Virgil S. Counseller

A clinical and surgical review of endometriosis

Abstract This review is a continuation of one which one of us (Counseller) presented before this Society in June 1938. In that report cases encountered at the Mayo Clinic from 1923 through 1937 were reviewed. This study, being similar, covers the ten-year interval from 1939 through 1948. In these ten years 1,342 patients received surgical treatment at the clinic for endometriosis. This is approximately 25 per cent of the total number of cases of endometriosis encountered during this period. To state it another way, we can say that only 25 per cent of all of the patients presenting evidence of endometriosis were subjected to some type of surgical treatment; the remainder were treated medically. The purpose of this study was to search for certain information or facts which would aid in the selection of treatment for these patients. In order to do this, it is necessary to inquire as to what changes took place in the menstrual cycle and what effect, if any, the previous surgical operations may have had; also, what influence did pain have in disability and, finally, when conservative operations were done, what were the effects, if any, on restoration of fertility and the relief of pelvic pain. In a way, we wish to apologize for adding another paper dealing with the surgical treatment of this disease, but it may be helpful in establishing a unanimity of opinion in the management of this rather serious and disabling disease. Furthermore, this condition has almost replaced the common pelvic inflammatory disease of preantibiotic days. Since blood in the peritoneal cavity is irritating, it may be confused with inflammatory disease in its early stages. In this connection it is interesting to note that therapy, such as hot douches and vaginal diathermy, aggravate rather than relieve the symptoms of endometriosis, which is a distinguishing feature between endometriosis and pelvic inflammatory disease.

Cylindroma of the cervix with procidentia

Abstract Prolapse of the uterus complicated by carcinoma of the cervix is a rare condition. In the case of this type reported, vaginal hysterectomy and repair of vaginal relaxation were employed. The tumor proved to be an adenocarcinoma of cylindroma type. No other cases of cylindroma of the cervix were found in the literature. Vaginal hysterectomy is probably the treatment of choice in cases of prolapse of the uterus and carcinoma of the cervix if the cervical tumor is definitely a carcinoma in situ or of Stage I. Radium therapy should be used first if the carcinoma has extended beyond the cervix.

The clinical significance of endometriosis

Abstract The various hypotheses regarding the etiology of endometriosis have been briefly outlined. From the manner of the distribution of the implants, the hypothesis that endometrial tissue from the uterus is carried by lymph channels to points outside the uterus presents the least objections to its explanation. The hypothesis is extremely simple, logical and entirely possible. Pelvic pain, quite definitely related to menstruation, is the principal reason the patient seeks relief. There is usually a ten-year history from the onset of the disease and the symptoms have been progressive. There are most likely two types of pain, visceral or sympathetic and somatic or spinal sensory. The latter becomes evident when the peritoneum of the cul-de-sac, lateral pelvic wall, and round ligaments is involved. Surgical treatment is either radical or conservative, depending on the extent and involvement of the lesions. If conservatice treatment is performed it is necessary to carry out such procedures as will relieve pain as well as conserve the menstrual or reproductive functions. The pain may be relieved or alleviated by complete excision of the lesions from the myometrium plus a presacral neurectomy when the lesions are limited to the uterus. Other heterotopic lesions may be attacked by complete excision where possible by the surgical loop diathermy or partial resection when lesions are located in the sigmoid or the rectovaginal septum.

Vesicourethral suspension for urinary stress incontinence: A study of the results obtained in 82 patients

Abstract Of 83 urethrovesical suspension operations performed on 82 patients with stress incontinence, 86 per cent have been successful and 14 per cent unsuccessful. The use of absorbable suture material may have been significant in the causation of 7 of the 11 operative failures. It appears that, compared with the Millin-Read and the Ingelman-Sundberg operative techniques, the Marshall-Marchetti-Krantz operation can be performed with less technical difficulty, with less postoperative bladder dysfunction, with a shorter period of hospitalization, and with equally successful results for the patient. Also, this procedure, frequently combined with preliminary vaginal repair of a cystourethrocele or dissection of a shortened, fixed urethra, is considered to be the operation of choice for most patients with recurrent stress incontinence, for incontinent patients with little relaxation of the vaginal wall, and for the incontinent patient in whom other pelvic disease demands a lower abdominal incision.

