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Retroperitoneal, Mediastinal, and Cervical Emphysema Following Culdoscopy
Retroperitoneal, Mediastinal, and Cervical Emphysema Following Culdoscopy Quincy E. Fortier, M.D.
of retroperitoneal structures depends upon introduction of gas into the peritoneal cavity. The possibility that this gas might pass into subserous or extracoelomic spaces does not appear to have been considered. Reports of 5 patients in whom this occurred follow:
CULDOSCOPIC VISUALIZATION
Case 1
"
J
:;
Mrs. W. H. J. was a 31-year-old woman complaining of sterility for three years. Routine examination was negative, except for x-ray evidence of Stein-Leventhal syndrome. Because of the enlarged ovaries culdoscopy was planned. The patient was placed kneeling on a proctoscopic knee rest and the table tilted to an angle of 45 degrees. She was then given 100 mg. of Demerol intravenously. The "blue area" of the posterior fornix was not well made out. However, Novocain was injected to form a wheal in the wall of the posterior fornix mid-way between the uterus and the rectum and an attempt made to insert the cannula and trocar. When the peritoneum seemed to be penetrated carbon dioxide was introduced under slight pressure because it did not flow readily. Approximately 500 cc. of gas was used. When the trocar was removed and visual system inserted it was evident penetration had not occurred and that retroperitoneal fat was being pushed ahead of the telescope. The trocar, sheath, and visual system were removed and a second attempt at penetration made. This was successful. About 1000 cc. of gas flowed readily into the peritoneal cavity. Because she complained of pain in the chest that came and went quite rapidly, her chest was examined. This revealed a precordial friction rub synchronous with her heart beat. For this reason she was x-rayed. This revealed pneumopericardium (Fig. 1). After she had rested a short time she was taken home. The next day the rub was gone and the discomfort in her shoulders and neck disappeared From the Department of Obstetrics and Gynecology, University of Minnesota Medical School, Minneapolis, Minnesota. 173
1A
1B
2A
2B
Fig. 1. Case 1. A, Chest film, showing pneumopericardium following attempted culdoscopy. B, Same after absorption of gas. Fig. 2. Case 2. A, Flat plate of abdomen before attempted culdoscopy. B, Same six days after attempted culdoscopy showing perirenal air.
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EMPHYSEMA AFTER CULDOSCOPY
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in about three to four days. Laparotomy four days later revealed air in the pelvic and abdominal retroperitoneal spaces.
Case 2 M. S., a 25-year-old sterility patient who had been married five and a half years, presented herself for culdoscopy on January 10, 1952. Closed tubes had been diagnosed by hysterosalpingography and operation, if indicated, was scheduled to follow culdoscopy. She was prepared for major surgery, placed in the knee chest position, and was anesthetized with Pentothal. Culdoscopy was attempted but failed. A laparotomy was performed. When the abdomen was opened, emphysema was noted
..
J
3A Fig. 3.
38
Case 3. A, Kidney, ureter, and bladder plate before attempted culdoscopy. B, Same after culdoscopy showing extensive retropneumoperitoneum and perirenal emphysema. along both sides of the bladder extending upward and laterally. The uterus was inHated with carbon dioxide and showed the tubes to be congenitally atretic beyond a point 2 cm. from the cornual end. The patient had a Hat plate x-ray of the abdomen and an excretory ureterogram on the sixth postoperative day to look for other urogenital anomalies. The x-rays showed the extracoelomic emphysema of the pelvis and abdomen, the kidneys still being outlined by the air (Fig. 2 B).
