of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 91 of 109)
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or be increased by administering salt solution.

This seemed rational and was done in several cases, two of
which will be briefly reported here; and while under the sugar
water instillation treatment, the specific gravity of the patient's
blood was observed by Hammerschlag's method and recorded.
It was found that remarkable improvement took place in the
condition of the patients under the continuous rectal administra-
tion of sugar water by the drop method (Murphy) and that the
specific gravity of the blood fell to 1052 from 1060.

Both cases made a good recovery. In addition to the sugar-
water instillation only water was given by mouth for three days
and the usual treatment in these cases carried out, namely,
veratrum viride hypodermatically, patient wrapped in blankets
surrounded by hot-water bottles to induce perspiration, cathar-
sis, later salt-free diet. It was astonishing to see the large
quantities of sugar water that were absorbed by these patients,
and how the quantity of urine and perspiration increased,



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jacobson: the treatment of eclampsia. 877

bringing about improvement in the patients' condition from
the start.

The following are the important points, told as briefly as pos-
sible, of the two cases mentioned above. They were both patients
at the Jewish Maternity Hospital and I want here to thank
Drs. Greenstein and Gosset, house surgeons, for constant care
and attention to these cases while carrying out the treatment
outlined.

Case I. — Mrs. S. K., a Russian by birth, married and mother of
one child, bom spontaneously and living now, was examined
in the antepartum room of the Jewish Maternity Hospital on
September 5, 1909. Her personal and family history were not
of importance as regards her present condition, except that she
menstruated for the last time on the first day of February, 1909,
and felt life about middle of June, 1909. She had complained
of occasional headache and slight dizziness for a few weeks.

Examination proved her heart and lungs to be normal. She
had slight edema of the ankles. The abdomen was of longitudi-
nal ovoid shape, the fundus uteri rose to a height corresponding
to about the eighth month. The child presented by the vertex,
occiput to the right, fetal heart sounds obtained. Pelvic meas-
urements were interspinous 20 cm., intercristal 24 cm., external
conj. 26 cm. Owing to distinct signs of nephritis she was asked
to report on the following day and bring a specimen of her urine
for examination.

However, she did not return.

When she was next heard from, it was a hurry call to her home.
She was there delivered on the outdoor service, on October 29.
Shortly after the delivery, which was spontaneous, the child
being alive, she had a convulsive seizure. She was treated in the
routine manner for eclampsia, by hypodermic injection of
Tr. veratrum viride, gtt. x every two to four hours; chloroform
during attacks; croton oil, gtt. i (once); compound jalap powder;
nitroglycerin, gr. i/ioo every three hours; hot pack and a copious
venesection followed by the usual intravenous saline infusion.
This was varied by administration of potassium acetate and
compound spirits of ether.

October 30. — Convulsions at 8, at 12.15, and at 3, lasting
about ten minutes. The pulse was between 120 and 150 from
I to 5 o'clock. Hot saline rectal irrigation. Morphine gr. 1/4
hypodermically and chloral hydrate grs. xx by mouth.

October 31. — Hot packs and same treatment continued.
No convulsions, but patient very restless and pulse still rapid and
of high tension.

November i. — Patient seen in hospital. Comatose. Face
flushed. Temperature 101.5° F. Pulse between 130 and 140,
high tension. Tendency to dilirium. Respirations 30. Stand-
ing orders. Modified Murphy drip started. This consists of a



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878 jacobson: the treatment of eclampsia.

rubber douche bag holding four quarts of sugar water, namely,
granulated sugar one teaspoonful to each quart of water, kept
at a temperature of 115° F., and the tube so constricted that the
solution will pass only drop by drop into the rectum. Tr. verat-
rum viride gtt. x hypodermically every four hours or of tener till
pulse drops below 80. Patient to be wrapped in blankets sur-
rounded by hot-water bottles to promote diaphoresis. If restless
codeine gr. 1/4 hypodermically. Nothing by mouth except
seltzer or plain water. Withhold salt in any form. Specific
gravity of blood 1058. This was practically the only treatment
for the next three days.

She absorbed several quarts of sugar solution each twenty-
four hours (exact amount not charted) perspired profusely, and
regained consciousness gradually, the specific gravity of the blood
came down to 1052 within a few days and she became quite
rational again.

