TUBERCULOSIS OF THE FEMALE GENITAL ORGANS 
(INCLUDING TUBERCULOSIS OF THE KIDNEY). 
BY 
ALBERT VAKDER VEER, M.D., 
PROFESSOR OF ABDOMINAL, DIDACTIC, AND CLINICAL SURGERY, ALBANY MEDICAL COLLEGE, 
ALBANY, NEW YORK. 
Read at the Annual Meeting of the American Surgical Association, 
at Detroit, Mich., May 26, 1896. TUBERCULOSIS OF THE FEMALE GENITAL ORGANS 
(INCLUDING TUBERCULOSIS OF THE KIDNEY). 
ALBERT VANDER VEER, M.D., 
ALBANY, N. Y. 
Mr. President and Fellows: The study given to the de- 
partment of surgery in the past decade has, in a most remark- 
able manner, helped to the better understanding of the subject 
assigned to me in this discussion. Those of us who, for many 
years, were guided in our pathological studies by Rokitansky, 
Virchow, Lebert, and others have a keen recollection of how 
silent they were regarding tuberculosis of the female genital 
organs, although it is to be remembered that previous to 1854 
Kiwisch had given a very accurate description of such condi- 
tions. It was not until we had reports from such earnest 
workers as Whitridge Williams, Osier, and Councilman, of 
Baltimore, and other American writers, together with a host 
of German investigators, that we were able to recognize, to 
demonstrate, and to comprehend that such cases were to be met 
with, and that a clear line of treatment was to be carried out. 
Even at the present time, with few exceptions, it is not from 
our modern text-books that we receive our greatest knowledge 
and instruction in the recognition, classification, and treatment 
of this subject. Even now some authors look upon tubercu- 
losis of the external organs as museum curiosities, and not to 
be taken into careful consideration in the classification of dis- 
eases that are known to occur among these anatomical struc- 
tures. It is somewhat startling to note in the careful investiga- 
tions made by some of the writers to whom I have just referred 
that, although tuberculosis of the vulva, the vagina, and of the 2 
VANDER VEER, 
cervix is yet exceedingly rare, still these cases have a clinical 
history to be recognized by differential diagnosis, so that when 
we consider the uterus and its appendages we come into such 
a frequency of this pathological condition as to bring us a much 
larger percentage of general tuberculosis than has been gen- 
erally supposed. The statements of Rokitansky, Virchow, 
Councilman, and others no longer hold good that tuberculosis 
of the ovaries, and, as mentioned in some of their writings, in- 
cluding the tubes, is exceedingly rare, for this has proven to be 
a fallacy, especially regarding the latter. 
Again, we are brought to the point of comfort that has come 
to us within a few years, i.e.f the result of our careful patholog- 
ical and histological work, and bacteriological investigation, and 
the infallibility of our diagnosis, when the crucial examination 
is made as to tubercle bacilli being present. We have here, it 
seems to me, the key of the arch of the structure in our patho- 
logical studies that gives us something positive, and that we 
are no longer to rely upon the macroscopical appearances as to 
the possibility of this and that case being a suspected one of 
struma, or tuberculosis; or that the cheesy material present in 
the tubes, cornu of the uterus, possibly the ovaries, is a doubt- 
ful condition, but rather, by careful histological and bacteriolog- 
ical investigation, finding the tubercle bacilli, we realize the 
grand progress that has been made in the advanced methods of 
pathological research. When we have such careful observers 
as Edebohls giving us a percentage of four, Martin a percent- 
age of three, Williams, of Johns Hopkins, a percentage of eight, 
as the result of their investigations in the operating theatre of 
general tuberculosis, and of the appendages removed for inflam- 
matory disease, we cannot but realize that the subject is one 
that has been thoroughly studied, and that there was an uncul- 
tivated field, a field that had been sadly neglected. With such 
a classification of cases we now have much reason to be grate- 
ful, and can advance upon a higher plane, working in a more 
intelligent atmosphere of certainty as to just what our patients 
are suffering from. 
When all modern writers in this country find in their post- TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
3 
mortem investigations, and in operated cases examined by them, 
that there is from one to eight and ten per cent, of tuberculous 
disease present in the female pelvic organs, it is certainly an 
impressive presentation of the subject. We find that it is a 
condition that has no limit as to months or years of life. 
General tuberculosis has been recognized at as early a period as 
ten weeks, but the greater number of cases have been between 
the ages of twenty and forty, and it is believed that it prevails 
to a larger extent during the latter period of sexual activity. 
As stated by Williams, he has observed cases as late as 
eighty-three years of age, and John D. Williams, of England, 
has reported cases at the ages of thirty-six and sixty-three 
years, respectively; while in this country we have had such 
conditions described by Homans, Goodell, Cabot, Morrell, 
Bradford, Munde, Kelly, myself, and others, in quite a good 
many instances, at all ages. 
In the study of the subject, general tuberculosis is to be noted 
at the age of ten years, as I have observed in one of my cases, 
the same as in extreme age; and, again, secondary infection is to 
be seen when the condition is not strictly a local or primary 
development. Further, in the study of this disease, as it pre- 
sents in the external organs of generation, we must ever take 
into careful consideration in the clinical history the possibility 
of specific disease—syphilis in some form, then, as to the 
possibility of malignancy being a factor, the time of life, etc., 
and finally an ulcer presenting that does not give the character- 
istics of either one of these lesions, we have the sure test and 
best aid in the use of the microscope. 
