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Pyometra of cervical stump in a case of arthritis
DAVID (E’ro~
the
Departm’ent
N.
BARROWS,
M.D., New
YORK, N. Y.
of Gynemlogy culd Obstetric% of New Bellcr~uc Hospitul Me&cd College)
Pork
LJ%iwrs-slty
ad
of the ESIDES being rare in our esperiencr, i.e., the only case of pyometra stump in more than the last 26,000 gynecologic admissions to Bellevue Bospnints of interest to those of us who are pital, this case has brought up several working with arthritics. In the past eight years of gynecologic work in the Arthritis Clinic of the Hospital for the Ruptured and Crippled, one of our most interesting problems has been to exactly locate the point where the pelvic focus persisted. We have seen many patients not relieved by supravaginal hysterectomy when t,he focus was apparently in the uterus or adnexa, and many not relieved by a high amputation of the cervix uteri where the focus seamed cervical.
B
Possibly this case suggests one reason why we have seen these disappointing results, and why we have had nrost sa.tisfaction from complete removal of the entire uterus in suitable cases of arthritis. In an article publisheli in 192ri (:. H. Mayo and cl. F. Dixon recommended removal of a residual cervix, in cases whcrr abdominal pain or chronic arthritis We proceeded, according to their persisted aftor suyravaginal hysterectomy. recommendations, in the case presented here: E.D., married, aged forty-two, U. S., admitted to the Gynecological Service of Bellevue Hospital, February 9, 1933, complaining of pain and swelling in lhr left knee and geuoral joint pains: duration one week. Her
family
hysterectomy
disease.
No
history was irrelevant, but her past history showed a supravaginal and bilateral salpingo-oophorectomy in 1917 for pelvic inflammatory recurrence of symptoms for which it was done.
Gravida iii, para none, three self-induced abortions, last 1916, no complieations. Menstruation began at eleven, always irregular of four to six days’ duration but no bleeding since 1917. Syphilis one year ago, one six-week course of treatment while in jail. Denied intercourse over period of four months. Physical examination revealed an enlarged and tender left knee joint held in flexion, an old midline suprapubic scar, tapering vagina with small conical cervix about two inches long. No fundus uteri, adnexal masses or tenderness were palpable in pelvis. .\ yollo\v vaginal discharge was twice negative for gonorrhea. In aspirating the knee joint: 33 VA:. of turbid greenish yellow fluid was obtained, which contained eonsitlerablc fibrin; 39 cc. of air was replaced. Culture was negative. The Orthopedic Department diagnosed case as infectious arthritis. One week later, she was operated upon vaginally under spinal anesthesia to remove a probable focus in a cystic cervix. Exposure was obtained by a lateral episiotomy, and the cervix, about two inches long, was pulled down, the mucous membrane being reflected on all sides. It the upper end of this cervical stump, a large pus pocket was discovered, holding between 5 and 19 C.C. of yellow odorless fluid pus. As the surrounding tissues were firmly adherent and the sac *PreSented
at a meeting
cf the New
Pork 774
Obstetrical
Society,
November
14. 1993.
SI,WvIONS:
775
,STEKII.IZA’~JON
friable, the upper wall of the cavity could not be removed in toto so was swabbed with phenol and alcohol, and cigaret drains were inserted before closing the vaginal mucosa with interrupted sutures. Similar sutures were used to close the episiotomy. Preoperative diagnosis, arthritis and chronic cervicitis, postoperative, arthritis and pyometra of uterine stump. Culture from the pus showed Staphylowcm mareus. The knee continued painful with some inflammatory thickening but no more fluid. It was stretched under a general anesthetic and put up in plaster cast in full extension. After several months of physiotherapy following removal of the cast, the patient was able to walk and left the hospital in July. She appeared for reexamination a year aft.er her discharge, and is working every day in a hotel as a chambermaid. Her knee has given her no pain since leaving the hospital, but the motion in the joint is limited. Her pelvic examination revealed no thickening which could be inflammatory. Her syphilis had been cleared up. SUMMARY 1. This comparatively large collection of pus at or in the upper end of a cervical stump some years after operation, indicates that similar smaller collections would be easier to miss. 2. This may have been a true pyometra in the remains of the uterine cavity or the abscess formation may have been associated with an old parametrial infection as in intramural abscess of the uterus. 3. A similar condition might followsupravagina1 hysterectomy for fibroids where the cervix is apparently perfecely innocuous.
130 EAST FIFTY-SIXTH
STREET DISCUSSION
DR. FREDERICK C. HOLDEN.-I think it is of interest that women with so much pus in the pelvis, in different locations in the cervix, the parametrium, and the tubes themselves may present an arthritis which is attributable to the genital tract. 1 personally can recall only 2 of 3 cases which could possibly be attributed to that cause. I certainly do not think that the fact that you occasionally find a patient similar to Dr. Barrows’ , justifies the doing of a compIete hysterectomy in preference to supravaginal hysterectomy. I do think, however, that if one is operating upon a patient with arthritis with the idea in mind of eliminating a focus of infection, the operation should be very extensive and thorough.
STERILIZATION
BY
TRANSPLANTING OF THE TUBES
J. MORRISSLEMONS,
A
PROCEDURE but the lack its value. Briefly surgical procedure
M.D.,
I;os
THE ANGELES,
UTERINE
END
CALIF.
employed consistently for ten years may not be called new. of novelty should be compensated by a more mature estimate of summarized this method of sterilization consists of a simple in two steps, namely, excision of the proximal end of both tubes
the
Departm’ent
N.