The sugar-water instillation was stopped and mouth feeding
begun. She was given milk, seltzer, and later cereals.

On the third day, by mistake, the patient was given an ounce
of magnesium sulphate, and twelve hours later became irrational
again and tried to get out of bed.

The specific gravity of the blood rose within a few days slowly
to 1056 and it remained there, till her discharge on November 14,
1909.

The urine on admission contained albumin and large and small
granular casts. These gradually disappeared until her discharge,
thirteen days later, when there was only a minute trace of
albumin and no casts could be found.

She was discharged with her baby on November 14 and
warned to abstain from the use of salt for at least six months.

Case II. — Mrs. B. F., aged sixteen and one-half years and
pregnant for the first time, was seen by courtesy of Dr. A.
Lowit, on March 27, 1910. Her family and personal history were
unimportant as regards this pregnancy, except that she is
married one year and menstruated in her usual way about eight
months previously.

She denies having had syphilis, gonorrhea, miscarriage, heart,
kidney, or lung trouble, and considered herself to be in average
health. For the last few weeks she noticed occasional but
transient dizziness, slight headache, and some "spots before the
eyes." She also noticed some swelling of her legs and in the
morning a slight swelling of the eyelids.

Dr. Lowit examined her urine and, finding evidences of
nephritis, requested the writer to see her.

On examination the young patient presented the typical pic-
ture of a nephritic. She was pale, her face somewhat bloated,
and her eyelids edematous. The skin of the abdomen and legs
pitted on pressure and the vulva was edematous to a degree.
Examination of the heart and lungs proved them normal. She
was pregnant toward the end of the ninth month with twins.



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jacobson: the treatment of eclampsia. 879

As eclampsia seemed imminent she was advised to immediately
enter the hospital and have labor induced. Upon her arrival
the same afternoon, a sterile soft-rubber rectal tube was inserted
into the uterus, the vagina packed with gauze, and the patient
put to bed.

Urinalysis showed the unmistakable signs of nephritis — the
urine boUed solid in the test-tube showing a large quantity of
albumin. Epithelial and granular casts were abundantly present.

Strong uterine contractions set in and as the pulse was hard
and 1 20 per minute the usual treatment for eclampsia was
instituted, namely, elaterin gr. i/io every six hours until copious
stools were obtained. Hypodermically veratrum viride gtt. x
every four hours or of tener till pulse rate came down to 80, dry
hot pack, etc.

About nine hours after induction of labor the first stage was
practically ended when the patient had a convulsion lasting about
a minute. Dr. Scadron applied forceps and delivered a girl
baby weighing four pounds and eleven ounces, then performed
version and delivered the other girl weighing four pounds and
three ounces, both living. An hour later the patient had another
convulsion.

The writer did venesection drawing ofif six ounces of blood.
Up to this time the patient had received hypodermically within
seven hours seventy minims of Tr. of veratrum viride without
showing any efifect on the pulse, which was still rapid and
hard. The writer concluded that the drug was probably inert,
so ordered a good fluid extract of veratrum administered instead.
This had the desired efifect.

The constant rectal instillation of sugar water was started
after the second convulsion, and she never had another convul-
sion. Diaphoresis became profuse. Specific gravity of the
blood taken on March 29 was 1060.

The urine showed remarkable increase in quantity the first
three days under the sugar- water instillation, namely:

First twenty-four hours lost a little urine (not measured) while
defecating and involuntarily, quantity said to have been very
small, and one ounce only was obtained by catheter for exami-
nation in laboratory. This boiled solid.

Second twenty-four hours under constant administration of hot
sugar water rectally, amount of urine passed thirty-seven ounces.

Third twenty-four hours, 115 ounces.

By this time the pulse was soft, below 80 per minute, and the
specific gravity of the blood 1056. On the sixth day post-
partum specific gravity of blood was 1052 and it remained there
until the eighth day postpartum which was the last day on
which it was taken. On April 7, the eleventh day postpartum,
the patient was convalescent, the urine normal — without a trace
of albumin or casts.

She was discharged with her babies on April nth, and cau-
tioned to avoid salt for a number of months.



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880 sturmdorf: metrorrhagia and uterine fibrosis.