Case 3 L. N., an 18-year-old gravida 0, was scheduled for culdoscopy because of a mass on the right side. This disappeared when she lay down but reappeared
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below her belt when she stood up. She was placed in the knee chest position and culdoscopy was attempted. The operator failed to penetrate into the cul-de-sac. Shortly after this the patient complained of severe flank pain, followed by chest pain, difficulty in breathing, and pain in the neck. The discomfort was so severe that she required narcotics for relief. These symptoms lasted four days. Two weeks later the patient returned as requested for a repeat attempt at culdoscopy. The first attempt again failed. A second attempt was immediately made closer to the rectum and was successful. Since the patient had had Nembutal 75 mg. and Demerol 75 mg. intravenously she complained only of slight flank pain. Nothing unusual was found except for a simple cyst of the left ovary measuring about 3 cm. in diameter. Since it seemed that the tumor was a ptotic kidney, an upright roentgenogram of the abdomen was performed after the last culdoscopy to take advantage of the pneumoperitoneum. The kidneys were visualized extremely well (Fig. 3 B). Dr. Bertram T. Levin, of the Radiology Department of the University of Minnesota, saw the films and inquired what technic had been employed to produce such excellent perirenal emphysema.
Case 4 B. R., a 29-year-old gravida I, para I, was admitted for study with a history of having had a pink vaginal discharge which began one week prior to the onset of her regular menstrual period. This was accompanied by crampy lower abdominal pains and left lower abdominal discomfort. The cramps perSisted through the period of bleeding and periodically became quite severe. Examination was essentially negative except for lower abdominal and pelvic findings. These consisted of retropubic tenderness to deep palpation, an anteflexed uterus of normal size, a large tender ovary on the right, and a tender doughy mass on the left, about 6 cm. in diameter, poorly demarcated from the surrounding tissue. The posterior fornix did not bulge and it was thought culdoscopy could be carried out since the mass appeared to be fairly high in the pelvis. The patient was placed in the knee chest position and given 75 mg. of Nembutal intravenously. The "blue area" of the fornix was infiltrated with 0.5 per cent Novocain and an attempt made to perforate it with the trocar and sheath. The tissue was tough and gave an abnormal amount of resistance. No gas was given because of the doubt that penetration had been successful. When the visual system was inserted the fact that penetration had failed was verified since only fat and connective tissue could be seen. A second attempt was likewise unsuccessful. Since the operators felt some air might have been drawn into the peritoneal cavity, x-rays were taken in the position described by Stein (Fig. 4 A) . There was no free air in the peritoneal cavity but retroperitoneal air was noted in the pelvis. Two masses could be seen, one on either side of the uterus. The one on the right appeared to be about 5 cm. and that on the left about 6 cm. in diameter. Abdominal and chest x-rays were taken which revealed extensive extracoelomic air (Fig. 4 B). Subsequently crepitation was felt in the neck and the patient's voice deepened. Neck x-rays were taken which revealed emphysema (Fig. 4 C). When the patient was questioned about symptoms after the examina-
"
4A
4B
4C
40
Fig. 4. Case 4. A, Pelvis after attempted culdoscopy showing subserous emphysema and ovarian masses. B, Perirenal and extensive extracoelomic air after attempted culdoscopy. C, X-ray of neck showing emphysema. D, X-ray of abdomen 13 days after attempted culdoscopy showing perirenal air still present but greatly diminished.
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tion she complained most of difficulty in breathing, deepening of the voice, and pain in the neck and both shoulders. The emphysema in the neck still persisted when the patient left the hospital six days later but was decreasing. On the thirteenth day after surgery roentgenograms taken with the patient in the upright position showed air still present about the kidneys although greatly diminished in amount (Fig. 4 D).
Case 5 M. P., a 29-year-old gravida 0, complained of sterility during four years of married life. The only significant history was that of an appendectomy about five years previously. Examination was essentially negative. Examination of the patient in the knee chest position revealed the vaginal wall of the posterior fornix to be thicker than normal and to exhibit no well-defined "blue area." However, what was believed to be an adequate free area was noted between rectum and cervix. When the mucosa was injected with Procaine and the needle pushed through the vaginal wall and withdrawn no "hiss" could be heard. The trocar and sheath were then thrust through the vaginal wall. Since no air could be heard to enter the abdomen, no carbon dioxide was introduced. Inspection through the visual system revealed only retroperitoneal fat which could not be penetrated. A second attempt was made. This likewise failed. Since this patient did not complain of the discomfort, as the other patients who took in large amounts of extracoelomic air had, it was thought that retropneumoperitoneum had not been produced. Roentgenograms were taken. These revealed diffuse subserous emphysema which showed up some pelvic vessels, the kidneys and even the pancreas (Fig. 5).
