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Chronic backache in gynecology
276
THE
AMERICAN
JOURNAL
OF
ORSTETRICS
AND
C,YNECOLOQY
Senile endometritis, coming on at the menopause, is an example. It is usually worst after an artificial menopause resulting from radiation or operative castration. Functional disturbances at puberty have a similar cause. This may be called metropathy. Its etiology, course, treatment and curative results are still indefinite. This second type is found in women who do hard work. Normal menstruation and endometrial secretion depend on a normal sexual life. Women doing men’s work usually do not lead such a life. Other etiologic factors are sexual perversions; abnormal sexual stimuli as found in the theater, dancing, etc. ; too little or too much cohabitation ; the various methods of contraception and especially coitus interruptus. The author believes that avoidance of normal childbearing is an important factor in causing functional derangements. Metroendometritis and metropathg are not sharply differentiable. The former bcgins as a local anatomic change, the latter with filnctional derangements leading secondarily to local anatomic changes. The best treatment for metroendometritis is curettage, but incidentally also the whole sexual life shouId be brought back to normal. FR-INK A. PENBERTOS.
Andrews,
H. R.: Backache
in Women.
British
hfedical
Journal,
1925,
ii,
1207.
The .following is a rough and ready classification of some of the causes of backache: (1) Disease or injury of some of the tissues of the back. This class emphasizes the importance, in the diagnosis of backache, of not trusting to abdominal, vaginal, rectal, and bimanual examination alone but examining the back itself. (2) Fatigue. A very large number of the chronic backaches of women are due to fatigue of the back muscles, often increased by weakness of the abdominal muscles and the consequent drag of the abdominal viscera. (3) Enteroptosis. Together with, or apart. from, the fati,gue element backache may be caused by enteroptosis and by enlargement of the abdomen from any cause. (4) Tumors, obesity. It is obvious that large ovarian and uterine tumors may cause backache by their weight, without any inflammatory changes, as may also a large collection of free fluid. (5) Carcinoma of the uterus and of the rectum. In some cases of this kind backache may be of almost intolerable severity. (6) Disease or infection of the kidney. Pyelitis or pyelonephritis is an exceedingly common condition, and often is not recognized until the patient has suffered from it for a long time, and has been uselessly treated for various conditions mistakenly held responsible for the backache. (7) Retroversion of the uterus. In the author’s opinion, retroversion of the uterus without He does not believe that uncomany fixation is sometimes responsible for backache. plicated retrorersion in young single women and in the eld,erly causes backache or calls for operation, and thinks that rrtroversions which cause backache would become less common if more care were taken during the puerperium to prevent the malposition. (8) Prolapse of the pelvic. contents. A warniug must be given once more against concentrating on treatment of weakness of the pelvic floor or rctroversion of the uterus in cases in which almost all the abdominal viscera as well as the pelvic organs are sagging doJvn. F. T,. ADAIR.
Dougal:
Chronic Backache
in Gynecology,
Lancet,
1924,
ii,
1220.
In this series of 1,000 patients he found that 235, or about 23 per cent, complained of backache, and that it was the principal symptom in one-third of this number. The diseases found to be most commonly associated with backache were: genital prolapse, chronic cervicitis, endometritis and metritis, adnexal and periuterine inflammation, uterine fibroids, adenomyoma, and cancer of the cervix. Retroversions and retroflexions of the uterus, in the opinion of the author, do not play a predominant part in producing backache, except so far as they are associated with chronic endomet&is, etc.