In conclusion it might be said that, while it is true that two
cases, even if successful, are not sufficiently strong from a numer-
ical standpoint to establish the claims of a new procedure in
medicine, nevertheless the results of the treatment were so strik-
ing as to compel attention. The writer may be pardoned for
expressing the hope that some of his colleagues who read this
article will give the method a trial in cases of eclampsia, because
he believes it to be a harmless and directly life-saving treatment.

6i6 Madison Avenue.



METRORRHAGIA AND UTERINE FIBROSIS.*

BY

ARNOLD STURMDORF, M. D.,

New York.

Among the more urgent gynecological contingencies, there is
probably none the occurrence of which we contemplate with
more complacency, or the control of which we assume with
greater confidence, than a bleeding uterus.

This complacency, born of familiarity with palpable routine
etiological factors and this confidence, based upon the usual
effectiveness of our therapeutic equipment against such factors,
may be seriously disturbed by an infrequent type of metror-
rhagia, occurring about the preclimacteric period, almost
exsanguinating in severity or persistence, for which no palpable
routine cause is in evidence and nothing in our therapeutic
equipment effective, short of hysterectomy.

In gross appearance such an extirpated uterus reveals pale
tissues of slightly augmented bulk and consistency.

Under the microscope, the small subendometrial vessels will
be found increased in number and deformed in outline by a
deposition of concentric fibrous layers, with well staining nuclei.

Similar vascular changes exist in the myometrium, the
muscular elements of which are encroached upon and replaced
by fibrous bundles and round-cell infiltration.

Clinically defined, uterine fibrosis represents a condition in
which the uterus is converted into a rigid, engorged organ
incapable of contraction, owing to a degeneration of its muscular
and elastic elements, which are largely replaced by fibrous tissue
traversed by stiff, tortuously deformed and dilated vessels.

* Read at a meeting of the Medical Society of the County of New York, April
25th, 1910.



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sturmdorf: metrorrhagia and uterine fibrosis. 881

The question as to the relative significance and natural
sequence of these vascular and myometrial degenerations in the
causation of the uncontrollable bleeding is at the present time
a theme of interesting debate among investigators.

Thus Theilhaber and his followers interpret the muscular
changes as the fundamental and primary element in the con-
dition, with the arteriosclerosis as a purely concomitant factor.

They base their contention upon an observation made by the
present writer some eight years ago, demonstrating that, follow-
ing established physiological laws, a normal uterus contracts at
regular intervals not only during pregnancy, but during its
entire functional existence: such contractions being essential
to its structural and circulatory integrity.

An immobile muscle whether in the uterus or elsewhere
degenerates; furthermore, the uterine veins being devoid of
valves, there is no provision other than such muscular contrac-
tion to prevent uterine stasis and its consequences.

The proportion of muscular and fibrous tissue in a given
uterus varies under normal conditions at dififerent periods of
life; thus, in the infant, approximately one-third of the myome-
trium — more properly called the ** mesometrium " — consists of
muscle tissue; at puberty, both blood-vessels and muscle develop
rapidly until the normal adult type shows about two-thirds of
its bulk to consist of muscular elements; after the menopause,
the vessels and muscle atrophy, so that by the sixtieth year a
marked preponderance of fibrous tissue normally prevails.

Any pronounced deviation from this essential proportion
of muscular element in the mesometrium, whether congenital,
i.e., " h)rpoplastic," or acquired, may, according to Theilhaber,
be productive of uterine hemorrhage.

It is axiomatically accepted, that under ordinary conditions,
bleeding from an otherwise normal uterus is controlled largely
by the contractility of its muscular and elastic elements, and it
would seem but logical to assume that any impairment of this
contractility must manifest itself by a proportional loss of
spontaneous uterine hemostasis.

Unfortunately, however, many facts obtrude themselves, the
elucidation of which would carry us far beyond the practical
limits of the present communication that will not permit of so
simple a solution of the problem under consideration.

Palmer Findley, an ardent opponent of the myopathic origin
of this form of bleeding, readopts Cruveilhier's term "Uterine



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882 sturmdorf: metrorrhagia and uterine fibrosis.

Apoplexy" and expresses his views as follows: "It is possible
that the increase in the connective tissue of the myometrium
may interfere with the circulation, but it is altogether certain,
that in many cases, the primary cause lies in the walls of the
blood-vessels, while the h)rperplasia of the uterus is secondary."