DISCUSSION That patients on whom culdoscopy has been attempted and failed, even though no gas has been used, frequently complain more acutely and longer of back, chest, shoulder, and even neck discomfort than do those on whom it has been successfully carried out has been observed for some time. Until the cases noted above were studied it was difficult to explain this. Undoubtedly the pain is due to the air dissecting upward through the subserous connective tissue. This passage of gas or air continues as long as the patient remains in the knee-chest position and the amount of air taken in depends apparently on the length of time the patient remains in this position. The patient in Case 4, who developed emphysema of the neck, remained in the knee-chest position longer than others because roentgenograms were repeated several times to get the desired view of the pelvis. It should be noted that all patients except the first took in air passively since no gas was administered. In the first case gas was attached to the sheath and this found its way into the pericardial sac.
6 Fig. 5. Case 5. A, X-ray of abdomen showing perirenal and extensive subserous emphysema. B, Lateral film of abdomen showing extracoelomic air and peripancreatic emphysema. C, X-ray of chest showing no air under diaphragm, indicating no penetration of peritoneal cavity took place. Fig. 6. X-ray of abdomen showing residual gas as found after successful culdoscopy for comparison with other x-rays showing retroperitoneal emphysema. Note practically all air has collected under the diaphragm.
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In culdoscopy with the patient in the knee-chest position, one finds negative pressures of about 20 cm. H20. This is created by the diaphragm moving upward as the bowel drops forward and downward. If a proctoscope or a tube is placed in the anus while the patient is in the knee-chest position the lower bowel dilates so that proctoscopy may be done without adding additional air, since air is drawn in passively.1 The knee-chest position is used for this reason in culdoscopy and dry cystoscopy (Fig. 6). It is only reasonable to believe that air or gas will be drawn upward into the loose connective tissue of the retroperitoneal space in the same way. At the same time infected materials such as vaginal discharge and rectal and bladder contents may also be drawn upward through a wound in any of these viscera if the patient is in the knee-chest position at the time the injury is sustained. It is easy to see how infection then can be spread almost instantly through the retroperitoneal space to the mediastinum and neck. Excellent papers have appeared on generalized subserous emphysema and pneumoretroperitoneum. 2,3 Ruiz Rivas describes two methods, one by injecting oxygen into the caudal canal and the second by injecting the same gas presacrally between the rectum and sacrum. Since these, other papers have appeared from time to time. A summary of these with a bibliography was given by Leucutia in 1953. In his second paper, published in 1950, Rivas discussed in detail and showed by diagrams how gas could spread in the retroperitoneal space. However, it should be noted that he and others have used gas under pressure. The question as to whether or not this extracoelomic emphysema may prove useful in diagnosis of pelvic, abdominal, mediastinal, and neck pathology has been adequately proved by Rivas. Whether or not producing this passively may have advantages over the actively produced emphysema still is open to question. We know that actively produced emphysema with the use of a small needle frequently give good emphysema in limited areas such as about one kidney and not the other. On the other hand emphysema produced passively by inserting the culdoscope trocar and sheath into the retroperitoneal tissue is generalized, giving more or less equal spread to all parts. This may be due to two reasons. The negative pressure is probably exerted in all directions equally while the air from one small needle under pressure tends to follow the path of least resistance. The second reason probably lies in the fact that
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EMPHYSEMA AFTER CULDOSCOPY
181