It is not possible to have the clinical history as clear as we 
have in other forms of disease, but we have this as a warning, 
i. e., if the patient is from a family possessing a tubercular dia- 
thesis, we should be thoroughly on our guard as to the possi- 
bility of this local lesion being of that nature. Therefore, we 
no longer have excuses, and must take into consideration, in a 
certain percentage of our cases, the possibility of tuberculosis 
being present in the ulcerative conditions that present in the 
external organs of generation. We must not lose sight of the 4 
VANDER VEER, 
fact that cases of lupus of the vulva have been described which 
were really tubercular ulceration in the advanced stage of pul- 
monary tuberculosis. 
That the disease is exceedingly rare as regards the external 
structures—and especially so of the vagina and cervix—there 
can be no doubt; that cases of tuberculosis of the uterus are 
not by any means infrequent is equally true, in a certain num- 
ber of cases, and not associated with general tuberculosis of 
the system. It may be said in regard to tuberculosis of the 
uterus, that in the majority of cases it is limited to the mucous 
membrane. 
It is here that we have also made a grand advance in the 
procuring of the leucorrhceal discharge, or of specimens, either 
by curetting or section, for microscopical study. 
When we come to the study of tuberculosis of the tubes and 
ovaries the clinical history is not, by any means, as clear as we 
could wish—cases are greatly obscured. 
The gonorrhoeal infection, known to be present in so many 
of these cases, is sometimes grafted upon a mass of what is 
really but a true condition of tubercular infection. The cases 
of pelvic peritonitis, ushered in by any one of the etiological 
factors that present in this condition, also make, to a certain 
extent, the true tubercular condition that is found when an 
operation is called for and performed. 
The extreme rarity with which we have true tuberculosis of 
the ovaries, yet found at times and associated with some condi- 
tion of the tubes, and of the general peritoneum, is also an 
obscure state that blinds us frequently in our study of the clin- 
ical history. Even at the present time we read of cases in 
which an operation has been suggested for relief of a supposed 
ovarian cyst, or possibly of general dropsy, or of presumed 
pyosalpinx, or hydrosalpinx, and yet when done told plainly 
that it was a case of tubercular trouble. 
The etiology of tuberculosis of the female genital organs is 
a subject for further and careful study. That it is, at times, a 
local manifestation of the condition of the system there can be 
no doubt. That it is, at times, but a local condition due to the TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
5 
planting of the tubercle bacilli there, either through the direct 
communication of soiled fingers or instruments, is equally true, 
and, as stated by Barbier, a woman can be infected by a tuber- 
cular husband during coitus, as bacilli have been found in the 
semen of tubercular patients, as well as in the discharge attend- 
ing tubercular epididymitis. 
That the disease originates more frequently in the tubes them- 
selves, as a local disease, or in connection with general tubercu- 
losis of the system, and then infects the uterus, also the cervix, 
is the strong point to be observed in the study of these lesions. 
Therefore, one cannot overlook the fact that the uterus occu- 
pies a point of attack from without as well as from within, and 
that we can now clearly understand why some of our old cases, 
previously called catarrhal disease of the body of the uterus, 
were clearly a condition of tubercular endometritis, the true 
diagnosis now being made by examination of material secured 
in simple curettement. 
Unquestionably laceration of the cervix, repeated abortions, 
renewed and continued attacks of pelvic peritonitis, gonorrhoeal 
infection, traumatisms, a constant and continued overloading 
and constipated state of the rectum, and a persistent leucor- 
rhceal discharge, are all etiological factors in the study of this 
subject. 
The symptoms and diagnosis are to be, undoubtedly, classi- 
fied still on the basis of exclusion. When a patient presents 
with local irritation, which she has observed in the form of a 
slightly hardened mass, sometimes described like that of a split 
pea, located about the vulva, found at some point about the 
anterior or posterior fourchette, or opening of the vaginal outlet, 
found within the walls of the vagina, perhaps located as a dis- 
tinct grayish-looking ulcer about the lacerated cervix, an elon- 
gated posterior lip with inflammatory tissue, possibly a profuse 
leucorrhceal discharge, in many instances not irritating, yet so 
great in amount as to be distressing, possibly now and then 
tinged with blood, we should not delay in looking for tubercle 
bacilli. 
When a serous bloody discharge is persistent we should 6 
VANDER VEER, 
carefully consider the element of malignancy, especially if the 
odor is very pronounced. 
Whenever the labia becomes the seat of local tuberculosis, 
the moisture and warmth of the parts favor early necrosis, but 
the odor is believed to be less unpleasant. The edges of the 
resulting ulcer are thin, purple, undermined, the base irregular, 
secreting a scanty, thin, puriform discharge. One point is at 
times healed, while the ulcer is spreading in another direction. 
Extension and destruction of tissues vary greatly. There may 
occur hemorrhage from erosion of bloodvessels. It is apt to 
occur more frequently in young people, accompanied by tuber- 
culosis of other parts of the body, and will recur at times after 
apparent healing. 
“ Differentiation is not always easy as between epithelioma 
and syphilitic ulceration, but may usually be based upon the 
following points: i. Age of patient; tuberculosis more fre- 
quent in early life, and epithelioma in later life. 2. The history; 
antecedent syphilis; tuberculosis in other parts of body. 3. 
Appearance of ulcer; more abundant, fetid secretions from 
epithelioma. 4. Effect of treatment. 5. Bacteriological tests.” 
When we have present these local conditions, then an imme- 
diate examination of a portion of the diseased tissue that can 
readily be removed, even from the vulva, from the vaginal walls, 
from the cervix or uterus, more easily by curetting, or from 
specimens of the leucorrhoeal discharge itself, should be made, 
and a careful microscopical search assists us at once in the diag- 
nosis of the case. 