Such, in sketchy outline, is the present status of the con-
troversy on the pathogenesis of this condition, which is accepted
as a clinical entity under the various terms, " Uterine Fibrosis, "
"Uterine Apoplexy," "Senile Hemorrhagic Endometritis,"
"Essential Metrorrhagia," "Metrorrhagia Myopathica," etc.,
etc.

Leaving the decision as to the relative significance of the
angiosclerotic and myogenic changes to academic discussion,
let us turn to those elements of clinical importance that demand
our most serious consideration.

The extensive literature on this subject that has accumulated
to the present time lacks convincing and elucidating data,
illustrating in most of the cases merely that natural preponder-
ance of fibrous tissue and arteriosclerosis normal to the senile
uterus.

Reinecke and Martin report thirteen hysterectomies for the
control of hemorrhage, all of the extirpated uteri revealed
sclerosis of vessels and musculature, but, as Findley pointedly
comments, these authors failed to exclude the possibility of
obstruction to the return circulation from thrombosis, cardiac,
pulmonary and hepatic disease, such as were found on autopsy
in each of the eight cases reported by Von Kahlden.

In a case reported by Popoff there were kidney and heart
lesions with pleural efifusion.

Herxheimer's case also presented cardiac and renal lesions
with aortic atheroma.

Palmer Findley reports one case of his own in which the im-
mediate cause of the uterine hemorrhage proved to be an embolus
or thrombus of the uterine artery, engrafted upon a generally
disturbed circulation.

This personal experience prompted him to the final conclusion,
that " Sclerosis of the uterine vessels alone ,and without co-
existing general circulatory disturbance is insufficient to cause
uterine hemorrhage."

This is true as far as it goes, but it does not go far enough, for
we must add the various hematogenic, toxemic, and metabolic
disorders as well as perverted ovarian functions, all and any of



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sttjrmdorf: metrorrhagia and uterine fibrosis. 883

which, singly or combined, recognizedly exercise an etiologic
influence in the production of metrorrhagia.

Terminology dominates our concept, jand the terms "Fibrosis
Uteri," " Senile Hemorrhagic Endometritis," " Myopathic
Metrorrhagia," etc., all applied to this condition, while path-
ologically descriptive, are clinically misleading, in that they
tend to circumscribe our diagnostic horizon and limit our thera-
peutic aim by focusing attention on local manifestations to
the exclusion of remote general underlying factors.

In the present state of our knowledge, the diagnosis of uterine
fibrosis could be established only upon the microscopic evidence
of its existence in the extirpated uterus and upon our ability
to exclude every other possible cause for, and our absolute
inability to control, the existing hemorrhage.

We meet many cases of profuse, persistent, and apparently
uncontrollable metrorrhagia, but, fortimately, we will find an
extremely small number that will not ultimately reveal causes,
other than uterine fibrosis, to account for the bleeding, and in our
search for such causes it is essential to realize that we are treat-
ing not merely a bleeding uterus, but a bleeding woman.

Spontaneous uterine hemostasis under ordinary conditions is
dependent upon a normal uterus plus a normal circulation of a
normally constituted blood.

A normal uterus contracts, so will an abnormal one, though to
a lesser degree, for no uterus was ever found to be entirely devoid
of contractile elements.

Uterine contraction alone, however, will not control its bleeding,
for an essential concomitant to such control is normal coagu-
lation, which demands normal blood under normal pressure.

It thus becomes evident that our search for the cause and
therapeutic indications in a given case of metrorrhagia must be
focused upon the uterus, the circulatory apparatus, and the
circulating blood.

An exhaustive elucidation of all the local and systemic causes
of metrorrhagia would constitute a voluminous treatise, while the
present communication must, for obvious reasons, be limited
to the barest suggestive outlines only.

Our operative records in a long series of metrorrhagic condi-
tions reveal one significant group of cases in which gross abnor-
malities within the uterus, by their nature and location, com-
pletely eluded tactile recognition prior to surgical intervention.

First in order of frequency among these unrecognized local



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884 sturmdorf: metrorrhagia and uterine fibrosis.

causes of metrorrhagia were fundal pol3rpi; second, submucous
or short pediculate myomata springing from the comual area of
the uterine cavity, and, last, malignant disease, limited to the
upper endometrial zone, especially adenocarcinoma, which is
notoriously insidious in development and progress, so that,
barring the hemorrhage, it yields no physical evidence of its
presence for a very long period.