many more potential spaces are opened by the large trocar and are held open by the sheath so that a more generalized spread is insured. It is possible that by the use of a trocar and a sheath placed in the presacral area, with the patient in the knee-chest position, emphysema will be more safely produced than by using the vaginal route. Carbon dioxide or oxygen may be used by attaching a source such as a 5-liter bag filled with the gas under practically no pressure (as we do in culdoscopy). In this case the trocar should be quickly removed and the end of the sheath covered with an air tight cap. Why air can be placed in the extracoelomic connective tissue without producing gas emboli is of interest. However, when we consider that there is a protective coat of connective tissue about the vessels one can readily see how gas is kept from entering their lumena unless a vessel is cut across in the process of producing the initial puncture. If relatively avascular areas are chosen, this should not occur. SUMMARY Five cases of passively produced generalized subserous emphysema proved by x-ray and/or operation are reported. These all followed at least one unsuccessful attempt to penetrate completely the vaginal wall in the posterior fornix. Three of these cases were consecutive culdoscopy failures and seem to indicate that perhaps nearly all penetrating wounds of the vaginal fornix not deep enough to penetrate the peritoneal cavity but deep enough to penetrate the vaginal mucosa with the patient in the knee-chest position will produce some degree of subserous emphysema. The question as to whether or not this method of producing extracoelomic emphysema is of value in diagnosis is discussed. REFERENCES 1.
C. Sigmoidoscopy, A New Surgical Position and Apparatus for Attaining and Maintaining It. Surg., Gynec. & Obst. 96:249, 1953. 2. RUIZ, R. M. Diagnostico radiologico, EI neumorrii'i6n. Tecnica original. Arch. espan. urol. 4:228, 1948. 3. RUIZ, R. M. Roentgenological diagnosis: Generalized subserous emphysema through a single puncture. Am. J. Roentgenol. 64:723, 1950. 4. LEUCUTIA, T. Pneumoperitoneum and pneumoretroperitoneum. Am. J. Roentgenol. 68:655, 1952. BLAIR, LYMAN
of retroperitoneal structures depends upon introduction of gas into the peritoneal cavity. The possibility that this gas might pass into subserous or extracoelomic spaces does not appear to have been considered. Reports of 5 patients in whom this occurred follow:
CULDOSCOPIC VISUALIZATION
Case 1
"
J
:;
Mrs. W. H. J. was a 31-year-old woman complaining of sterility for three years. Routine examination was negative, except for x-ray evidence of Stein-Leventhal syndrome. Because of the enlarged ovaries culdoscopy was planned. The patient was placed kneeling on a proctoscopic knee rest and the table tilted to an angle of 45 degrees. She was then given 100 mg. of Demerol intravenously. The "blue area" of the posterior fornix was not well made out. However, Novocain was injected to form a wheal in the wall of the posterior fornix mid-way between the uterus and the rectum and an attempt made to insert the cannula and trocar. When the peritoneum seemed to be penetrated carbon dioxide was introduced under slight pressure because it did not flow readily. Approximately 500 cc. of gas was used. When the trocar was removed and visual system inserted it was evident penetration had not occurred and that retroperitoneal fat was being pushed ahead of the telescope. The trocar, sheath, and visual system were removed and a second attempt at penetration made. This was successful. About 1000 cc. of gas flowed readily into the peritoneal cavity. Because she complained of pain in the chest that came and went quite rapidly, her chest was examined. This revealed a precordial friction rub synchronous with her heart beat. For this reason she was x-rayed. This revealed pneumopericardium (Fig. 1). After she had rested a short time she was taken home. The next day the rub was gone and the discomfort in her shoulders and neck disappeared From the Department of Obstetrics and Gynecology, University of Minnesota Medical School, Minneapolis, Minnesota. 173
1A
1B
2A
2B
Fig. 1. Case 1. A, Chest film, showing pneumopericardium following attempted culdoscopy. B, Same after absorption of gas. Fig. 2. Case 2. A, Flat plate of abdomen before attempted culdoscopy. B, Same six days after attempted culdoscopy showing perirenal air.