The general condition of the patient should be closely ob- 
served as to whether there is tubercular trouble elsewhere 
about her system. If this latter condition is present, then she 
should have the immediate benefit of constitutional treatment, 
such as plenty of fresh air, sunshine, relief from all nerve- 
strain, the very best of diet, tonics in some form, such as iron, 
arsenic, and the use of beechwood creosote, the latter of which 
the writer is much in favor of. 
When we are able to exclude all the external parts, and we 
find that the disease is confined mostly to the cervix, we must TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
7 
remember that the error has not infrequently been made of 
vaginal extirpation being performed for what was supposed to 
be carcinoma, but in reality proved to be simple tuberculosis ; 
therefore, it is our duty in all cases in which there may be the 
least possibility of doubt as to its being one of carcinoma or 
of tuberculosis, to make microscopical examination as early as 
possible. 
Tuberculosis of the cervix, whether primary or secondary, 
tends to limit itself to that structure, being in the first instance 
frequently the only tubercular lesion in the whole of the genera- 
tive tract. In these observations we find the most important 
bearing upon the theory of causation. In this we are led to 
the belief that the etiological factors must embrace something 
besides the theory of infection from tuberculous discharge 
higher up in the passages of the peritoneal cavity. The latter 
cause is sufficiently plausible and plain in some instances; but 
where the disease is confined entirely to the cervix, one must 
look for infection through the blood or directly from without 
for the real cause. Direct infection may occur, as previously 
stated, from unclean instruments, soiled fingers, or from coitus. 
The latter danger is emphatically contradicted by some author- 
ities from their comparison of the rarity of the disease in the 
cervix and vagina as found in the uterus and tubes. That 
this is a fallacy one can readily establish, when we reason 
from the analogy of the infrequency with which the disease 
is communicated from without through the agency of the 
mouth. 
This is a fact: that the disease when found about the vagina, 
in the vast majority of cases, is to be noted more particularly 
upon the posterior walls and upward toward Douglas’s cul-de-sac. 
This is probably due to the stagnation of infecting material, 
either from the uterus or from without the genital tract. We 
must bear in mind that it is possible for the vagina to become 
infected by tubercular ulceration of the rectum. Tuberculosis 
of the vagina is sometimes the cause of fistulous tracts leading 
to the bladder, urethra, or the rectum, and these fistulae are ex- 
ceedingly difficult of cure. The writer has seen cases of fistula 8 
VANDER VEER, 
extending up through the labia, upward into the buttocks, and 
becoming complicated with ischio-rectal abscesses. 
Miliary tuberculosis, as well as the caseous form of general 
tuberculosis, presents much in the same way, the microscopical 
examination showing the bacillus tubercle. 
It is interesting to observe that experiments upon rabbits 
have shown that bacilli introduced into the vagina, that organ 
having previously been irritated by the application of iodine, 
did not produce genital, but general tuberculosis. 
When the cervix is apparently not implicated, when we know 
from the condition of the patient as to the constant, continued 
discharge from the cavity of the uterus, when we have an en- 
larged organ, when we have symptoms of lasting anaemia to a 
certain extent, the absence of evidence of placental retention 
within the uterus, or of polypi, or interstitial growths, we should 
lose no time in procuring some of the uterine discharge for 
microscopical examination. The curette aids us in making the 
diagnosis of tubercular endometritis, cases often being cured 
under this thorough line of treatment. If the case be one in 
which the uterine walls are implicated, entire removal may be 
required, and is a justifiable operation at times. 
It is in the study of the tubes and ovaries that we find our 
greatest obscurity. It has been well stated that, “in the ab- 
sence of tubercular lesions of the vulva, vagina, and uterus, it 
is doubtful if infection of the Fallopian tubes can take place by 
the entrance of the bacilli through the genital tract, and the 
relatively frequent occurrence of the disease in that part of the 
genital organs is only explainable by attributing it to autoinfec- 
tion in the same way as we have explained the occurrence, for 
instance, of primary tuberculosis of joints and peritoneum. 
We can only safely assume that tubercular infection of the tube 
often, if not always, takes place upon the basis of pre-existing 
pathological conditions, taking it for granted that the healthy 
tubes do not present favorable conditions for the localization of 
the tubercle bacilli. A catarrhal condition of the lining mem- 
brane of the tubes, as in other organs, undoubtedly acts, in TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
9 
many instances, as a predisposing cause to localization of pre- 
existing micro-organisms in the circulation.” (Senn.) 
Beyond question a large proportion of tuberculosis of the 
Fallopian tubes occurs primarily, but, as has been well observed, 
it may occur secondarily. Uterine infection is frequently asso- 
ciated with pelvic peritonitis, and is a condition present in dis- 
eases of the lungs and of the intestines. Ulceration may pro- 
gress to suppuration of the tube, and, as has been observed by 
all of us, the latter is much thickened, associated with fibroid 
induration ; the tube distended, coiled upon itself, and even hav- 
ing the appearance of pyosalpinx, but is really of a tubercular 
character. In some cases the appearance of pus is supplanted 
by the cheesy, calcified material of the tubercular change, and 
in these cases the uterus becomes infected secondarily. 
Garrigues has well said that “ the wall is swollen, its epi- 
thelium is thrown off, the ostia are generally closed, the cal- 
ibre is enlarged, and the tube is filled with a caseous mass. 
The microscope reveals the characteristic formation of tubercles 
in the wall—nuclei centring around giant cells—and the pres- 
ence of Koch’s bacillus in the tissue and in the secretion. Often 
the peritoneum in the vicinity is studded with miliary tubercles. 
In advanced cases the whole mucous membrane is destroyed. 
The tubes are, in general, out of place, often drawn down along 
the edges of the uterus and bound to neighboring parts by ad- 
hesions. They may form tumors as large as a goose-egg, the 
shape of which is that of a sausage, a club, or, most frequently, 
a string of three to five beads, the single knobs of which are 
round or oval and hard, while in pyosalpinx they are soft.” 
