the fact that rough handling of the uterus exposes the patient to grave dangers. The experience of noted and skillful surgeons amply confirms the statement that the uterus can be, and often is, perforated with the most startling ease. Owing to the fact that clinicians are unwilling, as a rule, to give publicity to such an accident occurring in their practice, the frequency of traumatic perforations of the uterus cannot be accurately determined. Most, if not all, gynecologists of large experience have met with this accident not once, but several times, in their work (Baldwin). In the records of 3172 consecutive autopsies, held between February, 1898, to February, 1908, at the Cook County Hospital, Chicago, not a single case of uterine perforation is reported. In all the cases of abortion and in all the cases of pregnancy, treated at the same institution during the years 1903-1907 inclusive, 495 abortions, 2343 pregnancies, only three perforations of the uterus occurred; two died (autopsy denied); one, treated expectantly, recovered. By diligently searching the medical literature (American, French, English, and German) from 1895-1907 inclusive, I was able to collect only 160 cases of perforating wounds of the uterus inflicted during the course of intra-uterine instrumentation. Some additional cases are found in Rebreyend's These. They do not infirm; in fact, they confirm our conclusions. Uterine perforations can be classified into true and false perforations. True perforations may be spontaneous, may be consecutive to some insult to the uterine tissues. This insult may be thermic, chemical, bacterial, or traumatic in nature. All perforating wounds of the terus are true perforations. False perforations (pseudo-uterine perforations) are not perforations in fact. They constitute a condition in which the clinician is under the impression that he has perforated the uterus when in reality this accident has not taken place. Though pseudo-perforations are of very infrequent occurrence, it is important that clinicians be cognizant of the nature of the condition. A timely and accurate interpretation of its symptomatology will save the physician. much anxiety and the patient needless subjection to operative risks. As the failure to recognize this condition has led to serious mistakes, we will briefly discuss these pseudo-perforations and eliminate them from further consideration. This term (pseudo-perforation) though, in our opinion, not of unquestionable propriety, is used to designate a condition capable of conveying to the operator the impression that he has perforated the uterine wall, when, in fact, this mishap has not occurred. What, then, has occurred? 1. The uterine sound or other instrument may have slipped into a double uterus (uterus didelphys). It may have entered a uterus unicornis. 2. The instrument may have slipped into the dilated uterine end of a Fallopian tube (very rare) or into a bicornuate uterus. Watkins, after opening the abdomen, found that what he had diagnosed the passage of the curette into the peritoneal cavity was the passing of the curette into the Fallopian tube. In Hind's case the uterine sound was introduced in the uterus before incising the abdominal wall; after opening the abdominal cavity, it was seen that the sound had threaded the whole length of the Fallopian tube. It was presenting at abdominal orifice of the tube. In Floeck inger's case, laparotomy showed that the uterine sound was in the oviduct. In Thorn's case one uterus was myomatous, the other was latero-flexed and lateroverted. In the case of myoma of the uterus, the uterine sound was introduced 14 centimeters; suddenly there was a lack of resistance, hasty removal of the sound followed upon this. On opening the abdomen, it was seen that the sound had penetrated for a distance of 3 centimeters into the Fallopian tube. Ahlfeld also reports a case in which, after laparotomy, it was seen that the left oviduct had been entered by a sound introduced into the uterus. Nevertheless this occurrence, the introduction, by way of the uterus, of any instrument into the Fallopian tubes, is very infrequent, so infrequent that its possibility has been denied by competent observers, because: 1. Under natural conditions, the lumen of the uterine end of the oviduct is so small that it is only with difficulty that one can introduce a bristle into it. 2. Under normal conditions, the broad ligaments and also the ovarian ligaments maintain the Fallopian tubes in a transverse position in the pelvis. Lawson Tait was never able, on the cadaver, to sound the tubes through the uterus. He maintains that under normal conditions it is impossible to introduce, by way of the uterine canal, an instrument into the normal Fallopian tubes. Catheterization of the tubes is more liable to occur in the presence of such pathological conditions as uterine latero-version and latero-flexions, after interstitial gravidity, after hematometra, etc. 3. The instrument may have slipped into a small cavity, which has developed in the interior of a uterine fibromyema. 4. The sudden ballooning or relaxation of the uterus may also convey to the operator the impression that he has perforated the uterine wall. There is such a condition as atony of the uterus. The fact that at all periods of sexual life the uterus has the property of alternate contractions and relaxations, is regarded as proved by all physiologists. Contraction and relaxation are properties inherent to all muscular tissues, and the uterine muscularis is not an exception to the general rule. Keiffer's experiments, bimanual examinations, etc., point to a more or less periodic variation in the tone of the myometrium. During curettage one often notices a uterine lengthening of 1, 2, or 3 centimeters. It is no longer claimed, just because the curette in these cases is not kept in constant contact with the uterine wall, that these uterine lengthenings are instances of perforations of the