Congenital absence and traumatic obliteration of the vagina and its treatment with inlaying thiersch grafts

Abstract A brief review of the operative procedures for the correction of congenital absence or traumatic stricture of the vagina is presented. Some of the disadvantages associated with pedicle grafts and the risk involved in using any part of the intestinal tract are stressed. The McIndoe procedure is the operation of choice by reason of its simplicity and practicability. I have added certain modifications to this procedure which seem to me to be sound and useful. Five patients with congenital absence of the vagina and two with traumatic stricture of the vagina were treated successfully and without mortality by this method.

Ovarian neoplasms: Their pathologic and surgical significance

0 VARIAN neopIasms beIong to the group of most common Iesions encountered in the practice of medicine and surgery. Some are more important than others, yet not one, even if it is benign, can exist for very Iong without the Ioss of ovarian function and IinaIIy compIete destruction of the organ. The resuIts of treatment of both the benign and the maIignant types are often disappointing. In addition, the pathoIogic characteristics of these neopIasms, it seems to me, have not been suffrcientIy stressed. A cIear conception of the type of tissue being deaIt with is the fundamenta1 basis for the appIication of correct surgica1 principIes in treatment. Roentgen therapy sufhcient to produce a menopause, but in whom the ovary has not been removed or compIeteIy destroyed. At present, no one knows how much irradiation is required to produce the same effect as biIatera1 oophorectomy. These observations are cited mereIy to stimuIate interest in the complexity of the functions of the ovary and to emphasize that Iesions of the ovary, whether benign or maIignant, shouId receive more carefu1 consideration.

Prevention and treatment of postoperative thrombophlebitis

Summary No satisfactory routine procedure has been devised for the prevention of postoperative thrombophlebitis. Certain measures have been discussed which will help to minimize the three essential factors of local vein injury, slowing of venous blood flow and alteration in the coagulability of the blood. Postoperative thrombophlebitis Inay be successfully treated in the acute stage by adequate elevation of the limb and the use of extensive hot wet packs locally. It is advisable to get the patient up as soon as the temperature has been normal for three days, swelling below the knee has subsided and local tenderness in the involved veins has disappeared. As soon as the patient is out of bed it is necessary to equip him with an adequate leg support and for this a heavy pure rubber bandage is recommended. The bandage can usually be discarded in from three to twelve months without the subsequent appearance of any signs or sy-nlptoms of chronic venous insufficiency. Once the clinical picture of acute postoperative femoral or iliac thrombophlebitis has appeared, the danger of fatal pulmonary embolism is small.

Bilateral Transplantation of the Ureters of the Female

Summary Transplantation of the ureters of women to the sigmoid flexure is a sound surgical procedure for the treatment of huge vesicovaginal fistulas, chronic interstitial cystitis with secondary contraction of the bladder in cases in which the bladder has been rendered useless, and some carcinomas of the bladder. Thirteen illustrative cases have been briefly described. There were three deaths; one from peritonitis and bronchopneumonia, one from pulmonary embolism, and one from bronchopneumonia alone. In the one case in which the patient died of peritonitis and bronchopneumonia, death followed transplantation of a badly diseased ureter after previous transplantation of the opposite ureter; peritonitis developed because there was an infection of the upper portion of the urinary tract. The operative risk is decreased when one ureter is transplanted at a time. Introduction of intravenous urography has been beneficial in the study of the excretory function of the kidneys before and after transplantation of the ureters. It also aids in determining the degree of pyelectasis and ureterectasis following transplantation, and the return of the renal pelvis and ureter to normal several weeks or months later. The preparation of the patient for operation for ureterosigmoidal transplantation is just as essential as it is for other operations on the large bowel.

Lithopedion: Report of an unusual case and notes on two other cases

Abstract An unusual case of lithopedion has been presented, in which the patient had a double vagina and double cervix, with a single uterine cavity. A lithopedion was found in the cul-de-sac. Bilateral hematosalpinges were present. Organized placental tissue was found in one tube and a recent ectopic pregnancy in the other tube. Surgical removal of the lithopedion, both tubes, and cysts from both ovaries was successfully accomplished. Two other cases of lithopedion have been presented briefly, with the surgical and pathologic findings. In one of these the process was adherent to the anterior abdominal wall, sigmoid colon, and a few loops of small intestine. In the other case the lithopedion occupied the patients right Fallopian tube. The first had been present in the abdomen for nine months after fetal death, and the other for four years after fetal death.

A working classification of adnexal cysts and neoplasms

Abstract The classification given herewith is on an anatomicopathologic basis. It is sufficiently descriptive and is not confusing. In dealing with ovarian cysts and neoplasms sufficient knowledge of their characteristics and behavior is necessary for appropriate treatment to be instituted.