It is a well-known fact that in the few cases met with of in- 
fection of the vagina, the majority really were the result of the 
secretion passing down through the uterus, probably infecting 
the latter, and then the vagina more or less. Tubercular peri- 
tonitis may, in like manner, infect the vagina without any im- 
pression being made upon the tubes and ovaries. 
Tuberculosis of the tubes is not, by any means, as uncommon 
a disease as is generally supposed. 
The few cases in which it is met with primarily have been VANDER VEER, 
attributed to the direct infection, by having the semen of a 
tubercular man pass directly into the genital tract. This man 
may have been suffering not only from pulmonary tuberculosis, 
but from a tubercular testicle. Tuberculosis of the tubes may 
be, and is at times, a secondary disease, having appeared in 
other parts of the body, usually in the form of tubercular peri- 
tonitis. 
In the study of the symptoms and diagnosis of tuberculosis 
of the tubes and peritoneum without ascites, Edebohls has 
made the following excellent observations: “ The diagnosis of 
tubercular peritonitis, in the absence of ascites, is based mainly 
upon the detection of localized, irregular thickenings—tuber- 
cular tumors—in various parts of the abdominal cavity. These 
tumors are caused by thickened rolled-up omentum, agglutin- 
ated intestines, enlarged mesenteric glands, etc. Their existence 
presupposes a tolerably well-advanced stage of the disease, and 
they are consequently rarely available for an early diagnosis. 
The writer desires to call especial attention to one sign which 
has proved to him of the greatest value in the early diagnosis 
of peritoneal tuberculosis without ascites, and which he has thus 
far failed to find mentioned by any author. It has been the 
sign which has led him to a correct diagnosis in all the early 
cases in which he has been able to make a positive diagnosis 
before laparotomy. It consists in plaque-like localized thick- 
enings of the deeper portion of the abdominal parieties, per- 
ceptible to gentle touch. They impart to the palpating fingers 
the sensation as if the peritoneal surface of the abdominal walls 
were occupied by urticaria wheals or pomphi of various sizes. 
The author has met them from one up to eight centimetres in 
diameter. They may be quite numerous in a given case, or but 
two or three may be found scattered over the anterior and 
lateral walls of the abdominal cavity. By marking their site 
before laparotomy and carefully examining during the perform- 
ance of the operation the structures underlying the marks, the 
writer has satisfied himself that this sign—the plaque-like 
localized thickenings—depends for its existence upon a localized 
hyperasmia and swelling of the tissues of the abdominal wall TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
11 
immediately underlying the peritoneum, i. e., of the subperito- 
neal connective tissue. The peritoneum was frequently found 
unchanged, and not the seat of tubercular deposit at the precise 
spot where the induration had been felt. Indeed, the sign may 
be especially well-marked in cases where the peritoneal tuber- 
culosis is in its very incipiency, a few solitary tubercles being 
found scattered here and there in the peritoneal sac. When the 
tubercular peritonitis has led to universal and uniform thicken- 
ing of the entire peritoneum, the sign becomes less available 
for diagnosis. I consider it, therefore, of especial value in the 
diagnosis of the very early stages of peritoneal tuberculosis, 
and when it can be plainly made out in parts of the abdominal 
walls not overlying a solid viscus, I regard it as almost, if not 
quite, pathognomonic. The only other disease in which, to my 
mind, it might occur, is disseminated secondary carcinoma of 
the peritoneum. Inasmuch, however, as in the latter instance 
it could occur only toward the end of the disease, while in 
peritoneal tuberculosis it is an early manifestation, the differen- 
tial diagnosis ought rarely to present any difficulty. Our 
knowledge of the differential diagnosis of tubal tuberculosis 
from other diseases of the tubes leading to enlargement is as 
yet very meagre.” 
Osier offers us more valuable aid in the following sentence : 
“ The association of a tubal tumor with an ill-defined anomalous 
mass (tubercular tumor) in the abdominal cavity should arouse 
suspicion at once.” 
Edebohls is inclined to go a step further and submits the 
following proposition: “ The coexistence of tubal tumor or 
tumors with plaque-like thickenings of the subperitoneal tissues, 
above described, points with great positiveness to tuberculosis. 
The tuberculosis, under these conditions, may fairly be assumed 
to be primary in the tube or tubes, if no other deep-seated tumor 
can be palpated in the abdominal cavity. Exploratory puncture 
of the tubal tumor may, in exceptional instances, make positive 
the diagnosis of tubal tuberculosis.” 
It is to be noted that in the removal of tubercular Fallopian 
tubes, frequently on cutting them across they do not exude pus, 12 
VANDER VEER, 
but a caseous condition is observed. Again, the uterus is found 
free, the closed end of the tube indicating that the disease had 
not originated from the peritoneum, but clearly in the tubes 
themselves. 
It has been observed that it was very rare to find tuberculosis 
of the tubes alone in women who had been married for some 
years and who had borne children. 
Careful observations have shown that tubercular disease is 
confined mostly to the tube itself, occurring among the young 
and unmarried, and the following case bears out the theory 
nicely : Miss J. K., aged fifteen years, single, a student. Family 
history somewhat in the direction of tuberculosis. Menstruated 
at thirteen ; regular for one year, then profuse at times and 
somewhat painful. Patient now began to emaciate, and was 
treated for more than a year by a specialist, in his sanitarium, 
with hot-water douches, application of glycerin tampons, iodine, 
etc., without any very marked improvement. When she came 
under my observation there was bilateral enlargement of the 
tubes, the uterus somewhat fixed, patient greatly emaciated, and 
suffering, as I believed, from tubercular peritonitis. No abdom- 
inal fluid. On section the tubes were found greatly enlarged 
and distended; ovaries apparently healthy, but removed with the 
tubes. The latter on examination were found to be tuberculous 
in character. This patient made a most excellent recovery, and 
two years afterward her friends wrote me that she had remained 
in perfect health. 
