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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

of the uterine end of the oviduct is so be cognizant of the nature of the condition. 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

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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 under normal

course of conditions it is impossible to introduce, by

laparotomy; can be associated

with penetrating wounds (gunshot wounds, way of the uterine canal, an instrument

stab-wounds, and similar injuries) of the into the normal Fallopian tubes. Catheterization of the tubes is more liable to

abdominal wall; of the gluteal and other 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. 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 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. In case reported by


this article were always consecutive to Gheorghiu, the removed uterus showed no some intra-uterine maneuver, and always



as in

immediately so. In this class of uterine pulled through the uterine rent; wounds the vulnerating agent establishes a Holmes's case, in which intestines were direct communication between the uterine found between the woman's legs; as in and some adjacent cavity; the peritoneal Congdon’s case, in which the operator, cavity most always; rarely the vaginal or after pulling out 4072 centimeters of inthe vesical cavity; still more infrequently testines into the vagina, twisted them off. the lumen of the gut. In other cases the As in Davis's case, during the course of perforating instrument, after having intra-uterine maneuvers, the anterior wall pierced completely through a portion of of the uterus was perforated and the intesthe uterine wall not covered with perito- tines damaged to such an extent that over neum, enters the peri-uterine connective fifteen feet had to be removed. In antissues, penetrating between the folds of other case reported, the operator kept on the broad ligaments, parametrium. If the pulling intestines until he had drawn out violence still continues to act, the vul- six feet of bowel, which he cut off. This nerating instrument may perforate one or case terminated fatally; all the other cases both layers of this ligament and thereby mentioned above recovered. The perforaalso enter the peritoneal cavity. The per- tion may be large enough to allow the forating instrument may enter the vesico- escape of the fetal head into the peritouterine space, may enter and lodge in the neal cavity; may allow the escape of the space of Retzius, may enter and lodge in fetus into the peritoneal cavity, as in Whitthe Douglas cul-de-sac.

ney's case. In Tait's case, nine months Traumatic perforations can involve any

after the date of infliction of the perforaportion of the uterine wall. In my two

tion, the track of the curette could still cases the perforation, as is usual, as is

be seen.

The size and shape of the openalmost always the case, involved the poste-. ing are, to some extent, dependent upon rior wall; in Van Ripper's case the rent

the size and shape of the vulnerating inwas in the anterior wall; it extended from

strument. the fundus uteri to near the vaginal vault. The perforation may lead to the formaIn Harris's and Whitney's case the ante- tion of permanent abnormal channels of rior wall showed a transverse rent about communication between the uterine and 1/2 inches in length. In a case reported adjacent cavity, as in Dr. Lobdell's case, by Hall the uterus was perforated from in which the perforation of the uterus took horn to horn, and the perforation was place directly into the bladder, and a perfilled with omentum.

In one

case the manent vesico-uterine fistula resulted; may. perforation was situated at the anterior lead to the permanent prolapse of a porand left lateral surfaces of the supra- tion of the omentum into the uterine cavvaginal portion of the cervix. In another ity. Usually, after the infliction of the the perforation was also in the anterior injury, the vulnerating agent is removed. wall.

In some of the reported cases-exceptional The perforation may be in the cervix cases, I admit-it was abandoned in place, uteri; may be in the corpus uteri or may and was either expelled per vaginam or involve both; may be single; may be mul- eliminated by the aid of a slowly ulceratiple (they are, most usually, single); may tive, suppurative, or other pathological be small; may be large, or as in a case process through newly created avenues. reported in which the midwife produced a The perforating body may be eliminated uterine rent 20 centimeters long. In Ull- through the rupture of a near or of a dismann's case there were two perforations. tant abscess, or may be removed at an In Schenk's case there were three. In operation or at autopsy. In one of Treub's Werelius's case the uterus contained seven cases the bougie was imbedded in a retropunctures. The perforation may be barely uterine abscess. In his other case he revisible-in one of my cases merely a sub- moved, by an incision, the perforating peritoneal ecchymosis was present; may catheter from the space of Retzius. In be large enough to permit the escape of Johnson's case the patient was laparotoa large portion of the omentum and of mized, and the bougie, cause of perforaintestines through the rent, as in Hessert's tion, was found to be almost entirely case, in which four feet of gut had been folded in and covered by the omentum, an





evidence of the effort of nature to repair the damage and to prevent injury of the abdominal viscera. In Thorn's case the perforating bougie, after the patient had been laparotomized, found lying obliquely in Douglas's cul-de-sac. In Talmey's case the perforating bougie was found lying in front of the proximal edge of the right kidney. In Bullard's case the crochet hook was discharged through the anterior abdominal wall. It did not interfere with the continuance of gestation. In Perle's case the needle or trocar, that had perforated the uterus, was removed, some time after, from an abscess in the right inguinal region, where it had become encysted after its passage through the uterine wall. In Fairchild's case, at laparotomy, the hairpin was found, high up, in the abdominal cavity near the diaphragm. In Patru's case the perforating catheter was found imbedded in an abscess palpable through the anterior rectal wall. By means of an incision made in the anterior rectal wall, all the pus was evacuated and the bougie removed. In Marchand's case a Hegar's metallic, dilating bougie, No. 12, perforated the uterus, and was abandoned in the patient's body. After about a year of invalidism she was laparotomized, and the sound was found between two folds of mesentery. It was removed; recovery ensued.

