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UNDER CHARGE OF T. J. CROFFORD, M.D.
Consulting Gynecologist to St. Joseph's Hospital, Memphis, Tenn.
Two Cases of Perforation of the Uterus During Curettage.
Elder (Med. Press & Cir., vol. 67, no. 3013) reports two interesting cases of perforation of the uterus during curettage: The first occurred in the person of the wife of a medical man in the country, who was suffering from persistent metrorrhagia after a premature birth, which rest and the usual medicinal remedies had failed to check. The patient was a young, healthy woman--the mother of two children-and with no record of previous uterine mischief. Ether was given and the uterus examined bimanually to ascertain its size, direction and freedom from tubal or ovarian inflammatory mischief likely to contraindicate instrumental interference, and then dilated with Hegar's dilators. This was quickly and easily done, and a blunt curette introduced, when, to his astonishment, it passed in without any sensible obstruction until all but the handle had disappeared. A sound penetrated in the same manner, and the point of it could distinctly be felt under the abdominal parietes. Beyond packing the uterine cavity and vagina with iodoform gauze nothing further was done, and to operator's relief convalescence was smooth and uneventful.
The value of dilatation alone in such cases was shown by the patient having no return of the uterine hemorrhage. A few weeks afterward reporter was asked to curette a young woman for post-puerperal endometritis. Coming so soon after the other, even more than the usual care was taken in dilatation, and, just as in the previous case, the curette had hardly been used before the same accident occurred. To prove the matter beyond a doubt a piece of bowel presented in the cervical canal. This was replaced, and the uterine cavity and vagina packed, as before, with gauze. This patient also seemed none the worse for the perforation, and recovered well.
In both of these cases reporter is disposed to believe that the damage was done by the dilator and not by the curette, inasmuch as curettage had barely commenced before the perforation declared itself.
Curettage has now become so well established in the treatment and diagnosis of intrauterine troubles that one is apt to lose sight of its dangers and adopt it, when other and safer procedures might be substituted. It is well known that the uterine walls are softened and thinned by recent abortions or labors at term, by sepsis, and by cancerous, sarcomatous and tuberculous degeneration—conditions most exposed to injury from instruments-and it is just in these cases, whether for the removal of decidual remains or the clearing up of diagnostic doubts, that digital exploration is of service.
Adopting this method would greatly limit the need for curettage, and in the latter event the risk of accident is much diminished by a preliminary bimanual examination of the parts to ascertain the condition of the appendages and the direction of the uterine body. The selection of a means of dilatation is of great moment. Tents for this purpose on account of the danger of sepsis are now almost obsolete.
On account of their tendency to tear the tissues by reason of their shape, Elder has recently discarded Hegar's dilator for a modification-conical shaped
instead of cylindrical, and more finely graduated. Unless for scraping away malignant tissue he always uses a blunt curette.
With regard to the treatment of perforation, assuming that all needful antiseptic precautions have been taken before and during the operation, the packing with iodoform gauze is, in Elder's opinion, the best, leaving graver operations, such as opening the abdominal cavity, and suturing the rent or removing the septic uterus, for future consideration, should the symptoms point toward them. It is only in a very small minority that such occasions will arise.
The Diagnosis of Extrauterine Gestation.
Wiggins (Amer. Jour. of Obstet., etc., vol. 39, no. 253) in considering the diagnosis of intrauterine gestation, says:
If we take the abdominal lines suggested by Anderson and weed out the possibilities until we come to the probabilities, we will find that in these cases our main difficulty is to differentiate between uterine gestation with threatened abortion and extrauterine pregnancy. With those lines, we find that that space known as the hypogastrium contains normally, first, uterus and appendages; second, bladder; third, small intestine and portion of rectum. Except the uterus and appendages, none are liable to involvement which would elicit suggestive symptoms such as have been described.
Pelvic cellulitis might occasion some doubt, but would be eliminated by its history. In all diseases, typical or so-called "school cases are rare, and yet all diseases have certain symptoms which unmistakably point the way. If the oösperm was always arrested at a given point and the rupture took place in a certain direction at a regular time, we would have in these cases less latitude for doubt; if in these cases there was no decided sympathetic uterine involvement, there would be still less doubt and fewer unnecessary curettements. With the symptomatology of these conditions placed side by side, we find many points in common, but a marked difference in degree.
Naturally these symptoms merge each into the other in certain cases. It is a good rule, when doubt exists, to delay a full investigation until patient can be examined under anesthetic, with full preparation for celiotomy if found necessary.
OBSTETRICS AND PEDIATRICS.
UNDER CHARGE of E. P. Sale, m.d., Memphis.
The Cause of the Conflicting Statements Concerning the Bacterial Contents of the Vaginal Secretion of the Pregnant Woman. Williams (Amer. Jour. Obstet., etc., vol. 38, no. 252) contributes a most interesting and valuable study of the bacteria of the vaginal secretion of the pregnant His work shows conclusively that whenever pathogenic bacteria are present about the vaginal orifice, that they are carried into the vagina in about 50 per cent. of the cases, when an object the size of a small cylindrical speculum is introduced into the vagina and comes in contact with the margins of the hymen.
