatory conditions. If only a superficial exami-
nation of the case be made, this malformation may lead to the
making of a wrong diagnosis and therefore to improper treatment.

I come now to my second subdivision, cases in which there is
some pathological condition of the genital organs. A goodly



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stein: functional disorders of the bladder. 773

number of the women who come to the gynecologist for advice
complain of bladder symptoms. To convince myself as to how
many really make such a complaint I carefully examined the
histories of fifty-four patients. Thirty, that is 55 1/2 per cent.,
made no reference to the bladder; eighteen, that is 33 1/3 per
cent., complained of urinary symptoms, which on careful exami-
nation were found not to be due to changes in the bladder itself,
and only in six, that is in 11 i/io per cent., the symptoms were
due to inflammatory conditions in the bladder. In other words,
one-third of all the women seeking advice for some gynecological
trouble complain of urinary symptoms, though no real disease of
the bladder is present. We may then safely conclude that the
symptoms referable to the bladder in these cases are due to the
gynecological ailment.

You all know that the menstrual period, a physiological
and not a pathological state, can cause bladder symptoms. Very
often yoimg girls complain that they have a frequent desire to
urinate at the time of their menses. Here we are simply dealing
with a bladder which takes part in the general congestion occur-
ring in the pelvic organs during menstruation. Surely the weight
of the small anteflexed virgin uterus is not the cause.

Before referring to various pathological pelvic conditions I
want to emphasize that the first requisite, before making any
other examination, is to analyse the pains during micturition.
Pains occurring before urination and diminishing during the act,
point toward a true cystitis; if they are most marked during
urination, that is if the urine bums, a urethritis is the most
likely diagnosis. When the pains are referred to the lower
portion of the abdomen, occurring immediately after urination,
and continue for some time, we may safely conclude that the perit-
oneum is involved. Pains of this character frequently accompany
a pelvic peritonitis. Thus a patient with inflamed genital
organs may have urinary symptoms similar to those of a true
cystitis, while the bladder itself is absolutely normal.

To repeat, then, it is necessary to analyze urinary symptoms
when they exist. It will not do simply to note in the history
"increased frequency of urination" or "painful urination."
Mirabeau, in a recent publication, gave an excellent classifica-
tion of the various bladder symptoms. He distinguishes:

1. Pathological changes as to frequency of micturition.

2. Changes in the normal sensations during urination.

3. Disturbances as regards continence.



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774 stein: functional disorders of the bladder.

4. Changes in the character of the act, whether intermittent,
etc.

I have already mentioned that the congestion during men-
struation often causes an increased frequency of urination.
The same holds true during pregnancy, except that in the later
months lack of room is partly the cause of the symptoms. This
brings us up to the question of the relation between pelvic tumors
and bladder symptoms.

In 1674 myoma cases, Kelly and Cullen foimd an increased
desire to urinate in 109, that is 6 1/2 per cent. In twenty cases
there was a partial or complete retention of urine; in seven there
was partial or complete incontinence; in only two was there a
true cystitis present. A retroflexed pregnant or nonpregnant
uterus, hematoceles, ovarian cysts, and cystoceles may all
mechanically cause bladder symptoms of various kinds. Regard-
ing cysts, the dermoids, when they have ruptured into the bladder,
are especially liable to lead us to believe that we are dealing with
a catarrh of the bladder, for then, too, we meet with painful
micturition and pus in the urine. Nowadays, with more fre-
quent use of the cystoscope, mistakes in diagnosis should occur
but seldom along these lines.

An anteposition of the uterus and a retroflexio-versio have
the same effect on the bladder as a retroflexion. By anteposi-
tion we mean a uterus which is pushed forward in front of the
axis of the pelvis by some exudate, hematocele, or tumor lying
behind it. The immediate result of such uterine displacements
is an altered bladder function. The latter organ may be dis-
torted, or in advanced cases there may even be compression of the
neck of the bladder. Frequent desire and frequent voiding of
small quantities of urine are the symptoms accompanying this
condition, in fact ischuria paradoxa, that condition in which the
patient has a continuous desire to urinate with constant dribbling,
may result. Cystocele might also be mentioned here, for through
pulling and dragging on the bladder symptoms similar to a
cystitis may be caused.

I should just like to say another word regarding the influence
of pelvic inflammation on the bladder. We can readily under-
stand how purulent processes in the parametrium, specially
those in front of the uterus (the so-called " plastron " of the French
writers), can influence the bladder, either by pulling at it, by
pressure, or by a direct extension of the inflammatory process to
the perivesical tissue. So, too, a carcinoma of the uterus.



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 79 of 109)