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2a Leading Articles

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TRAUMATIC PERFORATIONS OF uterine perforations, treated expectantly THE UTERUS INFLICTED FROM and terminating in recovery, reviewed the WITHING THE CAVITY OF

subject quite exhaustively. In his article

Liebman makes the following statement: THIS ORGAN.

“In not one of the cases reported in medBY AIME PAUL HEINECK, M. D.,

ical literature, and they exceed thirty in

number, was the perforation of the uterine Professor of Surgery, Reliance Medical College;

wall followed by alarming symptoms." Adjunct Professor of Surgery. University of Illinois; Surgeon to the Cook County Hospital. Liebman compares the accident to para

centesis, to exploratory punctures of orContinued from page 20, March Summary]

gans, procedures which are generally considered harmless.

Lenoir says:

“These Perforating wounds of the uterus are al- perforations have proved interesting to us, ways of accidental occurrence. Nowadays not only on account of their frequency, but they are never intentionally inflicted. They also on account of their innocuousness." have occurred in the hands of the most Lawson Tait had never seen any ill redextrous, of the most clever operators. sults follow perforations of the uterus by The accident has occurred to Lawson Tait. a uterine sound. In not one of the reAuvard had one perforation in 270 uterine ported cases in which the perforating incurettements. It cannot always be stated strument was a sound, did death occur. that they are due to ignorance, to incompe- The sound is a much less dangerous intence, to carelessness; but it can be said strument than the curette. It makes a that in the hands of a novice, in the hands smooth hole, while that made by the cuof the careless, in the hands of the sur- rette is apt to be ragged. The aforegically unclean, all intra-uterine instru- mentioned authors conclude from their ments are dangerous. It can also be stated study of the literature and from their perthat in most of the cases in which death sonal experience that perforating wounds has followed upon uterine perforation, the of the uterus are relatively benign, are unperforating instrument had been introduced attended with danger. Their opinion is for criminal purposes. In 26 of the cases erroneous and is completely disproved by analyzed in the preparation of this article, the study of the literature of the subject the perforating instrument was introduced that has been published during the last to end an undesired pregnancy. In some

twelve years. of the fatal cases where the perforating The dangers of perforating wounds of instrument was not introduced for criminal the uterus are manifold. Independent of purposes, it had been guided by unclean the danger of shock, there is the danger hands.

of hemorrhage into the pelvic and general In 1873 L. E. Dupuy said: "I have peritoneal cavities, into the pelvic connecfound reported 17 cases in which the uter- tive tissues, of injuries to the peritoneum, ine wall has been perforated from within. of injuries of the intra-abdominal organs, In some of these cases the uterus had been etc. In 23 of the fatal cases it is definitely perforated at more than one point. All stated that a diffuse suppurative peritonitis these patients made uneventful recoveries, was present. There is danger of 'traumain none were any measures taken, either tizing the omentum, of traumatizing the inbefore or after the accident, to prevent the testines. In 35 cases it is stated that posidevelopment of complications.” In 1878 tive injury was inflicted to the intestines Carle Liebman, in reporting two cases of or to the omentum. Any of these dangers

ness.

can prove fatal. In Donald McCrae's case such as pus in the tubes, the ovaries, or the patient bled to death. She died three around the uterus, and in acute gonorrheal hours after the infliction of the perforation. endometritis, in acute septic endometritis, The uterus, in this case, showed practically etc. The existence of an extra-uterine no pathology. Several months before pa- pregnancy is a contra-indication to cutient had had a miscarriage. At the time rettage. of the perforation twenty-eight inches of D. By perfecting our surgical technique. intestines were pulled out through the per- E. By familiarizing ourselves with the foration and twisted off by actual force. conditions that predispose to the occur.Shock, hemorrhage, visceral injuries, and rence of uterine perforation. For instance, infection may be associated in the same in- in removing pedunculated uterine submudividual case. If a larger tear has been cous fibroids, the peritoneal cavity is liable made in the uterus, there is danger of a to be opened as in some cases. loop of intestines or of a part of the omen- In a few words, by keeping in mind in tum slipping into the rent and becoming connection with intra-uterine work that strangulated. The gut may only be incar- there are cerated, not strangulated, in the rent. In

dangerous instruments, Kustner's cases the omentum escaped into

dangerous uteri, the uterine cavity. Following these two

dangerous maneuvers. (Kustner's) unrecognized cases, prolonged The use in the uterus by inexperienced and irregular uterine bleeding occurred. hands of placental forceps is always danEventually vaginal hysterectomy was done gerous. It is needless, as the finger can do in both cases, and on section each uterus more effective work. Even the finger has was found to contain grapelike pieces of difficulty, at times, in differentiating beomentum. The omentum may plug the tween placental tissues, blood clot, and inuterine perforation. In cases of perfora- testines. The uterine sound, or hysterometion of the posterior wall of the uterus, ter, is an instrument of very little usefulnear the fundus, if the omentum hangs low

