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general line of treatment should be prac- trium, 12 gtts). If this does not materially tically the same, namely, to control con- reduce the pulse-rate within twenty or vulsions and hasten the work of elimina- thirty minutes, a second dose of about half tion. Now, in viewing puerperal eclamp- the quantity is given. If additional doses sia as the outcome of a toxemia, it is well are still needed, they are given by mouth. to note that many of these cases of tox- As soon as the pulse-rate is reduced to emia do not develop into convulsions at about sixty beats to the minute, a mixture all, just as delirium is not always produced containing chloral hydrate, bromide of potby the same degree of pyrexia even in the ash, and veratrum is prepared to be given same patient. In other words, there are at stated intervals (say, every two hours) various kinds and degrees of puerperal tox- in sufficient doses to keep the pulse-rate emia which may, or may not, produce con- within safe bounds, and furnish to the movulsions according to the conditions in each tor areas a nerve sedative. given case. I have seen in my own prac
The next feature to be considered in the tice uremic coma develop instead of con- treatment of eclampsia is that of eliminavulsions. This form of puerperal uremia tion. To this end two drops of croton oil, is to be the most dreaded, as it is likely with three grains each of calomel and to prove apoplectic in character.
jalap, are put upon the back of the tongue, glad to say I have had but one of such and teaspoonful doses of Epsom salts are a type in my practice. In this case early given every hour or two until free catharsis forceps delivery, venesection, etc., proved is accomplished. An enema of a normal fruitless. Up until this time I had followed salt solution is also often helpful. In some in all cases of puerperal eclampsia vene- cases the normal salt solution may be given section as the “life-saving agent.” And, subcutaneously with advantage. though yet a believer in the value of vene- Diuretics, as bitartrate of potassium, section in properly selected cases, yet of benzoate of sodium, should also be added late years I have omitted this means of at stated intervals. Later on, after decontrolling convulsions with the most grati- livery is accomplished and convulsions have fying results. Indeed, I have treated seven subsided, if the pulse should become weak, successive cases, several of which appeared the diuretics then should be exchanged for almost hopeless, with no mortality. Three others of a
more stimulating character of these were in persistent coma from (digitalis, strophanthus, etc.). Moreover, eighteen to thirty-six hours during the in- at any time during the course of treatment, tervals of violent convulsions. Two of the if patient's condition appears critical, the seven (primiparæ) were operative cases hot, wet pack must not be forgotten. Out under complete anesthesia, in one of which of my seven cases above referred to, the was required a high-forceps delivery. In most desperate were put in the hot pack this latter case (the only one of the seven with excellent results. My last case, after in which I had a consultant) convulsions having had nineteen convulsions, was put persisted even when the pulse had been in a hot pack and kept there for three reduced to fifty beats to the minute. My hours, and the process was repeated at consultant, regarding the case practically stated intervals until complete conscioushopeless, retired, leaving me to deliver her ness was restored and convalescence estabwithout medical aid. Following her deliv- lished. ery, cathartics (croton oil, calomel, jalap, In conclusion, I may add, by combining Epsom salts) and diuretics (bitartrate of
such drugs as morphine and veratrum in potassium and benzoate of sodium) were their proper proportions we avoid, in a freely used. Saline enemas and the hot,
measure, the great danger of over-dosing wet pack were also employed until con- with either drug. The same is true in sciousness was restored and convalescence regard to the second combination containestablished.
ing the chloral mixture. And when the Now a little more about treatment. Mor- hot pack is employed a still greater dimiphine and veratrum viride were used in- nution in these drugs can be allowed with stead of venesection. The first dose of a more or less proportionate degree of each is given together hypodermically safety. (morphine, gr. 16, and tincture of vira- Pungoteague, Va.
some designing demagogue as revealed
truth. The average medic is too blamed SO-CALLED.
busy to either make money or analyze what
he hears or reads. That's one thing that By Chas. S. MOODY, M. D.