Any instrument that can be used or misused in the uterine cavity is capable of perforating the uterine wall. All forms of uterine sounds, of uterine dilators, of curettes (curette included), can be incriminated. In one case mentioned thirty-one inches of gut had been torn away by the augur curette. In the cases reported during the last ten years, it is stated in unmistakable terms, that the vulnerating instrument was

1. Uterine douche tube, irrigator, catheter, 12 cases.

2. Uterine bougie, uterine sound, 17

Unfortunately I am reluctantly actuated to dissent from the able and interesting contribution of Dr. W. T. Marrs: “The Mind as a Factor in the Cause and Cure of Disease," in November SUMMARY, because the deductions are erroneous in every acceptation wherever suggestive and hypnotic affiliation is advanced, whose antithesis is as incongruous as the North Pole and the torrid clime, hence deplorably misleading

The text of the contribution is sublime, and the article would be a masterful portraiture of scientific suggestive therapy had it not been spoiled by lugubrious shadings of debasing hypnotism which I am unable to conjecture how so talented a writer could have the heart to introduce.

Suggestion is an attribute divine, whose mystic haunt is the subjective mind in the solar plexus of the brain, above and beyond the realm of mortal faculties, while hypnotism is of the flesh carnal, a domain of personal magnetism, far more intensely positive in some persons than in many others, to whose influence some are subject, others exempt; a power not all unlike that of the serpent's charm, whose victims are "Like the bird whose pinions quake

But cannot fly the gazing snake.”

Hypnotism is no element of medical science, while the supreme function of suggestion is scientific medication, applicable to the patient through the medium of the subjective mind, yet entirely free from any hypnotic symptom, and not available for any other purpose, even the infant, the idiot, and the moribund being alike susceptible to its influence, in each of whom the subjective mind is rationally enthroned till the heart pulsates no more, when that immortal element abandons its tenament of clay.

I am inexpressibly pained that Dr. Marrs referred to hypnotism or hypnotic experience, when he is certainly qualified to write a helpful suggestive contribution if he will but disabuse his mind of the harmful unprofessional fallacy of recognizing


3. Uterine dilators, 31 cases.
4. Uterine curette, 44 cases.
5. Miscellaneous agents, 50 cases.

In other cases the offending agent is either not stated or happened to be either a probe case, a wire, a meat skewer, an electrode. Chicago, Ills.


hypnotism as a participating element. dreds of patients in private practice domi

There is probably no practitioner any- nated by despair, most of whom would die where who employs suggestion more ex- under any state of circumstances without tensively than it comprises a predominat- the stimulating aid of suggestions. Suging part in my practice, nor one who has gestions and hyoscine are the team to used it longer, even before it had a gen- pull the insane out of the remorseless gulf erally recognized scientific name, and none of madness. who has a stronger founded faith in its It may be that I get better help from clinical value.

suggestion than the average practitioner I have repeatedly told SUMMARY readers because my faith is stronger and because my appreciation of suggestive medication I inspire patients with responsive faith. and how I employ it, and even wrote a I am discussing suggestive medication, not nutshell lesson to answer numerous impor- faith cure nonsense, in which I take no tunities for more elaborate explanation in stock; nor do I have any faith in suga booklet, "Specific Medication," many gestion to perform chemical effects, which physicians in the United States asked me are intensified by suggestion, but not thus to prepare, yet never contaminated with produced, suggestion being a systematic, a hypnotic tinge to which I am a clinical not a mechanical process. stranger.

I am endowed with physical properties I am writing this hoping to influence Dr. of magnetism proper for high degree hypMarrs to become a disciple of true sug- notic practice. I never employ, not even gestive therapy, for he surely is enthusi- for amusement, much less as a medical astically in earnest and sparkles with legiti- auxiliary, because it has no provice above mate suggestive illumination whenever he the animal realm, as already affirmed, and gets a lucid passage free from hypnotic cannot aspire to enter that of suggestion, enthrallment. I desire that not only Dr. a spiritual domain. Marrs, but every doctor anywhere may Booklet just off press (The Clinic Pubhave the suggestive auxiliary service that lishing Co., Chicago) I wrote to answer is mine so beautifully.

letters impossible to reply to personally, I put a felon in a 20-per-cent. carbolic gives as near a true lesson on suggestive acid solution, and apply chloroform sug

medication as it is possible to write, and gestively, telling the patient the province tells all anyone needs to know in adof each treatment with impressive par

vance desiring to migrate to Mexico or ticularity, and especially as to the chloro- the Spanish-Americas to seek medical forform, admonishing not to be foolish and tune-probably a wiser venture than that escape the influence prematurely and not of long study to pass State board examito remain under it longer than necessary;

nations, whose questions ability to answer yet such suggestion exercises no degree of

would not qualify to cope with tropical hypnotic influence as to the mere physical

fevers. action of the anesthetic, but serves to

Pichucalco, Chiapas, Mex. tranquilize the anatomy, preparing mental reconcilement to the lethargic superven

CHRONIC ARTHRITIS. tions over the vital faculties—an influence Dr. Bayard Holmes, in Lancet-Clinic, that seldom fails to dominate propitiously

says: “The treatment of a chronic arto the end of the operation.

thritis which has been demonstrated to be I cure hiccough ninety-seven times in a

non-tuberculous consists in at least three hundred suggestively, usually in a moment, distinct maneuvres. The first is designed yet I never try to cure grave emergencies to increase the elimination, promote nutrithus without chemical auxiliary.

tion and do away with the anemia; the Dr. Marrs is correct about the influence second is the eradication of the primary of the mind and its banefulness when in

infection upon which the arthritis is dea morbid trend. I have seen conscripts in pendent; and the third is the repair of the Confederate army die promptly with- the joint, the removal of the deformity and out a symptom of disease other than the the restoration of the joint and the surdemon thought of death that haunted rounding muscles to their normal condithem continually; and I have met hun- lion.”

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