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EMPHYSEMA AFTER CULDOSCOPY
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in about three to four days. Laparotomy four days later revealed air in the pelvic and abdominal retroperitoneal spaces.
Case 2 M. S., a 25-year-old sterility patient who had been married five and a half years, presented herself for culdoscopy on January 10, 1952. Closed tubes had been diagnosed by hysterosalpingography and operation, if indicated, was scheduled to follow culdoscopy. She was prepared for major surgery, placed in the knee chest position, and was anesthetized with Pentothal. Culdoscopy was attempted but failed. A laparotomy was performed. When the abdomen was opened, emphysema was noted
..
J
3A Fig. 3.
38
Case 3. A, Kidney, ureter, and bladder plate before attempted culdoscopy. B, Same after culdoscopy showing extensive retropneumoperitoneum and perirenal emphysema. along both sides of the bladder extending upward and laterally. The uterus was inHated with carbon dioxide and showed the tubes to be congenitally atretic beyond a point 2 cm. from the cornual end. The patient had a Hat plate x-ray of the abdomen and an excretory ureterogram on the sixth postoperative day to look for other urogenital anomalies. The x-rays showed the extracoelomic emphysema of the pelvis and abdomen, the kidneys still being outlined by the air (Fig. 2 B).
Case 3 L. N., an 18-year-old gravida 0, was scheduled for culdoscopy because of a mass on the right side. This disappeared when she lay down but reappeared
176
FORTIER
Fertility & Sterility
below her belt when she stood up. She was placed in the knee chest position and culdoscopy was attempted. The operator failed to penetrate into the cul-de-sac. Shortly after this the patient complained of severe flank pain, followed by chest pain, difficulty in breathing, and pain in the neck. The discomfort was so severe that she required narcotics for relief. These symptoms lasted four days. Two weeks later the patient returned as requested for a repeat attempt at culdoscopy. The first attempt again failed. A second attempt was immediately made closer to the rectum and was successful. Since the patient had had Nembutal 75 mg. and Demerol 75 mg. intravenously she complained only of slight flank pain. Nothing unusual was found except for a simple cyst of the left ovary measuring about 3 cm. in diameter. Since it seemed that the tumor was a ptotic kidney, an upright roentgenogram of the abdomen was performed after the last culdoscopy to take advantage of the pneumoperitoneum. The kidneys were visualized extremely well (Fig. 3 B). Dr. Bertram T. Levin, of the Radiology Department of the University of Minnesota, saw the films and inquired what technic had been employed to produce such excellent perirenal emphysema.
Case 4 B. R., a 29-year-old gravida I, para I, was admitted for study with a history of having had a pink vaginal discharge which began one week prior to the onset of her regular menstrual period. This was accompanied by crampy lower abdominal pains and left lower abdominal discomfort. The cramps perSisted through the period of bleeding and periodically became quite severe. Examination was essentially negative except for lower abdominal and pelvic findings. These consisted of retropubic tenderness to deep palpation, an anteflexed uterus of normal size, a large tender ovary on the right, and a tender doughy mass on the left, about 6 cm. in diameter, poorly demarcated from the surrounding tissue. The posterior fornix did not bulge and it was thought culdoscopy could be carried out since the mass appeared to be fairly high in the pelvis. The patient was placed in the knee chest position and given 75 mg. of Nembutal intravenously. The "blue area" of the fornix was infiltrated with 0.5 per cent Novocain and an attempt made to perforate it with the trocar and sheath. The tissue was tough and gave an abnormal amount of resistance. No gas was given because of the doubt that penetration had been successful. When the visual system was inserted the fact that penetration had failed was verified since only fat and connective tissue could be seen. A second attempt was likewise unsuccessful. Since the operators felt some air might have been drawn into the peritoneal cavity, x-rays were taken in the position described by Stein (Fig. 4 A) . There was no free air in the peritoneal cavity but retroperitoneal air was noted in the pelvis. Two masses could be seen, one on either side of the uterus. The one on the right appeared to be about 5 cm. and that on the left about 6 cm. in diameter. Abdominal and chest x-rays were taken which revealed extensive extracoelomic air (Fig. 4 B). Subsequently crepitation was felt in the neck and the patient's voice deepened. Neck x-rays were taken which revealed emphysema (Fig. 4 C). When the patient was questioned about symptoms after the examina-
"
4A
4B
4C
40
Fig. 4. Case 4. A, Pelvis after attempted culdoscopy showing subserous emphysema and ovarian masses. B, Perirenal and extensive extracoelomic air after attempted culdoscopy. C, X-ray of neck showing emphysema. D, X-ray of abdomen 13 days after attempted culdoscopy showing perirenal air still present but greatly diminished.