kept the medical profession back about a
thousand years. Some ancient disciple got I may be very easily wearied, but there in the habit of harking back to the Dark are some things in the current medical Ages for his medical wisdom, and he transpublications that are inclined to produce in mitted the habit to his successor, and beme that "tired feeling” we read so much fore we knew it the thing got to be about. With a very few exceptions—I can hereditary, so by the advent of our day we point them out if you wish me to—the cheerfully accept canned religion, politics, medical publications are stuffed full of music, medicine. The ministerial profes"papers” read by some ambitious medic at sion are ahead of us in one thing; the the County Medical Society meeting held preacher knows that his congregation will in Podunk Corners. Now, I haven't the
accept as words of great wisdom the simslightest objections to John Henry Smith, plest statement if he only utters it solemnly A. M., M. D., impressing the assembled enough. We fellows of the scalpel and representatives of the healing art from the
pill bags do the same thing, but we don't back districts with his wonderful erudi- know it. Let some chap with a local fame tion, but I do register a kick against the in the nearest overgrown town come out editors of journals that we pay our good to your county meeting and tell you that money for, aiding and abetting the said "the square erected on the hypotenuse of a John Henry in his nefarious attempt at right triangle is equal to the squares of impressing us with his superior knowledge. both its other sides," and if he says it These days it seems the proper thing for earnestly enough you will nearly faint with county medical societies to invite some wonder at his learning. professional "lion" to address them upon I object. I don't suppose it will do any some important topic. The greater the great amount of good, but I object any"lion" the better they like it. The lion way. I register my plaint for the hardcomes, shedding an air of importance, like worked country doctor who knows more an aura about him. He arises and pomp- medicine in a day than these sprigs of ously details some professional hodge- medical nobility will ever learn, and who podge that is the same old story in a new is so impressed by the glamor that surlaid gown, while the bucolic medics sit rounds one of these that he is happy to sit with mouths ajar and drink in the words and listen to the droning over of something of wisdom as though they were pure from that he knows better than his self-elected the Pierian spring. The “lion” does not instructor. I am for medical societies say so, of course, for that would be tell- where the brethren meet upon a common ing, but the inference very strongly is that level and relate to each other their sucall the brethren from the wood's pasture cesses and failures. I am for medical soshould send to him all such cases as come cieties where the members may listen to under the head of the particular paper he practical papers by practical men upon reads. They do it, too. They remark unto every day subjects, such papers written, themselves, "What wisdom! What knowl- not for the purposes of advertisement and edge. How can one head contain it all?" subsequent publication, but from a desire In fact, the whole screed is nothing but a to do good. I don't give a rap whether rehash, and generally a very poor one, of
the author murders the English grammar some chapter on the subject taken from or not. If the paper is stuffed full of good one of the standard authorities, and not things I can overlook the literary imperone of the “lion's” auditors but could pro- fections. I can cheerfully hit any gramduce a better one with both hands tied. matical error that I happen to see riding
One great trouble with the human family along on the train of an idea and knock is that they are lacking in the sense of him into the middle of next week, then humor; they are inclined—especially doc- appropriate the idea for my own consumptors—to accept the blatant assurance of tion.
Now, let me take an easy fall out of the ends he made traction until the uterus was medicals journals. About all the alleged well up against the wall; then the sutures important (?) journals find their way onto were firmly tied and the victim placed in our table. About all the journals that are bed. The author did not proceed to tell satisfied to occupy a lower niche in the us how soon she was placed in the casket, wall also drift in. The wrappers get re- and was equally negligent about informmoved from practically all of them. A ing us regarding the details of the funeral. few of them are read and filed. The big I wonder what sort of monuments they journals—those with a name-prove the erect to their dead in Canada ? O temleast interesting of all. Why is this? The pora! O mores! O mamma! reason is not far to seek. They, like the Now, my good country cousin (I'm one County Medical Society of Posey County of you myself, by the way) what do you meeting at Podunk Corners, have gone think of shucking out your good hard dol"lion” hunting. Their columns are filled lars for such medical “hog wash" as that? with alleged wisdom in the shape of pro- That was only an isolated instance. I can fessional "papers" upon unprofessional find you plenty niore of them if you care subjects. The average practitioner vainly to see them. The chances are that thouchews around over all the mess of verbiage sands of physicians read that thing and in the forlorn hope of extracting some- set the author down as a man of original thing that he can use in his work. Not a ideas, and they were correct, too. Nine glimmering of a thought, not an idea that physicians out of every ten would read rises above the dead level of the common- that thing, and if they were not doing a lot place. As Holmes remarked of the katy- of surgery, or seeing a lot of it done, would did, “Thou sayest an undisputed thing in pass it by without analysis. It's the tenth such a solemn way." They prattle along man that reads the ridiculous in these artifor several closely printed columns iterat- cles and "cusses” himself for throwing ing and reiterating things that have been away his good money. told in books since Aesculapius was in