BARROWS,
M.D., New
YORK, N. Y.
of Gynemlogy culd Obstetric% of New Bellcr~uc Hospitul Me&cd College)
Pork
LJ%iwrs-slty
ad
of the ESIDES being rare in our esperiencr, i.e., the only case of pyometra stump in more than the last 26,000 gynecologic admissions to Bellevue Bospnints of interest to those of us who are pital, this case has brought up several working with arthritics. In the past eight years of gynecologic work in the Arthritis Clinic of the Hospital for the Ruptured and Crippled, one of our most interesting problems has been to exactly locate the point where the pelvic focus persisted. We have seen many patients not relieved by supravaginal hysterectomy when t,he focus was apparently in the uterus or adnexa, and many not relieved by a high amputation of the cervix uteri where the focus seamed cervical.
B
Possibly this case suggests one reason why we have seen these disappointing results, and why we have had nrost sa.tisfaction from complete removal of the entire uterus in suitable cases of arthritis. In an article publisheli in 192ri (:. H. Mayo and cl. F. Dixon recommended removal of a residual cervix, in cases whcrr abdominal pain or chronic arthritis We proceeded, according to their persisted aftor suyravaginal hysterectomy. recommendations, in the case presented here: E.D., married, aged forty-two, U. S., admitted to the Gynecological Service of Bellevue Hospital, February 9, 1933, complaining of pain and swelling in lhr left knee and geuoral joint pains: duration one week. Her
family
hysterectomy
disease.
No
history was irrelevant, but her past history showed a supravaginal and bilateral salpingo-oophorectomy in 1917 for pelvic inflammatory recurrence of symptoms for which it was done.
Gravida iii, para none, three self-induced abortions, last 1916, no complieations. Menstruation began at eleven, always irregular of four to six days’ duration but no bleeding since 1917. Syphilis one year ago, one six-week course of treatment while in jail. Denied intercourse over period of four months. Physical examination revealed an enlarged and tender left knee joint held in flexion, an old midline suprapubic scar, tapering vagina with small conical cervix about two inches long. No fundus uteri, adnexal masses or tenderness were palpable in pelvis. .\ yollo\v vaginal discharge was twice negative for gonorrhea. In aspirating the knee joint: 33 VA:. of turbid greenish yellow fluid was obtained, which contained eonsitlerablc fibrin; 39 cc. of air was replaced. Culture was negative. The Orthopedic Department diagnosed case as infectious arthritis. One week later, she was operated upon vaginally under spinal anesthesia to remove a probable focus in a cystic cervix. Exposure was obtained by a lateral episiotomy, and the cervix, about two inches long, was pulled down, the mucous membrane being reflected on all sides. It the upper end of this cervical stump, a large pus pocket was discovered, holding between 5 and 19 C.C. of yellow odorless fluid pus. As the surrounding tissues were firmly adherent and the sac *PreSented
at a meeting
cf the New
Pork 774
Obstetrical
Society,
November
14. 1993.
SI,WvIONS:
775
,STEKII.IZA’~JON
friable, the upper wall of the cavity could not be removed in toto so was swabbed with phenol and alcohol, and cigaret drains were inserted before closing the vaginal mucosa with interrupted sutures. Similar sutures were used to close the episiotomy. Preoperative diagnosis, arthritis and chronic cervicitis, postoperative, arthritis and pyometra of uterine stump. Culture from the pus showed Staphylowcm mareus. The knee continued painful with some inflammatory thickening but no more fluid. It was stretched under a general anesthetic and put up in plaster cast in full extension. After several months of physiotherapy following removal of the cast, the patient was able to walk and left the hospital in July. She appeared for reexamination a year aft.er her discharge, and is working every day in a hotel as a chambermaid. Her knee has given her no pain since leaving the hospital, but the motion in the joint is limited. Her pelvic examination revealed no thickening which could be inflammatory. Her syphilis had been cleared up. SUMMARY 1. This comparatively large collection of pus at or in the upper end of a cervical stump some years after operation, indicates that similar smaller collections would be easier to miss. 2. This may have been a true pyometra in the remains of the uterine cavity or the abscess formation may have been associated with an old parametrial infection as in intramural abscess of the uterus. 3. A similar condition might followsupravagina1 hysterectomy for fibroids where the cervix is apparently perfecely innocuous.
130 EAST FIFTY-SIXTH
STREET DISCUSSION
DR. FREDERICK C. HOLDEN.-I think it is of interest that women with so much pus in the pelvis, in different locations in the cervix, the parametrium, and the tubes themselves may present an arthritis which is attributable to the genital tract. 1 personally can recall only 2 of 3 cases which could possibly be attributed to that cause. I certainly do not think that the fact that you occasionally find a patient similar to Dr. Barrows’ , justifies the doing of a compIete hysterectomy in preference to supravaginal hysterectomy. I do think, however, that if one is operating upon a patient with arthritis with the idea in mind of eliminating a focus of infection, the operation should be very extensive and thorough.
STERILIZATION
BY
TRANSPLANTING OF THE TUBES
J. MORRISSLEMONS,
A
PROCEDURE but the lack its value. Briefly surgical procedure
M.D.,
I;os
THE ANGELES,
UTERINE
END
CALIF.
employed consistently for ten years may not be called new. of novelty should be compensated by a more mature estimate of summarized this method of sterilization consists of a simple in two steps, namely, excision of the proximal end of both tubes