The investigator also believes that he will not go far wrong in stating that the positive results of the observers who employed specula for obtaining the vaginal secretion for examination are to be explained in the same way; and it would appear that Krönig was perfectly justified in stating that the positive results of most investigators were due to bacteria which they had introduced into the vagina themselves. He considers 25 cases, to be added to 92 cases reported last spring, in which the vaginal secretion was obtained by means of Menge's tube, and in which streptococci were not found at all, and staphylococci only in 2 cases. The author states that the practical results obtained from the 25 cases under consideration may be summarized in the following conclusions:
1. This work tends to reconcile the conflicting results of the various observers by showing that they are due to the difference in the technique by which the secretion was obtained for examination, and not to gross errors in bacteriological work.
Those who obtained the secretion by means of a speculum carried bacteria from the vulva up with it and necessarily got positive results, while those who obtained their secretion by means of a small tube avoided so doing and obtained negative results.
2. This series of cases serves to confirm the previous work of Krönig and himself, which conclusively shows that the various pyogenic bacteria which give rise to puerperal infection are not found in the vaginal secretion of pregnant
3. This being the case, autoinfection with these organisms cannot occur, and when they are found in the puerperal uterus they have been introduced from without. Accordingly, prophylactic vaginal douches are not necessary and are probably harmful, laboratory work thus standing in direct accord with the prac tical experience of most clinicians.
4. The work clearly demonstrates the danger of vaginal examinations, as the introduction of a small cylindrical speculum, which is certainly no larger than two fingers, carries up into the vagina, in 50 per cent. of the cases, whatever pathogenic organisms may be present at the vaginal entrance.
In view of the extreme sensibility of the vulva and the manifest impossibility of disinfecting it with anything like the certainty with which we can disinfect our hands, it becomes apparent that the introduction of a perfectly sterile finger into the vagina is not always a harmless procedure.
5. The danger of the vaginal examination being thus demonstrated, it is apparent that it must give place more and more to the external examination of the pregnant and parturient woman.
Milk Somatose in the Treatment of Intestinal Catarrh in Children. Oberlander of Bonn (Berlin Cor. Med. Press & Cir., vol. 66, no. 3017), after considerable experience of somatose in the treatment of infantile intestinal catarrh, has published a report of his experiences with this comparatively recent remedy. Where an astringent action is desired on the intestinal tract, the astringent must be introduced in a fairly insoluble form. For this reason Schmiedeberg does not recommend tannic acid itself, but vegetable extracts containing considerable quantities of it, from which the active ingredient is only gradually extracted, and combined with gummy or slimy parts, that prevents rapid absorption in the stomach. But in certain intestinal catarrhs, in which the mucous surface of the stomach must be most sparingly treated, the end aimed at is not completely attained.
A preparation that, according to observations made in the Bonn Poliklinik in cases of disorder of the intestinal tract, has proved, not only a readily digestible food, but also a useful astringent, is a combination of milk somatose (Bayer's Elberfeld) with tannin. The tannin is combined in a proportion of 5 per cent. The milk somatose is the albumen obtained from the caseine of milk, the active constituent of albuminous bodies as far as regards nourishment. The principal field of usefulness for somatose containing tannin, lies in atonic conditions of the intestinal musculature in enteroptosis and anemia, in enteritis depending on tuberculosis, if not too far advanced, and in typhoid fever. For very small children, three heaped up teaspoonfuls cooked with milk were ordered, increasing to three tablespoonfuls for larger children. No unpleasant effects were noted with these doses. Forty cases are reported as treated in this way, and from the report we learn that the treatment proved its value.
In many cases recovery took place in three or four days, in some after only one or two teaspoonfuls had been given. In cases where the disease had lasted a long time a week or more was required, or when the somatose had been given up too soon. In order to prevent relapses it is very desirable to continue the treatment for some time after the disappearance of the symptoms.
The best way of dissolving somatose is by sprinkling it slowly on to the surface of water, and allowing it to stand without stirring it. In ten or fifteen minutes the solution will be perfect. If stirred a sticky mass adheres to the spoon, which is brought in uniformity with the rest only with difficulty.
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AS THE NINETEENTH CENTURY GOES OUT. It is a lamentable reflection upon the intellectual development of the Anglo-Saxon race, especially the American portion of it, that the most of the latter-day fads and fooleries bearing relation to the healing art have received their origin and chief vogue in the countries peopled by this great body of civilization-bearers. Cultured Boston has gracefully passed through the travail attendant upon the production of the doctrines of the head fanatic of the faith-healing cult, who, in her own book,* with characteristic ingenuousness, assures her readers that "no intellectual proficiency is requisite in the learner!" How artful. Indeed we believe this, for the denser the individual certainly the more gullible. And the West has only recently seen consigned to oblivion Schlatter, the Healer. For months and months this divinely-inspired gentleman had flocking to his standard, seeking his God-given grace, hosts of the afflicted whose peans of praise grandly swelled upward
* Science and Health, with Key to the Scriptures, by Mary Baker G. Eddy, Boston, 1891.