Sandpoint, Idaho. swaddling clothes. Then the whole miserable mess is dignified by the ultra scientific journals as pure unadulterated science. As an illustration, people understand
TRAUMATIC PERFORATIONS OF better if things are mapped out for them. THE UTERUS INFLICTED FROM Several years ago I read in one of the
WITHING THE CAVITY OF great scientific (?) medical weeklies an article by some would-be surgeon just
THIS ORGAN. across the line, not so blamed far away but his name is pretty well known in your BY AIME PAUL HEINECK, M. D., Uncle Sam's domains, however. This is Professor of Surgery, Reliance Medical College; what he advocated as a substitute for ven- Adjunct Professor of Surgery, University of tro-fixation of the uterus. Listen closely: Illinois; Surgeon to the Cook County Hospital. He placed the victim (that's the only name for her) in the Sims's position and ex- For practical considerations, a three-fold posed the cervix uteri. Grasping the ante- division of this paper was deemed justirior lip of the cervix with a volsella, his
fiable. The first part will be devoted to assistant put the cul-de-sac of Douglas on a consideration of the subject as a whole; the stretch. With a long, curved needle the second part includes an analysis of all designed especially for that purpose, loaded the cases of uterine perforation consecutive with heavy catgut, the surgeon then passed
to intra-uterine maneuvers, published in it up through the cul-de-sac around the the English, French, and German medical fundus, carrying the ligature into the literatures from 1895 to 1907 inclusive; fundus near the top and bringing it out the third will embody what my clinical exthrough the abdominal wall. Unthreading perience leads me to consider safe, conhis needle and threading it upon the op- servative, and practical suggestions and posite end of the suture, he repeated the conclusions. performance. Grasping the two abdominal Practitioners must not be unmindful of the fact that rough handling of the uterus to recognize this condition has led to seriexposes the patient to grave dangers. The ous mistakes, we will briefly discuss these experience of noted and skillful surgeons pseudo-perforations and eliminate them amply confirms the statement that the from further consideration. This term uterus can be, and often is, perforated with (pseudo-perforation) though, in our opinthe most startling ease.
ion, not of unquestionable propriety, is Owing to the fact that clinicians are used to designate a condition capable of unwilling, as a rule, to give publicity to conveying to the operator the impression such an accident occurring in their prac- that he has perforated the uterine wall, tice, the frequency of traumatic perfora- when, in fact, this mishap has not occurred. tions of the uterus cannot be accurately What, then, has occurred? determined. Most, if not all, gynecologists 1. The uterine sound or other instrument of large experience have met with this ac
may have slipped into a double uterus cident not once, but several times, in their
(uterus didelphys). It may have entered work (Baldwin). In the records of 3172 a uterus unicornis. consecutive autopsies, held between Feb
2. The instrument may have slipped into ruary, 1898, to February, 1908, at the Cook
the dilated uterine end of a Fallopian tube County Hospital, Chicago, not a single case
(very rare) or into a bicornuate uterus. of uterine perforation is reported. In all
Watkins, after opening the abdomen, found the cases of abortion and in all the cases
that what he had diagnosed the passage of pregnancy, treated at the same insti
of the curette into the peritoneal cavity tution during the years 1903-1907 inclu
was the passing of the curette into the sive, 495 abortions, 2343 pregnancies, only Fallopian tube. In Hind's case the uterine three perforations of the uterus occurred;
sound was introduced in the uterus before two died (autopsy denied); one, treated
incising the abdominal wall; after openexpectantly, recovered.
ing the abdominal cavity, it was seen that By diligently searching the medical liter
the sound had threaded the whole length ature (American, French, English, and
of the Fallopian tube. It was presenting at German) from 1895-1907 inclusive, I was
abdominal orifice of the tube. In Floeckable to collect only 160 cases of perforat- inger's case, laparotomy showed that the ing wounds of the uterus inflicted during
uterine sound was in the oviduct. In the course of intra-uterine instrumenta
Thorn's case one uterus was myomatous, tion. Some additional cases are found in
the other was latero-flexed and lateroRebreyend's These. They do not infirm;
verted. In the case of myoma of the in fact, they confirm our conclusions.
uterus, the uterine sound was introduced 14 Uterine perforations can be classified into
centimeters; suddenly there was a lack of true and false perforations.
resistance, hasty removal of the sound folTrue perforations may be spontaneous,
lowed upon this. On opening the abdomen, may be consecutive to some insult to the
it was seen that the sound had penetrated uterine tissues. This insult may be ther
for a distance of 3 centimeters into the mic, chemical, bacterial, or traumatic in Fallopian tube. Ahlfeld also reports a case nature. All perforating wounds of the
in which, after laparotomy, it was seen that uterus are true perforations.