REVIEWS
AND
ABSTRACTS
“77
All operated eases were followed up aa to the effect on this particular syrr~ptom. Replies were received from 152 patients, of which 62 had had no backache since the operation. Forty-two were much improved and 41 were no better. Seventy-three per cent of backaches associated with a gynecologic abnormality were cured or much relieved by appropriate surgical treatment. The importance of backache in uncomplicated retroversion and retroflexion haa been much exaggerated, as it is found, almost as frequently, in cases where the uterus is in a forward position. The most important factor in produring backache is fatigue of muscles. Where there is a definite indication for surgical treatment the backache can be cured or much relieved in over seventy per cent of CRSI~S,the rpnu1t.s being especialI! good in cases of prolapse treated by colporrhaph~. NORMAN F. Mrra,c~. Huet: Rupture and Perforation of Pgosalpinx into the Peritoneal Cavity. Journal de ,Chirurgie, 1924, xxiii, 123. The frequency of ruptured pyosalpinx, as given by various authors, differs widely, but it, certainly cannot be classed as a rare occurrence. Rupture may be caused by direct trauma of some kind or may be due to the lighting up of an old infection. In the first type, there is found a distinct tear in the tubal wall, while in the second, the aperture is more of the nature of a perforation, being due to the formation of perforatire ulcers. In ten cases of rupture due to trauma there were only three deaths but in twelve perforations eight deaths. These perforations vary greatly in size and shape and often are surrounded by a necrotic zone. They are usually single but in one Case two openings were found. The rupture occurs most. frequently in the ampulla of the tube. The principal symptoms are severe pain, collapse, pallor, chills, and aeeeleratiou of pulse, followed by a steady rise in temperature, nausea and vomiting. The onset follows immediately the trauma in the cases of true rupture while in the cases of perforation the characteristic symptoms may not be present for several days. There is a marked rigidity of the abdomen with abdominal tenderness and lack of motion on respiration. Rupture of the bladder, ruptured appcndir and ruptured tubal pregnancy must be considered in the differential diagnosis. Where the diaguosis is made early, operatiuu is clearly indicated. If, however. the condition has progressed to the stage of abdominal dis:elltion, the prognosis is extremely poor. When the collection of pus is more or less loralized and low down in the pelvis a posterior colpotomy is the operation of choice. This, ho\\ever, implies the danger of leaving the infected tube as possible source of reinfection. Therefore, in those eases where laparotomy is necessary to reach the pus, he advocat?s a rcmoval of the tube. Following all such laparotomies he inserts a drain at the low\:c?l end of the incision down into the culdesac. THEODORE W. ADAMS. 111% Tixier and Rochet: Salpingitis in Elderly Women. Archives France-Belgcs Chirurgie, 1925, xxviii, 659. In patients from thirty-five to forty-five years of age salpingitis assumes an extremely grave aspect. It occurs unexpectedly both in women who have previously had,a genital infecticn, and in those in whom there is no tracae of previous infections pathology. In the latter type there often exists a source of latent infection such a?? In elderly women salpingitis is a degenerating fibroid or small local infections. cured but seldom by medical treatment and the prognosis is always poor even SO far as life is concerned. The treatment of choice is total hysterectomy as at this time of life the symptoms of postoperative menopause arc negligible. THEODORE
W. ADAMS.
THE
AMERICAN
JOURNAL
OF
ORSTETRICS
AND
C,YNECOLOQY
Senile endometritis, coming on at the menopause, is an example. It is usually worst after an artificial menopause resulting from radiation or operative castration. Functional disturbances at puberty have a similar cause. This may be called metropathy. Its etiology, course, treatment and curative results are still indefinite. This second type is found in women who do hard work. Normal menstruation and endometrial secretion depend on a normal sexual life. Women doing men’s work usually do not lead such a life. Other etiologic factors are sexual perversions; abnormal sexual stimuli as found in the theater, dancing, etc. ; too little or too much cohabitation ; the various methods of contraception and especially coitus interruptus. The author believes that avoidance of normal childbearing is an important factor in causing functional derangements. Metroendometritis and metropathg are not sharply differentiable. The former bcgins as a local anatomic change, the latter with filnctional derangements leading secondarily to local anatomic changes. The best treatment for metroendometritis is curettage, but incidentally also the whole sexual life shouId be brought back to normal. FR-INK A. PENBERTOS.
Andrews,
H. R.: Backache
in Women.
British
hfedical
Journal,
1925,
ii,
1207.
The .following is a rough and ready classification of some of the causes of backache: (1) Disease or injury of some of the tissues of the back. This class emphasizes the importance, in the diagnosis of backache, of not trusting to abdominal, vaginal, rectal, and bimanual examination alone but examining the back itself. (2) Fatigue. A very large number of the chronic backaches of women are due to fatigue of the back muscles, often increased by weakness of the abdominal muscles and the consequent drag of the abdominal viscera. (3) Enteroptosis. Together with, or apart. from, the fati,gue element backache may be caused by enteroptosis and by enlargement of the abdomen from any cause. (4) Tumors, obesity. It is obvious that large ovarian and uterine tumors may cause backache by their weight, without any inflammatory changes, as may also a large collection of free fluid. (5) Carcinoma of the uterus and of the rectum. In some cases of this kind backache may be of almost intolerable severity. (6) Disease or infection of the kidney. Pyelitis or pyelonephritis is an exceedingly common condition, and often is not recognized until the patient has suffered from it for a long time, and has been uselessly treated for various conditions mistakenly held responsible for the backache. (7) Retroversion of the uterus. In the author’s opinion, retroversion of the uterus without He does not believe that uncomany fixation is sometimes responsible for backache. plicated retrorersion in young single women and in the eld,erly causes backache or calls for operation, and thinks that rrtroversions which cause backache would become less common if more care were taken during the puerperium to prevent the malposition. (8) Prolapse of the pelvic. contents. A warniug must be given once more against concentrating on treatment of weakness of the pelvic floor or rctroversion of the uterus in cases in which almost all the abdominal viscera as well as the pelvic organs are sagging doJvn. F. T,. ADAIR.