In most cases the size, mobility, and into the pelvic cavity, it is very liable to position of the uterus can be better and become entangled in the curette and drawn more safely determined by bimanual vagthrough the perforation into the uterine ina abdominal examination. Laminaria cavity, even into the vagina. If the pa- tents should be always as long as the uterus, tient recover from the perforation, the site otherwise the lower end of the laminaria, of the cicatrix, apparently, does not in- instead of projecting a little below the exterfere with the subsequent development ternal os, is liable to slip into the uterine of pregnancy, as evidenced by a number cavity. Should then the long axis of the of cases.

In one case, though, the uterus laminaria not remain exactly in that of had been perforated at seven different the uterine cavity, the lower end of the places, patient subsequently became preg- tent becomes impinged against the uterine nant and was delivered of a living child. wall. The uterine contractions may drive

case the site of perforation was that end partly or entirely through the utersought at the time of delivery of a subse- ine wall. The use of laminaria tents proquent pregnancy. No trace of it could be duces a more gradual dilation of the cerfound. Henck's case is the only case re- vical canal. This is an advantage which, ported in which the perforation is said to in our opinion, is counterbalanced by the have enlarged at a subsequent pregnancy

fact that the patient has sixteen or twentyand to have complicated delivery.

four hours of pain. We believe that tupelo How can the frequency of these perfora- tents can, with advantage, be banished from tions be lessened? How can the morbidity the gynecologist's armamentarium. The and the mortality, incident to their occur- danger of infection from the use of tents is rence, be lessened?

great. (Dudley, Chicago; Kelly, BaltiA. By the non-employment of inappro- more.) priate or defective instruments.

The three-bladed steel dilator is considB. By never entering the uterine cavity ered dangerous. It has been nicknamed in the absence of indications.

"the perforating dilator.” Its use is to be C. By never entering the cavity of the discouraged. Hegar's graduated metallic uterus in the presence of contra-indications, dilating bougies are serviceable instru

In one

are:

ments. They should not be introduced Dilatation, or divulsion alone, is not to much beyond the external os. Their func- be considered a specific for dysmenorrhea. tion is to dilate the cavity of the cervix A considerable number of cases of dysmenuteri, not that of the corpus uteri. It orrhea are not in the slightest degree benewould be advisable that they be marked fited by this operative procedure. In off in centimeters, so that the operator marked dysmenorrhea, at times, associated would know at all times how deeply they

with uterine ante-flexion, Dudley's operaare introduced. Whenever the fundus tion will be found very serviceable. In dysuteri is perforated by a Hegar's dilator, the menorrhea, due to stenosis of the external operator is to blame.

os, Pozzi's operation is valuable. DilataAs to uterine curettes, there does not tion alone is valueless in the treatment of seem to be any pattern which cannot, suit- dysmenorrhea due to any of the various able conditions being present, determine a malpositions of the uterus. We must treat perforation of the uterus. The blunt and the cause or the causes which determine the sharp, the fenestrated and the non-fen- the occurrence of the symptom: dysmenestrated, the even-margined and the sinu- orrhea. ous margined curettes are each reported as The indications for uterine curettage having perforated the uterine wall. It is better to use a curette, the shank of which

1. To remove placental debris, etc.

In may be bent like a probe, so as to be made

this connection let us state that in the to conform to the direction of the uterine opinion of such men as Coe, Pinard, etc., canal. A curette which is pliable and

the aseptic finger is the best instrument to eurved and broad above, is less liable to

introduce into the puerperal uterus for cause perforation than one which has a

the purpose of removing decidual remnants narrower upper end and which is rigid

and blood clots. Pinard, for the post-aborand straight. Some models of fenestrated

tum, or post-partum, removal of placental curettes are very apt to catch muscular

debris, rejects the use of the curette and tissues.