178
FORTIER
Fertility & Sterility
tion she complained most of difficulty in breathing, deepening of the voice, and pain in the neck and both shoulders. The emphysema in the neck still persisted when the patient left the hospital six days later but was decreasing. On the thirteenth day after surgery roentgenograms taken with the patient in the upright position showed air still present about the kidneys although greatly diminished in amount (Fig. 4 D).
Case 5 M. P., a 29-year-old gravida 0, complained of sterility during four years of married life. The only significant history was that of an appendectomy about five years previously. Examination was essentially negative. Examination of the patient in the knee chest position revealed the vaginal wall of the posterior fornix to be thicker than normal and to exhibit no well-defined "blue area." However, what was believed to be an adequate free area was noted between rectum and cervix. When the mucosa was injected with Procaine and the needle pushed through the vaginal wall and withdrawn no "hiss" could be heard. The trocar and sheath were then thrust through the vaginal wall. Since no air could be heard to enter the abdomen, no carbon dioxide was introduced. Inspection through the visual system revealed only retroperitoneal fat which could not be penetrated. A second attempt was made. This likewise failed. Since this patient did not complain of the discomfort, as the other patients who took in large amounts of extracoelomic air had, it was thought that retropneumoperitoneum had not been produced. Roentgenograms were taken. These revealed diffuse subserous emphysema which showed up some pelvic vessels, the kidneys and even the pancreas (Fig. 5).
DISCUSSION That patients on whom culdoscopy has been attempted and failed, even though no gas has been used, frequently complain more acutely and longer of back, chest, shoulder, and even neck discomfort than do those on whom it has been successfully carried out has been observed for some time. Until the cases noted above were studied it was difficult to explain this. Undoubtedly the pain is due to the air dissecting upward through the subserous connective tissue. This passage of gas or air continues as long as the patient remains in the knee-chest position and the amount of air taken in depends apparently on the length of time the patient remains in this position. The patient in Case 4, who developed emphysema of the neck, remained in the knee-chest position longer than others because roentgenograms were repeated several times to get the desired view of the pelvis. It should be noted that all patients except the first took in air passively since no gas was administered. In the first case gas was attached to the sheath and this found its way into the pericardial sac.
6 Fig. 5. Case 5. A, X-ray of abdomen showing perirenal and extensive subserous emphysema. B, Lateral film of abdomen showing extracoelomic air and peripancreatic emphysema. C, X-ray of chest showing no air under diaphragm, indicating no penetration of peritoneal cavity took place. Fig. 6. X-ray of abdomen showing residual gas as found after successful culdoscopy for comparison with other x-rays showing retroperitoneal emphysema. Note practically all air has collected under the diaphragm.