the left oviduct had been entered by a False perforations (pseudo-uterine per- sound introduced into the uterus. Neverforations) are not perforations in fact.
theless this occurrence, the introduction, They constitute a condition in which the
by way of the uterus, of any instrument clinician is under the impression that he into the Fallopian tubes, is very infrequent, has perforated the uterus when in reality so infrequent that its possibility has been this accident has not taken place. Though denied by competent observers, because :pseudo-perforations are of very infrequent occurrence, it is important that clinicians
1. Under natural conditions, the lumen be cognizant of the nature of the condition.
of the uterine end of the oviduct is so A timely and accurate interpretation of its
small that it is only with difficulty that one
can introduce a bristle into it. symptomatology will save the physician much anxiety and the patient needless sub- 2. Under normal conditions, the broad jection to operative risks. As the failure ligaments and also the ovarian ligaments maintain the Fallopian tubes in a trans- trace of perforation. Kossman bears witverse position in the pelvis.
ness to similar facts. Lawson Tait was never able, on the ca
Perforating wounds of the uterus, espedaver, to sound the tubes through the
cially of the pregnant uterus, can be in
flicted from above; can occur during the uterus. He maintains that inder normal conditions it is impossible to introduce, by
course of a laparotomy; can be associated way of the uterine canal, an instrument
with penetrating wounds (gunshot wounds, into the normal Fallopian tubes. Cathet
stab-wounds, and similar injuries) of the
abdominal wall; of the gluteal and other erization of the tubes is more liable to occur in the presence of such pathological regions; can occur during the course of conditions as uterine latero-version and
delivery. Wounds so inflicted, though they
involve the same organ, though they also latero-flexions, after interstitial gravidity, after hematometra, etc.
extend through the entire thickness of the
uterine wall, demand, owing to their 3. The instrument may have slipped into method of infliction, owing to their portal a small cavity, which has developed in the of entrance, owing to their almost invariinterior of a uterine fibromyema.
able association with serious visceral or 4. The sudden ballooning or relaxation
other injuries, to be considered separately of the uterus may also convey to the op- from the perforating wounds of the uterus. erator the impression that he has perfo
that form the subject matter of this paper. rated the uterine wall. There is such a We will consider in this article only such condition as atony of the uterus. The perforating wounds of the uterus as are fact that at all periods of sexual life the due to violence, inflicted from within the uterus has the property of alternate con
uterine canal; that is, only those perfotractions and relaxations, is regarded as
rating wounds in which the vulnerating proved by all physiologists. Contraction agent has either been introduced through, and relaxation are properties inherent to
or has traversed the uterine cervical canal all muscular tissues, and the uterine mus- before perforating the uterine wall. The cularis is not an exception to the general
element of trauma is essential—is indisrule. Keiffer's experiments, bimanual ex- pensable to the accurate conception of these aminations, etc., point to a more or less
perforations. periodic variation in the tone of the myo
In the course of intra-uterine instrumenmetrium.
tations, diseased and healthy uteri have
been perforated, and most disastrous reDuring curettage one often notices a
sults have ensued. Wounds of the uterus, uterine lengthening of 1, 2, or 3 centime
like wounds of other organs or tissues, are ters. It is no longer claimed, just because
solutions of continuity of tissue. They are the curette in these cases is not kept in
always of sudden occurrence, and are alconstant contact with the uterine wall,
ways due to the direct application of methat these uterine lengthenings are in- chanical violence. stances of perforations of the uterus. They
To avoid misunderstandings, a distincare evidences of uterine relaxation. The
tion must be made between penetrating and system of uterine blood-vessels is adapted perforating wounds of the uterus. The to expansions and contractions. R. De
former only enter the uterine wall; the Bevis, in La Semaine Medicale, Paris,
latter traverse its entire thickness. There1906, vol. 26, p. 253, has an excellent and
fore the distinctive characteristic of perexhaustive article on pseudo-perforations
forating wounds of the uterus is, that they of the uterus.
involve the entire thickness of the uterine Though this condition, pseudo-perfora- wall. All the coats, or rather layers of the tion, is infrequent, its existence can no wall of the uterus, are interested: the mulonger be denied. In Craig's case the cosa, the muscularis, and the serosa (in operator, supposing that he had perforated those portions of the uterus that are covthe uterus, opened the abdomen; he then ered by the peritoneum). found the uterus to be uninjured ab- The uterine perforations discussed in solutely. case reported by N.
this article were always consecutive to Gheorghiu, the removed uterus showed no some intra-uterine maneuver, and always