Here the disease was confined entirely to the tubes, the 
ovaries and peritoneum having escaped. As stated, this case is 
confirmatory of the point in regard to the disease occurring 
among young, unmarried women. 
It is true that we do not find the ovaries implicated in many 
of these cases, and that the fimbriated end of the Fallopian 
tubes becomes closed, a wise protection on the part of Nature, 
it would seem, of the peritoneum from infection. 
In many of the cases of tubercular appendages it is really a 
local manifestation due to some etiological factor, to which we 
have referred, or as a proof of the tubercular blood or constitu- TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
13 
tion of which the patient is possessed; therefore, when we have 
a patient who suffers from pelvic disease, and all conditions, 
such as tumors, pelvic abscesses, etc., are to be excluded, and 
we have present the constitutional symptoms, such as tempera- 
ture, increase of pulse-rate, a hectic and anaemic appearance, all 
pointing to some obscure condition of the uterine appendages, 
we do not usually go astray in a direct exploration, and it is 
not surprising that we find a large number of these cases to be 
of the character of local or possibly general tuberculosis. 
Beyond a doubt tuberculosis of the ovaries is much rarer than 
tuberculosis of the uterus and tubes, and it is fair to infer that 
when infection takes place it is through the circulation more 
particularly. The ovary when in a condition of miliary tuber- 
culosis will present many raised points the size of millet-seed. 
When caseous tuberculosis exists the ovary will enlarge to the 
size of a large marble or hen’s egg. Acute peritonitis and 
tubercular peritonitis are sometimes caused by these tubercular 
nodules softening and rupturing into the peritoneal cavity. In 
tuberculosis of the ovaries miliary tubercles are'the exception. 
There are two chief forms of tubercular ovarian disease de- 
scribed: The first, minute miliary granulations on the surface 
of the organ; and the second, usually caseous masses. The 
latter may assume the size and shape of a small apple, dense 
on section, and containing numerous small cysts filled with viscid 
fluid. Such cases present little or no normal ovarian stroma. 
Either form, as here described, may be grafted upon papilloma- 
tous tumors, or other diseased conditions of the ovary. 
It is very difficult to make the diagnosis between tuberculosis 
of the ovaries and chronic oophoritis. When it is possible to 
make the former diagnosis the ovaries should be removed as 
promptly as possible. 
Ovarian cysts are sometimes studded with subperitoneal 
tubercles, as has been observed by a number of writers, yet 
removal of the cyst seems to relieve any sympathetic involve- 
ment. 
Symptoms. The primary sore, whether connected with the 
vulva or vaginal wall, will present at times a distinct ulcer, the 14 
VANDER VEER, 
margins of which are decidedly thickened and occasionally 
indurated, so as to give one the impression of a syphilitic 
sore. 
I call to mind an exceedingly sad case occurring in my own 
practice, an advanced case of phthisis, in which the local sore 
about the vulva gave rise to a very strong suspicion that she 
had contracted syphilis. The party was above all possible sus- 
picion, but a careless remark on the part of the medical attend- 
ant caused much heart-burning and distress in the family relations. 
Had I then known and made an examination for tubercle bacilli, 
I am sure it would have demonstrated that the case was one of 
infection from general tuberculosis of the system. 
The macroscopical search will often present the appearance 
of a cheesy-like substance attached to the floor of the ulcer, 
but when a careful examination of the secretion is made the 
tubercle bacilli will be found. 
I have seen a well-marked case of tuberculosis of the walls 
of the vagina in which the latter was studded with little eleva- 
tions appearing very much like a split pea, white in appearance, 
containing caseous material, strictly tubercular in character, the 
patient having a family history of tuberculosis. This patient 
progressed nicely to complete recovery under local treatment. 
In the study of symptoms one should be exceedingly cautious 
as to the classification of all symptoms, and not confound one 
diseased organ with another, the following case being a striking 
illustration : 
Mrs. H. S., aged twenty-six years ; two years married ; hus- 
band said to have had specific urethritis one year previous to 
marriage. Within a few months after marriage she developed 
a urethritis and cystitis, and it was supposed that she was suffer- 
ing from salpingitis due to gonorrhoeal poisoning. She was 
treated in a special sanitarium for uterine troubles; bladder 
washed out once or twice in twenty-four hours for a period of 
six months, local applications made to the cervix; vaginal 
douches in large quantities employed, but no improvement 
resulted, and patient emaciated constantly. When seen by me, 
October 1893, I found a double pyosalpinx, as I believed, and TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
15 
advised immediate operation, which was done a few days after- 
ward. This was found to be a case of tubercular tube trouble. 
The patient made a good recovery from the operation, but on 
the twenty-second day symptoms of intestinal obstruction pre- 
sented, which resulted in death five days later. 
This case bears out the observation made previously that we 
may have grafted upon tubercular tubes a pyosalpinx due possi- 
bly to specific infection. 
In the diagnosis and treatment of tubercular disease we 
should always take into consideration the constitutional ten- 
dency toward tuberculosis, and, if it exists to any great extent 
in that particular family, we should be cautious as to how long 
we continue hot-water douches and hot applications, but do 
that which is so important in these cases, i. e., an early explora- 
tion and operation for removal of what may be present in the 
way of diseased tissue. 
Many of the symptoms associated with this subject have 
been touched upon in various portions of this paper, therefore 
it does not seem necessary to go into details too closely. 