180
FORTIER
Fertility & Sterility
In culdoscopy with the patient in the knee-chest position, one finds negative pressures of about 20 cm. H20. This is created by the diaphragm moving upward as the bowel drops forward and downward. If a proctoscope or a tube is placed in the anus while the patient is in the knee-chest position the lower bowel dilates so that proctoscopy may be done without adding additional air, since air is drawn in passively.1 The knee-chest position is used for this reason in culdoscopy and dry cystoscopy (Fig. 6). It is only reasonable to believe that air or gas will be drawn upward into the loose connective tissue of the retroperitoneal space in the same way. At the same time infected materials such as vaginal discharge and rectal and bladder contents may also be drawn upward through a wound in any of these viscera if the patient is in the knee-chest position at the time the injury is sustained. It is easy to see how infection then can be spread almost instantly through the retroperitoneal space to the mediastinum and neck. Excellent papers have appeared on generalized subserous emphysema and pneumoretroperitoneum. 2,3 Ruiz Rivas describes two methods, one by injecting oxygen into the caudal canal and the second by injecting the same gas presacrally between the rectum and sacrum. Since these, other papers have appeared from time to time. A summary of these with a bibliography was given by Leucutia in 1953. In his second paper, published in 1950, Rivas discussed in detail and showed by diagrams how gas could spread in the retroperitoneal space. However, it should be noted that he and others have used gas under pressure. The question as to whether or not this extracoelomic emphysema may prove useful in diagnosis of pelvic, abdominal, mediastinal, and neck pathology has been adequately proved by Rivas. Whether or not producing this passively may have advantages over the actively produced emphysema still is open to question. We know that actively produced emphysema with the use of a small needle frequently give good emphysema in limited areas such as about one kidney and not the other. On the other hand emphysema produced passively by inserting the culdoscope trocar and sheath into the retroperitoneal tissue is generalized, giving more or less equal spread to all parts. This may be due to two reasons. The negative pressure is probably exerted in all directions equally while the air from one small needle under pressure tends to follow the path of least resistance. The second reason probably lies in the fact that
Vol. 5, No.2, 1954
EMPHYSEMA AFTER CULDOSCOPY
181
many more potential spaces are opened by the large trocar and are held open by the sheath so that a more generalized spread is insured. It is possible that by the use of a trocar and a sheath placed in the presacral area, with the patient in the knee-chest position, emphysema will be more safely produced than by using the vaginal route. Carbon dioxide or oxygen may be used by attaching a source such as a 5-liter bag filled with the gas under practically no pressure (as we do in culdoscopy). In this case the trocar should be quickly removed and the end of the sheath covered with an air tight cap. Why air can be placed in the extracoelomic connective tissue without producing gas emboli is of interest. However, when we consider that there is a protective coat of connective tissue about the vessels one can readily see how gas is kept from entering their lumena unless a vessel is cut across in the process of producing the initial puncture. If relatively avascular areas are chosen, this should not occur. SUMMARY Five cases of passively produced generalized subserous emphysema proved by x-ray and/or operation are reported. These all followed at least one unsuccessful attempt to penetrate completely the vaginal wall in the posterior fornix. Three of these cases were consecutive culdoscopy failures and seem to indicate that perhaps nearly all penetrating wounds of the vaginal fornix not deep enough to penetrate the peritoneal cavity but deep enough to penetrate the vaginal mucosa with the patient in the knee-chest position will produce some degree of subserous emphysema. The question as to whether or not this method of producing extracoelomic emphysema is of value in diagnosis is discussed. REFERENCES 1.
C. Sigmoidoscopy, A New Surgical Position and Apparatus for Attaining and Maintaining It. Surg., Gynec. & Obst. 96:249, 1953. 2. RUIZ, R. M. Diagnostico radiologico, EI neumorrii'i6n. Tecnica original. Arch. espan. urol. 4:228, 1948. 3. RUIZ, R. M. Roentgenological diagnosis: Generalized subserous emphysema through a single puncture. Am. J. Roentgenol. 64:723, 1950. 4. LEUCUTIA, T. Pneumoperitoneum and pneumoretroperitoneum. Am. J. Roentgenol. 68:655, 1952. BLAIR, LYMAN