Dougal:
Chronic Backache
in Gynecology,
Lancet,
1924,
ii,
1220.
In this series of 1,000 patients he found that 235, or about 23 per cent, complained of backache, and that it was the principal symptom in one-third of this number. The diseases found to be most commonly associated with backache were: genital prolapse, chronic cervicitis, endometritis and metritis, adnexal and periuterine inflammation, uterine fibroids, adenomyoma, and cancer of the cervix. Retroversions and retroflexions of the uterus, in the opinion of the author, do not play a predominant part in producing backache, except so far as they are associated with chronic endomet&is, etc.
REVIEWS
AND
ABSTRACTS
“77
All operated eases were followed up aa to the effect on this particular syrr~ptom. Replies were received from 152 patients, of which 62 had had no backache since the operation. Forty-two were much improved and 41 were no better. Seventy-three per cent of backaches associated with a gynecologic abnormality were cured or much relieved by appropriate surgical treatment. The importance of backache in uncomplicated retroversion and retroflexion haa been much exaggerated, as it is found, almost as frequently, in cases where the uterus is in a forward position. The most important factor in produring backache is fatigue of muscles. Where there is a definite indication for surgical treatment the backache can be cured or much relieved in over seventy per cent of CRSI~S,the rpnu1t.s being especialI! good in cases of prolapse treated by colporrhaph~. NORMAN F. Mrra,c~. Huet: Rupture and Perforation of Pgosalpinx into the Peritoneal Cavity. Journal de ,Chirurgie, 1924, xxiii, 123. The frequency of ruptured pyosalpinx, as given by various authors, differs widely, but it, certainly cannot be classed as a rare occurrence. Rupture may be caused by direct trauma of some kind or may be due to the lighting up of an old infection. In the first type, there is found a distinct tear in the tubal wall, while in the second, the aperture is more of the nature of a perforation, being due to the formation of perforatire ulcers. In ten cases of rupture due to trauma there were only three deaths but in twelve perforations eight deaths. These perforations vary greatly in size and shape and often are surrounded by a necrotic zone. They are usually single but in one Case two openings were found. The rupture occurs most. frequently in the ampulla of the tube. The principal symptoms are severe pain, collapse, pallor, chills, and aeeeleratiou of pulse, followed by a steady rise in temperature, nausea and vomiting. The onset follows immediately the trauma in the cases of true rupture while in the cases of perforation the characteristic symptoms may not be present for several days. There is a marked rigidity of the abdomen with abdominal tenderness and lack of motion on respiration. Rupture of the bladder, ruptured appcndir and ruptured tubal pregnancy must be considered in the differential diagnosis. Where the diaguosis is made early, operatiuu is clearly indicated. If, however. the condition has progressed to the stage of abdominal dis:elltion, the prognosis is extremely poor. When the collection of pus is more or less loralized and low down in the pelvis a posterior colpotomy is the operation of choice. This, ho\\ever, implies the danger of leaving the infected tube as possible source of reinfection. Therefore, in those eases where laparotomy is necessary to reach the pus, he advocat?s a rcmoval of the tube. Following all such laparotomies he inserts a drain at the low\:c?l end of the incision down into the culdesac. THEODORE W. ADAMS. 111% Tixier and Rochet: Salpingitis in Elderly Women. Archives France-Belgcs Chirurgie, 1925, xxviii, 659. In patients from thirty-five to forty-five years of age salpingitis assumes an extremely grave aspect. It occurs unexpectedly both in women who have previously had,a genital infecticn, and in those in whom there is no tracae of previous infections pathology. In the latter type there often exists a source of latent infection such a?? In elderly women salpingitis is a degenerating fibroid or small local infections. cured but seldom by medical treatment and the prognosis is always poor even SO far as life is concerned. The treatment of choice is total hysterectomy as at this time of life the symptoms of postoperative menopause arc negligible. THEODORE
W. ADAMS.