It is noteworthy that in all of these cases the unrecognized
pathological factor was located in, and limited to, the upper
lateral angles of the uterine cavity, thus eluding recognition.

Among hematologic causes, pernicious anemia, which, prior to
its hematological diagnosis, was interpreted as of simple nature
secondary to the metrorrhagia, proved to be the primary etiologi-
cal factor in two cases.

The mere mention of the various leukemic states, jaundice,
scorbutus, and other toxemias, will recall conditions recognized as
capable of inducing various degrees of a hemorrhagic tendency.

Functional disorders of the thyroid may influence menstrua-
tion to a marked degree, and the development of metrorrhagia in
exopthalmic goitre, as of amenorrhea in cretinism, disclose
etiologic probabilities as yet within that nebulous clinical vista
in which our present knowledge of the correlated or perverted
physiology of the ductless glands and their internal secretions
is still shrouded.

All of these factors must be included in the study and excluded
in a diagnosis of the condition under consideration.

The occurrence of a retinal hemorrhage or a sudden copious
epistaxis is frequently the initial symptom pointing to cardiac
or renal disease, yet these same conditions are but rarely sought
in explanation of the same symptom appearing from the uterus;
furthermore, the veins of the uterus and its adnexa, like those
in the gastrointestinal tract, are frequently varicosed by cir-
rhotic processes in the liver and other portal obstructions; yet,
while we recognize this varicosity as productive of hemorrhages
from mouth or anus, we fail to connect the same cause and eflfect
in metrorrhagia.

To recognize any S3rstemic condition thus outlined as a
cause of the uterine bleeding is to establish an imperative thera-
peutic indication and excludes uterine fibrosis; but while we are
searching for and correcting these systematic causes, the local
control of the hemorrhage urgently demands our prompt con-
sideration.



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sttjsmdorf: metrorrhagia and uterine fibrosis. 885

It cannot be sufficiently emphasized that the failure of ergot,
the tampon, and curet to control such hemorrhage does not
necessarily demonstrate its uncontrollability, nor establish the
diagnosis of uterine fibrosis; these are sovereign remedies when
used in their proper time, case, and manner.

Every clinical manifestation represents a normal function per-
verted or diverted, and every corrective efifort must be based
upon a familiarity with the normal mechanism of that function.

To check any bleeding we must induce coagulation. To
induce coagulation the blood current supplying the bleeding
area must be retarded and reduced.

In the normal uterus such retardation and reduction of its
circulation is accomplished by contraction, but it is a very
significant and important fact that the blood flowing from a
fibrous uterus like that shed from the normal uterus during its
menstrual cycle shows little if any tendency toward spon-
taneous coagulation.

In other words, aside from, and independent of, any circulatory
derangements, a condition seems to exist which may, for
descriptive purpose, be termed uterine hemophilia, normally
periodic in menstruation and abnormally persistent in fibrotic
metrorrhagia.

To attribute this absence of coagulability under the given
conditions to an intimate admixture of mucus with the blood,*
as hitherto taught and accepted, is clinically and experimentally
untenable.

Blood coagulates in the nose, mouth, gastrointestinal tract,
and upon all other actively secreting mucous membranes;
furthermore, the only true muciporous glands found within the
uterus are limited to the cervical area, while the corporeal
endometrium, into and from which the blood is first shed,
presents neither the histological nor physiological characters
of a mucous membrane, its scant serous secretion never yielding a
mucine reaction.

This secretion, howevety contains an element present normally
during the menstrual cycle and abnormally continuous in some
of the metrorrhagic cases mider consideration capable of inhibiting
coagulation in any blood with which it comes into contact.

This is the element which dominates the result of our treatment
and as we do not at present possess any direct means of
counteracting it, we must attempt its circumvention by retarding
the local and general circulation in a manner to induce coagu-



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886 sturmdorf: metrorrhagia and uterine fibrosis.

lation before the blood is extr^vasated into the uterine cavity-
proper. In other words, we must attempt to prevent contact
of the blood with this inhibiting element.

Such a result may be accomplished in most cases by a com-



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 91 of 109)