In the review of the treatment the author desires to report 
his own experience and add the observations made by others in 
their clinical work more especially. 
Though there may be evidence of pulmonary disturbance, yet 
it is in the cases of local ulceration that present about the vulva, 
about the walls of the vagina, and of the cervix, that the most 
gratifying results follow from the careful, thorough use of the 
thermocautery in some instances, of ichthyol, iodine, aristol, 
and careful curetting, complete extirpation of inflammatory 
areas of implicated tissue, the removal of diseased glands, re- 
pair of the lacerated cervix, the free lancing and leeching of 
vesicles that may present at different points, and packing with 
iodoform-gauze. I believe that in all cases of tubercular endo- 
metritis thorough curetting should be employed, the wiping 
out of the cavity of the uterus with carbolic acid, the use of 
the peroxide of hydrogen, and that careful packing by means 
of strips of iodoform-gauze is a procedure that should be tried 
exhaustively. This failing, then the total extirpation of the 16 
VANDER veer, 
uterus becomes necessary, and in no case of tuberculosis of the 
body of the uterus should the ovaries be left behind. 
Clearly in cases of tubercular disease of the tubes and ovaries 
there is but one course of treatment left for the attendant, and 
that is complete and thorough removal by operative interfer- 
ence. When this is once decided upon these tissues may be 
reached through the vagina, or the route left to the inclination 
of the operator himself, the writer of this paper preferring coeli- 
otomy, and has every reason to feel gratified with his results. 
Tuberculosis of the Kidney. Those of us who had the 
opportunity of attending and listening to the remarkable lec- 
tures of the late Alonzo Clark on the subject of the scrofulous 
kidney, or tubercular kidney, as he sometimes described it, will 
recall with what minute care he always endeavored to impress 
upon the students the differential diagnosis between this form 
of struma and that of the other diseases peculiar to the kidneys, 
his views to a certain extent holding good even at the present 
day. It does not take a very deep searching between the lines 
to note that the classification observed in the very latest works 
upon this subject carries out the impressions of this famous 
lecturer. So much has been written, so many text-books pub- 
lished within a short time of a surgical character, that it seems 
quite difficult for one to be able to present anything particularly 
new or positively impressive to the class of men supposed to 
listen to this portion of my paper, but it may safely be said that 
tuberculosis of the kidneys is classified under two forms, i. e., 
the miliary or general tuberculosis, and the caseous, scrofulous, 
or true tubercular disease of the kidneys. The two conditions 
are capable of developing separately, and present a train of 
symptoms peculiar to themselves. 
Tubercular kidney in itself, so far as its etiology and symp- 
toms are concerned, is a very difficult lesion to diagnose. It is 
far more difficult, and not at all so sure after much labor, to find 
tubercular bacilli in the secretions of the kidney, even when in 
this diseased condition, and it is here we fail in making use of 
that crucical test that is of so much value in the diagnosis of 
tubercular lesions elsewhere about the system. The patients TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
17 
who present with a tubercular kidney give a history of being 
sick, yet when you analyze their description of symptoms care- 
fully and closely you find that it is very difficult to make out a 
case of even renal colic, renal sand, renal catarrh, even of 
malignant disease, of pyelitis, of pyonephrosis or hydrone- 
phrosis, all these conditions being excluded for want of well- 
known symptoms. 
The real history of the case leads to a group or lot of symp- 
toms such as pain in the lumbar region, a sense of weight and 
dragging about the side affected, extending downward into the 
inguinal region, accompanied, perhaps, with some nausea, with 
loss of appetite, at times some emaciation, a languid, restless 
feeling, not suffering the acute pain that accompanies most of 
the other lesions of the kidneys; but the patient is not well. 
Under this head of symptoms there is some distinct differ- 
ence between miliary tuberculosis and the true scrofulous kid- 
ney, or chronic renal tuberculosis, the scrofulous pyelitis of 
Clark, or scrofulous pyonephrosis of later authors. Miliary tuber- 
culosis is usually accompanied with the development of this 
disease in other parts of the body, and by the very best writers 
it has been said that it is almost impossible to make a positive 
diagnosis of its appearance. Miliary tuberculosis is essentially 
the disease of childhood and adolescence, in children occurring 
more frequently up to about the tenth year of age. While it is 
not what may be called a primary disease, still in its development 
about the kidney the little millet-seed granulations are to be 
found through the cortical substance in close association with 
the minute bloodvessels, the deposits encroaching gradually 
upon the connective and vascular tissues into the uriniferous 
tubules along the pyramids, and gradually into the mucous and 
submucous tissues of the renal pelvis and ureter, extending 
down to the genito-urinary tract, in both the male and female, 
in this way. 
“ Donnadieu has endeavored to determine whether the tuber- 
cular lesions of the urinary tract are manifestations of an as- 
cending or descending process. Pathological anatomists tend 
to view the lesion as generally a secondary one in one or other 18 
VANDER VEER, 
kidney, extending thence downward along the ureter to the 
bladder, a mode of occurrence which the writer is disposed to 
accept in connection with acute general tubercular processes. 
But in the common, cheesy, surgical tubercular lesions the 
majority of clinicians tend to the idea that there occurs, as a 
rule, a primary tubercular focus in the lower urinary or genital 
structures, which gradually extends upward along the mucous 
surfaces to the bladder and ureter to the kidney. It is to be 
noted that in these cases there is rarely any chance of estimat- 
ing the relative age of the lesion in different parts attacked, the 
process being rarely met in the stage of the gray tubercle, but 
usually in the form of cheesy masses, or as ulcerations repre- 
senting the excavations in the mucous membrane due to the 
removal of such cheesy material.” (Sajous's Annual, 1894, vol. i.) 