teaches that in all cases of retained secThe introduction into the uterus of the

ondines, the finger should be employed for finger or of instruments should not be

their removal. He considers it safer and regarded lightly. With but few exceptions

more thorough. There are limits, however, all these perforations have occurred during

to the power of the human digits and, at the operations of dilatation of the cervical

times, the curette will be found a valuable canal or during that of curettement of the

auxiliary to the finger. For the explorauterine cavity. These two operations, tion of the uterine cavity, the finger, by cervical dilatation and uterine curettage, virtue of its tactile sensibility, is far supewhen performed with due precautions as to

rior to any instrument. The curette is a asepsis, as to pro-operative preparation of blind agent. (Le Page, Pinard, Budin.) the patient, such as emptying of the lower bowel and catheterization of the urinary

2. As an aid to diagnosis: In decidual bladder, are, relatively, of great simplicity

endometritis, uterine tuberculosis, carciof technique, of great benignancy and of

noma, chorion-epithelioma, and other intra

uterine inflammatory or neoplastic progreat efficiency. Following their performance, judicious after-treatment is of great

cesses, the use of the curette as a diagimportance, and should not be overlooked.

nostic aid is a recognized and sanctioned These two operations should not be per

procedure. formed in the absence of positive indica

Where carcinoma of the corpus uteri is tions. They are better performed with the

suspected, the curette must be used with aid of an assistant.

great precaution and only to remove small The indications for dilatation of the

pieces for diagnosis. Again, in those cases cervical canal are :

where curettage has been previously per1. As a preliminary measure to

formed, great care, great gentleness is nec(a) intra-uterine exploration.

essary, because it sometimes happens that (b) uterine curettage and other in

the uterine wall has been previously too tra-uterine maneuvers occurs.

deeply scraped, and then the danger of 2. As a therapeutic measure in dysmen

perforating the organ is imminent. orrhea.

abnormal endometrium

3. To

remove

In a

causing dysmenorrhea and sterility; to in- does not yield to the impact of the utemine duce involution of the uterus. As to

instrument; it does not accommodate itself whether it is wise to curette an empty to the pressure exerted by the sound, cuseptic uterus following on labor or abor- rette, etc. tion, clinicians differ. Naturally, if the 3. The presence or absence of tumors uterus contains retained placental tissue, upon or within the uterus. this must be removed. If the curette is 4. Some operations further recommend used, venous sinuses and lymphatic chan- that the depth and direction of the uterine nels are opened and the protecting barrier cavity be determined by the careful use of leucocytes is interfered with and pos- of the graduated uterine sound or by the sibly removed in places. Further, the Fal- hysterometer, and that any deviation from lopian tube may thus also become infected. the normal benoted. The use of the uterine

4. To remove the remains of a mole sound as means of ascertaining the depth pregnancy.

and direction of the uterine cavity is con5. In the treatment of inoperable car- demned by most operators. They rightly cinoma of the cervix. In this condition claim that the same information can be septic absorption is one of the common more safely determined by bi-manual vagcauses of immediate distress. Curetting ino-abdominal examination. All malposithe fungating mass and subsequent treat- tions, congenital or acquired, of the uterus, ment of the raw surface with strong for- if recognized, predispose to perforation malin, frequently does away with sepsis, during the course of intra-uterine manhemorrhage, and pain.

euvers. Malposed uteri are most frequently C. What are some of the contra-indica- perforated opposite the point of angulations to utero-cervical dilation or to uterine tion. The nutrition of the uterine tissues curettage ?

being impaired at the point of flexure, exa. The absence of a positive indication. plains the not uncommon occurrence of b. The presence of a suppurative process, perforation at this point.

retroeither in the uterus, in the uterine adnexæ, flexed uterus, it is the anterior wall which in the paramentrium, or in any other pelvic is more liable to be perforated; in an anteorgan or structure.

flexed uterus, the posterior wall. c. The presence of such conditions as 5. Get a mental picture, as clear as posphlegmasia alba dolens of uterine or peri- sible, of the pelvic organs. Having a defuterine thrombo-phlebitis. The curette is inite mind picture of the pelvic conditions liable to disturb the thrombi in the uterine existing in the individual case, if a uterine veins, at the placental site, or in the plexus perforation occurs, it is more immediately pampiniformis. (Byron Robinson.)

recognized, and one desists from further D. By perfecting our surgical technique, intra-uterine instrumentation. For inthe occurrence of this accident, perforation stance, suppose that in a given case the of the uterus, will become a rarity.

uterus has, by examination, been deterBefore undertaking any intra-uterine mined to be normal in size, in volume, and maneuver, determine:

in position, and that during the introduca. By vaginal examination.