uterus. They are evidences of uterine relaxation. The system of uterine blood-vessels is adapted to expansions and contractions. R. De Bevis, in La Semaine Medicale, Paris, 1906, vol. 26, p. 253, has an excellent and exhaustive article on pseudo-perforations of the uterus. Though this condition, pseudo-perforation, is infrequent, its existence can no longer be denied. In Craig's case the operator, supposing that he had perforated the uterus, opened the abdomen; he then found the uterus to be uninjured absolutely. In a case reported by N. Gheorghiu, the removed uterus showed no trace of perforation. Kossman bears witness to similar facts. Perforating wounds of the uterus, especially of the pregnant uterus, can be inflicted from above; can occur during the course of a laparotomy; can be associated with penetrating wounds (gunshot wounds, stab-wounds, and similar injuries) of the abdominal wall; of the gluteal and other regions; can occur during the course of delivery. Wounds so inflicted, though they involve the same organ, though they also extend through the entire thickness of the uterine wall, demand, owing to their method of infliction, owing to their portal of entrance, owing to their almost invariable association with serious visceral or other injuries, to be considered separately from the perforating wounds of the uterus. that form the subject matter of this paper. We will consider in this article only such perforating wounds of the uterus as are due to violence, inflicted from within the uterine canal; that is, only those perforating wounds in which the vulnerating agent has either been introduced through, or has traversed the uterine cervical canal before perforating the uterine wall. The element of trauma is essential-is indispensable to the accurate conception of these perforations. In the course of intra-uterine instrumentations, diseased and healthy uteri have been perforated, and most disastrous results have ensued. Wounds of the uterus, like wounds of other organs or tissues, are solutions of continuity of tissue. They are always of sudden occurrence, and are always due to the direct application of mechanical violence. To avoid misunderstandings, a distinction must be made between penetrating and perforating wounds of the uterus. The former only enter the uterine wall; the latter traverse its entire thickness. Therefore the distinctive characteristic of perforating wounds of the uterus is, that they involve the entire thickness of the uterine wall. All the coats, or rather layers of the wall of the uterus, are interested: the mucosa, the muscularis, and the serosa (in those portions of the uterus that are covered by the peritoneum). The uterine perforations discussed in this article were always consecutive to some intra-uterine maneuver, and always immediately so. In this class of uterine wounds the vulnerating agent establishes a direct communication between the uterine and some adjacent cavity; the peritoneal cavity most always; rarely the vaginal or the vesical cavity; still more infrequently the lumen of the gut. In other cases the perforating instrument, after having pierced completely through a portion of the uterine wall not covered with peritoneum, enters the peri-uterine connective tissues, penetrating between the folds of the broad ligaments, parametrium. If the violence still continues to act, the vulnerating instrument may perforate one or both layers of this ligament and thereby also enter the peritoneal cavity. The perforating instrument may enter the vesicouterine space, may enter and lodge in the space of Retzius, may enter and lodge in the Douglas cul-de-sac. Traumatic perforations can involve any portion of the uterine wall. In my two cases the perforation, as is usual, as is almost always the case, involved the poste-. rior wall; in Van Ripper's case the rent was in the anterior wall; it extended from the fundus uteri to near the vaginal vault. In Harris's and Whitney's case the anterior wall showed a transverse rent about 11⁄2 inches in length. In a case reported by Hall the uterus was perforated from horn to horn, and the perforation was filled with omentum. In one case the perforation was situated at the anterior and left lateral surfaces of the supravaginal portion of the cervix. In another the perforation was also in the anterior wall. The perforation may be in the cervix. uteri; may be in the corpus uteri or may involve both; may be single; may be multiple (they are, most usually, single); may be small; may be large, or as in a case reported in which the midwife produced a uterine rent 20 centimeters long. In Ullmann's case there were two perforations. In Schenk's case there were three. In Werelius's case the uterus contained seven punctures. The perforation may be barely visible-in one of my cases merely a subperitoneal ecchymosis was present; may be large enough to permit the escape of a large portion of the omentum and of intestines through the rent, as in Hessert's case, in which four feet of gut had been pulled through the uterine rent; as in Holmes's case, in which intestines were found between the woman's legs; as in Congdon's case, in which the operator, after pulling out 40% centimeters of intestines into the vagina, twisted them off. As in Davis's case, during the course of intra-uterine maneuvers, the anterior wall of the uterus was perforated and the intestines damaged to such an extent that over fifteen feet had to be removed. In another case reported, the operator kept on pulling intestines until he had drawn out six feet of bowel, which he cut off. This case terminated fatally; all the other cases mentioned above recovered. The perforation may be large enough to allow the escape of the fetal head into the peritoneal cavity; may allow the escape of the fetus into the peritoneal cavity, as in Whitney's case. In Tait's case, nine months after the date of infliction of the perforation, the track of the curette could still be seen. The size