This is quite different from the chronic renal tuberculosis. 
Careful study of these latter cases leads one to believe that it is 
more a disease of middle age and advanced life, than of child- 
hood. Undoubtedly there are some cases of this form of tuber- 
cular kidney in which the disease reaches the organ from with- 
out, possibly from the prostate gland, the vesicle seminalis, 
bladder, or, more especially, a scrofulous condition that finds 
its way up along the course of the ureter and infects the pelvis 
of the kidney, the disease usually beginning in the kidney and 
extending upward. The urine will present signs of pyelitis 
proper, and blood-corpuscles may be found in the sediment. 
The night and day urine present very much the same condition, 
no change being observed as to the appearance of blood. Albu- 
min is found present, and at times tube-casts. The urine pre- 
sents a mucus-like appearance, and pus is invariably present. 
Hemorrhage not often present, that is, the appearance of blood 
is frequently absent for long intervals. Pain, located more par- 
ticularly in the bladder and about the pelvis, sometimes extend- 
ing up to the lumbar region, is a symptom of this condition of 
the kidneys. The urine is apt to be viscid, cloudy, and opaque, 
and the albumin present is no more than the amount of pus 
can account for. 
Cadwaller insists that vesical pain and tenesmus may be re- TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
19 
liable signs of pyonephrosis, even when nothing can be dis- 
covered on the part of the kidneys. This has not been the 
experience of the author in observing his own cases. I have 
seen very decided amounts of pus in pyonephrosis that would 
produce no irritation whatever of the bladder, particularly so 
long as the urine remains normally acid. 
Osier, as an aid in the differential diagnosis of pyonephrosis 
and tubercular cystitis, states that the urine remains acid in renal 
tuberculosis unless there is extensive coexistent cystitis. The 
urine is likely to contain pus continuously, and granular debris, 
sometimes shreds of connective tissue, showing serious disin- 
tegration of the mucous membrane. 
Mitchell has well said that “ it is always wise to suspect 
tuberculosis if pyelitis or cysto-pyelitis exists without evidence 
of stone.” Patients often do suffer from a severe and frequent 
desire to micturate. 
In cases of tuberculosis of the kidney the temperature is the 
important symptom. The later condition will often rise from 
one to five degrees higher at night, continuing thus for several 
days, without our being able to account for it from any other 
state of the system. In all these suspected cases of scrofulous 
kidney it is well to look carefully over the system and see as to 
the evidence of past tuberculosis, or the presence of the acute 
condition. 
Direct examination of the kidney often leads to a more posi- 
tive diagnosis. It will, at times, be tender and sensitive to the 
touch, but not at all enlarged. There may be nodules present 
that, in a thin person, can be made out, located deep in the 
kidney. 
Tubercular hydronephrosis is sometimes diagnosed by re- 
moval of the fluid and careful examination instituted for tuber- 
cular bacilli. Sometimes the kidney is so enlarged as to indi- 
cate a decided growth, and in the absence of other evident 
disease we have reason to be suspicious of a tubercular kidney, 
especially if the family tendency is in that direction, and the 
patient has a tubercular diathesis. Heredity is the predisposing 
element in most of these cases. 20 
VANDER VEER, 
The urine should be examined by the best and most compe- 
tent bacteriologist. This should be kept up for some few days, 
and if the tubercle bacilli can be detected the diagnosis is certain. 
Another method, particularly in the female, is catheterization 
of the ureters to decide whether one or both kidneys are affected. 
This latter method is emphasized by Kelly, of Baltimore, and 
to which our attention has been so earnestly called by his very 
able article published in the Bulletin of the Johns Hopkins Hos- 
pital, vol. vii. Nos. 59-60, in which he gives us a great amount 
of information. This method of examining the kidney should 
be followed out in its most perfect manner. When once the 
diagnosis of tubercular kidney is made there can be but one 
line of treatment, i. e., removal of the kidney, providing the 
patient’s condition is such as to warrant it, and the disease is 
unilateral. The following case has a bearing upon this portion 
of my paper : 
Mrs. A. L., aged forty-eight years. Family history: father 
died, aged seventy-six years, from some kidney trouble ; mother 
living, aged seventy-seven years. Personal history: patient 
well as a child; menstruated at fourteen; frequently irregular, 
always accompanied with more or less pain until after birth of 
first child, when she suffered less and was more regular. Has 
had five children and three miscarriages. Menstruation ceased 
in November, 1892. In the summer and fall of 1889 patient 
suffered ill-defined pain about her back and side of abdomen, 
at times somewhat severe, but never amounting to renal colic; 
never passed blood in urine; very little evidence of bladder 
complication; did not feel well at times, and considered herself 
sick. Pain at times would start posteriorly to crest of ilium and 
shoot down into* groin. At times noticed an enlargement in 
the right lumbar region, which was tender and sensitive to the 
touch, preventing her from lying upon right side, yet she con- 
tinued about her duties as a housewife. In October, 1892, had 
much severe, aching pain for two months, when she was obliged 
to take anodynes and apply hot packs externally. From this 
time on the urine contained a large amount of thick, mucous 
deposits, but it did not give her any great distress about the TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
21 
bladder or ureter in passing. Diagnosis, by exclusion, elimin- 
ated every possible form of tumor or growth, except as to the 
possibility of a tubercular kidney. 
After having her under observation for a short time I advised 
her attending physician, Dr. Weckel, that an operation be done, 
inasmuch as there was every reason to believe the left kidney 
was in good condition, it presenting no sympathetic symptoms 
of infection. I attempted to catheterize the kidney, but was not 
successful. 