tion of the uterine instrument the latter b. By bi-manual, vagino-abdominal ex- slips much to one side of the median line amination.

and to a depth greater than that of the 1. The presence or absence of adnexial

uterine cavity, perforation will then immeor peri-adnexial disease. Curettement has diately be diagnosed. determined the rupture of tubal, peritubal, 6. Observe the most rigid asepsis durovarian, peri-ovarian, and peri-uterine pus ing the course of the operation and see that colections. Even the pulling down of the from the standpoint of asepsis and anticervix by tenacula has ruptured pus col- sepsis, the patient has been prepared as lections.

carefully as though you were going to per2. The size, the shape, the mobility, and form a laparotomy. A complication, necesthe consistency of the uterus. If the uterus sitating a laparotomy may suddenly arise. be bound down or immobile as a result of In uterine wounds, be they inflicted by the adhesions due to previous pelvic inflam- sound, by the uterine dilator, or by the matory processes, it is far more liable to curette, vou must minimize; you must be perforated. Under such conditions it avoid the liability of implantation of infec

was never severe.

tion. Not much can be done to cure exist

Ardor urinae persisted ing infection. Much can be done to pre- for but three days. He had no chordee, vent the occurrence of infection. The en- and but little discharge, though the gonodometrium sits directly on the myometrium cocus was repeatedly demonstrated microwithout an intervening sub-mucosa to check scopically. endometrial infectious invasion.

This was one of the rare cases where, by Chicago, Ill.

diligent treatment and inteligent co-operaTO BE CONTINUED.

tion on the part of the patient, the infection was prevented from extending back

into the posterior urethra. TWO CASES OF GONORRHEA.

The discharge disappeared at the end of

three weeks, but the patient still reported By Geo. B. LAKE, M, D.

faithfully for treatment. The moisture at

the meatus and the squeezings from the We take down our text-books and read

prostate were frequently submitted to mi"The approved treatment for gonorrhea”; croscopical examination. All the tests recwe pick up a medical journal and read “My ommended by Ferd. C. Valentine to determethod of treating clap," and sometimes mine the possibility of a recrudescence in this, even more, perhaps, than in other were finally tried, and the entire urethra diseases, some of us are apt to forget that was examined with the urethroscope and in reality it is individual patients (often specimens taken from various parts. The impatient) that we are treating, and not patient never once asked for a discontinua savage and baleful demon, as disease was ance of the treatment until I discharged regarded by our forebears.

him after seven negative findings, extendI am not going to give my treatment for ing over a period of four weeks, during clap. The journals are full of it, and with which time the tests alluded to bove had profit, for we need all the help we can get been conscientiously employed. The whole in many of these cases; but I want to point course of the case, from acceptance to disa moral from two cases of this disease charge, extended over eleven weeks. which were under my observation at the Mr. X. Y. Z. is a large, corpulent man, same time, and which called my attention florid and flabby. Married. A loose liver with peculiar forcefulness to the wide in every sense of the word. The number divergence met with in acute cases, even of his amours is legion, and his wine-cellar in the same stage, and to the great variety is notorious. In some way he had escaped of indications for therapeutic intervention venereal infection up to this time, but even which may arise.

after his suspicious relations he did not reThe two young men were not far from frain from cohabiting with his wife, and the same age, and they both came to me so, of course, he infected her, but that is with their first "dose" as soon as the initial another story. symptoms of the disease presented them- He presented himself with a red and selves; but here the similarity between the swollen member, a copious, creamy distwo cases ends.

charge, and agonizing pain on urination. Mr. A. B. C. is a small, slight man, sin- Chordee was of nightly occurrence. My gle and of unimpeachable habits. A man strict injunctions as to rest, diet, and the to whom all forms of debauchery are en- disuse of stimulants were more or less distirely foreign; whose life has always been regarded, and as a result, at the end of clean and above reproach, and whose lapses a week, he developed a left epididymitis. from strict continence could, in all prob- I put him to bed. and instituted approability, be counted upon the fingers of one priate treatment, under which he improved hand.

promptly and was soon anxious to get up. To him his clap was one of the epochal The first day that I permitted him to leave experiences of his life. He knew some- his bed he disobeyed my instructions as to thing of its seriousness and the difficulties rest and quiet by going for a walk, and attending a radical cure, and he placed the next day he rode a number of miles himself unreservedly in my hands, follow- behind a mettlesome horse and over rough ing all my instructions to the very letter roads. and reporting to me almost daily. His case But in spite of all this he continued to

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