and shape of the opening are, to some extent, dependent upon the size and shape of the vulnerating in strument. The perforation may lead to the formation of permanent abnormal channels of communication between the uterine and adjacent cavity, as in Dr. Lobdell's case, in which the perforation of the uterus took place directly into the bladder, and a permanent vesico-uterine fistula resulted; may. lead to the permanent prolapse of a portion of the omentum into the uterine cavity. Usually, after the infliction of the injury, the vulnerating agent is removed. In some of the reported cases-exceptional cases, I admit-it was abandoned in place, and was either expelled per vaginam or eliminated by the aid of a slowly ulcerative, suppurative, or other pathological process through newly created avenues. The perforating body may be eliminated through the rupture of a near or of a distant abscess, or may be removed at an operation or at autopsy. In one of Treub's cases the bougie was imbedded in a retrouterine abscess. In his other case he removed, by an incision, the perforating catheter from the space of Retzius. In Johnson's case the patient was laparotomized, and the bougie, cause of perforation, was found to be almost entirely 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, was 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. ensued. It was removed; recovery 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 cases. 3. Uterine dilators, 31 cases. 4. Uterine curette, 44 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. TO BE CONTINUED. SUGGESTION REPUDIATES HYPNOTISM. BY ROBERT GRAY, M. D. 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 quakeBut 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 hypnotism as a participating element. There is probably no practitioner anywhere who employs suggestion more extensively than it comprises a predominating part in my practice, nor one who has used it longer, even before it had a generally recognized scientific name, and none who has a stronger founded faith in its clinical value. I have repeatedly told SUMMARY readers my appreciation of suggestive medication and how I employ it, and even wrote a nutshell lesson to answer numerous importunities for more elaborate explanation in a booklet, "Specific Medication," many physicians in the United States asked me to prepare, yet never contaminated with a hypnotic tinge to which I am a clinical stranger. I am writing this hoping to influence Dr. Marrs to become a disciple of true suggestive therapy, for he surely is enthusiastically in earnest and sparkles with legitimate suggestive illumination whenever he gets a lucid passage free from hypnotic enthrallment. I desire that not only Dr. Marrs, but every doctor anywhere may have the suggestive auxiliary service that is mine so beautifully. I put a felon in a 20-per-cent. carbolic acid solution, and apply chloroform suggestively, telling the patient the province of each treatment with impressive particularity, and especially as to the chloroform, admonishing not to be foolish and escape the influence prematurely and not to remain under it longer than necessary; yet such suggestion exercises no degree of hypnotic influence as to the mere physical action of the anesthetic, but serves to tranquilize the anatomy, preparing mental reconcilement to the lethargic superventions over the vital faculties-an influence that seldom fails to dominate propitiously to the end of the operation. I cure hiccough ninety-seven times in a hundred suggestively, usually in a moment, yet I never try to cure grave emergencies thus without chemical auxiliary. Dr. Marrs is correct about the influence of the mind and its bane fulness when in a morbid trend. I have seen conscripts in the Confederate army die promptly without a symptom of disease other than the demon thought of death that haunted them continually; and I have met hun dreds of patients in private practice dominated by despair, most of whom would die under any state of circumstances without the stimulating aid of suggestions. Suggestions and hyoscine are the team to pull the insane out of the remorseless gulf of madness. It may be that I get better help from suggestion than the average practitioner because my faith is stronger and because I inspire patients with responsive faith. I am discussing suggestive medication, not faith cure nonsense, in which I take no stock; nor do I have any faith in suggestion to perform chemical effects, which are intensified by suggestion, but not thus produced, suggestion being a systematic, not a mechanical process. I am endowed with physical properties. of magnetism proper for high degree hypnotic practice. I never employ, not even for amusement, much less as a medical auxiliary, because it has no provice above the animal realm, as already affirmed, and cannot aspire to enter that of suggestion, a spiritual domain. Booklet just off press (The Clinic Publishing Co., Chicago) I wrote to answer letters impossible to reply to personally, gives as near a true lesson on suggestive medication as it is possible to write, and tells all any one needs to know in advance desiring to migrate to Mexico or the Spanish-Americas to seek medical fortune-probably a wiser venture than that of long study to pass State board examinations, whose questions ability to answer would not qualify to cope with tropical fevers. Pichucalco, Chiapas, Mex. CHRONIC ARTHRITIS. Dr. Bayard Holmes, in Lancet-Clinic, says: "The treatment of a chronic arthritis which has been demonstrated to be non-tuberculous consists in at least three distinct maneuvres. The first is designed to increase the elimination, promote nutrition and do away with the anemia; the second is the eradication of the primary infection upon which the arthritis is dependent; and the third is the repair of the joint, the removal of the deformity and the restoration of the joint and the surrounding muscles to their normal condi'ion." |