On April 17, 1893. I did a nephrectomy, removing the kidney, 
suprarenal capsule, and upper third of the ureter. The patient 
made a good recovery, and has remained in excellent health 
since, hearing from her only a few weeks ago. The kidney 
proved to be one of caseous tuberculosis. 
We must bear in mind that miliary tuberculosis is apt to be 
bilateral. In the scrofulous or chronic renal tuberculosis it is 
apt to be unilateral, and an operation upon the kidney more 
successful. Some few cases have recovered by incision and 
drainage, but it is a line of treatment not to be recommended if 
it is possible to do a nephrectomy. The following case illus- 
trates the above point: 
Mrs. F. L., aged forty-two years ; patient of Dr. Beach, of 
Gloversville. Patient gave a history of ill-defined pain about the 
lumbar region, left side, which gradually incapacitated her for 
work. Was admitted to the Albany Hospital, March 18, 1892, 
and diagnosis of abscess of the pelvis of the kidney made. I 
advised an immediate operation, and on exploration, March 23, 
1892, found what proved to be a tubercular condition of the 
kidney, but it seemed to be such a well-defined cavity that I 
introduced a T-drainage tube, draining and washing out with 
pyoktanin and various preparations of that kind. Patient was 
more than four months in recovering, but eventually made a 
good recovery and continued well for over a year, when I lost 
sight of the case. 
In the removal of the kidney the operation of nephro-ureter- 
ectomy, as performed by Dr. Howard Kelly, of Baltimore, and 
reported in his paper, published in the Bulletin of the Johns 22 
VANDER VEER, 
Hopkms Hospital, February and March, 1896, vol. vii., we have 
a most decided advance in the method of operating, and one 
that is likely to supersede other operations, where it becomes 
necessary to remove the entire kidney and ureter. The state- 
ment of the three cases presented in Dr. Kelly’s paper is very 
impressive, illustrating the great difficulty in the diagnosis of 
tubercular kidney, even with the advantages of a cystoscopic 
examination, done with the expertness for which Dr. Kelly 
is noted in these cases, and the examination of the urine. He 
states tubercular bacilli were found in the first case after a patient 
search. In the second case bacilli, undoubtedly tubercular 
bacilli, were found, which had more of the characteristics of the 
smegma bacillus. In the third case no bacilli were found, and 
the diagnosis depended upon the history and physical examina- 
tion. Dr. Kelly further states that by palpation in all cases the 
pelvic portion of the ureter was found to be enlarged and thick- 
ened, but only in the first case did it show any nodular enlarge- 
ment. 
There was also with each case a point of tenderness where 
the ureter crosses the pelvic brim. It was also shown by pal- 
pation that the ureter on the opposite side was normal. In 
using the renal catheter Dr. Kelly states that the separated 
urines showed that the abnormal constituents of the urine came 
entirely from the side indicated by this appearance in the bladder, 
and that the opposite side was sound. He states that diagnoses 
were made in these cases by symptoms, by palpation, by inspec- 
tion, and by the analysis of the separated urines. The patients 
all presented a history of pain in the side, extending down the 
course of the ureter, accompanied by frequent and painful mic- 
turition. In the first case the renal symptoms were masked by 
the strangury in the bladder. He also states that these cases 
had intense pain in the side, two of them being accompanied 
by attacks of renal colic, which pointed toward the chief focus 
of the disease. 
In summing up the operation Dr. Kelly speaks of it as 
follows: TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
23 
“The three cases whose histories I have given exhibit three 
different ways of removing the kidney with its ureter: 
“ 1. Transperitoneal, that is, through an incision through the 
abdominal wall, opening the peritoneal cavity. This incision 
involves the necessity of a second incision through the perito- 
neum, covering the posterior abdominal and pelvic walls, in 
order to get at the ureter. 
“ 2. Retroperitoneal; the extirpation of the kidney and ureter 
through a long abdominal incision beginning in the loin and 
extending downward and forward and ending somewhere in the 
neighborhood of the symphysis pubis. By this method the 
peritoneum is detached from its cellular connection with the 
abdominal and pelvic walls, lifted up, and the ureter exposed 
without opening the peritoneal cavity. 
“ 3. Retroperitoneal; by a short abdominal and vaginal inci- 
sion. By this procedure the kidney is detached and the ureter 
freed from all its connections through a short incision in the 
loin as far forward as the base of the broad ligament. The rest 
of the ureter is then pulled through an opening made in the 
vault of the vagina, and removed down to its vesical end by 
continuing the vaginal incision forwards toward the neck of the 
bladder. 
“Two of my friends, Dr. Clinton Cushing, of San Francisco, 
and Dr. C. P. Noble, of Philadelphia, were present when I per- 
formed the second operation. Dr. Cushing suggested removing 
the ureter through the vagina, and Dr. Noble suggested remov- 
ing the upper part of the ureter with the kidney through the 
incision in the abdominal wall, and at a later date taking out 
the pelvic end of the ureter. This was what I tried to do in the 
first case, but I .failed on account of the dense inflammatory 
tissue surrounding the lower end of the ureter. 
“ I look upon the three cases as evolutionary in respect to the 
best mode of operating, and I would prefer in the future in all 
cases to operate by an incision in the side, large enough to take 
out the kidney and easily admit a hand and forearm introduced 
for the purpose of detaching the ureter as far down as the vaginal TUBERCULOSIS OF FEMALE GENITAL ORGANS. 
vault. I would then tie the ureter at the lowest point, and re- 
move all that portion with the kidney above the ligature. I 
would complete the operation by removing the vesical end of 
the ureter through the vagina, with the patient in the lithotomy 
position.” 
These patients all require a general course of tonic treatment 
such as tends to relieve.general tuberculosis.